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
umbilicus to ASIS
What is McBurney’s Point?
- 2/3 from Umbilicus to ASIS
- Focus of peritoneal pain in late appendicitis
State features OE of a patient with Appendicitis
- Tachycardic
- Tachypnoeic
- Pyrexial
- Rebound tenderness and percussion pain over McBurneys point
- potential signs of guarding
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
DDx for Appendicitis
- Ectopic Pregnancy
- Ovarian Cyst
- Rupture Ureteric Stones
- Diverticulitis
- IBS
- PID
- UTI
- Testicular torsion
- Epididymo-orchitis
*
what investigations are done in ?appendicitis?
- urinalysis
- pregnancy test
- routine bloods
- USS
- CT
How would you manage an Appendicitis patient?
Laproscopic Appendicectomy
appendix sent to histopathology to look for malignancy
inspect rest of abdomen during laparoscopic procedure
Describe the complications of Appendicitis. How could we reduce the risk?
Perforation - if left untreated
Surgical Site infection
Appendiceal Mass - omentum and small bowel adhere to appendix
Pelvic Abscess - abx and abscess draining
antibiotics
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/anaemia
Mass in RIF
Describe 4 presentations of Left Sided Colorectal Cancer
Rectal Bleeding
Tenesmus
Change in bowel habit
Mass in LIF or on PR
What is the marker of Colorectal Cancer?
CEA
Not used in diagnosis but used to monitor progression
what presentations do NICE recommend get referred for urgent investigation?
- >40 eith unexplained weight loss
- >50 with unexplaied rectal bleeding
- >60 iron deficiency aneamia or change in bowel habit
- positive occult blood screening test
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 - Trough 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
when is chemotherapy indicated in patients with colorectal cancer?
in patients with advanced disease
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 but can be anywhere along large and small bowel
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 - just inflammation
Complicated (Abscess, Fistulae, Strictures, Perforation)
Diverticula are often asymptomatic, describe three Diverticular pain
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 Diverticular Disease 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 of 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
