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Colorectal Surgery Flashcards

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1
Q

What are the clinical features of UC?

A

Proctitis:

  • commonest presentation
  • urgency and frequency
  • bloody mucus diarrhea - mixed

Left sided colitis:

  • rectal irritation
  • bloody diarrhea
  • systemic features

Pancolitis:

  • backwash ileitis - irritation to ileum
  • diarrhea
  • systemic features
  • anaemia
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2
Q

What are the treatments for UC?

A

The main stay of treatment is 5-ASAs such as mesalazine.
these can be topical for more lower disease, or orally for higher disease.
1st line: mesalazine
2nd line: immunomodulation: azathioprine/ methotrexate

Proctitis:

  • 5- ASA topical
  • topical steroids - suppositories

Left sided:
- Oral/ Topical 5-ASA- foam enemas
+/- foam steroid
+/- systemic treatment - steroids

Pancolitis:

  • oral - 5 - ASA
  • Systemic treatment - steroids
  • azathioprine
  • cyclosporin
Surgical: 
reserved for severe acute that fails to medical therapy or when, symptoms  are not controlled, side effects are to great or evidence of dysplasia or cancer. 
- proctocolectomy - with ileoanal pouch 
- panproctocolectomy - with ileostomy 
- total abdominal colectomy
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3
Q

What is the management of severe acute colitis?

A

*remember this may be caused by an infective agent:

Symptoms:

  • diarrhea with blood. *if there is constipation it may suggest dilation of colon
  • abdominal pain
  • malaise
  • fever
  • abdominal tenderness - peritonitis - suggests perforation

Treatment:

  • resuscitation
  • catheterisation
  • bloods
  • establish diagnosis
  • send stool samples
  • AXR/ erect CXR
  • flexible sigmoidoscope - if possible

Medications:

  • IV hydrocortisone - 100mg qds
  • LMWH
72 hours worsening: 
- Ciclosporin 
or 
- infliximab 
\+/- 
- surgery
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4
Q

What is criteria for fulminant colitis?

A

Tachycardia >120 bpm

stool frequency > 10 per day
or
Albumin <25g/dL

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5
Q

What are the clinical features of Crohn’s disease?

A

Systemic features:

  • fever
  • malasia

Abdominal Pain
- RIF

Change in bowel habit
- diarrhea without blood

Weight loss

Perianal abscesses

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6
Q

What are extraintestinal manifestations of Crohn’s disease?

A

Associated with disease activity:

  • pyoderma gangrenosum
  • erythema nodosum

Independent of disease activity:

  • ankylosing spondylitis
  • polyarthritis
  • chronic active hepatitis
  • finger clubbing
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7
Q

Both Crohn’s and UC have an effect on the bile ducts of the liver, what are they and to which disease?

A

Primary biliary cirrhosis = Crohn’s

Primary Sclerosing cholangitis = UC

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8
Q

What are the gold standard investigations for IBD?

What other investigations can be done?

A

CT enterography
Colonoscopy with biopsy for diagnosis

other:
- CRP (good indication of disease severity)
- Faecal calprotectin
- FBC (anaemia)
- B12

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9
Q

What is the treatment for Crohn’s disease?

A 
Inducing remission: 
1st line: 
8 weeks steroids 
\+
stop smoking

2nd line:
mercaptopurine
or
Azathioprine

3rd line:
- infliximab

Maintaining remission:
- Azathioprine
or
- mercaptopurine

2nd line:
- methotrexate

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10
Q

What are some of the complications of Crohn’s disease?

A

Fistula formation

Stenosis

  • coiky pain
  • weight loss
  • distended bowel

anal disease

  • anal fissures
  • fistula in ano
  • anal mucosal thickening

B12 deficiency

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11
Q

List some risk factors towards colorectal cancer:

A

Age
> 50 years

History of polyps

Male

IBD

Heavy red mat diets

Smoking
- more so in males

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12
Q

What are the symptoms and clinical features of colorectal carcinoma?

A

Right sided;

  • anaemia
  • Coliky pains
  • appendcitis (>40 years should be investigated)

Left sided:
- PR bleeding - mixed with the stool

  • change in bowel habit - mixture of diarrhea and constipation
  • tenesmus
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13
Q

How is colorectal carcinoma diagnosed?

what further investigations are done?

A

Colonoscopy with biopsy

CT thoracic- abdominopelvic for metastasis

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14
Q

What blood marker of colorectal cancer can be used as a marker of disease monitoring, especially following resection?

