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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

umbilicus to ASIS

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 features OE of a patient with Appendicitis

A
  • Tachycardic
  • Tachypnoeic
  • Pyrexial
  • Rebound tenderness and percussion pain over McBurneys point
  • potential signs of guarding
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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

DDx for Appendicitis

A
  • Ectopic Pregnancy
  • Ovarian Cyst
  • Rupture Ureteric Stones
  • Diverticulitis
  • IBS
  • PID
  • UTI
  • Testicular torsion
  • Epididymo-orchitis
    *
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9
Q

what investigations are done in ?appendicitis?

A
  • urinalysis
  • pregnancy test
  • routine bloods
  • USS
  • CT
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10
Q

How would you manage an Appendicitis patient?

A

Laproscopic Appendicectomy

appendix sent to histopathology to look for malignancy

inspect rest of abdomen during laparoscopic procedure

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11
Q

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

A

Perforation - if left untreated

Surgical Site infection

Appendiceal Mass - omentum and small bowel adhere to appendix

Pelvic Abscess - abx and abscess draining

antibiotics

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12
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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13
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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14
Q

Give four risk factors for Colorectal Cancer

A

Age

IBD

Family History

Low Fibre Diet

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15
Q

Describe 3 presentations of Right Sided Colorectal Cancer

A

Late Presentation

Abdo Pain

Occult Bleeding/anaemia

Mass in RIF

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16
Q

Describe 4 presentations of Left Sided Colorectal Cancer

A

Rectal Bleeding

Tenesmus

Change in bowel habit

Mass in LIF or on PR

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17
Q

What is the marker of Colorectal Cancer?

A

CEA

Not used in diagnosis but used to monitor progression

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18
Q

what presentations do NICE recommend get referred for urgent investigation?

A
  • >40 eith unexplained weight loss
  • >50 with unexplaied rectal bleeding
  • >60 iron deficiency aneamia or change in bowel habit
  • positive occult blood screening test
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19
Q

Give three possible imaging techniques for Colorectal Cancer

A

Colonoscopy CT Scan MRI Rectum

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20
Q

Describe Duke’s Staging of Colorectal Cancer

A

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

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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 RIGHT Hemicolectomy?

A
  • Ileocolic
  • Right Colic
  • Right Middle Colic
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22
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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23
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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24
Q

Give an example of when an Anterior Resection is used

A

High rectal tumours

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25
Q

Give an example of when an AP Resection is used

A

Low Rectal Tumours

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26
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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27
Q

What other treatment can be used in Rectal Colorectal Carcinomas?

A

Radiotherapy

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28
Q

when is chemotherapy indicated in patients with colorectal cancer?

A

in patients with advanced disease

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29
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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30
Q

What is a Diverticulum?

A

Outpouching of the bowel wall, commonly in Sigmoid but can be anywhere along large and small bowel

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31
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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32
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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33
Q

Describe the manifestations of Chronic Diverticulitis

A

Fistulae (Colovesicle and Colovaginal)

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34
Q

Describe the two types of Diverticulitis

A

Simple - just inflammation

Complicated (Abscess, Fistulae, Strictures, Perforation)

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35
Q

Diverticula are often asymptomatic, describe three Diverticular pain

A

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

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36
Q

Describe the presentation of Diverticulitis

A

Acute Abdominal pain (usually sharp in LIF) Systemic Upset

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37
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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38
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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39
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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40
Q

When is surgical management of Diverticular Disease required?

A

If stage 4 Hinchey or overwhelming Sepsis Hartmann Procedure

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41
Q

When is surgery indicated in Crohns?

A

Failed Medical Treatment Severe Complications Growth Impairment in younger patients

42
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

43
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

44
Q

Why should you avoid anti-motility drugs in IBD?

A

They can precipitate Toxic Megacolon

45
Q

What are the indications for surgery in Ulcerative Colitis?

