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Lower GI Surgery Houda LmalakLearningObjectives • Understand the anatomy, function, and common diseases of the large bowel, including diagnosis and treatment • Accurately identifyand manage symptoms of large bowel disorders and lowerGI surgical conditions • Gain knowledge of surgical procedures for lowerGI issues, including indications, contraindications, and complications • Understand preoperative and postoperative care for large bowel surgeries • Develop skills in interpreting diagnostic tests like endoscopy, colonoscopy, imaging, and lab tests for lower GI assessmentAnatomyLargeBowelConditions AcuteAppendicitis Appendicitis refers to inflammation of the appendix and is a common acute surgical presentation Signsand Symptoms Investigations Central abdominalpain radiatingto the rightiliac Urinalysis fossa(RIF) Pregnancytest Tendernessat McBurney’spoint Inflammatorymarkers Rovsing’ssign Ultrasound Guarding Computed Tomography Reboundtenderness Management LaparoscopicAppendicectomy Prophylacticintravenousantibiotics InflammatoryBowelDisease A 31-year-old woman presents with a 4-month history of diarrhoea, tenesmus, and occasional rectal bleeding. She reports passing stools 6-8 times a day, often mixed withblood and mucus. She has also experienced fatigue and unintentional weight loss. Physical examination reveals mild tenderness in the left lower quadrant, but no palpable masses. Blood tests show haemoglobin of 108 g/L, CRP of 35 mg/L, and faecal calprotectin is elevated. Colonoscopy reveals continuous inflammationfrom the rectum extending to the sigmoid colon. What is the most likely diagnosis? A Crohn’s disease B Ulcerative colitis C Irritable bowel syndrome (IBS) D Ischaemic colitis InflammatoryBowelDisease A 31-year-old woman presents with a 4-month history of diarrhoea, tenesmus, and occasional rectal bleeding. She reports passing stools 6-8 times a day, often mixed withblood and mucus. She has also experienced fatigue and unintentional weight loss. Physical examination reveals mild tenderness in the left lower quadrant, but no palpable masses. Blood tests show haemoglobin of 108 g/L, CRP of 35 mg/L, and faecal calprotectin is elevated. Colonoscopy reveals continuous inflammationfrom the rectum extending to the sigmoid colon. What is the most likely diagnosis? A Crohn’s disease B Ulcerative colitis C Irritable bowel syndrome (IBS) D Ischaemic colitis UlcerativeColitis Signsand Symptoms Investigations Bloodydiarrhoea Routinebloodtests Abdominalpain inthe left lowerquadrant Faecal calprotectin Tenesmus StoolMC&S AbdominalX-ray Colonoscopy MacroscopicChanges Continuousinflammation(proximalfrom rectum) Management Mucosalinvolvementonly Pseudo-polypsandulceration Induce Mild-Moderate Severe MicroscopicChanges Crypt abscess Rectal aminosalicyte IVsteroids Reduced goblet cells Oralaminosalicyte OralCorticosertoid Extra-intestinalsigns Maintain Rectal aminosalicyte OralAzathioprine Erythema nodosum Oralaminosalicyte Oralmercaptopurine Uveitis PrimarysclerosingcholangitisUlcerativeColitisCrohn’sDisease Signsand Symptoms Investigations Non-bloodydiarrhoea Urinalysis Mouthulcers,perianal disease Pregnancytest Abdominalmass palpable inthe right iliacfossa Inflammatorymarkers Ultrasound Computed Tomography MacroscopicChanges Management Discontinuousinflammation(‘skiplesions’) Transmuralinvolvement Induce Fissuresanddeep ulcers(‘cobblestone appearance’) • Glucocorticoids Fistula formation • Mesalazine MicroscopicChanges Maintain Granulomatous • Azathioprine • Mercaptopurine • methotrexate Diverticulitis Asubsetofdiverticulardisease,occurswhendiverticulabecomeinflamedor infected Signs and Symptoms Investigations Altered bowelhabit CT scan rectal bleeding Bloodtests demonstrating inflammation(leukocytosis) Left lowerquadrant abdominalpain Flexiblesigmoidoscopy Fever Nausea and vomiting Management • Increase dietary fibreintake • Analgesia • Onlytaking clear liquids(avoidingsolidfood)until