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GI Clinical 2 Flashcards

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1
Q

What are the clinical signs of a small intestinal disorder?

A

Weight loss, increased appetite, diarrhoea, bloating, fatigue

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2
Q

What causes steatorrhoea?

A

Fat malaborption

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3
Q

Describe steatorrhoea

A

Pale, foul-smelling, stool less dense and floats, may leave oily marks or oil droplets

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4
Q

What minerals or vitamins may be deficient in a patient with a small intestinal disorder?

A

Iron, B12, folate, Ca2+, Mg2+, vitamin D, vitamin A, vitamin K, vitamin B complex, vitamin C

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5
Q

What is a sign of vitamin C deficiency?

A

Scurvy

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6
Q

What is a sign of deficient niacin (vitamin B complex)?

A

Dermatitis, unexplained heart failure

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7
Q

What is a sign of deficient thiamine (vitamin B complex)?

A

Memory, dementia

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8
Q

What can diseases of malabsorption (Crohn’s, coeliac) present as clinically?

A

Clubbing

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9
Q

What can finger clubbing mean clinically in the GIT?

A

Malabsorption (Crohn’s, Coeliac disease)

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10
Q

What can aphthous ulceration mean clinically in the GIT?

A

Crohn’s, Coeliac disease

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11
Q

What can be a cutaneous manifestation of coeliac disease?

A

Dermatitis herpetiformis:

Blistering, itchy (scalp, shoulders, elbows, knees)

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12
Q

What are some investigations for the structure of the GIT?

A 
Small bowel biopsy - endoscopy
Small bowel study - barium
CT scan
MRI enterography
Capsule enterography
White cell scan
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13
Q

What are tests for bacterial overgrowth in the small bowel?

A

H2 breath test

Culture a duodenal or jejunal aspirate

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14
Q

What can the H2 breath test investigate?

A

Bacterial overgrowth

Carbohydrate malabsorption e.g. lactose, glucose

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15
Q

What are the investigations for coeliac disease?

A

Serology - IgA tests (IgG if IgA deficient)
Distal duodenal biopsy
HLA status

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16
Q

What does a distal duodenal biopsy look at?

A

Villous atrophy

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17
Q

What is coeliac disease a sensitivity to?

A

Gliaden which is part of gluten (found in wheat, rye, barley)

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18
Q

What is the pathology of coeliac disease?

A

Produces inflammatory response
Partial or subtotal villous atrophy
Increased intra-epithelial lymphocytes

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19
Q

What is the gold standard diagnostic tool for coeliac disease?

A

Distal duodenal biopsy

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20
Q

What is the treatment for coeliac disease?

A

Withdraw gluten

Refer to dietician

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21
Q

What are some conditions associated with coeliac disease?

A 
Dermatitis herpetiformis
IDDM
Autoimmune thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Autoimmune gastritis
IgA deficiency
Downs syndrome
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22
Q

What are the complications of coeliac disease?

A 
Refractory coeliac disease
Small bowel lymphoma
Oesophageal carcinoma
Colon cancer
Small bowel adenocarcinoma
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23
Q

What are causes of malabsorption?

A

Inflammation e.g. Coeliac disease, Crohn’s
Infection e.g. tropical sprue, HIV, Giardia lamblia (parasite), Whipples’s disease
Infiltration
Impaired motility
Iatrogenic e.g. surgery
Pancreatic e.g. chronic pancreatitis, CF

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24
Q

What is giardia lamblia?

