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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
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
26
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
27
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
28
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
29
What is a Pseudocyst?
A collection of pancreatic fluids adjacent to the pancreas
30
What is ARDS?
Acute respiratory distress syndrome - Causes low blood oxygen
31
What is SIRS?
Systemic inflammatory response syndrome -An exaggerated defence response of the body to a noxious stressor
32
What are some complications of peptic ulcer disease?
Perforation - Erosion through mucosa into peritoneal cavity Severe haematemesis -Erosion into a vessel
33
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
34
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
35
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
36
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
37
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
38
What are the different types of gall stones?
Cholesterol stones (yellow) Mixed stones Pigment stones (black/darker)
39
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 
40
How does prolonged fasting/weight loss increase chances of gallstones?
It causes gallbladder hypomotility and increases cholesterol excretion in bile
41
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
42
What are some complications of acute cholecystitis?
Empyema/Mucocoele GB perforation (rare) GS ileus Pancreatitis
43
What is Empyema?
When pockets of pus that have collected inside a body cavity
44
What is mucocele?
A benign, mucus-containing cystic lesion of the minor salivary gland
45
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)
46
What is biliary colic?
Acute pain -Caused by contraction Brought on by fatty foods, systemically well
47
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?
48
What is scleroderma?
Autoimmune inflammation
49
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)
50
What is the management of oesophageal cancer?
Staging: CT, laparoscopy, EUS, PET Surgical: Oesophagectomy Medical: Chemotherapy/radiotherapy Palliative: Stenting Considerations: Analgesia and nutrition
51
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
52
What is GORD?
Gastro oesophageal reflux disease -Caused by decreased lower oesophageal sphincter tone. -Can lead to Barrett's oesophagus
53
What is a Benign oesophageal stricture?
Narrowing of the oesophagus causing dysphagia
54
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
55
What are the 4 types of cranial bleed?
Epidural Subdural Intracerebral (parenchymal) Subarachnoid
56
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
57
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
58
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
59
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
60
What are the risks of luminal testing for colorectal cancer?
Bleeding Perforation Missed pathology Acute kidney injury Risks of sedation (elderly, frail, aspiration)
61
What is a FOB test?
Faecal occult blood test Needs 3 faeces samples from 3 separate bowel movements
62
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
63
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
64
How does size of polyp relate to malignancy?
<1cm – 1% chance of malignancy overall >2cm – 40% chance of malignancy
65
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)
66
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
67
How are colorectal cancer staged?
Using the TNM system
68
What surveillance is done following treatment for colorectal cancer?
5 years Combination of colonoscopy, CT and CEA Clinical review
69
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
70
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
71
What is Hirschprung’s disease?
A disorder of the bowel causing severe constipation and intestinal obstruction
72
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
73
What is Rovsing’s sign?
Right lower quadrant pain elicited by palpation of the left lower quadrant in acute appendicitis
74
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
75
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
76
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
77
What is Diverticulosis?
Presence of diverticulae, usually asymptomatic but can cause IBS symptoms
78
What is Diverticulitis?
Inflammation of a diverticulum not necessarily due to bacteria
79
What are the complications of diverticular disease?
Abscess Fistula Stricture Perforation Haemorrhage Sepsis
80
Which inflammatory condition has an onset after quitting smoking?
Ulcerative colitis
81
What is Faecal Calprotectin?
A marker for inflammation in the gastrointestinal tract Used in young people IBD vs. IBS
82
Which type of inflammatory bowel disease always begins distally?
UC
83
Which inflammatory bowel disease is characterised by skip lesion?
Crohn's disease
84
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
85
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
86
What is the Truelove and Witts criteria?
Determines the severity of Acute severe ulcerative colitis (ASUC)
87
What are the indications for surgery to treat UC?
Fulminant colitis Colitis unresponsive to medical therapy Steroid dependence Dysplasia / Malignancy
88
What is Fulminant colitis?
Another way of saying acute severe colitis It's the most severe form of colitis
89
What is the treatment for Crohn's disease?
-Reducing course of oral prednisolone (Steroids) -Maintenance therapy established
90
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)
91
What are the drugs Azathioprine / Mercaptopurine used for?
Immunosuppression in IBD
92
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
93
What are some extra-intestinal manifestations of IBD?
Arthritis Mouth ulcers Erythema nodosum Pyoderma gangrenosum Scleritis Anterior Uveitis
94
What is cholangitis?
Infection of the bile ducts
95
What is Primary Sclerosing Cholangitis?
Progressive scarring/stricturing of bile ducts. Hepatitis, Liver fibrosis, Cirrhosis and Liver necrosis Treatment = Liver transplant

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