Small and Large Intestinal Disorders Flashcards
1
Q
What is the function of Trypsin?
A
Breakdown of proteins to ligopeptides and AAs
2
Q
What is the function of Lipase?
A
Breakdown of fats to glycerol and FFAs
3
Q
What is the function of Amylase?
A
Breakdown of Carbohydrates (starch/glycogen) to Disaccharides (maltose, sucrose, lactose)
4
Q
What is the management of SIBO?
A
- H2 Breath Test (!!!)
- Rotating abx: metronidazole, tetracycline, amoxicillin
- Vitamin + nutritional supplements
5
Q
What are the symptoms of Small Intestinal disease?
A
- Malabsorption*
- Weight loss/low or falling BMI
- Increased appetite
- Diarrhoea
- > usually watery
- > sometimes steatorrhoea
- Bloating
- Fatigue
- Steatorrhoea (pale, oily, floating, foul-smelling stools)
6
Q
What small intestinal disorders is Clubbing associated with?
A
- Coeliac Disease
- Crohn’s Disease
7
Q
What small intestinal disorders is Scleroderma associated with?
A
Systemic Sclerosis
8
Q
What small intestinal disorders is Aphthous ulceration associated with?
A
- Coeliac Disease
- Crohn’s Disease
9
Q
What small intestinal disorder is Dermatitis Herpetiformis associated with?
A
- Coeliac disease
Blistering, intensely itchy, scalp, shoulders elbows, knees
10
Q
What is the main sign of Iron, B12 and Folate-deficiency?
A
- Anaemia!!
11
Q
What are the signs of Ca2+, Mg2+ and Vitamin D-deficiency?
A
- Tetany
- Osteomalacia
(all vitamins interlinked -> cause hypocalcaemia)
12
Q
What are the signs of Vitamin A-deficiency?
A
- Night Blindness
13
Q
What are the signs of Vitamin K-deficiency?
A
- Raised PT time
needed for clotting factor production
14
Q
What are the signs of Thiamine (Vit B1) deficiency?
A
- Memory loss
- Dementia
15
Q
What are the signs of Niacin (vit B3) deficiency?
A
- Dermatitis
- Unexplained HF
16
Q
What are the signs of Vitamin C-deficiency?
A
- Scurvy!
17
Q
When should you suspect a diagnosis of Coeliac Disease?
A
Suspect in all those with Diarrhoea + weight loss or anaemia (esp. iron deficiency)
18
Q
What is Coeliac disease?
A
It is a T-cell-mediated autoimmune disease of the small intestine in which prolamin
(alcohol-soluble proteins in wheat, barley, rye ± oats) intolerance causes villous atrophy and malabsorption
19
Q
What is commonly associated with Coeliac Disease?
A
- HLA-DQ2/8
- Dermatitis Herpetiformis
20
Q
What are the clinical features of Coeliac Disease?
A
- Steatorrhoea
- Diarrhoea
- Abdominal pain
- Bloating
- N+V
- Aphthous ulcers
- Angular stomatitis (iron/nutritional deficiency)
- Weight loss
- Fatigue
- Weakness
- Osteomalacia
- Failure to thrive (children)
21
Q
What are the investigations for Coeliac Disease?
A
- make sure to investigate while pt. is still taking gluten in their diet!!* also: remember to exclude coeliac disease in all labelled as IBS!
- Coeliac serology: IgA transglutaminase (or IgG if IgA-deficient (always check totak plasma IgA as well!!)) or Anti-Gliadin antibodies
- Endoscopy + distal Duodenal biopsy = gold standard!!
- HLA status: HLA-DQ2/DQ8
(-> to exclude but not confirm coeliac disease)
22
Q
What are the characteristic histological findings of Coeliac disease?
A
Villous atrophy !!
(also: increased intra-epithelial lymphocytes)
(found on distal Duodenal biopsy)
23
Q
What is the treatment of Coeliac Disease?
A
- Lifelong Gluten-free diet
- MUST refer to state-registered Dietitian!!
24
Q
What conditions are associated with Coeliac Disease?
A
basically a lot of autoimmune conditions!!
- Dermatitis Herpetiformis (!!!)
- IDDM → Test ALL pts with Type 1 Diabetes for Coeliac Disease bc these diseases are often linked!!
