Flashcards in Review posters 16/05/2016 Deck (54):
What is IBS?
Characterised by chronic relapsing abdominal pain and discomfort. Associated with bloating.
Why do people get IBS?
Genetics and the environment.
Also 20% of people who have IBS had an infection of infectious gastroenteritis
Characteristics and symptoms of IBS
Disturbed gut motility- increase in duodenum but decreased in the stomach
Exaggerated by food
Mucus per rectum
Aggravated by stress
Rome III criteria
Over the period of a month having 3 or more days of abdominal pain or discomfort along with 2 of the following:
Improvement by defecation
Onset associated with a change in stool consistency
Difference in stool appearence
Pathogenesis of IBS
Peripheral sensitisation- inflammatory mediators up regulate the sensitivity of nocireceptors
Central sensitisation- spinal nerves become more sensitive
Treatment of IBS (non pharmacological)
Diet- decrease fibre intake
Try to stop tea and coffee
Reduce intake of resistent starch
Treatment of IBS pharmacological
Antispasmodics e.g. laxatives.
They will stop constipation. However senna is not could for long term use and lactulose promotes flatulence
Opiates- relax gut and decrease constipation. However not good for pain
Use PRN or prophylactically
Anti-depressents e.g. tricyclics e.g. amitryptiline
Help to regulate sleep pattern
Enlargement of vascular cushion in the lower rectum and anal canal
Symptoms of haemorrhoids
Bleeding (painless)- bright red, fresh and not mixed with stool
May be visible
Examination may be normal
Investigations into haemorrhoids
PR exam normal- haemorrhoids cannot be felt
Where do haemorrhoids normally present?
when patient is in lithotomy position they are at 3, 7 and 11 o clock due to this being where the branches of the superior haemorrhoidal artery are.
Treatment of haemorrhoids
Rubber band ligation
Sclerotherapy (involves inserting phenol and almond oil into the vessels)
HALO- haemorrhoidal artery ligation- blood vessels tied off- supposedly painless due to dentate line position
Could be complete or incomplete. Incomplete only involves the mucosal layer.
Symptoms of rectal prolapse
Protruding mass especially on defecation. May be reducible.
Bleeding and mucus per rectum
Examination always shows poor anal tone.
Management of complete rectal prolapse
Most patients too frail to undergo surgery so advice is given on self reducing and diet. Also given a bulking agent
Operations include perineal rectopexy or an abdominal rectopexy.
Tear in the anal margin due to constipation. Described as passing glass.
Symptoms of anal fissures
Bleeding per rectum
Dietary advice and stool softeners
Sphyncterectomy (pharmacological- 6 week treatment of GTN and diltiazem ointments)
Lateral sphyncterectomy- surgery
Fistula in ano
Abnormal communication between epithelial surfaces.
Presentation of fistula in ano
One or more external holes and an internal opening in the anus. Generally due to inadequately treated or delayed treatment of anorectal abscesses.
Treatment of fistula in ano
Two step process of an operation
Investigations of fistula in ano
Rectal exam under anaestetic
Which nerve is the fibrous pericardium supplied by?
The phrenic nerve
Which nerve is the diaphragm supplied by?
The phrenic nerve
What makes up the phrenic nerve?
Combined anterior rami of spinal nerves C3,4 and 5
Where is the cardiac plexus located?
On the pulmonary trunk
What does the cardiac plexus contain?
Visceral afferent fibres
Parasympathetic supply to the heart
How do cardiac visceral afferents travel?
Associated with sympathetic fibres
Describe the path of the phrenic nerve
Travels anteriorly to the scalenus anterior and into the chest descending over the lateral aspect of your fibrous pericardium.
Recurrent laryngeal nerve
Supplies laryngeal muscles
Innervation of the mouth down to the trachae
First part of nasal cavity- cranial nerve 5 branch 1
Second part of nasal cavity- cranial nerve 5 branch 2
Nasal pharynx and oral pharynx- cranial nerve 9 (glossopharyngeal)
Laryngopharynx- cranial nerve X (vagus)
Where is the pulmonary plexus?
The bifurcation of the trachae (carina)
What does the pulmonary plexus contain?
Sympathetic, parasympathetic and visceral afferents
Where do the sympathetic nerves supplying the lung, heart and oesophagus arise from?
Nervous supply of the ribs
Where do the intercostal nerves arise from?
Anterior rami of spinal nerves T1-T11
What do branches of the intercostal nerves go on to supply and what are their names?
They go on to supply the abdominal muscles. There is the subcostal nerve, then the iliohypogastric nerve and then the ilioinguinal nerve.
Organs within the abdomen are supplied by
enteric nervous system
Sympathetic supply to the gut
Leave by T5-L2 ( oesophagus T4-T6)
Liver, stomach, small intestine, pancreas T7-T9
Colon and appendix T10-T11
What do they become when they leave the sympathetic chain?
Where are the abdominal plexuses
Termed periarterial plexuses- they lie on the anterior of the descending aorta. Named according to the artery they are associated with e.g. coeliac plexus.
Adrenal gland nervous supply
Enter abdominopelvic sphlancic nerves
Carried with periarterial plexus to the adrenal gland where they synapse straight onto it.
Vagus nerve supplied whole GI system up to the splenic flexure. Nerves travel to periarterial plexuses and then synapse at the organ.
Then it is supplied by pelvic splanchnic nerves.
Causes of bowel obstruction
Volvulus- twisting of mobile bits of bowel causing obstruction at its head.
Adhesions or bands- could be congenital or could be from previous surgeries
Inflammatory strictures e.g. Crohns and UC
Bolus obstruction- food, impacted faeces, gallstones
Intususecpetion- occurs in children quite commonly- part of the bowel is swallowed by the bowel distal to it (telescoped)
Bowel strangulation- URGENT
Symptoms of bowel obstruction
How would vomiting differ depending on where the obstruction is?
Gastric outlet obstruction- semi-digested food that had been eaten a day or two previously
Upper small bowel obstruction- copious, bile stained fluid
Lower small bowel/colonic obstruction- thickened, brown, feaculent vomitus
The more proximal the obstruction occurs:
The earlier vomiting develops
Large bowel obstruction
Symptoms develop later due to massive capacity of the colon and the caecum.
Ileocaecal valve and large bowel obstruction
If the ileocaecal valve is competent- symptoms will arise sooner due to backward flow of accumalated bowel content being prevented.
The thin walled caecum distends with swallowed air and eventually may rupture.
If the ileocaecal valve is incompetent- the small bowel will distend delaying symptoms
Clinical features may be less clear
Vomiting may be intermittent and bowel habit may be erratic.
Chronic obstruction leads to gradual hypertrophy of the muscle wall.
Investigations into bowel obstruction
AXR supine- bowel proximal to obstruction is distended with gas
In a distended small bowel you can see plicae circularis
In a distended large bowel you can see haustra coli.
Management of bowel obstruction
Nil by mouth
IV cannula and send blood
Resusitate with IV fluids
Nasogastric tube to decompress stomach