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Medicine year 3 ANNA > Bowel Cancer > Flashcards

Bowel Cancer Flashcards

1
Q

Common causes of fresh blood in stool?

A
  1. Haemorrhoids
  2. Acute anal fissure (following trauma or severe constipation)
  3. Colo-rectal neoplasms
  4. Acute proctitis
  5. IBD
  6. Diverticular disease
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2
Q

Fresh blood in stool usually suggests bleeding from where?

A

Rectum or anal canal

N.B. Bleeding from further up the GI tract (stomach, small intestine, colon) is normally mixed with stool i.e. malaena (unless profuse)

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3
Q

What is an acute anal fissure?

A

Break/tear in the skin of the anal canal

  • Often directed posteriorly as anal wall is poorly supported posteriorly)
  • Can extend down to underlying sphincter muscles
  • Symptoms: severe pain (often when passing stool), fresh blood on toilet paper (rarely enough to cause anaemia)
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4
Q

What investigations are used to confirm/exclude bowel cancer?

A

WITHOUT major comorbidity:

  1. Colonoscopy (if no other major comorbidity)
  2. If suspicious lesion is detected –> biopsy (unless contraindicated e.g. clotting disorder)

WITH major comorbidity:

  1. Flexible sigmoidoscopy then barium enema
  2. If suspicious lesion is detected –> biopsy (unless contraindicated)

Consider CT colonography if radiology department is proficient –> then colonoscopy + biopsy if lesion detected.

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5
Q

What fraction of colorectal cancers are in the colon vs rectum?

A

Colon = 2/3

Rectum = 1/3

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6
Q

What could cause unexplained microcytic anaemia in an elderly patient?

A

Occult bleeding from a colonic malignancy

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7
Q

What staging system is used for Bowel cancer?

A

Duke’s system

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8
Q

What are Duke’s stages for Bowel cancer?

A
  • Dukes’ A = the cancer is only in the innermost lining (epithelium) of the colon or rectum or slightly growing into the muscle layer
  • Dukes’ B = means the cancer has grown through the muscle layer of the colon or rectum
  • Dukes’ C = means the cancer has spread to at least one lymph node in the area
  • Dukes’ D = means the cancer has spread to somewhere else in the body, such as the liver or lung. (Some doctors call this stage 4 or advanced bowel cancer)
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9
Q

What are the TNM stages for bowel cancer?

A

Tumour (T):

  • T1 = cancer has grown no further than the inner layer of the bowel
  • T2 = grown into the muscle layer of the bowel wall (but not through)
  • T3 = grown into the outer lining of the bowel wall
  • T4 = grown through outer lining of the bowel wall (into other parts of the bowel, nearby organ or body structure)

Node (N):

  • N0 = means there are no lymph nodes containing cancer cells
  • N1 = means that 1 to 3 lymph nodes close to the bowel contain cancer cells
  • N2 = means there are cancer cells in 4 or more nearby lymph nodes

Metastasis (M):

  • M0 = cancer not spread to other organs
  • M1 = cancer spread to other parts of body
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10
Q

What is a hemicolectomy?

A

Operation to remove either right or left side of colon

  • Resect 5cm eitherside of lesion
  • Right = caecum + some ascending colon removed
  • Left = some descending colon + sigmoid
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11
Q

What is an anterior resection?

A

Resection of colon (often descending, sigmoid or rectum) via the abdominal wall e.g. laproscopically

  • Commonly used name instead of left hemicolectomy
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12
Q

What is an Abdomino-Perineal (AP) resection?

A

Resection of the Rectum + Anus

  • Pathology is in low anus/rectum
  • Proximal resection margin is pulled through abdominal wall to form permanent end colostomy
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13
Q

What are operations that end in “-stomy”?

A

Operations to create artificial openings ‘Stoma’ into a hollow organ e.g. sigmoid colostomy

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14
Q

What are the 5-year survival rates for Duke’s stage A colorectal cancer compared with Duke’s stage D?

