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bookmarked qns surgery > Lower GI > Flashcards

Lower GI Flashcards

1
Q

What are the clinical features of an inguinal hernia and how can you distinguish between a direct and indirect hernia?

A

Lump in the groin that may reduce when lying down and gets worse on standing
If incarcerated can be tender, swollen, irreducible and erythematous and can have signs of bowel obstruction. Pain out of proportion to clinical signs
Reduce hernia and put pressure over deep inguinal ring (mid point of inguinal ligament). Ask to cough, if protrudes this is direct, if not this is indirect. Confirmed on surgery cannot be relied on

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2
Q

How are inguinal hernias managed generally?

A
  • If strangulated: urgent surgical exploration
  • If symptomatic: offer surgical intervention due to risk of strangulation
  • If asymptomatic: conservative but discuss risks of strangulation
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3
Q

What type of patients are at high risk of chronic pain with an open inguinal mesh repair?

A

Young and active
Previous chronic pain
Predominant symptom of pain

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4
Q

What are the complications of inguinal hernias and post-operative complications for their repair?

A

Inguinal Hernia: incarceration, obstruction, strangulation
post op: pain, bleeding ,recurrence, damage to vas deferens

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5
Q

What are some differential diagnoses for a femoral hernia?

A

Inguinal hernia
Femoral canal lipoma
Lymph node
Saphena varix (will disappear on lying and have palpable thrill)
Athletic pubalgia

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6
Q

How are femoral hernias managed?

A
  • Surgery within 2 weeks of presentation due to risk of strangulation

Operation involves reducing hernia and reducing size of femoral ring by suture pectineal and inguinal ligaments or putting in mesh plug
- High or Low approach (Inguinal ligament). Low less likely to damage inguinal structures but less space to remove any compromised bowel. High approach used in emergency

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7
Q

What is a paraumbilical hernia and how do they present?

A

Herniation through the linea alba around the umbilical region (not the actual umbilicus).

Due to chronic raised intraabdominal pressure and they have a lump around the umbilical region

Extremely common and often contain pre-peritoneal fat and sometimes bowel but rarely strangulate

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8
Q

How can you tell what causative organism caused gastroenteritis?

A

Time between ingestion of food and symptoms

Bacterial toxins = hours

Virus = days

Bacteria = weeks

Parasites = months

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9
Q

What are some important causes of dysentry you should consider when a patient presents with gastroenteritis?

A

Campylobacter
Shigella
Salmonella
Norovirus

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10
Q

What are some viral infective causes of gastroenteritis?

A
  • Norovirus: most common viral gastroenteritis in adults, usually abdominal cramps, D+V and lasts 1-3 days
  • Rotavirus: common in young children and resolves in about a week
  • Adenovirus: common in kids
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11
Q

What are some non-infective causes of gastroenteritis?

A
  • Radiation colitis
  • IBD (Crohn’s and UC)
  • Microscopic colitis
  • Chronic ischaemic colitis (usually affects watershed area around splenic flexure and is seen on endoscopy as blue swollen mucosa)
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12
Q

What is the pathophysiology of angiodysplasia?

A

Causes GI bleeds and it caused by formation of arteriovenous malformations between previously healthy blood vessels, usually in caecum and ascending colon
Most common cause of small bowel bleeds and second most common cause of rectal bleeding in over 60s
Can be acquired or congenital

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13
Q

What are the clinical features of angiodysplasia and what are some differential diagnoses?

A
  • Painless rectal bleeding AND
  • Anaemia

If upper GI bleed melena and haematemesis
If lower GI haematochezia
- Differentials: oesophageal varices, GI malignancies, diverticular disease, coagulopathies

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14
Q

What are some complications of angiodysplasia treatment?

A
  • Rebleeding post therapy

Risk of small bowel perforation in endoscopy
Risk of haematoma formation, arterial dissection, thrombosis and bowl ischaemia in mesenteric angiography

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15
Q

What are GEP-NETs and how are they classified?

A

Gastroenteropancreatic neuroendocrine tumours that originate from neuroendocrine cells in the tubular GI tract and pancreas and they have the potential to be malignant

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16
Q

What is the pathophysiology of appendicitis?

