Gastroenterology Flashcards

Question

GASTRIC NEOPLASMS: List risk factors for, the symptoms suggestive of and investigations for gastric cancers

Answer 1

**Risk factors:** * Pernicious anaemia¹ * H. Pylori infection * Increasing age * Smoking * Obesity and poor diet **Suggestive symptoms:** * Weight loss * Epigastric pain/discomfort * Early satiety/bloating * Dyspepsia (refractory to treatment) * **ALARMS55** * Melaena * Constitutional symptoms: Weight loss, night sweats **Investigations:** * Bloods * OGD with biopsy * CT CAP * PET scan to check for lymph node invasion 1: Pernicious anaemia arises due to autoimmune mediated destruction of intrinsic factor producing parietal cells, preventing absorption of Vitamin B12

Answer 2

**Epidemiology:** * Men \> women * More common with increasing age **Classification:** * Adenocarcinoma \*most common\* * Occur in the antrum * 'Leather bottle stomach' due to fibrous reaction * 'Krukenberg' tumours are the result of metastatic spread to the ovaries * Leiomyomas and leiomyosarcomas * Usually slower growing and benign

Answer 3

**Surgical procedures for gastric cancers** * Gastrectomy * For all patients with T2 or higher and any N, perioperative treatment should be given * Post-operative chemoradiation may be indicated * May be offered to palliative patients to improve symptoms such as bleeding and obstruction * Endoscopic musosal resection (EMR) is appropriate for patients with adenocarcinoma confined to the mucosa

Answer 4

Overall, the 5 year survival rate is \< 10%

Answer 5

'The rapid onset of **acute symptoms** that may indicate **severe and life-threatening intra-abdominal pathology** that requires **urgent surgical intervention**.' * Abdominal pain is usually a feature although pain-free acute abdomen can occur

Answer 6

**Symptoms:** * Abdominal pain * Vomiting * Peritonitis * Fever * Constipation * Melaena **Signs:** * Rebound tenderness * Pain on palpation * Abdominal distension * Jaundice * Signs of dehydration

Answer 7

Investigations to consider: * LFTs * U&Es * ESR/CRP/WCC * FBC * Imaging: USS, X-ray, CT * Pregnancy test/serum hCG * ABG * ?DKA

Answer 8

**Initial management:** A-E approach Airway: Check patency Breathing: RR, auscultate, percuss, pulse oximetry, ABG, oxygen Circulation: Pulse, BP, auscultate, ECG, fluids following insertion of 2 large bore cannulae, urinary catheter Disability: AVPU, glucose, Exposure **Patients requiring urgent intervention:** * Signs/symptoms of shock with a known or suspected haemoperitoneum * Unstable * Patients with AAA * Patients with suspected ectopic pregnancy * Abdominal pain disproportionate to physical signs, consider mesenteric ischaemia

Answer 9

**Causative pathogens:** Community * Viral: Norovirus, rotavirus * Bacterial: Campylobacter, E. coli, salmonella, shigella Tropical countries * Viral: Rotavirus, norovirus * Bacterial: E.coli, shigella, campylobacter * Parasitic¹: Giardia, entamoeba, cryptosporidium Subtropical countries 1: Persistent diarrhoea (\>14 days) may be of parasitic origin

Answer 10

**Community diarrhoea:** **ASK** if acute (\< 2 weeks) or chronic, as if persisting for longer periods an underlying condition must be considered as a cause **Travellers diarrhoea:** * Careful selection of food and beverages * Anti-motility agent e.g. loperamide * Oral rehydration therapy * Antibiotic therapy may be consider for severe diarrhoea¹ 1: Severe diarrhoea is incapacitating or completely prevents planned activities. Dysentry (mucus and blood in stools) and febrile diarrhoea are also considered severe)

Answer 11

**Risk factors associated with C.difficile infection:** * Recent antibiotic use, causing disruption to the normal GI flora * Particularly ampicillin, cephalosporins, clindamycin, carbapenems and fluoroquinolones * Advanced age * Hospitalisation or residence in a nursing home * Hx of C.difficile-associated disease **Prevention:** Cautious use of antibiotics and discontinuing as soon as possible. Probiotics for primary prevention. Infection control and hand washing to prevent patient to patient spread. **Treatment:** * PO vancomycin or fidaxomicin * Discontinuation of the causative agent * Supportive care * Infection control measures **Symptoms:** Diarrhoea with systemic upset, abdominal pain, leukocytosis, fever, abdominal tenderness and distension. Causes colitis, which may progress to toxic megacolon and multi-organ failure.

