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Colorectal Flashcards

1
Q

Features of hernias?

A

soft lump protruding through abdominal wall
lump may be reducible
lump may protrude on coughing (raising intra-abdominal pressure)
lump may protrude on standing (gravity)
aching, pulling or dragging sensation

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2
Q

3 key complications of hernias?

A

incarceration
obstruction
strangulation

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3
Q

What is a Richter’s hernia?

A

when only part of the bowel wall and lumen herniate through the defect, while the other section remains within the peritoneal cavity
high risk of strangulation, ischaemia and necrosis

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4
Q

What is a Maydl’s hernia?

A

when two different loops of bowel are contained within the hernia

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5
Q

Management of hernias?

A

conservative
tension-free repair
tension repair

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6
Q

Tension-free repair vs tension repair?

A

Tension-free repair involves placing a mesh over the hernia to prevent recurrence
Tension repair uses sutures (rarely done anymore)

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7
Q

DDx for inguinal lump?

A

inguinal hernia
femoral hernia
lymph node
saphena varix
femoral aneurysm
abscess
undescended/ectopic testis
kidney transplant
hydrocele
testicular torsion

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8
Q

Indirect vs Direct inguinal hernias?

A

indirect hernias protrude through the inguinal canal (when reduced, hernia will remain reduced if pressure is applied to the deep inguinal ring)

direct hernias protrude directly through the abdo wall, through Hesselbach’s triangle (pressure to deep inguinal ring will not stop herniation)

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9
Q

Boundaries of Hesselbach’s triangle?

A

Rectus abdominis
Inferior epigastric vessels
Poupart’s ligament (inguinal ligament)

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10
Q

Contents of the inguinal canal?

A

3 vessels (testicular artery + vein, vas deferens a+v, cremasteric a+v)
3 fasciae (external spermatic fascia, cremasteric fascia, internal spermatic fascia)
4 nerves (cremaster, sympathetic, ilioinguinal, genitofemoral)
3 others (spermatic cord, vas deferens, lymphatics)

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11
Q

Where do femoral hernias occur?

A

through the femoral canal, below the inguinal ligament

femoral ring is narrow -> high risk for incarceration, obstruction and strangulation

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12
Q

Boundaries of the femoral canal?

A

Femoral vein
Lacunar ligament
Inguinal ligament
Pectineal ligament

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13
Q

Boundaries of the femoral triangle?

A

Sartorius (lateral)
Adductor longus (medial)
Inguinal ligament (superior)

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14
Q

Contents of the femoral triangle?

A

Femoral Nerve
Femoral Artery
Femoral Vein
Femoral Canal (lymph)

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15
Q

Where does a Spigelian hernia occur?

A

between the lateral border of rectus abdominis and the linea semilunaris

not always a lump -> US used to confirm diagnosis

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16
Q

What occurs in diastasis recti?

A

widening of the linea alba, the aponeurosis which connects the two sides of the rectus abdominis muscle

can be congenital, or occur in pregnancy or obesity

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17
Q

Where do obturator hernias occur?

A

through the obturator foramen at the bottom of the pelvis
due to pelvic floor weakness (older women post-pregnancy)
often asymptomatic and found incidentally but may irritate the obturator nerve

CT or MRI to confirm diagnosis

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18
Q

Definition of a hernia?

A

abnormal protrusion of an organ (or part of an organ) through its containing body wall

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19
Q

Epidemiology of inguinal hernias?

A

M:F 8:1
men - 50-70yrs
women - 60-80yrs

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20
Q

What is a pantaloon hernia?

A

a combination of both an indirect and direct inguinal hernia

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21
Q

Investigations for inguinal hernia?

A

exam - often a clinical diagnosis
get to stand/cough/Valsalva
examine scrotum

bloods (WBC, CRP, U&E, lactate)
imaging (groin US if occult hernia or obstruction suspected)

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22
Q

Complications of inguinal hernia repair?

A

scrotal haematoma
wound infection
urinary retention
damage to ilioinguinal nerve (paraesthesia/pain in scrotum/labia)
damage to testicular artery (atrophy)
recurrence

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23
Q

Risk Factors for recurrence of hernias post-repair?

A

infection
poor operative technique
coughing
constipation
bladder outlet obstruction
heavy lifting (avoid for 6-8wks)

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24
Q

Epidemiology of femoral hernias?

