colorectal surgery Flashcards
(122 cards)
1
Q
what is rosvings sign?
A
Palpation of LIF causes pain in RIF (appendicitis)
2
Q
what is psoas sign?
A
discomfort upon hyperextension of right hip indicating inflamed retroperitineal, retrocecal appendix
3
Q
what is obturator sign?
A
pain in RIF from flexing and internally rotating the hip - usually seen in pelvic appencitis
4
Q
pathophys of diverticulosis?
A
- increased intraluminal pressure resulting in herniation of the mucosa through the muscularis layer
- typically at the entry point of the arterioles
5
Q
is diverticular bleeding painful?
A
no - painless
6
Q
presentation of diverticular bleed?
A
-painless, large volume, bright red blood per rectum
7
Q
Complications of diverticulosis
A
- pericolic and paracolic abscess
- peritinitis
- diverticular fistula
- stricture formation
8
Q
what is hinchey classification for?
A
acute diverticulitis
9
Q
hinchey classification IA
A
paracolic phlegmon
10
Q
hinchey classification IB
A
pericolic/mesenteric abscess
11
Q
hinchey classification II
A
diverticulitis with walled-off abscess
12
Q
hinchey classification III
A
purulent peritinitis
13
Q
hinchey classification IV
A
feaculent peritinitis
14
Q
MEDICAL management of diverticulitis
A
- IV antibiotics
- bowel rest, supportive managment, IV fluid therapy and analgesia
- radiologically guided drainage of abscess
15
Q
SURGICAL management of acute diverticulitis
A
- laparoscopy and washout
- resection of diseased bowel (Hartmanns procedure_
16
Q
Hartmanns procedure
A
resection of sigmoid with proximal colostomy
17
Q
what are the polyposis syndromes?
A
- FAP
- HNPCC
- juvenile polyposis
18
Q
risk factors for colorectal cancer?
A
- polyposis syndrome
- family history
- smoking
- ulcerative colitis or crohns
- diet poor in fruit and vegetables
- obesity
- smoking, heavy alcohol use, T2DM
19
Q
what are the three histologies of polyps?
A
- tubular adenomas
- villous adenomas
- tubulo-villous adenomas
20
Q
which type of polyp has the highest risk of becoming malignant?
A
villous
21
Q
where is most colorectal cancer?
A
descending and sigmoid colon
22
Q
presentation of right sided colorectal cancer?
A
Iron deficiency anemia
23
Q
presentation of left sided colorectal cancer?
A
PR bleeding, mixed with stool
Change in bowel habit
24
Q
presentation of distal colon cancer?
A
- PR bleeding
- tenesmus - difficult, painful defecation, sensation of incomplete evacuation
25
40% of colorectal carcinomas will present as...
large bowel obstruction
26
what is the name of the classifaction system for bowel cancer?
DUKES
27
Dukes classification
A- confined to bowel wall
B- through bowel wall
C-positive lymph nodes
D-metastasis
28
TNM staging of colon cancer. T ?
```
Tumour
T1 - invades submucosa
T2 - invades muscularis propria
T3 - invades through muscularis propria
T4 -invades visceral peritineum
```
29
TNM staging of colon cancer. N?
Nodes
N1- no lymph invasion
N2- 1-3 nodes
N3- 4+ lymph nodes
30
TNM staging of colon cancer. M?
M0 - no distant metastasis
| M1 - distant metastasis
31
what are the types of bowel obstruction?
large bowel obstruction or small bowel obstruction
| complete or incomplete
32
what is ileus?
the hypomobility of the GI tract in the absence of a mechanical obstruction
33
what is closed loop obstruction?
when the bowel (usually small bowel) is obstructed at two ends -> rapidly progresses to ischemia, necrosis and perforation
34
symptoms of bowel obstruction?
- pain
- obstipation (cant pass gas)
- vomiting
- abdominal distention
35
signs of bowel obstruction?
- distention
- tenderness
- rigidity/guarding
- high pitch/lack of bowel sounds
- DRE - empty rectum
36
Common aetiologies of SBO?
- strictures (crohns, radiation)
- adhesions
- hernias
- malignancy
- intussusception
- meckels diverticulum
37
common aetiologics of LBO?
- colon cancer
- hernias
- diverticulitis
- volvulus
- intussusception
- stricture
38
what is superior mesenteric artery syndrome?
when the duodenum is compressed between the SMA and aorta
39
what do you look for on a plain film abdominal xray in regards to bowel obstruction?
- dilation
- air fluid levels
- 3,6,9 rule
40
what is the 3,6,9 rule?
