Colorectal Surgery Flashcards
Right iliac fossa mass differentials
Appendix msss / abscess Caecal carcinoma Pelic mass Crohns disease Intussusception Transplanted kidney
Causes of abdominal distension
Flats Fat Fluid Faeces Fetus
Causes of ascites
Malignancy Infection - TB Decreased albumin Pancreatitis Myxoedema
Cirrhosis
Budd-chiari syndrome - a condition in which the hepatic veins (veins that drain the liver) are blocked or narrowed by a clot
Portal vein thrombosis
Presentation of appendicitis
Anorexia
Abdominal pain, vomiting
Abdo pain initially colicky, starts centrally then moves to RIF
RIF peritonism
Fever usually mild. If high = perforation or abscess
What is McBurneys point?
1/3 of the way from ASIS to umbilicus
If tenderness - suggestive of appendicitis
What is Rovsing’s sign?
RIF pain on pressing LIF
Suggestive of appendicitis
What is psoas sign?
Pain on extending the hip (if retrocaecal appendix)
What is cope sign?
Pain on flexion and internal rotation of the right hip - suggestive of appendicitis
How might appendicitis present in children?
Vague abdominal pain and child won’t eat
Investigations of appendicitis
Diagnosis usually clinical Bloods - raised WCC and CRP Urine - may contain WBCs Abdo-pelvic CT goof but often not required US acceptable alternative
Managment of acute appendicitis
Surgery - appendectomy is definitive (laparoscopic ideal)
Abx - 1hr pre-op and 24hrs after (pip/taz)
AXR signs of SBO
Dilated bowel - lines going all the way across (valvulae conniventes)
AXR signs of LBO
Dilated bowel - lines don’t go all the way through
AXR signs of sigmoid volvulus
Coffee bean sign (As the closed loop of the sigmoid colon distends with gas, apposition of the medial walls of the dilated bowel form the cleft of the coffee bean, while the lateral walls of the dilated bowel form the outer walls of the bean). closed loop = two points blocked in a loop
What is rigler’s sign?
Can see both sides of the bowel wall on an AXR. Sign of free air in the abdomen
Clinical features of bowel obstruction
Vomiting
Nausea and anorexia
Colic occurs early
Constipation (may be absolute in distal obstruction)
Abdominal distension
Active tinkling bowel sounds (silent in ileus)
What is an ileus?
Where bowel doesn’t contract
Common causes of bowel obstruction
SBO - ADHESIONS, hernias
LBO - COLON Ca, diverticulitis disease, volvulus
Management of bowel obstruction
Ileus and incomplete SBO can be managed conservatively
Drip and suck- IV fluids and NGT to empty stomach
Analgesia
Abc if perforation or surgery planned
DVT prophylaxis
Bloods - FBC, U+E, amylase
AXR, erect CXR
CT - FOR CAUSE
Surgery - strangulation, large BO,
Endoscopic stenting - LBO malignancy or in palliative
Risk factors for colorectal cancer
Polyps IBD genetic predisposition Smoking Alcohol Previous cancer Diet - low fibre and processed red meat
First and last section of large bowel (before rectum)
Caecum
Sigmoid
Presentation of colorectal cancer
LEFT-SIDED: Bleeding PR / mucus Altered bowel habit Obstruction Mass on PR
RIGHT-SIDED:
decreased weight
Anaemia
Abdo pain
Surgery for caecal, ascending or proximal transverse colorectal tumours
Right hemicolectomy
Surgery for distal transverse and descending colon tumours
Left hemicolectomy
Surgery for low sigmoid or high rectal tumours
Anterior resection - a surgical procedure to remove the diseased portion of your bowel and rectum (back passage). When possible, your surgeon will join the healthy ends of your bowel with stitches or staples.
Surgery for tumours low in the rectum (<9cm from anus)
Abdomino-perineal resection - The end of the remaining sigmoid colon is brought out permanently as an opening, called a colostomy, on the surface of the abdomen. Can be done laparoscopically.
AF with acute abdominal pain = suspect what?
Acute mesenteric ischaemia
What is acute mesenteric ischaemia?
Syndrome caused by inadequate blood flow through mesenteric vessels.
Almost always involves small bowel
Follows SMA
Thrombus, embolism is cause or non-occlusive disease
Presentation of acute mesenteric ischaemia
Classic triad - acute abdo pain, no/minimal abdo signs, rapid hypovolaemia
Pain constant, central or around RIF
Management of acute mesenteric ischaemia
Fluid resus Abx (pip/taz) Herparin/LMWH required Consider thrombolytics Surgery - dead bowel removed and revascularise viable bowel
Anal fissure presentation
Risk factors - constipation, IBD, sexuallh transmitted infections
Features - painful bright red rectal bleeding
90% occur on the posterior midline
Management of anal fissures
Acute (<1)
Soften stool
- dietary advice - fibre, high fluid intake
- bulk-forming laxatives - first line (lactulose)
- lubricants - petroleum jelly may be tried before defecation
- topical anaesthetics
- analgesia
Chronic
- all of the above
- topical GTN first line
- if not effective after 8 weeks- consider surgery (sphincterotomy) or botulinin
Complication of haemorrhoids
Thrombosed heamorrhoid
- significant pain and a tender lump
- purplish, oefematous tender subcutaneoud perinatal mass
- if presents within 72 hours- referral for excision otherwise can be managed with stool softeners, ice packs and analgesia. Symtpoms usually settle within 10 days
What is a harrmanns procedure?
Resection of the sigmoid colon, an end colostomy is fashioned
Often used in emergency situations
Diverticulitis management
Abx - co-amoxiclav
observation
Analgesia (avoiding nsaids and opiates)
Fluids
Management of sigmoid volvulus
Decompression via rigid sigmpidoscopy flats tube insertion
Management of caecal volvus
Usually operative
Right hemicolextomy is often needed
