Colon, Rectum, Anus

Question 1

How does appendiciits happen?

Answer 1

Fecalith obstructs (adults)/lymphoid aggregates post diarrhea (kids)–> obstruction distention–>edema and inflammation–>irritation of parietal peritoneum–> ischema,infarct–>perforation

Question 2

Periumbilical abdominal pain moves to RLQ

Answer 2

Appendicits

Question 3

Why is it that if there distention in the colon due to irritation/infection, then why doesnt it extend to the intestines?

Answer 3

Ileocecal valve prevents reflux of air

Question 4

Most common causes of a large bowel obstruction?

Answer 4

In US: Colorectal cancer
Global: sigmoid volvulus

Question 5

How do you work up a large bowel obstruction?

Answer 5

xray to look for distention and air
then CT w/IV contrast

Question 6

Whorl sign

Answer 6

Swirling appearence of mesentary suggestive of a volvulus

Question 7

Coffee bean on xray

Answer 7

sigmoid volvulus

Question 8

Internal or External Hemerroids: Bleed but do not hurt

Answer 8

Internal! No somatic innervation above the pectinate line

Question 9

Internal or External Hemerroids: Bleed and hurt

Answer 9

External!

Question 10

Problem for hairy ass’d people

Answer 10

pilonidal disease

Question 11

Infection of sinus tracts on butt

Answer 11

pilonidal disease

Question 12

HPVs that are associated w/anal sex

Answer 12

16, 18, and other

Question 13

What are some major risk factors for anal cancer?

Answer 13

HIV+ and anal receptive sex

Question 14

What is this characteristic of?

“There are subcutaneous sinuses that open onto pits found midline in the intergluteal fold. These pits, sinuses, and tracts (all the same thing) can have hair grow into them. There can also be skin, debris, and fluid. These sinuses chronically drain and can become acutely infected. The pits go unnoticed and unseen until an abscess forms. The abscess is treated like any other, with incision and drainage.”

Answer 14

Pilonidal disease

Question 15

What medical therapies help with anal fissures?

Answer 15

Dietary changes and regular defecationwill prevent the fissure from worsening. Then, it is all about relaxation of the anal sphincter. Medical therapy, including topical nitroglycerin, calcium-channel blockers (nifedipine), and botulinum toxin injections (try topical agents first), should be exhausted before going to surgery.

Question 16

Answer 16

diverticulitis

Question 17

Autoimmune disease that causes shallow, broad-based ulcers starting in colon and are continuous through the proximal colon Pt presents w/ Abdominal pain, bloody diarrhea, no malabsorption

Dx:Colonoscopy = Broad-based ulcers, pseudopolypsBiopsy = Crypt abscesses

Answer 17

Ulcerative colitis

Question 18

How does the presentation differ in left versus right sided colon cancer?

Answer 18

Left-sided colon cancer obstructs, and stricture causes pencil-thin stools, alternating constipation with diarrhea

Right-sided colon cancer bleeds

Question 19

How do we make sure dx before rushing domone off for an appendectomy?

Answer 19

Though point-of-care ultrasound may eventually replace CT for the diagnosis of acute appendicitis, CT remains the best radiological test to diagnose and stage the disease (just use low-dose radiation CTs).

Question 20

What are the hichney stages?

Answer 20

Its used to assess diverticulitis

Question 21

Which hichney stage gets you to the OR?

Answer 21

3 and 4

Hinchey stage 0 does not need treatment, Hinchey stage 1 needs antibiotics and bowel rest, Hinchey stage 2 needs IV antibiotics and a drain, and Hinchey stages 3 and 4 need sigmoidectomy.

Question 22

What is the process for treating anal fissures?

Answer 22

Anal fissures are treated first by getting the stool soft and bowel movements frequent;

second by relaxing the anal sphincter with topical medications or botulinum injections;

finally by performing a lateral internal sphincterotomy.

Question 23

How can you discern an ileocecal volvulus on XR?

