GI Flashcards
1
Q
What is GORD?
A
- Oesophagitis secondary to refluxed gastric contents
- Reflux of gastric contents into the oesophagus is normal. Clinical symptoms only occur when there is prolonged contact of gastric contents with the oesophageal muscosa.
2
Q
What are the causes of GORD?
A
- Anything that increases intra-abdo pressure/weakness of lower oesophageal sphincter
- Pregnancy
- Obesity
- Smoking, alcohol, fatty meals, coffee
- Large meals
- Achalasia
- Hiatus hernia
- Drugs: TCAs, anticholinergics, nitrates, CCBs, bisphosphonates, NSAIDs
3
Q
Normal defence mechanisms of oesophageal muscosa against reflux?
A
Surface – mucus and water layer trap bicarbonate, acts as as weak buffering system
Epithelium – apical cell membranes in the junctional complexes between cells act to limit diffusion of H+ into cells (this mechanism is impaired in oesophagitis)
Post-epithelium - bicarbonate normally buffers acid in the cells and intracellular spaces
Sensory mechanisms – acid stimulates the primary sensory neurones in the oesophagus by activating the canniloid-1 receptor
4
Q
Presentation of gord?
A
- Heartburn: aggravated by bending/lying
- Regurgitation of food and acid, particularly when bending or laying
- Odynophagia (painful swallowing)
- Cough/nocturnal asthma - from aspiration
- Chest pain
5
Q
How is GORD diagnoseD?
A
- Clinical diagnosis
- Trials of PPI: If sx persist, ambulatory pH and imedance monitoring
- OGD
- GOld standard for diagnosis is 24hour oesophageal pH monitoring
6
Q
Indications for performing OGD in someone with reflux
A
- Age >55
- Symptoms > 4weeks or tx resistant
- Dysphagia
- Relapsing sx
- Weight loss
- Haematamesis
- Anaemia
7
Q
Conservative treatment for GORD?
A
- Lifestyle changes: weight loss, avoid excess alcohol, caffeine and aggravating foods, smok cessation
- Antacids
- ## Raising bedhead
8
Q
What medications can be used for GORD?
A
- Alginate containing antacids: first line, forms foam raft on contents
- PPIs: block luminal secretion of gastric acid
- H2 receptor antagonists
- Dopamine antagonist pro-kinetic agents
9
Q
What mnemonic can be used to help remember GORD meds? x
A
GORD Gaviscon (antacid) Omeprazole (PPIs) Ranitidie (h2 resceptor antagonist) Domperidone (prokinetic)
10
Q
What are the surgical management options for GORD?
A
- Nissen fundoplication
w/ Laparoscopic approach
11
Q
Complications of GORD?
A
- Oesophagitis
- Ulcers
- Anaemia
- Benign strictures
- Barrett’s oesophagus
- Oesophageal carcinoma
12
Q
What is a Mallory-Weiss tear?
A
- A linear muscosal tear occuring at the oesophageal-gastric junction
- Produced by sudden increase in intra-abdominal pressure
- Often occurs after a bout of coughing or retching and is classically seen after alcohol dry heaves
13
Q
Risk factors for Mallory-Weiss tear?
A
- Excessive alcohol ingestion
- Hiatus hernia
- Gallstones/Cholecystitis
14
Q
How do mallory-weiss tears present?
A
- Acute upper GI bleeding
- Presents with haematemesis
15
Q
Management of mallory-weiss tears?
A
- Most bleeds are minor and pt discharged within 24hrs
- Early endoscopy confrims diagnosis and allows therapy if needed
- Surgery with sewing the tear is rarely needed
16
Q
What is a peptic ulcer?
A
- A breach in a membrane of the mucosa in or adjacent to an acid bearing area
- Consists of a break in the superficial epithelial cells penetrating down to the muscular mucosa of either the stomach or the duodenum
- Caused by a reduction of gastric mucosal resistance to acid
17
Q
Most common sites for peptic ulcer?
A
Dueodenum: more common. Particularly in the duodenal cap
Stomach: Most commonly on lesser curvature
18
Q
How does the stomach normally present itself agaisnt gastric acid?
A
1) Mucus production by goblet cells (alkaline mucus)
2) High turnover of cells
3) Feedback loops
4) Tight junctions between cells
19
Q
What are some causes of peptic ulcers?
A
- Helicobacter pylori and NSAIDs/Aspirin
- Corticosteroids alongside NSAIDs further increases risk
- Hyperparathyroidism
- Zollinger-Ellison syndrome
- Vascular insuffiency
- Sarcoidosis
- Crohns disease
20
Q
Risk factors for peptic ulcers?
A
- Smoking
- Alcohol
- Steroids
- NSAIDs
- Stress
21
Q
What is Zollinger-Ellison syndrome?
A
A condition in which a gastrin-secreting tumour or hyperplasia of the islet cells in the pancreas causes overproduction of gastric acid, resulting in recurrent peptic ulcers
22
Q
Presentation of peptic ulcers?
A
- Recurrent, burning epigastric pain
- Duodenal ulcer: Pain relieved by eating
- Gastric ulcer: Pain worsened by eating
- Pain relieved by antacids
- Nausa
- Vomiting
- Anorexia and weight loss
- back pain
- Heartburn
- Flatulence
23
Q
Investigations of PUD?
A
- Patients <55 with ulcer-type symptoms should undergo non-invasive testing for H Pylori infection: C13 Urea breath test, Stool antigen test , sreology, culture, histology
- Endoscopy can be used
- Barium meal if ?obstruction
24
Q
Management of PUD
A
- Treat underlying cause + lifestyle measure: Stop NSAIDS, stop smoking, reduce alcohol intake
- Treat H.Pylori - omeprazole, clarithromycin, and metranidazole for 7-14days
- Surgery - if recurrent haemorrahge
25
What is Helicobacter Pylori?
- Gram negative spiral bacteria
- Associated with a range of gastrointestinal problems
- Has a flagellum
- Produces urease
- Adheres to gastric epithelial cells in gastric pits
- Protected from gastric acid by the juxta-mucosal mucus layer which traps bicarbonate
- Most patients with the infection are asymptomatic
26
Diseases associated with H Pylori?
- PUD (95% of duodenal ulcers, 75% of gastric ulcers)
- Gastric cancer
- B Cell lymphoma of MALT tissue
- Atrophic gastritis
27
Presentation of H. Pylori?
- As PUD: Epigastric pain, nausea, anorexia
28
Investigations for H. Pylori infection?
- C-13 urea breath test: Gold standard
- Serology: for serum antibody detection
- Stool antigen test: immunoassage using monoclonal antibodies
- Culture
- Histology
- Biopsy urease test
29
Treatment of H. Pylori?
7 day course of:
1) A PPI + Amoxicillin + Clarithromycin
or
2) A PPI + Metronidazole + Clarithromycin
30
If H.Pylori treatment fails?
If triple therapy eradication fails give: bismuth + metronidazole + tetracycline + PPI for 14 days (but bear in mind bismuth tablets are extremely unpleasant so be aware of issues with compliance)
31
What are gastro-oesophageal varices?
- Abnormally dilated veins with a torturous course
| - Around oesophagus and stomach
32
What are the causes of oesophageal varices?
- Portal hypertension due to liver cirrhosis (either from alcohol or viral)
- Acute hepatitis
- Schistosomiasis
33
What are risk factors for variceal bleeding?
- Decompensation of liver disease
- Malnourishment
- Excess alcohol intake
- Physical exercise
- Circadian rhythms
- Increased intra abdo pressure
- Aspirin
- NSAIDs
- Bacterial infection
34
How do varices present?
- Haematemesis
- Abdo pain
- Dysphagia/odynophagia
- Confusion 2ndary to encephalopathy
- Pallor
- Hypotension and tachycardia
- Reduced urine output
35
What investigation for varices?
Endoscopy - to exclude bleeding from other sites/confirm site
36
Management of acute variceal haemorrhage?
- ABCDE
- Correct clotting: FFP, Vit K
- Vasoactive agents: Terlipressin
- Prophylactic antibiotics in pt with liver cirrhosis
- Endoscopy: Variceal band ligation
- Sengstaken-blakemore tube if uncontrolled haemorrhage
- Transjugular intrahepatuc portosystemic shunt (TIPSS) - if above measures fail
37
How to prevent re-bleed of varices?
- Propanolol
| - Endoscopic variceal band ligation
38
What is achalasia?
