G.I. Flashcards
Main types of hernia
Inguinal, femoral, incisional
Hernia definition
Protrusion of a viscus through a defect in the wall through its containing cavity
Hernia complications
Bowel obstruction, Incarceration (contests of hernial sac stuck), Strangulation (Ischaemia + Obstruction)
Inguinal ring Anatomy
Roof = Internal oblique and Transversus abdo
Floor = Inguinal ligament
Anterior = Apneurosis of external oblique
Posterior wall = Transversals fascia
Contents of inguinal canal
Men: Spermatic cord
Women: Round ligament
Why are hernias important
7% of ALL surgery
25% of men will get an INGUINAL hernia
Inguinal hernia
- Who / RF
- Types
Men (testes descend), obese, heavy lift, chronic cough
direct (directly through posterior wall - lateral to pubic tubercle)
indirect (through deep inguinal, medial to pubis, more likely to strangulate)
Inguinal hernia
- Pres
- Investigate
- Treat
Groin lump
Pain
Cough impulse (palpate when coughing)
USS if any doubt
Lifestyle: stop smoking, weight loss
Surgical reduction and mesh closure
More likely hernia will strangulate if
Small defect
Indirect hernia
Femoral hernia
Contents of Femoral canal
NAVYVAN
Femoral hernia
- Epidemiology
- Pres
- Complication
- Tx
More in women
Lump (inferior and lateral to pubic tubercle)
cough impulse
Pain if incarceration
High (20%) strangulation rat - surgical emergency)
Surgical repair all due to high risk
Strangulated hernia presentation
Red, tender, tense, irreducible ± colicky abdo pain + vomit + distension (obstruction - a surgical emergency)
Umbilical hernias assoc
Congenital
Assoc with ascites
Dyspepsia definition
Epigastric pain/discomfort due to acid reflux
Red flags in dyspepsia (ALARMS)
Anaemia Loss of weight Anorexia Recent onset Melaena Swallow difficulty
Stomach is battleground.
- Attack factors
- Defence factors
The balance prevents ulcer
Acid, pepsin, H.pylori, bile salts, smoking (impairs mucosal repair)
Mucin secretion, cellular mucus, bicarbonate secretion, mucosal blood flow
ROME criteria for dyspepsia
1 of the 4 = diagnostic
1) Bothersome postprandial fullness
2) Early satiety
3) Epigastric pain
4) Epigastric burning
Also: No evidence of other disease to explain symptoms
Early post prandial pain
Gastritis, Gastric ulcer, GORD, Gastric Ca
Late postprandial pain
Duodenal ulcer
Drugs that can cause dyspepsia
Nitrates Bisphosphonates Corticosteroids NSAIDs (Decrease mucus and bicarbonate secretion)
How do PPI work
Decreases expression of h=/K+ anti porter on luminal membrane of parietal cells
Dyspepsia investigations
FBC (Iron def anaemia = alarm -> chronic bleed)
H.pylori test
Endoscopy if WL, Dysphagia, chronic bleed (anaemia) etc or over 55
Dyspepsia Tx
Lifestyle: stop offending drugs, smoking, lose weight, aggravating foods
OTC antacids
PPI if ranitidine (H2 antagonist doesnt work)
Triple therapy H.Pylori if indicated: PAC: Amoxicillin, clarithromycin, PPI
Cell types in Stomach
CPL PIGEH GotGood DancingSkills
Chief - Pepsiongen
G-cells - Gastrin (antrum)
Parietal cells - IF & HCL (funds and body)
D-cells - Somatostatin (antrum)
Goblet cells (gastroprotective)- mucus and bicarbonate
Factors stimulating Acid production
Gastrin from G-cells (think, they are high up - astral)
Histamine (on H2)
ACh (M3)
Stop acid production
Somatostatin (also antrum)
Acid production
H20 + CO2 = H+ H2CO3-
H2CO3- swapped for Cl- form blood
cAMP related movement of Proton pump to luminal membrane to pump out H+
cAMP inc by gastrin, histamine, ACh
Cephalic phase
Gastric phase
Intestinal phase
what mediates and what is effect
Cephalic: Via Parasymp ANS - Vagus. Stimulates Gastric phase
Gastric: due to Gastrin, histamin secretions. From cephalic stem, proteins in stomach (G-cell) Stimulatory
Intetinal phase: nervous (intestinal stretch feedback) and hormonal (Somatostatin, incretins) inhibit Gastric phase
Chef brings you meat.
