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semester 2 (3rd year) > Case 14: Per rectum bleeding > Flashcards

Case 14: Per rectum bleeding Flashcards

1
Q

what can cause diarrhoea without blood loss

A

norovirus
coeliac
hyperthyroidism
IBS
lactose intolerance
bile acid diarrhoea
constipation with overflow diarrhoea
laxative abuse
giardia infection
pancreatic exocrine insufficiency

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2
Q

what can cause diarrhoea with the potential of blood loss

A

IBD
colorectal cancer
severe c.diff
diverticulitis
ischameic colitis
shinga toxin producing e.coli infection
shigella infection

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3
Q

what can cause visible blood loss without diarrhoea

A

haemorrhoids
perianal fissure

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4
Q

how long does norovirus typically last

A

24-72hrs

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5
Q

how long does giardia infection typically last

A

many weeks

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6
Q

what is giardia and how does it present

A

parasitic infection
foul smelling diarrhoea, bloating, cramping, abdominal pain and weight loss

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7
Q

route of infection with giardia

A

exposure to contaminated flood, water of faeces

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8
Q

1st line treatment for giardia

A

metronadiazole

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9
Q

what is pancreatic exocrine insufficiency

A

reduced secretion pancreatic enzymes meaning food cannot be broken down and absorbed

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10
Q

presentation of pancreatic exocrine insufficiency

A

weight loss
bloating abdominal pain
foul smelling diarrhoea
steatorrhea

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11
Q

causes of pancreatic exocrine insufficiency

A

pancreatitis
malignancy
previous surgery
diabetes
CF

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12
Q

rarer causes of ischaemic colitis in younger patients

A

sickle cell
vasculitis

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13
Q

what type of organism is shigella

A

bacteria

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14
Q

how is shigella spread?

A

contact with contaminated food, water or facaes
can be spread by sexual contact with infected person

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15
Q

presentation of shigella

A

bloody diarrhoea
crampy abdominal pain
fever

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16
Q

how long does shigella typically last

A

normal= symtoms resolve within one week

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17
Q

how should shigella be treated in immunocompromised patients

A

previously ciprofloxacin but due to antibiotic resistance azithromycin now used

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18
Q

how is shiga toxin producing e.coli spread

A

contaminated food, water or faeces

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19
Q

presentation of shiga toxin producing e.coli

A

damages bowel wall causing abdominal pain, bleeding and diarrhoea

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20
Q

treatment of shiga toxin producing e.coli

A

not treated with antibiotics due to risk of haemolytic uraemic syndrome (more common in children)

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21
Q

what is an anal fissure

A

small tear in the lining of the anal canal

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22
Q

presentation of anal fissure

A

sharp pain on defecation
bright red blood in stool/on wiping

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23
Q

what % of those with IBD have an affected 1st degree relative

A

10-25%

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24
Q

relation of smoking and IBD

A

is a risk factor for crohns
masked the symptoms of UC- smoking cessation can bring about disease

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25
Q

extra intestinal manifestations occur in what % of IBD patients

A

20-40%

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26
Q

what are these extra intestinal manifestations

A

arthritis
skin lesions
eye disease
liver disease

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27
Q

steps to take if your 1st differential is IBD

A

send blood tests
do feacal calprotectin (FCP) and stool cultures
urgent outpatient referral to gastroenterology

28
Q

which diarrhoea drug is contraindicated in IBD

A

loperamide
can increase the risk of bowel dilation and toxic megacolon in IBD

29
Q

aside from IBD, what other conditions can cause an increase in faecal calprotectin

A

severe c.diff mediated diarrhoea
PPIs
severe diverticulitis
acute appendicitis
ischaemic colitis

30
Q

changes to potassium, urea and albumin in chronic diarrhoea

A

low K+ due to loss from GI tract
raised urea due to dehydration
low albumin due to chronic inflammation causing increased albumin degradation

31
Q

other causes of hypokalaemia

A

vomiting
loop/thiazide diuretics
mineralocorticoid excess

32
Q

what issues can hypokalaemia cause

A

cardiac arrythmias
muscle cramps

33
Q

hypokalaemia ECG changes

A

T wave flattening
ST depression
U waves

34
Q

what is considered a fluid challenge

A

500ml of 0.9% sodium chloride over less than 15 mins

never give K+ with this as it can cause ventricular arrhythmias and death

35
Q

what 2 situations would you always give IV steroids despite infection

A

if you suspect acute adrenal crisis

if they are on long term steroids and now cannot take them orally (missing a dose may cause adrenal crisis)

36
Q

3 complications of UC (from most to least likely)

A

iron deficiency anaemia
colorectal cancer
primary sclerosing cholangitis

37
Q

what drug can cause rectal ulceration

A

nicorandil (anti-anginal drug)

