Medicine Finals - Imperial & Quick Medical Revision > Lower GI Surgery > Flashcards

Lower GI Surgery Flashcards

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1
Q

What are the small bowel benign neoplasms?

A
  • Lipoma
  • Leiomyoma
  • Neurofibroma
  • Haemangioma
  • Adenomatous polyp (FAP, Peutz-Jegher)
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2
Q

What are the small bowel malignant neoplasms?

A

65%

  • Adenocarcinoma
  • Carcinoid
  • Lymphoma (esp with Coeliac)
  • GIST
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3
Q

Presentation of small bowel neoplasms?

A
  • Often non-specific symptoms so present late
  • N/V, obstruction
  • Weight loss, abdominal pain
  • Bleeding
  • Jaundice from biliary obstruction or liver mets
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4
Q

Imaging for small bowel neoplasms?

A

AXR: SBO
Ba follow through
CT

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5
Q

Endoscopy investigation for small bowel neoplasms?

A

Push enteroscopy

Capsule endoscopy

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6
Q

Definition of acute appendicitis?

A

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

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7
Q

Epidemiology of acute appendicitis?

A

Incidence: 6% lifetime incidence, commonest surgical emergency

Age: rare <2yrs, maximal peak during child, decreased thereafter.

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8
Q

Pathogenesis of acute appendicitis?

A

Obstruction of the appendix

  • Faecolith most commonly
  • Lymphoid hyperplasia post-infection
  • Tumour (caecal Ca, carcinoid)
  • Worms (Ascaris lumbicoides, Schisto)

This means that gut organisms –> Infection behin obstruction
–> oedema, –> ischaemia, –> necrosis –> perforation

  • Peritonitis
  • Abscess
  • Appendix mass
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9
Q

Pattern of Abdominal Pain in Appendicitis

A

Early inflammation –>

appendiceal irritation

  • Visceral pain is not well localised compared with somatic pain
  • Pain referred to the dermatome corresponding to the spinal cord entry level of these sympathetic fibres
  • Append = midgut = Lesser splanch (T10/11) = umb.

Late inflammation –> parietal peritoneum irritation
- Pain localised in RIF

Remember
- Examine the testicles in a young man with RIF. Due to Torsion.

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10
Q

Symptoms of acute appendicitis?

A

Colicky abdo pain

  • Central –> Localised in RIF
  • Worse with movement

Anorexia
Nausea (vomiting is rarely prominent)
Constipation/diarrhoea

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11
Q

Signs of acute appendicitis?

A
  • Low-grade pyrexia: 37.5-38.5
  • Increased HR, shallow breathing
  • Foetor oris
    Guarding and tenderness @McBurney’s point.
    +ve cough/percussion tenderness
  • Appendix mass may be palpable in RIF
  • Pain PR suggest Pelvic appendix.
  • Rosving positive - Palpation in left causes pain in RIF.
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12
Q

Special signs for appendicitis?

A

Rovsing’s Sign
Psoas sign
Cope Sign

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13
Q

What is Rovsing’s sign?

A

Pressure in LIF –> more pain in RIF

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14
Q

What is psoas sign

A

Pain on extending the hip: retrocaecal appendix

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15
Q

What is cope sign

A

Flexion + internal rotation of R hip –> Pain

Appendix lying close to obturator internus

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16
Q

Differentials for acute appendicitis?

A

Surgical

  • Cholecystitis
  • Diverticulitis
  • Meckel’s diverticulitis

Gynae

  • Cyst accident
  • Salpingitis
  • Ruptured ectopic

Medical

  • Mesenteric adenitis
  • UTI
  • Crohns
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17
Q

Investigations for acute appendicitis?

A

Dx is principally clinical

Bloods: FBC, CRP, Amylase, G+S, clotting. Raised inflammatory markers + neutrophil-predominant leucocytosis.

Urine

  • Sterile pyuria may indicated bladder irritation
  • Ketones: Anorexia
  • Exclude UTI
  • B-HCG

Imaging

  • US: Exclude gynae path, visualise inflamed appendix
  • CT: can be used

Diagnostic lap

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18
Q

Management of acute appendicitis?

A
  • Fluid
  • Abx: cef 1.5g + met 500g IV TDS.
  • Analgesia: paracetamol, - NSAIDs, codeine phosphate
  • Certain Dx –> appendicectomy (open or lap)
  • Uncertain Dx –> Active observation

Consider underlying caecal malignancy or perforated sigmoid diverticular disease.

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19
Q

Complications of acute appendicitis

A

Appendix mass
- Inflamed appendix with 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
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20
Q

Appendix abscess?