- Autoimmune thyroid disease
- Autoimmune Hepatitis
- PBC
- Autoimmune Gastritis
- Sjogren’s syndrome
- IgA deficiency
- Down’s Syndrome
25
What are the complications of Coeliac Disease?
- Anaemia
- Refractory Coeliac disease
- Small bowel Adenocarcinoma
- Small bowel Lymphoma
- Oesophageal cancer
- Colon cancer
26
What diseases cause malabsorption?
Inflammatory disorders:
- Coeliac disease
- Crohn's disease
Infection:
- Tropical sprue
- HIV
- Giardiasis
- Whipple's disease
Infiltration:
- Amyloidosis
Impaired motility:
- Systemic sclerosis
- Diabetes
- Pseudo-obstruction
Iatrogenic:
- Gastric surgery
- Short bowel syndrome
- Radiation
Pancreatic:
- Chronic Pancreatitis
- Cystic Fibrosis
27
What are the most common infections causing Malabsorption?
- Tropical sprue
- HIV
- Giardiasis
- Whipple's Disease
28
What age does IBD typically present in?
15-35yrs
| median age at diagnosis is 29.5yrs
29
What are the different types of IBD?
- UC
- Crohn's
- IBD-U (Unclassified)
- Microscopic Colitis
- > Collagenous colitis
- > Lymphocytic colitis
30
What are the causes of IBD?
- >Unknown
- >Possible genetic susceptibility (FDR = 5-20x risk of IBD)
- >altered Microbiome
- >Environmental Factors:
- smokers
- diet
- meds
- hx of infective diarrhoea (gastro-enteritis)
- migration - young asian males 6x inc. risk
31
What are the extra-intestinal signs of IBD?
- Aphthous oral ulcers
- Skin rashes/lesions: Erythema
Nodosum, Pyoderma Gangrenosum
- MSK problems: axial disease (ank. spondylitis, sacroiliitis)
- Eye problems: episcleritis, scleritis, uveitis
- PSC (UC): UC + PSC = inc. risk of CRC (yrly colons)
32
Why should you perform yearly colonoscopy if a pt. has both UC + PSC?
Because they are at (50%) increased risk of CRC
33
What are the differential diagnoses of IBD?
Other causes of chronic diarrhoea:
- Malabsorption -> ie. pancreatic insufficiency, bile acid malabsorption, coeliac disease
- IBS
- Overflow Diarrhoea
- Ileo-caecal TB
- Colitis: distinguish from infective, amoebic + ischaemiac colitis
34
What are the main complications of UC?
- Perforation (!!!)
- Bleeding (!!)
- Toxic dilatation of the colon
- Venous Thrombosis (give prophylaxis to all inpatients)
- CRC -> 15% risk with pancolitis for 20yrs (relates to extent and duration of UC disease)
35
Describe the screening colonoscopy guidelines for UC
* Screening colonoscopy at 10yrs post-diagnosis of UC for CRC*
- Low risk: extensive colitis with no active inflammation, left-sided colitis = 5 yrly
- Intermediate risk: extensive colitis with mild-active inflammation, FH of CRC in FDR >50 = 3 yrly
- High risk: extensive colitis with moderate/severe active inflammation, PSC, FH of CRC in FDR <50 = 1 yrly
36
What are the investigations for UC?
- Bloods: FBC, ESR, CRP, U&E, LFT
- Exclude infection: blood culture, stool sample + culture
- Colonoscopy/ Sigmoidoscopy + Biopsy (gold standard!!): inflammatory infiltrate, goblet cell depletion, glandular distortion, mucosal ulcers; crypt abscesses.
- XR: to rule out complications (ie. ?toxic dilatation, ?perforation)
37
What are the Colonoscopic findings of UC?
* ONLY in the colom and rectum -> spreads proximal*
- Haemorrhagic granular mucosa
- Pseudopolyps (!!)
- Punctate ulcers
- Inflammation NOT transmural!
38
How do you assess the severity of UC?
| *using only stools*
* Truelove and Witts Criteria*
- Mild: <4 stools/day
- Moderate: 4-6 stools/day
- Severe: ≥6 bloody stools/day
- Fuliminant: 10 stools/day + continuous bleeding
39
What are the treatment options for inducing remission in UC?
