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3. Mondays > 304 GI surgery > Flashcards

304 GI surgery Flashcards

1
Q

What is an ileostomy?

A

A small bowel stoma

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2
Q

What are the indications for an ileostomy?

A

-To divert from a large bowel obstruction (tumour, stricture)
-To allow bowel rest (Fistula, perforation, anastomosis)
-Uncontrolled inflammatory bowel disease- Ulcerative colitis or Crohn’s

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3
Q

What are some different types of ileostomy?

A

End ileostomy: a permanent ileostomy with one opening from the ileum to the skin

Loop ileostomy: a temporary ileostomy. A slit is made and the bowel in made but nothing is removed. Allows for the bowel to be sutured and put back when ready

Double Barrelled stoma: a temporary ileostomy with 2 separate openings. Allows for draining of food contents and of the mucous from the unused end until they are ready to be sutured back together

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4
Q

Why might an ileostomy be used to rest the anastomosis?

A

-patients who are at high risk for anastomotic leak eg, malnourished, high-dose steroids, DM

-who have an intestinal anastomosis <5 to 7 cm from the anal verge (low anastomosis below the peritoneal reflection)

-hemodynamically unstable (eg, trauma, sepsis, perforation)

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5
Q

How does an ileostomy appear on examination?

A

-Usually placed on the right side
-Spouted to protect the skin
-Contents of the bag: Liquid stool
-Surrounding skin may be irritated, red and sore

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6
Q

What are the indications for a colonostomy?

A

-To divert from a large bowel obstruction (tumour, stricture)
-To allow bowel rest due to Fistula, perforation, complicated diverticulitis
-Trauma

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7
Q

What are some different types of colostomy?

A

Permanent end colostomy: In the case of a large resection and unable to join remaining bowel to the rectum or the patient is not fit for a second operation

Temporary end colostomy: In the case that pathology needs to settle or patient needs to be ‘fitter’ before the second operation. The rectum remains as a stump in the body until it’s ready to be reattached.

Loop colostomy: A slit is made to protect a distal anastomosis. The parts can be reattached when ready

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8
Q

How does a colostomy appear on examination?

A

-Usually on the left
-‘Flush’ to the skin
-The contents of the bag is usually more solid

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9
Q

What is a urostomy?

A

Created after cystectomy

-They drain urine from the ureters to the skin and into the stoma bag
-The connection between the ureters and the skin is made using an ‘ileal conduit’, a part of the ileum
-They are typically located in theright iliac fossa(RIF)

The bag will containurine

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10
Q

What is a cyctectomy?

A

Bladder removal

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11
Q

Where is a stoma positioned?

A

-Away from the site of the incision
-Away from bony prominences
-Where it can be strengthened by the rectus sheath
-Away from the belt line
-Accessible to the patient

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12
Q

What are some immediate (days) complications of stomas?

A

GA complications
Necrosis
Bleeding
Retraction
Infection
Psychological

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13
Q

What are some early (weeks) complications of stomas?

A

Stenosis/ obstruction
High output – dehydration/electrolyte imbalance
Retraction
Skin irritation
Infection
Psychological

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14
Q

What are some late (months) complications of stomas?

A

Stenosis/ obstruction
Parastomal hernia
Retraction
Prolapse
Fistula formation
Skin irritation
Infection
Psychological

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15
Q

What is a Hartmann’s procedure for stoma?

A

A type of temporary colectomy that removes part of the colon and sometimes rectum

The remaining rectum is sealed off to create a stump, creating what is known as Hartmann’s pouch. The remaining colon is redirected to a colostomy

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16
Q

What is the most common cause of a ileostomy stopping working in Crohn’s patients?

A

Crohn’s causes transmural inflammation and can lead to stenosis and or fistula formation

Other causes: constipation, adhesions, stenosis, parastomal hernia and need to exclude new onset malignancy

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17
Q

How much output is considered high in a stoma?

A

More than 500ml in 24hrs

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18
Q

What are the complications caused by a high output stoma?

