Bowel cancer

Question 1

Risk factors for bowel cancer

Answer 1

Family history 
Familial adenomatous polyposis (FAP) 
Hereditary nonpolyposis colorectal cancer (HNPCC), also known as Lynch syndrome
Inflammatory bowel disease 
Increased age
Diet (high in red and processed meat and low in fibre) 
Obesity and sedentary lifestyle
Smoking
Alcohol

Question 2

What is FAP

Answer 2

Autosomal dominant condition involving malfunctioning of the tumour suppressor genes called adenomatous polyposis coli (APC).

It results in many polyps (adenomas) developing along the large intestine.

Question 3

Procedure for patients with FAP to prevent bowel cancer

Answer 3

Patients have their entire large intestine removed prophylactically to prevent the development of bowel cancer (panproctocolectomy).

Question 4

What is HPNCC/Lynch syndrome

Answer 4

Autosomal dominant condition that results from mutations in DNA mismatch repair (MMR) genes.

Patients are at a higher risk of a number of cancers, but particularly colorectal cancer.

Unlikely FAP, it does not cause adenomas and tumours develop in isolation.

Question 5

Red flags - bowel cancer

Answer 5

Change in bowel habit (usually to more loose and frequent stools)
Unexplained weight loss
Rectal bleeding
Unexplained abdominal pain
Iron deficiency anaemia (microcytic anaemia with low ferritin)
Abdominal or rectal mass on examination

Question 6

When do NICE advise two week wait referral for colorectal cancer

Answer 6

Over 40 years with abdominal pain and unexplained weight loss
Over 50 years with unexplained rectal bleeding
Over 60 years with a change in bowel habit or iron deficiency anaemia

Question 7

Why is unexplained IDA without any other explanation an indication for two week wait

Answer 7

It is an indication for a “two week wait” cancer referral for colonoscopy and gastroscopy (“top and tail”) for GI malignancy.

This is because GI malignancies such as bowel cancer can cause microscopic bleeding (not visible in bowel movements) that eventually lead to iron deficiency anaemia.

Question 8

What is the FIT test

Answer 8

Faecal immunochemical tests (FIT) look very specifically for the amount of human haemoglobin in the stool

FIT tests can be used as a test in general practice to help assess for bowel cancer in specific patients who do not meet the criteria for a two week wait referral

Question 9

Age for bowel cancer screening

Answer 9

People aged 60 – 74 years are sent a home FIT test to do every 2 years. If the results come back positive they are sent for a colonoscopy.

Question 10

Gold standard ix for bowel cancer

Answer 10

Colonoscopy is the gold standard investigation. It involves an endoscopy to visualise the entire large bowel.

Any suspicious lesions can be biopsied to get a histological diagnosis, or tattoo in preparation for surgery.

Question 11

IX for staging bowel cancer

Answer 11

Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers.

Question 12

Use of CEA in bowel cancer

Answer 12

Carcinoembryonic antigen (CEA) is a tumour marker blood test for bowel cancer. This is not helpful in screening, but it may be used for predicting relapse in patients previously treated for bowel cancer.

Question 13

Classification of bowel cancer

Answer 13

Dukes’ classification now replaced by TNM

Question 14

General options for managing bowel cancer

Answer 14

Surgical resection
Chemotherapy
Radiotherapy
Palliative care

Question 15

What is a right hemicolectomy

Answer 15

Involves removal of the caecum, ascending and proximal transverse colon

Question 16

What is a left hemicolectomy

Answer 16

involves removal of the distal transverse and descending colon

Question 17

What is a high anterior resection

Answer 17

involves removing the sigmoid colon (may be called a sigmoid colectomy).

Question 18

What is a low anterior resection

Answer 18

involves removing the sigmoid colon and upper rectum but sparing the lower rectum and anus.

Question 19

What is an abdomino-perineal resection

Answer 19

involves removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy

Question 20

What is a hartmann’s procedure

Answer 20

Is usually an emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date

Question 21

Common indications for Hartmann’s procedure

Answer 21

Acute obstruction by a tumour, or significant diverticular disease.

Question 22

Complications of bowel cancer

Answer 22

Bleeding, infection and pain
Damage to nerves, bladder, ureter or bowel
Post-operative ileus
Laparoscopic surgery converted during the operation to open surgery (laparotomy)
Leakage or failure of the anastomosis
Intra-abdominal adhesions

Question 23

What is low anterior resection syndrome

Answer 23

Low anterior resection syndrome may occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectum

Question 24

Symptoms of low anterior resection syndrome

Answer 24

Urgency and frequency of bowel movements
Faecal incontinence
Difficulty controlling flatulence

Question 25

Follow-up post surgery for bowel cancer

Answer 25

Patients will be followed up for a period of time (e.g., 3 years) following curative surgery. This includes:

Serum carcinoembryonic antigen (CEA)
CT thorax, abdomen and pelvis

Question 26

Risk factors for gastric cancer

Answer 26

H pylori 
Atrophic gastritis 
Diet 
Smoking 
Blood group

Question 27

Features of gastric cancer

Answer 27

Abdominal pain 
Weight loss and anorexia 
Nausea and vomiting 
Dysphagia 
Over GI bleeding

Question 28

Lymphatic spread features of gastric cancer

Answer 28

left supraclavicular lymph node (Virchow's node)
periumbilical nodule (Sister Mary Joseph's node)

Question 29

diagnosis of gastric cancer

Answer 29

endoscopy with biopsy - signet ring cells

Question 30

Mx of gastric cancer

Answer 30

surgical options depend on the extent and side but include:
endoscopic mucosal resection
partial gastrectomy
total gastrectomy

chemotherapy

Question 31

Presentation of perianal abscess

Answer 31

Pain around anus, worse on sitting

Pus-like discharge from the anus

Systemic features of abscess

Question 32

Causes of perianal abscess

Answer 32

gut flora such as E coli

Staph aureus

Question 33

Gold standard imaging ix for perianal abscess

Answer 33

MRI

Question 34

Conditions associated with perianal abscess

Answer 34

Underlying IBD(Crohn’s)
Diabetes mellitus is a risk factor
Underlying malignancy

Question 35

Treatment of perianal abscess

Answer 35

Incision and drainage under local anaesthetic

Abx if systemic upset