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Yr3 - General Surgery > Large Bowel > Flashcards

Large Bowel Flashcards

1
Q

Risk factors of appendicitis

A

Family history
Ethnicity - more common in Caucasians
Environmental - seasonal presentation over summer

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2
Q

Symptoms of acute appendicitis

A 
Abdominal pain - peri-umbilical dull pain -> RIF well-localised and sharp pain
Vomiting
Anorexia
Nausea
Diarrhoea
Constipation
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3
Q

Clinical features of acute appendicitis

A

Tachycardia
Tachypnoeic
Pyrexia
Rebound tenderness
Percussion pain over McBurney’s point
Rovsing’s sign - RIF pain on palpation of LIF
Psoas sign - RIF pain on extension of right hip

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4
Q

Differential diagnosis of acute appendicitis

A 
Renal
- ureteric stones
- UTI
- pyelonephritis
GI
- mesenteric adneitis
- diverticulitis
- IBD
- Meckel's diverticulum
Urological
- testicular torsion
- epididymo-orchitis
Gynaecological
- PID
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5
Q

Investigations of acute appendicitis

A 
Urinalysis - exclude UTI
Pregnancy test or serum β-hCG
Routine bloods
Trans-abdominal US
CT scan
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6
Q

Treatment for acute appendicitis

A

Laparoscopic appendectomy

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7
Q

Complications of acute appendicitis

A

Perforation
Surgical site infection
Appendix mass - omentum and small bowel adhere to appendix
Pelvic abscess

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8
Q

Development of colorectal cancers

A

Most commonly adenocarcinoma

Progression of normal muscosa to colonic adenoma to invasive adenocarcinoma

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9
Q

Genetic mutations predisposing to colorectal cancers

A

Adenomatous polyposis coli (APC)
- tumour suppressor gene
- growth of adenomatous tissue
- assoicated with Familial Adenomatous Polyposis (FAP)
Hereditary NonPolyposis Colorectal Cancer (HNPCC)
- DNA mismatch repair gene
- associated with Lynch syndrome

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10
Q

Risk factors of colorectal cancer

A 
Increasing age
Family history
IBD
Low fibre diet
High processed meat intake
Smoking 
High alcohol intake
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11
Q

Common clinical features of bowel cancer

A 
Change in bowel habit
Rectal bleeding
Weight loss
Abdominal pain
Iron-deficiency anaemia
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12
Q

Clinical features of right-sided colon cancers

A 
Abdominal pain
Occult bleeding
Anaemia
Mass in RIF
Often present late
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13
Q

Clinical features of left-sided colon cancers

A

Rectal bleeding
Change in bowel habit
Tenesmus
Mass in LIF or on PR exam

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14
Q

2 week referral for suspected bowel cancer if

A

≥ 40 with unexplained weight loss and abdo pain
≥ 50 with unexplained rectal bleeding
≥ 60 with iron-deficiency anaemia or change in bowel habit
Positive occult blood screening test

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15
Q

Investigations for colorectal cancer

A

FBC - microcytic anaemia
Colonoscopy with biopsy
CT scan - look for distant metastases and local invasion
MRI rectum - asses depth of invasion
Endo-anal ultrasound - assess suitability for trans-anal resection

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16
Q

Duke’s staging for colorectal cancer

A

A - confined beneath the muscularis propria
B - extension through the muscularis propria
C - involvement of regional lymph nodes
D - distant metastasis

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17
Q

Treatment for colorectal cancer

A

Definitive option is surgery

Chemotherapy and radiotherapy for neoadjuvant and adjuvant treatment and palliation

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18
Q

Surgical treatment of colorectal cancer

A

Right hemicolectomy - caecal or ascending colon tumours
Left hemicoectomy - descending colon tumours
Sigmoidcolectomy
Anterior resection - high rectal tumours
Abdominoperineal resection - low rectal tumours

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19
Q

Describe Hartmann’s procedure

A

Used in emergency bowel surgery
Complete resection of recto-sigmoid colon
Formation of end colostomy and closure of rectal stump

