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Gastroenterology Flashcards

1
Q

Surgical differentials for acute abdominal pain

A

Peritonitis
Ruptured AAA
Appendicitis
Gallstones
Acute pancreatitis
Diverticulitis
Renal colic
Bowel obstruction
Acute mesenteric ischaemia
Obstructed/strangulated hernia
Testicular torsion
Volvulus
Meckel’s diverticulum
Adhesions

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2
Q

Medical differentials for acute abdominal pain

A

Gastritis/peptic ulcer
Pyelonephritis
Gastroenteritis
Constipation
Crohn’s/ UC
Hepatitis

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3
Q

Differentials for acute diarrhoea

A
  • Gastroenteritis (+ abdo pain / N+V)
  • Diverticulitis (left lower quadrant pain, diarrhoea, fever)
  • Antibiotic therapy (broad spec Abx)
  • Constipation causing overflow
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4
Q

Differentials for chronic diarrhoea

A
  • IBS
  • Ulcerative colitis (blood diarrhoea)
  • Crohn’s disease (mouth ulcers, perianal disease)
  • Colorectal cancer (rectal bleeding, weight loss)
  • Coeliac disease
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5
Q

Differentials for dysphagia

A
  • Oesophageal cancer
  • Oesophagitis
  • Oesophgeal candidiasis
  • Achalasia
  • Pharyngeal pouch
  • Systemic sclerosis
  • Myasthenia gravis
  • Globus hystericus
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6
Q

Causes of acute pancreatitis

A
  • Idiopathic
  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune
  • Scorpion venom
  • Hyperlipidaemia
  • ERCP = endoscopic retrograde cholangiopancreatography
  • Drugs = azathioprine, furosemide, corticosteroids, NSAIDs, ACE-i
  • Pregnancy and neoplasia
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7
Q

Presentation of acute pancreatitis

A
  • Severe epigastric or central abdominal pain that radiates to back
  • Sitting forward may relieve and worse on lying down
  • Anorexia
  • nausea and vomiting
  • Tachycardia
  • Fever
  • Jaundice
  • Dehydration
  • Hypotension
  • Abdominal guarding and tenderness
  • Cullen’s sign = periumbilical bruising
  • Grey Turner’s sign = left flank bruising
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8
Q

What is the difference between Cullen’s sign and Grey Turner’s sign?

A
  • Cullen’s sign = periumbilical bruising
  • Grey Turner’s sign = left flank bruising
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9
Q

Blood tests for acute pancreatitis

A

o Raised serum/urinary amylase
o Raised serum lipase = more sensitive and specific
o CRP level

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10
Q

Imaging for acute pancreatitis

A
  • Abdominal ultrasound = gallstone pancreatitis
  • Erect CXR
    o Exclude gastroduodenal perforation = raises serum amylase
    o May show gallstones or pancreatic calcification
  • Contrast enhanced CT = Identify extent of pancreatic necrosis
  • MRI = Identifies degree of pancreatic damage
    o Useful in differentiating fluid and solid inflammatory masses
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11
Q

What score can be used to assess severity in acute pancreatitis?

A

Glasgow score

PaO2 <60
- Age > 55
- Neutrophils >15
- Calcium <2
- uRea >16
- Enzymes = LDH >600 or AST/ALT >200
- Albumin <32
- Sugar = glucose >10

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12
Q

Management of acute pancreatitis

A
  • Severity assessment essential and careful monitoring
  • Nil by mouth = Nasogastric tube for dietary supplements to decrease pancreatic stimulation
  • IV fluids
  • Urinary catheter
  • Analgesia = IM pethidine or IV morphine
  • Endoscopic drainage of large pseudocysts
  • Prophylactic antibiotics like beta-lactams = Cerfuroximr
  • Surgery = remove infected pancreatic necrosis
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13
Q

