General Surgery/GI Flashcards
What diameter of abdominal aorta is considered abnormal - aneurysmal?
greater than 3cm
What are some risk factors for the development of abdominal aortic aneurysms?
male
higher age
smoking
hypertension
familial history
existing CV disease
How can patients with AAA (abdominal aortic aneurysm) present?
asymptomatic
non-specific abdo pain
pulsatile and expansive mass in the abdomen
incidental finding
What investigations are used to diagnose AAA?
ultrasound - imaging of choice
CT angiogram - useful for elective surgery
What is the screening programme for AAA?
men over 65 y.o. are offered abdominal ultrasound
What diameter would be a small AAA?
3 - 4.4 cm
What action is required in small AAA?
re-scan every 12 months
What diameter would be a medium AAA?
4.5 - 5.4 cm
What action is required in medium AAA?
re-scan every 3 months
What diameter would be a large AAA?
greater than 5.5 cm
What action is recommended in large AAA?
refer to vascular surgery within 2 weeks
What are some non-surgical management options for AAA?
treating reversible risk factors:
quitting smoking
hypertension management
healthy lifestyle (diet, exercise)
When is elective repair for AAA recommended?
- if symptomatic
- if > 5.5 cm
- if growing >1cm per year
What is the surgical management of AAA?
open laparotomy
EVAR - endovascular aneurysm repair
How does ruptured AAA present?
severe abdominal pain radiating to back or groin
haemodynamic instability - hypotension, tachycardia
pulsatile and expansive mass in the abdomen
collapse
loss of consciousness
What is the management for haemodynamically unstable patients with ruptured AAA?
taken to the theatre immediately
clinical diagnosis only - no imaging
lWhat is the management for frail patients with ruptured AAA?
consider palliative approach
What is the management for haemodynamically stable patients with ruptured AAA?
CT angiogram to confirm
then surgical repair
What are the risk factors for appendicitis?
male
in 20s
What is the typical pain in appendicitis?
central abdominal pain that moves to the R iliac fossa in the first 24hrs
then localised to the RIF
What is the McBurney’s point?
specific area one third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus
What is the typical presentation of appendicitis?
abdominal pain (central -> RIF)
loss of appetite
nausea and vomiting
low-grade fever
Rovsing’s sign
guarding on palpation
RIF rebound tenderness
percussion tenderness
What is Rovsing’s sign?
palpation of the left iliac fossa causes pain in the RIF
What are some signs of peritonitis?
rebound tenderness
percussion tenderness
guarding / rigid abdomen
How do you diagnose appendicitis?
clinical presentation
raised inflammatory markers - especially neutrophils!
What type of WBC is most typically raised in appendicitis?
neutrophils
What investigations are useful in appendicitis diagnosis?
bloods - esp. inflammatory markers (CRP, FBC)
ultrasound - esp. in females to exclude gynae pathology
CT - if suspecting other diagnoses
diagnostic laparotomy - if clinical presentation positive, findings negative
What are some key differentials of appendicitis?
ectopic pregnancy
ovarian cysts
Meckel’s diverticulum
mesenteric adenitis - inflammation of abdo. lymph nodes
What is the initial management of appendicitis?
analgesia
nil by mouth
IV fluids
What is the management of appendicitis?
appendicectomy (laparoscopic)
What is coeliac disease?
autoimmune condition caused by gluten sensitivity
What is the (basic) pathophysiology of coeliac disease?
sensitivity to gluten
repeated exposure leads to villous atrophy
this leads to malabsorption
What conditions are associated with coeliac?
dermatitis herpetiformis
other autoimmune conditions - T1DM, autoimmune thyroid disease
What are some possible presentations of coeliac?
asymptomatic
chronic / intermittent diarrhoea
persistent GI symptoms
bloating, abdo pain
fatigue
weight loss
mouth ulcers
failure to thrive (children)
unexplained anaemia - due to malabsorption of B12, iron, folate
dermatitis herpetiformis
neurological symptoms
How is coeliac diagnosed?
while patient continues to consume gluten (at least 6 weeks prior to testing)
blood tests - total IgA levels, anti-TTG antibodies
endoscopic intestinal biopsy - gold standard for diagnosis
What are the first-line blood tests for coeliac?
total IgA levels - to exclude IgA deficiency
anti-tissue transglutaminase antibodies (anti-TTG)
What is second-line blood test for coeliac?
anti-EMA (anti-endomysial antibodies_
Why do you need to check for IgA levels in suspected coeliac?
