GASTRO 2

Question 1

what can intestinal ischaemia be classified into ?

Answer 1

acute mesenteric ischaemia (embolic mesenteric ischaemia, thrombotic mesenteric ischaemia and venous mesenteric ischaemia)
chronic mesenteric ischaemia
colonic ischaemia (ischaemia colitis, the most common type and has the best prognosis)

Question 2

what are the causes for ischaemia bowel disease?

Answer 2

Arterial compromise
embolism - 50% of acute mesenteric events - usually originates from a left sided heart thrombus or from spontaneous or iatrogenic rupture and embolism from an aortic atherosclerotic plaque or aneurysm (interventional radiological procedures are the most common cause of iatrogenic plaque rupture.
thrombosis - acute ischaemia results from thrombus occurring as a progression of atherosclerosis at the origin of the superior mesenteric artery. subacute or chronic ischaemia may result from partial occlusion of the vessel.
vasculitis - different causes of vasculitis can lead to mesenteric ischaemia

Venous compromise
venous thrombosis - frequently involves the superior mesenteric vein. Usually associated with cirrhosis or portal HT.

Hypoperfusion - shock, hypotension or relative mesenteric hypotension. Heart failure, dialysis, drug related, recent surgery or trauma, infection.

Question 3

what is the blood supply to the foregut?

Answer 3

the foregut is the stomach and part of the duodenum, biliary system, liver, pancreas
it is supplied by celiac artery

Question 4

what is the blood supply to the midgut?

Answer 4

the mid gut is the duodenum to the 1st half of the transverse colon
it is supplied by the superior mesenteric artery

Question 5

what is the blood supply to the hindgut?

Answer 5

the hindgut is the snd half of the transverse colon to the rectum
it is supplied by the inferior mesenteric artery

Question 6

how does acute mesenteric ischaemia present?

Answer 6

acute severe abdominal pain , sudden onset and out-of-keeping with physical exam findings
later can develop shock, peritonitis and systemic inflammatory response

Question 7

how does chronic mesenteric ischaemia present?

Answer 7

relatively rare clinical diagnosis due to its non-specific feature and may be thought of as intestinal angina. Colicky, intermittent abdominal pain occurs.

abdominal bruit may be heard
there may be rectal bleeding, malabsorption and nausea and vomiting

Question 8

how do you manage acute mesenteric ischaemia?

Answer 8

urgent surgery is usually required - poor prognosis especially if surgery is delayed as life threatening complications such as septic peritonitis and progression of a systemic inflammatory response syndrome into a multi organ dysfunction syndrome mediated by bacterial translocation across the dying gut wall - if this happens resus with fluids and antibiotics is needed and usually a heparin is required

if non-occlusive - papaverine infusion and observation

if embolus - endovascular therapy, +/- open embolectomy or arterial bypass +/- bowel resection
if thrombosis - heparin plus endovascular therapy +/- arterial reconstruction or bypass +/-bowel resection plus papaverine infusion
if mesenteric vein thrombosis - anticoagulation plus observation
if vasculitis - corticosteroid - IV methylprednisolone

Question 9

how do you manage chronic mesenteric ischaemia?

Answer 9

surgical systemic-mesenteric bypass

if not surgical candidate - medical optimisation and percutaneous angioplasty and stenting

Question 10

which areas are most susceptible to ischaemia colitis?

Answer 10

watershed areas - splenic flexure and caecum

which are borders of the territory supplied by the superior and inferior mesenteric arteries.

Question 11

who is at risk of ischaemic colitis?

Answer 11

the elderly
people with underlying atherosclerosis and vessel occlusion
also occurs in younger people - associated with contraceptives, thrombophillia and vasculitis

Question 12

what is ischaemic colitis ?

Answer 12

it describes acute but transient compromise to the blood flow in the large bowel - it may lead to inflammation, ulceration and haemorrhage.

Question 13

what will x-ray show in someone with ischaemic colitis?

Answer 13

thumb printing due to mucosal oedema/haemorrhage

Question 14

how do you manage ischaemic colitis?

Answer 14

usually supportive
surgery may be required in a minority of cases if conservative measures fail - indications would include generalised peritonitis, perforation or ongoing haemorrhage

they may need segmental colectomy

Question 15

how would ischaemic colitis present?

