Lower GI Flashcards
(187 cards)
1
Q
What is erythema multiforme?
A
A skin reaction usually mild as allergic reaction to virus or drug etc
2
Q
What is leukoplakia?
A
Oral mucosal white patch that will not rub off and is not attributable to any other known disease
3
Q
Fluconazole?
A
Anti-fungal medication. Eg. to treat candidiasis - orally or IV administration
4
Q
Nystatin
A
Anti-fungal medication. Candidiasis is particularly sensitive
5
Q
Amphotericin
A
Anti-fungal medication. Sometimes used IV for systemic fungal infections
6
Q
Achalasia
A
Failure of oesophageal smooth muscle to relax. Aka sphincter can remain closed and fail to open when needed. Can happen throughout GIT
7
Q
What can masses in the right iliac fossa be due to? (x11)
A
Appendix mass/abscess Caecal carcinoma Intussusception Crohn's Disease Pelvic mass TB mass Amoebic abscess Actinomycosis Transplanted kidney Kidney malfunction Tumour in undescended testes
8
Q
5 F’s of abdominal distension
A
Flatus, Fat, Fluid, Faeces, Fetus
9
Q
2 tests to confirm ascites
A
Shifting dullness, fluid thrill/fluid wave test (pushing down prevents vibration from being transmitted through the abdominal wall)
10
Q
Causes of ascites (without portal hypertension) x6
A
Malignancy, Infection (eg. TB), low albumin (nephrosis/nephrotic syndrome) CCF, pancreatitis, myxoedema
11
Q
Causes of ascites with portal hypertension x4
A
Cirrhosis, Budd-Chiari syndrome, IVC or portal vein thrombosis, Portal nodes
12
Q
4 causes of pancreatic cysts (pseudocysts)
A
Congenital, cystadenomas, retention cysts of chronic pancreatitis, cystic fibrosis.
Pseudocysts = fluid in lesser sac from acute pancreatitis
13
Q
What are GIT synchronous tumours?
A
Two different GIT tumours at the same time
14
Q
What are metachronous tumours?
A
Second cancer, presents months to years after first cancer but in another part of GIT
15
Q
What met is sometimes present at presentation of colorectal cancer? What %?
A
37% have liver mets at presentation
16
Q
Where are colorectal cancers most commonly found?
A
Sigmoid or rectum (or unspecified descending colon)
17
Q
Typically colorectal presentation?
A
Rectal bleeding, change in bowel habits, lower abdominal discomfort, 1/2 stone weight loss
18
Q
Left sided colorectal cancer?
A
Bleeding and mucus PR, altered bowel habit or obstruction, tenesmus, mass PR (60%)
19
Q
Right-sided colorectal cancer?
A
Weight loss, low Hb, abdominal pain and obstruction less likely
20
Q
What is sister mary joseph nodule?
A
Peritoneal metastasis, tumour grows out umbilicus
21
Q
Importance of FHx in CR cancer
A
10% have FHx
22
Q
Risk factors for CR cancer x 10
A
age (8/10 >60), male, family history, alcohol, smoking, diet (red meat, processed meat, low fibre), abdominal fatness, previous cancer, previous polyp, pre-morbidities (IBD, PSC, acromegaly)
23
Q
Prevention of CR cancer x3
A
Aspiring >75mg/day, physical activity, foods containing dietary fibre
24
Q
Drug treatment for CR cancer
A
Chemotherapy - usually 5-fu with oxaliplatin
25
Drugs used in palliation of advanced CR cancer
Bevacizumab (anti-vegF antibody), Cetuximab and Panitumumab (in KRAS wild type CR cancer - anti-EGFR agents)
26
Surgery for CR cancer x6
```
Right hemicolectomy (for caecal, ascending or proximal transverse colon tumours)
Left hemicolectomy (for distal transverse or descending colon tumours)
Sigmoid colectomy (for sigmoid tumours)
Anterior resection of rectum (for low sigmoid or high rectal tumours) - usually no colostomy
Abdomino-perineal excision of rectum (for tumours low in rectum) - colostomy
```
Hartmann's procedure - usually emergency bowel surgery - removal of sigmoid colon and/or rectum - hartmann's because making a colostomy and leaving other end of bowel inside but closed off
27
Use of radiotherapy in CR cancer
Mostly palliation, occasionally pre-op to allow resection, post-op only in patients with rectal tumours at high risk of local recurrence
28
CR cancers - histologically
98% of colonic cancers are adenocarcinomas - from glandular epithelium
29
What do Duke stage C and D mean
```
C = Involvement of lymph nodes
D = distant mets
```
30
Indications for surgery to treat liver mets
Non-radiographic involvement of important vessels or lymph nodes
Complete resection must be feasible
Need enough liver left for function post-resection
No unretractable extra-hepatic sites
31
Bowel Cancer Screening
60-74
Home stool testing
Every 2 years
Colonscopy if positive test
32
Causes of CR cancer?
