Adult Medicine _ Gastroenterology/Hepatology

Question 1

Colon cancer screening begins at age ___ years. If one first-degree relative has colon cancer, begin screening at age ___ years, or ___ years before the age of onset of the relative.

Answer 1

Colon cancer screening begins at age 50 YEARS. If one first-degree relative has colon cancer, begin screening at age 40 YEARS, or 10 YEARS before the age of onset of the relative.

Question 2

Colorectal cancer tumor marker?

Answer 2

Carcinoembryonic antigen (CEA)

Question 3

Utilities (2) of CEA tumor marker?

Answer 3

1. Useful for baseline and recurrence surveillance

2. Prognostic significance: Patients with pre-operative CEA > 5 ng/mL have a worse prognosis

Question 4

Colorectal cancer metastasizes via hematogenous spread to what 2 organs?

Answer 4

1. Liver via portal circulation - Liver is MOST COMMON SITE of distant metastasis
2. Lungs via lumbar/vertebral veins

Question 5

Gastrointestinal disease a/w colorectal cancer?

Answer 5

Inflammatory bowel disease

• Ulcerative colitis
• Crohn’s disease

Question 6

Which inflammatory bowel disease poses a higher risk of colorectal cancer?

Answer 6

Ulcerative colitis

Incidence of colorectal cancer:

• 5-10% after having UC for 20 years
• 12-20% after having UC for 30 years

Question 7

Colorectal cancer:

- Most common presenting symptom?

Answer 7

Abdominal pain 2/2 partial obstruction or peritoneal dissemination

Question 8

Most common cause of large bowel obstruction in adults?

Answer 8

Colorectal cancer

Question 9

Colorectal cancer:

- Most life-threatening complication of CRC that presents with large bowel obstruction?

Answer 9

Colonic perforation leading to peritonitis

Question 10

Cardiovascular diagnosis that invites workup/evaluation for colorectal cancer?

Answer 10

Streptococcus bovis endocarditis

Question 11

Signs/symptoms of right-sided colorectal cancer (4)?

Answer 11

Melena
RLQ pain and/or palpable mass
Iron-deficiency anemia
Weakness

Notes

• Obstruction is uncommon b/c of the large luminal diameter of the right-sided colon
• Changes in bowel habits uncommon

Question 12

Signs/symptoms of left-sided colorectal cancer (4)?

Answer 12

Hematochezia
LLQ pain
Alternating constipation/diarrhea
Decreased stool caliber (pencil thin stools)

Notes
- Obstruction is common b/c of the small luminal diameter of the left-sided colon

Question 13

Left-sided colorectal cancer finding on barium x-ray?

Answer 13

“Apple-core” lesion

Question 14

Signs/symptoms of rectal cancer (4)?

Answer 14

Hematochezia
Tenesmus
Palpable rectal mass on DRE
Sensation of incomplete evacuation of stool

Notes
- Rectal cancer has a higher recurrence rate and a lower 5-year survival rate than colon cancer

Question 15

Colorectal cancer:

Treatment?

Answer 15

Surgical resection of tumor-containing bowel as well as resection of regional lymphatics

Notes
- Pre-operative CEA level should be obtained

Question 16

Colorectal cancer:

Post-resection follow up (3)?

Answer 16

1. Annual CT abdomen/pelvis and CXR for 5 years
2. Colonoscopy at 1 year and then every 3 years
3. Periodic CEA levels (every 3-6 months)

Notes

• Post-operative increase in CEA level is a sensitive marker of recurrence
• Approximately 90% of recurrences occur within 3 years after surgery

Question 17

Colonic polyps:

- Two categories?

Answer 17

1. Non-neoplastic polyps
   - Benign lesions with NO malignant potential
2. Adenomatous polyps
   - Benign lesions with SIGNIFICANT malignant potential
   - Precursors for adenocarcinoma

Question 18

Non-neoplastic colonic polyps:

- Three types?

Answer 18

1. Hyperplastic polyps
2. Juvenile polyps
3. Inflammatory polyps (pseudopolyps)

Question 19

Adenomatous colonic polyps:

- Three types?

Answer 19

1. Tubular
2. Tubulovillous
3. Villous

Question 20

Adenomatous colonic polyps:

- Malignancy potential of each type?

Answer 20

Villous > tubulovillous > tubular

1. Tubular
   - Smaller, pedunculated
   - Most common type of adenomatous polyp (60-80% of cases)
   - Approx. 5% malignancy potential
2. Tubulovillous
   - Approx. 20% malignancy potential
3. Villous
   - Larger, sessile
   - Approx. 40% malignancy potential

Question 21

Malignancy potential factors (4)?

Answer 21

1. Size
   - Larger the polyp, greater the malignancy potential
2. Histologic type
3. Atypia of cells
4. Shape
   - Sessile v. pedunculated
   - Sessile (flat) more likely to be malignant

Question 22

Colonic polyps:

Most common anatomic site?

