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CHAPTER12 Gastrointestinalmedicine
Hernias
• Irreduciblehernia
• Most types of hernia may become irreducible
• It may be the rst presentation of a hernia or a complication of a
longstanding hernia
• If obstructed (incarcerated) or strangulated (blood supply to bowel
contained within the hernia sac is compromised), the hernia is tender
and there are symptoms/ signs of small bowel obstruction
• If you are unable to reduce a hernia, admit for surgical assessment.
Inguinal hernia Protuberance of peritoneal contents through the ab-
dominal wall where it is weakened by the presence of the inguinal canal.
Common condition ( > ) which can occur at any age.
Presentation Lump in the groin ± discomfort on straining/ standing for any
length of time. There may be a distinct precipitating event (e.g. heavy lifting).
Risk factors:chronic cough (e.g. COPD), constipation, urinary obstruction,
heavy lifting, ascites, previous abdominal surgery. 2 types:
• Indirect (80%) Follow the course of the spermatic cord or round
ligament down the inguinal canal through the internal inguinal ring
(located at the mid- point of the inguinal ligament, 1.5cm above the
femoral pulse) and sometimes out through the external inguinal ring into
the scrotum/ vulva
• Direct (20%) Pass through a defect in the abdominal wall into the
inguinal canal. Rare in children and more common in the elderly
Dierential diagnosis ofgroin lumps Table 12.7
Examination Examine the patient standing up. Look for a bulge in the groin
above the line of the inguinal ligament. Unless incarcerated the lump should
have a cough impulse. Check that you are able to reduce the hernia—
sometimes it is easier if the patient lies down. Ask the patient to reduce the
hernia if you cannot.
Management Small hernias often require no treatment. For larger hernias
and smaller hernias that are symptomatic, consider referral for surgical repair. Various methods are used— all have a high level of success (<2% recurrence). Trusses can be useful for symptomatic hernias in elderly patients,
those unt for surgery, or while awaiting surgery (prescribe on FP10).
Inguinal hernias inchildren E p. 868
Femoral hernia Less common than inguinal hernia. > . The pa-
tient is usually elderly, although can occur at any age. Peritoneal contents
protrude down the femoral canal. Risk of strangulation is high. Presents as a
painful lump in the groin and/ or small bowel obstruction.
Examination Rounded swelling medially in the groin and lateral to the pubic
tubercle; if reducible a soft palpable lump remains after reduction.
Management Always refer for urgent surgical repair. Admit as surgical
emergency if obstructed or irreducible.
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HERNIAS
Table12.7 Dierential diagnosis ofgroin lumps
Position relative
to the skin
In the skin Lipoma, broma, haemangioma,
Deep to the skin Femoral or inguinal lymph nodes
Groin lump Position relative to
and other skin lumps
Saphena varix of the femoral vein
Femoral artery aneurysm
Femoral hernia
Inguinal hernia
the inguinal ligament
Above Below
Incisional hernia Breakdown of the muscle closure in an abdominal
wound sometime after surgery. There may be a history of wound sepsis,
haematoma, or breakdown. Presents with a bulge at the site of the operation scar ± discomfort.
Examination The hernia is usually visible when the patient stands— it can be
made more obvious by asking the patient to cough or straight leg raise while
lying at. The margins of the muscular defect are palpable under the skin.
Note whether fully reducible or not.
Management Often reassurance suces. If obstructed/ strangulated or
causing discomfort, then refer for surgical assessment.
Umbilical hernia Most common in infants (E p. 868). In adults para-
umbilical hernias, presenting as a bulge adjacent to the umbilicus, may
occur due to weakness in the linea alba. > . Refer adults for surgical
assessment— usually repaired as risk of strangulation is high. Admit as a surgical emergency if obstructed/ irreducible.
Epigastric hernia Midline hernia through a defect in the linea alba
above the umbilicus. Never contains bowel. Usually symptomless though
occasionally causes epigastric pain ± vomiting. Examination:epigastric mass
with cough impulse. Refer for surgical repair.
Spigelian hernia A hernial sac protrudes lateral to the rectus sheath
midway between umbilicus and pubic bone. Presents with discomfort ±
vomiting. Refer for surgical repair.
Obturator hernia Hernia protrudes out from the pelvis through the
obturator canal. Usually presents with strangulation ± pain referred to the
knee. Admit for surgery.
