Gastro Flashcards
Coeliac disease
Def, cause, sx, ix, mx
Coeliac disease is a T cell-mediated autoimmune disorder affecting the small intestine. The condition arises due to the production of an auto-antibody against gluten, specifically its component called prolamin, which results in inflammation and villous atrophy of the small bowel leading to malabsorption.
Cause:
Associated with fhx, HLA-DQ2 allele and type 1 diabetes
Sx:
- abdo pain
- distension
- nausea and vomiting
- diarrhoea
- steatorrhoea (severe)
- pallor (secondary to anaemia
- short stature and wasted buttocks (secondary to malnutrition)
- bruising (vitamin deficiency)
- dermatitis herpetiformis (pruritic papulovesicular lesions over the buttocks and extensor surfaces of the arms, legs, and trunk)
Ix:
- stool culture to exclude infection
- anti-TTG IgA and IgA then anti-TTG IgG, anti-endomyseal antibody
- OGD is gold standard
- histology shows sub-total villous atrophy, crypt hyperplasia, and intra-epithelial lymphocytes
Mx:
- diet change
- dapsone for Dermatitis herpetiformis
Constipation
Cause, sx, ix, mx
Cause:
- inadequate fibres
- hypercalcaemia
- opiates, CCB, antipsychotics
- spinal cord lesions, Parkinson’s, diabetic neuropathy
- hypothyroidism
- bowel obstruction
- anal fissures
Sx:
- less than 3 bowel movements per week
- tenesmus
- straining excessively
- abdo masses
- rectal bleeding
- fissures
- haemorrhoids
Ix:
- 2ww if weight loss, over 60 the urgent CT
- PR exam
- stool culture
- FIT
- abdo x ray
- barium enema
- colonoscopy
Mx:
- bulking agents eg. Ispaghula husk (contraindicated in dysphasia, GI obstruction and faecal impactation)
- stimulant eg. Senna (contraindicates in acute obstruction or colitis)
- stool softeners eg. Macrogol (contraindicated in ileum, obstruction, perforation, IBD
- osmotic laxatives eg. Lactulose ( contraindicated in hypersensitivity to lactulose and obstruction)
- phosphate enema (contraindicated in renal impairment, heart failure, electrolyte abnormalities)
GORD
Rf, sx, ix, mx
Risk factors contributing to the development of GORD include obesity, alcohol use, smoking, and intake of specific foods (e.g. coffee, citrus foods, spicy foods, fat).
Sx:
- dyspepsia
- acid regurgitation sensation
Ix:
- urea 13c breath test
- OGD
- manometry
Mx:
- lifestyle advice
- PPI
- antacids
- PPI and abx for H.pylori
Haemochromatosis
Def, cause, sx, ix, mx
disorder of iron metabolism resulting in excessive iron accumulation within various sites of the body
Cause:
- homozygosity for HFE C282Y on chromosome 6
Sx:
- Bronze skin
- Type 2 diabetes mellitus
- Fatigue
- Joint pain
- Sequalae of chronic liver disease/cirrhosis
- Adrenal insufficiency
- Testicular Atrophy
Ix:
- bloods: raised transferrin saturation (>55% in women and >50% in men)raised ferritin, raised iron, low TIBC
- genetic testing for HFE mutation
- MRI of brain and heart for iron deposition
- liver biopsy with pearls stain to check stores and loading
Mx:
- phlebotomy or venesection
- desferrioxamine
- avoid undercooked food
Splenectomy
Indications, ix, complications, mx
Indications:
- emergency= trauma and rupture eg. EBV infection
- elective= hypersplenism, haemolytic anaemia, ITP
Ix:
- patients post-splenectomy will have Howell-Jolly bodies and Pappenheimer bodies on blood film.
Complications:
- there is a reduced immune response against encapsulated organisms (haemophilus, pneumococcus, and meningococcus).
Mx:
- Pneumococcal vaccination (with regular boosters every 5 years).
- Seasonal influenza vaccination (yearly, typically every autumn).
- Haemophilus influenza type B vaccination (one-off).
- Meningitis C vaccination (one-off).
