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Gastroenterology Flashcards

1
Q

List the daily requirements of fat, protein, carbohydrate utilised by the body.

Know how to calculate daily requirements for protein, carbs and calories, based on weight and stress levels.

A

Fat: < 70g (9 kcal/g) (30%)

Protein: 50g (4 kcal/g2) (13%1)

Carbohydrate: at least 260g (4 kcal/g) (57%)

Calculations:

Basic energy requirements (BER) can be calculated as 1.3kcal/kg/hr

Protein: BER x 0.131 = x

x / 42 = grams

1: Percentage of dietary allowance for the macronutrient
2: Calories per gram for the macronutrient

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2
Q

List anthropomorphic measurements and objective parameters for assessment of nutritonal state

A

Anthropomorphic:

  • Height, weight
  • Mid-upper arm circumference
  • Skin fold thickness

Objective:

  • BMI
  • Hip:waist ratio
  • Waist circumference
  • DEXA
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3
Q

UPPER GASTROINTESTINAL TRACT: List the anatomical and physiological factors predisposing to gastro-oesophageal reflux disease

A

Anatomical:

  • Hernia: Hiatus hernia

Physiological:

  • Increased IAP: Obesity, pregnancy
  • H. Pylori infection
  • Smoking
  • Diet:
    • ​Spicy foods, fatty foods, high caffeine intake
  • Late night meals
  • Iatrogenic: Medications
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4
Q

UPPER GASTROINTESTINAL TRACT: Define hiatus hernia with regard to anatomical type

A

Sliding (A): The gastro-oesophageal junction (GOJ), abdominal part of the oesophagus and sometimes the cardia of the stomach slide upwards through the diaphragmatic hiatus into the thorax

Rolling (B): Gastric fundus is seen above the diaphragm, creating a ‘bubble’ of stomach in the thorax. This is a true hernia, with a peritoneal sac.

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5
Q

UPPER GASTROINTESTINAL TRACT: Name 3 typical symptoms of GORD

A
  • ‘Heartburn’/dyspepsia
  • Early satiety and bloating
  • Water brash
  • Odynophagia
  • Nocturnal cough/wheeze
  • Worsened by intake of certain foods/caffeine
  • Worsened by the supine position
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6
Q

UPPER GASTROINTESTINAL TRACT: Describe the investigations used to confirm a diagnosis of GORD

A

Hx: Symptoms, no red flags (ALARMS55)

Examination:

Investigations:

  • H. Pylori test
  • OGD
  • Barium swallow (if hiatus hernia is suspected)
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7
Q

UPPER GASTROINTESTINAL TRACT: Discuss general measures, medical therapy and surgical treatment for GORD.

A

General measures:

  • Avoid spicy, high fat and citrus foods
  • Reduce caffeine and alcohol intake
  • Weight loss
  • Avoid large meals, especially before bed

Medical therapy

  • PPI and H2 antagonist
  • Alginates
  • Triple therapy for H. Pylori: PPI, metronidazole and clarithromycin
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8
Q

UPPER GASTROINTESTINAL TRACT: Outline the possible long-term complications of GORD

A
  • Metaplasia of the oesophagus with increased risk of malignant transformation
    • Barrett’s oesophagus or oesophageal adenocarcinoma
  • Oesophaheal ulceration, haemorrhage or perforation
  • Benign strictures
  • Nutritional deficit due to odynophagia
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9
Q

UPPER GASTROINTESTINAL TRACT: Understand the presenting features, investigation and management of Barrett’s oesophagus

A

Presenting features:

  • May be asymptomatic
  • Symptoms of GORD
    • ​Regurgitation
  • Dysphagia/odynophagia (may indicate a stricture)
  • ?Globus sensation
  • ?Haemoptysis

Investigation:

  • OGD with biopsy
    • Violaceous epithelium proximal to the GOJ. ‘Salmon-coloured’ mucosa
  • ​Barium oesophagram

Management:

  • Non-dysplastic Barrett’s:
    • Reduce symptoms of gastric reflux:
      • PPI
    • Nissen fundoplication
  • Dysplasrtic Barrett’s
    • Endoscopic eradication therapies
    • Endoscopic mucosal resection (EMR)

Risk factors: GORD, increased age, male, white, smoking, obesity

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10
Q

DYSPHAGIA: List the common causes and discuss investigations of dysphagia

A

Common causes:

*OROPHARYNGEAL1 VS OESOPHAGEAL2 DYSPHAGIA (see below)

  • Stroke
  • Oesophageal motility disorders
    • Achalasia
    • Scleroderma
  • Malignancy
  • GORD
    • Strictures
  • Congenital abnormalities
    • ​Plummer-Vinson syndrome
  • Psychological
  • Infection: Pharyngitis, candidiasis, epiglottitis, tonsillitis, quinsy
  • Endocrine: Goitre
  • Neuromuscular disorders

Investigations:

  • 24-hour pH monitoring
  • OGD with biopsy
  • Barium swallow
  • CXR, CT

Oropharyngeal dysphagia: Difficulty initiating swallowing +/- choking and aspiration Most common neuromuscular in origin

Oesophageal dysphagia: Food sticks after swallowing

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11
Q

DYSPHAGIA: List the symptoms suggestive of oesophageal malignancy

A
  • Progressive oesophageal dysphagia
    • Starting with solids and then progressing to liquids
    • Short Hx of dysphagia
  • Constitutional symptoms: Weight loss, cachexia, night sweats, ALARMS55 criteria
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12
Q

DYSPHAGIA: Describe the pathology and natural history of oesophageal malignancy

A

Pathology:

  • Most occur in the lower third of the oesophagus and are adenocarcinomas
  • The remaining 2/3rds are SCCs
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13
Q

DYSPHAGIA: List the treatment options for an oesophageal maligancy.

Discuss staging and assessment of fitness for operation for oesophageal malignancy

A
  • Radiotherapy
  • Chemotherapy
  • Surgery - oesophagectomy, +/- pre-operative chemotherapy

Staging

  • Staging and grading1 via OGD + biopsy, CT CAP, PET to assess for metastatic disease
  • TNM

Assessment of fitness

  • Age and co-morbidities
  • Anaesthesetic risks

​1: Grading looks at the level of cellular differentiation

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14
Q

DYSPHAGIA: Outline the pathology, presentation and management of achalasia

A

Pathology:

An oesophageal motility disorder with loss of oesophageal peristalsis (aperistalsis) and failure of the lower oesophageal sphincter to relax upon swallowing.

