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Year 3 - Surgery > General Surgery - SBO + LBO > Flashcards

General Surgery - SBO + LBO Flashcards

1
Q

What is a hernia?

A

The protrusion of a viscus or part of a viscus through a defect of the walls of its containing cavity into an abnormal position

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2
Q

What is the difference between irreducible, obstructed, strangulated and incarcerated hernias?

A
  • Irreducible: contents cannot be pushed back into place
  • Obstructed: bowel contents cannot pass—features of intestinal obstruction
  • Strangulated: ischaemia occurs—the patient requires urgent surgery.
  • Incarceration: contents of the hernial sac are stuck inside by adhesions.
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3
Q

What is the difference between the indirect and direct hernias?

A
  • Direct inguinal hernia (20%)
    • Bowel enters the inguinal canal “directly” through a weakness in the posterior wall of the canal - Hesselbach’s triangle
    • More common in older patients, often secondary to abdominal wall laxity or a significant increase in intra-abdominal pressure
    • Medial to the inferior epigastric vessels.
  • Indirect inguinal hernia (80%)
    • Bowel enters the inguinal canal via the deep inguinal ring
    • Arise from incomplete closure of the processus vaginalis, an outpouching of peritoneum allowing for embryonic testicular descent (so are seemed to be congenital in origin) - hence more common in children
    • Lateral to the inferior epigastric vessels

NB: These two types of inguinal hernia can only be reliably differentiated at the time of surgery re relation to vessels

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4
Q

Which of the two are more dangerous?

A
  • Direct - less common. Reduce easily and rarely strangulate
  • Indirect - More common. Can strangulate
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5
Q

What are the risk factors for developing hernias?

A
  • Male
  • Increasing age
  • Raised intra-abdominal pressure (Chronic cough, heavy lifting, or chronic constipation)
  • Chronic
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6
Q

What makes up the floor, roof, anterior and posterior walls of the inguinal canal?

A
  • Floor: Inguinal ligament and lacunar ligament medially
  • Roof: Fibres of transversalis, internal oblique
  • Anterior: External oblique aponeurosis + internal oblique
  • Posterior: Laterally, transversalis fascia; medially, conjoint tendon.
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7
Q

What are the clinical features of hernia?

A
  • Lump in the groin - if reducible hernia will initially disappear with minimal pressure or when the patient lies down.
  • If incarcerated - painful, tender, and erythematous.
  • ? Clinical features of bowel obstruction - if the bowel lumen blocked
  • ? Features of strangulation* if the blood supply becomes compromised.
  • If lump visible - ask pt to reduce it
  • Cough impulse - Remember that an irreducible hernia may not have a cough impulse
  • ? Reducible – On lying down +/- minimal pressure
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8
Q

What position do we expect to see inguinal hernias?

A
  • Inguinal (superomedial to the pubic tubercle)
  • Femoral (inferolateral to the pubic tubercle)
  • This is not always clear on examination
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9
Q

How would you differentiate between an indirect and direct hernia on examination?

A
  • Reduce hernia and occlude the deep (internal) ring (midpoint of inguinal ligament) with two fingers.
  • Ask the patient to cough or stand
  • If the hernia is restrained, it is indirect; if not, it is direct.
  • Above is often unreliable. Gold standard: in surgery with relation to epigastric vessels
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10
Q

How are hernias managed?

A

Surgery

  • If symptomatic, offer surgery
  • Risk of strangulation would require urgent surgical intervention
  • Open repair - Lichtenstein technique most commonly used or
    • Open mesh repairs - a polypropylene mesh reinforces the posterior wall - prevents reoccurence
    • Preferred for those with primary inguinal hernias
  • Laparoscopic approach
    • Total extraperitoneal (TEP)
    • Transabdominal pre-peritoneal (TAPP)).
    • Preferred* in those with bilateral or recurrent inguinal hernias.
    • Also for certain pt with a primary unilateral hernia - at a high risk of chronic pain (young and active, previous chronic pain, or with a predominant symptom of pain)
    • Females (due to the increased risk of the presence of a femoral hernia).
  • Post surgical: Rest for 4wks and convalescence over 8wks with open approaches, but laparoscopic repairs may allow return to manual work (and driving) after ≤2wks if all is well
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11
Q

When are femoral hernias more common?

