Large bowel and other lower GI conditions Flashcards
What is IBS?
Functional bowel syndrome in which abdominal pain is associated with a change in bowel habit in the absence of structural pathology
Which sex is IBS more common in?
Females
What is important when taking a history of suspected IBS?
Detailed questions on nature of stools
Impact on daily activities
Diet, exercise, mental-wellbeing
What examinations should be done in suspected IBS?
BMI - for unexplained weight loss
Abdo exam for tenderness or masses
PR exam for rectal pathology
What must be ruled out before a diagnosis of IBS can be made?
IBD
Coeliac
Malignancy
What investigations should be done before a diagnosis of IBS?
FBC
CRP/ESR
Coeliac serology
If inflammation markers are raised, further investigation would be done
How is IBS managed?
Identify and avoid dietary or mental triggers Dietary advice (try low FODMAP diet) Recommend probiotics Medication can help with severe diarrhoea, constipation and abdominal pain
What are the main IBD GI manifestations?
Increased risk of colon cancer
Toxic megacolon (UC)
Bowel obstruction
Sclerosing cholangitis
Which part of the GI tract is most commonly affected by CD?
Terminal ileus
What are the characteristic features of CD?
Transmural inflammation
Cobble-stoning on endscopy
What are the investigations done when CD is suspected, and in what order?
- Examination
- Bloods
- Endoscopy
- Biopsy for diagnosis
- Imaging
What can be seen on examination in CD?
Weight loss
RIF mass
Peri-anal signs
What may be seen from taking bloods in CD?
Raised CRP/ESR, ferritin and vitamin B12 deficiency
What can be seen on endoscopy in CD?
Cobble-stoning
Skip lesions
What are the histological features of CD?
Granulomas
Loss of villi
What imaging is done for CD and what is it done for?
MRI
CT
Barium follow-through
Done to look for strictures, fistula and to give an indication of severity
What is the treatment for CD?
Lifestyle
- Steroids
- Immunosuppressants
- Anti-TNF
What are some side effects of steroids?
Weight gain
Osteoporosis
Thinning of skin
Hypertension
When is surgery done in CD?
If a flare up is particularly bad to cut out the bit causing problems
What are the risks of surgery in CD?
Short gut syndrome
Parenteral nutrition
What are the complications of CD?
Strictures Fistula Obstruction Malnutrition Short gut syndrome Colon cancer
What are the macroscopic features of UC on endoscopy?
Red, inflamed and friable mucosa
Pseudo-polyps
Thin wall
What are the microscopic features of UC?
Inflammation limited to mucosa (superficial)
Loss of goblet cells
Crypt abscesses
What are the symptoms of CD?
Abdominal pain Diarrhoea Weight loss Fatigue Malaise Fever Mouth ulcers Angular stomatitis Peri-anal disease
What are the symptoms of UC?
Bloody diarrhoea >6 weeks Faecal urgency/incontinence Tenesmus Pain before defecation, relieved once stool passed Non specific symptoms
What are the signs of UC?
Apthous ulcers
Finger clubbing
Pallor (anaemia)
Abdominal tenderness in LIF
What investigations can be done for UC?
P-ANCA positive FBC CRP U&Es, LFTs Coeliac serology Stool culture Faecal calprotectin Colonoscopy
Why might the following investigations be done for UC:
FBC, CRP, U&Es, LFTs, coeliac serology, stool culture, faecal calprotectin, colonoscopy?
FBC - check for anaemia and high platelets
CRP - raised
U&Es, LFTs - may be deranged
Coeliac serology - exclude coeliac
Stool culture - Exclude infection
Faecal calprotectin - raised suggests active inflammation
Colonoscopy - diagnosis
What is the medical management for UC?
- Topical then oral amino salicylate
- Topical or oral steroid
- Immunosuppression
- Anti-TNF
What medication is used in an acute exacerbation of UC?
IV steroids
What additional management is used in UC other than medical and surgical?
