Lower GI Flashcards
What is an anal fissure?
Split in the mucousal liing of the distal anal canal wth pain on defecation and rectal bleeding. Caused by hard stools and poor blood supply
RFs for anal fissure?
Hard stools, pregnancy, opiates (from constipation)
Presentation and Ix for anal fissure?
Very bad pain on defection ‘ shards of glass’
Tearing sensation and fresh blood on toilet paper
Clinical diagnosis for Iz 1st line and maybe EUA
Mx for anal fissure?
1st line = conservative (manage constipation, high fibre diet, adequate fluids and sitz baths)
Topical GTN
Topical diltiazem
Mx for persistent fissure?
> 8 weeks
Boutlinum toxin injection (EUA)
Surgical sphincterotomy
Aetiology and RFs for anal fistula?
Clogged anal glands and anal abscesses, crohns, radiation and trauma
Presentation of anal fistula?
Frequent anal abscess, pain and swelling around anus.
Bloody/foul pus drainage
Anal fistula Ix and Mx?
Examination: opening on skin around anus, anoscope or rectoscope
Surgical through fistulotomy or seton
Types of anal abscess?
Intersphincteric, perirectal, perianal, supralevator
Rfs and epidemiology of anal abscess?
RFs: anal fistula, crohns and constipation
M>F
Anal abscess presentation?
Perinanal pain, not related to defecation.
Perianal swellling and tenderness
Low grade fever and tachycardia (if systemic)
Anal abscess Ix?
1st line and diagnostic = clinical exam or EUA
CT/MRI for internal pelvic abscess
Mx for anal abscess?
1st line = surgical drainage
+fistulotomy
Broad Abx if systemic
Types of haemorrhoids?
can be above/belov the dentate/pectinate line
Grade 1: no prolapse, only bleeds
2: prolapse on bearing but reduce on their own
3: prolapse on bearing and need manual reduction
4: permanent prolapse and cannot be reduced
Rfs and presentation of haemorrhoids?
Constipation, pregnancy and SOL in pelvis
Bleeding on defection (painless)
Can be painful with palpable mass and anal pruritus
Ix for Haemorrhoids/
1st = anoscopic examination
Maybe colonoscopy or FBC for anaemia
Mx for haemorrhoids?
Conservative: constipation advice, disciourage straining
1: topical corticosteroids
2: rubber band ligation
3: ‘’
4: surgical haemorrhoidectomy (classic excision of using stapler)
Complications of haemorrhoids?
Thrombosed haemorrhoids: purple, painful, oedematous lump
What is a pilonidal sinus?
Forceful insertation of hairs into the skin of the natal cleft in the sacrococcygeal area promotes inflammation and causes a sinus
Rfs and epidemiology of pilonidal sinus?
80% male and peak 16-40YO
Young males with stiff hair, hirsuitism and sitting
Presentation of pilonidal sinus?
Sacrococcygeal, discharge, pain on sitting and swellign
Ix and Mx for pilonidal sinus?
Clinical diagnosis + history
Surgical treatment = excision of cyst + sinus + Abx + hair removal + hygeine advice
RFs for rectal prolapse?
Chronic constipation and straining, weakened pevic floor muscles (pregnanyc, surgery or trauma), obesity
Older ages
anything causing pelvic floor weakness
Presentation of rectal prolapse?
Painless protruding mass following defecation, mucoid discharge and incontinence
Not bleeding and much larger than haemorrhoids
Ix for rectal prolapse?
1st = clinical diagnosis O/E
Maybe anal manometry, colonoscopy
Mx = delormes
WHat are healthy bowel habits to advise?
Increase liquids and fibres and use wipes, pat gently wipe front to back, dont strain and dont spent loads of time, use foot stool
Features of colonic cancer>
Most common in western world and 4th death in US. 1 of 3 cancer screening in UK and adenocarcinoma is the type
Genes for colon cancer?
HNPCC (germline mutatons)
FAP (APC gene)
Peutz-Jeghers syndrome (STK11/LKB1)
UK colorectal screening features?
FIT test and one-off flexi
RFs for colonic cancer?
Increasing age, obesity, IBD (UC), acromgealy, poor fibre and limited physical activity
M>f, younger and younger patients in western countries
Presentation of colonic cancer?
1) change in bowel habits
2) rectal bleeding
3) Weight loss and FLAWs
Tenesmus
Anaemia symptoms
O/E
Anaemic, palpable mass, distention/ascites, lymohadenopathy
Ix for colonic cancer?
Bloods: FBC (anaemia, LFTS (mets)
CEA marker
Colonoscopy + biopsy is diagnostic
Double contrast Barium enema = apple core lesion as stricturing
Pre-op staging with CT CAP
Staging for colon cancer?
TNM classification
Dukes: A= Tumour 95% mucosa B= Tumour invading bowel wall C= lymph node mets D= distant mets
Management for Colorectal cancer?
