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Kofi: Surgery + Gastroenterology > Colon > Flashcards

Colon Flashcards

1
Q

What are differentials for Acute Appendicitis?

A
  • Renal: Ureteric Stones, Urinary Tract Infection, Pyelonephritis
  • Gastrointestinal: Mesenteric adenitis, Diverticulitis, Inflammatory bowel disease or Meckel’s diverticulum
  • Urological: Testicular Torsion, Epididymo-Orchitis o Gynaecological: Pelvic Inflammatory Disease
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2
Q

What is Acute Appendicitis?

A
  • Inflammation of the appendix.
  • Caused by direct luminal obstruction usually secondary to faecolith but may also be due to lymphoid hyperplasia, impacted stool, or rarely appendiceal or caecal tumour.
  • Typically affects those in second or third decade.
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3
Q

What are risk factors of Acute Appendicitis?

A
  • Family
  • Ethnicity
  • Environmental
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4
Q

What are clinical features of Appendicitis?

A
  • Abdominal Pain.
  • Initially periumbilical, dull and poorly localised. Later migrates to right iliac fossa where it is well-localised and sharp.
  • Nausea and Vomiting
  • Anorexia
  • Diarrhoea
  • Constipation
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5
Q

What are examination findings of Acute Appendicitis?

A
  • Tachycardia
  • Tachypnoeic
  • Pyrexial.
  • Rebound tenderness and percussion pain over McBurney’s point as well potential sign of guarding.
  • Rovsing’s sign: RIF fossa pain on palpation of the LIF
  • Psoas sign: RIF pain with extension of right hip. Psoas major affected
  • Pelvic examination required in females of reproductive age to assess for gynaecological pathology
  • An appendiceal abscess may also present with RIF mass
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6
Q

What are laboratory tests for Acute Appendicitis?

A
  • Urinalysis should be done for all patient with suspected appendiciti
  • For any woman of reproductive age, pregnancy test is also vital
  • Routine bloods importantly FBC and CRP, should be requested to assess for raised inflammatory markers as well as baseline blood tests required or potential pre-operative assessment.
  • Serum beta-hCG may also be taken.
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7
Q

What are imaging for Acute Appendicitis?

A
  • 1st Line: Trans-abdominal US
  • CT scan – more commonly used in older patients, especially to identify any potential malignancy masquerading as or causing an appendicitis
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8
Q

What is the management of Acute Appendicitis?

A
  • Laproscopic Appendecetomy is gold standard for treating appendicitis due to low morbidity from procedure
    • Appendix sent to histopathology to look for malignancy
    • Entirety of the abdomen inspected for any evident pathology including checking for any Meckel’s diverticulum present
  • Open approach may be used in pregnancy
  • Use of conservative antibiotic therapy in uncomplicated appendicitis
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9
Q

What are complications of Acute Appendicitis?

A
  • Perforation if left untreated the appendix can perforate and cause peritoneal contamination
  • Surgical site infection varying depending on simple or complicated appendicitis
  • Appendix mass, where omentum and small bowel adhere to the appendix
  • Pelvic Abscess
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10
Q

What are the symptoms investigations and management of Pelvic Abscesses?

A
  • Presents as fever with a palpable RIF mass yet typically requires US scan or CT scan for confirmation
  • Management usually with antibiotics and percutaneous drainage of abscess.
  • Follow-up with CT scan after conservative treatment is recommended in patients >40 yrs due to around 2% prevalence
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11
Q

What is a Volvulus?

A
  • Twisting of a loop of intestine around its mesenteric attachment resulting in a closed loop bowel obstruction.
  • Affected bowel often becomes ischaemic due to a compromised blood supply, rapidly leading to bowel necrosis and perforation
  • Most occur at sigmoid colon. Can also occur at the stomach, small intestine, caecum and transverse colon but are much rarer
  • Long mesentery of the sigmoid colon means it is prone to twisting on its mesenteric base to form a volvulus more than any other region.
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12
Q

What are risk factors that lead to formation of a volvulus?

A
  • Neuropsychiatric disorders
  • Resident in a nursing home
  • Advanced age
  • Chronic constipation
  • Laxative
  • Male gender
  • Previous abdominal surgeries
  • Diabetes mellitus.
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13
Q

What are clinical features of a Volvulus?

