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FY1 BSUH

FY1 BSUH. Upper GI Dyspepsia GORD Gastric & Duodenal ulcers Small Bowel Coeliac Crohns Large Bowel Ulcerative colitis Crohns disease Hepatology Hepatitis A, B, C Cirrhosis NAFLD & NASH. GORD / Dyspepsia.

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FY1 BSUH

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  1. FY1 BSUH

  2. Upper GI • Dyspepsia • GORD • Gastric & Duodenal ulcers Small Bowel • Coeliac • Crohns Large Bowel • Ulcerative colitis • Crohns disease Hepatology • Hepatitis A, B, C • Cirrhosis • NAFLD & NASH

  3. GORD / Dyspepsia

  4. A 56 yr old obese man presents to his GP with recurrent epigastric pain, made worse by eating and bending over. Pain is relieved by OTC antacids. He smokes 20 cigarettes per day and drinks a few pints daily. The most useful investigation would be What is the most likely diagnosis?

  5. A 56 yr old obese man presents to his GP with recurrent epigastric pain, made worse by eating and bending over. Pain is relieved by OTC antacids. He smokes 20 cigarettes per day and drinks a few pints daily. The next investigation would be • OGD • Double contrast barium meal • H.Pylori breath test • Abdominal x-ray • Abdominal CT

  6. A 56 yr old obese man presents to his GP with recurrent epigastric pain radiating to the back, made worse by eating and bending over. Pain is relieved by OTC antacids. He smokes 20 cigarettes per day and drinks a few pints daily. The most useful investigation would be • OGD • Double contrast barium meal • H.Pylori breath test • Abdominal x-ray • Abdominal CT

  7. Group of non-specific symptoms • Epigastric pain • Bloating • “heartburn” • Cough / Voice Change • May have a relationship to • Hunger • Specific foods • Position • Differential diagnosis • Oesophagitis/GORD • Duodenal or gastric ulcer • Gastric malignancy • Duodenitis • Gastritis • Angina?? Diagnosis requires very careful history taking & consideration of risk factors

  8. Anaemia Loss of weight Anorexia - loss of appetite – just in case they get confused Recent onset and progressive symptoms Melaena or haematemasis Swallowing difficulty - dysphagia

  9. Obesity or pregnancy – increased intra-abdominal pressure • Fatty diet • Drinking alcohol or coffee • Large meals • Smoking • Hiatus hernia • Drugs – NSAIDs, Anti-muscarinic, calcium channel blockers and nitrates

  10. If over 55 or ALARM signs • Upper GI endoscopy • If under 55 & no ALARM signs • **LIFESTYLE CHANGES** • Stop all drugs causing dyspepsia (eg. NSAIDS) • Over the counter antacids eg. Gaviscon • Review in 4 weeks • If no improvement, test for & treat h.pylori • Consider PPI

  11. A 56 yr old obese man presents to his GP with recurrent abdominal pain radiating to the back, made worse by eating and bending over. Pain is relieved by OTC antacids. He smokes 20 cigarettes per day and drinks a few pints daily. The most likely diagnosis is • Duodenal ulcer • GORD • Acute pancreatitis • Achalasia • Gastric ulcer

  12. A 56 yr old obese man presents to his GP with recurrent abdominal pain radiating to the back, made worse by eating and bending over. Pain is relieved by OTC antacids. He smokes 20 cigarettes per day and drinks a few pints daily. The most likely diagnosis is • Duodenal ulcer • GORD • Acute pancreatitis • Achalasia • Gastric ulcer

  13. GORD Tx • AGE – same as your previous slide but the management on this slide is correct • Lifestyle measures – (usually not enough...) • If no ALARM symptoms full-dose PPIs for one month. • H. pylori eradication is not recommended. • If symptoms return - step-down strategy to the lowest dose of PPI that provides effective relief of symptoms • All patients should have a treatment plan and should be told if they can stop if symptom-free.

  14. Gastric & Duodenal Ulcers

  15. Duodenal Ulcer • Mainly occur on lesser curve of stomach • Ulcers elsewhere are more likely to be malignant • 4% gastric ulcers malignant – therefore important to take multiple biopsies • H.pylori 70% • Exacerbated by food • Need to repeat upper GI endoscopy in 6 weeks for gastric ulcers to ensure healing due to risk of malignancy • 4x commoner than GU • Rarely malignant • Relieved by food • H.pylori 99% Gastric Ulcer

  16. Repeat Endoscopy in 6 weeks to ensure healing due to risk of malignancy • Lifestyle • Stop smoking • Avoid foods that worsen symptoms • H.pylori eradicaton • Successful in 80-85% • Acid reduction • PPI for 4 weeks for DU and 8 weeks for GU • NSAID ulcers • Stop NSAIDS

  17. 80% of people are asymptomatic • Affected individuals have a 10-20% chance of developing a peptic ulcer and 1-2% chance of developing gastric cancer • Eradication • PPI + Amoxicillin + Clarithromycin BD for 7/7 OR….. • PPI + Metronidazole + Clarithromycin BD for 7/7

