GI Flashcards
What is GORD?
- Oesophagitis secondary to refluxed gastric contents
- Reflux of gastric contents into the oesophagus is normal. Clinical symptoms only occur when there is prolonged contact of gastric contents with the oesophageal muscosa.
What are the causes of GORD?
- Anything that increases intra-abdo pressure/weakness of lower oesophageal sphincter
- Pregnancy
- Obesity
- Smoking, alcohol, fatty meals, coffee
- Large meals
- Achalasia
- Hiatus hernia
- Drugs: TCAs, anticholinergics, nitrates, CCBs, bisphosphonates, NSAIDs
Normal defence mechanisms of oesophageal muscosa against reflux?
Surface – mucus and water layer trap bicarbonate, acts as as weak buffering system
Epithelium – apical cell membranes in the junctional complexes between cells act to limit diffusion of H+ into cells (this mechanism is impaired in oesophagitis)
Post-epithelium - bicarbonate normally buffers acid in the cells and intracellular spaces
Sensory mechanisms – acid stimulates the primary sensory neurones in the oesophagus by activating the canniloid-1 receptor
Presentation of gord?
- Heartburn: aggravated by bending/lying
- Regurgitation of food and acid, particularly when bending or laying
- Odynophagia (painful swallowing)
- Cough/nocturnal asthma - from aspiration
- Chest pain
How is GORD diagnoseD?
- Clinical diagnosis
- Trials of PPI: If sx persist, ambulatory pH and imedance monitoring
- OGD
- GOld standard for diagnosis is 24hour oesophageal pH monitoring
Indications for performing OGD in someone with reflux
- Age >55
- Symptoms > 4weeks or tx resistant
- Dysphagia
- Relapsing sx
- Weight loss
- Haematamesis
- Anaemia
Conservative treatment for GORD?
- Lifestyle changes: weight loss, avoid excess alcohol, caffeine and aggravating foods, smok cessation
- Antacids
- ## Raising bedhead
What medications can be used for GORD?
- Alginate containing antacids: first line, forms foam raft on contents
- PPIs: block luminal secretion of gastric acid
- H2 receptor antagonists
- Dopamine antagonist pro-kinetic agents
What mnemonic can be used to help remember GORD meds? x
GORD Gaviscon (antacid) Omeprazole (PPIs) Ranitidie (h2 resceptor antagonist) Domperidone (prokinetic)
What are the surgical management options for GORD?
- Nissen fundoplication
w/ Laparoscopic approach
Complications of GORD?
- Oesophagitis
- Ulcers
- Anaemia
- Benign strictures
- Barrett’s oesophagus
- Oesophageal carcinoma
What is a Mallory-Weiss tear?
- A linear muscosal tear occuring at the oesophageal-gastric junction
- Produced by sudden increase in intra-abdominal pressure
- Often occurs after a bout of coughing or retching and is classically seen after alcohol dry heaves
Risk factors for Mallory-Weiss tear?
- Excessive alcohol ingestion
- Hiatus hernia
- Gallstones/Cholecystitis
How do mallory-weiss tears present?
- Acute upper GI bleeding
- Presents with haematemesis
Management of mallory-weiss tears?
- Most bleeds are minor and pt discharged within 24hrs
- Early endoscopy confrims diagnosis and allows therapy if needed
- Surgery with sewing the tear is rarely needed
What is a peptic ulcer?
- A breach in a membrane of the mucosa in or adjacent to an acid bearing area
- Consists of a break in the superficial epithelial cells penetrating down to the muscular mucosa of either the stomach or the duodenum
- Caused by a reduction of gastric mucosal resistance to acid
Most common sites for peptic ulcer?
Dueodenum: more common. Particularly in the duodenal cap
Stomach: Most commonly on lesser curvature
How does the stomach normally present itself agaisnt gastric acid?
1) Mucus production by goblet cells (alkaline mucus)
2) High turnover of cells
3) Feedback loops
4) Tight junctions between cells
What are some causes of peptic ulcers?
- Helicobacter pylori and NSAIDs/Aspirin
- Corticosteroids alongside NSAIDs further increases risk
- Hyperparathyroidism
- Zollinger-Ellison syndrome
- Vascular insuffiency
- Sarcoidosis
- Crohns disease
Risk factors for peptic ulcers?
- Smoking
- Alcohol
- Steroids
- NSAIDs
- Stress
What is Zollinger-Ellison syndrome?
A condition in which a gastrin-secreting tumour or hyperplasia of the islet cells in the pancreas causes overproduction of gastric acid, resulting in recurrent peptic ulcers
Presentation of peptic ulcers?
- Recurrent, burning epigastric pain
- Duodenal ulcer: Pain relieved by eating
- Gastric ulcer: Pain worsened by eating
- Pain relieved by antacids
- Nausa
- Vomiting
- Anorexia and weight loss
- back pain
- Heartburn
- Flatulence
Investigations of PUD?
- Patients <55 with ulcer-type symptoms should undergo non-invasive testing for H Pylori infection: C13 Urea breath test, Stool antigen test , sreology, culture, histology
- Endoscopy can be used
- Barium meal if ?obstruction
Management of PUD
- Treat underlying cause + lifestyle measure: Stop NSAIDS, stop smoking, reduce alcohol intake
- Treat H.Pylori - omeprazole, clarithromycin, and metranidazole for 7-14days
- Surgery - if recurrent haemorrahge
What is Helicobacter Pylori?
- Gram negative spiral bacteria
- Associated with a range of gastrointestinal problems
- Has a flagellum
- Produces urease
- Adheres to gastric epithelial cells in gastric pits
- Protected from gastric acid by the juxta-mucosal mucus layer which traps bicarbonate
- Most patients with the infection are asymptomatic
Diseases associated with H Pylori?
- PUD (95% of duodenal ulcers, 75% of gastric ulcers)
- Gastric cancer
- B Cell lymphoma of MALT tissue
- Atrophic gastritis
Presentation of H. Pylori?
- As PUD: Epigastric pain, nausea, anorexia
Investigations for H. Pylori infection?
- C-13 urea breath test: Gold standard
- Serology: for serum antibody detection
- Stool antigen test: immunoassage using monoclonal antibodies
- Culture
- Histology
- Biopsy urease test
Treatment of H. Pylori?
7 day course of:
1) A PPI + Amoxicillin + Clarithromycin
or
2) A PPI + Metronidazole + Clarithromycin
If H.Pylori treatment fails?
If triple therapy eradication fails give: bismuth + metronidazole + tetracycline + PPI for 14 days (but bear in mind bismuth tablets are extremely unpleasant so be aware of issues with compliance)
What are gastro-oesophageal varices?
- Abnormally dilated veins with a torturous course
- Around oesophagus and stomach
What are the causes of oesophageal varices?
- Portal hypertension due to liver cirrhosis (either from alcohol or viral)
- Acute hepatitis
- Schistosomiasis
What are risk factors for variceal bleeding?
- Decompensation of liver disease
- Malnourishment
- Excess alcohol intake
- Physical exercise
- Circadian rhythms
- Increased intra abdo pressure
- Aspirin
- NSAIDs
- Bacterial infection
How do varices present?
- Haematemesis
- Abdo pain
- Dysphagia/odynophagia
- Confusion 2ndary to encephalopathy
- Pallor
- Hypotension and tachycardia
- Reduced urine output
What investigation for varices?
Endoscopy - to exclude bleeding from other sites/confirm site
Management of acute variceal haemorrhage?
- ABCDE
- Correct clotting: FFP, Vit K
- Vasoactive agents: Terlipressin
- Prophylactic antibiotics in pt with liver cirrhosis
- Endoscopy: Variceal band ligation
- Sengstaken-blakemore tube if uncontrolled haemorrhage
- Transjugular intrahepatuc portosystemic shunt (TIPSS) - if above measures fail
How to prevent re-bleed of varices?
- Propanolol
- Endoscopic variceal band ligation
What is achalasia?
- Failure of oesophageal peristalsis and relaxation of lower oesophageal sphincter (LOS)
- Due to degenerative loss of ganglia from Auerbach’s plexus
- Leading to impaired oesophageal emptying
- LOS contracted, oesophagus above dilated
Clinical features of achalasia?