A
  • More common in women than men (ratio 3:1), because of the wider anatomy of the female bony pelvis
  • Middle age
  • Elderly
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12
Q

How are femoral hernias repaired?

A
  • Surgical repair is recommended.
  • Herniotomy is ligation and excision of the sac
  • Herniorrhaphy is repair of the hernial defect.
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13
Q

What is the location of the femoral hernia?

A

Found infero-lateral to the pubic tubercle (and medial to the femoral pulse)

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14
Q

How should femoral hernias be managed?

A

Surgically, ideally within 2 weeks of presentation, due to the high risk of strangulation.

  1. Low approach – the incision is made below the inguinal ligament, which has the advantage of not interfering with the inguinal structures but does result in limited space for the removal of any compromised small bowel
  2. High approach – the incision is made above the inguinal ligament is the preferred technique in an emergency intervention due to the easy access to compromised small bowel

The operation involves reducing the hernia and then narrowing the femoral ring with sutures medially between the pectineal and inguinal ligaments or with a mesh plug .

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15
Q

What are the serious complications of hernias that require intervention?

A
  • Strangulated - compression of hernia has blood supply is compromised, resulting in the bowel becoming ischaemic
  • Irreducible - the contents of the hernia are unable to return to their original cavity
  • Obstructed - the bowel lumen has become obstructed, leading to the clinical features of bowel obstruction
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16
Q

How is diarrhoea clasified?

A
  • Diarrhoea: 3 or more loose stools or stools with increased liquid per day (as defined by the WHO)
  • Acute diarrhoea: < 14 days
  • Chronic diarrhoea: > 14 days
  • Dysentery: Gastroenteritis characterised by loose stools with blood and mucus
  • Travellers’ diarrhoea: More than 3 loose stools commencing within 24 hours of foreign travel, with or without cramps, nausea, fever, or vomiting
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17
Q

What are the clinical fx of gastroenteritis?

A
  • Cramp-like abdominal pain
  • Diarrhoea (with or without blood or mucus)
  • Associated vomiting
  • Night sweats
  • Weight loss
  • On examination, the patient will often be dehydrated (of varying severity) with potential pyrexia.
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18
Q

What are some of the viral and bacterial causes of gastroenteritis?

A
  • Viral: adenovirus, norovirus, adenovirus
  • Bacteria (all are gram -ve bacillus)
    • Campylobacter - the most common cause of food poisoning
    • E. Coli – Gram -ve bacillus, typically transmitted through contaminated foodstuffs.
      • Enterotoxigenic E. coli (ETEC) is the most common cause of Travellers’ diarrhoea
    • Salmonella – Gram -ve flagellated bacillus (two serotypes most commonly associated with gastroenteritis, S. typhimurium and S. enteritidis), transmitted through undercooked poultry or raw eggs; results in fever, vomiting, abdominal cramps, and bloody diarrhoea
    • Shigella – Gram -ve bacillus, from contaminated dairy products and water; presents with fever, abdominal pain, or bloody diarrhoea
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19
Q

What is more likely to be the causative organism of travellers diarrhoa and can you provide any examples?

A
  • Parasites: Cryptosporidium, Entamoeba histolytica, Giardia intestinalis, Schistosoma
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20
Q

What is the main pathogen for hospital acquired gastroenteritis?

How does this happen?

A
  • C. difficile, a Gram positive organism
  • Develops following the use of broad-spectrum antibiotics, disrupting the normal microbiota of the bowel
  • C. difficile bacteria excessively overgrows and then produces large amounts of exotoxins A & B
  • Exotoxins A+B -> inflammatory exudate on the colonic mucosa -> severe bloody diarrhoea, which can turn into toxic megacolon
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21
Q

How do you investigate and treat C.Diff?

A
  • Investigation: stool culture and C. difficile Toxin (CDT) testing*.
  • Treatment: IV fluid rehydration and oral metronidazole; Vancomycin - severe disease or if no improvement is seen after 72 hours.
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22
Q

What is angiodysplasia?

