Colorectal surgery

Question 1

Most common anal cancer

Answer 1

SSC

Question 2

Borders of anal canal

Answer 2

Anorectal junction
Anal margin

Question 3

Where do anal margin tumours spread

Answer 3

inguinal lymph nodes

Question 4

Where to more proximal anal tumours spread

Answer 4

Pelvic lymph nodes

Question 5

RF for anal cancer

Answer 5

HPV
Anal intercourse
MM sex
HIV

Question 6

Presentation of anal cancer

Answer 6

Perianal pain
Perianal bleeding
A palpable lesion
Faecal incontinence

Question 7

Presentation of anal fissure

Answer 7

painful, bright red, rectal bleeding

Question 8

Where do 90% of anal fissures occur

Answer 8

Posterior midline
Alternative location ? consider underlying cause (e.g. crohns)

Question 9

RF for anal fissures

Answer 9

• constipation
• inflammatory bowel disease
• sexually transmitted infections e.g. HIV, syphilis, herpes

Question 10

Acute fissure management (<1wk)

Answer 10

• Dietary advice: high-fibre diet with high fluid intake
• Bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
• Lubricants such as petroleum jelly may be tried before defecation
• Topical anaesthetics
• Analgesia

Question 11

Chronic fissure management

Answer 11

topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure

Question 12

How are haemorrhoids classified ?

Answer 12

• 1st degree: no prolapse
• 2nd degree: prolapse when straining and return on relaxing
• 3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back
• 4th degree: prolapsed permanently

Question 13

Common presentation of haemorrhoids

Answer 13

-> Painless, bright red bleeding. Typically on the toilet tissue.
-> Sore / itchy
-> Feeling a lump around or inside the anus

Question 14

Treatment for haemorrhoids

Answer 14

• Increase fibre and fluids
• Topical : anusol
• Non surgical : rubber band ligation, injection sclerotherapy
• Surgical : haemorrhoidal artery ligation, haemorrhoidectoimy

Question 15

How can haemorrhoids be prevented

Answer 15

• Increasing the amount of fibre in the diet
• Maintaining a good fluid intake
• Using laxatives where required
• Consciously avoiding straining when opening their bowels

Question 16

Screening for colorectal cancer

Answer 16

• Faecal immunochemical test testing every 2 yrs for anyone aged 60-74
• Detects and quantifies amount of human blood in single stool sample

Question 17

Presentation of colorectal cancer

Answer 17

• Rectal bleeding
• Chnage in bowel habit
• Abdo pain and discomfort
• Unexplained weight loss
• Anaemia
• Bowel obstruction

Question 18

tumour marker for colorectal cancer

Answer 18

Carcinoembryonic antigen

Question 19

Colorectal cancer of caecal, ascending or proximal transverse colon

Answer 19

Right hemicolectomy with ileo-colic anastomosos

Question 20

cancer of Distal transverse, descending colon

Answer 20

Left hemicolectomy with Colo-colon anastomosis

Question 21

Cancer of sigmoid colon

Answer 21

High anterior resection with colo-rectal anastomosis

Question 22

Cancer of upper rectum

Answer 22

Anterior resection with colo-rectal anastomosis

Question 23

Cancer of low rectum

Answer 23

Anterior resection with colo-rectal anastomosis (+/- defunctionin stoma)

Question 24

RF for colon cancer

Answer 24

• FHx
• Familial adenomatous polyposis (AD)
• Hereditary nonpolyposis colorectal cancer (AD)
• IBD
• Obesity
• Smoking
• Alcohol

Question 25

What is diverticular disease

Answer 25

herniation of colonic mucosa through muscular wall of colon

Question 26

Risk factors for diverticulosis

Answer 26

- Increased age - Low fibre diet - Obesity - Use of NSAIDs

Question 27

Presentation of diverticulosis

Answer 27

- Lower left abdominal pain - Constipation - Rectal bleeding

Question 28

Management of diverticulosis

Answer 28

- Increased fibre diet - Bulk forming laxatives

Question 29

Presentation of acute diverticulitis (7)

