Lower GI Surgery Flashcards
What are the small bowel benign neoplasms?
- Lipoma
- Leiomyoma
- Neurofibroma
- Haemangioma
- Adenomatous polyp (FAP, Peutz-Jegher)
What are the small bowel malignant neoplasms?
65%
- Adenocarcinoma
- Carcinoid
- Lymphoma (esp with Coeliac)
- GIST
Presentation of small bowel neoplasms?
- Often non-specific symptoms so present late
- N/V, obstruction
- Weight loss, abdominal pain
- Bleeding
- Jaundice from biliary obstruction or liver mets
Imaging for small bowel neoplasms?
AXR: SBO
Ba follow through
CT
Endoscopy investigation for small bowel neoplasms?
Push enteroscopy
Capsule endoscopy
Definition of acute appendicitis?
Inflammation of the vermiform appendix ranging from oedema to ischaemic necrosis and perforatio
Epidemiology of acute appendicitis?
Incidence: 6% lifetime incidence, commonest surgical emergency
Age: rare <2yrs, maximal peak during child, decreased thereafter.
Pathogenesis of acute appendicitis?
Obstruction of the appendix
- Faecolith most commonly
- Lymphoid hyperplasia post-infection
- Tumour (caecal Ca, carcinoid)
- Worms (Ascaris lumbicoides, Schisto)
This means that gut organisms –> Infection behin obstruction
–> oedema, –> ischaemia, –> necrosis –> perforation
- Peritonitis
- Abscess
- Appendix mass
Pattern of Abdominal Pain in Appendicitis
Early inflammation –>
appendiceal irritation
- Visceral pain is not well localised compared with somatic pain
- Pain referred to the dermatome corresponding to the spinal cord entry level of these sympathetic fibres
- Append = midgut = Lesser splanch (T10/11) = umb.
Late inflammation –> parietal peritoneum irritation
- Pain localised in RIF
Remember
- Examine the testicles in a young man with RIF. Due to Torsion.
Symptoms of acute appendicitis?
Colicky abdo pain
- Central –> Localised in RIF
- Worse with movement
Anorexia
Nausea (vomiting is rarely prominent)
Constipation/diarrhoea
Signs of acute appendicitis?
- Low-grade pyrexia: 37.5-38.5
- Increased HR, shallow breathing
- Foetor oris
Guarding and tenderness @McBurney’s point.
+ve cough/percussion tenderness - Appendix mass may be palpable in RIF
- Pain PR suggest Pelvic appendix.
- Rosving positive - Palpation in left causes pain in RIF.
Special signs for appendicitis?
Rovsing’s Sign
Psoas sign
Cope Sign
What is Rovsing’s sign?
Pressure in LIF –> more pain in RIF
What is psoas sign
Pain on extending the hip: retrocaecal appendix
What is cope sign
Flexion + internal rotation of R hip –> Pain
Appendix lying close to obturator internus
Differentials for acute appendicitis?
Surgical
- Cholecystitis
- Diverticulitis
- Meckel’s diverticulitis
Gynae
- Cyst accident
- Salpingitis
- Ruptured ectopic
Medical
- Mesenteric adenitis
- UTI
- Crohns
Investigations for acute appendicitis?
Dx is principally clinical
Bloods: FBC, CRP, Amylase, G+S, clotting. Raised inflammatory markers + neutrophil-predominant leucocytosis.
Urine
- Sterile pyuria may indicated bladder irritation
- Ketones: Anorexia
- Exclude UTI
- B-HCG
Imaging
- US: Exclude gynae path, visualise inflamed appendix
- CT: can be used
Diagnostic lap
Management of acute appendicitis?
- Fluid
- Abx: cef 1.5g + met 500g IV TDS.
- Analgesia: paracetamol, - NSAIDs, codeine phosphate
- Certain Dx –> appendicectomy (open or lap)
- Uncertain Dx –> Active observation
Consider underlying caecal malignancy or perforated sigmoid diverticular disease.
Complications of acute appendicitis
Appendix mass
- Inflamed appendix with adherent covering of omentum and small bowel
Dx: US or CT
Mx;
- Initially: Abx + NBM
- Resolution of mass –> interval appendicectomy
- Exclude a colonic tumour: colonoscopy
Appendix abscess?
results if appendix mass doesn’t resolve
Mass enlarges, pt deteriorates
- Mx = Abx + NBM
- CT guided percutaneous drainage
- If no resolution, surgery may involve right hemicolectomy
Perforation of appendix?
- Commoner if faecolith present and in young children (as Dx is often delayed)
- Deteriorating pt with peritonitis
What is a diverticulum?
- Out-pouching of tubular structures
- Mostly found in sigmoid colon.
