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Section II General Surgery P203Surgical Recall Sixth > Colon and Rectum, C48 P308-325 > Flashcards

Colon and Rectum, C48 P308-325 Flashcards

1
Q

ANATOMY
Identify the arterial blood supply to the colon:
P308 (picture)

A
  1. Ileocolic artery
  2. Right colic artery
  3. Superior mesenteric artery (SMA)
  4. Middle colic artery
  5. Inferior mesenteric artery (IMA)
  6. Left colic artery
  7. Sigmoidal artery
  8. Superior hemorrhoidal artery
    (superior rectal)
  9. Middle hemorrhoidal artery
    10 Inferior hemorrhoidal artery
  10. Marginal artery of Drummond
  11. Meandering artery of Gonzalez
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2
Q

ANATOMY
What are the white lines of
Toldt?
P309

A

Lateral peritoneal reflections of the

ascending and descending colon

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3
Q

ANATOMY
What parts of the GI tract
do not have a serosa?
P309

A

Esophagus, middle and distal rectum

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4
Q 
ANATOMY
What are the major anatomic
differences between the
colon and the small bowel?
P309
A 
Colon has taeniae coli, haustra, and
appendices epiploicae (fat appendages),
whereas the small intestine is smooth
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5
Q 
ANATOMY
What is the blood supply to
the rectum:
Proximal?
P309
A 
Superior hemorrhoidal (or superior
rectal) from the IMA
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6
Q 
ANATOMY
What is the blood supply to
the rectum:
Middle?
P309
A 
Middle hemorrhoidal (or middle rectal)
from the hypogastric (internal iliac)
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7
Q 
ANATOMY
What is the blood supply to
the rectum:
Distal?
P309
A

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

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8
Q 
ANATOMY
What is the venous drainage
of the rectum:
Proximal?
P309
A

Via the IMV to the splenic vein, then to

the portal vein

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9
Q 
ANATOMY
What is the venous drainage
of the rectum:
Middle?
P309
A

Via the iliac vein to the IVC

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10
Q 
ANATOMY
What is the venous drainage
of the rectum:
Distal?
P309
A

Via the iliac vein to the IVC

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11
Q

COLORECTAL CARCINOMA
What is it?
P309

A

Adenocarcinoma of the colon or rectum

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12
Q

COLORECTAL CARCINOMA
What is the incidence?
P309

A 
Most common GI cancer
Second most common cancer in the
    United States
Incidence increases with age starting at
    40 and peaks at 70 to 80 years
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13
Q

COLORECTAL CARCINOMA
How common is it as a cause
of cancer deaths?
P309

A

Second most common cause of cancer

deaths

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14
Q

COLORECTAL CARCINOMA
What is the lifetime risk of
colorectal cancer?
P310

A

6%

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15
Q

COLORECTAL CARCINOMA
What is the male to female
ratio?
P310

A

≈1:1

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16
Q

COLORECTAL CARCINOMA
What are the risk factors?
P310

A 
Dietary: Low-fiber, high-fat diets
    correlate with increased rates
Genetic: Family history is important
    when taking history
    FAP, Lynch’s syndrome
IBD: Ulcerative colitis > Crohn’s
    disease, age, previous colon cancer
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17
Q

COLORECTAL CARCINOMA
What is Lynch’s syndrome?
P310

A

HNPCC = Hereditary NonPolyposis
Colon Cancer—autosomal-dominant
inheritance of high risk for development
of colon cancer

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18
Q 
COLORECTAL CARCINOMA
What are current ACS
recommendations for
polyp/colorectal screening
in asymptomatic patients
without family (first-degree)
history of colorectal
cancer?
P310
A 
Starting at age 50, at least one of the
following test regimens is recommended:
    Colonoscopy q 10 yrs
    Double contrast barium enema
       (DCBE) q 5 yrs
    Flex sigmoidoscopy q 5 yrs
    CT colonography q 5 yrs
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19
Q 
COLORECTAL CARCINOMA
What are the current recommendations
for colorectal
cancer screening if there is a
history of colorectal cancer
in a first-degree relative
less than 60 years old?
P310
A

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

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20
Q 
COLORECTAL CARCINOMA
What percentage of adults
will have a guaiac-positive
stool test?
P310
A

≈2%

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21
Q 
COLORECTAL CARCINOMA
What percentage of patients
with a guaiac-positive
stool test will have colon
cancer?
P310
A

