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CP1 > Upper GI & Colorectal > Flashcards

Upper GI & Colorectal Flashcards

1
Q

Anatomical & physiological factors predisposing to GORD

A

Anatomical: hiatus hernia
Physiological: raised intra-abdominal pressure
Large meals late at night
Smoking
High caffeinated drink intake
High fatty food intake
Drugs (anticholinergics, nitrates, tricyclics, calcium channel inhibitors)

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2
Q

Define the anatomical location of the oesophageal hiatus and what passes through it

A

Oval apeture in the right crus of the diaphragm at T10

Contents: oesophagus, vagal nerve trunks, oesophageal branches of left gastric vessels, lymphatics

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3
Q

Types of hiatus hernia

A

Sliding: gastroesophageal junction slides through the hiatus to lie above the diaphragm
30% adults >50, usually asymptomatic, may be associated reflux
Para-oesophageal/rolling: small part of the fundus rolls up through the hernia alongside the oesophagus, but the sphincter remains competent below the diaphragm
Occasionally severe pain, requiring surgical intervention for gastric volvulus/strangulation

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4
Q

Dyspepsia definition and types

A

Chronic upper abdominal pain/discomfort
Reflux-type: heartburn & regurgitation (GORD)
Ulcer type: epigastric pain
Dysmotility type: bloating and nausea

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5
Q

GORD symptoms

A

Dyspepsia: exacerbated by bending over/lying down, when drinking hot liquids or alcohol, relieved by antacids
Regurgitation of food/acid: passive (not vomiting), more common when bending/lying
Waterbrash: sudden filling of the mouth with dilute saliva
Odynophagia: painful swallowing
Atypical chest pain due to distal oesophageal muscle spasm
Nocturnal cough/wheeze (asthma-like)

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6
Q

Upper GI symptoms that would indicate need for an endoscopy

A 
ALARMS 55
Anaemia: Fe deficient
Loss of weight
Anorexia
Recent onset, progressive symptoms
Melaena/haematemeis
Swallowing difficulties
>55yo
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7
Q

Upper GI investigations

A

Endoscopy
Barium swallow
24h luminal pH monitoring and manometry: measures competent of sphincter - diagnose GORD if normal endoscopy

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8
Q

GORD long-term complications

A

Oesophagitis/ulcers
Benign strictures
Barratt’s oesophagus / oesophageal carcinoma

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9
Q

Barratt’s oeosphagus pathophysiology

A

Affects 2% adults in the UK
Long-standing reflux: normal stratified squamous epithelium undergoes metaplasia –> glandular columnar epithelium
Continued inflammation: dysplasia & malignant change (adenocarcinoma of the lower 1/3 of the oesophagus)

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10
Q

Barratt’s oesophagus presentation & investigations

A

Symptom’s of GORD

Diagnosis: upper GI endoscopy + biopsy to confirm

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11
Q

Causes of dysphagia

A

Diseases of the mouth/tongue: tonsillitis
Neuromuscular disorders: myasthenia gravis, motor neurone disease, bulbar palsy
Oesophageal motility disorders: achalasia, scleroderma, DM
Extrinsic pressure: goitre, lymph nodes, enlarged left atrium
Intrinsic lesion: foreign body, benign/malignant stricture, pharyngeal pouch, oesophageal web (Plummer-Vinson syndrome)

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12
Q

Types of dysphagia, causes and investigations

A

Oropharyngeal dysphagia: dfficulty initiating swallowing +/- choking/aspiration
Neurological disease
Investigate with neurological examination, videofluoroscopic swallowing assessment

Oesophageal dysphagia: food ‘sticks’ after swallowing +/- regurgitation
Dysmotility, stricture (benign peptic/intrinsic oesophageal malignancy/extrinsic bronchial carcinoma), oesophagitis, candidiasis in asthmatics/immunosuppressed, pharyngeal pouch
Investigate with barium swallow, endoscopy (OGD) and biopsy

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13
Q

Typical achalasia presentation

A

Young, long non-progressive Hx, no loss of weight

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14
Q

Typical upper GI malignancy presentation

A

Short Hx of progressive dysphagia, severe weight loss, elderly

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15
Q

Plummer-Vinson syndrome presentation

A

Triad of: dysphagia, koilonycia, glossitis

Pre-malignant condition due to hyperkeratinisation of the oesophagus causing an oesophageal web