Answer 29

- Pain and tenderness in the left iliac fossa / lower left abdomen - Fever - Diarrhoea - Nausea and vomiting - Rectal bleeding - Palpable abdominal mass (if an abscess has formed) - Raised inflammatory markers (e.g., CRP) and white blood cells

Question 30

Management of uncomplicated acute diverticulitis in primary care (4)

Answer 30

- Oral co-amoxiclav (at least 5 days) - Analgesia (avoiding NSAIDs and opiates, if possible) - Only taking clear liquids (avoiding solid food) until symptoms improve (usually 2-3 days) - Follow-up within 2 days to review symptoms

Question 31

Complications of diverticulitis

Answer 31

- Perforation - Peritonitis - Peridiverticular abscess - Large haemorrhage requiring blood transfusions - Fistula (e.g., between the colon and the bladder or vagina) - Ileus / obstruction

Question 32

Explain Duke's classification for colorectal cancer

Answer 32

A : confined to mucosa B : invades bowel wall C : lymph node mets D : distant mets

Question 33

Define ischaemic colitis

Answer 33

transient comprimise of blood flow to large bowel

Question 34

define acute mesenteric ischaemia

Answer 34

Embolism occluding artery suplying small bowel (e.g. superior mesenteric)

Question 35

Presentatio of acute mesenteric ischaemia

Answer 35

often AF Hx Abdo pain severe, sudden and out of keeping with physical exam findings

Question 36

Mx of acute mesenteric ischaemia

Answer 36

Immediate laparotomy

Question 37

3 causes of large bowel obstruction

Answer 37

1. tumour 2. volvulus 3. Diverticular diease

Question 38

Large bowel obstruction present ?

Answer 38

- Absence of passing flatus or stool - Abdominal pain - Abdominal distention - Nausea and vomiting are late symptoms that may suggest a more proximal lesion

Question 39

Diagnosis and key finding of bowel obstruction

Answer 39

- X ray = distended loops of bowel

Question 40

what will be seen on bloods in bowel obstruction and why ?

Answer 40

- Electrolyte imbalances - Metabolic alkalosis due to vomiting (VBG) - Raised lactate (bowel ischaemia)

Question 41

Initial management of bowel obstruction

Answer 41

" Drip and suck " - Nil by mouth (don’t put food or fluids in if there is a blockage) - IV fluids to hydrate the patient and correct electrolyte imbalances - NG tube with free drainage to allow stomach contents to freely drain and reduce the risk of vomiting and aspiration

Question 42

RF for volvulous

Answer 42

Neuropsychiatric disorders (e.g., Parkinson’s) Nursing home residents Chronic constipation High fibre diet Pregnancy Adhesions

Question 43

Investigation of choice for volvulus

Answer 43

Contrast CT

Question 44

Finding on abdominal x-ray in sigmoid volvulus

Answer 44

" Coffee bean "

Question 45

Features of perianal abscess

Answer 45

- Pain around the anus, which may be worse on sitting; - Hardened tissue in the anal region; - There may be pus-like discharge from the anus; - If the abscess is longstanding, the patient may have features of systemic infection.

Question 46

Tx of perianal abscess

Answer 46

- Incision and drainage

Question 47

What operation is done for colorectal cancer if they present with perforation

Answer 47

Hartmann's -> resection of sigmpid colon and end colostomy fashioned

Question 48

Most common histiological subtype of colorectal cancer

Answer 48

Adenocarcinoma

Question 49

Surgery for anal verge cancer (tumour of low rectum with a projection inferior to within 1cm of dentate line)

Answer 49

abdomino-perineal excision of rectum

Question 50

Location, appearance and ouput of ileostomy

Answer 50

- RIF - Spouted - Liquid contents

Question 51

Location, appearance and output of colostomy

Answer 51

- Varies, often left side - Flush with skin - Solid

Question 52

why are small bowel stomas often spouted and colonic ones are not ?

Answer 52

- Small bowel is spouted as the content is more irritant and so does not want to be in contact with skin - Colonic content is more alkaline and so can be flush with skin