Lower GI Flashcards

Question 1

Q

What conditions can affect the lower GI tract?

Answer

A

IBD[Crohn’s and UC]

IBS

Coeliac disease

Haemorrhoids

Anal fistula

Anal fissure

Colorectal cancer

Question 2

Q

Anal fissure

Definition

Types

Aetiology

Epidemiology

Symptoms

Investigations

Management

Answer

A

Anal fissure

Definition

Tear in lining of squamous epithelium of anal canal

Types

Acute < 6 weeks

Chronic > 6 weeks

Aetiology

Primary
no underlying disease
Posterioir midline
Secondary to underyling disease
Constipation
Crohns
Pregnancy
[Varying locations]

- Epidemiology

Common
Young

Symptoms

Pain on defecation
Bright red blood on wiping
Chronic ulcer= sentinel pile/ skin tag

Investigations

Clinical diagnosis
DON’T do DRE

- Management

Analgesia

paracetamol and ibuprofen
topical lidocaine
topical gtn/diltiazem if > one week

Conversative/to treat constipation

Fibre
Fiuid
Laxative

Surgical/for chronic ulcer

Botulinum injection
Internal sphincterotomy

Question 3

Q

Haemorrhoids

Definition

Types

Aetiology

Epidemiology

Symptoms and Signs

Investigations

Management

Complications

Answer

A

Haemorrhoids

Definition

Enlarged vascular cushions in anal canal

Types

Internal- above dentate line, not painful
External- below dentate line, painful

- Staging system for internal

Stage I- project into lumen- not palpable

Stage II- prolapse with straining, spontaneously reduces

Stage III- prolapse with straining- can be manually reduced

Stage IV- permanently prolapsed, irreducible

Aetiology

Constipation- pressure of straining , causes vascular engorgement
Raised intrabdominal pressure- due to pregnancy, cough, heavy lifting

Symptoms

Usually painless
Small amounts of right red blood, on wiping/ or found in bowl, unmixed with stool

Large haemorrhoids

Rectal fullness
Tenesmus
Soiling

Investigations

Protoscopy
Anaemia [from bleeding]

Management

Conservative- fluid, fibre, laxatives
If severe- rubber band ligation, injection sclerotherapy

Large haemmorhoid - haemorrhoidectomy

Complications

Thrombosis of external haemorrhoid
<72hr= surgical excision
Severe pain + purple oedematous perianal mass
Strangulation of internal haemorhhoid
Urgent haemorrhoidectomy
Severe pain

Question 4

Q

Anatomy of anal canal and different sections

Answer

A

Above dentate line- columnar epithelium - visceral innervation =two thirds of anal canal
Below dentate line- squamous epithelium- somatic innervation= one third of anal canal

Question 5

Q

When should you refer someone for an urgent two week wait for suspected colorectal cancer?

Answer

A

> 40y + unexplained weight loss + abdo pain [+/- blood in stool]
> 50y + unexplained rectal bleeding
> 60y + change in bowel habit or iron deficiency anaemia

Question 6

Q

Ulcerative Colitis

Definition

Pathology

Risk factors

Symptoms and signs

Extraintestinal manifestations- [general IBD + UC specific]

Investigations

Management

Complications

Answer

A

Ulcerative Colitis

Definition

Chronic relapsing remitting inflammatory disease of rectum and colon/large bowel

Pathology

Continuous, uniform inflammation of the colon from the rectum ascending upwards potentially up to ileocaecal valve
Affects only mucosa [and submucosa]

Risk factors

HLA B27
Genetics/PMH of autoimmune conditions
Smoking alleviates it

Symptoms and signs

Blood in stool
Diarrhoea
Left sided abdo pain
FLAWS- systemic B symptoms

Extraintestinal manifestations

General IBD

Erythema nodosum
Pyoderma gangrenosum
Clubbing
Joint pain- symmetrical polyarticular arthritis or asymmetrical oligoarthritis
Osteoarthritis

Ulcerative colitis specific

Uveitis
Primary sclerosing cholangitis
Cholangiocarcinoma

Investigations

Bloods:

