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Surgery Revision > Colorectal > Flashcards

Colorectal Flashcards

1
Q

Blood supply to the appendix

A

Appendicular artery

terminal branch of ileocolic artery - branch of the SMA

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2
Q

Things that can obstruct an appendix

A
  • faecoliths
  • calculi
  • lymphoid hyperplasia
  • infection
  • tumour
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3
Q

Pathogenesis of appendicitis

A
  • obstruction
  • increased luminal and intramural pressure
  • thrombosis and occlusion of small vessels and stasis of lymph
  • activation of visceral nerves T8-T10 = central pain
  • parietal inflammation = localised pain
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4
Q

Classical signs and symptoms of appendicitis

A
  • RLQ pain
  • anorexia
  • nausea and vomiting
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5
Q

Differentials for appendicitis

A
  • UTI
  • renal calculi
  • gastroenteritis
  • rupture ovarian cyst
  • PID
  • cholcystitis
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6
Q

3 Eponimous clinical signs in appendicitis

A
  • Rovsing’s sign
  • Obturator sign
  • Iliopsoas sign
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7
Q

Rovsing’s sign

A

Palpation of the lower left quadrant elicits pain in the right lower quadrant

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8
Q

Obturator sign

A

Pain with internal rotation of the hip (pelvic appendix)

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9
Q

Iliopsoas sign

A

Extension of the right hip elicits pain in the right hip (retrocecal appendix)

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10
Q

U/S findings in appendicitis

A

Want to exclude pelvic pathology

  • thickened wall >2mm
  • increased appendix diameter >6mm
  • free fluid
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11
Q

CT findings in appendicitis

A
  • thick wall
  • appendix diameter >7mm
  • appendicolith/abscess
  • free fluid
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12
Q

Management of appendicitis

A
  • admission
  • IV fluid + analgesia
  • if confident, appendectomy
  • investigation
  • diagnostic lap for young women
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13
Q

What is an appendicular mass?

A

> 5 days of symptoms
Findings in RLQ
palpable mass

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14
Q

Treatment of appendicular abscess

A

CT/US-guided percutaneous drainage

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15
Q

Definition of a volvulus

A

A loop of bowel and its mesentery twist on a fixed point at its base
Causes obstruction

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16
Q

Pathophysiology of volvulus

A
  • torsion and obstruction
  • gas an fluid production
  • loop distends
  • fluid and electrolyte loss
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17
Q

How does volvulus progress to gangrene?

A
  • obstruction of mesenteric blood flow
  • increased intraluminal pressure obstructs venous and arterial obstruction

Subserosal petechiae - blood stained ascites
- gangrene

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18
Q

Most common volvulus sites

A
  • sigmoid

- caecum

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19
Q

Less common volvulus sites

A
  • transverse colon
  • splenic flexure
  • descending colon
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20
Q

Risk factors for sigmoid volvulus

A
  • long sigmoid and mesocolon with narrow mesenteric attachements
  • chronic constipation
  • high fibre diet
  • use of enemas
  • altitude
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21
Q

Difference between endemic and sporadic volvulus

A

Endemic patients have increased blood supply and so present less with gangrene and more with fluid sequestration

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22
Q

Presenting features of sigmoid volvulus

A
  • recurrent abdo distention
  • constipation
  • pain
  • dyspnoea
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23
Q

Investigations to diagnose sigmoid volvulus

A
  • upright abdo XRAY
  • barium enema (bird’s beak)
  • CT (whirl)
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24
Q

XRAY findings in sigmoid volvulus

A
  • bent inner tube
  • coffee bean sign
  • summation light
  • liver overlap sign
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25
Q

Contraindications to sigmoidoscopy with sigmoid volvulus

A
  • gangrene

- compound volvulus

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26
Q

When to do an urgent lap for volvulus

A
  • failed decompression
  • features of peritonitis
  • gangrene
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27
Q

What is an ileo-sigmoid knot?

