1. Gastroenterology
WITH SURGICAL PROBLEMS

2. Basic Physiology

3. Investigations – Blood Tests
• FBC
• U&Es
• LFTs
• Amylase
• ESR/CRP
• Auto-Antibodies
• Tumour Markers
• Arterial Blood Gas
• Viral Serology
Anaemias, Raised WCC
Electrolyte disturbances
Albumin, Liver enzymes
Pancreatic Disease
Immune Response
Coeliac disease
Ca 19-9, CEA, AFP
Acidosis/Alkalosis, Hypoxia
Hepatitis antigens

4. Investigations - Imaging
• Abdominal X-ray
• CT scan
• MRI
• Barium Follow-Through/Enema

5. Investigations - Other
• CLO Test
• Flexible/Rigid Sigmoidoscopy
• Colonoscopy
• Endoscopy
• Endoscopic Retrograde Cholangiopancreotography
• Stool MSC

6. Scoring Systems
• Glasgow-Blatchford Score
• Rockall Score
• Modified Glasgow Score
• Child-Pugh score
• MELD score
• ALVARADO score
• Dukes’ Staging

7. 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.

8. 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

9. 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

10. Complications of GORD
• Barrett’s oesophagus
• Benign oesophageal stricture
• Oesophagitis/laryngitis
• Ulcerations

11. 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.

12. 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

14. Management
Patient Support
Oesophagectomy Endoscopic Therapy
Ablative Therapy
Mucosal
Resection
Further
Endoscopic
Therapy

15. Oesophageal Carcinoma
Dysphagia
Vomiting
Anorexia
GI Blood Loss
Odynophagia
Hoarseness
Retrosternal Pain
Lymphadenopathy
Intractable Hiccups

16. • 75% of oesophageal circumference must be involved to become
symptomatic
• 50% of patients who present due to symptoms already have
unresectable tumour/distant metastases

17. Investigations
• Urgent endoscopy
• Staging
• CXR
• Double-contrast barium swallow
• CR/MRI of chest, abdomen, pelvis
• Fluorodeoxyglucose positron emission topography (FDG-PET)

18. Management
Surgery
• 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

19. 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.

20. Assessment & Investigations
• Glasgow-Blatchford/Rockall Score
• CLO test
• FBC
• U&Es
• Coagulation Screen
• OGD

21. Management
• Acute Phase
• Terlipressin
• Prophylactic antibiotics
• Endoscopy & Band Ligation
• Prevention
• Propranolol
• Consider Transjugular Intrahepatic Portosystemic Shunt if bleeding
not controlled

22. 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.

23. Investigating Achalasia
• OGD
• X-ray
• Barium Swallow
• Oesophageal Manometry

24. Managing Achalasia
• Calcium-channel blockers & nitrates
• Pneumatic dilatation
• Endoscopic injection of botulinum toxin
• Heller myotomy

25. 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.

26. 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.

27. 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.

28. Investigations
• FBC
• CLO testing
• Endoscopy

29. Management
Behaviour
Modification
H pylori-
positive
H. pylori-negative,
NSAID induced
H pylori-negative,
NSAID-negative ulcer
REPEAT
ENDOSCOPY

30. 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.

31. 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

32. Palliation
Obstruction
• Stenting
• Gastrojejunostomy
• Endoscopic laser therapy
Anaemia
• Blood transfusions
Haemorrhage
• Treat the cancer
Pain
• Coeliac plexus nerve blocks

33. Prognosis
• Overall survival 15%
• 10-year survival is 11%
• If under 50 5-year survival is 15-20%
• If over 50 5-12%

34. 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.

35. Assessment
• FBC, U&Es, LFTs
• Phenotyping circulating lymphocytes
• Barium contrast studies of upper & lower GI tract
• CT/MRI scan
• Endoscopy
• Bone Marrow Aspiration

36. Staging
IE
IIE
IIIE
IV
L L
L
L

37. Management
PPI
H. Pylori
Eradication

38. 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

39. Gastroenteritis
• Amoebiasis
• Campylobacteriosis
• Cryptosporidiosis
• E. Coli
• Giardiasis
• Salmonellosis
• Shigellosis

40. 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.

41. Workup
• FBC
• PT/aPTT/INR
• LFTs
• Bilirubin
• Ammonia, Glucose, Lactate, Creatinine, Phosphate
• ABG
• Blood Cultures
• Viral Serology
• Autoimmune Markers
• Abdominal US/CT

42. Management ABC
Management of
Encephalopathy
& Oedema
Management of
Coagulopathy

43. Management
• Location
• Positioning
• Lactulose
• Haemodynamic monitoring
• Mannitol
• Hypothermia
Management of
Encephalopathy
& Oedema

44. Management
• Monitor INR
• FFP
• Cryoprecipitate
• Recombinant factor VIIa
• Platelet transfusions
Management of
Coagulopathy

45. Jaundice

46. Jaundice
History Bilirubin ALT AST ALP GGT
Pre-
Hepatic
Lethargy/fatigue
Stress
Trauma
Familial history
Raised
unconjugated
- - - -
Hepatic Preceding coryzal
symptoms
Medication
Previous liver disease
Risks for viral disease
Raised
unconjugated
AND conjugated Raised Raised
Normal/
Raised
Normal
Post-
Hepatic
Pale stool
Dark urine
RUQ pain (can be
painless)
Bilirubin
present in urine
Raised
conjugated
bilirubin
Raised Raised Raised Raised

47. The Path to Cirrhosis

48. Complications of Cirrhosis
• Hepatorenal syndrome
• Varices
• Infection (particularly bacterial peritonitis due to paracentesis)

49. Viral Hepatitis
• Hepatitis viruses
• Herpes viruses
• Epstein-Barr
• Cytomegalovirus
• Varicella
• Adenovirus
• Yellow fever
• Haemorrhagic viruses

50. 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)

51. 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.