A

CEA - Carcinoembryonic antigen

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15
Q

What staging is used for colorectal cancer and what are the stages? with 5 year survival rates:

A

Dukes

A - confined to mucosa - 75-90%

B - full thickness of wall through muscularis externa - 55-70%

C - Lymph node involvement - 30-60%

D - metastasis

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16
Q

What are common metastasis sites for colorectal cancer?

A

Lung

Liver

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17
Q

What kinda of surgery can be carried out for rectal carcinoma, and what increases the risk of anastomotic leak, and how can this be reduced?

A

Anterior resection

the lower the anastomosis the higher the risk of leakage.

Loop ileostomy can be done to reduce the risk of leakage.
*loop Ileostomies are partial disconnection proximal to the anastomosis which allow drainage of faeces to prevent damage further down at the anastomosis and for it to heal

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18
Q

What are the gold standard investigations into diverticular disease?

A

Contrast barium enema -

  • see leakage.
  • this is performed at a elective procedure

CT
- assess complications

**CT for acute situations* gold standard

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19
Q

What is the treatment of diverticulitis:

A 
High fibre 
oral antibiotics 
Analgesia
Rehydration 
Bed rest

If pain or fluids not managed:

  • Nil by mouth
  • IV antibiotics - triple therapy
  • IV fluids
  • IV analgesia

Complications
- surgical resection

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20
Q

What are the clinical symptoms of acute diverticulitis?

A
  • Rapid onset LIF pain
  • Low grade fever
  • loose stools
  • nausea
  • Bleeding
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21
Q

What are some complications of diverticula disease?

A

Abscess formation

  • pericolic
  • paracolic
  • presents with swinging fevers
  • unresolved pain

Peritonitis
- perforation - feculent peritonitis

Fistula formation

  • colovesical fistula - recurrent UTIs, bubbles in urine
  • colovaginal fistula - feculent discharge
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22
Q

What signs are seen with cecal volvulus?

A

embryo sign

- the caecum will also not be seen

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23
Q

What sign is seen with sigmoid volvulus?

A

coffee bean sign

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24
Q

What factors are absolute important for anastomosis to work?

A
  • Adequate blood supply
  • Mucosal Apposition
  • adequate tissue tension which is not tight

