Colorectal Flashcards
1
Q
Pathophysiology of Appendicitis
A
Appendix is blocked by:
Foecalith
Lymphoid
Neoplasms
IBS
The blocked appendix continues to secrete mucus and fluid, there is bacterial overgrowth and all this causes a cycle of luminal distension and inflammation increasing luminal pressure.
Luminal distension stimulates affarent visceral nerve fibres from T8-T10= vague periumbilical pain
Breech in epithelium lead to translocation of enteric bacteria
Transmural inflammation follows and inflamed outer serous layer of appendix irritates parietal peritoneum producing more localised pain at McBurney point.
With increased pressure, impaired venous and lymphatic drainage, then ongoing Ischemia + infection = perforation and contamination of peritoneal cavity
2
Q
Organisms associated with/w appendicitis
A
E.Coli
Bacteroides
Enterococcus
(Gram neg) so Augment good cover
3
Q
Which signs are elicited when examining for appendicitis
A
Rovsing: pain in RIF when palpating LIF
Dunphy: Pain in RIF when coughing
Iliopsoas: Pain in RIF on hyper extension of the R hip
Obturator: Pain in RIF on internal and external rotation of R hip
4
Q
Appendicitis is complicated by what
A
Appendix abscess
Phlegmon (appendix mass) give Ab
5
Q
Why is it difficult to diagnose appendicitis in pregnancy
A
Appendix is displaced up by uterus
WCC of up to 12000 is normal in pregnancy
Tachycardia is normal physiological change
N&V are presumed to be from hyperremesis gravidum
6
Q
Assessment of stoma
A
- Viability of the stoma (if it’s the right stoma, specific pouch type, one way valve in urine stoma and clip in colon/ileostomy, check any leakages etc)
- Size (measure all the time as it changes, pouching system needs to be cut to accommodate size of stoma measured)
- Consistency
- Skin peristomal and parastomal (adjust ouch if skin is sore, assess for infections, no oil based creams)
7
Q
Stoma complications
A
- Faecal contamination on the skin
Can also be due to
a) I’ll fitting stoma pouch system
b) incorrect size of stoma
c) allergy or skin irritation to product appliance - Adhesive pouch/ tape allergy
- Fungal infections (tx topical water based antifungal creams)
Surgical
1. Parastomal hernia
2. Stenosis: cutaneous and deep fascia (dilate with Hagar dilators)
3. Retraction (tx convex pouch systems)
4. Prolapse (try reduce, admit if strangulated)
5. Peristomal granulation (tx with silver nitrate)
6. Ischemia/necrosis
7. Bolus obstruction (hard foods, can also be adhesions/scar tissue
8. Stoma separation
8
Q
Mechanisms responsible for progression of volvulus to gangrene/necrosis
A
Ischemia of mesenteric from torsion and strangulation.
Distension of bowel causes intraminal pressure to exceed diastolic and systolic pressure, leading to arterial and venous obstruction
9
Q
pathophysiology of sigmoid volvulus
A
Torsion occurs as the base of loop causing obstruction
Ischemia due to 2 things: mesenteric obstruction and increased intraluminal pressure past the BP
Necrosis
10
Q
Aetiology if volvulus
A
Chronic constipation
High fibre diet
Use of enemas
Bowel habits
Length of sigmoid colon
11
Q
Presenting features of sigmoid vulvulus
A
- Pain, generally mild colicky or severe if gangrene. Radiate to the Back.