A

A parasite that causes giardiasis infection and malabsorption

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25
What can giardiasis be treated with?
Metronidazole
26
When can small bowel bacterial overgrowth happen?
In any condition that affects: motility, gut structure, immunity
27
What is the treatment for small bowel bacterial overgrowth?
Rotating antibiotics | Vitamin and nutrient supplements
28
What are the 2 broad categories of GI disease?
Structural and functional
29
What is meant by a structural GI disease?
Detectable pathology - macroscopic/microscopic | Prognosis depends on pathology
30
What is meant by a functional GI disease?
No detectable pathology Related to gut function Long-term prognosis good
31
What are examples of functional GI disorders?
``` Oesophageal spasm Non-ulcer dyspepsia (NUD) Biliary dyskinesia IBS Slow transit constipation Drug related effects ```
32
What is non-ulcer dyspepsia?
Dyspeptic type pain with no ulcer on endoscopy | Probably not a single disease
33
What is the investigation process for non-ulcer dyspepsia?
History and examination - FH H. pylori status Alarm symptoms
34
What is the treatment for non-ulcer dyspepsia if all investigations are negative?
Treat symptomatically
35
What is the treatment for non-ulcer dyspepsia if H.pylori positive?
Eradication therapy
36
What are the brain components of vomiting and nausea?
Vomiting centre | Chemoreceptor trigger zone (CTZ)
37
If symptoms occur immediately after food, what is the likely cause?
Psychogenic
38
If symptoms occur 1hr+ after food, what is the likely cause?
Pyloric obstruction | Motility disorders e.g. diabetes, post-gastrectomy
39
If symptoms occur 12hrs after food, what is the likely cause?
Obstruction
40
What are possible functional GI disorder causes?
``` Drugs Pregnancy Migraine Cyclical vomiting syndrome Alcohol ```
41
How does psychogenic vomiting usually present?
Often young women, often for years May have no preceding nausea May be self-induced (overlap with bulimia) Appetite usually not disturbed but may lose weight Often stops shortly after admission
42
What are functional diseases of the lower GIT?
IBS | Slow transit constipation
43
What is the average stool weight in the UK?
100-200g/day
44
What are the ALARM symptoms when assessing a patient?
``` >50yo Short symptom history Unintentional weight loss Nocturnal symptoms Male FH of bowel/ovarian cancer Anaemia Rectal bleeding Recent antibiotic use Abdominal mass ```
45
What investigations could you do for functional lower GIT symptoms?
``` FBC Blood glucose U+E Thyroid status Coeliac serology FIT testing Sigmoidoscopy Colonoscopy then biopsy ```
46
What is a FIT test?
Faecal immunological testing
47
What are some organic causes of constipation?
``` Strictures Tumours Diverticualr disease Proctitis Anal fissure ```
48
What is proctitis?
Inflammation of the lining of the rectum
49
What are some functional causes of constipation?
``` Megacolon Idiopathic constipation Depression Psychosis Institutionalised patients ```
50
What are some systemic causes of constipation?
DM Hypothyroidism Hypercalcaemia
51
What are some neurogenic causes of constipation?
``` Autonomic neuropathies Parkinson's Strokes MS Spina bifida ```
52
What are some synonyms for IBS?
Nervous colon, unstable colon, spastic colon, mucous colitis - ALL inappropriate
53
What are the clinical features of IBS?
Abdominal pain, altered bowel habit, abdominal bloating, bleching wind and flatus, mucus
54
What is the usual pattern of IBS symptoms?
Chronic relapsing, remitting manner
55
What are the NICE guidelines for diagnosing IBS?
``` Abdominal pain/discomfort relieved by defection or associated with altered stool frequency/form, plus two or more of: Altered stool passage Abdominal bloating/distention Symptoms made worse by eating Passage of mucus ```
56
What type of altered bowel habit might IBS patients experience?
``` Constipation (IBS-C) Diarrhoea (IBS-D) Both (IBS-M) Variability Urgency ```
57
What are the investigations for IBS?
``` Blood analysis: FBC, U+E, LFTs, Ca, CRP, TFTs, coeliac serology Stool culture Calprotectin FIT testing Rectal examination ?Colonscopy ```
58
What is calprotectin?
A protein biomarker present in faeces when intestinal inflammation occurs
59
What is calprotectin used for?
Differentiating between IBS and IBD and for monitoring IBD
60
Which is calprotectin present in: IBS or IBD?
IBD
61
