1
Q
Types of h.pylori test
A
- Helicobater Pylori C13 Breath Test
- Histology (OGD and Biopsy)
- OGD and Clotest (urease produced by H. pylori hydrolyzes urea to ammonia) - Helicobacter Pylori Stool Ag
- H.pylori serology
2
Q
Preparation for H.pylori breath test preparation
A
Requires Fasting for 6 hours
no PPI for 2 weeks before test
3
Q
Indications for H.pylori
A
Indigestion
Feeling of fullness or bloating
Nausea
Belching and regurgitation
4
Q
Explain endoscopy
A
- This is a test that allows the endoscopist to look directly at the lining of the gullet (oesophagus), stomach and first part of the small intestine (duodenum).
- A slim flexible tube with a light on the end is gently passed from your mouth into your stomach.
- Pictures from the tube are shown on a TV monitor and a clear view of your gullet, stomach and duodenum can be seen.
- A small sample of tissue (biopsy) can be taken for analysis in the laboratory.
- This is removed painlessly with a tiny pair of forceps.
- Other names used for an Upper GI Endoscopy that you may hear are Oesophagogastroduodenoscopy (OGD) and Gastroscopy.
5
Q
Complication of OGD
A
- bleeding or perforation (a small hole being made) of the bowel, stomach or gut.
- aspiration pneumonia
- damage to crowned teeth or dental bridgework.
6
Q
Preparing for OGD
A
- You should not have anything to eat or drink for at least 6 hours before your test but you can have water up to four hours.
- Do take any other regular medicines up to four hours before.
- No PPI for 2 weeks
7
Q
During OGD and after OGD
A
Most people do not require sedation and have the test with their throat numbed by a local anaesthetic spray.
If you have sedation:
for the next 24 hours:
- Do not drive
- Do not return to work or operate machinery
- Do not sign any important or legal documents
- Are not left alone, you may be at risk of injuring yourself
- Are not left alone to care for children
8
Q
Explain flexible sigmoidoscopy
A
A sigmoidoscopy is a routine test to examine the lining of your sigmoid colon. This is the lower
part of your colon, also called your bowel or large intestine.
9
Q
Indication for flexible sigmoidoscopy
A
- bleeding from your anus
- pain in the lower abdomen (tummy)
- persistent diarrhoea
- changes to your bowel habits
- a strong family history of bowel cancer
- had an X-ray test and more information is needed about the lower end of your bowel
- a pre-existing condition such as colitis that needs reviewing
10
Q
Define colonoscopy
A
A colonoscopy is a procedure that uses a narrow, flexible, telescopic camera called a colonoscope to look inside your large bowel.
11
Q
Indications for colonoscopy
A
- bowel cancer, such as bleeding from your bottom or a change in your bowel habits
- You have a strong family history of bowel cancer
- Investigating symptoms of inflammatory bowel disease and monitoring your bowel if you’ve been diagnosed with these conditions.
- Monitoring your bowel if you’ve previously had a polyp or cancer removed, or
- Following another test – such as a CT scan or virtual colonography, if you need further assessment or treatment.
12
Q
What is an ERCP?
A
endoscopic retrograde cholangio
pancreatogram
- a type of x-ray and camera examination to examine and/or
treat conditions of the biliary system
13
Q
How long does ERCP take & do you need sedation?
A
- Need sedation
- 15- 75 mins
14
Q
Indication of ERCP
A
- obstructive jaundice (jaundice caused by a
blockage in the bile drainage system). - It is sometimes used to help remove pancreatic stones
- to put a stent into a narrowed pancreatic duct
15
Q
What is laparoscopy?
A
- This procedure is also known as keyhole surgery or minimally invasive surgery.
- This is a small tube that has a light source and a camera, which relays images of the inside of the abdomen or pelvis to a television monitor.
16
Q
During laparoscopy
A
Done under GA
17
Q
Complications of laparoscopy
A
- infection
- minor bleeding and bruising around the incision
- feeling sick and vomiting
- damage to organ
18
Q
Indication for laparoscopy
A
- Appendicitis
- cholecystectomy
- GI cancer: liver, pancreas, gallbladder
- hernial repair
removing section of crohn’s disease - bleeding ulcer
19
Q
What is SeHCAT study?
A
A SeHCAT study investigates how well the body absorbs bile salts.
20
Q
Procedure of SeHCAT study
A
- swallow capsule:
synthetic bile salt with a small amount of radioactive tracer called Selenium (75Se). - Gamma camera takes photos.
- A set of pictures is taken which allow the computer program to analyse the images and
measure the radioactivity.
21
Q
Indications of SeHCAT
A
- Chronic diarrhoea
- suspected symptoms of bile acid malabsorption (BAM
22
Q
What is high resolution oseophageal manometry + 24 hour pH monitoring?
A
measures the pressure activity within the oesophagus and the sphincters
- The multi-pressure sensor catheter (tube) has sensors situated at 1cm intervals and allows for measurement along the entire length of the oesophagus and sphincters at each end simultaneously
- A 24 hour pH monitoring measures the amount of acid coming up (refluxing) into the oesophagus from the stomach over a 24 hour period. This allows us to establish whether your symptoms are due to acid reflux.