A

Duke’s A = 93% 5-year survival

Duke’s D = 7% 5-year survival

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15
Q

What are common symptoms / signs of colorectal cancer?

A

In order of coveying the highest to lowest risk of colorectal cancer:

  1. Rectal bleeding + change in bowel habit (35%)
  2. Abdominal/rectal mass (30%)
  3. Iron-deficient anaemia (30%)
  4. Intestinal obstruction (20%)
  5. Change in bowel habit alone (10%)
  6. Rectal bleeding without anal symptoms (6%)
  7. Rectal bleeding with anal symptoms (3%)
  8. Abdo pain (3%)
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16
Q

What symptoms are ‘high risk’ and warrant 2-week referral?

A
  1. >6 week change in bowel habit and bleeding (any age)
  2. >60yrs + change in bowel habit (loose) >6/52
  3. >60yrs + rectal bleeding without anal symptoms
  4. Palpable right sided mass any age
  5. Unexplained Iron-deficient anaemia
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17
Q

What ages are screened for colorectal cancer via FOBT (fecal occult blood test)?

A

Ages 60-69 every 2 years

Stats:

  • 2% are FOB +ve
  • Of those, 10% have colorectal cancer (>50% Dukes A)
  • 40% of +ve FOB have adenomas (removal of which provides risk reduction for developing colorectal cancer compared with not removing)
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18
Q

What is FAP (familial adenomatous polyposis)?

A

Define: Carpet of polyps throughout entire colon, often develop colorectal cancer in 20-30’s

Aetiology: Autosomal dominant, mutation of 1 APC allele (on chromosome 5q)

Epidemiology: 1 in 7000

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19
Q

What is Hereditary Non Polyposis Colorectal Cancer (HNPCC)?

A

Define: Also called Lynch syndrome, autosomal dominant, increase risk of various cancers (50-70% lifetime risk of colorectal cancer)

Common cancers: bowel (most common) endometrial (second most common), ovary, stomach, small intestine, upper urinary tract etc.

Aetiology: Autosomal dominant mutation in MMR genes (mis-match repair) –> causes replication error prone DNA - MLH1 + MSH2 account for 90%

Epidemiology: 1 in 500

Phenotype:

  • Proximal colon most common
  • 70-80% penetrance
  • Onset = 30-50s
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20
Q

What is the Amsterdam Criteria for HNPCC (Hereditary non polyposis colorectal cancer)?

A

​

3-2-1 criteria

  1. ≥3 relatives with confirmed colorectal cancer (FAP should be excluded)
  2. 2 succesive generations involved i.e. 1 person is a 1st degree relative of the other 2
  3. 1 or more with age of cancer onset < 50

‘Softer criteria’ were made to include cancers at other HNPCC sites + later onset

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21
Q

What are the most common areas for colorectal cancer?

A
  1. Sigmoid Colon
  2. Cecum
  3. Rectum
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22
Q

Colorectal cancer adjuvent therapy?

A
  • No role for radiotherapy
  • Dukes C –> can have 6/12 chemo with 5FU (fluorouracil), results in 5-7 more cured pts per 100 treated
23
Q

What is a metastectomy?

A

Resection of cancer metastasis

The most common of which is removal of liver mets associated with bowel cancer

24
Q

What are the signs of peritonitis?

A
  • Prostration (extreme exhaustion or lack of energy or power)
  • Shock
  • Lying still
  • Tenderness (± rebound/percussion pain)
  • Board-like abdominal rigidity
  • Guarding
  • Absent bowel sounds
  • +ve cough test (While looking at the face, ask the patient to cough. If this causes abdominal pain, flinching, or a protective movement of hands towards the abdomen, = +ive, suspect peritonitis)
25
Q

What is a laparotomy and when is it indicated?

A

A surgical incision (usually midline) and exploration of the abdomen

  • Indicated in the acute (“surgical”) abdomen to make a diagnosis, e.g. organ rupture or perforation.
26
Q

What is colic?

