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Lectures in Medicine:

Gastroenterology

Associate Professor Alex Boussioutas

Gastroenterologist

Western Hospital/Peter MacCallum Cancer Centre

[email protected]


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Outline

Terminology

Common Gastroenterological problems


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Common terminology Dyspepsia

Epigastric fullness, discomfort, vague term (indigestion)

Dysphagia

Difficulty swallowing, feeling of food sticking in oesophagus

Odynophagia

Painful swallowing usually associated with dysphagia Heartburn

Burning sensation retrosternally associated with reflux

Anorexia

Loss of appetite

Haematemesis

Vomiting blood (could be red or altered coffee ground) Melaena

Passing of black tarry, offensive stool (usually due to upper GI bleeding)

Haematochezia

Passing blood per rectum (PR bleeding)


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Common investigations


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Gastroesophageal Reflux Disease

(GERD/GORD)

Definition: Reflux of gastric contents (acid?) intooesophagus

Symptoms:

May be asymptomatic;

Heartburn +/- retrosternal chest pain

Regurgitation of gastric contents

Acidbrash, waterbrash (watery sensation in mouth)

Atypical chest pain

Nocturnal cough (exacerbation of asthma)

Dysphagia (long term symptoms)


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GERD

Mechanism GOJ incompetence

Due to transient LOS relaxation (tLOSR) (Common GERD)

Hypotensive LOS (More severe GERD)

Anatomical disturbance of LOS (Hiatus Hernia)

Epidemiology Common ~10-20% in West (5% in Asia) for weekly Sx

Exacerbated by: Obesity, caffeine, alcohol, smoking, fattymeal, medication, pregnancy (hormonal/anatomic)

Complications Barretts Oesophagus/malignancy

Ulcers/strictures


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GERD

Investigations

Endoscopy mainstay of diagnosis

Barium Meal not used much may be helpful in

diagnosis of hiatus hernia Manometry/pH studies useful to document reflux

Management

Lifestyle- Cease exacerbators, weight reduction,

posture Medication PPI, H2RAs

Surgery- Hiatus hernia repair


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Dysphagia

Swallowing disorders Dysphagia and Odynophagia

Differential Diagnoses Mechanical obstruction

Benign stricture (Schatzki ring, web, GERD)

Malignant obstruction (SCC, Adenocarcinoma)

Neurological Stroke

Achalasia

MND, Myaesthenia Gravis, Parkinsons

Functional Globus

Management Diagnosis specific and multifactorial


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Peptic Ulcer Disease

Ulceration in regions bathed with acid/pepsin Stomach, Oesophagus, Duodenum, Meckels

Symptoms

Often none Gnawing abdo pain (epigastric)

Vomiting/nausea

Complications

Haemorrhage Perforation/penetration

Gastric outlet obstruction


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Peptic Ulcer

Aetiology

Helicobacter pylori

Up to 90% ofDU and 75% of GU

NSAIDs (Non steroidal antiinflammatory drugs) Physiological stress

Mechanism

Hp infection causing gastrin release and local

inflammation

Loss of mucosal defence, mucous, prostaglandins,blood flow (NSAID)


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Peptic Ulcer

Investigation Non-invasive diagnosis of Hp

Endoscopy

BariumMeal

Management Complications

GI bleed, perforation

Healing the ulcer Eradicate Hp

Treat with PPI Prevent recurrence

Ensure eradication Hp

Longterm PPI prophylaxis if need NSAID (COX-2 selective?)


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Irritable Bowel Syndrome

Abdominal pain associated with altered stools No organic cause identifiable

Epidemiology

Very common ~10% Western population Up to 50% of visits to gastroenterology

Diagnosis Diagnostic criteria somewhat helpful

Rome III criteria Recurrent Abdo pain for 3 days in the last 3 months with 2 of:

Improvement with defecation

Onset associated with change in stool frequency

Onset associated with change in stool form


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IBS

Symptoms include

Bloating, flatus, mucous in stool

Exacerbated by stress

Investigation If typical syndrome in young (50, FHx Abnormal laboratory tests Need to exclude:

In young: Coeliac disease and IBD

In edlerly: Colorectal cancer, Coeliac disease, IBD


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IBS

Management

Supportive, Reassurance and explanation

Symptomatic

Analgaesia (antispasmodic)

Aperient,

Dietary

Psychological Counselling

Antidepressants


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Inflammatory Bowel Disease (IBD)

