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Colon and Rectum Flashcards

1
Q

What are the white lines of Toldt?

A

Lateral peritoneal reflections of the ascending and descending colon

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2
Q

What parts of the GI tract do not have a serosa?

A

Esophagus, middle and distal rectum

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3
Q

What are the major anatomic differences between the colon and the small bowel?

A

Colon has taeniae coli, haustra, and appendices epiploicae (fat appendages), whereas the small intestine is smooth

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4
Q

What is the blood supply to the proximal rectum?

A

Superior hemorrhoidal (or superior rectal) from the IMA

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5
Q

What is the blood supply to the middle rectum?

A

Middle hemorrhoidal (or middle rectal) from the hypogastric (internal iliac)

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6
Q

What is the blood supply to the distal rectum?

A

Inferior hemorrhoidal (or inferior rectal) from the pudendal artery (a branch of the hypogastric)

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7
Q

What is the venous drainage of the proximal rectum?

A

IMV to the splenic vein, then to the portal vein

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8
Q

What is the venous drainage of the middle rectum?

A

Iliac vein to the IVC

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9
Q

What is the venous drainage of the distal rectum?

A

Iliac vein to the IVC

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10
Q

What is colorectal carcinoma?

A

Adenocarcinoma of the colon or rectum

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11
Q

What is the incidence of colorectal carcinoma?

A

Most common GI cancer, second most common cancer in US

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12
Q

How common is colorectal carcinoma as a cause of cancer deaths?

A

Second most common cause of cancer deaths

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13
Q

What is the lifetime risk of colorectal carcinoma?

A

6%

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14
Q

What is the male:female ratio for colorectal carcinoma?

A

1:1

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15
Q

What are the risk factors for colorectal carcinoma?

A

Dietary (e.g. low-fiber, high-fat)
Genetic (e.g. FAP, Lynch’s syndrome)
IBD (e.g. UC > Crohn’s)

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16
Q

What is Lynch’s syndrome?

A

HNPCC = Hereditary NonPolyposis Colon Cancer.

AD inheritance of high risk for development of colon cancer.

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17
Q

What are current ACS recommendations for polyp/colorectal screening in asymptomatic patients without family history of colorectal cancer?

A

Starting at age 50, 1 of the following:

  1. Colonoscopy q10y
  2. Double contrast barium enema q5y
  3. Flex sigmoidoscopy q5y
  4. CT colonography q5y
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18
Q

What are the common recommendations for colorectal cancer screening if there is a history of colorectal cancer in a first-degree relative less than 60 years?

A

Colonoscopy at age 40, or 10 years before age at diagnosis of the youngest first-degree relative, and every 5 years thereafter

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19
Q

What percentage of adults will have a guaiac-positive stool test?

A

2%

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20
Q

What percentage of patients with a guaiac-positive stool test will have colon cancer?

A

10%

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21
Q

What signs and symptoms are associated with right-sided colon cancer?

A

May attain large size before presentation (as right side of bowel has a large luminal diameter).
Microcytic anemia, melena > hematochezia, postprandial discomfort, fatigue

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22
Q

What signs and symptoms are associated with left-sided colon cancer?

A

Change in bowel habits (small-caliber stools), colicky pain, signs of obstruction, abdominal mass, heme-positive or gross red blood, N/V, constipation

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23
Q

From which site of colon cancer is melena more common?

A

Right-sided colon cancer

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24
Q

From which site of colon cancer is hematochezia more common?

A

Left-sided colon cancer

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25
Q

What are the signs and symptoms of rectal cancer?

A

Most common symptom is hematochezia or mucus.

Tenesmus, feeling of incomplete evacuation of stool, rectal mass.

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26
Q

What is the incidence of rectal cancer?

A

Comprises 20-30% of all colorectal cancers

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27
Q

What is the differential diagnosis of a colon tumor or mass?

A

Adenocarcinoma, carcinoid tumor, lipoma, liposarcoma, leiomyoma, leiomyosarcoma, lymphoma, diverticular disease, UC, Crohn’s disease, polyps

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28
Q

Which diagnostic tests are helpful for colorectal cancer?

A

H&P; heme occult; CBC; barium enema; colonoscopy

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29
Q

What disease does microcytic anemia signify until proven otherwise in a man or postmenopausal woman?

A

Colon cancer

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30
Q

What tests help find colorectal cancer metastases?