Surgical excision + adjuvant or neoadjuvant chemo/radiotherapy
LLLBB mets
Crohns pathophysiology?
Transmural inflammation of the GI tract from mouth to anus. SKIP lesions
Commonly: terminal ileum and perianal
Corms non-caseating granuloma
RFs and epidemiology of Crohns?
FHx, smoking, OCP, high refined sugars, ?NSAIDS,?not brestfed
Ashkenazi jews and bimodal = 15-40 and 60-80
GI Presentation of Crohns?
ABDO pain, crampy or constant and in RLQ or peri-umbilical for terminal ileum
Diarrhoea, mucus, blood, pus, nocturnal occasionally,
Peri-anal lesions e.g. skin tags, fistulae, abscess
Fatigue, weight loss, painful oral lesions (apthous ulcers)
Extra- GI presentation og Crohns?
Arthropathy
Erytherma nodosum and pyoderma gangrenosum
Uveitis and episcleritis
Bloods for Crohns?
FBC, iron stidues and vitamin/folate as malnourished
CRP and ESR as inflammatory
Ix for Crohns?
Plain AXR - bowel dilation
CT = dowel wall thickening and skip lesions
XRay + barium enema = Rose thorn ulcers (ulceration) and string sign of Kantor (fibrosis + stricture)
Colonoscopy + Biopsy = ulcercer, cobblestone and skip lesions
Histo = trasmural involvement with noncaseating granuloma
Last is Confirmative test
Management of Crohns to induce remission?
1) steroids e.g. prednisolon, budenoside
2) Immunomodulators 1st = azathioprine, then mecraptopurine, methotrexate
3) biologic therapy (IV) 1st = adalimumab, infliximab, vedolizumamab
4) surgery
Adjuncts = nutritional therapy, perianal disease management nd smoking cessation
Crohns Mx for maintenance of remission?
Immunomodulators = Azathioprine, mercaptopurine, methotrexate
+- biologics e.g. INFLIXIMAB, adalimumab, Vedolizumab
Adjuncts = antispasmotics, antidiarrhoeals
UC pathophysiology?
Starts from rectum and works proximally and just the mucosa
Environmental + immune dysfunction + genetic predispostion (HLA-B27 e.g. ANkylosing spondylitis)
RFs and epidemiology of UC?
Rhx, HLA-B27, not smoking as smoking is protective
Western countries, M>F, biomdal 20-40 then >60`
UC GI presentation?
Bloody diarrhoea, rectal bleeding + mucus, abdo pain and cramps, tenemus and weight loss
UC extra-GI presentation?
Peripheral arthritis and ankylosing spondylitis
Erytherma nodosum and pyoderma gangrenosum
EPscleritis>uveitis
O/E: anaemic, DRE with gross, occult blood and abdo tenderness
UC Ix?
Bloods: FBC (anaemia), LFTS (PSC),, CRP and ESR for inflammatory
Stool sample for increased faecal calprotecting
pANCA 70% +ve
Complications of UC?
PSC and toxic megacolon
Colonic adenocarcinoma
Strictures -> obstruction -> perforation
UC scans?
Plain AXR = dilated e.g. toxic megacolon if >6cm ith thumbprinting
Double contrast barium enema = lead pipe appearance
Colonsocpy + biopsy -> continuous erytherma , bleeding and ulcers with histology = cryspt abscessm depletion of goblet cell mucin
UC management to induce remission?
1) Mesalazine (5-ASA) topical or oral
2) steroids e.g. oral beclametasone
UC management to maintain remission?
1) immunosuppresives e.g. AZAthioprine, mercaptopurine
2) biologics (anti-TNF) e.g. infliximab, adalimumab
3) Biologics (integrin recept antagonists) = vedolizumab
4) Ciclosporing
5) Total colectomy
Pathophysiology of Coeliac disease?
Autoimmune triggered by gliadin
Results in villous atrophy and hypertrophy of intestinal crypts
Increased lymphocytes in epithelium and lamina propria
Rfs for coeliac?
FHx, IgA deficiency, T1DM and autoimmune thyroid disease
F>M, western countries
Coeliac presentation?
Chronic or intermittent diarrhoea, bloating, abdo pain, discomfot,
Fatigue, weight loss, and dermatitis herptetiformis
Coeliac Ix?
IgA tTg elevated in bloods Endomysial Antibody (EMA)
Endoscopy = villous atropy and crypt hyperplasia
Mx for coelic?
Gluten free diet, vitamin and mineral supplements
What is IBS?
IBS with diarrhoea, with constipation or mixed
IBS Rfs and epidemiology?
Hx of phsyical sexual abuse, PTSD, PMHx of acte bacterial gastroenteritis, FHX
F>M
<50YO
IBS presentation?
Abdo Cramping, alteration of stool consistency and defecation relieves pain
Ix for IBS and Mx?
Rule out everything else
Lifetsyle = fibre, avoid caffeine, lactose, stress and education + probiotics
Medical = laxatives, antispasmotics and antidiarrhoeals
