GI Medicine Flashcards
Define Tenesmus
Give 4 causes
Sensation of incomplete emptying caused by
1) IBS
2) IBD (crohns and UC)
3) Tumour
4) Proctitis
5) Pelvic organ prolapse
What is Abdominal migraine?
Is it treated as a normal migraine?
Typically in children presenting with attacks of headache, nausea, and vomiting accompanying the abdominal pain.
Treated as migraine. Many of these children will go on to develop migraine
Define Constipation
2 or more the following:
1) Straining at defecation >1/4
2) Tenesmus >1/4
3) Lumpy and hard stool >1/4
4) Bowel movements twice or less a week. (normal is 3/day to 3/week)
Use this as history questions
Give 10 causes of Constipation
G|: Carcinoma, Diverticula, IBD (crohns), Stricture, Intussusception, Volvulus
Anorectal: Distal proctitis, anal fissure, perianal abscess, Anterior mucosal prolapse
Pelvic: Ovarian tumour, Uterine tumour, endometriosis, pelvic organ prolapse
Endocrine: Hypercalcaemia, Hypothyroidism, Autonomic neuropathy in DM
Drugs: Opioids, Benzos, Anticholinergics, Calcium-containing drugs (hypercalcemia), Antidepressants, anticonvulsants
Other: Pregnancy, Dehydration, Low fibre diet, low physical activity/sedentary lifestyle
A patient presents with constipation. They strain at every bowel movement and bowel movements only come twice a week. What investigations would you perform?
Bloods: FBC, ESR, U&E, LFT, TFT, serum glucose
Imaging: CT colography
Colonoscopy
What lifestyle advice would you give to a patient with constipation?
1) Increased fluid intake (8-10 cups/day)
2) Increase exercise
3) Increase fibre in diet (5 portions fruit and veg)
4) Avoid alcohol
5) Open bowel when needed, do not hold in to avoid impaction
A patient presenting constipation would like to try laxatives. What options are available in order of escalation?
Bulk-forming (Ispaghula)
Osmotic Laxative (Macrogol/MgOH)
Stimulant laxative (Senna)
Laxatives have proven to be ineffective and the patient still has constipation. You offer rectal measures to the patient (Suppositories). What suppositories would you prescribe?
Soft stool -> Bisacodyl suppositories
Hard stool -> Glycerol suppositories
A patient suffers from constipation. Oral laxatives and suppositories have not proven effective. Before referring them to a specialist, what would you try?
Enema: High phosphate Enema
Give the full management plan for constipation
A) Lifestyle advice
1) Increased fluid intake (8-10 cups/day)
2) Increase exercise
3) Increase fibre in diet (5 portions fruit and veg)
4) Avoid alcohol
5) Open bowel when needed, do not hold in to avoid impaction
B) Treat any reversible causes/refer (Diverticulitis, stricture…)
C) Oral Laxatives:
Bulk-forming (Ispaghula), Osmotic Laxative (Macrogol/MgOH), Stimulant laxative (Senna)
D) Suppositories:
Soft stool -> Bisacodyl suppositories
Hard stool -> Glycerol suppositories
E) Enema: High phosphate Enema
F) Specialist referral (refer early if young or suspicious of pathology)
How would an elderly patient present with constipation?
Normal sx of abdominal pain, nausea, vomiting etc..
+
Confusion
Urinary retention
Overflow diarrhoea
What is Non-Ulcer Dyspepsia
AKA Functional dyspepsia. It is dyspepsia without a known organic pathology and represents 60% of dyspepsia patients
Give 5 causes of Dyspepsia
1) GORD
2) Peptic Ulcer (includes duodenal)
3) Gastric Cancer
4) Non-ulcer dyspepsia
5) Oesophagitis
6) Medication-induced (NSAID)!
What is the most important sign/symptom to rule out with new onset dyspepsia?
Acute GI bleed => Admit
What is another word for dyspepsia?
How does Dyspepsia present?
A patient presents with these symptoms, what are your differentials?
