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CORE SURG > colorectal surgery > Flashcards

colorectal surgery Flashcards

1
Q

what is rosvings sign?

A

Palpation of LIF causes pain in RIF (appendicitis)

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2
Q

what is psoas sign?

A

discomfort upon hyperextension of right hip indicating inflamed retroperitineal, retrocecal appendix

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3
Q

what is obturator sign?

A

pain in RIF from flexing and internally rotating the hip - usually seen in pelvic appencitis

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4
Q

pathophys of diverticulosis?

A
  • increased intraluminal pressure resulting in herniation of the mucosa through the muscularis layer
  • typically at the entry point of the arterioles
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5
Q

is diverticular bleeding painful?

A

no - painless

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6
Q

presentation of diverticular bleed?

A

-painless, large volume, bright red blood per rectum

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7
Q

Complications of diverticulosis

A
  • pericolic and paracolic abscess
  • peritinitis
  • diverticular fistula
  • stricture formation
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8
Q

what is hinchey classification for?

A

acute diverticulitis

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9
Q

hinchey classification IA

A

paracolic phlegmon

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10
Q

hinchey classification IB

A

pericolic/mesenteric abscess

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11
Q

hinchey classification II

A

diverticulitis with walled-off abscess

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12
Q

hinchey classification III

A

purulent peritinitis

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13
Q

hinchey classification IV

A

feaculent peritinitis

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14
Q

MEDICAL management of diverticulitis

A
  • IV antibiotics
  • bowel rest, supportive managment, IV fluid therapy and analgesia
  • radiologically guided drainage of abscess
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15
Q

SURGICAL management of acute diverticulitis

A
  • laparoscopy and washout

- resection of diseased bowel (Hartmanns procedure_

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16
Q

Hartmanns procedure

A

resection of sigmoid with proximal colostomy

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17
Q

what are the polyposis syndromes?

A
  • FAP
  • HNPCC
  • juvenile polyposis
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18
Q

risk factors for colorectal cancer?

A
  • polyposis syndrome
  • family history
  • smoking
  • ulcerative colitis or crohns
  • diet poor in fruit and vegetables
  • obesity
  • smoking, heavy alcohol use, T2DM
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19
Q

what are the three histologies of polyps?

A
  • tubular adenomas
  • villous adenomas
  • tubulo-villous adenomas
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20
Q

which type of polyp has the highest risk of becoming malignant?

A

villous

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21
Q

where is most colorectal cancer?

A

descending and sigmoid colon

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22
Q

presentation of right sided colorectal cancer?

A

Iron deficiency anemia

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23
Q

presentation of left sided colorectal cancer?

A

PR bleeding, mixed with stool

Change in bowel habit

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24
Q

presentation of distal colon cancer?

A
  • PR bleeding

- tenesmus - difficult, painful defecation, sensation of incomplete evacuation

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25
Q

40% of colorectal carcinomas will present as…

A

large bowel obstruction

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26
Q

what is the name of the classifaction system for bowel cancer?

A

DUKES

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27
Q

Dukes classification

A

A- confined to bowel wall
B- through bowel wall
C-positive lymph nodes
D-metastasis

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28
Q

TNM staging of colon cancer. T ?

A 
Tumour
T1 - invades submucosa
T2 - invades muscularis propria
T3 - invades through muscularis propria 
T4 -invades visceral peritineum
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29
Q

TNM staging of colon cancer. N?

A

Nodes
N1- no lymph invasion
N2- 1-3 nodes
N3- 4+ lymph nodes

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30
Q

TNM staging of colon cancer. M?

A

M0 - no distant metastasis

M1 - distant metastasis

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31
Q

what are the types of bowel obstruction?

A

large bowel obstruction or small bowel obstruction

complete or incomplete

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32
Q

what is ileus?

A

the hypomobility of the GI tract in the absence of a mechanical obstruction

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33
Q

what is closed loop obstruction?