FBC- anaemia [of chronic disease], high platelets, high WCC

CRP + ESR- high

LFT- low albumin

U+ E- diarrhoea

Stool:

Faecal calprotectin

Stool culture- to rule out infective colitis

C difficile toxin

TO CONFIRM DIAGNOSIS:

Colonoscopy [only done after an acute episode]- loss of haustra + continuous inflammation

Barium enema

USS/CT to rule out other diff diagnosis

Management

To induce remission:

5-ASAs- Mesalazine

[topical if left sided, topical and oral if whole colon]

IV glucocorticoids if severe

To maintain remission:

Mesalazine

Azathioprine/mercaptopurine if severe

Acute management for flare up

Also make Nil by mouth and give IV fluids + analgesia if needed

Complications

Toxic mega colon
Colorectal cancer

Question 7

Q

What are the main types of extraintestinal manifestation in IBD?

Answer

A

WHEN IBD GETS MES- SY or MESH

Musculoskeletal- symmetrical polyarticular arthritis, asymmetrical oligoarthritis, osteoporosis
Eyes- uveitis [UC}, episcleritis [Crohns]
Skin - Erythema nodosum, pyoderma gangrenosum, clubbing
Hepatobiliary - PSC/cholangiocarcinoma [UC] + Gallstones/kidney stones [Crohns]

Question 8

Q

Red flags for lower GI symptoms- seven of them

Answer

A

>40 year old
PR bleeding
Anorexia, weight loss
Mouth ulcer
Abnormal CRP, Hb, coeliac serology
< 6 months history
Waking up at night= pain/diarrhoea

Question 9

Q

Coeliac disease

Definition

Risk factors

Epidemiology

Presentation- symptoms and signs

Investigations

Management

Answer

A

Coeliac disease

Definition

Autoimmune response which is T cell mediated triggered by dietary gluten, leading to small bowel and systemic disease

Risk factors

Other autoimmune disease - PMH or FH

HLA DQ2/8

Epidemiology

Women [because autoimmune]

Presentation- symptoms and signs

Malabsorption
weight loss, failure to thrive
Vitamins + minerals: osteoporosis, anaemia, neuropathy/parasthesia
Fats: steatorrhea
Chronic GI:
abdo pain, nausea, vomiting, diarrhoea, bloating
Dermatitis herpetiformis
looks like herpes, but isn’t

Investigations

Autoantibodies:

anti-TTG [tissue transglutaminase]
anti-endomysial

[^both IgA, so look at total IgA too]

Bloods:

Haematinics- low B12 and ferritin
Low vit D/calcium
Microcytic/macrocytic anaemia [increased range in size/red cell distribution width]
LFT- non specific transaminitis

Confirm diagnosis:

Endoscopy + duodenal biopsy after at least 6 weeks on gluten diet: shows:

villous atrophy, crypt hyperplasia and WBC intraepithelium

Management

Avoid gluten in diet

[bread, wheat, barley, rye- can eat rice, corn and potatoes]

Pneumococcal vaccine - every 5 years- hyposplenism

Complications

EATL- Enteropathy associated T cell lymphoma- coeliac specific, happens if untreated
Non Hodgkin’s/ Hodgkin’s lymphoma
Other small bowel adenocarcinoma

Question 10

Q

IBS- Irritable Bowel Syndrome
Definition

Risk factors

Aetiology

Epidemiology

Symptoms and signs

Investigations

Answer

A

IBS- Irritable Bowel Syndrome
Definition

More than 6 months of:

Abdominal pain- brought on by eating, relieved by defecation
Bloating/discomfort
Change in bowel habit- diarrhoea/constipation/mucus

Diagnosis of exclusion

Risk factors

Stress

Familial?

Aetiology

Unknown

Epidemiology

Young

Female

[Reconsider diagnosis if >40 years]

Symptoms and signs

Pellet like stool- buzzword

Abdo pain- generalised?

