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MRCS > Abdominal > Flashcards

Abdominal Flashcards

1
Q

Persistence of the Vitello-Intestinal Duct

A

Vitelline Fistual (meconium through umbilicus)

Proximal part only = Meckel’s Diverticulum

Does not communicate with ileum = Enterocystoma

Persistent umbilical portion of the duct, which forms a polypoidal raspberry-like tumour of the umbilicus = Entroteratoma

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2
Q

Meckel’s Diverticulum

A

Remnant of vitello-intestinal duct

Located on anti mesenteric border of the ileum

2% (of the population)
2 feet (proximal to the ileocecal valve)
2 inches (in length)
2 types of common ectopic tissue (gastric and pancreatic)
2 years is the most common age at clinical presentation
2:1 male:female ratio

Complications:
Bleeding
Obstruction
Herni (Littre's)
Diverticulitis 
Neoplastic change
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3
Q

Urachus

A

Urachus is a fibrous remnant of the allantois, a canal that drains the urinary bladder of the fetus that joins and runs within the umbilical cord.

Runs from apex of the bladder to the umbilicus

Normally obliterated

Persistence can cause:

  • Discharging umbilicus sinus
  • Cyst
  • Urinary fistula
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4
Q

Umbilical Sepsis

A

Neonatal

Causes serious complications:

  • Portal thrombophlebitis
  • Liver abscess
  • Jaundice
  • Portal vein thrombosis
  • Liver failure

Adults
Caused by retention of sebum within folds of umbilicus or from pilonidal sinus infection of umbilicus

Erythematous

Mixed staphylococcus and streptococcus growth

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5
Q

Haematoma of the rectus sheath

A

Spontaneous rupture of a branch of the inferior epigastric artery –> haematoma in rectus sheath

Presents as abdominal pain + rigidity on one side

More common in elderly people on anticoagulation

USS used to Dx

Mx: Conservative or drainage if problematic

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6
Q

Desmoid Tumour

A

Rare tumour of fibrous intra-muscular septa in the lower rectus abdominis

More common in females CBA

Associated with Gardener’s syndrome (AD polyposis with intra colic and extra colic tumours)

Mx: excised widely as high recurrence and can undergo malignant transformation (fibrosarcoma)

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7
Q

Littre’s Hernia

A

Hernia of Meckel’s Diverticulum

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8
Q

Richter’s Hernia

A

Hernia only involving part of the circumference of the bowel wall

Do not present with usual obstructive features

May present with ileum due to peritonism caused by necrotic bowel

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9
Q

Amyand’s Hernia

A

Hernia of incarcerated appendix

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10
Q

Sliding inguinal hernia

A

Herniating viscus forms part of the of the wall of the hernia sac

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11
Q

Pantaloon Hernia

A

Direct and indirect inguinal hernia

Hernias straddle inferior epigastric artery with bulges either side

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12
Q

Borders of the Inguinal Canal

A

Anterior: External oblique aponeurosis
Lateral 1/3: +Internal oblique

Floor: Inguinal ligament
Reinforced by lacunar ligament medial end

Posterior: Transversalis fascia

Roof: Internal oblique, transversis abdominis (and transversalis fascia)

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13
Q

Location of Deep Inguinal Ring

A

1cm above the Mid-point of the inguinal ligament

1/2 way along the inguinal ligament that arises at the ASIS and inserts on the pubic tubercle

Bound medially by inferior epigastric artery

Deep ring is defect in the transversalis fascia

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14
Q

Location of the Superficial Inguinal Ring

A

Just above and medial to the pubic tubercle

Defect in external oblique aponeurosis

Reinforced by medial and lateral crura

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15
Q

Contents of the Inguinal Canal

A

M: Spermatic Cord
F: Round ligament

Ilioinguinal nerve

  • Doesn’t enter through the deep ring
  • At -risk during hernia repair
  • Sensation to external genitalia

Genital branch of the the genitofemoral nerve

  • Supplies crmaster muscle
  • Anterior scrotal skin / mons pubis + labia majora
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16
Q

Coverings of the spermatic cord

A

Embryologically, takes a covering from each layer of the abdominal wall

Transversalis fascia –> Internal spermatic fascia

Internal oblique –> cremasteric muscle and fascia

External oblique –> external spermatic fascia

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17
Q

Contents of the spermatic cord

A

Spermatic cord contents “3 arteries, 3 nerves, 3 other things”:

3 arteries:

