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MBBS Surgery > Colorectal > Flashcards

Colorectal Flashcards

1
Q

Complications of stomas

A

Early: necrosis, obstruction from edema, high stoma output, enterocutaneous dehiscence, leakage -peristomal excoriations

Intermediate: prolapse, retraction, infection, bleeding

Late: stenosis, parastoma fistula, skin excoriation, parastomal hernia, psychological

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2
Q

High output stoma definition

A

output > 1000ml/day (significant when >2000)

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3
Q

Causes of high output stoma

A

physiological output (diagnosis of exclusion)

sx with <200cm residual small bowel and no colon
intra-abdominal sepsis
enteritis (c difficile)
disease relapse in remaining bowel (UC)
Medication (withdrawal of steroids, pro-kinetics - metoclopramide)
bowel obstruction

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4
Q

Cx of high output stoma

A

Dehydration
Renal impair - low urine o/p
Electrolytes: HypoNa, HypoMg, HypoK (sec hyperald)
Undernutrition
Frequent stoma empty prob - leakage/ excoriation++

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5
Q

Mgx of high output stoma

A

rule out intra ab sepsis and IO. check med lists. check for enteritis.

Rehydration IV 0.9 NS. 
Restrict PO fluids to 500ml daily.
Restrict hypotonic soln
correct elec, strict fluid balance, daily weights, serum biochem - inc mg lvls
Anti diarrhoea - loperamide
Omeprazole to reduce gastric secretions

refer to dietician if suspect undernutrition

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6
Q

Aim of stoma

A

Decompress, Defunction, Drain

rest an inflammed distal portion

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7
Q

What is

  • rigler sign/ double wall sign
  • thumbprinting
  • lead pipe
  • pneumatosis intestinalis
  • claw sign
  • falciform ligament sign
A
  • pneumoperitoneum
  • bowel edema/ inflammation
  • loss of haustra, long standing ulcerative colitis
  • ischemic bowel w necrosis (gas gangrene)
  • intussusception
  • pneumoperitoneum
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8
Q

Hinchey classification and mgx

A

Classification of colonic perforation due to divertiticulosis

I: paracolonic abscess: IV fluid, abx, nbm KIV IR
II: pelvic abscess: IR, KIV sx for 1stage segmental colectomy with Pri anastomosis
III: purulent peritonitis
IV: feculent peritonitis
both - Hartman + sec re-anas 3 months later

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9
Q

Blood supply of rectum

A

upper 1/3: superior rectal artery (IMA)

mid and lower 1/3: int iliac artery

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10
Q

Dentate line - what is it and significance

A

aka pectinate line
separates upper 2/3 and lower 1/3 of anal canal (4cm)

distal margin of tumour must be 1-2cm above dentate line (7cm above anal verge) for sphincter conserving surgery of rectal CA

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11
Q

Cx of Rectal Sx

A

Immediate: damage to surrounding structures (ureter)

Early: stoma complications, anastomotic leak (free/ contained), bleed, infection

Late: stoma complications, tumour recurrence, anastomotic stricture, anterior resection syndrome (urinary and stool urgency, fecal incontinence), impotence

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12
Q

What is TME

A

Trans mesorectal excision
indicated for low anterior resection
reduces local recurrence rates

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13
Q

RF for CRC

A

Modifiable: smoking, alcohol, obesity, processed/ red meat

Non modifiable: age >50, male, Chinese, family history (age at diagnosis), CRC syndromes, HNPCC, previous polyps, colitis (UC, Crohns)
ask for scopes, scans, screenings

protective: fruits, veg, high fibre, vit supplements, exercise, HRT, aspirin, NSAIDs

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14
Q

HNPCC diagnosis

A

Amsterdam II Criteria
3 - 3 relatives with histo confirmed CRC or HNPCC related CAs (1 must be first deg relative with another)
2 - 2 consecutive generations
1 - 1 whose diagnosis <50yo

FAP excluded

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15
Q

Management of internal hemorrhoids

A

based on Banov staging
I: does not prolapse - lifestyle, daflon
II: prolapse, spontaneously reduce - lifestyle, daflon, elastic ligation
III: manual reduction of prolapse - above + hemorrhoidectomy (staple/ open)
IV: unable to reduce - same

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16
Q

Difference between internal and external haemorrhoids

A

Internal

  • above dentate line (endoderm)
  • porto venous system
  • prolapse, ulceration

External

  • below dentate line (ectoderm)
  • superficial venous system
  • thrombosis, mucus, pruritus, bleeding
  • causes more symptoms
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17
Q

Causes of haemorrhoids

A
  1. impaired venous return (e.g. high intra-abdominal pressure), low fibre diet, straining
  2. portal hypertension
  3. increased rectal vein pressure: prolonged sitting, obesity
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18
Q

Most common location of hemorrhoids

A

3, 7, 11 o’clock position

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19
Q

Acutely thombosed haemorrhoids mgx

A

<24h: surgical excision of thrombosis, wound left open

>48h: symptomatic support

20
Q

How to acutely reduce prolapsed hemorrhoid

A

gauze with lignocaine + cold water + dextrose soln (hyperosmolar solution)

21
Q

Complications of hemorrhoidectomy

A

ARU, UTI, sphincter damage, bleeding, infection, anal stenosis

22
Q

stoma siting principles

A
  • over rectus sheath (reduce prolapse
  • away from sx incision (reduce infx)
  • away from skin creases, bony prominences (red skin gaps > excoriation)
  • away from old sx scar (incisional hernia)
  • sited for easy accessibility (pt can care/reach)
  • low tension area during op (vascularity to prevent necrosis)
23
Q

Advice for anal fissures

A 
increased fibre 
lactulose
sitz baths
topical nifedipine ointment
GTN paste
botulinum toxoid injections
24
Q

