Chapter 12, part 4 Flashcards by Deborah Karp

Familial adenomatous polyposis

Development of numerous colonic polyps >100

Autosomal dominant mutation of APC tumor suppressor gene located on chromosome 5q

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Gardner syndrome

Polyposis and osteomas, sarcomas, and epidermoid inclusion cysts

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Turcot syndrome

Polyposis and brain tumors

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When to screen for familial adenomatous polyposis

Starting for high risk ppl at 10 yo
If + for mutation: total proctocolectomy and permanent end ileostomy, total proctocolectomy with IPAA or total abdominal colectomy and ileorectal anastamosis

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What is the MCC of hereditary colon cancer?

Hereditary nonpolyposis colorectal cancer or Lynch syndrome

Defects in DNA mismatch repair genes

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When does hereditary nonpolyposis colorectal cancer (Lynch syndrome) usually become colon CA?

Around 44 yo

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What is recommended for women with hereditary nonpolyposis colorectal cancer (Lynch syndrome)?

Prophylactic total ab hysterectomy and bilateral salpingo-oophorectomy

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Amsterdam criteria

Three affected relatives, with 2 consecutive generations, and with at least 1 family member diagnosed before age 50
If identified via criteria, need colonoscopy q2yrs starting between 20-35, and then yearly after 35

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Multiple polyposis coli or juvenile polyposis coli

Autosomal dominant syndrome associated with SMAD4 gene

Hamartomas and bleeding

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Dx and tx of multiple polyposis coli or juvenile polyposis coli

Upper and lower endoscopy starting at 15-25

Endoscopic polypectomy

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Peutz-Jeghers syndrome

Autosomal dominant dz associated with mutations in STK11

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Presentation of Peutz-Jeghers syndrome

Multiple GI hamartomatous polyps and hyperpigmentation of lips, buccal mucosa, and digits

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Dx of Peutz-Jeghers syndrome

Endoscopy with polypectomy as indicated q2yrs

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Screening for cancer

Colonoscopy starting at 50 and q5-10 yrs: for no risk
Moderate risk (CA in 1st degree relative >60): start at 40 and do q5-10yrs
High risk (sigmoidoscopy): FAP-10 yo and yearly until 40
High risk-Lynch syndrome- 20 yo and q2yrs until 35, then yearly
High risk- IBD- 10 yr after start of colitis, then q1-2y

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Dx and staging of CA

Start with colonoscopy and then do radiographic exam to check for mets
MC site of mets= liver (need to do CT of abdomen)
CEA (food for surveillance after curative therapy)
PET
Cancers in mid and upper rectum- rigid proctoscopy

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How to treat a resectable tumor without mets in colon cancer

Segmental colectomy
Margins greater than or equal to 5 cm
Need minimum of 12 lymph nodes in specimen

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How to treat tumors adherent to adjacent organs in colon cancer

Resected en bloc

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What is offered to any pt with evidence of spread in colon cancer?

Chemo

5-FU or leucovorin with either oxaliplatin or irinotecan

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How to treat locally advanced rectal cancer

Neoadjuvant chemo

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How to treat total mesorectal excision in rectal cancer

Complete removal of rectal tumor and regional lymph nodes

2 cm distal margin

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How to treat tumor in mid/upper rectum

Low anterior resection (LAR) with colorectal anastamosis

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How to treat preexisting fecal incontinence or with very low rectal cancer

Abdominoperineal resection (APR)

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How to treat metastatic dz

Asymptomatic primary colon tumor and unresectable metastatic disease: chemo

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What is considered lower GI bleeding?

Bleeding distal to ligament of Treitz

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What is the MCC of lower GI bleeding? | 2nd MCC?