75% - sporadic CR cancer - isolated polyp becomes malignant
15% familial gene increases risk of polyp becoming malignant
5% hereditary non polyposis - multiple cancers run in family and increased risk of solid organ malignancies
33
Development of CR cancer
Lose APC protective gene and normal epithelium becomes early adenoma
Activation of promotor gene
Protective gene TP53 inactivated
34
Definition of Crohn's
Chronic inflammatory GI disease characterised by transmural granulomatous inflammation affecting any part of GIT. Skip lesions (unlike UC)
Especially affects terminal ileum and proximal colon
35
Genetic mutations which increase risk of Crohn's
NOD2 / CARD15
36
Prevalence and incidence of Crohn's vs UC
P of C = 0.5-1/1000, P of UC 1-2/1000
| I of C = 5-10/100,000/year, I of UC = 10-20/100,000/year
37
Age of presentation for Crohn's vs UC
Crohn's two peaks 20-30 years and 60-70years - worser prognosis if younger presentation
UC = 15-30
38
Associations of Crohn's vs UC
Smoking = 3-4x increase risk of Crohn's and decreases risk of UC
NSAIDs may exacerbate Crohn's disease
39
Symptoms of Crohn's x9
Diarrhoea/urgency, abdominal pain, weight loss, failure to thrive, malaise, fever, anorexia, putrid smelling stool, fluctuating symptoms
40
Signs of Crohn's x4 GIT and x4 systemic
Aphthous ulcerations, abdominal tenderness/mass, perianal abscess/fistulae/skin tags, anal strictures
Skin, joint and eye problems, clubbing
41
Complications of Crohn's x 14
```
Small bowel obstruction
Toxic dilatation (colon >6cm) - rarer than in UC
Abscess formation
Fistulae
Perforation
Rectal haemorrhage
Colon Cancer
Fatty Liver
PSC
Cholangiocarcinoma
Renal stones
Osteomalacia
Malnutrition
Amyloidosis
```
42
Stool tests - CDT and MC &S
CDT = c.diff toxin
| MC & S = microbiology, culture and sensitivity
43
Ileal disease detection test
Small bowel enema
44
Signs indicative of worse Crohn's severity x6
```
↑ Temperature
↑ Pulse
↑ ESR
↑ WCC
↑ CRP
low albumin
```
45
Treating a mild Crohn's attack
Prednisolone PO - decrease dose if symptoms resolve
46
Treating a severe Crohn's attack
NMB and IVI
Hydrocortisone IV
Metronidazole IV helps
If improving after 5 days switch to PO prednisolone
If not improving then monoclonal ab's may help
47
Rate of surgery in Crohn's and indications
50-80% need an operation in their life
| I = drug failure, GI obstruction from stricture, perforation, fistulae, abscess
48
Treatment for perianal disease in Crohn's (prevalence and x4 treatment)
Occurs in 50%
Oral antibiotics, immunosuppressant therapy
Local surgery +/- seton insertion
49
Definition of UC
Relapsing, remitting inflammatory disorder of the colonic mucosa
50
3 different types of UC
Proctitis - 50% - just rectum
Left-sided colitis - 30% - extends from rectum to affect part of the colon
Pancolitis - 20% - affects entire colon
51
Symptoms of UC x 6 and x2 for rectal UC
Diarrhoea (blood and mucus), abdominal discomfort, fever, malaise, anorexia and weight loss
Rectal UC = urgency and tenesmus
52
Acute severe UC signs x3
Fever, tachycardia, distended tender abdomen
53
Extraintestinal signs of UC x 15
```
Clubbing
Aphthous oral ulcers
Erythema nodosum
Pyoderma gangrenosum
Conjuncitivitis
