Colon conditions Flashcards
1
Q
Define IBS
A
Functional bowel disorder defined as:
recurrent episodes of abdominal pain/discomfort (in the absence of detectable structural pathology) for > 6 months
Relieved by defecation or associated with altered bowel frequency/stool form.
2
Q
State bowel dysfunctions that must be associated with abdominal pain to diagnose IBS
A
Abdo pain should be accompanied by at least two of the following:
- Altered stool passage i.e. straining, urgency, incomplete evacuation
- Abdominal bloating, distension, tension or hardness
- Symptoms made worse by eating
- Passage of mucus
ABC- abdo pain, bloating, change in bowel habits
3
Q
Give some risk factors for IBS
A
- physical and sexual abuse
- PTSD
- age <50 years
- female sex- 2:1 female/male ratio
- previous enteric infection
- family history
4
Q
Explain the aetiology of IBS
A
UNKNOWN
Believed to be a disorder of altered gastrointestinal motility.
Multiple contributing causes, including:
- visceral sensory abnormalities
- gut motility abnormalities
- psychosocial factors (e.g. stress)
- food intolerance (e.g. lactose)
- inflammatory or immune basis
5
Q
Summarise the epidemiology of IBS
A
- COMMON
- 10-20% of adults
- More common in females (2:1 ratio)
6
Q
Recognise the presenting symptoms of IBS
A
6+ months history of abdominal pain
- Pain is often colicky
- It is in the lower abdomen
- Relieved by defecation or passing of flatus
Altered bowel frequency (> 3 motions per day or < 3 motions per week)
- Abdominal bloating/distension
- Change in stool consistency
- Worsening of symptoms after food
- Passage with urgency or straining
- Tenesmus
Other symptoms: nausea, bladder symptoms, back ache
Symptoms are CHRONIC and exacerbated by stress, menstruation or gastroenteritis (post-infection IBS)
7
Q
Recognise the signs of IBS on physical examination
A
Usually NORMAL on examination
Sometimes the abdomen may appear distended and be mildly tender on palpation in one or both iliac fossae
8
Q
Identify appropriate investigations for IBS
A
Mostly clinical but need to exclude organic pathology
- FBC- check for anaemia/abnormalities (would suggest non-IBS)
- Fecal occult blood test- abnormalities sugest IBD/ca
-
Serologic tests for celiac disease
- IgA human anti-tissue transglutaminase (anti-tTG)
-
Faecal calprotectin/lactoferrin, CRP
- postive in IBD
- Ultrasound: exclude gallstone disease
- Urease breath test: exclude dyspepsia due to Helicobacter pylori
- Endoscopy: if other pathologies suspected
9
Q
List some dietary modifications for IBS
A
AVOID: fibre, lactose, fructose, wheat, starch, caffeine, alcohol, fizzy drinks
For constipation: increase soluble fibre, bisacodyl and sodium picosulfate
10
Q
State some medical treatment for different IBS symptoms
A
Bloating/colic:
- antispasmodics
- buscopan- hyoscyamine
- dicycloverine
Constipation:
- prokinetic agents: domperidone, metaclopramide (reduce N+V)
- laxatives: ispaghula, lactulose, movicol
Diarrhoea:
- loperamide
- colestyramine
Psychological symptoms/vixercal hypersensitvity:
- paroxetine
- citalopram
11
Q
What else may be recommended for IBS patients other than medical therapy?
A
Hypnotherapy and CBT
12
Q
Identify the possible complications of IBS
A
- Physical and psychological morbidity
- Increased incidence of colonic diverticulosis
13
Q
Summarise the prognosis for patients with IBS
A
- Chronic relapsing and remitting course of disease
- Often exacerbated by psychosocial stresses
14
Q
State the key pathological differences between Crohn’s and UC:
- Immune cells involved
- Gut layers affected
- Regions of gut affected
- Pattern of inflammation
- Histological features
A
Immune cells involved:
-
Crohn’s = Th1 mediated (main cytokine = TNF-a)
- Florid T cell expansion
- abnormal T cell apoptosis
-
UC = Th2 mediated (main cytokine = IL13)
- normal T cell apoptosis
Gut layers affected:
- Chron’s = all layers (transmural)
- UC = mucosa/submucosa
Regions of gut affected:
- Chron’s = entire GI tract; terminal ileum most common site
- UC = only colon affected; rectum involved in virtually all patients
Pattern of inflammation:
- Chron’s = patchy, skip lesions common
- UC = continuous proximal spread from rectum, decreased haustra
Histological features:
- Chron’s = cobblestone mucosa, creeping fat serosa, deep fissuring ulcers and fistulas
- UC = pseudopolyps, no serosal involvement, shallow ulcers
15
Q
What might you see in microscopy of UC versus Chron’s
A
Chron’s = non-caseating granulomas
UC = crypt abscesses
16
Q
What is the term for UC when it:
- is only in the rectum
- is only in the descending colon
- is affecting the entire colon
A
rectum = proctitis
descending colon = left-sided colitis
entire colon = pan-colitis
17
Q
WHich IBD can be cured fully?