A

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
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21
Q

Perforation of appendix?

A
  • Commoner if faecolith present and in young children (as Dx is often delayed)
  • Deteriorating pt with peritonitis
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22
Q

What is a diverticulum?

A
  • Out-pouching of tubular structures

- Mostly found in sigmoid colon.

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23
Q

What is a true diverticulum?

A

True = Composed of complete wall (Meckel’s)

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24
Q

What is a false diverticulum?

A

Composed of mucosa only (Pharyngeal, colonic)

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25
What is diverticular disease?
Symptomatic diverticulosis
26
What is diverticulitis?
Inflammation of diverticula
27
What is the epidemiology of diverticulitis?
30% of Westerner's have diverticulosis by 60yrs | F>M
28
What is the pathophysiology of diverticular disease?
Associated with increased 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 patients Uniting factor in Saint's triad - Hiatus hernia - Cholelithiasis - Diverticular disease
29
Symptoms of diverticular disease?
Altered bowel habit ± left-sided colic - Relieved by defection Nausea Flatulence Management - High fibre diet, mebeverine may help - Elective resection for chronic pain
30
What is diverticulitis?
- Inspissated faeces --> obstruction of diverticulum | - Elderly pt with prev hx of constipation
31
What is the presentation of diverticulitus?
- Abdominal pain and tenderness (guarding, rigidity, rebound tenderness) - Change in bowel habit - consitpaiton is more common but diarrhoea is also reported - Typically LIF - Localised peritonitis - Pyrexia - Urinary frequency, urgency or dysuria - due to irritation of the bladder by the inflamed bowel. - Tender LIF (w or w/i tender palpable mass) - Possibly reduced bowel sounds
32
Investigations for diverticular disease?
Blood - FBC: increased WCC - increased CRP and ESR - Amylase - G+S/match Imaging - Erect CXR: look for perforation - AXR: Fluid level/air in bowel wall/pneumoperitoneum. Need a CXR for pneumoperitoneum. - Contrast CT: for suspected abscesses - Gastrograffin enema Avoid colonoscopy due to increased risk of perforation in diverticulitis - Consider flexi sigmoidoscopy
33
What is the grading of diverticular disease?
Hinchey Grading 1) - Small confined pericolic abscesses - Surgery rarely needed. 2) Large abscess extending into pelvis - May resolve without surgery 3) Generalised purulent peritonitis - Needs surgery 4) Generalised faecal peritonitis - Needs surgery
34
What is the management of an acute attack of diverticulitis? - Mild
- Can be treated at home with bowel rest (fluids only) and augmentin ± metronidazole - If symptoms dont' settle within 72hrs, or patient presents with more severe symptoms, then admit for IV antibiotics.
35
When to admit an acute diverticulitis?
Unwell Fluids can't be tolerated Pain can't be controlled
36
What is the medical management of acute diverticulitis?
- NBM - IV fluids - Analgesia - Antibiotics: cefuroxime + - Metronidazole - Most cases settle
37
What are the surgical indications of acute diverticulitis?
Perforation Large haemorrhage Stricture --> Obstruction - Do a Hartmann's to resect diseased bowel. This is surgical resection of the rectosigmoid colon with closure of the anorectal stump and formation of an end colostomy. Also used to treat colon cancer. USed is limited to emergency surgery when immediate anastomosis is not possible. Therefore a colo-colo
38
What are the complications of diverticular disease?
``` Perforation Haemorrhage Abscess Fistulae = If patient has a colovesical fistula. Must use a CT to investigate. Stricture ```
39
What is the signs of a perforation in diverticular disease?
- Sudden onset pain (±preceding diverticulitis) - Generalised peritonitis and shock - CXR: air under diaphragm - Rx: Hartmann's
40
Signs of haemorrhage due to diverticular disease?
Sudden, painless bright red PR bleed. Ix: mesenteric angiography or colonscopy. Management - Stops spontaneously usually, may need transfusion. COlonoscopy ± diathermy/adrenaline. Embolisation + resection.
41
Management of abscess in diverticular disease?
- Walled-off perforation - Swinging fever - Localising signs - boggy rectal mass - Leukocytosis - Rx: Abx + CT/US guided drainage
42
Management of fistulae in diverticular disease?
Enterocolic Colovaginal Colovesicular: Pneumaturia + intractable UTIs management: resection
43
Strictures in diverticulitis?
