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MSRA Content > Gastrointestinal - Level 2.4 > Flashcards

Gastrointestinal - Level 2.4 Flashcards

1
Q

Definition of diverticula?

A

Sac-like protrusions of mucosa through muscular wall of colon

Usually multiple, 5-10mm in diameter and occur most in sigmoid colon

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2
Q

Definition of diverticulosis?

A

o Condition where diverticula are present without symptoms

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3
Q

Definition of diverticular disease?

A

o Condition where diverticula cause symptoms

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4
Q

Definition of diverticulitis?

A

o Diverticula become inflamed and infected

o Complicated when associated abscess, peritonitis, perforation or obstruction

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5
Q

Epidemiology of diverticular disease?

A
  • Mostly in sigmoid colon
  • Increasing incidence with age
  • Majority asymptomatic
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6
Q

Risk factors of diverticular disease?

A 
o	Genetics
o	Low fibre diet
o	Smoking
o	Obesity
o	NSAIDs, corticosteroids
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7
Q

Symptoms of diverticulosis?

A

o Asymptomatic and most people undiagnosed

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8
Q

Symptoms of diverticular disease?

A

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

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9
Q

Symptoms of diverticulitis?

A 
o	Constant abdominal pain, usually severe towards hypogastrium and LIF
o	Rectal bleeding
o	Change in bowel habit
o	Nausea, vomiting
o	Pyrexia
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10
Q

Investigations in diverticular disease?

A

o Routine referral to specialist colorectal surgeon
 Colonoscopy
 CT

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11
Q

Management of diverticulosis?

A

o Give information leaflet
o Recommend healthy, balanced diet with lots of fibre 30g/day (whole grains, fruit and vegetables)
o Increase fluid intake

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12
Q

Management of diverticular disease - if not confirmed?

A

For suspected diverticular disease, but not confirmed:

 Routine referral to specialist in colorectal surgery – colonoscopy or CT

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13
Q

Management of diverticular disease - if significant rectal bleeding?

A

o Urgent admission if diverticular disease with significant rectal bleedings (haemodynamically unstable)

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14
Q

Management of diverticular disease - acute diverticulitis referral?

A

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

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15
Q

Management of diverticular disease - general advice?

A 
	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
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16
Q

Management of diverticular disease - drug management?

A

 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

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17
Q

Management of diverticular disease - review?

A

Review in one month – refer to colorectal surgeon if:

 Persistent or refractory symptoms despite optimal management

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18
Q

Prognosis of diverticular disease?

A

o 1 in 4 with develop diverticulitis

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19
Q

Complications of diverticular disease?

A

o Haemorrhage
o Abscess
o Perforation/Peritonitis
o Fistulae/Strictures

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20
Q

Symptoms of diverticulitis?

A 
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
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21
Q

DDx of diverticulitis?

A
  • IBS
  • Gastroenteritis
  • Appendicitis
  • IBD
  • Bowel obstruction
  • Cancer
  • PID/UTI
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22
Q

When to suspect diverticulitis?

A

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

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23
Q

When to refer for same-day assessment of diverticulitis?

A

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

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24
Q

Investigations in complicated acute diverticulitis?

A

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)

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25
Q

Management of uncomplicated diverticulitis - general advice?

A

o Clear liquids only with gradual reintroduction of solid food if symptoms improve over 2-3 days
o Paracetamol analgesia

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26
Q

Management of uncomplicated diverticulitis - antibiotics - when?

A
  • If systemically unwell, immunosuppressed or significant co-morbidity
  • Oral if systemically unwell but not septic and needing hospital admission
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27
Q

Management of uncomplicated diverticulitis - antibiotics - which?

A

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

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28
Q

Management of uncomplicated diverticulitis - review?

A

o Review in 48 hours or come back if symptoms persist or worsen

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29
Q

Management of uncomplicated diverticulitis - when to refer to colorectal surgeon? What investigations and management?

A

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

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30
Q

Management of complicated diverticulitis - general advice?

A
  • IV analgesia (Morphine) and antiemetic (Cyclizine 50mg)
  • IV fluids
  • NBM
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31
Q

Management of complicated diverticulitis - Antibiotics?

A

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

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32
Q

Management of complicated diverticulitis - referral?

A

Refer to surgery

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33
Q

Management of complicated diverticulitis - surgical management of abscesses?

