Gastrointestinal (3) Flashcards
Define haemorrhoids
Enlargement, engorgement and protrusion of the haemorrhoidal vascular cushions in the anal canal which have a tendency to bleed or prolapse
Describe haemorrhoid classification
Internal haemorrhoids lie ABOVE the dentate line
External haemorrhoids lie BELOW the dentate line
Dentate line = divides upper 2/3 and lower 1/3 of the anal canal and represents the hindgut-proctodeum junction
1st Degree - haemorrhoids that do NOT prolapse
2nd Degree - prolapse with defecation but
reduce spontaneously
3rd Degree - prolapse and require manual reduction
4th Degree - prolapse that CANNOT be reduced
What are the risk factors of haemorrhoids?
Age 45-65
History of constipation
Increased intra-abdominal pressure: pregnancy and ascites
Presence of space occupying pelvic lesion
Prolonged straining
Derangement of the internal anal sphincter
Portal hypertension
Summarise the epidemiology of haemorrhoids?
More common in white patients
Most common at 45-65 years
Very common
What are the presenting symptoms of haemorrhoids?
Usually ASYMPTOMATIC
Bleeding - bright red blood on the toilet paper and drips
into the pan after passage of stool. NOT mixed with stool.
ABSENCE of alarm symptoms (weight loss, anaemia, change in bowel habit, passage of
clotted or dark blood, mucus mixed with the stool)
Itching Anal lumps Prolapsing tissue Perianal pain Sensation of incomplete evacuation
What are the signs on physical examination of haemorrhoids?
1st or 2nd degree haemorrhoids are NOT usually visible on external inspection
Internal haemorrhoids are NOT normally palpable on DRE unless they are thrombosed
Haemorrhoids are usually visible on proctoscopy
Anal mass
Tender palpable perianal lesion
What are the appropriate investigations for haemorrhoids?
DRE
Anoscopic examination
Proctoscopy
Colonoscopy/flexible sigmoidoscopy - exclude IBD, cancer
FBC - check for anaemia
Stool for occult haem - if no haemorrhoidal tissue seen on examination
What is the management of haemorrhoids?
Conservative:
High-fibre diet and increased fluid intake
Bulk laxatives
Topical creams (e.g. local anaesthetics, corticosteroids)
Injection Sclerotherapy - Induces fibrosis of the dilated veins
Banding - Barron’s bands are applied proximal to the
haemorrhoids which then fall off after a few days.
Infrared photocoagulation
Surgery:
Reserved for symptomatic 3rd and 4th degree haemorrhoids
Milligan-Morgan haemorrhoidectomy - excision of three haemorrhoidal cushions
Stapled haemorrhoidectomy is an alternative method
Post-operatively the patient should be given laxatives
to avoid constipation
What are the possible complications of haemorrhoids?
Anaemia Thrombosis Incarceration Faecal incontinence Pelvic sepsis Anal stenosis Bleeding Prolapse Gangrene
Injection Sclerotherapy Complications Prostatitis Perineal sepsis Impotence Retroperitoneal sepsis Hepatic abscess
Haemorrhoidectomy Complications Pain Bleeding Incontinence Anal stricture
What is the prognosis of haemorrhoids?
Often chronic with high rate of recurrence
Treatment results in resolution or improvement of symptoms with low rates of recurrence.
Surgical haemorrhoidectomy confers the best long-term effect with less than 20% symptom recurrence.
Define hepatocellular carcinoma
Primary malignancy of the liver parenchyma usually in a cirrhotic liver
What is the aetiology/risk factors of hepatocellular carcinoma?
Associated with chronic liver damage:
Cirrhosis Chronic HBV infection Chronic HCV infection Chronic heavy alcohol use Diabetes Obesity Family history Aflatoxin – Aspergillus flavus toxin on stored grains Autoimmune conditions e.g. PBC, PSC, haemochromatosis Metabolic conditions e.g. alpha-1 antitrypsin deficiency OCP Smoking Male
Summarise the epidemiology of hepatocellular carcinoma
COMMON
1-2% of all malignancies
LESS common than liver metastases
High incidence in regions where hepatitis B and C are endemic
What are the presenting symptoms of hepatocellular carcinoma?
Malaise Weight loss Loss of appetite/anorexia Abdominal distention Jaundice RUQ pain Early satiety Leg oedema
History of Exposure to Carcinogens:
High alcohol intake
Hepatitis B or C (e.g. sexual activity, IV drug use)
Aflatoxins
What are the signs on physical examination of hepatocellular carcinoma?