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16
Q

Symptoms suggestive of oesophageal malignancy

A 
>60y
Progressive dysphagia
Weight loss & anorexia
Retrosternal chest pain
Coughing/aspiration
Occasional lymphadenopathy
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17
Q

Adenocarcinoma of the oesophagus pathology

A

Most common oesophageal carcinoma
Arise from areas of metaplasia in the lower 1/3 (Barrett’s oesophagus)
Risk factors = GORD risk factors
Metastasise earlier than SCC via lymphatics: liver, lungs, bones
<10% 5y survival

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18
Q

Squamous cell carcinoma of the oesophagus pathology

A

Heavy smoking & drinking males
Present late: lumen compromised = dysphagia
Regional lymph spread: early & common
More responsive to radiotherapy
<10% 5y survival

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19
Q

Aetiology of peptic ulcer disease

A

Helicobacter Pylori infection (90% of duodenal, 70% of gastric)
NSAIDs (30%)
Zollinger-Ellison syndroms: non-insulin secreting islet cell tumour of pancreas secreting gastrin-like hormone –> excessive acid secretion
Smoking, coffee consumption, hepatic/renal failure

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20
Q

Peptic ulcer disease symptoms

A 
Epigastric pain, related to food intake, relieved by antacids
Duodenal ulcers: pain relieved by eating
Gastric ulcers: pain worstened by eating
Nausea
Weight loss &amp; anorexia
Haematemesis/malaena
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21
Q

Peptic ulcer disease investigations

A

Urgent oesophago-gastro-duodenoscopy (OGD) if fit ALARMS55 criteria: biopsies (histology) & brushing (cytology)
If previous ulcer, assume H. Pylori infection + commence triple therapy
If not ALARMS55 + symptoms persist: H. Pylori investigation

13C Urea breath test: patient ingests 13C labelled urea –> H. Pylori urease enzyme metabolises to 13CO2 –> detected on breath
No antibiotics for 4w, no PPIs for 2w = false -ve
OR gastric biopsy added to urea solution + phenol red –> colour change with H. Pylori present

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22
Q

Differences between gastric and duodenal ulcers

A

Gastric: >55y, lesser curve of stomach, pain worse on eating, relieved by antacids

Duodenal: 4x more common than gastric, 90% <2cm from pylorus
Pain at night before meals, relieved by eating/drinking milk
Alcohol intake = risk factor

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23
Q

H. Pylori mechanism of association to peptic ulcers

A

Produces gastritis, mainly in gastric antrum, activation of inflammatory infiltrate
Increased acid secretion: increased gastrin, decreased somatostatin –> epithelial damage
Abnormal mucus production –> epithelial damage
Atrophic gastritis in body of stomach –> metaplasia (pre-malignant)
Causally associated with duodenal ulcers

