Lower GI Conditions - Weebly

Lower GI Conditions - Weebly

Lower GI Conditions Dr. Nishan Silva (MBBS) Lower GI Bleeding Lower GI Bleeding A common presentation Arises from: Small Intestine, Colon, Rectum, Anus 3 categories Occult bleeding FBC Low Hb or +FOB Moderate bleeding PR Blood (fresh, mixed with stools or dark) Acute Massive Bleeding (rare) Large Vol. (Fresh PR) Start and stop spontaneously Haemodynamically unstable Shock A Surgical Emergency! ABCs OHCM 7th Ed p589

A typical scenario A 68-year old Glaswegian man presents to A+E with a 3 day history of rectal bleeding and lower abdominal pain. On enquiry, he admits to change in bowel habit with recent episodes of constipation and weight loss over the past 3-4 months. He has no past medical or surgical history, is a former smoker of 30 cigs/day for 26 years and does not drink alcohol. Causes of Lower GI bleeding

Colorectal Cancer IBD (UC, Crohns Disease) Diverticulosis Colonic Polyp(s) Rectal Varices Haemorrhoids Anal Fissure Rectal Prolapse Infective diarrhoea Angiodysplasia Ischaemic Colitis A Good History Age

PR Blood (and Mucus) Colour Type of Blood Quantity Previous episodes of PR bleeding Abdominal Pain or Tenderness Associated Anal pain +/- Defecation Altered Bowel habit Stool Frequency & Consistency Diarrhoea/Constipation/Both Tenesmus Anorexia and Weight Loss Dizziness, Collapse

A Good History PMHx: Gastric Ulcer, IBD, Cancer Metastases Drug Hx: Aspirin, Warfarin, Steroids, Iron for IDA Family Hx: Crohns, UC, Bowel Ca, Polyps, FAP Social Hx: Alcohol intake, Smoker, Anal Intercourse Systemic Enquiry: Mouth ulcers Eye problems Skin changes Joint pains Inspection

Examination Breathlessness, Jaundice, Cachexia Shock? Finger clubbing Signs of Anaemia (Conjunctival pallor, Koilonychia) Mouth Ulcers, Angular Stomatitis in IDA Scars, Stomas Abdominal distension Palpation Abdominal Tenderness or Pain (LIF Div, RIF Crohn/Caecal Ca) Mass felt with examining hand Hepatomegaly Liver Mets

PR exam Haemorrhoids, Prolapse, Fissures or Fistulas Palpable mass per rectum (up to 7cm) Stool colour/consistency Blood on examining finger Investigations FBC Ferritin & iron studies U+Es LFTs CRP Glucose Coagulation Screen

Group & Save If extensive bleeding Proctoscopy/Sigmoidoscopy Colonoscopy +/- Biopsy or Barium Enema Others: Upper GI Endoscopy (Melaena) Angiography (Mesenteric bleeding) Tc99 Red cell scan (GI Bleeding & Meckels)) Lower GI Bleeding

A few examples: Colorectal Cancer Inflammatory Bowel Disease (Ulcerative Colitis & Crohns disease) Others: Diverticulosis, Haemorrhoids, Anal Fissures, Fistula in Ano.... Sample EMQs Colorectal Cancer 3rd commonest malignancy in UK M:F = 3:1 peak age 45-70yo

Risk Factors: FH of Colorectal Ca, FAP, HNPCC, Prev Hx of Colon,Breast, Ovarian or Uterine Ca Prev Hx of Adenomatous Polyps Chronic UC or Colonic Crohns disease Western diet, Obesity, Smoking Presentation depends on site: *Taken from: Oxford Handbook of Clinical Medicine 7th Edition p613 Left-sided:Altered bowel habit (constipation & diarrhoea), PR bleeding bright red

coating the stool, Tenesmus, Painful defecation? Small diameter of Left Colon Tendency towards obstruction Right-sided: Present later. Weight loss, Right abdo pain/mass, Tendency to bleed, Blood mixed in with stools, high incidence of IDA Emergency (40%): Obstruction, Perforation w/Peritonitis, Acute Haemorrhage Colorectal Cancer Investigations:

FBC Microcytic hypochromic anaemia, LFTs deranged with hepatic spread + Faecal occult blood Sigmoidoscopy/Colonoscopy + biopsy Lesion (w/ 3-5% synchronous) Barium Enema may show Apple core appearance CT/MRI for rectal cancers, local pelvic spread and metastasis Liver US Hepatic Mets Raised Carcino-embryonic antigen (CEA) used for monitoring Taken from: www.WebMD.com Taken from: http://radiopaedia.org/images/894115 Pathology: Adenocarcinoma (95%) Character: ulcerating, stenosing, infiltrating Colorectal Cancer

Staging: Dukes Modified Criteria (1929) & TNM Staging (1958) Dukes Modified Criteria 5yr survival % TNM Staging A Limited to mucosa 90 B1 Involves muscularis propria 70 T 1 Confined to the mucosa and submucosa T2 Invasion of muscularis propria but no extension into serosa T3 Extends into serosal - no breach or local spread B2 Penetrates through muscle, extending to

serosa and bowel wall 60 T4 Direct invasion through serosa and local structures C1 Invades muscularis propria with lymph node involvement 30 C2 Penetrates through wall into serosa with lymph node involvement 30 M0/1 Metastases not present/present D Distant Metastatic Spread

<10 T1N0M0 & T2N0M0 = Dukes A T3N0M0 & T4N0M0 = Dukes B Any T with N1 or N2 = Dukes C & Any T&N with M1 = Dukes D N0/1/2 no nodes, 1-3 nodes, >4 nodes Treatment: Surgical Resection with curative intent +/- Chemo Right Hemicolectomy Caecal, Ascending, Proximal Transverse Ca Left Hemicolectomy Distal Transverse, Descending Sigmoidectomy Sigmoid Ca

Anterior Resection Low sigmoid/High Rectal Ca Abdominoperineal (A-P) Resection Low Rectal Tumours <8cm from Anal canal permanent colostomy **Hartmanns Carcinoma w/ Acute Obstruction (excision, colostomy, rectal stump) Other options: Chemotherapy (5-FU) for Dukes B&C, RT, Palliation A. AbdominoPerineal Resection (APR) A. AbdominoPerineal Resection (APR) A. AbdominoPerineal Resection (APR) Anterior Resection Inflammatory Bowel Disease

Ulcerative Colitis A relapsing and remitting inflammatory disease originating in the colonic mucosa and submucosa. UC is limited to the colon. Begins in the rectum and can extend proximally, but rarely beyond ileocaecal junction. M = F but 2 peaks: i) 14-40 years old ii) 15% of new pts >60 years old at diagnosis Unknown Aetiology

Associated RFs: HLA-DR130 association in severe UC 60% UC pts + pANCA autoantibodies 3-4 times increased risk in Non-smokers and Ex-smokers NSAIDs and stress implicated in UC flares Ulcerative Colitis Presentation Proctitis (50%) (commonest): Urgency and high frequency of defecation (4-15/day), diarrhoea mixed with blood and mucus, rectal irritability, tenesmus. Left-sided Colitis (30%): Rectal irritation, extensive blood & mucus in stool Bloody diarrhoea. Pancolitis (20%): Diarrhoea, crampy, distended abdomen with systemic features: pyrexia, anorexia, weight loss, malaise and tachycardia. May involve appendix. Severe Pancolitis Backwash ileitis into terminal ileum

Extraintestinal features: A PIE SAC Complications of UC: Perforation, Haemorrhage, Toxic Megacolon (hypotonic, grossly distended bowel > 5cm) Colorectal Ca & death if complication sinadequately treated Extraintestinal Manifestations in IBD A PIE SAC Aphthous Ulcers (CD only)

Pyoderma Gangrenosum I (Eye): Iritis,Uveitis, Episcleritis, Conjunctivitis (CD>UC) Erythema Nodosum (Primary) Sclerosing Cholangitis (pANCA UC>CD) / Sacroilitis

Arthritis (HLA-B27: AnkSpo) Clubbing of Fingers (CD>UC) Taken from: http://surgery.med.umich.edu/pediatric/clinical/physician_content/n-z/ulcerative_colitis.shtml Ulcerative Colitis Investigations:

FBC Low Hb due to blood loss, Raised WCC & Platelet count U+Es hypokalaemia due to mucus loss Raised CRP & ESR Low Albumin espec. during inflammation Stool Microscopy, Culture & Sensitivity Taken from: www. ulcerativecolitistreatment.net Taken from: web2.airmail.net/uthman/specimens/images/uc.htm l Barium enema indicates disease extent. Chronic UC: loss of haustrations, rigidity & shortening of colon Lead-pipe appearanceLead-pipe appearance. Excludes toxic megacolon in severe UC. Colonoscopy + Biopsy Inflamed, easily bleeding mucosa in rectum/distal colon. Inflammation limited to the mucosa with crypt distortion & abscess. Chronic UC Pseudopolyp formation. Taken from: www. Radiopedia.org

http://web2.airma Ulcerative Colitis Treatment aims: Induce disease remission & maintain remission and disease symptoms Medical Therapy Correct anaemia, hypokalaemia, hypoalbuminaemia, Corticosteroids: Oral Prednisolone induces remission. IV Hydrocortisone used in severe flares of colitis - Long-term avoided. Sulfasalazine or Mesalazine (5-ASA metabolites) have anti-inflammatory effect to induce remission. Also Rectal suppositories for distal colitis Azathioprine, 6-mercaptopurine immunosupression to prevent disease relapse or in cases of intolerance to steroids Anti-TNF Infliximab good in moderate-severe UC

Surgery indicated when: Acute colitis fails to respond to medical Tx. Chronic Colitis persists despite treatment, unacceptable Tx SEs, developmental delay, poor quality of life. Toxic megacolon (within 24hrs) Partial or Total Colectomy with Ileostomy usually cures Crohns Disease Chronic transmural inflammatory GI Disease which is non-caseating & granulomatous in nature. Associated with recurrence in severe disease and extraintestinal manifestations.

Can affect any portion of GI tract Termimal Ileum (50%) & Proximal Colon common. Inflammation is discontinuous and separated by normal gut mucosa (skip lesions). M = F affects any age but majority of cases between 11-35 years old Unknown aetiology. Commonest in White Anglo-Saxon & Ashkenzai Jews Associated Risk Factors:

CARD 15/NOD-2 mutations Family Hx of Crohns or UC Altered cell mediated immunity abnormal Th1 activity (IL-2, IFN-)) x3-4 risk in Smokers High sugar, low-fibre diet Crohns Disease Presentation Variable & dependent on site Diarrhoea, Abdominal Pain + Tenderness (terminal ileitis), RIF mass (inflamed bowel or abscess), Perianal abscesses/ fistulae/skin tags. Weight loss, malaise, fever occur in active disease. Failure To Thrive in children NB: Rectal bleeding less common in CD than UC

Extraintestinal signs: Aphthous ulcers,Uveitis, Iritis , pyoderma gangrenosum, erythema nodosum, polyarthritis, ankylosing spondylitis, sacroilitis Complications in CD: Full-thickness mucosal inflammationStrictureSmall bowel obstruction Abscess formation between loops of intestine Perforation Fistula formation: Enteroenteric, Enterocutaneous and Vesicocolic Investigations:

Crohns Disease FBC Low Hb (Vit B12 def., blood loss), High WCC Raised CRP & ESR Low Albumin due to malabsorption Stool Microscopy, Culture & Sensitivity *Taken from: James Going -SSC in Pathology IBD Lecture Taken Takenfrom: from:www. www.Learningradiology.com Flickr.com/photos/robhengxr/159283669 Barium Enema shows Kantors String sign of the terminal ileum. Also Rose-thorn ulcers Colonoscopy/Sigmoidoscopy+ Biopsy Red, oedematous thickened mucosa

with deep ulcerations and erosions, separated by normal mucosa producing a cobblestone appearance. Histology shows transmural inflammation, fissuring ulcers and non-caesating granulomas Crohns Disease Management: Medical vs Surgical Medical Mx aims to reduce inflammation & control complications. Also treat abnormal blood results eg. Anaemia Corticosteroids (Hydrocort, Predn) control inflammation exacerbations in moderate-severe disease Azathioprine or Cyclosporin immunosupression Methotrexate Anti-TNF Infliximab prevent fistula formation Metrondiazole used to treat Colonic fistulas Nutritional therapy - elemental diet to limit antigens & reduce inflamm

Surgical Mx aims to treat complications such as strictures, bowel obstruction, sepsis, perforation or fistula formation with minimal compromise to bowel. SURGERY MAY CAUSE NEW LESIONS 50-80% patients will require surgery throughout their lives Summary of other causes of Lower GI Bleeding Adapted from: Oxford Handbook of The Foundation Programme 2 nd Edition DESCRIPTION DIVERTICULAR DISEASE

