Abdominal pain and rectal bleeding Flashcards
GORD risk factors
smoking
alcohol
increased intra abdominal pressure- pregnancy, obesity, chronic cough
Meds that reduce LOS tone- eg NSAIDs and beta blockers
GORD symptoms
Burning epigastric pain- may radiate up to chest. Can last up to 2 hours and is worse after eating, lying down or bending over.
Acid-bitter taste in mouth
Chronic cough
Hoarse voice
Bad breath
GORD diagnosis
24 hour oesophageal pH monitoring
When do you offer urgent upper GI endoscopy 2ww for oesophageal cancer?
Dysphagia or 55+ w/ weight loss AND any of:
Upper abdo pain
Reflux
Dyspepsia
GORD non medical management
Reduce exacerbations:
stop smoking
reduce alcohol
avoid trigger foods
lose weight
Avoid precipitating situations:
raise head of bead (sleep w/ head higher than stomach)
eat earlier in the evening so stomach is empty when you lie down
wear looser clothes
GORD medical management
OTC antacids
PPI for 4 weeks- care acn lead to C diff
Where conservative mnagement fails- can do a Nissen fundoplication - involves wrapping fundus of the stomach around the lower oesophagus to reinforce the LOS
Complications of GORD
Chronic cough
Barret’s oesophagus- pre malignancy
Recurrent chest infections
Benign stricture
Oesophagitis
Barret’s oesophagus what epithelium change is it
Stratified squamous epithelium -> columnar epithelium
Barret’s oesophagus risk factors
Age
Obesity
Male White
Barret’s oesophagus symptoms
same as GORD
Barret’s oesophagus diagnosis
upper GI endoscopy w/ biopsy
Barret’s oesophagus management
Lifestyle changes:
smaller meals
lose weight
stop smoking
High dose PPI
Endoscopic surveillance w/ biopsies every 3-5 years.
If dysplasia- endoscopic intervention is offered:
Radiofrequency ablation to destroy the epithelium so it’s replace w/ normal cells
Peptic ulcer disease- gastric vs duodenal?
Gastric- older ppl. Epigastric pain WORSE WHEN EATING.
Duodenal- more common. Male and 45-64, epigastric pain when hungry, DECREASED BY EATING
Peptic ulcer risk factors
H pylori
Drugs- NSAIDs, SSRIs, Corticosteroids,
Alcohol
Malignancies
Zollinger- Ellison syndrome
Caffeine
Smoking
Spicy food
Stress
Peptic ulcer signs and symptoms
Sudden onset severe epigastric pain
Nausea
Dyspepsia
Heartburn
Mild epigastric tenderness
When peptic ulcer presents as an acute UGIB- what are the features?
Haematemesis +/- melaena
Bleeding- gastroduodenal artery can be source of a sig GI bleed
Shock
When peptic ulcer presents as a perforation- what are the features?
Acute, severe abdo pain and tenderness
Localised or generalised guarding
Shock
Usually sudden onset of epigastric pain before becoming more generalised. Also distention, nausea and vomiting
Peptic ulcer investigations
Diagnosed by endoscopy.
H pylori test can be done - C13 urea breath test or serological and stool antigen test.
Before the H pylori test- stop PPIs 2 weeks before and Abx 4 weeks before
Peptic ulcer management if H. Pylori positive
7 day course of PAC or PMC
PAC: PPI (eg esomeprazole) + amoxicillin + clarithromycin
PMC: if penicillin allergic: PPI + metronidazole + clarithromycin
Peptic ulcer management if H pylori negative
PPIs until ulcer is healed
Or H2 blockers like ranitidine
Perforated ulcer management
Laparotomy to repar the perforation and a washout of enteric contents from the peritoneal cavity
Gastric perforation causes
Peptic ulcer
Diverticulitis
Malignancies
Procedures
Trauma
IBD
Bowel obstructions
Mesenteric ischaemia
Gastric perforation signs and symptoms
Unwell
LOTS of pain
Peritonism- diffuse or local
Shock- septic and low BP
Gastric perforation investigations
CT scan- confirming presence of free air suggesting a location of the perforation
Raised WCC and CRP
CXR- may show air under the diaphragm in cases of pneumoperitoneum
AXR may show either Rigler’s sign (both sides of bowel visible) or psoas signs (loss of sharp delineation of the psoas muscle border)
Gastric perforation management
IV fluid resus
nil by mouth
broad spectrum abx
NG tube cosnidered to aspirate to clear out a small bowel obstruction
Pain relief (opioids)
Surgery- appropriate management of perforation
Thorough washout
Peptic ulcer perforation- patch of omentum (Graham patch) is tacked loosely over the ulcer. Midline laparotomy.