Episodic changes in bowel habit

Bloating

Belching/flatus

Investigations

Clinical diagnosis

Bloods:

FBC/CRP- rule out IBD

Coeliac antibodies- rule out coeliac

Management

Symptomatic:

Conservative: Diet- cut out/reduce alcohol, caffeine, fizzy drinks

Medical:

Pain- antispasmodic- anticholinergic= mebeverine, hyoscine, low dose TCA
Diarrhoea- loperamide
Constipation- laxative, high fibre, fluid
Psychological therapy- if lasts more than one year

Question 11

Q

A 28yr old man presents to his GP complaining of severe pain around his anus when he goes to the toilet. When questioned, he mentions that there also streaks of bright red blood on the toilet paper when he wipes. What is the next most appropriate step?

Perform a DRE
Prescribe paracetamol/ibuprofen and topical lidocaine
Prescribe paracetamol/ibuprofen topical diltiazem
Urgent haemorrhoidectomy
Injection sclerotherapy

Answer

A

Prescribe paracetamol/ibuprofen and topical lidocaine

Question 12

Q

Colorectal cancer

Definition

Types [and frequency of occurence]

Aetiology/risk factors

Epidemiology

Screening

Symptoms and signs

Investigations

Management

Answer

A

Colorectal cancer

Definition

Malignancy of large bowel

Types

Usually adenocarcinoma
Sometimes carcinoid [neuroendocrine], lymphoma, stromal [connective tissue]
Left sided
Right sided

Most commonly in:

Rectum> Sigmoid > Ascending Colon > Transverse Colon > Descending Colon

Aetiology/risk factors

Genetic/FH- FAP [APC gene], HNPCC
IBD- UC especially
Adenomatous/neoplastic polyps
Alcohol/smoking/diet/obesity

Epidemiology

Old
Male
Third most common cancer

Screening

FIT [Faecal immunochemical test] for faecal occult blood

Over 60 to 74y , every two years

FlexiSig at 56 years

Symptoms and signs

Insidious

Abdo pain
Weight loss
Fatigue
FLAWS- B sx

Right sided

Anaemia
Malabsorption

Left sided

Blood in stool/PR
Change in bowel habit- diarrhoea/squirrely stool
Signs of bowel obstruction/stricture:

tinkling/increased bowel sounds

abdominal distension

If in rectum:

Tenesmus
Mass on DRE

Investigations

Bloods:

FBC- anaemia
Tumour marker- CEA [not diagnostic]
LFT- mets

Colonoscopy - gold standard

Barium enema - apple core stricture

TNM/Duke’s staging

Management

First line:

Surgery

Right sided: R sided hemicolectomy

Left sided above sigmoid: L sided hemicolectomy

Sigmoid: Sigmoid colectomy

Rectum: anterior resection

[Either Hartmann’s procedure- end colostomy and rectal stump or anastomosis of colon ends]

Second line: Chemo, radio

Question 13

Q

Crohn’s disease

Definition

Pathology

Risk factors

Presentation - symptoms and signs

Investigations

Management

Complications

Answer

A

Crohn’s disease

Definition

Patchy areas of inflammation caused by chronic relapsing remitting inflammation throughout the GI tract

Pathology

Patches of inflammation from mouth to anus
Transmural inflammation
Cobblestone appearance on colonoscopy because discrete areas of inflammation with islands of normal tissue in between

Risk factors

Smoking
Genetic

Presentation - symptoms and signs

Diarrhoea
Abdo pain [Right sided]
Systemic B symptoms - FLAWS
Malabsorption

Extraintestinal manifestations [general IBD + Crohn’s specific]

V common in Crohn’s

General IBD

Musc- joint pain: symmetrical polyarticular arthritis/ asymmetrical oligoarthritis, osteoporosis

Skin- erythem nodosum, pyoderma gangrenosum, clubbing

Crohns specific

Eyes- episcleritis

Skin- mouth ulcer, perianal lesions

Hepatobiliary/kidney- gallstones/kidney stones

Investigations

Bloods:

_FBC- anaemia of chronic disease, high WCC, high platelet_s

U+ E- diarrhoea

LFT- low albumin

CRP/ESR- high

Stool:

Faecal calprotectin - inflammation

Stool culture

C diff toxin

Confirming diagnosis:

Colonoscopy - cobblestone appearance- do after acute episode/flare up

Barium enema- strictures etc.

