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Yr 3: CN2 > Colorectal I > Flashcards

Colorectal I Flashcards

1
Q
A
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2
Q

What’s a pneumonic for remembering the causes of small bowel obstruction?

A

“HANG IVs”

Hernias 2%
Adhesions (from previous surgery with formation of intra abdominal adhesions, commonly colorectal and gynaecological surgery)
Neoplasms (malignant, benign, primary or secondary) (5%)
Gallstone ileus
Intussusception
Volvulus
Strictures (eg Crohn’s disease (6%), ischaemia)

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3
Q

If surgery is indicated for SBO, patients should be given antibiotic prophylaxis of which antibiotics? [3]

A

cefoxitin, or ampicillin plus gentamicin

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4
Q

What is A?

Anal abscess
Anal fissure
Haemorrhoid
Anal fistula

A

What is A?

Anal abscess
Anal fissure
Haemorrhoid
Anal fistula

An anal fissure is a superficial tear in the skin distal to the dentate line

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5
Q

What does the following best describe?

abnormal tunnel under the skin that connects the anal canal in the colon to the skin of the buttocks

Anal abscess
Anal fissure
Haemorrhoid
Anal fistula

A

What does the following best describe?

abnormal tunnel under the skin that connects the anal canal in the colon to the skin of the buttocks

Anal abscess
Anal fissure
Haemorrhoid
Anal fistula

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6
Q

Describe the treatment algorithm for acute fissures

A

1st line: soften stool
- high fibre intak
- Bulk forming laxatives
- lubricants like petroleum jelly

2nd line:
- Glyceryl trinitrate

3rd line:
- topical diltiazem (if headaches from glyceryl trinitrate are too much)

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7
Q

Describe the treatment algorithm for chronic anal fissures [3]

A

topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure

Botulinum toxin or sphincterotomy is used after failure of topical treatment for 8 weeks

sphincterotomy:
The operation usually takes about 15 minutes. Your surgeon will make a small cut on the skin near your back passage. They will cut the lower part of the internal sphincter muscle. This will relieve the spasm in the sphincter, allowing a better blood supply to heal the fissure.

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8
Q

almost all diverticula are found in the []

A

almost all diverticula are found in the sigmoid colon

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9
Q

Describe two symptoms of complications of diverticulitis [2]

A

pneumaturia or faecaluria may suggest a colovesical fistula
vaginal passage of faeces or flatus may suggest a colovaginal fistula

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10
Q

What might an AXR show in diverticulosis? [3]

A

AXR: may show dilated bowel loops, obstruction or abscesses

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11
Q

Describe the treatment regime for diverticulitis? [4]

A

mild cases of acute diverticulitis may be managed with oral antibiotics, liquid diet and analgesia CKS

dicycloverine: antispasmodic

if the symptoms don’t settle within 72 hours, or the patient initially presents with more severe symptoms, the patient should be admitted to hospital for IV antibiotics

Consider open or laparoscopic resection for patients who have recovered from complicated acute diverticulitis but have continuing symptoms (such as stricture or fistula)

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12
Q

What is the name for the staging criteria of colorectal cancer? [1]
Describe each stage [4]

A

Duke’s classification

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13
Q

Describe the adjuvant chemotherapy given for colorectal cancer: [2]

Describe the biologicals used [3]

A

Dukes B if poor prognositic factors

Dukes C:
- Fluorouracil (5-FU)
- Capecitabine (first line)

Biologicals:
- Cetuximab (anti-EGFR)
- Panitumubab (anti-EGFR)
- Bevacizumab (anti-VEGF)

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14
Q

State 4 reasons why get referred to the two week cancer pathway for colorectal cancers [5]

A

Positive FIT test
Over 40 years with abdominal pain and unexplained weight loss
Over 50 years with unexplained rectal bleeding
Over 60 years with a change in bowel habit or iron deficiency anaemia
Any age with rectal or abdominal mass

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15
Q

What is the FOLFOX regime of treating colorectal cancer? [3]

A

Chemotherapy regime of:
* 5-FU
* Folinic acid
* Oxaliplatin

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16
Q

Which of the following involves removing the sigmoid colon and upper rectum but sparing the lower rectum and anus?