A

CXR (lung); LFTs (live); abdominal CT (liver)

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31
Q

What is the preoperative workup for colorectal cancer?

A

H&P, LFTs, CEA, CBC, Chem 10, PT/PTT, T&C, CXR, UA, abdominopelvic CT

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32
Q

What are the means by which colorectal cancer spreads?

A

Direct extension (circumferentially and then through bowel wall to later invade other abdominoperineal organs);
Hematogenous (portal circulation to liver, lumbar/vertebral veins to lungs);
Lymphogenous (regional lymph nodes);
Transperitoneal;
Intraluminal

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33
Q

Is CEA useful in colorectal cancer?

A

Not for screening but for baseline and recurrence surveillance (but offers no proven survival benefit)

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34
Q

What unique diagnostic test is helpful in patients with rectal cancer?

A

Endorectal U/S

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35
Q

How are colorectal tumors staged?

A

TMN staging system

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36
Q

What is stage I colorectal cancer?

A

Invades submucosa or muscularis propria

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37
Q

What is stage II colorectal cancer?

A

Invades through muscularis propria or surrounding structures but with negative nodes

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38
Q

What is stage III colorectal cancer?

A

Positive nodes, no distant metastasis

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39
Q

What is stage IV colorectal cancer?

A

Positive distant metastasis

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40
Q

What is the approximate 5-year survival for colorectal cancer by stage?

A

I: 90%, II: 70%, III: 50%, IV: 10%

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41
Q

What percentage of patients with colorectal cancer have liver metastases on diagnosis?

A

20%

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42
Q

What is the preoperative bowel prep for colorectal cancer?

A
  1. Golytely colonic lavage or Fleets Phospho-Soda until clear effluent per rectum
  2. PO antibiotics (1 gm neomycin and 1 gm erythromycin, 3 doses)
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43
Q

What are the common preoperative IV antibiotics in colorectal cancer?

A

Cefoxitin, Unasyn

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44
Q

If the patient is allergic (hives, swelling), what antibiotics should be prescribed before surgery for colorectal cancer?

A

IV Cipro and Flagyl

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45
Q

What are the treatment options for colorectal cancer?

A

Resection (wide surgical resection of lesion and its regional lymphatic drainage)

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46
Q

What decides low anterior resection vs. abdominal perineal resection for colorectal cancer?

A

Distance from the anal verge and pelvis size

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47
Q

What do all rectal cancer operations include?

A

Total mesorectal excision (remove the rectal mesentery, including the lymph nodes)

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48
Q

What is the lowest LAR possible?

A

Coloanal anastomosis (anastomosis normal colon directly to anus)

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49
Q

What do some surgeons do with any anastomosis

A

Temporary ileostomy to protect the anastomosis

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50
Q

What surgical margins are needed for colon cancer?

A

Traditionally > 5 cm (margins must be at least 2 cm)

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51
Q

What is the minimal surgical margin for rectal cancer?

A

2 cm

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52
Q

How many lymph nodes should be resected with a colon cancer mass?

A

12 LN minimum

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53
Q

What is the adjuvant treatment of stage III colon cancer?

A

5-FU and leucovorin (or levamisole) chemotherapy

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54
Q

What is the adjuvant treatment for T3-4 rectal cancer?

A

Preoperative radiation therapy and 5-FU chemotherapy as a radiosensitizer

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55
Q

What is the most common site of distant (hematogenous) metastasis from colorectal cancer?

A

Liver

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56
Q

What is the treatment of liver metastases from colorectal cancer?

A

Resect with > 1 cm margins and administer chemotherapy if feasible

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57
Q

What is the surveillance regimen for colorectal cancer?

A

PE; stool guaiac; CBC; CEA; LFTs (q3m for 3 years, then q6m for 2 years); CXR (q6m for 2 years, then yearly); colonoscopy (at year 1 and 3); CT

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58
Q

Why is followup so important the first 3 years postoperative for colorectal cancer?

A

90% of colorectal recurrences are within 3 years of surgery

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59
Q

What are the most common cause of colonic obstruction in the adult population?

A

Colon cancer, diverticular disease, colonic volvulus

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60
Q

What is the 5-year survival rate after liver resection with clean margins for colon cancer liver metastasis?

A

33%

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61
Q

What is the 5-year survival rate after diagnosis of unresectable colon cancer liver metastasis?

A

0%

62
Q

What are colorectal polyps?

