Year 4 > Surgery - Colorectal > Flashcards

Surgery - Colorectal Flashcards

(51 cards)

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1
Q

What are the peaks of incidence of IBD

A

2 peaks
10-40yrs
50-70yrs

Crohn’s more common than UC

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2
Q

What effect does smoking have in IBD?

A

Smoking ?helps UC

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3
Q

What is the pathophysiology of IBD

A

autoimmune, inappropriate response to gut flora in genetically susceptible individuals

  • immunological
  • environmental
  • genetics
  • diet
  • psychosocial
  • genetics
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4
Q

At the level of the colon describe the differences between UC and CD

A

UC:

  • colon and rectum only
  • continuous
  • mucosa only
  • reduced goblet cells
  • polyps and crypt abscesses

CD:

  • anywhere mouth to anus (commonly TI)
  • skip lesions
  • transmural
  • normal goblet cells
  • granulomas and fistulas

Fistulas = entero-enteric, colovesicle, colovaginal, enterocutaneous

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5
Q

What are the GI and extra-GI features of IBD?

A

GI: abdo pain, weight loss, tenesmus (UC), blood in stool, anal strictures, finger clubbing

Extra-GI: erythema nodosum, pyoderma gangrenosum, oral ulcers, finger clubbing, enteropathic arthritis

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6
Q

What is Truelove and Witts score?

A

Used to assess the severity of a UC flare

  • no. bloody stools, HR, temp, Hb, ESR/CRP
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7
Q

What investigations are carried out for IBD/and IBD flare?

A 
Bloods: FBC, ESR/CRP, U&E, LFT, INR, ferritin, TIBC, B12, folate
Blood cultures
Stool microbiology (exclude infection)
Stool cultures (?C.Diff)
Faecal calprotectin (will always be raised acutely)
Colonoscopy and biopsy
Capsule endoscopy
CTMRI
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8
Q

What are the treatments for CD?

A

Acutely: fluids, nutrition, prophylactic heparin, smoking cessation

Medical =

  • steroids
  • biologics
  • thiopurines (steroid sparing anti-inflammatories e.g. mercaptopurine/azathioprine)
  • 5-ASA (steroid sparing anti-inflammatory chemically related to aspirin)
  • METHOTREXATE

Surgery = resection, stricturoplasty, perianal drainage

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9
Q

What are the treatments for UC?

A

Acutely: fluids, nutrition, prophylactic heparin, smoking cessation

Medical =

  • steroids
  • biologics
  • thiopurines (steroid sparing anti-inflammatories e.g. mercaptopurine/azathioprine)
  • 5-ASA (steroid sparing anti-inflammatory chemically related to aspirin)

Surgery = resection, stricturoplasty, perianal drainage

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10
Q

What are complications of IBD?

A
  • NSAIDs can exacerbate disease
  • bowel obstruction
  • toxic dilatation
  • fistulae
  • cancer
  • malnutrition
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11
Q

What are the causes of bowel obstruction?

A 
Mechanical = structural pathology blocks intestinal contents passing
Functional = no mechanical blockage, due to -> inflammation, electrolyte imbalances, recent surgery (ileus)
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12
Q

Name causes of SB obstruction

A

adhesions from previous surgery (75%)
hernias
cancers/growth

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13
Q

Name causes of LB obstruction

A

cancers
diverticular strictures
rare (hernias/volvulus)

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14
Q

Why does third-spacing occur in bowel obstruction

A

Occluded bowel segment -> proximal dilatation -> increased peristalsis, increased hydrostatic pressure and large fluid movements into the bowel

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15
Q

What is volvulus and how is it managed?

A 
Twisting of bowel on its mesentery
common areas:
- sigmoid (coffee bean sign)
- caecum
Increased risk of ischaemia and perforation
- Treat by deflating through anal canal
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16
Q

What are the S/Sx of bowel obstruction?