Answer 15

abdominal pain and rectal bleeding

Question 16

what investigations would you preform for bowel ischaemia?

Answer 16

FBC (look for leukocytosis, anaemia, evidence of haemoconcentration)
chemistry panel including serum lactate
coagulation studies
ABG
ECG - look for AF, arrhythmia, acute MI which may have caused the intestinal ischaemia)
erect CXR - look for free air = perforation present
abdominal X-ray - air fluid levels, bowel dilation, bowel wall thickening, pneumatosis)
CT scan with conrast/CT angiogram
sigmoidoscopy or colonoscopy

Question 17

what are the risk factors for ischaemic bowel disease?

Answer 17

old age
smoking history 
hyper coagulable states 
AF
MI 
structural heart defects 
vasculitis

Question 18

what are haemorrhoids?

Answer 18

abnormal swelling or enlargement of the anal vascular cushions - the anal vascular cushions act to assist the anal sphincter in maintaining continence. When these cushions become abnormally enlarged they can cause symptoms and become pathological haemorrhoids.

Question 19

where are the hemorrhoidal cushions usually positioned?

Answer 19

left lateral, right posterior and right anterior portions (3 o’clock, 7 o’clock, 11 o’clock)

Question 20

how are haemorrhoids classified?

Answer 20

usually classified according to their size
1st degree - remain in the rectum
2nd degree - prolapse through the anus on defecation but spontaneously reduce
3rd degree - prolapse through anus on defecation but require digital reduction
4th degree - remain persistently prolapsed

there are two types:
external - originate below the dentate line, prone to thrombosis and may be painful
internal - originate above the detonate line and do not generally cause pain.

Question 21

what are the risk factors for haemorrhoids?

Answer 21

excessive straining (from chronic constipation)
increasing age 
raised intra-abdominal pressure (such as pregnancy, chronic cough or ascites)

Question 22

what are the clinical features of haemorrhoids?

Answer 22

painless bright red rectal bleeding, commonly after defecation and often seen either on paper or covering the pan - importantly blood is seen on the surface of the stool not mixed in.

there may be pruritus, rectal fullness or an anal lump and soiling.

large prolapsed haemorrhoids can thrombose - these can be very painful and patients frequently present as an emergency

examination may be normal unless haemorrhoids have prolapsed

Question 23

what differentials would you want to exclude with rectal bleeding?

Answer 23

malignancy
IBD
diverticular disease

other differentials to consider - fissure-in-ano, perianal abscess or fistula-in-ano.

Question 24

what investigations should be performed for haemorrhoids?

Answer 24

Proctoscopy is typically performed to confirm the diagnosis
may consider FBC if prolonged or significant bleeding
sigmoidoscopy or colonoscopy may be considered to exclude malignancy

Question 25

how are haemorrhoids managed?

Answer 25

dietary and lifestyle - increase fibre and adequate fluids for symptoms - anusol cream, local anaesthetic e.g. instillagel, topical steroids may also consider laxatives grade one - topical corticosteroids - hydrocortisone rectal grade 2 - rubber band ligation or haemorrhoidal artery ligation surgical options remain for grade 3 and 4 - haemorrhoidectomy (stapled haemorrhoidectomy or milligan morgan haemorrhoidectomy )

Question 26

what is a pilonidal sinus?

Answer 26

pilonidal sinus disease is a disease of the inner-gluteal region characterised by the formation of a sinus in the cleft of the buttock - most commonly affecting males aged 16-30 these do not communicate with the anal canal (this occurs in a perianal fistula)

Question 27

what causes a pilonidal sinus to occur?

Answer 27

hair follicles become inserted into the skin, creating a chronic sinus tract - this promotes a chronic inflammatory reaction, causing epithelialised sinus

Question 28

what are the risk factors for a pilonidal sinus?

Answer 28

caucasian males with coarse dark body hair classically associated with those who sit for prolonged periods ``` increased sweating buttock friction obesity poor hygiene local trauma ``` *typically does not occur after the age of 45

Question 29

what are the clinical features of pilonidal sinus?

