Casefiles 7: obesity, lower GIB, appendicitis, colon cancer

Question 1

disease attributed to obesity

Answer 1

hypertension, diabetes, coronary and hypertrophic heart disease, gallstones, GERD, sleep apnea, asthma, reactive pulmonary disease, osteoarthritis, lumbosacral disk disease, urinary incontinence, infertility, PCOS, and cancer

Question 2

recommended weight loss procedures

Answer 2

adjustable gastric band, sleeve gastrectomy, roux-en-Y gastric bypass, and duodenal switch procedure

Question 3

Roux-en-Y gastric bypass

Answer 3

Small proximal gastric pouch to Roux limb of jejunum

Question 4

Duodenal switch

Answer 4

Stomach reduction with division of duodenum at the pylorus. The distal small bowel is attached to the gastric tube, and the proximal small bowel is attached to the lower ileum

Question 5

All surgical candidates for weight reduction procedures must have ?

Answer 5

failed supervised weight-loss programs by diet, exercise, or medications, and fulfill minimum weight criteria that include BMI of 35 to 40 kg/m2 with comorbidity or BMI of greater than 40 kg/m2 without comorbidity.
must pass a psychological evaluation and be willing to comply with postoperative lifestyle changes and dietary restrictions, exercise, and follow-up programs

Question 6

What procedure will provide the best long-term weight reduction with minimal early and late long-term morbidity?

Answer 6

A small-pouch gastric bypass

Question 7

History of lower GIB patient

Answer 7

meds: NSAIDS, anti-platelet agents, and anticoagulants
determine whether the patient has had prior surgery for GI malignancies, history of prior abdominal aortic surgeries, and recent history of colonoscopies with polypectomies, as these circumstances can be associated with unique bleeding scenarios

Question 8

occult GIB is most commonly from

Answer 8

GI neoplasms, gastritis, and esophagitis

Question 9

angiodysplasia/AVM

Answer 9

a common and acquired degenerative vascular condition leading to the formation of small, dilated, thin-walled veins in the submucosa of the GI tract. It occurs most commonly in the cecum and ascending colon of individuals 60+ years old

Question 10

Approximately 50% of the patients with angiodysplasia have associated ?, and up to 25% of the patients have ?

Answer 10

cardiac diseases

aortic stenosis

Question 11

A patient who presents with GI bleeding and a previous abdominal aortic vascular reconstruction would require rapid assessment to rule out the possibility of ?, which can be assessed with either a ? or ?

Answer 11

an aorto-duodenal fistula
CT scan of the abdomen or upper GI endoscopy that includes direct visualization of the 3rd and 4th portions of the duodenum

Question 12

Melena (tarry stool) indicates ?; therefore, melena is generally encountered in patients with ?

Answer 12

degradation of hemoglobin by bacteria and this appearance is associated with intra-luminal contents remaining in the GI tract for more than 14 hours

upper GI bleeding that is not brisk

Question 13

The primary goals in the treatment of a patient with acute and continued lower GI bleeding are ? and then ?

Answer 13

maintaining hemodynamic stability with resuscitation and then localizing the bleeding site
but exploration of the abdomen should be avoided prior to precise localization of the bleeding site.

Question 14

? and ? are the two most commonly used initial diagnostic studies in patients with overt lower GI bleeding

Answer 14

CT angiography and colonoscopy

Question 15

? have evolved greatly during the past decade, and this has become the preferred treatment modality for lower GIB in some institutions

Answer 15

Visceral angiography and selective embolization techniques

Surgery is rarely needed for patients with acute lower GI bleeding

Question 16

mesenteric adenitis

Answer 16

An inflammatory condition occurring with a viral illness, resulting in painful LAD in the small bowel mesentery, and clinically “mimics” appendicitis. can be associated with RLQ pain and is more common in children

Question 17

Alvarado score for appendicitis

Answer 17

Migratory pain to RLQ (1)
Anorexia (1)
Nausea/or vomiting (1)
Tenderness in RLQ (2)
Rebound tenderness in RLQ (1)
Fever (temperature greater than 37.5°C or 99.5°F) (1)
White blood cell count greater than 10,000 (2)
Shift to the left in WBC (1)
TOTAL: 10

Question 18

Alvarado score interpretation

Answer 18

0 to 4: “low probability”
5 to 6: “compatible”
7 to 8: “probable” appendicitis
9 to 10: “highly probable.”

Question 19

CT is better for ? while US is more sensitive for ?

Answer 19

appendicitis

ovarian and other gynecologic processes

Question 20

Randomized controlled trials comparing appendectomy to antibiotics in patients with acute appendicitis showed that roughly ? of the patients can be successfully treated with antibiotics

Answer 20

2/3rds

Question 21

Most serrated adenomas or polyps are larger than ? and are found in the ?
why worrisome?

Answer 21

5 mm
right colon
high-risk lesions with approximately 15% of the lesions progress to become cancers

Question 22

APR: abdominal perineal resection

often applied when the patient has ?

