New GP Gastroenterology Flashcards
1
Q
A
2
Q
What is a haemorrhoid?
A
Enlarged anal vascular cushion
3
Q
Under what circumstances can haemorrhoids occur?
A
- Constipation + straining
- Increased intra-abdominal pressure (e.g. weightlifting or chronic coughing)
4
Q
What PMHx can increase the risk of haemorrhoids?
A
- Obesity
- Increased age
- Pregnancy (most likely due to constipation, pressure from the baby in the pelvis and the effects of hormones that relax connective tissues)
5
Q
What are anal cushions?
A
- Specialised submucosal tissue that contain connections between the arteries + veins → = very vascular (supported by smooth muscle + connective tissue)
- The blood supply = from the rectal arteries
6
Q
What is the function of anal cushions?
A
Help control anal continence - along with the internal + external sphincters
7
Q
Where are haemorrhoids usually located?
A
3, 7, 11o’clock
The location of pathology at the anus is described as a clock face, as though the patient was in the lithotomy position (on their back with their legs raised). 12 o’clock is towards the genitals and 6 o’clock is towards the back
8
Q
What are the classifications of haemorrhoids?
(Depends on size + whether they prolapse from the anus?)
A
- 1st degree: no prolapse
- 2nd degree: prolapse when straining and return on relaxing
- 3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back
- 4th degree: prolapsed permanently
9
Q
What are haemorrhoids often asssociated with?
A
Constipation + straining
10
Q
A patient present with:
* Painless, bright red bleeding (on tissue paper after opening bowels)
* The blood is not mixed with the stool
* They complain of a sore/itchy anus
* They can also feel a lump around and inside the anus
Possible diagnosis?
A
Haemorrhoids
11
Q
What will you see O/E of a patient with internal and external haemorrhoids?
A
- External (prolopsed) haemorrhoids = visable on inspection as swellings covered in mucosa
- Internal haemorrhoids = may be felt on PR exam (difficult or impossible)
They may appear (prolapse) if the patient is asked to ‘bear down’ during inspection
12
Q
What investigation is used to properly visualise haemorrhoids?
A
Proctoscopy
(Insert a hollw tube (proctoscope) into the anal cavity to visualise the mucosa)
13
Q
If a patient presents thinking they have haemorrhoids as there is blood in the stool, however it presents mixed in the stool, what should you think?
A
Alternative diagnosis
14
Q
What are some differential diagnoses for rectal bleeding?
A
- Haemorrhoids
- Anal fissures
- Diverticulosis
- Inflammatory bowel disease
- Colorectal cancer
15
Q
What investigation should you perform if there has been rectal bleeding (e.g. from haemorrhoids) for a while?
A
Test for anaemia (FBC)
(Check for clinical signs of anaemia)
16
Q
What first line topical treatments can be given for haemorrhoids?
A
Symptomatic relief + reduce swelling
- Anusol (contains chemicals to shrink the haemorrhoids – “astringents”)
- Anusol HC (also contains hydrocortisone – only used short term)
- Germoloids cream (contains lidocaine – a local anaesthetic)
17
Q
Prevention + treatment of constipation
(good to prevent subsequent haemorrhoids)
A
- Increasing the amount of fibre in the diet
- Maintaining a good fluid intake
- Using laxatives where required
- Consciously avoiding straining when opening their bowels
18
Q
Name a non-surgical treatment for haemorrhoids
A
- Rubber band ligation
- Injection sclerotherapy (injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy)
- Bipolar diathermy (electrical current applied directly to the haemorrhoid to destroy it)
19
Q
Name a surgical option for haemorrhoid management
A
- Haemorrhoidal artery ligation: involves using a proctoscope to identify the blood vessel that supplies the haemorrhoids and suturing it to cut off the blood supply.
- Haemorrhoidectomy: involves excising the haemorrhoid. Removing the anal cushions may result in faecal incontinence.
- Stapled haemorrhoidectomy
20
Q
What is a thrombosed haemorrhoid?
A
- Thrombosed haemorrhoids = caused by strangulation at the base of haemorrhoid → result in a thrombosis (clot) in the haemorrhoid → VERY PAINFUL
- Appearance: Purplish, very tender, swollen lumps around the anus
- PR exam = unlikely due to pain
- They will resolve with time, although this can take several weeks.
The NICE Clinical Knowledge Summaries (2016) suggests considering admission if the patient present within 72 hours with extremely painful thrombosed haemorrhoids. They may benefit from surgical management.
21
Q
A patient presents with purplish, very tender swollen lumps around the anus, they are very painful and there is bright red blood on the tissue after they open their bowels. Possible diagnosis?
A
Thrombosed haemorrhoids
22
Q
What is acute gastritis?
A
Stomach inflammation
(Presents wth epigastric discomfort, nausea and vomiting)
23
Q
What is enteritis?
A
Inflammation of the intestines
(Presents with abdominal + diarrhoea)
24
Q
What is gastroenteritis?
