8. Lower GI Flashcards
A 22 y/o female presents to her GP with a two year history of intermittent diarrhoea and constipation. She complains of bloating and abdominal pain, which eases with defecation. Which condition is she likely to have?
A. Coeliac disease B. Ulcerative colitis C. Crohn’s disease D. Irritable bowel syndrome E. Infectious diarrhoea
D. Irritable bowel syndrome
A 26 y/o male presents to his GP with weight loss, abdominal pain and watery diarrhoea. On examination he looks pale and you notice ulcers in his mouth. Which condition is he likely to have?
A. Coeliac disease B. Ulcerative colitis C. Crohn’s disease D. Irritable bowel syndrome E. Infectious diarrhoea
C. Crohn’s disease
A 23 y/o female presents to her GP with a limp. On further questioning she reveals she has recently lost weight and has had bloody, mucoid diarrhoea. On examination her right knee is tender and swollen, and her eyes are red. Which condition is she likely to have?
A. Coeliac disease B. Ulcerative colitis C. Crohn’s disease D. Irritable bowel syndrome E. Infectious diarrhoea
B. Ulcerative colitis
A 27 y/o male presents with a history of mucoid, bloody diarrhoea and weight loss. On examination you note a number of red marks on his shins. After a number of investigations his diagnosis is confirmed. Which treatment would you start him on?
A. IV corticosteroid B. Oral prednisolone C. Topical mesalazine D. Oral azathioprine E. IV cyclosporin
C. Topical mesalazine
A 31 y/o male presents with a history of diarrhoea, weight loss and RIF pain. On examination you note a number of red marks on his shins. After a number of investigations his diagnosis is confirmed. Which treatment would you start him on?
A. IV corticosteroid B. Oral prednisolone C. Oral mesalazine D. Oral azathioprine E. IV cyclosporin
B. Oral prednisolone
After starting treatment, his symptoms improve. Which additional treatment would you start him on to maintain his remission?
A. IV corticosteroid B. Oral prednisolone C. Oral mesalazine D. Oral azathioprine E. IV cyclosporin
D. Oral azathioprine
A 55 y/o female presents to her GP with an itchy rash on her forearms. On further questioning she reveals she has recently lost weight and has had mucoid diarrhoea. Which test will best confirm her diagnosis?
A. Endoscopy with duodenal biopsy B. Serum antibodies to tissue-transglutaminase C. Serum anti-endomysial antibodies D. Colonoscopy E. Endoscopy with ileal biopsy
A. Endoscopy with duodenal biopsy
UC Signs and Symptoms
Diarrhoea - With blood fresher and redder than upper GI bleeding; Mixed in (unlike anal fissure and haemorrhoids) + mucus
Abdominal pain
Relapsing-remitting
Extra-intestinal manifestations of IBD
A PIE SAC:
- Aphthous (mouth) ulcers [CD>UC]
- Pyoderma gangrenosum
- I (eye) – iritis, uveitis, episcleritis [CD>UC]
- Erythema nodosum - raised red marks
- Sclerosing cholangitis (primary) [UC]
- Arthritis
- Clubbing fingers [CD>UC]
CAI is more CD than UC
Invx for CD
- Stool sample (first line)
- Blood tests
- CT/MRI abdomen
- (Colonoscopy and biopsy)
Biopsy = confirmatory not diagnostic - crypt architectual changes
Invx for UC
- Stool sample (first-line)
- Blood tests - WBC, CRP, ESR, (inflam baseline) LFT (PSC)
- AXR: toxic megacolon, lead pipe
- Colonoscopy/flexible sigmoidoscopy and biopsy - necessary: mucin depletion, diffuse mucosal atrophy, continuous from the rectum with anal sparing.
Radiology signs in IBD
Where are they found?
Lead pipe sign: loss ofhaustral markings in the diseased section of colon; organ appears smooth-walled and cylindrical.Due to inflammation.
Thumbprinting (projections into aerated lumen) - large bowel wall (haustra) thickening at regular intervals, usually caused by oedema, related to an infective or inflammatory process (colitis).
In UC these signs will be focused near the rectum, in Crohn’s focused in terminal ileum.
