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GI > Colon Cancer + Anorectal Cancer > Flashcards

Colon Cancer + Anorectal Cancer Flashcards

1
Q

What is the most common colon cancer and where does it affect

A

Adenocarcinoma
Rectum + sigmoid
Other - HNPCC / FAP

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2
Q

What is an adenoma (polyp) and types

A

Benign
Pre malignant
Tubular (75%)
Villous (10%)

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3
Q

What are high risk polyps

A

Large
Numerous
High risk dysplasia
Villous archiecture

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4
Q

How does colon cancer develop

A

Activation of oncogenes (K-ras, c-myc)
Loss of tumour suppressor genes - APC / p53
Defective DNA repair

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5
Q

What are the RF for colon cancer

A 
Age
Male 
Smoking
Alcohol
DM 
FH
Diet
Previous adenoma
Genetics - HNPCC / FAP
Neoplastic polyps 
IBD
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6
Q

What are high risk features of bowel cancer

A 
Bowel habit change > 6 weeks
Rectal bleeding with NO anal symptoms
Persistent abdo pain >6 weeks 
Unexplained anaemia 
MAss
Anaemia - unexplained 
Loss of appetite 
Bloating / IBS Sx 
Weight loss + abdominal pain >40
FOB found on test 
Clinical doubt

Having diarrhoea at night = abnormal

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7
Q

What do high risk features automatically get

A

Colonoscopy +- biopsy

Can do sigmoid but only up to sigmoid - if fresh bleed

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8
Q

What do R sided (ascending) colon cancer normally present with

A 
Anaemia due to occult bleed
Change in bowel habit >6 weeks
- Increased frequency 
- Increased consistency = more common 
Weight loss
Vague pain
Weakness
Present later as lumen can get very tight before obstruction as more liquid
BEWARE APPENDICITIS 
- tumour can obstruct appendix or can perforate and give appendicitis picture
- do CT scan in all >40
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9
Q

What does L sided (descending) colon cancer present with

A 
More common 
Obstruction - can present
Stricture / perforation / fistula 
Bleeding / mucous PR due to haemorrhage
Altered bowel habit 
Weight loss / lethargy 
Tenesmus - need to evacuate 
Mass 
Perforation
Anaemia = rare as will present early with bleed
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10
Q

What are common symptoms in bowel cancer

A 
Persistent blood
Persistent change in bowel habit
Persistent lower abdominal pain
Anaemia 
Loss of appetite
Bloating 
Mass 
Can have emergency presentation
- Perforation
- Obstruction
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11
Q

What do you do if symptoms <6 weeks + <40

A

Watch and review

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12
Q

What other investigations for colon cancer

How do you stage

A

CT colonography if unfit for colonoscopy (6 months post MI / COPD)
- Bowl prep and air inflation required
FOB / qFIT - before colonoscopy
Bloods - FBC, U+E, LFT, TFT, coeliac, Ca, calprotectin - differentials, full iron
Urine dip - as 1% of qFIT due to renal haematuria

Staging 
CT - CAP with contrast 
MRI if below peritoneal reflection
Liver MRI / USS 
PET if single met but chance of cure
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13
Q

What are the stages of colon cancer

A 
Dukes criteria or TNM 
T1 A- mucosa 
T2 B- muscle 
T3 C- LN
T4 D- metastatic 
AJCC
Stage 1 = early (T1/2) 
Stage 2 = no nodes (T3/4) 
Stage 3 = no mets (any nodal spread) 
Stage 4 = mets (any mets)
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14
Q

How do you treat Dukes A

A

Endoscopic resection
Remove node for analysis
DVT and Ax prophylaxis

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15
Q

How do you treat more advanced cancer

A

MDT
Chemotherapy given after and before
Radiotherapy - palliation mostly or for rectal net-adjuvant
Surgery = only way to cure
NSAID - reduce polyps and prevent recurrence
Biologics in combination with chemo

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16
Q

What are the complications of surgery

A 
Anaeshtetic issue
Bleeding 
Infection / sepsis 
Pain 
Nerve or vessel damage
Damage to ureter / bowel 
DVT 
Wound hernia / dehiscence
Obstruction 
Post op ileus - give sugar before 
Anastomatic breakdown - day4-5
Post op fistula
Post op stricture
Adhesions
High output stoma = volume deplete/ electrolyte imbalance
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17
Q

