Colorectal Flashcards
1
Q
How would you treat an acute anal fissure?
A
Assess for red flag features
Stool softeners
GTN 0.2% for 8 weeks (or 2% Diltiazem) –> 60-70% response
If fails EUA +/- biopsy +/- Botox 25 units either side into internal anal sphincter (90% success)
If fails anal manometry and endoanal US
2
Q
What proportion of colorectal cancers are associated with HNPCC?
A
-This is Lynch syndrome - about 3-5%
3
Q
What is the Genetic defect in Lynch Syndrome?
A
Usually MMR deficiency
4
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
5
Q
What are the extra intestinal manifestations of Lynch syndrome?
A
30-70% endometrial cancer
5-10% Gastric cancer
(30-70% Colorectal cancer)
6
Q
What screening should patients with FAP receive?
A
Colonoscopy 1-3 yearly from 12-14 until resection.
OGD from 25
7
Q
What is the mutation seen in FAP?
A
5q21 APC gene (80%) Autoosomal dominant
8
Q
What surveillance should be performed in patients ‘at risk’ of APC without an identified APC mutation?
A
Colonoscopy 5 yearly from 12-14
9
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)
10
Q
What eye condition is associated with FAP?
A
Congenital hypertrophy retinal pigmentation epithelium (CHRPE)
11
Q
What is Gardner’s syndrome?
A
FAP + Oestoomas, thyroid cancer, epidermoid cysts and fibromas
Jaw osteomas, extra teeth
12
Q
What are some indications for surgery in FAP?
A
Polyps >10mm, HGD, substantial increase in polyp burden
13
Q
What medical treatments can be used for FAP with intra-abdominal desmoids?
A
Sulindac + SERM
14
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
15
Q
What is the mutation in Peutz Jeghers syndrome?
A
STK11 mutation on Chromosome 19 (Dominant)
16
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
17
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
18
Q
What effect does 5-ASA have on fertility?
A
80% of males develop sperm dysmotility
19
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.
20
Q
What proportion of patients develop parastomal hernias?
A
Colostomy - 60%
Ileostomy - 30%
21
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
22
Q
What proportion of patients with SRUS respond to biofeedback?
A
75%
If fails – consider stapled transanal rectal resection (STARR) or VMR
23
Q
What is the success rate of GTN/Diltiazem for fissure?
A
20-70%
24
Q
What medication can reduce the risk of CRC in Lynch syndrome?
A
Aspirin if taken for >2 years (NICE)
25
Which patients with rectal cancer should be offered radiotherapy/chemoradiotherapy
cT3-cT4 or cN1+
26
What is the recommended volume of procedures for rectal cancer?
Annual site of >10 and individual >5
27
Which patients with colon cancer should be considered for preoperative treatment?
cT4 only
FOXTROT trial 2019 - FOLFOX (5-FU, Folinic Acid and OXaliplatin)
28
What adjuvant treatments are suitable for colorectal cancer patients?
If short course RT or no preoperative treatment
Stage 3 disease (N+ve)
CAPOX 3 months or FOLFOX 6 months
29
What is the most common side effect of treatment with oxaliplatin?
Sensory neuropathy
30
What are common side effects of 5-FU?
Diarrhoea
Epistaxis
Plantar-palmar erythema
31
What is the most common site of large bowel carcinoid?
Caecum
32
Who receives bowel screening in the UK?
Every 2 years from 60-74 (working towards 50) --> FIT test, if abnormal --> colonoscopy
33
What is the risk of cancer in a 5mm polyp?
near 0%
6-15mm -3.3
26-25mm 18.7
26-35mm 42.7
>35 75.8
34
How are colonic polyps described?
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%)
35
What colonoscopic surveillance should be offered to patients treated for colorectal cancer?
Colonoscopy at 1 year
36
For patients with polyps found and excised at colonoscopy, how should they be surveilled?
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
37
Where is botulinum toxin A injected for fissure?
Internal anal sphincter 15-30 units
38
What is Park's classification of fistula?
Course relating to EAS/IAS and Levators
Inter, Trans, Supra, Extra
39
What is Goodsall's rule?
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
40
What proportion of patients with ileocaecal Crohns disease will require surgery?
>90% - mainly strictures
10-15% of colitis cannot differentiate CD from UC
41
What is the risk of colon cancer with UC with pancolitis?
5% at 10 years
20% at 20 years
Overall rates are 2% and 8% (similar for Crohns)
42
What proportion of patients with UC present with proctitis?
30%
43
What proportion of patients with UC have pancolitis?
20%
44
What histological findings are present with solitary rectal ulcer syndrome?
Extension of the muscularis mucosa between crypts and muscularis proprietor disorganisation
45
What is MUIR-TORRE syndrome?
HNPCC + associated skin lesions (epidermoid cysts + keratoacanthoma)
46
What is the active ingredient of Klean Prep?
Polyethylene glycol made into solution up to 4L
Difficult to consume, but minimal electrolyte disturbances
47
Sodium picosulphate is administered how?
2 x 45ml solutions - better tolerated, but risk of electrolyte disturbances
48
What is the recurrence rate after a Delormes'?
50% at 5 years
Unsuitable for internal prolapse
49
In which patients should a STARR procedure be considered?
High grade internal rectal prolapse with obstructive defecation symptoms
50
How are rectal tumours defined?
Within 15cm of anal verge.
Intramural spread is usually <1cm distally
51
When is EUS useful for rectal tumours?