A
UC- surgery is curative
proctocolectomy with ileostomy – surgical removal of colon, rectum and anal canal
or ileo-anal pouch formation
18
Q
Define Chron’s disease
A
Disorder of unknown aetiology characterised by transmural inflammation of any or all parts of the entire GI tract from mouth to perianal area
19
Q
What causes:
- intestinal obstruction
- fistulae
in chrons?
A
- Transmural inflammation → fibrosis → obstruction.
- The inflammation can also result in sinus tracts that burrow through and penetrate the serosa → perforations and fistulae
20
Q
Where is Chron’s most comoonly found?
A
40% terminal ileum
perianal also common
21
Q
What does the pathophysiology of Chron’s disease indicate as its cause?
A
Indicates a role for infectious, immunological, environmental, dietary, and psychosocial factors….
…in a genetically and immunologically susceptible person
22
Q
Describe the development of Chron’s lesions
A
- Starts as inflammatory infiltrate around crypts
- develops into ulceration of superficial mucosa
- Inflammation progresss to involve deeper layers
- eventually forms non-caseating granuloma
- granulomas involve all layers of the intestinal wall and the mesentery and regional lymph nodes.
23
Q
Describe what you would see on endoscopy of Chron’s
A
Early endoscopic findings: hyperaemia and oedema of the inflamed mucosa.
Progresses to discrete deep ulcers located transversely and longitudinally, creating a cobblestone appearance.
These lesions are separated by healthy areas known as skip lesions
24
Q
Define fistula
A
abnormal fusion between a hollow tubular organ and the body surface, or between two hollow/tubular organs
25
Summarise the epidemiology of Crohn's disease
* Highest incidence of CD is in northern climates and in developed countries,
* UK prevalence: **50-80/100,000**
* The peak age of onset: **15-40 years**
26
What are the presenting symtoms of Crohn's
* **Crampy abdominal pain** (due to inflammation, fibrosis or bowel obstruction)
* *right iliac fossa* if terminal ileum involved
* **Diarrhoea**
* **Anorexia, weight loss, malnutrition, nausea, fatigue**
* **Fever**
* Symptoms of complications –
* eye disease **(uveitis)**
* joint disease (s**eronegative arthritis**)
* skin disease (**erythema nodosum**)
* **anaemia**
27
What are the signs of Crohn's on examination?
* **Weight loss**
* **Clubbing**
* Signs of **anaemia**
* **Aphthous ulcers** in mouth
* **Perianal lesions**: skin tags, fistulae, abscesses, scarring, or sinuses
Signs of complications: Uveitis, erythema nodosum, pyoderma gangrenosum
28
How does diarrhoea differ between Chron's and UC?
**Crohn's = diarrhoea with mucus and bleeding**
**UC = very bloody diarrhoea** (inflammation is in rectum/sigmoid colon)
29
What blood investigations would you do for suspected Chron's? What wuld be a positive result?
1. **FBC-**
* _anaemia_ due to: chronic inflammation/blood loss, iron/B12/folate malabsorption
* _leukocytosis_
* _thrombocytosis_- active inflammation
2. **Iron studies**
* (serum iron, serum ferritin, total iron binding capacity [TIBC], transferrin saturation)
* Low due to bleeding/malabsorption
3. **Comprehensive metabolic panel (CMP)/LFT**s:
* _hypoalbuminaemia_
* _hypocholesterolaemia_
* _hypocalcaemia_
4. **CRP, ESR**
* elevated
5. **Serology to exclude Y enterocolitica,** a bowel pathogen that causes an acute ileitis.
