Colorectal Surgery Flashcards
(95 cards)
1
Q
Definition for Hartmans procedure
A
– resection of disease portion of bowl bring the proximal end out as a stoma and over sew the distal end
2
Q
3 causes of small bowl obstruction
A
- adhesions
- HERNIA
- Neoplasm in small bowl
3
Q
2 cases of large bowl obstruction
A
- Neoplasm
- diverticular disease
4
Q
MANTELS acute appendicitis
A
Migration of pain Anorexia Nausea/vomiting Tenderness RLQ Rebound pain Elevation of temperature Leukocytosis Shift to the left (Neutrophiles > 75% OR LLEFT SHIFT )
5
Q
Rovsing sign
A
palpation in LIF causes worse pain in the RIF
6
Q
Psoas sign
A
flexion of the right hip
liw patient on left and felt hip posteriorly
7
Q
Obturator sign
A
Pian in the right lilac fossa as a result of flexing and internally rotating the right hip
8
Q
Causes of appendicitis in adults DDX
A
Terminal ill pathology
Crohns
Meskel’s diverticulitis
GE
Kindly stones
pancreatitis
Ovarian cyst (where in menstrual cycle) ovarian tortion
9
Q
what score do you use for testing appendicitis severity
A
ALVARADO SCORIng SYSTEM - abdo pain which is localized in RIF - Nausea / Vomitting - Anorexia SIGNS - tenderness RIF - rebound tenderness - temperature LAB VALUES - leukocytosis > 10 000 Neutrophiles > 75% OR LLEFT SHIFT
10
Q
acute appendicitis treatment
A
OPEN or LAP
- 15% - negative
IV antibiotics at infuctioon
11
Q
Appendicitis abscess or appendicitis mass
A
IV ANTIBITOCIS
- may settle within 6 weeks
- if NOT – > surgery
Abscess - CT guided drainage
12
Q
how to do appendectomy
A
gridiron incision at McBurneys Point
lap approach
find appendix
divide mesentery
clamp appendix and tied at base then excised
investigate stump using purse=string in the wall of the caecum round the base of the appendix
13
Q
Complication of acute appendicitis
A
- perforation (localized or generalizEd )
- RIF appendix mass (appendicitis with densely adherent caecum and oentum forming a mass)
- RIF abscess
- Pelvic abscess
14
Q
blood supply to the appendix
A
terminal branch of ileocolic
15
Q
Diverticular disease
A
out pouching of sac like mucous projection through the colon wall
- usually in sigmoid colon
16
Q
Clinical Painful diverticulosis
A
intermitted LID pain - constipation and diarrhea
17
Q
Acute diverticulitis
A
LIF pain D/C Nause ± bleeding
Sign: dever, tachycardia , tender LIF ,guarding , rebound
Labs: HIGH neutrophils, elevated WCC and elevated CRP
18
Q
Diverticular bleeding
A
Spontaneous NO prodromal symptoms
LARGE BIGHT RECTAL BLEED due to rupture of PERIDIVERTICULA SUBMUCOSAL VESSEL
19
Q
complication of diverticular disease
A
pericolic and parabolic abscess
peritonitis
Diverticular FISTULA
STRICTURE FORMATION
20
Q
pericolic and parabolic abscess presenting symptoms and treatment
A
SPIKING and swinging fever and sepsis
(LIF pain, N V , WL , NS )
(from persistent colonic inflammation leading to pericolic abscess)
Tx:
- Antibiotics
- percutaneous radiologically guided draining w/ washout ± research of disease bowl
21
Q
difference b/w purulent peritonitis and faeculent peritonitis
A
Purulent - perforation of parabolic and pericolic abscess
Faeculent - free perforations of diverticular segment
22
Q
question to ask in diverticular history to outule fistula
A
recurrent UTI
pneumaturia
debris in the urine
23
Q
gold standard test for Diverticular disease
A
BARIUM ENEMA
COLONSCOPY
- not used in acute setting can PERFORATE the appendix
24
Q
treatment of acute diverticulitis
A
IV antibiotics (co-amoxiclav)
Bowl rest IV fluids
Radiology guided drainage if abscess present
Hartmans
25
when do you do surgery for acute diverticulitis
1. free perforation
2. fistula
3. acute inflammation unresponsive to medical treatment
4. undrainable abscess
26
HINCHY SCORE
Hinchey I - localised abscess (para-colonic)
Hinchey II - pelvic abscess
Hinchey III - purulent peritonitis (the presence of pus in the abdominal cavity)
Hinchey IV - feculent peritonitis.
