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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
Q

2 pathways for CRC?

A

Hereditary CRC
Sporadic CRC

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26
Q

Hereditary CRC syndromes?

A

FAP
Lynch Syndrome
Peutz-Jeghers syndrome
Juvenile Polyposis

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27
Q

2 pathways for sporadic CRC?

A

APC / chromosomal instability pathway 85%
Defect in DNA mismatch repair / microsatellite instability pathway 15%

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28
Q

Which gene mutated in FAP?

A

APC gene

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29
Q

Histopathology of FAP?

A

Innumerable adenomatous polyps, moderately differentiated adenoCA

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30
Q

Histopathology of HNPCC?

A

Mucinous, poorly differentiated with lymphocytic infiltrates

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31
Q

Histopathology of Left-sided predominant CRC?

A

Tubular, tubulovillous and villous adenomas. Moderately differentiated adenoCAs

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32
Q

Histopathology of right-sided predominant cancer?

A

No precursor lesions. Sessile serrated adenomas.
Large hyperplastic polyps, mucinous carcinomas.

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33
Q

Which CRC patients not fit for endoscopic evaulation?

A

Those with tumour complications e.g. IO

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34
Q

Why is IO less common in right sided colonic tumour than left-sided?

A

Stools more liquid and colon more spacious on right side.

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35
Q

Symptoms of right sided tumour?

A

Symptomatic anemia
Symptoms of IO

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36
Q

Symptoms of left sided colonic tumour?

A

Hematochezia
Symptoms of IO
Tumour perforation
Change in bowel habits

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37
Q

Symptoms of rectal tumour?

A

Tenesmus
Pencil thin stools
Mucoid stools
Hematochezia
Symptoms of IO
Change in bowel habits

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38
Q

What can tumour invasion of CRC cause?

A

Intractable pain - sacral nerves
LUTS - trigone of bladder

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39
Q

What can CRC tumour fistulation cause?

A

Fecaluria
Pneumaturia
Recurrent UTI (recto-bladder fistula)
Recto-vagina fistula
Gastrocolic fistula - faecal vomiting or severe diarrhoea

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40
Q

Lymphatic spread of CRC?

A

Spread from paracolic nodes along main colonic vessels eventually reaching para-aortic nodes.

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41
Q

Top 2 sites of CRC haematogenous mets?

A

Liver via portal venous
Lungs

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42
Q

Anatomical definition of rectal CA?

A

Tumour within 15cm of anal verge or within 11-12cm of anal verge.

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43
Q

What is anal verge?

A

in left lateral position, transition between non-hair bearing anal canal with hair-bearing perianal skin

44
Q

What does the dentate line divide?

A

Divide upper 2/3 and lower 1/3 of anal canal

45
Q

How many lateral inflexions in rectum?

A

3 inflexions, each capped by valve of Houston.

46
Q

INNERVATION OF INTERNAL SPHINCTER MUSCLE IN ANAL CANAL?

A

MYENTERIC PLEXUS, PARASYMPATHETIC AND SYMPATHETIC NERVOUS SYSTEM

47
Q

INNERVATION OF PUBORECTALIS MUSCLE?

A

4TH SACRAL NERVE ROOT AND/OR PUDENDAL NERVE

48
Q

How to perform tumour localization of rectal CA?

A

DRE, MRI, endoscopy

49
Q

1st line imaging to stage rectal CA locally?

A

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
Q

3 types of surgery for rectal CA?

A
  1. Local excision
  2. High or Low Anterior Resection with/wo diverting ileostomy
  3. APR with permanent colostomy (rare)
51
Q

Complications of colonic polypectomy?

A

Bleeding
Perforation
Post-polypectomy syndrome

52
Q

3 types of colorectal polyps? Paris Classification

A

Protruded
Flat elevated
Flat

53
Q

In which syndromes are genetic testing feasible for CRC?

A

FAP
MAP
HNPCC
JPS
PJS

MAP = MUTYH-associated polyposisx`

54
Q

Peutz-Jeghers syndrome raises risk of which CA?

A

Pancreatic - main
Breast
Lung
Uterine
Gastric

55
Q

Which genes mutated in FAP?

A

Tumour suppressor gene APC.
80% have +ve family Hx

56
Q

Types of surgery in Rectal CA?

A

Sphincter preserving surgery
APR

57
Q

What is PJS?

A

AD condition with multiple GI hamartomatous polyps and muco-cutaneous pigmentation with melanin spots on perioral and buccal mucosa.

58
Q

Total CRC tumour burden of HNPCC [Lynch syndrome]?

A

1-3%

59
Q

What cancers does Lynch syndrome predispose to?

A

CRC 80% risk
Gastric
Endometrial 30-50% risk
Genitourinary

60
Q

How will output from ileostomy present?

A

Watery greenish output

61
Q

Hartmann’s procedure?

A

Surgical resection of recto-sigmoid colon with temp end colostomy. Usually in emergency settings.

62
Q

What is panproctocolectomy used for?

A

Most commonly severe Ulcerative Colitis.
Some FAP, HNPCC.

63
Q

What is diverticular disease

A

Acquired pseudo-diverticular outpouching of colonic mucosa and submucosal at antimesenteric side.

64
Q

Proportion of symptomatic diverticular disease?

A

75% no complications
25% with abscess, fistula, obstruction, peritonitis, sepsis

65
Q

Diverticulitis in ____% of diverticulosis.

