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Oral Boards > Colon > Flashcards

Colon Flashcards

1
Q

Failure of Abx therapy for acute diverticulitis after this period of time

A

72 hours

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2
Q

Colovesicular fistula operative management

A

Small fistulae are just pinched off, larger required 2 layered closure. Leave foley for 7 days. Cystogram prior to Foley removal.

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3
Q

Immunosuppressed considerations for acute diverticulitis

A

May need colectomy during initial hospitalization due to higher risk of complications without resection.

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4
Q

Necessary before ileostomy closure

A

Gastrograffin or hypaque enema.

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5
Q

Key operative step when operating on either cecal or sigmoid volvulus

A

Divide the mesentery before detorsing to prevent cytokines and bacteria from going systemically.

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6
Q

Older adults, most common cause of LGIB

A
  1. Diverticulosis 2. Angiodysplasia 3. Neoplasm 4. Inflammatory bowel disease. 5. Ischemic colitis Also consider hemorrhoids and fissure
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7
Q

Children and younger adults, most common cause of LGIB

A
  1. Inflammatory bowel disease. 2. Meckel’s 3. Polyps Also consider hemorrhoids and fissure
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8
Q

Rate of spontaneous cessation of LGIB

A

80%

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9
Q

REasons NOT to do an ileorectal anastomosis, but rather an end ileostomy.

A
  1. HD unstable 2. IBD of terminal ileum or rectum 3. Poor continence pre op 4. Malnutrition
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10
Q

Percent of patients with CRC presenting with synchronous liver lesions

A

(within 6 months of primary diagnosis) 15%

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11
Q

Percent of patient with CRC presenting with metachronous liver lesions

A

(greater than 6 months after primary diagnosis) 20%

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12
Q

timing of liver resection for CRC mets after admin of FOLFOX and avastin

A

6 weeks off avastin and 4 weeks from chemo

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13
Q

5 year survival after resection of single hepatic liver met for CRC

A

50%

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14
Q

Large bowel obstruction complaining of RLQ abdominal pain

A

impending rupture of cecum since this is most at risk for mural vessel collapse and ischemia due to largest diameter.

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15
Q

Work up for colon cancer

A
  1. CT chest, abdomen and pelvis with IV/PO contrast
  2. CEA
  3. Full colonoscopy
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16
Q

Ways to possibly evaluate rest of colon before resection in large bowel obstruction

A
  1. Barium enema
  2. CT enterography
  3. On table colonoscopy
  4. Palpation of colon intraop
  5. 6 month post op colonoscopy
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17
Q

Vessels needed to divide and resect for adequate LN harvest for splenic flexure colon CA resection

A
  1. Left branch of middle colic
  2. left colic
  3. IMV

(need 12 LNs)

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18
Q

Indications for adjuvant therapy in stage 2 colon cancer

A
  1. LVI
  2. Perineural invasion
  3. Lack of microsatellite instablity
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19
Q

Surveillance post resection for colon cancer

A
  1. CT chest/A/P - annual for 3 years
  2. Colonoscopy - at 3 years
  3. CEA - every 3 months for 3 years
  4. H&P - every 6 months for 5 years
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20
Q

Anastomotic leak rate after sigmoid colon resection

A

5%

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21
Q

End loop stoma for anastomotic leak after right colectomy (patient with severe sepsis)

A

If patient stable, can resect and re-do anastomosis

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22
Q

Algorithms for the following:

  1. right sided leak - stable patient
  2. right sided leak - unstable patient
  3. left sided leak - stable patient - small leak
  4. left sided leak - unstable patient - large leak
A
  1. resect anastomosis and redo
  2. resect anastomosis and to end-loop (end ileostomy and take the antimesenteric corner from the colon and mature it.
  3. primary repair, omental butress, loop ileostomy, endoscopy +/- clipping
  4. Staple distal end, bring up end colostomy
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23
Q

Infectious causes of large bowel obstruction

A
  1. yersinia
  2. Ascaris
  3. Taneia
  4. TB
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24
Q

Extent of extended right colectomy in patient with transverse colon mass

A

Ascending branch of left colic

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25
Q

INdications for colectomy in recurrent uncomplicated diverticulitis

A
  1. Recurrent attackes crescendoing
  2. Stricture
  3. Demanding job that makes uncomplicated attack unsafe or inconvenient.

(rate of complication for resection of uncomplicated disease < 5%)

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26
Q

differential for abdominal pain and bloody BM

A
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27
Q

If surgery and resection for ischemic colitis after aortic surgery, should primary anastomosis be attemptoed

A

No, risk of graft contamination if leaks.