Answer 12

**Symptoms:** * Epigastric pain which then localises to the RIF, at McBurney's point¹ * Fever * Nausea/vomitng * Anorexia * Constipation/diarrhoea **Signs:** * Rebound and percussion tenderness * Rosving's sign: RIF pain \> LIF pain * Guarding * Positive psoas sign² * Positive obturator sign³ * Vital signs: Tachycardia, mild fever 1: McBurney's point is found 1/3 of the way between the ASIS and the umbilicus 2: Pain on hip extension. Seen when the appendix is positioned retoperitoneal retrocaecal (most common) 3: Pain on internal hip rotation. Seen when the appendix is positioned pelvically

Answer 13

**Ddx:** * GI: * Acute mesenteric adenitis, gastroenteritis, intussusception, IBD, * Renal: * Nephrolithiasis * Biliary: * Cholecystitis * Cholelithasis * Genito-urinary: * UTI * PID * Mittelschmerz * Ectopic pregnancy * Ovarian torsion **Investigations to rule-in/out differentials:** * Bloods: FBC¹, CRP, group and save, ?amylase * Imaging * Abdominal USS and/or CT * Urinalysis² * Pregnancy test 1: An elevated WBC and CRP is expected in acute appendicitis. If normal then a watch-and-wait approach may be adopted 2: If positive for red cells, white cells or nitrites then renal colic or UTI should be considered as possible causes

Answer 14

* Infants with D&V * Children with vague abdominal pain * Confused elderly pts * Females presenting with gynaecological issues

Answer 15

* Haemorrhage → shock * Peritonitis → sepsis * Appendix abscess * Appendix mass * Inflamed appendix becomes covered in omentum * Adhesions * Infertility: Due to tubal obstruction following pelvic inflammation (PID)

Answer 16

**Common complications:** * Infection * Bleeding * Adhesions

Answer 17

**Meckel's diverticulum:** ## Footnote A congenital malformation of the small bowel. Arises due to failure of the embryonic vitelline duct to obliterate, leaving an outpouching on the small intestine. The outpouching (formed from the vitelline duct remnant) contains cells capable to producing gastric acid, parietal cells. **Possible pathological effects:** * Most commonly presents before the ago of 2 with PR bleeding (haematochezia) or obstruction * Inflammation, adhesions, perforations, ulceration - caused by damage to local tissues by gastric acid release

Answer 18

* Usually are asymptomatic * Usually present before 2 years of age with lower GI bleeding or obstruction * Caecal volvulus: The outpouching can be tethered to the umbilicus, acting as a central point for the intestines to twist around to form a volvulus. * Intussusception * Appendicitis: Inflammation of the diverticulum presents in an identical fashion to appendicitis * Peptic ulceration: Due to ulceration caused by the gastric acid secreting epithelium * A sinus tract may be seen between the umbilicus and the diverticulum, known as a patent vitellointestinal duct **Investigations:** * Technetium-99m pertechnetate scan: Pertechnetate is preferentially taken up by the mucus-secreting cells of the ectopic gastric tissue in the diverticulum. Ectopic focus or 'hot spot' seen on the scan.

