HISTORY
·
Age
o
Crohn’s disease – 2 peaks (20-40, >70)
·
Gender
·
Presenting complaint
o
Bleeding PR
·
History of presenting complaint
o
Previously well
o
Color –
§
black/tarry – upper GI bleeding
§
red wine – proximal large bowel
§
bright red – anal, low rectum
o
Amount of bleeding
o
association with defecation
§
mixed with feces à
higher than sigmoid colon
§
on surface of feces à lower sigmoid colon, rectum,
anal canal
§
following defecation à haemorrhoids
§
blood passed by itself à rapidly bleeding Ca, IBD,
diverticulosis, severe upper GI bleeding
§
blood on toilet paper – haemorrhoids, anal
fissures
o
Mucus
o
Pain during defecation à fissure, anal Ca, rectal Ca
obstructing the lumen
o
Tenesmus – intense, painful, fruitless effort to
defecation à
space occupying lesion in the rectum
o
Previous bowel habits
§
Constipation
§
Frequent diarrhoea
§
Consistency of stools
§
Incontinence and soiling
o
Abdominal pain
o
DD
§
Haemorrhoids – pruritis, lump coming out
§
Colo-rectal Ca –
·
Cecal tumor à
RIF pain
·
Mucus à
mucus producing adenoma
·
Caecal tumor à
RIF pain
·
Ca rectum à
o
increased frequency with scanty amount
o
PR bleeding
o
Tenesmus
·
Ca at amula of rectum à early morning bloody
diarrhoea
§
Fissure in ano
§
IBD – mucus, joint problems, conjunctivitis
§
Solitary rectal ulcer
§
TB – cough, fever, night sweats
§
Bleeding disorders
§
Angiodysplasia
§
Bleeding disorders
§
Diverticular disease
o
Aetiology
o
Complications
§
Obstruction à
constipation, abdominal distension, vomiting, abdominal pain
§
Anaemia à
Faintishness, lethargy
§
Spread
·
Local à
o
recurrent
UTI
o
Vaginal discharge in females
o
Back pain radiating along the thigh (sacral
plexus)
o
Faecouria, pneumaturia, haematuria à bladder
o
Haematospermia à
o
Fistula
o
Lymphadenoma
·
Metastases
o
Liver à
history of jaundice, RHP, LOW, LOA
o
Lungs à
chest pain, SOB, persistent dry cough, wheezing, haemoptesis
o
Adrenals
o
Brain à
headache, visual disturbances, early morning vomiting, drowsiness, fits
o
Bone
o
Fitness for surgery and anaesthsia
§
Exertional dyspnoea, chest pain, orthopnoea, PND
§
Urinay habits
§
Lower limb joint problems
·
Positioning for APR
·
NSAIDS
·
IBD – extraintestinal manifestations
o
PMH
o
PSH
§
Colonic polyps, Ca, Haemorrhoeids, colonoscopy
and biopsy
§
Cholecystectomy à
increased risk
§
Uretero-sygmoidostomy à increased risk of stump Ca
o
Drug history à
aspirin, heparin, warfarin
o
Allergies à
foods, drugs and plasters
o
Family history
§
Polyposis coli
§
Bowel Ca
§
Breast Ca
§
Ovarian Ca
§
DM
§
HT
§
Prostate Ca
o
Dietary Histtory
·
High fat
·
Low fibre
o
Social history
§
Level of education
§
Details of the family
§
Income
§
Family support
§
Smoking
§
Alcohol
§
Toilet - ? public
§
Nearest hospital
§
Transport
§
Consent for colonostomy and surgery
EXAMINATION
General
·
BMI
·
Ill/well looking
·
Pale
·
Jaundice
·
Conjunctivitis, joint swelling (IBD)
·
Features of nutritional deficiencies
·
Supraclavicular lymph node
·
Ankle edema
Abdominal
Examination
·
Sister Mary Joseph’s node
PR Examination
·
Anal scars
·
Perineal tears in females
·
Skin tags
·
Skin excoriation
·
Prolapsed haemorrhoids
·
Genital and perianal warts
·
External opening og sinus/fistula
·
Sphincter tone/soiling
·
Sever pain à
anal fissure, abandon the procedure
·
Anal canal à
mass, polyp, ulcers,
·
If growth à
o
distant from anal verge
o
upper margin
o
contact bleeding
o
fixed to sacrum
o
circumference
o
consistency
o
tenderness
·
prostate
·
VE – masses in the pouch of Douglus
Anoscopy/proctoscopy
·
Haemorrhoids à
position
·
State of mucosa
·
Anal polyps
·
Anal growths
Biopsy
·
Yeoman’s Forceps
INVESTIGATIONS
For Diagnosis
·
Rigid sigmoidoscopy (25-30 cm)
o
Visualizes the anal canal and the rectum
o
Bowel preparation à
Micro-enema
·
Flexible sygmoidoscopy (70 cm)
o
Up to splenic flexure
·
Colonoscopy and biopsy
o
Preparation
§
Informed consent
§
Low fibre diet for 3 days
§
Liquid diet on the day
§
Polyethylene glycol (klean prep) 4 packets in 4
liters
·
1 L in 1 hr à
1 L clear water for 1 hr à
………………..
