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Surgery Block > General - Large Bowel > Flashcards

General - Large Bowel Flashcards

1
Q

What is the name given to acute pseudo-obstruction?

A

Oglivie’s syndrome

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2
Q

Define pseudo-obstruction

A

Dilation of the colon due to an adynamic bowel in the absence of mechanical obstruction

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3
Q

What is thought to cause pseudo obstruction?

A

Interruption of autonomic nervous supply to the colon resulting in the absence of smooth muscle action in the bowel

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4
Q

What are some of the common causes of pseudo obstruction?

A
  • Electrolyte imbalance
  • Endocrine disorders
  • Medication eg. opioids, CCBs, antidepressants
  • Recent stress to the body
  • Recent CVS event
  • Parkinsons
  • Hirschsprung’s
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5
Q

Describe the typical clinical presentation of pseudo obstruction

A
  • Abdo pain
  • Abdo distension
  • Constipation
  • Vomiting
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6
Q

What is focal tenderness indicative of on an abdo exam?

A

Ischaemia - key warning sign

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7
Q

Why do you still usually hear bowel sounds in pseudo obstruction?

A

Colon specific pathology

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8
Q

Give the main DDx for pseudo obstruction

A
  • Mechanical obstruction
  • Paralytic ileum
  • Toxic megacolon
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9
Q

How is pseudo-obstruction investigated for radiologically? Why?

A

CT Abdo-Pelvis with IV contrast

  • Dilation of colon
  • Excludes mechanical obstruction
  • Assesses for complications
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10
Q

What is done for cases of pseudo obstruction lasting >24hrs with conservative management?

A

Endoscopic decompression

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11
Q

What medication can be given in pseudo obstruction?

A

IV neostigmine (anti cholinesterase)

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12
Q

What is a volvulus?

A

Twisting of an intestinal loop around its mesenteric attachment causing a closed loop bowel obstruction

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13
Q

Why is the sigmoid colon the most common site of volvulus?

A

Long mesentery (which increases with age)

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14
Q

What are the risk factors for volvulus development?

A
  • Increasing age
  • Neuropsychiatric disorders
  • Nursing home resident
  • Chronic constipation/laxative use
  • Male
  • Previous abdo surgery
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15
Q

Describe the classical presentation of a sigmoid volvulus

A
  • Colicky pain
  • Abdo distension
  • Absolute constipation
  • Late vomiting
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16
Q

How may volvulus be differentiated from other obstructional causes in terms of presentation?

A

Rapid onset of symptoms (over a few hours) and degree of distension

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17
Q

What is the initial investigation for suspected bowel obstruction?

A

CT Abdo-Pelvis scan with contrast

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18
Q

What is seen on a CT scan of sigmoid volvulus?

A

Very dilated sigmoid colon with a ‘whirl sign’ (from twisting mesentery at base)

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19
Q

What is the characteristic finding on an AXR for sigmoid volvulus?

A

Coffee bean sign

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20
Q

What are the indications for surgical management of a sigmoid volvulus?

A
  • Colonic ischaemia
  • Perforation
  • Repeated failed attempts at decompression
  • Necrotic bowel noted at endoscopy
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21
Q

What is the initial management for sigmoid volvulus?

A

Sigmoidoscope decompression with insertion of a flatus tube

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22
Q

What surgery is definitive for recurrent volvulus?

A

Elective sigmoidectomy with primary anastomosis

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23
Q

In what age groups does caecal volvulus tend to occur?

A

Bimodal distribution

  • 10-29yrs
  • 60-79yrs
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24
Q

What is the management for caecal volvulus?

A

Laparotomy and ileocaecal resection

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25
Q

What is a diverticulum?

A

Outpouching of bowel wall composed of mucosa

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26
Q

What are the three manifestations of diverticular disease?

A
  • Diverticulosis = presence of diverticulum
  • Divertucular disease = symptomatic diverticulum
  • Diverticulitis = diverticular inflammation
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27
Q

Where are diverticulum most commonly found?

A

Sigmoid colon

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28
Q

Briefly describe the pathophysiology of divertucular disease

A
  1. With age there is weakening of the bowel wall
  2. Movement of stool causes an increase in luminal pressure
  3. This causes out pouching of the mucosa in weaker areas
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29
Q

What is complicated diverticulitis?

A

Presence of abscesses, fistulae, strictures, or free perforation

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30
Q

What risk factors are there for formation of diverticulum?