Presentation:

  • Slowly/non-progressive dysphagia
  • Tends to present in younger patients
  • Regurgitation
  • Retrosternal pain
  • ‘Mega-oesophagus’ (due to dilation) and tapering below (bird beak sign)

Management:

  • Symptomatic to reduce dysphagia
  • Lifestyle modifications: Eat sitting upright, chew food well, take plenty of water with meals
  • Surgical:
    • Pneumatic dilation of the lower oesophageal sphincter
    • Surgical cardiomyotomy: Incision into the muscle fibres across the lower oesophageal sphincter
  • Pharmacological:
    • Calcium channel blockers or nitrares to lower oesophageal sphincter pressure
  • Poor surgical candidates:
    • Endoscopic injection of botulinum toxin
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15
Q

PEPTIC ULCER DISEASE: List the main causes, symptoms and investigations of peptic ulcer disease

A

Main causes:

  • Iatrogenic: Gastric irritants, e.g. NSAID/aspirin/corticosteroids, use without gastric protection
  • H. Pylori infection
  • Zollinger-Ellison syndrome1
  • Risk factors: Smoking, increasing age, personal/FHx of peptic ulcer disease

Symptoms:

  • Epigastric pain, related to eating
  • Haematemesis and/or melaena
  • Symptoms of anaemia
  • Symptoms of gastric reflux: Dyspepsia, bloating/early satiety
  • Peritonitis if rupture occurs
  • CHECK for ALARMS55 symptoms

Investigations:

  • Bloods: FBC2
  • H. Pylori test
  • OGD

1: Zollinger-Ellison syndrome - a syndrome of gastric acid hypersecretion caused by a gastrin secreting neuro-endocrine tumour
2: Checking for anaemia, due to blood loss from the ulcer

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16
Q

PEPTIC ULCER DISEASE: Discuss the differences between gastric and duodenal ulcers

A
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17
Q

PEPTIC ULCER DISEASE: Discuss the relationship between H. Pylori, smoking, NSAIDs and peptic ulcer disease; including the mechanisms by which they cause peptic ulceration

A
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18
Q

PEPTIC ULCER DISEASE: Be aware of other therapies which may increase GI bleed risk

A
  • Anti-coagulants
  • Anti-platelets
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19
Q

PEPTIC ULCER DISEASE: List the complications of peptic ulcer disease and describe subsequent treatment

A

Complication and associated treatment:

  • Upper GI bleeding
    • Acute: Endoscope, surgical
    • Chronic: Causing anaemia. Iron supplementation
  • Gastric outlet obstruction1
  • Perforation
    • Surgical treatment

1: Gastric outlet obstruction may occur due to scarring and oedema. PC is often nausea, vomiting and weight loss.

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20
Q

GASTROINTESTINAL HAEMORRHAGE: Specify the symptoms and common causes of acute upper GI bleeding

A

Symptoms:

  • Shock
    • Hypotension, tachycardia
  • Melaena and/or haematemesis
    • ​Particularly ‘coffee-ground’ emesis
  • Return of blood through a nasogastric tube

Common causes of acute GI bleeding:

  • Ruptured oesophageal varices
  • Peptic ulcer disease
  • Mallory-Weiss tear
  • Malignancy
  • Oesophagitis
  • Iatrogenic
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21
Q

GASTROINTESTINAL HAEMORRHAGE: List the common causes of acute lower gastrointestinal bleeding

A
  • Diverticulitis/diverticular disease
  • Angiodysplasia
  • IBD: Crohn’s, UC
  • Intestinal perforation, secondary to GI obstruction
  • Ischaemic colitis1
  • Haemorrhoids
  • Malignancy
  • Anal fissure

1: Ischaemic colitis occurs when there is acute, transient interruption to GI perfusion such that the metabolic demands of the bowel cannot be met

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22
Q

GASTROINTESTINAL HAEMORRHAGE: List the commonest presentations of chronic GI blood loss

A
  • Iron deficiency anaemia
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23
Q

GASTROINTESTINAL HAEMORRHAGE: Discuss the initial management of a patient with gastrointestinal haemorrhage

A

A-E approach

  • 2 large bore cannulas (grey/brown)
    • Bloods from one for baseline biochemistry
    • IV fluids/blood components into the other
  • Insert a urinary catheter and monitor hourly urine output
  • Organise CXR, ECG and ABG
  • Alert a senior and the surgical team
    • +/- resus team
  • Arrange an urgent endoscopy
    • Immediately following resuscitation for unstable patients
    • Within 24 hours of admission for all other patients
    • Diagnostic and therapeutic1

The Rockall score is used to assess the risk of rebleeding and mortality.

The Glasgow-Blatchford bleeding score may be used to assess the need for admission in patients with upper GI bleeds. ?May also be used for inpatients

1: Therapeutic uses include adrenaline injection or diathermy for ulcers and banding for varices

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24
Q

GASTROINTESTINAL HAEMORRHAGE: List the criteria for endoscopic, surgical and radiological intervention

A

Surgical or radiological intervention is required if endoscopic intervention is unsuccessful i.e. bleeding reoccurs or is persistent despite treatment.

Endoscopic intervention includes administration of adrenaline, diathermy and banding.

Radiological intervention:

  • CT angiography to locate the exact site of the bleed
  • Embolisation through the introduction of an embolic agent into the bleeding vessel
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25
Q

GASTRIC NEOPLASMS: List risk factors for, the symptoms suggestive of and investigations for gastric cancers

A

Risk factors:

  • Pernicious anaemia1
  • H. Pylori infection
  • Increasing age
  • Smoking
  • Obesity and poor diet

Suggestive symptoms:

  • Weight loss
  • Epigastric pain/discomfort
  • Early satiety/bloating
  • Dyspepsia (refractory to treatment)
  • ALARMS55
  • Melaena
  • Constitutional symptoms: Weight loss, night sweats

Investigations:

  • Bloods
  • OGD with biopsy
  • CT CAP
  • PET scan to check for lymph node invasion

​1: Pernicious anaemia arises due to autoimmune mediated destruction of intrinsic factor producing parietal cells, preventing absorption of Vitamin B12

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26
Q

GASTRIC NEOPLASMS: Describe the epidemiology, classification, morphology and natural history of gastric cancers

