Lower GI Flashcards
IBD, coeliac, IBS, lower GI, colorectal cancer
1
Q
What are the two types of inflammatory bowel disease?
A
Crohn’s disease
Ulcerative colitis
2
Q
What is Crohn’s disease?
A
A disorder with unknown aetiology characterised by TRANSMURAL inflammation of the GI tract that can affect any part from mouth to anus.
Found as SKIP lesions
3
Q
What is ulcerative colitis?
A
Relapsing and remitting inflammatory disorder of the colonic mucosa.
4
Q
What is the aetiology of inflammatory bowel disease?
A
Both have an unknown aetiology.
5
Q
What are the risk factors for Crohn’s?
A
Smoking OCP Nutrition deficiency Previous GI infection FHx Diet high in refined sugars
6
Q
Epidemiology IBD
A
Ashkenazi Jews
Bimodal peak:
15-40
60-80
7
Q
Which layers of the gut are affected by Crohn’s?
A
All the layers:
- mucosa
- submucosa
- muscularis propria
- subserosa
- serosa
8
Q
Which layers of the gut are affected by UC?
A
Mucosa and submucosa
9
Q
Which parts of the GI tract are affected by Crohn’s?
A
Mouth to anus
Particularly terminal ileum + perianal
10
Q
Which parts of the GI tract are affected by UC?
A
Colon and rectum
11
Q
Which parts of the GI tract are inflamed in Crohn’s?
A
Random patches, with skip lesions
12
Q
Which parts of the GI tract are inflamed in UC?
A
Continuous from the anus proximally
13
Q
Which of the IBD’s commonly has fissures/abscesses?
A
Crohn’s
14
Q
What is the main bowel symptom in Crohn’s?
A
Diarrhoea +/- blood
15
Q
What is the main bowel symptom in UC?
A
Bloody +/- mucus diarrhoea
16
Q
What is the difference in flare pattern for Crohn’s and UC?
A
Crohn’s- systemically unwell
UC- feel well between flares
17
Q
Which of the IBD’s is curative via surgery?
A
UC
18
Q
How does the presence of blood present in IBD?
A
Mixed in with the stool
19
Q
Which IBD is likely to present with RIF pain?
A
Crohn’s (terminal ileitis)
20
Q
Which IBD is likely to present with mouth ulcers?
A
Crohn’s
21
Q
What are the extra-intestinal manifestations of IBD?
A PIE SAC
A
Aphthous ulcers (CD>UC) Pyoderma gangrenosum I- eye- iritis, uveitis, episcleritis (CD>UC) Erythema nodosum Sclerosing cholangitis (UC) Arthritis Clubbing fingers (CD>UC)
22
Q
What bedside/blood investigations would you do on a Pt with Crohn’s?
A
BLOODS:
FBC (anemia)
LFT’s (primary sclerosing cholangitis*)
CRP / ESR (inflammatory disease)
STOOL SAMPLE:
Increased faecal calprotectin (indicates inflammation)
OTHER:
pANCA (70% positive)
23
Q
What investigations would you do on a Pt with UC?
A
Stool sample
Blood tests
Abdo XR
Colonoscopy/flexisig and biopsy
24
Q
What would a colonoscopy and biopsy of a Pt with UC show as?
A
Mucin depletion
Diffuse mucosal atrophy
Continuous from the rectum with ANAL SPARING
25
What may you see on the Abdo XR of a Pt with UC?
Toxic megacolon
Lead piping
Thumb printing
26
Why would you measure the CRP and ESR of a Pt with IBD?
To provide baseline markers for inflammation
27
Why would you measure the LFTs of a Pt with IBD?
To check for primary sclerosing cholangitis (UC)
28
What is lead piping?
Loss of the haustral markings
| Due to inflammation
29
What is thumb printing?
Large bowel wall thickening
| Due to infective/inflammatory process
30
What is toxic megacolon?
IBD/C Diff progressing into inflammatory colitis progressing into toxic megacolon
31
What are the symptoms of a toxic megacolon?
Extreme vomiting
Abdo pain
Abdo distension
32
How do you induce remission for Crohn's?
Corticosteroids
33
What is the prognosis of a Pt with Crohn's?
Increased mortality
34
What is the prognosis of a Pt with UC?
Mortality not affected
| Risk of developing toxic megacolon
35
What is Coeliac disease?
Systemic autoimmune disease triggered by dietary gluten peptides- GLIADIN
36
What is the epidemiology of Coeliac disease?