IgA deficiency would give a false negative result in coeliac
What is the gold standard for coeliac diagnosis?
endoscopic intestinal biopsy - duodenum, jejunum
What would a positive intestinal biopsy show in coeliac?
villous atrophy
crypt hyperplasia
increase in intra-epithelial lymphocytes
infiltration of lamina propria with lymphocytes
What are some possible complications of coeliac?
nutritional deficiencies
anaemia
osteoporosis
hyposplenism
EATL - enteropathy-associated T-cell lymphoma
subfertility
What HLA (human leukocyte antigen) genotypes is coeliac associated with?
HLA-DQ2
HLA-DQ8
What is necrotising enterocolitis?
disorder affecting premature neonates, where part of the bowel becomes necrotic
one of the leading causes of death among premature infants
What is a typical presentation of necrotising enterocolitis?
feeding intolerance
green vomiting
tender and distended abdomen
bloody stools
absent bowel sounds
can progress to peritonitis -> generally very unwell
How is necrotising enterocolitis diagnosed?
abdominal X ray - gold standard
FBC
CRP
capillary blood gas - metabolic acidosis
blood culture - sepsis
What will abdominal X ray show in necrotising enterocolitis?
dilated bowel loops
bowel wall oedema
pneumatosis intestinalis - gas in bowel wall
pneumoperitoneum - free gas in peritoneal cavitity
gas in portal veins
How is necrotising enterocolitis managed?
surgical emergency - surgery often required
nil by mouth, IV fluids, TPN, ATB
What is volvulus?
bowel twisting around itself and the mesentery it’s attached to (which provides the blood supply to the bowel)
causes closed loop bowel obstruction
What are the two main common types of volvulus?
sigmoid volvulus
caecal volvulus
What is a typical presentation of volvulus?
constipation
abdominal pain
abdominal distention
vomiting (green)
What are the risk factors for sigmoid volvulus?
older patients
chronic constipation
neuropsychiatric conditions (e.g. Parkinson’s)
What are the risk factors for caecal volvulus?
adhesions
pregnancy
How is sigmoid volvulus diagnosed? What is the typical sign?
abdominal X-ray - coffee bean sign (sigmoid volvulus)
CT with contrast - to confirm the diagnosis
How is volvulus managed INITIALLY?
nil by mouth, IV fluids, NG tube
What is the conservative management of sigmoid volvulus?
insertion of flexible / rigid sigmoidoscope to correct the volvulus + insertion of rectal tube (kept in place for a couple of days) to decompress the bowel
What are the options for surgical management of sigmoid volvulus?
laparotomy
Hartmann’s procedure - removal of rectosigmoid colon and formation of colostomy
How is caecal volvulus managed?
ileocaecal resection
right hemicolectomy
What are the key features of IBS?
I - intestinal discomfort - abdominal pain related to the bowels
B - bowel habit abnormalities
S - stool abnormalities
What are the main symptoms of IBS? (at least 1 required over 6 months before diagnosis)
pain/discomfort relieved by opening bowels
bowel habit abnormalities
stool abnormalities
What are some common symptoms of IBS? (require 2 out of 4 to diagnose)
passing mucus
bloating
straining, urgent need to open bowels, incomplete emptying
worse after eating
What tests can be performed when suspecting IBS?
FBC - for anaemia
CRP
coeliac serology - anti-TTG
faecal calprotectin - for IBD
CA125 - for ovarian cancer
What are the red flags that would suggest a more sinister diagnosis than IBS?
rectal bleeding
unexplained weight loss
family history of ovarian / bowel cancer
onset after 60+ y.o.