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24
Q

Smoking mechanism of association to peptic ulcers

A

Impairs gastric mucosal healing

Nicotine increases acid secretion

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25
NSAID mechanism of association to peptic ulcers
NSAIDs inhibit COX enzymes --> anti inflammatory as COX-2 isoform normally causes inflammatory prostaglandin synthesis Adverse GI effects: inhibition of COX-1 in the stomach (responsible for production of prostaglandins that inhibit acid secretion and protect the mucosa) Co-administration of PPIs or PG analogues (misoprostol) can diminish NSAID negative effects Steroids = similar effect
26
Upper GI bleeding causes
``` Peptic ulceration (40%) Gastroduodenal erosions (15%) Oesophagitis (15%) Mallory-Weiss syndrome (15%): tears at gastroesophageal junction due to violent vomiting Varices (10%) Upper GI malignancy (1%) ```
27
Upper GI bleeding symptoms
Haematemesis Malaena (>50ml): blood altered by bacteria = tarry Haematochezia: unaltered PR blood Abdominal pain Signs of underlying cause/shock Chronic: signs/symptoms of iron deficiency anaemia
28
Risk factors of gastric cancer
H. Pylori infection leading to metaplasia High salt/nitrate (red meat) diet Smoking Genetic: blood group A/HPNCC (hereditary nonpolyposis colorectal cancer), Japanese heritage Pernicious anaemia Adenomatous polyps Low socio-economic status
29
Gastric cancer symptoms & signs
``` Often non-specific Epigastric pain (as with ulcer) Nausea + vomiting (especially if tumour near the fundus) Dysphagia (if near fundus) Anorexia/weight loss Palpable epigastric mass (50%) Virchow's node Hepatomegaly, jaundice, ascites Ancanthosis nigricans (areas of dark, velvety discoloration in body folds and creases) ```
30
Gastric cancer investigations
OGD & multiple ulcer edge biopsy Endoscopic USS and CT for staging Staging laparoscopy: locally advanced tumours if no other mets detected
31
Gastric cancer pathology
50-70y, Japanese Most adenocarcinomas in antrum Appear as polypoids/ulcerating lesions with rolled edges Intestinal metaplasia in surrounding tissue: H. Pylori Leather bottle stomach/linitis plastica: submucosal infiltration of tumour --> fibrous reaction --> small, thickened, contracted stomach Mets: local invasion of abdominal viscera, lymphatic (Virchow's), liver (portal dissemination) Transcoelomic spread: peritoneal seedings, bilateral ovarian 'Krukenberg' tumours Rare: stromal tumours (leiomyomas/leiomyosarcomas) from interstitial cells of Cajal
32
Acute abdomen inflammatory pain
Constant pain, raised temp, raised BP, leucocytosis Peritonitis: localised pain, worse with movement, coughing/inspiration Guarding: reflex contraction of abdominal muscles on palpation Rigidity: increased tone at rest
33
Acute abdomen obstructive pain
Colicky pain, agitated patient | May become constant with superimposed inflammation
34
Acute abdomen referred visceral pain
Generally midline Fore-gut: oesophagus to D2 (second part of duodenum): referred to upper abdomen Mid-gut: D2 to transverse colon: referred to middle abdomen Hind-gut: referred to lower abdomen
35
Acute abdomen differentials
Abdominal viscera: acute appendicitis, Meckel's diverticulitis, intestinal obstruction, perforated viscus, acute pancreatitis, acute cholecystitis/cholangitis, renal calculi, acute scrotum, IBS Vascular: AAA, mesenteric thrombosis/embolus Medical: GORD, referred pain from pneumonia, MI, UTI/pyelonephritis Gynae: ruptured ectopic, torted/ruptured ovarian cysts, salpingitis Other: non-specific mesenteric adenitis
36
Acute abdomen investigations
``` Bloods: FBC, U&Es, LFTs, CRP, amylase, ABG Pregnancy test Urinalysis Erect CXR/AXR USS/CT ```
37
Acute appendicitis pathology
1/6th population affected Appendix obstructed by a faecolith/foreign body, or lymphoid enlargement in the wall Can follow URTI Bacteria proliferate in closed bowel loop --> necrosis & perforation due to raised intraluminal pressure
38
Acute appendicitis symptoms
Dull central --> sharp localised RIF pain (McBurney's point) Constipation/diarrhoea Anorexia Nausea + vomiting after pain
39
Acute appendicitis signs
Rebound tenderness in RIF Percussion tenderness Guarding Rosving's sign (RIF more painful than LIF) PR painful on right Tachycardia Mild fever, flushing and fetor Tender mass (ocassionally) Psoas sign: pain on right hip extension: retroperitoneal retrocaceal appendix Obturator sign: pain on internal rotation of right hip: pelvic appendix
40
