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Junior Surgery > Abdo Pain And PR Bleeding > Flashcards

Abdo Pain And PR Bleeding Flashcards

1
Q

Risk factors for colorectal carcinoma

A

FH
Age
Western diet (low in dietary fibre, high in fat)
UC
Smoking

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2
Q

Protective factors for colorectal carcinoma

A

Fruit and veg / fibre consumption
Exercise
HRT
Aspirin / NSAIDs

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3
Q

Genetic aetiology of colorectal carcinomas

A

Familial adenomatous polyposis responsible for <1% of cancers and occurs due to tumour suppressor gene APC mutations

Hereditary non-polyposis colorectal cancer responsible for <5% of all cancers and arises from germline mutations in mismatch repair genes

Most cancers are sporadic however occurring without strong family history

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4
Q

Pathophysiology of colorectal carcinoma

A

Adenocarcinoma with characteristic signet ring cells on histology
Majority of tumours occur in the recto-sigmoid regions

Usually appear as a polyploid mass with ulceration spreading initially by direct infiltration through the bowel wall
Then involves the lymphatic and blood vessels, metastasising primarily to the liver

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5
Q

Clinical presentation of colorectal carcinoma

A

Abdominal mass
Abdo pain
GI haemorrhage or perforation
Right sided tumours often more asymptomatic
Iron deficiency anaemia / weight loss
Left sided tumours more commonly present with PR blood / mucus, altered bowel habit, tenesmus, obstruction and a mass on PR exam

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6
Q

What are the indications for a 2WW referral for urgent endoscopy in patients >40

A

Rectal bleeding or change in bowel habit for >6w
Persistent rectal bleeding in those over 45 with no obvious evidence of benign anal disease
Iron deficiency anaemia without an obvious cause
Palpable abdominal / PR mass

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7
Q

Investigations for colorectal carcinoma

A

FBC (microcytic anaemia), LFT (metastatic indicator)
Colonoscopy (gold standard)
CT chest, abdo, pelvis
Carcino-embryonic antigen can be used to monitor disease

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8
Q

TNM staging of colorectal carcinoma

A

T: the primary tumour is staged in terms of invasion through local structures
N: extent of associated lymph node disease scored
M: extent of distant metastases

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9
Q

Management of colorectal carcinoma

A

Often primarily surgical with possible adjuvant radiotherapy or chemotherapy
Wide resection of the growth and regional lymphatics

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10
Q

What is right hemicolectomy used for

A

Caecal, ascending and proximal transverse colon tumours
- may be temporary end ileostomy prior to colo-colic anastomosis

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11
Q

What is a sigmoid colectomy used for

A

Sigmoid tumours

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12
Q

What is anterior resection used for

A

Low sigmoid / high rectal tumours
Colo-rectal anastomosis achieved at first operation although this may be covered by a temporary loop ileostomy

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13
Q

What is an abdomino-perineal resection

A

For tumours low in the resection
- permanent colostomy with removal of rectum and anus
- no anastomosis

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14
Q

What is Hartmann’s procedure

A

For bowel obstruction or palliation
- resection of recto-sigmoid colon with temporary end colostomy and closure of the rectal stump

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15
Q

When is radiotherapy used in colorectal cancer

A

Used pre-operatively in rectal cancer to reduce recurrence and increase survival
Higher risks of post operative complications

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16
Q

When is chemotherapy used in colorectal cancer

A

Adjuvant 5-FU can reduce mortality of higher stage tumours
May be used with palliative intent to prolong survival in metastatic disease

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17
Q

What is an anorectal abscess

A

Associated with gut organisms with infection origination from an obstructed anal crypt gland
Associated with crohn’s, DM and malignancy

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18
Q

Presentation of perianal infection

A

Severe pain in the anal / rectal area
May be purulent discharge if the abscess has begun to drain spontaneously
Fever / constitutional symptoms are common

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19
Q

Examination of perianal infection / abscess

A

Area of skin with fluctuance, / induration / erythema overlying the perianal skin
Patients with deeper anorectal abscess may not have any physical findings other than severe pain on PR exam

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20
Q

Management of perianal infection / abscess

A

Always requires surgical incision / drainage
Abx post drainage to decrease recurrence rates

