Lower GI surgery Flashcards
what is the treatment of meckels diverticulum ?
surgical resection
state some causes of intussusception?
Hypertrophied Peyer’s patch Meckel’s HSP Peutz-Jeghers Lymphoma
what cell does carcinoid tumours originate from?
enterochromaffin cells
what can carcinoid tumours secrete ?
5HT (serotonin) VIP ( vasoactive intestinal peptide) gastrin glucagon insulin ACTH
is carcinoid tumours strongly or weakly associated with metastatic disease?
strongly associated
what common sites does carcinoid tumours occur?
appendix 45%
ileum 30%
colorectal 20%
stomach 10%
what is the presentation of carcinoid syndrome? FIVE HT
flushing - paroxysmal
intestinal - diarrhoea
valve fibrosis - tricuspid regurg + pulmonary stenosis
whEEze - bronchoconstrictor
hepatic involvement - bypassed 1st metabolism
tryptophan deficiency - pellagra
what is pellagra disease? 3Ds
disease characterised by diarrhoea, dermatitis and dementia as a result of niacin (vitamin B-3) deficiency.
what would be increased in urine and plasma with carcinoid tumours?
↑ urine 5-hydroxyindoleacetic acid
↑ plasma chromogranin A
what colour are carcinoid tumours?
very yellow
what medication can be given for carcinoid tumours?
octreotide (somatostatin analogue)
what is a carcinoid crisis ?
Tumour outgrows blood supply or is handled too much → massive mediator release
Vasodilatation, hypotension, bronchoconstriction, hyperglycaemia
what is the treatment for carcinoid crisis ?
high dose octreotide
what is whipples procedure used for?
pancreatic cancers
carcinoid tumours
state some common causes of acute appendicitis ?
obstruction from (faecolith, lymphoid hyperplasia, tumour) gut organisms
what dermatome might pain from acute appendicitis be referred?
T10/11
where will be the maximum pain with acute appendicitis ?
McBurney’s point
what is Psoas Sign?
Pain on extending the hip: retrocaecal appendix
what is cope sign?
flexion and internal rotation of R hip pain
what is Rovsing’s Sign?
Pressure in LIF → more pain in RIF
what are some DD of acute appendicitis ?
surgical
Cholecystitis
Diverticulitis
Meckel’s diverticulitis
Gynae
Cyst accident: torsion, rupture, haemorrhage Salpingitis / PID
Ruptured ectopic
Medical
Mesenteric adenitis
UTI
Crohn’s
what bloods should be done for acute appendicitis ?
FBC, CRP, amylase, group and save, clotting
what substance could be found in urine of acute appendicitis >
B HCG
what antibiotics should be given for acute appendicitis ?
cef 1.5g + met 500g IV TDS
what are three complications of UC?
toxic megacolon
bleeding
malignancy
what bloods should be done for UC?
FBC: ↓Hb, ↑WCC LFT: ↓albumin
↑CRP/ESR
Blood cultures
what is the treatment for acute UC?
IV fluids, NMB
hydrocortisone
LMWH
Monitor
if on the 3rd day of severe acute UC the pt isn’t improving what most likely needs to be done?
colectomy
what is the 1st and 2nd line inducing remission treatment for UC?
1 = 5ASAs 2 = prednisolone
what is the 1st, 2nd and 3rd line maintaining remission treatment for UC?
1 = 5ASAs (sulfasalizine) 2 = Azathioprine 3 = infliximab
state 4 indications for emergency surgery for UC?
Toxic megacolon
Perforation
Massive haemorrhage
Failure to respond to medical Rx
what 4 signs can be seen in crohns small bowel follow through?
skip lesions
rose thorn ulcers
cobblestoning
string sign of kantor
what is string sign of Kantor?
narrow terminal ileum
what is the management of a acute attack of crohns?
IV fluids NMB Hydrocortisone: IV + PR if rectal disease Abx: metronidazole PO or IV Thromboprophylaxis: LMWH dietician review
what is the main difference between UC and crohns acute attack management ?
crohns gets antibiotics
- metronidazole
what are some IBD surgical complications ?
small bowel obstruction
anastomotic stricture
stoma (retraction, stenosis, prolapse, dermatitis)
pouchitis
how should perianal disease in crohns be treated?
metronidazole
immunosuppression
local surgery
what treatment is used for inducing remission in crohns?