Examples of appendicitis which may be difficult to diagnose
Infants with D+V Children: vague abdominal pain Females: presenting with gynaelogical issues Confused elderly
41
Acute appendicitis investigations
``` PR Pelvic exam in females Pregnancy test Bloods: FBC, U&E, CRP/ESR Urinalysis USS/CT: if diagnostic uncertainty AXR/erect CXR: if questioning perforation ```
42
Complications of a perforated appendix
Peritonitis & sepsis Appendix mass: inflamed appendix becomes covered with omentum Appendix abscess: local, pelvic, subhepatic, subphrenic Adhesions Infertility: tubal obstruction after pelvic infection
43
Causes of a mass in the RIF
``` Inflammatory: appendix Lymphoma Crohn's Tumour: caecal/carcinoid Pelvic kidney ```
44
Carcinoid tumour pathophysiology
Tumours of argentaffin cells, produce serotonin/prostaglandins Can occur on tip of the appendix 10% associated with MEN-1 syndrome Characteristically take up silver stains readily >50y Carcinoid syndrome: facial flush & diarrhoea
45
Meckel's diverticulum aetiology
Caused by a remnant of the embryological vitellointestinal duct Occurs in 2% of the population, 2% produce symptoms 2cm long, antimesenteric border of the bowel, 60cm from ileocaceal valve Lined by gastric acid secreting epithelium, or heterotropic pancreatic tissue
46
Meckel's diverticulum presentation
Asymptomatic/mimic other conditions... Caecal volvulus: if tethered to umbilicus, present like volvulus with obstruction Intussuseption: gangrenous by operation Appendicitis: diverticulum becomes inflammed, presenting as appendicitis + umbilical cellulitis Peptic ulceration: pain around umbilicus related to mealtimes due to ulceration of gastric acid secreting epithelium Sinus tract: between diverticulum and umbilicus (patent vitellointestinal duct)
47
IBS symptoms
In presceding 12m, 12 consecutive weeks of abdominal discomfort/pain, with 2/3 of... relieved with defecation onset associated with change in frequency of stool onset associated with change in form of stool Other symptoms... Bloating Passage of mucus Stool passage symptoms: tenesmus, incomplete evacuation Associated gynaecological symptoms: dysmenorrhoea/dyspareunia Urinary symptoms: frequency, urgency, nocturia Back pain
48
Crohn's epidemiology
50/100,000 Incidence peaks at 15-30, then 60y Risk factors: poor diet, smoking, altered immune states
49
Crohn's pathology
Mouth to anus inflammation (commonly ileum and ascending colon) One/multiple areas Involved bowel: narrow, thickened wall, deep ulcers, involving all layers of the bowel Fistulae + stenosis common Cobblestone appearance on CT Histological: transmural inflammation, lymphoid hyperplasia and granulomas
50
Crohn's clinical features
``` Abdominal pain (varying) Steatorrhoea: ileal disease Bloody diarrhoea: colonic disease Weight loss/failure to thrive Severe apthous ulceration of the mouth (early sign) Anal complications (fissure, fistula, haemorrhoids, skin tags, abscesses) Extra GI manifestations Can present with acute RIF pain/mass ```
51
Ulcerative colitis epidemiology
100-200/100,000 Incidence peaks at 15-30, then 60y Smoking is protective F>M
52
Ulcerative colitis pathology
Inflammation beginning in rectum, extending proximally along the colon (proctitis affects rectum alone) Inflammation of terminal ileum (backwash ileitis Inflammation only affects mucosa: excessively ulcerated Adjacent mucosa has appearance of inflammatory polyps Histological: mucosal inflammation, crypt abscess and goblet cell depletion
53
Ulcerative colitis clinical features
Crampy lower abdominal discomfort Gradual onset diarrhoea (often bloody) Urgency and tenesmus (if disease confined to rectum) Extra GI symptoms
54
IBD investigations
Bloods: FBC, U&E, CRP/ESR, LFT, serum iron/B12/folate if anaemia Stool studies: stool chart, MCSxs (infective causes), calprotectin (rule out IBD in general practice) Radiology: AXR/CXR (acute), CT in Crohn's Endoscopy: rigid/flexible sigmoidoscopy in UC, colonoscopy, endoscopic rectal biopsy
55
General IBD complications
Bowel perforation Lower GI haemorrhage Toxic dilatation (more common in UC) Colonic carcinoma: crohn's>UC
56
Toxic dilatation presentation
Persistent pyrexia, tachycardia, loose blood-stained stool Falling albumin/K+ AXR: dilated >6cm colon with mucosal islands Perforation imminent
57
Crohn's disease complications
Small bowel obstruction Fistulae (10%) Abscess formation B12/folate/iron deficiency
58
Extra-colonic manifestations of IBD
