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FRCS > Colorectal > Flashcards

Colorectal Flashcards

1
Q

What proportion of colorectal cancers are associated with HNPCC?

A

-This is Lynch syndrome - about 3-5%

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2
Q

What is the Genetic defect in Lynch Syndrome?

A

Usually MMR deficiency

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3
Q

What screening should patients with Lynch syndrome receive?

A

2 yearly colonoscopy from 25-75 for MLH1/MLH2
and from 35 for MSH6/PMS2 mutations

2 yearly OGD from 50
Annual TVUSS and ca125
Annual renal USS

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4
Q

What are the extra intestinal manifestations of Lynch syndrome?

A

30-70% endometrial cancer
5-10% Gastric cancer

(30-70% Colorectal cancer)

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5
Q

What screening should patients with FAP receive?

A

Colonoscopy 1-3 yearly from 12-14 until resection.

OGD from 25

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6
Q

What is the mutation seen in FAP?

A

5q21 APC gene (80%) Autoosomal dominant

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7
Q

What surveillance should be performed in patients ‘at risk’ of APC without an identified APC mutation?

A

Colonoscopy 5 yearly from 12-14

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8
Q

Where are polyps seen in FAP?

A

Colonic - 100% - Cancer risk of near 100%
Gastric fundal - 50%
Duodenal 90% - if severe risk of 30% Ca at 10 years)

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9
Q

What eye condition is associated with FAP?

A

Congenital hypertrophy retinal pigmentation epithelium (CHRPE)

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10
Q

What is Gardner’s syndrome?

A

FAP + Oestoomas, thyroid cancer, epidermoid cysts and fibromas

Jaw osteomas, extra teeth

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11
Q

What are some indications for surgery in FAP?

A

Polyps >10mm, HGD, substantial increase in polyp burden

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12
Q

What medical treatments can be used for FAP with intra-abdominal desmoids?

A

Sulindac + SERM

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13
Q

What surveillance should be conducted for Peutz Jeghers syndrome?

A

OGD, Colonoscopy and video capsule at 8 years.

Capsule 3 yearly, if polyps also OGD/Colon 3 yearly, otherwise at 18

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14
Q

What is the mutation in Peutz Jeghers syndrome?

A

STK11 mutation on Chromosome 19 (Dominant)

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15
Q

What types of tumours are most commonly seen in Peutz Jeghers?

A

Harmartomas
20% risk of CRC and 5% Gastric Cancer
Also breast, ovarian, cervical, pancreatic and testicular

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16
Q

What is the mutation in Cowden disease?

A

PTEN 10q22

89% Ca any site
81% Breast
16% CRC

Also thyroid and uterine

Some overlap with Juvenile polyposis syndrome

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17
Q

What effect does 5-ASA have on fertility?

A

80% of males develop sperm dysmotility

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18
Q

What is 6-metacaptopurine (6-MP)

A

A thiopurine (purine analogue) depressing inflammatory cascade by affecting folic acid and DNA synthesis.

Can take up to 6 weeks for clinical response, 30% of patients are intolerant.

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19
Q

What proportion of patients develop parastomal hernias?

A

Colostomy - 60%

Ileostomy - 30%

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20
Q

How is a rectal prolapse graded?

A

Grade 1 - No lower than proximal limit of rectocele
Grade 2 - into rectocele but not top of anal canal
Grade 3 - descends to top of anal canal
Grade 4 - descends into anal canal
Grade 5 - protrudes from anus

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21
Q

What proportion of patients with SRUS respond to biofeedback?

A

75%

If fails – consider stapled transanal rectal resection (STARR) or VMR

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22
Q

What is the success rate of GTN/Diltiazem for fissure?

A

20-70%

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23
Q

What medication can reduce the risk of CRC in Lynch syndrome?

A

Aspirin if taken for >2 years

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24
Q

Which patients with rectal cancer should be offered radiotherapy/chemoradiotherapy

A

cT3-cT4 or cN1+

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25
Q

What is the recommended volume of procedures for rectal cancer?

A

Annual site of >10 and individual >5

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26
Q

Which patients with colon cancer should be considered for preoperative treatment?

A

cT4 only

FOXTROT trial 2019 - FOLFOX (5-FU, Folinic Acid and OXaliplatin)

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27
Q

What adjuvant treatments are suitable for colorectal cancer patients?

A

If short course RT or no preoperative treatment
Stage 3 disease (N+ve)

CAPOX 3 months or FOLFOX 6 months

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28
Q

What is the most common side effect of treatment with oxaliplatin?

A

Sensory neuropathy

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29
Q

What are common side effects of 5-FU?

A

Diarrhoea
Epistaxis
Plantar-palmar erythema

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30
Q

What is the most common site of large bowel carcinoid?

A

Caecum

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31
Q

Who receives bowel screening in the UK?

A

Every 2 years from 60-74 (working towards 50) –> FIT test, if abnormal –> colonoscopy

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32
Q

What is the risk of cancer in a 5mm polyp?

A

near 0%

6-15mm -3.3
26-25mm 18.7
26-35mm 42.7
>35 75.8

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33
Q

How are colonic polyps described?

A

Using the Haggitt and Kikuchi classifications.

The Haggitt classification is for pedunculated polyps - Level 1-4

Kikuchi for sessile

Haggitt 4 (into submucosa) and Kikuchi SM2/3need excision (LN 8-27%)

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34
Q

What colonoscopic surveillance should be offered to patients treated for colorectal cancer?

A

Colonoscopy at 1 year

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35
Q

For patients with polyps found and excised at colonoscopy, how should they be surveilled?

A

If ≥5 premalignant, or ≥2premalignant including 1 ≥10mm or dysplastic, or large polyp >2cm completely excised en bloc –> 3 yearly colonoscopy

If large polyp incompletely excised or piecemeal –> 2-6 month check and again at 1 year.

If none of these, discharge. Also if life expectancy less than 10 years or >75

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36
Q

Where is botulinum toxin A injected for fissure?

A

Internal anal sphincter 15-30 units

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37
Q

What is Park’s classification of fistula?

A

Course relating to EAS/IAS and Levators

Inter, Trans, Supra, Extra

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38
Q

What is Goodsall’s rule?

A

If external opening posterior to transverse anal line, will have curvilinear tract to posterior aspect of anal canal in midline

If external opening anterior to transverse anal line, will have a radial tract, unless >3cm from anus

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39
Q

What proportion of patients with ileocaecal Crohns disease will require surgery?