Richter hernia A knuckle of the side wall of the gut gets caught in a
hernia sac and becomes strangulated but the bowel is not obstructed.
Presents with abdominal pain which rapidly becomes worse ± shock. Admit
as for acute abdomen; diagnosis is usually made at surgery.
0 The inguinal ligament runs from the pubic tubercle medially to the anterior superior iliac spine laterally.
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CHAPTER12 Gastrointestinalmedicine
Appendicitis and small boweldisease
Acute appendicitis Most common surgical emergency in the UK.
Peak age:10– 30y. Presents with central abdominal colic that progresses
to localize in the right iliac fossa. Pain is worse on movement (especially
coughing, laughing) and associated with anorexia, nausea ± vomiting, dysuria, constipation, or rarely diarrhoea.
Assessment Watch for discomfort on walking (walk stooped). May be
ushed and unwell— pyrexial (737.5°C); furred tongue and/ or fetor oris;
tenderness, rebound tenderness and guarding in the right iliac fossa (especially over McBurney’s point— ⅔ of the distance between the umbilicus and
anterior superior iliac spine); pain in the right iliac fossa on palpation of the
left iliac fossa (Rovsing’s sign). Urinalysis is normal or +ve for protein and/
or leucocyte esterase but −ve for nitrites.
Dierentialdiagnosis
• Mesenteric adenitis
• Gastroenteritis
• Meckel’s diverticulum
• Intussusception
• Crohn’s disease
Management Admit as a surgical emergency— expect to be wrong 7½ the
time. Complications:generalized peritonitis 2° to perforation; appendix abscess; appendix mass; subphrenic abscess; female infertility
• Appendicitis inpregnancy Appendicitis aects 1 in 1000 preg-
nancies. Mortality is i and perforation more common (15– 20%). Fetal
mortality is 5– 10% for simple appendicitis; 30% when there is perforation.
Due to the pregnancy, the appendix is displaced— pain is often felt in the
paraumbilical region or subcostally. Admit immediately if suspected.
• Urological cause, e.g. UTI, testicular torsion
• Gynaecological cause, e.g. pelvic
inammatory disease, ectopic pregnancy
• Non- abdominal cause e.g. otitis media,
diabetic ketoacidosis, pneumonia
Children withappendicitis Symptoms/ signs of appendi-
citis may be atypical— especially if very young— as children localize pain poorly and signs of peritonitis can be dicult to elicit.
• If unsure of diagnosis, and the child is unwell, admit
• If unsure of diagnosis, and the child is well, either arrange to review
a few hours later or ask the carer to contact you if there is any
deterioration or change in symptoms
Mesenteric adentitis Inammation of the mesenteric LNs causing
abdominal pain in children. May follow URTI. Can mimic appendicitis.
Check MSU to exclude UTI. If guarding/ rebound tenderness, refer for
acute surgical assessment. Settles spontaneously with simple analgesia
and uids. If not settling in 1– 2wk refer for paediatric assessment.
Subphrenic abscess Rarely follows 7– 21d after generalized
peritonitis— particularly after acute appendicitis. Presents with general malaise, swinging fever, nausea and weight d ± pain in the upper abdomen radiating to the shoulder tip. Breathlessness can be associated due to reactive
pleural eusion or lower lobe collapse. Examination:subcostal tenderness ±
liver enlargement. FBC i WCC. If suspected admit.
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APPENDICITIS AND SMALL BOWELDISEASE
Meckel’s diverticulum Remnant of the attachment of the small bowel
to the embryological yolk sac. It is 2inches (~5cm) long, 72 foot (100cm)
proximal to the appendix, and present in 2% of the population. AMeckel’s
diverticulum may not cause any problems or cause an appendicitis- like picture; acute intestinal obstruction or GI bleeding. Symptoms can occur at any
age but are most common in children.
Intussusception E p. 869 Coeliac disease E p. 382
Crohn’s disease E p. 384 Obstruction and ischaemia
Ep.372
Adhesions Arise as a result of intra- abdominal inammation. Bowel loops
become adherent to each other, omentum, mesentery, and the abdominal
wall. Fibrous bands may form connecting adjacent structures. Presents with
abdominal pain ± obstruction. Causes:surgery; intra- abdominal sepsis (e.g.
appendicitis, cholecystitis; salpingitis); inammatory bowel disease; endometriosis. Refer to a surgeon. Treatment is dicult as any surgery may result in new adhesions; conservative management with analgesia and stool
softeners is preferred. Laparoscopic, or rarely open division of adhesions,
is occasionally necessary.
