4 - Benign Lower Abdominal Disease Flashcards

Question

How can diverticular disease present?

Answer 1

Fistulae Chronic stricture Chronic pain Chronic GI disturbance

Answer 2

An abnormal communication between two epithelial lined surfaces.

Answer 3

Conservative management - e.g. ABx Can have resection +/- anastomosis Defunctioning stoma

Answer 4

Up to 25% will still have Sx post surgery - this is because their Sx were not caused by the diverticulae but something else instead.

Answer 5

Grades I - IV

Answer 6

Constipation Straining Old age Inc abdo pressure

Answer 7

A tear in the anal mucosa

Answer 8

Due to high restring anal tone causing poor perfusion of the anal mucosa

Answer 9

Severe pain w/ defecation that remains for some time after Fresh PR bleeding (not always)

Answer 10

Avoidance of constipation Creams - dilitiazem or GTN ointment Botox into anal sphincter Lateral sphincterotomy

Answer 11

Most common = infection of anal glands Perianal absncess Crohns disease Obstetric injury Pelvic tumours and their tx

Answer 12

Exception = Crohn's disease - they travel in whatever direction they like.

Answer 13

Division and opening up - however cutting through the muscle can cause incontinence. >90% will heal this way.

Answer 14

Abdominal approach (retropexy) Perineal approach

Answer 15

UC = 20% Crohn's = 80%

Answer 16

Is continuous inflammation which starts at the distal rectum and extends for variable distance up to the ileocaecal junction.

Answer 17

Yes 2% risk at 10 years 8% at 20 years 18% at 30 years

Answer 18

Acute - failure of medical management or acute complication (perforated toxic megacolon) Elective - refractory disease, steroid dependancy or if dysplasia or cancer found.

Answer 19

UC Can also be caused by infections

Answer 20

Rare non obstructive dilation of the colon associated with systemic toxicity

Answer 21

Yes - if the entire colon is removed the P will be cured.

Answer 22

Strictures / obstruction Fistulae Abscesses Perforation Adhesions from previous surgery

Answer 23

25% of them will need further surgery within 10 years - may leave the P with a risk of short bowel syndrome.

Answer 24

Inflammatory - medical management Fibrotic - require surgical intervention

Answer 25

With multiple fistulae around the perineum = watering can perineum

Answer 26

Seton drain

Answer 27

Adhesional bowel obstruction Short Bowel Syndrome

Answer 28

When a loop of intestine has twisted around its mesentery causing an obstruction

Answer 29

8% Sigmoid colon

Answer 30

Neuropsychiatric disorders Chronic constipation Older age

Answer 31

Acute abdominal distension May have pain (not always) If PR bleeding, systemic toxicity or peritonitis - may have gangrene or perforation!

Answer 32

Decompression endoscopically May require surgery - if emergency or recurrent volvulus.

Answer 33

Sigmoid volvulus

Answer 34

Caecal volvulus Younger women

Answer 35

Often thought to be small bowel obstruction and then diagnosed on CT. Very hard to diagnose clinically.

Answer 36

End Loop (both ends of bowel brought out - one opening drains waste and the other opening drains mucus)

Answer 37

Ileostomy Colostomy Jejunostomy Duodenostomy Oesophagostomy Gastrostomy

Answer 38

Is a blowhole for mucus and air - when there is a proximal stoma and you need to deflate the distal part of the bowel.

Answer 39

On the RHS of the abdomen

Answer 40

To prevent irritation to the skin from the effluence

Answer 41

LHS of the abdomen

Answer 42

Early on = prolapse, retraction, ischeamia, mucocutaneous separation (separation between stoma and skin) LT = parastomal hernia Stoma granuloma - fibrosis and scar tissue

Answer 43

>1-2L effluence per day. >1L = worrisome.

Answer 44

Electrolyte and fluid losses - can be substantial = esp Na, Mg and K.

Answer 45

More likely in ileostomies (25% if these will be high output). Most will settle spontaneously

Answer 46

qFIT is the first line test for a patient with a change in bowel habit If this is normal it means that colorectal cancer is very unlikely (but not impossible) and the patient can be reassured to a point. If his symptoms are persistent, however, then further tests are indicated which could well include colonoscopy or VC. If qFIT is positive then urgent investigations (most likely colonoscopy unless contraindicated) will be required. Flexible sigmoidoscopy is used mostly for symptoms which are most likely attributable to the left colon (such as fresh rectal bleeding) but as it does not see the whole colon, on its own is probably not useful for patients with a positive qFIT (unless unfit for a full colonoscopy or other reasons). Plain CT is probably not that useful as it will only detect 80% of colorectal cancer (unlike >95% with VC and colonoscopy) and is poor for other colonic pathology, but is useful for frail patients who would not tolerate first line investigations. Faecal calprotectin is a specific test for IBD and would not likely be useful here as the clinical suspicion of IBD is low (no PR bleeding, older age at presentation).

