Bowel Flashcards
What is a paralytic ileus/pseudo obstruction
The bowel goes to sleep (peristalsis stops temporarily)
Very common post abdominal surgery
What are the causes of Ileus
Post abdo surgery Intra-abdominal infection / inflammation Pneumonia Trauma Electrolyte Imbalance
What are the signs and symptoms of Ileus
Similar to obstruction Abdominal distention and pain Constipation / no bowel movement / no flatulence Sluggish bowel sounds Vomiting
what is the management of Ileus
Nil by mouth / sips of water
NG tube if vomiting
Mobilise (to stimulate peristalsis)
IV fluids to prevent dehydration
Consider parenteral nutrition (IV nutrition) if prolonged period without food
Eventually bowels should regain function and the ileus resolve
What is diverticula
pouches in bowel wall (a defect in the bowel wall continuity), usually from 0.5 – 1cm
Or ‘Wear and tear of the bowel’
What is diverticulosis
the presence of diverticula without symptoms
What is diverticulitis
inflammation of diverticula
What are the signs and symptoms of diverticulosis
Left iliac fossa / lower left abdominal pain and tenderness Fever Diarrhoea PR blood / mucus Nausea and vomiting
What are the risk factors for diverticula
increasing age
low fibre diets
How is diverticulosis diagnosed and managed
- incidentally on colonoscopy or CT scan
- No treatment necessary
- advice: high fibre diet and weight loss
What is the management of diverticulitis
onsider admission if unwell Antibiotics Analgesia Fluid resuscitation May require surgical resection if severely septic / peritonitic or develops complications
What are the complications of diverticulitis
Haemorrhage Perforation Abscess Fistula (e.g. between colon and bladder / vagina) Ileus / obstruction
What is coeliacs Disease
- autoimmune condition where exposure to gluten causes an autoimmune reaction that causes inflammation in the small bowel. It usually develops in early childhood but can start at any age.
- auto-antibodies are created in response to exposure to gluten that target the epithelial cells of the intestine and lead to inflammation.
What two auto-antibodies are important in diagnosing coeliacs
- anti-tissue transglutaminase (anti-TTG)
- anti-endomysial (anti-EMA)
- Deaminated gliadin peptides antibodies (anti-DGPs)
- TOP TIP: Check for IgA deficiency first because if IgA low, the anti-TTG and anti-EMA will be low regardless
What histology may you see on biopsy in a patient with coeliacs disease
- atrophy of the intestinal villi
- “Crypt hypertrophy”
What is the presentation of coeliacs disease
- Often asymptomatic
- Failure to thrive in young children
- Diarrhoea
- Fatigue
- Weight loss
- Mouth ulcers
- Anaemia
- Dermatitis herpetiformis
What does coeliac cause anaemia
secondary to iron, B12 or folate deficiency
What is dermatitis herpetiforms
(an itchy blistering skin rash typically on the abdomen)
What rare neurological symptoms may you see in coeliacs disease
Peripheral neuropathy
Cerebellar ataxia
Epilepsy
What are the genetic associations of coeliacs disase
HLA-DQ2 gene (90%)
HLA-DQ8 gene
What other autoimmune diseases are associated with coeliacs
Type 1 Diabetes Thyroid disease Autoimmune hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis
What are the complications of untreated coeliacs disease
Vitamin deficiency Anaemia Osteoporosis Ulcerative jejunitis Enteropathy-associated T-cell lymphoma (EATL) of the intestine Non-Hodgkin lymphoma (NHL) Small bowel adenocarcinoma (rare)
What is the management of Coeliacs disease
Lifelong gluten free diet is essentially curative. Relapse will occur on consuming gluten again.
What is Irritable bowel syndrome
“functional bowel disorder”. This means that there is no identifiable organic disease underlying the symptoms. The symptoms are a result of the abnormal functioning of an otherwise normal bowel.
What are the symptoms of irritable bowel syndrome
Diarrhoea Constipation Fluctuating bowel habit Abdominal pain Bloating Worse after eating Improved by opening bowels
What pathology should be excluded before diagnosing irritable bowel syndrome
Normal FBC, ESR and CRP blood tests
Faecal calprotectin negative to exclude inflammatory bowel disease
Negative coeliac disease serology (anti-TTG antibodies)
Cancer is not suspected or excluded if suspected
According to NICE, was symptoms suggest irritable bowel syndrome
Abdominal pain / discomfort:
- Relieved on opening bowels, or
- Associated with a change in bowel habit
AND 2 of:
- Abnormal stool passage
- Bloating
- Worse symptoms after eating
- PR mucus
What diet advice do you give to patients with irritable bowel syndrome
Adequate fluid intake
Regular small meals
Reduced processed foods
Limit caffeine and alcohol
Low “FODMAP” diet (ideally with dietician guidance)
Trial of probiotic supplements for 4 weeks
What first line medications are used in irritable bowel syndrome
Loperamide for diarrhoea
Laxatives for constipation
Antispasmodics for cramps e.g. hyoscine butylbromide (Buscopan)
Which laxatives can worsen irritable bowel syndrome
Avoid lactulose as it can cause bloating. Linaclotide is a specialist laxative for patients with IBS not responding to first line laxatives
What are second line medications for the treatment of irritable bowel syndrome
Tricyclic antidepressants (i.e. amitriptyline 5-10mg at night)
What are third line medications for the treatment of Irritable bowel syndrome
SSRIs antidepressants
Cognitive Behavioural Therapy (CBT) is also an option to help patients psychologically manage the condition and reduce distress associated with symptoms.
What is inflammatory bowel disease
Umbrella term for two main diseases causing inflammation of the GI tract: Ulcerative Colitis and Crohn’s disease. They both involve inflammation of the walls of the GI tract and are associated with periods of remission and exacerbation.
Common features of Crohns Disease
N – No blood or mucus (less common)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
- weight loss, strictures and fistulas.
COmmon features of ulcerative colitis
C – Continuous inflammation L – Limited to colon and rectum O – Only superficial mucosa affected S – Smoking is protective E – Excrete blood and mucus U – Use aminosalicylates P – Primary Sclerosing Cholangitis
What presentation is common in patients with IBD
Diarrhoea
Abdominal pain
Passing blood
Weight loss
What investigations should be completed if suspecting Inflammatory bowel disease
- Routine bloods for FBC, CRP, TFTs, U&Es, LFTs
- CRP/ESR indicates inflammation and active disease
Faecal calprotectin
Endoscopy (OGD and colonoscopy) with biopsy is diagnostic
Imaging with ultrasound, CT and MRI : look for complications
What is faecal calprotectin
released by the intestines when inflamed) is a useful screening test (> 90% sensitive and specific to IBD in adults
Complications of inflammatory bowel disease
Strictures
fistulas
Abscesses
How do induce remission ins Crohns Disease
First line: Steroids (e.g. oral prednisolone or IV hydrocortisone)
If steroids alone don’t work, consider adding immunosuppressant medication under specialist guidance:
Azathioprine Mercaptopurine Methotrexate Infliximab Adalimumab
How do you maintain remission in patients with Crohns Disease
First line: - Azathioprine - Mercaptopurine Alternatives: - Methotrexate - Infliximab - Adalimumab
when is surgery indicated in Crohns disease
- When the disease only affects the distal ileum it is possible to surgically resect this area and prevent further flares of the disease
- Crohns typically involves the entire GI tract
- Surgery can also be used to treat strictures and fistulas
How do you induce remissions in patients with mild to moderate Ulcerative colitis
First line: aminosalicylate (e.g. mesalazine oral or rectal)
Second line: corticosteroids (e.g. prednisolone)
How do you induce remissions in patients with severe Ulcerative colitis
First line: IV corticosteroids (e.g. hydrocortisone)
Second line: IV ciclosporin
How do you maintain remission in patients with ulcerative colitis
Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine
When is surgery indicated in patients with ulcerative colitis
removing the colon and rectum (panproctocolectomy) will remove the disease. The patient is then left with either a permanent ileostomy or ileo-anal anastomosis (J-pouch)
What is an ileo-anal anastomosis (J-pouch)
the ileum is folded back in itself and fashioned into a larger pouch that functions a bit like a rectum. This “J-pouch” which is then attached to the anus and collects stools prior to the person passing the motion.
What are haemorrhoids
venous “vascular cushions” that have become enlarged due to increased pressure (e.g. secondary to straining in constipation)
What are the symptoms of haemorrhoids
No symptoms Constipation Painless bright red bleeding (on toilet paper or dripping) Sore / itchy anus Feeling a lump around or in anus
What grades can be given to haemorrhoids
1st degree: no prolapse
2nd degree: prolapse when straining and return on relaxing
3rd degree: prolapse when straining, do not return on relaxing but can be pushed back
4th degree: prolapsed permanently
What is a thrombosed haemorrhoid
Caused by strangulation at base of haemarrhoid causing thrombosis (a clot) in the haemarrhoid
Can be extremely painful
Appear as purple, very tender swollen lumps around anus
PR exam will be impossible due to pain
What may you see on examination of a patient with haemorrhoids
- External haemorroids visible on inspection
- Internal haemorrhoids difficult to feel (may not be possible) on PR exam
- Appear as swellings covered in mucosa, may appear (prolapse) if the patient is asked to” bear down” during inspection
- Proctoscopy is required for proper visualization and inspection
What is the management of haemorrhoids
- Symptomatic (anusol cream, local anaestetic e.g. instillagel, topical steroids)
- Laxatives
- Band ligation (tight rubber band around base to cut off blood supply)
- Surgical haemorrhoidectomy