- Mild-Moderate UC: 5-ASAs (Sulfasalazine)
- or oral pred (2nd line)
- Severe UC: IV hydrocortisone
40
When are topical therapies used for UC?
- for Proctitis!
41
What are the clinical features of Proctitis?
- Frequency, Urgency, Incontinence, Tenesmus
- Small volume mucus and blood (out of their behinds)
- Proximal faecal stasis (constipation)
42
What are the side-effects of 5-ASAs?
- Nausea, vomiting, watery diarrhoea
- Headache, indigestion
- Mild allergic reactions
- Rarely: interstitial nephritis, pulmonary fibrosis
43
What are the treatment options for maintaining remission in UC?
- 5ASAs (1st line!)
- Immunomodulator: Thiopurines (Azathiopurine)
- Monoclonal Abs
44
What are the side effects of steroids in UC?
* not for long-term use!!
- Diabetes
- Cataracts
- Osteoporosis
- Mood disturbance
- Obesity
45
What are the side-effects of Azathiopurine?
- Nausea, vomiting, flu-like symptoms
- Leucopoenia
- Hepatotoxicity
- Pancreatitis (check serum amylase if nausea, vomiting)
- Non-Melanoma skin cancer
- Lymphoma
* Requires blood monitoring!!*
46
What are the side-effects of Monoclonal Abs?
- Psoriasis
- Infections (TB reactivation)
- Worsening HF (hypersensitivity reaction)
- Cancers
- Demyelination (anti-TNFs -> symptoms similar to MS)
47
What is the first-line investigation for Proctitis?
Rectal swab!
48
What are the treatment options for inducing remission in Crohn's?
- Mild-moderate) = oral pred
| - Severe = IV hydrocortisone
49
Why are steroids used in IBD?
To induce remission!!!
50
What are the treatment options for maintaining remission in Crohn's?
* Immunomodulators*
- Thiopurine (ie. Azathiopurine) = 1st line
- Methotrexate - for steroid-dependent pts
51
When should you operate in IBD?
- Failed medical therapy (ie. IV hydrocortisone in the acute setting)
- Perforation
- Massive haemorrhage
- Toxic dilatation
52
What drug is never used to induce or maintain remission in Crohn's?
5-ASAs!!! (ie. Sulfasalazine)
53
What type of surgery is performed in IBD?
- Subtotal Colectomy, rectal preservation + ileostomy
Afterwards...
- Completion Proctectomy
- Pouch procedure
54
What are the Clinical Features of UC?
- Bloody Diarrhoea
- Abdominal Pain
- Weight Loss
- Fatigue
55
How to tell if a pt. is having an acute severe colitis attack?
* Life-threatening medical emergency!!!*
- Duration of UC symptoms >10 days
- Infection
56
What is the management of Acute Severe Colitis?
- IV Hydrocortisone (!!)
- IV hydration -> correct electrolytes to prevent toxic megacolon!
- LMWH -> risk of VTE
- AXR -> complications
- Blood tests
- Stool chart
- 4 stool cultures for C. Diff
- Avoid/stop NSAIDs, opiates, anti-diarrhoeals, anti-cholinergics
57
What are the immediate investigations for Acute Severe Colitis?
- Bloods -> markers of inflammation
- Stool culture -> (rule out infection)
- Faecal Calprotectin -> >200 = significant
- Colonoscopy + colon mucosal biopsies
58
When is Faecal Calprotectin indicated?
* note: +ve FCP does not mean IBD!! -> can be raised in other conditions!!*
- To differentiate between IBS and IBD when pt. presents with recent-onset lower GI sx. in whom cancer is not suspected
- Monitoring of known IBD pts.
59
What are the AXR findings for Acute Severe Colitis?
* AXR used to identify the suspected complications in Acute Severe Colitis*
- Toxic dilatation of the colon -> >5.5cm colon
- Featureless colon, mucosal thickening, gaseous small bowel loops
- Mucosal Oedema (thickening), Lead pipe, Proximal faecal loading
60
What is the name of the chart used by clinicians to aid in pt's stool descriptions?
Bristol Stool chart!!
61
What are the histological differences between UC and Crohn's Disease?