A

Tissue growth into bowel lumen, usually consisting of mucosa, submucosa, or both

63
Q

How are colorectal polyps anatomically classified?

A

Sessile (flat), pedunculated (on a stalk)

64
Q

What is the histology of inflammatory polyps?

A

Similar to Crohn’s disease or UC

65
Q

What is the histology of hamartomatous polyps?

A

Normal tissue in abnormal configuration

66
Q

What is the histology of hyperplastic polyps?

A

Benign, normal cells with no malignant potential

67
Q

What is the histology of neoplastic polyps?

A

Proliferation of undifferentiated cells (premalignant or malignant)

68
Q

What are the subtypes of neoplastic polyps

A

Tubular adenomas (usually pedunculated), tubulovillous adenomas, villous adenomas (usually sessile and look like broccoli heads)

69
Q

What determines malignant potential of an adenomatous polyp?

A

Size, histologic type, atypia of cells

70
Q

What is the most common type of adenomatous polyp?

A

Tubular (85%)

71
Q

What is the correlation between size and malignanta potential of an adenomatous polyp?

A

Polyps > 2 cm have a high risk of carcinoma (33-55%)

72
Q

What is the correlation between histology and malignancy potential of an adenomatous polyp?

A

Villous > tubulovillous > tubular

73
Q

Where are most polyps found?

A

Rectosigmoid

74
Q

What are the signs and symptoms of colorectal polyps?

A

Bleeding (red or dark blood), change in bowel habits, mucus per rectum, electrolyte loss, totally asymptomatic

75
Q

What are the diagnostic tests for colorectal polyps?

A

Colonoscopy, barium enema, sigmoidoscopy

76
Q

What is the treatment for colorectal polyps?

A 
Endoscopic resection (snared);
Large sessile villous adenomas should be removed with bowel resection and lymph node resection
77
Q

What is FAP?

A

Familial Adenomatous Polyposis

78
Q

What are the characteristics of FAP?

A

Hundreds of adenomatous polyps within the rectum and colon that begin developing at puberty.
Untreated patients develop cancer by age 40-50.

79
Q

What is the inheritance pattern of FAP?

A

AD

80
Q

What is the genetic defect in FAP?

A

APC (adenomatous polyposis coli) gene

81
Q

What is the treatment for FAP?

A
  1. Total proctocolectomy and ileostomy

2. Total colectomy and rectal mucosal removal (mucosal proctectomy) and ileoanal anastomosis

82
Q

What are the characteristics of Gardner’s syndrome?

A

Neoplastic polyps of the small bowel and colon.

Cancer by age 40 in 100% of undiagnosed patients.

83
Q

What are the associated findings with Gardner’s syndrome?

A

Desmoid tumors (in abdominal wall or cavity), osteomas of skull, sebaceous cysts, adrenal and thyroid tumors, retroperitoneal fibrosis, duodenal and periampullary tumors

84
Q

How can the findings associated with Gardner’s syndrome be remembered?

A

Gardener planting SOD:

Sebaceous cysts, Osteomas, Desmoid tumors

85
Q

What is a desmoid tumor?

A

Tumor of the musculoaponeurotic sheath, usually of the abdominal wall.
Benign, but grows locally.
Treated by wide resection.

86
Q

What medications may slow the growth of a desmoid tumor?

A

Tamoxifen, sulindac, steroids

87
Q

What is the inheritance pattern of Gardner’s syndrome?

A

AD, varying degree of penetrance

88
Q

What is the treatment of colon polyps in patients with Gardner’s syndrome?

A
  1. Total proctocolectomy and ileostomy

2. Total colectomy and rectal mucosal removal (mucosal proctectomy) and ileoanal anastomosis

89
Q

What are the characteristics of Peutz-Jegher’s syndrome?

A

Hamartomas throughout the GI tract (jejunum/ileum > colon > stomach)

90
Q

What is the associated cancer risk from polyps in Peutz-Jegher’s syndrome?

A

Increased

91
Q

What is the associated cancer risk for women with Peutz-Jegher’s syndrome?

A

Ovarian cancer (granulosa cell tumors is most common)

92
Q

What is the inheritance pattern of Peutz-Jegher’s syndrome?

A

AD

93
Q

What are the non-GI signs of Peutz-Jegher’s syndrome?

A

Melanotic pigmentation of buccal mucosa, lips, digits, palms, feet

94
Q

What is the treatment for Peutz-Jegher’s syndrome?

