Gastroenterology

Oesophagus & Dyspepsia · Stomach & Duodenum · Small Bowel & Malabsorption · Inflammatory Bowel Disease · Colon, Rectum & Anus · Liver · Biliary Tree & Pancreas · Acute GI & Abdominal Emergencies · Nutrition & Miscellaneous

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Oesophagus & Dyspepsia

Gastro-Oesophageal Reflux Disease: Investigation — poor correlation between symptoms and endoscopy appearance Indications for upper GI endoscopy:
Oesophageal Cancer — Until recent times oesophageal cancer was most commonly due to a squamous cell carcinoma but the incidence of adenocarci
Achalasia — Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ga
Drugs Causing Dyspepsia — bisphosphonates
Dyspepsia — Urgent (2-week) endoscopy referral: ALL dysphagia · upper abdominal mass consistent with stomach cancer · age ≥55 with w
Barrett's Oesophagus — Barrett's refers to the metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by
Pharyngeal Pouch — A pharyngeal pouch is a posteromedial diverticulum through Killian's dehiscence. Killian's dehiscence is a triangular ar
Dysphagia — The table below gives characteristic exam question features for conditions causing dysphagia: Causes Notes Oesophageal c
Oesophageal Disorders — The table below lists a small group of oesophageal disorders that are not covered elsewhere in the notes. Disorder Notes

Stomach & Duodenum

Pernicious Anaemia: Investigation — Investigation
Helicobacter Pylori — Helicobacter pylori is a Gram negative bacteria associated with a variety of gastrointestinal problems, principally pept
Gastric Cancer — There are 700,000 new cases of gastric cancer worldwide each year. Epidemiology
Helicobacter Pylori: Tests — Urea breath test
Zollinger-Ellison Syndrome — Zollinger-Ellison syndrome is condition characterised by excessive levels of gastrin, usually from a gastrin secreting t
Gastric MALT Lymphoma — associated with H. pylori infection in 95% of cases

Small Bowel & Malabsorption

Whipple's Disease — Whipple's disease is a rare multi-system disorder caused by Tropheryma whippelii infection. It is more common in those w
Coeliac Disease: Investigation — Coeliac disease is caused by sensitivity to the protein gluten. Repeated exposure leads to villous atrophy which in turn
Carcinoid Tumours — Carcinoid syndrome
Gastrointestinal Physiology: Enzymes — Amylase is present in saliva and pancreatic secretions. It breaks starch down into sugar The following brush border enzy
Bile-Acid Malabsorption — Bile-acid malabsorption is a cause of chronic diarrhoea. This may be primary, due to an excessive production of bile aci
Coeliac Disease — Coeliac disease is an autoimmune condition caused by sensitivity to the protein gluten. It is thought to affect around 1
Jejunal Villous Atrophy — Whilst coeliac disease is the classic cause of jejunal villous atrophy there are a number of other causes you need to be
Bacterial Overgrowth: Investigation — The gold standard investigation of bacterial overgrowth is small bowel aspiration and culture Other possible investigati
HLA-DQ2 — Coeliac disease has a strong association with HLA-DQ2 (present in 95% of patients) The correct answer is 2. This man is
Malabsorption — Malabsorption is characterised by diarrhoea, steatorrhoea and weight loss. Causes may be broadly divided into intestinal
HLA DQ2/DQ8 — HLA-DQ2 and/or DQ8 are present in almost all patients with coeliac disease
Coeliac Disease: Management — Management is a lifelong gluten-free diet. Gluten-containing cereals to avoid include:
Small Bowel Bacterial Overgrowth Syndrome — Small bowel bacterial overgrowth syndrome (SBBOS) is a disorder characterised by excessive amounts of bacteria in the sm
Villous Adenoma — Villous adenomas are colonic polyps with the potential for malignant transformation. They characteristically secrete lar

Inflammatory Bowel Disease

Ulcerative Colitis: Management — Severity: mild <4 stools/day ±little blood · moderate 4–6/day, no systemic upset · severe >6 bloody stools/day + systemi
Crohn's Disease: Investigation — Crohn's disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be see
Crohn's Disease: Management — General: strongly advise smoking cessation (smoking aggravates Crohn's).
Aminosalicylate Drugs — 5-aminosalicyclic acid (5-ASA) is released in the colon and is not absorbed. It acts locally as an anti-inflammatory. Th
Ulcerative Colitis — Ulcerative colitis (UC) is a form of inflammatory bowel disease. Inflammation always starts at rectum (hence it is the m
Inflammatory Bowel Disease: Key Differences — The two main types of inflammatory bowel disease are Crohn's disease and Ulcerative colitis. They have many similarities
Ulcerative Colitis: Colorectal Cancer — risk of colorectal cancer is significantly higher than that of the general population although studies report widely var
Crohn's Disease — Crohn's disease is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be see

