Summarise the management of anal fissures.
For 6 weeks try:
- Dietary: high-fibre and high-fluid
- Bulk-forming laxatives
- Lubricants (e.g. petroleum jelly) before defecation
- Topical anaesthetics
- Analgesia
After 6 weeks try:
- Topical GTN
- If after 8 weeks still not effective: surgery (sphinterotomy) or BOTOX
What are the NICE referral guidelines for suspected colorectla cancer?
Refer urgently (2 weeks) if:
- ≥40 with unexplained weight loss and abdominal pain
- ≥50 with unexplained rectal bleeding
- ≥60 with iron deficiency anaemia OR change in bowel habit
- Positive occult blood test
Consider referring urgently if:
- Rectal/abdominal mass
- Unexplained anal mass/ulceration
- <50 with rectal bleeeding and:
- Abdo pain
- Change in bowel habit
- Weight loss
- IDA
To whom should the faecal occult blood test screening be offered?
Screening: all people 60-74. In addition:
- ≥50 with unexplained abdo symptoms or weight loss
- <60 with change to bowel habit or IDA
- ≥60 with anaemia evenn without iron deficiency
What is the strongest risk factor for anal cancer?
HPV infection
What is solitary rectal ulcer syndrome?
It is caused by localized ischemic injury or prolapse of the distal rectal mucosa.
This is a rare disorder that involves straining during defecation, a sense of incomplete evacuation, and sometimes passage of blood and mucus by rectum.
Diagnosis is clinical with confirmation by flexible sigmoidoscopy and biopsy. Treatment is a bowel regimen for mild cases, but surgery is sometimes needed if rectal prolapse is the cause.
What type of surgery is indicated for cancer located in the rectum?
A rectal cancer needs to either be removed with an anterior resection or a abdominoperineal resection.
AP resections include removal of the anus, and are used for cancers that are in close proxmity to the rectal sphincter, i.e. in the lower third of the rectum.
Describe the grading system for hameorrhoids
- I: do not prolapse out of the canal
- II: Prolapse on defecation but reduce spntaneously
- III: Can be manually reduced
- IV: Cannot be reduced
What is the management of a diverticular bleed?
Isolated diverticular bleeds without evidence of infection do not require antibiotics or surgery.
Wht is gastric volvulus?
Gastric volvulus is rare. It is rotation of the stomach associated with obstruction.
Triad:
- Vomiting (non-bilious)
- Pain
- Failed attepts to pass NG tube
What would histology show for a solitary rectal ulcer syndrome?
Fibromuscular obliteration.
What type of analgesia is associated with faster return of bowel function after abdominal surgery?
High quality evidence suggests that epidural analgesia helps to accelerate the return of normal bowel function after abdominal surgery.
What would a blood gas for a patient with a high-output stoma show?
- Metabolic acidosis (as Bicarb is lost in stoma)
- ± Respiratory compensation (low pCO2)
- Low Bicarb
Talk me through the Duke’s staging system.
Dukes’ classification describes the extent of spread of colorectal cancer:
- Dukes A: Tumour confined to mucosa
- Dukes B: Tumour invading bowel wall
- Dukes C: LN metastases
- Dukes D: Distant metastases
What is the most common location for diverticular disease?
The sigmoid colon.
What does this Abdominal polain radiograph show?
Sigmoid volvulus.
Clear “coffee bean sign” and large-bowled obstruction.
What is the national screening programme for colorectal cancer in England and Scotland?
Faceal immunochemical test (FIT) every 2 years 60-74 (England) and 50-74 (Scotland)
In addition, a one-off flexible sigmoidoscopy at age 55 is offered to identify and treat polyps.
What is the most common histological subtype of colorectal cancer?
Adenocarcinoma.
What is a rectal intussceception?
Rectal intussceception (internal rectal prolapse) typically presents with symptoms of obstructed defecation. The pathology is best demonstrated by a defecating procotogram rather than barium enema.
What is the management of diverticulitis mild flare?
Patients with diverticulitis flares can be managed with oral antibiotics at home.
If they do not improve within 72 hours, admission to hospital for IV ceftriaxone + metronidazole is indicated
What does this AXR show?
Small bowel obstruction is clearly visible on this film (note the valvulae conniventes, mucosal folds, that cross the full width of the bowel) secondary to caecal volvulus. Note the left nephrostomy tube in-situ.
What is the usual purpose of a loop ileostomy?
A loop ileostomy can be used to defunction the colon to protect an anastomosis distally.
What does this AXR show?
You can see the typical ‘coffee bean’ appearance with three dense lines converging towards the site of obstruction (Frimann Dahl’s sign) in keeping with sigmoid volvulus.
What is the most appropriate investigation to assess the patency of an anastomosis?
A gastrografin enema involves passing a water soluble radiopaque liquid into the rectum, then taking radiographs to assess the rectum. If there are any leaks in a colorectal anastomosis, the radiopaque liquid should show up as free fluid in the abdomen. As this is a possibility gastrografin is preferred over barium as it is less toxic if it leaks into the abdominal cavity.
What is the management of sigmoid volvulus and caecal volvulus?
Sigmoid: rigid sigmoidoscope with rectal tube insertion.
Caecal: managment is usually operative; right hemicolectomy is often needed.