- Constipation
- Abdominal distension
- Vomiting
- Passing of flatus instead of reaches after attack
- Relief with enema
12
Q
Clinical features of sigmoid volvulus
A
Abdo distension
Dyspnoea
Remarkably little tenderness unless gangrene
Outline of distended bowel ‘Motorcycle tyre’
Tympanic abdomen
Visible peristalsis
Empty rectum on rectal exam
13
Q
Clinical features of sigmoid volvulus
A
Abdo distension
Dyspnoea
Remarkably little tenderness unless gangrene
Outline of distended bowel ‘Motorcycle tyre’
Tympanic abdomen
Visible peristalsis
Empty rectum on rectal exam
14
Q
Investigations to confirm sigmoid volvulus
A
- Abdo Xray (plain with pt upright)
- Bent inner tube
- Coffee been sign
- Summation line
- Walls of volvulus appear smooth
w’ no haustrations
-absent rectal gas
- Barium Enema
In cases where dx is difficult on AXR,
a limited barium enema will confirm
the dx.
Bird’s beak sign due to obstruction
Barium contraindicated in pts w’ suspected colon infarction or perforation.
CT scan
-Whirl sign which lead to the point of obstruction
15
Q
Management of Sigmoid Volvulus
A
Conservative
Sigmoidoscopy
-in patients with viable bowel
-diagnostic and therapeutic
-gently pass scope and relieves the torsion, passing of large flatus and fluid faeces
-site of torsion about 15cm above anal verge
-after detorsion pass a flatus tube and stitch to anal ring and leave for 2-3 days
Surgical Management (Mandatory after decompression)
1. Urgent laparotomy if:
-failed decompression
-features suggestive of peritonitis
-presence of gangrene seen on sigmoidoscopy
-features suggestive of perforation eg blood stained effluent from scope, fever, leukocytes after decompressions
After urgent Laparoscopy, Primary anastomosis or Colostomy and Hartman’s procedure
Elective surgery
2. Laparoscopic Resection of sigmoid colon after decompressed sigmoid volvulus.
Nonresectional surgery
3. Colopexy (Sigmoidopexy)
Suture sigmoid into anterior abdominal wall, less likely to twist.
4. Mesocoloplasy (Mesosigmoidoplasty)
16
Q
Contraindications of decompression with sigmoidoscopy
A
Features of gangrene eg peritonitis, unstable vitals
Presence of a compound vulvulus (knot !)
Failed attempt as sigmoidoscopy
17
Q
Complications of sigmoidoscopy in volvulus
A
Perforation
Reducing gangrene bowel
18
Q
Aetiology of ileo-sigmoid knot
A
Hyper mobile small intestine
Elongated mesentery having great breath and narrow base
Unusually redundant (big) mesocolon having narrow base of attachment
19
Q
Management of ileosigmoid knot
A
Resect both small and large bowel
Anastomoses if there is gangrene or colostomy and Hartman’s procedure
20
Q
Which polyps are high risk for malignancy
A
Large polyps >1cm
Villous polyps
Sessile/immobile
High grade dysplasia
21
Q
Risk factors for colon cancer
A
- Diet high in animal fat and meat
- Obesity (insulin resistance then insulin ⬆️=cancers)
- Family history (FAP, Attenuated FAP, Lynch syndrome,
- IBS
- Gardeners syndromes (linked to FAP also)
22
Q
Screening for colorectal cancer
A
At risk individuals (family hx)