Western countries
Peaks at infancy and 50-60 yrs
F:M 2:1
37
What are the 2 key histological features of Coeliac disease?
Villous atrophy
| Hypertrophy of intestinal crypts
38
What are the risk factors for Coeliac disease?
FHx
IgA deficiency
T1DM
Autoimmune thyroid disease
39
What symptoms may a Pt with Coeliac disease present with?
Symptoms can be vague/mild:
- Diarrhoea (chronic / intermittent)
- Bloating
- Abdominal pain / discomfort - after eating gluten
EXTRA INTESTINAL
- Fatigue
- Weight loss
- Dermatitis Herpetiformis (elbows)
40
What signs may a Pt with Coeliac disease present with?
- Anaemia
- Dermatitis herpetiformis- bilateral itchy vesicles and plaques, usually elbows/extensor surfaces
- B12/iron/folate deficiency symptoms
41
What 3 antibodies may be elevated in a patient with Coeliac disease?
1. IgA-tissue transglutaminase (IgA-TTG)
2. Anti-endomysial antibodies (EMA)
3. IgG DGP (deamidated gliadin peptide)
42
What will an endoscopy and duodenal biopsy show in a Pt with Coeliac disease?
Villous atrophy
Cryptal hyperplasia
Intraepithelial WBCs
43
How would you manage a Pt with Coeliac disease?
Gluten-free diet
| Vitamin D supplementation
44
What is the prognosis of a Pt with Coeliac disease?
>90% will have complete and lasting resolutions on a gluten-free diet
45
What are the complications of a Pt with Coeliac disease?
Upper GI lymphoma/carcinomas
Osteoporosis
Chronic dermatitis herpetiformis
46
What is irritable bowel syndrome?
```
Recurrent abdo pain in the past 3 months associated with at least 2 of the following:
-defecation
-change in stool frequency
-change in stool consistency
[Rome IV criteria]
```
47
How is IBS diagnosed?
Via a process of exclusion
48
How would you manage a Pt with IBS?
```
Avoid precipitating factors
FODMAP diet
Peppermint oil/tea
Anti-diarrhoeal (loperamide)
SSRIs (citalopram)
```
49
What is an anal fissure?
Anal fissure is a split in the mucosal lining of the distal anal canal characterised by pain on defecation and rectal bleeding
50
RF for anal fissures
HARD STOOL
PREGNANCY
OPIATES
Anything causing constipation
51
Where do anal fissures most commonly present?
Posterior midline of the anal canal (90%)
| Recent evidence suggests this may be due to ischaemia, as this is the location with poorest circulation
52
What symptoms may a Pt with an anal fissure present with?
PAIN ON DEFECATION- tearing sensation
“like passing sharp glass”
FRESH BLOOD on toiler paper
53
What investigations would do you do on a Pt with an anal fissure?
NA- anal fissures are a clinical diagnosis + DRE (may be under anaesthesia if very painful)
54
What is the treatment for a Pt with an anal fissure?
1st line – CONSERVATIVE- manage constipation:
- High fibre diet
- Adequate fluid intake
- Sitz baths
ANALGESIA- relaxes anal muscles
- Topical Glyceryl Trinitrate (GTN)
- Topical Diltiazem
55
What is the prognosis for a Pt with an anal fissure?
80% heal with treatment
56
What are the complications of an anal fissure?
Chronicity
| Incontinence post-op
57
What are haemorrhoids?
Vascular rich tissue cushions located within the anal canal
Prolonged/Repetitive straining causes disruption of the tissues and results in elongation/dilation of the haemorrhoidal tissues
58
What is the epidemiology of haemorrhoids?
4% of the population
| Common in 45-65 yrs
59
What is the main risk factor for haemorrhoids?
Raised intra-abdominal pressure:
- constipation
- chronic cough
- pregnancy
- obesity
- ascites
- SOL
60
What are the four degrees of haemorrhoids?
1- no prolapse, just prominent veins
2- prolapse upon bearing, spontaneously reduces
3- prolapse requiring manual reduction
4- prolapse which cannot be manually reduced
61
What symptoms may a Pt with haemorrhoids present with?
PAINLESS BLEEDING ASSOCIATED WITH DEFECATION
- Bright red PR bleed
- Sides of the pan
Can be painful and cause discomfort
Anal pruritus (itching)
Palpable mass felt
62
What investigations would you do on a Pt with haemorrhoids?
