Colorectal Surgery - 4th Year Medic

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gtaang
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245372
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Colorectal Surgery - 4th Year Medic
Updated:
2013-11-19 07:16:53
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Colorectal Surgery Medicine Finals
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Learning outcomes for General surgery medical finals.
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  1. Important Points in a Constipation History
    • Onset
    • Evolution
    • Definition - compared to the patient's normal
    • Is it long standing - why present now?
    • any associated symptoms - pain, tenesmus etc.
  2. Important Points in a Diarrhoea History
    • Onset
    • Evolution
    • Definition - is it the consistency or the number of motions
    • Long standing - why now?
    • Travel History
    • Food History
  3. Examination of patient with altered bowel habit
    • Examine for systemic disease - Thyroid status and neuromuscular disorders
    • Abdominal exam - masses, faecal loading and peritonitis
    • Check hernial orifices
    • PR - haemorrhoids, fissures and rectal masses
  4. Investigations of Constipation
    • Bloods:
    •    - TFTs 
    •    - Calcium
    •    - Routine bloods
    • Imaging:
    •    - AXR - faecal loading, obstruction
    •    - Sigmoidoscopy - mass, faecal loading
    • Other:
    •    - Colonic transit study
  5. Investigations of Diarrhoea
    • Routine Bloods
    • AXR - Colitis, mass
    • Scope - visualise mucosa
    • Biopsy
    • Anti alpha-gliadin antibodies
  6. Differential Diagnosis of Constipation
    • Functional:
    •   - Low fibre diet
    •   - Sedentary lifestyle
    •   - Irritable bowel syndrome
    • Systemic:
    •   - Drugs - e.g. opiates
    •   - Neuromuscular disorders
    •   - Metabolic disorders - e.g. thyroid
    • Colonic causes:
    •   - Colorectal Ca.
    •   - Diverticular Disease
    •   - Obstruction
    • Anal causes:
    •   - Fissures
    •   - Haemorrhoids
  7. Differential Diagnosis of Diarrhoea
    • Infection:
    •   - bacteria
    •   - viral
    •   - amoebic dysentery
    • Travelers' diarrhoea
    • Drugs:
    •   - Antibiotics
    •   - Laxatives
    • Small Bowel Disease:
    •  - Crohn's
    •  - Coeliac
    •  - Blind loop syndrome
    • Large Bowel Diease:
    •  - UC
    •  - Colorectal Ca.
    •  - IBS
    •  - Spurious
  8. PR bleeding in younger patients
    • Anal fissures
    • Haemorrhoids
    • Commonly benign in younger years, no surgical treatment needed. 
  9. PR bleeding in older population
    • Angiodysplasia
    • Diverticular Disease
    • Colorectal Cancer
  10. Investigation of PR bleeding
    • Rule out Upper GI bleeding in massive haemorrhage - OGD
    • Faecal occult blood
    • Urgent Colonoscopy
    • Visceral angiography
  11. Classification of Polyps
    • Neoplastic:
    •   - Adenoma:
    •         - Tubular
    •         - Tubullovillous
    •         - Villous
    • Non-neoplastic:
    •   - Hamartoma
    •   - Inflammatory
  12. Presentation of Colonic Polyps
    • Polyps are usually asymptomatic and devoid of signs
    • With multiple lesions bleeding may be obvious
    • Diagnosis is normally through screening or incidentally in investigation of unexplained iron deficiency anaemia.
    • Rare clinical syndrome where villous adenoma causes loss of K+ rich mucosa and causes hyperkalaemia.
  13. Investigation of Polyps
    • When a polyp is found, full examination of the large bowel and rectum should be undertaken.
    • Biopsies should be taken of all areas of concern for pathological opinion.
  14. Treatment of an adenomatous polyp
    • Finding of any polyps, especially those >1cm require:
    •       - Complete examination of the bowel under colonoscopy
    •       - Removal of all discovered lesions - usually endoscopically
    •       - Regular life-long surveillance for recurrence and/or the development of Bowel Ca.
  15. Follow up in patients with polyps
  16. Familial Adenomatous Polyposis
    • Autosomal Dominant Condition
    • Caused by mutations in APC gene
    • Polyps first appear between 13 and 30. 
