Colorectal Surgery Flashcards
What are the clinical features of UC?
Proctitis:
- commonest presentation
- urgency and frequency
- bloody mucus diarrhea - mixed
Left sided colitis:
- rectal irritation
- bloody diarrhea
- systemic features
Pancolitis:
- backwash ileitis - irritation to ileum
- diarrhea
- systemic features
- anaemia
What are the treatments for UC?
The main stay of treatment is 5-ASAs such as mesalazine.
these can be topical for more lower disease, or orally for higher disease.
1st line: mesalazine
2nd line: immunomodulation: azathioprine/ methotrexate
Proctitis:
- 5- ASA topical
- topical steroids - suppositories
Left sided:
- Oral/ Topical 5-ASA- foam enemas
+/- foam steroid
+/- systemic treatment - steroids
Pancolitis:
- oral - 5 - ASA
- Systemic treatment - steroids
- azathioprine
- cyclosporin
Surgical: reserved for severe acute that fails to medical therapy or when, symptoms are not controlled, side effects are to great or evidence of dysplasia or cancer. - proctocolectomy - with ileoanal pouch - panproctocolectomy - with ileostomy - total abdominal colectomy
What is the management of severe acute colitis?
*remember this may be caused by an infective agent:
Symptoms:
- diarrhea with blood. *if there is constipation it may suggest dilation of colon
- abdominal pain
- malaise
- fever
- abdominal tenderness - peritonitis - suggests perforation
Treatment:
- resuscitation
- catheterisation
- bloods
- establish diagnosis
- send stool samples
- AXR/ erect CXR
- flexible sigmoidoscope - if possible
Medications:
- IV hydrocortisone - 100mg qds
- LMWH
72 hours worsening: - Ciclosporin or - infliximab \+/- - surgery
What is criteria for fulminant colitis?
Tachycardia >120 bpm
stool frequency > 10 per day
or
Albumin <25g/dL
What are the clinical features of Crohn’s disease?
Systemic features:
- fever
- malasia
Abdominal Pain
- RIF
Change in bowel habit
- diarrhea without blood
Weight loss
Perianal abscesses
What are extraintestinal manifestations of Crohn’s disease?
Associated with disease activity:
- pyoderma gangrenosum
- erythema nodosum
Independent of disease activity:
- ankylosing spondylitis
- polyarthritis
- chronic active hepatitis
- finger clubbing
Both Crohn’s and UC have an effect on the bile ducts of the liver, what are they and to which disease?
Primary biliary cirrhosis = Crohn’s
Primary Sclerosing cholangitis = UC
What are the gold standard investigations for IBD?
What other investigations can be done?
CT enterography
Colonoscopy with biopsy for diagnosis
other:
- CRP (good indication of disease severity)
- Faecal calprotectin
- FBC (anaemia)
- B12
What is the treatment for Crohn’s disease?
Inducing remission: 1st line: 8 weeks steroids \+ stop smoking
2nd line:
mercaptopurine
or
Azathioprine
3rd line:
- infliximab
Maintaining remission:
- Azathioprine
or
- mercaptopurine
2nd line:
- methotrexate
What are some of the complications of Crohn’s disease?
Fistula formation
Stenosis
- coiky pain
- weight loss
- distended bowel
anal disease
- anal fissures
- fistula in ano
- anal mucosal thickening
B12 deficiency
List some risk factors towards colorectal cancer:
Age
> 50 years
History of polyps
Male
IBD
Heavy red mat diets
Smoking
- more so in males
What are the symptoms and clinical features of colorectal carcinoma?
Right sided;
- anaemia
- Coliky pains
- appendcitis (>40 years should be investigated)
Left sided:
- PR bleeding - mixed with the stool
- change in bowel habit - mixture of diarrhea and constipation
- tenesmus
How is colorectal carcinoma diagnosed?
what further investigations are done?
Colonoscopy with biopsy
CT thoracic- abdominopelvic for metastasis
What blood marker of colorectal cancer can be used as a marker of disease monitoring, especially following resection?
CEA - Carcinoembryonic antigen
What staging is used for colorectal cancer and what are the stages? with 5 year survival rates:
Dukes
A - confined to mucosa - 75-90%
B - full thickness of wall through muscularis externa - 55-70%
C - Lymph node involvement - 30-60%
D - metastasis
What are common metastasis sites for colorectal cancer?
