Gastrointestinal - Level 2.4 Flashcards
Definition of diverticula?
Sac-like protrusions of mucosa through muscular wall of colon
Usually multiple, 5-10mm in diameter and occur most in sigmoid colon
Definition of diverticulosis?
o Condition where diverticula are present without symptoms
Definition of diverticular disease?
o Condition where diverticula cause symptoms
Definition of diverticulitis?
o Diverticula become inflamed and infected
o Complicated when associated abscess, peritonitis, perforation or obstruction
Epidemiology of diverticular disease?
- Mostly in sigmoid colon
- Increasing incidence with age
- Majority asymptomatic
Risk factors of diverticular disease?
o Genetics o Low fibre diet o Smoking o Obesity o NSAIDs, corticosteroids
Symptoms of diverticulosis?
o Asymptomatic and most people undiagnosed
Symptoms of diverticular disease?
o Intermittent LIF pain triggered by eating and relieved by passage of stool
o Altered bowel habit – constipation or diarrhoea
o Rectal bleeds
o Bloating
o Nausea
o Flatulence
Symptoms of diverticulitis?
o Constant abdominal pain, usually severe towards hypogastrium and LIF o Rectal bleeding o Change in bowel habit o Nausea, vomiting o Pyrexia
Investigations in diverticular disease?
o Routine referral to specialist colorectal surgeon
Colonoscopy
CT
Management of diverticulosis?
o Give information leaflet
o Recommend healthy, balanced diet with lots of fibre 30g/day (whole grains, fruit and vegetables)
o Increase fluid intake
Management of diverticular disease - if not confirmed?
For suspected diverticular disease, but not confirmed:
Routine referral to specialist in colorectal surgery – colonoscopy or CT
Management of diverticular disease - if significant rectal bleeding?
o Urgent admission if diverticular disease with significant rectal bleedings (haemodynamically unstable)
Management of diverticular disease - acute diverticulitis referral?
Urgent hospital admission
Suspected complications – bleeding needing, transfusion, bowel perforation, peritonitis, abscess
Severe abdominal pain not managed in primary care
Dehydrated and unable to tolerate oral fluids at home
Unable to take oral antibiotics
Frail, significant comorbidities or immunocompromised
Management of diverticular disease - general advice?
Give information leaflet Recommend healthy, balanced diet with lots of fibre 30g/day (whole grains, fruit and vegetables) Increase fluid intake Smoking cessation Weight loss
Management of diverticular disease - drug management?
Constipation or diarrhoea symptoms persist - Consider bulk-forming laxative (Ispaghula husk and sterculia)
Analgesia if needed (paracetamol), avoid NSAIDs and codeine
Antispasmodic for abdominal cramping
Management of diverticular disease - review?
Review in one month – refer to colorectal surgeon if:
Persistent or refractory symptoms despite optimal management
Prognosis of diverticular disease?
o 1 in 4 with develop diverticulitis
Complications of diverticular disease?
o Haemorrhage
o Abscess
o Perforation/Peritonitis
o Fistulae/Strictures
Symptoms of diverticulitis?
o Constant abdominal pain, usually severe towards hypogastrium and LIF o Low grade pyrexia o Rigidity o Rectal bleeding o Change in bowel habit o Nausea, vomiting, shock
DDx of diverticulitis?
- IBS
- Gastroenteritis
- Appendicitis
- IBD
- Bowel obstruction
- Cancer
- PID/UTI
When to suspect diverticulitis?
o Constant abdominal pain, usually severe and localising in LIF with any of the following:
Fever
Sudden change in bowel habit and significant rectal bleeding or mucous
Tenderness in LIF, a palpable mass or distention with Hx of diverticular disease
When to refer for same-day assessment of diverticulitis?
Refer for same-day assessment if person has uncontrolled abdominal pain and any of following:
o Abdominal mass or peri-rectal fullness on DRE
o Abdominal guarding or rigidity
o Altered mental state, high RR, low BP, high HR, low temperature, no urine output
o Faecaluria, pneumauria, pyuria
o Colicky abdominal pain or absolute constipation
Investigations in complicated acute diverticulitis?