Answer 19

**Symptoms:** * Abdominal pain * Vomiting/nausea * Anorexia * (Absolute) constipation: No flatus or faeces is characteristic of absolute constipation * Change in bowel habit **Signs:** * Abdominal distention (the more distal the obstruction the greater the degree of distention) * Tingling bowel sounds (may be absent in the later stages of obstruction) * Tympanic abdomen * Palpable abdominal or rectal mass

Answer 20

* Intestinal necrosis¹: Onset of peritonitis, leukocytosis, dehydration and pre-renal AKI are all signs of intestinal necrosis * Intestinal perforation * Sepsis * Multi-organ failure * Short bowel syndrome following surgical resection of the affected section of bowel ## Footnote Sequelae of intestinal obstruction: Intestinal necrosis → intestinal perforation → sepsis and multi-organ failure 1: As the obstruction progresses, intestinal perfusion decreases with ischaemic change and necrosis following

Answer 21

**Laboratory tests:** * FBC: Hb, WCC * CRP * U&Es: Checking for signs of shock or organ failure. Elevated urine and creatinine may indicate dehydration. * Urea:creatinine ratio * ABG: Elevated lactate indicates poor tissue perfusion. Check glucose, ketones and pH for signs of DKA. * Serum lipase/amylase: To rule out pancreatitis as a cause of abdominal pain **Imaging:** * CT with oral and IV contrast according to local guidelines * PO Gastrografin, in combination with barium sulphate, may be given prior to CT * Allows the level and cause of obstruction to be identified * AXR * Erect CXR \*to check for pneumoperitoneum\*

Answer 22

Paralytic ileus describes a functional cause of bowel obstruction in which bowel motility is reduced. Paralytic ileus: Adynamic bowel due to loss of the peristaltic movement of the bowel.

Answer 23

**Symptoms:** * Increasing pain (colicky → constant) and _tenderness_ * Systemic upset **Signs:** * Leukocytosis * Peritonism * Absent bowel sounds Strangulation describes ischaemia and necrosis of the bowel, as vessels are stretched causing blood supply to the tissue to be compromised.

Answer 24

3 main elements: Fluid resuscitation, bowel decompression and analgesia * A-E assessment of the patient * Gain IV access and provide fluids¹ * Monitor urine output through a urinary catheter * Nasogastric decompression³: Insert a NG tube to allow drainage of gastric contents. Declare the patient nil by mouth - remember to calculate MUST score. * Provide analgesia, and an anti-emetic if indicated * Ongoing monitoring using the NEWS score * Surgical treatment² 2: Indications for surgery include closed loop/complete obstruction, strangulation and peritonitis arising due to any cause of bowel obstruction. Also, in those who do not respond to non-operative treatment after 72 hours. CT evidence of a non-adhesional cause (tumour, hernia, volvulus or gallstone) or evidence of bowel ischaemia is an indication for surgery. In complete bowel obstruction peritonitis will develop in time if not already present (abdominal tenderness, guarding, rebound tenderness). 1: In bowel obstruction peristalsis increases in an attempt to overcome the blockage. This causes increased secretion of fluid into the bowel. Not only does this cause distention but also dehydration, electrolyte imbalance, volume depletion and AKI. 3: Acts to prevent aspiration of vomit

Answer 25

**Clinical presentation:** * Diarrhoea * Faltering growth/weight loss * Steatorrhoea * Bloating * Lethargy **Investigations:** * Bloods: FBC, lipid profile, Fe, B₁₂, calcium * Coeliac disease tests: IgA-tTG (EMA if not available), IgG DGP * Sudan stain for fat globules * Faecal elastase¹ * Endoscopy and biopsy ^{1: Reduced when exocrine function of the pancreas is disrupted, e.g. chronic pancreatitis, CF, pancreatic tumour, cholelithasis or T1DM}

Answer 26

Most common causes in the UK are coeliac disease, Crohn's disease and chronic pancreatitis * Short bowel syndrome (iatrogenic) * Coeliac disease * Lactose intolereance, CMP allergy * IBD: Crohn's, UC * Infection: Giardiasis, TB, * Malignancy * Congenital abnormalities e.g. Hirschsprung's, atresia, Meckel's, cystic fibrosis * Endocrine: Thyroid disease, DM, Addison's disease, parathyroid disease

