6 - Lower GI Flashcards

Question

What is the definition of the following terms: - Diarrhoea - Acute and Chronic diarrhoea - Dysentry - Traveller's diarrhoea

Answer 1

Risk factors are poor food preparation, immunocompromised and poor personal hygeine

Answer 2

Time between ingestion of food and symptoms Bacterial toxins = hours Virus = days Bacteria = weeks Parasites = months

Answer 3

- Cramp-like abdominal pain and diarrhoea (with possible mucus and blood) - May have vomiting, night sweats and weight loss - May have pyrexia and dehydration

Answer 4

**Ix:** none unless blood/mucus in stool, immunocompromised or persistent, then do a stool culture **Mx:** rehydration, education to prevent in the future, exclusion from work for 48 hours from last episode of D+V, if food posioning report as notifiable disease

Answer 5

- Campylobacter - Shigella - Salmonella - Norovirus

Answer 6

**- Norovirus:** most common viral gastroenteritis in adults, usually abdominal cramps, D+V and lasts 1-3 days **- Rotavirus:** common in young children and resolves in about a week **- Adenovirus:** common in kids

Answer 7

- Campylobacter - Shigella - E.Coli - Salmonella ALL GRAM NEGATIVE

Answer 8

Usually acute onset D+V lasting 24 hours

Answer 9

More common in traveller's diarrhoea

Answer 10

**C.Difficile (Gram-positive)** usually arising following use of **broad spectrum abx** that disrupts normal microbiota so C.Diff can overgrow Produces **exotoxin A and B** that cause an immune response from the bowel so **inflammatory exudate on colonic mucosa** **Severe bloody diarrhoea** and risk of **toxic megacolon** (dilated bowel with risk of perforation)

Answer 11

**Ix:** stool culture and C.Diff Toxin (CDT) testing **Mx:** IV fluid rehydration, oral metronidazole (or vancomycin in severe cases) Have low threshhold for treatment with immunocompromised patients regardless of the cause of the gastroenteritis

Answer 12

**- Radiation colitis** **- IBD** (Crohn's and UC) **- Microscopic colitis** **- Chronic ischaemic colitis** (usually affects watershed area around splenic flexure and is seen on endoscopy as blue swollen mucosa)

Answer 13

Causes GI bleeds and it caused by formation of **arteriovenous malformations** between previously healthy blood vessels, **usually in caecum and ascending colon** Most common cause of small bowel bleeds and second most common cause of rectal bleeding in over 60s Can be **acquired** or **congenital**

Answer 14

**- Painless rectal bleeding** AND **- Anaemia** - If upper GI bleed melena and haematemesis - If lower GI haematochezia **_- Differentials:_** oesophageal varices, GI malignancies, diverticular disease, coagulopathies

Answer 15

**Lab tests:** blood tests including FBC, U+E's, LFTs, clotting, G+S or crossmatch **Imaging:** ***endoscopy or colonoscopy*** to rule out malignancy. may need ***capsule endoscopy*** if in small bowel. can do mesenteric angiography to plan for intervention

Answer 16

**_Conservative_** - If haemodynamically stable ***- Bed rest and IV fluids*** - Potential ***tranexamic acid*** **_Radiographically_** - If persistent or severe ***- Endoscopy*** that subjects bleeding vessel to argon and electrical current ***- Mesenteric angiograph***y for small bowel that cannot be reached on endoscopy. Embolisation of vessel after catheterisation **_Surgically_** ***- Bowel resection*** (high mortality so only do if necessary)

Answer 17

- Advancing age - Liver disease - Patient present in hypovolemic shock - Current inpatients

Answer 18

**- Rebleeding** post therapy - Risk of **small bowel perforation** in endoscopy - Risk of **haematoma formation, arterial dissection, thrombosis** and **bowl ischaemia** in mesenteric angiography

Answer 19

**Gastroenteropancreatic neuroendocrine tumours** that originate from neuroendocrine cells in the tubular GI tract and pancreas and they have the potential to be malignant Most located in small intestine, with the rest in the stomach and rectum

Answer 20

- Genetic - MEN1 - VHL disease - Tuberous sclerosis complex (TSC)

