UGI/CR - Colon part 2 Flashcards
Def Diverticulosis
Presence of diverticula
Def Diverticulitis
Inflammation of the diverticula
Def Diverticular disease
Symptomatic diverticula
What % people over 50 have diverticula
50%
Which part of the bowel are 95% diverticula
sigmoid
Most common cause diverticula
low fibre diet
3 rarer conditions diverticula are associated with
Marfans
PKD
Ehlers Danlos
Pathogenesis diverticula
hypertrophy of mm propria
Diverticula occur at sites of potential weakness in bowel wall
What is a ‘true’ diverticulum
Just mucosa
No muscle covering
Def diverticula
Outpouching of mucosa and submucosa that herniate through to colonic mm layers
What % of diverticulae are asymp
95%
If diverticulae are symptomatic, what do they mimic
Colon cancer
Complications of diverticulae (6)
Bleeding Perforation Ulceration Abscess Fistulae Strictures
Sx of diverticular disease (5)
Sudden painelss bleeding Nausea Flatulence Changes in bowel habit Left sided colic relieved by defacation
Sx diverticulitis (6)
LIF pain Localised peritonism Fever TachyC Nausea + vomiting Sometimes palpable mass
RF Diverticular disease (4)
Low fibre diet
High fat diet
Age
Constipation
Ix diverticular disease (4)
PR
Sigmoidoscopy/colonoscopy
Barium enema
CT
When should you be wary of doing a sigmoidoscopy diverticular disease
If bowel is inflamed
Due to risk of perforation
Mx diverticular disease
Mebeverine
+ laxatives + lifestyle advice
Why does diverticulitis occur?
Because of stagnation of contents of diverticula
Mx of mild diverticulitis (3)
Bowel rest @ home
PO Co-amoxiclav +/- metronidazole
Mx of severe attack diverticulitis (4)
Admit if pain not controlled Analgesia IV fl IV cefuroxine + metronidazole Keep NBM
Ix severe attack diverticulitis (3)
CXR
AXR
+ CT contrast
(to assess for complications)
What must you NOT do in an acute diverticulitis attack
Scope
Complications of diverticulae (6)
Perforation Bleeding Stricture Abscess Fistulae Intestinal obstruction
What can perforation lead to in acute diverticulitis (3)
Paracolic/pelvic abscess
Fistulae
Generalised peritonitis
PS perforation from diverticulitis (3)
Ileus
Peritonitis
Shock
Mortality rate perforation from diverticulitis
40%
Mx perforation from diverticulitis
Laparotomy +/- Hartmanns procedure
PS - abscess from diverticulitis (3)
Swinging fever
Leucocytosis
Localised booggy rectal mass
PS - bleed from diverticulitis
Sudden painless bleeding
Mx bleed from divertilculitis
Stop w/ bed rest
If doesn’t stop - locate w/ angiography + Tx w/ embolisation
+/- adrenaline + diathermy
2 types of fistulae from diverticulitis
Colovesical
Colovaginal
PS colovesical fistula
UTI + pneumaturia
PS colovaginal fistulae
Foul discharge
Where can obstruction occur as a result of repeated eps of diverticulitis
Sigmoid colon
Signs + Sx of malabsorption (8)
Diarrhoea/steatorrhoea W loss Lethargy Anaemia Bleeding disorders Oedema Osteomalacia Neuropathy
3 most common causes of malabsorption (Cs)
Coeliac
Crohn’s
Chronic pancreatitis
Rarer causes of malabsorption (3)
Reduced bile
Pancreatic insufficiency
Bacterial overgrowth
Ix Malabsoprtion - bloods (12)
FBC Fe studies B12/folate Ca Mg PO4 Lipid profile LFT TFT inflammatory markers Clotting Coeliac serology
Ix Malabsoprtion - stool studies (3)
MCS
Faecal elastase
Calprotectin
Pathology coeliac disease
inflammation of jejunum
Alpha gilandin = modified by TTG which activates autoimmune reaction against the mucosa
Biopsy findings coeliac (3)
Flattened mucosa b/c loss of villi
Hyperplasia of crypts
increased intraepithilial lymphocytes
PS coeiliac (10)
1/3 = asymp Non specific IDA, W loss Fatigue Apthous ulcers Diarrhoea Abdopain/bloating N+V Dermatitis heraptiformis
Ix coeliac (7)
FBC Clotting Bone profile EMA TTG antibodies Duodenal biopsy Done densitometry
What is gold standard Ix coeliac
Duodenal biopsy
WHy do bone densitometry coeliac Ix
B/c of increased risk OP
Which cancers are people w/ coeliac at a small increased risk of ? (2)
Small bowel lymphoma
Adenocarcinoma
Most common cause Chronic pancreatitis
Increased alcohol intake
Pathology chronic pancreatitis
Plugging pancreatic ducts –> space for infection/calcification –> ductal HTN –> fibrosis parenchyma + disturbed endocrine fct
PS chronic pancreatitis (8)
Epigastric pain radiating to back Relieved by sitting forward/hot water bottle W loss Bloating Steatorrhoea Brittle DM Obstructive jaundice Sx = relapsing + progressively worse
Ix chronic pancreatitis (5)
Faecal elastase elevated Trypsinogen > 10 = diagnostic Signs alcohol abuse TA USS Contrast CT/MRCP = diagnostic
What is seen on CT/MRCP chronic pancreatitis
Calcification
Mx chronic pancreatitis (5)
Analgesia Creon (lipase) Mutlivite (fat soluble vitamins) Monitor glucose Tx alcohol abuse Low fat diet
What is melaena due to?