Toxic megacolon
Definition
Symptoms
Mx
When IBD/C. diff is serious enough to cause inflammatory colitis.
Symptoms: extreme vomit, abdo pain and abdo distention (think obstructive symptoms). EMERGENCY!
§Treat with resuscitation (fluids, adrenaline etc, likely to be in shock), nasogastric decompression and corticosteroids in the case of IBD complication.
CD Management
Inducing remission: Corticosteroids
Maintaining remission: Azathioprine Methotrexate Cyclosporin Infliximab (TNFa)
Surgery: NOT curative
UC Management
Inducing remission: Aminosalycilates -Topical -Oral (low dose) -Oral (high dose)
Maintaining remission: Azathioprine Methotrexate Cyclosporin -
Surgery: Curative
Prognosis and Complications of IBD
Crohn’s: Increased mortality.
(Duration of the disease) higher comorbidity score increase this.
UC: Mortality not affected
But toxic megacolon is a concern
Coeliac disease: Definition and Epidemiology
Chronic autoimmune disease of the small intestine, characterised by gluten intolerance in genetically susceptible individuals.
Higher prevalence in Europeans.
Peaks at infancy and 50-60 years.
Aetiology of Coeliac’s
Autoimmune damage to the intestinal mucosa leads to: Villous atrophy WBC infiltration Cryptal hyperplasia = malabsorption
Risk factors of Coeliacs
Female sex (2:1)
Autoimmune background - T1DM, Thyroid disease
Family history
Symptoms of Coeliacs
Diarrhoea - Difficult to flush
Bloating
Abdo pain (After eating gluten)
Fatigue
Signs of Coeliacs
IgA deficiency (coming up as an incidental finding can indicate silent coeliac disease- still important due to complications)
Anaemia
Dermatitis herpetiformis
Coeliac disease: investigations
Stool sample
Serum antibody tests:
- Anti-tissue transglutaminase (TTG)
- Anti-endomysial
Endoscopy + duodenal biopsy (gold-standard)
- Villous atrophy
- Cryptal hyperplasia
- Intraepithelial WBCs
Coeliac disease: Mx
Gluten-free diet
Vitamin D supplementation
Coeliac disease: Prognosis and complications
Up to 90% will have complete and lasting resolution of symptoms on a gluten-free diet alone.
Complications:
- Upper GI lymphomas and carcinomas
- Osteoporosis (Vit D)
- Chronic dermatitis herpetiformis
Coeliac disease: Prognosis and complications
Up to 90% will have complete and lasting resolution of symptoms on a gluten-free diet alone.
Complications:
- Upper GI lymphomas and carcinomas
- Osteoporosis (Vit D)
- Chronic dermatitis herpetiformis
IBS: Diagnosis of Exclusion - Criteria
What has it been linked to?
What can be used for Mx?
Rome IV criteria: Recurrent abdo pain at least 1d/wk, on average, in the past 3 months a/w 2 or more of: - Defacation - Change in stool frequency - Change in form of stool
Symptom onset should occur at least 6 months prior to diagnosis; should be present during the past 3 months
Links to stress and inflammation - SSRIs can form part of treatment plan.
A 67 y/o male presents to his GP following an episode of rectal bleeding. He noticed fresh blood on the toilet paper after wiping. There was no blood mixed in with the stool. He is otherwise fit and well. What is the next appropriate step to take? A. Colonoscopy B. Faecal occult blood test C. Abdominal exam D. Digital rectal exam E. Sigmoidoscopy
C. Abdominal exam
But likely to be haemorrhoids
A 35 y/o male presents to his GP following an episode of rectal bleeding. He noticed fresh blood on the toilet paper after wiping. There was no blood mixed in with the stool. He adds that he is very sore ‘down there’ and it is agony to defecate. Which condition is he likely to have?
A. Haemorrhoids B. Anal fissure C. Crohn’s disease D. Ulcerative colitis E. Colorectal carcinoma
B. Anal fissure
A 67 y/o male presents to his GP complaining of rectal bleeding. Over the last few months he has noticed blood mixed in with his stool. He sometimes feels like he hasn’t completely emptied his bowels after defecating, and is more tired than usual. What is the next step to take?