What does the FODMAP diet stand for?
Fermentable Oligo-, Di- and Mono-Saccharides and Polyols
62
What is the FODMAP diet made up of?
Fructose, lactose, fructans, galactans, polyols
63
What are drug therapies for pain in IBS?
Antispasmodics
64
What are drug therapies for bloating in IBS?
Some probiotics | Linaclotide (IBS-C)
65
What are drug therapies for constipation in IBS?
Laxatives | Linaclotide
66
What are drug therapies for diarrhoea in IBS?
Antimotility agents | FODMAP
67
What are psychological interventions for IBS?
Relaxation training Hyponotherapy CBT Psychodynamic interpersonal therapy
68
What are some causes of IBS?
Altered motility Visceral hypersensitivity Stress, anxiety, depression
69
What is the pattern of disease in IBD?
Chronic relapsing
70
What is the classification system for Crohn's disease/IBD?
Montreal classification
71
When is the peak incidence of ulcerative colitis?
20-40yrs
72
Who is ulcerative colitis more common in: females or males?
Females
73
How does ulcerative colitis present?
Bloody diarrhoea, abdominal pain, weight loss
74
What are markers of a severe attack of ulcerative colitis?
``` Stool frequency: >6/day with blood AND Fever >37.5 Tachycardia = >90/min ESR(CRP) = raised Anaemia = Hb<10g/dl Albumin = <30g/l Leucocytosis, thrombocytosis ```
75
Where does ulcerative colitis only affect?
Colon
76
Where does Crohn's disease affect?
Mouth to anus
77
What are the clinical features of Crohn's disease?
Diarrhoea, abdominal pain, weight loss, malaise, lethargy, anorexia, N+V, low-grae fever, malabsorption signs: anaemia, vitamin deficiency
78
What are some of the complications of Crohn's disease?
Strictures, fistulas
79
What would test results be like for Crohn's disease?
``` Blood: High ESR+CRP High platelet count High WCC Low Hb Low albumin High calprotectin ```
80
What are the different values for calprotectin?
<50 normal 50-200 equivocal >200 elevated
81
What specific histology would you expect with Crohn's disease?
Granulomas
82
What are some extra-intestinal manifestations would you expect with IBD?
Eyes: uveitis, conjunctivitis Joints: sacroilitis, ankylosing spondylitis Renal caculi: in Crohn's Liver and biliary tree: gallstones, sclerosing cholangitis Skin: erythema nodosum, vasculitits
83
What are some DDs for IBD?
Chronic diarroheas Ileo-caecal TB Different colitis'
84
What is sclerosing cholangitis?
Disease of the bile ducts = multiple strictures
85
What is a long-term complication of colitis?
Colonic carcinoma
86
Which type of ulcerates colitis is more likely to develop colonic carcinoma?
Pancolitis
87
After what duration of having ulcerative colitis are you more at risk of developing colonic carcinoma?
20yrs
88
What is 5-ASA?
Aminosalicylates
89
What is the medical management for outpatients with ulcerative colitis?
Aminosalicylates (5-ASA) Steroids Immunosuppression
90
What is the medical management for inpatients with ulcerative colitis?
Steroids Anticoagulation Rest
91
What is an example of an aminosalicylate?
Mesalazine
92
What is the treatment for Crohn's?
``` Steroids e.g. prednisolone Thiopurines Methotrexate Immunosuppressants Biologics e.g. anti-TNFalpha antibodies Elemental feeding ```
93
What is the surgery for acutely ill severe colitis?
Total colectomy Rectal preservation Ileostomy
94
What surgical procedure requires no ileostomy?
Pouch procedure
95
What are bedside investigations for GI?
``` BMI Pulse oximetry (O2 sats) ECG Capillary glucose Urinalsysis ```
96
What investigations can you do from a stool sample?
FOB testing (faecal occult blood) Stool culture Faecal calprotectin Faecal elastase
97
What investigations can you do from a blood sample in GI?
``` U+E Calcium/magnesium Liver functions tests (hepatic: high ALT, GGT, obstructive: high bilirubin, ALP) CRP Thyroid function FBC: anaemia, WCC, platelet count Coagulation (hepatic dysfunction) Haematinics: B12, folate, ferritin Hepatic screen: hep B/C serology, autoantibodies, immunoglobulins, ferritin, alpha-1 antitrypsin, alpha fetoprotein Coeliac serology Tumour markers ```
98
What are examples of GI physiology investigations?
Breath testing: urea breath test (H.pylori), H+ breath test (bacterial overgrowth), lactose intolerance Oesophageal pH and manometry: assessment for oesophageal dysmotility and assess reflux
99
What can you also do whilst performing an upper GI endoscopy?
Biopsy | Stenting
100
What are the risks with upper GI endoscopy?
