GI + Colorectal Flashcards
What is ‘the acute abdomen’
An emergency surgical condition caused by damage to one or more of the abdominal organs due to injury or disease
Describe the ‘type’ of pain with inflammatory causes of the acute abdomen?
Constant pain supported by a raised temperature, pulse and leucocytosis
What symptoms are seen with peritonitis?
Localised pain worse with movement, coughing or inspiration
(patient lies still with shallow breathing)
Often associated with guarding (reflex contraction of abdominal muscles on examination) and rigidity (increased tone at rest)
What ‘type’ of pain is seen with obstructive causes of AA?
Colicky
patients often agitated
may become constant with superimposed inflammation
Where is pain from the foregut referred to?
Midgut?
Hindgut?
Upper abdomen
middle abdomen
Lower abdomen
What are the abdominal causes of the acute abdomen?
Acute appendicitis Meckel's diverticulitis Intestinal obstruction Perforated viscus (acute severe pain and shock) Acute pancreatitis Acute cholecystitis/cholangitis Renal calculi Acute scrotum Inflammatory bowel disease
What are the vascular causes of the acute abdomen?
AAA
Mesenteric thrombosis/embolus
What are the medical causes of the acute abdomen?
GORD referred pain from pneumonia MI UTI Pyelonephritis
What are the gynae cases of the acute abdomen?
Ruptured ectopic, sorted /ruptured ovarian cysts, salpingitis
What are the other causes of the acute abdomen
Non-specific mesenteric adenitis (pain in young children, often following URTI)
What investigations should be done for the acute abdomen?
FBC, U+E, LFTs, CRP, amylase and ABG
Pregnancy test
Urinalysis
Erect CXR, AXR
USS/CT
What is the initial management of the acute abdomen?
A-E
Certain presentations require urgent laparotomy: rupture of an organ (spleen/aorta/ectopic)
Peritonitis (perforated ulcer, diverticulum, appendix, gallbladder)
Pancreatitis can mimic these: always check amylase, lipase
When does appendicitis occur?
When the appendix is obstructed by a faecolith (hard bi of poo) or foreign body in the lumen, or lymphoid enlargement in the wall
Bacterial can proliferate in the closed loop of bowel, eventually leading to necrosis and perforation due to raised intraluminal pressure
What are the symptoms of acute appendicitis?
Abdo pain, starting dull and central before becoming localised and sharp in the RIF at McBurney’s point
Constipation (or sometimes diarrhoea)
Anorexia
N+V (after the pain)
Where is McBurney’s point?
One third of the way between the ASIS and the umbilicus
What are the signs of acute appendicitis?
Rebound (when the examiner moves hand away, tenderness in the RIF)
Percussion tenderness
Guarding
Rosving’s sign
PR painful on the RHS (if pelvis appendix or pus in pouch of Douglas)
Tachycardia
Mild fever, flushing and fetor
Tender mass (occasionally)
PSOAS sign (pain on R hip extension, retroperitoneal, retrocaecal appendix)
Obturator sign (pain on internal rotation of R hip: pelvic appendix)
What is Rosving’s sign?
More painful in RIF than LIF when LIF pressed
What investigations should be done for Acute appendicitis?
PR Pelvic examination in females Pregnancy test Bloods - FBC, U+E, CRP/ESR Urinalysis USS/CT - if diagnostic uncertainty
AXR/erect CXR - if questioning perforation
What is the management of a confirmed appendicitis?
Resuscitation:
IV metronidazole/cephalosporin
Laparoscopic appendectomy
What are the complications of appendicectomy?
Early - haematoma, wound infections
Late - small bowel obstruction (adhesions) or incisional herniae
What are the complications of a perforated appendix?
Peritonitis and sepsis
Appendix mass: inflamed appendix becomes covered with omentum
Appendix abscess: local/pelvic/subhepatic/subphrenic: develop if appendix mass fails to resolve
Adhesions
Infertility
What are the ddx of a mass int the RIF?
