Bowel, Rectum, Anus Flashcards
What are 3 red flag symptoms for a change in bowel habit that make functional disorders less likely?
Weight loss
Age >50
PR bleeding
What is the 1st line management for IBS?
Antispasmodic or laxative or antimotility
(Antimotility for diarrhea)
(Avoid lactulose laxative)
What antimotility agent is used in the management of diarrhea in IBS?
Loperamide
What antispasmodics are used in the management of IBS?
Meberevine
Peppermint oil
Alverine
UC or Crohn’s - which is granulomatous?
Crohn’s
UC or Crohn’s - which is transmural infalmmation?
Crohn’s
UC or Crohn’s - which is protected by smoking? which aggravated?
UC protected by smoking
Crohn’s aggravated by smoking
UC or Crohn’s - which has crypt abscesses?
UC
UC or Crohn’s - which has skip lesions?
Crohn’s
UC or Crohn’s - which is any part of GIT? which is limited to colon?
Crohn’s any part of GIT
UC colon
UC or Crohn’s - which is cobble stoning?
Crohn’s
UC or Crohn’s - which is rose thorn ulcers?
Crohn’s
UC or Crohn’s - which has a lead pipe colon on AXR and what is that??
UC
Loss of haustration
UC or Crohn’s - which is thumbprinting on AXR and what is that?
UC
Thickened haustra
What is fulminant disease?
Severe + rapid
UC or Crohn’s - which has perianal disease?
Crohn’s only
UC or Crohn’s - which is aggravated by NSAIDs?
UC
What blood test can be used for differentiating IBS and IBD?
Fecal calprotectin
Also inflam markers
UC or Crohn’s - which gets toxic megacolon?
UC
Where is first effected in UC?
Starts at rectum + progressed upwards
Ulcerative colitis Define: -Proctitis -Proctosigmoiditis -Left sided colitis -Extensive colitis -Panproctocolitis -Backwash ileitis
-Proctitis: rectum only
-Proctosigmoiditis: rectum + sigmoid
-Left sided colitis: up to splenic flexure
-Extensive colitis: to hepaitc flexure
-Panproctocolitis: whole colon
Backwash ileitis: terminal ileum
What effect does IBD have on:
- Hb
- WCC
- Neutrophils
- CRP
- Potassium
- Albumin
- Fecal calprotectin
- Low Hb
- High WCC
- High neutrophils
- High CRP
- Low potassium
- Low albumin
- High fecal calprotectin
(Crohn’s can also cause low B12 and low vit D)
A patient with UC has a distended tender abdomen and is septic - what is the Dx?
Toxic megacolon
What is the risk in toxic megacolon?
Perforation
How is toxic megacolon diagnosed?
AXR
What is the management of toxic megacolon?
Surgical decompression if no improvement at 24hr
What HLA type is associated with inflammatory bowel disease?
HLA B27
What part of the body is always effected in ulcerative colitis?
Rectum
What dermatological complaint is associated with IBD?
Erythema nodosum
What autoimmune hepatitic condition is associated with IBD?
Primary sclerosing cholangitis
How do you classify mild, moderate and severe UC?
Mild <4 bloody stools / day, normal CRP
Mod 4-6 bloody stools
Severe >6 bloody stools per day + systemic upset
How is inflammatory bowel disease diagnosed?
Colonoscopy biopsy (see crypt abscesses, psuedopolyps, widespread ulceration, depletion of goblet cells)
There is an increased risk of adenocarcinoma in UC, how often and how do you monitor for this?
Colonoscopy every 2yr from 10yr post Dx
Which layers of the bowel wall are inflamed in Crohn’s and in UC?
Crohn’s transmural inflammation
UC mucosa + submucosa
If you were to CT a patient with IBD would you see thickening or atrophy of the bowel wall?
Thickened bowel wall due to inflammation
What drugs are used 1st line to induce remission in proctitis, proctosigmoiditis, mild/moderate extensive disease and severe extensive disease?
Proctitis: topical 5-ASA
Proctosigmoiditis: topical 5-ASA
Mild/moderate extensive disease: topical + oral 5-ASA
Severe extensive disease: IV/PO steroids
In UC, if remission is not achieved after 4 weeks of topical 5-ASA, what is the next step in Mx?
Either oral 5-ASA or steroids
What DMARD is used in the management of Crohn’s and what are the indications for it?
Oral azathioprine if 2 exacerbations in 1 yr requiring oral steroids
Growth retardation in children with ulcerative colitis is an indication for elective surgery. T or F
True
What are the elective surgical 3 options in UC?
Ileoanal pouch
Protocolectomy with end ileostomy
Protocolectomy with ileorectal anastomosis
What drug is used to maintain remission 1st line in UC?
Topical / rectal / combined 5 ASA
What perianal disease is seen in Crohn’s disease?
Fissure, ulcers, abscesses, tags
Crohn’s disease could present with acute bowel obstruction, T or F
True
Is IBD associated with seronegative or seropositive large or small joint arthropathy?
Seronegative large joint arthropathy
If you suspect a patient with Crohn’s disease has a stricture or fistula, what test would you do?
MRI
How is remission induced in Crohn’s disease?
Steroids IV / PO depending on severity
To induce remission in Crohn’s disease, if a patient has no improvement after 3 days on IV steroids, what is the next step in management? Say drug name + class
Infliximab monoclonal antibody anti-TNF
What drug is 1st and 2nd line to maintain remission in Crohn’s disease?
