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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
what are three complications of UC?
toxic megacolon bleeding malignancy
26
what bloods should be done for UC?
FBC: ↓Hb, ↑WCC 􏰁 LFT: ↓albumin 􏰁 ↑CRP/ESR 􏰁 Blood cultures
27
what is the treatment for acute UC?
IV fluids, NMB hydrocortisone LMWH Monitor
28
if on the 3rd day of severe acute UC the pt isn't improving what most likely needs to be done?
colectomy
29
what is the 1st and 2nd line inducing remission treatment for UC?
``` 1 = 5ASAs 2 = prednisolone ```
30
what is the 1st, 2nd and 3rd line maintaining remission treatment for UC?
``` 1 = 5ASAs (sulfasalizine) 2 = Azathioprine 3 = infliximab ```
31
state 4 indications for emergency surgery for UC?
Toxic megacolon 􏰀 Perforation 􏰀 Massive haemorrhage 􏰀 Failure to respond to medical Rx
32
what 4 signs can be seen in crohns small bowel follow through?
skip lesions rose thorn ulcers cobblestoning string sign of kantor
33
what is string sign of Kantor?
narrow terminal ileum
34
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 ```
35
what is the main difference between UC and crohns acute attack management ?
crohns gets antibiotics | - metronidazole
36
what are some IBD surgical complications ?
small bowel obstruction anastomotic stricture stoma (retraction, stenosis, prolapse, dermatitis) pouchitis
37
how should perianal disease in crohns be treated?
metronidazole immunosuppression local surgery
38
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 ```
39
what treatment is used for maintaining remission in crohns?
1st line: azathioprine or mercaptopurine 􏰀 2nd line: methotrexate 􏰀 3rd line: Infliximab / adalimumab
40
state 4 features of small gut syndrome?
Steatorrhoea 􏰁 ADEK and B12 malabsorption 􏰁 Bile acid depletion → gallstones 􏰁 Hyperoxaluria → renal stones
41
what is diverticular disease?
out-pouching of tubular structure
42
is meckels diverticulum a true diverticulum ?
yes | - composed of complete wall
43
is pharyngeal pouch a true diverticulum ?
no | - composed of mucosa only
44
what gender is more affected by diverticular disease?
females
45
what are the symptoms of diverticular disease?
alerted bowel habit nausea flatulence
46
what are risk factors for diverticular disease?
low fibre diet increased intraluminal pressure constipation obesity
47
at what points of the lumen wall do mucosa herniate through the muscularis propria?
where perforating arteries pass through
48
where abouts in the bowel does diverticular disease commonly affect?
sigmoid colon
49
what bloods should be done for diverticulitis ?
FBC: ↑WCC 􏰁 ↑CRP/ESR 􏰁 Amylase 􏰁 G+S/x-match
50
what imaging should be done for diverticulitis?
Erect CXR: look for perforation 􏰁 AXR: fluid level / air in bowel wall 􏰁 Contrast CT 􏰁 Gastrograffin enema
51
can mild attacks of diverticulitis be treated at home?
yes - with fluids only and rest and augmentin
52
what is the medical treatment of diverticulitis?
NBM 􏰁 IV fluids 􏰁 Analgesia 􏰁 Antibiotics: cefuroxime + metronidazole
53
what are three indication of surgery for diverticulitis ?
Perforation 􏰂 Large haemorrhage 􏰂 Stricture → obstruction
54
what does augmentin contain?
amoxicillin clavulanate
55
what is Hartmanns procedure?
right proctosigmoidectomy
56
what will a CXR show for perforation?
free air under diaphragm
57
what investigation should be done for a colon haemorrhage ?
mesenteric angiography
58
what is simple bowel obstruction?
1 obstructing point + no vascular compromise
59
what is closed loop bowel obstruction?
Bowel obstructed @ two points
60
what is strangulated bowel obstruction?
compromised blood supply
61
what could cause closed loop bowel obstruction?
Volvulus - loop of intestine twists around itself and the mesentery that supports it
62
what is the presentation of strangulated bowel obstruction?
localised constant pain peritonism fever and increased WCC
63
what is the commonest cause of SBO?
adhesions
64
what are the common causes of LBO?
colorectal neoplasia diverticular stricture volvulus
65
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
66
what could cause paralytic ileus?
``` post op peritonitis anti AChM drugs metabolic - decreased K, Na, Mg, uraemia mesenteric ischaemia ```
67
what is the presentation of bowel obstruction?
abdo pain - colicky distension vomiting absolute constipation
68
what is ileus?
lack of movement somewhere in the intestines
69
are bowel sounds present with ileus?
no
70
what blood tests should be taken for bowel obstruction?
FBC, U&E, amylase, VBG, G&S
71
what would amylase show in bowel obstruction ?
very high if perforation or strangulation
72
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
73
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)
74
what must patients be consented for with surgical procedures for bowel obstruction?
possible resection and stoma
75
patients with SBO or LBO are most likely to need surgery?
LBO more likely for surgery
76
what is the most common volvulus?
sigmoid volvulus
77
what patients are at higher risk of sigmoid volvulus?
neuropsych puts (MS, PD, psychiatric) males elderly Hx of constipiation
78
what is the characteristic sign of sigmoid volvulus on AXR?
inverted U (coffee bean) sign
79
what is the management of sigmoid volvulus?
