Lower GI Surgery Flashcards

Question

Bowel Obstruction Classification

Answer 1

Simple  1 obstructing point + no vascular compromise  May be partial or complete ``` Closed Loop  Bowel obstructed @ two points - Left CRC c¯ competent ileocaecal valve - Volvulus  Gross distension → perforation ``` Strangulated  Compromised blood supply  Localised, constant pain + peritonism  Fever + ↑WCC

Answer 2

SBO  Adhesions: 60%  Hernia LBO  Colorectal Neoplasia: 60%  Diverticular stricture: 20%  Volvulus: 5%

Answer 3

```  Post-op  Peritonitis  Pancreatitis or any localised inflammation  Poisons / Drugs: anti-AChM (e.g. TCAs)  Pseudo-obstruction  Metabolic: ↓K, ↓Na, ↓Mg, uraemia  Mesenteric ischaemia ```

Answer 4

Impacted matter: faeces, worms, bezoars Intussusception Gallstones

Answer 5

``` Benign Stricture  IBD  Surgery  Ischaemic colitis  Diverticulitis  Radiotherapy ``` Neoplasia Congenital atresia

Answer 6

``` Hernia Adhesions Volvulus (sigmoid, caecal, gastric) Extrinsic compression  Pseudocyst  Abscess  Haematoma  Tumour: e.g. ovarian  Congenital bands (e.g. Ladd’s) ```

Answer 7

Abdominal Pain  Colicky  Central but level depends on gut region  Constant / localised pain suggests strangulation or impending perforation Distension (lower obstructions) Vomiting  Early in high obstruction  Late or absent in low obstructions Absolute Constipation: flatus and faeces

Answer 8

``` ↑HR: hypovolaemia, strangulation Dehydration, hypovolaemia Fever: suggests inflammatory disease or strangulation Surgical scars Hernias Mass: neoplastic or inflammatory ``` Bowel sounds  ↑: mechanical obstruction  ↓: ileus ``` PR  Empty rectum  Rectal mass  Hard impacted stool  Blood from higher pathology ```

Answer 9

Bloods  FBC: ↑WCC  U+E: dehydration, electrolyte abnormalities  Amylase: ↑↑ if strangulation/perforation  VBG: ↑ lactate in strangulation  G+S, clotting: may need surgery Imaging  Erect CXR  AXR: ± erect film for fluid levels  CT: can show transition point Gastrograffin studies  Look for mechanical obstruction: no free flow  Follow through or enema  Follow through may relieve mild mechanical obstruction: usually adhesional Colonoscopy  Can be used in some cases  Risk of perforation  May be used therapeutically to stent

Answer 10

Diameter ≥3 Location Central Markings Valvulae coniventes - completely across LB Gas Absent No. of loops Many Fluid levels Many, short

Answer 11

``` Diameter ≥6cm (caecum ≥9) Location Peripheral Markings Haustra - partially across LB Gas Present - not in rectum No. loops Few Fluid levels Few, long ```

Answer 12

Resuscitate: “Drip and Suck”  NBM  IV fluids: aggressive as pt. may be v. dehydrated  NGT: decompress upper GIT, stops vomiting, prevents aspiration  Catheterise: monitor UO ``` Therapy  Analgesia: may require strong opioid  Antibiotics: cef+met if strangulation or perforation  Gastrograffin study: oral or via NGT  Consider need for parenteral nutrition ``` Monitor - distension, pain/tenderness, HR/RR - Repeat image/bloods LBO more likely to need surgery

Answer 13

``` Indications  Closed loop obstruction  Obstructing neoplasm  Strangulation / perforation → sepsis, peritonitis  Failure of conservative Mx (up to 72h) ``` Principals  Aim to treat the cause  Typically resection obstructing lesion  Colon has not been cleansed :. most surgeons use proximal ostomy post-resection.  substantial comorbidity or unresectable tumours may offered bypass procedures.  Endoscopically placed expanding metal stents offer palliation or a bridge to surgery allowing optimisation.