What is a true diverticulum?
True = Composed of complete wall (Meckel’s)
What is a false diverticulum?
Composed of mucosa only (Pharyngeal, colonic)
What is diverticular disease?
Symptomatic diverticulosis
What is diverticulitis?
Inflammation of diverticula
What is the epidemiology of diverticulitis?
30% of Westerner’s have diverticulosis by 60yrs
F>M
What is the pathophysiology of diverticular disease?
Associated with increased intraluminal pressure
- Low fibre diet: no osmotic effect to keep stool wet.
Mucosa herniates through muscularis propria at points of weakness where perforating arteries enter.
Most commonly located in sigmoid colon
Commoner in obese patients
Uniting factor in Saint’s triad
- Hiatus hernia
- Cholelithiasis
- Diverticular disease
Symptoms of diverticular disease?
Altered bowel habit ± left-sided colic
- Relieved by defection
Nausea
Flatulence
Management
- High fibre diet, mebeverine may help
- Elective resection for chronic pain
What is diverticulitis?
- Inspissated faeces –> obstruction of diverticulum
- Elderly pt with prev hx of constipation
What is the presentation of diverticulitus?
- Abdominal pain and tenderness (guarding, rigidity, rebound tenderness)
- Change in bowel habit - consitpaiton is more common but diarrhoea is also reported
- Typically LIF
- Localised peritonitis
- Pyrexia
- Urinary frequency, urgency or dysuria - due to irritation of the bladder by the inflamed bowel.
- Tender LIF (w or w/i tender palpable mass)
- Possibly reduced bowel sounds
Investigations for diverticular disease?
Blood
- FBC: increased WCC
- increased CRP and ESR
- Amylase
- G+S/match
Imaging
- Erect CXR: look for perforation
- AXR: Fluid level/air in bowel wall/pneumoperitoneum.
Need a CXR for pneumoperitoneum.
- Contrast CT: for suspected abscesses
- Gastrograffin enema
Avoid colonoscopy due to increased risk of perforation in diverticulitis
- Consider flexi sigmoidoscopy
What is the grading of diverticular disease?
Hinchey Grading
1) - Small confined pericolic abscesses - Surgery rarely needed.
2) Large abscess extending into pelvis - May resolve without surgery
3) Generalised purulent peritonitis - Needs surgery
4) Generalised faecal peritonitis - Needs surgery
What is the management of an acute attack of diverticulitis?
- Mild
- Can be treated at home with bowel rest (fluids only) and augmentin ± metronidazole
- If symptoms dont’ settle within 72hrs, or patient presents with more severe symptoms, then admit for IV antibiotics.
When to admit an acute diverticulitis?
Unwell
Fluids can’t be tolerated
Pain can’t be controlled
What is the medical management of acute diverticulitis?
- NBM
- IV fluids
- Analgesia
- Antibiotics: cefuroxime +
- Metronidazole
- Most cases settle
What are the surgical indications of acute diverticulitis?
Perforation
Large haemorrhage
Stricture –> Obstruction
- Do a Hartmann’s to resect diseased bowel.
This is surgical resection of the rectosigmoid colon with closure of the anorectal stump and formation of an end colostomy.
Also used to treat colon cancer. USed is limited to emergency surgery when immediate anastomosis is not possible. Therefore a colo-colo
What are the complications of diverticular disease?
Perforation Haemorrhage Abscess Fistulae = If patient has a colovesical fistula. Must use a CT to investigate. Stricture
What is the signs of a perforation in diverticular disease?
- Sudden onset pain (±preceding diverticulitis)
- Generalised peritonitis and shock
- CXR: air under diaphragm
- Rx: Hartmann’s
Signs of haemorrhage due to diverticular disease?
Sudden, painless bright red PR bleed.
Ix: mesenteric angiography or colonscopy.
Management - Stops spontaneously usually, may need transfusion. COlonoscopy ± diathermy/adrenaline.
Embolisation + resection.
Management of abscess in diverticular disease?
- Walled-off perforation
- Swinging fever
- Localising signs - boggy rectal mass
- Leukocytosis
- Rx: Abx + CT/US guided drainage
Management of fistulae in diverticular disease?
Enterocolic
Colovaginal
Colovesicular: Pneumaturia + intractable UTIs
management: resection
Strictures in diverticulitis?
After diverticulitis, colon may heal with fibrous strictures
- Management
- Resection (usually primary anastomosis)
- Stenting
What is the classification of bowel obstruction?
Simple
Closed Loop
Strangulated
What is a simple bowel obstruction?
- 1 obstructing point + no vascular compromise
- May be partial or complete.