Colon, Rectum & Anus

Colorectal Cancer: Genetics — It is currently thought there are three types of colon cancer:
Melanosis Coli — Melanosis coli is a disorder of pigmentation of the bowel wall. Histology demonstrates pigment-laden macrophages It is a
Laxatives — Laxatives are one of the most commonly prescribed medicines in clinical practice. It should of course be remembered that
Peutz-Jeghers Syndrome — Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous hamartomatous polyps in the gastroin
Angiodysplasia — Angiodysplasia is a vascular deformity of the gastrointestinal tract which predisposes to bleeding and iron deficiency a
Anal Fissure — Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less
Skin Disorders Associated with Malignancy — Paraneoplastic syndromes associated with internal malignancies: Skin disorder Associated malignancies Acanthosis nigrica
Colorectal Cancer: Referral Guidelines — NICE updated their referral guidelines in 2015. The following patients should be referred urgently (i.e. within 2 weeks)
Irritable Bowel Syndrome — NICE published clinical guidelines on the diagnosis and management of irritable bowel syndrome (IBS) in 2008 The diagnos
Angiodysplasia — Angiodysplasia is a vascular deformity of the gastrointestinal tract which predisposes to bleeding and iron deficiency a
Colorectal Cancer: Screening — most cancers develop from adenomatous polyps. Screening for colorectal cancer has been shown to reduce mortality by 16%
Irritable Bowel Syndrome: Management — The management of irritable bowel syndrome (IBS) is often difficult and varies considerably between patients. NICE updat
Colorectal Cancer — Colorectal cancer is the third most common type of cancer in the UK and the second most cause of cancer deaths. Annually
Ischaemia to the Lower Gastrointestinal Tract — Ischaemia to the lower gastrointestinal tract can result in a variety of clinical conditions. Whilst there is no standar
Common Features in Bowel Ischaemia — Common predisposing factors

Liver

Wilson's Disease — Wilson's disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues.
Non-Alcoholic Fatty Liver Disease — Non-alcoholic fatty liver disease (NAFLD) is now the most common cause of liver disease in the developed world. It is la
Drug-Induced Liver Disease — Drug-induced liver disease is generally divided into hepatocellular, cholestatic or mixed. There is however considerable
Haemochromatosis: Investigation and Management — Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. It
Haemochromatosis: Features — Haemochromatosis is an autosomal recessive disorder of iron absorption and metabolism resulting in iron accumulation. It
Autoimmune Hepatitis — Autoimmune hepatitis is condition of unknown aetiology which is most commonly seen in young females. Recognised associat
Hepatocellular Carcinoma — Hepatocellular carcinoma (HCC) is the third most common cause of cancer worldwide. Chronic hepatitis B is the most commo
Ferritin — Ferritin is an intracellular protein that binds iron and stores it to be released in a controlled fashion at sites where
Pregnancy: Jaundice — Intrahepatic cholestasis of pregnancy Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis) occurs
Ischaemic Hepatitis — Ischaemic hepatitis is a diffuse hepatic injury resulting from acute hypoperfusion (sometimes known as 'shock liver'). I
Budd-Chiari Syndrome — Budd-Chiari syndrome, or hepatic vein thrombosis, is usually seen in the context of underlying haematological disease or
Pyogenic Liver Abscess — The most common organisms found in pyogenic liver abscesses are Staphylococcus aureus in children and Escherichia coli i
Gilbert's Syndrome — Gilbert's syndrome is an autosomal recessive* condition of defective bilirubin conjugation due to a deficiency of UDP gl
Hepatitis B Serology — Interpreting hepatitis B serology is a dying art form which still occurs at regular intervals in medical exams. It is im
Liver Cirrhosis — Liver cirrhosis remains a significant problem in the developed world, account for 60,000 deaths in the UK each year. Cau
Dubin-Johnson Syndrome — Dubin-Johnson syndrome is a benign autosomal recessive disorder resulting in hyperbilirubinaemia (conjugated, therefore
Acute Liver Failure — Acute liver failure describes the rapid onset of hepatocellular dysfunction leading to a variety of systemic complicatio
Scoring Systems for Liver Cirrhosis — For many years the Child-Pugh classification was used to classify the severity of liver cirrhosis. However, in recent ye
Hepatic Encephalopathy — Hepatic encephalopathy may be seen in liver disease of any cause. The aetiology is not fully understood but is thought t
Hepatitis B and Pregnancy — all pregnant women are offered screening for hepatitis B
Alcoholic Ketoacidosis — Alcoholic ketoacidosis is a non-diabetic euglycaemic form of ketoacidosis. It occurs in people who regularly drink large
Hepatosplenomegaly — Causes of hepatosplenomegaly
Liver Biopsy — Contraindications to percutaneous liver biopsy
Coagulopathy of Liver Disease — In liver failure all clotting factors are low, except for factor VIII which is paradoxically supra-normal. This is becau
Hepatitis D — Hepatitis D is a single stranded RNA virus that is transmitted parenterally. It is an incomplete RNA virus that requires
Alcoholic Liver Disease — The STOPAH study (see reference) compared the two common treatments for alcoholic hepatitis, pentoxyphylline and prednis
Hepatomegaly — Common causes of hepatomegaly

