Surgery.GI

What organ?
Where?
What pathological process?
Aetiologic clues
Sequelae & complications
Incidental and related
DDx

1) Size
2) Site
3) Shape
4) Surface
5) Margins
6) Tenderness
7) Consistency
8) Composition: consistency, fluid thrill, transillumination, resonance, pulsatility
9) Mobility/fixation
10) Overlying skin
11) Regional lymph nodes
12) Other

Left: Pedunculated polyp
Right: Sessile polyp

Shape:
1) Sessile
2) Pedunculated
Aetiology
3) Neoplastic - adenomatous polyp (>100 = FAP, Gardner's syndrome)
4) Hyperplastic - delayed shedding
5) Inflammatory - IBD (UC, CD)
6) Hamartomatous - Peutz-Jegher's syndrome
Adenomatous polyps
7) Tubular (pedunculated)
8) Villous (sessile, malignant)

Risk of malignancy (adenoma to adenocarcinoma):
Polyp size (>2cm=50%)
Architecture: Villous 40%, tubulovillous 20%, tubular 5%
Severity of epithelial dysplasia

FAP, HNPCC, Adenomatous polyps
FHX
IBD (esp. UC)
Diet, smoking, EtOH
DM, acromegaly
Low dietary fiber intake
Obesity, physical inactivity
Irradiation

Normal colonic epithelium  Hyperproliferative  Early Adenoma  Late adenoma  Carcinoma

- Ca develops from progressive accumulation of multiple genetic mutations

- Most cancers: Chromosomal instability pathway A
- HNPCC: Microsatellite instability pathyway B

Surgical resection:

5 cm margins.
Lymphovascular clearance (pericolic LNs)
Mesentary

Liver mets resected w/ 1-2cm margin + XRT/Chemo

XRT+Chemo only in rectal ca.

Right hemicolectomy

Caecum
Ascending colon
Part of transverse colon
Omentum
SMA branches: ileocolic, R colic, R branch of middle colic vessels

Anastamosis of lieum to transverse colon.

4 S's

Stricture at the perianal ring
String sign = luminal narrowing @ distal ileum
Skip lesions = separation from surrounding loops
Sinus tract = communication between pathologic space and cavity

"Lead pipe" colon = Loss of haustral markings
Shortening of colon
Toxic megacolon: dilated lumen (>6cm)

50% of CD patients
Skin tags
Fissures
Perianal sepsis
Anorectal strictures

CD: Any part of GI tract (mouth to anus)

UC: Colon only, rectum always involved

CD: Uncommon

UC: Very common (90%)

CD: Less prevalent

UC: Freuqent small stools

CD: Post-prandial / colicky

UC: Predefecatory urgency

CD: Common

UC: Uncommon

CD: Frequent, RLQ

UC: Rare

CD: Common

UC: Rare

CD: Transmural distribution, focal inflammation, non-caseating granulomas, glands intact

UC: Mucosal distribution, diffuse inflammation, granulomas absent, gland destruction, crypt abscess

CD: Apthoid ulcerations, patchy lesions

UC: Diffuse erythemia, friability, loss of normal vascular pattern, continuous lesions

CD: Strictures, fistula (=sinus tract), cobblestone mucosa, string sign (luminal narrowing), skip lesions

UC: Haustration loss, lead pipe appearance, shortening of colon, toxic megacolon (>6cm, dilated lumen)

UC: Not seen

CD: Common

UC: Normal
CD: Granular, fibrosed or 'flared'

UC: Mucosal (rarely submucosal)

CD: Transmural (full thickness)

UC: Minimal, no fibrosis

CD: Common

UC: None

CD: Common (>50%)

UC: No fissures

CD: Deep, linear --> fissures

UC: Mild

CD: Marked

UC: Diarrhoea w/ blood & mucus; cramping; urgency/tenesmus

CD: Diarrhoea +/- blood; abdo pain (obstipation)

UC: Rare (<25%)

CD: Common (75%)

UC: Sclerosing pericholangitis, uveitis, arthritis, pyoderma gangrenosum (rare)

CD: Uveitis, arthritis

ABC'S EFGHIV:

Adhesions, abscess
Bezoar (=foreign bodies)
Cancer (neoplasms)
Stricture
Extrinsic (annular pancreas)
Fibrosis (cystic)
Gallstones
Hernia
Intuussusception
Volvulus

Adenocarcinoma / Neoplasia
Diverticulitis
Volvulus

In lumen: feces, bezoar
In wall: stricture, Hirschprung's
Outside wall: tumour, hernia, adhesions

1) Colicky abdo pain
2) Vomiting: SBO=early, LBO=late
3) Distension: SBO=epi/hypogastric, LBO=generalized
4) Obstipation - SBO=late, LBO=early

Look: scars, hernia, abdo mass, distension, peristalsis

Feel.palpation: tendernesss

Feel.percussion: hyper-resonant

Listen: BS louder, more frequent & high pitched (tinkling)

