Master CPS - Gastroenterology/Nutrition
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Core Concepts
Gastroenterology covers conditions of the GI tract, liver, and pancreas. Key areas include inflammatory, functional, infectious, and neoplastic diseases. Common conditions like Gastro-Oesophageal Reflux Disease (GERD) and Peptic Ulcer Disease (PUD) often involve acid secretion and H. pylori. Inflammatory Bowel Disease (IBD) encompasses Crohn's disease (transmural inflammation, skip lesions) and Ulcerative Colitis (mucosal inflammation, continuous lesions). Irritable Bowel Syndrome (IBS) is a functional disorder. Celiac disease is an autoimmune response to gluten. Pancreatitis involves inflammation of the pancreas, commonly from gallstones or alcohol. Liver disease progresses from hepatitis to fibrosis and cirrhosis, leading to portal hypertension and hepatic decompensation. Malabsorption can result from various conditions affecting digestion or absorption. Nutritional assessment and support are crucial in many GI pathologies.
Clinical Presentation
- Abdominal Pain: Location (epigastric, RUQ, LLQ), character (burning, colicky, dull, constant), radiation. Suggests PUD, pancreatitis, biliary colic, appendicitis, diverticulitis, IBS, IBD.
- Dysphagia/Odynophagia: Difficulty/painful swallowing. Oesophageal causes (stricture, cancer, achalasia, oesophagitis).
- Nausea/Vomiting: Timing, content. Gastritis, obstruction, pancreatitis, infections.
- GI Bleeding: Haematemesis (UGIB), Melaena (UGIB/small bowel), Haematochezia (LGIB).
- Altered Bowel Habit: Diarrhoea (acute/chronic, fatty/bloody), Constipation. IBD, IBS, infection, malabsorption, cancer.
- Jaundice: Yellow skin/sclera. Pre-hepatic, hepatic, post-hepatic causes of hyperbilirubinemia.
- Weight Loss: Unexplained. Malignancy, malabsorption, IBD, hyperthyroidism.
- Systemic: Fever, fatigue, malaise, signs of malnutrition (cachexia, oedema), signs of liver failure (ascites, encephalopathy, spider naevi, palmar erythema).
Diagnosis (Gold Standard)
- GERD: Clinical diagnosis; Endoscopy if alarm symptoms, refractory, or pre-surgical assessment.
- Peptic Ulcer Disease (PUD): Oesophago-Gastro-Duodenoscopy (OGD) with biopsy for H. pylori.
- H. pylori: Urea breath test, stool antigen test, or biopsy urease test (CLO test) during OGD.
- Inflammatory Bowel Disease (IBD): Colonoscopy with biopsies (for characteristic histological features).
- Celiac Disease: Serology (Tissue Transglutaminase IgA, Total IgA) followed by Duodenal biopsy.
- Acute Pancreatitis: Clinical presentation + Lipase/Amylase >3x upper limit of normal. CT for severity/complications.
- Gallstones: Ultrasound abdomen. MRCP for suspected Common Bile Duct (CBD) stones.
- Hepatitis: Serology (viral hepatitis), LFTs. Liver biopsy for definitive staging/diagnosis of some chronic liver diseases.
- Cirrhosis: Clinical, LFTs, imaging (USS, Fibroscan), liver biopsy (definitive).
- Malabsorption: Faecal elastase (pancreatic insufficiency), stool fat, specific serologies/biopsies (e.g., Celiac).
- Acute GI Bleed: OGD for UGIB, Colonoscopy for LGIB.
Management (First Line)
- GERD: Lifestyle modifications (diet, weight loss, avoid triggers), Proton Pump Inhibitors (PPIs).
- PUD: PPIs. If H. pylori positive, eradication therapy (PPI + two antibiotics).
- IBD (Acute Flare): Oral/IV Corticosteroids.
- IBD (Maintenance): 5-Aminosalicylates (UC), Immunomodulators (Azathioprine, Methotrexate), Biologics (anti-TNF, etc.).
- Irritable Bowel Syndrome (IBS): Dietary modifications (FODMAPs), lifestyle advice, antispasmodics, laxatives/loperamide, tricyclic antidepressants.
- Celiac Disease: Strict lifelong gluten-free diet.
- Acute Pancreatitis: Aggressive IV fluid resuscitation, analgesia, nil per os (NPO), nutritional support (NG/NJ if prolonged), treat underlying cause (e.g., ERCP for gallstones).
- Symptomatic Gallstones: Laparoscopic cholecystectomy.
- Acute GI Bleed: ABCs, resuscitation (fluids, blood products), IV PPI (UGIB), endoscopic intervention (clipping, adrenaline, banding).
- Cirrhosis Complications: Diuretics (ascites), Lactulose/Rifaximin (encephalopathy), Non-selective Beta-blockers/Endoscopic variceal ligation (variceal bleeding prophylaxis).
Exam Red Flags
- Malignancy: Dysphagia/Odynophagia (especially new onset), unexplained weight loss, iron deficiency anaemia, persistent vomiting, palpable abdominal mass, persistent change in bowel habit (>6 weeks, particularly >40-60 years), new-onset PR bleeding (>40-50 years).
- Acute Abdomen: Severe, sudden onset abdominal pain; peritonism (guarding, rigidity, rebound tenderness); absent bowel sounds; hemodynamic instability; fever; raised inflammatory markers. Suggests perforation, peritonitis, ischaemic bowel, severe appendicitis/diverticulitis.
- Severe GI Bleeding: Hemodynamic instability (tachycardia, hypotension, pallor), large volume haematemesis or melaena, syncope/dizziness.
- Acute Liver Failure: Jaundice, coagulopathy (prolonged INR), and hepatic encephalopathy.
- Severe Pancreatitis: Systemic Inflammatory Response Syndrome (SIRS) criteria, organ failure (respiratory, renal, circulatory), persistent pain despite analgesia.
- Bowel Obstruction: Colicky abdominal pain, vomiting, abdominal distension, absolute constipation, tinkling bowel sounds (early) then absent (late).
Sample Practice Questions
A 28-year-old female presents with chronic watery diarrhoea, abdominal pain, and significant weight loss over the past 6 months. She reports occasional oral aphthous ulcers and perianal skin tags. Endoscopy reveals patchy inflammation with deep ulcerations in the terminal ileum and colon, with 'skip lesions'. Biopsies show non-caseating granulomas. Which of the following is the most likely diagnosis?
A 35-year-old female presents with recurrent episodes of crampy abdominal pain, bloody diarrhea, and weight loss over the past 6 months. Colonoscopy reveals transmural inflammation with skip lesions and cobblestoning in the terminal ileum and ascending colon. Biopsies show non-caseating granulomas. What is the most appropriate initial pharmacological treatment to induce remission?
A 68-year-old female with a history of hypertension and hyperlipidaemia presents with sudden onset of severe, diffuse abdominal pain, disproportionate to physical examination findings. She also reports bloody diarrhoea. Her medical history includes an episode of atrial fibrillation for which she is on no anticoagulation. On examination, her abdomen is soft with mild tenderness, but no guarding or rebound. Laboratory tests show elevated white blood cell count and lactate. What is the most probable diagnosis?
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