Abdominal Flashcards

1
Q

Persistence of the Vitello-Intestinal Duct

A

Vitelline Fistual (meconium through umbilicus)

Proximal part only = Meckel’s Diverticulum

Does not communicate with ileum = Enterocystoma

Persistent umbilical portion of the duct, which forms a polypoidal raspberry-like tumour of the umbilicus = Entroteratoma

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2
Q

Meckel’s Diverticulum

A

Remnant of vitello-intestinal duct
Asymptomatic : ileal mucosa
Symptomatic: Gastric
Located on anti mesenteric border of the ileum

2% (of the population)
2 feet (proximal to the ileocecal valve)
2 inches (in length)
2 types of common ectopic tissue (gastric and pancreatic)
2 years is the most common age at clinical presentation
2:1 male:female ratio

Complications:
Bleeding
Obstruction
Hernia (Littre’s)
Diverticulitis
Neoplastic change

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3
Q

Urachus

A

Urachus is a fibrous remnant of the allantois, a canal that drains the urinary bladder of the fetus that joins and runs within the umbilical cord.

Runs from apex of the bladder to the umbilicus

Normally obliterated

Persistence can cause:
-Discharging umbilicus sinus
-Cyst
-Urinary fistula

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4
Q

Umbilical Sepsis

A

Neonatal

Causes serious complications:
-Portal thrombophlebitis
-Liver abscess
-Jaundice
-Portal vein thrombosis
-Liver failure

Adults
Caused by retention of sebum within folds of umbilicus or from pilonidal sinus infection of umbilicus

Erythematous

Mixed staphylococcus and streptococcus growth

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5
Q

Haematoma of the rectus sheath

A

Spontaneous rupture of a branch of the inferior epigastric artery –> haematoma in rectus sheath

Presents as abdominal pain + rigidity on one side

More common in elderly people on anticoagulation

USS used to Dx

Mx: Conservative or drainage if problematic

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6
Q

Desmoid Tumour

A

Rare tumour of fibrous intra-muscular septa in the lower rectus abdominis

More common in females CBA

Associated with Gardener’s syndrome (AD polyposis with intra colic and extra colic tumours)

Mx: excised widely as high recurrence and can undergo malignant transformation (fibrosarcoma)

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7
Q

Littre’s Hernia

A

Hernia of Meckel’s Diverticulum

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8
Q

Richter’s Hernia

A

Hernia only involving part of the circumference of the bowel wall

Do not present with usual obstructive features

May present with ileum due to peritonism caused by necrotic bowel

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9
Q

Amyand’s Hernia

A

Hernia of incarcerated appendix

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10
Q

Sliding inguinal hernia

A

Herniating viscus forms part of the of the wall of the hernia sac

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11
Q

Pantaloon Hernia

A

Direct and indirect inguinal hernia

Hernias straddle inferior epigastric artery with bulges either side

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12
Q

Borders of the Inguinal Canal

A

Anterior: External oblique aponeurosis
Lateral 1/3: +Internal oblique

Floor: Inguinal ligament
Reinforced by lacunar ligament medial end

Posterior: Transversalis fascia

Roof: Internal oblique, transversis abdominis (and transversalis fascia)

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13
Q

Location of Deep Inguinal Ring

A

1cm above the Mid-point of the inguinal ligament

1/2 way along the inguinal ligament that arises at the ASIS and inserts on the pubic tubercle

Bound medially by inferior epigastric artery

Deep ring is defect in the transversalis fascia

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14
Q

Location of the Superficial Inguinal Ring

A

Just above and medial to the pubic tubercle

Defect in external oblique aponeurosis

Reinforced by medial and lateral crura

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15
Q

Contents of the Inguinal Canal

A

M: Spermatic Cord
F: Round ligament

Ilioinguinal nerve
-Doesn’t enter through the deep ring
-At -risk during hernia repair
-Sensation to external genitalia

Genital branch of the the genitofemoral nerve
-Supplies crmaster muscle
-Anterior scrotal skin / mons pubis + labia majora