A
  • Most common vascular abnormality of the gastrointestinal tract
  • It is caused by the formation of arteriovenous malformations between previously healthy blood vessels, most commonly in the caecum and ascending colon.
  • Second commonest cause of rectal bleeding in those >60yrs; it is the most common cause for bleeding from the small bowel.
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23
Q

How does angiodysplasia present?

A
  • rectal bleeding and anaemia.
  • Assymptomatic
  • Painless occult PR bleeding (majority of case)
  • Acute haemorrhage
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24
Q

How would you investigate angiodysplasia?

A
  • Blood tests: FBC*, U&Es, LFTs, and clotting. Group and Save or Crossmatch (if need for transfusion), haematinics (iron deficiency anaemia)
  • Imaging:
    • Exclude any malignancy - OGD/ colonoscopy/ FOB (depending on the suspected site of bleeding)
    • Wireless capsule endoscopy: for small bowel bleeds
    • Mesenteric angiography - to confirm location of a lesion in order to plan for intervention as necessary.
    • Angiography + radionuclide scanning, CT scanning, or MRI scanning to image the GI tract vascular supply after the injection of a radio-opaque contrast agent into the vessels.
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25
Q

How do you manage angiodysplasia?

A
  • Conservative: bed-rest and IV fluid support, tranexamic acid
  • Medical:
    • Endoscopy: argon plasma coagulation - treat bleeding vessel with electrical current
    • Other endoscopic techniques: monopolar electrocautery, laser photoablation, sclerotherapy, and band ligation.
  • Mesenteric angiography
    • Used for small bowel lesions that cannot be treated endoscopically.
    • Contrast dye is used to identify the bleeding vessel then super-selective catheterisation and embolization of it
  • Surgical: bowel resection and anastomoses of an affected section
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26
Q

How does acute appendicitis present?

A
  • Classically periumbilical pain that moves to the rif.
  • Pain over McBurneys point
  • Tachycardia
  • Fever
  • Peritonism with guarding and rebound or percussion tenderness in RIF
  • Lying still + shallow breathing
  • Pain on right during PR examination suggests an inflammed, low-lying pelvic appendix.
  • Anorexia!
  • Constipation
  • Possible diarrhoea
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27
Q

What three specific tests (on examination) suggest appendicitis?

A
  • Rovsing’s sign (pain > in rif than lif when the 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 in close relation to obturator internus).
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28
Q

What investigations should you perform for acute appendicitis?

A
  • Bedside: urine dipstick, pregnancy test
  • Blood tests: FBC: neutrophil leucocytosis, UE, CRP (elevated)
  • 1st line imaging: USS
  • 2nd line: CT
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29
Q

What risk stratification scores are used for appendicitis?

A
  • Men – Appendicitis Inflammatory Response Score
  • Women – Adult Appendicitis Score
  • Children – Shera score
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30
Q

How do you manage appendicitis?

A
  • Laparoscopic appendicectomy
    • Appendix should be sent to histopathology
  • ABx: Piperacillin/tazobactam 4.5g/8h, 1-3 doses iv starting 1h pre-op, reduces wound infections. Give a longer course if perforated
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31
Q

What are some of the complications of appendicitis?

A
  • Perforation - e.g. if a faecolith is present and in young children (delayed dx)
  • Appendix mass - may result when an inflamed appendix becomes covered with omentum.
  • Appendix abscess
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32
Q

What are the predisposing factors for colorectal carcinoma?

A

Neoplastic polyps ; IBD; genetic predisposition (<8%), eg FAP and HNPCC, diet (low-fibre; ↑red and processed meat); ↑alcohol; smoking; previous cancer.

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33
Q

How does colorectal carcinoma present?

A

Depends on site:

  • Left-sided: Bleeding/mucus pr; altered bowel habit or obstruction (25%); tenesmus; mass PR (60%).
  • Right: ↓Weight; ↓Hb; abdominal pain; obstruction less likely.
  • Either: Abdominal mass; perforation; haemorrhage; fistula.
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34
Q

How is colorectal carcinoma investigated?