Answer 29

intermittent red, painful and swollen mass in the sacrococcygeal region. commonly discharge form the sinus there may be systemic signs of infection

Question 30

what investigations would you perform for pilonidal disease?

Answer 30

usually a clinical diagnosis | a rigid sigmoidoscopy or MRI may be needed to distinguish between sinus and perianal fistula.

Question 31

how do you manage pilonidal disease?

Answer 31

doesn't always require surgical treatment - conservative management involves shaving the effected region and plucking the sinus free of any hair that is embedded. any accessible sinuses can be washed out with water to prevent infection pain relief abscess will require surgical drainage septic episodes can be treated with antibiotics (amoxicillin/clavulanate) surgical management abscesses - incision and drainage with washout treatment of chronic disease - Bascom procedure or the Karydakis procedure

Question 32

what is a perianal fistula ?

Answer 32

aka fistula-in-ano | refers to an abnormal connection between the anal canal and the perianal skin

Question 33

what causes perianal fistula?

Answer 33

typically occurs as a consequence of perianal abscess ``` other risk factors include: IBD systemic disease - TB, DM, HIV history of trauma in the anal region previous radiation therapy to the anal region ```

Question 34

how does a perianal fistula usually present?

Answer 34

either present with: - recurrent perianal abcesses - intermittent or continuous discharge onto the perineum, including mucus, blood, pus or faeces on examination, an external opening on the perineum may be seen; these can be fully open or covered in granulation tissue, a fibrous tract may be felt under the skin on digital rectal examination

Question 35

what is the Goodsall rule?

Answer 35

it can be used to clinically predict the trajectory of a fistula tract depending on the location of the external opening

Question 36

what classification system is used for anal fistula?

Answer 36

``` Park's classification system divides anal fistulae into four distinct types extrasphincteric suprasphinteric transsphincteric intershincteric ```

Question 37

what investigations would you perform for an anal fistula?

Answer 37

proctoscopy can be used to visualise the opening of the tract in the anal canal, for a complex fistula, MRI imaging is often required to visualise the anatomy of the tract..

Question 38

what is the management of anal fistula?

Answer 38

definitive management for an anal fistula depends largely on the cause and site. If the patient has no symptoms, a conservative approach may be used surgical options - fisulotomy - suitable for superficial disease, allows tissue to heal by secondary intention - placement of a seton through the fistula attemps to bring together and close the tract (suitable for high tract disease

Question 39

what is a perianal abscess?

Answer 39

it is a collection of pus within the subcutaneous tissue of the anus that has tracked from the tissue surrounding the anal sphincter the most common form of anorectal abscess they are most common in men aged around 40 they have high recurrence rates crohns disease is a risk factor usually caused by gut flora such as E.coli those cause by staph. aureus are more likely to be an infection of the skin rather than originating form the digestive tract

Question 40

what are the features of a perianal abscess?

Answer 40

pain around the anus - worse of sitting they may discover some hardened tissue in the anal region there may be pus like discharge from the anus they may have systemic features of infection of the abscess is long standing there may be localised swelling or itching on examination there will be a erythematous, fluctant, tender perianal mass which may be discharging pus or have surrounding cellulitis however deeper abscess may not have any obvious external signs

Question 41

what are the other types of anorectal abscess?

Answer 41

perianal ischiorectal intersphincteric supralevator

Question 42

what investigations would you perform for a perianal abscess?

Answer 42

most can be detected through inspection of the anus and digital rectal examination when querying underlying cause, colonoscopy, blood (cultures, inflammatory markers, FBC) imaging such as MRI and transperineal USS can be useful

Question 43

what conditions are associated with perianal abscess?

Answer 43

IBD - especially crohns DM is risk factor due to is ability to affect wound healing underlying malignancy

Question 44

how do you manage anorectal abscess?

Answer 44

incision and drainage | antibiotics

Question 45

what is a fistula?

Answer 45

a fistula is defined as an abnormal connection between two epithelial surfaces

Question 46

what are the four types of fistula?

Answer 46

enterocutaneous - these link the intestine to the skin - may be low or high output depending on the source (duodenal/jejunal = high volume, electrolyte rich secretions which can lean to severe excoriation of the skin. Colo-cutaneous fistulas will tend to leak faeculent material. both fistula may result from the spontaneous rupture of an abscess cavity onto the skin or as a result of iatrogenic input) enteroenteric or enterocolic - involves the large or small intestine. In these bacterial overgrowth may precipitate malabsorption syndromes. They may be seen in serious inflammatory bowel disease enterovaginal enterovesicular - fistula that goes into the bladder. May cause frequent UTIs or passage of gas from the urethra

Question 47

how are fistulas managed?

Answer 47

- if there is no underlying IBD or distal obstruction, they will heal so the best option is conservative - where there is skin involvement protect the skin, using a well fitted stoma bag - skin damage is difficult to treat - high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions - high volume may b need TPN to provide nutritional support

Question 48

what is irritable bowel syndrome?

Answer 48

it is a function bowel disorder this means no identifiable organic disease underlying the symptoms they symptoms are a result of an abnormal functioning bowel of an otherwise normal bowel

Question 49

what are the symptoms of IBS?

Answer 49

