Gastro Flashcards
Suspicion of IBD
- Diarrhoea for more than 4 weeks
- Opening the bowels more than twice a day
- wet/fluid-like stool
- Abdominal pain
- Stool containing blood, mucus or pus
Ulcerative colitis
- Chronic inflammatory bowel disease that is only localised in the mucus membrane of the colon/rectum.
- There are ulcers and signs of inflammation in the rectum and the colon. It is a recurrent disease.
- Diarrhoea, bloody stool, crampy abdominal pain, weight loss, loss of appetite
- Diffuse ulceration in colon mucus membrane, crypt abscess, infiltration.
Crohn’s disease
- Chronic, segmental or multi-segmental. All the layers of the intestine is affected
- Both small intestines and the colon might be affected
- Cramp-like abdominal pain, weight loss, diarrhoea, fever
- Local inflammation, micro-erosions, fissures, granuloma, fistulas, infiltrations, lymphatic vessel enlargement
Ulcerative Colitis Localisation
Sigmoid-rectum 54%
Left colon 27%
Pancolitis 19%
Crohn’s disease Localisation
Small intestine and colon 50%
Ileitis 29%
Colitis 19%
Anorectal 2%
Extraintestinal symptoms
Arthritis, polyarthritis 26%
Erythema nod., Pyoderma gangr. 19%
Fatty liver, Chr. Active hepatitis, PSC 7%
Iridocyclitis, Uveitis 4%
Oral, stomatitis aphtosa 4%
Alveolitis, lung fibrosis <1%
Diagnostics: Crohn’s disease
- Colonscopy, (biopsy) capsule-endoscopy
- X-ray, Barium enema and meal
- UH, CT
- Laboratory (blood) tests ( Sedimentation, WBC, CRP, liver enzymes, stool culture )
Diagnostics: Ulcerative colitis
- Colonscopy, (biopsy) capsule-endoscopy
- X-ray, Barium enema and meal
- UH, CT
- Laboratory (blood) tests ( Sedimentation, WBC, CRP, liver enzymes, stool culture )
Crohn’s disease: Therapy
- Acute fulminate: exclusion of abscess then Steroid 40-60 mg, wide spectrum antibiotics
- Subacute disease: Steroid in decreasing dosage Budenofalk, sulfasalazin, Pentasa, Salofalk, metronidasol
- Chronic: constant low dose steroid, Imuran, 5-aminosalicyl
Ulcerative colitis :Therapy
- Acute inflammation: Steroid, antibioticum, 5-ASA
- Chronic : 5-ASA, Imuran
Crohn’s disease: complications
- Stenosis, ileus (bowel obstruction)
- Fistula formation
- Abscess formation
- Bleeding
- Toxic megacolon
- Malignant transformation
Ulcerative colitis: complications
- Stenosis, ileus (bowel obstruction)
- bleeding
- Perforation, abscess formation, peritonitis
- Toxic megacolon
- Malignant transformation
Crohn’disease: Surgical therapy
- Maximally conservative !!!
- Resection (preserving as much small intestine as possible!)
- Srticturopalsty (small intestine)
- Toxic megacolon
Ulcerative colitis: Surgical treatment
In acute case: - Hartmann procedure - Proctocolectomy Elective operation: - Proctocolectomy with ileostomy - Total colectomy with ileo-rectal anastomosis - Proctocolectomia , ileo-analis anastomisis with ileum pauch - Proctocolectomia, Koch-reservoir
Clinical features which distinguish acute appendicitis from non-specific (non-surgical) abdominal pain
- Pain moving to right lower quadrant
- Pain aggravated by movement and coughing
- Nausea, vomiting and anorexia
- Facial flushing but with hyperpyrexia
- Focal tenderness in right lower quadrant
- Rebound tenderness plus muscle guarding
- Right focal (abdominal) tenderness on rectal exam
Clinical features suggesting perforated viscus
- Pain of sudden onset
- Constant sever pain
- Pain aggravated by movement, coughing and inspiration
- Decreased abdominal movements
- Diffuse tenderness
- Silent, rigid abdomen
Clinical features suggesting intestinal obstruction
- Colicky, severe pain
- No factor aggravating pain
- Vomiting and constipation
- Previous surgery
- Abdominal distension
- Bowel sounds hyperactive or absent
Features suggesting ectopic pregnancy
- Delayed, irregular periods
- Possible or confirmed pregnancy
- Faintness and dizziness
- Vaginal discharge
- Any abnormality on vaginal examination
Features suggesting intussusception
- Age less than 30 months
- Episodic pain
- Sever central pain
- No aggravating factors
- Blood in stool
- Distress or pallor
- Diffuse tenderness
- Muscle guarding
- Palpable mass
- Abnormal bowel sounds
Important features of cancer
- Intermittent pain over 48 hours’ duration
- Any alteration to bowel habits
- Abdominal distension
- Mass present