Hartmann’s procedure
High anterior resection
Left hemicolectomy
Low anterior resection
Right hemicolectomy

A

Which of the following involves removing the sigmoid colon and upper rectum but sparing the lower rectum and anus?

Hartmann’s procedure
High anterior resection
Left hemicolectomy
Low anterior resection
Right hemicolectomy

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17
Q

Describe the topical treatments used for haemorrhoids? [3]

A

Anusol:
- Chemicals used to shrink

Anusol HC
- As above but with hydrocortisone

Germoloids:
- Lidocaine

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18
Q

Describe the non-surgical treatments used for haemorrhoids? [4]

A

Rubber band ligation
Injection sclerotherapy
IR coagulation
Bipolar diathermy

PassMed: outpatient treatments: rubber band ligation is superior to injection sclerotherapy

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19
Q

What are the surgical treatment options for haemorrhoids? [4]

A

Surgical haemorrhoidectomy
Haemorrhoid artery ligation
Staple haemorrhoidectomy

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20
Q
  1. A 45-year-old man presents with a carcinoma 10cm from the anal verge, he has completed a long course of chemoradiotherapy and has achieved downstaging with no evidence of threatened circumferential margin on MRI scanning.

What is the most appropriate colonic resction for this patient?

A

Anterior resection with covering loop ileostomy
- ‘carcinoma 10cm from the anal verge’ implies that the anus is unaffected by the cancer. Abdominal-perineal excision of rectum is only used when the anus is involved.

Low rectal cancer is usually treated with a low anterior resection. Contraindications to this include involvement of the sphincters (unlikely here) and poor sphincter function that would lead to unsatisfactory function post resection. Most colorectal surgeons defunction resections below the peritoneal reflection as they have an intrinsically high risk of anastomotic leak. A loop ileostomy provides a safe an satisfactory method of defunctioning these patients. A contrast enema should be performed prior to stoma reversal.

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21
Q

After testing, he is found to be a carrier of the MSH2 gene and is subsequently diagnosed with HNPCC.

Aside from colorectal cancer, which of the following is the patient at greatest risk of developing?

Endometrial cancer
Lung cancer
Medulloblastoma
Pancreatic cancer
Thyroid cancer

A

After testing, he is found to be a carrier of the MSH2 gene and is subsequently diagnosed with HNPCC.

Aside from colorectal cancer, which of the following is the patient at greatest risk of developing?

Endometrial cancer
Lung cancer
Medulloblastoma
Pancreatic cancer
Thyroid cancer

HNPCC is associated with an increased risk of endometrial cancer, however this patient is male.

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22
Q

A fistula is defined as an abnormal connection between two epithelial surfaces.

What are the two most common causes of fistulae? [2]

A

diverticular disease and Crohn’s.

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23
Q

Describe how you treat fistulae if:
- No IBD or distal obstruction? [1]
- High-output is excessive? [2]
- Secondary to Crohns? [1]

A

No IBD or distal obstruction: Conservative management
- High-output is excessive: octreotide (reduces pancreatic secretions); TPN
- Secondary to Crohns: drain acute sepsis; seton placement

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24
Q

Low rectal cancer is usually treated with [] surgery.

How do you adapt ^ to avoid the high risk of anastomotic leak? [1]

What is the contraindication to this? [1]

A

Low rectal cancer is usually treated with a low anterior resection
- Contraindications to this include involvement of the sphincters
- Most colorectal surgeons defunction resections below the peritoneal reflection as they have an intrinsically high risk of anastomotic leak. A loop ileostomy provides a safe an satisfactory method of defunctioning these patients

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25
Q

What type of stoma is this? [1]

A

Loop stoma

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26
Q

What type of stoma is this? [1]
Label which of A & B is the proximal and distal part [2]

A

Double barrel stoma
A: Proximal
B: Distal

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27
Q

Physiological complications of high output ileostomy? [2]

A

○ > 1.5 - 2 litres

○ Fluid & Electrolyte imbalance
■ Dehydration, AKI
■ ↓Na, ↑K, ↓Mg (Addison’s picture)
■ Vitamin B12, Folate Def.}}