  1. Testicular artery (branch of aorta on R, branch of renal artery L)
  2. Deferential artery (artery to the ductus deferens)
  3. Cremasteric artery (branch of inferior epigastric)

3 nerves:

  1. Genital branch of the genitofemoral
  2. Cremasteric nerve
  3. Autonomics.

3 other things:
Ductus deferens
Pampiniform plexus
Lymphatics

Ilioinguinal nerve

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18
Q

Hernia passes above and medial to pubic tubercle

A

INGUINAL HERNIA

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19
Q

Hernia passes below and lateral to pubic tubercle

A

FEMORAL HERNIA

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20
Q

Hesselbach’s Triangle

A

Medial: lateral border of the rectus abdominis

Lateral: Inferior epigastric artery

Below: Inguinal ligament

(Above: Conjoint tendon)

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21
Q

Managemet of uncomplicated inguinal hernia

A

Neonate –> emergency

Children –> elective herniotomy

Symptomatic adults –> offered surgery

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22
Q

Indications for laparoscopic hernia repair

A

Bilateral hernias for repair

Recurrent hernia

Exploration of the groin when a symptomatic
hernia is suspected from

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23
Q

Age at which conservative management for umbilical hernia is switched to surgical management:

A

3 years

-95% resolve by then

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24
Q

Surgery to correct para-umbilical hernia

A

Mayo procedure

-Flap of rectus sheath and line alba above and below defect

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25
Q

Foramen of Winslow

A

foramen, between the greater sac (general cavity of the abdomen)
and the lesser sac

anterior: the free border of the lesser omentum, known as the hepatoduodenal ligament. This has two layers and within these layers are the common bile duct, hepatic artery, and hepatic portal vein. A useful mnemonic to remember these is DAVE: Duct, Artery, Vein, Epiploic foramen.
posterior: the peritoneum covering the inferior vena cava
superior: the peritoneum covering the caudate lobe of the liver
inferior: the peritoneum covering the commencement of the duodenum and the hepatic artery, the latter passing forward below the foramen before ascending between the two layers of the lesser omentum.

left lateral: gastrosplenic ligament and splenorenal ligament

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26
Q

Visceral referred pain from the abdominal cavity

A

Foregut: lower oesophagus to second part of duodenum –> Epigastric

Midgut: second part of duodenum to to splenic flexure –> Umbilicus

Hindgut: Splenic flexure to rectum –> Hypogastrium

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27
Q

Boas’s sign

A

In acute cholecystitis, pain radiates to the tip of the scapula and there is a tender area of skin just below the scapula, which is hyperaesthetic.

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28
Q

Causes of Raised Amylase

A

Pancreatic conditions
• Acute pancreatitis
• Pancreatic cancer
• Pancreatic trauma

Other intra-abdominal pathology
• Perforated peptic ulcer
• Acute appendicitis
• Ectopic pregnancy
• Intestinal infarction
• Acute cholecystitis

Decreased clearance of amylase
• Renal failure
• Macroamylaseaemia

Miscellaneous
• Head injury
• Diabetic ketoacidosis
• Drugs (e.g. opiates)

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29
Q

Causes of free sub-diaphragmatic gas

A
  • Perforation of an intra-abdominal viscus
  • Gas-forming infection
  • Pleuroperitoneal fistula
  • Iatrogenic: laparoscopy, laparotomy
  • Gas introduced per vaginam: post-partum
  • Interposition of bowel between liver and diaphragm
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30
Q

Common Sites for Intra-Abdominal Abscess

A

Subphrenic space

Subhepatic space

Pelvis

Between loops of bowel

‘pus somewhere, pus nowhere else, pus under the diaphragm’.

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31
Q

Anatomy of the Appendix

A

Blind ended tube situation on the posteromedial aspect of the caecum 2cm below the ileocaecal valve

Average 6-9cm in length

Found at the convergence of the three taenia coli

Has its own mesentry - mesoappendix

Supplied by the appendicular artery which is a branch if the ileocolic artery

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32
Q

Appendix Mass or Abscess

A

Mx Non-Operative as long as no peritonitis

Antibiotics and percutaneous drainage if abscess

Colonoscopy at 6 weeks to rule out malignancy

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33
Q

Appendix positions

A

Retrocaecal

Pelvic

Subcaecal

Paracaecal

Pre-ileal

Post-ileal

Pelvic most common on laparoscopy
Retrocaecal most common on cadaveric

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34
Q

Stimulants for release H2 from parietal cells

A

Vagus nerve acetylcholine

Gastrin

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35
Q

Inhibition of H2 from parietal cells

A

Somatostatin

Gastric inhibitory peptide

Vasoactive intestinal peptide (VIP)

