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Abdo Pain And PR Bleeding Flashcards

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1
Q

Risk factors for colorectal carcinoma

A

FH
Age
Western diet (low in dietary fibre, high in fat)
UC
Smoking

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2
Q

Protective factors for colorectal carcinoma

A

Fruit and veg / fibre consumption
Exercise
HRT
Aspirin / NSAIDs

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3
Q

Genetic aetiology of colorectal carcinomas

A

Familial adenomatous polyposis responsible for <1% of cancers and occurs due to tumour suppressor gene APC mutations

Hereditary non-polyposis colorectal cancer responsible for <5% of all cancers and arises from germline mutations in mismatch repair genes

Most cancers are sporadic however occurring without strong family history

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4
Q

Pathophysiology of colorectal carcinoma

A

Adenocarcinoma with characteristic signet ring cells on histology
Majority of tumours occur in the recto-sigmoid regions

Usually appear as a polyploid mass with ulceration spreading initially by direct infiltration through the bowel wall
Then involves the lymphatic and blood vessels, metastasising primarily to the liver

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5
Q

Clinical presentation of colorectal carcinoma

A

Abdominal mass
Abdo pain
GI haemorrhage or perforation
Right sided tumours often more asymptomatic
Iron deficiency anaemia / weight loss
Left sided tumours more commonly present with PR blood / mucus, altered bowel habit, tenesmus, obstruction and a mass on PR exam

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6
Q

What are the indications for a 2WW referral for urgent endoscopy in patients >40

A

Rectal bleeding or change in bowel habit for >6w
Persistent rectal bleeding in those over 45 with no obvious evidence of benign anal disease
Iron deficiency anaemia without an obvious cause
Palpable abdominal / PR mass

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7
Q

Investigations for colorectal carcinoma

A

FBC (microcytic anaemia), LFT (metastatic indicator)
Colonoscopy (gold standard)
CT chest, abdo, pelvis
Carcino-embryonic antigen can be used to monitor disease

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8
Q

TNM staging of colorectal carcinoma

A

T: the primary tumour is staged in terms of invasion through local structures
N: extent of associated lymph node disease scored
M: extent of distant metastases

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9
Q

Management of colorectal carcinoma

A

Often primarily surgical with possible adjuvant radiotherapy or chemotherapy
Wide resection of the growth and regional lymphatics

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10
Q

What is right hemicolectomy used for

A

Caecal, ascending and proximal transverse colon tumours
- may be temporary end ileostomy prior to colo-colic anastomosis

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11
Q

What is a sigmoid colectomy used for

A

Sigmoid tumours

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12
Q

What is anterior resection used for

A

Low sigmoid / high rectal tumours
Colo-rectal anastomosis achieved at first operation although this may be covered by a temporary loop ileostomy

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13
Q

What is an abdomino-perineal resection

A

For tumours low in the resection
- permanent colostomy with removal of rectum and anus
- no anastomosis

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14
Q

What is Hartmann’s procedure

A

For bowel obstruction or palliation
- resection of recto-sigmoid colon with temporary end colostomy and closure of the rectal stump

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15
Q

When is radiotherapy used in colorectal cancer

A

Used pre-operatively in rectal cancer to reduce recurrence and increase survival
Higher risks of post operative complications

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16
Q

When is chemotherapy used in colorectal cancer

A

Adjuvant 5-FU can reduce mortality of higher stage tumours
May be used with palliative intent to prolong survival in metastatic disease

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17
Q

What is an anorectal abscess

A

Associated with gut organisms with infection origination from an obstructed anal crypt gland
Associated with crohn’s, DM and malignancy

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18
Q

Presentation of perianal infection

A

Severe pain in the anal / rectal area
May be purulent discharge if the abscess has begun to drain spontaneously
Fever / constitutional symptoms are common

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19
Q

Examination of perianal infection / abscess

A

Area of skin with fluctuance, / induration / erythema overlying the perianal skin
Patients with deeper anorectal abscess may not have any physical findings other than severe pain on PR exam