Episcleritis
Iritis
Large joint arthritis
Sacroiliitis
Ankylosing spondylitis
```
```
Fatty liver
PSC
Cholangiocarcinoma
Nutritional deficits
Amyloidosis
```
54
AXR is UC - 3 signs
No faecal shadows, mucosal thickening and colonic dilatation
55
Complications of UC x5
Perforation, bleeding, toxic dilatation of colon, venous thrombosis, colonic cancer 15% increased risk with pancolitis
56
Mild UC maintenance treatment and remission induction
Anti-inflammatories - 5ASA
eg. Sulfasalazine, mesalazine or olsalazine
Steroids eg. prednisolone to induce remission
57
Moderate UC remission induction
Prednisolone with 5-ASA and steroid enemas
58
Severe UC remission induction
Admit - NBM and IVI
IV hydrocortisone, rectal steroids
Transfer to prednisolone with 5asa if improving
If no improvement - may need colectomy
Or immunosuppression can be used if no remission with steroids - azathioprine, methotrexate, monoclonal ab's
59
Surgery in UC - rates, indications and type
20% need it at some stage
Indications = perforation, massive haemorrhage, toxic dilatation, failed medical therapy
Proctocolectomy + terminal ileostomy
60
Side effects of 5ASA x8
Nausea, headache, anorexia, temperature, rash, haemolysis, hepatitis and pancreatitis
61
Maintenance therapy in Crohn's
Steroid sparing agents - because patients flare up every time you take them off steroids - mainstay is Azathioprine. Also steroid sparing in UC is 5asa not working.
6mp 6mecactopurine - used for steroid dependant UC or Crohn's
62
What are GI diverticulum and where do they occur?
Outpouchings of gut wall and usually at entry sites of perforating arteries
63
What is diverticulosis vs diverticular disease?
Presence of diverticulum vs symptomatic diverticulum
64
Where are most important/common diverticulum?
Colonic - sigmoid colon - where most complications occur
65
Pathology of diverticulum?
Lack of dietary fibre causes high intraluminal pressure - forces mucosa to herniate through muscle wall
66
How common are diverticulum?
30% of westerners by age 65
67
Symptoms of diverticulum?
Many are asymptomatic - can have bleeding, altered bowel habit, colic, nausea and flatulence
68
Symptoms of diverticulitis?
Same as diverticulum (nausea, colic, altered bowel habit, flatulence, bleeding) but also pyrexia, raised WCC and CRP and tender colon/localised peritonitis
69
Treatment of diverticulitis?
Bowel rest (fluid only- may be only treatment if mild), antibiotics if needed, analgesia, surgery not for abscesses but yes for peritonitis
70
Indications for elective surgery in diverticulitis?
Stenosis, fistula or recurrent bleeding
71
Signs of perforation in diverticulitis?
Ileus, peritonitis, shock
72
Management of haemorrhage in diverticulitis?
Usually just bed rest and it will stop - if bad may need surgery - diathermy can prevent need for this
73
Signs of abscesses in diverticulitis?
| Treatment?
Swinging fever, leucocytosis, localising signs (eg. Mass)
| Treatment = antibiotics - CT/US guided drainage may be needed
74
What is angiodysplasia?
Submucosal arteriovenous malformations that typically presents as fresh PR bleeding in the elderly - cause unknown
75
Where does angiodysplasia occur?
