Surgery - Colorectal + General Flashcards
What is the 1st line of management for peri-anal abscess?
Incision and drainage under local anaesthetic
How many weeks does an anal fissure have to last for to be classified as ‘chronic’?
> 6 weeks
What are the 1st and 2nd line management options for chronic anal fissure?
1st line: topical GTN/ dilitiazem/ nifedipine 2nd line (after 8 weeks): sphincterectomy
Which colorectal surgical procedure would leave someone with a transverse muscle splitting scar?
Right hemicolectomy
Recall 2 colorectal procedures that will not leave someone with laparoscopic port scars
Hartmann’s
Abdomino-perineal resection
What does a Hartmann’s procedure involve?
Sigmoid colectomy
Proximal bowel exteriorised as an end colostomy
Distal bowel oversewn to form a rectal stump
If a Hartmann’s is reversed, how long after the initial surgery will this be attempted?
3-6 months
What are the indications for a Hartmann’s?
Obstruction or perforation secondary to sigmoid tumour or diverticulitis
What is the main risk of a high output stoma?
Metabolic acidosis and respiratory compensation
Recall 3 small bowel and 3 large bowel causes of obstruction
SBO: hernia, adhesions, tumour
LBO: cancer, volvulus, strictures
Recall the Duke stages of colorectal cancer
Duke’s A: tumour confined to mucosa
Duke’s B: tumour invading bowel wall
Duke’s C: LN mets
Duke’s D: distant mets
Which type of colorectal cancer is more likely to present with anaemia?
Right sided
What is the current protocol for bowel cancer screening in the UK?
Between ages 60 and 74, invited every 2 years to do faceal occult blood test
What needs to be done in addition to a sigmoid colectomy to make it a cancer operation?
Complete removal of inferior mesenteric artery as this supplies lymph
How should post-op ileus be managed?
NG and IV fluids
How does anastomotic dehiscence present, and how common is it?
Day 6 with fever and sepsis, typically
10% of colorectal anastomoses
How many colonic adenomas would you expect to see in FAP?
> 100
Which types of cancer does Peutz-Jegher’s syndrome predispose to?
Colorectal (20%)
Gastric (5%)
What is the schedule of colorectal cancer screening in people who have HNPCC?
Colonoscopy every 1-2y from 25y
What is the typical sign on x ray for each of sigmoid and caecal volvulus?
Sigmoid: coffee bean sign
Caecal: embryo sign
Which type of volvulus is strongly associated with malignancy?
Caecal
What is the best way to treat sigmoid volvulus?
Sigmoidoscopy with air insufflation
Recall 5 associations with sigmoid volvulus
Age (older) Chagas disease Schizophrenia Chronic constipation Parkinson's
Which sort of bowel obstruction is pregnancy associated with and why?
Small bowel obstruction
Due to caecal volvulus which is associated with pregnancy
What are the most important imaging investigations to request in a suspected bowel obstruction?
AXR+CXR CT AP (can't go to theatre w/o this)
In what % of bowel obstruction cases caused by adhesions is conservative management (drip and suck) successful?
65-85%
What is Rigler’s sign, and what does it indicate?
Air seen on both sides of bowel wall
Indicative of pneumoperitoneum
What are the 2 most likley causes of pneumoperitoneum?
Perforation of diverticulum or duodenal ulcer
At how many cm is the colon pathologically dilated?
> 6cm
Where is an inguinal hernia in relation to the pubic tubercle
Superior and medial
Which types of hernia carry the highest risk of strangulation?
Femoral and paraumbilical
What is a ‘mayo repair’?
Surgical reparation of paraumbilical hernia
In which demographic group are epigastric hernias most common?
Men 20-30 years
Following a surgery to the abdomen, if someone has reduced oxygen saturations and a fever, what complication is most likely to have occured?
Atelectasis
What is the difference in appearance between a colostomy and ileostomy?
Colostomy: flush with skin, LIF
Ileostoy: sprouted from skin, RIF
If acute diverticulitis is not managed by oral abx, what is the next step in treatment?
IV ceftriaxone and metronidazole
At what level of haemoglobin should men of any age be 2ww for an upper and lower GI endoscopy?
<110g/L
A syndrome consisting of a PTEN mutation and intestinal hamartomas
Cowden disease
multiple intestinal hamartomas - increased breast cancer risk
A syndrome which may be present in a patient with multiple intestinal hamartomas and pigmentation spots around the mouth
Peutz-Jeghers syndrome
STK11
Multiple benign intestinal hamartomas
Episodic obstruction and intussusception
Increased risk of GI cancers
annual pan intestinal endoscopy each 2-3 yrs
A syndrome likely to be present in a 28-year-old man who presents with a locally advanced mucinous carcinoma of the caecum. There are scanty polyps in the remaining colon. His father died from colorectal cancer aged 34.
Lynch syndrome (HNPCC)
Scanty polps associated with coloreactal and endometrial cancer
Mainly right sided cancer
colonoscopy every 2-3 yrs, consider removal
What is Pilonidal disease
sinuses and cysts form near the upper part of the natal cleft of the buttocks
men around 20 - hair debris collects in pores
Clinical features of pilonidal disease
pain (may be severe)
purulent discharge
fluctuant swelling at the site
can be cyclical
Management of Pilonidal disease
asymp - conservative with hygeine
symp - acute - incision and drainage, wound to close
chronic - excision of pits and removal of underlying cavity
What are femoral hernias
section of the bowel or any other part of the abdominal viscera pass into the femoral canal
via the femoral ring
Features of a femoral hernia
inferolateral to pubic tubercle
non - reducible
cough impulse absence
more common in women e.g. pregnancy
Complications of femoral hernia
Incaration - cannot be reduced
Strangulation - surgical emergency, tender, non-reducible (more likely in femoral)
bowel obstruction
bowel ischaemia
Mx of a femoral hernia
surgical repair - laparoscopic/tomy
no support belts due to herniation
Risk factors for Anal fissure
constipation
inflammatory bowel disease
sexually transmitted infections e.g. HIV, syphilis, herpes
Features anal fissure
painful, bright red, rectal bleeding
around 90% of anal fissures occur on the posterior midline.
if the fissures are found in alternative locations then other underlying causes should be considered e.g. Crohn’s disease
Mx for acute and chronic anal fissure
acute less than 1 week
soften stool
high-fibre diet with high fluid intake
bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
lubricants such as petroleum jelly may be tried before defecation
topical anaesthetics
analgesia
chronic
the above techniques should be continued
topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
Main cause of neurogenic shock
Spinal cord transection
massive vasodilation due to either decreased sympathetic or increased parasympathetic tone
decreased preload hence cardiac output
treat with vasoconstrictors
If unfit for lap chole
percutaneous cholecystostomy
calot triangle: avoid right hep artery
empyema vs abscess
empyema in own body cavity
abscess creates its own
