Colorectal Flashcards
Impediments to spontaneous closure of fistulas
Foreign body, radiation, inflammation/infection, epithelialization, neoplasia, distal obstruction
Highest risk factor for post op anastomotic leak
Fecal contamination. Also, intraop blood loss
Management of fistula in Crohn’s disease
Infliximab
Most sensitive step during colonoscopy to rule out GI bleed
Intubated the TI
Rx for early return of bowel function after colon surgery
12mg Alvimopan preop continued 7 days postop
Haggitt classification
0 - superficial to muscularis mucosa
1 - submucosal invasion head of polyp
2 - neck
3 - stalk
4 - below stalk or sessile polyp
Kikuchi classification
Sm1 - Upper 1/3 submucosa
Sm2 - Upper 2/3
Sm3 - Lower 1/3
Operative planning rectal cancer
CT CAP
MRI pelvis
Rigid proctoscopy
Preop study prior to repair of bladder/rectum prolapse
Colonoscopy and urodynamic studies
Best surgical treatment for constipation
Total abdominal Colectomy with ileorectal anastomosis
Best diagnostic test for colonic inertia
Sitz marker study
UC extraintestinal conditions (which does not resolve with Colectomy)
Arthritis, ankylosing spondylitis, erythema nodosum, pyoderma gangrenosum, PSC*
Site of colon and rectum with greatest absorptive capacity
Ascending colon
DVT ppx s/p abdominal/pelvic cancer operations
28 days LMWH
T3/4 rectal cancer; tx
Neoadjuvant chemorads, surgery, adjuvant
Surveillance following endoscopic resection colon cancer
Scope 3month, 1 year, 3 years, 5 years
Correct ostomy placement
Summit of infraumbilical fold in rectus
Massive GI bleed; surgical tx
TAC with end ileostomy
Gold standard for dx of colonic pseudoobstruction
CT
Postop surveillance s/p colorectal cancer surgery
Clinical exam and CEA 3-6mo for 2, 6mo for 5
CT every 6-12mo for 5 if high risk for recurrence
Colonoscopy 1 yr, 3 then 5
IBS criteria
Rome IV; recurrent abdominal pain (at least 1 day/week in the last 3 months) associated with 2 or more:
Related to defecation
Change in stool frequency
Change in stool form
Criteria for transanal endoscopic microsurgery (TEM)
T1 without high risk features, <3cm, <30% circumference, 5-15cm from anal verge
Transvaginal repair of rectocele; Critical step
Plication of the vaginal muscularis and rectovaginal tissues
Polyp invading submucosa at splenic flexure; tx
Extended left hemicolectomy
Sigmoid volvulus; tx
Colonic decompression, but needs resection same admission due to high recurrence risk
UC with visible high grade dysplasia; next step
Repeat endoscopy with bx 3-6months
New diagnosis of UC; next screening colonoscopy
8 years
High risk based on fm hx for colon cancer; screening colonoscopy
Age 40 or 10 yrs earlier than relative’s age at dx
Rectal carcinoid <1cm; tx
Endoscopic or local excision alone
Indications for total proctocolectomy in patients with UC
Invisible multifocal low grade dysplasia, invisible high grade dysplasia
WHO classification polyps
Epithelial (adenoma, carcinoma, carcinoids, mixed)
Non-epithelial (lipoma, leiomyoma, GIST, angiosarcoma, melanoma, Kaposi’s sarcoma)
Polyps (hyperplastic, PJ, juvenile)
Secondary tumors
Rectal bleeding s/p AAA repair; next step
Sigmoidoscopy
Cefoxitin redosing intraop
2hrs
Endometrial, thyroid, breast, renal, colon cancer; syndrome and gene
Cowden syndrome, PTEN
May have hamartomas and skin lesions as well
FAP s/p TAC with IRA; surveillance
yearly endoscopy
Amsterdam II Criteria; dx, genes and criteria
HNPP or Lynch syndrome (MLH1, MSH2/6, PMS2)
At least 3 relatives with colorectal, endometrial, SB, ureter or renal pelvis cancer
At least 2 successive generations affected
At lest 1 before age 50
Gastric, pancreatic, SB cancer, cardiovascular defects; syndrome and gene
Juvenile polyposis syndrome, SMAD4 and BMPR1A
Gastric, panc, SB cancer with peri oral pigmentation; syndrome and gene
Peutz-Jegher, STK11
Gastric, duodenal, bladder, breast, ovarian cancer; syndrome and gene
MUTYH-asociated polyposis
Duodenal, gastric, pancreatic multiple polyps; syndrome and gene
Familial adenomatous polyposis, APC
Risks of colon radiation
Radiation colitis; ulcers, telangiectasias, fistulas
Bowel obstruction with pigmented mucosal lesions; dx
PJ, hamartomatous polyp causing intussusception
Post-strictureplasty hemorrhage; tx
Observe
Lower GI bleed stable after transfusion/resuscitation; next step
Prep -> colonoscopy
Colon cancer margin and nodes
2-5cm at least 12 nodes
Candidates for primary surgical therapy in rectal cancer
T1 or T2 (invade submucosa or muscular propria) without clinical nodes
Acute diverticulitis failed non-op management; tx
Sigmoidectomy with primary anastomosis with diversion vs end-colostomy
Ascending colon cancer; tx
Right colectomy
Hepatic flexure cancer; tx
Extended right colectomy
No prior colon evaluation now s/p colon resection for obstructing lesion; surveillance
3-6months post-op
Colonic lipoma; tx
Observe, if >2cm can be endoscopically resected
Hinchey Classification
Ia - pericolic inflammation/phlegmon
Ib - pericolic abscess
II - pelvic/distant abscess
III - purulent peritonitis
IV - feculent peritonitis
Normal colonoscopy polyps (10yr f/u)
20 or less hyperplastic polyps <1cm
3-4 tubular adenomas <1cm or greater 1cm hyperplastic polyp; surveillance interval
3-5yrs
5-10 adenomas
Sessile polyp > 1 cm
High-risk polyp (TV or Villous >1cm, high grade dysplasia; surveillance interval
3years
> 10adenomas; surveillence interval
1yr
Adenoma removed piecemeal; surveillance interval
3-6months
Appendiceal neuroendocrine tumors requiring staging workup and right hemicolectomy
> 2cm
Poor prog features (high mitotic or Ki67)
Involve base
Positive nodes/margins
Goblet cell histology
Appendiceal neuroendocrine tumors requiring staging workup and right hemicolectomy
> 2cm
Poor prog features (high mitotic or Ki67)
Involve base
Positive nodes/margins
Goblet cell histology
Antibiotic bowel prep prior to colon surgery
Neomycin 1g + Erythromycin 1g or Neomycin 1g + Metronidazole 1g (3 doses over 10hrs afternoon and evening before operation)
Preop IV abxs prior to colon surgery
Cephalosporin 2g + Flagyl 500mg IV OR Clinda 900mg + Levoflxacin 500mg (1hr prior)
Colon cancer preop workup
CT CAP, colonoscopy, CEA, labs
