Lower GI Conditions Flashcards
What is constipation?
Difficulty in passing stools or an inability to pass stools
How can constipation present?
Straining
Lumpy/Hard stools
Feeling of incomplete evacuation
Fewer than 3 bowel movements a week
What are some causes of constipation?
Normal transit constipation
Slow colonic transport
Defecation problems
What is the treatment for constipation?
Psychological support Increased fluid intake Increased activity Increased dietary fibre Fibre medication Laxitives
What is diarrhoea?
A symptom that occurs in many conditions. Presents as loose/watery stools passed more than 3 times a day
What causes diarrhoea?
An unwanted substance triggers gut motility and secretions to remove it, increasing water in the bowel
What are the 2 broad causes of diarrhoea?
Secretory causes
Osmotic causes
What are secretory causes of diarrhoea?
Excess ion secretion gives excess Cl- or HCO3- in the bowel
What are osmotic causes of diarrhoea?
Gut lumen contains too much osmotic material
What is the appendix?
Diverticula off the caecum
Which artery supplies the appendix?
Ileocolic branch of Superior Mesenteric
How can appendicitis present?
Acute
Gangrenous
How does acute appendicitis present?
Mucosal Oedema
How does gangrenous appendicitis present?
Transmural inflammation and necrosis
How can the causes of appendicitis be classified?
Classic
Alternative
What happens in classic appendicitis?
The lumen of the appendix becomes blocked, increasing intraluminal pressure.
Venous pressure rises giving oedema, reducing arterial supply to the appendix causing ischaemia
What happens in alternative appendicitis?
A viral/bacterial infection causes mucosal changes that allow for bacterial invasion of the appendiceal wall
How does appendicitis manifest?
Poorly-localised peri-umbilical pain that moves to the R iliac fossa after 12-24h
Anorexia
Nausea and Vomiting
Low Grade fever
Why can the pain for appendicitis be felt in areas other than the RIF?
The position of the appendix varies slightly
Which position can the appendix be found in?
Retrocoecal Subcoecal Pelvic Pre-ileal Post-ileal
What are some signs of appendicitis?
Patient appears ill Fever/Tachycardia Lie still due to inflamed peritoneum Localised R quadrant tenderness Reboud tenderness in RIF Pain localised to McBurney's Point
Where is McBurney’s Point?
2/3 of the way from Umbilicus to ASIS
How is the diagnosis of appendicitis confirmed?
History/exam is often enough
Bloods - Raised CRP/WCC
What needs to be excluded with possible appendicitis cases?
Ectopic pregnancy
What is the treatment for appendicitis?
Open appendicectomy
Laprascopic Appendicectomy
What is Diverticulosis?
Outpouchings of the mucosa and submucosa that herniate through the muscularis layers
Where is Diverticulosis common?
Colon, commonly sigmoid
What is thought to cause Diverticulosis?
Low fibre diet giving hard/bulky stool that needs more effort to pass
What is Acute Diverticulitis?
Diverticulae become inflamed/perforate.
The entrance to the diverticula is occluded by faeces giving inflammation
How can acute diverticulitis present?
Uncomplicated
Complicated
What is uncomplicated diverticulitis?
Diverticulitis with inflammation and small abscesses
What is complicated diverticulitis?
Diverticulitis with larger abcess formation
What are some symptoms of diverticulitis?
Abdo pain at sight of inflammation, usually lower left quadrant Fever Bloating Constipation Haematochezia Fresh PR bleed
What are some signs of diverticulitis?
Localised abdominal tenderness
Distension
Reduced bowel sounds
Signs of Peritonitis
What tests are appropriate in diverticulitis?
Bloods - WCC/CRP
USS
CT
Colonoscopy
What is the treatment of diverticulitis?
Antibiotics
Fluid resus
Analgesia
Surgical intervention if perforated
What is Acute Mesenteric Ischaemia?
The sudden decrease in blood supply to the bowel, leading to bowel ischaemia, gangrene and death
What are some causes of acute mesenteric ischaemia?
Thrombus in Situ
Embolism
Non-occlusive cause
Venous occlusion/congestion
What are some risk factors for acute mesenteric ischaemia?
Hypertension
Hyperlipidaemia
Smoking
Af
What are clinical features of acute mesenteric ischaemia?
Generalised abdominal pain
Diffuse, constant
Nausea and Vomiting
What will examination demonstrate in acute mesenteric ischaemia?
Often nothing
What are some differentials with acute mesenteric ischaemia?
Peptic Ulcer Disease
Bowel Obstruction
AAA
Which investigations are appropriate for acute mesenteric ischaemia?
ABG - ?Acidosis/Lactate
FBC, U+E,LFTs
Which investigation is definitive with acute mesenteric ischaemia?
