Gastro Flashcards
(56 cards)
1
Q
Suspicion of IBD
A
- Diarrhoea for more than 4 weeks
- Opening the bowels more than twice a day
- wet/fluid-like stool
- Abdominal pain
- Stool containing blood, mucus or pus
2
Q
Ulcerative colitis
A
- Chronic inflammatory bowel disease that is only localised in the mucus membrane of the colon/rectum.
- There are ulcers and signs of inflammation in the rectum and the colon. It is a recurrent disease.
- Diarrhoea, bloody stool, crampy abdominal pain, weight loss, loss of appetite
- Diffuse ulceration in colon mucus membrane, crypt abscess, infiltration.
3
Q
Crohn’s disease
A
- Chronic, segmental or multi-segmental. All the layers of the intestine is affected
- Both small intestines and the colon might be affected
- Cramp-like abdominal pain, weight loss, diarrhoea, fever
- Local inflammation, micro-erosions, fissures, granuloma, fistulas, infiltrations, lymphatic vessel enlargement
4
Q
Ulcerative Colitis Localisation
A
Sigmoid-rectum 54%
Left colon 27%
Pancolitis 19%
5
Q
Crohn’s disease Localisation
A
Small intestine and colon 50%
Ileitis 29%
Colitis 19%
Anorectal 2%
6
Q
Extraintestinal symptoms
A
Arthritis, polyarthritis 26%
Erythema nod., Pyoderma gangr. 19%
Fatty liver, Chr. Active hepatitis, PSC 7%
Iridocyclitis, Uveitis 4%
Oral, stomatitis aphtosa 4%
Alveolitis, lung fibrosis <1%
7
Q
Diagnostics: Crohn’s disease
A
- Colonscopy, (biopsy) capsule-endoscopy
- X-ray, Barium enema and meal
- UH, CT
- Laboratory (blood) tests ( Sedimentation, WBC, CRP, liver enzymes, stool culture )
8
Q
Diagnostics: Ulcerative colitis
A
- Colonscopy, (biopsy) capsule-endoscopy
- X-ray, Barium enema and meal
- UH, CT
- Laboratory (blood) tests ( Sedimentation, WBC, CRP, liver enzymes, stool culture )
9
Q
Crohn’s disease: Therapy
A
- Acute fulminate: exclusion of abscess then Steroid 40-60 mg, wide spectrum antibiotics
- Subacute disease: Steroid in decreasing dosage Budenofalk, sulfasalazin, Pentasa, Salofalk, metronidasol
- Chronic: constant low dose steroid, Imuran, 5-aminosalicyl
10
Q
Ulcerative colitis :Therapy
A
- Acute inflammation: Steroid, antibioticum, 5-ASA
- Chronic : 5-ASA, Imuran
11
Q
Crohn’s disease: complications
A
- Stenosis, ileus (bowel obstruction)
- Fistula formation
- Abscess formation
- Bleeding
- Toxic megacolon
- Malignant transformation
12
Q
Ulcerative colitis: complications
A
- Stenosis, ileus (bowel obstruction)
- bleeding
- Perforation, abscess formation, peritonitis
- Toxic megacolon
- Malignant transformation
13
Q
Crohn’disease: Surgical therapy
A
- Maximally conservative !!!
- Resection (preserving as much small intestine as possible!)
- Srticturopalsty (small intestine)
- Toxic megacolon
14
Q
Ulcerative colitis: Surgical treatment
A
In acute case: - Hartmann procedure - Proctocolectomy Elective operation: - Proctocolectomy with ileostomy - Total colectomy with ileo-rectal anastomosis - Proctocolectomia , ileo-analis anastomisis with ileum pauch - Proctocolectomia, Koch-reservoir
15
Q
Clinical features which distinguish acute appendicitis from non-specific (non-surgical) abdominal pain
A
- Pain moving to right lower quadrant
- Pain aggravated by movement and coughing
- Nausea, vomiting and anorexia
- Facial flushing but with hyperpyrexia
- Focal tenderness in right lower quadrant
- Rebound tenderness plus muscle guarding
- Right focal (abdominal) tenderness on rectal exam
16
Q
Clinical features suggesting perforated viscus
A
- Pain of sudden onset
- Constant sever pain
- Pain aggravated by movement, coughing and inspiration
- Decreased abdominal movements
- Diffuse tenderness
- Silent, rigid abdomen
17
Q
Clinical features suggesting intestinal obstruction
A
- Colicky, severe pain
- No factor aggravating pain
- Vomiting and constipation
- Previous surgery
- Abdominal distension
- Bowel sounds hyperactive or absent
18
Q
Features suggesting ectopic pregnancy
A
- Delayed, irregular periods
- Possible or confirmed pregnancy
- Faintness and dizziness
- Vaginal discharge
- Any abnormality on vaginal examination
19
Q
Features suggesting intussusception
A
- Age less than 30 months
- Episodic pain
- Sever central pain
- No aggravating factors
- Blood in stool
- Distress or pallor
- Diffuse tenderness
- Muscle guarding
- Palpable mass
- Abnormal bowel sounds
20
Q
Important features of cancer
A
- Intermittent pain over 48 hours’ duration
