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The Abdomen > Hindgut > Flashcards

Hindgut Flashcards

1
Q

What constitutes the hindgut

A

Distal third of the transverse colon and the splenic flexure, the descending colon, sigmoid colon and rectum

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2
Q

Length of the large bowel

A

1.5m

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3
Q

Distinguishing features of the large bowel

A
  • Omental appendices
  • Teniae coli
  • Haustra
  • Greater calibre
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4
Q

List the 3 tenia coli

A
  1. Mesocolic tenia - to which the transverse and sigmoid mesocolons attach
  2. Omental tenia - to which the omental appendices attach
  3. Free tenia - to which neither mesocolons or appendices attach
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5
Q

Blood supply of the caecum

A

Ileocolic artery (terminal branch of SMA)

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6
Q

Venous drainage of the caecum

A

Ileocolic vein (tributary of the SMV)

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7
Q

Lymphatic drainage of the caecum

A

Nodes of the mesoappendix and ileocolic nodes

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8
Q

Origin of the appendix

A

Posteromedial aspect of the caecum about 2.5cm below the ileocaecal valve

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9
Q

Typical position of the appendix

A

Retrocaecal

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10
Q

Blood supply to the appendix

A
  • Appendicular artery within the mesoappendix
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11
Q

Peritoneal covering of the ascending colon

A
  • Retroperitoneal

- Covered on the anterior and lateral aspects

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12
Q

Posterior relations of the ascending colon

A
  • Iliacus
  • Quadratus lumborum
  • Perirenal fascia over the lateral aspect of the right kidney
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13
Q

What separates the ascending colon from the anterolateral abdominal wall

A

Right paracolic gutter

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14
Q

Arterial supply of the ascending colon

A
  • Ileocolic

- Middle colic

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15
Q

Lymphatic drainage of the ascending colon

A

In order:

  1. Epicolic and paracolic nodes
  2. Ileocolic and intermediate right colic nodes
  3. Superior mesenteric nodes
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16
Q

Attachments of the transverse colon

A
  • Anterior border of the pancreas by the transverse mesocolon
  • Diaphragm via phrenicocolic ligament
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17
Q

Superior relations of transverse colon

A
  • Liver
  • GB
  • Greater curvature of the stomach
  • Spleen
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18
Q

Anterior relations of the transverse colon

A

Anterior layers of the greater omentum

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19
Q

Posterior relations of the transverse colon

A
  • Right kidney
  • Second part of duodenum
  • Pancreas
  • Small bowel
  • Left kidney
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20
Q

Arterial supply of the transverse colon

A

Mainly via the middle colic artery (branch of the SMA)

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21
Q

Lymphatic drainage of transverse colon

A

Middle colic nodes which drain into the superior mesenteric nodes

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22
Q

Peritoneal covering of the descending colon

A
  • Retroperitoneal

- Covered on its anterior and lateral aspects

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23
Q

Posterior relations of the descending colon

A
  • Left kidney
  • Quadratus lumborum
  • Iliacus
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24
Q

Course of the sigmoid colon

A

Commences at the pelvic brim and continue to the rectosigmoid junction

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25
Q

Significance of the sigmoid mesocolon

A

Extensive and may precipitate volvulus

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26
Q

Male and female relations of the sigmoid colon

A
  • Male = bladder

- Female = uterus and posterior fornix of vagina

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27
Q

Arterial supply of the sigmoid colon

A

Left colic and sigmoid arteries (branches of the IMA)

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28
Q

Venous drainage of the sigmoid

A

IMV (drains into splenic vein)

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29
Q

Lymphatic drainage of the sigmoid

A
  1. Epicolic and paracolic nodes
  2. Intermediate colic nodes
  3. Inferior mesenteric nodes
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30
Q

Describe the course of the rectum

A
  • Commences anterior to 3rd segment of sacrum

- Ends 2.5cm in front ot the coccyx where it bends backwards to become the anal canal

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31
Q

What happens to the tenia coli at the rectum

A

Form a continuous outer longitudinal layer of smooth muscle

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32
Q

Outline the peritoneal coverings of the rectum

A
  • Posterior = extraperitoneal
  • Upper 1/3 = covered on front and sides
  • Middle 1/3 = covered anteriorly
  • Inferior 1/3 = completely extraperitoneal
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33
Q