A

> 90% - mainly strictures

10-15% of colitis cannot differentiate CD from UC

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40
Q

What is the risk of colon cancer with UC with pancolitis?

A

5% at 10 years
20% at 20 years

Overall rates are 2% and 8% (similar for Crohns)

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41
Q

What proportion of patients with UC present with proctitis?

A

30%

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42
Q

What proportion of patients with UC have pancolitis?

A

20%

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43
Q

What histological findings are present with solitary rectal ulcer syndrome?

A

Extension of the muscularis mucosa between crypts and muscularis proprietor disorganisation

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44
Q

What is MUIR-TORRE syndrome?

A

HNPCC + associated skin lesions (epidermoid cysts + keratoacanthoma)

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45
Q

What is the active ingredient of Klean Prep?

A

Polyethylene glycol made into solution up to 4L

Difficult to consume, but minimal electrolyte disturbances

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46
Q

Sodium picosulphate is administered how?

A

2 x 45ml solutions - better tolerated, but risk of electrolyte disturbances

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47
Q

What is the recurrence rate after a Delormes’?

A

50% at 5 years

Unsuitable for internal prolapse

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48
Q

In which patients should a STARR procedure be considered?

A

High grade internal rectal prolapse with obstructive defecation symptoms

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49
Q

How are rectal tumours defined?

A

Within 15cm of anal verge.

Intramural spread is usually <1cm distally

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50
Q

When is EUS useful for rectal tumours?

A

If T1 where TEM is considered

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51
Q

What findings predict a clear CRM for rectal cancer?

A

Distance >1mm on MRI

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52
Q

When should surgery be performed after short course RT for rectal cancer?

A

4-8 weeks - similar oncological outcomes and decreased complications to 1 week

cf 6-10 weeks Long course CTX

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53
Q

How much radiotherapy is given for short course in rectal cancer?

A

25Gy (5 x 5)

vs 50.4 for long course (1.8 x 28)

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54
Q

Which trials support short course RT for rectal cancer?

A

Swedish Rectal Cancer Trial (cT1-3) - but before TME

Followed by CKVO 95-04 with TME, where reduced local recurrence but OS same

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55
Q

What evidence for long course CTX in rectal cancer?

A

German Rectal Cancer trial

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56
Q

When is long course CRT usually given for rectal cancers?

A

T4 with threatened CRM

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56
Q

When is long course CTX usually given in rectal cancer?

A

T4 with threatened CRM

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57
Q

When is a low anterior resection performed?

A

Rectal tumours where a 2-5cm distal clearance margin can be gained

Minimum of 1cm

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58
Q

How many lymph nodes should be examined in a CRC specimen?

A

At least 12

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59
Q

What is the local recurrence rate after a traditional AP?

A

about 15%

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60
Q

What chemotherapy is used in liver metastasis of CRC?

A

FOLFOX 4, started prior to liver resection for about 3 months

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61
Q

What is the rate of recurrence after liver resection for colorectal liver metastasis?

A

up to 60%, usually within 1-2 years

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62
Q

What features make a colorectal liver met resectable?

A

Four or fewer segments/deposits
Residual liver volume >40%
IVC not involved

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63
Q

What features make a colorectal liver met irresectable?

A

Invovement of two portal branches
Involvement of three hepatic veins
Marked extra hepatic disease

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64
Q

What is the commonest extraintestinal manifestation of UC?

A

Arthropathy (also in CD)

PSC and Uveitis more common in UC

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65
Q

Which eye manifestation of IBD is more common in Crohns?

A

Episcleritis

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66
Q

What are the pathological findings of UC?

A

Confined to mucosa/submucosa
Widespred superficial ulceration with preservation of adjacent mucosa (pseudopolyps)
Inflammatory cell infiltrate in lamina proprietor
Crypt abscesses
Depletion of goblet cells

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67
Q

What is the peak incidence of UC?

A

15-25 and 55-65.

UC is less common in smokers

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68
Q

What is the optimum length of ileostomy?

A

about 2.5cm

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69
Q

What is the output of a normal ileostomy?

A

5-10ml/kg/24 hours

If in excess of 20ml/kg/24hours will need supplementation

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70
Q

What is the most specific imaging investigation for colonic polyps?

A

CT colonoscopy

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71
Q

What injection sclerotherapy agent can be used for haemorrhoids?

A

5% phenol in almond oil (not 88%!)

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72
Q

What proportion of FAP cases are sporadic?

A

20-25%

Causes 0.5% of CRC

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73
Q

What proportion of adenomas >1cm have a KRAS mutation?

A

50%

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74
Q

When is cetuximab useful?

A

Wild type KRAS +/- irinotecan

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75
Q

What length of ileostomy can be denuded from its mesentery?

A

5cm

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76
Q

How should patients with cRC be imaged postoperatively?

A

Twice within 3 years usually at 6 and 18 months, with 6 monthly CEA for 3 years.

If having chemotherapy, perform first scan at end of treatment

If had liver resection usually 6monthly intervals for 2 years

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77
Q

Where do anal fissures most frequently occur?

A

Posterior midline (90%) - more likely to be anterior in females

Multiple fissures raises suspicion of Crohns disease, TB or internal rectal prolapse

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78
Q

What are the functional consequences of sphincerotomy?

A

Incontinence to flatus in 30%

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79
Q

For low pressure anal fissure, what is the definitive treatment of choice?

A

Advancement flap

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80
Q

How is a simple uncomplicated anal fistula defined?

A

Low, involving <30% of external sphincter

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81
Q

What is the success rate for fibrin glue for fistula?

A

50% healing at 6 months - of whom 25% will have a recurrence

Plugs (don’t work) and cutting setons (incontinence) not recommended

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82
Q

What is the success rate of a LIFT procedure?

A

Ligation of intersphincteric tract - up to 90%

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83
Q

What is the incidence of anastomotic leak in low anterior resection?

A

8-20%

There is no evidence that placement of drains affects this. For exam, should place defunctioning ileostomy

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84
Q

What is the 5 year survival of patients treated with salvage APER after failing to respond to CRT?

A

40%

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85
Q

What is the most common side effect of stapled haemorrhoidectomy?

A

Urgency

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86
Q

What is the most common type of Fistula-in-ano?

