Colorectal surgery

Question 1

What is the presentation of bowel obstruciton?

Answer 1

*Constipation, failure to pass flatus or stool
*Cramping, intermittent abdominal pain
*vomiting, may be bilious
*Abdominal distension/tenderness/mass
*Peritonitis
*Tinkling bowel sounds may be heard in early obstruction

Question 2

What are the causes of bowel obstruction?

Answer 2

*Adhesions (small) due to surgery, endometriosis, peritonitis, infection
*Hernia (small)
*Malignancy (large)
*Volvulus
*Diverticular disease

Question 3

What are the normal limits on CT for bowel

Answer 3

*Small = 3cm
*colon = 6cm
*Caecum= 9cm

Question 4

How can you tell what is small bowel/what is large bowel on CT/Xray

Answer 4

Small bowel has valvulae conniventes which extend the full width of the bowel, large bowel has haustra which do not extend the full width

Question 5

What is the management of bowel obstruction?

Answer 5

*ABCDE
*FBC
*UEs
*VBG
*Drip and suck: nill by mouth, IV fluids and NG tube with free drainage
*Consider surgery to fix underlying cause

Question 6

What is the most common types of colonic carcinoma?

Answer 6

Adenocarcinoma

Question 7

What are the risk factors of colonic cancer?

Answer 7

*APC mutation
*Lynch syndrome
*IBD
*Obesity
*Older age

Question 8

What is the presentation of colon cancer?

Answer 8

*Rectal bleeding
*Change in bowel habit
*Mass (abdominal or rectal)
*Anaemia (iron deficiency)
*Unexplained weight loss

Question 9

When would you urgently refer someone in the context of colon cancer

Answer 9

*>40 with abdominal pain and unexplained weight loss
*>50 with unexplained rectal bleeding
*>60 with a change in bowel habit/iron deficiency anaemia

Question 10

What investigations would you carry out in suspected colon cancer?

Answer 10

*FBC: anaemia
*UEs and LFTs to check baseline function
*Colonoscopy

Question 11

Once colon cancer has been confirmed what investigations should you carry out?

Answer 11

*Carcinoembryonic antigen (CEA)
*Genetic testing for lynch syndrome
*Staging CT of chest, abdo, pelvis

Question 12

What is the management of colon cancer?

Answer 12

*Surgical resection, post operative chemotherapy

Question 13

What is Hartmann’s procedure?

Answer 13

Emergency procedure if there is an acute obstruction or significant diverticular disease: removal of the rectosigmoid colon and colostomy

Question 14

What is the colon cancer screening programme?

Answer 14

*50-74
*Once every two years
*FIT - faecal immunochemical test
*If positive then colonscopy

Question 15

What is diverticulosis?

Answer 15

Herniation of the mucosa and the submucosa through the muscular layer of the abdominal wall

Question 16

What is the presentation of diverticular disease?

Answer 16

In uncomplicated disease:
- Mild left lower quadrant pain
- Bloating
- Constipation with episodes of diarrhoea

Question 17

What is the management of diverticular disease?

Answer 17

• Bulk forming laxatives if constipated
• healthy, balanced diet, increase fibre intake
• consider an anti-spasmodic to treat abdominal cramping
• paracetamol for abdominal pain

Question 18

What are the complications of diverticular disease?

Answer 18

*Fistula
*Colorectal neoplasm
*Abscess
*Perforation
*Strictures, obstruction

Question 19

What is the presentation of ano-rectal abscess?

Answer 19

• perianal pain
• perianal/rectal induration or swelling
• low grade fever
• tachycardia

Question 20

What are colonic polyps?

Answer 20

Adenomas

Question 21

What are the risk factors for colonic polyps?

Answer 21

• age
• family history or polyps or colorectal cancer
• previous history of polyps
• male
• acromegaly

Question 22

What is the management of colonic polyps?

Answer 22

• polypectomy
• consider familial syndrome if >10 and follow up in 3 years
• if 1-2 low grade adenomas, repeat colonoscopy in 5-10 years

Question 23

What gene is associated with familial adenomatous polyposis syndrome?

Answer 23

APC gene

Question 24

What is the site of a gastrostomy?

Answer 24

Epigastrium

Question 25

What is the site of a loop ileostomy?

Answer 25

Right iliac fossa

Question 26

What is the location of a loop colostomy?

Answer 26

Any region of the abdomen

Question 27

What is the difference between an ileostomy and colostomy?

Answer 27

• ileostomy spouted, colostomy is flush to skin
• ileostomy output is liquid, colostomy output is solid

Question 28

What is a low anterior resection?

Answer 28

Removal of the rectum

Question 29

What is a high anterior resection?

Answer 29

Sigmoid colon removed

Question 30

What is a left hemicolectomy?

Answer 30

Removal of the distal transverse and descending colon

Question 31

What is a right hemicolecotmy?

Answer 31

Removal of the caecum, ascending colon and proximal transverse colon

Question 32

What is the treatment for chronic anal fissure?

Answer 32

Topical glyceryl trinitrate

Question 33

What is the management of an anal fissure

Answer 33

Bulk forming laxative, dietary advice: increase fibre and liquid intake

Question 34

What stoma is formed from a subtotal colectomy?

Answer 34

End ileostomy

Question 35

What is the management of sigmoid volvulus causing bowel obstruction with signs of peritonism?

Answer 35

urgent midline laparotomy

Question 36

When should you refer a patient presenting with an anal fissure?

Answer 36

If it is lateral - if not anterior or posterior it is likely a secondary cause

Question 37

What are the signs of a gastric volvulus?

Answer 37

• vomiting
• pain
• failed attempts to pass a NG tube