Describe the 3 lateral flexures of the rectum

A
  • Superior and inferior on the left side
  • Intermediate on the right
    (Correspond to the internal transverse rectal folds)
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34
Q

Male anterior relations of the rectum

A
  • Rectovesical pouch
  • Base of bladder
  • Seminal vesicles
  • Prostate
  • Denonvilliers fascia separates it from the prostate
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35
Q

Female anterior relations of the rectum

A
  • Rectouterine pouch (of Douglas)

- Posterior wall of vagina

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36
Q

Posterior relations of the rectum

A

Waldeyers fascia lies between recut and sacrum

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37
Q

Lateral relations of rectum

A

Below peritoneal reflection lies the levator ani and coccygeus muscles

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38
Q

Outline the blood supply of the rectum

A
  • Proximal = superior rectal (IMA)
  • Middle and inferior = middle rectal (anterior division of internal iliac)
  • Anorectal junction = inferior rectal (internal pudendal)
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39
Q

Blood supply of the anal canal

A

Inferior rectal artery (branch of internal pudendal)

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40
Q

Venous drainage of the rectum

A
  • Superior rectal (drains into portal system via IMV)
  • Middle and inferior rectal (drain into systemic system via internal iliac vein)

The walls of the rectum are a site of portosystemic anastomosis

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41
Q

Length of the anal canal

A

4cm

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42
Q

Structure of the anal canal

A

2 layers of circular muscle form the wall:

  • Internal sphincter of smooth muscle
  • External sphincter of skeletal muscle
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43
Q

Columns of Morgani

A

Columns at the midpoint of the anal canal containing the anal valves of Ball

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44
Q

Anal valves of Ball

A

Contain the sinuses that open the anal glands

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45
Q

Histological change at the Dentate line

A
  • Above = columnar

- Below = squamous

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46
Q

Developmental significance of the Dentate line

A
  • Above = endoderm

- Below = ectoderm

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47
Q

Lymphatic drainage of the rectum and anal canal

A
  • Above dentate line = internal iliac nodes

- Below dentate line = palpable superficial inguinal nodes

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48
Q

Innervation of the external anal sphincter

A

Inferior branches of the pudendal nerve (S2)

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49
Q

Mechanism of water absorption in the colon

A

Na+ is transported from the lumen under the influence of aldosterone and water follows along osmotic gradient

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50
Q

Volume of water absorbed in the colon per day

A

1L

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51
Q

3 roles of colonic flora

A
  1. Fermentation of indigestible carbohydrates
  2. Degradation of bilirubin
  3. Synthesis of vitamin K, B12, thiamine, riboflavin
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52
Q

Speed of small bowel transit

A

5 hours

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53
Q

Speed of large bowel transit

A

20 hours

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54
Q

Region of peristalsis and mass movement in the colon

A

Transverse and distal colon

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55
Q

Stimulator of colonic motility

A

Vagal stimulation

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56
Q

How does the colon manipulate gastric motility

A

Releases Enteroglucagon in response to fat in the ileum/colon which inhibits gastric and small bowel motility

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57
Q

Four mechanisms of diarrhoea

A
  1. Osmotic
  2. Secretory
  3. Inflammatory
  4. Abnormal motility
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58
Q

8 essential amino acids

A
  1. Isoleucine
  2. Leucine
  3. Lysine
  4. Methionine
  5. Phenylalanine
  6. Threonmine
  7. Tryptophan
  8. Valine
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59
Q

Roles of fats

A
  • Support of other tissues (e.g. perirenal)
  • Stores fat-soluble vitamins
  • Nerve sheaths
  • Cell membranes
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60
Q

Where is the hunger/feeding centre

A

Lateral hypothalamus

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61
Q

Where is the satiety centre

A

Ventromedial hypothalamus

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62
Q

How is the satiety centre activated

A

By high blood glucose levels post-meal and gastric distension

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63
Q

Define Crohn’s disease

A

Transmural inflammatory bowel disease

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64
Q

Define UC

A

Mucosal inflammatory bowel disease

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65
Q

What percentage of UC cases spread beyond the splenic flexure

A

15%

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66
Q

Most common site of CD

A

Terminal ileum

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67
Q

Histological features of CD

A
  • Whole thickness of bowel
  • Chronic = hosepipe thickening with fibrosis
  • Cobblestone
  • Deep fissuring ulcers
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68
Q

