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Senior - Surgery 1 > 8 - Colon - Rectum - Anus > Flashcards

8 - Colon - Rectum - Anus Flashcards

1
Q

Diverticulum

A

A pouch which involves all layers of the bowel wall

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2
Q

Pseudodiverticulum

A

Pouch which only involves the outer layers

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3
Q

Diverticulosis

A

Diverticula present

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4
Q

Diverticulitis

A

Inflammation of the diverticula

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5
Q

Diverticular bleeding

A

Common complication of diverticulosis

Not seen with acute diverticulitis

Erosion of the vessel in the bowel wall

MC cause of colonic hemorrhage

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6
Q

What is the MC cause of colonic hemorrhage

A

Diverticular bleeding

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7
Q

Pt presentation with diverticular bleeding

A

Benign abdomen with massive rectal bleeding

Transfusion often req’d

Normally stops spontaneously

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8
Q

Txt for diverticular bleeding

A

Admit
Resuscitate
NPO in case surgery is indicated

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9
Q

Pathophys of diverticulosis

A

Vessels perforate the bowel wall

Intracolonic pressure pushes mucosa out through where the vessels emerge

Mostly left-sided

Most do not develop sxs

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10
Q

Diverticulosis is mostly benign course if:

A

High fiber diet

Exercise

Statin use

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11
Q

MC complications of diverticulosis?

A

Bleeding

Infection -> diverticulitis

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12
Q

Pathophys of diverticulitis

A

Diverticula with stool in lumen -> inflammation -> perforation, peritonitis/abscess OR obstruction

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13
Q

Presentation of diverticulitis

A

LLQ pain and tenderness, mass or phlegmon

Leukocytosis
Anorexia, N/V, constipation or diarrhea

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14
Q

Workup for diverticulitis

A

H and P

KUB

CT rectal and oral contrast

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15
Q

What should you avoid with diverticulitis?

A

Colonoscopy or flex-sig

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16
Q

Diverticulitis - management?

A 
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

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17
Q

Complications of divertifuclitis

A

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)

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18
Q

Indications for surgical management of diverticulitis

A

Perforation
Failure of other therapies
Fistula repair
>2 episodes

Segmental resection with anastomosis

Segmental colectomy with diversion (colostomy)

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19
Q

Lower GI bleeding originates below what anatomic landmark?

A

Ligament of Treitz

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20
Q

Don’t assume that GI bleeding is:

A

Hemorrhoids

Always investigate GI bleeding

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21
Q

Types of lower GI bleeding

A

Occult blood - guaiac positive

PRBPR - hematochezia

Black stools - melena

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22
Q

Diagnostics for LGI bleed

A

Fecal occult blood test (FOBT)

NGT suction / EGD

Colonoscopy

23
Q

Txt for lower GI bleeding

A

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)

24
Q

Pathophys of colorectal CA

A

Usually ADENOCARCINOMA

Normally first presents as: premalignant lesion

25
Q

CRC types

A

Adenomatous polyp - tubular adenoma

Villous polyp - villous adenoma

larger polyps have higher CA risk

26
Q

Screening for CRC starts when?

A

40 years of age or 10 yrs prior to Dx in a first degree relative

Follow up ever 5-10 yrs

27
Q

MC cause of colon obstruction in adults

A

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

28
Q

Workup for CRC

A

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

29
Q

CRC tx:

A

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

30
Q

Surgical techniques

A

Right/left sided hemicolectomy

Left-sided - segmental resection with anastomoses

Rectal - abdominal-peritoneal resection

31
Q

Pathophys of colon obstruction

A

MC cause = colon CA

Other causes = diverticulitis, volvulus, abscess

Not normally caused by adhesions

32
Q

Patient presentation for colon obstruction

A

Not passing stool, but may pass flatus initially

Crampy abd pain with distention, N/V

May have palpable mass

33
Q

Colon obstruction workup

A

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

34
Q

DDx for colon obstruction

A

Colonic volvulus - MC in elderly

Abscess - common in perforated appendicitis or diverticulitis

Hirschsprung - kids, massive stool in dilated colon

35
Q

Ulcerative colitis

A

Diffuse inflammatory disease

Limited to colon

Superficial mucosa

Abd pain, bloody diarrhea

36
Q

Ulcerative colitis surgical considerations

A

Failed medical treatment

Divert fecal stream helps symptoms

Perforation, stricture, massive bleeding, toxic megacolon, colon CA

37
Q

Pathophys of hemorrhoids

A

3 hemorrhoidal columns (venous)

Left lateral
Right anterior
Right posterior

These veins can dilate and prolapse -> hemorrhoids

Dentate line (pain below, no-pain above)

38
Q

Risk factors for developing hemorrhoids

A

Repeated straining

Pregnancy

Portal HTN

39
Q

Presentation of hemorrhoids

A

Normally painful or non-painful perianal mass

Extreme pain possible

Bleeding can occur

40
Q

Workup for hemorrhoids

A

H and P

Inspect anus

If not visible, have patient valsalva

Perform DRE

Anoscope to identify internal hemorrhoids

41
Q

Txt for hemorrhoids

A

Stool softener

Sitz bath

Topical anesthetic

Local anti-inflammatory wipes

42
Q

Surgery for hemorrhoids

A

Grade I-II - scleropathy by injection, rubber band ligation, I and D

Grade III-IV - formal procedure in OR, excision, stapling, hemorrhoidal columnectomy

43
Q

Ligations for external hemorrhoids?

A

Don’t do it

44
Q

If anal fissure lateral (3 or 9 oclock) consider

A

Crohns, TB, syphilis, CA

45
Q

Txt for anal fissure

A

Same conservative as hemorrhoids

Refer to colorectal surgery

NTG or diltiazem cream

Anal dilation

Botox

Lateral INTERNAL sphincterectomy (keep external intact to prevent incontinence)

46
Q

Perirectal (ischio-rectal) abscess - pathophy?

A

Infected mucus-producing gland

MC’ly found in the ischio-rectal fossa

Rapidly progress to septic shock (especially in immunocompromised)

47
Q

Presentation of perirectal abscess?

A

Pain in the ano-rectal area

Deep-seated pain or fullness in higher lesions

If abscess ruptures, seropurulent anal discharge

48
Q

Physical exam for perirectal abscess

A

Red, raised, tender, fluctuant mass lateral to the anal canal

Exquisitely tender rectal exam

49
Q

Txt for perirectal abscess?

A

Admission and resuscitation

IV antibiotics

To OR for I and D under anesthesia

50
Q

Perianal abscess - etiology?

A

Distal, vertical spread of infected cryptoglandular tissue of the anal canal

More common than perirectal abscess

51
Q

Perianal abscess physical exam

A

Tender, fluctuant mass on the anal verge

Localized induration, inflammation

52
Q

Perianal abscess treatment

A

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

53
Q

Pilonidal dz

A

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

54
Q

Redneck word of the day

“Rectum”

A

I had to nice 4 wheelers but then i rectum

Senior - Surgery 1 (8 decks)

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