Deck 6 Flashcards
Red flags for abdominal symptoms
Dysphagia, Tx resistant dyspepsia, Anorexia, unintentional weight loss (consider upper GI malignancy)
Anorexia, uninentional weight loss, haematemesis, altered bowel habit, iron deficiency, anaemia, unexplained rectal bleeding (consider lower GI malignancy).
Who might have pain free acute abdomen
Extremes of age, immunocompromised or last trimester of pregnancy
Acute abdomen epigastric, midgut and hindgut
Epigastric is oesophagus to D2
Midgut is D2 o transverse, rest is hindgut
Ischaemic bowel symptoms
Consider in patients with severe pain compared to signs (ischaemic until proven otherwise). Diffuse constant pain. Often unremarkable O/E. May have acidaemia and raised lactate. USe contrast CT to diagnose.
Pancreatitis
Look for 3xupper limit of amylase (lower can be perforation, ectopic or DKA). Check calcium and lipase
Appendicitis
Blockage of lumen (e.g. faecolith, lymph, tumour, parasites). Rebound tenderness over mcBurney’s point, Rovsigs sign, Psoas sign, obturator sign.
Imaging not essential for diagnosis, but USS/CT might be used.
Mana
Obturator sign
Pain on internal rotation of right hip (pelvic appendix)
Psoas sign
Pain on right hip extension - seen in retroperitoneal/retrocoecal appendix
Coeliac disease
T cell inflammation.
Gluten/prolamin stimulates abnormal mucosal response. Chronic inflammation and villous atrophy.
Coeliac disease histology
crypt hyperplasia, villous atrophy, lymphocytes in lamina propria
Coeliac disease clinical features and complications
mouth ulcer, diarrhoea, abdo pain, bloating, unexplained weight loss, malaise, weakness, steatorrhoea but 1/3 may be asymptomatic.
Skin manifestation is dermatitis herpetiformis (rare, but subepidermal skin blistering and itch)
Complications include malabsorption, anaemia, GI malignancy risk, T cell lymphoma risk, osteoporosis, hyposplenism
Coeliac disease RF
HLA DQ2, FHx, autoimmune (thyroid, T1DM)
Coeliac disease investigations
FBC, LFT, U&E, bone profile, Vitamin D, vitamin B12, haematinics, albumin, IgA tissue transglutimase (can do IgA endomysial antibody is only weakly positive).
Definitive by small bowel biopsy
IBS diagnosis
Consider if abdo pain/bloating/change in bowel habit for 6 months.
Diagnose if abdo pain either related to defecation and/or associated with altered stool frequency/appearance and 2 of:
- altered stool passage
- abdo bloating/distention/hardness
-symptoms aggrevated by eating
-passage of rectal mucus
In past 12 months with 12 weeks of symptoms
Additional symptoms may be lethargy, nausea, back ache and bladder symptoms
IBS
Functional disorder. Symptom based diagnosis.
Diet based Tx (avoid triggers, do more exercise) -loperamide for diarrhoea, antispasmodics for abdo cramps, peppermint oil/laxatives for constipation
Diverticulum definition
Outpouchings of bowel wall
Diverticulosis definition
Presence of diverticulum
Diverticulitis definition
Inflamed diverticulum
Diverticular disease RF
NSAIDs, FHx, smoking, obesity, male, Western diet, >50, meat eating, CT disease, PKD
Diverticular disease
Symptomatic diverticula
Colicky LLQ pain, relieved by defecation/flatus, made worse by eating. Get altered bowel habit, nausea, bloating and flatulence
Diverticulitis
left sided colic, constipation/overflow diarrhoea, symptoms mimic appendicitis but on left. Can get peritonitis symptoms if perforated- but steroids can mask presentation
Diverticular bleed
Erodes into vessel, causes large scale, painless bleed (typically dark red)
Ddx for diverticular disease
IBD, bowel cancer, ischaemic colitis, gynae causes, renal stones, IBS, coeliac disease
Admissions in diverticulitis
Uncontrolled pain, dehydration, significant comorbidities, immunocompromised, significant Pr bleed, 48h+ symptoms, peritonitic
Acute diverticulitis complications
Abscess, fistulas, perforation, bowel obstruction (inflammation and strictures)
Meckel’s diverticulum
Congenital abnormality
Failed vitiline closure
Affects 2% gen pop, 2:1 M:F, often presents under 2, 2 inches long, 2ft proximal to ileocaecal valve
Typically presents as melaenia followed by obstruction/intussesception. Can mimick appendicitis
Often have 2 different tissue types (gastric tissue present which may ulcerate and can have pancreatic).