Histological features of UC

A
  • Limited to mucosa (not affecting muscularis propria)
  • Pseudo-polyps
  • Small shallow ulcers
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69
Q

Microscopic features of CD

A
  • Non-caseating epitheloid granulomas
  • Transmural
  • Lymphoid follicles
  • Mucosal crypt distortion
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70
Q

Microscopic features of UC

A
  • Inflammatory infiltrate confined to lamina propria
  • Crypt abscesses
  • Crypt distortion
  • Metaplasia and dysplasia
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71
Q

Sexual distribution of IBD

A
  • CD more common in women

- UC equal

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72
Q

Percentage of CD patients with perianal disease

A

75%

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73
Q

Extra-intestinal manifestations of CD

A
  • Gallstones

- Oxalate renal stones

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74
Q

Extra-intestinal manifestations of UC

A
  • PSC
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75
Q

General extra-intestinal features of IBD related to disease severity

A
  • Skin = pyoderma gangrenosum, erythema nodosum
  • Mucous membranes = apthous ulcers of mouth and vagina
  • Eyes = iritis
  • Joints = activity-related arthritis
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76
Q

CD Barium enema features

A
  • Skip lesions
  • Rectal sparing is common
  • Cobblestone appearance
  • Rose-thorn ulcers
  • Fistulas
  • Strictures
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77
Q

UC Barium enema features

A
  • Hosepipe colon
  • Decreased haustrae
  • Affects rectum and spreads proximally
  • Mucosal distortion
  • Pseudo polyps
  • Shortened colon
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78
Q

Medical management of severe UC

A
  • Topical and oral mesalazine
  • Oral steroids
  • IV steroids
  • Ciclosporin and infliximab
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79
Q

Medical management of severe CD

A
  • IV hydrocortisone
  • PR hydrocortisone
  • Metronidazole
  • Infliximab/Adalimumab
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80
Q

Mechanism of action of Ciclosporin

A

Interferes with lymphocyte activation

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81
Q

What needs to be checked before commencing Azathioprine

A

TPMT

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82
Q

Principles of CD surgery

A
  • As limited as possible

- Bowel-preserving procedures wherever possible (e.g. stricturoplasty)

83
Q

Principles of UC surgery

A
  • Radical

- Removal of diseased segment should provide cure

84
Q

What is the typical operation for UC (middle-aged and elderly patients)

A

Proctocolectomy with ileostomy

85
Q

Best operation for UC in younger patients

A

Sphincter-preserving proctocolectomy with ileal pouch

86
Q

Site of pouch anastomosis in sphincter-preserving proctocolectomy

A

Dentate line

87
Q

Procedure for toxic megacolon

A

Subtotal colectomy with ileostomy +/- mucous fistula

88
Q

Complications of UC

A
  • Toxic megacolon
  • Perforation
  • Haemorrhage
  • Malignant change
89
Q

Complications of CD

A
  • Small-bowel strictures
  • Fistulation
  • Perianal sepsis
  • Perforation
90
Q

Of patients with UC for 20 years, what proportion will develop malignancy

A

12%

91
Q

Investigation to identify strictures in CD

A

Contrast studies

92
Q

Medication used for prophylaxis of perianal disease in CD

A

Metronidazole

93
Q

What percentage of colon cancers are distal to the splenic flexure

A

75%

94
Q

Three characteristics of colonic adenomas that correlate with malignant change

A
  1. Size
  2. Villious architecture
  3. Dysplasia
95
Q

Most common site of colon cancer

A

Sigmoid colon

96
Q

What proportion of colorectal cancers are associated with genetic factors

A

24%

97
Q

Proportion of colorectal cancer patients with synchronous tumours

A

3-5%

98
Q

Incidence of metachronous colorectal tumours

A

3% at 10-years post-treatment of the first tumour

99
Q

Outline the 5 methods of colorectal cancer spread

A
  1. Direct
  2. Lymphatic
  3. Blood-borne
  4. Transcoelomic
  5. Implantation
100
Q

