P year Gastro

Page 1

GI

Haemorrhoids ->

Painless bleeding, prolapse/ lump, mucous discharge, itch.

First degree- cushions that do not descend below the dentate line on straining

Dentate line divides upper two third and lower third of anal canal

Second degree- protrude below the line on straining

Third degree- Descend to the exterior on straining and need to be digitally reduced

Fourth degree- Mucosally covered external cushions that are permanently outside and return outside when they are reduced

Treatment ->

Advice

High fibre diet

Rubber band ligation

Injection sclerotherapy

Infrared photocoagulation

Open haemorrhoidectomy

PPH procedure for prolapse and haemorrhoids

HALO/ THD technique - Haemorrhoidal Artery Ligation Operation . Transanal Haemorrhoidal artery Devascularisation.

Anal Fissure ->

Painful bright red rectal bleeding

Usually at 6 or 12 o clock position

Associated skin tag- sentinel pile

Atypical- Chrohn's disease, HIV

Treatment ->

2% Diltiazem

0.2 % GTN

Botulinum Toxin

Surgery- LSIS laterual subcutaneous internal sphincterotomy (skin flap)

Perianal haematoma ->

Thrombosis of external vascular channels

Short history

Acutely painful lump

May have bled

Incision and drainage under local anaesthesia

Solitary rectal ulcer ->

Rare

Paradoxical contraction of anal sphincter during defaecation

Rectal bleeding

Anterior rectal mucosal ulceration

Pathology = fibromuscular obliteration, and crypts distortion

Treatment ->

Dietary changes, bulking agents

Avoid straining

Biofeedback

Very rarely surgery

Radiation Proctitis ->

Pelvic radiotherapy -> From cervical and prostate cancer.

Acute within a few weeks -> Diarrhoea, tenesmus, urgency

Chronic , maybe several years after treatment -> Bleeding, diarrhoea , difficult defecation

Acute, supportive care , usually resolves

Chronic-> 1. Topical steroids. 2. Sucralfate (treat active duodenal ulcers). 3. Argon plasma coagulation (endoscopic procedure stop GI bleeding). 4. 4% formaldehyde. 5. Hyperbaric oxygen therapy

Anal Warts ->

HPV 6, 11. Main ones 16,18

Up to one year incubation period

Transmission- usually sexual contact, can occur without anal intercourse.

Prevent by vaccination

Development of anal intraepithelial neoplasia

Treatment ->

Topical agents- imiquimod (aldara) , immune response modifier

Excision or ablation

Recurrence- virus remains in normal adjacent epithelium

Surveillance, AIN III

Anal Cancer ->

Within anal canal or anal margin

80% squamous cell cancer

Groin lymph nodes

Treat with chemoradiotherapy, mitomycin C and 5FU, surgery

Local excision alone only considered curative if less than 2cm, well differentiated and clear margin

Other indications for surgery = too large and significant symptoms, residual/ recurrence after chemotherapy

Usually requires abdomino-perineal excision with permanent colostomy

Rectal prolapse ->

Circumferential prolapse that starts 6cm above sphincters as internal intussception and with time and straining it progresses to external full thickness

Does occur in children but often spontaneously resolves

Risk factors = pregnancy, surgery, cystic fibrosis, neurological diseases, pelvic floor dysfunction

Partial thickness- rectal mucosa connective tissue laxity causing mucosal prolapse. Same pathophysiology as haemorrhoids and should be treated as such (banding, excision etc)

Surgical treatment ->

Perineal approach:

Delorme's procedure (UK)- mucosal resection and muscle plication

Altemeier's procedure (USA)- perineal excision of rectosigmoid and coloanal anastomosis

Abdominal Procedures (laparoscopic)

Suture rectopexy

Resection rectopexy

Ventral mesh rectopexy

Pruritus ani ->

Secondary to neoplasia, benign anorectal conditions like haemorrhoids or skin tags, infections like threadworm, dermatological conditions

Treat secondary conditions

Advise a lower fibre diet, probiotics, antimotility agents, avoid spicy foods and caffeine

Advise gentle cleaning

Advise loose underwear

'Break the cycle'- short term use of hydrocortisone crea

Anal fistulae ->

Fistula- an abnormal connection between two epithelial/ endothelial surfaces

Primary cause= cryptoglandular hypothesis (anal glands)

Secondary- chrohns. cancer

Presentation = recurrent perianal abscesses. Chronic discharge. Pain. Continued symptoms following incision and drainage of perianal abscess.

