Structural Lower GI Flashcards
What is diverticulosis?
The presence of diverticula
What is diverticular disease?
Diverticular which are symptomatic
What is diverticulitis?
Inflammation of a diverticulum
Why does a low fibre diet lead to diverticular disease?
The colon works harder to move faeces.
This increases the pressure in the lumen
Diverticula form as the mucosa herniates through the muscle layer to form an outpouching
Where are diverticula most common?
Sigmoid colon
Who tend to present with diverticular disease?
Those with a western lifestyle - processed foods with low fibre diet
Older patients
What are the signs and symptoms of diverticular disease?
Change to normal bowel habit
Left iliac fossa colic
What are the signs and symptoms of diverticulitis?
Severe pain in LIF
Fever
Tachycardia
Tenderness and guarding of the left side of the abdomen on examination
What investigations can discover diverticula?
Colonoscopy or sigmoidoscopy
Barium enema
What investigations can help diagnose diverticulosis?
Increased ESR/CRP
CT is investigation of choice
What are the complications of diverticular disease?
Perforation
Haemorrhage
Fistula
Stricture
What can a perforation of a diverticulum cause?
Peritonitis
Abscess
What is the classification system for acute diverticulitis?
Hinchey classification
What are the four stages of the Hinchey classification of acute diverticulitis?
- Pericolic abscess
- Pelvic abscess
- Purulent peritonitis
- Faecal peritonitis
What is the treatment of diverticular disease?
Balanced diet with enough fibre
Analgesia and possibly bulking laxative for symptoms
What is done for uncomplicated diverticulitis?
Watchful waiting
Analgesia if necessary
Antibiotics if suspected infection
IV fluids, IV antibiotics, bowel rest
What is done for complicated diverticulitis?
Percutaneous drainage of large abscess
Laparoscopic peritoneal lavage and drainage
Hartmann’s procedure
Primary resection
What is Hartmann’s procedure?
Remove the sigmoid colon and use a colostomy
What are the types of colonic polyps?
Adenoma
Serrated
Inflammatory
Hamartomatous
What are the most common colonic polyps?
Adenomas
When do inflammatory polyps occur?
IBD
When fo hamartomatous polyps occur?
Peutz-Jeghers syndrome
Which mutation causes familial adenomatous polyposis?
Mutation in the APC tumour suppressor gene
What is the % risk of colon cancer for patients with FAP?
Almost 100%
Describe the polyps Lynch syndrome causes?
Adenomas
Right-sided
Not always colonic, can be gastric, endometrial
Which mutation causes Lynch syndrome?
DNA mismatch
What are the characteristics of Peutz-Jeghers syndrome?
Hyperpigmentation
Hamartomatous polyps
What are the risk factors for colonic polyps?
Patients with inherited conditions
IBD
Smoking and alcohol
Older age
What are the symptoms of colonic polyps?
Usually asymptomatic
Rectal bleeding causing anaemia
Mucus in stool
Diarrhoea and constipation
What investigations can help diagnose colonic polyps?
Family history
Genetic testing
Colonoscopy
Biopsy
Which patients with colonic polyps are at risk of colonic cancer?
FAP
Lynch syndrome
People who have had adenomatous polyps removed before
People who have had IBD for 10+ years
What treatment is done for colonic polyps?
Screening
Adenomas are removed
FAP required prophylactic surgery in addition to screening
What is a hernia?
Protrusion of an organ or tissue out of the body cavity it is supposed to be in
What are the causes of hernias?
Structural weakness and increased pressure
What can cause structural weakness leading to hernia?
Normal anatomical weakness
Congenital abnormality resulting in a weakness
Surgical scar
What can cause increased pressure leading to hernia?
Strenuous activity
Chronic cough
Pregnancy
Straining bowel movements or urination
What is a reducible hernia?
One that can be pushed back into the abdomen
What is an irreducible hernia?
One that cannot be pushed back into the abdomen
What is an incarcerated hernia?
One where the contents of the hernia are stuck inside it by adhesions and can’t be reduced
What is an obstructed hernia?
Hernia causes bowel obstruction and bowel contents are unable to pass
Blood supply is still viable
Can progress to strangulation
What is a strangulated hernia?
Vascular supply to the contents of the hernia is compromised, ischaemia occurs and surgery is needed
What are the signs and symptoms of hernias?
