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Surgery Revision > Colorectal > Flashcards

Colorectal Flashcards

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1
Q

Blood supply to the appendix

A

Appendicular artery

terminal branch of ileocolic artery - branch of the SMA

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2
Q

Things that can obstruct an appendix

A
  • faecoliths
  • calculi
  • lymphoid hyperplasia
  • infection
  • tumour
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3
Q

Pathogenesis of appendicitis

A
  • obstruction
  • increased luminal and intramural pressure
  • thrombosis and occlusion of small vessels and stasis of lymph
  • activation of visceral nerves T8-T10 = central pain
  • parietal inflammation = localised pain
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4
Q

Classical signs and symptoms of appendicitis

A
  • RLQ pain
  • anorexia
  • nausea and vomiting
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5
Q

Differentials for appendicitis

A
  • UTI
  • renal calculi
  • gastroenteritis
  • rupture ovarian cyst
  • PID
  • cholcystitis
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6
Q

3 Eponimous clinical signs in appendicitis

A
  • Rovsing’s sign
  • Obturator sign
  • Iliopsoas sign
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7
Q

Rovsing’s sign

A

Palpation of the lower left quadrant elicits pain in the right lower quadrant

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8
Q

Obturator sign

A

Pain with internal rotation of the hip (pelvic appendix)

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9
Q

Iliopsoas sign

A

Extension of the right hip elicits pain in the right hip (retrocecal appendix)

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10
Q

U/S findings in appendicitis

A

Want to exclude pelvic pathology

  • thickened wall >2mm
  • increased appendix diameter >6mm
  • free fluid
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11
Q

CT findings in appendicitis

A
  • thick wall
  • appendix diameter >7mm
  • appendicolith/abscess
  • free fluid
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12
Q

Management of appendicitis

A
  • admission
  • IV fluid + analgesia
  • if confident, appendectomy
  • investigation
  • diagnostic lap for young women
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13
Q

What is an appendicular mass?

A

> 5 days of symptoms
Findings in RLQ
palpable mass

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14
Q

Treatment of appendicular abscess

A

CT/US-guided percutaneous drainage

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15
Q

Definition of a volvulus

A

A loop of bowel and its mesentery twist on a fixed point at its base
Causes obstruction

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16
Q

Pathophysiology of volvulus

A
  • torsion and obstruction
  • gas an fluid production
  • loop distends
  • fluid and electrolyte loss
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17
Q

How does volvulus progress to gangrene?

A
  • obstruction of mesenteric blood flow
  • increased intraluminal pressure obstructs venous and arterial obstruction

Subserosal petechiae - blood stained ascites
- gangrene

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18
Q

Most common volvulus sites

A
  • sigmoid

- caecum

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19
Q

Less common volvulus sites

A
  • transverse colon
  • splenic flexure
  • descending colon
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20
Q

Risk factors for sigmoid volvulus

A
  • long sigmoid and mesocolon with narrow mesenteric attachements
  • chronic constipation
  • high fibre diet
  • use of enemas
  • altitude
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21
Q

Difference between endemic and sporadic volvulus

A

Endemic patients have increased blood supply and so present less with gangrene and more with fluid sequestration

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22
Q

Presenting features of sigmoid volvulus

A
  • recurrent abdo distention
  • constipation
  • pain
  • dyspnoea
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23
Q

Investigations to diagnose sigmoid volvulus

A
  • upright abdo XRAY
  • barium enema (bird’s beak)
  • CT (whirl)
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24
Q

