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Surgery > Colorectal > Flashcards

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
Q

DDx for femoral hernias?

A

femoral canal lipoma
saphena varix
lymphadenopathy
femoral artery aneurysm
femoral artery pseudoaneurysm (post-angiography)
sarcoma

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26
Q

Risk Factors for incisional hernias?

A

post-op wound infection
abdominal obesity
poor muscle quality (smoking, anaemia)
multiple operations through same incision
incision size
poor choice of incision
inadequate closure

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27
Q

What is appendicitis?

A

inflammation of the appendix
most common cause of acute abdomen and most common indication for emergency surgery

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28
Q

Presentation of acute appendicitis?

A

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)

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29
Q

Where is McBurney’s point?

A

imaginary point 1/3rd of the way between ASIS and umbilicus

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30
Q

Diagnosis of appendicitis?

A

clinical diagnosis
raised inflammatory markers
CT scan if doubt
US (exclude gynae)

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31
Q

DDx for appendicitis?

A

ectopic pregnancy
ovarian cyst
Meckel’s diverticulum
mesenteric adenitis (children)

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32
Q

What is an appendix mass?

A

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

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33
Q

Management of acute appendicitis?

A

laparoscopic or open appendicectomy

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34
Q

Complications of appendicectomy?

A

Thromboembolic events
Bleeding
Infection (wound/intra-abdominal)
Removal of normal appendix
Damage to bladder, bowel, other organs
Dehiscence of wound
Scarring
Anaesthetic risks

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35
Q

Components of Alvarado Score?

A

abdo pain
anorexia
nausea/vomiting
RIF tenderness
rebound tenderness
temp > 37.5
WCC > 10
neutrophils > 75%

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36
Q

Complications of acute appendicitis?

A

perforation
RIF appendix mass
RIF abscess
pelvic abscess

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37
Q

Causes of small bowel obstruction?

A

adhesions
hernias
malignancy
intussusception
strictures (Crohn’s, radiation)
Meckel’s diverticulum

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38
Q

Causes of large bowel obstruction?

A

malignancy
hernias
diverticulitis
volvulus
intussusception
stricture

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39
Q

What causes adhesions?

A

abdo or pelvic sx (particularly open)
peritonitis
abdo or pelvic infections (PID)
endometriosis
congenital
secondary to radiotherapy

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40
Q

What is a closed-loop obstruction?

A

when there a two points of obstruction within the bowel, causing increased pressure and rupture of the compressed bowel
requires emergency sx

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41
Q

Causes of a closed-loop obstruction?

A

adhesions
hernias
volvulus (twist isolates section)
single point of obstruction with a competent ileocecal valve

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42
Q

Presentation of bowel obstruction?

A

vomiting
abdo distension
diffuse abdo pain
obstipation
‘tinkling’ bowel sounds in early obstruction

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43
Q

Diagnosis of bowel obstruction?

A

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

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44
Q

Management of bowel obstruction?

A

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)

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45
Q

Complications of bowel obstruction?

A

hypovolaemic shock (third-spacing)
bowel ischaemia
bowel perforation
sepsis
metabolic alkalosis (vomiting)

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46
Q

What is ileus?

A

condition affecting the small bowel, where normal peristalsis is interrupted

47
Q

Causes of ileus?

A

injury to bowel
handling of bowel during sx
inflammation or infection (peritonitis, appendicitis, pancreatitis, pneumonia)
electrolyte imbalance (hypokalaemia, hyponatraemia)

48
Q

Presentation of ileus?

A

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
Q

Management of ileus?

A

supportive care
nil by mouth
NG tube if vomiting
IV fluids
mobilisation (helps to stimulate peristalsis)
TPN

50
Q

What is a volvulus?

A

twisting of the bowel and the surrounding mesentery, resulting in a closed-loop obstruction

51
Q

Complications of a volvulus?

A

ischaemia
necrosis
perforation

52
Q

Types of volvulus?

A

sigmoid volvulus (more common, older patients)
caecal volvulus (less common, younger patients)

53
Q

Risk factors for a volvulus?

A

chronic constipation
high fibre diet
excessive use of laxatives
neuropsychiatric disorders (PD)
nursing home residents
pregnancy
adhesions

54
Q

Diagnosis of a volvulus?

