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Year 6 > Colorectal surgery > Flashcards

Colorectal surgery Flashcards

1
Q

Small bowel obstruction causes

A

Hernia
Adhesions
Tumour

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2
Q

Large bowel obstruction causes

A

Cancer
Volvulus
Strictures (diverticular disease > IBD)

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3
Q

Obstruction Ix

A

AXR

Definitive: CT abdomen

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4
Q

Colorectal cancer S+S

A 
Change in bowel habit 
PR bleeding
WL
Fatigue
Anaemia - more likely a R sided colorectal cancer if this is found (more indolent bleeding)
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5
Q

Colorectal Ca Ix

A

Sigmoidoscopy –> colonoscopy

Screening
55y = flexi sig –> colonoscopy if +
- Once
- Male and female

60-74 = faecal immunochemical test

  • every 2 years
  • male and female
  • if +ve, colonoscopy is offered
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6
Q

Colorectal Ca Mx

A
  • Resection (sigmoid colectomy is not a cancer operation – need to take the entire IMA for all lymph supply)
  • Heparin SC enoxaparin for 28d

± pre-operative (neoadjuvant) chemoradiotherapy if pelvic LN spread

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7
Q

Colorectal Ca post-op complications

A

Ileus - peristalsis halted - fluids stop moving in intestine - electrolytes diffuse into lumen –> low electrolytes in blood and dehydrated pictures despite positive fluid balance

Anasamotic dehiscence – day 6, fever, septic

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8
Q

Ileus Mx

A

NG + IV fluids

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9
Q

Blood supply to the large bowel

A

IMA splits into Left colic artery

SMA splits into R colic artery –> ileocolic and middle colic arteries

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10
Q

3 areas of bowel with poor perfusion

A

R colon - vulernable in systemic low flow states as marginal artery of Drummond is poorly develop in 50% of population

Splenic flexure - marginal artery of Drummond is tenuous here/ absent in 5%

Rectosigmoid junction - distal to last collateral connection with proximal arteries

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11
Q

Syndromes associated with colorectal cancer

A

Familial adenomatous polyposis

MYH associated polyposis

Peutz Jegher’s syndrome

Cowden disease

HNPCC

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12
Q

FAP inheritance pattern

A

AD

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13
Q

FAP features

A

> 100 colonic adenomas

Cancer risk of 100%

20% are new mutations

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14
Q

FAP screening and Mx

A

Risk –> predictive genetic testing as teenager

Annual flexi-sig from 15 years

No polyps found –> 5 yearly colonoscopies from 20yo

Polyps found = resection

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15
Q

FAP associated disorders

A

Gastric fundal polyps (50%)

Duodenal polyps 90%

If severe duodenal polyposis cancer risk of 30% at 10y

Abdominal desmoid tumours

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16
Q

MYH associated polyposis inheritance pattern

A

AR

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17
Q

MYH associated polyposis features

A

Multiple colonic polyps

Later onset right sided cancers more common than in FAP

100% cancer risk by age 60

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18
Q

MYH associated polyposis Mx

A

Resection and ileoanal pouch

Attenuated phenotype –> regular colonoscopy

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19
Q

MYH associated polyposis associations

A

Duodenal polyposis in 30%

Associated with increased risk of breast cancer

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20
Q

Peutz-Jegher’s syndrome inheritance pattern

A

AD

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21
Q

Peutz-Jegher’s syndrome features

A

Multiple benign intestinal hamartomas

Episodic obstruction / intussusception

Risk GI cancers (CRC 20%, gastric 5%)

Increased risk of breast, ovarian, cervical pancreatic and testicular cancers

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22
Q

Peutz-Jegher’s syndrome Ix Mx

A

Annual examination

Pan intestinal endoscopy every 2-3 years

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23
Q

Peutz-Jegher’s syndrome associations

A

Malignancies at other sites

Pigmentation pattern

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24
Q

Cowden disease inheritance pattern

A

AD

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25
Q

Cowden disease features

A

Macrocephaly

Multiple intestinal hamartomas

Multiple trichilemmomas

89% risk of cancer at any site
16% risk of colorectal cancer

26
Q

Cowden disease screening and Mx

A

Targeted individualised screening

27
Q

Cowden disease associated disorders

A

Breast cancer (81% risk)

Thyroid ca, non-toxic goitre

Uterine cancer

28
Q

HNPCC (Lynch syndrome) features

A

CRC 30-70%
Endometrial cancer 30-70%
Gastric cancer 5-10%

Scanty colonic polyps may be present

Colonic tumours likely to be right sided and mucinous

29
Q

HNPCC (Lynch syndrome) Screening and Mx

A

Colonoscopy every 1-2 years from 25yo

Prophylactic surgery

Extra colonic surveillance recommended

30
Q

HNPCC (Lynch syndrome) associated disorders

A

Extra colonic cancers

31
Q

Volvulus - what % many sigmoid and caecal

A

80% sigmoid

20% caecal

32
Q

what is a sigmoid volvulus

A

large bowel obstruction caused by sigmoid colon twisting on the sigmoid mesocolon