A

when the bowel (usually small bowel) is obstructed at two ends -> rapidly progresses to ischemia, necrosis and perforation

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34
Q

symptoms of bowel obstruction?

A
  • pain
  • obstipation (cant pass gas)
  • vomiting
  • abdominal distention
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35
Q

signs of bowel obstruction?

A
  • distention
  • tenderness
  • rigidity/guarding
  • high pitch/lack of bowel sounds
  • DRE - empty rectum
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36
Q

Common aetiologies of SBO?

A
  • strictures (crohns, radiation)
  • adhesions
  • hernias
  • malignancy
  • intussusception
  • meckels diverticulum
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37
Q

common aetiologics of LBO?

A
  • colon cancer
  • hernias
  • diverticulitis
  • volvulus
  • intussusception
  • stricture
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38
Q

what is superior mesenteric artery syndrome?

A

when the duodenum is compressed between the SMA and aorta

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39
Q

what do you look for on a plain film abdominal xray in regards to bowel obstruction?

A
  • dilation
  • air fluid levels
  • 3,6,9 rule
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40
Q

what is the 3,6,9 rule?

A
  • small bowel should be 3 cm or less, large bowel should be 6 or less, cecum should be 9 or less
  • Larger may suggest bowel obstruction
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41
Q

management of bowel obstruction

A
  • begin IV fluids
  • insert wide bore NG tube - decompress then leave on free drainage
  • analgesia, urinary catheter, I/O chart
  • manage electrolytes
  • further management depends on cause
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42
Q

treatment of volvulus

A

colonoscopy and pneumatic decompression

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43
Q

what type of muscle makes up the internal sphinctor of the anus?

A

circular, non-striated, involuntary, supplied by autonomic nerves

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44
Q

what type of muscle makes up the external sphinctor of the anus?

A

striated, voluntary muscle supplied by pudenal nerve

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45
Q

epithelial lining of the anal canal?

A

upper 2/3 - columnar

lower 1/3 - squamous epithelium

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46
Q

blood supply to anal canal?

A

upper 2/3 - superior rectal artery from IMA

lower 1/3 - inferior rectal artery from pudendal

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47
Q

lymph drainage of the anal canal?

A

upper 2/3 - internal iliac lymph nodes

lower 1/3 - inguinal lymph nodes

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48
Q

internal hemorhoids are above the….

A

dentate line

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49
Q

risk factors for hemorhoids?

A
  • poor dietary habits and constipation
  • prolonged straining
  • increased abdominal pressure (pregnancy)
50
Q

what are the four degrees of internal hemorhoids?

A

I - dont prolapse below the dentate line
II - prolapse below dentate line but reduce spontaneously
III - prolapse and can be reduced manually
IV - permanently prolapsed and may strangulate

51
Q

examinations/ix for hemorhoids?

A
  • DRE
  • proctoscopy
  • consider sigmoidoscopy to rule out rectal/colonic pathology
52
Q

Management of hemorhoids?

A
  • avoid straining/lingering on toilet
  • increase fiber and physical activity
  • sitz baths
  • injection sclerotherapy
  • rubber band ligation
  • transanal hemorhoid dearterialisation
53
Q

indications for operative treatment of hemorhoid?

A
  • 3rd or 4th degree hemorhoids
  • second degree hemorhoids that havent been cured by non operative measures
  • fibrosed hemorhoids
54
Q

should patients with rectal bleeding be referred for colonoscopy even if its highly suggestive of hemorhoids?

A

yes

55
Q

primary vs secondary anal fissure?

A

primary - from trauma, secondary - from disease (IBD, malignany, etc)

56
Q

acute vs chronic anal fissure?

A

ACUTE - <6 weeks old

CHRONIC - over 6 weeks or features showing fibrosis, fibrotic edges, perianal skin tag

57
Q

what is a fistula?

A

chronic abnormal connection between two epithelial lined surfaces

58
Q

clinical features of an anorectal fistula?