- CD = Granulomas, Transmural inflammation
- UC = Goblet cell depletion, Limited to Mucosa
- Crypt Abscesses: UC > CD
62
Which IBD is more likely to form Fistulas?
Crohn's!
63
What are the symptoms of Perianal Crohn's Disease?
- Perianal pain
- Pus secretion
- Unable to sit down
64
How to make diagnosis of Perianal Crohn's Disease?
- MRI Pelvis
+
- EUA!!!
65
What is the treatment of Perianal Crohn's Disease?
- Oral abx
- Biologics (anti-TNF)
immunosuppressant
- Surgery -> drain abscess + place seton stitch
66
What are the surgical indications for Crohn's Disease?
* Failure of medical management
* Relief of obstructive symptoms (small bowel)
* Management of fistulae - e.g. bowel to bladder
* Management of intra-abdominal abscess
* Management of anal conditions
* Failure to thrive
67
What are the most common functional GI disorders?
* no identifiable pathology*
- Oseophageal spasm
- Non-Ulcer Dyspepsia
- Biliary Dyskinesia
- IBS
- Slow-Transit Constipation
- Drug-Related effects
68
What are the common characteristics of a functional GI disorder?
* Very common cause of initial and return medical consultations
* Large impact on QoL
* Large cause of work absences
* Vast majority can be diagnosed with history and examination
* Psychological factors important
* Not associated with development of serious pathology
69
What are the causes of Non-Ulcer Dyspepsia?
* Dyspepsia = upper abdominal pain, typically after eating or drinking*
- Reflux
- Delayed Gastric emptying
- IBS
70
What are the clinical features of Non-Ulcer Dyspepsia?
- Epigastric (upper abdominal) pain - often related to hunger, specific foods, time of day
- Fullness after meals
- Heartburn - retrosternal pain
- Tender Epigastrium
71
What is the management of Non-Ulcer Dyspepsia?
- Careful hx. and examination -> FH
- H. Pylori status -> urea breath test -> if +ve then eradication therapy
- If ALARMS of >55 -> UGIE!
- Less likely to be Gastric cancer if <55
- If all -ve -> treat symptomatically!
72
What is the cause of the vomiting if it is straight after food ingestion?
- Psychogenic cause
73
What is the cause of the vomiting if it is 1 hour or more after food ingestion?
- Pyloric obstruction
| - Motility disorders: ie. Diabetes, Post-Gastrectomy
74
What is the cause of the vomiting if it is 12 hours after food ingestion?
- Small bowel obstruction
75
What are the functional causes of vomiting?
- Drugs
- Pregnancy
- Migraine
- Cyclical Vomiting syndrome -> onset in childhood, recurrent episodes
- Alcohol
76
What would you ask in a patient history for Constipation?
- What does pt. mean by constipation?
- >"What is normal for you?", change in frequency, consistency, blood, mucus, Bristol stool chart
- Duration?
- > ?from birth, ?recent onset
- Soiling?
- Drugs? (+ diet)
77
What would you ask in a patient history for Constipation?
* investigations may not be necessary in in an adult with functional constipation where there is no suspected underlying cause*
- Look for systemic disease
- Careful abdominal examination
- DRE
78
What are the red flag symptoms for Constipation?
* Requires colonoscopy/flexible sigmoidoscopy for further investigations!!*
- Age >50
- Short symptom history
- Unintentional weight loss
- Male sex
- FH of CRC/Ovarian cancer
- Anaemia
- Rectal bleeding
- Recent abx use
- Abdominal mass
79
What investigations would you do for constipation?
- None: in a young, mildly affected pt -> threshold for investigations diminishes w age
* nb. red flag symptoms!!*
- Bloods: FBCs, Blood Glucose, TFTs, Coeliac serology (undiagnosed), FIT testing
- Colonoscopy/ Sigmoidoscopy
80
What are the organic causes of constipation?
- Strictures
- Tumours
- Diverticular disease
- Proctitis
- Anal fissure
81
What are the functional causes of constipation?
- Toxic megacolon
- Idiopathic constipation
- Depression
- Psychosis
- Institutionalised patients
82
What are the systemic causes of constipation?
- Diabetes Mellitus
- Hypothyroidism
- Hypercalcaemia
83
What are the Neurogenic causes of constipation?