What are the key differentials in IBS?
bowel cancer
IBD
coeliac disease
ovarian cancer - can present with non-specific symptoms, esp. in 50+ y.o.
pancreatic cancer
What lifestyle management options are there for IBS?
drinking enough fluids
limiting caffeine, alcohol, fat intake
eating regular small meals
adjusting fibre intake based on symptoms
low FODMAP diet
regular exercise
psychological intervention
What is the first line pharmacological treatment for IBS?
pain: antispasmodics (mebeverine)
diarrhoea: loperamide
constipation: bulk-forming laxatives (ispaghula husk)
When is linaclotide considered in IBS?
if patient not responding to conventional laxatives
AND constipated for 12+months
What is the second line pharmacological treatment for IBS?
low-dose tricyclic antidepressants - e.g. amitriptyline
What are the foregut structures?
Oesophagus, stomach, Liver, biliary, pancreas and proximal duodenum
What are the midgut structures?
distal duodenum, jejunum, ileum, cecum, appendix, ascending colon, proximal 2/3 of transverse colon
What are the hindgut structures?
distal half of the transverse colon, descending colon, sigmoid colon, and the proximal third of the rectum
Where is referred pain from foregut structures perceived?
epigastric region
Where is referred pain from midgut structures perceived?
umbilical region
Where is referred pain from hindgut structures perceived?
suprapubic region
What does colicky pain that becomes constant suggest?
partial obstruction of a hollow viscus (e.g. bowel, bile duct, ureter)
What are the types of inguinal hernias?
Direct and indirect
What is a direct inguinal hernia?
leading area of weakness is the posterior wall of the inguinal canal, where viscera herniates anteriorly through Hesselbach’s triangle and not into scrotum
What is an indirect inguinal hernia?
the leading area of weakness is the deep inguinal ring where intra-peritoneal contents herniate into the inguinal canal alongside spermatic cord, and can exit the canal through the superficial inguinal ring and into the scrotum
What is a femoral hernia?
Below the inguinal ligament, inferior and lateral to the pubic tubercle
What is a reducible hernia?
The hernia can be manually pushed back (or ‘reduced’) into the abdominal cavity
What is an Irreducible hernia?
The hernia sac and its content cannot be pushed back into the abdomen
Whan is an incarcerated hernia?
The contents are fixed in the sac with adhesions. The hernia is irreducible but the organ within the sac is not compromised, but is at risk of strangulation
What is an obstructed hernia?
the bowel loop trapped within the sac causes bowel obstruction. With further oedema it can become strangulated
What are the criteria for urgent referral for colorectal cancer?
Any age with a rectal or abdominal mass
Age 40+ with unexplained weight loss and abdominal pain
Age 50+ with unexplained rectal bleeding
Age 60+ with iron deficiency anaemia
What are the possible causes of pancreatitis?
I GET SMASHED
I – Idiopathic
G – Gallstones
E – Ethanol (alcohol consumption)
T – Trauma
S – Steroids
M – Mumps
A – Autoimmune
S – Scorpion sting (the one everyone remembers)
H – Hyperlipidaemia, hypercalcaemia, hypothermia (like milk - fatty, full of calcium, and cold)
E – ERCP
D – Drugs (furosemide, thiazide diuretics and azathioprine)
What are the most common causes of pancreatitis?
alcohol
gallstones
post-ERCP
How does acute pancreatitis present?
severe epigastric pain (may radiate to the back)
vomiting
abdominal tenderness
generally unwell (low-grade fever, tachycardia)
What two signs are associated with acute pancreatitis?
Grey-Turner’s sign
Cullen’s sign
What is the Grey-Turner’s sign?
flank discolouration in acute pancreatitis
(Turner - “turn around” - flank)
What is Cullen’s sign?
periumbilical discolouration in acute pancreatitis
(Cullen - “central” - periumbilical)
What investigations are needed to calculate the Glasgow score in acute pancreatitis?
FBC (for white cell count)
U&E (for urea)
LFT (for transaminases and albumin)
Calcium
ABG (for PaO2 and blood glucose)
What is the Glasgow score for acute pancreatitis?