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28
Q

Ulcerative coliits - severe colitis (Truelove and Witts)

A
  1. > 6 bloody BMs per day and one of following
  2. Temp > 37.5
  3. Pulse > 90
  4. Hb < 10.5
  5. ESR > 30
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29
Q

Complications of IPAA

A
  1. Frequent BMs and leaking
  2. Pouchitis
  3. Pouch failure
  4. Infertility
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30
Q

Differential for RLQ pain

A
  1. Appendicitis
  2. Crohn’s
  3. Infecitous coliits
  4. Typhlitis
  5. Tubo-ovarian abscess
  6. Ovarian torsion
  7. Ectopic
  8. UTI
  9. Nephrolithiasis
  10. Meckel’s diverticulitis
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31
Q

3 categories of disease behavior for Crohn’s

A
  1. Inflammatory
  2. Stricuring
  3. Fistulizing
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32
Q

work up if concerned for Crohn’s

A
  1. MR enterography
  2. EGD w biopsy
  3. Colonoscopy (after inflammation resolved) - sigmoidoscopy for biopsy if need tissue
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33
Q

Induction and maintenance for mild to moderate Crohns and maintenance for moderate to severe

A

Induction

  1. Budesonide - mild
  2. Prednisone - moderate

Maintenance

  1. 5-ASA or mesalamine
  2. Moderate to severe-Anti TNF antibodies or 6-MP or azathioprine
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34
Q

Indications for surgery in Crohns

A
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35
Q

Risk of additional surgery necessary in Crohn’s diasease at 10 years?

A

50%

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36
Q

Breakdown of intestinal NETs

A
  1. Small bowel 50%
  2. Rectum 20%
  3. Appendix 20%
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37
Q

Breakdown of appendiceal tumors

A
  1. ?
  2. NET 30%
  3. Adenocarcinoma 30% (50% of which are mucinous)
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38
Q

Indications for further work up if appendiceal NET found

A
  1. size > 2 cm
  2. high grade (ki 67 > 20 or mitoses > 20)

(modalities include chromogranin A, Dotatate scan, colonoscopy and possibly EGD)

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39
Q

Difference between appendiceal NET and appendiceal adenocarcinoma

A

Appendectomy alone sometime appropriate for NET, but adenocarcinoma of appendix always requires right hemicolectomy

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40
Q

Unknown mass < 2 cm involving base of appendix

A

Perform cecectomy and appendectomy with en bloc resection of mesoappendix.

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41
Q

Chemoradiation regimen for locally advanced rectal cancer

A

5000 cGy over 25 fractions (5 weeks M-F) w oral capcitibine or infusional 5-FU

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42
Q

When is surgery scheduled for proctectomy after neoadjuvant chemoradiation

A

8-12 weeks (but only after repeat endoscopy and MRI)

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43
Q

Pre op discussion points for proctectomy

A
  1. Possible need for stoma
  2. LAR syndrome (frequent stooling)
  3. Sexual and bladder dysfunction
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44
Q

Fascia anterior to rectum in males

A

Denonvilliers fascia

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45
Q

Fascia posterior to rectum

A

Waldeyer’s fascia (describe dividing the avascular plane between the parietal and visceral endopelvic fascia)

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46
Q

Desired margin for high rectal cancers

A

5 cm

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47
Q

Margin needed for mid to low rectal cancers

A

ideally 2 cm, but even 1 cm if patient received neoadjuvant chemoradiation in okay.

48
Q

Anastomotic leak rate for low pelvic anastomosis

A

15%

49
Q

Surveillance for rectal cancer

A
  1. CEA every 3 months for 2 years, and 6 months for 3 years after with H&P and rectal exam
  2. CT C/A/P annually for 3 years
  3. Colonoscopy at 1 year and at 3 years
50
Q

STaging for anal cancer

A
51
Q

NIgro protocol for anal cancer (radiation and chemotherapy)

A

45 Gy administered over 25 fractions (5 weeks)

5FU (or capcitibine) on days 1-4, 29-32 and mitomycin c on days 1 and 29.

52
Q

Systemic treatment for metastatic

A

5-FU and cisplatin

53
Q

Treatment for T1 anal margin cancers

A

Wide local excision with 1 cm margin (re-excision if positive margin) or Nigro protocol if anatomically not possible.

54
Q

Response of anal cancer to Nigro protocol can continue for up to..