Inflammatory mass (appendix mass/abscess) lymphoma chron's disease tumour mass (caecal / carcinoid Pelvic kidney
What is the management of a mass in the RIF?
USS/CT to confirm diagnosis
Conservative management: IV cefuroxime and metronidazole - marking out the size of the mass to see if it develops into an abscess
If the mass does not resolve, perform percutaneous drainage of the abscess
What is a carcinoid tumour?
Tumour of argentaffin cells, which produce physically active substances such as serotonin/prostaglandins
usually occurs when metastases are present in the liver and release serotonin into the systemic circulation
Where do carcinoid tumours tend to occur?
on the tip of the appendix
When do carcinoid tumours present?
after the fourth decade, with the carcinoid syndrome (flushing of the face and diarrhoea, due to the endocrine products)
What is the prognosis for carcinoid tumours?
Prognosis is generally good, and the tumour is generally resectable, even when there are local deposits in the liver
What is the cause of a Meckel’s diverticulum?
Caused by a remnant of the embryological vitellointestinal duct
Occurs in 2% of the population and 2% of these develop symptoms
What is the location of the Meckel’s diverticulum?
The diverticulum is 2cm long, on the antimesenteric border of the bowel, 20 inches from the ileocaecal valve
May be lined by gastric acid secreting epithelium, or heterotrophic pancreatic tissue
What are the clinical presentations of Meckel’s diverticulum?
Asymptomatic, or mimics other conditions:
Caecal volvulus: if tethered to the umbilicus
Intussusception: gangrenous by point of operation
Appendicitis: diverticulum becomes inflamed, presenting identical to appendicitis (sometimes also with umbilical cellulitis)
Peptic ulceration: pain around the umbilicus that is related to mealtimes due to ulceration of the gastric acid secreting epithelium
Sinus tract
What IX are done for Meckel’s diverticulum?
Technetium scan - parietal cells will take up the radiolabelled 99TC
CT will also show the diverticulum
Describe the epidemiology of Chron’s?
Prevalence 50/100,000 M=F
Incidence peaks at 15-30 and also again in the 60s
What are the risk factors for Chron’s disease?
Poor diet
FH
smoking
altered immune states
Where does chron’s affect?
Any part of the GI tract (mouth to anus)
Most commonly terminal ileum and descending colon
Can affect just one area, or multiple area, leaving normal bowel in between
‘Skip lesions’
What is the appearance of affects bowels in Chron’s disease?
Narrow bowel due to the thickened wall, with deep ulcers
‘Rose-thorn ulcers’
‘Cobblestone appearance on CT (specific to Chron’s, not seen on XR)
Goblet cells
Granulomas
Inflammation extends through all layers of the bowel
Fistulae and stenosis are common
What are the clinical features of Chron’s disease?
Abdominal pain (varying in character) Diarrhoea (steatorrhoea in ileal disease, bloody in colonic disease)
Weight loss / FTT
Severe apthos ulceration of the mouth (early sign)
Anal complications (fissure, fistula, haemorrhoids, skin tags, abscesses)
Extra GI manifestations
Can present with acute RIF pain/mass
What is the histological appearance of Chron’s disease?
transmural inflammation, lymphoid hyperplasia, granulomas
Describe the pathology of UC?
Inflammation that starts in the rectum, extending proximally along the colon
Proctitis if affects the rectum alone
Inflammation of the distal terminal ileum (backwash ileitis)
Inflammation only affects the mucosa, which is excessively ulcerated. Gives adjacent mucosa the appearance of inflammatory polyps
What are the clinical features of UC?
Crampy lower abdominal discomfort
Gradual onset diarrhoea (often bloody)
Urgency and tenesmus if disease confined to the rectum
Extra-GI symptoms
What is the histological appearance in UC?
Mucosal inflammation, crypt abscesses and goblet cell depletion
Chron’s vs UC location?
Chron’s: Mouth to anus
UC: colon only
Chron’s vs UC anal involvement
Chron’s often
UC seldom
Chron’s vs UC continuity
Chron’s - discontinuous ‘skip lesions’
UC: continuous from rectum
Chron’s vs UC fistulae?