- Failure of oesophageal peristalsis and relaxation of lower oesophageal sphincter (LOS)
- Due to degenerative loss of ganglia from Auerbach’s plexus
- Leading to impaired oesophageal emptying
- LOS contracted, oesophagus above dilated
39
Clinical features of achalasia?
- Dysphagia of BOTH liquids and solids
- Variation in severity of sx
- Heartburn
- Regurg of food, particularly at night - may lead to cough, aspiration pneumonia
- Spontaneous chest pain due to oesophageal spasm
40
Investigating achalasia?
- Manometry: excessive LOS tone which doesnt relax on swallowing, most important diagnostic test
- Barium swallow: shows expanded oesophagus, fluid level, birds beak
- CXR: wide mediastinum, fluid level
- OGD
41
Management of achalasia?
- No cure – goals of treatment are symptom relief and improvement of oesophageal emptying
- Intra-sphincteric injection of BoTox
- Heller cardiomyotomy – surgical division of the LOS
- Endoscopic balloon dilatation
- Drug therapy - has a role but is limited by side-effects
- Oral nitrates
- Nifedipine (CCB)
42
Main side effect of treatment for achalasia?
GORD
43
Relationship between oesophageal motility and scleroderma?
- The oesophagus is involved in almost all patients with this disease
- Diminished peristalsis and oesophageal clearance due to replacement of the smooth muscle by fibrous tissue
- Detected manometrically or by barium swallow
- LOS pressure is decreased, allowing reflux with consequent mucosal damage
- Initially no symptoms, then dysphagia and heartburn
- Similar motility abnormalities may be found in other autoimmune disorders, particularly if Reynaud’s phenomenon is present
- Treatment is the same for reflux and benign stricture
44
What is gastritis?
Inflammation of the gastric mucosa
45
What is gastropathy?
Injury to the gastric mucosa associated with epithelial cell damage and regeneration. Little or no accompanying inflammation (eg damage due to NSAID use)
46
What are the causes of gastritis?
- Most common is H Pylori
- NSAIDs and Aspirin
- Alcohol excess
- Autoimmune: eg pernicious anaemia
- CMV
- HSV
- Duodeno-gastric reflux
- Crohns disease
47
Symptoms of gastritis?
- Indigestion (dyspepsia)
- Epigastric pain
- Loss of appetite
- Bloating
- Retching
- Nausea
- Vomiting
- Early satiety/feeling particularly full after a meal
48
Investigations for gastritis?
- Clinical diagnosis in most cases
- Gastroscopy is gold standard
- Biopsy
- H. Pylori testing (urea breath + stool antigen)
- Barium swallow
49
Management of gastritis?
```
Conservative:
- Smaller meals + avoiding spicy/acidic foods
- No alcohol
- No smoking
- Reducing stress
- Stop NSAID use
Medication:
- Antacids
- H2 blocker - ranitidine
- PPI
```
50
What is coeliac disease?
- Autoimmune condtion caused by sensitivity to gluten
| - Leads to villous atrophy, causing malabsorption
51
Causes of coeliac?
- Gluten sensitivity
- Genetic factors
- Environmental factors: Breastfeeding, age of introduction of gluten, rotavirus infection in pregnancy
52
Risk factors/associations for coeliac disease?
- T1DM
- Atopy
- Thyroid disease
- Sjorgens syndrome
- IBS
- Autoimmune hepatitis
- IgA deficiency
-
53
Presentation of coeliac disease?
- Chronic or intermittent diarrhoea
- Steatorrhoea
- Failure to thrive
- Persistent or unexplained gi sx inc. N+V
- Prolonged fatigue and malaise
- Recurrent abdo pain, cramping or distension
- W loss
- Unexplained anemia
54
Non Gi sx of coeliac?
- Mouth ulcers and angular stomatitis
- Infertility
- Neuropsychiatric symptoms (anxiety and depression)
- Rare: Tetany, osteomalacia, weakness, neuropathy
55
Skin consequence of coeliac disease?
Dermatitis Herpetiformis
56
How to investigate coeliac disease?
- Immunology and jejunal biopsy
| - Must be on a gluten diet at time
57
What will be seen on immunology for coeliac disease?
- Tissue transglutaminase antibodies (IgA)
- Endomysial antibodies
- Anti-casein antibodies in some
58
What is seen on jejunal biopsy for coeliac?
- Villous atrophy
| - Crypt hyperplasia
59
Management of coeliac disease?
- Education
- Lifelong gluten free diet
- Correct any vitamin deficiencies
- Pneumococcal vaccine
60
Complications of coeliac disease?
- Anaemia: Iron, folate and B12
- Hyposplenism
- Osteoporosis, osteomalacia
- Lactose intolerance
- Enteropathy-associated T-cell lymphoma of small intestine
- Subfertility, unfavourable preg outcomes
- RARE: Oesophageal cancer, other malignancies
61
What is dermatitis herpetiformis?
- An itchy, symmetrical eruption of vesicles and crusts over the extensor surfaces of the body with deposition of granular IgA
- Associated with a gluten-sensitive enteropathy – usually asymptomatic as the jejunal abnormalities are not as severe in coeliac disease
- Same inheritance and immunological abnormalities as coeliac disease
- The skin condition responds to dapsone (used to treat leprosy)
- Both skin and gut will improve on gluten free diet
62
What is tropical sprue?
- A progressive small intestinal disorder presenting with diarrhoea, steatorrhea and megaloblastic anaemia
- Occurs in residents or visitors to endemic areas in the tropics (Asia, some Caribbean islands, Puerto Rico and parts of South America)
- The term ”tropical sprue” is reserved for severe malabsorption (of 2 or more substances - particularly fat and b12) accompanied by diarrhoea and malnutrition
63
Presentation of tropical sprue?
- Can be acute or chronic
- DIarrhoea
- Steatorrhoea
- Anorexia
- Abdominal distension
- Weight loss
64
Investigating tropical sprue?
- Acute infective causes of diarrhoea must be excluded (especially Giardia which can produce a syndrome very similar to tropical sprue)
- Malabsorption should be demonstrated, particularly fat and B12
- Small bowel mucosal biopsy – partial villous atrophy, less severe but similar to in coeliac
- Coeliac screening
65
Management of tropical sprue>
- Many pt improve when leave area
- Folic acid
- Abx: eg tetracycline for 6 months
- Replace fluid nd electrolytes
- Correct any nutritional deficiencies
66
What is Crohns disease?
- IBD affecting anywhere from mouth to anus, but often terminal ileum and colon
67
Cause of crohns?
- Unknown
- Genetic susceptibility
- Environmental factors: Hygeine, NSAIDs, Smoking, stress
- Intestinal microbiota - increased E Coli
- Host immune response
68
Microscopic changes associated with Crohns?
- transmural inflammation
- Increase in chronic inflammatory cells
- Lymphoid hyperplasia
- Granulomas (non-caseating epithelioid cell aggregates with Langerhans giant cells)
69
Macroscopic changes associated with Crohns?
- Mouth to anus with skip lesions
- Involved bowel has a thickened wall an a narrow lumen
- Cobblestone appearance (ulcers and fissures)
- Fistulae and abcess
-
70
Symptoms of crohns disease?
- Triad: Diarrhoea, abdo pain, weight loss
- Non-specific sx: weight loss, lethargy, low grade fever, malaise
- Loss of appetite, N+V
- Steatorrhoea
- Perianal disease - skin tags or ulcers
- Anal disease - fistulae to bladder/vagina/abdo wall
71
Extra-intestinal features of crohns?
- Erythema nodosum
- Pyoderma gangernosum
- Arthritis
- Uveitis, epislceritis, conjucntivitis
- Osteoporosis
- Clubbin
- PSC
- Fatty liver
72
Investigations for crohns?
Bloods: CRP, anaemia, low vit D and B12
Stool: Faecal calprotectin
Colonoscopy w/ biopsy is diagnostic
Small bowel enema
73
Specific crohns features seen on small bowel enema?
- Strictures - kantors string sign
- Proximal bowel dilatation
- Rose thorn ulcers
- Fistulae
74
How to induce remission in crohns disease?
- Glucocorticoids eg. Prednisolone
- Enteral feeding with an elemental diet
- 5-ASA drugs eg. mesalazine
- Azathioprine or mercaptopurine
- Infliximab
- Metronidazole for isolated peri-anal disease
75
How to maintain remission in crohns?