Necessary resection margin for colorectal cancer

A

2cm

101
Q

How does colorectal cancer spread to the liver

A
  • Blood-borne

- Via the portal vein

102
Q

Dukes A

A

Tumour confined to the mucosa

103
Q

Dukes B1

A

Tumour growth into muscularis propria

104
Q

Dukes B2

A

Full thickness tumour growth

105
Q

Dukes C1

A

1-4 regional lymph nodes

106
Q

Dukes C2

A

More than 4 regional lymph nodes

107
Q

Dukes D

A

Distant metastasis (lung, liver, bone)

108
Q

R1 resection

A

Shows tumour at the resection margin = residual local disease (uncurable)

109
Q

R0 resection

A

Curative operation

110
Q

Non-genetic risk factors for colorectal cancer

A
  • Lack of fibre
  • High-fat diet
  • High level of bile acid
  • Previous cholecystectomy
111
Q

Procedure for obstructing colonic tumours

A

De-functioning loop colostomy

112
Q

Adenoma with greatest malignant potential

A

Villous adenomas (40%)

113
Q

Cause of pseudopolyps

A

Inflammatory - associated with UC

114
Q

FAP inheritance pattern

A

Autosomal dominant

115
Q

Site and name of gene responsible for FAP

A
  • Long arm of chromosome 5

- APC

116
Q

Features of Gardner’s syndrome

A
  • FAP related
  • Desmoid tumours
  • Osteomas of the mandible (extra teeth)
  • Sebaceous cysts
117
Q

HNPCC inheritance pattern

A

Autosomal dominant

118
Q

Genes implicated in HNPCC

A
  • hMSH 2
  • hMLH 1
  • hPMS 1 and hPMS 2
119
Q

Average age of diagnosis of HNPCC

A

45 years

120
Q

HNPCC extra-colonic associated cancers

A
  • Endometrial - 20-40%
  • Ovarian - 10%
  • Gastric - 6%
  • Biliary tract - 4%
  • Brain - 1%
  • Small bowel - 1%
121
Q

Most likely site of HNPCC

A

Proximal colon

122
Q

Outline the Amsterdam criteria for HNPCC

A
  • 3 or more family members with colorectal cancer
  • Colorectal cancer extending over 2 generations
  • One or more affected by 45
  • One affected relative is a first-degree of the other two
  • Exclusion of FAP
123
Q

Bowel preparation for colonic resections

A
  • 1 day of liquid diet

- 2 sachets of sodium picosulphate beforehand

124
Q

Curable procedure for non-obstructed right colon tumours

A

Right hemicolectomy and primary anastomosis sparing the middle colic arteries

125
Q

Curable procedure for non-obstructed transverse/splenic flexure tumours

A

Extended right hemicolectomy taking the middle colic arteries

126
Q

Curable procedure for non-obstructed sigmoid, middle/upper rectal tumours

A

Anterior resection taking the IMA and its sigmoid and upper rectal branches

127
Q

Curable procedure for low rectal and anorectal tumours

A

AP resection and end colostomy taking the IMA and meticulous dissection of the mesorectal fat and lymph nodes

128
Q

What does ELAPE entail

A

Rectum, anus, sphincter, and levator muscles are taken en block with AP resection

129
Q

Which rectal cancers can proceed straight to surgery

A

T1-3/N0

130
Q

Management of T4 rectal cancer

A
  • Neoadjuvant long course chemoradiotherapy

- Resection

131
Q

Most common site of distal mets in colorectal cancer

A

Liver (sometimes lungs)

132
Q

Management of liver metastases in rectal cancer

A

Solitary lesions can be resected

133
Q

Management of FAP

A
  1. Genetic testing if at risk
  2. Annual flexi sig from 15
  3. If no polyps - 5 yearly colonoscopy from 20
  4. Polyps found = prophylactic panproctocolectomy
134
Q

Management of HNPCC

A
  1. Colonoscopy every 1-2 years from 25
  2. Consider panproctocolectomy
  3. Extra-colonic surveillance
135
Q

Colonoscopy high risk polyp findings

A
  • More than 2 premalignant polyps including 1 or more advanced polyps, OR
  • More than 5 pre-malignant polyps
136
Q

