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92 Cards in this Set

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What is the definition of gastroesophageal reflux disease (GORD)?
Symptoms or mucosal damage (oesophagitis) resulting from exposure of the distal oesophagus to reflux of gastric contents. Symptoms must occur at least weekly.
What is the incidence of gastroesophageal reflux disease (weekly)?
10-20% of adults on a weekly basis.
What alarm symptoms might you elicit on the history in a patient with gastroesophageal reflux disease?
- Dysphagia.
- Painful swallowing.
- Haematemesis.
- Weight loss.
- New symptoms in > 50 year old.
- Not responding to PPI therapy.
- Long standing symptoms.
- History of Barrett's oesophagus.
What investigations can be done for suspected gastroesophageal reflux disease?
Upper endoscopy (gastroscopy) with biopsy for urease test for Helicobacter Pylori and tissue biopsies for dysplasia.
What are the aims of management of gastsroesophageal reflux disease?
- Relieving symptoms.
- Improving quality of life.
- Healing oesophagitis.
- Reducing risk of serious complications.
What lifestyle modifications are recommended in managing gastroesophageal reflux disease?
- Avoiding provocative foods (spicy/acidic).
- Avoiding bending over and lifting.
- Small meals.
- Not eating late at night.
- Minimising alcohol.
- Elevating head of bed.
- Weight loss.
- Cease smoking.
What can be surgically done for gastroesophageal reflux disease?
Laparoscopic fundoplication for resistant or severe disease.
What complications may occur with gastroesophageal reflux disease?
- Stricture and dysphagia.
- Ulcerative eosophagitis.
- Barrett's oesophagus (progress to adenocarcinoma).
What is Barrett's oesophagus?
The metaplasia of stratified squamous cells into columnar cells. These columnar cells are at risk of changing into adenocarcinoma.
What percentage of GORD patients get Barrett's oesophagus?
1.5-5%.
What investigations are done for suspected Barrett's oesophagus?
Endoscopic surveillance, biopsy and surgical referral if needed.
What is the definition of constipation?
Constipation is the difficult passage of hard bowel motions, which may be the same or less frequent as usual.
What is the definition of haemorrhoids?
Dilated blood vessels within the internal haemorrhoid venous plexus of the lower rectum.
How many degrees of severity are there for haemorrhoids?
1st to 4th degree haemorrhoids.
What is the definition of an anal fissure?
Crack or tear in the skin of the anus extending down the canal.
What is a perianal haematoma?
A purple tender swelling at the external anal margin caused by rupture of an external haemorrhoidal vein.
What aspects of the history needs to be elicited in a patient presenting with PR bleeding and constipation?
- Recent onset vs long history.
- Drug therapy that may contribute to constipation (TCA, opiates).
- Family history of bowel cancer.
- Bowel motion history - usual or change for the patient.
- Type of bleeding - streak vs blot on paper, in toilet, malaena.
- Pain: when and how severe.
- Diet/fluids/alcohol/exercise history.
- Differences in history between haemorrhoids, fissure, and haematoma.
What examinations can be done for constipation?
- Abdominal examination.
- PR.
- Proctoscopy.
What investigations can be done for constipation?
Sigmoidoscopy vs colonoscopy.
What are the principles of management of constipation?
- Exclude sinister causes.
- Exclude faecal impaction by always doing PR.
- Short term laxatives orally or PR (softeners vs motility agents).
- Increase fluids and exercise.
- High fibre diet and fibre supplements.
- Avoid medications that cause constipation (or if these medications are needed, then prescribe a laxative at the same time).
- Avoid long term use of stimulant laxatives.
What are some of the alarm/red flag symptoms for constipation that you need to look out for?
- New constipation after 40 years of age.
- Rectal bleeding.
- Family history of bowel cancer.
What management steps can be taken for haemorrhoids?
- Treat constipation.
- Topical creams and suppositories.
- Injecting vs banding vs surgical excision.
What management steps can be taken for anal fissures?
- Treat constipation.
- Topical nitrates and local anaesthetics.
- Surgical management.
What management steps can be taken for perianal haematoma?
- Treat constipation.
- Observation and sitz bath.
- Incision and drainage.
Colorectal cancer is the ___ most common cause of cancer death.
Colorectal cancer is the 2nd most common cause of cancer death.

Lung cancer is 1st.
Colorectal cancer is the ___ most common internal cancer in Australia.
Colorectal cancer is the 1st most common internal cancer in Australia.

