Large Bowel🥳 Flashcards
APPENDICITIS pathophysiology?
- normally direct luminal obstruction (by what?). also by lymphoid hyperplasia, impacted stool or rarely appendiceal/caecal tumour
- now commensal bacteria multiply leading to acute inflammation
- also reduced venous drainage
- both lead to inc pressure in appendix -> ischaemia
- untreated? necrosis … perforation
APPENDICITIS risk factors?
- FHx : ?% risk?
- ethnicity : more common in? greater risk of perf in?
- environmental: during what season is common?
APPENDICITIS clinical features?
- abdo pain. peri umbilical (dull & poorly localised - why?) —> RIF (sharp & well localised - why?)
- vomiting (before or after pain?)
- anorexia
- nausea
- diarrhoea/constipation
APPENDICITIS on examination?
- rebound tenderness & percussion pain & guarding over McBurney’s point (where is this?)
- severe? sepsis signs eg ?
- *appendiceal abscess may also present w RIF mass
APPENDICITIS specific signs on examination?
- rovsings sign - RIF pain on palpation of ?
- psoas sign - RIF pain with extension of right ? (suggests retrocaecal appendix)
APPENDICITIS differential diagnoses?
- gynae: ovarian cyst rupture, ectopic, PID
- renal: ureteric stones, UTI, pyelonephritis
- GI: IBD, meckel’s diverticulum, diverticula disease
- urological: testicular torsion, epididymo-orchitis
- **specifically in children? gastroenteritis, constipation, intussusception or UTI
APPENDICITIS lab tests?
- urinalysis- why? when can leukocytes be present in the urine still?
- preg test
- bloods - fbc, crp
APPENDICITIS imaging?
clinical diagnosis is normally sufficient.
if clinical features inconclusive:
- USS - first line (especially transvaginal if other gynae pathology differentials). why is it good in kids?
- CT
APPENDICITIS management?
- definitive treatment : laparoscopic appendicectomy
- maybe conservative antibiotic therapy in uncomplicated appendicitis
APPENDICITIS complications?
- perf -> peritonitis
- surgical site infection
- appendix mass - what is this?
- pelvic abscess - presents as palpable RIF mass, confirmed w CT, management?
DIVERTICULAR DISEASE information
- diverticulum = outpouching through bowel wall. common in sigmoid 4 manifestations of this condition: - diverticulosis - ? - diverticular disease - ? - diverticulitis- ? - diverticular bleed - ? - M>F, developed countries
DIVERTICULAR DISEASE pathophysiology
aging bowel has become weakened over time -> stool inc luminal pressure -> results in outpouching of the mucosa through the weaker areas of the bowel wall
…
bacteria can overgrown in the outpouchings leading to inflammation. they can perf leading to diffuse peritonitis sepsis
…
chronic? fistula can form. what ones are most common?x2
…
diverticulitis is either simple (?) or complicated (?)
DIVERTICULAR DISEASE risk factors?
inc age, low dietary fibre, obesity, smoking, fhx, nsaid use
DIVERTICULAR DISEASE diverticulosis clinical features?
asymptomatic and found incidentally on ct or routine colonoscopy
DIVERTICULAR DISEASE clinical features?
intermittent lower abdo pain - colicky in nature & relieved by defecation
other sx: altered bowel habit, associated nausea, flatulence. no systemic features
DIVERTICULAR DISEASE acute diverticulitis clinical features ?
- acute abdo pain, sharp, localised in the left iliac fossa, worsened w movement
- perf? signs of localised peritonism or generalised peritonitis. V UNWELL
- what meds can mask sx of diverticulitis?
DIVERTICULAR DISEASE differentials?
IBS, bowel CA, mesenteric ischaemia, gynae causes, renal stones
DIVERTICULAR DISEASE investigations?
- bloods: what ones?
- urine dip - why?
- CT AP - what findings?x5
- uncomplicated diverticular disease ? flex sig
DIVERTICULAR DISEASE management ?
- uncomplicated dd? analgesia, oral fluid intake encouragement. out pt colonoscopy to exclude CA
- diverticular bleeds? manage conservatively as mostly self limiting. significant bleeding? resus w appropriate blood products + stablisation
fail to respond? embolisation or surgical resection - acute diverticulitis? conservative mgmt - abx, iv fluids, analgesia. sx tend to improve in 2-3 days. clinical deterioration ? repeat imaging
DIVERTICULAR DISEASE surgical management?
- in pts w perf w faecal peritonitis or overwhelming sepsis
- hartmanns procedure (what is this?)