1. Faecal Immunohistochemical Testing (FIT) (detects occult blood doesn’t tell you if it’s cancer)
2. Colonoscopy in First degree relatives of colon cancer patients 10years prior to their onset of disease.
23
Q
Presenting features of colonic cancer
A
General:
1. Bleeding/mucoid
2. Pain
3. Obstructive symptoms
4. Change in bowel h habits
5. Constitutional: LOW, Anaemia
6. Mass
Rectosigmoid (present earlier, more common 50-60%)
Left sided
Right sided (least distinct presentation)
24
Q
Investigations for colon cancer
A
You have to Biopsy to make the diagnosis
- Colonoscopy (Gold standard)
- Protosigmoidoscopy
-sufficient to confirm dx in distal colonic lesions histological, only tells you level of tumour or whether or not it occupies part of the lumen
For staging
CXR
CT scan chest abdo and pelvis and features of the cancer
-size and primary depth of invasion
-involvement of adjacent structures
-nodal involvement
Mets signs on CT
-liver lesions, bone or lung lesions (opacities)
-pleural effusions
-ascites
US of abdo also used for assessment of metastatic disease
MRI for all rectal cancers
PET scan if still in doubt, isotope based study,isotope rapidly taken up by cancer cells
25
How to stage colorectal cancer
TNM
TX-T4
NX-N2
MX-M2
26
How to stage colorectal cancer
TNM
TX-T4
NX-N2
MX-M2
27
Management of colorectal cancer
Right hemi-colectomy
Left hemicolectomy
Sigmoid colectomy
Anterior resection and APR
28
Factors that determine resectibility in colon cancer
Will there be complete resection
Adequate nests of the resection (yield sufficient lymph nodes)
Features of advances disease (mets), can we resect them (eg lung, liver)
29
What determines the type of resection for colon cancer
Anatomical location
Blood supply
Size of tumour
Anatomical location and blood supply determines which segment will be respected
Size of tumour determines how radical the resection will be eg whether or not the adjacent organs will be respected eg uterus, small bowel.
30
What is an adenoma
Being epithelial neoplasm
31
FAP is caused by which gene mutation
APC gene on chromosome 6 (5)
32
Diverticulitis clinical presentation (6)
1. Left iliac fossa pain (it’s commonly in the sigmoid) pain may be colicky in nature
2. Bloating
3. Flatulence
4. Rectal bleeding in diverticula’s bleed (rare)
5. Altered bowel habit (constipation/diarrhea)
6. Sx dissapearing after defeacation of flatulence
7. Fever and leukocytosis on investigations
33
Investigations for diverticulitis
Best: CT SCAN
CT surpercedes colonoscopy and is being increasingly used, may be used to supplement colonoscopy
Colonoscopy supercedes barium enema (useful also if you suspect malignancy)
Barium enema is useful in planning surgery as it shows severity and extent of disease
Always do the colonoscopy after acute episode settles after some time.
34
Complications of diverticulitis
(Think of your 4s- perforation, obstruction, infection, bleeding)
1. Perforation
2. Bowel obstruction (structures)
3. Abscess formation (local or walled off pelvic abscess) then fistula
4. Bleeding
35
Management of uncomplicated diverticulitis
Admission
Antibiotics (Gram negative and Anaerobes cover) - Ciprofloxin and Metronidazole
Ab orally when tolerated for 7-10days
Colonoscopy after sx subside to exclude cancer and evaluate extent of diverticulitis
Elective Colostomy surgery recommended in repeated attacks decided upon on a case to case basis
Remember to recommend diet with fibre and taking of fluid to decrease pressure causing diverticulitis
36
Management of complicated diverticulitis
Mx of an Abscess:
Unless abscess is too small, it should
be drained percutaneously.
If the collection is inaccessible, a
laparotomy & open drainage may be
needed.
Recommended that pts should
undergo resection ~6wks after
drainage, but this is not necessary in
all pts.
Mx of a Fistula:
Fistula is excised along w’ the
diseased segment of colon w’ a
primary anastomosis. Omentum is
interposed btwn the colon & bladder.
A bladder catheter is left in situ for
~10d or until a cystogram
demonstrates that there’s no leak.
Mx of Perforation:
Initial - IV fluid resus; analgesia; Abx.
If generalised peritonitis – urgent
laparotomy/laparoscopy.
Often not possible to determine
whether perforation due to cancer or
diverticulitis. A Hartmann’s
procedure is the safest option.
Mx of Colonic Obstruction:
In acute setting – NGT drainage; Abx.
Mx of Haemorrhage:
Initial – resus; localise bleed; Mx
cause.
Best method of dx & Rx is
colonoscopy after rapid bowel prep.
If source of bleed can’t be identified,
CT angiography is investigation of
choice.
Sx reserved for failure of medical,
angiographic, or endoscopic Rx.