A

Epidemiology:

  • Men > women
  • More common with increasing age

Classification:

  • Adenocarcinoma *most common*
    • Occur in the antrum
    • ‘Leather bottle stomach’ due to fibrous reaction
    • ‘Krukenberg’ tumours are the result of metastatic spread to the ovaries
  • Leiomyomas and leiomyosarcomas
    • Usually slower growing and benign
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27
Q

GASTRIC NEOPLASMS: Outline the general principles of curative and palliative surgical procedures for gastric cancers and discuss the role of adjuvant and palliative therapy

A

Surgical procedures for gastric cancers

  • Gastrectomy
    • For all patients with T2 or higher and any N, perioperative treatment should be given
    • Post-operative chemoradiation may be indicated
    • May be offered to palliative patients to improve symptoms such as bleeding and obstruction
  • Endoscopic musosal resection (EMR) is appropriate for patients with adenocarcinoma confined to the mucosa
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28
Q

GASTRIC NEOPLASMS: Quantify the prognosis for gastric cancer

A

Overall, the 5 year survival rate is < 10%

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29
Q

THE ACUTE ABDOMEN: Define the acute abdomen

A

‘The rapid onset of acute symptoms that may indicate severe and life-threatening intra-abdominal pathology that requires urgent surgical intervention.’

  • Abdominal pain is usually a feature although pain-free acute abdomen can occur
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30
Q

THE ACUTE ABDOMEN: Identify the symptoms and signs of the acute abdomen

A

Symptoms:

  • Abdominal pain
  • Vomiting
  • Peritonitis
  • Fever
  • Constipation
  • Melaena

Signs:

  • Rebound tenderness
  • Pain on palpation
  • Abdominal distension
  • Jaundice
  • Signs of dehydration
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31
Q

THE ACUTE ABDOMEN: Discuss differential diagnosis, relating these to the pathology of the conditions

A
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32
Q

THE ACUTE ABDOMEN: Select appropriate investigations to avoid diagnosis and interpret these

A

Investigations to consider:

  • LFTs
  • U&Es
  • ESR/CRP/WCC
  • FBC
  • Imaging: USS, X-ray, CT
  • Pregnancy test/serum hCG
  • ABG
    • ?DKA
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33
Q

THE ACUTE ABDOMEN: Outline initial management and identify the patient needing urgent resuscitation and operative intervention on the basis of their clinical presentation

A

Initial management:

A-E approach

Airway: Check patency

Breathing: RR, auscultate, percuss, pulse oximetry, ABG, oxygen

Circulation: Pulse, BP, auscultate, ECG, fluids following insertion of 2 large bore cannulae, urinary catheter

Disability: AVPU, glucose,

Exposure

Patients requiring urgent intervention:

  • Signs/symptoms of shock with a known or suspected haemoperitoneum
  • Unstable
  • Patients with AAA
  • Patients with suspected ectopic pregnancy
  • Abdominal pain disproportionate to physical signs, consider mesenteric ischaemia
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34
Q

SMALL INTESTINE AND APPENDIX: List the common pathologens that may cause acute diarrhoea in the community and in travellers to tropical and sub-tropical countries

A

Causative pathogens:

Community

  • Viral: Norovirus, rotavirus
  • Bacterial: Campylobacter, E. coli, salmonella, shigella

Tropical countries

  • Viral: Rotavirus, norovirus
  • Bacterial: E.coli, shigella, campylobacter
  • Parasitic1: Giardia, entamoeba, cryptosporidium

Subtropical countries

1: Persistent diarrhoea (>14 days) may be of parasitic origin

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35
Q

SMALL INTESTINE AND APPENDIX: Outline the management of this problem

A

Community diarrhoea:

ASK if acute (< 2 weeks) or chronic, as if persisting for longer periods an underlying condition must be considered as a cause

Travellers diarrhoea:

  • Careful selection of food and beverages
  • Anti-motility agent e.g. loperamide
  • Oral rehydration therapy
  • Antibiotic therapy may be consider for severe diarrhoea1

​1: Severe diarrhoea is incapacitating or completely prevents planned activities. Dysentry (mucus and blood in stools) and febrile diarrhoea are also considered severe)

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36
Q

SMALL INTESTINE AND APPENDIX: Indicate the risk factors associated with C.difficile infection and discuss its prevention and treatment

A

Risk factors associated with C.difficile infection:

  • Recent antibiotic use, causing disruption to the normal GI flora
    • ​Particularly ampicillin, cephalosporins, clindamycin, carbapenems and fluoroquinolones
  • Advanced age
  • Hospitalisation or residence in a nursing home
  • Hx of C.difficile-associated disease

Prevention:

Cautious use of antibiotics and discontinuing as soon as possible.

Probiotics for primary prevention.

Infection control and hand washing to prevent patient to patient spread.

Treatment:

  • PO vancomycin or fidaxomicin
  • Discontinuation of the causative agent
  • Supportive care
  • Infection control measures

Symptoms: Diarrhoea with systemic upset, abdominal pain, leukocytosis, fever, abdominal tenderness and distension.

Causes colitis, which may progress to toxic megacolon and multi-organ failure.

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37
Q

ACUTE APPENDICITIS: List the symptoms and signs of acute appendicitis

A

Symptoms:

  • Epigastric pain which then localises to the RIF, at McBurney’s point1
  • Fever
  • Nausea/vomitng
  • Anorexia
  • Constipation/diarrhoea

Signs:

  • Rebound and percussion tenderness
  • Rosving’s sign: RIF pain > LIF pain
  • Guarding
  • Positive psoas sign2
  • Positive obturator sign3
  • Vital signs: Tachycardia, mild fever

1: McBurney’s point is found 1/3 of the way between the ASIS and the umbilicus
2: Pain on hip extension. Seen when the appendix is positioned retoperitoneal retrocaecal (most common)
3: Pain on internal hip rotation. Seen when the appendix is positioned pelvically

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38
Q

ACUTE APPENDICITIS: Formulate a differential diagnosis and outline appropriate investigations

A

Ddx:

  • GI:
    • Acute mesenteric adenitis, gastroenteritis, intussusception, IBD,
  • Renal:
    • Nephrolithiasis
  • Biliary:
    • Cholecystitis
    • Cholelithasis
  • Genito-urinary:
    • UTI
    • PID
    • Mittelschmerz
    • Ectopic pregnancy
    • Ovarian torsion

