Chapter_03.

indd 35

Chapter Three The Gastrointestinal System

MAP 3.1 Causes of Regional Abdominal Pain 36

MAP 3.2 Causes of Gastrointestinal (GI) Bleeding 37

MAP 3.3 Causes of Gastrointestinal (GI) Inflammation  38

MAP 3.4 Causes of Gastrointestinal (GI) Malabsorption 41

MAP 3.5 Gastro-Oesophageal Reflux Disease (GORD) 42

MAP 3.6 Jaundice 44

MAP 3.7 Hepatitis Virus 46

MAP 3.8 Colorectal Cancer (CRC) 48

MAP 3.9 Pancreatitis 50

TABLE 3.1 Microbiology of the Gastrointestinal (GI) Tract 52

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35 The Gastrointestinal System

Chapter_03.indd 36

36 The Gastrointestinal System Map 3.1 Causes of Regional Abdominal Pain

Right hypochondriac Epigastric region Left hypochondriac Left lumbar region

region • Heartburn. region • Kidney stones.
• Pancreatitis. • Pancreatitis. • Pancreatitis. • Urinary tract infection.
• Ulcer (gastric). • Epigastric hernia. • Ulcer (gastric or duodenal). • Constipation.
• Gallstones. • Gallstones. • Inflammatory bowel disease
• Biliary colic. • Ulcer (gastric). (IBD).
• Diverticular disease.

Umbilical region
Right lumbar region
• Gastric ulcer.
• Early stages of appendicitis.
• Kidney stones.
MAP 3.1 Causes of Regional Abdominal Pain • Aortic aneurysm.
• Urinary tract infection.
• Ruptured aortic aneurysm.
• Constipation.
• Pancreatitis.
• IBD.

Right iliac region Hypogastric region Left iliac region

• Appendicitis. • Urinary tract infection. • Diverticular disease.
• Ectopic pregnancy. • Appendicitis. • IBD.
• Ovarian torsion. • IBD. • Ectopic pregnancy.
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• Inguinal or femoral hernias. • Diverticular disease. • Ovarian torsion.

• Inguinal or femoral hernias.
Chapter_03.indd 37

Crohn’s disease Ulcerative colitis

Diverticulitis

Gastritis
Inflammatory bowel disease (IBD)

Peptic ulcers Haemorrhoids

Oesophageal varices

MAP 3.2 Causes of

Upper GI bleeds Lower GI bleeds
Gastrointestinal (GI) Bleeding

Polyps
Malignancy
Mallory–Weiss Malignancy
tear
Angiodysplasia

Infectious diarrhoea
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37 The Gastrointestinal System Map 3.2 Causes of Gastrointestinal (GI) Bleeding

Chapter_03.indd 38

38 The Gastrointestinal System Map 3.3 Causes of Gastrointestinal (GI) Inflammation

GASTRITIS IRRITABLE BOWEL SYNDROME (IBS)

What is gastritis? What is IBS?
This is inflammation of the stomach lining. Gastritis may be acute or chronic. This is a common functional disorder of
• Acute gastritis, caused by: the bowel.
○ Stress. ○ Uraemia. ○ Alcohol.
○ NSAIDs. ○ Burns: Curling’s ulcer.
Signs and symptoms
• Chronic gastritis: Recurrent abdominal pain, which
○ Type A:
- Autoimmune: autoantibodies are present to parietal cells. improves with defaecation; there is a
- Presents with pernicious anaemia. change in bowel habit, i.e. increased or
- Occurs in the fundus or body of the stomach. decreased frequency.
○ Type B:
- Most common. Investigations
- Associated with Helicobacter pylori infection. This is a clinical diagnosis.
Investigate for H. pylori infection:
• Bloods: anaemia and H. pylori. Treatment
• Urinalysis. • Conservative: education and avoidance
• Blood test – measures antibodies to H. pylori. of triggering factors, e.g. decrease stress.
• Carbon isotope–urea breath test. • Medical: depends on symptoms;
• Endoscopy with biopsy of stomach lining. antimuscarinics, laxatives, stool
• Stool microscopy and culture – may detect trace amounts of H. pylori. softeners, antispasmodics and
Treatment antidepressants may play a role.
• Triple therapy to eradicate H. pylori: proton pump inhibitor (PPI), with amoxicillin 1g and
clarithromycin 500 mg or metronidazole 400 mg and clarithromycin 250 mg, taken twice daily. Complications
• Step-wise approach to treating gastritis: • Depression and anxiety.
○ Mild – antacids or H2 receptor antagonists.
○ Moderate/severe – PPI.
Complications
• Peptic ulcers, anaemia (from bleeding ulcers), stricture formation, mucosa-associated lymphoid
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tissue (MALT) lymphoma.

