Colo Rectal Surgery Flashcards
disease spreads in a progressive distal to proximal manner in colon only
Ulcerative colitis
Mucosal change in UC
dysplastic transformation
Age of UC
Bimodal
B /w 15-25 & 55-65 years
Ulcerative colitis location
always starts at rectum, does not spread beyond ileocaecal valve
Continuous
most common extra-intestinal feature in both CD and UC
Arthritis
Unrelated to disease activity extraart8cular symptom of crohn
Primary sclerosing cholangitis
Unrelated to disease activity most common extraarticular symptom of UC
Uveitis
Extraarticular manifestation of Crohn vs UC Related to disease activity
Arthritis: pauciarticular, asymmetric
Erythema nodosum
Episcleritis
Osteoporosis
Barium enema finding of UC
Loss of haustrations
Superficial ulceration, ‘pseudopolyps’
Smoking in Crohns
Crohns disease is worse in smokers and smoking is an independent risk factor for disease recurrence following resection.
Crihn vs UC distribution
Crohn is transmural
UC is only mucosal
Macroscopic changes of UC vs Crohn
UC: contact bleeding
Crohn: cobblestone appearance, apthoid ulcr
Operation for rectal prolapse
Altmeir
Delormes
Rectopexy
1st two are perineal approaches
most commonly utilised treatment for fissure in ano
Topical vasodilator therapy
Surgical division of which sphincter for fissure
internal sphincter and not external
Rx of lower GI bleed 2° diverticular disease
Conservative management with close observation
Usual site of diverticular disease
between the taenia coli where vessels pierce the muscle to supply the mucosa
If visit in clinic with diverticular disease
Get Cologram
If visit to ER with diverticular disease then
Get Abd xray to rule out air
CT Abd for infective organ
Which Severity Classification for diverticular disease
Severity Classification- Hinchey
Severity Classification- Hinchey.
I= Para-colonic abscess
II= Pelvic abscess
III= Purulent peritonitis
IV= Faecal peritonitis
epithelial defect proximal to tip of coccyx and others too superiorly in the midline too
Pilonidal Sinus
In natal cleft
Surgery for pilonidal sinus
- Bascom Procedure
- Limberg procedure, Z-plasty or Karydakis procedure( these three to prevent tension free closure )
site in the abdomen for fluid to collect following a perforated appendix
Pelvis
Appendicitis few features
•Peri umbilical abdominal pain
• Once or twice vomiting not continuous
• Mild pyrexia( high fever typically suggests Mesenteric Adenitis)
• Diarrhea and Anorexia is rare.
Administration of which drug reduces wound infection rates.
Metronidazole
appendix mass without peritonitis treatment
Attempt conservative management for appendix mass without peritonitis
Ant vs Post Anal fissure
Post : 90%
Ant: 10% andmostly in females
most common complication vs most early complication of ileostomy
MCC is Dermatitis
Most early is Necrosis
loaction of ileostomy
right iliac fossa in a triangle between the anterior superior iliac spine, symphysis pubis and umbilicus
length of small bowelneeds to be taken out for ileostomy
2.5cm
At which point ileostomies should lie
one-third of the distance between the umbilicus and anterior superior iliac spine
Ileostomy output is roughly in the range of
5-10ml/Kg/ 24 hours
High output ileostomy
20ml/kg/24 hours
How to control high output ileostomies
•Administration of oral loperamide (up to 4mg QDS).
• Foods containing gelatine may also thicken output.
Fistula in IBD patients
management of fistula should be minimalistic like Insertion of a loose seton
Association of fistula in ano
Crohn’s disease, tuberculosis, lymphogranuloma venereum, actinomycosis, rectal duplication, foreign body and malignancy
sphincter saving operation for fistula only 10%
Ano-rectal advancement flaps
Ligation of the intersphincteric tract procedure
Best for intersphincteric fistula
/useful agent in reducing the output from pancreatic fistulae
Octreotide
Most fistula arises from
diverticular disease and Crohn’s
High vs low output fistula
high (>500ml) or low output (<250ml)
Issue with enteroenteric or enterocolic fistula
bacterial overgrowth may precipitate malabsorption syndromes.