What is a closed loop obstruction
Bowel obstructed @ two points
- Left CRC with competent ileocaecal valve
- Volvulus
Gross distention –> perforation
What is a strangulated bowel obstruction
- Compromised blood supply
Localised, constant pain + peritonism - Fever + Increased WCC
Commonest cause of small bowel obstruction?
SBO
- Adhesions: 60%
- Hernia
Commonest cause of large bowel obstruction
- Colorectal neoplasia: 60%
- Diverticular stricture: 20%
- Volvulus
Other causes of bowel obstruction
Non-mechanical = Paralytic ileus usually small bowel
- Post op
- Peritonitis
- Pancreatitis or any localised inflammation
- Poison
- Pseudo-obstruction
- Metabolic: decreased K, decreased Na, Decreased Mg, uraemia.
- Mesenteric ischaemia
Mechanical causes of BO?
Intraluminal
- Impacted matter: faeces, worms
- Intussusception
- Gallstones
Intramural
- Benign stricture (IBD, Surgery, Ischaemic colitis, diverticulitis, radiotherapy).
- Neoplasia
- Congenital atresia
Extramural - Hernia - Adhesions - Volvulus (sigmoid, caecal, gastric) - Extrinsic compression Pseudocyst Abscess Haematoma Tumour Congenital bands (Ladd's)
Presentation for BO?
Abdominal pain
- Colicky
- Central but level depends on gut region
- Constant/localised pain suggests strangulation or impending perforation
Distension
- Increased with lower obstructions
Vomiting
- Early in high obstruction
- Late or absent in low obstruction
Absolute constipation: Flatus and faeces
Examination of bowel obstruction?
HR increased: hypovolaemia, strnagulation
- Dehydration, hypovolaemia
- Fever: suggests inflammatory disease or strangulation
- Surgical scars
- Hernias
- Mass: neoplastic or inflammatory
- Bowel sounds
Increased: mechanical obstruction
Decreased movement: ileus
PR
- Empty rectum
- Rectal mass
- Hard impacted stool
- Blood from higher pathology
Investigations for bowel obstruction?
Bloods:
FBC: Increased WCC
U+E: Dehydration, electrolyte abnormalities
Amylase: Increased if strangulation/perforation
VBG: Increased lactate in strangulation
G+S, clotting: may need surgery
Imaging for bowel obstruction?
- Erect CXR
- AXR: ± erect film for fluid level
- CT: can show transition point
What does a gastrograffin study look for?
- Look for mechanical obstruction: No free flow
- Follow through or enema
- Follow through may relieve mild mechanical obstruction: usually adhesional.
What is a colonoscopy used for in bowel obstruction?
- Can be used in some cases
- Risk of perforation
- may be used therapeutically to stent
What are the finding on AXR in SBO?
Diameter >3cm Location: central Marking: Valvulae coniventes (completely across) LB Gas: Absent (large bowel gas) No. of loops: many Fluid: many, short.
What are the finding on AXR in LBO?
- > 6cm (Caecum >9)
- Peripherally
- Haustra (partially across)
- LB Gas: present - not in rectum.
- No of loops: Few
- Fluid level: Few, long.
What would you see in AXR in an ileus?
Both small and large bowels may be visible.
No clear transition point.
What is the general medical management of bowel obstruction?
Resuscitate: drip and suck
- NBM
- IV fluids: aggressive as patients may be v dehydrated
- NGT: decompress upper GIT, stops vomiting, prevents aspiration
- Catheterise: monitor UO
Therapy for Bowel obstruction management?
Analgesia: may require strong opoiod
Antibiotics: cef+met if strangulation or perforation
Gastrograffin study: oral or via NGT
Consider need for parenteral nutrition.
Avoid metoclopramide as it is a pro-kinetic anti-emetic so could cause perforation in bowel obstruction.
Monitor patient with bowel obstruction?
Regular clinical exam is necessary to ensure that the patient is not deteriorating
- Increased distension
- Increased pain or tenderness
- Increased HR or RR
- Repeat imaging and bloods
- Non-operative Mx successful in 80% of patients with SBO without peritonitis.
- Pts with LBO are likely to need surgery.
What are the surgical indications for bowel obstruction?
- Closed loop obstruction
- Obstructing neoplasm
- Strangulation/perforation –> sepsis, peritonitis
- Failure of conservative Mx (up to 72hr)
What are the principles of surgical management for bowel obstruction?
- Aim to treat the cause
- Typically involves resection of the obstructing lesions
- Colon has not been cleansed therefore most surgeons utilise a proximal ostomy post-resection
- Pts with substantial comorbidity or unresectable tumours may be offered bypass procedures.
- Endoscopically placed expanding metal stents offer palliation or a bridge to surgery allowing optimisation.
