Lecture 4 highlights

Question 1

1) Blood supply to colon comes from?
2) What abt to the rectum?
3) Venous drainage of rectum goes where?

Answer 1

1) SMA and IMA
2) IMA, internal iliac, internal pudendal​
3) IMV/portal and to systemic circulation​

Question 2

Differentiate Acquired (false or pseudo) diverticula and true diverticula

Answer 2

1) False: mucosal herniation through muscular layer of colon wall; related to diet, straining, age; more common
2) True: all layers; rare

Question 3

Define:
1) Diverticulosis
2) Diverticulitis

Answer 3

1) Diverticulosis: presence of diverticula
2) Diverticulitis: infectious process

Question 4

List some characteristics of diverticulosis

Answer 4

False diverticula
MC in sigmoid
Asymptomatic; can bleed

Question 5

Diverticulitis:
1) Main Sx?
2) Preferred initial study?

Answer 5

1) Progressive abd pain (usually LLQ)
2) CTA/Pw IV contrast

Question 6

When is emergent surgery indicated for diverticulitis?

Answer 6

Indicated for free (frank) perforation, obstruction, & persistent symptoms
ie Hinchey III & IV

Question 7

List the diverticulitis Hinchey classifications

Answer 7

Stage 0: mild clinical diverticulitis
Stage I: pericolic or mesenteric abscess
Stage II: walled-off pelvic abscess
—————
Stage III: generalized purulent peritonitis
Stage IV: generalized feculent peritonitis

Question 8

Elective diverticulitis surgery is typically performed __________ weeks after recovery from medical Tx

Answer 8

10-12

Question 9

List 4 Pre/peri-operative considerations for diverticulitis

Answer 9

1) Abx
2) Bowel prep
3) Stoma marking
4) Patient positioning

Question 10

1) What type of surgery for elective diverticulitis procedures?
2) What type for emergent procedures?

Answer 10

1) Sigmoid colectomy/ resection with primary anastomosis
-one stage, minimally invasive
2) 2 stage Hartmann’s procedure
-gold standard

Question 11

Most colorectal cancers (CRC) arise from ______________ colon polyps

Answer 11

adenomatous

Question 12

CRC:
1) How do most cases present?
2) Which lesion location may cause chronic blood loss resulting in iron deficiency anemia (fatigue, weakness)?

Answer 12

1) Asymptomatic (most) or positive occult blood
2) Right-sided

Question 13

1) What is the gold standard for CRC detection?
2) What is another option?

Answer 13

1) Colonoscopy
2) CT colonography (“virtual colonoscopy”)

Question 14

Descr CRC imaging

Answer 14

CT chest, abdomen & pelvis required for pre-operative staging
MRI may be better for rectal cancers, liver mets

Question 15

Name 1 supplemental approach for staging rectal cancer

Answer 15

MRI and ERUS

Question 16

CRC:
1) Main Tx?
2) How many lymph nodes should be resected to determine staging?

Answer 16

1) Resection of the primary colonic or rectal tumor + anastomosis
2) At least 12

Question 17

Rectal CA: Descr the main types of surgery options

Answer 17

1) Local excision
2) Radical excision: LAR or APR + TME

Question 18

What is gold standard for tumors of the middle and lower rectum?

Answer 18

Total mesorectal excision (TME)

Question 19

What is the MC site for metastatic CRC?

Answer 19

Liver

Question 20

1) What is the most common form of anorectal abscess?
2) How are all anorectal abscesses treated?

Answer 20

1) Perianal abscess
2) I&D

Question 21

Anal fistula:
1) What are the 2 main Tx options?
2) When are these not used?

Answer 21

1) Fistulotomy OR Sphincter-sparing approaches
2) If associated with Crohn’s, medical management (abx, biologics) is the treatment.

Question 22

Rectal prolapse: Who is it common in?

Answer 22

Most common in women > 50 y/o, esp with chronic constipation

Question 23

What is the main Tx for rectal prolapse?

Answer 23

Rectopexy

Question 24

Hemorrhoids:
1) What can exclude other diagnoses?
2) What are the main Sxs of internal cases?
3) What abt external?

Answer 24

1) Anoscopy
2) Painless BRBPR
3) Pain + pruritis

Question 25

Descr the grades of internal hemorrhoids

Answer 25

1) Grade 1 = medical Tx; only painless bleeding 2) Grade 2 = medical Tx 3) Grade 3 = medical Tx 4) Grade 4 = surgical Tx; lots of symptoms

Question 26

Which hemorrhoids pts are eligible for medical treatment/ office based procedures (ie ligation)?

Answer 26

Uncomplicated external hemorrhoids/internal grades 1-3

Question 27

What is the main symptom of anal fissures?

Answer 27

Sharp pain with defecation

Question 28

How do you determine anal fissure surgical Tx?

Answer 28

Based on risk of fecal incontinence (high risk = lateral internal sphincterotomy)

Question 29

Pilonidal disease: 1) How are acute abscesses treated? 2) What should you do if failure of conservative therapy for chronic draining pits (2-3mos)? 3) What abt if complex, recurrent disease with large, nonhealing wounds?

Answer 29

1) I&D with longitudinal incision >2cm lateral to midline 2) Lateral incision (important) & pit closure, incision left open for drainage 3) Complex flap surgery

Question 30

Pilonidal disease: List 2 surgical options for complex, recurrent pilonidal disease with large, nonhealing midline wounds

Answer 30

Kardyakis procedure Bascom cleft lift procedure (UTD link)

Question 31

1) Colon is most common site of bowel ischemia, and it's usually due to ___________ 2) What specific part of the colon?

Answer 31

1) Hypoperfusion 2) Splenic flexure and rectosigmoid junction (watershed areas)

Question 32

Descr the Intestinal vascular supply

Answer 32

Celiac artery (stomach & duodenum) Superior mesenteric artery (foregut; distal duodenum to mid-transverse colon) Inferior mesenteric artery (hindgut; transverse colon to rectum) Natural anastomoses: collateral pathways

Question 33

Descr Sxs of colonic ischemia

Answer 33

Dull pain that radiates to the back; nothing makes it better or worse Can be acute/ subacute/ chronic

Question 34

1) What are the 2 main tests for colonic ischemia? 2) When is urgent segmental resection & creation of stoma needed? 3) What should you do if suspected to have reversible ischemic colitis?

Answer 34

1) Colonoscopy and abd CT w contrast 2) If irreversible full-thickness necrosis or perforation 3) IVF, bowel rest, broad-spectrum abx, and observation with serial abd exams

Question 35

1) MC cause of large bowel obstruction? 2) What is the most useful single test for large bowel obstruction?

Answer 35

1) Neoplasms 2) CT with rectal contrast

Question 36

__________ obstructions almost always require intervention (extent of surgery depends on the pt’s acuity and etiology)

Answer 36

Mechanical

Question 37

What are the goals of LBO Tx?

Answer 37

Primary: Resection of all necrotic bowel & decompression Secondary: removal of obstructing lesion

Question 38

What is the MC location of volvus?

Answer 38

Sigmoid

Question 39

What are 3 imaging findings with sigmoid volvulus?

Answer 39

“Bent inner tube", "Bird’s beak” deformity, “Coffee bean” sign

Question 40

What is the primary Tx of cecal volvulus?

Answer 40

resection with right colectomy (ileocecectomy)

Question 41

What are some findings with cecal volvulus on imaging?

Answer 41

Coffee bean” sign with dilated cecum pointing to LUQ (may also see “bird’s beak”)