PARI et al
Chief cells make pepsinogen (pepsin) to digest proteins
Produce Acid, Release Intrinsic Factor
H.Pylori
- what is it
- What can it cause
- symptoms
Gram negative curved bacillus
Peptic ulcer disease, Gastric adenocarcinoma (X6 risk)
Epigastric pain/bloating, early satiety
H.Pylori mechanism
2 Mechanisms
Urease secretor, form ammonia to neutralise acid in stomach, alkaline damages stomach lining
If antral:
Damage to d-cells = low somatostatin = high HCL
Both mech can cause ulcer
H.Pylori Investigations
C13 urea breath test (if urea is split after 10-30 min then +ve)
Stool antigen test
CLO test (pink with H.Pylori) on endoscopy looking for urease
Note: no PPI or ABx 2 weeks prior to test
FBC: iron def anaemia?
H.Pylori Treatment
PPI + amoxicillin + clarithromycin/metronidazole (1 week)
Types of peptic ulcer
80% Duodenal
20% gastric
Causes / RF peptic ulcers
H.pylori (95% DU, 80% GU),
NSAIDs, smoking, alcohol, stress, bile acids, pepsin
Defence mechanisms against stomach acid
Mucus, bicarbonate, prostaglandins
Pathophysiology
Increase in attack (acid) or decrease in defence mechanisms (mucus - Prostaglandin stimulation, bicarbonate)
Acid erosion of super facial epithelial cells = ulcer
Artery at risk
- Gastric Ulcer
- Duodenal Ulcer
Left Gastric artery
Gastroduodenal artery
Presentation of Gastric/Duoden ulcer
Epigastric pain (DU 1-3 hrs post prandially - when food moves down to there, Gastric on eating)
Posteriorduodenal ulcer radiate to back
Nausea, oral flatulence, bloating, distension, early satiety
Peptic ulcer Ddx
AAA, GORD, GaCa, gallstones, Cx panc, IBS, drug-induced
Investigating Peptic ulcer disease
FBC (iron def anaemia
H.Pylori test (CLO, C13 Urea)
Endoscopy if: over 55, ALARMS
ALARMS = Red Flag symptoms Stomach
Anaemia Loss of weight Anorexia Recent onset Melaena Swallow difficulty
Peptic ulcer management
Stop offending drug (NSAIDs) & smoking
Triple therapy (Amoxacillin, Clarithromycin, PPI)
Peptic ulcer complications
Haematemisis/Melena if large blood vessel erosion (L Gastric, Gastroduodenal)
Acute abdo & Peritonism if perforated
Gastritis:
- What is
- Symptoms
- RF
- Tx
Inflammation of Stomach lining
Post-Prandial fullness, satiety, epigastric pain, nausea, vomiting
ALCOHOL, NSAIDs, H.Pylori, Reflux disease/Dyspepsia
Same as dyspepsia
Lifestyle (smoke, alc, wtlss), OTC/Ranitidine If not work - PPI
Triple therapy (C+A+P)
GORD
- Def
- chronic comp
Reflux of acid contents (bile - particularly caustic/acid) into oesophagus
oesophagitis/ulceration/stricture, Barrett’s Oesophagus (metaplasia of squamous to glandular epithelium, 1% progress to cancer)
GORD Causes
Inc abdo pressure: obesity, preg
Inc Gastric pressure: large meal
Deficient LOS: hiatus hernia (cardia above diaphragm hiatus), CCB, Trycylic antidepressants
Dec oesophageal peristalsis: SSc
Lifestyle: fat (delay gastric empty), coffee, smoke, alc.