  18. A 22 yr old female is noted to have both microcytic and macrocytic anaemia. She gives a history of intermittent diarrhoea with difficulty in flushing the stools. The most likely diagnosis is • Cystic fibrosis • IBS • Coeliac disease • Crohns disease • UC

  19. A 22 yr old female is noted to have both microcytic and macrocytic anaemia. She gives a history of intermittent diarrhoea with difficulty in flushing the stools. The most likely diagnosis is • Cystic fibrosis • IBS • Coeliac disease • Crohns disease • UC

  20. Coeliac Disease

  21. Gluten sensitive enteropathy • T-cell mediated autoimmune condition • Diarrhoea (hard to flush), weight loss & anaemia • Inflammation of jejunal mucosa • Villous atrophy on biopsy (2nd part of duodenum) – reduced absorption • Assoc with HLA-DQ2 in 95% (and HLA-DQ8)

  22. Anti-endomysial (anti-EMA) and Anti-tissue transglutaminase (anti-TTG) antibodies • 95% specific UNLESS patient is IgA deficient – or if patient already excluding gluten from diet • Anti-reticulin antibodies • Duodenal/Jejunal biopsy • Duodenal as good as jejunal if >4 taken • Haematology • DEXA scan

  23. Only effective treatment is a life-long gluten free diet

  24. Coeliac complications? • Osteoporosis • Delayed growth/puberty • Lymphomas of intestinal tract – MALT - rare

  25. IBDInflammatory Bowel Disease

  26. Crohns Disease • Rectum to caecum • F>M • Superficial ulceration • Goblet cell depletion • Glandular distortion • Mucosal ulcers • Crypt abcesses • Mouth to anus • F>>M • Chronic inflammation • Full thickness ulceration • Cobble stoning • Skip lesions • Rose thorn ulcers - seen on X-ray • Granuomas – non-caeseating - histology • Fistulas Ulcerative Colitis

  27. Acute • Steroids, cyclosporin, infliximab • Symptomatic relief • Chronic • 5ASAs eg pentasa, asacol • Azathioprine (steroid sparing agent) • Methotrexate • Anti TNFs eg Infliximab, adulimumab • Surgery

  28. Which of the following symptoms of UC is not associated with the activity of the colitis • Erythema nodosum • Primary sclerosing cholangitis • Episcleritis • Pyoderma gangrenosum • non-axial large joint arthropathy

  29. Which of the following symptoms of UC is not associated with the activity of the colitis • Erythema nodosum • Primary sclerosing cholangitis • Episcleritis • Pyoderma gangrenosum • non-axial large joint arthropathy

  30. Hepatitis

  31. Most common form of hepatitis worldwide • Often occurs in endemics • Spread is mainly faeco-oral assciated with contaminated food & water • Overcrowding and poor sanitation facilitate spread • No carrier state • Vaccine available • Notifiable disease in UK

  32. LFTs • ALT & ALT markedly raised • Bilirubin and INR may be elevated • Hepatitis serology • Hep A IgM confirms acute diagnosis • Hep A IgG antibodies shows lifelong immunity • Mx: supportive usually!

  33. Hep B Surface Antigen (HBsAg): first to appear and last to clear • If HBsAg present after 6 months = chronic carrier status (5-10% of cases) • Hep B e-antigen implies high infectivity • Antibodies to Hep B core antibody = past infection • Antibodies to HBsAg ONLY = vaccination

  34. Hep B mx? • Different depending on many variables • Aims either to control virus replication with antivirals ie not cure and in certain circumstances interferon • Antivirals: Lamivudine, adefovir, tenofovir (plus others).. • Must test for HIV if HepB positive as need triple therapy with antivirals

  35. Often asymptomatic • Commonest symptom is fatigue • 85% go on to become chronic carriers (ie. RNA is detected >6months after infection) • However, can be treated with pegalated interferon & ribavirin (50-80% cured) – there are also newer agents and a lot of current regimes are now with triple therapy • Those who develop cirrhosis (10-30%) may require liver transplant

  36. Infection • Hep B/C • Toxins • Alcohol • Methotrexate • Prolonged cholestasis • Biliary stricture • Autoimmune • PBC (ANA, AMA) • PSC association w IBD (p-ANCA) • AIH (ANA, anti-SMA) • Metabolic • Haemochromotosis • Wilsons • α-1 antitripsin deficiency • NAFLD/NASH • Venous stasis • Hepatic vein occlusion • Cryptogenic - no cause identified

  37. LFTS – AST>ALT • Synthetic liver function – INR, albumin • Send blood for alphafetoprotein for evidence of HCC • Imaging - Ultrasound • Gold standard - liver biopsy • Should also have an endoscopy for screening of oesophageal varices

  38. Weight loss • Nutritional advice • Surgery • Insulin sensitizers –GLP1 etc may have a role in diabetics • Risk factors are ie overweight, diabetic, hypercholesterolaemia therefore treatment means lifestyle and also treatment of the risk factors

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