    • FAP is associated with non-colonic manifestations:
    •         - Desmoid Tumours
    •         - CHRPE
    •         - Fibromas*
    •         - Osteomas*
    •         - Sebaceous cysts*
    • * + FAP = Gardner's Syndrome
    • Total colectomy before 25yo is normal, with ileo-anal pouch formation.
  17. Hereditary Non-Polyposis Colon Cancer
    • Autosomal Dominant Condition
    • High risk of many abdominal cancers
    • Caused by mutations in mismatch repair genes
    • Stratify risk of cancer using Amsterdam Criteria
    • Less polyps than FAP but more malignant condition
  18. Presentation of Right-sided colon tumours
    • Non-specific symptoms of malaise, weight loss and vague abdominal pain
    • Self-detected abdominal mass
    • Iron deficiency anaemia
    • Rarely, intestinal obstruction.
  19. Presentation of Left-sided colon tumours
    • More likely to cause an obstructed picture
    • Colicky abdominal pain
    • altered bowel habit
    • PR mucus
    • 10% present with visible PR blood
    • effects of local spread:
    •       - Faecal incontinence - anal sphincters
    •       - Back pain - sacral plexus
    •       - UTI - retrovesical fistula
    •       - Renal Failure - infiltration of ureters
  20. Risk Factors for Colon Cancer
    • Dietary Factors:
    •     - Bile salt conversion to carcinogens
    •     - Low intake of fibre = slow transit
    • Adenomatous polyps
    • Genetics:
    •     - FAP
    •     - HNPCC
    • Inflammatory Bowel Disease:
    •     - Ulcerative Colitis
    •     - Crohn's Disease
    • Alcohol and Tobacco
  21. Routes of Metastasis in Colorectal Cancer
    • Local Invasion:
    •      - Sacral plexus
    •      - Ureters
    •      - Bladder / uterus+cervix
    • Lymphatics:
    •      - Paracolic nodes
    •      - para-aortic nodes
    • Haematogenous:
    •      - Liver first then.....
    •      - Lung, kidney and bone
    • Transcoelomic:
    •      - Ascites
    •      - Ovaries
  22. Investigations of Colorectal Cancer
    • PR EXAM - must be done to confirm presence of blood and to check for rectal masses
    • Sigmoidoscopy - flexible sigmoidoscopy can get as far as splenic flexure
    • Colonoscopy - Full length colon examination is required even in the presence of a distal lesion.
    • Barium Enema - Traditional method of investigation colon
    • CT pneumocolon (virtual colonoscopy) - Can also check for mets
    • PETCT / MRI - used pre-op
  23. Staging Colorectal Cancer
    • Duke Classification is commonly used
    •         - A - Cancer confined to the mucosa - 90% 5yr-survival
    •         - - Tumour extends through full thickness of wall. Nodal involvement and mets absent - 75% 5yr-survival
    •         - C1 - Local lymph nodes involved - 50% 5yr-survival
    •         - C2 - More proximal lymph nodes involved - <50% 5yr-survival 
    •         - - Not in official classification, but denotes metastatic disease - 6% 5yr-survival
  24. Treating Colonic Cancer
    • Dukes A-C colon cancer is primarily treated by surgical removal. 
    • B and C tumours also receive adjuvant therapy.
    • Right-sided tumours are removed via a right hemicolectomy.
    • Left-sided tumours are removed by a resection tailored to the segment of bowel involved.
  25. Treating Rectal Cancer
    • Patients with locally advanced disease may receive pre-op chemo/radiotherapy to shrink the tumour
    • This reduces the risk of 'margin positive' resections and consequently, local recurrence
    • Rectal techniques:
    •         - Anterior resection - used in lesions of the upper 2/3 of rectum
    •         - Abdominoperineal (AP) excision - used in lower 1/3 rectal tumours
    •         - Hartmann's procedure - emergency procedure where anastomosis is not readily available, leaving rectal stump.
  26. Oncological Treatment of Colorectal Cancer
    • Radiotherapy:
    •     - can be used alone in small lesions
    •      - used after local excision
    •      - after margin positive resection
    •      - palliation
    • Chemotherapy:
    •      - After resection
    •      - FOLFOX / FOLFIRI
    •      - Cetuximab - used for liver metastases

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