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Y6 Senior Surgery COPY LaLz > Colorectal > Flashcards

Colorectal Flashcards

1
Q

What are causes of small bowel obsturction

A

HAT

Hernia
Adhesion
Tumour

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2
Q

What are causes of large bowel obstruction

A

CVS
Cancer
Volvulus
Strictures (from diverticulitis)=

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3
Q

What are big risks with bowel obstruction

A

Hypovolaemia > AKI (due to third spacing)
Perforation
Ischaemia

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4
Q

What is third spacing

A

Mechanical blockage of bowel > proximal dilation with increased peristalsis > draws more water into bowel > HYPOVOL SHOCK

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5
Q

What are classical sx of bowel obstruction

A

severe abdominal pain, colicky, widespread
Vomiting (bilious)
Distension
Absolute constipation

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6
Q

What are cllassical ssx of bowel obstruction

A

guarding
rebound tenderness
tinkling bowel sounds

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7
Q

What is the initial investigation that they often get with bowel obstruction

A

Erect CXR (to check for free fluid under diaphragm)
OR abdominal XR (to look at bowel distension)

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8
Q

Whart is definitive Ix for bowel obstruction

A

abdo CT

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9
Q

What will the abdo x ray show for small bowel vs large bowel obstruction

A

small bowel: >3cm, central, valvulae conniventes
large bowel: >6cm (colon), >9cm (sigmooid), haustrae

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10
Q

What is approach for bowel obstruction

A

NBM immediately
Drip and Suck - NG tube with free drainage + IV fluid resus
Surgery (emergency laparotomy to resolve cause)

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11
Q

What is volvulus

A

Twisting of intestinal loop around its mesenteric attachment > closed loop bowel obstruction

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12
Q

What are complications of volvulus

A

Bowel has compromised blood supply > rapid ischaemia, necrosis and perforation risk

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13
Q

what are two different types of volvulus

A

sigmoid (80%) vs caecal (20%)

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14
Q

Explain characteristic patient of sigmoid volvulus

and what occurs

A

Older, chronic constipation

sigmoid bowel twists around mesentery > large bowel obstruction

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15
Q

What is the cause of a caecal volvulus

A

abnormality in development (falure of peritoneal fixation) that makes the volvulus at risk of twisting&raquo_space; small bowel obstruction due to proximal large bowel obstruvtive cause

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16
Q

imaging of volvulus

A

sigmoid: AXR > COFFEE BEAN SIGN (+ normal LBO signs)

caecum: on AXR has normal SBO signs

CT ABDO PELVIS WITH CONTRAST > WHIRL SIGN

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17
Q

Management of sigmoid volvuluis

A

decompress with sigmoidoscope + flatus tube insertion
leave flatus tube in for up to 24h

if decompression fails repeatedly or peritonism: laparotony

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18
Q

Describe large bowel anatomy

A

Appendix > caecum > ascending colon > right colonic flexure > transverse colon > left colonic flexure > descending colon > sigmoid > rectum > anus

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19
Q

what is does a right hemicolectomy remove and when is it used?what type of anastamosis

A

the caecum and ascending coon
used for tumours in this caecum and proximal ascending colon

iliocolic anastamosis

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20
Q

what does an extended right hemicolectomy remove and when is it used?what type of anastamosis

A

caecum ascending colon and transverse colon

for tumours in distal descending colon or transverse oolon

iliocolic anastamosis

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21
Q

what is a left hemicolectomy used for, what does it remove? what is anastamosis

A

descending colon

for tumours in descending colon

colocolic anastamosis

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22
Q

what is hartmann’s procedure remove

A

sigmoid colon

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23
Q

when is hartmann’s used for

A

obstrution or perforation secondary to sigmoid tumour or diverticulitis – EMERGENCY