- Any alteration to bowel habits
- Abdominal distension
- Mass present
21
Q
Important features of vascular disease
A
- Sudden onset of pain
- Associated chest pain and arrhythmias
- Lower limb pulses diminished
- Pallor and cyanosis
22
Q
Features of colonic perforation
A
- Pain over 48 hours’ duration
- Pain onset in lower abdomen
- Any alteration in bowel habits
- Abdominal distension
23
Q
Diseases with abrupt, excruciating pain:
A
- Biliary colic
- Ureteral colic
- MI
- Perforated ulcer
- Ruptured aneurysm
24
Q
Diseases with Rapid onset of sever, constant pain:
A
- Acute pancreatitis
- Mesenteric thrombosis
- Strangulated bowel
- Ectopic pregnancy
25
Diseases with gradual, steady pain:
- Acute cholecystitis
- Acute cholangitis
- Acute hepatitis
- Appendicitis
- Acute salpingitis
- Diverticulitis
26
Diseases with intermittent, colicky pain, crescendo with free intervals:
- Early pancreatitis
- Small bowel obstruction
- IBD
27
Investigations used in the management of the acute abdomen
```
Urine
- Dipstick
- Mid-stream specimen
Blood
- Full blood count
- Urea and electrolytes
- Liver function test
- Serum amylase
- Blood gases, calcium, glucose
Radiography
- Chest radiograph
- Abdominal radiograph
- Contrast studies
Ultrasound
Axial CT
Peritoneal lavage
Laparoscopy
Laparotomy
```
28
Intra-abdominal diseases causing abscess formation:
- Perforated malignant tumors
- Perforated peptic ulcer
- Biliary disease
- Acute pancreatitis
- Ischemic bowel (including internal and external hernias)
- Meckel’s diverticulitis
- Appendicitis
- Crohn’s disease
- Pelvic inflammatory disease
- Pyelonephritis
- Uteric obstruction
- Diverticulitis
- Lower urinary tract infection
29
colorectal carcinomas
CRC= adenocarcinoma (mucinous, non-differentiated)
- Colon cc, rectum cc, anus (plano/squamous cell)
- II. cause of death in neoplastic mortality list
- 40-45% of all cases curable
30
Etiology of CRC
Familial: 20% (FAP, HNPCC, other)
Sporadic:
- low fiber diet, slow transit, high fat and meat content, (Africa
31
Pathogenesis of CRC
- Adenoma-carcinoma sequence, 10-15 yrs
- Sporadic cc: acquired mutations
- FAP: APC (inherited muation) HNPCC: mutation in mismatch repair genes
- K-ras (point mut.), myc (ampl.), src-kinase activation, DCC, p53
- HNPCC: Lynch I, II syndroms
32
HNPCC, Amsterdam - Bethesda criteria
1. At least two generations are affected
2. First appearance of CRC before age 50
3. At least two first degree realatives
4. FAP can be excluded
5. Extracolonic tu: gastric, endometrium, ovarium, biliary-, urinary
6. Synchron or metachron tumors
33
Layers of the wall of the colon - staging
```
TIS: Astler-Coller
T1: (Dukes) A
T2: (Dukes) B1, C1
T3: (Dukes B2, C2)
T4: (Dukes) D
```
34
Staging of CRC
T1: submucosa infiltration
T2: muscularis propria infitration
T3: subserosa or not peritonealized surface
T4: neighbouring organ, or peritoneum inf.
N0: absence of nodal infiltration
N1: metasis in 1-3 lymphnode
N2: metastasis in 4 lymph nodes
N3: metastasis along a main arterial branch
M0: no distant met.
M1: distant met.
35
Symptoms of CRC, right colon
- Anemia, weakness, melena, weight loss,
| - (palpable resistance in the right lower quadrant
36
Symptoms of CRC, left colon
- Blood in the stool, or tarry stool, change in bowel habit, alternation of diarrhoea and obstipation, ample voiding of mucus, incomplete evacuation, abdominal distension
- About 16% of CRC might be palpated throught the anus (rectal exam)
37
Incidence, prognosis
- 10- 16% in cecum
- 10 – 16% in ascending colon
- 2 – 6% in distal transverse colon
- 8 – 10% in desending colon
- 50 - 60% in sigmoid colon
38
Treatment of CRC: surgical
- Surgical treatment provides the only curative modality
- The basis of surgical tretament is radicality: removal of all tomor mass in continuity with lymphoid drainage
- Adjuvant modalities might be effective in certain cases
39
Surgical treatment of CRC
1. Segment resection (right and left hemicolectiomy)
2. Anterior resection of the rectum (Dixon)
3. Abdomino-perineal exstirpation of the rectum (Miles)
4. Resection and proximal stoma formation (Hartmann
40
Indications for acute procedures in CRC
- Ileus
- Bleeding
- Perforation
- Peritonitis
41
Postoperative care
- Postoperative „physiologic” ileus
- Enteral nutrition
- Anticoagulation
- Oncologic follow-up, at least 5 yrs
- Abd. US, chest x-ray, CT, MR.