Lung
Liver
What kinda of surgery can be carried out for rectal carcinoma, and what increases the risk of anastomotic leak, and how can this be reduced?
Anterior resection
the lower the anastomosis the higher the risk of leakage.
Loop ileostomy can be done to reduce the risk of leakage.
*loop Ileostomies are partial disconnection proximal to the anastomosis which allow drainage of faeces to prevent damage further down at the anastomosis and for it to heal
What are the gold standard investigations into diverticular disease?
Contrast barium enema -
- see leakage.
- this is performed at a elective procedure
CT
- assess complications
**CT for acute situations* gold standard
What is the treatment of diverticulitis:
High fibre oral antibiotics Analgesia Rehydration Bed rest
If pain or fluids not managed:
- Nil by mouth
- IV antibiotics - triple therapy
- IV fluids
- IV analgesia
Complications
- surgical resection
What are the clinical symptoms of acute diverticulitis?
- Rapid onset LIF pain
- Low grade fever
- loose stools
- nausea
- Bleeding
What are some complications of diverticula disease?
Abscess formation
- pericolic
- paracolic
- presents with swinging fevers
- unresolved pain
Peritonitis
- perforation - feculent peritonitis
Fistula formation
- colovesical fistula - recurrent UTIs, bubbles in urine
- colovaginal fistula - feculent discharge
What signs are seen with cecal volvulus?
embryo sign
- the caecum will also not be seen
What sign is seen with sigmoid volvulus?
coffee bean sign
What factors are absolute important for anastomosis to work?
- Adequate blood supply
- Mucosal Apposition
- adequate tissue tension which is not tight
sepsis, surgeon and patient comorbidities also play important point
List the surgeries typically seen in recto-sigmoidal cancers:
Sigmoid: High anterior resection
Upper rectum: anterior resection
Lower rectum: Low anterior resection
Anal verge: Abdomino- perineal excision of rectum
In emergency colectomies, what surgical procedure is best to do?
Hartmann’s
Anastomosis is risky in emergency situations and can be reversed.
What is used to test the integrity of an anastomosis?
Gastrografin
What classification system can be used to assess diverticular perforation?
Hinchey
I - localised abscess
II - Pelvic abscess
III - Purulent abscess - pus in peritoneum
IV - Feculent abscess - faeces in peritoneum
What conditions increase risk of colorectal cancer?
UC
Familial Adenomatous Polyposis (APC mutation)
Hereditary Non - Polyposis Colorectal Cancer
Juvenile Polyposis
What imaging modality is best for rectal cancer?
MRI
In patients with sigmoid volvulus, what is the best treatment?
Depends if the have peritonitis:
Rigid sigmoidoscope = if no peritonitis
Urgent Laparotomy = if peritonitis and bowel obstruction
What is the single best investigation for ano-fistula?
Pelvic MRI
*note in an emergency situation explorative surgery may be best
What are the symptoms of anorectal sepsis and how is it diagnosed? how is it treated?
Caused by abscess formation. features include: - Rapid onset pain - worse when sitting - fever - tachycardia - purulent discharge - swelling around anus
MRI is gold standard
- although in emergencies situations surgery is indicted
Antibiotics
Surgical drainage
- Prevention of recurrent sepsis is to use [loose seton suture].
- laying open the fistula in ano - open tracks of fistula and debriding tissue. can be done high and low.
What types of abscess around the anus can form?
Peri- anal - subcutaneous
Infra-sphincter
supralevator
Ischial rectal
- just outside the sphincters laterally
List several cause of PR bleeding:
Anorectal: bright red blood
- Haemorrhoids
- Acute anal fissure
- Proctitis
- Rectal prolapse
Rectosigmoid: darker red, clots, mixed
- Rectal tumours
- Proctocolitis
- Diverticula disease
Proximal colonic: dark red, mixed
- colonic tumours
- colitis
- angiodysplasia
- NSAID reduction
Upper g.i = melena
What Tests should be done in the presence of suspected UC?
FBC
- ESR
- Hb
Stool culture
- Microscopy, cultures and sensitivity
- C. Diff
Calprotectin
- show’s generalised inflammation
Gold standard:
- CT enterography
- Colonoscopy with biopsy
How is UC graded?