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36
Q

Pepsin Cells

A

Found in body and fundus of stomach

Produce Pepsinogen

–> Pepsin

Stimulated by acteylcholine from vagus nerve

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37
Q

Nissen Fundoplication

A

Hiatus hernia reduced

Crura approximated

Fundus mobilised from underside of diaphragm

Fundus wrapped posteriorly around lower oesophagus and attached to left side of proximal stomach (360 wrap)

Others:
Toupet: 270
Watson: 180

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38
Q

Components of lower oesophageal sphincter

A

Physiological high pressure area in lower oesophagus

Mucosal rosette of the cardia

Angle of oesophagus as it meets the cardia - Angle of His

Diaphragmatic sling / crura

Positive intra-abdominal pressure at lower end of oesophagus

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39
Q

Hiatus hernia

A

Sliding: 90%
Stomach slides through diaphragmatic hiatus, grastro-oesophageal junction lies in thorax
–> Lower sphincter incompetent

Rolling: 10%
Para-oesophageal
Cardia remains below diaphragm: sphincter competent
Stomach rolls up anteriorly through hiatus

(Mixed)

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40
Q

Ivor Lewis Oesophagectomy

A

Two stages

Laparotomy
Stomach fully mobilised on vascular pedicle
Left gastroepiploic and gastric artery divided

Right thoracotomy
Oesophagectomy
Bring up stomach
Anastomasois

Feeding jejunostomy

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41
Q

Trans-hiatal Oesophagectomy

A

Abdominal incision

Mobilise oesophagus through hiatus

Cervical oesophagus by left neck incision

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42
Q

Pharyngeal Pouch

A

Killian’s Dehiscence
Between thyropharyngeus and cricopharyngeus

Posterior pharyngeal pouch

Mx: Endoscopic stapling

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43
Q

Heller’s Myomotomy

A

Lower oesophageal sphincter divided 5cm above junction and 3cm below

+Anterior partial fundoplication to reduce subsequent GORD

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44
Q

Achalasia

A

Failure of relaxation of lower oesophageal sphincter and associated ineffective peristalsis

Degeneration of myenteric plexus of Auerbach

Mx
Balloon dilatation
Surgical: Heller’s

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45
Q

Management of diffuse oesophageal spasm

A

Calcium channel blockers

Sublingual GTN

PPI

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46
Q

Causes of peptic ulcers

A

H.Pylori

NSAIDs

Smoking

Zollinger-Ellison syndrome

Hyperparathyroidism –> hypercalcaemia

Blood group O

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47
Q

Surgical management of gastric ulcers

A

Failure to heal with medical therapy –> indication for surgery

Benign distal ulcers: Billroth I gastrectomy
-Distal stomach removed and proximal stump anastomosed with duodenum

Proximal ulcers: Polya-Type reconstruction
- Anastomosis of gastric remnant to jejunum

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48
Q

Complications of Gastrectomy

A

Dumping

  • Early
  • Late

Diarrhoea

Anaemia

Osteoporosis + Osteomalacia

Nutritional deficiencies

Carcinoma

  • Reflux of bile salts
  • Should be offered endoscopic surveillance
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49
Q

GIST

A

Dx: EUS

<2cm –> discharge

2-5cm –> surveillance

> 5cm –> resect

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50
Q

Meneteriers Disease

A

Gastric mucosal hypertrophy

Mucosal folds in body and fungus grossly enlarged

Leads to over-secretion of acid and mucus

Increased risk of malignancy –> prophylactic gastrectomy

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51
Q

Dumping

A 
Early: True
15-30 minutes post meal
Vasomotor symptoms
Tachycardia
Flushing
Light-headedness 
Sweating
--> Rapid emptying of hyperosmolar (mainly carbohydrates) into small bowel
--> Influx of fluids down osmotic gradient