A

more common in women
>70yrs

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25
DDx for femoral hernias?
femoral canal lipoma saphena varix lymphadenopathy femoral artery aneurysm femoral artery pseudoaneurysm (post-angiography) sarcoma
26
Risk Factors for incisional hernias?
post-op wound infection abdominal obesity poor muscle quality (smoking, anaemia) multiple operations through same incision incision size poor choice of incision inadequate closure
27
What is appendicitis?
inflammation of the appendix most common cause of acute abdomen and most common indication for emergency surgery
28
Presentation of acute appendicitis?
abdominal pain (typically peri-umbilical that migrates to RIF within 24hrs) tenderness in McBurney's point anorexia nausea & vomiting low-grade fever Rovsing's sign guarding rebound tenderness (peritonitis) percussion tenderness (peritonitis)
29
Where is McBurney's point?
imaginary point 1/3rd of the way between ASIS and umbilicus
30
Diagnosis of appendicitis?
clinical diagnosis raised inflammatory markers CT scan if doubt US (exclude gynae)
31
DDx for appendicitis?
ectopic pregnancy ovarian cyst Meckel's diverticulum mesenteric adenitis (children)
32
What is an appendix mass?
occurs when the omentum surrounds and sticks to the inflamed appendix, forming a RIF mass managed with supportive treatment and antibiotics and appendicectomy once resolved
33
Management of acute appendicitis?
laparoscopic or open appendicectomy
34
Complications of appendicectomy?
Thromboembolic events Bleeding Infection (wound/intra-abdominal) Removal of normal appendix Damage to bladder, bowel, other organs Dehiscence of wound Scarring Anaesthetic risks
35
Components of Alvarado Score?
abdo pain anorexia nausea/vomiting RIF tenderness rebound tenderness temp > 37.5 WCC > 10 neutrophils > 75%
36
Complications of acute appendicitis?
perforation RIF appendix mass RIF abscess pelvic abscess
37
Causes of small bowel obstruction?
adhesions hernias malignancy intussusception strictures (Crohn's, radiation) Meckel's diverticulum
38
Causes of large bowel obstruction?
malignancy hernias diverticulitis volvulus intussusception stricture
39
What causes adhesions?
abdo or pelvic sx (particularly open) peritonitis abdo or pelvic infections (PID) endometriosis congenital secondary to radiotherapy
40
What is a closed-loop obstruction?
when there a two points of obstruction within the bowel, causing increased pressure and rupture of the compressed bowel requires emergency sx
41
Causes of a closed-loop obstruction?
adhesions hernias volvulus (twist isolates section) single point of obstruction with a competent ileocecal valve
42
Presentation of bowel obstruction?
vomiting abdo distension diffuse abdo pain obstipation 'tinkling' bowel sounds in early obstruction
43
Diagnosis of bowel obstruction?
PFA -> dilated loops of bowel 3, 6, 9 (small, large, caecum) valvulae conniventes in small bowel haustra in large bowel CXR for air under diaphragm if perforation suspected contrast CT to confirm and to see cause
44
Management of bowel obstruction?
nil by mouth IV fluids NG tube with free drainage Sx intervention if needed - depends on cause (adhesiolysis, hernia repair, emergency resection, stents, colonoscopy and pneumatic decompression)
45
Complications of bowel obstruction?
hypovolaemic shock (third-spacing) bowel ischaemia bowel perforation sepsis metabolic alkalosis (vomiting)
46
What is ileus?
condition affecting the small bowel, where normal peristalsis is interrupted
47
Causes of ileus?
injury to bowel handling of bowel during sx inflammation or infection (peritonitis, appendicitis, pancreatitis, pneumonia) electrolyte imbalance (hypokalaemia, hyponatraemia)
48
Presentation of ileus?
most common in post-op patients vomiting (green, bilious) abdo distension abdo pain obstipation absent bowel sounds (as opposed to tinkling bowel sounds associated with mechanical obstruction)
49
Management of ileus?
supportive care nil by mouth NG tube if vomiting IV fluids mobilisation (helps to stimulate peristalsis) TPN
50
What is a volvulus?
twisting of the bowel and the surrounding mesentery, resulting in a closed-loop obstruction
