Gastroenterology Presentation (& some Abdominal Surgery Stuff!)
-
Upload
meducationdotnet -
Category
Documents
-
view
349 -
download
3
Transcript of Gastroenterology Presentation (& some Abdominal Surgery Stuff!)
![Page 1: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/1.jpg)
GastroenterologyWITH SURGICAL PROBLEMS
![Page 2: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/2.jpg)
Basic Physiology
![Page 3: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/3.jpg)
Investigations – Blood Tests• FBC• U&Es• LFTs• Amylase• ESR/CRP• Auto-Antibodies• Tumour Markers• Arterial Blood Gas• Viral Serology
Anaemias, Raised WCCElectrolyte disturbancesAlbumin, Liver enzymesPancreatic DiseaseImmune ResponseCoeliac diseaseCa 19-9, CEA, AFPAcidosis/Alkalosis, HypoxiaHepatitis antigens
![Page 4: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/4.jpg)
Investigations - Imaging• Abdominal X-ray• CT scan• MRI• Barium Follow-Through/Enema
![Page 5: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/5.jpg)
Investigations - Other• CLO Test• Flexible/Rigid Sigmoidoscopy• Colonoscopy• Endoscopy• Endoscopic Retrograde Cholangiopancreotography• Stool MSC
![Page 6: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/6.jpg)
Scoring Systems• Glasgow-Blatchford Score• Rockall Score• Modified Glasgow Score• Child-Pugh score• MELD score• ALVARADO score• Dukes’ Staging
![Page 7: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/7.jpg)
Gastro-oesophageal Reflux Disease
A 22-year old overweight female presents complaining of a 3-week history of occasional epigastric pain associated with heartburn. It comes on particularly bad after eating spicy food. She smokes 15 cigarettes a day and drinks alcohol most nights.
![Page 8: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/8.jpg)
How do you investigate/initially manage this lady?
Review Medications for a cause
ARE THERE ANY RED FLAG SYMPTOMS?YES
ENDOSCOPY
Test & Treat for H. pylori AND/OR treat with PPI
NO
Lifestyle Advice
Antacids or H2 antagonist
![Page 9: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/9.jpg)
Helicobacter Pylori• 3 options for detection• Carbon-13 urea breath test• Stool Antigen Test• Laboratory-based serology
• Eradication therapy – 7 day course• Full-dose PPI• Metronidazole 400mg and Clarithromycin 250mg BD• Amoxicillin 1g and Clarithromycin 500mg BD
![Page 10: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/10.jpg)
Complications of GORD• Barrett’s oesophagus• Benign oesophageal stricture• Oesophagitis/laryngitis• Ulcerations
![Page 11: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/11.jpg)
Barrett’s Oesophagus
15 years later the same lady comes in complaining of pain and difficulty when swallowing. She also reports persistently vomiting after meals and wretches a lot of the time when she isn’t eating. She has also been losing weight due to being unable to eat. You scan through her history on the computer and note she has repeatedly had to come back for courses of PPIs throughout the years. In the past 15 years there have been no scientific breakthroughs on health problems whatsoever.
![Page 12: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/12.jpg)
Pathology• Metaplasia in the lower portion of the oesophagus• Squamous epithelium replaced by goblet cells in response to chronic
acid exposure• High risk of continued carcinogenesis and leads on to oesophageal
adenocarcinoma
![Page 13: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/13.jpg)
![Page 14: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/14.jpg)
ManagementPatient Support
Oesophagectomy Endoscopic Therapy
Ablative Therapy Mucosal Resection
Further Endoscopic Therapy
![Page 15: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/15.jpg)
Oesophageal CarcinomaDysphagia
VomitingAnorexia
GI Blood Loss
Odynophagia
Hoarseness
Retrosternal Pain
Lymphadenopathy
Intractable Hiccups
![Page 16: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/16.jpg)
• 75% of oesophageal circumference must be involved to become symptomatic• 50% of patients who present due to symptoms already have
unresectable tumour/distant metastases
![Page 17: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/17.jpg)
Investigations• Urgent endoscopy• Staging• CXR• Double-contrast barium swallow• CR/MRI of chest, abdomen, pelvis• Fluorodeoxyglucose positron emission topography (FDG-PET)
![Page 18: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/18.jpg)
ManagementSurgery• Antibiotic & antithrombotic
prophylaxis• Endoscopy• Photodynamic therapy• Ablation• Resection
• Oesophagectomy• Radiotherapy for SCC• Chemotherapy for AC
Palliation• Radiotherapy/chemotherapy• Trastuzumab• Stenting• Liquid feeds, enteral nutrition or
PEG tubes• Pain relief
![Page 19: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/19.jpg)
Oesophageal Varices
A 46-year old male is admitted to A&E following an episode of haematemesis. He smells strongly of alcohol. On admission his observations are: HR 108bpm, BP 135/89, RR 24, SaO2 95% and Temp 37.3°C.
