General Surgery (Lower GI) Flashcards
Describe the pathophysiology of Appendicitis
Usually caused by luminal obstruction (secondary to faecoliths/lymphoid hyperplasia/impacted stool/tumour)
What are Faecoliths?
Faecal Debris and Calcium Salts
Give three risk factors of Appendicitis
Family History
Ethnicity (Caucasians)
Environmental (Seasonal - Summer)
Give 4 clinical features of Appendicitis
Pain (initial dull periumbilical, then later sharp in RIF)
Vomiting
Nausea
Anorexia
What is McBurney’s Point?
2/3 from Umbilicus to ASIS
Focus of peritoneal pain in late appendicitis
State three features OE of a patient with Appendicitis
Tachycardic
Tachypnoeic
Pyrexial
State two exams which would be positive in an Appendicitis patient
Psoas Sign - RIF pain with right hip extension (retrocoecal appendix irritates psoas muscle)
Rovsing’s Sign - RIF pain when LIF is palpated
Give 5 differentials for Appendicitis
Ectopic Pregnancy
Ovarian Cyst Rupture
Ureteric Stones
Diverticulitis
IBS
How would you manage an Appendicitis patient?
USS then CT
Laproscopic Appendicectomy
Describe 3 complications of Appendicitis. How could we reduce the risk?
Perforation
Appendiceal Mass
Pelvic Abscess
Antibiotic Treatment
Describe the pathophsyiology of Colorectal Cancer
Occurs via progression
Normal Mucosa to Colonic Adenoma (Polyps)
Colonic Adenoma to Invasive Adenocarcinoma
Describe the two genetic mutations associated with Colorectal Cancer
APC (Adenomatous Polyposis Coli) - Normally a tumour supressor gene, associated with FAP
HNPCC - DNA mismatch repair gene, associated with Lynch Syndrome
Give four risk factors for Colorectal Cancer
Age
IBD
Family History
Low Fibre Diet
Describe 3 presentations of Right Sided Colorectal Cancer
Late Presentation
Abdo Pain
Occult Bleeding
Describe 3 presentations of Left Sided Colorectal Cancer
Rectal Bleeding
Tenesmus
Change in bowel habit
What is the marker of Colorectal Cancer?
CEA
Not used in diagnosis but used to monitor progression
Give three possible imaging techniques for Colorectal Cancer
Colonoscopy
CT Scan
MRI Rectum
Describe Duke’s Staging of Colorectal Cancer
A - Confined to muscularis mucosa
B - Through muscularis mucosa
C - Regional Lymph Nodes
D - Distant Metastases
Surgery is the mainstay of treatment for Colorectal Cancer. What blood vessels would have to be dissected and reanastamosed in a RIGHT Hemicolectomy?
Ileocolic
Right Colic
Right Middle Colic
Surgery is the mainstay of treatment for Colorectal Cancer. What blood vessels would have to be dissected and reanastamosed in a LEFT Hemicolectomy?
IMV
Left Colic
Left branch of middle colic
Surgery is the mainstay of treatment for Colorectal Cancer. What blood vessels would have to be dissected and reanastamosed in a Sigmoidectomy?
Inferior Mesenteric Artery
Give an example of when an Anterior Resection is used
High rectal tumours
Give an example of when an AP Resection is used
Low Rectal Tumours
What is the Hartmann’s Procedure?
Used in emergency bowel surgery
Complete resection of rectosigmoid colon with formation of end colosomy and closure of rectal stump
Reversible
What other treatment can be used in Rectal Colorectal Carcinomas?
Radiotherapy
Describe the screening for Colorectal Cancer
Every 2 years for Men and Women aged 60-75
Uses Faecal Immunochemistry Test (Antibodies against Human Haemoglobin in Stools)
If positive then it is referred for Colonoscopy
What is a Diverticulum?
Outpouching of the bowel wall, commonly in Sigmoid
Describe the four manifestations of Diverticular Disease
Diverticulosis - Presence of Diverticula
Diverticular Disease - Symptomatic Diverticula
Diverticulitis - Inflammation of Diverticula
Diverticular Bleed - Diverticular erodes into vessels and cause large painless bleed
Describe the pathophysiology of Diverticular Disease
Bowel naturally weakens therefore stool passage increases intraluminal pressure
Outpouching where nutrient arteries perforate
Bacteria overgrow in outpouchings causing Diverticulitis
Describe the manifestations of Chronic Diverticulitis
Fistulae (Colovesicle and Colovaginal)
Describe the two types of Diverticulitis
Simple
Complicated (Abscess, Fistulae, Strictures)
Diverticula are often asymptomatic, describe three symptoms of diverticular disease
Intermittent lower abdominal pain (may be relieved by defaecation)
Altered Bowel Habit
Nausea & Flatulence
Describe the presentation of Diverticulitis
Acute Abdominal pain (usually sharp in LIF)
Systemic Upset
What two imaging techniques would you use for Diverticular disease
Flexible Sigmoidoscopy
CT Abdo Pelvis (showing thickening of colonic wall, localised air bubbles)
What is the Hinchey Classification?
