lower GI diseases - surgical Flashcards
incision
cutting with a sharp instrument
retract
the method of increasing space
suture
to join structures with lengths of material
ligate
to tie or close a lumen
staple
to join structures with metal
anastomosis
a connection between 2 structures
dissect
to separate 2 structures - often through natural planes
Meckel’s diverticulum pathogenesis/aetiology
persistence of the vitelline duct which forms an outpouching of ileum
some contain gastric mucosa which can secrete HCl and cause ulceration
Meckel’s diverticulum patient group
symptomatic cases at 2 years
males 2x more likely
can also present in adults
meckels diverticulum signs and symptoms
usually asymptomatic and an incidental finding
only symptomatic if complications arise
fresh, painless, rectal bleeding
symptoms mimicking appendicitis
Meckel’s diverticulum complications
ulceration, perforation and haemorrhage
diverticulitis
obstruction
malignant change
Meckel’s diverticulum treatment and management
surgical removal if complications arise
the rule of 2’s
2% of population 2 inches long 2 feet from ileocecal valve 2 years of age twice as often in males
atresia
congenital absence or abnormal closure of a body cavity
atresia pathogenesis/aetiology
usually due to problems in GI tract development oesophageal intestinal biliary presents in newborns
atresia signs and symptoms
oesophageal - US scan increases amniotic fluid, swallowing or breathing difficulties
intestinal - signs of obstruction, green vomit, swollen abdomen
biliary - post hepatic jaundice
meconium ileus pathogenesis/aetiology
meconium ileus is a intestinal obstruction caused by meconium that is difficult to pass because it is too sticky
90% of patients have CF
meconium ileus signs and symptoms
meconium is slow to pass
symptoms of obstruction
green vomit
swollen abdomen
omphalocele pathogenesis/aetiology
intestinal loop does not return to the abdomen during development
it herniates out into the umbilical cord and is contained within the peritoneal layer of the umbilical cord
omphalocele signs and symptoms
shiny sac at the base of the umbilical cord
intestines enclosed
gastroschisis
protrusion of the abdominal contents through a defect in the anterior abdominal wall lateral to the umbilical cord
not covered in peritoneum
intestinal malrotation +/- volvulus
a congenital issue in which the intestines are twisted into the gut incorrectly due to incorrect connection to the brick wall
can be accompanied by Ladd’s bands
twisting can obstruct the lumen of the intestine or block off the blood supply
90% diagnosed before 1
volvulus
when a loop of intestine is wrapped around its own mesentery
intestinal malrotation symptoms
obstruction symptoms green vomit abdominal pain - leg drawing abdominal distention failure to thrive diagnosed by x ray
intestinal malrotation management
Ladd’s procedure - open or laproscopic, Ladd’s bands are dissected off
intussusception
when a segment of the intestine telescopes inside another
mechanism of intestinal blockage
commonly at ileocaecal junction
more common in children
intussesception symptoms
blood and mucus stool
vomiting and diarrhoea
lethargy
abdominal mass
intussesception investigations
USS
x-ray / CT
air or barium enema
intussusception management
905 can be fixed with an enema
surgical release - RLQ transverse incision , manual reduction, segmental bowel resection
anal fissures
a small tear in the mucosa that lines the anus
can be very small to severe
anal fissures risk factors
common in very young and very old
traumatic - passing large/hard stools, recurrent straining, chronic diarrhoea, anal intercourse, childbirth
non traumatic - IBD, anal cancers, HIV, TB, syphilis
anal fissures symptoms
pain during or after bowel movements
bright red on paper after wiping
visible crack in the skin or small lump/tag
anal fissures investigation
good history and direct exam
longer than 8 weeks chronic
scoping - anoscopy, flexible sigmoidoscopy or colonoscopy
anal fissures treatment
conservative - topical nitroglycerin, topical anaesthetic, botox injection
surgical - lateral internal sphincterotomy, a small incision is made into the sphincter muscles, not cutting the fissures away
colorectal cancer
adenoma/adenocarcinoma
colorectal cancer risk factors
red meat, low fibre diet, smoking, IBD, familial adenoma polyposis (FAP), lynch syndrome
colorectal cancer signs and symptoms
pain, change in bowel habits, tenemus, abdominal mass
colorectal cancer investigations
colonoscopy/flexible sigmoidoscopy, pill endoscopy, CT colonography
colorectal cancer management
surgery
chemo has limited use
radiotherapy - adjuvant or post surgery
colorectal cancer surgery
right hemicolectomy extended right hemicolectomy transverse colectomy left hemicolectomy sigmoid colectomy subtotal colectomy
anorectal cancer
adenocarcinomas from colon or SCC from the adjacent skin
investigations and management are same as colorectal, local excision is more often used - also consider function of schincter and cosmesis
diverticulum
an outpouching of the gut wall
diverticulitis
presence of diverticula
diverticular disease
diverticula which are symptomatic
diverticulitis
inflammation of a diverticulum
complicated diverticular disease/diverticulitis
diverticulitis with complications
uncmplicated diveticular disease/diverticulitis
diverticulitis without complications
diverticulitis pathogenesis
low fibre diet
colon has to work harder to move feaces - higher pressure in the lumen - diverticula form as mucosa herniates through the muscle layer to form an outpouching
most common in sigmoid colon
diverticulitis risk factors
western lifestyle
processed fods with low fibre diet
older patients
diverticular disease signs and symptoms
altered/erratic bowel habit
left iliac fossa colic
similar to IBS
diverticulitis signs and symptoms
severe pain in the iliac fossa fever tachycardia tenderness and guarding of the left side of the abdomen on examination similar to appendicitis but on the left
