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Surgery > Colorectal > Flashcards

Colorectal Flashcards

1
Q

Altered bowel habit means?

A

Changes in

  • Frequency
  • Consistency
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2
Q

How to estimate roughly how much blood is in stool?

A

How many times do they go toilet to pass out blood in a day

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3
Q

Criteria for urgent referral colonoscopy within 2 weeks

A

> Unexplained rectal bleed with >= 1 of following:

  • fresh blood
  • blood mixed with stool
  • altered bowel habit
  • significant LOW

AND/OR

> Unexplained IDA

AND/ OR

> Palpable abdominal or rectal mass

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4
Q

Symptoms of right CCA vs left CCA vs rectal ca

A

> Right

  • IDA
  • Abdominal mass (cauliflower type)

> Left
- Intestinal obstruction (annular ring tumour, lumen smaller)

> Rectal

  • Tenesmus
  • Mucoid stool
  • Pencil-thin stool
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5
Q

Investigation for colon Ca

A

> Diagnosis
- Colonoscopy (direct visualization, biopsy, detection of synchronous lesion)

> Staging

  • CT TAP for CCA
  • MRI rectum for rectal Ca
  • EUS: depth of invasion
  • PET and Bone scan

> Assess complicaiton

  • FBC: IDA
  • RP: increase Cr at risk of contrast nephropathy
  • LFT: albumin for nutrition status, ALP for liver mets
  • Erect and supine AXR: intestinal obstruction
  • Erect CXR: air under diaphragm for perforated tumour
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6
Q

Management of rectal Ca

A

> From anal verge

  • 17-10cm: HAR
  • 10-5cm: LAR
  • 5-0cm: ULAR
  • Sphincter involved: APR

> Total mesorectal excision
- as part of LAR for middle and lower rectum Ca

> According to staging

  • T1: local excision
  • T2: local excision + adjuvant chemo/ RT OR radical resection
  • T3/4: Neoadjuvant CCRT before radical resection
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7
Q

Follow up for colorectal Ca

A
  • History, physical examination and CEA levels every 3-6 months for 5 years
  • Surveillance colonoscopy at year 1 and every 3-5 years thereafter
  • CT TAP performed annually for 3 years
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8
Q

Bowel prep for colonoscopy

A
  • Stop Fe tablet >5 days prior +- stop anticoagulant
  • Low residual diet 2-5 days prior
  • Clear liquid 1 day prior
  • NBM 6-8 hours prior
  • FLEET osmotic agent 2-3 packs (4pm, 8pm)
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9
Q

TNM staging for colorectal Ca

A

> Primary tumor

  • T1: invade submucosa
  • T2: invade muscularis propria
  • T3: invade through the muscularis propria into pericolorectal tissues
  • T4a: penetrate to the surface of visceral peritoneum
  • T4b: invades or adherent to other organs or structures

> Regional LN

  • N1: 1-3
  • N2: 4 or more

> Distance metastasis

  • M0: No
  • M1: Distance metastasis
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10
Q

Consent for a colon operation

A

> Explain about the surgery
Risk and complication
- injury to BV which may cause bleeding
- bleeding which may require a blood transfusion
- risk of transfusion: transfusion reaction, cross-infection (eg: HIV, Hep B/C)
- risk of injury to surrounding organs (eg: small bowel, bladder, liver)
- post-operative - wound infection/ breakdown
- general anesthesia risk and complication

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11
Q

Difference between ileostomy and colostomy

A

> Ileostomy

  • RIF
  • 3cm “spout” to prevent ileal content (corrosive) to contact the skin
  • watery greenish output

> Colostomy

  • LIF
  • flushed to the skin
  • firm brown fecal output
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12
Q

Complication of stoma

A

> Early

  • Infection
  • Necrosis
  • Obstruction (fecal impaction/ adhesion)
  • Leakage
  • Stoma diarrhea

> Intermediate

  • Prolapse of bowel
  • Retraction

> Late

  • Parastomal hernia
  • Stenosis
  • Skin excoriation
  • Fistulae
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13
Q

Cause of increased output in stoma patient (>1000ml/day)

A
  • Primary: loss of normal daily secretion (1.5L saliva, 2-3 gastric juice, 1.5L pancreatico-biliary)
  • Other: intra-abdominal sepsis, infective enteritis, intermittent bowel obstruction
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14
Q

What is rule of 2?