A

sigmoid volvulus -> coffee-bean appearance on X-ray
caecal volvulus -> embryo sign on X-ray
contrast CT to confirm

55
Q

Management of volvulus?

A

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
Q

What is diverticulosis?

A

the presence of diverticula, without inflammation or infection present

57
Q

What is diverticular disease?

A

clinically significant diverticulosis, e.g., bleeding, infection, perforation

58
Q

What are diverticula?

A

acquired outpouchings of sac-like mucosal projections through the colon wall

59
Q

Where do diverticula form?

A

sigmoid colon is most common
can affect all the GI tract
rectum rarely involved

outpouchings form between the taenia coli

60
Q

Risk factors for diverticula?

A

incr. age
low fibre diet
obesity
NSAIDs (incr. risk for bleeding)

61
Q

Presentation of diverticular disease?

A

often diagnosed incidentally on colonoscopy or CT (don’t treat if patient asymptomatic)

intermittent LIF pain, constipation, diarrhoea

62
Q

Presentation of acute diverticulitis?

A

‘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
Q

Management of symptomatic diverticulosis?

A

incr. fibre in diet
bulk-forming laxatives
avoid stimulant laxatives
sx if symptoms are severe

64
Q

Complications of diverticulitis?

A

pericolic/paracolic abscess
purulent peritonitis (abscess perforation)
feculent peritonitis (bowel perforation)
fistulae (colovaginal, colovesical)
stricture formation
large haemorrhage

65
Q

Presentation of colovesical fistula?

A

recurrent UTIs
pneumaturia
debris in urine

66
Q

Investigations in acute diverticulitis?

A

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
Q

What is Hinchey Classification used for?

A

to classify acute diverticulitis

68
Q

What are the levels in Hinchey Classification of diverticular disease?

A

1A - paracolic phlegmon
1B - pericolic/mesenteric abscess
2 - diverticulitis with walled-off abscess
3 - purulent peritonitis
4 - feculent peritonitis

69
Q

Medical management of acute diverticulitis?

A

uncomplicated diverticulitis

IV antibiotics (co-amoxiclav +/- gent +/- metronidazole)
bowel rest
IV fluids
analgesia
radiologically guided drainage of abscess

70
Q

Indications for surgical management of acute diverticulitis?

A

free perforation
fistula
refractory to medical treatment
undrainable abscess

71
Q

Surgical management of acute diverticulitis?

A

laparoscopy and washout
resection of diseased part of bowel (Hartmann’s)

manage complications

72
Q

Blood supply to the abdominal organs?

A

coeliac artery -> foregut
superior mesenteric artery -> midgut
inferior mesenteric artery -> hindgut

73
Q

Risk Factors for chronic mesenteric ischaemia?

A

incr. age
FHx
smoking
diabetes
HTN
hypercholesterolaemia

74
Q

Presentation of chronic mesenteric ischaemia?

A

‘intestinal angina’

central colicky abdo pain after eating
weight loss
abdominal bruit

75
Q

Diagnosis of chronic mesenteric ischaemia?

A

CT angiography

76
Q

Management of chronic mesenteric ischaemia?

A

reduce modifiable RFs
secondary prevention (statins, antiplatelets)
revascularisation (endovascular stenting first-line, open)

77
Q

Presentation of acute mesenteric ischaemia?

A

acute, severe, non-specific abdo pain
pain disproportionate to exam findings
shock, peritonitis and sepsis

78
Q

Risk Factors for acute mesenteric ischaemia?

A

AFib, elderly, CVD, Hx of chronic mesenteric ischaemia

79
Q

Investigations for acute mesenteric ischaemia?

A

contrast CT gold standard
metabolic acidosis
raised lactate levels

80
Q

Management of acute mesenteric ischaemia?

A

surgery to remove necrotic bowel
open or endovascular surgery to remove or bypass thrombus

very high mortality (over 50%)

81
Q

3 types of ischaemic bowel disease?

A

acute mesenteric ischaemia
chronic mesenteric ischaemia
ischaemic colitis

82
Q

RFs for colorectal carcinoma?