If T1 where TEM is considered
52
What findings predict a clear CRM for rectal cancer?
Distance >1mm on MRI
53
When should surgery be performed after short course RT for rectal cancer?
4-8 weeks - similar oncological outcomes and decreased complications to 1 week
cf 6-10 weeks Long course CTX
54
How much radiotherapy is given for short course in rectal cancer?
25Gy (5 x 5)
vs 50.4 for long course (1.8 x 28)
55
Which trials support short course RT for rectal cancer?
Swedish Rectal Cancer Trial (cT1-3) - but before TME
Followed by CKVO 95-04 with TME, where reduced local recurrence but OS same
56
What evidence for long course CTX in rectal cancer?
German Rectal Cancer trial
57
When is long course CRT usually given for rectal cancers?
T4 with threatened CRM
58
When is long course CTX usually given in rectal cancer?
T4 with threatened CRM
59
When is a low anterior resection performed?
Rectal tumours where a 2-5cm distal clearance margin can be gained
Minimum of 1cm
60
How many lymph nodes should be examined in a CRC specimen?
At least 12
61
What is the local recurrence rate after a traditional AP?
about 15%
62
What chemotherapy is used in liver metastasis of CRC?
FOLFOX 4, started prior to liver resection for about 3 months
63
What is the rate of recurrence after liver resection for colorectal liver metastasis?
up to 60%, usually within 1-2 years
64
What features make a colorectal liver met resectable?
Four or fewer segments/deposits
Residual liver volume >40%
IVC not involved
65
What features make a colorectal liver met irresectable?
Invovement of two portal branches
Involvement of three hepatic veins
Marked extra hepatic disease
66
What is the commonest extraintestinal manifestation of UC?
Arthropathy (also in CD)
PSC and Uveitis more common in UC
67
Which eye manifestation of IBD is more common in Crohns?
Episcleritis
68
What are the pathological findings of UC?
Confined to mucosa/submucosa
Widespred superficial ulceration with preservation of adjacent mucosa (pseudopolyps)
Inflammatory cell infiltrate in lamina propria
Crypt abscesses
Depletion of goblet cells
69
What is the peak incidence of UC?
15-25 and 55-65.
UC is less common in smokers
70
What is the optimum length of ileostomy?
about 2.5cm
71
What is the output of a normal ileostomy?
5-10ml/kg/24 hours
If in excess of 20ml/kg/24hours will need supplementation
72
What is the most specific imaging investigation for colonic polyps?
CT colonoscopy
73
What injection sclerotherapy agent can be used for haemorrhoids?
5% phenol in almond oil (not 88%!)
74
What proportion of FAP cases are sporadic?
20-25%
Causes 0.5% of CRC
75
What proportion of adenomas >1cm have a KRAS mutation?
50%
76
When is cetuximab useful?
Wild type KRAS +/- irinotecan
77
What length of ileostomy can be denuded from its mesentery?
5cm
78
How should patients with cRC be imaged postoperatively?
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
79
Where do anal fissures most frequently occur?
Posterior midline (90%) - more likely to be anterior in females
Multiple fissures raises suspicion of Crohns disease, TB or internal rectal prolapse
80
What are the functional consequences of sphincterotomy?
Incontinence to flatus in 30%
81
For low pressure anal fissure, what is the definitive treatment of choice?
Advancement flap
82
How is a simple uncomplicated anal fistula defined?
Low, involving <30% of external sphincter
83
What is the success rate for fibrin glue for fistula?
50% healing at 6 months - of whom 25% will have a recurrence
Plugs (don't work) and cutting setons (incontinence) not recommended
84
What is the success rate of a LIFT procedure?
Ligation of intersphincteric tract - up to 90%
85
What is the incidence of anastomotic leak in low anterior resection?
8-20%
There is no evidence that placement of drains affects this. For exam, should place defunctioning ileostomy
86
What is the 5 year survival of patients treated with salvage APER after failing to respond to CRT?
40%
87
What is the most common side effect of stapled haemorrhoidectomy?
Urgency
88
What is the most common type of Fistula-in-ano?
Intersphincteric (70%)
Trans (25%), Supra (4%), Extra (1%)
89
In infants how should low anal fistulas be managed?
Just lay them open. Rarely associated pathology
90
What is the predominant blood supply to the splenic flexure?
Left colic branch of IMA in 89% of cases --> default left hemicolectomy
In emergency setting for obstruction, probably extended Right is the correct choice
91
What is the risk of progression of AIN III to cancer?
10% at 10 years, 30% if HIV+ve
Therefore 6 monthly follow up
92
What is the innervation of the anal sphincter?
Pudendal nerve S2-4
Autonomic fibres from within colon and external innervate internal sphincter
93
How can faecal incontinence be graded?
Wexner faecal incontinence score (Cleveland clinic)
0 (absent) -4 (daily)
Incontience to gas, liquid, solid, wearing pad and lifestyle changes
9+ = severe
94
What investigations are warranted for faecal incotinence?
EUS
Anorectal physiology studies
Defecating proctogram
95
What are the treatment options for faecal incontinence?
Conservative (loperamide, laxative, biofeedback)
SNS modulation - usually S3 temporary electrode and permanent for responders. PNE or barbed wires
96
What is the Paris classification of polyps?
Global polyp description.
1 -protruded (pedunculated/sessile)
0IIa - Flat elevated
0IIb - Flat
0IIc - Flat depressed (highest risk)
97
What microscopic changes are seen with CMV colon (2)?