A

A regularly waxing and waning pain, caused by muscular spasm in a hollow viscus

  • e.g. gut, ureter, salpinx, uterus, bile duct, or gallbladder (in the latter, pain is often dull and constant)
  • Colic, unlike peritonitis, causes restlessness and the patient may well be pacing around!
27
Q

In which part of the colon is diverticular disease most common?

A

Sigmoid colon

Possibly due to pressure associated with chronic constipation and/or accumulation of faecal matter

28
Q

What is the difference between:

Diverticulosis

Diverticular Disease

Diverticulitis?

A
  • Diverticuloisis: Herniations/outpouchings of mucosa and submucosa through the muscular layer of the colon. Often asymptomatic
  • Diverticular disease: When this becomes symptomatic, e.g. rectal bleeding + altered bowel habits (exclude other pathologies first)
  • Diverticulitis: when inflammation occurs, symptoms are more severe + symptoms of inflammation e.g. tenderness
29
Q

What are common risk factors for Diverticular disease?

A
  1. Chronic constipation
  2. Low fibre diet
  3. High intake of meat/red meat
  4. Increasing age
  5. Hereditary factors
30
Q

What are common complications of Diverticular disease?

A
  1. Infection (diverticulitis) - presentation similar to acute appendicitis, but with pain often being located on left abdomen or hypogastrium
  2. Lower GI Bleeding - occult or overt
  3. Perforation (can cause peritonitis)
  4. Abscesss
  5. Fistula formation
31
Q

What are common causes of an acute abdomen (severe abdo pain often requiring emergency surgery) with generalised pain?

A
  1. Perforated viscus e.g. peptic ulcer, trauma, appendicitis, GI cancer, diverticulitis, IBD etc.
  2. Acute pancreatitis
  3. DKA
  4. Ischameic Bowel
  5. Bleeding e.g. ruptured AAA, ectopic pregnancy, peptic ulcer
32
Q

What forms can colonic malignancies take?

A
  • Ulcers
  • Polyps
  • Circumferential lesions
33
Q

Common causes of acute abdomen with right upper quadrant pain?

A
  1. Gallblader disease (e.g. cholecystitis, cholangitis, CBD stone)
  2. Duodenal ulcer
  3. Acute pancreatitis (e.g. in pregnant women due to displacement of pancreas by uterus)
  4. Hepatitis
  5. Hepatic absess
  6. Pyelonephritis
  7. Kidney Stones
  8. Pneumonia (referred pain)
34
Q

Common causes of acute abdomen with left upper quadrant pain?

A
  1. Acute pancreatitis
  2. Splenic infarction
  3. Ruptured splenic artery aneurysm
  4. Spontaneous splenic rupture
  5. Kidney Stones
  6. Pyelonephritis
  7. Pneumonia (referred pain)
35
Q

Common causes of acute abdomen with right iliac fossa pain?

A
  1. Acute appendicitis
  2. Perforated duodenal ulcer
  3. Crohn’s disease (often affects terminal ileum + ceacum) - can mimic appendicitis
  4. Diverticulitis
  5. Constipation
  6. Renal colic / kidney stones
  7. Strangulated hernia
  8. Obs&Gyn - ectopic pregnancy, ruptured ovarian cyst, salpingitis
36
Q

Common causes of acute abdomen with left iliac fossa pain?

A
  1. Diverticulitis
  2. Constipation
  3. Sigmoid volvulus (typically elderly pt)
  4. Crohn’s
  5. Ulcerative Colitis
  6. Kidney stones
  7. Strangulated hernia
  8. Obs&Gyn - ectopic pregnancy, ruptured ovarian cyst, salpingitis
37
Q

Common causes of acute abdomen with epigastric pain?

A
  1. Peptic Ulcer (gastric or duodenal)
  2. Acute pancreatitis
  3. Perforated oesophagus (Boerhaave syndrome - perforated due to vomiting)
  4. Mallory Weiss tear
  5. MI
38
Q

Common causes of acute abdomen with central pain?

