Matthew Charnock

Sam Newton

PC

HPC

RED FLAGS

ROS

MED Hx

FH

SOCIAL Hx

73 year old female

Suffers from T2DM and Ulcerative Colitis

Presented 3/52 history of rectal bleeding

Mixed in with stool

Loose stools for past 6 weeks

Lost 2 stone in past 12 weeks

Smokes 30/day for 50 years

No abdominal pain

DVT 4 weeks ago

Bloods

Imaging

Colorectal cancer is the third most common cancer in the UK

2nd most common cause of cancer death in the UK

75% occur in people aged 65 or over

Screening in UK - FOBT

Family history

Familial Syndromes

IBD

Smoking

Poor fibre/High fat diet

Alcohol

Etc

Right sided colon cancers

Change in bowel habit , weight loss, anaemia , occult bleeding , mass in right iliac fossa, disease more likely to be advanced at presentation

Left sided colon cancers colicky pain, rectal bleeding , bowel obstruction, mass in left iliac fossa, early change in bowel habit , less advanced disease at presentation

Rectal cancers as above + tenesmus

Jaundice?

Ascites?

Chronic cough?

Abdominal pain

Bloody diarrhoea

Weight loss

Fever

Signs of anaemia

Tenesmus

Peri-anal disease

Extra-intestinal manifestations

In children – FTT, delayed puberty, malnutrition

Crohns VS Ulcerative Colitis

Bloods (FBC, LFTs, ESR/CRP, Anti-

GGT/endomysial antibodies, Iron Studies,

B12/Folate levels)

Imaging

Colonoscopy + biopsy

Barium Follow through

Abdominal xray

Smoking cessation in Crohns

Medical

5 aminosalicyclic acid derivatives

(5ASA’s – mesalazine)

Corticosteroids (in acute flare up)

Enteral nutrition

Immunosuppressants

(cyclosporin/methotraxate/azathioprine)

Cytokine modulators (infliximab)

Indications in UC

Failure of medical treatment

Toxic megacolon

Perforation

Haemorrhage

Cancer prophylaxis

Procedure

Temporary – proctocolectomy with ileoanal pouch formation

Permanent – panproctocolectomy with end ileostomy

Indications in Crohns

Strictures - strictuoplasty

Fistulas – lay open (low)/seton suture (high)

Abscess – drainage +/- Abx

Unresponsive to medical treatment - segmental resection

Intolerable long term symptoms

Site

Contents of bag

Appearance

Obese 59 year old male

No significant past medical history

Presented to GP with a 2 week history of rectal bleeding

Small amount of blood on the toilet paper after defecating

First occurred following straining on the toilet

Also itching around the back passage

No pain, no change in bowel habit, no N+V

Feels otherwise well

ROS- none

Rectal examination?

Bloods?

Imaging?

Commonest cause of rectal bleeding

Benign condition in which the venous cushions within the rectum become enlarged

RF’s - prolonged straining and time on the toilet, raised intra-abdominal pressure eg- pregnancy, obesity, heavy lifting etc

Symptoms include- rectal bleeding, rectal itching

(pruritus ani), feeling of discomfort or discharge, may feel mass, may be asymptomatic

Blood should not be mixed in, usually on toilet paper or streaks in the bowl

Classification is broken into internal and external haemorrhoids, internal above the dentate line, external below dentate line.

1 st degree- do not prolapse

2 nd degree- prolapse on defecation return spontaneously

3 rd degree- prolapse on defecation, need to be manually reduced

4 th degree- permanently prolapsed

On rectal exam, typically present at the 3,7 and 11 o clock positions

Internal haemorrhoids may be impalpable and not visible on inspection

Internal haemorrhoids should be painless

Asking the patient to bear down may reveal haemorrhoids on inspection

Important to perform to exclude other anal pathology

Conservative- increase dietary fibre, decrease time on the toilet, strain less, lose weight, laxative (for 1 st and 2 nd degree)

Non- surgical (for 3 rd

/4 th not

1.

2.

3.

1.

or 1 st

/2 nd responding to conservative)

Banding

Sclerotherapy

Infrared coagulation

Surgical (3 rd

/4 th not responding or very large)

Circular stapled haemorrhoidectomy (better than traditional)

64 year old female

PMH of IHD and PVD

Presented with a 1 month history of LIF abdominal pain, bloating and change in bowel habit- constipated

Also noticed single episode of blood mixed in with stool

Also noticed intermittent nausea although no vomiting

No pyrexia

Otherwise well

ROS- frothy urine?

O/E- patient relatively well, abdo- some tenderness in the

LIF, PR- NAD

Bloods?

Imaging?

1.

2.

3.

Herniation's of mucosa through colonic muscle

Remember terminology

Diverticulosis- ASYPTOMATIC but has diverticula

Diverticular disease- SYPTOMATIC with diverticula

Diverticulitis- Infection with inflammation of a diverticula

RF’s- Age, low dietary fibre, obesity

More likely to occur on the left in Caucasians and commonly occur at the insertion points of blood vessels

1.

2.

3.

4.

1.

2.

3.

4.

Diverticular disease:

Abdo pain, usually left sided

Abdo bloating

Change in bowel habit

Rectal bleeding

Diverticulitis:

More severe LIF pain with localised tenderness

Pyrexia, fever, tachycardia- may be in shock

Possibly N+V

Haemorrhage and other complications

1.

2.

Bloods- FBC, U+E, CRP, ESR, Clotting, Group+ save

Imaging-

Colonoscopy- exclude other pathology and confirm diagnosis, NOT in acute presentation- why?

Barium enema

3.

4.

Erect CXR- why?

AXR- may show evidence of complications

5.

CT- useful acutely when colonoscopy CI’d

1.

2.

Fistula-

Colovesical- pneumaturia- frothy urine

Colovaginal

3.

Coloenteric

Bowel obstruction

Abscess

Perforation

Stricture

Haemorrhage

1.

Diverticular disease-

High fibre diet

2.

3.

1.

Good fluid intake

May require laxatives, antispasmodics, analgesia

Diverticulitis-

May require hospital admission

2.

3.

4.

5.

Antibiotics- may need broad spectrum

Fluids

Analgesia

Manage complications- eg may require blood transfusion etc

1.

2.

3.

15-30% may need surgery

Emergency procedure for acute diverticulitis is a

HARTMANNS procedure

Involves removing affected part and bringing part of the large bowel to the surface of the skin to create a temporary colostomy which can be reversed at a later date upon recovery

Surgery may also be performed for complications including:

Fistula

Obstruction

Stricture (possibly)

Person

40 years of age and older

60 years of age and older

Symptoms and signs

Rectal bleeding with a change in bowel habit towards looser stools and/or increased stool frequency persisting for

6 weeks or more.

Rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms. A change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding.

Of any age A right abdominal mass consistent with involvement of the large bowel. A palpable rectal mass (intraluminal and not pelvic; a pelvic mass outside the bowel would warrant an urgent referral to a urologist or gynaecologist).

Women (not menstruating)

Men of any age

Unexplained iron deficiency anaemia and haemoglobin

10 g/100 mL or less.*

Unexplained iron deficiency anaemia and haemoglobin

11 g/100 mL or less.*

* Anaemia considered, on the basis of history and examination in primary care, not to be related to other sources of blood loss (e.g. ingestion of nonsteroidal anti-inflammatory drugs) or blood dyscrasia.

1.

2.

Anal fissure

Gastroenteritis

3.

4.

Angiodysplasia

Meckel's diverticulum

5.

Polyp

6.

7.

Trauma

Rectal varices

Any Questions?

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