General Surgery (colorectal) Flashcards
What are the causes of pancreatitis?
Gallstones
Alcohol
Steroids
Other:
- trauma, mumps, SLE, ERCP, hypothermia, hypercalcaemia
Drugs:
- azathioprine and mesalazine, NSAIDs, diuretics, sodium valproate
Brief pathophysiology of pancreatitis
duct obstruction leads to ischaemia and acinar cell injury
- lipase released: fat necrosis with fatty acids binding calcium leading to hypocalcaemia
- islet cells damaged: hyperglycaemia
- protease and elastase released: haemorrhage
All leading to infection and inflammation
Aside from pancreatitis, when else would amylase be raised?
Ectopic pregnancy Renal failure DKA cholecystitis mesenteric ischaemia
Why is serum lipase not accurate in diagnosing pancreatitis?
It takes 8 hours after symptom onset to rise
If you were to do an AXR or CXR in pancreatitis, what might it show?
CXR: pneumoperitoneum or pleural effusion
AXR: sentinel loop sign (dilated proximal bowl)
What are the signs and symptoms of pancreatitis?
Epigastric pain radiating to the back
Guarding
Nausea and vomiting
Tetany (hypocalcaemia)
Tachycardic and hypotensive
Cullens: peri-umbilical brusing
Grey-turners: flank brusing
Left sided pleural effusion
What system would you use to calculate the severity/prognosis? What are some markers used in this score?
Glasgow scoring system
Low sats
>55
Raised neutrophils
Raised Urea
Raised LDH
Raised glucose
Hypoalbuminaemia
Hypocalcaemia
What is the management of pancreatitis?
IV Fluids
Analgesia
Antiemetics
Monitor Blood Glucose
Analgesia
What are some complications of pancreatitis?
Infective necrosis Abscess Pseudocyst Chronic pancreatitis DIC ARDS and pleural effusions
What is the difference between acute and chronic pancreatitis? Therefore, how does chronic pancreatitis present?
In chronic pancreatitis it is the secretory function of the pancreas that is damaged
Diabetes
Steatorrhea
+ pain after eating
What are the causes of chronic pancreatitis?
Alcohol
Cystic fibrosis
Duct obstruction with tumour or stones
How should you investigate chronic pancreatitis? What is seen?
CT
Shows pancreatic calcifications
How is chronic pancreatitis managed?
Fat soluble vitamins
Pancreatic enzymes
Analgesia
Where are pancreatic pseudocysts most commonly located?
Lesser sac
Gastro-epiploic foramen
How do pancreatic pseudocysts present?
Biliary or gastric outlet obstruction
When and how does post-op ileus present?
Few days post-op
!!Hypovolaemia and low electrolytes despite positive fluid balance!!
Distension
N&V
Absolute constipation
What is third spacing?
How is it managed?
obstruction = proximal bowel hugely dilates = increased peristalsis = electrolyte rich secretions move from vascular space to bowel
Fluid resus
How does bowel obstruction present?
Distension + absolute constipation + vomiting + pain + empty rectum
What measurements constitute enlarged small bowel, large bowel and caecum?
small >3cm
large >6cm
caecum >9cm
What causes large bowel obstruction?
Colorectal cancer
Diverticulitis
Volvulus
IBD
What causes small bowel obstruction?
Hernia
Adhesions
Tumours, peritoneal metastasis, lymphomas
Compare what you’d hear on auscultation of large and small bowel obstruction
Large: loud but normal pitch
Small: high pitch tinkling
Percussion of a small bowel obstruction sounds like what?
Tympanic
How is bowel obstruction managed?
Fluid resuscitation
NG tube to decompress
A competent ileo-caecal valve leads to what?
Worsening bowel obstruction as material continues to pass in to the caecum leading to it rupturing
Where are peptic ulcers most commonly found?
lesser curve and antrum of the stomach
anterior proximal duodenum
What are the risk factors for developing peptic ulcers?
