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D3 > Lower GI Surgery > Flashcards

Lower GI Surgery Flashcards

1
Q

Small Bowel Neoplasms

A 
Benign: 35%
 Lipoma
 Leiomyoma
 Neurofibroma
 Haemangioma
 Adenomatous polyps (FAP, Peutz-Jeghers)

Malignant: 65% (only 2% of GI malignancies)
 Adenocarcinoma (40% of malignant tumours)
 Carcinoid (40% of malignant tumours)
 Lymphoma (esp. c¯ Coeliac disease: EATL)
 GIST

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2
Q

Small Bowel Neoplasms Presentation

A

Often non-specific symptoms so present late
N/V, obstruction
Wt. loss and abdominal pain
Bleeding
Jaundice from biliary obstruction or liver mets.

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3
Q

Meckel’s Diverticulum

A

Ileal remnant of vitellointestinal duct
 Joins yoke sac to midgut lumen

Features
 A true diverticulum
 2 inches long
 2 ft from ileocaecal valve on antimesenteric border
 2% of population
 2% symptomatic
 Contain ectopic gastric or pancreatic tissue

Presentation of Symptomatic Meckel’s
Rectal bleeding: from gastric mucosa
Diverticulitis mimicking appendicitis
Intussusception
Volvulus
Malignant change: adenocarcinoma
Raspberry tumour: mucosa protruding at umbilicus
 A vitello-intestinal fistula
Littre’s Hernia: herniation of Meckel’s

Dx
 Tc pertechnecate scan +ve in 70% (detects gastric
mucosa)

Rx
 Surgical resection

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4
Q

Intussusception

A

Portion of intestine (the intussusception) is invaginated into its own lumen (the intussuscipiens)

Cause
 Hypertrophied Peyer’s patch
 Meckel’s
 HSP
 Peutz-Jeghers
 Lymphoma
Presentation
 6-12mo
 Colicky abdo pain:
 Episodic inconsolable crying, drawing up legs
 ± bilious vomiting
 Redcurrent jelly stools
 Sausage-shaped abdominal mass

Mx
 Resuscitate, x-match, NGT
 US + reduction by air enema
 Surgery if not reducible by enema
NB. Intussusception rarely occurs in an adult
 If it does, consider neoplasm as lead-point

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5
Q

Mesenteric Adenitis

A

Viral infection / URTI → enlargement of mesenteric LNs
 → pain, tenderness and fever

Differentiating features
 Post URTI
 Headache + photophobia
 Higher temperature
 Tenderness is more generalised
 Lymphocytosis
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6
Q

Acute Appendicitis

A

Inflammation of the vermiform appendix ranging from oedema to ischaemic necrosis and perforation.

Commonest surgical emergency
Maximal peak in childhood, rare <2y

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7
Q

Acute Appendicitis Pathogenesis

A 
Obstruction of the appendix
 Faecolith most commonly
 Lymphoid hyperplasia post-infection
 Tumour (e.g. caecal Ca, carcinoid)
 Worms (e.g. Ascaris lumbicoides, Schisto)

Gut organisms → infection behind obstruction

→ oedema → ischaemia → necrosis → perforation
 Peritonitis
 Abscess
 Appendix mass

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8
Q

Acute Appendicitis Pattern of Abdo Pain

A

Early inflammation > appendiceal irritation

  • visceral pain not well localised cf somatic pain
  • Nociceptive info > sympathetic afferent fibres that supply viscus
  • pain referred to dermatome corresponding to spinal cord entry level of sympathetic fibres
  • append - midgut - lesser splanch (T10/11) - umb

Late inflammation
- pain localised in RIF

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9
Q

Acute Appendicitis Sx and Signs

A 
Sx 
Colicky abdo pain
 Central → localised in RIF
 Worse c¯ movement
Anorexia
Nausea (vomiting is rarely prominent)
Constipation / diarrhoea 
Signs 
Low-grade pyrexia: 37.5 – 38.5
↑HR, shallow breathing
Foetor oris - unpleasant smell
Guarding and tenderness: @ McBurney’s point
 +ve cough / percussion tenderness
Appendix mass may be palpable in RIF
Pain PR suggests pelvic appendix.
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10
Q

Acute Appendicitis Special Signs

A

Rovgins’s Sign - Pressure in LIF > RIF pain

Psoas sign - pain on extending the hip - retrocaecal appendix

Cope sign - flexion + internal rotation of the hip

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11
Q

Acute Appendicitis Ix

A

Dx is principally clinical

Bloods: FBC, CRP, amylase, G+S, clotting

Urine
 Sterile pyuria: may indicate bladder irritation
 Ketones: anorexia
 Exclude UTI
 β-HCG

