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Alimentary System > Small and Large Intestinal Disorders > Flashcards

Small and Large Intestinal Disorders Flashcards

1
Q

What is the function of Trypsin?

A

Breakdown of proteins to ligopeptides and AAs

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2
Q

What is the function of Lipase?

A

Breakdown of fats to glycerol and FFAs

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3
Q

What is the function of Amylase?

A

Breakdown of Carbohydrates (starch/glycogen) to Disaccharides (maltose, sucrose, lactose)

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4
Q

What is the management of SIBO?

A
  • H2 Breath Test (!!!)
  • Rotating abx: metronidazole, tetracycline, amoxicillin
  • Vitamin + nutritional supplements
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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)
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6
Q

What small intestinal disorders is Clubbing associated with?

A
  • Coeliac Disease

- Crohn’s Disease

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7
Q

What small intestinal disorders is Scleroderma associated with?

A

Systemic Sclerosis

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8
Q

What small intestinal disorders is Aphthous ulceration associated with?

A
  • Coeliac Disease

- Crohn’s Disease

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9
Q

What small intestinal disorder is Dermatitis Herpetiformis associated with?

A
  • Coeliac disease

Blistering, intensely itchy, scalp, shoulders elbows, knees

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10
Q

What is the main sign of Iron, B12 and Folate-deficiency?

A
  • Anaemia!!
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11
Q

What are the signs of Ca2+, Mg2+ and Vitamin D-deficiency?

A
  • Tetany
  • Osteomalacia

(all vitamins interlinked -> cause hypocalcaemia)

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12
Q

What are the signs of Vitamin A-deficiency?

A
  • Night Blindness
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13
Q

What are the signs of Vitamin K-deficiency?

A
  • Raised PT time

needed for clotting factor production

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14
Q

What are the signs of Thiamine (Vit B1) deficiency?

A
  • Memory loss

- Dementia

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15
Q

What are the signs of Niacin (vit B3) deficiency?

A
  • Dermatitis

- Unexplained HF

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16
Q

What are the signs of Vitamin C-deficiency?

A
  • Scurvy!
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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)

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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

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19
Q

What is commonly associated with Coeliac Disease?

A
  • HLA-DQ2/8

- Dermatitis Herpetiformis

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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)
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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)
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22
Q

What are the characteristic histological findings of Coeliac disease?

A

Villous atrophy !!

(also: increased intra-epithelial lymphocytes)

(found on distal Duodenal biopsy)

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23
Q

What is the treatment of Coeliac Disease?

A
  • Lifelong Gluten-free diet

- MUST refer to state-registered Dietitian!!

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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
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25
Q

What are the complications of Coeliac Disease?

A
  • Anaemia
  • Refractory Coeliac disease
  • Small bowel Adenocarcinoma
  • Small bowel Lymphoma
  • Oesophageal cancer
  • Colon cancer
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26
Q

What diseases cause malabsorption?

A

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
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27
Q

What are the most common infections causing Malabsorption?

A
  • Tropical sprue
  • HIV
  • Giardiasis
  • Whipple’s Disease
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28
Q

What age does IBD typically present in?

A

15-35yrs

median age at diagnosis is 29.5yrs

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29
Q

What are the different types of IBD?

A
  • UC
  • Crohn’s
  • IBD-U (Unclassified)
  • Microscopic Colitis
  • > Collagenous colitis
  • > Lymphocytic colitis
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30
Q

What are the causes of IBD?

A
  • > 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
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31
Q

What are the extra-intestinal signs of IBD?

A
  • 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)
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32
Q

Why should you perform yearly colonoscopy if a pt. has both UC + PSC?

A

Because they are at (50%) increased risk of CRC

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33
Q

What are the differential diagnoses of IBD?

A

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
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34
Q

What are the main complications of UC?

A
  • 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)
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35
Q

Describe the screening colonoscopy guidelines for UC

A
  • 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
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36
Q

What are the investigations for UC?

A
  • 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)
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37
Q

What are the Colonoscopic findings of UC?

