GI: Viral Gastroenteritis, GERD, Constipation, Rectal bleeding, Functional dyspepsia, dLFT, Diarrhea Flashcards
Viral GE
Microbiology
Viral GE
Clinical presentation
Viral GE
Red flag S/S
Viral GE
Dehydration S/S
Viral GE
Management
Viral GE
ORS preparation
Common prescription
Loperamide
* Indicated in patients with absent of fever and stools are not bloody
* Avoid in patients with dysentery in fear of prolonging disease in such infection
* Anti-motility agent (Opioid receptor agonist)
Antibiotics
* Do NOT routinely recommend empiric antibiotics in patients with acute diarrhea
Indications
o Severe disease with fever, diarrhea > 6/day, volume depletion
o Invasive bacterial infection suggested by bloody or mucoid stools
o Prolonged disease refractory to treatment
o Host factors that increases risk for complications including age > 70 and
comorbidities such as immunocompromise conditions and cardiac disease
Antibiotic choice
o Fluoroquinolones: Ciprofloxacin/ Levofloxacin
o Macrolides: Azithromycin/ Erythromycin
Dietary recommendations
* Avoidance of food with high fat content
* Avoidance of dairy products
Diarrhea
Differentiate acute vs chronic, small vs large bowel, organic vs functional
Infective diarrhea
Microbiology
Non-infective diarrhea
Causes
Diarrhea
Key questions
Diarrhea
P/E
Diarrhea
Biochemical tests
Diarrhea
Radiological Ix
GERD
Definition
Pathological vs physiological reflux?
GERD
Classification
GERD
Risk factors
GERD
Pathophysiology
GERD
Clinical presentation
Red flags: Dysphagia/ Odynophagia/ Hematemesis/ Melena/ Anemia/ Vomiting/ Weight loss/ Family history of esophageal or gastric cancer/ Chronic NSAIDs usage
GERD
Ddx
GERD
Biochemical test
Approach to NCCP:
1. Clinical diagnosis by Hx & P/E (esp. Cardiovascular exam), Validated Chinese GERD Questionnaire (7 questions)
2. PPI at standard dose b.d. for 4-8w
3. If failed, 24h Oesophageal pH Monitoring
4. If failed (-ve result), Manometry for Oesophageal motility disorder
GERD
Radiological Ix
GERD
Lifestyle modification and advice
GERD
Medical treatment
-Regimen Now: Step-down regimen (from PPI)
* Quick symptom control & oesophagitis healing
* Confirm diagnosis
* Low drug & consultation cost
Drug given lifelong/ intermittently/ on demand
GERD
Surgical treatment
GERD
Common prescriptions
Deranged liver function test
Components of liver function test
dLFT
Patterns of deranged LFT
ALT AST
Refernce range
Location
ALT AST
Ratio significance
dLFT
Ddx marked vs mild elecation
dLFT
Cholestatic pattern ddx
ALP GGT
ddx mild vs marked elevation
Evaluation of elevated ALP
Common drugs causing dLFT
IBS
Pathophysiology
IBS
Subtypes
b
IBS
Clinical presentation
IBS
Diagnosis
IBS
Ix
IBS
Management
Constipation
Causes
Constipation
Clinical presentation
Constipation
Complications
Constipation
P/E
Constipation
Ix
Assessment of complications to decide on operative vs non-operative Mx
□ CBC, L/RFT: infection, anaemia, dehydration
□ ABG + lactate: acidosis (ischaemia), alkalosis (vomiting)
□ Amylase to r/o acute pancreatitis
□ Erect CXR + E/S AXR for perforation and strangulation
Radiographic Ix:
Erect/supine AXR
Contrast CT abdomen
Water soluble contrast study by gastrografin (GGF)
Lower endoscopy
Constipation
Management
Common prescriptions for Constipation
- Bulk Laxatives: Methylcellulose 500mg tablets PO 3-6 tablets b.d.
- Osmotic Laxatives: Lactulose 680mg/ml solution PO 15ml b.d.