1st line + Diagnostic = ANOSCOPIC EXAMINATION
- Visualise haemorrhoids
- Confirm diagnosis
Colonoscopy (exclude DDx)
63
What signs can be seen on a PR exam of a Pt with haemorrhoids?
Visible lump
| 3/4th degree may be visible on inspection
64
What is the management for a Pt with haemorrhoids?
CONSERVATIVE MX:
- Constipation advice
- Discourage straining
GRADE 1: Topical corticosteroids (alleviates pruritus)
GRADE 2+3: Rubber band ligation
GRADE 4: Surgical Haemorrhoidectomy
65
What are the complications of haemorrhoids?
Anaemia
Thrombosis- purplish, oedematous, tender subcutaneous perianal mass causing significant pain
Incarceration
66
What is the prognosis for a Pt with haemorrhoids?
Surgery has the lowest recurrence rates: 20%
67
What is the ranking for colorectal cancer in terms of incidence?
3rd commonest cancer in the UK
| Most common cancer in the Western world
68
What is the most common type of colorectal cancer?
Adenocarcinoma
Majority of cases they arise from dysplastic adenomatous polyps = adenoma --> carcinoma sequence
69
What are the risk factors for colorectal cancer?
```
>60yrs
Alcohol/smoking/high red meat diet
Polyps
Genetic conditions (FAP/HNPCC)
Obesity
IBD (UC)
Acromegaly
Poor fibre intake
Limited physical activity
```
70
What are the symptoms of a left sided colorectal cancer?
```
Weight loss
Anaemia
Distension / Ascites (late)
Lymphadenopathy (late)
Palpable mass (late)
```
71
What are the symptoms of a right sided colorectal cancer?
```
PR bleeding/mucus
Altered bowel habit
Tenesmus
Obstruction
PR mass
```
72
Which sided colorectal cancer presents earlier, and is easier to detect?
Left sided
73
What investigations would you do on a Pt with colorectal cancer and why?
BLOODS
- FBC- iron deficiency (microcytic) anaemia
- LFTs- baseline/mets
- CEA- colorectal ca marker
1. Colonoscopy + Bx = DIAGNOSTIC
2. Double contrast barium enema- staging (supplanted by CT colonography)
3. CT chest/abdo/pelvis - pre-op + staging
74
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
Fits Rome IV criteria
75
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
Mouth ulcers
76
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
Blood, mucoid- likely UC
77
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 mesalazine
Likely to be UC
78
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
Terminal ileitis- likely Crohn's
79
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 taking oral prednisolone, his symptoms improve. Which additional treatment would you start him on to maintain his remission?
```
A. IV corticosteroid
B. Increase oral prednisolone
C. Oral mesalazine
D. Oral azathioprine
E. IV cyclosporin
```
D. Oral azathioprine
80
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
81
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
| [Note from Chang, would argue that DRE is also appropriate]
82
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
83
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
| [Note from Chang, would argue that "B. Urgent referral to colorectal surgeons"]
84
What is the diagnostic histological finding in chrons?
TRANSMURAL, NON-CEASETING GRANULOMA FORMATION
85
How does Chron's present?
Abdominal pain
- Crampy or constant
- RIF + Peri Umbilical (terminal ileum)
Diarrhoea
- Mucus, Blood, Pus
- May be nocturnal
Peri anal lesions
- skin tags
- fistulae
- abscesses
fatigue, weight loss, malnutrition
86
State the extra-intestinal manifestations of chron's
Occur in 20-40% of pts
Arthropathy
Erythema nodosum
Pyoderma gangrenosum
Uveitis, episcleritis
87
What might you find on examination of a patient with CD?
Abdominal tenderness / mass in RIF (terminal ileum)
Apthous ulcers
Peri anal lesions:
Skin tags
Fistulae
Absesses
88
Bloods for CD
```
FBC
Iron studies
Vitamin / Folate levels
CRP
ESR
```
89
What Ix would you do for CD?
```
Plain AXR
CT abdo pelvis
Bowel Series (Xray + Barium enema)
Colonoscopy + BX
HISTOLOGY = diagnostic
```
90
What would you see on CT in CD?
Bowel wall thickening, Skip lesions
91
What would you see on AXR in CD?
bowel dilatation
92
What would you see on x-ray + barium enema in CD?
“rose thorn ulcers” = deep ulceration
| “string sign of Kantor” = fibrosis + strictures
93
What would you see on colonoscopy in CD?
