Lower GI Clinical Flashcards
1
Q
Describe the four terms used to distinguish hernias.
A
- reduced: can be manipulated back through defect
- irreducible: cannot be reduced w/out surgery
- incarcerated: irreducible hernia with contents trapped
- strangulated: ischaemia is occurring, leading to necrosis and potential sepsis; associated with extreme tenderness/erythema, and systemic upset (e.g., vomiting, fever).
2
Q
Describe the surgical management of inguinal (direct/indirect), umbilical, and femoral hernias.
A
- surgical repair is with mesh placement
- inguinal: distinction between indirect and direct does not change management. refer for routine surgery
– unilateral hernia: open approach
– bilateral/recurrent: laparoscopic approach
– complications: bruising, wound infection, chronic pain, recurrence, damage to ilioinguinal nerve - umbilical: most common in neonates, babies and toddlers; if non-strangulated, the approach is typically watch and wait:
– small, asymptomatic: if still present at 4-5yr, elective surgical repair
– large or symptomatic: elective repair 2-3yr - femoral: much more common in women and has a much higher chance of strangulation, so requires emergency surgical repair
3
Q
Describe the signs and management of a congenital diaphragmatic hernia (CDH).
A
- important cause of respiratory distress in the newborn and is associated with pulmonary hypoplasia
- the main sign is the presence of (tinkling) bowel sounds on respiratory examination and may be picked up on chest XR
- initial management is to prevent air entry to the gut; therefore intubate and ventilate if cyanotic
- definitive management is with surgical repair of the diaphragm
4
Q
Topic: scrotal swellings
Give the signs and management of the following scrotal swellings: inguinal hernia, testicular cancer, epididymo-orchitis, epidydimal cyst, hydrocele, testicular torsion, and hydrocele.
A
- inguinal hernia: cannot get ‘above’ swelling on exam, may have cough reflex; Mx: routine surgical mesh repair
- testicular cancer: discrete testicular nodule, +/- signs of metastasis; Ix: testicular USS, serum AFP and beta-HCG; Mx: orchidectomy via inguinal approach
- epidydmo-orchitis: tends to be associated with urinary symptoms (dysuria, discharge) due to Chlamydia infection. AS OPPOSED TO TORSION, elevating the testis eases tenderness & the cremaster reflex is present
- epidydimal cysts: painless, separate nodules posterior to the testis therefore can get ‘above’ on exam; Mx: excised surgically
- hydrocele: transilluminates, non-painful and fluctuant. can get ‘above’ on exam. can be presenting feature of testicular cancer in young men.
- testicular torsion: severe, sudden onset pain associated with undescended testes in young or adolescent males. AS OPPOSED TO EPIDYDIMO-ORCHITIS pain is not eased on testis elevation (patient often refuses exam) and cremaster reflex is absent; Mx: urgent surgery and fixation of BOTH testes
- varicocele: ‘bag of worms’ (varicosity of pampiniform plexus); typically left as drains into renal vein. associated with infertility and may be presenting sign of RCC. Mx is conservative unless infertility is the concern -> surgical or radiological management
5
Q
Give the significant differences between Crohn’s and Ulcerative Colitis.
A
- Crohn’s disease: CROHNS and NESTS
– CROHNS
— cobblestone appearance on endoscopy
— rose-thorn ulcers
— obstruction of bowel
— hyperplasia of mesenteric lymph nodes
— narrowing of intestinal lumen
— skip lesions
– NESTS
— no blood or mucous
— entire GI tract
— skip lesions
— terminal ileum most common location + transmural (full colon thickness)
— smoking is a risk factor - Ulcerative colitis: CLOSEUP
– CLOSEUP
— continuous disease
— limited to colon and rectum
— only submucosa affect
— smoking protective
— excretes blood +/- mucous
— use aminosalicylates
— primary sclerosing cholangitis
6
Q
Give the key differences between Crohn’s and Ulcerative Colitis regarding extra-intestinal symptoms, complications, and histology.
