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Y4 Gen Surg > Lower GI surgery > Flashcards

Lower GI surgery Flashcards

1
Q

what is the treatment of meckels diverticulum ?

A

surgical resection

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2
Q

state some causes of intussusception?

A 
Hypertrophied Peyer’s patch
􏰀 Meckel’s
􏰀 HSP
􏰀 Peutz-Jeghers
􏰀 Lymphoma
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3
Q

what cell does carcinoid tumours originate from?

A

enterochromaffin cells

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4
Q

what can carcinoid tumours secrete ?

A 
5HT (serotonin)
VIP ( vasoactive intestinal peptide)
gastrin 
glucagon 
insulin 
ACTH
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5
Q

is carcinoid tumours strongly or weakly associated with metastatic disease?

A

strongly associated

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6
Q

what common sites does carcinoid tumours occur?

A

appendix 45%
ileum 30%
colorectal 20%
stomach 10%

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7
Q

what is the presentation of carcinoid syndrome? FIVE HT

A

flushing - paroxysmal
intestinal - diarrhoea
valve fibrosis - tricuspid regurg + pulmonary stenosis
whEEze - bronchoconstrictor
hepatic involvement - bypassed 1st metabolism
tryptophan deficiency - pellagra

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8
Q

what is pellagra disease? 3Ds

A

disease characterised by diarrhoea, dermatitis and dementia as a result of niacin (vitamin B-3) deficiency.

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9
Q

what would be increased in urine and plasma with carcinoid tumours?

A

↑ urine 5-hydroxyindoleacetic acid

􏰀 ↑ plasma chromogranin A

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10
Q

what colour are carcinoid tumours?

A

very yellow

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11
Q

what medication can be given for carcinoid tumours?

A

octreotide (somatostatin analogue)

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12
Q

what is a carcinoid crisis ?

A

Tumour outgrows blood supply or is handled too much → massive mediator release
􏰀 Vasodilatation, hypotension, bronchoconstriction, hyperglycaemia

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13
Q

what is the treatment for carcinoid crisis ?

A

high dose octreotide

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14
Q

what is whipples procedure used for?

A

pancreatic cancers

carcinoid tumours

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15
Q

state some common causes of acute appendicitis ?

A 
obstruction from (faecolith, lymphoid hyperplasia, tumour) 
gut organisms
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16
Q

what dermatome might pain from acute appendicitis be referred?

A

T10/11

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17
Q

where will be the maximum pain with acute appendicitis ?

A

McBurney’s point

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18
Q

what is Psoas Sign?

A

Pain on extending the hip: retrocaecal appendix

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19
Q

what is cope sign?

A

flexion and internal rotation of R hip pain

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20
Q

what is Rovsing’s Sign?

A

Pressure in LIF → more pain in RIF

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21
Q

what are some DD of acute appendicitis ?

A

􏰁surgical
Cholecystitis
􏰁 Diverticulitis
􏰁 Meckel’s diverticulitis

􏰀 Gynae
􏰁 Cyst accident: torsion, rupture, haemorrhage 􏰁 Salpingitis / PID
􏰁 Ruptured ectopic

􏰀 Medical
􏰁 Mesenteric adenitis
􏰁 UTI
􏰁 Crohn’s

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22
Q

what bloods should be done for acute appendicitis ?

A

FBC, CRP, amylase, group and save, clotting

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23
Q

what substance could be found in urine of acute appendicitis >

A

B HCG

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24
Q

what antibiotics should be given for acute appendicitis ?

A

cef 1.5g + met 500g IV TDS

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25
Q

what are three complications of UC?

A

toxic megacolon
bleeding
malignancy

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26
Q

what bloods should be done for UC?

A

FBC: ↓Hb, ↑WCC 􏰁 LFT: ↓albumin
􏰁 ↑CRP/ESR
􏰁 Blood cultures

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27
Q

what is the treatment for acute UC?

A

IV fluids, NMB
hydrocortisone
LMWH
Monitor

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28
Q

if on the 3rd day of severe acute UC the pt isn’t improving what most likely needs to be done?

A

colectomy

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29
Q

what is the 1st and 2nd line inducing remission treatment for UC?