- small bowel should be 3 cm or less, large bowel should be 6 or less, cecum should be 9 or less
- Larger may suggest bowel obstruction
41
management of bowel obstruction
- begin IV fluids
- insert wide bore NG tube - decompress then leave on free drainage
- analgesia, urinary catheter, I/O chart
- manage electrolytes
- further management depends on cause
42
treatment of volvulus
colonoscopy and pneumatic decompression
43
what type of muscle makes up the internal sphinctor of the anus?
circular, non-striated, involuntary, supplied by autonomic nerves
44
what type of muscle makes up the external sphinctor of the anus?
striated, voluntary muscle supplied by pudenal nerve
45
epithelial lining of the anal canal?
upper 2/3 - columnar
| lower 1/3 - squamous epithelium
46
blood supply to anal canal?
upper 2/3 - superior rectal artery from IMA
| lower 1/3 - inferior rectal artery from pudendal
47
lymph drainage of the anal canal?
upper 2/3 - internal iliac lymph nodes
| lower 1/3 - inguinal lymph nodes
48
internal hemorhoids are above the....
dentate line
49
risk factors for hemorhoids?
- poor dietary habits and constipation
- prolonged straining
- increased abdominal pressure (pregnancy)
50
what are the four degrees of internal hemorhoids?
I - dont prolapse below the dentate line
II - prolapse below dentate line but reduce spontaneously
III - prolapse and can be reduced manually
IV - permanently prolapsed and may strangulate
51
examinations/ix for hemorhoids?
- DRE
- proctoscopy
- consider sigmoidoscopy to rule out rectal/colonic pathology
52
Management of hemorhoids?
- avoid straining/lingering on toilet
- increase fiber and physical activity
- sitz baths
- injection sclerotherapy
- rubber band ligation
- transanal hemorhoid dearterialisation
53
indications for operative treatment of hemorhoid?
- 3rd or 4th degree hemorhoids
- second degree hemorhoids that havent been cured by non operative measures
- fibrosed hemorhoids
54
should patients with rectal bleeding be referred for colonoscopy even if its highly suggestive of hemorhoids?
yes
55
primary vs secondary anal fissure?
primary - from trauma, secondary - from disease (IBD, malignany, etc)
56
acute vs chronic anal fissure?
ACUTE - <6 weeks old
| CHRONIC - over 6 weeks or features showing fibrosis, fibrotic edges, perianal skin tag
57
what is a fistula?
chronic abnormal connection between two epithelial lined surfaces
58
clinical features of an anorectal fistula?
- intermitten rectal pain
- chronic purulent discharge and lesion in perianal or buttock region
- intermittent and malodorous discharge
- pruritis
59
diagnosis of pilonodal sinus?
clinical
60
treatment of a pilonodal sinus?
skin hygeine and hair exfoliation
61
If someone presents acutely with a pilonodal abscess, whats the treatment?
incision and drainage
| -secondary incision later to remove sinus tract
62
Risk factors for anal cancer?
- female
- infection with HPV 16 18
- receptor of anal sex
- smoking
- higher number of sexual partners
- history of anorectal condyloma
- HIV
63
what is anal intraepithelial neoplasia?
-precursor to invasive squamous anal carcinoma
64
AIN III aka...
bowens disease
65
what are the two types of cancers in the anal region?
Anal canal cancers - tumours that develop from the anal mucosa
Perianal/anal margin cancers - tumours that arise within the skin distal to the squamo mucocutaneous junction
66
lymphatic drainage of anal tumours above the dentate line?
perirectal and paravertebral nodes
67
lymphatic drainage of anal tumours below the dentate line?
superficial inguinal nodes and femoral nodes
68
what is a loop ileostomy?
- loop of ileum in RIF, with 2 lumens
| - one lumen is active and spouted
69
what are the contents of a loop ileostomy?
liquid or soft effluence
70
is a loop ileostomy usually temporary or permanent?
temporary - used to promote bowel healing distal to the stoma
71
what is an end ileostomy?
- stoma in RIF with only one lumen
| - spouted
72
contents of end ileostomy?
-liquid of soft effluence
73
what is a panproctocolectomy?
- colon, rectum and anus removed
| - results in permanent end ileostomy
74
indications for a panproctocolectomy?
IBD, family adenomatous polyposis
75
what is a total colectomy?
- surgery from the cecum to the rectum
- rectum and anus present
- can be reversed
76
what is an ileoanal J-pouch?
-the ileum is folded into a J shape and stapled to make a pouch which is attached to the anus
77
what is an end colostomy?
- stoma in LIF
| - single lumen, flush with skin
78
content of an end colostomy?
solid effluence
79
what is hartmanns procedure?