Complications of acute pancreatitis

A
  • Pancreatic necrosis
  • Haemorrhage
  • Infection in necrotic area
  • Pseudocysts
  • Chronic pancreatitis
  • Peripancreatic fluid collections
  • Pancreatic abscess
  • Acute respiratory distress syndrome
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14
Q

Causes of chronic pancreatitis

A
  • (Long-term) Alcohol excess
  • Genetic (Hereditary pancreatitis) = Defects in trypsinogen gene, Cystic fibrosis
  • Infection = HIV, mumps, coxsackie, echinococcus
  • Autoimmune pancreatitis
  • Hyperlipidaemia
  • Structural = obstruction by trauma
  • Chronic kidney disease
  • Idiopathic
  • Recurrent acute pancreatitis
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15
Q

Presentation of chronic pancreatitis

A
  • Epigastric pain that ‘bores’ through to back
    o Episodic or unremitting = relieved by sitting forward
    o Exacerbated by alcohol
  • Nausea and vomiting
  • Decreased appetite
  • Weight loss
  • Diarrhoea
  • Steatorrhea = pale, loose, fatty, foul smelling stools that float
  • Protein deficiency
  • Diabetes mellitus
  • Jaundice
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16
Q

Investigations for chronic pancreatitis

A
  • Serum amylase and lipase normal
  • Faecal elastase normal
  • Abdominal ultrasound and contrast-enhance CT = Detects pancreatic calcification and dilated pancreatic duct
  • MRI with MRCP = Identify more subtle abnormalities
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17
Q

Management of chronic pancreatitis

A
  • Alcohol cessation
  • Analgesia = NSAIDs  opiates  tricyclic antidepressants
  • Duct drainage
  • Shock wave lithotripsy = Fragment gallstones in head of pancreas
  • Pancreatic enzyme supplements
  • PPI = lansoprazole to help supplement pass stomach
  • Diabetes = Insulin
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18
Q

Complications of chronic pancreatitis

A
  • Malabsorption and steatorrhea
  • Pseudocyst
  • Diabetes
  • Biliary or duodenal obstruction
  • Splenic vein thrombosis
  • Pseudoaneurysm
  • Pancreatic ascites
  • Pancreatic carcinoma
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19
Q

Causes of gastroenteritis

A
  • E.coli
  • Giardiasis
  • Cholera
  • Shigella
  • Staphylococcus aureus
  • Campylobacter
  • Bacillus cereus (reheated rice)
  • Amoebiasis
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20
Q

Presentation of gastroenteritis

A
  • Watery stools
  • Abdominal cramps
  • Nausea and vomiting
  • May be blood in diarrhoea
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21
Q

Incubation periods for bacteria in gastroenteritis

A
  • 1-6hrs = staph. Aureus, bacillus cereus
  • 12-48 hrs = salmonella, E.coli
  • 48-72 hrs = shigella, campylobacter
  • > 7 days = giardiasis, ameobiasis
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22
Q

What is coeliac disease?

A

Autoimmune condition where exposure to gluten causes inflammation in the small bowel

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23
Q

Risk factors for coeliac disease

A
  • Other autoimmune diseases = T1DM, thyroid disease, primary biliary cirrhosis
  • IgA deficiency
  • Age of introduction to gluten into diet
  • Rotavirus infection in infancy
  • HLADQ2 and 8 association
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24
Q

Presentation of coeliac disease

A
  • 1/3 asymptomatic = only detected on routine blood tests
  • Failure to thrive = children
  • Diarrhoea
  • Fatigue
  • Weight loss
  • Steatorrhoea (Stinking stools/fatty stools)
  • Abdominal pain
  • Bloating
  • Nausea and vomiting
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25
Q

Examination findings in coeliac disease

A
  • Dermatitis herpetiformis = Red raised patches, often with blisters that burst on scratching
  • Mouth ulcers
  • Angular stomatitis = inflammation of one or both corners of mouth
  • Clubbing
  • Amenorrhoea
  • Rare = Peripheral neuropathy, cerebellar ataxia, epilepsy
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26
Q

What is required before investigating for coeliac disease

A

Maintain gluten for at least 6 weeks before testing to get true results

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27
Q

What antibodies are present in coeliac disease?

