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Gastrointestinal > Colorectal Surgery > Flashcards

Colorectal Surgery Flashcards

1
Q

Anal Cancer

a) What type do they tend to be (80%)?
b) What are the risk factors?
c) What clinical features are seen?

A

a) SSC

b)
- MSM
- HPV
- HIV
- cervical cancer / CIN
- immunosuppression drugs for transplants
- smoking

c) 
perianal pain 
perianal bleeding 
palpable mass 
faecal incontinence 
women may present with rectovaginal fistula
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2
Q

Anal Fissure

a) What are they?
b) When are they acute/chronic?
c) What are the risk factors?
d) What clinical features are seen?

e) How is it managed if:
i) acute
ii) chronic

A

a) tear in the squamous lining of anal canal
b) before/after 6 weeks

c)
- constipation
- IBS
- STIs

d)
perianal pain
perianal bleeding
should be at posterior midline (if not investigate other causes e.g. crohn’s)

e)

ii)
- diet: fluids + fibre
- bulking laxatives (if doesn’t work try lactulose)
- analgesia / lubricants / topical anaesthetics

ii)
- continue acute management
- topical GTN (glyceryl trinitrate) spray (can consider diltiazem [CCB] if this doesn’t work or causes headaches)

if doesn’t work after 8 weeks consider surgical repair or botox

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3
Q

Proctitis

a) What is it?
b) Other than IBD, what can cause proctitis?

A

a) inflammation of lining of rectum

b) c. diff.

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4
Q

What can often cause rectal prolapse?

A

childbirth

rectal intussusception

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5
Q

Abdo stomas

  1. Where are the following stomas located?
    a) gastrostomy
    b) percutaneous jejunostomy
    c) ileostomy (loop or end)
    d) end colostomy
    e) caecostomy
    f) mucous fistula, loop colostomy, loop jejunostomy
  2. What appearance will small-bowel-ostomy and colostomy have
A

a) epigastrium
b) LUQ
c) RIF
d) L or R iliac fossa
e) RIF
f) anywhere

  1. small bowel (ileostomy or jejunostomy) = spouted
    colostomy = flush to skin

this is because the small bowel’s contents are alkaline and irritant to the skin, whereas this is not the case for the colon

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6
Q

Based on the following sites of colorectal cancer, what type of resection is performed and what is the anastomosis?

  1. caecum, ascending/proximal transverse colon
  2. distal transver/descending colon
  3. sigmoid
  4. upper rectum
  5. lower rectum
  6. anal verge
A
  1. right hemicolectomy
    ileo-colic
  2. left hemicoloectomy
    colo-colon
  3. high anterior resection
    colo-rectal
  4. anterior resection (TME)
    colo-rectal
  5. anterior resection (low TME)
    colo-rectal +/- temporary de functioning stoma (which is loop ileostomy)
  6. abdomin-perineal excision of rectum
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7
Q

Colorectal referral

  1. When should a patient be urgently referred?
  2. When should urgent referral be considered?

NOTE: patient likely to get colonoscopy - faecal occult for screening not diagnosis

A
  1. > 40 unexplained weight loss + abdominal pain

> 50 unexplained rectal bleeding

> 60 iron-deficiency anaemia or change in bowel habit

    • rectal or abdominal mass
    • anal bleeding or ulceration

<50 unexplained rectal bleeding + any of:

  • abdominal pain
  • weight loss
  • change in bowel habit
  • iron-deficiency anaemia
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8
Q

Faecal Immunochemical Test (FIT)

  1. When is it offered?
  2. What is done if results are abnormal?
A
    • anyone aged 60-74 (50-74 in Scotland)
  • > 50 unexplained abdominal pain OR weight loss
  • <60 iron-deficiency anaemia or change in bowel habit
  • > 60 any anaemia
    2. colonoscopy
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9
Q

Diverticular Disease

  1. What is it?
  2. Where does it tend to occur?
  3. Where is spared and why?
  4. What clinical features are seen?
  5. How can it be diagnosed?
  6. How is it managed?
A
  1. herniation of the bowel mucosa through muscular wall of colon
  2. at taenia coli - where vessels break through muscle to supply mucosa, most commonly in sigmoid colon
  3. rectum - no taenia coli
    • altered bowel habit
    • rectal bleeding
    • abdominal pain
    • bloating
  5. CT (best for detecting abscesses)
    barium swallow
    colonoscopy
  6. increase fibre intake

complication treatment: drain abscesses, faecal peritonitis requires resection + stoma

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10
Q

What are the possible complications of diverticulosis?

