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Y3(S) - General > Large Bowel > Flashcards

Large Bowel Flashcards

1
Q

What are some differential diagnosis for a patient with right iliac fossa pain?

What is the most important differential to rule out?

A

Acute appendicitis
Renal colic
Ovarian cyst rupture
Ovarian torsion
Crohns
Meckels diverticulum
PID
Mittleschmerz

RUPTURED ECTOPIC PREGNANCY MUST BE RULED OUT IN ALL PRE MENOPAUSAL FEMALES

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2
Q

How does the location of pain typically change as appendicitis progresses?

A

Peri umbilical/suprapubic then radiates/localises to the right iliac fossa

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3
Q

Why does the location of the pain change as acute appendicitis progresses?

A

Pain initially dull and poorly localised initially since the inflammed appendix irritates the visceral peritoneum which has poor sensory supply.

As it becomes further and further inflammed it compresses/irritates the parietal peritoneum which has a much better sensory supply leading to localised and sharp pain in the RIF

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4
Q

What point is pain the worst in acute appendicitis? (Rebound tenderness)

A

McBurney’s point

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5
Q

Where is McBurney’s point?

A

2/3s from the umbilicus to the ASIS

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6
Q

What feature usually suggests a patient is peritonitic/septic (potentially due to a burst appendix)?

A

Guarding

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7
Q

What are the 2 signs that may be found on examination of a patient with acute appendicitis?

A

Rovsings sign

Psoas sign

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8
Q

What is Rovsings sign?

A

Palpating left iliac fossa will lead to right iliac fossa pain (appendicitis)

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9
Q

What is the Psoas sign?

What is it suggestive of?

A

Right iliac fossa pain relieved with right hip Flexion/worsened with right hip extension (Psoas muscle irritates it)

Suggests retrocaecal appendix

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10
Q

What is the typical pathophysiology of acute appendicitis?

A

Luminal obstruction leads to acute inflammation, this impairs venous drainage with further increases the pressure in the appendix. This leads to ischaemia of the appendiceal wall which can lead to necrosis and perforation of the appendix

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11
Q

What is Mittleschmerz?

A

Pain associated with ovulation on day 14 of the menstrual cycle

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12
Q

What investigations do you do for a female, RIF pain, vomiting?

A

Pregnancy test/serum B-HCG (ruptured ectopic)
FBC (WCC for infection)
Urine dip (UTI/stones)
U+Es (renal pathology like pyelonephritis)
CRP
G+S

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13
Q

What imaging would you do if a female with RIF pain and vomiting has a +ve pregnancy test?

A

Transvaginal ultrasound

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14
Q

What imaging would you do when suspecting acute appendicitis?

A

US abdomen
Or
CT abdo-pelvis with IV contrast

US good for kids and pregnant, if US inconclusive do CT AP contrast

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15
Q

What are the risk factors for acute appendicitis?

A

FHx
Ethnicity (Caucasians)
Environmental (SUMMER)

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16
Q

What is the management for acute appendicitis?

A

Laparoscopic appendicectomy

Abx technically an option but not very effective

Don’t give Abx if can do appendicectomy within 6hrs

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17
Q

What are the complications of acute appendicitis?

A

Perforation -> peritoneum -> sepsis

Surgical site infection

Appendiceal mass

Abscess formation

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18
Q

What is an appendiceal mass?

A

When omentum and loops of small bowel form to the appendix

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19
Q

What are some differentials for Left iliac fossa pain?

A

Diverticular disease
Diverticulitis
Sigmoid volvulus
Ulcerative colitis
Ovarian torsion
Ovarian cyst rupture
Renal colic
PID

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20
Q

What is diverticulosis?

A

Presence of diverticula without sings of infection or inflammation

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21
Q

What is diverticular disease?

A

Symptoms like pain from the diverticula without inflammation or infection

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22
Q

What is diverticular disease?

A

Symptoms like pain from the diverticula without inflammation or infection

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23
Q

What is diverticulitis?

A

Infection/inflammation of the diverticular

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24
Q

What is a diverticula?

What is its pathophysiology?

A

Outpouchings of mucosa through the bowel wall

Bacteria can overgrow in the outpouchings leading to inflammation (diverticulitis)
Perforation of the diverticula can occur leading to peritonitic sepsis and death