33
Q

What is a caecal volvulus

A

small bowel obstruction caused from a proximal LBO cause of a congenital abnormality

34
Q

Sigmoid volvulus associations

A 
older
chagas disease
chronic constipation 
pyschiatric condiiton (schizo)
neuro condiiton (PD)
35
Q

Caecal volvulus associatoins

A

all ages
adhesions
pregnancy

36
Q

volvulus S+S

A

constipation
abdo pain
abdo bloating
N/V

37
Q

volvulus Ix

A

AXR

sigmoid - LBO coffee bean sign –haustra, large dilated loops of colon, often with air-fluid levels

Caecal - SBO valvule conniventes, mucosal folds that cross entire width of bowel wall

38
Q

Volvulus Mx

A

Sigmoid - therapeutic sigmoidoscopy with rectal tube insertion (if peritonism – laparotomy)

Caecal volvulus – laparotomy (R hemicolectomy often needed)

39
Q

Bowel obstruction Mx

A

1st - drip and suck - + conservative

2nd - adhesiolysis

40
Q

Position of inguinal hernia

A

Above and medial to pubic tubercle

41
Q

Femoral hernia position

A

Below and lateral to pubic tubercle

42
Q

Is inguinal or femoral more common in women

A

Femoral

43
Q

Inguinal hernia - strangulation risk

A

rare

44
Q

Femoral hernia - strangulation risk

A

high risk of obstruction and strangulation

45
Q

Femoral hernia Mx

A

surgical repair needed

46
Q

Difference between umbilical and paraumbilical hernia

A

Umbilical = symmetrical bulge under umbilicus

Paraumbilical = asymmetrical bulge - half the sac is covered by skin of abdomen directly above or below the umbilicus

Paraumbilical = high risk of strangulation

47
Q

Paraumbilical hernia Mx

A

Mayo repair

48
Q

Epigastric hernia location

Most common in

A

Lump in midline between umbilicus and xiphisternum

men aged 20-30

49
Q

Spigelian hernia also known as

A

lateral ventral hernia

50
Q

Spigelian hernia location

seen in

A

A hernia through the spigelian fascia (aponeurotic layer between rectus abdominis muscle and semilunar line)

Rare and seen in older patients

51
Q

Obturator hernia location

F or M?

A

hernia which passes through obturator foramen

F>M

52
Q

Obturator hernia presentation

A

obstruction

53
Q

Richter hernia location and presentation

A

A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect (i.e. only ONE of the intestinal walls herniates through the bowel wall)

Richter’s hernia can present with strangulation without symptoms of obstruction

54
Q

Types of hernia surgery

A

herniotomy - ligation and excision of hernial sac

herniorrhaphy - repair of abdominal wall defect

hernioplasty - mesh implant

55
Q

Hernia RF

A

obesity, ascites, increasing age, surgical wounds

56
Q

Hernia Mx

A

Strangulated/ incarcerated - emergency surgery

Not strangulated/ incarcerated

Adult - inguinal - repeat
femoral - urgent repair

Child
inguinal 
<6w - operate within 2 days
<6m - operate within 2 weeks
<6y - operate within 2 months

umbilical
- most resolve by 4-5y

57
Q

Femoral hernia repair approaches

elective vs emergency

A

eLective = Lockwood Low approach (low incision over hernia with herniotomy/herniorrhaphy)

eMergency = McEvedy high approach (via inguinal region to inspect and resect non-viable bowel)

58
Q

Hernia repair incision and risk of damage to

A

McBurney’s - oblique

Lanz - transverse incision

to Iliohypogastric and ilioinguinal nerves

59
Q

Hernia post-op advice

A

 Must pass urine before discharge
 Mobilise early (work in 1-2 weeks; ≥6 weeks if work involves heavy lifting)
 Adequate analgesia and avoid constipation (lactulose prescription)
 Keep area clean and dry
 Can bathe immediately

60
Q

Complications of gastrectomy

A

Physical:

  • Gastric cancer risk
  • Reflux / bilious vomiting
  • Abdominal fullness
  • Stricture
  • Stump leakage

Metabolic:
- Dumping syndrome (abdominal distension, flushing, fainting, sweating)
- Blind loop syndrome (malabsorption, diarrhoea)
- Malnutrition:
• Vitamin deficiency
• Weight loss

Year 6 (8 decks)

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