§
IV cannulae
§
Iv midazolam 2-3 mg à microenema in morning
Hiscosin bromide
·
Double contrast Ba enema
o
Determines the level of obstruction
o
Ca of colon
o
Ulcerative colitis
o
Diverticular disease of the colon
o
Familial adenomatous polyposis
o
Assessment of anastomotic leak
For Staging
·
USS abdomen
o
Liver 2ries
o
Lymph node enlargement
o
Ascites
·
Transrectal ultrasonography
·
CXR
o
Lung mets
o
Pleural effusion
o
Osteolytic lesions of the ribs
o
Mediastinal lymph nodes
·
CT abdomen
o
Better soft tissue enhancement
o
Liver mets, liver enlargement
o
Tumor
o
Level of invasion
·
Bone scan
·
CT Brain
To Assess Fitness
for Anaesthesia
·
FBC with Hb
·
FBS
·
BU
·
SE
·
PT/INR
·
Serum proteins
·
ECG à
echo, exercise ECG
·
CXR
MANAGEMENT
SEVERE PR BLEEDING
·
Assessment and resuscitation
o
ABC, IV fluids, blood transfusion
·
History, examination
·
Monitor à
PR, RR, BP, input/output, CVP
·
UGIE
·
Colonoscopy
·
If colonoscopy cannot be done à angiography,
radio-isotope scan (radio-labelled RBCs)
HAEMORRHOIDS
·
Exclude
o
Colorectal malignancy
o
IBD
o
Diverticular disease
o
Adenomatous polyposis à loose stools, lower abdominal
pain, weight loss, blood and mucus diarrhoea
·
Stool softners
·
Bulking agents
·
Increased intake of fluids
·
1st degree à
o
Sclerotherapy
§
2-5 ml of 5% phenol in olive oil is injected
above each haemorrhoids
§
If injected too superficial à mucosal sloughing (a
white wheel)
§
If injected too deep à
·
Males – chemical prostatitis, impotence
·
Females – ano-vaginal fistula
§
Bradycardia
·
Leave the patient for sometime and ensure that
PR is normal
·
No nausea, vomiting, light headedness à can go
§
Allergic reactions à anaphylaxis
·
2nd degree
o
Elastic band ligation
·
3rd and 4th degree
o
Hamorrhoidectomy
o
Stapled haemorrhoidoplexy
EXTERNAL PLEXUS HAEMATOMA
·
Perianal haematome
·
Maximum severity of pain – 2-3 days
·
May take up to 2 weeks to resolve
·
Tense dark blue swelling at the anal margin
·
Reassurance and analgesia
·
If large/ extremely painful à excision under LA
FISTULA IN ANO
·
Anal fistlectomy
ANAL FISSURE
·
Stool softners
·
Bulking agents
o
§
Peutz-Jegher’s polyps
§
Juvenile polyp
o
Neoplastic
§
Adenomas à
tubular, tubular villous, villous
§
Adeno Ca
§
Carcinoid tumor
CA COLON
·
Columnar cell adeno carcinoma
·
Clinical features
§
Left side
·
Stenoting variety
·
Features of intestinal obstruction
·
Pain – suprapubic coloc, constant ache
(advanced)
·
Alteration of bowel habits – episodes of
constipation followed by attacks of diarrhoea
·
Distension – relieved by passage of flatus
·
Palpable lump
·
Sigmoid – tenesmus, bladder symptoms
§
Right side
·
Anaemia – severe, unyielding to treatment
·
Mass in RIF
·
Intussusceptions – features of intermittent
obstruction
·
Treatment
o
Remove the 1ry tumor and its draining
locoregional lymph nodes
§
Right hemi-colectomy
§
Extended right hemicolectomy
§
If no obstruction à
1ry anastomosis
§
If obstruction à
stoma
o
Inoperable tumors
§
Ascending colon – bypass using a iliocolic
anastomosis
§
Upper part of the left colon – transverse
colectomy
§
Pelvic colon – LIF colostomy
o
Adjuvant therapy
CA RECTUM
·
Clinical features
o
Can occur in youth
o
Adult presentation 55 years
o
Bleeding
§
Earliest and most common symptom
§
Stimulates haemorrhoids
o
Sense of incomplete defecation
§
Tenesmus
o
Alteration of the bowel habits
o
Ampulla of rectum à
early morning bloody diarrhoea
o
Pain
§
Late symptom
§
Due to some degree of intestinal obstruction/local
invasion
TREATMENT
·
Surgery
o
Sphincter saving AR
o
Removal of rectum with permanent colostomy APR
o
Endo-anal excision
o
=>3cm from the anal verge à APR
o
=>5 cm from anal verge à AR
o
=>2 cm from anal verge à ultra low AR
o
Fit enough to surgery + small tumor à curative surgery
o
Fit enough to surgery + metastasis à palliative surgery,
colostomy
o
Fit enough to surgery + features of obstruction à defunctioning
ileostomy/colostomy
o
Fit enough to surgery + extensive local spread à neo-adjuvant
chemotherapy =/- small amount of radiotherapy à
if done surgery should be done within 2 weeks à
Downgrade the tumor (2-3 months) à
surgery à
chemoradiation (5-flouroucil + folinic acid
o
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