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25
How does diverticulitis present?
Older patient in LLQ pain Vomiting Unwell Small volume rectal bleeds Tenderness (Guarding if perforated)
26
Where does diverticular disease most commonly occur and why?
Sigmoid colon This is the area of the bowel typically under the highest pressure so gets weaker with age more easily
27
What are some complications of diverticulitis?
Bowel perforation -> peritonitis -> sepsis Diverticular stricture -> Large bowel obstruction Fistulae formation
28
What type of fistulae can form as a result of chronic diverticulitis?
Colovesical fistula Colovaginal fistula
29
What are the signs of a colovesical fistula?
Recurrent UTIs Pneumoturia (gas bubbles in urine) Faecal matter in urine
30
What are the signs of a colovaginal fistula?
Copious vaginal discharge Recurrent vaginal infections
31
What are the risk factors for diverticular disease/diverticulitis?
Old Low fibre Obese Smoking Family history NSAID
32
What investigations would you do with a potential diverticulitis?
FBC CRP U+Es Faecal calprotectin (blood in stool?) Urine dip Pregnancy test G+S VBG DRE (ANAL PATIENT WITH BLOOD IN STOOL)
33
What imaging would you do for a patient with potential diverticulitis?
CT AP with IV contrast Can do a flexisigmoidoscopy if uncomplicated diverticular disease (NEVER FOR DIVERTICULITIS)
34
What is the treatment for uncomplicated diverticular disease?
Analgesia Encourage oral fluid intake Weight loss High fibre May need surgery if complicated
35
What is the conservative management for acute diverticulitis?
Abx IV fluids Analgesia
36
What is the surgical management for diverticulitis? When is this done?
Hartmanns procedure When perforated with faecal peritonitis or overwhelming sepsis.
37
What is a Hartmanns procedure?
Sigmoid colectomy with formation of an end colostomy
38
How can Ulcerative colitis present?
Haematochezia (fresh red blood in stool) Mucous in stool Stool frequency Stool urgency. Tenesmus
39
What are some extra intestinal manifestations of ulcerative colitis?
Enteropathic arthritis Erythema nodosum Pyoderma gangrenosum Episcleriits Iritis Primary Sclerosing cholangitis
40
What is the pathophysiology of ulcerative colitis?
Continous superficial mucosal inflammation typically starting from the rectum spreading proximally
41
What histological changes occur with ulcerative colitis?
Non granulomatous inflammation Crypt abcesses Goblet cell HYPOPLASIA
42
What investigations should be done if suspecting Ulcerative colitis?
FBC CRP Faecal calprotectin U+E Urine dip LFT Preg test Stool MC&S
43
What imaging is required for ulcerative colitis?
Colonoscopy with biopsy CT AP IV contrast with acute UC flare
44
What changes can be seen on a plain film abdominal radiograph with ulcerative colitis?
Thumb printing of bowel indicating oedmatous inflamed bowel LEAD PIPE COLON
45
What are the complications of ulcerative colitis?
TOXIC MEGACOLON Bowel perforation Bowel obstruction Colorectal adenocarcinoma Pouchitis
46
How is mild-moderate ulcerative colitis medically managed?
Mesalazine If mesalazine doesn’t work try corticosteroids
47
How is moderate-severe ulcerative colitis managed?
Corticosteroids given to achieve remission Once in remission can switch to azathioprine
48
How is an acute severe flare of ulcerative colitis managed?
IV corticosteroids IV fluids Prophylactic heparin + Antiembolic stockings (IBD flares a prothrombotic)
49
When is ulcerative colitis managed surgically?
Toxic megacolon Colon perforation Uncontrollable bleeding
50
What is the surgical management of ulcerative colitis?
Emergency = segmental colectomy Orr subtotal colectomy Elective = pouch (IPAA)
51
Ulcerative colitis features: 1.) inflammation depth 2.) location 3.) inflammation pattern 4.) associated pathology 5.) smoking effect 6.) inflammation type/histopathological changes
1.) superficial 2.) starts rectum and moves proximal to ilocaecal join 3.) continuous 4.) No Perianal disease 5.) smoking dampens pain 6.) Non granulomatous inflammation, crypt abcesses, DECREASED GOBLET CELLS
52
What is the main differential from this presentation? Epigastric abdominal pain Diarrhoea Bloody stool Mucous in stool Perianal disease Pyoderma gangrenosum
Crohn’s disease
53
What are some extra intestinal manifestations of Crohn’s disease?
Erythema nodosum Pyoderma gangrenosum Uveitis Iritis Primary Sclerosing cholangitis
54
What are 2 key differentiating features of Crohns and ulcerative colitis?
Crohns = Perianal disease + mouth ulcers Since Crohns can affect whole GI tract
55
What investigations for Crohns?
FBC U+Es CRP Preg test Urine dip Stool MC+S Faecal calprotectin
56
What imaging is done for Crohn’s disease?
COLONOSCOPY (GOLD STANDARD) Can MRI small bowel MRI rectum and EUA for fistulating Perianal disease
57
Crohn’s disease features: 1.) inflammation depth 2.) location 3.) inflammation pattern 4.) associated pathology 5.) smoking effect 6.) inflammation type/histopathological changes