A 
> For Merkel's diverticulum
○ 2 inches in length, 2cm wide
○ 2 feet (60cm) from ileocecal valve
○ 2% of the population
○ 2:1 ratio (M:F)
○ 2-4% symptomatic
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15
Q

Investigation for Merkel’s diverticulum

A 
○ Blood 
	§ Same as IO/ LGIB
○ Imaging
	§ Meckel's scan
		□ Technetium-99m pertechnetate scan
		□ Detect gastric mucosa
	§ Barium studies
                □ Small bowel enterocolitis
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16
Q

Definitive management of Merkel’s diverticulum

A

§ Broad base - wedge ileal resection with anastomosis

§ Narrow base - resection of the diverticulum

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17
Q

What is pectate line

A
  • Irregular circle form by anal valve

- Divide anal canal into endodermal and ectodermal origin

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18
Q

What is McBurney point

A
  • Point that lies 1/3 of the distance laterally on a line drawn from the umbilicus to the right ASIS
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19
Q

3 cardinal features of appendicitis

A
  • Low grade pyrexia
  • Localized abdominal tenderness
  • Muscle guarding and rebound tenderness
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20
Q

Rovsing sign

A

RIF pain with deep palpation of the LIF

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21
Q

Psoas sign

A

RIF pain with right hip flexed (as inflamed appendix lying on psoas muscles)

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22
Q

Obturator sign

A

RIF pain with internal rotation of a flexed right hip (for pelvic appendix)

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23
Q

Component of Alvarado score

A

> MANTRELS

  • Migratory RIF pain
  • Anorexia
  • Nausea/ Vomiting
  • Tenderness at RIF (2 points)
  • Rebound tenderness
  • Elevated temperature (>37.3’C)
  • Leukocytosis (2 points)
  • Shift of neutrophils to left
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24
Q

Management of appendicitis

A

> Supportive

  • NBM, IV drip, IV antibiotics
  • Antiemetics and analgesia

> Definitive

  • Appendectomy (open/ laparoscopic)
  • Peritoneal toilet
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25
Q

Hinchey classification

A

> Staging for diverticulitis

  • Stage 1 Pericolonic/ Mesenteric abscess
  • Antibiotics, NBM, IV fluids
  • KIV percutaneous drainage of acute pericolonic abscess
  • Stage 2 Pelvic/ retroperitoneal abscess
  • Percutaneous drainage under radiological guidance
  • KIV elective 1 stage surgery - resection of segmental colectomy with primary anastomosis
  • Stage 3 Purulent peritonitis * Debate whether same as stage 2 or 4
  • Stage 4 Fecal peritonitis - 2 stage operation - Hartmann’s procedure + secondary re-anastomosis 3 months later
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26
Q

Investigation for acute diverticulitis

A
  • FBC: leukocytosis, ESR
  • Erect CXR: r/o perforation
  • AXR: ileus, air fluid level
  • Contrast CT: diverticular elsewhere, confirm colitis
  • Laparoscopic: if diagnosis doubt
  • AVOID barium enema, colonoscopy
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27
Q

Management of acute diverticulitis

A

> Uncomplicated - CONSERVATIVE

  • NBM
  • Analgesia
  • IV Abx (10-14 days)
  • Colonoscopy 4-6 weeks later (confirm diagnosis + exclude colon Ca)

> Complicated - SURGICAL

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28
Q

Complication of acute diverticulitis

A
  • LGIT hemorrhage
  • Fistula formation
  • Perforation (phlegmon -> diverticular abscess -> peritonitis)
  • Bowel obstruction
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29
Q

Small vs Large bowel obstruction

A

> Small bowel

  • More acute
  • Central and colicky pain
  • Early, profuse, biliary vomiting
  • Radiological: central, 30mm diameter, valvular conniventes

> Large bowel

  • More gradual onset
  • Localized tenderness
  • Vomiting: late, feculent, may be absent
  • Radiological: peripheral, 60mm, haustra might present
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30
Q

Diagnostic investigation for intestinal obstruction

A

Erect AXR
- Air fluid level ≥5

Supine AXR

  • Jejunum (>3cm), Colon (>6cm), Cecum (>9cm)
  • Valvular conniventes/ Haustration might present

CT abdomen

  • Perform if not complete obstructed
  • Determine site/ cause of obstruction (transition point hard to see in X-ray)

Barium enema/ Gastrografin
- Rarely needed due to availability/ accuracy of CT

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31
Q

Hartmann’s procedure describe

A
  • Involves resecting the diseased colonic segment
  • Creating an end colostomy and a rectal stump
  • Reversing the colostomy in the future (50% did not perform due to technically difficult with high morbidity and mortality rate)
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32
Q