Intestinal non- Hodgkin’s lymphoma The majority of intestinal
NHLs are B- cell- type lymphomas, but coeliac disease is associated with Tcell intestinal lymphoma. Abdominal symptoms:non- specic abdominal pain
(70– 80%); perforation (up to 25%); bowel obstruction; abdominal mass;
intussusception; malabsorption (usually lymphoma associated with coeliac
disease) or alteration in bowel habit (small intestine NHL may present like
Crohn’s disease). Systemic symptoms:weight d (30%), fatigue, sweats, unexplained fevers. 0 Lymphadenopathy and hepatosplenomegaly are usually
absent.
Management E p. 656. Gastric lymphoma may remit with treatment of
H.pylori infection.
Carcinoid tumours Slow- growing tumours of low malignancy which
arise from neuroendocrine cells or their precursors. Incidence: 3– 4/
100,000. Peak age:61y. > . 60% are in the midgut (especially appendix
and terminal ileum). Examination may reveal an abdominal mass and/ or
enlarged liver. Rarely presents with bowel obstruction. Ileal carcinoids are
multiple in 30%. Non- intestinal sites:lung, testes, and ovary.
Carcinoid syndrome Aects <10% of patients with a carcinoid tumour.
Develops when serotonin (5HT) is released by the tumour and not degraded by the liver due to hepatic metastases. Features:
• Paroxysmal ushing, e.g. following alcohol or certain foods
• Watery, explosive diarrhoea
• Abdominal pain
• Rash— symmetrical, pruritic erythematous rash which blisters/ crusts
Management Refer for urgent assessment if suspected. Therapeutic options include surgery, somatostatin analogues such as octreotide, or
radiofrequency ablation of liver metastases. Prognosis— if no metastases,
median survival is 5– 8y; with metastases median survival is 38mo.
• Bronchoconstriction (like asthma)
• Right heart failure
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CHAPTER12 Gastrointestinalmedicine
Colorectal cancerscreening
Screening for colorectal cancer is available throughout the UK. Overall colorectal cancer 5y survival 850%. Patients presenting with tumour conned
to the bowel wall have >90% long- term survival. Screening aims to detect
colorectal cancer at an early stage to i survival chances.
Screening test Faecal immunochemical test (FIT) kits are sent every 2y
to all patients aged 60– 74y with instructions for completion/ return. Results
are sent to the patients in <2wk.
Screening by a one- o exible sigmoidoscopy is being introduced gradually
across England for all patients >55y.
Screening outcomes All those who have a positive FIT test are invited
for a colonoscopy pre-assessment appointment. Possible outcomes from
colonoscopy are summarized in Table 12.8. If 60% of those aged 60– 69y do
the FIT test, 1200 deaths would be prevented each year.
Family history If a patient has one rst- degree relative (mother, father,
sister, brother, daughter, or son) with colorectal cancer, risk of developing
colorectal cancer is i 2– 3×.
Refer forcolonoscopy At presentation or aged 35– 40y (whichever is later)
and repeat colonoscopy aged 55y if:
• 2× rst- degree relatives with a history of colorectal cancer or
• 1× rst- degree relative with a history of colorectal cancer aged <45y
Refer forspecialist follow- up and genetic counselling If:
• >2× rst- degree relatives with a history of colorectal cancer or
• Family history of:
• Familial adenomatous polyposis (FAP)— usually develop cancer aged
<40y. Lifetime risk of colorectal cancer is 1:2.5
• Juvenile polyposis— lifetime risk of colorectal cancer is 1:3
• Peutz– Jeghers syndrome— autosomal dominant disorder. Benign
intestinal (usually small intestine) polyps in association with dark
freckles on lips, oral mucosa, face, palms, and soles. May cause GI
obstruction or GI bleeding. Malignant change occurs in 83%
• Hereditary non- polyposis colorectal cancer (Lynch syndrome)— ≥3
family members with colorectal cancer where ≥2 generations have
been aected and ≥1 aected family member developed the disease
<50y of age; 40% lifetime risk of colorectal cancer
• MMR (mismatch repair) oncogene
Ulcerative colitis i risk of colorectal cancer. Oer all patients a follow-
up plan agreed with their specialist. In some cases, prophylactic colectomy
is appropriate.