A 
1 = 5ASAs
2 = prednisolone
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30
Q

what is the 1st, 2nd and 3rd line maintaining remission treatment for UC?

A 
1 = 5ASAs (sulfasalizine) 
2 = Azathioprine 
3 = infliximab
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31
Q

state 4 indications for emergency surgery for UC?

A

Toxic megacolon
􏰀 Perforation
􏰀 Massive haemorrhage
􏰀 Failure to respond to medical Rx

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32
Q

what 4 signs can be seen in crohns small bowel follow through?

A

skip lesions
rose thorn ulcers
cobblestoning
string sign of kantor

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33
Q

what is string sign of Kantor?

A

narrow terminal ileum

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34
Q

what is the management of a acute attack of crohns?

A 
IV fluids 
NMB
Hydrocortisone: IV + PR if rectal disease
􏰀Abx: metronidazole PO or IV
􏰀Thromboprophylaxis: LMWH
dietician review
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35
Q

what is the main difference between UC and crohns acute attack management ?

A

crohns gets antibiotics

- metronidazole

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36
Q

what are some IBD surgical complications ?

A

small bowel obstruction
anastomotic stricture
stoma (retraction, stenosis, prolapse, dermatitis)
pouchitis

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37
Q

how should perianal disease in crohns be treated?

A

metronidazole
immunosuppression
local surgery

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38
Q

what treatment is used for inducing remission in crohns?

A 
1st line
􏰁 Ileocaecal: budesonide
􏰁 Colitis: sulfasalazine
􏰀 2nd line: prednisolone (tapering)
􏰀 3rd line: methotrexate
􏰀 4th line: infliximab or adalimumab
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39
Q

what treatment is used for maintaining remission in crohns?

A

1st line: azathioprine or mercaptopurine 􏰀 2nd line: methotrexate
􏰀 3rd line: Infliximab / adalimumab

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40
Q

state 4 features of small gut syndrome?

A

Steatorrhoea

􏰁 ADEK and B12 malabsorption

􏰁 Bile acid depletion → gallstones 􏰁

Hyperoxaluria → renal stones

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41
Q

what is diverticular disease?

A

out-pouching of tubular structure

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42
Q

is meckels diverticulum a true diverticulum ?

A

yes

- composed of complete wall

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43
Q

is pharyngeal pouch a true diverticulum ?

A

no

- composed of mucosa only

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44
Q

what gender is more affected by diverticular disease?

A

females

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45
Q

what are the symptoms of diverticular disease?

A

alerted bowel habit
nausea
flatulence

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46
Q

what are risk factors for diverticular disease?

A

low fibre diet
increased intraluminal pressure
constipation
obesity

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47
Q

at what points of the lumen wall do mucosa herniate through the muscularis propria?

A

where perforating arteries pass through

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48
Q

where abouts in the bowel does diverticular disease commonly affect?

A

sigmoid colon

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49
Q

what bloods should be done for diverticulitis ?

A

FBC: ↑WCC 􏰁
↑CRP/ESR
􏰁 Amylase
􏰁 G+S/x-match

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50
Q

what imaging should be done for diverticulitis?

A

Erect CXR: look for perforation
􏰁 AXR: fluid level / air in bowel wall 􏰁
Contrast CT
􏰁 Gastrograffin enema

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51
Q

can mild attacks of diverticulitis be treated at home?

A

yes
- with fluids only and rest
and augmentin

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52
Q

what is the medical treatment of diverticulitis?

A

NBM
􏰁 IV fluids
􏰁 Analgesia
􏰁 Antibiotics: cefuroxime + metronidazole

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53
Q

what are three indication of surgery for diverticulitis ?

A

Perforation
􏰂 Large haemorrhage
􏰂 Stricture → obstruction

54
Q

what does augmentin contain?

A

amoxicillin clavulanate

55
Q

what is Hartmanns procedure?

A

right proctosigmoidectomy

56
Q

what will a CXR show for perforation?

A

free air under diaphragm

57
Q

what investigation should be done for a colon haemorrhage ?

A

mesenteric angiography

58
Q

what is simple bowel obstruction?

A

1 obstructing point + no vascular compromise

59
Q

what is closed loop bowel obstruction?

