Lower GI Flashcards
What conditions can affect the lower GI tract?
IBD[Crohn’s and UC]
IBS
Coeliac disease
Haemorrhoids
Anal fistula
Anal fissure
Colorectal cancer
Anal fissure
Definition
Types
Aetiology
Epidemiology
Symptoms
Investigations
Management
Anal fissure
Definition
Tear in lining of squamous epithelium of anal canal
Types
Acute < 6 weeks
Chronic > 6 weeks
Aetiology
- Primary
- no underlying disease
- Posterioir midline
- Secondary to underyling disease
- Constipation
- Crohns
- Pregnancy
- [Varying locations]
- Epidemiology
- Common
- Young
Symptoms
- Pain on defecation
- Bright red blood on wiping
- Chronic ulcer= sentinel pile/ skin tag
Investigations
- Clinical diagnosis
- DON’T do DRE
- Management
Analgesia
- paracetamol and ibuprofen
- topical lidocaine
- topical gtn/diltiazem if > one week
Conversative/to treat constipation
- Fibre
- Fiuid
- Laxative
Surgical/for chronic ulcer
- Botulinum injection
- Internal sphincterotomy
Haemorrhoids
Definition
Types
Aetiology
Epidemiology
Symptoms and Signs
Investigations
Management
Complications
Haemorrhoids
Definition
- Enlarged vascular cushions in anal canal
Types
- Internal- above dentate line, not painful
- External- below dentate line, painful
- Staging system for internal
Stage I- project into lumen- not palpable
Stage II- prolapse with straining, spontaneously reduces
Stage III- prolapse with straining- can be manually reduced
Stage IV- permanently prolapsed, irreducible
Aetiology
- Constipation- pressure of straining , causes vascular engorgement
- Raised intrabdominal pressure- due to pregnancy, cough, heavy lifting
Symptoms
- Usually painless
- Small amounts of right red blood, on wiping/ or found in bowl, unmixed with stool
Large haemorrhoids
- Rectal fullness
- Tenesmus
- Soiling
Investigations
- Protoscopy
- Anaemia [from bleeding]
Management
- Conservative- fluid, fibre, laxatives
- If severe- rubber band ligation, injection sclerotherapy
Large haemmorhoid - haemorrhoidectomy
Complications
- Thrombosis of external haemorrhoid
- <72hr= surgical excision
- Severe pain + purple oedematous perianal mass
- Strangulation of internal haemorhhoid
- Urgent haemorrhoidectomy
- Severe pain
Anatomy of anal canal and different sections
- Above dentate line- columnar epithelium - visceral innervation =two thirds of anal canal
- Below dentate line- squamous epithelium- somatic innervation= one third of anal canal
When should you refer someone for an urgent two week wait for suspected colorectal cancer?
- > 40y + unexplained weight loss + abdo pain [+/- blood in stool]
- > 50y + unexplained rectal bleeding
- > 60y + change in bowel habit or iron deficiency anaemia
Ulcerative Colitis
Definition
Pathology
Risk factors
Symptoms and signs
Extraintestinal manifestations- [general IBD + UC specific]
Investigations
Management
Complications
Ulcerative Colitis
Definition
Chronic relapsing remitting inflammatory disease of rectum and colon/large bowel
Pathology
- Continuous, uniform inflammation of the colon from the rectum ascending upwards potentially up to ileocaecal valve
- Affects only mucosa [and submucosa]
Risk factors
- HLA B27
- Genetics/PMH of autoimmune conditions
- Smoking alleviates it
Symptoms and signs
- Blood in stool
- Diarrhoea
- Left sided abdo pain
- FLAWS- systemic B symptoms
Extraintestinal manifestations
General IBD
- Erythema nodosum
- Pyoderma gangrenosum
- Clubbing
- Joint pain- symmetrical polyarticular arthritis or asymmetrical oligoarthritis
- Osteoarthritis
Ulcerative colitis specific
- Uveitis
- Primary sclerosing cholangitis
- Cholangiocarcinoma
Investigations
Bloods:
FBC- anaemia [of chronic disease], high platelets, high WCC
CRP + ESR- high
LFT- low albumin
U+ E- diarrhoea
Stool:
Faecal calprotectin
Stool culture- to rule out infective colitis
C difficile toxin
TO CONFIRM DIAGNOSIS:
Colonoscopy [only done after an acute episode]- loss of haustra + continuous inflammation
Barium enema
USS/CT to rule out other diff diagnosis
Management
To induce remission:
- 5-ASAs- Mesalazine
[topical if left sided, topical and oral if whole colon]
- IV glucocorticoids if severe
To maintain remission:
Mesalazine
Azathioprine/mercaptopurine if severe
Acute management for flare up
Also make Nil by mouth and give IV fluids + analgesia if needed
Complications
- Toxic mega colon
- Colorectal cancer
What are the main types of extraintestinal manifestation in IBD?
