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Chronic abdominal pain Ayah ShahChronic abdominal pain history • 55 year old male is presenting with chronic abdominal pain, please take a history. • What questions would you ask? History taking • Presenting complaint: • Explode the PC: • SOCRATES the pain • If other symptoms e.g. CIBH ask when it starts, acute/gradual onset, how long, progression (is it getting worse), always there or intermittent?, etc. • Ask about associated symptoms (GI review) • Start at the top: • Mouth ulcers • Nausea and vomiting (blood in vomit? • Dysphagia • Abdominal pain • Any change in bowel habits, if so what (diarrhea, constipation, greasy stools, hard to flush?) • Any blood or mucus in the stools. If bloods, how much, what colour, mixed in with the stools, on wiping, etc., is there pain on defecation • Systems review • ICE!!! • PMH • Medications & allergies • FH • Social history • Smoking • Alcohol • Work • Travel • Impact on lifeInflammatory Bowel Disease • Inflammatory bowel condition that results in periods of remission as well as flares. • Which two conditions come under the label of IBD? • Ulcerative colitis & Crohn’s disease • Name some differences between the two IBD - differences Crohn’s disease - Crows NESTS Ulcerative colitis- CLOSEUP N – No blood or mucus (less common) C – Continuous inflammation E – Entire GIT L – Limited to colon and rectum S – Skip lesions O – Only superficial mucosa affected T – Terminal ileum most commonly S – Smoking is protective affectedand transmural inflammation E – Excrete blood and mucus S – Smoking is a risk factor (don’t set U – Use aminosalicylates nest on fire) P – Primary Sclerosing Cholangitis Also associated with weight loss, strictures and fistulasSymptomsPyoderma gangrenosum Erythema nodosumIBD - Investigations • FBC, U&Es, LFTs, TFTs • CRP • Faecalcalprotectin • Released during intestinal inflammation, useful for screening • Endoscopy and coloscopy • Imaging e.g. US, CT, MRI – for complicationse.g. fistulas, abscess & strictures Colonoscopy: • Deep ulcers, skip lesions Histology: Crohn’ s • Goblet cells of all layers disease - • Granulomas Small bowel enema: Findings • Proximal bowel dilationing sign • Rose thorn ulcers • FistulaeKantor’s string sign Pathology: • Red, raw mucosa, bleeds easily • no inflammation beyond submucosa (unless fulminant disease) Ulcerative • widespread ulceration with preservation of adjacent mucosa • inflammatory cell infiltrate in lamina propriaps') • neutrophils migrate through the walls of glands to form crypt colitis- abscesses • depletion of goblet cells and mucin from gland epithelium • granulomas are infrequent Findings Barium enema: • Loss of haustrations • Superficial ulceration, pseudopolyps • Drainpipe colonDrainpipe colon Crohn’s disease Ulcerative Colitis Features Diarrhoea usually non-bloody Bloody diarrhoeamore common Weight lossmore prominent Abdominal pain in the left lower quadrant Upper gastrointestinal symptoms, mouth ulcers, perianal Tenesmus disease Abdominal mass palpable in the right iliac fossa Extra-intestinal Gallstones are more common secondary to reduced bile acid Primary sclerosing cholangitis more common reabsorption Complications Obstruction, fistula, colorectal cancer Risk of colorectal cancer high in UC than CD Pathology Lesions may be seen anywhere from the mouth to anus Inflammation always starts at rectum and never spreads beyondileocaecal valve Skip lesions may be present Continuous disease Histology Inflammation in all layers from mucosa to serosa No inflammation beyond submucosa(unless fulminant disease)- inflammatory cell increased goblet cells infiltrate in lamina propria granulomas neutrophils migrate through the walls of glands to form crypt abscesses depletion of goblet cells and mucin from gland epithelium granulomas are infrequent Endoscopy Deep ulcers, skip lesions - 'cobble-stone' appearance Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps ('pseudopolyps') Radiology Small bowel enema Barium enema high sensitivity and specificity for examination of the terminalloss of haustrations ileum superficial ulceration, 'pseudopolyps' strictures: 'Kantor's string sign' long standing disease: colon is narrow and short-'drainpipe colon' proximal bowel dilation 'rose thorn' ulcers fistulae Some patients may undergo surgery. If the disease is limited to the distal ileum you can remove this area Crohn’s management whole GI tract. typically affects the Surgery can be useful in managing complicationse.g. strictures,fistulas Inducing remission Maintaining Remission 1 line: 1 line: Steroids e.g. Prednisolone, Azathioprine Hydrocortisone Mercaptopurine Step up if not controlled on steroids: Alternatives: Azathioprine Methotrexate Mercaptopurine Infliximab Methotrexate Adalimumab Infliximab Adalimumab Usually only affects the colon and rectum called a pan-proctocolectomy leaving the Ulcerative Colitis management patient with