Answer 22

resection of the rectum and anus thus leaving the patient with a permanent colostomy (open or laparoscopically)

low-lying invasive rectal cancer that is at the level of the levator and rectal sphincter muscles

Question 23

low anterior resection

done when the cancer is where ?

Answer 23

resection of the rectum and lower sigmoid colon
done when the cancer is above the levator muscles and the anal sphincters
preserves the patient’s continence and anal sphincter mechanisms

Question 24

The development and progression of CRCs follow what sequences?

Answer 24

the adenoma–carcinoma sequence (most common), de novo cancer sequence, serrated polyp to cancer sequence, and the dysplasia–carcinoma sequence

Question 25

The recent discovery of serrated polyps suggests that these are variants of hyperplastic polyps that carry the genetic signatures for CRC development, for example ?

Answer 25

BRAF mutation, KRAS mutation, and microsatellite instability

Question 26

Complaints reported by patients with left-sided tumors include ? whereas patients with right-sided colon cancers tend to present more often with ?

Answer 26

left: change in stool caliber and diarrhea
right: anemia

Question 27

if cancer within the polyp does not penetrate the submucosa, ?is considered sufficient treatment
However, with submucosa penetration by the cancer, the spread of tumor to the regional LNs become possible, and treatment should include ?

Answer 27

polypectomy with clear margins

resection of the involved area of the colon/rectum

Question 28

For patients with colon cancers identified by colonoscopy and confirmed by biopsy, ? should be obtained to define the local extent of disease as well to look for metastases
most common site of metastasis?

Answer 28

CT scans of the abdomen/pelvis and chest x-rays

liver

Question 29

invansive colon cancer treatment begins with resection, during which strong efforts should be made to harvest ? so that the regional disease would be appropriately staged

Answer 29

more than 12 lymph nodes

Question 30

The two most common CRC adjuvant systemic therapy regimens currently used are ?

Answer 30

FOLFOX4 (oxaliplatin, 5-fluorouracil, and leucovorin)
FOLFIRI (irinotecan, 5-fluorouracil, leucovorin).
The duration of adjuvant therapy is generally 6 months or longer

Question 31

why do invasive rectal cancers have a much greater risk of local recurrences following treatment ?
also more likely to metastasis to ?

Answer 31

the rectum differs from the colon in that it is extraperitoneal in location, it is not covered by the visceral peritoneum, and it is in close proximity to neighboring structures
mets to lung via IVC (vs to liver via portal venous system from colon cancer)

Question 32

Metastases are classified as synchronous (identified the same time as the primary tumor) or ?

Answer 32

metachronous (identified after the primary had been treated)

Prognostically, the patients with metachronous metastases do better than patients with synchronous metastases

Question 33

What is the prophylactic surgery recommend for FAP patients prior to the age of 20 to 25 years?

Answer 33

Total proctocolectomy

Question 34

Chemoprevention of adenomatous polyps has been found effective with long-term intake of ?

Answer 34

sulindac or celcoxib (COX-2 inhibitors).

Intake is also associated with the regression of small polyps.

Question 35

CRC screening Average-Risk Individuals Age 50 or Older (~60%-65% of US population)

Answer 35

annual FOBT
flex sig every 5 years
Colonoscopy every 10 years or double contrast barium enema every 5 years
For patients who cannot tolerate colonoscopy, CT colography can be applied

Question 36

CRC screening Moderate-Risk Individuals (~25% of US population)

Answer 36

Based on personal history: if 3 to 10 adenomatous polyps, one polyp greater than 1 cm, or polyps with high-grade dysplasia needs clearance of all polyps and then repeat colonoscopy in 3 years
Based on family history: if first-degree relative with CRC diagnosed before age 60 should have first colonoscopy at age 40 or 10 years before the youngest diagnosed family member; the patients need surveillance colonoscopy every 5 years

Question 37

CRC screening for High-Risk Individuals (FAP, HNPCC, or IBD)*(6%-8% of US population)

Answer 37

FAP patients need sigmoidoscopy or colonoscopy starting at age 10 to 12 years and continued until proctocolectomy
HNPCC patients need colonoscopy every 1 to 2 years beginning at age 20 to 25 or 10 years before the youngest family member’s age of CRC diagnosis
IBD patients need colonoscopy with biopsies every 1 to 2 years starting at 8 years after diagnosis of pancolitis or 12 to 15 years after diagnosis of left-sided colitis

Question 38

symptoms in Crohn disease are likely to be from ?