Surgical procedures for management of SBO/LBO?
Must consent pt for possible resection ± Stoma
- SBO: adhesiolysis
- LBO
Hartmann’s
Colectomy + primary anastomosis + on table lavage.
- Palliative bypass procedure
- Transverse loop colostomy or loop ileostomy
- Caecostomy
What is a sigmoid volvulus?
- Older patients
- Long mesentery with narrow base predisposes to torsion
- Usually due to sigmoid elongation 2ndry to chronic constipation
- increased risk in neuropsych patients: MS, PD, psychiatry (diseases that interfere with intestinal motility)
- Chagas disease
- Closed loop obstruction
Presentation of sigmoid volvulus?
- Commoner in males
- Often elderly, constipated,
- co-morbid patients
- Massive distension with tympanic abdomen
What do you see on AXR with a sigmoid volvulus?
Inverted U or Coffee Bean sign
Management of Sigmoid volvulus?
Relieved by sigmoidoscopy and flatus tube insertion
- Monitor for signs of bowel ischaemia following decompression
If a patient has symptoms of peritonitis, skip the flexible sigmoid and treat with urgem midline laparotomy.
- Sigmoid colectomy occasionally required
if failed endoscopic decompression or bowel necrosis - Often recurs therefore elective sigmoidectomy may be needed.
What is a caecal volvulus?
Associated with congenital malformation where caecum is not fixed in the RIF.
Adhesions and pregnancy.
Only ~10% of patients can be detorsed with colonoscopy therefore will require surgery.
Right hemi with primary ileocolic anastomosis
Requires operative management - Caecostomy.
What is a gastric volvulus triad?
Triad of gastro-oesophageal obstruction
- Vomiting –> retching with regurgitation of saliva
- Pain
- Failed attempts to pass an NGT.
Borchardt’s triad = epigastric pain, retching and inability to pass an NG tube.
Risk factors for gastric volvulus?
Congenital
- bands
- rolling/paraoesophageal hernia
- Pyloric stenosis
Acquired
- Gastric/oesophageal surgery
- Adhesions
Investigations of gastric volvulus?
Gastric Dilatation
Double fluid level on erect films
Management of gastric volvulus?
Endoscopic manipulation
Emergency laparotomy
What is a paralytic ileus?
- Adynamic bowel 2ndry to the absence of normal peristalsis
- Usually SBO
- Reduced or absent bowel sound
- Mild abdominal pain: not colicky.
Causes of paralytic ileus?
Post-op
Peritonitis
Pancreatitis or any localised inflammation
Poisons/Drugs: anti-AChM (TCAs)
- Pseudo-obstruction
- Metabolic: decreased K, Decreased Na, Decreased Mg, uraemia
- Mesenteric ischaemia
Prevention of paralytic ileus?
Decreased bowel handling
Laparoscopic approach
Peritoneal lavage after peritonitis
Unstarched gloves
Management of paralytic ileus?
- Drip and suck management
Correct any underlying causes - Drugs
- Metabolic abnormalities
- Consider need for parenteral nutrition
- Exclude mechanical cause if protracted.
Colonic pseudo-obstruction
- Clinical signs of mechanical obstruction but no obstructing lesions found
- Usually distension only: no colic
Causes - Unknown - Associated with Elderly Cardiorespiratroy disorders Pelvic surgery: e.g hip arthroplasty Trauma
Investigation
- Gastrograffin enema
Management
- Neostigmine: anti-cholinesterase
- Colonoscopic decompression: 80%
What is the epidemiology of colorectal cancer?
3rd commonest cancer
2nd commonest cause of cancer deaths (16,000/yr).
Age: peak in 60s
Sex: rectal Ca commoner in men
Geo: Western disease
Pathophysiology of colorectal cancer?
Colonic adenomas
- Benign precursor to CRC
- Characterised by dysplastic epithelium
Classification
- Tubular: small, pedunculated, tubular glands
- Villous: large, sessile, covered by villi
- Tubulovillous: mixture
Presentation
- Typically asymptomatic
- Large polyp can bleed –> IDA
- Villous adenoma –> decreased K+ and hypoproteinaemia.
Malignant potential
- Increased size
- Dysplasia
- Villous component
What is APC and its involvement in colorectal carcinoma?
- APC binds + promotes degradation of B-catenin
- APC mutation –> Increased B-catenin –> increased transcription of genes which promote cell proliferation.
Proliferation –> Mutation of other genes which promote growth and prevent apoptosis
What is the sequence of adenoma change?
- First hit: mutation of one APC copy
- Second hit: Mutation of second APC copy –> Adenoma formation
- Additional mutations in adenoma –> malignant transformation. e.g KRAS, p53.