CT Abdo/Pelvis with Contrast
What is the management for acute mesenteric ischaemia?
Surgical intervention
Excision of the Necrotic Bowel
Revascularisation of the bowel
What is Crohn’s Disease?
A form of inflammatory bowel disease
Which areas of bowel are affected by Crohn’s disease?
Any part of the GI tract, commonly the distal ileum or proximal colon
How is Crohn’s disease characterised?
Transmural inflammation, procuding deep ulcers and fissures giving affected bowel a cobblestone appearance
Is the inflammation in Crohn’s disease constant?
No, the inflammation is intermittent forming skip lesions
How does Crohn’s disease appear microscopically?
Non-caseating granulomatous inflammation
What are some risk factors of Crohn’s disease?
Family Hx
Smoking
White European descent
Previous Appendicectomy
What are some clinical features of Crohn’s disease?
Episodic abod pain and diarrhoea Mucus/Blood in diarrhoea Malaise Anorexia Low grade fever Oral and Peri-anal ulcers
What are some extra-intestinal features of Crohn’s?
MSK - Nail clubbing, metabolic bone disease Skin - Erythema Nodosum Eyes - Episcleritis, Iritis HPB - Primary Sclerosing Cholangitis Renal - Stones
What investigations are appropriate with Crohn’s disease?
Bloods Faecal Calprotectin AXR Colonoscopy CT
What is the management for Crohn’s?
Fluid Resuscitation
Corticosteroids + Immunosuppresion
Smoking cessation
What surgical options are there for Crohn’s disease?
Ileocoecal Resection
Surgery for Peri-anal disease
Stricturoplasty
Small/Large Bowel resections
What are some complications of Crohn’s Disease?
Fistulae Stricture formation Recurrent Peri-anal abscesses/fistulae GI malignancy Malabsorption Osteoporosis Increased risk of gallstones/renal stones
What is Ulcerative colitis?
Most common form of IBD
How is UC characterised?
Diffuse continuous mucosal inflammation of the large bowel, beginning in the rectum and spreading proximally
Histologically, how does UC present
Inflammation of the mucosa and submucosa, crypt abscesses and goblet cell hyperplasia
What are some clinical features of UC?
Bloody diarrhoea
Malaise
Anorexia
Low Grade Pyrexia
What are some extra-intestinal manifestations of UC?
MSK - Nail clubbing
Skin - Erythema Nodosum
Eyes - Episcleritis/Iritis
HPB - Primary Sclerosing Cholangitis
What is Peritonitis?
Inflammation of the serosal membrane that lines the abdominal cavity. Breakdown of the peritoneal membranes allows foreign substances into the cavity giving inflammation
How can Peritonitis be classified?
Primary/Spontaneous Bacterial Peritonitis
Secondary/Surgical Peritonitis
What is Primary peritonitis?
Infection of ascitic fluid within the abdomen, often secondary to chronic liver disease
How is primary peritonitis diagnosed?
Aspiration of the ascitic fluid
What is Secondary peritonitis?
Inflammation of the peritoneum secondary to inflammation/perforation of an intra-abdominal/retroperitoneal structure
What are some causes of secondary peritonitis?
Peptic ulcer disease Appendicitis Diverticulitis Post-surgery Tubal pregnancy Ovarian cyst
How does peritonitis present?
Acute
Diffuse abdominal pain
What is the treatment for peritonitis?
Supportive
Antibiotics
Surgical washout if appropriate
What is a Hernia?
Protrusion of part of the abdominal contents beyond the normal confines of the abdominal wall
What does a hernia consist of?
Sac - Pouch of peritoneum
Contents - Bowel etc
Coverings - Layers of abdominal wall
What are some pre-disposing factors for hernias?
Inguinal/Femoral canals
Umbilicus
Previous incisions
How does an indirect inguinal hernia present?
Lateral to inferior epigastric vessels
How does a direct inguinal hernia present?
Medial to inferior epigastric vessels, through hesselbachs triangle
What are the borders of hesselbachs triangle?
Medial - Rectus Abdominus
Superior - Inferior Epigastric Vessels
Inferior - Inguinal ligament
What is a stoma?
Opening of bowel/intestine onto the surface of the abdomen
How does a stoma appear?
Fleshy and moist, patients have no sensation of sphincter
Which types of stoma are there?
Ileostomy
Colostomy
Loop
End
What is an Ileostomy?
Made from Ileum of small bowel in RIF
Sprouted to help drainage
Produces porridge-like stools
Drainable bag in place
What is a Colostomy?
Large bowel stoma, usually L sided, often sigmoid
Flush to skin
Soft to formed stool output
Closed bag
What is a Loop Ileostomy?
