Week 209 - IBS/Constipation Flashcards
1
Q
A patient arrives to A and E with a form of anal prolapse - how can you tell the difference between rectal prolapse and prolapsed Haemorrhoids?
A
The difference is in observation. There are longitudinal lines in prolapsed Haemorrhoids, and circumferential lines (circular rings) in prolapsed colon.
2
Q
List four indications for per rectal examinations.
A
- ) Rectal bleeding
- ) Constipation
- )Change of bowel habit
- ) Problems with urinary or faecal incompetence
3
Q
Which finger do you use for a PR exam?
A
Index finger of the right hand.
4
Q
Give two reasons why you would not perform a PR.
A
- ) Patient refusal - no consent obtained.
- ) Examination not indicated
5
Q
What position would you ask a patient to get in, in order to perform a per rectal examination?
A
POSITION =Left lateral position, with knees pulled up towards chest.
6
Q
You conduct a PR examination, and upon inspection see the following. What do you see?
A
Erythematous right buttock.
7
Q
You examine a patient per rectally and find that he has an increased anal tone and a palpable smooth surface mass on the right hand side of the rectum. This is tender to palpate. What other feature of this mass might you expect to be present on palpation?
A
Other feature of the mass = Fluctuant (unstable/moveable/compressable).
8
Q
Other than the rectum, which organ is palpable through a PR exam?
A
The prostate.
9
Q
You examine a patient per rectally and find that he has an increased anal tone and a palpable smooth surface mass on the right hand side of the rectum. This is tender to palpate. What two laboratory investigations you would like to perform to help with diagnosis and management? What is the most likely diagnosis?
A
Investigations = FBC, culture of exudate
Likely diagnosis = Peri anal abscess
10
Q
What condition is this?
A
The image shows full thickness rectal prolapse.
11
Q
Define Rectal Prolapse.
A
Rectal prolapse = is the protrusion of either the rectal mucosa or the entire wall of the rectum.
12
Q
Define partial (rectal) prolapse.
A
Partial prolapse = involves only the mucosa and usually only protrudes by a few centimetres.
13
Q
Define complete (rectal) prolapse.
A
Complete prolapse = involves all layers of the rectal wall.
14
Q
In which two groups is rectal prolapse most common?
A
1.) Elderly females
2.) Children < 3 years (especially in first year of life)
15
Q
In children, rectal prolapse may be associated with which conditions?
A
cystic fibrosis
Ehlers-Danlos syndrome
Hirschsprung’s disease
congenital megacolon
malnutrition and rectal polyps.
16
Q
List four risk factors for rectal prolapse.
A
ANY 4 OF THE FOLLOWING:
1.) Increased intra-abdominal pressure
eg constipation, diarrhoea, benign prostatic hypertrophy, pregnancyChronic cough (eg COPD/cystic fibrosis/whooping cough).
- 2.)* Previous surgery.
3. ) Pelvic floor dysfunction.
4. ) Parasitic infections, eg amoebiasis, schistosomiasis.
5. ) Neurological disease
eg previous lower back or pelvic trauma, lumbar disc disease, cauda equina syndrome, spinal tumours, multiple sclerosis.
6.) Psychiatric disease.
17
Q
Name the symptoms of rectal prolapse.
A
- Mass protruding through the anus
- Pain
- Constipation
- Faecal incontinence
- Discharge of mucus
- Rectal bleeding
18
Q
What are the signs of rectal prolapse?
A
- Protruding mass
- should show concentric rings of mucosa = classic signs of rectal prolapse
- Rectal ulcer
- Decreased anal sphincter tone.
19
Q
What is this?
A
Thrombosed external hemorrhoid
20
Q
What is this?
A
Thrombosed external hemorrhoid.
21
Q
What is this?
A
Thrombosed external hemorrhoid.
22
Q
What is this?
A
Anal warts.
23
Q
What is this?
A
Anal warts.
24
Q
What is this?
A
Anal warts.
25
What is this?
Anal warts.
26
What is this?
Squamous cell carcinoma of the anus.
27
28
What is this?
Anal skin tags.
29
What is this?
Anal skin tags.
30
What is this?
Anal fissure.
31
What is this?
A child with an anal skin tag and anal fissure.
