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Clinical Surgery > Colorectal Surgery > Flashcards

Colorectal Surgery Flashcards

1
Q

Pathophysiology of Acute Apendicitis?

A

Luminal Obstruction (due to lymphoid hyperplasia or fecolith, more rarely stricture, tumor or parasite)

=> INC Luminal pressure and Reduced lymphatic/venous drainage

=> Necrosis of appendix w/ venous congestion

=> Bacterial proliferation due to stasis/ischemia

=> invasion to the submucosa and muscularis propria, causing acute appendicitis

=> Further ischemia can lead to a gangrenous appendix and bacterial spread to the serosa, and in cases of perforation spread to the peritoneal cavity=> peri-appendiceal abscess

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2
Q

Presentation of Acute Apendicitis

A
  • Classical history is Colicky Periumbilical Pain (‘midgut’) which migrates to and becomes localized in the RIF (worsened by coughing/movement)
  • Nausea and anorexia are common
  • low grade fever (usually 37.5-38) and slight tachycardia. High temperatures are more typical of perforated appendicitis
  • Urinary symptoms sometimes if appendix is sitting on the bladder (Urinealysis will show leucocytes but NO NITRATES in keeping with ‘steile pyruria’)
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3
Q

Risk Factors for Acute appendicitis?

A
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4
Q

Clinical Signs of Acute Appendicitis

  • What is the point of maximum tenderness/Where is it Located?
  • Other Signs and how they’re Illicited?
A
  • On palpation of the abdomen, McBurney’s point is classically the point of maximal tenderness, with associated guarding and rebound tenderness (1/3 along a line drawn from the Anterior Superior Iliac Spine (ASIS) to the umbilicus)
  • A retrocaecal appendix may have relatively few abdominal signs
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5
Q

Scoring System for Acute Pancreatitis?

A

Alvarado Score for Acute Appendicitis (MANTRELS)

  • Migratory abdominal pain (1)
  • Anorexia (1)
  • Nausea (1)
  • Tender right lower quadrant (2)
  • Rebound pain (1)
  • Elevated temperature (1)
  • Leucocytosis (2)
  • Shift in WCC to the left (1)
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6
Q

Differential Diagnoses for Acute Apendacitis?

A
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7
Q

Complications of Acute Appendicitis?

A
  • Perforation w/ local peritonitis
  • Perforation w/ diffuse peritonitis
  • Septic Shock
  • Appendiceal Mass
  • Appendiceal Abscess
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8
Q

Investigations for Acute Appendicitis?

  • Bloods
  • Radiology (Demographics?)
A
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9
Q

Indications for conservative management of acute appendicitis?

A

Peri-apendiceal or phlemonous mass

  • non-operative management w/ aim of cooling inflammation is first step as surgery carries an increased risk at this time
  • Younger patients (<40 years) with an appendiceal mass, an observation period of 6 months should be undertaken. If the patient has recurrent symptoms in this time, an interval appendicectomy should be offered.
  • Patients over 40 years with a conservatively managed appendiceal mass have a higher likelihood of underlying malignant pathology and a much lower threshold for offering interval appendicectomy should be utilized. Shoul receive a colonoscopy 6 weeks following event to ruleout malignancy

Uncomplicated appendicitis

  • Confirmed by CT
  • Comparable alternative, though high rate of recurrence

30% of patients treated conservatively for acute uncomplicated appendicitis will require an appendicectomy for recurrence within the first year

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10
Q

Surgical management of acute appendicitis?

A
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11
Q

Consenting laparoscopic appendicectomy

  • General Risks
  • Specific Risks
  • post-operative care/follow-up
A

General

  • bleeding
  • surgical site infection
  • post-operative pain
  • venous thromboembolism
  • respiratory infection
  • anaesthetic risks

Specific

  • conversion to an open procedure
  • pelvic/intraabdominal abscess (up to 10%)
  • damage to surrounding structures
  • leak from appendiceal stump
  • stump appendicitis
  • possibility of the need for more extensive resection
  • possibility of a normal appendix o histology
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12
Q

Most common sites for Diverticular disease/Diverticulosis?

Pathogenesis?

A

The insertion points of the vessels supplying the colon, vasa recta, are common sites for diverticula.

Diverticula most commonly occur in the sigmoid colon. The increased pressure theory is that because of a low fibre diet there is increased intraluminal pressure over time and this leads to building of mucosa and submucosa the site of weaknesses in the wall of the colon between the taenia coli where the vasa recta penetrate.

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13
Q

True vs. False Diverticula?

A

True diverticula involve all layers of the muscle wall e.g. Meckel’s Diverticulum.

False diverticula do not involve all layers (submucosa and mucosa only) e.g. colonic diverticula

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14
Q

Uncomplicated vs. Complicated Diverticulitis?

