Lower GI Surgery

Learning Objectives
Acute appendicitis Bowel obstruction Sigmoid volvulus Hernias Colorectal cancer IBD Diverticular disease

Acute Appendicitis
Definition
sudden inflammation of the appendix due to obstruction of lumen and invasion of appendix wall by gut flora

Epidemiology
Most common surgical emergency UK incidence 80 000 people per year

Aetiology
Unknown

Acute Appendicitis
Pathology Appendix wall becomes inflamed and lumen fills with pus Oedema decreases blood supply leading to infarction Organisms from lumen enter de-vitalised wall Damage and perforation of appendix wall occurs

Acute Appendicitis
Clinical features
Abdo pain- central colicky and vague, localising to RIF after 24h and becoming sharp and constant RIF pain at McBurneys point Tenderness, guarding, and rebound Rovsings sign- pain RIF>LIF when LIF is pressed
Psoas sign- pain on extending hip if retrocaecal appendix Cope sign- pain on flexion and internal rotation of right hip of appendix in close relation to obturator internus Nausea, vomiting, and anorexia Pyrexia Dry tongue, coated with foetor

Acute Appendicitis
Investigations
WCC- leucocytosis and neutrophilia Urinalysis- haematuria or WBC if pelvic or retrocaecal appendix USS- to exclude ovarian cyst, pyosalpinx, ectopic pregnancy. Limited in diagnostic value Diagnostic laparoscopy AXR- to exclude obstruction, perf, or ureteric colic

Management
Conservative- abx and observation Surgical- laparoscopic/open appendicectomy

Complications
Pre-op: perf, peritonitis, abscess Early post-op: residual abscess, faecal fistula, ileus, inguinal hernia, urinary retention Late post-op: incisional hernia, adhesions

Lap Appendicectomy

Bowel Obstruction
Epidemiology
LBO less common than SBO

Aetiology
Tumour, diverticular stricture, sigmoid or caecal volvulus

Clinical features
Symptoms: pain, distension, vomiting, constipation Signs: tachycardia, hypotension, dehydration, abdo tenderness, high-pitched bowel sounds (obstruction), reduced bowel sounds (bowel ischaemia), DRE
Mechanical obstruction- rectum empty and collapsed Pseudo-obstruction- dilated, gas filled rectum with a gush of air, or liquid faeces

Bowel Obstruction
Pathophysiology
Fluid and gas accumulate behind obstruction

Proximal bowel dilates Peristaltic activity increases (colicky pain) Eventual inhibition of motor activity

Strangulation caused by intra-luminal pressure or direct vascular occlusion by obstructing lesion

Venous compromise leads to oedema, in turn leads to arterial compressions, ischaemia, and intestinal necrosis, which may lead to perforation

Bowel Obstruction
Investigations
FBC, U&Es, amylase, x-match AXR
Haustrae which incompletely traverse the gut Pathological dilatation if >8cm Caecal dilatation significant if >10cm Sigmoid or caecal volvulus

Barium enema CT

Management
Conservative if simple obstruction- NBM, IVI, NG decompression ( risk of aspiration of gastric contents), analgesia, O2, ABG

Bowel Obstruction
Surgical if complicated by strangulation or ischaemia- eg left hemicolectomy

Complications
Iatrogenic injury (post-op ileus) Recurrence of intestinal obstruction

Large Bowel Obstruction

Sigmoid Volvulus
Definition
Large sigmoid loop full of faeces and distended with gas twists on its mesenteric pedicle to create a closed-loop obstruction

Epidemiology
Responsible for 4% of intestinal obstruction cases in UK

Predisposing factors
Elderly Hx of constipation laxative abuse for many years Redundant sigmoid colon

Pathophysiology
Bowel twists in an anti-clockwise direction Circulation impaired after one and a half twists

Sigmoid Volvulus
Clinical features
Acute abdo pain, N/V, distention, absolute constipation Gangrenous bowel- peritonitis, toxaemia, and tachycardia

Investigations
AXR- typical distended loop of large bowel full of air

Management
Endoscopic decompression with insertion of flatus tube past the twist and left in situ for 24 h If volvulus cannot be untwisted then an urgent op is indicated Reduction of volvulus, sigmoid resection, and primary anastomosis

Complications
Gangrene, perforation, faecal peritonitis, death

Sigmoid Volvulus

Caecal Volvulus

Sigmoid Volvulus

Hernias
Inguinal
Direct Indirect

Femoral Paraumbilical Incisional Epigastric Spigelian Lumbar Other

Gluteal Sciatic

Inguinal Hernia
Indirect
Passes through the internal inguinal ring and if large, out through the external ring May extend to scrotum Reduces upwards and laterally Moves downward and medially on release Controlled by pressure over deep ring

Inguinal Hernia
Direct
Pushes its way directly forward through the posterior wall of the inguinal canal into a defect of the abdominal wall (Hesselbachs triangle) Does not extend to scrotum Reduces straight back Not controlled by pressure over mid point of inguinal ligament Commoner in elderly

Inguinal Hernia
Deep/internal ring
The mid-point of the inguinal ligament and 1.5cm above the femoral pulse (which crosses the mid-inguinal point)

Superficial/external ring
Is a split in the external oblique aponeurosis just superior and medial to the pubic tubercle

Hesselbachs triangle
Medial to inferior epigastric artery and lateral to rectus abdominus

Deep and Superficial Inguinal Rings

Inguinal Hernia
Management
Open repair (mesh)
Complications- haematoma, wound and mesh infection, recurrence, testicular atrophy, ischaemic orchitis, temporary urinary retention

Laparoscopic

Complications of hernias
Incarceration- hernia is irreducible but the contents are not necessarily strangulated or obstructed Obstruction- lumen of bowel obstructed by neck of hernia or fibrosis or swelling of peritoneum or bowel Strangulation- blood supply to contents is cut off leading to ischaemia