PANCREAS:
P – Pa02 < 8 KPa A – Age > 55 N – Neutrophils (WBC > 15) C – Calcium < 2 R – uRea >16 E – Enzymes (LDH > 600 or AST/ALT >200) A – Albumin < 32 S – Sugar (Glucose >10)
What investigations, other than the ones required for Glasgow score, do you need in acute pancreatitis?
amylase / lipase - if 3x the upper limit
CRP
USS abdomen - initial investigation of choice to assess for gallstones
CT abdomen - good to assess for complications; usually not required
How is acute pancreatitis staged, according to the Glasgow score?
0 or 1 – mild pancreatitis
2 – moderate pancreatitis
3 or more – severe pancreatitis
How is acute pancreatitis managed?
if moderate/severe - consider HDU/ICU admission
Initial resuscitation (ABCDE approach) IV fluids Analgesia Nutritional support (by mouth wherever possible, with parenteral nutrition if oral intake is not possible) Careful monitoring Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy) Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area) Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)
What are the possible complications of acute pancreatitis?
Necrosis of the pancreas
Infection in a necrotic area
Abscess formation
Acute peripancreatic fluid collections
Pseudocysts (collections of pancreatic juice) can develop 4 weeks after acute pancreatitis
Chronic pancreatitis
ARDS (acute respiratory distress syndrome) - systemic complication
What is chronic pancreatitis?
chronic inflammation of the pancreas
leads to fibrosis and reduced function
What is the most common cause of chronic pancreatitis?
alcohol
What are the features of chronic pancreatisis?
similar to acute, but longer-lasting and less intense
pain worse after a meal
diabetes
steatorrhoea - fatty stools
fat malabsorption
fat-soluble vitamin deficiency
What are the possible complications of acute pancreatitis?
Chronic epigastric pain
Loss of exocrine function, resulting in a lack of pancreatic enzymes (particularly lipase) secreted into the GI tract
Loss of endocrine function, resulting in a lack of insulin, leading to diabetes
Damage and strictures to the duct system, resulting in obstruction in the excretion of pancreatic juice and bile
Formation of pseudocysts or abscesses
How is chronic pancreatitis managed?
Abstinence from alcohol and smoking
Analgesia
Replacement pancreatic enzymes (Creon) - if loss of pancreatic enzymes (i.e. lipase)
lack of enzymes leads to malabsorption of fat, greasy stools (steatorrhoea), and deficiency in fat-soluble vitamins
Subcutaneous insulin - to treat diabetes
ERCP with stenting - to treat strictures and obstruction to the biliary system and pancreatic duct
How is chronic pancreatitis investigated?
abdominal x-ray - pancreatic calcification
CT - pancreatic calcification
functional tests - faecal elastase to assess exocrine function if imaging inconclusive
What is Charcot’s triad?
RUQ pain
Fever
Jaundice (raised bilirubin)
What is Charcot’s triad sign of?
acute cholangitis
What is acute cholangitis?
infection and inflammation in the bile ducts
it’s a surgical emergency
What are the main causes of acute cholangitis?
obstruction in the bile ducts (e.g. gallstones in the common bile duct)
infection introduced during ERCP
benign or malignant stricture
sclerosing cholangitis
What is sclerosing cholangitis?
chronic liver disease causing inflammation and scarring of bile ducts
What is Reynold’s pentad?
jaundice
RUQ pain
fever
hypotension
confusion
(Charcot’s triad + hypotension + confusion)
What are the most common infective organisms responsible for acute cholangitis?
Escherichia coli
Klebsiella species
Enterococcus species
How is acute cholangitis initially managed?
Nil by mouth
IV fluids
Blood cultures
IV antibiotics (as per local guidelines)
analgesia
Involvement of seniors and potentially HDU or ICU
How is acute cholangitis diagnosed?
Abdominal ultrasound scan (least sensitive) - first line imaging
CT scan
Magnetic resonance cholangio-pancreatography (MRCP)
Endoscopic ultrasound (most sensitive)
How is acute cholangitis managed?
ERCP (endoscopic retrograde cholangio-pancreatography)
PTC (percutaneous transhepatic cholangiogram) - for patients unsuitable for ERCP
What is ERCP?