30
What other non-invasive investigations would you carry out in suspected Crohn's? what would they show?
1. **Stool microscopy and culture**
* See absence of infectious elements eg C. Difficile
* exclude infective colitis
2. **Plain abdominal X-ray**
* Good to assess severity
* would see: small bowel or colonic dilation; calcification; sacroiliitis; intra-abdominal abscesses
3. **Small bowel follow through**
* xray with barium contrast
4. **CT abdo w/contrast**
* Localisation
* Diagnose fistulae, abscesses, and other extra-mural complications
* **MRI** if young patient/CT contrast contraindicated
31
What 3 specific diagnostic markers would you see in a small bowel follow through of a Chron's patient?
1. **Fibrosis/strictures** (**string sign of Kantor** - part of the intestine looks like a piece of string, showing incomplete filling of the intestinal lumen)
2. **Deep ulceration** (rose thorn ulcers)
3. **Cobblestone mucosa**
32
What invasive investigations would oyu do for suspeted Chron's? what is the positive result?
1. **Colonoscopy-** definitive test to diagnose CD
* see: aphthous ulcers, hyperaemia, oedema, cobblestoning, skip lesions
2. **Tissue biopsy**
* transmural involvement with non-caseating granulomas
* for monitoring malignancy and disease progression
3. **OGD**
* to differentiate from PUD
* see aphthous ulcers; mucosal inflammation
33
State the extraintestinal manifestations common to UC and CD and those which are specific
_Both:_
* **Aphthous ulcers** mouth
* **Uveitis, iritis**
* Seronegative **arthritis, spondyloarthropathy**
* **Erythema nodosum,** pyoderma gangrenosum
* **Thromboembolic** disease
_UC:_
* Increased risk of **gallstones**
_CD:_
* Association with **primary sclerosing cholangitis**
34
Generate a management plan for acute exacerbation of Crohn's disease
* **Fluid resuscitation,** may also be on oral iron
* **IV/oral corticosteroids**- prednisolone, budenoside
* **5-ASA analogues**
* **mesalazine** is absorbed in small bowel and colon
* **olsalazine** requires activation by colonic flora so absorbed in colon only
* **Analgesia**
* **Parenteral nutrition** may be necessary
* **Monitor** markers of disease activity e.g. fluid balance, ESR, CRP, platelets, Hb
35
Describe the long-term management plan for Crohn's disease
1. **Oral corticosteroids**- **budesonide**
2. **5-ASA analogues** -
* decreases the frequency of relapses (mild-moderate disease)
* More commonly used in UC
3. **Immunosuppression**- steroid-sparing agents
* (e.g. azathioprine, 6-mercaptopurine, methotrexate)
* reduces the frequency of relapses
4. **Anti-TNF agents:**
* (e.g. infliximab and adalimumab)
* very effective at inducing and maintaining remission.
* Usually reserved for refractory Crohn's.
36
What are 5-ASA analogues? give an example
Aminosalicylates e.g. mesalazine
37
Give examples of immunsoupressants used in Crohn's disease (steroid sparing agents)
**azathioprine**, 6-mercaptopurine, methotrexate
38
For mildly active-moderate disease, which steroids would be used for:
* iliocaecal
* colonic
...inflammation?
For iliocaecal inflammation: **budesonide**
For colonic inflammation: **prednisolone**
39
What is the only lifestyle modification shown to have an effect in preventing the recurrence of Crohn's disease?
Smoking cessation
40
When is surgeyr indicated in Crohn's? What are the options?
**Medical treatment fails, stricture forms**
**Failure to thrive** in children in the presence of complications
Involves **resection** of affected bowel and **stoma** formation -
NOTE: there is a risk of disease recurrence and short bowel syndrome
41
Possible GI complications for Crohn's?