![Page 20: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/20.jpg)
Assessment & Investigations• Glasgow-Blatchford/Rockall Score• CLO test• FBC• U&Es• Coagulation Screen• OGD
![Page 21: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/21.jpg)
Management• Acute Phase• Terlipressin• Prophylactic antibiotics• Endoscopy & Band Ligation
• Prevention• Propranolol
• Consider Transjugular Intrahepatic Portosystemic Shunt if bleeding not controlled
![Page 22: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/22.jpg)
Achalasia
A 27-year old male presents complaining of difficulty swallowing food and bring up food shortly after eating. He reports the problem also happens with liquids, but this has occurred more recently. He has lost some weight over the past few months and had had retro-sternal chest pain.
![Page 23: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/23.jpg)
Investigating Achalasia• OGD• X-ray• Barium Swallow• Oesophageal Manometry
![Page 24: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/24.jpg)
Managing Achalasia• Calcium-channel blockers & nitrates• Pneumatic dilatation• Endoscopic injection of botulinum toxin• Heller myotomy
![Page 25: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/25.jpg)
Gastritis
A 46-year old woman complains of central upper abdominal pain, that does not radiate. The pain is associated with nausea, and she has noticed that she gets full very early. Because of this she is losing her appetite and has lost weight.
![Page 26: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/26.jpg)
Mallory-Weiss Tear
A 27-year old known alcoholic presents to A&E with blood-stained vomiting. He describes it as fresh blood and isn’t sure when it actually started. He said he was out last night and had a lot to drink. A friend informs you that he was vomiting from about 3 in the morning and fresh blood appeared quite late into it.
![Page 27: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/27.jpg)
Peptic Ulcer Disease
A 22-year old female presents complaining of a 3-week history of occasional epigastric pain associated with heartburn. It comes on particularly bad after eating spicy food. She smokes 15 cigarettes a day and drinks alcohol most nights.
![Page 28: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/28.jpg)
Investigations• FBC• CLO testing• Endoscopy
![Page 29: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/29.jpg)
ManagementBehaviour Modification
H pylori-positive
H. pylori-negative, NSAID induced
H pylori-negative, NSAID-negative ulcer
REPEAT ENDOSCOPY
![Page 30: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/30.jpg)
Gastric Adenocarcinoma
The history is basically the same as everything else. RED FLAGS are indication for urgent referral to endoscopy. Not going to talk about investigations because again it’s essentially the same. Just important to remember keep patients free from acid suppression for the 2 weeks and do a full blood count.
![Page 31: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/31.jpg)
Management• Surgery• Subtotal gastrectomy• Total gastrectomy• Local clearance of lymph nodes• Only remove pancreas/spleen if direct invasion!!
• Perioperative combination chemotherapy• 5-fluorouracil = most effective
![Page 32: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/32.jpg)
PalliationObstruction• Stenting• Gastrojejunostomy• Endoscopic laser therapy
Anaemia• Blood transfusions
Haemorrhage• Treat the cancer
Pain• Coeliac plexus nerve blocks
![Page 33: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/33.jpg)
Prognosis• Overall survival 15%• 10-year survival is 11%• If under 50 5-year survival is 15-20%• If over 50 5-12%
![Page 34: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/34.jpg)
MALT Lymphoma
A 62-year old woman presents complaining of long-standing indigestion. She has also been incredibly tired over the past few years, feelsslightly feverish and she notices her clothes have been becoming looser. Her husband informs you he often wakes up in the middle of the night because the sheets are soaking from her sweating. Her temperature is 37.5°C and you note that she has had several respiratory tract infections over the past year or two.
