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RCSI SURGERY > Colorectal Surgery > Flashcards

Colorectal Surgery Flashcards

1
Q

Definition for Hartmans procedure

A

– resection of disease portion of bowl bring the proximal end out as a stoma and over sew the distal end

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2
Q

3 causes of small bowl obstruction

A
  • adhesions
  • HERNIA
  • Neoplasm in small bowl
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3
Q

2 cases of large bowl obstruction

A
  • Neoplasm

- diverticular disease

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4
Q

MANTELS acute appendicitis

A 
Migration of pain
 Anorexia
Nausea/vomiting
Tenderness RLQ 
Rebound pain
 Elevation of temperature
 Leukocytosis
Shift to the left (Neutrophiles > 75% OR LLEFT SHIFT  )
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5
Q

Rovsing sign

A

palpation in LIF causes worse pain in the RIF

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6
Q

Psoas sign

A

flexion of the right hip

liw patient on left and felt hip posteriorly

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7
Q

Obturator sign

A

Pian in the right lilac fossa as a result of flexing and internally rotating the right hip

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8
Q

Causes of appendicitis in adults DDX

A

Terminal ill pathology
Crohns
Meskel’s diverticulitis
GE

Kindly stones
pancreatitis

Ovarian cyst (where in menstrual cycle) 
ovarian tortion
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9
Q

what score do you use for testing appendicitis severity

A 
ALVARADO SCORIng SYSTEM 
- abdo pain which is localized in RIF 
- Nausea / Vomitting 
- Anorexia 
SIGNS 
- tenderness RIF 
- rebound tenderness 
- temperature 
LAB VALUES 
- leukocytosis > 10 000 
Neutrophiles > 75% OR LLEFT SHIFT
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10
Q

acute appendicitis treatment

A

OPEN or LAP
- 15% - negative
IV antibiotics at infuctioon

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11
Q

Appendicitis abscess or appendicitis mass

A

IV ANTIBITOCIS

  • may settle within 6 weeks
  • if NOT – > surgery

Abscess - CT guided drainage

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12
Q

how to do appendectomy

A

gridiron incision at McBurneys Point
lap approach
find appendix
divide mesentery
clamp appendix and tied at base then excised
investigate stump using purse=string in the wall of the caecum round the base of the appendix

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13
Q

Complication of acute appendicitis

A
  • perforation (localized or generalizEd )
  • RIF appendix mass (appendicitis with densely adherent caecum and oentum forming a mass)
  • RIF abscess
  • Pelvic abscess
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14
Q

blood supply to the appendix

A

terminal branch of ileocolic

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15
Q

Diverticular disease

A

out pouching of sac like mucous projection through the colon wall
- usually in sigmoid colon

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16
Q

Clinical Painful diverticulosis

A

intermitted LID pain - constipation and diarrhea

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17
Q

Acute diverticulitis

A

LIF pain D/C Nause ± bleeding
Sign: dever, tachycardia , tender LIF ,guarding , rebound
Labs: HIGH neutrophils, elevated WCC and elevated CRP

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18
Q

Diverticular bleeding

A

Spontaneous NO prodromal symptoms

LARGE BIGHT RECTAL BLEED due to rupture of PERIDIVERTICULA SUBMUCOSAL VESSEL

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19
Q

complication of diverticular disease

A

pericolic and parabolic abscess
peritonitis
Diverticular FISTULA
STRICTURE FORMATION

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20
Q

pericolic and parabolic abscess presenting symptoms and treatment

A

SPIKING and swinging fever and sepsis
(LIF pain, N V , WL , NS )
(from persistent colonic inflammation leading to pericolic abscess)

Tx:

  • Antibiotics
  • percutaneous radiologically guided draining w/ washout ± research of disease bowl
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21
Q

difference b/w purulent peritonitis and faeculent peritonitis

A

Purulent - perforation of parabolic and pericolic abscess

Faeculent - free perforations of diverticular segment

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22
Q

question to ask in diverticular history to outule fistula

A

recurrent UTI
pneumaturia
debris in the urine

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23
Q

gold standard test for Diverticular disease

A

BARIUM ENEMA
COLONSCOPY
- not used in acute setting can PERFORATE the appendix

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24
Q

treatment of acute diverticulitis

A

IV antibiotics (co-amoxiclav)
Bowl rest IV fluids
Radiology guided drainage if abscess present
Hartmans

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25
Q

when do you do surgery for acute diverticulitis

A
  1. free perforation
  2. fistula
  3. acute inflammation unresponsive to medical treatment
  4. undrainable abscess
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26
Q

HINCHY SCORE

A

Hinchey I - localised abscess (para-colonic)
Hinchey II - pelvic abscess
Hinchey III - purulent peritonitis (the presence of pus in the abdominal cavity)
Hinchey IV - feculent peritonitis.

