NO DRE - that would be v painful, don't do that - clinical diagnosis instead

Pain - paracetamol/ibuprofen - topical lidocaine - topical GTN/diltiazem if > 1 week Constipation - increase fibre/fluid intake - laxative; bulk forming => osmotic => stimulant

Lower GI Flashcards by H Jalisi

Types of anal fissures

Tear in squamous epithelium of anal canal
- Primary => usually posterior line
- Secondary => varying locations (constipation, Crohn’s disease, pregnancy)
AND
- squamous epithelium => lower 1/3 anal canal => somatic innervation => usually visible on inspection
- columnar epithelium => upper 2/3 anal canal => visceral innervation => not visible on inspection

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Ix for anal fissure

NO DRE

that would be v painful, don’t do that
clinical diagnosis instead

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Presentation of an anal fissure

Young
Painful rectal bleeding on defecation
Blood on tissue
Chronic ulcer => sentinel pile/skin tag

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Mx for anal fissures

Pain

paracetamol/ibuprofen
topical lidocaine
topical GTN/diltiazem if > 1 week

Constipation

increase fibre/fluid intake
laxative; bulk forming => osmotic => stimulant

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Types of haemorrhoids

External
- below dentate line, painful
Internal
I - project into lumen, not palpable
II - prolapse w/ straining, spontaneously reduce; above dentate line, not painful
III - prolapse w/ straining, manually reducible
IV - irreducible

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Presentation of haemorrhoids

Usually painless rectal bleeding

Large haemorrhoids cause rectal fullness/tenasmus/soiling

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Ix and mx for haemorrhoids

Ix: anaemia, protoscopy
Mx:
I - stool softening (fibre/fluid/laxative)
II - rubber band ligation/injection sclerotherapy
III - large grade 3/4; haemorrhoidectomy

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Complications of haemorrhoids

Thrombosis of external haemorrhoids
- severe pain and purplish oedematous perianal mass, <72 hrs need to surgically incise
Strangulation of internal haemorrhoids
- severe pain, urgent haemorrhoidectomy

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Causes of colorectal cancer

*usually adenocarcinoma
Genetic
- FHx, FAP (APC gene), HNPCC [AD]
Male
Environment
- alcohol, smoking, diet, obesity
Other
- IBC (UC>Crohn's), adenomatous/neoplastic polyps

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Sx for colorectal cancer

Abdo pain, fatigue, wt loss:
Right-sided => anaemia (less common, present later)
Left-sided => PR bleeding, change in bowel habit, tenasmus, mass on DRE, can present w/ obstruction (more common, present earlier)

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Ix for colorectal cancer

I - bloods: FBC (anaemia), LFTs (mets), CEA (tumour marker)
II - colonoscopy (GOLD STANDARD); Duke’s staging
III - barium enema; apple core stricture

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Mx for colorectal cancer

I - surgery => resection, hemicolectomy, colectomy

II - radiotherapy, chemotherapy

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What screening is done for colorectal cancer?

FIT = 60-74yo every 2 years

FlexiSig at 56 yo

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Extra manifestations specific to the two IBDs

UC: uveitis, PSC/cholangicarcinoma

Crohn’s; episcleritis, gallstones + kidney stones

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Compare UC and Crohn’s

a) RFs
b) Pathology

a) RFs:
Crohn’s = smoking, UC = HLA-B27
b) Pathology:
Crohn’s = anus -> mouth, discontinuous inflammation, transmural
UC = rectum -> ileco-caecal valve, continuous inflammation, mucosa only

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Compare UC and Crohn’s

a) Presentation
b) Complications

a) Presentation:
Crohn’s = right-sided abdo pain, diarrhoea, B sx, perianal lesions and mouth ulcers, malabsorption
UC = left-sided abdo pain, bloody diarrhoes, B sx
b) Complications:
Crohn’s = fistulae, abcess
UC = toxic megacolon, colorectal cancer

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Extra manifestations of IBD

Clubbing, osteoporosis, pyoderma gangrenosum, symmetrical polyarticular arthritis, asymmetrical oligoarthritis, erythema nodusum

Tx for Crohn’s

Steroids (induction)
- topical, oral, IV
Azathioprine/mercaptopurine => methotrexate (maintenance => 2nd line)

Tx for UC

Mesalazine (5-ASA) (induction)
- topical/oral
Mesalazine => azathioprine/mercaptopurine (maintenance => severe)

How is IBS diagnosed?

Diagnosis of exclusion; clinical diagnosis
>6 months of either
- Abdo pain/discomfort relieved by defecation, brought on by eating
- Bloating
- Change in bowel habit, stool form (incl. mucus) = pellet-like stools
Ix to rule out other causes: bloods (FBC/CRP), coeliac antibodies

Mx for IBS

Diet = decrease caffeine, fizzy, alcohol, increase water
Pain = low dose TCA, anti-spasmodics; mebeverine
Diarrhoea = loperamide
Constipation = laxative (NOT lactulose)
=> psychological therapy after 12 months

How may coeliac disease present?

