General - Lower GI Flashcards
Where does an epigastric hernia occur?
In the upper midline, through the fibres of the linea alba
Where does a paraumbilical hernia occur?
Through the linea alba, around the umbilical region
Where does an obturator hernia occur?
A hernia of the pelvic floor, through the obturator foramen into the obturator canal
What is the pathophysiology of Angiodysplasia?
The formation of ateriovenous malformations between previously healthy blood vessels.
In which areas of the GI tract is angiodysplasia most common?
Caecum & Ascending colon
Clinical features of angiodysplasia?
Painless PR bleed
Acute haemorrhage
Anaemia
Melena
How would you investigate angiodysplasia?
Blood tests (FBC, U&E, LFT, Clotting, G&S)
Upper GI endoscopy
Colonoscopy
Wireless capsule endoscopy
Management of angiodysplasia?
IV fluid support
Tranexamic acid
Endoscopy + argon plasma coagulation
Mesenteric angiography
Bowel resection
Indications for bowel resection in patients with angiodysplasia?
Continuation of severe bleeding despite angiographic & endoscopic management
Severe acute life-threatening GI bleeding
Multiple angiodysplastic lesions that cannot be treated medically
Risks of mesenteric angiography as a treatment for angiodysplasia?
Haematoma formation
Arterial dissection
Thrombosis
Bowel ischaemia
What is a femoral hernia?
The abdominal viscera/omentum passes through the femoral ring into the femoral canal
What are the borders of the femoral canal?
Anterior border - Inguinal ligament
Posterior border - Pectineus
Lateral border - Femoral vein
Medial border - Lacunar ligament
Risk factors for femoral hernia?
Female
Pregnancy
Raised intra-abdominal pressure
Increasing age
Features of femoral hernia?
Small lump in groin
Infero-lateral to the pubic tubercle
Unlikely to be reducible
Differential diagnoses of femoral hernia/
Inguinal hernia
Femoral canal lipoma
Lymph node
Saphena varix
Investigations for femoral hernia?
US abdo-pelvis
Management for femoral hernia?
Always surgical due to high strangulation risk
Emergency presentations of femoral hernias that require urgent intervention?
Irreducible
Bowel Obstruction
Strangulation
What is an inguinal hernia?
Abdominal cavity contents enter into the inguinal canal.
What is a direct inguinal hernia?
Bowel enters the inguinal canal through a weakness in the posterior wall of the canal.
What is an indirect inguinal hernia?
Bowel enters the inguinal canal via the deep inguinal ring
Which is the most common type of inguinal hernia?
Indirect inguinal hernia (80%)
Risk factors for inguinal hernia?
Male
Increasing age
Raised intra-abdominal pressure
Obesity
Management of symptomatic inguinal hernia?
Laparoscopic repair
Open mesh repair
Where are the majority of gastroenteropancreatic neuroendocrine tumours located?
Small intestine
Risk factors for neuroendocrine tumours?
MEN1/2
Neurofibromatosis type 1
von Hippel-Lindau
Female
Family history
Clinical features of GEP-NETs?
Vague abdominal pain
Nausea & vomiting
Abdominal distension
Carcinoid syndrome
What is carcinoid syndrome?
Metastatic carcinoid tumour cells oversecrete serotonin, prostaglandin and gastrin into the circulation. Presents with flushing, palpitations, intermittent abdominal pain, diarrhoea.
Which markers are useful for identifying GEP-NETs?
Chromogranin A
Pancreatic polypeptide
5-HIAA
What imaging tests should be used in a patient with suspected GEP-NET?
Endoscopy
CT CAP
What is the management of a Gastric NET?
Endoscopic resection of tumour
Gastrectomy with regional lymph node clearance
What is the management of Small intestinal NETs?
Tumour resection with mesenteric lymph node clearance
What is the management of Appendiceal NETs?
Appendicectomy
Right hemicolectomy
What is the management of Colonic NETs?
Segmental colectomy with regional lymph node clearance
Where do most small bowel tumours arise?
Duodenum
Risk factors for small bowel adenocarcinoma/
Increasing age
Crohn’s disease
FAP
Smoking
Obesity
High dietary red meat
Alcohol excess
Clinical features of small bowel tumour?
Small bowel obstruction
Fresh PR bleed / melena
Hepatomegaly
Ascites
What tumour marker for small bowel adenocarcinoma?
CEA (Carcinoembryonic Antigen)
What is the surgical management of small bowel cancer?
Segmental resection
Whipple’s procedure (pancreaticduodenectomy)
Adjuvant chemotherapy
What age group is most commonly affected with appendicitis?
20-30yrs
Clinical features of acute appendicitis?
