Lower GI Flashcards
Abdo pain, bloating, vomiting post bowel surgery?
post op ileus
Explain what anal fissures are?
- A tear in the sensitive skin-lined lower anal canal, distal to the dentate/pectinate line
- They can be primary or secondary
- Primary: no apparent cause
- Secondary: constipation, inflammatory bowel disease, STI, rectal malignancy
- In primary the exact aetiology is not understood
Presentation of anal fissure?
- Severe pain on defaecation “like passing shards of glass”
- There may be bleeding on passing stools, if present it is seen as bright red blood on the stool or toilet paper
- The fissure can be seen on external examination of the anus
- Usually, it is in the form of a linear split of the mucosa
- Should not attempt DRE in acute as will be very painful but if think there is a need can get patient to return
Investigation for anal fissure?
- Diagnosis can usually be made on history and physical examination
- Further investigations only required if there are features of an underlying pathology
Management of anal fissures?
Primary Care
* Advise children and adults to take measures to keep stools regular and soft: adequate fluid intake, increase fibre content, consider use of laxative
* Pain relief e.g., paracetamol or ibuprofen, consider GTN ointment which relaxes smooth muscle and reduces anal tone, consider topical anaesthetic e.g. lidocaine for extreme pain
* Refer children with anal fissure that has not healed within 2 weeks, refer adults with ongoing pain which has not resolved within 6-8 weeks, refer adults who do not have symptoms but still have fissure after 12-16 weeks
* Consider earlier referral in elderly as it is less common in this group and there is a higher chance of malignancy
Secondary Care
* Topical diltiazem a CCB may be used
* Nifedipine another CCB may be used
* Botox may be used as a last resort
* Surgery might be done
Define diverticula, diverticular disease, diverticulosis and diverticulitis?
- Diverticula are abnormal sacs or pockets in the GI tract thought to form due to increased luminal pressure and a low fibre diet
- Diverticulosis = presence of diverticula in the colon without symptoms
- Diverticular disease = the presence of diverticula with mild abdominal pain or tenderness and no systemic symptoms
- Diverticulitis = inflammation of diverticula
Diverticula are most commonly found in what part of the colon?
sigmoid colon
Who tends to get diverticula?
the elderly
Presentation of diverticulosis, diverticular disease and diverticulitis?
- Diverticulosis is asymptomatic
- Diverticular disease presents with mild and intermittent left lower quadrant pain with constipation, diarrhoea or occasional rectal bleeds
- Diverticulitis presents with constant abdominal pain, usually severe and localising to the left quadrant, fever, sudden change in bowel habit, significant rectal bleeding, a palpable abdo mass or distension may be felt
Investigations for diverticulosis, diverticular disease and diverticulitis?
- Those with diverticular disease do not need referred unless they have not been able to have routine endoscopic or radiological investigations in primary care, or they have cancer red flags or colitis
- Those with complicated acute diverticulitis suspected need referred to hospital for FBC, U and Es, CRP and a contrast CT
Management for diverticulosis, diverticular disease and diverticulitis?
- Those with diverticulosis just need reassurance and advice on a high fibre diet
- Those with diverticular disease do not need antibiotics, they should be advised to stop smoking, weight loss, high fibre diet, can consider bulk forming laxatives, simple analgesia and/ or antispasmodics if needed
- Those with uncomplicated acute diverticulitis likely need antibiotics but in some cases can be sent home with simple analgesia to see if resolves
- Those with complicated will be given IV antibiotics (amoxicillin, metronidazole and gentamicin)
What is Crohn’s disease?
- Inflammatory bowel disease that can affect any part of the GI tract from mouth to anus but most commonly affects the terminal ileum and colon
- Inflammation is discontinuous and occurs in skip lesions
- Inflammation is transmural meaning it extends down to the serosa
Who gets crohn’s disease?
- Crohn’s disease is thought to be an immune-mediated condition caused by environmental triggering events in genetically susceptible people
- Risk factors include a family history of inflammatory bowel disease, smoking, previous infectious gastroenteritis, and drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs)
Presentation of Crohn’s disease?
- Depends on what part of the GI tract is affected
- Persistent diarrhoea with potential blood or mucus in the stool
- Abdominal pain and/ or discomfort
- Weight loss and failure to thrive in children
- Fatigue, malaise, anorexia or fever
- On examination may have abdo tenderness, perianal pain or tenderness as well as perianal skin tags, abscesses, fissures or fistulas
- May also see extra-intestinal manifestations
Investigations for crohns disease?