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24
Q

what colorectal procedures leave you with a stoma

A

Hartmsnn’s
AP resection
Anterior resection

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25
where and what stoma do you get with Hartmann's
single lumen colostomy in LIF
26
what is an AP resection
Abdominal Perineal Resection aka BARBIE BUTT PROCEDURE
27
What does an AP resection remove
Abdominal incision: sigmoid, rectum and mesorectal nodes Perineal incision: anus removed
28
what stoma do you get with AP resection
single lumen colostomy in LIF
29
what are indications forAP resection
rectal cancer LESS THAN 4-5 cm from anal verge ==> LOW RECTAL TUMOUR (Anal Proximity tumour!!)
30
what are indications for anterior resection
rectal cancer MORE THAN 4-5 cm from anal verge ==> MID/HIGH RECTAL TUMOUR you resect part of rectum and sigmoid colon
31
what stoma are you left with in anterior resection
DOUBLE LUMEN loop ileostomy in RIF
32
what are classical symptoms of colorectal cancer
change in bowel habit PR bleed WL, fatigue ANaemia
33
what is the most important ix to get in suspected colorectal cancer
COLONOSCOPY
34
what colorectal cancer screening currently exists in UK
60-74 years old receive FIT test faecal immunochemical test (FIT) every 2 yearts this is essentially a FOB that recognises antibodies against human Hb
35
what happens if FIT +ve
colonoscopy offered
36
How do you manage colorectal cancer
resection +-neoadjuvant chemo/radiotherapy
37
what is the most common type of abdominal hernia
INGUINAL hernia
38
what is the risk in a man of having an INGUINAL hernia
1 in 4
39
What are the two types of inguinal hernia?
INDIRECT vs DIRECT hernia
40
Explain INDIRECT hernia
Common in young boys peritoneal sac protrudes through deep ingluinal ring > inglluinal canal > superficial ring > testes due to weakness of deep inguinal ring (which is where structures pass during development to reach external genitalia=
41
Explain DIRECT inguinal hernia
DIRECT inguinal hernia still more common in men, but this time RF are age, lifting heavy weights peritoneal sac enters through weakening in abdominal wall eventually into inguinal canal (through superficial ring)
42
where are ingluinal hernias found
Above and medial to pubic tubercle
43
where are femoral hernias found
Below and lateral to pubic tubercle
44
Explain how femoral hernias occur
weakness in abdominall wall causes protrusion of intestinal content through femoral canal
45
WHo are femoral hernias most common in
WOMEN due to large pelvis (which means tissues are more stretched)
46
What are femoral hernias at high risk of
strangulation and obstruction
47
What type of hernia respods to cough impulse
INGUINAL
48
what is incarceration of a hernia
hernia CANNOT be reduced
49
what is strangulation of a hernia
hernia becomes ischaemic due to compromised blood supply
50
What do you do if hernia is incarc / strangulated?
EMERGENCY surgery
51
what do you do if hernia is not strangulated / incarc?
depends on type of hernia if inguinal: ruotine repair, even if asymptomatic if femoral: urgent repair (due to high risl of strangulation)
52
What are the two approaches to femoral hernia repair
if eLective: Lockwood Low approach (low incision over hernia with herniotomy/herniorrhaphy) if eMergency: McEvedy High approach (via inguinal region to inspect and resect non viable bowel)
53
What are the types of surgery you can use for hernia repar
herniotomy: ligation + excision of hernial sac herniorrhaophy: repair of abdo wall defect hernioplasty: mesh implant
54
what incisions do you leave for herni repain
McBurney (oblique) Lanz (transverse)
55
how do you differentiate between direct and indirect inguinal hernia
1. reduce the hernia 2. press on deep inguinal ring 3. Ask patent to cough if the hernia is DIRECT: it will protrude if hernia is INDIRECT: it will NOT protrude as you are blocking its way out
56
what does pain suggest in jaundice?
PAINFUL jaundice = gallstone disease painLESS jaundice = pancreatric cancer
57
what is toxic megacolon
acute colonic distension (dilatation >6cm on AXR) + systemic symptoms of infection (fevers, shock)
58
causes of toxic megacolon
- IBD (most common - most likely UC) - C diff - Ischaemic colitis - bowel cancer - volvulus
59
risk with toxic megacolon
likely to PERFORATE >> death
60
Ix toxic megacolon
SEPSIS 6 Ix: FBC, CRP, UE, LFT, stool sample AXR and abdo CT
61
Mx of toxic megacolon
NBM Drip and suck start IV Abx Involve surgeons early If no improvement within 72 hours / deterioraton: take for emergency laparotomy
62
how does perforation show on CXR
free air under diaphragm BILATERALLY
63
how does perforation show on AXR
RIGLER SIGN = double wall sigh Both the LUMINAL surface and the SEROSAL surface are seen. ** the SEROSAL surface should not be visible as it is normally in contact with other intra-abdominal content of similar density (other loops of bowel, omentum, fluid).
64
what is MESENTERIC ADENITIS
inflammation of the mesenteric lymph nodes - due to infecton (adenovirus, EBV, beta haem step)
65
how does MESENTERIC ADENITIS present
Similar to appendicitis - except for HIGH FEVER
66
what does laparotomy show on mesenteric adenitis
enlarged mesenteric lymph nodes
67
What is meckels' diverticulitis - and how does it present
ectopic gastric mucosa RIF pain (worse after eating) bleeding (IDA)
68
what investigation is important if anal fistula in Chrons
get an MRI to check track of fistula
69
what does an ileostomy drain?
the SMALL BOWEL (ILEO = ileum)
70
Where is an ileostomy typically?
RIF
71
What does an ileostomy shape typically loook like?