≈10%

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22
Q 
COLORECTAL CARCINOMA
What signs/symptoms are
associated with the following
conditions:
Right-sided lesions?
P311
A 
Right side of bowel has a large luminal
    diameter, so a tumor may attain a
    large size before causing problems
Microcytic anemia, occult/melena more
    than hematochezia PR, postprandial
    discomfort, fatigue
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23
Q 
COLORECTAL CARCINOMA
What signs/symptoms are
associated with the following
conditions:
Left-sided lesions?
P311
A 
Left side of bowel has smaller lumen and
     semisolid contents
Change in bowel habits (small-caliber
    stools), colicky pain, signs of
    obstruction, abdominal mass,
    heme() or gross red blood
Nausea, vomiting, constipation
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24
Q

COLORECTAL CARCINOMA
From which site is melena
more common?
P311

A

Right-sided colon cancer

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25
``` COLORECTAL CARCINOMA From which site is hematochezia more common? P311 ```
Left-sided colon cancer
26
COLORECTAL CARCINOMA What is the incidence of rectal cancer? P311
Comprises 20% to 30% of all colorectal | cancer
27
COLORECTAL CARCINOMA What are the signs/ symptoms of rectal cancer? P311
Most common symptom is hematochezia (passage of red blood ± stool) or mucus; also tenesmus, feeling of incomplete evacuation of stool (because of the mass), and rectal mass
28
``` COLORECTAL CARCINOMA What is the differential diagnosis of a colon tumor/ mass? P311 ```
Adenocarcinoma, carcinoid tumor, lipoma, liposarcoma, leiomyoma, leiomyosarcoma, lymphoma, diverticular disease, ulcerative colitis, Crohn’s disease, polyps
29
COLORECTAL CARCINOMA Which diagnostic tests are helpful? P311
History and physical exam (Note: 10% of cancers are palpable on rectal exam), heme occult, CBC, barium enema, colonoscopy
30
``` COLORECTAL CARCINOMA What disease does microcytic anemia signify until proven otherwise in a man or postmenopausal woman? P312 ```
Colon cancer
31
COLORECTAL CARCINOMA What tests help find metastases? P312
``` CXR (lung metastases), LFTs (liver metastases), abdominal CT (liver metastases), other tests based on history and physical exam (e.g., head CT for left arm weakness looking for brain metastasis) ```
32
``` COLORECTAL CARCINOMA What is the preoperative workup for colorectal cancer? P312 ```
History, physical exam, LFTs, CEA, CBC, Chem 10, PT/PTT, type and cross 2 u PRBCs, CXR, U/A, abdominopelvic CT
33
COLORECTAL CARCINOMA What are the means by which the cancer spreads? P312
``` 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 ```
34
COLORECTAL CARCINOMA Is CEA useful? P312
Not for screening but for baseline and recurrence surveillance (but offers no proven survival benefit)
35
``` COLORECTAL CARCINOMA What unique diagnostic test is helpful in patients with rectal cancer? P312 ```
Endorectal ultrasound (probe is placed transanally and depth of invasion and nodes are evaluated)
36
COLORECTAL CARCINOMA How are tumors staged? P312
TMN staging system
37
COLORECTAL CARCINOMA Give the TNM stages: Stage I P312
Invades submucosa or muscularis propria | T1–2 N0 M0
38
COLORECTAL CARCINOMA Give the TNM stages: Stage II P312
Invades through muscularis propria or surrounding structures but with negative nodes (T3–4, N0, M0)
39
COLORECTAL CARCINOMA Give the TNM stages: Stage III P313
Positive nodes, no distant metastasis | any T, N1–3, M0
40
COLORECTAL CARCINOMA Give the TNM stages: Stage IV P313
Positive distant metastasis (any T, any | N, M1)
41
``` COLORECTAL CARCINOMA What is the approximate 5-year survival by stage: Stage I? P313 ```
90%
42
``` COLORECTAL CARCINOMA What is the approximate 5-year survival by stage: Stage II? P313 ```
70%
43
``` COLORECTAL CARCINOMA What is the approximate 5-year survival by stage: Stage III? P313 ```
50%
44
``` COLORECTAL CARCINOMA What is the approximate 5-year survival by stage: Stage IV? P313 ```
10%
45
``` COLORECTAL CARCINOMA What percentage of patients with colorectal cancer have liver metastases on diagnosis? P313 ```
≈20%
46
COLORECTAL CARCINOMA Define the preoperative “bowel prep.” P313
``` Preoperative preparation for colon/rectal resection: 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) Note: Patient should also receive preoperative and 24-hr IV antibiotics ```
47
``` COLORECTAL CARCINOMA What are the common preoperative IV antibiotics? P313 ```