51
Complications of a volvulus?
ischaemia necrosis perforation
52
Types of volvulus?
sigmoid volvulus (more common, older patients) caecal volvulus (less common, younger patients)
53
Risk factors for a volvulus?
chronic constipation high fibre diet excessive use of laxatives neuropsychiatric disorders (PD) nursing home residents pregnancy adhesions
54
Diagnosis of a volvulus?
sigmoid volvulus -> coffee-bean appearance on X-ray caecal volvulus -> embryo sign on X-ray contrast CT to confirm
55
Management of volvulus?
initial -> nil by mouth, NG tube, IV fluids conservative -> pneumatic decompression with flexible sigmoidoscope (risk of recurrence 60%) surgical -> laparotomy, Hartmann's (sigmoid), ileocaecal resection or right hemicolectomy (caecal)
56
What is diverticulosis?
the presence of diverticula, without inflammation or infection present
57
What is diverticular disease?
clinically significant diverticulosis, e.g., bleeding, infection, perforation
58
What are diverticula?
acquired outpouchings of sac-like mucosal projections through the colon wall
59
Where do diverticula form?
sigmoid colon is most common can affect all the GI tract rectum rarely involved outpouchings form between the taenia coli
60
Risk factors for diverticula?
incr. age low fibre diet obesity NSAIDs (incr. risk for bleeding)
61
Presentation of diverticular disease?
often diagnosed incidentally on colonoscopy or CT (don't treat if patient asymptomatic) intermittent LIF pain, constipation, diarrhoea
62
Presentation of acute diverticulitis?
'left-sided appendicitis' LIF pain, nausea, diarrhoea/constipation fever, tachycardia, tenderness and guarding of LIF raised WCC, raised neutrophils, raised CRP PR bleeding (if haemorrhage) palpable mass (if abscess)
63
Management of symptomatic diverticulosis?
incr. fibre in diet bulk-forming laxatives avoid stimulant laxatives sx if symptoms are severe
64
Complications of diverticulitis?
pericolic/paracolic abscess purulent peritonitis (abscess perforation) feculent peritonitis (bowel perforation) fistulae (colovaginal, colovesical) stricture formation large haemorrhage
65
Presentation of colovesical fistula?
recurrent UTIs pneumaturia debris in urine
66
Investigations in acute diverticulitis?
FBC (WCC, neutrophilia) U&E (pre-renal, hypokalaemia if diarrhoea) CRP Blood culture (sepsis) Erect CXR (perforation) PFA (obstruction) CT with contrast (complications) Colonoscopy (not done acutely due to risk of perforation, 6wks to exclude underlying malignancy and assess for complications)
67
What is Hinchey Classification used for?
to classify acute diverticulitis
68
What are the levels in Hinchey Classification of diverticular disease?
1A - paracolic phlegmon 1B - pericolic/mesenteric abscess 2 - diverticulitis with walled-off abscess 3 - purulent peritonitis 4 - feculent peritonitis
69
Medical management of acute diverticulitis?
uncomplicated diverticulitis IV antibiotics (co-amoxiclav +/- gent +/- metronidazole) bowel rest IV fluids analgesia radiologically guided drainage of abscess
70
Indications for surgical management of acute diverticulitis?
free perforation fistula refractory to medical treatment undrainable abscess
71
Surgical management of acute diverticulitis?
laparoscopy and washout resection of diseased part of bowel (Hartmann's) manage complications
72
Blood supply to the abdominal organs?
coeliac artery -> foregut superior mesenteric artery -> midgut inferior mesenteric artery -> hindgut
73
Risk Factors for chronic mesenteric ischaemia?
incr. age FHx smoking diabetes HTN hypercholesterolaemia
74
Presentation of chronic mesenteric ischaemia?
'intestinal angina' central colicky abdo pain after eating weight loss abdominal bruit
75
Diagnosis of chronic mesenteric ischaemia?
CT angiography
76
Management of chronic mesenteric ischaemia?
reduce modifiable RFs secondary prevention (statins, antiplatelets) revascularisation (endovascular stenting first-line, open)
77
Presentation of acute mesenteric ischaemia?
acute, severe, non-specific abdo pain pain disproportionate to exam findings shock, peritonitis and sepsis
78
Risk Factors for acute mesenteric ischaemia?
AFib, elderly, CVD, Hx of chronic mesenteric ischaemia
