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Surgery > Lower GI Surgery > Flashcards

Lower GI Surgery Flashcards

1
Q

what is Meckel’s Diverticulum formed from?

A

ileal remnant of vitellointestinal duct

(joins yoke sac to midgut lumen)

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2
Q

features of meckels’ diverticulum?

A

a true diverticulum

2 inches long

2 ft from ileocaecal valve

2% of population

2% symptomatic

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3
Q

what type of tissue does meckel’s diverticulum contain?

A

ectopic gastric

or pancreatic tissue

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4
Q

presentation of symptomatic meckels’

A

rectal bleeding - from gastric mucosa

diverticulitis mimicking appendicitis

intussusception

volvulus

malignant change: adenoca

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5
Q

hernia containing meckel’s diverticulum

called?

A

Littre’s Hernia

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6
Q

what is the investigation of choice for meckel’s diverticulum?

A

Tc 99 (Technetium-99m) pertechnetate scan

  • detects gastric mucosa
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7
Q

Mx of Meckel’s Diverticulum

A

Surgical resection if symptomatic

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8
Q

Tc-99 pertechnetate scan -?

A

Meckel’s Diverticulum

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9
Q

causes of intussusception

A

idiopathic

hypertrophied peyer’s patch- following bacterial/ viral GI infections

Meckel’s Diverticulum

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10
Q

presentation of intussusception?

A

episodic inconsolable crying

drawing up legs

-> colicky abdo pain

redcurrant jelly stools

sausage-shaped abdo mass

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11
Q

mx of intussusception

A

resuscitation, nil by mouth, x-match

Reduction by rectal air insufflation

(perform in theatre)

25% failure - conduct surgery

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12
Q

presentation of mesenteric adenitis

A

abdo pain

presents similarly to appendicitis

fever

tenderness

  • post URTI/ concurrent URTI
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13
Q

differentiating features

mesenteric adenitis vs appendicitis

A

progressively better rather than worse

post viral infection

headache +

higher temp

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14
Q

Types of malignant small bowel neoplasms?

A

AdenoCa (40%)

Carcinoid (40%)

Lymphoma (EATL assoc w Coeliac)

GI stromal tumours

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15
Q

presentation of small bowel malignancies

A

often presents late due to non-specific symptoms

weight loss, abdo pain

N+V, obstruction

bleeding

jaundice from biliary obstruction/ liver mets

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16
Q

Imaging of Small Bowel Cancer

A
  • abdo Xray: SBO
  • Barium follow through (Small bowel)
  • CT scan
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17
Q

features of duodenal atresia?

A

polyhydramnios

vomiting - usually bile stained

distended stomach

strongly associated w downs syndrome

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18
Q

diagnosis of duodenal atresia?

A

abdo x ray : double bubble sign

ie. distension of stomach and proximal duodenum w absence of gas throughout the rest of the bowel

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19
Q

tx of duodenal atresia

A

duodenojejunostomy

or

gastrojejunostomy

+ rehydration and gastric aspiration

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20
Q

syndrome in which a non-insulin-secreting islet cell tumour of the pancreas produces a potent gastrin-like hormone

A

zollinger-Ellison syndrome

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21
Q

Zollinger-Ellison syndrome:

what is produced that leads to the ulceration?

A

multiple ulcers due to potent gastrin-like hormone

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22
Q

why do NSAIDs predispose to peptic ulceration?

A

NSAIDs inhibit the production of protective prostaglandins in the mucosa

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23
Q

what medications may increase risk of peptic ulceration?

A

NSAIDs

steroids

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24
Q

what lifestyle factors may lead to increased risk of peptic ulceration?

A

smoking

stress

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25
Q

peptic ulcer assoc with elevated intracranial pressure?

A

Cushing’s ulcer

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26
Q

peptic ulcer assoc w severe burns?

A

Curling’s Ulcer

a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa.

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27
Q

episodic epigastric pain usually 2 h after meal

pain aggravated by spicy foods and relieved by milk and alkalis

A

Duodenal ulcer

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28
Q

ix with suspected duodenal ulcer?

A

endoscopy: to visualize oesophagus, stomach and duodenum and obtain biopsy to differentiate between benign/malignant ulcer

H pylori detection: - endoscopic biopsy (urease test), 13C-labelled urea breath test, seological testing of Hy pylori antibodies

Faecal occult blood often positive.

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29
Q

complications of peptic ulcer

A

chronicity

  • long term symptoms of pain

perforation

stenosis

haemorrhage

gastric ulcers may undergo malignant change

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30
Q

tx of peptic ulcer

1st line

A

eradication of H pylori.

Omeprazole (PPI for acid reduction)
+ Clarithromycin/ Amoxicillin

+ metronidazole

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31
Q

what to avoid when a peptic ulcer is present?

A

violent gastric acid stimulants e.g. alcohol

medications e.g. aspirin/ NSAIDs

smoking

stress

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32
Q

How were gastric ulcers surgically treated traditionally?

A

Billroth I gastrectomy.

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33
Q

what was a traditional surgical procedure for duodenal ulcers?

A

Simple longitudinal duodenotomy, closed as a pyloroplasty, with under-running of the bleeding vessel performed + acid suppression w PPI

and

Polya gastrectomy with under-running of the vessel

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34
Q

surgical tx of gastric / duodenal ulcers?

