Week 4 Common Conditions Flashcards

Question

What is the management of haemorrhoids?

Answer 1

Rectal examination Sigmoidoscopy/colonoscopy to exclude other causes of bleeding Symptom relief Oral or topical preparations (ointments, suppositories) to reduce pain &/or inflammation Hydrocortisone/Cinchocaine Ointment Corticosteroid combined with local anaesthetic Increasing dietary fibre: reduces the need for surgical intervention

Answer 2

DEFINITION: Inflammation of the appendix INCIDENCE Most common surgical emergency of the abdomen Affects 7-12% of the population Can develop at any age, peak age for diagnosis 20-30 years

Answer 3

? Exact causative mechanism Most common theory relates to obstruction of the lumen and consequent bacterial infection Obstruction due to stool (faecolith), tumour or foreign body

Answer 4

Obstruction of the lumen prevents proper drainage As mucosal secretions continue, intraluminal pressure increases (decreases mucosal blood flow) Hypoxia-induced ulceration promotes bacterial invasion & inflammation Gangrene develops from thrombosis of the luminal blood vessels, followed by perforation of the appendix Complications: Peritonitis, abscess formation

Answer 5

Abdominal pain Initially vague, constant and felt in the gastric or peri-umbilical region Increases over 3-4 hours Visceral pain is replaced by intense somatic pain in the RLQ Mediated by a different neural pathway (thoracoabdominal nerves) Indicates extension of inflammation to parietal peritoneum The somatic pain is sharp, well-localised and sensitive to stretch e.g. inspiration, rebound tenderness Common: Nausea, vomiting, anorexia and fever Bowel habit can vary from diarrhoea to a sensation of constipation

Answer 6

Appendectomy For simple or perforated appendicitis Laparoscopic or open Antibiotic therapy Alternative to surgery Some evidence: resolution of mild-moderate appendicitis with antibiotics alone However, it carries a risk of recurrence and the factors leading to the failure of antibiotic therapy are not well known Usually reserved for patients too frail to undergo surgery

Answer 7

Ulcerative colitis & Crohn’s disease are referred to as the inflammatory bowel diseases Affect > 75, 000 Australians Common to both diseases: Genetic predisposition Autoimmune dysfunction Abnormal gut microflora 10-20% of cases – not possible to distinguish which disease is involved

Answer 8

A chronic inflammatory disease that causes ulceration of the colonic mucosa, usually in the rectum & sigmoid colon INCIDENCE: Affects ~33,000 Australians Peak age for diagnosis 20-40 years

Answer 9

Exact cause is undetermined Genetic, immunological & infectious factors are usually involved Autoimmune dysfunction: Anti-colon antibodies Increased levels of inflammatory cytokines: TNF-α, Interleukins

Answer 10

Inflammation begins at the crypts of large intestine, but does not usually spread beyond the submucosa Most severe at rectum & sigmoid colon (40% of cases spread to the appendix, terminal ileum rarely affected) Mucosa becomes swollen & hyperaemic (contains excess blood and readily bleeds) Small erosions form and develop into ulcers (mucosa adopts a ragged appearance) Healing with fibrosis leads to pseudopolyp formation (clumps of granulation tissue) Oedema & thickening of the muscularis narrows the lumen

Answer 11

Initial attack is most severe Subsequent course involves remissions & exacerbations (vary in intensity) Large volumes of watery diarrhoea +/- blood, mucous, pus Paradoxically, there may be constipation (due to strictures or reflex bowel spasm) Lower abdominal pain, tenderness or cramping Proctitis leads to tenesmus ``` Severe episodes > 20 bowel motions/day Dehydration, tachycardia Fever (interleukin = endogenous pyrogen) Anaemia ```

Answer 12

A chronic inflammatory disorder that can affect any part of the GIT from the mouth to the anus INCIDENCE Affects 28,000 Australians (lower incidence than UC) Peak age for diagnosis 20 – 40 years

Answer 13

As for UC, there is strong evidence of autoimmune involvement Dysregulation of humoral & cell mediated immunity Bacterial flora Susceptibility genes

Answer 14

Inflammation begins in the submucosa and spreads to involve the entire thickness of the intestinal wall Most common sites: terminal ileum, ascending colon & transverse colon Skip lesions: inflammation can affect some regions of the GIT but not others (rectum is seldom involved) Chronic inflammation leads to the development of granulomas (clusters of modified macrophages) These occur in the gut wall, mesentery & mesenteric lymph nodes The intestinal wall adopts a cobblestone appearance, due to lines of ulceration surrounding areas of mucosal swelling