A

Uncomplicated: Simple inflammation of the diverticular segment.

Complicated: Associated abscess, perforation, peritonitis, stricturing, fistulae or haemorrhage.

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15
Q

Complications of Diverticulosis?

A
  • Diverticulitis
  • Diverticular bleeding
  • Diverticular fistula (most commonly a colovesical or colovaginal fistula)
  • Faecal peritonitis
  • Diverticular abscess
  • Diverticular stricture (causing large bowel obstruction)
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16
Q

Classification of Diverticulitis?

A

Hinchey 1a: Paracolonic inflammation, no abscess

Hinchey 1b: Paracolonic abscess <4cm

Hinchey 2: Pelvic abscess, interloop abscess, para-colonic abscess >4cm

Hinchey 3: Purulent peritonitis (four-quadrant pus)

Hinchey 4: Faeculent peritonitis (four quadrant feces)

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17
Q

Epidemiological/Genetic Factors contributing to Diverticulosis

A

The majority of diverticulosis is left-sided involving the sigmoid colon in the Western World, whereas right-sided diverticulosis is more common in Asian populations suggesting some genetic component.

Connective tissue disease (Marfan’s syndrome, Ehler-Danlos syndrome) also increases the risk.

10% of patients aged>40 years and over 50% of people >80 will have colonic diverticula, but a much smaller proportion (2-25%)will develop symptoms

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18
Q

Diverticulitis History/Exam

A
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19
Q

Diverticular Abscess History/Exam

A
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20
Q

Diverticular Stricture History/Exam

A
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21
Q

Diverticular Bleed History/Exam

A
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22
Q

Diverticular Fistula History/Exam

A
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23
Q

Investigations for Diverticulitis?

A
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24
Q

Management of Acute uncomplicated diverticulitis?

A
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25
Q

Management of Diverticular Abscess

A
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26
Q

Management of Diverticular Stricture

A
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27
Q

Management of Diverticular Bleed?

A
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28
Q

Management of Diverticular Fistula

A
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29
Q

Management of Diverticular Perforation?

A

Hartmann’s procedure: Emergency resection of the sigmoid colon with formation of an end colostomy and leaving the stapled off rectal stump in the abdominal cavity

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30
Q

Risk Factors for Colorectal Cancer

A
  • Age >50
  • Family History
  • Genetic Condition (FAP, HNPCC)
  • Adenomatous Polyps
  • Inflammatory Bowel Disease
  • Previous Colorectal Cancer
  • Obsesity
  • Diet high in fat/red meat
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31
Q

Bowel Cancer Screening Guidelines

A
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32
Q

Clinical Features of Colorectal Cancer

  • Presentation
  • Examination
A
33
Q

Investigations for Colorectal Cancer?

A
34
Q

Alternatives to Colonoscopy?

A
35
Q

Staging Investigations for Colorectal Cancer?

A

Standard staging for distant metastases in colon and rectal cancer is a CT TAP

In rectal cancer, an MRI of the rectum is needed for local staging

If CT Abnormallities=> MRI of the liver or a PET scan to further evaluate for metastatic disease

36
Q

Colorectal Cancer Staging System and Survival Rates

A
37
Q

Management of Colon Cancer?

  • Surgical
  • Adjuvant Chemo Options?
A
38
Q

Management of Rectal Cancer?

A

Rectal cancer management depends on how close the tumour is to the resection margin(CRM)

Rectal cancer surgery involves a total mesorectal excision, taking the entire envelope the rectum is enclosed in, as this results in an oncological lymph node excision.

T1/T2: Upfront surgery w/o neoadjuvant chemoradiotherapy

T3 w/ threated CRM + T4 are offered neoadjuvant (prior to survey) chemoradiotherapy

39
Q

Management of Emergency Obstructing Colonic Tumor?

A
40
Q

Type of Surgical Resection/Anastamosis for Cancer in the Caecum and Ascending Colon

A

Right Hemicolectomy

Ileocolic

41
Q

Type of Surgical Resection/Anastamosis for Cancer in the Transverse Colon

A

Extended Right Hemicolectomy

Ileocolic

42
Q

Type of Surgical Resection/Anastamosis for Cancer in the Splenic Flexure

A

Extended Right Hemicolectomy OR Left Hemicolectomy

Ileocolic OR colo-colon

43
Q

Type of Surgical Resection/Anastamosis for Cancer in the Descending Colon

A

Left Hemicolectomy

Colo-colon

44
Q

Type of Surgical Resection/Anastamosis for Cancer in the Sigmoid Colon

A

High anterior resection

Colorectal

45
Q

Type of Surgical Resection/Anastamosis for Cancer in the Upper Rectum

A

Anterior resection with total mesorectal excision

Colorectal

46
Q

Type of Surgical Resection/Anastamosis for Cancer in the Lower Rectum

A

Low anterior resection with total mesorectal excision and defunctioning ileostomy