A

-Risk of dehydration and electrolyte disturbance
-IV fluids, correct electrolytes, may take time for body to adjust to the new stoma, may need loperamide to bulk up the stool

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19
Q

What is a true parasternal hernia?

A

A complication of a stoma

Not uncommon. Weakness in the abdominal wall leads to the protrusion of bowel

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20
Q

What is a loop colostomy prolapse?

A

When the intestine falls out after a loop colostomy

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21
Q

How is a loop colostomy prolapse treated?

A

Cool compresses and application of an osmotic agent (sugar) to reduce oedema, followed by manual reduction of the prolapse and application of a binder

Requires surgical intervention- resection and refashioning of stoma to stop recurrence

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22
Q

What are the 2 main caused of pancreatitis?

A

Gallstones or excess alcohol

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23
Q

What is the ‘I GET SMASHED’ acronym stand for?

A

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia/Hypothermia/Hypocalcaemia
ERCP
Drugs

Causes of pancreatitis

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24
Q

How is gallstone pancreatitis caused?

A

A stone travels really low and gets stuck in the common bile duct, blocking pancreatic ducts

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25
Q

What is the modified Glasgow score?

A

Criteria for acute pancreatitis

P- PO2 <8
A- Age >55
N- Neutrophilia WCC >15
C- Ca+ <2mmol/L
R- Renal Function- Urea >16mmol/L
E- Enzymes- AST LDH > 600, AST >200
A- Albumin <32g/L
S- Sugar- >10mmol

1= Mild 2 = Moderate ≥3 = Severe

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26
Q

How is acute pancreatitis managed?

A

Initial: ABCD
Analgesia +++
IV fluids +++
+/- O2
Catheter + fluid balance
NBM ±NGT
+/- detox regime
+/- anti-emetic

Further: MRCP/ERCP, +/- HDU/ITU, complications

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27
Q

What are some complications of acute pancreatitis?

A

-Hypovolaemic shock
-Haemorrhagic pancreatitis: Grey Turner’s/Cullen’s signs
-Pseudocyst formation
-Infected necrosis
-ARDS
-SIRS
-T2DM
-Chronic pancreatitis
-Multi organ failure
-Death

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28
Q

What are Grey Turner’s/Cullen’s signs for acute pancreatitis?

A

Grey Tuner’s: purple discolouration around the belly button

Cullen’s sign: Purple discolouration on the sides of waist

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29
Q

What is a Pseudocyst?

A

A collection of pancreatic fluids adjacent to the pancreas

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30
Q

What is ARDS?

A

Acute respiratory distress syndrome
- Causes low blood oxygen

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31
Q

What is SIRS?

A

Systemic inflammatory response syndrome
-An exaggerated defence response of the body to a noxious stressor

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32
Q

What are some complications of peptic ulcer disease?

A

Perforation
- Erosion through mucosa into peritoneal cavity

Severe haematemesis
-Erosion into a vessel

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33
Q

What is the management for peptic ulcer disease in the ER?

A

Initial:
ABCD
Analgesia and anti-emetic
IV fluids
±O2
Catheter + fluid balance
NBM
IV PPI

Further:
CT if stable
+/- HDU/ITU
Laparotomy + washout

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34
Q

What are the risk factors for peptic ulcer disease?

A

H.Pylori
NSAIDS
Smoking
Alcohol
Spiced foods
Blood group O
Social deprivation/alienation

Stress Ulcers
Zollinger-Ellison syndrome
Gastrinomas leading to hypersecretion of HCL
Curling ulcers, secondary to burns
Cushing ulcers, secondary to raised ICP

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35
Q

What is Zollinger-Ellison syndrome?

A

When gastrinomas (tumours) link, and cause the stomach to make too much acid

located mainly in your pancreas or duodenum

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36
Q

What are the differences between gastric and duodenal ulcers?

A

Gastric are exacerbated by food, Duodenal are relieved by food

Duodenal occur earlier in life. 25-30 compared to peak at 50 for gastric ulcers

Duodenal have a higher association with H Pylori

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37
Q

What is Murphy’s sign?