Cefoxitin, Unasyn®
48
``` COLORECTAL CARCINOMA If the patient is allergic (hives, swelling), what antibiotics should be prescribed? P313 ```
IV Cipro® and Flagyl®
49
COLORECTAL CARCINOMA What are the treatment options? P313
Resection: wide surgical resection of | lesion and its regional lymphatic drainage
50
``` COLORECTAL CARCINOMA What decides low anterior resection (LAR) versus abdominal perineal resection (APR)? P314 ```
Distance from the anal verge, pelvis size
51
COLORECTAL CARCINOMA What do all rectal cancer operations include? P314
Total mesorectal excision—remove the rectal mesentery, including the lymph nodes (LNs)
52
COLORECTAL CARCINOMA What is the lowest LAR possible? P314
``` Coloanal anastomosis (anastomosis normal colon directly to anus) ```
53
``` COLORECTAL CARCINOMA What do some surgeons do with any anastomosis less than 5 cm from the anus? P314 ```
Temporary ileostomy to “protect” the | anastomosis
54
``` COLORECTAL CARCINOMA What surgical margins are needed for colon cancer? P314 ```
Traditionally >5 cm; margins must be at | least 2 cm
55
COLORECTAL CARCINOMA What is the minimal surgical margin for rectal cancer? P314
2 cm
56
``` COLORECTAL CARCINOMA How many lymph nodes should be resected with a colon cancer mass? P314 ```
12 LNs minimum = for staging, and may | improve prognosis
57
``` COLORECTAL CARCINOMA What is the adjuvant treatment of stage III colon cancer? P314 ```
5-FU and leucovorin (or levamisole) chemotherapy (if there is nodal metastasis postoperatively)
58
``` COLORECTAL CARCINOMA What is the adjuvant treatment for T3–T4 rectal cancer? P314 ```
Preoperative radiation therapy and | 5-FU chemotherapy as a “radiosensitizer”
59
``` COLORECTAL CARCINOMA What is the most common site of distant (hematogenous) metastasis from colorectal cancer? P314 ```
Liver
60
``` COLORECTAL CARCINOMA What is the treatment of liver metastases from colorectal cancer? P314 ```
Resect with ≥1-cm margins and | administer chemotherapy if feasible
61
COLORECTAL CARCINOMA What is the surveillance regimen? P315
``` Physical exam, stool guaiac, CBC, CEA, LFTs (every 3 months for 3 years, then every 6 months for 2 years), CXR every 6 months for 2 years and then yearly, colonoscopy at years 1 and 3 postoperatively, CT scans directed by exam ```
62
``` COLORECTAL CARCINOMA Why is follow-up so important the first 3 postoperative years? P315 ```
≈90% of colorectal recurrences are | within 3 years of surgery
63
``` COLORECTAL CARCINOMA What are the most common causes of colonic obstruction in the adult population? P315 ```
Colon cancer, diverticular disease, | colonic volvulus
64
``` COLORECTAL CARCINOMA What is the 5-year survival rate after liver resection with clean margins for colon cancer liver metastasis? P315 ```
≈33% (28%–50%)
65
``` COLORECTAL CARCINOMA What is the 5-year survival rate after diagnosis of unresectable colon cancer liver metastasis? P315 ```
0%
66
COLONIC AND RECTAL POLYPS What are they? P315
Tissue growth into bowel lumen, usually | consisting of mucosa, submucosa, or both
67
COLONIC AND RECTAL POLYPS How are they anatomically classified? P315
Sessile (flat) | Pedunculated (on a stalk)
68
``` COLONIC AND RECTAL POLYPS What are the histologic classifications of the following types: Inflammatory (pseudopolyp)? P315 ```
As in Crohn’s disease or ulcerative colitis
69
``` COLONIC AND RECTAL POLYPS What are the histologic classifications of the following types: Hamartomatous? P315 ```
Normal tissue in abnormal configuration
70
``` COLONIC AND RECTAL POLYPS What are the histologic classifications of the following types: Hyperplastic? P315 ```
Benign—normal cells—no malignant | potential
71
``` COLONIC AND RECTAL POLYPS What are the histologic classifications of the following types: Neoplastic? P316 ```
Proliferation of undifferentiated cells; | premalignant or malignant cells
72
COLONIC AND RECTAL POLYPS What are the subtypes of neoplastic polyps? P316
Tubular adenomas (usually pedunculated) Tubulovillous adenomas Villous adenomas (usually sessile and look like broccoli heads)
73
``` COLONIC AND RECTAL POLYPS What determines malignant potential of an adenomatous polyp? P316 ```
Size Histologic type Atypia of cells
74
``` COLONIC AND RECTAL POLYPS What is the most common type of adenomatous polyp? P316 ```
Tubular 85%
75
``` COLONIC AND RECTAL POLYPS What is the correlation between size and malignancy? P316 ```