- If suspected need referred to secondary care
- Initial investigations include FBC, CRP, ESR, U and Es, LFTs, stool culture and microscopy (inflammatory markers likely to be raised)
- Faecal calprotectin and lactoferrin are usually raised in active inflammatory intestinal disease
- Diagnosis generally needs biopsy from colonoscopy and/ or endoscopy
- May be ASCA positive
Management of crohns disease?
- Give steroids to induce remission and manage flares
- Azathioprine or mercaptopurine can be used to maintain remission
- Anti-TNF e.g. infliximab and adalimumab are used in severe cases
- Surgery for Crohns can be done but is not curative and need to minimise the amount of bowel removed
What are some extra-intestinal manifestations of crohns and UC?
- Enteropathic arthritis
- Skin rashes – erythema nodosum, pyoderma gangrenosum, anal skin tags, enterocutaneous fistulas, anal fissures
- Osteoporosis and osteomalacia (partially due to disease and also use of steroids)
- Uveitis and episcleritis
- Primary sclerosing cholangitis, gallstones, hepatitis, fatty liver disease
- Anaemia
List some complications of crohns?
- Abscesses
- Strictures
- Fistulas
- Malnutrition and altered growth in children
- Cancer of the small and large intestine
What is ulcerative colitis?
- Inflammatory bowel disease confined to the colon and rectum, inflammation is continuous and moves from the rectum upwards
- Can occur in the form of a proctitis (inflammation involving only the rectum), a left sided colitis (up to the splenic flexure), or as a pancolitis (the whole colon)
- Inflammation only extends to the submucosa and there are no granulomas
Who gets ulcerative colitis?
- Thought to be autoimmune disease with environmental triggers in susceptibly genetic individuals
- Smoking has actually been shown to be protective
Presentation of ulcerative colitis?
- Bloody diarrhoea
- Rectal bleeding
- Faecal urgency or incontinence
- Nocturnal defaecation
- Tenesmus (feeling that you need to pass stools even though bowels are already empty)
- Abdominal pain
- Fatigue, weight loss, anorexia or fever
- On examinations may find pallor, clubbing, abdominal distension, tenderness or mass
Investigations for ulcerative colitis?
- May be PANCA positive
- Initial investigations include FBC, CRP, ESR, U and Es, LFTs, stool culture and microscopy (inflammatory markers likely to be raised)
- Faecal calprotectin and lactoferrin are raised in active intestinal disease
- Colonoscopy is usually done for diagnosis and biopsy taken
Raised faecal ______ can suggest active inflammatory bowel disease
lactoferrin and calprotectin
UC may be _______ positive and crohns may be ______ positive
uc - PANCA
crohns - ASCA
Management of uc?
- Aminosalicylates are first line for UC to induce and maintain remission e.g. delzicol, asacol HD, pentasa (can be topical first if not extensive disease then may convert to oral if not enough)
- If remission still not achieved use steroid
- Biologics and immunosuppressants can be used for severely active disease
- Surgery can be done in severe disease and in UC this is curative and also eliminates the risk of colorectal cancer
Complications of uc?
- Toxic megacolon
- Increased risk of primary sclerosing cholangitis and developing cholangiocarcinoma
8 differences between crohns and UC?
Crohns:
disease anywhere from mouth to anus
discontinuous skip lesions
granulomas present
inflammation is transmural
surgery is not curative
less increased risk of colorectal cancer
smoking aggravates disease
anal disease is common
Ulcerative colitis:
only the rectum and colon
continues inflammation from rectum upwards
granulomas absent
inflammation is confined to the mucosa and submucosa
surgery is curative
increased risk of colorectal cancer
smoking is protective against disease
PSC and cholangiocarcinoma increased risk
What is IBS?
- Functional GI disorder
- Characterised by abdominal discomfort, bloating or pain associated with defaecation or a change in bowel habit
Risk factors for IBS?
- It is not fully understood but thought to be some motor/ sensory dysfunction in the GI tract or changes in gut reactivity
- IBS is more common in middle aged women and is thought to be associated with emotional stimuli such as stress or abuse and is also linked to trauma
- Sometimes has initial trigger of gastroenteritis
- Related to other functional disorders e.g. fibromyalgia
Presentation of IBS?
- Abdominal pain and cramping
- Generally pain is relieved by defaecating
- Diarrhoea
- Constipation
- Food intolerance
- Can be classified as IBS with diarrhoea, IBS with constipation or mixed IBS
- Might get worse with stress
Diagnosis of IBS?
