Colorectal Surgery Flashcards
A 55 year old man undergoes a colonoscopy and a colonic polyp is identified. It has a lobular appearance and is located on a stalk in the sigmoid colon. Which of the processes below best accounts for this finding?
Apoptosis Metaplasia Dysplasia Calcification Degeneration
C- Dysplasia
Most colonic polyps described above are adenomas. These may have associated dysplasia. The more high grade the dysplasia the greater the level of clinical concern.
A 19 year old male presents with bright red rectal bleeding that occurs post defecation onto the paper and into the pan. Apart from constipation his bowel habit is normal. Digital rectal examination is normal. What is the most likely cause?
Haemorrhoidal disease Fissure in ano Solitary rectal ulcer Rectal cancer Crohns disease
Haemorrhoidal disease
Uncomplicated grade 1 or 2 haemorrhoids are usually impalpable
This is likely to be haemorrhoidal disease. A sigmoidoscopy should always be performed to exclude more sinister pathology.
Which of the following hepatobiliary disorders are most classically associated with ulcerative colitis?
Gallstones Primary sclerosing cholangitis Bile duct stones Liver hamartomas Hepatocellular carcinoma
Primary sclerosing cholangitis
Primary sclerosing cholangitis is an idiopathic inflammation of the bile ducts. It may result in episodes of cholestasis and cholangitis and ultimately result in the need for liver transplantation. It carries a 10% risk of malignant transformation. Crohns disease is associated with gallstones due to impaired entero-hepatic circulation. Apart from PSC, ulcerative colitis does not increase the risk of other liver lesions.
A 75 year old lady is admitted with a 12 hour history of absolute constipation, vomiting and colicky abdominal pain. On examination, her abdomen is distended and she has right sided tenderness. Imaging demonstrates an obstructing hepatic flexure tumour with a caecal diameter of 11cm. What is the best course of action?
Undertake an immediate laparotomy
Commence resuscitation with intravenous fluids and then undertake a laparotomy 2-4 hours later
Administer antibiotics and intravenous fluids and schedule surgery for the following day
Arrange a colonoscopy
Administer oral sodium picosulphate
Commence resuscitation with intravenous fluids and then undertake a laparotomy 2-4 hours later
The sun should not rise and set on unrelieved large bowel obstruction! This patient has a competent ileocaecal valve. As a result lack of surgery would result in caecal perforation leading to faecal peritonitis with and associated high mortality rate.
A 43 year old woman undergoes a sigmoid colectomy for carcinoma. The histology report shows pT3, pN1, systemic staging is M0. She is otherwise well. What is the most appropriate course of action?
Active surveillance with CT scans at 6 and 12 months and monthly CEA measurement
Referral for chemotherapy
Radiotherapy to the resection site
Active surveillance with colonoscopy at 12 months and CT scan at 6 months and 3 monthly CEA measurement
Discharge
Referral for chemotherapy
Chemotherapy for colonic cancer is offered when patients have nodal disease.
Diagnose with CRC
- Colonoscopy/ Ct colonography
A 55 year old man is found to have an anal cancer. His staging investigations show no metastatic disease. What is the most appropriate treatment?
Radical abdominoperineal excision of the anus and rectum Radical chemoradiotherapy Excision proctectomy External beam irradiation alone Chemotherapy alone
Radical chemoradiotherapy
Combined chemoradiotherapy is the standard treatment for anal cancer
A 53 year old man presents with a full thickness external rectal prolapse. Which of the following procedures would be the most suitable surgical option?
Rectopexy Delormes Altmeirs Thirsch tape Abdomino-perineal excision of the rectum
Rectopexy
As this man is relatively young and has full thickness prolapse a rectopexy is the most appropriate procedure. It will give the lowest recurrence rates.
A 78 year old lady from a nursing home is admitted with a 24 hour history of absolute constipation and abdominal pain. On examination, she has a distended abdomen with a soft mass in her left iliac fossa. An x-ray is performed which shows a large dilated loop of bowel in the left iliac fossa which contains a fluid level. What is the most likely diagnosis?
Caecal volvulus Sigmoid volvulus Incarcerated femoral hernia Diverticular stricture Malignant colonic stricture
Sigmoid volvulus
Sigmoid volvulus may present with an asymmetrical mass in an elderly patient. It may contain a fluid level, visible on plain films. It’s very rare for femoral hernia to cause large bowel obstruction.
