5. Colorectal Disease Flashcards
1
Q
What is an inflammatory cause of bowel urgency
A
Proctitis
2
Q
Coffee brown vomit indicator of?
A
UGIB
3
Q
Fresh red vs dark red blood in stools
A
Fresh red means more recent, severe
4
Q
What can cause Tenesmus
A
IBS or IBD- Incomplete emptying
Can be IBS or IBD- due to inflm of rectum pushing up tgt.
May be tumor- DRE to feel for lump
5
Q
Weight loss in colorectal disease likely due to
A
Inflmtn or neoplastic
6
Q
What is Thomas’ sign
A
ampullary carcinoma- steatorrhea + melena - silver stool
7
Q
Tx for IBS
A
FODMAP diet
8
Q
What diseases suggest increase likelihood of IBD
A
Diabetes, thyroid, RA, Ank spond, psoriasis- (immune mediated inflammatory disorder)
9
Q
How does smoking affect risk of CD and UC
A
Smoker more likely to get CD but decreases UC risk while smoking, doubles after quitting smokinng
10
Q
What drugs may cause microscopic colitis, what is common Px and which pop is it more common in
A
antidepressants like SSRIS and PPIs like Lansaprazole, profuse water diarrheoa, more common in older women
11
Q
Tx for microscopic colitis
A
budesonide
12
Q
In what disease can dairrheoa be exacerbated by alcohol
A
IBS
13
Q
What is one parasitic cause of diarrheoa in travellers
A
amoebiasis
14
Q
What is a histological finding in coeliac disease and what other tests can be done
A
- Lymphocytes in villi and epithelium
-Anti-TTG (if gluten has been taken) - Gastroscopy @ duodenum
15
Q
Red flag for colon cancer
A
Change in bowel habit over age of 50
16
Q
Another AID common in IBD pts
A
Hyperthyroidism-
heat intolerant, losing weight, horrible diarrhoea
17
Q
Dx and Tx for SIBO
A
Rifaximin course- see if it resolves. Lactulose can see if bacteria is metabolising but not very specific
18
Q
Sx and Tx of Bile Acid Malabsorbtion
A
- Secretory Diarrhoea, Steatorrhoea
- Colestyramine
19
Q
Where is B12 absorbed
A
TI
20
Q
What tumours may cause diarrheoa
A
NETS - due to carcinoid syndrome, serotonin is produced. If meta to liver, may have diarrheoa, wheezing, hot flushes
21
Q
General Ix for Diarrheoa
A
- coeliac serology on almost all pts esp those young
- FC to exclude CD or UC
- Qfit - above 10 cant exclude cancer if hv symptoms , need to do colonscopy
- CT colonoscopy
- CT CAP esp if hv weight loss
SB MRI for intestinal CD- hyper enhanced or narrowed
22
Q
5 Yr intermmitent Sx, 3/day, mushy and hard rock stool alternating, FC <20 - likely Dx and possible other Sx
A
- Mixed type IBS
- Abd pain better when move bowels
- Sx worse on bread, milk, tomatoes and diet drinks
23
Q
6mo mushy stools, 4.day on bad say, BS=6, Normal 1 EOD, BS-4
No nocturnal urgency
Weight loss
Assoc abdominal pain
Pain better when bowels moved
Worse with bread
Likely Dx?
Other Sx?
PMHx?
A
- Coeliac, Dematitis herpetiformis- rash on arms, knees, assoc with coeliac
- FMhx thyroid
24
Q
6mo prog fluffy stools
7/day BS=6
Urgency and 2 ep incont
Bleeding mixed in stool
Overnight x2 /2 weeks
Weight loss
Rash on shins
FC >2000
Anaemic
Likely Dx?
Ix and Obs?
A
- Low ani-TTG
Erythema nodosum - rash on shins, may be in IBD
25
80+ yo
4 wk explosive watery diarrheoa
Bad - 4 day , BS=7
2 ep incont
Ondanston 4mg TDS
Cocodamol
Likely Dx?
XR appearace?
FC, RBC and anti-TTG?
- Drugs can lead to overflow diarrhoea- slow bowel movement- impacted stool
- Speckled appearrance on X ray
- Low FC
- Slightly anaemic,
- Low anti-TTG
26
2mo light grey porridge like stools
Diff to flush smelly
Oil droplets
Prev alc dep
Recurrent abd pain
Likely Dx?
Ix?
Tx?
