Colon conditions Flashcards
Constipation - causes, syx, ex, mx
- Bowel movement <3/week (Rome IV diagnostic criteria)
- Chronic constipation = syx present for at least 3m.
Causes
- Dietary: lack of fibre/fluid intake, lack of exercise
- Motility: IBS
- Structural: colonic carcinoma, diverticular disease
- Drugs: opiates, iron supp
- Other: hypthyroid, pregnancy, hypercalcaemia, depression
Syx
- Reduced BO or bowel movement associated with excessive straining
- Lower abdo pain/discomfort
- Distention/bloating
- Suspect faecal impaction if: regularly soiled, excessive wiping or loose stools, using manual measures to relieve constipation
Ix
Most constipation does not require investigations especially in young mildly affected pts
- abdo ex
- dre
- Bloods: FBC, TFT, ca
- Imaging: AXR, CT or barium enema, sigmoidoscopy
Mx
Conservative
- Management of underlying causes, reduce/stop medication,
- Increase fibre + fluid intake
Medical - if above fails Laxatives step approach, use for short period of time - bulk-forming laxatives - add/switch to osmotic (lactulose) - add stimulant laxative (senna) - Consider prucalopride
Ibs - dx, ix, mx
DX: Rome IV Classification
Recurrent abdo pain at least 1/week in last 3m and associated with 2 or more of following:
- Related/relieved by defecation
- Associated with a change in frequency of stool
- Associated with a change in form
NOTE: this criteria must be fulfilled for the last 3m with sx onset of symptoms at least 6m
Ix, IBS screen:
- FBC, ESR, CRP
- tTG-IgA
- Ca125 if ovarian ca suspected
- Faecal calprotectin test
mx
Conservative
- Keep syx diary
- Reduce stress, caffeine, lactose/fructose
Syx management
- Constipations = low fibre diet or laxatives
- Diarrhoea = avoid sweeteners/ alcohol/ caffeine, bulking ages e.g. loperamide
- Bloating = antispasmodics, mebeverine or hyoscine
- Psychological Sx = CBT
Infectious diarrohea - what is acute + chronic diarrohea….
Gastroenteritis: causes, syx, ix, mx
Acute <14d, Chronic >14d
Causes: ecoli (traveller’s diarrohea), S.aureus, B.cereus, C.Perfringens, salmonella, shigella, rotavirus (infantile gastroenteritis), norovirus, schistosoma
Clinical features
- diarrhoea (>3 loose stools/day) +/- following:
- abdo cramps
- fever
- N+V
- bloody (shigella, e.coli, salmonella, shigella, campylobacter)
Ix
(1. ) Stool cultures (not routinely needed) indicated:
- systemically unwell or IMC
- dysentery (acute painful diarrhoea or blood, mucus and/or pus in the stool)
- diarrhoea not resolved by day 7
- recent abx or ppi rx or hosp admission (to r/o clostridium difficile)
- recent travel to an at-risk destination
(2. ) Assess dehydration in children
- Clinical dehydration: irritable, lethargic, dec U/O, sunken eyes, dry mucous mb, tachy, reduce skin tugor
- Clinical shock: dec consciousness, pale or mottled skin, cold extremities, prolonged CRT, hypotension
Mx
- Notifiable disease if food poisoning
- Advising on methods to prevent transmission
- Fluids
- ORS
- Abx if severe, systematiclly unwell, IMC, elderly
- Avoid loperamide in dysentry
Clostridium Difficile - complications, rf/causes, syx, ix. mx
Complications: pseudomembranous colitis, toxic megacolon, perforation, sepsis, death
RF/causes:
- Abx: Clindamycin Ciprofloxacin Cephalosporins, borad-sepctrum Penicillins
- PPI
- Long stay at hospital or care home
- > 65y
- IBD, Ca, kidney disease
- IMC
Syx
- diarrhoea +/- blood
- abdo pain
- nausea
- fever
- wt loss
- loss of appetitie
- signs of dehydration: dry mucous mb, tachy, oliguria
Dx: clostridium difficile toxins (CDT) in stool
Mx
- Review and stop if possible current abx
- First episode: PO Vancomycin for 10d
- Recurrent episode: PO fidaxomicin
- Life-threatening: oral vancomycin AND IV metronidazole
- Avoid loperamide
- Self isolate until free from diarrhoea for 48hrs.