Answer 21

- Non-specific symptoms like vague abdominal pain, N+V, andominal distension - Unintentional weight loss - Can be functioning or non functioning depending on hormonal hypersecretion

Answer 22

- Chromogranin A and 5-HIAA levels - Routine bloods including FBC, LFTs, pancreatic peptides - Genetic testing - Endoscopy or CT enterocylsis depending on location - If metastatic with unknown primary do whole body somatostatin receptor schintography SSRS

Answer 23

Often palliative as metastatic on presentation **Poorly differentiated:** surgical resection then chemo if localised or if metastatic just palliative chemo **Well differentiated:** localised disease and any liver metastases should be resected

Answer 24

Usually affects people between aged 10-30 Usually due to **luminal obstruction** of appendix from a **faecolith, lymphoid hyperplasia**, impacted stool or rarely a tumour When obstructed **commensal bacteria in appendix multiply** so acute inflammation. **Reduced venous drainage and localised inflammation** leads to **increased pressure** in the appendix and in turn **ischaemia** If ischaemia untreated can lead to **necrosis** and then **perforation**

Answer 25

**Risk factors:** FHx, caucasian (but ethnic minorities more likely to perforate if get it), summer **Differentials:** see image

Answer 26

**_Lab Tests:_** urinalysis to exclude UTI, serum b-hCG to exclude pregnancy, FBC to look for raised inflammatory markers and for pre-op assessment **_Imaging:_** often not needed as clinical diagnosis but if uncertainty can do USS first line (especially for children as lower radiation) or CT

Answer 27

**_Men:_** Appendicitis inflammatory response score **_Women:_** Adult Appendicitis score **_Children:_** Shera score Helps to work out how probable the diagnosis is appendicitis

Answer 28

**- Laparascopic appendectomy** is gold standard **- If appendiceal mass give antibiotics** then interval appendectomy 6-8 weeks later - After removal **send to histology** to rule out malignancy and then look around rest of abdomen to look for any other pathology and look for Meckel's diverticulum

Answer 29

**- Perforation** and peritoneal contamination **- Surgical site infection** **- Appendix mass** where omentum and small bowel adhere to appendix **- Pelvic abscess** with fever and palpable RIF mass that can be confirmed on CT then percutaneous drainage

Answer 30

**- Dull poorly localised peri-umbilical pain** that **migrates to RIF** and is **sharp and well localised** - Can have **vomiting, anorexia, nausea, constipation** **- Rebound tenderness** and percussion pain over **McBurney's point** **- Guarding** if perforated but this will also show tachycardia and hypotension

Answer 31

- Often present in atypical manner e.g diarrhoea, urinary symptoms, left sied pain - Always examine urinary, cardiorespiratory and genitals if male - Children under 6 who have had symptoms for over 48 hours more likely to have perforated

Answer 32

- Fourth most common cancer and second highest mortality - Mostly **adenocarcinomas** - Progression of normal mucosa to colonic adenoma (polyp) to invasive adenocarcinoma (**adeno-carcinoma sequence)** **- APC** and **HNPCC** predisposes people to colorectal cancer

Answer 33

- 75% are sporadic with no risk factors - Increasing age - FHx - IBD - Low fibre diet - High processed meat intake - Smoking - High alcohol intake **Differentials**: IBD and haemorrhoids

Answer 34

Change in bowel habit, rectal bleeding, weight loss, abdominal pain, iron deficiency anaemia **Right sided:** abdominal pain, occult bleeding/anaemia, mass in RIF, presents late **Left sided**: PR bleeding, change in bowel habit, tenesmus, mass in LIF or on PR

Answer 35

* ≥40yrs with unexplained weight loss and abdominal pain * ≥50yrs with unexplained rectal bleeding * ≥60yrs with iron‑deficiency anaemia or change in bowel habit * Positive occult blood screening test

Answer 36

**- FBC**, LFTs, clotting (may show microcytic iron deficiency anaemia) **- CEA tumour marker** to monitor disease progression - Gold standard is **colonoscopy with biopsy** - Once diagnosed stage with **CT Chest/Abdo/Pelvis** to look for metastases, can use **MRI/Endo-anal US** to assess any rectal cancers depth of invasion and suitability for trans-anal resection