A

diverticulitis
diverticular phlegm
haemorrhage
fistula
-> (pneumaturia / faecaluria suggests colo-vesical, vaginal faeces/flatus suggest colo-vaginal)
perforation -> can lead to faecal peritonitis or development of abscess
(think on exam will see guarding, rigidity)

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11
Q

Diverticulitis

  1. a) how many people with diverticulosis develop diverticular disease?
    b) How many people with diverticulosis experience a bout of diverticulitis?
  2. What are the RFs?
  3. What clinical features are seen?
  4. What investigation should be avoided at first?
  5. How is it managed?
A

1
NOTE: diverticulosis is the presence of diverticulum, diverticular disease is experience symptoms from this

1

a) 25%
b) 75%

2. 
Lack of fibre
Age 
Obesity 
Sedentary life-style
  1. LIF pain (or can be right-sided in asian patients)
    N+V (20-60%)
    change in bowel habit (constipation 50%, diarrhoea 25%)
    bloating

signs: fever, tachycardia, tender LIF
4. colonoscopy - increases risk of perforation

  1. mild: oral Abx
    severe / symptoms don’t settle within 72hrs: admit for IV Abx
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12
Q

Haemorrhoids

  1. Where are they most likely to occur?
  2. What clinical features are seen?
  3. How are they graded?
  4. How are they managed?
A
  1. left lateral wall, right posterior wall, right anterior wall
    • painless rectal bleeding
    • itch
    • incontinence in 3rd/4th degree
3.
I - no prolapse 
II - prolapse on defection 
III - prolapse can be reduced
IV - prolapse cannot be reduced
    • soften stools: increase fibre + fluid intake
    • topical anaesthetics and steroids
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13
Q

Haemorroidal thrombosis

  1. What clinical features are seen?
  2. How can they be managed?
A
  1. sudden, significant pain
    exam: purplish, oedematous, tender perianal mass
  2. if within 72hrs consider removal
    if not regular haemorrhoid treatment and symptoms should settle within 10 days
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14
Q

Large bowel obstruction

  1. What can cause it?
  2. Where are these causes most commonly in the large bowel?
  3. What clinical features are seen?
  4. How is it diagnosed on investigation?
  5. How is it managed?
A
  1. tumour
    volvulus
    diverticular disease
  2. tumour - most common in rectum + sigmoid due to smaller lumen
    volvulus - most common in sigmoid
    diverticulum - most common in sigmoid
    • absence of passing stool / flatulence
    • colicky abdominal pain + distension
    • N+V (late symptoms / indicative of more proximal lesion)
4. 
caecum >12mm 
ascending colon >8mm
sigmoid/rectum >6.5mm
(+ haustra visible which extend 1/3 of the way across bowel)
    • nil by mouth
    • IV fluids
    • NG tube
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15
Q

Small Bowel Obstruction

  1. What can cause it?
  2. What clinical feature can be seen?

(same management as large bowel obstruction)

A
    • adhesions (often caused by previous surgery)
      - hernia
    • ‘tinkling’ bowel sounds
    • absent faeces and flatulence
    • N+V
    • abdominal distension
    • AXR: valvulae conniventes “coiled spring” appearance with visible distended small bowel >3cm (this is visible valvulae conniventes: lines which extend across whole small bowel)

Note: femoral hernia more likely to cause obstruction and this is much more common in females

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16
Q

Bowel Perforation

  1. What clinical features are seen?
  2. How is it treated?
A
    • peritonism
    • > severe pain, guarding + rigidity on exam
  2. IV antiobiotics + surgery planned
17
Q

What is pseudo obstruction?

What will be seen on investigation?

A

when very unwell / elderly / psychiatric patient has atonic bowel

AXR: bowel extended all the way from top to rectum

bloods: deranged electrolytes

18
Q

Perianal abscess

  1. What is the typical patient?
  2. What clinical features are seen?
  3. What diseases are associated with them?
A
  1. male around 40
    • anal pain, exacerbated by sitting
    • feeling of mass
    • pus discharge
    • spiking temperatures (as infection!)
    • IBD (especially Crohn’s)
    • cancer
    • DM
19
Q

Volvulus

  1. What are the 2 types of volvulus and what are their associations?
  2. What is seen on investigation?
  3. How is it managed
    a) normally
    b) bowel obstruction + peritonism
A 
1. 
sigmoid 
- elderly patients 
- chronic constipation 
- neuro + psych conditions

caecum

  • any age
  • adhesions
  • pregnancy
  • small bowel obstruction
  1. dilated loop of colon + coffee bean sign
  2. a) therapeutic sigmoidoscopy
    b) urgent laparotomy
20
Q

What should you suspect if there is “foul smelling” discharge from the anus?

A

ano-rectal fistula

can often occur following ano-rectal sepsis

21
Q
  1. What is an enema?

2. What is a gastrografin enema?

A
  1. insertion of a substance via the rectum

NOTE: can be for relieving constipation or for an exam or medication

  1. gastrografin is a water soluble contrast which may be used if there is high chance of a leak in the GI tract as it is less toxic than barium
22
Q

In a subtotal colectomy, what stoma will someone then have post-op?

A

ileostomy

because think the colon has been removed!

23
Q

Fistula in ano

  1. What clinical feature is seen?
  2. What is the best investigation to determine its course prior to intervention?
  3. How is it managed?
A
  1. persistent discharge into the perineum separate from the anus
  2. pelvic MRI
  3. either by laying it open (fistulotomy) or placing in seton (tube to help it drain)
24
Q

How would angiodysplasia present?

A

dark red PR bleeding (as more common on right side of large colon), which may be massive

25
Q

When should Hartmann’s procedure be carried out?

A

when there is a sigmoid bowel emergency (I.e. obstruction or perforation)

this involves resection of sigmoid colon + rectum with insertion of end stoma and closure of rectal stump
(can be anastomosed at later date)

26
Q

What type of analgesia is often used after bowel surgery and why?

A

epidural - shown to have a faster return to normal bowel function

Gastrointestinal (11 decks)

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