Follow-up plan if high risk polyps identified at colonoscopy

A

One off surveillance scope at 3 years

137
Q

Post-operative antibiotics after colonic resection

A

3 doses of cef and met

138
Q

Features of anastomotic leak

A
  • Occurs 7-10 days post-op
  • Risk is higher in low anastamosis
  • Results in pelvic abscess, fistulation, death
139
Q

What cardiac condition is associated with angiodysplasia

A

Aortic stenosis

140
Q

How is angiodysplasia investigated

A
  1. Colonoscopy

2. Mesenteric angiography if acutely bleeding

141
Q

How is angiodysplasia managed

A
  1. Endoscopic cautery or argon plasma coagulation

2. TXA and oestrogens

142
Q

What is the most common causes of mesenteric ischaemia

A

Embolus

143
Q

How does acute mesenteric ischaemia present

A
  • Sudden onset abdominal pain
  • Followed by profuse diarrhoea
  • Rapid clinical deterioration
144
Q

How does chronic mesenteric ischaemia present

A

Post-prandial abdominal pain and weight loss dominate

145
Q

What is the GOLD standard investigation for arterial and venous mesenteric disease

A

CT angiogram in the arterial phase (with thin slices <5mm)

146
Q

How is mesenteric vein thrombosis managed

A

If no peritonism - IV heparin

147
Q

Define haemorrhoids

A

Enlargement and distal displacement of the normal arteriovenous anal cushions

148
Q

Where are the vascular cushions of the rectum located

A
  • 3 o’clock
  • 7 o’clock
  • 11 o’clock
149
Q

What supplies the cushions of the rectum

A

Superior rectal artery branches

150
Q

What predisposes to haemorrhoids

A
  • Pregnancy
  • Cardiac failure
  • Excessive use of purgatives
  • Chronic constipation
  • Portal hypertension
151
Q

Outline the classification of haemorrhoids

A
  • 1st degree = confined to anal canal
  • 2nd degree = prolapse on defaecation, spontaneously reduce
  • 3rd degree = prolapse spontaneously, digitally reduced
  • 4th degree = irreducible
152
Q

How may 1st degree haemorrhoids be managed

A

Conservatively with increasing fibre content of diet or use of bulking agents

153
Q

When is banding or injection sclerotherapy indicated

A
  • 1st/2nd degree resistant to medical intervention

- 3rd/4th in those reluctant to undergo surgery

154
Q

In who is haemorrhoid banding contraindicated

A
  • Warfarin
  • Clotting disorder
  • Immunosuppressed
155
Q

Where does the injection/banding take place with respect to the dentate line

A

Above

156
Q

How many haemorrhoids should be treated in one go

A

No more than 3

157
Q

How should 3rd degree haemorrhoids that straddle the dentate line or that are too large to band be treated

A

Milligan-Morgan Haemorrhoidectomy

158
Q

Describe fissure in ano

A

Longitudinal tear of the squamous-lined lower half of the anal canal from the anal verge towards the dentate line

159
Q

Where is the most common site of fissure in ano

A

In the midline posteriorly

160
Q

Presentation of fissure in ano

A
  • Pain on defaecation
  • Bright-red rectal bleeding
  • Constipation secondary to pain
  • Pruritus
  • Watery discharge
161
Q

When does a sentinel pile form

A

When the skin at the base of the fissure becomes oedematous and hypertrophied

162
Q

Outline the management of fissure in ano

A
  • 1st line = GTN paste OR diltiazem cream
  • EUA to exclude cancer is a must
  • Lateral-sphincterotomy
163
Q

What typically causes an anorectal abscess

A

Infection of one of the 10-12 anal glands that lie in the intersphincteric space

164
Q

How are anorectal abscesses managed

A

I+D under GA

165
Q

Describe I+D of anorectal abscess

A
  • Incise at point of maximum tenderness
  • Explore cavity with finger
  • Excise corners of cruciate excision and de-roof cavity
  • Pack with ribbon gauze soaked in betadine
  • Do NOT probe suspected fistulas
166
Q

What conditions are associated with anal fissures

A
  • STI
  • CD
  • Leukaemia
  • TB
  • Previous anal surgery
167
Q

Describe chronic intersphincteric abscess

A
  • Intersphincteric abscess is walled off by fibrosis and does not track to the exterior
  • Bouts of anal pain without discharge
  • Internal opening lies posteriorly in the midline
168
Q