WHEN IBD GETS MES- SY or MESH
- Musculoskeletal- symmetrical polyarticular arthritis, asymmetrical oligoarthritis, osteoporosis
- Eyes- uveitis [UC}, episcleritis [Crohns]
- Skin - Erythema nodosum, pyoderma gangrenosum, clubbing
- Hepatobiliary - PSC/cholangiocarcinoma [UC] + Gallstones/kidney stones [Crohns]
Red flags for lower GI symptoms- seven of them
- >40 year old
- PR bleeding
- Anorexia, weight loss
- Mouth ulcer
- Abnormal CRP, Hb, coeliac serology
- < 6 months history
- Waking up at night= pain/diarrhoea
Coeliac disease
Definition
Risk factors
Epidemiology
Presentation- symptoms and signs
Investigations
Management
Coeliac disease
Definition
Autoimmune response which is T cell mediated triggered by dietary gluten, leading to small bowel and systemic disease
Risk factors
Other autoimmune disease - PMH or FH
HLA DQ2/8
Epidemiology
Women [because autoimmune]
Presentation- symptoms and signs
- Malabsorption
- weight loss, failure to thrive
- Vitamins + minerals: osteoporosis, anaemia, neuropathy/parasthesia
- Fats: steatorrhea
- Chronic GI:
- abdo pain, nausea, vomiting, diarrhoea, bloating
- Dermatitis herpetiformis
- looks like herpes, but isn’t
Investigations
Autoantibodies:
- anti-TTG [tissue transglutaminase]
- anti-endomysial
[^both IgA, so look at total IgA too]
Bloods:
- Haematinics- low B12 and ferritin
- Low vit D/calcium
- Microcytic/macrocytic anaemia [increased range in size/red cell distribution width]
- LFT- non specific transaminitis
Confirm diagnosis:
Endoscopy + duodenal biopsy after at least 6 weeks on gluten diet: shows:
villous atrophy, crypt hyperplasia and WBC intraepithelium
Management
- Avoid gluten in diet
[bread, wheat, barley, rye- can eat rice, corn and potatoes]
- Pneumococcal vaccine - every 5 years- hyposplenism
Complications
- EATL- Enteropathy associated T cell lymphoma- coeliac specific, happens if untreated
- Non Hodgkin’s/ Hodgkin’s lymphoma
- Other small bowel adenocarcinoma
IBS- Irritable Bowel Syndrome
Definition
Risk factors
Aetiology
Epidemiology
Symptoms and signs
Investigations
IBS- Irritable Bowel Syndrome
Definition
More than 6 months of:
Abdominal pain- brought on by eating, relieved by defecation
Bloating/discomfort
Change in bowel habit- diarrhoea/constipation/mucus
Diagnosis of exclusion
Risk factors
Stress
Familial?
Aetiology
Unknown
Epidemiology
Young
Female
[Reconsider diagnosis if >40 years]
Symptoms and signs
Pellet like stool- buzzword
Abdo pain- generalised?