Diverticular Disease + Diverticulitis: Syx, Ix, Mx
Diverticular disease = painless rectal bleeding, altered bowel habits, nausea
Diverticulitis = severe LLQ pain, fever, anorexia, N+V, rectal bleeding or mucus, LIF mass if abscess or inflammation, reduced bs
Ix
Diverticular disease
- FBC
- colonoscopy: confirm dx and rule out other possible dx, especially bowel cancer
Diverticulitis
- Urinedip
- FBC, UE, CRP, G&S, clotting: High WCC + CRP
- Blood cultures
- CT
Mx
Diverticular disease: hi fibre diet, fluit, pcm, antispasmodics, avoid nsaids + opiates.
Diverticulitis: - discharge + abx if uncomplicated CT - sepsis 6 - analgesia - IV abx - NBM + laparoscopic lavage indicated if: o Purulent or faecal peritonitis o Uncontrolled sepsis o fistula o Obstruction o Inability to exclude carcinoma
Appendicitis - syx, ix, mx
faecolith being the most common cause
syx
- Umbilical pain that moves to RIF within 24hrs. Movement + coughing can aggravate the pain
- Anorexia, N+V, low grade fever, bowel changes
O/e: RIF tenderness, guarding, rebound tenderness, +ve Rosving sign, Psoas sign, Obturator sign
Ix
Dx made on clinical presentation + raised inflammatory markers, and then proceed with diagnostic laparoscopy.
- Alvarado scoring system may be used to assess likelihood of appendicitis
- urinedip
- fbc, crp, ue, lft, amylase, clotting, g&s
- vbg - check lactate
- blood culutres if septic
- bhcg
- CT / USS
Mx
- NBM + Appendectomy (laparoscopic or open) GOLD STANDARD
- Analgesia
- Antiemetics
- IV fluids
- IV Abx
- VTE prophylaxis
Intussusception - what is it, syx, ix, mx
Bowel telescopes into itself which thickens the overall size but narrows the lumen - leading to a palpable mass and obstruction of the bowel.
Syx
Typical SBA = child had recent URTI and experiencing jelly like stools, vomiting/ constipation.
- Severe, colicky Abdo pain, episodes can last 2-3mins
- N+V (20%)
- redcurrant jelly stools
- O/e: Guarding, lethargic, distention RUQ sausage mass, reduced BS
Ix
Dx made with USS or contrast enema*
- Abdo USS shows donut or bull-eyes sign
Mx
- IV fluids if dehydrated
- Consider NG tube
- Abx
- Surgery: therapeutic barium or air enema causes bowel to unfold into normal position
Ischemic bowel disease - what is it, rf, different types w/syx, dx, mx
Heterogenous group of disorders where there is a reduced blood flow through mesenteric vessles that supply the intestines. RF: >50y, smoking, AF, DM, FH
Acute mesenteric ischaemia - sudden SMA blockage from emboli, 50% mortality.
- SBA = abdo pain and AF suspect acute mesenteric ischemia***
- sudden severe abdo pain
- no/minimal abdo signs
- dx: CT angio
- Ix: FBC, CRP, ABG, UE, metabolic acidosis + raised lactate.
- mx: ABCDE, LMWH, NGT, Surgery
Chronic mesenteric ischaemia/ Intestinal Angina- narrowing due to atheroma
- triad of severe colicky abdo pain after eating, wt loss, abdo bruits
- +/- PR bleeding
- N+V
- Fear of eating causes wt loss
- dx: CT Angiogram
- Mx: Surgical revascularisation
Colonic ischaemia/ Ischaemic Colitis - reduced IMA flow, large intestine ischamia. >70y.
- Acute LIF pain, N+V, loose + dark stools
- ix: Colonoscpy
- mx: fluid, abx, surgery + stoma if gangene
Obstruction - causes, ix, mx
Causes
- Small bowel: adhesions, hernias
- Large bowel: malignancy, diverticular strictures, volvulus
- Other: crohns strictures, gallstone ileus, intussusception, TB, foreign body
- DDx: Paralytic ileus – obstruction not due to physical blockage problem with muscle contractions.
