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Year 3 Surgery > 4 - Benign Lower Abdominal Disease > Flashcards

4 - Benign Lower Abdominal Disease Flashcards

1
Q

What is the gold standard investigation for the whole colon?

A

Colonoscopy

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2
Q

How far does a flexible sigmoidoscopy travel in the colon?

A

As far as the splenic flexure

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3
Q

What percentage of bowel cancers and polyps are found in the LHS of the colon?

A

75%

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4
Q

Which side of the colon does fresh PR bleeding come from? Where does darker blood come from?

A

Fresh PR blood - more likely to be LHS colon. Darker blood is more likely to come from the RHS.

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5
Q

What is the drawback of using virtual colonoscopy for polyps?

A

It is less accurate at detecting small polyps under 6mm

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6
Q

What is MRI primarily used for in terms of LGIT?

A

Anorectal assessment - rectal tumours and fistulas

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7
Q

What are the most common causes of PR bleeding?

A

Haemorrhoids
Fissures

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8
Q

When should you be suspicious of PR bleeding?

A

Older age first onset
Associated CIBH
IDA
Not associated with defecation
Chronic and continuous

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9
Q

What exams are done for Ps with PR bleeding?

A

DRE - masses, fissures, haemorrhoids?
Rigid sigmoidoscopy / proctoscopy - looking for inflammatory changes

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10
Q

When is LGI bleeding deemed severe?

A

> 24 hours
Hb drop >20g/L
Transfusion of >2 units blood needed

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11
Q

What are the biggest causes of LGI bleeds?

A

Diverticulosis (30%)
Haemorrhoids (14%)
Ischaemic colitis (12%)

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12
Q

In acute LGI bleeding, if it doesn’t settle, how can you establish the source of the bleeding?

A

Colonoscopy
Red cell scan
CT mesenteric angiography
Mesenteric angiography

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13
Q

How can you treat LGI bleeding if it doesn’t stop spontaneously?

A

Embolisation
Surgery - resection / subtotal colectomy

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14
Q

What is the commonest cause of CIBH?

A

IBS

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15
Q

When is CIBH more suspicious?

A

Associated Sx (bleeding, weight loss, IDA)
Continuous rather than intermittent Sx
New onset at older age

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16
Q

What is IBS?

What are the criteria to satisfy a diagnosis?

A

A chronic and intermittent disorder of the gut-brain interaction.

Abdo pain >6m + relief w/defecation or altered bowel freq / form

AND 2 or + of:
- altered stool passage
- abdominal bloating
- worse after eating
- passage of mucous

AND - alternative diagnoses excluded

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17
Q

What investigations should you do for CIBH?

A

qFIT
FBC (anaemia)
Coeliac bloods
Faecal calprotectin

If positive qFIT - colonoscopy or virtual colonoscopy.

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18
Q

What do the following stool colours tell you?
- Red
- Black
- Pale
- Yellow
- Green

A
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19
Q

What percentage of adults experience faecal incontinence?

A

Estimated 1-10%

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20
Q

What are the RF for incontinence?

A
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21
Q

What is diverticular disease?

A

Protrusion of mucosal pouches through the muscle layers of the colon (true diverticulum = travels through all the layers)

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22
Q

Where are diverticulae most common??

A

In the sigmoid colon - is where the luminal pressures are the highest.

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23
Q

What percentage of ppl will have diverticular at 50 and at 80?

What percentage of diverticulae are symptomatic?

A

50% at 50

80% at 80

Only 10% are symptomatic

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24
Q

What is the most common incidental finding in lower GI pathology?

A

Diverticular disease

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25
Q

How can diverticular disease present?

A
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26
Q

Which chronic problems can diverticular disease cause?

A

Fistulae
Chronic stricture
Chronic pain
Chronic GI disturbance

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27
Q

What is a fistula?

A

An abnormal communication between two epithelial lined surfaces.

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28
Q

How are fistulae in the LGI managed?

A

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

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29
Q

What is common in patients who have surgery for chronic diverticular disease?

