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

Case 14: Per rectum bleeding Flashcards

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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
extra intestinal manifestations occur in what % of IBD patients
20-40%
26
what are these extra intestinal manifestations
arthritis skin lesions eye disease liver disease
27
steps to take if your 1st differential is IBD
send blood tests do feacal calprotectin (FCP) and stool cultures urgent outpatient referral to gastroenterology
28
which diarrhoea drug is contraindicated in IBD
loperamide can increase the risk of bowel dilation and toxic megacolon in IBD
29
aside from IBD, what other conditions can cause an increase in faecal calprotectin
severe c.diff mediated diarrhoea PPIs severe diverticulitis acute appendicitis ischaemic colitis
30
changes to potassium, urea and albumin in chronic diarrhoea
low K+ due to loss from GI tract raised urea due to dehydration low albumin due to chronic inflammation causing increased albumin degradation
31
other causes of hypokalaemia
vomiting loop/thiazide diuretics mineralocorticoid excess
32
what issues can hypokalaemia cause
cardiac arrythmias muscle cramps
33
hypokalaemia ECG changes
T wave flattening ST depression U waves
34
what is considered a fluid challenge
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
what 2 situations would you always give IV steroids despite infection
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
3 complications of UC (from most to least likely)
iron deficiency anaemia colorectal cancer primary sclerosing cholangitis
37
what drug can cause rectal ulceration
nicorandil (anti-anginal drug)
38
what are the 5 cardinal features of acute inflammation
pain swelling redness heat loss of function
39
pathophysiology of acute inflammation
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
the eventual potential outcomes of acute inflammation
complete resolution fibrosis and formation of scar tissue chronic inflammation formation of an abscess
41
what is an abscess
localised collection of pus walled off by granulation tissue
42
what does the pus contain in an abscess
necrotic tissue neutrophils pathogens it is usually under pressure as enzymes continually break down proteins which increase oncotic pressure (this causes pain)
43
management of an abscess
incision and drainage if it is within a cavity (peritoneal) it may be appropriate to radiologically insert a drain to remove the pus
44
what is necrotising fasciitis
subset of aggressive soft tissue and skin infections that cause necrosis of the muscle fascia and subcutaneous tissues
45
clinical features of necrotising fasciitis
skin necrosis skin crepitus (air bubbles under skin- gas forming organism) septic shock
46
mortality rate of necrosting fasciits
it leads to sepsis 20% mortality
47
management of necrosting fasciits
urgent debridement- removal of surface debris, slough, and infected matter from the wound bed
48
causes of perianal abscess
blocked glands in the anal area infection of an anal fissure STD trauma
49
risk factors for perianal abscess
diabetes anal sex chemotherapy IBD corticosteroids weakened immune system (HIV/AIDS)
50
what are haemorrhoidal cushions
highly vascular structures around the rectum that help with stool control and continence
51
what are haemorrhoids
when these cushions get inflamed, swell and start prolapsing downwards under pressure
52
what are internal haemorrhoids
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
what are external haemorrhoids
below dentate line prolapses outwards and is palpable by patient usually painless usually painless unless they become acutely thrombosed (swelling and pain)
54
grades of internal haemorrhoids (1-4)
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
medical management of grade 1-2 internal haemorrhoids
lifestyle- high fibre diet laxatives rubber bad ligation of internal haemorrhoids using proctoscope or endoscope
56
surgical management of grade 2-3 internal haemorrhoids
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
surgical mama gent of grade 4 internal/external haemorrhoids
excisional haemorroidectomy to physically exercise the haemorrhoid either with energy device or stapler
58
colorectal cancer suspicion endoscopy referral
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
what position is perianal abscess typically
3 o clock 9 o clock
60
what position is perianal fissure typically
12 o clock 6 o clock
61
what is the pain like with perianal fissure
sharp glass-like pain which radiates up into the rectum on defecation
62
common causes of perianal fissure
mechanical stretching (such as constipation)- usually seen at 12/6oclock
63
atypical causes of perianal fissures
IBD immunocompromised status carcinoma TB these can cause tears at any point around anus
64
what typically surrounds a perianal fissure on examination
white scar tissue
65
treatment of perianal fissure
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
risks of lateral sphincterotomy
high risk of incontinence to both flatus and faeces
67
features of derv inflammatory bowel disease
pyrexia tachycardia visible blood in stool spontaneous bleeding and ulceration on endoscopy

Semester 2 (3rd year) (12 decks)

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