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GI and General Surgery > Large Bowel > Flashcards

Large Bowel Flashcards

1
Q

Where is the appendix found?

A

base attachment to the caecum

where 3 taenia coli converge

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2
Q

What are the taenia coli?

A

3 longitudinal bands of muscle

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3
Q

What are the clinical features of appendicitis?

A 
vomiting 
anorexia 
nausea 
diarrhoea or constipation 
abdo pain
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4
Q

Describe the abdo pain in appendicitis.

A

periumbilical to RIF because:

  1. appendix is a midgut organ
  2. dull and poorly localised pain from midgut felt in umbilical region (T8-T10) as visceral afferents enter spinal cord at these regions
  3. inflamed appendix starts to irritate parietal peritoneum in RIF - somatic nerve supply
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5
Q

What is found on examination in appendicitis?

A

pyrexia, tachypnoea, tachycardia
rebound tenderness
percussion pain - McBurneys point (2/3rds between umbilicus and ASIS)

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6
Q

How is appendicitis diagnosed?

A

clinical diagnosis
increased WCC
acute abdo investigations
USS, CT abdo (only done if uncertain diagnosis)

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7
Q

How is appendicitis managed?

A

lap appendectomy

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8
Q

What is diverticular disease? Where does it commonly occur?

A

outpouching of bowel wall

commonly sigmoid colon

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9
Q

What are the 4 manifestations of diverticular disease?

A

diverticulosis
diverticular disease
diverticulitis
diverticular bleed

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10
Q

What is diverticulosis? How does it present?

A

presence of diverticula (asymptomatic)

incidental finding

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11
Q

What is diverticular disease? How does it present?

A

symptomatic diverticula

intermittent lower abdo pain (usually left)
PR bleeding
altered bowel habit
flatulence

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12
Q

What is diverticulitis? How does it present?

A

inflammation of diverticula

acute abdo pain
localised tenderness
pyrexia
systemic upset

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13
Q

What is a diverticular bleed?

A

erodes into large vessel

large volume painless bleed

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14
Q

What are complications of diverticular disease?

A

perforation
fistula formation e.g. colovesical, colovaginal
bowel obstruction (secondary to strictures)
pericolic abscess

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15
Q

What are the investigations for diverticular disease?

A 
routine bloods, group and save 
flexi sig (uncomplicated diverticular disease)
CT abdo pelvis (suspected diverticulitis) 
- can't sigmoidoscopy - risk of perforation
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16
Q

What is the management of diverticular disease?

A

uncomplicated:

  • analgesia
  • increase fibre intake

diverticulitis:

  • analgesia, IV fluids
  • IV amox, met and gent

diverticular bleed:

  • appropriate resus
  • usually self limiting, if not embolisation or surgical resection
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17
Q

How is a perforated diverticulum managed?

A

surgical management if perforation + faecal peritonitis

- sigmoid colectomy and end colostomy

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18
Q

What is the most common form of colorectal cancer?

A

adenocarcinoma

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19
Q

How does colorectal adenocarcinoma usually progress?

A

normal mucosa to colonic adenoma (polyps)
to invasive adenocarcinoma
(10% adenomas become malignant)

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20
Q

What genetic mutations predispose to colorectal cancer?

A

HNPCC (assoc w Lynch syndrome)

APC

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21
Q

What are risk factors for colorectal cancer?

A 
adenomatous polyps 
increased age
family history 
IBD 
processed and red meat intake 
alcohol, smoking
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22
Q

What is used for colorectal cancer screening? When does it take place?

A

FIT - faecal immunochemistry test

50-75 every 2 years

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23
Q

What are the clinical features of colorectal cancer?

A
  • change in bowel habit
  • PR bleeding
  • weight loss
  • iron deficiency anaemia
  • abdo pain
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24
Q

What are the NICE guidelines for urgent referral for colorectal cancer?

