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Year 3 Surgery > General Surgery (Lower GI) > Flashcards

General Surgery (Lower GI) Flashcards

1
Q

Describe the pathophysiology of Appendicitis

A

Usually caused by luminal obstruction (secondary to faecoliths/lymphoid hyperplasia/impacted stool/tumour)

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2
Q

What are Faecoliths?

A

Faecal Debris and Calcium Salts

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3
Q

Give three risk factors of Appendicitis

A

Family History
Ethnicity (Caucasians)
Environmental (Seasonal - Summer)

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4
Q

Give 4 clinical features of Appendicitis

A

Pain (initial dull periumbilical, then later sharp in RIF)
Vomiting
Nausea
Anorexia

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5
Q

What is McBurney’s Point?

A

2/3 from Umbilicus to ASIS
Focus of peritoneal pain in late appendicitis

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6
Q

State three features OE of a patient with Appendicitis

A

Tachycardic
Tachypnoeic
Pyrexial

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7
Q

State two exams which would be positive in an Appendicitis patient

A

Psoas Sign - RIF pain with right hip extension (retrocoecal appendix irritates psoas muscle)
Rovsing’s Sign - RIF pain when LIF is palpated

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8
Q

Give 5 differentials for Appendicitis

A

Ectopic Pregnancy
Ovarian Cyst Rupture
Ureteric Stones
Diverticulitis
IBS

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9
Q

How would you manage an Appendicitis patient?

A

USS then CT
Laproscopic Appendicectomy

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10
Q

Describe 3 complications of Appendicitis. How could we reduce the risk?

A

Perforation
Appendiceal Mass
Pelvic Abscess

Antibiotic Treatment

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11
Q

Describe the pathophsyiology of Colorectal Cancer

A

Occurs via progression
Normal Mucosa to Colonic Adenoma (Polyps)
Colonic Adenoma to Invasive Adenocarcinoma

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12
Q

Describe the two genetic mutations associated with Colorectal Cancer

A

APC (Adenomatous Polyposis Coli) - Normally a tumour supressor gene, associated with FAP

HNPCC - DNA mismatch repair gene, associated with Lynch Syndrome

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13
Q

Give four risk factors for Colorectal Cancer

A

Age
IBD
Family History
Low Fibre Diet

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14
Q

Describe 3 presentations of Right Sided Colorectal Cancer

A

Late Presentation
Abdo Pain
Occult Bleeding

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15
Q

Describe 3 presentations of Left Sided Colorectal Cancer

A

Rectal Bleeding
Tenesmus
Change in bowel habit

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16
Q

What is the marker of Colorectal Cancer?

A

CEA
Not used in diagnosis but used to monitor progression

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17
Q

Give three possible imaging techniques for Colorectal Cancer

A

Colonoscopy
CT Scan
MRI Rectum

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18
Q

Describe Duke’s Staging of Colorectal Cancer

A

A - Confined to muscularis mucosa
B - Through muscularis mucosa
C - Regional Lymph Nodes
D - Distant Metastases

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19
Q

Surgery is the mainstay of treatment for Colorectal Cancer. What blood vessels would have to be dissected and reanastamosed in a RIGHT Hemicolectomy?

A

Ileocolic
Right Colic
Right Middle Colic

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20
Q

Surgery is the mainstay of treatment for Colorectal Cancer. What blood vessels would have to be dissected and reanastamosed in a LEFT Hemicolectomy?

A

IMV
Left Colic
Left branch of middle colic

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21
Q

Surgery is the mainstay of treatment for Colorectal Cancer. What blood vessels would have to be dissected and reanastamosed in a Sigmoidectomy?

A

Inferior Mesenteric Artery

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22
Q

Give an example of when an Anterior Resection is used

A

High rectal tumours

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23
Q

Give an example of when an AP Resection is used

A

Low Rectal Tumours

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24
Q

What is the Hartmann’s Procedure?