Colorectal Cancer
Epidemiology
2nd most common cause of death from malignancy in the UK <5% of patients aged <40 yr Peak incidence is in people aged 70-80 yr F>M

Predisposing factors
Diet, genetic (FAP, HNPCC), IBD

Pathology
Patients with familial colon cancer, FAP, or HNPCC have a higher incidence of R sided tumours 3% of patients with a successfully treated Ca colon will have recurrence within 10 years

Colorectal Cancer
12.5% caecum and ascending colon, 12.5% transverse and descending colon, 25% sigmoid colon, and 50% rectum 90% of ca colon are adenocarcinomas Spread of colorectal cancer Direct, lymphatic, blood, trans-coelomic, and implantation Both TNM and Dukes staging systems used

Clinical features
Anaemia, anorexia, weight loss, COBH, PR bleeding, abdo pain, mass, systemic features, eg jaundice, ascites, bowel obstruction

Investigations
Flexible sigmoidoscopy, colonoscopy, CT/US/MRI, barium enema

Dukes Staging
Dukes stage A B Extent of tumour Frequency at presentation Confined to bowel wall 11% 5-yr survival rate 83% 64%

Through wall; 35% lymph nodes not involved LN involved; no other mets Highest node involved Distant mets 29% 26%

C C2 D

38%

3%

Colorectal Cancer
Complications
Obstruction, perforation, fistulas, eg vesico-colic, recto-vaginal, haemorrhage, intussuception, invasion into other organs

Management
RT/chemo Hemicolectomy, Hartmanns, sigmoid colectomy, abdominoperoneal excision of rectum

Post-op complications
PE/DVT, renal failure, anastomotic leak/stricture, wound infection and dehiscence, intestinal obstruciton, injury of urinary tract, erectile dysfunction, altered bowel function

Inflammatory Bowel Disease

Definition
Chronic inflammation without identifiable cause. Includes Crohns disease and ulcerative colititis.

Epidemiology
More common in developing countries and in younger adults Crohns affects F>M Incidence of UC 26/100 000 and of Crohns 6/100 000

Predisposing factors
FHx, autoimmune, environmental, and dietary factors

Crohns Disease

Crohns Disease
Macroscopic features
Affects any part of alimentary canal but mainly ileum and colon Skip lesions

Microscopic features
Non-caseating epithelioid granulomas Trans-mural inflammation Fissuring ulcers Lymphoid follicles Mucosal crypt distortion Whole thickness of bowel wall Cobblestone appearance Serosa- fatty enroachment Ulcers deep, fissuring can cause fistulas

Histology

Ulcerative Colitis

Ulcerative Colitis
Macroscopic features
Only large bowel, mainly rectum and sigmoid

Microscopic features
Granulomas Inflammatory infiltrate confined to lamina propria Crypt abscesses Crypt distortion Metaplasia and dysplasia (predisposes to carcinoma

Histology
Limited to mucosa Atrophic mucosa Ulcers small and shalllow

Inflammatory Bowel Disease

Clinical features
Crohns- diarrhoea, mucus, bleeding, anal fissure, ulcers, infections, skin tags, chronic intestinal obstruction (stricture formation), abscess, fistula formation, extra-intestinal, anorexia, weight loss, anaemia, nausea UC- bloody diarrhoea, mucus, urgency, incontinence, constipation, cramping abdo pain, anorexia, weight loss, malnutrition, anaemia, nausea, extra-intestinal features Severe acute colitis >10 stools/24h with blood, wasting, pallor, tachycardia, pyrexia, tender and distended abdo May progress to acute toxic dilatation

Pyoderma Gangrenosum

Erythema Nodosum

Inflammatory Bowel Disease

Investigations
Sigmoidoscopy, colonoscopy, barium enema, bloods, stool MC&S (to differentiate between IBD and infective colitis)

Management
Medical: 5-ASA (eg mesalazine), steroids, ciclosporin, azathioprine, replacement of nutrients, water and electrolytes, antiTNF (infliximab), sometimes abx Surgical:
UC- proctocolectomy with with ileostomy, shincter-preserving proctocolectomy with ileal pouch UC and Crohns- colectomy with ileo-rectal anastomosis

Complications
UC- toxic megacolon, perforation, haemorrhage, malignant change Crohns- small bowel strictures, fistulation, peri-anal sepsis, perforation

Diverticular Disease
Definitions

Diverticulum- an outpouching of gut wall Diverticulosis- diverticula present Diverticular disease- these are symptomatic Diverticulitis- inflammation of a diverticulum
Common in developed countries Incidence is increasing Incidence increases with age 10% of people aged 40 yr are affected, 60% of people aged 80 yr are affected

Epidemiology

Diverticular Disease
Pathology
Factors such as lack of dietary fibre lead to slow transit of food High intra-luminal pressure Force mucosa to herniate through muscle layers of gut at weak points (adjacent to penetrating vessels)

Diverticular Disease

Diverticular Disease
Clinical features
COBH, pellet like stools, abdo discomfort and bloating, LIF pain, PR bleeding and mucus, nausea, anorexia, pyrexia, tahcycardia, peritonism, distension, diminished BS

Investigations
FBC, urine microscopy (if netero-vesical fistula suspected), erect CXR (if perf suspected), AXR (bowel obstruction or ileus), contrast studies, colonoscopy (polyps), CT (in complex diverticulitis- eg compllicated by abscess)

Management
Conservative- diet, anti-muscarinics, anti-spasmodics Medical- NBM, IVI, abx, NG if ileus Surgical- recurrence of attacks, chronic complications

Any Questions?

Thank You!