Answer 23

There is distension of the proximal colon (the dilation is on the left side of the image, right side of the patient) without gas patterns for the transverse, descending, or sigmoid colon, indicating that this is an ileocecal volvulus (cecal volvulus)

Question 24

deep palpation of the LLQ leading to RLQ pain . . . which is a more brutal version of the rebound method described in Approach to Abdominal Pain; do not perform a maneuver to elicit this sign

Answer 24

Rovsings sign
appendicitis

Question 25

elicited by passive extension of the hip

Answer 25

psoas sign

appendicitis

Question 26

passive internal rotation of a flexed hip elicits pain

Answer 26

obturator sign

Question 27

Uncomplicated appendicits doesnt need surgery. What do we mean by uncomplicated?

Answer 27

Uncomplicated appendicitis is inflamed and swollen but without necrosis/perf

Question 28

What are the theorized causes of anal fissures?

Answer 28

The cause is unknown, but several theories exist. The initial tear is likely a result of antecedent constipation. A big, hard stool is passed through the sphincter and the sphincter tears. However, because so many successful medical therapies involve relaxation of the sphincter muscle, another potential cause is a hypertonic anal sphincter (insert inappropriate tight ass joke here). The patient will complain of intense pain with defecation that lasts for hours. These patients tend to associate defecation with pain, so they voluntarily withhold stool, making constipation—and the fissure—worse.

Question 29

Where is UC lesions vs crohn?

Answer 29

UC= COLON
Crohn=ANYWHERE mouth to anus

Question 30

Depth of invasion: UC v crohn

Answer 30

UC= mucosa only
crohn=transmural

Question 31

Diffuse continuous lesions: UC or crohn

Answer 31

Diffuse=UC

Question 32

Crypt abscesses

Answer 32

UC

Question 33

Skip lesions

Answer 33

crohn

Question 34

When is cancer a problem in IBD?

Answer 34

when it involves the colon, so in all UC and in some CROHN

Question 35

REctal exam shows an exquisitely tender, purple mass just below the dentate line. What is your next step in managment?

Answer 35

hemorrhoidectomy (not rubber band ligation)
this is a thrombosed external hemorrhoid

Question 36

Right-sided colon cancers _______________, left-sided colon cancers ______________.

Answer 36

R bleed, L obstruct

Question 37

L or R sided colon cancer: iron deficiency anemia

Answer 37

R sided bleeds, bleeding causes iron-deficiency anemia in a man or postmenopausal woman.

Question 38

L or R sided colon cancer: pencil thin stools

Answer 38

Obstruction alters the caliber of stools (pencil thin)

Question 39

First line medical management of UC

Answer 39

UC (Ulcerative colitis)
Salicylates (5-asa, mesalamine)

Question 40

When do we start screening with a colonoscopy in a person with UC?

Answer 40

In a person with ulcerative colitis, we start 8 years after dx and q1yr until soemthing bad is found

Question 41

Most common site of colon volvulus

Answer 41

sigmoid colon

Coffee bean on xr

Question 42

Diverticula appear where luminal pressures are highest, in the _____________________

Answer 42

sigmoid colon

Question 43

What is the approach for treating diverticulitis

Answer 43

If there are only microperforations (the peritoneum is not perforated and infection is contained), as evidenced by the absence of free air under the diaphragm or diffuse peritonitis, the patient can be treated with IV Abx alone if there is no abscess, and IV Abx + perc drain if there is an abscess. If macroperforations are present(diffuse peritonitis) then IV Abx with sigmoid resection is preferred.

Question 44

Anal cancer can be screened for with

Answer 44

Anal cancer can be screened for with an anal Pap test.

Question 45

How do we treat anal fissures?

Answer 45

FIBER is for starters

Medical therapy, including topical nitroglycerin, calcium-channel blockers (nifedipine), and botulinum toxin injections (try topical agents first), should be exhausted before going to surgery. When medical therapy fails, anoscopy with biopsy is performed to make sure the diagnosis is correct. Ultimately, a lateral internal sphincterotomy is performed.