Indigestion
Presents with:
Epigastric pain
Fullness
bloating
nausea/vomiting
Heartburn
Reflux
Anaemia (+sx of anaemia)
Differentials:
1) Cardiac pain (angina/MI)
2) Gallstone pain
3) Pancreatitis
4) Bile reflux
What are some red flags you are looking out for in a hx of dyspepsia
Hematemesis, Malena, weight loss
Helicobacter pylori infection is one of the leading causes of dyspepsia and PUD. It is also associated with gastric cancer and Cardiovascular disease.
As a GP, how would you screen for Helicobacter pylori?
How would you manage?
Although the gold standard is Antral biopsy and histology with CLO-urease testing…
Screen:
1) Urea breath test
2) Fecal antigen testing
(Remember serology is not useful)
Management:
PAC 500 - Omeprazole 20mg + Amoxicillin 1g + Clarithromycin 500mg, All BD for 7/7
PMC 250 - Omeprazole 20mg + Metronidazole 400mg + Clarithromycin 250mg, All BD for 7/7
What drugs precipitate dyspepsia?
NSAIDs, Bisphosphonates (Ibandronate), steroids, SSRI
What foods may precipitate Dyspepsia and hence we need to advice against?
alcohol, coffee, chocolate, fatty foods
What is the conservative management of dyspepsia
Lifestyle:
Reduce weight
Healthy diet avoiding precipitation by alcohol, coffee, chocolate, fatty foods.
Smoking cessation
Stop or reduce dosage of NSAIDs, Bisphosphonates (Ibandronate), steroids, SSRI.
For dyspepsia, If lifestyle advice alone fails, what is the medical management and further escalation
Medical:
a) PPI (20-40mg Omeprazole) for 1 month trial
b) H2 receptor antagonist (Ranitidine)
c) Prokinetic (Domperidone)
d) Referral for endoscopy
+PAC500 or PMC250 for H.pylori if confirmed
How would you manage Dyspepsia in general?
1) Lifestyle:
Reduce weight
Healthy diet avoiding precipitation by alcohol, coffee, chocolate, fatty foods.
Smoking cessation
Stop or reduce dosage of NSAIDs, Bisphosphonates (Ibandronate), steroids, SSRI.
2) Medical:
a) PPI (20mg Omeprazole) for 1 month trial
b) H2 receptor antagonist (Ranitidine)
c) Prokinetic (Domperidone)
d) Referral for endoscopy
+PAC500 or PMC250 for H.pylori if confirmed
A patient presents with dyspepsia and haematemesis. What is your next step?
Admit to hospital A&E
Define Heartburn
Burning restrosternal or epigastric pain which worsens on bending, stooping, lying flat, or hot drinks (any motion that allows acid into oesophagus)
Define GORD
How does GORD present?
Gastroesophageal reflux disease is the retrograde flow of gastric contents through an incompetent gastroesophageal junction
Presentation:
1) !! Heartburn: Burning retrosternal or epigastric pain which worsens on bending, stooping!!!, lying or hot drinks
2) Water brash
3) Acid reflux
4) Nausea/vomiting
5) Nocturnal cough or wheeze
6) Recurrent chest infections
GORD and dyspepsia typically have normal examination. When asked in an exam to perform a focused examination on anything GI, what should you always check for?
Abdominal massess
Sx of anaemia
Epigastric mass/tenderness
Hepatomegaly
Lymph nodes in neck (most imp supraclavicular left -> Virchow’s)
Define Waterbrash
Mouth filling with saliva (like when someone is going to throw up)
Why would a patient with GORD present with a cough or wheeze?
Aspiration of stomach acid at night (when lying flat) => recurrent chest infections
Give 5 RF for GORD
1) Environmental (Smoking, alcohol)
2) Diet (Coffee, fatty food, big meals)
3) Obesity
4) Hiatus Hernia
5) Pregnancy
6) Drugs: NSAIDs, SSRI, anticholinergics, TCA
7) Tight clothes
Define Hiatus Hernia
There are 2 types of hiatus hernia. What are they?
What is the main RF?
Hiatus hernia is the herniation of the proximal stomach through the diaphragmatic hiatus into the thorax. There are 2 types:
1) 80% Sliding Hernia: The Gastroesophageal junction slides into thorax
2) 20% Rolling Hernia: Bulge of stomach herniates into thorax but Gastroesophageal junction remains in abdomen
Obesity is the main rf (a/w tight clothes, fatty food…)
List 5 complications of GORD
1) Oesophagitis
2) Oesophageal stricture
3) Barret’s oesophagus
4) Oesophageal haemorrhage
5) Anaemia
What is another term for Gastro-oesophageal junction? (From a histologists POV)
Squamocolumnar junction
Define Barrett’s Oesophagus
What is the main RF/cause?