What are the other aetiological factors associated with colorectal cancer?
Diet: decreased diet + increased refined carbs
IBD: CRC in 15% with pancolitis for 20yrs
Familial: FAP, HNPCC, Peutz-Jegher
Smoking
Genetics
- No relative: 1/50 CRC risk
- One 1st degree: 1/10
NSAIDS/Aspirin: protective
What is the pathology of adenocarcinoma?
95% of CRC is adenocarcinoma
- Others are lymphoma, GIST, Carcinoid.
Location
- Rectum: 40%
- Sigmoid: 30%
- Caecum and ascending colon: 20%
- Transverse: 10%
- Descending: 5%
Proximal tumour: Sessile or polypoid
Distal tumours: Annular stenosing
What is the spread of colorectal cancer?
Local
Lymphatic
Blood (liver, lungs)
Transcoelomic (across peritoneal cavity)
What is the presentation of a left sided colorectal carcinoma?
Altered bowel habit PR mass (60%) Obstruction (25%) Bleeding/mucus PR Tenesmus
What are the symptoms of a right sided colorectal carcinoma?
Anaemia
Weight loss
Abdominal pain
What are the symptoms of both a right and a left sided colorectal carcinoma?
Abdominal mass
Perforation
Haemorrhage
Fistula
What would you see on examination of a colorectal cancer?
- Palpable mass: per abdomen or PR
- Perianal fistulae
- Hepatomegaly
- Anaemia
- Signs of obstruction
What are the investigations for colorectal carcinoma?
All 2WW.
- Send for colonoscopy immediately.
Patient >40 with unexplained weight loss AND Abdo pain
Patient >50 with unexplained rectal bleeding
Patient >60 with iron deficiency anaemia OR change in bowel habit.
Test shows occult blood in faeces
Consider 2WW if
- Rectal or abdo mass
- Unexplained anal mass or anal ulceration
- Patient <50 with rectal bleeding AND any of the following unexplained symptoms/findings
- abdopain , change in bowel habit, weight loss, IDA.
Bloods
- FBC: hb
- LFTs: mets
- Tumour markers: CEA (carcinoembryonic Ag)
Imaging - CXR: Lung mets - US liver: mets - CT and MRI Staging MRI best for rectal Ca and liver mets
- Endoanal US: staging rectal tumour
- Ba/gastrograffin enema: apple-core lesions
Endoscopy + biopsy
- Flexi sig: 65% of tumours accessible
- Colonoscopy
Dukes staging for colorectal cancer?
Staging done through CT of chest, abdo and pelvis.
A - confined to bowel wall
B - Through bowel wall but no LNs
C - Regional LNs
D - Distant mets
TNM staging for colorectal cancer?
Tis: carcinoma in situ T1: Submucosa T2: muscularis propria T3: Subserosa T4: through the serosa to adjacent organs N1: 1-3 nodes N2: >4 noses
General Management of CRC?
- Manage in an MDT
- Confirmation of Dx
- Stage with CT or MRI
- 60% amenable to radical surgery. Always treated with surgery.
Surgery of CRC?
Use ERAS pathway
Pre-operative bowel prep (except R sided lesion)
E.g Kleen Prep (Macrogol) the day before and phosphate enema in the AM.
Consent: discuss stoma
Stoma nurse consult for siting.
Principles in CRC?
Excision depends on lymphatic drainage which follows arterial supply . Resection of certain lymphatic chains.
Mobility of bowel and blood supply at cut ends is also important.
Hartmann’s often used if obstruction
Laparoscopic approach is the standard of care.
Following resection - ensure anastomosis heals well (adrequate blood supply, mucosal apposition and no tissue tension). Might sometimes be safet to construct a stoma.
What is the management of a sigmoid tumour?
High anterior resection or sigmoid colectomy.
This alongside a colo-rectal anastomosis
What is the management of a caecal/ascending or proximal transverse colon?
Right hemicolectomy
- Ileo-colic anastomosis
Management of a distal/descending colon tumour?
Left hemicolectomy - Colo-colon.
Management of rectal cancer?
REctum’s anatomical location poses different challenges.
Either an anterior resection or an abdomino-perineal excision of the rectum (APER)
If there is involvement of the sphincter complex or very low tumours an APER is required. (distal 8cm of rectum) . Leaves a permanent colostomy.
In addition to excision of the rectal tube an integral part of the procedure is a meticulous dissection of the mesorectal fat and lymph nodes.
Rectal cancer has high risk of disease recurrence because it is an extraperitoneal structure (so can be irradiated) - neoadjuvant.
T4 = Long course chemoradiotherapy.