Important features of vascular disease
- Sudden onset of pain
- Associated chest pain and arrhythmias
- Lower limb pulses diminished
- Pallor and cyanosis
Features of colonic perforation
- Pain over 48 hours’ duration
- Pain onset in lower abdomen
- Any alteration in bowel habits
- Abdominal distension
Diseases with abrupt, excruciating pain:
- Biliary colic
- Ureteral colic
- MI
- Perforated ulcer
- Ruptured aneurysm
Diseases with Rapid onset of sever, constant pain:
- Acute pancreatitis
- Mesenteric thrombosis
- Strangulated bowel
- Ectopic pregnancy
Diseases with gradual, steady pain:
- Acute cholecystitis
- Acute cholangitis
- Acute hepatitis
- Appendicitis
- Acute salpingitis
- Diverticulitis
Diseases with intermittent, colicky pain, crescendo with free intervals:
- Early pancreatitis
- Small bowel obstruction
- IBD
Investigations used in the management of the acute abdomen
Urine - Dipstick - Mid-stream specimen Blood - Full blood count - Urea and electrolytes - Liver function test - Serum amylase - Blood gases, calcium, glucose Radiography - Chest radiograph - Abdominal radiograph - Contrast studies Ultrasound Axial CT Peritoneal lavage Laparoscopy Laparotomy
Intra-abdominal diseases causing abscess formation:
- Perforated malignant tumors
- Perforated peptic ulcer
- Biliary disease
- Acute pancreatitis
- Ischemic bowel (including internal and external hernias)
- Meckel’s diverticulitis
- Appendicitis
- Crohn’s disease
- Pelvic inflammatory disease
- Pyelonephritis
- Uteric obstruction
- Diverticulitis
- Lower urinary tract infection
colorectal carcinomas
CRC= adenocarcinoma (mucinous, non-differentiated)
- Colon cc, rectum cc, anus (plano/squamous cell)
- II. cause of death in neoplastic mortality list
- 40-45% of all cases curable
Etiology of CRC
Familial: 20% (FAP, HNPCC, other)
Sporadic:
- low fiber diet, slow transit, high fat and meat content, (Africa<Europe, America)
- Predisposing diseases: Crohn, ulcerative colitis, adenomas, previous CRC (metachron tumors)
Pathogenesis of CRC
- Adenoma-carcinoma sequence, 10-15 yrs
- Sporadic cc: acquired mutations
- FAP: APC (inherited muation) HNPCC: mutation in mismatch repair genes
- K-ras (point mut.), myc (ampl.), src-kinase activation, DCC, p53
- HNPCC: Lynch I, II syndroms
HNPCC, Amsterdam - Bethesda criteria
- At least two generations are affected
- First appearance of CRC before age 50
- At least two first degree realatives
- FAP can be excluded
- Extracolonic tu: gastric, endometrium, ovarium, biliary-, urinary
- Synchron or metachron tumors
Layers of the wall of the colon - staging
TIS: Astler-Coller T1: (Dukes) A T2: (Dukes) B1, C1 T3: (Dukes B2, C2) T4: (Dukes) D
Staging of CRC
T1: submucosa infiltration
T2: muscularis propria infitration
T3: subserosa or not peritonealized surface
T4: neighbouring organ, or peritoneum inf.
N0: absence of nodal infiltration
N1: metasis in 1-3 lymphnode
N2: metastasis in 4 lymph nodes
N3: metastasis along a main arterial branch
M0: no distant met.
M1: distant met.
Symptoms of CRC, right colon
- Anemia, weakness, melena, weight loss,
- (palpable resistance in the right lower quadrant
Symptoms of CRC, left colon
- Blood in the stool, or tarry stool, change in bowel habit, alternation of diarrhoea and obstipation, ample voiding of mucus, incomplete evacuation, abdominal distension
- About 16% of CRC might be palpated throught the anus (rectal exam)
Incidence, prognosis
- 10- 16% in cecum
- 10 – 16% in ascending colon
- 2 – 6% in distal transverse colon
- 8 – 10% in desending colon
- 50 - 60% in sigmoid colon
Treatment of CRC: surgical
- Surgical treatment provides the only curative modality
- The basis of surgical tretament is radicality: removal of all tomor mass in continuity with lymphoid drainage
- Adjuvant modalities might be effective in certain cases
Surgical treatment of CRC
- Segment resection (right and left hemicolectiomy)
- Anterior resection of the rectum (Dixon)
- Abdomino-perineal exstirpation of the rectum (Miles)
- Resection and proximal stoma formation (Hartmann
Indications for acute procedures in CRC
- Ileus
- Bleeding
- Perforation
- Peritonitis
Postoperative care
- Postoperative „physiologic” ileus
- Enteral nutrition
- Anticoagulation
- Oncologic follow-up, at least 5 yrs
- Abd. US, chest x-ray, CT, MR.