A

 CT-guided percutaneous drainage (or surgery if abscess >3cm)
 Send samples from pus to microbiology for sensitivities

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34
Q

Management of complicated diverticulitis - surgical management of bowel perforations?

A

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)

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35
Q

Complications of diverticulitis??

A

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

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36
Q

Definition of appendicitis?

A
  • 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
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37
Q

Epidemiology of appendicitis?

A
  • 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
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38
Q

Risk factors of appendicitis?

A
  • Age
  • Male sex
  • Frequent antibiotic use
  • Smoking
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39
Q

Symptoms of appendicitis?

A
  • Periumbilical, colicky pain that moves to RIF
  • Anorexia, vomiting, constipation/diarrhoea
  • Coughing hurts
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40
Q

Signs of appendicitis?

A
  • 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
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41
Q

DDx of appendicitis?

A
  • Ectopic Pregnancy
  • UTI
  • Mesenteric Adenitis
  • Cystitis
  • Cholecystitis
  • Diverticulitis
  • PID
  • Dysmenorrhoea
  • Crohn’s Disease
  • Perforated ulcer
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42
Q

Investigations of appendicitis?

A

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

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43
Q

Management of appendicitis - initial management?

A
  • Obtain IV Access
  • IV Fluids
  • IV Opioid
  • IV Antiemetic
  • NBM
  • Refer to surgery
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44
Q

Management of appendicitis - further management?

A

Diagnostic laparoscopy

Laparoscopic/Open appendicectomy (surgical removal of the appendix)

Antibiotics 1-hour pre-op
 Metronidazole + Cefuroxime starting pre-op

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45
Q

Complications of appendicitis?

A
  • Perforation
  • Appendix Mass
  • Appendix Abscess
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46
Q

Definition of bowel obstruction?

A
  • Can be mechanical or paralytic (paralytic ileus – post-op, peritonitis pseudo-obstruction)
  • Leads to bowel dilatation and secretion of fluid
  • In strangulation – gangrene, perforation
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47
Q

Definition of paralytic ileus?

A

o Adynamic bowel due to absence of normal peristalsis

o Factors – surgery, pancreatitis, spinal injury, hypokalaemia, hyponatraemia, uraemia, sepsis and drugs

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48
Q

Definition of pseudo-obstruction?

A

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

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49
Q

Aetiology of small bowel obstruction?

A 
	Adhesions (80%)
	Hernia
	Crohn’s Disease
	Tumours
	Strangulation
	TB
	Gallstone Ileus
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50
Q

Aetiology of large bowel obstruction?

A 
	Carcinoma of colon
	Sigmoid/Caecal volvulus
	Constipation
	Strangulation
	Diverticular disease
	TB
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51
Q

Symptoms of bowel obstruction?

A

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

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52
Q

Signs of bowel obstruction?

A

o Fever, shock
o Tender distended abdomen
o Bowel sounds tinkling or absent
o PR and hernia exams

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53
Q

Investigations in bowel obstruction - bloods?

A

o FBC, U&E, LFTs, CRP, glucose, amylase, clotting, group and save

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54
Q

Investigations in bowel obstruction - imaging?

A

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

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55
Q

Investigations in bowel obstruction - others?

A
  • DRE
  • ECG (if middle aged/elderly)
  • ABG (If shocked, check SpO2, ABG and lactate)
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56
Q

Management of bowel obstruction - initial management?

A

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 &amp; catheter
o	Monitor hourly fluids with 4-hourly aspiration of NG
o	Refer to surgical team
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57
Q

Management of bowel obstruction - when to refer to surgical teams?

A

 Suspicion of ischaemia or closed loop bowel obstruction
 SBO in virgin abdomen
 Strangulated hernia or obstructing tumour
 Patients failing to improve with conservative measures

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58
Q

Management of bowel obstruction - surgical management?

A

 Laparotomy +/- resection
 Strangulation or closed loop – emergency laparotomy
 Stents used for large bowel malignancies
 SBO with adhesions should rarely have surgery

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59
Q

Complications of bowel obstruction?

A
  • Bowel ischaemia

- Perforation

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60
Q

Definition of paralytic ileus?

A

o Slowing of GI motility that is not associated with mechanical obstruction
o Diagnosis of exclusion after bowel obstruction ruled out

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61
Q

Definition of pseudoobstruction?