Patients with obstructing rectal cancer should have a defunctioning loop colostomy, this is because rectal surgery is more technically demanding, therefore anastomotic leak is higher and danger of positive resection margin.
In emergency setting bowel is perforated risk of an anastomosis is much greater - especially when colon-colon. Therefore end colostomy is often safer and is reversed later. The resection of the sigmoid colon is performed and an end colostomy is fashioned - this is a hartman.
Therefore management of rectal Ca?
Neo-adjuvant radiotherapy may be used to decrease local recurrence and increase 5yrs.
Anterior resection: if tumour 4-5cm from anal verge.
Defunction with loop ileostomy. - Spout an ileostomy to prevent skin coming into contact with enzymes in small intestine.
Abdomino-peritoneal excision of rectum: <4cm from anal verge
+ total mesorectal excision for tumours of the middle and lower third.
- Aim to decreased recurrence
- Increased anastomotic leak and faecal incontinence.
What other management can be used for colorectal cancer?
Local excision - Transanal endoscopic microsurgery
Bypass surgery: palliation
Hepatic resection: if single lobe mets only
Stenting: palliation or bridge to surgery in obstruction
Chemo
- Adjuvant 5-FU for Dukes C decreased mortality by 25%
- i.e LN +ve pts.
High grade tumour
Palliation of metastatic disease.
What is the NHS screening for colorectal cancer?
Home-based kit - faecal Immunochemical test for older adults.
One off flexible sigmoidoscopy offered at age 55 to detect and treat polyp.
Can self-refer for bowel screening with sigmoidoscopy up to age of 60, if the offer of routine one-off screening at age 55 had not been takenu p.
What is a faecal immunochemical test?
National programme - every 2 years to all men and women aged 60-74.
- Sent a faecal immunochemical test through post.
- Uses antibodies to detect human haemoglobin.
- More sensitive than FOB.
At colonoscopy
- 5-10 will have a normal exam
- 4-10 will have polys which can be removed
- 1 out of 10 will have cancer.
What is the flexi sig screening
People who are 55 yrs old.
Bowel scope screening.
Use a sigmoidoscopy up to age of 60.
What are the familial CRC syndromes ?
- Familial Adenomatous Polyposis
- Hereditary non-polyposis colorectal cancer
- Peutz-Jegher syndrome
What is FAP?
APC gene, autosomal dominant.
Presentation
- 100-1000s adenomas by 16 uyrs
- Mainly in large bowel
- Aslo stomach and duodenum
100% develop CRC by ~40yrs
May be associated with congenital hypertrophy of the retinal pigment epithelium.
What is a FAP variant?
Attenuated FAP: <100 adenomas - later CRC (>50)
Gardner’s TODE
- Thyroid tumours
- Osteomas of the mandible, skull and long bones
- Dental abnormalities: supernumarary teeth
- Epidermal cysts.
- Multiple colonic polyps
- Extracolonic disease
- Desmoid tumours
- MUtations of APC gene
- Colonic polyps most patients undergo colectomy
- Variant for FAP.
What is the management of FAP?
Prophylactic colectomy before 20yrs
Total colectomy + IRA (ileo-rectal anastomosis)
- Requires life-long stump surveillance
- Proctocolectomy + IPAA (ileo pouch anal anastomosis)
- Remains @ risk of Ca in stomach and duodenum.
What is hereditary non-polyposis colorectal cancer?
Autosomal dominant
- Mutation of mismatch repair enzyme.
- commonest cause of hereditary CRC: 3% of all CRC
Mutations of MSH2 or MSH1.
Presentation
- Lynch 1: right sided CRc
- Lynch 2: CRC + gastric, endometrial, prostate, breast.
Endometrial is the most common association of HNPCC. Mr Lynch is CEO.
AD = develop colonic cancer and endometrial cancer at young age. 80% of affected individuals get colonic or endometrial cancer.
Also pancreatic cancer.
3,2,1 rule
- >3 family members over 2 generations with one <50.
What is peutz-jegher’s syndrome?
~10-15 yrs
- Mucocutaneous hyperpigmentation
- Macules on palms, buccal mucosa
Multiple GI hamartomatous polyps
- Intussusception
- Haemorrhage
Ca risk
- CRC, pancreas, breast, lung, ovaries, uterus.
What are GI Polyp syndromes?
Inflammatory pseudopolpys
- Regenerating islands of mucosa in UC
Hyperplastic Polyps
- Piling up of goblet cells and absorptive cells
- Serrated surface architecture
- No malignant potential
Hamartomatous
- Tumour-like growths composed of tissues present at site where they develop
- Sporadic or part of familial syndromes
- Juvenile polyp: Solitary hamartoma in children
- Cherry on stalk.
