Adult Medicine _ Gastroenterology/Hepatology Flashcards
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.
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.
Colorectal cancer tumor marker?
Carcinoembryonic antigen (CEA)
Utilities (2) of CEA tumor marker?
- Useful for baseline and recurrence surveillance
2. Prognostic significance: Patients with pre-operative CEA > 5 ng/mL have a worse prognosis
Colorectal cancer metastasizes via hematogenous spread to what 2 organs?
- Liver via portal circulation - Liver is MOST COMMON SITE of distant metastasis
- Lungs via lumbar/vertebral veins
Gastrointestinal disease a/w colorectal cancer?
Inflammatory bowel disease
- Ulcerative colitis
- Crohn’s disease
Which inflammatory bowel disease poses a higher risk of colorectal cancer?
Ulcerative colitis
Incidence of colorectal cancer:
- 5-10% after having UC for 20 years
- 12-20% after having UC for 30 years
Colorectal cancer:
- Most common presenting symptom?
Abdominal pain 2/2 partial obstruction or peritoneal dissemination
Most common cause of large bowel obstruction in adults?
Colorectal cancer
Colorectal cancer:
- Most life-threatening complication of CRC that presents with large bowel obstruction?
Colonic perforation leading to peritonitis
Cardiovascular diagnosis that invites workup/evaluation for colorectal cancer?
Streptococcus bovis endocarditis
Signs/symptoms of right-sided colorectal cancer (4)?
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
Signs/symptoms of left-sided colorectal cancer (4)?
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
Left-sided colorectal cancer finding on barium x-ray?
“Apple-core” lesion
Signs/symptoms of rectal cancer (4)?
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
Colorectal cancer:
Treatment?
Surgical resection of tumor-containing bowel as well as resection of regional lymphatics
Notes
- Pre-operative CEA level should be obtained
Colorectal cancer:
Post-resection follow up (3)?
- Annual CT abdomen/pelvis and CXR for 5 years
- Colonoscopy at 1 year and then every 3 years
- 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
Colonic polyps:
- Two categories?
- Non-neoplastic polyps
- Benign lesions with NO malignant potential - Adenomatous polyps
- Benign lesions with SIGNIFICANT malignant potential
- Precursors for adenocarcinoma
Non-neoplastic colonic polyps:
- Three types?
- Hyperplastic polyps
- Juvenile polyps
- Inflammatory polyps (pseudopolyps)
Adenomatous colonic polyps:
- Three types?
- Tubular
- Tubulovillous
- Villous
Adenomatous colonic polyps:
- Malignancy potential of each type?
Villous > tubulovillous > tubular
- Tubular
- Smaller, pedunculated
- Most common type of adenomatous polyp (60-80% of cases)
- Approx. 5% malignancy potential - Tubulovillous
- Approx. 20% malignancy potential - Villous
- Larger, sessile
- Approx. 40% malignancy potential
Malignancy potential factors (4)?
- Size
- Larger the polyp, greater the malignancy potential - Histologic type
- Atypia of cells
- Shape
- Sessile v. pedunculated
- Sessile (flat) more likely to be malignant
Colonic polyps:
Most common anatomic site?
Rectosigmoid region
Colonic polyps:
- Most patients are asymptomatic
- In symptomatic patients, what is the most common symptom?
Rectal bleeding
Diverticulosis
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
Diverticulosis:
Most common site of diverticula?
Sigmoid colon
Diverticulosis:
- Most patients are asymptomatic
- Occasionally may present with vague LLQ abdominal pain
- Complications (2)?
- Hematochezia
- Painless rectal bleeding in up to 40% of patients with diverticulosis
- Diverticulosis is the most common cause of hematochezia - Diverticulitis
- 15-25% of patients
Diverticulosis:
- Diagnostic test of choice?
Barium enema
Diverticulitis:
- Diagnostic test of choice?
CT abdomen/pelvis with IV and oral contrast
Diverticulitis:
- Contraindicated diagnostic tests (2)?
Barium enema
Colonoscopy
- Risk of perforation
Diverticulitis:
- Signs/symptoms (3)?
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
Diverticulitis:
- Treatment/management (4)?
- NPO –> Bowel rest
- IV fluids w/ potassium
- IV antibiotics
- 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
Diverticulitis:
- Complications (4)?
- Colovesical fistula
- Fistula b/w colon and bladder
- Presents w/ air (pneumaturia) and/or stool in urine
- A/w recurrent UTIs - Abscess formation
- Bowel obstruction
- Colonic perforation –> Peritonitis
Age-related prevalence of adenomatous colonic polyps:
- ___% at age 50 years
- ___% at age 60 years
- ___% at age 70 years
- ___% at age 80 years
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
Diverticulitis:
- Bacterial organisms (2)?
E. coli
Bacteroides fragilis
Angiodysplasia
- Acquired malformation of mucosal/submucosal venules in colonic wall
- Very common cause of lower GI bleeding in patients > 60 years old
Angiodysplasia:
- Most common anatomic sites (2)?
Cecum and proximal ascending colon
Angiodysplasia:
- Diagnostic test of choice?
Colonoscopy
Angiodysplasia:
- Treatment?
- Bleeding self-resolves in 90% of patients
- If bleeding persists, treat with colonoscopic coagulation
- If bleeding continues to persist, consider right hemicolectomy
Angiodysplasia:
- A/w what 2 medical conditions?
- 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
Prophylactic therapy for cirrhotic patients with known esophageal varices?
Beta-blockers to prevent bleeding
Management of ascites in cirrhotic patients?
- Low-sodium diet
- Diuretics - Furosemide + spironolactone
- Therapeutic paracentesis if tense ascites, SOB, or early satiety
Hepatocellular adenoma: Risk factors (3)?
Benign liver tumor
- Female sex
- Oral contraceptive use
- Anabolic steroid use
Jaundice: Main causes (3)?
- Hemolysis
- Liver disease
- Biliary obstruction
Total bilirubin level at/above which clinical jaundice usually becomes evident?
Total bilirubin > 2 mg/dL
