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Y6 Senior Surgery > Colorectal > Flashcards

Colorectal Flashcards

1
Q

What are causes of small bowel obsturction

A

HAT

Hernia
Adhesion
Tumour

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2
Q

What are causes of large bowel obstruction

A

CVS
Cancer
Volvulus
Strictures (from diverticulitis)=

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3
Q

What are big risks with bowel obstruction

A

Hypovolaemia > AKI (due to third spacing)
Perforation
Ischaemia

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4
Q

What is third spacing

A

Mechanical blockage of bowel > proximal dilation with increased peristalsis > draws more water into bowel > HYPOVOL SHOCK

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5
Q

What are classical sx of bowel obstruction

A

severe abdominal pain, colicky, widespread
Vomiting (bilious)
Distension
Absolute constipation

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6
Q

What are cllassical ssx of bowel obstruction

A

guarding
rebound tenderness
tinkling bowel sounds

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7
Q

What is the initial investigation that they often get with bowel obstruction

A 
Erect CXR (to check for free fluid under diaphragm)
OR abdominal XR (to look at bowel distension)
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8
Q

Whart is definitive Ix for bowel obstruction

A

abdo CT

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9
Q

What will the abdo x ray show for small bowel vs large bowel obstruction

A

small bowel: >3cm, central, valvulae conniventes

large bowel: >6cm (colon), >9cm (sigmooid), haustrae

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10
Q

What is approach for bowel obstruction

A

NBM immediately
Drip and Suck - NG tube with free drainage + IV fluid resus
Surgery (emergency laparotomy to resolve cause)

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11
Q

What is volvulus

A

Twisting of intestinal loop around its mesenteric attachment > closed loop bowel obstruction

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12
Q

What are complications of volvulus

A

Bowel has compromised blood supply > rapid ischaemia, necrosis and perforation risk

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13
Q

what are two different types of volvulus

A

sigmoid (80%) vs caecal (20%)

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14
Q

Explain characteristic patient of sigmoid volvulus

and what occurs

A

Older, chronic constipation

sigmoid bowel twists around mesentery > large bowel obstruction

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15
Q

What is the cause of a caecal volvulus

A

abnormality in development (falure of peritoneal fixation) that makes the volvulus at risk of twisting&raquo_space; small bowel obstruction due to proximal large bowel obstruvtive cause

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16
Q

imaging of volvulus

A

sigmoid: AXR > COFFEE BEAN SIGN (+ normal LBO signs)
caecum: on AXR has normal SBO signs

CT ABDO PELVIS WITH CONTRAST > WHIRL SIGN

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17
Q

Management of sigmoid volvuluis

A

decompress with sigmoidoscope + flatus tube insertion
leave flatus tube in for up to 24h

if decompression fails repeatedly or peritonism: laparotony

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18
Q

Describe large bowel anatomy

A

Appendix > caecum > ascending colon > right colonic flexure > transverse colon > left colonic flexure > descending colon > sigmoid > rectum > anus

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19
Q

what is does a right hemicolectomy remove and when is it used?what type of anastamosis

A

the caecum and ascending coon
used for tumours in this caecum and proximal ascending colon

iliocolic anastamosis

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20
Q

what does an extended right hemicolectomy remove and when is it used?what type of anastamosis

A

caecum ascending colon and transverse colon

for tumours in distal descending colon or transverse oolon

iliocolic anastamosis

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21
Q

what is a left hemicolectomy used for, what does it remove? what is anastamosis

A

descending colon

for tumours in descending colon

colocolic anastamosis

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22
Q

what is hartmann’s procedure remove

A

sigmoid colon

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23
Q

when is hartmann’s used for

A

obstrution or perforation secondary to sigmoid tumour or diverticulitis – EMERGENCY

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24
Q

what colorectal procedures leave you with a stoma

A

Hartmsnn’s
AP resection
Anterior resection

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25
Q

where and what stoma do you get with Hartmann’s

A

single lumen colostomy in LIF

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26
Q

what is an AP resection

A

Abdominal Perineal Resection

aka BARBIE BUTT PROCEDURE

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27
Q

What does an AP resection remove

A

Abdominal incision: sigmoid, rectum and mesorectal nodes

Perineal incision: anus removed

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28
Q

what stoma do you get with AP resection

A

single lumen colostomy in LIF

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29
Q

what are indications forAP resection

A

rectal cancer LESS THAN 4-5 cm from anal verge ==> LOW RECTAL TUMOUR
(Anal Proximity tumour!!)