It's only outnumbered by skin cancer.
What percentage of the population are likely to develop colorectal cancer?
5%.
Who are at high risk of colorectal cancer?
Family history cluster with 3 or more of the following:
- CRC
- FAP
- HNPCC
- IBD with > 8 years duration.
Who are at above-average risk of colorectal cancer?
Family history of:
- CRC in one relative <55 years of age.
- CRC in two relatives at any age.
- Past resection of CRC.
- Adenomatous polyps.
Who are at average risk of colorectal cancer?
- All people above the age of 50.
- Family history of 1 relative above the age of 55.
How frequently should high and above average risk for CRC patients have a colonoscopy?
Every 2-5 years.

Just FOBT population screening for average risk.
Traditional colonoscopy has been proposed as a 'screening test'. What are its advantages?
- Gold standard.
- Can visualise and remove or biopsy lesions.
Traditional colonoscopy has been proposed as a 'screening test'. What are its disadvantages?
- High cost.
- Limited access.
- Rectal lesions can be missed (must do PR).
- Sedation required.
- Bowel preparation.
- Risk of need for transfusion 1:500.
- Risk of perforation 1:1000.
- Risk of death 1:10,000.
What are the advantages of Faecal Occult Blood Testing (FOBT)?
- 33% reduction in death from CRC with yearly FOBT (USA).
- Newer tests require no dietary modification.
- Very sensitive for colonic bleeding.
- Simple.
- Can be performed at home.
What are the disadvantages of Faecal Occult Blood Testing (FOBT)?
- Not funded by government until 2007.
- Cost is $32 a patient.
- Bleeding may occur from other lesions (not specific).
- Anxiety with positive test.
What are the advantages of CT colonography (Virtual colonoscopy)?
- More acceptable to patients.
- No sedation.
- Less invasive.
- 'Newer' technology.
What are the disadvantages of CT colonography (Virtual colonoscopy)?
- Restricted funding by medicare.
- High x-ray exposure.
- Bowel preparation still needed.
- Tube inserted into anus to insufflate air.
- Can't biopsy or retrieve polyps.
- 27% need to proceed to traditional colonoscopy.
- Specialised hardware (16 detector spiral CT) software and specially trained radiologists are required.
Irritable Bowel Syndrome is a diagnosis of exclusion. What other diagnoses need to be ruled out first?
- CRC.
- Diverticular disease.
- IBD.
- Coeliac's disease.
- Lactose intolerance.
What is the peak age of irritable bowel syndrome?
30-50 years old.
What sex is irritable bowel syndrome more common in?
Females.
What symptoms can occur with irritable bowel syndrome?
- Abdominal pain.
- Bloating and distension.
- Wind.
- Change and urge to defecate.
- Diarrhoea or constipation or alternating.
What alarm/red flag symptoms and investigations do you need to consider before you can make a diagnosis of irritable bowel syndrome?
- Weight loss.
- New symptoms with age >40 years old.
- Rectal bleeding.
- Family history of CRC or IBD.
- Anaemia.
- Elevated ESR/CRP.
Irritable bowel syndrome is a common sequel of ______ in 25% of patients.
Irritable bowel syndrome is a common sequel of gastroenteritis in 25% of patients.
The pathological mechanism underlying irritable bowel syndrome is believed to involve...
Altered gut sensitivity and nerve plexus hyperactivity.

Small bowel overgrowth of bacteria is proposed as one possible etiology.
What is the pain from IBS usually due to?
- Dysmotility.
- Gaseous distention of the small bowel.
Management of irritable bowel syndrome involves what?
- Exclude other causes based on history, examination and investigations.
- Dietary high fibre and supplements (useful in both diarrhoea and constipation).
- Antispasmodics for cramping pain (colofac, buscopan).
- TCA in low dose alters nerve hyperactivity (can constipate).
- 5HT4 partial agonists act on coeliac plexus (only useful in women with constipation predominant form of IBS and no safety data exists beyond 8 weeks).
- SSRIs (sertraline) often has diarrhoea as a side effect but can treat constipation predominant IBS.
- Complementary therapies.
What are names of two antispasmodics often used to treat cramping pain in IBS?
- Colofac.
- Buscopan.
How is TCA supposed to treat IBS?
- Alters nerve hyperactivity.
- Can help reduce diarrhoeal symptoms (but shouldn't use for constipation-predominant IBS).
What complementary/alternative therapies exist for treating irritable bowel syndrome?
- Peppermint oil, ginger, aloe vera juice.
- Chinese herbal therapies.
- Probiotics (lactobacillus).
- Hypnotherapy.
- Relaxation therapy.
- Stress management.
What further investigations can be done for suspected haemochromatosis?
- FBE/UEC/LFT.
- Liver ultrasound scan.
- Referral to gastroenterologist.
- Liver biopsy if age at diagnosis > 50 years old or ferritin > 1000.
What is the treatment for hereditary haemochromatosis?
- Education and family genetic tracing.
- Low iron diet - avoid supplements with iron, avoid fortified cereals and fortified milk/juice, avoid vitamin C with meals.
- Education and information support - refer to haemachromatosis society.
- Venesections of 500ml weekly until ferritin < 50 (250mg of iron removed for each 500mL blood) - may take 6 months to 3 years.
- Maintenance venesection every 1-6 months titrated against keeping ferritin < 50 and second yearly liver USS to exclude hepatoma.
What are the potential complications of hereditary haemachromatosis?
- Liver cirrhosis and liver cancer (rion in liver).
- Impotence and low testosterone (iron in pituitary).
- Cardiac arrhythmias and failure (iron in heart).
- NIDDM (iron in pancreas).
- Arthritis (uncertain aetiology).
What is the definition of colonic diverticular disease?
The combination of increased intraluminal pressure and weakness in the muscle coat of the colon results in the mucosa bulging through the muscle and causing a 'pocket' (diverticula). It is associated with low fibre western diets leading to constipation.
What is the difference between diverticulosis and diverticulitis?
Diverticulosis - asymptomatic diverticula.