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21
Q

Complications of perianal infection / abscess

A

Recurrence - seen in 44%
Anal fistula formation

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22
Q

What is an anal fistula

A

Epithelialised track that connects the abscess with skin or adjacent organs
Usually the result of an abscess discharging internally to form a fistula
Patients present with intermittent rectal pain as well as intermittent and malodorous perianal drainage

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23
Q

Risk factors for anal fistula formation

A

Crohn’s
Diverticular disease
Rectal carcinoma
Immunocompromisation

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24
Q

Anal fistula management

A

Primarily surgical but can be difficult to treat
Superficial and low level fistulae are laid open to heal by secondary intention
High fistulae involve the continence muscles of the anus and may be injected with fibrin glue or fistula plug

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25
Q

What are haemorrhoids

A

Disrupted / dilated anal cushions which are used to maintain the internal and external anal sphincters and therefore control continence

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26
Q

Anatomy of haemorrhoids

A

Anal canal runs from superior aspect of pelvic diaphragm to the anus and is normally collapsed
The internal anal sphincter is an involuntary sphincter surrounding the upper 2/3 of the anal canal
External anal sphincter surrounds the lower 2/3 of the anal canal and is under voluntary control mediated by inferior rectal nerve

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27
Q

What causes haemorrhoids to form

A

Prolapses of anal cushions
Caused by a breakdown of smooth muscle layer (muscularis mucosae)

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28
Q

Aetiology of haemorrhoids

A

Mainly idiopathic
Increased anal tone (chronic constipation)
Factors that cause congestion of superior rectal veins : cardiac failure, liver cirrhosis, pregnancy, rectal carcinoma, raised IAP

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29
Q

Haemorrhoids classification

A

1st degree: confined to the anal canal, bleed but do not prolapse
2nd degree: prolapse on defecation then reduce spontaneously
3rd degree: prophase outside the anal margin on defecation but can be manually reduced
4th degree: remain prolapsed outside the anal margin at all times

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30
Q

Haemorrhoid symptoms

A

Rectal bleeding (bright red blood)
Prolapse
Mucous discharge
Pruritis ani
Pain if the piles become thrombosed

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31
Q

OE for haemorrhoids

A

Abdo exam: examine for palpable masses, enlarged liver
Rectal examination: prolapsing piles are obvious
Proctoscopy / rigid sigmoidoscopy: can visualise the piles and assess for a lesion higher in the rectum

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32
Q

Complications of haemorrhoids

A

Anaemia if there is severe / continuous bleeding
Thrombosis - if prolapsing piles are gripped by the anal sphincter then venous return is occluded leading to thrombosis
Haemorrhoids swell, become purple and tense and cause pain

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33
Q

How to treat thrombosed piles

A

Often fibrose within 2-3 weeks - spontaneous cure
Cold compress
Opioids
Rest

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34
Q

Management of haemorrhoids

A

Conservative management
- plenty of fluids, dont strain
- topical analgesia / astringents and a bulk forming laxative

Sclerotherapy
- 5% phenol in almond oil injected above each pile as a sclerosing injection
- suitable for 1st and 2nd degree piles
- painless

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35
Q

What is banding (haemorrhoids)

A

Application of a small rubber band to the protruding mucosa
- leads to strangulation
3rd degree piles
Care must be taken out position band above dentate line

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36
Q

Describe surgery as a management for haemorrhoids

A

Reserved for 3rd and 4th degree piles
Stapled haemorrhoidpexy or haemorrhoidal artery ligations are the main methods used

37
Q

What are anal fissures

A

A tear in the sensitive anal canal distal to the dentate line producing pain on defecation most commonly seen in males

38
Q

Aetiology of anal fissures

A

Mainly due to hard faeces with 10% of the anterior tears due to parturition
Occur at the midline more as the blood supply to this area is worse and thus healing is more difficult
Sometimes caused by infection, trauma, crohn’s, anal cancer and psoriasis

39
Q

Anal fissures symptoms

A

Pain worse on defecation, lasting for hours afterwards
Associated constipation
Pruritis ani
Bleeding on defecation

40
Q

OE of anal fissures

A

Midline longitudinal tear in the rectal mucosa
PR may not be possible due to pain and sphincter spasm

