1
Q
describe nutritional failure
A
- failure to meet the nutritional requirements of the individual.
- causes the development of deficiencies.
2
Q
what is malnutrition?
A
a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients, causes measurable adverse effects on tissue/body form, (body size, shape composition) body function and clinical outcome.
3
Q
discuss overnutrition
A
- over nutrition leads to obesity, which leads to longer-term problems.
- these are often hidden and only become apparent over time.
4
Q
describe undernutrition
A
- under nutrition leads to weight loss and impaired function.
- it strongly associates with illness.
5
Q
how is BMI calculated?
A
weight (kg) / height^2 (m)
6
Q
what cancers is obesity strongly linked to?
A
breast and bowel.
7
Q
what conditions occur with metabolic syndrome (caused by obesity)?
A
- hypertension.
- CVD.
- type II diabetes mellitus.
- fatty liver.
- NASH.
- cirrhosis.
8
Q
what percentage of adults (45-65 years old) are overweight or obese in the UK?
A
over 70%.
9
Q
what are the three malnutrition levels based on BMI?
A
BMI < 20 underweight
BMI < 18 physical impairment
BMI < 16 increasingly severe consequences.
10
Q
what screening tool is used when assessing patients at risk of malnutrition?
A
MUST screening tool
11
Q
what do MUST scores indicate?
A
- a score over 2 suggests a risk of undernutrition > dietary advice, oral nutrient supplements and monitor.
- score 1 > supplements and watch.
- score 0 > monitor.
12
Q
what risk factors are associated with malnutrition?
A
illness
social isolation
age
socially vulnerable groups
13
Q
what are the clinical consequences of malnutrition?
A
- impaired immune response.
- reduced muscle strength.
- impaired wound healing.
- impaired psycho-social function.
- impaired recovery from illness and surgery.
- poorer clinical outcomes.
14
Q
what are some causes of malnutrition?
A
- appetite failure: anorexia nervosa, disease related.
- access failure: teeth, stroke, cancer of head and neck, head injury, poverty.
- intestinal failure: loss of functional gut tissue > impaired digestion and absorption of nutrients.
15
Q
describe percutaneous endoscopic gastrostomy (PEG)
A
PEG is an endoscopic medical procedure in which a tube is passed into a patient’s stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate
16
Q
are food and fluid considered basic care or treatment?
A
basic care
17
Q
what is the second leading cause of cancer death in the western world?
A
colorectal cancer
18
Q
What are inheritable conditions which can cause colorectal cancer?
A
- HNPCC (5%) hereditary non-polyposis colorectal cancer.
- FAP (<1%) familial adenomatous polyposis.
- MAP (MUTYH- associated poluposis)
19
Q
what % of colorectal cancer is associated with IBD?
A
1%
20
Q
what are risk factors for sporadic cases of colorectal cancer?
A
- age
- male gender
- previous adenoma/CRC.
- diet: low fibre, low fruit and veg intake, low calcium intake, red meat, alcohol).
- obesity
- lack of exercise
- smoking
- diabetes mellitus
21
Q
the majority of colorectal cancers arise from?
A
pre-existing polyps
22
Q
describe colorectal polyps (adenomas)
A
- protuberant growths.
- benign, pre-malignant.
- epithelial in origin.
23
Q
what is the clinical presentation of colorectal cancer?
A
- rectal bleeding (especially if mixed in with stool).
- altered bowel opening to loose stools > 4 weeks.
- iron deficiency anaemia.
- palpable rectal or right lower abdominal mass.
- acute colonic obstruction if stenosing tumour.
- systemic symptoms: weight loss, anorexia.
24
Q
discuss the investigation of colorectal cancer
A
- colonoscopy (first-line): tissue biopsies can be taken, therapeutic as well as diagnostic.
- radiological imaging: barium enema, CT colonography, CT (abdo/pelvis).
25
what investigations are used to stage colorectal cancer
- CT scan chest/abdomen/pelvis.
- MRI scan for rectal tumours.
- PET scan/rectal endoscopic ultrasound in selected cases.
26
what blood test is used in the scottish bowel screening program?
faecal occult blood test (FOBT) ORIGINALLY..
now faecal immunochemical test (FIT)
27
describe familial adenomatous polyposis (FAP)
- autosomal dominant condition.
- >100 adenomas throughout colon: 50% by age 15, 95% by age 35.
- mutation of the APC gene on chromosome 5 (most commonly but can be other mutations).