A

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

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30
Q

Does younger age at first presentation increase risk of further issues for diverticular disease?

A

No

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31
Q

How are haemorrhoids graded?

A

Grades I - IV

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32
Q

What are the RF for haemorrhoids?

A

Constipation
Straining
Old age
Inc abdo pressure

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33
Q

How to we diagnose haemorrhoids?

A
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34
Q

How can haemorrhoids be treated as an outpatient?

A
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35
Q

What is an anal fissure?

A

A tear in the anal mucosa

36
Q

Why can anal fissures persist?

A

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

37
Q

How do anal fissures present?

A

Severe pain w/ defecation that remains for some time after

Fresh PR bleeding (not always)

38
Q

How are anal fissures managed?

A

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

39
Q

What is an anal fistulae caused by?

A

Most common = infection of anal glands

Perianal absncess
Crohns disease
Obstetric injury
Pelvic tumours and their tx

40
Q

Which rule applies to the prediction of where the internal opening of a fistula will be?

What is the exception to this rule?

A

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

41
Q

What is the best treatment for a fistula tract?

A

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

42
Q

What are the RF for a rectal prolapse?

A
43
Q

What are the two options for surgery of a rectal prolapse?

A

Abdominal approach (retropexy)

Perineal approach

43
Q

What percentage of Ps with
(a) UC
(b) Crohns
will require surgery at some point?

A

UC = 20%

Crohn’s = 80%

44
Q

Where does UC start and end?

A

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

45
Q

Does UC inc the risk of colorectal cancer?

A

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

46
Q

When does UC require surgery?

A

Acute - failure of medical management or acute complication (perforated toxic megacolon)

Elective - refractory disease, steroid dependancy or if dysplasia or cancer found.

47
Q

What is the most common cause for toxic megacolon?

A

UC

Can also be caused by infections

48
Q

What is toxic megacolon?

A

Rare non obstructive dilation of the colon associated with systemic toxicity

49
Q

Is there a curative surgical approach for UC?

A

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

50
Q

Is there a curative surgical option for Crohn’s?

A

No

51
Q

When is surgery indicated in Crohn’s Ps?

A

Strictures / obstruction
Fistulae
Abscesses
Perforation
Adhesions from previous surgery

52
Q

What risk do Ps who have surgery for Crohn’s disease face?

A

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

53
Q

What are the two types of strictures found in Crohn’s disease?

How are they both managed?

A

Inflammatory - medical management
Fibrotic - require surgical intervention

54
Q

How can perianal fistulae in Crohn’s disease present?

A

With multiple fistulae around the perineum = watering can perineum

55
Q

What type of drain can be put in a perianal fistulae?

A

Seton drain

56
Q

How should abscesses be treated?

A

Drainage

57
Q

What complications can arise from surgery for Crohn’s?

A

Adhesional bowel obstruction
Short Bowel Syndrome

58
Q

What is a volvulus?

A

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

59
Q

What percentage of bowel obstructions are caused by volvulus?

Where is the commonest site of volvulus?

A

8%

Sigmoid colon

60
Q

What are the RF for sigmoid volvulus?

A

Neuropsychiatric disorders
Chronic constipation
Older age

61
Q

How does sigmoid volvulus often present?

A

Acute abdominal distension
May have pain (not always)

If PR bleeding, systemic toxicity or peritonitis - may have gangrene or perforation!

62
Q

How is sigmoid volvulus treated?

A

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

63
Q

Which is the more common type of volvulus?

A

Sigmoid volvulus

64
Q

What is the rarer type of volvulus?

Which population has this more often?

A

Caecal volvulus

Younger women

65
Q

How is caecal volvulus often diagnosed?

A

Often thought to be small bowel obstruction and then diagnosed on CT.

Very hard to diagnose clinically.

66
Q

What are the two major types of stoma?

A

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

67
Q

What types of stoma are there based on the anatomical site?