- daily low-dose prophylactic antibiotics (phenoxymethypenicillin or clarithromycin if allergic)
Infectious colitis
Cause, rf, sx, ix, mx
Cause:
- E.coli
- salmonella
- shigella
- campylobacter
- C.diff
- norovirus
- rotavirus
Rf:
- contaminated food or water
- travel to poor sanitation places
- recent abx use
- weak immunity
Sx:
- diarrhoea
- abdo pain
- fever
- nausea and vomiting
- dehydration
Ix:
- stool analysis
- colonoscopy
Mx:
- rehydration
- abx
- vancomycin for c.diff
- ciprofloxacin for shigella and salmonella
- azithromycin for campylobacter and e.coli (none for shigella toxin producing)
Infectious mononucleosis
Def, sx, ix, mx
Infectious mononucleosis (IM) is a condition caused by infection with the Epstein Barr virus (EBV). It is commonly known as the “kissing disease”, “glandular fever” or “mono”. This virus is found in the saliva of infected individuals. Infection may be spread by kissing or by sharing cups, toothbrushes and other equipment that transmits saliva. EBV is secreted in the saliva of infected individuals and can be infectious several weeks before the illness begins and intermittently for the remainder of the patient’s life. Most people are infected with EBV as children, when it causes very few symptoms. When infection occurs in teenagers or young adults, it causes more severe symptoms. It is the symptomatic infection with EBV that is called infectious mononucleosis.
Sx:
Fever
Sore throat
Fatigue
Lymphadenopathy (swollen lymph nodes)
Tonsillar enlargement
Splenomegaly and in rare cases splenic rupture
Ix:
- Monospot test (conducted in 2nd week of illness)
Mx:
- avoid alcohol
- avoid contact sports
IBS
Sx, ix, mx
Sx:
The Manning criteria for diagnosis of IBS includes:
- Abdominal discomfort or pain relieved by defecation OR associated with altered bowel frequency or stool form
- At least two of the following:
- Altered stool passage (e.g., straining or urgency)
- Abdominal bloating
- Symptoms worsened by eating
- Passage of mucus
Ix:
- faecal calprotectin to rule out IBD
- coeliac serology
Mx:
- FODMAP diet
- antispasmodics (mebeverine, laxatives or anti-diarrhoeal)
- 2nd line is low dose tricyclic antidepressants
Malabsorption
Def, cause, sx, ix, mx
impaired absorption of nutrients, vitamins, or minerals from the diet, resulting in nutritional deficiencies and associated symptoms. The absorption process can be disrupted at any point along the gastrointestinal tract, with the small intestine being most commonly affected.
Cause:
- post- gastrectomy (dumping syndrome)
- coeliac
- crohn’s
- small bowel resection
- pancreatitis
- cystic fibrosis
- biliary cirrhosis
- ileal resection
- post-cholecystectomy
- giardiasis
- whipples disease
Sx:
- diarrhoea
- steatorrhoea
- weight loss
- anaemia
- osteoporosis
- peripheral neuropathy
Ix:
- stool analysis
- abdo US, CT or MRI
- endoscopy and biopsy
Mx:
- treat underlying cause
- supplementation
- cholestyramine for bile acid malabsorption
Malnutrition
Def, cause, sx, ix, mx
Def:
- A body mass index (BMI) of less than 18.5 kg/m2.
- Unintentional weight loss greater than 10% within the last 3–6 months.
- A BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months.
Cause:
- poor diet
- pregnancy
- growth
- illness
- crohns
- coeliac
- pancreatitis
- post-surgery
- cancer
- HF
- CKD
- COPD
Sx:
- weight loss
- fatigue
- poor concentration
- low immunity
- muscle wasting
- oedema (protein deficiency)
- brittle hair and nails
- dry scaly skin
- delay wound healing
Ix:
- MUST screening tool
- bloods
- DEXA
- endoscopy and biopsy
Mx:
- supplements and diet change
- treat underlying cause
- enteral or paraenteral feeding
Necrotising enterocolitis
Def, rf, sx, ix, mx
severe gastrointestinal disease that primarily affects premature infants. The condition is characterised by necrosis (tissue death) of the intestine due to ischaemia (lack of blood flow) and infection, leading to severe illness and sometimes perforation of the bowel.