Bloods - FBC (Increased WCC), CRP, ESR, U&E, if infection – blood cultures
Imaging - Contrast CT within 24 hours (if raised inflammatory markers)
• If CI – non-contrast CT, MRI or US
If signs of intestinal obstruction:
• AXR
• Erect CXR (shows subdiaphragmatic gas in free peritoneum)
Management of uncomplicated diverticulitis - general advice?
o Clear liquids only with gradual reintroduction of solid food if symptoms improve over 2-3 days
o Paracetamol analgesia
Management of uncomplicated diverticulitis - antibiotics - when?
- If systemically unwell, immunosuppressed or significant co-morbidity
- Oral if systemically unwell but not septic and needing hospital admission
Management of uncomplicated diverticulitis - antibiotics - which?
Oral
o Co-amoxiclav 500/125mg TDS for 5 days
o Alternatives (cefalexin + metronidazole or trimethoprim + metronidazole)
IV
o Co-amoxiclav 1.2g TDS + Metronidazole 400mg TDS
Management of uncomplicated diverticulitis - review?
o Review in 48 hours or come back if symptoms persist or worsen
Management of uncomplicated diverticulitis - when to refer to colorectal surgeon? What investigations and management?
Refer to colorectal surgeon if frequent or severe recurrent episodes of acute diverticulitis:
Specialist investigations
• USS of abdomen
• CT
• Colonoscopy
Specialist Management
• Acutely – IV antibiotics, fluids, analgesia, surgery for complicated diverticulitis
• Elective surgery if recurrent complicated diverticulitis (strictures, fistula formation) or immunocompromised at high risk of complications
Management of complicated diverticulitis - general advice?
- IV analgesia (Morphine) and antiemetic (Cyclizine 50mg)
- IV fluids
- NBM
Management of complicated diverticulitis - Antibiotics?
1st line – co-amoxiclav 1.2g TDS
2nd line – cefuroxime 750mg TDS/QDS + metronidazole 500mg TDS
3rd line – amoxicillin 500mg TDS + gentamicin 5-7mg/kg OD + metronidazole 500mg TDS
Management of complicated diverticulitis - referral?
Refer to surgery
Management of complicated diverticulitis - surgical management of abscesses?
CT-guided percutaneous drainage (or surgery if abscess >3cm)
Send samples from pus to microbiology for sensitivities
Management of complicated diverticulitis - surgical management of bowel perforations?
Laparoscopic lavage or resectional salvage if perforation with generalised peritonitis
• Primary anastomosis (with or without diverting stoma) or
• Hartmann’s procedure (resection with end stoma)
Complications of diverticulitis??
o Haemorrhage - Treated IV fluids, IV Abx (Cefuroxime + Metronidazole), PPI, Stool chart and surgery
o Abscess - Abx plus CT-guided percutaneous drainage
o Perforation - Hartmann’s laparotomy and anastomosis
o Fistulae/Strictures
Definition of appendicitis?
- Acute inflammation of the appendix
- Gut organisms invade appendix wall after lumen obstruction by lymphoid hyperplasia, faecolith or worms
- Leads to oedema, ischaemic necrosis and perforation
Epidemiology of appendicitis?
- Commonest cause of abdominal pain in childhood requiring surgical intervention
- Lifetime incidence 6%
- Very uncommon in <3 years old, highest between 10-20 years old
Risk factors of appendicitis?
- Age
- Male sex
- Frequent antibiotic use
- Smoking
Symptoms of appendicitis?
- Periumbilical, colicky pain that moves to RIF
- Anorexia, vomiting, constipation/diarrhoea
- Coughing hurts
Signs of appendicitis?
- Tachycardia, fever, furred tongue, fetor oris
- Lying still, shallow breaths, moribund and septic shock
- Guarding (McBurneys point) and rebound tenderness in RIF, PR painful on right side (sign of low-lying appendix)
- Rovsing’s Sign – pain > in RIF than LIF when LIF is pressed
- Psoas Sign – pain on extending hip if retrocaecal appendix
- Cope Sign – pain on flexion and internal rotation of right hip if appendix is close to obturator internus
DDx of appendicitis?
- Ectopic Pregnancy
- UTI
- Mesenteric Adenitis
- Cystitis
- Cholecystitis
- Diverticulitis
- PID
- Dysmenorrhoea
- Crohn’s Disease
- Perforated ulcer
Investigations of appendicitis?