What is the main complication?
How is it managed along with the escalations?
Barrett’s oesophagus or Intestinal metaplasia is where the squamous mucosa of the oesophagus becomes columnar => upward migration of the squamocolumnar junction (=> increased length of the squamocolumnar junction)
Caused by chronic GORD
Very high risk of adenocarcinoma a/w length of barret’s oesophagus (or how much the squamocolumnar junction migrated upwards)
Management:
1) Long term PPI (20mg)
2) Laser therapy
3) Resection
A patient presents with epigastric pain, acid reflux, and recurrent chest infections (but is currently well). What investigations should be performed for diagnosis?
Endoscopy referral or Barium study referral (best to assess dilatation and strictures - in general)
What is the medical management of GORD?
It is managed with the same escalations as Dyspepsia (Stop NSAIDs, bisphosphonates, SSRIs… -> PPI -> H2 receptor antagonist - Ranitidine)
+
If positive Endoscopy or evidence of dilatation on barium study, dosages for PPI would be full dose omeprazole (40mg) for 1 months and if severe, double dose (80mg)
In Dyspepsia it was 1 month trial of 20mg omeprazole PRN/BD
What is the full management of GORD?
1) Lifestyle:
Reduce weight
Healthy diet avoiding precipitation by alcohol, coffee, chocolate, fatty foods.
Smoking cessation
Stop or reduce dosage of NSAIDs, Bisphosphonates (Ibandronate), steroids, SSRI.
can gastritis and peptic ulcers be used interchangeably?
Define Acute Gastritis
nope theyre opposites
Acute gastritis is mucosal inflammation of the stomach with NO ulcers
Acute gastritis is classified as Type A, B and C. What do each mean?
Type A - Entire stomach is affected
Type B - Antrum + duodenum affected
Type C - Inflammation due to irritants (NSAIDs, alcohol, bile reflux)
How does Acute gastritis present?
Just as dyspepsia
Presents with:
Epigastric pain
Fullness
bloating
nausea/vomiting
Heartburn
Reflux
Anaemia (+sx of anaemia)
What is the full management plan for Acute gastritis
Exactly the same as Dyspepsia. It presents the same way too
1) Lifestyle:
Reduce weight
Healthy diet avoiding precipitation by alcohol, coffee, chocolate, fatty foods.
Smoking cessation
Stop or reduce dosage of NSAIDs, Bisphosphonates (Ibandronate), steroids, SSRI.
2) Medical:
a) PPI (20mg Omeprazole) for 1 month trial
b) H2 receptor antagonist (Ranitidine)
c) Prokinetic (Domperidone)
d) Referral for endoscopy
+PAC500 or PMC250 for H.pylori if confirmed
Go do PUD from med surg!!
Ya ttek
Differentiate between gastric and duodenal ulcers
Food: Gastric exacerbated by food, duodenum relieved
Weight: Weight loss in gastric, weight gain in duodenal (makes sense)
Nausea/vomiting, Fe anaemia more commonly and more severely occurs in gastric
Duodenal ulcers mostly cause pain at night and early morning (when basically fasting) => sleep disturbance
What cell type(s) is/are most involved in oesophageal cancer
Same for gastric
Oesophageal: 50% squamous cell and 50% adenocarcinoma
Gastric: 95% adenocarcinoma
What is the presentation of oesophageal malignancy?
Rapidly progressive Dysphagia affecting solids first then liquids
Weight loss
Haematemesis
Choking
Cough/hoarseness => Aspiration => recurrent chest infections
You conduct barium swallow on a patient with dysphagia. There appears to be a stricture at the middle of the oesophagus. On OGD it is confirmed to be a carcinoma. You take a biopsy. What type of oesophageal carcinoma is it most likely? why?
As it occurs in the middle it is likely to be squamous cell carcinoma.
Oesophagus is composed of squamous cells while the stomach is composed of columnar epithelium => in patients with GORD or acid reflux, barrett’s oesophagus may occur leading to metaplasia. If the cancer is in the lower 1/3 it is likely to be adenocarcinoma.