- Laboratory: blood counts, tu. markers
- colonoscopy
Special features of rectal cancer
- Worse prognosis
- Neoadjuvant radiochemotherapy may improve results
- Techniquely more challenging intervention
- Quality of life is more deeply affected by the intervetion (sphincter, vegetative nerves)
Bowel obstruction-ileus
Key points
- A group of diseases with diverse etiology
- The common feature is obstruction of the bowel
- Similar set of symptoms, which may vary according to site and cause of obstruction
- Therapy is according to etiology, aiming at relief from obstruction, and treatment of primary disease
- May be mechanical or paralytic (US: ileus)
Site of obstruction
Luminal: Intussusception, Meconium, Polypoid tumor, Gallstone, Bezoar, Parasites, Feces
Mural:
Stricture (Crohn’s disease, radiation)
Small bowel tumor
Congenital atresia, stenosis, duplication
Extrinsic:
Adhesion
Hernia
Malignant or inflammatory mass Volvulus
Clinical signs and symptoms of bowel obstruction
- Nausea and vomiting
- Abdominal distension
- Decreased passage of flatus and stool
- Possible causes of obstruction:
o previous operations, presence of hernias,
o previous irradiation, previous malignancy
Changes with level of obstruction
HIGH: Frequent vomiting, No distention, Intermittent pain but not classic crescendo type
MIDDLE: Moderate vomiting, Moderate distention, Intermittent pain (crescendo, colicky) with free intervals
LOW: Vomitting late, feculent, marked distention, Variable pain
Pathophysiology of bowel obstruction
- Obstruction-incresased luminal pressure-increased secretion, decreased absorption
- Increased peristalsis-stasis-bacterial overgrowth-translocation-septic complications
- Sequestration of fluid-third spacing-hypovolemia
- Impared perfusion-ischemia-necrosis
Examination of bowel obstruction
- Degree of distress
- Severity of dehydration
- Evidence of sepsis
- Inspection: scars, hernia orifices, distension
- Auscultation: tinkling, splashing, quiet abdomen
- Palpation: location of tenderness, rigidity, garding
- Rectal exam
Laboratory of bowel obstruction
- Degree of dehydration
- Electrolyte imbalance
- Exclusion of possible other diseases (eg.: pancreatitis)
- Imaging: plain abdominal films, ultrasound
- CT in special cases (tu. recurrence, radiation enteritis, Crohn’s disease)
Large bowel obstruction
- Longer anamnesis
- Gradual increase of dull pain (cramping is rare)
- No passage of flatus or stool
- Blood may be found in feces
- Vomiting comes late, may be feculent if ileocecal valve is incompetent
- Cecum is the most prone to perforation
Causes of large bowel obstruction
- Cancer
- Diverticulitis - chr. inflammation – scarring - stenosis
- Sigmoid-, cecal volvulus
- Ogilvie’s syndrom (colonic pseudo-obsruction-paralysis
Role of the ileocecal valve
A: Competent valve: closed large bowel loop
B: Incompetent valve: distension reaches the small bowel loops
Treatment options in obstructing large bowel cancer
- Two stage procedure (Hartmann’s)
- Extended resection, primary anastomosis
- Subtotal colectomy
- On table lavage, primary anastomosis
- Loop colostomy in inoperable cases
- Non-operative decompression-semielective operation
- Henrik Kehlet
Hartmann’s operation
- surgical resection of the rectosigmoid colon with closure of the rectal stump and formation of an end colostomy
- used in colon cancer in diverticulitis
Colonic pseudo-obstruction, Ogilvie’s syndrom
Causes:
o DM, hypothyreosis, kidney insuff, opiates, antiparkinson drugs
o cong. heartfailure, MS, lupus, amyloidosis, dermatomyositis, scleroderma, sepsis, trauma (head, spine) operation (abdominal, heart, neurosurgery)
Therapy of Ogilvie’s syndrome
o Eliminate instigating factors (if possible),
o Enema, laxatives
o Cholinesterase blocker,
o Ganglion blockers
o Colonoscopy-may be therapeutic
o Surgery: perforation, failure of cons. meas