A

Ileostomy
Colostomy
Jejunostomy
Duodenostomy
Oesophagostomy
Gastrostomy

68
Q

What is a bladder resection stoma called?

A

Urostomy

69
Q

What is the purpose of a mucous fistula?

A

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

70
Q

Where are ileostomies usually positioned?

A

On the RHS of the abdomen

71
Q

Why are ileostomies usually spouted rather than flat?

A

To prevent irritation to the skin from the effluence

72
Q

Where do sigmoid colostomies tend to be round?

A

LHS of the abdomen

73
Q

What percentage of stomas will need further surgery?

A

20%

74
Q

What are the commonest complications of a stoma?

A

Early on = prolapse, retraction, ischeamia, mucocutaneous separation (separation between stoma and skin)

LT = parastomal hernia
Stoma granuloma - fibrosis and scar tissue

75
Q

What is the definition of a high output stoma?

A

> 1-2L effluence per day.

> 1L = worrisome.

76
Q

What are the problems caused due to a high output stoma?

A

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

77
Q

Which stomas are more likely to be highoutput.

A

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

Most will settle spontaneously

78
Q

How are high output stomas managed?

A
79
Q

A 73 year old patient presents to their GP with a diarrhoea for the last 6 months which is worsening. He has had no PR bleeding, weight loss or abdominal pain. What would be the most appropriate first test for the GP to arrange?

Colonoscopy

Flexible sigmoidoscopy

CT scan

qFIT

Virtual colonoscopy

Faecal calprotectin

A

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).

80
Q

An 80 year old man presents to a urology clinic with a 4 month history of pneumaturia (air in the urine), cloudy urine with debris, frequent UTIs and suprapubic abdominal pain. His only past surgical history is a appendicectomy 25 years ago. He has a long history of constipation and a colonoscopy done for constipation 5 years ago showed uncomplicated diverticular disease. What is the most likely cause for this patient’s symptoms?

Recurrent UTIs from obstructive uropathy

Colovescical fistula from diverticular disease

Pyelonephritis caused by gas forming organisms

Enterovescical fistula caused by small bowel damage during his appendicectomy

Colorectal cancer with metastasis to the bladder

A

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.

81
Q

Haemorrhoids are graded I-IV. Upon which criteria is this grading system based?

Size of the haemorrhoids

Degree of bleeding

Severity of pain

Number of haemorrhoids

Degree of prolapse

A

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.

82
Q

What is Goodsall’s rule?

Painless obstructive jaundice with a palpable gallbladder is most likely not due to gallstones

Predicts the site of the internal opening of an anal fistula from the position of the external opening.

Pressure in the left iliac fossa causes pain to be felt in the right iliac fossa which is indicative of appendicitis

In closed loop large bowel obstruction, caecal wall tension is highest because the luminal diameter is greatest

Abdominal wall mass closure should be done using sutures with 1cm bites placed 1cm apart

A

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.

83
Q

Which of the following are risk factors for a sigmoid volvulus (select all correct answers)?

Ulcerative colitis

Older age group

Previous abdominal surgery

Frequent diarrhoea

Chronic constipation

Diabetes

Colorectal cancer

Neuropsychiatric disorders

A

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.

84
Q

For each patient state what type of stoma they most likely have

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.

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.

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.

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.

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.

A

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

85
Q

A patient with a high output stoma is most at risk of becoming deficient in which electrolytes?

Potassium and hydrogen

Sodium and potassium

Sodium and magnesium

Magnesium and chloride

Chloride and bicarbonate

A

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.

86
Q

Which of the following is true of toxic megacolon?

It occurs more commonly with Crohn’s disease than ulcerative colitis

It is caused by fibrotic strictures within the distal colon causing large bowel obstruction

The diagnosis is made solely on an abdominal X-ray which shows a colonic diameter of 6cm

It is a non obstructive dilatation of the colon associated with systemic toxicity

The clinical diagnosis is made in all patients with severe sepsis and abdominal bloating

A

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.

Year 3 Surgery (15 decks)

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