Surgery conditions (2) Flashcards
Shoulder tip pain following a peritoneal perforation suggests irritation of where?
Diaphragm
What’s intussusception?
Intussusception ⇒ the invagination of one portion of bowel into the lumen of the adjacent bowel, most commonly around the ileo-caecal region
Intussusception usually affects infants between 6-18 months old.
Boys are affected twice as often as girls
Presentation/features of Intussusception
- paroxysmal abdominal colic pain
- during paroxysm the infant will characteristically draw their knees up and turn pale
- vomiting
- bloodstained stool - ‘red-currant jelly’ - is a late sign
- sausage-shaped mass in the right upper quadrant
Ix for Intussusception (1)
ultrasound → may show a target-like mass
Management of intussusception
- reduction by air insufflation under radiological control→ first-line
- if this fails + signs of peritonitis → surgery
Possible cause of intussusception
- Hypertrophied Peyer’s patch
- Meckel’s
- HSP
- Peutz-Jeghers
- Lymphoma
Does intussusception occur in adults?
Intussusception rarely occurs in an adult
• If it does, consider neoplasm as lead-point
What is the blood supply to the ascending colon?
Superior Mesenteric Artery
Causes of GI (gastro-intestinal) perforation
The most common: peptic ulcers (gastric or duodenal) and sigmoid diverticulum
-
Chemical
- Peptic ulcer disease
- Foreign body (e.g. battery or caustic soda)
-
Infection
- Diverticulitis
- Cholecystitis
- Meckel’s Diverticulum
-
Ischaemia
- Mesenteric ischaemia
- Obstructing lesions → resulting in bowel distension and subsequent ischaemia and necrosis
-
Colitis
- Toxic Megacolon (e.g. Clostridum Difficile or Ulcerative Colitis)
-
Iatrogenic
- Recent surgery (including anastomotic leak)
- Endoscopy or overzealous NG tube insertion
-
Penetrating or blunt trauma
- Shear forces from acceleration-deceleration or high forces over small surface area (e.g. a handle bar)
-
Direct rupture
- Excessive vomiting leading to oesophageal perforation (Boerhaave Syndrome)
Clinical features of GI perforation
- pain → typically this is rapid onset and sharp in nature.
- systemically unwell → may also have associated malaise, vomiting, and lethargy
- features of sepsis
- features of peritonism, which may be localised or generalized (a rigid abdomen)
Ix in GI perforation
- ### routine baseline blood tests + G&S
- WCC and CRP → commonly raised
- amylase → often mildly elevated in perforation
- urinalysis → to exclude both renal and tubo-ovarian pathology
- erect chest radiograph (eCXR) can show free air under the diaphragm. Pneumomediastinum or widened mediastinum
- CT scan → confirming any free air presence and suggesting a location of the perforation (as well as a possible underlying cause).
- abdominal radiograph (AXR) → show signs of perforation
Signs of GI perforation on abdominal X ray
- Rigler’s sign – both sides of the bowel wall can be seen, due to free intra-abdominal air acting as an additional contrast
- Psoas sign – loss of the sharp delineation of the psoas muscle border, secondary to fluid in the retroperitoneum
Management of GI perforation (general)
- Broad spectrum antibiotics should be started early, especially in patients
- NIL and NG tube
- IV fluid support
- analgesia
Following this standard initial approach, management becomes highly individualised, taking into account the site of perforation and patient factors. However, most patients with a perforated viscus will require theatre for repair and control of contamination.
Key aspects to consider in surgical intervention for perforated GI (3)
- Identification and (where possible) management of underlying cause
- Appropriate management of perforation, such as:
- Repairing perforated peptic ulcer with an omental patch
- Resecting a perforated diverticulae (e.g. via a Hartmann’s procedure)
- Thorough washout
In which groups of patients, should we consider conservative management of GI perforation?