- Stop smoking
- Azathioprine or mercaptopurine
- Methotrexate
- 5-ASA;s
76
Surgical options for Crohns?
- Ileocaecal resection
- Segmental small bowel resections
- Stricturoplasty
- Colonic surgery: Sub-total colectomy, panproctocolectomy
- Surgical management of fistulae
77
Complications that can arise from Crohns?
- Fistulae
- Small bowel cancer
- Colorectal cancer
- OP
78
What is Ulcerative Colitis?
- Form of IBD
- Inflammation restricted to colon
- Continuous
79
Causes of ulcerative colitis?
- Unknown
- Genetic
- Environment: Smok and breastfeeding protetctive
- Psycho: chronic stress, deprivation
- Intestinal microbiota
- Host immune response
80
Macrosopic changes in UC?
- Colon only
- Reddended mucosa, inflamed and bleeds easily
- Extensive ulceration
81
Microscopic changes in UC?
- Mucosa shows chronic inflammatory cell infiltrate in the lamina propria
- Crypt abcesses
- Goblet cell depletion
82
Presentation of UC?
- Intermittent sx
- Bloody diarrhoea
- Mucus in stool
- Urgency
- Tenesmus
- Abdo pain
- Malaise, lethargy, anorexia, w loss
83
Extraintestinal manifestations of UC?
- Mouth ulcers
- Arthritis
- Erythema nodosum
- Pyoderma gangrenosum
- Uveitis
- PsC
84
Investiagtions for US?
Bloods: ID anaemia, WCC and platelets raised, ESR and CRP raised, pANCA+Ve
Colonoscopy with biopsy gold standard
Barium enema
85
Signs of UC on barium enema?
- Loss of haustrations
- Superficial ulcerations - psuedopolyps
- Narrow and short colon
86
What is toxic megacolon?
- Serious complication with UC
- Plain AXR sows dilated, thin-walled colon with diameter >6cm, gas filled and contains mucosal islands
- Risk of perforation...needs surgery
87
How to induce remission in UC?
- Rectal aminosalicylates
- Oral aminosalicylates
- Oral prednisolone
- Severe colitis needs IV steroids
88
How to maintain remission in UC?
- Oral aminosalicylates - mesalazine
- Azathioprine and mercaptopurine
- Surgery: colectomy
89
What is intestinal obstruction?
Blockage to the transit of intestinal contents through the gut
90
What is volvulus?
Twist/rotation of bowel segment
91
What are adhesions?
Sticking together of bowel contents.
92
What is intussusception?
Telescoping of one part of the bowel into a more distal part.
93
What is atresia?
Absence of opening or failure of development of a hollow structure.
94
Complications of untreated bowel obstruction?
- Ischaemia
- Necrosis
- Perforation
95
Clinical features of bowel obstruction?
- Vomiting: Projectile, faeculant
- Pain: Colicky
- Constipation and obstipation
- Abdo distension
- Tenderness
96
Management principles of bowel obstruction?
- ABCDE
- Fluid resus
- Pain relief
- Decompress - NG tube
- Accurate diagnosis
- Surgery
97
Causes of SBO in adults?
- Adhesions - commonest in developed world, usually due to prev abdo surgery
- Hernia
- Crohns
- Malignancy
98
Causes of SBO in children?
- Appendicitis
- Intussusception
- Atresia
- Hypertrophic pyloric stenosis
- Volvulus
99
Rare causes of SBO?
- Radiation
- Gallstones
- Diverticulitis, appendicitis
- Abcess
- Foreign bodies - ie hair balls in ill
100
Symptoms of SBO?
- Pain: Colicky to start, precedes pain
- Vomiting: follows pain. Projectile. Bilous/faecal. If coffee>necrosis
- Nausea/Anorexia
- Distension
- Constipation
101
Signs of SBO?
- Tachycardia, hypotension, pyrexia
- Tenderness
- Abdo distension
- Resonance: tympanic sounds (gas filled)
- Bowel sounds: increased in early stages,, absent later
102
Investigating SBO?
- Bloods: FBC, U&E, lactate
- Radiology: Plain erect Xray - SB loops with fluid levels
- CT: investigation of choice. w/contrast
- Ultrasound
- MRI
103
Management of SBO?
- Aggressive fluid resus
- Nasogastric decompression
- Analgesia and antiemetic
- Early surgical consultation
- IV abx
104
Causes of LBO in adults?
- Malignancy (90% in the west)
- Volvulus (50% of africa cases)
- Paralytic ileus
- Strictures
105
Causes of LBO in children?
- Imperforate anus
- Hirchsprungs disease
- Cystic Fibrosis - meconium ileus
106
Pathophysiology of LBO?
- The colon proximal to the obstruction dilates
- Increased colonic pressure causing decreased mesenteric bloodflow
- Mucosal oedema – transudation of fluid and electrolytes from the lumen in the bowel wall
- The arterial supply is compromised causing mucosal ulceration – leading to full thickness necrosis and perforation
- Bacterial translocation (from inside the bowel leaking out due to perforation) = sepsis (so patient may even present with signs of septic shock)
If ileocaecal wall is competent the caecum is likely to perforate
If ileocaecal valve is incompetent then faeculent vomiting can occur
107
Where do colorectal tumours cause obstruction?
- 70% on left side - distal to transverse colon
108
Symptoms of LBO due to malignancy or strictures?
- Average of 5 day sx
- Abdo discomfort
- Fullness/bloating/nausea
- Altered bowel habit: Tenesmus, difficulty opening bowels, blood in stool, constipation
- Abdo pain - colicky, tender
- Vomiting
- W loss
109
Symptoms of LBO due to volvulus?
- Sudden onset
- Pain
- Localised tenderness and distension
110
Clinical signs of LBO?
- Abdo distension: Resonance on percussion, sounds tinkling then absent, tender
- Palpable mass
- Rigidity and peritonitis
- DRE: empty rectum, hard stools, blood
111
Investigations for LBO?
- Proctoscopy/Sigmoidoscopy
- Bloods: FBC, U&E, lactate
- Ct+/- contrast is best
112
Management of LBO?
- NBM
- O2
- IV Fluid resus
- Monitor urine
- NG decompression
- Antibiotics
113
How to treat suspected perforation?
- Laparotomy
- Resect perforated segment
- Irrigate
114
How to manage LBO due to colorectal cancer?
- Initial resus as normal
- Relieve obstruction - stent decompression
- CT staging
- Neoadjuvant therapy - shrink before surgery
- Surgery
115
Normal max diameter of large bowel?
55mm
116
Normal max diamter of small bowel?
35mm
117
What is non-mechanical bowel obstruction?
- Adynamic obstruction, paralytic ileus
| - Failure of peristalsis
118
Causes of non-mechanical bowel obstruction?
- Post op: Laparotomy, thoracotomy
- Ileus associated with systemic illness: MI, pancreatitis, sepsis
- Narcotic ileus: Intestinal movements stop when on morphine
119
Symptoms of non-mechanical bowel obstruction?
- Painless distension
- Vomiting
- Absent or minimal bowel sounds - tinkling
120
Investigations for non-mechanical bowel obstruction?
- Bloods: FBC, U&E, magnesium
| - Radiology: XR, CT
121
How to manage non-mechanical bowel obstruction?
- NBM
- IV fluids
- NG aspiration
- Tx of underlying cause
- Avoid opiates
- Support nutrition
122
What is blood supply to colon?
- Superior and inferior mesenteric arteries
123
Common predisposing factors for bowel ischaemia?
- Increasing age
- AF
- Endocarditis, malignancy (as they cause emboli)
- CVD rf: Smoking, htn, hyperlipidaemia, diabetes
- Cocaine
124
Common features of bowel ischaemia?
- Abdo pain
- Rectal bleeding
- Diarrhoea
- Fever
- Bloods: Raised WBC
125
What causes acute mesenteric ischaemia?
- Embolism resulting in occulusion of an artery which supplies the small bowel
- Eg the SMA
- Classically they have hx of AF
126
Management of acute mesenteric ischaemia?
- Urgent surgery req
| - Poor prog :/
127
What is chronic mesenteric ischaemia?
- Relatively rare clinical diagnosis
- May be thought of as 'intestinal angina'
- Colicky, intermittent abdo pain occurs
128
What is ischaemic colitis?