H.Pylori and GORD
No relation
Presentation GORD
Heart burn: postural and related to meals
Waterbrash: inc salivation
Odynophagia: painful swallowing
Belching
Atyp: Chronic cough, aspiration pneumonia, chronic hoarseness
GORD investigations
Endoscopy = Gold standard
FBC (exclude anaemia)
Barium swallow (hiatus hernia)
±CXR (Hiatus hern, Cardiac Ddx)
Hiatus hernia
- def
- RF
- types
Abdo viscera herniation through diaphragmatic hiatus. Mainly Gastric Cardia
Anything increasing abdo pressure (obese, preg, ascites, age)
Sliding (90% - Gast-oes junc slide into thoracic cavity) -> more common GORD as sphincter involved
Rolling (10% - Gast-oes junc remains in place but stomach herniates next to oesoph)
Hiatus hernia Investigations
CXR
Barium swallow
Endoscopy
Hiatus hernia Ttx
Lifestlye as GORD
+ PPI longterm
+ surgery e.g. gastropexy if refractory
Oesophageal muscle and epithelium:
Upper
Middle
Lower
Striated (voluntary) & stratified squamous
Mixed & strat squamous
Smooth muscle & squamo/cloumnar junc
Causes of oesophagitis
Same as GORD (LOS weakness, inc abdo pressure) but ALSO drugs taken without water (direct burning)
Can cause mucosal breaks
Barretts
- Def
- Cause
- Investigations
Any portion of distal squamous epithelium replaced by metaplastic columnar epithelium (occurs following mucosal inflammation and erosion)
Chronic GORD ± HH
Observed on Endoscopy
Confried on Biopsy (histology)
Baretts
- Treatment
- Complications
Tx as for GORD (lifestyle & PPI) ± ablation
High grade: oesophagectomy
5% progress to adenocarcinoma in 10-20yrs
Oesophageal cancer
- Types
- RF
- Typical patient
Upper 2/3 = Squam
Lower 1/3 = adeno
Smoking, alcohol, Barretts, GORD, chronic stasis (achalasia)
Older man from middle east
RED FLAGS in Oesophagus
Anaemia Loss of weight Anorexia/vomiting Recent onset Melena Swallowing difficulty (progressive, solids more than liquids)
Other: persistent retrosternal pain, intractable hiccups (infiltrations)
Investigating Oesophageal Ca
FBC (anaemia)
Endoscopy with biopsy
CXR - mets
CT/MRI staging (if emts seen more local stafgin not needed)
Barium swallow (dysphagia)
Oesophageal
- Sites of spread
- Tis, T1, T4
Liver, lung, stomach, LNs (coeliac LNs)
Tis - In situ
T1 - lamina propria/sub-mucosa invasion
T4 - Adjacent structure invasion
Oesophageal cancer Tx
Surgery ( with adjacent lymphadenectomy) - Ivor Lewis ± chemo
Mucosal resection (endocscopically) for early stage cancers
Palliation - Stenting/Radiotherapy
Oesophageal cancer prognosis
5 year survival 20%
Ddx for Dysphagia
Oesophageal: GORD, Pesophagitis, Ca (oesophageal, pharyngeal)
Neurological: CVA, Achalasia, MS, MND
Other: pouch, CREST
Achalasia
- def
- pres
Loss of Aubarches plexus
Impaired smooth muscle peristalsis and LOS fails to relax
Dysphagia to solids and liquids, Regurgitation
Achalasia Investigations
CXR - dilated oesophagus
Barium swallow - Birds beak (dilated with distal narrowing)
Manometry (Gold Standard) - high resting pressure on swallow
Achalasia treatment
CCB/nitrates (reduce LOS pressure may = GORD)