A

If symptomatic (i.e. bleeding, intussusception, obstruction, > 1.5 cm), removal of polyps

95
Q

What are juvenile polyps?

A

Benign hamartomas in the small bowel and colon.

Also called retention polyps.

96
Q

What is Cronkhite-Canada syndrome?

A

Diffuse GI hamartoma polyps associated with malabsorption/weight loss, diarrhea, and loss of electrolytes/protein.
Signs include alopecia, nail atrophy, skin pigmentation.

97
Q

What is Turcot’s syndrome?

A

Colon polyps with malignant CNS tumors (glioblastoma multiforme)

98
Q

What is diverticulosis?

A

Condition in which false diverticula can be found within the colon, especially the sigmoid

99
Q

What is the pathophysiology of diverticulosis?

A
  1. Weakness in the bowel wall develops at points where nutrient blood vessels enter between anti-mesenteric and mesenteric taeniae.
  2. Increased intraluminal pressures then cause herniation through these areas.
100
Q

What is the incidence of diverticulosis?

A

50-60% by age 60 (10-20% symptomatic)

101
Q

What is the most common site for diverticulosis?

A

Sigmoid colon (95%)

102
Q

Who is at risk for diverticulosis?

A

Low-fiber diet, chronic constipation, family history

103
Q

What are the symptoms and complications of diverticulosis?

A

Bleeding (may be massive), diverticulitis

104
Q

What is the diagnostic approach to suspected diverticulosis with bleeding?

A

Colonoscopy

105
Q

What is the diagnostic approach to suspected diverticulosis with pain and signs of inflammation?

A

Abdominal and pelvic CT

106
Q

What is the treatment of diverticulosis?

A

High-fiber diet

107
Q

What are the indications for operation with diverticulosis?

A

Complications of diverticulitis (e.g. fistula, obstruction, stricture); recurrent episodes; hemorrhage; suspected carcinoma; prolonged symptoms; abscess no drainable by percutaneous approach

108
Q

With diverticulosis, when is it safe to get a colonoscopy, barium enema, or sigmoidoscopy?

A

Due to risk of perforation, this is performed 6 weeks after inflammation resolves to rule out colon cancer

109
Q

What is diverticulitis?

A

Infection or perforation of a diverticulum

110
Q

What is the pathophysiology of diverticulitis?

A

Obstruction of diverticulum by a fecalith leading to inflammation and microperforation

111
Q

What are the signs and symptoms of diverticulitis?

A

LLQ pain (cramping or steady), change in bowel habits, diarrhea, fever, chills, anorexia, LLQ mass, N/V, dysuria

112
Q

What are the associated lab finding with diverticulitis?

A

Increased WBCs

113
Q

What are the associated radiographic findings with diverticulitis?

A

XR: ileus, partially obstructed colon, air-fluid levels, free air if perforated;
Abdominal/pelvic CT: swollen, edematous bowel wall

114
Q

What are the associated barium enema findings with diverticulitis?

A

Should be avoided in acute cases!

115
Q

Is colonoscopy safe in acute diverticulitis?

A

No, increased risk of perforation

116
Q

What are the possible complications of diverticulitis?

A

Abscess, diffuse peritonitis, fistula, obstruction, perforation, stricture

117
Q

What is the most common fistula with diverticulitis?

A

Colovesical fistula

118
Q

What is the best test for diverticulitis?

A

CT

119
Q

What is the initial therapy for diverticulitis?

A

IV fluids; NPO; broad-spectrum antibiotics with anaerobic coverage; NG suction

120
Q

When is surgery warranted for diverticulitis?

A

Obstruction, fistula, free perforation, abscess no amenable to percutaneous drainage, sepsis, deterioration with initial conservative treatment

121
Q

What is the lifelong risk of recurrence after the first episode of diverticulitis?

A

33%

122
Q

What is the lifelong risk of recurrence after the second episode of diverticulitis?

A

50%

123
Q

What are the indications for elective resection for diverticulitis?

A

2 episodes of diverticulitis.

Should be considered after the first episode in a young, diabetic, or immunosuppressed patient

124
Q

What surgery is usually performed electively for recurrent bouts of diverticulitis?

A

One-stage operation:

Resection of involved segment and primary anastomosis

125
Q

What type of surgery is usually performed for an acute case of diverticulitis with a complication?