A

Usually due to luminal obstruction of appendix from a faecolith, lymphoid hyperplasia, impacted stool or rarely a tumour

When obstructed commensal bacteria in appendix multiply so acute inflammation. Reduced venous drainage and localised inflammation leads to increased pressure in the appendix and in turn ischaemia

If ischaemia untreated can lead to necrosis and then perforation

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17
Q

differentials for appendicitis

A

ovarian cyst, ectopic pregnancy, renal colic, IBD,diverticular disease, kidney stones, UTI

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18
Q

when would you delay laparoscopic appendectomy?

A
  • If appendiceal mass give antibiotics then interval appendectomy 6-8 weeks later
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19
Q

What are some complications with appendicitis?

A
  • Perforation and peritoneal contamination
  • Surgical site infection
  • Appendix mass where omentum and small bowel adhere to appendix
  • Pelvic abscess with fever and palpable RIF mass that can be confirmed on CT then percutaneous drainage
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20
Q

What are some clinical features of appendicitis and what features can you elicit on examination?

A
  • Dull poorly localised peri-umbilical pain that migrates to RIF and is sharp and well localised

Can have vomiting, anorexia, nausea, constipation
- Rebound tenderness and percussion pain over McBurney’s point

  • Guarding if perforated but this will also show tachycardia and hypotension
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21
Q

What are the clinical features of colorectal cancer

A

Change in bowel habit, rectal bleeding, weight loss, abdominal pain, iron deficiency anaemia

Right sided: abdominal pain, occult bleeding/anaemia, mass in RIF, presents late

Left sided: PR bleeding, change in bowel habit, tenesmus, mass in LIF or on PR

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22
Q

According to NICE guidelines, what patients should be sent for urgent investigations for suspected colorectal cancer?

A

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

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23
Q

whats dukes staging criteria?

A

A:confined beneath muscularis propria
b:extension thru muscularis propria
C:involvement of regional lymph nodes
D: distant mets

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24
Q

What are the different management options for colorectal cancer?

A

Only definitive cure is surgery

Surgical

Regional colectomy to ensure removal of primary tumour with adequate margins and lymphatic drainage followed by anastomosis or formation of stoma

Chemotherapy

Usually used adjuvantly in advanced disease
FOLFOX regime
Radiotherapy

Used in rectal cancer neoadjuvantly (if threatened circumferential resection on MRI) to shrink tumour to increase chance of complete resection
Not used in colon cancer due to risk of damage to small bowel
Palliative

  • Endoluminal stenting to relieve acute bowel obstruction but risk of perforation, incontinence and migration and cannot be used in rectal as tenesmus
  • Stoma formation to relieve same

Resection of metastases

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25
Q

What are the different colonic resections used for colorectal cancer?

A

Right hemicolectomy: for caecal or ascending colon tumours. ileocolic, right colic and right branch of middle colic (SMA branches) are divide and removed

Left hemicolectomy: descending colon tumours. left branch of middle colic vessels, inferior mesenteric vein and left colic vessels divided

Sigmoidcolectomy: sigmoid colon tumours, IMA fully dissected out

Anterior resection: high rectal tumours >5cm from anus. favoured as leaves anal sphincter. often perform defunctioning loop ileostomy to protect anastomosis but can be reversed

Abdominoperineal Resection (AP): low rectal tumours <5cm from anus. Excision of distal colon, rectum and anal sphincters so needs permanent colostomy

26
Q

What is Hartmann’s procedure?

A

Used in emergency bowel surgery (e.g perf or obstruction)

Complete resection of recto-sigmoid colon with formation of end colostomy and closure of rectal stump.

Done when condition means primary anastomosis is not ideal

27
Q

What are the four different manifestations of diverticulum?

A
  • Diverticulosis – the presence of diverticula (asymptomatic, incidental on imaging)
  • Diverticular disease – symptoms arising from the diverticula
  • Diverticulitis – inflammation of the diverticula
  • Diverticular bleed – where the diverticulum erodes into a vessel and causes a large volume painless bleed

More common in men and developing countries

28
Q

What are some risk factors and differentials for diverticular disease?

