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Matthew Charnock Sam Newton.  PC  HPC  RED FLAGS  ROS  MED Hx  FH  SOCIAL Hx.

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Presentation on theme: "Matthew Charnock Sam Newton.  PC  HPC  RED FLAGS  ROS  MED Hx  FH  SOCIAL Hx."— Presentation transcript:

1 Matthew Charnock Sam Newton

2  PC  HPC  RED FLAGS  ROS  MED Hx  FH  SOCIAL Hx

3  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

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5  Bloods  Imaging

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8  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

9  Family history  Familial Syndromes  IBD  Smoking  Poor fibre/High fat diet  Alcohol  Etc

10  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

11  Jaundice?  Ascites?  Chronic cough?

12  Abdominal pain  Bloody diarrhoea  Weight loss  Fever  Signs of anaemia  Tenesmus  Peri-anal disease  Extra-intestinal manifestations  In children – FTT, delayed puberty, malnutrition

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18 Crohns VS Ulcerative Colitis

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20  Bloods (FBC, LFTs, ESR/CRP, Anti- GGT/endomysial antibodies, Iron Studies, B12/Folate levels) Imaging  Colonoscopy + biopsy  Barium Follow through  Abdominal xray

21  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)

22 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

23 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

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25  Site  Contents of bag  Appearance

26 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

27 Rectal examination? Bloods? Imaging?

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29 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.

30 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

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32 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

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34 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 or 1 st /2 nd not responding to conservative) 1. Banding 2. Sclerotherapy 3. Infrared coagulation Surgical (3 rd /4 th not responding or very large) 1. Circular stapled haemorrhoidectomy (better than traditional)

35 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

36 Bloods? Imaging?

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38 Herniation's of mucosa through colonic muscle Remember terminology 1. Diverticulosis- ASYPTOMATIC but has diverticula 2. Diverticular disease- SYPTOMATIC with diverticula 3. 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

39 Diverticular disease: 1. Abdo pain, usually left sided 2. Abdo bloating 3. Change in bowel habit 4. Rectal bleeding Diverticulitis: 1. More severe LIF pain with localised tenderness 2. Pyrexia, fever, tachycardia- may be in shock 3. Possibly N+V 4. Haemorrhage and other complications

40 Bloods- FBC, U+E, CRP, ESR, Clotting, Group+ save Imaging- 1. Colonoscopy- exclude other pathology and confirm diagnosis, NOT in acute presentation- why? 2. Barium enema 3. Erect CXR- why? 4. AXR- may show evidence of complications 5. CT- useful acutely when colonoscopy CI’d

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43 Fistula- 1. Colovesical- pneumaturia- frothy urine 2. Colovaginal 3. Coloenteric Bowel obstruction Abscess Perforation Stricture Haemorrhage

44 Diverticular disease- 1. High fibre diet 2. Good fluid intake 3. May require laxatives, antispasmodics, analgesia Diverticulitis- 1. May require hospital admission 2. Antibiotics- may need broad spectrum 3. Fluids 4. Analgesia 5. Manage complications- eg may require blood transfusion etc

45 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: 1. Fistula 2. Obstruction 3. Stricture (possibly)

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47 PersonSymptoms and signs 40 years of age and olderRectal bleeding with a change in bowel habit towards looser stools and/or increased stool frequency persisting for 6 weeks or more. 60 years of age and olderRectal 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 ageA 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)Unexplained iron deficiency anaemia and haemoglobin 10 g/100 mL or less.* Men of any ageUnexplained 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.

48 1. Anal fissure 2. Gastroenteritis 3. Angiodysplasia 4. Meckel's diverticulum 5. Polyp 6. Trauma 7. Rectal varices

49  Any Questions?


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