Rf:
- prematurity
- low birth weight
- sepsis
- congenital heart disease
- maternal drug use and HIV
Sx:
- vomiting
- bloody stools
- abdo distension
- absent bowel sounds
Staging:
- Bells classification
Ix:
- acidosis on venous blood gas
- main ix is abdo x-ray showing dilated bowel loops, gas in bowel wall, portal venous gas, rigler or football sign
Mx:
- nil by mouth
- broad spectrum abx
- supportive treatment
- paraenteral nutrition
Surgery
Oesophageal cancer
Def, cause, rf, sx, ix, mx
cancer that originates from the epithelial cells lining the oesophagus, primarily categorised into adenocarcinoma (most prevalent in western world and often seen in lower 1/3) or squamous cell carcinoma (most prevalent globally and often seen in the upper 2/3s)
Rf:
- smoking
- alcohol
- obesity and GORD (adenocarcinoma)
- achalasia
- zenker diverticulum
- hot beverages
- nitrosamines
Sx:
- dysphagia
- weight loss
- odynophagia (pain on swallowing)
- hoarseness
Ix:
- 2ww upper GI endoscopy for dysphagia, above 55 and weight loss
- staging with CT chest, abdo and pelvis, MRI, endoscopic US, PET scan, laparoscopy
Mx:
- primary choice is surgical resection
- endoscopic mucosal resection or endoscopic submucosal dissection
- radio or chemotherapy
Pancreatic cancer
Cause, rf, sx, ix, mx
The most prevalent type of pancreatic cancer is pancreatic adenocarcinoma, which usually originates from the head of the pancreas. Pancreatic cancer often metastasises early to the lung, liver, and bowel.
Rf:
- age
- smoking
- obesity
- diabetes
- pancreatitis
- fhx
- BRCA2, lynch syndrome, FAMMM
Sx:
- abdo pain
- nausea
- weight loss
- Courvoisier’s sign - painless jaundice with a palpable gallbladder
- advanced= obstructive jaundice, diabetes mellitus, steatorrhoea, trousseaus syndrome, DIC
Ix:
- 2ww for CT or US if over 40 and jaundice
- MRCP
- PET and MRI
Mx:
- surgical resection if no SMA or coeliac involvement and nor evidence of metastases. The common surgical procedure for tumours in the head of the pancreas is the Kausch-Whipple procedure (radical pancreaticoduodenectomy). Then adjuvant chemo
- palliative therapy for advanced (endoscopic stent in common bile duct, surgery, chemo, radiotherapy)
Peptic ulcer disease and gastritis
Def, cause, sx, ix, mx
painful sores or ulcers in the lining of the stomach or the duodenum, duodenal ulcers are 4x more prevalent than gastric ulcers.
Cause:
Duodenal:
- 90% are caused by H.pylori
- NSAIDs
- steroids
- SSRIs
- increased secretion of gastric acid
- smoking
- O blood
- accelerated gastric emptying
Gastric:
- NSAIDs
- H.pylori
- smoking
- delayed gastric emptying
- stress
Sx:
- abdo pain
- nausea and vomiting
- loss of appetite
- weight loss
- coffee ground vomit
- duodenal present with epigastric pain relieved on eating
- gastric sx are worsened by eating
Ix:
- 2ww for OGD if >55 with weight loss and dyspepsia to ix for cancer
- C-13 urea breath test
- endoscopy
- biopsy to rule out cancer
- AXR and CXR to look for pneumoperitoneum if perforates peptic ulcer
Mx:
- no h.pylori= 4-8 week course of PPI and lifestyle changes
- h.pylori and associates with NSAID= 8 week PPI followed by first-line eradication therapy - PPI (omeprazole/lansoperazole) + amoxicillin + clarithromycin/metronidazole for 7 days
- h.pylori and no NSAID= PPI (omeprazole/lansoperazole) + amoxicillin + clarithromycin/metronidazole for 7 days
- gastric ulcers= repeat endoscopy 6-8 weeks after mx and C-13 urea breath test (stool antigen second line)
- complicated peptic ulcer= surgical intervention with OGD
GI perforation
Causes, sx, ix, mx
Causes:
Causes of upper Gl tract perforation include:
• Oesophageal or gastric malignancies
• Peptic ulcer disease
• Boerhaave syndrome (oesophageal rupture secondary to forceful vomiting)
• Ingestion of sharp or caustic materials
• latrogenic e.g. during surgery or endoscopy
Causes of lower Gl tract perforation include:
• Diverticulitis
• Colorectal cancer
• Bowel obstruction
• Colitis (e.g. inflammatory bowel disease)
• Appendicitis
• Infection (e.g. toxic megacolon secondary to C. difficile infection)
• latrogenic (e.g. abdominal surgery or colonoscopy)
• Mesenteric ischaemia
• Invasion of the bowel by other tumours
Sx:
• Abdominal pain, which is sudden in onset and severe
• Nausea and vomiting
• Malaise
• Lethargy
• Peritonism e.g. guarding, rebound tenderness, rigidity on palpation of the abdomen
• Hypotension
• Tachycardia
• Tachypnoea
• Fevers
Ix:
Bedside tests:
• Blood gas to measure lactate and acid-base status which may be deranged due to bowel ischaemia or sepsis
• Pregnancy test in women of childbearing age to rule out obstetric causes of abdominal pain such as ectopic pregnancy.