23
Q
Indications for oseophageal manometry
A
- evaluation of non-obstructive dysphagia
- peristaltic reserve prior to anti-reflux surgery
- symptoms of regurgitation and non-cardiac chest pain
24
Q
What is barium swallow & meal?
A
- involves drinking a white liquid called barium and then having X-rays taken.
- The barium coats the inside of your throat, oesophagus (the pipe that goes from your mouth to your stomach), stomach and small bowel.
- A barium swallow test looks at your throat and oesophagus.
- A barium meal looks at your oesophagus, stomach and the first part of your bowel.
25
indications for barium swallow
1. Cancer of the head and neck, pharynx, or esophagus
2. Hiatal hernia.
3. Structural problems, such as pouches (diverticula), narrowing (strictures), or growths (polyps)
4. Enlarged veins (esophageal varices)
5. Muscle disorders, such as difficulty swallowing (dysphagia) or spasms
6. Achalasia
7. Gastroesophageal reflux disease (GERD) and ulcers
26
What is barium enema?
1. X-ray of the lower gastrointestinal (GI) tract.
2. The large intestine, including the rectum, is made visible on X-ray film by filling the colon with a liquid suspension called barium sulfate (barium).
3. highlights the large bowel
27
Indications for barium enema
1. Ulcerative colitis.
2. Ulcerations and inflammation of the large intestine.
4.Crohn's disease. ...
Obstructions and polyps (growths)
5. Cancer.
6. Unusual bloating or lower abdominal pain.
7. Unexplained weight loss.
8. Irritable bowel syndrome.
9. Changes in bowel movements.
28
Investigations for large bowel obstruction
1st line = AXR
- dilated bowel > 3 cm
CT scan
29
Investigations for small bowel obstruction
1st line = AXR
Definitive = CT scan
30
Indication for liver biopsy
- alcoholic liver disease
- non-alcoholic steatohepatitis
- autoimmune hepatitis
- primary biliary cirrhosis
- primary sclerosing cholangitis
31
Investigation for Alcoholic and non alcoholic fatty liver
1. Blood tests – FBC, - plts/anaemia, INR
2. ALT, Gamma- Glutamate Glutamyl Transferase, Bilirubin, ALP, Albumin
3. Hepatitis B and C serology
4. Autoimmune conditions – Primary Biliary Cirrhosis, Primary Sclerosing Cholangitis – anti Sm AB, Anti M Ab
5. USS Abdomen
6. Fibroscan
32
gold standard for coeliac disease
Gold standard: OGD with duodenal biopsies / Endoscopic intestinal biopsy
Check the serum immunoglobulin (Ig)A tissue transglutaminase antibody (tTGA) and total IgA first-line.
- TTG: monitoring after diagnosis
33
Ix for diarrhoea
```
FBC,
Iron studies
B12/Folate
U/E’s
ESR, CRP
TFTs
Coeliac screen
```
```
Stool M C and S
Ova,cysts and parasites
Faecal calprotectin
Faecal elastase
Sigmoidoscopy
Colonoscopy
Breath test
```
34
What is AST?
- AST - Aspartate Aminotransferase
- Detect liver damage
- AST - enzyme found in heart + liver, released when injured
- To test for:
- hepatitis
- alcohol excess
- hx of liver disease in family
- drugs which affect liver
- Results:
- very high (> 10 x upper limit) = acute hepatitis
- cause by : virus or toxin/drug (paracetamol overdose)
35
ALT indicates
hepatitis
| - specific for liver injury
36
ALP indicates
Raised in cholestasis / biliary
| obstruction
37
GGT indicates
- alcohol related
| - medication damage
38
What is armamentarium?
1. Liver enzymes (AST, ALT, ALP, GGT):
- Reflect integrity of hepatocytes or bile ducts
- Do NOT reflect liver function
2. Liver function tests:
- INR (international normalized ratio / prothrombin time)
- Albumin
- *bilirubin
39
Examples of aminotranferases
AST & ALT located in hepatocyte cytosol
40
Albumin
- synthesised by liver
- Changes in albumin due to reduced
synthetic or distribution
41
Bilirubin indicates
Total bilirubin measures jaundice
- cause itch
Can indicate cholestasis or failure to
conjugate
42
Interpresting LFT
Pattern of LFTs:
1. Hepatitic (ALT or AST +++)
2. Cholestatic (ALP / GGT +++)
3. Mixed picture (ALT+ ALP+)
2. Severity of hepatitic injury:
- Mild <5x ULN
- Moderate 5-10x ULN
- Severe > 10x ULN
43
Screening test for celiac disease
Blood test for antitissue transglutaminase Ab (IgA)
44
Types of stool test
1. Faecal Elastase
2. Faecal Calprotectin
3. Quantitative Faecal Immunochemical
Test (qFIT)
45
Indication for Faecal Elastase
Elastase is a protease synthesised by the pancreatic
acinar cells and secreted into the duodenum.