Break down of blood in small intestine for an UGI bleed
What % of pt w/ CRC PS w/ mets on diagnosis
20%
RF CRC (10)
FHx Age Western diet Obesity Physical inactivity UC DM Smoking Alcohol XS Personal Hx bowel cancer
Protective factors CRC (4)
Healthy diet
Exercise
HRT
Aspirin/NSAIDs
What % of CRC is caused by FAP
Familial adenomatous polyposis
<1%
Genes assoc w/ CRC (3)
FAP
HNPCC
BRCA1
Histology CRC
Signet ring cells
What part of the colon has the highest prevalence for CRC
25% sigmoid
How many polyps in colon = likely to be malignant
> 5
Appearance of CRC on colonoscopy
Polypoid mass w/ ulceration
Spread CRC
Direct infiltration through bowel wall
Lymphatics/BV
mets of CRC (6)
Liver ** Lung Bone Brain LN Ovaries
Staging for CRC
Dukes
Dukes A
Tumours invade submucosa +/- mm propria
Dukes B
Tumours invade past mm propria (no nodal involvement )
Dukes C
Regional LN involvement (C1 - local)
C2 = apical
Dukes D
Distant mets
What type of cancer are the majority of anal cancers
SCC
RF anal cancer (4)
Anoreceptive sex
Syphillis
Anal warts/HPV
Immunosuppression
Which line is v important in anal cance r
Pectinate line
Pectinate line (dentate)
Embryological division between upper 2/3 and lower 1/3 of anal canal
Features of anal cancers above pectinate line
Columnar epithelium
Lymph drainage to int iliac nodes + portal venous drainage
Mets anal ca above pectinate line
Hepatic mets
Features of anal ca below pectinate line
Squamous epithelium
Lymph drainage to superficial inguinal nodes
+ Caval vv drainage
Mets anal ca below pectinate line
Pulmonary mets
Who are anal ca above pectinate line more common in
F (+ worse prog)
Who are anal ca below pectinate line > common in
M ( + better prog)
Sx R sided CRC
Often asymp
W loss
Lethargy/malaise/non-specfiic
Why do R sided CRC PS late
Because of large width of R colon
Ix results R sided CRc (3)
IDA
Low Hb
+ Low MCV
Sx L sided CRC (3)
Obstruction Sx
Changed in bowel habit
Blood streaked stools
Sx Caecal CRC (5)
Anaemia Obstruction --> faecalant vom Mass Dyspepsia Appendicitis
Sx Rectal CRC (5)
Bright red PR bleed Tenesmus Dull pain May be able to feel mass on PR Bladder Sx
Sx Anal cancer (5)
Bleeding Pain Changes to bowel habit Pruritis ani Mass Stricture
Indications for 2WW Rx pt >40 CRC (4)
Rectal bleed/change bowel habit for >6w
Persisitet rectal bleed >45 w/ no obvious ev benign anal disease
IDA w/o obvious cause
Palpable abdo/PR mass
Ix CRC (6)
FBC/LFT Colonoscopy CT chest abdo pelvis (stage) EAU + pelvic MRI - rectal CA ONLY CEA - monitor disease FTT test
What FTT test result is normal
<10
indication - right hemicolectomy (3)
Caecal tumours
Ascending colon tumours
proximal transverse colon tumours
indication - left hemicolectomy
Distal transverse/descending colon tumours
indications - sigmoid colectomy
Sigmoid tumours
indications - anterior resection (2)
Low sigmoid tumours
High rectal tumours
indication - AP resection
Tumours low in rectum
Indication - Hartmanns procedure (2)
Bowel obstruction
Palliation
Use of radiotherapy in rectal cancer
Pre-op to shrink tumour
When to use radiotherapy post op (CRC)
If high risk local recurrence
When is chemotherapy used in CRC
To reduce mortality of high stage tumours/palliation
Tx of anal carcinoma (3)
Radiotherapy
5FU
Cisplatin chemo
What % of pt post anal carcinoma Tx retain normal anal fct
75%