![Page 35: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/35.jpg)
Assessment• FBC, U&Es, LFTs• Phenotyping circulating lymphocytes• Barium contrast studies of upper & lower GI tract• CT/MRI scan• Endoscopy• Bone Marrow Aspiration
![Page 36: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/36.jpg)
StagingIE
IIE
IIIE
IV
L L L
L
![Page 37: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/37.jpg)
Management
PPIH. Pylori Eradication
![Page 38: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/38.jpg)
Gastroenteritis• Assess for dehydration• Investigate potential causes• Assess risk factors & medications• Admt to hospital if vomiting and unable to retain fluids, or features of
shock/severe dehydration• Do not give antidiarrhoeal drugs• Do not give antibiotics• Anti-emetics are usually not necessary
![Page 39: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/39.jpg)
Gastroenteritis• Amoebiasis• Campylobacteriosis• Cryptosporidiosis• E. Coli• Giardiasis• Salmonellosis• Shigellosis
![Page 40: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/40.jpg)
Acute Liver Failure
A 46-year old male presents to A&E jaundiced with a distended abdomen. He has strange bruises all over his body and is very agitated. He does not know where he is and tries to attack one of the nurses.
On examination he is incredibly tender in the upper abdomen and has hepatomegaly. He has a positive shifting dullness and begins to vomit clear fluid.
![Page 41: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/41.jpg)
Workup• FBC• PT/aPTT/INR• LFTs• Bilirubin• Ammonia, Glucose, Lactate, Creatinine, Phosphate• ABG• Blood Cultures• Viral Serology• Autoimmune Markers• Abdominal US/CT
![Page 42: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/42.jpg)
Management ABC
Management of Encephalopathy & Oedema
Management of Coagulopathy
![Page 43: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/43.jpg)
Management• Location• Positioning• Lactulose• Haemodynamic monitoring• Mannitol• Hypothermia
Management of Encephalopathy & Oedema
![Page 44: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/44.jpg)
Management• Monitor INR• FFP• Cryoprecipitate• Recombinant factor VIIa• Platelet transfusions
Management of Coagulopathy
![Page 45: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/45.jpg)
Jaundice
![Page 46: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/46.jpg)
JaundiceHistory Bilirubin ALT AST ALP GGT
Pre-Hepatic
Lethargy/fatigueStressTraumaFamilial history
Raised unconjugated
- - - -
Hepatic Preceding coryzal symptomsMedicationPrevious liver diseaseRisks for viral disease
Raised unconjugated AND conjugated Raised Raised Normal/
Raised Normal
Post-Hepatic
Pale stoolDark urineRUQ pain (can be painless)
Bilirubin present in urineRaised conjugated bilirubin
Raised Raised Raised Raised
![Page 47: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/47.jpg)
The Path to Cirrhosis
![Page 48: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/48.jpg)
Complications of Cirrhosis• Hepatorenal syndrome• Varices• Infection (particularly bacterial peritonitis due to paracentesis)
![Page 49: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/49.jpg)
Viral Hepatitis• Hepatitis viruses• Herpes viruses• Epstein-Barr• Cytomegalovirus• Varicella• Adenovirus• Yellow fever• Haemorrhagic viruses
![Page 50: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/50.jpg)
Effects
Symptoms• Fever• Malaise• Abdo discomfort• Jaundice• 3-6 weeks then subside• ‘Waves’ of symptoms
Signs• Spider naevi• Jaundice• URQ tenderness• Hepatomegaly• Splenomegaly (in EBV/CMV)
![Page 51: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/51.jpg)
A
A 22-year old gap year student presents to you one month after getting back from his trip to Sub-Saharan Africa. He was helping communities that had been damaged by recent flooding, and had stayed in a small hut with 20 locals. He had vague abdominal pain, and felt a bit feverish. This has lasted about 2 weeks and he mentions a lot of his friends have been calling him Bart Simpson as they said he looks a bit yellow.
![Page 52: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/52.jpg)
B
A 45-year old businessman presents 3 months after he returned from a trip to Thailand. He has vague abdominal pain, nausea and vomiting. On examination he is tender in his right upper quadrant and you can feel the liver border quite easily. You note in his history he used IV drugs when he was younger.