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16
Q

Coverings of the spermatic cord

A

Embryologically, takes a covering from each layer of the abdominal wall

Transversalis fascia –> Internal spermatic fascia

Internal oblique –> cremasteric muscle and fascia

External oblique –> external spermatic fascia

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17
Q

Contents of the spermatic cord

A

Spermatic cord contents “3 arteries, 3 nerves, 3 other things”:

3 arteries:
1. Testicular artery (branch of aorta on R, branch of renal artery L)
2. Deferential artery (artery to the ductus deferens)
3. Cremasteric artery (branch of inferior epigastric)

3 nerves:
1. Genital branch of the genitofemoral
2. Cremasteric nerve
3. Autonomics.

3 other things:
Ductus deferens
Pampiniform plexus
Lymphatics

Ilioinguinal nerve

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18
Q

Hernia passes above and medial to pubic tubercle

A

INGUINAL HERNIA

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19
Q

Hernia passes below and lateral to pubic tubercle

A

FEMORAL HERNIA

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20
Q

Hesselbach’s Triangle

A

Medial: lateral border of the rectus abdominis

Lateral: Inferior epigastric artery

Below: Inguinal ligament

(Above: Conjoint tendon)

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21
Q

Managemet of uncomplicated inguinal hernia

A

Neonate –> emergency

Children –> elective herniotomy

Symptomatic adults –> offered surgery

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22
Q

Indications for laparoscopic hernia repair

A

Bilateral hernias for repair

Recurrent hernia

Exploration of the groin when a symptomatic
hernia is suspected from

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23
Q

Age at which conservative management for umbilical hernia is switched to surgical management:

A

3 years
-95% resolve by then

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24
Q

Surgery to correct para-umbilical hernia

A

Mayo procedure
-Flap of rectus sheath and line alba above and below defect

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25
Foramen of Winslow
foramen, between the greater sac (general cavity of the abdomen) and the lesser sac anterior: the free border of the lesser omentum, known as the hepatoduodenal ligament. This has two layers and within these layers are the common bile duct, hepatic artery, and hepatic portal vein. A useful mnemonic to remember these is DAVE: Duct, Artery, Vein, Epiploic foramen. posterior: the peritoneum covering the inferior vena cava superior: the peritoneum covering the caudate lobe of the liver inferior: the peritoneum covering the commencement of the duodenum and the hepatic artery, the latter passing forward below the foramen before ascending between the two layers of the lesser omentum. left lateral: gastrosplenic ligament and splenorenal ligament
26
Visceral referred pain from the abdominal cavity
Foregut: lower oesophagus to second part of duodenum --> Epigastric Midgut: second part of duodenum to to splenic flexure --> Umbilicus Hindgut: Splenic flexure to rectum --> Hypogastrium
27
Boas’s sign
In acute cholecystitis, pain radiates to the tip of the scapula and there is a tender area of skin just below the scapula, which is hyperaesthetic.
28
Causes of Raised Amylase
Pancreatic conditions • Acute pancreatitis • Pancreatic cancer • Pancreatic trauma Other intra-abdominal pathology • Perforated peptic ulcer • Acute appendicitis • Ectopic pregnancy • Intestinal infarction • Acute cholecystitis Decreased clearance of amylase • Renal failure • Macroamylaseaemia Miscellaneous • Head injury • Diabetic ketoacidosis • Drugs (e.g. opiates)
29
Causes of free sub-diaphragmatic gas
• Perforation of an intra-abdominal viscus • Gas-forming infection • Pleuroperitoneal fistula • Iatrogenic: laparoscopy, laparotomy • Gas introduced per vaginam: post-partum • Interposition of bowel between liver and diaphragm
30
Common Sites for Intra-Abdominal Abscess
Subphrenic space Subhepatic space Pelvis Between loops of bowel ‘pus somewhere, pus nowhere else, pus under the diaphragm’.
31
Anatomy of the Appendix
Blind ended tube situation on the posteromedial aspect of the caecum 2cm below the ileocaecal valve Average 6-9cm in length Found at the convergence of the three taenia coli Has its own mesentry - mesoappendix Supplied by the appendicular artery which is a branch if the ileocolic artery
32
Appendix Mass or Abscess
Mx Non-Operative as long as no peritonitis Antibiotics and percutaneous drainage if abscess Colonoscopy at 6 weeks to rule out malignancy
33
Appendix positions
Retrocaecal Pelvic Subcaecal Paracaecal Pre-ileal Post-ileal Pelvic most common on laparoscopy Retrocaecal most common on cadaveric
34
Stimulants for release H2 from parietal cells
Vagus nerve acetylcholine Gastrin
35
Inhibition of H2 from parietal cells
Somatostatin Gastric inhibitory peptide Vasoactive intestinal peptide (VIP)
36
Pepsin Cells
Found in body and fundus of stomach Produce Pepsinogen --> Pepsin Stimulated by acteylcholine from vagus nerve
37
Nissen Fundoplication
Hiatus hernia reduced Crura approximated Fundus mobilised from underside of diaphragm Fundus wrapped posteriorly around lower oesophagus and attached to left side of proximal stomach (360 wrap) Others: Toupet: 270 Watson: 180
38
Components of lower oesophageal sphincter
Physiological high pressure area in lower oesophagus Mucosal rosette of the cardia Angle of oesophagus as it meets the cardia - Angle of His Diaphragmatic sling / crura Positive intra-abdominal pressure at lower end of oesophagus
39
Hiatus hernia
Sliding: 90% Stomach slides through diaphragmatic hiatus, grastro-oesophageal junction lies in thorax --> Lower sphincter incompetent Rolling: 10% Para-oesophageal Cardia remains below diaphragm: sphincter competent Stomach rolls up anteriorly through hiatus (Mixed)
40
Ivor Lewis Oesophagectomy
Two stages Laparotomy Stomach fully mobilised on vascular pedicle Left gastroepiploic and gastric artery divided Right thoracotomy Oesophagectomy Bring up stomach Anastomasois Feeding jejunostomy