H-pylori infection NSAIDs Smoking Alcohol Zollinger Ellison
Briefly, how does H-pylori lead to ulcers?
- reduced bicarbonate production
- reduced mucous production
- increased histamine leading to excessive acid
What is H-pylori?
spiral shaped gram -ve bacteria
How does peptic ulcers present in general?
What features point towards the ulcer being in the stomach vs duodenum?
Epigastric pain
Weight loss due to pain and early satiety
stomach: pain just before and whilst eating
duodenal: improved by eating then pain worse hours after
How would you investigate peptic ulcer disease?
urease breath test
stool antigen test
+/- endoscopy and biopsy
What does H-pylori eradication involve?
Omeprazole
Amoxicillin
Metronidazole or clarithromycin
What are the complications of peptic ulcer disease?
perforation leading to peritonitis anaemia malignancy haemorrhage - stomach = left gastric - duodenum = gastroduodenal
How is haemorrhage resulting from peptic ulcer erosion managed?
inject adrenaline
cauterize
omeprazole
What can cause peritonitis?
GI tract perforation
Spontaneous bacteria peritonitis (seen in ascites)
Peritoneal dialysis
Surgical complication
Non-infectious eg with SLE
How does peritonitis present?
acute abdominal pain
washboard rigidity
fever
shock
What are the complications of peritonitis?
abscess formation
sepsis
fluid and electrolyte disturbances
breathing difficulties if diaphragm irritated or under pressure in abdomen distension
What nerves cause the classic generalised then localising to RIF pain seen in appendicitis?
General: visceral splanchnic
Localised: peritoneal
What are some examination findings in appendicitis?
RIF rebound tenderness Guarding Rosvings: RIF pain when LIF palpated Psoas sign: RIF pain on right hip extension Palpable mass if abscess present
What are some signs, symptoms and blood results that would indicate the need for an appendicectomy?
migration of pain N&V Rebound tenderness Fever neutrophil predominate leukocytosis
Define a hernia
protrusion of viscera from its containing cavity
Describe the anatomy of a direct and indirect inguinal hernia
direct: enters through a defect in the posterior wall of the inguinal canal at Hesselbachs
indirect: enters through the deep ring and travels through the canal exiting at the superficial ring
How do you differentiate between a direct and indirect inguinal hernia?
Direct are found medial to IEVs
Indirect are found lateral to IEVs
How do you differentiate between an inguinal vs a femoral hernia?
inguinal are superior to the pubic tubercle
inguinal head towards the groin
femoral are infero-lateral to the pubic tubercle
femoral head straight down the leg
femoral are medial to the pulse
How would an obturator hernia present?
mass in the upper medial thigh
nerve compression = pain on hip extension, medial rotation and abduction
What are some differentials for hernias?
lymphadenopathy
aneurysm
saphena varix
How are hernias managed?
weight loss
open repair: generally if one off unilateral
laparoscopic repair: generally if recurrent, females, young, bilateral
What are some complications of hernias? Describe briefly what these terms mean
obstructed: bowel contents within the hernia becomes obstructed
incarcerated: contents is stuck inside the sack because of adhesions. The hernia can’t be reduced
strangulated: ischaemia of the tissue within the hernia
How would a strangulated hernia present?
What should you not do whilst awaiting surgery?
Pain out of proportion
Fever
Erythema of the overlying skin
Peritonitic features: guarding
Do not try to reduce it - this can lead to generalised peritonitis
Describe the types of hiatus hernias
sliding: gastroduodenal junction moves above the diaphragm in to the thoracic cavity
rolling: gastroduodenal junction remains in the abdomen but the fundus herniates in to the thoracic cavity
How does a hiatus hernia present?
