Colorectal Flashcards
What are the 4 types of fistula?
- Enterocutaneous (intestine - skin)
- Enteroenteric/enterocolic (large/small intestine)
- Enterovaginal
- Enterovesical (bladder)
When to suspect an enterocutaneous fistula?
if there is excessive drainage and bubbles
Pus
If there is any uncertainty, methylene blue can be given. If methylene blue is found in the drain, this confirms a fistula.
Difference between high and low output enterocutaneous fistulas?
high (>500ml) or low output (<250ml)
Difference between duodenal/jejunal fistulas and colo-cutaneous fistulas?
Duodenal /jejunal fistulae -high volume, electrolyte rich secretions which can lead to severe excoriation of the skin
Colo-cutaneous fistulae will tend to leak faeculent material
Sequelae of enteroenteric/enterocolic fistula?
bacterial overgrowth may precipitate malabsorption syndromes
Main principles of fistula management?
- Normally heal spontaneously provided no IBD/distal obstruction
- Protect overlying skin if skin involvement with a fitted stoma bag
- In high output use ocrreotide to reduce the volume of pancreatic secretions
- Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN
- When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present
- W hen perianal fistulae occur secondary to Crohn’s disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons
- for abscesses and fistulae that have an intra abdominal source the use of barium and CT studies should show a track
Peak incidence of ulcerative colitis?
aged 15-25 years and in those aged 55-65 years. It is less common in smokers.
Features of ulcerative colitis?
bloody diarrhoea
urgency
tenesmus
abdominal pain, particularly in the left lower quadrant
extra-intestinal features (see below)
Extra intestinal features of IBD?
Related to disease activity:
Arthritis: pauciarticular, asymmetric
Erythema nodosum
Episcleritis
Osteoporosis
Unrelated to disease activity:
Arthritis: polyarticular, symmetric
Uveitis
Pyoderma gangrenosum
Clubbing
Primary sclerosing cholangitis
Which extra intestinal features are more common to UC and which are more common to CD?
Arthritis is the most common extra-intestinal feature in both CD and UC
More common in crohns:
Episcleritis
More common in UC:
PSC
Uveitis
Pathology of ulcerative colitis?
Red, raw mucosa, bleeds easily
No inflammation beyond submucosa (unless fulminant disease)
Widespread superficial ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
Inflammatory cell infiltrate in lamina propria
Neutrophils migrate through the walls of glands to form crypt abscesses
Depletion of goblet cells and mucin from gland epithelium
Granulomas are infrequent
What is seen in barium enema with ulcerative colitis?
Loss of haustrations
Superficial ulceration, ‘pseudopolyps’
Long standing disease: colon is narrow and short -‘drainpipe colon’
What is seen on endoscopy with ulcerative colitis?
Superficial inflammation of the colonic and rectal mucosa
Continuous disease from rectum proximally
Superficial ulceration, mucosal islands, loss of vascular definition and continuous ulceration pattern.
Management of ulcerative colitis?
-increased risk of development of malignancy
-Acute exacerbations are generally managed with steroids, in chronic patients agents such as azathioprine and infliximab may be used
Individuals with medically unresponsive disease usually require surgery- in the acute phase a sub total colectomy and end ileostomy. In the longer term a proctectomy will be required. An ileoanal pouch is an option for selected patients
Usual site of diverticular disease?
Taenia coli where vessels pierce the muscle to supply the mucosa
Symptoms of diverticular disease?
Altered bowel habit
Bleeding
Abdominal pain
Complications of diverticular disease?
Diverticulitis
Haemorrhage
Development of fistula
Perforation and faecal peritonitis
Perforation and development of abscess
Development of diverticular phlegmon
Diagnostic work up of diverticular disease?
Patients presenting in clinic will typically undergo either a colonoscopy, CT cologram or barium enema as part of their diagnostic work up.
Plain abdominal films and an erect chest x-ray will identify perforation. An abdominal CT scan (not a CT cologram) with oral and intravenous contrast will help to identify whether acute inflammation is present