* lack of nerve supply to the bowels -> slow-transit of faeces in the colon*
- Autonomic neuropathies
- Parkinson's disease
- Strokes
- Multiple Sclerosis
- Spina bifida
84
What is IBS?
A mixed group of abdominal symptoms for which no organic cause can be found
85
What are the clinical features of IBS?
- Abdominal pain
- > vague, bloating, burning, sharp; worse after eating and better after defecating, occasionally radiates to lower back, rarely occurs at night (psychological)
- Altered bowel habit
- >ie. constipation (IBS-C), diarrhoea (IBS-D), both (IBS-M), variability, urgency
- Abdominal bloating
- > belching, wind + flatus, mucus
86
What is the diagnostic criteria for IBS?
- ROME III
| - NICE
87
What is the ROME III diagnostic criteria for IBS diagnosis?
Recurrent abdominal pain/discomfort for >3 days/month in the past 3 months, associated with 2 or more of:
- Improvement with defecation
- Onset associated with change in stool frequency
- Onset associated with change in stool form
88
What is the NICE diagnostic criteria for IBS diagnosis?
Abdominal pain/discomfort relieved by defecation or associated with altered stool frequency/form, plus 2 or more of:
- Altered stool passage
- Abdominal bloating/ distension
- Symptoms made worse by eating
- Passage of mucus
89
How do you make a diagnosis of IBS?
- Meets diagnostic criteria (ie. NICE or ROME III)
- Compatible history
- Normal physical examination
90
When should you think of an alternative diagnosis for IBS?
- If age >60
- History <6 months
- Anorexia
- Weight loss
- Waking AT NIGHT with pain/diarrhoea
- Mouth ulcers
- Abnormal CRP/ESR/Coeliac serology
91
What is the management of IBS?
- Education and reassurance
- Diet review: reduce tea, coffee, alcohol, sweeteners, lactose/gluten exclusion trial, low-FODMAP diet
- Psychological interventions: relaxation training, hypnotherapy, CBT
- Drugs - Alosetron
92
What is the Aetiology of IBS?
- Altered motility
- > contractions may be stronger and more frequent than normal (IBS-D), or reduced (IBS-C)
- Gut Hypersensitivity
- > gut contractions triggered by waking/eating -> stronger than normal (IBS-D), reduced (IBS-C)
- > Brain hears gut too loudly (urge to defecate more -> incontinence!)
- Stress, Anxiety, Depression
- > chronic stress response -> gut more sensitive to stress
93
How common is CRC?
- 2nd leading cause of cancer death
| - 3rd commonest cancer diagnosis overall
94
What is the most common type of CRC?
- Adenocarcinoma
| - 2/3 Colon, 2/3 Rectal
95
What diseases are high-risk for CRC?
- HNPCC (most common heritable cause)
- FAP
- MAP
- IBD
96
What is the most common cause of CRC?
Sporadic!! (85%)
97
What are the risk factors for CRC?
- Age
- Male gender
- Previous Adenoma/CRC
- Environmental influences: diet (low-fibre, low fruit + veg, low ca2+, increased red meat, increased alcohol), obesity, lack of exercise, smoking, DM
98
What is the most common histological type of Adenomatous Colorectal Polyp?
Tubular! (75%)
99
What lesions are high-risk for Adenomatous CRC?
- Size
- Number
- Degree of Dysplasia
- Villous architecture (!!)
- > shouldn't be any villi in the colon lol
100
What is the Clinical Presentation of CRC?
| Red-flag symptoms!!
- (active) Rectal bleeding: esp. if mixed in w stool
- Persistent change in bowel habit, esp. to looser stools (>4 weeks)
- unexplained Iron-deficiency Anaemia: men of any age and non-menstruating women (more likely to be right-sided colonic malignancy)
- Palpable rectal or right lower abdominal mass
- Acute colonic obstruction: if stenosing tumour
- Systemic symptoms of malignancy: weight loss, anorexia
101
What investigations would you do for CRC?
- FIT Test (ie. for pts w blood in the stool)
- Colonoscopy + Biopsy (!!!
- Staging: CT Chest/Abdo/Pelvis, MRI (rectal tumours), PET scan/Rectal EUS (in selected cases)
102
What is a FIT Test used for?