What is the Goodsall rule for anal fistulas

A

For fistula within 3cm of the anal verge and posterior to line drawn through ischial spines if
o Anterior to transverse anal line: straight radially directed tract into anal canal
o Posterior to transverse anal line: curve tract open into anal canal midline posteriorly (at
level of dentate line) 6OC

25
Q

mgx of anal fistulas

A

based on Garg classification
I/II will benefit from fistulotomy
III-V will not

low fistula: fistulotomy and lay open/ fistulectomy
high fistula: seton

26
Q

Classification of bowel prep

A

Boston classification

27
Q

Cx of colectomy

A

immediate:
- damage to surrounding organs

Early:

  • anas leak (D4-7)
  • wound infx
  • bleeding
  • early stoma cx

Late: impotence, adhesions, anas strictures, diarrhoea, late stoma cx, anterior resection syndrome (urgency, fecal incontinence, frequency), tumour recurrence

28
Q

diff between high, low and ultraslow AR

A
  • High: anas above peritoneal reflection
  • Low: colon anastomosed to small anal rectal remains (below)
  • Ultra low: anas within 2cm of dendate line
29
Q

Margins for rectal ca sphincter sparing sx

A 
proximal 5cm
distal 
- 2cm if above distal mesolectal margin
- 1cm if at or below margin
radial: 1mm
30
Q

Cx of sphincter conserving sx and mgx

A

LARS syndrome

Fecal urgency, frequency, clustering, incontinence, emptying difficulties, increased intestinal gas (25-80%)

Mgx

  • kegel exercise
  • stoma enema & irrigation
  • tx as per LARS score
31
Q

Types of anal fistula

A

Park classification

  • intersphincteric
  • transphincteric
  • suprasphincteric
  • extraesphincteric
32
Q

Radiological signs of pneumoperitoneum

A
  • Rigler sign (adjacent side must not be bowel)
  • Falciform ligament sign
  • Football sign
  • Continuous diaphragm sign
33
Q

Ix of LGBIT

A 
colonoscopy (rates doesn't matter)
radionuclide imaging 0.1-0.5ml/min
- tagged RBC
- technetium sulphur colloid
CT angiography (0.3-0.5ml/min)
Mesenteric angiography (0.5-1ml/min)

last resort: laparotomy with saline lavage (on table angiogram)

  • oversew of bleeding vessel
  • colectomy
34
Q

CEA normal levels

- other causes of raised CEA?

A

n: 0-2.5
smokers: 0-5

what causes raised CEA: smoking, adjuvant therapy with 5FU, inflammatory states (pancreatitis, diverticulitis, cholecystitis) and cancers (stomach, lung, breast, pancreas, cervix, bladder, kidney)

35
Q

Bowel prep for colonoscopy

A

MEDS:

  • stop Fe tablet 5 day
  • stop anticoag
  • adjust insulin/ metformin
  • NSAIDs, aspirin can continue

DIET
- low residue > clear feed 1 day prior > NBM for 6-8h

PREP

  • evening 4L PEG OR
  • split dose (2L evening, 2L AM)

ADJUNCT: metoclopramide

36
Q

resection margins required for CRC

A

5cm proximally and distally

37
Q

Reconstruction options after colectomy for colon cancer

A

straight colonial anastomosis is a/w poor function - reservoir function

  • colonic J pouch (ileal pouch anal anastomosis)
  • coloplasty
38
Q

Extracolonic manifestations of FAP

A

Benign: ABCDE (adrenal glands, bony osteoma (of skull/ mandible), congenital hypertrophy of retinal pigment epithelium, desmoid tumors, epidermoid tumors)

Malignant: hepatoblastoma, thyroid Ca (follicular, papillary), brain tumour (medulloblastoma - CP angle turcot syndrome), pancreatic/ duodenal cancers

39
Q

Screening for colon cancer

  • normal risk
  • HNPCC
  • FAP
  • UC/ Crohns
A

-

40
Q

Cancers a/w HNPCC

A

colorectal, small bowel, gastric
endometrial, ovarian
hepatobiliary
urinary: renal pelvis, ureter cancers

41
Q

Indications for urostomy

A

bladder Ca, neuropathic bladder, resistant urinary incontinence

42
Q

RF for diverticulosis

A

i. Non modifiable: ADPKD pt on dialysis
ii. Modifiable
Red meat, low dietary fiber, high fat
lack of exercise, high BMI, smoking

43
Q

Meckel’s diverticulum features

A

Rule of 2s

  • 2 inches in length, 2cm wide
  • 2 feet from iliocecal valve
  • 2% of population
  • 2:1 male to female
  • 2-4% symptomatic
  • 2 types of ectopic tissue: gastric, pancreatic
44
Q

Cx of Meckel’s divert

A 
hematochezia
IO: intussusception, volvulus, little hernia, diverticulitis
Diverticulitis
Chronic peptic ulceration
perforation
tumour
umbilical fistula
45
Q

IX and Mgx of meckel

A

Ix: Meckel scan (find gastric mucosa), barium study, CT angio

Mgx:

  • asymptomatic: resect if seen during sx for young pts or adults <50 (with >2cm, large base >2cm, palpable)
  • do not resect in pt >50yo
  • symptomatic: sx
    > broad base: wedge ileal resection with anastomosis
    > narrow: resection of diverticulum
46
Q

main arterial supply of the colon

A

SMA (ileocecal, right colic, middle colic, appendiceal branches)
IMA (left colic, sigmoid and superior rectal branches)

47
Q

how do you assess bowel viability intra-operatively

A

give 100% O2 and warm packs to reverse any low flow rates

2 main techniques:
Visible light spectrophotometry (VLS)
Laser Doppler flowmetry (LDF)

MBBS Surgery (18 decks)

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