Chapter_03.indd 39

APPENDICITIS
MAP 3.3 Causes of Gastrointestinal (GI) Inflammation
What is appendicitis?
This is inflammation of the appendix that presents with pain that can
originate in the umbilical area before migrating to the right iliac fossa.

Investigations
Diagnosis is clinical:
• Bloods: FBC, U&Es, CRP.
• Ultrasound.
• Pregnancy test in females of child bearing age to rule out ectopic
pregnancy.

Treatment
• Surgical excision.

Complications
• Peritonitis.

Inflammatory bowel disease (IBD) (Continued )

Continued overleaf
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39 The Gastrointestinal System Map 3.3 Causes of Gastrointestinal (GI) Inflammation

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40 The Gastrointestinal System Map 3.3 Causes of Gastrointestinal (GI) Inflammation

Inflammatory bowel disease (IBD) (Continued )

ULCERATIVE COLITIS CROHN’S DISEASE

What is ulcerative colitis? What is Crohn’s disease?
This is a relapsing remitting autoimmune condition that is not This is a disordered response to intestinal bacteria with transmural inflammation.
associated with granulomas. It affects the colon and rarely the It may affect any part of the gastrointestinal tract but often targets the terminal
terminal ileum (backwash ileitis). ileum. It is associated with granuloma formation.
Signs and symptoms Signs and symptoms
Remember the 5Ps: • Weight loss, abdominal pain (with palpable mass), diarrhoea, fever,
• Pyrexia. skip lesions, clubbing, cobblestone mucosa, fistula formation, fissure
• Pseudopolyps. formation and linear ulceration.
• lead Pipe radiological appearances. Investigations
• Poo (bloody diarrhoea). • Bloods: FBC and platelets, U&Es, LFTs and albumin, ESR and CRP.
• Proctitis. • Colonoscopy (with biopsy): diagnostic.
Investigations • Radiology: small bowel follow through (diagnostic) and abdominal X-ray
• These are the same as Crohn’s disease. (for toxic megacolon and excluding perforation).
Treatment Treatment
• Conservative: patient education; smoking has been shown • Conservative: smoking cessation, low residue diet may be encouraged
to be protective but is not advised. but usually diet is normal.
• Medical: corticosteroids, 5-aminosalicylic acid (5-ASA) • Medical: corticosteroids, infliximab, 5-ASA analogues (sulfasalazine),
analogues (sulfasalazine), mesalazine, 6-mercaptopurine, azathioprine, methotrexate.
azathioprine. • Surgical: remove strictured or obstructed region of bowel.
• Surgical: colectomy. Complications
Complications • Stricture formation, fistula formation, obstruction, pyoderma gangrenosum,
• Toxic megacolon, increased incidence of colon cancer, primary anaemia and osteoporosis.
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sclerosing cholangitis and osteoporosis (from steroid use).

Chapter_03.indd 41

Tropical sprue Causes A-beta-lipoproteinaemia

• Cause unknown. Remember as These • Cause: autosomal
• Can affect all of the small Definitely Cause Absorption recessive disorder.
intestine. Problems: • Results in the inability to
• Treatment: folic acid and • Tropical sprue. synthesise chylomicrons.
tetracycline. • Disaccharidase deficiency. • Treatment: vitamin E.
• Coeliac disease and Crohn’s disease.
Coeliac disease • A-beta-lipoproteinaemia.
• Cause: autoantibodies to • Pancreatic insufficiency.
gliadin.
• Proximal small intestine
mainly affected.
• Treatment: gluten-free diet.