Answer 27

**Underlying pathology:** * Autoimmune destruction of villi, leading to blunting * Gluten derived peptides trigger an immune reaction, leading to local inflammation and subsequent destruction **Associated clinical conditions:** * Malabsorption: Leading to anaemia etc. * Osteoporosis/osteopenia * Dermatitis herpetiforms (look at images) * Malignancy * Idiopathic recurrent acute pancreatitis/chronic pancreatitis

Answer 28

* FBC and blood smear¹ * IgA-tTG * EMA is an alternative to IgA-tTG * Skin biopsy² * IgG DPD or IgA/IgG DPD * Should be used for pts with IgA deficiency * Small bowel histology * Essential and the gold-standard for diagnosis 1: Iron deficiency anaemia is the most common presenting feature of coeliac disease 2: For patients with evidence of dermatitis herpetiformis

Answer 29

* Alternating diarrhoea and constipation * Abdominal pain and bloating that is associated with changes in stool form or frequency * Symptoms may be relieved by defaecation * Stress related symptoms * Age \< 50 \*chnage in bowel habit over this age should prompt consideration of malignancy\* * Normal abdominal examination

Answer 30

* Believed to have multiple contributing causes * A disorder of altered gastrointestinal mobility

Answer 31

**Possible investigations:** * Ascertain whether there is a causal relationship between certain foods/drink and symptoms * Test for coeliac disease, lactose intolerance, IBD * Test for endocrine causes of changes in bowel habit: Thyroid function, Hba1c, parathyroid hormone * General tests for wellbeing: FBC, U&Es, thyroid function, **Therapeutic approaches:** Lifestyle and dietary changes * FODMAP diet * Avoid precipitating foods e.g. caffeine Managing change in bowel habits * Anti-diarrhoeal: Loperamide * Laxative: Ispaghula Managing bowel spasms/cramps - antispasmodic * Dicycloverine * Peppermint oil Optional treatments * TCA or SSRI

Answer 32

**Crohn's:** * 'Mouth to anus' distribution * Full thickness/transmural inflammation * 'Skip lesions' * Can lead to adhesions between bowel and other pelvic organs * Cobblestoning * Non-caseating granulomatous tissue throughout all layers **UC:** * Begins at the rectum and ascends * Continuous inflammation * Crypt abscess, granulomatous inflammation, paneth cell metaplasia

Answer 33

Diagnosis is most frequently seen between the age of 15 and 35 **Crohn's disease:** * Change in bowel habit: Diarrhoea * Cramping/abdominal pain * Weight loss * Systemic symptoms such as fatigue, malaise and anorexia * Perianal abscess/fistulae/skin tags * Extra-articular manifestations: Joint, eyes, dermatological (erythema nodosum), clubbing **Ulcerative Colitis:** * Change in bowel habit: Diarrhoea +/- blood and mucus * Abdominal cramps * Bowel frequency relates to severity * Systemic symptoms: Weight loss, malaise, anorexia, fever * Nutritional deficit * Extraintestinal signs: Clubbing, oral ulcers, erythema nodosum, pyoderma gangrenosum, conjunctivitis, episcleritis, iritis, large joint arthritis, AS, PSC

Answer 34

**Complications of Crohn's disease:** * Adhesion and subsequent fistulae * Entero-enteric * Colovesical * Colovaginal * Perianal * Abscess formation * Perianal disease * Small bowel obstruction * Colon cancer * PSC **Complication of Ulcerative Colitis:** * Toxic dilatation of the colon (→ perforation) * VTE * Colonic cancer **Surgery in IBD:** Crohns: * Needed in 50-80% of pts but NOT curative * Indications include failure of medical treatment, obstruction due to strictures, abscess and fistulae formation Ulcerative Colitis: * Required in ~ 20% of pts * Indicated for failure of medical treatment or due to toxic dilatation * May be completion procectomy (permanent stoma) or ileo-anal pouch (option of stoma reversal and the possibilty of long term continence)

Answer 35

Increased risk **Risk of colon cancer in UC:** * Risk is proportional to the extent and activity of the disease