Ulcers
cobblestone” appearance
skip lesions
94
Management of CD flare-up
1. STEROIDS (oral or IV +/- topical)
Prednisolone, Budesonide
2. IMMUNOMODULATORS (oral or IV)
Azathioprine, Mercaptopurine, Methotrexate
3. BIOLOGICAL THERAPY (IV)
Adalimumab, Infliximab, Vedolizumab
4. SURGERY
For severe remissions/presentation, refractory disease and obstructed pts
95
Adalimumab, Infliximab are examples of what type of drug?
TNF-a inhibitors
96
Maintaining remission in CD
IMMUNOMODULATORS
- Azathioprine, Mercaptopurine, Methotrexate
+ / - BIOLOGICS
- Infliximab, Adalimumab, Vedolizumab
ADJUNCTS
- Anti-spasmotics (cramp relief)
- Anti-diarrhoeals
97
70% of UC patients are positive for which blood marker?
p-ANCA
| - perinuclear anti-neutrophil cytoplasmic antibodies
98
What are are the most common and most severe complications of UC?
Toxic megacolon
PSC
Colonic adenocarcinoma
Strictures --> LBO --> perforation
99
Which stool test indicates bowel inflammation?
faecal calprotectin
100
What imaging would you do for UC? What classic signs would you see?
- Plain AXR > dilated bowel = THUMBPRINTING
- Double contrast barium enema = LEAD PIPE
- Colonoscopy + Biopsy = CONTINUOUS erythema, bleeding, ulcers
101
What histology would you see in UC?
Crypt abscesses
| Depletion of goblet cell mucin.
102
What type of enema do you use in UC investigations?
DOUBLE contrast barium enema
single = less sensitive so cannot detect early changes/small polyps
103
What might be seen on barium enema in UC?
LEAD PIPE APPEARANCE = complete loss of haustral markings throughout the colon
STRICTURING
104
Compare the diameter and markings of the small vs large bowel on AXR
SMALL
- max diameter = 35mm
- valvulae coniventes extend all the way across
LARGE
- max diameter = 55mm
- haustra extend 1/3rd the way across
105
How is remission induced in UC?
1. MESALAZINE (5-ASA) = aminosalycate
Oral / topical - high dose
2. STEROIDS
Oral Beclamethasone
106
How is remission maintained in UC?
1. IMMUNOSUPRESSIVES
Azathioprine, Mercaptopurine
2. BIOLOGICS (anti- TNFa)
Infliximab, Adalimumab
3. BIOLOGICS (integrin receptor antagonists)
Vedolizumab
4. CICLOSPORIN
5. TOTAL COLECTOMY= curative
107
Which genotype increases risk of UC?
HLA-B27
108
Which rheumatological condition may be present in UC patients?
ankylosing spondylitis
109
What investigations would you do for coeliac disease?
serology - IgA tTG + anti-EMA
| Endoscopy
110
Define IBS
Chronic conditions characterised by recurrent abdominal pain associated with bowel dysfunction
111
How can IBS be classified?
IBS-D (with diarrhoea)
IBS-C (with constipation)
IBS-M (mixed)
112
RF for IBS
History of Physical/Sexual Abuse
PTSD
PMHx: Acute bacterial gastroenteritis
FHx
113
Epidemiology IBS
Females > M (2:1)
| <50yo
114
How does IBS present?
- Abdominal cramping in lower/mid abdomen
- Alteration of stool consistency (diarrhoea ↔ constipation)
- Defecation RELIEVES abdominal pain/discomfort *
OE: NORMAL
115
What tests might you want to do in IBS to exclude other differentials?
- Anti-tTG (coeliac)
- Fecal calprotectin, lactoferrin (IBD)
- Serum CRP (IBD)
- Colonoscopy (IBD)
- FBC (anaemia – consider CRC)
- FOB test (CRC)
116
Lifestyle advice for IBS
- Fibre
- Avoid: caffeine, lactose, fructose.
- Stress management
- Education + Reassurance
- + Probiotics ?
117
medical management IBS
symptoms:
- Laxatives (IBS-C) = lactulose
- Antispasmotics (cramps) = dicyclomine
- Antidiarrhoeals (IBS-D) = loperamide
118
Management of persistent fissures
Botulinum Toxin Injection (EUA) – Botox
| Surgical sphincterectomy
119
Define fistula
abnormal connection between vessels or organs that do not usually connect.
