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Lower GI

IBS

Aetiology
•  Func%onal bowel disorder
•  Abdominal pain associated with defeca%on
•  Young women affected 2-3x more than men
•  Co-exis%ng condi%ons
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Non-ulcer dyspepsia
Chronic fa%gue syndrome
Dysmenorrhoea
Fibromyalgia
A significant propor%on of sufferers have been vic%ms of physical
or sexual abuse

Presentation
•  Recurrent colicky abdominal pain
•  Altered bowel habit – usually alterna%ng between diarrhoea
and cons%pa%on
•  Abdominal disten%on
•  Rectal mucus
•  Feeling of incomplete defeca%on

Investigations
•  Diagnosis made on clinical observaton
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Symptoms >6/12
Frequent consulta%ons for non-GI problems
Previous medically unexplained symptoms
Stress worsens symptoms

•  Rule of other bowel condi%ons
•  Bloods: FBC, faecal calprotec%n
•  Sigmoidoscopy (colonoscopy in older pa%ents to exclude colorctal
cancer)
•  Exclude: microscopic coli%s, lactose intolerance, bile acid
malabsorp%on, coeliac disease, thyrotoxicosis, parasi%c infec%on

Management
REASSURANCE – many pa%ents are worried about cancer or IBD
Treatment is tailored to predominant symptoms


•  Diarrhoea predominant
•  Avoid legumes and excessive
fibre
•  An%diarrhoeal drugs
•  Loperamide
•  Codeine phosphate
•  Colestyramine
•  Amitriptyline
•  Cons0pa0on predominant
•  High-roughage diet
•  Mo%lity drugs
•  Ispaghula
•  Lactulose

•  Pain and bloa0ng
•  Spasmoly%c drugs
•  Mebeverine
•  Peppermint oil
•  alverine
•  Amitryptyline
•  Probio%cs
•  Dietary changes (exclude wheat/
dairy)

Complications
•  Pa%ents with intractable symptoms can benefit from several
months’ amytrip%line therapy à AEs include dry mouth and
drowsiness
•  Psychological interven%ons such as CBT and hypnotherapy
may also be used in severe cases
•  Exacerba%ons o\en follow stressful life events

Malabsorption and
Coeliac Disease

Aetiology
•  Inflammatory disorder of the small bowel resul%ng from
intolerance to wheat gluten

Presentation
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Can present at any age
Diarrhoea
Malabsorp%on
In babies, failure to thrive
Some adults develop non-specific symptoms such as %reness,
weight loss, folate or iron deficiency

Investigations
Duodenal biopsy is gold standard – look for villous atrophy
Tissue transglu%mate (tTG) assay
IgA an%bodies
FBC and biochemical tests to look for evidence of malnutri%on
and inflamma%on
•  DEXA scan should be performed in older women to check for
osteoporosis
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Management
•  Gluten-free diet
•  Correct exis%ng deficiencies

Complications
•  2x risk of malignancy
•  Osteoporosis
•  Osteomalacia

Bowel Infections

Tropical sprue
•  Chronic malabsorp%on that occurs a\er visi%ng Asia or West
Indies
•  Small bowel overgrowth of E
...
Diff
•  Occurs a\er broad spectrum an%bio%c use
•  Treated with metronidazole or vancomycin

IBD

Aetiology
•  Abnormal host reponse to environmental trigger causing
inflamma%on
•  Inflammatory mediators such as TNF, IL-12 and IL-23 cause
%ssue damage
•  Intes%nal wall is infiltrated with acute and chronic
inflammatory cells

UC Presentation
•  Clinical features
•  Bloody diarrhoea (+ mucus)
•  First ahack usually most severe
•  Relapse provoked by emo%onal stress, infec%on, an%bio%cs or
NSAIDs
•  Severe cases: fever, malaise, weight loss, abdo pain, peritoneal
inflamma%on

•  Histology
Only in large bowel
Inflamma%on more severe distally
Pseudopolyps
Inflamma%on limited to mucosa – spares deeper layers or bowel
wall
•  Cryp%%s and crypt abscesses
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Crohn’s Presentation
•  Clinical features
Abdominal pain
Diarrhoea
Weight loss due to anorexia b/c ea%ng causes pain
Diarrhoea not usually bloody
Crohn’s coli%s presents iden%ally to UC but it spares the rectum
and may present as perianal CD, unlike UC
•  May present with bowel obstruc%on
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•  Histology
•  Terminal ilium and right side of colon most common
•  En%re wall of bowel is thickened and oedematous, with
inflamma%on throughout all layers of bowel wall
•  Deep ulcers – o\en appear as linear fissures which may penetrate
into other structures e
...
vagina, bladder