37
Classification of complicated diverticulitis
Hinchey classification
Stage 1: pericolic or mesenteric abscess
Stage 2: walled off pelvic abscess
Stage 2: generalised purulent peritonitis
Stage 4: generalised faecal peritonitis
38
How to manage diverticular haemorrhage
Rescuscitate
Find source of bleeding and manage
Colonoscopy and Adrenalin injection or heater probe
CTA if colonoscopy unsuccessful(requires bleeding rate of atleast 1ml/min)
If scope and angiograph fails, intra op colonoscopy
Right colon common cause of bleeding, in persistent bleeding subtotal colectomy with ileorectal anastomosis May be required if colonoscopy and angiograph doesn’t identify bleeding site
39
Ulcerative colitis Vs Crohns
1.
UC : affects colon
Crohns: Can affect any part of the GIT
2.
UC: Continuous and extends proximal
Crohns: It May be patchy and have skip lesions
3.
UC: usually involves rectum
Crohns: commonly affects terminal ileum and proximal colon
4.
UC: involves mucosa
Crohns: has deep fissuring ulcers that penetrate through abdominal wall to involve adjacent organs
5.
UC: Crypt abscesses on Microscopy
Crohns: Non-caseating granulomas on microscopy
6.
UC: Smoking is protective
Crohns: Smoking is a risk factor
Crohns:
40
Clinical presentation on IBS (UC and Crohns) (5)
Diarrhea
Faecal urgency
With or without rectal bleeding
Constitutional sx of LOW etc
Severe attack: >6stools a day with 2 of ff: pyrexia, tachycardia anaemia
Crohns May present with other sx additionally depending on site, May mimic acute appendicitis
41
Investigations for IBS
Imaging
1. Sigmoidoscopy (flexible or gentle rigid first line, colonoscopy contraindicated as can cause perforation)
2. Daily erect Chest and Abdo X-rays
Labs
1. Stool cultures to exclude infectious diarrhoea in UC
42
Management of Acute Attack (>6stools +2 of pyrexia, tachycardia or anaemia)
Rescusc
Confirm dx with sigmoidoscopy flexible.
Exclude infection with stool culture
Daily erext XCR and Abdo XR
Atleast rice a day assessment by medical and surgical gastro
High dose IV steroids
Within 3-5 days if patients hasn’t settled consider surgery or rescue therapy with cyclosporine or anti TNF agents
43
Surgical management for ulcerative colitis
Emergency surgery
Total colectomy with an end ileostomy. Rectum is left in the patient with proximal end closed off.
1. Toxic mega colon:
-emergency colectomy if megacolon occurs while on medical tx,
-if it occurs while not on medical tx, short trial of medical therapy (hours), if doesn’t resolve emergency colectomy.
2. Colonic perforation
-if acute abdomen, perforation likely. Clinical signs of perforation may be suppressed by steroids. Emergency Colectomy
3. Massive haemorrhage
Urgent surgery
Colectomy and ileostomy, leave rectum.
1. Failed medical therapy
3-5 days of high dose steroids and patient hasn’t recovered, change to anti TNF or cyclosporine or consider surgery.
Elective surgery
1. Chronically ill health
Colectomy with ileostomy and preserve rectum as with above.
2. Risk of malignancy (increases by 1% a year for about 8-19years after 1st attack). Proctolectomy reduces risk to very low level. Repeat colonoscopies at 10yr interval as surveillence, if malignancy proctocolectomy
44
Operations done for Ulcerative Colitis
Restorative Proctolectomy and Proctolectomy are the 2 definitive and most preferred.
1. Proctocolectomy:Removal of colon with rectum and a permanent iliostomy. Disadvantage is permanent stoma
2. Restorative proctocolectomy: Colon and rectum are removed, a pouch is created at the end of small bowel and joined to anus, usually done elective with temporary ileostomy.
3. Colectomy and ileostomy with preservation of anus operation of choice for critically ill, allows pt to recover from acute attack then one of the 2 above is done as definitive treatments
4. Colectomy and ileorectal anastomosis is done where stoma is avoided, when there are issues with creating a pouch with sufficient length to reach rectum . UC can ecru in the rectum.