an ileostomy or and ileoanal anastomosis called a J pouch. Inducing remission Maintaining remission If mild-moderate: Aminosalicylate e.g. mesalazine st 1 line: aminosalicylate e.g. Azathioprine mesalazine Mercaptopurine 2 : corticosteroids e.g. prednisolone Severe disease: 1 line: IV corticosteroids e.g. hydrocortisone nd 2 line: IV ciclosporinGrading severity of UC flareCoeliac disease • An autoimmune condition resulting in inflammation in response to gluten. • What are the antibodies involved in this condition? • Anti-tissue transglutaminase (anti-TTG) and anti-endomysial antibodies (anti-EMA) • When the patient eats something containing glucose, these autoantibodies are released and attack the epithelial lining of the intestines, resulting in inflammation. • The inflammation is mainly in the small intestine, mainly the jejenum. • It results in villous atrophy and crypt hypertrophy. • All of this results in malabsorption. Coeliac disease – presentation • May be asymptomatic • Failure to thrive in children • Diarrhoea • Fatigue • Weight loss • Mouth ulcers • Anaemia – iron, folate or B12 deficiency • Dermatitis herpetiformis (itchy skin rash)Coeliac disease - investigations • FBC, U&Es, LFTs, TFTs, faecalcalprotectin • Auto-antibodies: • Tissue transglutaminase antibodies(anti-TTG) • Endomysial antibodies (EMAs) • Deaminated gliadin peptides antibodies (anti-DGPs) • What is the main point to remember with these tests? • If the patient has IgA deficiency, these antibodies will be low and could result in a false negative. Therefore you need to make sure to test for total IgA first to rule out IgAdeficiency. If there is an IgA deficiency you should test for the IgG version of the antibodies or proceed with biopsies on endoscopy. • Endoscopy with intestinal biopsy • What did we say you would find on this? Villous atrophy and crypt hypertrophy • What other condition should you make sure to test for? • Type 1 diabetes mellitus • What advice should you give patients when you want to investigate for Coeliac disease? • The patient should be consuming gluten for at least 6 weeks before having this test, this is because when on a gluten free diet, you may not find anyantibodies or inflammation to confirm the diagnosis.Coeliac disease • Type 1 Diabetes • Thyroid disease associated • Autoimmune hepatitis autoimmune • Primary biliary cirrhosis conditions • Primary sclerosing cholangitis •free dietgement of coeliac disease is a lifelong gluten •(maize) free foods include rice, potatoes and corn Coeliac •hyposplenism, what would you offer them for this? • Pneumococcal vaccine with a booster every 5 years disease – management • Complications if this condition if left untreated: • Vitamin deficiency and • Anaemia • Osteoporosis complications • Ulcerative jejunitis • Enteropathy associated T cell lymphoma of the intestines • Non-hodgkins lymphoma • Small bowel adenocarcinomaIrritable Bowel Syndrome (IBS) • Known as a functional bowel disorder meaning the bowel is normal but is functioning abnormally. • For thisreasonit is a diagnosis of exclusion you want to rule out any organic disease before you diagnose IBS!!!IBS - Symptoms • Diarrhoea • Constipation • Fluctuating bowel habit • Abdominal pain • Bloating • Worse after eating • Improved by opening bowels What signs and symptoms would make you consider a different diagnosis? female with IBS symptoms e.g. IBS - Diagnosis bloating is ovarian cancer!!! • What investigations would you like to do any why? • Normal FBC, ESR, CRP - signs of anaemia, infection, inflammation, etc. • TSH – thyroid dysfunction can affect bowel habits • Faecalcalprotectin– rule our IBD • Coeliac serology (Anti-TTG antibodies) – rule out coeliac disease • IF cancer suspected rule it outIBS – medical management • Medications: st • 1 line: • Loperamide – diarrhoea • Laxatives (EXCEPT LACTULOSE – causes bloating)– constipation • Antispasmodics (e.g. hyoscine butylbromide) cramps • 2 line: • Tricyclic antidepressantg. amitryptinline • 3 line: • SSRIs • Some patients may benefit from CBT to help with the psychosocial impact of IBS • Lifestyle modifications: • Drinking good amounts of fluids • Small regular meals IBS – lifestyle • Less processed foods management • Reduced caffeine • Reduced alcohol • Low FODMAP diet • Trial probiotic supplements for 4 weeksProgress questions A 23 yearold femalepresents to gastroenterology clinic with a three month history of unintentional weight loss and Question 1 diarrhea. She is referredfora colonoscopy which showed: • Transmural granulomatous • Deep ulceration of the terminalileum and colon inflammation – Crohn’s associated with skip lesions disease Biopsy showed: • Transmural granulomatous inflammation • 1 line management of acute flare of Crohn’s is steroids! What is the most appropriate management option to induce remission: 1. Azathioprine 2. Infliximab 3. Mesalazine 4. Methotrexate 5. PrednisoloneQuestion 2 Which of the following