A
  • Bloods: FBC (microcytic anaemia); faecal occult blood; UE, LFT, CEA
  • Imaging:
    • Gold standard: colonoscopy with biopsy
    • Otherwise: flexible sigmoidoscopy orCT colonography
    • Metastases: CT staging (chest abdo pelvis), liver MRI/US, MRI rectum (for rectal cancer), endo-anal ultrasound
  • If family history of FAP, refer for dna test once >15yrs old.
35
Q

What classification is used for the staging of colorectal cancer?

A

TNM is now preferred to the older Dukes’ classification

36
Q

Who is colorectal cancer screening offered in the UK?

A
  • Screening is offered every 2 years to men and women aged 60-74 years.
  • >74 - make own appointments
  • Faecal immunochemistry test (FIT) is used - utilises antibodies against human haemoglobin to detect blood in faeces.
  • If +ve - further investigation via colonoscopy

Since its introduction in 2006, the NHS Bowel Cancer Screening Programme has increased detection of colorectal cancer in people aged 60-69 by 11%.

37
Q

Where can colorectal cancer spread to?

A

Local, lymphatic, by blood (liver, lung, bone) or transcoelomic

38
Q

What is the NICE criteria for urgent investigation (2WW) of suspected bowel cancer

A
  • ≥40yrs with unexplained weight loss and abdominal pain
  • ≥50yrs with unexplained rectal bleeding
  • ≥60yrs with iron‑deficiency anaemia or change in bowel habit
  • Positive occult blood screening test
  • Adults with rectal or abdominal mass

2WW for <50 yo with rectal bleeding and any of the following:

  • Abdominal pain
  • Change in bowel habit
  • Weight loss
  • Iron-deficiency anaemia

*As opposed to upper GI malignancies, progressive weight loss is usually only present in colorectal cancer cases with associated metastasis (or rarely in sub-acute bowel obstruction)

39
Q

What is an ileostomy and when is it used?

A
  • RIF: Protrude from skin and emit frequent fluid motions which contain active enzymes (protect skin!)
  • Used to relieve distal obstruction or protect distal anastomoses
    • Loop ileostomies: temporary measure eg during control of difficult perianal Crohn’s disease
    • End ileostomy: after total or subtotal -colectomy for UC : formation of ileal pouch-anal anastomosis
40
Q

What are urostomies?

A

Bring urine from ureter to the abdominal wall via ileal conduit that is usually incontinent

41
Q

What are the early and late complications of stomas?

A
  • Early: haemorrhage, ischaemia, high output (hypokalaemia), obstruction secondary to adhesions, stoma retraction
  • Late: obstruction, dermatitis, stoma prolapse, intussuception, stenosis, parastomal hernia, fistulae, physiological problems
42
Q

When are permanent end or temporary end colostomies used?

A
  • Permanent:
    • For abdominoperineal resection of large rectal cancers leading to the removal of the entire rectum.
  • Temporary:
    • Rest the bowel such as in the case of diverticulitis or obstruction.
    • As part of a two-stage Hartmann’s procedure, the rectum and bowel will be re-anastomosed at a later date.
43
Q

What are some alternatives to colostomies?

A
  • Low ultra low anterior resection: all or part of the rectum is excised and the proximal colon anastomosed to the top of the anal canal
  • Ileoanal pouch formation: colon and rectum are removed and a pouch of the ileum is joint to the upper anal canal
  • Transanal endoscopic microsurgery: allows excision of small tumours within rectum.
44
Q

What are the different types of colostomies used?

A

Temporary or permanent

  1. Loop colostomy: Usually performed to protect distal anastomoses after recent surgery.

A loop of bowel will be brought to the surface and half-opened, this allows the faecal matter to drain into the stoma bag without reaching the distal anastomoses.

  1. End colostomy
    • Resected - AP resection
    • Closed and left - Hartmans
    • Exteriorized - to form a mucous fistula
  2. Paul-mikulicz: A double-barrelled colostomy in which the colon is divided completely. Each end is exteriorized as two separate stomas.​
45
Q

What is a defunctioning stoma?

A

.e.g. loop colostomy or ileostomy

Used to relieve distal obstruction or protect distal anastomoses

46
Q

When are Temporary vs Permanent End-ileostomy bags created?