A
  • Clinical features of bowel obstruction
    • Previous history of volvulus common
    • Vomiting is a late sign with colicky pain, abdominal distension
    • Absolute constipation occur earlier on in clinical course.
    • Abdomen is markedly distended with increased bowel sounds and tympanic percussion
  • If examination shows signs of perforation or generalised peritonism, it is a surgical emergency
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14
Q

What are tests for Volvulus?

A
  • Routine Bloods taken including electrolytes, Ca2+ and TFTs to exclude any potential pseudo-obstruction
  • Abdominal X-ray: Classically show coffee-bean sign arising from left iliac fossa. If ileocaecal valve incompetent, shows sign of small bowel of dilatation
  • If suspected bowel ischaemia, CT scan may be done; CT imaging classically will document ‘whirl sign’ from twisting mesentery around its base.
  • Barium enema can aid in any unclear diagnosis yet rarely performed
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15
Q

How is a Volvulus conservatively managed?

A
  • Decompression with sigmoidoscope and insertion of a flatus tube.
  • Flatus tube often left in situ for period of time after initial decompression to allow for continued passage of contents and aid recovery of the affected area.
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16
Q

What are indications for Surgery for Volvulus?

A
  • Repeated failed attempts at decompression
  • Necrotic bowel noted at endoscopy
  • Suspected (or proven) perforation or peritonitis
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17
Q

How is the decision for which surgery to undertake made?

A
  • Decision on which operation to perform will depend on patient’s nutritional status, adequacy of blood supply, haemodynamic stability and presence of any perforation or peritonitis
  • Patients with recurrent volvulus who are otherwise healthy may choose an elective procedure to prevent further recurrence.
    • Commonly sigmoidectomy with primary anastomosis)
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18
Q

What are complications for Volvulus?

A
  • Main immediate complication of sigmoid volvulus is bowel ischaemia and perforation.
  • Longer term complications are mainly the risk of recurrence and complication arising from any stoma placed
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19
Q

How is a Caecal violins managed?

A
  • Diagnosis once again may be made initially via abdominal X-ray, showing coffee bean with lead point from right lower quadrants.
    • Barium enema can also help to aid an unclear diagnosis
  • 1st Line: Surgical Management via detorsion and caecostomy.
    • Due to higher chance of ischaemia in caecal volvulus
  • 2nd Line: Endoscopic decompression.
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20
Q

What is Diverticulosis, Diverticular disease and Diverticulitis?

A
  • Diverticulosis – Presence of Diverticulum
  • Diverticular Disease – Symptomatic Diverticulum
  • Diverticulitis – Inflammation of the Diverticulum
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21
Q

What is a diverticulum?

A
  • Diverticulum is outpouching of bowel wall composed of mucosa.
  • Most commonly found in sigmoid colon but can be present
  • Present in around 50% of >50yrs and 70% of >80yrs, yet only 25% of cases become symptomatic. Disease affect more men and more prevalent in developed countries through the bowel.
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22
Q

How can diverticulitis be classified?

A
  • Classified as simple or complicated
    • Complicated diverticulitis refers to abscess presence, fistula formation or free perforation
    • Simple diverticulitis describes just inflammation.
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23
Q

What are risk factors for Diverticular Disease?

A
  • Low dietary fibre intake
  • Smoking
  • Family history
  • NSAID use
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24
Q

How does Diverticulititis develop?

A
  • Aging bowel has naturally become weakened in certain areas over time, movement of stool within the lumen will cause an increase in luminal pressure.
  • Result in outpouching of mucosa through weaker areas of bowel wall creating pockets in which bowel contents including bacteria can accumulate
  • Bacteria can overgrow within the outpouchings leading to inflammation of the diverticulum.
  • If it perforates into abdominal cavity, diffuse peritonitis will result however if it remain contained within diverticula, an abscess or phegmon can develop which presents localised peritoneal signs
25
Q

What are complications of severe or chronic diverticular disease?

A
  • Pericolic abscess
    • Often treated initially with antibiotics and bowel rest, before CT guided drainage or laparoscopic washout.
  • Fistula Formation
    • Common fistula subtypes include colovesical fistula or colovaginal fistulas. Require surgical resection and repair
  • Bowel obstruction
    • Secondary to stricture formation, can be managed through either stenting or bowel resection
26
Q

What are clinical features of Diverticular Disease?

A
  • Left lower abdominal pain (typically colicky pain, relieved by defecation)
  • Altered bowel habit
  • Nausea
  • Flatulence
27
Q

What are clinical features of Diverticulitis?