Endoscopic retrograde cholangio-pancreatography
insertion of endoscope to the sphincter of Oddi
retrograde injection of contrast into the duct through the sphincter of Oddi and x-ray images to visualise biliary system
What procedures can be performed during an ERCP?
Cholangio-pancreatography: retrograde injection of contrast into the duct through the sphincter of Oddi and x-ray images to visualise biliary system
Sphincterotomy: making a cut in the sphincter to dilate it and allow stone removal
Stone removal: a basket can be inserted and pulled through the common bile duct to remove stones
Balloon dilatation: a balloon can be inserted and inflated to treat strictures
Biliary stenting: a stent can be inserted to maintain a patent bile duct (for strictures or tumours)
Biopsy: a small biopsy can be taken to diagnose obstructing lesions
What risks are associated with ERCP?
bleeding
acute pancreatitis
gastric / duodenal perforation
cholangitis
What is PTC?
Percutaneous transhepatic cholangiogram
radiologically guided insertion of a drain through the skin and liver, into the bile ducts to relieve immediate obstruction
stent can be inserted as a long-term solution
suitable for patient who are unsuitable for ERCP
What is cholecystitis?
inflammation of the gallbladder caused by a blockage of the cystic duct preventing the gallbladder from draining
What are the main types of acute cholecystitis?
calculous cholecystitis - secondary to gallstones
acalculous cholecystitis - after long period of fasting, TPN etc. (gallbladder not regularly stimulated)
How does acute cholecystitis typically present?
RUQ pain (may radiate to right shoulder)
nausea + vomiting
Fever
Tachycardia (fast heart rate) and tachypnoea (raised respiratory rate)
Murphy’s sign
Raised inflammatory markers and white blood cells
LFTs usually normal
What is Murphy’s sign?
sign of acute cholecystitis
inspiratory arrest upon palpation of the right upper quadrant
What imaging can be used to diagnose acute cholecystitis?
abdominal USS - first line imaging
MRCP (magnetic resonance cholangio-pancreatography)
What will abdominal USS show in acute cholecystitis?
Thickened gallbladder wall
Stones or sludge in gallbladder
Fluid around the gallbladder
What is the immediate (conservative) management of acute cholecystitis?
emergency admission
nil by mouth
analgesia
IV fluids
IV antibiotics
NG tube / antiemetics
What is the ultimate management for cholecystitis?
ERCP - to remove the stones
cholecystectomy - ideally within 1 week of diagnosis
What are some possible complications of cholecystitis?
sepsis
gallbladder empyema
gangrenous gallbladder
perforation
What is gallbladder empyema?
infected tissue and pus collecting in the gallbladder
How is gallbladder empyema treated?
IV antibiotics and
cholecystectomy OR
cholecystostomy - drain into the gallbladder to drain the infected contents
What are the risk factors for developing gallstones?
Fat
Fair
Forties
Female
What is biliary colic?
severe pain in RUQ/epigastrium caused by stones temporarily obstructing the drainage of the gallbladder
often triggered by eating
How do patients with gallstones typically present?
asymptomatic
biliary colic
complications of gallstones (cholecystitis, cholangitis, pancreatitis, obstructive jaundice)
What causes elevated bilirubin?
obstruction in the biliary system
may be caused by
- gallstone in the bile duct
- mass pressing on the bile ducts (e.g. cholangicarcinoma, head of pancreas tumour)
What can raised alkaline phosphatase (ALP) suggest?
liver / bone problems (incl. malignancy)
pregnancy
biliary obstruction (if RUQ pain/jaundice as well)
What is the first-line imaging when you suspect gallstones?
USS abdomen
What can raised alanine aminotransferase (ALT) and aspartate aminotransferase (AST) suggest?
obstructive picture - slightly raised ALT and AST in patients with cholestasis
hepatic picture - if AST and ALT significantly higher compared to ALP -> suggests hepatocellular injury
What diameter should the bile duct normally be?
less than 6mm
What is MRCP and what is it used for?