45
Surgical management of Crohns
Usually for complications : abscesses, strictures, fistulas.
Management depends on type of complication and the site.
1. Anal abscesses
Examine under anaesthesia. Drain abscesses
2. Fistulas: usually managed conservatively with setons as healing is unusual.
3. Small bowel and colonic diseases: if segment <10cm an experienced surgeon may choose to resect it
46
Investigations for bowel obstruction
1. Abdo XRay
2. CT with rectal contrast also CT chest, abdo and bone if cancer to rule out mets.
3. Barium enema avoided as impedes diagnostic and therapeutic colonoscopy
47
Initial management of bowel obstruction
Large bore IV access.
Resus as needed.
Urinary catheter for monitoring
NGT may be used if pt is vomiting but
in early LBO is often pointless.
Blood sample should be sent to assess
renal function & electrolytes, and
these corrected accordingly.
48
Surgical management of bowel obstruction
3 stage procedure
2 stage procedure
1 stage procedure
3 stage procedure
- used in rectal cancer obstructing
Stage 1: proximal stoma to decompress
Stage 2: obstructing lesion is removed (eg cancer)
Stage 3: stoma is closed
2 stage procedure
Stage 1: resection of obstructing lesion and colostomy placement
Stage 2: closure of colostomy
1 Stage procedure ( 2 options)
-Subtotal colectomy and ileorectal anastomosis
-Segmental colectomy with proximal decompression and washing out effluent.
Endoscopic(Colonoscopy) Stent placement
-Self Expanding Metal Stent (SEMS)
49
Presenting features of bowel obstruction
Constipation
Abdominal distension
Mild abdo pain
Vomiting (late)
50
Causes of bowel obstruction
Intraluminal
-Impacted faeces
-large polyp
-Foreign body
-Gall stones
Intramural
-Strictures (IBS/Crohns or Diverticulitis)
-Cancer
-Intescussception (related to tumour in adults)
-Infarction (Hirschsprung’s also?)
Extraluminal
-Volvulus
-Incarcerated hernia
-Cancer from adjacent compressing
-Adhesionolysis (past surgery, IBD, congenital bands)
Small bowel: Adhesions and strangulated hernias common
Large bowel: colon cancer, diverticulitis, Volvulus common.
51
What is occult bleeding
Evidence of blood loss but no obvious signs or symptoms. Confirm blood in stool by positive faecal occult blood test
52
Causes of Lower GI bleed
1. Diverticulosis
- acute, painless bright red bleeding
2. Angiodysplasia
-degenerative vascular malformations of GI tract characterised by fragile vessels. Bleeding is result of coagulopathy or platelet dysfunction.
3. Colitis
-Ischemia Colitis
-Infectious colitis
-IBS can also cause bloody diarrhea leading to Iron deficiency anaemia
4.Polyos and Carcinomas
-low grade bleeding leading to iron deficiency anaemia
5. Haemorrhoids / Anorectal disease
-Anal fissures and fistulas often present with intermittent spotting
6. Drug related
Anticoagulants, Asprin and NSAIDS
53
Investigations in rectal bleeding
Bloods:
- ABG
-FBC
-platelets; clotting factors.
-Low MCV suggests chronic blood loss. Norm. Hb doesn’t discount blood loss.
-Do crossmatch esp in acute bleeding
-Other lab investigations as
appropriate.
Imaging:
(colonoscopy then CT percutaneous angiograph are for therapeutic interventions, technitium scan useful in stable pt)
1. Endoscopy: (Sigmoid-/Colonoscopy)
-Primary dx & Rx modality for LGIB!
2. AXR:
-Useful in pts w’ bleeding due to IBS.
3. CT w’ Mesenteric Angiography:
-Shows site of bleeding in 50-90%.- More accurate in pts w’ active
bleeding.