After diverticulitis, colon may heal with fibrous strictures - Management - Resection (usually primary anastomosis) - Stenting
44
What is the classification of bowel obstruction?
Simple Closed Loop Strangulated
45
What is a simple bowel obstruction?
- 1 obstructing point + no vascular compromise | - May be partial or complete.
46
What is a closed loop obstruction
Bowel obstructed @ two points - Left CRC with competent ileocaecal valve - Volvulus Gross distention --> perforation
47
What is a strangulated bowel obstruction
- Compromised blood supply Localised, constant pain + peritonism - Fever + Increased WCC
48
Commonest cause of small bowel obstruction?
SBO - Adhesions: 60% - Hernia
49
Commonest cause of large bowel obstruction
- Colorectal neoplasia: 60% - Diverticular stricture: 20% - Volvulus
50
Other causes of bowel obstruction
Non-mechanical = Paralytic ileus usually small bowel - Post op - Peritonitis - Pancreatitis or any localised inflammation - Poison - Pseudo-obstruction - Metabolic: decreased K, decreased Na, Decreased Mg, uraemia. - Mesenteric ischaemia
51
Mechanical causes of BO?
Intraluminal - Impacted matter: faeces, worms - Intussusception - Gallstones Intramural - Benign stricture (IBD, Surgery, Ischaemic colitis, diverticulitis, radiotherapy). - Neoplasia - Congenital atresia ``` Extramural - Hernia - Adhesions - Volvulus (sigmoid, caecal, gastric) - Extrinsic compression Pseudocyst Abscess Haematoma Tumour Congenital bands (Ladd's) ```
52
Presentation for BO?
Abdominal pain - Colicky - Central but level depends on gut region - Constant/localised pain suggests strangulation or impending perforation Distension - Increased with lower obstructions Vomiting - Early in high obstruction - Late or absent in low obstruction Absolute constipation: Flatus and faeces
53
Examination of bowel obstruction?
HR increased: hypovolaemia, strnagulation - Dehydration, hypovolaemia - Fever: suggests inflammatory disease or strangulation - Surgical scars - Hernias - Mass: neoplastic or inflammatory - Bowel sounds Increased: mechanical obstruction Decreased movement: ileus PR - Empty rectum - Rectal mass - Hard impacted stool - Blood from higher pathology
54
Investigations for bowel obstruction?
Bloods: FBC: Increased WCC U+E: Dehydration, electrolyte abnormalities Amylase: Increased if strangulation/perforation VBG: Increased lactate in strangulation G+S, clotting: may need surgery
55
Imaging for bowel obstruction?
- Erect CXR - AXR: ± erect film for fluid level - CT: can show transition point
56
What does a gastrograffin study look for?
- Look for mechanical obstruction: No free flow - Follow through or enema - Follow through may relieve mild mechanical obstruction: usually adhesional.
57
What is a colonoscopy used for in bowel obstruction?
- Can be used in some cases - Risk of perforation - may be used therapeutically to stent
58
What are the finding on AXR in SBO?
``` Diameter >3cm Location: central Marking: Valvulae coniventes (completely across) LB Gas: Absent (large bowel gas) No. of loops: many Fluid: many, short. ```
59
What are the finding on AXR in LBO?
- >6cm (Caecum >9) - Peripherally - Haustra (partially across) - LB Gas: present - not in rectum. - No of loops: Few - Fluid level: Few, long.
60
What would you see in AXR in an ileus?
Both small and large bowels may be visible. No clear transition point.
61
What is the general medical management of bowel obstruction?
Resuscitate: drip and suck - NBM - IV fluids: aggressive as patients may be v dehydrated - NGT: decompress upper GIT, stops vomiting, prevents aspiration - Catheterise: monitor UO
62
Therapy for Bowel obstruction management?
Analgesia: may require strong opoiod Antibiotics: cef+met if strangulation or perforation Gastrograffin study: oral or via NGT Consider need for parenteral nutrition. Avoid metoclopramide as it is a pro-kinetic anti-emetic so could cause perforation in bowel obstruction.
63
Monitor patient with bowel obstruction?
Regular clinical exam is necessary to ensure that the patient is not deteriorating - Increased distension - Increased pain or tenderness - Increased HR or RR - Repeat imaging and bloods - Non-operative Mx successful in 80% of patients with SBO without peritonitis. - Pts with LBO are likely to need surgery.
64
What are the surgical indications for bowel obstruction?
- Closed loop obstruction - Obstructing neoplasm - Strangulation/perforation --> sepsis, peritonitis - Failure of conservative Mx (up to 72hr)
65
What are the principles of surgical management for bowel obstruction?