A
  • intermitten rectal pain
  • chronic purulent discharge and lesion in perianal or buttock region
  • intermittent and malodorous discharge
  • pruritis
59
Q

diagnosis of pilonodal sinus?

A

clinical

60
Q

treatment of a pilonodal sinus?

A

skin hygeine and hair exfoliation

61
Q

If someone presents acutely with a pilonodal abscess, whats the treatment?

A

incision and drainage

-secondary incision later to remove sinus tract

62
Q

Risk factors for anal cancer?

A
  • female
  • infection with HPV 16 18
  • receptor of anal sex
  • smoking
  • higher number of sexual partners
  • history of anorectal condyloma
  • HIV
63
Q

what is anal intraepithelial neoplasia?

A

-precursor to invasive squamous anal carcinoma

64
Q

AIN III aka…

A

bowens disease

65
Q

what are the two types of cancers in the anal region?

A

Anal canal cancers - tumours that develop from the anal mucosa
Perianal/anal margin cancers - tumours that arise within the skin distal to the squamo mucocutaneous junction

66
Q

lymphatic drainage of anal tumours above the dentate line?

A

perirectal and paravertebral nodes

67
Q

lymphatic drainage of anal tumours below the dentate line?

A

superficial inguinal nodes and femoral nodes

68
Q

what is a loop ileostomy?

A
  • loop of ileum in RIF, with 2 lumens

- one lumen is active and spouted

69
Q

what are the contents of a loop ileostomy?

A

liquid or soft effluence

70
Q

is a loop ileostomy usually temporary or permanent?

A

temporary - used to promote bowel healing distal to the stoma

71
Q

what is an end ileostomy?

A
  • stoma in RIF with only one lumen

- spouted

72
Q

contents of end ileostomy?

A

-liquid of soft effluence

73
Q

what is a panproctocolectomy?

A
  • colon, rectum and anus removed

- results in permanent end ileostomy

74
Q

indications for a panproctocolectomy?

A

IBD, family adenomatous polyposis

75
Q

what is a total colectomy?

A
  • surgery from the cecum to the rectum
  • rectum and anus present
  • can be reversed
76
Q

what is an ileoanal J-pouch?

A

-the ileum is folded into a J shape and stapled to make a pouch which is attached to the anus

77
Q

what is an end colostomy?

A
  • stoma in LIF

- single lumen, flush with skin

78
Q

content of an end colostomy?

A

solid effluence

79
Q

what is hartmanns procedure?

A
  • resection of sigmoid colon and upper rectum

- can be reversed

80
Q

name some stoma complications

A
  • stoma stenosis
  • stoma retraction
  • stoma fistula
  • parastomal hernia
  • stoma necrosis
  • high output stoma
81
Q

stoma stensosis is frequently associated with what disease?

A

crohns disease

82
Q

what are the causes of stoma stenosis?

A

hyperplasia, infections, radiation before surgery, local inflammation, hyperkeratosis

83
Q

clinical presentation of stoma stenosis?

A

bowel obstruction

-initial sign is increased flatus

84
Q

management of stoma stenosis?

A

CONSERVATIVE: low-residue diet, increased fluid, stool softeners/laxatives

SURGICAL: if partial or complete obstruction at the fascial layer

85
Q

what is stoma retraction?

A

when all or PART of the stoma retracts into the skin

86
Q

MOST COMMON causes of stoma retraction?

A

-MOST COMMON: tension in the intestine or obesity

87
Q

causes of stoma retraction in the early post op phase?

A

-poor blood flow, poor nutrition, stenosis, early removal of supportive device, stoma placement in deep skinfold, thick abdominal walls

88
Q

management of stoma retraction?

A
  • pouch seal and stoma belt

- surgery if recurrent peristomal skin problems

89
Q

clinical features of stoma necrosis?

A
  • cyanotic, dark red, black, dusky blue/purple
  • foul smell
  • may be hard/dry or flaccid
90
Q

stoma necrosis usually happens when?

