Page 172 - Medicine and Surgery

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168 Chapter 4: Gastrointestinal system

Complications Sex
Perforation presents as an acute abdomen with peri- 1M:2F

tonitis.
Bleeding which may be significant.
Aetiology/pathophysiology
Obstruction due to oedema, fibrosis or adherence of
50% of patients seen in gastroenterology clinics at-
small bowel loops. tribute the onset of their symptoms to a stressful
Stricture formation in long-standing disease difficult
event including physical or sexual abuse as child or
to differentiate from malignant strictures. adult. Patients have a higher incidence of psycholog-
Fistulae may occur to skin or viscera. A colovesical
ical symptoms, psychiatric disease and other somatic
fistula presents with painful passage of pneumaturia. complaints.
10–20% of patients relate the onset of their symp-

toms to an acute gastrointestinal illness. Food allergy
Investigations
is rare but many patients believe that certain foods ex-
Barium enema can be used to demonstrate the presence
acerbate symptoms. There is no consistent evidence
of diverticulae. They may be seen on colonoscopy (con-
of abnormal motility.
traindicated in acute diverticulitis).
Some patients with irritable bowel syndrome exhibit

evidence of altered CNS processing of visceral pain.
Management
Most patients improve on a high-fibre diet and bulk-
Clinical features
forming laxatives such as Fybogel.
Patients complain of recurrent abdominal pain, most
Acute diverticulitis is treated with bowel rest, intra-

often in the left iliac fossa, associated with disturbed
venous fluids and broad-spectrum antibiotics.
bowel habit (including the passage of mucous). There
Surgery may be indicated for refractory symptomatic

is often a sensation of bloating and the frequent passage
diverticulosis. A sigmoid colectomy and end-to-end
of small volume stool, which may relieve discomfort.
anastomosis is performed.
Non-gastrointestinal symptoms include lethargy, poor
Perforation is treated with resuscitation and surgical

sleep, generalised aches and pains. Examination is
resection. If there is peritonitis a Hartman’s proce-
unremarkable.
dure (distal segment is oversewn and returned to the
abdomen, proximal segment brought to surface as
Investigations
acolostomy) or exteriorisation of both ends of the
Investigation is required if there is weight loss, rec-
bowel is performed, with secondary anastomosis 6–8
tal bleeding, nocturnal symptoms, anaemia or an
weeks later.
atypical history particularly in older patients. In-
Stricturesorobstructionsaretreatedbysurgicalresec-

vestigation may include flexible sigmoidoscopy, with
tion followed by primary or secondary anastomosis.
colonoscopy/barium enema in patients with onset of
Severe bleeding may require embolisation or surgery.

symptoms over the age of 45 years.
Irritable bowel syndrome Management
Definition Psychological support and reassurance is essential.
Acondition of disordered lower gastrointestinal func- Coexistent psychological disorders should be iden-
tion in the absence of known pathology of structure. tified and treated; relaxation therapy, biofeedback
training and cognitive behavioural therapy may be of
Prevalence benefit.
Common, affecting ∼10% of the population. Asensible balanced diet avoiding food fads and exces-
sive caffeine.
Age Antispasmodicsmayhelp,e.g.hyoscinebutylbromide,
Any mebeverine. Alternatively a tricyclic antidepressant