A

Used in emergency bowel surgery

Complete resection of rectosigmoid colon with formation of end colosomy and closure of rectal stump

Reversible

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25
Q

What other treatment can be used in Rectal Colorectal Carcinomas?

A

Radiotherapy

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26
Q

Describe the screening for Colorectal Cancer

A

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

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27
Q

What is a Diverticulum?

A

Outpouching of the bowel wall, commonly in Sigmoid

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28
Q

Describe the four manifestations of Diverticular Disease

A

Diverticulosis - Presence of Diverticula
Diverticular Disease - Symptomatic Diverticula
Diverticulitis - Inflammation of Diverticula
Diverticular Bleed - Diverticular erodes into vessels and cause large painless bleed

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29
Q

Describe the pathophysiology of Diverticular Disease

A

Bowel naturally weakens therefore stool passage increases intraluminal pressure
Outpouching where nutrient arteries perforate

Bacteria overgrow in outpouchings causing Diverticulitis

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30
Q

Describe the manifestations of Chronic Diverticulitis

A

Fistulae (Colovesicle and Colovaginal)

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31
Q

Describe the two types of Diverticulitis

A

Simple
Complicated (Abscess, Fistulae, Strictures)

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32
Q

Diverticula are often asymptomatic, describe three symptoms of diverticular disease

A

Intermittent lower abdominal pain (may be relieved by defaecation)
Altered Bowel Habit
Nausea & Flatulence

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33
Q

Describe the presentation of Diverticulitis

A

Acute Abdominal pain (usually sharp in LIF)
Systemic Upset

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34
Q

What two imaging techniques would you use for Diverticular disease

A

Flexible Sigmoidoscopy
CT Abdo Pelvis (showing thickening of colonic wall, localised air bubbles)

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35
Q

What is the Hinchey Classification?

A

Used to stage Diverticulitis

1 - Diverticulitis with pericolic abscess
2 - Diverticulitis with pelvic abscess
3 - Diverticulitis with purulent peritonitis
4 - Diverticulitis with faecal peritonitis

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36
Q

Describe the management of uncomplicated, diverticulitis and diverticular bleeds respectively

A

Uncomplicated - Analgesia and fluids
Diverticulitis - Abx
Diverticular Bleeds - Embolisation and Surgical resection

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37
Q

When is surgical management of Diverticulitis required?

A

If stage 4 Hinchey or overwhelming Sepsis

Hartmann Procedure

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38
Q

When is surgery indicated in Crohns?

A

Failed Medical Treatment
Severe Complications
Growth Impairment in younger patients

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39
Q

Describe four different possible surgeries for Crohns disease

A

Ileocaecal Resection
Surgery for peri-anal disease (abscess drainage, fistulae resection)
Stricturoplasty
Small or large bowel resection

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40
Q

Why does Crohns increase the risk of Renal Stones?

A

Fat Malabsorption causes calcium to remain in the lumen and oxalate to be freely absorbed
Resulting in Oxalate Stone formation

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41
Q

Why should you avoid anti-motility drugs in IBD?

A

They can precipitate Toxic Megacolon

42
Q

What are the indications for surgery in Ulcerative Colitis?

A

Refractory to medical management
Toxic Megacolon
Bowel Perforation
Dysplastic Cells when monitoring

43
Q

What are the two surgical options for Ulcerative Colitis?

A

Total Protocolectomy (can use ileostomy, or can create ileal pouch anal anastamoses to maintain faecal continence)
Subtotal Colectomy (Rectum sparing)

44
Q

Describe three complications of UC

A

Toxic Megacolon
Colorectal Carcinoma
Osteoporosis

45
Q

Define Pseudo-Obstruction (AKA Ogilvie Syndrome)

A

Dilation of the colon due to adynamic bowel in absence of mechanical obstruction
Commonly affects caecum and ascending colon

46
Q

Give four causes of Pseudo-Obstruction

A

Thought to be due to interruption of autonomic supply to bowel
Electrolyte Imbalances, Hypothyroidism, Medication, Neurological Disease

47
Q

Describe four clinical features of Pseudo-Obstruction

A

Abdominal Pain
Abdominal Distension
Constipation
Late Vomiting

48
Q

What is the gold standard investigation for Pseudo-Obstruction?