Answer 15

Will vary - depending on site affected, extent and duration of disease Early stages may mimic irritable bowel, or even a peptic ulcer Diarrhoea: most common symptom If colon affected: blood, pus, mucous Weight loss and abdominal pain If small bowel affected: issues related to malabsorption Steatorrhoea Hypoalbuminaemia Vitamin D Vitamin B12 Iron

Answer 16

``` Ankylosing spondylitis Biliary Tree Disorders (cirrhosis, stones) Eye Disorders (conjunctivitis) Renal Disorders (stones) Skin Disorders (erythema nodosum) ```

Answer 17

Risk for colorectal cancer: increased in both UC & CD Bowel obstruction Repeated inflammation  fibrosis Features of acute obstruction: colicky pain, vomiting, nausea, excessive borborygmi UC - Toxic megacolon If ulceration is severe enough to affect muscularis Results in dilated, atonic section of bowel CD - Chronic anal fissures, fistula development Coloenteric, colovesical, colovaginal

Answer 18

Anti-inflammatory agents Corticosteroids e.g. prednisolone, budesonide, hydrocortisone Oral: enteric-coated, sustained-release tables Suppository/enema 5-Aminosalicylic Acid (5-ASA) Sulphasalazine (prodrug) is hydrolysed to 5-ASA in the colon Mechanism: prostaglandin synthesis inhibitor Biological agents Anti-TNFa antibodies e.g. infliximab (chimeric Ab), adalimumab (human Ab) Mechanism: targets & reduces levels of the cytokine TNFa. Immunosuppressants e.g. methotrexate, cyclosporin, azathioprine Anti-diarrhoeal agents

Answer 19

Regular endoscopic surveillance CD: dietary management for malabsorption High protein, high energy diet recommended Supplementation for specific deficiencies Severe Exacerbations: Hospitalisation required Rehydration, plasma or blood transfusions Exclusive enteral nutrition: useful in achieving remission Sometimes total parenteral nutrition may be necessary

Answer 20

Despite its length, cancer affecting the small bowel is rare (difference due to transit times?) Large bowel: slow transit rate (greater exposure of mucosa to potential carcinogens)

Answer 21

Accounts for > 90% of intestinal malignancies 2nd most common malignancy overall & 2nd highest cause of cancer-related deaths Overall risk: 1 in 11 (M) and 1 in 16 (W) Peak age for diagnosis: late 60s Incidence is dropping in women, but still rising in men Failure of men to change their diets?

Answer 22

Like most cancers, CRC arises from complex interplay between environmental & genetic factors Dietary factors: Low-fibre diets, high-fat diets, diets high in charred red meats Smoking Inflammatory bowel disease Familial component Increased risk if a first-degree relative has had CRC Familial adenomatous polyposis Polyp: benign, finger-like projection of mucosal epithelium

Answer 23

Uncommon autosomal dominant disorder (1/8,000) that results in numerous polyps throughout the bowel In FAP, polyps undergo malignant change in ~15 yrs

Answer 24

The general population has a 1 in 10 -15 risk for CRC Those with a first-degree relative have a 1 in 3 risk 100% of those with FAP will develop CRC by age 40-50

Answer 25

Most tumours develop in pre-existing adenomatous polyps Risk of malignancy increases with polyp size 50% chance of finding neoplastic cells in polyps >4cm Most common sites: rectum (M), sigmoid colon (F) Caecum & ascending colon next most common for both sexes.

Answer 26

Malignant polyps can ulcerate: bloody or mucoid diarrhoea Distal bowel - frank blood Proximal bowel – occult blood Caecal tumours – asymptomatic until large Alternatively, a large polyp can restrict the bowel lumen: constipation Lower abdominal pain: can vary from vague discomfort to colic Palpable mass Non-specific features Features of metastasis (direct spread, lymphatics, blood) Liver mets are especially common

Answer 27

Diagnosis: colonoscopy with biopsy Surgical resection is the only definitive treatment. Polyp – endoscopic mucosal resection Simple resection w. end-to-end anastomosis Temporary/permanent colostomy Radiotherapy & chemotherapy: adjuncts to surgery or palliation SCREENING Faecal occult blood test & endoscopy FAP: regular endoscopy starting age 10 If first-degree relative has had CRC – from age 25 General population: routine endoscopy every 5 years after age of 40