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MedEd GKP/AB/VP > GI Surgery - GI Vasculature and Rectal Bleeding > Flashcards

GI Surgery - GI Vasculature and Rectal Bleeding Flashcards

1
Q

Superior Mesenteric Artery supplies…

A

Jejunum

Transverse colon

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2
Q

Inferior Mesenteric Artery supplies…

A

Descending colon

Rectum

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3
Q

Superior Mesenteric Artery –> ischaemia

A

“Acute mesenteric ischaemia”

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4
Q

Diffuse mesenteric atherosclerosis

A

“Chronic mesenteric ischaemia”

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5
Q

Inferior Mesenteric Artery –> ischaemia

A

Ischaemic Colitis (AKA chronic colonic ischaemia)

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6
Q

Acute mesenteric ischaemia

Clinical presentation, Ix, Rx

A

Clinical Triad:
Acute severe abdominal pain
Abdominal exam normal
Hypovolaemic shock

Ix:
Raised WCC
Metabolic acidosis
AXR “gasless abdomen”

Rx:
Manage peritonitis
Remove dead bowel

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7
Q

Ischaemic colitis spectrum

A

Mild ischaemia –> gangrenous colitis

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8
Q

Ischaemic colitis

Presentation, Ix

A

Presentation:
LLQ abdominal pain
Bloody diarrhoea

Ix:
Colonoscopy + Biopsy (gold standard)
Barium enema: “thumb printing”

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9
Q

Chronic mesenteric ischaemia

Presentation

A

AKA intestinal angina

Colicky post-prandial pain
Wt loss (by eating less)
Upper abdominal bruit

History of Vascular disease - 95% have diffuse atherosclerosis throughout gut arteries

Rare

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10
Q

A 65-year-old man presents with a 5 hour history of acute, severe pain in the centre of his abdomen. He had stopped taking his amiodarone for a “heart condition” a month ago, saying that he no longer needed it. Abdominal examination shows a rigid abdomen. His blood pressure is 76/40 and HR is 128 bpm. Blood tests show a raised WCC, and his abdominal X-ray shows a gasless abdomen. Select the likely diagnosis:

Ischaemic colitis
Toxic Megacolon
Acute mesenteric ischaemia
Appendicitis
Small bowel obstruction
A

Acute mesenteric ischaemia

Acute severe pain
Centre
Heart condition
Rigid abdomen
Raised wcc
gasless abdomen
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11
Q

An 85-year-old lady presents with left-sided lower abdominal pain and bloody diarrhoea. She has noticed blood mixed in with stool, but not in the pan/toilet paper. A recent ECHO showed her Left Ventricular Ejection Fraction stands at 35%. Her blood pressure is 100/80, HR is 80 bpm. Her abdomen is soft and non-tender. She appears systemically well. Select the likely diagnosis:

Diverticular disease
Ulcerative colitis
Colon cancer
Ischaemic colitis
Rectal varices
A

Ischaemic Colitis

LL abdo pain
Bloody diarrhoea
Mixed in
LVEJ at 35%
systemically unwell
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12
Q

An obese 50-year old man presents with colicky central abdominal pain 5 minutes after eating food, particularly heavy meals. This pain never occurs at rest, and tends to resolve itself after 15 minutes. He has recently noticed 5kg weight loss, but has no fatigue. He has a family history of ischaemic heart disease, and himself has stable angina. His GP has tried “Triple Therapy” to no effect. Select the likely diagnosis:

Chronic mesenteric ischaemia
Peptic Ulcer Disease
Ischaemic Colitis
Gallstones
Gastric carcinoma
A

Chronic mesenteric ischaemia

5 mins after eating food
never occurs at rest
resolves itself
wt loss
no fatigue
IHD
stable angina
no effect
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13
Q

Sources of GIT blood

A

Upper GI:
Peptic ulcer
Oesophageal Varices
Mallory-Weiss

Colonic:
Diverticular disease
Ischaemic Colitis
Infectious Colitis
IBD
Anorectal:
Haemorrhoids
Fissures
Cancer
Trauma
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14
Q

Rectal Bleeding DDx

A

Blood mixed with stool:
Painful - Colitis
Painless - Colon tumour; Colitis

Blood streaked in stool:
Painful - Anal tumour
Painless - Rectal tumour

Blood in the pan (separate):
Painful - Colitis
Painless - Haemorrhoids; Diverticular Disease; Colitis (+mucus)

Blood on the paper:
Painful - Anal fissure
Painless - Haemorrhoids

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15
Q

Dentate/Pectinate line

A

Line that divides bottom third/top two thirds of anal canal. Separates somatic (painful) and visceral (painless) innervation.