A

gastric ulcers: antrectomy + Roux-en-Y gastroenterostomy

duodenal ulcers: removing the bulk of the acid-secreting area of the stomach (the body and the lesser curve), and re-establishing gastric drainage via a Roux-en-Y gastroenterostomy

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35
Q

causes of constipation?

organic obstruction

A
  • colon carcinoma
  • diverticular disease
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36
Q

causes of constipation?

painful anal conditions

A

anal fissure

prolapsed piles

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37
Q

causes of constipation?

causing an adynamic bowel

A

Hirschsprung’s

senility

spinal cord injuries and disease

myxoedema

Parkinsons’ disease

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38
Q

causes of constipation?

drugs

A

aspirin

opiate analgesics (codeine e.g.)

anticholinergics

ganglion blockers

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39
Q

causes of constipation?

habit and diet

A

dehydration

starvation

dyschezia (suppression of urge to defecate)

lack of bulk in diet

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40
Q

what is a true vs a false diverticulum?

A

true: an outpouching covered by all the layers of the bowel wall
e. g. Meckel’s diverticulum
false: lacking the normal muscle coat of the bowel
e. g. colonic diverticula

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41
Q

what are the appendices epiploicae?

A

epiploic appendices are small pouches of the peritoneum filled with fat and situated along the colon, but are absent in the rectum.

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42
Q

gas in the urine called?

A

pneumaturia

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43
Q

most common cause of colovesical fistula?

A

diverticulitis

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44
Q

ix of diverticulitis?

A

CT abdo

Sigmoidoscopy (fibreoptic sigmoidoscopes)/ Colonoscopy

Barium Enema

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45
Q

what can a rigid sigmoidoscope visualize?

A

rectum only

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46
Q

tx of acute diverticulitis

A

conservative mx

  • fluid diet
  • antibiotics (metronidazole w penicillin/ gentamicin)
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47
Q

ix of angiodysplasia?

A

colonoscopy

  • lesions appear as bright red 0.5cm-1cm diameter submucosal lesions w small, dilated vessels

mesenteric angiogram

  • contrast medium leaks into the lumen
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48
Q

tx of angiodysplasia

A

blood transfusion if haemorrhage severe

colonoscopic electrocoagulation or argon plasma coagulation may be curative

resection may be necessary

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49
Q

five main causes of colitis

A
  1. UC
  2. Crohns colitis
  3. antibiotic-associated colitis
  4. Infective colitis
  5. Ischaemic colitis
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50
Q

ulcerative colitis - is smoking protective or not?

A

yes

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51
Q

ulcerative colitis pathology?

A

crypt abscesses

oedema and submucosal fibrosis in walls of colon

smooth, atrophic mucosa

bowel wall thinned

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52
Q

local complications of ulcerative colitis

A

toxic dilatation -> peritonitis

haemorrhage

stricture

malignant change

perianal disease

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53
Q

diarrhoea of ulcerative colitis may be controlled by?

A

codeine phosphate

loperamide

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54
Q

what medication to induce remission in an acute attack of ulcerative colitis?

A

corticosteroids

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55
Q

what medications to maintain remission of UC?

A

salicylates such as mesalazine or sulfasalazine

or

anti-TNF antibodies infliximab or adalimumab

or

azathioprine/ ciclosporin

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56
Q

indications for surgery in UC?

A

fulminating disease not responding to medical treatment

chronic disease not responding to medical tx

prophylaxis against malignant change w long-standing disease

complications of colitis

*usually total removal of the colon and rectum w either a permament ileostomy or an ileoanal anastomosis

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57
Q

non-invasive screening test for familial adenomatous polyposis?

A

affected individuals usually have hypertrophy of the retinal pigment layer

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58
Q

symptoms of colon ca?

A

change in bowel habit

intestinal obstruction

perforation of the tumour

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59
Q

what adjuvant chemotx is used post-operatively w colon cancer?

A

5-fluorouracil (5-FU)

with folinic acid

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60
Q

what does the superior mesenteric artery supply?

A

midgut components

e.g. caecum, ascending colon, 2/3 of the transverse colon

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61
Q

what does the inferior mesenteric artery supply?

A

hindgut components

e.g. distal transverse colon, descending colon, sigmoid and rectum

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62
Q

what is the watershed area of the colon?

A

the area between the superior and inferior mesenteric artery supply

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63
Q

what surgical mx of a right sided lesion?

A

right hemicolectomy

w ileocolic anastomosis

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64
Q

what surgical mx of a left sided lesion?

A

left hemicolectomy

or

sigmoid colectomy

w anastomosis of colon to rectum

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65
Q

What surgical mx of a sigmoid lesion?

A

sigmoid colectomy

elective

or emergency (Hartmann’s)

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66
Q

indications for colostomy formation

A

to divert faeces to allow healing of a more distal anastomosis or fistula

to decompress a dilated colon, as a prelude to resection of the obstructing lesion

removal of the distal colon and rectum

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67
Q

what is a loop colostomy?

A

colon brought to surface and antimesenteric border opened

rod used to stop opened bowel loop from falling back inside

  • used to divert faeces and is simple to reverse
  • loop ileostomy preferred because of better blood supply to the bowel facilitating subsequent closure
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68
Q

complications of colostomy formation

A

retraction: colon disappears down the hole
stenosis: opening becomes smaller. may be due to ischaemia or poor apposition of colonic mucosa w skin edge

paracolostomy hernia: peritoneal contents herniate through the abdo wall defect made to accommodate the stoma

prolapse: in which colon intussuscepts out of the stoma

lateral space small bowel obstruction

skin excoriation due to ill-fitting stoma appliances or poorly constructed stomas

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69
Q

why are ileostomies spouted?

A

ileostomy effluent is very irritant and causes severe skin excoriation

-> ileostomy constructed w a spout to keep the effluent off the skin

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70
Q

what helps stoma patients produce bulky, formed stool?

A

Fybogel or Celevac

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71
Q

what are the usual positions of haemorrhoids in a patient?