- An acute but transient compromise in blood flow to the large bowel
- More likely to occur in the 'watershed' areas such as splenic flexure that are located at the borders of the aterrial territories
- May lead to: inflammation, ulceration and haemorrhage
129
Classical investigation for ischaemic colitis?
- 'thumbprinting' on AXR
| - Due to mucosal oedema/haemorrhage
130
Management of ischaemic colitis?
- Usually supportive
- Surgery may be needed in minority
- Indcations for surgery: Generalised peritonitis, perforation, ongoing haemorrgage
131
What are haemorrhoids?
- A swollen vein or group of veins in region of anus
- Most common cause of rectal bleeding
- It is the enlargement/congestion of normal mucosal vascular cushions which contribute to anal continence
132
Different types of haemorrhoids?
External:
- Originate below the dentate line
- Prone to thrombosis, may be painful
Internal:
- Originate above the dentate line
- Do not generally cause pain
133
How can internal haemorrhoids be graded?
Grade 1 - do not prolapse out of anal canal
Grade 2 - prolapse on defecation but reduce spontaneously
Grade 3 - can be manually reduced
Grade 4 - Cannot be reduced
134
Causes/rf for haemorrhoids?
- Low fibre diet causing patient to overly strain when having a bowel movement
- Pregnancy
- Prolonged sitting on the toilet
- Obesity
- Diarrhoea (both acute and chronic)
- Colon cancer
- Previous rectal surgery
- Spinal cord injury and lack of erect
posture
135
Symptoms of haemorrhoids?
- Painless rectal bleeding
- Pruritus ani
- Pain
- Soiling may occur with 3rd or 4th degree
136
Diagnosis of haemorrhoids?
- Inspection
- Rectal exam
- Proctoscopy
137
Management of haemorrhoids?
- Soften stools: Increase dietary fibre and fluids
- Topical local anaesthetics and steroids eg anusol
- Outpatient tx: Rubber band ligation, injection scleropathy
- Surgery: If large and symptomatic
- New treatments: Doppler guided haemorrhoidal artery ligation and stapled haemorrhoidopexy
138
How do acutely thrombosed external haemorrhoids present?
- Typically present with significant pain
- On examination
- Purple, oedematous, tender subcutaneous perianal mass
- If patient presents within 72 hours, referral should be considered for excision
- Otherwise, patients can usually be managed with:
- Stool softeners, ice packs and analgesia
- Symptoms usually settle within 10 days
139
What are anal fissures?
- A tear in the lower anal canal distal to the dentate line which produces pain on defecation
- Location: midline 6 and 12 o'clock postios
140
Causes of anal fissures?
- Most cases: constipation/hard stool tears lining of anal canal
- Can occur in IBD - perianal abcesses and anal fistulae may complicate
- Other causes: persistent diarrhoea, pregnancy, childbirth, unusally tight anal sphincter muscles
141
Symptoms of anal fissures?
- Pain on defecation (sharp pain)
- Often followed by deep burning pain that may last several hours
- Bleeding when passing stool - small amount of bright red blood in stools or on toilet paper
142
Features of chronic anal fissures?
- Symptoms of >6weeks
| - Triad of: Ulcer, sentinel pile, enlarged anal papillae
143
How is anal fissure diagnosed?
- Clinical diagnosis: Hx and exam
- Peri-anal inspection
- Rectal exam often not possible due to pain
- Proctoscopy can be done under anaesthesia to exclude other disease
144
How are anal fissures treated?
- Local anaesthetic gel
- Stool softeners
- Botox on chronic fissures
- Reduce risk by: High fibre diet, well hydrated pt, not ignoring urge to pass stools, exercising regularly
145
What is an anal fistula?
- Abnormal communication between anus and the perianal skin
- Usually due to previous ano-rectal abcess
- Can be : intersphincteric, transsphincteric, suprasphincteric, extrasphincteric
146
What rule is used to determind location of the anal fistula?
- Goodsalls rule
147
Causes of anal fistulae?
- Previous abcess (common cause)
- Crohns disease
- Anorectal cancer
- TB
- HIV/AIDS
- Chlamydia
- Syphilis
- Previous ulcer
- Complication of surgery
- Complication of a congenital problem
148
Risk factor for anal fistulae?
- Smoking - as it impairs healing
149
How to investigate anal fistula?
- Endo-anal ultrasound
| - MRI and or exam under anaesthetic
150
Management of anal fistula?
- Surgical incision and drainage
| - Antibiotics
151
What is a pilonidal sinus/abcess?
- Small hole or tunnel under the skin that usually develops in the cleft of the buttocks where the buttocks seperate
- More than one hole may develop that are often linked by tunnels under the skin
- Dont normally cause sx unless infected.
152
Main infecting organisms of ano-rectal abcess?
- E.Coli
| - Staph aureus
153
Possible positions of rectal abcess?
- Perianal
- Ischiorectal
- Pelvirectal
- Intersphincteric
154
Risk factors for pilnonidal sinuses?
- Obesity
- Large amount of body hair
- Having a job that involves a lot of sitting/driving
155
How are pilonidal sinuses/abcesses treated?
- Keep area clean and dry
- Remove hair near sinus
- Antibiotics
- Pus drainage and surgical incision
156
What is irritable bowel syndrome?
- A functional bowel disease causing an alteration in bowel habit and other GI symptoms
- Can be classified according to pattern:
- IBS w/ constipation
- IBS w/ diarrhoea
- Mixed IBS
157
When should a diagnosis of IBS be considered?
If the patient has had the following for at least 6 months:
- Abdo pain and/or
- Bloating and/or
- Change in bowel habit
158
Diagnostic criteria for IBS?
- Abdominal pain relieved by defecation or associated with altered bowel habit
- Plus 2 of the following:
- Altered stool passage (straining, urgency, incomplete evac)
- Abdo bloating, distension or hardness
- Symptoms made worse by eating
- Passage of mucus
- Features such as lethargy, nausea, backache and bladder symptoms may also support dx
159
red flag features in IBS hx?
- Rectal bleed
- Weight loss
- FHx of bowel or ovarian cancer
- Onset after 60yrs
160
Cause of IBS?
- Thought to be of biospychsocial origin - brain gut axis
- Depression and anxiety
- GI infection
- Stress and trauma
- Abx therapy
- Sexual, physical, verbal abuse
- Pelvic surgeryu
- Eating disorders
161
Risk factors for IBS?
- Female gender
- Traumatic life event
- High hypo-chondrial anxiety scores
- Prev episodes of infectious diarrhoea
162
Symptoms of IBS?
- Crampy abdominal pain relieved by defecation or the passage of wind
- Altered bowel habit
- Sensation of incomplete evacuation
- Abdominal bloating and distention
- Diarrhoea without pain (formed stools followed by loose mushy stools, mainly in the morning)
- Systemic symptoms, can co-exist with:
- Chronic fatigue syndrome
- Fibromyalgia
- TMJ syndrome
163
Investigating IBS?
- Exam usually normal
- Initial ix by GP - FBC/ESR/CRP +coeliac
- Sigmoidoscopy with air sufflation may reproduce pain
- Rectal biopsy to exclude IBD
- Colonoscopy, esp in >50 to r/o sinister pathology
- It is a diagnosis of exclusion.
164
First line pharmacological remedies for symptomatic relief in IBS?
Remedy according to predominant symptom?
- Pain: antispasmodic agents (mebevrine, peppermint oil)
- Constipation: laxatives (soluble fibre supplements)
- Diarrhoea: loperamide
165
Second line pharma treatment for IBS?
- Low dose TCAs eg. amitriptyline 5-10mg
| - SSRI can be used too
166
Psychological interventions for IBS?
- CBT
- Hypnotherapy
- Psychological therapy
167
General dietary advice for IBS?
| this has loads on it
- Explore dietary triggers and refer to a dietician
- Have regular meals and take time to eat
- Avoid missing meals or leaving long gaps between eating
- Drink at least 8 cups of fluid per day (water or herbal tea)
- Restrict tea and coffee to 3 cups per day
- Reduce intake of alcohol and fizzy drinks
- Consider limiting intake of high fibre food (wholemeal and whole grains)
- Reduce intake of ‘resistant starch’ often found in processed foods
- Limit fresh fruit to 3 portions per day
- For diarrhoea – avoid sorbitol (found in some fruits)
- For wind and bloating – consider increasing intake of oats and linseeds
168
What is diverticular disease?
pouches of mucosa extrude through the colonic muscular wall via weakened areas near blood vessels to form diverticula
169
What is diverticulosis?
the presence of diverticula (multiple outpouchings of the bowel wall)
170
What is diverticulitis?
implies inflammation, which occurs when faeces obstruct the neck of the diverticulum
171
Most common site for diverticular disease?