28
describe HNPCC
- autosomal dominant condition.
- mutation in DNA mismatch repair genes (MMR) genes e.g. MLH1 and MSH2.
- Patients have an 80% risk of developing colorectal cancer by their 30s.
29
what is considered a positive qFIT test when sreening for colorectal cancer?
FIT >/= 10ug Hb/g
30
in scotland, who do we screen for colorectal cancer?
| and how often?
ages 50-74, every 2 years
31
why is a pre-operative MRI essential in rectal cancer?
- best imaging modality for looking at circumferential resection margins (CRM).
- restaging 6-8 weeks later following neoadjuvant treatment.
- surgery 8-10 weeks after treatment (total mesorectal excision).
32
del
del
33
what are cardinal signs and symptoms of bowel obstruction?
- abdominal pain
- vomiting
- absolute constipation (flatus and solids)
- abdominal distension
34
what % of large bowel obstructions have a malignant cause?
60%
35
what are the biggest causes of small bowel obstructions?
- adhesions
- hernias
36
what are the types of acid suppression drugs called? (not specific drug names)
anatacids:
- H2 receptor antagonists
- PPI
37
what are drugs affecting motility called?
anti-emetics
anti-muscarinics
anti-spasmodics
anti-motility
38
what drugs are used for treating IBD?
aminosalicylates
corticosteroids
immunosuppresants
biologics
39
what are drugs affecting biliary secretions called?
bile acid sequestrants
ursodeoxycholic acid (UDCA)
40
what is the role of prostaglandin (PGE2 and I2) in the GI tract?
inhibit acid
increase mucus production
41
describe the triple therapy used to treat H.pylori
PPI and two antibacterials: amoxicillin and metronidazole/clarithromycin
42
what type of drug is gaviscon and how does it work?
alginate
creates a protective reflux barrier
43
give an example of a H2-receptor antagonist, how do they work and when are they indicated?
- rantidine (given orally or IV)
- block histamine receptor thereby reducing acid secretion
- indicated in GORD/peptic ulcer disease
44
give an example of a proton pump inhibitor, how do they work and when are they indicated?
- omeprazole (oral or IV)
- irreversible inhibitor of H+-K+-ATPase.
- targets parietal cells (weak base, accumulates in parietal canaliculi).
- indicated in GORD/peptic ulcer disease (and H.pylori).
45
what are some adverse effects of omeprazole use?
C.difficile
B12 deficiency
ECL tumours
acute interstitial nephritis(CYP2C19)
46
what drugs are used to treat motion sickness?
- 'inputs' H1RA such as cyclizine and promethazine
- anti-muscarinics > hycosine
47
what drugs are used to treat pregnancy sickness?
D2 antagonists such as prochlorperazine, metoclopramide, domperidone.
48
list the different types of purgatives for treating constipation
- bulk laxatives (methylcellulose etc.) > bulky hydrated mass.
- osmotic laxatives (saline, lactulose) > poorly absorbed solutes, draws water.
- faecal softeners (docusate sodium) > surface active, weak stimulant.
49
how do stimulant purgatives work?
- increase electrolyte secretion by gut mucosa > therefore increase water secretion.
50
what is domperidone and what does it do?
- D2 antagonist
- increase motility
- increases LOS pressure (GORD), increases gastric emptying and duodenal peristalsis.
51
what does metaclopramide do?
- increases gastric motility and emptying.
52
what is loperamide and what is it used for, how does it work?
- opiate drug.
- used in treatment of diarrhoea.
- reduces smooth muscle contraction and increases anal sphincter tone.
53
what are usual concerns and contraindications in corticosteroid treatment for IBD?
- osteoporosis
- cushingoid features
- increased susceptibility to infection
- addisonian crisis with abrupt withdrawal
54
give examples of aminosalicylates?
mesalazine
olsalazine
55
adverse effects of aminosalicylates?
GI upset
blood dyscrasias
renal impairment
56
give examples of immunosuppressants used in the treatment of IBD
azathioprine
cyclosporin
6-mercaptopurine
57
how do immunosuppresant drugs like azathioprine work in IBD?
prevents formation of purines required for DNA synthesis so reduces immune cell proliferation.
58
what classification is used to allow sensible dosing in cases of hepatic impairment?
Child-Pugh classification
59
additional info on prescribing in liver disease is contained in the..
BNF
60
what are the main drug classes used in the treatment of GI disorders?
- acid suppression
- drugs affecting motility (anti-emetics; anti-muscarinics; anti-spasmodics; anti-motility).