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30
Q

what are indications for anterior resection

A

rectal cancer MORE THAN 4-5 cm from anal verge ==> MID/HIGH RECTAL TUMOUR

you resect part of rectum and sigmoid colon

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31
Q

what stoma are you left with in anterior resection

A

DOUBLE LUMEN loop ileostomy in RIF

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32
Q

what are classical symptoms of colorectal cancer

A

change in bowel habit
PR bleed
WL, fatigue
ANaemia

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33
Q

what is the most important ix to get in suspected colorectal cancer

A

COLONOSCOPY

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34
Q

what colorectal cancer screening currently exists in UK

A

60-74 years old receive FIT test faecal immunochemical test (FIT) every 2 yearts

this is essentially a FOB that recognises antibodies against human Hb

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35
Q

what happens if FIT +ve

A

colonoscopy offered

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36
Q

How do you manage colorectal cancer

A

resection +-neoadjuvant chemo/radiotherapy

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37
Q

what is the most common type of abdominal hernia

A

INGUINAL hernia

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38
Q

what is the risk in a man of having an INGUINAL hernia

A

1 in 4

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39
Q

What are the two types of inguinal hernia?

A

INDIRECT vs DIRECT hernia

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40
Q

Explain INDIRECT hernia

A

Common in young boys
peritoneal sac protrudes through deep ingluinal ring > inglluinal canal > superficial ring > testes

due to weakness of deep inguinal ring (which is where structures pass during development to reach external genitalia=

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41
Q

Explain DIRECT inguinal hernia

A

DIRECT inguinal hernia
still more common in men, but this time RF are age, lifting heavy weights

peritoneal sac enters through weakening in abdominal wall eventually into inguinal canal (through superficial ring)

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42
Q

where are ingluinal hernias found

A

Above and medial to pubic tubercle

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43
Q

where are femoral hernias found

A

Below and lateral to pubic tubercle

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44
Q

Explain how femoral hernias occur

A

weakness in abdominall wall causes protrusion of intestinal content through femoral canal

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45
Q

WHo are femoral hernias most common in

A

WOMEN

due to large pelvis (which means tissues are more stretched)

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46
Q

What are femoral hernias at high risk of

A

strangulation and obstruction

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47
Q

What type of hernia respods to cough impulse

A

INGUINAL

48
Q

what is incarceration of a hernia

A

hernia CANNOT be reduced

49
Q

what is strangulation of a hernia

A

hernia becomes ischaemic due to compromised blood supply

50
Q

What do you do if hernia is incarc / strangulated?

A

EMERGENCY surgery

51
Q

what do you do if hernia is not strangulated / incarc?

A

depends on type of hernia

if inguinal: ruotine repair, even if asymptomatic
if femoral: urgent repair (due to high risl of strangulation)

52
Q

What are the two approaches to femoral hernia repair

A

if eLective: Lockwood Low approach (low incision over hernia with herniotomy/herniorrhaphy)
if eMergency: McEvedy High approach (via inguinal region to inspect and resect non viable bowel)

53
Q

What are the types of surgery you can use for hernia repar

A

herniotomy: ligation + excision of hernial sac
herniorrhaophy: repair of abdo wall defect
hernioplasty: mesh implant

54
Q

what incisions do you leave for herni repain

A

McBurney (oblique)

Lanz (transverse)

55
Q

how do you differentiate between direct and indirect inguinal hernia

A
  1. reduce the hernia
  2. press on deep inguinal ring
  3. Ask patent to cough

if the hernia is DIRECT: it will protrude
if hernia is INDIRECT: it will NOT protrude as you are blocking its way out

56
Q

what does pain suggest in jaundice?

