MedEd lower GI Flashcards
What lower GI cancer is screened for in the UK?
Colonic cancer
What is the most common type of colon cancer?
Adenocarcinoma
What does colon cancer arise from?
Dysplastic adenomatous polyps
What sequence does colon cancer follow?
Adenoma carcinoma sequence
What genes are associated with colonic cancer?
HNPCC (lynch syndrome)
FAP
Peutz- Jeghers syndrome
What syndrome is associated with colonic cancer?
Lynch syndrome
What are RF for colonic cancer?
Age obesity IBD- especially UC Acromegaly Poor diet Males
What IBD is associated with colon cancer?
UC
What sex is colon cancer more common in?
Males
How does colon cancer present?
Change in bowel habits- any deviation from norm
Rectal bleeding mixed IN the stool- not bright red blood
Weight loss (lots)
FLAWS
Tenesmus
How is blood in the stool in colon cancer?
Mixed in with the stool and not bright red
What will you see on examination in someone with colon cancer
Anemia features
Palpable mass
Distention/ascites if lever mets
Lymphadenopathy
What is done first if you suspect colon cancer?
2 week referral
What ix might you do for colon cncer? What is GS
DRE
Bloods- anaemia, LFTs to check mets
GS- colonoscopy and biopsy
CT abdo pelvis for mets
What is diagnostic imaging for colon cancer and what do you see?
Double contrast barium enema, you will see apple core lesion
What is dx and GS ix for colon cancer?
dx= double contrast barium enema GS= colonoscopy with biopsy
What special staging criteria is used for colorectal cancer?
Duke’s criteria
How is colorectal cancer managed?
Surgical resection- hemicolectomy/lower anterior resection
Neoadjuvant chemo or radiotherapy
Where does colon cancer metastasise to? What acronym can be used to remember this?
LLBB: liver- most common lung brain bone
What is the common site of metastasise for colon cancer?
Liver
What is the pattern of inflammation in crohns disease?
Transmural
What lesions are seen in crohns?
Skip lesions or patch lesions
What are the most commonly affected sights in crohns?
Terminal ileum- ileocaecal valve
Peri anal area
What does transmural inflammation mean and in what condition is it seen?
It means inflammation of all layers
It is seen in the gut in crohns
What are characteristic features of crohns?
Skip lesions Mouth to anus affected Transmural inflammation Non caseating granulomas Involves terminal ileum or peri anal area
What does inflammation cause in crohns?
Non caseating granulomas
What are RF for crohns?
Smoking OCP Bad diet Fhx Ashkenazi jews Bimodal age distrib: 15-40 and 60-80y/o
How does crohns present?
Crampy abdo pain RLQ and peri umbilical
Diarrhoea- involves mucus, blood and pus (10-15x day), nocturnal
Peri anal lesions- skin tags, fistulae, abscess
Apthous ulcers (oral)
What areas is abdo pain in crohns?
RLQ
Peri umbilical
What are extra articular features of crohns?
Joint pain
Skin lesions- erytherma nodosum, pyoderma gangrenosum
Ocular symptoms- uveitis and episcleritis
Where is pyoderma gangrenosum found and what does it look like?
usually affects legs
Is red and purple
Where is erythema nodosum found and what does it look like?
Affects shins and is red
What is seen on examination in crohns?
Tender abdomen- most lower right (terminal ileum)
Apthous ulcers in mouth
Skin lesions eg skin tags, fistula etc
What ix are done in crohns? What do you see
Bloods- FBC, iron studies (low), vitamin and folate levels, CRP/ESR may be raised
Plain x ray- bowel dilation
CT- bowel wall thickening and skip lesions
Bowel series- rose thorn ulcers (deep ulceration) and string sign of kantor (fibrosis and strictures)
Colonoscopy and biospy- ulcers, cobblestone appearance, skip lesions
Histology- transmural involvement and non caseating granulomas
What is seen on x ray in crohns?
Bowel dilation
What is seen on CT in crohns?
Bowel wall thickening
Skip lesions
What is seen on bowel series (x ray and barium enema in crohns? Why do these arise
Rose thorn ulcers- ulceration is deep
String sign of kantor- due to fibrosis and sclerosis
What is seen on colonoscopy and biopsy in crohns?
Ulcers
Cobblestones appearance
Skip leasions
What is seen on histology in crohns?
Transmural involvement with non caseating granulomas
What are buzzwords for crohns?
Skip lesions
Rose thorn ulcers
String sign of kantor
How is crohns managed?
