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 35-year-old female presents with persistent difficulty swallowing solids and liquids, progressive weight loss, and recurrent regurgitation of undigested food, particularly at night. She describes a sensation of food getting 'stuck' in her chest. Barium swallow shows a 'bird's beak' appearance of the distal esophagus. Which of the following is the most likely underlying cause of her symptoms?
A 72-year-old male with a history of atrial fibrillation on warfarin presents with melena and dizziness. His hemoglobin is 7.2 g/dL. On examination, he is pale and tachycardic. An urgent upper endoscopy reveals a bleeding duodenal ulcer. After initial resuscitation, which of the following is the most appropriate immediate endoscopic intervention?
A 28-year-old male with a history of recurrent peptic ulcers, recently diagnosed with Zollinger-Ellison syndrome, is being managed with high-dose omeprazole. He now presents with muscle weakness, polyuria, and polydipsia. Blood tests show a serum calcium of 3.1 mmol/L (normal range 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level. His initial investigations for Zollinger-Ellison syndrome included gastrin levels and a secretin stimulation test. Which of the following conditions is MOST likely to be associated with this patient's presentation?
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