27
Treatment of acute diverticulitis
Hinchey I: conservative (high fibers, stool softeners)
Hinchey II: CT guided drainage and wash
Hinchey III: usually operation (Hartmans)
Hinchey IV: always operation(Hartmans)
28
Diverticular disease: definition
symptomatic diverticulae
29
Diverticulitis: definition
inflammation & infection associated with diverticula
30
Hold old for colorectal cancer
55-75 years MEN increase 3X
31
RF for Colorectal cancer
- polyposis syndrome (FAP , HNPCC, juvenile polyposis )
- strong history of colorectal carcinoma
- UC and Choirs
- deit poor in fruit and vegetables
- diet risk in red meat processes met and animal fat
- obesity
MOST ARISE FROM PRE EXCITING ADENOMA
32
how does colorectal cancer metastasize
lymphatics
| hematogenous - liver
33
how can Colorectal cancer occur
Polypoid
ulceration
stenosing
infiltrative tumour mass
34
location of Colorectal cancer
RECTUM ( 30%)
Descending and sigmoid - 45%
transverse - 5%
Right sided 20%
35
definition of tenesmus
difficult painful defecation and sensation of incomplete evacuation
- THINK SOL
36
how does Right sided colorectal cancer present
iron deficiency anemia
37
Descending / sigmoid colorectal cancer presents as
PR bleed and Change in bowl habit
38
Dx CR cancer
```
ELECTIVE:
PR exam
signmoidscopy and BX
Colonoscopy and BX
CT colonagiography if colonoscopy not possible
```
EMERGENCY - CT
39
how to stage CR cancer
1. LOCAL
- CT - colon cancer
- pelvic MRI and transrectal US - rectal CA
2. METS
- CT TAP - GOLD STANDARD
- Pet
3. SYNCHRONOUS TUMOUR - colonoscopy and Barium enedma
4. CEA - tumor marker
5. PATHOLOGY - DUKES classification , TNM
40
Management - potential curative treatment with NO mets evidence
OPERATIVE
Right / traverse - right / extended right hemicolectomy
LEFT colon - left hemicolectomy
Sigmoid /upper - high anterior resection
lower rectum - LOW anterior resection / APR
Anorectal - APR
41
general treatment of CR cancer
1. OPERATIVE
2. RTX (NEOADJUVANT) - reduces local recurrence
3. ADJUVANT CHEMO - tumour with positive LN or evidence of vascular invasion
4. HEPATIC or LUNG resection - in its with retractable mets and resectable primary tumour
5. PALLITIVE
42
Palliative treatment in CR cancer
for unrescetbale
1. CTX
2. ENDOLUMINAL stents with self expanding metal steps for obstruction colon tumours
3. transanal ablation of rectal obstruction tumours
4. surgery for untreatable obstruction / bleeding / severe symptoms
43
follow up post CR Cancer treatment
1/ Outpatient review - Hx and exam , PR and CEA
2/ Colonoscopy
3/ CT scan
44
Internal sphicheter type of cell
Circular, non striated involuntary autonomic nerve
45
external sphicheter
started , voluntary supplied by pudenal nerve
46
lymph drainage to lower part of anal canal
injunial LN
47
what cells line lower part of anal canal
squamous cell
48
treatment of haemorrhoids
1. normalize bowel and defamatory habits
2. injection sclerotherapy (1st and second)
3. rubber band ligation (second degree haemorrhoids )
4. Transanal heamorrhoidal dearterilisation (2nd and third)
49
indication for a heamoroidectomy
1. 3rd and 4th degree haemorrhoid
2. 2nd degree that is not cured with non operative approach
3. fibroses haemorrhoid
4. intern-external haemorrhoid when the external haemorrhoid is well defined
50
types of heamorroidectomy
OPEN - milligan morgan
Closed - ferguson
Stapled
51
thrombosed external haemorrhoid presentation and treatment
EXCRUTIATING PAIN
| Sx treatment of haemorrhoid and overlying skin - immediate relief
52
anal fissure definition
longitudinal split in the anoderm of the distal anal cancel which extends from the anal verge proximately towards but not belong the dentate line
53
Chronic fissure
> 6 weeks and presents with
- firbsosi
- fibrotic edge
- perianal skin tag
54
Conservative Treatment of fissure
Conservation
- warm sits baths
- constipation relief
- analgesia
- tx underlying condition
- TOPICAL NITRIC OXIDE DONORS - by decreasing spasm , pain is relieved and increased vascular perfusion and promotes healing (0.2% NO and 2% diltiazam )
55
Operation for fissure
lords anal stretch (historical interest only) - high risk of incontinence
Lateral SPINCTEROTOMY ( GOLD STANDARD)
- closed
- open
56
define anorectal abscess
acute phase manifestation of a collection of purulent material that originates from an infection arising in the cyrptoglandular epithelium lining the anal canal at the dentate line
57
Investigation anorectal abscess
Pelvic CT or MRI
58
Tx anorectal abscess
primarily surgical - anesthesia , sigmoidoscopy and proctoscopy with adequate draining of pus
59
presentation of anorectal abscess
Severe perianal and rectal pain, constitutional symptoms - fever , malaise
PURULENT DISCHARGE - if abscess spontaneously drained
60
Anal fistula definition
Chronic abnormal connection b/w 2 epithelial lined surfaces
| - usually lined with granulation tissue
61
exam of fistula
1. perianal skin may be excoriated and inflamed
2. external open visual or palpated as undulation just below the skin
3. hands into fistula to determine the internal opening using rotoscope or sigmoidoscope
62
types of anal fistula (Parks classification )
