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Surgery > Colorectal > Flashcards

Colorectal Flashcards

1
Q

What are haemorrhoids and where are they located?

A

Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. They are mucosal cushions found in the left lateral, right posterior and right anterior portions of the anal canal – 3, 7 and 11 o’clock positions, respectively.

Haemorrhoids exist once they become enlarged, congested, and symptomatic.

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2
Q

How are haemorrhoids classified by their location?

A

Can be internal or external
External – originate below the dentate line, prone to thrombosis and are painful
Internal – originate above the dentate line and generally are not painful

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3
Q

How are haemorrhoids classified by their features?

A

Grade I – do not prolapse out of the anal canal
Grade II – prolapse on defecation but reduce spontaneously
Grade III – can be manually reduced
Grade IV – cannot be reduced

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4
Q

What clinical features do haemorrhoids present with?

A

Painless rectal bleeding seen on toilet paper and dripping into pan
May be history of straining and altered bowel habit
Importantly blood not mixed in with the stool
Pruritic
Pain – usually no significant unless piles are thrombosed
Soiling may occur as a result of 3rd or 4th degree piles

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5
Q

How should suspected haemorrhoids be investigated?

A

All patients presenting with anal bleeding should have a DRE and procto-sigmoidoscopy as a bare minimum
Routine bloods

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6
Q

How can haemorrhoids be managed?

A

Conservative
• Soften stool by increasing dietary fibre and water intake
• Topical local anaesthetic and steroid creams may be useful
Outpatient
• Rubber band ligation
• Injection sclerotherapy
Surgery (reserved for large symptomatic haemorrhoids not responding to the above)
• Haemorrhoidectomy
• Doppler guided haemorrhoidal artery ligation operation (HALO procedure)
• Stapled haemorrhoidopexy – may cause urgency as a side effect

Residual skin tags may be removed by surgical means if necessary, after haemorrhoid treatment.

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7
Q

How do acutely thrombosed haemorrhoids present

How are they managed?

A

Typically present with significant pain and a purplish, oedematous tender subcutaneous perianal mass. If presenting within 72 hours, then referral for excision should be considered. Otherwise manage conservatively with stool softeners, ice packs, topical GTN or diltiazem to reduce sphincter spasms and analgesia, symptoms should settle within 5-7 days.

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8
Q

What are anal fissures?

A

Longitudinal or elliptical tears of the squamous lining of the distal anal canal.

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9
Q

What are the risk factors for anal fissures?

A

Constipation
Inflammatory bowel disease
Sexually transmitted infections – especially HIV, syphilis and herpes

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10
Q

What are the clinical features of anal fissures?

A

Painful bright red rectal bleeding
90% occur on the posterior midline (if elsewhere consider underlying cause e.g. Crohn’s)
Chronic fissure triad – ulcer, sentinel pule and enlarged anal papillae

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11
Q

How should anal fissures be investigated?

A

All patients presenting with anal bleeding should have a DRE and procto-sigmoidoscopy as a bare minimum
Routine bloods

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12
Q

How are acute anal fissures managed?

A

Dietary advice – high fibres and high fluid intake
Bulk forming laxatives – if not tolerated then lactulose
Lubricants such as petroleum jelly prior to defecation
Topical anaesthetics
Analgesia

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13
Q

How are chronic anal fissures managed?

A

Continue management as for acute anal fissures
Topical glyceryl trinitrate first line for chronic anal fissures or diltiazem cream
If not effective after 8 weeks, then referral to secondary care for sphincterotomy or botulinum toxin.

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14
Q

What are anorectal abscess?

A

Definition – pus filled space adjacent to the anus. Very common in Crohn’s disease.

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15
Q

Where can anorectal abscess be located?

A
  • Perianal (most common)
  • Ischiorectal – found between the obturator internus muscles and external anal sphincter
  • Supralevator – infection tracks superiorly from the peri-sphincteric area to above the levator ani
  • Intersphincteric – rare and found between internal and external anal sphincters
  • Pelvirectal – horseshoe abscess found in the potential space between the coccyx and anal canal and can form as a complication of other anorectal abscess.
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16
Q

What organisms usually cause anorectal abscess?

A

E. Coli

Staphylococcus Aureus and MRSA

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17
Q

What underlying conditions can lead to anorectal abscess?