Large intranuclear inclusions body
Smaller cytoplasmic inclusions
98
What microscopic changes are seen with UC (3)?
Alteration of crypt architecture
Dense neutrophilic infiltrates and crypt abscesses
Ulceration with pseudo polyps
99
What microscopic changes are seen with Crohns disease (4)?
Granulomas (non caveating epiheliod cell aggregates with Langhans' giant cells
Submucosal fibrosis
Fissuring
Areas of chronic inflammation
100
What microscopic changes are seen with radiation enteritis (4)?
Disordered crypts
Endarteritis obliterans
Fibrosis of lamina propria
Ulceration and fistulation
101
What microscopic changes are seen with infective colitis (3)?
Increased cellularity in the lamina propria
Neutrophilic infiltrates
Loss of crypts
102
What microscopic changes are seen with SRUS (3)?
Fibromuscular obliteration
Surface ulceration
Little inflammatory activity
103
How frequently does pouchitis occur?
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
104
What are the common extra intestinal manifestations of Crohns disease (10)?
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%)
105
With anal cancers, what proportion of enlarged inguinal nodes are metastatic?
About 50%. The remainder being enlarged due to infection
106
What investigations are required for Anal cancer?
EUA, rigid sigmoidoscopy + biopsy
If confirmed, MRI, CTCAP, PET-CT
107
What is the primary treatment strategy for anal cancer?
Chemoradiotherapy - IV 5-FU and Mitomycin C with 50gy of radiation --> 80% cure rate
Combined > Radiotherapy
Complications - Diarrhoea, mucositis, myelosuppresion, skin erythema, desquamation, anal stenosis and fistula formation
108
What is the FIT test?
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%
109
What is the prevalence of diverticular disease at 40, 50 and 80?
10% <40
50% >50
70% 80
110
Which rectal tumours can be considered for local excision? (TEMS, TAMIS, TEO)
Well/moderately differentiated
No EMVI
<4cm and <30% circumference
T1
111
What is the rate of lymph node metastasis according to SM stage for T1b rectal cancer?
SM1 - <3%
SM2 8-11%
SM3 12-25%
112
What are the modalities of obstetric faecal incontinence?
1) Sphincter injury (tear, forceps)
2) Pudendal neuropathy (reduced anal sensation and squeeze pressures)
113
What are contraindications to placement of a SNS?
Full thickness rectal prolapse
Active IBD
Pregnancy
Skin disease
Anatomical limitations
Psychiatric disease
Congenital malformations
114
When might you consider an anal sphincter repair?
Young patient failed conservative treatment
Non smokers, normal BMI
At least 3 clock face arm defect
115
What are the Spigelman criteria?
For assessing duodenal polyps in FAP and deciding on screening/intervention
116
What is the most common cause of death in patients with FAP?
Intra-abdominal desmoid
117
In patients at high risk of FAP how should they be surveilled?
Annual Flexi from 13 and colonoscopy every 5 years from 20.
No OGD unless diagnosed FAP
118
When should surgery for FAP be performed
Usually 16-18 - then 6-12 monthly Flexi sig if IRA and annual pouchoscopy if RPC.
Don't forget OGD at 25
119
What is the cumulative rectal cancer risk with a colectomy/IRA in patients with FAP?
30% by 60
120
What is the difference between traditional APE and Extra-levator APE? (ELAPE)
APE has higher CRM+ and perforation than anterior resection
ELAPE avoids the coning down that occurs towards the anal canal
121
In which patients with UC should a pouch not be considered?
Poor anal sphincter
Possibility of Crohns
Active anal lesions
Sclerosing cholangitis (high rate of pouchitis)
Fecundity
122
What are the potential complications of pouch surgery?
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%
123
How are obstetric injuries classified?
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
124
What are the side effects of taking long term metronidazole?
Peripheral neuropathy if > 6weeks
125
How is a high anterior resection defined?
Tumour above peritoneal reflection.
Alternatively could say >10cm from anal verge (low 6-10 and ultra low <6)
126
What surgical approach is optimal for Rectal prolapse?
The PROSPER trial 2013 showed no difference between approaches (recurrence 13-24%), but was abdominal/perineal approach was surgeons choice
127
Which study provides evidence for the use of TXA in a trauma setting?
The CRASH 2 trial
Early administration (<1 hours > than 1-3 hours) reduces risk of death in bleeding patients
128
How should an extraperitoneal rectal injury be managed?
If <25% circumference and accessible transanally can be repaired primarily. If no accessible, then can observe. If >25% circumference will need drainage and diversion
129
How is a colonic transit study conducted?
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
130
What are the Truelove and Witts criteria?
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
131
For patients with severe colitis and >8 stools per day at 48 hours, how frequently is a colectomy required?
85% chance - also if raised CRP >45 and 3-8 stools per day
If stable can still have Infliximab or Cyclosporin
132
What are some options for surgical treatment of pilonidal disease?
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
133
Which HPV serotypes are associated with anal SCC/AIN?
16 and 18
134
In diverticular abscess, what is the failure rate of percutaneous drainage?
>20%
135
How should patients with colitis be surveilled?
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
136
What tumour genetics are important when working patients up for CRC?
MMR, KRAS, BRAF
137
Which Colon cancers benefit from neoadjuvant treatment?
pMMR, T4, left sided
138
How are T4 rectal cancer managed in the neoadjuvant setting
Total neo-adjuvant - SCRT + Oxaliplatin - RAPIDO trial
Also T3 with involved CRM, EMVI, N2, lateral pelvic nodes
139
How are haemorrhoids graded?