* **obstruction** (due to stricture)
* **intra-abdominal sepsis**
* **abscess**
* **Fistulae** (between bowel, bladder, vagina)
* **Perianal fistulae** and abscesses
* **toxic megalcolon**
* anaemia, **malabsorption**
* **short bowe**l syndrome
* **malignancy**
* **methotrexate-associated:** hepatotoxicity/ pulmonary fibrosis/ myelosuppression
* **metabolic bone disease** due to: corticosteroid therapy, malabsorption, inflammation
42
State some extraintestinal complications for Crohn's
_Ocular:_
* **uveitis**
* **iritis**
* **episcleritis**
_Hepatobilliary:_
* **Gallstones** (cholethiasis)
* **Kidney stones**
* **Primary sclerosing cholangitis**
* **liver abscess**
_Arthropathy:_
* **sacroiliitis**
* **ankylosing spondylitis**
* undifferentiated spondyloarthropathy.
_Cutaneous_
* **Erythema nodosum**
* **pyoderma gangrenosum**
43
Summarise the prognosis for patients with Crohn's disease
* It is a **chronic relapsing** condition
* **2/3** of patients will require **surgery** at some stage
* 2/3 of these patients require **more than 1 operation**
44
Define ulcerative colitis
**Chronic relapsing and remitting** type of inflammatory bowel disease that characteristically involves the **rectum** and **extends proximally** to affect a variable length of the colon.
45
Explain the aetiology/risk factors for ulcerative colitis
**Family history** of IBD (10-20% sufferers have FHx)
**HLA- B27**- susceptibility locus on **chromosome 12,** and other loci on chromosomes 2, 3, 6, and 7
**Infection-** immune response to bacterial or self-antigens, environmental factors, altered neutrophil function and abnormality in epithelial cell integrity
**Not smoking/former smoker**
46
What condition is associated with UC?
**Primary sclerosing cholangitis**- 70% of patients have UC
47
Summarise the epidemiology of ulcerative colitis
* More common in the **western and northern hemispheres**
* Uncommon before the age of **10 yrs**
* Peak onset: **20-40 yrs**
* **Equal sex ratio** up to the age of 40 yrs (higher in males from then on)
48
What are the presenting symptoms of UC?
* **Bloody diarrhoea**
* History of **cramping lower abdominal pain**
* **Mucus discharge, faecal urgency and rectal tenesmus**
* Presence of extraintestinal manifestations:
* **erythema nodosum**
* **acute arthropathy**
* **arthritis** and **spondylitis**
Anorexia, weight loss, malnutrition, anaemia, nausea, fatigue
49
What are the signs of ulcerative colitis on physical examination?
* Signs of **iron deficiency anaemia** (e.g. conjunctival pallor)
* **Dehydration**
* **Clubbing**
* **Abdominal tenderness**
* **Tachycardia**
* **Blood, mucus and tenderness** on PR examination
* Extra-GI manifestations:
* **erythema nodosum**
* **pyoderma gangrenosum**
* **episcleritis**
50
Identify appropriate investigations for ulcerative colitis
* **Stool studies-**
* + **faecal calprotectin** - IBS DDx
* **- culture**- infectious colitis DDx
* **_Bloods_**
* **FBC**
* anaemia, leukocytosis, or thrombocytosis
* **Comprehensive metabolic panel (including LFTs)**
* check for primary sclerosing cholangitis
* low albumin
* **ESR, CRP**
* **plain abdominal radiograph**
* rule out toxic megacolon
* estimate of the extent of disease- ulcerated colon = solid faeces = dilated loops
* **flexible sigmoidoscopy**/**colonoscopy**
* **biopsies-** essential for diagnosis
51
State some reasons for doing a flexible sigmoidoscopy/colonoscopy in suspected UC
* **Determines severity**, **confirms diagnosis:**
* continuous uniform + rectal involvement
* loss of vascular marking
* diffuse erythema
* mucosal granularity
* fistulas
* **Histological confirmation**- rule out infections (particularly cytomegalovirus and Clostridium difficile)
* **Detection of dysplasia-** essential cancer screening long term
52
Why is sigmoidoscoy preferred to colonscopy?
**_Colonoscopy:_**
* Expensive
* requires full bowel preparation and sedation
* should be performed in a special setting (endoscopy suite).
**_Sigmoidoscopy:_**
* Less expensive
* does not require sedations
* can be performed in the surgery.
53
What investigation can be perfomed ONLY during a mild exacerbation of UC?
**Barium enema**
During acute exacerbation, can increase risk of perforation
54
What would a barium enema show in UC?