Risk factor colon Ca

A

> Modifiable

  • Diet: red meat
  • Lifestyle: smoking, alcohol

> Non-modifiable

  • Age >40 years old
  • Chinese
  • Family history
  • FAP/ HPNCC
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33
Q

HPNCC (Lynch syndrome) vs FAP

A

> HPNCC

  • 1-3% of all CRC
  • Autosomal dominant
  • Age: >40 (15% cancer by 40)
  • Fewer polyps
  • Right-sided Ca

> FAP

  • 1% of all CRC
  • Autosomal dominant
  • Age: 20 (90% cancer by 45)
  • Usually >100 polyps
  • Left-sided Ca (80%)
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34
Q

Surgery for sigmoid cancer + describe

A
  • Sigmoid colectomy
  • Removes the sigmoid colon, including the associated mesentery, with the inferior mesenteric vessels ligated close to their origin to optimally resect lymphovascular tissue
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35
Q

Complication for hemicolectomy

A

> Immediate
- Damage to ureter

> Early

  • Anastomosis leakage
  • Wound infection
  • Bleeding

> Late

  • Impotence
  • Adhesion
  • Tumor recurrence
36
Q

Lanz vs Gridiron incision

A

Lanz incision

  • Transverse
  • More aesthetically pleasing
  • Reduce scarring

Gridiron incision
- Oblique

37
Q

Etiology of acute appendicitis

A
  • Fecaliths
  • Lymphoid hyperplasia
  • Less common cause: Parasites, TB, Tumor, FB
38
Q

Non-operative management of acute appendicitis

A
  • Only when appendicular mass present
  • Ochsner-Sherren regimen (hospitalization + IV fluid + antibiotics + analgesics + strict vital sign monitoring)
  • 80-90% mass resolve without complication
  • Debate continues as immediate surgery may reduce hospital stays and obviate need for second admission
39
Q

Cause of umbilical pain in acute appendicitis

A
  • Stimulation of visceral afferent nerve that arise from T10 (innervate umbilicus also)
  • Well-localized pain later when involve adjacent peritoneum
40
Q

Complication of appendicectomy

A
  • Stump
  • Hemorrhage
  • Infection
  • Paralytic ileus
41
Q

How to classify intestinal obstruciton

A
  • Pathological: mechanical vs functional
  • Anatomical: small vs large
  • Clinical: acute vs chronic
  • Pathological changes: simple vs strangulated
  • Severity: partial vs complete
42
Q

Causes of intestinal obstruction

A

> More common

  • Intraperitoneal adhesion
  • Tumors
  • Complicated hernia

> Others

  • Volvulus
  • Gallstones
  • Intussusception
43
Q

Definition keyword of surgical site infection

A
  • 30 days following surgery

- 90 days if implant involved

44
Q

Type of SSI

A
  • Superficial incisional SSI
  • Deep incisional SSI
  • Organ or space SSI
45
Q

Imaging for acute appendicitis

A

> Abdominal ultrasound

  • Diameter >6mm
  • Peri-appendicular fluid collection

> CECT abdomen

  • Enlarge diameter
  • Thicken wall
  • Fat stranding
  • Appendicolith

> Erect CXR
- R/o perforation, lobar pneumonia

46
Q

Investigation for PUD

A

> OGDS

  • Confirmation + location
  • Biopsy TRO malignancy, H. pylori
  • Therapeutic

> FBC

  • IDA if bleeding
  • Leukocytosis if perforated

> Urea breath test
- H. pylori infection

47
Q

Indication for biopsy PUD

A
  • Malignant looking (irregular, thickened margin)

- Benign looking but in area with high incidence

48
Q

Management of peptic ulcer disease

A

> Medical and lifestyle

  • PPI
  • Smoking and alcohol cessation
  • NSAID discontinue
  • H. pylori eradication

> Endoscopic therapy

  • Injection therapy
  • Thermal coagulation
  • Hemoclip

> Surgery

  • Duodenal ulcer: Truncal vagotomy with pyloroplasty
  • Gastric ulcer: Wedge resection/ Antrectomy/ Total gastrectomy
49
Q

Describe H. pylori eradication therapy

A

> First line:

  • Omeprazole 20mg BD for 6 weeks
  • Amoxicillin 1g BD, Clarithromycin 500mg BD for 10-14 days