A

o IgA Tissue transglutaminase antibody
o IgA Endomyseal antibody
o General IgA (deficiency)

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28
Q

What is the definitive investigation for coeliac disease?

A
  • Endoscopy and duodenal biopsy
    o Villous atrophy, crypt hyperplasia
    o All reverse on gluten free diet
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29
Q

What is the definitive management of coeliac disease?

A
  • Lifelong gluten free diet = serum antibody testing for monitoring
    o Eliminate wheat, barley, rye
    o Dietician review
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30
Q

What other parts of management of coeliac disease are important?

A
  • Correction of vit and mineral deficiencies = B12, folate, iron, calcium and vit D
  • DEXA scan to monitor osteoporotic risk
  • Checking coeliac antibodies to monitor
  • Offered pneumococcal vaccine every 5 years
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31
Q

Complications of coeliac disease

A
  • Anaemia (pernicious)
  • Enteropathy associated T-cell lymphoma
  • Non-Hodgkin lymphoma
  • Increased risk of malignancy
  • Osteopenia/osteoporosis
  • Neuropathies
  • Subfertility
  • Ulcerative jejunitis
  • Vitamin deficiency
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32
Q

What are the causes of malabsorption?

A

Pancreatic insufficiency
Pancreatitis
Cystic fibrosis
Biliary obstruction
Ileal resection
Bacterial overgrowth
Giardia lamblia
Small intestine resection/bypass
Lactose intolerance
Bacterial overgrowth
Abetalipoproteinaemia
Primary bile acid malabsorption
Lymphoma
TB

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33
Q

What is GORD?

A

Reflux of stomach contents through lower oesophageal sphincter and irritates lining of oesophagus

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34
Q

Risk factors for GORD

A
  • Hiatus hernia
  • Obesity
  • Pregnancy = increased abdo pressure
  • Gastric acid hypersecretion
  • Slow gastric emptying
  • Overeating
  • Smoking
  • Alcohol
  • Fat, chocolate, coffee ingestion
  • Systemic sclerosis
  • Drugs = nitrate, tricyclics, CCBs, antimuscarinic
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35
Q

Presentation of GORD

A
  • Burning chest pain aggravated by bending, stooping and lying down
    o Relieved by anti-acids
    o Worse with hot drinks or alcohol
  • Belching
  • Food, acid or bile regurgitation
  • Retrosternal or epigastric pain
  • Bloating
  • Water brash = increased salivation
  • Odynophagia = painful swallowing
  • Nocturnal cough
  • Hoarse voice
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36
Q

Red Flags for GORD

A
  • Symptoms >4 wks
  • Dysphagia, weight loss, haematemesis, anaemia
  • Persistent vomiting
  • GI bleeding
  • Palpable mass
  • Over 55
  • Symptoms despite treatment
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37
Q

Investigations for GORD

A

If Red flag symptoms then endoscopy and barium swallow

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38
Q

Lifestyle changes for GORD

A

o Encourage weight loss
o Smoking cessation
o Small, regular meals
o Avoid hot drinks, excess alcohol, citrus fruits, aggregating foods and eating less than 3 hours before bed
o Sleep with head of bed raised
o Reduce stress and anxiety
o Review medications

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39
Q

Medication options for GORD

A

o Antacids = magnesium trisilicate mixture
o Alginates = Gaviscon
o Proton pump inhibitor = lansoprazole
o H2 receptor antagonists (antihistamine)= ranitidine

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40
Q

Surgery options for GORD

A

laparoscopic fundoplication = Tying fundus of stomach around lower oesophagus to narrow lower oesophageal sphincter

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41
Q

Complications of GORD

A

Oesophagi’s
Peptic stricture
Barrett’s oesophagus

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42
Q

Differences between Crohn’s and Ulcerative Colitis

A

Crohn’s (NESTS)
No blood or mucus
Entire GI tract
Skip lesions
Terminal ileum most affected and Transmural inflammation
Smoking = risk factor