41
Trans-hiatal Oesophagectomy
Abdominal incision Mobilise oesophagus through hiatus Cervical oesophagus by left neck incision
42
Pharyngeal Pouch
Killian's Dehiscence Between thyropharyngeus and cricopharyngeus Posterior pharyngeal pouch Mx: Endoscopic stapling
43
Heller's Myomotomy
Lower oesophageal sphincter divided 5c, above junction and 3cm below +Anterior partial fundoplication to reduce subsequent GORD
44
Achalasia
Failure of relaxation of lower oesophageal sphincter and associated ineffective peristalsis Degeneration of myenteric plexus of Auerbach Mx Balloon dilatation Surgical: Heller's
45
Management of diffuse oesophageal spasm
Calcium channel blockers Sublingual GTN PPI
46
Causes of peptic ulcers
H.Pylori NSAIDs Smoking Zollinger-Ellison syndrome Hyperparathyroidism --> hypercalcaemia Blood group O
47
Surgical management of gastric ulcers
Failure to heal with medical therapy --> indication for surgery Benign distal ulcers: Billroth I gastrectomy -Distal stomach removed and proximal stump anastomosed with duodenum Proximal ulcers: Polya-Type reconstruction - Anastomosis of gastric remnant to jejunum
48
Complications of Gastrectomy
Dumping -Early -Late Diarrhoea Anaemia Osteoporosis + Osteomalacia Nutritional deficiencies Carcinoma -Reflux of bile salts -Should be offered endoscopic surveillance
49
GIST
Dx: EUS <2cm --> discharge 2-5cm --> surveillance >5cm --> resect
50
Meneteriers Disease
Gastric mucosal hypertrophy Mucosal folds in body and fungus grossly enlarged Leads to over-secretion of acid and mucus Increased risk of malignancy --> prophylactic gastrectomy
51
Dumping
Early: True 15-30 minutes post meal Vasomotor symptoms Tachycardia Flushing Light-headedness Sweating --> Rapid emptying of hyperosmolar (mainly carbohydrates) into small bowel --> Influx of fluids down osmotic gradient Late 4 hours -->Reactive hypoglycaemia
52
Zollinger-Ellison Syndrome
Gastrinoma Normally in pancreas but can be in duodenum or stomach MEN 1: 30% Present with diarrhoea and pain --> Peptic ulceration
53
Liver surface anatomy
5th intercostal down to right costal margin Extends to left mid-clavicle
54
Bilirubin level of clinical jaundice
50
55
Right Hepatic and Right portal vein supply
Right hemiliver Lobes V - VIII
56
Left Hepatic and Left portal vein supply
Left hemiliver I --> Caudate II and III --> Left lobe IV --> Quadrate
57
Causes of portal hypertension
Pre-Hepatic Congenital atresia of portal vein Portal vein thrombosis: Neonatal Sepsis, Pyelophlebitis, Trauma, Tumour Extrinsic compression: Pancreatic, Biliary Hepatic: Cirrhosis Schistosomiasis Post-Hepatic: Budd-Chiari syndrome Cosntrictive pericarditis (Increased blood flow due to arteriovenous fistula or hyperspenlism)
58
Hydatid Cyst
Tapeworm infection: Echinococcus granulosus E. Multiocularis Adult tapeworm lives in intestine of dog Ingested ova hatch in duodenum --> portal venous sytem Leads to cyst with a surrounding fibrosis of the adventitial layer Rupture can lead to anaphylaxis Eosinophilia Mx: Mebendazole
59
Pyogenic liver abscess pathogens
Strep milleri E.coli Strep faecalis Staph aureus Anaerobes
60
Amoebic liver abscess
Entamoeba histolytica Intestine --> trophozoites --> portal vein --> Liver Right lobe ascess with thin-walles Solitary Stool: Ameobae cysts
61
Mx of Acites
Spironolactone Fluid restriction and Salt restriction +/- LeVeen shunt for refractory ascotes Peritoneum --> external jugular
62
Budd Chiari
Portal HTN Caudate hypertrophy Liver failure Gross ascites
63
Compenents of Child Score
Encephalopathy Ascites Bilirubin Albumin Prothrombin ratio
64
Antibiotic prophylaxis in Varices
Ciprofloxacin 500mg BD
65
Diagnosis of HCC
If resection planned do NOT biopsy Diagnosis Two imaging modalities showing arterial hypervascularisation (regardless of AFP) OR Single modality showing lesion + AFP >400 OR Histological diagnosis <2cm
66
Mx of HCC
Resection when possible Chemo: Doxorubicin, 5-flurouracil, Sorafenib: Tyrosine kinase inhibitor
67
Milan Criteria
Criteria for liver transplant in HCC Sinlge tumour <5cm 3 or less tumours no bigger than 3cm
68
Angiosarcoma of the liver
Vinyl chloride Thorotrost
69
Liver cell adenoma