- Screening asymptomatic individuals for CRC (ie. for pts w blood in the stool)
- Assess and Triage of symptomatic pts attending primary care (red-flag symptoms)
103
What is the radical treatment of CRC?
- SURGERY - 80% of pts w CRC -> Dukes A + cancer polyps
- Chemo - adjuvant (after) surgery -> Dukes B(?) and C if positive LN histology
- RT - rectal cancer only -> neoadjuvant (before) +/- chemo
104
What is the palliative treatment of CRC?
* Dukes D*
- Chemo
- Colonic Endoscopic stenting (prevents obstruction)
105
Describe the Scottish Bowel Screening programme
- Aims to detect pre-malignant adenomas/early cancers in the general population
- FIT test (stool sample)
- Age 50-74 yrs
- Every 2 yrs
106
How often is screening colonoscopy done for heritable conditions that are high risk of CRC?
- HNPCC = 2-yrly from 25yrs
- FAP = annual from 10-12yrs
- MAP = annual from 18-20yrs
107
How often is screening colonoscopy done for IBD?
- 10yrs post diagnosis
| - Then dependent on how bad disease is (ie. duration, extent and activity of inflammation and presence of dyplasia)
108
How often is screening colonoscopy done in a pt. with a FH of CRC?
- High-Moderate risk = 5yrly from age 50
| - Low-Moderate risk = once only at age 55
109
How often is screening colonoscopy done if pt. has had previous adenomas/CRC?
- Previous CRC = 5yrly colonoscopy
| - Previous Adenomas = dependent on no. of polyps, size and degree of dysplasia
110
What is the genetic basis of FAP?
- Heritable condition
- Autosomal dominant
- Mutation of APC gene on chromosome 5
111
What are people with FAP offered at aged 16-25yrs?
- a Prophylactic Proctocolectomy!
112
What conditions is FAP associated with?
Extracolonic manifestations:
- Benign gastric fundic cystic hyperplastic polyps
- Duodenal adenomas
- Desmoid tumours
- CHRPE (Congenital Retinal Hypertrophy of the Pigment Epithelia)
113
What is the genetic basis of MAP?
- mutation of MUYTH base excision repair gene
114
What conditions is MAP associated with?
- Duodenal Adenomas
115
What is the genetic basis of HNPCC?
- mutation in DNA mismatch repair (MMR) genes (ie. MLH1, MLH2)
- tumours typically have MSI (microsatellite instability)
116
What are haemorrhoids?
Disrupted and dilated anal cushions
117
What is the most common cause of haemorrhoids?
Constipation with prolonged straining
118
What are the symptoms of Haemorrhoids?
- Bright red rectal bleeding
-> often coating stools, on the tissue, or dripping
into the pan after defecation.
- Painless
- Straining
119
What is the treatment of Haemorrhoids?
1 - Treat underlying cause: Constipation (increased fluid + fibre) +/- topical analgesics + stool softeners
2 - Rubber Band Ligation
3 - Surgical: HALO, Anopexy, Haemorrhoidectomy
120
What are Anal Fissures/Fissure-in-Ano?
- Painful tear in the squamous lining of the lower Anal canal
121
What is the identifying feature of Anal Fissures/Fissure-in-Ano?
- "Sentinel" mucosal skin tag in external aspect
122
What are the most common causes of Anal Fissures/Fissure-in-Ano?
- Most due to hard faeces
| - Rarely: syphilis, herpes, Crohn's, anal cancer, psoriasis
123
What are the symptoms of Anal Fissures/Fissure-in-Ano?
- Pain when defecating
- > ie. as opposed to haemorrhoids which are painless!!
- Bleeding (on tissue when wiping)
- > ie. as opposed to haemorrhoidal bleeding which is straight into the pan
- Glass splinters -> ie. feels like ur passing broken glass!
124
What is the treatment of Anal Fissures/Fissure-in-Ano?
1 - Treat underlying cause - Constipation (stool softeners, laxatives), medical: GTN/Diltiazem + lignocaine (for pain)
2 - Surgical: Botox, Sphincterotomy
125
What are the most common causes of Peri-Anal Abscesses?