Ulcerative Colitis (CLOSEUP)
Continuous inflammation
Limited to colon and rectum
Only superficial mucosa
Smoking is protective
Excrete blood and mucus
Use aminosalicylates
Primary Sclerosing Cholangitis

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43
Q

Risk factors for ulcerative colitis

A
  • Family history
  • NSAIDs = onset of IBD and flares of disease
  • Chronic stress and depression triggers flares
44
Q

Protective factors for ulcerative colitis

A
  • Smoking
  • Appendicectomy
45
Q

Presentation of ulcerative colitis

A
  • Runs in course of remissions and exacerbations
  • Restricted pain usually to lower left quadrant
  • Episodic or chronic diarrhoea (with blood and mucus)
  • Crampy abdominal discomfort
  • Bowel frequency linked to severity
  • Acute attack = bloody diarrhoea, diarrhoea at night with urgency and incontinence that is disabling
  • Acute UC = fever, tachycardia and tender distended abdomen
  • Clubbing
  • Erythema nodusum = red lumps below skin
  • Pyoderma gangrenosum = painful ulcers on skin
46
Q

SEverity of ulcerative colitis

A
  • Mild  <4 stools/day, only small amount of blood
  • Moderate  4-6 stools/day, varying amounts of blood, no systemic upset
  • Severe >6 bloody stools per day + systemic upset
47
Q

Blood tests for ulcerative colitis

A

o WCC and platelets raised
o Normochromic, normocytic anaemia = Fe/B12/folate deficiency anaemia or anaemia of chronic disease
o ESR and CRP raised
o Hypoalbuminemia in severe disease
o pANCA (Anti-neutrophilic cytoplasmic antibody) may be positive

48
Q

Gold standard investigation for ulcerative colitis

A

Colonoscopy with mucosal biopsy
o Inflammatory infiltrate
o goblet cell depletion
o crypt abscesses and mucosal ulcers
o loss of haustrations/drain pipe colon
o No granulomata

49
Q

Inducing remission in mild-moderate UC

A

o rectal aminsalicyclate (mesalazine)
o then add oral if remission not within 4 wks
o then add topical/oral steroid

50
Q

Inducing remission in severe UC

A

o Admit and IV steroids
o Add IV ciclosporin if not improvement in 72 hrs
o Infliximab is 3rd line

51
Q

Maintaining remission for UC

A

oral/topical mesalazine, azathioprine, mercaptopurine

52
Q

Indications for surgery in UC

A

ileocaecal resection
o Indicated for severe colitis that fails to respond to treatment

53
Q

Complications of ulcerative colitis

A
  • Primary Sclerosing cholangitis
  • Colorectal cancer
  • Ankylosing spondylitis
  • Arthritis
  • Iritis
  • Uveitis
  • Episcleritis
54
Q

What is Crohn’s disease?

A

Transmural granulomatous inflammation affecting any part of gut from mouth to anus (especially terminal ileum and proximal colon)

55
Q

Risk factors for Crohn’s disease

A
  • Genetic association = Mutations on NOD2 gene on chromosome 16 increases risk
  • Smoking
  • NSAIDs
  • Family history
  • Chronic stress and depression triggers flares
  • Good hygiene = poor hygiene families have lower risk of developing CD
  • Appendicectomy
  • Other autoimmune disease
56
Q

Presentation of Crohn’s disease

A
  • Diarrhoea with urgency, bleeding and pain due to deification
  • Abdominal pain = Emergency with acute right iliac fossa pain (Mimics appendicitis)
  • Weight loss and anorexia
  • Malaise
  • Fatigue
  • Abdominal tenderness/mass
  • Perianal abscess
  • Aphthous oral ulcers
  • Clubbing
  • Skin, joint and eye problems
57
Q