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20
Q

Management of perianal infection / abscess

A

Always requires surgical incision / drainage
Abx post drainage to decrease recurrence rates

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21
Q

Complications of perianal infection / abscess

A

Recurrence - seen in 44%
Anal fistula formation

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22
Q

What is an anal fistula

A

Epithelialised track that connects the abscess with skin or adjacent organs
Usually the result of an abscess discharging internally to form a fistula
Patients present with intermittent rectal pain as well as intermittent and malodorous perianal drainage

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23
Q

Risk factors for anal fistula formation

A

Crohn’s
Diverticular disease
Rectal carcinoma
Immunocompromisation

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24
Q

Anal fistula management

A

Primarily surgical but can be difficult to treat
Superficial and low level fistulae are laid open to heal by secondary intention
High fistulae involve the continence muscles of the anus and may be injected with fibrin glue or fistula plug

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25
What are haemorrhoids
Disrupted / dilated anal cushions which are used to maintain the internal and external anal sphincters and therefore control continence
26
Anatomy of haemorrhoids
Anal canal runs from superior aspect of pelvic diaphragm to the anus and is normally collapsed The internal anal sphincter is an involuntary sphincter surrounding the upper 2/3 of the anal canal External anal sphincter surrounds the lower 2/3 of the anal canal and is under voluntary control mediated by inferior rectal nerve
27
What causes haemorrhoids to form
Prolapses of anal cushions Caused by a breakdown of smooth muscle layer (muscularis mucosae)
28
Aetiology of haemorrhoids
Mainly idiopathic Increased anal tone (chronic constipation) Factors that cause congestion of superior rectal veins : cardiac failure, liver cirrhosis, pregnancy, rectal carcinoma, raised IAP
29
Haemorrhoids classification
1st degree: confined to the anal canal, bleed but do not prolapse 2nd degree: prolapse on defecation then reduce spontaneously 3rd degree: prophase outside the anal margin on defecation but can be manually reduced 4th degree: remain prolapsed outside the anal margin at all times
30
Haemorrhoid symptoms
Rectal bleeding (bright red blood) Prolapse Mucous discharge Pruritis ani Pain if the piles become thrombosed
31
OE for haemorrhoids
Abdo exam: examine for palpable masses, enlarged liver Rectal examination: prolapsing piles are obvious Proctoscopy / rigid sigmoidoscopy: can visualise the piles and assess for a lesion higher in the rectum
32
Complications of haemorrhoids
Anaemia if there is severe / continuous bleeding Thrombosis - if prolapsing piles are gripped by the anal sphincter then venous return is occluded leading to thrombosis Haemorrhoids swell, become purple and tense and cause pain
33
How to treat thrombosed piles
Often fibrose within 2-3 weeks - spontaneous cure Cold compress Opioids Rest
34
Management of haemorrhoids
Conservative management - plenty of fluids, dont strain - topical analgesia / astringents and a bulk forming laxative Sclerotherapy - 5% phenol in almond oil injected above each pile as a sclerosing injection - suitable for 1st and 2nd degree piles - painless
35
What is banding (haemorrhoids)
Application of a small rubber band to the protruding mucosa - leads to strangulation 3rd degree piles Care must be taken out position band above dentate line
36
Describe surgery as a management for haemorrhoids
Reserved for 3rd and 4th degree piles Stapled haemorrhoidpexy or haemorrhoidal artery ligations are the main methods used
37
What are anal fissures
A tear in the sensitive anal canal distal to the dentate line producing pain on defecation most commonly seen in males
38
Aetiology of anal fissures
Mainly due to hard faeces with 10% of the anterior tears due to parturition Occur at the midline more as the blood supply to this area is worse and thus healing is more difficult Sometimes caused by infection, trauma, crohn’s, anal cancer and psoriasis