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28
Q

Problems associated with low volume ileostomy? [2]

A

● Low Volume (↓frequency & or quantity)
○ Stenosis
○ Impending obstruction}

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29
Q

Treatment for high output stomas? [5]

A

● Hydrate (fluid and high salt replacement)
○ Glucose-electrolyte solution aids sodium absorption
○ Restrict low sodium (Hypotonic) fluid (500-1000ml/day)

● Anti-diarrhoeal medication, eg loperamide

● Anti-secretory drugs
○ PPI (omeprazole) ○ Octreotride (rarely)

● Correct Hypomagnesaemia

● Opiates (codeine phosphate)

30
Q

Define what is meant by a parasternal hernia [1]

A

Parastomal hernia is a type of incisional hernia occurring in abdominal integuments in the vicinity of a stoma, i.e. a condition wherein abdominal contents, typically the bowel or greater omentum, protrude through abdominal integuments surrounded by the hernia sac at the location of formed stoma

31
Q

What are the NICE guidelines on what makes patients with colorectals adenomas low, intermediate and high risk? [3]
How often should low, intermediate and high risk colorectal adenoma patients be offered colonoscopies? [3]

A

Classification of risk and advised management in patients with colorectal adenomas are as follows:

Low risk
- one or two adenomas smaller than 10 mm
- should be considered for colonoscopy at five years

Intermediate risk
- three/four adenomas smaller than 10 mm
or
- one/two adenomas if one is 10 mm or larger
- should be offered a colonoscopy at three years

High risk
- five or more adenomas smaller than 10 mm
or
- three or more adenomas if one is 10 mm or larger
- offered a colonoscopy at one year.

32
Q

Define what is meant by a Pantaloon hernia [1]

A

A pantaloon hernia, also known as a saddlebag hernia, is defined as any combination of two adjacent hernia sacs of the femoral or inguinal region (direct or indirect inguinal hernias (alternative plural: herniae)) on the same side

Thus, examples include: femoral with direct hernias, femoral with indirect hernias, indirect with direct hernias.

33
Q

Describe the management of uncomplicated hernia [4]

A

Surgery:
Open mesh repair:
- Direct hernia: plication
- Indirect: sac excision
- Both: add mesh which produces fibrosis

Laporoscopic mesh repair:
- As above, but reduced injury of nerves & post-op chronic pain
- Reinforces wall to elimiante reoccurence

Laporoscopic pre-peritoneal mesh repair

Suture repair (high chance of reoccurance

PassMed:
Primary unilateral/ bilateral hernia:
* Mesh repair(Lichtenstein’s or endoscopic repair), the mesh repair uses polypropylene mesh to reinforce the posterior wall. A recurrence rate of 2-10% for both procedures.

Recurrent inguinal hernia:
* If previous anterior hernia repair: open preperitoneal mesh or endoscopic approach
* If previous posterior hernia repair: Lichtenstein’s totally extraperitoneal (TEP). A minimally invasive procedure where the mesh is used to seal the hernia from outside the peritoneum.

34
Q

Describe the method used to test for indirect inguinal hernia c.f. direct [2]

A

To test for indirect inguinal hernias:
- finger pressure should be applied over the deep inguinal ring. The finger pressure will control the hernia when the patient coughs.

To test for direct hernias:
- instruct the patient to cough, and a bulge should appear medial to point of finger pressure.
- If a hernia reappears it is more likely to be a direct inguinal hernia whereas if it does not, it is more likely to be an indirect inguinal hernia.

35
Q

What is the surgical procedure for recurrent inguinal hernia:
- If previous anterior hernia repair? [1]
- If previous posterior hernia repair? [1]

A

If previous anterior hernia repair:
- open preperitoneal mesh or endoscopic approach

If previous posterior hernia repair:
- Lichtenstein’s totally extraperitoneal (TEP). A minimally invasive procedure where the mesh is used to seal the hernia from outside the peritoneum.