Peri-umbilical pain, migrating to RIF
Nausea & vomiting
Rebound tenderness
Percussion pain over McBurney’s point
Investigations for acute appendicitis?
Routine bloods
Urinalysis
Pregnancy test
USS abdomen
Management of acute appendicitis?
Laparoscopic appendectomy
Potential complications of acute appendicitis?
Perforation
Surgical site infection
Pelvic abscess
What is the most common type of Colorectal cancer?
Adenocarcinoma
Which genetic mutations predispose an individual to colorectal cancer?
APC
HNPCC
Risk factors for colorectal cancer?
Increasing age
Family history
Inflammatory bowel disease
Low fibre diet
High processed meat intake
Smoking
Excess alcohol intake
Clinical features of bowel cancer?
Change in bowel habit
Rectal bleeding
Weight loss
Abdominal pain
Anaemia
Referral criteria for investigation of suspected bowel cancer?
> 40 with unexplained weight loss & abdominal pain
50 with unexplained rectal bleeding
60 with iron-deficiency anaemia or change in bowel habit
When is colorectal cancer screening offered?
Every 2 years in those aged 60-75
What is the gold standard diagnostic investigation for colorectal cancer?
Colonoscopy with biopsy
What staging system is used for colorectal cancer?
Duke’s Staging
What is Duke’s stage A of colorectal cancer?
Confined beneath the muscularis propria
What is Duke’s stage B of colorectal cancer?
Extension through the muscularis propria
What is Duke’s stage C of colorectal cancer?
Involvement of regional lymph nodes
What is Duke’s stage D of colorectal cancer?
Distant metastasis
What is the surgical management for a caecal or ascending colon tumour?
Right hemicolectomy
What is the surgical management for descending colon tumours?
Left hemicolectomy
What is the surgical management of sigmoid colon tumours?
Sigmoidcolectomy
What is the surgical management of high rectal tumours?
Anterior resection
What is the surgical management of low rectal tumours?
Abdominoperineal resection
What area of the GI tract does Crohn’s disease affect?
Any part of the GI tract
What are the macroscopic changes in Crohn’s disease?
Skip lesions (discontinuous inflammation)
Cobblestone appearance
Fistula formation
What are the microscopic changes in Crohn’s disease?
Non-caseating granulomas
What type of inflammation is present in Crohn’s disease?
Transmural inflammation
Risk factors for Crohn’s disease?
Family history
Smoking
Clinical features of Crohn’s disease?
Episodic abdominal pain
Diarrhoea (blood/mucus)
Oral aphthous ulcers
Perianal abscess
Nail clubbing
Erythema nodosum
Weight loss
Malaise
Gold standard investigation for Crohn’s disease?
Colonoscsopy
Long term management of Crohn’s disease?
Smoking cessation
Azathioprine
Enteral nutrition support
How to induce remission in an acute attack of Crohn’s disease?
Fluid resuscitation
Prophylactic heparin
Corticosteroid therapy
Potential complications of Crohn’s disease?
Fistula
Stricture formation
GI malignancy
Osteoporosis
Gallstones
Renal stones
Malabsorption
Risk factors for formation of a diverticulum?
Increasing age
Low dietary fibre intake
Obesity
Smoking
Family history
NSAID use
Clinical features of diverticular disease?
Intermittent lower abdominal pain
Pain relieved on defecation
Altered bowel habit
Nausea
Flatulence
Clinical features of acute diverticulitis?
Acute abdominal pain (LIF)
Pain worse on movement
Localised tenderness
Decreased appetite
Pyrexia
Nausea
Investigations for suspected diverticulosis?
Routine bloods
G&S
VBG
CT AP
Management of uncomplicated diverticular disease?
Simple analgesia
Encourage oral fluid intake
Management of acute diverticulitis?
Antibiotics
IV fluids
Analgesia
Complications of diverticulitis?
Recurrence
Diverticular stricture
Fistula
What is Pseudo-obstruction?
Dilatation of the colon due to adynamic bowel, in the absence of mechanical obstruction.
Causes of pseudo-obstruction?
Hypercalcaemia
Hypothyroidism
Opioids
CCBs
Anti-depressants
Cardiac ischaemia
Parkinson’s disease
MS
Clinical features of pseudo-obstruction?
Abdominal pain
Abdominal distension
Constipation
Vomiting
Differential diagnoses of suspected pseudo-obstruction?
Mechanical obstruction
Paralytic ileus
Toxic megacolon
Investigations for suspected pseudo-obstruction?
CT AP with IV contrast
Blood tests (U&E, bone profile, TFTs)
AXR
Management of pseudo-obstruction/
Treat underlying cause
NBM
IV fluids
Endoscopic decompression (if no resolution within 24-48hrs)