- Dysphagia of BOTH liquids and solids
- Variation in severity of sx
- Heartburn
- Regurg of food, particularly at night - may lead to cough, aspiration pneumonia
- Spontaneous chest pain due to oesophageal spasm
Investigating achalasia?
- Manometry: excessive LOS tone which doesnt relax on swallowing, most important diagnostic test
- Barium swallow: shows expanded oesophagus, fluid level, birds beak
- CXR: wide mediastinum, fluid level
- OGD
Management of achalasia?
- No cure – goals of treatment are symptom relief and improvement of oesophageal emptying
- Intra-sphincteric injection of BoTox
- Heller cardiomyotomy – surgical division of the LOS
- Endoscopic balloon dilatation
- Drug therapy - has a role but is limited by side-effects
- Oral nitrates
- Nifedipine (CCB)
Main side effect of treatment for achalasia?
GORD
Relationship between oesophageal motility and scleroderma?
- The oesophagus is involved in almost all patients with this disease
- Diminished peristalsis and oesophageal clearance due to replacement of the smooth muscle by fibrous tissue
- Detected manometrically or by barium swallow
- LOS pressure is decreased, allowing reflux with consequent mucosal damage
- Initially no symptoms, then dysphagia and heartburn
- Similar motility abnormalities may be found in other autoimmune disorders, particularly if Reynaud’s phenomenon is present
- Treatment is the same for reflux and benign stricture
What is gastritis?
Inflammation of the gastric mucosa
What is gastropathy?
Injury to the gastric mucosa associated with epithelial cell damage and regeneration. Little or no accompanying inflammation (eg damage due to NSAID use)
What are the causes of gastritis?
- Most common is H Pylori
- NSAIDs and Aspirin
- Alcohol excess
- Autoimmune: eg pernicious anaemia
- CMV
- HSV
- Duodeno-gastric reflux
- Crohns disease
Symptoms of gastritis?
- Indigestion (dyspepsia)
- Epigastric pain
- Loss of appetite
- Bloating
- Retching
- Nausea
- Vomiting
- Early satiety/feeling particularly full after a meal
Investigations for gastritis?
- Clinical diagnosis in most cases
- Gastroscopy is gold standard
- Biopsy
- H. Pylori testing (urea breath + stool antigen)
- Barium swallow
Management of gastritis?
Conservative: - Smaller meals + avoiding spicy/acidic foods - No alcohol - No smoking - Reducing stress - Stop NSAID use Medication: - Antacids - H2 blocker - ranitidine - PPI
What is coeliac disease?
- Autoimmune condtion caused by sensitivity to gluten
- Leads to villous atrophy, causing malabsorption
Causes of coeliac?
- Gluten sensitivity
- Genetic factors
- Environmental factors: Breastfeeding, age of introduction of gluten, rotavirus infection in pregnancy
Risk factors/associations for coeliac disease?
- T1DM
- Atopy
- Thyroid disease
- Sjorgens syndrome
- IBS
- Autoimmune hepatitis
- ## IgA deficiency
Presentation of coeliac disease?
- Chronic or intermittent diarrhoea
- Steatorrhoea
- Failure to thrive
- Persistent or unexplained gi sx inc. N+V
- Prolonged fatigue and malaise
- Recurrent abdo pain, cramping or distension
- W loss
- Unexplained anemia
Non Gi sx of coeliac?
- Mouth ulcers and angular stomatitis
- Infertility
- Neuropsychiatric symptoms (anxiety and depression)
- Rare: Tetany, osteomalacia, weakness, neuropathy
Skin consequence of coeliac disease?
Dermatitis Herpetiformis
How to investigate coeliac disease?
- Immunology and jejunal biopsy
- Must be on a gluten diet at time
What will be seen on immunology for coeliac disease?
- Tissue transglutaminase antibodies (IgA)
- Endomysial antibodies
- Anti-casein antibodies in some
What is seen on jejunal biopsy for coeliac?
- Villous atrophy
- Crypt hyperplasia
Management of coeliac disease?
- Education
- Lifelong gluten free diet
- Correct any vitamin deficiencies
- Pneumococcal vaccine
Complications of coeliac disease?
- Anaemia: Iron, folate and B12
- Hyposplenism
- Osteoporosis, osteomalacia
- Lactose intolerance
- Enteropathy-associated T-cell lymphoma of small intestine
- Subfertility, unfavourable preg outcomes
- RARE: Oesophageal cancer, other malignancies
What is dermatitis herpetiformis?
- An itchy, symmetrical eruption of vesicles and crusts over the extensor surfaces of the body with deposition of granular IgA
- Associated with a gluten-sensitive enteropathy – usually asymptomatic as the jejunal abnormalities are not as severe in coeliac disease
- Same inheritance and immunological abnormalities as coeliac disease
- The skin condition responds to dapsone (used to treat leprosy)
- Both skin and gut will improve on gluten free diet
What is tropical sprue?
- A progressive small intestinal disorder presenting with diarrhoea, steatorrhea and megaloblastic anaemia
- Occurs in residents or visitors to endemic areas in the tropics (Asia, some Caribbean islands, Puerto Rico and parts of South America)
- The term ”tropical sprue” is reserved for severe malabsorption (of 2 or more substances - particularly fat and b12) accompanied by diarrhoea and malnutrition
Presentation of tropical sprue?
- Can be acute or chronic
- DIarrhoea
- Steatorrhoea
- Anorexia
- Abdominal distension
- Weight loss
Investigating tropical sprue?
- Acute infective causes of diarrhoea must be excluded (especially Giardia which can produce a syndrome very similar to tropical sprue)
- Malabsorption should be demonstrated, particularly fat and B12
- Small bowel mucosal biopsy – partial villous atrophy, less severe but similar to in coeliac
- Coeliac screening
Management of tropical sprue>
- Many pt improve when leave area
- Folic acid
- Abx: eg tetracycline for 6 months
- Replace fluid nd electrolytes
- Correct any nutritional deficiencies
What is Crohns disease?
- IBD affecting anywhere from mouth to anus, but often terminal ileum and colon
Cause of crohns?
- Unknown
- Genetic susceptibility
- Environmental factors: Hygeine, NSAIDs, Smoking, stress
- Intestinal microbiota - increased E Coli
- Host immune response
Microscopic changes associated with Crohns?
- transmural inflammation
- Increase in chronic inflammatory cells
- Lymphoid hyperplasia
- Granulomas (non-caseating epithelioid cell aggregates with Langerhans giant cells)
Macroscopic changes associated with Crohns?
- Mouth to anus with skip lesions
- Involved bowel has a thickened wall an a narrow lumen
- Cobblestone appearance (ulcers and fissures)
- ## Fistulae and abcess
Symptoms of crohns disease?
- Triad: Diarrhoea, abdo pain, weight loss
- Non-specific sx: weight loss, lethargy, low grade fever, malaise
- Loss of appetite, N+V
- Steatorrhoea
- Perianal disease - skin tags or ulcers
- Anal disease - fistulae to bladder/vagina/abdo wall
Extra-intestinal features of crohns?
- Erythema nodosum
- Pyoderma gangernosum
- Arthritis
- Uveitis, epislceritis, conjucntivitis
- Osteoporosis
- Clubbin
- PSC
- Fatty liver
Investigations for crohns?
Bloods: CRP, anaemia, low vit D and B12
Stool: Faecal calprotectin
Colonoscopy w/ biopsy is diagnostic
Small bowel enema
Specific crohns features seen on small bowel enema?
- Strictures - kantors string sign
- Proximal bowel dilatation
- Rose thorn ulcers
- Fistulae
How to induce remission in crohns disease?
- Glucocorticoids eg. Prednisolone
- Enteral feeding with an elemental diet
- 5-ASA drugs eg. mesalazine
- Azathioprine or mercaptopurine
- Infliximab
- Metronidazole for isolated peri-anal disease
How to maintain remission in crohns?
- Stop smoking
- Azathioprine or mercaptopurine
- Methotrexate
- 5-ASA;s
Surgical options for Crohns?