3. Technetium-Labelled RBC Scan:
-Use limited by availability of
resources and false localisation rate
of up to 25%.
4. Selective Mesenteric Angiography:
-Dx & Rx (trans-catheter embolization)
- Infusion of vasopressin into the
bleeding vessel will stop bleeding in
majority of cases, but 50% will
rebleed.
54
Treatment of lower GI bleeding
Resuscitation
Localise bleeding
Haemostasis
55
Treatment of lower GI bleeding
1. Resuscitation
2. Localise bleeding
3. Haemostasis
1. Rescusc
-Large bore IV line and fluids
-crossmatch and ABG and your bloods for FBC etc
-Vit K and clotting factor replacement if needed
-NG tube to source Upper GI bleeding
2. Localisation of bleeding
-Colonoscopy primary
-CT with mesenteric angio second line
-percutaneous angiographic technique for interventional radiography
-Technitium scanning in stable pt with difficult localising bleeding
3. Haemostasis
Often stops spontaneiously in 80%
-colonoscopy 1st line:
1. Coagulation
2. Haemoclip
3. Injection therapy (Adrenalin?)
If cooonoscooy fails, Angiography for intervention.
56
Peesentation of anal abscess and fistula
Abscess
Pain of increasing severity, throbbing and made worse by deafacation
Fever
Pus discharge
Episodic anal pain that last a few days and resolves spontaneously sometimes
Constipation from painful deafacation
Fistula will have a purukent d/c
Pain may occur, relieve by discharge of pus
57
Differentials for anorectal sepsis
58
Which nerve innervates the external anal sphincter
Pudendal nerve S4
59
Risk factors for anorectal abscessses
1. Bowel inflammation: IBD esp Crohns, Diverticulitis, TB, Hidradenitisbsuppurativa
2. Immunosuppression: HIV, DM
3. Trauma: rectal foreign bodies, anal sex
4. Demographic and social: male, age 20-60
60
Diagnosing anorectal abscesses and fistulas
Clinical (under anaesthesia)
Deeper abscesses may require endoanal US or MRI
61
Differentials foe anorectal abscesses
Fissures
Perianal haematoma
Haemorrhoid that’s thromboses
Anal carcinoma
Infected sebaceous cyst
Hidradenitisbsuppurativa
Cutaneous Boil/furunclen
62
Management of anorectal abscesses
Sx drainage.
Most can safely be Mx as outpatients
without admission. However, pts w’
the below factors should be admitted
and given broad-spec Abx…
- Very large abscess.
- Immunosuppressed pt.
- Pt w’ diabetes or other systemic
disorder.
Performed under general anaesthesia.
Rigid sigmoidoscopy should also be
performed to exclude rectal disease
-saline soaked gauze followed by dry pad is applied
63
Management of anorectal fistula
Principles of Mx…
a. Lay open the primary tract.
b. Drain secondary tracts & abscesses.
c. Create a wound that is easy to
dress.
d. Preserve continence.
Also done under GA.
Goodsall’s Rule – ant. fistulas tend
to be straight & radial, while post.
ones are more likely to have complex
tracts but usually have a midline
internal opening.
Post-Op Analgesia – tramadol;
NSAIDs on first post op evening
Laxatives must also be given post-op.
