Lower GI Flashcards by Osaruese Egharevba

Genes and conditions associated with colon cancer

HNPCC (Lynch syndrome)
- hereditary non-polyposis colorectal cancer
- FHx of bowel cancer at young age
- colonoscopy: tumour without polyps (exclude FAP)

FAP (familial adenomatous polyposis)

Peutz-Jeghers syndrome
- increased risk for developing hamartomatous polyps in the digestive tract as well as other types of cancers

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most common colon cancer type

adenocarcinoma

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UK colorectal cancer screening

offered every 2 years to all men and women 60-74 yrs in england. patients over 74 may request

FIT test and one off flexible sigmoidoscopy

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colon cancer risk factors and epidemiology

increasing age
obesity
IBD (UC)
acromegaly
poor fibre intake
limited physical activity
m > f
western countries

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colon cancer presentation

for osces: male>55 with FLAWS + altered bowel habits

change in bowel habits
rectal bleeding - not bright red
weight loss (FLAWS)
tenesmus
(microcytic) anaemia symptoms

on examination:
anaemia features
palpable mass (late)
distension/ ascites (late)
lymphadenopathy (late)

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colon cancer investigations

bloods:
- FBC (anaemia)
- LFTs (mets)

colonoscopy + biopsy
- visualisation of lesion
- diagnostic

double contrast barium enema:
- apple core lesion - cancer causes stricturing

pre-op staging
-CT chest/abdo/pelvis (mets)

cancer marker:
carcinoembryonic antigen (CEA) to monitor recurrence or assess response to treatment

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staging of colon cancer

TNM and Dukes (specific for colon cancer)

Dukes’ A: tumour confined to the mucosa
Dukes’ B: tumour invading bowel wall
Dukes’ C: lymph node metastases
Duke’s D: distant metastases

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colorectal cancer management

surgical excision + adjuvant or neoadjuvant chemo/radiotherapy

tumour in patient from HNPCC may be better with panproctocolectomy than segmental resection

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common metastasis

liver lung bone brain

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difference in inflammation pattern with Crohns vs UC

crohns: patchy inflammation throughout small and large bowel

uc: continuous and uniform inflammation in large bowel. affects mucosa only

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crohns pattern of inflammation

transmural inflammation of the GI tract that can affect any part from mouth to anus. found as skip lesions
most commonly affects terminal ileum and perianal

inflammation > ulceration > all layers affected > non-caeseating granuloma formation

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crohns disease risk fctors

FHx
smoking
oral contraceptive pill
diet high in refined sugars
maybe NSAIDs

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crohns disease epidemiology

ashkenazi jews
bimodal peak with age:
15-40
60-80

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crohns presentation

abdominal pain:
- crampy or constant
- RLQ + peri umbilical (terminal ileum)

diarrhoea:
- mucus, blood, pus
- nocturnal sometimes

peri anal lesions:
- skin tags, fistulae, abscesses

other:
- fatigue
- weight loss (they are malnourished)
- painful oral lesions

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Crohn’s Ix

Bloods
- FBC, iron studies, vitamin/folate levels, CR, ESR

Plain abdo XR - bowel dilation
CT- bowel wall thickening, skip lesions
barium enema- rose thorn ulcers, string sign of Kantor (fibrosis and strictures)
colonoscopy- ulcers, cobblestone appearance, skip lesions

histology- transmural involvement with non-caseating granulomas

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crohns management

1) steroids (can’t maintain remission)
- prednisolone, budesonide

2) immunomodulators
- azathioprine, methotrexate

3) biological therapy
- adalimumab, infliximab

4) surgery
- severe presentations, obstruction, etc

adjuncts
- nutritional therapy
- perianal disease mx
- smoking cessation
- anti-spasmotics
- anti-diarrhoeals

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which gene predisposes you to ulcerative colitis

HLA-B27

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is smoking a risk factor for ulcerative colitis

no. smoking is protective in ulcerative colitis

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ulcerative colitis presentation

bloody diarrhoea
rectal bleeding + mucus
abdominal pain + cramps
tenesmus
weight loss

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Ulcerative colitis extra-intestinal manifestations

joints
- peripheral arthritis
- ankylosing spondylitis

skin
- erythema nodosum
- pyoderma gangrenosum

occular
- episcleritis

anaemia signs
DRE- gross or occult blood
abdo tenderness

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ulcerative colitis Ix

Bloods
-FBC (anaemia)
-LFTs (primary sclerosing cholangitis)
-CRP/ESR (inflammatory disease)

Stool sample
- increased faecal calprotectin

other
-pANCA (70% positive)

AXR- dilated bowel, thumbprinting
double contrast barium enema- lead pipe appearance
colonoscopy - erythema, bleeding ulcers
histology- crypt abscesses, depletion of goblet cell mucin