A. Routine referral to colorectal surgeons
B. Urgent referral to colorectal surgeons
C. FBC
D. Abdominal exam
E. Faecal occult blood test
D. Abdominal exam
But this likely to be CRC
Anal fissure: Definition and Aetiology.
Epidemiology
Anal fissure = split in the skin of the distal anal canal.
Can be linked to previous constipation/Ischaemia (90% occur along the posterior midline of the anal canal, where there is the poorest circulation.)
Common in young, white males.
Anal Fissure Symptoms:
Invx
Pain (Tearing sensation)
Blood (Small amounts - on paper)
Purely clinical Dx
Anal Fissure Management:
Fluids and fibre
Topical Analgesia
Can add topical GTN or diltiazem (relaxes musculature and blood vessels surrounding, to promote adequate blood flow for healing.)
Surgery in severe, chronic cases (avoid - incontinence risk - bigger QoL impact)
Anal Fissure Prognosis and Complications
80% heal with treatment.
60% heal after 6-8 weeks with fluids and fibre.
A further 20% heal with the addition of diltiazem.
Complications:
- Chronicity
- Incontinence from surgery.
Haemorrhoids (Haemorrhoidal cushions)
Haemorrhoids: Definition, Epidemiology and Aetiology
Normal anatomical structures located within the anal canal. As they get inflamed/enlarge, they can protrude outside the anal canal causing symptoms.
4% of population, peak between 45-65 years.
Main risk factor: increased intra-abdominal pressure (Straining - constipation, chronic cough, pregnancy, obesity, ascites, SOL)
Haemorrhoids classification
1st Degree: No Prolapse, Just prominent blood vessels
2nd: Prolapse upon bearing down, reduces spontaneously
3rd: Prolapse upon bearing down, requires manual reduction
4th: Prolapsed and cannot be manually reduced
Haemorrhoids: Symptoms, Signs, Invx
Symptoms:
Rectal bleeding (always) - Bright red, Sides of the pan
Rectal pain (may be present)
NB CR carcinoma - darker
Signs/Invx Abdo exam Lump on DRE 3/4th may be visible on inspection Colonoscopy (for painful 1st or 2nd degree)
Haemorrhoids: Management
1st degree: fluid and fibre, topical analgesics, stool softener, topical steroids (min time)
2nd or 3rd degree: non-operative
Rubber band ligation
Infra-red coagulation
Cryotherapy
4th: Excisional haemorrhoidectomy
Haemorrhoids: Complications and Prognosis
Complications (rare):Anaemia, thrombosis, incarceration.
Prognosis: generally good
Surgery has lowest recurrence rates: around 20%.
Colorectal cancer: Definition, Epi and RF
Colorectal cancer (CRC) is 3rd commonest cancer in UK Mostly adenocarcinoma (glandular tissue origin) Mostly >60yrs
Risk factors: Alcohol / Smoking / High red meat diet Polyps Genetic conditions (FAP/HNPCC)
Colorectal cancer: Signs and Symptoms
R-sided tumour: - Weight loss - Anaemia - Abdominal pain - Obstruction less likely Harder to detect, presents later
L-sided tumour - Bleeding/mucus PR - Altered bowel habit - Tenesmus - Obstruction - Mass PR Easier to detect, presents earlier
Both has abdo mass
Symptoms can be heterogenous so in exam questions look out for FLAWS first, coupled with some risk factors and abdo symtpoms.
Colorectal cancer: Investigations
Bloods
- FBC (anaemia)
- LFTS (baseline)
- Renal function (baseline)
Colonoscopy/ barium enema/CT colonography
- To find and stage the tumour
Biopsy (may be concurrent with complete surgical excision)
- To grade the tumour
Differentiators for CD, UC, Coeliac, Anal Fissure, Haemorrhoids, CRC
Crohns: Diarrhoea AND systemically unwell, mouth ulcers
Ulcerative Colitis: Diarrhoea with mixed blood
Coeliac: Other autoimmune conditions
Anal fissure: TEARING pain
Haemorrhoids: Bright red blood splashes the pan
Colorectal cancer: FLAWS, presence of risk factors (AGE)
