Small Bowel and Colon Flashcards
define Crohn’s disease
chronic inflammatory condition of anywhere in the GI tract, associated with NOD2 and TH1. Patchy, segmental disease with non-caveating granuloma formation. fistulas and strictures can lead to small bacterial overgrowth which causes malabsorption
diagnosis of small bowel bacterial overgrowth
schilling test- B12
14C breath test
presentation of Crohn’s
- oral lesions
- cobble-stoning mucosa (deep fissuring ulceration)
- abdominal pain
- diarrhoea
- perianal disease
diagnosis of Crohn’s
bloods (anaemia, raised CRP) stool sample (faecal calciprotectin to distinguish from IBS) colonoscopy shows cobble-stoning mucosa with punched out lesions
management of Crohn’s
smoking cessation
steroids e.g. prednisolone or budesonide
immunosuppressants e.g. azathioprine or methotrexate
anti-TNF e.g. infliximab or adalimumab
- surgery: resections can lead to short gut syndrome
define UC
chronic inflammatory condition confined to the colon and rectum, associated with NOD2 and TH1 and TH2
what does UC increase the risk of?
colorectal carcinoma
presentation of UC
- PR bleeding
- diarrhoea
- tenesmus
- extra GI manifestations e.g. uveitis, PSC, arthritis
diagnosis of UC
- Truelove and Witt criteria
- bloods
- AXR (toxic megacolon)
- colonoscopy with biopsy
management of UC
- surveillance for colorectal carcinoma
- nutrition
- 5ASA e.g. mesalazine or sulphasalazine
- steroids e.g. prednisolone or budesonide
- immunosuppressants e.g. azathioprine or methotrexate
- anti-TNF
- surgery
define IBS
altered bowel habit for a period of greater than 6 months
presentation of IBS
- absence of red flag symptoms
- abdominal pain, bloating, diarrhoea, constipation (Bristol stool chart)
diagnosis of IBS
- Rome II diagnostic criteria (3 per month)
- normal bloods
- rule out other
management of IBS
- lifestyle: diet, stress, FODMAP, exercise
- anti-spasmodics, laxatives and antidiarrhoeals
define coeliacs disease
autoimmune disease caused by an abnormal reaction to gluten (gliadin) with strong association with HLA-DQ2 and HLA-DQ8 which causes enterocyte loss
presentation of coeliacs
- abdominal pain, bloating, diarrhoea
- weight loss
- anaemia, vitamin deficient
- dermatitis herpetiformis (vesicular rash)
diagnosis of coeliacs
IgA anti-tissue transglutaminase test (tTGA)
management of coeliacs
gluten-free diet to reverse villus atrophy
define lactose intolerance
this is a deficiency in the enzyme lactase leading to an inability to digest lactose correctly
presentation of lactose intolerance
abdominal pain, bloating, diarrhoea
diagnosis of lactose intolerance
hydrogen breath test
oral lactose tolerance test
management of lactose intolerance
lactose free diet
define intestinal failure
this is an inability of the intestines to maintain adequate nutrition and fluid status
presentation of intestinal failure
lack of energy
anaemia
vitamin deficiencies (glossitis for folate, B12 and iron)
management of intestinal failure
- nutrition
- PPIs
- octreotide (palliation)
- transplant for type 3
three types of small bowel cancer
- lymphomas (non-hodgkins T cells) and maltomas (B cells)
- carcinoid tumour (yellow, slow-growing, hormones)
- carcinomas (coeliacs and UC)
define Meckel’s diverticulum
this is a small bulge in the small intestine due to incomplete regression of the vietello-intestinal duct
presentation of Meckel’s diverticulum
- before 2 years
- mimics appendicitis
diagnosis of Meckel’s diverticulum
colonoscopy
CT
management of Meckel’s diverticulum
resection
define appendicitis
inflammation of the appendix
presentation of an appendicitis
- central pain that migrates to RIF (McBurnery’s point- worse on coughing)
- nausea and vomiting
- children won’t eat or sleep
diagnosis of appendicitis
USS in women and children
bloods (increased WCC)
Alvarado score
CT
management of appendicitis
appendicectomy
how are carcinoids of the appendix diagnosed?
chromagrannin stain
define ischaemia of the small bowel
lack of blood supply to the small bowel which leads to infarction. It can be occlusive or non-occlusive (damage on reperfusion)
presentation of ischaemia of the small bowel
sudden abdominal pain
bowel movements
abdominal tenderness and distension
diagnosis of ischaemia of the small bowel
angiography
define a hernia
abnormal protrusion of the cavity’s contents through a weakness in the wall of the cavity, can be reducible, incarcerate or strangulated
presentation of hernia
lump
sudden onset pain
vomiting
presentation of a small bowel obstruction
colicky pain
absolute constipation
vomiting with copious bile-stained fluid
distension
diagnosis of a small bowel obstruction
tinkling bowel sounds
AXR
CT contrast
gastrograffin studies
management of a small bowel obstruction
- NG tube
fluids
define peritonitis
infection of ascites
who can peritonitis be fatal in?
elderly
immunosuppressed
diabetics
those without an momentum (previous surgery)
presentation of peritonitis
foetal position, shallow respiration
guarding
diagnosis of peritonitis
FBC
ascites fluid aspiration
management of perionitis
amoxicillin + gentamicin + metronidazole
define mesenteric ischaemia
lack of blood supply to the mesentery causing infarction
presentation of mesenteric ischaemia
pain out of proportion with examination
diagnosis of mesenteric ischaemia
acidotic ABGs
elevated lactase
CT
angiography
management of mesenteric ischaemia
thrombolytics
resuscitation
endovascular repair (stenting)
define diverticular disease
Mucosal herniation through the wall of the colon forms diverticulosis and when they become infected it is diverticulitis. Often presents in the sigmoid colon due to a low fibre diet.