41
Q

Management of early, small anal fissures

A

Early small fissures may heal spontaneously
Local anaesthetic ointments and a lubricant laxative can be used for symptomatic relief
High fibre diet, lots of fluid and bulk forming laxative

42
Q

Management of chronic anal fissures

A

GTN cream is used to relax anal sphincter and allow torn epithelium to heal
- can give headaches
Botulinum toxin injection - same effect but for 8 weeks but can cause incontinence

Intractable fissures of recurrent cases may require sphincterotomy under GA

43
Q

What is Diverticular disease

A

Diverticula are sac like protrusions of mucosa through the muscular wall of the colon, causing a spectrum of disease
Diverticular disease is the presence of symptomatic diverticula causing intermittent lower abdo pain, without inflammation and infection

44
Q

What is diverticulosis

A

The presence of diverticula

45
Q

What is diverticulitis

A

The presence of inflamed diverticula
Uncomplicated: diverticula inflammation without symptoms of acute abdomen or signs of perforation or abscess formation
Complicated: diverticulitis with complications such as abscess, peritonitis, fistula, obstruction or perforation

46
Q

Pathophysiology of Diverticular disease

A

50% of patients over the age of 50
Most frequently in the sigmoid with 99% of complications at this site

Hypertrophy of the muscular propria with diverticula then occurring at sites of potential weakness in the bowel wall

47
Q

Risk factors for Diverticular disease

A

Age
Genetics
Low fibre diet
Obesity
Smoking
Marfaans
Ehlers-Danlos syndrome
PKD

48
Q

Symptoms of diverticula (if symptomatic)

A

Exactly mimic carcinoma of the colon
- left sided colic, relieved by defecation
- altered bowel habit
- nausea
- flatulence
- severe pain and constipation

49
Q

Diverticula disease investigations

A

PR (look for masses)
Sigmoidoscopy / colonoscopy - to rule of CRC

50
Q

Management of diverticula disease

A

Diet and lifestyle advice
High fibre diet + bulk forming laxatives
Antispasmodic agents

51
Q

What is acute diverticulitis

A

Acute infection of diverticula that occurs due to stagnation of pouch contents

52
Q

Symptoms of acute diverticulitis

A

Severe left sided colicky abdo pain
Constipation or overflow diarrhoea
Symptoms mimicking appendicitis but on the left

53
Q

Signs of acute diverticulitis

A

Fever and tachycardia - systemic illness
Tenderness, guarding and rigidity on the left side
Palpable mass on the LIF

54
Q

What is a mild attack of acute diverticulitis and how is it managed

A

Absence of fever
Mild pain
Minimal abdominal tenderness / guarding
Normal observations

Managed in community with rest, fluids, oral analgesia
High risk pts may be prescribed oral abx or hospital admission

55
Q

What is a severe attack of acute diverticulitis and how is it managed

A

High grade fever
Severe pain
Significant abdo tenderness / guarding
Signs of systemic illness

Admit to hospital
Give analgesia, IV fluid, IV abx
Bloods
Imaging : CXR, CTAP

56
Q

Complications of Diverticular disease

A

Perforation
Abscess formation
Bleeding
Fistula formation
Strictures / intestinal obstruction

57
Q

Describe perforations as a complication in Diverticular disease

A

Usually in acute diverticulitis
Can lead to formation of a paracolic or pelvic abscess or generalised peritonitis
Classically presents with ileus and peritonitis +/- shock
40% mortality
Management is with laparotomy +/- hartmann’s procedure

58
Q

Describe abscess formation as a complication in Diverticular disease

A

Usually in acute diverticulitis
Presents with swinging fever, leucocytosis and localising signs
These should be drained under CT guidance

59
Q

Describe bleeding as a complication of Diverticular disease

A

Sudden, painless bleeding as a result of erosion of vessels at the fundus of the diverticulum
Large volumes can be lost, requiring transfusion
Bleeds often stop spontaneously with bed rest
If doesn’t stop treat with angiography and arterial embolisation

60
Q

What is haematochezia

A

Unaltered PR blood most commonly seen in the context of lower GI haemorrhage
Can originate from massive upper GI bleeds
Can be associated with haematemesis and maelena

61
Q

Define lower GI bleeding

A

Blood loss originating from a site distal to the ligament of treitz (at the level of the duodenojejunal junction)

