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