A

Risk factors: age, low fibre intake, obesity, smoking, FHx, NSAID use

Differentials: IBD, bowel cancer, mesenteric ischaemia, gynaecological causes, renal stones

29
Q

What are the clinical features of the following:

Diverticulosis
Diverticular disease
Acute diverticulitis

A

Diverticulosis: Asymptomatic found incidentally on imaging

Diverticular disease: Intermittent colicky lower abdominal pain that can be relieved by defecation. Altered bowel habit, nausea, flatulence

Acute diverticulitis: Acute sharp abdominal pain usually localised in LIF and worsened by movement. Localised tenderness and systemic symptoms e.g pyrexia, anorexia. If perforated signs of peritonitis

30
Q

what can mask symptoms on diverticulosis

A

corticosteriods and NSAIDS

31
Q

What is a diverticular abscess and how is it managed?

A

Complicated diverticulitis

Managed with IV antibiotics but if doesn’t gett better do radiological drainage

If complicated multi-loculated abscess will need laparoscopic washout or Hartmann’s

32
Q

Why should you not perform a colonoscopy with a suspected presentation of diverticulitis?

A

Increased risk of perforation

33
Q

How is diverticular disease managed?

A

Uncomplicated can be managed as outpatient with analgesia and fluid intake and arrange colonoscopy to exclude any masked malignancies
If diverticular bleed manage conservatively as often self-limiting
If significant bleed appropriate resuscitation with blood products, if fails embolisation or surgical resection

34
Q

How is acute diverticulitis managed?

A

Conservative: Abx, IV fluids, analgesia. Symptoms often improve after 2-3 days, if deterioraion repeat imaging to look for disease progression

Surgical (if perforation with faecal peritonitis or overwhelming sepsis): Hartmann’s procedure with reversal of colostomy at later date

35
Q

What are some complications of diverticular disease?

A
  • High rate of recurrence: may opt for elective segmental resection
  • Diverticular stricture: from repeated acute inflammation so bowel scarred and fibrotic. can cause large bowel obstruction, needs sigmoid colectomy
  • Fistula formation: colovesical or colovaginal
36
Q

What antibiotics are used for acute diverticulitis?

A

5 days Co-amoxiclave or combination of cefalexin with metronidazole if allergic

Avoid NSAIDs and codeine due to risk of perforation

37
Q

What are some clinical features of Crohn’s disease?

A

Episodic colicky abdominal pain and diarrhoea
Diarrhoea is chronic and can contain blood and mucus
Systemic malaise, anorexia and low grade fever
Malnourishment
- Oral aphthous ulcers

  • Perianal disease
38
Q

What are some extra-intestinal features of Crohn’s?

A
  • MSK: enteropathic arthritis and metabolic bone disease
  • Skin: erythema nodosum and pyoderma gangrenosum
  • Eyes: anterior uveitis, iritis
  • HPB: PSC, cholangiocarcinoma, gallstones
  • Renal: renal stones
39
Q

How is Crohn’s managed?

A

Acute attack: Fluid resus, nutritional support, prophylatic heparin and anti-embolic stockings as prothrombotic state when in IBD flare

Inducing remission: Corticosteroids and immunosuppressants like azathioprine. Can trial biologics like infliximab as rescue therapy

Maintaining remission: Azathioprine as monotherapy, can consider biologics if this fails or add in methotrexate. Smoking cessation. Colonoscopic surveillance due to risk of malignancy. Referred to IBD nurse specialist and offered enteral nutritional support

Surgical (when medical management fails, severe complications or growth impairment in younger pt): see image but as patients are high risk need to do preoperative optimisation. Take bowel-sparing aproach to avoid short gut syndrome

40
Q

What drug should you avoid in an acute attack of Crohn’s or UC and why?

A

Anti-motility drugs like loperamide as can precipitate toxic megacolon
Also avoid colonoscopy due to risk of perforation
Refer to gastroenterologist

41
Q

What are some of the complications of Crohn’s?

A

Fistula
Stricture formation leading to bowel obstruction
Recurrent perianal abscesses and fistula
GI malignancy
Extraintestinal

Malabsorption and growth delay
Osteoporosis due to malabsorption and long term steroids
Increased risk of gallstones due to less bile salts reabsorbed in terminal ilium
Increase risk of renal stones due to malapsorption of fats so calcium stays in lumen but oxalate still absorbed freely so oxalate stones

42
Q

When should emergency surgery for Crohn’s be carried out?

A

Cases not responding to medical management
Bowel perforation
Toxic megacolon
Pay close attention to nutritional status!!!!

43
Q

What are some extra-intestinal manifestations of UC?