Bloods for Crohns

A

o Normochromic, normocytic anaemia = deficiency of iron and folate
o Raised ESR and CRP
o Raised WCC and platelets
o Hypoalbuminaemia present in severe disease
o LFTs may be abnormal
o Negative pANCA

58
Q

Gold standard investigation for Crohns

A

o Skip lesions and granulomatous transmural inflammation
o Increase in chronic inflammatory cells and lymphoid hyperplasia
o Non-caseating epithelioid cell aggregates with Langerhans giant cells
o Goblet cells are present
o Cobblestone appearance due to ulcers and fissures in mucosa

59
Q

What is shown on a barium swallow in Crohn’s

A

Cobblestone appearance

60
Q

Management of acute Crohns flare

A
  1. Corticosteroids (oral prednisolone or IV hydrocortisone)
  2. Immunosuppressant (azathioprine, mercaptopurine, methotrexate, infliximab, adalimumab)
61
Q

Maintaining remission in Crohn’s

A

azathioprine, mercaptopurine

62
Q

Surgery in Crohns

A

Ileocaecal resection
o Indicated in medical therapy failure, failure to thrive and perianal sepsis
o Resection at worst areas = can result in short bowel syndrome

63
Q

Complications of Crohns

A
  • Anaemia
  • Osteoporosis
  • Obstruction = strictures
  • Fistulas
  • Adenocarcinomas
  • Malabsorption
  • Amyloidosis
  • Perianal abscess
64
Q

Side effects of azathioprine

A

bone marrow depression,
N+V,
pancreatitis,
increased risk of non-melanoma skin cancer

65
Q

Risk factors for IBS

A
  • Previous severe and long diarrhoea
  • Mental health problems
  • FHx of IBS
66
Q

Triggers of IBS

A
  • Depression, anxiety
  • Psychological stress and trauma
  • GI infection
  • Sexual, physical or verbal abuse
  • Eating disorders
67
Q

Presentation of IBS

A
  • Fluctuating bowel habit (Diarrhoea/ Constipation)
    o Worse after eating, stress, menstruation or gastroenteritis
    o Improved by opening bowels
  • Abdominal pain
  • Bloating
  • Fatigue
  • Nausea
  • Mucus in stool
68
Q

Diagnosis criteria for IBS

A

Rome III diagnostic criteria:
Recurrent abdominal pain/discomfort at least 3 days a month in past 3 months associated with 2+ of
o Improvement with defecation
o Onset associated with change in frequency of stool
o Onset associated with change in form of stool

69
Q

Lifestyle Management of IBS

A
  • Adequate fluid intake
  • Regular small meals
  • Reduced processed foods
  • Limit caffeine and alcohol
  • Low FODMAP diet
  • Probiotic supplements for 4 weeks
70
Q

Medication options in IBS

A
  • 1st line medication
    o Loperamide = diarrhoea
    o Laxatives = constipation
    o Antispasmodics (hyoscine butylbromide) = cramps
  • 2nd line
    o Tricyclic antidepressants (amitriptyline)
    o CBT
71
Q

Risk factors for peptic ulcers

A
  • Stress
  • Alcohol
  • Caffeine
  • Smoking
  • Spicy foods
72
Q

Causes of peptic ulcers

A
  • Helicobacter pylori infection
  • Drugs = NSAIDs, steroids and SSRIs
  • Delayed gastric emptying
  • Bile reflux
  • Mucosal ischaemia
73
Q

Presentation of peptic ulcers

A
  • Recurrent burning epigastric pain
    o Pain occurs at night and worse when hungry
    o Duodenal improve on eating, Gastric get worse when eating
    o Can be relieved by antacids
  • Nausea
  • Anorexia and weight loss = gastric ulcers
  • Dyspepsia
  • Haematemesis (coffee ground vomit)
  • Melaena (dark sticky faeces containing partial digested blood)
74
Q

Investigations of peptic ulcers

A
  • Endoscopy
  • Biopsy during endoscopy to exclude malignancy
  • C-urea breath test/stool antigen test = H.pylori
75
Q