1. Found in high concentrations in faeces
2. Low levels can be linked with pancreatic insufficiency
3. Allows the diagnosis or exclusion of pancreatic exocrine
insufficiency (causes include chronic pancreatitis, cystic
fibrosis, pancreatic tumour, cholelithiasis, diabetes
mellitus)
4. investigating diarrhoea of pancreatic origin (does not detect mild disease)
46
What is faecal calprotectin?
1. Calcium-binding protein
2. Inflammatory marker: derived from activated neutrophils as a
result of inflammation
3. Released into the faeces when pathology resulting in an
inflammatory process occurs in the intestine
4. Resistant to degradation in the gut
47
What conditions is it useful to do faecal calprotectin?
Measurement in faeces has high sensitivity and specificity for organic disease – can distinguish between organic and functional (eg IBS)
Raised in:
- IBD
- Bacterial infection
- colorectal and stomach cancer
- colonic polyps
- diverticula disease
48
How can faecal calprotectin be used to monitor disease?
1. used to assess disease activity
2. monitoring response
to treatment
3. help to indicate who may need a follow up
colonoscopy
49
What is Quantitative Faecal Immunochemical
| Test (qFIT)?
- Replaces the previously used faecal occult blood test (FOB)
- Used to detect occult blood in faeces as part of the colorectal screening
programme
- An abnormal result leads to a colonoscopy
50
What does perianal swab look for?
threadworm
51
When is stool sample requested?
1. TO investigate changes in bowel habit- typically diarrhoea.
2. Routine testing can include culture for Campylobacter,
Salmonella, Shigella and E.Coli 015.
3. Can request investigation for:
• Rotavirus
• Clostridium difficile
• Ova/parasites- collect 3 samples over <10 day period, no more then one within a 24 hr period.
52
Abdo USS good at ....
identifying dilated CBD
53
Abdo USS + pancreas
Poor pancreas visualization
54
CT abdo + pancreas
Visualizes pancreas well
55
MRI abodmen facts
1. No radiation
2. MRCP excellent for biliary
pathology
3. MRI liver great for liver lesions
4. Avoid if metallic implants
56
Diagnosis using ERCP
not diagnostic!
57
When is Liver biospy useful?
Useful when liver screen is negative and imaging not helpful
a) Provide diagnostic clues
b) Identify dominant pathologies when more than one could be responsible
c) Severity of a disease process - inflammation and fibrosis
58
What Ix are useful in detecting bowel cancer?
1. FIT test
2. Sigmoidoscopy
3. Double barium contrast enema is a series of X-rays of the colon and rectum. The patient is given an enema with a white, chalky solution that outlines the colon and rectum on the X-rays.
4. Colonoscopy
59
NHS Bowel cancer screening programme
1. Screening every two years to all men and women aged 60 to 74 in England using a FIT
2. 1st-degree relative has had bowel cancer : Screening should start 10 years prior to the age that relative was diagnosed to help identify possible pre-cancerous polyps.
60
Ix for diagnosis of IBD
1. Faecal calproteectin
- increased in IBD not IBS
- need further ix to confirm IBD
2. Colonoscopy:
Crohn's :
1. 'Cobble-stone appearance (skip lesions)
UC:
1. biopsy needed for diagnosis
2. appearance of polyps (pseudopolyps)
3. Abdo X-Ray:
UC : lead Pipe radiological appearance
61
When is stool culture requested?
1. Diarrhoea for several days +/- blood & mucus
| 2. Recheck after confrmed bacterial infection esp with Salmonella typhi
62
What is Clostridioides difficile and C. difficile Toxin Testing?
Test detect the presence of Clostridioides difficile or toxins produced by C. difficile in a fresh or frozen stool sample
63
When is C. difficile Testing requested?
Patient over two years old or an outpatient over 65 years old has frequent loose stools (diarrhoea) that does not have another obvious cause.
If a patient treated for antibiotic-associated diarrhoea or colitis relapses and symptoms re-emerge, C. difficile toxin testing may be requested to confirm the presence of the toxin.
64
What can be used to diagnose C-Diff colitis
An endoscopic procedure can be used to diagnose C. difficile colitis.
65
Diagnosis of IBS
Diagnosis of exclusion:
FBC
ESR/CRP
Coeliac disease screen
66
Diagnosis of constipation
PR exam
| AXR - Sitzmarks
67
Diagnosis of acute cholecystitis
LFTs typically normal
| 1st line = Abdo USS
68
Ix for chronic cholecystitis
AXR : porcelain gallbladder
69
Diagnosis of acute pancreatitis
WIthout imaging =
If characteristic pain + amylase /lipase > 3 time upper limit of normal
Imaging:
USS
Other : contrast - CT
70
Two- week Rule Clinics
History/examination – often GI investigations – OGD/colonoscopy blood tests and CT (luminal GI cancer)
Biliary/pancreatic/liver – maybe be CT/MRI
Some TWR clinics will have attached CNS, link to upper/lower GI MDT, MDT co-ordinator, pathays to capture all patients on pathway
ICM - OBS
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