A

Abdo CT with IV contrast

49
Q

Describe the conservative management of Pseudo-Obstruction

A

NBM and IV Fluids
If vomiting - NG tube to aid decompression
If not resolved in 48h - Endocscopic decompression (via flatus tube) and IV Neostigmine

50
Q

Describe the two surgical options for Pseudo - Obstruction

A

Segmental Resection
Caecostomy/Ileostomy to decompress bowel

51
Q

Define Volvulus

A

Twisting of bowel around its mesentery, and can compromise blood supply leading to infarction and necrosis

52
Q

Give four risk factors for Volvulus

A

Age
Neuropsychiatric Disorders
Chronic Constipation OR Laxative Use
Previous Abdo Surgery

53
Q

Describe the clinical features of Sigmoid Volvulus

A

Early - Colicky Pain, Abdo Distension, Absolute Constipation
Late - Vomiting

54
Q

What imaging would you use if you suspected Volvulus?

A

CT Abdo Pelvis with Contrast - Whirl Sign
Abdominal Xray - Coffee Bean Sign in LIF

55
Q

Describe the conservative management of a Volvulus

A

Fluids
Decompression by sigmoidoscope and insertion of flatus tube

56
Q

What indicates surgical management in Volvulus?

A

Ischaemia/Perforation
Failed attempts at decompression
Necrotic bowel

Hartmann

57
Q

Describe the bimodal age distribution for Caecal Volvulus

A

10 - 29
60 - 79

58
Q

What are Haemorrhoids?

A

Abnormal swelling/enlargement of anal vascuar cushions

59
Q

Describe the normal anatomy of anal vascular cushions

A

Assist anal sphincter in maintaining continence
3 vascular cushions (3,7,11)

60
Q

Describe the classification of Haemorrhoids

A

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

61
Q

Give three risk factors of Haemorrhoids

A

Chronic Constipation
Increased age
Increased intra-abdo pressure

62
Q

Describe three features of Haemorrhoids

A

Painless bright red rectal bleeding (on paper)
Pruritus
Rectal fullness

63
Q

What happens when Haemorrhoids become painful?

A

The Haemorrhoids have become thrombosed, will appear purple/blue which is an emergency

64
Q

Describe the conservative management of Haemorrhoids

A

Fluid/Fibre/Lacatives
Topical Lidocaine
1st and 2nd Degree - Rubber band ligation

65
Q

When would you treat Haemorrhoids with surgery?

A

If unresponsive to conservative but not suitable for banding
Stapled or Milligan Morgan Technique

66
Q

What is a Pilonoidal Sinus?

A

Formation of a sinus in the cleft of the buttocks, commonlly affecting males aged 16-30

67
Q

Describe the pathophysiology of a Pilonoidal Sinus in three steps

A

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

68
Q

Give 3 risk factors for the formation of a Pilonoidal Sinus

A

Caucasian males with coarse dark hair
Those who sit for prolonged periods
Increased sweating

69
Q

Describe three clinical features of Pilonoidal Sinuses

A

Intermittent red/painful/swollen mass in sacrococcygeal region
Discharge and signs of infection
Opens up to skin but does not communicate with anal canal

70
Q

Describe the non surgical management of Pilonoidal Sinuses

A

Plucking the affected region
Any abscess requires draining

71
Q

Describe the two surgical methods of managing Pilonoidal Sinuses (if chronic)

A
  • Excise tract and lay open to heal by secondary intention
  • Excise tract and close the wound (higher rates of recurence)
72
Q

Define Anal Fistula

A

Abnormal connection between anal canal and perianal skin

73
Q

Give 3 causes of Anal Fistulae

A

IBD
History of Trauma
Previous Radiation to the area

74
Q

Describe the clinical features of Anal Fistulae

A

Recurrent Perianal Abscesses
Intermittent/Continuous discharge onto perineurium

75
Q

Describe the Goodsall Rule

A

Predicts the trajectory of an Anal Fistula tract

Closer to the post aspect - curved course
Closer to the ant aspect - straight course

