Diverticular disease differentials
colonic cancer
pelvic abcess
Diverticulosis management
Asymptomatic in 95%
no treatment
increase dietary fibre
What not to do in acute attack of diverticulitis
colonoscopy/sigmoidoscopy
Acute diverticulitis
IV abx
can normally go home if no complications
Perforation
A–> E ileus, peritonitis, shock
surgery
stricture
hartmanns if obstructed
Abcess
<5cm heal with abx and supportive care
>5cm needs draining
all pelvic abcesses need drainage
Fistula
surgery but if not fit manage symptoms
ABx for recurrent UTIs
uncomplicated but symptomatic diverticulae
Mebeverine
inhibiting polyp growth
low dose aspirin (ulcer risk)
CEA
tumor marker, used to monitor treatment
CRC surgery
wide resection of growth and regional lymphatics
right hemicolectomy
caecal, ascending, proximal transverse tumors
temporary: end ileostomy
ileo-colic anastamosis
left hemicolectomy
distal transverse/descending colon tumours
temp end ileostomy/before colo-colic anastamosis
high anterior resection (sigmoid colectomy)
sigmoid tumors
Anterior resection
low sigmoid/high rectal tumors
colo rectal anastamosis acheived @ first operation
maybe covered by temp. loop ileostomy
AP (abdominoperineal ) resection
tumors low in rectum
permenant colostomy
no anastamosis
Hartmann’s
palliation
perforation
endoscopic stenting
palliative
Radiotherapy
pre-op in rectal cancer
high risk of dvt, pathological fractures, fistula formation
post op only if high recurrence risk
Chemotherapy
adjuvant 5 FU and folic acid
reduces mortality
palliation if metastatic disease
Anal carcinoma treatment
radio + chemo (5FU and mitomycin/cisplatin)
75% retain normal anal function
surgery for small tumors not affecting sphincter
Management of obstructing colonic cancer
A--E IVI, NGT analgesia FBC, u&E, amylase AXR erect CXR catheterise to monitor fluid status consider early CT stents in palliation
Causes of SBO
adhesions gall stone ileus hernia Crohns intussception caecal mass
Causes of LBO
carcinoma of colon
diverticular disease
sigmoid volvulus
constipation
contrast enema
differentiates obstruction and pseudo obstruction
gastrograffin may have therapeutic effect
differentiating ileus + paralytic ileus
SBO: bowel sounds, no air in colon on AXR
Paralytic ileus: Diffuse air fluid levels, air in colon
constipation IX
fbc, u+e, tfts, calcium, esr
then endoscopy
1st degree haemorrhoids
laxative analgesia avoid opioids (constipation) avoid NSAIDS if rectal bleeding topical haemorrhoidal preparations for short term relief
Non-surgical
if 1st degree medical management fails/for 2nd/3rd degree
rubber band ligation (up to 3 haemorrhoids in 1 visit)
Injection sclerotherapy w/ phenol oil
infrared coagulation/photocoagulation
Surgical haemorrhoid treatment
heamorrhoidectomy
only if symptomatic
stapled haemorrhoidectomy
haemorrhoidal artery ligation
Perianal haematoma management
evacuated under LA/resolve spontaneously with analgesia - hot baths and reassurance if already discharging/resorbing when seen
anorectal abcess
I&D to prevent fistula formation/rupture
pilonidal sinus
excise sinus tract, primary closure, pre-op abx
give hygenie + hair removal advice
if complex, laid open and packed /use skin flaps to cover
perianal wart
podophyllin paint
cryotherapy
surgical excision
investigation fistula in ano
v painful, under anaesthetic
endoanal USS
Goodsall’s rule
o If the external opening of the fistula is in the anterior half of the anal canal, the fistula opens in a straight path directly into the canal
o If the external opening is in the posterior half, it will open at the midline of the posterior wall of the anal canal, with a curved track
exception to Goodsall’s rule
anterior fistulas >3cm away from anus, can drain like posterior ones w/curved track
Fistula in ano management
I+D of abcess
low fistulae = laid open, heal by secondary intention, division of sphincters = no risk to continence
High fistulae- need a seton suture –> tighthened over time to maintain continence
Fissure management
small may heal spontaneously -LA ointment, lubricant laxative shallow warm bath rectal GTN/botox high fibre and fluid intake bulk forming laxative last line = sphincertotomy