Late
4 hours
–>Reactive hypoglycaemia

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52
Q

Zollinger-Ellison Syndrome

A

Gastrinoma
Normally in pancreas but can be in duodenum or stomach

MEN 1: 30%

Present with diarrhoea and pain

–> Peptic ulceration

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53
Q

Liver surface anatomy

A

5th intercostal down to right costal margin

Extends to left mid-clavicle

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54
Q

Bilirubin level of clinical jaundice

A

50

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55
Q

Right Hepatic and Right portal vein supply

A

Right hemiliver

Lobes V - VIII

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56
Q

Left Hepatic and Left portal vein supply

A

Left hemiliver

I –> Caudate
II and III –> Left lobe
IV –> Quadrate

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57
Q

Causes of portal hypertension

A

Pre-Hepatic
Congenital atresia of portal vein
Portal vein thrombosis: Neonatal Sepsis, Pyelophlebitis, Trauma, Tumour
Extrinsic compression: Pancreatic, Biliary

Hepatic:
Cirrhosis
Schistosomiasis

Post-Hepatic:
Budd-Chiari syndrome
Cosntrictive pericarditis

(Increased blood flow due to arteriovenous fistula or hyperspenlism)

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58
Q

Hydatid Cyst

A

Tapeworm infection:
Echinococcus granulosus
E. Multiocularis

Adult tapeworm lives in intestine of dog
Ingested ova hatch in duodenum –> portal venous sytem

Leads to cyst with a surrounding fibrosis of the adventitial layer

Rupture can lead to anaphylaxis
Eosinophilia

Mx: Mebendazole

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59
Q

Pyogenic liver abscess pathogens

A 
Strep milleri
E.coli
Strep faecalis
Staph aureus
Anaerobes
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60
Q

Amoebic liver abscess

A

Entamoeba histolytica

Intestine –> trophozoites –> portal vein –> Liver

Right lobe ascess with thin-walles
Solitary

Stool: Ameobae cysts

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61
Q

Mx of Acites

A

Spironolactone

Fluid restriction and Salt restriction

+/- LeVeen shunt for refractory ascotes
Peritoneum –> external jugular

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62
Q

Budd Chiari

A

Portal HTN

Caudate hypertrophy

Liver failure

Gross ascites

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63
Q

Compenents of Child Score

A

Encephalopathy

Ascites

Bilirubin

Albumin

Prothrombin ratio

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64
Q

Antibiotic prophylaxis in Varices

A

Ciprofloxacin 500mg BD

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65
Q

Diagnosis of HCC

A

If resection planned do NOT biopsy

Diagnosis
Two imaging modalities showing arterial hypervascularisation (regardless of AFP)

OR

Single modality showing lesion + AFP >400

OR

Histological diagnosis <2cm

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66
Q

Mx of HCC

A

Resection when possible

Chemo: Doxorubicin, 5-flurouracil,

Sorafenib: Tyrosine kinase inhibitor

67
Q

Milan Criteria

A

Criteria for liver transplant in HCC

Sinlge tumour <5cm

3 or less tumours no bigger than 3cm

68
Q

Angiosarcoma of the liver

A

Vinyl chloride

Thorotrost

69
Q

Liver cell adenoma

A

Require resection as may undergo malignant change

Assoc oral contraceptive pill

Right flank pain due to haemorrhage

Solitary well encapsulated

Nearly always in F

70
Q

Focal nodular hyperplasia of the liver

A

Do not require resection, do not undergo malignant transformation

Central fibrous scar seen on CT

F>M

71
Q

Cavernous haemangioma

A

Commonest benign liver tumour

Pain, swelling and haemorrhage

If arteriovenous communication develops can lead to high output heart failure

Mx: Resection if large

72
Q

Biliary hamartoma

A

Small fibrous lesion just beneath liver capsule

Biopsy usually needed to rule out HCC

73
Q

Course of biliary system

A

Right and left hepatic ducts converge to make the common hepatic duct

Joined by the cystic duct to form common bile duct

Passes behin first part of the duodenum

Passes close to head of pancreas

Joins Pancreatic duct just prior to ampulla of vater

74
Q

Post-Cholecystectomy Syndrome

A

Post-prandial flatulence

Fat intolerance

Epigastric and right hypochondrium discomfort

75
Q

Asiatic chlangiohepatitis

A

Pigment stones form in the intrahepatic and extrahepatic biliary tree

Supparative cholangitis

E.Coli
Strep Faecalis
–> Deconjugation of bilirubin –> stones

Mx:
Endoscopic or percutaneous removal of stones

Ductal obsruction

  • Choledoduodenostomy
  • Hepatojejunostomy
76
Q

Klatskin tumour

A

Sclerotic cholangiocarcinoma involving the confluence of the hepatic ducts

77
Q

Intrahepatic duct dilataion and collapsed gallbladder

A

=cholangiosarcoma

obstruction above cystic duct at hepatic ducts

78
Q

Biliary Atresia

A

1 / 20,000

Commonest cause of prolonged jaundice in infancy

Jaundice at 2-3 weeks of life

Hepatomegaly and splenomegaly

Mx: Early Kasai’s
If identified late –> transplant

79
Q

Infections in bile

A

E. Coli

Klebsiella

Strep facealis

80
Q

Cholechondral cysts

A

Cystic transformation of the biliary tree

Saccular dilatation of the common bile duct
–> often abnormal termination as the common bile duct enters pancreatic head to join pancreatic duct