Answer 36

**Diverticulosis:** Herniation of the mucosa and submucosa of the gut wall, due to smooth muscle over-activity **Aetiology/Risk factors:** * Low dietary fibre intake * Obesity * Tobacco smoking * Excessive alcohol and caffeine intake * Steroids * NSAIDs * Connective tissue disorders e.g. Ehlers-Danlos syndrome,

Answer 37

**Morphology:** * Out-pouching of the gut **Pathological consequences:** * Diverticular disease - any clinical symptoms arising as a consequence of diverticulosis * Diverticulitis - Inflammation. May be caused by infection. * GI bleeds * Fistulas * Perforation * Obstruction * Abscess * Neoplasm

Answer 38

**Clinical features:** * **Symptoms:** * Altered bowel habit * Left sided colic relieved by defecation, nausea and flatulence * Systemic symptoms: Pyrexia, fever, fatigue, anorexia * Melaena **Signs:** * Localised or generalised peritonitis * Elevated WCC, ESR/CRP

Answer 39

* Perforation: Ileus, peritonitis and shock * Haemorrhage * Fistulae * Abscess: Swinging fever, leucocytosis * Post-infective strictures

Answer 40

**Conservative management** * Asymptomatic diverticulosis, discovered incidentally, generally requires no treatment * Antispasmodic e.g. mebeverine * Some evidence to suggest that increasing dietary fibre may help **Surgical management** * Occasionally resorted to

Answer 41

Elective * Fistula formation * ?Stricture Emergency * Haemorrhage

Answer 42

**Aetiology:** * Familial polyps (FAP, Lynch syndrome) * Increased age * Obesity * Diet: Low fibre, high in processed meats * Smoking * IBD * FHx **Morphology** * The vast majority are adenocarcinomas * 'Signet ring cells' on histology * The vast majority occur in the recto-sigmoid region of the colon, with 45% in the rectum **Pathology** *

Answer 43

**Dukes' classification:** A: limited to the bowel wall B: through the bowel wall C: regional lymph nodes metastasis. **TNM:** Once TNM categories have been determined the information is combined to provide the stage of the tumour.

Answer 44

\* Most commonly seen in the recto-sigmoid region of the colon\*

Answer 45

**Anal cancer** * Mainly SCC * RFs: Anoreceptive sex, syphilis infection, HPV infection, immunosuppression, **Colorectal cancer** * Mainly adenocarcinomas

Answer 46

Consider a **2WW referral** for colorectal cancer, when: * Occult blood in faeces (FIT) * Rectal or abdominal mass * 40 years or \> with unexplained weight loss and abdominal pain * 50 years or \> with unexplained rectal bleeding and any of the following - abdominal pain, change in bowel habit, weight loss, iron-deficiency anaemia * 60 years or \> with iron-deficiency anaemia (with no identifiable cause) or changes in bowel habit * For anal cancer, unexplained anal mass or anal ulceration * ALARMS55

Answer 47

**Laboratory tests** * FBC: ?anaemia, WCC * LFT: ?derangement due to mets * Tumour markers: * CEA (should only be measured after confirmation of diagnosis) - can be used to monitor disease * AFP * U&Es * Faecal calprotectin: ?raised due to inflammation * CRP/ESR: ?inflammation **Radiological studies** * CT CAP * Double-contrast barium enema¹ * CT colonography * PET scan **Endoscopic investigations** * Colonoscopy with biopsy 1: Characteristic 'apple core' lesion

Answer 48

* Laparoscopic resection * Right/left hemicolectomy according to the site of the mass * Endoscopic stenting in palliation * Radiotherapy is usually used in palliation or pre-op in rectal cancer * Adjuvant chemotherapy for stage 3 disease

Answer 49

**Management of anal carcinoma** * Chemotherapy (5-FU or mitomycin) plus radiotherapy * 75% retain normal anal function In contract, colorectal cancer management mainly involves resection of the mass and local tissue. NOTE: Squamous cell anal carcinoma is the most common (below the pectinate line). Adenocarcinomas (above the pectinate line) should be treated as rectal cancer.