A

Intersphincteric (70%)

Trans (25%), Supra (4%), Extra (1%)

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87
Q

In infants how should low anal fistulas be managed?

A

Just lay them open. Rarely associated pathology

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88
Q

What is the predominant blood supply to the splenic flexure?

A

Left colic branch of IMA in 89% of cases –> default left hemicolectomy

In emergency setting for obstruction, probably extended Right is the correct choice

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89
Q

What is the risk of progression of AIN III to cancer?

A

10% at 10 years, 30% if HIV+ve

Therefore 6 monthly follow up

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90
Q

What is the innervation of the anal sphincter?

A

Pudendal nerve S2-4

Autonomic fibres from within colon and external innervate internal sphincter

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91
Q

How can faecal incontinence be graded?

A

Wexner faecal incontinence score (Cleveland clinic)
0 (absent) -4 (daily)
Incontience to gas, liquid, solid, wearing pad and lifestyle changes

9+ = severe

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92
Q

What investigations are warranted for faecal incotinence?

A

EUS
Anorectal physiology studies
Defecating proctogram

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93
Q

What are the treatment options for faecal incontinence?

A

Conservative (loperamide, laxative, biofeedback)

SNS modulation - usually S3 temporary electrode and permanent for responders. PNE or barbed wires

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94
Q

What is the Paris classification of polyps?

A

Global polyp description.

1 -protruded (pedunculated/sessile)
0IIa - Flat elevated
0IIb - Flat
0IIc - Flat depressed (highest risk)

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95
Q

What microscopic changes are seen with CMV colon (2)?

A

Large intranuclear inclusions body

Smaller cytoplasmic inclusions

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96
Q

What microscopic changes are seen with UC (3)?

A

Alteration of crypt architecture
Dense neutrophilic infiltrates and crypt abscesses
Ulceration with pseudo polyps

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97
Q

What microscopic changes are seen with Crohns disease (4)?

A

Granulomas (non caveating epiheliod cell aggregates with Langhans’ giant cells
Submucosal fibrosis
Fissuring
Areas of chronic inflammation

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98
Q

What microscopic changes are seen with radiation enteritis (4)?

A

Disordered crypts
Endarteritis obliterans
Fibrosis of lamina propria
Ulceration and fistulation

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99
Q

What microscopic changes are seen with infective colitis (3)?

A

Increased cellularity in the lamina propria
Neutrophilic infiltrates
Loss of crypts

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100
Q

What microscopic changes are seen with SRUS (3)?

A

Fibromuscular obliteration
Surface ulceration
Little inflammatory activity

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101
Q

How frequently does pouchitis occur?

A

50% after restorative proctocolectomy, with chronic pouchitis accounting for 10% of pouch failures.

Should be diagnosed luminally followed by treatment with 2/52 of metro/cipro

Sometimes get prophylaxis

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102
Q

What are the common extra intestinal manifestations of Crohns disease (10)?

A 
Related to disease extent	  Unrelated to disease extent
Aphthous ulcers (10%)	                Sacroiliiitis (10-15%)
Erythema nodosum (5-10%)	        Ankylosing spondylitis (1-2%)
Pyoderma gangrenosum (0.5%)	Primary sclerosing cholangitis (Rare)
Acute arthropathy (6-12%)	        Gallstones (up to 30%)
Ocular complications (up to 10%)	 Renal calculi (up to 10%)
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5
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103
Q

With anal cancers, what proportion of enlarged inguinal nodes are metastatic?

A

About 50%. The remainder being enlarged due to infection

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104
Q

What investigations are required for Anal cancer?

A

EUA, rigid sigmoidoscopy + biopsy

If confirmed, MRI, CTCAP, PET-CT

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105
Q

What is the primary treatment strategy for anal cancer?

A

Chemoradiotherapy - IV 5-FU and Mitomycin C with 50gy of radiation

Combined > Radiotherapy

Complications - Diarrhoea, mucositis, myelosuppresion, skin erythema, desquamation, anal stenosis and fistula formation

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106
Q

What is the FIT test?

A

Antibiodies that specifically recognise human Hb

Reduced false positives compared to FOB

FIT <10 0.6% CRC
FIT>10 9.4% CRC
FIT >400 22.4% CRC

Sensitivity 70-80%

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107
Q

What is the prevalence of diverticular disease at 40, 50 and 80?

A

10% <40
50% >50
70% 80

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108
Q

Which rectal tumours can be considered for local excision? (TEMS, TAMIS, TEO)

A

Well/moderately differentiated
No EMVI
<4cm and <30% circumference
T1

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109
Q

What is the rate of lymph node metastasis according to SM stage for T1b rectal cancer?

A

SM1 - <3%
SM2 8-11%
SM3 12-25%

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110
Q

What are the modalities of obstetric faecal incontinence?

A

1) Sphincter injury (tear, forceps)

2) Pudendal neuropathy (reduced anal sensation and squeeze pressures)

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111
Q

What are contraindications to placement of a SNS?

A 
Full thickness rectal prolapse
Active IBD
Pregnancy
Skin disease
Anatomical limitations
Psychiatric disease
Congenital malformations
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112
Q

When might you consider an anal sphincter repair?

A

Young patient failed conservative treatment
Non smokers, normal BMI
At least 3 clock face arm defect

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113
Q

What are the Spigelman criteria?

A

For assessing duodenal polyps in FAP and deciding on screening/intervention

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114
Q

What is the most common cause of death in patients with FAP?

A

Intra-abdominal desmoid

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115
Q

In patients at high risk of FAP how should they be surveilled?

A

Annual Flexi from 13 and colonoscopy every 5 years from 20.

No OGD unless diagnosed FAP

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116
Q

When should surgery for FAP be performed

A

Usually 16-18 - then 6-12 monthly Flexi sig if IRA and annual pouchoscopy if RPC.

Don’t forget OGD at 25

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117
Q

What is the cumulative rectal cancer risk with a colectomy/IRA in patients with FAP?

A

30% by 60

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118
Q

What is the difference between traditional APE and Extra-levator APE? (ELAPE)

A

APE has higher CRM+ and perforation than anterior resection

ELAPE avoids the coning down that occurs towards the anal canal

119
Q

In which patients with UC should a pouch not be considered?

A 
Poor anal sphincter
Possibility of Crohns
Active anal lesions
Sclerosing cholangitis (high rate of pouchitis)
Fecundity
120
Q

What are the potential complications of pouch surgery?