Chron’s common
UC: uncommon
Chron’s vs UC histology
Chron’s: Transmural inflammation, granulomas, goblet cells present
UC: mucosal inflammation only, crypt abscesses, goblet cell depletion
Chron’s vs UC smoking
Chron’s: increases risk
UC: protective
Chron’s vs UC cure
Chron’s: surgery less effective
UC: colectomy
What bloods should be done for IBD?
FBC, U&E, CRP/ESR, LFT
Serum iron/B12/folate if anaemia
What stool studies should be done in ?IBD??
Stool chart
MCS/3 to exclude infective causes
calprotectin (may be ordered to rule out IBD in general practice)
What radiology should be done in IBD?
AXR/CXR: in acute disease
CT in Chron’s: to look for complications
What other ix can be done in IBD?
endoscopy:
rigid/flexi sigmoidoscopy in UC
Colonoscopy
Endoscopic rectal biopsy may be taken
What medication can be given in an acute Chron’s flare?
Mild?
Severe?
Mild - oral pred (+ review in clinic)
Severe: admission if systemic or low albumin
Steroids: hydrocortisone 100mg/6hr
NBM with parenteral nutrition
Thiopurines second line
Biological agents used in refractory disease not responding to medical treatment
Once improving - transfer to oral prednisolone as per mild attack
Last resort: surgery
What drugs are used in the maintenance of Chron’s?
Thiopurines first line: azathioprine or 6-mercaptopurine (check TPMT first)
Methotrexate second line: If thiopurines contraindicated, unsuccessful or if methotrexate was used to induce remission
Oral metronidazole for anal disease
What is the management of a mild/moderate UC flare?
Mild: <4 stools/day
Mod: 4-6 stools/day
Severe 6+ stools/day + blood + systemic disturbance
Mild/Moderate: topical (rectal) aminosalicylate
if remission is not achieved within 4 weeks, add an oral aminosalicylate
if remission still not achieved add topical or oral corticosteroid
(extensive disease - start with topical and rectal aminosalicylate)
What is the management of acute severe/fulminating UC?
MDT IV corticosteroids Assess for ?Surgery SC heparin No anti motility drugs
Second line: IV cyclosporin if symptoms worsen or no improvement within 72 hours of steroids
3rd line: biological agents, considered by specialist
What is likelihood of surgery in UC suggested by?
> 8 motions per day, pyrexia, tachycardia, colonic dilatation, low albumin, low Hb or CRP >45
What drugs are given for the maintenance of UC?
topical (rectal) aminosalicylate alone (daily or intermittent) or
an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent)
Following a severe relapse or >=2 exacerbations in the past year:
oral azathioprine or oral mercaptopurine
What are the general complications of IBD?
Bowel perforation
Lower GI haemorrhage
toxic dilatation (more common in UC)
Colonic carcinoma (more in UC) - surveillance colonoscopy if patient has UC with pan colitis
What are the features of toxic dilatation?
Features of persistent fever, tachycardia, loose blood stained stool
Ix: falling albumin/potassium
AXR shows a dilated >6cm colon with mucosal islands
Perforation is imminent and thus, surgery is often required
What complications can occur specifically in Chron’s?
Small bowel obstruction
Fistulae (10%)
Abscess formation
B12/Folate / iron studies
What are the indications for surgery in Chron’s disease?
Never curative
Temporary ileostomies can be used to ‘rest’ distal diseased bowel
Limited resection of the worse areas - short bowel syndrome: malabsorption if <1m small bowel remains
What emergency procedures can be done for UC?
Emergency procedures: subtotal colectomy + end ileostomy: leaves rectal stump (proctitis and cancer risk), can be anastomosis at a later date
Proctocolectomy and end ileostomy: rectal stump also removed, if patient happy to manage a stoma, and don’t want further surveillance etc
What elective procedures can be done for UC?
