GI/GEN - Anorectal Conditions Flashcards
Crohn’s Disease (IBD)
Risk Factors
Clinical Features
Investigations
Imaging
1.) Risk Factors
- age (15-30/60-80), smoking, FH of IBD
- white european, appendicectomy
2.) Clinical Features - episodic abdominal pain and chronic diarrhoea which may contain blood or mucus
- pain can be anywhere but most common in RLQ
- malaise, malabsorption, weight loss
- oral aphthous ulcers, perianal disease
- extra-intestinal features
3.) Investigations
- routine bloods: anaemia, low albumin, inflammation
- stool sample, faecal calprotectin
- proctisigmoidoscopy to for perianal fistulae
4.) Imaging
- colonoscopy (gold): gross pathological changes
- CT-AP: for bowel obstruction, perforation, fistulae
- MRI: MREnterography for SI involvement and enteric fistulae, MRI-Rectum for peri-anal disease
Management and Complications of Crohn’s Disease
Inducing Remission
Maintaining Remission
Surgical Intervention
GI Complications
Extraintestinal Complications
1.) Inducing Remission - for acute attacks
- IV fluids (resus), nutritional support
- prophylactic heparin (IBD is pro-thrombotic)
- IV hydrocortisone 100mg QDS for 3-5d (very unwell)
- steroids also given topically (enemas) or orally (pred)
2.) Maintaining Remission
- azathioprine
- biologics (first line for perianal or fistulating Crohn’s)
- rescue therapy: biologics or surgery
3.) Surgical Intervention - often bowel resections
- reasons: failed medical management, severe complications, growth impairment in children
4.) GI Complications
- fisulas, strictures, recurrent perinanal abscesses
- GI malignancy: colorectal cancer, small bowel cancer
5.) Extraintestinal Complications - due to malabsorption
- growth delay in children, osteoporosis
- ↑risk of gallstones and renal stones
Ulcerative Colitis (IBD)
Risk Factors
Clinical Features
Investigations
Imaging
1.) Risk Factors
- age (15-25/55-65), FH of IBD
- smoking is a protective factor (reduces risk)
2.) Clinical Features - bloody diarrhoea
- change in bowel habits: PR bleed, mucus discharge, ↑frequency, urgency of defecation, tenesmus
- dehydration, malaise, low-grade fever, anorexia
- abdominal pain for complications: toxic megacolon, perforation, fulminant colitis, peritonitis
3.) Investigations
- routine bloods: anaemia, low albumin, inflammation
- LFTs deranged in patinets on medical treatment
- clotting can be deranged in severe attacks
- stool sample, faecal calprotectin
4.) Imaging
- colonoscopy (gold): gross pathological changes
- flexible sigmoidoscopy may be sufficient
- acute exacerbations: AXR (thumbprinting) or CT for complications
Management and Complications of Ulcerative Colitis
Induce Remission
Maintain Remission
Surgical Intervention
Complications
1.) Induce Remission - for acute attacks
- IV fluids (resus), nutritional support
- prophylactic heparin (IBD is pro-thrombotic)
- IV hydrocortisone 100mg QDS for 3-5d (very unwell)
- steroids also given topically (enemas) or orally (pred)
2.) Maintain Remission
- mesalazine first line
- azathioprine or biologics if mesalazine ineffective
- rescue therapy: cyclosporin, biologics, surgery
3.) Surgical Intervention - often bowel resections
- reasons: failed medical management, toxic megacolon, bowel perforation, ↓risk of carcinoma
- total proctocolectomy is curative
4.) Complications
- toxic megacolon: severe abdo pain and distension, w/ pyrexia and systemic toxicity, need decompression
- colorectal carcinoma: undergoing screening 10yrs from diagnosis
- osteoporosis
- pouchitis: inflammation of ileal pouch
Colorectal Cancer
Risk Factors
Clinical Features
Colorectal Cancer Screening
Investigations/Imaging
1.) Risk Factors
- ↑age, FH, IBD, low fibre, smoking, alcohol, meat
- APC: mutation of APC gene (TSG) –> growth of adenomatous tissue (associated w/ FAP)
