Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

FINALSEAZY Gastroenterology Megan Hodgson Question 1 A 49-year-old man presents to the GP with A Oesophageal adenocarcinoma worsening difficulty swallowing both solids and liquids for 4 weeks. He also reports a retrosternal B Unstable Angina chest pain that can come on at rest and weight loss of 4.5kg over the last month. PMHx: Stable Angina (the patient thought this wasC Achalasia the cause, but his GTN spray does not help these symptoms). D Oesophageal stricture What is the most likely diagnosis? E Distal oesophageal spasm Question 1 A 49-year-old man presents to the GP with A Oesophageal adenocarcinoma worsening difficulty swallowing both solids and liquids for 4 weeks. He also reports a retrosternal Unstable Angina chest pain that can come on at rest and weight B loss of 4.5kg over the last month. PMHx: Stable Angina (the patient thought this was C Achalasia the cause, but his GTN spray does not help these symptoms). D Oesophageal stricture What is the most likely diagnosis? E Distal oesophageal spasm Motility condition – dysphagia of both solids & liquids concurrently Structural condition – dysphagia of solids first, dysphagia to liquids later if severe OESOPHAGEAL CONDITIONS DYSPHAGIA MOTILITY STRUCTURAL • Oesophageal Cancer • Achalasia • Distal Oesophageal Spasm • Gastrooesophageal Reflux Disease (GORD) • Oesophageal Strictures • Plummer-Vinson Syndrome • Zenker’s Diverticulum Achalasia Definition & Pathophysiology Signs & Symptoms • Failure of oesophageal peristalsis and • Progressive dysphagia of BOTH liquids & relaxation of the lower oesophageal sphincter solids (LOS) • Regurgitation of food (hours after eating, • Due to degenerative loss of ganglia from common at night) Auerbach's plexus • Heart burn • Causes: Idiopathic (most common) & • Weight loss Trypanosoma cruzi infection (Chagas disease) • History of recurrent upper respiratory tract • Risk Factors: Age <50 infections / Cough / Aspiration pneumonia Investigations Management • Diagnostic: Oesophageal Manometry • Heller Cardiomyotomy • Measures pressures at different points in the • Pneumatic (balloon) dilation oesophagus  excessive LOS tone, no • Botulinum Toxin intra-sphincter injection relaxation on swallowing • Upper GI Endoscopy (exclude malignancy) • Barium Swallow • ‘Bird beak sign’ – pooling of barium above LOS, grossly dilated taper oesophagus with fluid level Distal Oesophageal Spasm Definition & Pathophysiology Signs & Symptoms • Dysphagia • Uncoordinated contraction & relaxation of the oesophagus during • Dyspepsia (indigestion) • Chest pain peristalsis • Retrosternal • Impaired inhibitory innervation to • Intermittent oesophageal muscles • No relation to exertion • Relieved by nitrates • Precipitated by drinking cold liquids Investigations Management • Diagnostic: Oesophageal Manometry • 2+ uncoordinated contractions during 10 • Calcium channel blockers – Nifedipine (reduce amplitude of consecutive wet swallows contractions) • Upper GI Endoscopy (exclude malignancy) • ECG (exclude cardiac causes) • Nitrates (reduce spasm by • Barium Swallow gradually relaxing smooth • ‘Corkscrew appearance’ muscle) Gastrooesophageal Reflux Disease Definition & Pathophysiology Signs & Symptoms • Inflammation of the Oesophagus • Heartburn (dyspepsia) • Retrosternal, central / epigastric chest pain (oesophagitis) secondary to refluxed • Worse after meals gastric contents entering the distal • Worse on lying down / bending forwards oesophagus • Dysphagia (difficulty swallowing) • Odynophagia (painful swallowing) • Risk Factors: high BMI, stress, smoking, • Cough pregnancy, drugs (nitrates, CCB, caffeine), • Hoarseness (laryngitis) male, hiatus hernia Investigations Management • Conservative: • Type of Diagnosis: Clinical • Patient education (no eating