64
What are haemorrhoids
Enlarged, symptomatic vascular cushions
65
Classification of haemorrhoids
Internal and External haemorrhoids
Internal:
-covered by mucosa
-not sensitive
-drain to the liver
External: (originate below dentate line)
-acutely sensitive
-covered anoderm(modified skin)
-drain to IVC
Can be mixed
66
Aetiology of haemorrhoids
Low diet fibre
Lack of water in diet
Constipation and Diarrhoea
RF: pregnancy, middle aged
67
Clinical stages of Internal haemorrhoids
Grade 1: Never prolapse. Just bright red bleeding
Grade 2: Prolapse and reduce spontaneously
Grade 3: Prolapse and require manual reduction
Grade 4: irreducible (often doesn’t bleed as covered by anoderm)
68
Clinical Presentation in Haemorrhoids
Bleeding
Prolapse
Pain
Anal Pain
Constipation or diarrhea (often cause not as a results of them)
69
Investigations for harmorrhoids
1. DREA
2. Proctoscope
-Internal haemorrhoids seen as purple bulging projections into anal canal
3. Colonoscopy
-to exclude other things eg cancers, polyps, highly recomended to patients
70
Management of Haemorrhoids
Noninterventional
-Reassure, avoid straining, soften stool with fibre and fluids
-Topical local anaesthetic cream
Interventional
1. Rubber band ligation
-for most internal haemorrhoids
-can be in outpatient and GP using protoscope
-band falls off in 7-10 days with some bleeding
2. Hemorrhoidectomy
3. Stapling (similar to rubber band ligation but is irreversible)
4. Infrared photocoagulation
5. Doppler guided haemorrhoids artery ligation
71
Differentials for a thrombosed haemorrhoid
Infection: perianal sepsis
Skin tags
Neoplasms: benign and malignant
1. Benign: warts/ condylomata acuminatum
-Naevus
2. Malignant: squamous cell carcinoma of anal verge
-Malignant melanoma
72
Clinical presentation of thrombosed haemorrhoids
Painful perianal lump
73
Management of thrombosed haemorrhoids
Conservative:
Analgesia control with NSAIDS
Stool softening with fibre and fluids and laxatives
Personal hygiene by bathing area with warm water twice a day and after bowel action
Surgical
Outpatient operating theatre
Clean area with with water based iodine based antiseptic
Apply local anaesthesia
Radical Incision made over centre of lesion and deeper until thrombus entered. Evacuate the thrombus .
Wound may be left open or closed with 1or2 absorbable sutures
Post op:
NsAIDs
Counsel on hygiene
Laxative to prevent constipation
74
Management of anal fissures
Conservative
-Soften stool by high fibre, liquids
-avoid straining in the toilet
-proper hygiene
-Sitz warm baths
-Stool softener/laxative if dietary interventions not helping
If doesn’t heal in 3-6 weeks
-Topical nitrates or calcium blocker creams
-side effect: headache
Nitrates Work by increasing blood flow to anus and relieves pain on deafacation
Surgical (if medical doesn’t work)
1. Botulinum toxin injection to anaesthetise for few months
2. Surgery: Sphincteretomy (might be incontinent)
75
Classification of hernia
According to Anatomical position
According to Presentation
According to Contents of hernia
Anatomical Position or Site
1. Groin Hernias
-Inguinal (direct-medial and Indirect-lateral)
-Femoral
2. Ventral
Primary (Congenital) vs Incisional (Iatrogenic or wound healing problem)
Primary Hernias
Midline
-Epigastric
-True Umbilical
-Para Umbilical
Lateral
-Spigelian
-Lumbar
Incisional Hernias
Midline
-Epigastric
-Paraumbilical
-Sub-Xiphoidal
-Suprapubic
Lateral
-Subcoastal
-Flank
3. Diaphragm
Hiatus
Bochdalek
Morgagni
According to presentation
1. Reducible
2. Irreducible (incarcerated)
3. Obstructed
4. Strangulated (ischemic)
According to contents
1. Slidding hernia: contains organ
2. Richters hernia: only part of the circumference of bowel becomes incarcerated or strangulated at the neck
3. Litttre hernia: hernia contains Meckels diverticulum in the hernia sac
4. Amyand hernia: rare form of inguinal hernia inwhivh appendix is found within hernia sac
5. De Garengeot hernia: femoral hernia containing the appendix (weird I know)
76
How to differentiate between hernia and abscess
In hernia clinical symptoms of bowel obstruction, distension, vomiting
US confirms present of bowel contents
77
Anatomy of the Inguinal Canal
Remember anatomy of the abdominal muscles
1. Transversalis fascia
2. Transversus abdominus
3. Internal Oblique
4. External oblique Aponeurosis
Roof of canal
1. Transversal is fascia
2. Transversus abdominus
2. Internal oblique
Floor of canal
1. Inguinal ligament
2. LACUNAR ligament
Anterior wall
1. Apeunurosis of External oblique
2. Internal oblique
Posterior wall
1. Transversalis fascia
78
Contents of spermatic cord
Testicular vessels (artery and vein)
Vas deferens
Tunica vaginalis
Lymphatic ducts
79
Diffrence between direct and indirect Inguinal hernias
Indirect Hernias
Most common hernia found in young
ppl; incidence tapers off after age 30.