A

Inflammatory bowel disorders (especially Crohn’s)
Diabetes mellitus – effect on wound healing
Underlying malignancy

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18
Q

What are the clinical features of anorectal abscess?

A

Dull aching pain, worse when sitting down or just before defecation
Pain relieved after defecation
Feeling of hardened tissue in the anal region
Pus-like discharge from the anus

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19
Q

How should suspected anorectal abscess be investigated?

A

Good history and examination
To investigate the cause – colonoscopy and blood tests e.g. cultures and inflammatory markers
MRI and transperineal USS (gold standard) but these are rarely used
Must rule out haemorrhoids

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20
Q

How should anorectal abscess be managed?

A

Surgical incision and drainage under local anaesthetic. Wound is usually packed or left open but not stitched healing in around 3-4 weeks
Antibiotics only used if systemic sign of infection

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21
Q

What is a volvulus?

A

Torsion of the colon around its mesenteric axis resulting in compromised blood flow and closed loop obstruction.

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22
Q

Where are the most common locations for volvuli to occur?

A

Sigmoid is the most common location accounting for 80% of colonic volvuli, Caecal volvuli make up the other 20% and this usually occurs in people where developmental issues has resulted in their caecum not being retroperitoneal.

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23
Q

What are the risk factors for sigmoid volvulus?

A

Older patients
Chronic constipation
Chagas disease
Neurological conditions e.g. Parkinson’s disease and DMD
Psychiatric conditions such as schizophrenia

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24
Q

What are the risk factors for caecal volvulus?

A

All ages
Adhesions
Pregnancy

25
Q

What are the clinical features of volvuli?

A

Constipation
Abdominal bloating
Abdominal pain
Nausea and vomiting

26
Q

How should you investigate for a suspected volvuli?

A

Plain AXR – sigmoid should a coffee bean sign with large bowel obstruction, caecal volvulus shows small bowel obstruction

27
Q

How are sigmoid and caecal volvuli managed?

A

Sigmoid – rigid sigmoidoscopy with rectal tube insertion

Caecal – usually surgical management with a right hemicolectomy

28
Q

What is a stoma?

A

A stoma is a connection from the proximal bowel to the outside via the outside through a hole in the abdomen. The location of a stoma varies depending on what bowel is involved however the area should be marked and agreed with the patient to ensure they have the ability to access their stoma.

29
Q

What is the difference between a small bowel and large bowel stoma?

A

Small bowel stomas – spouted so irritant contents are not in contact with the skin
Colonic stomas – no need to be spouted as their contents are less irritant

30
Q

What can happen if a stoma leaks?

A

Leakage of a stoma and the subsequent maceration of the surrounding skin can rapidly progress into spiralling loss of control of stoma contents.

31
Q

What does an end -ostomy mean?

A

An end – ostomy means all bowel contents will enter out through the stoma

32
Q

What does a loop -ostomy mean?

A

A loop – ostomy means only the wall of the bowel has been brought out and some material may still pass distal to the stoma

33
Q

What is a percutaneous -ostomy mean?

A

Percutaneous – ostomy means a tube has been inserted through the abdominal wall into the jejunum.

34
Q

What are gastrostomies used for and where are they located?

A

Gastrostomy – used for gastric decompression or fixation and feeding – sited in the epigastrium

35
Q

What are loop jejunostomies used for and where are they located?

A

Loop jejunostomy – seldom used as very high output but may be used following emergency laparotomy with planned early closure – can be sited anywhere

36
Q

What are percutaneous jejunostomies used for and where are they located?

A

Percutaneous jejunostomy – performed for feeding purposes – sited in the left upper quadrant

37
Q

What are loop ileostomies used for and where are they located?

A

Loop ileostomy – defunctioning of colon such as following rectal cancer surgery – usually sited in right iliac fossa

38
Q

What are end ileostomies used for and where are they located?

A

End Ileostomy – following complete excision of the colon or where the ileocolic anastomosis is not planned – usually sited in the right iliac fossa

39
Q

What are end colostomies used for and where are they located?

A

End colostomy – colon is diverted or resected, and anastomosis is not primarily achievable or desirable – can be sited in either left or right iliac fossa

40
Q

What are loop colostomies used for and where are they located?