Require resection as may undergo malignant change Assoc oral contraceptive pill Right flank pain due to haemorrhage Solitary well encapsulated Nearly always in F
70
Focal nodular hyperplasia of the liver
Do not require resection, do not undergo malignant transformation Central fibrous scar seen on CT F>M
71
Cavernous haemangioma
Commonest benign liver tumour Pain, swelling and haemorrhage If arteriovenous communication develops can lead to high output heart failure Mx: Resection if large
72
Biliary hamartoma
Small fibrous lesion just beneath liver capsule Biopsy usually needed to rule out HCC
73
Course of biliary system
Right and left hepatic ducts converge to make the common hepatic duct Joined by the cystic duct to form common bile duct Passes behin first part of the duodenum Passes close to head of pancreas Joins Pancreatic duct just prior to ampulla of vater
74
Post-Cholecystectomy Syndrome
Post-prandial flatulence Fat intolerance Epigastric and right hypochondrium discomfort
75
Asiatic chlangiohepatitis
Pigment stones form in the intrahepatic and extrahepatic biliary tree Supparative cholangitis E.Coli Strep Faecalis --> Deconjugation of bilirubin --> stones Mx: Endoscopic or percutaneous removal of stones Ductal obsruction -Choledoduodenostomy -Hepatojejunostomy
76
Klatskin tumour
Sclerotic cholangiocarcinoma involving the confluence of the hepatic ducts
77
Intrahepatic duct dilataion and collapsed gallbladder
=cholangiosarcoma obstruction above cystic duct at hepatic ducts
78
Biliary Atresia
1 / 20,000 Commonest cause of prolonged jaundice in infancy Jaundice at 2-3 weeks of life Hepatomegaly and splenomegaly Mx: Early Kasia's If identified late --> transplant
79
Infections in bile
E. Coli Klebsiella Strep facealis
80
Cholechondral cysts
Cystic transformation of the biliary tree Saccular dilatation of the common bile duct --> often abnormal termination as the common bile duct enters pancreatic head to join pancreatic duct Undergo malignant transformation Mx: Excision
81
Complications of acute pancreatitis
Infected pancreatic necrosis Pancreatic pseudocyst Pancreatic abscess Progressive jaundice Gastrointestinal bleeding (splenic artery) Gastrointestinal ischaemia/fistulae
82
Management of chronic pancreatitis
Conservative: -Stop cause -CREON -Glucose control Endoscopic: -Stenting Surgical -Beger -Frey
83
Pancreatic ductal adenocarcinoma (PDAC)
60% arising in the head characterized by groups of infiltrating carcinoma cells often some distance apart, interspersed by a fibrous stroma involvement of nerves, vessels, lymphatics and lymph nodes Metastatic spread is most commonly to the liver and lung; 80%
84
Intraductal papillary mucinous neoplasm (IPMN)
Group of lesions characterized by a papillary growth of the ductal epithelium with rich mucin production and cystic expansion of the affected duct Two types, 1) Main duct: Definite malignant potential --> Resection 2) Branch duct: Most;ly benign, resect if >3cm or if septae/nodularity Survival reaching 80–90% for in situ carcinoma, and 50–70% in the presence of invasive carcinoma Differ from cystic mucinous -Direct communication with the Wirsung duct -Absence of ovarian-type stroma
85
Mucinous cystic neoplasm
F>>M Multiloculated tumours with a characteristic dense fibrous wall and occasional calcification Oversecretion of the mucus by the hyperplastic columnar lining of the ducts and therefore contain thickened viscous material, Can be haemorrhagic. These tumours should be considered potentially malignant but are classified histologically as benign, borderline, or malignant based on degree of dysplastic changes.
86
Serous cystic neoplasm
Serous cystic neoplasms are most commonly Microcystic Can present in an ‘oligocystic’ or ‘macrocystic’ form when differentiation from other cystic neoplasms can be difficult. In the presence of multiple serous cysts Von Hippel–Lindau syndrome should be considered Present as incidental findings or with pressure symptoms or a palpable mass when large. Dense, internal, lacelike, honeycombed matrix composed of fibrous septae, and often a central scar. Diagnosis preoperatively, resection is usually not required as serous cystic tumours have virtually no malignant potential.