``` diarrhoea constipation fluctuating bowel habit abdominal pain bloating worse after eating improved by opening bowels ```

Question 50

what are the criteria for diagnosis of IBS?

Answer 50

other pathology should be excluded: - normal FBC, ESR and CRP blood tests - faecal calprotectin negative to exclude IBD - negative coeliac disease serology - cancer is not suspected or excluded if suspected ``` symptoms should suggest IBS - abdominal pain/ discomfort which is relieved on opening bowels or associated with a change in bowel habit and 2 of: - abnormal stool passage - bloating - worse symptoms after eating - PR mucus ```

Question 51

how is IBS managed ?

Answer 51

general healthy diet and exercise - adequate fluid intake - regular small meals - reduced processed foods - limit caffeine and alcohol - low FODMAP diet - trial of probiotic for diarrhoea - loperamide laxative for consitpation - avoid lactulose as can cause bloating. Linaclotide is a specialist laxative for patients for IBS 2nd line - TCA - amitriptyline 3rd line - SSRIs

Question 52

what is a diverticulum?

Answer 52

it is an outpouching if the bowel wall - most commonly found in the sigmoid colon, but can be present throughout the small and large bowel. it is often describe as wear and tear to the patients

Question 53

what are the four manifestations of diverticular disease?

Answer 53

diverticulosis - the presence of diverticular- asymptomatic, incidental finding on imaging. Very common as people age, low fibre and obesity are risk factor diverticular disease - symptoms arising from the diverticula diverticulitis - inflammation of the diverticula diverticular bleed - where the diverticular erodes into a vessel and causes a large volume painless bleed.

Question 54

what are risk factors for diverticular disease?