Swelling an a particular location
May be reducible
May protrude on coughing or standing
Pain and tenderness at the site of the hernia in strangulation
What investigations are done for hernias?
Examination of the swelling
Ultrasound scan sometimes
What are the possible complications of hernias?
Hernia becomes irreducible
Incarceration
Strangulation
Obstruction
What are the types of hernia?
Hiatus Epigastric Umbilical Paraumbilical Spigelian Inguinal Femoral Parastomal Lumbar Incisional
What is an inguinal hernia?
Part of the abdominal contents protrudes through the inguinal canal
What is a direct inguinal hernia?
The bowel herniates through a weakness in the floor of the inguinal canal and through Hasselback’s triangle to come out of the superficial ring
Reappears after reduction
What is an indirect inguinal hernia?
Bowel herniates though the deep inguinal ring and out the superficial ring
Doesn’t reappear after reduction
What is a hiatus hernia?
The herniation of the stomach through the diaphragm
How does a hiatus hernia present?
Reflux die to reduced efficiency of the LOS which can lead to GORD
What is the treatment for hernia?
Conservative or surgical dependent on type and presence of complications
What is the treatment for hiatus hernia?
Conservative (lose weight, treat GORD) or surgical if symptoms persist
What is a sliding hiatus hernia?
Gastro-oesophageal junction and part of the stomach slides up into the chest
What is a para-oesophageal hernia?
Part of the stomach herniates up into the chest alongside the oesophagus
What is an epigastric hernia?
Bowel herniates though a fascial defect in the lineament alba in the epigastric region of the abdomen
Usually symptomatic but can be painful
What is a spigelian hernia?
Bowel herniates though the spigelian fascia
Looks like a lump below and lateral to the umbilicus
What is a femoral hernia?
Bowel herniates though the femoral canal
Looks like a lump in the upper medial thigh that points down towards the leg
Which hernias always require surgical treatment?
Spigelian Femoral Lumbar Incisional Para-stomal Para-umbilical
What is a lumbar hernia?
Bowel herniates through the lumbar triangles
Looks like a lump in the back
What is an incisional hernia?
Hernia post-surgery
Looks like a pump along the line of previous incision
What is a para-stomal hernia?
Hernia through the abdominal wall defect created when a stoma is formed
What is a para-umbilical hernia?
Bowel herniates through an acquired weakness of the abdominal wall around the umbilicus
Looks like a lump at/near the umbilicus
Often painful
What are the risk factors for para-umbilical hernia?
Obesity
Ascites
Multiple pregnancies
What is an umbilical hernia?
Bowel herniates due to congenital weakness from the persistence of an abdominal wall defect at the site of the umbilicus
Looks like a lump at the umbilicus
Usually resolve but may need treated
Which hernia requires surgery because of the high incidence of incarceration and strangulation?
Para-umbilical
Which inguinal hernia passes through the deep ring and which through the superficial ring?
Indirect hernias pass through the deep ring and the superficial ring
Direct hernias pass through Hasslebach’s triangle instead of the deep ring and pass through the superficial ring
What are the types of inguinal hernia’s relationships to the inferior epigastric artery?
Direct - medial
Indirect - lateral
What are the types of inguinal hernia’s relationships to the spermatic cord?
Direct - parallel
Indirect - within
What is a haemorrhoid?
Enlargement of vascular cushions (rectal venous plexuses) in the wall of the anus and rectum due to increased pressure
What are the signs and symptoms of haemorrhoids?
Painless bright red bleeding PR
Perianal itch
No change in bowel habit or weight
What investigations are done for haemorrhoids?
PR exam
Proctoscopy
Rigid sigmoidoscopy
Flexible sigmoidoscopy to rule out malignancy
What is the possible complication of haemorrhoids?
Can become strangulated and cause pain
What is the conservative therapy for haemorrhoids?
Increased fluid and fibre to prevent constipation, with bulking laxatives and analgesia if necessary
Anal hygiene to aid healing
What are the non-surgical therapy for haemorrhoids?
Sclerosation therapy
Rubber band ligation
What are the surgical therapies for haemorrhoids?
Haemorrhoidectomy
Stapled haemorrhoidectomy
HALO/THD procedure to cut off blood supply
What are rectal varies due to?
Portal hypertension
What do rectal varies present with?
PR bleeding