MAP 3.4 Causes of Gastrointestinal (GI)

Malabsorption

Pancreatic insufficiency
• Cause: diseases such as
Whipple’s disease cystic fibrosis, cancer and
• Cause: Tropheryma Disaccharidase deficiency pancreatitis.
whipplei. • Cause: a deficiency in • Results in deficiency of
• This is a Gram-positive enzymes required for vitamins A, D, E, K (these
bacterium. digestion and absorption, are fat soluble vitamins).
• Treatment: antibiotics for e.g. beta-glycosidase complex. • Treatment: pancrelipase
1–2 years. • Treatment: restricted diet. (CREON®).
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41 The Gastrointestinal System Map 3.4 Causes of Gastrointestinal (GI) Malabsorption

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42 The Gastrointestinal System Map 3.5 Gastro-Oesophageal Reflux Disease (GORD)

What is GORD? Causes Investigations

This is abnormal reflux where acid from the stomach • Genetic inheritance of Age dependent:
refluxes into the oesophagus subsequently damaging angle of lower • If the patient is <55 years old:
the squamous oesophageal lining, causing discomfort. oesophageal sphincter. ○ Proceed to treatment unless
• Oesophagitis. they have ALARM symptoms,
Signs and symptoms • Sliding hiatus hernia. e.g. unintentional weight loss,
• Heartburn – pain is worse in certain positions, e.g. lying • Rolling hiatus hernia. dysphagia, haematemesis,
down/stooping and is worse after heavy meals. melaena and anorexia.
• Acid taste in mouth. Risk factors • If >55 years old:
○ Regurgitation. • Smoking. ○ Send patient to endoscopy:
• Water brash (excess salivation). • Excessive alcohol. diagnostic and allows for biopsy.
• Dysphagia. • Excessive coffee. ○ 24-h pH monitoring.
• Nocturnal asthma/chronic cough. • Obesity.
• Laryngitis. • Pregnancy.
• Drugs, e.g. calcium channel
blockers, antimuscarinics and
tricyclic antidepressants.

MAP 3.5 Gastro-Oesophageal Reflux Disease (GORD)

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Chapter_03.indd 43

Treatment Complications: Barrett’s oesophagus

• Conservative: education, weight loss, What is Barrett’s oesophagus?
raising head of bed at night and This is metaplasia of the normal squamous
avoidance of precipitating factors, e.g. smoking, epithelium of the lower oesophagus to
large meals. columnar epithelium. This occurs in patients
• Medical: who suffer with GORD for several years.
○ Antacids, e.g. aluminium hydroxide. It is a premalignant lesion.
○ H2 receptor antagonists, e.g. ranitidine.
○ Proton pump inhibitors, e.g. omeprazole. Investigations
• Surgical: Nissen’s fundoplication. • Endoscopy with biopsy in all 4 quadrants.

Treatment
• HALO® system radiofrequency ablation or
mucosal resection for highly dysplastic lesions.

Complications
• Adenocarcinoma of the oesophagus.
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43 The Gastrointestinal System Map 3.5 Gastro-Oesophageal Reflux Disease (GORD)