Neoplastic
- tubular or villous adenomas
- Asymptomatic
- May have blood /mucus PR, tenensmus.
Other hamartomatous polyposis syndromes?
Juvenile Polyposis
- > 10 hamartomatous polyps
- Increased risk of CRC
Cowden Syndrome
- Auto dominant
- Macrocephaly + skin stigmata
- INtestinal hamartomas
- Increased risk of extra-instestinal Ca.
What are the causes of acute mesenteric ischaemia?
Arterial (70%)
- Thrombotic
- Embolic
Non-occlusive
- Splanchnic vasocontriction e.g 2ndry to shock
- Venous thrombosis
Other: trauma, vasculitis, strangulation
Presentation of acute mesenteric ischaemia?
Nearly always small bowels (SMA is suppling small bowel)
IMA - Main arterial supply of splenic flexure to the sigmoid colon. Starts from L3.
Coeliac trunk - T12, SMA = L1.
Coealic = Foregut SMA = 2nd part of duodenum to proximal 2/3 transverse colon.
- Triad
- Acute severe abdominal pain ± PR bleed
- Rapid hypovolaemia –> Shock
- No abdominal signs (Soft but tender)
Degree of illness»_space;> clinical signs
May be in AF
Presentation is - CVD, High lactate and soft but tender abdomen.
Investigations for mesenteric ischameia
Bloods
- Increased Hb: plasma loss
- Increased WCC
- Increased amylase
- Persistent metabolic acidosis: increased lactate
Imaging
- AXR: gasless abdomen
- Arteriography/CT/MRI angio
Complications of mesenteric ischaemia
septic peritonitis
SIRS –> MODS
Management of mesenteric ischaemia?
Fluids
Abs: gent and met
LMWH
Laparotomy: resect necrotic bowel
What is chronic small bowel ischaemia?
Causes: Atheroma + low flow state (e.g LVF)
Presentation
- Severe, colicky post-prandial abdo pain (gut claudication)
- PR bleeding
- Malabsorption
- Weight loss
management - angioplasty
What is chronic large bowel ischaemia?
Causes: Follows low flow in IMA territory
Remember SMA supplies ascending + transverse.
IMA supplies descending.
Presentation
- Lower, left sided abdominal pain
- BLoody diarrhoea
- Pyrexia
- Tachycardia
Ix
- Increased WCC
- Ba enema: thumb printing
- MR angiography
Complications
- May –> peritonitis and septic shock
- Strictures in the long-term
Management
- Usually conservative: fluids + Abx
- Angioplasty + endovascular stenting
What does the SMA split into and supply?
Middle Colic
Right Colic
Ileocolic
Ileo-jejunal collic
IMA supply + split?
Left colic, sigmoid
Superior rectal
What are the common causes of lower GI bleed?
Rectal: Haemorrhoid, fissures
Diverticulitis
Neoplasm
Other causes of lower GI bleeding?
- Inflammation: IBD
- Infection: Shigella, campylobacter, C.diff
Polyps - Large upper GI bleed
- Angio: Dysplasia, ischaemic colitis, HHT
Investigations of Lower GI bleed
Bloods: FC, U+E, LFTs, x-match, clotting, amylase
Stools
: MCS
- Imaging
AXR, erect CXR
Angiography: necessary if no source on endoscopy
Red cell scan
Endoscopy
- 1st: rigid proctoscopy/sigmoidoscopy
- 2nd OGD
- Colonoscopy: difficult in major bleeding
Management of lower GI bleed?
Resus Urinary catheter ABx if septic PPI: if upper GI bleed possible - Keep bed bound: need to pass stool may be large bleed = collapse - Stool chart - Diet: keep on clear fluids - Surgery: only if unremitting, massive bleed.
What is angiodysplasia?
Submucosal AV malformation
70-90% occur in right colon
Can affect anywhere in GIT
presentation
- elderly
- Fresh PR bleeding
Ix
- Exclude other Dx
- PR exam
- Ba enema
- Colonoscopy
MEsenteric angiography or CT angiography
Tc - labelled RBC scan: identify active bleeding
Management
- Embolisation
- endoscopic laser electrocoagulation
- Resection
Mittelschmerz
Only seen in females
Mid cycle
Usually 2 weeks after last menstrual period
Normal everything. May show trace of pelvic free fluid.
manage conservatively.
Rectal Varices?
Consider in a patient with portal HTN and lower GI bleeding.
What to do if source of colonic bleeding is unclear?
Laparotomy
On table colonic lavage
Attempt a resection.
Acute lower GI bleding
- Over 60
- Haemodynamically unstable
- On aspirin or NSAIDs
- Significant co morbidity
Management
- All patients should have history + exam PR and proctoscopy.