Answer 14

SBO - adhesiolysis LBO  Hartmann’s  Colectomy + 1O anastomosis + on table lavage  Palliative bypass procedure  Transverse loop colostomy or loop ileostomy  Caecostomy

Answer 15

Long mesentery w narrow base > ^p(torsion) Usually due to sigmoid elongation 2ndary to chronic constipation ↑ risk in neuropsych pts.: MS, PD, psychiatric  Disease or Rx interferes w intestinal motility → closed loop obstruction Presents M>F, elderly constipated, comorbid pts Massive Distension w TYMPANIC ABDOMEN

Answer 16

AXR - inverted U/coffee bean sign Mx Often relieved by sigmoidoscopy and flatus tube insertion  Monitor for signs of bowel ischaemia following decompression. Sigmoid colectomy occasionally required  Failed endoscopic decompression  Bowel necrosis Often recurs  elective sigmoidectomy may be needed

Answer 17

Assw congen malformation - caecum not fixed in RIF. Only ~10% of pts. can be detorsed w colonoscopy typically requires surgery Right hemi w primary ileocolic anastomosis Caecostomy

Answer 18

Triad of gastro-oesophageal obstruction  Vomiting → retching c¯ regurgitation of saliva  Pain  Failed attempts to pass an NGT ``` Risk Factors Congenital  Bands  Rolling / Paraoesophageal hernia  Pyloric stenosis Acquired  Gastric / oesophageal surgery  Adhesions ``` Ix  Gastric dilatation  Double fluid level on erect films Mx  Endoscopic manipulation  Emergency laparotomy

Answer 19

``` Presentation  Adynamic bowel 2ndary to absence of normal peristalsis  Usually SBO  Reduced or absent bowel sounds  Mild abdominal pain: not colicky ``` ``` Cause  Post-op  Peritonitis  Pancreatitis or any localised inflammation  Poisons / Drugs: anti-AChM (e.g. TCAs)  Pseudo-obstruction  Metabolic: ↓K, ↓Na, ↓Mg, uraemia  Mesenteric ischaemia ```

Answer 20

``` Prevention  ↓ bowel handling  Laparoscopic approach  Peritoneal lavage after peritonitis  Unstarched gloves ``` ``` Mx  Conservative “drip and suck” Mx  Correct underlying causes - Drugs/Metabolic abnormalities  Consider need for parenteral nutrition  Exclude mechanical cause if protracted ```

Answer 21

Clinical signs of mechanical obstruction but no obstructing lesion found Usually distension only: no colic Cause unknown - assw elderly, cardioresp disorders, pelvic surgery, trauma Ix - gastrograffin enema - exclude mechanical cause Mx - neostigmine (anticholinesterase) - colonoscopic decompression 80% successful

Answer 22

Use ERAS pathway (enhanced recovery after surgery) Pre-operative bowel prep (except R sided lesions)  E.g. Kleen Prep (Macrogol: osmotic laxative) the day before and phosphate enema in the AM. Consent: discuss stomas (Stoma nurse consult for siting) Principles Excision depends on lymphatic drainage which follows arterial supply.  Mobility of bowel and blood supply at cut ends is also important.  Hartmann’s often used if obstruction.  Laparoscopic approach is the standard of care

Answer 23

Neo-adjuvant radiotherapy may be used to ↓ local recurrence and ↑5ys Anterior resection: tumour 4-5cm from anal verge  Defunction c¯ loop ileostomy AP (abdominopernieal) resection: <4cm from anal verge + Total mesorectal excision for tumours of the middle and lower third.  Aims to ↓ recurrence  ↑ anastomotic leak and faecal incontinence

Answer 24

high anterior resection or sigmoid colectomy

Answer 25

left hemicolectomy Extended right hemicolectomy Right hemicolectomy

Answer 26

Local excision: e.g. Transanal Endoscopic Microsurg Bypass surgery: palliation Hepatic resection: if single lobe mets only Stenting: palliation or bridge to surgery in obstruction ``` Chemo  Adjuvant 5-FU for Dukes’ C ↓ mortality by 25%  i.e. LN +ve pts.  High grade tumour  Palliation of metastatic disease ```