A

3, 7 and 11 oclock

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72
Q

How to grade haemorrhoids?

A

Grade I: confined to anal canal

II: prolpase on defecation and reduce spontaneously

III: prolapse on defecation and manually replaced

IV: remain prolpased outside anal margin at all times

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73
Q

predisposing factors to haemorrhoids

A

may be aggravated by factors that produce congestion of the superior rectal veins

e.g.

pregnant uterus

cardiac failure

pelvic tumour

excessive use of purgatives

chronic constipation

rectal ca

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74
Q

what to do examination/ investigation wise when suspecting haemorrhoids

A
  1. examination of abdomen

to exclude palpable lesions of the colon or aggravating factors for haemorrhoids (pelvic mass e.g.)

  1. Rectal exam
  2. Proctoscopy
  3. Sigmoidoscopy to eliminate lesion higher in the rectum
  4. Colonoscopy or flexi sigmoidoscopy when symptoms point to a more sinister condition than internal haemorrhoids
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75
Q

complications of haemorrhoids

A

anaemia: following severe/ continued bleeding
thrombosis: prolapsed piles strangulated by anal sphincter -> painful + suppuration/ ulceration may occur

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76
Q

conservative advice for haemorrhoids

A

pt should avoid straining at stool and aim to pass a firm, soft motion daily.

bulk laxative + adequate fluid intake

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77
Q

mx of haemorrhoids

A

1st line: band ligation

then sclerotherapy (for first / second degree haemorrhoids)

surgery- haemorrhoidectomy for 3rd/4th degree haemorrhoids

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78
Q

what does banding of haemorrhoids involve?

A

application of small O-ring rubber band to areas of protruding mucosa

  • > strangulation of mucosa
  • > falls away after few days

must be placed above the detate line, if not pt would feel the application

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79
Q

mx of thrombosed strangulated piles?

A

foot of bed elevated

opiate analgesia

local cold compresses

often thrombosed piles fibrose completely w spontaneous cure

or

haemorrhoidectomy at once

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80
Q

complications of haemorrhoidectomy

A

acute retention of urine due to discomfort post-operatively

stricture - when excessive amounts of skin are excised

post operative haemorrhage

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81
Q

anal fissures- usual position?

A

posterior in the midline

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82
Q

tx of anal fissures

A

local anaesthetic ointment

+

lubricant laxative

+ GTN or diltiazem cream to relax the anal sphincter

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83
Q

what is a fistula?

A

an abnormal communication between two epithelial surfaces

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84
Q

what is a sinus?

A

a granulating track leading from a source of infection to a surface

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85
Q

tx of superficial and low-level anal fistulae?

A

laid open and allowed to heal by granulation

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86
Q

mx of high fistulae (suprasphincteric, transsphincteric)

A

fistula track can be injected w fibrin glue/ bio-prosthetic fistula plug

or

lower part of the track laid open and a seton passed through the upper part of the track and left for 2-3 wks so that the spincter is fixed by scar tissue.

the track is then divided by repeated tightening of the ligature.

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87
Q

Systematic approach of AXR?

A
  1. Bowel Gas Pattern
    - bowel diameter
    - position
  2. extraluminal gas (under diaphragm, riglers sign)
  3. Soft tissues
  4. Calcification
  5. Masses
  6. Bones
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88
Q

Difference between small and large bowel on AXR?

A

Small bowel:

more central

normal diameter <3 cm

valvulae conniventes - which go across the whole colon

Large bowel:

more peripheral - can see ascending, transverse and descending colon

haustra (only go part of the way across)

normal diameter of transverse <6 cm

caecam < 8cm

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89
Q
A

Presence of valvulae conniventes

cluster of dilated small bowel loops in the central abdomen

-> Small bowel obstruction (ileus would usually affect both large and small)

most common cause: adhesions from prev surgeries

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90
Q
A

dilated large bowel from caecum to mid descending colon

diagnosis: large bowel obstruction

(small bowel not obstructed here bec ileocaecal valve is still competent)

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91
Q
A

gas on both sides of bowel wall

Rigler’s sign

diagnosis: intestinal perforation w free intraperitoneal gas

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92
Q
A

gas under diaphragm

-> perforation

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93
Q
A

Distended loop of colon (see haustra) arising from pelvis

diagnosis: sigmoid volvulus (twisting of segment of bowel around its mesentery)

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94
Q
A

large calcific opacity overlying right renal outline

upper part is same shape as renal collecting system

diagnosis: right renal staghorn calculus

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95
Q
A

multiple opacities within the pancreas

-> chronic pancreatitis

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96
Q
A

Gallstones

e.g. calcium oxalate

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97
Q
A

Pregnancy

  • see fetal spine, skull, legs

in general, women of child bearing age imaging of abdo / pelvis using ionising radiation should be restricted to the 10 days following menstruation

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98
Q

presentation of small bowel neoplasm?

A

often non specific symptoms so present late

n/v, obstruction

weight loss and abdo pain

bleeding

jaundice from biliary obstruction or liver mets

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99
Q

imaging of small bowel neoplasia?

A

AXR: SBO

Ba follow through

CT

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100
Q

types of benign small bowel neoplasms?

A

adenomatous polyps (FAP, Peutz-Jeghers)

Haemangioma

Neurofibroma

Leiomyoma

Lipoma

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101
Q

What gut lymphoma is assoc w coeliac disease?

A

Enteropathy associated t cell lymphoma (EATL)

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102
Q

carcinoid tumours are?

A

neuroendocrine tumours of enterochromaffin cell origin capable of producing 5HT

may secrete: 5-HT, VIP, gastrin, glucagon, insulin, ACTH

most commonly in appendix

103
Q

features of carcinoid syndrome?