79
Investigations for acute mesenteric ischaemia?
contrast CT gold standard metabolic acidosis raised lactate levels
80
Management of acute mesenteric ischaemia?
surgery to remove necrotic bowel open or endovascular surgery to remove or bypass thrombus very high mortality (over 50%)
81
3 types of ischaemic bowel disease?
acute mesenteric ischaemia chronic mesenteric ischaemia ischaemic colitis
82
RFs for colorectal carcinoma?
FHx FAP HNPCC ulcerative colitis obesity diet smoking alcohol T2DM acromegaly
83
Pathophysiology of colorectal cancer?
adenocarcinoma most arise from pre-existing adenomas
84
Types of adenomas?
tubular villous tubulo-villous serrated villous have greatest potential for malignant transformation
85
Presentation of colorectal cancer?
depends on location right-sided - IDA left-sided - PR bleeding, change in bowel habit distal lesion - PR bleeding, tenesmus may present as obstruction
86
Investigations for colorectal cancer?
PR exam FIT colonoscopy and biopsy CT colonography if colonoscopy not possible if emergency -> CT CT for staging MRI for staging rectal CEA
87
Mx of colorectal cancer?
Sx resection depending on tumour location neoadjuvant chemorads adjuvant chemo if LN or vascular invasion palliative
88
Follow up in colorectal cancer patients?
colonoscopy at 1 year, every 3-5yrs after CT scans annually for 3 yrs CEA monitoring
89
Options for resection of bowel?
right hemicolectomy left hemicolectomy high anterior resection low anterior resection abdominoperineal resection
90
What are haemorrhoids?
vascular and connective tissue columns that exist in three columns on the anal canal (3, 7, 11 o'clock)
91
Internal vs External haemorrhoids?
internal: above dentate line painless bleed and prolapse external: below dentate line may thrombose and cause pain and itching
92
RFs for haemorrhoids?
hereditary factor diet prolonged straining increased intra-abdominal pressure
93
Degrees of haemorrhoids?
1st degree - bleed but no prolapse 2nd degree- prolapse but reduce spontaneously 3rd degree- prolapse and have to be manually reduced 4th degree- permanently prolapsed
94
Complications of haemorrhoids?
bleeding prolapse
95
Investigations for haemorrhoids?
exclude other cause of bleeding DRE proctoscopy, sigmoidoscopy, colonoscopy
96
Mx of haemorrhoids?
conservative medical (topical analgesics, steroids, injection sclerotherapy, rubber band ligation) surgical (haemorrhoidectomy)
97
Indications for haemorrhoidectomy?
3rd and 4th degree 2nd degree that have not been cured by other mx fibrosed haemorrhoids
98
Causes of anal fissures?
primary: local trauma secondary: Crohn's granulomatous disease malignancy communicable diseases
99
Types of anal fissure?
acute <6wks chronic >6wks
100
Presentation of anal fissure?
pain bleeding pruritus ani
101
Mx of anal fissure?
DRE too painful conservative medical (analgesia, local anaesthetic, TGN, diltiazem) surgical (lateral sphincterotomy)
102
Causes of anorectal fistula?
anorectal abscess Crohn's radiation proctitis rectal foreign bodies
103
Features of anorectal fistula?
intermittent pain chronic purulent discharge pustule-like lesion in perianal or buttock area
104
Mx of anorectal fistula?
fistulotomy fistulectomy Seton insertion advancement flap plugs and glues
105
Mx of pilonidal sinus and abscess?
incision and drainage acutely second operation to excise sinus
106
RFs for anal cancer?
female HPV incr. sexual partners smoking anal intercourse HIV
107
Features of anal cancer?
rectal bleeding pain rectal mass
108
Mx of anal cancer?
wide surgical excision chemorads APR
109
Features of loop ileostomy?
two lumen spouted liquid or soft faeces usually temporary to defunction the bowel
110
Features of end ileostomy?
spouted single lumen RIF typically liquid/soft faeces
111
Features of end colostomy?
single lumen flush to skin solid faeces
112
Features of loop colostomy?
two lumen flush to skin solid faeces usually temporary
113
Complications of stomas?
stenosis retraction necrosis granulomas parastomal hernia high output stoma skin complications psychological effects

Surgery (10 decks)

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