is associated with ulcerative colitis? • All of these are signs of Crohn’s disease exceptfortheesions affecting entire GI tract pseudopolyps 2.Granulomas 3.Skip lesions 4.Pseudopolyps 5.TransmurainflammationQuestion 3 A 32 year old female with coeliac disease is presenting to clinic to discuss her management. • Patients with coeliac disease have a risk of functional Which of the following will be part of the hyposplenism so they are recommendations? recommended to receive 1. Pertussis vaccine pneumococcal infection. • Calprotectin is used forgut 2. Pneumococcal vaccine inflammation – IBD 3. Five yearly FBC and ferritin levels • FOB test is if there is concern 4. Annual stool checks for blood of colorectal cancer 5. Annual stool checks for calprotectinQuestion 4 A 23 year old male presents with a 3 month history of diarrhea. For the past 5 days these symptoms have worsened and he has even noticed some blood in his stools. He also • Diverticulitis and colorectal describes a sensation of not fully being able to empty his cancer less likely due to age bowels. On examination, he has some tenderness of the lower left quadrant. Which of the following most likely • Crohn’s is a differential explains his symptoms? however ulcerative colitis is more likely to present with blood in the stools 1. Diverticulitis • The patient has had 2. Colorectal cancer symptomsformonths so 3. Crohn’s disease infective diarrhoea is unlikely 4. Infective diarrhea 5. Ulcerative colitis as this would be more acuteQuestion 5 A 26 year old femalepresents with bloating and diarrhea. Her friend suggested a gluten free diet which she foundhas significantly improved her symptoms. Investigations were performed to diagnose coeliac disease however • Both serology and these were negative. inflammation may be normal What is the most likely cause of this negative result? in coeliac patients when they are on a gluten free diet, 1. Falsenegative, needs to be repeated immediately therefore, to confirm the 2. Patientunlikely to have coeliac disease,consider alternative diagnosis you want them to diagnosis. have been eating gluten for 3. The test isn’t sensitive enough so the patient needs to be at least 6 weeks referred for small bowel biopsy. 4. Patients needto eat gluten for2 weeksat least before testing 5. Patients need to eat gluten for 6 weeks at least before testingQuestion 6 A 21 year old man presents with weight loss, bloating, diarrhea and on-and-off abdominal pain. Investigations reveal a positive IgA anti-TTG • the gold standard for coeliacis disease – perform this if you antibody result. suspect coeliac following Which of the following will confirm the diagnosis? serology 1. Abdominal ultrasound scan • Anti-TTG antibodies are a lot endomysial, you wouldn’t be 2. Capsule endoscopy able to diagnose coeliac based 3. IgA anti-endomysial antibodies on anti-endomysial 4. Ileal biopsy • Ileal biopsy is used for Crohn’s • In Coeliac the jejunum and 5. Jejunal biopsy duodenum would show villous but the ileum may be normaly giving false negativeQuestion 7 A 36 year old female presents for a review of her Crohn’s disease. She is to be started on maintenance therapy, the doctor decides she needs to be started on maintenance st therapy. • 1 line in maintaining remission in Crohn’s disease Which of the following drugs is the most appropriate to of the following is prescribe? Azathioprine 1. Azathioprine 2. Budesonide 3. Mesalazine 4. Methotrexate 5. Oral glucocorticoidsQuestion 8 A 32 year old female presents with intermittent abdominal cramps. Her bowel habits alternative from constipation to Diarrhea but no blood or mucus. There is no weight loss or relevant family history. Abdominal examination was normal. • Faecalcalprotectin negative Investigations showedNormal IgA anti-TTG, CRP, ESR, calcium, and makes UC and Crohn’s less thyroid function. likely Stool microscopy and fecal calprotectin werelso normal. • Negative anti-TTG serology What is the most likely diagnosis? makes Coeliac unlikely 1. Irritable bowel syndrome • PID unlikely as no history of 2. Ulcerative colitis gynae symptoms/infection 3. Pelvic inflammatory disease 4. Coeliac disease 5. Crohn’s diseaseOSCE stuff • Histories – examples of presenting complaints could be • Change in bowel habit • Abdominal pain • Blood/mucus in stools • Oscestop – how to take common gastro histories • https://oscestop.com/Abdomen_histories.pdf • Abdominal examination • Make sure to mention peripheral signs and what they indicate e.g. oral ulceration may suggest IBD • Explanation stations: • Usual format that we explained in our previous slides • IBS is a good one to practice as it has a combination of lifestyle and medical management, also make sure to reassure the patient that there is no underlying pathology! • Data interpretation: • Abdominal X-rays- https://geekymedics.com/abdominal-x-ray-interpretation/ Zerotofinals Geeky medics Resources Passmed Quesmed NHS website