Physiologically well patients may be managed conservatively, including patients with:
- Localised diverticular abscess / perforation with only localised peritonitis and tenderness, and no evidence of generalised contamination on CT imaging
- Patients with a sealed upper GI perforation on CT imaging without generalised peritonism
- Elderly frail patients with extensive co-morbidities who would be very unlikely to survive surgery
Complications of GI perforation
- infection (peritonitis and sepsis)
- haemorrhage,
Surgical approach in perforation of stomach and duodenum
- Any stomach or duodenum perforation can be accessed typically via an upper midline incision (also can be done laparoscopically), and a patch of omentum is tacked loosely over an ulcer which would otherwise be difficult to oversew due to tissue inflammation
- All gastric ulcers should be biopsied to exclude malignancy
The surgical approach in perforation of small bowel
- Small bowel perforations can be accessed via a midline laparotomy
- small perforations can be oversewn if the bowel is viable, yet any doubt about the condition of bowel should lead to resection and primary anastomosis +/- stoma formation
Surgical approach to large bowel perforation
- can be accessed via midline laparotomy
- anastomosis in the presence of faecal contamination and an unstable patient is not recommended, so a resection with stoma formation is the preferred option
What’s GIST?
Gastro-Intestinal stromal tumour
- Commonest mesenchymal tumour of the GIT
- >50% occur in the stomach
Epidemiology
- M=F
- ~60yrs
- ↑ with NF1
Pathophysiology of GIST
- what cells
- what is seen on OGD
GIST = gastro-intestinal stromal tumour
- Arise from intestinal cells of Cajal
- Located in muscularis propria
- Pacemaker cells
• OGD: well-demarcated spherical mass with central
punctum
Presentation of GIST (2)
GIST = gastro-intestinal stormal tumour
- Mass effects: abdo pain, obstruction
- Ulceration: → bleeding
Management of GIST
GIST = gastro-intestinal stromal tumours
Medical
- Unresectable, recurrent or metastatic disease
- Imatinib: selective tyrosine kinase inhibitor
Surgical
- Resection
NHS screening for colorectal cancer: who, when and what?
- screening every 2 years to all men and women aged 60 to 74 years in England
- Patients aged over 74 years may request screening
- eligible patients are sent Faecal Immunochemical Test (FIT) tests through the post
- a type of faecal occult blood (FOB) test which uses antibodies that specifically recognise human haemoglobin (Hb)
- used to detect, and can quantify, the amount of human blood in a single stool sample
- a patient will be informed if the test is normal or abnormal
- abnormal results → colonoscopy
(3) types of genetic colorectal cancer
- sporadic (95%)
- hereditary non-polyposis colorectal carcinoma (HNPCC, 5%)
- familial adenomatous polyposis (FAP, <1%)
What’s FAP?
FAP = Familial Adenomatous Polyposis
- autosomal dominant condition
- formation of hundreds of polyps by the age of 30-40 years
- Patients inevitably develop carcinoma
- mutation in a tumour suppressor gene called adenomatous polyposis coli gene (APC), located on chromosome 5
Management of FAP
FAP = familial adenomatous polyposis
- Genetic testing →analysing DNA from a patient’s white blood cells
- Patients generally have a total colectomy with ileo-anal pouch formation in their 20s
*Patients with FAP are also at risk from duodenal tumours
*A variant of FAP called Gardner’s syndrome → feature osteomas of the skull and mandible, retinal pigmentation, thyroid carcinoma and epidermoid cysts on the skin
What’s HNPCC?
Pathophysiology
Cancers that are associated with HNPCC
HNPCC = Hereditary Non-Polyposis Colorectar Carcinoma
- autosomal dominant condition
- the most common form of inherited colon cancer
- around 90% of patients develop cancers, often of the proximal colon, which are usually poorly differentiated and highly aggressive
- mutations of DNA mismatch repair genes
Higher risk of other cancers: endometrial cancer being the next most common association, after the colon
Amsterdam’s criteria
- what are they used for?
- describe
Use: for HNPCC (Hereditary Non-Polyposis Colorectal Ca)
The Amsterdam criteria → used to aid diagnosis:
- at least 3 family members with colon cancer
- the cases span at least two generations
- at least one case diagnosed before the age of 50 years
Who to refer urgently for 2ww colorectal Ca service?