Management

Acute episode- nil by mouth, IV fluids, analgesia if needed

To induce remission:

Steroids/glucocorticoids- IV, oral, topical
Elemental/enteral feeding
If only isolated perianal disease: metronidazole
Second line: azathioprine/mercaptopurine, infliximab, mesalazine-5ASA

To maintain remission:

Azathioprine/mercaptopurine
Second line: Methotrexate
Surgery [resulting in stoma} common

Complications

Fistulae

Abscess

Strictures

Question 14

Q

Table comparing Crohn’s and UC

Question 15

Q

A 23yr old lady presents to A&E with a 1 week history of passing 8 stools a day, right sided abdominal discomfort, and fatigue. On examination, she has a painful mouth ulcer and tender violaceous nodules on her shins. Her CRP is 152. What is the next best step?

A.NBM, fluids and oral mesalazine

B.NBM, fluids and IV methotrexate

C.NBM, fluids and IV azathioprine

D.NBM, fluids and IV hydrocortisone

E.NBM, fluids and IV mesalazine

Answer

A

D.NBM, fluids and IV hydrocortisone

Likely diagnosis= Crohns

Question 16

Q

A 28 yr old lady presents to her GP with a 1 year history of “bowel problems”. She mentions that she often gets diarrhoea after eating and that for the past couple of months she has been feeling very bloated and lethargic. What is the next best step?

A.Check total IgA, anti-ttG, and anti-endomysial antibody levels

B.Endoscopy & duodenal biopsy

C.Prescribe loperamide and send home

D.Review in 3 months

E.Send stool cultures

Answer

Study These Flashcards

A

A.Check total IgA, anti-ttG, and anti-endomysial antibody levels??

Question 17

Q

A 30yr old woman with a history of constipation presents to her GP with a 1 week history of painless PR bleeding. She describes passing bright red blood on defecation, visible in the toilet bowl and separate from her stool. On examination, you feel a mass when she bears down that recedes when she relaxes. What is the most appropriate initial management of her condition?

A: Advise her to increase her fluid and fibre intake, and prescribe stool softeners

B: Referral for rubber band ligation

C: Referral for injection sclerotherapy

D: Advise her to increase her fluid and fibre intake, and prescribe topical lidocaine

E: Referral for surgical haemorrhoidectomy

Answer

Study These Flashcards

A

A: Advise her to increase her fluid and fibre intake, and prescribe stool softeners

Question 18

Q

A 19 yr old woman presents to her GP with a 3 day history of an itchy, blistering rash on her elbows. She mentions that she has also felt increasingly lethargic over the past 3 months, and that she occasionally gets feelings of numbness and tingling in her hands. Her mother suffers from hypothyroidism. What is the most likely diagnosis?

A: Eczema herpeticum

B: Dermatitis herpetiformis

C: Herpetic whitlow

D: Shingles

E: Pretibial myxoedema

Answer

Study These Flashcards

A

B: Dermatitis herpetiformis

Question 19

Q

A 32 year old man presents to his GP with a 2 week history of bloody diarrhoea. He mentions that he has been going to the toilet 4 times a day, and passes loose stools with bright red blood every time. He mentions that this is the second time that this has happened in the past 3 months. His past medical history is otherwise unremarkable aside from occasional joint pains. On examination he is slightly febrile with a temperature of 37.5oC, and he has tenderness in his left lower quadrant. What is the most likely diagnosis?

A.Dysentry

B.Crohn’s disease

C.Viral gastroenteritis

D.Angiodysplasia

E.Ulcerative colitis

Answer

Study These Flashcards

A

E.Ulcerative colitis ?

Question 20

Q

A 67yr old man presents to his GP saying that he has been feeling much more tired than usual for the past month. A routine set of bloods showed that he has a mild iron-deficiency anaemia. What is the next best step?

A.Review in 4 weeks

B.Prescribe iron supplements and send home

C.Urgent 2ww referral for colonoscopy

D.Routine referral to haematology

E.Request a blood film