If a colocutaneous fistula with no distal obstruction then
Provide local wound care and await spontaneous resolution
Genes involved in adenoma-carcinoma sequence in colorectal cancer?
C-myc
APC
p53
K-ras
(HNPCC) or Lynch syndrome genes
IGF1
MCC
DCC
c-yes
bcl-2
Characteristic of an adenoma which indicates it’s malignant nature
Increased size
Villous architecture
Dysplasia
Large bowel obstruction
Right hemi plus ileo colic anastomosis
Left colon obstruction surgery
Sub total colectomy and anastomosis
Left hemicolectomy with on table lavage and primary anastomosis
Left hemicolectomy and end colostomy formation
which surgery for colon below peritoneal re flections
Loop Colostomy
Ist line Rx of right sided colonic cancers
ght sided colonic cancers should proceed straight to surgery.
High vol andhigh fistula RX
TPN . + Octreotide
R x ofrectal cancer
Total Mesorectal Excision
Site of fissures in IBD
Ant wall
most marked finding on examination of UC
Proctitis
Mostcommon site of Perianal fistula
inter-sphincteric
Acute colonic pseudo-obstruction mostly occurs in
Left colon
Mostcommon sute of volvulus
Sigmoid colon
Xray finding of volvulus
dilated sigmoid colon, loss of haustra and U shape
If focaltenderness in obstructive bowel on examination indicates
Ischemia
tense, tympanic abdomen which is not painful.
colonic pseudo-obstruction (Ogilvies syndrome
Cellular process in a polyp
Dysplasia
No of polyps in FAP
More than 100
High risk findings of polyps
High risk findings
More than 2 premalignant polyps including 1 or more advanced colorectal polyps
OR
More than 5 pre malignant polyps
If failed colonoscopy then 2hat procedu4e to undertake
CT colonography
If a sigmoid stricture with large bowel obstruction then
Laprotomy and Hartmann
No coloanal anastomosis
Patients who do not respond to supportive measures with Colonic pseudo-obstruction should be treated with
attempted colonoscopic decompression and/ or the drug neostigmine
Colon tumour in a patient from a HNPCC family
panproctocolectomy rather than segmental resection
anastomosis to heal the key technical factors
adequate blood supply, mucosal apposition and no tissue tension
Defuction of tumor by stomq
Can be done in rectal ones but not in colon
Postresection chemo for colon cancer
Chemo is
a combination of 5FU and oxaliplatin is common
Extraintestinal manifestation of inflammatory bowel disease
: A PIE SAC
Aphthous ulcers
Pyoderma gangrenosum
Iritis
Erythema nodosum
Sclerosing cholangitis
Arthritis
Clubbing
Fistula in ano Rx
Lay open: if low, no sphincter involvement or no IBD.
Seton: if complex, high or IBD.
Rx of Acutely thrombosed haemorroids
usually conservative and consists of stool softeners, ice compressions and topical GTN or diltiazem to reduce sphincter spasm
- Large Chronic internal hemorrhoids Rx
- Large external hemorrhoids Rx
- stapled haemorroidopexy
- Milligan Morgan style conventional haemorroidectomy.
Milligan Morgan style conventional haemorroidectomy.
three haemorroidal cushions are excised, together with their vascular pedicle
the most efficient and definitive treatment for fissure in ano is
lateral internal sphincterotomy.
Chronic fissure > 6/52: triad
Ulcer
Sentinel pile
Enlarged anal papillae
Diverticulitis vs diverticulosis
Diverticular disease bleeds are classically painless, whilst
diverticulitis associated bleeds are often painful, secondary to the localised inflammation.