A

Bowel obstructed @ two points

60
Q

what is strangulated bowel obstruction?

A

compromised blood supply

61
Q

what could cause closed loop bowel obstruction?

A

Volvulus - loop of intestine twists around itself and the mesentery that supports it

62
Q

what is the presentation of strangulated bowel obstruction?

A

localised constant pain
peritonism
fever and increased WCC

63
Q

what is the commonest cause of SBO?

64
Q

what are the common causes of LBO?

A

colorectal neoplasia
diverticular stricture
volvulus

65
Q

state some mechanical and non mechanical causes of bowel obstruction ?

A

non mechanical
- paralytic ileus

mechanical

  • intussusception
  • gallstones
  • benign stricture
  • neoplasia
  • congenital atresia
  • hernia
  • extrinsic compression
66
Q

what could cause paralytic ileus?

A 
post op 
peritonitis 
anti AChM drugs 
metabolic - decreased K, Na, Mg, uraemia 
mesenteric ischaemia
67
Q

what is the presentation of bowel obstruction?

A

abdo pain - colicky
distension
vomiting
absolute constipation

68
Q

what is ileus?

A

lack of movement somewhere in the intestines

69
Q

are bowel sounds present with ileus?

70
Q

what blood tests should be taken for bowel obstruction?

A

FBC, U&E, amylase, VBG, G&S

71
Q

what would amylase show in bowel obstruction ?

A

very high if perforation or strangulation

72
Q

what does drip and suck mean?

A

NBM

􏰀 IV fluids: aggressive as pt. may be v. dehydrated

􏰀 NGT: decompress upper GIT, stops vomiting, prevents
aspiration 􏰀 􏰀

Catheterise: monitor UO

73
Q

state 4 indications for surgical treatment for bowel obstruction?

A

Closed loop obstruction
Obstructing neoplasm
Strangulation / perforation → sepsis, peritonitis Failure of conservative Mx (up to 72h)

74
Q

what must patients be consented for with surgical procedures for bowel obstruction?

A

possible resection and stoma

75
Q

patients with SBO or LBO are most likely to need surgery?

A

LBO more likely for surgery

76
Q

what is the most common volvulus?

A

sigmoid volvulus

77
Q

what patients are at higher risk of sigmoid volvulus?

A

neuropsych puts (MS, PD, psychiatric)
males
elderly
Hx of constipiation

78
Q

what is the characteristic sign of sigmoid volvulus on AXR?

A

inverted U (coffee bean) sign

79
Q

what is the management of sigmoid volvulus?

A

Often relieved by sigmoidoscopy and flatus tube insertion

sigmoid colectomy

80
Q

what is caecal volvulus associated with?

A

congenital malformations

81
Q

what is the treatment for caecal volvulus?

A

caecostomy

82
Q

what are three features of gastric volvulus?

A

Vomiting → retching ̄c regurgitation of saliva

􏰀 Pain

􏰀 Failed attempts to pass an NGT

83
Q

what are risk factors for gastric vulvulus?

A

Congenital
􏰁 Bands
􏰁 Rolling / Paraoesophageal hernia 􏰁 Pyloric stenosis
􏰀 Acquired
􏰁 Gastric / oesophageal surgery 􏰁 Adhesions

84
Q

does paralytic ileus usually result in SBO or LBO

85
Q

what is colonic pseudo obstruction?

A

Clinical signs of mechanical obstruction but no obstructing lesion found

86
Q

what is the cause of colonic pseudo obstruction?

87
Q

what is colonic pseudo obstruction associated with?

A

elderly
CVS disorders
pelvic surgery
trauma

88
Q

what investigation has to be done for colonic pseudo obstruction to exclude mechanical causes of obstruction?

A

gastrograffin enema

89
Q

what is the management of colonic pseudo obstruction?

A

neostigmine (anti AChase)

colonoscopic decompression

90
Q

what are the three types of colonic adenomas?

A

tubular
vilious
tubulovillious

91
Q

what is the presentation of left sided CRC?

A 
􏰀 Altered bowel habit
􏰀 PR mass (60%)
􏰀 Obstruction (25%)
􏰀 Bleeding / mucus PR
􏰀 Tenesmus
92
Q

what is the presentation of right sided CRC?