![Page 53: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/53.jpg)
Hepatitis B Testing
![Page 54: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/54.jpg)
B
A 45-year old businessman presents 3 months after he returned from a trip to Thailand. He has vague abdominal pain, nausea and vomiting. On examination he is tender in his right upper quadrant and you can feel the liver border quite easily. You note in his history he used IV drugs when he was younger.
![Page 55: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/55.jpg)
C
A 53-year old female presents to you feeling feverish, nauseous and with abdominal pain. She received a blood transfusion in 1989 after a car accident.
![Page 56: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/56.jpg)
Autoimmune Hepatitis
A 17-year old female presents to her GP feeling fatigued, nausea and an all-over itch. Abdominal examination reveals nothing abnormal other than slightly jaundiced sclera.
You take some bloods and her LFTs return deranged showing raised ALT and AST. ALP is normal. She also has a normochromic anaemia.
You decide at this point to test for autoantibodies and refer for a liver biopsy.
She is treated with Prednisolone in conjunction with Azathioprine.
![Page 57: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/57.jpg)
Monitoring• Test for hep A&B vaccinate if needed• Monitor LFTs, glucose and FBC• DEXA scan before starting steroids and repeat 1-2 years• Screen for glaucoma and cataracts after 1 months treatment
![Page 58: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/58.jpg)
Complications• Hyperviscosity syndrome• Hepatocellular carcinoma
![Page 59: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/59.jpg)
Biliary Colic
A 44-year old female presents with intermittent upper abdominal pains. She states they are worse about 2-3 hours after food and it particularly happens after fast food. She does feel a bit nauseous, but she hasn’t actually thrown up from the pain. She has had a few episodes of diarrhoea since the onset of symptoms.
On examination she is tender in her right upper quadrant but Murphy’s sign is negative.
![Page 60: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/60.jpg)
Cholecystitis
The same lady returns one year later with similar symptoms. Her previous ultrasound was inconclusive so she was given analgesia and then her symptoms resolved spontaneously.
She now has pain in her right scapula, and has thrown up from the pain. It has gone from being intermittent to a constant severe pain in the right upper quadrant. Examination reveals a low-grade fever and a positive Murphy’s sign.
![Page 61: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/61.jpg)
Investigations• Ultrasound visualisation• ALP• GGT• WCC
![Page 62: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/62.jpg)
ComplicationsAscending CholangitisRupture/PerforationPseudodiverticular of the gallbladderGallstone Ileus
![Page 63: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/63.jpg)
Investigations & Management• Ultrasound• Pain relief• Lithotripsy• Laparoscopic cholecystectomy
![Page 64: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/64.jpg)
Ascending Cholangitis
A 55-year old man with a history of gallstone disease presents with a two day history of pain in the right upper quadrant. He feels ‘fluey’ and has had a fever. On examination his temperature is 38.0°C, pulse 103/min and blood pressure 105/63 mmHg. He is tender in the right upper quadrant and his sclera are tinged yellow.
![Page 65: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/65.jpg)
Sepsis 6Give 3• High flow oxygen• IV antibiotics• IV fluids
Take 3• Blood cultures• Urine output• Hb/Lactate
![Page 66: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/66.jpg)
Other Investigations (& Management)• Full Blood Count• Liver Function Tests• Ultrasound• ERCP
Raised white cell countRaised bilirubin ALP and GGTDiagnosisERCP – visualise & remove obstruction
![Page 67: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/67.jpg)
Acute Pancreatitis
A 40-year old female is bought into A&E complaining of severe vomiting. It is associated with extreme pain that radiates to the back. She has a past history of gallstones. She is tachycardic, hypertensive, tachypnoeic and apyrexial. Her O2 sats are 94% on air. You notice some unusual bruising in her abdominal flanks.