Answer 54

``` age low dietary fibre intake smoking obesity family history NSAID use ```

Question 55

what are the clinical features of diverticular disease?

Answer 55

a large proportion of individuals remain asymptomatic they may have intermittent lower abdominal pain - typically colicky in nature and may be relieved by defecation. Other symptoms include altered bowel habit, associated nausea and flatulence diverticulitis - acute abdominal pain, typically sharp in nature and usually in the left iliac fossa, worsened by movement - localised tenderness - systemic upset * *corticosteroid or immunosuppressants can mask these symptoms perforated diverticulum will present with sigs of localised peritonism or generalised peritonitis

Question 56

what is a diverticular absess?

Answer 56

a diverticular abscess (often called a pericolic abscess) occurs as a sequelae in complicated diverticulitis

Question 57

what is a hartmann's procedure?

Answer 57

A Hartmann's procedure is a type of surgical operation which is performed for several bowel problems including cancer and diverticular disease. Surgery involves removing the affected section of the bowel and creating an alternative path for faeces to be passed

Question 58

what investigations should you perform for diverticular disease?

Answer 58

FBC abdo x-ray CT of abdomen (CT cologram) barium enema colonoscopy should never be perofmred in any presenting cases of diverticulitis due to the increased risk of perforation if uncomplicated diverticular disease - flexible sigmoidoscopy could be considered if acutely unwell - chest x-ray to look for perforation

Question 59

how do you manage diverticular disease?

Answer 59

if asymptomatic no treatment required dietary modification and fibre supplementation antibiotics - amoxicillin/clavulanate or ciprofloxacin plus metronidazole simple analgesia if there is an abscess it should be drained either surgically or radiologically recurrent episodes requiring hospitalisation are a relative indication for a segmental resection if there is uncontrolled pain, concerns of dehydration, significant co-morbidities or immunocompromised, significant bleeding or symptoms persisting for longer than 48 hours despite conservative management hospitalisation may be needed.

Question 60

what classification is used to stage diverticular disease?

Answer 60

Hinchey classification - from CT description stage 1 - Phlegmon (1a) or diverticulitis with pericolic or mesenteric abscess (1b) stage 2 - diverticulitis with walled off pelvic abscess stage 3 - diverticulitis with generalised purulent peritonitis stage 4 - diverticulitis with generalised faecal peritonitis

Question 61

what are the complications of diverticular disease?

Answer 61

stricture - can occur following repeated episodes of acute inflammation - the bowel becomes scarred and fibrotic resulting in a benign stricture Fistula formation - colovesical fistula, colovagnal fistula haemorrhage perforation abscess ileus/obstruction

Question 62

what s the appendicitis?

Answer 62

The appendix is a small, thin tube of bowel sprouting from the caecum Appendicitis is inflammation of the appendix Results from obstruction of the appendix and subsequent infection and inflammation of the appendix obstruction is usually from a faecolith but can also be due to lymphoid hyperplasia, impacted stool or rarely, an appendiceal or caecal tumour Peak incidence in ages 10-20

Question 63

what are the clinical features of appendicitis?

Answer 63

abdominal pain - typically starts central (dull and poorly localised) and 1 to 12 hours later moves to the right iliac fosse (localised and sharp) as the inflammation progresses. anorexia nausea and vomiting diarrhoea or constipation

Question 64

what may you find on examination of someone with appendicitis?

Answer 64

``` tachycardia tachypnoeic pyrexial rebound tenderness percussion pain over McBurney's point potential guarding especially if perforated ``` specific signs - Rovsing's sign - RIF fossa pain on palpation of the LIF - now thought to be of limited value - Psoas sign - RIF pain with extension of the right hip *retrocaecal appendicitis may have relatively few signs

Question 65

what investigations would you perform for appendicitis?

Answer 65

``` FBC, CRP serum beta HCG to rule out ectopic urinalysis to rule out renal or urological cause USS CT ```

Question 66

what are DD for appendicitis ?

Answer 66

gynaecological - ovarian cyst rupture, ectopic pregnancy, PID Renal - ureteric stones, UTI, pyelonephritis GI - mesenteric adenitits, diverticulitis, IBD, Meckel's diverticulum

Question 67

what risk stratification scores are there for appendicitis?

Answer 67

Men – Appendicitis Inflammatory Response Score Women – Adult Appendicitis Score Children – Shera score

Question 68

how do you manage appendecitis?

Answer 68

laparoscopic appendicectomy | prophylactic IV antibiotics reduces the risk of wound infection rates

Question 69

what are the complications of appendicitis?

Answer 69

- perforation - surgical site infection - appendix mass - pelvic abscess

Question 70

what are the complications of an appendicectomy?

Answer 70

- bleeding/infection/pain/scars - damage to bowel, bladder or other organs - removal of normal appendix - anaesthetic risk - DVT/PE

Question 71

what is acute pancreatitis?

Answer 71

Acute pancreatitis refers to inflammation of the pancreas | pancreatic enzymes amylase/lipase attach the pancreatic tissue

Question 72

what can cause acute pancreatitis | ?

Answer 72

most commonly due to alcohol or gallstones GET SMASHED Gallstones Ethanol (Alcohol) Trauma Steroids Mumps Autoimmune disease, such as SLE Scorpion venom (a rare and unlikely cause in most countries) Hypercalcaemia Endoscopic retrograde cholangio-pancreatography (ERCP) Drugs, such as Azathioprine, NSAIDs, or Diuretics Unfortunately, no evident cause will be found in 10-20% of patients with acute pancreatitis

Question 73

what are the clinical features of acute pancreatitis?

Answer 73

severe epigastric pain that can radiate through to the back nausea and vomiting on examination - epigastric tenderness with or without guarding - in severe cases there may be haemodynamically instability due to the inflammatory response occurring - cullens sign - bruising around umbilicus - Grey turners sign - bruising in the flanks these signs represent retroperitoneal haemorrhage - there may be jaundice (if caused by gallstones)

Question 74

what are the DD for acute pancreatitis?

Answer 74

``` peptic ulcer abdominal aortic aneurysm chronic pancreatitis aortic dissection oesophageal spasm ```

Question 75

what investigations would you perform for acute pancreatitis?