1.) transmural/full thickness 2.) entire GI system can be affected 3.) Skip like lesions, fissures and deep ulcers creating cobblestone like appearance, fistulae 4.) PERIANAL disease 5.) worsens pain/risk factor 6.). GRANULOMATOUS inflammation (non caseating)
58
What type of giant cell is involved in the granulomatous inflammation of Crohn’s disease? What is the appearance of these cells?
Langhans giant cell Horse shoe shaped arrangement of nuclei
59
What are some risk factors for Crohn’s disease?
Smoking Family history
60
What Perianal disease is associated with Crohn’s disease?
Perianal fistulae Perianal abcess Perianal ulcers
61
What is the management for an acute severe flare of Crohn’s disease?
IV corticosteroids like hydrocortisone (remission) Switch to azathioprine once in remission Attempt mesalazine if corticosteroids fail to achieve remission Fluid resus + Prophylactic heparin + TED stockings
62
What lifestyle change is very important to remain in remission for Crohn’s disease?
Smoking cessation
63
Why do patients with Crohn’s disease require colonoscopic surveillance?
Continual inflammation increase risk of bowel cancer
64
What are some complications of Crohn’s disease?
Fistulae Strictures Perianal disease GI malignancy Malabsorption Inc gallstone risk Inc renal stone risk
65
Why do patients with Crohn’s disease have an increased gallstone risk?
Less bile salts absorbed at terminal ileum due to ileum being damaged Bile salts prevent the cholesterol in bile being to concentrated and stops stone formation
66
Why are patients with Crohn’s disease at increased risk of renal stones?
Fats not absorbed properly, fats bind to calcium allowing more Oxalate to remain free Inc calcium oxalate stone formation
67
What approach should be taken when surgically managing Crohn’s disease?
Bowel sparring approach To prevent short gut syndrome
68
What are some features in a history might you find with a colorectal cancer?
Old Change in bowel habits Haematochezia Weight loss General malaise Anaemic
69
What is the most common type of colorectal cancer?
Adenocarcinoma
70
What is the normal adenoma-carcinoma sequence for colorectal cancers?
Normal mucosa progresses to colonic adenoma (POLYPS) to invasive adenocarcinoma
71
What are 2 genetic risk factors for developing colorectal cancers?
FAP (Familial adenomatous Polyposis) HNPCC (Hereditary Non-Polyposis Colorectal Cancer)
72
What is affected ini HNPCC?
DNA mismatch repair gene (lynch syndrome)
73
What are some risk factors for colorectal cancers?
FAP HNPCC Age Male Family history IBD Low fibre high processed meat diet Smoking High alcohol intake
74
What investigations should be done on a patient with: -right sided abdopain -weight loss -change in bowel habit -smoker -low fibre diet -drinker
FBC (WCC and Hb for anaemia) U+Es LFTs Clotting G+S CEA tumour marker Fecal immunohistochemistry (check for occult blood) DRE
75
What imaging needs to be done for the patient with: -right sided abdopain -weight loss -change in bowel habit -smoker -low fibre diet -drinker What are we suspecting?
Colonoscopy with biopsy (or CT colon gram if cant tolerate/unsuitable) CT CAP (IV contrast) for staging Suspecting large bowel cancer
76
What is the staging system for bowel cancer?
Dukes staging system
77
How do you prep a patients bowels for colonoscopy?
Laxatives Cease iron tablets a week before (stains bowel black)
78
What are the risks of bowel prep/laxatives?
Dehydration Nausea Electrolyte imbalances
79
What are the risks of colonoscopy?
Bowel perforation Infection Bleeding Sedation risks
80
How are colorectal cancers typically managed?
Surgical treatment +/- neo or adjuvant chemo or radiotherapy
81
What type of cancer do you always give neoadjuvant radiotherapy first?
Rectal cancers
82
What procedure would be done for a patient with a caecal tumour or ascending colon tumour?
Right hemicolectomy An extended right hemicolectomy can be done for transverse colon tumours
83
What structures are removed in a right hemicolectomy to treat a caecal or ascending colon tumour?
Caecum Ascending colon Iliocolic artery /vein Right colic artery /vein Right branch of middle colic artery /vein The arteries associated lymph nodes and mesentries
84
What procedure would be done to manage a descending colon tumour?
Left hemicolectomy
85
What structures are removed in a left hemicolectomy to manage a descending colon tumour?
Descending colon Left branch of middle colic artery/vein Left colic artery and vein Inferior mesenteric vein
86
What is the most likely diagnosis when a patient is 3-5days post op from right or left hemicolectomy and they’re extremely unwell?
Anastomotic leak
87
How is an anastomotic leak managed?
Start sepsis 6 CT AP IV contrast If peritonitis emergency laparotomy and stoma
88
How is mild diverticulitis managed?
oral co-amoxiclav, if no improvement in 72hrs attend hospital for more antibiotics
89
What antibiotics are given if co-amoxiclav 72hrs doesn’t improve the diverticulitis?
IV Ceftriaxone + Metronidazole

Y3(S) - General (5 decks)

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