32
Describe the abnormality with this radiograph.
Anal insertion (gone very very wrong)!
33
34
What are the **functions** of the Large Bowel?
1.) **Modification**, storage and evacuation of waste
products of digestion and metabolism (faeces).
2.) **Extraction** of water & electrolytes from the fluid
ileal contents.
3.) **Maintenance of bacterial flora** and absorption of
nutrients derived from bacterial degradation of
luminal contents.
35
What are the functions of the colon?
1.) Colon absorbs large quantities of fluid and electrolytes
and converts liquid to solid stool (2L to 200mL)
2.) Absorbs short- chain fatty acids formed by catabolism (or
fermentation) of dietary carbohydrates that are not
absorbed in small bowel
3.) Reservoir function for storage of content
4.) Elimination of contents in controlled and regulated
fashion.
36
The colon is described as functioning like two organs. What is meant by this statement?
1. ) Proximal colon i.e. ascending and transverse –fluids/electrolytes and bacterial fermentation.
2. ) Distal i.e. distal and recto-sigmoid reservoir function.
37
What is the normal colonic transit time?
25-40 hours.
38
Both non propulsive segmentation and mass peristalsis occurs in the proximal colon. **What is meant by "non propulsive segmentation"?**
Non-propulsive segmentation is generated by slow wave activity which produces circular muscle contraction. This produces the appearance of segments or haustra). Mixing/ absorption of contents is the purpose, **not** propulsion.
39
How often does mass peristalsis occur in the proximal colon?
1-3 X a day.
40
What is the primary activity of the distal colon?
Non-propulsive segmentation.
41
What directly controls the contracitle behaviour of the colon?
The intramural plexi.
42
What are the stimulatory neurotransmitters of gut motility?
Acetylcholine and substance P.
43
What are the inhibitory neurotransmitters of gut motility?
VIP and Nitric Oxide.
44
45
Where is Auerbach's plexus located.?
Auerbach's plexus exists between the longitudinal and circular layers of muscularis externa in the gastrointestinal tract.
46
What is Hirschsprung's disease?
**_Hirschsprung's disease (HD)_** is a disorder of the abdomen that occurs when part or all of the large intestine or antecedent parts of thegastrointestinal tract **_have no ganglion cells_** and therefore cannot function.
47
What pathology/complication is a result of Hirschsprung's disease?
The affected segment of the colon **cannot relax** and pass stool through the colon, creating an **obstruction**.
48
Which part of the colon is usually affected by Hirschsprung's disease.
In **most** affected people, the disorder affects the part of the colon that is **nearest the anus**. In **rare** cases, the lack of nerve bodies involves **more of the colon**. In five percent of cases, the entire colon is affected.
49
During normal fetal development, cells from the neural crest migrate into the large intestine (colon) to form two nerve networks. What are they called?
During normal fetal development, cells from the neural crest migrate into the large intestine (colon) to form the networks of nerves called **Auerbach's plexus and Meissner's plexus.**
50
51
Can you name the two types of **Automimmune Microscopic** colitis?
- **Collagenous** Colitis
- **Lymphocytic** Colitis
52
Week 209. What does this GI histology slide show?
This is **Collagenous Colitis**. Note the thickened subepithelial collagenous band \>15 micrometer (2RBC diameter).
53
Week **209**. What does this histology slide show?
This is **Lymphocytic colitis**. Note the **increased** number of **lymphocytes** in the Epithelium.
54
Which **two parts** of the GI tract does **Ulcerative Colitis** tend to affect?
The **Colon** and the **Rectum**.
55
What is the **commonest** cause of **bloody diarrhoea** in the **UK**?
Ulcerative Colitis.
56
What is **Proctitis**?
Inflammation of the **rectum** and **anus**.
57
What is **Proctocolitis**?
This is a general term used to describe **inflammation** of the rectum and/or colon.
58
What is meant by the term **Pancolitis**?
Pancolitis is a very **severe** form of **ulcerative coliti**s. Pan refers to the fact that the disease is **spread throughout the large intestine**, from the cecum to the rectum. Symptoms are very similar to those of any ulcerative colitis patient except more severe.
59
Week 209. What risk is associated with **Fulminant** Ulcerative Colitis?