Diverticulitis - symptomatic infection of diverticula.
On examination, what do you need to do for suspected colonic diverticular disease?
- Vital signs - HR, BP, Temp.
- Abdominal exam and PR.
- May be febrile and tender on PR.
- Mass may be palpable in LIF.
- May have tenderness, guarding and rigidity in LIF.
What investigations are done for suspected colonic diverticular disease?
Investigations (if symptomatic):
- Stool culture - may be mucous, blood and pus.
- FBE showing high WCC.
- Abdominal CT scan.
- Barium enema.
- Sigmoidoscopy.
- Colonoscopy.
What might the stool culture have present in diverticular disease?
- Blood.
- Mucous.
- Pus.
What might the FBE show in diverticulitis?
High WCC.
How long do you need to wait to wait after treatment of acute diverticulitis before you can use barium enema, sigmoidoscopy or colonoscopy?
6 weeks (risks if earlier).
What is the treatment and prevention of diverticulitis?
- Prevention when well includes high fibre diet and avoiding constipation.
- Investigate with FBE and CT scan (if not done previously).
- Treat out of hospital with oral fluids and rest gut, oral antibiotics, including amoxycillin and metronidazole, analgesia.
- Treat in hospital if severe or not settling with nil by mouth, IV fluids and antibiotics, analgesia.
- May require percutaneous drainage of abscess or bowel resection if not settling in hospital or complications occur like bleeding or perforation.
At present, what percentage of bowel cancers are detected early?
40%.
What are the screening tests for colon cancer?
- FOBT.
- Colonoscopy
- Micro-camera colonoscopy.
- CT 'Virtual' colonoscopy.
How effective is FOBT in screening for bowel cancer? (How many preventions per 1000 people per year).

How does it compare with breast and cervical cancer screening?
Results suggest that a bowel cancer screening program
using FOBT has the potential to save three lives from death
from bowel cancer in 1 year per 1000 people tested. This
is better than existing cancer screening programs; with one life saved from breast cancer per year for 1000 women undergoing breast screening, and one life saved from cervical cancer per 1000 women screened by Pap testing
over 35 years.
What should you prescribe for GORD?
4 week course of PPI will control symptoms and heal gastro-oesophageal lesions.

Oesophagitis healing rate average about 75% after 4 weeks of therapy.
What could you do for patients with predominant symptoms of heartburn or acid regurgitation (but no alarm symptoms)?
- Likely to have GORD and empirical PPI might be done.
- If failed with 4 week PPI therapy, test-and-treat for Helicobacter.
If a patient at high risk of gastric ulcers requires an NSAID, what should be done?
Use one of the following in conjunction with the NSAID:
- PPI.
- Double dose H2 antagonist.
- Misoprostol.
What gastrointestinal side effects might misoprostol have?
Diarrhoea and nausea.
After an initial 4–8 week course of a standard-dose PPI regime effectively treats GORD, what needs to be done?
Treatment is to be 'stepped down'to the minimum dose that maintains symptom control.
What are the options for 'stepping down' PPI therapy after treating an acute case of GORD?
- Low dose maintenance therapy.
- Intermittent, symptom driven use.
- Step-Off PPI.
What lifestyle interventions can reduce GORD?
- Raise head of the bed.
- Avoid exacerbating foods.
- Lose weight.
- Stop smoking.
What is the only advantage that esomeprazole has over other PPIs?
Produced slightly higher healing rates with patients with erosive oesophagitis. That's it.
What is the test-and-treat approach to people who present with dyspepsia?
Patient is given a non-invasive test for helicobacter pylori.