What is the screening programme for bowel cancer

A 
50-74 
FOBT / qFIT every 2 years
If +Ve = colonoscopy 
Recognises Hb
Different if FAP etc
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18
Q

What is FAP

A

Autosomal dominant APC mutation (tumour suppressor)
Annual colonoscopy from age 10
Prophylactic protocolectomy at 16

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19
Q

What do you get if you are HNPCC +Ve

A

AD mutation in DNA mismatch repair gene
2 year colonoscopy from 25
Endometrial / colon cancer / ovarian / pancreatic

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20
Q

What do you get if you have IBD

A

Colonoscopy 10 year post diagnosis

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21
Q

What is considered high risk FH

A

Colon cancer in 3 FDR

5 year colonoscopy at 55

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22
Q

What do you get if low risk

A

Single colonoscopy at 55

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23
Q

Where does colon cancer spread too

A

Local
Lymphatic
Blood - liver = most common, lung, bone
Transcoelomic

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24
Q

What factors play a role in whether anastomose or stoma

A

Blood supply - e.g. PVD will most likely have stoma
Tissue tension
Sepsis
Unstable patient

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25
Q

Where is an ileostomy typically

A

R iliac fossa
Stump
Emit frequent fluid motion with active enzyme so need to protect skin

Same with urostomy as urine = toxic

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26
Q

Where is a colostomy

A

L iliac fossa
Flatter stump as not as acidic to skin - this tells you what it is rather than side
Solid faeces inside
If need replaced will be on different sides

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27
Q

What are palliative options

A

Chemo / RT
Diversion stoma
COlonic stenting

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28
Q

When would you do endoscopy / colonoscopy

A

Unexplained iron deficiency as risk of malignancy / bleeding / coeliac

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29
Q

What are your differentials to look for in blood

A 
Caclium
Thyroid 
Urine dipstick 
FBC
qFIT 
COeliac serology
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30
Q

What does pT3 mean in lab report

A

Pathology reports umour as stage T3

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31
Q

What does yP

A

After neoajuvant treatment

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32
Q

ANATOMY

A

SMA 2nd part of duodenum to 2/3 tranverse
IMA supplies the rest to superior rectum
Marginal artery supplies whole gut (supplies colon in L colonic resection as on L side)
SMA = L1
IMA = L3

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33
Q

What are the flexures of the colon

A

Hepatic - SMA

Splenic - IMA

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34
Q

What are the nodes of the colon

A

Same as arterial supply
Level of resection determined by nodes invollved as must remove all nodes supplying tumour
Can’t see node so look at arteries

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35
Q

What is difference between end stoma or loop

A

End = irreversible
- One lumen
Loop is to defunction to protect distal anastomoses
- Two lumen

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36
Q

What side is more likely to need temp stoma

A

More distal = more likely to need stoma
R side usually okay
L side as presents obstructed
Rectal = most common

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37
Q

What side tend to do worse

A

R side as SMA blood supply

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38
Q

If person presents obstructed / perforation what do you do

A

Anastomosis is difficult
Stent = option
Loop stoma then fix at later date - ileostomy

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39
Q

When can you anastomose even in emergency

A

Ileo-caecal

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40
Q

What is HArtman’s procedure for

A

Emergency procedure for ruptured sigmoid / L colon with end colostomy formed in LIF
Proctosigmoidectomy with end colostomy
Rectum stump closed
Can go back after and reconnect
NO ANASTOMOSIS so no risk of anastomotic leak

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41
Q

When do you do left hemicolectomy

A

Splenic
Descending
Colon-colon

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42
Q

When do you do R hemicolectomy

A

Caecal
Transverse
Ileo-colon

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43
Q

What tumour marker for disease progression

A

CEA

Not useful for screening

44
Q

When do you do urgent referral within 2 weeks

A

> 40 weight loss and abdominal pain
50 bleed
60 anaemia or change in bowel
+ve QFIT