A

flushing: paroxysmal, upper body +/- wheals
intestinal: diarrhoea

valve fibrosis: tricuspid regurg and pulm stenosis

wheeze: bronchoconstriction

tryptophan deficiency -> pellagra (3Ds - dementia, diarrhoea, dermatitis)

104
Q

ix of carcinoid syndrome?

A

increased urine 5-hydroxyindoleacetic acid

CT/MRI: find primary

105
Q

mx of carcinoid syndrome?

A

symptoms: octreotide or loperamide
curative: resection

106
Q

what is carcinoid crisis?

A

massive mediator release

-> vasodilation, hypotension, bronchoconstriction, hyperglycaemia

107
Q

mx of carcinoid crisis?

A

high-dose octreotide

108
Q

definition of appendicitis?

A

inflammation of the vermiform appendix randing from oedema to ischaemic necrosis and perforation

109
Q

reason behind pattern of abdo pain in acute appendicitis?

A

early inflammation -> appendiceal irritation

nociceptive info travels in the sympathetic afferent fibres that supply the viscus

-> pain referred to dermatome corresponding to spinal cord entry level of these sympathetic fibres

appendix = midgut = (T10/11)

Late inflammation -> parietal peritoneum irritation

  • pain localised in RIF
110
Q

signs of Acute appendicitis?

A

guarding and tenderness @ McBurney’s point (1/3 between asis and umbilicus)

appendix mass may be palpable in RIF

Rovsing’s sign: pressure in LIF -> more pain in RIF

Psoas sign: pain on extending the hip- retrocaecal appendix

Cope sign: flexion + internal rotation of R hip -> pain

  • appendix lying close to obturator internus
111
Q

mx of acute appendicitis?

A

prep for theatre: NBM, x-match, G+S

fluids

abx: cef n met
analgesia: paracetamol, NSAIDs, codeine

diagnostic lap

uncertain dx -> acute observation

112
Q

complications of acute appendicitis?

A

appendix mass

appendix abscess

perforation: deteriorating pt w peritonitis

113
Q

smoking in crohns vs UC?

A

smoking protective in UC

but increases risk in Crohns

114
Q

pathology of UC vs Crohns?

A

UC:

continuous mucosal inflammation from rectum upwards

shallow, broad ulcers

Crohns:

transmural inflammation from mouth -> anus esp terminal ileum

skip lesions

strictures

cobblestone mucosa

marked fibrosis

granulomas

fistulae

115
Q

skin findings in IBD?

A

clubbing

erythema nodosum

pyoderma gangrenosum (esp UC)

116
Q

eyes symptoms in IBD?

A

anterior uveitis

conjunctivitis

episcleritis

scleritis

117
Q

joints in IBD?

A

(enteropathic) arthritis

sacroilitis

ank spond

118
Q

hepatobiliary features in IBD?

A

PSC + cholangiocarcinoma (UC)

gall stones (esp crohns)

fatty liver

119
Q

extra- abdominal features of IBD?

A

Crohns:

aphthous ulcers, glossitis

perianal abscesses, fistulae, tags

anal strictures

amyloidosis

oxalate renal stones (esp crohns)

120
Q

Ix in Ulcerative colitis?

A

Bloods:

FBC etc

blood cultures

Stool cultures to exclude infectious cause

Imaging:

AXR- megacolon, wall thickening

CXR - perforation

Ba/ gastrograffin enema

ileocolonoscopy + regional biopsy

121
Q

Barium/ gastrograffin enema findings of Ulcerative colitis?

A

Lead pipe colon: no haustra

thumbprinting: mucosal thickening
pseudopolyps: regenerating mucosa

122
Q

In Truelove and Witts Criteria determining severity of UC, what is considered severe?

A

Motions: >6

PR bleed: large

temp: >37.8

HR: >90

Hb <10.5

ESR > 30

123
Q

In Truelove and Witts Criteria determining severity of UC, what is considered moderate?

A

Motions 4-6

PR bleed: moderate

Temp: 37.1-37.8

HR 70-90

Hb 10.5-11

124
Q

In Truelove and Witts Criteria determining severity of UC, what is considered mild?

A

Motions: <4

PR bleed: small

Temp: apyrexic

HR <70

Hb >11

ESR <30

125
Q

Mx of acute severe UC?

A

resus: admit, IV fluids, NBM

Hydrocotrisone IV 100 mg QDS

Transfuse blood if required

Thromboprophylaxis: LMWH

Monitor bloods (FBC, ESR, CRP, U+E), vitals + stool chart, twice daily examination +/- AXR

126
Q

acute complications of Severe UC?

A

perforation

bleeding

toxic megacolon (>6 cm)

VTE

127
Q

mx of acute severe UC with improvement on IV hydrocortisone?

A

switch to oral pred + a 5-ASA

taper pred after full remission

128
Q

mx of acute severe UC w no improvement on IV hydrocortisone?

A

On day 3: stool freg >8 or CRP >45

  • > predicts 85% chance of needing a colectomy during the admission
    medical: ciclosporin, infliximab
    surgical: subtotal colectomy
129
Q

1st line therapies in inducing remission in ulcerative colitis?

A

1st line: 5-ASAs

2nd line: prednisolone

130
Q

medication for Maintaining remission in UC?

A

1st line: 5-ASAs PO- sulfasalazine or mesalazine

(topical tx may be used in proctitis)

2nd line: azathioprine or mercaptopurine

3rd line: infliximab/ adalimumab

131
Q

indications for emergency surgery in UC?

A

toxic megacolon

perforation

massive haemorrhage

failure to respond to medical tx

132
Q

AXR findings SBO vs LBO?

