Bowel Flashcards
STOMAS
resection, diversion/rest, decompression
early: infection, hge, isch, high output, retraction, adhesion, obstruction
late: prolapse, hernia, obstruction, intuss, stenosis, fistula, dermatitis, psych
ileo: spout, RHS, liquid, 1-2day, IBD Hx
colo: flush, LHS, semi/formed, daily bag change
*anastamoses: gastrograffin
Appendix Sx2
abdo pain: dull central => sharp RIF
constipation, anorexia, N&V
rebound/percussion
guarding, peritonitis, shallow/still/cough
Rovsing’s, PR tender, ?tender mass
psoas (hip extension) or cope/obturator (flexion)
tachyC, tachyP, fever, fetor, flush
Appendix Alvarado
migrating pain: KEY anorexia (appe unlikely if hungry) N&V tender RIF (2pt): KEY rebound/percussion: KEY elevated temp: usually low grade leucocytosis (2 points) shifted left
5-6 possible; 7-8 probably, 9-10 v. likely
Appe Mx (Ix + Tx)
must do b-HCG and amylase UA (?UTI), FBC, UE, CRP PR, PV (?PID/gynae) USS: ?fatal delay; good for ?O&G CT: ?fatal delay; good for ?Dx AXR/eCXR: rarely used laparoscopy: early Dx + resection
ABx once op decided (Cef + met)
?delayed closure/drainage if perf
exclude CRC, Meckel’s, PID, IBD
drain abscesses
Appe perf complications
mass, abscess local or general peritonitis adhesions, fistulae, obstruction portal pyaemia retained faecolith (chronic infection) infertility (tubal) overwhelming sepsis + death
post-op: haematoma, infection, dehiscence, abscess, obstruction, hernia
Meckel’s
aSx, intuss/volvulus, diverticulitis (‘appe’), perf, PUD, hge, cyst, fistula
2s: 2-4% prev, 2” long, 2’ from IC valve, 2yo, 2x M, 2 types (gastric or heterotopic panc)
obstruction 4s
Sx: vom (+/-N&V), colic, constipation, distention
signs: distension, tinkling, empty PR, dehydration
SBO: adhesions, herniae, IBD/stricture, intuss
LBO: CRC, volv, diverticular, stricture
other: gallstone, ileus (L/S)/pseudo (L),
Tx: resus (NBM + fluids), drip and suck (most resolve 4/7), enema/evac, surgery
*surgery: refractory, ischaemia, tumour/hernia, perf, competent IC valve
Obstruction complications
distension + oedema: electrolytes, toxins, dehyd
bacteria: infection, ulceration
perforation (closed loop)
incomplete obstruction: slow CRC, visible peristalsis
strangulation/ischaemia/necrosis (peritonism, sharp, more ill)
paralytic ileus/pseudo-obstruction
ileus: SB > LB; hypoK, leak, sepsis, opiates, surgery
pseudo: LB; AKI, trauma, metabolic, drugs
no pain, absent BS
contrast enema diagnostic
Coeliac
tTG and EMA IgA gluten enteropathy
steatorrhoea/dd, weight loss, lethargy, pain, derma herpi
anaemia (mixed/normo), hypoalbo/Ca/vit D
Ab + Bx (jej/duo): flat mucosa, atrophy, hyperplasia, wcc
small lymphoma/AC risk
malabsorption investigations
FBC: anaemia + deficiency (Fe, B12, Ca)
high INR, lipids, serology
stool: sudan (fat globules)
barium: diverticula, Crohn’s
breath hydrogen: bacteria overgrowth
endoscopy + biopsy
ERCP: biliary/chronic panc
malabsorption DDx
coeliac Crohn's disease reduced bile: PBC, obstruction pancreatic: CF, CA, chronic/pseudocyst small bowel: Whipple (PAS), enzymes, infiltration, resection infection/overgrowth:
Chronic Panc
calcified proteins => obstruction
epigastric pain, erythema ab igne, brittle DM
analgesia, Creon, Multivate, DM control, diet
pancreatectomy, pancreaticojejunostomy
DD mechanisms
osmotic: malsorp => substances; watery
secretory: secretion + reduced absorption of fluid/electro
inflamm/mucosal: damage => fluid loss +/- blood
motility: altered peristalsis; anxiety, ANS/DM, IBS
DD history
Red Flags: nocturnal, blood/mucus, responds to fasting, weight loss
duration, previous, ‘FUN’, tenesmus/incomplete
volume, colour, smell, blood/mucus
assoc: pain, vom, systemic, food
PMH/DH: RDT, panc, systemic, lactase, ABx
SH: travel, drugs
FH: IBD, coeliac, neoplasm
Acute DD
watery: cholera, E. coli, rota/adenovirus, AAD, giardia
blood: campylo, shigella, EHEC, salmo, Yersinia, C. diff, schisto, IBD, diverticula, amoeba
Chronic DD
colon: CA, IBD, IBS, colitis
SB: coeliac, IBD, bile acid, lactase, bacteria, ischaemia, RDT, lymphoma, infection
panc: chronic panc, CF, cancer
endo: hyperthy, DM, addison’s, carcinoid
other: IBS, surgery, drugs, overflow
IBS
3d/month for 3/12
discomfort/pain, defaecate, frequency, form
abn freq/form/passage (strain, urgency, tenesmus)
bloating/distension, gynae and urinary Sx
sleep, back, headache, fatigue, hallitosis
- > 40yo, acute (<6/12), anorexia/weight, nocturnal
- exclude ovarian/CRC
- Ix if other symptoms (e.g. dysphagia, reflux)
Tx: fibre, fluid, antispasm, antacid, ?TCA, CBT
IBD - presentation/patho
Crohn’s: pain + weight loss + dd; perianal + systemic common
*skip, mouth-anus, transmural, cobblestone + fissure
UC: bloody dd; systemic = severe; tenesmus; non-smoker
*continuous, colonic, mucosal, pseudopolyps
IBD - investigations and RF
RF: smoking (CD), FHx, GE, appendicitis, diet
Ix: bloods (incl. CRP/ESR, Fe, B12, folate, albumin) and cultures
scope + Bx, Ba (enema/follow-through), AXR, MRI (pelvic)
IBD - treatment
Crohn’s: steroids (IV if severe); CST/immosupp; cipro/inflixi for fistulae
UC: ASA + CST (PR + IV CST if severe); ASA +/- immosupp;
surgery: complications/refractory; cure in UC, recurs in CD
IBD (UC) severity
Mild: <4 stools/day, no systemic, CRP/ESR normal
Mod: 4-6 stools/day
Severe: systemic (Fever, tachy, Hb, alb), 6+ stools
*severe = Admit!