Episodic changes in bowel habit
Bloating
Belching/flatus
Investigations
Clinical diagnosis
Bloods:
FBC/CRP- rule out IBD
Coeliac antibodies- rule out coeliac
Management
Symptomatic:
- Conservative: Diet- cut out/reduce alcohol, caffeine, fizzy drinks
Medical:
- Pain- antispasmodic- anticholinergic= mebeverine, hyoscine, low dose TCA
- Diarrhoea- loperamide
- Constipation- laxative, high fibre, fluid
- Psychological therapy- if lasts more than one year
A 28yr old man presents to his GP complaining of severe pain around his anus when he goes to the toilet. When questioned, he mentions that there also streaks of bright red blood on the toilet paper when he wipes. What is the next most appropriate step?
- Perform a DRE
- Prescribe paracetamol/ibuprofen and topical lidocaine
- Prescribe paracetamol/ibuprofen topical diltiazem
- Urgent haemorrhoidectomy
- Injection sclerotherapy
Prescribe paracetamol/ibuprofen and topical lidocaine
Colorectal cancer
Definition
Types [and frequency of occurence]
Aetiology/risk factors
Epidemiology
Screening
Symptoms and signs
Investigations
Management
Colorectal cancer
Definition
Malignancy of large bowel
Types
- Usually adenocarcinoma
- Sometimes carcinoid [neuroendocrine], lymphoma, stromal [connective tissue]
- Left sided
- Right sided
Most commonly in:
Rectum> Sigmoid > Ascending Colon > Transverse Colon > Descending Colon
Aetiology/risk factors
- Genetic/FH- FAP [APC gene], HNPCC
- IBD- UC especially
- Adenomatous/neoplastic polyps
- Alcohol/smoking/diet/obesity
Epidemiology
- Old
- Male
- Third most common cancer
Screening
FIT [Faecal immunochemical test] for faecal occult blood
Over 60 to 74y , every two years
FlexiSig at 56 years
Symptoms and signs
Insidious
- Abdo pain
- Weight loss
- Fatigue
- FLAWS- B sx
Right sided
- Anaemia
- Malabsorption
Left sided
- Blood in stool/PR
- Change in bowel habit- diarrhoea/squirrely stool
- Signs of bowel obstruction/stricture:
tinkling/increased bowel sounds
abdominal distension
If in rectum:
- Tenesmus
- Mass on DRE
Investigations
Bloods:
- FBC- anaemia
- Tumour marker- CEA [not diagnostic]
- LFT- mets
Colonoscopy - gold standard
Barium enema - apple core stricture
TNM/Duke’s staging
Management
First line:
Surgery
Right sided: R sided hemicolectomy
Left sided above sigmoid: L sided hemicolectomy
Sigmoid: Sigmoid colectomy
Rectum: anterior resection
[Either Hartmann’s procedure- end colostomy and rectal stump or anastomosis of colon ends]
Second line: Chemo, radio
Crohn’s disease
Definition
Pathology
Risk factors
Presentation - symptoms and signs
Investigations
Management
Complications
Crohn’s disease
Definition
Patchy areas of inflammation caused by chronic relapsing remitting inflammation throughout the GI tract
Pathology
- Patches of inflammation from mouth to anus
- Transmural inflammation
- Cobblestone appearance on colonoscopy because discrete areas of inflammation with islands of normal tissue in between
Risk factors
- Smoking
- Genetic
Presentation - symptoms and signs
- Diarrhoea
- Abdo pain [Right sided]
- Systemic B symptoms - FLAWS
- Malabsorption
Extraintestinal manifestations [general IBD + Crohn’s specific]
V common in Crohn’s
General IBD
Musc- joint pain: symmetrical polyarticular arthritis/ asymmetrical oligoarthritis, osteoporosis
Skin- erythem nodosum, pyoderma gangrenosum, clubbing
Crohns specific
Eyes- episcleritis
Skin- mouth ulcer, perianal lesions
Hepatobiliary/kidney- gallstones/kidney stones
Investigations
Bloods:
_FBC- anaemia of chronic disease, high WCC, high platelet_s
U+ E- diarrhoea
LFT- low albumin
CRP/ESR- high
Stool:
Faecal calprotectin - inflammation
Stool culture
C diff toxin
Confirming diagnosis:
Colonoscopy - cobblestone appearance- do after acute episode/flare up
Barium enema- strictures etc.