A

diameter: SBO ≥3 cm

LBO ≥ 6cm

(Caecum ≥ 9cm)

Location: SBO- central

LBO- peripheral

SBO: valvulae conniventes

LBO: haustra

SBO: many loops

LBO: few

133
Q

Mx of Bowel obstruction?

A

Resus: NBM

IV fluids

NGT: decompress upper GIT, stops vomiting, prevents aspiration

catheterise: monitor UO

analgesia

antibiotics: cef n met if strangulation or perf

gastrograffin study: oral or via NGT

consider need for parenteral nutrition

non operative mx sucessful in 80% of pts w SBO w/o peritonitis

otherwise: surgery

134
Q

indications for elective surgery of ulcerative colitis?

A

chronic symptoms despite medical therapy

carcinoma or high grade dysplasia

135
Q

what surgeries are done electively for UC?

A

panproctocolectomy w end ileostomy or IPAA (ileal pouch anal anastomosis)

or

total colectomy w Ileal rectal anastomosis

136
Q

UC surgical complications?

A

abdo: SBO (adhesions), anastomotic stricture, pelvic abscess

Stoma: retraction, stenosis, prolapse, dermatitis

Pouch: pouchitis, faecal leakage

137
Q

ix (diagnostic) of Crohns?

A

ileocolonoscopy + regional biopsy

138
Q

ix of Crohns duriing a severe attack?

A

high temp, raised HR, high CRP+ ESR, high WCC, low albumin

139
Q

what blood results are severity markers of crohns?

A

FBC: low Hb, high WCC

LFT: low albumin

raised CRP/ESR

140
Q

mx of Severe attack of Crohns?

A

resus: admit, NBM, IV fluids

Hydrocortisone IV + PR if rectal disease

ABx: metronidazole PO or IV

thromboprophylaxis: LMWH

Dietician review: elemental diet, consider parenteral nutrition

monitoring: vitals, stool chart, daily exam

141
Q

following mx if improvement following IV + PR hydrocortisone in severe attack of crohns?

A

Switch to oral prednisolone (40mg/ day)

142
Q

following mx if no improvement following IV + PR hydrocortisone in acute severe attack of Crohns?

A

discussion between pt, physician and surgeon

medical: methotrexate +/- infliximab

surgical

143
Q

inducing remission in mild / mod Crohns disease?

A

supportive: high fibre diet, vitamin supplements

Oral:

1st line

  • ileocaecal: budesonide
  • colitis: sulfsalazine

2nd line: prednisolone (tapering)

3rd: methotrexate
4th: infliximab or adalimumab

144
Q

maintaining remission in Crohns?

A

1st line: azathioprine or mercaptopurine

2nd: methotrexate
3rd: infliximab/ adalimumab

145
Q

indications for surgery in Crohns?

A

emergency:

failure to respond to medical tx

intestinal obstruciton/ perforation

massive haemorrhage

elective:

abscess or fistula

perianal disease

chronic ill health

carcinoma

146
Q

what surgical procedures are carried out in Crohns disease?

A

limited resection e.g. ileocaecal

stricturoplasty (alleviate bowel narrowing due to scar tissue)

defunction distal disease w temporary loop ileostomy

147
Q

complications of surgery in crohns?

A

stoma complications

enterocutaneous fistula

anastomotic leak or stricture

148
Q

features of short gut?

A

<1 -2m small bowel

steatorrhoea

ADEK and B12 malabsorption

bile acid depletion -> gall stones

hyperoxaluria -> renal stones

149
Q

definition of diverticulum?

A

outpouching of tubular structure

true = composed of complete wall e.g. Meckels

false = composed of mucosa only (pharyngeal, colonic)

150
Q

definition of diverticular disease?

A

symptomatic diverticulosis

151
Q

definition of diverticulitis?

A

inflammation of diverticula

152
Q

pathophysiology of diverticular disease?

A

assoc w raised intraluminal pressure

(low fibre diet)

mucosa herniates through muscularis propria at points of weakness where perforating arteries enter

most commonly in sigmoid colon

commoner in obese pts

153
Q

features of diverticular disease?

A

altered bowel habit

left sided pain /colic

relieved by defecation

nausea

flatulence

154
Q

mx of diverticular disease?

A

high fibre diet, mebeverine (relaxing gut muscles) may help

elective resection for chronic pain

155
Q

presentation of diverticulitis?

A

faeces -> obstruction of diverticulum

abdo pain and tenderness

  • typically LIF
  • localised peritonitis

pyrexia

156
Q

ix in diverticulitis?

A

Bloods:

WCC, CRP/ESR, Amylase, G+S/x match

Imaging:

erect cxr- look for perforation

AXR- fluid level/ air in bowel wall

contrast CT

gastrograffin enema

endoscopy: flexi sig, colonoscopy (not in acute attack -> can perf)

157
Q

Mx of acute diverticulitis?

A

if mild:

treat at home w bed rest (fluids only) and augmentin +/- metronidazole

admit if unwell, fluids not tolerated, pain uncontrolled

Medical: NBM, IV fluids, analgesia, antibiotics: cef n met

most cases settle

if not, Surgery: Hartmanns to resect diseased bowel

158
Q

indications for surgery in acute diverticulitis

A

perforation

large haemorrhage

stricture -> obstruction

159
Q

Surgical mx of Acute Diverticulitis?

A

Hartmann’s procedure:

surgical resection of the rectosigmoid colon w closure of the anorectal stump and formation of end colostomy

(in emergency, immediate anatomosis is not possible)

160
Q

complications of diverticulitis?