A

Loop colostomy – to defunction a distal segment of colon, distal lumen can act as a vent – may be sited in any region of the abdomen depending upon colonic segment used

41
Q

What are caecostomies used for and where are they located?

A

Caecostomy – stoma of last resort where loop colostomy is not possible – sited in the right iliac fossa

42
Q

What are mucous fistulas used for and where are they located?

A

Mucous fistula – to decompress a distal segment of bowel following colonic division or resection or where closure of a distal resection margin is not safe or achievable – may be sited in any region of the abdomen according to clinical need

43
Q

What determines how blood appear in lower GI bleeds?

A

Typically, colonic bleeding presents with bright or dark red blood as it has a powerful laxative effects and the small bowel enzymes are not present to digest the blood into malaena. If bleeding is right sided this will be darker in colour and on the right side it will present brighter.

44
Q

What can cause lower GI bleeding?

A 
Colitis 
Diverticular disease 
Cancer 
Haemorrhoidal bleeding 
Angiodysplasia
45
Q

How is lower GI bleeding investigated?

A

If haemorrhoidal bleeding suspected, then proctosigmoidoscopy is reasonable
If unstable – angiogram
If stable – colonoscopy in elective/outpatient setting
DRE

46
Q

How is a lower GI bleed managed in the acute setting?

A

ABCDE and correct haemodynamic instability
Patients with UC a significant bleeding then sub total colectomy should be done, especially is medical management is not effective
Selective mesenteric embolization if life threatening bleed

47
Q

What are the general indications for surgery in lower GI bleeding?

A

Patient > 60yrs
Continued bleeding despite endoscopic intervention
Recurrent bleeding
Known cardiovascular disease with poor response to hypotension

48
Q

What are perianal fistulas?

A

Abnormal connection between the anal canal and the perianal skin.

49
Q

What are the most common causes of perianal fistulas?

A

Most commonly a complication of ano-rectal abscess
Inflammatory bowel disease
Trauma
Radiation therapy
Systemic disease such as TB, diabetes or HIV

50
Q

What are the clinical features of perianal fistulas?

A

Recurrent perianal abscess
Discharge onto the peritoneum – mucus, blood, pus or faeces
Fibrous tract felt underneath the skin

51
Q

What is Goodsall rule regarding perianal fistulas?

A

Used clinically to predict trajectory of the fistula
• External opening posterior to the transverse anal line – fistula tract will follow a curved course to the posterior midline
• External opening anterior to the transverse line – fistula tract with follow a straight radial course to the dentate line

52
Q

How should perianal fistulas be investigated?

A

Proctoscopy to determine route

MRI if complex

53
Q

What is Park’s classification rules of perianal fistulas?

A 
Park’s classification rule 
•	Intersphincteric (most common)
•	Transphincteric
•	Suprasphincteric (least common)
•	Extrasphincteric.
54
Q

How are perianal fistulas managed?

A

If symptomless then conservative

Surgical
• Fistulotomy which involves laying open the fistula surgically
• Placement of a seton

55
Q

What is a pilonidal sinus?

A

Definition – formation of a sinus in the cleft of the buttocks most commonly affecting men aged 16-30. This occurs as a result of an infected hair follicle in the intergluteal the inflammation that follows results in a pit and a foreign body type reaction occurring.

56
Q

What are the risk factors for pilonidal sinuses?

A 
Caucasian 
Male 
Coarse dark body hair 
Sitting for long periods of time 
Obesity 
Poor hygiene
Local trauma
57
Q

What are the clinical features of pilonidal sinuses?

A

Discharging and intermittently painful sinus
Swelling and erythema
No communication with anal canal

58
Q

Why do pilonidal sinuses need to be investigated and how is this done?

A

If suspicious of perianal fistula is raised, then rigid sigmoidoscopy or MRI

59
Q

How are pilonidal sinuses managed?

A

Conservative – shaving area and plucking any embedded hair, if sinus is accessible then flushing
If acute or abscess present, then surgical incision and drainage with antibiotics
If chronic disease, then removal of the pilonidal sinus tract via excision of the tract and laying open of the wound allowing closure to secondary intention OR excision of the tract following by primary closure of the wound (higher recurrence rates)

Surgery (6 decks)

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