A

Tests for acute cholecystitis

Patient takes in and holds a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive

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38
Q

What are the different types of gall stones?

A

Cholesterol stones (yellow)
Mixed stones
Pigment stones (black/darker)

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39
Q

What are the risk factors for developing gallstones?

A

-Crohn’s disease
-Diabetes mellitus
-Diet - high in triglycerides, refined carbs and low in fibre
-Medication:Eg. Ceftriaxone
-Non-alcoholic fatty liver disease
-Obesity
-Prolonged fasting/weight loss
-Use of hormone replacement therapy (HRT)

3F:2M

40
Q

How does prolonged fasting/weight loss increase chances of gallstones?

A

It causes gallbladder hypomotility and increases cholesterol excretion in bile

41
Q

What is the management of acute cholecystitis?

A

Initial: ABCD
IV abx
Analgesia and anti-emetic
IV fluids
±O2
NGT if vomiting
Low fat diet
Fluid balance (consider catheter

Further:
Rx complications
‘hot’ or interval cholecystectomy

42
Q

What are some complications of acute cholecystitis?

A

Empyema/Mucocoele
GB perforation (rare)
GS ileus
Pancreatitis

43
Q

What is Empyema?

A

When pockets of pus that have collected inside a body cavity

44
Q

What is mucocele?

A

A benign, mucus-containing cystic lesion of the minor salivary gland

45
Q

What is ascending cholangitis?

A

Infection of the bile duct
Usually caused by ascending bacteria from duodenum

Other causes:
Gallstones
Strictures (benign/malignant)
Malignancy (CBD/pancreas)
Iatrogenic (eg ERCP)

46
Q

What is biliary colic?

A

Acute pain
-Caused by contraction

Brought on by fatty foods, systemically well

47
Q

What questions do you need to ask in a history of dysphagia?

A

-Difficulty swallowing solids and liquids from the start?
-Is it difficult to make the swallowing movement?
-Is swallowing painful (odynophagia)?
-Is the dysphagia intermittent or is it constant and getting worse?
-Does the neck bulge or gurgle on drinking?

48
Q

What is scleroderma?

A

Autoimmune inflammation

49
Q

What is a pharyngeal pouch?

A

AKA Zenker’s diverticulum

A sac or pocket which can develop between the lower part of the throat (pharynx) and the upper part of the gullet or food pipe (oesophagus)

50
Q

What is the management of oesophageal cancer?

A

Staging: CT, laparoscopy, EUS, PET
Surgical: Oesophagectomy
Medical: Chemotherapy/radiotherapy

Palliative: Stenting
Considerations: Analgesia and nutrition

51
Q

What are the 2 main types of oesophageal cancer?

A

Squamous cell carcinoma
-Tends to affect upper 2/3
-Smoking and alcohol related

Adenocarcinoma
-Tends to affect lower 1/3
- Associated with GORD, Barrett’s oesophagus, and obesity
-More common in the UK

52
Q

What is GORD?

A

Gastro oesophageal reflux disease
-Caused by decreased lower oesophageal sphincter tone.
-Can lead to Barrett’s oesophagus

53
Q

What is a Benign oesophageal stricture?

A

Narrowing of the oesophagus causing dysphagia

54
Q

What is an oesophageal web/ring?

A

Membranous structures in which a thin fold of tissue creates at least a partial obstruction of the oesophageal lumen

Cause is unknown

55
Q

What are the 4 types of cranial bleed?

A

Epidural
Subdural
Intracerebral (parenchymal)
Subarachnoid

56
Q

What are the risk factors for colorectal cancer?

A

-Male
-Increasing age
-Smoking
-Alcohol
-Obesity
-Family history
-Inflammatory bowel disease
-Socioeconomic related to race and class
-Higher rates in working class communities of all races and ethnicities as a result of social deprivation

57
Q

What are some red-flags in history suggesting colorectal cancer?

A

Over 40 with UNEXPLAINED weight loss
Over 50 with rectal bleeding
60 or over with iron deficiency anaemia
60 or over with a change in bowel habit
Palpable mass abdominally or rectally

58
Q

What are some tests for colorectal cancer?

