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GS Medbear > Colorectal > Flashcards

Colorectal Flashcards

1
Q

Self-limiting PR bleeding suggests?

A

Benign causes of bleeding - anal fissures, haemorrhoids

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2
Q

Persistent and progressive PR bleeding suggests?

A

Malignant causes e.g. tumour bleed

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3
Q

What does hematemesis suggest?

A

Massive UBGIT

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4
Q

Some random conditions for Colon?

A

NSAID induced colitis
bleeding diathesis
Ischemic colitis

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5
Q

What to look for in DRE?

A

Anal fissures, prolapse hemorrhoids, hematochezia, melena, brown stools, any masses.
BUT if there is anal fissure, he will be too tender to allow PR exam.

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6
Q

Some random conditions in SI?

A

Angiodysplasia (commonest)
Meckel’s diverticulum
Crohn’s
Enteritis
Aortoduodenal fistula

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7
Q

Common area for ischemia in colon?

A

Water-shed area. splenic flexure and recto-sigmoid junction

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8
Q

Imaging for GI bleeding?

A

CT Mesenteric Angiogram
Selective Mesenteric Angiography/Angioembolization
Radionuclide imaging (99mTc-RBC)

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9
Q

What would necessitate surgical intervention?

A

If source of bleeding cannot be identified and patient has persistent LBGIT.

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10
Q

Preferred investigation of choice for hemodynamically unstable patients?

A

CTMA.

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11
Q

Commonest cause of intestinal ischemia?

A

Ischemic colitis

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12
Q

Classify risk factors for ischemic colitis.

A

Occlusive and non-occlusive vascular disease

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13
Q

Pathophysiology of ischemic colitis?

A

Non-occlusive colonic ischemia 95%.
- Embolic and thrombotic arterial occlusion
- Mesenteric vein thrombosis

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14
Q

Non-occlusive vascular diseases that raise risk of ischemic colitis?

A
  • Recent hx of hypotensive episodes e.g. CHF, shock, AMI
  • Surgical hx
  • Hypercoagulability e.g. thrombophilia, Factor 5 Leiden mutation, Protein C/S deficiency, anti-phospholipid syndrome
  • CVS Hx
  • …others
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15
Q

Bacterial causes of ischemic colitis?

A

E. Coli
Salmonella
Shigella
Campylobacter Jejuni
Entamoeba Histolytica
Histoplasma
CMV

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16
Q

Level of SMA? And branches

A

L1.
Ileocolic, Right Colic and middle colic arteries

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17
Q

Level of IMA? and branches

A

L3.
Left colic, sigmoid, superior rectal arteries.

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18
Q

3 phases of ischemic colitis?

A

Hyperactive phase = Severe abdo pain with mildly bloody stools
Paralytic phase = Pain is more continuous and diffuse, abdo more tender and distended wo bowel sounds
Shock phase = Massive fluid, protein and electrolytes leak through damaged gangrenous mucosa. Severe dehydration with shock + met acidosis

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19
Q

Some biochemical markers in ischemia?

A

Lactate - metabolic acidosis possible.
LDH
Amylase
Leukocytosis
ALP

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20
Q

Borrmann’s classification for gastric CA?

A

Type 1 - polypoid tumours (non-ulcerated)
Type 2 - fungating (ulcerated)
Type 3 - ulcerative
Type 4 - infiltrating / diffuse thickening / linitis plastica

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21
Q

Distribution of gastric CA?

A

Gastric CA - pylorus and antrum
Pylorus + antrum (50-60%)
Cardia 25%

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22
Q

How to classify esophageal vs gastric CA based on location?

A

Arise from EGJ or in stomach within 5cm from EGJ and cross EGJ = esophageal CA

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23
Q

Which LNs can gastric CA spread to?

A

Perigastric LNs.
Further spread follows arterial supply
Further spread to para-aortic LNs
Virchow’s Node

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24
Q

Investigations to confirm diagnosis of gastric CA?