Need to exclude red flag symptoms for cancer:
* https://www.cancerreferral.scot.nhs.uk/lower-gastrointestinal-cancer/
* Bleeding – repeated rectal bleeding without an obvious anal cause or any blood mixed with stool
* Bowel habit – persistent (more than 4 weeks) change in bowel habit especially to looser stools (not so interested in constipation)
* Pain – abdominal pain with weight loss
* Iron deficiency anaemia – unexplained iron deficiency anaemia
Then need to exclude inflammatory bowel disease:
* Inflammatory markers blood test
Need to exclude Coeliac disease
Tests:
* QFit to check for blood in stool (sign of IBD or cancer)
* FBC (checking for anaemia and signs of a systemic disease)
* ESR AND CRP (for IBD)
* TTG (for coeliacs)
If all these tests come back negative can diagnose IBS
Management of IBS?
- Education and information on lifestyle, physical activity, diet and relaxation
- Diet and nutritional advice – general advice such as reducing caffeine and sugary drinks, reducing high fibre foods and resistant starch (recooked foods have this), if going to recommend the FODMAP diet should refer to a dietician
- Antispasmodic agents e.g. mebeverine hydrochloride, alverine citrate and peppermint oil
- Laxatives can be used and titrated to effect for those with constipation
- Loperamide can be used for acute diarrhoea
- Tricyclics and SSRIs can be used for pain
What is ascites? when will it be detected clinically?
- Excessive accumulation of fluid in the abdominal cavity
- To detect it clinically > 1500 ml needs to present
List some causes of ascites?
- Cirrhosis and hepatocellular carcinoma (sodium and water retention and hypoalbuminaemia)
- Malignancy – GI tract malignancies or metastatic disease in abdominal cavity, lymphoma, Meigs syndrome (benign ovarian tumour, ascites and pleural effusion) – generally get ascites if the cancer has spread to the liver or it is the peritoneum and making vessels leaky
- Heart failure (back up of blood in veins due to poor heart pumping power means fluid leaks out)
- Nephrotic syndrome (low albumin means fluid leaks)
- Pancreatitis (as a complication where there is leakage from the pancreatitis)
- Tuberculosis
How can you assess ascites?
- On examination look for shifting dullness – percuss abdomen when supine and find where at side it gets dull, then get patient to go on side and percuss again, should now be dull in centre but not dull at the sides as fluid has moved
- Abdominal ultrasound can be good for assessing ascites
- Other investigations are more for looking at underlying cause of ascites
- Ascites can be monitored by serial measurements of abdominal girth and of body weight
What is Meig’s syndrome?
benign ovarian tumour, ascites and pleural effusion
Management of ascites?
- Treat underlying cause if possible
- 1st line management is to sodium restrict and give a diuretic, in cirrhosis use spironolactone, other diuretic that may be used is a loop
- Can do therapeutic paracentesis
- May do TIPS procedure in refractory ascites
Complications of ascites?
- Electrolyte imbalances
- Spontaneous bacterial peritonitis
Most colorectal cancers develop ______
difference between growth of right and left sided?
as a result of progression from normal mucosa to adenoma to invasive cancer (adenocarcinoma)
* Cancers on the right vs left tend to grow and present differently
* Right sided cancers tend to grow as a polyploid carcinoma, cancers on the left tend to grow as a stenosing carcinoma
Colorectal cancers most commonly metastasise to?
the liver or lungs
Staging for colorectal cancer?
tnm (dukes is no longer used)
Risk factors for colorectal cancer?
- 2 main genetic conditions can predispose to colorectal cancer:
1) Lynch Syndrome (AKA Hereditary Non-Polyposis Colorectal Cancer)
2) Familial Adenomatous Polyposis (FAP) - Inflammatory bowel disease particularly ulcerative colitis increases risk of developing colorectal cancer
- Other risk factors are increasing age, male sex, diet high in red meat and fat, smoking, obesity, lack of physical activity
describe 2 genetic conditions that increase risk of colorectal cancer?
1) Lynch Syndrome (AKA Hereditary Non-Polyposis Colorectal Cancer)- this is caused by mutations in genes that are responsible for repair of DNA mismatches and is autosomal dominant and predisposes to cancer as a cell only then needs to lose one copy of mismatch repair genes before cancer can develop
2) Familial Adenomatous Polyposis (FAP)- this is an autosomal dominant condition that causes numerous adenomatous polyps to develop in childhood in the colon, in untreated individuals carcinoma is inevitable by 40 yrs, gene responsible is APC gene and this condition is more easily recognised compared to lynch syndrome as if do colonoscopy hundreds of polyps will be seen lining the bowel
Presentation of colorectal cancer?