- laxatives
- drugs for treating IBD (aminosalicylates; corticosteroids; immunosuppressants; biologics).
- drugs affecting biliary secretions.
61
what is the source and function of gastrin?
- Source: Gastrin is produced by G cells in the stomach lining.
- Function: Gastrin stimulates the secretion of gastric acid (HCl) and pepsinogen, essential for the digestion of proteins in the stomach. It also promotes gastric motility and contributes to the growth of the gastric mucosa.
62
what is the source and function of CCK?
- Source: CCK is released by I cells in the duodenal and jejunal mucosa of the small intestine.
- Function: CCK stimulates the gallbladder to release bile, which emulsifies fats for digestion. It also inhibits gastric emptying, allowing the small intestine more time to digest and absorb nutrients. CCK also acts on the pancreas, promoting the release of digestive enzymes.
63
what is the source and function of secretin?
- Source: Secretin is produced by S cells in the duodenal mucosa.
- Function: Secretin stimulates the pancreas to release bicarbonate-rich pancreatic juice, which neutralizes the acidic chyme entering the small intestine from the stomach. It also inhibits gastric acid secretion and motility.
64
what are the side-effects of drugs used to treat sickness during pregnancy (D2 agonists)?
- drowsiness.
- movement disorder.
- prolactin release.
65
what are adverse affects of immunosuppressants such as azathioprine?
- mainly related to bone marrow suppression but also azathioprine hypersensitivity and organ damage (lung, liver, pancreatitis)
66
what are the treatment options for haemorrhoids?
- treat underlying cause > constipation.
- rubber band ligation.
- surgical: HALO, anopexy, haemorrhoidectomy.
67
which one is usually painful; haemorrhoids or anal fissure?
anal fissure
68
what are the treatment options for anal fissures?
- treat underlying cause > constipation.
- GTN/diltiazem + lignocaine.
- surgical: botox, sphincterectomy.
69
what are risk factors of perianal abscess?
- DM.
- high BMI.
- immunosuppression.
- trauma.
70
what are the treatment options for a perianal abscess?
- antibiotics if septic.
- incision and drainage.
- do not go looking for fistulas.
71
what are features of a anal fistula?
- peri-anal sepsis
- persisting pus discharge with flare up
- +/- faecal soiling
72
what are the treatment options for anal fistula?
- very difficult to treat.
- surgical: 50% failure rate:
> seton- to drain sepsis/mature
tract.
> sphincter preservation
techniques.
> lay open: BEWARE women.
73
features of anal/rectal cancer?
- painful/painless
- bleeding
- indurated (hardened)
- red flag signs
- FIT test +ve
74
what is the aetiology of pelvic floor dysfunction: colorectal?
- child-birth related.
- surgery.
- perianal sepsis.
- LARS.
75
what is the most common cause of chronic constipation?
dietary cause
76
how is chronic constipation investigated?
exclusion:
- colonoscopy/CT colon.
- baseline bloods: exclude anaemia.
- symptomatic qFIT.
- coeliac serology.
- faecal calprotectin.
- detailed history including dietary.
- colonic transit studies.
- defecating proctogram.
77
what are the types of faecal incontinence?
- passive > internal sphincter defect.
- urge > rectal pathology, functional.
- mixed > prolapse.
- overflow > constipation.
78
what is the function of anal manometry?
- anal sphincter function: resting pressure, squeeze increment, duration of squeeze.
- estimation of functional length of anal canal.
- anorectal pressure responses during abrupt increases in IAB: e.g. cough.
- changes in anal pressure during defaecation.
- recto-anal inhibitory reflex (RAIR).
79
WHAT IS THE FUNCTION OF A DEFAECATING PROCTOGRAM?
- best modality to assess anatomy and dynamic function.
- provides info on:
> pelvic floor mobility.
> pathological function of the musculature.
> changed to form and axis of organs (deformation and morphology).
> compensated/decompensated function.
-> internal hernias (enterocoel).
80
what are the conservative measures for managing faecal incontinence?
- low fibre diet.
- loperamide.
- pelvic floor exercises.
- EMG if required.
- irrigation.
- anal plug.
81
what are surgical interventions for faecal incontinence?
- sphincter repair.
- correct anatomical defect.
- sacral nerve stimulator.
- anal bulking agent for passive FI: permacol, gatekeeper, sphinkeeper.
82
what is a surgical option for rectal prolapse?
if fit/active patient > rectopexy.