A 
Anastomotic Leak 5%
Pouch failure 10%
Stricture and SBO 10%
Pelvic sepsis 15%
Pouchitis 30% (occurs in 10% in FAP)
Reduced fertility in women and sexual dysfunction (25%)

Stool frequency x 8 and 2 at night
Incontinence 5-10%

Mortality 0.4%, morbidity 30%, reoperation 16%

121
Q

How are obstetric injuries classified?

A 
Sultan system
1st - perineal skin/vaginal mucosa
2nd - perineal muscles only
3a - <50% EAS
3b - >50% EAS
3c Both EAS and IAS
4 rectal mucosa
122
Q

What are the side effects of taking long term metronidazole?

A

Peripheral neuropathy if > 6weeks

123
Q

How is a high anterior resection defined?

A

Tumour above peritoneal reflection.

Alternatively could say >10cm from anal verge (low 6-10 and ultra low <6)

124
Q

What surgical approach is optimal for Rectal prolapse?

A

The PROSPER trial 2013 showed no difference between approaches (recurrence 13-24%), but was abdominal/perineal approach was surgeons choice

125
Q

Which study provides evidence for the use of TXA in a trauma setting?

A

The CRASH 2 trial

Early administration (<1 hours > than 1-3 hours) reduces risk of death in bleeding patients

126
Q

How should an extraperitoneal rectal injury be managed?

A

If <25% circumference and accessible transanally can be repaired primarily. If no accessible, then can observe. If >25% circumference will need drainage and diversion

127
Q

How is a colonic transit study conducted?

A

Ten makers ingested on six consecutive days with an AXR on the 7th day.

2.4 x number of markers == colonic transit time

Delayed if 48 hours or 20 markers visible

128
Q

What are the Truelove and Witts criteria?

A

Combination of number of blood motions, pulse, temperature, Hb and ESR/CRP.

Severe features suggest need for colectomy, especially at 48 hours
Blood stool >6, tachycardia, fever, anaemia, CRP>90/ESR>30

129
Q

For patients with severe colitis and >8 stools per day at 48 hours, how frequently is a colectomy required?

A

85% chance - also if raised CRP >45 and 3-8 stools per day

If stable can still have Infliximab or Cyclosporin

130
Q

What are some options for surgical treatment of pilonidal disease?

A

Bascom 1 – Lateral Incision and excision of pits with diamond shaped
Bascom 2/cleft lift – Excision of large area off midline but including midline. Lateral side mobilised, about 4cm excised, superficial flap
Karydakis – similar but a deep flap sutured to deep fascia
Gips – trephine pit excision

Limberg, Z-plasty, V-Y flaps, Rhomboid

131
Q

Which HPV serotypes are associated with anal SCC/AIN?

A

16 and 18

132
Q

In diverticular abscess, what is the failure rate of percutaneous drainage?

A

> 20%

133
Q

How should patients with colitis be surveilled?

A

Personalised -

Low risk (extensive colitis with no inflammation, left side only, Crohns <50%) - 5 years

Intermediate risk (mildly active extensive, pseudopolyps, FH>50FDR) - 3 years

Higher risk (mod/severe extensive, stricture, dysplasia, PSC (inc post transplant), FH<50FDR) 1 year

134
Q

What tumour genetics are important when working patients up for CRC?

A

MMR, KRAS, BRAF

135
Q

Which Colon cancers benefit from neoadjuvant treatment?

A

pMMR, T4, left sided

136
Q

How are T4 rectal cancer managed in the neoadjuvant setting

A

Total neo-adjuvant - SCRT + Oxaliplatin - RAPIDO trial

Also T3 with involved CRM, EMVI, N2, lateral pelvic nodes

137
Q

How are haemorrhoids graded?

A

Golighers classfication

1: No Prolapse
2: Prolapse and spontaneously reduce
3: Prolapse and Digital reduced
4: Prolapse and don’t reduced

138
Q

How are haemorrhoids best treated?

A

1: RBL
2: RBL
3: MMH vs pexy vs RBL (Hubble shows equivalence)
4: MMH 2-8% recurrence, 4 weeks of pain. Consider metronidazole

139
Q

Where are anal cushions (internal haemorrhoids) normally located?

A

In the anal canal above the dentate line

Mucosa, submucosal fibroelastic cognitive tissue and smooth muscles in an AV channel system

140
Q

What is the external haemorrhoidal plexus?

A

The external haemorrhoidal plexus is a venous plexus encircling the anal verge. Therefore is the source of perianal haematoma - not external haemorrhoids

141
Q

What is the aetiology of haemorrhoids?

A

Anal cushions fixed in anal canal by Trietz’s ligaments - remants of rectal muscularis mucosa.

These are fragmented by repeated straining.

Other factors include:
Diarrhoea
Pregnancy
Raised intra-abdominal pressure
Hereditary
142
Q

What are the common causes of anal stenosis?

A

Haemorrhoidectoy with excessive mucocutaneous excision is most common (particularly where below the dentate line):

Other -
Congenital
Acquired ( irradiation, injury, post op e.g. anastomotic leak)
Neoplastic
Inflammatory
143
Q

What is the most common associated feature of pruritus ani?

A

Minor faecal incontinence

144
Q

What factors are associated with increased incidence of Hidradenitis suppurative?

A

Female gender, obesity, smoking, Africa-Americans
FH (42%, AR)

High risk of CVD

145
Q

What histological findings can be seen with Hidradenitis suppurativa?

A

Follicular hyperkeratosis, hyperplasia nad occlusion

Spongiform infundibulofoclliculitis

146
Q

What systemic treatments are recommended for treatment of HS?

A 
12 weeks of oral tetracyclines
-->
10-12 weeks of clindamycin + rifampicin 
-->
acitretin (males) or dapsone
-->
Adalimumab or Infliximab
147
Q

What is the most common location of Angiodysplasia in the colon?

A

Caecum and ascending colon (54-82%)
About 0.8% prevalence

In Japan it is the descending colon

MA develop secondary to chronic low-grade intermittent obstruction of submucosal veins with increased VEGF-dependent proliferation

148
Q

What is the first line treatment for patients with Angiodysplasia of the colon?

A

Argon plasma coagulation (85%)

If fails - thalidomide (71.4%) or octreotide (77%)

149
Q

What is the syndrome of Aortic Stenosis and Angiodysplasia?