- Between taenia coli where vessels pierce the muscle to supply the mucosa
- For this reason the rectum (no taenia coli) is often spared
172
Symptoms of diverticular disease?
- Altered bowel habit
- PR bleeding
- Abdominal pain
173
Complications of diverticular disease?
- Diverticulits
- Haemorrhage
- Fistula development
- Perforation and faecal peritonitis
- Perforation and abcess development
- Development of diverticular phelgmon
174
How to diagnose diverticular disease?
Pt will undergo either:
- Colonoscopy
- CT cologram
- Barium enema
175
What is the Hinchey classification of severity for diveritcular disease?
I – Para-colinic abscess
II – pelvic abscess
III - purulent peritonitis
IV - faecal peritonitis
176
How is diverticular disease treated?
- Increase dietary fibre intake
- Mild attacks of diverticulitis may be managed with Abx
- Peri-colonic abscesses – drained surgically or radiologically
- Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative indication for a segmental resection
- Hinchey IV perforations will require resection and usually stoma
177
Most common site for diverticulosis?
- Sigmoid colon
| - Multiple outpouchings of the bowel wall
178
Presentation of diverticulosis?
- Painful diverticular disease:
- Altered bowel habit
- Colicky left sided abdo pain
- High fibre diet recommended
- Diverticulitis
179
How does acute diverticulitis present?
- Severe left iliac fossa pain and tenderness
- Anorexia, nausea and vomiting
- Change in bowel habit – constipation or diarrhoea
- Urinary frequency, urgency or pain (bladder irritated by inflamed bowel)
- Features of infection – pyrexia, raised WBC and CRP
- PR bleeding in some cases
Usually affects 50-70 year olds
80% of patients are >50
180
How does chronic diverticulits present?
- Intermittent abdominal pain - particularly in LLQ
- Bloating
- Change in bowel habit - constipation or diarrhoea
181
Physical signs of diverticulitis?
- Low grade fever
- Tachycardia
- Tender LIF
- Possible reduced bowel sounds
- Guarding, rigidity and rebound tenderness
- Lack of improvement with tx suggests abcess
182
Risk factors for diverticulitis?
- Age
- Lack of dietary fibre
- Obesity
- Sedentary lifestyle
- Smoking
- NSAID use
183
Investigating diverticulits?-
FBC - raised WCC
CRP - raised
Erect CXR - may show pneumoperitoneum if perforation
AXR - may show dilated bowel loops, obstruction of abcesses
CT - best imaging modality
Avoid colonoscopy initially due to increased risk of perforation in diverticulitis
184
How is diverticulits managed?
Mild attacks: Oral antibiotics
More significant req admission:
- NBM
- IV fluids
- IV ABx - typically a cephalosporin + metronidazole
185
What are the possible complications of diverticulits?
- Abscess formation
- Peritonitis
- Obstruction
- Perforation
186
What is Meckels diverticulum?
- A congenital diverticulum of the small intestine
- Remnant of the vitelline duct (aka omphalomesenteric duct)
- Contains ectopic ileal, gastric or pancreatic mucosa
- Rules of 2s: 2% of population, 2 feet from ileocaecal valve, 2inches
187
How does meckels diverticulum present?
- Usually aymptomatic
- Abdo pain mimicking appendicitis
- Rectal bleeding
- Intestinal obstruction secondary to:
- Omphalomesenteric band, volvulus, intussuception.`
188
How is meckels diverticulum managed?
- Removal if narrow neck or symptomatic
- Options are between:
- wedge excision
- formal small bowel resection and anastamosis
189
What is acute appendicitis?
- The most common acute abdominal condition requiring surgery
- Can occur any age, commonly 10-20
- Occurs when the luemn of the appendix becomes obstructed by a faecolith
- The bacteria inside the faecolith stagnate inside the appenix
- Causes inflammation
190
Presentation of appendicitis?
Abdominal pain:
- Peri-umbilical initially
- Migrates to RIF - McBurneys point
- Pain often worse on coughing, going over speed bumps
- Children cant hop on their right leg due to pain
Other features: N+V, Diarrhoea, Low grade fever, anorexia
191
Signs of appendicitis on abdo exam?
- Localised peritonism (tenderness and guarding)
- Rebound tenderness in RIF
- May be a tender mass present if there is an appendiceal abcess
192
What investigations should be done for appendicitis?
- Blood tests: Raised WBC, CRP and ESR
- Urinalysis: Exclude preg, exclude UTI and renal colic. May show leucocytes but no nitrates
- USS: Inflamed appendix and/or mass
- CT scans: Highly sensitive and specific. gold standard.
193
Management of appendicitis?
- Appendicectomy
- Metronidazole to reduce wound infection rates
- If perforated appendicitis - abdominal lavage
194
Complications of appendicitis?
- Gangrene or perforation
| - Leading to localised abcess formation or generalised peritonitis
195
2 histological types of oesophageal cancer?
- Squamous cell carcinoma: usually middle 1/3 of oesophagus
| - Adenocarcinoma: lower 1/3rd
196
What are the causes/rf of squamous cell carcinoma of the oesophagus?
- Smoking
- Excess alcohol consumption
- Pre-existing oesophageal disease (achalasia and strictures)
- Coeliac disease
- Reflux
- Scleroderma
- Diets rich in nitrosamines (bacon, cured meats, beer)
197
What are causes/rf of adenocarcinoma of the oesophagus?
- GORD
- Barretts oesophagus
- Smoking
- Obesity
198
Symptoms of oesophageal cancer?
- Dysphagia (increases as tumour grows, solids then liquids)
- Vomiting
- Weight loss and anorexia
- Odynophagia
- Hoarse voice
- Cough
- GI bleeding - haematemesis, melena
- Dyspepsia and reflux sx
- Symptoms of anaemia
199
Signs of oesophageal cancer?
- Anaemia
- Malnutrition
- Supraclavicular lymphadenopathy (virchows node)
- Pleural effusion
- Hepatomegaly
- Ascites
- Vocal cord paralysis/voice change
200
Investigations for oesophageal cancer?
- Upper GI endoscopy: First line investigation
- Contrast swallow
- Staging: Ct chest, abdo, pelvis
201
Management of oesophageal cancer?
- Operable disease managed by surgical resection
- Neoadjuvant chemotherapy
- Stenting is option for palliation, however sx relief only
202
Main complications of oesophageal cancer resection?
- Anastomotic leak: Intrathoracic anastomosis will result in mediastinitis. high mortality.
203
What type of cancer is gastric cancer?
Adenocarcinoma - because stomach cells are secretory
204
When does gastric cancer often present?
70-80yrs.
205
Risk factors/associations of gastric cancer?
- H.Pylori infection
- Blood group A
- Gastric adenomatous polyps
- Pernicious anaemia
- Smoking
- Aspirin
- Diet: salt, spicy, nitrates
- Low socioeconomic groups
206
How does gastric cancer present?
- Dyspepsia
- N+V
- Anorexia and W loss
- Dysphagia
- Outflow obstruction
- If metastasis: ascites and hepatomegaly
207
How is gastric cancer investigated?
- Diagnosis: Endoscopy and biopsy
- Staging: CT or endoscopic ultrasound
- Laparoscopy to identify occult peritoneal disease
- PET CT
208
How is gastric cancer treated?
- Proximal disease greater than 5-1-cm from the OG junction – sub-total gastrectomy
- Total gastrectomy if tumour is <5cm from OG junction
- Surgical options – gastric resection, lymphadenectomy, reconstruction
- Pre-op chemo improves survival
- Adjuvant chemotherapy after surgery if operable
- Palliative chemotherapy if inoperable
209
What are the types of cancers that can affect small intestines?
These are RARE
- Adenocarcinoma – 50% increased incidence in Coeliac and Crohn’s
- Non-Hogkin’s lymphoma – may be B or T cell in origin, increased frequency in coeliac disease
- Benign small intestinal tumours
- Peutz-Jeghers syndrome (autosomal dominant)
- Familial adenomatous polyposis (FAP)
- Carcinoid tumours
210
How do small bowel tumours present?
- Abdominal pain
- Diarrhoea
- Anorexia
- Anaemia
211
What are carcinoid tumours?
