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TESTE DEIN WISSEN
What are the primary investigations for Chronic Pancreatitis 
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  • LFTs: abnormal if co-existent liver disease; AST>ALT suggests alcoholic liver disease
  • HbA1c: islet cell destruction results in reduced endocrine function 
  • Transabdominal ultrasound: advised by NICE as the first-line imaging modality [3]. The pancreas may appear atrophic, calcified, or fibrotic   
  • CT abdomen: if ultrasound is suggestive, CT should be conducted and may demonstrate: Pancreatic calcifications (80% sensitivity and 85% specificity)
  • Pancreatic atrophy 
  • Duct dilatation
Lösung ausblenden
TESTE DEIN WISSEN

What types of infections can give you diarrhoea?

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TESTE DEIN WISSEN

Gastroenteritis which can be caused by:

1. Virus e.g. Rotavirus (common in young children & self-limiting within 1 week)


2. Parasites 

such as giardia, entamoeba, cyclospora, and cryptosporium will cause a prolonged diarrhoea for >14 days usually with/without vomiting


3. Cholera presents with profuse watery diarrhoea with or without abdominal pain or fever

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TESTE DEIN WISSEN

Describe the symptoms of UC and Crohn's 

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UC 

Abdominal, pain, bloody diarrhoea, mucus, weight loss


Crohn's

Abdominal pain, usually non-bloody diarrhoea, significant weight loss, aphthous ulcers

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TESTE DEIN WISSEN
What is the Modified Glasgow Score in acute pancreatitis?
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TESTE DEIN WISSEN
The modified Glasgow score is used to guide whether the patient may require high-dependency care based on the severity of their pancreatitis [3]. Patients with a score of 3 points or more within the first 48 hours should be considered for referral to high-dependency care.


P
pO2
<8kPa
A
Age
>55 years
N
Neutrophils
WCC >15x109/L
C
Calcium
<2mmol/L
R
Renal function
Urea >16mmol/L
E
Enzymes
AST >200U/L OR LDH >600U/L
A
Albumin
<32g/L
S
Sugar
Blood glucose >10mmol/L

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TESTE DEIN WISSEN

What are the presenting signs and symptoms of IBS

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TESTE DEIN WISSEN

Abdominal Pain

Bloating

Change in Bowel Habit



Make the diagnosis of IBS if a person has abdominal pain which is:


  • Relieved by defecation, and/or
  • Associated with altered stool frequency (diarrhoea or constipation), and/or
  • Associated with altered stool form or appearance (hard, lumpy, loose, or watery); and there are at least two of the following:
  • Altered stool passage (straining, urgency, or incomplete evacuation).
  • Abdominal bloating, distension, or hardness
  • Symptoms worsened by eating
  • Passage of mucus and alternative conditions with similar symptoms have been excluded
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TESTE DEIN WISSEN

How do we invesetigate IBS 

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TESTE DEIN WISSEN

IBS is a diagnosis of exclusion, there is no specific investigation to confirm the diagnosis.


As per NICE CKS (2020), the following investigations may be considered to exclude an alternative diagnosis:

  • Full blood count (FBC)
  • Inflammatory markers: ESR and CRP
  • Coeliac serology
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TESTE DEIN WISSEN

What is ulcerative colitis (UC)?

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TESTE DEIN WISSEN

Ulcerative colitis (UC) is a form of inflammatory bowel disease (IBD). UC most commonly affects the rectum (proctitis) and involves inflammation of the rectum which extends proximally to affect a variable length of continuous colon. It never spreads proximally beyond the ileocaecal valve and is, therefore, confined to the large bowel. It does not affect the anus.

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TESTE DEIN WISSEN
How is Coelic Disease managed?
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TESTE DEIN WISSEN
  • Gluten free diet
  • Dietary Supplements - Iron, Vitamin D & Calcium deficient
  • Dietician input: 
    • Patients may be offered input regarding their diet and risks associated with non-compliance with dietary measures
  • Vaccinations: 
    • Due to functional hyposplenism, coeliac patients are at risk of pneumococcal infection so should all be offered vaccination, with a booster every 5 years [9]; influenza vaccination is offered on an individual basis
  • Refer to a specialist: 
    • If symptoms persist despite a gluten-free diet or significant extra-intestinal manifestations, the patient may require referral to a gastroenterologist
Lösung ausblenden
TESTE DEIN WISSEN
What is acute pancreatitis 
Lösung anzeigen
TESTE DEIN WISSEN
Acute pancreatitis occurs due to inflammation of the pancreas and has a variety of different causes


Iatrogenic 

Gallstones
Ethanol Abuse 
Trauma 

Scorpion and spider bites (rare, e.g. Tityus trinatis scorpion in Trinidad)
Mumps Virus
Autoimmune
Steroids
Hypercalcaemia, hyperlipidaemia
ERCP (also other procedures e.g. gastric surgery)
Drugs (e.g. valproate, azathioprine, thiazide diure