What is the most common type of anorectal fistula

A

Intersphincteric

169
Q

What percentage of recurrent anorectal abscesses are associated with a fistula

A

80%

170
Q

What causes anorectal fistulas

A
  • Anorectal abscesses
  • CD
  • TB
  • Trauma
  • Radiotherapy
  • Carcinoma
171
Q

Where does the internal opening of an anorectal fistula most commonly lie

A

Posteriorly in the midline

172
Q

Describe Goodsall’s rule

A
  • External opening posterior to the transverse anal line – fistula tract will follow a curved course to the posterior midline
  • External opening anterior to the transverse anal line – fistula tract will follow a straight radial course to the dentate line
173
Q

How are anal fistulas investigated

A
  • Proctoscopy

- MRI

174
Q

How are suprasphincteric and high trans-sphincteric fistulas managed

A

Seton suture

175
Q

How are low anorectal fistulas managed

A

Fistulotomy - laying open the tract by cutting through the skin and subcutaneous tissue allowing it to heal by secondary intention

176
Q

Describe pilonidal sinus

A

A subcutaneous sinus that contains hair, and is most commonly found in the natal cleft associated with chronic inflammation and acute abscess formation

177
Q

Definitive treatment for pilonidal sinus

A

Bascom procedure with excision of the pits and obliteration of the underlying cavity (definitive treatment should never be undertaken whilst acute infection or abscess is present)

178
Q

How should acute pilonidal sinuses be managed

A

Incision and drainage

179
Q

Describe the 3 types of rectal prolapse

A
  1. Complete prolapse - full thickness of the rectum prolapses through the anus (prolapse contains two layers of rectum with intervening peritoneal sac)
  2. Incomplete prolapse - the prolapse is limited to two layers of mucosa, often associated with haemorrhoids
  3. Concealed prolapse - internal intussusception of the upper rectum into the lower rectum
180
Q

List the risk factors for rectal prolapse

A
  • Multiparity
  • Pelvic floor trauma
  • Connective tissue disorders
181
Q

How are internal rectal prolapses diagnosed

A

Defecating proctography and EUA

182
Q

How is rectal prolapse managed

A
  • Delormes operation (perineal approach)

- Rectopexy (abdominal procedure)

183
Q

Most common type of anal cancer

A

SCC

184
Q

Lymphatic spread of anal cancer

A
  • Below dentate line (anal margin cancer) = inguinal nodes

- Above dentate line (anal canal cancer) = internal iliac nodes

185
Q

Who is predisposed to anal cancer

A
  • Male homosexuals
  • People who practice anal sex
  • People with a history of genital warts (HPV 16)
186
Q

1st line management of anal cancer

A

Chemoradiotherapy

187
Q

2nd line management of anal cancer

A

Salvage radical AP resection of anus and rectum

188
Q

Level of the IMA

A

L3

189
Q

Formation of the IVC level

A

L5

190
Q

Where do the teniae coli converge

A

Base of the appendix

191
Q

How is the caecum mobilised in appendicectomy

A

By division of the lateral peritoneal attachments

192
Q

Eponymous name for pseudo-obstruction

A

Ogilvies syndrome

193
Q

How should appendix mass be managed

A

Conservatively unless perforated

194
Q

What part of the large bowel is spared from diverticulosis

A

Rectum

195
Q

What causes Rovsing’s sign

A

Any progressed RIF pathology

196
Q

Where are colonic tumours most likely found in HNPCC Lynch syndrome

A

Right-sided

197
Q

How is nodal disease in colorectal Ca managed

A

Chemotherapy

198
Q

What colonic disorder is caused by laxative abuse

A

Melanosis coli

199
Q

What vascular condition can complicate major abdominal sepsis causing bowel necrosis

A

Mesenteric vein thrombosis

200
Q

Characteristics of mesenteric cyst

A

Mobile RIF mass in children

201
Q

When can you eat after uncomplicated bowel anastomosis

A

Within 24 hours

202
Q

Describe Cowden disease

A

PTEN mutation causing hamartomatous polyps

203
Q

Lynch syndrome inheritance

A

Autosomal dominant

204
Q

Earliest complication of ileostomy

A

Necrosis

The Abdomen (8 decks)

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