Chronic GI sx = N&V, diarrhoea, bloating
Malabsorption = wt loss/failure to thrive, osteoporosis, anaemia, neuropathy, steatorrhoea
Dermatitis herpetiformis = pink-purple on elbows, blistering, itchy skin

RFs: Hx/FHx AI conditions, women, HLADR2/8 allele

What will ix for coeliac show?

T-cell mediated AI reaction to dietary gluten SO

BLOODS

micro/macro anaemia, increased RCDW
decreased B12 + ferritin
decreased Ca2+/vit. D
LFT; non-specific transaminitis

Confirm diagnosis

endoscopy and duodenal biopsy after gluten diet for 6 weeks shows:
1. villous hypertrophy
2. crypt hyperplasia
3. intraepithelial WBC

AUTOANTIBODIES
=> IgA anti-endomysial antibodies
=> IgA anti-tissue transglutaminase (TTG)

Mx for coeliac

Gluten free diet
- incl. wheat, barley, rye and exc. rice, corn, potatoes

Pneumooccal vaccine (every 5 years)
- due to hyposplenism

A 22 y/o female presents to her GP with a two year history of intermittent diarrhoea and constipation. She complains of bloating and abdominal pain, which eases with defecation. ``` Which condition is she likely to have? A. Coeliac disease B. Ulcerative colitis C. Crohn’s disease D. Irritable bowel syndrome E. Infectious diarrhoea ```

D. Irritable bowel syndrome

A 26 y/o male presents to his GP with weight loss, abdominal pain and watery diarrhoea. On examination he looks pale and you notice ulcers in his mouth. ``` Which condition is he likely to have? A. Coeliac disease B. Ulcerative colitis C. Crohn’s disease D. Irritable bowel syndrome E. Infectious diarrhoea ```

C. Crohn's disease

A 23 y/o female presents to her GP with a limp. On further questioning she reveals she has recently lost weight and has had bloody, mucoid diarrhoea. On examination her right knee is tender and swollen, and her eyes are red. ``` Which condition is she likely to have? A. Coeliac disease B. Ulcerative colitis C. Crohn’s disease D. Irritable bowel syndrome E. Infectious diarrhoea ```

B. Ulcerative colitis

A 27 y/o male presents with a history of mucoid, bloody diarrhoea and weight loss. On examination you note a number of red marks on his shins. After a number of investigations his diagnosis is confirmed. ``` Which treatment would you start him on? A. IV corticosteroid B. Oral prednisolone C. Topical mesalazine D. Oral azathioprine E. IV cyclosporin ```

C. Topical masalazine

A 31 y/o male presents with a history of diarrhoea, weight loss and RIF pain. On examination you note a number of red marks on his shins. After a number of investigations his diagnosis is confirmed. ``` Which treatment would you start him on? A. IV corticosteroid B. Oral prednisolone C. Oral mesalazine D. Oral azathioprine E. IV cyclosporin ```

B. Oral prednisolone

After starting treatment for a Crohn's patient, his symptoms improve. ``` Which additional treatment would you start him on to maintain his remission? A. IV corticosteroid B. Oral prednisolone C. Oral mesalazine D. Oral azathioprine E. IV cyclosporin ```

D. oral azathioprine

A 55 y/o female presents to her GP with an itchy rash on her forearms. On further questioning she reveals she has recently lost weight and has had mucoid diarrhoea. Which test will best confirm her diagnosis? A. Endoscopy with duodenal biopsy B. Serum antibodies to tissue-transglutaminase C. Serum anti-endomysial antibodies D. Colonoscopy E. Endoscopy with ileal biopsy

A. Endoscopy with duodenal biopsy

A 67 y/o male presents to his GP following an episode of rectal bleeding. He noticed fresh blood on the toilet paper after wiping. There was no blood mixed in with the stool. He is otherwise fit and well. ``` What is the next appropriate step to take? A. Colonoscopy B. Faecal occult blood test C. Abdominal exam D. Digital rectal exam E. Sigmoidoscopy ```

C. Abdominal exam

A 35 y/o male presents to his GP following an episode of rectal bleeding. He noticed fresh blood on the toilet paper after wiping. There was no blood mixed in with the stool. He adds that he is very sore ‘down there’ and it is agony to defecate. ``` Which condition is he likely to have? A. Haemorrhoids B. Anal fissure C. Crohn’s disease D. Ulcerative colitis E. Colorectal carcinoma ```

B. Anal fissure

A 67 y/o male presents to his GP complaining of rectal bleeding. Over the last few months he has noticed blood mixed in with his stool. He sometimes feels like he hasn’t completely emptied his bowels after defecating, and is more tired than usual. What is the next step to take? A. Routine referral to colorectal surgeons B. Urgent referral to colorectal surgeons C. FBC D. Abdominal exam E. Faecal occult blood test

D. Abdominal exam

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? a) Perform a DRE b) Prescribe paracetamol/ibuprofen and topical lidocaine c) Prescribe paracetamol/ibuprofen and topical diltiazem d) Urgent haemorrhoidectomy e) Injection sclerotherapy

b) Prescribe paracetamol/ibuprofen and topical lidocaine

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

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

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