A
  • ONLY in the colom and rectum -> spreads proximal*
  • Haemorrhagic granular mucosa
  • Pseudopolyps (!!)
  • Punctate ulcers
  • Inflammation NOT transmural!
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38
Q

How do you assess the severity of UC?

using only stools

A
  • Truelove and Witts Criteria*
  • Mild: <4 stools/day
  • Moderate: 4-6 stools/day
  • Severe: ≥6 bloody stools/day
  • Fuliminant: 10 stools/day + continuous bleeding
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39
Q

What are the treatment options for inducing remission in UC?

A
  • Mild-Moderate UC: 5-ASAs (Sulfasalazine)
  • or oral pred (2nd line)
  • Severe UC: IV hydrocortisone
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40
Q

When are topical therapies used for UC?

A
  • for Proctitis!
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41
Q

What are the clinical features of Proctitis?

A
  • Frequency, Urgency, Incontinence, Tenesmus
  • Small volume mucus and blood (out of their behinds)
  • Proximal faecal stasis (constipation)
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42
Q

What are the side-effects of 5-ASAs?

A
  • Nausea, vomiting, watery diarrhoea
  • Headache, indigestion
  • Mild allergic reactions
  • Rarely: interstitial nephritis, pulmonary fibrosis
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43
Q

What are the treatment options for maintaining remission in UC?

A
  • 5ASAs (1st line!)
  • Immunomodulator: Thiopurines (Azathiopurine)
  • Monoclonal Abs
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44
Q

What are the side effects of steroids in UC?

A
  • not for long-term use!!
  • Diabetes
  • Cataracts
  • Osteoporosis
  • Mood disturbance
  • Obesity
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45
Q

What are the side-effects of Azathiopurine?

A
  • Nausea, vomiting, flu-like symptoms
  • Leucopoenia
  • Hepatotoxicity
  • Pancreatitis (check serum amylase if nausea, vomiting)
  • Non-Melanoma skin cancer
  • Lymphoma
  • Requires blood monitoring!!*
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46
Q

What are the side-effects of Monoclonal Abs?

A
  • Psoriasis
  • Infections (TB reactivation)
  • Worsening HF (hypersensitivity reaction)
  • Cancers
  • Demyelination (anti-TNFs -> symptoms similar to MS)
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47
Q

What is the first-line investigation for Proctitis?

A

Rectal swab!

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48
Q

What are the treatment options for inducing remission in Crohn’s?

A
  • Mild-moderate) = oral pred

- Severe = IV hydrocortisone

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49
Q

Why are steroids used in IBD?

A

To induce remission!!!

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50
Q

What are the treatment options for maintaining remission in Crohn’s?

A
  • Immunomodulators*
  • Thiopurine (ie. Azathiopurine) = 1st line
  • Methotrexate - for steroid-dependent pts
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51
Q

When should you operate in IBD?

A
  • Failed medical therapy (ie. IV hydrocortisone in the acute setting)
  • Perforation
  • Massive haemorrhage
  • Toxic dilatation
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52
Q

What drug is never used to induce or maintain remission in Crohn’s?

A

5-ASAs!!! (ie. Sulfasalazine)

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53
Q

What type of surgery is performed in IBD?

A
  • Subtotal Colectomy, rectal preservation + ileostomy

Afterwards…

  • Completion Proctectomy
  • Pouch procedure
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54
Q

What are the Clinical Features of UC?

A
  • Bloody Diarrhoea
  • Abdominal Pain
  • Weight Loss
  • Fatigue
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55
Q

How to tell if a pt. is having an acute severe colitis attack?

A
  • Life-threatening medical emergency!!!*
  • Duration of UC symptoms >10 days
  • Infection
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56
Q

What is the management of Acute Severe Colitis?

A
  • 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
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57
Q

What are the immediate investigations for Acute Severe Colitis?

A
  • Bloods -> markers of inflammation
  • Stool culture -> (rule out infection)
  • Faecal Calprotectin -> >200 = significant
  • Colonoscopy + colon mucosal biopsies
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58
Q

When is Faecal Calprotectin indicated?