Undergo malignant transformation

Mx: Excision

81
Q

Complications of acute pancreatitis

A

Infected pancreatic necrosis

Pancreatic pseudocyst

Pancreatic abscess

Progressive jaundice

Gastrointestinal bleeding (splenic artery)

Gastrointestinal ischaemia/fistulae

82
Q

Management of chronic pancreatitis

A

Conservative:

  • Stop cause
  • CREON
  • Glucose control

Endoscopic:
-Stenting

Surgical

  • Beger
  • Frey
83
Q

Pancreatic ductal adenocarcinoma (PDAC)

A

60% arising in the head

characterized by groups of infiltrating carcinoma cells often some distance apart, interspersed by a fibrous stroma

involvement of nerves, vessels, lymphatics and lymph nodes

Metastatic spread is most commonly to the liver and lung; 80%

84
Q

Intraductal papillary mucinous neoplasm (IPMN)

A

Group of lesions characterized by a papillary growth of
the ductal epithelium with rich mucin production and cystic expansion of the affected duct

Two types,
1) Main duct: Definite malignant potential –> Resection

2) Branch duct: Most;ly benign, resect if >3cm or if septae/nodularity

Survival reaching 80–90% for in situ carcinoma,
and 50–70% in the presence of invasive carcinoma

Differ from cystic mucinous

  • Direct communication with the Wirsung duct
  • Absence of ovarian-type stroma
85
Q

Mucinous cystic neoplasm

A

F»M

Multiloculated tumours with a characteristic dense fibrous wall and occasional calcification

Oversecretion of the mucus by the hyperplastic columnar lining of the ducts and therefore contain thickened viscous material,

Can be haemorrhagic.

These tumours should be considered potentially malignant but are classified histologically as benign, borderline, or malignant based on degree of dysplastic changes.

86
Q

Serous cystic neoplasm

A

Serous cystic neoplasms are most commonly Microcystic

Can present in an ‘oligocystic’ or ‘macrocystic’ form when differentiation from other cystic neoplasms can be difficult.

In the presence of multiple serous cysts Von Hippel–Lindau syndrome should be considered

Present as incidental findings or with pressure symptoms or a palpable mass when large.

Dense, internal, lacelike, honeycombed matrix
composed of fibrous septae, and often a central scar.

Diagnosis preoperatively, resection is usually not required as serous cystic tumours have virtually
no malignant potential.

87
Q

Acinar cell carcinoma of the pancreas

A

Tumour cells also may secrete pancreatic
enzymes, most commonly lipase.

Presentation may therefore be confused with acute pancreatitis

88
Q

Whipples

A

Block resection of the:
-Head of the pancreas

  • Distal half of the stomach
  • Duodenum
  • Gallbladder and common bile duct

Reconstruction is achieved by anastomoses of the pancreatic tail remnant to the jejunum (or stomach)

AND

Anastomosing the common hepatic duct and the stomach to the jejunum.

89
Q

Tumours sited in the head of the pancreas Mx

A

Whipples

90
Q

Tumours sited in the tail of the pancreas Mx

A

Distal pancreatectomy and Splenectomy

Most are unresectable

91
Q

PET syndromes

A

MEN 1: 40%

von Hippel-Lindau 10-15%

92
Q

Confusion, sweating, dizziness,
weakness, unconsciousness, relief
with eating

A

Insulinoma

93
Q

Zollinger–Ellison syndrome or severe

peptic ulceration and diarrhoea

A

Gastrinoma

94
Q

Necrolytic migratory erythema, weight
loss, diabetes mellitus, stomatitis,
diarrhoea

A

Glucagonoma

95
Q

Werner–Morrison syndrome of
profuse watery diarrhoea with marked
hypokalaemia

A

VIPoma

96
Q

Cholelithiasis; weight loss; diarrhoea

and steatorrhoea. Diabetes mellitus

A

Somatostatinoma

97
Q

MEN-1

A

Hyperplasia and/or neoplasm of the parathyroid glands

Enteropancreatic NETs

Pituitary adenomas.