symptoms improve(usually2-3 days) • Segmental resection ColorectalCancer Signsand Symptoms Management • Changeinbowelhabit (usuallyto morelooseand Surgicalresection frequentstools) Chemotherapy • Unexplained weightloss Radiotherapy • Rectal bleeding Palliativecare • Unexplained abdominalpain • Irondeficiencyanaemia • Abdominalorrectal mass onexamination Investigations Faecal immunochemicaltests (FIT) Colonoscopy Sigmoidoscopy Staging CT scan Carcinoembryonicantigen(CEA) BowelResections A 48-year-old man presents with a 6-month history of intermittentleft-sided abdominal pain, altered bowel habits, and weightloss. He has a 20-year history of diverticular disease. A recent colonoscopy revealed a large, circumferential mass in the sigmoid colon, suspicious for malignancy. A CT scan shows thickening of the sigmoid colon, no distant metastases, and no signs of perforation or abscess. What is the most appropriate surgical resection for thispatient? A Right hemicolectomy B Subtotal colectomy C Sigmoid colectomy D Hartmann's procedure BowelResections A 48-year-old man presents with a 6-month history of intermittentleft-sided abdominal pain, altered bowel habits, and weightloss. He has a 20-year history of diverticular disease. A recent colonoscopy revealed a large, circumferential mass in the sigmoid colon, suspicious for malignancy. A CT scan shows thickening of the sigmoid colon, no distant metastases, and no signs of perforation or abscess. What is the most appropriate surgical resection for thispatient? A Right hemicolectomy B Subtotal colectomy C Sigmoid colectomy D Hartmann's procedureBowelResectionsStomas Stomas are artificialopenings of bowel,which is artificiallyopened onto the surface of the abdomen, allowingfaeces or urine to drain, bypassing the distal portions of the bowel or urinary tract Colostomy Ileostomy Left iliacfossa Rightiliacfossa Large bowl(colon) Endportionofthe smallbowel Drainssolidstool (ileum) Flushto the skin Liquidcontents are moreirritating Contents areless irritating to the surroundingskin Spout Drainliquidstools directly into stoma bag Stomas End vs Loop? • End Colostomy: After removinga sectionofthe bowel,the proximal end is broughtto the skin,allowingwaste to exit througha stoma intoa bag. The distal end isclosedand leftinthe abdomen.It can be temporary (forhealing) orpermanent (after majorsurgeries likeabdominoperinealresection). • distal bowelor anastomosis,can be reversedafter 6-8 weeks. Bothends of the bowelarebroughtto the skin,with the proximalendforminga spoutfor waste drainage,andthe distal end flattened. • extensivebowelresections,suchas forcancer, whiletemporary stomas are used forshort-term bowelrest duringhealing. • Thechoicebetween loopileostomyand loopcolostomydepends onthe surgicalgoal,with loopileostomiesoften usedto protect distal obstructionor inflammation.omiesused to manageconditionslike bowel Stomas Site Lumens Appearance Effluent Anatomy Indications Leftiliac 1 lumen Flush Solidor Sigmoid Temporary:allowbowelrest(e.g. End colostomy fossa semisolid Descendingcolon diverticulitis,obstruction,leak) faeces Permanent: after abdominoperineal resectionoflowrectal oranal cancer Loop colostomy Leftiliac 2 lumens Flush Solidor Sigmoid Projectdistal anastomoses fossa close semisolid Descendingcolon Decompressdistal bowelobstruction together faeces End ileostomy Rightiliac 1 lumen Spout Mushyor Usuallydistal Temporary:emergencyresectionswhere fossa liquidsmall Terminalileum it isunsafe to performan anastomosis bowel (e.g.diseasedbowel,sepsis,shock) content Permanent: after panproctocolectomy (e.g.ulcerativecolitis) Loop ileostomy Rightiliac 2 lumens Spout Mushyor Usuallyterminal Protectdistal anastomoses fossa close liquidsmall ileum Decompressdistal bowelobstruction together bowel contentAnorectalConditions AnorectalDisorders discomfort, and a sensation of incomplete evacuation. She reports prolapseal of a lump during defecation that she has to manually reduce. She