1st line Ileocaecal: budesonide Colitis: sulfasalazine 2nd line: prednisolone (tapering) 3rd line: methotrexate 4th line: infliximab or adalimumab
what treatment is used for maintaining remission in crohns?
1st line: azathioprine or mercaptopurine 2nd line: methotrexate
3rd line: Infliximab / adalimumab
state 4 features of small gut syndrome?
Steatorrhoea
ADEK and B12 malabsorption
Bile acid depletion → gallstones
Hyperoxaluria → renal stones
what is diverticular disease?
out-pouching of tubular structure
is meckels diverticulum a true diverticulum ?
yes
- composed of complete wall
is pharyngeal pouch a true diverticulum ?
no
- composed of mucosa only
what gender is more affected by diverticular disease?
females
what are the symptoms of diverticular disease?
alerted bowel habit
nausea
flatulence
what are risk factors for diverticular disease?
low fibre diet
increased intraluminal pressure
constipation
obesity
at what points of the lumen wall do mucosa herniate through the muscularis propria?
where perforating arteries pass through
where abouts in the bowel does diverticular disease commonly affect?
sigmoid colon
what bloods should be done for diverticulitis ?
FBC: ↑WCC
↑CRP/ESR
Amylase
G+S/x-match
what imaging should be done for diverticulitis?
Erect CXR: look for perforation
AXR: fluid level / air in bowel wall
Contrast CT
Gastrograffin enema
can mild attacks of diverticulitis be treated at home?
yes
- with fluids only and rest
and augmentin
what is the medical treatment of diverticulitis?
NBM
IV fluids
Analgesia
Antibiotics: cefuroxime + metronidazole
what are three indication of surgery for diverticulitis ?
Perforation
Large haemorrhage
Stricture → obstruction
what does augmentin contain?
amoxicillin clavulanate
what is Hartmanns procedure?
right proctosigmoidectomy
what will a CXR show for perforation?
free air under diaphragm
what investigation should be done for a colon haemorrhage ?
mesenteric angiography
what is simple bowel obstruction?
1 obstructing point + no vascular compromise
what is closed loop bowel obstruction?
Bowel obstructed @ two points
what is strangulated bowel obstruction?
compromised blood supply
what could cause closed loop bowel obstruction?
Volvulus - loop of intestine twists around itself and the mesentery that supports it
what is the presentation of strangulated bowel obstruction?
localised constant pain
peritonism
fever and increased WCC
what is the commonest cause of SBO?
adhesions
what are the common causes of LBO?
colorectal neoplasia
diverticular stricture
volvulus
state some mechanical and non mechanical causes of bowel obstruction ?
non mechanical
- paralytic ileus
mechanical
- intussusception
- gallstones
- benign stricture
- neoplasia
- congenital atresia
- hernia
- extrinsic compression
what could cause paralytic ileus?
post op peritonitis anti AChM drugs metabolic - decreased K, Na, Mg, uraemia mesenteric ischaemia
what is the presentation of bowel obstruction?
abdo pain - colicky
distension
vomiting
absolute constipation
what is ileus?
lack of movement somewhere in the intestines
are bowel sounds present with ileus?
no
what blood tests should be taken for bowel obstruction?
FBC, U&E, amylase, VBG, G&S
what would amylase show in bowel obstruction ?
very high if perforation or strangulation
what does drip and suck mean?
NBM
IV fluids: aggressive as pt. may be v. dehydrated
NGT: decompress upper GIT, stops vomiting, prevents
aspiration
Catheterise: monitor UO
state 4 indications for surgical treatment for bowel obstruction?
Closed loop obstruction
Obstructing neoplasm
Strangulation / perforation → sepsis, peritonitis Failure of conservative Mx (up to 72h)
what must patients be consented for with surgical procedures for bowel obstruction?
possible resection and stoma
patients with SBO or LBO are most likely to need surgery?
LBO more likely for surgery
what is the most common volvulus?
sigmoid volvulus
what patients are at higher risk of sigmoid volvulus?
neuropsych puts (MS, PD, psychiatric)
males
elderly
Hx of constipiation
what is the characteristic sign of sigmoid volvulus on AXR?
inverted U (coffee bean) sign
what is the management of sigmoid volvulus?
Often relieved by sigmoidoscopy and flatus tube insertion
sigmoid colectomy
what is caecal volvulus associated with?
congenital malformations
what is the treatment for caecal volvulus?
caecostomy
what are three features of gastric volvulus?