> If failed -> quadruple therapy
- Colloidal bismuth sub-citrate 120mg QDS, Tetracycline 500mg QDS, Metronidazole 400mg BD, Omeprazole 20mg BD for 7-14 days

50
Q

How and where injection adrenaline peptic ulcer

A
  • 30ml diluted adrenaline (1:10000)

- 4 quadrant around the ulcer

51
Q

Describe CLO test

A
  • Urease convert urea into ammonia that raise pH of medium, detect by phenol red and color changed from yellow (negative) to red (positive)
52
Q

Risk factor for SSI

A

> Non-modifiable
- Older age

> Modifiable

  • Cigarette smoking
  • Vascular disease
  • Obesity
  • Malnutrition
  • Diabetes
  • Immunosuppressive disease
53
Q

How TB infection cause intestinal obstruction

A
  • Through progressive stricture and adhesion
54
Q

Cause of persistent high CEA after colon ca resection

A
  • Overlooked metastases
  • Inadequate surgery
  • Smoking habit
  • Renal insufficiency
  • Chronic liver disease
55
Q

What is CEA

A
  • Protein normally found in embryonic or fetal tissue
  • Serum level disappear almost completely after birth, but small amount may be present in colon
  • Elevated in malignancy that produce the protein (eg: GIT, ovary)
56
Q

Ulcerative colitis vs Crohn’s disease

A

> Ulcerative colitis

  • Affects only large intestine
  • Continuous inflammation
  • Mucosal and submucosal affected

> Crohn’s disease

  • May affect any part of the GIT
  • Discontinuous patchy inflammation
  • Transmural (affects the full thickness of the bowel wall)
57
Q

Why Crohn’s disease cause fistula

A
  • Due to the transmural inflammatory nature of Crohn’s disease that lead to formation of sinus tracts or fistula
  • Eg: enterovesical, enterocutaneous, enteroenteric, enterovaginal
58
Q

When do we do reversal of Hartmann

A
  • At least after 6-9 months (No consensus yet)
  • Allow the adhesion to soften, reducing operative difficulty
  • Longer time may have inferior outcome -> due to shrinkage of rectal stump?
59
Q

Complication of reversal of Hartmann

A
  • Anastomotic leakage
  • Wound infection
  • Incisional hernia
  • Ileus
  • Complication rate high, reason why many patient never reverse
60
Q

Principle of colon Ca surgery

A
  • En-bloc resection of tumor: 5cm proximally and distally
  • Resect adjacent draining LN
  • Reconstruct the bowel, if possible
61
Q

Chemotherapy regime for colon Ca

A
  • Initiate within 6-8 weeks of surgery
  • 6 months course of oxaliplatin based regimen
    (FOLFOX: oxaliplatin + leucovorin and short term infusion 5-FU)
  • Each cycle last 2 weeks (2 days infusion, 12 days rest), might up to 12 cycles
62
Q

How to follow up after colon Ca

A
  • 3 monthly for the first 2 years, then 6 monthly for the next 3 years, and subsequent yearly
  • History, PE, and CEA every 3-6 months for 5 years
  • Surveillance colonoscopy at year 1 and every 3-5 years thereafter
  • CT TAP performed annually for 3 years
63
Q

Complication of colonoscopy

A
  • Complication related to sedation (eg: cardiopulmonary)
  • Complication related to preparation (eg: fluid and electrolyte imbalance, abdominal bloating)
  • Perforation (from mechanical trauma, barotrauma, or electrocautery injury during polypectomy)
  • Infection (rare, due to improper endoscope reprocessing)
64
Q

Management of perforation during colonoscopy

A
  • Immediate erect CXR - air under diaphragm
  • NBM, IV fluid, IV Abx
  • Surgical consultation immediately
65
Q

Dukes’ classification

A
  • A: confined to mucosa
  • B1: growth into muscularis propria
  • B2: growth through muscularis propria and serosa
  • C1: spread to 1-4 regional LN
  • C2: spread to >4 LN
  • D: distance metastasis
66
Q

TMN vs Duke’s classification

A
  • TMN is preferred over traditional Duke classification
  • Duke primarily to determine prognosis
  • TMN can aid determination of optimal therapy and assessment of response to therapy
67
Q

Clinical sign of anastomotic leak

A
  • Pain
  • Fever
  • Peritonitis
  • Feculent drainage
  • Purulent drainage
68
Q