A

Luminal (Tissue):
Gold standard – colonoscopy – RISKS Flexible sigmoidoscopy LIMITED STUDY OGD – IDA or obstructive symptoms

Radiological:
CT / MRI / USS / PET CT
‘Virtual colonoscopy’ – CT Colonography

Other – Blood tests – CEA, LFT, FBC

FIT/FOB

59
Q

What is a CEA test?

A

A tumour marker for colon and rectum cancer blood test

CarcinoEmbryonicAntigen
- A glycoprotein produced in foetal GI tissue involved in cell adhesion

Production stops at birth. Normal levels in adults 2-4 ng/ml.

A rising CEA level CAN indicate progression or recurrence of tumour

However not specific also raised in smokers and Cancer of prostate, ovary, lung, thyroid, liver cirrhosis, Non cancerous breast disease and emphysema

60
Q

What are the risks of luminal testing for colorectal cancer?

A

Bleeding
Perforation
Missed pathology
Acute kidney injury
Risks of sedation (elderly, frail, aspiration)

61
Q

What is a FOB test?

A

Faecal occult blood test

Needs 3 faeces samples from 3 separate bowel movements

62
Q

What is a FIT test?

A

Faecal immunochemical test
- An improved tool from FOB

More sensitive
Measures how much blood there is in the stool
Only 1 sample is needed

63
Q

What are some different types of polyps?

A

-Hyperplastic – benign
-Tubular adenoma <5% malignant. 70% of adenomas
-Villous adenoma 30-40% malignant. 10% polyps
-Tubulovillous adenoma 25% malignant. 20% of polyps

64
Q

How does size of polyp relate to malignancy?

A

<1cm – 1% chance of malignancy overall
>2cm – 40% chance of malignancy

65
Q

What are some treatments for big colonic polyps?

A

-TEMS – transanal endoscopic microsurgery
-TAMIS – transanal minimally invasive surgery
-Open surgery/ Laparoscopic/ Robotic
-Colonoscopic endoscopic surgery
-EMR (Endoscopic Mucosal Resection)

66
Q

What are some risks of surgery to treat colorectal cancer?

A

-Infection
-Bleeding
-DVT/PE
-Injury to Bowel/Bladder/Ureteric/Vascular/Injury/Pelvic Nerves
-Anastomotic leak (5-20%)
-MI/CVA/Resp failure/AKI
-Bowel function
-Sexual function
-Chronic pain
-Continence concerns
-Body image / workplace issues
-Financial impact
-Stoma prolapse / retraction / hernia
-Stoma reversal surgery, further staged procedures

67
Q

How are colorectal cancer staged?

A

Using the TNM system

68
Q

What surveillance is done following treatment for colorectal cancer?

A

5 years
Combination of colonoscopy, CT and CEA
Clinical review

69
Q

What are the causes of small bowel obstructions?

A

Adhesions (60%)
Neoplasms (20%)
Hernias(10%)
Crohn’s (5%)
Volvulus (3%)
Pseudo-obstruction
Foreign bodies (eg GS ileus)
Ischaemic strictures
Intussusception (children)
Radiation enteritis

70
Q

What are the causes of large bowel obstruction?

A

Neoplasms (60%)
Diverticulitis (20%)
Caecal/sigmoid volvulus (5%)
Hernias
IBD
Adhesions
Constipation/faecal impaction
Pseudo-obstruction
MND/MS/spinal cord lesions
Hirschprung’s disease-children

71
Q

What is Hirschprung’s disease?

A

A disorder of the bowel causing severe constipation and intestinal obstruction

72
Q

What are some differentials for Right iliac fossa pain?

A

Appendicitis
Gynae:
Ectopic
Ovarian torsion
Ruptured ovarian cyst
Mesenteric adenitis
Hernia
Meckel’s diverticulum
Caecal tumours/diverticulum
UTI
Renal colic
Testicular torsion
Gastroenteritis
Cholecystitis/Pancreatitis

73
Q

What is Rovsing’s sign?