38
Q

what are the 5 cardinal features of acute inflammation

A

pain
swelling
redness
heat
loss of function

39
Q

pathophysiology of acute inflammation

A

histamines and prostaglandins cause vasodilation of arterioles resulting in local hyperaemia

this causes redness and heat

increase in capillary permeability causes fluid exudate from the vascular space into the interstitial space

this results in pain, oedema and reduced movement

neutrophils move from blood vessels to the affected area by marginating along the endothelium before attaching to the endothelial wall via adhesion to emigrate thought the wall towards the affected area

here the neutrophil does phagocytosis

40
Q

the eventual potential outcomes of acute inflammation

A

complete resolution

fibrosis and formation of scar tissue

chronic inflammation

formation of an abscess

41
Q

what is an abscess

A

localised collection of pus walled off by granulation tissue

42
Q

what does the pus contain in an abscess

A

necrotic tissue
neutrophils
pathogens
it is usually under pressure as enzymes continually break down proteins which increase oncotic pressure (this causes pain)

43
Q

management of an abscess

A

incision and drainage
if it is within a cavity (peritoneal) it may be appropriate to radiologically insert a drain to remove the pus

44
Q

what is necrotising fasciitis

A

subset of aggressive soft tissue and skin infections that cause necrosis of the muscle fascia and subcutaneous tissues

45
Q

clinical features of necrotising fasciitis

A

skin necrosis
skin crepitus (air bubbles under skin- gas forming organism)
septic shock

46
Q

mortality rate of necrosting fasciits

A

it leads to sepsis
20% mortality

47
Q

management of necrosting fasciits

A

urgent debridement- removal of surface debris, slough, and infected matter from the wound bed

48
Q

causes of perianal abscess

A

blocked glands in the anal area
infection of an anal fissure
STD
trauma

49
Q

risk factors for perianal abscess

A

diabetes
anal sex
chemotherapy
IBD
corticosteroids
weakened immune system (HIV/AIDS)

50
Q

what are haemorrhoidal cushions

A

highly vascular structures around the rectum that help with stool control and continence

51
Q

what are haemorrhoids

A

when these cushions get inflamed, swell and start prolapsing downwards under pressure

52
Q

what are internal haemorrhoids

A

above dentate line (within the anal canal)

usually painless

can present with bright red rectal bleeding associated with bowel movements

blood coats the outside surface of the stool (haematochezia)

53
Q

what are external haemorrhoids

A

below dentate line

prolapses outwards and is palpable by patient

usually painless

usually painless unless they become acutely thrombosed (swelling and pain)

54
Q

grades of internal haemorrhoids (1-4)

A

1= no prolapse of the mucosa

2= haemorrhoid prolapses on bearing down but reduced spontaneously

3= haemorrhoid prolapses on bearing down but requires manual reduction

4= haemorrhoid prolapses but cannot be reduced

55
Q

medical management of grade 1-2 internal haemorrhoids

A

lifestyle- high fibre diet
laxatives
rubber bad ligation of internal haemorrhoids using proctoscope or endoscope

56
Q

surgical management of grade 2-3 internal haemorrhoids

A

rafelo procedure (radiofrequency ablation of haemorrhoids under local anaesthetic)- uses radiofrequency energy to cauterise the blood supply causing it to retract

haemorrhoidal artery ligation operation (HALO)- ultrasound probe identifies the feeding haemorrhoidal artery which is the ligated with a suture to cut the blood supply off causing thrombosis, fibrosis and retraction of the haemorrhoid

57
Q

surgical mama gent of grade 4 internal/external haemorrhoids

A

excisional haemorroidectomy to physically exercise the haemorrhoid either with energy device or stapler

58
Q

colorectal cancer suspicion endoscopy referral

A

over 40 with unexplained weight loss and abdominal pain

over 50 with unexplained rectal bleeding

over 60 with iron deficiency anaemia or changes in bowel habits or test show occult blood in faeces

59
Q

what position is perianal abscess typically

A

3 o clock
9 o clock

60
Q

what position is perianal fissure typically

A

12 o clock
6 o clock

61
Q

what is the pain like with perianal fissure

A

sharp glass-like pain which radiates up into the rectum on defecation

62
Q

common causes of perianal fissure

A

mechanical stretching (such as constipation)- usually seen at 12/6oclock

63
Q

atypical causes of perianal fissures

A

IBD
immunocompromised status
carcinoma
TB
these can cause tears at any point around anus

64
Q

what typically surrounds a perianal fissure on examination

A

white scar tissue

65
Q

treatment of perianal fissure

A

first give stool softeners and/or laxatives to reduce straining

GTN ointment (0.4%), stool softeners, botox to the anal sphincter to relax it and reduce spasm

surgery where both conservative and medical have failed- do lateral sphincterotomy where the interval sphincter is divided to reduce sphincter spasm

66
Q

risks of lateral sphincterotomy

A

high risk of incontinence to both flatus and faeces

67
Q

features of derv inflammatory bowel disease

A

pyrexia
tachycardia
visible blood in stool
spontaneous bleeding and ulceration on endoscopy

semester 2 (3rd year) (12 decks)

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