Rectal examination
Pregnancy and urinalysis
Clinical diagnosis
Bloods
• FBC (Neutrophil leucocytosis), U&E, LFTs, elevated CRP, ESR, bHCG, amylase, blood cultures, clotting and group and save
Urgent abdominal USS and TVUS (rule out gynaecological pathology if indicated)
CT diagnostic but may delay treatment
Management of appendicitis - initial management?
- Obtain IV Access
- IV Fluids
- IV Opioid
- IV Antiemetic
- NBM
- Refer to surgery
Management of appendicitis - further management?
Diagnostic laparoscopy
Laparoscopic/Open appendicectomy (surgical removal of the appendix)
Antibiotics 1-hour pre-op
Metronidazole + Cefuroxime starting pre-op
Complications of appendicitis?
- Perforation
- Appendix Mass
- Appendix Abscess
Definition of bowel obstruction?
- Can be mechanical or paralytic (paralytic ileus – post-op, peritonitis pseudo-obstruction)
- Leads to bowel dilatation and secretion of fluid
- In strangulation – gangrene, perforation
Definition of paralytic ileus?
o Adynamic bowel due to absence of normal peristalsis
o Factors – surgery, pancreatitis, spinal injury, hypokalaemia, hyponatraemia, uraemia, sepsis and drugs
Definition of pseudo-obstruction?
o Mechanical obstruction with no cause for obstruction found
o Acute pseudo-obstruction – Ogilvie’s syndrome
o Treatment is neostigmine or acutely with colonoscope decompression
Aetiology of small bowel obstruction?
Adhesions (80%) Hernia Crohn’s Disease Tumours Strangulation TB Gallstone Ileus
Aetiology of large bowel obstruction?
Carcinoma of colon Sigmoid/Caecal volvulus Constipation Strangulation Diverticular disease TB
Symptoms of bowel obstruction?
Colicky, abdominal Pain
Severe suggest strangulation and developing ischaemia
Distention
Vomiting
Nature of vomit (faeculent) may point to site of obstruction
Constipation
No flatulence
Ask about previous surgery
Signs of bowel obstruction?
o Fever, shock
o Tender distended abdomen
o Bowel sounds tinkling or absent
o PR and hernia exams
Investigations in bowel obstruction - bloods?
o FBC, U&E, LFTs, CRP, glucose, amylase, clotting, group and save
Investigations in bowel obstruction - imaging?
Erect CXR
AXR
Small Bowel – distended loops proximal (>3cm), central gas shadow with valvulae commitantes crossing lumen
Large Bowel – Peripheral gas shadow proximal but not in rectum, haustra do not cross lumen (>6cm in colon, >9cm in caecum)
CT if inconclusive
Investigations in bowel obstruction - others?
- DRE
- ECG (if middle aged/elderly)
- ABG (If shocked, check SpO2, ABG and lactate)
Management of bowel obstruction - initial management?
Initial management & conservative management (adhesional small bowel obstruction)
o Admission o IV cannula o IVI 0.9% saline o IV analgesia (Morphine) and IV antiemetics (Cyclizine 50mg) o NBM o Insert NG tube & catheter o Monitor hourly fluids with 4-hourly aspiration of NG o Refer to surgical team
Management of bowel obstruction - when to refer to surgical teams?
Suspicion of ischaemia or closed loop bowel obstruction
SBO in virgin abdomen
Strangulated hernia or obstructing tumour
Patients failing to improve with conservative measures
Management of bowel obstruction - surgical management?
Laparotomy +/- resection
Strangulation or closed loop – emergency laparotomy
Stents used for large bowel malignancies
SBO with adhesions should rarely have surgery
Complications of bowel obstruction?
- Bowel ischaemia
- Perforation
Definition of paralytic ileus?
o Slowing of GI motility that is not associated with mechanical obstruction
o Diagnosis of exclusion after bowel obstruction ruled out
Definition of pseudoobstruction?
o Mechanical GI obstruction with no cause found
o Acute pseudo-obstruction – Ogilvie’s syndrome
o Management – Neostigmine or colonoscopic decompression
When is paralytic ileus most common?