A

Heyde’s syndrome

Patients with Von Willebrand disease and CRF are also at risk of AD

150
Q

What is the mechanism of Argon plasma coagulation?

A

Synchronised delivery of electrical current and argon

The argon is ionised and transmits the high frequency current to the tissue

151
Q

How are haemangiomas classified?

A

Mulliken and Glowacki:

Haemangiomas vs vascular malformations
Haemangiomas - high endothelial cell turnover, not present at birth but develop in first few weeks, often spontaneously involute

Intestinal malformations:

  • Capillary (perianal skin, small bowel, appendix)
  • Cavernous (localised vs diffuse - 80% rectum)
  • Mixed
  • Hemangiomatosis
152
Q

How does a harmartoma differ from a neoplasm?

A

Overgrowth of multiple aberrant cells within a systemic genetic condition rather than a clonal proliferation of a single stated cell

153
Q

How is the rectum defined?

A

Fusion of two anti mesenteric Taenia
15cm from anal verge on rigid sig
Large bowel within true pelvis

154
Q

In what proportion of CRC do LN mets skip a tier?

A

About 30%

155
Q

In what proportion of CRC are APC mutations found?

A

About 60%

156
Q

What is the sequence of events in the adenoma carcinoma sequence in CRC?

A

-APC
+Kras
-DCC
-p53

157
Q

What are dietary and lifestyle influences on CRC?

A 
\+ 
Red meat
Animal fat
Sugar
Smoking
Sedentary

-
Dieary fibre, exercise
Garlic
Non starchy vegetables

158
Q

What are the Amsterdam criteria?

A

For diagnosis of HNPCC (Lynch) - 3 -2 - 1 rule

3- relatives (or of related cancers - e.g. endometrium si or renal tract)

2- successive generations

1 - <50 and 1 should be a FDR of other 2

159
Q

What are the T and N stages of CRC?

A

T1 submucosa
T2 muscularis propria
T3 into subseorsa or non-peritnoealised tissues
T4 other organs or visceral peritoneum

N1 - 1-3
N2 - 4+

160
Q

What are microsatellites?

A

Short DNA sequence repeats (up to 5)

Mutations in MMR problems (e.g. HNPCC)
15% of sporadic CRC

MSI-High if >30% micro satellites mutated

161
Q

What is the York Mason transsphincteric procedure?

A

Repair of rectourethral fistula

162
Q

Where is the Waldeyers fascia?

A

Rectosacral region.

It defines the inferior border of the presaral space

163
Q

What are the borders of the presacral space?

A

Superior - peritoneal reflection
Inferior - Waldeyers fascia
Lateral - endopelvic fascia, utterers and iliac vessels

164
Q

What are the most common type of presacral tumours?

A

Most frequently congenital (2/3), with 50% malignant

Also inflammatory, neurogenic, osseous and miscellaneous
Solid masses more likely to be malignant

Most frequently resection is warranted due to risk of progression/malignant transformation

Biopsies generally avoided

165
Q

What is the Kraske operation?

A

A trans sacral approach for resection of retrorectal/presacral tumours

166
Q

When should patients with UC receive screening colonscopy?

A

8-10 years after diagnosis then:
5 years if low risk
3 years if intermediate risk
1 year if high risk

167
Q

How are acute and chronic radiation injuries to bowel defined?

A

< 6 weeks - diarrhoea, urgency, incontinence, bleeding - acute mucosal sloughing

For chronic - progressive endothelial dysfunction –> ischaemia and fibrosis

167
Q

How are acute and chronic radiation injuries to bowel defined?

A

< 6 weeks - diarrhoea, urgency, incontinence, bleeding - acute mucosal sloughing

For chronic - progressive endothelial dysfunction –> ischaemia and fibrosis

168
Q

To which lymph nodes do anal cancers spread?

A

Perirectal group –> inguinal, haemorrhoids and lateral pelvic lymph nodes

169
Q

Where does the rectum become the anal canal?

A

The dentate line.

Surgically the anal canal is about 4cm long with 2/3 above dentate line.

The dentate line is a fusion of anoderm and post allantoic gut

170
Q

What is the anorectal ring?

A

Ring of muscle about 5cm from anus including puborectalis, superior aspects of internal and external sphincter

171
Q

What are the components of the anal sphincter?

A

Internal smooth muscle (continuous with rectum), surrounding upper 2/3 of anal canal, sympathetic supply

External striated smooth muscle - inferior rectal branch of Pudendal nerve and perineal branch of S4 nerve root. Leaves pelvis via greater sciatic notch under piriformis, then crosses through lesser sciatic notch via pudendal (Alcock’s canal) into ischiorectal fossa

Puborectalis fuses (mainly S4 root) with EAS superiorly

Other branch of pudendal – perineal nerve — urethral sphincters and dorsal nerve of clitoris/penis

172
Q

What is the histological transition of the anal canal?

A

Stratified squamous –> dentate line (80% of cancers)

Transition zone

Rectal mucosa

173
Q

What are the Harvey Bradshaw and Crohns disease activity indexes?

A

CDAI <150 remission, >450 severely ill

Combination of stools, pain, well being, complications, abdominal mass

CDAI adds use of opiates, haematocrit, %SD of weight

174
Q

What are the microscopic appearances of CMV colitis?

A

Cytomegalovirus - Large intra nuclear inclusion body and smaller cytoplasmic inclusions

Ulcerative colitis

Alteration of crypt architecture. Branching crypts with marked deviation of the crypt axis from the perpendicular; variation in crypt size and/or shape; shortened crypts, with bases of crypts elevated off the muscularis mucosae
Dense neutrophilic infiltrates and neutrophils in crypts (crypt abscesses)
Ulceration may be identified, although fissuring is often absent

Crohns disease

Areas of chronic inflammation, comprising increased lamina propria plasma cells and lymphocytes, in association with chronic architectural distortion with patchy, mild to severe, neutrophilic inflammation, including neutrophilic cryptitis, crypt abscesses, or erosions/ulcers
Skip lesions
Granulomas
Sub mucosal fibrosis
Fissuring

Radiation enteritis -Disordered crypts
Endarteritis obliterans
Fibrosis of the lamina propria
Ulceration and fistulation

Infective colitis -Increased cellularity in the lamina propria, Neutrophilic infiltrates, Loss of crypts

Lymphocytic colitis Normal crypts with lymphocytic infiltrates
Collagenous colitis Normal crypts with lymphocytic infiltrates and collagen deposition in the lamina propria
SRUS = Fibromuscular obliteration, Surface ulceration, Little inflammatory activity

175
Q

When is a diagnosis of indeterminate colitis important?