- Aim to treat the cause - Typically involves resection of the obstructing lesions - Colon has not been cleansed therefore most surgeons utilise a proximal ostomy post-resection - Pts with substantial comorbidity or unresectable tumours may be offered bypass procedures. - Endoscopically placed expanding metal stents offer palliation or a bridge to surgery allowing optimisation.
66
Surgical procedures for management of SBO/LBO?
Must consent pt for possible resection ± Stoma - SBO: adhesiolysis - LBO Hartmann's Colectomy + primary anastomosis + on table lavage. - Palliative bypass procedure - Transverse loop colostomy or loop ileostomy - Caecostomy
67
What is a sigmoid volvulus?
- Older patients - Long mesentery with narrow base predisposes to torsion - Usually due to sigmoid elongation 2ndry to chronic constipation - increased risk in neuropsych patients: MS, PD, psychiatry (diseases that interfere with intestinal motility) - Chagas disease - Closed loop obstruction
68
Presentation of sigmoid volvulus?
- Commoner in males - Often elderly, constipated, - co-morbid patients - Massive distension with tympanic abdomen
69
What do you see on AXR with a sigmoid volvulus?
Inverted U or Coffee Bean sign
70
Management of Sigmoid volvulus?
Relieved by sigmoidoscopy and flatus tube insertion - Monitor for signs of bowel ischaemia following decompression If a patient has symptoms of peritonitis, skip the flexible sigmoid and treat with urgem midline laparotomy. - Sigmoid colectomy occasionally required if failed endoscopic decompression or bowel necrosis - Often recurs therefore elective sigmoidectomy may be needed.
71
What is a caecal volvulus?
Associated with congenital malformation where caecum is not fixed in the RIF. Adhesions and pregnancy. Only ~10% of patients can be detorsed with colonoscopy therefore will require surgery. Right hemi with primary ileocolic anastomosis Requires operative management - Caecostomy.
72
What is a gastric volvulus triad?
Triad of gastro-oesophageal obstruction - Vomiting --> retching with regurgitation of saliva - Pain - Failed attempts to pass an NGT. Borchardt's triad = epigastric pain, retching and inability to pass an NG tube.
73
Risk factors for gastric volvulus?
Congenital - bands - rolling/paraoesophageal hernia - Pyloric stenosis Acquired - Gastric/oesophageal surgery - Adhesions
74
Investigations of gastric volvulus?
Gastric Dilatation | Double fluid level on erect films
75
Management of gastric volvulus?
Endoscopic manipulation | Emergency laparotomy
76
What is a paralytic ileus?
- Adynamic bowel 2ndry to the absence of normal peristalsis - Usually SBO - Reduced or absent bowel sound - Mild abdominal pain: not colicky.
77
Causes of paralytic ileus?
Post-op Peritonitis Pancreatitis or any localised inflammation Poisons/Drugs: anti-AChM (TCAs) - Pseudo-obstruction - Metabolic: decreased K, Decreased Na, Decreased Mg, uraemia - Mesenteric ischaemia
78
Prevention of paralytic ileus?
Decreased bowel handling Laparoscopic approach Peritoneal lavage after peritonitis Unstarched gloves
79
Management of paralytic ileus?
- Drip and suck management Correct any underlying causes - Drugs - Metabolic abnormalities - Consider need for parenteral nutrition - Exclude mechanical cause if protracted.
80
Colonic pseudo-obstruction
- Clinical signs of mechanical obstruction but no obstructing lesions found - Usually distension only: no colic ``` Causes - Unknown - Associated with Elderly Cardiorespiratroy disorders Pelvic surgery: e.g hip arthroplasty Trauma ``` Investigation - Gastrograffin enema Management - Neostigmine: anti-cholinesterase - Colonoscopic decompression: 80%
81
What is the epidemiology of colorectal cancer?
3rd commonest cancer 2nd commonest cause of cancer deaths (16,000/yr). Age: peak in 60s Sex: rectal Ca commoner in men Geo: Western disease
82
Pathophysiology of colorectal cancer?
Colonic adenomas - Benign precursor to CRC - Characterised by dysplastic epithelium Classification - Tubular: small, pedunculated, tubular glands - Villous: large, sessile, covered by villi - Tubulovillous: mixture Presentation - Typically asymptomatic - Large polyp can bleed --> IDA - Villous adenoma --> decreased K+ and hypoproteinaemia. Malignant potential - Increased size - Dysplasia - Villous component
83
What is APC and its involvement in colorectal carcinoma?
- APC binds + promotes degradation of B-catenin - APC mutation --> Increased B-catenin --> increased transcription of genes which promote cell proliferation. Proliferation --> Mutation of other genes which promote growth and prevent apoptosis
84
What is the sequence of adenoma change?