- patients >= 40 years with unexplained weight loss AND abdominal pain
- patients >= 50 years with unexplained rectal bleeding
- patients >= 60 years with iron deficiency anaemia OR change in bowel habit
- tests show occult blood in their faeces (see below)
Staging of colorectal cancer (3)
- Staging using CT of the chest/ abdomen and pelvis
- entire colon → colonoscopy or CT colonography
- If tumour lie below the peritoneal reflection → mesorectum MRI
Treatment of colonic cancer
- Palliative adjuncts: stents, surgical bypass and diversion stomas
- Resectional surgery is the only option for cure
- if an obstructing lesion→ either stent it or resect
- chemotherapy (following resection) → a combination of 5FU and oxaliplatin is common
What does resectional surgery for colonic cancer involve?
The procedure is:
- tailored to the patient and the tumour location
- The lymphatic drainage of the colon follows the arterial supply and therefore most resections are tailored around the resection of particular lymphatic chains (e.g. ileo-colic pedicle for right sided tumours).
- Confounding factors that will govern the choice of procedure: HNPCC family may be better served with a panproctocolectomy rather than segmental resection.
(2) techniques of surgical resection in rectal cancer
- anterior resection
- abdomino-perineal excision of rectum (APER)
When APER is chosen as a surgical resection technique for rectal cancer? (2)
APER = abdominoperineal excision of the rectum
- the involvement of the sphincter complex
OR
- very low tumours
Most common type of colorectal cancer
95% adenocarcinoma
*Others: lymphoma, GIST, carcinoid
Risk factors/ associations with colorectal ca
- Diet: ↓ fibre + ↑ animal fat / protein
- IBD: CRC in 15% c¯ pancolitis for 20yrs
- Familial: FAP, HNPCC, Peutz-Jeghers
- Smoking
- Genetics
- No relative: 1/50 CRC risk
- One 1st degree: 1/10
Presentation of colorectal cancer
- Left-located
- Right-located
Left
- Altered bowel habit
- PR mass (60%)
- Obstruction (25%)
- Bleeding / mucus PR
- Tenesmus
Right
- Anaemia
- Wt. loss
- Abdominal pain
Either
- Abdominal mass
- Perforation
- Haemorrhage
- Fistula
Clinical examination of a patient with suspected colorectal ca (possible findings)
- Palpable mass: per abdomen or PR
- Perianal fistulae
- Hepatomegaly
- Anaemia
- Signs of obstruction
Investigations for colorectal ca
Bloods
- FBC: Hb
- LFTs: mets
- Tumour Marker: CEA (carcinoembryonic Ag)
Imaging
- CXR: lung mets
- US liver: mets
- CT and MRI
Staging
•MRI best for rectal Ca and liver mets
• Endoscopy + Biopsy
•Colonoscopy
Duke staging for Colorectal ca (components)
TMN staging for colorectal ca
What does the grading of ca depend on?
Grading from low to high
- Based on cell morphology
- Dysplasia, mitotic index, hyperchromatism
What’s Gardener’s syndrome?
Gardener’s (TODE)
- Thyroid tumours
- Osteomas of the mandible, skull and long bones
- Dental abnormalities: supernumerary teeth
- Epidermal cysts
Peutz-Jeghers syndrome genetics
Peutz-Jeghers Syndrome
- Autosomal dominant
- STK11 mutation
Presentation and risks associated with Peutz-Jeghers syndrome
Presentation at 10-15yrs:
• Mucocutaneous hyperpigmentation
(macules on palms, buccal mucosa)
• Multiple GI hamartomatous polyps
(Intussusception, Haemorrhage)
Cancer risks:
- CRC, pancreas, breast, lung, ovaries, uterus
What are inflammatory pseudopolyps?
Regenerating islands of mucosa in UC
What are hyperplastic polyps?
- Piling up of goblet cells and absorptive cells
- Serrated surface architecture
- No malignant potential
What are Hamartomatous polyps?
- 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 a stalk”
Juvenile Polyposis
- genetics
- number of polyps
- risk
Juvenile Polyposis
- Autosomal dominant
- >10 hamartomatous polyps
- ↑ CRC risk: need surveillance and polypectomy
What’s Cowden Syndrome?
- Auto dominant
- Macrocephaly + skin stigmata
- Intestinal hamartomas
- ↑ risk of extra-intestinal Ca