A

PAINFUL jaundice = gallstone disease

painLESS jaundice = pancreatric cancer

57
Q

what is toxic megacolon

A

acute colonic distension (dilatation >6cm on AXR) + systemic symptoms of infection (fevers, shock)

58
Q

causes of toxic megacolon

A
  • IBD (most common - most likely UC)
  • C diff
  • Ischaemic colitis
  • bowel cancer
  • volvulus
59
Q

risk with toxic megacolon

A

likely to PERFORATE&raquo_space; death

60
Q

Ix toxic megacolon

A

SEPSIS 6

Ix: FBC, CRP, UE, LFT, stool sample
AXR and abdo CT

61
Q

Mx of toxic megacolon

A 
NBM
Drip and suck 
start IV Abx 
Involve surgeons early
If no improvement within 72 hours / deterioraton: take for emergency laparotomy
62
Q

how does perforation show on CXR

A

free air under diaphragm BILATERALLY

63
Q

how does perforation show on AXR

A

RIGLER SIGN = double wall sigh

Both the LUMINAL surface and the SEROSAL surface are seen.

** the SEROSAL surface should not be visible as it is normally in contact with other intra-abdominal content of similar density (other loops of bowel, omentum, fluid).

64
Q

what is MESENTERIC ADENITIS

A

inflammation of the mesenteric lymph nodes - due to infecton (adenovirus, EBV, beta haem step)

65
Q

how does MESENTERIC ADENITIS present

A

Similar to appendicitis - except for HIGH FEVER

66
Q

what does laparotomy show on mesenteric adenitis

A

enlarged mesenteric lymph nodes

67
Q

What is meckels’ diverticulitis - and how does it present

A

ectopic gastric mucosa

RIF pain (worse after eating)
bleeding (IDA)
68
Q

what investigation is important if anal fistula in Chrons

A

get an MRI to check track of fistula

69
Q

what does an ileostomy drain?

A

the SMALL BOWEL (ILEO = ileum)

70
Q

Where is an ileostomy typically?

A

RIF

71
Q

What does an ileostomy shape typically loook like?

A

SPOUTED

due to the acidic nature with high enzyme contents, which irritates the surrounding skin. A spout minimises this

72
Q

what is output of ileostomy like?

A

LIQUID to SEMI-LIQUID output (as this is small bowel content)

Usually high output, so 500ml - 1L/day

73
Q

where is a colostomy usually located

A

LIF

74
Q

what is the shape of a colostomy look like

A

FLUSH to the skin

75
Q

what does the content of a colostomy looko like

A 
Semi solid to solid (faecal matter) 
low output (200-300ml)
76
Q

when do you do a double lumen (loop) stoma

A

both ends connect out

this is temporary, to allow distal bowel to rest. Wll then be reversed

77
Q

complications of stoma

A

immediate: bleeding, necrosis from poor blood supply
early: high outpput causing dehydration and micronutrient lot, obsructon, retraction
late: obstruction, prolapse (out of skin), parasternal hernia (contained within the skin), skin irritation, psych

78
Q

what do you do if at GP, seen pt >60 with IDA?

A

URGENT referral to colorectal team for COLONOSCOPY +- OGD

79
Q

what is the method of inheriitance of FAP

A

Autosoml DOMINANT

mutation of APC gene

80
Q

what occurs in FAP

A

mutation of APC gene
hundreds of colonic adenomas develop
so the cancer risk is 100%

81
Q

how do you manage FAP

A

annual flexi-sigmoidoscopy from age of 15
if no polyps found > 5 yearly colonoscopy from 20y
if polyps found > resection

82
Q

method of inheritaance of Peutz-Jeguers

A

autosomal DOMINANT

83
Q

presentation of Peutz-Jeguers

A

multiple benign intestinal hamatomas + PIGMENTATION PATTERN
can cause episodic obstruction or intussusception
risk of GI cancer and risk of breast, ovarian, cervical, pancfreatic and testicular cancers