Investigations = endoanal ultrasound, MRI, examination under anaesthesia, exlude secondary causes

Treatment ->

Laying open anal fistula (low fistulae). Complication is minor incontinence, flatus, soiling.

Seton stitch, loose tight or chemical

Advancement flaps

Plugs and glues

LIFT (ligation of intersphincteric fistula tract) procedure

Chrohn's disease - infliximab

Hidradenitis suppurativa ->

Chronic, recurrent and painful disease in which there is inflammation in areas of the apocrine sweat glands

Chrohn's Disease Medical treatment ->

5- ASA products, colonic disease

Steroids- budesonide (ileal/ right colon), prednisolone

Antibiotics- metronidazole, ciprofloxacine, perianal disease

Nutrition -elemental/ polymeric diets

Immunomodulatory: azathioprine, 6-mercaptopurine

Biological agents- infliximab, adalimumab

Microscopic colitis ->

Long term watery diarrhoea

Normal appearances of the colonic mucosa at endoscopy

Histology- collagenous or lymphocytic colitis

20% have chrohns

Screen for diabetes, coeliac and thyroid disease

Treatment->

Anti- diarrhoea agents (loperamide), modify diet, withdraw drugs

Anti inflammatory drugs- 5-ASA, budesonide, methotrexate

Surgery- ileostomy

Constipation ->

Less than 2 stools per week , straining at stool more than 25% of the time

Extra-colonic / rectal causes

Slow transit constipation

Obstructive defaecation ( rectocele, rectal intussusception, pelvic floor dyssynergia)

Investigations -> Ca, TFT, Glucose,K. Colonic transit studies. Defaecating proctography ( Barium, isotope, MRI)

Treatment ->

Laxatives

Suppositories / enemas / rectal irrigation

Prokinetics- prucalopride, lubiprostone, linaclotide

Faecal incontinence ->

Colonic- conditions leading to diarrhoea

Rectal- conditions leading to a stiff, non compliant rectum which will not dilate when stool enters (proctitis)

Sphincter insufficiency- obstetric injury, surgical injury

Treatment -> anal plug, enemas, dietary modification, anti diarrhoeal agents (loperamide), Sphincteroplasty

Goblet cells are seen in Crohn's. Goblet cells are mucin secreting intestinal cells forming the mucus layer that protects the mucosal surface. Ulcerative colitis (UC) has been associated with a defective colonic mucus layer and a reduced number of goblet cells

Secretin is a hormone that regulates water homeostasis throughout the body and influences the environment of the duodenum by regulating secretions in the stomach, pancreas, and liver. It is a peptide hormone produced in the S cells of the duodenum, which are located in the intestinal glands. In humans, the secretin peptide is encoded by the SCT gene.

Secretin helps regulate the pH of the duodenum by inhibiting the secretion of gastric acid from the parietal cells of the stomach and stimulating the production of bicarbonate from the centroacinar cells and intercalated ducts of the pancreas. It also stimulates bile production by the liver; the bile emulsifies dietary fats in the duodenum so that pancreatic lipase can act upon them. Meanwhile, in concert with secretin's actions, the other main hormone simultaneously issued by the duodenum, CCK, is stimulating the gallbladder to contract, delivering its stored bile for the same reason.