A

26 weeks

55
Q

Treatment for anal cancer still present after Nigro protocol and appropriate observation

A

APR (+/- ingiunal node dissection if tumor present in nodes)

56
Q

Post chemo survellance for anal cancer

A

Essentially same as CRC

H&P and exam every 3 months for 2 years and 6 months for additional 3 years; with anoscopy and acetic acid testing

CT C/A/P for 3 years

57
Q

Areas of peri-anal/rectal abscesses

A
  1. Perianal
  2. Intersphincteric
  3. Ischiorectal
  4. Supralevator
58
Q

Work up for GI neuroendocrine tumors

A
  1. CT C/A/P with IV contrast
  2. Biochemical markers as appropriate
  3. Gallium dotatate PET scan
  4. Colonoscopy for colon NET, EGD/EUS for gastric or duodenal NET, Endorectal U/S for rectal NET, capsule endoscopy for small bowel NET.
59
Q

Treatement for rectal NET

A
  1. Make sure to fully evaluate colon with colonoscopy and then CT scans and gallium dotatate scan
  2. Lesions < 1 cm - endoscopic resection with close surveillance
  3. Lesions < 2 cm and T1 lesions - transanal excision
  4. Lesions > 2 cm, T2, dor LN involvement - LAR or APR
60
Q

Duration of therapy for adjuvant chemotharapy for high risk stage II or stage III colon cancer

A

Multidisciplinary conference

3-6 months of Cape-OX or FOLFOX

61
Q

Numbers of new colon cancer diagnosed per year (rectal cancer? )

A

100k new colon cancer diagnoses per year

44 k new rectal cancer diagnoses per year.

62
Q

Indications for adjuvant chemotherapy for colon cancer

A
  1. All stage III (FOLFOX or CAPEOX)
  2. Stage II with high risk features (FOLFOX or CAPEOX)
  3. Stage II with Microsatellite stable (MSS) or proficient MMR can be observed or capecitibine or 5FU/leucovorin

(stage II with MSI-H and stage I should not get adjuvant therapy)

63
Q

Lesion requirements for transanal excision of rectal cancer

A
  1. T1
  2. < 3 cm
  3. < 30% of circumference
  4. < 8 cm from anal verge
  5. No PNI or LVI
64
Q
A
65
Q

Rate of local recurrence for rectal cancer

A

German, Dutch, and swedish rectal cancer studies

With neoadjuvant therapy (radiation or chemoradiation) ranges from 2-11% local recurrence.

66
Q

Work up for diagnosed anal or perianal cancer

A
  1. History and physical exam to include DRE, anoscopy, inguinal exam
  2. CT C/A/P
  3. PET scan
  4. HIV testing
  5. Gynecologic exam with cerivcal screening if female.
67
Q

What defines stage III anal cancer

A

Any N or T4 (invading bladder, vagina, urethra)

68
Q

HPV subtypes with anal cancer

A

16, 18

69
Q

Treatement for AIN

A

Imiquimod or topical 5-FU (HPV immunization also likely preventative)

70
Q

Superficially invasive anal cancer treatment

A

Local excision (with biopsy) if < 3 mm invasion of basement membrane and < 7 mm horitzontal spread

71
Q
A
72
Q

Excision of perianal cancer is acceptable if

A

(T1 (< 2 cm) or limited T2 lesion) that are well differentiated that do not involve sphincter

73
Q

Surveillance after treated anal or perianal cancer

A
  1. DRE, H&P every 6 months for 5 years
  2. Anoscopy every 6 months for 3 years
  3. CT C/A/P annually for 3 years
74
Q

Treatment for groin recurrence but good response to anal lesion

A

Groin dissection or chemoradiation to groin.

75
Q

Treatment for progressive or recurrent anal diasese

A

APR

76
Q

Indications for repeat colonoscopy in 5 years

A

Low risk adenoma or low risk sessile serrated polyp (< 1cm), less than or equal to 2 adenomatous polyps

77
Q

Indications for repeat colonoscopy in 3 years

A

Villou or tubulovillous adenoma

adenoma > 1 cm

betweeen 3-10 adenomatous or sessile polyps

High grade dysplasia

78
Q

Surveillance after removal of large polyp (lateral spreading lesion > 2 cm)

A

Repeat colonoscopy in 1 year (6 months of removed piecemeal)

79
Q

Colonoscopy indications in UC or Crohn’s colitis

A

8 years after diagnosis

Chromendoscopy with targeted biopsy

HD White light endoscopy with 4 quadrant biopsies every 10 cm

80
Q

Colonoscopy indications for greater than or equal to 1 first degree relative with CRC (or with advanced adenoma)

A

Colonoscopy at 40 or 10 years before diagnosis of relative, followed by repeat colonoscopy every 5 years

81
Q

Lynch syndrome screening highlights

A

Colonoscopy starting at 20 or 5 years before familial diagnosis, then repeat every 1-2 years

May be benefit for prophylactic BSO at some point

Screening MRCP starting at 50 for pancreatic cancer.

82
Q

FAP (with known APC positive) screening

A

annual colonoscopies starting age 15

EGDs starting age 20

thyroid U/S

83
Q

When is colectomy recommended for FAP, attenuated FAP, or mFAP

A

when polp burden such that can’t be evaluated or dysplasia present.