Which of the following statements in relation to fistula in ano is untrue?
High fistulae are safest treated with a seton insertion
Low fistulae may be laid open
They are typically probed with Lockhart Mummery probes
When discovered during incision and drainage of peri anal abscess; should always be probed to locate the internal opening
When complicating Crohns disease, may respond to infliximab
When discovered during incision and drainage of peri anal abscess; should always be probed to locate the internal opening
Probing fistulae during acute sepsis is associated with a high complication rate and should not be undertaken routinely.
A 34 year old male presents with painful rectal bleeding and a fissure in ano is suspected. On examination he has an epithelial defect at the mucocutaenous junction that is located anteriorly. Approximately what proportion of patients with fissure in ano will present with this pattern of disease?
90% 10% 50% 25% 100%
10%
Only a minority of patients with fissure in ano will have an anteriorly sited fissure. They are particularly rare in males and an anterior fissure in a man should prompt a search for an underlying cause.
A 62 year old man has previously undergone a left hemicolectomy for carcinoma of the descending colon. On follow up imaging he is found to have two deposits of metastatic disease located in the right lobe of his liver. What is the best treatment strategy?
Chemotherapy alone Chemotherapy followed by surgical resection Radiofrequency ablation Chemoradiotherapy Palliation
Chemotherapy followed by surgical resection
Liver metastasis from colorectal cancer are still potentially curable.
Radiofrequency ablation is an option for those patients who lack the physiological reserve for surgery. However, there is a higher longer term recurrence rates with all the non resectional strategies. There is no role for radiotherapy.
A 23 year old man presents with diarrhoea and passage of mucous. He is suspected of having ulcerative colitis. Which of the following is least likely to be associated with this condition?
Superficial mucosal inflammation in the colon
Significant risk of dysplasia in long standing disease
Episodes of large bowel obstruction during acute attacks
Haemorrhage
Disease sparing the anal canal
Episodes of large bowel obstruction during acute attacks
Large bowel obstruction is not a feature of UC, patients may develop megacolon. However, this is a different entity both diagnostically and clinically. Ulcerative colitis does not affect the anal canal and the anal transitional zone. Inflammation is superficial. Dysplasia can occur in 2% overall, but increases significantly if disease has been present over 20 years duration. Granulomas are features of crohn’s disease.
Other features:
Disease maximal in the rectum and may spread proximally
Contact bleeding
Longstanding UC crypt atrophy and metaplasia/dysplasia
What is the main risk factor for the development of anal cancer?
Smoking Ano-receptive intercourse Immunosuppression Infection with Epstein Barr virus Infection with Human Papilloma virus
Infection with Human Papilloma virus
Anal cancer is strongly associated with HPV 16 infection
A 22 year old man presents with a 6 day history of passage of bloody diarrhoea with passage of mucous and slime. He is passing an average of 8 to 9 bowel movements per day. On digital rectal examination there is no discrete abnormality to feel, but there is some blood stained mucous on the glove. What is the most likely diagnosis?
Solitary rectal ulcer syndrome Ulcerative colitis Irritable bowel syndrome Rectal cancer Diverticulitis
Ulcerative colitis
The passage of bloody diarrhoea together with mucus and a short history makes this a likely first presentation of inflammatory bowel disease. A rectal malignancy in a 22 year old would be a very unlikely event. The history is too short to be consistent with solitary rectal ulcer.
A 65 year old lady is admitted with large bowel obstruction. On investigation with CT, she is found to have a tumour of the mid rectum with no evidence of metastatic disease. What is the most appropriate course of action?
Formation of a loop colostomy Laparotomy and Hartmanns procedure Pan proctocolectomy and end ileostomy Low anterior resection and covering loop ileostomy Low anterior resection and end colostomy
Formation of a loop colostomy
Avoid emergency resections in large bowel obstruction due to rectal cancer
This patient has presented with large bowel obstruction. However, in the case of rectal cancer, she is incompletely staged as ability to completely resect the lesion can only be determined with MRI scanning and this information is not provided. Even if the lesion were resectable, in the emergency setting, it is often safer to undertake a simple procedure such as a loop colostomy and then complete surgery at a later date. A low anterior resection and loop ileostomy in this situation would almost certainly leak (and for the reasons outlined above, may be incomplete).
A 30 year old lady presents with painful bright red bleeding that occurs post defecation. Digital rectal examination is too uncomfortable for the patient, perineal inspection shows a prominent posterior skin tag. What is the best course of action?