Truelove and Witts criteria:
Motions a day: <4, 5, >6 Rectal bleeding: small, moderate, large Temp: Resting pulse: <70, 70-90, >90 Hb: >110, 105-10, <105 ESR: <30, >30 or CRP >45
What are the extraintestinal signs of UC?
Finger Clubbing
Primary Sclerosing Cholangitis
Erythema Nodosum
Pyoderma gangrenosum
Episcleritis
What is the common causes of Ano-fistula?
Chronic Abscess
- which typically starts at the crypts
Crohn’s disease
LGV Chlamydia
Rectal foreign bodies
What is the treatment for Crohn’s:
Symptomatic but systemically well:
7 week prednisolone 40mg. reduce by 5mg weekly.
Severe: admit. IV hydrocortisone.
+
enoxaparin 40mg
If there is a patient with the red flags of cancer and has continuous UTIs, what is an important differential diagnosis?
Enterovesical fistula
- caused by colorectal cancer
If there is a tumour on the lower 1/3rd of the rectum, i.e. within the anus. what is the best surgical treatment?
Abdomino-perineal resection (AP resection)
*this takes the anus as well - differentiating it from an anterior resection
What is the strongest risk factor for anal cancer?
HPV infection
Why would a loop ileostomy be preferred over a loop colonstomy?
healing rates. ileostomies heal at a much better rate
What surgery is carried out during an emergency of the colon which will involve resection?
Hartmann’s procedure
What is the classification system used in diverticulitis?
Hinchey
What is the management of Crohn’s disease?
Induce remission:
- stop smoking
- Steroids
Maintenance:
- azathioprine
- mesalazine
What are the typical surgical complications seen in Crohn’s?
Ileocaecal resection
Surgery for perianal
- abscess drainage
- seton suturing
Strictureplasty
Small bowel resection
What are some complications of Crohn’s disease?
Small bowel cancer
Osteoporosis
Large bowel cancer
What are some other types of Colon cancers other than adenocarcinoma?
Sarcoma
Cacinoid
Lymphoma
List some risk factors for colorectal carcinoma:
Male
Age
Low fibres
Polyps
Family history
IBD - ulcerative colitis
Heavy red meats
What are the symptoms of bowel cancer?
Left sides:
- Bleeding
- Change in bowel habit
- Tenemus
- Weight loss
- Mass in iliac fossa
- Sciatica
Right sided:
- Anaemia
- Change in bowel habit
- Abdominal pain - colicky pain
- Mass felt in right iliac fossa
Acute presentation:
- Perforation
- Obstruction
- PR bleeding
What are some differentials to colorectal carcinoma?
IBD
IBS
Hemorrhoids
Diverticula disease
When should someone be referred regarding colorectal symptoms?
> 40 years with unexplained weight loss and abdominal pain
> 50 years with unexplained PR bleeding
> 60 years with iron deficiency anaemia or change in bowel habit
Positive screening
When is screening offered for colorectal carcinoma?
Every 2 years
60-74 (Scotland 50-74)
Faecal immunochemistry test
- Hb against human haemoglobin
What tests should be done in primary practice when referring someone for a colonoscopy?
FBC
Carcinoembryonic Antigen/ CEA levels
- which can be used to assess treatment as well
What additionals investigations should be done following a positive biopsy from colonoscopy of colorectal carcinoma?
CT scan - chest/ abdo/ pelvis
MRI Rectum - for rectal cancers only
- to assess depth of invasion
Endoanal ultrasound
- t1 and t2 only
What are the different types of surgeries that can be done for colorectal cancer, depending on their location:
Caeca/ Ascending/ Transverse tumours:
• Right Hemicolectomy
Descending Tumours:
• Left Hemicolectomy
Sigmoidal Tumours:
• Sigmoidcolectomy
High rectal tumours >5cm from anus:
• Anterior resection
This approach is favoured as it leaves scope for anastomosis as there is still anal sphincter left.
Low Rectal tumours <5cm from anus:
• Abdominoperineal resection/ AP resection
*this will result in a permeant colostomy as the entire:
- Distal colon
- Rectum
- Anal sphincters
Are removed.
When is chemotherapy usually indicated in bowel cancer?
> Duke C
What palliative procedures can be done in colorectal carcinoma?
Endoluminal stenting
- to by pass blockages
Stoma formations
What are the peak incidences of Crohn’s disease?