84
Q

Muir Torre syndrome is associated with colorectal cancer and this carcinoma (dominant or recessive)

A

Sebaceous gland tumors (dominant)

85
Q

Toxic megacoloin in Ulcerative Colitis is a diameter of the transverse colon greater than

A

6 cm

86
Q

Requirements for endoscopic surveillance after endoscopic surveillance after endoscopic excision of invasive colon cancer

A
  1. single specimen with invasive disease
  2. Polyp is successfully removed with favorable histology (Grade I or II and no evidence of LVI)
  3. Margins are clear (margin 2 mm or greater)
87
Q

Blood supply to colon after extended right colectomy

A

Marginal artery of Drummond.

88
Q

Most important prognostic indicator in GIST

A

mitotic index (> 5-50)

other incluse size > 5 cm, location outside of stomach, necrosis

89
Q

Most common cause of anorectal bleeding

A

hemorrhoids followed by fissure then ulcers

90
Q

5 year survival after complete resection of colorectal liver met

A

40%

91
Q

Indications for transanal resection of rectal cancer

A
  1. Within 8 cm of anal verge
  2. < 30% circumference
  3. T1 lesion
  4. Mobile, non fixed
  5. < 3 cm in size
92
Q

Indications for resection of colonic lipoma

A
  1. Size > 2 cm
  2. Bleeding
  3. Obstruction
93
Q

Indications for adjuvant chemotherapy in Stage II colon cancer

A
  1. Inadequate nodal harvest
  2. LVI
  3. PNI
    4.
94
Q

Total mesorectal excision stats

Improved survival (what to what)

Decreased local recurrence (what to what)

A
  1. 50% to 75%
  2. 30% to 5%
95
Q

Gardeners syndrome

A

abdominal wall and mesenteric desmoid

osteomas of mandible or skull

epidermoid cysts

96
Q

Turcot’s syndrome

A

Central nervous system tumors

GI polyposis

Colorectal cancer

97
Q

HPV types in benign condyloma acuminata (2) and anal SCC (2)

A

Benign 6 and 11

SCC 16, 18

98
Q

Excision margin if high grade intraepithelial SCC is resected

A

high grade 6 mm

(after failure of topical therapy - imiquimod, topical 5FU,

99
Q

GIST percentages (small bowel, stomach, rectal, colonic)

A

25%, 30%, 15%, 10%

100
Q

Incidence of metastasis to LN of colon NET based on size (< 1cm, 2cm or greater)

A

< 5%, 79%

101
Q

Modified Hanley procedure

A

Treatment of horshoe abscess (posterior midline incision for post anal space with bilateral ischiorectal fossa incisions)

102
Q

Treatment for well or moderately differentiated, T`1N0, SCC of the anal canal

A

Excision with 1 cm margins (compared to poorly differentiated T1N0 or higher, which gets Nigro protocol)

103
Q

Treatment for anal melanoma (non metastatic)

A

local exision vs APR

104
Q

Treatment for anal adenocarcinoma

A

APR with adjuvant chemotherapy

105
Q

Mismatch repair proficient responds to chemotherapy (T/F)

A

pMMR DOES respond to chemotherapy , dMMR does NOT

(deficient (negative) no chemotherapy (but better prognosis))

106
Q

Indications for right hemicolectomy for appendiceal NET (carcinoid)

A
  1. Any size at base
  2. > 2 cm at tip/body
  3. Any size with LVI
  4. Any size with > 3 mm invasion into mesoappendix
  5. Mixed histology (goblet cell carcinoid, adenocarcinoid)
  6. High grade (G2/G3 or high mitotic/Ki67 index)
107
Q

Percentage of recurrent appendicitis after treatment of appendicitis with Abx

A

5-35%

108
Q

follow up after piecemeal resection of adenomatous polyp

A

6 months

109
Q

Maximum diameter of vessel that can be sealed with energy device

A

7mm

110
Q

Upper Endoscopy intervals for following

FAP

Varices after banding

Gastric ulcer

Esophageal ulcer

Barretts

Barrets with LGD

A

EGD every 1-2 years

6-8 weeks

Q6 weeks until healed

Q6 weeks until healed

Q 1-2 years

6 months

111
Q

Malignant potential of small bowel villous adenoma

A

30-40%

112
Q

Brunner’s gland adenoma (small bowel) has malignant potential (T/F)

A

False

113
Q

Most common small bowel tumor

A

adenoma

114
Q

Three most common small bowel malignancies

A

Adenocarcinoma (50%)

Carcinoid (NET)(40%)

GIST (10%)

115
Q

Second most common cause of death in FAP

A

desmoid tumors

(second most common malignant cause - periampullary tumors)

116
Q

What size duodenal polyps are amenable to endoscopic resection

A

1cm

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