Biliary Tree & Pancreas

Primary Biliary Cholangitis: Features — Primary biliary cholangitis (previously referred to as primary biliary cirrhosis) is a chronic liver disorder typically
Acute Pancreatitis: Causes — Vast majority of UK cases: gallstones and alcohol.
Primary Biliary Cholangitis — Primary biliary cholangitis (previously referred to as primary biliary cirrhosis) is a chronic liver disorder typically
Pancreatic Cancer: Features — Pancreatic cancer is often diagnosed late as it tends to present in a non-specific way. Over 80% of pancreatic tumours a
Chronic Pancreatitis — Chronic pancreatitis is an inflammatory condition which can ultimately affect both the exocrine and endocrine functions
Gallstones — Up to 24% of women and 12% of men may have gallstones. Of these up to 30% may develop local infection and cholecystitis.
Hepatorenal Syndrome: Management — The management of hepatorenal syndrome (HRS) is notoriously difficult. The ideal treatment is liver transplantation but
HIV: Biliary and Pancreatic Disease — The most common cause of biliary disease in patients with HIV is sclerosing cholangitis due to infections such as CMV,
Cholangiocarcinoma — Features - persistent biliary colic symptoms - associated with anorexia, jaundice and weight loss - a palpable mass in t
Primary Sclerosing Cholangitis — Primary sclerosing cholangitis is a biliary disease of unknown aetiology characterised by inflammation and fibrosis of i
Chronic Pancreatitis — Chronic pancreatitis is an inflammatory condition which can ultimately affect both the exocrine and endocrine functions
Pancreatic Cancer — Pancreatic cancer is often diagnosed late as it tends to present in a non-specific way. Over 80% of pancreatic tumours a
Ascending Cholangitis — Ascending cholangitis is a bacterial infection of the biliary tree. The most common predisposing factor is gallstones. C
Post-Cholecystectomy Syndrome — Post-cholecystectomy syndrome is a recognised complication of cholecystectomies. Typically symptoms of dyspepsia, vomiti
Management of Pancreatitis — Diagnosis: amylase ≥3× normal (false +/− occur); serum lipase more sensitive & specific, longer half-life; amylase does

Acute GI & Abdominal Emergencies

Clostridium Difficile — Clostridium difficile is a Gram positive rod often encountered in hospital practice. It produces an exotoxin which cause
Acute Appendicitis — Acute appendicitis is the most common acute abdominal condition requiring surgery. It can occur at any age but is most c
Acute Upper Gastrointestinal Bleeding — Risk assessment: Blatchford score at first assessment · full Rockall score after endoscopy (NICE CG141) · Blatchford 0 →
Upper Gastrointestinal Bleeding — Patients may present with the following:
Trauma Management — The cornerstone of trauma management is embodied in the principles of ATLS. Following trauma there is a trimodal death d
Variceal Haemorrhage — Acute variceal bleeding: resuscitate first (ABC, two wide-bore cannulae) · transfuse red cells using a restrictive thres
Spontaneous Bacterial Peritonitis — SBP: peritonitis in ascites secondary to cirrhosis.

Nutrition & Miscellaneous

MLH1 (30%) — Patients with HNPCC are also at a higher risk of other cancers, with endometrial cancer being the next most common assoc
Enteral Feeding — Identify patients as malnourished or at risk (see below)
ESR/CRP — coeliac disease screen (tissue transglutaminase antibodies)
Food Energy — Food energy is expressed in calories (kcal). Per unit weight, fat contains roughly twice the energy of protein or carboh
Obesity: Bariatric Surgery — The use of bariatric surgery in the management of obesity has developed significantly over the past decade.
Refeeding Syndrome — Refeeding syndrome describes the metabolic abnormalities which occur on feeding a person following a period of starvatio
Energy From Food — The amount of energy that may be derived from 1 gram of food is as follows:
Complications Following Renal Transplant — Renal transplantation is widely practised. The commonest technical related complications are related to the ureteric ana
Hb DNA — Hepatitis B DNA titre Anti-HBs Anti Hepatitis B surface antibody Anti-HBc IgM Anti Hepatitis B core antibody Anti-HD IgM
Hb DNA — positive Anti HBs negative Anti HBc IgM positive Anti HD IgM negative Bloods: Today HBs Ag positive HBe Ag positive HB D
Total Parenteral Nutrition — Commonly used in nutritionally compromised surgical patients
Apache II >8 — Glasgow score of 3 or more
Crp>150 — 48 hours after admission
CRP >150 — Persisting or progressive organ failure Table adapted from UK guidelines for management of acute pancreatitis. GUT 2005,
Malnutrition — Malnutrition is an important consequence of and contributor to chronic disease. It is clearly a complex and multifactori