Cachexia Lymphadenopathy Hepatomegaly (may be nodular) Jaundice Ascites Bruit over the liver Hepatic encephalopathy Splenomegaly Asterixis Spider naevi Palmar erythema Fetor hepaticus
What are the appropriate investigations for hepatocellular carcinoma?
Bloods FBC - low MCV and platelets Urea - high Sodium - low ESR LFTs - high ALP, AST, ALT, bilirubin, low albumin Clotting Alpha-fetoprotein - tumour marker for liver cancer Hepatitis serology
PT time - normal or elevated
Imaging:
Abdominal US
CT/MRI - GOLD STANDARD for staging
Histology/Cytology - Ascitic tap my be sent for cytological analysis
Define a hernia
- Direct Inguinal
- Indirect Inguinal
- Femoral
- Epigastric
- Umbilical
Abnormal protrusion of a viscus through a defect in its containing compartment and its coverings into an abnormal position
Inguinal hernias are above and medial to pubic tubercle
Direct Inguinal Hernia:
Protrusion of the hernial sac directly through a weakness in the transversalis fascia and posterior wall of the inguinal canal.
Arises medial to the inferior epigastric vessels
WEAKNESS IN ABDOMINAL WALL EVOLVES INTO LOCALISED HOLE
Indirect Inguinal Hernia:
Protrusion of the hernial sac through the deep inguinal ring, following the path of the inguinal canal. Occurs lateral to inferior epigastric artery. Due to lax deep ring or patent processus vaginalis.
Femoral hernia - inferior and lateral to the pubic tubercle.
Epigastric – at site of midline union of rectus muscles
Umbilical – present in 3% at birth (normally resolves <3 years), transversalis fascia defect
What is the aetiology/risk factors for an inguinal hernia?
Congenital - abdominal contents enter the inguinal canal through a patent processus vaginalis
Acquired - due to increased intra-abdominal pressure along with muscle and transversalis fascia weakness. Degeneration, fatty changes etc
Risk Factors: Male Prematurity Chronic lung disease Age Obesity Raised intra-abdominal pressure (e.g. chronic cough) Constipation Bladder outflow obstruction Intraperitoneal fluid (e.g. ascites) Connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome) Smoking Family history AAA Previous RLQ incision Heavy lifting BPH
Summarise the epidemiology of hernias
COMMON
Peak age in adults: 55-85 yrs
9 x more common in MALES
Groin hernias affect 27% of men and 3% of women at some point in their life
What are the presenting symptoms of hernias?
Asymptomatic
Patient notices a ‘lump in the groin’
May cause discomfort and pain
May be irreducible
May present because it has increased in size
May present because of complications (e.g. bowel obstruction) - nausea and vomiting, constipation
What are the signs on physical examination of a hernia?
Visible or palpable groin lump that extends to the scrotum (males) or labia (women)
Check for cough impulse
Indirect hernias can be reduced and controlled by applying pressure over the deep inguinal ring
Auscultation - there may be bowel sounds over the hernia
Tenderness if strangulated
Check for signs of complication
What are appropriate investigations for hernia?
Mainly a clinical diagnosis
Bloods: FBC U&Es CRP Clotting Group and save (if operation is likely)
ABGs - may show lactic acidosis from bowel ischaemia
Imaging:
Erect CXR - check for perforation
USS - exclude other causes of groin lump
AXR - check for obstruction
What is the management for hernias?
If small, asymptomatic hernia then watchful waiting
Surgical
Usually elective repair of uncomplicated hernias
Mesh Repair - The hernia is surgically reduced and a mesh is inserted to reinforce the defect in the transversalis fascia
Laparoscopic Mesh Repair
Prophylactic antibiotics given
EMERGENCY: If obstructed or strangulated, laparotomy with bowel resection may be indicated if the bowel is
gangrenous - NG feeding, fluid resuscitation
What are the possible complications of hernias?
Incarceration
Strangulation
Bowel obstruction
Surgery Complications: Pain Wound infection Haematoma Penile/scrotal oedema Mesh infection Testicular ischaemia Urinary retention Bowel obstruction
What is the prognosis of hernias?
Prognosis is excellent after surgical repair.
The incidence of recurrent hernia with mesh repair is reported to be less than 2%.
Moderate to severe chronic groin pain is reported to occur in 10% to 12% of patients after inguinal hernia repair.
Groin pain higher incidence after open repair compared to laparoscopic repair.
Define hiatus hernia
The protrusion of intra-abdominal contents through an enlarged oesophageal hiatus of the diaphragm. It most commonly contains a variable portion of the stomach but can contain transverse colon, omentum, small bowel, or spleen.