A
  • Low fibre
  • Obesity
  • Smoking
  • FHx
  • NSAID use
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31
Q

How is diverticulosis normally diagnosed?

A

Incidentally on a routine CT or colonoscopy

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32
Q

Describe the classic clinical features of a patient with diverticular disease

A
  • Left lower abdo pain
  • Colicky pain relieved by defecation
  • Altered bowel habit
  • Nausea
  • Flatulence
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33
Q

What will diverticulitis typically present with?

A
  • Abdominal pain
  • Localised tenderness (Typically LIF)
  • Pyrexia
  • N +/- V
  • PR bleeding (sudden + painless)
  • Anorexia
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34
Q

List the main complications of diverticular disease

A
  • Pericolic abscess
  • Fistula formation
  • Bowel obstruction
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35
Q

What are the main DDx for diverticular disease?

A
  • IBD

- Bowel cancer

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36
Q

What initial investigation is used for diverticular disease?

A

Flexible sigmoidoscopy

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37
Q

Why should a sigmoidoscopy or colonoscopy never be used for suspected diverticulitis?

A

Risk of perforation

38
Q

What investigation is used for suspected diverticulitis?

A

CT abdo-pelvis scan

39
Q

What findings are seen on a CT scan in diverticulitis?

A
  • Thickening of colonic wall
  • Pericolonic fat stranding
  • Abscesses
  • Localised air bubbles/free air
40
Q

What staging system is used for acute diverticulitis?

What is it based on?

A

Hinchey Classification

Uses CT findings

41
Q

What conservative management should be given for suspected diverticulitis?

A
  • IV ABx
  • IV fluids
  • Bowel rest
  • Analgesia
42
Q

How long do symptoms typically take to improve with conservative management of diverticulitis?

A

2-3 days

43
Q

When is emergency surgery needed for diverticulitis?

A
  • Perforation with faecal peritonitis

- Overwhelming sepsis

44
Q

When is urgent surgery indicated in diverticulitis?

A

Those failing to improve despite medical therapy or percutaneous drainage

45
Q

What surgical intervention may be indicated for diverticulitis?

A

Bowel resection - typically Hartmann’s procedure

46
Q

What is Hartmann’s procedure?

A

Resection of the sigmoid colon with the formation of an end colostomy and closure of the rectal stump

47
Q

What is needed following resolution of diverticulitis?

A

Outpatient colonoscopy

48
Q

What causes appendicitis?

A

Direct luminal obstruction:

  • Faecolith
  • Lymphoid hyperplasia
  • Impacted stool
  • Appendiceal or caecal tumour
49
Q

What age group does appendicitis tend to affect?

A

20-30yrs

50
Q

List the main risk factors for appendicitis

A
  • FHx
  • Caucasian
  • Seasonal presentation in summer
51
Q

Describe the pain felt in appendicitis

A

Peri-umbilical dull and poorly localised initially, then migrates to RIF and is well localised and sharp

52
Q

What are the main symptoms patients experience in appendicitis?

A
  • Abdominal pain (periumbilical then RIF)
  • Vomiting (after pain)
  • Anorexia
  • Nausea
  • Diarrhoea
  • Constipation
53
Q

What specific signs are seen on examination of a patient with appendicitis?

A
  • Rebound tenderness
  • Percussion pain over McBurney’s point
  • Rovsing’s sign
  • Psoas sign
  • Guarding (perf)
54
Q

What is Rovsing’s sign?

A

RIF pain on palpation in LIF

55
Q

What is Psoas sign?

A

RIF pain with extension of the right hip

56
Q

What are the main GI DDx for appendicitis?

A
  • Mesenteric adenitis
  • Diverticulitis
  • IBD
  • Meckel’s diverticulum
57
Q

What are the main renal DDx for appendicitis?

A
  • Ureteric stones
  • UTI
  • Pyelonephritis
58
Q

What are the main GU DDx for appendicitis?

A
  • Ectopic preg
  • Ovarian cyst rupture
  • Testicular torsion
  • Epidiymo-orchitis
  • PID
59
Q

What investigations are required for a patient with appendicitis?

A
  • Urinalysis
  • Pregnancy test
  • Routine bloods
60
Q

What imaging techniques can be used for appendicitis?

A
  • Trans abdominal USS

- CT scan

61
Q

In which patients is an abdo USS used for appendicitis?

A

Children

62
Q

Why is a CT scan useful when assessing appendicitis?

A

Identifies any potential malignancy causing or presenting as appendicitis

63
Q

What risk stratification scores are there for appendicitis?