Answer 37

Duke's Staging or TNM

Answer 38

Only definitive cure is surgery **_Surgical_** **Regional colectomy** to ensure removal of primary tumour with adequate margins and lymphatic drainage followed by **anastomosis or formation of stoma** **_Chemotherapy_** - Usually used ***adjuvantly*** in ***advanced disease*** - FOLFOX regime **_Radiotherapy_** - Used in **rectal cancer neoadjuvantly** (if **threatened circumferential resection** on MRI) to shrink tumour to increase chance of complete resection - Not used in colon cancer due to risk of damage to small bowel **_Palliative_** ***- Endoluminal stenting*** to relieve acute bowel obstruction but risk of perforation, incontinence and migration and cannot be used in rectal as tenesmus ***- Stoma formation*** to relieve same - Resection of metastases

Answer 39

**_Right hemicolectomy:_** for ***caecal*** or ***ascending colon tumours.*** ileocolic, right colic and right branch of middle colic (SMA branches) are divide and removed **_Left hemicolectomy:_** ***descending colon tumours***. left branch of middle colic vessels, inferior mesenteric vein and left colic vessels divided **_Sigmoidcolectomy:_** ***sigmoid colon tumours***, IMA fully dissected out **_Anterior resection:_** ***high rectal tumours \>5cm from anus.*** favoured as leaves anal sphincter. often perform defunctioning loop ileostomy to protect anastomosis but can be reversed **_Abdominoperineal Resection (AP):_** ***low rectal tumours \<5cm*** from anus. Excision of distal colon, rectum and anal sphincters so needs ***permanent colostomy***

Answer 40

Used in emergency bowel surgery (e.g perf or obstruction) **Complete resection of recto-sigmoid colon with formation of end colostomy and closure of rectal stump.** Done when condition means primary anastomosis is not ideal

Answer 41

**- Diverticulosis –** the presence of diverticula (asymptomatic, incidental on imaging) **- Diverticular disease –** symptoms arising from the diverticula **- Diverticulitis –** inflammation of the diverticula **- Diverticular bleed –** where the diverticulum erodes into a vessel and causes a large volume painless bleed More common in men and developing countries

Answer 42

**Aging bowel** becomes weakened and **increase in intraluminal pressure from stool** passing through causes **outpouching of mucosa** through **weaker bits of bowel wall** (the junctions between triangular muscles) ## Footnote - Bacteria can overgrow in outpouchings causing **inflammation** - In chronic cases **fistula** can form (colovesical and colovaginal) **- Simple** or **Complicated** (abscess presence or free perforation)

Answer 43

**Risk factors:** age, low fibre intake, obesity, smoking, FHx, NSAID use **Differentials:** IBD, bowel cancer, mesenteric ischaemia, gynaecological causes, renal stones

Answer 44

**Diverticulosis:** Asymptomatic found incidentally on imaging **Diverticular disease:** Intermittent colicky lower abdominal pain that can be relieved by defecation. Altered bowel habit, nausea, flatulence **Acute diverticulitis:** Acute sharp abdominal pain usually localised in LIF and worsened by movement. Localised tenderness and systemic symptoms e.g pyrexia, anorexia. If perforated signs of peritonitis

Answer 45

If taking corticosteroids or immunosuppressants can mask symptoms of diverticulitis even if perforated Pain may be in lower right quadrant or suprapubic

Answer 46

Complicated diverticulitis Managed with **IV antibiotics** but if doesn't get better do **radiological drainage** If complicated multi-loculated abscess will need **laparoscopic washout** or **Hartmann's**

Answer 47

**Lab Tests**: FBC, CRP, U+E's, consider faecal calprotectin, G+S, venous blood gas, urine dipstick to rule out urological causes **Imaging:** ***CT abdomen pelvis*** then ***flexible sigmoidoscopy*** or ***CT colonography***

Answer 48

Increased risk of perforation

Answer 49

**Hinchey Classification** based on CT findings helps clinical management

Answer 50

- Uncomplicated can be managed as outpatient with **analgesia** and **fluid intake** and **arrange colonoscopy** to exclude any masked malignancies - If diverticular bleed manage conservatively as often self-limiting - If significant bleed appropriate resuscitation with blood products, if fails embolisation or surgical resection