- Pancreatitis (calcified) , possibly due to alcohol
- BM= 18
- Vit ADEK all low
- Faecal elastase low pancreatic exocrine insufficient BUT may give false +ve in very water diarrheoa
- Usually give creon as tx
27
64 YO male
1 mo abd pain
Worse 1-2 h after eating
Eat small meals
Incr stool freq 2-3 day
Current smoker, prev MI and TIA
No weight loss
Mesenteric ischemia- stenosis in gut
28
Factors that increase the risk of bowel cancer
Smoking, alcohol, increased BMI, red/processed meat, TIIDM
29
Polyposis related colorectal cancer syndrome vs nonpolyposis
Serrated polyposis syndrome vs Lynch syndrome
30
3 pathways to CRC
Adenoma-cancer (70-90%), chromosomal instability from APC mutation then RAS activation or loss of TP53
Serrated neoplasia (10-20%), primary RAS/ RAF mutations followed by CPG island mutation
Microsatellite instability (2 -7%), Germline mutations in MMR genes (MSH2,6, MLH1,3, PMS 2,6) - Lynch syndrome
31
Sx of CRC
Occult or overt rectal bleeding
Change in bowel habit
Anaemia
Abd pain
MAY BE ASx
32
Dx for CRC
- Colonoscopy + pathology (staining for hist subtype, grading, invasion etc. , can confirm presence of high grade dysplasia +tumour based marker, MSI)
- CT CAP for staging
- MRI (if at rectum) , required for loco-regional rectal cancer staging
- CT colonoscopy for incomplete/ inadequate colonoscopy, old patients etc.
33
How to manage early polyp cancer
Via en-bloc endoscopy like EMR / SED during endoscopy
34
General Mx for CRC
- Surgery
- Chemo/radiotherapy
35
Chemoprophylaxis for lynch syndrome pts
Aspirin
36
When should colonoscopy be oferred to the public fo bowel cancer screening
> 55yo, or occult blood in stool, or IBD
37
What is colorectal screening in UK
home-based, Faecal Immunochemical Test (FIT) screening to older adults (50-74) , colonoscopy if results are abnormal
38
Sx of LGIB
PR bleeding, haemochezia ( passage of altered blood and stool), breathlessness, headache, cheat pain and fatigue ( 4 Sx of anaemia), and dizziness, blackout, collapse ( 3 Sx of shock)
39
PMHx for LGIB
Diverticular disease, chronic liver disease, recent surgery/endoscopy
40
What drugs may increase risk of LGIIB
DOACs, warfarin
41
Bloods for LGIB
FBC, U and E, LFT, clotting, lactate
42
Causes of LGIB
Diverticular bleeding ( most common for acute), haemorrhoids, anal fissures, ( subacute/chronic)
angiodysplasia, IBD, rectal ulcers,
rectal polapse, rectal varices, colorectal cancer, post-polypectomy, radiation colitis/ proctitis
43
What increases likelihood of rectal varices
COmorbid CLD and portal hypertension
44
Dx of LGIB
Colonoscopy
CT angiogram ( 1st line if pt shocked), catheter angiography with embolisation should be performed.
Colonoscopy if pt shocked but CT angiogram not clear
45
What score to classify LGIB, and what is the benchmark, what are the factors
Oakland score, <= 8 - minor bleed, discahrge w/ OP Ix, >8 - major bleed, hopsitalisation for assess., resusc and Ix
Factors include Age, gender, previous LGIB adm, DRE findings, HR, SBP, Hb
46
Mx of LGIB
Endoscopic - clips as first line +/- Adr. injxn,
heater prob,
Heamosprat as last resort
APC for coagulation therapy
Thrombin/glue injxn
Interventional radioolgy- embolisation of bleeding vessels with coils, liquid agents and particals, but ischaemia possible in up to 24%
Surgery
47
Sx of IDA
May be aSx, or have breathlessness, fatigue, angina, angular stomatitis, koilonychia, restless leg syndrome, papophagia
48
Pathological causes of IDA -
Neoplasia, IBD, peptic ulcer, vascular malformation eg. angiodyplasia, haematuria, gynaecological blood loss
Coeliac and Crohn's, Hypochlorohydria -atrophic gastritis, H. pylori and gastrectomy/bypass
49
Is IDA macro or micro cytic and hypo or hyper chromic
micro, hypo
50
What should be first measured for IDA and what are the caveats
Ferritin most specific, true IDA if ferritin low, but may be elevated in inflmt states/ infxn
51
Iron studies- what should be seen in IDA
Decreased serum iron, transferrin saturation, increased serum transferrin, soluble transferrin receptor and TIBC, ferritin decreased or normal
52
What to do if Dx of IDA is in doubt
Trial oral iron for 2-4 weeks, if Hb rise >10g/L in 2 weeks, suggestive of IDA
53
Ix in IDA
Bi-directional endoscopy in men and post meno women, CT colonoscopy if multiple co-morbidities
Urinalysis for microscopic haematuria, coeliac serology, Ix of small bowel if no other cause found
54
Colour of rectal bleeding
Bright red
55
How can SoBoE be present in pts with CRC- bloods??
Pts may have microcytic anaemia
56
First line investigation in pt with microcytic anaemia and suspected ca
endoscopy first, then colonoscopy if nothing found
57
Where is squamous cell cancer found in the GI tract
only anus
58
What are the categories for staging CRC
- T
- T1 - mucosa/submucosa
- T2 - muscle
- T3- serosa
- T4- outside
- N
- 1-3
- 3-7
- >7
- M
- 0/1 if there’s metastasis
59
Tx for rectal ca
Resection - may need to remove sigmoid colon
60
When should adjuvant chemotherapy be given for caecal cancer
for those fit enough, or node positive, or bad Duke’s B (T4, poor diff., lymphovasc inv. etc.)