A

perforation: sudden onset pain, generalised peritonitis and shock
haemorrhage: sudden, painless bright red PR bleed
abscess: swinging fever, localising signs

fistulae

strictures

161
Q

mx of perforation in acute diverticulitis?

A

hartmanns

162
Q

mx of haemorrhage in acute diverticulitis?

A

usually stops spontaneously

may need transfusion

colonoscopy +/- diathermy/ adrenaline

embolisation

resection

163
Q

mx of abscess in acute diverticulitis?

A

abx + CT/ US guided drainage

164
Q

features of colovesicular fistulae?

A

pneumaturia

intractable UTIs

tx: resection

165
Q

mx of strictures following acute diverticulitis?

A

resection

stenting

166
Q

commonest cause of SBO?

A

adhesions: 60%

hernias

167
Q

commonest causes of LBO?

A

colorectal neoplasia: 60%

diverticular stricture: 20%

volvulus: 5%

168
Q

types of bowel obstruction?

A

simple: 1 obstructing point + no vascular compromise

may be partial or complete

closed loop:

bowel obstructed @ 2 points

  • volvulus
  • competent ileocaecal valve
  • > gross distension -> perforation

strangulated: compromised blood supply

localised constant pain + peritonism

fever + raised WCC

169
Q

paralytic ileus may occur when?

A

usually small bowel ileus

post op

peritonitis

pancreatitis

poisons/ drugs e.g. TCAs

metabolic: low K, Na, mg, uraemia

mesenteric ischaemia

170
Q

causes of mechanical bowel obstruction?

A

intraluminal:

impacted matter: faeces, worms

intussusception

gallstones

intramural:

benign stricture (IBD, surgery, diverticulitis, radiotx)

neoplasia

congenital atresia

extramural:

hernia

adhesions

volvulus

extrinsic compression: tumour, abscess, haematoma, pseudocyst, congenital bands (e.g. Ladd’s)

171
Q

features of bowel obstruction?

A

colicky abdo pain

distension: increases w lower obstructions
vomiting: early in high obstruction, late or absent in low obstructions

absolute constipation: no faeces or flatus

172
Q

examination of bowel obstruction?

A

fluid status

fever

surgical scars

hernias

mass: neoplastic/ inflammatory

bowel sounds: increased / tinkling in mechanical obstruction

decreased in ileus

173
Q

imaging in bowel obstruction?

A

erect CXR: free air

AXR: bowel obstruction

CT: can show transition point

Gastrograffin studies: look for mechanical obstruction

follow through may relieve mild mechanical obstruction: usually adhesional

174
Q

Bloods in Bowel obstruction?

A

FBC: raised WCC

U+E; dehydration, electrolyte abnormalities

Amylase: raised if strangulation/ perforation

VBG: raised lactate in strangulation

G+S/ clotting: may need surgery

175
Q

indications for surgical treatment of bowel obstruction?

A

closed loop obstruction

obstructing neoplasm

strangulation/ perforation -> sepsis, peritonitis

failure of conservative mx (up to 72h)

176
Q

surgical procedures for SBO?

A

adhesiolysis

177
Q

surgical procedures for LBO?

A

Hartmann’s

Colectomy + primary anastomosis

Palliative bypass procedure

tranverse loop colostomy or loop ileostomy

caecostomy

178
Q
A

Sigmoid volvulus

(80% of volvulus)

  • > characteristin inverted U/ Coffee bean sign
  • long mesentery w narrow base predisposes to torsion
179
Q

presentation of sigmoid volvulus?

A

often elderly, constipated, co morbid pts

assoc w neuropsych conditions e.g. parkinsons, schizophrenia

massive distension w tympanic abdomen

180
Q

AXR signs of sigmoid volvulus?

A

coffee bean

/ inverted U sign

181
Q

Mx of sigmoid volvulus?

A

often relieved by sigmoidoscopy and flatus tube insertion

-> monitor for signs of bowel ischaemia following decompression

sigmoid colectomy occassionally required

-> when failed endoscopic decompression/ bowel necrosis

often recurs -> elective sigmoidectomy may be needed

182
Q
A

Caecal volvulus

kidney bean sign

assoc w adhesions

183
Q

mx of caecal volvulus

A

only 10% of pts can be detorsed w colonoscopy -> typically requires surgery

right hemicolectomy w primary ileocolic anastomosis

caecostomy

184
Q

features of gastric volvulus?

A

triad of gastro-oesophageal obstruction:

vomitng -> retching w regurgitation of saliva

pain

failed attempts to pass an NG tube

185
Q

risk factors for gastric volvulus?

A

congenital:

bands, rolling/ paraoesophageal hernia, pyloric stenosis

acquired:

gastric/ oesophageal surgery

adhesions

186
Q

Ix of gastric volvulus?

A

Xray shows gastric dilatation and double fluid level on erect films

187
Q

Mx of gastric volvulus?

A

endoscopic manipulation

emergency laparotomy

188
Q

presentation of paralytic ileus?

A

adynamic bowel secondary to absence of normal peristalsis

usually SBO

reduced or absent bowel sounds

mild abdo pain: not colicky

189
Q

prevention of paralytic ileus?

A

decreased bowel handling

laparoscopic approach

peritoneal lavage after peritonitis

unstarched gloves

190
Q

mx of paralytic ileus?

A

conservative drip and suck mx

correct any underlying causes: e.g. drugs, metabolic abnormalities

consider need for parenteral nutrition

exclude mechanical cause if protracted

191
Q

What is Ogilvie’s syndrome?

A

Colonic Pseudo obstruction

acute dilation of the colon in the absence of any mechanical obstruction in severely ill patients.

massive dilatation of the cecum (diameter > 10 cm) and right colon on abdominal X-ray.