36
Q

If a hernia cannot be reduced it is referred to as an [] hernia - these are typically [painful / painless]

A

If a hernia cannot be reduced it is referred to as an incarcerated hernia - these are typically painless

37
Q

Describe the medical and surgical management for hiatus hernias [2]

A

medical management: proton pump inhibitor therapy
surgical management: only really has a role in symptomatic paraesophageal hernias

38
Q

Which type of repair is best suited for unilateral [1] and bilateral or recurrent inguinal hernias [1]?

A

unilateral inguinal hernias are generally repaired with an open approach
bilateral and recurrent inguinal hernias are generally repaired laparoscopically

39
Q

Label E & F
What type of surgeries would they be used for? [1]

A

E: Battle
F: Lanz

Both for open appendicectomy

40
Q

Label B [1]

What is the indication for B? [1]

A

Rooftop scar: Liver transplant

41
Q

Label A [1]
What would indicate A? [1]

A

Kocher scar: open cholecystectomy

42
Q

How long before an operation should stop the pill? [1]

A

4 weeks

43
Q
A
44
Q

Post-op N&V can be treated using which three drugs? [3]

Name their side effects

A

Ondansetron:
- Long QT

Prochlorperazine:
- Parkinsons

Cyclizine:
HF

45
Q

How much glucose [1], Na, Cl and K [1] and water should be given a day? [3]

A

Glucose: 50-100g per day
Na K Cl: 1mmol/kg/day
Water: 25-30ml/kg/day

46
Q

Name [1] and describe the classification used for PAD [4]

A

Fontaine classification

47
Q

Describe the surgical treament options for PAD [3]

A

Angioplasty:
- inserting a catheter through the arterial system under x-ray guidance
- at the site of the stenosis, a balloon is inflated to create space in the lumen. A stent is can be ( but not always) inserted to keep the artery open

Endarterectomy
- cutting the vessel open and removing the atheromatous plaque

Bypass surgery
- using a graft to bypass the blockage
- may have to remove valve in a vein
- can use prosthetic graft if needed (Goretex / PTFE)
- veins last longer that prosthetic grafts}

48
Q

How do you manage acute limb ischaemia? [6]

A

Acute emergency!

Endovascular thrombolysis:
- inserting a catheter through the arterial system to apply thrombolysis directly into the clot

Endovascular thrombectomy:
- inserting a catheter through the arterial system and removing the thrombus by aspiration or mechanical devices

Surgical thrombectomy
- cutting open the vessel and removing the thrombus

Endarterectomy
Bypass surgery

Amputation of the limb if it is not possible to restore the blood supply

49
Q

Describe the surgical procedures used to treat AAA [2]

A

Open AAA surgery:
- cross clamp the AA above & below aneursym
- open aneursym and remove clot
- stitch in graft

Endovascular aneurysm repair (EVAR)
- A wire is passed under fluoroscopic guidance through the aneurysm sac and a stent-graft is inserted to occlude the aneurysm from the inside
- local anaesthetic

50
Q

Describe the clinical complications of varicose veins [10]

A

1. Swelling at ankles

2. Discomfort

3. Itching

4. Varicose eczema

6. Lipodermatosclerosis

7. Bleeding

8. Ulceration: high pressure clip off arterioles supplying oxygen to the skin in the extremities, leading to itchiness and dryness of the skin. If people itch the skin, they can break down and become an ulcer.

9. Haemosiderin: rbc red cells leaking out of insufficient veins that breaks down and Hb breaks down and becomes oxidised

10. Thrombophlebitis: inflammation of the superficial veins of the legs; constant pain that causes it to be hard, and painful

51
Q

Describe the conservative [1], medical [1] and surgical [3] treatment of varicose veins

A

Conservative:
- Leg elevation
- Class 1/2 compression hosiery
- Weight loss

Medical:
- Topical relief for thrombophlebitis

Surgical:
- Endothermal ablation – inserting a catheter into the vein to apply radiofrequency ablation
- Foam sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein
- Stripping – the veins are ligated and pulled out of the leg}

52
Q

Dukes Classification of colorectal cancer:
What are the 4 stages? [4]

A

T1 and T2 is when the tumour is still within the mucosal wall.