Arrange for removal of the skin tag Arrange a haemorrhoidectomy Prescribe topical diltiazem Injection of 88% aqueous phenol Arrange a sphincterotomy
Prescribe topical diltiazem
The skin tag will be the sentinel pile of a posterior fissure and removal would be unwise. Fissures should be treated medically in the first instance.
A 73 year old lady is admitted with a brisk rectal bleed. She is otherwise well and the bleed settles. On examination, her abdomen is soft and non tender. Elective colonoscopy shows a small erythematous lesion in the right colon, but no other abnormality. What is the likely cause?
Diverticular bleed Angiodysplasia Colonic cancer Ischaemia Infective colitis
Angiodysplasia
Angiodysplasia can be difficult to identify and treat. The colonoscopic stigmata are easily missed by poor bowel preparation.
A 24 year old man presents with a 10 day history of right sided abdominal pain. Prior to this he was well. On examination, he has a low grade fever and a mass palpable in the right iliac fossa. The rest of his abdomen is soft. An abdominal USS demonstrates matted bowel loops surrounding a thickened appendix. What is the best course of action?
Arrange a laparotomy and right hemicolectomy Perform a laparoscopic appendicectomy Perform an open appendicectomy Manage conservatively with antibiotics Arrange a colonoscopy
Manage conservatively with antibiotics
This man is likely to have an appendix mass. There is no history suggestive of inflammatory bowel disease. These are usually managed without surgery, especially in the absence of peritoneal signs. Broad spectrum antibiotics are required. In the past an interval appendicectomy was performed. This is rare now and in most cases the process resolves with fibrosis of the appendix.
Administration of metronidazole reduce wound infection rate
What is the most likely explanation for a 63 year old male to complain of a painless blood stained mucous rectal discharge 6 months following a Hartmann’s procedure?
Pelvic abscess Crohns disease Dysplasia of the rectal stump Diversion proctitis Fissure in ano
Diversion proctitis
Once the bowel has been disconnected, a degree of inflammation is commonly seen in the quiescent bowel. This is typically referred to as diversion colitis. Dysplasia is not usually seen in this context as a Hartmanns procedure is not usually a treatment modality used for IBD (which is the main risk factor for dysplasia).
A 59 year old man presents with recurrent episodes of urinary sepsis. In his history he mentions that he has suffered from recurrent attacks of left iliac fossa pain over the past few months. He has also notices bubbles in his urine. He undergoes a CT scan which shows a large inflammatory mass in the left iliac fossa. No other abnormality is detected. The most likely diagnosis is:
Ulcerative colitis Crohns disease Mesenteric ischaemia Diverticular disease Rectal cancer
Diverticular disease
is one of the commonest causes of colovesical fistula
Recurrent attacks of diverticulitis may cause the development of local abscesses which may erode into the bladder resulting in urinary sepsis and pneumaturia. This would be an unusual presentation from Crohns disease and rectal cancer would be more distally sited and generally evidence of extra colonic disease would be present if the case were malignant and this advanced.
A 28 year old male presents with painful, bright red, rectal bleeding. On examination he is found to have a posteriorly sited, midline, fissure in ano. What is the most appropriate treatment?
Topical GTN paste Sub lingual GTN paste Anal stretch Advancement flap Tailored division of the external anal sphincter
Topical GTN paste
Topical vasodilator therapy is the most commonly utilised treatment for fissure in ano. Surgical division of the internal anal sphincter is a reasonable treatment option in a young male. Division of the external sphincter will almost certainly result in incontinence and is not performed. Anal stretches were associated with a high rate of external sphincter injuries and have been discontinued for this reason.
A 70 year old female is admitted with a history of passing brown coloured urine and abdominal distension. Clinically she has features of large bowel obstruction with central abdominal tenderness. She is maximally tender in the left iliac fossa. There is no evidence of haemodynamic instability. What is the most appropriate investigation?
Cystogram
Abdominal X-ray of the kidney, ureters and bladder
Computerised tomogram of the abdomen and pelvis
Flexible sigmoidoscopy
Barium enema
Computerised tomogram of the abdomen and pelvis
This lady is most likely to have a colovesical fistula complicating diverticular disease of the sigmoid colon. In addition she may also have developed a diverticular stricture resulting in large bowel obstruction. A locally advanced tumour of the sigmoid colon may produce a similar clinical picture. The best investigation of this acute surgical patient is an abdominal CT scan, this will demonstrate the site of the disease and also supply regional information such as organ involvement and other local complications such as a pericolic abscess.