Answer 50

* All pts undergoing surgery require colonoscopy before or soon after to look for additional lesions/metachronous tumours¹ * Stage II/III disease: CEA every 3/12 and colonoscopy every 3 years ## Footnote NHS bowel cancer screening programme sees FIT every 2 years for pts aged 60 - 74. 1: Metachronous tumours - Primary CRC developing 6 months after previous colorectal surgery for CRC

Answer 51

* Insert a NG tube for gastric decompression and analgesia * Provide IV fluids * Use AXR and erect CXR to confirm diagnosis and to look for signs of perforation (pneumoperitoneum) * CT to determine the level of obstruction * Surgery for resolution or endoscopic stenting if palliative

Answer 52

**Symptoms** * Absolute constipation * Abdominal distension and pain **Signs** * Absent bowl sounds * Resonance to percussion * Palpable mass * **No** abdominal tenderness \*unless strangulated\* THINK is there a functional (ileus) or mechanical obstruction?

Answer 53

* AXR and CXR * CT to identify the level of the obstruction * Oral Gastrografin may be given prior to CT to help identify the level of obstruction and may have mild therapeutic effect on the obstruction

Answer 54

* NEC -AXR * Volvulus - AXR, barium CT * Intussusception * Malrotation * Strictures * Secondary to Meckel's diverticulum * Hirschsprung disease - biopsy

Answer 55

Severe constipation can cause faecal impaction. **General factors:** Poor diet, dehydration, lack of exercise, IBS, old age, pain **Anorectal disease:** Fissure, stricture, rectal prolapse **Metabolic/endocrine:** Hypercalcaemia, hypothyroid, hypokalaemia **Drugs:** Opiates, anticholinergics, iron, aluminium based antacids, diuretics **Neuromuscular:** Diabetic neuropathy, spinal/pelvic nerve injury, Hirschprung's disease **Investigations:** * FBC, ESR, U&Es, calcium, TFTs

Answer 56

**Haemorrhoids:** Disrupted and dilated anal cushions. Anal cushions contribute to anal closure. There are 3 anal cushions can be seen at 3, 7 and 11 o'clock in the lithotomy position. Haemorrhoids may be internal (origin above the dentate line), external (origin below the dentate line) or mixed.

Answer 57

Internal anal sphincter: * Under involuntary control, surrounding the upper 2/3 of the anal canal * Smooth muscle External anal sphincter: * Under voluntary control (inferior rectal nerve, S4), surrounds the lower 2/3 of the anal canal * Striated muscle

Answer 58

* Straining (chronic constipation or diarrhoea) * Increased IAP (obesity, pregnancy) * Pelvis masses which reduce vascular return, resulting in anal vascular engorgement * Increased anal tone (stress)

Answer 59

**Symptoms:** * PR bleeding: fresh, associated with wiping * Pain (if thrombosis occurs) * Pruritis ani * Prolapse of haemorrhoids (piles) **Complications:** * Anaemia * Thrombosis: If prolapsing vessels become compressed by the anal sphincter (strangulation) the cessation of venous return can lead to thrombosis. Treatment is conservative, as they often resolve spontaneously. Cold compress, opioids and rest are advised.

Answer 60

* Haemorrhoids * IBD * Malignancy * Anal fissure * Trauma * GI bleed e.g. diverticulitis, ulceration * Gastroenteritis * Perianal haematoma

Answer 61

**Inspection** * Visibly protruding haemorrhoids (piles) * PR bleeding * Exocoriations **Abdominal examination** * Check for palpable masses (as pelvic masses may reduce vascular return) and hepatomegaly **Proctoscope** * Piles can be visualised * Assess for any lesions higher within the anus and rectum which may have caused bleeding Colonoscopy/flexible sigmoidoscopy - if a more sinister pathology is suspected