A

Right lower quadrant pain elicited by palpation of the left lower quadrant in acute appendicitis

74
Q

What is McBurney’s point?

A

The point on the lower right quadrant of the abdomen at which tenderness is maximal in cases of acute appendicitis

Half way between the belly button and the ASIS in the RLQ

75
Q

What is the treatment for appendicitis?

A

Initial: ABCDE
NBM
IV fluids
Analgesia
Fluid balance (consider urinary catheter
±O2
±Anti-emetic
Antibiotics

Further:
Lap/open appendicectomy

76
Q

What is Diverticular disease?

A

Acquired outpouchings of colonic mucosa and overlying connective tissue through the colonic wall
-Tend to occur along lines where colonic arteries penetrate

Peak age 50-70

77
Q

What is Diverticulosis?

A

Presence of diverticulae, usually asymptomatic but can cause IBS symptoms

78
Q

What is Diverticulitis?

A

Inflammation of a diverticulum not necessarily due to bacteria

79
Q

What are the complications of diverticular disease?

A

Abscess
Fistula
Stricture
Perforation
Haemorrhage
Sepsis

80
Q

Which inflammatory condition has an onset after quitting smoking?

A

Ulcerative colitis

81
Q

What is Faecal Calprotectin?

A

A marker for inflammation in the gastrointestinal tract

Used in young people IBD vs. IBS

82
Q

Which type of inflammatory bowel disease always begins distally?

A

UC

83
Q

Which inflammatory bowel disease is characterised by skip lesion?

A

Crohn’s disease

84
Q

What is the management for severe acute UC?

A

-Admit for clinical assessment
-AXR ? Toxic
-CT abdo/pelvis
-Medical management including Thrombo-prophylaxis
-IV steroids +/- rectal steroid enemas & Adcal D3
-Anti-inflammatory
-Immunosuppression
-Biologics

Inform surgical team / stoma nurses
Inform patient re possibility of needing surgery

85
Q

What is toxic mega-colon?

A

Defined as a nonobstructive dilation of the colon, which can be total or segmental and is usually associated with systemic toxicity

86
Q

What is the Truelove and Witts criteria?

A

Determines the severity of Acute severe ulcerative colitis (ASUC)

87
Q

What are the indications for surgery to treat UC?

A

Fulminant colitis
Colitis unresponsive to medical therapy
Steroid dependence
Dysplasia / Malignancy

88
Q

What is Fulminant colitis?

A

Another way of saying acute severe colitis

It’s the most severe form of colitis

89
Q

What is the treatment for Crohn’s disease?

A

-Reducing course of oral prednisolone (Steroids)
-Maintenance therapy established

90
Q

What are some complications of using steroids to treat IBD?

A

Weight gain and abnormal fat distribution (buffalo hump, moon face)
Thin skin, easy bruising, striae, acne, red face
Hirsutism or hair loss
Osteoporosis
Proximal myopathy
Menstrual irregularities
Hypertension
Hypokalaemia (and therefore alkalosis)
Impaired glucose tolerance
Depression / Mental disturbance / psychosis
(In children – growth and developmental delay)

91
Q

What are the drugs Azathioprine / Mercaptopurine used for?

A

Immunosuppression in IBD

92
Q

What are some complications for using immunosuppressants in IBD?

A

Myelotoxicity
Hepatotoxicity
Pancreatitis
Gastrointestinal intolerance
Flu-like symptoms
Susceptibility to infection – esp. viral
Lymphoma
Skin cancer

93
Q

What are some extra-intestinal manifestations of IBD?

A

Arthritis
Mouth ulcers
Erythema nodosum
Pyoderma gangrenosum
Scleritis
Anterior Uveitis

94
Q

What is cholangitis?

A

Infection of the bile ducts

95
Q

What is Primary Sclerosing Cholangitis?

A

Progressive scarring/stricturing of bile ducts. Hepatitis, Liver fibrosis, Cirrhosis and Liver necrosis

Treatment = Liver transplant

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