``` Polyps larger than 2 cm have a high risk of carcinoma (33%–55%) ```
76
``` COLONIC AND RECTAL POLYPS What about histology and cancer potential of an adenomatous polyp? P316 ```
Villous > tubovillous > tubular (Think: | VILLous = VILLain)
77
``` COLONIC AND RECTAL POLYPS What is the approximate percentage of carcinomas found in the following polyps overall: Tubular adenoma? P316 ```
5%
78
``` COLONIC AND RECTAL POLYPS What is the approximate percentage of carcinomas found in the following polyps overall: Tubulovillous adenoma? P316 ```
20%
79
``` COLONIC AND RECTAL POLYPS What is the approximate percentage of carcinomas found in the following polyps overall: Villous adenoma? P316 ```
40%
80
COLONIC AND RECTAL POLYPS Where are most polyps found? P316
Rectosigmoid (30%)
81
COLONIC AND RECTAL POLYPS What are the signs/symptoms? P316
Bleeding (red or dark blood), change in bowel habits, mucus per rectum, electrolyte loss, totally asymptomatic
82
COLONIC AND RECTAL POLYPS What are the diagnostic tests? P316
Best = colonoscopy Less sensitive for small polyps = barium enema and sigmoidoscopy
83
COLONIC AND RECTAL POLYPS What is the treatment? P317
Endoscopic resection (snared) if polyps; large sessile villous adenomas should be removed with bowel resection and lymph node resection
84
``` POLYPOSIS SYNDROMES FAMILIAL POLYPOSIS What is another name for this condition? P317 ```
Familial adenomatous polyposis (FAP)
85
POLYPOSIS SYNDROMES FAMILIAL POLYPOSIS What are the characteristics? P317
Hundreds of adenomatous polyps within the rectum and colon that begin developing at puberty; all undiagnosed; untreated patients develop cancer by ages 40 to 50
86
``` POLYPOSIS SYNDROMES FAMILIAL POLYPOSIS What is the inheritance pattern? P317 ```
``` Autosomal dominant (i.e., 50% of offspring) ```
87
POLYPOSIS SYNDROMES FAMILIAL POLYPOSIS What is the genetic defect? P317
APC (adenomatous polyposis coli) gene
88
POLYPOSIS SYNDROMES FAMILIAL POLYPOSIS What is the treatment? P317
Total proctocolectomy and ileostomy Total colectomy and rectal mucosal removal (mucosal proctectomy) and ileoanal anastomosis
89
``` POLYPOSIS SYNDROMES GARDNER’S SYNDROME What are the characteristics? P317 ```
Neoplastic polyps of the small bowel and colon; cancer by age 40 in 100% of undiagnosed patients, as in FAP
90
``` POLYPOSIS SYNDROMES GARDNER’S SYNDROME What are the other associated findings? P317 ```
Desmoid tumors (in abdominal wall or cavity), osteomas of skull (seen on x-ray), sebaceous cysts, adrenal and thyroid tumors, retroperitoneal fibrosis, duodenal and periampullary tumors
91
``` POLYPOSIS SYNDROMES GARDNER’S SYNDROME How can the findings associated with Gardner’s syndrome be remembered? P317 ```
Think of a gardener planting “SOD”: Sebaceous cysts Osteomas Desmoid tumors
92
POLYPOSIS SYNDROMES GARDNER’S SYNDROME What is a desmoid tumor? P318
Tumor of the musculoaponeurotic sheath, usually of the abdominal wall; benign, but grows locally; treated by wide resection
93
``` POLYPOSIS SYNDROMES GARDNER’S SYNDROME What medications may slow the growth of a desmoid tumor? P318 ```
Tamoxifen, sulindac, steroids
94
``` POLYPOSIS SYNDROMES GARDNER’S SYNDROME What is the inheritance pattern? P318 ```
Varying degree of penetrance from an | autosomal-dominant gene
95
``` POLYPOSIS SYNDROMES GARDNER’S SYNDROME What is the treatment of colon polyps in patients with Gardner’s syndrome? P318 ```
Total proctocolectomy and ileostomy Total colectomy and rectal mucosal removal (mucosal proctectomy) and ileoanal anastomosis
96
``` POLYPOSIS SYNDROMES PEUTZ-JEGHERS’ SYNDROME What are the characteristics? P318 ```
Hamartomas throughout the GI tract | jejunum/ileum > colon > stomach
97
``` POLYPOSIS SYNDROMES PEUTZ-JEGHERS’ SYNDROME What is the associated cancer risk from polyps? P318 ```
Increased
98
``` POLYPOSIS SYNDROMES PEUTZ-JEGHERS’ SYNDROME What is the associated cancer risk for women with Peutz-Jeghers? P318 ```
``` Ovarian cancer (granulosa cell tumor is most common) ```
99
``` POLYPOSIS SYNDROMES PEUTZ-JEGHERS’ SYNDROME What is the inheritance pattern? P318 ```
Autosomal dominant
100
POLYPOSIS SYNDROMES PEUTZ-JEGHERS’ SYNDROME What are the other signs? P318
Melanotic pigmentation (black/brown) of buccal mucosa (mouth), lips, digits, palms, feet (soles) (Think: Peutz = Pigmented)
101
POLYPOSIS SYNDROMES PEUTZ-JEGHERS’ SYNDROME What is the treatment? P318