Golighers classfication
1: No Prolapse
2: Prolapse and spontaneously reduce
3: Prolapse and Digital reduced
4: Prolapse and don't reduced
140
How are haemorrhoids best treated?
1: RBL
2: RBL
3: MMH vs pexy vs RBL (Hubble shows equivalence)
4: MMH 2-8% recurrence, 4 weeks of pain. Consider metronidazole
141
Where are anal cushions (internal haemorrhoids) normally located?
In the anal canal above the dentate line
Mucosa, submucosal fibroelastic cognitive tissue and smooth muscles in an AV channel system
142
What is the external haemorrhoidal plexus?
The external haemorrhoidal plexus is a venous plexus encircling the anal verge. Therefore is the source of perianal haematoma - not external haemorrhoids
143
What is the aetiology of haemorrhoids?
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
144
What are the common causes of anal stenosis?
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
145
What is the most common associated feature of pruritus ani?
Minor faecal incontinence
146
What factors are associated with increased incidence of Hidradenitis suppurative?
Female gender, obesity, smoking, Africa-Americans
FH (42%, AR)
High risk of CVD
147
What histological findings can be seen with Hidradenitis suppurativa?
Follicular hyperkeratosis, hyperplasia nad occlusion
Spongiform infundibulofoclliculitis
148
What systemic treatments are recommended for treatment of HS?
12 weeks of oral tetracyclines
-->
10-12 weeks of clindamycin + rifampicin
-->
acitretin (males) or dapsone
-->
Adalimumab or Infliximab
149
What is the most common location of Angiodysplasia in the colon?
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
150
What is the first line treatment for patients with Angiodysplasia of the colon?
Argon plasma coagulation (85%)
If fails - thalidomide (71.4%) or octreotide (77%)
151
What is the syndrome of Aortic Stenosis and Angiodysplasia?
Heyde's syndrome
Patients with Von Willebrand disease and CRF are also at risk of AD
152
What is the mechanism of Argon plasma coagulation?
Synchronised delivery of electrical current and argon
The argon is ionised and transmits the high frequency current to the tissue
153
How are haemangiomas classified?
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
154
How does a harmartoma differ from a neoplasm?
Overgrowth of multiple aberrant cells within a systemic genetic condition rather than a clonal proliferation of a single stated cell
155
How is the rectum defined?
Fusion of two anti mesenteric Taenia
15cm from anal verge on rigid sig
Large bowel within true pelvis
156
In what proportion of CRC do LN mets skip a tier?
About 30%
157
In what proportion of CRC are APC mutations found?
About 60%
158
What is the sequence of events in the adenoma carcinoma sequence in CRC?
-APC
+Kras
-DCC
-p53
159
What are dietary and lifestyle influences on CRC?
+
Red meat
Animal fat
Sugar
Smoking
Sedentary
-
Dieary fibre, exercise
Garlic
Non starchy vegetables
160
What are the Amsterdam criteria?
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
161
What are the T and N stages of CRC?
T1 submucosa
T2 muscularis propria
T3 into subseorsa or non-peritnoealised tissues
T4 other organs or visceral peritoneum
N1 - 1-3
N2 - 4+
162
What are microsatellites?
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
163
What is the York Mason transsphincteric procedure?
Repair of rectourethral fistula
164
Where is the Waldeyers fascia?
Rectosacral region.
It defines the inferior border of the presaral space
165
What are the borders of the presacral space?
Superior - peritoneal reflection
Inferior - Waldeyers fascia
Lateral - endopelvic fascia, utterers and iliac vessels
166
What are the most common type of presacral tumours?
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
167
What is the Kraske operation?
A trans sacral approach for resection of retrorectal/presacral tumours
168
When should patients with UC receive screening colonscopy?
8-10 years after diagnosis then:
5 years if low risk
3 years if intermediate risk
1 year if high risk
169
How are acute and chronic radiation injuries to bowel defined?
< 6 weeks - diarrhoea, urgency, incontinence, bleeding - acute mucosal sloughing
For chronic - progressive endothelial dysfunction --> ischaemia and fibrosis
170
How are acute and chronic radiation injuries to bowel defined?
< 6 weeks - diarrhoea, urgency, incontinence, bleeding - acute mucosal sloughing
For chronic - progressive endothelial dysfunction --> ischaemia and fibrosis
171
To which lymph nodes do anal cancers spread?
Perirectal group --> inguinal, haemorrhoids and lateral pelvic lymph nodes
172
Where does the rectum become the anal canal?
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
173
What is the anorectal ring?
Ring of muscle about 5cm from anus including puborectalis, superior aspects of internal and external sphincter
174
What are the components of the anal sphincter?
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
175
What is the histological transition of the anal canal?
Stratified squamous --> dentate line (80% of cancers)
Transition zone
Rectal mucosa
176
What are the Harvey Bradshaw and Crohns disease activity indexes?
CDAI <150 remission, >450 severely ill
Combination of stools, pain, well being, complications, abdominal mass
CDAI adds use of opiates, haematocrit, %SD of weight
177
What are the microscopic appearances of CMV colitis?
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
178
When is a diagnosis of indeterminate colitis important?
If considering RPC with IPAA for supposed UC - not a good idea
179
Which STDs present with proctitis?
Gonorrhea
Chlamydia
HSV
Syphilis
180
Which STDs present with ulcers?