- First hit: mutation of one APC copy - Second hit: Mutation of second APC copy --> Adenoma formation - Additional mutations in adenoma --> malignant transformation. e.g KRAS, p53.
85
What are the other aetiological factors associated with colorectal cancer?
Diet: decreased diet + increased refined carbs IBD: CRC in 15% with pancolitis for 20yrs Familial: FAP, HNPCC, Peutz-Jegher Smoking Genetics - No relative: 1/50 CRC risk - One 1st degree: 1/10 NSAIDS/Aspirin: protective
86
What is the pathology of adenocarcinoma?
95% of CRC is adenocarcinoma - Others are lymphoma, GIST, Carcinoid. Location - Rectum: 40% - Sigmoid: 30% - Caecum and ascending colon: 20% - Transverse: 10% - Descending: 5% Proximal tumour: Sessile or polypoid Distal tumours: Annular stenosing
87
What is the spread of colorectal cancer?
Local Lymphatic Blood (liver, lungs) Transcoelomic (across peritoneal cavity)
88
What is the presentation of a left sided colorectal carcinoma?
``` Altered bowel habit PR mass (60%) Obstruction (25%) Bleeding/mucus PR Tenesmus ```
89
What are the symptoms of a right sided colorectal carcinoma?
Anaemia Weight loss Abdominal pain
90
What are the symptoms of both a right and a left sided colorectal carcinoma?
Abdominal mass Perforation Haemorrhage Fistula
91
What would you see on examination of a colorectal cancer?
- Palpable mass: per abdomen or PR - Perianal fistulae - Hepatomegaly - Anaemia - Signs of obstruction
92
What are the investigations for colorectal carcinoma?
All 2WW. - Send for colonoscopy immediately. Patient >40 with unexplained weight loss AND Abdo pain Patient >50 with unexplained rectal bleeding Patient >60 with iron deficiency anaemia OR change in bowel habit. Test shows occult blood in faeces Consider 2WW if - Rectal or abdo mass - Unexplained anal mass or anal ulceration - Patient <50 with rectal bleeding AND any of the following unexplained symptoms/findings - abdopain , change in bowel habit, weight loss, IDA. Bloods - FBC: hb - LFTs: mets - Tumour markers: CEA (carcinoembryonic Ag) ``` Imaging - CXR: Lung mets - US liver: mets - CT and MRI Staging MRI best for rectal Ca and liver mets ``` - Endoanal US: staging rectal tumour - Ba/gastrograffin enema: apple-core lesions Endoscopy + biopsy - Flexi sig: 65% of tumours accessible - Colonoscopy
93
Dukes staging for colorectal cancer?
Staging done through CT of chest, abdo and pelvis. A - confined to bowel wall B - Through bowel wall but no LNs C - Regional LNs D - Distant mets
94
TNM staging for colorectal cancer?
``` Tis: carcinoma in situ T1: Submucosa T2: muscularis propria T3: Subserosa T4: through the serosa to adjacent organs N1: 1-3 nodes N2: >4 noses ```
95
General Management of CRC?
- Manage in an MDT - Confirmation of Dx - Stage with CT or MRI - 60% amenable to radical surgery. Always treated with surgery.
96
Surgery of CRC?
Use ERAS pathway Pre-operative bowel prep (except R sided lesion) E.g Kleen Prep (Macrogol) the day before and phosphate enema in the AM. Consent: discuss stoma Stoma nurse consult for siting.
97
Principles in CRC?
Excision depends on lymphatic drainage which follows arterial supply . Resection of certain lymphatic chains. 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. Following resection - ensure anastomosis heals well (adrequate blood supply, mucosal apposition and no tissue tension). Might sometimes be safet to construct a stoma.
98
What is the management of a sigmoid tumour?
High anterior resection or sigmoid colectomy. This alongside a colo-rectal anastomosis
99
What is the management of a caecal/ascending or proximal transverse colon?
Right hemicolectomy | - Ileo-colic anastomosis
100
Management of a distal/descending colon tumour?
Left hemicolectomy - Colo-colon.
101
Management of rectal cancer?
REctum's anatomical location poses different challenges. Either an anterior resection or an abdomino-perineal excision of the rectum (APER) If there is involvement of the sphincter complex or very low tumours an APER is required. (distal 8cm of rectum) . Leaves a permanent colostomy. In addition to excision of the rectal tube an integral part of the procedure is a meticulous dissection of the mesorectal fat and lymph nodes. Rectal cancer has high risk of disease recurrence because it is an extraperitoneal structure (so can be irradiated) - neoadjuvant. T4 = Long course chemoradiotherapy. Patients with obstructing rectal cancer should have a defunctioning loop colostomy, this is because rectal surgery is more technically demanding, therefore anastomotic leak is higher and danger of positive resection margin. In emergency setting bowel is perforated risk of an anastomosis is much greater - especially when colon-colon. Therefore end colostomy is often safer and is reversed later. The resection of the sigmoid colon is performed and an end colostomy is fashioned - this is a hartman.