Previous colorectal cancer i risk of developing a second colorectal
primary. After successful treatment, younger patients are routinely followed
up with colonoscopy every 5y until 70y. Remain vigilant for recurrences and
re- refer urgently if suspected.
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COLORECTAL CANCERSCREENING
Table12.8 Colonoscopy outcomes
• ~2% of those FIT tested are referred on for colonoscopy— uptake of
colonoscopy is ~80%
• Sensitivity of colonoscopy to detect signicant abnormalities is ~90%
• Polyps found during colonoscopy are usually removed
• Complications of colonoscopy include heavy bleeding (1:150); bowel
perforation (1:1500); death (1:10,000)
Colonoscopy result Explanation Action
Normal (~50%) No abnormalities
Polyp
Low risk 1– 2 small (<1cm)
(~40%)
Intermediate
risk
High risk ≥5 adenomas or ≥3
Cancer (~10%) Colorectal cancer
Other pathology Other pathology
Technical diculty Unable to perform the
detected
adenomas
3– 4 small (<1cm)
adenomas or ≥1 adenoma
≥1cm
adenomas of which at
least 1 is ≥1cm
detected at colonoscopy
(e.g. UC) detected at
colonoscopy
procedure adequately
FIT screening oered again in
2y if <70y
FIT screening oered again in
2y if <70y
3 yearly colonoscopy until
2× negative examinations
Colonoscopy at 12mo then
3yearly colonoscopy until
2× negative examinations
Refer urgently for further
treatment
Refer/ treat/ advise as
necessary
Repeat colonoscopy or
alternative imaging
FIT testing for symptomatic patients FIT tests should be oered
to adults without rectal bleeding who are:
• Aged ≥50y with unexplained abdominal pain or weight loss, or
• Aged <60y with changes in bowel habit or iron deciency anaemia, or
• Aged ≥60y with anaemia without iron deciency
Further information
NHS Bowel Cancer Screening Programme M https:// www.gov.uk/ guid-
ance/ bowel- cancer- screening- programme- overview
NICE (2015, updated 2017)Suspected cancer:recognition and referral. M
www.nice.org.uk/ guidance/ ng12
NICE (2017) Quantitative faecal immunochemical tests to guide referral for
colorectal cancer in primary care. M https://www.nice.org.uk/guidance/dg30
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CHAPTER12 Gastrointestinalmedicine
Colorectalcancer
Lifetime risk of developing colorectal cancer is 1:15 for and 1:19 for .
Colorectal cancer accounts for 14% of all cancers and 16,000 deaths/ y in
the UK. ⅔ arise in the colon and ⅓ in the rectum; 72% of tumours occur in
patients >65y and >95% are adenocarcinomas.
Adenomatous polyps Bowel cancers arise from polyps over many
years. Polyps may be removed because of risk of malignant change. Followup surveillance with repeated colonoscopy may be necessary depending on
the number of polyps and their size (Table 12.8, E p. 369).
