Lower GI Flashcards
Treatment of colon cancer with liver mets
Chemo then surgery
Palliate if widespread or frail
Conditions associated with anal fissures
Sexually transmitted diseases (syphilis, HIV)
Inflammatory bowel disease (Crohn’s up to 50%)
Leukaemia (25% of patients)
Tuberculosis
Previous anal surgery
Mx of IBD with megacolon who has failed conservative tx
Sub total colectomy with loop ileostomy
What can genital skin tags be associated with
Anal fissure
Adenoma with the highest risk of dysplasia
Villous adenoma
Diverticular disease vs diverticulitis presentation
D Disease can bleed- causing no symptoms apart from dark blood per rectum
Diverticulitis- fever, pain, rarely bleeds
Mx of caecal obstruction
If > 12 cm, With functioning valve- will cause perf
Reusus with fluids- laparotomy 2-4 hours later
Mx of high anatomical enter-cutaneous fistula
TPN and ocreotide
Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin.
Mx of rectal cancer causing obstruction
As if a rectal canacer is adnvaced enough to cause obstruction- likey has spread
So best inital plan is to Create loop colostomy to aid obstrcution then plan definitive surgery if required
Mx of rectal cancer near verge
Patients with T1, 2 and 3 /N0 disease on imaging do not require irradiation and should proceed straight to surgery.
Then AP resection
Patients with T4 disease will typically have long course chemo radiotherapy.
Obstrcuted right colon cancer mx
Right hemicolectomy
Ileocolic anastomosis
Follow up on polyps on colonoscopy
Colorectal cancer- Colonoscopy 1 year post resection
High risk- >5 adenomas, or 3 adenoma with 1 >1cm- 3 year
LNPCP( larger than 2cm)
Large non pedunculated colorectal polyps (LNPCP) R1 or non en bloc resection- Site check at 2-6 months and then a further scope at 12 months
Large non pedunculated colorectal polyps (LNPCP), R0 resection- one off scope 3 years
High risk findings polyp
More than 2 premalignant polyps (adenoma <1cm) including 1 or more advanced colorectal polyps (>1cm)
OR
More than 5 pre malignant polyps
If Surgery for UC?
segmental resections are not undertaken for UC
Histological features of UC vs crohns
Crohns -Granulomas (non caseating epithelioid cell aggregates with Langhans’ giant cells)
UC-Crypt abscesses, Inflammatory cells in the lamina propria
Features typical of crohns vs UC
Crohns- fistula, small bowel strictures, rose thorn ulcers, fat wrapping of terminal ileum
UC- pseudopolyps (mucosal islands)
Treatment of fistulas in ano
Low fistula, intersphincteric- fistulotomy
Dentate line+ above or IBD- loose seton
Trans- seton then fistulotomy later
Supra- seton then fistuolotmy later
Mx of bleeding rectal varices
IV terlipressin
Types of laxatives
Bulk-ispaghula husk and methylcellulose
Osmotic-
Magnesium sulphate
Magnesium citrate
Sodium phosphate
Sodium sulphate
Potassium sodium tatrate
Polyethylene glycol
Docusate
Lactulose
Stimulant-
Bisacodyl
Sodium picosulphate
Senna
What would imply T4 colon cancer
Broken out of colon- i.e tethered to prostate
Mx of bleeding diverticula disease
Conservational and observation
Solitary rectal ulcer syndrome sx
Solitary rectal ulcers are associated with chronic constipation and straining.
Indurated area located proximal to anal verge
It will need to be biopsied to exclude malignancy
Mx of diverticular stricture causing obstruction in sigmoid
Hartmanns
Features of acute appendicits
Neutrophillia
Protein on urine dip
Anorexia
Low grade pyrexia
No diarrhoea or profuse vomitting
Low grade fever and a mass palpable in the right iliac fossa. The rest of his abdomen is soft. An abdominal USS demonstrates matted bowel loops surrounding a thickened appendix.