sepsis, surgeon and patient comorbidities also play important point

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25
List the surgeries typically seen in recto-sigmoidal cancers:
Sigmoid: High anterior resection Upper rectum: anterior resection Lower rectum: Low anterior resection Anal verge: Abdomino- perineal excision of rectum
26
In emergency colectomies, what surgical procedure is best to do?
Hartmann's Anastomosis is risky in emergency situations and can be reversed.
27
What is used to test the integrity of an anastomosis?
Gastrografin
28
What classification system can be used to assess diverticular perforation?
Hinchey I - localised abscess II - Pelvic abscess III - Purulent abscess - pus in peritoneum IV - Feculent abscess - faeces in peritoneum
29
What conditions increase risk of colorectal cancer?
UC Familial Adenomatous Polyposis (APC mutation) Hereditary Non - Polyposis Colorectal Cancer Juvenile Polyposis
30
What imaging modality is best for rectal cancer?
MRI
31
In patients with sigmoid volvulus, what is the best treatment?
Depends if the have peritonitis: Rigid sigmoidoscope = if no peritonitis Urgent Laparotomy = if peritonitis and bowel obstruction
32
What is the single best investigation for ano-fistula?
Pelvic MRI *note in an emergency situation explorative surgery may be best
33
What are the symptoms of anorectal sepsis and how is it diagnosed? how is it treated?
``` Caused by abscess formation. features include: - Rapid onset pain - worse when sitting - fever - tachycardia - purulent discharge - swelling around anus ``` MRI is gold standard - although in emergencies situations surgery is indicted Antibiotics Surgical drainage - Prevention of recurrent sepsis is to use [loose seton suture]. - laying open the fistula in ano - open tracks of fistula and debriding tissue. can be done high and low.
34
What types of abscess around the anus can form?
Peri- anal - subcutaneous Infra-sphincter supralevator Ischial rectal - just outside the sphincters laterally
35
List several cause of PR bleeding:
Anorectal: bright red blood - Haemorrhoids - Acute anal fissure - Proctitis - Rectal prolapse Rectosigmoid: darker red, clots, mixed - Rectal tumours - Proctocolitis - Diverticula disease Proximal colonic: dark red, mixed - colonic tumours - colitis - angiodysplasia - NSAID reduction Upper g.i = melena
36
What Tests should be done in the presence of suspected UC?
FBC - ESR - Hb Stool culture - Microscopy, cultures and sensitivity - C. Diff Calprotectin - show's generalised inflammation Gold standard: * CT enterography * Colonoscopy with biopsy
37
How is UC graded?
Truelove and Witts criteria: ``` Motions a day: <4, 5, >6 Rectal bleeding: small, moderate, large Temp: Resting pulse: <70, 70-90, >90 Hb: >110, 105-10, <105 ESR: <30, >30 or CRP >45 ```
38
What are the extraintestinal signs of UC?
Finger Clubbing Primary Sclerosing Cholangitis Erythema Nodosum Pyoderma gangrenosum Episcleritis
39
What is the common causes of Ano-fistula?
Chronic Abscess - which typically starts at the crypts Crohn's disease LGV Chlamydia Rectal foreign bodies
40
What is the treatment for Crohn's:
Symptomatic but systemically well: 7 week prednisolone 40mg. reduce by 5mg weekly. Severe: admit. IV hydrocortisone. + enoxaparin 40mg
41
If there is a patient with the red flags of cancer and has continuous UTIs, what is an important differential diagnosis?
Enterovesical fistula | - caused by colorectal cancer
42
If there is a tumour on the lower 1/3rd of the rectum, i.e. within the anus. what is the best surgical treatment?
Abdomino-perineal resection (AP resection) *this takes the anus as well - differentiating it from an anterior resection
43
What is the strongest risk factor for anal cancer?
HPV infection
44
Why would a loop ileostomy be preferred over a loop colonstomy?
healing rates. ileostomies heal at a much better rate
45
What surgery is carried out during an emergency of the colon which will involve resection?
Hartmann's procedure
46
What is the classification system used in diverticulitis?
Hinchey
47
What is the management of Crohn's disease?
Induce remission: - stop smoking - Steroids Maintenance: - azathioprine - mesalazine
48
What are the typical surgical complications seen in Crohn's?
Ileocaecal resection Surgery for perianal - abscess drainage - seton suturing Strictureplasty Small bowel resection
49
What are some complications of Crohn's disease?
Small bowel cancer Osteoporosis Large bowel cancer
50
What are some other types of Colon cancers other than adenocarcinoma?
Sarcoma Cacinoid Lymphoma
51
List some risk factors for colorectal carcinoma:
Male Age Low fibres Polyps Family history IBD - ulcerative colitis Heavy red meats
52
What are the symptoms of bowel cancer?
Left sides: - Bleeding - Change in bowel habit - Tenemus - Weight loss - Mass in iliac fossa - Sciatica Right sided: - Anaemia - Change in bowel habit - Abdominal pain - colicky pain - Mass felt in right iliac fossa Acute presentation: - Perforation - Obstruction - PR bleeding
53
What are some differentials to colorectal carcinoma?
IBD IBS Hemorrhoids Diverticula disease
54
When should someone be referred regarding colorectal symptoms?
>40 years with unexplained weight loss and abdominal pain >50 years with unexplained PR bleeding >60 years with iron deficiency anaemia or change in bowel habit Positive screening
55
When is screening offered for colorectal carcinoma?
Every 2 years 60-74 (Scotland 50-74) Faecal immunochemistry test - Hb against human haemoglobin
56