Those who test positive receive eradication treatment while uninfected people receive a trial of a standard-dose PPI or H2 antagonist.

People whose symptoms persist can then be referred for
specialist management.
What are the non-invasive tests available for helicobacter pylori in general practice?
- Urea breath test.
- Faecal antigen test.
- Serology.
What are the indications for immediate endoscopy for suspected upper
gastro-intestinal cancers in new patients with dyspepsia?
- Difficulty or pain on swallowing.
- Recurrent vomiting.
- Unexplained weight loss.
- Upper abdominal mass.
- Evidence of GI bleeding.
- Age > 45.
What is the potential disadvantages of the test-and-treat strategy to dyspepsia?
- Development of resistance with wider use of eradication therapy.
- Complications such as pseudomembranous colitis.
What are the potential advantages of the test-and-treat strategy to dyspepsia?
- Achieving symptom resolution in a small proportion of people with non-ulcer dyspepsia.
- Removing a risk factor for future peptic ulcer disease and gastric cancer.
- Preventing gastric mucosal changes that may predispose to cancer in long-term PPI users infected with H. pylori.
When is the test and treat approach for H.pylori appropriate?
When the patient has ALL the following criteria:
- Adult patient < 45 years presenting to primary care.
— Uninvestigated dyspepsia lasting > 4 weeks.
— No alarm symptoms
— the patient is not using NSAIDs
— gastro-oesophageal reflux disease (GORD) has been excluded by symptomatology.
Which patients SHOULDN'T have their PPI stepped down after 4-8 weeks of therapy for GORD?
Patients with severe oesophagitis, scleroderma,
strictures or Barrett’s oesophagus.
What drugs are known to cause or worsen reflux disease?
- Anticholinergic drugs.
- Aspirin.
- Bisphosphonates.
- Calcium channel blockers.
- Conventional NSAIDs.
- Corticosteroids.
- COX-2 selective NSAIDs.
- Dopaminergic drugs.
- Nitrates.
- Tetracycline.
- Theophylline.
Lifestyle changes may be a useful adjunct in managing the symptoms of GORD and offer general health benefits. Such advice might include what?
- Avoiding food that provokes reflux symptoms (e.g. fatty food, spicy food, acidic drinks, coffee).
- Reducing weight (if overweight or obese).
— Stopping smoking.
— Moderating alcohol intake.
— Avoiding late, large meals.
— Elevating the bed head (may be beneficial for marked nocturnal symptoms).
What are the potential side effects of using PPIs?
PPIs are generally very safe
drugs, with a low incidence of side effects, but there does seem to be an increased risk of intestinal infections, the rare case
of interstitial nephritis and, in the case of lansoprazole, a risk of microscopic colitis.
What percentage of GORD patients will have normal endoscopy?
About 50%.
What are symptoms that are highly specific for GORD?
- Heartburn (rising burning sensation behind the breastbone).
- Regurgitation (often precipitated by certain foods like coffee, fat)
- Recumbency.
What is the risk of Barrett's changes for a patient who's GORD symptoms have been present 1-5 years, and a ptient who's GORD symptoms have been present for 10 years?
The risk of Barrett’s changes is increased threefold if the symptoms have been present for 1-5 years, and almost sevenfold if symptoms have been present for more than
10 years.
What drugs may decrease the lower oesophageal sphincter tone?
Calcium channel blockers.
TCAs.
H. pylori infection increases the risk of developing reflux oesophagitis. True or false?
False.
H. pylori infection does not increase the risk of
developing reflux oesophagitis.
Who has a greater risk of complications of surgery and local recurrence? A patient with a colonic tumour or a patient with a rectal tumour?
Patient with rectal tumour.
What age should patients start getting regular FOBT tests and how frequently?
It is recommended that people aged 50 years and over have
faecal occult blood tests (FOBT) at least every 2 years.
What changes to the diet can be done to prevent CRC?
- Restrict energy intake.
- 5 portions per day.
- Reduce dietary fat.
- Lots of vegetables and fruit.
- Lots of fibre.
- Lots of calcium.
How long does CRC surgery generally last?
1-4 hours.
How long would a post-operative patient for CRC need to stay in hospital?
5-10 days. Sometimes up to 2 weeks.
Afte surgery, most patients will be 'off work' for how long?
6 weeks. Also, 8 weeks before vigorous physical labour can be undertaken.