Surgery - Colorectal + General

Question 1

What is the 1st line of management for peri-anal abscess?

Answer 1

Incision and drainage under local anaesthetic

Question 2

How many weeks does an anal fissure have to last for to be classified as ‘chronic’?

Answer 2

> 6 weeks

Question 3

What are the 1st and 2nd line management options for chronic anal fissure?

Answer 3

1st line: topical GTN/ dilitiazem/ nifedipine
2nd line (after 8 weeks): sphincterectomy

Question 4

Which colorectal surgical procedure would leave someone with a transverse muscle splitting scar?

Answer 4

Right hemicolectomy

Question 5

Recall 2 colorectal procedures that will not leave someone with laparoscopic port scars

Answer 5

Hartmann’s

Abdomino-perineal resection

Question 6

What does a Hartmann’s procedure involve?

Answer 6

Sigmoid colectomy
Proximal bowel exteriorised as an end colostomy
Distal bowel oversewn to form a rectal stump

Question 7

If a Hartmann’s is reversed, how long after the initial surgery will this be attempted?

Answer 7

3-6 months

Question 8

What are the indications for a Hartmann’s?

Answer 8

Obstruction or perforation secondary to sigmoid tumour or diverticulitis

Question 9

What is the main risk of a high output stoma?

Answer 9

Metabolic acidosis and respiratory compensation

Question 10

Recall 3 small bowel and 3 large bowel causes of obstruction

Answer 10

SBO: hernia, adhesions, tumour
LBO: cancer, volvulus, strictures

Question 11

Recall the Duke stages of colorectal cancer

Answer 11

Duke’s A: tumour confined to mucosa
Duke’s B: tumour invading bowel wall
Duke’s C: LN mets
Duke’s D: distant mets

Question 12

Which type of colorectal cancer is more likely to present with anaemia?

Answer 12

Right sided

Question 13

What is the current protocol for bowel cancer screening in the UK?

Answer 13

Between ages 60 and 74, invited every 2 years to do faceal occult blood test

Question 14

What needs to be done in addition to a sigmoid colectomy to make it a cancer operation?

Answer 14

Complete removal of inferior mesenteric artery as this supplies lymph

Question 15

How should post-op ileus be managed?

Answer 15

NG and IV fluids

Question 16

How does anastomotic dehiscence present, and how common is it?

Answer 16

Day 6 with fever and sepsis, typically

10% of colorectal anastomoses

Question 17

How many colonic adenomas would you expect to see in FAP?

Answer 17

> 100

Question 18

Which types of cancer does Peutz-Jegher’s syndrome predispose to?

Answer 18

Colorectal (20%)

Gastric (5%)

Question 19

What is the schedule of colorectal cancer screening in people who have HNPCC?

Answer 19

Colonoscopy every 1-2y from 25y

Question 20

What is the typical sign on x ray for each of sigmoid and caecal volvulus?

Answer 20

Sigmoid: coffee bean sign
Caecal: embryo sign

Question 21

Which type of volvulus is strongly associated with malignancy?

Answer 21

Caecal

Question 22

What is the best way to treat sigmoid volvulus?

Answer 22

Sigmoidoscopy with air insufflation

Question 23

Recall 5 associations with sigmoid volvulus

Answer 23

Age (older) 
Chagas disease
Schizophrenia
Chronic constipation 
Parkinson's

Question 24

Which sort of bowel obstruction is pregnancy associated with and why?

Answer 24

Small bowel obstruction

Due to caecal volvulus which is associated with pregnancy

Question 25

What are the most important imaging investigations to request in a suspected bowel obstruction?

Answer 25

``` AXR+CXR CT AP (can't go to theatre w/o this) ```

Question 26

In what % of bowel obstruction cases caused by adhesions is conservative management (drip and suck) successful?

Answer 26

65-85%

Question 27

What is Rigler's sign, and what does it indicate?

Answer 27

Air seen on both sides of bowel wall | Indicative of pneumoperitoneum

Question 28

What are the 2 most likley causes of pneumoperitoneum?

Answer 28

Perforation of diverticulum or duodenal ulcer

Question 29

At how many cm is the colon pathologically dilated?

Answer 29

>6cm

Question 30

Where is an inguinal hernia in relation to the pubic tubercle

Answer 30

Superior and medial

Question 31

Which types of hernia carry the highest risk of strangulation?

Answer 31

Femoral and paraumbilical

Question 32

What is a 'mayo repair'?

Answer 32

Surgical reparation of paraumbilical hernia

Question 33

In which demographic group are epigastric hernias most common?

Answer 33

Men 20-30 years

Question 34

Following a surgery to the abdomen, if someone has reduced oxygen saturations and a fever, what complication is most likely to have occured?

Answer 34

Atelectasis

Question 35

What is the difference in appearance between a colostomy and ileostomy?

Answer 35

Colostomy: flush with skin, LIF Ileostoy: sprouted from skin, RIF

Question 36

If acute diverticulitis is not managed by oral abx, what is the next step in treatment?

Answer 36

IV ceftriaxone and metronidazole

Question 37

At what level of haemoglobin should men of any age be 2ww for an upper and lower GI endoscopy?

Answer 37

<110g/L

Question 38

A syndrome consisting of a PTEN mutation and intestinal hamartomas

Answer 38

Cowden disease | multiple intestinal hamartomas - increased breast cancer risk

Question 39

A syndrome which may be present in a patient with multiple intestinal hamartomas and pigmentation spots around the mouth

Answer 39

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

Question 40

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.

Answer 40

Lynch syndrome (HNPCC) Scanty polps associated with coloreactal and endometrial cancer Mainly right sided cancer | colonoscopy every 2-3 yrs, consider removal

Question 41

What is Pilonidal disease

Answer 41

sinuses and cysts form near the upper part of the natal cleft of the buttocks men around 20 - hair debris collects in pores

Question 42

Clinical features of pilonidal disease

Answer 42

pain (may be severe) purulent discharge fluctuant swelling at the site | can be cyclical

Question 43

Management of Pilonidal disease

Answer 43

asymp - conservative with hygeine symp - acute - incision and drainage, wound to close chronic - excision of pits and removal of underlying cavity

Question 44

What are femoral hernias

Answer 44

section of the bowel or any other part of the abdominal viscera pass into the femoral canal | via the femoral ring

Question 45

Features of a femoral hernia

Answer 45

inferolateral to pubic tubercle non - reducible cough impulse absence more common in women e.g. pregnancy

Question 46

Complications of femoral hernia

Answer 46

Incaration - cannot be reduced Strangulation - surgical emergency, tender, non-reducible (more likely in femoral) bowel obstruction bowel ischaemia

Question 47

Mx of a femoral hernia

Answer 47

surgical repair - laparoscopic/tomy no support belts due to herniation

Question 48

Risk factors for Anal fissure

Answer 48

constipation inflammatory bowel disease sexually transmitted infections e.g. HIV, syphilis, herpes

Question 49

Features anal fissure

Answer 49

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

Question 50

Mx for acute and chronic anal fissure

Answer 50

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

Question 51

Main cause of neurogenic shock

Answer 51

Spinal cord transection massive vasodilation due to either decreased sympathetic or increased parasympathetic tone decreased preload hence cardiac output | treat with vasoconstrictors

Question 52

If unfit for lap chole

Answer 52

percutaneous cholecystostomy | calot triangle: avoid right hep artery

Question 53

empyema vs abscess

Answer 53

empyema in own body cavity abscess creates its own