87
Acinar cell carcinoma of the pancreas
Tumour cells also may secrete pancreatic enzymes, most commonly lipase. Presentation may therefore be confused with acute pancreatitis
88
Whipples
Block resection of the: -Head of the pancreas -Distal half of the stomach -Duodenum -Gallbladder and common bile duct Reconstruction is achieved by anastomoses of the pancreatic tail remnant to the jejunum (or stomach) AND Anastomosing the common hepatic duct and the stomach to the jejunum.
89
Tumours sited in the head of the pancreas Mx
Whipples
90
Tumours sited in the tail of the pancreas Mx
Distal pancreatectomy and Splenectomy Most are unresectable
91
PET syndromes
MEN 1: 40% von Hippel-Lindau 10-15%
92
Confusion, sweating, dizziness, weakness, unconsciousness, relief with eating
Insulinoma
93
Zollinger–Ellison syndrome or severe peptic ulceration and diarrhoea
Gastrinoma
94
Necrolytic migratory erythema, weight loss, diabetes mellitus, stomatitis, diarrhoea
Glucagonoma
95
Werner–Morrison syndrome of profuse watery diarrhoea with marked hypokalaemia
VIPoma
96
Cholelithiasis; weight loss; diarrhoea and steatorrhoea. Diabetes mellitus
Somatostatinoma
97
MEN-1
Hyperplasia and/or neoplasm of the parathyroid glands Enteropancreatic NETs Pituitary adenomas. PPP 11q13 gene Familial MEN-1: First degree relative with at least one of the Ps tumour For PETs, 90% have multiple which is juxtaposed to sporadic-type tumours that tend to be solitary It is recommended that carriers of MEN-1 mutation are screened biochemically every 1–3 years for hyperparathyroidism, prolactinoma, gastrinoma, insulinoma, and other enteropancreatic tumours.
98
Indications for splenectomy
Trauma Blunt / penetrating trauma Iatrogenic intraoperative / endoscopic trauma Haematological The purpuras Haemolytic anaemia Hypersplenism Proliferative disease Misc Distal pancreatectomy (for benign or malignant disease) Proximal gastrectomy Splenorenal shunt
99
Post-splenectomy immunization
Pneumococcal vac repeat Influenza immunization Life long antibiotics are phenoxymethylpenicillin or erythromycin If not previously immunized: Haemophilus influenza type b Meningococcal group C conjugate vaccine Elective splenectomy should be preceded by the administration of vaccines 2–3weeks prior to surgery
100
True rectum
Coalescence of the taeniae coli of the sigmoid colon to form a continuous outer muscular tube
101
Faecal calprotectin
Nonspecific test of intestinal inflammation that can be used to monitor inflammatory bowel disease activity
102
Trotter's triad
Diagnosis of nasopharyngeal carcinoma -Unilateral conductive hearing loss - Ipsilateral facial & ear pain - Ipsilateral paralysis of soft palate
103
Tumours of the appendix
Carcinoid -Appendicectomy sufficient unless >2cm or invokves caecum --> R hemicolectomy Adenocarcinoma -R hemicolectomy +/- chemo Pseudomyxoma peritonei -Seeding from cystadenoma of appendix
104
Indications for surgery Crohn's
Elective • Chronic subacute obstruction due to fibrotic strictures, adhesions or refractory disease • Symptomatic disease unresponsive to, or poorly controlled by medical management • Chronic relapsing disease on discontinuation of medical management and steroid dependency • Complications of medical management (e.g. osteoporosis) • Concerns about long-term immunosuppression, risk of malignancy and viral/atypical infections • Perianal sepsis and fistula • Enterocutaneous fistula • Onset of malignancy, including colorectal adenocarcinoma and small bowel lymphoma • Rarely, control of debilitating extra-colonic manifestations such as iritis and sacroiliitis. Emergency • Fulminant colitis or acute small bowel relapse unresponsive to medical management • Acute bowel obstruction • Life-threatening haemorrhage • Abscess or free perforation • Perianal abscess.
105
Indications for surgery UC
Elective • Symptomatic disease unresponsive to, or poorly controlled by, medical management • Chronic relapsing disease on discontinuation of medical management and steroid dependency • Complications of medical management • Concerns about long-term immunosuppression, risk of malignancy and viral/atypical infections • Severe dysplasia on surveillance biopsies of colorectal epithelium • Onset of colorectal adenocarcinoma • Rarely, control of debilitating extra-colonic manifestations such as iritis and sacroiliitis. Emergency • Fulminant colitis unresponsive to maximal medical management • Toxic megacolon • Free perforation • Life-threatening haemorrhage • Acute complications of medical management.