Chagas disease ->

Tropical parasitic disease

Linked to sigmoid volvulus

Caused by protist Trypanosomo cruzi

Spread mostly by bugs known as Triatominae aka kissing bugs as blood sucking

Can be spread through blood transfusion, organ transplantation, vertical transmission

Ulcerative Colitis ->

To induce remission in adults with a mild to moderate first presentation or inflammatory exacerbation of left-sided or extensive ulcerative colitis:

offer a high induction dose of an oral aminosalicylate

consider adding a topical aminosalicylate or oral beclometasone dipropionate (steroid), taking into account the person's preferences.

- For distal colitis, rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates

- Oral prednisolone second line for patients who fail to respond to oral aminosalicylates. Wait 4 weeks to decide if first line treatment has failed

- Severe colitis should be treated in hospital. IV steroids first line.

Maintaining remission :

oral aminosalicylates

azathioprine and mercaptopurine

Abdominal scars ->

Midline incision - commonest approach to the abdomen. Diagnostic laparatomy. Upper midline from xiphoid process to umbilicus. Lower midline from umbilicus to pubic symphysis. Trauma surgery.

Paramedian incision. Kidney, spleen, adrenal.

Battle scar similar to paramedian but rarely used nowadays. Rectus displaced medially.

Kocher's- cholecystectomy. Incision under right subcostal margin. Oblique. Some operations on the liver, gallbladder and biliary tract.

Lanz. Appendicectomy. Right iliac fossa.

Gridiron- obliqu incision centred over McBurney's point, usually appendicectomy. Not as cosmetically great.

Gable / rooftop. Whipple's procedure, liver transplant. Useful for access to both liver and spleen (occasionally for radical procedures e.g. Whipple’s/gastrectomy/bilat adrenalectomy)

Pfannenstiel's- Transverse supra pubic, primarily used to access pelvic organs. Emergency cesarean section, abdominal hysterectomy.

McEvedy's - Groin incision e.g. Emergency repair strangulated femoral hernia

Rutherford Morrison- Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is the approach of choice for first time renal transplantation.

Carcinoid tumours ->

usually occurs when metastases are present in the liver and release serotonin into the systemic circulation

may also occur with lung carcinoid as mediators are not 'cleared' by the liver

Features

flushing (often earliest symptom)

diarrhoea

bronchospasm

hypotension

right heart valvular stenosis (left heart can be affected in bronchial carcinoid)

other molecules such as ACTH and GHRH may also be secreted resulting in, for example, Cushing's syndrome

pellagra (Niacin vit B3 deficiency = diarrhoea, dementia, dermatitis) can rarely develop as dietary tryptophan is diverted to serotonin by the tumour

Investigation

urinary 5-HIAA (metabolite of serotonin)

plasma chromogranin A y

Management

somatostatin analogues e.g. octreotide

diarrhoea: cyproheptadine may help

Hereditary haemorrhagic telangiectasia ->

Hereditary haemorrhagic telangiectasia is associated with mucocutaneous lesions and iron-deficiency anaemia but intestinal polyps are not a feature

ANCA anti neutrophil cytoplasmic antibodies ->

There are two main types of anti-neutrophil cytoplasmic antibodies (ANCA) - cytoplasmic (cANCA) and perinuclear (pANCA)

cANCA - granulomatosis with polyangiitis (Wegener's granulomatosis) positive in 90%

pANCA - Churg-Strauss syndrome and others

cANCA most common target serine proteinase 3 (PR3)

pANCA most common target is myeloperoxidase (MPO). Associated with immune crescentic glomerulonephritis. Microscopic polyangiitis. Churg-Strauss syndrome, positive in 60%. Primary sclerosing cholangitis, positive in 60-80%. Granulomatosis with polyangiitis, positive in 25%

Other causes of positive ANCA (usually pANCA) inflammatory bowel disease (UC > Crohn's) , connective tissue disorders: RA, SLE, Sjogren's, autoimmune hepatitis

Eosinophilic granulomatosis with polyangiitis AKA Churg-Strauss syndrome is an extremely rare autoimmune condition that causes inflammation of small and medium-sized blood vessels (vasculitis) in persons with a history of airway allergic hypersensitivity (atopy).