Blood tests:
• FBC and CRP for inflammatory markers
• LFTs and U&Es which may be deranged in sepsis
• Clotting screen and group and saves to prepare for possible surgery; a coagulopathy may develop secondary to sepsis
• Blood cultures if febrile or other signs of infection to help target antibiotic treatment
Imaging:
• CT with contrast looking for free air (confirming perforation) and the site of perforation; an underlying cause may also be seen (e.g. an obstructing tumour
- Oral contrast may be used as well as IV in order to better identify the site of perforation
• Chest X-ray may show air under the diaphragm (pneumoperitoneum) but is significantly less sensitive than CT
• Abdominal X-ray may show Rigler’s sign (where gas outlines both sides of the bowel wall as it is in the peritoneal cavity as well as the lumen) - also not a first-line test due to limited sensitivity
Mx:
Conservative:
• Make the patient nil by mouth
• Urgent surgical review
• May require critical care input e.g. in cases of organ failure secondary to sepsis
• Consider nasogastric tube insertion e.g. in severe vomiting
Medical:
• Start IV broad spectrum antibiotics
• IV fluid resuscitation as required
• Give analgesia and antiemetics - may need to be parenteral
• Certain cases of perforation may be managed with medical treatment only, for example a localised diverticular perforation in a well patient
Surgical:
• Most cases of perforation will require surgical management with a laparotomy
• This usually involves a thorough washout, identifying the cause of perforation and repairing the defect
• For example, cases of bowel perforation would usually be managed with a bowel resection and formation of a temporary stoma to protect the site of repair
Peritonitis
Causes, sx, ix, mx
Causes:
- perforation of a hollow viscus (eg. Oesophagus , duodenal or peptic ulcer
- infection
Sx:
- severe abdo pain
- systemic signs eg. Fever, haemodynamic instability and tachycardia
- nausea and vomiting
- abdominal rigidity and guarding
- rebound tenderness
- percussion tenderness
Ix:
- bloods for infection
- abdo x-ray (look for free gas eg. Riglers sign)
- US
- CT
Mx:
- surgery to control source of inflammation
- antibiotics
- supportive care
Acute pancreatitis
Causes, sx, ix, staging and mx
Causes:
GET SMASHED
• Gallstones
• Ethanol (alcohol)
• Trauma
• Steroids
• Mumps
• Autoimmune disease (e.g. systemic lupus erythematosus, Sjogren’s syndrome)
• Scorpion stings
• Hypercalcaemia, hypertriglyceridemia, hypothermia
• ERCP
• Drugs (e.g. thiazides, azathioprine, sulphonamides)
Sx:
• The main symptom of acute pancreatitis is epigastric pain which may radiate to the back
• Nausea and vomiting are also common symptoms
• Diarrhoea can occur
On examination, signs may include:
• Abdominal tenderness
• Peritonism, rebound tenderness and guarding may be seen
• Abdominal distension
• Fevers (which may be due to inflammation or superadded infection)
• Tachycardia and hypotension if shocked
• Haemorrhagic pancreatitis may present with Grey-Turner’s sign (bruising in the flank area), Cullen’s sign (bruising around the umbilicus) or Fox’s sign (bruising over the inguinal ligament)
Staging:
Severity of pancreatitis is stratified using the Glasgow Score - each of the following scores 1 point and a score of 3 or more predicts severe pancreatitis:
• PaCO2 < 8kPa
• Age > 55 years
• Neutrophils > 15
• Calcium < 2
• Renal i.e. Urea > 16
• Enzymes i.e. LDH > 600 or AST > 200
• Albumin < 32
• Sugar i.e. Glucose > 10
This should be calculated on admission and at 48 hours.