39
Anal fissures symptoms
Pain worse on defecation, lasting for hours afterwards Associated constipation Pruritis ani Bleeding on defecation
40
OE of anal fissures
Midline longitudinal tear in the rectal mucosa PR may not be possible due to pain and sphincter spasm
41
Management of early, small anal fissures
Early small fissures may heal spontaneously Local anaesthetic ointments and a lubricant laxative can be used for symptomatic relief High fibre diet, lots of fluid and bulk forming laxative
42
Management of chronic anal fissures
GTN cream is used to relax anal sphincter and allow torn epithelium to heal - can give headaches Botulinum toxin injection - same effect but for 8 weeks but can cause incontinence Intractable fissures of recurrent cases may require sphincterotomy under GA
43
What is Diverticular disease
Diverticula are sac like protrusions of mucosa through the muscular wall of the colon, causing a spectrum of disease Diverticular disease is the presence of symptomatic diverticula causing intermittent lower abdo pain, without inflammation and infection
44
What is diverticulosis
The presence of diverticula
45
What is diverticulitis
The presence of inflamed diverticula Uncomplicated: diverticula inflammation without symptoms of acute abdomen or signs of perforation or abscess formation Complicated: diverticulitis with complications such as abscess, peritonitis, fistula, obstruction or perforation
46
Pathophysiology of Diverticular disease
50% of patients over the age of 50 Most frequently in the sigmoid with 99% of complications at this site Hypertrophy of the muscular propria with diverticula then occurring at sites of potential weakness in the bowel wall
47
Risk factors for Diverticular disease
Age Genetics Low fibre diet Obesity Smoking Marfaans Ehlers-Danlos syndrome PKD
48
Symptoms of diverticula (if symptomatic)
Exactly mimic carcinoma of the colon - left sided colic, relieved by defecation - altered bowel habit - nausea - flatulence - severe pain and constipation
49
Diverticula disease investigations
PR (look for masses) Sigmoidoscopy / colonoscopy - to rule of CRC
50
Management of diverticula disease
Diet and lifestyle advice High fibre diet + bulk forming laxatives Antispasmodic agents
51
What is acute diverticulitis
Acute infection of diverticula that occurs due to stagnation of pouch contents
52
Symptoms of acute diverticulitis
Severe left sided colicky abdo pain Constipation or overflow diarrhoea Symptoms mimicking appendicitis but on the left
53
Signs of acute diverticulitis
Fever and tachycardia - systemic illness Tenderness, guarding and rigidity on the left side Palpable mass on the LIF
54
What is a mild attack of acute diverticulitis and how is it managed
Absence of fever Mild pain Minimal abdominal tenderness / guarding Normal observations Managed in community with rest, fluids, oral analgesia High risk pts may be prescribed oral abx or hospital admission
55
What is a severe attack of acute diverticulitis and how is it managed
High grade fever Severe pain Significant abdo tenderness / guarding Signs of systemic illness Admit to hospital Give analgesia, IV fluid, IV abx Bloods Imaging : CXR, CTAP
56
Complications of Diverticular disease
Perforation Abscess formation Bleeding Fistula formation Strictures / intestinal obstruction
57
Describe perforations as a complication in Diverticular disease
Usually in acute diverticulitis Can lead to formation of a paracolic or pelvic abscess or generalised peritonitis Classically presents with ileus and peritonitis +/- shock 40% mortality Management is with laparotomy +/- hartmann’s procedure
58
Describe abscess formation as a complication in Diverticular disease
Usually in acute diverticulitis Presents with swinging fever, leucocytosis and localising signs These should be drained under CT guidance
59
Describe bleeding as a complication of Diverticular disease
Sudden, painless bleeding as a result of erosion of vessels at the fundus of the diverticulum Large volumes can be lost, requiring transfusion Bleeds often stop spontaneously with bed rest If doesn’t stop treat with angiography and arterial embolisation