Answer 51

**Conservative:** Abx, IV fluids, analgesia. Symptoms often improve after 2-3 days, if deterioraion repeat imaging to look for disease progression **Surgical** (if perforation with faecal peritonitis or overwhelming sepsis): Hartmann's procedure with reversal of colostomy at later date

Answer 52

**- High rate of recurrence:** may opt for elective segmental resection **- Diverticular stricture:** from repeated acute inflammation so bowel scarred and fibrotic. can cause large bowel obstruction, needs sigmoid colectomy **- Fistula formation:** colovesical or colovaginal

Answer 53

5 days Co-amoxiclav or combination of cefalexin with metronidazole if allergic Avoid NSAIDs and codeine due to risk of perforation

Answer 54

**Remitting and relapsing** IBD with **bimodal age distribution** of 15-30 and then again at 60-80 Can affect **any part of GI** from mouth to anus but usually affects **distal ileum** and **proximal colon.** **Transmural inflammation** with **cobble stone appearance** and **skip lesions**

Answer 55

Unknown but **family history, smoking, white european** (Ashkenazi Jews) and **appendicetomy** all increase the risk of developing

Answer 56

- Crohn's has **perianal disease** but UC doesn't - UC has **bloody diarrhoea** but Crohn's doesn't - UC **continuous** but Crohn's is skip lesions - **Smoking** is protective for UC but risk factor for Crohn's

Answer 57

- Episodic colicky **abdominal pain** and **diarrhoea** - Diarrhoea is chronic and can contain blood and mucus - Systemic **malaise, anorexia** and **low grade fever** - Malnourishment **- Oral aphthous ulcers** **- Perianal disease** On examination look for abdominal tenderness, mouth or perianal lesions, signs of malabsorption/dehydration, extraintestinal manifestations

Answer 58

**- MSK:** enteropathic arthritis and metabolic bone disease **- Skin:** erythema nodosum and pyoderma gangrenosum **- Eyes:** anterior uveitis, iritis **- HPB:** PSC, cholangiocarcinoma, gallstones **- Renal:** renal stones

Answer 59

**_Supportive_** **- Routine bloods:** look for anaemia, low albumin due to malabsorption, raised inflammatory markers **- X-ray/CT** in acute setting to rule out obstruction or toxic megacolon **- Faecal calprotectin** and consider **stool sample** **_Diagnostic_** - Gold standard **colonoscopy with biopsy** - CT abdomen pelvis - MRI to look for fistulae and perianal disease - Can do proctosigmoidoscopy under anaesthesia to examine and treat perianal fistula

Answer 60

**Acute attack:** ***Fluid resus, nutritional support, prophylatic heparin*** and ***anti-embolic stockings*** as prothrombotic state when in IBD flare **Inducing remission:** ***Corticosteroids*** and ***immunosuppressants*** like ***azathioprine***. ***Can trial biologics*** like infliximab as rescue therapy **Maintaining remission:** ***Azathioprine*** as monotherapy, can consider biologics if this fails or add in methotrexate. ***Smoking cessation***. ***Colonoscopic surveillance*** due to risk of malignancy. Referred to ***IBD nurse specialist*** and offered ***enteral nutritional support*** **Surgical (when medical management fails, severe complications or growth impairment in younger pt):** see image but as patients are high risk need to do preoperative optimisation. Take ***bowel-sparing aproach to avoid short gut syndrome***

Answer 61

- Anti-motility drugs like loperamide as can precipitate toxic megacolon - Also avoid colonoscopy due to risk of perforation - Refer to gastroenterologist

Answer 62

**_Gastrointestinal_** - Fistula - Stricture formation leading to bowel obstruction - Recurrent perianal abscesses and fistula - GI malignancy **_Extraintestinal_** - Malabsorption and growth delay - Osteoporosis due to malabsorption and long term steroids - Increased risk of gallstones due to less bile salts reabsorbed in terminal ilium - Increase risk of renal stones due to malapsorption of fats so calcium stays in lumen but oxalate still absorbed freely so oxalate stones

Answer 63

- Cases not responding to medical management - Bowel perforation - Toxic megacolon Pay close attention to nutritional status!!!!