If the cancer is in the upper 2/3 it is likely to be
Give the strongest RF for Oesophageal malignancy and then give 4 others
Strongest = Barrett’s oesophagus as part of chronic GORD
Environmental (smoking, alcohol)
Diet (obesity, low fruit intake)
Mediastinal radiotherapy (hx of breast cancer or lymphoma)
Plummer Vinson syndrome
What is Plummer Vinson Syndrome
Oesophageal web + Fe anaemia
What is the management of a patient with oesophageal carcinoma?
Urgent endoscopy referral
Specialist resection, radiotherapy, chemotherapy, or palliative care with stenting tube (which gets blocked often)
A 65 year old patient presents to your clinic with acute onset dyspepsia and unintentional weight loss. What are you suspecting
Gastric malignancy
Give 5 RF for gastric malignancy
Environment: smoking and alcohol
Diet: Poor diet and obesity
Surgeries involving stomach (Partial gastrectomy, Bariatric surgery)
H.pylori infection!!
Pernicious anaemia
Blood group A
Atrophic gastritis
How would a patient with gastric carcinoma present?
Dyspepsia,
weight loss, anorexia, early satiety
Nausea/vomitting
Anemia
How will you manage a patient presenting with gastrinoma?
Referral for endoscopy where it will be decided if the patient will undergo curative partial gastrectomy or palliative care (if late stage)
You refer a patient with a suspected gastric carcinoma for endoscopy. Results show a lesion that is curative via partial gastrectomy. What are the complications of partial gastrectomy
1) Abdominal fullness
2) Bilious vomiting/attack
3) Dumping (early/late)
4) Typical complications such as GA, VTE, haemorrhage, infection…
5) Diarrhoea
6) Anaemia
7) Gastric Ca recurrence (Partial gastrectomy itself is a RF for Gastric Ca, 7x risk)
What is abdominal fullness?
What would you advise a patient post-gastrectomy to avoid this?
Feeling of early satiety +/- weight loss (basically like gastric sleeve).
Advise the patient to have small but frequent meals
Intermittent sudden attacks of epigastric cramping pain after eating and is relieved by vomiting is consistent with?
How would you resolve this?
Bilious vomiting as a complication of partial gastrectomy.
Metoclopramide, surgical review if recurrent
Explain the concept of dumping as a complication of partial gastrectomy
How is it generally managed?
Dumping is abdominal distension, colic, and vasomotor disturbance after meals. In english, this means that there is rapid gastric emptying into the duodenum
Early dumping occurs directly after meals where rapid gastric emptying into duodenum activating chemo and baroreceptors to release large amounts of GI hormones. This leads to sweating, flushing, tachycardia, palpitations, nausea, and vomiting
Late dumping occurs 1-3 hours after eating. Here it is due to the rapid absorption of glucose into bloodstream causing a spike. This causes insulin to respond, overcompensating leading to rebound hypoglycemia => faintness, tremor, sweating, and nausea
Advise patients to have small, dry meals with restricted carb intake (refer to dietician)
Diarrhoea after partial gastrectomy is typically episodic and unpredictable. How would you manage this?
Loperamide
What type of anaemia typically occurs after a partial gastrectomy (assuming no haemorrhage)?
How would you manage this?
Pernicious anaemia due to reduced B12 intrinsic factor (as we took off part of the stomach that produces it) => B12 injections and Fe supplements
A patient presents with anal pain. Give 6 Differentials
Anal causes
1) Anal fissure
2) Haemorrhoids
3) Anal fistula
4) Rectal/Anal cancer
5) Anal ulcer
Perianal:
1) Perianal fistula
2) Skin infection
3) Perianal abscess
4) Pilonidal sinus
Functional pain
What are the 2 types of haemorrhoid?
State 5 RFs for Haemorrhoids
How would you grade classify haemorrhoids?
Internal and external (Perianal haematoma/ Thrombosed external haemorrhoid)
RF:
1) Constipation (low fibre, smoking, obesity, dehydration…)
2) Varicose veins (=> also 3) portal HTN)
4) pregnancy
5)pelvic tumour
6) increased anal tone
1st degree = Remains within anal canal
2nd degree = Prolapse out of anal verge but spontaneously reduces
3rd degree = Prolapse out of anal verge + requires digital reduction
4th degree = Permanently prolapsed
Regarding an internal haemorrhoid,
Define Haemorrhoid
What is the lay word for haemorrhoid?