A
  • Abdominal pain and localised tenderness classically in left iliac fossa.
  • Potential Pyrexia
  • Nausea +/- vomiting
  • PR bleeding
    • PR exam is typically unremarkable
  • Anorexia.
28
Q

What are indications of a Perforated Diverticulum and how can it present differently?

A
  • Perforated diverticulum will present with signs of localised peritonism or generalised peritonitis
    • If patient is on corticosteroids or immunosuppressant, this can mask the symptoms of diverticulitis even if perforated
    • In patient with redundant sigmoid colon, pain may often be in the right lower quadrant or suprapubic area
29
Q

What are tests for Diverticulitis?

A
  • Routine bloods, alongside a Group and Save and venous blood gas.
  • Urine dipstick may prove useful to exclude urological causes
30
Q

What are tests for Diverticular Disease?

A
  • For suspected uncomplicated diverticular disease, Flexible Sigmoidoscopy as this will identify any obvious rectosigmoidal lesion
  • Sigmoidoscopy or Colonoscopy should never be done for presenting case of suspected diverticulitis due to increased risk of perforation
31
Q

What are test for suspected Diverticulitis?

A
  • CT abdo-pelvis Scan
    • Findings to suggest diverticulitis include:
      • Thickening of Colonic Wall
      • Pericolonic Fat Stranding
      • Abscesses
      • Localised air bubbles or free air.
  • Microperforation is radiologic diagnosis that reflects a localised perforation and inflammation
32
Q

How is Diverticulitis Staged?

A
  • Stage 1: Phlegmon (1a) or Diverticulitis with pericolic or mesenteric abscess (1b)
  • Stage 2: Diverticulitis with walled off pelvic abscess
  • Stage 3: Diverticulitis with generalised purulent peritonitis
  • Stage 4: Diverticulitis with generalised faecal peritonitis
33
Q

How is Diverticular Disease conservatively managed

A
  • Simple analgesia and encouraging oral fluid intake
  • Hospital admission may be required if:
    • Uncontrolled pain
    • Concerns of dehydration
    • Significant co-morbidities
    • Immunocompromised
    • Significant PR bleeding or symptoms persisting for longer than 46 hours despite conservative management
34
Q

How is Diverticulitis Conservatively managed?

A
  • IV antibiotics, IV fluids, bowel rest and Analgesia
  • Any significant PR haemorrhage will need resuscitation with IV fluids and blood products. Diverticular bleed in most patients will be self-limiting however options such as embolization or surgical resection may be needed if cases do not settle with conservative approaches
  • If second bleeding episode occurs there is a significant chance of further episodes hence can be best to discuss early with interventional radiologists for planning further management options
  • Symptoms typically improve within 2-3 days
  • Often diet can be advanced from clear liquids to low residue diet and IV antibiotic therapy swapped to oral treatment.
  •  Clinical deterioration or lack of improvement should prompt repeat imaging
35
Q

What is the surgical management of Diverticulitis?

A

Urgent surgery required in those failing to improve despite medical therapy and percutaneous drainage

  • 1st line/Emergency Surgery: Hartmann’s Procedure (15%-30% of patient admitted)
    • Required in perforration with faecal peritonitis or overwhelming sepsis
    • Hartmann’s procedure involves resection of sigmoid colon, with formation of end colostomy and closure of rectal slump.
    • Anastomosis with reversal of colostomy may be possible later
  • 2nd Line:Resection with primary anastomosis and loop ileostomy may also be attempted.
    • Recurrence of diverticulitis after episode around 10-35%. Elective segmental resection may be performed in patient with recurrent disease
    • Outpatient colonoscopy following resolution of diverticulitis should be arranged
36
Q

What are risk factors for Colorectal Cancer?

A
  • Age
  • Family history
  • Inflammatory bowel disease
  • Low fibre diet
  • High processed meat intake
  • Smoking
  • High alcohol intake.
37
Q

How common is colorectal cancer?

A
  • Third most common cancer in UK and second highest mortality figures of any cancer. Occurrence is strongly associated with age as over 85% presentation in those >60yrs.
  • Can occur in patient in their 20-30 yrs particularly in patient with inherited cancer syndromes
38
Q

How do colorectal cancers typically develop?

A
  • Originate form epithelial cells lining the colon and rectum typically as adenocarcinomas. Rarer rectal cancers include lymphoma, carcinoid and sarcoma
  • Develop via progression of normal mucosa to colonic adenoma (polyps) to invasive adenocarcinoma.
  • Adenoma may be present for 10 years or more before becoming malignant and progression to adenocarcinoma occurs in 10% of adenoma
39
Q

What are some genetic predispositions for Colorectal Cancer?