192
Q

cause of colonic pseudo-obstruction?

A

aetiology unknown

assoc w:

elderly

cardioresp disorders

pelvic surgery e.g. hip arthoplasty

trauma

193
Q

Mx of colonic pseudo-obstruction?

A

neostigmine: anticholinesterase

colonoscopic decompression: 80% successful

194
Q

types of colonic adenomas?

A

colonic adenomas are benign precursors to colorectal cancer

characterised by dysplastic epithelium

tubular: small, pedunculated tubular glands

villous: large, sessile, covered by villi

tubulovillous: mixture

195
Q

presentation of colonic adenomas?

A

typically asymptomatic

large polyps can bleed -> IDA

villous adenomas can -> low K+ and hypoproteinaemia

196
Q

what increases the malignant potential of a colonic adenoma?

A

large size

large amount of dysplasia

increased villous component

197
Q

what gene mutation is assoc w colorectal cancer?

A

APC gene

oncogene

also kras

p53

198
Q

other risk factors for colorectal cancer?

A

diet: low fibre, high refined carb

IBD

Familial: FAP, HNPCC, Peutz Jeghers

Smoking

Genetics

NSAIDs/ Aspirin: protective

199
Q

most common type of colon cancer?

A

95% adenocarcinoma

most commonly in rectum 35% then sigmoid 25%

200
Q

You are a new Foundation Year 1 (FY1) doctor working on a colorectal surgery ward and notice many patients are having post-operative analgesia given via an epidural.

What is the main benefit of this form of analgesia compared to alternative forms?

A

faster return of normal bowel function

201
Q

presentation of colon cancer?

A

altered bowel habit

PR bleeding/ mucus

tenesmus

PR mass

obstruction

right sized mass: anaemia, weight loss

202
Q

examination of colon cancer?

A

abdo exam: palpable mass/ hepatomegaly/ signs of obstruction

PR exam: mass, perianal fistulae

203
Q

What tumour marker is most assoc w colorectal ca?

A

CEA

carcinoembryonic antigen

204
Q

what imaging is required in pt diagnosed w colorectal ca?

A

CT chest abdo pelvis for complete staging

Entire colon should be evaluated w colonoscopy or CT colonography

those w tumours pelow the peritoneal reflection should have their mesorectum evaluated w MRI

205
Q

ix for suspected colorectal ca?

A

Bloods:
FBC- Hb

LFTs- Liver mets

Tumour marker - CEA

Imaging: CXR, US liver- mets

CT and MRI- staging

Ba/ gastrograffin enema - apple core lesion

endoscopy + biopsy: flexi sig/ colonosocopy

206
Q

staging of Colon cancer?

A

Dukes criteria

A: confined to bowel wall

B: through bowel wall but no LNs

C: regional LNs

D: distant mets

207
Q

TNM staging of colon cancer?

A

TIS: carcinoma in situ

T1: submucosa

T2: muscularis propria

T3: subserosa

T4: through the serosa to adjacent organs

N1: 1-3 nodes

N2: >4 nodes

Grading: low to high based on cell morphology. dysplasia, mitotic index, hyperchromatism

208
Q

Mx of colon cancer?

A

MDT

surgical resection of cancer - tailored to tumour location

-> + resection of supplying lymphatic chains (which follows arterial supply)

or palliation: stents, surgical bypass, diversion stomas

then chemotx

209
Q

prior to surgery for colon ca- what advice?

A

preop bowel prep (except R sided lesions)

e. g. Kleen Prep (Macrogol: osmotic laxative) the day before and phosphate enema in the AM
consent: discuss stomas

stoma nurse consult for siting

210
Q

what is required for anastomosis to heal?

A

adequate blood supply

mucosal apposition

no tissue tension

surrounding sepsis, unstable pts and inexperienced surgeons may compromise these key principles -> may be safer to construct end stoma rather than attempting an anastomosis

211
Q

Mx of Rectal Cancer?

A

MDT

Surgeries: Anterior resection or APR (Abdomino-perineal excision of rectum)

+ total mesorectal excision (meticulous dissection of mesorectal fat and LNs) for tumours of the middle and lower third

Neo-adjuvant radio therapy to decrease local recurrence

212
Q

w rectal ca, when do you decide to anterior resection vs Abdominoperineal excision of the rectum?

A

APR:

involvement of the sphincter complex or v low tumours (ie. <4 cm from anal verge)

213
Q

What type of resection and anastomosis is required for cancer in caecum, ascending or proximal transverse colon?

A

Right hemicolectomy w ileocolic anastomosis

214
Q

what type of resection and anastomosis is required for cancer in distal transverse and descending colon?

A

Left hemicolectomy w colo-colon anastomosis

215
Q

what type of resection and anastomosis is required if cancer is in the sigmoid colon?

A

high anterior resection w colo-rectal anastomosis

216
Q

what type of resection and anastomosis is required in cancer in the upper rectum?

A

anterior resection with total mesorectal excision

and a colo-rectal anastomosis

217
Q

what type of resection and anastomosis is required in pt w cancer in low rectum?

A

anterior resection with low total mesorectal excision

and a colorectal anastomosis +/- defunctioning stoma

218
Q

what type of resection and anastomosis is recommended for pt w ca in anal verge?

A

abdominoperineal excision of rectum

no anastomosis

219
Q

is anastomosis of colon done in the emergency setting?

A

no

in emergency setting e.g. when bowel has perforated the risk of anastomosis is much greater, particularly when anastomosis is colon-colon

end colostomy safer and can be reversed later

resection of sigmoid colon+ end colostomy = Hartmanns procedure

220
Q

what screening is available for colorectal cancer?