A

o Mechanical GI obstruction with no cause found
o Acute pseudo-obstruction – Ogilvie’s syndrome
o Management – Neostigmine or colonoscopic decompression

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62
Q

When is paralytic ileus most common?

A
  • Most commonly lasts 2-4 days after surgery
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63
Q

Causes of paralytic ileus?

A

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)

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64
Q

Symptoms of paralytic ileus?

A

o Nausea and vomiting
o Abdominal distention/pain
o No evidence of mechanical obstruction

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65
Q

Signs of paralytic ileus?

A

Silent bowel sounds

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66
Q

Investigations of paralytic ileus?

A

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

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67
Q

Management of post-operative ileus

A 
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
68
Q

Management of non-surgical causes of ileus?

A 
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
69
Q

Monitoring in ileus?

A

Daily U&Es

70
Q

Complications in ileus?

A

o Prolonged hospital stay

o Delayed wound healing

71
Q

Pathology of colorectal cancer?

A

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.

72
Q

Histology of colorectal cancer?

A

o Epithelial – 95% adenocarcinoma (mucinous or signet ring), rarely SCC and adenosquamous carcinoma
o Carcinoid
o Stromal tumour
o Primary malignant lymphoma

73
Q

Spread of colorectal cancer?

A

o Local, lymph, blood (liver, lung, bone), transcoelomic

74
Q

Epidemiology of colorectal cancer?

A

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

75
Q

Aetiology of colorectal cancer?

A 
o	Diet rich in animal fats and red meat, poor in fibre
o	IBD 
o	Familial
o	Alcohol
o	Smoking
o	Age
76
Q

Symptoms of colorectal cancer?

A 
o	Altered bowel habit
o	Looser, frequent
o	Rectal bleeding
o	Colicky abdominal pain
o	Tenesmus
o	Weight loss
77
Q

Signs of colorectal cancer?

A

o Iron deficiency anaemia
o Palpable mass
o Hepatomegaly

78
Q

Red flag symptoms of colorectal cancer?

A 
Weight loss
Altered blood PR
Change in bowel habit
Abdominal pain 
Mucous PR
Anorexia
79
Q

Investigations to perform in colorectal cancer?

A
  • Rectal Examination
  • Bloods
    o FBC, ferritin, LFTs
    o CEA (carcino-embryonic antigen)
80
Q

Diagnostic and staging investigations of colorectal cancer?

A
  • Colonoscopy/Rigid/Flexible Sigmoidoscopy
    o Biopsies taken
  • CT chest/abdomen/pelvis staging
81
Q

Staging of colorectal cancer?

A 
o	Dukes Staging
	A – Invasion into bowel wall
	B – Invasion through bowel wall but not into nodes
	C – Lymph node involvement
	D – Distant Metastases
82
Q

Screening of colorectal cancer - when and how? Management of result?

A

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

83
Q

Referral of colorectal cancer on 2-week wait pathway?

A 
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
84
Q

Management of local colon & rectal tumours? -

A

 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

85
Q

Management of metastatic colorectal cancer?

A

 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

86
Q

Follow up in colorectal cancer?

A

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

87
Q

Prognosis of colorectal cancer?

A

o Stage A – 80%

o Stage D – 5%

88
Q

Definition of Irritable bowel syndrome?

A
  • 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
89
Q

Classification of Irritable bowel syndrome?

A 
-	Rome IV Classification:
o	Diarrhoea predominant (IBS-D) – most common
o	Constipation predominant (IBS-C)
o	Mixed
o	Unclassified
90
Q

Mechanisms of Irritable bowel syndrome?

A

o Visceral hypersensitivity
o Abnormal GI immune function
o Changes in colonic microbiota
o Abnormal autonomic activity or GI motility

91
Q

Epidemiology of Irritable bowel syndrome?

A
  • Prevalence 5-20%
  • 20-30 years and prevalence decreases with age
  • Women > Men
92
Q

Risk factors of Irritable bowel syndrome?

A 
o	FHx
o	Enteric infection
o	GI inflammation
o	Diet (caffeine, alcohol, spicy foods, fatty food)
o	Drugs – antibiotics
o	Anxiety/depression
93
Q

Symptoms of Irritable bowel syndrome?

A 
-	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
94
Q

Examinations to perform of Irritable bowel syndrome?

A

o Abdomen palpation

o Rectal examination

95
Q

Diagnosis of Irritable bowel syndrome when?