A
  • 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
Q

What are the AXR findings for Acute Severe Colitis?

A
  • 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
Q

What is the name of the chart used by clinicians to aid in pt’s stool descriptions?

A

Bristol Stool chart!!

61
Q

What are the histological differences between UC and Crohn’s Disease?

A
  • CD = Granulomas, Transmural inflammation
  • UC = Goblet cell depletion, Limited to Mucosa
  • Crypt Abscesses: UC > CD
62
Q

Which IBD is more likely to form Fistulas?

A

Crohn’s!

63
Q

What are the symptoms of Perianal Crohn’s Disease?

A
  • Perianal pain
  • Pus secretion
  • Unable to sit down
64
Q

How to make diagnosis of Perianal Crohn’s Disease?

A
  • MRI Pelvis
    +
  • EUA!!!
65
Q

What is the treatment of Perianal Crohn’s Disease?

A
  • Oral abx
  • Biologics (anti-TNF)
    immunosuppressant
  • Surgery -> drain abscess + place seton stitch
66
Q

What are the surgical indications for Crohn’s Disease?

A
  • 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
Q

What are the most common functional GI disorders?

A
  • no identifiable pathology*
  • Oseophageal spasm
  • Non-Ulcer Dyspepsia
  • Biliary Dyskinesia
  • IBS
  • Slow-Transit Constipation
  • Drug-Related effects
68
Q

What are the common characteristics of a functional GI disorder?

A
  • 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
Q

What are the causes of Non-Ulcer Dyspepsia?

A
  • Dyspepsia = upper abdominal pain, typically after eating or drinking*
  • Reflux
  • Delayed Gastric emptying
  • IBS
70
Q

What are the clinical features of Non-Ulcer Dyspepsia?

A
  • Epigastric (upper abdominal) pain - often related to hunger, specific foods, time of day
  • Fullness after meals
  • Heartburn - retrosternal pain
  • Tender Epigastrium
71
Q

What is the management of Non-Ulcer Dyspepsia?

A
  • 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
Q

What is the cause of the vomiting if it is straight after food ingestion?

A
  • Psychogenic cause
73
Q

What is the cause of the vomiting if it is 1 hour or more after food ingestion?

A
  • Pyloric obstruction

- Motility disorders: ie. Diabetes, Post-Gastrectomy

74
Q

What is the cause of the vomiting if it is 12 hours after food ingestion?

A
  • Small bowel obstruction
75
Q

What are the functional causes of vomiting?

A
  • Drugs
  • Pregnancy
  • Migraine
  • Cyclical Vomiting syndrome -> onset in childhood, recurrent episodes
  • Alcohol
76
Q

What would you ask in a patient history for Constipation?

A
  • 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
Q

What would you ask in a patient history for Constipation?

A
  • 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
Q

What are the red flag symptoms for Constipation?

A
  • 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
Q

What investigations would you do for constipation?

A
  • 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
Q

What are the organic causes of constipation?

A
  • Strictures
  • Tumours
  • Diverticular disease
  • Proctitis
  • Anal fissure
81
Q

What are the functional causes of constipation?

A
  • Toxic megacolon
  • Idiopathic constipation
  • Depression
  • Psychosis
  • Institutionalised patients
82
Q

What are the systemic causes of constipation?

A
  • Diabetes Mellitus
  • Hypothyroidism
  • Hypercalcaemia
83
Q

What are the Neurogenic causes of constipation?

A
  • 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
Q

What is IBS?

A

A mixed group of abdominal symptoms for which no organic cause can be found

85
Q

What are the clinical features of IBS?

A
  • 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
Q

What is the diagnostic criteria for IBS?

A
  • ROME III

- NICE

87
Q

What is the ROME III diagnostic criteria for IBS diagnosis?

A

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
Q

What is the NICE diagnostic criteria for IBS diagnosis?

A

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
Q

How do you make a diagnosis of IBS?

A
  • Meets diagnostic criteria (ie. NICE or ROME III)
  • Compatible history
  • Normal physical examination
90
Q

When should you think of an alternative diagnosis for IBS?