Originate from enterochromaffin cells of the intestine (produce histamine and serotonin)
212
What is carcinoid syndrome?
- The term applied to the symptoms that arise as a result of serotonin (5-HT), kinins, histamine and prostaglandins being released into the circulation by the tumour
- Usually occurs when metastases are present in the liver and release serotonin into the systemic circulation
- May also occur with lung carcinoid as mediators are not ‘cleared’ by the liver
213
What are the features of carcinoid syndrome?
- Flushing
- Diarrhoea
- Bronchospasm + wheezing
- Hypotension
- Right heart valvular stenosis
- Other molecules such as ACTH and GHRH may also be secreted resulting in, for example, Cushing's syndrome
214
How to diagnoise carcinoid tumour/syndrome?
- Urinary 5-HIAA levels raised (breakdown product of serotonin)
- Plasma chromogranin A
- Liver USS scan
215
Treatment of carcinoid syndrome/tumours?
- Somatostatin analogues eg. octreotide
- Diarrhoea give cyproheptadine
- Tumour reduced via surgery or chemo
216
3 different types of colon cancer?
1) sporadic (95%)
2) hereditary non-polyposis colerectal carcinoma
3) familial adenomatous polyposis
217
What is the histology of colorectal cancer?
Adenocarcinoma
218
Inheritance pattern of HNPCC?
- Autosomal dominant
- Most common inherited cancer
- aka Lynch Syndrome
219
If you have HNPCC, what are you also at risk of?
- Endometrial cancer (commonly)
- Gastric cancer
- Pancreatic cancer
220
Criteria for HNPCC diagnosis?
Amsterdam criteria
1) At least 3 family members with colon cancer
2) The cases span at least 2 generations
3) At least once case diagnosed before age 50
221
Inheritance pattern of FAP?
AD
| Mutation in the tumour suppression gene called adenomatous polyposis coli gene (APC) on chromosome 5
222
What are the features of FAP?
- Formation of hundreds of polyps by age 30-40yrs
- Inevitable they will develop carcinoma of large bowel
- Gardners syndrome is an FAP variant, you also get: osteoma of skull/mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts
223
How to manage FAP?
- Genetic testing: analyse DNA from WBC
| - Total colectomy with ileo-anal pouch formation in their 20s
224
Risk factors for colorectal cancer?
- Fhx
- Diet: lack of fibre, red meat, alcohol
- Smoking
- Past history of bowel conditions - adenoma, ulcerative colitis
225
Where are large bowel cancers often found?
- Rectal 40%
- Sigmoid 30%
- Asc colon and caecum 15%
- Transverse colon 10%
- Descending colon 5%
226
Generic features of bowel cancer?
- Bleeding
- Mucous
- Change in bowel habit
- Difficulty defecating of bowel obstruction
- Weight loss
- Night sweats/fevers
- Hepatomegaly
227
How does rectal cancer present?
Early: PR bleeding, mucus
Late: Thin stools, tenesmus
228
How does left sided and sigmoid cancer present?
Change in bowel habit: Diarrhoea, constipation, thin/altered stools
PR bleeding
229
How does right sided bowel cancer present?
- Later than left sided
- Anaemia
- Mass
230
How may bowel cancer present acutely?
Bowel obstruction with four cardinal signs
1) Absolute constipation
2) Colicky abdo pain
3) Abdominal distension
4) Vomiting
231
When to refer URGENT to colorectal?
- Patients ≥ 40 with unexplained weight loss AND abdominal pain
- Patients ≥ 50 with unexplained rectal bleeding
- Patients ≥ 60 years with iron deficiency anaemia OR change in bowel habit
- Occult blood found in faeces
232
When to refer 2WEEKWAIT to colorectal?
- Rectal or abdominal mass
- Unexplained anal mass or anal ulceration
- Patients < 50 years with rectal bleeding AND any of the following explained symptoms/findings:
- Abdominal pain
- Change in bowel habit
- Weight loss
- Iron deficiency anaemia
233
Investigations for colorectal cancer?
- Tumor markers: CEA can be useful
- Colonoscopy is gold standard with biopsy and polyp removal.
- Double contrast barium enema
- CT colonoscopy
234
Risks of colonoscopy?
- Bleeding
- Infection
- Perforation
- Missed dx
- Anaesthetic risks
235
How is colorectal cancer staged?
TNM
| Dukes
236
TNM staging for colorectal?
```
T0 = tumour confined to mucosa
T1 = tumour invades submucosa
T2 = tumour invades muscularis propria
T3 = tumour invades serosa
T4 = tumour invades other organs
```
```
N0 = no nodal involvement, N1 = 1-3 nodes involved, N2 = ≥ 4 nodes
M0 = no distant mets, M1 = distant mets present
```
237
Dukes classification of colorectal?
A: Tumour confined to mucosa
B: Tumour invading bowel wall
C: LN metastases
D: Distant mets
238
Management of colorectal cancer?
- MDT meeting essential – decides on surgical/non-surgical/both
- Surgery - only chance of cure
- Resection – tailored to the patient and tumour location
- Post-operative (adjuvant) chemotherapy – increases survival
- Radiotherapy – either pre-operative or palliative to improve symptoms
- If liver mets – hepatic resection offered
- Palliative chemotherapy – for those with unresectable metastatic disease, improves QoL and median survival
- Palliative surgery – stents, bypass, diversion stomas
239
What is peritonitis?
Inflammation of the peritoneum
240
Difference between localised and generalised peritonitis?
Localised:
- Occurs with all acute inflammatory GI conditions
- Management depends on the underlying condition e.g. appendicitis, cholecystitis
Generalised
- Occurs as a result of rupture of an abdominal viscus (e.g. perforated DU or appendix)
- Sudden onset of abdominal pain which becomes rapidly generalised
- Patient is shocked and lies still as movement exacerbates the pain
241
Causes of primary peritonitis?
- Extremely rare
- Haematogenous - originates/carried in the blood or from LN
- Risk groups:
- Liver disease (Spontaneous bacterial peritonitis)
- Females
- Immune compromised
- Post-splenectomy
- Peritoneal dialysis pts
- Patients with ascites
242
Causes of secondary peritonitis?
- Perforation of hollow viscus (generalised peritonitis)
- Peptic ulcer, colonic diverticulum, appendix
- Inflammation of abdo organs (localised peritonitis)
- Peritoneal dialysis
- TB
- Ischaemia of hollow viscus
- Chemical contamination eg glove left in after surgery
243
Symptoms of peritonitis?
- Acute presentation
- Pain
- Tenderness
- Systemic sx: Nausea, chills, rigors, dizziness, weakness, immobile due to pain
244
Clinical exam findings for peritonitis?
```
General exam:
- Pyrexia, tachycardic, signs of shock
- Confusion
- Pt lie still
Abdo exam:
- Guarding
- Hard, rigid abdomen
- Rebound tendernes
- Silent abdomen (ominous sign)
```
245
Investigating ?peritonitis?
- Blood tests: FBC,U&E,amylase, LFTs, CRP
- ABG - look for sepsis
- Plaiin XR
- CT abdo
- Culture: Blood and ascitic fluid
246
How to manage peritonitits?
- ABCDE approach to resuscitation
- Sepsis 6
- Broad spectrum IV antibiotics
- Treat underlying cause
- Medical Mx of primary peritonitis – IV Abx (SPB, PID, PD related)
- Surgical Mx of secondary peritonitis – repair or removal of perforated viscus
247
What is a hernia?
Protrusion of a viscus or part of a viscus through a natural orifice or weakness into another compartment.
All abdo wall hernias present as a lump
248
Common types of hernia?
```
Inguinal (direct or indirect)
Femoral
Umbilical
Paraumbilical
Epigastric
Incisional
Parastomal
Hiatus
```
249
How to classify hernias?
```
Reducible
Irreducible
Incarcerated
Obstructed
Strangulated
```
250
What is a reducible hernia?
- Can be pushed back in
- Can be spontaneous or manual
- Most are reducible when they first appear
251
What is an irreducible hernia?
- Impossible to return contents of hernia to abdo cavity
- Usually involve bowel
- Can be partial or complete
252
What is hernial incarceration?
- Contents of hernia sac are stuck inside by adhesions
253
What is an obstructed hernia?
- Pressure from edges of hernia means bowel contents cannot pass through - causes feature of intestinal obstruction
254
What is a strangulated hernia?