84
Q

how do you screen for peutz jeugers

A

intestinal endoscopy every 2-3 yeas

85
Q

cancers associuated with HNPCC

A

COLORECTAL + Endometrial, gastric, pancreatic cancer

86
Q

which geneit condition needs prophylactic surgery

A

HNPCC

87
Q

what situations require a 2ww colorectal referral

A
  • over 40 with WL and abdo pian
  • over 50 with rectal bleed
  • over 60 with IDA
  • FOB+ve
88
Q

what are the two commonest post op complications of colorectal tumour resection

A

ileus

anastamotic dehiscence

89
Q

what occurs with ileus after colorectal tumour resection

A

peristalsis stops > electrolytes and fluid dissolve into lumen > low electrolytes in blood and dehydrated picture despite normla fluid balance

90
Q

how do you manage ileuas

A

NG tube + fluids

91
Q

how does an anastamotic dehiscence present

A

day 6, fever, septic picturw

92
Q

which area of the gut has the WORSE perfusion

A

the splenic flexure (between transverse and descending colon=)

93
Q

mangement of caecal volculus

A

lapatotomy (right hemicolectomy often needed)

94
Q

what key sx does rectal intussusception (internal rectal prolapse) present with

A

obstructed defecation – associated with childbirth

95
Q

what kinds of surgery are commonly done with chron’s disease

A

perianal fistula = seton suture
perianal disease = proctectomy
terminal ileum = iliocaecal resection

96
Q

which procedure must you avoid in chroons and why

A

avoid ILIOANAL POUCH

high risk of failure

97
Q

what is a total proctocolectomy

A

complete removal of large inteestine (colon) and rectum (procto)

98
Q

what is a subtotal colectomy

A

removal of colon but NOT of rectum

99
Q

what is the indication for ilio-anal pouch

A

used for UC after a SUBTOTAL COLECTOMY
can only be performed if the rectum is still in place (as patient still needs to pass stool. by themselves > still need to have rectal continence)

avoids a stoma! :)

100
Q

what surgery is classically done in UC patient in emergency situation

A

subtotal colectomy + loop ileostomy

later consider ilioanal pouch to avoid stoma bag

101
Q

ilioanal pouch complications

A

anastomotic dehiscence
pouchitis
poor physiological function with seepage and soiling.

102
Q

what marker is used to monitor the response to treatment in colorectal cancer?

A

CEA

103
Q

what is the important finding that you see in the rest of the bowel with a caecal volvulus

A

no other gas findings in the rest of the bowel

becuase NOTHING can get through

104
Q

where are primary anal fissures (due to constipation) most likely located

A

90% are posterior

10% anterior

105
Q

what do lateral anal fissures inidicate

A

that the anal fissure is the secondary conodition > look for the cause!

106
Q

how do you manage a pt with mild diverticulitis

and what do you do if they do not improve

A

oral abx, send home
if do not improve within THREE DAYS

admit for CEF AND MET IV

107
Q

sx of acute diverticulitiis (esp location of pain)

A

Severe LIF pain (as sigmoid colon is where colon narrows down)
bloody stool
fever
urinary sx (diverticular fistulation into bladder)

108
Q

explain dukes staging for colorectal cancer

A

Dukes A: confined to mucosa
B: through bowel wall
C: lymph node invasion
D: distant mets

109
Q

when do you need to do a laparotomy in sigmoids volvulus

A 
if PERITONITIC (so skip sigmoidoscopy) 
or if REPEATED FAILED ATTEMPTS
110
Q

what is the key sx difference between haemorrhoids and anal fissures in MCQ land

A

haemorrhoids are painless (unless thrombosed)

111
Q

mx of anal fissure

A

<6weeks: dietary advice, bulk-forming laxatives
>6 weeks: try topical GTN or topical diltaziem, nifedipine
after 8 weels:_ refer for sphincterotomy of botulinum toxin

112
Q

triad of gastric volvulus

A

vomiting
pain
failed attempts at passing NG tube

113
Q

what kind of stoma should you aim for in distal bowel cancer

A

a loop ileostomy

to allow rest of distal bowel prior to reversal

114
Q

when would you use IV iron compared to PO

A

when:
- oral replacement is ineffective or intolerable
- ferritin is very low and needs to be replaced very quickly

115
Q

what investigation must you do to ensure that anastamosis has healed

A

GASTROGAFFIN contrast enema

Y6 Senior Surgery (10 decks)

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