Endoscopic dilatation surgery (risk perforation)
Systemic sclerosis GI
- Paphys
- Pres
- Tx
Dysmotility due to collagen deposition
Reflux, delayed emptying
High dose PPI, Promotility agents (Domperidone)
dilatation of structure
Upper GI bleeding
- Ddx
- Pres
- Investigation
Peptic ulcer (most common - L gast/gastroduoden artery), Varices, oesophagitis, Mallory-Weiss, malignancy
Haematemisis (fresh = red, stomach or below = ground coffee)
Melaena - black tarry stools (Upper GI bleed, occasionally small bowel iron sups also give this)
Signs of anaemia/shock –> extent of blood loss
(postural hypotension = over 20%)
ENDOSCOPY urgently
Acute bleed = emergency,
Mallory-Weiss
- def
- cause
- pres
- Investigations
Mucosal tear in OG junction
Persistent vomit/wretching
(Excess alc, bulimia, gastroenteritis)
Haematemisis, melena, dizzyness
Endoscopy, FBC & Haemocrit (assess severity), Renal function/U&E for fluid replace, cross match
Boerhaave
- def + site
- complications
Oesophageal tear due to vom or trauma (e.g. endoscopy)
Pneumomediastinum, surgical emphysema (air in skin of chest/neck)
Oesophageal varices
Dilated veins in distal oesophagus/proximal stomach. Due to portal HTN caused by congested/diseased liver/
Chronic Liver disease (cirrhosis)
Haematemisis, Melena, Liver disease features
Endoscopy, FBC (Hb), LFT, Clotting, renal function
Investigation upper GI bleed
Assess for shock (pallor, anaemia, Cap refill, pulse, BP, cool extremities)
Liver disease stigmata (LFTs)
Endoscopy - post resuscitation or within 24 hours
Cross match (2-6 units)
Upper GI bleed correcting hypovolaemia
What is done after
If shock = O2 + fluid resus (500ml over 15 mins)
Transfuse: Crossmatched blood, FFP (if INR over 1.5)
Endoscopy
Upper GI bleed management
Ulcer as cause: Endoscopic
- thermal coag active bleeds
- Fibrin/Thrombin with adrenaline
- Mechanical clips
Variceal bleed:
- Terlipressin at presentation
- Prophylactic Abx
- Oseoph: band ligation
- Gastric: N-butyl-2-cyanoacrylate ± TIPS
Define
- Ileus
- Paralytic ileus
Ileus - non-mechanical obstruction, paralytic ileus - bowel inactivity
Small bowel obstruction cause
Adhesions (75% - from prior operations), Strangulated hernia, Malignancy (caecum as small bowel malignancy rare) or volvulus
Large bowel obstruction causes
Colorectal malignancy, Volvulus (Sigmoid = 5% all obstructions, caecal)
Ogilvie’s - loss of peristalsis
Pos-op ileus
Congenital: Neonatal e.g. CF, Hirschprungs (aganglionic section of bowel)
Presentation of intestinal obstruction
Nausea and vomit (early in high level, faecal in low level) - May give hypotension
Abdo pain (severe) and increasing distension
Failure to pass bowel movements (constipation (early on in low level, late in high level)
If ischaemic/perforation: Pyrexia (acute abdo, peritonism)
Intestinal obstruction investigations
Abdo Xray: distended bowel loops proximal to OBs, fluid levels
Gas under diaphragm - perforation
Intestinal obstruction management
Fluid resus + correct electrolytes
Colon insulation used in volvulus, Endoscopic decompression may be used for proximal.