Lifestyle changes in peptic ulcers

A

reduce stress, stop smoking, reduce alcohol, avoid irritating foods, lose weight

76
Q

Medication management in peptic ulcers

A
  • Stop NSAIDs
  • H.pylori eradication
    o PPI for acid suppression = lansoprazole
    o 2 antibiotics = metronidazole + clarithromycin/amoxicillin
  • H2 antagonists = ranitidine
77
Q

Complications in peptic ulcers

A
  • Bleeding
  • Perforation = acute abdomen and peritonitis
  • Scarring and strictures = pyloric stenosis
  • Acute pancreatitis
78
Q

What is diverticulitis?

A

inflammation of diverticulum (outpouching of gut wall, usually at sites of entry of perforating arteries)

79
Q

Risk factors for diverticulitis

A
  • Low fibre diet
  • Obesity and sedentary lifestyle
  • Smoking
  • NSAIDs
80
Q

Presentation of diverticulitis

A
  • Intermittent Left iliac fossa/lower left abdo pain
  • Fever
  • Diarrhoea/constipation
  • Bloating
  • PR blood/mucus
  • Nausea and vomiting
  • Febrile
  • Tachycardia
  • Tenderness, guarding and rigidity on left side of abdomen
  • Palpable tender mass sometimes felt in LIF
  • Urinary frequency, urgency and dysuria
  • Possible reduced bowel sounds
81
Q

Investigations for diverticulitis

A
  • Blood tests = raised WCC, ESR and CRP
  • CT = Colonic wall thickening and diverticula, Pericolic collections and abscesses
  • CXR  pneumoperitoneum in cases of perforation
  • AXR  Identify obstruction of free air, dilated bowel loops, abscesses
  • Barium enema = Clarify diagnosis in patients with abdominal pain and altered bowel habit
  • Colonoscopy  avoided initially due to increase risk of perforation in diverticulitis
82
Q

Management of diverticulitis

A
  • Mild  oral Antibiotics (ciprofloxacin), liquid diet, analgesia
  • If Sx don’t settle within 72 hrs or more severe Sx  admit for IV Abx
  • Surgical resection if severely septic/complications
83
Q

Complications of diverticulitis

A
  • Perforation
  • Fistula formation
    o Bladder = dysuria (pain when urinating) or pneumaturia (gas/air in urine resulting in bubbles)
    o Vagina resulting in discharge
  • Intestinal obstruction
  • Bleeding
  • Mucosal inflammation
  • Abscess
  • Peritonitis
84
Q

Causes of gastritis

A
  • Helicobacter pylori infection
  • Autoimmune gastritis
  • Viruses = cytomegalovirus and herpes simplex
  • Duodenogastric reflux = Bile salts enter stomach and damage mucin protection
  • Crohn’s
  • Mucosal ischaemia
  • Stress
  • Aspirin and NSAIDs = naproxen
  • Alcohol
85
Q

Presentation of gastritis

A
  • Nausea or recurrent upset stomach
  • Abdominal bloating
  • Epigastric pain
  • Haematemesis (Vomiting)
  • Indigestion
86
Q

Investigations for gastritis

A
  • Endoscopy and Biopsy
  • H.pylori = Urea breath test, Stool antigen test
87
Q

Management of gastritis

A
  • Remove causative agents = alcohol
  • Reduce stress
  • H.pylori eradication
    o PPI for acid suppression = lansoprazole or omeprazole
    o Plus 2 of: metronidazole, clarithromycin, amoxicillin, tetracycline, bismuth
  • H2 antagonist (Ranitidine or cimetidine) = Reduce acid release
  • Antacids
88
Q

Prevention of gastritis

A
  • Give PPIs alongside NSAIDs
  • Prevents bleeding from acute stress ulcers and gastritis
89
Q

What are haemorrhoids?