AIDS
Lymphogranuloma venereum
Primary Syphilis
Chancroid (Haemophilus Ducreyi - school of fish pattern)
Granuloma inguinale (Calymmatobacterium ganulomatis)
HSV
181
Which STDs present with fistulas?
Lymphogranuloma venereum
Complex Bushke-Lowenstein Tumours (giant anal condylomata associated with HPV 6/11)
182
What test modality is most frequently used to test for Chlamydia?
Nucleic acid amplification tests (NAATs)
LGV strains associated with HIV are more severe and can result in a necrotising lymphatic phenotype
183
What are the types of laxative?
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)
184
How is chronic proctalgia defined?
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
185
What is the mainstay of treatment for Levator Ani syndrome?
Biofeedback
186
What is the mainstay of treatment for Levator Ani syndrome?
Biofeedback
187
What is the functional anatomy of the ureters?
- 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
188
What is the risk of cancer in patients presenting with diverticulitis?
2% uncomplicated
11% complicated --> colonoscopy if not <2 years 6-8 weeks
189
What are the relevant trials associated with treatment of diverticulitis?
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
190
What is the size threshold for drainage of diverticular abscess?
>4cm
10-30% failure
191
What proportion of CRC present as an emergency?
20%, treatment with curative intent in only 52%, 11.5% 90d mortality
192
What are contraindications to SEMS in obstructing rectal cancer?
1 - <5cm from dentate line
2 - perforation
3 - peritonitis
4 - benign pathology
5 - Hx of bevacizumab treatment
80-90% success
193
What is the median survival after bypass for obstructing carcinomatosis?
< 3 months
194
What are the outcomes after perforated CRC?
Higher rate of local/peritoneal recurrence but distant metastasis similar
195
What is the risk of colonic ischaemia after embolisation for LGIB?
4-11%
196
What proportion of Cardiac Output does the splanchnic circulation receive?
15-35%
197
What proportion of patients with pseudo-obstruction resolve with conservative management?
70% if caecum <12cm in 48-72hrs
If fails --> colonoscopic decompression/neostigmine
198
What are the most common causes of LGIB?
Diverticular disease (60%) followed by anorectal conditions
23% diagnosis not found
199
How should Warfarin be managed with LGIB?
Stop
If unstable --> PCC + Vit K
Low risk - restart 7 days post bleeding
High risk - consider bridging with LMWH
200
How should DAPT be managed in LGIB?
Rebleed x 5 risk
Generally discontin clopidogrel and continue aspirin and restart 5 days
201
What is the Oakland score?
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
202
How frequently does stomal prolapse occur with a transverse colostomy?
42% - cf 4-5% of others
203
How may the open abdomen be classified?
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
204
How frequently do fistulas occur with MMFT?
<10%, with 80-100% primary closure rate
205
What proportion of perianal abscesses lead to fistulas?
17%
206
What is the risk of perforation with colonoscopy?
<0.2% general
8% therapeutic
For screening present immediately - barotrauma
For interventional also risk of thermal/electrical trauma - perforates 24-72hrs)
207
What are risk factors for perforation at colonoscopy (8)?
Intervention
Right side
Low BMI
Increased age
Surgery
Female
GA
Crohn's
208
How is UC classified in the elective setting?
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)
209
What is the risk of VTE with IBD?
Significantly raised
UC 2.1%
Crohns 4.1%
Consider extended prophylaxis
210
What proportion of patients with CD require surgery?
50% at 5 years, 70% at 15 years
211
What types of stricturoplasty are used?
Heineke-Mikulicz - longitudinal incision anti mesenteric border <5cm
Finney - side-side anastomosis without division 5-20cm
Michelassi - isoperistaltic side-side after division
212
What are the indications for surgery in Crohns?
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)
213
What are the Truelove and Witts criteria?
Acute severe colitis
Bowel motion ≥6
Systemic toxicity - HR ≥90, T≥37.5, ESR >30, Hb <10.5
214
What is the composition of desmoid tumours?
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
215
What treatment options exist for intra-abdominal desmoids?
Surgery
NSAIDs (sulindac) +/- Tamoxifen
216
What is desmoid-type fibromatosis?
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
217
When should patients with rectal cancer proceed straight to surgery?
cT3a or less with no threatened Crm, cN0 no EMVI
218
When should patients with rectal cancer receive a PET?
Suspicion of occult disease, e.g. external iliac nodes
219
What is Li Fraumeni Syndrome
P53 mutation, AD, early onset of tumours
50% <30
Breast, sarcoma, brain, adrenal
220
What is the UK prevalence of Crohn’s disease?
150/100,000
221
Which HPv serotypes does Gardasil protect against?
6, 11, 16 and 18
222
What factors increase the risk of CRC in patients with IBD?
Duration and extent
PSC
FH
Young age at diagnosis
223
How can anal adenocarcinomas be differentiated from rectal cancers on IHC?
Anal - CK7+/CK20-
Rectal - CK7-/CK20+
Prostate CK7-/CK20-
224
What factors predict prognosis in anal SCC?
Females better
Tumour stage
Nodal involvement
Response
225
What is the most important risk factor for small bowel adenocarcinoma?
Crohns diseasd
226
In children what is the most common extra intestinal manifestation of IBD?
Erythema nodosum
227
What proportion of screen detected cancers are polyp cancers?
10-25%
30%A and 30%B
228
What proportion of FIT tests are positive?
1-3%
229
What is the most common malignancy in the retrorectal space?