45
Q

When should you consider referral

A

Mass
<50 PR bleed +- abdominal pain / change in bowel / weight loss / anaemia

do QFIT if don’t meet
- e.g. abdo pain and weight loss - no bleed

46
Q

What is used post op for analgesia and why

A

Epidural as reduced time for normal gut transit to return

47
Q

How do you check anastomoses has worked

A

Gastrograffin enema

48
Q

How does anastomotic leak present

A 
Usually day 4-5 
Septic peritonitis depending on size
Faecal / other material in drain bag 
Pain
Guarding
No bowel movement
Hypotension
Tachycardia
Fever
49
Q

How do you Dx

A

Gastrograffin

CT

50
Q

How do you Rx

A

Surgery

51
Q

What do you do if wound breaks down

A

Surgery
Emergency if deep and bowel showing
Can pack if superficial

52
Q

What are early complications of stoma

A 
Haemorrhage
Stoma ishcaemia 
High output which can lead to hypokalaemia / dehydration / acidosis due to loss of bicarb
- SOB etc do ABG if suspect 
Malabsorption as lose bowel length 
Obstruction 2 to adhesion
Stoma retractions
Infections 
Infarction = necrotic
53
Q

What d you consider in high output

A

Loperamide + codeine to thicken

54
Q

What are delayed complications

A 
Skin irritation  / dermatitis 
Prolapse 
Obstruction 
Granuloma
Intussception 
Stenosis 
Hernia - increase in size when cough 
Fistula
55
Q

How do you follow up after curative resection

A

CT CAP - 1,2,3 years
Colonsocpy at 1 and 5 years
CEA 6 monthly for 3 years

56
Q

What can anorectal cancer be

Key anatomy

A

Squamous = 80%
Adenocarcinoma if purely rectal

Split into 3rds
Top 3rd completed covered by peritoneum
Middle third covered anteriorly by peritoneum
Both supplied by superior rectal (branch of IMA)

Lower 3rd has no periotneal covering
Supplied by middle and inferior rectal artery (branch of common iliac)
Rectal more common spread to lung as inferior rectal vein goes direct to IVC not portal HTN

57
Q

How does it present

A 
Similar to haemorrhoids / fissure
Bleeding - bright red (compared to dark red in L side) 
Itch
Lumps
Obstruction 
Feeling of incomplete evacuation 
- due to tumour stretching rectum
Mucous discharge = characteristic 
Loss of continence
Morning diarrhoea 
- Constipated due to tumour but in the morning wake up and blood and mucous fall out
58
Q

How do you investigate / prepare for pre-op

A 
Bloods 
Rectal exam + Procotscopy / sigmoidoscopy for initial Sx
Colonoscopy / CTC to look for further cancer 
Biopsy
Staging-  CT CAP 
Local staging - MRI / EUS 
Bowel prep 
Stoma marking
59
Q

What do you test for if Dx

A

HIV

60
Q

Where does anorectal cancer spread too

A

Proximal / above dentate = to pelvic
Anal margin = inguinal
More distant is uncommon

61
Q

What do you do if present obstructed

A

Defuction stoma until can stage cancer

Don’t resect as won’t be able to anastomose

62
Q

What are RF

A

HPV
SMoking
Weakened immune system - HIV

63
Q

How do you treat SCC prior to surgery

A

RT as extraperitoneal and high risk of recurrence (can’t have RT in colon)
80% = squamous

64
Q

How do you treat adenocarcinoma (rare) prior to surgery

A

Chemo + RT
RT only in rectal
Laparoscopic resection

65
Q

Surgical options

A 
Anterior perineal if 
If sphincter invovled
Very low 
2cm clearance margin needed 
Leaves patient with permanent colostomy

Anterior resection if upper / middle rectum (part of bowel and rectum)

  • Most surgeons defunction below peritoneal reflection as high risk of anastomotic leak below
    e. g. loop ileostomy (temp stoma to allow time to heal)
  • Closed in 6-8 weeks if Gastrograffin enema shows no leak or stricture)
66
Q

What are complications

A

Recto-vaginal fistula
Damage to ureter / spleen as L colon fully mobilised during operation
Anastomotic leak
Abscess

Sexual / urinary dysnfciton = later complication

67
Q

What is the peritoneal reflection

A

Upper third of rectum covered by peritoneum

Lower 2/3 aren’t

68
Q

Post op analgesia

A

Epidural useful as decreased time to normal bowel function

69
Q

What should be done before reverse of loop stoma to check anastomosis has worked

A

Gastrograffin

70
Q

What is the least risky stoma to create which can be easily reversed

A

Loop ileostomy

Could do colonostomy but large bowel takes longer to heal and higher risk of anastomotic leak