A

Disrupted and dilated anal cushions (masses of spongy vascular) tissue due to swollen veins around anus

90
Q

Risk factors for haemorrhoids

A
  • Age
  • Posture
  • Heavy lifting
  • FHx
  • Constipation with prolonged straining
  • Diarrhoea
  • Effects of gravity due to posture
  • Congestion from pelvic tumour, pregnancy, portal hypertension
  • Anal intercourse
  • Persistent cough/vomiting
91
Q

Classification of haemorrhoids

A
  • Internal haemorrhoids = origin above the dentate line
    o 1st = remain in rectum
    o 2nd = prolapse through anus on defecation but spontaneously reduce
    o 3rd = prolapse but can be reduced manually
    o 4th = remain persistently prolapsed
  • External haemorrhoids = origin below dentate line
    o May be visible externally
    o Extremely painful since sensory nerve
92
Q

Presentation of haemorrhoids

A
  • Severe anaemia
  • Bright red rectal bleeding often coats stools
  • Mucus discharge and itchy bottom
  • Weight loss and change in bowel habit
  • Only painful if below dentate line
93
Q

Investigations of haemorrhoids

A
  • Proctoscopy  Internal haemorrhoids
  • Sigmoidoscopy  Rectal pathology higher up
94
Q

Management of haemorrhoids

A
  • 1st degree  Increase fluid and fibre, Topical analgesic and stool softener
  • 2nd and 3rd degree
    o Rubber band ligation  Cheap and produces ulcer to anchor mucosa
    o Infra-red coagulation  Locally coagulates vessels and tethers mucosa to subcutaneous tissue
  • 4th degree
    o Excisional haemorrhoidectomy
    o Stapled haemorrhoidopexy
  • Prolapsed or thrombosed piles
    o Treated with analgesia, ice packs and stool softeners
    o Pain usually resolved in 2-3 weeks
95
Q

What is an anal fistulae?

A

Blockage of deep intramuscular gland ducts thought to predispose to formation of accesses, which discharge to form fistula

96
Q

Causes of anal fistulae

A
  • Perianal sepsis
  • Abscesses
  • Crohn’s
  • TB
  • Diverticular disease
  • Rectal carcinoma
97
Q

Presentation of anal fistulae

A
  • Pain
  • Bloody or mucus discharge
  • Itchy bottom
  • Systemic abscess if infected
98
Q

Investigations of anal fistulae

A
  • MRI  Exclude sepsis and Detect associated conditions (Crohn’s or TB)
  • Endoanal ultrasound  Determine tracks location and underlying causes
99
Q

Management of anal fistulae

A
  • Surgical  Fistulotomy and excision
  • Drain abscess with antibiotics if infected
100
Q

What is an anal fissure?

A

Painful tear in sensitive skin-lined lower anal canal, distal to dentate line

101
Q

Risk factors for anal fissure

A
  • Constipation
  • IBD
  • STI (HIV, syphilis, herpes)
  • Childbirth
  • Trauma
  • Anal cancer
102
Q

Presentation of anal fissure

A
  • Extreme pain especially on defecation
  • Bright red rectal Bleeding
  • 90% are posterior
    PR exam often not possible due to pain and sphincter spasm
103
Q

Management of acute anal fissure

A

o Increase dietary fibre and fluids = make stools softer
o Bulk forming laxatives then lactulose if not tolerated
o Lubricants before defecation
o Lidocaine ointment and GTN ointment or topical diltiazem
o Analgesia

104
Q

Management of chronic anal fissure

A

o Continue above techniques
o Topical GTN
o If this not effective after 8 wks then secondary care referral

105
Q

Secondary care treatment options for anal fissure

A

o Botulinum toxin injection
o Sphincterotomy

106
Q

Causes of metabolic alkalosis

A

Vomiting/aspiration
Diuretics
Hypokalaemia
Primary hyperaldosteronism
Cushing’s syndrome
Bartter’s syndrome

107
Q

Side effects of PPIs

A

Hyponatraemia
Hypomagnesaemia
Osteoporosis
Microscopic colitis
C. diff

Finals (23 decks)

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