Imaging
 US: exclude gynae path, visualise inflamed
appendix
 CT: can be used

Diagnostic lap

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12
Q

Acute Appendicitis Mx

A

 Fluids
 Abx: cef 1.5g + met 500g IV TDS
 Analgesia: paracetamol, NSAIDs, codeine phosphate
 Certain Dx → appendicectomy (open or lap)
 Uncertain Dx → active observation

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13
Q

Acute Appendicitis Complications

A 
Appendix Mass
- Inflamed appendix c¯ adherent covering of omentum and
small bowel
- Dx: US or CT
- Mx
 Initially: Abx + NBM
 Resolution of mass → interval appendicectomy
 Exclude a colonic tumour: colonoscopy
Appendix Abscess
- Results if appendix mass doesn’t resolve
- Mass enlarges, pt. deteriorates
- Mx
Abx + NBM
 CT-guided percutaneous drainage
 If no resolution, surgery may involve right
hemicolectomy

Perforation
 Commoner if faecolith present and in young children (as
Dx is often delayed)
 Deteriorating pt. c¯ peritonitis.

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14
Q

Diverticular Disease

A

Diverticulum = out-pouching of tubular structure
 True = composed of complete wall (e.g. Meckel’s)
 False = composed of mucosa only (pharyngeal, colonic)

Diverticular disease: symptomatic diverticulosis

Diverticulitis: inflammation of diverticula

f>m

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15
Q

Diverticular disease pathophysiology

A

Assoc. c¯ ↑ intraluminal pressure
 Low fibre diet: no osmotic effect to keep stool wet

Mucosa herniates through muscularis propria at points
of weakness where perforating arteries enter.

Most commonly located in sigmoid colon

Commoner in obese pts.
 Uniting factor in Saint’s Triad?
 Hiatus Hernia
 Cholelithiasis
 Diverticular disease
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16
Q

Diverticular Disease Sx + Rx

A

Altered bowel habit ± left-sided colic
 Relieved by defecation
Nausea
Flatulence

Rx
 High fibre diet, mebeverine may help
 Elective resection for chronic pain

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17
Q

Diverticulitis Presentation

A

Insipissated faeces > obstruction of diverticulum
Elderly w Hx of constipation

Presents
abdo pain + tenderness 
- typically LIF
- localised periotnitis 
pyrexia
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18
Q

Diverticulitis Ix

A 
Bloods
 FBC: ↑WCC
 ↑CRP/ESR
 Amylase
 G+S/x-match
Imaging
 Erect CXR: look for perforation
 AXR: fluid level / air in bowel wall
 Contrast CT
 Gastrograffin enema

Endoscopy
 Flexi Sig
 Colonoscopy: not in acute attack

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19
Q

Hinchey Grading

A

Diverticulitis
1 Small confined pericolic abscesses - Surgery rarely
needed
2 Large abscess extending into pelvis - May resolve w/o
surgery
3 Generalised purulent peritonitis - Surgery needed
4 Generalised faecal peritonitis - Surgery needed

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20
Q

Mx of acute Diverticulitis

A

Mild Attacks - can be Mx at home w bowel rest (fluids only) + augmentin+/-metronidazole

Admit if - unwell, fluids not tolerated, pain uncontrolled

Medical - NBM, IV fluids, analgesia

  • abx (cefuroxime + metronidazole)
  • most cases settle
Surgical if 
- perforation
- large haemorrhage
- Stricture → obstruction
Procedure
- Hartmann's to resect diseased bowel
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21
Q

Other complications of diverticular disease

Perforation

A
  • sudden onset of pain (w/(o) preceedint diverticulitis)
  • generalised peritonitis + shock
  • CXR - free air under diaphragm
  • Rx haartmann’s
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22
Q

Other complications of diverticular disease

Abscess

A

Walled-off perforation
 Swinging fever
 Localising signs: e.g. boggy rectal mass
 Leukocytosis

Rx: Abx + CT/US-guided drainage

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23
Q

Other complications of diverticular disease

Fistulae

A

Enterocolic
Colovaginal
Colovesicular: pneumaturia + intractable UTIs

Rx: resection

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24
Q

Other complications of diverticular disease

Strictures

A

After diverticulitis, colon may heal c¯ fibrous strictures

Rx
 Resection (usually c¯ 1O anastomosis)
 Stenting

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25
Q

Bowel Obstruction Classification

A

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

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26
Q

Commonest Causes of Bowel Obstruction

A

SBO
 Adhesions: 60%
 Hernia

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

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27
Q

Non-mechanical causes of bowel obstruction

Paralytic ileus (usually small bowel)

A 
 Post-op
 Peritonitis
 Pancreatitis or any localised inflammation
 Poisons / Drugs: anti-AChM (e.g. TCAs)
 Pseudo-obstruction
 Metabolic: ↓K, ↓Na, ↓Mg, uraemia
 Mesenteric ischaemia
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28
Q