A 
>40 years, weight loss + abdo pain 
>50 years + PR bleeding 
>60 years  + anaemia 
>60 years + change in bowel habit 
positive screening test
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25
What are the investigations for suspected colorectal cancer?
``` FBC - microcytic anaemia imaging - colonoscopy and biopsy - flexi sig or CT colongraphy if too frail staging - CT CAP - MRI rectum CEA - used to monitor disease progression ```
26
When is radiotherapy used in treatment of colorectal cancer?
rectal cancers - chemoradiotherapy can be curative | post op decreased local recurrence
27
How is colorectal cancer treated?
surgery - curative for localised malignancy | chemoradiotherapy (advanced disease or rectal cancers)
28
What is the surgery for colorectal cancer management?
regional colectomy + primary anastomosis or stoma formation
29
What are palliative options for colorectal cancer?
stenting - for obstruction stoma formation resection of secondaries
30
When is an anterior resection used for rectal tumours?
high rectal tumours >5cm from anus
31
When is an abdominoperineal resection used for rectal tumours?
low rectal tumours <5cm from anus
32
When is Hartmaan's procedure used?
obstruction or perforation (emergency bowel surgery)
33
What is Hartmaan's procedure?
complete resection of the recto-sigmoid colon and end colostomy
34
What kind of inflammation do you get in Crohn's disease?
non-caseating granulomatous inflammation transmural skip lesions
35
Where can Crohn's disease affect?
any part of the GI tract, mouth to anus
36
Why do you get fistula formation in Crohn's disease?
transmural inflammation (all layers)
37
What does Crohn's look like macroscopically?
skip lesions fissures and deep ulcers ('cobblestone') fistula formation
38
What are the GI and intestinal features of Crohn's?
``` episodic abdo pain and diarrhoea mouth ulcers, stomatitis perianal disease (fistule, abcesses, skin tags) ```
39
What are the systemic features of Crohn's?
malaise anorexia low grade fever malnutrition (terminal ileum effected - B12 deficiency and anaemia)
40
What are the extra intestinal features of Crohn's?
``` anterior uveitis gallstones, cholangiocarcinoma renal stones erythema nodosum large joint arthritis pyoderma gangrenosum ```
41
How is Crohn's disease investigated?
``` bloods: FBC, raised CRP and WCC, B12? stool sample: infective cause? faecal calprotectin imaging: - colonoscopy w/ biopsy (gold standard) - CT (acute, severe disease) - MRI (perianal disease) ```
42
How is an acute attack of Crohn's managed?
fluid resus nutritional support IV steroids
43
How is remission induced and maintained in Crohn's?
induced: - corticosteroids - 5 ASA drugs e.g. mesalazine (less effective) - + immunosuppression e.g. aziothioprine, methotrexate - biologics used if other therapies fail e.g. infliximab maintained: - smoking cessation - azathioprine or mercaptopurine - methotraxate 2nd line
44
When is surgery indicated in Crohn's?
failed medical treatment severe complications e.g. strictures, fistulae growth impairment (younger patients)
45
What are some surgical options in Crohn's?
bowel resection peri-anal disease surgery (abscess drainage) stricturoplasty (if obstructed)
46
Why can renal stones happen in Crohn's?
malabsorption of fats in small intestine
47
Why do gallstones happen in Crohn's?
decreased reabsorption of bile salts in terminal ileum
48
What is the inflammation like in UC?
diffuse continual mucosal inflammation of large bowel
49
What does UC look like macroscopically?
pseudopolyps and ulcers | starts in rectum and spreads proximally
50
What is 'backwash ileitis'?
incompetent ileocaecal valve + UC | effects distal ileum
51
What are the GI symptoms of UC?
bloody diarrhoea mucus crampy abdo pain frequency, urgency, tenesmus
52
What are the extra intestinal symptoms of UC?
large joint arthritis erythema nodosum anterior uveitis PSC
53
In which do you tend to see more systemic symptoms - UC or Crohn's?
Crohn's
54
What scoring system is used to grade UC? What are the headings?
Truelove and Witt ``` bowel movements per day blood pyrexia pulse >90 anaemia ESR ```
55
How is UC investigated?
``` bloods stool sample faecal calprotectin imaging - colonoscopy with biopsy - (flexi sig may be adequate) - CT (toxic megacolon, bowel perforation) or AXR (mural thickening, thumbprinting) ```
56
How is remission induced in UC?
mild to moderate: - step 1 - mesalazine or sulfasalazine - step 2 - prednisolone + tacrimolimus severe: - IV corticosteroids - surgery? - + infliximab
57
How is remission maintained in UC?
mesalazine or sulfasalazine next line - biologics (infliximab)
58
What are indications for surgery in UC?
perforation non response to medical therapy masssive haemorrhage toxic megacolon
59
What are surgical options for UC?
subtotal colectomy - for disease control, preservation of rectum total proctocolectomy + ileostomy (curative)
60
Where would you normally find an ileostomy?
right hand side
61
Where would you normally find a colostomy?
left hand side
62
Which type of stoma is spouted?
ileostomy - protect skin from irritant contents
63
What is the consistency of contents in an ileostomy vs colostomy?
watery greenish colostomy - more fully formed faeces

GI and General Surgery (10 decks)

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