diverticular disease investigations
colonoscopy/sigmoidoscopy
barium enema
diverticulitis investigations
increase ESR and CRP
CT
don’t scope in acute attack - can cause perforation
complicated diverticulitis
perforation - peritonitis, abscess
haemorrhage
fistula
stricture
acute diverticulitis stage 1 Hinchey classification
pericolic abscess
surgery rarely needed
diverticulitis stage 2
pelvic abscess
may resolve without surgery
diverticulitis stage 3
purulent peritonitis
surgery required
diverticulitis stage 4
faecal peritonitis
surgery required
diverticular disease management
balanced diet with enough fibre and fluid intake
analgesia
bulking laxative
uncomplicated diverticulitis management
watchful waiting
analgesi
antibiotics
IV fluid, IV antibiotics and bowel rest
complicated diverticulitis abscess/peritonitis management
percutaneous drainage of large abscess
laparoscopic peritonel lavage and drainage
Hartmann’s procedure
primary resection/anastomosisi
colonic polyps
abnormal growth of tissue projecting from the colonic mucosa
colonic polyps types
adenoma
serrated
inflammatory - IBD
hamartomatous - Peutz-Jeghers syndrome
colonic polyps pathogenesis
adenoma - adenocarcinoma
colonic polyps signs and symptoms
asympomatic incidental finding rectal bleeding - anaemia mucus in stool abdominal pain diarrhoea or constipation
colonic polyps investigations
family history - inherited conditions, family history of colon cancer
genetic testing
colonoscopy - screening, incidental
biopsy of removed polyp
colonic polyp complications
cancer
majority of colonic cancer arise from pre-existing adenomatous polyps
transformation of polyp to cancer - 3-5 years
colonic polyps management
screening with colonoscopy
all adenomas removed due to cancer risk
FAP - prophylactic surgery - colectomy
lynch syndrome - prophylactic surgery in some cases
hernias
a protrusion of an organ or tissue out of the body cavity it is supposed to be in
hernia aetiology
structural - normal anatomical weakness, congenital abnormality resulting in a weakness
surgical scar
increased pressure - strenuous activity, chronic cough, pregnancy, straining
hernia classification
reducible - can be pushed back in
irreducible - can’t be pushed back
incarcerated - contents of the hernia are stuck inside it by adhesions
obstructed - causes bowel obstruction and bowel contents are unable to pass
strangulated - vascular supply to the hernia contents is compromised
hernias signs and symptoms
swelling in a particular location
patient may be able to reduce the hernia
may protrude on coughing or standing
pain and tenderness at the site of hernia
hernia investigations
examination of the swelling
ultrasound
hernia complications
irreducible
incarceration
strangulation
obstruction
hernia management
conservative or surgical
hernia types
inguinal hiatus epigastric spigelian femoral lumbar incisional parastomal paraumbilical umbilical
direct inguinal hernia
bowel herniates through a weakness in the floor of the inguinal canal and out the superficial ring
indirect inguinal hernia
bowel herniates through the deep and out the superficial ring
doesn’t reappear after reduction
hasselbach’s triangle
area of potential weakness in the abdominal wall through which direct inguinal herniation can occur
inferior epigastric artery
rectus abdominus
inguinal ligament
hiatus hernia
herniation of the stomach through the diaphragm at the oesophageal hiatus
presents with reflux
haemorrhoids
enlargement of the vascular cushions in the wall of the anus and rectum due to increased pressure
haemorrhoids signs and symptoms
painless bright red PR bleeding
perianal itch
no change in bowel habit or weight
haemorrhoids complications
can become strangulated causing pain
haemorrhoids management
conservative - increased fluid and fibre to prevent constipation - bulking laxatives and analgesia if necessary, anal hygiene to aid healing
non-surgical - sclerosation therapy, rubber band ligation
surgical - haemorrhoidectomy, stapled haemorrhoidectomy, HALO/THD procedure
rectal varices
due to portal hypertension
another cause of PR bleeding
bowel obstruction
blockage of the boel leading to - accumulation of fluid/gas, ischaemia or perforation
intraluminal, luminal, extraluminal
bowel obstruction symptoms
colicky central abdomen pain absolute constipation vomiting borborygmus abdominal distention
bowel obstruction investigation
tinkling bowel sounds
AXR or contrast CT
ABGs and bloods
ischaemic colitis
commonest problem of bowel ischaemia
inflammation but not total tissue death due to ischaemia
atherosclerosis
ischaemic colitis symptoms
abdominal pain
fresh blood in stool]urgency
diarrhoea
nausea
ischaemic colitis investigations
USS/AXR/CT
CT/MRI angiography
colonoscopy
ischaemic colitis
mild - self resolve, analgesi, IV fluid and fix cause
major - embolectomy, bypass of the afflicted artery, colectomy assorted if an area is non salvageable
“true” bowel ischaemia/infarction
death of colonic tissue due to lack of blood supply
often due to an atherosclerotic event
can be due to obstruction
bowel infarction symptoms
sudden often severe abdominal pain
blood in stool
forceful/painful bowel movements
confusion can occur in elderly patients
bowel infarction investigation
exploratory laparotomy
CT/MRI angiography
bowel infarction management
colectomy to remove the infarcted tissue
embolectomy
bypass
grafting
classification of complications
immediate - 24hrs early - 2-3 weeks late genera - affecting any of the body systems local - specific to the operation
cardiovascular complication
MI
haemorrhage
DVT
respiratory complication
atelectasis
pneumonia
PE
GI complications
ileus
anastamosis dehiscence
adhesions
short gut syndrome
wound complications
infection
dehiscence
hernia
urinary complications
retention of urine
UTI
urethral stricture
AKI
neurological complications
confusion
stroke
peripheral nerve injury
pyrexia 5 W
wind - atelectasis or pneumonia water - UTI wound - infection walking - DVT wonder drugs - drug induced fever