- COlonoscopic haemostasis aimed for in post polypectomy or diverticular bleeding.
Indications for splenectomy
Uncontrolled splenic bleeding in trauma patients is indication for splenectomy.
Hilar vascular injuries
Devascularized spleen.
Splenic trauma?
Conservative
- Small subcapsular haematoma
- Minimal intra abdominal blood
- No hilar disruption
Laparotomy with conservation
- Increased amounts of intra abdominal blood
- moderate haemodynamic compromise
- Tears or lacerations affecting <50%.
Resection
- Hilar injuries
- Major haemorrhage
- Major associated injuries.
Allograft?
Transplant of tissue from genetically non identical donor from the same species
Isograft
Graft of tissue between two individuals who are genetically identical
Autograft
Transplantation of organs or tissues from one part of the body to another in the same individual - Skin graft.
Xenograft
Tissue transplanted from another species
Grey Turner sign
Severe haemorrhagic pancreatitis.
Local fat destruction, results in blood tracking in the tissue planes of the retroperitoneum.
Cullens
Pancreatitis
Boas sign
Cholecystitis - Hyperaesthesia beneath the right scapula.
Rovsing
Appendicitis
Retractile testis
A testis that appears in warm conditions or which can be brought down on clinical examination and does not immediately retract is usually a retractile testis.
Cryptorchidism?
A congenital undescended testis is one that has failed to reach the bottom of the scrotum by 3 months of age.
Can be due:
- Patent processus vaginalis
- Abnormal epididymis
- Cerebral palsy
- Mental retardation
- Wilms tumour
- Abdominal wall defects (e.g. gastroschisis, prune belly syndrome)
DDx
- Retractile testes
- Absent bilateral testes (intersex conditions)
Reasons for correction of cryptorchidism?
- Reduce risk of infertility
- Allows the testes to be examined for testicular cancer
- Avoid testicular torsion
- Cosmetic appearance
Treatment
- Orchidoplexy at 6- 18 months of age. The operation usually consists of inguinal exploration, mobilisation of the testis and implantation into a dartos pouch.
- Intra-abdominal testis should be evaluated laparoscopically and mobilised. Whether this is a single stage or two stage procedure depends upon the exact location.
- After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy.
Renal vein thrombosis?
Renal vein thrombosis is a common feature of renal cell carcinoma.
Other features include PUO, left varicocele, Paraneoplastic endocrine effect due to erythropoietin.
TPN blood derangement
known of derange LFTs.
Longer term infusions should be administered into central vein via PICC line.
Pseudomyxoma peritonei?
Rare mucinous tumour arising from appendix.
Leads to large amounts of mucinous material in the abdominal cavity.
Retroperitoneal fibrosis?
Ureters are displaced medially.
Most retroperitoneal malignancies are displaced laterally.
HTN is a common finding.
CT scan will often show a para-aortic mass.
Minor surgery?
LA
- Lidocaine. Rapid onset and anaesthesia lasts for 1 hour.
- Maximum safe dose is 3mg/kg. BNF states 200mg (or 500mg) if given in adrenaline.
- Premixed with adrenaline available - reduced blood loss due to vasoconstriction. Dont use in extremities due to risk of ischaemia.
Absorbable sutures
Vicryl
Dexon
PDS
Non-absorbable sutures?
Silk
Novafil
Prolene
Ethilon
Removal of sutures?
Face = 3-5 days
Scalp, limbs, chest = 7-10 days
Hand, foot, nack = 10-14
Gastrostomy indications?
Gastric decompression or fixation
Feeding
Site is in the epigastrium
Loop jejunostomy?
Seldom used as very high output.
USed in emergency laparotomy
Percutaneous jejunostomy?
Usually performed for feeding purposes and site in the proximal bowel.
Usually left upper quadrant
Loop ileostomy
Defunctioning of colon e.g. following rectal cancer surgery
Does not decompress colon (if ileocaecal valve competent)
End ileostomy
Usually following complete excision of colon or where ileocolic anastomosis is not planned
May be used to defunction colon, but reversal is more difficult
Caecostomy?
Stoma of last resort where loop colostomy is not possible.
right iliac fossa.
Mucous fistula
To decompress a distal segment of bowel following colonic division or resection
Where closure of a distal resection margin is not safe or achievable
Why epidural analgesia for colorectal patients ?
Accelerates the return of normal bowel function after abdo surgery.
Post op ileostomy complications?
High-output bag.
Patients may develop volume depletion, U+E disturbances.
Patient has descending colon tumour removed. Surgeon wants to defunction the bowel. How?
Do an loop ileostomy to protect the colon’s anastomosis.