``` Removal of polyps, if symptomatic (i.e., bleeding, intussusception, or obstruction) or large (>1.5 cm) ```
102
POLYPOSIS SYNDROMES PEUTZ-JEGHERS’ SYNDROME What are juvenile polyps? P318
Benign hamartomas in the small bowel and colon; not premalignant; also known as “retention polyps”
103
``` POLYPOSIS SYNDROMES PEUTZ-JEGHERS’ SYNDROME What is Cronkhite-Canada syndrome? P319 ```
Diffuse GI hamartoma polyps (i.e., no cancer potential) associated with malabsorption/weight loss, diarrhea, and loss of electrolytes/protein; signs include alopecia, nail atrophy, skin pigmentation
104
POLYPOSIS SYNDROMES PEUTZ-JEGHERS’ SYNDROME What is Turcot’s syndrome? P319
Colon polyps with malignant CNS | tumors (glioblastoma multiforme)
105
DIVERTICULAR DISEASE OF THE COLON DIVERTICULOSIS What is diverticulosis? P319 (picture)
``` Condition in which diverticula can be found within the colon, especially the sigmoid; diverticula are actually false diverticula in that only mucosa and submucosa herniate through the bowel musculature; true diverticula involve all layers of the bowel wall and are rare in the colon ```
106
DIVERTICULAR DISEASE OF THE COLON DIVERTICULOSIS Describe the pathophysiology P319
Weakness in the bowel wall develops at points where nutrient blood vessels enter between antimesenteric and mesenteric taeniae; increased intraluminal pressures then cause herniation through these areas
107
DIVERTICULAR DISEASE OF THE COLON DIVERTICULOSIS What is the incidence? P319
≈50% to 60% in the United States by age 60, with only 10% to 20% becoming symptomatic
108
DIVERTICULAR DISEASE OF THE COLON DIVERTICULOSIS What is the most common site? P319
95% of people with diverticulosis have | sigmoid colon involvement
109
DIVERTICULAR DISEASE OF THE COLON DIVERTICULOSIS Who is at risk? P320
People with low-fiber diets, chronic constipation, and a positive family history; incidence increases with age
110
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULOSIS What are the symptoms/ complications? P320 ```
Bleeding: may be massive | Diverticulitis, asymptomatic (80% of cases)
111
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULOSIS What is the diagnostic approach: Bleeding? P320 ```
Without signs of inflammation: colonoscopy
112
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULOSIS What is the diagnostic approach: Pain and signs of inflammation? P320 ```
Abdominal/pelvic CT scan
113
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULOSIS What is the treatment of diverticulosis? P320 ```
High-fiber diet is recommended
114
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULOSIS What are the indications for operation with diverticulosis? P320 ```
Complications of diverticulitis (e.g., fistula, obstruction, stricture); recurrent episodes; hemorrhage; suspected carcinoma; prolonged symptoms; abscess not drainable by percutaneous approach
115
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULOSIS When is it safe to get a colonoscopy or barium enema/sigmoidoscopy? P320 ```
Due to risk of perforation, this is performed 6 weeks after inflammation resolves to rule out colon cancer
116
DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What is it? P320
Infection or perforation of a diverticulum
117
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What is the pathophysiology? P320 ```
Obstruction of diverticulum by a fecalith leading to inflammation and microperforation
118
DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What are the signs/symptoms? P320
``` LLQ pain (cramping or steady), change in bowel habits (diarrhea), fever, chills, anorexia, LLQ mass, nausea/vomiting, dysuria ```
119
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What are the associated lab findings? P320 ```
Increased WBCs
120
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What are the associated radiographic findings? P320 ```
On x-ray: ileus, partially obstructed colon, air-fluid levels, free air if perforated On abdominal/pelvic CT scan: swollen, edematous bowel wall; particularly helpful in diagnosing an abscess
121
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What are the associated barium enema findings? P321 ```
Barium enema should be avoided in | acute cases
122
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS Is colonoscopy safe in an acute setting? P321 ```
No, there is increased risk of perforation
123
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What are the possible complications? P321 ```