- an anastomoses w reversal or colostomy may be possible at a later date
DIVERTICULAR DISEASE complications?
- recurrence
- diverticular stricture - following repeated episodes of inflammation. bowel becomes scarred and fibrotic resulting in a benign stricture. can cause large bowel obstruction so sigmoid colectomy needed
- fistula - due to repeated inflammation. most common types?? how do they present??
CROHNS clinical features?
episodic abdo pain (colicky), diarrhoea (may contain blood or mucus). systemic sx: malaise, anorexia, low grade fever, malabsorption & malnourishment. oral aphthous ulcer & perianal disease
extra intestinal features: msk (?), skin (?), eyes (?), HPB (?), renal (?)
CROHNS investigations?
- bloods -?
- faecal calprotectin
- gold standard - colonoscopy
CROHNS management ?
- medical : gastroenterologist. induce remission:1st corticosteroid then azatioprine etc. maintain remission:azathiprine, smoking cessation. colonoscopies offered if has disease for >10 yrs and >1 segment of bowel affected due to inc CA risk. IBD nurse specialist
- surgical: if failed medical mgmt or severe comps (eg strictures or perks). ops inc: ileocaecal resection, small bowel/large bowel resection, peri anal disease surgery, stricturoplasty. ** pre op optimisation important !!
CROHNS comps?
- gi: fistula, stricture, recurrent perianal fistula, gi CA
- extra intestinal : malabsorption,osteoporosis, inc risk gallstones, inc risk renal stones
explain all above!!!
UC clincial features?
insidious in onset - bloody diarrhoea, proctitis, pr bleed, mucus discharge, inc fre & urgency defecation, tenesmus
more widespread colonic involvement? bloody diarrhoea + clinical features of dehydration & electrolyte imbalance
systemic sx? malaise, anorexia, low grade pyrexia
- OE? normal…severe abdo pain???? suspect toxic megacolon etc!! will show sings of peritonism
- extra intestinal features : msk (?), skin (?), eyes (?), HPB (?)
UC differentials?
crohns chronic infections (eg?x3) mesenteric ischaemia radiation colitis CA IBS coeliac
UC investigations ?
- bloods - ?
- faecal calprotectin
- stool sample sent for MC&S
- colonoscopy w biopsy
- acute exacerbation? AXR or CT to assess for toxic megacolon or perf
typical AXR features?x3
UC management ?
- medical: gastroenterologist. inducing remission : corticosteroid + immunosuppressive therapy. maintain remission: immunosuppressive eg mesalazine, >10 yr of disease + >1 segment affected? colonoscopy due to inc CA risk, IBD nurse specialist
- surgical : indications for acute surgical treatment: refractory to med management, toxic megacolon, bowel perf. typically require segmental bowel resection & defunctioning stoma (why/). elective? total proctocolectomy (w end ileostomy) is curative but disease control: IRA or panprctocolectomy w IPAA
VOLVULUS what is it?
twisting of a loop of intestine around its mesenteric attachment resulting in a closed loop bowel obstruction. affected bowel can become ischaemic due to compromised blood supply leading to necrosis & perf
VOLVULUS most common site?
sigmoid - long mesentery (inc w age) means this portion is more prone to twisting on its mesenteric base.
other common places?
VOLVULUS risk factors?
inc age, neuropsychiatric disorders, nursing home resident, chronic constipation or laxative use, male, prev abdo ops
VOLVULUS clinical features?
pt presents w bowel obstruction
- colicky pain, abdo distension, absolute constipation, vomiting (later on, why?)
- rapid onset (?), high degree of abdo distension
VOLVULUS OE?
- abdo is tympanic to percussion
- examine for signs of perf or peritonism!!
VOLVULUS differentials?
- alternative causes for bowel obstruction
- severe constipation
- severe sigmoid diverticular disease
VOLVULUS investigations ?
- bloods - ?
- CT AP w contrast - what does it identify ? it’ll show very dilated sigmoid w a ? sign from the twisted mesentery
- AXR shows ? sign in the LIF. if ileocaecal valve incompetent?
VOLVULUS management?
- conservative: decompression by sigmoidscope (describe this process) & insertion of a flatus tube (what is this?)
- surgery (hartmanns) is indicated if: there’s colonic ischaemia or perf, there were repeated failed attempts @ decompression or there was necrotic bowel noted @ endoscopy.
VOLVULUS comps?
- immediate: bowel ischaemia, perf
- long term: risk of recurrence, stoma comps
VOLVULUS caecal vs sigmoidal
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