Answer 47

Although this is a LGI session, it is important to understand that LGI pathology can present via a number of channels. Clearly the history here is very urological and hence the patient was referred to the urology clinic. Pneumaturia and debris in the urine are fairly pathognomonic of a GI-bladder fistula, the commonest of which is a diverticular colovescical fistula (answer b) which is the correct answer here), especially in a man who has had known diverticulosis. Obstructive uropathy is less likely from the history and pyelonephritis is rarely caused by gas forming organisms. Colorectal cancer can cause colovescical fistulae but this is unusual and invariably due to direct invasion of the bladder rather than metastasis. Answer d) is highly unlikely because the appendicectomy was so long ago, even though iatrogenic injury is the most common cause of small bowel perforation.

Answer 48

Haemorrhoidal grading is only based on the degree of prolapse (answer e is therefore correct): Grade I – No prolapse Grade II – Prolapse but spontaneously revert Grade III – Prolapse and require manual replacement Grade IV – Prolapse and cannot be replaced.

Answer 49

Goodsall’s rule predicts the internal opening of a fistula from the position of the external opening – anterior fistulas tend to travel radially towards the anal canal from the external opening whereas posterior fistulas tend to arc around to an internal opening at 6 o’clock. This rule does NOT hold for Crohn’s fistulas. Painless jaundice with a palpable gallbladder is Courvoisier’s sign, Pressure in the LIF causing pain in the RIF is Rovsing’s sign, caecal perforation is most likely with closed loop LBO according to Laplace’s law and abdominal wall closure is guided by Jenkin’s rule.

Answer 50

b (older age group), e (chronic constipation) and h (neuropsychiatric disorders – such as MS and Parkinson’s disease) are the correct answers here. The other conditions listed are not risk factors for sigmoid volvulus.

Answer 51

1 Spouted stoma in the right iliac fossa with 2 lumens formed at the time of an anterior resection for rectal cancer and which produces liquid stools. Correct: Loop ileostomy 2 Flush stoma in the left iliac fossa which has only 1 lumen and produces formed stools. The stoma was made at the time of a laparotomy for sigmoid perforation due to diverticular disease. Correct: End (sigmoid) colostomy 3 Large but flush stoma in the right upper quadrant which has 2 lumens and produces semi solid stools. The patient was admitted with large bowel obstruction from a sigmoid cancer which is locally advanced and currently inoperable and hence this stoma was formed to relieve the obstruction. Correct: Transverse loop colostomy 4 Spouted single lumen stoma in the right iliac fossa formed during a cystectomy for bladder cancer. On day 1 post operatively there are 2 plastic tubes coming out of it and the stoma is producing straw coloured liquid. Correct: Urostomy (also referred to as an ileal conduit) 5 A patient undergoes an emergency operation for fulminant colitis refractory to medical therapy. They have a subtotal colectomy and a stoma is formed in the right iliac fossa which has only 1 lumen. Correct: End ileostomy

Answer 52

The correct answer here is c) sodium and magnesium. Sodium is found in significant amounts in bowel contents and a high stoma output means a lot of this is lost rather than being reabsorbed. Loss of magnesium is multifactorial – it is passively absorbed by diffusion from the small bowel and colon so shorter bowel may mean less area for absorption. Fatty acids bind magnesium and prevent its absorption, and when dietary fat is not absorbed due to shorter bowel length or unabsorbed carbohydrates undergo fermentation by gut bacteria then fatty acids are more abundant in the bowel. Finally, loss of sodium and water leads to hyperaldosteronism which increases sodium absorption at the expense of potassium and magnesium. Potassium and bicarbonate can also be lost in high output stomas but the highest risk of electrolyte imbalances comes from sodium and magnesium.

Answer 53

The correct answer is d) which is that toxic megacolon is a non obstructive dilatation of the colon associated with systemic toxicity. It is most often associated with ulcerative colitis and is not often seen in Crohns disease which much less commonly affects the colon. The diagnosis of toxic megacolon by definition is ruled out if a mechanical obstruction is seen (hence answer b) is incorrect). Patients who are severely septic not unusually develop pseudo-obstruction (Ogilvie’s syndrome) which would be much more likely than toxic megacolon in this group and although the diagnosis requires a colonic diameter of 6cm or greater on imaging, answer c is not correct because there has to be toxicity and proof that there is no mechanical obstruction, so an abdominal x-ray in isolation is not enough.