Ulcerative colitis typically only affects the colon and rectum. Therefore, removing the colon and rectum (panproctocolectomy) will remove the disease. The patient is then left with either a permanent ileostomy or something called an ileo-anal anastomosis (J-pouch). This is where the ileum is folded back in itself and fashioned into a larger pouch that functions a bit like a rectum. This “J-pouch” which is then attached to the anus and collects stools prior to the person passing the motion.
colectomy and ileorectal anastomosis:anastomosis formed in single procedure, but the recutm remains (proctitis/cancer risk)
What are the extra-colonic manifestations of IBD?
Eyes: conjunctivitis, episcleritis, iritis
Joints: arthralgia
Skin: erythema nodosum
pyoderma gangrenosum
Others: venous thrombosis, fatty liver
What other conditions can occur in IBD?
Autoimmune hepatitis gallstones renal calculi PSC (UC) cholangiocarcinoma (UC)
Ank spond (HLA B27 positive Chron’s)
What are the symptoms of malabsorption?
Diarrhoea/steatorrhoea
weight loss
lethargy
What are the signs in malabsorption (of deficiency)
Anaemia (Fe, B12, folate) Bleeding disorders (vitamin K) Oedema (decreased protein) Osteomalacia (vitamin D) Neuropathy
What are the most common causes of malabsorption?
Coeliac disease
Chronic pancreatitis
Chron’s disease
What are the rarer causes of malabsorption?
Reduced bile (obstruction, cholestyramine, ileal resection)
Pancreatic insufficiency (CF, cancer)
Bacterial overgrowth
Infection
What investigations (BLOODS) can be done for malabsorption?
bloods: FBC, iron studies, B12 and folate, calcium, magnesium, phosphate, lipid profile, LFTs, TFTs, inflammatory
clotting + coeliac seriology
What stool studies can be done for malabsorption?
MCS (microscopy, culture, sensitivity)
OCP (ova, cysts and parasites if recent travel
C.diff toxin if recent antibiotics
Faecal elastase (if suspecting chronic pancreatitis) calprotectin (to rule out IBD)
What imaging investigations can be done for malabsorption?
Endoscopy: OGD + duodenal biopsy: coeliac disease
Colonoscopy + biopsy: Chron’s disease
ERCP: biliary obstruction / chronic pancreatitis
Breath hydrogen analysis: bacterial overgrowth
How does Coeliac disease occur?
Inflammation of the jejunal mucosa in response to gluten
TTG enzymes modify ‘alpha-gliandin’
which then activates an autoimmune reaction against the mucosa
What does biopsy of duodenal mucosa show in coeliac disease?
Flattened mucosa due to loss of the villi
Hyperplasia of the crypts to compensate
There will also be increased intraepithelial lymphocytes
What is the presentation of Coeliac disease?
1/3 asymptomatic
Non specific features of IDA, weight loss/fatigue or apthous ulcers
There may be diarrhoea, abdominal pain, bloating, nausea and vomiting
Dermatitis herpetiformis
What are the positive investigations for Coeliac disease?
FBC- anaemia
clotting - prolonged
bone profile: suggestive of osteomalacia
Endomysial antibodies (EMA) and TTG antibodies present Duodenal biopsy
Bone densitometry should be performed due to osteoporosis risk
What is the management of Coeliac disease?
Lifelong gluten free diet (rice, potatoes, oats and sugar are fine)
Verify that gluten free diet is working with endomysial antibody tests
Small increased risk of small bowel lymphoma / adenocarcinoma
Describe the pathology of chronic pancreatitis?
Most commonly due to high alcohol intake, leading to inappropriate enzyme activity within the pancreas
This leads to precipitation of proteins that plug the pancreatic ducts, providing a nidus for infection, calcification and cause ductal hypertension
End result = fibrosis of the parenchyma and disturbed exocrine function (trypsins, amylases and lipases)
What is the presentation of pancreatitis?
Epigastric pain, radiating to back - relieved by sitting forwards
Weight loss, bloating and steatorrhoea
Brittle diabetes: insulin dependant DM, characterised by sudden swings in glucose level for no apparent reason
Obstructive jaundice
relapsing symptoms and progressively worse
