GI 2 Flashcards by Joe Smith

What are some mechanisms of intestinal obstruction?

Mechanical

True (intraluminal/extraluminal)

Functional - paralytic ileus

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What can cause intestinal obstruction?

Tumour - carcinoma, lymphoma

Diaphragm disease

meconeum ileus

gallstone ileus

crohn’s

diverticulitis

hirschprung’s

adhesions (most common)

volvulus

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How does small intestinal obstruction present?

pain - colicky then diffuse, pain higher than in large bowel obstruction

profuse vomiting that follows pain

less distension than LBO

nausea

tenderness = strangulation

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How would you investigate a SBO?

Abdo X-ray - partial SBO = gas throughout the abdomen and into the rectum

complete SBO = no distal gas, staggered air-fluid levels

FBC

Urea

Electrolyte panel

Abdo CT

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How would you a treat a SBO?

Emergency laparotomy plus fluid resus

Preoperative antibiotic prophylaxis - ampicilin + gentamicin

morphine

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How would a large bowel obstruction present?

on av. 5 days of symptoms - present slower and later than in SBO

abdo pain that is more constant than in SBO

bowel sounds normal then quiet

palpable mass

late vomiting

constipation

fullness/bloating/nausea

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How would you investigate a LBO?

FBC

serum electrolytes

renal function

serum amylase/lipase

erect chest x-ray

plain abdo x -ray- gaseous distension of large bowel, kidney shape seen in volvulus

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How would you manage a LBO?

emergency surgery

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What causes LBO?

colorectal malignancy

volvulus

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What is a pseudo-obstruction?

clinical picture mimicking obstruction but with no mechanical cause

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What are some causes of pseudo-obstruction?

intra-abdominal trauma

pelvic, spinal and femoral fractures

postoperative states

intra-abdominal sepsis

pneumonia

drugs (opiates, antidepressants)

metabolic disorders (electrolyte disturbances, malnutrition)

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What are the 3 main types of bowel ischaemia?

acute mesenteric ischaemia

chronic mesenteric ischaemia (intestinal angina)

ischaemic colitis (chronic colonic ischaemia)

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Where is blood supply to colon come from?

What are watershed areas which are most susceptible to ischaemia?

inferior and superior mesenteric arteries

splenic flexure and caecum

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What is acute mesenteric ischaemia? What are the causes?

bowel ischaemia affecting the small bowel

caused by superior mesenteric thrombosis

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How does acute mesenteric ischaemia present?

Acute severe abdominal pain - constant, central or around right iliac fossa

No abdo signs

Rapid hypovolaemia - shock

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How would you investigate ischaemic bowel disease?

CT - first line

sigmoidoscopy or colonoscopy

FBC

Chemistry panel - acidosis, uraemia, elevated creatinine

Coag panel - underlying prothrombotic disorder

ABG/lactate level

ECG - arrthmias or acute infarct that may be cause

Erect CXR - free air if perforation present

Abdo x-rays

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How would you manage iscahemic bowel disease when there is no sign of infarction, perforation or peritonitis?

Supportive - NG tube, NBM, O2

Empiric Abx - ceftriaxone and metronidazole

SMA Embolus - open embolectomy or arterial bypass +/- bowel resection

Papaverine - antispasmodic

Chronic mesenteric ischaemia - medical optimisation + surgival systemic mesenteric bypass

Non-acute colonic ischaemia - segmental colectomy

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What are the causes/RFs of Ischaemic Colitis?

Low flow in the inferior mesenteric artery territory

thrombosis
emboli
decreased cardiac output
drugs - oestrogen, antihypertensives, vasopressin

surgery

vasculitis - SLE, sickle cell

Coag disorders

COCP

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How would ischaemic colitis present?

sudden onset lower left side abso pain

bright red blood without diarrhoea

signs of shock

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What are some causes of haemorrhoids?

constipation

diarrhoea

congestion - pelvic tumour, pregnancy, portal hypertension

anal intercourse

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When do haemorrhoids become painful?

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Only painful if they are below the dentate line - protrude and are gripped by the anal sphincter

How would you classify internal haemorrhoids?

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1st - remain in rectum

2nd - prolapse through the anus on defection but then reduce

3rd - prolapse but can be reduced manually

4th - remain persistently prolapsed

How would haemorrhoids present?