- HNPCC: mutation to HNPCC gene (DNA mismatch repair gene) –> defects in DNA repair
2.) Clinical Features
- obstruction: abdo pain/distension, N/V, constipation
- PR bleeding: haematochieza more likely
- change in bowel habit
- weight loss, iron-deficiency anaemia, tenesmus, >50
3.) Colorectal Cancer Screening
- every 2 years to men and women aged 60-75
- or 10yrs after UC
- faecal immunochemistry test (FIT)
4.) Investigations/Imaging
- routine bloods: FBC (anaemia), CEA
- colonoscopy w/ biopsy (gold) (flexible sigmoidoscopy or CT colonography if contraindicated)
- staging CT for mets
- rectal cancer: MRI rectum, endo-anal ultrasound
Haemorrhoids
Risk Factors
Clinical Features
Grades of Internal Haemorrhoids
Investigations
Management
1.) Risk Factors
- ↑age, chronic constipation (excessive straining)
- ↑intra-abdo pressure: pregnancy, cough, ascites
- abdo/pelvic masses, FH, cardiac failure, portal HTN
2.) Clinical Features
- painless, bright red PR bleeding
- pruritus, rectal fullness, soiling
- thrombosed: blue, tense, tender perianal mass
3.) Grades of Internal Haemorrhoids - grades 1-4
- 1: prominent blood vessels with no prolapse
- 2: prolapse during defecation, but spontaneous reduction
- 3: prolapse, but requires manual reduction
- 4: prolapse w/ inability to be manually reduced
4.) Thrombosed External - haemorrhoidal tissue become engorged and forms clots
- acutely severe pain, tender (blue-black) perianal lump/mass
- if <72 hrs refer for excision/reduction
- if >72 hrs, manage w/ stool softeners, ice packs and analgesia, sx usually settle within 10 days
5.) Investigations
- proctoscopy to confirm the diagnosis
- FBC, coagulation screen (signs of anaemia)
Management of Haemorrhoids
Conservative Management
Rubber-Band Ligation
Surgical Management
1.) Conservative Management - majority
- lifestyle: avoid straining, ↑fibre, ↑fluids, laxatives
- topical agents: analgesia, AnuSol (contains zinc sulfate monohydrate), hydrocortisone, Xyloproct,
- reassurance bleeding is not sinister
2.) Rubber-Band Ligation - non surgical
- used for symptomatic 1st/2nd degree haemorrhoids
- rubber band placed over the haemorrhoid neck
- other non-surgical: injection sclerotherapy, infrared coagulation/photocoagulation, and bipolar diathermy and direct-current electrotherapy
3.) Surgical Management - favoured when symptomatic and prolapsed
- haemorrhoidal artery ligation (2/3rd degree)
- haemorrhoidectomy (3/4th degree),
Anal Fissures
What is it? (inc risk factors)
Clinical Features
Acute Management
Chronic Management
1.) What is it? - tear in the mucosal lining of the anal canal often due to defecation of hard stool
- acute is <6wks, chronic is >6wks
- risk factors: constipation, IBD, STIs, dehydration, diarrhoea
- 90% occur on the posterior midline, should consider underlying causes e.g. Crohn’s disease when in an alternative location
2.) Clinical Features
- intensely painful, bright red PR bleeding
- pain occurs post-defecation (can last several hrs)
- fissures can be visible or palpable
- DRE often too painful so anaesthesia needed for proctoscopy to view fissures within the anal canal
3.) Acute Management - <6 weeks
- dietary advice: high fibre diet w/ high fluid intake
- bulk-forming laxatives (e.g. ispaghula husk): help faeces retain water making it easier to pass
- lubricants (e.g. Vaseline) before defecation, warm baths
- analgesia, topical anaesthetics (e.g. lignocaine)
- topical steroids are NOT used as they have very little benefit
4.) Chronic Management - >6 weeks, as above ^^^
- 1°topical (PR) GTN cream (diltiazem OR nifedipine if contraindicated)
- referral for surgery if topical GTN is ineffective after 8 weeks: intersphincteric Botox or lateral internal sphincterotomy