A

Abdominal pain (crampy)
Vomiting (gastric contents -> bilious -> faecal)
Abdo distension
Complete constipation
O/Ex: scars from previous surgery, absence of bowel sounds

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17
Q

How is potential bowel obstruction investigated?

A

Bloods: FBC, U&E, CRP, LFT, G&S/CM
Venous blood gas: ?high lactate, assess degree of metabolic derangement (e.g. dehydration and vomiting)
Imaging: AXR, CT (erect CXR ?perforation)

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18
Q

What are features of SB obstruction on AXR?

A
  • dilatation >3cm
  • central swelling
  • valvulae conniventes/plicae circularis (completely across diameter)
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19
Q

What are features of LB obstruction on AXR?

A
  • dilatation >7cm (>9 in caecum)
  • peripheral location
  • haustral lines visible (half way)
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20
Q

How is bowel obstruction managed?

A
  • urgent A-E and fluid resuscitation
  • conservative: drip and suck (NG tube and IV fluids), catheter, analgesia, anti-emetics
  • surgery (usually laparoscopic) if = ischaemia, closed loop obstruction, strangulation, pt has a virgin abdomen
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21
Q

What are complications of bowel obstruction?

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A

Bowel ischaemia
Perforation and faecal peritonitis
Dehydration and AKI

22
Q

Name three inherited bowel genetic conditions and describe them

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A

1) FAP (familial adenomatous polyposis)
- APC mutations, many polpys develop and 100% pts have CRC by 40yrs, get prophylactic colectomy

2) HNPCC (hereditary non-polyposis colorectal cancer)/Lynch syndrome
- MMR mutation, quick progression of adenoma -> carcinoma sequence, Lynch 2 associated with endometrial/gastric/breast cancer

3) Peutz-Jeghers syndrome
- SKT11 mutation, mucosal hyperpigmentation, polyps, intusseption and haemorrhage

23
Q

What are symptoms of a R sided CRC?

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A

anaemia
weight loss
abdominal pain

24
Q

What are symptoms of a L sided CRC?