- Ischaemia occurs --> gangrene and perforation of hernia contents
255
What is an inguinal hernia?
- Most common type of hernia
- Accounts for 75% of abdo wall hernieas
- 95% male
256
Predisposing factos for inguinal hernia?-
- Male gender
- Chronic cough
- Constipation
- Urinary obstruction
- heavy lift
- Ascites
- past abdo surgery
257
Features of inguinal hernias?
- Groin lump: disappears on pressure or where pt lies down
- Discomfort and ache
- Strangulation is rare
258
Direct vs indirect inguinal hernia?
- Direct: Through posterior wall of inguinal canal
| - Indirect: Hernia through inguinal canal
259
Management of inguinal hernia?
Treat medically fit patients even if they are asymptomatic
Surgical repair with polyproylene mesh
If patient not fit for surgery – hernia truss may be an option, no role in other patients
260
When can pt return to work after hernia repair?
Open repair – 2-3 weeks (non manual work only)
Laparoscopic repair – 1-2 weeks
261
Complications of hernia repair?
Early: Bruising and wound infection
Late: Chronic pain and recurrence
262
Main risk of femoral hernia?
HIGH risk of strangulation
263
How do femoral hernias present?
Mass on medial thigh.
| More often women
264
Treatment of femoral hernia?
Either:
Herniotomy: ligation and excision of sac
Herniorrhaphy: Repair of hernia defect (ie with mesh)
265
What is an incisional hernia?
- Occur through sites of surgical access into the abdominal cavity.
- Most common following surgical wound infection
To minimise following midline laparotomy Jenkins Rule should be followed:
- This necessitates a suture length 4x length of incision
- With bites taken at 1cm intervals, 1 cm from the wound edge.
- Repair may be performed either at open surgery or laparoscopically and a wide variety of techniques are described
266
Risk factors for incisional hernia?
- Obesity
- Emergency surgery
- Wound infection post op
- Persistent coughing
- Poor nutrition
- Heavy lifting
- Other pre-existing health condition that slows healing eg HIV or diabetes
267
What is an umbilical hernia?
- Hernia through weak umbilicus
- Usually presents in childhood
- Often asymptomatic
- Equal sex incidence
- 95% will resolve by age 2
- Thereafter try surgical repair
268
Rf for umbilical hernia?
- Black kids
- Obesity
- Ascites
- Heavy lifting
- Persistent coughing
- Multiple pregnancies
269
Management of umbilical hernia?
< 2 years – leave alone
>2 years – surgical repair of the rectus sheath (Mayo repair)
270
What is a hiatus hernia?
Herniation of part of the stomach above the diaphragm through the oesophageal hiatus
2 types:
Sliding
Rolling (Para-oesophageal)
271
What are Sliding hiatus hernia?
- Account for 95% of hiatus hernias
- The gastroesophageal junction moves above the diaphragm
- Asymptomatic unless there’s associated reflux
272
What is a rolling hiatus hernia?
- Uncommon
- Gastric fundus rolls up through the hiatus alongside the oesophagus
- Gastro-oesophageal junction remains below the diaphragm
- Poses a serious risk of complications – gastric volvulus (rotation and strangulation of the stomach), bleeding and respiratory complications
- Should be treated surgically
273
What is a volvulus?
- Complete twisting of a loop of intestine around its mesenteric attachment site
- Resulting in compromised blood flow and closed-loop obstruction
- Can occur at various locations e.g. stomach, small intestine, caecum, transverse and sigmoid colon
274
Most common site for volvulus?
- Sigmoid is 80% (LBO caused by sigmoid colon twisting on its mesentery)
- Caecum is 20%
275
Associations with sigmoid volvulus?
- Older patients
- Chronic constipation
- Chagas disease (American trypanosomiasis)
- Neurological conditions e.g. Parkinson's disease, Duchenne muscular dystrophy
- Psychiatric conditions e.g. schizophrenia
276
Associations with caecal volvulus?
- All ages
- Adhesions
- Pregnancy
277
Features of volvulus?
Sx of BO:
- Constipation
- Abdo bloating
- Abdo pain
- N+V
278
Diagnosis of volvulus?
- Usually diagnosed on abdo film (XR)
- Sigmoid: LBO (large dilated loop of colon) and Coffee Bean sign
- Caecal: SBO seen
279
Management of volvulus?
Sigmoid volvulus - rigid sigmoidoscopy with rectal tube insertion
Caecal volvulus - management is usually operative. Right hemicolectomy is often needed
280
What is diarrhoea?
- Liquid form loose stools
| - Often frequent/urgent passing
281
DIfference between chronic and acute diarrhoea?
- Acute: Usually due to infection or food poisoning
| - Chronic: defined as diarrhoea persisting for >14 days.
282
List some infectious causes of diarrhoea?
- Infectious = gastroenteritis. May occur at home or whilst travelling abroad
- Viral – rotavirus, norovirus
- Foodborne – often bacterial
- Antibiotic associated diarrhoea (wipes out normal gut flora)
- Travel related – E.coli, Giardiasis etc
- Diarrhoea in the immunocompromised
- Can be a feature of systemic infection (e.g. sepsis, malaria)
283
Non infectious causes of diarrhoea?
- IBD
- Malabsoprtion eg Coeliac disease
- Malignancy
- Overflow w/ constipation
- Endocrine eg thyrotoxicosis
- Medicines eg. laxative abuse, metforin
284
Clues about cause of infective diarrhoea?
- History of contact with other cases - Norovirus
- Small children – rotavirus
- Fresh water – Aeromonas
- Puppies, chicken restaurant – Campylobacter
- Reptiles – Salmonella
- Well water – Giardia
- Flooding/water problems – Cryptosporidiosis
- Raspberries – Cycospora
285
Management of diarrhoea?
- Oral rehydration salts (dioralyte)
| - Loperamide: acts on opioid receptors to slow gut down. Doesnt cross BBB so no neuro sx
286
Side effects and C/I for loperamide?
Side effects
- Constipation
- Abdominal cramps
- Dizziness
Contraindications
- Ulcerative colitis
- Infective diarrhoea associated with bloody stools – as you actually want to
clear this kind of diarrhoea, not stop it
287
Define travellers diarrhoea?
At least 3 loose watery stools in 24 hours
With or without one or more of:
- Abdominal cramps
- Fever
- Nausea
- Vomiting
- Blood in the stool
288
Most common cause of travellers diarrhoea?
E. Coli
289
What is acute food poisoning?
Sudden onset of nausea, vomiting and diarrhoea after the ingestion of a toxin.
290
Most common causes of acute food poisoning?
- Staphylococcus aureus
- Bacillus cereus
- Clostridium perfringens
291
Describe history of E.Coli diarrhoea?
- Common amongst travellers
- Watery stools
- Abdominal cramps and nausea
- Incubation period 12-48 hours
292
Describe history of Giardasis diarrhoea?
- Prolonged
- Non-bloody diarrhoea
- Incubation period > 7 days
- Parasitic infection rather than bacterial
293
Describe history of cholera diarrhoea?
- Profuse, watery diarrhoea
- Severe dehydration resulting in weight loss
- Not common amongst travellers
294
Describe hx of shigella diarrhoea?
- Bloody diarrhoea
- Vomiting and abdominal pain
- Incubation period - 48-72 hours
295
Describe hx of staph aureus infection?
- Severe vomiting
| - Short incubation period (1-6hrs)
296
Describe hx of campylobacter diarrhoea?
- Flu-like prodrome
- Crampy abdominal pains
- Fever
- Diarrhoea which may be bloody
- Complications include GBS
- Incubation period 48-72 hours
297
Describe hx of bacillus cereus?
Two types of illness seen:
- vomiting within 6 hrs, stereotypically due to rice
- Diarrhoeal illness occuring after 6hrs
298
Describe hx of amoebiaisis diarrhoea?-
- gradual onset bloody diarrhoea
- abdo pain and tenderness
- may last several weels
299
What is Clostridium difficile?
- A gram positive rod bacteria (purple in gram stain)
- Often encountered in hospital setting
- Develops when the normal gut flora are suppressed by broad spectrum antibiotics
300
Main complication of C Diff?
Pseudomembranous colitis.
| Occurs due to C.Diff exotoxin causing intestinal damage
301
Risk facotrs for C Diff infection?
- Broad spectrum abx: 3rd gen cephalosporins are leading cause (cefotaxime and ceftriaxone etc)
- Use of PPI and H2 receptor antagonists
- Being hospitalised
- Contact with infected persons
302
Clinical features of C Diff?