Investigations
•  Bloods

•  FBC – may show anaemia
•  CRP and ESR – elevated in exacerba%ons due to inflammatory response
•  Albumin – may be reduced due to protein-losing enteropathy, inflammatory
disease or poor nutri%on

•  Stool culture

•  Rule out infec%on

•  Endoscopy with biopsy
•  Crohn’s
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•  UC
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Patchy inflamma%on
Discrete, deep ulcers
Perianal disease (fissures, fistulas, skin tags)
Rectal sparing
Strictures are common
Loss of vascular pahern
Granularity
Friability
Ulcera%on
Stricture forma%on does not happen in absence of carcinoma

•  Radiology
•  Barium enema can iden%fy strictures and narrowing – not commonly used, MRI
more reliable
•  Plain XR in severe ac%ve disease can reveal dila%on, oedema or perfora%on

Management – Crohn’s disease
•  Treat acute ahacks
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Aminosalicylates and cor%costeroids
Abscess or fistula%ng disease must be ruled out before i
...
steroids
Nutri%onal therapy – polymeric or elemental diets
An%-TNF an%bodies (infliximab and adalimumab) effec%ve in CD but
enteracept is not

•  Prevent relapse
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Thiopurines
Methotrexate
Smoking cessa%on
Aggressive disease managed with immunosuppressives and an%-TNF
therapy

•  Detect carcinoma
•  Select pa%ents for surgery

•  At early stage for those who respond poorly to drug therapy
•  Required in fistulae to prevent sepsis

Management – UC
•  Treat acute ahacks

•  Mesalazine – oral combined with suppositories or enemas
•  Pa%ents who fail to respond can be given prednisolone
•  Pa%ents who do not respond to cor%costeroids can be given
ciclosporin or infliximab
•  IV fluids

•  Prevent relapse

•  Life-long maintenance therapy
•  Oral aminosalicylates (mesalazine or balsalazide)
•  Sulfasalazine has more AEs but can be used in a pt with coexis%ng
arthropathy
•  Thiopurines can be used in those who relapse even though on
aminosalicylates

•  Detect carcinoma
•  Select pa%ents for surgery

•  Colectomy in those who fail to respond to drug treatments or those
who develop colonic dilata%on

Complications
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Predisposed to carcinoma
Pregnancy – drug treatments can be con%nued
Osteomalacia can occur in CD due to malabsorp%on
Keep steroid use minimal to avoid osteoporosis

Diverticular Disease

Aetiology
•  Life-long diet rela%vely deficient in fibre is believed to be
responsible
•  Postulated that small volume stools require high intracolonic
pressures
•  This leads to hernia%on between the teniae coli
•  Diver%cula are protrusions of mucosa covered by peritoneum
•  Inflamma%on results from impac%on of diver%cula with
faecoliths

Presentation
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Cons%pa%on
Colicky pain in le\ iliac fossa
Sigmoid colon may be palpable
In ahacks
•  Local guarding
•  Rigidity (“le\-sided appendici%s”)
•  May be a palpable mass

•  May also be diarrhoea, rectal bleeding or fever

Investigations
•  Barium enema – confirms presence of diver%culae, strictures
and fissures
•  Flexible sigmoidoscopy – to exclude neoplasm
•  Colonoscopy – carries risk of perfora%on, needs expertese
•  CT – can be used to assess complica%ons

Management
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If asymptoma%c, requires no treatment
Cons%pa%on – high fibre diet
Can use bulking laxa%ves, never use s%mulant laxa%ves
An%spasmodics may help
Acute ahack – 7d metronidazole w/ cephalosporin or
ampicillin
Severe cases – IV fluids, IV an%bio%cs, analgesia, NG suc%on
Emergency surgery – severe haemorrhage or perfora%on
Percutaneous drainage of acute paracolic abscesses may
avoid the need for emergency surgery
Elev%ve surgery may be performed a\er recovery from
repeated ahacks of obstruc%on – resec%on of affected
segment with primary anastamosis

Complications
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Haemorrhage
Perfora%on
Local abscess forma%on
Fistulae
Peritoni%s
Repeated ahacks of inflamma%on lead to thickening of the
bowel wall, narrowing of the lumen and eventually,
obstruc%on

Colorectal Cancer

Aetiology

Presentation

Investigations

Management

Complications



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