has tried over-the-counter creams withno relief.On examination, external haemorrhoidal lumps are noted, and anoscopy reveals grade IIIinternal haemorrhoids. What is the next best step in management? A Rubber band ligation B Conservative management with fibre supplements and topical treatment C Haemorrhoidectomy D Sclerotherapy AnorectalDisorders discomfort, and a sensation of incomplete evacuation. She reports prolapseal of a lump during defecation that she has to manually reduce. She has tried over-the-counter creams withno relief.On examination, external haemorrhoidal lumps are noted, and anoscopy reveals grade IIIinternal haemorrhoids. What is the next best step in management? A Rubber band ligation B Conservative management with fibre supplements and topical treatment C Haemorrhoidectomy D Sclerotherapy Haemorrhoids Haemorrhoids are abnormal swellings or enlargement of the anal vascular cushions Signsand Symptoms Investigations Painlessbrightred PRbleeding (unlessthrombosed) Digital rectal exam Anal pruritus Proctoscopy A palpable orprotrudingmass onexamination Management topical corticosteroidsto alleviatepruritusandincreasedietary fibre Grade 2: Managementmay involverubber band ligation(preferred), sclerotherapy,orinfraredphotocoagulation Grade 3: Rubber band ligation Grade 4: Surgicalhaemorrhoidectomy AnalFissures An anal fissure refers to a tear in the liningof the anus or anal canal Signsand Symptoms Investigations PainfulPRbleeding Around90% ofanalfissuresoccuronthe posterior Constipation midline. Ifthe fissuresare foundinalternative locationsthen other underlyingcauses shouldbe considerede.g. Crohn's disease Management Laxatives anddietary fibre Useoftopical analgesics,suchas lidocainecream or jelly. Topicalglyceryltrinitrate (GTN) BotoxInjection Sphincterotomy AnorectalAbscess An anorectal abscess is a localised collection of pus in the perianalor rectal spaces, commonly arising from an infection in the anal glands Signsand Symptoms Investigations Perianalpainworseonsitting Physicalexamination/ digital rectal examination Perianalswelling- fluctuant and tender onexamination MRIpelvis Systemic symptoms: Low-grade pyrexia,tachycardia Transperinealultrasound Management Antibioticsdrainageundergeneralor localanaesthetic AnalFistula An abnormal connection between the epithelialised surface of the anal canal and the perianal skin. Signsand Symptoms Investigations Anal discharge Digital rectal examination Anal discomfortor pain,often exacerbated by sitting or Openingsofthe fistulamay bevisible defecation MRI Characterise the fistula'scourseanddelineate soft tissue structures effectively Management Painmanagementandwoundcare Anti-TNF agents may beused ifcrohn'sreleated Antibiotics incases ofongoinginfection Steton FistulotomyGeneralSurgeryPresentationsAcuteAbdomen Constipation vomiting, and distension. He reportsthat his vomiting has become bilious, and he has not passed any flatus or stool for 48 hours. He has a history of colorectal cancer surgery 3 years ago. On examination,his abdomen is distended with high-pitched bowel sounds. An abdominal X-ray shows dilated loops of bowel withair-fluidlevels but no gas in the rectum. What is the most likely type of bowel obstruction? A Small bowel obstruction B Large bowel obstruction C Paralytic ileus D Sigmoid volvulus Constipation vomiting, and distension. He reportsthat his vomiting has become bilious, and he has not passed any flatus or stool for 48 hours. He has a history of colorectal cancer surgery 3 years ago. On examination,his abdomen is distended with high-pitched bowel sounds. An abdominal X-ray shows dilated loops of bowel withair-fluidlevels but no gas in the rectum. What is the most likely type of bowel obstruction? A Small bowel obstruction B Large bowel obstruction C Paralytic ileus D Sigmoid volvulus BowelObstruction Causes Investigations Adhesions(smallbowel) Abdominalx-ray is firstline Hernias(smallbowel) Erect chest x-ray - perforation