A
  • Alvorado score

- Appendicitis Inflammatory Response Score (AIR)

64
Q

What does an AIR score of 9-12 mean?

A

High risk patient - surgical exploration recommended

65
Q

What is the definitive management for appendicitis?

A

Laparoscopic appendicectomy

66
Q

List the main complications of appendicitis

A
  • Perforation
  • Surgical site infection
  • Appendix mass
  • Pelvic abscess
67
Q

What is an appendix mass?

A

Where the momentum and small bowel adhere to the appendix

68
Q

What conservative management is there for appendicitis?

A

Antibiotics (not fully evidence supported yet)

69
Q

What does a positive psoas sign suggest?

A

Inflamed appendix abutting the psoas major muscle in the retrocaecal position

70
Q

What type of cancer does colorectal cancer tend to be?

A

Adenocarcinoma

71
Q

What name is given to the process by which colorectal cancer develops? What is this?

A

Adenoma-carcinoma sequence –> progression of normal mucosa to colonic adenoma to invasive adenocarcinoma

72
Q

What genetic mutations of note are there for colorectal cancer?

A
  • Adenomatous polyposis coli (APC)

- Hereditary nonpolyposis colorectal cancer (HNPCC)

73
Q

What does a mutation in the adenomatous polyposis coli gene cause?

A

APC is a tumour suppressor gene, so inactivation results in growth of adenomatous tissue
+ responsible for familial adenomatous polyposis (FAP)

74
Q

What is hereditary nonpolyposis colorectal cancer (HNPCC)?

A

Mutation to DNA mismatch repair gene –> defects in DNA repair
(accounts for familial risk in colorectal cancer)

75
Q

What risk factors are there for colorectal cancer?

A
  • Age >60yrs
  • FHx
  • IBD
  • Low fibre diet
  • High processed meat diet
  • Smoking
  • High alcohol intake

NB most are sporadic

76
Q

What are the common clinical features of bowel cancer?

A
  • Change in bowel habit
  • Rectal bleeding
  • Weight loss
  • Abdominal pain
  • Iron deficiency anaemia
77
Q

What symptoms are specifically seen in RIGHT sided colon cancer?

A
  • Abdominal pain
  • Occult bleeding
  • Mass in RIF
78
Q

What symptoms are specifically seen in LEFT sided colon cancer?

A
  • Rectal bleeding
  • Change in bowel habit or tenesmus
  • Mass in LIF/mass on PR
79
Q

What are the NICE guidelines on urgent referral for suspected colon cancer?

A
  • ≥40yrs with unexplained weight loss + abdominal pain
  • ≥50yrs with unexplained rectal bleeding
  • ≥60yrs with iron deficiency anaemia/changes to bowel habit
  • +ve faecal occult blood test
80
Q

What are the main DDx to consider for colorectal cancer?

A
  • IBD
  • Haemorrhoids
  • Diverticulitis
81
Q

What is the screening programme in the UK for colorectal cancer?

A

Every 2 years to people 60-75yrs –> FOB home testing (3 samples)
If any +ve then requires colonoscopy

82
Q

What may be seen on the FBC for colorectal cancer?

A

Microcytic anaemia (especially right sided)

83
Q

What is the tumour marker for colorectal cancer? What is it used for?

A 
Carcinoembryonic antigen (CEA)
--> Monitor disease progression
84
Q

What is the gold standard diagnostic investigation for colorectal cancer?

A

Colonoscopy with biopsy

85
Q

What investigations are required for staging of colorectal cancer?

A
  • CT chest/abdo/pelvis
  • MRI rectum (rectal cancers)
  • Endo-anal USS
86
Q

What staging system was used for colorectal cancer?

A

Duke’s staging

87
Q

What is the curative management for colorectal cancer?

A

Surgery - regional colectomy followed by either primary anastomosis or formation of a stoma

88
Q

When is radiotherapy used in colorectal cancer? Why not in other cases?

A

Rectal cancer

Not in colon due to risk of damage to the small bowel

89
Q

What palliative care can be given to patients with colorectal cancer?

A
  • Endoluminal stenting –> acute large bowel obstruction
  • Stoma formation –> acute obstruction
  • Resection of secondaries
90
Q

Briefly outline Duke’s staging criteria

A

A - Confined beneath muscular propria
B - Extension through the muscular propria
C - Involvement of regional lymph nodes
D - distant metastasis

Surgery Block (12 decks)

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