Week 4: common colorectal surgical problems

Question 1

Diverticular disease -etiology

Answer 1

-more common in the colon. Are be acquired and false. False meaning that it doesn’t include all layers of bowel wall, only mucosa and submucosa outputting.
-95% are in sigmoid colon
Etiology
-Disease of western countries, dietary influences -fiber content
-intraluminal pressure causes an outward pressure, and protrudes through weakness in wall, where the muscular artery penetrates the colon wall

Question 2

Signs and symptoms of diverticulosis

Answer 2

• found incidentally
• mostly asymptomatic
• common symptoms: episodic Left lower quadrant pain, constipation, diarrhea
• signs: LLQ tenderness

Question 3

Diagnosis of diverticulosis

Answer 3

• definition: presence of diverticula
• barium enema
• colonoscopy
• must be differentiated from carcinoma, essential to do colonoscopy if bleeding

Question 4

Complications of diverticulosis

Answer 4

1. progression to diverticulitis
2. Hemorrhage
   - erosion can lead to bleeding

Question 5

Treatment of diverticulosis

Answer 5

• asymptomatic: increase fiber in diet, better than commercial bulking agents
• education, reassurance
• surgery: for hemorrhage, colon resection is rare

Question 6

clinical findings and Diagnosis of diverticulitis

Answer 6

• acute abdominal pain, aching
• left lower quad. tenderness and /or mass
• nausea and vomiting
• mild abdominal distention
• FEVER AND LEUKOCYTOSIS
• radiologic findings: plain film may show free air, ileus, left lower quad. mass. CT may show air pockets, thickened wall of colon, abscess

Question 7

pathophysio of diverticulitis

Answer 7

• result of perforation due to intraluminal pressure, or it begins as infection in a diverticulum
• microperforation leads to localized inflammation, then to abscess, then to generalized peritonitis
• can be free perforation, indirect perforation from spreading abscess, mesenteric abscess

Question 8

Complications of diverticulitis

Answer 8

1. free perforation leading to abscess
2. fistulization (commonly colo-vesicular)-between colon and bladder
3. stricture leading to obstruction
4. sepsis

Question 9

Treatment of diverticulitis

Answer 9

• admit, NPO, IV antibiotics
• if peritonitis, go to OR
• CT scan to confirm diagnosis, drain abscess
• indications for resection: recurrent disease, persistent diverticulitis, young age, inability to rule out cancer
• surgical: Goal to get to one stage
• one stage: remove sigmoid and reconnect
• two stage-hartmanns: remove sigmoid, put in colostomy bag, then go back and put together

Question 10

Surgical options in colorectal cancer

Answer 10

-wide surgical excision of lesion based on vascular/lymphatic supply
-staging using CT scan
-For rectal cancer
Total mesorectal excision
Abdominoperineal resection: remove distal sigmoid, rectum, and anus with permanent end sigmoid colostomy

Question 11

ileostomy

Answer 11

• can be permanent or temporary
• terminal ileum brought out as end or loop
• complications: most common is skin irritation
• watch for salt and water depletion

Question 12

Colostomy

Answer 12

• indications: decompress an obstructed colon, diversion of the fecal stream i preparation for resection, allows evac of stool if rectum/anus is resected, protection of distal anastomosis
• 20% complication rate: parastomal hernia is most common. Can have prolapse, necrosis/retraction.