304 GI surgery Flashcards
What is an ileostomy?
A small bowel stoma
What are the indications for an ileostomy?
-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
What are some different types of ileostomy?
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
Why might an ileostomy be used to rest the anastomosis?
-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)
How does an ileostomy appear on examination?
-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
What are the indications for a colonostomy?
-To divert from a large bowel obstruction (tumour, stricture)
-To allow bowel rest due to Fistula, perforation, complicated diverticulitis
-Trauma
What are some different types of colostomy?
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
How does a colostomy appear on examination?
-Usually on the left
-‘Flush’ to the skin
-The contents of the bag is usually more solid
What is a urostomy?
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
What is a cyctectomy?
Bladder removal
Where is a stoma positioned?
-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
What are some immediate (days) complications of stomas?
GA complications
Necrosis
Bleeding
Retraction
Infection
Psychological
What are some early (weeks) complications of stomas?
Stenosis/ obstruction
High output – dehydration/electrolyte imbalance
Retraction
Skin irritation
Infection
Psychological
What are some late (months) complications of stomas?
Stenosis/ obstruction
Parastomal hernia
Retraction
Prolapse
Fistula formation
Skin irritation
Infection
Psychological
What is a Hartmann’s procedure for stoma?
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
What is the most common cause of a ileostomy stopping working in Crohn’s patients?
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
How much output is considered high in a stoma?
More than 500ml in 24hrs
What are the complications caused by a high output stoma?
-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
What is a true parasternal hernia?
A complication of a stoma
Not uncommon. Weakness in the abdominal wall leads to the protrusion of bowel
What is a loop colostomy prolapse?
When the intestine falls out after a loop colostomy
How is a loop colostomy prolapse treated?
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
What are the 2 main caused of pancreatitis?
Gallstones or excess alcohol
What is the ‘I GET SMASHED’ acronym stand for?
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia/Hypothermia/Hypocalcaemia
ERCP
Drugs
Causes of pancreatitis
How is gallstone pancreatitis caused?
A stone travels really low and gets stuck in the common bile duct, blocking pancreatic ducts
What is the modified Glasgow score?
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
How is acute pancreatitis managed?
Initial: ABCD
Analgesia +++
IV fluids +++
+/- O2
Catheter + fluid balance
NBM ±NGT
+/- detox regime
+/- anti-emetic
Further: MRCP/ERCP, +/- HDU/ITU, complications
What are some complications of acute pancreatitis?
-Hypovolaemic shock
-Haemorrhagic pancreatitis: Grey Turner’s/Cullen’s signs
-Pseudocyst formation
-Infected necrosis
-ARDS
-SIRS
-T2DM
-Chronic pancreatitis
-Multi organ failure
-Death
What are Grey Turner’s/Cullen’s signs for acute pancreatitis?
Grey Tuner’s: purple discolouration around the belly button
Cullen’s sign: Purple discolouration on the sides of waist
What is a Pseudocyst?
A collection of pancreatic fluids adjacent to the pancreas
What is ARDS?
Acute respiratory distress syndrome
- Causes low blood oxygen
What is SIRS?
Systemic inflammatory response syndrome
-An exaggerated defence response of the body to a noxious stressor
What are some complications of peptic ulcer disease?
Perforation
- Erosion through mucosa into peritoneal cavity
Severe haematemesis
-Erosion into a vessel
What is the management for peptic ulcer disease in the ER?
Initial:
ABCD
Analgesia and anti-emetic
IV fluids
±O2
Catheter + fluid balance
NBM
IV PPI
Further:
CT if stable
+/- HDU/ITU
Laparotomy + washout
What are the risk factors for peptic ulcer disease?
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
What is Zollinger-Ellison syndrome?
When gastrinomas (tumours) link, and cause the stomach to make too much acid
located mainly in your pancreas or duodenum
What are the differences between gastric and duodenal ulcers?
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
What is Murphy’s sign?
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
What are the different types of gall stones?
Cholesterol stones (yellow)
Mixed stones
Pigment stones (black/darker)
What are the risk factors for developing gallstones?
-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
How does prolonged fasting/weight loss increase chances of gallstones?
It causes gallbladder hypomotility and increases cholesterol excretion in bile
What is the management of acute cholecystitis?
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
What are some complications of acute cholecystitis?
Empyema/Mucocoele
GB perforation (rare)
GS ileus
Pancreatitis
What is Empyema?
When pockets of pus that have collected inside a body cavity
What is mucocele?
A benign, mucus-containing cystic lesion of the minor salivary gland
What is ascending cholangitis?
Infection of the bile duct
Usually caused by ascending bacteria from duodenum
Other causes:
Gallstones
Strictures (benign/malignant)
Malignancy (CBD/pancreas)
Iatrogenic (eg ERCP)
What is biliary colic?
Acute pain
-Caused by contraction
Brought on by fatty foods, systemically well
What questions do you need to ask in a history of dysphagia?
-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?
What is scleroderma?
Autoimmune inflammation
What is a pharyngeal pouch?
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)
What is the management of oesophageal cancer?
Staging: CT, laparoscopy, EUS, PET
Surgical: Oesophagectomy
Medical: Chemotherapy/radiotherapy
Palliative: Stenting
Considerations: Analgesia and nutrition
What are the 2 main types of oesophageal cancer?