A
- extra-intestinal:
– Crohn’s: gallstones (reduced bile acid resorption) and oxalate renal stones (reduced calcium resorption); weight loss
– UC: PSC, uveitis - complications:
– Crohn’s: bowel obstruction, fistulae
– UC: colorectal cancer - histology:
– Crohn’s: increased goblet cells, granulomas
– UC: decreased goblet cells, crypt abscess (neutrophil infiltration)
7
Q
Describe the radiological differences between Crohn’s and Ulcerative Colitis.
A
- Crohn’s with small bowel enema (increased specificity and sensitivity for the terminal ileum, the most commonly affected area)
– Kantor’s string sign (narrowing of colon)
– proximal bowel dilation
– rose thorn ulcers, fistulae - UC with barium enema
– loss of haustrations
– scantly preserved mucosa gives the appearance of polyps - these are pseudopolyps
– drainpipe colon: narrowing and shortening of the colon
8
Q
Describe the grading of haemorrhoids.
A
- grade 1: no prolapse, just prominent blood vessels
- grade 2: prolapse upon bearing down, but spontaneous reduction
- grade 3: prolapse upon bearing down, requires manual reduction
- grade 4: prolapse with inability to be manually reduced.
9
Q
Describe the management of haemorrhoids.
A
- conservative management
- soften stool (increase fibre and fluid intake)
- topical local anaesthetics, steroids
- outpatient procedures
- rubber band ligation (1st line)
- injection sclerotherapy (2nd line)
- surgical management (haemorrhoidectomy) is reserved for those with large, symptomatic disease that does not respond to previous management
- includes Doppler-guided haemorrhoidal artery ligation and stapled haemorrhoidopexy
10
Q
Describe the presentation and subsequent management of thrombosed haemorrhoids.
A
- significant pain, tender lump
- O/E a purplish, oedematous, tender, subcutaneous perianal mass
- if <72hr, consider for excision
- otherwise, manage conservatively with stool softeners, ice packs, and analgesia, with a view to symptoms resolving within 10 days
11
Q
Describe the presentation and management of anal fissures.
A
- longitudinal or elliptical tears of the squamous lining of the distal anal canal
- very painful rectal bleeding
- 90% occur at the posterior midline (6 o’clock); if elsewhere, consider secondary causes (e.g. Crohn’s)
- may be associated with sentinel skin tags
- management of an acute fissure:
- soften stool (high fibre diet, high fluid intake)
- bulk-forming laxitaves > lactulose
- lubricants, topical anaesthetic, analgesia etc. prior to defecation
- once chronic (>6wk), add topical GTN
- sphincterotomy (or Botox) can be considered if GTN ineffective after 8 weeks
12
Q
Describe the histology associated with Solitary Rectal Ulcer Syndrome (SRUS).
A
Mucosal thickening and a lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)
13
Q
Name the symptoms associated with colorectal cancer.
A
- change in bowel habit
- rectal bleeding or blood in the stool
- abdominal pain or discomfort
- unexplained weight loss
- anaemia (fatigue, weakness, dyspnoea)
- bowel obstruction (30% of large bowel cancers present this way)
- asymptomatic (FIT screening)
14
Q
Describe the investigations for colorectal cancer.
A
- FBC (?IDA - low Hb, ferritin, MCV)
- LFTs (raised may indicate liver mets)
- U&Es (raised calcium may indicate bone metastases)
- colonoscopy with biopsy is the gold standard investigation
- CT abdo/pelvis can be used in patients with significant co-morbidity or frailty
- TNM staging is performed with CT CAP
15
Q
Describe the Dukes staging system of colorectal cancer (and how it relates to the TNM classification).
A
- Dukes A: TNM 1,0,0 or 2,0,0 (invasion into the bowel wall but not through it)
- Dukes B: TNM 3,0,0 or 4,0,0 (invasion through the bowel wall but not involving lymph nodes)
- Dukes C: TNM X,1,0 or X,2,0 (involvement of lymph nodes)
- Dukes D: TNM X,X,1 (widespread metastases)