Lösung ausblenden
TESTE DEIN WISSEN
What is Coelic Disease?
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TESTE DEIN WISSEN
Coeliac disease is a systemic autoimmune disorder that affects the small intestine and is triggered by the ingestion of gluten peptides found in wheat, barley, rye and other related grains.
Lösung ausblenden
TESTE DEIN WISSEN
How should we investigate coelic disease
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TESTE DEIN WISSEN
If possible, patients should be on a gluten-containing diet for 6 weeks prior to investigations


First line  - tTG-igA test

Second line - Endomysial antibodies (IgA): 
  • Second-line serological test and performed if anti-tTG is weakly positive 
Lösung ausblenden
TESTE DEIN WISSEN
How do we investigate acute pancreatitis?
Lösung anzeigen
TESTE DEIN WISSEN
Acute pancreatitis can be diagnosed when 2 out of the following 3 criteria are met [8]:
  • Clinical features are consistent with pancreatitis (e.g. classical-sounding pain)
  • Elevation of serum amylase OR serum lipase (at 3x the upper limit of normal); these are diagnostic (not prognostic) factors
  • Radiological features are consistent with pancreatitis (e.g. inflammation on CT)


Primary diagnostic investigations:
  • Serum amylase: amylase rises faster than lipase but also normalises faster; less specific than lipase; is not of prognostic value
  • Serum lipase: more specific for acute pancreatitis; levels rise slower than amylase but have a longer half-life. Amylase is tested more frequently in the UK


Primary investigations for severity scoring:
  • FBC: white blood cell count is required for severity scoring
  • U&Es: renal function is required for severity scoring 
  • LFTs: required for severity scoring [4]; an ALT of >150 U/L has an 95% positive predictive value for gallstone-related pancreatitis
  • Arterial blood gas: arterial pO2 and lactate are required for severity scoring
  • Serum glucose: glucose levels are required for severity scoring
  • Serum LDH: required for severity scoring (if AST is not available)
  • Serum calcium: calcium levels are required for severity scoring and identifying significant hypocalcaemia 

Investigations to consider: 
  • Chest X-ray: to assess for the development of ARDS, as well as pleural effusions
  • Abdominal X-ray: to exclude bowel obstruction, as the clinical picture can overlap 
  • Abdominal ultrasound: to identify gallstones as an underlying cause or evidence of duct dilatation
  • CT abdomen: a contrast-enhanced CT is not ordered routinely for diagnosisFeatures include local oedema and swelling, whilst non-enhancing areas suggest pancreatic necrosis
  • A CT scan to assess for complications or severity should ideally be performed at 72-96 hours from symptom onset as CT is often inconclusive if performed within 24-48 hours
Lösung ausblenden
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Q:
What are the primary investigations for Chronic Pancreatitis 
A:
  • LFTs: abnormal if co-existent liver disease; AST>ALT suggests alcoholic liver disease
  • HbA1c: islet cell destruction results in reduced endocrine function 
  • Transabdominal ultrasound: advised by NICE as the first-line imaging modality [3]. The pancreas may appear atrophic, calcified, or fibrotic   
  • CT abdomen: if ultrasound is suggestive, CT should be conducted and may demonstrate: Pancreatic calcifications (80% sensitivity and 85% specificity)
  • Pancreatic atrophy 
  • Duct dilatation
Q:

What types of infections can give you diarrhoea?

A:

Gastroenteritis which can be caused by:

1. Virus e.g. Rotavirus (common in young children & self-limiting within 1 week)


2. Parasites 

such as giardia, entamoeba, cyclospora, and cryptosporium will cause a prolonged diarrhoea for >14 days usually with/without vomiting


3. Cholera presents with profuse watery diarrhoea with or without abdominal pain or fever

Q:

Describe the symptoms of UC and Crohn's 

A:

UC 

Abdominal, pain, bloody diarrhoea, mucus, weight loss


Crohn's

Abdominal pain, usually non-bloody diarrhoea, significant weight loss, aphthous ulcers

Q:
What is the Modified Glasgow Score in acute pancreatitis?
A:
The modified Glasgow score is used to guide whether the patient may require high-dependency care based on the severity of their pancreatitis [3]. Patients with a score of 3 points or more within the first 48 hours should be considered for referral to high-dependency care.