No clear diagnosis: Laparotomy + stoma consent (early if peritonitis/perforation
Sigmoid volvulus
- Def
- RF
- Pres
Faeces and gas filled sigmoid loop twists on mesentery to cause obstruction
Elderly, constipation, previous occur
Sudden onset colicky lower abdo pain with distension and fail to pass flatus/stool. may have palpable mass
Sigmoid volvulus
- Investigations
- Treatment
Empty rectum,
Abdo XR: dilted, coffee bean sign
CT to assess bowel wall ischaemia
Decompress with sigmoidoscope with insulation
elective surgery for recurrence
Paralytic ileus
- def
- who
- causes
- pres
- investigation
No peristalsis causing pseudo-obstruction
elderly
Olgives (opioids, Parkinsons, post-op)
Large bowel obstruction with absent bowel sounds
ABX
GO obstruction & triad
Gastric outlet obstruction
Obstruction at level of pylorus
Seen in children (projectile vomit, Tx with pyloromyotomy)
Ddx for Acute abdomen
Appendicitis Peritonitis Pancreatitis Ectopic preg Diverticulitis Cholecystitis Renal colic/pyelonephritis PID AAA
Primary and secondary causes of Peritonitis
Primary = spontaneous bacterial peritonitis from ascites
Sec = pathology adjacent e.g. perforation
May be localised (e.g. appendix) or generalised
omentum function
Attempts to confine infection by wrapping around it (e.g. appendicitis)
Peritonitis presentation (e.g. appendicitis)
High fever, tachycardia, tenderness on palpation, guarding, rebound tenderness
Causes of intra-abdominal sepsis
Peritonitis (.g. from SBP or perforation)
Abscess
Investigating intra-abdo sepsis
FBC: leukocytosis
U&E: dehydration
Blood/Peritoneal fluid cultures
AXR, CXR (air under diaphragm)
Treatment of intra-ado sepsis
Abscess&Peritonitis:
- Fluids
- Broad spec Abx (metronidazole, 3rd gen cephalosporin)
- Surgical drain with open/laparoscopic surgery
Anal fistula
- Def
- Cause
- Investigations
- Tx
Communication between skin and anorectal canal
Abscess, Crohn, Carcinoma
MRI
Surgical
Pilonidal sinus
- def
- complication
- Tx
Small hole at skin caused by obstruction of hair follicles
Abscess formation and sinus
Surgical excision of sinus tract and closure
Haemorrhoids:
- What
- Tx
Dilated vascular plexuses in anal canal. May prolapse out
Painful,
Bleeding on defecation (on paper, not mixed with stool)
Prevent consitipation, 2 week wait if suspect anal cancer, lubber band ligation
Appendicitis
- Def
- Complications
- Epi
Invasion of appendix by gut flora with inflammation
Rupture - life threatening peritonitis (20% perforate)
Most common cause acute abdo, males 10-20
Appendicitis
- Pres
Periumbilical pain (T10 - referred) moves to RIF (McBurney’s 1/3 way from ASIS - umbilicus) once peritoneum involved
Nausea, vomiting (a little), anorexia
Low grade fever, Tenderness/gaurding, rebound tenderness (inflammatory mediators moving back)
Shallow breathing - movement aggrivates
Appendicitis management
Admit all
Laparoscopic/Open appendicectomy
IV fluids + opiates
IV metronidazole + Ceftriaxone
Appendicitis
- Ddx
- Investigate
GI: obstruction, Meckel’s, Crohn’s
GU: Torsion, Calculi, UTI
Gyn: Ectopic, ovary cyst, PID
DKA
Clinical diagnosis so rule out other things.
Urinalysis (UTI), preg test, FBC (Raised WCC), USS (rule out gynae issues)
Diverticular disease
- definition/location
- -losis Vs -litis
- RF
Herniation of mucosa through colonic muscle. Typically descending colon/sigmoid
asymptotic diverticula Vs inflammation (fever, tachycardia)
Age, Obese, low fibre diet
Diverticulitis
- Pres
- Complications (POFAS)
LLQ pain, bleeding, fever, tachycardia
Anorexia, vomiting, nausea
Perforation Obstruction Fistula Abscess Stricture
Diverticular disease
- Invetigation
- Management
Colonoscopy/flexisig
FBC (raised WCC = -litis, Bleeding - anaemia)
Barium enema
High fibre
para for pain
-litis: admit, fluid/blood resus. 7d Co-amoxiclav. 30% need surgery (resection+colostomy for Perforation)
Meckel’s diverticulum
- what is it
- complications
Remnant of viteline duct
Haemorrhage or intestinal obstruction (can cause intussusception)
Types of bowel ischaemia
Acute mesenteric
(Embolus)
Chronic mesenteric (intestinal angina)
Ischaemic colitis (Shock, trauma, cocaine, dec CO = lower blood flow to SMA)
Acute mesenteric ischaemia
- Def
- RF
- Pres
- Investigate
- Tx
- Prog
Sudden ischaemia can be arterial/venous thrombus.