**Perforation** through muscle, and bowel wall.
60
Week 209. What does this image show?
This image shows **Ulcerative Colitis**. Note the more obvious changes at the **DISTAL** end.
61
Week 209. What does this image show?
This image shows **Fulminant Colitis** (Super de' Deuper bad Ulcerative Colitis)
62
Week 209. What does this histology slide show?
This shows **Ulcerative Colitis**. Note that the inflammation is contained within the **mucosa and submucosa** - the luscle layer is unaffected.
63
Week 209. The following sample was taken from a patient with **Ulcerative colitis**. What **histological feature** is prominent?
**Crypt Abscess**. Crypts become distended with **neutrophils** to produce crypt abscesses
64
Week 209. In **most** patients, **Crohn's disease** is confined to which area of the GI tract?
In **66% of Crohn's patients**, disease is confined to the **small Bowell alone**.
65
Week 209. With reference to Crohn's Disease, what is meant by the term "**Skip lesions**"?
The term "skip lesions" refers to lengths of diseased bowel, **separated** by normal bowel.
66
As best as you can, describe the **pathology** of **Crohn's** Disease.
* Segmental – lengths of diseased bowel, separated by normal bowel – “skip lesions”.
* Initially - shallow aphthoid ulcers
* Later - longitudinal ulcers and fissures
‘cobblestone appearance’
* Full thickness of wall involved
* Transmural inflammation
* Develop fibrosis and strictures
67
Week 209. What **disease** does this image show? What **parts** of the Bowel can you see here?
This is **Crohn's Disease**. Both the **terminal ileum**, and the **Caecum** are visible here.
68
Week 209. Which **disease** does this image show? What is the name of this **abnormality**?
This is **Crohn's Disease**. The abnormality is a **stricture**.
69
Week 209. As best as you can, summarise the **microscopy** findings typical in **Crohn's Disease**.
* Discontinuous, patchy inflammation.
* Transmural inflammation with lymphoid aggregates in wall.
* Fissuring ulceration.
* Granulomas.
70
Week 209. What **disease** is shown in this TS slide? What are the defining **features**?
* This is **Crohn's Disease**.
* Transmural lymphoid aggregates (the dark purple dots)
* Fissuring Ulcers
71
What **disease** is this? What is indicated by the black arrow?
This is **Crohn's disease**. The arrow indicates a **granuloma**.
72
Week 209. What three things can be associated with **ischaemia** of the **colon**?
1. Acute **small bowel ischaemia**
2. Hernia - **strangulation**
3. **Volvulus** – Loop of bowel (usually sigmoid, can be caecum, twists around itself due to abnormally long mesentery)
73
74
75
Which **three** bacterial infections **commonly** cause **inflammation** of the **colonic mucosa**?
1. Campylobacter
2. Salmonella
3. Shigella
76
Week **209**. The bacterial infection ***Pseudomembranous colitis*** refers to infection with **which organism**? What commonly **causes** this organism to become **pathogenic**?
Pseudomembranous colitis is **caused by** infection with the toxin producing ***Clostridium difficile*. **
This can be a normal commensal (2-3%).
**Overgrowth occurs** when the normal gut flora is disturbed, whether by **antibiotics**, **enemas**, or **GI surgery**.
77
What is the **name** given to this **condition**? What is the responsible **organism**?
The condition shown here is **Pseudomembranous colitis**.
This is caused by infection from **Clostridium Difficile**.
78
What **pathology** is indicated on this slide? What **key sign** informs your decision?
This is **Pseudomembranous colitis**.
## Footnote
**Key sign: Eruptive (volcano like) exudates.**
79
Week **209**. Which **Viral infection** can cause an **inflamed** colon (with an appearance **very similar to that of Ulcerative Colitis**)?
**Cytomegalovirus** (CMV)
80
Week **209**. **Which infection** is indicated in this slide? **What** leads you to this conclusion?
This is an **infective viral** condition - **Cytomegalovirus**.
This is indicated by **Large intranuclear viral inclusion**.
81
Week **209**. **Which** infective **protozoal condition**, **rare in temperate** climates, presents with **Diarrhoea and bloody stools**?
For an extra mark - can you say what ***can develop*** as a result?