P
pO2
<8kPa
A
Age
>55 years
N
Neutrophils
WCC >15x109/L
C
Calcium
<2mmol/L
R
Renal function
Urea >16mmol/L
E
Enzymes
AST >200U/L OR LDH >600U/L
A
Albumin
<32g/L
S
Sugar
Blood glucose >10mmol/L

Q:

What are the presenting signs and symptoms of IBS

A:

Abdominal Pain

Bloating

Change in Bowel Habit



Make the diagnosis of IBS if a person has abdominal pain which is:


  • Relieved by defecation, and/or
  • Associated with altered stool frequency (diarrhoea or constipation), and/or
  • Associated with altered stool form or appearance (hard, lumpy, loose, or watery); and there are at least two of the following:
  • Altered stool passage (straining, urgency, or incomplete evacuation).
  • Abdominal bloating, distension, or hardness
  • Symptoms worsened by eating
  • Passage of mucus and alternative conditions with similar symptoms have been excluded
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Q:

How do we invesetigate IBS 

A:

IBS is a diagnosis of exclusion, there is no specific investigation to confirm the diagnosis.


As per NICE CKS (2020), the following investigations may be considered to exclude an alternative diagnosis:

  • Full blood count (FBC)
  • Inflammatory markers: ESR and CRP
  • Coeliac serology
Q:

What is ulcerative colitis (UC)?

A:

Ulcerative colitis (UC) is a form of inflammatory bowel disease (IBD). UC most commonly affects the rectum (proctitis) and involves inflammation of the rectum which extends proximally to affect a variable length of continuous colon. It never spreads proximally beyond the ileocaecal valve and is, therefore, confined to the large bowel. It does not affect the anus.

Q:
How is Coelic Disease managed?
A:
  • Gluten free diet
  • Dietary Supplements - Iron, Vitamin D & Calcium deficient
  • Dietician input: 
    • Patients may be offered input regarding their diet and risks associated with non-compliance with dietary measures
  • Vaccinations: 
    • Due to functional hyposplenism, coeliac patients are at risk of pneumococcal infection so should all be offered vaccination, with a booster every 5 years [9]; influenza vaccination is offered on an individual basis
  • Refer to a specialist: 
    • If symptoms persist despite a gluten-free diet or significant extra-intestinal manifestations, the patient may require referral to a gastroenterologist
Q:
What is acute pancreatitis 
A:
Acute pancreatitis occurs due to inflammation of the pancreas and has a variety of different causes


Iatrogenic 

Gallstones
Ethanol Abuse 
Trauma 

Scorpion and spider bites (rare, e.g. Tityus trinatis scorpion in Trinidad)
Mumps Virus
Autoimmune
Steroids
Hypercalcaemia, hyperlipidaemia
ERCP (also other procedures e.g. gastric surgery)
Drugs (e.g. valproate, azathioprine, thiazide diure

Q:
What is Coelic Disease?
A:
Coeliac disease is a systemic autoimmune disorder that affects the small intestine and is triggered by the ingestion of gluten peptides found in wheat, barley, rye and other related grains.
Q:
How should we investigate coelic disease
A:
If possible, patients should be on a gluten-containing diet for 6 weeks prior to investigations


First line  - tTG-igA test

Second line - Endomysial antibodies (IgA): 
  • Second-line serological test and performed if anti-tTG is weakly positive 
Q:
How do we investigate acute pancreatitis?
A:
Acute pancreatitis can be diagnosed when 2 out of the following 3 criteria are met [8]:
  • Clinical features are consistent with pancreatitis (e.g. classical-sounding pain)
  • Elevation of serum amylase OR serum lipase (at 3x the upper limit of normal); these are diagnostic (not prognostic) factors
  • Radiological features are consistent with pancreatitis (e.g. inflammation on CT)


Primary diagnostic investigations:
  • Serum amylase: amylase rises faster than lipase but also normalises faster; less specific than lipase; is not of prognostic value
  • Serum lipase: more specific for acute pancreatitis; levels rise slower than amylase but have a longer half-life. Amylase is tested more frequently in the UK


Primary investigations for severity scoring:
  • FBC: white blood cell count is required for severity scoring
  • U&Es: renal function is required for severity scoring 
  • LFTs: required for severity scoring [4]; an ALT of >150 U/L has an 95% positive predictive value for gallstone-related pancreatitis
  • Arterial blood gas: arterial pO2 and lactate are required for severity scoring
  • Serum glucose: glucose levels are required for severity scoring
  • Serum LDH: required for severity scoring (if AST is not available)
  • Serum calcium: calcium levels are required for severity scoring and identifying significant hypocalcaemia 

Investigations to consider: 
  • Chest X-ray: to assess for the development of ARDS, as well as pleural effusions
  • Abdominal X-ray: to exclude bowel obstruction, as the clinical picture can overlap 
  • Abdominal ultrasound: to identify gallstones as an underlying cause or evidence of duct dilatation
  • CT abdomen: a contrast-enhanced CT is not ordered routinely for diagnosisFeatures include local oedema and swelling, whilst non-enhancing areas suggest pancreatic necrosis
  • A CT scan to assess for complications or severity should ideally be performed at 72-96 hours from symptom onset as CT is often inconclusive if performed within 24-48 hours
GASTRO - ABDOMINAL PAIN

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