- Most commonly lasts 2-4 days after surgery
Causes of paralytic ileus?
o Postoperative ileus
o Acute illness – Pneumonia, MI, cholecystitis, pancreatitis, peritonitis, sepsis, AKI, DKA
o Drugs – analgesics, anaesthetics, anticholinergics
o Stroke
o Puerperium
o Trauma
o Severe hypothyroidism
o Electrolyte imbalance (hypokalaemia, hyponatraemia, hypomagnesaemia)
Symptoms of paralytic ileus?
o Nausea and vomiting
o Abdominal distention/pain
o No evidence of mechanical obstruction
Signs of paralytic ileus?
Silent bowel sounds
Investigations of paralytic ileus?
Bloods
o U&Es, Mg, FBC, CRP, glucose
o LFTs, amylase, lipase
AXR
o Air-fluid levels may be diffuse, no gas pattern
CT scan if obstruction suspected
Management of post-operative ileus
o NBM o IV hydration o Correct electrolytes o Manage underlying conditions o If repeated vomiting – NG tube o If >3 days or prolonging post-operative recovery – TPN nutrition
Management of non-surgical causes of ileus?
o NBM o IV hydration o Correct electrolytes o Manage underlying conditions o If repeated vomiting – NG tube o If >3 days or prolonging post-operative recovery – TPN nutrition
Monitoring in ileus?
Daily U&Es
Complications in ileus?
o Prolonged hospital stay
o Delayed wound healing
Pathology of colorectal cancer?
o Polyps progress into cancer
o Stepwise accumulation of genetic defects
o APC mutations associated with benign adenomas
o Progression to invasive carcinoma requires further mutations e.g. p53, DCC and RAS.
Histology of colorectal cancer?
o Epithelial – 95% adenocarcinoma (mucinous or signet ring), rarely SCC and adenosquamous carcinoma
o Carcinoid
o Stromal tumour
o Primary malignant lymphoma
Spread of colorectal cancer?
o Local, lymph, blood (liver, lung, bone), transcoelomic
Epidemiology of colorectal cancer?
2nd most common cause of death from cancer in UK
Adenocarcinoma most common
80% >60 years
Location
o 1/3 in rectum
o 1/3 in left side
o 1/3 in remainder
Aetiology of colorectal cancer?
o Diet rich in animal fats and red meat, poor in fibre o IBD o Familial o Alcohol o Smoking o Age
Symptoms of colorectal cancer?
o Altered bowel habit o Looser, frequent o Rectal bleeding o Colicky abdominal pain o Tenesmus o Weight loss
Signs of colorectal cancer?
o Iron deficiency anaemia
o Palpable mass
o Hepatomegaly
Red flag symptoms of colorectal cancer?
Weight loss Altered blood PR Change in bowel habit Abdominal pain Mucous PR Anorexia
Investigations to perform in colorectal cancer?
- Rectal Examination
- Bloods
o FBC, ferritin, LFTs
o CEA (carcino-embryonic antigen)
Diagnostic and staging investigations of colorectal cancer?
- Colonoscopy/Rigid/Flexible Sigmoidoscopy
o Biopsies taken - CT chest/abdomen/pelvis staging
Staging of colorectal cancer?
o Dukes Staging A – Invasion into bowel wall B – Invasion through bowel wall but not into nodes C – Lymph node involvement D – Distant Metastases
Screening of colorectal cancer - when and how? Management of result?
Faecal occult blood offered every 2 years between 60-74 (replaced in 2019 by faecal immunochemical test with threshold of 120ug/g)
Two samples collected from 3 separate bowel motions
If abnormal – colonoscopy
• No abnormalities – routine follow up
• Low risk adenoma – routine follow up
• Intermediate/High risk adenoma – colonoscopic surveillance
One-off flexible sigmoidoscopy to patients >55 and living in areas where test is available are sent invitation
If polyps identified, they are biopsied and rest of bowel examined
Referral of colorectal cancer on 2-week wait pathway?