**Mucosal ulceration** with granular appearance and filling defects (due to pseudopolyps)
**Narrowed colon**
Loss of haustral pattern - **leadpipe** appearance
55
What are some markers for increased disease activity in UC?
* Decreased **Hb**
* Decreased **albumin**
* Increased **ESR** and **CRP**
* **Diarrhoea frequency:**
* \< 4 = mild
* 4-6 = moderate
* 6+ = severe
* **Bleeding**
* **Fever**
56
What is the management of an Acute Exacerbation of UC?
* **IV fluids**
* **IV corticosteroids**- hydrocortisone sodium succinate
* **Ciclosporin or infliximab** - if IV steroids don't work 72h
* Parenteral feeding may be necessary
* DVT prophylaxis
If **toxic megacolon** - the patient is likely to need a **proctocolectomy** because toxic megacolon has a high mortality
57
How would you manage moderate to severe UC?
* Oral **steroids- prednisolone**
* Oral and/or rectal **5-ASA- mesalazine**
* Immunosuppression **- infliximab, cyclosporin**
* (anti-TNF monoclonal antibody)
58
How is mild UC managed?
oral + topical (rectal) **mesalazine (5-ASA)**
AND/OR
**oral/rectal corticosteroids -** eg beclometasone, hydrocortisone
59
What are the 2 main surgical procedures to treat UC?
**Proctocolectomy with ileostomy** – surgical removal of colon, rectum and anal canal
**Ileo-anal pouch** formation
60
Identify some GI complications of UC
* **Haemorrhage**
* **infection-** CMV and C. difficile may complicate UC.
* **Toxic megacolon** – acute toxic colitis w/colonic dilatation (\> 6cm). High risk of perforation= colectomy
* **Perforation-** 50% mortality
* **Colonic adenocarcinoma**
* **benign stricture** → obstruction
* **Primary sclerosing cholangitis**
* **pseudopolyps**
61
Identify some extra-GI complications of UC
* Uveitis
* Renal calculi
* Arthropathy
* Sacroiliitis
* Ankylosing spondylitis
* Erythema nodosum
* Pyoderma gangrenosum
* Osteoporosis (from chronic steroid use)
* Amyloidosis
less common than in Crohn's
62
State some poor prognostic factors for UC
* Low **albumin** (\< 30 g/L)
* PR **blood**
* Raised **CRP**
* **Dilated loops** of bowel
* **8+** bowel movements per day
* **Fever**
63
What is the prognosis for UC patients?
Overall mortality **does not appear to be increased**
highest cause of death = **toxic megacolon**
64
65
Define diverticular disease/diverticulosis/diverticulitis
_Diverticulosis:_
**Herniation of the mucosa and submucosa through the muscular layer of the colonic wall**
_Diverticular disease:_
**Diverticulosis associated with** **complications** e.g. haemorrhage, infection, fistulae
_Diverticulitis:_
**Acute inflammation and infection** of colonic diverticulae
66
Describe the Hinchey Classification of Acute Diverticulitis
**Stage I:** small or confined pericolic or mesenteric abscess.
**Stage II:** large paracolic abscess often extending into pelvis.
**Stage III:** perforated diverticulitis where a peri-diverticular abscess has perforated resulting in purulent peritonitis.
**Stage IV:** perforated diverticulitis where there is free perforation and is associated with faecal peritonitis.
67
Explain the aetiology/pathogenesis of diverticular disease
1. A **low-fibre diet** increases **intestinal transit time** and decreases **stool volume**
2. Results in **increased intraluminal pressure** and colonic segmentation
3. Leads to the **herniation** of the mucosa and submucosa
4. Occurs between the tenia coli at presumed sites of **weakness where the vasa recti penetrate** the colonic wall.
68
Describe the typical location of diverticlae and where they are not found
* Most commonly found in the **sigmoid** and **descending colon**
* However, they can also be **right-sided**
* Diverticulae are **NOT found in the rectum**
* Diverticulae are found particularly at **sites of nutrient artery penetration**
69
Summarise the epidemiology of diverticular disease
* Diverticular disease is VERY COMMON
* **60%** of people living in industrialised countries will develop colonic diverticulae
* Rare **\< 40 yrs**
* **Right-sided** diverticulae are more common in **Asia**
70
What are the presenting symptoms of diverticular disease?