Can affect anywhere in the GI tract but 70-90% of lesions occur in right colon
76
What is good for diagnosis of angiodysplasia?
Mesenteric angiography - shows early filling at site and then extravasation
77
Treatment of angiodysplasia
Embolisation, endoscopic laser electro coagulation, resection
78
What is a hernia?
Protrusion of a viscus through a defect of the walls of its containing cavity into an abnormal position
79
What is an incarcerated hernia?
Contents of hernial sac are stuck inside by adhesions
80
What is a strangulated hernia?
One where ischaemia occurs
81
Indirect vs direct inguinal hernia
Indirect - through internal inguinal ring. Direct - through abdominal wall through posterior wall of inguinal canal
82
What is defect in abdominal wall called and what are its boundaries?
Hesselbach triangle - laterally - inferior epigastric artery, medially - rectus abdominis, inferiorly - inguinal ligament
83
Risk factors for inguinal hernia x7
Male (8:1), chronic cough, constipation, urinary obstruction, heavy lifting, ascites, previous abdominal surgery
84
Differentiating direct from indirect
Gold standard is surgically - direct are lateral to inferior epigastric vessels and indirect arise medially
85
Direct vs indirect - which is more common?
Which strangulates more?
Which is more
Often reducible?
Indirect more common 80%
Direct reduce more easily
Indirect strangulate more easily
86
Repairs of hernia x2
Polypropylene mesh to reinforce posterior wall. Laparoscopic repair
87
Where do femoral hernias appear?
Mass in upper medial thigh or above inguinal ligament (points down the leg as opposed to inguinal pointing to the groin)
88
3 features of femoral hernias
More common in women, irreducible and strangulate easily due to rigidity of canal borders
89
Boundaries of femoral canal
Anteriorly - inguinal ligament, medially - lacunar ligament and pubic bone, laterally - femoral vein, posteriorly - pectineal ligament and pectineus
90
DDX of femoral hernia x6
Inguinal hernia, saphena varix, enlarged cloquets node, lipoma, femoral aneurysm, psoas abscess
91
Risk factors for paraumbilical hernia x2
Obesity and ascites
92
Where do epigastric hernias go?
Through linea alba above umbilicus
93
What is gastroschisis?
Congenital defect causing protrusion of abdominal contents through a defect in the anterior abdominal wall
94
Definition of IBS
Mixed group of abdominal symptoms for which no organic cause can be found
95
Prevalence of IBS, age at onset and F:M ratio
10-20% (probably higher)
96
Features required for IBS diagnosis
1) Abdominal pain/discomfort is relieved by defecation
OR
2) Altered stool or bowel frequency - constipation and diarrhoea alternate
```
Plus >2 of
Urgency
Incomplete evacuation
Abdominal bloating/distention
Mucus PR
Worsening of symptoms after food
```
DIAGNOSIS OF EXCLUSION
97
Other symptoms present in IBS
```
Nausea
Bladder symptoms
Chronic >6months
Backache
Exacerbated by stress, menstruation or gastroenteritis
```
98
Treatment of IBS
```
Rarely successful
Just make symptoms less intrusive
Things which may worsen disease:
- Fibre
- Lactose
- Fructose
- Wheat
- Starch
- Caffeine
- Sorbitol
- Alcohol
- Fizzy drinks
```
99
Management of IBS if constipation
High fibre can make worse
Avoid insoluble fibre
Bisacodyl and sodium picosulfate can make better
Ispaghula has non-fermentable water-soluble fibre
100
Management of IBS if diarrhoea
Avoid sorbitol sweeteners
| Try bulking agent +/- loperamide after each loose stool
101
Management of IBS if colic/bloating
Oral antispasmodics
| Active bacillus
102
Symptoms of gastrointestinal malabsorption
```
Diarrhoea
Weight Loss
Lethargy
Steatorrhoea (hard to flush away)
Bloating
```
103
Signs of deficiencies due to GI malabsorption
```
Anaemia (Iron, folate and B12)
Bleeding disorders (vitamin K)
Oedema (protein)
Metabolic bone disease (vitamin D)
Neurological features
```
104
Tests in GI malabsorption
Bloods - low b12, folate, iron, calcium
Stool - fat globules (Sudan stain), microscopy (infestation)
Barium-follow through (Diverticula, crohns)
Breath hydrogen (bacterial overgrowth)
ERCP - pancreatitis, biliary obstruction
105
Common causes of GI malabsorption in UK
Coeliac disease
Chronic pancreatitis
Crohn's disease
106
Rarer causes of GI malabsorption
PBC
Ileal resection
Biliary obstruction
Pancreatic cancer
CF
Tropical disease
Surgery to have removed part of digestive system
107
What is Coeliac's disease
T-cell mediated autoimmune disease of small bowel
| Where prolamin intolerance (in wheat etc) causes villous atrophy and malabsorption
108
When do you suspect Coeliacs?