A

OGD + Biopsy
Barium swallow
Histology

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25
2 pathways for CRC?
Hereditary CRC Sporadic CRC
26
Hereditary CRC syndromes?
FAP Lynch Syndrome Peutz-Jeghers syndrome Juvenile Polyposis
27
2 pathways for sporadic CRC?
APC / chromosomal instability pathway 85% Defect in DNA mismatch repair / microsatellite instability pathway 15%
28
Which gene mutated in FAP?
APC gene
29
Histopathology of FAP?
Innumerable adenomatous polyps, moderately differentiated adenoCA
30
Histopathology of HNPCC?
Mucinous, poorly differentiated with lymphocytic infiltrates
31
Histopathology of Left-sided predominant CRC?
Tubular, tubulovillous and villous adenomas. Moderately differentiated adenoCAs
32
Histopathology of right-sided predominant cancer?
No precursor lesions. Sessile serrated adenomas. Large hyperplastic polyps, mucinous carcinomas.
33
Which CRC patients not fit for endoscopic evaulation?
Those with tumour complications e.g. IO
34
Why is IO less common in right sided colonic tumour than left-sided?
Stools more liquid and colon more spacious on right side.
35
Symptoms of right sided tumour?
Symptomatic anemia Symptoms of IO
36
Symptoms of left sided colonic tumour?
Hematochezia Symptoms of IO Tumour perforation Change in bowel habits
37
Symptoms of rectal tumour?
Tenesmus Pencil thin stools Mucoid stools Hematochezia Symptoms of IO Change in bowel habits
38
What can tumour invasion of CRC cause?
Intractable pain - sacral nerves LUTS - trigone of bladder
39
What can CRC tumour fistulation cause?
Fecaluria Pneumaturia Recurrent UTI (recto-bladder fistula) Recto-vagina fistula Gastrocolic fistula - faecal vomiting or severe diarrhoea
40
Lymphatic spread of CRC?
Spread from paracolic nodes along main colonic vessels eventually reaching para-aortic nodes.
41
Top 2 sites of CRC haematogenous mets?
Liver via portal venous Lungs
42
Anatomical definition of rectal CA?
Tumour within 15cm of anal verge or within 11-12cm of anal verge.
43
What is anal verge?
in left lateral position, transition between non-hair bearing anal canal with hair-bearing perianal skin
44
What does the dentate line divide?
Divide upper 2/3 and lower 1/3 of anal canal
45
How many lateral inflexions in rectum?
3 inflexions, each capped by valve of Houston.
46
INNERVATION OF INTERNAL SPHINCTER MUSCLE IN ANAL CANAL?
MYENTERIC PLEXUS, PARASYMPATHETIC AND SYMPATHETIC NERVOUS SYSTEM
47
INNERVATION OF PUBORECTALIS MUSCLE?
4TH SACRAL NERVE ROOT AND/OR PUDENDAL NERVE
48
How to perform tumour localization of rectal CA?
DRE, MRI, endoscopy
49
1st line imaging to stage rectal CA locally?
Local staging = MRI rectum. Superior to CT for delineating TN staging. Superior to EUS as can assess CRM and can identify tumour in relation to peritoneal reflection. For systemic staging = CT TAP
50
3 types of surgery for rectal CA?
1. Local excision 2. High or Low Anterior Resection with/wo diverting ileostomy 3. APR with permanent colostomy (rare)
51
Complications of colonic polypectomy?
Bleeding Perforation Post-polypectomy syndrome
52
3 types of colorectal polyps? Paris Classification
Protruded Flat elevated Flat
53
In which syndromes are genetic testing feasible for CRC?
FAP MAP HNPCC JPS PJS | MAP = MUTYH-associated polyposisx`
54
Peutz-Jeghers syndrome raises risk of which CA?
Pancreatic - main Breast Lung Uterine Gastric
55
Which genes mutated in FAP?
Tumour suppressor gene APC. 80% have +ve family Hx
56
Types of surgery in Rectal CA?
Sphincter preserving surgery APR
57
What is PJS?
AD condition with multiple GI hamartomatous polyps and muco-cutaneous pigmentation with melanin spots on perioral and buccal mucosa.
58
Total CRC tumour burden of HNPCC [Lynch syndrome]?
1-3%
59
What cancers does Lynch syndrome predispose to?
CRC 80% risk Gastric Endometrial 30-50% risk Genitourinary
60
How will output from ileostomy present?
Watery greenish output
61
Hartmann's procedure?
Surgical resection of recto-sigmoid colon with temp end colostomy. Usually in emergency settings.
62
What is panproctocolectomy used for?
Most commonly severe **Ulcerative Colitis.** Some FAP, HNPCC.
63
What is diverticular disease
Acquired pseudo-diverticular outpouching of colonic mucosa and submucosal at antimesenteric side.
64
Proportion of symptomatic diverticular disease?
75% no complications 25% with abscess, fistula, obstruction, peritonitis, sepsis
65
Diverticulitis in ____% of diverticulosis. ## Footnote 151
15-25%. Bleeding in 5-15%.
66
Clinical presentation of acute diverticulitis?
LLQ pain (colicky) N/V Constipation/diarrhoea Urinary urgency
67
Signs of acute diverticulitis?
Low-grade fever, localized LLQ tenderness, w/wo mass Change in bowel habits Urinary urgency and frequency (15%)
68
Accurate predictor of acute diverticulitis?
LLQ pain + lack of vomiting + raised CRP
69