Chordoma
More common in males 4th to 5th decade
230
In what condition is a scimitar sign seen?
Retrorectal meningocele
231
How do rectal duplication cysts appear?
Multilobular cyst with several satellite lesions. More common in women
232
How should patients diagnosed with perforation post colonoscopy be managed.
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
233
What provides the greatest reduction in risk of parastomal hernia?
Placement of mesh at primary surgery
234
What are risk factors for stercoral perforation?
Chronic constipation
NSAID use
Anticholinergic agents
235
What contraindications to neostigmine use?
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.
236
How often should patients with PSC have a colonoscopy?
Annually
237
What is the Spigelman Classification?
Duodenal carcinoma risk in FAP
238
What type of colonic polyp carries the highest risk of malignancy?
Villous (40%) > TV (20%) > Tubular (5%)
239
What type of polyps are found in Juvenile polyposis?
Harmartomas
240
What are the primary energy source of colonocytes?
Short chain fatty acids (SCFAs) - acetate, butyrate and propionate.
Can be used as treatment for diversion colitis
241
What is the most diagnostic feature for appendicitis?
Localising tenderness at McBurney's point
242
What is the most common cause of rectovaginal fistula?
Obstetric injury
243
What immunoglobulin is secreted by the appendix?
IgA
244
What is the most common intestinal parasite worldwide?
Ascariasis lumbricoides
245
What is the arterial supply of the rectum?
IMA --> Superior rectal artery (1/3)
IIA --> Middle rectal artery
Internal Pudendal A --> Inferior rectal artery
246
What is the venous supply of the rectum?
SRV --> IMV --> Splenic vein --> Portal vein
MRV/IRV --> IIV
247
What is the normal small bowel length?
About 600cm, range of 300-800cm
<100cm no colon
<50cm with colon
likely to lead to PN dependence.
248
What intra-abdominal infections are classically associated with fistulating disease?
TB and actinomycosis
249
What are the three phases of intestinal failure?
1) Hypersecretory
2) Adaptation - less reliant on fluids, 3-12 months (ileum better than jejunum)
3) Stabilisation - 1- 2 years
250
What volume of fluid is produced by the proximal GI tract?
7litres, of which 6 litres reabsorbed proximal to ICJ, 800ml in colon and 200ml in stool.
251
Which part of the GI tract has the highest concentration of Potassium in secretions?
Rectum (30mmol/l)
SI/STomach (10mmol/l)
Bile/Pancreas (5mmol/l)
252
Where is sodium primarily absorbed in the GI tract?
Ileum > Colon
80% Co-transport (AA, glucose, bile) 20% active pump
Water passively follows this.
253
How much sodium can be lost with a high fistula or jejunostomy?
300-400mmol/day and 3-4l of water
254
How much water and sodium can be absorbed in the colon?
Sodium up to 700mmol
Water up to 7L of water
40mmol Potassium
255
What nutrients are absorbed in the jejunum?
Carbohydrates, protein and water soluble vitamins
Except zinc - which may become deficient
256
Where are fat, bile acids and fat soluble vitamins (A,D,E,K) absorbed?
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
257
Where is Vitamin B12 absorbed?
Distal ileum
258
Where is iron primarily absorbed?
Duodenum, upper jejunum
about 10% of dietary absorbed (Fe2+>Fe3+)
Increased by Vit C, acid, decreased by PPI, tannin
259
What stone disease occurs after small bowel resections?
Calcium oxalate renal stones --> increased colonic absorption of oxalate
Gallstones
260
What are the energy requirements of males and females?
M - 25-30kcal/kg/day
F - 20-25kcal/kg/day
261
What are the normal daily requirements of fluid, potassium and sodium?
25-30ml/kg/water
1mmol/kg/day potassium, sodium and chloride
50-100g/day of glucose
NICE
262
What are the electrolyte concentrations of Hartmanns and NS?
Hartmanns - Na 130, CL 109, K 4, Ca 3, Lact 28
NS - Na 154, Cl 154
263
Where is the highest concentration of sodium found in GI losses?
Pancreatic, bile and small bowel - 140mmol/l
264
What volume of secretions are typically produced in the GI tract?
Saliva 1L
Stomach 1-2L
Pancreas 1L
Bile 1L
SB 2-5L
LB 0.2L - 1L
Sweat 0.2-1L
265
Deficiencies of which vitamins are associated with peripheral neuropathy?
Vit B6/B12
266
What are the characteristic findings of Zinc deficiency?
Parakeratosis (dry thick skin) and facial rash
267
What are the types of Intestinal failure?
Type 1 - self limiting (ileus/inflammation)
Type 2 - prolonged (complication, EC fistula, sepsis)
Type 3 - Long term (SBS, obstruction, motility disorder)
268
What is the critical length of small bowel before the development of IF?
<100-150cm if no colon
<50cm if colon insitu
269
What are standard CHO and lipid requirements?
2-4g/Kg/day 0.7-1.25g/kg/day
270
What are the indications for supplemental nutrition on ITU?
ESPEN
- ICU>2 days
- Mechanical ventilation
- Infection
- Underfeeding >5 days
- Severe chronic disease
271
What is the calorie content of Propofol?
1.1kcal/ml
272
What are the route related nutritional complications?
Parenteral - Catheter related vs infectious
Enteral - GI disturbances vs mechanical
273
What are the metabolic complications of supplementary nutrition?