A

Anaemia
􏰀 Wt. loss
􏰀 Abdominal pain

93
Q

what metabolic changes can vilious adenomas result in?

A

↓K + hypoproteinaemia

94
Q

what shape do vilious adenomas have?

A

large, sessile, covered by villi

95
Q

what shape do tubular adenomas have?

A

small, pedunculated, tubular glands

96
Q

what does APC negatively regulate?

97
Q

what pathway is B catenin part of?

A

WNT pathway

98
Q

what proto oncogene is involved with CRC?

99
Q

what tumour supressor genes are involved with CRC?

100
Q

what medication is thought to be protective from CRC?

101
Q

what three familial conditions are associated with CRC?

A

FAP
HNPCC
Peutz-Jeghers

102
Q

where does CRC most commonly occur?

103
Q

what tumour marker is present in CRC?!?!

A

CEA (carcinoembryonic Ag)

104
Q

what sign will barium enema show for CRC?

A

apple core lesion

105
Q

what staging criteria does CRC have?

106
Q

what is the ERAS pathway?

A

Enhanced recovery after surgery

107
Q

what surgical procedure is used for obstruction?

108
Q

what does excision of CRC depend on ?

A

Excision depends on lymphatic drainage which follows arterial supply.

109
Q

what adjuvant chemo can be used for Dukes C pts?

A

5FU (Fluorouracil)

110
Q

what screening is available for CRC screening?

A

FOB testing

- faecal occult blood

111
Q

what age is FOB testing available ?

A

60yrs - 75yrs

112
Q

as well as FOB testing what other screening tool is available ?

A

flexible sigmoidoscopy

- one time only

113
Q

what mutation causes of FAP?

A

APC gene on 5q21

114
Q

what does FAP stand for?

A

Familial Adenomatous Polyposis

115
Q

what are the four features of gardeners

A

Thyroid tumours

􏰁 Osteomas of the mandible, skull and long bones 􏰁

Dental abnormalities: supernumerary teeth

􏰁 Epidermal cysts

116
Q

what surgery can be done for FAP?

A

Prophylactic colectomy before 20yrs

117
Q

what do FAP pts have a higher risk of?

A

Remain @ risk of Ca in stomach and duodenum

118
Q

what mutation causes HNPCC?

A

Mutation of mismatch repair enzymes

􏰁 E.g. MSH2 on Chr 2p

119
Q

where does HNPCC type 1 usually occur?

A

Lynch 1: right sided CRC

120
Q

where does HNPCC type 2 usually occur?

A

Lynch 2: CRC + gastric, endometrial, prostate, breast

121
Q

what mutation causes Peutz jeghers syndrome?

A

STK11 mutation

122
Q

what are two features of Peutz jeghers syndrome?

A

Mucocutaneous hyper pigmentation

Multiple GI hamartomatous polyps

123
Q

what cancer is peutz jeghers syndrome at increased risk of?

A

CRC, pancreas, breast, lung oversee, uterus

124
Q

are hyper plastic polyps pre malignant?

125
Q

what do hyerplastic polyps look like?

A

Serrated surface architecture

126
Q

what conditions have Hamartomatous polyps in the colon?

A

Juvenille polyposis

cowden syndrome

127
Q

during mesenteric ischeamia, what are the levels of Hb, WCC, amylase, lactate?

A

↑Hb: plasma loss
􏰁 ↑WCC
􏰁 ↑ amylase
􏰁 Persistent metabolic acidosis: ↑lactate

128
Q

what is a complication of mesenteric ischaemia?

A

Septic peritonitis

129
Q

what is the management of mesentric ischaemia?

A

Fluids
􏰀 Abx: gent + met
􏰀 LMWH
􏰀 Laparotomy: resect necrotic bowel

130
Q

what causes chronic small bowel ischaemia?

A

atheroma + low flow state (e.g. LVF)

131
Q

what is the treatment for chronic small bowel ischaemia ?

A

angioplasty

132
Q

what are three important causes of lower GI bleeds?

A

Rectal: haemorrhoids, fissure 􏰀 Diverticulitis

􏰀 Neoplasm

Y4 Gen Surg (7 decks)

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