Investigations to rule-in/out differentials:

  • Bloods: FBC1, CRP, group and save, ?amylase
  • Imaging
    • Abdominal USS and/or CT
  • Urinalysis2
  • Pregnancy test

1: An elevated WBC and CRP is expected in acute appendicitis. If normal then a watch-and-wait approach may be adopted
2: If positive for red cells, white cells or nitrites then renal colic or UTI should be considered as possible causes

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39
Q

ACUTE APPENDICITIS: List the common situations in which appendicitis is difficult to diagnose or manage

A
  • Infants with D&V
  • Children with vague abdominal pain
  • Confused elderly pts
  • Females presenting with gynaecological issues
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40
Q

ACUTE APPENDICITIS: List the complications of a perforated appendix

A
  • Haemorrhage → shock
  • Peritonitis → sepsis
  • Appendix abscess
  • Appendix mass
    • Inflamed appendix becomes covered in omentum
  • Adhesions
  • Infertility: Due to tubal obstruction following pelvic inflammation (PID)
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41
Q

ACUTE APPENDICITIS: List and discuss the common complications following appendicetomy and how each can be prevented

A

Common complications:

  • Infection
  • Bleeding
  • Adhesions
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42
Q

ACUTE APPENDICITIS: List the causes of a mass in the RIF and outline assessment, investigation and management

A
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43
Q

MECKEL’S DIVERTICULUM: Describe the nature of a Meckel’s diverticulum and its possible pathological effects.

A

Meckel’s diverticulum:

A congenital malformation of the small bowel. Arises due to failure of the embryonic vitelline duct to obliterate, leaving an outpouching on the small intestine.

The outpouching (formed from the vitelline duct remnant) contains cells capable to producing gastric acid, parietal cells.

Possible pathological effects:

  • Most commonly presents before the ago of 2 with PR bleeding (haematochezia) or obstruction
  • Inflammation, adhesions, perforations, ulceration - caused by damage to local tissues by gastric acid release
44
Q

MECKEL’S DIVERTICULUM: Describe the variable clinical presentations of a patient with a Meckel’s diverticulum

A
  • Usually are asymptomatic
  • Usually present before 2 years of age with lower GI bleeding or obstruction
  • Caecal volvulus: The outpouching can be tethered to the umbilicus, acting as a central point for the intestines to twist around to form a volvulus.
  • Intussusception
  • Appendicitis: Inflammation of the diverticulum presents in an identical fashion to appendicitis
  • Peptic ulceration: Due to ulceration caused by the gastric acid secreting epithelium
  • A sinus tract may be seen between the umbilicus and the diverticulum, known as a patent vitellointestinal duct

​Investigations:

  • Technetium-99m pertechnetate scan: Pertechnetate is preferentially taken up by the mucus-secreting cells of the ectopic gastric tissue in the diverticulum. Ectopic focus or ‘hot spot’ seen on the scan.
45
Q

INTESTINAL OBSTRUCTION: Describe the symptoms and signs in a patient with intestinal obstruction

A

Symptoms:

  • Abdominal pain
  • Vomiting/nausea
  • Anorexia
  • (Absolute) constipation: No flatus or faeces is characteristic of absolute constipation
  • Change in bowel habit

Signs:

  • Abdominal distention (the more distal the obstruction the greater the degree of distention)
  • Tingling bowel sounds (may be absent in the later stages of obstruction)
  • Tympanic abdomen
  • Palpable abdominal or rectal mass
46
Q

INTESTINAL OBSTRUCTION: List the common causes and the associated pathology of intestinal obstruction

A
47
Q

INTESTINAL OBSTRUCTION: Discuss the complications of small bowel obstruction and their recognition

A
  • Intestinal necrosis1: Onset of peritonitis, leukocytosis, dehydration and pre-renal AKI are all signs of intestinal necrosis
  • Intestinal perforation
  • Sepsis
  • Multi-organ failure
  • Short bowel syndrome following surgical resection of the affected section of bowel

Sequelae of intestinal obstruction: Intestinal necrosis → intestinal perforation → sepsis and multi-organ failure

1: As the obstruction progresses, intestinal perfusion decreases with ischaemic change and necrosis following

48
Q

INTESTINAL OBSTRUCTION: List the appropriate laboratory and imaging tests to be employed in a patient with suspected small intestinal obstruction

A

Laboratory tests:

  • FBC: Hb, WCC
  • CRP
  • U&Es: Checking for signs of shock or organ failure. Elevated urine and creatinine may indicate dehydration.
  • Urea:creatinine ratio
  • ABG: Elevated lactate indicates poor tissue perfusion. Check glucose, ketones and pH for signs of DKA.
  • Serum lipase/amylase: To rule out pancreatitis as a cause of abdominal pain

Imaging:

  • CT with oral and IV contrast according to local guidelines
    • PO Gastrografin, in combination with barium sulphate, may be given prior to CT
    • Allows the level and cause of obstruction to be identified
  • AXR
  • Erect CXR *to check for pneumoperitoneum*
49
Q

INTESTINAL OBSTRUCTION: Differentiate between mechanical small bowel obstruction and paralytic ileus

A

Paralytic ileus describes a functional cause of bowel obstruction in which bowel motility is reduced.

Paralytic ileus: Adynamic bowel due to loss of the peristaltic movement of the bowel.

50
Q

INTESTINAL OBSTRUCTION: List the signs and symptoms suggestive of strangulation

A

Symptoms:

  • Increasing pain (colicky → constant) and tenderness
  • Systemic upset

Signs:

  • Leukocytosis
  • Peritonism
  • Absent bowel sounds

Strangulation describes ischaemia and necrosis of the bowel, as vessels are stretched causing blood supply to the tissue to be compromised.

51
Q

INTESTINAL OBSTRUCTION: Compare and contrast a large bowel obstruction and small bowel obstruction

A
52
Q

INTESTINAL OBSTRUCTION: Outline a plan of treatment in a patient with small bowel obstruction including consideration of fluid and electrolyte therapy, antibiotic therapy, intestinal intubation and operative therapy

A

3 main elements: Fluid resuscitation, bowel decompression and analgesia

  • A-E assessment of the patient
  • Gain IV access and provide fluids1
  • Monitor urine output through a urinary catheter
  • Nasogastric decompression3: Insert a NG tube to allow drainage of gastric contents. Declare the patient nil by mouth - remember to calculate MUST score.
  • Provide analgesia, and an anti-emetic if indicated
  • Ongoing monitoring using the NEWS score
  • Surgical treatment2

2: Indications for surgery include closed loop/complete obstruction, strangulation and peritonitis arising due to any cause of bowel obstruction. Also, in those who do not respond to non-operative treatment after 72 hours. CT evidence of a non-adhesional cause (tumour, hernia, volvulus or gallstone) or evidence of bowel ischaemia is an indication for surgery.