Often relieved by sigmoidoscopy and flatus tube insertion sigmoid colectomy
80
what is caecal volvulus associated with?
congenital malformations
81
what is the treatment for caecal volvulus?
caecostomy
82
what are three features of gastric volvulus?
Vomiting → retching ̄c regurgitation of saliva 􏰀 Pain 􏰀 Failed attempts to pass an NGT
83
what are risk factors for gastric vulvulus?
Congenital 􏰁 Bands 􏰁 Rolling / Paraoesophageal hernia 􏰁 Pyloric stenosis 􏰀 Acquired 􏰁 Gastric / oesophageal surgery 􏰁 Adhesions
84
does paralytic ileus usually result in SBO or LBO
SBO
85
what is colonic pseudo obstruction?
Clinical signs of mechanical obstruction but no obstructing lesion found
86
what is the cause of colonic pseudo obstruction?
unknown
87
what is colonic pseudo obstruction associated with?
elderly CVS disorders pelvic surgery trauma
88
what investigation has to be done for colonic pseudo obstruction to exclude mechanical causes of obstruction?
gastrograffin enema
89
what is the management of colonic pseudo obstruction?
neostigmine (anti AChase) colonoscopic decompression
90
what are the three types of colonic adenomas?
tubular vilious tubulovillious
91
what is the presentation of left sided CRC?
``` 􏰀 Altered bowel habit 􏰀 PR mass (60%) 􏰀 Obstruction (25%) 􏰀 Bleeding / mucus PR 􏰀 Tenesmus ```
92
what is the presentation of right sided CRC?
Anaemia 􏰀 Wt. loss 􏰀 Abdominal pain
93
what metabolic changes can vilious adenomas result in?
↓K + hypoproteinaemia
94
what shape do vilious adenomas have?
large, sessile, covered by villi
95
what shape do tubular adenomas have?
small, pedunculated, tubular glands
96
what does APC negatively regulate?
B catenin
97
what pathway is B catenin part of?
WNT pathway
98
what proto oncogene is involved with CRC?
KRAS
99
what tumour supressor genes are involved with CRC?
APC | p53
100
what medication is thought to be protective from CRC?
aspirin
101
what three familial conditions are associated with CRC?
FAP HNPCC Peutz-Jeghers
102
where does CRC most commonly occur?
rectum
103
what tumour marker is present in CRC?!?!
CEA (carcinoembryonic Ag)
104
what sign will barium enema show for CRC?
apple core lesion
105
what staging criteria does CRC have?
Dukes
106
what is the ERAS pathway?
Enhanced recovery after surgery
107
what surgical procedure is used for obstruction?
Hartmanns
108
what does excision of CRC depend on ?
Excision depends on lymphatic drainage which follows arterial supply.
109
what adjuvant chemo can be used for Dukes C pts?
5FU (Fluorouracil)
110
what screening is available for CRC screening?
FOB testing | - faecal occult blood
111
what age is FOB testing available ?
60yrs - 75yrs
112
as well as FOB testing what other screening tool is available ?
flexible sigmoidoscopy | - one time only
113
what mutation causes of FAP?
APC gene on 5q21
114
what does FAP stand for?
Familial Adenomatous Polyposis
115
what are the four features of gardeners
Thyroid tumours 􏰁 Osteomas of the mandible, skull and long bones 􏰁 Dental abnormalities: supernumerary teeth 􏰁 Epidermal cysts
116
what surgery can be done for FAP?
Prophylactic colectomy before 20yrs
117
what do FAP pts have a higher risk of?
Remain @ risk of Ca in stomach and duodenum
118
what mutation causes HNPCC?
Mutation of mismatch repair enzymes | 􏰁 E.g. MSH2 on Chr 2p
119
where does HNPCC type 1 usually occur?
Lynch 1: right sided CRC
120
where does HNPCC type 2 usually occur?
Lynch 2: CRC + gastric, endometrial, prostate, breast
121
what mutation causes Peutz jeghers syndrome?
STK11 mutation
122
what are two features of Peutz jeghers syndrome?
Mucocutaneous hyper pigmentation | Multiple GI hamartomatous polyps
123
what cancer is peutz jeghers syndrome at increased risk of?
CRC, pancreas, breast, lung oversee, uterus
124
are hyper plastic polyps pre malignant?
no
125
what do hyerplastic polyps look like?
Serrated surface architecture
126
what conditions have Hamartomatous polyps in the colon?
Juvenille polyposis | cowden syndrome
127
during mesenteric ischeamia, what are the levels of Hb, WCC, amylase, lactate?
↑Hb: plasma loss 􏰁 ↑WCC 􏰁 ↑ amylase 􏰁 Persistent metabolic acidosis: ↑lactate
128
what is a complication of mesenteric ischaemia?
Septic peritonitis
129
what is the management of mesentric ischaemia?
Fluids 􏰀 Abx: gent + met 􏰀 LMWH 􏰀 Laparotomy: resect necrotic bowel
130
what causes chronic small bowel ischaemia?
atheroma + low flow state (e.g. LVF)
131
what is the treatment for chronic small bowel ischaemia ?
angioplasty
132
what are three important causes of lower GI bleeds?
Rectal: haemorrhoids, fissure 􏰀 Diverticulitis | 􏰀 Neoplasm

Y4 Gen Surg (7 decks)

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