Chapter_03.indd 44

44 The Gastrointestinal System Map 3.6 Jaundice

What is jaundice? Treatment Investigations

Jaundice, also known as icterus, Treat the underlying cause. You must determine underlying cause.
is the yellow discolouration of Use these tests to determine the type of jaundice:
mucous membranes, sclera and skin. Complications • Appearance of urine and stool.
This happens due to the accumulation • LFTs.
of bilirubin. Jaundice may be seen at a
• Liver failure.
• Renal failure. • Bilirubin levels.
bilirubin concentration >2.5–3.0 mg/dL • Alkaline phosphatase levels.
(42.8–51.3 mmol/L).
• Sepsis.
• Pancreatitis.
• Biliary cirrhosis The different blood results for different types of jaundice:
Causes • Cholangitis Prehepatic Intrahepatic Posthepatic
The causes of jaundice • Kernicterus (a serious Investigations jaundice jaundice jaundice
may be split into 3 categories complication of
(see Table below): jaundice in neonates). Appearance of Normal Dark Dark
1 Prehepatic jaundice. urine
2 Intrahepatic jaundice. Appearance of Normal Pale Pale
3 Posthepatic jaundice. stool
Conjugated Normal ↑ ↑
bilirubin
Unconjugated Normal or ↑ ↑ Normal
bilirubin
Total bilirubin Normal or ↑ ↑ ↑
Alkaline Normal ↑ ↑
phosphatase
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Chapter_03.indd 45

MAP 3.6 Jaundice

The causes of different types of jaundice

Prehepatic jaundice Intrahepatic jaundice Posthepatic jaundice
Crigler–Najjar syndrome Viral and drug induced hepatitis Gallstones in common bile duct
Gilbert’s syndrome Alcoholic liver disease Pancreatic cancer
Haemolysis, e.g. thalassaemia, Hepatic cirrhosis Schistosomiasis
sickle cell anaemia
Drugs, e.g. rifampicin Primary biliary cirrhosis Biliary atresia
Malaria Leptospirosis Cholangiocarcinoma
Haemolytic uraemic syndrome Physiological neonatal jaundice Mirizzi’s syndrome
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45 The Gastrointestinal System Map 3.6 Jaundice

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46 The Gastrointestinal System Map 3.7 Hepatitis Virus

HEPATITIS A (HAV) HEPATITIS B (HBV)

What is HAV? What is HBV?
It is a RNA picornavirus. A partially stranded, enveloped DNA virus. It has an e-antigen that
indicates increased infectivity.
Transmission
Faecal–oral transmission, associated with contaminated shellfish. The virus Transmission
passes into bile after replication within liver cells. The immune system is • Vertical transmission.
activated by this process and leads to necrosis predominantly in zone 3 • Contaminated needles.
of the hepatic lobule. • Infected blood products.
• Sexual intercourse.
Incubation period
• 2–3 weeks. Incubation period
• 1–5 months.
Investigations
• Anti-HAV IgM in serum. Investigations
HBV DNA in serum, HBsAg, HBeAg, anti-HBc; HBsAg presents on histology
Treatment with a ‘ground glass’ appearance.
• Conservative: vaccine for travellers to endemic areas.
• Medical: supportive since HAV is often self-resolving. Treatment
• Conservative: education and prevention of disease; vaccine
Complications for at-risk groups, e.g. health workers.
• Rarely acute liver failure. • Medical: antiviral medications, e.g. pegylated alpha-2a interferon,
adefovir, entecavir, lamivudine, tenofovir, telbivudine.

Complications
MAP 3.7 Hepatitis Virus • Hepatic cirrhosis, hepatocellular carcinoma (HCC), fulminant hepatitis B.
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Chapter_03.indd 47

HEPATITIS C (HCV) HEPATITIS D (HDV) Hepatitis E (HEV)

What is HCV? What is HDV? What is HEV?
It is a single stranded, enveloped RNA virus and a member It is a single stranded defective RNA virus It is a single stranded RNA virus.
of the flavivirus family. that co-infects with hepatitis B virus.
Co-infectivity with HDV leads to Transmission
Transmission an increased chance of liver failure. • Faecal–oral transmission, associated with
• Vertical transmission (occasionally). contaminated water.
• Contaminated needles. Transmission
• Infected blood products. • Contaminated needles. Incubation period
• Infected blood products. • 2–3 weeks.
Incubation period • Sexual intercourse (rare).
• Intermediate (6–9 weeks). Investigations
Incubation period • IgG and IgM anti-HEV.
Investigations • 1–5 months.
• Antibody to HCV in the serum. Treatment
Investigations • Usually self-limiting.
Treatment • Serum IgM anti-D.
• Conservative: education and prevention of disease. Complications
• Medical: antiviral medications, e.g. pegylated alpha-2a Treatment • High mortality of pregnant women (~20%).
interferon, ribavirin, taribavirin, telaprevir. • Pegylated alpha-2a interferon.