before • Most accurate investigation: pH monitoring sleeping) • Red-flag symptoms: Upper GI endoscopy • Lifestyle modification (e.g. diet, weight loss, • Age > 55, anaemia, weight loss, anorexia, smoking cessation) • Medical: progressive/refractory symptoms, mass, • PPI (e.g. omeprazole) melaena, dysphagia, odynophagia • Antacids or H2 antagonists • Surgical: Nissen fundoplication COMPLICA TIONS OF GORD Erosive Oesophagitis Oesophageal Strictures Barrett’s Oesophagus • Most common • Scarring & • Metaplasia: squamous complication circumferential epithelium  simple • Inflammation of narrowing of distal columnar epithelium oesophagus oesophagus  • Premalignant condition – predisposes to secondary to erosion dysphagia by stomach acid • Mx: Dilation or stent oesophageal • Causes peptic ulcers, adenocarcinoma bleeding & strictures • 3-5 yearly surveillance endoscopy Oesophageal Rupture Hiatus Hernia Boerhaaves Syndrome Partial stomach herniation above the Spontaneous full thickness oesophageal tear Full thickness oesophageal break (in absence of diaphragm Risk Factors: Persistent vomiting, alcohol pre-existing pathology) 2 types: sliding (GOJ above diaphragm) & Subcutaneous crepitus – air trapped under the Cause: Iatrogenic (endoscopy) – RARE rolling (GOJ below diaphragm, with separate skin, feels like bubble wrap Signs & Symptoms: severe chest pain, vomiting, part of stomach herniating) Subcutaneous crepitus Risk Factors: Obesity, Ascites, Multiparity CXR: Pneumomediastinum Symptoms & management similar to GORD Mx: Surgical Correction OTHER OESOPHAGEAL CONDITIONS Zenker’s Diveticulum Plummer-Vinson Syndrome Cause: chronic iron deficiency anaemia Posterior outpouching of the upper pharygealconstrictor Triad: muscles through Killian’sdehiscence • Painless, Intermittent Dysphagia (due to oesophageal webs) Signs & Symptoms: Dysphagia, Halitosis, Regurgitationof • Iron Deficiency Anaemia food, Palpable neck mass • Glossitis (inflammation of the tongue) Ix: Barium swallow & dynamic video fluoroscopy, not upper Mx: Iron supplementation, Dilation of webs GI endoscopy (risk of perforation) Increased risk of Squamous Cell Carcinoma Mx: Surgical repair (if symptomatic) Question 2 An 82-year-old man represents to A&E with severe A Stool C. Difficile toxin abdominal pain and watery diarrhoea. He was discharged from hospital 8 days ago after Urea Breath Test antibiotic treatment of a hospital-acquired B pneumonia. Observations: HR 130bpm, BP 92/51mmHg, O2 C Rapid Urase Test SATS 97% on air, RR 24, Temp 38.4°C. Blood tests reveal a WBC count of 15.2 x 10 /L (4-11 9 D Stool C. Difficile antigen x 10 /L). E Endoscopy What is the most definitive investigation to determine the current most likely diagnosis? Question 2 An 82-year-old man represents to A&E with severe A Stool C. Difficile toxin abdominal pain and watery diarrhoea. He was discharged from hospital 8 days ago after antibiotic treatment of a hospital-acquired B Urea Breath Test pneumonia. Observations: HR 130bpm, BP 92/51mmHg, O2 C Rapid Urase Test SATS 97% on air, RR 24, Temp 38.4°C. 9 Blood tests reveal a WBC count of 15.2 x 10 /L (4-11 D Stool C. Difficile antigen x 10 /L). What is the most definitive investigation to E Endoscopy determine the current most likely diagnosis? C. Difficile infection often occurs after broad spectrum antibiotic use C. Difficile antigen shows exposure to the bacteria (NOT current infection) Clostridium Difficile Definition & Pathophysiology Signs & Symptoms • Clostridium difficile: gram positive rod • Watery Diarrhoea • Hospital-acquired Infection • Days-Weeks after starting antibiotics • Infection develops when normal gut flora are • Crampy Abdominal Pain suppressed by broad-spectrum abx: • Nausea • Cephalosporins (e.g Ceftriaxone) • Fever • Clindamycin • Loss of appetite / weight loss • Co-amoxiclav • Dehydration (e.g. dry mucous membranes) • Fluoroquinolones (e.g. Ciprofloxacin) Investigations Management • Supportive Care • Definitive: Clostridium difficile toxin (CDT) in Stool • 1 episode infection (mild/moderate): Sample • Oral Vancomycin • Clostridium difficile antigen shows exposure • Recurrent infection: (not current infection) • Oral vancomycin OR fidaxomicin • FBC (raised in moderate, severe or life-threatening • 2+ episodes: Faecal microbiota transplant infections) • CT Abdomen  Colitis • Life-threatening infection: • Oral Vancomycin & IV Metronidazole • Referral to specialists C. Difficile Public Health Severity Scale MILD 01 02 MODERATE Normal WCC WCC: 11-15 x 10 /L 3-5 loose stools / day SEVERE LIFE THREATENING 03 04 WCC: >15 x 10 /L Hypotension Acutely raised Creatinine (>50% above Toxic megacolonlete ileus Temperature > 38.5°C CT evidence of severe disease Evidence of severe colitis (abdominal or radiological signs) Question 3 A 54-year-old man presents to the GP with severe A Increase PPI dose burning, epigastric abdominal pain and weight gain beginning 3 weeks ago. The GP suspects a Prescribe triple eradication B peptic ulcer and refers him for a H. Pylori breath therapy test. The result returns negative. PMHx: GORD & HTN. DHx: Omeprazole, Ramipril & C Fasting Gastrin Levels Atorvastatin. D Upper GI endoscopy What is the next best course of action? E Repeat test Question 3 A 54-year-old man presents to the GP with severe A Increase PPI dose burning, epigastric abdominal pain and weight gain beginning 3 weeks ago. The GP suspects a Prescribe triple eradication B peptic ulcer and refers him for a H. Pylori breath therapy test. The result returns negative. PMHx: GORD & HTN. DHx: Omeprazole, Ramipril & C Fasting Gastrin Levels Atorvastatin. D Upper GI endoscopy What is the next best course of action? E Repeat test Patients must not take a PPI for 2 weeks or antibiotics for 4 weeks before H. pylori breath testing  False negative Peptic Ulcer Disease Definition & Pathophysiology Signs & Symptoms • An open sore that develops on the inside lining • Epigastric, Burning Pain (mucosa) of the stomach and duodenum • Relieved by eating / weight gain  • 2 types: Duodenal Ulcer • Worsened by eating / weight loss  Gastric • Duodenal ulcers (more common) Ulcer • Gastric Ulcers • Upper GI bleeding (haematemesis, melaena) • Nausea & Vomiting • Dyspepsia (heartburn) • Feeling of Fullness / Bloating Investigations Management • Conservative: Avoid triggers (e.g. NSAIDs, stress, • Urea Breath / Stool Antigen test (H. pylori) spicy foods) • Medical (if no bleeding): • MUST NOT take PPI for 2 weeks and antibiotics • H. pylori NEG: High Dose PPI for 4 weeks before testing  false negatives • Gold Standard: Upper GI endoscopy with biopsy • H. pylori POS: Triple Eradication Therapy (perform if bleeding) • Surgical: • Fasting gastrin levels & secretin stimulation test • Vagotomy (removal of vagus nerve) (Zollinger Ellison syndrome) • Subtotal Gastrectomy • Gastric ulcers: Follow-up endoscopy in 6-8 weeks → assess for malignancy ANA TOMY CAUSES Most common: H. Pylori NSAIDs Most common artery damaged in gastric ulcers: Left Gastric Artery Most common site of gastric ulcers: Other Lesser curvature of gastric antrum • Drugs (corticosteroids, SSRIs, bisphosphonates) • Stress • Zollinger-Ellison syndrome (a rare gastrin-secreting tumour resulting in increased acid production) • Burns Most common site of duodenal ulcers: • Malignancy 1 part of duodenum (superior) • Crohn's disease Most common artery damaged in duodenal ulcers: Gastroduodenal Artery • Delayed healing: Smoking & Alcohol H. Pylori Pathophysiology Management • Gram-negative spiral shaped rod • Faecal-oral transmission DRUGS • Causes 95% of duodenal ulcers 3 PPI: Omeprazole &75% of gastric ulcers 2x Antibiotics: Amoxicillin + • Risk of gastric adenocarcinoma (Metronidazole OR Clarithromycin) 2x Antibiotics (penicillin allergic): Metronidazole + Clarithromycin Investigations TIMES A DAY • Urea Breath Test 2 • MUST NOT take PPI for 2 weeks and antibiotics for 4 weeks before testing  false negatives • Patients drink radiolabeled carbon WEEK isotope 13 (13C) enriched urea  urea 1 broken down by H. pylori urease Question 4 A 62-year-old woman presents to A&E with severe A Band Ligation haematemesis and epigastric abdominal pain. She also reports her stool is very dark. On general Terlipressin & Broad-Spectrum B clinical examination, there is a palpable liver edge Antibiotics and red palms. Observations: HR 140bpm, BP 89/46mmHg, O2 C Cyanoacrylate SATS 98% on air, RR 20, Temp 37.1°C. D Endoscopic Clipping & After taking an ABCDE approach, what is the next Adrenaline best step in the patient’s management? E IV PPI Question 4 A 62-year-old woman presents to A&E with severe A Band Ligation haematemesis and epigastric abdominal pain. She also reports her stool is very dark. On general Terlipressin & Broad-Spectrum B clinical examination, there is a palpable liver edge Antibiotics and red palms. Observations: HR 140bpm, BP 89/46mmHg, O2 C Cyanoacrylate SATS 98% on air, RR 20, Temp 37.1°C. D Endoscopic Clipping & After taking an ABCDE approach, what is the next Adrenaline best step in the patient’s management? E IV PPI Variceal Bleed: Terlipressin & Broad- spectrum antibiotics → Endoscopy Non-Variceal Bleed: Endoscopy  IV PPI Upper GI Bleed Pathophysiology Signs & Symptoms • Bleeding from a source within the GI system • Haematemesis (proximal cause) proximal to the ligament of Trietz • Coffee ground vomit (more distal • Causes: • Oesophageal: varices, mallory-weiss tear, cause, e.g. peptic ulcer) oesophagitis, malignancy • Melaena • Gastric: bleeding ulcer, gastritis, malignancy • Duodenal: bleeding ulcer, duodenitis, • Fresh blood in stool (fast transit) aortiduodenal fistula Investigations Diagnosis • Glasgow Blatchford Score • Diagnostic & Therapeutic: Upper GI • PRE-ENDOSCOPY Endoscopy • Identify which patients with upper GI bleeding • Raised Urea (blood contains proteins, require medical intervention (e.g. endoscopy, blood transfusion) and should be admitted broken down as food by gut bacteria) • 1 of more = Inpatient setting • Anaemia • Rockall Score • Hypotension • POST-ENDOSCOPY • Risk of mortality & re-bleeding post-endoscopy Upper GI Bleed ABCDE Approach Calculate Glasgow Blatchford Score Non-Variceal Bleed Variceal Bleed (e.g. Bleeding Peptic Ulcer) PRE-Endoscopy: terlipressin & Upper GI Endoscopy: • Endoscopic Clipping broad-spectrum abx • Thermal coagulation ± adrenaline • Sclerotherapy + adrenaline Upper GI Endoscopy: • Oesophageal: Band Ligation • Gastric: Cyanoacrylate POST-Endoscopy: IV PPI If Fails: TIP(transjugular intrahepatic portosystemic shunt) Secondary Prevention: Propranolol Question 5 A 46-year-old female is being investigated for liveA ERCP for Stone Removal metastases of her breast cancer using an abdominal ultrasound. The ultrasound was Emergency Laparoscopic reported normal, except for 3 gallstones visible B cholecystectomy 2 within her gallbladder. Her BMI is 32kg/m . She is otherwise well. C Observation What is the most appropriate management of the Elective Laparoscopic D gallstones? cholecystectomy E Colestyramine & Ursodeoxycholic acid Question 5 A 46-year-old female is being investigated for liverA ERCP for Stone Removal metastases of her breast cancer using an abdominal ultrasound. The ultrasound was Emergency Laparoscopic reported normal, except for 3 gallstones visible B cholecystectomy 2 within her gallbladder. Her BMI is 32kg/m . She is otherwise well. C Observation What is the most appropriate management of the Elective Laparoscopic D