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eMRCS questions > Lower GI > Flashcards

Lower GI Flashcards

1
Q

Treatment of colon cancer with liver mets

A

Chemo then surgery
Palliate if widespread or frail

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2
Q

Conditions associated with anal fissures

A

Sexually transmitted diseases (syphilis, HIV)
Inflammatory bowel disease (Crohn’s up to 50%)
Leukaemia (25% of patients)
Tuberculosis
Previous anal surgery

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3
Q

Mx of IBD with megacolon who has failed conservative tx

A

Sub total colectomy with loop ileostomy

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4
Q

What can genital skin tags be associated with

A

Anal fissure

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5
Q

Adenoma with the highest risk of dysplasia

A

Villous adenoma

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6
Q

Diverticular disease vs diverticulitis presentation

A

D Disease can bleed- causing no symptoms apart from dark blood per rectum

Diverticulitis- fever, pain, rarely bleeds

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7
Q

Mx of caecal obstruction

A

If > 12 cm, With functioning valve- will cause perf
Reusus with fluids- laparotomy 2-4 hours later

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8
Q

Mx of high anatomical enter-cutaneous fistula

A

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.

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9
Q

Mx of rectal cancer causing obstruction

A

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

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10
Q

Mx of rectal cancer near verge

A

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.

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11
Q

Obstrcuted right colon cancer mx

A

Right hemicolectomy
Ileocolic anastomosis

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12
Q

Follow up on polyps on colonoscopy

A

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

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13
Q

High risk findings polyp

A

More than 2 premalignant polyps (adenoma <1cm) including 1 or more advanced colorectal polyps (>1cm)
OR
More than 5 pre malignant polyps

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14
Q

If Surgery for UC?

A

segmental resections are not undertaken for UC

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15
Q

Histological features of UC vs crohns

A

Crohns -Granulomas (non caseating epithelioid cell aggregates with Langhans’ giant cells)

UC-Crypt abscesses, Inflammatory cells in the lamina propria

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16
Q

Features typical of crohns vs UC

A

Crohns- fistula, small bowel strictures, rose thorn ulcers, fat wrapping of terminal ileum

UC- pseudopolyps (mucosal islands)

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17
Q

Treatment of fistulas in ano

A

Low fistula, intersphincteric- fistulotomy
Dentate line+ above or IBD- loose seton

Trans- seton then fistulotomy later
Supra- seton then fistuolotmy later

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18
Q

Mx of bleeding rectal varices

A

IV terlipressin

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19
Q

Types of laxatives

A

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

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20
Q

What would imply T4 colon cancer

A

Broken out of colon- i.e tethered to prostate

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21
Q

Mx of bleeding diverticula disease

A

Conservational and observation

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22
Q

Solitary rectal ulcer syndrome sx

A

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

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23
Q

Mx of diverticular stricture causing obstruction in sigmoid

A

Hartmanns

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24
Q

Features of acute appendicits

A

Neutrophillia
Protein on urine dip
Anorexia
Low grade pyrexia

No diarrhoea or profuse vomitting

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25
Q

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.

A

Appendix mass

Antibiotics

  • no peritoneal signs no surgery
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26
Q

Where fissures present usually

A

90% posteriorly
10% anteriorly

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27
Q

Most common and earliest and other complications of a ileostomy

A

Dermatitis- common
Earliest- necrosis

Other- obstruction and prolapse

28
Q

What blood results point more towards colon cancer

A

Low Hb
Low albumin

29
Q

Colonic pseudo obstruction, Ix, and mx

A

(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

30
Q

Appendicits vs UTI urine

A

Urine often only leucocyte + in appendicitis

31
Q

If laparoscopic approach for appendicitis but no free fluid or peritonitis what do you do

A

Place in drain and ABx

32
Q

Angiodysplasia presentation

A

Brisk bleed- minor other symptoms

colonoscopy shows a small erythematous lesion in the right colon

33
Q

Mx of familial polyposis coli when colonoscopy shows widespread polyps, with high grade dysplasia in a polyp

A

Pan proctocolectomy

34
Q

Management of colonocutaneous fistula

A

Peritonitic- surgery
Wound sepsis- ABx
Absent distal obstruction- heal spontaneously

35
Q

% of patients with synchronous colon cancer

A

5%

36
Q

Right standard vs extended hemicoletomy

A

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.

37
Q

Histological description of adenomas

A

Dysplastic

38
Q

Commonest anal fistula

A

Intersphincteric

39
Q

Mx of anal fissures

A

Stool softeners
Topical GTN
Then consider botulism injection

In males a lateral internal sphincterotomy would be an acceptable alternative.

40
Q

Tx of pilondial abcess

A

Incision and drainage

Definitive treatments such as a Bascoms procedure should not be undertaken when acute sepsis is present.

41
Q

Mx of obstructed sigmoid cancer

A

Sigmoidectomy and end colostomy

42
Q

Anal cancer management

A

Radical chemo

Second line treatment for non metastatic disease is with salvage radical abdominoperineal excision of the anus and rectum

43
Q

Surgical mx of crohns with rectal disease only

A

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.

44
Q

Goodsall rule

A

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

45
Q

What does a T tube do in bile duct how is it managed when removed

A

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.

46
Q

Imaging if failed colonoscopy

A

CT colonoscopy

47
Q

Extra-intestinal sx of crohns

A

Aphthous ulcers
Pyoderma gangrenosum
Iritis
Erythema nodosum
Sclerosing cholangitis
Arthritis
Clubbing

48
Q

Genes involved in adenoma-carcinoma sequence in colorectal cancer?

A

c myc
APC
p53
K ras

49
Q

Least likely place for diverticulitis

A

Rectum

50
Q

Biggest anal cancer RF

A

HPV

51
Q

Mx of prolapsed haemorrhoids and symptomatic

A

excisional haemorrhoidectomy

52
Q

What should you avoid in management of fistula if inflamed

A

Probing

53
Q

If resected colon cancer had nodal involvement what is the post op mx

A

Chemo

54
Q

Discharge and bleeding per rectum after hartmanns

A

Diversion proctitis

Once the bowel has been disconnected, a degree of inflammation is commonly seen in the quiescent bowel.

55
Q

Active heavy rectal bleeding- endoscopy normal then what?

A

CT angio

56
Q

When to suspect enteric cutaneous fistula

A

Excessive draining and bubbles

57
Q

Mx of rectal prolapse

A

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

58
Q

Cell types of fistula wall

A

Sqaumous

59
Q

T staging of colon cancer

A

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

60
Q

EIM of crohns

A

Aphthous ulcers
Pyoderma gangrenosum
Iritis
Erythemanodosum
Sclerosing cholangitis
Arthritis
Clubbing

61
Q

What is the earliest complication that can occur following construction of an ileostomy?

A

Necrosis

62
Q

Causes of pruritus ani

A

Systemic (DM, Hyperbilirubinaemia, aplastic anaemia)
Mechanical (diarrhoea, constipation, anal fissure)
Infections (STDs)
Dermatological
DrugIs (quinidine, colchicine)
Topical agents

63
Q

If nodal disease present in colon cancer

A

Chemo

64
Q

Least likely place for diverticulitis to occur in colon

A

Rectum

65
Q
A

eMRCS questions (45 decks)

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