120
Define anal fistula
A connection between the last part of the bowel and the skin around the anus
121
RF for anal fistula
Clogged anal glands and anal abscesses
Crohn’s disease
Radiation (cancer)
Trauma
122
How does anal fistula present?
Frequent anal abscesses
Pain and swelling around the anus
Bloody / Foul smelling drainage (pus)
123
What might you use to examine an anal fistula?
Anoscope / Rectoscope
124
How is anal fistula managed?
SURGICAL MANAGEMENT
Fistulotomy
Seton- encourage drainage before repair
125
How are anal abscesses classified?
according to location:
- Intersphincteric
- Perianal
- Perirectal
- Supra levator
126
RF for anal abscess
Anal fistula
Crohn’s disease
Constipation
M>F
127
How does anal abscess present?
Perianal Pain
Not related to defecation! (not fissures)
Perianal Swelling and Tenderness
Low grade fever & Tachycardia - if systemic
128
Ix for anal abscess
1st line & DIAGNOSTIC = CLINICAL EXAMINATION or EUA
| CT / MRI for internal pelvic abscesses
129
Mx anal abscess
1st line – SURGICAL DRAINAGE OF ABSCESS
( + fistulotomy)
If systemic infection = Broad spectrum AB
130
3 key red flag symptoms for colon cancer
Change in bowel habits
Rectal bleeding
- “mixed in the stool”
- Not bright red
Weight loss
- FLAWS
131
What might you see on double contrast barium enema of a colorectal cancer patient?
apple core lesion
| – cancer causes stricturing
132
What cancer marker is used in CR cancer?
Carcinoembryonic antigen (CEA)
- May be used to monitor for recurrence / assess response to treatment
- used to assess other types of cancer eg lung/breast
133
What staging system is used in CR cancer? For each stage, state the 5yr survival
DUKES
- Dukes' A Tumour confined to the mucosa- 95%
- Dukes' B Tumour invading bowel wall- 80%
- Dukes' C Lymph node metastases- 65%
- Dukes' D Distant metastases- 5% (20% if resectable)
134
What is the management of CR cancer?
Surgical excision + adjuvant or neoadjuvant chemo / radiotherapy
135
Common areas of metastases for CR cancer
Liver, Lung, Bone, Brain
| "LL BB”
136
Where are the commonest locations for CR cancer?
rectal: 40%
sigmoid: 30
137
Which 3 genetic conditions put people at increased risk of CR cancer?
1. HNPCC – heretidary non-polyposis colorectal cancer
- FHx of bowel cancer at very young age
2. FAP – familial adenomatous polyposis
3. Peutz-Jeghers syndrome: inherited condition with increased risk of hamartomatous polyps in the digestive tract + other cancers
138
What is the pathophysiology of pilonidal sinus?
Caused by the forceful insertion of hairs into the skin of the natal cleft in the sacrococcygeal area.
Promotes inflammation and causes a sinus.
139
Epidemiology pilonidal sinus
80% M
| Peak: 16-40
140
RF pilonidal sinus
Young males
Stiff hair
Hirsutism
141
How does pilonidal sinus present?
SACROCOCCYGEAL:
- Discharge – offensive, staining underwear
- Pain – worst on sitting down
- Swelling
142
Mx pilonidal sinus
Surgical excision of pilonidal cyst + sinus
+ AB
+ Hair removal (laser/shaving)
+ Local Hygiene advice
143
RF for rectal prolapse
Chronic constipation + straining
Weakened pelvic floor muscles
Natural birth, surgery, trauma
Obesity
ANYTHING CAUSING WEAKNESS / PRESSURE ONTO PELVIC FLOOR
144
Epidemiology rectal prolapse
older age
145
How does rectal prolapse present?
- Painless protruding mass following defecation
(or straining eg: coughing)
- Mucoid discharge
- Incontinence
Differences with haemorrhoids:
Not bleeding
Much much larger
146
Ix for rectal prolapse
CLINICAL DIAGNOSIS- ask patient to strain to elicit prolapse
- Anal manometry
- Colonoscopy (check for other pathologies)
- MRI – detailed imagery
147
Outer appearance of different stomas
ileostomies RHS
colostomies LHS
(you can also have urostomys which is the connection of the ureter to the abdominal wall)
148
4 types of stoma
LOOP allow bowel rest after resection
END- permanent
FLUSH- colostomies
SPOUT- ileostomies, don't want stomach acid/enzymes in contact with skin