PR exam: feces, blood, mucus

Supine and erect AXR, CXR
FBC, U&E
Abdo CT
SBS (Small bowel series)

"GAPS":

1) Gas absent in colon
2) Air fluid levels
3) Plicae circularae (ladder pattern)
4) Sentinel loops
5) String of beads (fluid filling)

Position: Central

Picture frame pattern
Haustral markings (plicae semicircularis=extend only part way across lumen)
Air-fluid levels
Distension (proximal colon)
Gas absent in rectum

Position: Peripheral

Conservative: Drip and suck
Surgical: LOA (lysis of adhesions), herniorrhaphy

Adhesion  internal herniation of bowel contents  bowel obstruction  impaired venous drainage  engorgement & haemorrhage  impaired arterial flow  infarction

Small bowel obstruction

Large bowel obstruction

Ostomy: GIT connected to the abdominal wall skin.

Stoma: The opening of the ostomy.

Epitheliaisation (mucosa to skin) prevents closure

Temporary = loop ileostomy/colostomy.

Permanent = end ileostomy/colostomy.

Temporary:
Protect anastamosis
Divert stool from anorectum
Caecal volvulus

Permanent:
Following colectomy if cannot anastamose
Following removal of anorectum
Severe faecal incontinence

PRE-OP:

Education, counselling

POST-OP:

Input - Diet (no nuts, popcorn), NBM until peristalsis or POD2-5
Output - Normal=500-1000 mL/day

Regular monitoring of viability

Stomal remeasurement in 4/52

Adhesion, abscess (parastomal)
Bleeding
Constipation, osbtruction (SBO)
Dehydration
Stricture
Fistula
Herniation (parastomal)
Ischaemia, ileus, infection, irritation of the skin
Prolapse
Retraction
Ulceration (parastomal)
Volvulus

WHAT? Solitary true diverticulum. 2 types of ectopic tissue (gastric + pancreatic)

WHY? Failure of involution of the vitelline duct (yolk sack to primitive midgut)

WHERE? Anti-mesenteric side of the terminal ilium (within 2 feet of ileocecal valve)

WHO? 2% of population, presents at age 2

Ulceration
(ectopic gastric mucosa) = bleeding or perforation

Diverticulitis
Resembles appendicitis

Obstruction
Volvulus or intussusception

2% of population
2% symptomatic
2 y/o presentation
2 feet from ileocecal valve
2 inches long
2% symptomatic
1/2 will have ectopic tissue

Dilated submucosal veins of the internal haemorrhoidal plexus

2o to venous pressure within haemorrhoidal plexus:
- Constipation
- Pregnancy (venous stasis)
- Collaterals in portal HT

Classically situated @ 3,7,11 o'clock. (left lateral, right posterior, right anterior) >-

"BUM Lump"

Bleeding - bright red, post-defacation
Uncomfortable (discomfort), pruritis. (Uncomplicated=not painful, thrombotic/strangulated=severe pain)
Mucus discharge (PR)

Lump after defacation (palpable)

Location: External and Internal

External haemorrhoids: develop in inferior haemorrhoidal plexus, located below the anorectal (DENTATE) line = skin tags

Internal haemorrhoids: dilation of the superior haemorrhoidal plexus. Grades 1-4

Internal haemorrhoid grades

1: small haemorrhoids that bleed, but remain in rectum

2: prolapse on defecation/Valsalva & retract spontaneously

3: Prolapse on defacation/valsalve but require manual reduction

4: prolapse from anus, irreducible

Concomitant CRC

Altered bowel habit? Anaemia? Colonscopy & sigmoidoscopy essential.

Used to treat 2o, 3o internal haemorrhoids.

Forceps isolate and draw haemorrhoid into barrel of band ligator. Elastic band is released and occludes circulation to the haemorrhoid. Destruction via necrosis.

Complications: Haemorrhage, sepsis, pain

Conservative:
Dietary fibre, local hydrocortisone and analgesia (topical or suppositories)

Symptoms persist >4-6/52?...

Surgery:
Injection sclerotherapy by proctoscopy
Infrared photocoagulation
Haemorrhoidectomy (excision)

Haemorrhage
Infection
Anal stenosis
Fecal incontinence

Incisional Hernia

Portrusion of the pertinoeum and abdo contents into the subcutaneous plane through a defect at the surgical site scar

Symptoms:
Nagging discomfort
Bulge

Signs:
Reducible lump
Expansile cough impulse
Accentuated by tensing the recti

Wound infection (most common)

Incision shape - T,V, angulated

Incision location - Midline > Paramedian/upper > lower

Devitalized tissue

Suture material - Absorbable > non-absorbable

Age
Obesity
Systemic: DM, corticosteroids, malnutrition
Local: Foreign body, haematoma, movement

Surgically repaired
Reducible: Appose edges or mesh
Irreducible: Open, mobilize, dissect; excise omentum

Pre-op: weight reduction, PT, smoking cessation

Post-op: Prophylactic AB, drainage