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GIHEP > 23. Colorectal Cancer And Diverticular Disease > Flashcards

23. Colorectal Cancer And Diverticular Disease Flashcards

1
Q

What is the aetiology of colorectal cancer?
(5)

2nd commonest cause of cancer death in Ireland and UK

A
  1. Fam history (HNPCC 5%, FAP 1%): 2 first degree relates 1/6 lifetime risk
  2. Polyps: adenocarcinoma
  3. Environment: low fibre diet, low veggie intake, smoking
  4. Syndromes: chronic UC or colonic Crohn’s disease (UC > Crohn’s), Gardners, Peutz- Jegher
  5. Obesity, male, age 55-75
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2
Q

What are the macroscopic types?
(4)

Where can be the tumours be found?
(4)

A

MACROSCOPIC TYPES

  1. Fungating polypoid tumours (best prognosis)
  2. Annular constricting tumour
  3. Flat ulcerated
  4. Mucinous

LOCATIONS

  1. Rectum - 40%
  2. Sigmoid - 35%
  3. Caecum - 20%
  4. Transverse / Descending - 5%
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3
Q

What are the signs of colorectal cancer?
(5)

What are the symptoms of colorectal cancer?
(5)

A

SIGNS

  1. Cachexia (temporalis, zygoma)
  2. Anaemia
  3. Abdo mass
  4. Rectal lesions on pr (within 10cm of anal verge)
  5. Hepatomegaly

SYMPTOMS

  1. Distal lesions: PR bleeding (blood on surface of stool), tenesmus
  2. RS lesions: iron def anemia
  3. LS lesions: PR bleeding (blood mixed with stool), change in bowel habit
  4. Constitutional: weight loss, lower abdo pain
  5. Emergency presentations (40%): large bowel obstruction, perforation with peritonitis, acute PR bleed
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4
Q

What investigations are performed?

10

A
  1. History and full physical exam
  2. Bloods: FBC, U+E, LFTs, CEA (raised in 60% of colorectal cancer)

RADIOLOGICAL

  1. CXR (if perforation)
  2. PFA (if obstruction)
  3. Double contrast
  4. CT abdo
  5. CT colonoscopy

ENDOSCOPY

  1. Rigid sigmoidoscopy
  2. Flexible sigmoidoscopy
  3. Colonoscopy
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5
Q

What tumour staging is used? Describe.

5

A

Duke’s Classification

  1. Duke’s A: confined to bowel wall (90% 5y survival)
  2. Duke’s B: through muscularis propria (75%)
  3. Duke’s C: regional lymphoma nodes (30-60%)
  4. Duke’s D: distant metastasis (5%)
  5. TNM more comprehensive
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6
Q

What are the treatments for colon cancer?

2 categories - 7 treatments total

A

POTENTIALLY CURATIVE

  1. Surgery: right colon (right hemicolectomy), left colon (left hemicolocetomy)
  2. Rectal tumours: depends on stage of local advancement may be candidates for neoadjuvant chemoradiotherapy (reduces local recurrence)
  3. Adjuvant chemotherapy for tumours w/ positive lymph nodes or evidence of vascular invasion

PALLIATIVE (unresectable mets or unresectable tumours)

  1. Chemo
  2. Endoluminal stents with self expanding metal stends for obstructing colon tumours
  3. Transanal ablation of rectal obstructing tumours
  4. Surgery for untreatable obstruction, bleeding, or severe symptoms
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7
Q

What are the margins for resection in rectal cancer?

A
  1. Proximal margins at least >5cm - dictated by blood supply
  2. Distal margins in upper + middle 1/3 —> aim 5cm
  3. For distal margins in lower 1/3, 1cm for well/moderately differentiated and 2cm for poorly differentiated
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8
Q

What are the treatments for rectal cancer?
(2)

What are the principles of cancer surgery?
(3)

A
  1. Upper 1/3 cancers: high anterior resection, no J pouch
  2. Middle and lower 1/3 cancers: abdominal-perineal resection (APR), usually for lesions <5cm from anal verge + low anterior resection

Principles of cancer surgery:

  • TME: total mess recital excision
  • High ligation of pedicure vessels
  • Colonic J pouch vs. Coloplasty (rare)
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9
Q

What screening is done for colorectal cancer?

2

A
  1. Colorectal Screen: faecal occult blood testing in >50y every year +/- sigmoidoscopy
    - if POSITIVE: FOB or microcytic anaemia —> referred for full colonoscopic eval
    - if microcytic anaemia should also get OGD
  2. Carcinoembryonic Antigen (CEA): glycoprotein, not specific to colorectal cancer (also seen in cancers of stomach, lung, breast)
    - Elevated in non-malignant conditions = alcoholic liver cirrhosis, IBD, pancreatitis, COAD
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10
Q

What is the pathophysiology of diverticular disease?

A

Acquired outpouchings of sac-like mucosal projections through colon wall (affects sigmoid colon mostly)
A/w increased colonic pressure and constipation
Can cause bleeding and obstruction

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11
Q

What is the difference between diverticulosis and diverticulitis?

A

Diverticulosis: prescence of outpouchings, asymptomatic and dx as incidental finding

Diverticulitis: inflammation of one of these outpouchings

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12
Q

What are the signs of diverticulitis?
(4)

What are the symptoms of diverticulitis?
(4)

A

SIGNS

  1. Fever
  2. Tachycardia
  3. Tender LIF
  4. Guarding / rebound

SYMPTOMS

  1. LIF Pain
  2. Diarrhoea / constipation
  3. PR bleeding
  4. Nausea and vomiting
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13
Q

What is a common presentation of diverticular disease?

A

Acute diverticular bleed

  • painless
  • spontaneous with no prodromal symptoms
  • large volume of blood, bright red, due to rupture of peridiverticular submucosal vessel
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14
Q

What are the complications of diverticular disease?

6

A 
1. Inflammation = diverticulitis (Hinchey) 
—> Managed conservatively 
—> Tx: antibiotics 
2. PR bleeding (stops spontaneously) 
3. Perforation 
4. Obstruction 
5. Strictures
6. Fistula: connection between colon and bladder
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15
Q

What is the treatment for complications?

2

A
  1. Surgery for emergencies and failure of other therapies —> Hartmann’s Procedure = surgery for obstruction
  2. Inflammation = antibiotics
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16
Q

What is acute diverticulitis?

How is it classified?
4

A

Inflammation fo diverticulum

Hinchey’s Classification 
1A: parabolic phelgmon 
2B: pericolic / mesenteric abscess
3: purulent peritonitis = perforated abscess cavity 
4: faeculent peritonitis
17
Q

What is the treatment for acute diverticulitis?
Uncomplicated (3)
Complicated (1)

A

UNCOMPLICATED

  1. Start with medical management
  2. IV antibiotics and fluids, bowel rest, analgesia, radiology-guided drainage of abscess
  3. If medical management fails, consider surgery

COMPLICATED
1. Surgical management
- Laparoscopy and washout
- Segmental colonoscopy
—> if patient is UNWELL or perforation = end colostomy (Hartmann’s)
—> if patient is WEL or no perforation = =primary anastomoses of colon

GIHEP (3 decks)

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