A

MSK: enteropathic arthritis or nail clubbing

Skin: erythema nodosum

Eyes: episcleritis, anterior uveitis, iritis

HPB: primary sclerosing cholangitis

44
Q

What are some differentials for UC?

A

Crohn’s (UC is more bloody stools)
Chronic infections (Schistosomiasis, Giardiasis, TB)
Mesenteric Ischaemia
Radiation colitis
Malignancy
IBS
Coeliacs

45
Q

If someone is having an acute flare of UC what will be seen on AXR?

A

Mural thickening and thumbprinting due to severe inflammation
- Lead pipe colon can be seen on barium studies with toxic megacolon

46
Q

How is UC managed?

A

A
Acute attack: Fluid resus, nutritional support, prophylatic heparin

Inducing remission: Corticosteroids and immunosuppressants e.g Sulfasalazine, with biologics trialled as rescue therapy, e.g Infliximab

Maintaining remission: Immunomodulators like sulfasalazine or biologics if first line fails. Colonoscopic surveillance due to risk of malignancy. IBD nurse specialist and enteral nutritional support

Surgical: around 30% will need this in their life, on another flashcard

47
Q

How is UC surgically managed?

A
  • Total proctocolectomy with require ileostomy is curative
48
Q

What are some complications of UC?

A
  • Toxic megacolon (needs decompression of bowel ASAP due to high risk of perforation)
  • Colorectal carcinoma
  • Osteoporosis
  • Pouchitis (abdominal pain, bloody diarrhoea, nausea that needs to be treated with metronidazole and ciprofloxacin)
49
Q

How does toxic megacolon present?

A

In IBD when bowel cannot get rid of air and faeces so dilates

Abdominal distension
Abdominal pain
Fever
Rapid heart rate
Shock
Guarding/rigidity

50
Q

What is the pathophysiology of a pseudoobstruction?

A
  • Ogilvie syndrome: dilatation of the colon due to an adynamic bowel in the absence of a mechanical obstruction, often affects caecum and ascending colon

Thought to be due to interruption of the autonomic nervous supply resulting in absence of smooth muscle action
Can lead to toxic megacolon, bowel ischaemia, perforation

51
Q

What are the clinical features of a pseudoobstruction?

A

Abdominal pain and distension
Constipation
Late vomiting
On examination abdomen is distended, tympanic but soft and non-tender. If focal tenderness it is a sign of ischaemia so warning sign

52
Q

What is the difference between a paralytic ileus and pseudoobstruction?

A

Pseudoobstruction is limited to colon and ileus is small and large bowel

53
Q

What are some clinical features of a volvulus and what are some differentials?

A

Features of bowel obstruction
- Colicky pain, abdominal distension, absolute constipation

Compared to other bowel obstructions there is a faster onset and higher degree of abdominal distension
Abdomen tympanic to percussion
If signs of peforation or peritonism surgical emergency as this indicates ischaemia or perforation
Differentials: bowel obstruction, severe constipation, pseudoobstruction, sigmoid diverticular disease

54
Q

How is a sigmoid volvulus managed?

A

Conservative

  • Rigid sigmoidoscopy with flatus tube insertion

Surgical

Laparotomy for Hartmann’s procedure
If recurrent volvulus may have elective sigmoidectomy to prevent further recurrence

55
Q

What are some differentials for RUQ pain?

A

Acute cholecysitis
Pyelonephritis
Pneumonia
Hepatitis
Small bowel obstruction

56
Q

What is choledocholithiasis?

A

Gallstone in the CBD

57
Q

What are some differentials for LIF pain?

A

Diverticulitis
IBD
Ureteric colic
Testicular tumour
Inguinal hernia
UTI
PID

58
Q

What are the indications for surgery in IBD?

A

Perforation
Lack of improvement with medical management
Fulminant colitis
Massive hemorrhage
Haemodynamic instability
Fistulas and Abscesses

59
Q

What antibiotics are used to treat diverticulitis?

A

Co-amoxiclav and Metronidazole

60
Q

What is the advantage of a flexi sigmoidoscopy over colonoscopy?

A

Doesn’t need bowel preparation

61
Q

What are some complications of diverticulitis and what are the indications for surgery?

A

Perforation
Diverticular strictures
Fistula formation
PR bleeding
Sepsis
Surgery when evidence of perforation, sepsis not responding to antibiotic therapy, or failure to improve despite conservative management

bookmarked qns surgery (10 decks)

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