- Laboratory: blood counts, tu. markers
- colonoscopy
42
Special features of rectal cancer
- Worse prognosis
- Neoadjuvant radiochemotherapy may improve results
- Techniquely more challenging intervention
- Quality of life is more deeply affected by the intervetion (sphincter, vegetative nerves)
43
Bowel obstruction-ileus
Key points
- A group of diseases with diverse etiology
- The common feature is obstruction of the bowel
- Similar set of symptoms, which may vary according to site and cause of obstruction
- Therapy is according to etiology, aiming at relief from obstruction, and treatment of primary disease
- May be mechanical or paralytic (US: ileus)
44
Site of obstruction
```
Luminal:
Intussusception, Meconium,
Polypoid tumor, Gallstone,
Bezoar, Parasites,
Feces
```
Mural:
Stricture (Crohn’s disease, radiation)
Small bowel tumor
Congenital atresia, stenosis, duplication
Extrinsic:
Adhesion
Hernia
Malignant or inflammatory mass Volvulus
45
Clinical signs and symptoms of bowel obstruction
- Nausea and vomiting
- Abdominal distension
- Decreased passage of flatus and stool
- Possible causes of obstruction:
o previous operations, presence of hernias,
o previous irradiation, previous malignancy
46
Changes with level of obstruction
HIGH: Frequent vomiting, No distention, Intermittent pain but not classic crescendo type
MIDDLE: Moderate vomiting, Moderate distention, Intermittent pain (crescendo, colicky) with free intervals
LOW: Vomitting late, feculent, marked distention, Variable pain
47
Pathophysiology of bowel obstruction
- Obstruction-incresased luminal pressure-increased secretion, decreased absorption
- Increased peristalsis-stasis-bacterial overgrowth-translocation-septic complications
- Sequestration of fluid-third spacing-hypovolemia
- Impared perfusion-ischemia-necrosis
48
Examination of bowel obstruction
- Degree of distress
- Severity of dehydration
- Evidence of sepsis
- Inspection: scars, hernia orifices, distension
- Auscultation: tinkling, splashing, quiet abdomen
- Palpation: location of tenderness, rigidity, garding
- Rectal exam
49
Laboratory of bowel obstruction
- Degree of dehydration
- Electrolyte imbalance
- Exclusion of possible other diseases (eg.: pancreatitis)
- Imaging: plain abdominal films, ultrasound
- CT in special cases (tu. recurrence, radiation enteritis, Crohn’s disease)
50
Large bowel obstruction
- Longer anamnesis
- Gradual increase of dull pain (cramping is rare)
- No passage of flatus or stool
- Blood may be found in feces
- Vomiting comes late, may be feculent if ileocecal valve is incompetent
- Cecum is the most prone to perforation
51
Causes of large bowel obstruction
- Cancer
- Diverticulitis - chr. inflammation – scarring - stenosis
- Sigmoid-, cecal volvulus
- Ogilvie’s syndrom (colonic pseudo-obsruction-paralysis
52
Role of the ileocecal valve
A: Competent valve: closed large bowel loop
B: Incompetent valve: distension reaches the small bowel loops
53
Treatment options in obstructing large bowel cancer
- Two stage procedure (Hartmann’s)
- Extended resection, primary anastomosis
- Subtotal colectomy
- On table lavage, primary anastomosis
- Loop colostomy in inoperable cases
- Non-operative decompression-semielective operation
- Henrik Kehlet
54
Hartmann’s operation
- surgical resection of the rectosigmoid colon with closure of the rectal stump and formation of an end colostomy
- used in colon cancer in diverticulitis
55
Colonic pseudo-obstruction, Ogilvie’s syndrom
Causes:
o DM, hypothyreosis, kidney insuff, opiates, antiparkinson drugs
o cong. heartfailure, MS, lupus, amyloidosis, dermatomyositis, scleroderma, sepsis, trauma (head, spine) operation (abdominal, heart, neurosurgery)
56
Therapy of Ogilvie's syndrome
o Eliminate instigating factors (if possible),
o Enema, laxatives
o Cholinesterase blocker,
o Ganglion blockers
o Colonoscopy-may be therapeutic
o Surgery: perforation, failure of cons. meas