A

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

46
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)

47
Q

Describe three complications of UC

A

Toxic Megacolon Colorectal Carcinoma Osteoporosis

48
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

49
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

50
Q

Describe four clinical features of Pseudo-Obstruction

A

Abdominal Pain Abdominal Distension Constipation Late Vomiting

51
Q

What is the gold standard investigation for Pseudo-Obstruction?

A

Abdo CT with IV contrast

52
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

53
Q

Describe the two surgical options for Pseudo - Obstruction

A

Segmental Resection Caecostomy/Ileostomy to decompress bowel

54
Q

Define Volvulus

A

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

55
Q

Give four risk factors for Volvulus

A

Age Neuropsychiatric Disorders Chronic Constipation OR Laxative Use Previous Abdo Surgery

56
Q

Describe the clinical features of Sigmoid Volvulus

A

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

57
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

58
Q

Describe the conservative management of a Volvulus

A

Fluids Decompression by sigmoidoscope and insertion of flatus tube

59
Q

What indicates surgical management in Volvulus?

A

Ischaemia/Perforation Failed attempts at decompression Necrotic bowel Hartmann

60
Q

Describe the bimodal age distribution for Caecal Volvulus

A

10 - 29 60 - 79

61
Q

What are Haemorrhoids?

A

Abnormal swelling/enlargement of anal vascuar cushions

62
Q

Describe the normal anatomy of anal vascular cushions

A

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

63
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

64
Q

Give three risk factors of Haemorrhoids

A

Chronic Constipation Increased age Increased intra-abdo pressure

65
Q

Describe three features of Haemorrhoids

A

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

66
Q

What happens when Haemorrhoids become painful?

A

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

67
Q

Describe the conservative management of Haemorrhoids

A

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

68
Q

When would you treat Haemorrhoids with surgery?

A

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

69
Q

What is a Pilonoidal Sinus?

A

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

70
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

71
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

72
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

73
Q

Describe the non surgical management of Pilonoidal Sinuses

A

Plucking the affected region Any abscess requires draining

74
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)
75
Q

Define Anal Fistula

A

Abnormal connection between anal canal and perianal skin

76
Q

Give 3 causes of Anal Fistulae

A

IBD History of Trauma Previous Radiation to the area

77
Q

Describe the clinical features of Anal Fistulae

A

Recurrent Perianal Abscesses Intermittent/Continuous discharge onto perineurium

78
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

79
Q

Describe the Park’s Classification of Anal Fistulae

A

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

80
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

81
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)

82
Q

How would an Anorectal Abscess present?

A

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

83
Q

How would you manage an Anorectal Abscess?

A

Antibiotic Therapy and Analgesia Incision and drainage

84
Q

Define Anal Fissure

A

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

85
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

86
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)

87
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

88
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

89
Q

Describe the pathophysiology of a Full Thickness Rectal Prolapse

A

Form of sliding hernia through defect in fascia

90
Q

Describe the pathophysiology of a Partial Thickness Rectal Prolapse

A

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

91
Q

Describe the presentation of a Rectal Prolapse

A

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

92
Q

How would you examine a suspected Rectal prolapse?

A

DRE under anaesthesia

93
Q

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

A

Perineal Approach Abdominal Approach

94
Q

Describe the histological difference in Anal Cancers

A

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

95
Q

Give three risk factors for Anal Cancers

A

HPV HIV Crohns

96
Q

Give four features of Anal Cancer

A

Rectal Pain/Bleeding Anal Discharge Pruritus Sphincters involved - tenesmus

97
Q

What imaging is best for Anal Cancer?

A

MRI Pelvis

98
Q

Describe the management of Anal Cancer

A

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

99
Q

Give 3 complications of Anal Cancer

A

ED Rectovaginal Fistula Proctitis

100
Q

What is a common differential for Appendicitis in children?

A

Mesenteric Adenitis

101
Q

What is Chilidaiti’s Sign?

A

Loop of bowel between the liver and diaphragm Normal

Year 3 Surgery (10 decks)

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