Ix:
Bedside tests:
• ABG if low oxygen saturations to help with risk stratification (the p02 is needed for the Glasgow criteria)
• ECG to rule out acute coronary syndrome as a cause of pain
• Pregnancy test in women of child-bearing age to rule out causes of abdominal pain such as ectopic pregnancy.
• Capillary blood glucose as hyperglycaemia indicates severe pancreatitis
Blood tests:
• FBC and CRP for inflammatory markers
• U&Es to look for kidney injury; urea is part of the Glasgow criteria
• LFTs are often deranged; a low albumin and high AST indicate severe pancreatitis
• Amylase is the key diagnostic test, with levels over 3x the upper limit of normal indicating acute pancreatitis
• Lipase is not usually measured but can also be used to diagnose pancreatitis
- it is more sensitive and specific than amylase
• LDH and a bone profile for calcium are also required for the Glasgow criteria with hypocalcaemia being a poor prognostic factor
• Blood cultures in patients with fevers or other signs of infection
• Coagulation screen as a baseline - may be deranged in severe illness
• Lipid profile if hypertriglyceridaemia is suspected as a cause of pancreatitis
• Autoimmune markers if the cause of pancreatitis is unclear
Imaging:
• Abdominal ultrasound looking for gallstones and duct dilation
• Chest X-ray for complications such as pleural effusions or acute respiratory. distress syndrome
• CT pancreas with contrast should be done in patients who are deteriorating or have signs of sepsis or organ failure after 6-10 days - may detect complications such as pseudocysts or necrotising pancreatitis
• Magnetic Resonance Cholangiopancreatography (MRCP) may be required in cases of pancreatitis secondary to gallstones
Mx:
Conservative:
• Ensure patients with severe pancreatitis (e.g. Glasgow score 3+, hypotension, oliguria, respiratory distress) are referred for intensive care assessment and input
• Catheterise and monitor input-output
• Insert an NG tube if significant vomiting
• If the patient can eat, encourage oral intake as tolerated - they should not be made nil by mouth unless there is another reason for this
• Enteral nutrition should be started within 72 hours of presentation (e.g. NG feeding) - if this fails parenteral nutrition should be considered
Medical:
• IV fluid resuscitation is the mainstay of treatment - crystalloids should be used and should be titrated to achieve an adequate urine output
• Ensure adequate analgesia is given - opioids may be required
• Antiemetics for nausea and vomiting
• Antibiotics should not be given routinely - in some cases (e.g. confirmed pancreatic necrosis) broad-spectrum antibiotics should be given
• Monitor for and treat any complications
• For alcohol-related pancreatitis, alcohol withdrawal treatment may be required (i.e. benzodiazepines and pabrinex)
Surgical:
• The underlying cause of pancreatitis should be treated; an ERCP may be required for gallstones in cases of jaundice, cholangitis or a dilated common bile duct on imaging
• Laparoscopic cholecystectomy for gallstone pancreatitis should ideally be done in the same admission unless the patient is not fit for surgery
• Surgical or interventional management may be required for complications e.g. drainage of large pancreatic pseudocysts or debridement of pancreatic necrosis
Appendicitis
Hx, ix, mx
Hx
• Abdominal Pain – Starts central, radiates to RIF
• Associated Symptoms – nausea/vomiting/fever
• Also sometimes develop diarrhoea, constipation or polyuria
• Reduced oral intake
• Often not a typical history/presentation
• Rovsing Sign (palpation of the left iliac fossa causes pain in the RIF)
• Guarding on abdominal palpation
• Rebound tenderness is increased pain when quickly releasing pressure on the right iliac fossa
• Murphy’s Triad (abdo pain, vomiting, fever)
• McBurney’s Point (this is a localised area one third the distance from the anterior superior iliac spine (ASIS) to the umbilicus)
Ix
- Urinanalysis
- BM
- Bloods- raised WCC, U&E, CRP
- Ultrasound
Mx
Appendectomy
Gastric cancer
Rf, sx, ix, mx
Rf:
- smoking
- pernicious anaemia
- h.pylori
- >6 units alcohol
- dietary nitrosamines
- atrophic gastritis
- blood group a
- adenomatous polyps
- achlorhydria
Sx:
• Anaemia (iron deficient)
• Weight loss
• Anorexia (early satiety)
• Recent onset/progression of symptoms
• Melaena/haematemesis
• Swallowing difficulty (dysphagia)
• Lymphadenopathy - may suggest early spread
• Left supraclavicular lymph node (Virchow’s node)
• Periumbilical nodule (Sister Mary Joseph’s node)
Ix:
- endoscopy
- biopsy
- CT
- MRI
Mx:
- gastrectomy
- chemo
Gallstone disease
Causes, types, rf, sx, ix, mx
Causes:
- super saturation of bile with cholesterol
- gallbladder dysmotility leading to stasis
- excessive bilirubin excretion
Types:
- pigment (haemolysis, stasis and infection)
- cholesterol (female, age and obesity)
- mixed
Risk factors:
- 4Fs: female, fat, 40 and fertile
- diabetes
- FHx
- crohns
- bariatric surgery
- sickle cell anaemia
Sx:
• Biliary colic: Colicky right upper quadrant pain, worse after eating, no fever, negative Murphy’s sign.