A
Inflammation all the way from the stomach to the intestines
(Presents with pain, nausea, vomiting and diarrhoea)
25
What type of organism is the most common cause of **gastroenteritis**?
**Virus**
(Viral gastroenteritis = very easily spread, and patients often have an affected family member or contact. It is essential to isolate the patient)
26
Name the 3 viruses that cause viral gastroenteritis
* **Rotavirus**
* **Adenovirus** (tends to cause respiratory problems)
* **Norovirus**
| RAN (As is diarrhoea runs!)
27
Name some bacteria that cause gastroenteritis
* E. coli (some strains inc E. colu 0157) (Shiga toxin)
* Campylobacter jejuni
* Shigella (Shiga toxin)
* Salmonella
* Bacillus cereus (cerulide)
* Yersinia enterocolitica
* Staphylococcus aureus (enterotoxins)
28
How does E.coli cause gastroenetritis?
* **E. coli 0157**= produces **Shiga toxin** → causing **abdominal cramps + bloody diarrhoea + vomiting**
* **Shiga toxin** = also **destroys RBCs** → leading to **haemolytic uraemic syndrome** (HUS)
29
Why shouldn't you prescribe antibiotics to a patient with gastroenteritis - that E. coli is the cause?
**Antibiotics** **= increase risk of haemolytic uraemic syndrome**
(Therefore, antibiotics should be avoided if E. coli gastroenteritis is a possibility)
30
What is E. coli spread?
Contact with:
* Infected faeces
* Unwashed salads
* Contaminated water
31
Which bacteria is a common cause of travellers' diarrhoea?
Campylobacter jejuni
| It is the most common bacterial cause of gastroenteritis worldwide
32
What type of bacteria is campylobacter jejuni?
Gram-negative
(curved or spiral-shaped)
33
How is campylobacter jejuni spread?
* Raw or improperly cooked poultry
* Untreated water
* Unpasteurised milk
34
How does travellers' diarrhoea (campylobacter jejuni) present?
Incubation = usually 2 to 5 days.
Symptoms = resolve after 3 to 6 days.
Symptoms are:
* Abdominal cramps
* Diarrhoea often with blood
* Vomiting
* Fever
35
What is the management for travellers' diarrhoea?
For severe symptoms or other risk factors (HIV, heart failure)
* **First line: clarithromycin**
* Second line: Azithromycin, ciprofloxacin
| **C**ampylobacter → **C**larithromycin
36
How does Shigella spread?
* Faeces
* Person-to-person
* Contaminated drinking water or food
37
How does Shigella gastroenteritis present?
* Bloody diarrhoea
* Abdominal cramps
* Fever
| The incubation period = 1-2 days
Symptoms resolve within one week
38
Shigella causes gastroenteritis by releasing the Shiga toxin. So what is the patient at risk of developing?
Haemolytic uraemic syndrome
39
How do you treat severe shigella gastroenteritis?
Azithromycin or ciprofloxacin
40
How is salmonella spread?
* Eating **raw eggs** or **poultry**
* Eating contaminated food with infected faeces of small animals
41
How does salmonella gastroenteritis present?
* Watery diarrhoea (may have mucus or blood)
* Abdominal pain
* Vomiting
| Incubation period = 12hrs to 3 days
Symptoms usually resolve in a week
42
When is treatment (Abx) for salmonella gastroenteritis appropirate?
* Only in severe cases
* Abx guided by stool culture + sensitivities
43
How is Bacillus cereus spread?
* Bacillus cereus = spread through contaminated food
* Grows on food not immediately refrigerated after cooking (e.g fried rice or cook pasta left at room temperature)
44
How does bacillus cereus gastroenteritis present?
* Within **5 hours** of ingestion → **Abdominal cramping + Vomiting**
* Within **8 hours** → **watery diarrhoea**
**Resolution** with **24 hours**
45
How does bacillus cereus cause gastroenteritis?
* Grows on food and produces a toxin called **cereulide**
* When Bacillus cereus arrives in the intestines → produces different toxins that cause **watery diarrhoea** (**8 hours** after ingestion)
Reheating food can kill the bacteria → but not the toxin!
46
A persons develops abdominal crmaps + vomiting approx 5 hours after some egg fried rice that had been left out. After 8 hours he had watery diarrhoea. The next day his symptoms had resolved. What bacteria do you think caused his gastroenteritis?
Bacillus cereus
47
Although bacillus cereus can cause gastroenteritis, what can it cause in IVDU?
Infective endocarditis (where heroin is contaminated)
| But Staph aureus is the most common cause of IE in IVDU
48
What are key carriers for Yersinia Enterocolitica?
**Pigs**
* Eating raw or undercooked pork can cause infection
* It is also spread through contact with infected humans, animals or faeces.
49
How does Terinia enterocolitica gastroenteritis present?