Appendicitis clinical sign ->

Rovsing's sign is positive if palpation of the left lower quadrant of the abdomen increases the pain felt in the right lower quadrant. This may be an indicator of appendicitis, although it is not positive in all cases.

Psoas sign/ Cope's test- Patient lies on their left side and the clinician extends the right hip with the knee fully extended. Abdominal pain on this movement indicates irritation of iliopsoas and possible appendicitis. This test usually indicates an appendix that lies in the retrocaecal position.

Surgical Jaundice ->

FBC is useful for determining whether the cause of the isolated hyperbilirubinaemia is due to haemolysis or Gilbert's syndrome

In post hepatic jaundice, the stools are often pale

Rare time that cholecystitis presents with jaundice = Mirizzi syndrome. When a gallstone compresses the bile duct directly.

Cholangitis- ascending infection of the bile ducts usually by e Coli and by definition occcuring in a stagnant pool of bile. Should receive broad spectrum antibiotics and then biliary decompression (may cause a septic episode)

TPN associated jaundice after long term use- due to hepatic dysfunction and fatty liver

Ciproflaxacin can cause cholestasis leading to jaundice

Bile salts are absorbed in the terminal ileum. When this process is impaired as in Crohns the patient may develop gallstones, if these pass into the CBD then obstructive jaundice will result

Acute pancreatitis ->

Rare feature = ischaemic (purtscher's) retinopathy which may cause temporary or permanent blindness

Pancreatitis Sequelae ->

Peripancreatic fluid collections - occur in 25%. Located in or near the pancreas and lack a wall of granulation or fibrous tissue. May resolve or turn into pseudocysts or abscesses. Since most resolve, aspiration and drainage is best avoided as it may precipitate infection.

Pseudocysts- In acute pancreatitis, result from organisation of peripancreatic fluid collection. They may or may not communicate with the ductal system. The collection is walled by fibrous or granulation tissue, and typically occurs 4 weeks or more after an attack of acute pancreatitis. Most are retrogastric. 75% are associated with a persistant mild elevation of amylase. Investigation is with CT, ERCP and MRI or Endoscopic USS. Symptomatic cases can be observed for 12 weeks as 50% resolve. Treatment is either with endoscopic or surgical cystogastrostomy or aspiration

Pancreatic necrosis- May involve both the pancreatic parenchyma and surrounding fat. Complications are directly linked to extent of parenchymal necrosis and extent of necrosis overall. Early necrosectomy is associated with high mortality rate. Sterile necrosis should be managed conservatively. Some centres will perform fine needle aspiration sampling of necrotic tissue if infection is suspected but false negatives may occur and the extent of sepsis and organ dysfunction may be a better guide for surgery.

Pancreatic Abscess- Intra-abdominal collection of pus associated with pancreas but in the absence of necrosis. Typically occur as result of an infected pseudocyst. Transgastric or endoscopic drainage.

Haemorrhage- Infected necrosis may involve vascular structures with resultant haemorrhage that may occur de novo or as a result of surgical necrosectomy. When retroperitoneal haemorrhage occurs, Grey-Turners Sign.

Gastric MALT lymphoma ->

Mucosa associated lymphoid tissue

Associated with H pylori 95% of the time

Good prognosis

If low grade then 80% respond to H pylori eradification

Pneumaturia ->

The passage of gas mixed with urine, may be a result of a fistula between the bladder and bowel (vesico-colic fistula). Patient may present with dysuria and frequency, and describe bubbles in urine.

Diverticular Disease ->

Herniation of colonic mucosa through the muscular wall of the colon

Usual site is between the taenia coli where vessels pierce the muscle to supply the mucosa.