In complete bowel obstruction peritonitis will develop in time if not already present (abdominal tenderness, guarding, rebound tenderness).

1: In bowel obstruction peristalsis increases in an attempt to overcome the blockage. This causes increased secretion of fluid into the bowel. Not only does this cause distention but also dehydration, electrolyte imbalance, volume depletion and AKI.
3: Acts to prevent aspiration of vomit

53
Q

MALABSORPTION AND COELIAC DISEASE: Describe the clinical presentation of malabsorption and outline appropriate investigations

A

Clinical presentation:

  • Diarrhoea
  • Faltering growth/weight loss
  • Steatorrhoea
  • Bloating
  • Lethargy

Investigations:

  • Bloods: FBC, lipid profile, Fe, B12, calcium
  • Coeliac disease tests: IgA-tTG (EMA if not available), IgG DGP
  • Sudan stain for fat globules
  • Faecal elastase1
  • Endoscopy and biopsy

​1: Reduced when exocrine function of the pancreas is disrupted, e.g. chronic pancreatitis, CF, pancreatic tumour, cholelithasis or T1DM

54
Q

MALABSORPTION AND COELIAC DISEASE: List causes of malabsorption

A

Most common causes in the UK are coeliac disease, Crohn’s disease and chronic pancreatitis

  • Short bowel syndrome (iatrogenic)
  • Coeliac disease
  • Lactose intolereance, CMP allergy
  • IBD: Crohn’s, UC
  • Infection: Giardiasis, TB,
  • Malignancy
  • Congenital abnormalities e.g. Hirschsprung’s, atresia, Meckel’s, cystic fibrosis
  • Endocrine: Thyroid disease, DM, Addison’s disease, parathyroid disease
55
Q

MALABSORPTION AND COELIAC DISEASE: Outline the pathology of malabsorption of key nutrients and consequent presentation and management for each.

A
56
Q

MALABSORPTION AND COELIAC DISEASE: Describe the pathology underlying coeliac disease and list clinical conditions that may be associated with it.

A

Underlying pathology:

  • Autoimmune destruction of villi, leading to blunting
  • Gluten derived peptides trigger an immune reaction, leading to local inflammation and subsequent destruction

Associated clinical conditions:

  • Malabsorption: Leading to anaemia etc.
  • Osteoporosis/osteopenia
  • Dermatitis herpetiforms (look at images)
  • Malignancy
  • Idiopathic recurrent acute pancreatitis/chronic pancreatitis
57
Q

MALABSORPTION AND COELIAC DISEASE: Outline the investigations undertaken to diagnose coeliac disease.

A
  • FBC and blood smear1
  • IgA-tTG
    • EMA is an alternative to IgA-tTG
  • Skin biopsy2
  • IgG DPD or IgA/IgG DPD
    • Should be used for pts with IgA deficiency
  • Small bowel histology
    • Essential and the gold-standard for diagnosis

1: Iron deficiency anaemia is the most common presenting feature of coeliac disease
2: For patients with evidence of dermatitis herpetiformis

58
Q

IRRITABLE BOWEL SYNDROME: Describe symptoms that may suggest a diagnosis of IBS.

A
  • Alternating diarrhoea and constipation
  • Abdominal pain and bloating that is associated with changes in stool form or frequency
  • Symptoms may be relieved by defaecation
  • Stress related symptoms
  • Age < 50 *chnage in bowel habit over this age should prompt consideration of malignancy*
  • Normal abdominal examination
59
Q

IRRITABLE BOWEL SYNDROME: Outline current theories regarding the pathophysiology of IBS

A
  • Believed to have multiple contributing causes
  • A disorder of altered gastrointestinal mobility
60
Q

IRRITABLE BOWEL SYNDROME: Discuss possible investigations and outline therapeutic approaches.

A

Possible investigations:

  • Ascertain whether there is a causal relationship between certain foods/drink and symptoms
  • Test for coeliac disease, lactose intolerance, IBD
  • Test for endocrine causes of changes in bowel habit: Thyroid function, Hba1c, parathyroid hormone
  • General tests for wellbeing: FBC, U&Es, thyroid function,

Therapeutic approaches:

Lifestyle and dietary changes

  • FODMAP diet
  • Avoid precipitating foods e.g. caffeine

Managing change in bowel habits

  • Anti-diarrhoeal: Loperamide
  • Laxative: Ispaghula

​Managing bowel spasms/cramps - antispasmodic

  • Dicycloverine
  • Peppermint oil

​Optional treatments

  • TCA or SSRI
61
Q

INFLAMMATORY BOWEL DISEASE: Describe the morphology and pathological consequences of Crohn’s disease and ulcerative colitis.

A

Crohn’s:

  • ‘Mouth to anus’ distribution
  • Full thickness/transmural inflammation
  • ‘Skip lesions’
  • Can lead to adhesions between bowel and other pelvic organs
  • Cobblestoning
  • Non-caseating granulomatous tissue throughout all layers

UC:

  • Begins at the rectum and ascends
  • Continuous inflammation
  • Crypt abscess, granulomatous inflammation, paneth cell metaplasia
62
Q

INFLAMMATORY BOWEL DISEASE: Describe common presenting symptoms (including extraintestinal manifestations)

A

Diagnosis is most frequently seen between the age of 15 and 35

Crohn’s disease:

  • Change in bowel habit: Diarrhoea
  • Cramping/abdominal pain
  • Weight loss
  • Systemic symptoms such as fatigue, malaise and anorexia
  • Perianal abscess/fistulae/skin tags
  • Extra-articular manifestations: Joint, eyes, dermatological (erythema nodosum), clubbing

Ulcerative Colitis:

  • Change in bowel habit: Diarrhoea +/- blood and mucus
  • Abdominal cramps
  • Bowel frequency relates to severity
  • Systemic symptoms: Weight loss, malaise, anorexia, fever
  • Nutritional deficit
  • Extraintestinal signs: Clubbing, oral ulcers, erythema nodosum, pyoderma gangrenosum, conjunctivitis, episcleritis, iritis, large joint arthritis, AS, PSC
63
Q

INFLAMMATORY BOWEL DISEASE: Discuss the investigation of a patient with suspected inflammatory bowel disease.