Colonoscopy if: <50 with abdominal pain/weight loss <60 with rectal bleeding >60 with iron def anaemia, change in bowel habit Positive occult blood test
Management of local colon & rectal tumours? -
Surgery
• Radical resection usually for early stage – hemicolectomy, anterior resection, sigmoid colectomy, dependent on location
• Indicated in advanced disease, can resect liver and palliatively to prevent obstruction
Neoadjuvant radiotherapy (+chemo if high risk) used in moderate risk
Chemotherapy for 3-6 months for Stage 3 colon cancer
Management of metastatic colorectal cancer?
Test for RAS and BRAFV600E mutations in all people
1st line Chemotherapy
• Oral capecitabine
1st line Biological Agents
• Anti-angiogenic (Panitumumab) and anti-EGF (cetuximab) can be effective added to chemotherapy in advanced disease
Alternative Therapy
• Trifluridine-Tipiracil
Follow up in colorectal cancer?
o If curative – see in 6 weeks
o 6 monthly blood tests -CEA
o At least 2 CT scans of chest, abdomen, pelvis in first 3 years
o Colonoscopy
1 year after surgery and if normal, 3 yearly
Prognosis of colorectal cancer?
o Stage A – 80%
o Stage D – 5%
Definition of Irritable bowel syndrome?
- Chronic, relapsing and often lifelong disorder of lower GI tract with no structural or biochemical cause
- Typically presents with abdominal pain, which may be related to defaecation, and associated with change in stool form and/or frequency
Classification of Irritable bowel syndrome?
- Rome IV Classification: o Diarrhoea predominant (IBS-D) – most common o Constipation predominant (IBS-C) o Mixed o Unclassified
Mechanisms of Irritable bowel syndrome?
o Visceral hypersensitivity
o Abnormal GI immune function
o Changes in colonic microbiota
o Abnormal autonomic activity or GI motility
Epidemiology of Irritable bowel syndrome?
- Prevalence 5-20%
- 20-30 years and prevalence decreases with age
- Women > Men
Risk factors of Irritable bowel syndrome?
o FHx o Enteric infection o GI inflammation o Diet (caffeine, alcohol, spicy foods, fatty food) o Drugs – antibiotics o Anxiety/depression
Symptoms of Irritable bowel syndrome?
- Symptoms (>6 months) o Abdominal Pain o Bloating o Change in bowel habit Stool frequency Stool form (lumpy, hard, loose or watery) o Fatigue, lethargy o Nausea o Headache o Bladder symptoms
Examinations to perform of Irritable bowel syndrome?
o Abdomen palpation
o Rectal examination
Diagnosis of Irritable bowel syndrome when?
Initial Diagnosis of IBS if abdominal pain which is either:
o Relieved by defaecation
o Associated with altered stool frequency or stool form (hard, lumpy, loose and watery) and there if >2 of:
Altered stool passage (straining, urgency, incomplete evacuation)
Abdominal bloating, distention
Symptoms worsened by eating
Passage of rectal mucous
Confirming diagnosis of Irritable bowel syndrome?
o Faecal calprotectin – determine between IBD and IBS
o FBC, ESR, CRP, coeliac serology
Other investigations to consider in patient with symptoms of Irritable bowel syndrome?
o Food diary
o Endoscopy, colonoscopy
o Duodenal biopsy
o Ca125
Management of Irritable bowel syndrome - general advice?
o IBS Network & CORE charity -support for patients and families
o Identify any stress, anxiety and/or depressi
on
o Regular physical activity and weight loss
Management of Irritable bowel syndrome - diet?
Eat regular meals with healthy, balanced diet and adjust fibre intake according to symptoms
Avoid missing meals, long gaps
Limit fresh fruit to 3 portions per day
Drink >8 cups of fluid per day
Restrict coffee to <3 cups per day
Reduce alcohol and fizzy drinks
Management of Irritable bowel syndrome - general advice - if symptoms of diarrhoea/bloating predominate?
Reduce intake of insoluble fibre (wholemeal, high-fibre flour, breads and cereals)
Reduce exacerbating foods (caffeine, alcohol, carbonated drinks)
Management of Irritable bowel syndrome - general advice- if symptoms of constipation?
Try soluble fibre supplements (ispaghula) or food high in fibre (oats and linseed)
Increase fibre intake gradually
Management of Irritable bowel syndrome - drug management - if constipation?