Abdominal distension
Can be fat, fluid, flatus, mass or foetus. DDx include bowel obstruction, constipation, paralytic ileus, hypokalaemia, sepsis, abscess, toxic megacolon,
Pseudomembranous colitis
C diff infection (toxic megacolon)
Bowel obstruction symptoms
- Vomiting (even if NBM)- often early feature of SBO
- Absolute constipation (early in LBO)
- Abdominal distension (proximal bowel fluid/gas filled and distends - eventially spreads distal to obstruction)
Colicky abdominal pain (seen in mechanical, but functional can be painless. SBO often periumbilical, LBO tends to be suprapubic. If constant pain and pain on movement then ?perforation)
Additional signs
- Abdominal distension
- Abdominal tenderness
- Central resonance to percussion
- Tinkling bowel sounds (increased persistalsis)
- Dehydration (vomiting/anorexia, fluid sequestration - hypotension, tachycardia, loss of turgor, low JBP, dry mouth, oliguria, sunken eyes, sleepiness, thirst, muscle weakness, headache, dizziness, dark urine)
3rd spacing causes the dehydration, but can also see AKI and hypokalaemia on bloods
Strangulating obstruction
Blockage with ischaemia, can perforate. Can be closed loop with two obstruction points. At ileocaecal valve, more likely if valve is competent. Can also be sigmoid volvulus (coffee bean on AXR)
Sigmoid volvulus RF
elderly, constipated male (4:1), psychiatric illness
Mechanical bowel obstruction
80% SBO (often previous surgery, but can be hernias and Crohns)
20%LBO (normally malignancy, typically sigmoid ut also diverticular disease, volulus, constipation)
Functional ileus
Resolves after a few days, typically painless
Bowel obstruction investigations
Hypokalaemia, metabolic acidosis due to bicarbonate secretion, raised uraemia.
AXR has 3/6/9 rule
CT can differentiate from pseudoobstruction.
Management of bowel obstruction
General is NBM, IV fluids
SVO is drip and suck, but may need surgery (esp hernia)
LBO usually needs surgery
Volvulus needs flatus tube if sigmoid, laparotomy is caecal.
Ischaemia needs urgent surgery
RIF mass ddx
Inflammation of appendix/abscess, lymphoma, Crohn’s disease, tumour mass (caecal/carcinoid), pelvic kidney
Use CT/USS to confirm.
Abscess needs surgical drainage
Cariconoid tumour on appendix
Argentaffin cell producing serotinin PGs. May be associated with MEN-1.
Can present in 4th decade with carcinoid syndrome (flushing and diarrhoea)
pannus cells
small intestine cells
Colorectal cancer distribution
Most common site is rectum, then sigmoid, then ascending colon, then transverse, then descending
Colorectal cancer
Commonly adenocarcinoma (signet ring cells on histology), but can be swuamous in rectum
CEA blood test
Carbinoembryonic antigens, can be marker for colon cancer, rectal cancer, lung cancer, breast cancer, liver cancer, stomach cancer, ovarian cancer but cn also be raised in liver disease and IBD
2WW for colorectal cancer
40+ with PR bleed or change in bowel habit
OR 45+ with persistent PR bleed and no other cause
Colorectal cancer RF
Age (esp 40+), male sex for rectal cancer, ethnicity (african), T2DM, crohn’s disease, UC, FHx (HNPCC/lynch, FAP, MUTYH)
Red meat/processed food, obesity, inactivity, alcohol, smoking
Right sided colorectal cancer symptoms
Typically pain and bleeding, but can be asymptomatic.
Left sided colorectal cancer symptoms
Annular, so cause earlier obstruction. May cause Pr bleed, mucus, altered bowel habit or tenesmus
Colorectal cancer metastases symptoms
Hepatic (jaundice, RUQ pain, early satiety) Peritoneal (ascites/pain) Colo-vesicle (pneumaturia/UTI) Weight loss Can also get bone and lung mets
Colorectal cancer screening
Regular colonoscopy for high risk groups (FAP, HNPCC, MUTYH).