First line oral/IV/topical steroids- prednisolone
Immunomodulators oral/IV- azathioprine most commonly but also mercaptopurine or methotrexate
Biological therapy IV- adalimumab most commonly but also infliximab or vedolizumab
Surgery for severe disease
Name the steroids, immunomodulators and biological therapies used in crohns disease
Steroid- prednisolone
Immunomodulators- azathioprine most commonly, otherwise mercaptopurine oe methotrexate
Biological therapies- adalimumab most commonly, otherwise infliximab or vedolizumab
How is remission maintained in crohns?
Same as normal treatment but remove steroids- give immunomodulators and biologic therapy
How does management for inducing remission in crohns differ from maintaining remission?
Induce remission= steroid first line+ immunomodulator+ biologic agent
Maintain remission= immunomodulator+ biologic agent
What is UC?
Diffuse inflammation of colonic mucosa affects only rectum and colon
Where does crohns start and continue?
Starts at rectum and extends proximally
What gene is associated with UC?
HLA B27
What conditions is HLA b27 associated with?
Ankylosing spondylitis
UC
What are RF for UC?
HLA b27 Fhx Not smoking (smoking is protective) Western countries Male sex Bimodal peak 20-40 then >60
In what disease is smoking actually good?
UC- it has a protective affect for some reason
How does UC present?
Blood diarrhoea Rectal bleeding and mucus Abdominal pain and cramps Tenesmus Weight loss
How will they differentiate diarrhoea in UC vs crohns in SBAs?
Bloody diarrhoea= UC
Diffuse diarrhoea with crampy abdo pain= Crohns
What are extra articular features of UC?
Skin= erythema nodosum and pyoderma gangrenosum Joints= peripheral arthritis and ankylosing spondylitis Ocular= episcleritis is more common than uveitis
What extra articular eye manifestation is more common in UC then in crohns?
Episcleritis
What might you see on examination in UC?
Anaemia signs
DRE- gross or occult blood
Abdominal tenderness
What ix are done for UC and what will you see?
Bloods- FBC (anaemia), LFTs (primary sclerosing cholangitis), CRP/ESR raised
Stool sample- increased faecal calprotectin
pANCA positive
Abdo x ray- dilated bowel (if over 6cm= toxic megacolon) and thumbprinting sign
Double contrast barium enema- lead pipe appearance
Colonoscopy and biospy- continuous erythema, bleeding and ulcers
Histology- crypt abscesses, depletion of goblet cell mucin
What might be raised in a stool sample in UC?
Faecal calprotectin
What antibody might be positive in UC?
pANCA
What is seen in LFTs in UC?
Primary sclerosing cholangitis
What is seen on abdo x ray in UC?
Dilated bowel with thumbprinting sign
What is seen on double barium contrast enema in UC?
Lead pipe appearance
What are some buzzwords for UC?
Abdo x ray- thumbprinting sign
Double contrast barium enema- lead pipe appearance
How dilated does the bowel have to be to diagnose toxic megacolon?
More than 6cm
What does a bowel thats dilated more than 6cm suggest?
Toxic megacolon
What is seen on colonoscopy in UC?
Continuous erythema, bleeding and ulcers
What is seen on histology in UC?
Crypt abscesses, depletion of goblet cell mucin
How is remission induced in UC?
Mesalazine (5-ASA)
Steroids- beclamethasone
How is remission maintained in UC?
Immunosupressants- azathoprine
Biologics (anti TNF alpha)- infliximab
Biologics (integrin receptor antagonists)- vedolizumab
Ciclosporin
How can UC be cured?
Total colectomy via J puch surgery
What anti TNF alpha and integrin receptor antagonists biologics and used to maintian remission in UC?
anti TNF alpha= infliximab
integrin receptor antagonists= vedolizumab
What are the main complications of UC?
Toxic megacolon
Primary sclerosing cholangitis
Colonic adenocarcinoma
Strictures, obstruction and perforation
What dietary gluten peptide causes coealiacs?
Gliadin
What does coeliacs disease cause?
Villous atrophy
Hypertrophy of crypts
What is there atrophy and hypertrophy of in coeliacs?
Atrophy= of villi Hypertrophy= of intestinal crypts
What are RF for coeliacs?
Fhx IgA deficiency T1DM Autoimmune thyroid disease Female sex Western countries
What antibody is deficient in coeliacs?
IgA
How does coeliacs disease present?
Diarrhoea Bloating Abdo pain Fatigue Weight loss Dermatitis herpetiformis
What skin rash is associated with coeliacs, what does it look like and where is it found?
Dermatitis herpetiformis
Is red and found on elbows
What ix are done for coeliacs and what is seen?
IgA tTG= elevated titre
EMA= elevated titre
endoscopy= villous atrophy and crypt hyperplasia
How is coeliacs managed?
Gluten free diet
Vitamin and mineral supplements
refer to specialist if needed
What is IBS?
Chronic condition characterised by recurrent abdo pain associated with bowel dysfunction
What are the classifications of IBS?
