GI

Cases

IBD
1. Management of flare-ups
2. Diagnosis
3. Start of biological therapies
Infective Gastroenteritis
Malabsorption
1. Elective work up
2. TPN
3. Side-effects of treatment

(Most GI long cases are surgical)

IBD

1. Infective Exacerbation

UC vs Crohns on history?

UC
o PR bleeding
o Diarrhoea (frequent & large volume)
o Bloody diarrhoea first differential always UC
o Shorter period of symptoms
Crohns
o Crampy abdominal pain, classically RIF (but can be anywhere)
o Low grade fever= quite common
o Malaise, fatigue
o Longer period of symptoms

UC
Bloody diarrhoea DDx
UC
Mesenteric Ischaemia
Infective
o E. Coli
o Campylobacter
o Salmonella
o Shigella
o Others

Bloody Diarrhoea Questions

Abdominal Pain?
 Number bowel motions per day?
Volume of bowel motions?
Blood Mixed in? On toilet paper? After bowel motion? Bright or dark?
Rectal Symptoms Tenesmus (Sense of incomplete emptying on defecation?)

Other GI Symptoms

Weight loss- QUANTIFY!! (kgs & time)

**Toxic Megacolon**

Criteria= >8 bowel motions per day

Bowel motions at night time (always organic pathology- never get with IBS)
Fevers, rigors, temperatures at home, sweating
Palpitations (tachycardia)
Abdominal distension
Anorexia & inability to oral intake (worried about dehydration)

Infective Causes

Timeline- days as opposed to weeks

Linked to ingestion of high risk food
Nausea and vomiting (much more likely to be a/w bloody diarrhoea than UC)
Riskstake away food, meat that could have been undercooked
Watery diarrhoea= a/w bacillus, usually rice and grains
Campylobacter - Pork
E.Coli Beef

Mesenteric Ischaemia
VERY SUDDEN ONSET! No warning
Redcurrant jelly stool
99% have risk factors- A. Fib= classic
Hx of PVD, MI, TIA, Stroke, hypertension, hyperlipidaemia
Mesenteric Angina

Crohns
Crampy Abdominal Pain DDx

Medical

IBD
Infective colitis
IBS (Rule out as they wont be an inpatient for a long case!)
Surgical

RIF
Appendicitis
Ovarian Cyst
Appendiceal Abscess
Appendiceal Mass e.g. Loculated Cyst
Backwash Ileitis (IBD)
Mesenteric Adenitis (usually adolescents)
TB- Appendiceal TB
Bowel Obstruction (but tends not to be localised to RIF)

LIF

Diverticulitis
Ovarian
Cancer
Obstruction
Proctitis
Rectal colitis

Diffuse Crampy Abdominal Pain

**Bowel Obstruction**
Could be Crohns, Colitis, Mesenteric Ischaemia (but all less likely to cause global)

Appendicitis Qs

Anorexia
Nausea
Fevers
Vomiting

Ovarian Qs

LMP
Hx symptoms suggestive of endometriosis (which could cause ovarian cyst)
o e.g. dysmenorrhoea, menorrhagia

Others= radiological diagnosis. Except maybe Appendiceal mass which could have swinging
fevers and other systemic symptoms like arthralgia, myalgia

Crohns Qs

Pain
Fever
 Nausea
Anorexia
Not much weight loss or diarrhoea
Other parts of GIT
o Mouth ulcers
o Upper GI- dyspepsia, waterbrash, nausea, vomiting

Risk factors for IBD

Smoking (Exacerbates Crohns, ?protective against UC)

Family history- 1st degree (siblings, parents, children)

Extra-GI manifestations

Lead in- You can get complications from your Crohns/UC in other parts of your body so Im
going to ask you questions about that (Do in any systemic disease e.g.CF)
Eyes- Dry, gritty, red eyes? Ever in past?
Joints- Ever been told arthritis in any joints?
Liver- Ever been told liver affected? (PSC with UC, Gallstones with Crohns due to terminal
ileum disease and decreased absorption of bile salts)
Coagulopathy- Both UC & Crohns (Acute flares are thromboembolic states- should have low
threshold for anticoagulation) Ever told clotting was abnormal?
Skin- Rashes now or in past?
o Erythema Nodosum- Raised, painful, nodular rash, usually seen on the shins, that
heels with bruising
o Pyoderma Gangrenosum- Purplish, ulcerated, discrete edges, target lesions
(Deepening of colour in middle, can get central necrosis. Usually lower limbs but can
occur anywhere)
Psychiatric Problems any systemic illness. DONT take a depression History! But afterwards
may be asked who else to get involved e.g. liaison psych referral
Anaemia- ever told blood count low? Or low in iron? Or low B12?

Other questions

How many admissions to hospital in last 2 years?

