Large Bowel Flashcards
What are some differential diagnosis for a patient with right iliac fossa pain?
What is the most important differential to rule out?
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
How does the location of pain typically change as appendicitis progresses?
Peri umbilical/suprapubic then radiates/localises to the right iliac fossa
Why does the location of the pain change as acute appendicitis progresses?
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
What point is pain the worst in acute appendicitis? (Rebound tenderness)
McBurney’s point
Where is McBurney’s point?
2/3s from the umbilicus to the ASIS
What feature usually suggests a patient is peritonitic/septic (potentially due to a burst appendix)?
Guarding
What are the 2 signs that may be found on examination of a patient with acute appendicitis?
Rovsings sign
Psoas sign
What is Rovsings sign?
Palpating left iliac fossa will lead to right iliac fossa pain (appendicitis)
What is the Psoas sign?
What is it suggestive of?
Right iliac fossa pain relieved with right hip Flexion/worsened with right hip extension (Psoas muscle irritates it)
Suggests retrocaecal appendix
What is the typical pathophysiology of acute appendicitis?
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
What is Mittleschmerz?
Pain associated with ovulation on day 14 of the menstrual cycle
What investigations do you do for a female, RIF pain, vomiting?
Pregnancy test/serum B-HCG (ruptured ectopic)
FBC (WCC for infection)
Urine dip (UTI/stones)
U+Es (renal pathology like pyelonephritis)
CRP
G+S
What imaging would you do if a female with RIF pain and vomiting has a +ve pregnancy test?
Transvaginal ultrasound
What imaging would you do when suspecting acute appendicitis?
US abdomen
Or
CT abdo-pelvis with IV contrast
US good for kids and pregnant, if US inconclusive do CT AP contrast
What are the risk factors for acute appendicitis?
FHx
Ethnicity (Caucasians)
Environmental (SUMMER)
What is the management for acute appendicitis?
Laparoscopic appendicectomy
Abx technically an option but not very effective
Don’t give Abx if can do appendicectomy within 6hrs
What are the complications of acute appendicitis?
Perforation -> peritoneum -> sepsis
Surgical site infection
Appendiceal mass
Abscess formation
What is an appendiceal mass?
When omentum and loops of small bowel form to the appendix
What are some differentials for Left iliac fossa pain?
Diverticular disease
Diverticulitis
Sigmoid volvulus
Ulcerative colitis
Ovarian torsion
Ovarian cyst rupture
Renal colic
PID
What is diverticulosis?
Presence of diverticula without sings of infection or inflammation
What is diverticular disease?
Symptoms like pain from the diverticula without inflammation or infection
What is diverticular disease?
Symptoms like pain from the diverticula without inflammation or infection
What is diverticulitis?
Infection/inflammation of the diverticular
What is a diverticula?
What is its pathophysiology?
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
How does diverticulitis present?
Older patient in
LLQ pain
Vomiting
Unwell
Small volume rectal bleeds
Tenderness
(Guarding if perforated)
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
What are some complications of diverticulitis?
Bowel perforation -> peritonitis -> sepsis
Diverticular stricture -> Large bowel obstruction
Fistulae formation
What type of fistulae can form as a result of chronic diverticulitis?
Colovesical fistula
Colovaginal fistula
What are the signs of a colovesical fistula?
Recurrent UTIs
Pneumoturia (gas bubbles in urine)
Faecal matter in urine
What are the signs of a colovaginal fistula?
Copious vaginal discharge
Recurrent vaginal infections
What are the risk factors for diverticular disease/diverticulitis?
Old
Low fibre
Obese
Smoking
Family history
NSAID
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)
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)
What is the treatment for uncomplicated diverticular disease?
Analgesia
Encourage oral fluid intake
Weight loss
High fibre
May need surgery if complicated
What is the conservative management for acute diverticulitis?
Abx
IV fluids
Analgesia
What is the surgical management for diverticulitis?
When is this done?
Hartmanns procedure
When perforated with faecal peritonitis or overwhelming sepsis.
What is a Hartmanns procedure?
Sigmoid colectomy with formation of an end colostomy
How can Ulcerative colitis present?
Haematochezia (fresh red blood in stool)
Mucous in stool
Stool frequency
Stool urgency.
Tenesmus
What are some extra intestinal manifestations of ulcerative colitis?