What examination finding might you find?
reflux dysphagia weight loss hiccups vomiting
How are hiatus hernias managed?
weight loss, stop smoking, stop alcohol
PPIs
fundoplication
What would you see at endoscopy of a hiatus hernia?
upward displacement of the z-line
What are some complications of fundoplication for hiatus hernia?
recurrence of the hernia
dysphagia if done too tightly
bloating - inability to belch
fundal necrosis
What is a complication of a rolling hiatus hernia? How would this present?
gastric volvulus
- Inability to pass an NG tube
- Retching but no vomiting
- Pain
What is diverticulosis, diverticular disease and diverticulitis?
diverticulosis: outpouchings of mucosa between the teniae coli
disease: symptoms arising from the diverticulosis
diverticulitis: inflammation and infection of the diverticulosis often due to faces and food getting stuck in the neck of the outpouching
Where does diverticulosis most commonly occur?
sigmoid colon
can also be descending colon
What are the causes/risk factors for developing diverticulosis?
low fibre diet and constipation
What are the symptoms of diverticular disease?
erratic bowel habits: constipation and diarrhoea
painless bleeding
Colicky LIF pain that is relieved by defecation
How is diverticular disease managed?
How and when is acute diverticulitis managed?
increased fibre
laxatives
analgesia
If >72 hours with no improvement or if severe
- NBM, IV fluids, IV metronidazole + a cephalosporin
How does acute diverticulitis present?
LIF pain N&V Erratic bowel habits Fever Painful bleeding Abdominal distension
What are some complications of diverticular disease?
Fistula - vaginal = brown discharge - bladder = frothy urine and UTIs Perforation Strictures Haemorrhage (erosion in to vessels)
Compare the 2 histological subtypes of oesophageal cancer, their locations and the risk factors for them
squamous cell: upper 2/3rds
- alcohol, smoking, achalasia, reduced vit A
adeno: lower 1/3rd
- obesity, fatty diet, GORD
What are the red flags 2 week wait criteria for oesophageal cancer?
Dysphagia!! +
>55 with dyspepsia and weight loss
Compare Mallory Weiss and Boerhave
Mallory Weiss: superficial mucosa tear
Boerhave: full thickness oesophageal tear
How would an oesophageal tear present?
Retrosternal pain
Respiratory distress
Subcutaneous emphysema
How is oesophageal tear investigated? What would you see?
CT CAP with IV and oral contrast
- can see the oral contrast leaking out
How is oesophageal tear managed?
repair the tear
decontaminate the mediastinum and pleural cavity
abx
feeding via jejunostomy
What is achalasia?
failure of the LOS to relax
eventual failure of the oesophageal smooth muscle
this leads to the food bolus getting stuck
proximal damage of the oesophagus due to force against a blockage
How does achalasia present?
dysphagia to solids and liquids
weight loss
regurgitation
chest pain
How would you investigate achalasia? What would the results be?
Barium swallow
- bird beak appearance, dilated oesophagus, fluid level
CXR
- widened mediastinum
Oesophageal manometry
- failure of peristalsis, high LOS resting pressure and failure of it to relax
How is achalasia managed?
Pneumatic balloon dilation Surgical - Hellers cardiomyotomy Botox into the LOS CCBs and nitrates (little effect) Small meals and sleep with ++pillows
What is diffuse oesophageal spasm?
multifocal, high amplitude spasms due to dysfunctional oesophageal inhibitory nerves
How would you investigate diffuse oesophageal spasm? What would the results be?
barium swallow
- see a corkscrew oesophagus
oesophageal manometry
- repetitive, simultaneous, ineffective contractions
How is diffuse oesophageal spasm managed?
CCBs and nitrates
What dose plummer-vinson consist of?
Dyspahgia due to oesophageal webs
Glossitis
Iron deficiency anaemia
How is plummer-vinson managed?
dilation of the webs
iron
A diabetic patient presents with an IBS picture, what could it be?
Who else is at risk of this condition?
Small bowel bacterial overgrowth
Scleroderma patients
How is small bowel bacterial overgrowth managed?
Rifaxamin
Where are most gastroenteropancreatic neuroendoctine tumours found?
small intestine
sometimes stomach and rectum
In whom and how do gastroenteropancreatic neuroendoctine tumours present?