106
GIST
Bengin and malignant C-kit = malignant -->imatinib
107
Peritoneal coverings of the rectum
Upper third: Anterior and sides covered in peritoneum Middle third: Peritoneum anteriorly Lower thid: Extraperitoneal
108
Superior rectal artery
Continuation of Inferior mesenteric artery Communicates with middle and lower rectal arteries which are an extension of internal iliac artery
109
Drainage of inferior mesenteric vein
Drains into splenic vein
110
Lymph drainage of rectum
Drains upwards to Superior rectal and inferior mesenteric lymph nodes
111
Lymph drainage of anal canal
Drains to inguinal nodes
112
Position of the appendix
Medial wall of caecum 2cm below ileocaecal valve Taenia coli converge at appendix
113
Management of bile salt diarrhoea
Seen in crohns Cholestyramine
114
5-aminosalicylic acid agents
Mesalazine Olsalazine Used for maintenance therapy for people with colonic IBD
115
Indications for surgery in Crohns disease (4)
1. Complications of luminal disease: fulminant colitis, life-threatening haemorrhage, obstruction, abscess, sepsis, perforation, fistulation 2. Acute on chronic medical therapy failure / complications of medical therapy 3. Treatment or prophylaxis of malignancy 4. Peri-anal disease
116
Communication between superior mesentric artery and ceolicac axis
Pancreaticoduodenal arcade
117
Communication between superior mesenteric artery and inferior mesenteric artery
Marginal artery
118
Cells of the small bowel
Columnar glandular epithelium APUD: Amine precursor uptake decarboxylation Paneth cells
119
Test for bacterial overgrowth
C-Xylose C-Glucochelote Breath test
120
Tumour of APUD cells
Carcinoid Most common sit eis appendix Appendectomy -if >2cm, nodal involvement or involves caecum --> R Hemicolectomy
121
Appendix adenocarcinoma
Assoc with Lynch syndrome
122
Mucin-secreting cyst adenoma
Pseudomyxoma peritoni
123
Truelove and Witts
Mild, Moderare Severe Severe Stools / day: >6 Pulse: >90 Temp: >37.8 Hb <105 ESR >30 CRP >30
124
c-kit in GIST
=malignant
125
imatinib mesylate
Tyrosine kinase inhibitor Used in GIST
126
Urinary 5-HIAA
Carcinoid tumour
127
Competent ileocaecal valve and large bowel obstruction
--> Caecal perforation Largest diamter, Laplace law
128
Small bowel most susceptible to readiation enteritis
Jejunum
129
Typical electrolyte abnormalities causing ileus
Hypokalaemia Hyponatraemia Uraemia DKA
130
Drugs that cause a paralytic ileus
Tricyclic antidepressants Lithium Excess opiates
131
Management of pseudo obstruction
Management is conservative and involves stimulant enemas. Colonoscopic deflation may be required in cases where caecal distension Intravenous erythromycin has been shown to stimulate motility by binding to colonic motilin receptors. Intravenous neostigmine
132
Commonest site of diverticulosis
Sigmoid
133
Solitary diverticulum of caecum
Arise from medial wall close to ileocaecal valve Rare Can extend upwards retroperitoneally If becomes obstructed and inflammed, clinically same as appendicitis
134
Management of uncomplicated diverticulitis
High fibre diet Supplemented by bran or a bulk laxative such as methylcellulose Stimulant laxatives and purgatives are to be avoided. Antispasmodics, such as propantheline or mebeverine NSAIDs increase complications - AVOID
135
Hinchley Grade
Severity of diverticulitis I: localised para-colic abscess II: distant abscess e.g. pelvis or sub-diaphragmatic III: Peritonitis IV: Faecal peritonitis
136
RET gene mutations
Associated with Hirschsprung's disease MEN II
137
DUKES: Spread to involve lymph nodes
Dukes C
138
DUKES: Spread through full thickness of bowel wall
Dukes B
139
DUKES: Metastatic
Dukes D
140
DUKES: Spread into, but not beyond, muscularis propria
Dukes A
141
Indications for radiotherapy for rectal carcinoma
High-risk tumours Risk factors include - Low tumour - Bulky fixed lesion - Anterior lesion - Evidence of T3 or T4 stage and/or involved lymph nodes on imaging.