gallstones? cholecystectomy E Colestyramine & Ursodeoxycholic acid Many people have asymptomatic gallstones, these do not require active treatment Biliary System Pathologies Risk Factors for Gallstones: 5 Fs FEMALE Abdominal ultrasound is the 1 line investigation for biliary system FAT pathologies FORTY FAIR FERTILE Acute Cholecystitis • Acute inflammation of the gallbladder • Most common cause: impaction of gallstone at cystic / common bile duct • RUQ continuous pain, nausea • FEVER (systemic upset), NO jaundice • MURPHY’S SIGN POSITIVE • Raised inflammatory markers (WCC, CRP) • Mx: IV Abx & Laparoscopic cholecystectomy within 2 days of diagnosis Biliary Colic Gallstone Ileus • Presence of gallstones in the • Small bowel obstruction caused by gallbladder (no infection or an impaction of a gallstone within inflammation) the lumen of the small intestine • RUQ colicky pain, following a fatty • Cause: Fistula between a gangrenous meal gallbladder and the duodenum • NO FEVER (systemically well) (cholecystoenteric fistula) • NO raised inflammatory markers • Abdominal pain & distension, (WCC, CRP) vomiting • Mx: Analgesia, Elective laparoscopic • AXR: SBO (dilated small bowel), air in cholecystectomy within 6 weeks the biliary tree (pneumobilia) Ascending Cholangitis Primary Sclerosing Cholangitis • Inflammation and fibrosis of both • Bacterial infection of the biliary tree • Most common causative agent: E. intra- and extra-hepatic bile ducts coli • Risk Factors: Ulcerative Colitis • Causes: Gallstones, post-ERCP • Charcot’s triad of cholangitis: RUQ pain, Fever, Jaundice • Charcot’s triad: RUQ pain, Fever, • Pruritis, Fatigue Jaundice (+ hypotension & confusion in Reynold’s Pentad) • ERCP: ‘beads on a string’ appearance • Mx: IV Abx, Urgent ERCP for stone • Mx: Colestyramine & Fat soluble removal vitamin supplementation (A,,D, E, K) Primary Biliary Cholangitis • An autoimmune condition causing destruction of the intralobular ducts in the liver • Risk Factors: Female, middle-age, other autoimmune conditions • Causes Obstructive Jaundice & Liver cirrhosis • RUQ pain, generalised pruritis, pale stools, dark urine • M Rule: Middle aged female, Raised IgM, anti-mitochondrial antibodies • Mx: Ursodeoxycholic acid (UDCA), Colestyramine, Fat soluble vitamin supplementation (A,,D, E, K) Question 6 A 23-year-old female presents to the GP with A Examination for extra- intestinal symptoms crampy abdominal pain, which is relieved by defecation and worsened when she eats. She also Presence of defecation-related B experiences mucus in her stools, and her stools abdominal pain have been predominantly looser than previously. The GP wants to rule out IBD before giving a C PR examination diagnosis of IBS. D Tissue transglutaminase IgA What investigation can be used to differentiate antibodies between these diagnoses? E Faecal Calprotectin Question 6 A 23-year-old female presents to the GP with A Examination for extra- intestinal symptoms crampy abdominal pain, which is relieved by defecation and worsened when she eats. She also Presence of defecation-related B experiences mucus in her stools, and her stools abdominal pain have been predominantly looser than previously. The GP wants to rule out IBD before giving a C PR examination diagnosis of IBS. D Tissue transglutaminase IgA What investigation can be used to differentiate antibodies between these diagnoses? E Faecal Calprotectin FBC, CRP/ESR & Faecal Calprotectin are elevated in IBD and not IBS Irritable Bowel Syndrome (IBS) Definition & Pathophysiology Signs & Symptoms • A chronic functional GI disorder characterised by • Chronic Abdominal pain • Crampy chronic abdominal pain and altered bowel habits • Relieves with defecation (i.e. constipation / diarrhoea) • 3 types of IBS: • Better at night • IBS C – Constipation predominant • Triggered by eating