All with diarrhoea, weight loss and anaemia
109
Prevalence of Coeliacs
1 in 300-1500
More common in the Irish
Peaks in infancy and 50-60 years
110
Associations of Coeliacs
Familial component
HLA DQ2 in 95% (rest are DQ8)
111
Presentation of Coeliacs
Stinking stools/steartorrhea
Diarrhoea
Abdominal pain
Bloating
N and v
Weight loss
Fatigue and weakness
Aphthous ulcers
Angular somatitis
Osteomalacia
Easy bruising
Children fail to thrive (wasted buttocks)
112
Diagnosis of Coeliacs - blood test
Low Hb and ferritin
RCDW increase
Low B12
113
Antibodies in Coeliacs
IgG Anti-gliadin
| IgA, IgG Anti-endomysial transglutaminase
114
Last diagnosis for Coeliacs
Biopsy at endoscopy
Shows subtotal villous atrophy
Raised intraepithelial WBCs
Features reverse on gluten-free diet
115
Treatment of Coeliacs
Life-long gluten free diet
Rice, maize, soya, potatoes, oats and sugar are okay
116
Complications of Coeliacs
Anaemia
Secondary lactose-intolerance
GI T-cell lymphoma
Increase risk of other malignancy (gastric, oesophageal, bladder, breast, brain)
Myopathies
Neuropathies
Hyposplenism
Osteoporosis
117
Digestion of carbohydrates
Starch breakdown - starts in mouth but most occurs under action of pancreatic amylase in upper intestine - sugars!!
118
Digestion of protein
Pancreatic proteolytic enzymes into amino acids and peptides - occurs in duodenum
119
Digestion of fat
Digestion by bile and pancreatic lipase in duodenum
| Bile salts absorbed in terminal ileum
120
Water and electrolyte absorption
Upper jejunum - ileum - colon
121
Water soluble vitamins
Small intestine, vitamin B12 and bile salts - terminal ileum
122
Treatment of pruritus ani?
Careful hygiene
Moist wipe post-defecation
No spicy food
Anaesthetic cream
No steroid/antibiotic cream
123
What is an anal fissure?
Painful tear in squamous lining of lower anal canal
124
Where are anal fissures usually located?
90% are posterior
125
Causes of anal fissure
Most are due to hard faeces
| Spasm may constrict inferior rectal artery - causing ischaemia - making healing difficult and perpetuating the problem
126
Other rare causes of anal fissure
Syphilis, herpes, trauma, crohn's, anal cancer and psoriasis
127
Medical treatment of anal fissure
5% lidocaine ointment
GTN ointment
```
Topical diltiazem (calcium channel blocker)
Botox injections
```
128
Conservative treatment of anal fissure
Increase dietary fibre
Fluids + stool softener
Hygiene advice
129
What is anal fistula? How arise pathologically?
Track communicates between skin and anal canal/rectum
Blockage of deep intramuscular glands thought to predispose to formation of abscesses - this discharge to the skin to form fistulas
130
Symptoms of anal fistula
Pain and irritation
131
Causes of anal fistula
Perianal sepsis
TB
Abscesses
Crohn's disease
Diverticular disease
Rectal carcinoma
132
Tests in anal fistula
MRI
| Endoanal US scan
133
Treatment of anal fistula
Fistulotomy and excision
134
What needs to happen in excision of a high fistula?