Common organism for Ano rectal abscess
Ecoli
Staph aureus
Which prolapse Rx has riskof anastomotic leak
Altmeirs procedure
Fe deficiency anemia in elderly
Right colon involvement
Anemia as occult blood loss
More common site of Angio dysplasia
Rightside of colon
Bleeding from cancer
1st sign in mostcases
Usually present only when the disease is advanced.
significant haemorrhag in UC Patients especiallywith failed medical Rx
sub total colectomy
Indications for surgery in lower GI bleeding
Patients > 60 years
Continued bleeding despite endoscopic intervention
Recurrent bleeding
Known cardiovascular disease with poor response to hypotension
Anal fissures are associated with:p which diseases
Sexually transmitted diseases (syphilis, HIV)
Inflammatory bowel disease (Crohn’s up to 50%)
Leukaemia (25% of patients)
Tuberculosis
Probing fistula during infection
Don’t do it
Increase chances of complication
Some points regarding fistula in ano
Typically probed by Lockhart Mummery probes
May respond to Infliximab if complicated Crohn disease
1st test to perform if suspected colorectal cancer
Colonoscopy
Diverticulosis is mostly diagnosed
Incidentally
Acute abdominal pain with more Localized in Leftiliac fossa
Diagnosis
Acute Diverticulitis
1St line investigation For complicated VS uncomplicated diverticular disease
Complicated: CT abd and Pelvis
Uncomplicated: flexible sigmoidoscopy
Bleeding 2° varices
Rx’
IV Terlipressin ( a vaso constrictor )
Montreal Score
Mayo Score of
Ulcerative colitis
The Montreal score can be used for quantifying disease extent and the Mayo score for disease severity.
definitive diagnosis for ulcerative colitis is via
colonoscopy with biopsy*.
Acute vs elective surgical treatment of UC
Acute: segmental resection(subcolectomy) withstoma
Elective: Panproctocolectomy is curative
absolute indication for a proctocolectomy in UC
Dysplastic transformation of the colonic epithelium with associated mass lesions
DVT in IBD
Patients with IBD have a high incidence of DVT and appropriate thromboprophylaxis is mandatory
Indications for surgery in Crohns
complications such as fistulae, abscess formation and strictures.
Ileoanal pouch in which IBD
In UC and not Crohns
commonest disease site for crohns
Terminal ileum
Severe perianal and / or rectal Crohns may require
proctectomy
The presence of pain and the sentinel tag suggests a
posterior fissure in ano.
Diff between hemorrhoids and fissure pain
anal fissures and hemorrhoids is that anal fissures tend to only show symptoms during bowel movements, while hemorrhoids tend to be painful throughout the day.
Obstructed defecation+chronic constipation
Straining during bowel movement
Solitary rectal ulcer syndrome
Which colonic polyp type carry the highest risk of malignant transformation
Villous adenomas .
PRx of colorectal liver metastasis
chemotherapy followed by surgical resection as it’s treatable
Nocturnal diarrhea and incontinence are symptoms of
IBD
painless, profuse rectal bleeding of dark blood in patients taking clopidogrel
Rx
Diverticular bleed
As they are mostly present in benign setting
commonest type of fistula I ano
Intersphincteric fistulas are the commonest type
left hemicolectomy for Crohn’s then development of which kind of fistula
Colovesicall fistula
colovesical v S ileovesical fistula
Colovesical fistulae primarily result from sigmoid diverticular disease. Ileovesical fistulae are most likely associated with Crohn disease.