XRAY findings in sigmoid volvulus

A
  • bent inner tube
  • coffee bean sign
  • summation light
  • liver overlap sign
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25
Contraindications to sigmoidoscopy with sigmoid volvulus
- gangrene | - compound volvulus
26
When to do an urgent lap for volvulus
- failed decompression - features of peritonitis - gangrene
27
What is an ileo-sigmoid knot?
- volvulus of both small and large bowel
28
Two types of caecal volvulus
- axial ileo-colic volvulus | - caecal bascule
29
Signs and symptoms of a caecal volvulus
- abdo pain and distension - constipation/obstipation - vomiting
30
XRAY findings in a caecal volvulus
- single fluid level in a dilated caecum | - absence of gas in the distal colon
31
3 types of urgent surgery for a caecal volvulus
- right hemicolectomy - caecopexy - caecostomy
32
Definition of a polyp
A localised elevated lesion arising from an epithelial surface
33
Types of adenomatous polyps
- villous adenoma | - tubular villous adenoma
34
Evidence for the polyp-cancer sequence
- polpectomy decreases cancer incidence - colonic adenomas occur more frequently with cancers - large adenomas are more likely to have cancer - severe dysplasia in polyps progresses to cancer - residual adenomatous tissue is found in invasive cancers - 100% of FAP develop cancer - high rate of adenomas where there is a high cancer rate
35
Symptoms of polyps
- bleeding - mucus - prolapse
36
When to follow up a polyp patient
- high risk: 2-3 years | - low risk: 4-5 years
37
Types of polyp syndromes
- Juvenile polyp - Juvenile polyposis - Peutz-Jeglers polyposis - FAP
38
Where is the mutation in FAP?
APC gene on chromosome 6
39
What is Gardener's syndrome?
FAP with extra-intestinal features
40
Extra-intestinal features of Gardener's syndrome
- osteomata of the skull - epidermoid cyst - soft tissue skin tumours - dental abnormalities
41
Other associations with FAP
- desmoid tumours - Congenital hypertrophy of retinal pigment epithelium - malignant lesions
42
3 prophylactic surgeries for FAP
- proctocolectomy - colectomy with ileo-rectal anastomosis - restorative proctocolectomy
43
What is a diverticulum?
A sac-like protrusion of colonic wall
44
How do patients with diverticuli present?
- asymptomatic - symptomatic - diverticular bleed - diverticulitis
45
Complications of diverticuli
- abscess - fistula - peritonitis (purulent/faeculent) - stricture and obstruction
46
Explain the Hinchey classification for diverticuli
Stage 1 = pericolic/mesenteric abscess Stage 2 = walled-off pelvic abscess Stage 3 = generalised purulent peritonitis Stage 4 = generalised faeculent peritonitis
47
How does diverticular haemorrhage present?
- abrupt and painless bleeding - potentially life-threatening - mostly from the right colon
48
Potential etiology of IBD
- genetic predisposition - infection - hypersensitivity
49
Pathological features of UC
- usually in the colon - continuous - involves the rectum - involves the mucosa - crypt abscesses - smoking is protective
50
Pathological features of Crohns
- found usually in terminal ileum and proximal colon - patchy with skip lesions - deep fissuring ulcers that penetrate through the wall - non-caseating granulomas - smoking = risk factor
51
Definition of an acute severe attack of UC
6 or more stools a day with 2 or more of: - pyrexia - anaemia - tachycardia
52
Initial management of IBD
- resus - confirm Dx with rigid/flexi (NOT C-SCOPE) - stool cultures - daily chest and abdo XRAY - 2x daily Dr assessement - high dose IV steroids - after 3-5 days: surgery/rescue therapy
53
Medical rescue therapy for IBD
- cyclosporine | - anti-TNF therapy
54
When do you need to do emergency surgery for IBD?
- toxic megacolon - colonic perforation - massive haemorrhage
55
When do you need to do urgent surgery for IBD?
Failed medical therapy
56
When do you need to do elective surgery for IBD?
- chronic ill health | - risk of malignancy
57
Operations for UC
- proctocolectomy with removal of anus and permanent end ileostomy - restorative proctocolectomy - colectomy and ileostomy - colectomy and ileorectal anastomosis
58
La Place's Law
As the radius increases with a constant pressure, the tension exerted on the wall will increase
59
Etiology of large bowel obstruction
- colorectal cancer - volvulus - diverticular stricture - Other (fecal impaction, hernia, foreign body)
60
Differential diagnoses for large bowel obstruction
- small bowel obstruction - ileus - Hirschsprungs - colonic pseudo-obstruction - congenital leiomyopathy - toxic megacolon
61
Presenting features of large bowel obstruction
- early onset obstipation and distension - mild abdo pain - vomiting (late)
62
Investigations for large bowel obstruction
- Abdo XRAY - water soluble contrast enema - CT-scan with rectal contrast
63
XRAY features of small bowel
- central | - linea coniventes
64
XRAY features of large bowel
- peripheral | - haustral markings
65
Operation for a R-sided obstruction
- midline lap + - R hemicolectomy/ extended R hemicolectomy - primary anastomosis
66
Operations for a L-sided obstruction
- 3 stage (for rectal cancer) - 2 stage (for obstructing sigmoid cancer) - 1 stage (for young patients with good sphincters)
67
Definition of a lower GIT bleed
- bleeding that occurs distal to the ligament of Treitz
68
Presentation of lower GIT bleed
- acute - chronic - occult
69
Features of a massive LGIB
- large amounts of red/ maroon blood - haemodynamic shock/instability - Hb of 8 or less - need to transfuse >2 U of blood - bleeding continues for 3 days - significant rebleed within 1 week
70
Most common causes of LGIB
- diverticulosis - angiodysplasia - colitis - neoplasia - haemorrhoids etc - drug-related
71
Radiology options for LGIB