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20
Q

Palliative treatment for colorectal cancer

A

Endoluminal stenting - relieve acute bowel obstruction in LS tumours
Stoma formation
Resection of secondaries

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21
Q

Define diverticulum

A

Outpouching of bowel wall

Commonly found in sigmoid colon

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22
Q

Describe 4 different manifestations of diverticular disease

A

Diverticulosis - presence of diverticula
Diverticular disease - symptomatic diverticula
Diverticulitis - inflammation of diverticula
Diverticular bleed - diverticulum erodes into a vessel causing large volume painless bleed

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23
Q

Pathophysiology of diverticular disease

A

Aging bowel becomes weakened
Movement of stool leads to increase in luminal pressure
Outpouching of mucose through weaker areas of bowel wall
Bacterial overgrow in outpouchings - diverticulitis

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24
Q

Risk factors of diverticular disease

A 
Low dietary fibre intake
Obesity
Smoking
Family history
NSAIDs
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25
Q

Features of diverticulitis

A 
Acute abdominal pain - localised in LIF, worsened by movement
Localised tenderness
Systemic upset
- decreased appetite
- pyrexia
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26
Q

Complications of diverticular disease

A

Pericolic abscess
Fistula formation
Bowel obstruction

27
Q

Diverticular disease investigations

A 
Routine bloods
Faecal calprotecin
Venous blood gas
Flexible sigmoidoscopy
CT abdomen-pelvis scan
28
Q

Conservative management of diverticulitis

A

IV antibiotics
IV fluids
Bed rest

29
Q

Surgical management of diverticular disease

A

Perforation with faecal peritonitis or overwhelming sepsis

Hartmann’s procedure

30
Q

Crohn’s disease

A

Entire GI tract
Transmural inflammation
Granulomatous microscopic changes
Skip lesions, cobblestone appearance and fistula formation

31
Q

Ulcerative colitis

A

Large bowel
Inflammation of mucosa only
Crypt abscess formation, reduced goblet microscopic changes
Continuous inflammation, pseudopolyps and ulcers

32
Q

Crohn’s risk factors

A

Family history
Smoking
White European descent
Appendicectomy

33
Q

Clinical features of Crohn’s disease

A 
Episodic abdominal pain and diarrhoea
Systemic symptoms and malnourishment
Oral aphthous ulcers
Perianal disease
Abdominal tenderness
34
Q

Extra-luminal features of Crohn’s disease

A 
Musculoskeletal
- enteropathic arthrits or nail clubbing
- metabolic bone disease
Skin 
- erythema nodosum
- pyoderm gangrenosum
Eyes
- episcleritis
- anterior uvetitis
HPB
- PSC
- cholangiocarcinoma
- gallstones
Renal
- renal stones
35
Q

Investigations for Crohn’s disease

A 
Routine bloods - anaemia, low albumin, raised CRP and WCC
Faecal calprotectin
Stool sample - infective cause
Colonoscopy with biopsy
CT scan
MRI scan
36
Q

Inducing remision of Crohn’s disease

A

Fluid resuscitation
Nutritional support
Prophylactic heparin + anti-embolic stockings
Corticosteriod therapy
Immunosuppresive agents - mesalazine or azathioprine
Biological agents - infliximab

37
Q

Maintaining remission in Crohn’s disease

A

Azathioprine or mercaptopurine monotherapy
Smoking cessation
Colonoscopic surviellance - increased risk of colorectal malignancy

38
Q

Surgical management of Crohn’s disease

A

Ileocaecal resection
Surgery for peri-anal disease - abscess drainage
Stricutroplasty - division of stricture
Small or large bowel resection

39
Q

Surgical intervention indicated in Crohn’s disease

A

Failed medical management
Severe complications
Growth impairment in younger patients

40
Q

Complications of Crohn’s disease

A 
Gastrointestinal
- fistula
- stricture formation
- recurrent perianal abscesses/fistula
- GI malignancy
Extraluminal
- malabsorption
- osteoporosis
- increased risk of gallstones
- increased risk of renal stones
41
Q