102
Therefore management of rectal Ca?
Neo-adjuvant radiotherapy may be used to decrease local recurrence and increase 5yrs. Anterior resection: if tumour 4-5cm from anal verge. Defunction with loop ileostomy. - Spout an ileostomy to prevent skin coming into contact with enzymes in small intestine. Abdomino-peritoneal excision of rectum: <4cm from anal verge + total mesorectal excision for tumours of the middle and lower third. - Aim to decreased recurrence - Increased anastomotic leak and faecal incontinence.
103
What other management can be used for colorectal cancer?
Local excision - Transanal endoscopic microsurgery 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 decreased mortality by 25% - i.e LN +ve pts. High grade tumour Palliation of metastatic disease.
104
What is the NHS screening for colorectal cancer?
Home-based kit - faecal Immunochemical test for older adults. One off flexible sigmoidoscopy offered at age 55 to detect and treat polyp. Can self-refer for bowel screening with sigmoidoscopy up to age of 60, if the offer of routine one-off screening at age 55 had not been takenu p.
105
What is a faecal immunochemical test?
National programme - every 2 years to all men and women aged 60-74. - Sent a faecal immunochemical test through post. - Uses antibodies to detect human haemoglobin. - More sensitive than FOB. At colonoscopy - 5-10 will have a normal exam - 4-10 will have polys which can be removed - 1 out of 10 will have cancer.
106
What is the flexi sig screening
People who are 55 yrs old. Bowel scope screening. Use a sigmoidoscopy up to age of 60.
107
What are the familial CRC syndromes ?
- Familial Adenomatous Polyposis - Hereditary non-polyposis colorectal cancer - Peutz-Jegher syndrome
108
What is FAP?
APC gene, autosomal dominant. Presentation - 100-1000s adenomas by 16 uyrs - Mainly in large bowel - Aslo stomach and duodenum 100% develop CRC by ~40yrs May be associated with congenital hypertrophy of the retinal pigment epithelium.
109
What is a FAP variant?
Attenuated FAP: <100 adenomas - later CRC (>50) Gardner's TODE - Thyroid tumours - Osteomas of the mandible, skull and long bones - Dental abnormalities: supernumarary teeth - Epidermal cysts. - Multiple colonic polyps - Extracolonic disease - Desmoid tumours - MUtations of APC gene - Colonic polyps most patients undergo colectomy - Variant for FAP.
110
What is the management of FAP?
Prophylactic colectomy before 20yrs Total colectomy + IRA (ileo-rectal anastomosis) - Requires life-long stump surveillance - Proctocolectomy + IPAA (ileo pouch anal anastomosis) - Remains @ risk of Ca in stomach and duodenum.
111
What is hereditary non-polyposis colorectal cancer?
Autosomal dominant - Mutation of mismatch repair enzyme. - commonest cause of hereditary CRC: 3% of all CRC Mutations of MSH2 or MSH1. Presentation - Lynch 1: right sided CRc - Lynch 2: CRC + gastric, endometrial, prostate, breast. Endometrial is the most common association of HNPCC. Mr Lynch is CEO. AD = develop colonic cancer and endometrial cancer at young age. 80% of affected individuals get colonic or endometrial cancer. Also pancreatic cancer. 3,2,1 rule - >3 family members over 2 generations with one <50.
112
What is peutz-jegher's syndrome?
~10-15 yrs - Mucocutaneous hyperpigmentation - Macules on palms, buccal mucosa Multiple GI hamartomatous polyps - Intussusception - Haemorrhage Ca risk - CRC, pancreas, breast, lung, ovaries, uterus.
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What are GI Polyp syndromes?
Inflammatory pseudopolpys - Regenerating islands of mucosa in UC Hyperplastic Polyps - Piling up of goblet cells and absorptive cells - Serrated surface architecture - No malignant potential Hamartomatous - Tumour-like growths composed of tissues present at site where they develop - Sporadic or part of familial syndromes - Juvenile polyp: Solitary hamartoma in children - Cherry on stalk. Neoplastic - tubular or villous adenomas - Asymptomatic - May have blood /mucus PR, tenensmus.
114
Other hamartomatous polyposis syndromes?
Juvenile Polyposis - >10 hamartomatous polyps - Increased risk of CRC Cowden Syndrome - Auto dominant - Macrocephaly + skin stigmata - INtestinal hamartomas - Increased risk of extra-instestinal Ca.
115
What are the causes of acute mesenteric ischaemia?