Answer 64

**Remitting and relapsing disease** that is usually in **Caucasians** with **bimodal age distribution** of 15-25 and then 66-65. Unknown aetioloy but **FHx** and **environmental triggers** are risk factors. **Smoking** is protective factor

Answer 65

- Insidious onset of **bloody diarrhoea** **- PR bleeding** and **mucus discharge** - Increased frequency and urgency of defecation **- Tenesmus** - Abdominal pain - May have **anorexia** and **low grade pyrexia** Clinical exam usually remarkable but if severe abdominal pain consider toxic megacolon and perforation

Answer 66

Truelove and Witt Criteria

Answer 67

**MSK:** enteropathic arthritis or nail clubbing **Skin:** erythema nodosum **Eyes:** episcleritis, anterior uveitis, iritis **HPB:** primary sclerosing cholangitis

Answer 68

- Crohn's (UC is more bloody stools) - Chronic infections (Schistosomiasis, Giardiasis, TB) - Mesenteric Ischaemia - Radiation colitis - Malignancy - IBS - Coeliacs

Answer 69

**Lab Tests**: Routine bloods (FBC, U+Es, CRP, LFTs, clotting) to look for anaemia or deranged LFTs if acute flare, low albumin (malabsorption), raised CRP/ESR **Faecal Calprotectin and Stool Sample:** Raised in IBD but not IBS and should be done on patients with recent onset lower GI symptoms **Imaging:** Gold standard diagnostic is ***colonscopy with biopsy*** but avoid in acute exacerbation (sometimes flexi sig sufficient) If ***acute flare do AXR or CT*** to assess for toxic megacolon and/or perforation

Answer 70

- **Mural thickening and thumbprinting** due to severe inflammation **- Lead pipe colon** can be seen on barium studies with toxic megacolon

Answer 71

**Acute attack:** Fluid resus, nutritional support, prophylatic heparin **Inducing remission:** Corticosteroids and immunosuppressants e.g Sulfasalazine, with biologics trialled as rescue therapy, e.g Infliximab **Maintaining remission:** Immunomodulators like sulfasalazine or biologics if first line fails. Colonoscopic surveillance due to risk of malignancy. IBD nurse specialist and enteral nutritional support **Surgical:** around 30% will need this in their life, on another flashcard

Answer 72

**- Total proctocolectomy** with require ileostomy is curative - Some people go for subtotal colectomy and preserve the rectum May need acute surgical treatment if refractory to medical management or toxic megacolon or bowel perforation or dysplastic cells found on routine monitoring so reduces risk of colonic carcinoma

Answer 73

**- Toxic megacolon** (needs decompression of bowel ASAP due to high risk of perforation) **- Colorectal carcinoma** **- Osteoporosis** **- Pouchitis** (abdominal pain, bloody diarrhoea, nausea that needs to be treated with metronidazole and ciprofloxacin)

Answer 74

In IBD when bowel cannot get rid of air and faeces so dilates - Abdominal distension - Abdominal pain - Fever - Rapid heart rate - Shock - Guarding/rigidity

Answer 75

**- Ogilvie syndrome:** dilatation of the colon due to an adynamic bowel in the absence of a mechanical obstruction, often affects caecum and ascending colon - Thought to be due to interruption of the autonomic nervous supply resulting in absence of smooth muscle action - Can lead to toxic megacolon, bowel ischaemia, perforation

Answer 76

- Abdominal pain and distension - Constipation - Late vomiting - On examination abdomen is distended, tympanic but soft and non-tender. If focal tenderness it is a sign of ischaemia so warning sign

Answer 77

**- Blood tests**: to assess for endocrine or biochemical causes e.g U+Es, Ca, Mg, TFTs **- AXR:** only shows distension, cannot rule out mechanical obstruction **- Abdominal Pelvis with IV contrast:** definitive diagnosis as can rule out mechanical obstruction and look at any complications

Answer 78

**_Conservative_** - Make patient NBM - Start IV fluids and fluid balance chart - If vomiting place NG tube to help decompression - If does not resolve in 24-48 hours **insert flatus tube endoscopically** - If above doesn't work trial **neostigmine** - Consider nutritional support **_Surgical (if non-responding or perforation)_** - If non responding but no perforation/iscaemia may need segmental resection +/- anastomosis - Can do caecostomy or ileostomy to decompress bowel long term