Answer 27

``` Faecal occult blood testing  60-75yrs  Home FOB testing every 2yrs: ~1/50 have +ve FOB  Colonoscopy if +ve: ~1/10 have Ca - reduces risk of dying from CRC by 25% ``` ``` Flexi Sig  55-60yrs  Once only flexi Sig  ↓ CRC incidence by 33%  ↓ CRC mortality by 43% ```

Answer 28

AD APC geng 5q21 100-1000s of adenomas by ~16yrs  Mainly in large bowel  Also stomach and duodenum (near ampulla) 100% develop CRC, often by ~40yrs May be assw congen hypertrophy of the retinal pigment epithelium (CHPRE)

Answer 29

Attenuated FAP: <100 adenomas, later CRC (>50yrs) Gardener’s (TODE)  Thyroid tumours  Osteomas of the mandible, skull and long bones  Dental abnormalities: supernumerary teeth  Epidermal cysts Turcot’s: CNS tumours: medullo- and glio-blastomas

Answer 30

AD mutation of mismatch repair enzymes Commonest cause of all hereditary CRC Presentation  Lynch 1: right sided CRC  Lynch 2: CRC + gastric, endometrial, prostate, breast Dx: “3, 2, 1, rule”  ≥3 family members over 2 generations c¯ one <50yrs

Answer 31

AD STK11 mut ~ 10-15yrs Mucocutaneous hyperpigmentation  Macules on palms, buccal mucosa Multiple GI hamartomatous polyps  Intussusception  Haemorrhage ↑ Ca risk  CRC, pancreas, breast, lung, ovaries, uterus

Answer 32

Inflammatory pseudopolyps - regen islands of mucosa in UC Hyperplastic polyps - piling up of goblet cells + absorptive cells - serrated surface architecture No malignant potential Harmatomatmous - tumour-like growths composed of tissues present at site where they develop - sporadic or part of familial syndromes - juvenile polyp - solitary harmatoma in children (cherry on stalk) Neoplastic - tubular or villous adenomas - usually ASx - may have blood/mucus PR, tenesmus

Answer 33

 Autosomal dominant  >10 hamartomatous polyps  ↑ CRC risk: need surveillance and polypectomy

Answer 34

 Auto dominant  Macrocephaly + skin stigmata  Intestinal hamartomas  ↑ risk of extra-intestinal Ca

Answer 35

Arterial: thrombotic (35%), embolic (35%) Non-occlusive (20%)  Splanchnic vasoconstriction: e.g. 2O to shock Venous thrombosis (5%) Other: trauma, vasculitis, strangulation

Answer 36

Nearly always small bowel Triad  Acute severe abdominal pain ± PR bleed  Rapid hypovolaemia → shock  No abdominal signs Degree of illness >> clinical signs May be in AF

Answer 37

``` Bloods  ↑Hb: plasma loss  ↑WCC  ↑ amylase  Persistent metabolic acidosis: ↑lactate ``` Imaging  AXR: gasless abdomen  Arteriography / CT/MRI angio

Answer 38

Complications  Septic peritonitis  SIRS → MODS ``` Mx  Fluids  Abx: gent + met  LMWH  Laparotomy: resect necrotic bowel ```

Answer 39

Cause - atheroma + low flow state (eg LVF) Presents - severe colicky post prandial abdo pain (gut claudication) - PR Bleeding - Malabs, wt loss Mx - angioplasty

Answer 40

Cause - follows low flow IMA territory Presents - lower LS abdo pain - Bloody diarrhoea - Pyrexia Tachycardia Ix -  ↑WCC  Ba enema: thumb-printing  MR angiography Complications - may > peritonitis + septic shock - long term strictures Mx  Usually conservative: fluids and Abx  Angioplasty and endovascular stenting

Answer 41

Common / Important  Rectal: haemorrhoids, fissure  Diverticulitis  Neoplasm Other  Inflammation: IBD  Infection: shigella, campylobacter, C. diff  Polyps  Large upper GI bleed (15% of lower GI bleeds)  Angio: dysplasia, ischaemic colitis, HHT

Answer 42

Bloods: FBC, U+E, LFT, x-match, clotting, amylase Stool: MCS Imaging  AXR, erect CXR  Angiography: necessary if no source on endoscopy  Red cell scan Endoscopy  1st: Rigid proctoscopy / sigmoidoscopy  2nd: OGD  3rd: Colonoscopy: difficult in major bleeding

Answer 43

 Resuscitate  Urinary catheter  Abx: if evidence of sepsis or perf  PPI: if upper GI bleed possible  Keep bed bound: need to pass stool may be large bleed → collapse  Stool chart  Diet: keep on clear fluids (allows colonoscopy)  Surgery: only if unremitting, massive bleed

Answer 44

Submucosal AV malformation (mainly right colon) Can affect anywhere in GIT Presents - elderly - fresh PR bleed ``` Ix Exclude other Dx  PR exam  Ba enema  Colonoscopy Mesenteric angiography or CT angiography Tc-labelled RBC scan: identify active bleeding ``` Rx  Embolisation  Endoscopic laser electrocoagulation  Resection

Lower GI Surgery Flashcards

(68 cards)