Arterial (70%) - Thrombotic - Embolic Non-occlusive - Splanchnic vasocontriction e.g 2ndry to shock - Venous thrombosis Other: trauma, vasculitis, strangulation
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Presentation of acute mesenteric ischaemia?
Nearly always small bowels (SMA is suppling small bowel) IMA - Main arterial supply of splenic flexure to the sigmoid colon. Starts from L3. Coeliac trunk - T12, SMA = L1. ``` Coealic = Foregut SMA = 2nd part of duodenum to proximal 2/3 transverse colon. ``` - Triad - Acute severe abdominal pain ± PR bleed - Rapid hypovolaemia --> Shock - No abdominal signs (Soft but tender) Degree of illness >>> clinical signs May be in AF Presentation is - CVD, High lactate and soft but tender abdomen.
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Investigations for mesenteric ischameia
Bloods - Increased Hb: plasma loss - Increased WCC - Increased amylase - Persistent metabolic acidosis: increased lactate Imaging - AXR: gasless abdomen - Arteriography/CT/MRI angio
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Complications of mesenteric ischaemia
septic peritonitis | SIRS --> MODS
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Management of mesenteric ischaemia?
Fluids Abs: gent and met LMWH Laparotomy: resect necrotic bowel
120
What is chronic small bowel ischaemia?
Causes: Atheroma + low flow state (e.g LVF) Presentation - Severe, colicky post-prandial abdo pain (gut claudication) - PR bleeding - Malabsorption - Weight loss management - angioplasty
121
What is chronic large bowel ischaemia?
Causes: Follows low flow in IMA territory Remember SMA supplies ascending + transverse. IMA supplies descending. Presentation - Lower, left sided abdominal pain - BLoody diarrhoea - Pyrexia - Tachycardia Ix - Increased WCC - Ba enema: thumb printing - MR angiography Complications - May --> peritonitis and septic shock - Strictures in the long-term Management - Usually conservative: fluids + Abx - Angioplasty + endovascular stenting
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What does the SMA split into and supply?
Middle Colic Right Colic Ileocolic Ileo-jejunal collic
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IMA supply + split?
Left colic, sigmoid | Superior rectal
124
What are the common causes of lower GI bleed?
Rectal: Haemorrhoid, fissures Diverticulitis Neoplasm
125
Other causes of lower GI bleeding?
- Inflammation: IBD - Infection: Shigella, campylobacter, C.diff Polyps - Large upper GI bleed - Angio: Dysplasia, ischaemic colitis, HHT
126
Investigations of Lower GI bleed
Bloods: FC, U+E, LFTs, x-match, clotting, amylase Stools : MCS - Imaging AXR, erect CXR Angiography: necessary if no source on endoscopy Red cell scan Endoscopy - 1st: rigid proctoscopy/sigmoidoscopy - 2nd OGD - Colonoscopy: difficult in major bleeding
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Management of lower GI bleed?
``` Resus Urinary catheter ABx if septic 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 - Surgery: only if unremitting, massive bleed. ```
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What is angiodysplasia?
Submucosal AV malformation 70-90% occur in right colon Can affect anywhere in GIT presentation - elderly - Fresh PR bleeding Ix - Exclude other Dx - PR exam - Ba enema - Colonoscopy MEsenteric angiography or CT angiography Tc - labelled RBC scan: identify active bleeding Management - Embolisation - endoscopic laser electrocoagulation - Resection
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Mittelschmerz
Only seen in females Mid cycle Usually 2 weeks after last menstrual period Normal everything. May show trace of pelvic free fluid. manage conservatively.
130
Rectal Varices?
Consider in a patient with portal HTN and lower GI bleeding.
131
What to do if source of colonic bleeding is unclear?
Laparotomy On table colonic lavage Attempt a resection. Acute lower GI bleding - Over 60 - Haemodynamically unstable - On aspirin or NSAIDs - Significant co morbidity Management - All patients should have history + exam PR and proctoscopy. - COlonoscopic haemostasis aimed for in post polypectomy or diverticular bleeding.
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Indications for splenectomy
Uncontrolled splenic bleeding in trauma patients is indication for splenectomy. Hilar vascular injuries Devascularized spleen.
133
Splenic trauma?
Conservative - Small subcapsular haematoma - Minimal intra abdominal blood - No hilar disruption Laparotomy with conservation - Increased amounts of intra abdominal blood - moderate haemodynamic compromise - Tears or lacerations affecting <50%. Resection - Hilar injuries - Major haemorrhage - Major associated injuries.