- Stimulant Laxatives: Bisacodyl 5-10mg tablet q.d., taken at night
Dyspepsia
Definition
Red flag S/S
Dyspepsia
Causes
Dyspepsia
Pathogenesis
Dyspepsia
Key questions
Dyspepsia
P/E
Dyspepsia
Ix
Functional dyspepsia diagnosed by exclusion after investigations
Dyspepsia
Treatment
Rectal bleeding/ LGIB
Causes
Diverticular bleeding (15 – 55%) (most common)
* Bleeding is usually painless with mild abdominal discomfort and cramping due to colonic spasm from intraluminal blood
* Risk factors include advanced age, obesity, hypertension, hyperlipidemia, IHD, chronic renal insufficiency and use of aspirin or NSAIDs
Angiodysplasia (most common in age > 65)
* Acquired conditions associated with degeneration of vascular walls from aging
Hemorrhoids (most common in age < 50)
* Usually asymptomatic but can present with painless hematochezia, thrombosis, strangulation or pruritus
Colitis
* Infectious/ Ischemic/ Radiation colitis
Inflammatory bowel disease
Colorectal Cancer
Anorectal diseases: rectal ulcers, rectal varices, anal ulcers, anal fissures and Dieulafoy’s lesions
Following biopsy or polypectomy
Radiation telangiectasia and proctitis
Massive bleeding from small bowel sources
* Meckel’s diverticulitis
* Crohn’s disease
* Angiodysplasia
* Hemangioma
Rectal bleeding/ LGIB
Key questions
Rectal bleeding/ LGIB
P/E
Rectal bleeding/ LGIB
Biochemical Ix
Rectal bleeding/ LGIB
Radiological Ix
Proctoscopy (first-line)
Colonoscopy
OGD
CT angiography/ IV angiography
Common S/S of anorectal diseases
Bleeding (fresh)
Anal pain
Discharge (bloody or purulent)
Prolapse
Peranal mass
Pruritis ani
Incontinence
Investigations for anorectal diseases
Imaging
Physiological tests
P/E:
General exam
Abdominal exam
Perianal exam
Digital rectal exam
Proctoscopy
Imaging:
Rigid sigmoidoscopy
Flexible endoscopy
Transrectal ultrasound
MRI: complicated abscesses/ fistulas
Others (old, superceded): Defecography, Fistulogram
Physiological: constipation and incontinence
Anorectal manometry
Electromyogram
Pudendal nerve latency test
Hemorrhoids
Risk factors
Degrees
Risk factors:
Low fibre diet
Family history of hemorrhoids
Increased intra-abdominal pressure
Pregnancy
Constipation, straining
Chronic cough
Obesity
Four degrees of internal hemorrhoids
1st degree: Bleeding only without prolapse
2nd degree: Prolapse at defecation but reduce spontaneously afterwards
3rd degree: Prolapse and have to be manually reduced
4th degree: Permanently prolapsed, Cannot reduce
Hemorrhoids
Clinical presentation
Irritation or pruritus
Bright-red painless bleeding (ALWAYS exclude other possible sources of PR bleeding)
Mucous discharge
Prolapsed mass
Pain (from complications like thrombosis, prolapse)
Hemorrhoids
Management
Conservative:
Diet modification: High fiber diet
Sitz bath: relax sphincter muscles and reduce spasm, pruritis, inflammation
For significant haemorrhoids with prolapse
Ointment and suppositories
- Analgesic cream: mixed lidocaine/ hydrocortisone
- Hydrocortisone suppositories: shrink hemorrhoids
- Venoactive agents: Phlebotonics e.g. Daflon to control bleeding
Laxatives/ Stool softeners
* Osmotic laxative e.g. Lactulose
* Bulk laxative e.g. Methycellulose
* Stimulant laxative e.g. Senna/ Bisacodyl
Office procedures:
* Rubber band ligation
* Sclerotherapy
* Infra-red coagulation
In-patient surgeries:
* Surgical hemorrhoidectomy
* Stapled haemorrhoidopexy
* Transanal hemorrhoidal artery devascularization
Complications of untreated hemorrhoids
Complications of hemorrhoids
Strangulation and thrombosis
Gangrene
Ulceration
Fibrosis
Portal pyemia
Anal fissures
Causes
- Primary causes
Local trauma to anal canal
* Passage of hard stools
* Prolonged diarrhea
* Vaginal delivery
* Anal sex
Secondary causes
Inflammatory bowel disease
* Crohn’s disease
* Ulcerative colitis
Granulomatous disease
* Extrapulmonary TB
* Sarcoidosis
Malignancy
* Squamous cell anal cancer
* Leukemia
Sexually-transmitted diseases
* HIV infection
* Syphilis
* Chlamydia
Fissure-in-ano
S/S
Typical and atypical features
Signs and symptoms:
1. Painful defecation
* Tearing pain with passage of bowel movements
2. Bright rectal bleeding
* Limited to a small amount on toilet paper or surface of stool
3. Perianal pruritus or skin irritation
Typical features:
* Single posterior or anterior fissure without evidence of Crohn’s disease
Atypical features
* Multiple, recurring, non-healing, deep or wide, painless and at off-midline locations
* Suggests secondary causes of anal fissures
Physical examination technique for anorectal fissure
