GI Conditions Differential Diagnosis OSCE PDF

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Summary

Abdo. Pain DESCRIPTION RISK FACTOR HISTORY INVESTIGATION MANAGEMENTAppendicitisInflammation of Appendix – causing obstruction of opening due to hard pooAge: 10 - 20 More common in men Smoking at homeYoung, Anorexia Periumbilical pain, moves to RIF Nausea & Vomiting Fever, DiarrhoeaRIF Tender...

Description

Abdo. Pain Appendicitis

Acute Pancreatitis

Gastric/ Peptic Ulcer

DESCRIPTION

RISK FACTOR

HISTORY

Inflammation of Appendix – causing obstruction of opening due to hard poo

Age: 10 -20 More common in men Smoking at home

Young, Anorexia Periumbilical pain, moves to RIF Nausea & Vomiting Fever, Diarrhoea

Acute inflammation of Pancreas caused by hypersecretion or backflow (due to obstruction) of exocrine digestive enzymes, causing autodigestion of pancreas Most caused by Gallstone/ Alcohol

Male gender Age, Smoking Obesity, Gallstones, Trauma & Drugs

Severe epigastric/ central pain radiates to back. Relief - sitting forward Vomiting, less appetite PMH gallstones, biliary disease

NSAIDs Alcohol Spicy Food

Epigastric pain Related to meals Burning Stomach Pain, Intolerance to fatty food, Bloating, Nausea Often vomit blood red/black

Occur on inside of stomach/ duodenum Commonly caused by H. Pylori Bacterium, Overuse of NSAID irritates and inflames lining

Diverticulitis

Infection or Inflammation of diverticula in LI. Lack of fibre means muscle of colon works harder to move poo. Causes high pressure in colon and so some part of mucosa will form outpouchings

Bowel Obstruction

Caused by Adhesion, Hernia, Tumour, Crohn’s

Ectopic Pregnancy

Pregnancy outside of uterus

IVF, Endometriosis

Abdominal/ pelvic pain, Vaginal bleeding, Dizziness, Fainting

Biliary Colic

When gallbladder neck impacted by gallstone. No inflammatory response but contraction of gallbladder against occluded neck causes pain.

Fat, Female, Fertile, Forty, Family History

Intermittent RUQ Pain Sudden and dull Exacerbated by fatty food Nauseous & Vomiting

Elderly Lack of fibre in diet

LIF Pain Pyrexia (Fever), Palpable Mass, Tachycardia

Vomiting, Abdominal Pain & No Bowel Motion

INVESTIGATION RIF Tenderness, RLQ inflammation Rule out UTI Blood glucose, electrolytes: low due to nausea, vomit and anorexia FBC = Raised WBC, CRP = Inflammation Ultrasound: >6mm & wall thickening Epigastric tenderness Abdominal Distension, Reduced bowel sounds, Cullen (peri-umbilical bruise) and Grey Turner Sign (flank bruise) Amylase/ Lipase > x 3 normal ECG to avoid MI Breath, Blood, stool test for H. Pylori Endoscopy to look for ulcer: may take biopsy too Barium Swallow to look at upper GI: barium makes ulcer more visible Peptic ulcer = during food, Duodenal ulcer = before/ at night

Barium Enema, US to check wall thickness, Blood Culture, FBC, LFT

Distended, Tender Abdomen Tinkling Bowel Sounds (auscultation) Bloods: FBC, LFT, CRP, Amylase, INR AXR, CT abdomen/pelvis hCG urine dipstick = +ve ectopic Urinalysis = rule out UTI FBC, CRP – high WBC, Ultrasound

Analgesia, OPT Cholecystectomy

MANAGEMENT Appendicectomy: removal of appendix Observation: Antibiotics & IV

IV Fluid resuscitation, correct electrolyte disturbance Analgesia : IV Paracetamol, Antiemetics and Nutrition Stop alcohol Antibiotic to kill H.pylori – Amoxicillin Block acid production & promote healing (PPI) – reduce stomach acid by blocking acid secretion (Omeprazole) Histamine H2 blocker – reduce stomach acid, Antacid to reduce stomach acid Antibiotics (Metronidazole) Fluids, Analgesia (careful as can increase pressure) May need surgery to resect sigmoid colon = severe IV Fluid, Analgesia (Paracetamol) & Antiemetic NBM, NG Tube & Laparoscopy Surgical removal of ectopic pregnancy

Analgesia OPT Cholecsystectomy

Cholecystitis

Inflammation of gallbladder that happens when gallbladder blocks the cystic duct

Constant tenderness & pain in RUQ/ epigastrium Fat, Female, Fertile, Forty, Family History