IBD complications
CD: fistulae, strictures, adhesions, fissures, abscess/mass, episcleritis
UC: PSC and uveitis more common, TMC, CRC
both: arthritis (Commonest), ulcers, NASH, VTE, renal stones
Diverticular disease
PR, scope, CT/USS
symptomatic: colic, bowel habit, nausea, flatulance
Tx: diet, mebeverine (SM relax)
complications: perforation (common Hartmann's) peritonitis, abscess stricture, fistulae, obstruction bleeding: usually painless and large
diverticulitis
eCXR, USS, contrast CT
inflammation: severe colic, constipation, LHS ‘appe’, systemic, mass
may be peritonic: tender, gaurding, high temp (?septic)
*bleeding = not diverticulitis (mutually exclusive)
Tx: bowel rest, ABx, drain (abscess), op (perf)
CRC presentation
bowel habit, bleeding (incl. FOB), constitutional, pain (rare), pruritus ani, mass
30% emergencies: obstruction, perf, hge
RHS: often aSx; IDA, weight, pain
LHS: PR bleed, obstruction, tenesmus, PR mass
Red flags: tenesmus, nocturnal, age, habit + PR bleed, IDA, mass
CRC RF
age, male, PMH Ca, FHx
polyposis (FAP, HPNCC, Lynch)
IBD (UC pancolitis)
western diet (low fibre, fat, meat), ciggs, alc, obesity
*anal Sqcc: HPV (Warts), infection; RDT +CTX
TMN staging
Stage I: T1 (submucosa) or T2 (MP)
Stage IIa: T3 (subserosa)
Stage IIb: T4 (local invasion)
Stage IIIa: T1/2 + N1 (1-3 nodes)
IIIb = T3/4; IIIc = N2 (>3 nodes)
Stage IV: any M1
Modified Duke’s Staging
A: within MP; S1 (T1/2)
B: subserosa/invasion; S2 (T3/4)
C: lymph nodes (C1 = local, C2 = apical); stage 3 (N1/2)
D: mets; stage 4 (M1)
*5ys: 80-95%; 66-85%; 35-65%; 5-7%
CRC Mx (Ix + Tx)
FBC (IDA), FOB (Screening), scope +Bx, enema/CT pneumocolon
staging: LFTs, CT/MRI, liver USS
CEA (monitoring), DNA (?familial)
surgery: hemi/sigmoid/AR/APR, liver mets
hge, infection, CVS/VTE, AKI, damage, ileus/adhesions
RDT: neo for rectal, post if high recurrence risk
CTX: adjuvant for Dukes’ C+
Pall: CTx, surgery, stent
CRC Screening + f/u
screening: FOB 2-yearly (60-69yo), sigscope (LHS), colonoscopy (high risk)
f/u: CEA 3-monthly + scope 3-yearly
Haemorrhoids
3/7/11
bright PR bleed, prolapse, incontinence
pruritis, mucus d/c, anaemia, pain (thrombosis)
RF: constipation, stress, trauma, pelvic pressure/portal HTN
1st: no prolapse; 2nd: spont reduction; 3rd: digital; 4th: persistent prolapse
Mx: scope (Dx); diet (fibre, fluids, no caff), lax, PK
IF-coag, sclerosant, ligation, cryo, ectomy (4th)
perianal disease
Fistula: abscess/CD/diverticular/CA; MRI/EUS
- goodsall: anterior straight, posterior/>3cm curve to midline
- Tx: excision/open + drain; incont risk
fissure (6/9/antlat): extreme pain, lasts hours; PR bleed, pruritus, constipation; IBD/sinus/skin tag
- Tx: scope (dx), diet/softener, LA cream, SM relax (GTN, CCB)
- sphincterotomy if refractory
infection: red, swollen, tender, fever, d/c
* abscess: surgery emergency; severe pain; GA drain
* pilonidal: natal cleft; excise tract