A 21 year old lady presents with a 6 month history of an offensive discharge from the anus. She is otherwise well, but is increasingly annoyed at the need to wear pads. On examination, she has a small epithelial defect in the 5 o’clock position, approximately 3cm from the anal verge. What is the most likely cause?
Fissure in ano Fistula in ano External haemorrhoid Squamous cell carcinoma of the anus Proctalgia fugax
Fistula in ano
Fistulas usually occur following previous ano-rectal sepsis. The discharge may be foul smelling and troublesome. Patients should be listed for examination under anaesthesia. Fistulas which are low and have little or no sphincter involvement are usually laid open.
A 39 year old man has suffered from terminal ileal Crohns disease for the past 20 years. Which condition is he least likely to develop?
Gallstones Malabsorption Pyoderma gangrenosum Amyloidosis Feltys syndrome
Feltys syndrome
Feltys syndrome:
Rheumatoid disease
Splenomegaly
Neutropenia
Feltys syndrome is associated with rheumatoid disease. Individuals with long standing Crohns disease are at risk of gallstones because of impairment of the enterohepatic recycling of bile salts. Formation of entero-enteric fistulation may produce malabsorption. Amyloidosis may complicate chronic inflammatory states.
A 24 year old woman presents with a long history of obstructed defecation and chronic constipation. She often strains to open her bowels for long periods and occasionally notices that she has passed a small amount of blood. On examination, she has an indurated area located anteriorly approximately 3cm proximal to the anal verge. What is the most likely diagnosis?
Haemorrhoids Rectal cancer Ulcerative colitis Solitary rectal ulcer syndrome Fissure in ano
Solitary rectal ulcer syndrome
Solitary rectal ulcers are associated with chronic constipation and straining. It will need to be biopsied to exclude malignancy (the histological appearances are characteristic). Diagnostic work up should include endoscopy and probably defecating proctogram and ano-rectal manometry studies.
A 23 year old lady presents with a posteriorly sited fissure in ano. Treatment with stool softeners and topical GTN has failed to improve matters. Which of the following would be the most appropriate next management step?
Lords procedure Injection of botulinum toxin Lateral internal sphincterotomy Endoanal advancement flap Surgical division of the external anal sphincter
Injection of botulinum toxin
The next most appropriate management option when GTN or other topical nitrates has failed is to consider botulinum toxin injection. In males a lateral internal sphincterotomy would be an acceptable alternative. In a female who has yet to conceive this may predispose to delayed increased risk of sphincter dysfunction. Division of the external sphincter will result in faecal incontinence and is not a justified treatment for fissure.
A 19 year old lady has a long standing history of diarrhoea and weight loss. She is investigated with an upper gastro intestinal endoscopy which is normal. A small bowel contrast study shows a terminal ileal stricture. A colonoscopy was performed which was normal but the endoscopist was unable to intubate the terminal ileum. One week after the colonoscopy she is admitted with small bowel obstruction. Steroids are administered but despite this she fails to improve. What is the most appropriate treatment?
Administration of steroids at increased dose Right hemicolectomy Small bowel resection Sub total colectomy Pan proctocolectomy
Right hemicolectomy
Crohns disease commonly affects the terminal ileum and in this case the ileocaecal valve, this means some form of colonic resection will be needed in addition to the small bowel resection.
It is likely that this lady has terminal ileal disease. Although first presentation of Crohns disease is usually managed with IV steroids, these have been trialed here and failed. A resection will remove the stricturing disease. If proximal small bowel disease has not been excluded pre-operatively then this must be evaluated during surgery to exclude other small bowel strictures. Note that since the endoscopist could not enter the terminal ileum, the ICV is also involved and this means some form of right sided colonic resection is needed. It is not appropriate to simply excise the valve and small bowel and then proceed to an ileocolic anastomosis at the site of the old ICV.
Which of the following is not an extraintestinal feature of Crohns disease?