Clinical features of UC

A 
Insidious in onset
Bloody diarrhoea
Proctitis
PR bleeding and mucus discharge
Systemic features
42
Q

Extra-luminal manifestations of UC

A 
Musculoskeletal
- enteropathic arthirits
- nail clubbing
Skin
- erythema nodosum
Eyes
- episclertitis
- anterior uveitis
HPB 
- PSC
43
Q

UC Investigations

A

Routine bloods - anaemia, low ablumin and raised CRP and WCC
Faecal calprotectin
Stool sample
Colonoscopy with biopsy/flexible sigmoidoscopy

44
Q

Inducing remission in UC

A 
Fluid resuscitation
Nutitional support
Prophylactic heparin
Corticosteriod therapy
Immunosuppressive agents - mesalazine or azathioprine
Biological agents - infliximab
45
Q

NICE UC treatment guidlines

A

Mild to Moderate
- topical mesalazine or sulfasalazine
- add oral prednisolone
- add oral tacrolimus
Mild to Moderate - extensive inflammation
- high oral dose mesalazine or sulfasalazine
- add oral prednisolone
- add oral tacrolimus
Severe
- intravenous corticosteriods and assess the need for surgey
- add infliximab if no short-term response

46
Q

Maintaining remission of UC

A

Immunomodulators - mesalazine or sulfasalazine
Infliximab
Colonoscopic surveilllance - increased risk of colorectal malignancy

47
Q

Surgical management of UC

A

Total proctocolectomy is curative

Initally sub-total colectomy with preservation of rectum

48
Q

Indications for surgical management of UC

A

Disease refractory to mediacal management
Toxic megacolon
Bowel perforation
Reduce risk of colonic carcinoma

49
Q

Complications of UC

A

Toxic megacolon
Colorectal megacolon
Osteoporosis
Pouchitis

50
Q

Define pseudo-obstruction

A

Dilation of the colon due to an adynamic bowel in the absence of mechanical obstruction

51
Q

Mechanism of pseudo-obstruction

A

Interruption of the autonomic nervous supply to the colon resulting in the absence of smooth muscle action in the bowel wall

52
Q

Causes of pseudo-obstruction

A

Electrolyte imbalance or endocrine disorders
Medication
- opoids, calcium-channel blockers, anti-depressants
Recent surgery, severe illness or trauma
Recent cardiac event
Parkinson’s disease
Hirschsprung’s disease

53
Q

Clinical features of pseudo-obstruction

A

Abdo pain
Abdo distention
Constipation
Vomiting

54
Q

Investigations for pseudo-obstruction

A

FBC, CRP, U&Es, Ca2+, Mg2+ and TFTs
AXR - shows bowel distention
Abdominal-pelvis CT with IV contrast

55
Q

Management of pseudo-obstruction

A

Most cases managed conservatively
NBM and IV fluids - NG tube if vomiting
Endoscopic decompression
Nutritional support

56
Q

Define volvulus

A

Twisting of loop of intesting around its mesenteric attachment -> closed loop bowel obstruction
Affected bowel becomes ischaemic due to compromised blood supply -> bowel necrosis and perforation

57
Q

Risk factors of volvulus

A 
Increasing age
Neuropsychiatric disorders
Resident in a nursing home
Chronic constipation or laxative use
Male gender
Previous abdominal operations
58
Q

Clinical features of volvulus

A

Colicky pain
Adbominal distention
Absolute constipation
Rapid onset and degree of abdo distention

59
Q

Investigations for volvulus

A

Routine bloods - exclude psuedo-obstruction
CT scan abdomen-pelvis with contrast
AXR - coffee bean sign

60
Q

Conservative management of volvulus

A

Decompression by sigmoidoscope

Insertion of flatus tube

61
Q

Surgical management of volvulus

A

Sigmoidectomy with primary anastomosis

62
Q

Indications of surgery of volvulus

A

Colonic ischaemia or perforation
Repeated failed attempts at decompression
Necrotic bowel

63
Q

Complications of volvulus

A

Bowel ischaemia and perforation
Risk of recurrence
Stoma complications

Yr3 - General Surgery (17 decks)

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