A
  1. Early appendicitis
  2. Small intestine obstruction
  3. Mesenteric ischaemia (thrombosis)
  4. Acute pancreatitis
  5. Leaking/ruptured AAA
39
Q

Common causes of acute abdomen with suprapubic pain?

A
  1. Acute urinary retention
  2. UTI
  3. Ectopic pregnancy
40
Q

What are the classic signs of an acute abdomen?

A
  1. Fever (low grade)
  2. Tenderness
  3. Rigidty and guarding
  4. Rebound tenderness
  5. Bowel sounds - absent (peritonitis), increased (small bowel obstruction)
  6. Abdominal distension (Fluid, Fat, Flatus, Faeces, Foetus, Flippin big mass)
41
Q

What investigations would you do for an acute abdomen?

A
  1. FBC - infection, Hb drop due to bleed
  2. U+Es - determine kidney function, dictates use of certian medication, ↑ urea if AAA/dissection has compromised renal arteries
  3. LFTs
  4. CRP
  5. Serum glucose - may be elevated in pancreatitis (lack of insulin)
  6. Serum Amylase - ↑ in acute pancreatitis
  7. Serum Lipase - ↑ in acute pancreatitis
  8. ABG + lactate - lactic acidosis can occur is bowel ischaemia due to an embolism e.g. mesenteric artery
  9. Pregnancy test in women (always!)
  10. Urine dipstick - UTI (haematuria), pyelonephritis (↑ leucocytes)
  11. Erect CXR - GI perf can cause gas to build under diaphragm
  12. Supine AXR
42
Q

What is a hernia?

A

A condition in which part of an organ is displaced/protrudes through the wall of the cavity containing it. E.g. Inguinal hernia, femoral hernia, umbilical hernia, hiatus hernia, diaphragmatic hernia

43
Q

Red Flags for Colon Cancer?

A
  1. Change in bowel habit in person >60yrs
  2. Unexplained weight loss
  3. Rectal or abdominal mass
  4. Rectal bleeding
  5. Anaemia
  6. Family Hx of bowel cancer
44
Q

Elderly patients with acute abdomen tend to present early in the course of their illness - true or false?

A

False Elderly patients tend to present later

45
Q

Signs typical of acute appendicitis?

A
  1. Raised temp to 37.3 - 38.3
  2. Loss of appetite - associated with nausea and vomiting
  3. Dull pain near the navel, upper or lower abdomen, that becomes sharp as you move to the RIF
46
Q

What is the cut off in cm for a Toxic Megacolon?

A

6cm

47
Q

In what groups of people does acute abdomen present atypically?

A

1) Elderly
2) Immunocompromised
3) Pregnancy

48
Q

What are the common patterns of referred pain for 1) perforacted ulcer, 2) pyelonephritis, renal or ureteral colic?

A
49
Q

What are the common patterns of referred pain for 1) Cholecystitis, 2) Pancreatitis 3) Appendicitis?

A
50
Q

A patient with abdo pain who is moving around unable to find a comfortable position is typical of what type of pain?

A

Renal Colic

51
Q

A patient with abdo pain who is still and reluctant to move is typical of what condition?

A

Peritonitis

52
Q

What is Cullen’s Sign and what does it indicate?

A

Cullen’s Sign = superficial bruising around umbilicus

  1. Acute pancreatitis which is bleeding into abdomen
  2. Aortic rupture
  3. Ruptured ectopic pregnancy
53
Q

What is Grey-Turner’s Sign and what does it indicate?

A

Grey-Turner’s Sign = bruising of the flanks

  1. Acute pancreatitis which is bleeding into retropertoneum
  2. Aortic rupture
  3. Ruptured ectopic pregnancy
54
Q

What is a Hartmann’s Procedure?

A
  • Pathology is in descending, sigmoid or rectum
  • Surgeon closes distal resection margin, leaving rectal stump
  • Proximal resection margin is brought through anterior abdominal wall to form an end colostomy
  • This surgery can be reversed at a later date

Medicine year 3 ANNA (30 decks)

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