Answer 79

Pseudoobstruction is limited to colon and ileus is small and large bowel

Answer 80

**Twisting a loop of intestine around its mesentry** so there is a closed **loop bowel obstruction** This **compromises blood supply** so leads to necrosis and perforation Mostly occurs at **sigmoid** as has a **long mesentry** that gets bigger with age

Answer 81

- Increasing age - Neuropsychiatric disorders - Live in nursing home - Chronic constipation or laxative use - Male - Previous abdominal operations

Answer 82

- Features of bowel obstruction **- Colicky pain, abdominal distension, absolute constipation** - Compared to other bowel obstructions there is a **faster onset** and **higher degree of abdominal distension** - Abdomen tympanic to percussion - If signs of peforation or peritonism surgical emergency as this indicates ischaemia or perforation **Differentials:** bowel obstruction, severe constipation, pseudoobstruction, sigmoid diverticular disease

Answer 83

**- Routine bloods** including electrolytes to rule out pseudo-obstruction - Initial **CT abdomen pelvis with contrast.** Will show very dilated sigmoid colon with **'whirl sign'** due to twisting on mesentry - Can perform **AXR** and will have **'coffee bean sign'** from LIF

Answer 84

**_Conservative_** ***- Rigid sigmoidoscopy with flatus tube insertion*** **_Surgical_** - ***Laparotomy for Hartmann's procedure*** - If recurrent volvulus may have elective sigmoidectomy to prevent further recurrence

Answer 85

- Bowel ischaemia and perforation - Risk of recurrence (90% of patients) - Complications from stoma if place High mortality from surgery as often old and frail and has been a delay to getting them to surgery

Answer 86

- Second most common volvulus and occurs in bimodal age distribution age 10-29 (**intestinal malformation and excessive exercise**) and age 60-79 (**chronic constipation, dementia, distal obstruction)** **- CT imaging** diagnosis with distended caecum and mesenteric swirl and small bowel obstruction **- Laparotomy and Ileocaecal resection always!!!!**

Answer 87

- Can drive after 24 hours of anaesthetic if not taking strong painkillers but recommended not to drive for 2-4 weeks after laparoscopic and 4-6 weeks after open - Can return to work as soon as feeling well enough but can take 4-6 weeks. Avoid strenous activity and heavy lifting for 6 weeks

Answer 88

- Acute cholecysitis - Pyelonephritis - Pneumonia - Hepatitis - Small bowel obstruction

Answer 89

Gallstone in the CBD

Answer 90

When they are symptomatic or risk of gallbladder cancer

Answer 91

- Diverticulitis - IBD - Ureteric colic - Testicular tumour - Inguinal hernia - UTI - PID

Answer 92

- Sharp pain in LIF that is worse on movement - Focal tenderness and/or guarding in LIF - May feel palpable mass in LIF - Decreased appetitie, nausea, pyrexia - If perforated will have signs of peritonitis (lying still) BE CAREFUL IF PATIENT TAKING STEROIDS OR IMMUNOSUPPRESSANTS AS WILL MASK SYMPTOMS OF THIS AND PERFORATION

Answer 93

- Perforation - Lack of improvement with medical management - Fulminant colitis - Massive hemorrhage - Haemodynamic instability - Fistulas and Abscesses

Answer 94

**Low:** Africa and Asia **High**: Western countries due to the lack of fibre

Answer 95

- Perforation - Diverticular strictures - Fistula formation - PR bleeding - Sepsis Surgery when evidence of perforation, sepsis not responding to antibiotic therapy, or failure to improve despite conservative management

Answer 96

Risk of damaging superior hypogastric plexus so urinary and erectile issues

Answer 97

Co-amoxiclav and Metronidazole

Answer 98

Doesn't need bowel preparation

Answer 99

- Proctoscope to help grade haemorrhoid - \>40 with new onset then flexible sigmoidoscopt as can be presentation of colon cancer

Answer 100

Non-manual work after 2-3 weeks for open, or 1-2 weeks laparoscopic

6 - Lower GI Flashcards

(126 cards)