Aspiration, perforation, haemorrhage
101
What is EMR?
Endoscopic mucosal resection
102
What can you also do whilst performing a colonoscopy/
Biopsy EMR Polypectomy
103
What are the risks with colonoscopy?
``` Haemorrhage Renal impairment (bowel preparation - Picolax) ```
104
What is ERCP?
Endoscopic retrograde cholangio-pancreatography
105
What does a ERCP allow you to do?
Visualise ampulla, biliary system and pancreatic ducts | Biopsy/cytology, stone removal, stunting, dilatation
106
What are the risks of ERCP?
Pancreatitis, haemorrhage, perforation, infection, mortality
107
What is EUS?
Endoscopic ultrasound
108
When is EUS used?
Diagnosis and staging | Allows biopsy and cyst drainage
109
What is enteroscopy used for?
Small intestine | Biopsy/therapy for small bowel pathology
110
What are the advantages and disadvantages of capsule enteroscopy?
Pro: less invasive Con: no biopsy possible
111
What type of pain accompanies acute pancreatitis?
Upper abdominal pain
112
What is particularly elevated with acute pancreatitis?
Serum amylase
113
What are the biggest causes of acute pancreatitis?
Alcohol abuse | Gallstones
114
What are the investigations for acute pancreatitis?
``` Blood tests: amylase/lipase, FBC, U+Es, LFTs, Ca2+, glucose, ABGs, lipids, coagulation screen Abdominal XR CXR Abdominal ultrasound CT scan ```
115
What criteria is used to assess the criteria of acute pancreatitis?
Glasgow criteria
116
What is the acronym for the Glasgow criteria for acute pancreatitis
``` PANCREAS PO2 <60mmHg Age >55 Neutrophilia WBC >15 Calcium <2mmol/l Renal urea >16mmol/l Enzymes (AST >200iu/l, LDH >600iu/l) Albumin <32g/l Sugar glucose >10mmol/l ```
117
When does the Glasgow criteria indicate severe pancreatitis?
Score >3 within 48hrs admission
118
What CRP also indicates severe pancreatitis?
>150mg/l CRP
119
What is the management of acute pancreatitis?
``` Analgesia (pethidine, indomethacin) IV fluids Blood transfusion (Hb<10g/dl) Monitor urine output (catheter) NG tube Oxygen May need insulin Nutrition ```
120
What is the management of pancreatic necrosis?
CT guided aspiration -> antibiotics +/- surgery
121
What is the management in acute pancreatitis if there are gallstones?
EUS/MRCP/ERCP | Cholecystectomy
122
What are the complications of acute pancreatitis?
Abcess -> antibiotics and drainage | Pseudocyst
123
What is a pseudocyst in relation to acute pancreatitis?
Fluid collection without epithelial lining Comes with persistent hyperamylasaemia and/or pain Complications: jaundice, infection, haemorrhage, rupture <6cm diameter -> resolve spontaenously Endoscopic drainage or surgery if persistant pain or complications
124
What is chronic pancreatitis?
Continuing inflammatory disease of the pancreas characterised by irreversible glandular destruction and typically causing pain and/or permanent loss of function
125
Does chronic pancreatitis affect males or females more?
Males
126
What is the typical age of onset of chronic pancreatitis?
35-50yrs
127
What are the causes of chronic pancreatitis?
``` Alcohol Cystic fibrosis (2%) - gene mutations Congenital anatomical abnormalities Hereditary pancreatitis (rare; auto. dom.) Hypercalcaemia ?Diet ```
128
What are the most well-recognised pancreatitis-susceptibility genes?
PRSS1 SPINK1 CFTR
129
What is the pathogenesis of chronic pancreatitis?
Duct obstruction: calculi, inflammation, protein plugs ?Abnormal sphincter of Oddi function: spasm/relaxation ?Genetic polymorphisms: abnormal trypsin activation
130
What is the pathology of chronic pancreatitis?
Glandular atrophy and replacement by fibrous tissue Ducts become dilated, tortuous and strictured Inspissated secretions may calcify 'Exposed' nerves due to loss of perineural cells Splenic, SMV and portal veins may thrombus -> portal hypertension
131
What are the clinical features of chronic pancreatitis?
``` Early disease = asymptomatic Abdominal pain (exacerbated by food+alcohol) Weight loss (pain, anorexia, malabsorption) Exocrine insufficiency: fat malabsorption (steatorrhoea), protein malabsorption, decrease in fat soluble vitamins Endocrine insufficiency (diabetes) Jaundice, portal hypertension, GI haemorrhage, pseudocysts, ?pancreatic carcinoma ```
132
What investigations would you do for chronic pancreatitis?
``` Plain AXR US EUS CT Blood tests: serum amylase, albumin, Ca2+, Mg2+, vit B12, LFTs, prothrombin time, glucose Pancreatic function tests ```
