8 - Colon - Rectum - Anus Flashcards
Diverticulum
A pouch which involves all layers of the bowel wall
Pseudodiverticulum
Pouch which only involves the outer layers
Diverticulosis
Diverticula present
Diverticulitis
Inflammation of the diverticula
Diverticular bleeding
Common complication of diverticulosis
Not seen with acute diverticulitis
Erosion of the vessel in the bowel wall
MC cause of colonic hemorrhage
What is the MC cause of colonic hemorrhage
Diverticular bleeding
Pt presentation with diverticular bleeding
Benign abdomen with massive rectal bleeding
Transfusion often req’d
Normally stops spontaneously
Txt for diverticular bleeding
Admit
Resuscitate
NPO in case surgery is indicated
Pathophys of diverticulosis
Vessels perforate the bowel wall
Intracolonic pressure pushes mucosa out through where the vessels emerge
Mostly left-sided
Most do not develop sxs
Diverticulosis is mostly benign course if:
High fiber diet
Exercise
Statin use
MC complications of diverticulosis?
Bleeding
Infection -> diverticulitis
Pathophys of diverticulitis
Diverticula with stool in lumen -> inflammation -> perforation, peritonitis/abscess OR obstruction
Presentation of diverticulitis
LLQ pain and tenderness, mass or phlegmon
Leukocytosis
Anorexia, N/V, constipation or diarrhea
Workup for diverticulitis
H and P
KUB
CT rectal and oral contrast
What should you avoid with diverticulitis?
Colonoscopy or flex-sig
Diverticulitis - management?
Admit, resuscitate Broad spectrum ABX NPO with mIVF NG suction if N/V Serial ABD exams
Outpatient - metronidazole + fluoroquinolone for 10-14 days
6-8 wks later you should be able to do a colonoscopy
Complications of divertifuclitis
Perforated colon -> peritonitis / pneumoperitoneum
Abscess -> fever, chills, sepsis, TTP (tx with percutaneous drainage)
Colo-vesicle fistula (pneumouria, recurrent UTI - tx with segmental colectomy and bladder repair)
Indications for surgical management of diverticulitis
Perforation
Failure of other therapies
Fistula repair
>2 episodes
Segmental resection with anastomosis
Segmental colectomy with diversion (colostomy)
Lower GI bleeding originates below what anatomic landmark?
Ligament of Treitz
Don’t assume that GI bleeding is:
Hemorrhoids
Always investigate GI bleeding
Types of lower GI bleeding
Occult blood - guaiac positive
PRBPR - hematochezia
Black stools - melena
Diagnostics for LGI bleed
Fecal occult blood test (FOBT)
NGT suction / EGD
Colonoscopy
Txt for lower GI bleeding
Admit and resuscitate
Surgical considerations: patient deterioration, persistent bleeding (>3 units PRBCs), recurrent bleeding
Prior to surgery: locate the bleed (colonoscopy, tagged RBC scan, CTA, mesenteric angiogram)
Pathophys of colorectal CA
Usually ADENOCARCINOMA
Normally first presents as: premalignant lesion
CRC types
Adenomatous polyp - tubular adenoma
Villous polyp - villous adenoma
larger polyps have higher CA risk
Screening for CRC starts when?