Impaired blood and bacterial translocation = sepsis
hypercoag, Protein C+S deficiency, tumour, infection
Severe poorly localised colicky pain
AXR for obstruction, Angiography (gold standard)
Fluid resus, O2, Heparin for thrombus, surgical angioplasty
90% mortality
Chronic mesenteric ischaemia
- Cause
- RF
- Pres
- Investigate
- Treat
Atherosclerotic disease (intestinal angina)
Smoking, HTN, DM, hyperlipidaemia
Postprandial pain, weight loss
Arteriography is gold standard
Nitrate therapy, anticoagulant, bypass surgery
Treating bowel ischaemic colitis:
Releive hypoperfusion
Bowel rest
supportive care
Malabsorption
- sympt
- signs
- important causes
Change in weight/growth, Chronic diarrhoea, Steatorrhoea
Iron/Float/B12 anaemia
Bleeding (Vit K),
Oedema (protein def)
Coeliac, CD, Chronic pancreatitis
Malabsorption causes
1) Mucosal
2) Intraluminal
3) Structural
4) Extra-GI
1) coeliac, cow’s milk protein intol
2) Pancreatic insufficiency (CF), bile acid malprod/secrete
3) intestinal hurry, CD (fistulae, short bowel syndrome)
4) hypo/hyper thyroid, DM , carcinoid syndrome
Malabsorption investigations
FBC, LFT Iron/Folate/B12 (pallor glossitis) Anti-Transglutaminase (IgA) - coeliac Faecal elastase AUSS gallbladder Stool - foul smelling, floating, pale (steatorrhoea)
Coeliac:
- def
- pres
- assoc diseases
heightened immune response to gluten (gliadin protein) leading to malabsorption
Diarrhoea, weight loss, steatorrhoea, abdo pain, anaemia (80% iron, B12, folate def - mouth ulcers, angular stomatitis)
Skin: dermatitis
Neuro: peripheral neuropathy
T1DM, Thyroid dis, Down’s, Turner’s, primary biliary sclerosis/ primary sclerosis cholangitis
Coeliac autoantibodies What is important before testing for these
Must have been eating wheat for 6 WEEKS pre-testing
Tissue transglutaminase (IgA) Endomysial antibodies (IgA)
Coeliac
- Investigations
- Definitive diagnosis
Autoantibodies (IgA)
Bloods: anaemia
Low B12/Ferritin/Floate
LFT: PBC, PSC AI dis
Distal ileum biopsy showing villous atrophy and crypt hyperplasia
Coeliac management & complications
Lifelong gluten free diet
Calcium/Vit D supps
Delayed diagnosis = Osteoporosis, anxiety/depression, infertility
Gastric Cancer
- Epidemiology/RF
Japan, China Over 55yrs Male H.Pylori (X2) Salt/pickeld foods Smoking Pernicious anaemia Nutrosamine exposure
Gastric Ca
- Pres (problem)
- RF symptoms
Vague: weight loss, vomit, dysphagia, most present late
Troisier’s sign: Virchow’s node
ALARMS
Gastric Ca investigations
FBC (anaemia - GI bleed)
LFT (spread to liver)
Endoscopy + Biopsy (multiple ulcer edge biopsies) - Signet ring cells
Gastric Ca spread
Staging
- How?
- T1?
- T4?