- resection of sigmoid colon and upper rectum
| - can be reversed
80
name some stoma complications
- stoma stenosis
- stoma retraction
- stoma fistula
- parastomal hernia
- stoma necrosis
- high output stoma
81
stoma stensosis is frequently associated with what disease?
crohns disease
82
what are the causes of stoma stenosis?
hyperplasia, infections, radiation before surgery, local inflammation, hyperkeratosis
83
clinical presentation of stoma stenosis?
bowel obstruction
| -initial sign is increased flatus
84
management of stoma stenosis?
CONSERVATIVE: low-residue diet, increased fluid, stool softeners/laxatives
SURGICAL: if partial or complete obstruction at the fascial layer
85
what is stoma retraction?
when all or PART of the stoma retracts into the skin
86
MOST COMMON causes of stoma retraction?
-MOST COMMON: tension in the intestine or obesity
87
causes of stoma retraction in the early post op phase?
-poor blood flow, poor nutrition, stenosis, early removal of supportive device, stoma placement in deep skinfold, thick abdominal walls
88
management of stoma retraction?
- pouch seal and stoma belt
| - surgery if recurrent peristomal skin problems
89
clinical features of stoma necrosis?
- cyanotic, dark red, black, dusky blue/purple
- foul smell
- may be hard/dry or flaccid
90
stoma necrosis usually happens when?
first 5 days post op
91
management of stoma necrosis?
- If its superficial it should slough off
| - if fascia involve, surgery required
92
when do parastomal hernias usually occur?
within the first two years
93
risk factors for parastomal hernia?
- obesity
- poor nutritional status
- presurgical steroid therapy
- wound sepsis
- chronic cough
94
what amoutn of fluid is considered a high output stoma?
>1500 ml in 24 hours
95
aeitiology of a high output stoma?
- when theres <200 m of small bowel
- intraabdominal sepsis
- enteric infection
- recurrent disease in bowel
- radiation enteritis
- medications
96
does a patient after surgery for a perianal abscess need post op packing or antibiotics
no
97
treatment of refractive anal fissure?
botox
| lateral sphincterotomy
98
multiple, large, irregular, off the midline anal fissures should raise concern for..
-IBD, HIV, TB or malignancy
99
management of rectal prolapse?
- stop bleeding
- reduce it immediately
- 50% dextrose and ICE to reduce swelling
100
'indeterminate colitis' has features of both..
ulcerative colitis and crohns
101
which layers of the bowel does UC effect?
mucosa and submucosa
102
which part of the bowel is ALWAYS involved in ulcerative colitis?
rectum
103
Medical management of UC?
- local therapy - steroid enemas, foams
- systemic steroids
- 5-ASA preps
- 6-Mercaptopurine
- infliximab
104
Surgical management of UC?
- subtotal colectomy with ileostomy
- panproctocolectomy with permanent ileostomy
- restorative proctocolectomy with ilealanal pouch
105
crohns is most common in what race?
caucasians
106
ix for suspected crohns disease?
- endoscopy - upper and lower (for diagnosis)
- small bowel enema - can detect strictures
- CT w/ contrast
- MRI - detects perianal disease
107
what is seen on endoscopy with crohns disease?
cobblestone mucosa
108
medical treatment of crohns?
- corticosteroids
- 5-ASA
- 6-mp
- infliximab
109
skin manifestations of IBD?
-erythema nodosum, pyoderma gangrenosum, psoriasis, oral ulcers, acute inflammatory dermatitis
110
MSK manifestations of IBD?
- arthritis
| - ankylosing sponylitis
111
hepatobiliary manifestations of IBD?
sclerosing cholangitis
112
eye manifestations of IBD?
-episcleritis, uveitis, corneal ulcers
113
why should you avoid a barium enema in someone with diverticulitis?
risk of chemical peritinitis if it extravasates
114
should you scope a patient with acute diverticulitis?
no -risk of perforation
115
treatment of acute diverticulitis
- NPO, IV fluids
- broad spectrum antibiotics
- low residue diet
- analgesia
116
which marker is positive in 30-50% of crohns cases?
ASCA
117
antibiotics early in life is a risk for...
crohns
118
what causes the loss of haulstra (lead pipe colon) in UC?
fibrosis of the mucosa and submucosa -> loss of haulstra
119
what kind of cell is seen in the non caseating granulomas of crohns disease?
multinucleated giant cells
120
why is there hypokalemia with pancolitis?
problems with water and sodium resorption
121
why is there hypoalbunimia in pancolitis?
-negative acute phase reactant
122
why may someone with crohns disease develop fecal incontinence
disruption of the sphinctor musculature from repeated inflammation, abscess formation, fibrotic changes and repeated episodes of surgical drainage
