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BTK Review 2023 > Colorectal > Flashcards

Colorectal Flashcards

1
Q

What are the two major collaterals between the SMA and IMA?

A
  • the marginal artery
  • the arc of Riolan
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2
Q

What are the watershed areas of the colon?

A

the splenic flexure and the transition zone between superior and middle rectum

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3
Q

What is the blood supply to the rectum?

A
  • superior rectal artery off the IMA
  • middle off the internal iliac
  • inferior off the pudendal
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4
Q

What is the venous drainage of the rectum?

A
  • superior to the IMA and portal circulation
  • middle and inferior to the internal iliac and systemic circulation
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5
Q

What defines the anal canal?

A
  • proximal: puborectalis sling
  • distal: anal verge
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6
Q

What defines the anal margin?

A

within 5cm of the anal verge

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7
Q

How are anal fissures treated?

A
  • start with fiber, sit baths, and topical anesthetics
  • can advance to topical nitrates and CCBs
  • consider botox, LIS, or anocutaneous flap
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8
Q

What are contraindications to lateral internal sphincterotomy for anal fissure?

A
  • fecal incontinence
  • women of childbearing age
  • prior obstetrical injuries
  • IBD
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9
Q

Describe the course of most anorectal fistulas.

A
  • anteriorly they tend to be linear unless > 3cm from the anal verge
  • posteriorly then tend to be curvelinear
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10
Q

When are antibiotics indicated for those with anorectal abscesses?

A

when there is cellulitis, systemic signs of infection, or they are immunocompromised

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11
Q

What proportion of patients with anorectal abscesses develop fistulas?

A

about one third

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12
Q

What is the difference between a high and low trans-sphincteric anorectal fistula?

A
  • high involve > 33% of the sphincter complex
  • low involve less
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13
Q

What is the goal of a fistula?

A

to convert a high fistula to a low one, thereby preparing the tract for later intervention

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14
Q

How are internal hemorrhoids classified?

A
  • I: internal only
  • II: spontaneously reduce
  • III: manually reduce
  • IV: don’t reduce
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15
Q

How should thrombosed hemorrhoids be managed?

A
  • can do a thrombectomy if < 72hrs after onset
  • otherwise manage expectantly with symptomatic control
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16
Q

When should patients with diverticulitis have a colonoscopy?

A

6 weeks after resolution of their episode

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17
Q

Describe the natural course of diverticulitis.

A

the first episode tends to be the worst

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18
Q

Who should have a sigmoidectomy for diverticulitis?

A
  • anyone with complicated disease needs an operation at some point
  • those with uncomplicated disease get a more customized approach with shared decision making since the first episode tends to be the worst
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19
Q

What is the surgery of choice for someone with complicated C. diff?

A

subtotal colectomy with ileostomy

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20
Q

Sigmoid volvulus is discovered on AXR, what are the next steps?

A
  • CT scan to evaluate colonic viability
  • endoscopic decompression
  • sigmoidectomy during index admission
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21
Q

What are the risk factors for colonic perforation?

A
  • cecum > 12 cm
  • duration of Ogilvie’s > 6 days
22
Q

What medication is used to treat Ogilvie’s and what is the predominant side effect to know?

A
  • can use neostigmine (anti-acetylcholinesterase)
  • causes bradycardia
23
Q

What is the key component to a trans-abdominal rectal prolapse repair?

A

rectopexy, can add LAR or sigmoidectomy if patient has constipation

24
Q

What is the difference between a Delorme and Altemeier procedure?

A
  • Delorme: mucousectomy via perineal approach with muscle plication
  • Altemeier: full thickness rectosigmoidectomy via perineal approach with coloanal anastomosis
25
Q

What is the main nutrient for colonocytes?

A

short chain fatty acids

26
Q

What is the main nutrient for enterocytes?

A

glutamine

27
Q

Which extra-colonic manifestations of UC typically improve with colectomy?

A
  • arthropathy, erythema nodosum, and episcleritis
  • hepatic issues (PSC) do not
28
Q

What are the colonoscopy recommendations for those with UC?