FIT/FOB for 50-74, single flex sig at 55
DDx for colorectal cancer
Other malignancy (lymphoma, carcinoid tumour, kaposi sarcoma, invasive prostate cancer), benign polyps, pseudo polyps in psuedomembranous colitis, endometriosis, lipoma, abdominal TB
GSTD investigation for colorectal cancer
Colonoscopy as allows biopsy/polypectomy
Staging of colorectal cancer
Once t4 then through intestine. Previous staging by Dukes A->D, B is invaded muscular layer. C is lymph node, D is distant mets
Aggressive colorectal cancers
signet ring, mucineous, medullary adenocarcinomas
lower anterior resection
sigmoid colon and inferior rectum
High anterior resection
Sigmoif colon and superior rectum
Abdomino-peritoneal resection
sigmoid, rectum and anus
Total protocolectomy
colon to anus
Subtotal colectomy
Ascending, transverse and descending colon
Total abdominal colectomy
Colon to end of sigmoid
Extended right hemicolectomy
Ascending colon, hepatic flexure, transverse colon)
Upper anal canal
muscularis proprium - smooth muscle (involuntary)
upper 2/3s.
Lower 1/3 of anal canal
external anal sphincter (S4 nerve) - blends with puborectalis
dentate line is formed from
mucosal gathering into longtidinal folds around anal glands
Above dentate line
hindgut derived, columnar epithelium. Supplied by superior rectal artery from IMA. Drained by superior rectal vein (IMV).
Drained by internal iliac lymph nodes.
Stretch sensation only (inferior hypogastric plexus)
Below dentate line
ectoderm, non kertinised (but below verge is) squamous.
Inferior rectal artery (from internal pudendal (internal iliac) and drained by corresponding vein.
Drained by superficial inguinal lymph nodes
Sense pain, pressure, touch and temperature
Anal cancer lymph
Often squamous, can see lymphadenopathy in superficial inguinal lymph nodes
Haemorrhoid locations
3/7/11 (vascular cushions)
Haemorrhoid RF
Straining, low fibre diet, costipation, congestion of superior rectal veins (HF, rectal carcinoma), pregnancy,
Haemorrhoid symptoms
asymptomatic.
Itching, painless fresh PR bleed, mucous discharge
Can rarely present as painful perianal lumo (when external ones thrombose)
Haemorrhoid investigation
DRE (feel external ones), protoscopy (visualise internal ones), endoscopy may be needed to exclude cancer
Abdo exam required
Haemorrhoid classification
Confined to anal canal
Prolapse on defecation but reduce spontaneously
Prolapse outside anal margin on defecation, may reduce manually
Non reducable, outside anus at all times
Haemorrhoids management
Supprotive management (ice pack, analgesia, topical instillagel, laxatives). If bleeding, may need surgical management (sclerosing agents, HALO, haemorrhoidectomy)
Anal fissure
Normally at 6 oclock (posterior) but can be anterior (12 - more concerning).
Must distinguish from anal cancer, herpes and nicorandil ulceration.
Anal fissure presentation
Severe pain post defecation, fresh PR and itch
Can’t do PR exam (may need GA to perform)
May see breaks or ulcers on exam.
Typically acute following constipation, but can be chronic in Crohns
Anal fissure management
Convervative management with diet, laxatives, instillagel, topical diltiazem or GTN. Can do botox in chronic, or lateral sphincterotomy.
Pilonidal sinus
Natal cleft follicles obstructed 6cm above anus. Hair ingrowth, can getabscess and discharge
Peri-anal abscess RF
Pregnancy, women (more likely to be recurrent), Corhn’s, DM, malignancy
Typical bacterial cause in peri-anal abscess
Crytoglandular plugging, infiltration by E.coli, bacteriodes spp, enterococcus spp.
Peri-anal abscess symptoms and investigation and management
painful, hot, perianal lump, may have pus, may be septic (caution in diabetes)
Clinical, but may need CT/MRI
Surgical incision and drainage with healing by secondary intention
Fistula in ano RF and symptoms and investigation
IBD, systemic disease (HIV, TB, diabetes), trauma, pelvic radiation
Abscess? blood/pus/mucous drainage. See small opening in perineum, granulation tissue that may discharge on palpation. Thickened fibrous tract in skin
Use proctoscope to investigate. If horseshoe then may do MRI.
Goodsall’s rule
If external opening is anterior to transverse line (in lithotomy position) then likely short radicular tract
If posterior then likely curved/horseshoe
Management of fistula in ano
Always surgical. Can use band if muscle involvement, or fistulotomy )
Anal cancer
Generally SCC
Anal cancer RF
anoreceptive sex, syphilis, warts, cervical cancer, immunosuppresion
Anal cancer above pectinate line
Columnar epithelium, drains to internal lymph and ortal venous (hepatic met risk). More common in women. Worse prognosis
Anal cancer below pectinate line
squamous, drians to superficial lymph nodes and IVC (lung mets more likely). More common in men, better prongosis.