For this reason, the rectum which lacks taenia is often spared

Symptoms= abdominal pain, altered bowel habit, bleeding

Complications = diverticulitis, haemorrhage, development of fistula, perforation and faecal peritonitis, perforation and development of abscess, development of diverticular phlegmon

Patients presenting in clinic will typically undergo colonoscopy, CT cologram, or barium enema

Severity Classification- Hinchey

Para-colonic abscess

Pelvic abscess

Purulent peritonitis

Faecal peritonitis

Diverticular Disease treatment ->

Increased dietary fibre intake

Mild attacks of diverticulitis may be managed conservatively with antibiotics

Peri colonic abscesses should be drained either surgically or radiologically

Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative indication for segmental resection

Hinchey IV perforations (faecal peritonitis) will require a resection and usually a stoma. This group have a very high risk of post operative complications and usually require HDU admission. Less severe perforations may be managed by laparoscopic washout and dain insertion

Abdominoperoneal resection ->

For tumours that are in the distal 8cm of the rectum

Anus, rectum and distal sigmoid are removed

Remaining sigmoid is brought out to the surface as a permanent colostomy

Anterior resection ->

Tumors in the proximal part of the rectum

Removal of tumour

Remaining sigmoid is anastamosed to the lower rectum

Approach is anterior through the abdominal wall

May need to have a temporary stoma for a few months to allow the join in the rectum to heal.

Solitary rectal ulcer ->

Patients with chronic constipation and repeated straining

Must biopsy

Treatment directed at correcting the reason for the underlying constipation

Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)

Fissure in ano ->

Cause of painful rectal bleeding

Longitudinal or eliptical teats in the squamous lining of the distal anal canal

Chronic when longer than 6 weeks

Risk factors : constipation, IBD, HIV, Syphillis , herpes

DRE best when the fissure is less painful and hopefully healed

Distal to dentate line

Can have sentinel skin tag- They get their name because they “stand up” almost as if keeping guard over the site of the problem at the anal rim. They normally grow when the anal rim has been damaged and if this anal skin tag is painful it normally indicates that a problem is lurking down there that needs a doctors examination. These skin tags do not grow anywhere else – only on the anal rim apparaently. The cause needs to be fixed, and the skin tags would most likely need surgery to remove

Management acute fissure- high fibre diet and high fluid intake, bulk forming laxative ispaghula husk and methylcellulose, lubricants like petroleum jelly before defecation, topical anaesthetics,

Management chronic fissure- as acute, topical GTN, if after 8 weeks of GTN persists then surgery or botulin toxin

Crohns patients more likely to get fissure

Proctitis causes ->

Crohns

UC

C Difficile

Bleeding and nocturnal diarrhoea and incontience (signs of IBD)

Ano rectal abscess ->

Ecoli, staph aureus

Perianal, ischiorectal, pelvirectal, intersphincteric

Anal fistula ->

Usually due to previous ano rectal abscess

Can have foul smelling discharge

Patients should be listed for examination under anaesthesia

Pain in haemorrhoids ->

Feature of thrombosed extenal haemorrhoids

Uncommon with internal haemorrhoids

Malignancies ->

Anal cancer = squamous cell carcinoma#

Rectal cancer = adenocarcinoma

Emergency Hartmanns ->

Resection of rectosigmoid colon

End colostomy formed and rectal stump sewn

Indicateed by perforation of the rectosigmoid bowel and subsequent peritonism,

Causes of peritonism include diverticulitis, colon cancer, trauma

Colostomies are brought out onto the left side of the abdomen, and sewn flush with the skin

Rectal Intussceception ->

aka internal rectal prolapse

Presents with symptoms of obstructed defecation

Perform defecating proctogram

Crohn's surgery ->

Surgery does not equate to cure but may improve symptoms

Indications include strictures, fistulae, abscess formation

Extensive small bowel resections may result in short bowel syndrome and localised stricturoplasty may allow preservation of intestinal length

Complex perianal fistulae are best managed with long term draining seton sutures, as complex attempts at fistula closure (advancement flaps), may be complicated by non healing and fistula recurrence