Protective and riskfactors
Lifestylefactors
• Obesity— i risk by 15% if overweight and 30% if obese
• Dietary factors— diets with less red and processed meat, and more
vegetables, bre, sh, and milk are associated with d risk (diet is thought
to explain geographic variations)
• Alcohol— i risk for heavy drinkers— especially if also low folate
• Physical activity— i physical activity can d risk by 30%
Medicationhistory
• HRT— risk d by 20% if ever taken; d by 30% if taking HRT currently
• COC pill— risk d by 18% if ever taken
• Statins— risk is d after 5y use
• Aspirin— 75mg od taken for >5y d risk by 40%
Other medicalhistory
• History of gallbladder disease and/ or cholecystectomy— 50% i in risk
• Type 2 (non- insulin dependent) diabetes— 30% i risk
• UC or Crohn’s disease— i risk (E p. 384)
Family history E p.368
Bowel cancer screening E p. 368
Presentation May be found at bowel cancer screening. Clinical presen-
tation depends on site involved:
• Change in bowel habit Diarrhoea ± mucus, constipation or alternating
diarrhoea and constipation, tenesmus
• Intestinal obstruction Pain, distension, absolute constipation, ±
vomiting. May be an acute, sudden event (20% of patients not detected
by screening present with an acute obstruction) or gradually evolve
• Rectal bleeding Bright red rectal bleeding or +ve faecal occult blood
test— 60% rectal tumours. Rarely melaena if high tumour
• Perforation Causing generalized peritonitis, or into an adjacent viscus
(e.g. bladder) resulting in a stula
• Spread Abdominal distension 2° to ascites, jaundice, rectal/ pelvic pain
• General eects Weight d, anorexia, anaemia, malaise
Examination andinvestigation
• General examination— cachexia, jaundice, anaemia (check FBC)
• Abdominal mass • Hepatomegaly • Ascites
• Rectal examination— detects >75% of rectal tumours
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COLORECTALCANCER
•Suspicious lower GI symptoms and signs Refer urgently (to
be seen in <2wk) to a team specializing in lower GI malignancyN:
Anyage
• Rectal or abdominal mass consistent with involvement of large bowel.
0 Apelvic mass outside the bowel warrants urgent referral to a
urologist or gynaecologist
• Rectal bleeding AND abdominal pain or change in bowel habit, weight
d or iron deciency anaemia
Aged ≥40y With unexplained weight d and abdominal pain
Aged ≥50y With unexplained rectal bleeding
Aged ≥60y With iron deciency anaemia or changes in bowel habit or
tests showing faecal occult blood in their faeces
Specialist management Conrmation of diagnosis with sigmoid-
oscopy/ colonoscopy and/ or CT colonography. If diagnosis is conrmed
further investigations include LFTs, tumour markers (carcinoembryonic
antigen or CEA is produced in >80% advanced tumours), CXR, CT/ MRI,
and USS to evaluate spread.
Treatment Laparoscopic or open surgical resection when possible.
Staging based on ndings at surgery dictates further management with
chemotherapy. For patients with more advanced disease, resection of or
radioablation of hepatic metastases may be an option.
Adverse pathological features Adverse clinical features
• Presence/ number of involved LNs
• Lymphovascular, perineural, or
venousinvasion
• Depth of bowel wall penetration
• Positive resection margin
• Mucinous histology
• Emergency presentation
with bowel obstruction or
perforation
• Incomplete resection
• Metastatic disease
• Presentation aged <50y
Further information
NICE (2011, updated 2014)Colorectal cancer. M www.nice.org.uk/ guid-
ance/ CG131
NICE (2015, updated 2017)Suspected cancer:recognition and referral. M
www.nice.org.uk/ guidance/ ng12
SIGN (2011) Diagnosis and management of colorectal cancer. M www.
sign.ac.uk/ sign- 126- diagnosis- and- management- of- colorectal- cancer.html
Patient advice and support
British Colostomy Association F 0800 328 4257 M www.
colostomyassociation.org.uk
Cancer Research UK F 0808 800 4040 M www.cancerhelp.org.uk
Macmillan Cancer Support F 0808 808 0000 M www.macmillan.org.uk
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CHAPTER12 Gastrointestinalmedicine
Other large bowelconditions
Intestinal obstruction Blockage of the bowel due to either mechan-
ical obstruction or failure of peristalsis (ileus). Causes:
• Obstruction from outside the bowel Adhesions/ bands; volvulus;
obstructed hernia (E p. 364); neighbouring malignancy (e.g. bladder)
• Obstruction from within the bowel wall Tumour; infarction; congenital
atresia; Hirschsprung’s disease; inammatory bowel disease (E p. 384);
diverticulitis
• Obstruction in the lumen Impacted faeces/ constipation (E p. 350);
bolus obstruction (e.g. swallowed foreign body); gallstone ileus;
intussusception (E p. 869); large polyps
• Ileus/ functional obstruction Postoperatively; electrolyte disturbance;
uraemia; DM; back pain; anticholinergic drugs
Presentation Anorexia; nausea; vomiting (may be feculent) gives relief; colicky central abdominal pain and distension; absolute constipation for stool
and gas (though if high obstruction constipation may not be absolute).
Examination:uncomfortable and restless; abdominal distention ± tenderness (though no guarding/ rebound); active tinkling bowel sounds or quiet/
absent bowel sounds (later).