142
Indications for chemotherapy for colorectal cancer
Post-operative chemotherapy for Dukes C and D Combine capecitabine with oxaliplatin New Abs Cetuximab: monoclonal antibody against epidermal growth factor receptor Bevacizumab: monoclonal antibody to vascular endothelial growth factor
143
Position of anorectal cushions
3, 7, and 11 oclock Corrospond to three terminal branches of superior rectal artery Left Right posterior Right anterior
144
Cell lining below dentate line
Keratinised squamous cell
145
Cell lining transition zone of anal canal
Non-keratinised squamous cell
146
Cell lining anal canal above transition zone
Columnar epithelium
147
Structures maintaining faecal continence
Intact anorectal and pelvic floor sensation Intact anal sphincters and levator ani Preservation of the anorectal angle The bulk provided by the anal haemorrhoidal ‘cushions’.
148
Staging of haemorrhoids
First-degree piles are those that bleed, are visible on proctoscopy but do not prolapse Second-degree piles are those that prolapse during defaecation but reduce spontaneously Third-degree piles are prolapsed constantly but can be reduced manually Fourth-degree piles are irreducibly prolapsed.
149
Sites of ano-rectal abscess
Peri-anal: common, simple drainage Intersphincteric: common Ischiorectal: can become bilateral as no fascial planes - usually require drainage and antibioitcs High-intermuscular: more complex, can become circumferential Pelvirectal: more complex, can become circumferential
150
Goodsall's Rule
Anterior opening of fistula on perianal skin: Radial tracking of fistula directly into anal canal Posterior opening: Line can be drawn between 3 o'clock and 9 o'clock positions then the tract usually passes circumferentially backwards and enters the anal canal in the midline (6 o'clock position)
151
Management of fistulas-in-ano
Low fistulae should be laid open Complex high fistulae require repair and/or seton insertion -Advancement flap -+/- defunctioning
152
Types of fistula-in-ano
Low intersphinteric Trans-sphinteric Supra-sphincteric Ischiorectal fistula
153
Causes of fistula-in-ano
Common • Idiopathic (cryptoglandular) due to blockage of anal gland duct • Crohn's disease • Anorectal trauma • Iatrogenic (surgical) • Anorectal carcinoma Rare causes • Ulcerative colitis • Tuberculosis • Actinomycosis
154
Mx of anal warts
Topical podophyllin
155
Anal verge cancer lymph spread
Inguinal lymph nodes
156
Anal canal lymph spread
Proximal to mesorectal nodes or internal iliac nodes via the middle rectal lymph nodes
157
Management of anal cancer
T1N0 lesions: Local surgical excision only T2, T3, or T4 lesions: Chemoradiotherapy -external beam radiotherapy -capecitabine and mitomycin / capecitabine and cisplatinum Abdominoperineal resection is reserved for failures of chemoradiation.
158
Management of rectal prolapse
Childhood rectal prolapse -Conservative -Regular bowel habits and reduction of the prolapse Mucosal prolapse -submucosal injection of sclerosant, by photocoagulation or by applying Barron's bands to the prolapsed area -resistant cases: limited excision of the area or stapled anorectal rectopexy Full-thickness Perianal Approach -Delorme's procedure -Perianal rectosigmoidectomy -Altmeier procedure Abdominal approach -Laparoscopic rectopexy and resection of the redundant sigmoid colon
159
Solitary rectal ulcer syndrome
Inordinate amount of time in the toilet attempting to defaecate Diagnosis: Anterior ulcer in the low rectum, and biopsy shows submucosal fibrosis, hypertrophy of the muscularis mucosae and overlying ulceration Mx Stool softners and psych
160
Traumatic cause of anal incontinence
Obstetric sphincter injury Trauma Surgical / iatrogenic (drainage or perianal abscess, fistula opening, haemorrhoidectomy) Perianal sepsis
161
Congenital causes of anal incontinence
Anorectal atresia Spina bifida
162
Neurological causes of anal incontince
Denervation of pelvic floor following childbirth Multiple sclerosis Low spinal or sacral tumour Spinal trauma Dementia
163
Treatment of idiopathic faecal incontinence
Avoiding dietary stimulants Fybogel + loperamide
164
Treatment of rectal irritability
Amitriptyline 25mg ON