Management
Acute episode- nil by mouth, IV fluids, analgesia if needed
To induce remission:
- Steroids/glucocorticoids- IV, oral, topical
- Elemental/enteral feeding
- If only isolated perianal disease: metronidazole
- Second line: azathioprine/mercaptopurine, infliximab, mesalazine-5ASA
To maintain remission:
- Azathioprine/mercaptopurine
- Second line: Methotrexate
- Surgery [resulting in stoma} common
Complications
Fistulae
Abscess
Strictures
Table comparing Crohn’s and UC
A 23yr old lady presents to A&E with a 1 week history of passing 8 stools a day, right sided abdominal discomfort, and fatigue. On examination, she has a painful mouth ulcer and tender violaceous nodules on her shins. Her CRP is 152. What is the next best step?
A.NBM, fluids and oral mesalazine
B.NBM, fluids and IV methotrexate
C.NBM, fluids and IV azathioprine
D.NBM, fluids and IV hydrocortisone
E.NBM, fluids and IV mesalazine
D.NBM, fluids and IV hydrocortisone
Likely diagnosis= Crohns
A 28 yr old lady presents to her GP with a 1 year history of “bowel problems”. She mentions that she often gets diarrhoea after eating and that for the past couple of months she has been feeling very bloated and lethargic. What is the next best step?
A.Check total IgA, anti-ttG, and anti-endomysial antibody levels
B.Endoscopy & duodenal biopsy
C.Prescribe loperamide and send home
D.Review in 3 months
E.Send stool cultures
A.Check total IgA, anti-ttG, and anti-endomysial antibody levels??
A 30yr old woman with a history of constipation presents to her GP with a 1 week history of painless PR bleeding. She describes passing bright red blood on defecation, visible in the toilet bowl and separate from her stool. On examination, you feel a mass when she bears down that recedes when she relaxes. What is the most appropriate initial management of her condition?
A: Advise her to increase her fluid and fibre intake, and prescribe stool softeners
B: Referral for rubber band ligation
C: Referral for injection sclerotherapy
D: Advise her to increase her fluid and fibre intake, and prescribe topical lidocaine
E: Referral for surgical haemorrhoidectomy
A: Advise her to increase her fluid and fibre intake, and prescribe stool softeners
A 19 yr old woman presents to her GP with a 3 day history of an itchy, blistering rash on her elbows. She mentions that she has also felt increasingly lethargic over the past 3 months, and that she occasionally gets feelings of numbness and tingling in her hands. Her mother suffers from hypothyroidism. What is the most likely diagnosis?
A: Eczema herpeticum
B: Dermatitis herpetiformis
C: Herpetic whitlow
D: Shingles
E: Pretibial myxoedema
B: Dermatitis herpetiformis
A 32 year old man presents to his GP with a 2 week history of bloody diarrhoea. He mentions that he has been going to the toilet 4 times a day, and passes loose stools with bright red blood every time. He mentions that this is the second time that this has happened in the past 3 months. His past medical history is otherwise unremarkable aside from occasional joint pains. On examination he is slightly febrile with a temperature of 37.5oC, and he has tenderness in his left lower quadrant. What is the most likely diagnosis?
A.Dysentry
B.Crohn’s disease
C.Viral gastroenteritis
D.Angiodysplasia
E.Ulcerative colitis
E.Ulcerative colitis ?
A 67yr old man presents to his GP saying that he has been feeling much more tired than usual for the past month. A routine set of bloods showed that he has a mild iron-deficiency anaemia. What is the next best step?
A.Review in 4 weeks
B.Prescribe iron supplements and send home
C.Urgent 2ww referral for colonoscopy
D.Routine referral to haematology
E.Request a blood film
C. Urgent 2ww referral for colonoscopy
In which cancer are these antibodies prominant