Bulk-forming laxative
• Adjust dose according to symptom response
• Ispaghula husk, methycellulose
• Must not be taken before bed, takes 2-3 days to effect
If constipation >12 months and laxative max dose – linaclotide and review after 12 weeks
Management of Irritable bowel syndrome - drug management - if diarrhoea?
o If diarrhoea symptoms persist – loperamide
Dose taken for up to 5 days, initially 4mg and then 2mg to be taken after each loose stool
Management of Irritable bowel syndrome - drug management - if abdominal pain?
o Antispasmodic drug – mebeverine hydrochloride, alverine citrate, peppermint oil
If abdominal pain persists:
• Low-dose TCA (amitriptyline)
• SSRIs
• Referral to psychiatrist, gastroenterologist, dietician if persist or uncertainty
Follow up of IBS?
o Review annually
Prognosis of IBS?
- Fluctuate over years
- Post-infectious IBS tends to improve prognosis compared to typical IBS
- Poor prognosis with: long duration of symptoms, Previous Hx of surgery, higher somatic scores, co-morbid anxiety and depression
Definition of rectal prolapse?
- Protrusion of either rectal mucosa or entire wall of rectum
Types of rectal prolapse?
o Partial – only mucosa protrudes out of anus
o Complete – all layers of rectal wall protrude out of anus
Cause of rectal prolapse?
Due to lax sphincter, prolonged straining, chronic neurological and psychological disorders
Epidemiology of rectal prolapse?
- Most common in elderly, females
Risk factors of rectal prolapse?
o Increased intra-abdominal pressure – constipation, diarrhoea, BPH, pregnancy, cough
o Previous surgery
o Pelvic floor dysfunction
o Neurological disease – spine trauma, lumbar disc disease, cauda equina, MS
Symptoms of rectal prolapse?
Mass protruding through anus
Initially only after bowel movements, usually retracts when patient stands up
Later, may protrude when straining or Valsalva then continual
Pain, constipation, faecal incontinence and discharge of mucous or blood
Signs of rectal prolapse?
o Protruding mass show concentric rings of mucosa
Investigations of rectal prolapse?
- Barium Enema
- Colonoscopy
- Anal physiology studies (to distinguish between mucosal and full-thickness)
o Defecography, manometry, continence tests and electromyography - Rigid proctosigmoidoscopy
Management of rectal prolapse - treat cause?
Treat diarrhoea, constipation, cough
Management of rectal prolapse - conservative management?
Conservative Management (children or elderly unfit for surgery)
o Increase dietary fibre and fluid intake
o Avoid straining
o Laxatives
o Circumanal rubber ring
Management of rectal prolapse - surgical management?
Surgical Management – if irreducible
Abdominal approach
Rectopexy (fix rectum to sacrum)
• With mesh insertion +/- rectosigmoidectomy
Laparoscopic ventral mesh rectopexy
Perineal approach
Delorme’s procedure (resect close to dentate line and suture muscoal boundaries)
Anal encirclement with Thiersch wire
Complications of rectal prolase?
o Mucosal ulceration
o Necrosis of rectal wall
o Recurrence
Definition of haemorrhoids?
- Abnormally swollen vascular mucosal cushions present in anal canal
- In anus – three vascular mucosal cushions
o At left lateral (3 o’clock), right posterior (7), right anterior (11)
Classification of haemorrhoids - external?
o External – originate below dentate line (situated 2cm from anal verge and marks transition between upper and lower anal canal) and covered in squamous epithelium
Classification of haemorrhoids - internal?
o Internal – origin above dentate line and columnar epithelium
1st degree (grade 1) – project into lumen of anal canal but do not prolapse
2nd degree (grade 2) – protrude beyond anal canal on straining but spontaneously reduce when stop straining
3rd degree (grade 3) – protrude outside anal canal and reduce fully on manual pressure
4th degree (grade 4) – protrude outside anal canal and cannot be reduced
Epidemiology of haemorrhoids?