A

60-75 yrs

home faecal occult blood testing every 2 yrs (2% false positive)

colonoscopy if FOB +ve

221
Q

what is familial adenomatous polyposis?

A

autosomal dominant

APC gene on 5q21

100-1000s of adenomas by 16 yrs

  • mainly in large bowel
  • also affects stomach and duodenum

100% develop colorectal cancer

222
Q

what is attenuated FAP?

A

<100 adenomas

Colorectal ca later in life (>50 yrs)

223
Q

What is Gardener’s syndrome?

A

subtype of FAP

will lead to colorectal cancer

also TODE

Thyroid tumours

Osteomas of the mandible, skull and long bones

Dental abnormalities: supernumerary teeth

epidermal cysts

224
Q

what is Turcot’s syndrome?

A

assoc w FAP/ HNPCC

characterised by multiple adenomatous colon polyps

+ CNS tumours: medullo and glioblastomas

225
Q

mx of Familial adenomatous polyposis?

A

prophylactic colectomy before 20 yrs

total colectomy + ileorectal anastomosis

-> requires life long stump surveillance

proctocolectomy + ileal pouch-anal anastomosis

risk of ca in stomach and duodenum remain -> regular endoscopic screening

226
Q

What is hereditary non polyposis colorectal cancer?

A

autosomal dominant

commonest cause of hereditary colorectal cancers

assoc with gastric, endometrial, prostate, breast, ovarian ca

227
Q

dx of HNPCC?

A

321 rule

≥3 family members over 2 generations w one < 50 yrs

228
Q

in patients w fulminant UC, why is the rectum not taken out during emergency surgery?

A

subtotal colectomy is safest tx option

rectum is left in situ as resection of the rectum in these acutely unwell patients carries an extremely high risk of complications

-> if bowel is v oedematous, may be brought to surface as mucous fistula

229
Q

mx of severe perianal and or rectal crohns?

A

proctectomy

  • ileoanal pouch reconstruction in crohns carries a high risk of fistula formation and pouch failure and is not recommended
230
Q

what is Peutz Jeghers syndrome?

A

autosomal dominant

mucocutaneous hyperpigmentation - on palms, buccal mucosa

multiple GI hamartomatous polyps

-> increased risk of haemorrhage, intussusception

increased ca risk of colorectal ca, pancreas, breast, lung, ovaries, uterus

231
Q

causes of acute mesenteric ischaemia?

A

arterial: thrombotic (35%), embolic (35%)

non occlusive: splanchnic vasoconstriction secondary to shock

venous thrombosis

trauma, strangulation, vasculitis

232
Q

presentation of mesenteric ischaemia?

A

nearly always small bowel

triad:

  1. acute severe abdo pain +/- PR bleed
  2. rapid hypovolaemia -> shock
  3. no abdo signs

degree of illness >> clinical signs

may be in AF

233
Q

ix of mesenteric ischaemia?

A

bloods:

high Hb: plasma loss

high WCC

high amylase

persistent metabolic acidosis: raised lactate

imaging:

AXR- gasless abdo

arteriography/ CT/MRI angio

234
Q

complications of mesenteric ischaemia?

A

septic peritonitis

SIRS

235
Q

mx of mesenteric ischaemia?

A

fluids

abx: gent + met

LMWH

laparotomy: resect necrotic bowel

236
Q

ileostomy vs colostomy stoma?

A

small bowel stomas should be spouted so that their irritant contents are not in contact with the skin

usually more high output than colonic stomas

colonic stomas: flat

237
Q

cause of chronic small bowel ischaemia?

A

atheroma + low flow state e.g. LVF

238
Q

features of chronic small bowel ischaemia?

A

severe, colicky post prandial abdo pain

‘gut claudication’

PR bleeding

malabsorption

weight loss

239
Q

what is a mucous fistula?

A

To decompress a distal segment of bowel following colonic division or resection

Where closure of a distal resection margin is not safe or achievable

240
Q

mx of chronic small bowel ischaemia?

A

angioplasty

241
Q

features of chronic large bowel ischaemia?

A

lower, left sided abdo pain

bloody diarrhoea

pyrexia

tachycardia

242
Q

ix of chronic large bowel ischaemia?

A

raised WCC

barium enema: thumb printing

MR angiography

243
Q

complications of chronic large bowel ischaemia?

A

may -> peritonitis and septic shock

strictures in the long term

244
Q

mx of chronic large bowel ischaemia?

A

usually conservative: fluids, abx

angioplasty and endovascular stenting

245
Q

causes of lower GI bleed?

A

rectal: haemorrhoids, fissure

diverticulitis

neoplasm

inflammation: IBD

infection

polyps

large upper GI bleed

angio: dysplasia, ischaemic colitis, HHT

246
Q

1st line ix for lower GI bleed?

A

1st: rigid proctoscopy/ sigmoidoscopy
2nd: OGD

247
Q

mx of lower GI bleed?

A

resus

abx: if evidence of sepsis or perf

PPI: if upper GI bleed possible

keep bed bound

stool chart

diet: keep on clear fluids
surgery: only if unremitting, massive bleed

248
Q

role of CEA in colorectal ca?

A

used to monitor for recurrence in patients post-operatively or to assess response to treatment in patients with metastatic disease

249
Q

most common type of anal ca?

A

80% are SCC

250
Q
A
251
Q

ix of angiodysplasia?

A

exclude other dx:

PR exam, barium enema, colonoscopy

mesenteric angiography or CT angio

Tc labelled RBC scan: identify active bleeding

252
Q

mx of angiodysplasia?

A

embolisation

endoscopic laser electrocoagulation

resection

253
Q
A

Surgery (17 decks)

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