Gen Surg - Others Flashcards
haemorrhoids anal fissures anal fistula upper GIB dysphagia & odynophagia GERD barrett's oesophagus hiatal hernia
what are haemorrhoids
normal vascular and CT columns that exist in the anal canal — there are 3 in total
split into internal and external haemorrhoids — internal = above dentate line; external = below dentate line
internal = can bleed or prolapse
external = can thrombose
what causes haemorrhoids
poor dietary habits
constipation — prolonged straining
increased intra-abdominal P
what are the 4 degree of internal haemorrhoids
1st degree: bleeds only
2nd degree: prolapses BUT reduces spontaneously
3rd degree: prolapses BUT has to be manually reduced
4th degree: permanently prolapsed — may strangulate
how does thrombosed external haemorrhoids present + how to manage
presentation : acute excruciating pain
Tx: surgical evacuation of haemorrhoid + excision of skin overlying
how would u manage internal haemorrhoids that is bleeding/prolapsed
conservative Tx
secondary prevention
only evacuate when the natural desire to do so arises
minimise straining or lingering
increased dietary fibre
increased physical activity
sitz baths — warm water + 3x a day
(to clean perineum)
medical Tx
laxatives — stool softeners or bulking agents
topical analgesia + steroids
injection sclerotherapy —- for 1st or 2nd degree
rubber band ligation —- for 2nd degree
trans-anal haemorrhoidal dearterialisation — for 2nd & 3rd degree
surgical Tx = haemorrhoidectomy
what are anal fissures
longitudinal split of the anoderm in the distal anal canal — extending from the anal verge proximally — towards (but not extending beyond) the dentate line
what causes anal fissures
primary causes = local trauma
passage of hard stool
prolonged diarrhoea
vaginal delivery
anal sex
secondary causes
IBD — eg. CD
granulomatous diseases — eg. extrapulmonary TB, sarcoidosis
malignancy — eg. squamous cell anal ca, leukaemia
communicable diseases — eg. HIV, syphillis, chlamydia
what defines acute or chronic anal fissure
acute = <6 wks of onset
chronic = >6wks of onset OR certain features
eg. fibrosis, fibrotic edges, perianal skin tag
how do anal fissures present
pain — exacerbated by defecation
+/- bleeding
+/- perianal skin tags
+/- puritus ani
how to manage anal fissures
conservative Tx = prevention
healthy bowel habits
high fibre diet
adequate fluids
medical Tx
laxatives
warm sitz baths — ie local wound care
analgesia
what is an anal fistula
fistula: chronic abnormal connection between 2 epithelial-lined surfaces
anal fistula is when a fistula forms between the anus and an adjacent structure
what can cause anal fistulas
anorectal abscess —- ruptures or is drained
CD
lymphogranuloma venereum
radiation proctitis
rectal foreign bodies
primary perianal actinomycosis
how would an anal fistula present
symptoms (Hx)
intermittent rectal pain
chronic purulent discharge
pustule-like lesion in the peri-anal or buttock area
intermittent + malodorous perianal drainage & pruritus
signs (exam)
perianal skin — excoriated + inflamed
induration just below skin
proctosigmoidoscopy
what classification used for anal fistulas
park’s classification
intersphincteric
trans-sphincteric
extrasphincteric
suprasphincteric
management of anal fistulas
EUA examination under anaesthesia
options
fistulotomy
fistulectomy
seton insertion
advancement flap
plus and glues
causes of upper GIB
peptic ulcers 36%
oesophagitis 24%
gastritis 22%
varices 11%
risk factors for upper GIB
chronic liver disease
alcohol
smoking
NSAIDs
vomiting
steroids
PUD
Ix for upper GIB
bloods
FBC
U&E
GXM if severe
coag profile
ABG + lactate
OGD
CT angiogram
scoring system for upper GIB
Glasgow Blatchford scoring system
predicts need for intervention in upper GIB
management of upper GIB
IV PPI bolus/transfusion
if stable = GI endoscopy in 24 hrs
if unstable = urgent endoscopy
stop haemorrhage via haemostatic clips, adrenaline injections, haemostatic powder
if massive haemorrhage = ABCDs
2 large bore 14-16G IV cannulas
transfuse IV crystalloids, if severe = unmatched O -ve blood initially —- matched blood once available
activate massive transfusion protocol
balanced transfusion — 1:1:1 RCC, FFP, platelets
reverse any anticoags + correct any underlying coag deficits
if suspected variceal bleeding = IV terlipression + octreotide
+/- Sengstaken-Blakemore tube (in ED setting)
OGD for variceal banding
+/- TIPS Transjugular intrahepatic portosystemic shunt
what is dysphagia and odynophagia and what are their DDx
dysphagia: difficulty swallowing
odynophagia: painful swallowing
DDx
intraluminal
foreign body
food bolus
oesophageal webs
intramural
lump — benign vs malignant
GERD
oesophagitis
dysmotility disorders
scleroderma
stricture
eosinophilic oesophagitis
neuro
hiatal hernia
volvulus
extraluminal
lymphadenopathy
goitre
pharyngeal pouch
haematoma
others
oesophageal rupture
Mallory-Weiss tear
oesophageal ulcers
what is GERD
it is a condition that develops when reflux of stomach contents causes troublesome symptoms and/or complications
risk factors of GERD
causes of increased intra-abdominal P
obesity
pregnancy
causes of loss of anti-reflux mechanisms
alcohol
smoking
fam Hx
DM
hiatal hernia
oesophageal dysmotility
gastric dysfunction
meds
Ix for GERD
urease breath test — for H.pylori
Upper GI Endoscopy
contrast swallow
ambulatory pH and impedence monitoring
oesophageal manometry