• Acute cholecystitis: Right upper quadrant/epigastric pain (radiating to right shoulder tip if the diaphragm is irritated), fever, nausea and vomiting, right upper quadrant tenderness, positive Murphy’s sign.
• Ascending cholangitis: Right upper quadrant pain, fever, jaundice, hypotension, and confusion if sepsis is severe.
• Mirizzi’s syndrome: Chronic right upper quadrant pain, intermittent jaundice due to extrinsic compression of the common hepatic duct by an impacted stone in the cystic duct or gallbladder neck.
• Chronic cholecystitis: Flatulent dyspepsia, vague abdominal pain, nausea, bloating, symptoms worsening after a fatty meal, occasional colicky pain.
• Gallstone ileus: Signs of small bowel obstruction due to gallstone migration.
• Cholangiocarcinoma: Abdominal pain, jaundice, anorexia, weight loss, possible right upper quadrant mass.
Ix:
- bloods (LFTs, CRP
- US as first line imaging
- CT (better for stones)
- MRCP
- ERCP
Mx:
- IV fluids, antibiotics and critical care
- biliary drainage via ERCP
- cholecystectomy
Haemorrhoids
Def, grades, cause, sx, ix, mx
Haemorrhoids are a pathological condition where the vascular cushions within the anal canal abnormally expand and can protrude outside the anal canal.
They are graded as below:
• Grade 1 - no prolapse
• Grade 2 - prolapse on straining which spontaneously reduces
• Grade 3 - prolapse on straining and require manual reduction
• Grade 4 - prolapse on straining and can’t be manually reduced, external haemorrhoids, or lower grade haemorrhoids failing to respond to less invasive measures
Cause:
• Constipation
• Pregnancy
• Increased intra-abdominal pressure due to causes like obesity, chronic cough or space-occupying lesions
• Portal hypertension, particularly secondary to cirrhosis, due to increased pressure at the rectal porto-systemic anastomosis
Sx:
• Bright red PR bleeding, often associated with defecation and on wiping
• Absence of pain, unless the patient has a thrombosed external haemorrhoid or another condition such as an anal fissure
• Anal pruritus
• A palpable or protruding mass in the anal region during examination, suggestive of prolapsing haemorrhoids
Ix:
- PR exam
- anoscopic exam
Mx:
• Grade 1: Conservative management, including potential use of topical corticosteroids to alleviate pruritus
• Grade 2: Management may involve rubber band ligation (preferred), sclerotherapy, or infrared photocoagulation
• Grade 3: Rubber band ligation is the treatment of choice
• Grade 4: Surgical haemorrhoidectomy may be necessary In all cases, patients should be advised to maintain a diet rich in fibre and fluids to reduce the risk of constipation, thereby limiting exacerbation of haemorrhoids.
For thrombosed haemorrhoids, which present as painful, purple protrusions, conservative measures such as ice packs, laxatives, and lidocaine gel are first-line treatments. If these measures fail, haemorrhoidectomy may be required.
Perianal abscesses and fistulae
Def, causes, sx, ix, mx
An anorectal abscess is a localized collection of pus in the perianal or rectal spaces, commonly arising from an infection in the anal glands.