61
Side effect of CAPOX
Peri neuropathy
62
Ix for rectal cancer
Will need full colonoscopy for distal polyps
- Look for resection margin → TMA
- May need radiotherapy pre-operatively to down stage disease and chemo to stop widespread of ca
- Neoadjuvant (preop) radioT can result in 30% red. in local RR
- No overall mort. red. for any XRT ref.
- Long course given prior to pt w/ any high risk features
- Short course don’t get chemo
63
Stage T3/4, N+ M1 is stage what cancer? how to treat?
Stage 4 ca, just palliative intent with Sx control ( pain, profuse diarrheoa, obstructive sx)
- Can resect obst, put stent to reat obst, and bring out defunctioning stomas laprascopically
64
What to do for qFIT +ve pts who are older ( check benchmark)
Colonoscopy to rule out cancer
65
Observation vs resection for adenocarcinoma
- High risk factors
- Poor diff,
- Venous invasion
- Lymphatic inv,
- distance to deep margine <1mm,
- **If none of these than >99% cured by polypectomy alone ( can consider cured for polyp cancer once removed)**
66
What should be done if pedunculated polyps is found on colonoscopy
Usually excise it with snare polypectomy then do histology
67
Dx of anal fissures or haemorrhoidal bleeding
Haemorrhoidal bleeding is bright red and occurs during or after defecation. Proctoscopy can be used to make the diagnosis, but individuals who have altered bowel habit and those who present over the age of 40 years should undergo colonoscopy to exclude coexisting colorectal cancer. Anal fissure should be suspected when fresh rectal bleeding and anal pain occur during defecation.
68
Risk factors for anal fissures
Constipation
inflammatory bowel disease
sexually transmitted infections e.g. HIV, syphilis, herpes
69
What is the presentation of ticular disease
Alternating constipation and diarrheoa, altered bowel habit
Intermittent abd cramps
70
What are diverticulae
Bulges of colonic wall
71
Where are diverticulae most frequently found in
Sigmoid colon
72
How to manage diverticulae
Increase fluid intake to keep motions regular and soft
Add high fibre
73
Sx of diverticulitis
Severe abdominal pain in the left lower quadrant
this may be in the right lower quadrant in some Asian patients
Nausea and vomiting (20-60%)
this may be due to ileus or complicated diverticulitis with colonic obstruction
Change in bowel habit
constipation is more common (seen in 50%)
diarrhoea is also reported (25%)
Urinary frequency, urgency or dysuria (10-15%)
this is due to irritation of the bladder by the inflamed bowel.
PR bleeding
74
What are complications of diverticulitis
Infection or inflammation - may present with abd pain, fever, high inflammatory markers. May also have peritonism/guarding
Diarrhoea/PR bleeding are also common complications
75
Mx of diverticulitis
Abx
76
Ix of diverticulitis
CT abd and pelvis with IV contrast
Erect CXR if perforation suspected
77
Complications of diverticvulae
May be a cause of perforation ( assoc with abscess and diverticulitis) or LGIB ( not assoc with diverticulitis)
78
What is the presentation of haemorrhoids
PAINLESS, birght red rectal bleeding after moving bowels
May have had constipation and mucous discharge, normal abd and PR examination
Other sx include itching, may also have prolapse, thrombosis and pain
79
Mx of haemorrhoids
Increase dietary fibre and fluid intake, prescribe laxatives, may use steroids to reduce swellinng
80
Management of an acute anal fissure (< 1 week)
soften stool-
dietary advice: high-fibre diet with high fluid intake
bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
lubricants such as petroleum jelly may be
tried before defecation
topical anaesthetics
analgesia
81
Contributing factors to haemorrhoids
Constipation, older age, chronic cough, straining and raised intra-abdominal pressure
82
Are haemorrhoids palpable
NO not always esp if internal, but may become palpable lump at anal verge and may have persistent bleeding and haemorrhoids if prolapsed
83
What are functional disorders that can cause incontinence
Chronic diarrhoea (IBD, malabsorption), radiation proctotiitis and overflow diarrhoea ( due to constipation)
84
Management of faecal incontinence in adults
Optimising stool consistency - bulking agents like fybogel or methylcellulose
Slow sown bowwel motilitly using loperamide, ondasentron, codeine
Among other things
85
Diff between anal fissure and haemorrhoids
Anal fissure more likely to be painful
86
Diverticular disease px
Chronic history of:
Intermittent abdominal pain: particularly in the left lower quadrant
Bloating
Change in bowel habit: constipation or diarrhoea
87
Causes of faecal incontinence
Diarrhoea/constipation, muscle or nerver damage, CRC, IBD, Coeliac, GE, IBS, sphincter dysfx, MS or CES, stroke, overflow diarrhoea
88
