GI Surgery

Question 1

Summarise the management of anal fissures.

Answer 1

For 6 weeks try:

• Dietary: high-fibre and high-fluid
• Bulk-forming laxatives
• Lubricants (e.g. petroleum jelly) before defecation
• Topical anaesthetics
• Analgesia

After 6 weeks try:

• Topical GTN
  
  • If after 8 weeks still not effective: surgery (sphinterotomy) or BOTOX

Question 2

What are the NICE referral guidelines for suspected colorectla cancer?

Answer 2

Refer urgently (2 weeks) if:

• ≥40 with unexplained weight loss and abdominal pain
• ≥50 with unexplained rectal bleeding
• ≥60 with iron deficiency anaemia OR change in bowel habit
• Positive occult blood test

Consider referring urgently if:

• Rectal/abdominal mass
• Unexplained anal mass/ulceration
• <50 with rectal bleeeding and:
  
  • Abdo pain
  • Change in bowel habit
  • Weight loss
  • IDA

Question 3

To whom should the faecal occult blood test screening be offered?

Answer 3

Screening: all people 60-74. In addition:

• ≥50 with unexplained abdo symptoms or weight loss
• <60 with change to bowel habit or IDA
• ≥60 with anaemia evenn without iron deficiency

Question 4

What is the strongest risk factor for anal cancer?

Answer 4

HPV infection

Question 5

What is solitary rectal ulcer syndrome?

Answer 5

It is caused by localized ischemic injury or prolapse of the distal rectal mucosa.

This is a rare disorder that involves straining during defecation, a sense of incomplete evacuation, and sometimes passage of blood and mucus by rectum.

Diagnosis is clinical with confirmation by flexible sigmoidoscopy and biopsy. Treatment is a bowel regimen for mild cases, but surgery is sometimes needed if rectal prolapse is the cause.

Question 6

What type of surgery is indicated for cancer located in the rectum?

Answer 6

A rectal cancer needs to either be removed with an anterior resection or a abdominoperineal resection.

AP resections include removal of the anus, and are used for cancers that are in close proxmity to the rectal sphincter, i.e. in the lower third of the rectum.

Question 7

Describe the grading system for hameorrhoids

Answer 7

• I: do not prolapse out of the canal
• II: Prolapse on defecation but reduce spntaneously
• III: Can be manually reduced
• IV: Cannot be reduced

Question 8

What is the management of a diverticular bleed?

Answer 8

Isolated diverticular bleeds without evidence of infection do not require antibiotics or surgery.

Question 9

Wht is gastric volvulus?

Answer 9

Gastric volvulus is rare. It is rotation of the stomach associated with obstruction.

Triad:

• Vomiting (non-bilious)
• Pain
• Failed attepts to pass NG tube

Question 10

What would histology show for a solitary rectal ulcer syndrome?

Answer 10

Fibromuscular obliteration.

Question 11

What type of analgesia is associated with faster return of bowel function after abdominal surgery?

Answer 11

High quality evidence suggests that epidural analgesia helps to accelerate the return of normal bowel function after abdominal surgery.

Question 12

What would a blood gas for a patient with a high-output stoma show?

Answer 12

• Metabolic acidosis (as Bicarb is lost in stoma)
• ± Respiratory compensation (low pCO2)
• Low Bicarb

Question 13

Talk me through the Duke’s staging system.

Answer 13

Dukes’ classification describes the extent of spread of colorectal cancer:

• Dukes A: Tumour confined to mucosa
• Dukes B: Tumour invading bowel wall
• Dukes C: LN metastases
• Dukes D: Distant metastases

Question 14

What is the most common location for diverticular disease?

Answer 14

The sigmoid colon.

Question 15

What does this Abdominal polain radiograph show?

Answer 15

Sigmoid volvulus.

Clear “coffee bean sign” and large-bowled obstruction.

Question 16

What is the national screening programme for colorectal cancer in England and Scotland?

Answer 16

Faceal immunochemical test (FIT) every 2 years 60-74 (England) and 50-74 (Scotland)

In addition, a one-off flexible sigmoidoscopy at age 55 is offered to identify and treat polyps.

Question 17

What is the most common histological subtype of colorectal cancer?

Answer 17

Adenocarcinoma.

Question 18

What is a rectal intussceception?

Answer 18

Rectal intussceception (internal rectal prolapse) typically presents with symptoms of obstructed defecation. The pathology is best demonstrated by a defecating procotogram rather than barium enema.

Question 19

What is the management of diverticulitis mild flare?

Answer 19

Patients with diverticulitis flares can be managed with oral antibiotics at home.

If they do not improve within 72 hours, admission to hospital for IV ceftriaxone + metronidazole is indicated

Question 20

What does this AXR show?

Answer 20

Small bowel obstruction is clearly visible on this film (note the valvulae conniventes, mucosal folds, that cross the full width of the bowel) secondary to caecal volvulus. Note the left nephrostomy tube in-situ.

Question 21

What is the usual purpose of a loop ileostomy?

Answer 21

A loop ileostomy can be used to defunction the colon to protect an anastomosis distally.

Question 22

What does this AXR show?

Answer 22

You can see the typical ‘coffee bean’ appearance with three dense lines converging towards the site of obstruction (Frimann Dahl’s sign) in keeping with sigmoid volvulus.

Question 23

What is the most appropriate investigation to assess the patency of an anastomosis?

Answer 23

A gastrografin enema involves passing a water soluble radiopaque liquid into the rectum, then taking radiographs to assess the rectum. If there are any leaks in a colorectal anastomosis, the radiopaque liquid should show up as free fluid in the abdomen. As this is a possibility gastrografin is preferred over barium as it is less toxic if it leaks into the abdominal cavity.

Question 24

What is the management of sigmoid volvulus and caecal volvulus?

Answer 24

Sigmoid: rigid sigmoidoscope with rectal tube insertion.

Caecal: managment is usually operative; right hemicolectomy is often needed.

Question 25

What is a Richter Hernia?

Answer 25

A Richter Hernia is when only one side of the bowel wall has herniated. This means that the lumen of the intestine is incompletely contained in the defect, while the rest remians completely in the peritoneal cavity.

This mean there can be ischaemia and bowel necrosis without obstruction.