- Left sided cancers (tend to present with symptoms of obstruction): altered bowel habit, worsening constipation, tenesmus, rectal bleeding
- Right sided cancers (vague symptoms): unexplained iron deficiency anaemia, persistent tiredness, persistent and unexplained change in bowel habit, unexplained weight loss, colicky abdominal pain, lump in the abdomen
Note: cancers in the transverse colon are very rare
Investigations for colorectal cancer?
- Diagnosed by colonoscopy or sigmoidoscopy
- Chest, abdo and pelvis CT is done to assess spread
Management of colorectal cancer?
- Treatment of cancer depends on stage, a total or partial colectomy can be done
- If cancer is advanced may do chemo or radiotherapy depending on location
- Palliation may involve stenting the colon or de-functioning the colon by leaving the cancer but bringing a stoma above to relieve symptoms of obstruction
Screening for colorectal cancer?
- In Scotland men and women aged 50-74 are offered screening for colorectal cancer
- A testing kit is sent to house called the FIT test every 2 years and this looks for blood in the stool, if it comes back positive people are usually offered a colonoscopy or sigmoidoscopy
Symptoms of ascites?
- Abdo distension and weight gain
- Nausea and anorexia
- Increasing dyspnoea
Explain what haemorrhoids are and internal and external haemorrhoids?
- Haemorrhoids are abnormally enlarged vascular mucosal cushions on the anal canal
- These mucosal cushions are normal findings and help to maintain continence but when they become enlarged and start to cause symptoms they are haemorrhoids
- Dentate (pectinate) line divides the anal canal into upper two thirds and lower one third, above and below are completely different neurovascular supplies and histology
- External haemorrhoids originate below the dentate line and are covered by modified squamous epithelium, which is richly innervated in pain fibres so external haemorrhoids can be painful and itchy, they may be visible on examination
- Internal haemorrhoids arise above the dentate line and are covered by columnar epithelium which have no pain fibres so are therefore not sensitive to touch, temperature or pain (unless they become strangulated)
- Internal and external haemorrhoids can co-exist
- Internal haemorrhoids are classified on their degree of prolapse
Risk factors/ who gets haemorrhoids?
Pretty common
Proposed risk factors include:
* Constipation
* Prolonged straining and time spent on the toilet
* Chronic diarrhoea
* Increased abdominal pressure e.g. ascites or pregnancy and childbirth
* Obesity
* Heavy lifting
* Chronic cough
* Injury to spinal cord or rectum
* IBD
* Ageing and hereditary factors
Presentation of haemorrhoids?
- Can be asymptomatic
- Bright red painless rectal bleeding with defecation – streaks on toilet paper or dripping into toilet – blood may coat stools but should not be mixed with it
- Anal itching and irritation
- Feeling of rectal fullness, discomfort or incomplete evacuation
- Lump at anal verge (if haemorrhoids have prolapsed)
- Soiling due to mucus discharge or impaired continence may be experienced
- Thrombosed haemorrhoids are painful
- On examination internal haemorrhoids are not evident on inspection and difficult to feel on PR
- Asking patient to strain may allow haemorrhoids to become visible
- Although internal haemorrhoids are not palpable on PR it is essential to do one to rule out other pathology
Investigations for haemorrhoids?
- A rigid anoscope, protoscope or rectoscope can be used to make diagnose of haemorrhoids, classify their severity and exclude sinister pathology, where the facilities or expertise are not available the person may need referred for assessment
Management of haemorrhoids?
- Consider admitting if extremely painful, acutely thrombosed external haemorrhoids or internal haemorrhoids which have prolapsed and become swollen, incarcerate and thrombosed
- Others may need referred for assessment if suspect other pathology or if haemorrhoids and complications too complicated to manage in primary care
- Secondary care treatments involves rubber band ligation, injection sclerotherapy, infrared coagulation, haemorrhoidectomy
General management:
* Ensure stools are easy to pass
* Lifestyle advice on anal hygiene – clean and dry, pat dry – advise against stool withholding and straining
* Manage any other symptoms e.g. simple analgesia, topic haemorrhoid preparations
What is necrotising enterocolitis?
- Most common GI emergency in neonates where there is inflammation and ischaemic necrosis
Who gets necrotising enterocolitis?
- Mainly affects premature infants who have survived a difficult neonatal period
- Thought to be due to immature GI tract and exaggerated immune response