Causes:
- anal fistulae (connections between surface of anal canal and external skin)
- Crohn’s
Sx:
- perianal pain
- perianal swelling
- systemic (pyrexia, tachycardia and potentially sepsis if there is spread)
Ix:
- PR exam
- FBC, CRP, ESR and flood cultures
- MRI pelvis is gold standard
Mx:
- drainage under local
- incision and drainage under general when degree of tissue damage is unknown or in the case of a deep perirectal abscess with sphincter extension
- antibiotics if underlying diabetes or immunosuppression. IV if presentation is already septic
Colorectal cancer
Rf, sx, staging, screening, ix, mx
Rf:
- age
- FAP (familial adenomatous polyposis)
- lynch syndrome
- juvenile polyposis
- peutz-jeghers syndrome
- alcohol
- tobacco
- processed meat
- obesity
- radiation
- IBD
Sx:
- rectal bleeding
- weight loss
- change in bowel habit
- abdo pain
- iron deficiency anaemia
- bowel obstruction resulting in nausea and vomiting
Staging:
TNM (tumour, node, metastases) is a more recent classification system (replacing the Duke’s classification), which provides a more uniform classification of colorectal cancer.
• T: Tis (carcinoma in situ/intramucosal cancer), T1 (extends through the mucosa into the submucosa), T2 (extends through the submucosal into the muscularis), T3 (extends through the muscularis into the subserosa), T4 (extends into neighbouring organs or tissues).
• N: NO (no regional lymph node involvement), N1 (metastasis to 1-3 regional lymph nodes), N2 (metastasis to 4 or more regional lymph nodes).
• M: MO (no distant metastasis), M1 (distant metastasis).
Staging informs both the prognosis and the treatment plan.
Patients with Duke’s stage C or stage III (T1-4, N1-2, MO) colon cancer benefit from adjuvant chemotherapy. Note that patients without lymph node involvement but with high risk features (such as vascular or perineural invasion) also show improved survival with adjuvant chemotherapy.
Screening:
• Faecal immunochemical test (FIT) every 2 years for men and women age 60-74. If positive patients are referred for colonoscopy. >10
Ix:
• Bloods - FBC (anaemia), iron studies, and carcinoembryonic antigen (CEA) are useful initial investigations
• CEA is not used as a diagnostic tool but is a tumour marker that can be used to monitor therapeutic response to interventions.
• The gold standard investigation is a colonoscopy. It allows
• Direct visualisation of the colon
• Biopsies to be taken
• Removal of any polyps seen
• If colonoscopy cannot be performed, either due to technical difficulties, poor tolerance of bowel preparation or there is an increased risk of colonic perforation a CT colonoscopy is a suitable alternative but does not allow biopsy.
• After a histological diagnosis is made, a CT chest, abdomen and pelvis should be performed to stage the disease, so an appropriate intervention can be planned.
• In rectal disease, a pelvic MRI or endorectal ultrasound are preferred over
CT scan, as are better for identifying locally invasive disease.
Mx:
For patients with colon cancer suitable for surgery:
• Stage I-III disease: surgical resection ‡ adjuvant chemotherapy.
The type of surgery depends on the tumour site: right hemicolectomy for tumours of the caecum and ascending colon, left hemicolectomy for tumours of the distal transverse colon and descending colon, and sigmoid colectomy for tumours of the sigmoid colon.
• Stage IV disease (metastases): treatment is as above, but neoadjuvant chemotherapy may also be performed. The staged colectomy and resection of metastatic disease is performed after neoadjuvant chemotherapy.
• In terms of specific surgical procedures, patients with caecal and ascending colon tumours undergo right hemicolectomy
For patients with rectal cancer suitable for surgery:
• Anterior resection for tumours >8 cm from the anal canal or involving the proximal 2/3 of the rectum.
• Abdomino-perineal (AP) resection for tumours <8 cm from the anal canal or involving the distal 1/3 of the rectum.
• Patients with stage Ill disease benefit from adjuvant chemotherapy.
• Patients with stage IV disease benefit from adjuvant chemoradiotherapy
Diverticular disease
Def, rf, sx, ix, mx
Def:
- Diverticular disease is a term used to describe conditions related to the presence of diverticula, which are small, bulging pouches that can form in the lining of the digestive system, most commonly in the lower part of the colon (sigmoid colon).