MEN 1, neurofibromatosis 1, tuberous sclerosis
non specific abdominal signs and symptoms
What is carcinoid syndrome?
over due to liver metastasis there is secretion of serotonin +/- prostaglandins, gastrin and ACTH
How does carcinoid syndrome present?
Flushing
Diarrhoea
Wheeze
Palpitations, tricuspid insufficiency, pulmonary stenosis
How do you investigate carcinoid syndrome?
urine 5-HIAA
plasma chromogranin A
How does a carcinoid crisis present?
Extremely low BP
How is carcinoid syndrome managed?
octreotide - somatostatin analogue
What is a pseudo-obstruction?
dilation of the bowel with no obstructive cause
What can cause pseudo-obstruction?
Hypercalcaemia and hypomagnesemia opioids and CCBs post-surgical hypothyroidism Neurological: MS and Parkinsons
How is a pseudo-obstruction managed?
endoscopic decompression
neostigmine
How does volvulus present? Symptoms and key examination finding
What in the history would point towards a caecal volvulus rather than the classic sigmoid?
Abdominal distension
absolute constipation
Colicky pain
Tympanic on percussion
caecal: adhesions so previous surgery or pregnancy
What is a volvulus?
Twisting of the intestine on its mesentery leading to obstruction and a reduced blood supply so necrosis
How is volvulus managed?
decompress with a flatus tube
may need resection with Hartman’s if necrotic bowel or perforation
What can cause acute mesenteric ischaemia? Therefore what are the risk factors?
- Atherosclerosis
- Embolism: AF, AAA, prosthetic valve, post-MI, hypercoagulable (including malignancy)
- Non-occlusive: shock
How does acute mesenteric ischaemia present?
Pain out of proportion
N&V
Bloody diarrhoea
What ABG results would indicate acute mesenteric ischaemia?
raised lactate
acidotic
How is acute mesenteric ischaemia imaged? What would you see?
Contrast CT
- bowel wall oedema
- gas within the bowel wall
- reduced bowel wall enhancement
How is acute mesenteric ischaemia managed?
Abx in case of perforation
Bowel excision if necrotic
Mesenteric angioplasty
What is the cause of chronic mesenteric ischaemia?
atherosclerosis
What in the history would suggest chronic mesenteric ischaemia?
cardiovascular risk factors
post-prandial pain
weight loss due to the pain and malabsorption
How is chronic mesenteric ischaemia diagnosed and managed?
CT angiogram
Mesenteric angioplasty and stent
What stain and shape is C-Diff?
Gram +ve
Rod
What commonly causes c-diff infection?
Cephalosporins (ceftriaxone or clindamycin)
PPIs increase a patients risk
What can c-diff infection lead to?
pseudomembranous colitis
How would you investigate ?c-diff and what would the results be?
Bloods: ++WCC
C-Diff antigen: shows exposure not necessarily acute infection
C.diff toxin in stool
AXR: thumbprinting + loss of bowel wall architecture
How is c-diff managed?
- Metronidazole
2. recurrent or severe: Vancomycin
What is melanosis coli? What causes it?
pigmentation of the bowel wall
due to laxative abuse
Disease of the rectum requires what surgery and/or anastomoses or stoma?
Anterior resection
Can do colorectal anastomoses or a defunctioning stoma
When is an abdo-perineal resection required?
Involvement of the anal verge
Involvement of the sphincter
Disease within 2cm of the dentate line
What are haemorrhoids? Where on PR examination would you classically see them?
Enlarged vascular cushions
At 3, 7 and 11 o’clock
What are the grades of haemorrhoids?
1: don’t prolapse
2: prolapse on defecation but spontaneously reduce
3: manually reduce
4: don’t reduce
Internal haemorrhoids are defined as what?
Originating above the dentate line
What management options are available for haemorrhoids?
Increased fibre diet
Laxatives
Local anaesthetic creams
Rubber band ligation
Haemorrhoid artery ligation
Haemorrhoidectomy
How do haemorrhoids present?