A

Permanent ileostomies are typically created after a panproctocolectomy for ulcerative colitis or familial adenomatous polyposis.

A temporary end-ileostomy is typically created during emergency bowel resection where it is considered unsafe to form an anastomosis with the remaining bowel at that time (e.g. intra-abdominal sepsis or bleeding).

47
Q

What are the surgical methods of management of colorectal carcinoma? Which position are they?

A

Elective colectomies often laparoscopic: faster recovery times, reduced surgical site infection risk, and reduced post-operative pain.

  • Right hemicolectomy - caecal, ascending, or proximal transverse colon tumours.
    • Removes: ileocolic, right colic, and right branch of the middle colic vessels (branches SMA) are divided and removed with their mesenteries
  • Left hemicolectomy - tumours in distal transverse or descending colon.
    • Removes: the left branch of the middle colic vessels (branch of SMA/SMV), the IMV and the left colic vessels (branches of the IMA/IMV)
  • Sigmoid colectomy - sigmoid tumours.
    • IMA is fully dissected out
  • Anterior resection - low sigmoid or high rectal tumours typically if >5cm from the anus.
    • Leaves rectal sphincter in tact if anastomoses is performed
    • Temporary loop ileostomy: to protect the anastomosis and reduce complications in event of anastomotic leak. This can be reversed electively four to six months later
  • Abdomino-perineal (AP) - Low rectal tumours
    • Permanent colostomy
    • (≲8cm from anus): excision of the distal colon, rectum and anal sphincters
  • Transanal endoscopic microsurgery - allows local excision through a wide proctoscope for localized rectal disease.
48
Q

What is a Hartman’s procedure?

A
  • Used in emergency bowel surgery, such as bowel obstruction or perforation.
  • This involves a complete resection of the recto-sigmoid colon with the formation of an end colostomy and the closure of the rectal stump
49
Q

When is radio and chemo therapy used for colorectal carcinoma? What is used?

A

Chemotherapy

  • For pt with advanced disease - Dukes’ C
  • FOLFOX: Folinic acid, Fluorouracil (5-FU), and Oxaliplatin
  • Biologics: Bevacizumab, cetuximab and panitumumab (anti-egfr agents) improve response rate

Radiotherapy

  • Rectal cancer (it is rarely given in colon cancer due to the risk of damage to the small bowel)
  • Use in patients with rectal cancers which look on MRI to have a “threatened” circumferential resection (i.e. within 1mm).
  • They can undergo pre-operative long-course chemo-radiotherapy to shrink the tumour
50
Q

What palliative options are used for those with advanced colorectal cancer?

A
  • Endoluminal stenting - relieve acute bowel obstruction in patients with left-sided tumours
  • Stoma formation - acute obstruction
  • Resection of secondary mets - + adjuvant chemotherapy for any liver mets
51
Q

What is diverticular disease?

A
  • A diverticulum is an outpouching of the bowel wall.
  • They are most commonly found in the sigmoid colon, but can be present throughout the large and small bowel.
  • Bacteria can grow in the outpouchings -> inflammation of the diverticulum (diverticulitis) which can sometimes perforate
52
Q

How do diverticulum, diverticulosis and diverticulitis differ?

A
  • Diverticulosis – the presence of diverticula (asymptomatic, incidental on imaging)
  • Diverticular disease – symptoms arising from the diverticula
  • Diverticulitis – inflammation of the diverticula
  • Diverticular bleed – where the diverticulum erodes into a vessel and causes a large volume painless bleed
53
Q

How does diverticulitis arise?

A

Low fibre -> High intraluminal pressures -> force the mucosa to herniate through the muscle layers of the gut at weak points adjacent to penetrating vessels.

54
Q

How does diverticular disease + diverticulitis present?

A
  • Intermittent abdominal pain - LLQ
  • Altered bowel habit ± left-sided colic relieved by defecation; nausea and flatulence.
  • Tenderness LLQ on abdominal examination.

Diverticulitis

  • All of the above
    • pyrexia, ↑wcc, ↑crp/esr, a tender colon ± localized or generalized peritonism
55
Q

How is diverticular disease/ diverticulitis investigated?