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
What is GORD?
Gastro oesophageal reflux disease
-Caused by decreased lower oesophageal sphincter tone.
-Can lead to Barrett’s oesophagus
What is a Benign oesophageal stricture?
Narrowing of the oesophagus causing dysphagia
What is an oesophageal web/ring?
Membranous structures in which a thin fold of tissue creates at least a partial obstruction of the oesophageal lumen
Cause is unknown
What are the 4 types of cranial bleed?
Epidural
Subdural
Intracerebral (parenchymal)
Subarachnoid
What are the risk factors for colorectal cancer?
-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
What are some red-flags in history suggesting colorectal cancer?
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
What are some tests for colorectal cancer?
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
What is a CEA test?
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
What are the risks of luminal testing for colorectal cancer?
Bleeding
Perforation
Missed pathology
Acute kidney injury
Risks of sedation (elderly, frail, aspiration)
What is a FOB test?
Faecal occult blood test
Needs 3 faeces samples from 3 separate bowel movements
What is a FIT test?
Faecal immunochemical test
- An improved tool from FOB
More sensitive
Measures how much blood there is in the stool
Only 1 sample is needed
What are some different types of polyps?
-Hyperplastic – benign
-Tubular adenoma <5% malignant. 70% of adenomas
-Villous adenoma 30-40% malignant. 10% polyps
-Tubulovillous adenoma 25% malignant. 20% of polyps
How does size of polyp relate to malignancy?
<1cm – 1% chance of malignancy overall
>2cm – 40% chance of malignancy
What are some treatments for big colonic polyps?
-TEMS – transanal endoscopic microsurgery
-TAMIS – transanal minimally invasive surgery
-Open surgery/ Laparoscopic/ Robotic
-Colonoscopic endoscopic surgery
-EMR (Endoscopic Mucosal Resection)
What are some risks of surgery to treat colorectal cancer?
-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
How are colorectal cancer staged?
Using the TNM system
What surveillance is done following treatment for colorectal cancer?
5 years
Combination of colonoscopy, CT and CEA
Clinical review
What are the causes of small bowel obstructions?
Adhesions (60%)
Neoplasms (20%)
Hernias(10%)
Crohn’s (5%)
Volvulus (3%)
Pseudo-obstruction
Foreign bodies (eg GS ileus)
Ischaemic strictures
Intussusception (children)
Radiation enteritis
What are the causes of large bowel obstruction?
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
What is Hirschprung’s disease?
A disorder of the bowel causing severe constipation and intestinal obstruction
What are some differentials for Right iliac fossa pain?
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
What is Rovsing’s sign?
Right lower quadrant pain elicited by palpation of the left lower quadrant in acute appendicitis
What is McBurney’s point?
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
What is the treatment for appendicitis?
Initial: ABCDE
NBM
IV fluids
Analgesia
Fluid balance (consider urinary catheter
±O2
±Anti-emetic
Antibiotics
Further:
Lap/open appendicectomy
What is Diverticular disease?
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
What is Diverticulosis?
Presence of diverticulae, usually asymptomatic but can cause IBS symptoms
What is Diverticulitis?
Inflammation of a diverticulum not necessarily due to bacteria
What are the complications of diverticular disease?
Abscess
Fistula
Stricture
Perforation
Haemorrhage
Sepsis
Which inflammatory condition has an onset after quitting smoking?
Ulcerative colitis
What is Faecal Calprotectin?
A marker for inflammation in the gastrointestinal tract
Used in young people IBD vs. IBS
Which type of inflammatory bowel disease always begins distally?
UC
Which inflammatory bowel disease is characterised by skip lesion?
Crohn’s disease
What is the management for severe acute UC?
-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
What is toxic mega-colon?
Defined as a nonobstructive dilation of the colon, which can be total or segmental and is usually associated with systemic toxicity
What is the Truelove and Witts criteria?
Determines the severity of Acute severe ulcerative colitis (ASUC)
What are the indications for surgery to treat UC?
Fulminant colitis
Colitis unresponsive to medical therapy
Steroid dependence
Dysplasia / Malignancy
What is Fulminant colitis?
Another way of saying acute severe colitis
It’s the most severe form of colitis
What is the treatment for Crohn’s disease?
-Reducing course of oral prednisolone (Steroids)
-Maintenance therapy established
What are some complications of using steroids to treat IBD?
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)
What are the drugs Azathioprine / Mercaptopurine used for?
Immunosuppression in IBD
What are some complications for using immunosuppressants in IBD?
Myelotoxicity
Hepatotoxicity
Pancreatitis
Gastrointestinal intolerance
Flu-like symptoms
Susceptibility to infection – esp. viral
Lymphoma
Skin cancer
What are some extra-intestinal manifestations of IBD?
Arthritis
Mouth ulcers
Erythema nodosum
Pyoderma gangrenosum
Scleritis
Anterior Uveitis
What is cholangitis?
Infection of the bile ducts
What is Primary Sclerosing Cholangitis?
Progressive scarring/stricturing of bile ducts. Hepatitis, Liver fibrosis, Cirrhosis and Liver necrosis
Treatment = Liver transplant