What does CTAP of diverticulitis show?
Localized bowel wall thickening >4mm Fat stranding Colonic diverticula **Pericolonic abscess, fistula, peritonitis** in complicated divert
70
Hinchey classification for diverticulitis?
Stage 1 = pericolic abscess confined by mesocolon Stage 2 = Pelvic/retroperitoneal abscess Stage 3 = Purulent peritonitis Stage 4 = Faecal peritonitis
71
Risk of recurrence of diverticulitis?
20-40%. Similar to 1st episode
72
Indications for emergency operation for diverticulitis?
Hinchey 3 or 4 acute diverticulitis
73
Impt differentials for recurrent diverticulitis?
IBS, IBD, Ischemic colitis
74
Commonest primary malignancy of SI?
Neuroendocrine tumours
75
Cardinal symptoms of IO?
Abdo pain Abdo distension No bowel output / constipation Vomiting
76
Presentation of Meckel's ?
Hematochezia / Melena IO Meckel's Diverticulitis Chronic PUD Umbilical Fistula
77
Which SI patho can present exactly like acute appendicitis?
Meckel's diverticulitis
78
Difference in Mx of Crohn's vs UC?
UC can be treated surgically. Just take out colon Crohn's treated medically
79
Biochemical markers raised in IBD?
ASCA in Crohn's p-ANCA in UC
80
Commonest cause of IO? 2nd?
Malignancy. 2nd is sigmoid volvulus
81
What sign does sigmoid volvulus show on XR?
Coffee bean sign
82
Banov grading for internal haemorrhoids?
G1 = Non-prolapsing G2 = Reduce spontaneously G3 = Need manual reduction G4 = irreducible
83
Procedure for internal haemmorhoids?
G1 = Lifestyle, Daflon, stool softener G2 = G1+ rubber band ligation G3 + G4 = Ferguson + stapled haemorrhoidectomy
84
Frequency of colonoscopy?
10 years if no adenomas found unless RF exist 5 years if low risk adenomas 3 years if high risk adenomas
85
What proportion of external sphincter can be resected before risk of incontinence?
30%
86
How to check SI?
Capsule endoscopy - e.g. Crohn's
87
Preferred treatment for bleeding PUD?
Endoscopic therapy - inject epinephrine, mechanical hemo-clip, thermal heater probe
88
GI effects of Parkinson's?
Drooling, dyspepsia, constipation, abdominal pain and fecal incontinence are frequently a source of patient distress.
89
Mx of IO 2! to intra-abdo adhesions?
1st line is conservative. NBM, NGT on intermittent suction, IV rehydration
90
Difference between left and right sided lesions?
Chronic occult bleeding + Fe deficient anemia dominate in Right sided. Obstructive symptoms dominate in left
91
How to rule out admission for appendicitis?
Alvarado score 5 or lower. MANTRELS!!!!
92
Alvarado score for appendicitis?
Migratory RIF pain Anorexia N/V Tenderness RIF Rebound tenderness Fever Leukocytosis Left shift of neutrophils
93
Surgery for pyloric stenosis?
Ramstedt pyloromyotomy
94
Do cancers cause massive bleeding?
No, usually occult bleeding, slow and chronic.
95
Which colorectal polyp causes hypersecretory syndromes? What can this syndrome manifest?
Villous polyps [worst prognosis]. Can cause hypokalemia and profuse mucous discharge
96
Common cause of colovesical fistula?
Sigmoid diverticulitis
97
Common causes of appendicitis?
Bacterial infection 2! to obstruction of appnediceal lumen. Adults = commonly fecoliths Kids = commonly lymphoid hyperplasia after viral illness. Low dietary fibre and high refined carbohydrate intake can predispose as well.
98
Physical signs to elicit in appendicitis?
Rovsing sign = RIF pain with deep palpation of LIF Psoas sign = RIF pain with passive R hip flexion Obturator sign = RIF pain with internal rotation of flexed R hip
99
What is an anal fistulae?
Hollow tracts lined with granulation tissue connecting primary opening inside anal canal to secondary opening in perineal skin. Usu a/w anorectal abscesses.
100
Presentation of anal fistula?
Intermittent purulent discharge w/wo bleeding. Pain that relieves temporarily with pus discharge.
101
Characteristic positioning of internal haemorrhoids?
3, 7 and 11 o'clock positions when pt is in lithotomy position
102
4 red flags for Colorectal cancer?
Spurious diarrhea TEnesmus Pencil thin stools Alternating constipation and diarrhoea
103
What is toxic megacolon?
Acute dilation of colon associated with systemic toxicity. Very dangerous!! Invx = Abdo XR (colonic dilation, multiple air-fluid levels) Supportive treatment with Broad-spectrum IV abx | Oral vanco for C. diff colitis
104
105
Where do internal haemorrhoids usually lie?
In 3, 7 and 11 o' clock position. Pt in lithotomy position.
106
How to differentiate Small Intestine vs Colon obstruction on supine AXR?
SBO = Stack of coins appearance Dilatation >3cm is abnormal Centrally located multiple gas filled bowels Large BO = Haustrations (incomplete bands spaced irregularly, does not span bowel diameter) Dilation of Cecum >9cm and Colon >6cm abnormal Peripherally located dilated bowels

GS Medbear (14 decks)

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