- abdo X-ray - CT with mesenteric angiography - Technetium-labeled RBC scanning - selective mesenteric angiography
72
Other investigations for a LGIB
- endoscopy | - colonoscopy
73
Ways to achieve haemostasis in a LGIB
- colonoscopy (coag, haemoclip, injecion) - formal angiography (trans cath embolization) - surgery
74
Pre-op management of anal sepsis
- diagnosis - exclusion of other pathology - determine anatomical extent
75
Diseases associated with anorectal sepsis
- Crohns - UC - hidradenitis suppurativa - carcinoma of anus/ lower rectum - TB - pelvic sepsis - foreign bodies - lymphogranuloma venereum - actinomycosis
76
Pathways of anal fistulas
- intersphincteric - transsphincteric - suprasphincteric - extrasphincteric
77
What is a simple fistula?
- one opening and easily identifiable primary tract
78
What is a complex fistula?
- multiple external openings and secondary tracts
79
Symptoms of an acute anal abscess
- pain worsening over a few days - worse with defeacation - fever - discharge/ painful swelling
80
Who needs inpatient treatment for an anal abscess?
- very large abscess - immunocomp - diabetic/systemically unwell
81
How to drain an abscess
- under GA - EUA and rigid (exclude rectal disease) - incision at max flux - pus swab - break loculi - trim edges - saline soaked gauze, dry pad and disposable panty
82
Surgical management of a fistula
- lay open the primary tract - drain secondary tracts - create a wound that's easy to dress - preserve continence
83
Goodsall's rule
- anerior fistulas tend to be straight and radial | - posterior fistulas are more likely to be complex, but usually have a midline internal opening
84
Features of a thrombosed perianal varix
- sudden onset pain - worse when walking/sitting - pain subsides over 10 days - obvious tender lump covered by stratified squamous epithelium - bluish and rubbery
85
Function of a temporary stoma
To assume the function of elimination of waste, to permit healing or rest the gut or section of bowel
86
Function of a permanent stoma
To take over the function of elimination of the bowel that has been removed or permanently bypassed
87
Three classifications of stomas
- input stomas - diverting stomas - output stomas
88
Examples of input stomas
- gastrostomy | - jejenostomy
89
Examples of diverting stomas
- ileostomy | - loop colostomy
90
Examples of output stomas
- bladder/bowel
91
Indications for stoma surgery
- congenital - acquired - traumatic - infective - neoplastic
92
Most commonly created output stomas
Faecal: colostomy and ileostomy Urinary: ileal conduit/ urostomy and nephrostomy
93
Factors taken into consideration when siting a stoma
- loaction of the rectus muscle - the waistline/beltline - hobbies, work, sport, activities
94
Places to avoid when siting a stoma
- lower costal margins - planned incisions - old scars - obvious creases - umbilicus - iliac crests
95
Types of colostomies
- end colostomy - loop colostomy - divided colostomy - Double-Barrel/ Mikulicsz
96
Factors influencing stool frequency and consistency
- site in the colon - precipitating condition or disease process - previous GIT surgery - radio/chemotherapy - medication - physical status - eating and drinking habits
97
Size of ideal colostomy
approx 1cm
98
Size of ideal ileostomy
approx 3 cm
99
Things to assess when thinking of doind a stoma
- output/effluent of the stoma - stool consistency - condition of the skin - diameter of the stoma - financial consideration - patient's ability to manage - availability of the product
100
Dermatological complications of a stoma
- faecal contamination - allergy to tape - mechanical - bacterial/fungal infection
101
Surgical complications of a stoma
- parastomal hernia - stenosis - retraction - prolapse - peristomal granulation - bolus obstruction - stoma separation - ischaemia
102
Polyps that are considered high risk for cancer
- large polyps >1cm - villous lesions - sessile lesions - high grade dysplasia
103
Where are polyps most commonly found?
- in the recto-sigmoid area
104
Hereditary colorectal cancers
- FAP - Attenuated FAP - Lynch syndrome - MUYTH associated polyposis
105
Factors in IBD that increase risk of cancer
- greater extent of disease - evidence of mucosal dysplasia - sclerosing cholangitis - family history of cancer
106
How often should first degree relatives of colorectal cancer patients have a colonoscopy?
10 years prior to age of onset of disease in affected relative
107
Symptoms of rectal tumours
- mucoid discharge - alteration in bowel habit - obstructive symptoms - perianal pain`
108
Symptoms of left-sided colonic tumours
- intermittent constipation or diarrhoea - obstructive symptoms - bleeding - LOW - palpable mass
109
Symptoms of right-sided colonic tumours
- unexplained anaemia and/or weight loss - occult faecal blood - obstructive features uncommon
110
Diagnosis of colorectal cancer
Only on histological assessment
111
Investigation of colorectal cancer
- procto-sigmoidoscopy (only for distal lesions) - colonoscopy (gold standard) - barium enemas
112
How to stage a colorectal cancer
- chest XRAY - U/S (liver, ascites, lymphadenopathy) - CT - MRI - PET
113
Surgeries for colorectal cancer
- right hemi-colectomy - left hemi-colectomy - sigmoid colectomy - anterior resection and abdomino-perineal resection
114
Factors that confer poorer prognosis for colorectal cancer
- tumour at surgical margins - obstructed tumour at presentation - poorly diff tumour - inadequate lymph node yield - perineural invasion - peritoneal deposits/micromets
115
When do most recurrences of colorectal cancers occur?
In the first two years following surgery
116
Tumour markers for colorectal cancers
- carcino-embryonic antigen (CEA

Surgery Revision (8 decks)

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