A
  • start 8 years after diagnosis
  • perform every 1-2 years
  • taking random biopsies at 10cm intervals
29
Q

When is malignancy an indication for colectomy in those with UC?

A
  • multifocal invisible low grade dysplasia
  • invisible high grade dysplasia
  • frank malignancy
30
Q

If patients with UC have an uninvolved rectum and get an ileorectal anastomosis, what are the screening recommendations?

A

annual endoscopy

31
Q

What are Finney and Michelassi stricturopalsties?

A
  • Finney: fold structured segment and make a common channel in the loop
  • Michelassi: side-to-side is-peristaltic stricturoplasty
32
Q

What are the colon cancer screening recommendations for FAP?

A

start at 10-12 and perform annual sigmoidoscopies

33
Q

What are the colon cancer screening recommendations for Lynch syndrome?

A
  • start at 20-25 or ten years before the youngest family member
  • perform colonoscopies every 1-2 years
34
Q

When should a surveillance colonoscopy be performed for the following:
- 1 to 2 tubular adenomas
- 3 adenomas
- advanced adenomas (>1 cm, high grade dysplasia, villous histology)
- hyperpalstic polyps

A
  • 1 to 2 tubular adenomas: in 5 years
  • 3 adenomas: in 3 years
  • advanced adenomas (>1 cm, high grade dysplasia, villous histology): in 3 years
  • hyperpalstic polyps: in 10 years
35
Q

Which colon cancers can be managed endoscopically?

A

those that can:
- be removed in one piece
- with negative margins
- that are well-to-moderately differentiated
- without lymphovascluar involvement
- that are limited to the submucosa

36
Q

How is colon cancer staged?

A
  • T1: invades submucosa
  • T2: invades muscularis propria (stage I)
  • T3: invades pericolonic tissue
  • T4: invades serosa or surrounding structures (stage II)
  • N1: 1-3 nodes
  • N2: 4+ nodes (stage III)
37
Q

What should be the distal margin on colon cancer resection?

A

5-7 cm to ensure adequate lymphadenectomy (need 12)

38
Q

How many lymph nodes should be taken during colon resection for cancer?

A

at least 12

39
Q

Which metastatic colon cancers can be resected?

A

those with limited hepatic or pulmonary mets

40
Q

Which colon cancer patients get adjuvant therapy?

A

stage III and above (any nodal involvement)

41
Q

What is FOLFOX?

A
  • leucovorin (folinic acid)
  • fluorouracil
  • oxaliplatin
42
Q

What is the most important prognostic factor when staging a rectal cancer?

A

identify the total distance between tumor and mesolectal fascia (the CRM, circumferential margin)

43
Q

Who gets neoadjuvant chemoradiation for colon cancer? Adjuvant therapy?

A
  • neoadjuvant for those with T3 or greater disease or any nodal disease
  • adjuvant for anyone with nodal disease who did not receive neoadjuvant therapy (anyone understaged) or anyone high stage II or greater who received neoadjuvant therapy
44
Q

What are the histologic variants for anal squamous cell carcinoma?

A
  • cloacogenic
  • basaloid
  • epidermoid
  • mucoepidermoid
45
Q

What HPV serotypes are associated with anal SCC?

A

16 and 18

46
Q

What is the nigro protocol?

A
  • chemoradiation protocol as a first line treatment for anal SCC rather than APR
  • consists of 5-FU, mitomycin C, and radiation
  • followed by salvage APR if needed
47
Q

How do you treat SCC of the anal margin?

A

like skin cancer with wide local excision

48
Q

How is anal melanoma treated?

A

with APR

49
Q

How is pouchitis treated in those with IPAA?

A

antibiotics, supportive care, and budesonide enemas if unresponsive

50
Q

What should you suspect in a UC patient who develops chronic pouchitis?

A

misdiagnosis, actually have Crohn’s

51
Q

During a laparoscopy for possible appendicitis, it appears normal and the TI is inflamed. What is the diagnosis and next steps?

A
  • likely Crohn’s
  • if the cecum is uninvolved, still do the app but if it is involved, leave the appendix in place

BTK Review 2023 (18 decks)

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