Continence of muscles of anus affected therefore 'seton suture' needed - tightened over time to maintain continence
135
What usually causes anorectal abscesses?
Normally gut organisms
136
Treatment of anorectal abscess
Incise and drain under GA
137
Associations of anorectal abscess
DM
Crohn's
Malignancy
Fistulae
138
What is a perianal haematoma, what does it look like and how treated?
Thrombosed external pile. 2-4mm 'dark blueberry' under skin at anal margin
Can be evacuated under LA or left to resolve spontaneously
139
What is pilonidal cyst?
Ingrowing hair 6cm above anus - causes foreign body reaction - foul-smelling discharge
M:F = 10:1
More common in obese caucasians and people from Asia, Middle East and Mediterranean (more bodily hair)
140
Treatment of pilonidal cyst
Excision of sinus tract +/- primary closure
Ab's pre op
141
What happens in rectal prolapse?
Mucosa - partial/type 1
Or all layers - complete/type 2 (more common)
protrude through the anus
Incontinence in 75%
Descent of >3cm when asked to strain
142
Causes of rectal prolapse
Lax sphincter, prolonged straining
| Also related to chronic neurological disease
143
Treatment of rectal prolapse - 2 approachs
1) Abdominal approach
- Fix rectum to sacrum (rectopexy) +/- mesh insertion +/- rectosigmoidectomy (prolapsed bit removed and two ends joined up) = Altemeier's procedure
2) Perineal approach = Delorme's procedure - resect mucosa close to the dentate line - push muscle back up and suture mucosal boundaries - mucosa excess stitched back to cover repair
- Anal encirclement with a Thiersch wire
144
Treatment of anal warts?
imiquimod and podophyllotoxin
145
What is Proctalgia fugax?
Idiopathic, intense brief stabbing, crampy rectal pain
Often worse at night
Mainstay treatment is reassurance
146
How do you test muscular and sensory innervation?
Anocutaneous reflex - lightly stroking anal skin - sphincter should contract briefly
147
Risk factors for anal cancer?
Syphilis
Anal warts
Anoreceptive homosexuals
148
What sort of cancer is anal cancer normally?
Squamous cell - 85%
149
When are anal canal tumours associated with poor prognosis?
If spread above dentate line
Poorly differentiated
Non-keratinizing
150
Where does anal cancer spread to?
Above dentate line - to pelvic lymph nodes
Below dentate line - to inguinal lymph nodes
151
Presentation of anal cancer
```
Bleeding
Pain
Altered bowel habit
Pruritus ani
Masses/stricture
```
152
Treatment of anal cancer
Chemo-irradiation - usually preferable to anorectal excision & colostomy
153
Prognosis of anal cancer
75% retain normal anal function
154
What are piles/haemorrhoids?
Anus is lined by spongy vascular tissue = anal cushions - where 3 major arteries feed the vascular plexuses and enter the anal canal
These contribute to anal closure
Piles is when they get disrupted and dilated
155
What causes the cushions to form piles?
Effects of gravity
Increased anal tone
Straining at stool - constipation
All cause them to become bulky and loose and then they protrude
156
Why called haemorrhoids?
Because they bleed readily from the capillaries underlying
Bright red blood because from capillaries
157
Are haemorrhoids painful?
