GI

Question 1

What are haemorrhoids?

Answer 1

Enlarged symptomatic anal vascular cushions (not just dilated veins)

-Anal vascular cushions –> part normal anatomy, containing AV channels that connect superior rectal artery and vein, usually positioned 3, 7, 11 oclock. Can be smaller additional ones in haemorrhoids.

RF –> middle age, constipation w prolonged straining, pregnancy

Question 2

What is the typical presentation of haemorrhoids?

What is the grading of haemorrhoids?

Answer 2

Bright red rectal bleeding –> on toilet paper and often coating stools, or dripping into toilet.

• There may be mucous discharge and pruritus ani.
• Usually painless, thrombosed external haemorrhoids can be painful and present acutely.
• Severe anaemia may occur.
• Symptoms such as weight loss, tenesmus, and change in bowel habit should prompt thoughts of other pathology.

Grading 
1 Never prolapse 
2 Prolapse and reduce spontaneously
3 Prolapse and require manual reduction 
4 Irreducible

Question 3

What are the investigations for haemorrhoids?

Answer 3

• DRE –> internal haemorrhoids can be hard to palpate
• Proctoscope for examining haemorrhoids –> examine colour and pain. Internal ask to strain and appear blue. Thrombosed painful and purple.
• In all rectal bleeding do –> An abdominal examination to rule out other diseases, PR exam: prolapsing piles are obvious. Internal haemorrhoids are not palpable. Colonoscopy/flexible sigmoidoscopy to exclude proximal pathology if >50 years old.
• FBC –> Check anaemia

Question 4

How should haemorrhoids be managed?

What are the options?

Answer 4

1 –> 1st degree –> Medical –> -Reassure, avoid straining, soften stools (fibre and fluids, bulk). Topical local anaesthetic cream (short term)

2 –> Non operative –> 2 and 3 degree or 1st and medical not working –> Rubber band litigation (IMPORTANT) (not for external as normal sensory supply). Sclerosants (phenol oil). Infrared coag, coags vessels less painful. Bipolar diathermy and direct current electrotherapy causes coag and fibrosis.

3 –> Surgery –> Excisional haemorrhoidectomy is the most effective treatment (excision of piles ± ligation of vascular pedicles, as day-case surgery, needing ~2wks off work). Stapled haemorrhoidopexy (procedure for prolapsing haemorrhoids) may result in less pain, a shorter hospital stay, and quicker return to normal activity than conventional surgery.

-Prolapsed, thrombosed piles –> Analgesia, ice packs, and stool softeners. Pain usually resolves in 2–3wks. Some advocate early surgery.

Question 5

What is appendicitis?

Answer 5

• Inflammation of the vermiform (worm shaped tube extending from caecum) appendix.
• Most commonly results from obstruction of appendiceal lumen –> usually secondary to a faecolith (hardened mass of faeces) obstruction w subsequent bacterial overgrowth leading to infection and pus formation(b frigilis, e.coli)
• Obstruction –> increase pressure of appendix –> compromise blood supply –> ischaemia, perforation, gangrene
• Lifetime risk 1 in 15
• RF –> constipation, younger age common in early teens
• Uncomplicated, non perforated. Complicated perforated.

Question 6

What is the typical presentation of appendicitis?

Answer 6

• Anorexia commonly 1st sign, followed by abdo pain and vomiting.
• Abdo pain initially visceral colicky pain in umbilical region, then moves to RIF over 24-48 hours and becomes consistent.
• RIF pain –> inflammation affecting the tissue and peritoneum surrounding appendix.
• RIF peritonism –> pain on moving or coughing, guarding, rebound tenderness.
• Fever tends to be mild.
• Tenderness can be localised to mcburnies point

Question 7

What are three potential signs in appendicitiis?

Answer 7

• Rovsings –> press in LIF and get RIF pain
• Psoas sign –> pain on extending hip (when retrocaecal appendix)
• Cope (obturator) sign –> pain on flexion and internal rotation of right hip

Question 8

What are the differential diagnosis in appendicitis?

Answer 8

Meckels diverticulitis, , gastroenteritis, intussusception, crohns,
PID, ovarian cyst, ectopic pregnancy
UTI, renal colic

Question 9

What are the investigations for appendicitis?

Answer 9

• Diagnosis –> most cases clinical.
• Bloods –> increased CRP and WBC.
• Diagnosis not sure or in older may have imaging
• Abdo pelvis CT –> best imaging often not required. US less sensitive but acceptable in pregnancy and children.

Question 10

What is the management for appendicitis?

Answer 10

• Surgery –> appendectomy definitive. Laparoscopic fewer complications e.g abscess formation. In pregnancy open is safer.
• Ab before surgery and 24 hours after, urgently when perforated. Ab –> cover g+ve and –ve e.g coamoxiclav.

-Most cases of uncomplicated appendicitis resolve in 10 days w Ab alone but surgery performed as high risk recurrence w/o surgery, 25% within 1 year and 40% within 5 years.

Question 11

What are the complications of appendicitis?

Answer 11

• Untreated can lead to perforation, generalised peritonitis and abscess formation
• Appendix mass, omentum and small bowel may adhere to inflamed appendix.
• Abscess can be treated w IV Ab and CT drainage. Abscess –> internal appendicectomy –> few weeks are intiial presentation following course Ab.