Lower GI Surgery Flashcards
define Meckel’s diverticulum and its common features, just FYI
Meckel’s Diverticulum
• Ileal remnant of vitellointestinal duct
§ Joins yoke sac to midgut lumen
Features
• A true diverticulum
• 2 inches long
• 2 ft from ileocaecal valve on antimesenteric border
• 2% of population
• 2% symptomatic
• Contain ectopic gastric or pancreatic tissue
presentation of sympto Meckel’s diverticulum
rectal bleeding
appendicitis mimic
intuss/volvulus
symptoms triggered by gastric secretions in wrong place
inv and management Meckel’s
nothing if no signs
technecium scan identifies most
resect diverticulum
intussusception
6-12 months, colicky abdo pain bowel invaginated into itself bilious vomiting inconsolable crying redcurrant jelly stools sausage-shaped mass
management intussusception
resus, x match, NGT
air enema + USS
surgery if air not worked
*rarely occurs in adults, if so, exclude cancers
mesenteric adenitis
viral infection / URTI triggers enlargement of LNs in mesentery
generalised pain + fever + tenderness
lymphocytosis
appendix mimic
presentation bowel cancers
nausea, vomiting, obstructed
weight loss, abdo pain
bleeding
jaundice if obstructed / metastasis
do AXR, CT
bowel cancers distribution
1/3 benign - polyp, haemangioma etc
2/3 malignant - adenocarcinoma, carcinoid
carcinoid tumour presentation
may present as blockage etc
otherwise:
Flushing: paroxysmal, upper body ± wheals
• Intestinal: diarrhoea
• Valve fibrosis: tricuspid regurg and pulmonary stenosis
• whEEze: bronchoconstriction
• Hepatic involvement: bypassed 1st pass metabolism
• Tryptophan deficiency → pellagra (3Ds)
investigating and treating carcinoid tumour
urine 5 HIA
plasma chromogranin A
CT/MRI
give octreotide/loperamide
resect very yellow tumour
carcinoid crisis
Vasodilatation, hypotension, bronchoconstriction,
hyperglycaemia
occurs with overhandling / outgrowing blood supply = dumping of mediators
give high dose octreotide to treat
DDx appendicitis
Surgical
§ Cholecystitis
§ Diverticulitis
§ Meckel’s diverticulitis
• Gynae
§ Cyst accident: torsion, rupture, haemorrhage
§ Salpingitis / PID
§ Ruptured ectopic
• Medical
§ Mesenteric adenitis
§ UTI
§ Crohn’s
appendicitis special signs o/e x 3
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
presentation of appendicits
colicky abdo pain gradually localised to RIF guarding anorexia nausea low grade fever obs off palpable RIF mass maybe
if pain on PR consider pelvic appendicitis
investigating ? appendicitis
- Dx is principally clinical
- Bloods: FBC, CRP, amylase, G+S, clotting
• Urine § Sterile pyuria: may indicate bladder irritation § Ketones: anorexia § Exclude UTI § β-HCG
• Imaging § US: exclude gynae path, visualise inflamed appendix § CT: can be used • Diagnostic lap
treating appendicitis
Fluids + resus
• Abx: cef 1.5g + met 500g IV TDS
• Analgesia: paracetamol, NSAIDs, codeine phosphate
• Certain Dx → appendicectomy (open or lap)
• Uncertain Dx → active observation
complications of appendicitis
perforation, abscess
UC pathology
rectum, colon, backwash ileitis
continuous
shallow broad inflammation
pseudopolyps
no fistulae, granulomas
Chron’s pathology
whole GI tract transmural skip lesions cobblestone inflammation strictures fibrosis granulomas fistulae
extra-intestinal manifestations IBD
commonest: clubbing e nodosum iritis arthritis
Skin
- Clubbing
- Erythema nodosum
- Pyoderma gang (esp. UC)
Eyes
- Iritis
- Conjunctivitis
- Episcleritis
- Scleritis
Joints
• Arthritis (non-deforming, asymmetrical)
• Sacroiliitis
• Ank spond
Hepatobiliary
• PSC + cholangiocarcinoma (esp. UC)
• Gallstones (esp. Crohn’s)
• Fatty liver
Other
• Amyloidosis
• Oxalate renal stones (esp. Crohns)
classic UC presentation
diarrhoea blood and mucus PR abdo discomfort tenesmus faecal urgency fever distended abdo
complications of UC