certain foods or stress • IBS D – Diarrhoea predominant • Bloating • Change in Bowel Habit (Diarrhoea / Constipation) • IBS M – Mixed picture • Mucus in stool • Risk Factors: Young adult, Anxiety, Depression, • Change in stool frequency Stress • Straining, urgency or incomplete evacuation Investigations Management • Conservative: Diagnosis of Exclusion • Remove trigger foods, Regular small meals, limit caffeine & alcohol, reduce processes foods & adequate fluid intake • Differentiation between IBS & IBD: Faecal • FODMAP (Fermentable oligo-, poly-, di, mono- Calprotectin saccharides and polyols) diet - reduce inflammation • Faecal calprotectin present in intestinal • Medical: • Abdominal Pain: Antispasmodics (e.g. Buscopan), inflammation (protein found in neutrophils) Antidepressants (e.g. SSRI) • Inflammatory markers (FBC, CRP)  Normal • Diarrhoea: Low fibre diet, Loperamide • Coeliac Screen • Constipation: High fibre diet, bulk-forming laxatives (e.g. Fybogel) Question 7 A 24-year-old female with known Ulcerative ColitisA PR Mesalazine presents to A&E with increasing bowel movements (7 per day) with visible blood in her B Oral Mesalazine stool. Observations: HR 108bpm, BP 122/89mmHg, O2 SATS 98% on air, RR 19, Temp 37.9°C. C Oral Prednisolone What is the most appropriate management of this D Oral Hydrocortisone patient? E IV Hydrocortisone Question 7 A 24-year-old female with known Ulcerative Colitis A PR Mesalazine presents to A&E with increasing bowel movements (7 per day) with visible blood in her Oral Mesalazine stool. B Observations: HR 108bpm, BP 122/89mmHg, O2 SATS 98% on air, RR 19, Temp 37.9°C. C Oral Prednisolone What is the most appropriate management of this D Oral Hydrocortisone patient? E IV Hydrocortisone A severe UC flare is classified by 6+ bowel movements a day & systemic symptoms A severe flare of UC requires admission to hospital & IV Hydrocortisone Ulcerative Colitis (UC) Definition & Pathophysiology Signs & Symptoms • An inflammatory bowel disease (IBD) causing • Bloody diarrhoea inflammation of the rectum & colon • Abdominal pain (LLQ) • Relapsing-remitting course • Fever • Most commonly affected site: Rectum • Superficial inflammation (mucosa & sub-mucosal • Weight loss involvement only) • Fatigue (due to anaemia) • Continuous inflammation extending proximally from • Urgency • Tenesmus rectum • PSC  Pruritis, fatigue, liver cirrhosis signs • Smoking is protective in UC • No oral or peri-anal involvement Investigations Types of UC • 1 line: Faecal calprotectin (↑) • Proctitis  rectum • Colonoscopy with biopsy • Proctosigmoiditis  • Microscopic Findings: Decreased Goblet Cells, rectum & sigmoid Crypt Abscesses • Distal Colitis  rectum, • Macroscopic Findings: Superficial inflammation, sigmoid, descending colon Erythematous mucosa, Deep ulceration, • Extensive colitis majority of colon Pseudopolyps • CT during acute flares • Pancolitis  all of colon • Raised leukocytes (during flare) Severity of UC Flare (T ruelove & Witt’ s Criteria) MILD MODERATE SEVERE Bowel Movements <4 4-6 >6 Blood in Stool NONE / SMALL MODERATE / SEVERE VISIABLE BLOOD Pyrexia (>37.8°C) NO INTERMEDIATE YES Tachycardia NO INTERMEDIATE YES Anaemia NO INTERMEDIATE <105g/L ESR ≤30 INTERMEDIATE >30 Management of UC Maintaining Remission Inducing Remission Mild-Moderate Flare Proctitis / Proctosigmoiditis Proctitis / Proctosigmoiditis / Distal Colitis Topical Mesalazine (ASA) ± oral Mesalazine Topical Mesalazine (ASA) + oral Mesalazine (if topical tx alone fails) Distal colitis / Extensive Colitis / Pancolitis Extensive Colitis / Pancolitis Low dose oral Mesalazine (ASA) Topical Mesalazine (ASA) + high dose oral After severe relapse OR ≥2 exacerbations in past year Mesalazine + oral prednisolone (if above fails) Oral Azathioprine or Mercaptopurine Severe Flare Admit to Hospital