Answer 38

inflammation, fibrosis, penetration (fistulization), or combo
Inflammatory obstructions and certain fistulizing diseases are more likely to resolve with medical treatment regimens, whereas strictures that are primarily fibrotic in nature are less likely to respond to medications and may need operative treatment

Question 39

Crohn disease can be ?, ?, or both

Answer 39

intra-abdominal (stricture, penetration, or inflammation)

perianal (anal strictures, fistula-in-ano, or perirectal abscesses)

Question 40

Step-up/Top-down approach for Crohn disease

Answer 40

5-ASA/Sulfasalazine (First-line) Biologic (First-line) Corticosteroids AZA/MTX Azathioprine (AZA)/ methotrexate (MTX) Combination therapy Biologic (Last-line) Corticosteroids (Last-line)

Question 41

Strictureplasty

Answer 41

strictured segment of the intestine is opened longitudinally and then closed transversely, thus increasing the diameter of the bowel segment without having to remove that segment

Question 42

nonspecific symptoms of Crohn disease

Answer 42

chronic abdominal pain, postprandial crampy pain, weight loss, and fever

Question 43

bowel involvement in Crohn disease

Answer 43

Ileum and right colon: 35% to 50% 
ileum: 30% to 35%
colon:25% to 35% 
stomach and duodenal: 0.5% to 4% 
In 10% of patients with Crohn disease, anorectal disease is the initial manifestation of their disease

Question 44

Vienna Classification of Crohn disease

Answer 44

takes into account the age of diagnosis, anatomic location of disease, and disease type (inflammatory, fibrostenosis, or penetrating)

Question 45

first-line therapy for mild-to-moderate Crohn disease is usually either antimicrobial or anti-inflammatory modalities including ?

Answer 45

metronidazole or ciprofloxacin
Long-term metronidazole treatment is poorly tolerated because of its associated nausea, metallic taste, disulfiram-like reactions, and peripheral neuropathies

Question 46

why is long-term metronidazole treatment is poorly tolerated ?

Answer 46

because of its associated nausea, metallic taste, disulfiram-like reactions, and peripheral neuropathies

Question 47

Aminosalicylates (5-ASA) are effective in maintenance therapy and in the treatment of mild active disease. Limitations include ?

Answer 47

GI tract and systemic side effects, and hypersensitivity reactions
Sperm abnormalities, folate malabsorption, nausea, dyspepsia, headache

Question 48

Mild to moderate Crohn disease

Answer 48

Ambulatory, eating and drinking without dehydration, toxicity, abdominal tenderness, painful mass, obstruction or greater than 10% weight loss

Question 49

Moderate to severe Crohn disease

Answer 49

Failure of response to mild medical therapies or fevers, significant weight loss, abdominal pain or tenderness, intermittent nausea and vomiting (without obstructive findings) or significant anemia

Question 50

Severe to fulminant Crohn disease

Answer 50

Persistent symptoms despite use of corticosteroids as outpatient or high fevers, persistent vomiting, evidence of intestinal obstruction, rebound tenderness, cachexia, evidence of abscess

Question 51

Crohn therapy

Answer 51

http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=130869375&gbosContainerID=92&gbosid=246089

Question 52

corticosteroids including ? for moderate to severe disease

Answer 52

Budesonide is a newer corticosteroid agent that is being utilized as it is metabolized more rapidly than prednisone and is associated with fewer side effects

Question 53

In patients with moderate to severe disease in remission after a course of corticosteroids treatment, immunomodulators such as ? are sometimes prescribed for maintenance therapy

Answer 53

Azathioprine (AZT) and 6-mercaptopurine (6-MP)
SEs: bone marrow suppression, nausea, fever, rash, hepatitis, and pancreatitis
otherwise MTX
SEs: nausea, headache, stomatitis, bone marrow suppression, hepatitis, and pneumonitis

Question 54

another potent immunosuppressive medication that often produces disease improvements in patients with severe fistulizing diseases
largely replaced by ?

Answer 54

Cyclosporine A (CSA)
SEs: hypertension, hyperesthesias, tremor, and nephrotoxicity

infliximab (a chimeric monoclonal antibody targeting the TNF receptor)
SEs: opportunistic infections and B-cell lymphoma development.

Question 55

most common reasons that surgeons are consulted for Crohn disease patients

Answer 55

medical treatment failures, medical treatment side effects affect quality of life, to help treat disease complications including obstruction, fistulization, and neoplastic transformation (i.e. adenocarcinoma of small bowel)

Question 56

Surgical treatment options for Crohn disease include ?

Answer 56

intestinal resection, strictureplasty, intestinal bypass, endoscopic dilatation

Question 57

When considering intestinal resections, the initial operations should be conservative, why?

Answer 57

50% of patients will eventually require a second operation
One potential long-term complication associated with reoperative treatments for patients with Crohn disease is loss of bowel length to maintain normal nutritional functions (short bowel syndrome); reported in less than 1% of patients with Crohn disease.

Question 58

the use of ? and/or ? have been linked to disease flare-ups and recurrences; therefore, the patient should be counseled regarding these risks

Answer 58

NSAIDs and/or tobacco smoking

Question 59

Which medical treatment has been shown to be most effective in reducing recurrences of Crohn disease following surgical treatments?

Answer 59

anti-TNF therapy

Question 60

lethal triad of burns

Answer 60

hypothermia, acidosis, coagulopathy