Complications Complications
• Hepatic cirrhosis, HCC, liver failure. • Hepatic cirrhosis, HCC.
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47 The Gastrointestinal System Map 3.7 Hepatitis Virus

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48 The Gastrointestinal System Map 3.8 Colorectal Cancer (CRC)

What is CRC? Risk factors

This is cancer of the colon and rectum and is the third most common malignancy. • Smoking.
Usually adenocarcinoma on histology. • Increased age.
• Family history of CRC.
Signs and symptoms • Inflammatory bowel disease (IBD).
• Abdominal pain. • Streptococcus bovis bacteraemia.
• Unintentional weight loss. • Congenital polyposis syndromes:
• Altered bowel habit. ○ Juvenile polyposis syndrome:
• Faecal occult blood. – Autosomal dominant but it may occur spontaneously.
• Anaemia. – Not malignant.
• Fatigue. ○ Peutz–Jeghers syndrome:
– Autosomal dominant.
Causes – Increases risk of CRC.
Multifactorial and often unknown. There are risk factors that may predispose an – Melanosis is present on the oral mucosa.
individual to develop CRC (see risk factor box). • Genetic predisposition:
○ Familial adenomatous polyposis (FAP):
Investigations – Autosomal dominant.
• Bowel Cancer Screening Programme: faecal occult blood test in men and women – Mutation of APC gene on chromosome 5.
aged 60–69 years. – 100% lead to CRC.
• Bloods: FBC for iron deficiency anaemia and carcinoembryonic antigen (CEA) ○ Hereditary nonpolyposis colorectal cancer (HNPCC):
tumour marker. – Autosomal dominant.
• Endoscopy: colonoscopy/sigmoidoscopy. – Mutation of DNA mismatch repair gene.
• Imaging: double contrast barium enema study ‘apple core’ sign; virtual colonoscopy.

Treatment
Depends on the extent of disease. This is assessed using Dukes staging system or
TNM system.
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• Conservative: patient education and referral to Macmillan nurses.

Chapter_03.indd 49

• Medical: chemotherapy (oxaliplatin, folinic acid and 5-fluorouracil is the most

common regime); radiotherapy may also be used.
• Surgery: surgical resection is usually treatment of choice.

Complications
• Obstruction and metastasis.

MAP 3.8 Colorectal Cancer (CRC)

Duke’s staging system TNM system

Stage Description 5-year survival T – Carcinoma in situ
T1 – Submucosa invaded
A Confined to 90% T2 – Muscularis mucosa invaded
muscularis mucosa T3 – Tumour has invaded subserosa but other organs have not been penetrated
B Extends through 65% T4 – Adjacent organs invaded
muscularis mucosa
N1 – Metastatic spread to 1–3 regional lymph nodes
C Lymph node 30% N2 – Metastatic spread to ≥4 regional lymph nodes
involvement
M0 – No distant metastases present
D Distant metastases <10% M1 – Distant metastases present
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49 The Gastrointestinal System Map 3.8 Colorectal Cancer (CRC)

Chapter_03.indd 50

50 The Gastrointestinal System Map 3.9 Pancreatitis

MAP 3.9 Pancreatitis

ACUTE PANCREATITIS CHRONIC PANCREATITIS

What is acute pancreatitis? What is chronic pancreatitis?
This is inflammation of the pancreatic parenchyma, with This is where the structural integrity of the pancreas is
biochemical associations of increased amylase and raised lipase permanently altered as a direct result of chronic inflammation.
enzymes on blood test.
Signs and symptoms
Signs and symptoms Pain! The pain is:
Remember these as PAN: • Epigastric in origin.
• Epigastric Pain that radiates to the back. • Recurrent.
• Anorexia. • Radiates to the back.
• Nausea and vomiting. • Relieved by sitting forward.
• Grey Turner’s sign: flank bruising. • Worse when eating/drinking heavily.
• Cullen’s sign: periumbilical bruising.
Causes
Causes Remember these as CAMP:
Remember these as GET SMASHED: • Cystic fibrosis.
• Gallstones. • Alcohol.
• Ethanol. • Malnourishment.
• Trauma. • Pancreatic duct obstruction.
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Chapter_03.indd 51