Crohns Disease Pathology throughout GI tract

Often skip lesions with intervening normal gut

Transmural inflammation and fistulous disease

Ulcerative Colitis Localised to the colon and rectum

Mucosal inflammation characteristic

Usually contiguous disease

Occasionally difficult to distinguish the two Indeterminate Colitis

Epidemiology Incidence in Western countries up to14/100,000

Prevalence in West up to 240/100,000


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IBD

Aetiology Probable polygenic disease

Environmental (gut infection)

Immunological

Symptoms Can be varied depending on site

Often: Diarrhea, abdominal pain, PR bleeding, PR mucous,LOW, LOA

Nutritional disorders Iron deficiency, Vitamin B12 deficiency, Folate deficiency etc

Extraintestinal manifestations Arthritis, Uveitis, Skin changes, Primary Sclerosing Cholangitis


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Crohns Disease

Medical Nutritional replacement

Oral 5-aminosalicylates Sulphasalazine, Mesalazine

Antibiotics Corticosteroids (oral/IV)

Immunomodulators Azathioprine,

Methotrexate

Anti-TNF antibodies Infliximab, Adalumimab

Experimental therapies

Surgical Resection of bowel

Abscess drainage

Fistula repair

Strictureoplasty Management

Multidisciplinary Gastroenterologist

Surgeon

Dietician Nurse

Psychologist

Radiologist


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Management Ulcerative colitis

Medical Nutritional replacement

Topical 5-ASA

Oral 5-aminosalicylates Sulphasalazine, Mesalazine

Antibiotics

Corticosteroids (oral/IV)

Immunomodulators Azathioprine, Cyclosporine

Anti-TNF antibodies Infliximab, Adalumimab

Experimental therapies

Endoscopic Surveillance for CRC

Surgical Resection of bowel

Abscess drainage

Management

Multidisciplinary Gastroenterologist

Surgeon

Dietician

Nurse

Psychologist

Radiologist


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Colorectal Cancer

Epidemiology

Second most common solid cancer globally

Risk related to Age and FHx

Genetic risk

FAP

HNPCC (Lynch Syndrome)

Other Polyposis (MUTYH, Juvenile Polyposis)

Environmental factors

Alcohol, obesity, Diabetes


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Colorectal cancer- genetic syndromes

FAP (Familial Adenomatouspolyposis) Autosomal dominant

Colonic Polyposis (classical>1000 polyps; attenuated>20-100 polyps)

Extracolonic manifestations Gastric Cancer

Duodenal and ampullarycancer

Desmoid disease

Osteoma (commonly ofmandible)

Skin lesions

Lynch Syndrome Autosomal dominant

Most common hereditary Syn

Extracolonic cancers Endometrial cancer

Gastric cancer

Ovarian Cancer Uro-epithelial cancer

Skin lesions (Muir-Torre)

Genetic testing Appropriate referral to

genetic service

Screen FHx Pregentic tests

Genetic test APC gene

MMR genes (MLH1, MSH2,MSH6, PMS2)


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Colorectal cancer - clinical

Symptoms Often none

Altered bowel habit, PR bleeding, LOW, Malaise, Irondeficiency anaemia

Investigation Colonoscopy

Barium Enema/CT colography

Management Part of MDT (Surgeon, Oncologist, Radiologist, Pathologist,

Nurse, Stomaltherapist) Resection

Surveillance


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Colorectal cancer - prevention

Primary prevention-screening Average risk

Population screening at 50 FOBT

Other variations Colonoscopy at 50; Sigmoidoscopy every 5 yrsfrom 50

Moderate risk 1r Relative with CRC 8 years Colonoscopy yearly with surveillance biopsies

High Risk FAP gene carrier

ColonoscopySigmoidoscopy at 12-15yo every 1-2yrs

Gastroscopy/Duodenoscopy

Lynch Syndrome gene carrier Colonoscopy/Gastroscopy at 25 and every 1-2 years


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Coeliac Disease

Immune mediated disease due to allergy to

dietary gluten (protein in wheat, rye, barley)

Pathology Exposure to gluten causes damage to small

intestine leading to malabsorption

Strong genetic association with HLA-DQ2 HLA-DQ8

Environmental factors important

Prevalence 1:100


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Coeliac Disease

Symptoms

GI: diarrhoea, bloating, mouth ulcers, IBS type

Anaemia, Osteoporosis, lethargy Chronic fatigue

Thyroid disease, Type 1 DM

Migraines

Infertility

Abnormal liver function Arthralgia

Asymptomatic


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Coeliac Disease

Diagnosis/Investigation

Coeliac serology Tissue Transglutaminase ab

Endoscopy with small bowel biopsy

Establish diagnosis and assess disease Therapeutic trial

Improvement on gluten free diet

Important in paediatric setting but helpful for adult

Therapy Lifelong gluten free diet

Dietician important

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