![Page 68: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/68.jpg)
Other causesIdiopathicGallstonesEthanolTraumaSteroidsMumpsAutoimmuneScorpion venomHyperlipidemia, Hypothermia, HypercalcemiaERCP & emboliDrugs
![Page 69: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/69.jpg)
Investigations• Amylase• FBC, U&E, Glucose, CRP• LFTs• Serum calcium• ABG• Erect X-ray• Ultrasound scan
![Page 70: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/70.jpg)
Management• Pain relief• IV fluids• IV antibiotics if severe pancreatic necrosis• Enteral nutrition• ERCP• Cholecystectomy• Hyperbaric oxygen therapy• Whipple’s procedure
![Page 71: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/71.jpg)
Chronic Pancreatitis
The same 40-year old recovers successfully from her cholecystectomy, but has begun to drink alcohol due to the stress of the episode. She has recurrent episodes of pancreatitis and successfully cuts down her drinking but doesn’t wish to stop.
At the age of 42 she begins to get constant pain deep in the epigastric region radiating to the back. It gets much worse when eating and she feels sick. She has been having steatorrhoea and losing weight.
On examination her fingers are clubbed and you notice a dusky discolouration of the skin over her epigastrium.
![Page 72: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/72.jpg)
Appendicitis
A 17-year old is referred to A&E with acute abdominal pain that began centrally and has migrated over to the right hand side. He has vomited 4 times. On examination his temperature is 37.6°C, he is tender over McBurney’s point and has a positive Psoas sign. There is no evidence of peritonism.
![Page 73: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/73.jpg)
Irritable Bowel Syndrome
A 23-year old goes to the GP complaining of bowel problems. She has always had irregular bowel habits, and they have recently become worse. She notes that she gets a lot of cramping and bloating sensations throughout the day. She often has periods where she is constipated then has loose stools. She has noticed it is particularly worse on Wednesdays when her and her co-workers get a milkshake. She has also been under a lot of stress recently with finances and her husband being busy and unable to help with the children or housework.
![Page 74: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/74.jpg)
Investigations• NO investigation to confirm IBS• Full blood count• ESR/CRP• Antibody testing for coeliac disease
![Page 75: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/75.jpg)
Management• Assess diet & nutrition• Physical activity levels• Psychological status• Dietary advice• Treat constipation/diarrhoea appropriately
![Page 76: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/76.jpg)
Coeliac Disease
A 27-year old male presents feeling tired all the time. Upon further questioning he has had recurrent diarrhoea associated with abdominal cramping and feeling nauseous. You note that blood tests performed a week ago by the practice nurse reveal an iron deficiency anaemia.
![Page 77: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/77.jpg)
Management• Gluten-free diet• Follow-up in secondary care until satisfactory progression on diet is
achieved• Routinely assess:-• BMI• Symptoms• Coeliac Serology• FBC, ferritin, calcium and vitamin D• B12• U&Es• TFTs
![Page 78: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/78.jpg)
ASSESS for osteoporosis• Lifestyle & supplementation advice• DEXA scan
![Page 79: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/79.jpg)
Complications• Anaemia• Hyposlenism• Osteoporosis• Lactose intolerance• Enteropathy-associated T-cell lymphoma of small intestine• Subfertility• Oesophageal Cancer
![Page 80: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/80.jpg)
Crohn’s Disease
A 15-year old attends GP with his mother. He has had a 2-month history of abdominal pain and change in bowel habit. The abdominal pain is the largest problem for him. His mother informs you he has been much more lethargic than usual and it is affecting his school work.
His father had a history of bowel troubles, but they aren’t sure what they were as he left when he was 6 months old. He admits to smoking 10-cigarettes a day regularly for the past 2 years.
On examination he is tender in the right lower quadrant and has some fluctuation of his nail beds.