133
What would you expect serum amylase to be in chronic pancreatitis?
Raised serum amylase
134
What do a lot (not all) of plain AXRs show for those with chronic pancreatitis?
Calcification of pancreas
135
What is the management for chronic pancreatitis?
``` Avoid alcohol Pancreatic enzyme supplements Opiate analgesia Coeliac plexus block (for pain) Referral to pain clinic Endoscopic treatment of pancreatic duct stones and strictures Surgery Low fat diet Insulin (diabetes) ```
136
What is the most common carcinoma of the pancreas?
Duct cell mutinous adenocarcinoma
137
Which part of the pancreas is most commonly affected by carcinoma?
Head
138
What are the clinical features of pancreatic cancer?
``` Upper abdominal pain Painless obstructive jaundice Weight loss Anorexia, fatigue, diarrhoea/steatorrhoea, nausea, vomiting Tender subcutaneous fat nodules Thrombophlebitis migrans Ascites Portal hypertension ```
139
What are the physical signs of pancreatic cancer?
``` Hepatomegaly Jaundice Abdominal mass Abdominal tenderness Ascites, splenomegaly Supraclaviclar lymphadenopathy Palpable gallbladder ```
140
What imaging modalities could you use for pancreatic cancer?
``` USS CT MRI EUS ERCP Percutaenous needle biopsy ```
141
If there is jaundice and a mass, what investigation would you do?
ERCP +/- stent
142
If there is mass without jaundice, what investigation would you do?
EUS/percutaneous needle biopsy
143
What is the management for pancreatic cancer?
``` Radical surgery = pancreatoduodenectomy (Whipple's procedure) Palliation of jaundice = stent/cholechoduodenostomy Pain control (opiates, coeliac plexus block, radiotherapy) ```
144
What is the radical surgery for pancreatic cancer?
Pancreatoduodenectomy
145
What is the criteria for a pancreatoduodenoectomy?
Patient is fit Tumour <3cm diameter No metastases
146
What is the mean survival for pancreatic cancer in inoperable cases?
<6 months | 1% 5yr survival
147
What is the mean 5yr survival for pancreatic cancer in operable cases?
15%
148
How would you assess if a patient were fit for pancreatic resection?
Basic history and examination CXR, ECG Respiratory function tests Physiological scoring system
149
What is the first investigation for pancreatic cancer to see if it is resectable?
USS
150
If it is unresectable after USS, what is the next step?
ERCP + stent
151
What is Kausch-Whipple/Whipple surgery?
Pancreatoduodenectomy = due to shared blood supply often means surgical removal of head of pancreas, duodenum, proximal jejunum, gallbladder and occasionally part of the stomach
152
What is PPPD surgery?
Pylorus preserving pancreatoduodenectomy
153
How would you manage obstructive jaundice?
Palliative bypass | ERCP or PTC stenting
154
How would you manage duodenal obstruction?
Palliative bypass | Duodenal stent
155
How is mild acute pancreatitis classified?
Associated with minimal organ dysfunction and uneventful recovery
156
How is severe acute pancreatitis classified?
Associated with organ failure or local complication
157
What are local complications of acute pancreatitis?
Acute fluid collections Pseudocyst Pancreatic abscess Pancreatic necrosis
158
What is the mnemonic for remembering the causes of acute pancreatitis?
GET SMASHED ``` G = gallstones E = ethanol (alcohol) T = trauma ``` ``` S = steroids M = mumps (viruses) A = autoimmune S = scorpion bites H = hypercalcaemia, hyporthermia, hyperlipidaemia E = ERCP D = drugs (azathiaprin) ```
159
What can you use to predict how severe acute pancreatitis is?
Clinical assessment Modified Glasgow criteria CT scanning Individual markers: CXR, CRP (>200), IL 6, TAP
160
What is CT scanning useful for in acute pancreatitis?
Helpful to diagnose Days 4-10 to identify necrosis Useful for complications e.g. ascitic fluid collections, abscess, necrosis, monitoring progress of disease
161
What is the mnemonic for remembering the causes of chronic pancreatitis?
O-A-TIGER ``` O = obstruction of main pancreatic duct (tumour, sphincter of Oddi dysfunction etc.) A = autoimmune T = toxin (alcohol, smoking, drugs) I = idiopathic G = genetic (auto. Dom., CF) E = environmental (tropical chronic pancreatitis) R = recurrent injuries (biliary, hyperlipidaemia, hypercalcaemia) ```
162
What causes release of bile from the gallbladder
CKK
163
What is cholesterosis?
Cholesterolosis occurs when there’s a buildup of cholesteryl esters and they stick to the wall of the gallbladder forming polyps