Used to stage Diverticulitis
1 - Diverticulitis with pericolic abscess
2 - Diverticulitis with pelvic abscess
3 - Diverticulitis with purulent peritonitis
4 - Diverticulitis with faecal peritonitis
Describe the management of uncomplicated, diverticulitis and diverticular bleeds respectively
Uncomplicated - Analgesia and fluids
Diverticulitis - Abx
Diverticular Bleeds - Embolisation and Surgical resection
When is surgical management of Diverticulitis required?
If stage 4 Hinchey or overwhelming Sepsis
Hartmann Procedure
When is surgery indicated in Crohns?
Failed Medical Treatment
Severe Complications
Growth Impairment in younger patients
Describe four different possible surgeries for Crohns disease
Ileocaecal Resection
Surgery for peri-anal disease (abscess drainage, fistulae resection)
Stricturoplasty
Small or large bowel resection
Why does Crohns increase the risk of Renal Stones?
Fat Malabsorption causes calcium to remain in the lumen and oxalate to be freely absorbed
Resulting in Oxalate Stone formation
Why should you avoid anti-motility drugs in IBD?
They can precipitate Toxic Megacolon
What are the indications for surgery in Ulcerative Colitis?
Refractory to medical management
Toxic Megacolon
Bowel Perforation
Dysplastic Cells when monitoring
What are the two surgical options for Ulcerative Colitis?
Total Protocolectomy (can use ileostomy, or can create ileal pouch anal anastamoses to maintain faecal continence)
Subtotal Colectomy (Rectum sparing)
Describe three complications of UC
Toxic Megacolon
Colorectal Carcinoma
Osteoporosis
Define Pseudo-Obstruction (AKA Ogilvie Syndrome)
Dilation of the colon due to adynamic bowel in absence of mechanical obstruction
Commonly affects caecum and ascending colon
Give four causes of Pseudo-Obstruction
Thought to be due to interruption of autonomic supply to bowel
Electrolyte Imbalances, Hypothyroidism, Medication, Neurological Disease
Describe four clinical features of Pseudo-Obstruction
Abdominal Pain
Abdominal Distension
Constipation
Late Vomiting
What is the gold standard investigation for Pseudo-Obstruction?
Abdo CT with IV contrast
Describe the conservative management of Pseudo-Obstruction
NBM and IV Fluids
If vomiting - NG tube to aid decompression
If not resolved in 48h - Endocscopic decompression (via flatus tube) and IV Neostigmine
Describe the two surgical options for Pseudo - Obstruction
Segmental Resection
Caecostomy/Ileostomy to decompress bowel
Define Volvulus
Twisting of bowel around its mesentery, and can compromise blood supply leading to infarction and necrosis
Give four risk factors for Volvulus
Age
Neuropsychiatric Disorders
Chronic Constipation OR Laxative Use
Previous Abdo Surgery
Describe the clinical features of Sigmoid Volvulus
Early - Colicky Pain, Abdo Distension, Absolute Constipation
Late - Vomiting
What imaging would you use if you suspected Volvulus?
CT Abdo Pelvis with Contrast - Whirl Sign
Abdominal Xray - Coffee Bean Sign in LIF
Describe the conservative management of a Volvulus
Fluids
Decompression by sigmoidoscope and insertion of flatus tube
What indicates surgical management in Volvulus?
Ischaemia/Perforation
Failed attempts at decompression
Necrotic bowel
Hartmann
Describe the bimodal age distribution for Caecal Volvulus
10 - 29
60 - 79
What are Haemorrhoids?
Abnormal swelling/enlargement of anal vascuar cushions
Describe the normal anatomy of anal vascular cushions
Assist anal sphincter in maintaining continence
3 vascular cushions (3,7,11)
Describe the classification of Haemorrhoids
1st degree - remain in rectum
2nd degree - prolapse through anus on defaecation but spontaneously reduce
3rd degree - prolapse through anus on defaecation and requires digital reduction
4th degree - Permanently prolapsed
Give three risk factors of Haemorrhoids
Chronic Constipation
Increased age
Increased intra-abdo pressure
Describe three features of Haemorrhoids
Painless bright red rectal bleeding (on paper)
Pruritus
Rectal fullness
What happens when Haemorrhoids become painful?
The Haemorrhoids have become thrombosed, will appear purple/blue which is an emergency
Describe the conservative management of Haemorrhoids
Fluid/Fibre/Lacatives
Topical Lidocaine
1st and 2nd Degree - Rubber band ligation
When would you treat Haemorrhoids with surgery?
If unresponsive to conservative but not suitable for banding
Stapled or Milligan Morgan Technique
What is a Pilonoidal Sinus?