How to differentiate acute from chronic fissure
Most common location of primary anal fissure is posterior anal midline
Spread buttock to reveal fissure, DO NOT PERFORM RECTAL EXAM OR PROCTOSCOPY
Acute fissure (Pathognomonic feature = Superficial tear)
o Superficial tear
o Fresh laceration resembling a paper cut
Chronic fissure (Pathognomonic feature = Hypertrophied with skin tags or papillae)
o Raised edges exposing white horizontally oriented fibers of the internal anal sphincter muscle fibers at the base of fissure
o Hypertrophied anal papillae at the proximal end of fissure
o Skin tags (sentinel pile) at the distal end of fissure
Surgical treatment options for fissure-in-ano
Indicated in patients who fail 8 weeks of initial medical treatment
Botulinum toxin type A injection
Lateral internal sphincterotomy
Anorectal abscess
Etiologies
Cryptoglandular infection
* Infection of the anal glands
Other infections
* Inflammatory bowel disease
* Tuberculosis
* Actinomycosis
* Foreign body
- Surgical
Malignancies
Anorectal abscess
Pathogenesis
S/S
Treatment
Pathogenesis of an anal abscess
Originates from an infected anal crypt gland which penetrate the internal sphincter and end in the intersphincteric plane
Obstruction of anal crypt gland with inspissated debris permits bacterial growth and abscess formation
Signs and symptoms
Pain in anal or rectal area
* Constant pain
* Not necessarily associated with a bowel movement
* Associated with symptoms including fever and malaise
Purulent discharge
Constipation
Urinary difficulties
Tx:
Incision and drainage
Antibiotics has MINIMAL role
* Except in patients with cellulitis, valvular heart disease, prosthetic heart valves and immunosuppression
Causes/ etiologies of anorectal fistula
Ddx
Anorectal abscesses (most common >90%)
* Often evolves from a spontaneously draining anorectal abscess originating from the crypts of Morgagni (cryptoglandular infection) which are located between two layers of anal sphincter
Other causes:
Crohn’s disease, Lymphogranuloma venereum (Chlamydia trachomatis), Radiation proctitis, Rectal foreign bodies, Actinomycosis
Ddx:
Anal abscess
Anal fissure
Anal ulcers or sores
Anorectal fistula
S/S
Painful defecation
* Intermittent rectal pain particularly during defecation but also with sitting and activity
Bleeding
Swelling
Purulent drainage - lowers pain
* Intermittent and malodorous perianal drainage
Perianal pruritus
Anorectal fistula
Investigations
Indication for imaging
Internal and external opening of fistula tract need to be identified
Anorectal examination
Anoscopy or sigmoidoscopy
Radiological tests
Examination under anesthesia (EUA) with Fistula Probe
Imaging modalities:
* Endosonography (EUS)
* CT/ MRI anal canal
* Fistulography
MRI for: complicated high fistula, recurrent fistula, poor anatomy
Anorectal fistula
Surgical treatment options
Alternative/ advanced treatment options
Simple low fistula - Fistulotomy/ Fistulectomy
Complicated high fistula/ transphincteric fistula with muscle involvement:
Setons: Cutting (snug) seton, Draining seton
Endorectal advancement flap: Closing off the internal opening of fistula by a mobilized flap
Anal fistula plug: ameliorate postoperative incontinence
Ligation of intersphincteric fistula tract (LIFT): Secure closure of internal opening and removal of infected cryptoglandular tissues
Others:
Video-assisted anal fistula treatment (VAAFT)
- FiLaC (Fistula tract laser closure)
- Permacol paste injection
- Stem cell treatment
Rectal prolapse
Definition
Cause
Differentiate complete and partial prolapse
Rectal prolapse is a pelvic floor disorder. Full thickness protrusion of rectum through anal sphincters
Failure of pelvic floor muscles/ levator ani (puborectalis + pubococcygeus + iliococcygeus muscles)
Extent of rectal prolapse
* Complete rectal prolapse refers to protrusion of all layers of rectum through the anus
* Partial rectal prolapse refers to protrusion of the mucosa only
Rectal prolapse
Etiologies
Neurological disorders: Dementia, Stroke
Parity, female, age>40, vaginal delivery
Chronic Constipation/ straining/ diarrhea
Childhood factors: Cystic fibrosis, Whooping cough, Developmental abnormalities, Malnutrition
Rectal prolapse
Treatment options for abdominal and perineal repair
Abdominal repair:
Rectal fixation (suture/ mesh)
Sigmoid resection
Proctectomy
Combination rectal fixation and sigmoid resection
Laparoscopic Ventral Mesh Rectopexy
Perineal repair:
Full thickness resection
Mucosal resection with muscular reefing
Anal encirclement