A

FHx
FAP
HNPCC
ulcerative colitis
obesity
diet
smoking
alcohol
T2DM
acromegaly

83
Q

Pathophysiology of colorectal cancer?

A

adenocarcinoma

most arise from pre-existing adenomas

84
Q

Types of adenomas?

A

tubular
villous
tubulo-villous
serrated

villous have greatest potential for malignant transformation

85
Q

Presentation of colorectal cancer?

A

depends on location

right-sided - IDA
left-sided - PR bleeding, change in bowel habit
distal lesion - PR bleeding, tenesmus

may present as obstruction

86
Q

Investigations for colorectal cancer?

A

PR exam
FIT
colonoscopy and biopsy
CT colonography if colonoscopy not possible

if emergency -> CT

CT for staging
MRI for staging rectal
CEA

87
Q

Mx of colorectal cancer?

A

Sx resection depending on tumour location
neoadjuvant chemorads

adjuvant chemo if LN or vascular invasion

palliative

88
Q

Follow up in colorectal cancer patients?

A

colonoscopy at 1 year, every 3-5yrs after
CT scans annually for 3 yrs
CEA monitoring

89
Q

Options for resection of bowel?

A

right hemicolectomy
left hemicolectomy
high anterior resection
low anterior resection
abdominoperineal resection

90
Q

What are haemorrhoids?

A

vascular and connective tissue columns that exist in three columns on the anal canal (3, 7, 11 o’clock)

91
Q

Internal vs External haemorrhoids?

A

internal:
above dentate line
painless
bleed and prolapse

external:
below dentate line
may thrombose and cause pain and itching

92
Q

RFs for haemorrhoids?

A

hereditary factor
diet
prolonged straining
increased intra-abdominal pressure

93
Q

Degrees of haemorrhoids?

A

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
Q

Complications of haemorrhoids?

A

bleeding
prolapse

95
Q

Investigations for haemorrhoids?

A

exclude other cause of bleeding
DRE
proctoscopy, sigmoidoscopy, colonoscopy

96
Q

Mx of haemorrhoids?

A

conservative

medical (topical analgesics, steroids, injection sclerotherapy, rubber band ligation)

surgical (haemorrhoidectomy)

97
Q

Indications for haemorrhoidectomy?

A

3rd and 4th degree
2nd degree that have not been cured by other mx
fibrosed haemorrhoids

98
Q

Causes of anal fissures?

A

primary:
local trauma

secondary:
Crohn’s
granulomatous disease
malignancy
communicable diseases

99
Q

Types of anal fissure?

A

acute <6wks
chronic >6wks

100
Q

Presentation of anal fissure?

A

pain
bleeding
pruritus ani

101
Q

Mx of anal fissure?

A

DRE too painful

conservative

medical (analgesia, local anaesthetic, TGN, diltiazem)

surgical (lateral sphincterotomy)

102
Q

Causes of anorectal fistula?

A

anorectal abscess
Crohn’s
radiation proctitis
rectal foreign bodies

103
Q

Features of anorectal fistula?

A

intermittent pain
chronic purulent discharge
pustule-like lesion in perianal or buttock area

104
Q

Mx of anorectal fistula?

A

fistulotomy
fistulectomy
Seton insertion
advancement flap
plugs and glues

105
Q

Mx of pilonidal sinus and abscess?

A

incision and drainage acutely
second operation to excise sinus

106
Q

RFs for anal cancer?

A

female
HPV
incr. sexual partners
smoking
anal intercourse
HIV

107
Q

Features of anal cancer?

A

rectal bleeding
pain
rectal mass

108
Q

Mx of anal cancer?

A

wide surgical excision
chemorads
APR

109
Q

Features of loop ileostomy?

A

two lumen
spouted
liquid or soft faeces
usually temporary to defunction the bowel

110
Q

Features of end ileostomy?

A

spouted
single lumen
RIF typically
liquid/soft faeces

111
Q

Features of end colostomy?

A

single lumen
flush to skin
solid faeces

112
Q

Features of loop colostomy?

A

two lumen
flush to skin
solid faeces
usually temporary

113
Q

Complications of stomas?

A

stenosis
retraction
necrosis
granulomas
parastomal hernia
high output stoma
skin complications
psychological effects

Surgery (10 decks)

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