60
What is haematochezia
Unaltered PR blood most commonly seen in the context of lower GI haemorrhage Can originate from massive upper GI bleeds Can be associated with haematemesis and maelena
61
Define lower GI bleeding
Blood loss originating from a site distal to the ligament of treitz (at the level of the duodenojejunal junction)
62
How to differentiate between different lower GI bleeds
Left sided (ascending) colonic bleeds tend to be bright red Right sided (descending) colonic bleeds tend to be dark or maroon
63
Anatomic aetiology of lower GI bleeding
Diverticulosis (most common cause of lower GI haemorrhage)
64
vascular causes of lower GI bleeding
Angiodysplasia (dilated, tortuous submucosal vessels that occur secondary to degeneration of the bowel wall with age) , haemorrhoids, ischaemic colitis, radiation induced bleeding - classically seen in patients with aortic stenosis (heydes syndrome)
65
Inflammatory aetiology of lower GI bleeding
IBD infective colitis
66
Malignant causes of lower GI bleeding
Polyp Carcinoma
67
What is a Diverticular bleed associated with
LLQ pain
68
What is anal fissure associated with
Pain on defecation
69
What is rectal cancer associated with
Tenesmus PR bleed with defecation
70
What is colon cancer associated with
Change in bowel habit Weight loss
71
What is colitis associated with
Diarrhoea and abdo pain
72
Prognosis of upper GI bleed
Bleeds will resolve spontaneously in 85% of cases without the need for intervention Mortality rate is 2-4%
73
Primary causes of constipation
Slow transit constipation - prolonged delay in stool transit through colon, occurring mainly in young women Defecatory disorders - difficulty expelling stool from the rectum IBS
74
Secondary causes of constipation
- neurogenic : MS, Parkinson’s, autonomic neuropathy, hirchsprungs, spinal cord injury - non-neurogenic: hypothyroid, anorexia nervosa, pregnancy, hypokalaemia - iatrogenic: anticholinergics, iron supplements, aluminium antacids, opioids
75
Risk factors for constipation
Age Female Inactivity Poly pharmacy Decreased oral intake Depression
76
Clinical features of constipation
Infrequent stools <3/week Unsatisfactory defecation / feeling of incomplete evacuation Difficulty with stool passage: straining, lumpy hard stools, use of digital manoeuvres Overflow incontinence
77
Red flag symptoms of constipation
Acute onset or change to regular bowel habit PR bleeding / iron deficiency anaemia Weight loss Severe persistent constipation
78
OE for constipation
Abdominal and rectal examination Examine for masses, hard stool, anal fissure, haemorrhoids and sphincter tone
79
Constipation investigations
Bloods to rule out secondary causes FBC, TFTs, UEC, CMP Endoscopy if red flag symptoms persist
80
Constipation management
1. Ensure adequate fluid intake and exercise 2. Dietary changes: increase fibre / whole foods 3. Behavioural: attempting to defecate at the same time daily / positioning 4. Laxatives 5. Suppositories / enemas: can be helpful for defecatory dysfunction 6. Manual disimpactation - last line manoeuvre
81
What do bulk forming laxatives do
Absorb water to increase faecal mass
82
What do surfactant laxatives do
Decrease surface tension of stool allowing more water to enter
83
What do osmotic agent laxatives do
Cause intestinal water secretion
84
What do stimulant agent laxatives do
Alter electrolyte transport in the intestinal mucosa to increase motor activity
85
Complications of constipation
Anal fissures Haemorrhoids Faecal impaction Stercoral perforation
86
Differentials for abdominal pain with PR bleeding
IBD Diverticular disease Malignancies (bowel / anal) Angiodysplasia Ischaemic colitis Haemorrhoids
87
What is the sepsis 6
1. Give O2 to keep SATS above 94% 2. Take blood cultures 3. Give IV abx 4. Give a fluid challenge 5. Measure lactate 6. Measure urine output
88
What. Are the causes of abdominal distension (6F’s)
Fat Fluid Flatus Faeces Fetus Fulminant mass

Junior Surgery (7 decks)

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