Local, lymphatic, haematogenous
To lung and liver
CT abdo/thorax for mets
CXR, Transabdo USS, MRI
TNM
T1= Lamina propria/submucosa
T4 = to adjacent spleen/colon
Gastric Ca
- Manage
- Palliation
- Prognosis
Nutritional support
Surgery (distal = subtotal gastrectomy, proximal = total gastrectomy) Perioperative chemo (5-FU)
Palliation: Epirubucin + Cisplatin + 5-FU
15% 5 year survival
MALT lymphoma
- Type of lymphoma
- Cause
- Pres
- Investigate
- Treat
Non-Hodgkin
Autoimmune or infection (H.Pylori)
Dyspepsie ± fever, nausea, constipation, weight loss, pain, ulcer
Endoscopy and biopsy
H.Pylori eradication (triple therapy: C.A.P) = remission in 70%
Advanced disease: Rituximab (anti-B-cell)
Gastric carcinoid
- What
- Assoc gene
- Mets
- Secrete + action
- Investigate
- Management
- Tx carcinoid crisis
Neuro-endocrine tumour
MEN1
Liver
Serotonin + Bradykinin
Carcinoid syndrome: Flushing, diarrhoea, abdo pain, palpitations, hypotension, wheeze
24hr urinary 5-HIAA
Endoscopy, CT/MRI (staging - liver)
Surgical resection
Ocreotide (somatostatin analogue prevents 5-HT release)
Colorectal cancer:
- Location of tumour
- Type of tumour
- Mets
- RF
2/3 colon, 1/3 rectum. 40% in rectum and sigmoid
Mainly adenocarcinoma
Liver
Fam Hx (FAP, HNPCC, Obesity, smoking, alcohol, DM
Colorectal cancer
- Presentation
Change in bowel habit Rectal bleeding/anaemia Mass weight loss occult bleed (Right)/Rectal bleed(let) Obstruction Tenesmus
Colorectal cancer genetics
FAP: APC gene mutation with 100% penetrance
HNPCC: AD, 80% risk (3+ relatives with colorectal Ca, 2+ successive generations, 1 before 50 = Amsterdam criteria)
Colorectal cancer
Investigations
PR exam + Colonoscopy + biopsy of lesion
FBC and LFT (anaemia and liver mets)
Flexible sigmoidoscopy (detects 60%)
CEA: carcinoembryonic antigen
FOB - faecal occult blood (also in screening)
Colorectal cancer Staging
Dukes A = mucosa (90% survival) B = through serosa (70%) C = regional LN (30%) D = Distant mets/Liver (5%)
Colorectal cancer screening?
Who
How
60-75, 2 yearly
Feacal occult blood test
If +ve then colonoscopy
Treatment of Colorectal cancer
Surg: Hemicolectomy/colectomy + LN clearance
Chemo: FOLFOX (Folinic acid + Fluorouracil + Oxaliplatin
Colorectal cancer mutation pathway
*Normal cell* APC mutation K-ras SMAD 2-4 P53 *Adenocarcinoma*
Polyp type and Colorectal cancer
Tubulovillous adenoma = highest risk
IBS
- def
- cause
- Types
Abdo pain relieved by defecation and a change in bowel habit. impact on QoL
Psychological distress assoc with abnormal smooth muscle activity
IBS-C (constipation main)
IBS-D (diarrhoea main)
IBS-M (mix)
IBS
- diagnostic criteria
6 month of ABC
- Abdo pain
- Bloating
- Change in bowel habit
AND
Relieved by defecation,
worse on eating,
Management
De-stress, less caffeine, fluids, fibre
Meds
Diarrhoea: loperimide
Constipation: laxatives: Lactulose
Pain: busman (antispasmodic)
IBS Ddx investigations
FBC (Ca - iron def anaemia) Coeliac screen (TTG/EMA) Faecal calprotectin (IBD) Faecal occult TFT
CD Vs UC
Macro
Micro
Barium
CD - rectal sparing, skip lesions, mucus cobblestoning
UC - non-rectal sparing, continuous disease, ulcers, polyps
CD - transmural inflammatory cell infiltrate, granuloma, focal crypt abscess, increased goblet cells
UC - inflammatory cell infiltrate confined to mucosa and submucosa, focal crypt abscess, goblet cell depletion
CD - rose thorn ulcers, kantors string sign (stricture)
UC - loss of haustrations, narrow short colon (lead pipe)
Crohn’s disease
- desc
- location
- RF
chronic relapsing IBD
Mouth to anus (ileum/colon classic)
Genetics (FH 20%), Smoking, NSAIDs, URTI infection
Crohn’s disease presentation
+
Complications
Diarrhoea (chronic - over 6w) ± blood
Weight loss
Periods of exacerbation
Systemis symp: malaise, anorexia, fever, joints (large jet, sacroilitis), eyes (iritis, episcleritis)
POMFAN: perforation, oralulcer/obstruction, malabsorption (B12, Folate), fissure/fistula, anal skin tags/abscess, neoplasia,
Investigation
FBC (pancytopenia)
LFT (fatty liver disease = complication)
Faecal calprotectin
Stool culture
Ileocolonoscopy + biopsy
Barium enema
What does faecal calprotectin indicate?