MRI for the biliary system
useful for biliary tree disease
How are asymptomatic gallstones managed?
conservatively
How are symptomatic gallstones managed?
cholecystectomy
What are some possible complications of cholecystectomy?
bleeding
infection
damage to bile duct
damage to bowel and other organs
VTE
post-cholecystectomy syndrome
What is post-cholecystectomy syndrome?
non-specific symptoms after a cholecystectomy
diarrhoea
indigestion
epigastric / RUQ pain
nausea
intolerance of fatty foods
flatulence
What are some presenting features of colorectal cancer?
change in bowel habits - usually more loose and frequent
rectal bleeding - bright red/melena
abdominal pain/discomfort
unexplained weight loss
iron deficiency anaemia - microcytic, low ferritin -> SoB, fatigue
bowel obstruction - if tumour obstructs the lumen -> severe pain, nausea, vomiting
rectal/abdominal mass on examination
What are some risk factors for colorectal cancer?
FH of bowel cancer
FAP - familial adenomatous polyposis
HNPCC (Lynch syndrome) - hereditary nonpolyposis colorectal cancer
IBD
higher age
diet low in fibre and high in red/processed meat
obesity, sedentery lifestyle
smoking
alcohol
What is FAP (familial adenomatous polyposis)?
autosomal dominant condition
mutation of tumour suppressor gene APC (adenomatous polyposis coli gene)
formation of hundreds of polyps by 30-40 y.o.
usually become cancerous by 40 y.o.
prophylactic panproctocolectomy
What is HNPCC / Lynch syndrome?
hereditary non-polyposis colorectal cancer
autosomal dominant
most common form of inherited colorectal cancer
mutations in DNA mismatch repair genes MLH1/MLH2
tumours in proximal colon, poorly differentiated and aggressive
What is FIT test?
faecal immunochemical test - type of faecal occult blood test which uses antibodies that specifically recognise human Hb
When is FIT test offered to patients?
as a part of bowel cancer screening programme:
- every 2 years from 60-74 y.o.
- if abnormal - colonoscopy
test in GP for patients who do not meet the criteria for 2 week referral (e.g. only change in bowel habit, only weight loss etc.)
What are some criteria for the 2-week wait referral for colonoscopy?
positive FIT test and
- abdominal mass
- change in bowel habits
- iron-deficiency anaemia
- 40+ and unexplained weight loss and abdo pain
- <50 with rectal bleeding and abdo pain/weight loss
- 50+ and rectal bleeding/abdo pain/weight loss
- 60+ and anaemia
How is bowel cancer investigated?
colonoscopy / sigmoidoscopy
CT colonography - CT scan with bowel prep and contrast; if patient not fit for colonoscopy
staging CT scan - CT TAP
carcinoembryonic antigen (CEA) - tumour marker
How is tumour invasiveness staged?
T1 - submucosa involvement
T2 - involvement of muscularis propria
T3 - involvement of subserosa and serosa
T4 - spread through the serosa
What surgical procedures are performed in bowel cancer?
right hemicolectomy
left hemicolectomy
high anterior resection
low anterior resection
abdomino-perineal resection
Hartmann’s procedure
What is right hemicolectomy?
removal of caecum, ascending colon, proximal transverse colon
What is left hemicolectomy?
removal of distal transverse and descending colon
What is high anterior resection?
removal of sigmoid colon
What is low anterior resection?
removal of sigmoid colon and upper rectum
What is abdomino-perineal resection?
removal of rectum and anus -> permanent colostomy
What is Hartmann’s procedure?
usually emergency procedure
removal of rectosigmoid colon (rectal stump sutured closed)
can be reversed
What is low anterior resection syndrome?
after low anterior resection
urgency and frequency of bowel movements
faecal incontinence
difficulty controlling flatulence
What treatments (other than surgery) can be used in bowel cancer?
radiation therapy
chemotherapy
targeted therapies - e.g. bevacizumab, cetuximab
What is constipation?
infrequent stools (<3x per week)
difficult stool passage (straining, discomfort)
incomplete defecation
How is constipation managed?