A
  • If age >60
  • History <6 months
  • Anorexia
  • Weight loss
  • Waking AT NIGHT with pain/diarrhoea
  • Mouth ulcers
  • Abnormal CRP/ESR/Coeliac serology
91
Q

What is the management of IBS?

A
  • 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
Q

What is the Aetiology of IBS?

A
  • 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
Q

How common is CRC?

A
  • 2nd leading cause of cancer death

- 3rd commonest cancer diagnosis overall

94
Q

What is the most common type of CRC?

A
  • Adenocarcinoma

- 2/3 Colon, 2/3 Rectal

95
Q

What diseases are high-risk for CRC?

A
  • HNPCC (most common heritable cause)
  • FAP
  • MAP
  • IBD
96
Q

What is the most common cause of CRC?

A

Sporadic!! (85%)

97
Q

What are the risk factors for CRC?

A
  • 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
Q

What is the most common histological type of Adenomatous Colorectal Polyp?

A

Tubular! (75%)

99
Q

What lesions are high-risk for Adenomatous CRC?

A
  • Size
  • Number
  • Degree of Dysplasia
  • Villous architecture (!!)
  • > shouldn’t be any villi in the colon lol
100
Q

What is the Clinical Presentation of CRC?

Red-flag symptoms!!

A
  • (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
Q

What investigations would you do for CRC?

A
  • 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
Q

What is a FIT Test used for?

A
  • 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
Q

What is the radical treatment of CRC?

A
  • 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
Q

What is the palliative treatment of CRC?

A
  • Dukes D*
  • Chemo
  • Colonic Endoscopic stenting (prevents obstruction)
105
Q

Describe the Scottish Bowel Screening programme

A
  • Aims to detect pre-malignant adenomas/early cancers in the general population
  • FIT test (stool sample)
  • Age 50-74 yrs
  • Every 2 yrs
106
Q

How often is screening colonoscopy done for heritable conditions that are high risk of CRC?

A
  • HNPCC = 2-yrly from 25yrs
  • FAP = annual from 10-12yrs
  • MAP = annual from 18-20yrs
107
Q

How often is screening colonoscopy done for IBD?

A
  • 10yrs post diagnosis

- Then dependent on how bad disease is (ie. duration, extent and activity of inflammation and presence of dyplasia)

108
Q

How often is screening colonoscopy done in a pt. with a FH of CRC?

A
  • High-Moderate risk = 5yrly from age 50

- Low-Moderate risk = once only at age 55

109
Q

How often is screening colonoscopy done if pt. has had previous adenomas/CRC?

A
  • Previous CRC = 5yrly colonoscopy

- Previous Adenomas = dependent on no. of polyps, size and degree of dysplasia

110
Q

What is the genetic basis of FAP?

A
  • Heritable condition
  • Autosomal dominant
  • Mutation of APC gene on chromosome 5
111
Q

What are people with FAP offered at aged 16-25yrs?

A
  • a Prophylactic Proctocolectomy!
112
Q

What conditions is FAP associated with?

A

Extracolonic manifestations:

  • Benign gastric fundic cystic hyperplastic polyps
  • Duodenal adenomas
  • Desmoid tumours
  • CHRPE (Congenital Retinal Hypertrophy of the Pigment Epithelia)
113
Q

What is the genetic basis of MAP?

A
  • mutation of MUYTH base excision repair gene
114
Q

What conditions is MAP associated with?

A
  • Duodenal Adenomas
115
Q

What is the genetic basis of HNPCC?

A
  • mutation in DNA mismatch repair (MMR) genes (ie. MLH1, MLH2)
  • tumours typically have MSI (microsatellite instability)
116
Q

What are haemorrhoids?

A

Disrupted and dilated anal cushions

117
Q

What is the most common cause of haemorrhoids?

A

Constipation with prolonged straining

118
Q

What are the symptoms of Haemorrhoids?