SPOUTED due to the acidic nature with high enzyme contents, which irritates the surrounding skin. A spout minimises this
72
what is output of ileostomy like?
LIQUID to SEMI-LIQUID output (as this is small bowel content) Usually high output, so 500ml - 1L/day
73
where is a colostomy usually located
LIF
74
what is the shape of a colostomy look like
FLUSH to the skin
75
what does the content of a colostomy looko like
Semi solid to solid (faecal matter) low output (200-300ml)
76
when do you do a double lumen (loop) stoma
both ends connect out this is temporary, to allow distal bowel to rest. Wll then be reversed
77
complications of stoma
immediate: bleeding, necrosis from poor blood supply early: high outpput causing dehydration and micronutrient lot, obsructon, retraction late: obstruction, prolapse (out of skin), parasternal hernia (contained within the skin), skin irritation, psych
78
what do you do if at GP, seen pt >60 with IDA?
URGENT referral to colorectal team for COLONOSCOPY +- OGD
79
what is the method of inheriitance of FAP
Autosoml DOMINANT mutation of APC gene
80
what occurs in FAP
mutation of APC gene hundreds of colonic adenomas develop so the cancer risk is 100%
81
how do you manage FAP
annual flexi-sigmoidoscopy from age of 15 if no polyps found > 5 yearly colonoscopy from 20y if polyps found > resection
82
method of inheritaance of Peutz-Jeguers
autosomal DOMINANT
83
presentation of Peutz-Jeguers
multiple benign intestinal hamatomas + PIGMENTATION PATTERN can cause episodic obstruction or intussusception risk of GI cancer and risk of breast, ovarian, cervical, pancfreatic and testicular cancers
84
how do you screen for peutz jeugers
intestinal endoscopy every 2-3 yeas
85
cancers associuated with HNPCC
COLORECTAL + Endometrial, gastric, pancreatic cancer
86
which geneit condition needs prophylactic surgery
HNPCC
87
what situations require a 2ww colorectal referral
- over 40 with WL and abdo pian - over 50 with rectal bleed - over 60 with IDA - FOB+ve
88
what are the two commonest post op complications of colorectal tumour resection
ileus anastamotic dehiscence
89
what occurs with ileus after colorectal tumour resection
peristalsis stops > electrolytes and fluid dissolve into lumen > low electrolytes in blood and dehydrated picture despite normla fluid balance
90
how do you manage ileuas
NG tube + fluids
91
how does an anastamotic dehiscence present
day 6, fever, septic picturw
92
which area of the gut has the WORSE perfusion
the splenic flexure (between transverse and descending colon=)
93
mangement of caecal volculus
lapatotomy (right hemicolectomy often needed)
94
what key sx does rectal intussusception (internal rectal prolapse) present with
obstructed defecation -- associated with childbirth
95
what kinds of surgery are commonly done with chron's disease
perianal fistula = seton suture perianal disease = proctectomy terminal ileum = iliocaecal resection
96
which procedure must you avoid in chroons and why
avoid ILIOANAL POUCH high risk of failure
97
what is a total proctocolectomy
complete removal of large inteestine (colon) and rectum (procto)
98
what is a subtotal colectomy
removal of colon but NOT of rectum
99
what is the indication for ilio-anal pouch
used for UC after a SUBTOTAL COLECTOMY can only be performed if the rectum is still in place (as patient still needs to pass stool. by themselves > still need to have rectal continence) avoids a stoma! :)
100
what surgery is classically done in UC patient in emergency situation
subtotal colectomy + loop ileostomy later consider ilioanal pouch to avoid stoma bag
101
ilioanal pouch complications
anastomotic dehiscence pouchitis poor physiological function with seepage and soiling.
102
what marker is used to monitor the response to treatment in colorectal cancer?
CEA
103
what is the important finding that you see in the rest of the bowel with a caecal volvulus
no other gas findings in the rest of the bowel becuase NOTHING can get through
104
where are primary anal fissures (due to constipation) most likely located
90% are posterior 10% anterior
105
what do lateral anal fissures inidicate
that the anal fissure is the secondary conodition > look for the cause!
106
how do you manage a pt with mild diverticulitis and what do you do if they do not improve
oral abx, send home if do not improve within THREE DAYS admit for CEF AND MET IV
107
sx of acute diverticulitiis (esp location of pain)
Severe LIF pain (as sigmoid colon is where colon narrows down) bloody stool fever urinary sx (diverticular fistulation into bladder)
108
explain dukes staging for colorectal cancer
Dukes A: confined to mucosa B: through bowel wall C: lymph node invasion D: distant mets
109
when do you need to do a laparotomy in sigmoids volvulus
if PERITONITIC (so skip sigmoidoscopy) or if REPEATED FAILED ATTEMPTS
110
what is the key sx difference between haemorrhoids and anal fissures in MCQ land
haemorrhoids are painless (unless thrombosed)
111
mx of anal fissure
<6weeks: dietary advice, bulk-forming laxatives >6 weeks: try topical GTN or topical diltaziem, nifedipine after 8 weels:_ refer for sphincterotomy of botulinum toxin
112
triad of gastric volvulus
vomiting pain failed attempts at passing NG tube
113
what kind of stoma should you aim for in distal bowel cancer
a loop ileostomy to allow rest of distal bowel prior to reversal
114
when would you use IV iron compared to PO
when: - oral replacement is ineffective or intolerable - ferritin is very low and needs to be replaced very quickly
115
what investigation must you do to ensure that anastamosis has healed
GASTROGAFFIN contrast enema

Y6 Senior Surgery COPY LaLz (10 decks)

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