Yersinia = typically affects children
* **Watery or bloody diarrhoea**
* **Abdominal pain**
* **Fever**
* Incubation = 4-7 days
* **Symptoms** = can last **3 weeks or more**
Older children + adults may present with:
* **Right-sided abdominal pain** → due to mesenteric lumphadenitis (inflammation in the intestinal lymph nodes)
* **Fever**
Giving an **apendicitis impression**
50
What is the management for Yersinia enterocolitica gastroenteritis?
Antibiotics = only appropriate in severe cases
(Guided by stool culture + sensitivities)
51
What toxin does staphylococcus aureus produce to cause gastroenteritis?
**Enterotoxins**
52
How does gastroenteritis caused by staphylococal enterotoxins present?
Symptoms = start within hours of ingestion + settle within 12-24 hours
Symptoms:
* Diarrhoea
* Vomiting
* Abdomianl cramps
* Fever
53
What parasite can cause gastroenteritis?
Giardia lamblia
(Giardiasis)
54
How does Giardia lamblia spread tp end up cause gastroenteritis?
* Giardia lamblia = microscope parasite that lives in the **small intestine** of mammals
* These mammals may be pets, farmyard animals or humans.
* It releases **cysts in the faeces** → the **cysts may contaminate food or water** → eaten → infect a new host.
= **faecal-oral transmission**
55
How does gastroenteritis caused by Giardia lamblia present?
* Asymptomatic
* OR chronic diarrhoea
56
What are the investigations for gastroenteritis caused by Giardia lamblia?
**Stool testing**
(NAAT or EIA testing)
57
What is the management for gastroenteritis caused by Giardia lamblia?
Metronidazole
(or tinidazole)
58
Is food poisoning a notifiable disease?
Yes!
59
How do you prevent gastroenteritis?
* Good hygeine
* Isolation of patient
* Barrier nursing
* Infection control
60
What is the main concern with gastroenteritis?
Dehydration
61
What is the management for gastroenteritis?
* **Supportive treatment** for **hydration**: **oral rehydration salts** (glucose, potassium, sodium) or **IV fluids**
* **Antidiarrhoeal drugs** (e.g., **loperamide**) and **antiemetics** (e.g., **metoclopramide**) are generally **avoided**, as they can worsen the condition. NICE suggest **antidiarrhoeal drugs** may be helpful in **mild-moderate diarrhoea** but should be **avoided** with **E. coli 0157, shigella or bloody diarrhoea**.
* **Antibiotics** are only used in patients at **risk of complications** once the causative organism is confirmed.
* Patients should stay off work or school for 48 hours after symptoms resolve entirely.
62
Name some post-gastroenteritis complications
* Lactose intolerance
* Irritable bowel syndrome
* Reactive arthritis
* Guillain–Barré syndrome
* Haemolytic uraemic syndrome
63
Name some differentials for diarrhoea
* Infection (gastroenteritis)
* Inflammatory bowel disease
* Lactose intolerance
* Coeliac disease
* Cystic fibrosis
* Toddler’s diarrhoea
* Irritable bowel syndrome
* Medications (e.g. antibiotics)
64
A 35-year-old woman presents to the general practice with a 2-week history of severe pain during and after bowel movements, accompanied by small amounts of bright red blood on the toilet paper. Possible diagnosis?
Anal fissures
65
What are anal fissures?
Anal fissures = small tears or cuts in the lining of the anal canal
(The main cause of anal fissures is **trauma** to the **anal canal**, usually from passing hard or large stools)
66
Causes of anal fissures
* **Primary or idiopathic**: no identifiable cause, often associated with high resting anal canal pressures
* **Secondary** : caused by conditions such as **inflammatory bowel disease**, malignancy, **trauma**, or sexually transmitted infections
67
Risk factors for anal fissures
* Chronic constipation
* Persistent diarrhoea
* Straining during bowel movements
* Passing hard or large stools
* Anal intercourse
* Inflammatory bowel disease
* Pregnancy and childbirth
68
Clinical features of anal fissures
Signs:
* Tenderness on DRE
* Visible tear in anus lining
* Skin tag or sentinel pile, present if chronic
* Hypertrophied anal papilla in chronic cases
Symptoms:
* **Severe pain during** + **after** bowel movements
* **Bright red blood** on toilet paper
* **Itching** around the anus
69
Investigations for anal fissures
Anal fissures → clinical diagnosis
Investigations to consider:
**Anoscopy** or **proctoscopy** : These investigations may be necessary when clinical diagnosis is uncertain or to rule out other conditions such as malignancy
70
Management of anal fissures
First-line:
* **Dietary modifications: increasing dietary fibre + fluid intake** to soften the stools and reduce straining
* **Laxatives**: softening the stool using laxatives may treat the underlying cause in most instances
* **Topical glyceryl trinitrate (GTN) ointment**: this helps to relax the anal sphincter, reducing pressure on the fissure and improving blood supply for healing
* **Topical anaesthetics**: these can provide symptomatic relief from pain, such as lidocaine
Second-line:
* **Lateral internal sphincterotomy**: for fissures that don't respond to conservative treatment
