surgery - colorectal

Question 1

typically present with significant pain and a tender lump
examination reveals a purplish, oedematous, tender subcutaneous perianal mass

suggestive of:

Answer 1

thrombosed haemorrhoids

- pain on defaecation, tender lump, on background of haematochezia

Question 2

management for patients presenting with symptoms of large bowel obstruction due to hepatic flexure cancer.

Answer 2

right hemicolectomy

- removing cecum, ascending colon, proximal third of transverse colon

Question 3

What is Hartmann’s procedure?

Answer 3

• in emergencies
• such as bowel obstruction or perforation
• involves complete resection of rectum and sigmoid colon with formation of an end colostomy and closure of rectal stump

Question 4

76 y/o male with mid-rectal tumour. Post CT, tumour graded T2N0M0.

surgical option for this patient?

Answer 4

low anterior resection

Question 5

A 66-year-old man attends the emergency department with a 4-day history of progressive abdominal pain. Today, he has also been feeling nauseated and has vomited twice. His bowels have not opened for 5 days and he is not passing wind.

He has a past medical history of hypertension. He takes amlodipine and ramipril every morning and smokes 15 cigarettes a day.

On examination, he appears pale. His abdomen is distended and tender on palpation.

What is the most likely underlying diagnosis?

Answer 5

colorectal cancer

- bowel cancer common cause of large bowel obstruction

Question 6

what is the most common cause of small bowel obstruction?

Answer 6

adhesions

nausea and vomiting are early signs of proximal lesion

Question 7

causes of large bowel obstruction?

Answer 7

• bowel cancer
• diverticular stricture
• volvulus

Question 8

investigations for large bowel obstruction?

Answer 8

abdominal X-RAY

CT
- highly sensitive

Question 9

what is volvulus?

Answer 9

• torsion of colon around mesenteric axis

- leads to compromised blood flow and closed loop obstruction

Question 10

sign of volvulus on x-ray?

Answer 10

‘coffee-bean’ sign

Question 11

which is used to monitor patients with colorectal cancer?

• CA125
• Alpha-fetoprotein
• CA199
• CA153
• Carcinoembryonic antigen

Answer 11

carcinoembryonic antigen

- used to monitor for recurrence in patients post-operatively

Question 12

colorectal screening for adults involves?

Answer 12

• faecal immunochemical test (FIT) screening to older adults

Question 13

The stoma is pink and flush to the surface of the abdomen

what type of stoma bag is this?

Answer 13

colostomy

• flush to skin
• enzymes in colon less alkaline than those in small intestine

ileostomy is spouted
- to prevent the surrounding skin from coming into contact with alkaline enzymes in the small intestine

Question 14

A 23-year-old male presents with bright red rectal bleeding that occurs post defecation onto the toilet paper. He has been suffering from severe pain associated with this. On external anal examination there is a skin tag located at the 6 O’clock position.

Answer 14

fissure in ano

Question 15

Severe rectal Crohns that has developed complications such as haemorrhage and multiple fistulae is usually best managed with…

Answer 15

proctectomy

- surgery to remove all or part of the rectum

Question 16

A 54 year old man is referred to clinic with change in bowel habit, blood in his stools, lethargy and weight-loss. A colonoscopy is ordered which shows a high rectosigmoid mass. Which operation would be most appropriate?

Answer 16

anterior resection

- remaining sigmoid is anastomosed to the lower rectum

Question 17

Which classification describes the extent of spread of colorectal cancer?

Answer 17

Duke’s classification

Duke A - tumour confined to mucosa

Duke B - tumour invading bowel wall

Duke C- lymph node metastases

Duke D - distant metastases

Question 18

what might be considered for patients with a history of an anal fissure which has failed to resolve with conservative methods?

Answer 18

sphincterotomy

Question 19

management of acute anal fissure

Answer 19

1. soften stool
   - high fibre with high fluid
   - laxatives , lactulose
2. lubricants before defecation
3. topical anaesthetics
4. analgesia

Question 20

management of a chronic anal fissure?

Answer 20

• topical GTN first line

- then sphincterotmy referral or botulinum toxin

Question 21

triad of vomiting, pain and failed attempts to pass an NG tube

patient also has

• distended abdomen
• vomiting

indicative of:

Answer 21

gastric volvulus

• severe epigastric pain
• retching
• inability to pass an NG tube

Question 22

this is a method to divert bowel contents away from a distal anastomosis. It is often indicated in rectal cancers

Answer 22

loop ileostomy