Severe perianal an/or rectal Crohn's may require a proctectomy . Ileoanal pouch reconstruction in Crohn's carries a high risk of fistula formation and pouch failure and is not recommended

Terminal ileal Crohn's may be treated with limited ileocaecal resections

UC surgery ->

Longstanding UC is associated with a risk of malignant transformation. Dysplastic transformation of the colonic epithelium with associated mass lesions is an absolute indication for proctocolectomy

Emergency presentations of poorly controlled colitis that fails to respond to medical therapy should be managed with a sub total colectomy. Excision of the rectum is a procedure with a higher morbidity and is generally not performed in an emergency setting. An end ileostomy is usually created and the rectum either stapled off and left in situ, or if the bowel is very oedematous may be brought to the surface as a mucous fistula.

Patients with IBD have a high risk of DVT and appropriate thromboprophylaxis is mandatory

Stomas ->

Gastrostomy - Gastric decompression or fixation. Feeding. In the epigastrium

Loop jejunostomy - Seldom used as very high output. May be used following emergency laparotomy with planned early closure. In any location according to need.

Percutaneous jejunostomy- Usually performed for feeding purposes and site in the proximal bowel. Usually in the left upper quadrant.

Loop ileostomy- defunctioning of the colon eg following rectal cancer surgery. Does not decompress colon if ileocaecal valve competent. Usually in right iliac fossa.

End ileostomy- Usually following complete excision of the colon or where ileocolic anastamosis is not planned. May be used to defunction colon, but reversal is more difficult. Usually in right iliac fossa.

End colostomy- where a colon is diverted or resected and anastomosis is not primarily achievable or desirable. Either in left or right iliac fossa.

Loop colostomy- To defunction a distal segment of colon. Since both lumens are present the distal lumen acts as a vent. May be located in any region of the abdomen, depending upon colonic segment used

Caecostomy- Stoma of last resort where loop colostomy is not possible. In the right iliac fossa.

Mucous fistula- to decompress a distal segment of bowel following colonic division or resection. Where closure of a distal resection margin is not safe or achievable. May be located in any region of the abdomen according to clinical need.

Gastrografin enema ->

Involves passing water soluble radioopaque liquid into the rectum.

Then take radiographs to assess the rectum

If there are any leaks in a colorectal anastamosis, the radioopaque liquid should show up as free fluid in the abdomen.

Gastrografin is prefered to barium as it is less toxic if it leaks into the abdominal cavity

Acute cholecystitis ->

Acute cholecystitis treatment: intravenous antibiotics + early laparoscopic cholecystectomy within 1 week of diagnosis

Bowel obstruction from cancer ->

A loop colostomy is used to defunction and decompress the colon in obstructing cancers

Obstructing sigmoid cancer -Assuming the ileocaecal valve is competent, the only option for this would be a loop colostomy as a loop ileostomy would not allow decompression of the bowel.

A Hartmann's procedure would be an option to treat the tumour but it is inappropriate to do so in the context of an acute obstruction as the quality of the bowel is poor and the inflammation makes it difficult to ensure adequate resection. Furthermore, a Hartmann's procedure is irreversible and associated with a high morbidity and mortality

Lateral anal fissure ->

Look for other causes

The most common (and benign) cause of fissures is constipation and hard stools causing tearing of the anal mucosa during straining. Due to the shape of the sphincters, a fissure due to this is most likely to occur at the 6 o'clock position (90% of the time) or the 12 o'clock position.

Fissures occurring laterally are rarer and suggest a more sinister underlying pathology of which the most worrying would be anal cancer.

Inflammatory bowel disease, especially Crohn's, would be the other important differential. Given this, the only appropriate option would be to refer this man urgently to see a specialist.

Pigmented gallstones ->

Associated with sickle cell anaemia as it results in increased red cell hemolysis and thus pigmented gallstone.

Primarily made of bilirubin

Also associate with liver cirrhosis