1. Intersphincteric
2. trans-sphincteric
3. suprasphincteric
4. extrasphincteric primary tracts
63
Parks classification note
Low or high depending on weather the internal opening is above or below the puborectalis
64
Goodshall's rule
all fistula tract with external openings within 3 cm of the anal verge and posterior to a line drawn through the ischial spines travel in a curvilinear fusion to the posterior midline. All tracks with external openings anterior to this line enter the canal in a radial fashion
65
how to you make a definite of a fistula
Examination under anesthesia - to determine internal and external openings
66
Treatment fistula
1. FISTULOTOMY - if the fistula lies below the puborectalis
2. FISTULECTOMY - either loose tight or chemical - used for low anorectal fistulas
3. SETON INSERTION - high anorectal fistulas
4. ADVANCED FLAP
5. PLUGS AND GLUES
67
SENTON INSERTION
this is done loose right or chemical - used for HIGH
- staged fistulotomy by placing a seton suture that is sporadically tightened so to gently cut through the tract and muscle while allowing healin and fibrosis to develop between diced muscles thus preserving function and fecal continence
68
pionidial sinus
pilus - means hair
sinus - means blind ending tract - usually lined with granulation tissue
infection of the skin and subcutaneous tissue at or near the upper part of the natal cleft of the buttock
69
pathogenesis pionidial sinus
- loose hair gathers toward natal cleft
- draws hair deeper into the pore - suction of buttock movement
- friction causes hair to form a sinus
Pore becomes infected - abscess
70
treatment of pilonidal sinus
skin hygiene
acute: incision and drainage of pilonidal abscess
Chronic - phenol injection every 4-6 weeks till wound is healed
71
techniques for pilonidal sinus surgery
1. excise sinus tract
BASCOM's operation - lateral to midline incision to cruette the deep cavity and excision of the primary midline pits
Primary closure of the midline incision and lateral wound left to heal by secondary intention
2. Karydakis procedure - smilateral D shaped incision incubating the sinus down to the pre sacral facia - the flap of tissue on the vertical young side is mobilized and brought to the convex would wedge and sutured in the layers over a drain
72
treatment for recurrent pilonidal sinus
ROTATIONAL FLAB PROCEDURE - pasty, modified , limber flap
73
anal cancer RF
```
female
infection with HPV 16 and 18
lifetime number of sexual partners
genital warts
cigarette smoke
receptive anal intercourse
infection with HIV
```
74
AIN
precursor for invasive squamous anal carcinoma
75
Bowen's disease
high proportion of AIN III progresses to carcinoma
76
anal cancer above the dentate line drains to
perirectal and paravertebral nodes
77
anal cancer below the dentate line drains to
superficial injunial and femoral nodes
78
investigation of anal canal
1. under anesthesia - Bx
2. CT
3. MRI
4. endoanal ultrasound
79
Treatment of anal cancer
MDT
- wide surgical excision (T1No)
CHEMORADIO - T2 T 3 T4
APR - in advanced disease of anus and rectal tumour
80
why do you get that colour of melon in upper GI bleed
b/c the blood becomes altered from gastric and upper GI enzymes
81
isolated streaks of blood
issues in uno
82
differential dx for mucous in stool
```
Rectal Ca
UC
Chrons of the rectum
adenoma
Colitis - other cause
```
83
investigation of rectal bleed
- FBC - hb and platlets
- U/E - disproportionately raised urea due to increase creatinine in Upper GI bleed
- call
LFT
PDA - obstruction / Toxic megacolon
Colonoscopy . barium enema, proctoscope / sigmodscope
OGD
Mesternic angiography or technetium scan
84
what can a small bowel enema show in chons
Stricture
| Prestonitic dilation
85
Kantor string sign
luminal narrowing revealed on x-ray as a thin line of barium terminating at the ileocecal junction.
Area which is narrowed and irregular
86
what can CT scan show in churns
FATD
Fistulae
Inter-abdominal abscess
bowl thickening
Dilatation
87
MRI USE IN chorns
to detect perianal involvement
88
MR enteroclysis IN chorns
small bowel structuring in young children
89
Fistulography
Helps demonstrate enterocutaneous fistulae with more complexity and allow adequate panning of surgery
90
Surgery for chrons
1. ileocecal resection
2. segmental resection
3. colectomy and ileocecal anastomosis
4. subtotal colectomy and ileostomy
5. strictuotomy
91
what do you see on X-ray of UC
```
lead pipe colon
thumb printing (mucosal edema)
```
92
how does pancolittis present in uC
may have backwash ileitis - SYSTEMICALLY unwell
HYPOkalemia from mucous production
Hypoalbuminemia from systemic response and decreased oral intake
Anemia from blood loss and inflammatory response
93
Toxic megacolon present
MASSIVELY dilated and patchy necrosis
Systemically ill with high fever marked tacky and dehydration
Culminates in perforation and detail peritonitis unless emergency colectomy is done
94
CT in UC
thickened bowl wall and inflammation stranding in the colonic mesentery
95
Surgery for UC
Subtotal colectomy with ileostomy
Panprotocolectomy with permenanat ileostomy
Restorative protocolectomy (ileoanal pouch and parks pouch )