A

first 5 days post op

91
Q

management of stoma necrosis?

A
  • If its superficial it should slough off

- if fascia involve, surgery required

92
Q

when do parastomal hernias usually occur?

A

within the first two years

93
Q

risk factors for parastomal hernia?

A
  • obesity
  • poor nutritional status
  • presurgical steroid therapy
  • wound sepsis
  • chronic cough
94
Q

what amoutn of fluid is considered a high output stoma?

A

> 1500 ml in 24 hours

95
Q

aeitiology of a high output stoma?

A
  • when theres <200 m of small bowel
  • intraabdominal sepsis
  • enteric infection
  • recurrent disease in bowel
  • radiation enteritis
  • medications
96
Q

does a patient after surgery for a perianal abscess need post op packing or antibiotics

A

no

97
Q

treatment of refractive anal fissure?

A

botox

lateral sphincterotomy

98
Q

multiple, large, irregular, off the midline anal fissures should raise concern for..

A

-IBD, HIV, TB or malignancy

99
Q

management of rectal prolapse?

A
  • stop bleeding
  • reduce it immediately
  • 50% dextrose and ICE to reduce swelling
100
Q

‘indeterminate colitis’ has features of both..

A

ulcerative colitis and crohns

101
Q

which layers of the bowel does UC effect?

A

mucosa and submucosa

102
Q

which part of the bowel is ALWAYS involved in ulcerative colitis?

A

rectum

103
Q

Medical management of UC?

A
  • local therapy - steroid enemas, foams
  • systemic steroids
  • 5-ASA preps
  • 6-Mercaptopurine
  • infliximab
104
Q

Surgical management of UC?

A
  • subtotal colectomy with ileostomy
  • panproctocolectomy with permanent ileostomy
  • restorative proctocolectomy with ilealanal pouch
105
Q

crohns is most common in what race?

A

caucasians

106
Q

ix for suspected crohns disease?

A
  • endoscopy - upper and lower (for diagnosis)
  • small bowel enema - can detect strictures
  • CT w/ contrast
  • MRI - detects perianal disease
107
Q

what is seen on endoscopy with crohns disease?

A

cobblestone mucosa

108
Q

medical treatment of crohns?

A
  • corticosteroids
  • 5-ASA
  • 6-mp
  • infliximab
109
Q

skin manifestations of IBD?

A

-erythema nodosum, pyoderma gangrenosum, psoriasis, oral ulcers, acute inflammatory dermatitis

110
Q

MSK manifestations of IBD?

A
  • arthritis

- ankylosing sponylitis

111
Q

hepatobiliary manifestations of IBD?

A

sclerosing cholangitis

112
Q

eye manifestations of IBD?

A

-episcleritis, uveitis, corneal ulcers

113
Q

why should you avoid a barium enema in someone with diverticulitis?

A

risk of chemical peritinitis if it extravasates

114
Q

should you scope a patient with acute diverticulitis?

A

no -risk of perforation

115
Q

treatment of acute diverticulitis

A
  • NPO, IV fluids
  • broad spectrum antibiotics
  • low residue diet
  • analgesia
116
Q

which marker is positive in 30-50% of crohns cases?

A

ASCA

117
Q

antibiotics early in life is a risk for…

A

crohns

118
Q

what causes the loss of haulstra (lead pipe colon) in UC?

A

fibrosis of the mucosa and submucosa -> loss of haulstra

119
Q

what kind of cell is seen in the non caseating granulomas of crohns disease?

A

multinucleated giant cells

120
Q

why is there hypokalemia with pancolitis?

A

problems with water and sodium resorption

121
Q

why is there hypoalbunimia in pancolitis?

A

-negative acute phase reactant

122
Q

why may someone with crohns disease develop fecal incontinence

A

disruption of the sphinctor musculature from repeated inflammation, abscess formation, fibrotic changes and repeated episodes of surgical drainage

CORE SURG (14 decks)

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