(DIVERTICULOSIS) AVM in colonic submucosa Usually proximal transverse colon HAEMORRHOIDS Outpouching in bowel wall weakest point

vasa recta meet muscular propria Marfan, EhlersDanlos, Polycystic Kidney ANGIODYSPLASIA HISTORY Low fibre diet & constipation

Abdominal Pain (LIF) Sigmoid Colon PR Blood or Mucus Massive painless dark red PR Bleeding Bleeding selflimiting Tenderness (LIF) +/- Peritonism

Irregular Bowel Habit (diarrhoea constipation) Fever/Pyrexia Old Age Often Asymptomatic Recurrent & brisk Fresh Blood PR

Dilated& displaced vascular anal cushions Multiple pregancies, obese, anal sex Straining at Stool Multiple vaginal deliveries

Painless Fresh Blood on Toilet Paper or stools Perianal Itch INVESTIGATIONS & TREATMENT EXAMINATION PR Blood or Melaena

Ex may be Normal Low Hb Diverticulae on Colonscopy

Tx: High fibre diet Abx in acute disease (co-amox/metro/cipro) Surgical resection if persistent bleeding (recurrent diverticulitis, abscess/fistula/obstruction Low Hb give FeSO4

FOB+ Lesion on Colonoscopy Consider Angiography Tx: Arterial Embolisation, Endoscopic coagulation Often not Palpable on PR unless prolapsed

Perianal tags May have rectal Prolapse Haemorrhoids on Proctoscopy Tx: High fibre diet, Anusol, Sclerosant, Band ligation or Haemorrhoidectomy DESCRIPTION RECTAL PROLAPSE ANAL FISSURE ANAL FISTULAS

HISTORY Descent of mucosa or entire rectum through anus Weak rectal support lax of pelvic floor and anal sphincters due to chronic straining ++mucus PR

Usually small vol. bright red bleed Elderly, postmenopausal pts, multiple vaginal deliveries Repeated defecation (mucosal) or Incontinence (full) Something coming down

EXAMINATION INVESTIGATIONS Prolapse may be demonstrated on straining in clinic Prolapse may be ulcerated & bleeding Sigmoidoscopy mucosal inflamm Defecating proctogram if uncl

diagnosis MedMx: Stool softeners for constipation SurgMx: Rectoplex fix rectum to sacrum Children constipation, CF, whooping cough

Anal tear posteriorly May be associated with Crohns or Cancer Posterior/Anterior tear at anal margin Severe knife-like pain on defecation Sigmoidoscopy if Colorectal Ca

Deep throbbing pain Tx: High fibre diet Previous Pregnancy Hx Constipation, Straining ++

Associated: Perianal tags, ulcers, fistulae 5% lignocaine therapy PR Tenderness Fresh Blood on Toilet paper PR blood on examining

finger Botox injection Sphincerotomy Abnormal epithelial connection seen between anus and skin Surgery Fistulotomy or

Erythema Staged sphincter repair All ages Pain

Infection commonest IBD (CD>UC) Bloody or Purulent anal discharge Trauma:episiotomy, prostatectomy, anal sex Anal Ca

Anal itching Systemic symptoms if infected abscess Hemorrhoids Hemorrhoids are dilated, twisted (varicose) veins located in the wall of the rectum and anus. Hemorrhoids occur when the veins in the rectum or anus become enlarged; they may eventually bleed. Hemorrhoids may also become inflamed or may develop a blood clot (thrombus).

Etiology Most common cause - constipation Prolonged straining Pregnancy Heredity Increased intra-abdominal pressure Aging (due to thinning of supportive tissue) Internal / External Hemorrhoid Classification of Internal Hemorrhoids Grade I Seen on anoscopy, may bulge a short way into anal canal; does

not extend below dentate line Grade II Prolapses out of anal canal with straining or defecation; reduces spontaneously Grade III Prolapses out of anal canal with straining or defecation; reduces manually Grade IV Irreducible;may strangulate Prolapsed Hemorrhoid Diagnosis The diagnosis of internal or external hemorrhoids is made by inspection digital exam

direct vision through the anoscope & proctosocpe Treatment Treatment includes medical as well as surgical modalities With medical therapy, bleeding and pain usually improve over a 6 week period Medical Therapy Stool bulking agent Psyllium Methylcellulose Sitz baths probably most effective topical treatment for relief of symptoms Surgical Therapy Rubber Band Ligation One of most widely used techniques