53
Q

What is the surgical plan for treating symptomatic
- Direct inguinal hernia
- Strangulated hernia

A

Direct inguinal hernia:
- Open mesh repair

Strangulated hernia:
- Open non-mesh repair

NB: asymompatic hernia tx: watchful waiting & 6 month follow up

54
Q

Which drug is often prescribed post Milligan Morgan style conventional haemorroidectomy to reduce pain? [1]

A

metronidazole

55
Q

how would you treat haemorrhoids if there are more marked symptoms of bleeding and occasional prolapse, where the haemorroidal complex is largely internal? [1]

A

stapled haemorroidopexy
- excises rectal tissue above the dentate line and disrupts the haemorroidal blood supply
- At the same time the excisional component of the procedure means that the haemorroids are less prone to prolapse

56
Q

Name and describe the treatment for Large haemorroids with a substantial external component? [1]

A

Large haemorroids with a substantial external component may be best managed with a Milligan Morgan style conventional haemorroidectomy.
- three haemorroidal cushions are excised, together with their vascular pedicle.

57
Q

What is the treatment for large, external haemorrhoids?

stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy

A

What is the treatment for large, external haemorrhoids?

stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy

58
Q

What is the definitive treatment for fissure in ano?
stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy

A

What is the definitive treatment for fissure in ano?

stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy

59
Q

What is the usual first line therapy for fissure in ano?

stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy

A

What is the usual first line therapy for fissure in ano?

stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy

60
Q

What is the usual third line therapy for fissure in ano?

stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy

A

What is the usual third line therapy for fissure in ano?

stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy

61
Q

What is the usual second line therapy for haemorrhoids?

stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy

A

What is the usual second line therapy for haemorrhoids?

stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy

62
Q

Treatment failures which fail topical therapy will usually go on to have what treatment fpr fissure in ano?

stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy

A

Treatment failures which fail topical therapy will usually go on to have what treatment fpr fissure in ano?

stapled haemorroidopexy
botulinum toxin
lateral internal sphincterotomy
topical GTN or diltiazem
Milligan Morgan style conventional haemorroidectomy

63
Q

What is the scar called? [1]
Whats the indication? [1]

A

Rutherford Morison

64
Q

This type of scar is used for a open cholecystectomy

Rutherford Morrison
Lanz
Kocher
Hockey-Stick
Chevron
Gridiron
Pfannenstiel

A

This type of scar is used for a open cholecystectomy

Rutherford Morrison
Lanz
Kocher
Hockey-Stick
Chevron
Gridiron
Pfannenstiel

64
Q

Label A-C

A

The gridiron and lanz incisions are muscle-splitting incisions which are the incisions of choice for open appendicectomy.

They differ in the orientation of the skin incision alone. The gridiron incision can be more readily extended laterally into an oblique, curvilinear muscle-cutting incision: the Rutherford Morison.

65
Q

This type of scar is A

Rutherford Morrison
Lanz
Kocher
Hockey-Stick
Chevron
Gridiron
Pfannenstiel

A

This type of scar is A

Rutherford Morrison
Lanz
Kocher
Hockey-Stick
Chevron
Gridiron
Pfannenstiel

66
Q

This type of scar is B

Rutherford Morrison
Lanz
Kocher
Hockey-Stick
Chevron
Gridiron
Pfannenstiel

A

This type of scar is B

Rutherford Morrison
Lanz
Kocher
Hockey-Stick
Chevron
Gridiron
Pfannenstiel

67
Q

This type of incision could be used for an adrenalectomy

Rutherford Morrison
Lanz
Kocher
Hockey-Stick
Chevron
Gridiron
Pfannenstiel

A

This type of incision could be used for an adrenalectomy

Rutherford Morrison
Lanz
Kocher
Hockey-Stick
Chevron - aka rooftop
Gridiron
Pfannenstiel

68
Q

This type of incision could be used for kidney transplant

Rutherford Morrison
Lanz
Kocher
Hockey-Stick
Chevron
Gridiron
Pfannenstiel

A

This type of incision could be used for kidney transplant

Rutherford Morrison
Lanz
Kocher
Hockey-Stick
Chevron
Gridiron
Pfannenstiel

69
Q
A

Yr 3: CN2 (29 decks)

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