40 years of age or 10 yrs prior to Dx in a first degree relative
Follow up ever 5-10 yrs
MC cause of colon obstruction in adults
Colorectal CA
MC’ly left-sided
Hematochezia
Change in bowel habits (thinner stool)
Right-sided - acute blood loss anemia, hematochezia, palpable RUQ mass
Rectal - hematochezia and tenesmus
Workup for CRC
Iron deficiency anemia in patients is colon CA until proven otherwise
Labs (CEA, CBC, CMP, CXR, CT abd and pelvis)
Colonscopy, flex sig, ACBE
PET scan
Refer to surgery
CRC tx:
Curative - removes all tumor and nodes prior to mets
Palliative - remove tumor burden to avoid obstruction and bleeding in metastatic lesion
Check liver and lung for metastases
Consider colectomy
Neoadjuvant radiation and/or chemotherapy
Surgical techniques
Right/left sided hemicolectomy
Left-sided - segmental resection with anastomoses
Rectal - abdominal-peritoneal resection
Pathophys of colon obstruction
MC cause = colon CA
Other causes = diverticulitis, volvulus, abscess
Not normally caused by adhesions
Patient presentation for colon obstruction
Not passing stool, but may pass flatus initially
Crampy abd pain with distention, N/V
May have palpable mass
Colon obstruction workup
Admission and resuscitation
mIVF and NPO with NGT suctioning
Upright ABD film (air-fluid levels)
Barium enema (apple core lesion = CA)
CT abd/pelvis
Colonoscopy
DDx for colon obstruction
Colonic volvulus - MC in elderly
Abscess - common in perforated appendicitis or diverticulitis
Hirschsprung - kids, massive stool in dilated colon
Ulcerative colitis
Diffuse inflammatory disease
Limited to colon
Superficial mucosa
Abd pain, bloody diarrhea
Ulcerative colitis surgical considerations
Failed medical treatment
Divert fecal stream helps symptoms
Perforation, stricture, massive bleeding, toxic megacolon, colon CA
Pathophys of hemorrhoids
3 hemorrhoidal columns (venous)
Left lateral
Right anterior
Right posterior
These veins can dilate and prolapse -> hemorrhoids
Dentate line (pain below, no-pain above)
Risk factors for developing hemorrhoids
Repeated straining
Pregnancy
Portal HTN
Presentation of hemorrhoids
Normally painful or non-painful perianal mass
Extreme pain possible
Bleeding can occur
Workup for hemorrhoids
H and P
Inspect anus
If not visible, have patient valsalva
Perform DRE
Anoscope to identify internal hemorrhoids
Txt for hemorrhoids
Stool softener
Sitz bath
Topical anesthetic
Local anti-inflammatory wipes
Surgery for hemorrhoids
Grade I-II - scleropathy by injection, rubber band ligation, I and D
Grade III-IV - formal procedure in OR, excision, stapling, hemorrhoidal columnectomy
Ligations for external hemorrhoids?
Don’t do it
If anal fissure lateral (3 or 9 oclock) consider
Crohns, TB, syphilis, CA
Txt for anal fissure
Same conservative as hemorrhoids
Refer to colorectal surgery
NTG or diltiazem cream
Anal dilation
Botox
Lateral INTERNAL sphincterectomy (keep external intact to prevent incontinence)
Perirectal (ischio-rectal) abscess - pathophy?
Infected mucus-producing gland
MC’ly found in the ischio-rectal fossa
Rapidly progress to septic shock (especially in immunocompromised)
Presentation of perirectal abscess?
Pain in the ano-rectal area
Deep-seated pain or fullness in higher lesions
If abscess ruptures, seropurulent anal discharge
Physical exam for perirectal abscess
Red, raised, tender, fluctuant mass lateral to the anal canal
Exquisitely tender rectal exam
Txt for perirectal abscess?
Admission and resuscitation
IV antibiotics
To OR for I and D under anesthesia
Perianal abscess - etiology?
Distal, vertical spread of infected cryptoglandular tissue of the anal canal
More common than perirectal abscess
Perianal abscess physical exam
Tender, fluctuant mass on the anal verge
Localized induration, inflammation
Perianal abscess treatment
May I and D in clinic or ER
Rule out deeper infection
Pain meds, ABX
Loose packaging, daily changes
Sitz bath
High fiber diet
Analgesia
Pilonidal dz
Hair nest along gluteal cleft
Not true cysts - lack epithelial lining
Young, hairy males
Sometimes mass with foul smelling discharge
Shaving, laser depilation, waxing
Operative - I and D
Redneck word of the day
“Rectum”
I had to nice 4 wheelers but then i rectum