investigate and exclude any secondary causes, red flag symptoms
exclude faecal impaction (faeces stuck in the rectum)
lifestyle advice - increase fibre, ensure adequate liquid intake, ensure adequate activity levels
laxatives
- first-line: bulk-forming laxatives - e.g. ispaghula husk
- second-line: osmotic laxatives - e.g. macrogol
What are the possible complications of constipation?
overflow diarrhoea
acute urinary retention
haemorrhoids
What are red flag symptoms in constipation?
neurological signs and symptoms, esp. in LL (spinal cord lesion)
vomiting (obstruction)
ribbon stool (anal stenosis)
abnormal anus (anal stenosis, IBD)
abnormal lower back, buttocks (spina bifida, spinal cord lesions)
acute severe abdominal pain and bloating (obstruction)
What are diverticula?
blood vessels supplying the colon penetrate the circular muscle of the colon - areas of weakness
if increased pressure - gaps form in these areas of circular muscle
mucosa herniates through these gaps - formation of pouches (diverticula)
they do NOT form in the rectum
What are the symptoms of diverticular disease?
altered bowel habit
rectal bleeding
abdominal pain
What are some complications of diverticular disease?
diverticulitis - inflammation of diverticula
haemorrhage
formation of fistula
perforation + faecal peritonitis
perforation + formation of abscess
development of diverticular phlegmon
How is diverticular disease diagnosed?
colonoscopy / CT cologram / barium enema
How is diverticulitis classified based on the severity?
Hinchey severity classification:
1 - para-colonic abscess
2 - pelvic abscess
3 - purulent peritonitis
4 - faecal peritonitis
How is diverticular disease treated?
increase fibre intake
ATB - if mild diverticulitis
if more severe - draining of abscess / segmental resection
What is diarrhoea?
3+ loose/watery stools per day
acute diarrhoea < 14 days
Persistent diarrhoea 2-4 weeks
chronic diarrhoea > 4 weeks
What are the common causes of acute diarrhoea?
gastroenteritis - abdo pain, nausea, vomiting
diverticulitis - LQ pain, fever
ATB therapy - more common in broad spectrum ATBs
constipation causing overflow - alternating diarrhoea and constipation
Medications - laxative overuse, metformin (esp. at the start of the treatment)
What are the common causes of chronic diarrhoea?
IBS - abdo pain, bloating, change in bowel habit, fatigue
ulcerative colitis - bloody diarrhoea, cramping abdo pain, weight loss, faecal urgency, tenesmus
Crohn’s - cramping abdo pain, mouth ulcers, obstruction
colorectal cancer - rectal bleeding, anaemia, constitutional symptoms
coeliac - lethargy, anaemia, weigh loss
How is diarrhoea investigated?
stool sample if
- patient systemically unwell and needs ATB / hospital admission
- blood / pus in stool
- immunocompromised
- recent ATB, PPI, hospital admission
- recent foreign travel
- public health indication
bloods - not routinely done
- AKI, hypokalaemia, hyponatraemia if severe
What are the features of small bowel obstruction?
vomiting first, then constipation
diffuse central abdominal pain
N+V (typically bilious vomiting)
constipation
lack of flatulence
abdominal distention
tinkling bowel sounds
focal tenderness, guarding, rebound tenderness
How is small bowel obstruction investigated?
abdo XR - distended small bowel loops (>3cm in diameter) with fluid levels
CT with contrast - definitive investigation
How is small bowel obstruction managed?
NBM
IV fluids
nasogastric tube with free drainage
surgery
What are the most common mechanical causes of small bowel obstruction?
- extramural - adhesions, hernias, neoplasm
- mural - inflammatory strictures, Meckel’s diverticulum
- intraluminal - gallstone ileus, ingested foreign body
What are the most common mechanical causes of large bowel obstruction?
extramural - diverticular disease, volvulus
mural - colorectal adenocarcinoma
intraluminal - faecal impaction
What are the clinical features of large bowel obstruction?
constipation first, then vomiting
absence of passing flatus / stool
abdominal pain
abdominal distention
nausea and vomiting (feculent)
peritonism (if also perforation)
How is large bowel perforation investigated?
abdo XR
CT with contrast
How is large bowel perforation managed?