- Ileocaecal resection
- Segmental small bowel resections
- Stricturoplasty
- Colonic surgery: Sub-total colectomy, panproctocolectomy
- Surgical management of fistulae
Complications that can arise from Crohns?
- Fistulae
- Small bowel cancer
- Colorectal cancer
- OP
What is Ulcerative Colitis?
- Form of IBD
- Inflammation restricted to colon
- Continuous
Causes of ulcerative colitis?
- Unknown
- Genetic
- Environment: Smok and breastfeeding protetctive
- Psycho: chronic stress, deprivation
- Intestinal microbiota
- Host immune response
Macrosopic changes in UC?
- Colon only
- Reddended mucosa, inflamed and bleeds easily
- Extensive ulceration
Microscopic changes in UC?
- Mucosa shows chronic inflammatory cell infiltrate in the lamina propria
- Crypt abcesses
- Goblet cell depletion
Presentation of UC?
- Intermittent sx
- Bloody diarrhoea
- Mucus in stool
- Urgency
- Tenesmus
- Abdo pain
- Malaise, lethargy, anorexia, w loss
Extraintestinal manifestations of UC?
- Mouth ulcers
- Arthritis
- Erythema nodosum
- Pyoderma gangrenosum
- Uveitis
- PsC
Investiagtions for US?
Bloods: ID anaemia, WCC and platelets raised, ESR and CRP raised, pANCA+Ve
Colonoscopy with biopsy gold standard
Barium enema
Signs of UC on barium enema?
- Loss of haustrations
- Superficial ulcerations - psuedopolyps
- Narrow and short colon
What is toxic megacolon?
- Serious complication with UC
- Plain AXR sows dilated, thin-walled colon with diameter >6cm, gas filled and contains mucosal islands
- Risk of perforation…needs surgery
How to induce remission in UC?
- Rectal aminosalicylates
- Oral aminosalicylates
- Oral prednisolone
- Severe colitis needs IV steroids
How to maintain remission in UC?
- Oral aminosalicylates - mesalazine
- Azathioprine and mercaptopurine
- Surgery: colectomy
What is intestinal obstruction?
Blockage to the transit of intestinal contents through the gut
What is volvulus?
Twist/rotation of bowel segment
What are adhesions?
Sticking together of bowel contents.
What is intussusception?
Telescoping of one part of the bowel into a more distal part.
What is atresia?
Absence of opening or failure of development of a hollow structure.
Complications of untreated bowel obstruction?
- Ischaemia
- Necrosis
- Perforation
Clinical features of bowel obstruction?
- Vomiting: Projectile, faeculant
- Pain: Colicky
- Constipation and obstipation
- Abdo distension
- Tenderness
Management principles of bowel obstruction?
- ABCDE
- Fluid resus
- Pain relief
- Decompress - NG tube
- Accurate diagnosis
- Surgery
Causes of SBO in adults?
- Adhesions - commonest in developed world, usually due to prev abdo surgery
- Hernia
- Crohns
- Malignancy
Causes of SBO in children?
- Appendicitis
- Intussusception
- Atresia
- Hypertrophic pyloric stenosis
- Volvulus
Rare causes of SBO?
- Radiation
- Gallstones
- Diverticulitis, appendicitis
- Abcess
- Foreign bodies - ie hair balls in ill
Symptoms of SBO?
- Pain: Colicky to start, precedes pain
- Vomiting: follows pain. Projectile. Bilous/faecal. If coffee>necrosis
- Nausea/Anorexia
- Distension
- Constipation
Signs of SBO?
- Tachycardia, hypotension, pyrexia
- Tenderness
- Abdo distension
- Resonance: tympanic sounds (gas filled)
- Bowel sounds: increased in early stages,, absent later
Investigating SBO?
- Bloods: FBC, U&E, lactate
- Radiology: Plain erect Xray - SB loops with fluid levels
- CT: investigation of choice. w/contrast
- Ultrasound
- MRI
Management of SBO?
- Aggressive fluid resus
- Nasogastric decompression
- Analgesia and antiemetic
- Early surgical consultation
- IV abx
Causes of LBO in adults?
- Malignancy (90% in the west)
- Volvulus (50% of africa cases)
- Paralytic ileus
- Strictures
Causes of LBO in children?
- Imperforate anus
- Hirchsprungs disease
- Cystic Fibrosis - meconium ileus
Pathophysiology of LBO?
- The colon proximal to the obstruction dilates
- Increased colonic pressure causing decreased mesenteric bloodflow
- Mucosal oedema – transudation of fluid and electrolytes from the lumen in the bowel wall
- The arterial supply is compromised causing mucosal ulceration – leading to full thickness necrosis and perforation
- Bacterial translocation (from inside the bowel leaking out due to perforation) = sepsis (so patient may even present with signs of septic shock)
If ileocaecal wall is competent the caecum is likely to perforate
If ileocaecal valve is incompetent then faeculent vomiting can occur
Where do colorectal tumours cause obstruction?
- 70% on left side - distal to transverse colon
Symptoms of LBO due to malignancy or strictures?
- Average of 5 day sx
- Abdo discomfort
- Fullness/bloating/nausea
- Altered bowel habit: Tenesmus, difficulty opening bowels, blood in stool, constipation
- Abdo pain - colicky, tender
- Vomiting
- W loss
Symptoms of LBO due to volvulus?
- Sudden onset
- Pain
- Localised tenderness and distension
Clinical signs of LBO?
- Abdo distension: Resonance on percussion, sounds tinkling then absent, tender
- Palpable mass
- Rigidity and peritonitis
- DRE: empty rectum, hard stools, blood
Investigations for LBO?
- Proctoscopy/Sigmoidoscopy
- Bloods: FBC, U&E, lactate
- Ct+/- contrast is best
Management of LBO?
- NBM
- O2
- IV Fluid resus
- Monitor urine
- NG decompression
- Antibiotics
How to treat suspected perforation?
- Laparotomy
- Resect perforated segment
- Irrigate
How to manage LBO due to colorectal cancer?
- Initial resus as normal
- Relieve obstruction - stent decompression
- CT staging
- Neoadjuvant therapy - shrink before surgery
- Surgery
Normal max diameter of large bowel?
55mm
Normal max diamter of small bowel?
35mm
What is non-mechanical bowel obstruction?
- Adynamic obstruction, paralytic ileus
- Failure of peristalsis
Causes of non-mechanical bowel obstruction?
- Post op: Laparotomy, thoracotomy
- Ileus associated with systemic illness: MI, pancreatitis, sepsis
- Narcotic ileus: Intestinal movements stop when on morphine
Symptoms of non-mechanical bowel obstruction?
- Painless distension
- Vomiting
- Absent or minimal bowel sounds - tinkling
Investigations for non-mechanical bowel obstruction?
- Bloods: FBC, U&E, magnesium
- Radiology: XR, CT
How to manage non-mechanical bowel obstruction?
- NBM
- IV fluids
- NG aspiration
- Tx of underlying cause
- Avoid opiates
- Support nutrition
What is blood supply to colon?
- Superior and inferior mesenteric arteries
Common predisposing factors for bowel ischaemia?
- Increasing age
- AF
- Endocarditis, malignancy (as they cause emboli)
- CVD rf: Smoking, htn, hyperlipidaemia, diabetes
- Cocaine
Common features of bowel ischaemia?
- Abdo pain
- Rectal bleeding
- Diarrhoea
- Fever
- Bloods: Raised WBC
What causes acute mesenteric ischaemia?
- Embolism resulting in occulusion of an artery which supplies the small bowel
- Eg the SMA
- Classically they have hx of AF
Management of acute mesenteric ischaemia?
- Urgent surgery req
- Poor prog :/
What is chronic mesenteric ischaemia?
- Relatively rare clinical diagnosis
- May be thought of as ‘intestinal angina’
- Colicky, intermittent abdo pain occurs
What is ischaemic colitis?
- An acute but transient compromise in blood flow to the large bowel
- More likely to occur in the ‘watershed’ areas such as splenic flexure that are located at the borders of the aterrial territories
- May lead to: inflammation, ulceration and haemorrhage
Classical investigation for ischaemic colitis?