ABCDE approach High Dose IV hydrocortisone If no improvement within 72 hours: • Ciclosporin • Infliximab • Surgery Crohn’s Disease Definition & Pathophysiology Signs & Symptoms • Non-Bloody diarrhoea – most common symptom in • An inflammatory bowel disease (IBD) causing adults inflammation throughout the GI tract (mouth  anus) • Relapsing-remitting course • Abdominal pain (RLQ) – most common symptom in • Most commonly affected site: Terminal ileum children • Transmural inflammation (full thickness) • Fever • Skip lesions • Weight loss • Fatigue (due to anaemia) • Smoking worsens Crohn’s disease • Malabsorption  vitamin deficiencies • Rectum typically spared • Perianal disease (skin tags, fissures, fistulae, abscesses) Management Investigations st • Conservative: Smoking cessation • 1 line: Faecal calprotectin (↑) • Medical (Maintaining remission): • Colonoscopy with biopsy • Azathioprine / Mercaptopurine (check TPMT) • Microscopic Findings: Increased Goblet Cells, Non- • Medical (Inducing remission): caseating granuloma, Lymphoid Hyperplasia • Elemental diet • Macroscopic Findings: Transmural Inflammation, • Budesonide → Oral Prednisolone → IV Skip lesions, Cobblestone appearance to mucosa, Hydrocortisone Fistulas, Strictures • Extensive disease: Infliximab • CT during acute flares • Surgical: NOT curative • Raised leukocytes (during flare) • Only localized disease or complications (strictures, fistulas) Ulcerative Colitis Microscopic Findings: • Decreased Goblet Cells • Crypt Abscesses Macroscopic Findings: • Superficial inflammation (mucosa & submucosa only) • Erythematous mucosa •iIncreased Goblet Cells • Deep ulceration • Non-caseating granuloma • Pseudopolyps VS • Lymphoid Hyperplasia Macroscopic Findings: • Transmural Inflammation • Skip lesions • Cobblestone appearance to mucosa • Fistulas • Strictures Crohn’s Disease ULCERA TIVE COLITIS CROHN’S DISEASE • Age: Any age • Age: 15-35 years • Site: Colon only (rectum most common) • Site: Anywhere along GI tract (terminal • Pattern: Continuous inflammation ileum most common) (extends proximally from rectum) • Pattern: Skip lesions • Course: Relapsing-Remitting • Course: Relapsing-Remitting • Distal GI tract: Rectal involvement • Distal GI tract: Anal involvement • Extra-articular manifestations: PSC, • Extra-articular manifestations: Gallstones, Autoimmune hepatitis, Uveitis Renal stones, Episcleritis • Smoking: Protective • Smoking: Harmful Question 8 A 61-year-old man presents to A&E with diffuse, A Raised WBC intermittent abdominal pain that began suddenly this afternoon. B Decreased WBC Clinical Examination: Patient is writhing in severe pain. Quiet Bowel sounds. PMHx: HTN, Type 2 DM C Raised Lactate Social Hx: 50-year pack history An ECG reveals an irregular R-R interval. BaselineD Decreased Hb bloods are taken during the patient’s work up. What is the most likely finding seen on blood E Raised Hb results? Question 8 A 61-year-old man presents to A&E with diffuse, A Raised WBC intermittent abdominal pain that began suddenly this afternoon. Decreased WBC Clinical Examination: Patient is writhing in severe B pain. Quiet Bowel sounds. PMHx: HTN, Type 2 DM C Raised Lactate Social Hx: 50-year pack history An ECG reveals an irregular R-R interval. Baseline D Decreased Hb bloods are taken during the patient’s work up. E Raised Hb What is the most likely finding seen on blood results? Ischaemic Bowel raises lactate levels. Patients will be in pain out of keeping with clinical findings. ISCHAEMIC BOWEL Ischaemic Colitis Acute Mesenteric Chronic Mesenteric Ischaemia Ischaemia • Acute, transient • Narrowing / blockage of • ‘Intestinal angina’ compromise in the blood arteries supplying blood to • Risk Factors: AF, Smoking, flow to the large bowel bowel Diabetes, MI, HTN, Structural, • Risk Factors: AF, Age, CVD Heart