1st azathioprine
2nd mercaptopurine
In Crohn’s disease if a patient has many surgeries, what complication are they are risk of?
Short gut syndrome
What is short gut syndrome?
Insufficient bowel left for essential nutrient absorption <1m
What is a seton suture?
Surgical Mx of anal fistula in Crohn’s disease
There is a risk of CRC in Crohn’s disease, how and how often is this monitored for?
If have a colon at 10 yr post Dx (i.e. not surgically removed), colonoscopy every 2yr
Before initiating azathioprine in Crohn’s disease, what blood test should you do to check for what potential side effect?
TPMT levels
Agranulocytosis
What HLA type is celiac disease?
HLA-DQ2
What is the 1st line investigation for celiac disease?
Anti-TTG
What test is diagnostic of celiac disease?
Duodenal biopsy shows villous atrophy
What vaccine is offered to those with celiac disease and why?
Pneumococcal vaccine due to hyposplenism
Which immunoglobulin is involved in celiac disease?
IgA
What dermatological presentation is associated with celiac disease?
Dermatitis herpetiformis
Can celiac disease cause bloody diarrhea?
No
Does celiac disease cause diarrhea or constipation?
Diarrhea
What is a colorectal adenoma?
Dysplastic polyp
What screening test is used for CRC?
qFIT
Define neoplasia
Abnormal uncoordinated growth
Name 2 genetic disorders associated with CRC?
FAP familial adenomatous polyposis
HNPCC hereditary non-polyposis colorectal cancer
What staging criteria is used for CRC? Name the components
Duke criteria A confined to mucosa B invades muscularis propria C regional LN D distant
Name the CRC tumour marker
Cea
What type of scan is used for staging CRC?
CT
MRI for rectal tumours
A 67 year old male has an incidental finding of iron deficiency anaemia. What tests should you do 1st and 2nd line to look for a cause?
1st IgA TTG + colonoscopy
2nd OGD
When taking a history and a patient mentions they have bloody diarrhea, what should you ask about the blood?
Mixed in, on paper or on stool
Colour
Quantity
Where are CRC tumours most likely to cause obstrution?
Caecum
What procedure can be used palliatively to prevent bowel obstruction in CRC?
Palliative stenting
What test is used for diagnosis in CRC? What about in frail elderly patients?
Colonoscopy biopsy
If frail elderly patients just do CT colonography
The risk of anastomotic leak post bowel resection increases as you move [towards / away] from the rectum
Towards
What are the indications for screening for CRC with a 1-2 yearly colonoscopy from age 25?
3 first degree relatives with CRC/Lynch Ca with 1 aged under 50
Unless Lynch excluded in which case frequency of colonoscopy may be reduced
What are the indications for screening for CRC with 5 yearly colonoscopy aged 50 - 75yr?
3 first degree relatives degree relatives with CRC aged >50
OR
2 relatives with CRC with mean age <60
What are the indications for screening for CRC with a single colonoscopy age 55?
1 1st degree relative with CRC age <50
OR
2 relatives with mean age >60
In CRC pathogenesis, does a polyp progress to an adenoma or an adenoma progress to a polyp?
Polyp > adenoma > cancer
When should you refer a patient from primary care for suspected CRC?
For 2 week wait if Occult blood in their faeces OR >40yr + unexplained weight loss + abdo pain OR >50yr with unexplained rectal bleeding OR >60yr with Fe anaemia OR >60yr with change in bowel habit *SAW another diagram that kinda disagrees*
A remnant of the omphalomesenteric duct describes …
Meckel’s diverticulum
Where is Meckel’s diverticulum located?
60cm from ileocaecal valve
Meckel’s diverticulum has the rule of 2… expand
2% population
2% symptomatic
Usually present before age 2
What is the management of symptomatic and incidental Meckel’s diverticulum?
Symptomatic - laparoscopic resection
Incidental - leave alone
How does Meckel’s diverticulum present if symptomatic?
Painless rectal bleeding in a toddler
What is occult bleeding?
Microscopic
detectable in investigations eg caecal tumour
Are haemorrhoids a consequence of portal hypertension?
No
What is the role of steroids in haemorrhoids?
There isn’t one
Steroids are used for inflammation
Haemorrhoids aren’t usually inflamed
Are internal haemorrhoids palpable?
No
PR exams to feel for mass or prostate not for haemorrhoids
Anal fissures
- painful or painless
- longitudinal or horizontal cut in mucosa
- usually due to constipation of diarrhea
- acute or chronic
- blood on wiping or mixed in with stool
- requires a PR exam yes or no
Painful Longitudinal cut Constipation May be acute or chronic Blood on wiping Doesn't require a PR exam
What anatomical landmark separates internal and external haemorrhoids?
Pectinate line
How are internal haemorrhoids visualised?
Proctoscopy
Do haemorrhoids cause blood mixed in with stool, coating stool or on wiping? What colour is the blood?
Bright red
On wiping or coats stool
May be mixed with stool if internal haemorrhoids
What is the 1st line management of haemorrhoids?
Conservative manage constipation - increase fluid / fibre intake
Laxido / stool softener + analgesia
What is the 2nd line management of haemorrhoids?
Rubber band ligation or inject sclerosing agent
What is the last line management of haemorrhoids?
Surgical haemorrhoidectomy
What is the 1st + 2nd line management of an anal fissure?
1st line conservative lifestyle manage constipation
2nd relieve contraction of anal sphincter - topical diltiazem or GTN ointment