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bright red rectal bleeding - on tissue or drips onto toilet

mucus discharge

pruritus ani

severe anaemia

change in bowel habit

How would you investigate haemorrhoids?

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anoscopic examination

colonoscopy - exclude serious pathology such as IBD

FBC

How would you manage haemorrhoids?

25-30g of fibre bowel habit advice rectal hydrocortisone rubber band ligation or sclerotherapy surgical haemorroidectomy

What are some causes of anal fistula formation?

perianal sepsis abscesses crohns TB diverticular disease rectal carcinoma

How would an anal fistula present?

pain discharge pruritus ani systemic abscess

How would you treat an anal fistula?

fistulotomy and excision drain abscess with abx if infected

What is a fissure-in-ano?

painful tear distal to dentate line 90% posterior 10% anterior most likely following childbirth

What are some causes of fissure-in-ano?

hard faeces childbirth syphilis herpes trauma crohns anal cancer

How would you treat fissure-in-ano?

diet - fibre and fluids lidocaine ointment + GTN ointment or topical diltiazem botox

What are the 3 types of IBS?

IBS-C - constipation IBS-D - diarrhoea IBS-M - constip and diarrhoea

What are some intestinal presentations of IBS?

ABC + 2 more Abdo pain/discomfort Bloating Change in bowel habit 2 more of = urgency incomplete evacuation abdo bloating/distension muscous in stool worsening symptoms after food

What are some extra-intestinal presentations of IBS?

urinary frequency, urgency, nocturia bac pain joint hypermobility fatigue nausea

What are some red flag symptoms to be aware when investigating IBS?

unexplained weight loss PR bleed/blood in stool FHx of bowel or ovarian cancer change in bowel habit >50 rectal/abdo mass raised inflamm markers anaemia

What is the ROME IV criteria for IBS?

Recurrent abdominal pain, on average, at least 1 day/week in the last 3 months, associated with two or more of the following criteria: i) Related to defecation ii) Associated with a change in frequency of stool iii) Associated with a change in form (appearance) of stool.

How would you investigate IBS?

diagnosis of exclusion FBC - investigate anaemia Stool study - rule out infection Anti-endomysial & tTG - rule out coeliac abdo x-ray - obstruction colonoscopy - IBD

How would you manage IBS?

Constip i) laxative (lactulose) ii) antispasmodics (dicycloverine, peppermint oil) iii) SSRI (citalopram) Diarrhoea I) loperamide ii) dicycloverine iii) TCA - amitriptyline

What are some differentiating factors between IBS and IBD?

IBD more systemic : ``` Fever Extra-intestinal symptoms Melena Weight loss Mouth ulcers ```

What is diverticulosis, diverticular disease and diverticulitis?

Diverticulosis = presence of diverticula Diverticular disease = diverticula are symptomatic Diverticulitis = inflammation of a diverticulum

What are some causes of diverticulitis?

low fibre diet Obesity Smoking NSAIDs Over 50

How would diverticulitis present?

Asymp in 95% Intermittent left iliac fossa pain Erratic bowel habit Constipation *similar to appendicitis but left sided febrile tachycardia tendernessand guarding on left side

What are some complications of diverticular disease?

perforation fistula formation - into bladder = dysuria - into vagina = discharge intestinal obstruction bleeding mucosal inflammation

How would you investigate diverticular disease?

FBC - polymorphonuclear leucocytosis CT colonography Abdo x-ray

How would you treat diverticular disease?

Dietary - fibre Amoxicillin Paracetmol/Tramadol/Morphine Low residue diet - refined bread, white rice, vegetable without pulp endoscopic embolization surgery

What is Meckel's diverticulum?

most common congenital abnormality of GI tract diverticulum projects from the wall of the ILEUM can secrete HCL = peptic ulcers

Where is the appendix located?

McBurney's point = 2/3rds of the way from the umbilicus to the ASIS

What are the causes of appendicitis?

faecolith lymphoid hyperplasia filarial worms

How does acute appendicitis present?

pain umbilical region that migrates to the right iliac fossa (McBurney's) anorexia nausea and vomiting constipation fever

How would you investigate acute appendicitis?

FBC - mild leucocytosis abdo and pelvic CT scan pregnancy test - rule out ectopic

How would you treat acute appendicitis?

appendectomy IV abx - cefoxitin

GI 2 Flashcards

(51 cards)