No because there are no sensory fibres
But can thrombose when protrude if they are gripped by the anal sphincter as this blocks venous return = painful
158
Classification of piles
1st degree - remain in rectum
2nd degree - prolapse through anus on defecation but spontaneously reduce
3rd degree - same as 2nd but require digital reduction
4th degree - persistently prolapsed
159
Difference between external and internal haemorrhoid
External - origin below dentate line (ex.rectal plexus)
Internal - origin above dentate line (int.rectal plexus)
160
Symptoms of piles
Bright red rectal bleeding
May be mucous discharge and pruritus ani
Severe anaemia can occur
161
Medical treatment of piles - when and what? x4
```
For 1st degree
Increase fluid and fibre
Topical analgesics
Stool softener
Topical steroids for a short period
```
162
Non-operative treatment of piles - when and what? x4
For 2nd and 3rd degree
1) Rubber band ligation - produces an ulcer therefore bleeding pain and infection are SE's
- lowest recurrence rate
2) Sclerosants - 2ml of 5% phenol in almond oil injected into pile
- recurrence higher
- SE: impotence, prostatitis
3) Infra-red coagulation
- as successful as banding and might be less painful
4) Cryotherapy
- Not recommended as high complication rate
163
Surgical treatment of piles - when and what? x2
For 4th degree piles
1) Excisional haemorrhoidectomy
- Most effective
- Excision of piles and ligation of vascular pedicles
- Day-case surgery
2) Stapled haemorrhoidectomy
- Less pain maybe
- When there is a large internal component
- Higher recurrence rate
164
Treatment of prolapsed thrombosed piles
Analgesia, ice packs and stool softeners
Pain usually resolves in 2-3 weeks
Some say surgery
165
What is dermatitis herpetiformis
Intense, itchy blisters seen on elbows, knees or buttocks
| Skin condition linked to coeliacs
166
Tumour markers in CR cancer
CEA (used to monitor disease progression and Ca 19-9
167
Type of surgery for CR cancer in caecum, ascending colon, proximal transverse colon
Right hemicolectomy
168
Type of surgery for CR cancer in distal transverse colon, descending colon
Left hemicolectomy
169
Type of surgery for CR cancer in sigmoid colon
Sigmoid colectomy
170
Type of surgery for CR cancer in high rectum
Anterior resection
171
Type of surgery for CR cancer in low rectum
Abdo-perineal resection and end colostomy formation
172
What is Duke Stage B
CR cancer staging
| Breached serosa but negative lymph nodes
173
What is Duke Stage A
CR cancer confined to bowel wall
174
Investigation features of Crohns
Cobblestone mucosa
rose-thorn fissures
Barium showing fissures or strictures (string sign of kantor)
175
What is ischaemic colitis?
Ischaemia of the colon due to decreased colonic blood supply which can lead to muscosal inflammation, oedema, necrosis and ulceration
176
Where is most commonly affected by ischaemic colitis
Splenic flexure - watershed between superior and inferior mesenteric arteries
177
Cause of ischaemic colitis normally
Occlusion of large vessels by thrombosis/embolism
| therefore increased risk with atherosclerosis and AF
178
Cause of ischaemic colitis in young patients
Small vessel vasculitis
Vasospasm (cocaine)
Hypercoagulable states
179
Symptoms of ischaemic colitis
Can be acute or chronic in onset
Crampy abdominal pain, may be post-prandial 'gut claudication' therefore 'food fear'
Fever, nausea, bloody diarrhoea
180
Signs of ischaemic colitis
```
Abdominal distention and tenderness
Local peritonism (worse on left)
Fever and tachycardia depending on severity
```
181
Blood in ischaemic colitis
Raised LDH, lactate and CK
182
Imaging signs in ischaemic colitis
Thickening of wall, intramural air - thumbprinting (submucosal oedema)
183
Management of ischaemic colitis
Supportive, NBM and surgery if necrosis or perforated bowel
184
What is pseudomembranous colitis
Large bowel inflammation with mucosal destruction and inflammatory exudates forming pseudomembranes on bowel wall - due to toxin releasing C-Diff
185
Features of pseudomembranous colitis
Recent antibiotic therapy
Watery diarrhoea, may become bloody with crampy abdominal pain
Pyrexia and abdominal tenderness
Treat with metronidazole and vancomycin
186
Faecal test for UC
Faecal calprotectin (marker for disease severity)
187
Barium enema signs with UC
Loss of haustral pattern - leadpipe or hosepipe appearance