- Diverticulosis refers to the simple presence of diverticula. In many cases, diverticulosis is asymptomatic, and individuals may not even be aware that they have these diverticula as they are typically discovered incidentally during tests for other conditions.
- Diverticulitis, a subset of diverticular disease, occurs when these diverticula become inflamed or infected. This condition is typically characterized by severe abdominal pain, fever, and nausea. Diverticulitis often requires treatment, which can include antibiotics, pain relievers, and, in severe cases, surgery.
Rf:
- age
- low fibre diet
- obesity
- lack of exercise
- NSAIDs
- opiates
Sx:
- constipation
- LLQ pain
- rectal bleeding
Diverticulitis sx:
- fever
- nausea/vomiting
- pyrexia
- guarding
- diffuse abdominal tenderness suggestive of peritonitis
Ix:
- CT or ultrasound
- bloods for inflammation
- colonoscopy or endoscopy
Mx:
- increase fibre and hydration
- analgesia
- antibiotics
- surgery for obstruction
- recurrence may need elective colectomy
Direct and indirect inguinal hernias
Def, cause, sx, ix, mx
• Indirect inguinal hernias: These hernias follow the path of the descent of the testes, which occurs via the processus vaginalis during fetal development. They are typically congenital and often observed in young males.
• Direct inguinal hernias: These hernias protrude through a weakness in the abdominal wall, specifically the inguinal triangle (Hesselbach’s triangle). They are usually acquired and more common in elderly males.
Causes:
• Indirect inguinal hernias are generally congenital, resulting from a patent processus vaginalis.
• Direct inguinal hernias are typically acquired, caused by factors that raise intra-abdominal pressure such as chronic cough (e.g., in smokers), constipation, heavy lifting, or obesity.
Sx:
- groin swelling
- pain
- palpable mass
Ix:
- clinical diagnosis
- bloods: raised lactate and raised inflammation
- US
- CT
- X ray
Mx:
Open or laparoscopic mesh repair
Femoral hernia
Def, causes, sx, ix, mx
A femoral hernia is a type of hernia that develops in the femoral canal, a space near the groin and thigh. It is often marked by the presence of an irreducible lump in the groin area located inferior to the inguinal ligament and inferior and lateral to the pubic tubercle.
Causes:
- lifting heavy objects
- chronic cough
- constipation
- obesity
- pregnancy
Sx:
- groin lump
- irreducibility
- inflammation
- bowel obstruction features
Ix:
- physical exam
- US
- CT
Mx:
Open or laparoscopic mesh repair
Hiatus hernia
Def, types, sx, ix, mx
Abdominal contents protrude through an enlarged oesophageal hiatus in the diaphragm
Sx:
- heartburn
- dysphagia
- regurgitation
- odynophagia
- SOB
- chronic cough
- chest pain
Ix:
- barium swallow
- endoscopy
- oesophageal manometry
Mx:
- weight loss
- elevate bed head
- avoid large meals 3-4 hours before bed
- avoid alcohol and acidic foods
- smoking cessations
- PPIs
- Nissens fundoplication
Mesenteric adenitis
Def, pathogen, cause, sx, ix, mx
• Inflammation of intra-abdominal lymph nodes following a viral infection
path
• most common pathogen is yersinia enterocolitica
Cause
• History of recent infection, usually an upper respiratory tract infection or gastroenteritis
sx
• Acute pain can mimic appendicitis
• No signs of peritonism or guarding on examination with red throat or cervical lymphadenopathy
ix
• FBC and US abdo showing enlarged lymph nodes and hypervascular
mx
• Self-limiting
• Conservative management with analgesic
Inflammatory bowel disease (IBD)
Types, sx, ix, mx
Inflammatory bowel disease is the umbrella term for the two main diseases that cause inflammation of the GI tract: ulcerative colitis and Crohn’s disease. They both involve inflammation of the walls of the GI tract and are associated with periods of remission and exacerbation.
Extra-intestinal manifestations:
Finger clubbing
Erythema nodosum
Pyoderma gangrenosum
Episcleritis and iritis
Inflammatory arthritis
Primary sclerosing cholangitis (ulcerative colitis)
Ix
- Bloods – FBC, UE, LFTs, TFTs, CRP
- Facael calprotectin
- Endoscopy (gold standard)
- USS, CT, MR