A

If considering RPC with IPAA for supposed UC - not a good idea

176
Q

Which STDs present with proctitis?

A

Gonorrhea
Chlamydia
HSV
Syphilis

177
Q

Which STDs present with ulcers?

A

AIDS
Lymphogranuloma venereum
Primary Syphilis
Chancroid (Haemophilus Ducreyi - school of fish pattern)
Granuloma inguinale (Calymmatobacterium ganulomatis)
HSV

178
Q

Which STDs present with fistulas?

A

Lymphogranuloma venereum

Complex Bushke-Lowenstein Tumours (giant anal condylomata associated with HPV 6/11)

179
Q

What test modality is most frequently used to test for Chlamydia?

A

Nucleic acid amplification tests (NAATs)

LGV strains associated with HIV are more severe and can result in a necrotising lymphatic phenotype

180
Q

What are the types of laxative?

A

Bulk forming (Fybogel, ispaghula husk)
Osmotic (lactulose, macrogol i.e. laxido/movicol, PEG)
Stimulant (Biscodyl, Senna, sodium pico sulphate)
Softeners (sodium decussate, arachis oil)
Prokinetic (Cisapride, Prucalopride)

181
Q

How is chronic proctalgia defined?

A

Rome III criteria

  • chronic or recurrent rectal pain lasting at least 20 minutes
  • absence of structural or systemic disease explanations

Cf proctalgia fugax <20mins

Two subtypes

  • Levator ani syndrome (LAS) -with pain on palpation
  • unspecified
182
Q

What is the mainstay of treatment for Levator Ani syndrome?

A

Biofeedback

182
Q

What is the mainstay of treatment for Levator Ani syndrome?

A

Biofeedback

183
Q

What is the functional anatomy of the ureters?

A
  • Originate at PUJ posterior to renal artery/vein
  • Anterior edge of psoas muscle transverse processes of L2-L5
  • Gonadal vessels cross anteriorly 1/3 of way to bladder
  • Cross anterior to common iliac at bifurcation and pelvic brim
  • lateral pelvic side walls to ischial spines then anteromedially and into bladder obliquely

-Segmental blood supply - 1/3 renal, middle 1/3 common iliac, aorta, gonadal, distal 1/3 internal iliac

184
Q

What is the risk of cancer in patients presenting with diverticulitis?

A

2% uncomplicated

11% complicated –> colonoscopy if not <2 years 6-8 weeks

185
Q

What are the relevant trials associated with treatment of diverticulitis?

A

DIVER - ambulatory treatment safe Hinchey 1/2a<3cm
AVOD/DIABLO - Antibiotics can be avoided, RF CRP >170, younger
LADIES/SCANDIV/DILALA - laparoscopic lavage higher rate of reintervention/complications

DIRECT - elective surgery, 20-30% permanent stoma, 11% leak rate

186
Q

What is the size threshold for drainage of diverticular abscess?

A

> 4cm

10-30% failure

187
Q

What proportion of CRC present as an emergency?

A

20%, treatment with curative intent in only 52%, 11.5% 90d mortality

188
Q

What are contraindications to SEMS in obstructing rectal cancer?

A 
1 - <5cm from dentate line
2 - perforation
3 - peritonitis
4 - benign pathology
5 - Hx of bevacizumab treatment

80-90% success

189
Q

What is the median survival after bypass for obstructing carcinomatosis?

A

< 3 months

190
Q

What are the outcomes after perforated CRC?

A

Higher rate of local/peritoneal recurrence but distant metastasis similar

191
Q

What is the risk of colonic ischaemia after embolisation for LGIB?

A

4-11%

192
Q

What proportion of Cardiac Output does the splanchnic circulation receive?

A

15-35%

193
Q

What proportion of patients with pseudo-obstruction resolve with conservative management?

A

70% if caecum <12cm in 48-72hrs

If fails –> colonoscopic decompression/neostigmine

194
Q

What are the most common causes of LGIB?

A

Diverticular disease (60%) followed by anorectal conditions

23% diagnosis not found

195
Q

How should Warfarin be managed with LGIB?

A

Stop
If unstable –> PCC + Vit K

Low risk - restart 7 days post bleeding
High risk - consider bridging with LMWH

196
Q

How should DAPT be managed in LGIB?

A

Rebleed x 5 risk

Generally discontin clopidogrel and continue aspirin and restart 5 days

197
Q

What is the Oakland score?

A

A composite score for rebleeding risk in LGIB.

Comprises, age gender, previous admission, DRE, HR/SBP and Hb. If ≤8 then 95% chance of successful discharge

198
Q

How frequently does stomal prolapse occur with a transverse colostomy?

A

42% - cf 4-5% of others

199
Q

How may the open abdomen be classified?

A

Grade 1 - 4

1 - no fixation
2 - Developing fixation
3 - Frozen abdomen
4 - Frozen with entero-atmospheric fistula

a - clean
b - contaminated
e - enteric leak

200
Q

How frequently do fistulas occur with MMFT?

A

<10%, with 80-100% primary closure rate

201
Q

What proportion of perianal abscesses lead to fistulas?

A

17%

202
Q

What is the risk of perforation with colonoscopy?

A

<0.2% general
8% therapeutic

For screening present immediately - barotrauma
For interventional also risk of thermal/electrical trauma - perforates 24-72hrs)

203
Q

What are risk factors for perforation at colonoscopy (8)?

A 
Intervention
Right side
Low BMI
Increased age
Surgery
Female
GA
Crohn's
204
Q

How is UC classified in the elective setting?

A 
Montreal classification
Extent
E1 - proctitis
E2 - left sided (distal)
E3 - pancolitis (proximal to splenic flexure)

S0 - remission
S1 - mild (≤4 stools, no systemic disease)
S2 - moderate (>4, minimal systemic)
S3 - severe (≥6 bloody stools, HR ≥90, T≥37.5, Hb<10.5, ESR≥30)

205
Q

What is the risk of VTE with IBD?

A

Significantly raised
UC 2.1%
Crohns 4.1%

Consider extended prophylaxis

206
Q

What proportion of patients with CD require surgery?

A

50% at 5 years, 70% at 15 years

207
Q

What types of stricturoplasty are used?