Abscess, diffuse peritonitis, fistula, | obstruction, perforation, stricture
124
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What is the most common fistula with diverticulitis? P321 ```
Colovesical fistula (to bladder)
125
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What is the best test for diverticulitis? P321 ```
CT scan
126
DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What is the initial therapy? P321
IV fluids, NPO, broad-spectrum antibiotics with anaerobic coverage, NG suction (as needed for emesis/ileus)
127
DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS When is surgery warranted? P321
Obstruction, fistula, free perforation, abscess not amenable to percutaneous drainage, sepsis, deterioration with initial conservative treatment
128
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What is the lifelong risk of recurrence after: First episode? P321 ```
33%
129
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What is the lifelong risk of recurrence after: Second episode? P321 ```
50%
130
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What are the indications for elective resection? P321 ```
Two episodes of diverticulitis; should be considered after the first episode in a young, diabetic, or immunosuppressed patient
131
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What surgery is usually performed ELECTIVELY for recurrent bouts? P321 ```
One-stage operation: resection of involved segment and primary anastomosis (with preoperative bowel prep)
132
``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What type of surgery is usually performed for an acute case of diverticulitis with a complication (e.g., perforation, obstruction)? P321 ```
``` 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) ```
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``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What is the treatment of diverticular abscess? P322 ```
Percutaneous drainage; if abscess is not amenable to percutaneous drainage, then surgical approach for drainage is necessary
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``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS How common is massive lower GI bleeding with diverticulitis? P322 ```
Very rare! Massive lower GI bleeding is | seen with diverticulosis, not diverticulitis
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``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What are the most common causes of massive lower GI bleeding in adults? P322 ```
Diverticulosis (especially right sided), | vascular ectasia
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``` DIVERTICULAR DISEASE OF THE COLON DIVERTICULITIS What must you rule out in any patient with diverticulitis/ diverticulosis? P322 ```
Colon cancer
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DIVERTICULAR DISEASE OF THE COLON COLONIC VOLVULUS What is it? P322
Twisting of colon on itself about its mesentery, resulting in obstruction and, if complete, vascular compromise with potential necrosis, perforation, or both
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``` DIVERTICULAR DISEASE OF THE COLON COLONIC VOLVULUS What is the most common type of colonic volvulus? P322 ```
``` Sigmoid volvulus (makes sense because the sigmoid is a redundant/“floppy” structure!) ```
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DIVERTICULAR DISEASE OF THE COLON SIGMOID VOLVULUS What is it? P322 (picture)
Volvulus or “twist” in the sigmoid colon
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DIVERTICULAR DISEASE OF THE COLON SIGMOID VOLVULUS What is the incidence? P323
≈75% of colonic volvulus cases (Think: | Sigmoid = Superior)
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``` DIVERTICULAR DISEASE OF THE COLON SIGMOID VOLVULUS What are the etiologic factors? P323 ```
``` High-residue diet resulting in bulky stools and tortuous, elongated colon; chronic constipation; laxative abuse; pregnancy; seen most commonly in bedridden elderly or institutionalized patients, many of whom have history of prior abdominal surgery or distal colonic obstruction ```
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DIVERTICULAR DISEASE OF THE COLON SIGMOID VOLVULUS What are the signs/symptoms? P323
Acute abdominal pain, progressive abdominal distention, anorexia, obstipation, cramps, nausea/vomiting
143