What tests should be done in primary practice when referring someone for a colonoscopy?
FBC Carcinoembryonic Antigen/ CEA levels - which can be used to assess treatment as well
57
What additionals investigations should be done following a positive biopsy from colonoscopy of colorectal carcinoma?
CT scan - chest/ abdo/ pelvis MRI Rectum - for rectal cancers only - to assess depth of invasion Endoanal ultrasound - t1 and t2 only
58
What are the different types of surgeries that can be done for colorectal cancer, depending on their location:
Caeca/ Ascending/ Transverse tumours: • Right Hemicolectomy Descending Tumours: • Left Hemicolectomy Sigmoidal Tumours: • Sigmoidcolectomy High rectal tumours >5cm from anus: • Anterior resection This approach is favoured as it leaves scope for anastomosis as there is still anal sphincter left. Low Rectal tumours <5cm from anus: • Abdominoperineal resection/ AP resection *this will result in a permeant colostomy as the entire: - Distal colon - Rectum - Anal sphincters Are removed.
59
When is chemotherapy usually indicated in bowel cancer?
> Duke C
60
What palliative procedures can be done in colorectal carcinoma?
Endoluminal stenting - to by pass blockages Stoma formations
61
What are the peak incidences of Crohn's disease?
Bi-modal. 15-30years 60-80 years
62
Surveillance of polyps is dependent on what?
Size Number Histology
63
What is the management of polyps?
Colonoscopic polypectomy Large ones that are unable to removed by colonoscopy are done so by: - segmental removal of bowel FAP is treated with by: - proctocolectomy - ileoanal pouch formation
64
Following a severe remission of UC, or >2 remission in one year what medication should a person be put on?
Oral Azathioprine
65
What drug increases the risk of Crohn's disease?
NSAIDs
66
During an acute flare of UC, what do you want monitored?
Stats, including temperature | Stool frequency and character - Bristol stool chart
67
What features of colonoscopy might be seen in UC?
Pseudopolyps
68
What features may be seen on colonoscopy in Crohn's?
Cobbled stoned appearance Skip lesions Increased goblet cells
69
On a barium enema of Ulcerative colitis, what might be seen?
Loss of haustra
70
How is the severity of a UC attack monitored?
``` Motions Rectal bleeding Temperature Pulse rate Hb ESR ```
71
What inflammatory marker is used to assess Ulcerative colitis?
ESR
72
Why do you want ABX in Ulcerative colitis?
Assess for toxic megacolon Assess where faecal impaction ends. this gives good idea where the disease process goes to, as distal to this the inflamed bowel will just empty
73
What are the indications for surgical input for UC and what two operations are usually performed?
Fulminant disease Failure of medical management Complications - Toxic megacolon, perforation Malignant changes Operations: - total proctocolectomy + Ileostomy or - Colectomy with Stump sewn or Ileostomy
74
What is used for bowel preparation surgery and what are some risks associated with this?
Sodium Picosulfate - Hyponatremia - Hypokalemia
75
What are the indications for surgery in diverticulitis?
``` Perforation Fistula formation Massive haemorrhage Obstruction Abscess formation ```
76
what is the general management for Colonic cancer?
Surgical resection + lymph nodes and Blood supply Adjuvant therapy Anastomosis/ Ileostomy Palliative
77
What are the types of anal abscess that can form?
Intrasphincteric Supralevator Peri-anal Ischiorectal
78
What are the follow ups of Colorectal cancer?
1,2,3 years - CT of chest/ Abdo/ Pelvis 1 and 5 year colonoscopy CEA every 6 months for 5 years
79
What are the Hinchey classifications and which require immediate surgery?
Stage 1. - localised abscess pericolic Stage 2. - Advanced abscess into the pelvis Stage 3. - Purulent abscess Stage 4. - Faecolith abscess Stages 3 and 4 require immediate surgery
80
What inflammatory marker is used in Ulcerative Colitis?
ESR
81
How would you investigate colon cancer?
Bloods: - FBC - blood loss - LFTs - metastasis - CEA Orifices: PR examination Colonoscopy X-rays: - CT - Barium Enema - apple core sign
82
When carrying out bowel removal surgery for colorectal cancer, what else must be taken?
Mesentry Lymph nodes Blood supply
83
When investigating anorectal pathology,what investigations should be conducted?
``` PR exam Proctoscopy MRI Scan +/- Examination under GA +/- Manometry of sphincter ```
84
When there is anal sepsis with fistula, when should a seton be used and when should laying open be used?
If fistula is present supra-sphincter then seton suture If sub-sphincter it should be laid open
85
Risk factors for diverticular disease:
Low fibre Use of NSAIDs Smoking Obesity
86
What are the signs and symptoms of diverticulitis and diverticular disease?
Diverticular disease: - Flatulence - distension - Left iliac pain - Constipation - Intermittent nature - Nausea * classic triad is: - Intermittent - Bloating - LLQ pain Diverticulitis: - LLQ Pain - acute and sharp - PR blood - Tachycardia - Low grade fever - Nausea - High white cell count - UTI like symptoms
87
Should Barium Enema be used in acute diverticulitis?
No - risk of perforation
88
What is the finding seen on barium swallow in Crohn's disease?
String sign of Kantor Rose thorn appearance
89
What are the causes to a fistula in Ano and what is the rule associated with it?
Crohn's disease TB Goodall's rule. If anterior the exit will be anterior and straight line. If posterior the exit will be posterior and take a curved course.
90
What are the location of haemorrhoids?
3, 7, 11

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