A

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

96
Q

Confirming diagnosis of Irritable bowel syndrome?

A

o Faecal calprotectin – determine between IBD and IBS

o FBC, ESR, CRP, coeliac serology

97
Q

Other investigations to consider in patient with symptoms of Irritable bowel syndrome?

A

o Food diary
o Endoscopy, colonoscopy
o Duodenal biopsy
o Ca125

98
Q

Management of Irritable bowel syndrome - general advice?

A

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

99
Q

Management of Irritable bowel syndrome - diet?

A

 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

100
Q

Management of Irritable bowel syndrome - general advice - if symptoms of diarrhoea/bloating predominate?

A

 Reduce intake of insoluble fibre (wholemeal, high-fibre flour, breads and cereals)
 Reduce exacerbating foods (caffeine, alcohol, carbonated drinks)

101
Q

Management of Irritable bowel syndrome - general advice- if symptoms of constipation?

A

 Try soluble fibre supplements (ispaghula) or food high in fibre (oats and linseed)
 Increase fibre intake gradually

102
Q

Management of Irritable bowel syndrome - drug management - if constipation?

A

 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

103
Q

Management of Irritable bowel syndrome - drug management - if diarrhoea?

A

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

104
Q

Management of Irritable bowel syndrome - drug management - if abdominal pain?

A

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

105
Q

Follow up of IBS?

A

o Review annually

106
Q

Prognosis of IBS?

A
  • 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
107
Q

Definition of rectal prolapse?

A
  • Protrusion of either rectal mucosa or entire wall of rectum
108
Q

Types of rectal prolapse?

A

o Partial – only mucosa protrudes out of anus

o Complete – all layers of rectal wall protrude out of anus

109
Q

Cause of rectal prolapse?

A

Due to lax sphincter, prolonged straining, chronic neurological and psychological disorders

110
Q

Epidemiology of rectal prolapse?

A
  • Most common in elderly, females
111
Q

Risk factors of rectal prolapse?

A

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

112
Q

Symptoms of rectal prolapse?

A

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

113
Q

Signs of rectal prolapse?

A

o Protruding mass show concentric rings of mucosa

114
Q

Investigations of rectal prolapse?

A
  • Barium Enema
  • Colonoscopy
  • Anal physiology studies (to distinguish between mucosal and full-thickness)
    o Defecography, manometry, continence tests and electromyography
  • Rigid proctosigmoidoscopy
115
Q

Management of rectal prolapse - treat cause?

A

Treat diarrhoea, constipation, cough

116
Q

Management of rectal prolapse - conservative management?

A

Conservative Management (children or elderly unfit for surgery)
o Increase dietary fibre and fluid intake
o Avoid straining
o Laxatives
o Circumanal rubber ring

117
Q

Management of rectal prolapse - surgical management?

A

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

118
Q

Complications of rectal prolase?

A

o Mucosal ulceration
o Necrosis of rectal wall
o Recurrence

119
Q

Definition of haemorrhoids?

A
  • 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)
120
Q

Classification of haemorrhoids - external?

A

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

121
Q

Classification of haemorrhoids - internal?

A

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

122
Q

Epidemiology of haemorrhoids?

A
  • Peak 45-65
123
Q

Risk factors of haemorrhoids?

A 
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
124
Q

Symptoms of haemorrhoids?

A

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

125
Q

When to refer with red flag signs of colorectal cancer?

A

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

126
Q

Examination of haemorrhoids?

A

o Lie in left lateral position
o Inspect perineum – ask to strain
 Check for skin tags, fissures, masses
o DRE

127
Q

Investigations of haemorrhoids?

A

o Proctoscopy – referral may be needed for this

o Bloods – FBC if signs of anaemia or significant rectal bleeding

128
Q

Management of haemorrhoids - admission?

A

o If painful, acutely thrombosed external haemorrhoid presenting within 72 hours
o Incarcerated internal haemorrhoids
o Perianal sepsis

129
Q

Management of haemorrhoids referral?

A

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

130
Q

Management of haemorrhoids - general measures?

A

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

131
Q

Management of haemorrhoids - topical creams?

A

o Topical haemorrhoidal creams
 Contain lubricant, antiseptic, local anaethetic and/or steroid
 Anusol, anacal, anodesyn, germoloids

132
Q

Management of haemorrhoids - secondary care treatment - non-surgical?