``` DIVERTICULAR DISEASE OF THE COLON SIGMOID VOLVULUS What findings are evident on abdominal plain film? P323 ```
Distended loop of sigmoid colon, often in the classic “bent inner tube” or “omega” sign with the loop aiming toward the RUQ
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``` DIVERTICULAR DISEASE OF THE COLON SIGMOID VOLVULUS What are the signs of necrotic bowel in colonic volvulus? P323 ```
Free air, pneumatosis (air in bowel wall)
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DIVERTICULAR DISEASE OF THE COLON SIGMOID VOLVULUS How is the diagnosis made? P323
Sigmoidoscopy or radiographic exam with | gastrografin enema
146
``` DIVERTICULAR DISEASE OF THE COLON SIGMOID VOLVULUS Under what conditions is gastrografin enema useful? P323 ```
If sigmoidoscopy and plain films fail to confirm the diagnosis; “bird’s beak” is pathognomonic seen on enema contrast study as the contrast comes to a sharp end
147
``` DIVERTICULAR DISEASE OF THE COLON SIGMOID VOLVULUS What are the signs of strangulation? P323 ```
``` 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, ↑ WBCs ```
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``` DIVERTICULAR DISEASE OF THE COLON SIGMOID VOLVULUS What is the initial treatment? P323 ```
``` Nonoperative: If there is no strangulation, sigmoidoscopic reduction is successful in ≈85% of cases; enema study will occasionally reduce (5%) ```
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``` DIVERTICULAR DISEASE OF THE COLON SIGMOID VOLVULUS What is the percentage of recurrence after nonoperative reduction of a sigmoid volvulus? P323 ```
≈40%!
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``` DIVERTICULAR DISEASE OF THE COLON SIGMOID VOLVULUS What are the indications for surgery? P324 ```
``` Emergently if strangulation is suspected or nonoperative reduction unsuccessful (Hartmann’s procedure); most patients should undergo resection during same hospitalization of redundant sigmoid after successful nonoperative reduction because of high recurrence rate (40%) ```
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DIVERTICULAR DISEASE OF THE COLON CECAL VOLVULUS What is it? P324
Twisting of the cecum upon itself and the | mesentery
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``` DIVERTICULAR DISEASE OF THE COLON CECAL VOLVULUS What is a cecal “bascule” volvulus? P324 ```
Instead of the more common axial twist, the cecum folds upward (lies on the ascending colon)
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DIVERTICULAR DISEASE OF THE COLON CECAL VOLVULUS What is the incidence? P324
≈25% of colonic volvulus (i.e., much less | common than sigmoid volvulus)
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DIVERTICULAR DISEASE OF THE COLON CECAL VOLVULUS What is the etiology? P324
Idiopathic, poor fixation of the right colon, many patients have history of abdominal surgery
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``` DIVERTICULAR DISEASE OF THE COLON CECAL VOLVULUS What are the signs/ symptoms? P324 ```
``` Acute onset of abdominal or colicky pain beginning in the RLQ and progressing to a constant pain, vomiting, obstipation, abdominal distention, and SBO; many patients will have had previous similar episodes ```
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DIVERTICULAR DISEASE OF THE COLON CECAL VOLVULUS How is the diagnosis made? P324
``` Abdominal plain film; 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 (must rule out gastric dilation with NG aspiration) ```
157
``` DIVERTICULAR DISEASE OF THE COLON CECAL VOLVULUS What diagnostic studies should be performed? P324 ```
Water-soluble contrast study (gastrografin), | if diagnosis cannot be made by AXR
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DIVERTICULAR DISEASE OF THE COLON CECAL VOLVULUS What is the treatment? P324
Emergent surgery, right colectomy with primary anastomosis or ileostomy and mucous fistula (primary anastomosis may be performed in stable patients)
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``` DIVERTICULAR DISEASE OF THE COLON CECAL VOLVULUS What are the major differences in the EMERGENT management of cecal volvulus versus sigmoid? P325 ```
``` Patients with cecal volvulus require surgical reduction, whereas the vast majority of patients with sigmoid volvulus undergo initial endoscopic reduction of the twist ```

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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