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complications of ulcerative colitis

primary sclerosing cholangitis
toxic megacolon
colonic adenocarcinoma

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ulcerative colitis mx

1) Induce remission

mesalazine
steroids (oral beclamethasone)

2) maintain remission

immunosuppressives
- azathioprine, mercaptopurine

biologics (anti-TNFa)
- infliximab

biologics (integrin receptor antagonist)
- vedolizumab

ciclosporin

total colectomy (cure)

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what triggers coeliac disease

gliadin

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coeliac risk factors

FHx IgA deficiency T1DM autoimmune thyroid disease Female

coeliac disease presentation

diarrhoea bloating abdo pain fatigue weight loss dermatitis herpetiformis b12/iron/folate deficiency symptoms

coeliac disease ix

immunoglobulin A tissue trans glutaminase endomysial antibody endoscopy - villous atrophy + crypt hyperplasia FBC +blood smear

coeliac mx

gluten free diet vitamin + mineral supplements

IBS classification

IBS - D(iarrhoea) IBS - C(onstipation) IBS - M(ixed type)

IBS risk factors

history of physical/sexual abuse PTSD PMHx FHx Female

IBS presentation

abdo cramping in lower/mid abdomen alteration of stool consistency defecation relieves abdo pain/discomfort

IBS Ix

diagnosis of exclusion Anti-tTG (coeliac) fecal calprotectin (IBD) serum CRP (IBD) colonoscopy (IBD) FBC (anaemia- consider CRC) FOB test (CRC)

IBS Mx

fibre avoid caffeine, lactose, fructose stress management education probiotics laxatives (IBS-C) antispasmotics antidiarrhoeals (IBS-D)

mesenteric adenitis risk factors

viral infections bacterial infections IBD lymphoma children, young adults

mesenteric adenitis presentation

RLQ pain history of gastroenteritis

mesenteric adenitis ix

raised CRP USS - enlarged mesenteric lymph nodes

mesenteric adenitis management

self-limiting simple analgesia

constipation RFs

low fibre intake, no water sedentary lifestyle meds: opiates, CCB disease: IBS, IBD, cancer psychological

constipation presentation

infrequent stools difficulty defecating tenesmus excessive straining abdominal mass (LLQ) anal fissures haemorrhoids hard stools

constipation mx

1st line: lifestyle: high fibre, water, exercise avoid triggering factors 2nd line: osmotic laxatives: macrogol, lactulose 3rd line: stimulant laxatives: senna, bisacodyl deal with primary cause

haemorrhoids presentation

painless bleeding associated with defecation can be painful and cause discomfort anal pruritus palpable mass felt

haemorrhoids investigations

anoscopic examination colonoscopy (to exclude other pathologies) FBC (anaemia)

haemorrhoid mx

constipation advice discourage straining grade 1: topical corticosteroids (alleviates pruritus) grade 2: rubber band ligation grade 3: rubber band ligation grade4: surgical haemorrhoidectomy

thrombosis of haemorrhoid presentation

sudden onset perianal pain and the appearance of a tender nodule adjacent to the anal canal often following a period of vigorous activity

haemorrhoid thrombosis mx

pain relief stool softener consider excision

rectal prolapse presentation

painless protruding mass following defecation or straining mucoid discharge incontinence

rectal prolapse ix

ask pt to strain to elicit prolapse

anal fissures risk factors

anything causing constipation like opiates or pregnancy

anal fissure presentation

pain on defecation tearing sensation on defecation fresh blood on toilet paper

anal fissure ix

clinical diagnosis (hx) impossible to do DRE - usually examinations under anaesthesia

anal fissure mx

conservative - manage constipation - high fibre, hydration - sitz baths topical GTN (analgesia) topical diltiazem (analgesia) for persistent fissures - botox injection - surgical sphincterectomy

anal fistula RFs

clogged anal glands and anal abscesses crohn's disease radiation trauma

anal fistula presentation

frequent anal abscesses pain and swelling around the anus bloody/foul smelling drainage

anal fistula ix

examination -opening on skin around anus -not always visible -anoscope/rectoscope consider -EUA MRI

anal fistula mx

fistulotomy seton

anal abscess risk factors

anal fistula crohn's constipation

anal abscess presentation

perianal pain not related to defecation perianal swelling and tenderness maybe low grade fever and tachycardia

anal abscess ix

clinical examination EUA CT/MRI

anal abscess management

surgical drainage of abscess fistulotomy maybe broad spectrum AB

what is pilonidal sinus

caused by the forceful insertion of hairs into the skin of the natal cleft in the sacrococcygeal area. promotes inflammation and creates a sinus

pilonidal sinus RFs

male 16-40 stiff hair hirsutism

pilonidal sinus presentation

sacrococcygeal: discharge pain (worse sitting down) swelling

pilonidal sinus ix

clinical diagnosis

pilonidal sinus mx

surgical excision of pilonidal cyst + sinus + AB + hair removal (laser) + local hygiene advice