Pruritis
Painless rectal bleeding not mixed in with stool
Feeling of rectal fullness
Haemorrhoids can thrombose, how would this present?
++ pain and tenderness
Oedematous, purple lump on examination
What is a pilonidal sinus?
a sinus within the buttock cleft region that starts with an inflamed hair follicle
In whom and how would a pilonidal sinus present?
Sweaty, hairy, sit down a lot, obese, poor hygiene
Often cyclical:
Red, painful swelling in the buttock cleft region
Discharge
How is a pilonidal sinus managed?
Drain any abscess
Abx
Shave
What is a perianal fistula and what are the causes/risk factors?
Connection between the anus and the skin of the perineum
Recurrent abscesses
IBD
TB and HIV
radiation to the area
How does a perianal fistula present?
Recurrent abscesses
Discharge on to the skin
How are perianal fistulas managed?
Fistulotomy
Seton
What are the types of anorectal abscesses?
perianal
intersphinteric
ischiorectal
supralevator
How do anorectal abscess present?
Pain on sitting down
Swelling or hard lump felt
Discharge
+/- Cellulitis and systemically unwell
How are anorectal abscesses managed?
Incision and draining
Antibiotics
What is an anal fissure?
Tear in the mucosal lining of the anal canal
What are the risk factors for anal fissures?
Constipation (and therefore dehydration)
IBD
How do anal fissures present?
Pain on defecation that can last for hours
Fresh rectal blood
Itch
How are anal fissures managed?
Increase fluid and fibre intake
Bulk forming laxatives
Lubricants
Topical local anaesthetics
> 6 weeks of symptoms = GTN cream
8 weeks of GTN = sphincterotomy
AV malformations in the large bowel are known as what? How do they present?
Angiodysplasia
Painless PR bleed
Describe a partial vs a full rectal prolapse
partial: rectal mucosa prolapses out of the anus
full: rectal wall prolapses out of the anus
What are the risk factors for rectal prolapses?
Constipation
Long standing haemorrhoids
Childbirth
Cough
How do rectal prolapses present?
Initially a feeling of fullness and tenesmus
Faecal incontinence
Discharge
Bleeding and ulceration
How are rectal prolapses managed?
Increased fluid and fibre
Surgical management
What are the histological subtypes of anal cancer?
above dentate: adenocarcinoma
below dentate: squamous cell carcinoma
What are the risk factors for anal cancer?
HPV 16 and 18
HIV
IBD
immunosuppressed
How does rectal cancer present?
Painful rectum Bleeding Palpable mass Itch Discharge
Which lymph nodes does anal cancer spread to?
Proximal: pelvic
Anal margin: inguinal
Where does the spleen get its blood supply from?
splenic and left gastroepiploic
What are the causes of a splenic infarct?
Embolism: AF and post-MI
Abnormal blood: Sickle cell, CML, myelofibrosis
How would a splenic infarct present?
LUQ pain
+/- fever, N&V
How would you investigate a ?splenic infarct and what would this show?
CT with contrast
Hypo-attenuated wedge shaped area
How is a splenic infarct managed in the short and long term?
Immediate: treat the underlying cause
Long term: long term penicillin + pneumonia, influenza and meningitidis vaccines
What are the causes of splenic rupture?
Trauma
Massive splenomegaly
How does a splenic rupture present?
Shock
Peritonism
LUQ and shoulder tip pain
Someone comes in with a ruptured spleen and is unstable, what do you do?
Immediate laparotomy
Someone comes in with a ruptured spleen and is stable, what do you do?
CT CAP
Permissive hypotension
Vessel embolization
What are the complications of a splenic rupture and its management?
Necrosis
Abscess
DVT and PE (thrombocytosis)
Overwhelming post-splenectomy infection
What is the macroscopic and microscopic appearance of Crohns disease?
Where does it most commonly affect?
Macro: skip lesions, cobblestone (deep ulcers and fissures)
Micro: non-caseating granulomas, increased goblet cells
Location:
From mouth to anus
It most commonly affects the terminal ileum and proximal colon
How would Crohns disease present?