62
Q

How to differentiate between different lower GI bleeds

A

Left sided (ascending) colonic bleeds tend to be bright red
Right sided (descending) colonic bleeds tend to be dark or maroon

63
Q

Anatomic aetiology of lower GI bleeding

A

Diverticulosis (most common cause of lower GI haemorrhage)

64
Q

vascular causes of lower GI bleeding

A

Angiodysplasia (dilated, tortuous submucosal vessels that occur secondary to degeneration of the bowel wall with age)
, haemorrhoids,
ischaemic colitis,
radiation induced bleeding

  • classically seen in patients with aortic stenosis (heydes syndrome)
65
Q

Inflammatory aetiology of lower GI bleeding

A

IBD
infective colitis

66
Q

Malignant causes of lower GI bleeding

A

Polyp
Carcinoma

67
Q

What is a Diverticular bleed associated with

A

LLQ pain

68
Q

What is anal fissure associated with

A

Pain on defecation

69
Q

What is rectal cancer associated with

A

Tenesmus
PR bleed with defecation

70
Q

What is colon cancer associated with

A

Change in bowel habit
Weight loss

71
Q

What is colitis associated with

A

Diarrhoea and abdo pain

72
Q

Prognosis of upper GI bleed

A

Bleeds will resolve spontaneously in 85% of cases without the need for intervention
Mortality rate is 2-4%

73
Q

Primary causes of constipation

A

Slow transit constipation - prolonged delay in stool transit through colon, occurring mainly in young women
Defecatory disorders - difficulty expelling stool from the rectum
IBS

74
Q

Secondary causes of constipation

A
  • neurogenic : MS, Parkinson’s, autonomic neuropathy, hirchsprungs, spinal cord injury
  • non-neurogenic: hypothyroid, anorexia nervosa, pregnancy, hypokalaemia
  • iatrogenic: anticholinergics, iron supplements, aluminium antacids, opioids
75
Q

Risk factors for constipation

A

Age
Female
Inactivity
Poly pharmacy
Decreased oral intake
Depression

76
Q

Clinical features of constipation

A

Infrequent stools <3/week
Unsatisfactory defecation / feeling of incomplete evacuation
Difficulty with stool passage: straining, lumpy hard stools, use of digital manoeuvres
Overflow incontinence

77
Q

Red flag symptoms of constipation

A

Acute onset or change to regular bowel habit
PR bleeding / iron deficiency anaemia
Weight loss
Severe persistent constipation

78
Q

OE for constipation

A

Abdominal and rectal examination
Examine for masses, hard stool, anal fissure, haemorrhoids and sphincter tone

79
Q

Constipation investigations

A

Bloods to rule out secondary causes
FBC, TFTs, UEC, CMP
Endoscopy if red flag symptoms persist

80
Q

Constipation management

A
  1. Ensure adequate fluid intake and exercise
  2. Dietary changes: increase fibre / whole foods
  3. Behavioural: attempting to defecate at the same time daily / positioning
  4. Laxatives
  5. Suppositories / enemas: can be helpful for defecatory dysfunction
  6. Manual disimpactation - last line manoeuvre
81
Q

What do bulk forming laxatives do

A

Absorb water to increase faecal mass

82
Q

What do surfactant laxatives do

A

Decrease surface tension of stool allowing more water to enter

83
Q

What do osmotic agent laxatives do

A

Cause intestinal water secretion

84
Q

What do stimulant agent laxatives do

A

Alter electrolyte transport in the intestinal mucosa to increase motor activity

85
Q

Complications of constipation

A

Anal fissures
Haemorrhoids
Faecal impaction
Stercoral perforation

86
Q

Differentials for abdominal pain with PR bleeding

A

IBD
Diverticular disease
Malignancies (bowel / anal)
Angiodysplasia
Ischaemic colitis
Haemorrhoids

87
Q

What is the sepsis 6

A
  1. Give O2 to keep SATS above 94%
  2. Take blood cultures
  3. Give IV abx
  4. Give a fluid challenge
  5. Measure lactate
  6. Measure urine output
88
Q

What. Are the causes of abdominal distension (6F’s)

A

Fat
Fluid
Flatus
Faeces
Fetus
Fulminant mass

Junior Surgery (6 decks)

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