164
What are gallstones made from?
Mixed (cholesterol and pigment)
165
What is choledocholithiasis?
Stones in the bile ducts
166
What are the symptoms and signs of obstructive jaundice?
Pain, jaundice, dark urine, pale stool, pruritus, steatorrhoea
167
What are the clinical signs of choledocholithiasis?
Obstructive jaundice Acute pancreatitis Ascending cholangitis
168
What are the investigations for gallstones?
``` Blood tests: LFTs, amylase, lipase, WCC USS EUS Oral cholecystography CT scan Radio isotope scan IV cholangiography MRCP PTC ERCP ```
169
What are LFTs?
AST, ALT, ALP
170
What are the causes of benign biliary tract disease?
Congenital - biliary atresia, choledochal cysts | Benign biliary stricture - iatrogenic, gallstone related, inflammatory
171
What is biliary atresia?
One or more bile ducts is abnormally narrowed, blocked or absent
172
What are choledochal cysts?
Congenital conditions involving cystic dilatation of bile ducts
173
What is cholangiocarcinoma?
Malignancy of the bile ducts
174
What are the risk factors for cholangiocarcinoma?
``` > Age PSC Congenital cystic disease Biliary-enteric drainage Hepatolithiasis Carcinigens ```
175
What is the presentation of cholangiocarcinoma?
Obstructive jaundice Itching Non-specific symptoms
176
What are the investigations for cholangiocarcinoma?
``` Lab tests USS EUS CT MRCP PTC Angiography PET ERCP Cholangioscopy Cytology ```
177
What is the management for cholangiocarcinoma?
Surgery: only curative option Palliative: Surgical bypass, stenting, palliative radiotherapy, chemotherapy, PDT, liver transplant (not standard)
178
What are the common presentations of anorectal disorders?
Pain Haemorrhage Dysfunction
179
What are examples of anorectal congenital abnormalities?
Imperforate anus Uro-genital fissure Hirshprung's myenteric plexus deficiency
180
What are examples of acquired anorectal abnormalities?
``` Haemorrhoids Fissure Abscess Fistula-in-ano Ulceration Cancer Control of continence ```
181
What is stapled anopexy?
A procedure for prolapse and haemorrhoids (PPH)
182
What happens in stapled anopexy?
The operation pulls the swollen and prolapsing blood vessels of the haemorrhoids (piles) back into their normal position by removing a circumferential section (complete ring) of the internal rectal lining
183
What is the management of anal fissures?
Medical - topical nitrate oxide, glyceryl trinitrate paste, diltiazem calcium blocker Surgical - internal lateral sphincterotomy
184
What is the aim of management of anal tissues?
Relax internal anal sphincter
185
What is the management of perianal abscess?
Incision and drain
186
Where is the most common colorectal cancer sites?
Left colon, then right colon
187
What are the investigations for colorectal cancer?
Colonscopy CT colonography MRI guided colonscopy
188
What is the treatment for anorectal cancer?
Anal squamous - radiotherapy | Rectal adenocarcinoma - neoadjuvant ChemoRad, laparoscopic resection
189
What is a similar staging to TMN used in bowel cancer?
Duke's staging
190
What are causes of anal ulceration?
Crohn's disease Malignancy Syphilis (Chancre) Nicorandil
191
What is management of control of bowel continence?
Sacral nerve root stimulator implant
192
What are associated symptoms of constipation?
Headaches, nausea, loss of appetite, abdominal distention
193
How do you treat secretory diarrhoea?
Oral rehydration therapy
194
How does oral rehydration therapy treat diarrhoea?
Enterotoxins don't damage villous cells, give sodium/glucose solution which drives H2O reabsorption and rehydrates, need to drink more to wash away infection
195
If there are problems with the colon and rectum what do patients usually present with?
Change in bowel habit/continence Bleeding Pain Non-intestinal manifestations
196
What is visceral pain?
Pain receptors are in smooth muscle but pain is poorly localised
197
How do the impulses run with visceral pain?
Afferent impulses run with sympathetic fibres accompanying segmental vessels (CP, SMA, IMA)
198
What is the protocol for rectal bleeding if the symptoms are <6wks, with anal symptoms and patient is less than 40yo (low risk features)?
Watch and wait (6wks) | If issues after -> visualisation of large bowel
199
What is the protocol for persistent change in bowel habit >6wks, persistent rectal bleeding without anal symptoms, right sided abdominal mass, palpable rectal mass, unexplained iron deficiency anaemia (high risk features)?