Iritis Clubbing Aphthous ulcers Erythema multiforme Pyoderma gangrenosum
Pyoderma gangrenosum
Extraintestinal manifestation of inflammatory bowel disease: A PIE SAC
Aphthous ulcers Pyoderma gangrenosum Iritis Erythema nodosum Sclerosing cholangitis Arthritis Clubbing
A 22 year old man has a long history of ulcerative colitis. His symptoms are well controlled with steroids. However, attempts at steroid weaning and use of steroid sparing drugs have repeatedly failed. He wishes to avoid a permanent stoma. Which of the following is the best operative option?
Pan proctocolectomy and end ileostomy
Abdomino perineal excision of the colon and rectum and end colostomy
Abdomino perineal excision of the colon and rectum and construction of an ileo anal pouch
Pan proctocolectomy and construction of an ileo anal pouch
Sub total colectomy and construction of an ileo anal pouch
Pan proctocolectomy and construction of an ileo anal pouch
Don’t confuse AP resection and proctectomy. The former is a cancer related procedure.
In patients with UC where medical management is not successful, surgical resection may offer a chance of cure. Those patients wishing to avoid a permanent stoma may be considered for an ileoanal pouch. However, this procedure is only offered in the elective setting.
A 62 year old man is identified as having a rectal cancer. Following diagnostic work up no metastatic disease is identified. The tumour is 2cm from the anal verge. On MRI, lesion is T2, N0. Which of the following represents the correct course of action?
Proceed to abdomino-perineal excision of the colon and rectum (ELAPE)
Undertake a low anterior resection and loop ileostomy
Undertake a Hartmanns procedure
Offer radical external beam radiotherapy followed by abdomino-perineal excision of the colon and rectum (ELAPE)
Offer radical radiotherapy followed by low anterior resection and loop ileostomy
Proceed to abdomino-perineal excision of the colon and rectum (ELAPE)
The tumour is too low for restorative surgery to be considered with an acceptable functional outcome. The tumour will therefore require an ELAPE style abdomino perineal resection. Since the lesion is T2 there is no prognostic benefit from adding radiotherapy which will confer additional morbidity.
A 63 year old man presents with episodic rectal bleeding the blood tends to be dark in colour and may be mixed with stool. His bowel habit has been erratic since an abdominal aortic aneurysm repair 6 weeks previously. What is the most likely cause?
Ischaemic colitis Diverticulitis Angiodysplasia Cancer Ulcerative colitis
Ischaemic colitis
The inferior mesenteric artery may have been ligated and being an arteriopath collateral flow through the marginal may be imperfect.
A 22 year old lady has a long history of severe perianal Crohns disease with multiple fistulae. She is keen to avoid a stoma. However, she has progressive disease and multiple episodes of rectal bleeding. A colonoscopy shows rectal disease only and a small bowel study shows no involvement with Crohns. What is the best operative strategy?
Abdomino perineal excision of the colon and rectum Proctectomy and end stoma Pan proctocolectomy and ileoanal pouch Loop colostomy alone Sub total colectomy
Proctectomy and end stoma
Crohns disease is a contra indication to having an ileo-anal pouch as its associated with very poor pouch function and significant complications.
Whilst the patient wishes to avoid a stoma, that’s inevitable here.
During a colonoscopy, a patient is found to have a colonic cancer in the caecum and a 1cm polyp (which looks adenomatous) in the sigmoid colon. What is the correct management of the sigmoid polyp?
Undertake a snare polypectomy
Leave in situ until the cancer has been resected
Perform a hot biopsy
Perform a cold biopsy
Resect the sigmoid at the same time as the cancer resection
Leave in situ until the cancer has been resected
Dysplasia and cancer are not the same disease. All colonic adenomas are dysplastic. Adenomas greater than 2cm may harbor foci of malignancy within them. However, many have dysplastic cells only. These do not require segmental resection.
When a cancer has been identified during endoscopy, it is safest to avoid undertaking polyp interventions as there is a risk of seeding.
In summary, do NOT remove polyps until after the cancer has been resected.
A 73 year old lady presents with large bowel obstruction. On examination, she has a rectal cancer 6cm from the anal verge which has occluded the colonic lumen. An abdominal x-ray shows a caecal diameter of 7cm. Which of the management strategies outlined below is the most appropriate?
Construction of a loop ileostomy
Construction of a loop colostomy
Construction of a venting caecostomy
Abdomino-perineal resection of the colon and rectum
Low anterior resection and loop ileostomy
Construction of a loop colostomy
Bowel obstruction due to RECTAL cancer should be treated by loop colostomy.
Bowel obstruction due to obstructing left sided COLON cancer is usually treated by resection of the primary lesion and formation of colostomy.