A
64
Q

INFLAMMATORY BOWEL DISEASE: Describe the medical therapy available, including the management of acute flares of colitis and the use of immunosuppressives and biological treatments.

A
65
Q

INFLAMMATORY BOWEL DISEASE: Discuss complications of Crohn’s disease and ulcerative colitis and indications for surgery.

A

Complications of Crohn’s disease:

  • Adhesion and subsequent fistulae
    • ​Entero-enteric
    • Colovesical
    • Colovaginal
    • Perianal
  • Abscess formation
  • Perianal disease
  • Small bowel obstruction
  • Colon cancer
  • PSC

Complication of Ulcerative Colitis:

  • Toxic dilatation of the colon (→ perforation)
  • VTE
  • Colonic cancer

​Surgery in IBD:

Crohns:

  • Needed in 50-80% of pts but NOT curative
  • Indications include failure of medical treatment, obstruction due to strictures, abscess and fistulae formation

Ulcerative Colitis:

  • Required in ~ 20% of pts
  • Indicated for failure of medical treatment or due to toxic dilatation
  • May be completion procectomy (permanent stoma) or ileo-anal pouch (option of stoma reversal and the possibilty of long term continence)
66
Q

INFLAMMATORY BOWEL DISEASE: List the extra-colonic manifestations of inflammatory bowel disease and discuss the response to each to surgery.

A
67
Q

INFLAMMATORY BOWEL DISEASE: Outline the risk of colonic malignancy in inflammatory bowel disease

A

Increased risk

Risk of colon cancer in UC:

  • Risk is proportional to the extent and activity of the disease
68
Q

DIVERTICULAR DISEASE: Outline the theories on the aetiology of diverticulosis of the colon including age, diet and vascular anatomy of the colon.

A

Diverticulosis: Herniation of the mucosa and submucosa of the gut wall, due to smooth muscle over-activity

Aetiology/Risk factors:

  • Low dietary fibre intake
  • Obesity
  • Tobacco smoking
  • Excessive alcohol and caffeine intake
  • Steroids
  • NSAIDs
  • Connective tissue disorders e.g. Ehlers-Danlos syndrome,
69
Q

DIVERTICULAR DISEASE: Describe the morphology and pathological consequences of diverticulosis of the colon.

A

Morphology:

  • Out-pouching of the gut

Pathological consequences:

  • Diverticular disease - any clinical symptoms arising as a consequence of diverticulosis
  • Diverticulitis - Inflammation. May be caused by infection.
  • GI bleeds
  • Fistulas
  • Perforation
  • Obstruction
  • Abscess
  • Neoplasm
70
Q

DIVERTICULAR DISEASE: Describe the clinical features, symptoms and signs of diverticulitis.

A

Clinical features:

Symptoms:

  • Altered bowel habit
  • Left sided colic relieved by defecation, nausea and flatulence
  • Systemic symptoms: Pyrexia, fever, fatigue, anorexia
  • Melaena

Signs:

  • Localised or generalised peritonitis
  • Elevated WCC, ESR/CRP
71
Q

DIVERTICULAR DISEASE: Outline the complications of diverticulosis.

A
  • Perforation: Ileus, peritonitis and shock
  • Haemorrhage
  • Fistulae
  • Abscess: Swinging fever, leucocytosis
  • Post-infective strictures
72
Q

DIVERTICULAR DISEASE: Describe the management of asymptomatic diverticulae of the colon

A

Conservative management

  • Asymptomatic diverticulosis, discovered incidentally, generally requires no treatment
  • Antispasmodic e.g. mebeverine
  • Some evidence to suggest that increasing dietary fibre may help

​Surgical management

  • Occasionally resorted to
73
Q

DIVERTICULAR DISEASE: Discuss the presentation, ddx, investigations and management of complications of colonic diverticulae

A
74
Q

DIVERTICULAR DISEASE: Discuss indications for elective and emergency surgery

A

Elective

  • Fistula formation
  • ?Stricture

Emergency

  • Haemorrhage
75
Q

CARCINOMA OF THE COLON, RECTUM AND ANUS: Describe the aetiology, morphology and pathology of carcinoma of the large bowel

A

Aetiology:

  • Familial polyps (FAP, Lynch syndrome)
  • Increased age
  • Obesity
  • Diet: Low fibre, high in processed meats
  • Smoking
  • IBD
  • FHx

Morphology

  • The vast majority are adenocarcinomas
    • ‘Signet ring cells’ on histology
  • The vast majority occur in the recto-sigmoid region of the colon, with 45% in the rectum

Pathology

*

76
Q

CARCINOMA OF THE COLON, RECTUM AND ANUS: Describe Dukes and TNM staging systems

A

Dukes’ classification:

A: limited to the bowel wall

B: through the bowel wall

C: regional lymph nodes metastasis.

TNM:

Once TNM categories have been determined the information is combined to provide the stage of the tumour.

77
Q

CARCINOMA OF THE COLON, RECTUM AND ANUS: Discuss the frequency of each accoding to the location of the carcinoma, particularly with rectal and carcinoma of the caecum

A

* Most commonly seen in the recto-sigmoid region of the colon*

78
Q

CARCINOMA OF THE COLON, RECTUM AND ANUS: Identify the common symptoms and signs of carcinoma of the colon, rectum and anus

A

x

79
Q

CARCINOMA OF THE COLON, RECTUM AND ANUS: Identify the pathological differences between colorectal and anal cancer

A

Anal cancer

  • Mainly SCC
  • RFs: Anoreceptive sex, syphilis infection, HPV infection, immunosuppression,

Colorectal cancer

  • Mainly adenocarcinomas
80
Q

CARCINOMA OF THE COLON, RECTUM AND ANUS: Identify the common symptoms and signs of carcinoma of the colon, rectum and anus

A
81
Q

CARCINOMA OF THE COLON, RECTUM AND ANUS: List the clinical features which would raise suspicion of carcinoma and indicate urgent patient referral

A

Consider a 2WW referral for colorectal cancer, when:

  • Occult blood in faeces (FIT)
  • Rectal or abdominal mass
  • 40 years or > with unexplained weight loss and abdominal pain
  • 50 years or > with unexplained rectal bleeding and any of the following - abdominal pain, change in bowel habit, weight loss, iron-deficiency anaemia
  • 60 years or > with iron-deficiency anaemia (with no identifiable cause) or changes in bowel habit
  • For anal cancer, unexplained anal mass or anal ulceration
  • ALARMS55
82
Q

CARCINOMA OF THE COLON, RECTUM AND ANUS: Discuss appropriate laboratory tests, radiological studies and endoscopic investigations to investigate a pt with suspected colonic or rectal carcinoma

A

Laboratory tests

  • FBC: ?anaemia, WCC
  • LFT: ?derangement due to mets
  • Tumour markers:
    • ​CEA (should only be measured after confirmation of diagnosis) - can be used to monitor disease
    • AFP
  • U&Es
  • Faecal calprotectin: ?raised due to inflammation
  • CRP/ESR: ?inflammation

Radiological studies

  • CT CAP
  • Double-contrast barium enema1
  • CT colonography
  • PET scan

Endoscopic investigations

  • Colonoscopy with biopsy

​1: Characteristic ‘apple core’ lesion

83
Q

CARCINOMA OF THE COLON, RECTUM AND ANUS: Outline the treatment of carcinoma of the colon, rectum and anus and define appropriate resection levels according to lymphatic drainage

A
  • Laparoscopic resection
    • Right/left hemicolectomy according to the site of the mass
  • Endoscopic stenting in palliation
  • Radiotherapy is usually used in palliation or pre-op in rectal cancer
  • Adjuvant chemotherapy for stage 3 disease
84
Q

CARCINOMA OF THE COLON, RECTUM AND ANUS: Outline the management of carcinoma of the anus and contrast it to management of colorectal carcinoma

A

Management of anal carcinoma

  • Chemotherapy (5-FU or mitomycin) plus radiotherapy
  • 75% retain normal anal function

In contract, colorectal cancer management mainly involves resection of the mass and local tissue.

NOTE: Squamous cell anal carcinoma is the most common (below the pectinate line). Adenocarcinomas (above the pectinate line) should be treated as rectal cancer.

85
Q

CARCINOMA OF THE COLON, RECTUM AND ANUS: Discuss follow up recurrence and metachronous tumours

A
  • All pts undergoing surgery require colonoscopy before or soon after to look for additional lesions/metachronous tumours1
  • Stage II/III disease: CEA every 3/12 and colonoscopy every 3 years

NHS bowel cancer screening programme sees FIT every 2 years for pts aged 60 - 74.

1: Metachronous tumours - Primary CRC developing 6 months after previous colorectal surgery for CRC

86
Q

CARCINOMA OF THE COLON, RECTUM AND ANUS: Outline management of an obstructing colonic cancer

A
  • Insert a NG tube for gastric decompression and analgesia
  • Provide IV fluids
  • Use AXR and erect CXR to confirm diagnosis and to look for signs of perforation (pneumoperitoneum)
  • CT to determine the level of obstruction
  • Surgery for resolution or endoscopic stenting if palliative
87
Q

INTESTINAL OBSTRUCTION: List the symptoms and signs of large bowel obstruction

A

Symptoms

  • Absolute constipation
  • Abdominal distension and pain

Signs

  • Absent bowl sounds
  • Resonance to percussion
  • Palpable mass
  • No abdominal tenderness *unless strangulated*

​THINK is there a functional (ileus) or mechanical obstruction?

88
Q

INTESTINAL OBSTRUCTION: Discuss the diagnostic aids available for the diagnosis of large bowel obstruction

A
  • AXR and CXR
  • CT to identify the level of the obstruction
  • Oral Gastrografin may be given prior to CT to help identify the level of obstruction and may have mild therapeutic effect on the obstruction
89
Q

INTESTINAL OBSTRUCTION: List the causes of intestinal obstruction in children and outline the diagnostic tests most appropriate for each

A
  • NEC -AXR
  • Volvulus - AXR, barium CT
  • Intussusception
  • Malrotation
  • Strictures
  • Secondary to Meckel’s diverticulum
  • Hirschsprung disease - biopsy
90
Q

INTESTINAL OBSTRUCTION: Outline a diagnostic plan to identify aetiological factors of faecal impaction

A

Severe constipation can cause faecal impaction.

General factors: Poor diet, dehydration, lack of exercise, IBS, old age, pain

Anorectal disease: Fissure, stricture, rectal prolapse

Metabolic/endocrine: Hypercalcaemia, hypothyroid, hypokalaemia

Drugs: Opiates, anticholinergics, iron, aluminium based antacids, diuretics

Neuromuscular: Diabetic neuropathy, spinal/pelvic nerve injury, Hirschprung’s disease

Investigations:

  • FBC, ESR, U&Es, calcium, TFTs
91
Q

HAEMORRHOIDS: Discuss the anatomy of haemorrhoids

A

Haemorrhoids: Disrupted and dilated anal cushions.

Anal cushions contribute to anal closure. There are 3 anal cushions can be seen at 3, 7 and 11 o’clock in the lithotomy position.

Haemorrhoids may be internal (origin above the dentate line), external (origin below the dentate line) or mixed.

92
Q

HAEMORRHOIDS: Describe the role of the anal sphincters in maintaining faecal continence

A

Internal anal sphincter:

  • Under involuntary control, surrounding the upper 2/3 of the anal canal
  • Smooth muscle

External anal sphincter:

  • Under voluntary control (inferior rectal nerve, S4), surrounds the lower 2/3 of the anal canal
  • Striated muscle
93
Q

HAEMORRHOIDS: State the aetiological factors or haemorrhoids

A
  • Straining (chronic constipation or diarrhoea)
  • Increased IAP (obesity, pregnancy)
  • Pelvis masses which reduce vascular return, resulting in anal vascular engorgement
  • Increased anal tone (stress)
94
Q

HAEMORRHOIDS: Describe the symptoms and complications of haemorrhoids

A

Symptoms:

  • PR bleeding: fresh, associated with wiping
  • Pain (if thrombosis occurs)
  • Pruritis ani
  • Prolapse of haemorrhoids (piles)

Complications:

  • Anaemia
  • Thrombosis: If prolapsing vessels become compressed by the anal sphincter (strangulation) the cessation of venous return can lead to thrombosis. Treatment is conservative, as they often resolve spontaneously. Cold compress, opioids and rest are advised.
95
Q

HAEMORRHOIDS: Discuss the ddx of rectal bleeding

A
  • Haemorrhoids
  • IBD
  • Malignancy
  • Anal fissure
  • Trauma
  • GI bleed e.g. diverticulitis, ulceration
  • Gastroenteritis
  • Perianal haematoma
96
Q

HAEMORRHOIDS: Describe the physical examination of a patient with haemorrhoids, including proctosigmoidoscopy

A

Inspection

  • Visibly protruding haemorrhoids (piles)
  • PR bleeding
  • Exocoriations

Abdominal examination

  • Check for palpable masses (as pelvic masses may reduce vascular return) and hepatomegaly

Proctoscope

  • Piles can be visualised
  • Assess for any lesions higher within the anus and rectum which may have caused bleeding

Colonoscopy/flexible sigmoidoscopy - if a more sinister pathology is suspected

97
Q

HAEMORRHOIDS: Outline the principles of management of patients with symptomatic haemorrhoids including investigation and differential diagnosis appropriate to patient factors including history and age

A

Investigations

  • Examination: Abdo examination, proctoscopy, ?colonoscopy - if sinister cause suspected

Management

  • 1st line: Dietary and lifestyle modification - increased fibre and ensure adequate fluids. Avoid excessive straining.
    • ​Adjunct: Short course of topical corticosteroid to reduce pruritis

For prolapsing internal haemorrhoids

  • Rubber band ligation or sclerotherapy or infrared photocoagulation or haemorrhoid arterial ligation

For grade 4 internal/external/mixed internal or external haemorrhoids

  • Surgical haemorrhoidectomy

Ddx

  • Malignancy
  • Anal fissure
  • Perianal haematoma
  • Abscess
98
Q

HAEMORRHOIDS: Describe symptoms and signs of perianal haematoma and outline management

A

Caused by rupture of a vein beneath the anal skin, with onset after a heavy effort (lifting/coughing/sneezing/straining at stool). It is not related at all to haemorrhoids.

Signs:

  • Tense, smooth, dark blue/black lump close to the anal verge

Symptoms:

  • Acute onset pain

Management:

  • If treatment is sought within a few hours of onset then incision and drainage can be performed.
  • Generally the perianal haematoma resolves within a few days. Oral analgesia and hot baths can be advised.
99
Q

PERIANAL INFECTION: Discuss the role of anal crypts in perianal infection

A
  • Anal crypts act to release mucous when compressed by faeces, aiding evacuation of the anal canal
  • The crypts are the most common site of infection
100
Q

PERIANAL INFECTION: Outline the symptoms of patients with perianal infections

A
  • Pain, tenderness and swelling around the anus
  • Perianal infection can leads to the formation of a perianal abscess
    • Visibly red, exquisitely tender swelling next to the anus
  • Perianal cellulitis may also be seen: Erythema, swelling, hot
101
Q

PERIANAL INFECTION: Describe the various types of perianal infection

A
  • Perianal cellulitis
  • Perianal abscess
  • Pilonidal sinus
  • Perianal warts
102
Q

PERIANAL INFECTION: Describe the physical examination of patients with perianal infections

A

Inspect

  • Scars
  • Visible signs of infection, swelling, lumps
  • Anal skin tags/fissures/ulcers

Proctoscopy

PR examination

Any discharging area near the anus should be assumed to communicate with the anorectum, until proven otherwise. MRI or operative exploration may be used to investigate.

103
Q

PERIANAL INFECTION: Describe fistula in ano

A

A tract communicates between the skin and the anal canal/rectum.

Blockage of deep IM gland ducts is thought to predispose to the formation of abscesses, which then discharge to form a fistula.

Other RFs: IBD, diabetes, TB, HIV, history of anal trauma

Clinical features:

  • Recurrent perianal abscess
  • Intermittent/continuous discharge onto the perineum (mucus, blood, pus or faeces)

Goodsall Rule

Can be used to predict the trafectory of a fistula tract, through looking at the location of the exteral opening.

External opening posterior to the transverse anal line - fistula follows a curved course to the posterior midline

External opening anterior to the transverse anal line - fistula tract will follow a straight radial course to the dentate line

104
Q

PERIANAL INFECTION: Outline the principles of management of patients with perianal infections, including management of fistula in ano

A

Management of fistula in ano

*** Dependent upon the cause and site of the fistula

  • No symptoms → conservative approach
  • Symptoms →
    • ​Fistulotomy: Laying the tract open and allowing healign through secondary intention
    • Placement of a seton through the fistula to allow the tract to drain, encouraging healing
105
Q

FISSURE IN ANO: Describe anal fissure

A

A painful tear in the squamous lining of the lower anal canal/split in the skin of the distal anal canal.

If the tear is chronic it my be associated with a ‘sentinal pile’ or mucosal tag at the external aspect.

106
Q

FISSURE IN ANO: Describe the symptoms and physical examination of patients with fissure-in-ano

A

Risk factors: Hard stools, pregnancy, opiate analgesia

Symptoms

  • Pain on defecation - ‘like passing broken glass’
    • ​May continue for 1-2 hours after defecation and can be burning in nature
  • PR bleeding - fresh blood on stool/paper
  • Tearing sensation when passing stool
  • Anal spasm

Physical examination

  • Fissure visible on retraction of the buttock
  • Associated sentinel pile or mucosal tag
  • Proctoscopy *may not be possible due to pain*
  • Colonoscopy should be performed to rule out more sinister causes/ other anorectal conditions
107
Q

FISSURE IN ANO: Discuss current theories of the aetiology of anal fissure and describe the principles of management.

A

Current theories of aetiology:

  • Hard stools
  • Pregnancy
  • Opiate use

Management

On 1st presentation:

  • Conservative treatment: High fibre diet, topical analgesia, sitz baths, stool softeners to make defecation more comfortable
  • Adjunct: Topical GTN (causes relaxation of the anal sphincter but may not be tolerated by patients due to the occurence of headaches with use)

Recurrent fissures:

  • Botulinum toxin: Relaxes the anal sphincter (inhibits pre-synaptic ACh release)
  • Surgical sphincterotomy

CP3 (14 decks)

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