134
Allograft?
Transplant of tissue from genetically non identical donor from the same species
135
Isograft
Graft of tissue between two individuals who are genetically identical
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Autograft
Transplantation of organs or tissues from one part of the body to another in the same individual - Skin graft.
137
Xenograft
Tissue transplanted from another species
138
Grey Turner sign
Severe haemorrhagic pancreatitis. Local fat destruction, results in blood tracking in the tissue planes of the retroperitoneum.
139
Cullens
Pancreatitis
140
Boas sign
Cholecystitis - Hyperaesthesia beneath the right scapula.
141
Rovsing
Appendicitis
142
Retractile testis
A testis that appears in warm conditions or which can be brought down on clinical examination and does not immediately retract is usually a retractile testis.
143
Cryptorchidism?
A congenital undescended testis is one that has failed to reach the bottom of the scrotum by 3 months of age. Can be due: - Patent processus vaginalis - Abnormal epididymis - Cerebral palsy - Mental retardation - Wilms tumour - Abdominal wall defects (e.g. gastroschisis, prune belly syndrome) DDx - Retractile testes - Absent bilateral testes (intersex conditions)
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Reasons for correction of cryptorchidism?
- Reduce risk of infertility - Allows the testes to be examined for testicular cancer - Avoid testicular torsion - Cosmetic appearance Treatment - Orchidoplexy at 6- 18 months of age. The operation usually consists of inguinal exploration, mobilisation of the testis and implantation into a dartos pouch. - Intra-abdominal testis should be evaluated laparoscopically and mobilised. Whether this is a single stage or two stage procedure depends upon the exact location. - After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy.
145
Renal vein thrombosis?
Renal vein thrombosis is a common feature of renal cell carcinoma. Other features include PUO, left varicocele, Paraneoplastic endocrine effect due to erythropoietin.
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TPN blood derangement
known of derange LFTs. Longer term infusions should be administered into central vein via PICC line.
147
Pseudomyxoma peritonei?
Rare mucinous tumour arising from appendix. Leads to large amounts of mucinous material in the abdominal cavity.
148
Retroperitoneal fibrosis?
Ureters are displaced medially. Most retroperitoneal malignancies are displaced laterally. HTN is a common finding. CT scan will often show a para-aortic mass.
149
Minor surgery?
LA - Lidocaine. Rapid onset and anaesthesia lasts for 1 hour. - Maximum safe dose is 3mg/kg. BNF states 200mg (or 500mg) if given in adrenaline. - Premixed with adrenaline available - reduced blood loss due to vasoconstriction. Dont use in extremities due to risk of ischaemia.
150
Absorbable sutures
Vicryl Dexon PDS
151
Non-absorbable sutures?
Silk Novafil Prolene Ethilon
152
Removal of sutures?
Face = 3-5 days Scalp, limbs, chest = 7-10 days Hand, foot, nack = 10-14
153
Gastrostomy indications?
Gastric decompression or fixation Feeding Site is in the epigastrium
154
Loop jejunostomy?
Seldom used as very high output. USed in emergency laparotomy
155
Percutaneous jejunostomy?
Usually performed for feeding purposes and site in the proximal bowel. Usually left upper quadrant
156
Loop ileostomy
Defunctioning of colon e.g. following rectal cancer surgery | Does not decompress colon (if ileocaecal valve competent)
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End ileostomy
Usually following complete excision of colon or where ileocolic anastomosis is not planned May be used to defunction colon, but reversal is more difficult
158
Caecostomy?
Stoma of last resort where loop colostomy is not possible. right iliac fossa.
159
Mucous fistula
To decompress a distal segment of bowel following colonic division or resection Where closure of a distal resection margin is not safe or achievable
160
Why epidural analgesia for colorectal patients ?
Accelerates the return of normal bowel function after abdo surgery.
161
Post op ileostomy complications?
High-output bag. Patients may develop volume depletion, U+E disturbances.
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Patient has descending colon tumour removed. Surgeon wants to defunction the bowel. How?
Do an loop ileostomy to protect the colon's anastomosis.
Medicine Finals - Imperial & Quick Medical Revision
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