• Scorpion sting (Tityus trinitatis). Investigations

• Mumps. • Decreased faecal elastase.
• Autoimmune disease. • CT scan: shows calcification (may also be seen on
• Steroids. abdominal X-ray).
• Hyperlipidaemia/Hypercalcaemia. • Magnetic resonance cholangiopancreatography (MRCP).
• Endoscopic retrograde cholangiopancreatography (ERCP).
• Drugs, e.g. azathioprine. Treatment
• Conservative: alcohol cessation.
Investigations • Medical: analgesia, e.g. tramadol and pancreatic enzyme
• Raised serum amylase and lipase. replacement therapy; start insulin therapy if diabetes has
• Detect cause, e.g. ultrasound scan to detect presence of developed.
gallstones.
• CT scan to rule out complications (not within <72 h of acute Complications
presentation unless clinically indicated). Remember these as PODS:
• Pseudocysts.
Treatment • Obstruction (pancreatic).
• This is usually symptomatic relief. Keep ‘nil by mouth’ (NBM), • Diabetes mellitus.
IV fluids and analgesia, e.g. tramadol • Steatorrhoea.
• Treat underlying causes, e.g. ERCP to remove gallstones.

Complications
Remember these as HDAMN:
• Haemorrhage.
• Disseminated intravascular coagulation (DIC).
• Acute respiratory distress syndrome (ARDS).
• Multiorgan failure.
• Necrosis.
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51 The Gastrointestinal System Map 3.9 Pancreatitis

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52 The Gastrointestinal System Table 3.1 Microbiology of the Gastrointestinal (GI) Tract

TABLE 3.1 Microbiology of the Gastrointestinal (GI) Tract

Organism Illness caused Other
Vibrio vulnificus Food poisoning Found in seafood; Gram-negative bacterium
Bacillus cereus Food poisoning Found in reheated rice; Gram-positive bacterium
Staphylococcus aureus Food poisoning Found in contaminated meat and mayonnaise; Gram-positive bacterium
Clostridium botulinum Food poisoning Found in poorly canned foods; Gram-positive bacterium
Escherichia coli O157:H7 Food poisoning and Found in meat that is undercooked; enteropathogenic E.coli causes diarrhoea in children; also
diarrhoea causes haemolytic uraemic syndrome (HUS); Gram-negative bacterium
Campylobacter jejuni Bloody diarrhoea Found in animal faeces and poultry; it is associated with Guillain–Barré syndrome, which is an
ascending paralysis; Gram-negative bacterium
Salmonella Bloody diarrhoea Found in contaminated food; Gram-negative bacterium
Shigella Bloody diarrhoea Produces shiga toxin; Gram-negative bacterium
Yersinia enterocolitica Bloody diarrhoea Associated with outbreaks in nurseries; Gram-negative bacterium
Enterotoxic Escherichia coli Traveller’s diarrhoea Traveller’s diarrhoea is usually self-limiting; Gram-negative bacterium
Vibrio cholerae Rice water diarrhoea Produces cholera toxin; Gram-negative bacterium
Cryptosporidium Cryptosporidiosis Associated with AIDS patients; protozoon
Norwalk virus Gastroenteritis Most common viral cause of nausea and vomiting
Helicobacter pylori Risk factors for peptic Produces urease; treat with ‘triple therapy’, i.e. a proton pump inhibitor (PPI) with either
ulcers, gastritis and clarithromycin and amoxicillin or clarithromycin and metronidazole; Gram-negative bacterium
gastric adenocarcinoma
Toxoplasma gondii Toxoplasmosis Cysts are found in meat or cat faeces; causes brain abscesses in AIDS patients; protozoon
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Taenia solium Intestinal tapeworms Found in undercooked pork; cestode