A
  • volvulus of both small and large bowel
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28
Q

Two types of caecal volvulus

A
  • axial ileo-colic volvulus

- caecal bascule

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29
Q

Signs and symptoms of a caecal volvulus

A
  • abdo pain and distension
  • constipation/obstipation
  • vomiting
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30
Q

XRAY findings in a caecal volvulus

A
  • single fluid level in a dilated caecum

- absence of gas in the distal colon

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31
Q

3 types of urgent surgery for a caecal volvulus

A
  • right hemicolectomy
  • caecopexy
  • caecostomy
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32
Q

Definition of a polyp

A

A localised elevated lesion arising from an epithelial surface

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33
Q

Types of adenomatous polyps

A
  • villous adenoma

- tubular villous adenoma

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34
Q

Evidence for the polyp-cancer sequence

A
  • polpectomy decreases cancer incidence
  • colonic adenomas occur more frequently with cancers
  • large adenomas are more likely to have cancer
  • severe dysplasia in polyps progresses to cancer
  • residual adenomatous tissue is found in invasive cancers
  • 100% of FAP develop cancer
  • high rate of adenomas where there is a high cancer rate
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35
Q

Symptoms of polyps

A
  • bleeding
  • mucus
  • prolapse
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36
Q

When to follow up a polyp patient

A
  • high risk: 2-3 years

- low risk: 4-5 years

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37
Q

Types of polyp syndromes

A
  • Juvenile polyp
  • Juvenile polyposis
  • Peutz-Jeglers polyposis
  • FAP
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38
Q

Where is the mutation in FAP?

A

APC gene on chromosome 6

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39
Q

What is Gardener’s syndrome?

A

FAP with extra-intestinal features

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40
Q

Extra-intestinal features of Gardener’s syndrome

A
  • osteomata of the skull
  • epidermoid cyst
  • soft tissue skin tumours
  • dental abnormalities
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41
Q

Other associations with FAP

A
  • desmoid tumours
  • Congenital hypertrophy of retinal pigment epithelium
  • malignant lesions
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42
Q

3 prophylactic surgeries for FAP

A
  • proctocolectomy
  • colectomy with ileo-rectal anastomosis
  • restorative proctocolectomy
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43
Q

What is a diverticulum?

A

A sac-like protrusion of colonic wall

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44
Q

How do patients with diverticuli present?

A
  • asymptomatic
  • symptomatic
  • diverticular bleed
  • diverticulitis
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45
Q

Complications of diverticuli

A
  • abscess
  • fistula
  • peritonitis (purulent/faeculent)
  • stricture and obstruction
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46
Q

Explain the Hinchey classification for diverticuli

A

Stage 1 = pericolic/mesenteric abscess
Stage 2 = walled-off pelvic abscess
Stage 3 = generalised purulent peritonitis
Stage 4 = generalised faeculent peritonitis

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47
Q

How does diverticular haemorrhage present?

A
  • abrupt and painless bleeding
  • potentially life-threatening
  • mostly from the right colon
48
Q

Potential etiology of IBD

A
  • genetic predisposition
  • infection
  • hypersensitivity
49
Q

Pathological features of UC

A
  • usually in the colon
  • continuous
  • involves the rectum
  • involves the mucosa
  • crypt abscesses
  • smoking is protective
50
Q

Pathological features of Crohns

A
  • found usually in terminal ileum and proximal colon
  • patchy with skip lesions
  • deep fissuring ulcers that penetrate through the wall
  • non-caseating granulomas
  • smoking = risk factor
51
Q

Definition of an acute severe attack of UC

A

6 or more stools a day with 2 or more of:

  • pyrexia
  • anaemia
  • tachycardia
52
Q

Initial management of IBD

A
  • resus
  • confirm Dx with rigid/flexi (NOT C-SCOPE)
  • stool cultures
  • daily chest and abdo XRAY
  • 2x daily Dr assessement
  • high dose IV steroids
  • after 3-5 days: surgery/rescue therapy
53
Q

Medical rescue therapy for IBD

A
  • cyclosporine

- anti-TNF therapy

54
Q

When do you need to do emergency surgery for IBD?

A
  • toxic megacolon
  • colonic perforation
  • massive haemorrhage
55
Q

When do you need to do urgent surgery for IBD?

A

Failed medical therapy

56
Q

When do you need to do elective surgery for IBD?