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A

tenesmus
altered bowel habit
blood/mucous PR
PR mass

25
Describe the staging methods of CRC
TNM ``` Duke's: A) confined to the bowel wall B) through the bowel wall C) through the bowel wall + LN involvement D) distant metastases ```
26
How is suspected CRC investigated?
1) Examination (abdo + PR) 2) Bloods - FBC, LFT, haematinics, tumour markers (CEA, AFP) 3) Imaging - CXR (mets), liver USS (mets), CT/MRI (staging), barium enema (apple core) 4) Endoscopy - flexible sigmoidoscopy/colonoscopy
27
What are the treatment options for CRC
Surgery +/- neoadjuvant chemo Palliative bypass, stenting also options
28
Describe a right hemicolectomy
removal of caecum and ascending colon
29
Describe a left hemicolectomy
removal of splenic flexure and descending colon | Usually an anastomosis and no stoma needed
30
Describe an anterior resection
For rectal/sigmoid disease Removal of sigmoid colon and rectum May anastomose end of descending colon to anal stump but put on a stoma at first to allow anastomosis to heal, then later reverse the stoma in a few months
31
Describe an AP (abdominal perineal) resection
Removal of sigmoid colon, rectum and anus | Formation of an end colostomy
32
Describe a Hartmann's procedure
Usually performed for an obstructing cancer/diverticular disease Resection of sigmoid colon +/- rectum (with rectum it is called a procto-sigmoidoscopy) Can be temporary or permanent Distal anal end can be stitched closed if permanent, or can be brought to the surface creating a mucous fistula
33
Describe the screening process for CRC
1) FOB testing: 50-74yr olds (2 yrly) - ~70-80% sensitivity 3) new Q-FIT (quantitative faecal IHC testing) - will have ~90% sensitivity
34
What are the 4 layers of the colon?
Mucosa Submucosa Muscularis propria/externa Serosa/adventitia
35
Describe diverticular disease and its causes
the clinical state relating to symptoms caused by colonic diverticulae Diverticular disease = altered bowel habit, L colic (relieved by defectation), nausea, flatulence Diverticulitis = impacted faeces causes infection, LIF tenderness, pyrexia and localised peritonitis Can be congenital or acquired Rare <60yrs Due to genetics + low fibre diet and environmental factors (NSAID use, collagen structure)
36
How is diverticular disease investigated?
Colonoscopy (gold standard for diagnosis, but NOT used in acute setting) Bloods - FBC, CRP, ESR, amylase (raised), G&S, CM Imaging - CT abdo, erect CXR (perf?), AXR (obstruction?)
37
What staging system is used for Diverticular disease and describe it
Hinchey classification - looks at the degree of infective complications with diverticular disease and the need for surgery 1A - phlegmon 1B - pericolic abscess 2 - pelvic abscess (surgery rarely needed and CT-guided percutaneous drainage sufficient) 3 - generalised purulent peritonitis 4 - generalised faecal peritonitis (need surgery)
38
How is diverticular disease managed?
High fibre diet Hospital admission if uncontrolled pain and fluids not tolerated Medical: NMB, IV fluids, analgesia, laxatives, antibiotics Surgery: if perforation/strictures/obstruction/haemorrhage -> usually Hartmann's procedure to resect the diseased bowel
39
What is ano-rectal sepsis
due to a perianal abscess
40
What is fistula-in-ano
Formation of an anal fistula between the bowel & skin in the perineal/perianal area
41
Name the 6 types of anal fistula
Named based on the tissues through which they track - submucosal - inter-sphincteric - transphincteric (high or low) - supratransphincteric - extratransphincteric
42
How is ano-rectal sepsis managed?
Antibiotics (manage symptoms but will not cure underlying disease) Surgical - Drainage - Lateral internal sphincterotomy (to reduce internal pressure and allow fissure to heal) - Fissurectomy (removal of tract) - Anal advancement flap (avoids need to cut sphincter muscles and less risk of incontinence)
43
Describe the types of colonic polyps
Pedunculated (on a stalk) Sessile (flat) Or can be a combination of both
44
How do colonic polyps present?
``` Normally asymptomatic and found on imaging/scopes Can present with: - bleeding - mucous discharge - prolapse (if low in the rectum) ```
45
How are colonic polyps investigated:
``` Colonoscopy Genetic mutation testing: APC gene = FAP MMR gene = HNPCC STK11 gene = Peutz-Jeghers syndrome ```
46
Describe haemorrhoids and risk factors for developing them:
XS amounts of the normal endovascular cushions consisting of: - anorectal mucosa - submucosal tissue - mucosal blood vessels (small arterioles and veins) Common in young adults and RFx include: - constipation - pregnancy - chronic straining - irregular bowel habits - obesity - genetics (absence of valves in haemorrhoid veins)
47
How are haemorrhoids described
Classified by dentate line as internal/external (dentate line divides lower 1/3rd anal canal from upper 2/3rds) - typically occur in the same location as the main anal blood vessel pedicles: 11 o'clock 3 o'clock 7 o'clock
48
How might haemorrhoids present?
``` Internal = painless bleeding and itch External = bleeding, swelling, mucous, painful! ```
49
How can haemorrhoids be managed?
Medical (diet, high fibre, creams) | Surgical (banding, HALO = haemorrhoid artery ligation operation, stapled anopexy, haemorrhoidectomy)
50
Describe causes of rectal bleeding
Anorectal = bright red blood on paper/in stool - haemorrhoids - fissures - proctatisis (rectal inflammation) - rectal prolapse Rectosigmoid = darker blood with clots - rectal tumour - proctocolitis - diverticular disease
51
What is a pilonidal sinus and how it is caused?
A sinus existing in the midline of the buttock clefts Usually contains - hair, secretions, debris Lateral tracts may run into neighbouring buttock tissue Commonest in men/hirsute people Often precipitated by long periods of sitting: - lorry drivers - computer operators
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