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16
Q

Haemorrhoids

Pathogenesis/Rx/Positions

A

Disrupted and dilated anal cushions which are prone to rupture.

11/3/7 o’clock - 3 anal cushions

Pathogenesis:

  1. Gravity/Increased anal tone/Straining
  2. Anal cushions become bulky and loose
  3. Stools cause rupture

Rx:
Excisional haemorrhoidectomy
Stapled haemorrhoidopexy

17
Q

Haemorrhoids

Classification

A

1st Degree:
No prolapse; just prominent blood vessels.

2nd Degree: Prolapse upon bearing down but spontaneously reduced.

3rd Degree: Prolapse upon bearing down and requires manual reduction.

4th Degree: Prolapsed and cannot be manually reduced.

18
Q

Internal vs External Haemorrhoids

A

Division via Dentate/Pectinate line

19
Q

Infectious Colitis Causes

A

CHESS

Campylobacter jejunii
Haemorrhagic E. coli
Entamoeba histolytica
Shigella
Salmonella
20
Q

C. Difficile

Complications and Rx

A

Typically folowing a hospital stay or recurrent antibiotic use

Complications:
Pseudomembranous colitis
Toxic Megacolon (Surgical Emergency)
Bowel Perforation (Surgical Emergency)

Rx:
Metronidazole (mild/moderate)
Vancomycin (severe)

21
Q

Anal Fissure

Presentation and Rx

A

Painful tear in the squamous lining of the lower anal canal.
Mostly due to hard faeces - secondary to low fibre diet.

Rx:
Increase fibre and fluid intake.

22
Q

Anal Fistulae

pathogenesis

A

A track communicates between skin and the anal canal

Pathogenesis:
Blockage of deep glands
Abscess formation
Progression to fistula

Does not present with PR bleeding.

23
Q

An 18-year old student presents to his GP worried about pain and blood on toilet paper after passing stool. Typically, he says, he also notices a couple of drops of bright red blood in the pan, but none mixed in the stool. The pain is sharp, made worse when wiping and resolves itself within seconds. He tends to pass hard stools infrequently (once per week), which is less often than normal since he moved to halls and started living off Deliveroo meals and pot noodle. What is the likely diagnosis?

Haemorrhoids
Anal fissure
Anal fistula
Rectal tumour
Infectious colitis
A

Anal fissure

Pain
Blood on toilet paper
Bright red blood in the pan
Sharp
When wiping
Hard stools infrequently
Deliveroo meals and pot noodles
24
Q

A 50-year-old man presents with painless PR bleeding. Blood is seen coating the stool, and in the pan. He reports feeling constipated for the past 2 weeks, leading to increased straining when defecating. He has no sensation of tenesmus or discomfort on sitting. On DRE, no masses are palpable. Proctoscopy, however, shows two spherical masses. Select the likely diagnosis:

Anal Abscess
External haemorrhoids
Rectal tumour
Internal haemorrhoids
Anal Fissure
A

Internal haemorrhoids

Painless PR bleeding
Coating the stool
Pan
Constipated
Straining
No masses
Proctoscopy - two spherical masses
25
Q

A 41-year-old woman presents with a 5-day history of painful PR bleeding, which coats the stool and pan, and is accompanied with great discomfort on sitting. She reports no tenesmus, weight loss or change in bowel habit. She takes ferrous sulphate tablets for iron deficiency anaemia. O/E: two non-reducible masses are visible at 3 and 7 o’clock outside the anus, which are exquisitely tender to touch. They are not reducible. Select the likely type of haemorrhoid:

2nd degree, internal
3rd degree, internal
3rd degree, external
4th degree, internal
4th degree, external
A

4th Degree External

Painful PR bleeding
Stool and pan
Discomfort on sitting
Ferrous sulphate tablets
Two non reducible masses at 3/7
Exquisitely tender
26
Q

An 11-year-old boy presents with 6 days of bloody, loose stools and cramping abdominal pain following a dodgy school lunch. The blood is mixed in with the stool, which is also coated in mucus. Select the likely causative organism:

E. coli
Salmonella
Vibrio cholerae
Giardia lamblia
Campylobacter jejunii
A

Camplyobacter jejunii

Bloody loose stools
Cramping abdominal pain
Dodgy school lunch
Mixed in + mucus

27
Q

A UN aid worker presents to A&E with bloody diarrhoea and cramping abdominal pain upon returning from a project in the Ivory Coast. She reports the blood is mixed in with the stool, which is loose and watery. Select the likely causative organism:

Entamoeba histolytica
C. difficile
E. coli
Serratia marcascens
Cholera vibrium
A

Entamoeba histolytica

UN Aid worker
Cramping abdo pain
Ivory coast
Mixed in
Loose and watery

MedEd GKP/AB/VP (28 decks)

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