presentation of diverticular disease
LIF pain/tenderness
altered bowel habit
diagnosis of diverticular disease
bloods
sigmoidoscopy
Hinchey classification
management of diverticular disease
- antibiotics
- if complicated Hartmann procedure (rectosigmoid colon removed and left with colostomy)
- diet modification
define colitis
inflammation of the inner lining of the colon
different types of colitis
Crohns
UC
ischaemic
infective
diagnosis of ischaemic colitis
thumb printing on AXR at the splenic flexure
define colonic angiodysplasia
vascular malformations in the colon
presentation of colonic angiodysplasia
submucosal lakes of blood, PR bleeding
diagnosis of colonic angiodysplasia
angiography
colonscopy
management of colonic angiodysplasia
embolisation
endoscopic ablation
surgical resection
presentation of a large bowel obstruction
- symptoms develop gradually because of the large capacity of the colon
- the more proximal the obstruction the earlier the vomiting develops (faeculent)
- colicky pain with distension
- absolute constipation
what does tenderness of an obstruction indicate?
strangulation
what does an incomplete bowel obstruction cause?
hypertrophy of the bowel wall
causes of dynamic bowel obstruction
paralytic ileus
pseudo-obstruction (Oglivie’s syndrome)
define pseudo-obstruction
no mechanical obstruction (elderly and debilitated)
diagnosis of large bowel obstruction
- supine AXR
- tinkling bowel sounds
management of large bowel obstruction
- replace fluids and electrolytes
- NG tube to decompress stomach
- stenting and surgery
define volvulus
the intestine and mesentery twists resulting in an obstruction
presentation of volvulus
fever
tenderness
constipation
vomiting
diagnosis of volvulus
AXR and rectal contrast
- coffee-bean = sigmoid volvulus
- haustra maintained= caecal volvulus
management of volvulus
surgery resection (Ladd procedure) flatus tube
two functional bowel disorders
- constipation
- faecal impaction
presents with malaise from prolonged distension
management of functional bowel disorders
laxatives
enemas
manual evacuation
management of diarrhoea
anti-infectives
antidiarrhoeals
rehydration
replace potassium lost
classification of colorectal carcinoma
- polyps
- adenomas (pre-malignant)
- adenocarcinomas
two hereditary colorectal carcinomas
- HNPCC/Lynch syndrome
2. FAP
describe Lynch syndrome
this is less polyps than FAP, AD, right sided, mucinous tumours with Crohn’s-like inflammatory response
describe FAP
more than 100 polyps, AD, left sided, defect in tumour suppressor and no inflammatory response
right-sided tumour presentation
anaemia persistent tiredness change in bowel habit weight loss colicky pain lump
left-sided tumour presentation
PR bleeding
altered bowel habit
tenesmus
constipation
diagnosis of colorectal carcinoma
bowel screening (faecal antigen test) CEA tumour marker SOPD, endoscopy, sigmoidoscopy or CT colongraphy
bowel prep for?
CT colonography with picolax and omnipaque
management of colorectal carcinoma
palliation e.g. stenting with chemo/radio
surgery e.g. right hemicolectomy
what should be screened for before using infliximab?
TB
UC inducing remission mild/ moderate
aminosalicylates
corticosteroids (pred)
UC inducing remission severe
IV corticosteroids (hydrocortisone) IV ciclosporin
UC maintaining remission
- aminosalicylate
- azathioprine
- mercaptopurine
which laxative to avoid in IBS?
lactulose as causes bloating
what needs to be tested for in Coeliac’s?
IgA deficiency
T1DM
what is mesenteric adenitis?
inflamed abdominal lymph nodes
presentation of mesenteric adenitis
abdominal pain
what is mesenteric adenitis associated with?
tonsilitis
URTI
causes of small bowel obstruction
intussusception adhesions incarcerated hernia Meckel's diverticulum strictures tumours gall stone ileus foreign body congenital atresia
how does gallstone ileus come about?
fistula causes stone to get through and cause an obstruction
what is a paralytic ileus?
temporary impairment of peristalsis in the absence of mechanical obstruction
what is mesenteric ischaemia?
lack of blood supply to the mesentery through mesenteric vessels resulting in intestinal ischaemia and can lead to infarction
vessels involved usually in mesenteric ischaemia
SMV
SMA
non-occlusive
key RF for mesenteric ischaemia
AF
what is chronic mesenteric ischaemia?
intestinal angina - low flow states due to atherosclerosis
chronic mesenteric ischaemia triad
- central colicky abdominal pain after eating
- weight loss due to food avoidance
- abdominal bruit
why are diverticula not in the rectum?
it only has longitudinal muscle and these are circular muscle
diagnosis of mesenteric ischaemia
CT angiography or MR angiography
management of mesenteric ischaemia
angioplasty stent insertion statins antiplatelets RF reduction
causes of large bowel obstruction
cancer stricture volvulus adhesions hernia bolus obstruction faecal impaction Hirschsprung's meconium ileus rectal atresia intussusception
what does an incomplete obstruction cause?
hypertrophy of the bowel wall
special reasons for a stool culture in diarrhoea
food poisoning outbreak travel recent antibiotic use rectal intercourse immunocompromised raw seafood
presentation of steatorrhoea
shiny
malodourous
hard to flush
stain for fat in poo
sudan stain
what is Hirschsprung’s?
explosive passage of stool following PR exam due to nerves in the colon not forming properly
needs biopsy
