Review posters 16/05/2016 Flashcards Preview

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Flashcards in Review posters 16/05/2016 Deck (54):
1

What is IBS?

Characterised by chronic relapsing abdominal pain and discomfort. Associated with bloating.

2

Why do people get IBS?

Genetics and the environment.
Also 20% of people who have IBS had an infection of infectious gastroenteritis

3

Characteristics and symptoms of IBS

Disturbed gut motility- increase in duodenum but decreased in the stomach
Exaggerated by food
Bloating
Diarrhoea/constipation
Nocturia
Mucus per rectum
Aggravated by stress

4

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

5

Pathogenesis of IBS

Peripheral sensitisation- inflammatory mediators up regulate the sensitivity of nocireceptors
Central sensitisation- spinal nerves become more sensitive

6

Treatment of IBS (non pharmacological)

Diet- decrease fibre intake
Try to stop tea and coffee
Reduce intake of resistent starch
FODMAP diet

7

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
Antidiarrhoeals- loperamide
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
Reduce diarrhoea

8

Haemorrhoids

Enlargement of vascular cushion in the lower rectum and anal canal

9

Symptoms of haemorrhoids

Bleeding (painless)- bright red, fresh and not mixed with stool
Perianal itchiness
May be visible
Examination may be normal

10

Investigations into haemorrhoids

PR exam normal- haemorrhoids cannot be felt
Rigid sigmoidoscopy

11

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.

12

Treatment of haemorrhoids

Rubber band ligation
Sclerotherapy (involves inserting phenol and almond oil into the vessels)
Open haemorrhoidectomy
HALO- haemorrhoidal artery ligation- blood vessels tied off- supposedly painless due to dentate line position

13

Rectal prolapse

Could be complete or incomplete. Incomplete only involves the mucosal layer.

14

Symptoms of rectal prolapse

Protruding mass especially on defecation. May be reducible.
Bleeding and mucus per rectum
Examination always shows poor anal tone.

15

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.

16

Anal fissure

Tear in the anal margin due to constipation. Described as passing glass.

17

Symptoms of anal fissures

Bleeding per rectum
Acute presentation
PAIN

18

Treatment

Botox injections
Dietary advice and stool softeners
Sphyncterectomy (pharmacological- 6 week treatment of GTN and diltiazem ointments)
Lateral sphyncterectomy- surgery

19

Fistula in ano

Abnormal communication between epithelial surfaces.

20

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.

21

Treatment of fistula in ano

Two step process of an operation

22

Investigations of fistula in ano

Rectal exam under anaestetic
Rigid sigmoidoscopy
Flexible sigmoidoscopy
MRI

23

Which nerve is the fibrous pericardium supplied by?

The phrenic nerve

24

Which nerve is the diaphragm supplied by?

The phrenic nerve

25

What makes up the phrenic nerve?

Combined anterior rami of spinal nerves C3,4 and 5

26

Where is the cardiac plexus located?

On the pulmonary trunk

27

What does the cardiac plexus contain?

Sympathetic axons
Parasympathetic axons
Visceral afferent fibres

28

Parasympathetic supply to the heart

Vagus nerve

29

How do cardiac visceral afferents travel?

Associated with sympathetic fibres

30

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.

31

Recurrent laryngeal nerve

Supplies laryngeal muscles

32

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)

33

Where is the pulmonary plexus?

The bifurcation of the trachae (carina)

34

What does the pulmonary plexus contain?

Sympathetic, parasympathetic and visceral afferents

35

Where do the sympathetic nerves supplying the lung, heart and oesophagus arise from?

T4-T6

36

Nervous supply of the ribs

Intercostal nerves

37

Where do the intercostal nerves arise from?

Anterior rami of spinal nerves T1-T11

38

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.

39

Organs within the abdomen are supplied by

enteric nervous system
Parasympathetic
Sympathetic
Visceral afferents

40

Sympathetic supply to the gut

Leave by T5-L2 ( oesophagus T4-T6)
Liver, stomach, small intestine, pancreas T7-T9
Colon and appendix T10-T11
Rectum T12

41

What do they become when they leave the sympathetic chain?

Abdominosphlancic nerves

42

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.

43

Adrenal gland nervous supply

T10-L1
Enter abdominopelvic sphlancic nerves
Carried with periarterial plexus to the adrenal gland where they synapse straight onto it.

44

Parasympathetic supply

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.

45

Causes of bowel obstruction

Volvulus- twisting of mobile bits of bowel causing obstruction at its head.
Hernias
Adhesions or bands- could be congenital or could be from previous surgeries
Tumours
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

46

Symptoms of bowel obstruction

Vomiting
Constipation
Abdominal distention
Pain

47

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

48

The more proximal the obstruction occurs:

The earlier vomiting develops

49

Large bowel obstruction

Symptoms develop later due to massive capacity of the colon and the caecum.

50

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

51

Incomplete obstruction

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.

52

Investigations into bowel obstruction

AXR supine- bowel proximal to obstruction is distended with gas
CT
In a distended small bowel you can see plicae circularis
In a distended large bowel you can see haustra coli.

53

Management of bowel obstruction

Nil by mouth
IV cannula and send blood
Resusitate with IV fluids
Nasogastric tube to decompress stomach

54

Adynamic bowel obstruction

Paralytic ileus- failure of peristalsis- symptoms and signs similar to bowel obstruction. Risk factors are recent GI surgery, peritonitis and diabetic keto acidosis.
Treat 'drip and suck' while awaiting peristalsis to resume
Psuedo obstruction- acute dilation of the colon in the abscense of obstruction in acutely unwell patients