Appendix mass
Antibiotics
- no peritoneal signs no surgery
Where fissures present usually
90% posteriorly
10% anteriorly
Most common and earliest and other complications of a ileostomy
Dermatitis- common
Earliest- necrosis
Other- obstruction and prolapse
What blood results point more towards colon cancer
Low Hb
Low albumin
Colonic pseudo obstruction, Ix, and mx
(Ogilvies syndrome)-Progressive and painless dilation of the colon. The abdomen may become grossly distended and tympanic
Diagnosis involves excluding a mechanical bowel obstruction with a plain film and contrast enema. The underlying cause is usually electrolyte imbalance
Patients who do not respond to supportive measures should be treated with attempted colonoscopic decompression and/ or the drug neostigmine
Appendicits vs UTI urine
Urine often only leucocyte + in appendicitis
If laparoscopic approach for appendicitis but no free fluid or peritonitis what do you do
Place in drain and ABx
Angiodysplasia presentation
Brisk bleed- minor other symptoms
colonoscopy shows a small erythematous lesion in the right colon
Mx of familial polyposis coli when colonoscopy shows widespread polyps, with high grade dysplasia in a polyp
Pan proctocolectomy
Management of colonocutaneous fistula
Peritonitic- surgery
Wound sepsis- ABx
Absent distal obstruction- heal spontaneously
% of patients with synchronous colon cancer
5%
Right standard vs extended hemicoletomy
Standard right hemicolectomy involves colonic division to the right of the middle colic vessels
Extended right hemicolectomy involves division of the middle colic vessels and usually resection of the splenic flexure as well.
Histological description of adenomas
Dysplastic
Commonest anal fistula
Intersphincteric
Mx of anal fissures
Stool softeners
Topical GTN
Then consider botulism injection
In males a lateral internal sphincterotomy would be an acceptable alternative.
Tx of pilondial abcess
Incision and drainage
Definitive treatments such as a Bascoms procedure should not be undertaken when acute sepsis is present.
Mx of obstructed sigmoid cancer
Sigmoidectomy and end colostomy
Anal cancer management
Radical chemo
Second line treatment for non metastatic disease is with salvage radical abdominoperineal excision of the anus and rectum
Surgical mx of crohns with rectal disease only
Protectomy and end stoma
Crohns disease is a contra indication to having an ileo-anal pouch as its associated with very poor pouch function and significant complications.
Goodsall rule
Anterior- straight to opening
i.e 3 o’clock to 3
Posterior - curved - will track to the posterior midline
i.e 7 to 6 o’clock
What does a T tube do in bile duct how is it managed when removed
Post cholecystectomy- T tube placed to keep CBD open
When the bile duct is closed over a T Tube the latex in the T tube encourages tract fibrosis. This actually encourages a fistula to develop. The result is that when the tube is removed any bile which leaks will usually drain through the tract. Provided that there are no residual stones in the duct the fistula will slowly close. Persistent high volume drainage may be managed with ERCP and sphincterotomy.
Imaging if failed colonoscopy
CT colonoscopy
Extra-intestinal sx of crohns
Aphthous ulcers
Pyoderma gangrenosum
Iritis
Erythema nodosum
Sclerosing cholangitis
Arthritis
Clubbing
Genes involved in adenoma-carcinoma sequence in colorectal cancer?
c myc
APC
p53
K ras
Least likely place for diverticulitis
Rectum
Biggest anal cancer RF
HPV
Mx of prolapsed haemorrhoids and symptomatic
excisional haemorrhoidectomy
What should you avoid in management of fistula if inflamed
Probing
If resected colon cancer had nodal involvement what is the post op mx
Chemo
Discharge and bleeding per rectum after hartmanns
Diversion proctitis
Once the bowel has been disconnected, a degree of inflammation is commonly seen in the quiescent bowel.
Active heavy rectal bleeding- endoscopy normal then what?
CT angio
When to suspect enteric cutaneous fistula
Excessive draining and bubbles
Mx of rectal prolapse
Rectopexy - this is an abdominal procedure. The rectum is mobilised and fixed onto the sacral promontary. A prosthetic mesh may be inserted. The recurrence rates are low and the procedure is well tolerated- suited to young pateints
Perineal approaches include the Delormes operation, this avoids resection and is relatively safe but is associated with high recurrence rates. An Altmeirs operation involves a perineal excision of the sigmoid colon and rectum, it may be a more effective procedure than a Delormes but carries the risk of anastomotic leak
Cell types of fistula wall
Sqaumous
T staging of colon cancer
0- in situ in mucosa
1- in subserosa
2- to muscular propia
3- beyond propia but not out of bowel/to other organs
4- beyond bowel/to other organs
EIM of crohns
Aphthous ulcers
Pyoderma gangrenosum
Iritis
Erythemanodosum
Sclerosing cholangitis
Arthritis
Clubbing
What is the earliest complication that can occur following construction of an ileostomy?
Necrosis
Causes of pruritus ani
Systemic (DM, Hyperbilirubinaemia, aplastic anaemia)
Mechanical (diarrhoea, constipation, anal fissure)
Infections (STDs)
Dermatological
DrugIs (quinidine, colchicine)
Topical agents
If nodal disease present in colon cancer
Chemo
Least likely place for diverticulitis to occur in colon
Rectum