Neutrophil migration into the intestinal mucosa as seen in inflammatory bowel (UC&CD)
CD management
Oral prednisolone.IV hydrocortisone to induce remission. If another exacerbation in 12M add Azothiaprine (Or MTX + folic acid)
Surgery if limited to distal ileum
Maintain remission:
- stop smoking
- monotherapy (MTX, azathioprine)
- monitor osteopenia.osteoporosis
Ulcerative colitis
- def
- smoking?
relapsing remitting chronic inflammatory disease ONLY colon. Distal to proximal pattern.
Smoking protective
Ulcerative colitis presentation + complications
Bloody diarrhoea
Tenesmus, colicky pain (LIF), urgency, mucus
Systemic: fever, malaise, weight loss, anaemia, Arthritis (large joints, Ank spondylitis), Eyes( episcleritis, anterior uveitis), Liver (primary sclerosis chlangitis)
Toxic Megacolon - admit!
2X risk cancer, risk toxic megacolon by opiates and osteoporos with steroids
Ulcerative colitis
- investigations
FBC (pancytopenia), LFT (PSC), faecal calprotectin
1st line = colonoscopy and multiple biopsies
Toxic megacolon - AXR
Ulcerative colitis
- Treatment
Avoid antispasmodic - megacolon
for mild disease and to maintain remission = topical/oral Mesalazine (salycilate ani-inflam)
IV hydrocortisone added for more severe
Toxic megacolon if non-responsive then surgery is curative
Constipation:
- def
- common cause
- Investigate
- Tx
infrequent stools or hard stools
Low fibre, dehydration, immobility, IBS
metabol (hypothyroid), opioids, spinal nerve injury
investigate if over 40, recent change, weight loss, bleeding, tenesmus
FBC, UE, Calcium, TFT, sigmoidoscopy+biopsy
Treat Cause, fluids, anticonstipation
Anti-constipation drug types
Bulk, osmotic, stimulant
Bulk forming - increase faecal mass, stimulating peristalsis ispaghula husk
Stimulant - increase motility e.g. senna, docusate
Osmotic - retain fluid in bowel - e.g. lactulose
Acute diarrhoea causes
Infection (with fever, sudden)
Drugs: Abx, cytotoxic, NSAID, metformin, SSRI
Constipation with overflow
Anxiety
Food allergy
Things to ask regarding diarrhoea
Foreign travel, fever, food poisoning, stress
Diarrhoea Red Flags
Blood (CMV, shigella, salmonella, c.jej, e.histolytica)
recent ABX (c.diff), vomiting, wt loss,
watery + high volume (dehydration) (Vibrio Cholerae)
Diarrhoea investigate
dehydration (mod/severe: confused, muscle cramps, hypotensive less than 90 systolic)
Stool sample culture and sensitivity
Diarrhoea Tx
supportive: fluids and food
Only give drugs if cause clear. giving loperamide in obstruction is not good
admit if cant stop vomiting, bloody diarrhoea, dehydration/shock
Causes and time to improv
Usually
Rotavirus
C.jej/Salmonella
Giardia
2-4 days
3-8 days
2-7 days
Persists to chronic
Cause of diarrhoea:
Traveler ABx Small child Vom Within 6h food Bloody Bloody and Haemolytic uraemia syndrome
E.coli
C.diff
Rotavirus
S.aureus
Shigella, Salmonella
Enterohaemorhagic E.coli (O157:H7)
Chronic diarrhoea causes
Malabsorption -> osmotic (coeliac)
Inflammatory (CD&UC)
IBS
Neoplasia
Hyperthyroid
Carcinoid tumour
ABx & C.diff
Alcohol
Chronic diarrhoea Tx
TFT, Coeliac (EMA, TTG), B12/Folate if malabsorp,
Treat cause - may be call for antimotility drugs e.g. codeine/loperamide
Chronic diarrhoea Red flags
Blood (CMV, shigella, salmonella, c.jej, e.histolytica), recent ABX (c.diff), vomiting, wt loss