Eye's : conjunctivitis/episcescleritis/iritis Joints: arthralgia of large joints Skin: erythema nodosum, pyoderma gangrenosum Venous thrombosis Fatty liver Associated: autoimmune hepatitis, gallstones, renal calculi, primary sclerosing cholangitis (UC), cholangiocarcinoma (UC), ankylosing spondylitis (HLA B27 +ve crohns)
59
Aetiology of diverticulosis
50% >50y Frequently in sigmoid (95%) Associated with a low fibre diet (soft stools = higher luminal pressure to move them), Marfan's, Ehlers-Danlos syndrome, PKD Hypertrophy of the muscular propria, diverticula occuring at sites of potential weakness in the bowel wall (entry points of blood vessels) Diverticulosis: the presence of diverticula Diverticitis: inflammation of diverticula Diverticular disease: symptomatic diverticula
60
Clinical features of diverticular disease
Asymptomatic: 95% cases Symptoms mimic carcinoma of the colon... Left-sided colic, relieved by defecation Altered bowel habit: blood and mucus passage Nausea, flatulence, severe pain, constipation
61
Diverticular disease investigations
PR: pelvic abscess/colorectal cancer Sigmoidoscopy/colonoscopy Barium enema CT
62
Diverticulitis symptoms & signs
Severe left-sided colic Constipation/overflow diarrhoea Symptoms mimicking appendicitis but on left Fever & tachycardia Left-sided tenderness, rigidity and guarding Sometimes left palpable mass in LIF Raised WCC and inflammatory markers
63
Diverticular perforation pathophysiology & presentation
Acute diverticulitis --> formation of paracolic/pelvic abscess, fistula, generalised peritonitis Presents: ileus & peritonitis +/- shock Mortality = 40%
64
Abscess formation from diverticulae presentation
Swinging fever, leucocytosis, localising signs (e.g. boggy rectal mass)
65
Bleeding from diverticulae presentation
Sudden painless bleeding Chronic occult loss Large volumes can be lost, requiring transfusion Bleeding often stops with bed rest
66
Fistula formation from diverticulae presentation
Colovesicle: leading to UTI, pneumaturia Colovaginal: foul discharge
67
Intestinal obstruction from diverticulae presentation
Commonly in the sigmoid | Chronic inflammation --> scarring --> formation of diverticular mass: causes obstruction/mimics colonic carcinoma
68
Stricture formation from diverticulae presentation
Post-infective strictures | Similar to malignant strictures on barium studies
69
Colorectal cancer risk & protective factors
Risk: Family history (+FAP/HNPCC), age, western diet (low in dietary fibre, high in fats), ulcerative colitis, smoking Protective: fruit, veg, fibre, exercise, HRT, aspirin, NSAIDs
70
Colorectal cancer genetic aetiology
Familial adenomatous polyposis (FAP): <1%, APC tumour supressor mutations Hereditary non-polyposis colorectal cancer (HNPCC): <5%, germline mutations in mismatch repair genes
71
Colorectal cancer morphology/natural history
Adenocarcinoma: signet ring cells on histology Polypoid mass with ulceration, spreading by direct infiltration of bowel wall, then involves lymphatics and blood, mets in liver/transcoleomic spread Caecum & ascending: 15% Transverse: 10% Descending: 5% Sigmoid: 25% Rectum: 45%
72
Duke's staging of colorectal cancer
A: tumours invade submucosa +/- muscularis propria B: tumour invades past the muscularis propria into suberosa/directly into other organs, but no nodal involvement C: regional lymph node involvement D: distant mets
73
Anal cancer risk factors
Anoreceptive sex Syphilis Anal warts/cervical cancer (HPV) Immunosuppression
74
Anal cancer pathology
Mainly SCC Above pectinate line: columnar epithelium, lymph drainage to internal iliac nodes & portal venous drainage --> hepatic mets Below pectinate line: squamous epithelium, lymph drainage to superficial inguinal nodes & caval venous drainage --> pulmonary mets
75
Colorectal/anal tumour presentation
``` Abdominal mass, abdominal pain, haemorrhage, perforation, fistula Right sided (proximal): more asymptomatic, iron deficiency anaemia/weight loss Left sided (distal): PR blood/mucus, altered bowel habit, tenesmus, obstruction/mass on PR Anal: bleeding, pain, changes in bowel habit, pruritis ani, masses/stricture ```
76
Indications for a 2WW referral for colorectal carcinoma
>40y with... Rectal bleeding/change in bowel habit >6w >45y & persistant rectal bleeding with no evidence of benign anal disease IDA (Hb<10g/dl) without an obvious cause Palpable abdominal/PR mass
77
Colorectal carcinoma investigations
Bloods: FBC (microcytic anaemia), LFT (metastatic indicator) Colonoscopy: biopsy & polypectomies CT: chest, abdo (staging) Carcino-embryonic antigen: monitor disease