A
  • Bedside: urine dipstick (rule out urological causes)
  • Bloods: FBC, UE, CRP, LFT, faecal calprotectin (if uncertain)
  • Acute diverticulitis
    • Gold standard: CT abdo pelvis - thickening of bowel wall, mass, abscess, streaky mesenteric fat; may show gas in the bladder in cases of fistula
    • 2nd: Abdo USS (if CT not possible)
    • Abdo X ray; contrast enema
    • Angiogram - can be used for acute bleeds
  • If divertulosis: can use colonoscopy, flexible sigmoidoscopy
56
Q

How is diverticulitis managed?

A

Diverticular disease:

  • High-fibre diets do not help symptoms
  • Try antispasmodics, eg mebeverine 135mg/8h po.
  • Simple analgesia (paracetemol) and encouraging oral fluid intake. Outpatient colonoscopy
  • Diverticular bleeds
    • ​Can be managed conservatively
    • Any significant bleeding will need appropriate resuscitation, including the use of blood products, and stabilisation.

Acute Diverticulitis

  • Conversative initially: antibiotics, IV, and analgesia.
    • Young pt: uncomplicated diverticulitis can be considered for ambulatory management,
    • Sx should improve 2-3 days
    • If fluids and pain not tolerated: admit for analgesia, NBM, IV fluids and IV abx.
  • Ix: CT abdo pelvis + contrast- gold standard
  • If abscesses: drain via percutanoeus CT guided drainage
  • Surgery: perforation with faecal peritonitis or overwhelming sepsis
    • ​Hartmann’s procedure: sigmoid colectomy with formation of an end colostomy
    • Anastomosis with reversal of colostomy
    • Elective resection: after an acute episode ONLY if there is stenosis, fistulae or recurrent bleeding
57
Q

What staging is used for diverticular disease ?

A

Hinchey Classification

58
Q

What are the indications for elective surgery for diverticular disease?

A

Stenosis, fistulae, or recurrent bleeding

59
Q

What are the complications of diverticular disease? How can these be managed?

A
  • Perforation: ileus, peritonitis ± shock. Mortality: 40% Manage as for an acute abdomen.
  • Haemorrhage: Embolization (at angiography) or colonic resection only if massive bleeding and colonoscopic haemostasis has been unsuccessful.
  • Fistulae: Enterocolic, colovaginal, or colovesical
    • Treatment is surgical, eg colonic resection.
  • Abscesses: swinging fever, leucocytosis, and localizing signs, eg boggy rectal mass (pelvic abscess—drain rectally).
    • If no localizing signs, remember the aphorism: pus somewhere, pus nowhere = pus under the diaphragm. - A subphrenic abscess is a horrible way to die, so do an urgent ultrasound.
    • Management: Antibiotics ± US/ CT guided percutaneous drainage - if these are ABOVE 5cm
  • Post-infective strictures may form in the sigmoid colon. These can cause LBO:
    • Mgmt: sigmoid colectomy - electively or urgently
60
Q

How is acute diverticulitis managed?

A
  • Mild attacks: at home with bowel rest (fluids only) +/- antibiotics
  • Admit to hospital for analgesia, NBM and IV fluids , IV abx can can be given in uncomplicated diverticulitis
  • Attacks and abscess formation: percutanoeus CT guided drainage
  • Imaging: CXR + USS can detect perforation. CT with contrast is more accurate.
  • Elective resection after an acute episode is rarely recommended unless stenosis, fistulae and recurrent bleeding
61
Q

How would you manage acute rectal bleeding?