1/2 occur from diverticular dz | Arteriovenous malformations

Dx of lower GI bleed

Find the bleed NG tube lavage to r/o upper GI bleed Proctoscopy to r/o anorectal cause Need large-bore IV access and fluid resuscitation

Labs/rads for lower GI bleed

CBC and coag studies Type and cross Colonoscopy would not be good if a ton of blood Could do radionuclide scan and inject tagged RBCs (but need to be actively bleeding) Selective visceral angiography- better info and can offer therapeutic options

Tx of lower GI bleed

Surgery may be needed if ongoing transfusion requirement (6 L over 24 hrs)

What cancers are MC found in the appendix?

Carcinoid tumors

When is carcinoid syndrome caused?

When carcinoid tumors get to the base of the appendix

Presentation of carcinoid syndrome

Cutaneous flushing Bronchospasm Secretory diarrhea Cardiac valvular lesions

Mucocele

Accumulation of mucin within the lumen d/t proximal obstruction

Mucinous crystadenomas

Benign lesions associated with dilated mucin filled appendix and adenomatous epithelium

Mucinous crystadenocarcinoma

Malignant Can cause pseudomyxoma peritonei- peritoneal cancer becomes seeded by cancer cells that continue to secrete mucin- treat with surgical debulking

Abscess or fistula-in-ano

Obstruction of anal glands can lead to infection and if they track down toward anal orifice, perianal abscess MC type of anorectal abscess

Intersphincteric abscess

Infection can remain in intersphincteric plane

Ischiorectal abscess

Can penetrate laterally through the external sphincter

Supralevator abscess

Can track superiorly above levator ani

Horseshoes

Infection starts in postnatal space and spread bilaterally

What are 50% of anal abascesses?

Fistula in ano

How can the general course of tract of fistulas in ano be predicted?

On the basis of site of external opening using Goodsall's rule

Presentation of abscess or fistula in ano

Anal pain Swelling Fever Tender mass

Dx of abscess or fistula in ano

CT or MRI

Tx of abscess or fistula in ano

Incised and drained External opening should be made on the anal side of the abscess Intershpincteric- drain into anal canal via sphincterotomy Postnatal- incising between the coccyx and anus Horseshoe- Hanley technique

Tx of fistula in ano

If identified with abscess: seton should be placed Then staged procedure 8 wks later Intersphincteric and superficial transphincteric fistulas: open and close by secondary intent= fistulotomy

Types of hemorrhoids

Right anterior Right posterior Left lateral

Internal hemorrhoids

Above dentate line- BRB and prolapse

1st degree internal hemorrhoids

Bulging within lumen without prolapse

2nd degree internal hemorrhoids

Prolapse with straining but reduces

3rd degree internal hemorrhoids

Prolapse that reduces only with digital manipulation

4th degree internal hemorrhoids

Irreducible prolapse

External hemorrhoids

Below dentate line | Acute discomfort

Dx of hemorrhoids

Anoscopy

Tx of hemorrhoids

1st and 2nd: nonsurgical therapy: rubber band ligation Symptomatic 2nd, 3rd, and 4th: surgical tx Hemorrhoidectomy: prone jackknife position

Pilonidal dz

Episodic infection of subcutaneous tissues of the superior gluteal cleft Subcutaneous abscess that drains spontaneously or requires surgical drainage

What leads to recurring infections in pilonidal dz

Complex tunneling sinuses

Tx of pilonidal dz

Need surgical resection MIdline excision with/without primary closure of the defect Marsupialization: skin at wound edge can be sutured to the base to eliminate overhang and make the wound smaller

Anal fissue

Linear tears in the andoderm distal to the dentate line

Where do most anal fissures occur?

Posterior midline

Presentation of anal fissure

Constipation or intense pain with defecation is a common complaint Chronic fissure is classically associated with heaped up epidermis (sentinel tag), which is a marker of chronic inflammation

Tx of anal fissue

Conservative- fiber supplements and sitz bath | Refractory cases: lateral internal sphincterotomy

When is rectal prolapse most common?

Women > 50 yo

Presentation of rectal prolapse

Extrusion of rectal mucosa from the anus when a pt bears down

Tx of rectal prolapse

Rectoplexy with or without resection of the redudant sigmoid colon Altemeir procedure- most common perineal approach