**Amoebiasis** (*Entamoeba histiolytica*)
This can develop:
* **Strictures**
* **Metastatic amoebic abscesses**
82
Week 209. Which **organism** causes this infection?
*Entamoeba histiolytica* (This is **Amoebiasis**)
83
What **ingredient** in "**Sugar-free**" sweets has a **laxative** effect?
**Sorbitol**
84
What is the **name** given to the **Iatrogenic** pigmentation of large bowel mucosa due to **chronic laxative abuse**?
Melanosis coli.
85
Week **209**. What is the **name** given to this condition?
Melanosis coli.
86
This sample was taken from a patient that **chronically abuses laxatives**. What **can you see** to support this history?
There is deposition of **lipofuscin** pigment in **macrophages**, in the **lamina propria**.
87
Week 209. Benign neoplastic adenomas of the colon and rectum account for 90% of what?
**Adenocarcinomas**. Dysplasia brings about further change. 90% of adenocarcinomas of the colon and rectum arise from adenomas.
88
Week **209**. What are the **four stages** in the transformation of rectal/colon tissue into a carcinoma?
1. Normal epithelium
2. Adenoma (low-grade dysplasia)
3. Adenoma (high-grade dysplasia)
4. Adenocarcinoma
89
Week **209**: What does this slide **show** (hint\* it was taken during colonscopy).
This shows a **normal** mucous membrane.
90
Week **209**. What does this slide show? Hint\* *It was taking during colonoscop*y.
This slide shows a benign neoplasm of the gut mucosa. This is **Adenoma** with **low-grade** dysplasia.
91
Week **209**. What does this image show? Hint\* It was taken during colonscopy.
This shows **neoplastic** benign **adenoma** with **high-grade** dysplasia.
Next step....adenocarcinoma.
92
Week **209**. What does this slide show? Hint\* this was taken during colonoscopy.
Neoplastic benign Adenoma with high-grade dysplasia.
93
Week **209**. This is a sample from a removed **benign adenoma** (from the colon). But what type of adenoma is is? \*Hint - look at the **shape**!
This is a **tubular adenoma**!
94
Week **209**. This is a sample from a **benign Adenoma** removed during surgery. But **what type** of adenoma is is?
This is a **Villous Adenoma**.
95
Week **209**. In which **part of the GI tract** are neoplastic malignant adenocarcinomas most **often** found?
These are most often found in the **Rectum**.
other areas (descening most to least common):
* Sigmoid
* Caecum
* Rest of colon
96
Week **209**. This prosection shows **which disease**?
**Adenocarcinoma**, likely arising from benign neoplastic adenoma of the colon.
97
Week **209**. This biopsy shows advanced pathology. But **what** is it?
This is neoplastic malignant **adenocarcinoma**.
98
Week **209**. In the **staging of Bowel cancer**, what do the letters **TNM** stand for?
T = Tumour
N = Node
M= Metastases
99
Week **209**. In Bowel cancer staging, **T1** means what?
T1 means the tumour is only in the inner layer of the bowel.
100
Week **209**. In bowel cancer staging **T2** means what?
T2 means the tumour has grown into the muscle layer of the bowel wall.
101
Week 209. In bowel cancer staging T3 means what?
T3 means the tumour has grown into the outer lining of the bowel wall.
102
Week** 209**. In bowel cancer staging **T4** means what?
T4 means the tumour **has grown through the outer lining of the bowel wall**. It may have grown into another part of the bowel, or other nearby organs or structures. Or it may have broken through the membrane covering the outside of the bowel (the peritoneum)
103
Week 209. In bowel cancer staging N0 means what?
N0 means there are no lymph nodes containing cancer cells.
104
Week 209. In bowel cancer staging N1 means what?
N1 means that 1 to 3 lymph nodes close to the bowel contain cancer cells.
105
Week 209. In bowel cancer staging N2 means what?
N2 means there are cancer cells in 4 or more nearby lymph nodes.
106
Week 209. In bowel cancer staging M0 means what?
M0 means the cancer **has not spread** to other organs.
107
Week 209. In bowel cancer staging M1 means what?
M1 means **the cancer has spread** to other parts of the body.
108
Week **209**. Relate **Dukes**' cancer staging (colorectal cancer) to **TNM** staging.