80-90% asymptomatic
* **Left lower quadrant abdominal pain-** common, may be mild in uncomplicated disease
* guarding
* tenderness
* **Leukocytosis**
* **Low grade pyrexia**
* **PR bleeding**- less common, if acute. Profuse, arterial, painless
* **Bloating, constipation**
* ****may alternate with episodes of diarrhoea
71
What are some signs that there may be diverticular fistulation?
pneumaturia, faecaluria, recurrent UTI
72
State the appropriate investigations for ACUTE diverticular disease and what you would see
* **_FBC with differential_**
* see **polymorphonuclear leukocytosis**
* raised **CRP**
* check clotting and cross-match if bleeding
* culture if signs of septic
* **_CT abdomen_**
* **thickening of bowel wall**, mass, abscess, streaky mesenteric fat
* may show gas in the bladder in cases of fistula
73
State the appropriate investigations for chronic/sub-acute diverticular disease
NOT when acute → perforation
**Barium enema w/contrast**
* when initial acute symptoms have resolved- confirmation
**Flexible Sigmoidoscopy and Colonoscopy:**
* Diverticulae can be visualised
* Other pathology (e.g. polyps and tumours, ischaemia) can be excluded
74
How would diverticulitis be managed?
* **Analgesia**
* **IV antibiotics**- if no improvement after 72 hours oral
* **Low residue diet/**bowel rest
* **IV fluids/rehydration**
* Abscesses may be drained by radiologically sited drains
75
What surgical procedures are considered for refractive/recurrent/complicated diverticulitis?
**Hartmann's procedure-** proctosigmoidectomy and stoma formation
**One-stage resection + anastomosis**
* risk of leak
* with/without defunctioning stoma
L**aparoscopic drainage, peritoneal lavage** and **drain placement** can be effective
76
Identify the possible complications of diverticular disease
* Diverticulitis
* Pericolic abscess
* Perforation
* Faecal peritonitis
* Colonic obstruction
* Fistula formation (bladder, small intestine, vagina)
* Haemorrhage
* Post infective strictures
* Abscesses
77
Summarise the prognosis for patients with diverticular disease
**10-25%** have one or more episodes of diverticulitis
78
Define volvulus
Rotation of a loop of bowel around the axis of its mesentery that results in bowel obstruction and potential ischaemia.
79
Which areas of the bowel are most commonly affected by volvulus?
* **Sigmoid colon** - 65%
* **Caecum** - 30%
* **Volvulus Neonatorum** - occurs in neonates and typically affects the **midgut**
80
What are the risk factors for volvulus?
* Long sigmoid colon
* Long mesentery
* Mobile caecum
* Chronic constipation
* Adhesions
* Chagas disease
* Parasitic infections
* Neonatal- malrotation
81
State some presenting symptoms of volvulus
* **Severe colicky abdominal pain** and swelling
* swelling shows ischaemia
* Absolute **constipation**
* **Bilous (green) vomiting**
* There may be a **history of transient attacks** in which spontaneous reduction of the volvulus has occurred
* Neonatal volvulus presents mostly before 3 months
82
Recognise the signs of volvulus on physical examination
* Abdominal **distension**
* **Rebound tenderness and guarding**
* **Absent or tinkling bowel sounds** (intestinal obstruction)
* **Fever**
* **Tachycardia**
* with hypertension = initially, due to severe pain
* with hypotension = if tissue infarction causes systemic response
* Signs of dehydration
83
Identify appropriate investigations for volvulus
1. **FBC, ABG**
* lactic acidosis with resp alkalosis leading to low pCO2
* due to inappropriate bowel perfusion
2. **AXR (and CXR if perforation suspected)**
* distended bowel loops above volvulus
* HORSESHOE SIGN
3. **GI contrast series**
* either upper GI or enema (lower GI)
4. **CT abdomen w/contrast**
* IV contrast shows no contrast in SMA
* oral contrast shows no contrast beyond duodenum
84
Define perineal abscess
pus collection in the perineal region
85
Define perineal fistula
an abnormal **chronically infected tract** communicating between the **perineal skin** and either the **anal canal** or the **rectum**
86
List some risk factors for perineal fistulas/abscesses
* **IBD**- fistulae can develop as a complication of CD
* 'pepperpot perineum' = multiple fistulae
* **Systemic diseases** - TB, diabetes, HIV.