What are the types of hiatus hernia?
Congenital
Traumatic
Non-traumatic
Sliding (90-95%) - the hernia moves in and out of the chest. Usually protrusion of gastro-oesophageal junction followed by body of stomach above diaphragm which causes a decreased LOS pressure.
Paraoesophageal (rolling) (5-10%) - the hernia goes through a whole in the diaphragm next to the oesophagus. The fundus or body of stomach usually herniate and the gastro-oesophageal junction remains below the diaphragm.
This can produce rotation and twisting of the stomach, leading to intermittent strangulation with obstruction and ischaemia.
What is the aetiology/risk factors of a hiatus hernia?
Aetiology is unknown however can be congenital, traumatic and non-traumatic (sliding or para-oesophageal)
Risk factors: Obesity Previous gastro-oesophageal procedure Elevated intra-abdominal pressure: Chronic cough, Ascites, Multiparity, pregnancy Low-fibre diet Male Advanced age Structural abnormality of oesophageal hiatus Chronic oesophagitis
Summarise the epidemiology of hiatus hernias
Estimates of the prevalence of hiatus hernia in western populations range up to 50%.
The prevalence may be lower in eastern populations.
The incidence of symptomatic cases of hiatus hernia is closely related to the diagnosis of GORD
Sliding hernias are the most common.
70% of patients are over 70 years old.
What are the presenting symptoms of hiatus hernias?
Mostly asymptomatic
Sliding hernias most likely to cause symptoms. Present with symptoms of GORD:
Heartburn
Regurgitation
Waterbrash
Chest pain (oesophageal spasm)
Dysphagia/odynophagia (oesophagitis)
Haematemesis
Cough/wheeze (aspiration)
What are the signs on physical examination of hiatus hernias?
No signs
What are the appropriate investigations for hiatus hernias?
CXR - gastric air bubble may be seen above the diaphragm
Upper gastrointestinal series (X ray of upper GI tract) - shows intrathoracic stomach
OGD - inflammation of oesophagus and proximal migration of gastro-oesophageal junction
CT or MRI
Oesophageal manometry or pH monitoring - double hump configuration
Bloods
FBC - check for iron deficiency anaemia
What is the management of a hiatus hernia?
Medical:
Modify lifestyle factors (e.g. lose weight)
Inhibit acid production (e.g. PPIs)
Enhance upper GI motility
Surgical with or without anti-reflux procedure:
Necessary in a MINORITY of patients - those with complications of reflux disease despite medical treatment or pulmonary complications (e.g. aspiration pneumonia)
Nissen Fundoplication:
The stomach is pulled down through the oesophageal hiatus and part of the stomach is wrapped (360 degrees) around the oesophagus to make a new
sphincter and reduce the likelihood of herniation
What are the possible complications of hiatus hernias?
Oesophageal: Intermittent bleeding Oesophagitis Erosions Barrett's oesophagus Oesophageal strictures
Non-Oesophageal:
Incarceration of para-oesophageal hiatus hernia - strangulation and perforation
Gastric volvulus
Obstruction
Surgical complications: Dysphagia Haemorrhage Fundal necrosis Diarrhoea
What are the possible complications of a hiatus hernia?
Generally GOOD
Sliding hernias have a better prognosis than rolling hernias
Define intestinal ischaemia
Obstruction of a mesenteric vessel causing reduced blood flow to the GI tract leading to bowel inflammation, odeoma, ulceration, ISCHEMIA AND NECROSIS.
Most commonly affects the splenic flexure (the watershed between the SMA and IMA).
Explain the aetiology of intestinal ischaemia
Embolus (60%)
Thrombosis (40%)
Can be a consequence of: Volvulus Intussusception Bowel strangulation Failed surgical resection
Arterial inflow obstruction: Atheroma Thrombosis Embolism (cardiac arrhythmia) Vasculitis
Venous outflow obstruction
Reduced perfusion - Hypotension, Shock
What are the risk factors of intestinal ischaemia?
AF Endocarditis (can throw emboli)
Arterial Thrombosis: hypercholesterolaemia, hypertension, diabetes mellitus, smoking
Venous Thrombosis: portal hypertension, splenectomy, septic thrombophlebitis, OCP, thrombophilia
Old age
Hypercoagulable states
Myocardial infarction
History of vasculitis
Summarise the epidemiology of intestinal ischaemia
Uncommon
More common in elderly (60-80 years)
More common in those with co-morbidities (AF, MI, atherosclerosis)