A: T1/2 N0 M0
B: T3/4 N0 M0
C: Any T, Any N, M0
D: Any T, any N, M1
109
This is a squamous cell carcinoma of whic part of the body?
The anus.
110
Week **209**. Describe the the fundamental histological difference between **Adenocarcinoma** and **Squamous Cell carcinoma**.
In malignant **adenocarcinoma**, histology shows malignant **gland like structures** (they look like pink blobs often).
In Malignant **Squamous cell carcinoma**, the deformity is excessive **Keratinisation**.
111
What is another term for **Hirschprung's** disease? How would you concisely **describe** it's symptoms?
Congenital **aganglionic** megacolon.
**Enlarged, dilated proximal large bowel** because of obstruction.
112
What is the **name** given to the disease in this slide? What **informs** your decision?
This is Hirschprung's disease. There are **no ganglion cells** in the **myenteric** plexus.
113
Week **209**. Which **congenital** disorders cause GI blockage?
**Intestinal atresia** (compromised blood supply leading to incomplete bowel)
**Imperforate anus** (no anus present).
114
Which **degenerative** disease of the **bowel** is associated with **herniation of mucosa** through the bowel wall?
What can this **develop into**, and what are the **signs/symptoms**?
This is **Diverticular disease** of the colon.
This can cause inflammation with **fibrosis**, and can lead to **stricture formatio**n.
Patients may present with: ** pain, altered bowel habit, bleeding, perforation and/or obstruction.**
115
Week **209**. Which **disease** is shown in this picture?
This is **Diverticular disease**. Note the outpouching of the mucosa through the wall of the bowel.
116
Week 209. Which **Endocrine disorder** can cause **diarrhoea**, and **why**?
**Thyrotoxicosis. **
** **The effect of **Thyroid hormone**s on the sympathetic nervous sytem causes **increased gut motility** and diarrhoea.
117
Week 209. What is the effect of hypothyroidism on bowel habit?
Constipation.
118
Week **209**. Which **autosomal dominant** condition causes **multiple adenomas** of the colon (which usually progress to adenocarcinomas)?
**Familial Adenomatous Polyposis** (FAP)
Most commonly due to mutation in APC (**Adenomatosis polyposis coli**) gene.
Usually require colectomy before 25 YO.
119
Week **209**. Where is the **APC** gene located, and what is its function?
This is a **tumour supressor** gene, located on the **long arm of chromosome 5**.
120
Week **209**. This is a piece of removed **colon**. What is the name given to this **disease**?
This is **Familial adenomatous polyposis**. Note the plethora of small benign adenomas.
121
Week **209**. What is the difference between primary and secondary constipation?
Primary: Dysmotility, or mechanical obstruction.
Secondary: Other obstruction, drugs, or metabolic causes.
122
Week **209**. **Cleveland** and **Vaizey** scores are used to assess what?
Quality of life (QOL).
123
What are the classical signs of **idiopathic slow transit constipation**?
* **Young females**
* BO 1 / 2-3 weeks
* Absence of **call to stool**
* Abdominal discomfort
* **Family history**
* Abnormal motility
* Small proportion of patients
124
Week **209**. Name **three** **surgical** options for bowel **dysmotility**.
1. **Colectomy and IRA** (Ileorectal anastamoses)
2. **Sacral Nerve stimulation **
3. **Antegrade colonic Enema**
125
Week **209**. **Describe**, in very **basic** terms, what happens in a **colectomy and IRA**.
126
Week **209**. When considering a surgical **colectomy**, what **other factors** should you exclude/take into account?
* Disorders of defaecation
* Small bowel motility is normal
* Weak sphincters
* Other causes
* Inappropriate expectations from patient and family
127
Week **209**. **Sacral nerve stimulation** allows for mechanical control over defaecation. What are it's **advantages**?
* Increased frequency of defaecation
* Reduced incomplete evacuation
* Decrease abdominal pain and bloating
* Reduced Cleveland Clinic constipation score
* Quality of life significantly improved
128
Week **209**. How might a patient with **obstructed defaecation** **present**?
* External prolpase
* Rectocoele
* Rectal intussusception
* Anismus
* Idiopathic megarectum
129
Week 209. What is a **rectocoele**?