A

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

133
Q

Management of haemorrhoids - secondary care treatment - surgical?

A

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

134
Q

Prognosis of haemorrhoids?

A

o Many symptomatic episodes settle with conservative measures
o 10% need surgery

135
Q

Complications of haemorrhoids?

A 
o	Perianal thrombosis
o	Incarceration of prolapsing haemorrhoidal tissue
o	Ulceration
o	Skin tags
o	Anal stenosis
o	Anaemia
136
Q

Definition of perianal abscess?

A
  • 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
137
Q

Epidemiology of perianal abscess?

A

Males mostly

138
Q

Risk factors of perianal abscess?

A

o Anal fistula, DM, immunocompromised, receptive anal sex, Crohn’s, malignancy

139
Q

Organisms of perianal abscess?

A

o E.coli, Bacteroides, Enterococcus

140
Q

Location of perianal abscess?

A

o Perianal 45%
o Ischiorectal 30%
o Intersphincteric 20%
o Supralevator 5%

141
Q

Symptoms of perianal abscess?

A 
o	Acute, perianal pain
	Gradual onset
	Becomes more severe, throbbing
	Worse on sitting down
o	Defaecation difficult
o	Fever, chills
142
Q

Signs of perianal abscess?

A

o Patient sitting with one buttock raised
o Localised tenderness and swelling
o May see pus

143
Q

Investigations of perianal abscess?

A
  • DRE
  • Proctosigmoidoscopy
  • Pus culture (with acid fast bacilli)
  • MRI if atypical
144
Q

Management of perianal abscess?

A
  • 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
145
Q

Complications of perianal abscess?

A
  • Sepsis
  • Fissure in ano
  • Recurrence
146
Q

Definition of anal fissure?

A
  • A tear or ulcer in lining of anal canal, immediately within anal margin
147
Q

Classification of anal fissure?

A

o Acute - <6 weeks
o Chronic - >6 weeks
o Primary – no clear cause
o Secondary – underlying cause

148
Q

Epidemiology of anal fissure?

A
  • More common in 15-40
  • Common in pregnancy
  • 90% are posterior
149
Q

Causes of anal fissure?

A 
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
150
Q

Symptoms of anal fissure?

A 
-	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
151
Q

What examination should you not perform in anal fissure?

A

DO NOT DRE

152
Q

Management of anal fissure - referral?

A
  • Refer to specialist if caused by IBD, STIs
153
Q

Management of anal fissure - primary care - general advice?

A

Ensure stools are soft to pass
 Adequate fibre intake
 Drink plenty of fluids

Anal hygiene
 Keep clean and dry
 Avoid straining or stool withholding

154
Q

Management of anal fissure - primary care - analgesia?

A

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

155
Q

Management of anal fissure - primary care - follow up?

A

 Review in 6-8 weeks (2 weeks in children)

156
Q

Management of anal fissure - secondary care -management?

A

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
157
Q

Prognosis of anal fissure?

A

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

158
Q

Complications of anal fissure?

A 
o	Failure to heal
o	Recurrent Fistula
o	Anorectal fistula
o	Infection or abscess
Faecal impaction
159
Q

Definition of sigmoid volvulus?

A
  • Bowel twists on mesentery, which can produce severe, rapid, strangulated obstruction
  • If uncorrected – venous infarction, perforation and faecal peritonitis
160
Q

Risk factors of sigmoid volvulus?

A

o Male
o Elderly
o Chronic constipated
o Megacolon

161
Q

Symptoms of sigmoid volvulus?

A 
o	Sudden-onset colicky lower abdominal pain
o	Abdominal distention
o	Failure to pass flatus or stool
o	Vomiting (late)
162
Q

Signs of sigmoid volvulus?

A

o Distended, tympanic abdomen

o Palpable mass sometimes felt

163
Q

Investigations of sigmoid volvulus?

A
  • DRE – empty rectum
-	Bloods
o	FBC – raised WCC if perforation
o	U&amp;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
164
Q

Management of sigmoid volvulus - if no peritonitis - conservative??

A

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

165
Q

Management of sigmoid volvulus - if no peritonitis - indications and type of surgery?

A

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

166
Q

Complications of sigmoid volvulus?

A
  • Recurrence
  • Bowel Obstruction
  • Perforation and peritonitis

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