- Diarrhoea
- Abdo pain
- Raised WBC count
- If severe: Toxic megacolon
303
Diagnosis of C Diff how?
- Stool sample: Detection of clostridium difficile toxin in the stool
304
How is C Diff treated?
- Isolate
- First line therapy – oral metronidazole for 10 - 14 days
- If severe or not responding to metronidazole – oral vancomycin may be used
- Patients who don’t respond to vancomycin may respond to oral fidaxomicin
- For life-threatening infections – combination of oral vancomycin and IV metronidazole should be used
- Patients with severe and unremitting colitis should be considered for colectomy
305
Why is diarrhoea common in pt with HIV?
- May be due to opportunistic infections
| - Or due to effects of virus itself
306
Causes of diarrhoea in HIV patients?
- Most common = cryptosporidium
- Detected with modified Ziehl-Neelsen stain for acid fast bacilli
- Other protozoa too
- Cytomegalovirus
- Mycobacterium avium intracellulare
- Giardia
307
What causes amoebiasis?
- Entamoeba histiolytica
- Spread by faecal oral route
- 10% of worlds pop are chronically infected
308
Features of amoebiasis?
- Can be asymptomatic
- Can cause mild diarrhoea or severe amoebic dysentery
- Can also cause liver and colon abscesses
- Amoebic dysentery:
- Profuse, bloody diarrhoea
- Stool microscopy – trophozoites
- Treat w/ metronidazole
- Amoebic liver abscess:
- Usually a single mass in the right lobe (may be multiple)
- Features - fever, RUQ pain
- Serology positive in >90%
309
How is malnutrition diagnosed?
Unintentional weight loss greater than 10% within the last 3-6 months
Or A body mass index of less than 18.5kg/m²
Or A body mass index of less than 20kg/m² and unintentional weight loss greater than 5% within the last 3-6 months
310
How can pancreatitis be classified?
Acute pancreatitis = inflammation of a previously normal pancreas. The inflammation that occurs is reversible
Chronic pancreatitis = continuing inflammation with irreversible structural changes
311
Exocrine functions of pancreas?
- The exocrine glands of the pancreas produce enzymes used for digestion
- These enzymes include
- Trypsin and chymotrypsin – protein digestion
- Amylase – carbohydrate digestion
- Lipase – breakdown of fats
- These are released into the pancreatic duct when food enters the stomach
- Ampulla of Vater releases these into the duodenum
312
Endocrine functions of pancreas?
- Endocrine component of the pancreas consists of islet cells (islets of Langerhans) which release hormones directly into the bloodstream
- The 2 main hormones are
- Insulin – acts to lower blood sugar
- Glucagon – acts to raise blood sugar
313
Causes of acute pancreatitis?
```
Most commonly = gallstones and alcohol
IGETSMASHED
Idiopathy
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion stings
Hypothermia/hypercalcaemia
ERCP (endoscopic retrograde cholangiopancreatography)
Drugs - azathioprine, oestrogens, steroids, didanosine
```
314
Sx of acute pancreatitis?
- Severe epigastric pain - may radiate through to back
- Vomiting
- Anorexia/Nausea
- Hx of gallstones or alcohol abuse
315
Signs of acute pancreatitis?
- Abdominal examination – widespread tenderness and guarding
- Ileus – may have absent bowel sounds
- Low-grade fever
- In severe cases – signs of septic shock: tachycardia, hypotension, dehydration, oliguria
- Described but rare
- >Periumbilical discolouration - Cullen’s sign
- >Flank discolouration – Grey-Turner’s sign
316
How can acute pancreatitis be classified?
Oedematous – 70%
Severe/necrotising – 25%, necrosis
Haemorrhage – 5% (this is when you will see Cullen’s/Grey Turner’s sign)
317
Blood tests for suspected acute pancreatitis?
Serum amylase – 3x higher than normal level (but there are other reasons for hyperamylasaemia). Serum amylase levels do not correlate with disease severity
Serum lipase – raised, more sensitive and specific than serum amylase. It also has a longer half life
Urinary amylase – will still be raised if the patient present late and the serum amylase levels have dropped again
FBC, CRP, U&E, LFT, plasma Ca2+ and ABGs – measured on admission and at 24-48 hours to assess the severity of the pancreatitis
318
What else can cause raised amylase?
- Acute pancreatitis
- Pancreatic pseduocyst
- Mesenteric infarct
- Perforated viscus/peptic ulcer
- Acute cholecystitis
- Diabetic ketoacidosis
319
Imaging for ?acute pancreatitis?
- Erect CXR to r/o perforated peptic ulcer
- Abdominal USS for gallstones
- Contrast CT
- ERCP
320
Scoring systems for pancreatitis severity?
- Abbreviated Glasgow scoring system
- Ranson criteria
- Balthazar Score
- APACHE score – may also be used but usually only done in intensive care
CRP can also be used to assess severity
321
Components of abbreviated glasgow system?
Composed of 8 clinical indicators (PANCREAS), score of >3 indicates the for supportive ITU treatment or anaesthetic review
- PaO2 < 8 kPa – low
- Age > 55 years
- Neutrophils > 15x10^9 – raised
- Calcium < 2 mmol/l – low
- Raised urea > 15 mmol/l
- Elevated enzymes (LDH or AST)
- Albumin < 32 g/l - low
- Sugar – serum glucose >15 mmol/l - raised
322
management of pancreatitis?
- Analgesia very important
- ABCDE approach to resuscitation/shock
- Surgery:
- Patients with acute pancreatitis due to gallstones should undergo early cholecystectomy
- Patients with obstructed biliary system due to stones – ERCP
- Patients who fail to settle with necrosis and have worsening organ dysfunction may require debridement
- Patients with infected necrosis - either radiological drainage or surgical necrosectomy
323
How is mild pancreatitis managed?
Medical therapy consisting of
- Pain control – tramadol or other opiates, fentanyl
- NBM
- IV fluids
- NG tube
Monitor for complications
324
Management of severe pancreatitis?
- The same medical therapy for mild disease (IV fluids, analgesia)
- Consider ITU
- Prophylactic Abx – usually cephalexin/metronidazole
- Nasogastric or nasojejunal feeding
- ERCP within 48 hours if gallstones – extraction can be performed
- Anticoagulation with LMWH for DVT prophylaxis
325
Complications of acute pancreatitis?
Systemic inflammatory response syndrome
Multiple organ dysfunction syndrome (MODS) – pancreatitis causing loss of body homeostatic mechanisms
326
What is chronic pancreatitis?
- Inflammation of pancreas lasting >12 weeks
- Damage is irreversible
- Can lead to dysfunction of both exocrine and endocrine functions of pancreas. Leading to malabsoption and diabetes respectively.
- Difficult to dx and manage
327
Causes of chronic pancreatitis?
- 80% of cases due to alcohol
- Autoimmune
- Idiopathic
- Cystic fibrosis
- Trauma
- Hypercalcaemia
328
Features of chronic pancreatitis?
- Epigastric pain – typically worse 15-30 minutes after a meal
- Exocrine dysfunction - causing steatorrhea and other symptoms of pancreatic insufficiency (usually develops 5-25 years after the onset of pain)
- Endocrine dysfunction – DM occurs in majority of patients, usually 20 years after symptoms begin
- Severe weight loss and anorexia
- Nausea and vomiting
- Can occasionally present with jaundice – due to obstruction of CBD during its course through the fibrosed head of pancreas
329
How is chronic pancreatitis investigated?
```
Imaging:
- Abdo XR - can show calcification
- USS
- CT - more sensitive
- MRCP and endoscopic USS
- ERCP
Functional/biochemical
- Faecal elastase - reduced
- Blood glucose - raised, indicated DM
- Serum amylase
```
330
Management of chronic pancreatitis?
- Advise patient to stop drinking alcohol
- Analgesia
- Surgical resection combined with drainage of the pancreatic duct into the small bowel
- ERCP – to amend pancreatic strictures or stones
- Pancreatic enzyme supplements – useful for those with steatorrhoa, may reduce frequency of attacks of pain in those with recurrent symptoms
- If diabetes has occurred – dietary control, oral hypoglycaemics or insulin
331
Complications of chronic pancreatitis?
- Pseudo-cyst (fluid collection surrounded by granulation tissue)
- Ascites and pleural effusion
- Pancreatic cancer