Small bowel perforation- can be accessed via a midline laparotomy
Gastric cancer risk factors
Age
Male
H pylori
EBV
Familial adenomatous polyposis (FAP)
Smoking
Alcohol
Diet- salt
Obesity
Presenting features of Gastric cancer
dyspepsia
Abdo pain- typically vague, epigastric pain
weight loss and anorexia
N&V
Dysphagia
Haematemsis/melaena
Virchow’s node
Gastric cancer 2 www (gastroscopy w/ biopsy) criteria
Presenting w/ one of:
Upper abdo mass consistent w/ gastric cancer
New onset dysphagia
Aged > 55 presenting w/ weight loss and either upper abdo pain, reflux or dyspepsia
IF taking a PPi of H2RB then stop it at least 2 weeks before endoscopy as it oculd mask serious underlying pathology like gastric cancer
gastric cancer management
MDT
adequate nutrition
Chemo, radiotherapy
Operable ones are T1N0 or less
Survival is bad- average is 20% @ 5 years
Early stage is 90% but rarely present early
Pancreatic cancer risk factors
Age
Smoking
Diabetes
Genetics
Pancreatic cancer features
painless obstructive jaundice
palpable gall bladder (f bile isn’t flowing thru biliary tree), GB is enlarged.
Epigastric pain to back
weight loss
Hepatomegaly and malignant ascites
Courvoisier’s law RUQ mass- (palpable gall bladder) + painless jaundice, then it’s not a gallstone, implies a possible malignancy of pancreas or GB
Pancreatic cancer 2 ww referral criteria
Over 40 and new onset jaundice
Pancreatic cancer investigations- LFT findings and CT findings
LFTs- obstructive picture- raised bilirubin, ALP and GGT.
CT- diagnostic and staging- double duct sign- CBD and PD are dilated
Pancreatic cancer treatment
often terminal, so pain relief, mental health, nutrition and mental health,
ERCP w/ stenting- open it up to alleviate some sypmtoms
Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in head of pancreas. Remove head of pancreas + duodenum + GB/bile duct. Attach what’s left of pancreas/stomach/bile duct -> small intestine. Side effects are dumping syndrome and peptic ulcer disease
Appendicitis risk factors
Caucasians
Teens-40s
Appendicitis symptoms
Peri umbilical pain- migration of pain from umbilical region to right iliac fossa. Classically dull and poorly localised initially but later migrates to the RIF where it’s well localised and sharp.
Low grade fever
N&V
Diarrhoea
Change in bowel habits - loose stools of constipation
Appendicitis signs
RIF tenderness
Rebound tenderness- pain when pressure is REMOVED from the abdomen.
Percussion pain over McBurney’s point (2/3rds of the way bwt umbilicus and ASIS)
Rosving’s sign- RIF pain on palpation of LIF
Appendicitis investigations
Clinical diagnosis
Raised inflamamtory markers
Imaging- USS can show inflamed appendix and free fluid
CT- good sensitivity and specificity
Appendicitis management
Laparoscopic appendicectomy
In some cases abx is commenced and appendicectomy is delayed.
Appendix should routinely be sent to histopathology to look for malignancy.
As pear any laparoscopic procedure, the entire abdomen should be inspected for any other evident patholology
AAA risk factors
Atherosclerosis
Smoking
HTN
Hyperlipidaemia
AAA symptoms and signs non ruptured
usually asymptomatic
symptoms can be abdo pain
back/loin pain
distal embolisation producing limb ischaemia
Ruptured AAA symptons and signs
Sudden collapse/shock
Persistent severe central abdominal pain radiating to the back/flank
V unwell
Haemodynamically compromised: hypotensive
Shock
Tachycardic
Reduced GCS
Cap refill prolonged
cold peripgeries
AAA investigations for rupture
If haemodynamically unstable- diagnosis is clinical and taken theatre ASAP.
If haemodynamically stable- send for CT angiogram where diagnosis is in doubt this may also assess the suitability of endovascular repair
AAA unrputured management
Men over 65, women over 70 w/ comorbidities invited to GP for US. If low rupture risk then surveillance.
IF high risk, refer within 2 weeks to vascualr surgery- elective endavascular repair or open repair- midline laparotomy exposing the aorta and clamping the aorta proximally and the iliac arteries distally, before the segment is then removed and replaced w/ a prosthetic graft.