Enteropathic arthritis
Erythema nodosum
Pyoderma gangrenosum
Episcleriits
Iritis
Primary Sclerosing cholangitis
What is the pathophysiology of ulcerative colitis?
Continous superficial mucosal inflammation typically starting from the rectum spreading proximally
What histological changes occur with ulcerative colitis?
Non granulomatous inflammation
Crypt abcesses
Goblet cell HYPOPLASIA
What investigations should be done if suspecting Ulcerative colitis?
FBC
CRP
Faecal calprotectin
U+E
Urine dip
LFT
Preg test
Stool MC&S
What imaging is required for ulcerative colitis?
Colonoscopy with biopsy
CT AP IV contrast with acute UC flare
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
What are the complications of ulcerative colitis?
TOXIC MEGACOLON
Bowel perforation
Bowel obstruction
Colorectal adenocarcinoma
Pouchitis
How is mild-moderate ulcerative colitis medically managed?
Mesalazine
If mesalazine doesn’t work try corticosteroids
How is moderate-severe ulcerative colitis managed?
Corticosteroids given to achieve remission
Once in remission can switch to azathioprine
How is an acute severe flare of ulcerative colitis managed?
IV corticosteroids
IV fluids
Prophylactic heparin + Antiembolic stockings (IBD flares a prothrombotic)
When is ulcerative colitis managed surgically?
Toxic megacolon
Colon perforation
Uncontrollable bleeding
What is the surgical management of ulcerative colitis?
Emergency = segmental colectomy Orr subtotal colectomy
Elective = pouch (IPAA)
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
What is the main differential from this presentation?
Epigastric abdominal pain
Diarrhoea
Bloody stool
Mucous in stool
Perianal disease
Pyoderma gangrenosum
Crohn’s disease
What are some extra intestinal manifestations of Crohn’s disease?
Erythema nodosum
Pyoderma gangrenosum
Uveitis
Iritis
Primary Sclerosing cholangitis
What are 2 key differentiating features of Crohns and ulcerative colitis?
Crohns = Perianal disease + mouth ulcers
Since Crohns can affect whole GI tract
What investigations for Crohns?
FBC
U+Es
CRP
Preg test
Urine dip
Stool MC+S
Faecal calprotectin
What imaging is done for Crohn’s disease?
COLONOSCOPY (GOLD STANDARD)
Can MRI small bowel
MRI rectum and EUA for fistulating Perianal disease
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)
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
What are some risk factors for Crohn’s disease?
Smoking
Family history
What Perianal disease is associated with Crohn’s disease?
Perianal fistulae
Perianal abcess
Perianal ulcers
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
What lifestyle change is very important to remain in remission for Crohn’s disease?
Smoking cessation
Why do patients with Crohn’s disease require colonoscopic surveillance?
Continual inflammation increase risk of bowel cancer
What are some complications of Crohn’s disease?
Fistulae
Strictures
Perianal disease
GI malignancy
Malabsorption
Inc gallstone risk
Inc renal stone risk
What 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
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
What approach should be taken when surgically managing Crohn’s disease?
Bowel sparring approach
To prevent short gut syndrome
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
What is the most common type of colorectal cancer?
Adenocarcinoma
What is the normal adenoma-carcinoma sequence for colorectal cancers?
Normal mucosa progresses to colonic adenoma (POLYPS) to invasive adenocarcinoma
What are 2 genetic risk factors for developing colorectal cancers?
FAP (Familial adenomatous Polyposis)
HNPCC (Hereditary Non-Polyposis Colorectal Cancer)
What is affected ini HNPCC?
DNA mismatch repair gene (lynch syndrome)
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
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
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
What is the staging system for bowel cancer?
Dukes staging system
How do you prep a patients bowels for colonoscopy?
Laxatives
Cease iron tablets a week before (stains bowel black)
What are the risks of bowel prep/laxatives?
Dehydration
Nausea
Electrolyte imbalances
What are the risks of colonoscopy?
Bowel perforation
Infection
Bleeding
Sedation risks
How are colorectal cancers typically managed?
Surgical treatment +/- neo or adjuvant chemo or radiotherapy
What type of cancer do you always give neoadjuvant radiotherapy first?
Rectal cancers
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
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
What procedure would be done to manage a descending colon tumour?
Left hemicolectomy
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
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
How is an anastomotic leak managed?
Start sepsis 6
CT AP IV contrast
If peritonitis emergency laparotomy and stoma