- Peak 45-65
Risk factors of haemorrhoids?
o Constipation o Straining o Ageing o Raised intra-abdominal pressure - Pregnancy, childbirth, ascites, pelvic mass o Chronic cough o Heavy lifting o Exercising o Low fibre diet
Symptoms of haemorrhoids?
o Bright, red painless rectal bleeding
Occur with defaecation, streaks on toilet paper or in bowel
o Anal itching or irritation
o Rectal fullness, discomfort or incomplete evacuation
o Soiling
o Pain is rare
When to refer with red flag signs of colorectal cancer?
o 40 and over with unexplained weight loss and abdominal pain or
o 50 and over with unexplained rectal bleeding or
o 60 and over with:
Iron-deficiency anaemia or
Changes in their bowel habit
o Tests show occult blood in their faeces
Examination of haemorrhoids?
o Lie in left lateral position
o Inspect perineum – ask to strain
Check for skin tags, fissures, masses
o DRE
Investigations of haemorrhoids?
o Proctoscopy – referral may be needed for this
o Bloods – FBC if signs of anaemia or significant rectal bleeding
Management of haemorrhoids - admission?
o If painful, acutely thrombosed external haemorrhoid presenting within 72 hours
o Incarcerated internal haemorrhoids
o Perianal sepsis
Management of haemorrhoids referral?
o 4th degree haemorrhoids or 3rd degree if too large
o Combined with severe symptoms
o Thrombosed haemorrhoids
o Large skin tags
o Not responding to general advice, recurrent symptoms
Management of haemorrhoids - general measures?
o Ensure stools are soft to pass – increase fibre intake and adequate fluid intake
o Anal region kept clean and dry to aid healing
o Careful perianal cleansing with moistened towels/baby wipes and pat area
o Analgesia – PRN paracetamol (avoid opioids)
o Once healed – continue with lifestyle measures
Management of haemorrhoids - topical creams?
o Topical haemorrhoidal creams
Contain lubricant, antiseptic, local anaethetic and/or steroid
Anusol, anacal, anodesyn, germoloids
Management of haemorrhoids - secondary care treatment - non-surgical?
Rubber band ligation
• Band applied to base of haemorrhoid – becomes necrotic and sloughs off – fixation by fibrotic wound healing – up to 3 per visit
Injection sclerotherapy
• Phenol injected into submucosa of rectum – induces fibrotic reaction – atrophy of haemorrhoid
Infrared Coagulation/photocoagulation
• Infrared energy to fibrose tissue – mucosal fixation and less likely to prolapse
Bipolar diathermy
Management of haemorrhoids - secondary care treatment - surgical?
Haemorrhoidectomy
• Only if symptomatic
• Complications – urinary retention, secondary haemorrhage, anal stricture/abscess/fistula, skin tags
Stapled haemorrhoidectomy
• Circular stapling gun to excise mucosa and lift cushons back within canal
Haemorrhoidal artery ligation
• Using proctoscope – ligated and sutured to remove blood flow
Prognosis of haemorrhoids?
o Many symptomatic episodes settle with conservative measures
o 10% need surgery
Complications of haemorrhoids?
o Perianal thrombosis o Incarceration of prolapsing haemorrhoidal tissue o Ulceration o Skin tags o Anal stenosis o Anaemia
Definition of perianal abscess?
- Perianal abscess is collection of pus in anal or rectal region
- Formed due to infection in perianal gland
- Gland lies between internal and external sphincter and drain into pits along dentate line
- Ducts become obstructed and infected
Epidemiology of perianal abscess?
Males mostly
Risk factors of perianal abscess?
o Anal fistula, DM, immunocompromised, receptive anal sex, Crohn’s, malignancy
Organisms of perianal abscess?
o E.coli, Bacteroides, Enterococcus
Location of perianal abscess?
o Perianal 45%
o Ischiorectal 30%
o Intersphincteric 20%
o Supralevator 5%
Symptoms of perianal abscess?
o Acute, perianal pain Gradual onset Becomes more severe, throbbing Worse on sitting down o Defaecation difficult o Fever, chills
Signs of perianal abscess?
o Patient sitting with one buttock raised
o Localised tenderness and swelling
o May see pus
Investigations of perianal abscess?
- DRE
- Proctosigmoidoscopy
- Pus culture (with acid fast bacilli)
- MRI if atypical
Management of perianal abscess?