Vomiting → retching ̄c regurgitation of saliva
Pain
Failed attempts to pass an NGT
what are risk factors for gastric vulvulus?
Congenital
Bands
Rolling / Paraoesophageal hernia Pyloric stenosis
Acquired
Gastric / oesophageal surgery Adhesions
does paralytic ileus usually result in SBO or LBO
SBO
what is colonic pseudo obstruction?
Clinical signs of mechanical obstruction but no obstructing lesion found
what is the cause of colonic pseudo obstruction?
unknown
what is colonic pseudo obstruction associated with?
elderly
CVS disorders
pelvic surgery
trauma
what investigation has to be done for colonic pseudo obstruction to exclude mechanical causes of obstruction?
gastrograffin enema
what is the management of colonic pseudo obstruction?
neostigmine (anti AChase)
colonoscopic decompression
what are the three types of colonic adenomas?
tubular
vilious
tubulovillious
what is the presentation of left sided CRC?
Altered bowel habit PR mass (60%) Obstruction (25%) Bleeding / mucus PR Tenesmus
what is the presentation of right sided CRC?
Anaemia
Wt. loss
Abdominal pain
what metabolic changes can vilious adenomas result in?
↓K + hypoproteinaemia
what shape do vilious adenomas have?
large, sessile, covered by villi
what shape do tubular adenomas have?
small, pedunculated, tubular glands
what does APC negatively regulate?
B catenin
what pathway is B catenin part of?
WNT pathway
what proto oncogene is involved with CRC?
KRAS
what tumour supressor genes are involved with CRC?
APC
p53
what medication is thought to be protective from CRC?
aspirin
what three familial conditions are associated with CRC?
FAP
HNPCC
Peutz-Jeghers
where does CRC most commonly occur?
rectum
what tumour marker is present in CRC?!?!
CEA (carcinoembryonic Ag)
what sign will barium enema show for CRC?
apple core lesion
what staging criteria does CRC have?
Dukes
what is the ERAS pathway?
Enhanced recovery after surgery
what surgical procedure is used for obstruction?
Hartmanns
what does excision of CRC depend on ?
Excision depends on lymphatic drainage which follows arterial supply.
what adjuvant chemo can be used for Dukes C pts?
5FU (Fluorouracil)
what screening is available for CRC screening?
FOB testing
- faecal occult blood
what age is FOB testing available ?
60yrs - 75yrs
as well as FOB testing what other screening tool is available ?
flexible sigmoidoscopy
- one time only
what mutation causes of FAP?
APC gene on 5q21
what does FAP stand for?
Familial Adenomatous Polyposis
what are the four features of gardeners
Thyroid tumours
Osteomas of the mandible, skull and long bones
Dental abnormalities: supernumerary teeth
Epidermal cysts
what surgery can be done for FAP?
Prophylactic colectomy before 20yrs
what do FAP pts have a higher risk of?
Remain @ risk of Ca in stomach and duodenum
what mutation causes HNPCC?
Mutation of mismatch repair enzymes
E.g. MSH2 on Chr 2p
where does HNPCC type 1 usually occur?
Lynch 1: right sided CRC
where does HNPCC type 2 usually occur?
Lynch 2: CRC + gastric, endometrial, prostate, breast
what mutation causes Peutz jeghers syndrome?
STK11 mutation
what are two features of Peutz jeghers syndrome?
Mucocutaneous hyper pigmentation
Multiple GI hamartomatous polyps
what cancer is peutz jeghers syndrome at increased risk of?
CRC, pancreas, breast, lung oversee, uterus
are hyper plastic polyps pre malignant?
no
what do hyerplastic polyps look like?
Serrated surface architecture
what conditions have Hamartomatous polyps in the colon?
Juvenille polyposis
cowden syndrome
during mesenteric ischeamia, what are the levels of Hb, WCC, amylase, lactate?
↑Hb: plasma loss
↑WCC
↑ amylase
Persistent metabolic acidosis: ↑lactate
what is a complication of mesenteric ischaemia?
Septic peritonitis
what is the management of mesentric ischaemia?
Fluids
Abx: gent + met
LMWH
Laparotomy: resect necrotic bowel
what causes chronic small bowel ischaemia?
atheroma + low flow state (e.g. LVF)
what is the treatment for chronic small bowel ischaemia ?
angioplasty
what are three important causes of lower GI bleeds?
Rectal: haemorrhoids, fissure Diverticulitis
Neoplasm