A
  • Bright red rectal bleeding
    -> often coating stools, on the tissue, or dripping
    into the pan after defecation.
  • Painless
  • Straining
119
Q

What is the treatment of Haemorrhoids?

A

1 - Treat underlying cause: Constipation (increased fluid + fibre) +/- topical analgesics + stool softeners

2 - Rubber Band Ligation

3 - Surgical: HALO, Anopexy, Haemorrhoidectomy

120
Q

What are Anal Fissures/Fissure-in-Ano?

A
  • Painful tear in the squamous lining of the lower Anal canal
121
Q

What is the identifying feature of Anal Fissures/Fissure-in-Ano?

A
  • “Sentinel” mucosal skin tag in external aspect
122
Q

What are the most common causes of Anal Fissures/Fissure-in-Ano?

A
  • Most due to hard faeces

- Rarely: syphilis, herpes, Crohn’s, anal cancer, psoriasis

123
Q

What are the symptoms of Anal Fissures/Fissure-in-Ano?

A
  • 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
Q

What is the treatment of Anal Fissures/Fissure-in-Ano?

A

1 - Treat underlying cause - Constipation (stool softeners, laxatives), medical: GTN/Diltiazem + lignocaine (for pain)

2 - Surgical: Botox, Sphincterotomy

125
Q

What are the most common causes of Peri-Anal Abscesses?

A
  • Idiopathic
  • Infection by gut organisms
  • Clogged glands
  • STD
  • Trauma
126
Q

What are the risk factors for Peri-Anal Abscess?

A
  • DM
  • BMI
  • Immunosuppression
  • Trauma
127
Q

What are the signs of a Peri-anal Abscess?

A
  • Excruciating pain

- Signs of Sepsis

128
Q

What is the treatment of Peri-anal abscess?

A
  • Abx if Septic

- Incision + drainage (under GA)

129
Q

What are the most common causes of Fistula in Ano?

A
  • Peri-anal Sepsis
  • Peri-anal Abscess (!!) → 10-20% of pts
  • Crohn’s Disease
  • TB
  • Immunocompromised
130
Q

What are the symptoms of Fistula in Ano?

A
  • Peri-anal sepsis
  • Persistent pus discharge with flare up
  • +/- faecal soiling
131
Q

What is the treatment of Fistula in Ano?

A

Surgical

Fistulotomy and excision, then…

  • Seton suture: high fistular
    or
  • Lay open: low fistulae
132
Q

What are the most common causes of Anal/Rectal Cancer?

A
  • Anoreceptive intercourse
  • HPV
  • HIV
133
Q

What are the clinical features of Anal/Rectal Cancer?

A
  • Painful/painless
  • Bleeding
  • Indurated
  • Red flag signs
  • FIT test +ve
134
Q

What are the most common causes of Chronic Constipation?

A
  • 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
Q

What are the investigations of Chronic Constipation?

A
  • 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
Q

What is the treatment of Chronic constipation?

A
  • 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
Q

What are the most common causes of Faecal incontinence?

A
  • increasing incidence with increasing age*
  • Passive: internal sphincter defect
  • Urge: Rectal pathology, functional
  • Mixed: Prolapse
  • Overflow: Chronic constipation
138
Q

How to diagnose Faecal incontinence?

A
  • Detailed history to determine urge/ passive/ overflow, obstetric/surgery history, ?trauma/abuse
  • Clinical examination - DRE
  • Anorectal physiology
  • Endoanal USS
  • Defecatory Proctogram
139
Q

What is the management of Faecal Incontinence?

A
  • 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
Q

What is Anal Manometry used for?

A
  • 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)
141
Q

What is a Rectocele? Why is it an issue?

A
  • 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
142
Q

What is Internal Rectal Prolapse? What are its symptoms?

A
  • 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
143
Q

What is the management of Rectocele and Internal Rectal Prolapse?

A
  • Improve rectal evacuation using different techniques
  • Biofeedback
  • Enemas/Loperamide (anti-motility med -> to treat diarrhoea)
  • Surgical intervention
144
Q

What is the treatment of choice Rectal Prolapse?

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