Colorectal

47
Q

Type of Surgical Resection/Anastamosis for Cancer involving the Anal Verge

A

Abdomino-peroneal excision of the rectum +/- colon

Anal canal excised and sewn closed

48
Q

Follow-up after colorectal cancer

A

CT thorax/abdomen/pelvis every year for 5 years

Colonoscopy at year 1 and year 4

CEA 6-monthly during the surveillance window

49
Q

Define Bowel Obstruction

A

Mechanical/functional obstruction of the GI tract inhibiting normal transit of enteric contents. May be a partial or complete obstruction. Can be acute or subacute

Simple Obstruction: One obstruction point & no vascular compromise.

50
Q

Define Ileus

A

Disruption to normal gut motility due to a malfunction of peristalsis in the absence of a mechanical obstruction.

A common post-operative complication

51
Q

Define a Closed Loop Obstruction

A

Bowel obstruction at two points, can result in ischaemia, necrosis or bowel perforation. Surgical emergency requiring urgent diagnosis and surgical intervention.

52
Q

Define a Strangulated Bowel

Signs of it?

Bloods?

A

Bowel obstruction with compromised blood supply and abdominal tenderness as a common sign

Systemic features of toxicity such as pyrexia

Blood indices including elevated inflammatory markers and lactate.

53
Q

Causes of Small Bowel Obstruction

A

The majority are adhesional or secondary to a hernia

Other causes include:

  • bowel strictures
  • Meckel’s diverticulum
  • bowel intussusception
  • malignancy
54
Q

Causes of Large Bowel Obstruction

A

Colorectal neoplasia is most common.

Other causes include:

  • diverticular stricture (narrowing)
  • volvulus (twisting)
  • hernias
  • strictures related to inflammatory bowel disease such as Crohn’s Disease
55
Q

Non-Mechanical Causes of Bowel Obstruction

A
  • Post-operative
  • Peritonitis
  • Drugs (opioids/antimuscarinics)
  • Hypokalaemia
  • Hyponatraemia
  • Hypomagnesaemia
56
Q

Mechanical Causes of Bowel Obstruction

A

Intraluminal:

  • Impacted stool
  • foreign body
  • gallstones

Mural:

  • Benign stricture
  • neoplasia
  • atresia (passage is closed or absent)
  • ileus (lack of movement)
  • intussusception.

Extramural:

  • Hernia
  • adhesions
  • volvulus
  • extrinsic compression.
57
Q

Types of Vomit Expected in Bowel Obstruction

A

o Early in high obstruction

o Bilious contents if high obstruction

o Faeculent in distal obstructions

58
Q

Signs of Bowel Obstruction

A
59
Q

Investigations for Bowel Obstruction

A
60
Q

3, 6, 9 Rule of Bowel Obstructions?

A
61
Q

Management of Bowel Obstruction

Indications for Surgery?

A
62
Q

Paralytic Ileus

  • Causes
  • Prevention
  • Management
A
63
Q

Ogilvie’s Syndrome

  • Cause
  • Investigations
  • Management
A
64
Q

Definition and Etiology of Hemorrhoids

Above vs. Bellow Dentate Line?

A
65
Q

Classification of Hemorrhoids

A
66
Q

Causes of Hemorrhoids?

A

1°: Constipation w/ prolonged straining of hard stool (Poor dietary habits, decreased fiber intake, decreased fluid intake.)

2°: Pregnancy and other causes of raised intraabdominal pressure

67
Q

Signs/Symptoms of Hemorrhoids?

A
68
Q

Management of Hemorrhids?

  • Conservative
  • Medical
  • Proctoscopy
  • Surgical (indications)
A
69
Q

Classification of Anal Fistula

A
70
Q

Anterior vs. Posterior Anal Fistula?

A
71
Q

Investigations for Anal Fistula

A
72
Q

Surgical Management of Anal FIstula

A
73
Q

Anal Fissure

  • Pathophysiology
  • Etiology
  • Symptoms
  • Signs
  • Investigations
  • Management (Conservative/Medical/Surgical)
A
74
Q
A
75
Q
A
76
Q
A
77
Q
A
78
Q

Risk Factors for Anal Carcinoma

A
79
Q

Arterial/Venous/Lymph Drainage of Anal Canal Above/Bellow Dentate Line

A

Above

  • superior rectal artery/veins (→ hepatic portal system).
  • lumbar (paraaortic) lymph nodes.

Below

  • middle and inferior rectal veins/arteries (→body circulation).
  • inguinal lymph nodes.
  • pudendal nerve is responsible for the sensory innervation.

Clinical Surgery (20 decks)

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