Answer 62

**Investigations** * Examination: Abdo examination, proctoscopy, ?colonoscopy - if sinister cause suspected **Management** * 1st line: Dietary and lifestyle modification - increased fibre and ensure adequate fluids. Avoid excessive straining. * Adjunct: _Short course_ of topical corticosteroid to reduce pruritis For prolapsing internal haemorrhoids * Rubber band ligation or sclerotherapy or infrared photocoagulation or haemorrhoid arterial ligation For grade 4 internal/external/mixed internal or external haemorrhoids * Surgical haemorrhoidectomy **Ddx** * Malignancy * Anal fissure * Perianal haematoma * Abscess

Answer 63

Caused by rupture of a vein beneath the anal skin, with onset after a heavy effort (lifting/coughing/sneezing/straining at stool). It is not related at all to haemorrhoids. **Signs:** * Tense, smooth, dark blue/black lump close to the anal verge **Symptoms:** * Acute onset pain **Management:** * If treatment is sought within a few hours of onset then incision and drainage can be performed. * Generally the perianal haematoma resolves within a few days. Oral analgesia and hot baths can be advised.

Answer 64

* Anal crypts act to release mucous when compressed by faeces, aiding evacuation of the anal canal * The crypts are the most common site of infection

Answer 65

* Pain, tenderness and swelling around the anus * Perianal infection can leads to the formation of a perianal abscess * Visibly red, exquisitely tender swelling next to the anus * Perianal cellulitis may also be seen: Erythema, swelling, hot

Answer 66

* Perianal cellulitis * Perianal abscess * Pilonidal sinus * Perianal warts

Answer 67

Inspect * Scars * Visible signs of infection, swelling, lumps * Anal skin tags/fissures/ulcers Proctoscopy PR examination Any discharging area near the anus should be assumed to communicate with the anorectum, until proven otherwise. MRI or operative exploration may be used to investigate.

Answer 68

A tract communicates between the skin and the anal canal/rectum. Blockage of deep IM gland ducts is thought to predispose to the formation of abscesses, which then discharge to form a fistula. **Other RFs:** _IBD_, diabetes, TB, HIV, history of anal trauma **Clinical features:** * Recurrent perianal abscess * Intermittent/continuous discharge onto the perineum (mucus, blood, pus or faeces) **Goodsall Rule** Can be used to predict the trafectory of a fistula tract, through looking at the location of the exteral opening. External opening posterior to the transverse anal line - fistula follows a curved course to the posterior midline External opening anterior to the transverse anal line - fistula tract will follow a straight radial course to the dentate line

Answer 69

**Management of fistula in ano** ## Footnote \*\*\* Dependent upon the cause and site of the fistula * No symptoms → conservative approach * Symptoms → * Fistulotomy: Laying the tract open and allowing healign through secondary intention * Placement of a seton through the fistula to allow the tract to drain, encouraging healing

Answer 70

A painful tear in the squamous lining of the lower anal canal/split in the skin of the distal anal canal. If the tear is chronic it my be associated with a 'sentinal pile' or mucosal tag at the external aspect.

Answer 71

**Risk factors:** Hard stools, pregnancy, opiate analgesia **Symptoms** * Pain on defecation - 'like passing broken glass' * May continue for 1-2 hours after defecation and can be burning in nature * PR bleeding - fresh blood on stool/paper * Tearing sensation when passing stool * Anal spasm **Physical examination** * Fissure visible on retraction of the buttock * Associated sentinel pile or mucosal tag * Proctoscopy \*may not be possible due to pain\* * Colonoscopy should be performed to rule out more sinister causes/ other anorectal conditions

Answer 72

**Current theories of aetiology:** * Hard stools * Pregnancy * Opiate use **Management** On 1st presentation: * Conservative treatment: High fibre diet, topical analgesia, sitz baths, stool softeners to make defecation more comfortable * Adjunct: Topical GTN (causes relaxation of the anal sphincter but may not be tolerated by patients due to the occurence of headaches with use) Recurrent fissures: * Botulinum toxin: Relaxes the anal sphincter (inhibits pre-synaptic ACh release) * Surgical sphincterotomy

Gastroenterology Flashcards

(107 cards)