- ‘thumbprinting’ on AXR
- Due to mucosal oedema/haemorrhage
Management of ischaemic colitis?
- Usually supportive
- Surgery may be needed in minority
- Indcations for surgery: Generalised peritonitis, perforation, ongoing haemorrgage
What are haemorrhoids?
- A swollen vein or group of veins in region of anus
- Most common cause of rectal bleeding
- It is the enlargement/congestion of normal mucosal vascular cushions which contribute to anal continence
Different types of haemorrhoids?
External:
- Originate below the dentate line
- Prone to thrombosis, may be painful
Internal:
- Originate above the dentate line
- Do not generally cause pain
How can internal haemorrhoids be graded?
Grade 1 - do not prolapse out of anal canal
Grade 2 - prolapse on defecation but reduce spontaneously
Grade 3 - can be manually reduced
Grade 4 - Cannot be reduced
Causes/rf for haemorrhoids?
- Low fibre diet causing patient to overly strain when having a bowel movement
- Pregnancy
- Prolonged sitting on the toilet
- Obesity
- Diarrhoea (both acute and chronic)
- Colon cancer
- Previous rectal surgery
- Spinal cord injury and lack of erect
posture
Symptoms of haemorrhoids?
- Painless rectal bleeding
- Pruritus ani
- Pain
- Soiling may occur with 3rd or 4th degree
Diagnosis of haemorrhoids?
- Inspection
- Rectal exam
- Proctoscopy
Management of haemorrhoids?
- Soften stools: Increase dietary fibre and fluids
- Topical local anaesthetics and steroids eg anusol
- Outpatient tx: Rubber band ligation, injection scleropathy
- Surgery: If large and symptomatic
- New treatments: Doppler guided haemorrhoidal artery ligation and stapled haemorrhoidopexy
How do acutely thrombosed external haemorrhoids present?
- Typically present with significant pain
- On examination
- Purple, oedematous, tender subcutaneous perianal mass
- If patient presents within 72 hours, referral should be considered for excision
- Otherwise, patients can usually be managed with:
- Stool softeners, ice packs and analgesia
- Symptoms usually settle within 10 days
What are anal fissures?
- A tear in the lower anal canal distal to the dentate line which produces pain on defecation
- Location: midline 6 and 12 o’clock postios
Causes of anal fissures?
- Most cases: constipation/hard stool tears lining of anal canal
- Can occur in IBD - perianal abcesses and anal fistulae may complicate
- Other causes: persistent diarrhoea, pregnancy, childbirth, unusally tight anal sphincter muscles
Symptoms of anal fissures?
- Pain on defecation (sharp pain)
- Often followed by deep burning pain that may last several hours
- Bleeding when passing stool - small amount of bright red blood in stools or on toilet paper
Features of chronic anal fissures?
- Symptoms of >6weeks
- Triad of: Ulcer, sentinel pile, enlarged anal papillae
How is anal fissure diagnosed?
- Clinical diagnosis: Hx and exam
- Peri-anal inspection
- Rectal exam often not possible due to pain
- Proctoscopy can be done under anaesthesia to exclude other disease
How are anal fissures treated?
- Local anaesthetic gel
- Stool softeners
- Botox on chronic fissures
- Reduce risk by: High fibre diet, well hydrated pt, not ignoring urge to pass stools, exercising regularly
What is an anal fistula?
- Abnormal communication between anus and the perianal skin
- Usually due to previous ano-rectal abcess
- Can be : intersphincteric, transsphincteric, suprasphincteric, extrasphincteric
What rule is used to determind location of the anal fistula?
- Goodsalls rule
Causes of anal fistulae?
- Previous abcess (common cause)
- Crohns disease
- Anorectal cancer
- TB
- HIV/AIDS
- Chlamydia
- Syphilis
- Previous ulcer
- Complication of surgery
- Complication of a congenital problem
Risk factor for anal fistulae?
- Smoking - as it impairs healing
How to investigate anal fistula?
- Endo-anal ultrasound
- MRI and or exam under anaesthetic
Management of anal fistula?
- Surgical incision and drainage
- Antibiotics
What is a pilonidal sinus/abcess?
- Small hole or tunnel under the skin that usually develops in the cleft of the buttocks where the buttocks seperate
- More than one hole may develop that are often linked by tunnels under the skin
- Dont normally cause sx unless infected.
Main infecting organisms of ano-rectal abcess?
- E.Coli
- Staph aureus
Possible positions of rectal abcess?
- Perianal
- Ischiorectal
- Pelvirectal
- Intersphincteric
Risk factors for pilnonidal sinuses?
- Obesity
- Large amount of body hair
- Having a job that involves a lot of sitting/driving
How are pilonidal sinuses/abcesses treated?
- Keep area clean and dry
- Remove hair near sinus
- Antibiotics
- Pus drainage and surgical incision
What is irritable bowel syndrome?
- A functional bowel disease causing an alteration in bowel habit and other GI symptoms
- Can be classified according to pattern:
- IBS w/ constipation
- IBS w/ diarrhoea
- Mixed IBS
When should a diagnosis of IBS be considered?
If the patient has had the following for at least 6 months:
- Abdo pain and/or
- Bloating and/or
- Change in bowel habit
Diagnostic criteria for IBS?
- Abdominal pain relieved by defecation or associated with altered bowel habit
- Plus 2 of the following:
- Altered stool passage (straining, urgency, incomplete evac)
- Abdo bloating, distension or hardness
- Symptoms made worse by eating
- Passage of mucus
- Features such as lethargy, nausea, backache and bladder symptoms may also support dx
red flag features in IBS hx?
- Rectal bleed
- Weight loss
- FHx of bowel or ovarian cancer
- Onset after 60yrs
Cause of IBS?
- Thought to be of biospychsocial origin - brain gut axis
- Depression and anxiety
- GI infection
- Stress and trauma
- Abx therapy
- Sexual, physical, verbal abuse
- Pelvic surgeryu
- Eating disorders
Risk factors for IBS?
- Female gender
- Traumatic life event
- High hypo-chondrial anxiety scores
- Prev episodes of infectious diarrhoea
Symptoms of IBS?
- Crampy abdominal pain relieved by defecation or the passage of wind
- Altered bowel habit
- Sensation of incomplete evacuation
- Abdominal bloating and distention
- Diarrhoea without pain (formed stools followed by loose mushy stools, mainly in the morning)
- Systemic symptoms, can co-exist with:
- Chronic fatigue syndrome
- Fibromyalgia
- TMJ syndrome
Investigating IBS?
- Exam usually normal
- Initial ix by GP - FBC/ESR/CRP +coeliac
- Sigmoidoscopy with air sufflation may reproduce pain
- Rectal biopsy to exclude IBD
- Colonoscopy, esp in >50 to r/o sinister pathology
- It is a diagnosis of exclusion.
First line pharmacological remedies for symptomatic relief in IBS?
Remedy according to predominant symptom?
- Pain: antispasmodic agents (mebevrine, peppermint oil)
- Constipation: laxatives (soluble fibre supplements)
- Diarrhoea: loperamide
Second line pharma treatment for IBS?
- Low dose TCAs eg. amitriptyline 5-10mg
- SSRI can be used too
Psychological interventions for IBS?
- CBT
- Hypnotherapy
- Psychological therapy
General dietary advice for IBS?
this has loads on it
- Explore dietary triggers and refer to a dietician
- Have regular meals and take time to eat
- Avoid missing meals or leaving long gaps between eating
- Drink at least 8 cups of fluid per day (water or herbal tea)
- Restrict tea and coffee to 3 cups per day
- Reduce intake of alcohol and fizzy drinks
- Consider limiting intake of high fibre food (wholemeal and whole grains)
- Reduce intake of ‘resistant starch’ often found in processed foods
- Limit fresh fruit to 3 portions per day
- For diarrhoea – avoid sorbitol (found in some fruits)
- For wind and bloating – consider increasing intake of oats and linseeds
What is diverticular disease?
pouches of mucosa extrude through the colonic muscular wall via weakened areas near blood vessels to form diverticula
What is diverticulosis?
the presence of diverticula (multiple outpouchings of the bowel wall)
What is diverticulitis?
implies inflammation, which occurs when faeces obstruct the neck of the diverticulum
Most common site for diverticular disease?