A

Heineke-Mikulicz - longitudinal incision anti mesenteric border <5cm
Finney - side-side anastomosis without division 5-20cm
Michelassi - isoperistaltic side-side after division

208
Q

What are the indications for surgery in Crohns?

A

1) Failure of medical treatment (8-12 weeks after start)
2) growth retardation
3) Ileojejunal stricture (1/3 of patients can try balloon dilatation)
4) Abscess
5) Perforation
6) Fistula (not entero-enteric unless malabsorption)

209
Q

What are the Truelove and Witts criteria?

A

Acute severe colitis

Bowel motion ≥6
Systemic toxicity - HR ≥90, T≥37.5, ESR >30, Hb <10.5

210
Q

What is the composition of desomoid tumours?

A

Myofibroblast clonal proliferations - occur in 15% of patients with FAP with mortality rate of 10%

Most frequently occur in small bowel mesentery or abdominal wall

211
Q

What treatment options exist for intra-abdominal desmoids?

A

Surgery

NSAIDs (sulindac) +/- Tamoxifen

212
Q

What is desmoid-type fibromatosis?

A

Benign clonal tumour with locally aggressive but not metastatic tendencies

May be better suited by watchful waiting as local recurrence rates are very high after complete excision

Chemotherapy with doxorubicin may be helpful, even as NA.

Other treatments similar to desmoids

213
Q

When should patients with rectal cancer proceed straight to surgery?

A

cT3a or less with no threatened Crm, cN0 no EMVI

214
Q

When should patients with rectal cancer receive a PET?

A

Suspicion of occult disease, e.g. external iliac nodes

215
Q

What is Li Fraumeni Syndrome

A

P53 mutation, AD, early onset of tumours

50% <30

Breast, sarcoma, brain, adrenal

216
Q

What is the UK prevalence of Crohn’s disease?

A

150/100,000

217
Q

Which HPv serotypes does Gardasil protect against?

A

6, 11, 16 and 18

218
Q

What factors increase the risk of CRC in patients with IBD?

A

Duration and extent
PSC
FH
Young age at diagnosis

219
Q

How can anal adenocarcinomas be differentiated from rectal cancers on IHC?

A

Anal - CK7+/CK20-
Rectal - CK7-/CK20+

Prostate CK7-/CK20-

220
Q

What factors predict prognosis in anal SCC?

A

Females better
Tumour stage
Nodal involvement
Response

221
Q

What is the most important risk factor for small bowel adenocarcinoma?

A

Crohns diseasd

222
Q

In children what is the most common extra intestinal manifestation of IBD?

A

Erythema nodosum

223
Q

What proportion of screen detected cancers are polyp cancers?

A

10-25%

30%A and 30%B

224
Q

What proportion of FIT tests are positive?

A

1-3%

225
Q

What is the most common malignancy in the retrorectal space?

A

Chordoma

More common in males 4th to 5th decade

226
Q

In what condition is a scimitar sign seen?

A

Retrorectal meningocele

227
Q

How do rectal duplication cysts appear?

A

Multilobular cyst with several satellite lesions. More common in women

228
Q

How should patients diagnosed with perforation post colonoscopy be managed.

A

If stable with no signs of sepsis and bowel prepped –> conservative treatment with bowel rest (2-6d) and IV Abx (3-5d) + IVI

If unstable –> laparoscopy +/- proceed

WSES Guidelines 2017

229
Q

What provides the greatest reduction in risk of parastomal hernia?

A

Placement of mesh at primary surgery

230
Q

What are risk factors for stercoral perforation?

A

Chronic constipation
NSAID use
Anticholinergic agents

231
Q

What contraindications to neostigmine use?

A 
2nd/3rd degree HB
ACS
Urinary retention
Asthma
Bronchospasm

Reversible cholinesterase inhibitor 80-90% success to single IV 2mg. Can give 2-3 boluses or continuous infusion.

232
Q

How often should patients with PSC have a colonoscopy?

A

Annually

233
Q

What is the Spigelman Classification?

A

Duodenal carcinoma risk in FAP

234
Q

What type of colonic polyp carries the highest risk of malignancy?

A

Villous (40%) > TV (20%) > Tubular (5%)

235
Q

What type of polyps are found in Juvenile polyposis?

A

Harmartomas

236
Q

What are the primary energy source of colonocytes?

A

Short chain fatty acids (SCFAs) - acetate, butyrate and propionate.

Can be used as treatment for diversion colitis

237
Q

What is the most diagnostic feature for appendicitis?

A

Localising tenderness at McBurney’s point

238
Q

What is the most common cause of rectovaginal fistula?

A

Obstetric injury

239
Q

What immunoglobulin is secreted by the appendix?

A

IgA

240
Q

What is the most common intestinal parasite worldwide?

A

Ascariasis lumbricoides

241
Q

What is the arterial supply of the rectum?

A

IMA –> Superior rectal artery (1/3)
IIA –> Middle rectal artery
Internal Pudendal A –> Inferior rectal artery

242
Q

What is the venous supply of the rectum?

A

SRV –> IMV –> Splenic vein –> Portal vein

MRV/IRV –> IIV

243
Q

What is the normal small bowel length?

A

About 600cm, range of 300-800cm

<100cm no colon
<50cm with colon

likely to lead to PN dependence.

244
Q

What intra-abdominal infections are classically associated with fistulating disease?

A

TB and actinomycosis

245
Q

What are the three phases of intestinal failure?

A

1) Hypersecretory
2) Adaptation - less reliant on fluids, 3-12 months (ileum better than jejunum)
3) Stabilisation - 1- 2 years

246
Q

What volume of fluid is produced by the proximal GI tract?

A

7litres, of which 6 litres reabsorbed proximal to ICJ, 800ml in colon and 200ml in stool.

247
Q

Which part of the GI tract has the highest concentration of Potassium in secretions?

A

Rectum (30mmol/l)
SI/STomach (10mmol/l)
Bile/Pancreas (5mmol/l)

248
Q

Where is sodium primarily absorbed in the GI tract?

A

Ileum > Colon
80% Co-transport (AA, glucose, bile) 20% active pump

Water passively follows this.

249
Q

How much sodium can be lost with a high fistula or jejunostomy?

A

300-400mmol/day and 3-4l of water

250
Q

How much water and sodium can be absorbed in the colon?