76
Q

Describe the Park’s Classification of Anal Fistulae

A

Intersphincteric (between internal and external anal sphincter)
Transphincteric (across sphincter horizontally)
Suprasphincteric
Extrasphincteric

77
Q

Describe two surgical managements of Anal Fistulae

A

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

78
Q

Define Anorectal Abscess

A

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)

79
Q

How would an Anorectal Abscess present?

A

Pain in perineum (exacerbated by sitting down)
Localised swelling/itching/discharge
If severe - systemic symptoms

80
Q

How would you manage an Anorectal Abscess?

A

Antibiotic Therapy and Analgesia
Incision and drainage

81
Q

Define Anal Fissure

A

Tear in the mucosal lining of anal canal
Primary - No underlying disease
Secondary - Underlying disease (IBD)

82
Q

Describe the clinical features of Anal Fissures

A

Intense pain on defaecation (can last several hours)
Bleeding (bright red on paper)
90% on posterior midline

83
Q

Describe the conservative management of Anal Fissures

A

Increase fibre and fluids
Stool softening laxatives
Hot Baths
GTN/Diltiazem cream (promotes blood supply to area and hence healing)

84
Q

Describe the surgical management of Anal Fissures

A

Generally only reserved for chronic fissures
Botox - causing internal and external sphincter to relax, promoting healing
Lateral Sphincterotomy - Divides internal anal sphincter

85
Q

What is a Rectal Prolapse? What are the two types?

A

Protrusion of rectal tissue out of the anus
Partial Thickness - Rectal Mucosa protrudes out of anus
Full Thickness - Rectal wall protrudes out of anus

86
Q

Describe the pathophysiology of a Full Thickness Rectal Prolapse

A

Form of sliding hernia through defect in fascia

87
Q

Describe the pathophysiology of a Partial Thickness Rectal Prolapse

A

Loosening and stretching of Connective Tissue (normally due to haemorrhoidal disease)

88
Q

Describe the presentation of a Rectal Prolapse

A

Rectal Discharge/Bleeding
Faecal Incontinence
Full Thickness - Fullness, Tenesmus

89
Q

How would you examine a suspected Rectal prolapse?

A

DRE under anaesthesia

90
Q

Surgery is the definitive treatment for Rectal Prolapse, describe the two approaches

A

Perineal Approach
Abdominal Approach

91
Q

Describe the histological difference in Anal Cancers

A

Below Dentate Line - Squamous Cell Carcinomas (AIN is precancerous conditions)
Above Dentate Line - Adenocarcinomas

92
Q

Give three risk factors for Anal Cancers

A

HPV
HIV
Crohns

93
Q

Give four features of Anal Cancer

A

Rectal Pain/Bleeding
Anal Discharge
Pruritus
Sphincters involved - tenesmus

94
Q

What imaging is best for Anal Cancer?

A

MRI Pelvis

95
Q

Describe the management of Anal Cancer

A

Chemoradiotherapy for all of them except T1N0 (where excision is normally sufficient)
Surgery - AP Resection

96
Q

Give 3 complications of Anal Cancer

A

ED
Rectovaginal Fistula
Proctitis

97
Q

What is a common differential for Appendicitis in children?

A

Mesenteric Adenitis

98
Q

What is Chilidaiti’s Sign?

A

Loop of bowel between the liver and diaphragm
Normal

99
Q

How should diverticulitis be managed?

A

Initially oral antibiotics at home
If no improvement after 72h then admit for IV abx

100
Q

How can a high-output stoma result in acidosis?

A

Loss of bicarbonates from stomach

101
Q

How should thrombosed haemorrhoids be managed?

A

If presenting within 72h of onset then can be referred for excision
If over 72h - ice packs/analgesia/stool softeners

Year 3 Surgery (11 decks)

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