This patient should be defunctioned, definitive surgery should wait until staging is completed. A loop ileostomy will not satisfactorily decompress an acutely obstructed colon. Low rectal cancers that are obstructed should not usually be primarily resected. The obstructed colon that would be used for anastomosis would carry a high risk of anastomotic dehiscence. In addition, as this is an emergency presentation, staging may not be completed, an attempted resection may therefore compromise the circumferential resection margin, with an associated risk of local recurrence.
A 77 year old man is admitted with large bowel obstruction and on investigation with an abdominal CT scan is found to have an obstructing cancer of the sigmoid colon. What is the most appropriate course of action?
Laparotomy, sigmoid colectomy and formation of end colostomy
Laparotomy and loop colostomy
Laparotomy and loop ileostomy
Laparotomy, high anterior resection and colo-rectal anastomosis
Palliation
Laparotomy, sigmoid colectomy and formation of end colostomy
Obstructing sigmoid cancers can be resected or stented. If stented, then the patient may need definitive surgery later. If resected, then a resection and end colostomy (Hartmann’s ) procedure is usually undertaken because of the risks of anastomotic leak in the setting of anastomosing obstructed colon to rectum.
Which of the following is seen more commonly with Crohns disease rather than ulcerative colitis?
Mucosal islands at endoscopy Goblet cell depletion on biopsy Fat wrapping of the terminal ileum Attenuated symptoms in smokers Toxic megacolon
Fat wrapping of the terminal ileum
Crohns disease is worse in smokers and smoking is an independent risk factor for disease recurrence following resection.
Fat wrapping of the terminal ileum is commonly seen in patients with ileal disease (the commonest disease site). The mesenteric fat in patients with IBD is often dense, hard and prone to considerable haemorrhage during surgery. At endoscopy, the mucosa in patients with Crohns disease is said to resemble cobblestones, mucosal islands (pseudopolyps) are seen in ulcerative colitis.
A 24 year old male was admitted with bloody diarrhea, cramping abdominal pain and weight loss. Colonoscopy revealed a friable, diffusely red mucosa involving the rectum and sigmoid colon. The mucosa was normal proximal to this. The disease progressed with time to involve most of the entire colon, but not the ileum. Many years later, a colonic biopsy shows high grade epithelial dysplasia. What is the most likely initial diagnosis?
Colonic tuberculosis Collagenous colitis Ulcerative colitis Crohns disease Ischaemic colitis
Ulcerative colitis
Ulcerative colitis spreads in a progressive distal to proximal manner. Over time a dysplastic transformation is recognised. Such endoscopic findings mandate a minimum of close endoscopic surveillance and if they occur in association with a colonic mass then usually a pancproctocolectomy.
A 74 year old gentleman presents with an obstructing carcinoma of the splenic flexure. Attempts at placement of a colonic stent have failed. Which of the operative options listed below offers the best solution to this problem?
Sub total colectomy Extended right hemicolectomy Standard right hemicolectomy Standard left hemicolectomy Transverse colectomy
Extended right hemicolectomy
Standard right hemicolectomy involves colonic division to the right of the middle colic vessels
Extended right hemicolectomy involves division of the middle colic vessels and usually resection of the splenic flexure as well.
The question always causes confusion and to understand it the information needs to be carefully read. Firstly, the tumour is definitely at the splenic flexure and the second point is that the operation is definitely an extended right hemicolectomy. A left hemicolectomy or even the older operation of a transverse colectomy could be considered if the patient was not obstructed. However, when obstruction is present, an extended right hemicolectomy (which involves an ileocolic anastomosis) is relatively safe even in the obstructed setting.
A 78 year old man has undergone a hemi-arthroplasty for an intracapsular hip fracture. Post operatively he develops electrolyte derangement and receives intravenous fluids. Over the next 24 hours he develops marked abdominal distension. On examination, he has a tense, tympanic abdomen which is not painful. A contrast enema shows flow of contrast through to the caecum and through the ileocaecal valve. What is the most likely cause?
Ogilvies syndrome Diverticular stricture Malignant stricture Volvulus Adhesive obstruction
Ogilvies syndrome
Patients with electrolyte disturbance and previous surgery may develop colonic pseudo-obstruction (Ogilvies syndrome). The diagnosis is made using a contrast enema and treatment is usually directed at the underlying cause with colonic decompression if indicated.