78
Bowel obstruction symptoms & signs
Vomiting: undigested food=gastric outlet obstruction, bilous=upper SBO, faeculent=distal SBO Pain: colicky, may be absent in long-standing obstruction Constipation: may not be absolute in proximal obstruction Distention Tinkling bowel sounds Dehydration Central resonance to percussion, dull flanks Scars: previous surgery --> adhesions Palpable mass No abdominal tenderness unless strangulation
79
Common causes of small bowel obstruction
Adhesions (80%) Hernias Crohn's Intususseption
80
Common causes of large bowel obstruction
Colon carcinoma Diverticular disease Sigmoid volvulus Constipation
81
Bowel obstruction complications
Bowel wall: oedematous & distended --> vessels stretched + blood supply compromised --> strangulation --> ischaemia + necrosis Proliferation of bacteria Perforation of bowel Symptoms develop gradually in large bowel obstruction & ileo-caecal valve incompetence
82
Bowel obstruction investigations
Bloods: FBC, U&E, amylase, LFTs ABG Urinalysis Supine AXR: distended proximal bowel, absent gas distally Erect CXR: fluid level in SBO, air below diaphragm if perforation Contrast enema: differentiates obstruction/pseudo-obstruction, identify obstruction level & ileo-caecal competency CT: indicate obstruction level, not always diagnose
83
Strangulation symptoms
Usually volvulus/hernia Increasing pain/tenderness + leucocytosis & systemic upset --> peritonism & absent bowel sounds Sigmoid volvulus: elderly constipated patients Caecal volvulus: congenital malrotation
84
The role of anal sphincters in maintaining faecal continence
Runs from superior aspect of pelvic diaphragm to anus, normally collapsed Internal anal sphincter: involuntary, surrounding upper 2/3 of anal canal Tonic contraction stimulated by sympathetic fibres from superior rectal/hypogastric plexus Parasympathetic fibres inhibit tonic contraction: contraction of puborectalis/external anal sphincter maintains continence External anal sphincter surrounds the lower 2/3 of the anal canal: voluntary control, mediated by inferior rectal nerve (S4)
85
Haemorrhoids pathology
Anal cushions: smooth muscle with subepithelial anastomoses of rectal arteries/veins (3, 7, 11 o'clock from lithotomy position) Haemarrhoids: prolapsed anal cushions Arise due to breakdown of smooth muscle layer (muscularis mucosae) Superior rectal vein drains into inferior mesenteric (portal) therefore anal cushion anastomoses are porto-caval anastomoses. In portal hypertension = ano-rectal varices Haemorrhoids commonly arise in the absense of portal hypertension
86
Haemorrhoids aetiology
Mainly idiopathic Increased anal tone (chronic constipation) Factors that cause congestion of superior rectal veins (cardiac failure, pregnancy, rectal carcinoma, raised IAP)
87
Haemorrhoids classification
1st degree: confined to anal canal, do not prolapse 2nd degree: prolapse on defecation, reduce spontaneously 3rd degree: prolapse on defecation, manually reducible 4th degree: remain prolapsed at all times
88
Haemorrhoids symptoms
``` Rectal bleeding Prolapse Mucous discharge Pruritus ani Pain if piles become thrombosed ```
89
Haemorrhoids complications
Anaemia: severe/continued bleeding Thrombosis: strangulated by anal sphincter --> venous return occluded --> swollen, purple, tense haemorrhoids (painful) Thrombosed piles fibrose within 2-3w = spontaneous cure
90
Haemorrhoids investigation
Abdo exam: palpable masses/enlarged liver? Rectal exam: any prolapse? Proctoscopy/rigid sigmoidoscopy: visualise, assess for higher lesions Colonoscopy/flexi-sigmoidoscopy: if more sinister pathology suspected
91
Rectal bleeding differentials
``` Haemorrhoids: most common Anal fissure: skin tag, tenderness Diverticulitis: LIF symptoms Rectal cancer: tenesmus, PR bleeding Colon cancer: blood mixed with stool Ulcerative colitis: abdo pain, urgency Crohn's: weight loss, chronic diarrhoea Massive upper GI bleed: malaena + haematemsis Trauma Ischaemic/infective colitis Angiodysplasia ```
92
Types of perianal infections
Anorectal abscesses: gut organisms, crohn's, DM, malignancy Pilonidal sinus: obstruction of natal cleft hair follicles/ingrown hair --> abscess formation/pilonidal sinus Perianal warts
93
Anal fissure symptoms + O/E
Pain, worse on defecation, lasting for hrs afterwards Associated constipation Pruritis ani Bleeding on defecation O/E: midline longitudinal tear + mucosal tag

CP1 (12 decks)

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