How many courses of steroids in the last 2 years? How many oral vs IV?
During hospital
o TPN
o NG
Surgeries?
Last scope? And where were you told the inflammation was?

Past Medical History

When diagnosed?
 Ongoing IBD
o First year- how often did you come into hospital?
o How often do you come in now?
Other complications if not asked in HPC
Malabsorption
o a/w Crohns due to terminal ileum involvement or ileal resection
o Are you taking any fat soluble vitamins like AquADEKs?
o Calcium?
o Vitamin D?
o Iron?
o B12?
o Folate?
o DEXA scan? What did it show?
Surgical History
o Which surgery each time
o Crohns
Resection with primary anastomosis
Resection with de-functioning ileostomy
Repair of fistula (of any sort)
Strictures
Repair of fissures
Adhesiolysis
Lap Chole (if gallstones)
o UC
Total or partial colectomy
Blood transfusions

Medications

Acute Flare
o Steroids IV (Hydrocortisone 200mg TDS/QDS)
o Maybe antibiotics (Broad spectrum e.g. 3rd Gen Ceph & Metronidazole)
o Steroid-sparing immunosuppressants e.g. Azathioprine, Mercaptopurine, 5-ASA
Refractory to IV steroids?
o Deteriorate on steroids Intervene immediately
o No improvement on steroids Wait 72 hours and then decide on alternative
o Alternatives
Fulminant Colitis/Toxic Megacolon
Colon >6cm PFA
>8 bowel motions per day
Neutrophilic Leucocytosis
Fever
 Tachycardia
Surgically decompress Panproctocolectomy (definitive therapy)
Other option= IV Cyclosporin
TNF
o Indication= Failed steroid therapy
o Infliximab most common in IBD
o Etanercept most common in RA & Psoriatic Athropathies
o Not for Toxic Megacolon

Infliximab Qs

What do you need to do before you start it?

o Screen for TB- Mantoux, CXR reported by consultant radiologist
Commonest S/E?
o Flu-like symptoms (but without ESR & CRP)
o Reactivation TB
o Immunosuppression
o Can precipitate CCF in patients with underlying CCF

Questions for Patient

Put on Steroids?
How many days have you been on them?
On them for more than 3 days- Getting better? Consultant happy that youre starting to
improve?
Have they told you about whats going to happen next? Talked to about maybe starting a
medication called Cyclosporin? Or maybe having surgery?
Infliximab? When did you start? CXR before you started? Take once a week or every second
week? (Normally IM fortnightly)
Azathioprine?
Mercaptopurine?
How long have you been on X? Ever come off them? (May stop if in remission for long time)
Have doses increased or more therapies added in?
Vitamin K- if coagulopathy
ADEK- if malabsorption
Calcichew
Bisphosphonates
Iron
Folic Acid
3 monthly B12 injection
Nutritional Supplements
o Fortisip
o Calogen
o Ensure
o NG
 o TPN
o PEG
Elemental Diets

Other things

New stoma- How are you managing? Seen dietician?

Missed a lot of work?

Malabsorption Syndromes

Pancreatic Insufficiency
o CF
o Chronic Pancreatitis
Coeliac
Ileal
o Crohns
o Ileal resection
o Backwash ileitis

Symptoms

**Weight loss** (Quantify, timeline)

*Steatorrhoea*
o Mucous in bowel motions?
o Hard to flush?
o Foul smelling?
o Oily residue?

Pancreatic insufficiency due to CF?

o Respiratory
o Diabetes

Pancreatic insufficiency due to chronic pancreatitis?

o Chronic intractable pain (Very hard to manage)
o Usually significant alcohol history
o Therefore may have all symptoms of chronic liver disease- ascites, varices,
encephalopathy, jaundice
Coeliac
o Crampy abdominal pain (usually after ingestion of high carbohydrate meal)
o Abdominal distension (linked to eating)
o Rash Dermatitis Herpetiformis (Vesicular, occurs mainly elbows, incredibly
pruritic, usually regresses with treatment, if not can use Dapsone)
o On examination Cachexia, muscle wasting, evidence of recent weight loss,
abdominal distension, buttock atrophy
 Ileal Disease
o History of Crohns or Ileal resection (e.g. tumour, appendiceal mass)

Chronic Biliary Disease

o CF- cholestasis
o PBC
o Treatment= Ursodeoxycholic Acid (Ursofalk)

Long Case Questions for IBD

1. Criteria for Toxic Megacolon (most NB= colon >6cm on PFA/CT)

2. Different Manifestations based on different parts of bowel affected
UC Rectal/Sigmoidsymptoms bright red blood PR, tenesmus, bloody diarrhoea
(but not large volume because its from the distal colon)
Crohns Terminal IleumCrampy abdominal pain & symptoms a/w malabsorption
3. Listing extra-GI manifestations
4. Listing types of surgery that might be options
5. Complications of immunosuppression ( infections & bone marrow suppression)