How do haemorrhoids present?
What examination should be performed?
How would you manage this patient?
A haemorrhoid AKA pile is the distention of the submucosal plexus of veins in the anus, typically at 3 o clock, 7 o clock and 11 o clock (+4 each time)
Presents with
1) Discomfort when sitting
2) Hematochezia with frank blood
3) Tenesmus
4) Mucous discharge
5) Pruritis Ani
DRE should be performed to palpate and visualise the haemorrhoid and have it classified.
Tx:
1) Treat constipation => Ispaghula Husk
2) Treat pain => Analgesia
3) Refer for surgical assessment if it does not settle
You conduct a DRE on a patient presenting with discomfort when sitting and hematochezia with frank blood. The patient complains of an itchy sensation as well. What is the most likely diagnosis?
On examination nothing is palpable nor visible. Why would that be? What will you do next?
Haemorrhoids
If nothing is visible or palpable on exam, it could be a 1st degree haemorrhoid!, poor examiner performance or alternate pathology
=> Refer for proctoscopy or sigmoidoscopy
What are the 2 main complications of haemorrhoids?
1) Strangulation (anal sphincter blocking vascular supply)
2) Thrombosis leading to perianal haematoma (or thrombosed external haemorrhoid)
Both present with intense pain and anal sphincter spasm. If it does not settle with pain relief, icepacks and rest, admit.
A patient presents with discomfort and pruritis ani. You suspect haemorrhoids but on examination you note that there is none palpable or visible. The patient has no bleeding. What are alternate causes to this?
What is the main complication associated with pruritis ani?
what would you tell the patient to avoid this happening again?
1) Anus is soiled or moist due to poor hygiene, faecal incontinence, fistulas, fissures, tight underwear
2) Dermatological conditions such as Lichen Sclerosis and contact dermatitis
Main complication: Threadworm infection which would appear as circular, well circumscribed erythematous lesions.
Prevention: Encourage hygiene, loose underwear, avoid spicy food. Check for fistula or reason behind incontinence
What is a perianal haematoma? Define it
How does it present?
It is a thrombosed external haemorrhoid due to ruptured superficial perianal vein causing a subcutaneous buildup of blood
Just like a haemorrhoid but more acute and severe
1) Sudden onset Severe pain worse when sitting
2) Hematochezia with frank blood
3) Tenesmus
4) Mucous discharge
5) Pruritis Ani
A patient presents with sudden onset pain worse when sitting. They noted frank red blood on the tissue paper when wiping. They have a history of haemorrhoids. What is the most likely diagnosis?
What examination findings would you expect to find for your most likely diagnosis?
How would you manage?
Perianal haematoma (not the same as typical haemorrhoids but also called external thrombosed haemorrhoid)
On exam, tender 2-4mm dark blueberry swelling under skin adjacent to anus
GP: Pain => Analgesia
Refer to hospital If <1 day old => small incision under local anaesthesia to evacuate haematoma
Rectal prolapse typically occurs wither in the very young or >60.
What are the 2 types?
If a 2 year old presents with their mother with evidence of rectal prolapse which type would it be and what would be the most likely cause?
If a 65 year old woman presents with their mother with evidence of rectal prolapse which type would it be and what would be the most likely cause?
If a 50 year old male presents with evidence of rectal prolapse which type would it be and what would be the most likely cause?
In all of these cases, how would you manage?
2 types are:
Mucosal: Bowel musculature not affected but the !redundant mucosa prolapses!
Complete: Weak pelvic floor => descent of upper rectum into the lower anal canal causing !bowel wall prolapse!
2 year old => typically connective tissue disease such as Ehler danlos syndrome => complete due to weak pelvic floor
65 year old female => typically due to multiparity with large babies, prolonged straining, obesity, chronic cough, ace, smoking… or the most likely cause being menopause. In all cases, complete
50 year old male typically due to a !3rd degree haemorrhoid! => Mucosal
In all cases, refer for surgery
A patient presents with pain on defecation, constipation and haematochezia. On examination, the anal mucosa appears to be torn on the posterior aspect. What is the most likely diagnosis?