![Page 81: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/81.jpg)
Complications• Psychological effects• Intestinal strictures• Abscesses in the wall of the intestine• Fistulas• Anaemia• Malnutrition• Colorectal and small bowel cancers
![Page 82: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/82.jpg)
Extra-intestinal manifestations
Related to Disease Activity• Arthritis• Erythema nodosum• Aphthous ulcers• Episcleritis• Metabolic bone disease
Unrelated to Disease Activity• Axial/polyarticular arthritis• Pyoderma gangrenosum• Uveitis• Hepatobiliary conditions• Bronchiectasis/bronchitis
![Page 83: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/83.jpg)
Management of Established Crohn’s
Primary Care Management• Advice and support• Monitor & prescribe recommended drug
treatments• Screen for complications• Manage specific symptom-control issues• Smoking cessation• Discuss colorectal cancer screening• Ensure osteoporosis risk is managed
appropriately
Secondary Care Management• Corticosteroid therapy• Immunosuppresant• Aminosalicylates
![Page 84: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/84.jpg)
Managing ‘Flares’• CRP is raised AND:• Cachexia/dramatic weight loss• Obstruction/abscess• Systemic illness• Persistent symptoms• Severe diarrhoea
• Short course of corticosteroids
![Page 85: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/85.jpg)
Diarrhoea• Symptomatically• Anti-motility drugs• Anti-spasmodic drugs• Bulking agents
• REFER if systemically unwell
![Page 86: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/86.jpg)
• Refer fistulas• Give metronidazole/ciprofloxacin
• Refer suspected obstruction• Likely to require endoscopy/surgery to dilate/excise stricture
• Refer dyspepsia• Follow usual pathway, refer on 2-week wait
• Give topical steroids/immunomodulators for oral disease• Manage pain as normal• AVOID NSAIDs
![Page 87: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/87.jpg)
Ulcerative Colitis
A 57-year old male attends with a year-long history of worsening bowel symptoms. He describes blood diarrhoea, and often having the urge to just go to the toilet. He has had some accidents in public. He describes abdominal pain in the left lower quadrant.
![Page 88: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/88.jpg)
Features
Crohn’s• Diarrhoea usually non-bloody• Weight loss• Upper GI symptoms• Abdominal mass in RIF
Ulcerative Colitis• Bloody diarrhoea• Abdominal pain in the left lower
quadrant• Tenesmus
![Page 89: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/89.jpg)
Complications
Crohn’s• Obstruction• Fistula• Colorectal Cancer
Ulcerative Colitis• Risk of colorectal cancer higher
in UC than CD• Primary sclerosing cholangitis
more common• HLA-B27 disease associations
![Page 90: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/90.jpg)
Pathology
Crohn’s• Lesions seen anywhere from
mouth to anus• Skip lesions
Ulcerative Colitis• Inflammation starts at rectum• Never beyond ileocaecal valve• Continuous disease
![Page 91: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/91.jpg)
Histology
Crohn’s• Inflammation in all layers from
mucosa to serosa• Increased goblet cells• Granulomas
Ulcerative Colitis• No inflammation beyond
submucosa• Neutrophils migrate through
walls of glands to form crypt abscesses• Depletion of goblet cells
![Page 92: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/92.jpg)
Endoscopy
Crohn’s• Deep ulcers• Skip lesions• Cobble-stone appearance
Ulcerative Colitis• Widespread ulceration• Preservation of adjacent mucosa• Pseudopolyps
![Page 93: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/93.jpg)
Radiology
Crohn’s• Small-bowel enema• High sensitivity and specificity• Strictures – Kantor’s string sign• Proximal bowel dilation• Rose thorn ulcers• Fisulae
Ulcerative Colitis• Barium enema• Loss of haustrations• Pseudopolyps• Narrow short colon
![Page 94: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/94.jpg)
Toxic Megacolon• Rare complication of UC• Triggered by:-• Hypokalaemia• Opiates• Anticholinergics• Barium enemas
• Colon becomes acutely dilated and patients are severely ill• IV fluids, IV steroids, antibiotics, IV ciclosporin• May require total colectomy
![Page 95: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/95.jpg)
Diverticular Disease
A 67-year old woman presents complaining of intermittent left iliac fosse pain. Defecation takes considerable straining and she often passes broken pellet-like stools. She is not peritonitic and PR exam reveals nothing.
![Page 96: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/96.jpg)
Hernias
A 72-year old obese male presents with a scrotal swelling. It is not painful but it is quite distressing for him. He can push it back but it returns very easily.
On examination there is a palpable lump, located above and medially to the pubic tubercle. It can be reduced but coughing brings it back. It is not pulsatile and you can hear bowel sounds in the lump.
