Colorectal & Hepatobiliary Surgery
Decide when to drain, scope, ERCP, or take a belly to the operating room
Diverticulitis and perforation
Osis vs itis. Diverticulosis is asymptomatic outpouching of the colon wall, mostly in the sigmoid with a low-fiber Western diet; it is also the classic cause of painless hematochezia in older adults. Diverticulitis is when one diverticulum becomes inflamed or microperforated.
Diagnosis. Left lower quadrant pain, low-grade fever, and leukocytosis suggest it. CT of the abdomen and pelvis with IV and oral contrast is the test: bowel wall thickening, pericolic fat stranding, and diverticula, and it also shows abscess or free air. Avoid colonoscopy in the acute phase because of perforation risk.
- UncomplicatedNo abscess, perforation, obstruction, or fistula: outpatient oral antibiotics covering gram-negatives and anaerobes (ciprofloxacin plus metronidazole, or amoxicillin-clavulanate) and clear liquids. Selected mild cases in immunocompetent patients may skip antibiotics.
- Small abscessAntibiotics alone.
- Abscess >3–4 cmCT-guided percutaneous drainage plus IV antibiotics.
- Purulent or feculent peritonitis, free perforationUrgent surgery, classically a Hartmann procedure: sigmoid resection with end colostomy.
- After recoveryColonoscopy at 6 to 8 weeks to exclude a cancer mimicking diverticulitis after complicated diverticulitis, or after uncomplicated diverticulitis if there is no recent high-quality colonoscopy.
Hinchey classification. I pericolic abscess, II pelvic abscess, III purulent peritonitis, IV feculent peritonitis. Stages I–II are drained or treated medically; stages III–IV go to the operating room. Elective sigmoid resection is generally offered after a complicated episode.
Colovesical fistula is the most common diverticular fistula: pneumaturia, fecaluria, and recurrent polymicrobial UTIs. It is more common in men because in women the uterus sits between colon and bladder. CT shows air in the bladder; treatment is sigmoid resection with fistula repair.
Free perforation. A perforated hollow viscus causes sudden diffuse pain, a rigid abdomen with rebound, absent bowel sounds, and sepsis. Free air under the diaphragm on an upright chest x-ray (or on CT, which is more sensitive) confirms it.
Free air plus peritonitis means NPO, IV fluids, broad-spectrum antibiotics, and emergent exploratory laparotomy; do not wait for repeat films or a scope.
Colorectal cancer
| Feature | Right (cecum, ascending) | Left (descending, sigmoid) |
|---|---|---|
| Presentation | Occult bleeding → iron-deficiency anemia, fatigue, positive fecal occult blood | Obstructive symptoms, pencil-thin stool, hematochezia |
| Growth | Often larger, exophytic; wide lumen and liquid stool delay obstruction | Annular and constricting in a narrower lumen with formed stool |
| Imaging clue | Mass on colonoscopy | Apple-core lesion on barium study |
Iron-deficiency anemia in an older man or a postmenopausal woman is colon cancer until proven otherwise, and so is Streptococcus gallolyticus (bovis) bacteremia: both prompt colonoscopy.
Screening colonoscopy for average-risk adults starts at age 45. A first-degree relative with colorectal cancer moves screening earlier.
Colon cancer treatment. Segmental resection with regional lymphadenectomy; at least 12 lymph nodes are needed for adequate staging. CEA is drawn at baseline and for surveillance for recurrence, not for screening, because it lacks sensitivity and specificity. Adjuvant FOLFOX (5-FU, leucovorin, oxaliplatin) is given for node-positive (stage III) disease. The liver is the most common site of distant spread, and isolated colorectal liver metastases can be resected for cure.
Rectal cancer. Local staging uses pelvic MRI or endorectal ultrasound. Locally advanced tumors (T3/T4 or node-positive) get neoadjuvant chemoradiation before surgery. Total mesorectal excision reduces local recurrence. Low anterior resection (LAR) preserves the sphincter; abdominoperineal resection (APR) removes it for very low tumors and leaves a permanent colostomy, so distance from the anal verge drives the choice.
Anorectal disease
| Condition | Key features | Treatment |
|---|---|---|
| Internal hemorrhoids | Above the dentate line (visceral, insensate): painless bright-red bleeding and prolapse, graded I–IV | Fiber, water, sitz baths; band ligation for grades I–III; hemorrhoidectomy for grade IV or failure |
| External hemorrhoids | Below the dentate line (somatic): painful, especially when thrombosed | Thrombosed within 72 h of onset: excise; after 72 h: conservative care |
| Anal fissure | Posterior midline tear; tearing pain with defecation and bright blood | Fiber, sitz baths, topical nitrate or calcium channel blocker; sphincterotomy if refractory |
| Perianal abscess | Constant throbbing pain, fluctuant tender mass, fever | Incision and drainage, not antibiotics alone |
| Fistula-in-ano | Chronic drainage; follows up to half of abscesses | Fistulotomy (seton if much sphincter is involved) |
Goodsall rule. It predicts the internal opening of a fistula: an external opening anterior to a transverse line through the anus tracks straight (radially) into the canal, whereas a posterior opening curves to the posterior midline.
Multiple or recurrent perianal fistulas, or a fissure off the midline, should raise suspicion for Crohn disease.
Biliary disease
| Condition | Clues | Test | Management |
|---|---|---|---|
| Biliary colic | Postprandial RUQ pain that resolves within hours; no fever, normal labs | Ultrasound: stones | Elective laparoscopic cholecystectomy |
| Acute cholecystitis | RUQ pain after fatty meals that persists, fever, Murphy sign (inspiratory arrest on palpation), leukocytosis | Ultrasound: stones, wall >3 mm, pericholecystic fluid; HIDA if equivocal (nonvisualized gallbladder) | IV antibiotics and laparoscopic cholecystectomy, ideally within 72 h |
| Choledocholithiasis | Jaundice, elevated bilirubin and alkaline phosphatase | CBD >6 mm on ultrasound; MRCP if uncertain | ERCP stone extraction, then cholecystectomy |
| Ascending cholangitis | Charcot triad: fever, RUQ pain, jaundice; Reynolds pentad adds hypotension and confusion | Ultrasound, labs, blood cultures | IV antibiotics plus urgent ERCP decompression |
| Gallstone pancreatitis | Stone lodged at the ampulla; epigastric pain, raised lipase | Lipase, ultrasound | Supportive care; cholecystectomy before discharge once it settles |
Too sick for surgery. Critically ill patients with cholecystitis (including acalculous cholecystitis after burns, trauma, or prolonged TPN) can be temporized with a percutaneous cholecystostomy tube. If ERCP fails in cholangitis, percutaneous transhepatic drainage decompresses the duct.
Cholangitis is a biliary emergency: the obstructed, infected duct must be decompressed, and antibiotics alone are not enough.
Pancreatic and liver resection
Pancreatic head and periampullary cancer. Adenocarcinoma here presents with painless jaundice and the Courvoisier sign: a palpable, nontender gallbladder with jaundice suggests malignant distal obstruction, not stones (a gallbladder scarred by chronic stone disease rarely distends). Localized, non-metastatic tumors are resected with a Whipple procedure (pancreaticoduodenectomy: pancreatic head, duodenum, distal bile duct, and gallbladder), but most patients present with unresectable disease. CA 19-9 is used to follow the disease, not to screen.
Liver resection. It is indicated for hepatocellular carcinoma when liver function is preserved and for isolated colorectal liver metastases.