Presentation
- diffuse central abdo pain
- N+V
- constipation
- tinkling BS or absent
- distention
Ix
- amylase, FBC, UE, G&S, clotting, CRP, LFT
- AXR 1st line
- CT
Mx
- NBM, IV fluids, NGT (drip + suck): some settle with this, others may require surgery if not resolved after 72hrs
- Emergency surgery: if perforation, peritonitis
Toxic megacolon - syx, ix, mx
syx
- Abdo pain
- Abdo distention
- N+V
- Diarrohea
- Shock
- Fever/chills
- Tachycardia
- Dec BS
- Peritonitis syx = fever, abdo pain, tenderness, altered mental status, hypotension)
Ix
- FBC, UE, CRP, lactate, blood cultures
- AXR, CT:Dilation of colon >6cm
Mx
- Electrolyte correction
- IV fluids
- IV steroids
- Abx
- Consider Surgery: Subtotal colectomy with ileostomy
crohns- biopsy features, syx, ix, mx
biopsy features:
- transmural inflammation, affects mouth to anus, skip lesions, cobble stone
syx
- RIF abdo pain, diarrohea, wt loss, fatigue
Ix
- obs, abdo ex, drre
- FBC, U&E, LFTs, CRP, clotting, iron, B12, folate: checkfor malabsorption
- Faecal calprotectin
- Colonoscopy and biopsy
- imaging
Mx
Conservative: Specialist nurse, smoking cessation, manage stress, lopermide (CI in flare), colestyramine, Antispasmodics
Induce remission
- Oral/topical/IV Prednisolone
- Elemental and polymeric diet
Maintain therapy
- Azathioprine or mercaptopurine (1st line)
ulcerative colitis - biopsy features, syx, ix, mx
Typically begins in the rectum and may extend continuously to involve the entire colon
biopsy
- mucosal inflammation, ulceration, pseudo polpys, crpt abscess
syx
- LLQ pain, diarrohea +/- blood, urgency/tenesmus, wt loss, fatigue
ix
- obs, abdo ex, drre
- FBC, U&E, LFTs, CRP, clotting, iron, B12, folate: checkfor malabsorption
- Faecal calprotectin
- Colonoscopy and biopsy
- imaging to r/o toxic megacolon
mx
induce remission
- mild: topical/orally 5-ASA (mesalazine)
- moderate: topical AND orally 5-ASA
- severe: admit, IV fluids, enteral feeding, IV steriods
maintance therapy
- 5-ASA
- if relapse, consider = thiopurine, biological therapy
Extra-intestinal Manifestations of IBD
- Joints: arthritis/ankylosing spondylitis
- Skin: Erythema nodosum (tender, red nodules on anterior shin), pyoderma gangrenosum (painful ulcer with blue undermined borders)
- Anaemia: inflammation interfering with ability to absorb iron/B12/folic /vits/ minerals or blood loss from intestinal bleeding
- Bones: osteoporosis, osteopenia, osteomalacia
- Eyes o Uveitis (painful inflammation of the uvea, middle layer of the eye wall) o Keratopahy (an abnormality of the cornea) o Episcleritis (inflammation of the outer coating of the white of the eye) o Dry eyes (caused by a vitamin A deficiency)
- Liver: primary sclerosing cholangitis in UC, gallstones in CD
Coeliac - syx, ix, mx
syx
- Fatigue
- Abdo distention/ cramping/ pain
- Diarrhoea
- Failure to thrive
- Wt loss
- IDA
- dermatitis herpetiformis (vesicular, pruritic skin eruption affects knee, elbow, scalp, buttock). Dx = skin biopsy. Rx = Dapsone
- Aphthous ulcer
- Angular stomatitis
Ix
Dx = serology + duo/jej biopsy on gluten diet
- FBC, B12, folate, ferritin
- IgA-anti-TTG (1st line)
- anti-endomysial (anti-EMA).
- Endoscopy + biopsy (dx) shows villous atrophy, crypt hyperplasia, can be graded using MARSH STAGE.
Mx
- Lifelong gluten free diet
- pneumoccocal vaccine every 5y (as some pt with coeliac have hyposplenism)