Short term - refeeding/acutemetabolic changes
Long term - TPN related
274
Where should the tip of a TPN line be seen on a CXR?
Below the level of the Carina
275
What is the key biochemical abnormality in refeeding syndrome?
Phosphate <0.65mmol/l, or drop of >0.16mmol/l,
but does not always correlate with clinical findings
276
What is the key biochemical abnormality detected in refeeding syndrome?
Phosphate <0.65mmol/l, or drop of >0.16mmol/l,
but does not always correlate with clinical findings
Nb low K+ and Mg2+, hypernatraemia
277
What is the key driver of refeeding syndrome?
Glucose --> High insulin levels --> intracellular, glucose, phosphate and thiamine and Na/K exchange
278
How can sphincter pain after MM haemorrhoidectomy be managed?
Diltiazem cream/GTN
279
What is the Hinchey classification?
1a -- Pericolic Inflammation
1b -- Pericolic abscess
2a -- Abscess amenable to drainage
2b -- Complex abscess +/- fistula
3 -- Purulent peritonitis
4 -- Faecal peritonitis
280
What is Cowden syndrome?
Multiple Harmartoma syndrome
AD inheritance
Multiple mucoscutaneous lesions
50% Breast Ca, 75% FCD breast
15-20% risk of CRC
Thyroid cancer
281
How frequently should patients treated with chemorad for anal cancer be followed up?
Clinical 6-8 weeks then
Clinical 4-8 weeks then
MRI 3-6 months then
CT at 12 months
282
What is the incidence of incontinence in adults?
Up to 10% of all adults
283
What is the incidence of adenomatous polyps on colonoscopy for >70 year olds?
>50%
284
What is the importance of cribriform colorectal cancer?
About 7%
Increased lymph node metastasis
Central necrosis
285
What is the commonest side effect of diltiazem treatment?
Pruritus
286
what is the reduction in fertility seen with IPAA?
50%
287
what proportion of CRC are MSI-high?
20% (only 3% Lynch)
Proximal colon >Distal colon
Mucin, lymphocytic infiltrate, signet ring
Slightly better prognosis
288
What proportion of anal SCC have mets at presentation?
5%
289
What age threshold for colonoscopy for BRRB?
≥45 (ACPGBI)
290
In which situation is TTG negative in patients with coeliac disease?
IgA deficiency
291
What defines a moderate risk of CRC in non -Lynch patients?
1 x FDR <50 or 2 xFDRs age age --> one off colonoscopy at 55
292
What defines a high risk of CRC in non -Lynch patients?
3 x FDRs across >1 generation
Colon 5 yearly from 40
293
Damage to which structures in anterior resection can cause erectile dysfunction?
Inferior hypogastric plexus
294
Which trans-anal approach to rectal cancer excision carries a high multifocal recurrence risk?
TA-TME
295
How would you manage a patient with suspected anal cancer?
History, examination (abdomen, rectum, groin)
Investigations - EUA + sig + biopsy, FNA any inguinal nodes, CT CAP + MRI rectum. Also colonoscopy
Treatment - IV 5-FU and Mitomycin C + radiotherapy (NIGRA protocol)
Poor response or recurrent --> salvage APER
296
How can colonic polyps be classified?
Adenomatous
Hyperplastic
Inflammatory
Harmartoma
297
What are the extra-colonic features of FAP?
Ectoderm - eye and brain
Mesoderm - dental, bone, desmoids
Endoderm - derail, thyroid, biliary
Adenomas and carcinomas of duodenum, stomach, small bowel
298
What is normal pouch function?
6-8 times in 24 hours (1-2 times at night)
Porridge stool
May have faecal leakage at night
299
What differentiates different types of anal cancer anatomically?
>5cm from anal verge = Skin cancer
<5cm from anal verge = anal cancer (SCC)
<1cm above dentate line = squamous epithelium = SCC
>1cm above dentate line = adenocarcinoma
300
How should AIN be treated?
LSIL (AIN 1) --> observation
HSIL (AIN 2/3) --> treatment, topical treatment (imiquimod) or excision
Regular follow up and anoscopy and mapping
301
What is the TNM staging of anal cancer?
T1 <2
T2 2-5
T3 >5
T4 locally invasive
N1 - perirectal lymph nodes
N2 - unilateral internal iliac/inguinal (25%)
N3 - bilateral or preirectal and distant
302
How can colonic polyps be classified?
Epithelial - adenoma (tubular/tubulovillous/villous)/metaplastic
Mesodermal - lipoma, leiomyoma, haemangioma
Harmartoma- juvenile polyps, peutz-jeghers polyp
303
What Spigelman score suggests need for intervention (Whipple)?
>9
304
What macroscopic/microscopic findings might you expect to see in a patient undergoing resection for Crohns disease?
Macro - skip lesions, fat wrapping, strictures, 1-30cm.
-- can have dilatation/collapse
-- phelgmon/mass/fistula
-- cobblestone mucosal ulceration
Micro- non-caseating granuloma, mucosal lymphoid aggregates, transmural inflammation, chronic inflammatory cell infiltration
305
What is obstructed defecation?
Difficulty in rectal evaluation characterised by a absence of incomplete evacuation, straining, prolonged or recurrent attempts to evacuate and digital evacuation
306
What is the value of ELAPE?
Reduced specimen perforation 20-->10%
Reduced CRM 50-->20%
Higher rate of perineal complications (20-->40%) --> VRAM
307
What is LARS?