A
  • chronic ill health

- risk of malignancy

57
Q

Operations for UC

A
  • proctocolectomy with removal of anus and permanent end ileostomy
  • restorative proctocolectomy
  • colectomy and ileostomy
  • colectomy and ileorectal anastomosis
58
Q

La Place’s Law

A

As the radius increases with a constant pressure, the tension exerted on the wall will increase

59
Q

Etiology of large bowel obstruction

A
  • colorectal cancer
  • volvulus
  • diverticular stricture
  • Other (fecal impaction, hernia, foreign body)
60
Q

Differential diagnoses for large bowel obstruction

A
  • small bowel obstruction
  • ileus
  • Hirschsprungs
  • colonic pseudo-obstruction
  • congenital leiomyopathy
  • toxic megacolon
61
Q

Presenting features of large bowel obstruction

A
  • early onset obstipation and distension
  • mild abdo pain
  • vomiting (late)
62
Q

Investigations for large bowel obstruction

A
  • Abdo XRAY
  • water soluble contrast enema
  • CT-scan with rectal contrast
63
Q

XRAY features of small bowel

A
  • central

- linea coniventes

64
Q

XRAY features of large bowel

A
  • peripheral

- haustral markings

65
Q

Operation for a R-sided obstruction

A
  • midline lap +
  • R hemicolectomy/ extended R hemicolectomy
  • primary anastomosis
66
Q

Operations for a L-sided obstruction

A
  • 3 stage (for rectal cancer)
  • 2 stage (for obstructing sigmoid cancer)
  • 1 stage (for young patients with good sphincters)
67
Q

Definition of a lower GIT bleed

A
  • bleeding that occurs distal to the ligament of Treitz
68
Q

Presentation of lower GIT bleed

A
  • acute
  • chronic
  • occult
69
Q

Features of a massive LGIB

A
  • large amounts of red/ maroon blood
  • haemodynamic shock/instability
  • Hb of 8 or less
  • need to transfuse >2 U of blood
  • bleeding continues for 3 days
  • significant rebleed within 1 week
70
Q

Most common causes of LGIB

A
  • diverticulosis
  • angiodysplasia
  • colitis
  • neoplasia
  • haemorrhoids etc
  • drug-related
71
Q

Radiology options for LGIB

A
  • abdo X-ray
  • CT with mesenteric angiography
  • Technetium-labeled RBC scanning
  • selective mesenteric angiography
72
Q

Other investigations for a LGIB

A
  • endoscopy

- colonoscopy

73
Q

Ways to achieve haemostasis in a LGIB

A
  • colonoscopy (coag, haemoclip, injecion)
  • formal angiography (trans cath embolization)
  • surgery
74
Q

Pre-op management of anal sepsis

A
  • diagnosis
  • exclusion of other pathology
  • determine anatomical extent
75
Q

Diseases associated with anorectal sepsis

A
  • Crohns
  • UC
  • hidradenitis suppurativa
  • carcinoma of anus/ lower rectum
  • TB
  • pelvic sepsis
  • foreign bodies
  • lymphogranuloma venereum
  • actinomycosis
76
Q

Pathways of anal fistulas

A
  • intersphincteric
  • transsphincteric
  • suprasphincteric
  • extrasphincteric
77
Q

What is a simple fistula?

A
  • one opening and easily identifiable primary tract
78
Q

What is a complex fistula?

A
  • multiple external openings and secondary tracts
79
Q

Symptoms of an acute anal abscess

A
  • pain worsening over a few days
  • worse with defeacation
  • fever
  • discharge/ painful swelling
80
Q

Who needs inpatient treatment for an anal abscess?

A
  • very large abscess
  • immunocomp
  • diabetic/systemically unwell
81
Q

How to drain an abscess

A
  • under GA
  • EUA and rigid (exclude rectal disease)
  • incision at max flux
  • pus swab
  • break loculi
  • trim edges
  • saline soaked gauze, dry pad and disposable panty
82
Q

Surgical management of a fistula

A
  • lay open the primary tract
  • drain secondary tracts
  • create a wound that’s easy to dress
  • preserve continence
83
Q

Goodsall’s rule

A
  • anerior fistulas tend to be straight and radial

- posterior fistulas are more likely to be complex, but usually have a midline internal opening

84
Q

Features of a thrombosed perianal varix

A
  • sudden onset pain
  • worse when walking/sitting
  • pain subsides over 10 days
  • obvious tender lump covered by stratified squamous epithelium
  • bluish and rubbery
85
Q

Function of a temporary stoma

A

To assume the function of elimination of waste, to permit healing or rest the gut or section of bowel

86
Q

Function of a permanent stoma

A

To take over the function of elimination of the bowel that has been removed or permanently bypassed