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27
Q

Treatment of acute diverticulitis

A

Hinchey I: conservative (high fibers, stool softeners)

Hinchey II: CT guided drainage and wash

Hinchey III: usually operation (Hartmans)

Hinchey IV: always operation(Hartmans)

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28
Q

Diverticular disease: definition

A

symptomatic diverticulae

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29
Q

Diverticulitis: definition

A

inflammation & infection associated with diverticula

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30
Q

Hold old for colorectal cancer

A

55-75 years MEN increase 3X

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31
Q

RF for Colorectal cancer

A
  • polyposis syndrome (FAP , HNPCC, juvenile polyposis )
  • strong history of colorectal carcinoma
  • UC and Choirs
  • deit poor in fruit and vegetables
  • diet risk in red meat processes met and animal fat
  • obesity

MOST ARISE FROM PRE EXCITING ADENOMA

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32
Q

how does colorectal cancer metastasize

A

lymphatics

hematogenous - liver

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33
Q

how can Colorectal cancer occur

A

Polypoid
ulceration
stenosing
infiltrative tumour mass

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34
Q

location of Colorectal cancer

A

RECTUM ( 30%)
Descending and sigmoid - 45%
transverse - 5%
Right sided 20%

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35
Q

definition of tenesmus

A

difficult painful defecation and sensation of incomplete evacuation
- THINK SOL

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36
Q

how does Right sided colorectal cancer present

A

iron deficiency anemia

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37
Q

Descending / sigmoid colorectal cancer presents as

A

PR bleed and Change in bowl habit

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38
Q

Dx CR cancer

A 
ELECTIVE: 
PR exam 
signmoidscopy and BX 
Colonoscopy and BX 
CT colonagiography if colonoscopy not possible

EMERGENCY - CT

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39
Q

how to stage CR cancer

A
  1. LOCAL
    - CT - colon cancer
    - pelvic MRI and transrectal US - rectal CA
  2. METS
    - CT TAP - GOLD STANDARD
    - Pet
  3. SYNCHRONOUS TUMOUR - colonoscopy and Barium enedma
  4. CEA - tumor marker
  5. PATHOLOGY - DUKES classification , TNM
40
Q

Management - potential curative treatment with NO mets evidence
OPERATIVE

A

Right / traverse - right / extended right hemicolectomy
LEFT colon - left hemicolectomy
Sigmoid /upper - high anterior resection
lower rectum - LOW anterior resection / APR
Anorectal - APR

41
Q

general treatment of CR cancer

A
  1. OPERATIVE
  2. RTX (NEOADJUVANT) - reduces local recurrence
  3. ADJUVANT CHEMO - tumour with positive LN or evidence of vascular invasion
  4. HEPATIC or LUNG resection - in its with retractable mets and resectable primary tumour
  5. PALLITIVE
42
Q

Palliative treatment in CR cancer

A

for unrescetbale

  1. CTX
  2. ENDOLUMINAL stents with self expanding metal steps for obstruction colon tumours
  3. transanal ablation of rectal obstruction tumours
  4. surgery for untreatable obstruction / bleeding / severe symptoms
43
Q

follow up post CR Cancer treatment

A

1/ Outpatient review - Hx and exam , PR and CEA
2/ Colonoscopy
3/ CT scan

44
Q

Internal sphicheter type of cell

A

Circular, non striated involuntary autonomic nerve

45
Q

external sphicheter

A

started , voluntary supplied by pudenal nerve

46
Q

lymph drainage to lower part of anal canal

A

injunial LN

47
Q

what cells line lower part of anal canal

A

squamous cell

48
Q

treatment of haemorrhoids

A
  1. normalize bowel and defamatory habits
  2. injection sclerotherapy (1st and second)
  3. rubber band ligation (second degree haemorrhoids )
  4. Transanal heamorrhoidal dearterilisation (2nd and third)
49
Q