Answer 75

serum lipase or amylase - raised >3 times the upper limit of normal range LFTs - predicts gallstones as underlying cause FBC - leukocytosis is often seen CRP - >200units/L is associated with pancreatic necrosis abdominal USS abdominal XR can show a sentinal loop sign CXR should be performed - may show atelectasis and pleural effusion contrast enhanced abdominal CT

Question 76

what scores are used to identify severe cases of acute pancreatitis?

Answer 76

Glasgow score Ranson score APACHE score

Question 77

what are some common factors indicating severe pancreattits?

Answer 77

``` age >55 hypocalcaemia hyperglycaemia hypoxia neutrophilia elevated LDH and AST ```

Question 78

how do you manage acute pancreatitis?

Answer 78

elevate care according to glascow score IV fluids and oxygen therapy as required - a crystalloid should be used analgesia - opioids may be needed for effective pain control a broad spectrum antibiotic such as imipenem should be considered for prophylaxis against infection of confirmed pancreatic necrosis treat underlying cause once patient has been stabilised for those caused by gallstones - early laparoscopic cholecystectomy is advised. if obstructed biliary system due to stone they should undergo early ERCP

Question 79

what are the complications of acute pancreatitis?

Answer 79

``` pancreatic necrosis infection in necrotic areas pseudocysts chronic pancreatitis haemorrhage pancreatic abscess abdominal compartment syndrome acute respiratory distress syndrome ```

Question 80

what is chronic pancreatitis?

Answer 80

a chronic fibro-inflammatory disease of the pancreas resulting in progressive and irreversible damage to the pancreatic parenchyma. it can affect both exocrine and endocrine functions of the pancreas. around 80% of cases are due to alcohol excess with up to 20% of cases being unexplained.

Question 81

what are the causes of chronic pancreatitis?

Answer 81

around 80% of cases are due to alcohol excess with up to 20% of cases being unexplained. other than alcohol, causes include: genetic - cystic fibrosis, haemochromatosis ductal obstruction - tumours, stones, structural abnormalities

Question 82

what are the features of chronic pancreatitis?

Answer 82

pain - typically worse 15-30 minutes following a meal steatorrhoea - symptoms of pancreatic insufficiency usually develop between 5 and 25 years after onset of pain diabetes mellitus develops in the majority of patients - typically more than 20 years after symptoms begin symptoms of malabsorption weight loss nausea and vomiting they may get recurring attacks of acute pancreatitis Endocrine insufficiency – secondary to damage to the endocrine tissue of the pancreatic gland (islets of Langerhans), there is subsequent failure to produce insulin, resulting in impaired glucose regulation or eventual diabetes mellitus* Exocrine insufficiency – secondary to damage to the acinar cells, resulting in failure to produce digestive enzymes, causing malabsorption, presenting with weight loss, diarrhoea, or steatorrhoea

Question 83

what investigations would you perform for chronic pancreatitis

Answer 83

blood glucose CT scan - will show pancreatic calcifications abdominal USS abdominal X-ray - will show pancreatic calcifications endoscopic retrograde cholangiopancreatography (ERCP) - will show beading of the main pancreatic duct magnetic resonance cholangiopancreatography (MRCO) - may show beaded appearance of the pancreatic duct as well as larger calcifications

Question 84

how do you manage chronic pancreatitis?

Answer 84

``` analgesics - use pain ladder alcohol and cigarette smoking cessation pancreatic enzymes (creon) plus PPI antioxidant vitamin supplementation those with diabetes may need insulin ``` if there is a targetable underlying cause ERCP can be used for diagnostic and therapeutic purposes to remove stones, place stent or sphincterotomy steroid are effective at reducing symptoms in chronic pancreatitis with an immune aetiology