LB Disease Flashcards
What causes appendicitis?
Direct luminal obstruction
(usually secondary faecolith*, May lymphoid hyperplasia, impacted stool, appendiceal/ caecal tumour)
Lifetime risk 7-8%
2nd/ 3rd decade
*hardened, sometimes calcified stool (worse than impacted)
Signs of appendicitis
Rebound tenderness/ percussion pain McBurney’s point
- Rovsing’s sign
RIF pain on palpation of LIF - Psoas sign
RIF pain with extension of R hip
Aetiology of colorectal cancers
3rd most common cancer UK
2nd highest mortality
Originate epithelial cells, mostly adenocarcinoma
Rarer: lymphoma, carcinoid, sarcoma
Adenoma-carcinoma sequence:
Normal mucosa -> colonic adenoma (polyps) 10+yrs -> 10% invasive adenocarcinoma
Genetics: adenomatous polyposis coli, hereditary non polyposis colorectal cancer
75% sporadic
Clinical features of bowel cancer
Change in bowel habit Rectal bleeding WL Abdo pain Fe deficiency anaemia
Right sided
Abdo pain, occult bleeding/ anaemia, mass RIF, present late
Left
PR bleeding, change BH, tenesmus, mass LIF/ DRE
What is anterior resection? What about abdominoperineal resection?
High rectal tumours
>5cm from anus
Loop ileostomy (temporary)
Low rectal tumours (<5cm)
Rectum & anus (including sphincter muscles) removed
Stoma (colostomy) permanent
What is Hartmann’s procedure?
Emergency bowel surgery
Obstruction/ perforation
Complete resection recto-sigmoid colon
-> end colostomy & closure rectal stump
Define: diverticulum Diverticulosis Diverticula disease Diverticulitis
Outpouching of the bowel wall (most commonly SC)
Presence of diverticula
(50% >50yrs, mostly asymptomatic)
Symptomatic diverticula (diverticula pain - intermittent lower abdo, colicky, relived defecation, altered BH, N, flactulence)
Inflammation of diverticula
(Acute abdo pain, sharp, LIF, worsened movement, loss appetite/ pyrexia/ N)
Pathophysiology of diverticula & some complications
Weakened bowel -> stool ⬆️luminal P -> outpouching of mucosa
Bacteria can overgrow -> diverticulitis -> perforate -> peritonitis
Chronic cases - fistulae - colovesical (pneumoturia, recurrent UTIs) colovaginal (vaginal discharge, infections)
Diverticula bleed (diverticula, erodes into vessel -> large, painless bleed)
Diverticulitis simple/ complicated
Complicated - abscess (pericolic - ABs, bowel rest-> drainage & washout) / fistula/ stricture (-> bowel obstruction) / free perforation
Investigations for diverticular disease & diverticulitis
DD:
FBC
CRP
Faecal calprotectin
Diverticulitis:
G&S, routine bloods, VBG, urine dipstick
Imaging:
Uncomplicated DD - flexible sigmoidoscopy (never colonoscopy)
Diverticulitis - CT abdo-pelvis
Features of Crohn’s disease
Mouth - anus (commonly distal ileum, proximal colon) Transmural inflammation (all layers) Deep ulcers & fissures (cobblestone) Skip lesions Fistulas
Microscopic: non- caseating granulomatous inflammation
Perianal disease common
Oral aphthous ulcers
Clinical features of Crohn’s disease (symptoms)
Abdo pain colicky Diarrhoea (May blood/ mucous) chronic MalAise Anorexia Pyrexia Malnourishment
Extra-intestinal features of Crohn’s disease
Enteropathic arthritis
Metabolic bone disease
Erythema nodosum (subcut nodules, shins)
Pyoderma gangrenosum (pustules -> deep ulcer, shins)
Episcleritis
Uveitis
Iritis
Primary sclerosis group cholangitis
Cholangiocarcinoma
Gallstones
Renal stones
Investigations for Crohn’s disease
Routine bloods AXR CT (acute) Faecal calprotectin Stool sample
Colonoscopy + biopsy
MRI (non acute)
EUA + proctosigmoidoscopy
Medical Management of Crohn’s disease
Inducing remission: Fluid resus Nutritional support Heparin Anti embolism stockings - corticosteroid - immunosuppressives (mesalazine, azathioprine) - biological agents (infliximab)
Maintaining remission:
- azathiprine/ mercaptopurine
- methotrexate
Surgical management of Crohn’s disease
70-80% require surgery
Failed medical management/ severe complications/ growth impairment
Ileocaecal/ SB/ LB resection
Stricturoplasty
Features of ulcerative colitis
Continually mucosal inflammation
LB (rectum-> proximal, can get backwash ileitis)
Microscopic:
Crypt abscess
Reduced goblet cells
Non-granulomatous
Macroscopic:
Pseudopolyps
Ulcers
Clinical features ulcerative colitis (symptoms)
Blood diarrhoea (visible >90%)
Proctitis (inflammation confined rectum) PR bleed Mucus discharge Change BH Malaise Anorexia Pyrexia
Extra intestinal features UC
Enteropathic arthritisErythema nodosum
Episcleritis
Uveitis
Iritis
Primary sclerosis cholangitis
Investigations UC
Routine bloods
Faecal calprotectin (IBD+, IBS -)
Stool sample
Imaging:
Colonoscopy + biopsy
Flex sigmoidoscopy
AXR - mural Thickening, thumb printing, lead pipe colon/ CT (acute)
Medical management UC
Inducing remission: Fluid resus Nutritional support Heparin - Corticosteroid - immunosuppression (mesalazine/ azathiprine) - biological agents (infliximab)
Maintaining remission:
Immunomodulators (mesalazine/ sulfasalazine)
Monoclonal ABs
Colonoscopy survellience
Surgical management UC
30%
Not responding medical
Toxic megacolon
Bowel perf
Risk carcinoma
Total proctocolectomy curative - ileostomy
Sub total colectomy
What is pseudo obstruction/ ogilvie syndrome?
Dilation of colon due a dynamic bowel absence mechanical obstruction
Commonly caecum & AC
Rare
Elderly
Pathophysiology of pseudo obstruction
Interruption ANS supply to colon -> absence smooth muscle action
Increased risk:
Toxic megacolon
Perforation
Bowel ischaemia
Causes:
Electrolyte imbalance / endocrine disorders
Medication (opioids, CCBs, antidepressants)
Recent surgery, severe illness, trauma
Neurological disease
Clinical Features of pseudo obstruction
Abdo pain
Abdo distension
Constipation
Vomiting
Tympanic abdo