indication for a heamoroidectomy

A
  1. 3rd and 4th degree haemorrhoid
  2. 2nd degree that is not cured with non operative approach
  3. fibroses haemorrhoid
  4. intern-external haemorrhoid when the external haemorrhoid is well defined
50
Q

types of heamorroidectomy

A

OPEN - milligan morgan
Closed - ferguson
Stapled

51
Q

thrombosed external haemorrhoid presentation and treatment

A

EXCRUTIATING PAIN

Sx treatment of haemorrhoid and overlying skin - immediate relief

52
Q

anal fissure definition

A

longitudinal split in the anoderm of the distal anal cancel which extends from the anal verge proximately towards but not belong the dentate line

53
Q

Chronic fissure

A

> 6 weeks and presents with

  • firbsosi
  • fibrotic edge
  • perianal skin tag
54
Q

Conservative Treatment of fissure

A

Conservation

  • warm sits baths
  • constipation relief
  • analgesia
  • tx underlying condition
  • TOPICAL NITRIC OXIDE DONORS - by decreasing spasm , pain is relieved and increased vascular perfusion and promotes healing (0.2% NO and 2% diltiazam )
55
Q

Operation for fissure

A

lords anal stretch (historical interest only) - high risk of incontinence

Lateral SPINCTEROTOMY ( GOLD STANDARD)

  • closed
  • open
56
Q

define anorectal abscess

A

acute phase manifestation of a collection of purulent material that originates from an infection arising in the cyrptoglandular epithelium lining the anal canal at the dentate line

57
Q

Investigation anorectal abscess

A

Pelvic CT or MRI

58
Q

Tx anorectal abscess

A

primarily surgical - anesthesia , sigmoidoscopy and proctoscopy with adequate draining of pus

59
Q

presentation of anorectal abscess

A

Severe perianal and rectal pain, constitutional symptoms - fever , malaise
PURULENT DISCHARGE - if abscess spontaneously drained

60
Q

Anal fistula definition

A

Chronic abnormal connection b/w 2 epithelial lined surfaces

- usually lined with granulation tissue

61
Q

exam of fistula

A
  1. perianal skin may be excoriated and inflamed
  2. external open visual or palpated as undulation just below the skin
  3. hands into fistula to determine the internal opening using rotoscope or sigmoidoscope
62
Q

types of anal fistula (Parks classification )

A
  1. Intersphincteric
  2. trans-sphincteric
  3. suprasphincteric
  4. extrasphincteric primary tracts
63
Q

Parks classification note

A

Low or high depending on weather the internal opening is above or below the puborectalis

64
Q

Goodshall’s rule

A

all fistula tract with external openings within 3 cm of the anal verge and posterior to a line drawn through the ischial spines travel in a curvilinear fusion to the posterior midline. All tracks with external openings anterior to this line enter the canal in a radial fashion

65
Q

how to you make a definite of a fistula

A

Examination under anesthesia - to determine internal and external openings

66
Q

Treatment fistula

A
  1. FISTULOTOMY - if the fistula lies below the puborectalis
  2. FISTULECTOMY - either loose tight or chemical - used for low anorectal fistulas
  3. SETON INSERTION - high anorectal fistulas
  4. ADVANCED FLAP
  5. PLUGS AND GLUES
67
Q

SENTON INSERTION

A

this is done loose right or chemical - used for HIGH
- staged fistulotomy by placing a seton suture that is sporadically tightened so to gently cut through the tract and muscle while allowing healin and fibrosis to develop between diced muscles thus preserving function and fecal continence

68
Q

pionidial sinus

A

pilus - means hair
sinus - means blind ending tract - usually lined with granulation tissue

infection of the skin and subcutaneous tissue at or near the upper part of the natal cleft of the buttock

69
Q

pathogenesis pionidial sinus

A
  • loose hair gathers toward natal cleft
  • draws hair deeper into the pore - suction of buttock movement
  • friction causes hair to form a sinus