Bi-modal.
15-30years
60-80 years
Surveillance of polyps is dependent on what?
Size
Number
Histology
What is the management of polyps?
Colonoscopic polypectomy
Large ones that are unable to removed by colonoscopy are done so by:
- segmental removal of bowel
FAP is treated with by:
- proctocolectomy
- ileoanal pouch formation
Following a severe remission of UC, or >2 remission in one year what medication should a person be put on?
Oral Azathioprine
What drug increases the risk of Crohn’s disease?
NSAIDs
During an acute flare of UC, what do you want monitored?
Stats, including temperature
Stool frequency and character - Bristol stool chart
What features of colonoscopy might be seen in UC?
Pseudopolyps
What features may be seen on colonoscopy in Crohn’s?
Cobbled stoned appearance
Skip lesions
Increased goblet cells
On a barium enema of Ulcerative colitis, what might be seen?
Loss of haustra
How is the severity of a UC attack monitored?
Motions Rectal bleeding Temperature Pulse rate Hb ESR
What inflammatory marker is used to assess Ulcerative colitis?
ESR
Why do you want ABX in Ulcerative colitis?
Assess for toxic megacolon
Assess where faecal impaction ends. this gives good idea where the disease process goes to, as distal to this the inflamed bowel will just empty
What are the indications for surgical input for UC and what two operations are usually performed?
Fulminant disease
Failure of medical management
Complications - Toxic megacolon, perforation
Malignant changes
Operations:
- total proctocolectomy + Ileostomy
or
- Colectomy with Stump sewn or Ileostomy
What is used for bowel preparation surgery and what are some risks associated with this?
Sodium Picosulfate
- Hyponatremia
- Hypokalemia
What are the indications for surgery in diverticulitis?
Perforation Fistula formation Massive haemorrhage Obstruction Abscess formation
what is the general management for Colonic cancer?
Surgical resection + lymph nodes and Blood supply
Adjuvant therapy
Anastomosis/ Ileostomy
Palliative
What are the types of anal abscess that can form?
Intrasphincteric
Supralevator
Peri-anal
Ischiorectal
What are the follow ups of Colorectal cancer?
1,2,3 years - CT of chest/ Abdo/ Pelvis
1 and 5 year colonoscopy
CEA every 6 months for 5 years
What are the Hinchey classifications and which require immediate surgery?
Stage 1.
- localised abscess pericolic
Stage 2.
- Advanced abscess into the pelvis
Stage 3.
- Purulent abscess
Stage 4.
- Faecolith abscess
Stages 3 and 4 require immediate surgery
What inflammatory marker is used in Ulcerative Colitis?
ESR
How would you investigate colon cancer?
Bloods:
- FBC - blood loss
- LFTs - metastasis
- CEA
Orifices:
PR examination
Colonoscopy
X-rays:
- CT
- Barium Enema - apple core sign
When carrying out bowel removal surgery for colorectal cancer, what else must be taken?
Mesentry
Lymph nodes
Blood supply
When investigating anorectal pathology,what investigations should be conducted?
PR exam Proctoscopy MRI Scan \+/- Examination under GA \+/- Manometry of sphincter
When there is anal sepsis with fistula, when should a seton be used and when should laying open be used?
If fistula is present supra-sphincter then seton suture
If sub-sphincter it should be laid open
Risk factors for diverticular disease:
Low fibre
Use of NSAIDs
Smoking
Obesity
What are the signs and symptoms of diverticulitis and diverticular disease?
Diverticular disease:
- Flatulence
- distension
- Left iliac pain
- Constipation
- Intermittent nature
- Nausea
- classic triad is:
- Intermittent
- Bloating
- LLQ pain
Diverticulitis:
- LLQ Pain - acute and sharp
- PR blood
- Tachycardia
- Low grade fever
- Nausea
- High white cell count
- UTI like symptoms
Should Barium Enema be used in acute diverticulitis?
No - risk of perforation
What is the finding seen on barium swallow in Crohn’s disease?
String sign of Kantor
Rose thorn appearance
What are the causes to a fistula in Ano and what is the rule associated with it?
Crohn’s disease
TB
Goodall’s rule.
If anterior the exit will be anterior and straight line.
If posterior the exit will be posterior and take a curved course.
What are the location of haemorrhoids?
3, 7, 11