* **History of trauma** to the anal region.
* **Previous radiation therapy** to the anal region- eg from cancer treatment
87
Explain the aetiology of perineal abscess/fistula
* 90% cases: perianal fistula forms as a **consequence of perianal abscess**
* **Blockage of anal duct** → fluid stasis → **infection** and abscess
* Common causative organisms:
* **E. coli**
* **Bacteriodes spp.**
* **Enterococcus spp..**
88
Recognise the presenting symptoms of anal abscesses and fistulae
Anal fistulae usually present with either
1. Throbbing, continuous **pain** in perineum
2. intermittent or continuous **discharge** onto the perineum, including **mucus, blood, pus, or faeces.**
3. Personal or family history of **IBD**
89
What are the signs of anal fistulae/abscesses O/E?
an **external opening** on the perineum may be seen; these can be fully open or covered in granulation tissue.
A **fibrous tract** may be felt underneath the skin on DRE
DREs are not always possible due to pain and anal sphincter spasm
90
Describe the Goodsall rule
The Goodsall rule can be used clinically to predict the **trajectory of a fistula tract,** depending on the location of the external opening:
1. External opening **posterior** to the **transverse anal line** – fistula tract will follow a **curved** course to the posterior midline
2. External opening **anterior** to the transverse anal line – fistula tract will follow a **straight radial** course to the dentate line
91
Identify appropriate investigations for perianal abscesses and fistulae
* **Bloods**
* FBC
* CRP
* ESR
* **Blood culture**
* **Proctoscopy** can be used to visualise the opening of the tract in the anal canal.
* For complex fistula, **MRI imaging** is often required to visualise the anatomy of the tract.
92
Describe the treatment of perianal abscesses and fistulae
Requires SURGICAL treatment:
**Open Drainage of Abscess,** or
1. **Fistulotomy (superficial disease)**
* Opening tract by cutting through skin and subcutaneous tissue
* Allows to heal by secondary intention
* care to prevent sphincter damage
2. **The placement of a seton (high tract disease)**
* non-absorbable suture that is threaded through the fistula
* allows drainage of the localised infection and slow healing
may need MULTIPLE operations
93
Identify possible complications of perianal abscesses and fistulae
* **Recurrence**
* Damage to internal anal sphincter → **incontinence**
* Persisting **pain**
94
Summarise the prognosis for patients with perianal abscesses and fistulae
High recurrence rate without complete excision
95
96
Provide examples of extra-intestinal conditions related to activity of colitis
* Erythema nodosum
* Aphthous ulcers
* Episcleritis
* Anterior uveitis
* Acute arthropathy
Not related to activity of colitis:
* Sacroileitis /Ankylosing spondylitis
* Primary sclerosing cholangitis
97
85-95% Caucasian patients with axial spondyloarthropathy are positive for which gene mutation?
HLA-B27
98
What is conditions required to classift severe colitis?
* ≥6 stools per day
* bloody stools
* pulse \>90
99
What is the first line management for acute severe colitis?
**IV hydrocortisone**
Antibiotics would only be started if there was concern about toxic megacolon and risk of perforation or signs of infection which are not apparent in this case
100
What is the next management step if there is no response to IV hydrocortisone in acute severe colitis? What are the contraindications for this drug?
**IV ciclosporin**
contraindicated in renal impairment and hypertension
101
Specify the criteria for mild/moderate/severe colitis
* Mild disease* = **\<4 stools** a day with **no systemic disturbance** and normal CRP and ESR.
* Moderate disease =* **4-6 stools**/day with minimal systemic disturbance.
* Severe disease* = **\>6 stools**/day and evidence of systemic disturbance.
102
Once remission has been induced what maintenance therapy should be commenced in UC?
**oral/topical mesalazine**
Topical application is better than topical prednisolone at inducing remission in colitis
103
major differential diagnoses for painless GI bleed?
* **oesophageal varices** (which may present with acute lower GI bleeding if large enough volume)
* **GI malignancies**
* **diverticular disease**
* **coagulopathies**
* **angiodysplasia** (commonest vascular abnormality of the GI tract)