Pore becomes infected - abscess

70
Q

treatment of pilonidal sinus

A

skin hygiene
acute: incision and drainage of pilonidal abscess
Chronic - phenol injection every 4-6 weeks till wound is healed

71
Q

techniques for pilonidal sinus surgery

A
  1. excise sinus tract
    BASCOM’s operation - lateral to midline incision to cruette the deep cavity and excision of the primary midline pits
    Primary closure of the midline incision and lateral wound left to heal by secondary intention
  2. Karydakis procedure - smilateral D shaped incision incubating the sinus down to the pre sacral facia - the flap of tissue on the vertical young side is mobilized and brought to the convex would wedge and sutured in the layers over a drain
72
Q

treatment for recurrent pilonidal sinus

A

ROTATIONAL FLAB PROCEDURE - pasty, modified , limber flap

73
Q

anal cancer RF

A 
female 
infection with HPV 16 and 18 
lifetime number of sexual partners 
genital warts 
cigarette smoke 
receptive anal intercourse 
infection with HIV
74
Q

AIN

A

precursor for invasive squamous anal carcinoma

75
Q

Bowen’s disease

A

high proportion of AIN III progresses to carcinoma

76
Q

anal cancer above the dentate line drains to

A

perirectal and paravertebral nodes

77
Q

anal cancer below the dentate line drains to

A

superficial injunial and femoral nodes

78
Q

investigation of anal canal

A
  1. under anesthesia - Bx
  2. CT
  3. MRI
  4. endoanal ultrasound
79
Q

Treatment of anal cancer

A

MDT
- wide surgical excision (T1No)
CHEMORADIO - T2 T 3 T4
APR - in advanced disease of anus and rectal tumour

80
Q

why do you get that colour of melon in upper GI bleed

A

b/c the blood becomes altered from gastric and upper GI enzymes

81
Q

isolated streaks of blood

A

issues in uno

82
Q

differential dx for mucous in stool

A 
Rectal Ca 
UC 
Chrons of the rectum 
adenoma 
Colitis - other cause
83
Q

investigation of rectal bleed

A
  • FBC - hb and platlets
  • U/E - disproportionately raised urea due to increase creatinine in Upper GI bleed
  • call
    LFT
    PDA - obstruction / Toxic megacolon
    Colonoscopy . barium enema, proctoscope / sigmodscope
    OGD
    Mesternic angiography or technetium scan
84
Q

what can a small bowel enema show in chons

A

Stricture

Prestonitic dilation

85
Q

Kantor string sign

A

luminal narrowing revealed on x-ray as a thin line of barium terminating at the ileocecal junction.

Area which is narrowed and irregular

86
Q

what can CT scan show in churns

A

FATD

Fistulae
Inter-abdominal abscess
bowl thickening
Dilatation

87
Q

MRI USE IN chorns

A

to detect perianal involvement

88
Q

MR enteroclysis IN chorns

A

small bowel structuring in young children

89
Q

Fistulography

A

Helps demonstrate enterocutaneous fistulae with more complexity and allow adequate panning of surgery

90
Q

Surgery for chrons

A
  1. ileocecal resection
  2. segmental resection
  3. colectomy and ileocecal anastomosis
  4. subtotal colectomy and ileostomy
  5. strictuotomy
91
Q

what do you see on X-ray of UC

A 
lead pipe colon
thumb printing (mucosal edema)
92
Q

how does pancolittis present in uC

A

may have backwash ileitis - SYSTEMICALLY unwell
HYPOkalemia from mucous production
Hypoalbuminemia from systemic response and decreased oral intake
Anemia from blood loss and inflammatory response

93
Q

Toxic megacolon present

A

MASSIVELY dilated and patchy necrosis
Systemically ill with high fever marked tacky and dehydration
Culminates in perforation and detail peritonitis unless emergency colectomy is done

94
Q

CT in UC

A

thickened bowl wall and inflammation stranding in the colonic mesentery

95
Q

Surgery for UC

A

Subtotal colectomy with ileostomy
Panprotocolectomy with permenanat ileostomy
Restorative protocolectomy (ileoanal pouch and parks pouch )

RCSI SURGERY (7 decks)

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