Answer 22

Rectosigmoid region

Question 23

Colonic polyps:

• Most patients are asymptomatic
• In symptomatic patients, what is the most common symptom?

Answer 23

Rectal bleeding

Question 24

Diverticulosis

Answer 24

Diverticula:

• Outpouchings of colonic mucosa and submucosa into/through muscularis propria (false diverticulum)
• Arise where the vasa rectae (blood vessels) traverse muscularis propria
• –> Area of weakness in colonic wall
• Caused by increased intraluminar pressure and wall stress
• A/w constipation, straining, and low fiber diet

Question 25

Diverticulosis: | Most common site of diverticula?

Answer 25

Sigmoid colon

Question 26

Diverticulosis: - Most patients are asymptomatic - Occasionally may present with vague LLQ abdominal pain - Complications (2)?

Answer 26

1. Hematochezia - Painless rectal bleeding in up to 40% of patients with diverticulosis - Diverticulosis is the most common cause of hematochezia 2. Diverticulitis - 15-25% of patients

Question 27

Diverticulosis: | - Diagnostic test of choice?

Answer 27

Barium enema

Question 28

Diverticulitis: | - Diagnostic test of choice?

Answer 28

CT abdomen/pelvis with IV and oral contrast

Question 29

Diverticulitis: | - Contraindicated diagnostic tests (2)?

Answer 29

Barium enema Colonoscopy - Risk of perforation

Question 30

Diverticulitis: | - Signs/symptoms (3)?

Answer 30

LLQ pain Fever Leukocytosis Notes - "Left-sided appendicitis" - Other signs/symptoms may include alternating constipation/diarrhea, vomiting - Lower GI bleeding (melena, hematochezia) VERY RARE in diverticulitis

Question 31

Diverticulitis: | - Treatment/management (4)?

Answer 31

1. NPO --> Bowel rest 2. IV fluids w/ potassium 3. IV antibiotics 4. NG tube placement if abdominal distention and/or vomiting present * Mild cases of uncomplicated diverticulitis may be treated on an outpatient basis if the patient is reliable and has no/few co-morbidities Notes - Diverticulitis recurs in about 30% of patients treated medically, usually within the first 5 years

Question 32

Diverticulitis: | - Complications (4)?

Answer 32

1. Colovesical fistula - Fistula b/w colon and bladder - Presents w/ air (pneumaturia) and/or stool in urine - A/w recurrent UTIs 2. Abscess formation 3. Bowel obstruction 4. Colonic perforation --> Peritonitis

Question 33

Age-related prevalence of adenomatous colonic polyps: * ___% at age 50 years * ___% at age 60 years * ___% at age 70 years * ___% at age 80 years

Answer 33

Age-related prevalence of adenomatous polyps: 30% at age 50 years 40% at age 60 years 50% at age 70 years 55% at age 80 years

Question 34

Diverticulitis: | - Bacterial organisms (2)?

Answer 34

E. coli | Bacteroides fragilis

Question 35

Angiodysplasia

Answer 35

- Acquired malformation of mucosal/submucosal venules in colonic wall - Very common cause of lower GI bleeding in patients > 60 years old

Question 36

Angiodysplasia: | - Most common anatomic sites (2)?

Answer 36

Cecum and proximal ascending colon

Question 37

Angiodysplasia: | - Diagnostic test of choice?

Answer 37

Colonoscopy

Question 38

Angiodysplasia: | - Treatment?

Answer 38

- Bleeding self-resolves in 90% of patients - If bleeding persists, treat with colonoscopic coagulation - If bleeding continues to persist, consider right hemicolectomy

Question 39

Angiodysplasia: | - A/w what 2 medical conditions?

Answer 39

- von Willebrand's disease (vWD) - Calcified aortic stenosis - -> As many as 25% of patients with angiodysplasia have aortic stenosis - -> However, no cause-and-effect relationship has been proven

Question 40

Prophylactic therapy for cirrhotic patients with known esophageal varices?

Answer 40

Beta-blockers to prevent bleeding

Question 41

Management of ascites in cirrhotic patients?

Answer 41

- Low-sodium diet - Diuretics - Furosemide + spironolactone - Therapeutic paracentesis if tense ascites, SOB, or early satiety

Question 42

``` Hepatocellular adenoma: Risk factors (3)? ```

Answer 42

Benign liver tumor - Female sex - Oral contraceptive use - Anabolic steroid use

Question 43

``` Jaundice: Main causes (3)? ```

Answer 43

- Hemolysis - Liver disease - Biliary obstruction

Question 44

Total bilirubin level at/above which clinical jaundice usually becomes evident?

Answer 44

Total bilirubin > 2 mg/dL