- Idiopathic
- Infection by gut organisms
- Clogged glands
- STD
- Trauma
126
What are the risk factors for Peri-Anal Abscess?
- DM
- BMI
- Immunosuppression
- Trauma
127
What are the signs of a Peri-anal Abscess?
- Excruciating pain
| - Signs of Sepsis
128
What is the treatment of Peri-anal abscess?
- Abx if Septic
| - Incision + drainage (under GA)
129
What are the most common causes of Fistula in Ano?
* Peri-anal Sepsis
* Peri-anal Abscess (!!) → 10-20% of pts
* Crohn's Disease
* TB
* Immunocompromised
130
What are the symptoms of Fistula in Ano?
- Peri-anal sepsis
- Persistent pus discharge with flare up
- +/- faecal soiling
131
What is the treatment of Fistula in Ano?
*Surgical*
Fistulotomy and excision, then...
- Seton suture: high fistular
or
- Lay open: low fistulae
132
What are the most common causes of Anal/Rectal Cancer?
- Anoreceptive intercourse
- HPV
- HIV
133
What are the clinical features of Anal/Rectal Cancer?
* Painful/painless
* Bleeding
* Indurated
* Red flag signs
* FIT test +ve
134
What are the most common causes of Chronic Constipation?
- Dietary (commonest)
- Drugs
- opiates
- anti-depressants
- anti-muscarinics
- iron supplements, calcium supplements
- some antacids
- diuretics
- CCBs
- Organic
- Hirshprung
- EDS
- Functional
- Slow transity
- Evacuation-related
- Combination
135
What are the investigations of Chronic Constipation?
- Exclude sinister pathology: colonic imaging, baseline bloods, symptomatic (qFIT), coeliac serology, faecal calprotectin
- Detailed history: including dietary to establish type of constipation
- Colonic transit studies
- Defecating proctogram
- May need more investigations to exclude Hirschsprung/EDS
136
What is the treatment of Chronic constipation?
- Conservative management:
- >aggressive dietary management:
- ensure adequate water intake
- caffeinated coffee
- high fibre diet + exercise
- >biofeedback for learning/relearning toileting habits/posture
- Medical:
- >start w regular baseline laxatives
- > consider combo therapy
- Surgery
137
What are the most common causes of Faecal incontinence?
* increasing incidence with increasing age*
- Passive: internal sphincter defect
- Urge: Rectal pathology, functional
- Mixed: Prolapse
- Overflow: Chronic constipation
138
How to diagnose Faecal incontinence?
- Detailed history to determine urge/ passive/ overflow, obstetric/surgery history, ?trauma/abuse
- Clinical examination - DRE
- Anorectal physiology
- Endoanal USS
- Defecatory Proctogram
139
What is the management of Faecal Incontinence?
- Aggressive conservative measures: low fibre diet, loperamide, pelvic floor exercises
- EMG, if required
- Irrigation
- Anal plug
- Surgical interventions: sphincter repair, correct anatomical defect, sacral nerve stimulation anal bulking agent for passive FI
140
What is Anal Manometry used for?
- Anal sphincter function: resting pressure, squeeze increment, duration of squeeze
- Estimation of functional length of anal canal
- Anorectal pressure responses during abrupt increases in Intra-Anal Balloon (ie. during cough)
- Changes in anal pressure during defecation
- Recto-Anal Inhibitory Reflex (RAIR) -> need to have a drop of resting pressure for this reflex (this reflex is absent in Hirschprung's disease)
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What is a Rectocele? Why is it an issue?
- A Rectocele is a type of prolapse where the supportive wall of tissue between a woman's rectum and vaginal wall weakens → without the support of these pelvic floor muscles and ligaments, the front wall of the rectum sags and bulges into the vagina
- Passive loss of stool from being trapped due to incomplete evacuation
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What is Internal Rectal Prolapse? What are its symptoms?
- When the lining of your rectum slides down inside your rectum but doesn't reach as far as your anus
- Symptoms of obstructive defecation and FI
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What is the management of Rectocele and Internal Rectal Prolapse?
* Improve rectal evacuation using different techniques
* Biofeedback
* Enemas/Loperamide (anti-motility med -> to treat diarrhoea)
* Surgical intervention
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What is the treatment of choice Rectal Prolapse?
- Rectopexy