A

Hartmann’s procedure:
Resection of involved segment with an end colostomy and stapled rectal stump (will need subsequent reanastomosis of colon usually after 2-3 postoperative months)

126
Q

What is the treatment of diverticular abscess?

A

Percutaneous drainage (if abscess is not amenable to percutaneous drainage, then surgical approach for drainage is necessary)

127
Q

How common is massive lower GI bleeding with diverticulitis?

A

Very rare (more associated with diverticulosis)

128
Q

What are the most common causes of massive lower GI bleeding in adults?

A

Diverticulosis, vascular ectasia

129
Q

What must you rule out in any patient with diverticulitis or diverticulosis?

A

Colon cancer

130
Q

What is colonic volvulus?

A

Twisting of colon on itself about its mesentery, resulting in obstruction and, if complete, vascular compromise with potential necrosis, perforation, or both

131
Q

What is the most common type of colonic volvulus?

A

Sigmoid volvulus

132
Q

What is sigmoid volvulus?

A

Twist in the sigmoid colon

133
Q

What are the etiologic factors for sigmoid volvulus?

A

High-residue diet resulting in bulky stools and tortuous, elongated colon; chronic constipation; laxative abuse; pregnancy; bedridden

134
Q

What are the signs and symptoms of sigmoid volvulus?

A

Acute abdominal pain, progressive abdominal distention, anorexia, obstipation, cramps, N/V

135
Q

What findings are evident with sigmoid volvulus on abdominal plain film?

A

Distended loop of sigmoid colon, often in the classic “bent inner tube” or “omega” sign with the loop aiming toward the RUQ

136
Q

What are the signs of necrotic bowel in colonic volvulus?

A

Free air, pneumatosis (air in bowel)

137
Q

How is the diagnosis of sigmoid volvulus made?

A

Sigmoidoscopy or radiographic exam with gastrografin enema

138
Q

Under what conditions is gastrografin enema useful for sigmoid volvulus?

A

If sigmoidoscopy and plain films fail to confirm the diagnosis.
“Bird’s beak” is pathognomonic as seen on enema contrast study

139
Q

What are the signs of strangulation with sigmoid volvulus?

A

Discolored or hemorrhagic mucosa on sigmoidoscopy; bloody fluid in the rectum; frank ulceration or necrosis at the point of the twist; peritoneal signs; fever; hypotension; increased WBCs

140
Q

What is the initial treatment for sigmoid volvulus?

A

Non-operative; if there is no strangulation, sigmoidoscopic reduction is successful in 85% of cases (enema study with occasionally reduce)

141
Q

What is the percentage of recurrence after non-operative reduction of a sigmoid volvulus?

A

40%

142
Q

What are the indications for surgery for sigmoid volvulus?

A

Strangulation is suspected or non-operative reduction is unsuccessful.
Most patients should undergo Hartmann’s procedure during same hospitalization of redundant sigmoid after successful non-operative reduction because of high recurrence rate

143
Q

What is cecal volvulus?

A

Twisting of the cecum upon itself and the mesentery

144
Q

What is a cecal bascule volvulus?

A

Instead of the more common axial twist, the cecum folds upward (lies on the ascending colon)

145
Q

What is the incidence of cecal volvulus?

A

25% of colonic volvulus

146
Q

What is the etiology of cecal volvulus?

A

Idiopathic, poor fixation of the right colon

147
Q

What are the signs and symptoms of cecal volvulus?

A

Acute onset of abdominal or colicky pain beginning in the RLQ and progressing to a constant pain, vomiting, obstipation, abdominal distention, and SBO

148
Q

How is the diagnosis of cecal volvulus made?

A

AXR: dilated, ovoid colon with large air/fluid level in the RLQ often forming the classic “coffee bean” sign with the apex aiming toward the epigastrium or LUQ

149
Q

What diagnostic studies should be performed with cecal volvulus?

A

Water-soluble contrast study (gastrografin), if diagnosis cannot be made by AXR

150
Q

What is the treatment for cecal volvulus?

A

Emergent surgery:
Right colectomy with primary anastomosis or ileostomy and mucous fistula (primary anastomosis may be performed in stable patients)

151
Q

What are the major differences in the emergent management of cecal volvulus vs. sigmoid?

A

Patients with cecal volvulus require surgical reduction, whereas the vast majority of patients with sigmoid volvulus undergo initial endoscopic reduction

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