- Between taenia coli where vessels pierce the muscle to supply the mucosa
- For this reason the rectum (no taenia coli) is often spared
Symptoms of diverticular disease?
- Altered bowel habit
- PR bleeding
- Abdominal pain
Complications of diverticular disease?
- Diverticulits
- Haemorrhage
- Fistula development
- Perforation and faecal peritonitis
- Perforation and abcess development
- Development of diverticular phelgmon
How to diagnose diverticular disease?
Pt will undergo either:
- Colonoscopy
- CT cologram
- Barium enema
What is the Hinchey classification of severity for diveritcular disease?
I – Para-colinic abscess
II – pelvic abscess
III - purulent peritonitis
IV - faecal peritonitis
How is diverticular disease treated?
- Increase dietary fibre intake
- Mild attacks of diverticulitis may be managed with Abx
- Peri-colonic abscesses – drained surgically or radiologically
- Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative indication for a segmental resection
- Hinchey IV perforations will require resection and usually stoma
Most common site for diverticulosis?
- Sigmoid colon
- Multiple outpouchings of the bowel wall
Presentation of diverticulosis?
- Painful diverticular disease:
- Altered bowel habit
- Colicky left sided abdo pain
- High fibre diet recommended
- Diverticulitis
How does acute diverticulitis present?
- Severe left iliac fossa pain and tenderness
- Anorexia, nausea and vomiting
- Change in bowel habit – constipation or diarrhoea
- Urinary frequency, urgency or pain (bladder irritated by inflamed bowel)
- Features of infection – pyrexia, raised WBC and CRP
- PR bleeding in some cases
Usually affects 50-70 year olds
80% of patients are >50
How does chronic diverticulits present?
- Intermittent abdominal pain - particularly in LLQ
- Bloating
- Change in bowel habit - constipation or diarrhoea
Physical signs of diverticulitis?
- Low grade fever
- Tachycardia
- Tender LIF
- Possible reduced bowel sounds
- Guarding, rigidity and rebound tenderness
- Lack of improvement with tx suggests abcess
Risk factors for diverticulitis?
- Age
- Lack of dietary fibre
- Obesity
- Sedentary lifestyle
- Smoking
- NSAID use
Investigating diverticulits?-
FBC - raised WCC
CRP - raised
Erect CXR - may show pneumoperitoneum if perforation
AXR - may show dilated bowel loops, obstruction of abcesses
CT - best imaging modality
Avoid colonoscopy initially due to increased risk of perforation in diverticulitis
How is diverticulits managed?
Mild attacks: Oral antibiotics
More significant req admission:
- NBM
- IV fluids
- IV ABx - typically a cephalosporin + metronidazole
What are the possible complications of diverticulits?
- Abscess formation
- Peritonitis
- Obstruction
- Perforation
What is Meckels diverticulum?
- A congenital diverticulum of the small intestine
- Remnant of the vitelline duct (aka omphalomesenteric duct)
- Contains ectopic ileal, gastric or pancreatic mucosa
- Rules of 2s: 2% of population, 2 feet from ileocaecal valve, 2inches
How does meckels diverticulum present?
- Usually aymptomatic
- Abdo pain mimicking appendicitis
- Rectal bleeding
- Intestinal obstruction secondary to:
- Omphalomesenteric band, volvulus, intussuception.`
How is meckels diverticulum managed?
- Removal if narrow neck or symptomatic
- Options are between:
- wedge excision
- formal small bowel resection and anastamosis
What is acute appendicitis?
- The most common acute abdominal condition requiring surgery
- Can occur any age, commonly 10-20
- Occurs when the luemn of the appendix becomes obstructed by a faecolith
- The bacteria inside the faecolith stagnate inside the appenix
- Causes inflammation
Presentation of appendicitis?
Abdominal pain:
- Peri-umbilical initially
- Migrates to RIF - McBurneys point
- Pain often worse on coughing, going over speed bumps
- Children cant hop on their right leg due to pain
Other features: N+V, Diarrhoea, Low grade fever, anorexia
Signs of appendicitis on abdo exam?
- Localised peritonism (tenderness and guarding)
- Rebound tenderness in RIF
- May be a tender mass present if there is an appendiceal abcess
What investigations should be done for appendicitis?
- Blood tests: Raised WBC, CRP and ESR
- Urinalysis: Exclude preg, exclude UTI and renal colic. May show leucocytes but no nitrates
- USS: Inflamed appendix and/or mass
- CT scans: Highly sensitive and specific. gold standard.
Management of appendicitis?
- Appendicectomy
- Metronidazole to reduce wound infection rates
- If perforated appendicitis - abdominal lavage
Complications of appendicitis?
- Gangrene or perforation
- Leading to localised abcess formation or generalised peritonitis
2 histological types of oesophageal cancer?
- Squamous cell carcinoma: usually middle 1/3 of oesophagus
- Adenocarcinoma: lower 1/3rd
What are the causes/rf of squamous cell carcinoma of the oesophagus?
- Smoking
- Excess alcohol consumption
- Pre-existing oesophageal disease (achalasia and strictures)
- Coeliac disease
- Reflux
- Scleroderma
- Diets rich in nitrosamines (bacon, cured meats, beer)
What are causes/rf of adenocarcinoma of the oesophagus?
- GORD
- Barretts oesophagus
- Smoking
- Obesity
Symptoms of oesophageal cancer?
- Dysphagia (increases as tumour grows, solids then liquids)
- Vomiting
- Weight loss and anorexia
- Odynophagia
- Hoarse voice
- Cough
- GI bleeding - haematemesis, melena
- Dyspepsia and reflux sx
- Symptoms of anaemia
Signs of oesophageal cancer?
- Anaemia
- Malnutrition
- Supraclavicular lymphadenopathy (virchows node)
- Pleural effusion
- Hepatomegaly
- Ascites
- Vocal cord paralysis/voice change
Investigations for oesophageal cancer?
- Upper GI endoscopy: First line investigation
- Contrast swallow
- Staging: Ct chest, abdo, pelvis
Management of oesophageal cancer?
- Operable disease managed by surgical resection
- Neoadjuvant chemotherapy
- Stenting is option for palliation, however sx relief only
Main complications of oesophageal cancer resection?
- Anastomotic leak: Intrathoracic anastomosis will result in mediastinitis. high mortality.
What type of cancer is gastric cancer?
Adenocarcinoma - because stomach cells are secretory
When does gastric cancer often present?
70-80yrs.
Risk factors/associations of gastric cancer?
- H.Pylori infection
- Blood group A
- Gastric adenomatous polyps
- Pernicious anaemia
- Smoking
- Aspirin
- Diet: salt, spicy, nitrates
- Low socioeconomic groups
How does gastric cancer present?
- Dyspepsia
- N+V
- Anorexia and W loss
- Dysphagia
- Outflow obstruction
- If metastasis: ascites and hepatomegaly
How is gastric cancer investigated?
- Diagnosis: Endoscopy and biopsy
- Staging: CT or endoscopic ultrasound
- Laparoscopy to identify occult peritoneal disease
- PET CT
How is gastric cancer treated?
- Proximal disease greater than 5-1-cm from the OG junction – sub-total gastrectomy
- Total gastrectomy if tumour is <5cm from OG junction
- Surgical options – gastric resection, lymphadenectomy, reconstruction
- Pre-op chemo improves survival
- Adjuvant chemotherapy after surgery if operable
- Palliative chemotherapy if inoperable
What are the types of cancers that can affect small intestines?
These are RARE
- Adenocarcinoma – 50% increased incidence in Coeliac and Crohn’s
- Non-Hogkin’s lymphoma – may be B or T cell in origin, increased frequency in coeliac disease
- Benign small intestinal tumours
- Peutz-Jeghers syndrome (autosomal dominant)
- Familial adenomatous polyposis (FAP) - Carcinoid tumours
How do small bowel tumours present?
- Abdominal pain
- Diarrhoea
- Anorexia
- Anaemia
What are carcinoid tumours?