NBM
IV fluids
nasogastric tube with free drainage
surgery - if symptoms after 72hrs of conservative management
IV ATB - if perforation / surgery
What are the 3 main categories of bowel ischaemia?
acute mesenteric ischaemia
chronic mesenteric ischaemia
ischaemic colitis
What are the typical features of bowel ischaemia?
abdominal pain - often sudden onset, severe
rectal bleeding
diarrhoea
fever
elevated WBC - lactic acidosis
How is bowel ischaemia investigated?
CT
What is acute mesenteric ischaemia?
typically caused by an embolism -> occlusion of artery supplying the small bowel
typically Hx of AF
sudden onset severe pain
How is acute mesenteric ischaemia managed?
urgent surgery
poor prognosis tho
What is ischaemic colitis?
acute but transient compromise in blood flow to the colon
may lead to ulceration, inflammation, haemorrhage
more likely to occur in “watershed” areas - e.g. splenic flexure
How is ischaemic colitis investigated?
abdo XR - thumbprinting (due to mucosal oedema/haemorrhage)
How is ischaemic colitis managed?
supportive management
surgery - if conservative management fails or generalised peritonitis / perforation / ongoing haemorrhage
What is chronic mesenteric ischaemia?
“intestinal angina”
narrowing of mesenteric arteries by atherosclerosis
intermittent abdominal pain
What is the classical presentation of chronic mesenteric ischaemia?
central colicky abdominal pain after eating
weight loss (due to food avoidance -> pain)
abdominal bruit
What are the risk factors for chronic mesenteric ischaemia?
higher age
FH
smoking
diabetes
high cholesterol
HTN
How is chronic mesenteric ischaemia diagnosed?
CT angiography
How is chronic mesenteric ischaemia managed?
reduce modifiable risk factors
secondary prevention (statins, antiplatelets)
revascularisation (e.g. percutaneous mesenteric artery stenting, open surgery like bypass grafting)
What are the most common causative organisms of gastroenteritis?
viruses:
rotavirus
norovirus
adenovirus (also causes respiratory symptoms)
What signs on general inspection can a patient with colorectal cancer have?
pallor
cachexia
koilonychia
What are the features of haemorrhoids?
painless rectal bleeding
pruritus - itch
pain
soiling
What are the two main types of haemorrhoids?
internal - above dentate line, do not cause pain
external - below dentate line, prone to thrombosis, may be painful
How are internal haemorrhoids graded?
grade 1 - do not prolapse out of the anal canal
grade 2 - prolapse on defecation, reduce spontaneously
grade 3 - can be manually reduced
grade 4 - cannot be manually reduced
How are haemorrhoids managed?
stool softening - increase fibre and fluid intake
topical local anaesthetics and steroids
rubber band ligation
What will DRE show in mechanical bowel obstruction?
collapsed rectum
What will DRE show in functional bowel obstruction?
distended rectum
What does neoadjuvant chemotherapy mean?
chemotherapy started before surgery to shrink the tumour
When do you give ATBs in gastroenteritis?
if high risk:
- elderly
- immunocompromised
- systemically unwell
What is the most common cause of bacterial gastroenteritis?
campylobacter
- bloody diarrhoea
-
How does gastroenteritis typically present?
N+V
(bloody) diarrhoea
dehydration
abdominal pain
What are the features of bacterial gastroenteritis?
bloody diarrhoea
little vomiting
fever
abdominal pain
What are the features of viral gastroenteritis?
watery diarrhoea
vomiting
can have fever
can have abdo pain
What is Peutz-Jeghers syndrome?
autosomal dominant
numerous hamartomatous polyps in GI tract
pigmented freckles on lips, face, palms, soles
often small bowel obstruction
conservative management
How is bowel obstruction initially managed?
Nil-by-mouth (NBM)
IV fluids & correct electrolyte disturbances (‘drip’)
Nasogastric tube (NG tube) to decompress the bowel (‘suck’) and prevent aspiration
Urinary catheter for fluid balance
Analgesia as required with suitable anti-emetics
VTE prophylaxis (high risk of DVT given cancer diagnosis)
Antibiotics