toxic megacolon (and consequent perf risk)
bleeding
malignancy
cholangiocarcinoma
strictures
venous thrombosis
classic Chron’s history and exam
non bloody diarrhoea
abdo pain
FTT in appearance
weight loss
aphthous ulcers, glossitis abdo tender RIF mass perianal abscess, fistula perianal tags anal, rectal strictures
complications of Chron’s
fistulae - can be into bladder / vagina, perianal ‘pepperpot anus’
strictures and obstruction
abscesses
malabsorption: of fat = steatorrhoea, gallstones of B12 = megalo anaemia vit D = osteomalacia protein = oedema
investigation findings in UC (at presentation)
buzzwords
• Bloods: § FBC: ↓Hb, ↑WCC § LFT: ↓albumin § ↑CRP/ESR § Blood cultures
• Stool
§ MCS: exclude Campylo, Shigella, Salmonella…
§ CDT: C. diff may complicate or mimic
faecal calprotectin
• Imaging § AXR: megacolon (>6cm), wall thickening § CXR: perforation § CT § Ba / gastrograffin enema § Lead-pipe: no haustra § Thumbprinting: mucosal thickening § Pseudopolyps: regenerating mucosal island • Ileocolonoscopy + regional biopsy: Baron Score
measuring severity of UC
Truelove criteria
depends on number of BO
fever
anaemia
bleeds etc
management acute attack of UC
• Resus: Admit, IV hydration, NBM • Hydrocortisone: IV 100mg QDS + PR • Transfuse if required • Thromboprophylaxis: LMWH • Monitoring § Bloods: FBC, ESR, CRP, U+E § Vitals + stool chart § Twice daily examination § ± AXR
managing acute attack of UC depending on progress
progress seen -> taper preds and move onto sulfa and oral steroid
no progress -> majority will require colectomy, can try aggressive Isuppression
maintaining UC remission
1st line: 5-ASAs PO – sulfasalazine or mesalazine
• 2nd line: Azathioprine or mercaptopurine
§ Relapsed on ASA or are steroid-dependent
§ Give 6-mercaptopurine if azathioprine intolerant
• 3rd line: Infliximab / adalimumab
surgery in UC
total /subtotal colectomy with end ileostomy
investigation findings in Chron’s (at presentation)
buzzwords
Bloods: (top 3 are severity markers) § FBC: ↓Hb, ↑WCC § LFT: ↓albumin § ↑CRP/ESR § Haematinics: Fe, B12, Folate § Blood cultures
• Stool
§ MCS: exclude Campylo, Shigella, Salmonella…
§ CDT: C. diff may complicate or mimic
faecal calprotectin
• Imaging § AXR: obstruction, sacroileitis § CXR: perforation § MRI § Assess pelvic disease and fistula § Assess disease severity § Small bowel follow-through or enteroclysis § Skip lesions § Rose-thorn ulcers § Cobblestoning: ulceration + mural oedema § String sign of Kantor: narrow terminal ileum • Endoscopy § Ileocolonoscopy + regional biopsy: Ix of choice § Wireless capsule endoscopy § Small bowel enteroscopy
managing severe Chron’s relapse
• Resus: Admit, NBM, IV hydration • Hydrocortisone: IV + PR if rectal disease • Abx: metronidazole PO or IV • Thromboprophylaxis: LMWH • Dietician Review § Elemental diet - Liquid prep of amino acids, glucose and fatty acids § Consider parenteral nutrition • Monitoring § Vitals + stool chart § Daily examination
oral therapy Chron’s
1st line
§ Ileocaecal: budesonide
§ Colitis: sulfasalazine
- 2nd line: prednisolone (tapering)
- 3rd line: methotrexate
- 4th line: infliximab or adalimumab
maintaining remission in Chron’s
1st line: azathioprine or mercaptopurine
• 2nd line: methotrexate
• 3rd line: Infliximab / adalimumab
short gut syndrome
following resections
• <1-2m small bowel • Features § Steatorrhoea § ADEK and B12 malabsorption § Bile acid depletion → gallstones § Hyperoxaluria → renal stones • Rx § Dietician § Supplements
why surgery in Chron’s?
Emergency
§ Failure to respond to medical Rx
§ Intestinal obstruction or perforation
§ Massive haemorrhage
• Elective § Abscess or fistula § Perianal disease § Chronic ill health § Carcinoma
Procedures
• Limited resection: e.g. ileocaecal
• Stricturoplasty
• Defunction distal disease ¯c temporary loop ileostomy