With diarrhoea
With constipation
Mixed
What are RF for IBS
Physical/sexual abuse PTSD Pmhx of acute gastroenteritis Fhx Female sex Younger ages
How does IBS present?
Cramping
Diarrhoea
Constipation
Defecation relieves pain/discomfort
What key feature of defecation is seen in IBS?
Defecation relieves pain in IBS
How is IBS diagnosed?
Theres no test
Its a diagnosis of exclusion
What conditions do you need to exclude for IBS diagnosis? What ix should you do to exlcude these
Coeliacs- anti tTG
IBD- faecal calprotectin, CRP, colonoscopy
Colorectal cancer- FBC (is there anaemia?), FOB test
What stool test is done for colorectal cancer?
Faecal occult blood test
How is IBD managed?
Lifestyle- high fibre, low caffiene/fructose/lactose, stress management, education/reassurance, probiotics maybe
Medical- laxatives, antispasmodics, antidiarrhoeals
When an SBA asks what will confirm the diagnosis what should you immediately think to help you answer it?
Think about your top differential
Then think about which test is used to definitively diagnose it
What are haemorrhoids?
Vascular rich tissue cushions located within the anal canal
Describe the 4 grades of haemorrhoids
Grade 1= no prolapse just prominent blood vessels, only bleeds
Grade 2= prolapse upon bearing down but spontaneously reduce
Grade 3= prolapse upon bearing down and require manual reduction
Grade 4= permanent prolapse and cannot be manually reduced
If a haemorrhoid is described as ‘no prolapse just prominent blood vessels, only bleeds’ what grade is it?
1
If a haemorrhoid is described as ‘prolapses upon bearing down but spontaneously reduces ‘ what stage is it?
2
if a haemorrhoid is described as ‘prolapses upon bearing down and requires manual reduction’ what stage is it?
3
if a haemorrhoid is described as ‘permanently prolapsed and cannot be manually reduced’ what stage is it?
4
What does prolapse mean in terms of haemorrhoids?
Protrusion beyond the anal canal opening
What are RF for haemorrhoids
Constipation
Pregnancy
Space occupying pelvic lesion
How do haemorrhoids present?
Painless bright red blood associated with defecation
May be painful
May be itchy
May feel mass if prolapsed
What ix are done for haemorrhoids? whats first line
Anoscopic examination- is diagnostic
How are haemorrhoids managed?
Conservative= constipation, lifestyle eg discourage straining
Grade 1= topical cotricosteroids
Grade 2/3= rubber band ligation
Grade 4= surgical haemorrhoidectomy
What is management for grade 1 haemorrhoids?
Topical corticosteroids
What is management for grade 2 and 3 haemorrhoids?
Rubber band ligation
What is management for grade 4 haemorrhoids?
haemorrhoiectomy
How is haemorrhoiectomy performed?
Under general
20 mins
Surgeon can do open excision or use a stapler to remove it
What is rectal prolapse?
When the rectum slides out of the anal canal
What are RF for rectal prolapse?
Chronic constipation and straining
Weakened pelvic floor muscles- natural birth/surgery/trauma
Obesity
Older ages
How does a prolapsed rectum present?
Painless protruding mass following defecation/ straining/coughing
Mucoid discharge
Incontinence
Is rectal prolapse painful? Do they bleed?
No and no
How is rectal prolapse managed?
DeLormes procedure
How is rectal prolapse diagnosed?
Clincally, you just have to examine the patient
How are anal fissures managed?
First line conservative management
Topical GTN- analgesia
Topical diltiazem- analgesia
if persistent then botox injections, anal sphincterectomy
What is an anal fissure?
Split in the anal mucosa
How is anal fistula managed?
Fistulotomy
Seton procedure
What are anal fistulae?
Abnormal openings/canals between the last part of the bowel and skin around the anus
How do anal fistulae present?
frequent abscesss, puss and pain round area
What ix are done for anal fistulae?
EUA
MRI
what is an anal abscess?
infection of soft tissue and collection of pus around the anus
What are the 4 types of anal abscess? how are they classed
They are classed by location: Intersphincteric Perianal Perirectal Supra levator
How is anal abscess managed?
Surgical drainage
How does anal abscess present?
Anal pain not related to defecation
How is anal abscess diagnosed?
Clinically by examining the patient
Can also do EUA or MRI
What is a pilonidal sinus?
When hair follicles become inserted into the skin causing inflammation and a sinus- natal cleft
How does pilonidal sinus present?
Pain, swelling, discharge
How is pilonidal sinus diagnosed?
By history and visualise the lesion by examining the patient
How is pilonodial sinus managed?
Surgical excision, ABx, hair removal and local hygiene advice
How do you describe where a perianal lesion is?
Use a clock format, 12 oclock is right above the butthole