87
Q

Three classifications of stomas

A
  • input stomas
  • diverting stomas
  • output stomas
88
Q

Examples of input stomas

A
  • gastrostomy

- jejenostomy

89
Q

Examples of diverting stomas

A
  • ileostomy

- loop colostomy

90
Q

Examples of output stomas

A
  • bladder/bowel
91
Q

Indications for stoma surgery

A
  • congenital
  • acquired
  • traumatic
  • infective
  • neoplastic
92
Q

Most commonly created output stomas

A

Faecal: colostomy and ileostomy

Urinary: ileal conduit/ urostomy and nephrostomy

93
Q

Factors taken into consideration when siting a stoma

A
  • loaction of the rectus muscle
  • the waistline/beltline
  • hobbies, work, sport, activities
94
Q

Places to avoid when siting a stoma

A
  • lower costal margins
  • planned incisions
  • old scars
  • obvious creases
  • umbilicus
  • iliac crests
95
Q

Types of colostomies

A
  • end colostomy
  • loop colostomy
  • divided colostomy
  • Double-Barrel/ Mikulicsz
96
Q

Factors influencing stool frequency and consistency

A
  • site in the colon
  • precipitating condition or disease process
  • previous GIT surgery
  • radio/chemotherapy
  • medication
  • physical status
  • eating and drinking habits
97
Q

Size of ideal colostomy

A

approx 1cm

98
Q

Size of ideal ileostomy

A

approx 3 cm

99
Q

Things to assess when thinking of doind a stoma

A
  • output/effluent of the stoma
  • stool consistency
  • condition of the skin
  • diameter of the stoma
  • financial consideration
  • patient’s ability to manage
  • availability of the product
100
Q

Dermatological complications of a stoma

A
  • faecal contamination
  • allergy to tape
  • mechanical
  • bacterial/fungal infection
101
Q

Surgical complications of a stoma

A
  • parastomal hernia
  • stenosis
  • retraction
  • prolapse
  • peristomal granulation
  • bolus obstruction
  • stoma separation
  • ischaemia
102
Q

Polyps that are considered high risk for cancer

A
  • large polyps >1cm
  • villous lesions
  • sessile lesions
  • high grade dysplasia
103
Q

Where are polyps most commonly found?

A
  • in the recto-sigmoid area
104
Q

Hereditary colorectal cancers

A
  • FAP
  • Attenuated FAP
  • Lynch syndrome
  • MUYTH associated polyposis
105
Q

Factors in IBD that increase risk of cancer

A
  • greater extent of disease
  • evidence of mucosal dysplasia
  • sclerosing cholangitis
  • family history of cancer
106
Q

How often should first degree relatives of colorectal cancer patients have a colonoscopy?

A

10 years prior to age of onset of disease in affected relative

107
Q

Symptoms of rectal tumours

A
  • mucoid discharge
  • alteration in bowel habit
  • obstructive symptoms
  • perianal pain`
108
Q

Symptoms of left-sided colonic tumours

A
  • intermittent constipation or diarrhoea
  • obstructive symptoms
  • bleeding
  • LOW
  • palpable mass
109
Q

Symptoms of right-sided colonic tumours

A
  • unexplained anaemia and/or weight loss
  • occult faecal blood
  • obstructive features uncommon
110
Q

Diagnosis of colorectal cancer

A

Only on histological assessment

111
Q

Investigation of colorectal cancer

A
  • procto-sigmoidoscopy (only for distal lesions)
  • colonoscopy (gold standard)
  • barium enemas
112
Q

How to stage a colorectal cancer

A
  • chest XRAY
  • U/S (liver, ascites, lymphadenopathy)
  • CT
  • MRI
  • PET
113
Q

Surgeries for colorectal cancer

A
  • right hemi-colectomy
  • left hemi-colectomy
  • sigmoid colectomy
  • anterior resection and abdomino-perineal resection
114
Q

Factors that confer poorer prognosis for colorectal cancer

A
  • tumour at surgical margins
  • obstructed tumour at presentation
  • poorly diff tumour
  • inadequate lymph node yield
  • perineural invasion
  • peritoneal deposits/micromets
115
Q

When do most recurrences of colorectal cancers occur?

A

In the first two years following surgery

116
Q

Tumour markers for colorectal cancers

A
  • carcino-embryonic antigen (CEA

Surgery Revision (8 decks)

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