Originate from enterochromaffin cells of the intestine (produce histamine and serotonin)
What is carcinoid syndrome?
- The term applied to the symptoms that arise as a result of serotonin (5-HT), kinins, histamine and prostaglandins being released into the circulation by the tumour
- Usually occurs when metastases are present in the liver and release serotonin into the systemic circulation
- May also occur with lung carcinoid as mediators are not ‘cleared’ by the liver
What are the features of carcinoid syndrome?
- Flushing
- Diarrhoea
- Bronchospasm + wheezing
- Hypotension
- Right heart valvular stenosis
- Other molecules such as ACTH and GHRH may also be secreted resulting in, for example, Cushing’s syndrome
How to diagnoise carcinoid tumour/syndrome?
- Urinary 5-HIAA levels raised (breakdown product of serotonin)
- Plasma chromogranin A
- Liver USS scan
Treatment of carcinoid syndrome/tumours?
- Somatostatin analogues eg. octreotide
- Diarrhoea give cyproheptadine
- Tumour reduced via surgery or chemo
3 different types of colon cancer?
1) sporadic (95%)
2) hereditary non-polyposis colerectal carcinoma
3) familial adenomatous polyposis
What is the histology of colorectal cancer?
Adenocarcinoma
Inheritance pattern of HNPCC?
- Autosomal dominant
- Most common inherited cancer
- aka Lynch Syndrome
If you have HNPCC, what are you also at risk of?
- Endometrial cancer (commonly)
- Gastric cancer
- Pancreatic cancer
Criteria for HNPCC diagnosis?
Amsterdam criteria
1) At least 3 family members with colon cancer
2) The cases span at least 2 generations
3) At least once case diagnosed before age 50
Inheritance pattern of FAP?
AD
Mutation in the tumour suppression gene called adenomatous polyposis coli gene (APC) on chromosome 5
What are the features of FAP?
- Formation of hundreds of polyps by age 30-40yrs
- Inevitable they will develop carcinoma of large bowel
- Gardners syndrome is an FAP variant, you also get: osteoma of skull/mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts
How to manage FAP?
- Genetic testing: analyse DNA from WBC
- Total colectomy with ileo-anal pouch formation in their 20s
Risk factors for colorectal cancer?
- Fhx
- Diet: lack of fibre, red meat, alcohol
- Smoking
- Past history of bowel conditions - adenoma, ulcerative colitis
Where are large bowel cancers often found?
- Rectal 40%
- Sigmoid 30%
- Asc colon and caecum 15%
- Transverse colon 10%
- Descending colon 5%
Generic features of bowel cancer?
- Bleeding
- Mucous
- Change in bowel habit
- Difficulty defecating of bowel obstruction
- Weight loss
- Night sweats/fevers
- Hepatomegaly
How does rectal cancer present?
Early: PR bleeding, mucus
Late: Thin stools, tenesmus
How does left sided and sigmoid cancer present?
Change in bowel habit: Diarrhoea, constipation, thin/altered stools
PR bleeding
How does right sided bowel cancer present?
- Later than left sided
- Anaemia
- Mass
How may bowel cancer present acutely?
Bowel obstruction with four cardinal signs
1) Absolute constipation
2) Colicky abdo pain
3) Abdominal distension
4) Vomiting
When to refer URGENT to colorectal?
- Patients ≥ 40 with unexplained weight loss AND abdominal pain
- Patients ≥ 50 with unexplained rectal bleeding
- Patients ≥ 60 years with iron deficiency anaemia OR change in bowel habit
- Occult blood found in faeces
When to refer 2WEEKWAIT to colorectal?
- Rectal or abdominal mass
- Unexplained anal mass or anal ulceration
- Patients < 50 years with rectal bleeding AND any of the following explained symptoms/findings:
- Abdominal pain
- Change in bowel habit
- Weight loss
- Iron deficiency anaemia
Investigations for colorectal cancer?
- Tumor markers: CEA can be useful
- Colonoscopy is gold standard with biopsy and polyp removal.
- Double contrast barium enema
- CT colonoscopy
Risks of colonoscopy?
- Bleeding
- Infection
- Perforation
- Missed dx
- Anaesthetic risks
How is colorectal cancer staged?
TNM
Dukes
TNM staging for colorectal?
T0 = tumour confined to mucosa T1 = tumour invades submucosa T2 = tumour invades muscularis propria T3 = tumour invades serosa T4 = tumour invades other organs
N0 = no nodal involvement, N1 = 1-3 nodes involved, N2 = ≥ 4 nodes M0 = no distant mets, M1 = distant mets present
Dukes classification of colorectal?
A: Tumour confined to mucosa
B: Tumour invading bowel wall
C: LN metastases
D: Distant mets
Management of colorectal cancer?
- MDT meeting essential – decides on surgical/non-surgical/both
- Surgery - only chance of cure
- Resection – tailored to the patient and tumour location
- Post-operative (adjuvant) chemotherapy – increases survival
- Radiotherapy – either pre-operative or palliative to improve symptoms
- If liver mets – hepatic resection offered
- Palliative chemotherapy – for those with unresectable metastatic disease, improves QoL and median survival
- Palliative surgery – stents, bypass, diversion stomas
What is peritonitis?
Inflammation of the peritoneum
Difference between localised and generalised peritonitis?
Localised:
- Occurs with all acute inflammatory GI conditions
- Management depends on the underlying condition e.g. appendicitis, cholecystitis
Generalised
- Occurs as a result of rupture of an abdominal viscus (e.g. perforated DU or appendix)
- Sudden onset of abdominal pain which becomes rapidly generalised
- Patient is shocked and lies still as movement exacerbates the pain
Causes of primary peritonitis?
- Extremely rare
- Haematogenous - originates/carried in the blood or from LN
- Risk groups:
- Liver disease (Spontaneous bacterial peritonitis)
- Females
- Immune compromised
- Post-splenectomy
- Peritoneal dialysis pts
- Patients with ascites
Causes of secondary peritonitis?
- Perforation of hollow viscus (generalised peritonitis)
- Peptic ulcer, colonic diverticulum, appendix
- Inflammation of abdo organs (localised peritonitis)
- Peritoneal dialysis
- TB
- Ischaemia of hollow viscus
- Chemical contamination eg glove left in after surgery
Symptoms of peritonitis?
- Acute presentation
- Pain
- Tenderness
- Systemic sx: Nausea, chills, rigors, dizziness, weakness, immobile due to pain
Clinical exam findings for peritonitis?
General exam: - Pyrexia, tachycardic, signs of shock - Confusion - Pt lie still Abdo exam: - Guarding - Hard, rigid abdomen - Rebound tendernes - Silent abdomen (ominous sign)
Investigating ?peritonitis?
- Blood tests: FBC,U&E,amylase, LFTs, CRP
- ABG - look for sepsis
- Plaiin XR
- CT abdo
- Culture: Blood and ascitic fluid
How to manage peritonitits?
- ABCDE approach to resuscitation
- Sepsis 6
- Broad spectrum IV antibiotics
- Treat underlying cause
- Medical Mx of primary peritonitis – IV Abx (SPB, PID, PD related)
- Surgical Mx of secondary peritonitis – repair or removal of perforated viscus
What is a hernia?
Protrusion of a viscus or part of a viscus through a natural orifice or weakness into another compartment.
All abdo wall hernias present as a lump
Common types of hernia?
Inguinal (direct or indirect) Femoral Umbilical Paraumbilical Epigastric Incisional Parastomal Hiatus
How to classify hernias?
Reducible Irreducible Incarcerated Obstructed Strangulated
What is a reducible hernia?
- Can be pushed back in
- Can be spontaneous or manual
- Most are reducible when they first appear
What is an irreducible hernia?
- Impossible to return contents of hernia to abdo cavity
- Usually involve bowel
- Can be partial or complete
What is hernial incarceration?
- Contents of hernia sac are stuck inside by adhesions
What is an obstructed hernia?
- Pressure from edges of hernia means bowel contents cannot pass through - causes feature of intestinal obstruction
What is a strangulated hernia?
- Ischaemia occurs –> gangrene and perforation of hernia contents
What is an inguinal hernia?