Management of anastomotic leak

A
  • IV fluid resuscitation and broad spectrum Abx
  • Bowel rest, percutaneous drainage
  • Colonic stenting
  • Surgery: resection of the anastomosis with end stoma/ resection of the anastomosis with re-anastomosis and proximal diversion
69
Q

Open vs Laparoscopic appendectomy for perforated appendicitis

A

> Open

  • Lower intra-op complication
  • Lower hospital cost

> Laparoscopic

  • Shorter hospital stay
  • Lower risk of SSI
  • Feasible for experience surgeon
70
Q

Therapeutic function of colonoscopy

A
  • Polypectomy
  • Endoscopic hemostasis
  • Dilation of colonic or anastomotic strictures
  • Stent placement for malignant disease
  • Endoscopic mucosal resection/ submucosal dissection of GIT tumor
  • Foreign body removal
71
Q

Screening for colorectal ca

A

> Average risk

  • No family hx, age >50
  • Yearly iFOBT, stop at 75

> Moderate risk

  • > 1FDR; 1FDR and >1 SDR; >3 and one must be FDR
  • Diagnosed <60 y/o: colonoscopy @ age 40/ 10 year younger than affected FDR; repeat 3-5 years
  • Diagnosed >60 y/o: colonoscopy @ age 40; repeat 10 years
  • Stop at 75

> High risk

  • CRC <50, FAP, HPNCC
  • Colonoscopy @ age 40/ 10 year younger than affected FDR; repeat 3-5 years
72
Q

When can patient return to activity after appendicectomy

A
  • Jogging: 1 week

- Weight lifting: 3 months

73
Q

If do open surgery and found appendix not inflamed

A
  • Still remove the appendix to avoid future confusion due to the scar
74
Q

Cause of terminal ileitis

A
  • Crohn’s disease
  • NSAID use
  • Tuberculosis
  • Radiation
  • Autoimmune disorder
75
Q

What are Batson plexus

A
  • Network of paravertebral veins with no valve drain the bladder, prostate, and rectum to the internal vertebral venous plexus
  • Provide route for cancer metastases or infection to the spine
76
Q

Define synchronous tumor

A
  • Second primary cancer is diagnosed within 6 months of the primary cancer; (metachronous = more than 6 months)
77
Q

Signs of bowel viability

A
  • Color of serosa surface
  • Presence of bowel peristalsis
  • Pulsation and bleeding from the marginal artery
78
Q

Investigation for intestinal obstruction

A

> Diagnosis

  • Erect/ Supine AXR
  • CT abdomen
  • Barium enema

> Complication

  • BUSE/ Cr (electrolyte imbalance)
  • ABG (alkalosis from vomiting)
79
Q

Management for intestinal obstruction

A

> Acute management

  • Keep NBM, NG tube suction
  • Analgesics
  • Urinary catherization to monitor urine output
  • Correct electrolyte abnormalities
  • Surgical intervention: strangulated/ failed conservative >72 hours
80
Q

Presentation of gastric outlet obstruction

A
  • Epigastric pain
  • Nausea, vomiting
  • Early satiety
  • Abdominal distension or bloating
  • Weight loss
81
Q

Condition associated with multiple anal fistula

A
  • Crohn disease
  • TB
  • Actinomycosis
82
Q

Describe Goodsall’s rules

A
  • Used to predict the trajectory of fistula tract
  • All fistula tracks with external opening within 3cm of the anal verge and posterior to a line drawn through the ischial spines travel in a curvilinear fashion to the posterior midline
    All tracks with external openings anterior to this line enter the anal canal in a radial fashion
  • Fistula tracks longer than 3cm from the anal verge do not necessarily follow Goodsall’s rule; they often have an internal opening in the posterior midline
83
Q

X-ray finding for sigmoid volvolus

A
  • Coffee bean sign
  • Distended large bowel proximal to the sigmoid
  • Air fluid level in the small bowel
84
Q

2 causes of sigmoid volvulus

A
  • Anatomic factors: long redundant sigmoid colon with narrow mesenteric attachment
  • Colonic dysmotility: prolonged colonic transit through the sigmoid colon and rectum
85
Q

Management for sigmoid volvulus

A
  • Sign of perforation/ peritonitis -> immediate surgical resection management; generally, should not have their volvulus detorsed to avoid reperfusion injury
  • No sign of perforation/ peritonitis -> flexible sigmoidoscopy to detorsed the twisted segment, if successful, surgical resection shortly thereafter

Surgery (11 decks)

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