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What are the drug causes of constipation?
- opiates
- aluminium hydroxide
- iron
- anticholinergics: tricyclics, phenothiazines
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name 3 anorectal causes of constipation
- anal fissure
- anal stricture
- rectal prolapse
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what are general lifestyle causes of constipation?
- poor diet
- reduced fibre
- reduced fluid intake or dehydration
- low activity levels
- IBS
- old age
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name some hospital causes of constipation
- post op pain
- hospital environment: lack of privacy, having to use a bed pan
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name some causes of intestinal obstruction that will cause constipation
- colorectal carcinoma
- benign stricures: crohn's
- diverticulosis
- pelvic mass - fetus of fibroids (uterine aka leiomyoma)
- pseudo obstruction
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what are the neuromuscular causes of constipation?
- Hirschprung's disease
- Chagas disease
- Diabetic neuropathy
- Systemic sclerosis
- Spinal or pelvic injury - trauma or surgery
-
what are the metabolic or endocrine causes of constipation?
- hypothyroidism
- hypercalcaemia
- hypokalaemia
- porphyria
- lead poisoning
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how does carcinoma of the caecum usually present?
- insidious way
- microcytic anaemia
- weight loss
- ache or palpable mass in RIF
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what are typical features of IBS?
- young patient
- stress or dietary intolerance
- alternating constipation and diarrhoea
- cramp like abdo pains relieved by defaecation
- abdo bloating
- mucus PR
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how would you manage IBS? stepwise
- 1. exclude other diagnosis: RBC, ESR, LFT, coeliac serology, urinalysis, sigmoidoscopy, rectal biopsy if YOUNG
- 2. if over 45 and other marker of organic disease then do colonoscopy
- 3. if diarrhoea prominent do LFT, stool culture, TFT, B12/folate, anti endomysial, barium follow through if small bowel disease, rectal biopsy
- if IBS explain and reassure
- food tolerance: exclusion diets
- constipation: incerase fibre intake ispaghula, methylcullulose NB non fermentable fibre better as less gas and bloating (i.e. don't give lactulose)
- diarrhoea: loperamide after each loose stool
- colic and bloating: anti spasmodics - mebeverine
- dyspeptic symptoms: metocloperamide or antacids
- psychological: TCA amitriptyline may help but SE dry mouth, constipation..
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where is sigmoid volvulus more common? what diet?
- equatorial countries
- high fibre
-
presentation of sigmoid volvulus?
- pain
- bloating
- emergency sometimes
-
what does plain AXR look like of sigmoid volvulus?
large double colonic loop like COFFEE BEAN
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how do left sided colonic tumours present as opposed to R? why? 2 reasons
- OBSTRUCTION!
- because L has more narrow calibre of colon
- and more solid consistency of faeces as fluid has been absorbed
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what would AXR look like of sigmoid colon cancer?
- gross faecal loading proximal to cancer
- absence of bowel gas distally
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how does UC usually present?
- 30s
- chronic low grade illness
- bloody diarrhoea
- abdo pain
- fever
- extracolonic: arthritis, iritis, liver probs, rash
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how would you differentiate acute cholecystitis from biliary colic?
- AC has fever, sometimes rigors, SEVERE RUQ pain, positive murphys sign
- note if jaundice then must urgent US check GS in CBD as risk cholangitis
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An 83-year-old man presents following a collapse. He is not tachycardic but has a postural drop in blood pressure. He has mild epigastric discomfort. You note he has a history of arthritis and hypertension. diagnosis?
- bleeding peptic ulcer
- arthritis so on NSAID so bleed - hypovol - postural drop BP
- why not tachycardic? as on a blockers for HTN
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what is the differential diagnosis for acute appendicitis?
- APPENDICITIS
- appendicitis
- PID or period (Mittelschmerz - painful ovulation in middle of cycle)
- pancreatitis, perf peptic ulcer
- ectopic pregnancy
- neoplasia
- diverticulitis
- IBS
- Cyst
- IBD - crohns
- Torsion ovary
- Intussussception
- Stone
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name 4 conditions or RF predispose to oesophageal cancer and why?
- plummer vinson: IDA and oes web causing dysphagia its premalignant
- achalasia: prolonged stasis contributes to mucosal changes
- male
- reflux oesophagitis: Barrett's oesophagus
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what are the complications of diverticular disease and how do they present?
- haemorrhage: profuse bright red rectal bleed, NOT precipitated by defaecation
- fistula due to per and abscess of inflamed diverticulum
- skin fistula
- bladder fistula: pneumaturia - air in urine
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what are pseudopolps and which disease are they a feature of?
- areas of inflamed oedematous and swollen mucosa NEXT to the ulcerated areas of colon
- ulcerative colitis
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name 3 conditions that cause fistula in ano?
- Crohn's disease - confirm by biopsy
- anorectal tumour
- leukaemia patients have inc risk anorectal disorders esp. fissure in ano and fistula in ano
-
what is the incidence of gastric adenocarcinoma like worldwide?
- generally marked decrease in incidence (due to treating H pylori?)
- but increase at GOJ (Barrett's?)
- common in Japan
-
what are the associations for gastric adenocarcinoma?
- blood group A
- lower social class
- H pylori
- atrophic gastritis
- pernicious anaemia
- adenomatous polyps
- smoking
-
name 3 pathological types of gastric adenocarcinoma:
- polypoid
- ulcerating
- linitis plastic (leather bottle)
- n.b. if confined to mucosa and submucosa then its 'early'
-
what are the symptoms of gastric adenocarcinoma?
- dyspepsia (above 50y and longer than 1 month)
- dysphagia
- weight loss
- anaemia
- vomiting
-
what are the signs of gastric adenocarcinoma?
- epigastric mass
- Virchow's node: large left supraclav node (trosier's sign)
- hepatomegaly - mets
- jaundice
- ascites
- acanthosis nigricans
-
spread of gastric adenocarcinoma?
- local
- lymphatic
- blood
- transcoelomic to ovaries = Krukenberg tumour
-
investigations for gastric adenocarcinoma?
- 1. gastroscopy and multiple biopsies around ulcer edge
- NB malignant ulcers may appear to heal on drug treatment
- 2. staging: EUS, CT, MRI
-
treatment of gastric adenocarcinoma?
- if tumour in distal 2/3: partial gastrectomy
- proximal tumour: total gastrectomy
- chemo:epirubicin, cisplatin, 5-FU
- palliative: for obstruction, pain or haemorrhage
-
what are the early complications of stomas?
- haemorrhage at stoma site
- dermatitis: effects of contents of stoma or due to contact dermatitis from allergy to adhesive appliance
- high output: fluid and electrolyte loss esp. ileostomy
- obstruction due to adhesions
- stoma retraction
- stoma ischaemia - change in colour to black
-
what are the late complications of stomas?
- parastomal hernia
- psychological probs
- prolapse of stoma
- fistulae
- dermatitis
- renal calculi: high ileostomy losses - met acid and low urine volume
- cholesterol GS: if loss of TI - interrupt enterohepatic circ of bile salts
-
which part of the bowel does diverticular disease commonly affect?
sigmoid colon
-
what is the treatment for acute diverticular disease?
- hospitalisation
- rest
- analgesia - avoid morphine as it increases muscle spasm
- antibiotics: metronidazole
- surgery rarely needed acutely
- bleeding normally stops spontaneously and doesn't need treatment
-
what are the complications of gastric surgery?
-
which type of GS are associated with bacteria in the bile?
pigment rather than cholesterol
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