+ve Murphy sign

Murphy sign: Apply pressure in RUQ, ask px to inspire) if halt in inspiration due to pain = inflamed gallbladder Trans abdominal US: for gallstone, thickness, duct dilatation FBC & CRP = raised inflammatory marker LFT = high ALP, normal ALT & Bilirubin

CBD Stone

Cholangitis

Presence of gallstones in common bile duct

Fat, Female, Fertile, Forty, Family History

Jaundice RUQ Pain

Inflammation of bile duct system

Fat, Female, Fertile, Forty, Family History

Fever Rigour RUQ Pain Jaundice

DESCRIPTION

Bowel Change

RISK FACTOR

Timing: when did it start, acute/ gradual, duration, progression Colon Cancer

Gastroenteritis

Inflammatory Bowel Disease

Cancer that begins in LI Start as benign polyps inside colon epithelium Adenocarcinoma Viral cause: here: Norovirus – outbreak on hospital ward Rotavirus & Adenovirus common in children, Ebola common in Africa They disrupt intestinal mucosa causing Na+ & Cl- to release and H2O to expel

Crohn’s

Inflammatory bowel disease: Young, 15-35yrs Affects terminal ileum but can affect other parts

Elderly FHX, diet, IBD

Travel Consumption of improper, raw food

Caucasians, FHX

Obstructive picture

Antibiotics (cephalosporin) Cholecystectomy Gallbladder removal to reduce risk of acute cholecystitis coming back Reduce high cholesterol food eaten Continuous IVI prevent hepatorenal syndrome ERCP

Inflammatory markers are raised Trans abdominal US: for gallstone, thickness, duct dilatation

HISTORY

INVESTIGATION

IV Antibiotics (Tazocin) Treat cause

MANAGEMENT

Stool: How much/ often/ consistency, contents (mucus, blood, bile) Blood in stool/ Melaena Weight Loss Change in bowel

Iron deficiency anaemia Complete colonoscopy & biopsy Palpation, DRE Screening tessts

Stage to be able to manage: Surgical resection & metastasis May need chemo &/or radiation

Acute Diarrhoea Nausea & Vomiting Loss of appetite

Blood and Stool Culture: Bloody Diarrhoea = Bacterial presentation (E.coli, Salmonella) FBC (WBC) , Urea, Electrolytes, USS, CT

Oral rehydration (dioralyte) Food: avoid fatty & spicy Anti-emetic (Domperidone)

Vitamin B12 & Iron deficiency Barium Swallow shows area of stricture, shortening of small bowel CT – shows area of wall thickening, stricture Colonoscopy used to biopsy

Cessation of smoking B12 and Iron supplements Low residue diets Antibiotics Corticosteroids & immunosuppressants

RIF pain Blood/ Mucus in stool (colour) Abdominal Pain

UC

Chronic inflammatory disease affecting LI & Rectum. Most common 15-30 yrs and 50-70yrs

Autoimmune disorder characterised by gluten sensitivity. Gliadin in gluten is not broken down fully and passes through intestinal epithelial layer triggering immune response.

Coeliac Disease

Gliadin binds to HLA DQ2 This activates T cells in intestinal mucosa causing immune response This leads to chronic inflammation in SI, damaging epithelium

FH of IBD Recent GI infection NSAID Smoking Cessation

Genetics Autoimmune thyroid disease Genetic syndrome: Down’s T1DM IgA deficiency

Diarrhoea (due to excess mucus production) Blood/ Mucus in stool (colour) Abdominal Pain Less severe than Crohn

Failure to thrive Chronic Diarrhoea Constipation Abdominal Bloating Features of Anaemia Nausea and Vomiting Fatigue

Diarrhoea due to excess mucus Barium Enema = Reduced haustral folds due to fibrosis Finger clubbing FBC:Signs of Anaemia – pale and fatigue Joint Pain, Erythema Nodosum Stooltest: faecal calprotectin raised in UC: marker of inflammation Endoscopy: Sigmoidoscopy, Colonoscop tTg antibody and total IgA count: if strongly positive = Coeliac disease If TTG > x10 then EMA Screen done EMA = IgG Endomysial Antibodies Diagnostic Duodenal biopsy FBC = as can have low iron Low Vitamin B12 and folate

Aminosalicylates (Mesalazine) 5-ASA Corticosteroid (Prednisolone) initiate remission Use immunosuppressants Surgery ifnothing works

Lifelong gluten free diet: avoid rye, wheat, barley and oats Immunisation: individuals with coeliac disease have defective immune response and so need vaccine every 5 yrs...