Approximately 5-7 days after procedure the banded tissue sloughs-off Infrared Photocoagulation Laser not often used Sclerotherapy Phenol 5% Sodium tetradecyl sulfate Anal Fissure Anal Fissure and Sphincterotomy Anal Fistula Fistula in ano Fistula Types - Fistulectomy PeriAnal Abscess

Pilonidal Disease Pilonidal disease is an infection caused by a hair that injures the skin at the top of the cleft between the buttocks. A pilonidal abscess is a collection of pus at the infection site; a pilonidal sinus is a chronic draining wound at the site. Rectal Prolapse Rectal prolapse causes the rectum to turn inside out, so that the rectal lining is visible as a dark red, moist fingerlike projection from the anus. Less commonly, the rectum protrudes into the vagina Foreign Objects Surgeries and Other Procedures

Bowel anastamosis Colostomy Illeostomy Illeostomy Illeostomy Abdomino-perineal resection Whipples procedure Special considerations should be made in Bowel anastamosis 3-4 days of fasting Colostomy Reduce fibre, Reduce gas

Illeostomy Increase fibre Bowel handling Nil by mouth till bowel sounds Sigmoidoscopy / colonoscopy Low fibre for 3 days Clear liquids for one day Energy liquids Laxatives MEQs Rectal Bleeding 1) A 30 yo male with bloody diarrhoea 20 times/ day, weight loss and colonoscopy showing inflammation from the rectum to caecum

(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca

Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis MEQs Rectal Bleeding 1) A 30 yo male with bloody diarrhoea 20 times/ day, weight loss and colonoscopy showing inflammation from the rectum to caecum

(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids

Rectal proplase Diverticulosis Ulcerative colitis MEQs Rectal Bleeding 2) A 25 yo woman, 6 weeks post-partum with PR bleeding, puritis and perianal pain (a) (b) (d)

(e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis MEQs Rectal Bleeding 2) A 25 yo woman, 6 weeks post-partum with PR bleeding, puritis and perianal pain

(a) (b) (d) (e) (f) (g) (h) (i) (j)

Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis MEQs Rectal Bleeding 3) A 21 yo lady with rectal bleeding and severe pain on defecation

(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase

Diverticulosis Ulcerative colitis MEQs Rectal Bleeding 3) A 21 yo lady with rectal bleeding and severe pain on defecation (a) (b) (d) (e)

(f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis MEQs Rectal Bleeding 4) A 90 yo woman with PR bleeding and something coming down every time she defecates

(a) (b) (d) (e) (f) (g) (h) (i) (j)

Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis MEQs Rectal Bleeding 4) A 90 yo woman with PR bleeding and something coming down every time she defecates

(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids

Rectal proplase Diverticulosis Ulcerative colitis MEQs Rectal Bleeding 5) A 26 yo man presents with chronic bloody diarrhoea and RIF pain. He has lost weight recently and feels generally unwell and pyrexial. He is also complaining of joint pains and barium enema shows altered mucosal pattern with deep-fissured ulcers.

(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis

MEQs Rectal Bleeding 5) A 26 yo man presents with chronic bloody diarrhoea and RIF pain. He has lost weight recently and feels generally unwell and pyrexial. He is also complaining of joint pains and barium enema shows altered mucosal pattern with deep-fissured ulcers. (a) (b) (d) (e)

(f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis MEQs Rectal Bleeding 6) A 32 yo woman presents with rectal bleeding, which occurs post-defecation. The bleeding is bright red and painless. Endoscopy is normal.

(a) (b) (d) (e) (f) (g) (h) (i) (j)

Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids Rectal proplase Diverticulosis Ulcerative colitis MEQs Rectal Bleeding 6) A 32 yo woman presents with rectal bleeding, which occurs post-defecation. The bleeding is bright red and painless. Endoscopy is normal.

(a) (b) (d) (e) (f) (g) (h) (i) (j) Colon Ca Crohns Disease Fissure in ano Fistula in ano Gastroenteritis Haemorrhoids

Rectal proplase Diverticulosis Ulcerative colitis

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