AAA ruptured management
Treat shock
ABCDE
High flow O2
IV fluid resus
Major haemorrhage protocol
Transfer to local vascular unit
IBS risk factors
Women
Anxiety/depression
Concurrent GI infection
Stress event
Endometriosis
IBS diagnostic criteria
Consider if patient has had the following for at least 6 months:
Abdo pain and/or
Bloating and/or
Change in bowel habit
Positive diagnosis should be made if pt has abdo pain relieved by defecation or associated w/ altered bowel frequency and stool form, in addition to 2 of the following 4 symptoms:
Altered stool passage (straining, urgency, incomplete evacuation), Abdominal bloating, distension, hardness, Symptoms worsened by eating, Passage of mucus
IBS medical management
First line- according to predominant symptom-
Pain- antispasmodic agents
Constipation- laxatives eg senna
Diarrhoea- loperamide
Low dose tricyclic antidepressants
SSRIs
IBS alternative management
Dietary advice:
Regular meals
Adequate fluid intake
Reduce processed foods
Reduce caffeine and alcohol
Low FODMAP diet - ideally w/ dietician advice (eg Eggs, meat, almond milk)
Food diary- try avoid trigger foods if any
Try probiotics for a month- see if they help
Psychological intervention- consider CBT referral if no response after 12 months pharma treatment. Helps psychologically manage the illness and any distress associated w/ the symptoms.
What is coeliac disease
Autoimmune disorder due to gluten sensitivity. Repeated exposure leads to villous atrophy, which causes malabsorption. Immune response- chronic inflammation in small bowel.
Coeliac disease signs and symptoms
Diarrhoea
Failure to thrive
Fatigue
Weight loss
Mouth ulcers
Recurrent abdo pain, cramping or disension
Unexplained iron deficiency anaemia
Coeliac disease investigations and diagnosis
Serology-
Check total immunoglobulin A (IgA) antibodies to exclude IgA deficiency before checking
Tissue transglutaminase (TTG) antibodies - raised in coeliac, Endomyseal antibodies - raised in coeliac.
Carry out investigations while patient remains on diet containing gluten.
Gold standard for diagnosis- endoscopic intestinal biopsy- will show villous atrophy, crypt hyperplasia
Coeliac disease management
Gluten free diet is essentially curative. Gluten containing cereals: wheat, barley-beer, oats.
Gluten free foods- rice, potatotes, corn (maize)
Peritonitis common cause
spontaneous bacterial peritonitis usually seen in pts w/ ascites secondary to liver cirrhosis
Peritonitis symptoms
Severe abdo pain- worse on movement, patients stay rigid, abdo distention, N&V, fever, sweating.
Peritonitis signs
Absent/decreased bowel sounds- bcos of bowel obstruction -often caused by adhesions
Peritonitis management
surgical exploration- fix what’s causing hte peritonitis eg ruptured ulcer, adhesion causing SB obstruction etc.
Abx broad spectrum- high dose follow local guideliens
Supportive treatment: oxygen, fluids etc
Diverticulosis vs Dicerticular disease vs Diverticulitis
Diverticulosis = presence of diverticula w/o inflammation or infection
Diverticular disease- abdo pain but not inflam
Diverticulitis- inflammation and infection of diverticula
Diverticulosis risk factors
Low fibre
Obesity
NSAIDs
Diverticulosis symptoms and signs
Lower left abdo pain, constipation or rectal bleeding
Diverticulosis management
Increased fibre in diet and bulk forming laxatives. Surgery to remove affected area may be required if sig symptoms. Treatment not necessary if asymptomatic
Diverticulitis presentation
Sharp pain and tenderness in LIF
Fever
Change in bowel habit- constipation and diarrhoea
N&V
Rectal bleeding
Diverticulitis investigations
FBC and CRP
Erect CXR may show pneumoperitoneum in cases of perforation
CT= could show thickening of colonic wall, localised air bubbles, free air etc.
Diverticulitis management
Oral Abx, liquid diet and analgesia. Oral co amoxiclav (at least 5 days)
Surgical intervention is required in those w/ perforation w/ faecal peritonitis or sepsis. Inovlves a Hartmann’s procedure ( a sigmoid colectomy w/ formation of an end colostomy); an anastomosis w/ reversal of colostomy may be possible at a later date.
Ulcerative Colitis what is it
diffuse continual mucosal inflammation of the large bowel- starting in the rectum and spreading proximally
UC histological changes
mucosa to lamina propria only
Loss of goblet cells
Crypt abscess formation
NO SKIP LESIONS- CONTINUOUS INFLAMMATIOn
UC symptoms
Diarrhoea w/ or w/o blood
Increased frequency and urgency of defecation
Tenesmus (feeling need to poo)
Abdo pain, particularly in LLQ
Mucus discharge
Weight loss
UC extra intestinal manifestations
Conjunctivitis
Anterior uveitis
Enteropathic arthritis
Clubbing
Osteoporosis
Ankylosing spondylitis
Primary sclerosing cholangitis
Erythema nodosum
Pyoderma gangrenosum
UC investigations
Faecal calprotectin is raised in IBD but unchanged in IBS
Stool sample
Definitive diagnosis is colonoscopy w/ biopsy. Characteristic findings are continuous inflammation w/ possible ulcers and pseudopolyps visible
AXR findings on UC
Lead pipe colon
Toxic megacolon
UC management
Severity is classed:
mild <4 stools/day
moderate 4-6 stools/day
severe >6 bloody stools/day + systemic upset
Inducing remission- treating mild - to moderate:
first line- topical, then add oral mesalazine
second line- prednisolone
Inducing remission for severe UC:
fisrt-line: IV hydration and hydrocortisone w/ thromboprophylaxis
second-line: IV ciclosporin
Maintaining remission: mesalazine oral or rectal, oral azathioprine
Surgery- can remove colon and rectum- panproctocolectomy. permanent ileostomy can be given
What is Crohn’s disease
Crows NESTS- No blood or mucus (less common), Entire GI tract, Skip lesions on endoscopy, Terminal ileum most affected, smoking is a risk factor
Inflammation occurs in all layers, down to serosa across the GIT. Most commonly targets distal ileum/proximal colon. Skip lesions. Relapsing remitting.
Crohn’s disease histological changes
All layers inflamed
Increased goblet cells
Granuloma
Cobblestone appearance
Crohn’s disease symptoms
Episodic abdominal pain- may be colicky and site varies
Diarrhoea- often chronic and may contain blood/mucus
Oral ulcers
Perianal disease- inflammation at/near anus- including w/ perianal abscess
Systemic symptoms- malaise, fever, anorexia
Palpable RIF mass- often confused w/ appendicitis
Crohn’s extra intestinal features
same as UC- PSC, gallstones, oral ulcers, arthritis, pyoderma gangrenosum/erythema nodosum
Crohn’s investigations (including x ray features)
Faecal calprotectin is raised
Colonoscopy w/ biopsy is gold standard- features suggestive of Crohn’s include deep ulcers, skip lesions
CT abdo- can demo bowel obstruction.
AXR- Kantor’s string sing: stricture formation narrows the bowel to appear like a string. Rosethorn ulcers: ulcer formation thru all layers of the mucosa generates a pattern that looks like a rose stem.
Order is AXR/faecal calprotectin -> CT and/or SB pelvic MRI -> colonoscopy/ UGI endoscopy w/ biopsy
Crohn’s management
Inducing remission:
Steroids first line-
Mild/moderate: Budesonide and taper
Mod-severe: Prednisolone
Offer enteral nutrition instead of steds where steds aren’t working
Maintenance:
Stop smoking
Azathioprine and mercaptopurine first line
Biologics
Surgery if needed
Colorectal cancer- location, most common type, genetic mutations
40% rectal
30% sigmoid
adenocarcinoma
APC (TSG- mutation results in growth of adenomatous tissue such as familial adenomatous polyposis (FAP)) FAP- hundreds of polyps in colon
Hereditary nonpolyposis colorectal cancer (HNPCC)- scanty polyps, usually right sided + increased risk of cancers
Colorectal cancer symptoms
Changes in bowel habit
Rectal bleeding- Haematochezia
Weight loss
Appetite loss
Iron deficiency anaemia
Abdo or rectal mass
Unexplained abdo pain
Location specific symptoms:
Right sided
Left sided
Right sided- iron deficiency anaemia, presents later
Left sided- apple core appearance- on barium enema they look like they have an apple core shape. Presents earlier
Colorectal cancer 2ww criteria for usually a colonoscopy
Pts >=40 w/ unexplained weight loss AND abdo pain
Pts >= 50 w/ unexplained rectal bleeding
Pts >= 60 w/ iron deficiency anaemia OR change in bowel habit
colorectal cancer investigations and diagnosis
FBC- microcytic anaemia (an iron deficiecny anaemia)
Haematinics/ferritin
Carcinoembryonic antigen (CEA)- tumour marker for colorectal cancer
Colonoscopy + biopsy = gold standard
CT colonography
Colorectal cancer management
MDT- palliative care, nurses, Macmillan
Definitive- surgery/resection eg Hartmann’s procedure- removal of rectosigmoid colon and creation of a colostomy.
Chemotherapy and radiotherapy: neoadjuvant, adjuvant, palliative
Bowel obstruction common causes
SBO- adhesions and herniae
LBO- malignancy, diverticular disease and volvulus
Bowel obstruction presentation
Colicky abdominal pain (anytime there’s peristalsis, there’s pain)
Vomiting- usually bileous
Abdominal distention
Absolute constipation bcos of true obstruction
Bowel obstruction signs
distention
focal tenderness- guarding and rebound tenderness on palpation
Auscultation- tinkling bowel sounds
Bowel obstruction investigations
Gold standard- CT w/ contrast
Bowel obstruction management
nil by mouth
NG tube
IV fluids
Analgesia and anti emetics
Gastroenteritis what is it? common causes? risk factors
inflammation of the stomach/intestinal system caused usually by a virus or a bacteria. Staph aureus, Norovirus.
Foreign travel
Gastroenteritis presentation
Acute- happens within 2 weeks at most
N&V
Diarrhoea
Dehydration
Abdo pain
Gastroenteritis diagnosis
Stool MCS
Gastroenteritis management
lock in side room
fluids
avoid antidiarrhoeal meds
only give abx if high risk
Haemorrhoids- what are they and risk factors
enlarged anal vascular cushions
pregnancy
obesity
age
increased intra-abdo pressure
haemorrhoids symptoms and signs
often associated w/ constipation and straining
painless, bright red bleeding0 blood is not mixed w/ stool
sore,itchy anus
lump around/inside the anus
external haemorrhoids are visible on inspection as swellings covered in mucosa
internal haemorrhoids may be felt on PR exam
haemorrhoids management
soften stools- increase dietary fibres and fluid intake
Topical local anaesthetics and steroids to help symptoms- eg anusol- shrinks haemorrhoids
Outpt treatment- rubber band ligation to cut off blood supply
Anal fissures what are they- risk factors
Tears in the mucosal lining of the anal canal, most commonly due to trauma from defecation of hard stool.
Constipation, dehydration, IBD, chronic diarrhoea, STIs
anal fissure symptoms and signs
sharp pain on defecation
intense pain post defecation
bright red, rectal bleeding
fissures can be visible and/or palpable (painfully) on DRE
anal fissure management
soften stool:
dietary advice- high fibre w/ high fluids
bulk forming laxatives
lubricants like petroleum jelly may be tried before defecation
topical anaeshtetics
analgesia
If chronic: GTN cream/diltiazem cream- increases blood supply to region and relaxes IAS
can consider referral for surgery if GTN is not effective after 8 weeks
Perianal abscess and fistula - what is it and common causative organisms, risk factors
collection of pus in subcut tissue of anus
E. Coli
Male
Crohns
Diabetes
Perianal abscess symptoms and signs
skin irritation around anus
anal pain- worsened by sitting
pus-like discharge from anus
bleeding
Erythematous, fluctuant tender perianal mass, which may be discharging pus
perianal abscess investigations
Diagnosis is typically clinical
MRI is gold standard for imaging
perianal abscess management
incision and drainage- wound will heal in 3-4 weeks
Abx can be used, but only if there’s systemic upset
Perianal fistula what is it- causes and risk factors
abnormal connection bwt anal canal and perianal skin
IBD
systemic disease
diabetes
perianal fistula symptoms and signs
recurrent perianal abscesses
intermittent or continuous discharge onto the perineum, including mucus, blood, pus or faeces
perianal fistula management
most common surgical methods used:
Fistulotomy- laying the tract open by cutting thru skin and subcut tissue, allowing it to heal by secondary intention
chronic mesenteric ischaemia presentation
intermittent central colicky abdo pain after eating
weight loss
chronic mesenteric ischaemia diagnosis management
CT angiography
reduce risk factors
secondary prevention eg statin antiplatelets
revascularisation- endovascular procedures first line (ie percutaneous mesenteric artery stenting)
acute mesenteric ischaemia cause and risk factor
usually caused by a thrombous stuck in the artery/embolus, blocking blood flow.
AF is risk factor due to thromboembolism formation
acute mesenteric ischaemia diagnosis and management
CT contrast, pts will have metabolic acidosis and raised lactate due to ischaemia
Pts require surgery to remove necrotic bowel, remove/bypass the thrombus in the blood vessel )open surgery or endovascular procedures may be used)