![Page 97: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/97.jpg)
Inguinal Hernia Anatomy
![Page 98: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/98.jpg)
Management• Elective Hernia Repair• Avoid strangulation/ischaemia• Admit as emergency if suspected
![Page 99: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/99.jpg)
Other hernias• Umbilical• Paraumbilical• Incisional• Diaphragmatic/Hiatus• Epigastric• Obturator• Perineal
![Page 100: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/100.jpg)
Bowel Obstruction
Small Bowel• Colicky pain• Vomiting occurs before
constipation• Bilious vomiting
Large Bowel• Pain lower in abdomen• Spasms last longer• Constipation occurs earlier• Vomiting less prominent• Can be faeculant
![Page 101: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/101.jpg)
Causes
Small Bowel• Adhesions• Hernias• Crohn’s• Neoplasms• Intussusception• Ischaemic strictures
Large Bowel• Neoplasms• Diverticulitis• Hernias• Inflammatory Bowel Diseas• Volvulus• Adhesions
![Page 102: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/102.jpg)
Imaging
![Page 103: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/103.jpg)
Managing Small Bowel Obstruction• Aspirate fluid via Ryles Tube• Imaging• X-ray• Ultrasound• Contrast enema• CT scan
• Antiemetics• Pain relief• Complete obstruction that does not settle requires surgery
![Page 104: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/104.jpg)
Large bowel obstruction• NEED surgical intervention
![Page 105: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/105.jpg)
Colorectal Cancer
Left sided• Change in bowel habits• Obstructive symptoms• Diarrhoea
• Loose stools• Blood in stools
Right sided• Mass• Abdominal pain• Fever• Sweating• Anaemia
![Page 106: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/106.jpg)
Referral• Proforma for 2 week wait• From presenting to GP, decision to treat must be made within 62 days
![Page 107: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/107.jpg)
Investigations• Flexible sigmoidoscopy + barium enema• Colonoscopy• CT Colonography• Endoscopy• BIOPSY
![Page 108: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/108.jpg)
Stage• Contrast enhanced CT chest abdomen pelvis• Stage officially using TNM• Dukes helps with learning prognosis (5-year survival)• A = >90%• B = 70-85%• C = ~30%• D = <5%
• If rectal cancer offer MRI• Assess risk of local recurrence
![Page 109: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/109.jpg)
Management – Local Tumours• MDT discussion• Assess if suitable for local resection• If unresectable offer high dose brachytherapy to reduce tumour bulk
• Offer information• Treatment options• Likelihood of stoma & management
• Laparoscopic surgery
![Page 110: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/110.jpg)
Management – Metastatic Tumours• Bowel cancer commonly spreads to Liver and Lungs• Lungs• Radiofrequency ablation• Cytoreduction surgery
• Liver• Hepatic resection• Microwave ablation
• Chemotherapy• XELOX regime – capecitabine, oxaliplatin• FOLFOX regime – folinic acid, 5-fluorouracil, oxaliplatin
![Page 111: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/111.jpg)
Ongoing Care• Two CTs of chest abdomen pelvis in first three years AND 6 monthly
CEA tests• Surveillance colonoscopy at 1 year• Follow-up after 5-years
![Page 112: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/112.jpg)
Hereditary Nopolyposis Colorectal Cancer• 5% inherited cancers• Autosomal dominant• Mismatch repair gene mutation
• Type 1 = colorectal cancer• Type 2 = + endometrial, ureteric, stomach, small bowel• Regular surveillance once identified
![Page 113: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/113.jpg)
Familial Adenomatous Polyposis• <1% hereditary cancers• Mutation of APC gene• High malignant potential
![Page 114: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/114.jpg)
Peutz-Jegher Syndrome• VERY RARE• Hereditary intestinal polyposis syndrome• Autosomal dominant• Criteria• Family history• Mucocutaneous lesions• Hamartomatous polyps
![Page 115: Gastroenterology Presentation (& some Abdominal Surgery Stuff!)](https://reader035.fdocuments.us/reader035/viewer/2022062523/587175681a28ab230b8b4de5/html5/thumbnails/115.jpg)
Anal Fissures• Tear in the internal anal sphincter• Spasm of the internal anal sphincter which worsens the tear• Causes pain and bleeding• Medical – glycerol suppository, lactulose, movicol
Diltiazem cream with nitrate• Surgical – botox injection, lateral sphincterotomy