A
  • Adenomatous polyposis coli (APC) gene
    • Early APC gene (a tumour suppressor gene) mutation and inactivation results in growth of adenomatous tissue.
    • Also responsible for the development of Familial Adenomatous Polyposis (FAP).
    • Patients generally have a total colectomy with ileo-anal pouch formation in their twenties.
    • A variant of FAP called Gardner’s syndrome can also feature osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin
  • Hereditary nonpolyposis colorectal cancer (HNPCC)
    • Mutation to DNA mismatch repair (MMR) genes leading to defects in DNA repair, commonly accounting for the familial risk associated with colorectal cancer.
    • Most common form of inherited colon cancer. 90% develop.
    • Endometrial cancer is the next most common association
40
Q

What are some clinical features of Colorectal cancer?

A
  • Change in Bowel Habit
  • Rectal Bleeding
  • Weight Loss. Progressive weight loss only present in colorectal cancer cases with associated metastasis
  • Abdominal pain and Iron deficiency anaemia
    • Right sided colon cancer – abdominal pain, occult bleeding or mass in right iliac fossa
    • Left sided colon cancer – rectal bleeding, change in bowel habit or tenesmus or mass in left iliac fossa/mass on PR exam
41
Q

What are the referral criteria for Colorectal Cancer?

A
  • ≥40yrs with unexplained weight loss and abdominal pain
  • ≥50yrs with unexplained rectal bleeding
  • ≥60yrs with iron deficiency anaemia or changes in bowel habit
  • Positive occult faecal blood test
42
Q

What is the screening used for Colorectal Cancers?

A
  • Faecal Occult Blood Test
    • Offered every 2 years to men and women aged 60-75.
      • Conducted using faecal occult blood home testing kits
      • 3 stool samples are required for analysis.
    • If any samples positive, patient offered appointment with specialist nurse and further investigation via colonoscopy
  • Bowel Scope
    • Offered an One-off to women and men over 55
43
Q

What are tests for Colorectal Cancer?

A

Routine bloods

  • Full blood count may show microcytic anaemia
  • U&Es, LFTs, and Coagulation screens
  • Tumour marker Carcinoembryonic Antigen (CEA) should not be used as diagnostic test due to poor sensitivity and specificity.
    • Used to monitor disease progression and should be conducted pre- and post- treatment
44
Q

What are imaging investigations for Colorectal Cancers?

A
  • Gold standard: Colonoscopy with biopsy.
    • If unsuitable for patient, due to frailty, co-morbidities or intolerance then flexible sigmoidoscopy or CT colonography

Once diagnosis made, several other investigations are required for staging

  • CT scan (Chest/Abdomen/Pelvis) to look for distant metastases and local invasion
  • Full colonoscopy or CT colonogram to check for 2nd (synchronous) tumour if not used initially
  • MRI rectum (rectal cancers only) to asses depth of invasion
  • Endo-anal ultrasound to assess suitability for trans-anal resection
45
Q

Describe the Stages of Duke criteria?

A
  • Stage A: Confined beneath the muscularis mucosa
  • Stage B: Extension through muscularis mucosa
  • Stage C: Involvement of regional lymph nodes
  • Stage D: Distant metastasis
46
Q

How is Colorectal cancer surgically managed?

A

Mainstay of curative management for localised malignancy in the bowel is suitable regional colectomy to ensure removal of the primary tumour with adequate margins and lymphatic drainage, followed either by primary anastomosis or formation of a stoma to restore bowel function

  • Right Hemicolectomy and Extended Right Hemicolectomy
  • Left Hemicolectomy
  • Sigmoidcolectomy
  • Anterior resection – rectum and upper anaus
  • Abdominoperineal Resection – lower anal region
  • Hartmann’s Procedure
    • Used in emergency bowel surgery such as bowel obstruction or perforation.
    • Involves complete resection of the recto-sigmoid colon with formation of end-colostomy and closure of rectal stump
47
Q

How is Colorectal cancer medically managed?

A
  • Chemotherapy
    • Indicated typically in patient with metastatic disease. Which agents to use decided in MDT meeting
  • Radiotherapy
    • Used in rectal cancer most often as neo-adjuvant treatment
    • Particular use in patients with rectal cancer. Can undergo pre-operative long-course chemo-radiotherapy to shrink the tumour, thereby increasing chance of complete resection and cure
48
Q

How is Colorectal Cancer palliatively managed?