defects, • Risk Factors: AF, Smoking, • Causes: thrombus, embolus Hypercholesterolaemia MI, Vasculitis, HTN, Structural • Most common site of • S&S: Diffuse, colicky, heart defects occlusion: SMA • Most common site: intermittent abdominal pain ‘Watershed’ areas – splenic • S&S: Severe, diffuse, sudden (worse after eating), weight loss flexure abdominal pain (out of proportional to clinical • S&S: Intermittent, diffuse, findings), PR bleeding, Quiet sudden abdominal pain (out bowel sounds of proportional to clinical • CT angiogram  findings) hypoperfusion • AXR: thumbprinting • ABG: Metabolic acidosis & raised lactate (mucosal oedema / • Mx: IV fluid, High dose LMWH, haemorrhage) • Mx: Supportive Immediate Laparotomy surgery Question 9 A 49-year-old female is undergoing an abdominal A Battle examination at the GP to investigatenew abdominal pain. Upon inspection, a straight scar is B Lanz seen in the RUQ of her abdomen. On questioning, she reveals to you she had her gallbladder removed openly a few years ago. C Gridiron What is the name of the scar she has? D Kocher’s E McEvedy’s Question 9 A 49-year-old female is undergoing an abdominal A Battle examination at the GP to investigate new abdominal pain. Upon inspection, a straight scar is B Lanz seen in the RUQ of her abdomen. On questioning, she reveals to you she had her gallbladder removed openly a few years ago. C Gridiron What is the name of the scar she has? D Kocher’s E McEvedy’s There are many different types of abdominal scars which can indicate which previous surgery has been undertaken • Commonest incision • Use: Access most intra-abdominal structures Midline • Avascular linea alba, minimal muscle fibre damage Abdominal Incisions • Layers: skin, Camper’s fascia, Scarpa’s fascia, linea Incision alba, transversalis fascia, extraperitoneal fat, peritoneum Paramedian • Parallel to midline, 3-4cm in length • Layers: anterior rectus sheath, rectus muscle, Incision extraperitoneal fat, peritoneumersalis fascia, • Diagonal line • Similar distance from midline incision as Battle paramedian incision • Not used commonly today • Incision under right subcostal margin Kocher’s • Use: Open Cholecystectomy & access liver / biliary tree • Horizontal Incision in right iliac fossa • Use: Open Appendicectomy Lanz • Cosmetically subtle • Oblique Incision over McBurney’s point Abdominal Incisions Gridiron • Use: Open Appendicectomy • Less cosmetically subtle than Lanz • Rooftop Incision along subcostal margins Gable • Use: access oesophagus, stomach & liver • Transverse suprapubic incision • Use: access pelvic organs, Radical open Pfannenstiel’s prostatectomy, cystectomy, C-section • Oblique Groin Incision McEvedy’s • Use: Emergency repair of strangulated femoral hernia • Curved LLQ incision Rutherford • Use: Access to LLQ & RLQ (e.g. ascending colon, iliac vessels), Renal Morrison transplantation Ileostomy Colostomy • A surgical diversion of the small • A surgical diversion of the large intestine to an artificial opening on intestine to an artificial opening on the abdomen the abdomen • Location: Right Iliac Fossa • Location: Left side of abdomen • Appearance: Spouted (variable) • Output: Liquid • Appearance: Flushed • Output: Solid Right Hemicolectomy • Pathology site: Caecal, ascending or proximal transverse colon GI Surgeries • Anastomosis: Ileo-colic Left Hemicolectomy • Pathology site: Distal transversecolon, descending colon • Anastomosis: Colo-colonic High Anterior Resection • Pathology site: Sigmoid colon • Anastomosis: Colo-rectal Anterior Resection • Pathology site: Upper rectum • Anastomosis: Colo-rectal Low Anterior Resection • Pathology site: Low rectum • Anastomosis: Colo-rectal Abdominoperineal excision of rectum • Pathology site: Anal verge • Anastomosis: NonePLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK