Bowel Cancer and Acute Abdomen Flashcards
what are some causes of fresh blood in stools?
haemorrhoids acute anal fissures colorectal neoplasms acute proctitis IBD
what causes black stools or malaena?
bleeding from further up the GI tract, including small intestine or stomach
what are some risk factors for colorectal cancer?
family history
previous cancers
IBD
red meat and low fibres
where are the cancers most common?
2/3 in colon and rest in rectum
more left colon than right
recto-sigmoid colon most frequent site
what are the symptoms of bowel cancer?
change in bowel habit weight loss PR bleeding tenesmus IDA = TWO WEEK WAIT bowel obstruction
when would you give a two week wait for CRC
> 6week change in bowel habit AND pr bleeding any age
change in BH >6 weeks and age >60
RB without any other symptoms and >60
palpable mass right sided or rectal any age
IDA any age
what investigations can you do for CRC
colonoscopy - first line and biopsy
barium enema
CT colonography (in patients less fit for colonoscopy)
CT TAP for metastasis in patients with weight loss
what is screening like in the UK for CRC?
Faecal immunochemical test: every 2 years to people age 60-74
faecal occult blood test
THEN colonoscopy
also - flexible cystoscopy
what is a polyp?
growth of tissue from a mucous membrane off a surface
benign or malignant, can become malignant
hyperplastic = completely benign
what is the dukes classification?
A - only mucosa and part of bowel wall - 90% prognosis
B - extending through muscle of bowel wall - 70-80%
C - lymph node involvement 50%
D - metastatic 5-10%
what other staging is used in CRC?
TNM staging - refer to notes
what are the treatment options for CRC?
surgical resection
chemotherapy
radiotherapy
palliation
polypectomy for prevention
what is FAP and how is it treated?
familial adenoma polyptosis - polyps in whole colon which will develop into cancer
total colectomy with ileo-anal pouch
what is the genetics of FAP
mutation in Apc gene - TSG
95% penetrance, CRC in 20-30s
what is hNPCC?
hereditary non-polyposis colon cancer
autosomal dominant
inherited mismatch repair genes
- 70% penetrance, 30-50s age range, rapid progression and highly aggressive
- use amsterdam criteria to exclude FAP
what are the types of surgical resection for CRC?
right hemicolectomy - tumours in caecam, ascending and proximal colon
left hemi-colectomy - tumours of distal transverse and descending colon
sigmoid colectomy - tumours of sigmoid colon
anterior resection - tumours of low SC or higher rectum
abdominoperineal resection - tumours of lower rectum; remove rectum and anus and suturing over, leaving them with permanent colostomy
what does a surgical resection involve?
removing a tumour and creating an end to end anastomosis
what is a covering loop ileostomy
temporary ileostomy to protect distal anastomosis
let it heal for 6-8 weeks tgeb reverse
loop: 2 ends of a section of small bowel being brought out onto skin (look for diagram)
lower right side of abdomen
what are complications of surgical resections for CRC?
bleeding infection pain damage to nerves, ureter, bladder etc anaesthetic risks anastomosis leak stoma? failure
what are the follow ups for curative resections?
CT TAP at 1 and 2 and 3 years
Colonoscopy at 1 and 5 years
CEA every 6 months for 3 years
what is CEA?
carcinoembryonic antigen
tumour marker blood test for bowel cancer
useful to predict relapse of prev treated CRC
what is diverticular disease
outpouching of the colonic mucosa and submucosa through WEAKNESS in the outer muscle layers
- commonest site is sigmoid colon due to pressure effects: chronic constipation and accumulation of faecal matter
what is diverticulosis?
presence of diverticula without symptoms
common as people age
no treatment
what is diverticulitis and what are the symptoms?
inflammation of the pouches/diverticula
- left iliac fossa pain and tenderness
- fever
- diarrhoe
- may have RB and mucus in stools
- nausea and vomiting
how do you manage diverticulitis?
admission if unwell or haemodynamically unstable antibiotics analgesia fluid resuscitation surgical resection ?
what are the complications of diverticular disease?
bleeding
infection —> diverticulitis
perforation; faeces leaking leading to peritonitis
abscess formation
FISTULA from colon to bladder: increase susceptibility to UTIs
obstruction
how do you explain diverticular disease to patients
wear and tear of the bowel
what are the RF for diverticular disease
high intake red meat freq use of laxatives chronic constipation and low fibre hereditary factors age
what are the investigations you should do for diverticulitis?
FBC for infection and anaemia
U&E’s for CT contrast, electrolyte imbalance due to diarrhoea
CRP for inflammation
ABG for metabolic acidosis or alkalosis
lactate for sepsis in severe cases
blood cultures to rule out gastroenteritis
imaging: CT AP with contrast
what is an acute abdomen?
condition of severe abdominal pain, usually requiring emergency surgery
caused by acute disease of or injury to internal organs
what causes abdominal pain over the whole abdomen?
perforated viscous
acute pancreatitis
medical causes like DKA
what causes RUQ pain?
biliary colic
acute cholecystitis
acute cholangitis
what causes LUQ pain?
acute pancreatitis
spontaneous splenic rupture
medical disorders eg pneumonia
what causes right iliac fossa pain?
acute appendicitis diverticulitis (less likely in right) ectopic pregnancy ovarian cyst crohn's
what causes epigastric pain?
pancreatitis
peptic ulcer disease
AAA
what causes central umbilical pain?
AAA early appendicitis intestinal obstruction ischaemic colitis mesenteric thrombosis - in elderly
what causes left iliac fossa pain?
diverticulitis
constipation
ectopic pregnancy
ovarian cyst
what causes suprapubic pain?
acute urinary retention
pelvic inflammatory disease
UTI
ectopic pregnancy
what causes loin to groin pain?
renal colic
AAA
pyelonephritis
what are some classical signs of acute abdomen?
fever low grade tenderness rigidity and guarding rebound tenderness bowel sounds: - absent in peritonitis - increased in small bowel obstruction
abdo distension
what investigations would you do for an acute abdomen?
FBC U&E for CT contrast LFTs CRP amylase INR: synthetic function of liver, coagulation before theatre ABG: PO2 and calcium for acute pancreatitis lactate: tissue ischaemia abdo xray for bowel obstruction erect CXR for bubble under diaphragm USS abdo: gall stones, biliary duct dilatation and gynae CT
how do you manage an acute abdomen?
ABCDE nil by mouth IV access IV fluids analgesia and anti-emetics NG tube if vomiting and suspected obstruction catheterise for fluid balance monitoring escalate care
what is peritonitis
inflammation of peritoneum
localised: cause: underlying organ inflammation
generaliseD: perforation of abdo organ eg ulcer/appendix
spontaneous bacterial: infection of ascites in cirrhotic liver disease
what are some other symptoms of peritonitis and how do you treat it?
guarding
rebound tenderness
minimal bowel sounds
- laparotomy
what is a hernia?
structure that passes through space or defect into an abnormal location
how do you describe a hernia?
reducible
irreducible
obstructed (bowel lumen is no longer open)
strangulated - compression around hernia preventing BF to bowel lumen
how does a hernia present?
painless swelling
may be asymptomatic
or pain when coughing, change in bowel habits, constipation, scrotal swelling
what is an inguinal hernia, how is it caused and treated?
protrusion of abdominal contents emerging through superficial ring as an exit
caused by weakening of muscles/increased intra-abdominal pressure so eg chronic cough, constipation, heavy lifting
treated via open or laparoscopic
reduce hernial contents back into cavity and put mesh that strengthens wall
what is a femoral hernia
just below inguinal ligament, abdo contents pass through weakening in femoral canal
higher risk of strangulation
what are the other types of hernias?
- umbilical
- incisional: near or on surgical site
what is a hiatus hernia
herniation of stomach through opening in diaphragm (LES)
herniation causes contents to reflux up oesophagus and give reflux symptoms
treatment: medical management of symptoms or surgical
what are direct inguinal hernias
pierces posterior wall, doesn’t go through deep ring and then exits through superficial
what are indirect inguinal hernias?
does not pierce posterior wall, passes through deep inguinal ring then into inguinal canal and exits superficial ring
how do you tell on examination the difference between indirect and direct
put finger over deep inguinal ring = can control indirect but not direct
what is bowel obstruction
mechanical blockage of intestinal contents
= gross dilatation of proximal bowel
secretions of large volumes of electrolyte rich fluid into bowel
what are the types of bowel obstruction?
functional or paralytic ileus = when bowel not mechanically blocked but inflammation / electrolyte imbalance/ surgery means not working properly
closed loop: second obstruction proximally
sugrical emergency
what causes bowel obstruction?
small bowel - adhesions and hernia
large - malignancy and diverticular disease
intraluminal: gallstone ileus, ingested foreign body
mural: obstruction from bowel wall eg cancer, strictures, DD
extramural: outside of bowel causing obstruction by narrowing lumen eg hernia
what are the cardinal features of BO?
Abdominal pain colicky vomiting abdo distension absolute constipation (Early in distal and late in proximal obst)
what are the clinical features of BO?
guarding and rebound tenderness - NONE
tympanic sound or tinkling bowel sounds on percussion and auscultation
what are the differentials for obstructed bowel disease?
toxic megacolon
constipation
how do you test for BO?
bloods for electryolytes and third space losses
venous blood gas bc evaluate signs of ischaemia
CT contrast AP
AXR
erect CXR to assess for free air under diaphragm
what is small bowel obstruction
dilated bowel >3cm
central
valvulae conniventes visible
what is large bowel obstruction?
dilated bowel >6cm
peripheral location
haustral lines visible
how do you treat BO?
fluid resusc
catheter
surgical if necessary
conservative: drip and suck = nil by mouth, insert NG tube
IV fluids and correct electrolytes
what is the surgical intervention for BO?
resection
what are the complications of bowel obstruction
bowel ischaemia
bowel perforation
dehydration and renal impariment