- Most common type of hernia
- Accounts for 75% of abdo wall hernieas
- 95% male
Predisposing factos for inguinal hernia?-
- Male gender
- Chronic cough
- Constipation
- Urinary obstruction
- heavy lift
- Ascites
- past abdo surgery
Features of inguinal hernias?
- Groin lump: disappears on pressure or where pt lies down
- Discomfort and ache
- Strangulation is rare
Direct vs indirect inguinal hernia?
- Direct: Through posterior wall of inguinal canal
- Indirect: Hernia through inguinal canal
Management of inguinal hernia?
Treat medically fit patients even if they are asymptomatic
Surgical repair with polyproylene mesh
If patient not fit for surgery – hernia truss may be an option, no role in other patients
When can pt return to work after hernia repair?
Open repair – 2-3 weeks (non manual work only)
Laparoscopic repair – 1-2 weeks
Complications of hernia repair?
Early: Bruising and wound infection
Late: Chronic pain and recurrence
Main risk of femoral hernia?
HIGH risk of strangulation
How do femoral hernias present?
Mass on medial thigh.
More often women
Treatment of femoral hernia?
Either:
Herniotomy: ligation and excision of sac
Herniorrhaphy: Repair of hernia defect (ie with mesh)
What is an incisional hernia?
- Occur through sites of surgical access into the abdominal cavity.
- Most common following surgical wound infection
To minimise following midline laparotomyJenkins Ruleshould be followed:
- This necessitates a suture length 4x length of incision - With bites taken at 1cm intervals, 1 cm from the wound edge.
- Repair may be performed either at open surgery or laparoscopically and a wide variety of techniques are described
Risk factors for incisional hernia?
- Obesity
- Emergency surgery
- Wound infection post op
- Persistent coughing
- Poor nutrition
- Heavy lifting
- Other pre-existing health condition that slows healing eg HIV or diabetes
What is an umbilical hernia?
- Hernia through weak umbilicus
- Usually presents in childhood
- Often asymptomatic
- Equal sex incidence
- 95% will resolve by age 2
- Thereafter try surgical repair
Rf for umbilical hernia?
- Black kids
- Obesity
- Ascites
- Heavy lifting
- Persistent coughing
- Multiple pregnancies
Management of umbilical hernia?
< 2 years – leave alone
> 2 years – surgical repair of the rectus sheath (Mayo repair)
What is a hiatus hernia?
Herniation of part of the stomach above the diaphragm through the oesophageal hiatus
2 types:
Sliding
Rolling (Para-oesophageal)
What are Sliding hiatus hernia?
- Account for 95% of hiatus hernias
- The gastroesophageal junction moves above the diaphragm
- Asymptomatic unless there’s associated reflux
What is a rolling hiatus hernia?
- Uncommon
- Gastric fundus rolls up through the hiatus alongside the oesophagus
- Gastro-oesophageal junction remains below the diaphragm
- Poses a serious risk of complications – gastric volvulus (rotation and strangulation of the stomach), bleeding and respiratory complications
- Should be treated surgically
What is a volvulus?
- Complete twisting of a loop of intestine around its mesenteric attachment site
- Resulting in compromised blood flow and closed-loop obstruction
- Can occur at various locations e.g. stomach, small intestine, caecum, transverse and sigmoid colon
Most common site for volvulus?
- Sigmoid is 80% (LBO caused by sigmoid colon twisting on its mesentery)
- Caecum is 20%
Associations with sigmoid volvulus?
- Older patients
- Chronic constipation
- Chagas disease (American trypanosomiasis)
- Neurological conditions e.g. Parkinson’s disease, Duchenne muscular dystrophy
- Psychiatric conditions e.g. schizophrenia
Associations with caecal volvulus?
- All ages
- Adhesions
- Pregnancy
Features of volvulus?
Sx of BO:
- Constipation
- Abdo bloating
- Abdo pain
- N+V
Diagnosis of volvulus?
- Usually diagnosed on abdo film (XR)
- Sigmoid: LBO (large dilated loop of colon) and Coffee Bean sign
- Caecal: SBO seen
Management of volvulus?
Sigmoid volvulus - rigid sigmoidoscopy with rectal tube insertion
Caecal volvulus - management is usually operative. Right hemicolectomy is often needed
What is diarrhoea?
- Liquid form loose stools
- Often frequent/urgent passing
DIfference between chronic and acute diarrhoea?
- Acute: Usually due to infection or food poisoning
- Chronic: defined as diarrhoea persisting for >14 days.
List some infectious causes of diarrhoea?
- Infectious = gastroenteritis. May occur at home or whilst travelling abroad
- Viral – rotavirus, norovirus
- Foodborne – often bacterial
- Antibiotic associated diarrhoea (wipes out normal gut flora)
- Travel related – E.coli, Giardiasis etc
- Diarrhoea in the immunocompromised
- Can be a feature of systemic infection (e.g. sepsis, malaria)
Non infectious causes of diarrhoea?
- IBD
- Malabsoprtion eg Coeliac disease
- Malignancy
- Overflow w/ constipation
- Endocrine eg thyrotoxicosis
- Medicines eg. laxative abuse, metforin
Clues about cause of infective diarrhoea?
- History of contact with other cases - Norovirus
- Small children – rotavirus
- Fresh water – Aeromonas
- Puppies, chicken restaurant – Campylobacter
- Reptiles – Salmonella
- Well water – Giardia
- Flooding/water problems – Cryptosporidiosis
- Raspberries – Cycospora
Management of diarrhoea?
- Oral rehydration salts (dioralyte)
- Loperamide: acts on opioid receptors to slow gut down. Doesnt cross BBB so no neuro sx
Side effects and C/I for loperamide?
Side effects
- Constipation
- Abdominal cramps
- Dizziness
Contraindications
- Ulcerative colitis
- Infective diarrhoea associated with bloody stools – as you actually want to
clear this kind of diarrhoea, not stop it
Define travellers diarrhoea?
At least 3 loose watery stools in 24 hours
With or without one or more of:
- Abdominal cramps
- Fever
- Nausea
- Vomiting
- Blood in the stool
Most common cause of travellers diarrhoea?
E. Coli
What is acute food poisoning?
Sudden onset of nausea, vomiting and diarrhoea after the ingestion of a toxin.
Most common causes of acute food poisoning?
- Staphylococcus aureus
- Bacillus cereus
- Clostridium perfringens
Describe history of E.Coli diarrhoea?
- Common amongst travellers
- Watery stools
- Abdominal cramps and nausea
- Incubation period 12-48 hours
Describe history of Giardasis diarrhoea?
- Prolonged
- Non-bloody diarrhoea
- Incubation period > 7 days
- Parasitic infection rather than bacterial
Describe history of cholera diarrhoea?
- Profuse, watery diarrhoea
- Severe dehydration resulting in weight loss
- Not common amongst travellers
Describe hx of shigella diarrhoea?
- Bloody diarrhoea
- Vomiting and abdominal pain
- Incubation period - 48-72 hours
Describe hx of staph aureus infection?
- Severe vomiting
- Short incubation period (1-6hrs)
Describe hx of campylobacter diarrhoea?
- Flu-like prodrome
- Crampy abdominal pains
- Fever
- Diarrhoea which may be bloody
- Complications include GBS
- Incubation period 48-72 hours
Describe hx of bacillus cereus?
Two types of illness seen:
- vomiting within 6 hrs, stereotypically due to rice
- Diarrhoeal illness occuring after 6hrs
Describe hx of amoebiaisis diarrhoea?-
- gradual onset bloody diarrhoea
- abdo pain and tenderness
- may last several weels
What is Clostridium difficile?
- A gram positive rod bacteria (purple in gram stain)
- Often encountered in hospital setting
- Develops when the normal gut flora are suppressed by broad spectrum antibiotics
Main complication of C Diff?
Pseudomembranous colitis.
Occurs due to C.Diff exotoxin causing intestinal damage
Risk facotrs for C Diff infection?
- Broad spectrum abx: 3rd gen cephalosporins are leading cause (cefotaxime and ceftriaxone etc)
- Use of PPI and H2 receptor antagonists
- Being hospitalised
- Contact with infected persons
Clinical features of C Diff?