This is like a prolapse, only *internally*, like a large distended loop off of the rectum.
130
Week **209**. What is **Anismus**?
Anismus refers to an **inability to defecate** as a result of **failed relaxation** of the **Pelvic Floor** muscles.
131
Week **209**. If transverse distension of the colon is what leads to rectocele, what does **longitudinal distension of the colon lead to**?
Internal intussception/external prolapse.
132
Week **209**. Can you name **two surgical procedures**, directed at the correction of **rectal redundancy**?
1. Rectopexy
2. Perineal approach (Delormes procedure)
133
Week 209. A Rectocoele is a protrusion of the ___ rectal/\_\_\_\_\_ vaginal wall, which is commonly found following childbirth.
Anterior Rectal
Posterior Vaginal
134
Define ***Constipation***:
Constipation is defecation that is
* *unsatisfactory** because of **infrequent** stools,
* *difficult** stool **passage**, or seemingly
* *incomplete** defecation.
135
Week 209. What is **Functional Constipation**?
Functional constipation is **chronic constipation without a known cause**. Functional constipation is also known as primary constipation and idiopathic constipation.
136
Week **209**. What is meant by the term ***Secondary Constipation***?
This is constipation **caused by a drug or a medical condition** - there is a *reason* for it.
137
Week **209**. What is meant by the term(s) **Faecal loading/impaction**?
**This is retention of faeces to the extent that spontaneous evacuation is unlikely**. Retained faeces are usually palpable on abdominal examination, and may be felt on internal rectal examination or by external palpation around the anus.
138
Week **209**. The Rome criteria for constipation states a definition as being bowel movements that occur **how frequently**?
Bowel movements occuring **less than three times a week** is one of the Rome criteria for constipation.
139
Week **209**. Could you list a few basic **medications** that would **contribute to constipation**?
* Narcotics
* Iron supplements
* Nonmagnesium antacids
* Calcium-channel blockers
* Inadequate thyroid hormone supplementation
* Many psychotropic drugs
* Anticholinergic agents
140
Please look at this Abdominal X-Ray film. The patient feels bloated and has not passed stools for four days. What do you think?
This is Chronic **Constipation**.
141
Week **209**. What are the **Rome II Criteria** for identifying I**rritable Bowel Syndrome** (IBS)?
* Abnormal frequency of stools
* Abnormal form
* Abnormal passage
* Presence of mucous
* Bloating with distension
142
Week **209**. What test could you perform to **evaluate** the degree of **constipation** in a patient?
Evaluation of Constipation can be via **Colonic transit study** (this is a radiological study).
143
Week **209**. 5 days after beginning a **colonic transit study**, an abdominal **X-ray** is performed. **_No markers_** are seen on the film. What can you deduce from this?
If 5 or fewer markers remain, patient has **grossly normal colonic transit.**
144
Week **209**. 5 days after beginning a **colonic transit study**, an abdominal **X-ray** is performed. **_Most markers are scattered about the colon_**. What can you deduce from this?
It is most likely that this patient has **hypomotility** or **colonic inertia**.
145
Week **209**. 5 days after beginning a **colonic transit study**, an abdominal X-ray is performed. **_Most markers are gathered in the rectosigmoid_**. What can you deduce from this?
It is most likely that the patient has a **functional outlet obstruction**.
146
Week 209. How do **bulk forming laxatives** work?
Bulk-forming laxatives **retain fluid within the stool** and **increasing faecal mass, stimulate peristalsis**. They also have stool-softening properties.
Examples: (ispaghula husk, methylcellulose, and sterculia)
147
Week 209. How do **Osmotic laxatives** work? Give an example.
Osmotic laxatives **increase fluid in the large bowel**. **Produces distension, leading to stimulation of peristalsis**. Lactulose and macrogols also have stool-softening properties.
Example: **lactulose**
148
Week 209. How do **Stimulant Laxatives** work?
These cause peristalsis by **stimulating colonic nerves** (senna) or **colonic and rectal nerves** (bisacodyl, sodium picosulfate).
Example: **Senna** (hydrolyzed to the active metabolite by bacterial enzymes in the large bowel.)
