Gastrointestinal/abdominal Flashcards
Why would we reserve colonoscopy in the investigation of a suspected functional GI disorder?
There is a risk of bowel perforation.
Should be reserved for red flag symptoms.
Why would we reserve CT scans in the investigation of a possible functional GI disorder?
There is a significant radiation burden of CT scans.
A CT should be reserved for red flag symptoms
What are the gastrointestinal red flags for urgent referral to secondary care and further investigation?
- Age 60+
- Rectal bleeding
- Anaemia
- Unintended weight loss (>5% over 6-12 months: for average 80kg man - 4kg)
- Abdominal or rectal mass
- Raised CRP
- Raised ESR
- Raised faecal calprotectin
What is the investigation pathway for someone presenting with:
Abdominal pain/discomfort or change in bowel habit for at least 6 months?
- Check for red flag indicators:
A - Cancer
B - inflammatory markers for IBD - Upon finding red flag symptom: refer to secondary care
What is the diagnostic pathway for irritable bowel syndrome?
IBS is a diagnosis of exclusion
- A)Patient presents with abdominal pain or discomfort and bowel movement changes
- Exclude cancer-
2. Check for red flag symptoms
-Initial diagnosis-
3. One core requirement for the pain/discomfort:
A- Relieved by defaecation, or
B- Associated with altered bowel frequency or stool form
- Two or more satellite requirements:
C- Altered stool passage (Straining, urgency or tenesmus)
D- Abdominal bloating/distension/tension/hardness
E- Symptoms are made worse by eating
F- Passage of mucus - FBC, ESR and CRP - exclusion of other diagnoses
- Exclude IBD-
6. Faecal calprotectin - positive result supports (but doesn’t diagnose) IBD
- negative result confirms diagnosis of IBS
IBS diagnosis = clinical signs WITHOUT positive calprotectin test
(Calprotectin alone doesn’t constitute diagnosis of IBD, it merely distinguishes IBD and IBS)
How does the diagnostic pathway change for a woman over the age of 50 presenting with signs of IBS?
PC = bloating and abdominal discomfort for
You must rule out ovarian cancer:
- USS of ovaries
- Ca125 level (a serum protein produced by ovarian cancer cells)
What is a faecal calprotectin test?
A test for the presence of calprotectin in the faeces.
It is used to distinguish between inflammatory bowel diseases and irritable bowel syndrome.
It is not diagnostic, it is only supportive in the diagnosis, which is a clinical diagnosis.
Calprotectin is a substance released from neutrophils when there is inflammation within the intestines. It is caused by neutrophils migrating to the mucosa.
What is the diagnostic pathway for H.pylori infected peptic ulcer?
- Symptoms of dyspepsia
- Mouth or bum: Carbon-13 breath test or stool antigen test
- Confirm diagnosis: Retest with carbon-13 breath test
What should be the first investigation for a patient presenting with dyspepsia?
Endoscopy (OGD)
What are the investigations for acute abdomen? (Severe acute abdominal pain)
Examination: including DRE and hernial orifices
Bloods: FBC, U+E, LFTs, CRP, serum amylase, serum glucose, ABG+lactate
Urine dipstick (any damage/infection to urinary tract)
Pregnancy test - ectopic pregnancy
Erect CXR (- air under diaphragm)
Supine abdominal film
How should a suspected hernia be clinically examined?
Inspection:
- Site
- Number of swellings
- Shape: spherical, ovoid, kidney shaped or irregular
- Size
- Surface colour
- Surface smooth/irregular
- Skin normal, inflamed or ulcerated
- Movements of swelling: pulsatile
- Cough impulse
- Movement tests
Palpation:
1. Temperature - compared to normal skin
2. Tenderness
3. Smooth surface or lobular surface
4. Edge:
well defined and regular; benign swelling
well defined and irregular; malignancy
diffuse and ill defined; swelling/abscess - inflammation
Slipping edge - can get under a lipoma
5. Paget’s test: hold skin taut, press edge then press centre (solid = firmer in centre than at edge, liquid/cystic = softer at centre than at edge)
6. Sign of moulding - holds shape after being pressed; sign of cyst
If swelling is soft:
- Fluctuation - propagation of impulse in multiple directions; (hold one finger on one side and press the other end, impulse is felt in other finger, repeat at 90 degrees) indicates fluid is present
- Transillumination - implies presence of clear fluid, blood and pus will not transilluminate
- Cough impulse - if the swelling is communicating with the peritoneal/pleural/cranial cavities or spinal canal, the swelling will tense or expand on straining/coughing/on force of gravity
- Reducibility - compression of the swelling will reduce the size, if the swelling is communicative (as above) it will increase in size upon straining/coughing/ force of gravity
- Compressibility - after compression, the swelling immediately expands to it’s original size = vascular
- Pulsatility - is a finger lifted up only (transmitted through lump; non-pulsatile) or two fingers on either side are lifted in different directions (expansile lump)
Relationship to skin; fixity:
- Fixity to skin - skin cannot be pinched over it
- Tethering to subcutaneous material - skin can be pinched but on moving the skin it becomes puckered
- Tethering to muscle - ask patient to flex underlying muscle; becomes fixed and immobile
Why is an ABG with lactate important in investigation of acute abdomen?
A bowel infarction can cause a metabolic acidosis via anaerobic metabolism and lactic acid accumulation
An ABG should have lactate level included, since this indicates the degree of ischemia in organs, including the bowel.
How is appendicitis diagnosed?
- Bloods: often a neutrophil leucocytosis and raised CRP, not always
- USS
- If diagnosis is still unclear - CT
What are the truelove and witts severity index?
The truelove and witts severity index categorises ulcerative colitis is to mild moderate and severe
Categories are: No. Of bowel movements per day Blood in stools Pyrexia Pulse greater than 90 Anaemia present ESR
Only in the severe category do we have blood in stools, pyrexia, inc pulse rate, anaemia and increased ESR
Can we use endoscopy in possible toxic megacolon?
No, it is not safe - we must image instead