A
  • Endoluminal Stenting can be used to relieve acute large bowel obstruction in patients with left-sided tumours yet cannot be used in low rectal tumours due to unpleasant side-effect of intractable tenesmus.
    • Main side effects of stents are perforation, migration and incontinence
  • Stoma Formation can be performed for patient with acute obstruction usually with either a defunctioning stoma or palliative bypass
  • Resection of Secondaries can be done with adjuvant chemotherapy for any liver metastases but not commonly done
49
Q

What is Pseudo-obstruction?

A
  • Disorder characterised by dilatation of the colon due to an adynamic bowel in the absence of mechanical obstruction.
  • Most commonly affects caecum and ascending colon.
  • Rare condition yet is most common in elderly.
50
Q

How does Pseudo-obstruction occur?

A
  • Thought to be interruption in autonomic nervous supply to the colon resulting in absence of smooth muscle action in bowel wall
  • If untreated, can result in an increasing colonic diameter, leading to an increased risk of toxic megacolon, bowel ischaemia and perforation
  • Variety of causes such as:
    • Electrolyte imbalance or endocrine disorders (hypercalcaemia, hypothyroidism, or hypomagnesaemia
    • Medication including opioids, calcium channel blockers, or anti-depressants
    • Recent surgery, severe illness, or trauma
    • Recent cardiac event
    • Parkinson’s disease
    • Hirschsprung’s disease
51
Q

What are clinical features of Pseudo-obstruction?

A
  • Abdominal pain
  • Abdominal distension
  • Constipation due to adynamic bowel, whilst not passing normal stool. Often patients may have paradoxical diarrhoea
  • Vomiting typically a late feature due to colon being most distal in GI tract
52
Q

What are examination findings of Pseudo-Obstruction?

A
  • Bowel sounds often present. Abdomen will be tympanic due to distension and palpation for focal tenderness should be done
  • Focal tenderness indicates ischaemia
  • Patient with bowel obstruction may be uncomfortable on palpation due to discomfort from pressing on a distended abdomen but there should be no focal tenderness, guarding or rebound tenderness unless ischaemia is developing
53
Q

What are tests used to assess Pseudo-obstruction?

A

Initial blood test to assess for infective or electrolyte:

  • FBC
  • CRP
  • U&Es
  • LFTs
  • Ca2+, Mg2+
  • TFTs
54
Q

What are imaging tests for Pseudo-obstruction?

A
  • Plain abdominal films show bowel distension
  • Abdominal-pelvis CT scan with IV contrast
    • Shows dilatation of the colon as well as definitively excluding a mechanical obstruction and assessing any complications (e.g. perforation)
  • Motility studies often required in long-term and potential biopsy of colon at colonoscopy
55
Q

How is Pseudoobstruciton conservatively managed?

A
  • Most cases managed conservatively and does not require surgical intervention. Treatment of underlying acute illness will be required.
  • Patient should be made Nil-by-mouth and started on IV fluids with fluid balance chart started. If patient vomiting, NG tube should be inserted to aid decompression
  • Ensure appropriate analgesics and prokinetic anti-emetic also prescribed
  • Pseudo-obstruction affects distal part of GI tract, vomiting is a late-stage of disease progression hence may not always be warranted
56
Q

How is Pseudo-Obstruction medically managed?

A
  • Most cases do not result within 24 hours and endoscopic decompression is mainstay of treatment. Involves insertion of flatus tube and allowing region to decompress
  • Patient should be reviewed regularly to assess condition’s progression. If limited resolution, use of IV neostigmine may be trailed
  • Nutritional support should be considered in patient particularly if recurrent as this may lead to weight loss and malnutrition. Regular small soft or liquid meals may be easier to digest
57
Q

How is Pseudoobstruction surgically managed?

A
  • Suspected ischaemia or perforation or those not responding to conservative management, surgery may be indicated
  • Absence of perforation, segment resection +/- anastomosis will often be performed however unless affected areas are removed it’s not curative
  • Alternatives such as caecostomy or ileostomy may be done to decompress bowel in long term
58
Q

What is the Amsterdam Criteria?

A

The Amsterdam criteria are sometimes used to aid diagnosis of genetic colon cancer:

  • at least 3 family members with colon cancer
  • the cases span at least two generations
  • at least one case diagnosed before the age of 50 years

Kofi: Surgery + Gastroenterology (14 decks)

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