149
Week **209**. How do **Surface Wetting Agent** Laxatives work?
Surface-wetting agents **reduce the surface tension of the stool**, allowing water to penetrate and soften it.
150
Week 209. What is the "order of draw" of laxative treatments, from first to last?
1. Bulk forming
2. Osmotic
3. Stimulant
151
Week **209**. What is a **probiotic**? Which strain has shown to be effective in some cases of **IBS**?
A Probiotic is a live **non-pathogenic microorganism** that is believed to have **beneficial effects** when ingested.
Some changes in cytokine profile seen with ***Bifidobacterium*** strain.
152
Week **209**. What is the effect of **Selective Type-2 Chloride Channel activator** Therapies?
These work from the **luminal side** of the mucosa to **stimulate chloride and water secretion** into the lumen.
153
Week **209**. **Manometry** is used to measure what?
Resting Pressure (**Internal Sphincter**)
Maximum Squeeze (**External Sphincter**)
154
Week 209: What is a **Fistula**?
An abnormal tract between two epithelial or endothelial lined surfaces.
155
Week **209**. What is a Sinus?
Granulation or epithelized blind-ending tract.
156
Week 209. What is a **Fistulotomy**?
A **fistulotomy** is the **surgical opening** of a fistulous tract.
157
Week 209. A 50 YO M presents with **Painless bright rectal bleeding** on defecation, **chronic constipation** and lumps (prolapse). What could this be?
**Engorged arterio-venous plexuses (Haemorrhoids!)**
•Normal variant
•15% contribution to continence
158
Week **209**. Approximately to what **volume** does the **rectum** fill (in **normal** defecation)?
In normal defecation, the rectum fills to approximately **200 mls**.
159
Week **209**. What is the **Recto-rectal reflex**?
In normal Defecation, the **Recto-Recta**l reflex is: **Proximal bowel constriction syncronous with distal bowel relaxation**.
160
Week 209. What is the **Recto-anal inhibitory reflex**?
The rectoanal inhibitory reflex (RAIR) is an **involuntary IAS relaxation in response to rectal distension**, allowing some rectal contents to **descend into the anal cana**l where it is brought into contact with specialized sensory mucosa to detect consistency.
161
Week 209. To which **lymph nodes** does the anus drain?
Drainage is via **inguinal lymph nodes** if low (**not** Superior Rectal).
162
Week 209. What is the name given to the **"lines"** that **do not completely cross the large bowel**?
**Haustra**
163
Week 209. What is the name given to the "**lines**" that **completely cross the small bowel**?
**Valvuli coniventes**
164
Week **209**. Is an appendic **thicker than 6mm** normal?
Usually - **No**.
165
Week **209**. Tumours of **endocrine** cells are called ___ Tumours.
**Carcinoid Tumours. **
166
Week **209**. What is the **anatomical difference** between the **Transverse/sigmoid colon**, and the **caecum/ascending colon/descending colon**?
The transverse and sigmoid colon are **intra-peritonea**l.
The Caecum, ascending colon and descending colon are **retroperitoneal**.
167
Week 209. What are the **clinical signs of Appendicitis**?
* Peri-umbilical pain
* vomiting
* fever
* Pain localised to right iliac fossa, guarding and rebound tenderness
* Generalised abdominal pain, guarding and rebound tenderness
168
Week **209**. What are the **complications** of **Appendicitis**?
* **Perforation** -septic shock and death if not treated
* **Sub phrenic abscess** leading to persistent signs of infection
* **A walled off abscess** may result in a chronic appendix mass. This may lead to fistulas to other organs
* **Infection** may involve the portal veins causing **portal vein thrombosis** or hepatic abscesses
169
Week 209. Which **cells** are involved in **acute** inflammation?
**Neutrophils** and **eosinophils** (polymorphonuclear leukocytes).
170
Week 209. Which **cells** are involved in **Chronic** inflammation?
**Lymphocytes, plasma cells, macrophages** (mononuclear leukocytes).
171
What proportion of **appendicectomies** are **normal**?
1 in 5
172
Week 209. What does this image show?
Endocrine cells.
173
Week 209. What does this image show?
Threadworm/Pinworm
174
Week 209. What does this image show?
Mucosal Crypts (Appendix).
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