Colorectal surgery

Question 1

Lower left-sided abdominal pain, worse on eating and better with defecation; with PR bleed, bloating, constipation?

Answer 1

Uncomplicated diverticular disease/ diverticulitis

Question 2

Severe lower left-sided abdominal pain with generalised peritonitis, worse on eating and better with defecation; with pyrexia, tachycardia, nausea/ vomiting, anorexia, PR bleed, bloating, constipation

Answer 2

Complicated diverticular disease/ diverticulitis e.g. with bowel perforation, abscess formation

Question 3

What is dumping syndrome?

Answer 3

A complication that arises after gastric surgery e.g. gastric bypass surgery or gastrectomy. Symptoms of abdominal cramping, bloatedness, nausea/ vomiting occurs within 30 min (early) or 2-3 hours (late) after a meal.

Question 4

How do you manage diverticulitis?

Answer 4

Patient only to have clear fluids, moving to solid intake over 3 days. Give PO or IV antibiotics. Consider surgery.

Question 5

What is Hartmann’s procedure?

Answer 5

The surgical resection of the rectosigmoid colon with closure of the anorectal stump and formation of an end colostomy. It may be used in emergency or acute scenarios, and is reversible.

Question 6

What are some protective factors against bowel cancer?

Answer 6

High fibre diet, physical activity, aspirin

Question 7

What is the most common cause of bowel cancer, and what is the most common first abnormality?

Answer 7

Adenocarcinoma; unexplained anaemia

Question 8

What are the most common sites ad symptoms for bowel cancer?

Answer 8

Rectum and sigmoid cancer (left sided) - PR bleeding, tenesmus, change in bowel habit

Right sided cancer - bowel obstruction and abdo pain more common

Weight loss, abdo pain, IDA in both.

Question 9

What is the blood supply to the foregut, midgut, hindgut?

Answer 9

Foregut - coeliac
Midgut - superior mesenteric
Hindgut - inferior mesenteric

Question 10

What is a radiological sign of pneumoperitoneum?

Answer 10

Double wall/ Rigler’s sign - seen on an abdominal radiograph when gas is outlining both sides of the bowel wall, i.e. gas within the bowel’s lumen and gas within the peritoneal cavity

Question 11

What are the parameters for bowel dilatation on AXR?

Answer 11

Small bowel >3cm
Large bowel >6cm
Caecum >9cm

Question 12

What are signs of small vs. large bowel obstruction?

Answer 12

Small - valvulae conniventes

Large - haustra

Question 13

What are the criteria for diagnosing ARDS?

Answer 13

1. Hypoxemia - PaO2/ FiO2 <200
2. Acute onset
3. Bilateral pulmonary infiltrates on CXR
4. Pulmonary capillary wedge pressure

Question 14

How do you manage bowel obstruction?

Answer 14

Drip and suck - NGT/ Ryles tube in, maintenance fluids, NBM, catheterise, AXR/ CXR, bloods
CT scan - establish cause of obstruction

Gastrograffin - diagnostic and therapeutic (peristaltic effects)

Surgery (in strangulation/ closed loop obstruction)

Large bowel obstruction usually managed conservatively ~ endoscopic stenting or with Hartmann’s if high risk of perforation

Question 15

What is Hartmann’s procedure?

Answer 15

Resect a part of the colon, bring the open end of the bowel to the abdo wall, create an anorectal stump and a reversible stoma

Question 16

How do you manage a patient with a 4 day history of perianal swelling and pain not improving with PO flucloxacillin?

Answer 16

Suspicion of perianal abscess. Discuss and consent for examination under anaesthetic (EUA) - incision and drainage.

Question 17

What is the 1st line investigation in an older patient with abdo pain, fevers, change. in bowel habit?

Answer 17

In older patients you may be worried about diverticulitis and would like to exclude malignancy - do a CT abdo pelvis w contrast