Increased frequency of stool
Urgency/incontinence
Feeling of incomplete emptying
Fragmentation of stool
Difficulty in distinguishing gas and stool
308
Prior to surgery how should patients with IBD be optimised?
• Resolution of sepsis (radiological/antibiotics)
• Reversal of nutritional depletion
• Eliminating immunosuppressants (esp. steroids)
309
What is the risk of VTE with IBD?
• IBD 2.85 x risk of VTE
• 2.7% after surgery for IBD, more than cancer surgery, more likely with stoma, preoperative steroids, ileo-anal pouch
• Higher in UC than Crohn’s (4.1 vs 2.1%)
• Consider long course thromboprophylaxis on discharge
310
What types of stricture-pasty may be employed?
Heineke-Mikulicz
• Longitudinal incision of antimesentric border closed transversely
• Use for short <5cm strictures (up to 7cm)
Finney
• Use for 5-20cm
• Side-side anastomosis without division
Michelassi
• Similar – isoperistaltic side-side anastomosis after division
311
What are the contents of the ischiorectal fossa?
Fat pad
Pudendal canal
Transversely - inferior rectal vessels and pudendal nere
Posteriorly - perineal branch S4
312
What are the borders of the ischiorectal fossa?
Base
Medial wall - anal canal and levator ani
Lateral wall - ischial tuberosity and obturator internus
Apex - medial and lateral walls
313
Where does the left ureter run?
Arises from pole of renal pelvis at L1
Runs medial border of psoas
Crosses gonadal vessels
Runs at base of sigmoid mesocolon
Crosses anterior to left CIA bifurcation
Runs anterior to LIIA on pelvic side wall then runs medially into bladder
314
What evidence for fistula plugs?
FIAT trial - similar outcome to surgeons choice, more expensive, healing in about 55% of patients in both groups
LIFT likely best
315
What evidence for prophylactic mesh placement in end-colostomy?
PREVENT - reduces hernia rate
STOMAMESH 2022 - no difference
316
How would you manage an irreducible rectal prolapse?
Apply large amount of granulated sugar to prolapse
Leave 15 minutes and reduce
317
How is Hidradenitis managed medically?
Hurley stage 1 - topical antibiotics, intralesional steroids,
Hurley stage 2 - oral antibiotics, dapsone, acitretin
Hurley stage 3 - Adalimumab, Infliximab, Steroids
318
What is Ustekinumab?
Anti IL-12/IL-23
319
How should acutely thrombosed haemorrhoids be managed?
ACPGBI Guidelines 2020
Conservatively - topical analgesia, bed rest, ice packs, stool softeners
If ischaemic or ulcerated, may have limited haemorrhoidectomy
320
How should a necrotic stoma be managed?
Inspection with light for extent of necrosis
If viable at fascia then manage conservatively and refashion when well
If not viable at fascia then re-laparotomy, more mobilisation
321
Where would you site a stoma?
In general I would place it 1/3 between the umbilicus and ASIS, at least 5cm from the midline
But ideally I would ask for a stoma nurse to mark it pre-operatively, taking into account body habitus, clothes line so that the patient can change the bag and it is less likely to leak.
I tend to place my stomas through the rectus sheath but the EHS say this doesn't reduce the risk of parastomal hernia formation.
322
What anastomosis would you do for a right hemicolectomy?
Generally a stapled isoperistaltic side-side
A Cochrane review from 2011 suggests this has a Lower leak rate than hand sewn
323
From what structures is the anal sphincter complex comprised?
EAS - voluntary striated pudendal
IAS - involuntary smooth (sympathetic relax)
Haemorrhoidal plexus
324
What was the FACS trial?
Intensive follow up after colorectal cancer increases surgical treatment of recurrence (2.3% vs 6-8%), but not OS, but not powered to survival outcome
325
What are the risk factors for bleeding post GI surgery?
Patient - active bleeding, bleeding disorder or tendency, FH of bleeding disorder or tendency, massive transfusion, male gender, malignancy
Technical/drug - anti platelets, anticoagulants, heparinisation, major surgery, prolonged surgery, hypothermia, acidosis.
Staple lines probably more common after stomach than colon than SB anastomosis
326
What are the indications for biologics in IBD?
UC - treat with Steroids then maintenance 5-ASA
If fails (2+ courses steroids/year) can give azathioprine or Anti-TNF of choice
CD - steroids then early use of biologics (NB remember to consider Lap Ileocaecal resection if isolated and patient choice). Can us combination of azathioprine and infliximab
327
What are predisposing factors to Volvulus?
Neuropsychiatric conditions
Laxative abuse
Chronic constipation
Adhesions
Pregnancy
Malrotation
Hirschprungs disease
328
What is the life time risk of CRC?
about 4% in US
Lynch syndrome 15-20%
FAP 100%
329
How should incidentally found terminal ileitis suspicious of CD be managed at laparoscopy for appendicitis?
European Crohns and Colitis Organisation guidelines
- No routine resection
- Appendicectomy if macroscopically normal has a higher incidence of faecal fistula
330
What is the mechanism of action of Prucalopride?
5-HT4 antagonist - stimulates colonic activity
331
How should a supralevator abscess be drained?
According to Parks
If intersphincteric tract --> drain to lumen
If transpincteric tract --> drain to ischioanal fossa
332
What are the Kudo pit patterns of polyps?
1 - round - normal
2 - asteroid - hyperplasia
3 - tubular - adenoma
4 - branch/gyrus like - adenoma
5 - non structural pits - carcinoma