Mechanical causes of bowel obstruction

Intraluminal

A

Impacted matter: faeces, worms, bezoars

Intussusception

Gallstones

29
Q

Mechanical causes of bowel obstruction

Intramural

A 
Benign Stricture
 IBD
 Surgery
 Ischaemic colitis
 Diverticulitis
 Radiotherapy

Neoplasia
Congenital atresia

30
Q

Mechanical causes of bowel obstruction

Extramural

A 
Hernia
Adhesions
Volvulus (sigmoid, caecal, gastric)
Extrinsic compression
 Pseudocyst
 Abscess
 Haematoma
 Tumour: e.g. ovarian
 Congenital bands (e.g. Ladd’s)
31
Q

Bowel Obstruction Presentation

A

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

32
Q

Bowel Obstruction Examination

A 
↑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
33
Q

Bowel Obstruction Ix

A

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

34
Q

AXR Findings of Small Bowel obstruction

A

Diameter ≥3
Location Central
Markings Valvulae coniventes
- completely across

LB Gas Absent
No. of loops Many
Fluid levels Many, short

35
Q

AXR Findings of Large Bowel obstruction

A 
Diameter ≥6cm (caecum ≥9)
Location Peripheral
Markings Haustra - partially across
LB Gas Present - not in rectum
No. loops Few
Fluid levels Few, long
36
Q

Bowel Obstruction Medical Mx

A

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

37
Q

Surgical Mx of Bowel Obstruction

A 
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.

38
Q

Surgical Mx of Bowel Obstruction

PROCEDURES

A

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

39
Q

Sigmoid Volvulus

A

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

40
Q

Sigmoid Volvulus AXR + Mx

A

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

41
Q

Caecal Volvulus

A

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

42
Q

Gastric Volvulus

A

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

43
Q

Paralytic Ileus Presentation + causes

A 
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
44
Q

Paralytic Ileus Prevention and M

A 
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
45
Q

Colonic Pseudo-obstruction

Ogilvie’s Syndrome

A

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

46
Q

Colorectal Carcinoma Surgery

A

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

47
Q

Rectal carcinoma Surgery

A

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

48
Q

Sigmoid tumour Surgery

A

high anterior resection or sigmoid colectomy

49
Q

Left sided bowel tumours Surgery

Transverse bowel tumour surgery

Caecal/right sided bowel tumorus surgery

A

left hemicolectomy

Extended right hemicolectomy

Right hemicolectomy

50
Q

Other procedures/treatment for bowel cancer

A

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
51
Q

NHS Screening for CRC

A 
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%
52
Q

Familial Adenomatous Polyposis

A

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)

53
Q

FAP Variants

A

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

54
Q

Hereditary Non-Polyposis Colorectal Cancers

A

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

55
Q

Peutz- Jehgers Syndrome

A

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

56
Q

GI polyps

A

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
57
Q

Juvenile Polyposis

A

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

58
Q

Cowden Syndrome

A

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

59
Q

Acute Mesenteric Ischaemia Causes

A

Arterial: thrombotic (35%), embolic (35%)

Non-occlusive (20%)
 Splanchnic vasoconstriction: e.g. 2O to shock

Venous thrombosis (5%)

Other: trauma, vasculitis, strangulation

60
Q

Acute Mesenteric Ischaemia Presentation

A

Nearly always small bowel

Triad
 Acute severe abdominal pain ± PR bleed
 Rapid hypovolaemia → shock
 No abdominal signs

Degree of illness&raquo_space; clinical signs
May be in AF

61
Q

Acute Mesenteric Ischaemia Ix

A 
Bloods
 ↑Hb: plasma loss
 ↑WCC
 ↑ amylase
 Persistent metabolic acidosis: ↑lactate

Imaging
 AXR: gasless abdomen
 Arteriography / CT/MRI angio

62
Q

Acute Mesenteric Ischaemia Complications Mx

A

Complications
 Septic peritonitis
 SIRS → MODS

Mx
 Fluids
 Abx: gent + met
 LMWH
 Laparotomy: resect necrotic bowel
63
Q

Chronic Small Bowel Ischaemia

A

Cause - atheroma + low flow state (eg LVF)

Presents

  • severe colicky post prandial abdo pain (gut claudication)
  • PR Bleeding
  • Malabs, wt loss

Mx - angioplasty

64
Q

Chronic Large Bowel Ischaemia

A

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

65
Q

Lower GI bleed Causes

A

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

66
Q

Lower GI bleed Ix

A

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

67
Q

Lower GI bleed Mx

A

 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

68
Q

Angiodysplasia

A

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

D3 (14 decks)

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