Lower GI Flashcards
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
most common colon cancer type
adenocarcinoma
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
colon cancer risk factors and epidemiology
increasing age
obesity
IBD (UC)
acromegaly
poor fibre intake
limited physical activity
m > f
western countries
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)
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
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
colorectal cancer management
surgical excision + adjuvant or neoadjuvant chemo/radiotherapy
tumour in patient from HNPCC may be better with panproctocolectomy than segmental resection
common metastasis
liver lung bone brain
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
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
crohns disease risk fctors
FHx
smoking
oral contraceptive pill
diet high in refined sugars
maybe NSAIDs
crohns disease epidemiology
ashkenazi jews
bimodal peak with age:
15-40
60-80
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
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
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
which gene predisposes you to ulcerative colitis
HLA-B27
is smoking a risk factor for ulcerative colitis
no. smoking is protective in ulcerative colitis
ulcerative colitis presentation
bloody diarrhoea
rectal bleeding + mucus
abdominal pain + cramps
tenesmus
weight loss
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
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
complications of ulcerative colitis
primary sclerosing cholangitis
toxic megacolon
colonic adenocarcinoma
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)
what triggers coeliac disease
gliadin
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