How would you manage this patient
Anal fissures (important to note the tearing of the anal mucosa on the posterior aspect which is the definition of anal fissure)
Treat the constipation => Ispaghula Husk
Pain => Analgesic Suppository/cream
You attept to treat a patient with an anal fissure with an analgesic suppository however the patient comes back stating that defecating has been harder and that the anus is “stuck closed”. What symptom is being described?
How is this treated if analgesia has not worked?
Anal sphincter spasm consistent with anal fissures.
GTN
A patient presents with sudden onset severe pain on sitting and defecation.
Define Perianal abscess including its location
Infection of the perianal gland between internal and external sphincter
A patient presents with a persistent perianal discharge and pruritis ani. The patient has a history of recurrent perianal abscess. What is the most likely diagnosis? How is it managed?
Anal/perianal fistula
Refer for surgical repair
There are 2 types of fistulas, high and low. Which type is more common?
What are the causes of a high fistula?
How would you determine if a fistula is considered high or low?
Low is more common
High is rarer and caused by UC, Crohn’s or a tumour
Low and high are with respect to the deep external anal sphincter
A patient presents with a painful swelling on their very lower back. It is 2cm in diameter. It has a foul-smelling discharge which is sometimes blood-stained. What is the most likely diagnosis?
What is the most likely cause of this?
What is the most likely location of this?
How is it managed
Pilonidal Sinus (pilonidus means hair-nest). Due to obstruction of hair follicle (in-grown hair) causing a foreign body reaction by immune system (may even form a fistula).
Almost always occurs right above the tailbone.
Based on severity either give antibiotics (practice) or refer for surgery (book)
State 2 causes of an anal ulcer
Crohn’s
tumour
syphilis
A 78 year old patient presents with subacute onset of hematochezia, pain on defecation, tenesmus, change in bowel habits and pruritis. They note that their clothes are becoming loose. What is the most likely diagnosis?
Anal cancer
Anal cancer:
What type of cancer is the most common?
Give 2 RF
How would this patient be managed
SCC
HPV, Anal sex, Syphilis
Referral to surgery for excision, chemo, radio, brachytherapy
What is the national screening protocol for colorectal cancer?
FIT kits - Faecal Immunochemical tests. All patients aged 60-74 are included in this
If positive they are referred for Colonoscopy
List 10 RF for Colorectal Ca
Genetic: (Polyposis)
1) FAP - Familial Adenomatous Polyposis
2) Juvenile Polyposis
3) Peutz-Jegher’s disorder
4) Lynch Syndrome - HNPCC - Hereditary Non-Polyposis Colorectal Cancer
Lifestyle:
1) Obesity
2) Low physical activity
3) Diet: Red meat, processed meat + low veg, fibre
4) Alcohol use
Medical Hx of:
1) Gallbladder disease/cholecystectomy
2) T2DM
3) IBD (UC/Crohn’s)
4) Colorectal Ca (lol)
What red flag signs are you looking out for with regards to colorectal cancer? Where would you refer them?
What yellow flag signs are you looking out for? Where would you refer them?
Red flags: Refer directly for endoscopy
1) Unexplained rectal bleeding/persistent rectal bleeding
2) Change in bowel habits
3) Unexplained weight loss
4) Significant family history
Yellow flags: Refer for Colorectal OPD
1) Palpable abdominal/rectal/anal mass
2) Anal ulceration
What cancers are associated with Lynch/HNPCC
Stomach
Pancreas
Colorectal
Urinary tract
Endometrial
Ovary
Prostate
What is considered a significant family history for colorectal cancer
- 1st degree family member diagnosed with colorectal cancer at age <50
- Two or more relatives with colorectal or endometrial cancer (atleast 1 of which 1st degree)
- A family hx of colorectal cancer syndromes such as FAP, Lynch…(main 2 rly)
State the features/presentation of Colorectal Ca
You are asked to conduct a focused examination on a patient with suspected colorectal Ca. Go through it
1) Intestinal obstruction: Pain, distension, (absolute) constipation, vomiting
2) Change in bowel habit: Alternating constipation/diarrhoea, Tenesmus
3) Rectal bleeding: Haematochezia/+ve faecal occult blood
4) Metastasis: Abdominal distension secondary to liver metastasis (ascites)
5) General effects of Ca: Weight loss, anorexia, anaemia, night sweats, malaise
6) Perforation: Generalised peritonitis, fistula formation.