A
  • ABC resuscitation, if necessary.
  • History and examination
  • Blood tests: FBC, UE, LFT, clotting, amylase, CRP, G+S—await Hb result before crossmatching unless unstable and bleeding.
  • Imaging: May only need plain AXR, but if request CXR if there are signs of perforation (eg sepsis, peritonism) or cardiorespiratory comorbidity
  • Fluid management: 2 cannulae (≥18g) into the ACF.
    • Urinary catheter - if suspicion of haemodynamic compromise
    • IV fluid replacment and maintenance
    • Blood transfusion only if significant blood loss
  • Clotting: Withold ± reverse anticoagulation and antiplatelet agents (vitamin K)
  • Abx: if there evidence of sepsis or perforation, eg piperacillin/tazobactam 4.5g/8h iv.
  • Keep bedbound: even if they want to get out of bed to pass stool, but this could be another large bleed, resulting in collapse if they try to walk. Don’t allow them to mobilize and inform the nursing staff of this.
  • Start a stool chart to monitor volume and frequency of motions.
    • Send sample for mc&s (×3 if known to have compromising comorbidity eg IBD).
  • Diet: Clear fluids
  • If bleeding does not settle: interventions if bleeding not settling with conservative management:
    • Angiography + therapeutic embolization; CT angiography
    • Colonoscopy - only if haemodynamically stable
  • Surgery: if massive bleeding that cannot be controlled
62
Q

What is Chrohns and how does it differ from UC?

A
63
Q

Who does Chrohns affect?

A

Bimodal peak age: 15-30 years and then again at 60-80 years

64
Q

What are the RFs for developing Chrohns?

A
  • FMH
  • Smoking
  • White European descent
  • Appendicectomy
65
Q

What are the sx of Chrohns?

A
  • Abdominal pain: colicky - usually RIF
  • Diarrhoea: chronic and may contain blood or mucus
  • Systemic symptoms: malaise, anorexia and low-grade fever
66
Q

What are some the extra intestinal features of Chrohns

A
  • Similar to UC:
    • MSK: Enteropathic arthritis (sacroiliac and other large joints) or nail clubbing. Metabolic bone disease (secondary to malabsorption)
    • Skin: Erythema nodosum + Pyoderma gangrenosum
    • Eyes: Episcleritis, anterior uvetitis, or iritis
    • HPB: PSC (more associated with UC), cholangiocarcinoma, gallstones
    • Renal: Renal stones
67
Q

What Ix would you use for IBD?

A
  • Bloods: fbc, esr, crp, u&e, lft, inr, ferritin, tibc, b12, folate.
  • Stool tests: stool sample (microscopy + culture); faecal calprotectin
  • Imaging: AXR/ CT (for toxic megacolon)
  • Colonoscopy with biopsy - Gold standard
  • Flexible sigmoidoscopy / colonoscopy / capsule endscopy (proximal chrohns)
68
Q

What are the complications of Crohns?

A
  • SBO: toxic dilatation: colonic diameter >6cm (rarer than in UC)
  • Abscess formation: abdominal, pelvic, or perianal
  • Fistulae: eg entero-enteric, colovesical (bladder), colovaginal, perianal, enterocutaneous; perforation
  • Colon cancer
69
Q

How is Crohns managed?

A

Inducing Remission

  • Acute attacks: IV fluid resuscitation, nutritional support, and prophylactic heparin and anti-embolic stockings (due to the prothrombotic state of IBD flares).
  • 1st line: Glucocorticosteroid (prednisolone, methylprednisolone or IV hydrocortisone)
  • 2nd line: + mesalazine or azathioprine
  • 3rd line: + Biologics - Infliximab and adalimumab

Maintaining remission

  • 1st line: monotherapy: Azathioprine or mercaptopurine
  • 2nd line: Biological agents: infliximab
  • Smoking cessation: IBD-nurse specialists, enteral nutrition support
  • Offer colonoscopic surveillance

Surgery: used in those for whom medical management has failed

  • Ileocaecal resection: removal of terminal ileum and caecum with primary anastomosis
  • Surgery for peri-anal disease: e.g. abscess drainage, seton insertion, or laying open of fistulae
  • Stricturoplasty: division of a stricture that is causing bowel obstruction
  • Small bowel or large bowel resections
70
Q

What are some of the extra intestinal complications of Crohns?

A
  • Malabsorption
  • Osteoporosis
  • Stones: gallstones/ renal stones
71
Q

What are some of the signs and sx of UC?

A
  • Cardinal feature: Bloody diarrhoea: visible blood in stool
  • Proctitis: inflammation is confined to the rectum -
    • > PR bleeding and mucus discharge
    • -> Urgency/tenesmus
  • Crampy abdominal discomfort
  • Systemic sx: fever, malaise, anorexia, ↓weight.
72
Q

What is the criteria used to grade any exacerbations of UC?