Lifestyle, support groups Bone health assessment Colonic cancer surveillance Monitor nutrition status Flu and pneumococcal vaccines
What is re-feeding syndrome?
A metabolic problem when a malnourished person is reintroduced to food too quickly
What is osmotic diarrhoea?
Lots of non-digestible substances in the bowel cause water to move into the lumen
How is osmotic diarrhoea resolved?
Avoidance of the substance that caused it and increasing absorption
What are examples of causes of osmotic diarrhoea?
Certain purgatives
Malabsorptive conditions
What is secretory diarrhoea?
The secretion of electrolytes into he lumen in response to a signal, which are followed by water
What are causes of secretory diarrhoea?
Enterotoxin from E.coli, C.diff and cholera
Hormones
How is secretory diarrhoea resolved?
Replacing fluids and electrolytes
What is inflammatory diarrhoea?
Damage to mucosal cells leads to loss of blood and fluid
Decrease in absorptive function causes a build up in malabsorbed substances
What is a cause of inflammatory diarrhoea?
IBD
How is inflammatory diarrhoea resolved?
Treat underlying cause and replace fluid and electrolytes
What questions are important to ask when taking a history of diarrhoea?
Acute or chronic? Frequency, urgency, nature of stool? Blood mucous or pus? Explosive (cholera)? Other associated symptoms? Constipation? Social history
What is the nature of diarrhoea caused by infection?
Sudden onset
Crampy abdominal pain
Fever
Can be a trigger
What is the nature of diarrhoea caused by IBD?
Loose
Blood stained stools
Chronic history
Extra-GI symptoms
What is the nature of diarrhoea caused by IBS?
No blood
Triggering events
Alternating diarrhoea and constipation
What is the nature of diarrhoea caused by pancreatic dysfunction?
Steatorrhoea
What is the nature of diarrhoea caused by colorectal cancer?
Blood
Mass
What are causes of constipation?
Poor diet and fluid intake
Obstruction (stricture, colorectal cancer, diverticulosis)
IBS
Anorectal disease (stricture, prolapse, diverticulosis)
Functional/idiopathic
Metabolic
Drugs
What is necrotising enterocolitis?
Condition in premature babies where the GI wall is invaded by bacteria
What is the pathogenesis of necrotising enterocolitis?
GI wall is invaded by bacteria
Bowel becomes inflamed and leads to necrosis of tissue
Bowel contents leak into peritoneal cavity and cause peritonitis
What are the symptoms of necrotising enterocolitis?
Poor feeding
Abdominal distension
Bile stained vomit
Sepsis
What is peritonitis?
Inflammation of the peritoneum
What are causes of peritonitis?
Underlying GI condition Perforated organ or ulcer Peritoneal dialysis Ascites related to liver disease TB
What are causes of localised peritonitis?
Acute inflammation (acute appendicitis, acute cholecystitis)
What are the features of localised peritonitis?
Pain and localised tenderness with a more gradual onset
What are the causes of generalised peritonitis?
Inflammation of the peritoneal cavity due to irritation of the peritoneum because of infection or chemical irritation due to leakage of intestinal contents
What are the signs and symptoms of peritonitis?
Rigid abdomen Rebound tenderness Abdominal pain and tenderness Distended abdomen if ascites High temperature Tachycardia
What are the investigations for peritonitis?
Erect CXR showing air under the diaphragm if due to perforation
Abdominal paracentesis
What is the management for peritonitis?
Resuscitation
Surgery - peritoneal lavage
What are the complications of peritonitis?
Sepsis
Multi-organ failure
Abscess formation
What are the features of Peutz-Jegher’s syndrome?
Lots of hamartomatous GI polyps and mucocutaneous hyperpigmentation
What are associated complications of Peutz-Jegher’s syndrome?
Bowel obstruction
Intussusception
What management is done in Peutz-Jegher’s syndrome?
Active cancer surveillance
Prophylactic polypectomy
