Colorectal

Question 1

Main types of stomas, and their positions?

Answer 1

Loop ileostomy
- Defunctioning of colon (e.g. after colon ca.)
- RIF

End Ileostomy
- Usually after pancolectomy
- RIF

End colostomy
- LIF (or RIF)

Loop colostomy
- Defunction a distal segment of bowel
- Any region

Question 2

Most common type of anal cancer?

Answer 2

SCC

Question 3

What lymph nodes do the anal cancers spread to?

Answer 3

Anal margin - to the pelvic lymph nodes
Proximal tumours - inguinal

Question 4

What is the most common cause of SCC cancer of the anus?

Answer 4

HPV infection.

Question 5

Anal cancer presentation?

Answer 5

Perianal pain, perianal bleeding
A palpable lesion
Faecal incontinence
A neglected tumour in a female may present with a rectovaginal fistula.

Question 6

What staging do you use for anal cancer?

Answer 6

T staging

Question 7

Management of an anal fissure?

Answer 7

Acute (<6 weeks):

• Dietary advice: high-fibre diet with high fluid intake
  bulk-forming laxatives are first line - if not tolerated then lactulose should be tried
• Lubricants such as petroleum jelly may be tried before defecation
• Topical anaesthetics

Chronic (>6 weeks)

• GTN first line
• Botox through referral is second

Question 8

Types of haemorrhoids, management?

Answer 8

Location: 3, 7, 11 o’clock position

Internal or external

Treatment:
- Conservative
- Rubber band ligation
- Haemorrhoidectomy

Question 9

Different causative organisms in ano-rectal abscesses?

Answer 9

E.coli, staph aureus

Question 10

How do you stage a colorectal cancer?

Answer 10

CT chest abdo/pelvis

Should also have had colonoscopy/CT colonoscopy

Question 11

Treatment of colonic cancer options?

Answer 11

Surgical resection (unless palliative)

If HNPCC consider panproctocolectomy

Either then anastomosed or end stoma

Question 12

What are the key factors influencing the choice for anastomosis or end stoma?

Answer 12

Adequate blood supply
Mucosal apposition
No tissue tension

Question 13

Management of rectal cancer?

Answer 13

Anterior resection if the tumour is high up.

Adominoperineal excision of the rectum if it is low lying or involves the sphincter

Adjuvant radiotherapy should be offered

Question 14

What are the definite referral 2ww guidelines for colorectal Ca.?

Answer 14

patients >= 40 years with unexplained weight loss AND abdominal pain.

patients >= 50 years with unexplained rectal bleeding.

patients >= 60 years with iron deficiency anaemia OR change in bowel habit.

tests show occult blood in their faeces (see below).

Question 15

Colorectal cancer screening programme details?

Answer 15

Screening every 2 years to all men and women aged 60 to 74 years. Faecal occult blood test

Question 16

Symptoms of diverticulitis?

Answer 16

Altered bowel habit
Bleeding
Abdominal pain

Question 17

Diverticular disease complications?

Answer 17

Diverticulitis
Haemorrhage
Development of fistula
Perforation and faecal peritonitis
Perforation and development of abscess
Development of diverticular phlegmon

Question 18

Treatment of diverticular disease?

Answer 18

Increase dietary fibre intake.

Mild attacks of diverticulitis may be managed conservatively with antibiotics.

Peri colonic abscesses should be drained either surgically or radiologically.

Recurrent episodes of acute diverticulitis requiring hospitalisation are a relative indication for a segmental resection.

Hinchey IV perforations (generalised faecal peritonitis) will require a resection and usually a stoma. This group have a very high risk of post operative complications and usually require HDU admission. Less severe perforations may be managed by laparoscopic washout and drain insertion.

Question 19

Diverticulitis presentation?

Answer 19

Symptoms
Severe abdominal pain in the left lower quadrant: this may be in the right lower quadrant in some Asian patients

Nausea and vomiting (20-60%)

Change in bowel habit: constipation is more common (seen in 50%)

Urinary frequency, urgency or dysuria (10-15%): this is due to irritation of the bladder by the inflamed bowel.

PR bleeding (in some cases).

Signs
- Low grade pyrexia

• Tachycardia
• Tender LIF: in 20% there will be a tender palpable mass due to inflammation or an abscess

Question 20

Dukes classification for colorectal cancer?

Answer 20

Dukes’ A
- Tumour confined to the mucosa
- 95% survival

Dukes’ B
- invading bowel wall
- 80% survival

Dukes’ C
- Lymph node metastases
- 65% survival

Dukes’ D
- Distant metastases
- 5% survival (20% if resectable)

Question 21

Presentation of haemorrhoids?

Answer 21

Painless rectal bleeding is the most common symptom

Pruritus

Pain

Question 22

Types of haemorrhoids?

Answer 22

External:
- originate below the dentate line
prone to thrombosis, may be painful

Internal:
- originate above the dentate line
do not generally cause pain

Question 23

Ano-rectal abscess presentation?

Answer 23

Patients may describe pain around the anus, which may be worse on sitting

They may have also discovered some hardened tissue in the anal region

There may be pus-like discharge from the anus

If the abscess is longstanding, the patient may have features of systemic infection.

Question 24

Presentation and management of volvulus?

Answer 24

Presentation:
- Constipation
- Abdominal bloating
- Abdominal pain
- Nausea/vomiting

Management
- Sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion
- If peritonism then just do laparotomy

• Caecal volvulus: management is usually operative. Right hemicolectomy is often needed