A

Truelove and Witt Criteria

73
Q

What X ray changes are visible for UC?

A
  • Mural thickening and thumbprinting
  • Chronic cases of UC: lead-pipe colon is often described – usually best seen on barium studies
74
Q

How is UC managed?

A

Acute attacks: (same as Crohns)

  • IV fluid resuscitation
  • Nutritional support
  • Prophylactic heparin

Inducing Remission: see attached photo

  • Fluid resuscitation, nutritional support, and prophylactic heparin (due to the prothrombotic state of IBD flares).
  • Medical: corticosteroid therapy and immunosuppresive agents, such as mesalazine or azathioprine.
  • 3rd: Biological agents

Maintaining Remission:

  • 1st line: mesalazine or sulfasalazine
  • 2nd line: Infliximab or alternative

Surgical if disease refractory to medical management, toxic megacolon, or bowel perforation

  • Total proctocolectomy
  • Sub-total colectomy
75
Q

What are some of the complications of UC?

A
  • Toxic Megacolon
  • Colorectal Carcinoma
  • Osteoporosis
  • Pouchitis: inflammation of an ileal pouch
76
Q

What are some of RFs for developing volvulus?

A
  • Increasing age
  • Neuropsychiatric disorders
  • Resident in a nursing home
  • Chronic constipation or laxative use
  • Male gender
  • Previous abdominal operations
77
Q

What are the clinical features of volvulus?

A
  • Patients with a volvulus will present with the clinical features of bowel obstruction.
  • Early: Colicky pain, abdominal distension, and absolute constipation
  • Late: Vomiting
  • Abdomen is often very tympanic to percussion
78
Q

What investigations are used for identifying sigmoid volvulus?

A
  • Routine bloods: FBC, UE, CRP + electrolytes, Ca2+, and TFTs to exclude any potential pseudo-obstruction
  • CT scan abdomen-pelvis with contrast
  • AXR:“coffee-bean sign” from LIF
79
Q

How is volvulus managed?

A
  • Conservative: Decompression by sigmoidoscope and insertion of a flatus tube.
    • Lubricated sigmoidoscope gently guided into the rectum.
    • Once sigmoidoscope is in correct position, there will be a rush of air and liquid faeces as the obstruction is relieved.
  • Surgical Management: laparotomy for a Hartmann’s procedure
    • Used if: colonic ischaemia or perforation; repeated failed attempts at decompression; necrotic bowel noted at endoscopy
80
Q

What is pseudo obstruction?

A
  • Disorder characterised by dilatation of the colon due to an adynamic bowel, in the absence of mechanical obstruction.
  • Also known as Ogilvie syndrome
81
Q

What are some of the causes of pseudo obstruction?

A
  • Electrolyte imbalance or endocrine disorders: hypercalcaemia, hypothyroidism, or hypomagnesaemia
  • Medication: opioids, CCB, or anti-depressants
  • Surgery: illness, trauma, cardiac ischaemia
  • Neurological disease: Parkinson’s disease, MS, and Hirschsprung’s disease
82
Q

What are the clinical features of pseudo obstruction?

A
  • Abdominal pain
  • Abdominal distension
  • Constipation: Due to an adynamic bowel
  • Vomiting: late
83
Q

How would you investigate pseudo obstruction?

A
  • Bloods: U&Es, Ca2+, Mg2+, and TFTs
  • AXR
  • CT scan abdominal-pelvis with IV contrast: will show dilatation of the colon
  • Motility studies, biopsy of the colon at colonoscopy.
84
Q

How would you manage a pseudo obstruction?

A
  • Conservative: NBM, IV fluids (+fluid balance chart), NG tube (if pt is vomiting to aid decompression)
  • Medical:
    • Endoscopic decompression (insertion of a flatus tube and allowing the region to decompress)
    • IV neostigmine (an anticholinesterase)
  • Surgical: segmental resection +/- anastomosis: caecostomy or ileostomy

Year 3 - Surgery (10 decks)

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