PPP

11q13 gene

Familial MEN-1: First degree relative with at least one of the Ps tumour

For PETs, 90% have multiple which is juxtaposed to sporadic-type tumours that tend to be solitary

It is recommended that carriers of MEN-1 mutation are screened biochemically every 1–3 years for hyperparathyroidism, prolactinoma, gastrinoma, insulinoma, and other enteropancreatic
tumours.

98
Q

Indications for splenectomy

A

Trauma
Blunt / penetrating trauma
Iatrogenic intraoperative / endoscopic trauma

Haematological
The purpuras
Haemolytic anaemia
Hypersplenism
Proliferative disease
Misc
Distal pancreatectomy (for benign or
malignant disease)
Proximal gastrectomy
Splenorenal shunt
99
Q

Post-splenectomy immunization

A

Pneumococcal vac repeat
Influenza immunization
Life long antibiotics are phenoxymethylpenicillin or erythromycin

If not previously immunized:
Haemophilus influenza type b
Meningococcal group C conjugate vaccine

Elective splenectomy should be preceded by the
administration of vaccines 2–3weeks prior to surgery

100
Q

True rectum

A

Coalescence of the taeniae coli of the sigmoid colon

to form a continuous outer muscular tube

101
Q

Faecal calprotectin

A

Nonspecific test of intestinal inflammation that can be used to monitor inflammatory bowel disease activity

102
Q

Trotter’s triad

A

Diagnosis of nasopharyngeal carcinoma

  • Unilateral conductive hearing loss
  • Ipsilateral facial & ear pain
  • Ipsilateral paralysis of soft palate
103
Q

Tumours of the appendix

A

Carcinoid
-Appendicectomy sufficient unless >2cm or invokves caecum –> R hemicolectomy

Adenocarcinoma
-R hemicolectomy +/- chemo

Pseudomyxoma peritonei
-Seeding from cystadenoma of appendix

104
Q

Indications for surgery Crohn’s

A

Elective
• Chronic subacute obstruction due to fibrotic strictures,
adhesions or refractory disease
• Symptomatic disease unresponsive to, or poorly
controlled by medical management
• Chronic relapsing disease on discontinuation of medical
management and steroid dependency
• Complications of medical management (e.g. osteoporosis)
• Concerns about long-term immunosuppression, risk of
malignancy and viral/atypical infections
• Perianal sepsis and fistula
• Enterocutaneous fistula
• Onset of malignancy, including colorectal
adenocarcinoma and small bowel lymphoma
• Rarely, control of debilitating extra-colonic manifestations such as iritis and sacroiliitis.

Emergency
• Fulminant colitis or acute small bowel relapse
unresponsive to medical management
• Acute bowel obstruction
• Life-threatening haemorrhage
• Abscess or free perforation
• Perianal abscess.
105
Q

Indications for surgery UC

A

Elective
• Symptomatic disease unresponsive to, or poorly
controlled by, medical management
• Chronic relapsing disease on discontinuation of medical management and steroid dependency
• Complications of medical management
• Concerns about long-term immunosuppression, risk of
malignancy and viral/atypical infections
• Severe dysplasia on surveillance biopsies of colorectal
epithelium
• Onset of colorectal adenocarcinoma
• Rarely, control of debilitating extra-colonic manifestations such as iritis and sacroiliitis.

Emergency
• Fulminant colitis unresponsive to maximal medical
management
• Toxic megacolon
• Free perforation
• Life-threatening haemorrhage
• Acute complications of medical management.

106
Q

GIST

A

Bengin and malignant

C-kit = malignant
–>imatinib

107
Q

Peritoneal coverings of the rectum

A

Upper third: Anterior and sides covered in peritoneum

Middle third: Peritoneum anteriorly

Lower thid: Extraperitoneal

108
Q

Superior rectal artery

A

Continuation of Inferior mesenteric artery

Communicates with middle and lower rectal arteries which are an extension of internal iliac artery