71
Q

What is important when thinking of complications

A

Anatomy of where structures are

72
Q

If R colon what are important relations

A

DUODENUM = most important
R kidney
R urea

73
Q

If transverse colon

A

Stomach

Pancreas

74
Q

If L colon

A

Spleen = most important
L kidney
L ureter

75
Q

If duodenum was damaged how may the present

A

Bile in drain causing leak into colon

76
Q

If spleen was damaged

A

Cause bleeding

Patient would be tachycardia then shock

77
Q

If ureter damaged

A

May get urine in drain (need to analyse fluid)

May have AKI

78
Q

Appendicitis and colon cancer

A

Tumour can obstruct appendix

Tumour can perforate and produce an appendicitis picture with raised inflammatory

79
Q

What should you do if >40 + appendicitis

A

CT scan

80
Q

Prior to elective op what is needed as FY1

A

Bloods
Colonic visualisation
Staging
Bowel prep

81
Q

What bloods

A

FBC
U+E
LFT
Probs more e.g. X-match etc

82
Q

What do you do if low Hb

A

If 70-100 ask senior

If <70 then transfuse

83
Q

Why U+E / LFT

A

Liver mets

Tumour can obstruct ureter

84
Q

What colonic visualisation is required

A

Colonoscopy

CT colonograph

85
Q

What is used to stage

A

CT CAP

86
Q

Why is bowel prep required

A

Increase likelihood of successful anastomosis
If large-large and full of faces won’t be successful
If small - large ie. in R hemicolectomy then will be fine as small bowel just liquid

87
Q

What do you do

A

ASK NURSE for consultant preference as all different

88
Q

What else can be used to view the colon

A

Proctoscopy

Flex sigmoidoscopy

89
Q

What does colonoscopy require

A

Bowel prep
Sedation
Not suitable if CVS disease
Small risk of perforation / bleed

90
Q

When do you use

A

If suspect colon as must see whole colon due to having multiple tumours
PR bleed
Anaemia
Change in bowel

91
Q

When would you do CT colonograoh

A

If elderly / frail

Has high radiation dose

92
Q

When do you do proctoscopy

A

To view ANAL canal for haemorrhoids

93
Q

When would you do flex sigmoid

A

If young patient with PR bleed
Can see up to splenic flexure (70% malignancy)
Also if PR bleed must have come from below

94
Q

What does consent for an op involve

A 
Why needed 
Whats involved
Any alternative 
Possible complications
Risk of stoma
95
Q

What post op care is needed

A 
Pain relief
DVT prophylaxis
IV fluid
Monitor urine output
Physio 
Possible oral intake
96
Q

What are complications of heme-colectomy

A 
General surgery
INtra-abdo abscess
Anastomotic leak
Damage to structure 
- Duodenum
- Spleen
- Ureter 
Haemorrhage shock
97
Q

When is emergency surgery to colon carried out

A

Obstruction
Complicated diverticular disease
Perforation

98
Q

If R colon what can you do

A

Ileo-colic anastomosis if resectable (less risk as more proximal)
Ileostomy if non-resectable

99
Q

If L colon what can you’d o

A

Proximal stoma with ileo-colic anastomosis

Hartmann’s

100
Q

If want to avoid stoma what can you do

A

Resection of tumour with primary anastomosis - high risk of leak
+- defunctioning stoma

101
Q

When are colonic stents used

A

If unfit
If high volume metastatic disease
As bridge to surgery in LBO

102
Q

What are complications

A

Perforation
Migration
Obstruction

103
Q

Other indications stoma

A

IBD
AFP
Sepsis - intra-abdo
Haemorrhage

104
Q

What do you do if someone has stoma

A 
Full Hx
Fluid balance 
Obs 
Bloods - FBC, U+E, CRP 
CT AP if comlplications
105
Q

What is important post op

A

VTE prophylaxis as high risk

NUTRITION

106
Q

What can you do for metastatic disease

A

Can remove

Before or after the primary

GI (29 decks)

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