- PRN analgesia
- Incision and drainage under GA
o Need to stay in hospital for 3-7 days
o Warm baths 2 to 3 times daily - Antibiotics only if DM, immunocompromise, older age, cardiac valve disease, cellulitis
o Ampicillin/cefoxitin and Metronidazole IV
Complications of perianal abscess?
- Sepsis
- Fissure in ano
- Recurrence
Definition of anal fissure?
- A tear or ulcer in lining of anal canal, immediately within anal margin
Classification of anal fissure?
o Acute - <6 weeks
o Chronic - >6 weeks
o Primary – no clear cause
o Secondary – underlying cause
Epidemiology of anal fissure?
- More common in 15-40
- Common in pregnancy
- 90% are posterior
Causes of anal fissure?
o Constipation o IBD o STIs (HIV, syphilis, HSV) o Colorectal cancer o Psoriasis, pruritus ani (itch if anus is moist) o Skin infection o Anal trauma – surgery/anal sex o Drugs – opioids, chemotherapy o Pregnancy and childbirth
Symptoms of anal fissure?
- Anal pain with defaecation o Severe and sharp on passing stool o Deep pain that persists for hours after - Bleeding may occur – bright red blood - May feel tearing sensation
What examination should you not perform in anal fissure?
DO NOT DRE
Management of anal fissure - referral?
- Refer to specialist if caused by IBD, STIs
Management of anal fissure - primary care - general advice?
Ensure stools are soft to pass
Adequate fibre intake
Drink plenty of fluids
Anal hygiene
Keep clean and dry
Avoid straining or stool withholding
Management of anal fissure - primary care - analgesia?
PRN paracetamol and ibuprofen
Sit in shallow, warm bath several times a day
If severe – topical lidocaine 5% ointment before passing stool
If >1 week:
• Rectal GTN 0.4% ointment BDS for 6-8 weeks
Management of anal fissure - primary care - follow up?
Review in 6-8 weeks (2 weeks in children)
Management of anal fissure - secondary care -management?
If unhealed and no symptomatic improvement with GTN
Either repeat 6-8 week course of GTN 0.4% ointment or refer to specialist • Diltiazem 2% • Botulinum Toxin Injection • Surgical Options: o Lateral Partial Internal Spincterotomy
Prognosis of anal fissure?
o Acute typically resolve over 6-8 weeks of conservative treatment
o Chronic may require more intensive treatments
o Recurrence is common if lifestyle measures not adhered to
o Secondary – depends on cause
Complications of anal fissure?
o Failure to heal o Recurrent Fistula o Anorectal fistula o Infection or abscess Faecal impaction
Definition of sigmoid volvulus?
- Bowel twists on mesentery, which can produce severe, rapid, strangulated obstruction
- If uncorrected – venous infarction, perforation and faecal peritonitis
Risk factors of sigmoid volvulus?
o Male
o Elderly
o Chronic constipated
o Megacolon
Symptoms of sigmoid volvulus?
o Sudden-onset colicky lower abdominal pain o Abdominal distention o Failure to pass flatus or stool o Vomiting (late)
Signs of sigmoid volvulus?
o Distended, tympanic abdomen
o Palpable mass sometimes felt
Investigations of sigmoid volvulus?
- DRE – empty rectum
- Bloods o FBC – raised WCC if perforation o U&E - dehydration o Amylase/Lipase o Coagulation
- Erect CXR
o Free air indicates perforation and need for urgent surgery - Plain AXR
o Grossly dilated inverted U loop of sigmoid bowel – coffee bean
o Projected towards right side of abdomen - CT scan can assess ischaemia
Management of sigmoid volvulus - if no peritonitis - conservative??
Flexible/Rigid Sigmoidoscopy + Endoscopic Decompression
Patient in left lateral position
Insertion of rectal tube into obstructed loop
Left in situ for 24 hours to prevent recurrence
Management of sigmoid volvulus - if no peritonitis - indications and type of surgery?
Indications for surgery:
Colonic ischaemia, repeated failed decompression, necrotic bowel on endoscopy
Type of surgery:
Laparotomy with Hartmann’s procedure (proctosigmoidectomy and end colostomy)
If recurrent and otherwise healthy – sigmoidectomy with primary anastomosis
Complications of sigmoid volvulus?
- Recurrence
- Bowel Obstruction
- Perforation and peritonitis