Management Admit as surgical emergency.
Diverticulosis Common condition of the colon associated with muscle
hypertrophy and i intraluminal pressure. Mucosa- lined pouches are pushed
out through the colonic wall usually at the entry points of vessels. These
pouches are the diverticula; 95% are in the sigmoid colon although they may
occur anywhere in the bowel. They are present in >1:3 people >60y in the
UK. Risk factors include low- roughage diet and age. Diverticular disease
implies the diverticula are symptomatic— Table 12.9.
Ischaemic bowel Interruption of the blood supply of the bowel.
• 1° ischaemia Usually due to either mesenteric embolus from the right
side of the heart, or venous thrombosis and typically occurs in elderly
patients who might have pre- existing heart or vascular disease
• 2° ischaemia Usually due to intestinal obstruction (e.g. strangulated
hernia, volvulus, intussusception)
Presentation Sudden onset of abdominal pain which rapidly becomes
severe. There may be a prior history of pain worse after meals (mesenteric angina). Rarely presents with PR bleeding. Examination:very unwell;
shocked; may be in AF; generalized tenderness but normally no guarding/
rebound. Often signs are out of proportion to symptoms.
Management Give opioid analgesia. Admit as surgical emergency.
Sigmoid volvulus Occurs in people who have redundant colon on a
long mesentery with a narrow base. The sigmoid loop twists causing intestinal obstruction. The loop may become ischaemic. Risk factors: constipation, laxatives, tranquillizers. Presents with acute onset of abdominal
distention and colicky abdominal pain with complete constipation and absence of atus. There may be a history of repeated attacks.
Management Admit acutely to hospital. Treatment is release by passing a
atus tube and/ or surgery. Once treated, d recurrences by preventing constipation and stopping tranquillizers if possible.
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OTHER LARGE BOWELCONDITIONS
Table12.9 Presentation and management ofdiverticular disease
Presentation Management
Chronic
diverticulitis
(painful
diverticular
disease)
Acute
diverticulitis
Diverticular
abscess
Perforated
diverticulum
Fistula
formation
Diverticular
haemorrhage
Post- infective
stricture
Presents with altered bowel
habit, abdominal pain (often
colicky and left sided), nausea,
and atulence
Symptoms are often improved by
defecation
Presents with:
• Altered bowel habit
• Colicky left- sided abdominal
pain— may become continuous
and cause guarding/ peritonism
in the left iliac fossa
• Fever
• Malaise ± nausea
• Flatulence
0 There may be few abdominal
signs in the elderly
Presents with swinging fever,
general malaise, ± other localizing
symptoms, e.g. pelvic pain
Presents with ileus, peritonitis
and shock
A stula may form if a
diverticulum perforates into
bladder, vagina, or small bowel—
E p. 352
Common cause of rectal
bleeding— usually sudden and
painless
Fibrous tissue formation following
infection can cause narrowing of
the colon l obstruction
Investigate for change in bowel
habit (E p. 370)
Once diverticular disease is
conrmed, treat with high- bre
diet ± antispasmodics (e.g.
mebeverine 135mg tds)
Refer if severe symptoms
Treat with oral antibiotics (e.g.
co- amoxiclav 250mg tds or
cefaclor 250– 500mg tds and
metronidazole 400mg bd or
ciprooxacin 500– 750mg bd)
There may also be some benet
from a low- residue diet
If severe symptoms, uncertain
diagnosis, or not settling, admit
as an acute surgical emergency
Refer for urgent surgical
assessment/ admit as a surgical
emergency
Admit as an acute surgical
emergency
Refer for surgical assessment
Treatment is usually surgical
Gain IV access
Admit as an acute surgical
emergency (E p. 1061)
Keep stool soft
If recurrent problems refer for
surgery
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Hirschsprung’s disease Caused by absence of the ganglion
cells of the myenteric plexus in the distal bowel. Presents with
delay in passing meconium, abdominal distension, vomiting, and
poor feeding in a neonate. If only a short segment is aected,
presentation may be much later with chronic constipation. Diagnosis is
conrmed with rectal biopsy. Refer to surgery. Treatment is surgical removal of the aected area of bowel.
Carcinoma ofthe colon E p. 370
Anal conditions E p. 374
Inammatory bowel disease E p. 384
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