109
Q

Drainage of inferior mesenteric vein

A

Drains into splenic vein

110
Q

Lymph drainage of rectum

A

Drains upwards to Superior rectal and inferior mesenteric lymph nodes

111
Q

Lymph drainage of anal canal

A

Drains to inguinal nodes

112
Q

Position of the appendix

A

Medial wall of caecum

2cm below ileocaecal valve

Taenia coli converge at appendix

113
Q

Management of bile salt diarrhoea

A

Seen in crohns

Cholestyramine

114
Q

5-aminosalicylic acid agents

A

Mesalazine

Olsalazine

Used for maintenance therapy for people with colonic IBD

115
Q

Indications for surgery in Crohns disease (4)

A
  1. Complications of luminal disease: fulminant colitis, life-threatening haemorrhage, obstruction, abscess, sepsis, perforation, fistulation
  2. Acute on chronic medical therapy failure / complications of medical therapy
  3. Treatment or prophylaxis of malignancy
  4. Peri-anal disease
116
Q

Communication between superior mesentric artery and ceolicac axis

A

Pancreaticoduodenal arcade

117
Q

Communication between superior mesenteric artery and inferior mesenteric artery

A

Marginal artery

118
Q

Cells of the small bowel

A

Columnar glandular epithelium

APUD: Amine precursor uptake decarboxylation

Paneth cells

119
Q

Test for bacterial overgrowth

A

C-Xylose

C-Glucochelote

Breath test

120
Q

Tumour of APUD cells

A

Carcinoid

Most common sit eis appendix

Appendectomy

-if >2cm, nodal involvement or involves caecum –> R Hemicolectomy

121
Q

Appendix adenocarcinoma

A

Assoc with Lynch syndrome

122
Q

Mucin-secreting cyst adenoma

A

Pseudomyxoma peritoni

123
Q

Truelove and Witts

A

Mild, Moderare Severe

Severe
Stools / day: >6
Pulse: >90
Temp: >37.8
Hb <105
ESR >30
CRP >30
124
Q

c-kit in GIST

A

=malignant

125
Q

imatinib mesylate

A

Tyrosine kinase inhibitor

Used in GIST

126
Q

Urinary 5-HIAA

A

Carcinoid tumour

127
Q

Competent ileocaecal valve and large bowel obstruction

A

–> Caecal perforation

Largest diamter, Laplace law

128
Q

Small bowel most susceptible to readiation enteritis

A

Jejunum

129
Q

Typical electrolyte abnormalities causing ileus

A

Hypokalaemia

Hyponatraemia

Uraemia

DKA

130
Q

Drugs that cause a paralytic ileus

A

Tricyclic antidepressants

Lithium

Excess opiates

131
Q

Management of pseudo obstruction

A

Management is conservative and involves stimulant enemas.

Colonoscopic deflation may be required in cases where caecal distension

Intravenous erythromycin has been shown to stimulate motility by binding to colonic motilin receptors.

Intravenous neostigmine

132
Q

Commonest site of diverticulosis

A

Sigmoid

133
Q

Solitary diverticulum of caecum

A

Arise from medial wall close to ileocaecal valve

Rare

Can extend upwards retroperitoneally

If becomes obstructed and inflammed, clinically same as appendicitis

134
Q

Management of uncomplicated diverticulitis

A

High fibre diet

Supplemented by bran or a bulk laxative such as
methylcellulose

Stimulant laxatives and purgatives are to be avoided.

Antispasmodics, such as propantheline or
mebeverine

NSAIDs increase complications - AVOID

135
Q

Hinchley Grade

A

Severity of diverticulitis

I: localised para-colic abscess

II: distant abscess e.g. pelvis or sub-diaphragmatic

III: Peritonitis

IV: Faecal peritonitis

136
Q

RET gene mutations

A

Associated with Hirschsprung’s disease

MEN II

137
Q

DUKES: Spread to involve lymph nodes

A

Dukes C

138
Q

DUKES: Spread through full thickness

of bowel wall

A

Dukes B

139
Q

DUKES: Metastatic

A

Dukes D

140
Q

DUKES: Spread into, but not beyond,

muscularis propria

A

Dukes A

141
Q

Indications for radiotherapy for rectal carcinoma

A

High-risk tumours

Risk factors include

  • Low tumour
  • Bulky fixed lesion
  • Anterior lesion
  • Evidence of T3 or T4 stage and/or involved lymph nodes on imaging.
142
Q

Indications for chemotherapy for colorectal cancer

A

Post-operative chemotherapy for Dukes C and D

Combine capecitabine with oxaliplatin

New Abs
Cetuximab: monoclonal antibody against epidermal growth factor receptor
Bevacizumab: monoclonal antibody to vascular endothelial growth factor

143
Q

Position of anorectal cushions

A

3, 7, and 11 oclock

Corrospond to three terminal branches of superior rectal artery
Left
Right posterior
Right anterior

144
Q

Cell lining below dentate line

A

Keratinised squamous cell

145
Q

Cell lining transition zone of anal canal

A

Non-keratinised squamous cell

146
Q

Cell lining anal canal above transition zone

A

Columnar epithelium

147
Q

Structures maintaining faecal continence

A

Intact anorectal and pelvic floor sensation
Intact anal sphincters and levator ani

Preservation of the anorectal angle

The bulk provided by the anal haemorrhoidal ‘cushions’.