Volvulus(largebowel) CT is definitive Malignancy(largebowel) U&Es- electrolyte imbalances Venousbloodgas Signsand Symptoms - Metabolic alkalosisdue to vomiting Biliousvomiting Raisedlactate dueto bowelischaemia Abdominaldistention Diffuseabdominalpain Management Absolute constipationandlack of flatulence “Drip and suck” SurgicalIntervention “Tinkling”bowelsounds Nil by mouth Exploratory surgery inpatients with an unclearunderlyingcause Complications IV fluids Adhesiolysisto treat adhesions Hypovolaemicshock NG tube with free drainage Hernia repair Bowelischaemia Emergency resection foran obstructing Bowelperforation tumour SepsisBowelobstruction • Please duplicate thisslide as you go along.Bleeding • SBA Bleeding bleeding and dizziness. She reports passing large volumes of fresh blood into the toilet bowl but denies any abdominal pain or vomiting. Her past medical history includes diverticulosis and hypertension. On examination, she is hypotensive witha blood pressure of 90/55 mmHg and tachycardic at 110 bpm. Digital rectal examinationconfirms fresh blood. Blood tests reveal haemoglobin of 70 g/L and a raised urea-to-creatinine ratio. What is the most likely cause of her bleeding? A Diverticular bleeding B Upper gastrointestinal bleed C Haemorrhoids D Ischaemic colitis Bleeding bleeding and dizziness. She reports passing large volumes of fresh blood into the toilet bowl but denies any abdominal pain or vomiting. Her past medical history includes diverticulosis and hypertension. On examination, she is hypotensive witha blood pressure of 90/55 mmHg and tachycardic at 110 bpm. Digital rectal examinationconfirms fresh blood. Blood tests reveal haemoglobin of 70 g/L and a raised urea-to-creatinine ratio. What is the most likely cause of her bleeding? A Diverticular bleeding B Upper gastrointestinal bleed C Haemorrhoids D Ischaemic colitis Melena&RectalBleeding Rectal bleeding (or haematochezia) is the passage of fresh blood per rectum, while melena refers to black tarry stools Investigations Stoolsamples, FIT testing, faecal calprotectin Causes Fullbloodcount(anaemia,infection/inflammatory Highinthe GItract: melaena, often dueto peptic ulcer response) disease, gastritis, oesophagealvarices,ormalignancy. Coagulationstudies GroupandSave At the levelofthe colon:Bloodmixedwith the stool, PRexamination potentially causedby ulcerativecolitis,tumors, Upper GI endoscopy diverticulitis. Colonoscopy/Sigmoidoscopy At orjustabovethe anus:Bright redblood,indicating Management conditionssuchas haemorrhoidsor analfissures. Treat underlyingcause Hb <70g/L requireblood transfusion Patients onanti-coagulationshouldhave this reversedurgently Haematemesis Haematemesis is a clinical emergency characterised by thevomiting of blood, often due to upper gastrointestinal bleeding Causes Investigations Peptic Ulcers Fullbloodcount OesophagealVarices Coagulationprofile Gastrointestinal Tumours Upper Gastrointestinal Endoscopy Mallory-WeissTears GroupandSave Coagulopathies Cross-match Signsand Symptoms VomitingofBrightRed orCoffeeGround-Like Material Management Haemodynamic Instability Resuscitation-A-E with intravenousfluids,blood Melaena products, andcorrectionofcoagulopathies AbdominalPain EndoscopicHaemostasis Dysphagia Dysphagia refers to difficulty swallowing Investigations 2week-wait criteria: Causes Oesophageal/gastriccancer - OfferurgentOGD inpeoplewith Mechanical: Oesophageal,Gastric, orHead & Neck cancer dysphagia orthose aged 55 yearsandoverwith weightloss Benignoesophagealstrictures andanyofthe following: upperabdominalpain,reflux, Extrinsic compression(e.g.thyroid goitre) ordyspepsia. Pharyngealpouch Bariumswallow Motility: Manometry (goldstandard for achalasia) Cerebrovascularaccident Achalasia Management Diffuseoesophagealspasm Treatment ofthe underlyingcause Eosinophilicoesophagitis SALT assessmentand swallowingtherapy witha speech- Neurologicaldisorders languagespecialist Nutritionalstatus andinvolvementofa dieticianSurgicalScarsThankyou!