52. 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.

53. Hepatitis B Testing

54. 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.

55. 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.

56. 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.

57. 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

58. Complications
• Hyperviscosity syndrome
• Hepatocellular carcinoma

59. 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.

60. 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.

61. Investigations
• Ultrasound visualisation
• ALP
• GGT
• WCC

62. Complications
Ascending Cholangitis
Rupture/Perforation
Pseudodiverticular of the gallbladder
Gallstone Ileus

63. Investigations & Management
• Ultrasound
• Pain relief
• Lithotripsy
• Laparoscopic cholecystectomy

64. 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.

65. Sepsis 6
Give 3
• High flow oxygen
• IV antibiotics
• IV fluids
Take 3
• Blood cultures
• Urine output
• Hb/Lactate

66. Other Investigations (& Management)
• Full Blood Count
• Liver Function Tests
• Ultrasound
• ERCP
Raised white cell count
Raised bilirubin ALP and GGT
Diagnosis
ERCP – visualise & remove obstruction

67. 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.

68. Other causes
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidemia, Hypothermia, Hypercalcemia
ERCP & emboli
Drugs

69. Investigations
• Amylase
• FBC, U&E, Glucose, CRP
• LFTs
• Serum calcium
• ABG
• Erect X-ray
• Ultrasound scan

70. Management
• Pain relief
• IV fluids
• IV antibiotics if severe pancreatic necrosis
• Enteral nutrition
• ERCP
• Cholecystectomy
• Hyperbaric oxygen therapy
• Whipple’s procedure

71. 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.

72. 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.

73. 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.

74. Investigations
• NO investigation to confirm IBS
• Full blood count
• ESR/CRP
• Antibody testing for coeliac disease

75. Management
• Assess diet & nutrition
• Physical activity levels
• Psychological status
• Dietary advice
• Treat constipation/diarrhoea appropriately

76. 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.

77. 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

78. ASSESS for osteoporosis
• Lifestyle & supplementation advice
• DEXA scan

79. Complications
• Anaemia
• Hyposlenism
• Osteoporosis
• Lactose intolerance
• Enteropathy-associated T-cell lymphoma of small intestine
• Subfertility
• Oesophageal Cancer

80. 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.

81. Complications
• Psychological effects
• Intestinal strictures
• Abscesses in the wall of the intestine
• Fistulas
• Anaemia
• Malnutrition
• Colorectal and small bowel cancers

82. 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

83. 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

84. Managing ‘Flares’
• CRP is raised AND:
• Cachexia/dramatic weight loss
• Obstruction/abscess
• Systemic illness
• Persistent symptoms
• Severe diarrhoea
• Short course of corticosteroids

85. Diarrhoea
• Symptomatically
• Anti-motility drugs
• Anti-spasmodic drugs
• Bulking agents
• REFER if systemically unwell

86. • 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

87. 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.

88. 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

89. 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

90. Pathology
Crohn’s
• Lesions seen anywhere from
mouth to anus
• Skip lesions
Ulcerative Colitis
• Inflammation starts at rectum
• Never beyond ileocaecal valve
• Continuous disease

91. 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

92. Endoscopy
Crohn’s
• Deep ulcers
• Skip lesions
• Cobble-stone appearance
Ulcerative Colitis
• Widespread ulceration
• Preservation of adjacent mucosa
• Pseudopolyps

93. 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

94. 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

95. 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.

96. 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.

97. Inguinal Hernia Anatomy

98. Management
• Elective Hernia Repair
• Avoid strangulation/ischaemia
• Admit as emergency if suspected

99. Other hernias
• Umbilical
• Paraumbilical
• Incisional
• Diaphragmatic/Hiatus
• Epigastric
• Obturator
• Perineal

100. 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

101. Causes
Small Bowel
• Adhesions
• Hernias
• Crohn’s
• Neoplasms
• Intussusception
• Ischaemic strictures
Large Bowel
• Neoplasms
• Diverticulitis
• Hernias
• Inflammatory Bowel Diseas
• Volvulus
• Adhesions

102. Imaging

103. 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

104. Large bowel obstruction
• NEED surgical intervention

105. Colorectal Cancer
Left sided
• Change in bowel habits
• Obstructive symptoms
• Diarrhoea
• Loose stools
• Blood in stools
Right sided
• Mass
• Abdominal pain
• Fever
• Sweating
• Anaemia

106. Referral
• Proforma for 2 week wait
• From presenting to GP, decision to treat must be made within 62 days

107. Investigations
• Flexible sigmoidoscopy + barium enema
• Colonoscopy
• CT Colonography
• Endoscopy
• BIOPSY

108. 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

109. 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

110. 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

111. 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

112. 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

113. Familial Adenomatous Polyposis
• <1% hereditary cancers
• Mutation of APC gene
• High malignant potential

114. Peutz-Jegher Syndrome
• VERY RARE
• Hereditary intestinal polyposis syndrome
• Autosomal dominant
• Criteria
• Family history
• Mucocutaneous lesions
• Hamartomatous polyps

115. 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