148
Q

Staging of haemorrhoids

A

First-degree piles are those that bleed, are visible on
proctoscopy but do not prolapse

Second-degree piles are those that prolapse during
defaecation but reduce spontaneously

Third-degree piles are prolapsed constantly but can be reduced manually

Fourth-degree piles are irreducibly prolapsed.

149
Q

Sites of ano-rectal abscess

A

Peri-anal: common, simple drainage

Intersphincteric: common

Ischiorectal: can become bilateral as no fascial planes - usually require drainage and antibioitcs

High-intermuscular: more complex, can become circumferential

Pelvirectal: more complex, can become circumferential

150
Q

Goodsall’s Rule

A

Anterior opening of fistula on perianal skin: Radial tracking of fistula directly into anal canal

Posterior opening: Line can be drawn between
3 o’clock and 9 o’clock positions
then the tract usually passes circumferentially backwards and enters the anal canal in the midline (6 o’clock position)

151
Q

Management of fistulas-in-ano

A

Low fistulae should be laid open

Complex high fistulae require repair and/or seton insertion

  • Advancement flap
  • +/- defunctioning
152
Q

Types of fistula-in-ano

A

Low intersphinteric

Trans-sphinteric

Supra-sphincteric

Ischiorectal fistula

153
Q

Causes of fistula-in-ano

A 
Common
• Idiopathic (cryptoglandular) due to blockage of anal gland duct
• Crohn's disease
• Anorectal trauma
• Iatrogenic (surgical)
• Anorectal carcinoma

Rare causes
• Ulcerative colitis
• Tuberculosis
• Actinomycosis

154
Q

Mx of anal warts

A

Topical podophyllin

155
Q

Anal verge cancer lymph spread

A

Inguinal lymph nodes

156
Q

Anal canal lymph spread

A

Proximal to mesorectal nodes or internal iliac nodes via the middle rectal lymph nodes

157
Q

Management of anal cancer

A

T1N0 lesions: Local surgical excision only

T2, T3, or T4 lesions: Chemoradiotherapy

  • external beam radiotherapy
  • capecitabine and mitomycin / capecitabine and cisplatinum

Abdominoperineal resection is reserved for failures of
chemoradiation.

158
Q

Management of rectal prolapse

A

Childhood rectal prolapse

  • Conservative
  • Regular bowel habits and reduction of the prolapse

Mucosal prolapse

  • submucosal injection of sclerosant, by photocoagulation or by applying Barron’s bands to the prolapsed area
  • resistant cases: limited excision of the area or stapled anorectal rectopexy
Full-thickness
Perianal Approach
-Delorme's procedure
-Perianal rectosigmoidectomy
-Altmeier procedure

Abdominal approach
-Laparoscopic rectopexy and resection of the redundant sigmoid colon

159
Q

Solitary rectal ulcer syndrome

A

Inordinate amount of time in the toilet attempting
to defaecate

Diagnosis: Anterior ulcer in the low rectum, and biopsy shows submucosal fibrosis, hypertrophy of the muscularis mucosae and overlying ulceration

Mx
Stool softners and psych

160
Q

Traumatic cause of anal incontinence

A

Obstetric sphincter injury

Trauma

Surgical / iatrogenic (drainage or perianal abscess, fistula opening, haemorrhoidectomy)

Perianal sepsis

161
Q

Congenital causes of anal incontinence

A

Anorectal atresia

Spina bifida

162
Q

Neurological causes of anal incontince

A

Denervation of pelvic floor following childbirth

Multiple sclerosis

Low spinal or sacral tumour

Spinal trauma

Dementia

163
Q

Treatment of idiopathic faecal incontinence

A

Avoiding dietary stimulants

Fybogel + loperamide

164
Q

Treatment of rectal irritability

A

Amitriptyline 25mg ON

MRCS (24 decks)

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