A

Sodium up to 700mmol
Water up to 7L of water
40mmol Potassium

251
Q

What nutrients are absorbed in the jejunum?

A

Carbohydrates, protein and water soluble vitamins

Except zinc - which may become deficient

252
Q

Where are fat, bile acids and fat soluble vitamins (A,D,E,K) absorbed?

A

Vitamins absorbed over length of intestine, however bile salt deficiency (as absorbed in ileum) can result in reduced absorption of fats and therefore reduced vitamins

If ileum removed can result in bile salt secretory diarrhoea

253
Q

Where is Vitamin B12 absorbed?

A

Distal ileum

254
Q

Where is iron primarily absorbed?

A

Duodenum, upper jejunum
about 10% of dietary absorbed (Fe2+>Fe3+)

Increased by Vit C, acid, decreased by PPI, tannin

255
Q

What stone disease occurs after ill resections?

A

Calcium oxalate renal stones –> increased colonic absorption of oxalate

Gallstones

256
Q

What are the energy requirements of males and females?

A

M - 25-30kcal/kg/day

F - 20-25kcal/kg/day

257
Q

What are the normal daily requirements of fluid, potassium and sodium?

A

25-30ml/kg/water

1mmol/kg/day potassium, sodium and chloride

50-100g/day of glucose

NICE

258
Q

What are the electrolyte concentrations of Hartmanns and NS?

A

Hartmanns - Na 130, CL 109, K 4, Ca 3, Lact 28

NS - Na 154, Cl 154

259
Q

Where is the highest concentration of sodium found in GI losses?

A

Pancreatic, bile and small bowel - 140mmol/l

260
Q

What volume of secretions are typically produced in the GI tract?

A 
Saliva 1L
Stomach 1-2L
Pancreas 1L
Bile 1L
SB 2-5L
LB 0.2L - 1L
Sweat 0.2-1L
261
Q

Deficiencies of which vitamins are associated with peripheral neuropathy?

A

Vit B6/B12

262
Q

What are the characteristic findings of Zinc deficiency?

A

Parakeratosis (dry thick skin) and facial rash

263
Q

What are the types of Intestinal failure?

A

Type 1 - self limiting (ileus/inflammation)
Type 2 - prolonged (complication, EC fistula, sepsis)
Type 3 - Long term (SBS, obstruction, motility disorder)

264
Q

What is the critical length of small bowel before the development of IF?

A

<100-150cm if no colon

<50cm if colon inset

265
Q

What are standard CHO and lipid requirements?

A

2-4g/Kg/day 0.7-1.25g/kg/day

266
Q

What are the indications for supplemental nutrition on ITU?

A

ESPEN

  • ICU>2 days
  • Mechanical ventilation
  • Infection
  • Underfeeding >5 days
  • Severe chronic disease
267
Q

What is the calorie content of Propofol?

A

1.1kcal/ml

268
Q

What are the route related nutritional complications?

A

Parenteral - Catheter related vs infectious

Enteral - GI disturbances vs mechanical

269
Q

What are the metabolic complications of supplementary nutrition?

A

Short term - refeeding/acutemetabolic changes

Long term - TPN related

270
Q

Where should the tip of a TPN line be seen on a CXR?

A

Below the level of the Carina

271
Q

What is the key biochemical abnormality in refeeding syndrome?

A

Phosphate <0.65mmol/l, or drop of >0.16mmol/l,

but does not always correlate with clinical findings

272
Q

What is the key biochemical abnormality detected in refeeding syndrome?

A

Phosphate <0.65mmol/l, or drop of >0.16mmol/l,

but does not always correlate with clinical findings

Nb low K+ and Mg2+, hypernatraemia

273
Q

What is the key driver of refeeding syndrome?

A

Glucose –> High insulin levels –> intracellular, glucose, phosphate and thiamine and Na/K exchange

274
Q

How can sphincter pain after MM haemorrhoidectomy be managed?

A

Diltiazem cream/GTN

275
Q

Hinchey?

A 
1a -- Pericolic Inflammation
1b -- Pericolic abscess
2a -- Abscess amenable to drainage
2b -- Complex abscess +/- fistula
3 -- Purulent peritonitis
4 -- Faecal peritonitis
276
Q

What is Cowden syndrome?

A

Multiple Harmartoma syndrome
AD inheritance

Multiple mucoscutaneous lesions
50% Breast Ca, 75% FCD breast
15-20% risk of CRC
Thyroid cancer

277
Q

How frequently should patients treated with chemorad for anal cancer be followed up?

A

Clinical 6-8 weeks then
Clinical 4-8 weeks then
MRI 3-6 months then
CT at 12 months

278
Q

What is the incidence of incontinence in adults?

A

Up to 10% of all adults

279
Q

What is the incidence of adenomatous polyps on colonoscopy for >70 year olds?

A

> 50%

280
Q

What is the importance of cribriform colorectal cancer?

A

About 7%
Increased lymph node metastasis
Central necrosis

281
Q

What is the commonest side effect of diltiazem treatment?

A

Pruritus

282
Q

what is the reduction in fertility seen with IPAA?

A

50%

283
Q

what proportion of CRC are MSI-high?

A

20% (only 3% Lynch)
Proximal colon >Distal colon
Mucin, lymphocytic infiltrate, signet ring
Slightly better prognosis

284
Q

What proportion of anal SCC have mets at presentation?

A

5%

285
Q

What age threshold for colonoscopy for BRRB?

A

≥45 (ACPGBI)

286
Q

In which situation is TTG negative in patients with coeliac disease?

A

IgA deficiency

287
Q

What defines a moderate risk of CRC in non -Lynch patients?

A

1 x FDR <50 or 2 xFDRs age age –> one off colonoscopy at 55

288
Q

What defines a high risk of CRC in non -Lynch patients?

A

3 x FDRs across >1 generation

Colon 5 yearly from 40

289
Q

Damage to which structures in anterior resection can cause erectile dysfunction?

A

Inferior hypogastric plexus

290
Q

Which trans-anal approach to rectal cancer excision carries a high multifocal recurrence risk?

A

TA-TME

291
Q

What are the common causes of Colovesical fistula?

A

Diverticular (60-70%)
Cancer (10-20%)
Crohns (5-7%)
Radiation, iatrogenic injury, trauma, TB (rare)

292
Q

How is Hirschprung’s disease diagnosed?

A

Suction rectal biopsy in children

Full thickness biopsy adult

FRCS (13 decks)

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