- Diarrhoea
- Abdo pain
- Raised WBC count
- If severe: Toxic megacolon
Diagnosis of C Diff how?
- Stool sample: Detection of clostridium difficile toxin in the stool
How is C Diff treated?
- Isolate
- First line therapy – oral metronidazole for 10 - 14 days
- If severe or not responding to metronidazole – oral vancomycin may be used
- Patients who don’t respond to vancomycin may respond to oral fidaxomicin
- For life-threatening infections – combination of oral vancomycin and IV metronidazole should be used
- Patients with severe and unremitting colitis should be considered for colectomy
Why is diarrhoea common in pt with HIV?
- May be due to opportunistic infections
- Or due to effects of virus itself
Causes of diarrhoea in HIV patients?
- Most common = cryptosporidium
- Detected with modified Ziehl-Neelsen stain for acid fast bacilli - Other protozoa too
- Cytomegalovirus
- Mycobacterium avium intracellulare
- Giardia
What causes amoebiasis?
- Entamoeba histiolytica
- Spread by faecal oral route
- 10% of worlds pop are chronically infected
Features of amoebiasis?
- Can be asymptomatic
- Can cause mild diarrhoea or severe amoebic dysentery
- Can also cause liver and colon abscesses
- Amoebic dysentery:
- Profuse, bloody diarrhoea
- Stool microscopy – trophozoites
- Treat w/ metronidazole - Amoebic liver abscess:
- Usually a single mass in the right lobe (may be multiple)
- Features - fever, RUQ pain
- Serology positive in >90%
How is malnutrition diagnosed?
Unintentional weight loss greater than 10% within the last 3-6 months
Or A body mass index of less than 18.5kg/m²
Or A body mass index of less than 20kg/m² and unintentional weight loss greater than 5% within the last 3-6 months
How can pancreatitis be classified?
Acute pancreatitis = inflammation of a previously normal pancreas. The inflammation that occurs is reversible
Chronic pancreatitis = continuing inflammation with irreversible structural changes
Exocrine functions of pancreas?
- The exocrine glands of the pancreas produce enzymes used for digestion
- These enzymes include
- Trypsin and chymotrypsin – protein digestion
- Amylase – carbohydrate digestion
- Lipase – breakdown of fats
- These are released into the pancreatic duct when food enters the stomach
- Ampulla of Vater releases these into the duodenum
Endocrine functions of pancreas?
- Endocrine component of the pancreas consists of islet cells (islets of Langerhans) which release hormones directly into the bloodstream
- The 2 main hormones are
- Insulin – acts to lower blood sugar
- Glucagon – acts to raise blood sugar
Causes of acute pancreatitis?
Most commonly = gallstones and alcohol IGETSMASHED Idiopathy Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion stings Hypothermia/hypercalcaemia ERCP (endoscopic retrograde cholangiopancreatography) Drugs - azathioprine, oestrogens, steroids, didanosine
Sx of acute pancreatitis?
- Severe epigastric pain - may radiate through to back
- Vomiting
- Anorexia/Nausea
- Hx of gallstones or alcohol abuse
Signs of acute pancreatitis?
- Abdominal examination – widespread tenderness and guarding
- Ileus – may have absent bowel sounds
- Low-grade fever
- In severe cases – signs of septic shock: tachycardia, hypotension, dehydration, oliguria
- Described but rare
- >Periumbilical discolouration - Cullen’s sign
- >Flank discolouration – Grey-Turner’s sign
How can acute pancreatitis be classified?
Oedematous – 70%
Severe/necrotising – 25%, necrosis
Haemorrhage – 5% (this is when you will see Cullen’s/Grey Turner’s sign)
Blood tests for suspected acute pancreatitis?
Serum amylase – 3x higher than normal level (but there are other reasons for hyperamylasaemia). Serum amylase levels do not correlate with disease severity
Serum lipase – raised, more sensitive and specific than serum amylase. It also has a longer half life
Urinary amylase – will still be raised if the patient present late and the serum amylase levels have dropped again
FBC, CRP, U&E, LFT, plasma Ca2+ and ABGs – measured on admission and at 24-48 hours to assess the severity of the pancreatitis
What else can cause raised amylase?
- Acute pancreatitis
- Pancreatic pseduocyst
- Mesenteric infarct
- Perforated viscus/peptic ulcer
- Acute cholecystitis
- Diabetic ketoacidosis
Imaging for ?acute pancreatitis?
- Erect CXR to r/o perforated peptic ulcer
- Abdominal USS for gallstones
- Contrast CT
- ERCP
Scoring systems for pancreatitis severity?
- Abbreviated Glasgow scoring system
- Ranson criteria
- Balthazar Score
- APACHE score – may also be used but usually only done in intensive care
CRP can also be used to assess severity
Components of abbreviated glasgow system?
Composed of 8 clinical indicators (PANCREAS), score of >3 indicates the for supportive ITU treatment or anaesthetic review
- PaO2 < 8 kPa – low
- Age > 55 years
- Neutrophils > 15x10^9 – raised
- Calcium < 2 mmol/l – low
- Raised urea > 15 mmol/l
- Elevated enzymes (LDH or AST)
- Albumin < 32 g/l - low
- Sugar – serum glucose >15 mmol/l - raised
management of pancreatitis?
- Analgesia very important
- ABCDE approach to resuscitation/shock
- Surgery:
- Patients with acute pancreatitis due to gallstones should undergo early cholecystectomy
- Patients with obstructed biliary system due to stones – ERCP
- Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement
- Patients with infected necrosis - either radiological drainage or surgical necrosectomy
How is mild pancreatitis managed?
Medical therapy consisting of
- Pain control – tramadol or other opiates, fentanyl
- NBM
- IV fluids
- NG tube
Monitor for complications
Management of severe pancreatitis?
- The same medical therapy for mild disease (IV fluids, analgesia)
- Consider ITU
- Prophylactic Abx – usually cephalexin/metronidazole
- Nasogastric or nasojejunal feeding
- ERCP within 48 hours if gallstones – extraction can be performed
- Anticoagulation with LMWH for DVT prophylaxis
Complications of acute pancreatitis?
Systemic inflammatory response syndrome
Multiple organ dysfunction syndrome (MODS) – pancreatitis causing loss of body homeostatic mechanisms
What is chronic pancreatitis?
- Inflammation of pancreas lasting >12 weeks
- Damage is irreversible
- Can lead to dysfunction of both exocrine and endocrine functions of pancreas. Leading to malabsoption and diabetes respectively.
- Difficult to dx and manage
Causes of chronic pancreatitis?
- 80% of cases due to alcohol
- Autoimmune
- Idiopathic
- Cystic fibrosis
- Trauma
- Hypercalcaemia
Features of chronic pancreatitis?
- Epigastric pain – typically worse 15-30 minutes after a meal
- Exocrine dysfunction - causing steatorrhea and other symptoms of pancreatic insufficiency (usually develops 5-25 years after the onset of pain)
- Endocrine dysfunction – DM occurs in majority of patients, usually 20 years after symptoms begin
- Severe weight loss and anorexia
- Nausea and vomiting
- Can occasionally present with jaundice – due to obstruction of CBD during its course through the fibrosed head of pancreas
How is chronic pancreatitis investigated?
Imaging: - Abdo XR - can show calcification - USS - CT - more sensitive - MRCP and endoscopic USS - ERCP Functional/biochemical - Faecal elastase - reduced - Blood glucose - raised, indicated DM - Serum amylase
Management of chronic pancreatitis?
- Advise patient to stop drinking alcohol
- Analgesia
- Surgical resection combined with drainage of the pancreatic duct into the small bowel
- ERCP – to amend pancreatic strictures or stones
- Pancreatic enzyme supplements – useful for those with steatorrhoa, may reduce frequency of attacks of pain in those with recurrent symptoms
- If diabetes has occurred – dietary control, oral hypoglycaemics or insulin
Complications of chronic pancreatitis?
- Pseudo-cyst (fluid collection surrounded by granulation tissue)
- Ascites and pleural effusion
- Pancreatic cancer