151

A

15-25%. Bleeding in 5-15%.

66
Q

Clinical presentation of acute diverticulitis?

A

LLQ pain (colicky)
N/V
Constipation/diarrhoea
Urinary urgency

67
Q

Signs of acute diverticulitis?

A

Low-grade fever, localized LLQ tenderness, w/wo mass
Change in bowel habits
Urinary urgency and frequency (15%)

68
Q

Accurate predictor of acute diverticulitis?

A

LLQ pain + lack of vomiting + raised CRP

69
Q

What does CTAP of diverticulitis show?

A

Localized bowel wall thickening >4mm
Fat stranding
Colonic diverticula
Pericolonic abscess, fistula, peritonitis in complicated divert

70
Q

Hinchey classification for diverticulitis?

A

Stage 1 = pericolic abscess confined by mesocolon
Stage 2 = Pelvic/retroperitoneal abscess
Stage 3 = Purulent peritonitis
Stage 4 = Faecal peritonitis

71
Q

Risk of recurrence of diverticulitis?

A

20-40%. Similar to 1st episode

72
Q

Indications for emergency operation for diverticulitis?

A

Hinchey 3 or 4 acute diverticulitis

73
Q

Impt differentials for recurrent diverticulitis?

A

IBS, IBD, Ischemic colitis

74
Q

Commonest primary malignancy of SI?

A

Neuroendocrine tumours

75
Q

Cardinal symptoms of IO?

A

Abdo pain
Abdo distension
No bowel output / constipation
Vomiting

76
Q

Presentation of Meckel’s ?

A

Hematochezia / Melena
IO
Meckel’s Diverticulitis
Chronic PUD
Umbilical Fistula

77
Q

Which SI patho can present exactly like acute appendicitis?

A

Meckel’s diverticulitis

78
Q

Difference in Mx of Crohn’s vs UC?

A

UC can be treated surgically. Just take out colon
Crohn’s treated medically

79
Q

Biochemical markers raised in IBD?

A

ASCA in Crohn’s
p-ANCA in UC

80
Q

Commonest cause of IO? 2nd?

A

Malignancy. 2nd is sigmoid volvulus

81
Q

What sign does sigmoid volvulus show on XR?

A

Coffee bean sign

82
Q

Banov grading for internal haemorrhoids?

A

G1 = Non-prolapsing
G2 = Reduce spontaneously
G3 = Need manual reduction
G4 = irreducible

83
Q

Procedure for internal haemmorhoids?

A

G1 = Lifestyle, Daflon, stool softener
G2 = G1+ rubber band ligation
G3 + G4 = Ferguson + stapled haemorrhoidectomy

84
Q

Frequency of colonoscopy?

A

10 years if no adenomas found unless RF exist
5 years if low risk adenomas
3 years if high risk adenomas

85
Q

What proportion of external sphincter can be resected before risk of incontinence?

A

30%

86
Q

How to check SI?

A

Capsule endoscopy - e.g. Crohn’s

87
Q

Preferred treatment for bleeding PUD?

A

Endoscopic therapy - inject epinephrine, mechanical hemo-clip, thermal heater probe

88
Q

GI effects of Parkinson’s?

A

Drooling, dyspepsia, constipation, abdominal pain and fecal incontinence are frequently a source of patient distress.

89
Q

Mx of IO 2! to intra-abdo adhesions?

A

1st line is conservative.
NBM, NGT on intermittent suction, IV rehydration

90
Q

Difference between left and right sided lesions?

A

Chronic occult bleeding + Fe deficient anemia dominate in Right sided.
Obstructive symptoms dominate in left

91
Q

How to rule out admission for appendicitis?

A

Alvarado score 5 or lower.
MANTRELS!!!!

92
Q

Alvarado score for appendicitis?

A

Migratory RIF pain
Anorexia
N/V
Tenderness RIF
Rebound tenderness
Fever
Leukocytosis
Left shift of neutrophils

93
Q

Surgery for pyloric stenosis?

A

Ramstedt pyloromyotomy

94
Q

Do cancers cause massive bleeding?

A

No, usually occult bleeding, slow and chronic.

95
Q

Which colorectal polyp causes hypersecretory syndromes? What can this syndrome manifest?

A

Villous polyps [worst prognosis].
Can cause hypokalemia and profuse mucous discharge

96
Q

Common cause of colovesical fistula?

A

Sigmoid diverticulitis

97
Q

Common causes of appendicitis?

A

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
Q

Physical signs to elicit in appendicitis?

A

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
Q

What is an anal fistulae?

A

Hollow tracts lined with granulation tissue connecting primary opening inside anal canal to secondary opening in perineal skin.
Usu a/w anorectal abscesses.

100
Q

Presentation of anal fistula?

A

Intermittent purulent discharge w/wo bleeding.
Pain that relieves temporarily with pus discharge.

101
Q

Characteristic positioning of internal haemorrhoids?

A

3, 7 and 11 o’clock positions when pt is in lithotomy position

102
Q

4 red flags for Colorectal cancer?

A

Spurious diarrhea
TEnesmus
Pencil thin stools
Alternating constipation and diarrhoea

103
Q

What is toxic megacolon?

A

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
Q
A
105
Q

Where do internal haemorrhoids usually lie?

A

In 3, 7 and 11 o’ clock position.
Pt in lithotomy position.

106
Q

How to differentiate Small Intestine vs Colon obstruction on supine AXR?

A

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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