Occurs when abdo contents protrude
through the internal inguinal ring and
into the inguinal canal.
Occurs lateral to the IEVs.
Contents may extend into scrotum.
The degree of patency of the tunica
vaginalis determines what can enter.
If the canal is very small, as w’ some
congenital communicating hernias or
in adults w’ ascites or on peritoneal
dialysis, it will only allow fluid to
enter (communicating hydrocele),
which is dx by transillumination.
Large ones allow content to enter.
Indirect hernias may occur at any
age, w’ 1-3% in new-born babies and
an incidence 30x higher in pre-terms.
Direct Hernias
Occur through the Hesselbach’s
triangle (medial to IEVs).
Usually in older people.
Because of its anatomical position &
usual type of pts (older w’ weak
tissue), direct hernias have a wide
neck and are much shallower than
indirect hernias, so they seldom
complicate.
They do cause discomfort and impair
ability to increase intra-abdo pressure
at stooling or when lifting an object.
May occur simultaneously w’ an
indirect hernia (Pantaloon),
straddling the deep IEVs.
Due to their anatomical position,
direct hernias can’t descend into the
scrotum.
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Femoral hernia anatomy
Protrudes through the femoral canal,
which is situated medial to the
femoral vein and dissects downwards
inferior to the inguinal ligament into
the upper thigh and later forward to
exit through the fossa ovalis.
More common in females.
If present, usually symptomatic.
Should be repaired urgent electively.
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Differentials for groin lump
Inguinal and femoral hernias
Lymphadenopathy
Abscess
Saphena varix (dilation of saphenous vein)
Aneurysm
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Tabulate the differences between Indirect Inguinal hernia, Direct Inguinal and Femoral hernias
1. Common in which group
2. Gender
3. Scrotal or not?
4. Where it protrudes from (canal)
5. Above or below inguinal ligament
6. Does it incarcerate and strangulate
7. How to reduce (does closing internal inguinal ring)
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83
Indications for repair in umbilical hernias (3)
Incarcerated and strangulated (not frequent)
Size of orifice, if can admit 2 fingers
At age of 5-7 all diagnosed umbilical hernias need to be repaired
84
Principle of management of hernias
Content of the hernia sac must be
reduced back into the cavity.
All adhesions either in the sac or
against the abdominal wall must be
released for reduction.
Excess sac must be removed, and the
remining edge of the sac sutured
closed at the neck.
Defect in the wall needs to be closed.
Sutures must be tense free
Sutures material strong as tissue sutured
Do not tighten muscle sutures, causing ischemia
Use nonabsorbable mesh
Dotted line suture
Approximate do not strangulate
85
Difference between synchronous and metochronous tumours in colorectal cancer
Synchronous are present elsewhere in colon at time of primary diagnosis
Metochronous are present atleast 6months after primary resection
Recurrent is when it returns at the margins of primary surgical resection or mesentery
86
What is bowel prep
Preparing bowel for colonoscopy or surgery by emptying it using polyethylene glycol the patient drinks on the day prior to surgery
87
What operations are offered to rectal cancer patients
Low anterior resection LAR: If cancer is 2cm proximal to rectum
Abdominoperineal resection APR: if cancer is within 2cm of dentate line. permanent colostomy