Granulomatous (non-caseating) vs non granulomatous microscopic change in IBD
G: In Crohns
Non G: In U C
Microscopic Changes of UC
non-granulomatous inflammation of the mucosa and submucosa, crypt abscesses and goblet cell hypoplasia.
which Caecal diameter suggest s impending Perforation
A caecal diameter of 12cm or more
which Caecal diameter suggest s impending Perforation
A caecal diameter of 12cm or more
Type of cancer in anus
Squamous cell Ca
Anal cancer is linked to which infection strongly
HPV 16 infection
Lymphatic spread from anus below dentate line
Inguinal nodes
Most common surgery for UC and Crohn
UC: Proctocolectomy with Ileal Pouch-Anal Anastomosis (IPAA)
Crohn: laparoscopic ileo-cecal resection,
Goodall rule
For all fistula in 3.75cm or 3cm radius of anus
Except those ant fistula which are more than 3.75cm away from anus and drain in post midline direction curved form
If severe anal pain with unable to perform -DRE
If fever is also present along with these symptoms then
Go f9r abscess rather than fissure
Chances of synchronous tumor in colorectal Ca
5 %
ER vs elective surgery for UC
ER: Sub total colectomy, end ileostomy and a mucous fistula.
Elective: Pan proctocolectomy, an ileoanal pouch
Anal cancer is strongly associated
HPV infection
Commonest tumor in colon
Adenocarcinoma
first and 2nd line Rx of Non metastatic Anal Cancer
First line: Combined chemoradiotherapy.
2nd line: Radical abdominoperineal excision of the anus and rectum
Differentiate b/w Diverticular bleed and Angio dysplasia
Div Bleed: Mostly on left colon
Angio: Mostly on right side
Angiodysplasia diagnostic points
Brisk bleeding
small erythematous lesion in the right colon on colonoscopy
No other symptoms
Rectal prolapse is associated with
Associated with childbirth and rectal intussceception.
Tests to perform in lower GI bleed
1st UGI Endoscopy
If Endoscopy -ve for blood then Perform
CT Angiogram to rule out lower GI Causes
if life threatening lower GI bleeding
Selective mesenteric embolisation
Liver association with crohn and UC
Crohn: PSC and gallstones
UC : only PSC
If any major surgery and PRbleed post surgery then it can be dueto
An artery ligation and collateral flow may be imperfect
Stimulant laxatives
senna, picosulphate
Osmotic laxatives
lactulose, movicol, docusate
Bulk forming laxatives
Bran
Psyllium
Methylcellulose
when to give chemo in colon Ca
When nodes are involved
when to give chemo in colon Ca
When nodes are involved
Which haemorrhoids are impalpable
Uncomplicated grade 1 or 2 haemorrhoids are usually impalpable
Anal Ca features
squamous cell cancer
pruritus ani
bright red rectal bleeding
If a rectal obstruction 2° Ca
Which surgery to do
Formation of loop colostomy in ER setting
CAUSES OF PRURITIS ANI:
Systemic (DM, Hyperbilirubinaemia, aplastic anaemia)
Mechanical (diarrhoea, constipation, anal fissure)
Infections (STDs)
Dermatological
Drugs (quinidine, colchicine)
Topical agents
If tuMor is close to anal verge then surgery to Perform is
Abdomino-perineal excision of colon and rectum
Patients with T1, 2 and 3 /N0 rectal disease on imaging
do not require irradiation and should proceed straight to surgery.
Sigmoid volvulus may present
an asymmetrical mass in an elderly patient. It may contain a fluid level, visible on plain films
Extra colonic diseases and of Gardners
skull osteoma, thyroid cancer and epidermoid cysts
Extra colonic diseases and of Gardners
skull osteoma, thyroid cancer and epidermoid cysts
Extra colonic diseases and of Gardners
skull osteoma, thyroid cancer and epidermoid cysts
Gardners syndrome features .
Autosomal dom
APC gene
Multiple Polyps = High malignancy chance
Desmoid tumors in 15%
Lynch Syndrome has which Ca
colonic and/ or endometrial cancer
Li-Fraumeni Syndrome has
osteosarcomas and leukaemias
P53 mutation
criteria of diagnosis of Li-Fraumeni Syndrome
Individual develops sarcoma under 45 years
*First degree relative diagnosed with any cancer below age 45 years and another family member develops malignancy under 45 years or sarcoma at any age
Nerve damage with no soft tissue injury what will be the rate of neuron growth
1 mm per day