Often temporary
A loop of bowel is brought to the skin surface, opened, inverted and sutured
2 openings, 1 used
Usually to “Defunction” bowel to allow anastomosis healing
What is an End Ileostomy?
The cut end of bowel is moved to the surface, inverted and sutured.
Permanent
What is a Volvulus?
Twisting of a loop of intestine around its mesenteric attachment leading to a closed loop bowel obstruction
What can Volvulus lead to?
Ischaemia of the affected bowel giving bowel necrosis and perforation
Where do Volvuli commonly occur?
Sigmoid colon
What are some risk factors for Sigmoid volvulus?
Increasing age Neuropsychiatric Disorders Resident in a Nursing Home Chronic constipation Male gender Previous abdominal operations
What are some clinical features of a Sigmoid Volvulus?
Colicky Pain
Abdominal distension
Rapid onset
What investigations are appropriate for a suspected Sigmoid Volvulus?
AXR - ?Coffee Bean sign
CT Abdo
What are the management options for a sigmoid volvulus?
Decompression with endoscopy + flatus tube insertion
Resection of necrotic bowel
What is Pseudo-Obstruction
Dilation of the Colon due to an adynamic bowel in the absence of mechanical obstruction
Which area of colon most commonly has Pseudo-Obstruction?
Caecum and Ascending Colon
What is thought to be the pathophysiology of pseudo-obstruction?
Interruption of the autonomic nervous supply in the colon leading to an absence of smooth muscle action
What are the possible complications of pseudo-obstruction?
Toxic Megacolon
Bowel Ischaemia
Perforation
What are some causes of pseudo-obstruction?
Electrolyte imbalance
Medication
Recent surgery, illness or trauma
Neurological disease
What are some clinical features of pseudo-obstruction?
Abdominal pain/distension
Constipation
Vomiting
Which investigations are appropriate for suspected pseudo-obstruction?
AXR - ? Dilated bowel loops
CT
What management for pseudo-obstruction is appropriate?
NBM NG to decompress stomach Endoscopic decompression with flatus tube Nutritional support Surgical resection
What is Bowel Obstruction?
A mechanical blockage of the bowel where a structural pathology physically blocks the passage of intestinal contents
Once occluded, what happens to the affected section of Bowel?
Gross dilatation of the proximal limb of the bowel leading to increased peristalsis. This also leads to secretions of large volumes of electrolyte-rich fluid into the bowel
What is a Closed-Loop obstruction?
Two occlusions affecting the same loop of bowel
Why is a Closed-Loop obstruction a surgical emergency?
The bowel will continue to distend, leading to eventual ischaemia and/or perforation
What are some common causes of Small Bowel Obstruction?
Adhesions
Herniae
What are some common causes of Large Bowel Obstruction?
Malignancy
Diverticular Disease
Volvulus
Where can the obstruction be located irrespective of the bowel segment?
Intraluminal
Mural
Extramural
What are some Intraluminal causes of bowel obstruction?
Gallstone Ileus
Ingested foreign body
Faecal impaction
What are some Mural causes of bowel obstruction?
Carcinoma Inflammatory strictures Intussusception Diverticular strictures Meckel's Diverticulum Lymphoma
What are some Extramural causes of bowel obstruction?
Hernias
Adhesions
Peritoneal Metastases
Volvulus
What are some common clinical features with Bowel obstruction?
Abdo pain - Colicky/Cramping in nature
Vomiting - Initially gastric, then billious and faeculent
Abdo distension
Absolute constipation
What may become apparent in bowel obstruction on examination?
Signs of underlying cause - Surgical scars, cachexia from malignancy Abdo distension Focal tenderness Guarding Rebound tenderness Tympanic to percussion Tinkling bowel sounds
Which investigations are appropriate with suspected bowel obstruction?
FBC,U+E,CRP,LFTs,G+S
VBG - ?Ischaemia
CT Abdo + Contrast
CXR/AXR
What conservative management is recommended with confirmed obstruction?
Drip and Suck
What steps are involved with Drip and Suck?
NBM NG tube to decompress stomach IV fluids Urinary Catheter Anaelgesia
When is a water-soluble contrast study recommended with confirmed obstruction?
If there is no improvement in symptoms 24 hours post commencement of management
When is surgical intervention appropriate with confirmed bowel obstruction?
Suspicion of Intestinal Ischaemia or Closed-Loop obstruction
SBO in a virgin abdomen
Cause that needs surgical intervention
Failure to improve after 48h
What procedure is appropriate to correct bowel obstruction?
Laparotomy or resection
What are some potential complications of Bowel Obstruction?
Ischaemia
Bowel perforation giving peritonitis
Dehydration leading to renal impairment