Visualisation of large bowel: colonoscopy, sigmoidoscopy +/- barium enema, CT colonography
200
What are things to consider when performing colon resection/surgery?
Restoration of continuity Preservation of function Faecal diversion
201
What is Hirshsprung's disease?
A condition that affects the large intestine (colon) and causes problems with passing stool. The condition is present at birth (congenital) as a result of missing nerve cells in the muscles of the baby's colon
202
What are the causes of colorectal cancer?
Sporadic (no familial/genetic influence), familial, inheritable (HNPCC, FAP), underlying IBD
203
What type of cancer are most CRCs?
Adenocarcinomas
204
What do the majority of CRCs arise from?
Pre-existing polyps
205
What are the main histological types of colorectal adenoma?
Tubular, villous, indeterminate tubulovillous
206
What are the two morphological types of colorectal adenoma?
Pedunculated or sessile
207
What leads to cell growth, proliferation and apoptosis in carcinoma?
Activation of oncogene Loss of tumour suppressor gene Defective DNA repair pathway genes (microsatellite instability)
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What is the presentation of CRC?
Rectal bleeding (especially mixed with stool) Altered bowel opening to loose stools >4wks Iron deficiency anaemia Palpable rectal or right lower abdominal mass Acute colonic obstruction Systemic symptoms of malignancy: weight loss, anorexia
209
What is the investigation of choice for CRC?
Colonoscopy (+/- biopsy, polypectomy)
210
What are the risks of colonoscopy?
Perforation, bleeding
211
What investigations can you do for CRC?
Colonscopy Barium enema CT colonography CT abdo/pelvis
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What are the staging investigations for CRC?
CT chest/abdo/pelvis MRI PET scan/rectal endoscopic US
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What is the treatment for colorectal cancer?
Surgery Chemotherapy Radiotherapy (rectal)
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What is the prevention guidance for CRC?
Physical activity Healthy BMI Fruit and veg No smoking
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What are the population screening methods for CRC?
Scottish Bowel Screening Programme | Faecal immunological testing (FIT)
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What are other screening methods for CRC?
Faecal occult blood test (FOBT) Flexible sigmoidoscopy Colonoscopy CT colonography
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What is the Scottish Bowel Screening programme?
50-74yrs FOBT every two years FOBT+ -> colonoscopy
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Why is FOBT not always good?
Lower positivity in women
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What is the FIT test specific for?
Human haemoglobin
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What is the FIT good for which FOBT isn't?
Provides flexibility to alter cut-off to accommodate risk factors including age and gender Specific for human haemoglobin Automated, quantative
221
Which goops are high risk and are therefore screened for CRC?
Heritable conditions: HNPCC, FAP IBD Familial risk Previous adenomas/CRC
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What is FAP (familial adenomatous polyposis)?
Autosomal dominant - mutation of APC gene on chromosome 5 | Multiple (>100) adenomas throughout colon which have high risk of malignant change
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How are those with FAP screened?
Annual colonoscopy from age 10-12yrs | Prophylactic proctocolectomy usually age 16-25yrs
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What are the extracolonic manifestations of FAP?
Benign gastric fundic cystic hyperplastic Duodenal adenomas in 90% with periampullary cancer Desmoid tumours (noncancerous growths in CT) Congenital retinal hypertrophy of the pigment epithelia (CHRPE)
225
Which class of drug has been shown to reduce polyp number in FAP?
NSAIDs
226
What is HNPCC (hereditary nonpolypsis CRC)?
Autosomal dominant - mutation in MMR genes Early onset CRC right sided Associated with endometrial, genitourinary, stomach, pancreas cancers
227
Who are high risk groups of CRC?
Familial history CRC IBD Previous CRC Previous adenomas

GI (6 decks)

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