Formation of a sinus in the cleft of the buttocks, commonlly affecting males aged 16-30
Describe the pathophysiology of a Pilonoidal Sinus in three steps
1) Hair follicle in intergluteal cleft becomes infected/inflamed
2) Inflammation obstructs opening, extending inwards to form a pit
3) Inflammation tracks to form a cavity connected by epithelial sinus to surface
Give 3 risk factors for the formation of a Pilonoidal Sinus
Caucasian males with coarse dark hair
Those who sit for prolonged periods
Increased sweating
Describe three clinical features of Pilonoidal Sinuses
Intermittent red/painful/swollen mass in sacrococcygeal region
Discharge and signs of infection
Opens up to skin but does not communicate with anal canal
Describe the non surgical management of Pilonoidal Sinuses
Plucking the affected region
Any abscess requires draining
Describe the two surgical methods of managing Pilonoidal Sinuses (if chronic)
- Excise tract and lay open to heal by secondary intention
- Excise tract and close the wound (higher rates of recurence)
Define Anal Fistula
Abnormal connection between anal canal and perianal skin
Give 3 causes of Anal Fistulae
IBD
History of Trauma
Previous Radiation to the area
Describe the clinical features of Anal Fistulae
Recurrent Perianal Abscesses
Intermittent/Continuous discharge onto perineurium
Describe the Goodsall Rule
Predicts the trajectory of an Anal Fistula tract
Closer to the post aspect - curved course
Closer to the ant aspect - straight course
Describe the Park’s Classification of Anal Fistulae
Intersphincteric (between internal and external anal sphincter)
Transphincteric (across sphincter horizontally)
Suprasphincteric
Extrasphincteric
Describe two surgical managements of Anal Fistulae
Fistulotomy - lay it open and allow to heal by secondary intention
Seton Placement - Rubber sling goes through anal sphincter and fistula entrance to bring it closer together
Define Anorectal Abscess
Collection of pus in anal or rectal region
Caused by plugging of anal ducts (which normally produce mucous to lubricate anal canal)
Can be in four different areas (Perianal, Intersphincteric, Ischiorectal, Supralevator)
How would an Anorectal Abscess present?
Pain in perineum (exacerbated by sitting down)
Localised swelling/itching/discharge
If severe - systemic symptoms
How would you manage an Anorectal Abscess?
Antibiotic Therapy and Analgesia
Incision and drainage
Define Anal Fissure
Tear in the mucosal lining of anal canal
Primary - No underlying disease
Secondary - Underlying disease (IBD)
Describe the clinical features of Anal Fissures
Intense pain on defaecation (can last several hours)
Bleeding (bright red on paper)
90% on posterior midline
Describe the conservative management of Anal Fissures
Increase fibre and fluids
Stool softening laxatives
Hot Baths
GTN/Diltiazem cream (promotes blood supply to area and hence healing)
Describe the surgical management of Anal Fissures
Generally only reserved for chronic fissures
Botox - causing internal and external sphincter to relax, promoting healing
Lateral Sphincterotomy - Divides internal anal sphincter
What is a Rectal Prolapse? What are the two types?
Protrusion of rectal tissue out of the anus
Partial Thickness - Rectal Mucosa protrudes out of anus
Full Thickness - Rectal wall protrudes out of anus
Describe the pathophysiology of a Full Thickness Rectal Prolapse
Form of sliding hernia through defect in fascia
Describe the pathophysiology of a Partial Thickness Rectal Prolapse
Loosening and stretching of Connective Tissue (normally due to haemorrhoidal disease)
Describe the presentation of a Rectal Prolapse
Rectal Discharge/Bleeding
Faecal Incontinence
Full Thickness - Fullness, Tenesmus
How would you examine a suspected Rectal prolapse?
DRE under anaesthesia
Surgery is the definitive treatment for Rectal Prolapse, describe the two approaches
Perineal Approach
Abdominal Approach
Describe the histological difference in Anal Cancers
Below Dentate Line - Squamous Cell Carcinomas (AIN is precancerous conditions)
Above Dentate Line - Adenocarcinomas
Give three risk factors for Anal Cancers
HPV
HIV
Crohns
Give four features of Anal Cancer
Rectal Pain/Bleeding
Anal Discharge
Pruritus
Sphincters involved - tenesmus
What imaging is best for Anal Cancer?
MRI Pelvis
Describe the management of Anal Cancer
Chemoradiotherapy for all of them except T1N0 (where excision is normally sufficient)
Surgery - AP Resection
Give 3 complications of Anal Cancer
ED
Rectovaginal Fistula
Proctitis
What is a common differential for Appendicitis in children?
Mesenteric Adenitis
What is Chilidaiti’s Sign?
Loop of bowel between the liver and diaphragm
Normal
How should diverticulitis be managed?
Initially oral antibiotics at home
If no improvement after 72h then admit for IV abx
How can a high-output stoma result in acidosis?
Loss of bicarbonates from stomach
How should thrombosed haemorrhoids be managed?
If presenting within 72h of onset then can be referred for excision
If over 72h - ice packs/analgesia/stool softeners