Abdominal pain !Weight loss! mucous diarrhoea (+/- blood) Malaise (B12 and iron deficiency) Oral ulcers Perianal fistula Skin tags
What are the dermatological manifestations of Crohns disease?
Pyoderma gangrenosum
- ulcers on the legs
Erythema nodosum
- tender, subcutaneous nodules on the shins
Aside from dermatological, what are the other extra-colonic manifestations of Crohns disease?
Episcleritis
Sacroiliac arthritis (arthritis is most common manifestation)
Renal stones (oxalate)
!Gallstones!
What bloods results would you expect in IBD?
B12 deficient
Raised CRP and WCC
Hypalbuminaemia (poor absorption)
Aside from bloods and imaging how else is IBD diagnosed?
Faecal calprotectin
Which type of endoscopy is first line in ?Crohns vs ?UC
Crohns: colonoscopy
UC: flexible sigmoidoscopy
How is remission of Crohns induced?
Stop smoking!
- Steroids
2: Mesalazine
3: + Azathiorprine or methotrexate or mercaptopurine
4: infliximab
Once in remission, what is the management of Crohns
1: Azathioprine or mercaptopurine
2: Methotrexate
Aside from immunosuppressing drugs, what else must you remember to give in an IBD flare?
Heparin as they are pro-thrombotic
Where does UC affect? Location and layers
Begins in the rectum and spreads proximally
Never spreads beyond ileocecal valve
Mucosa and submucosa only
What is the macro and microscopic appearance of UC?
Macro: crypt abscesses and pseudopolyps (inflamed tissue due to cycle of ulcers and healing)
Micro: decreased goblet cells
How does UC present?
Abdominal pain
Bloody diarrhoea +/- mucous
Tenesmus
Malaise
How would you categorise the severity of UC?
Truelove and Wit
mild: <4 stools/day
moderate: 4-6 stools/day +blood
severe: >6 stools/day + blood + systemic upset (fever, tachycardia, anaemia)
How is a mild or moderate flare of UC managed?
Just left sided disease
- topical aminosalicylates
- add oral after 4 weeks
- topical or oral steroids
Extensive disease
- Topical AND oral aminosalicylates (mesalazine)
- Add oral steroids
How is a severe flare of UC managed?
IV steroids
+ IV ciclosporin if no improvement after 72 hours
+ infliximab
Once in remission, how is UC managed?
Topical or oral aminosalicylates (mesalazine)
If a patient suffers >2 flares of UC per year, what management is considered?
oral azathioprine or mercaptopurine
How would toxic megacolon present?
Fever + distension + pain
What are the extra colonic manifestations of UC?
Arthritis
Primary sclerosing cholangitis
Anterior uveitis
Erythema nodosum
Compare the appearance of Crohns and UC on barium enema
Crohns:
- long strictured segment seen as “Kantors string sign”
- ulcers
- proximal bowel dilation
- fistulae
UC:
- loss of haustra
- “lead pipe” thin and no short
- superficial ulceration seen as pseudopolyps
What are the complications of Crohns and its management?
Fistulae Abscesses Strictures leading to obstruction Small bowel and colorectal cancer Osteoporosis Short bowel syndrome as a result of multiple small bowel resections
What are the symptoms of GORD?
dyspepsia - burning
acid taste in the mouth
regurgitation
cough
How is GORD managed?
Full dose PPI for 1 month
Then lower tailored dose
If a GORD patient is going for endoscopy what do you need to tell them about their medication?
Stop their PPI 2 weeks before
What are the complications of GORD?
Pneumonia
Cancer
Barret’s oesophagus
What is Barret’s oesophagus?
Metaplasia of stratified squamous epithelium to glandular simple columnar
Describe the OGD findings in Barret’s oesophagus
Red and velvety appearance
Before an appendicectomy what needs to be done for the patient?
Prophylactic IV abx to reduce wound infection rates