Examination:
Inspection: Distended abdomen, anaemia (+ its features), jaundice
Palpation: Tenderness +/- guarding and rigidity, hepatomegaly, abdominal mass
Percussion: Ascites (shifting dullness)
Auscultation: Tinkling bowel sounds (constipation)
+!!!!DRE
You have referred a patient to secondary care for suspicion of of colorectal Ca. What investigations will be performed there?
How would they treat colorectal ca?
Bloods: Tumour markers CEA, LFT
imaging: CT Colonography + Sigmoidoscopy/colonoscopy + CXR for perforation and lung metastasis
Tx: Laparoscopic/open to stage (like ovarian Ca), excise the tumour + adjuvant chemotherapy +/- Resection or radioablation of liver metastasis
Define Irritable bowel syndrome
Chronic (>6m) relapsing remitting condition of unknown cause/diagnosis of exclusion
IBS presents as most things in GI which is pain, discomfort, bloating, change in bowel habits, lethargy, nausea, vomiting, backache, and bladder sx.
With that in mind, when you know its a GI case, give your differentials
What investigations can you perform to rule them out?
1) IBS (dx of exclusion)
2) IBD
3) Coeliac
4) Colonic Ca
5) Endometriosis
6) PID
7) Thyrotoxicosis
8) GI infection
1) Fecal calprotectin + Colonoscopy (IBD, Ca)
2) TFTs
3) Stool sample sent to lab (GI infection)
4) Endocervical swab (PID)
5) Diagnostic Laparoscopy (endometriosis)
IBS presents as most things in GI which is pain, discomfort, bloating, change in bowel habits, lethargy, nausea, vomiting, backache, and bladder sx.
Once you have excluded your differentials, what is needed to diagnose IBS?
Diagnosis:
Abdominal pain that is either relieved by defecation or associated with altered bowel frequency/stool form
+ 2 ore more of
a) Altered stool passage (straining, tenesmus, urgency)
b) Abdominal bloating
c) Exacerbated by eating
d) Passage of mucus
What are the 2 main types of IBS
May be Constipation dominant or Diarrhoea dominant
Over 50% of patients are still symptomatic after 5 years despite management. How would you manage IBD in general?
1) Education: Explain that all investigations returned negative and that this is a diagnosis of exclusion. Also explain that it is very prevalent with over 20% of the population suffering from it.
2) Lifestyle changes
a) Stress: Increased leisure time and regular physical activity (for both)
b) Diet: Example here is for diarrhoea-dominant (use this to treat any diarrhoea rly unless infectious then do opposite)
- Encourage patients to have regular meals and avoid missing meals or leaving long gaps between meals.
- Ensure fluid intake is <8cups. Restrict caffeine, tea, fizzy drinks, and alcohol
- Reduce intake of high-fibre foods
- Reduce intake of resistant starch found in processed foods
- Limit fresh fruit to 3 portions of 80g per day
c) Food diary to identify foods that provoke symptoms
d) dietician referral
First it is important to note what type of IBS is present in order to give the correct advice.
c) Specific measures:
Constipation-predominant IBS - Fibre/bulking agents (Ispaghula Hulk) or laxatives (aboid lactulose)
Diarrhoea-predominant - Loperamide (obv avoid weak opioids)
Other therapies with evidence (just for your eyes to see): Probiotics,
Antispasmodics (mebeverine or peppermint oil - try different ones as different preparations suit different people),
FODMAP diet (dietitician),
Low dose amitriptyline
Psychotherapy
When conducting an abdominal exam. What are you looking for in the eyes and mouth?
Eyes:
Conjunctivitis
Conjunctival pallor
Subconjunctival haemorrhage
Scleral icterus
Corneal arcus (hyperlipidaemia)
Xanthelasma
!!Fundoscopy to check for papilloedema, cotton wool spots, haemorrhages etc…
Mouth:
Cyanosis
Apthous ulcers
Angular stomatitis
Tongue candidiasis
Dental hygiene
