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Colorectal Flashcards

1
Q

MC cause of death after TAC in FAP

How to prevent

A

duodenal adenomas and adenocarcinoma.

Prevention includes regular upper esophagogastroduodenoscopy every 2 to 3 years @ 20-25 YO

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2
Q

How to monitor anal tissue after TAC in FAP?

A

Regular procto with Bx

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3
Q

surveillance after TAC with IPAA in FAP?

A

q1 year vs q2 (elevated risk for rectal recurrence)
score says q1yr endoscopy

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4
Q

when to perfrom an IPAA after proctocolectomy

A

6 mos at least.. still need a DLI x 6-8 wks fr IPAA to heal

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5
Q

FAP surveillance?

A

Flex proctosigmoidoscopy @10 to 12 years (repeated every 1-2 years until age 35 and every 3 years thereafter)
Upper endoscopy every 1 to 3 years once polyps are identified

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6
Q

Cowden disease surveillance?

A

PTEN mutation (hamartoma dz)

Clinical thyroid examination (annually)
Mammography annually beginning at age 30 or 5 years before earliest breast cancer diagnosis in family members
Routine colonoscopic surveillance

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7
Q

Peutz Jeghers syndrome surveillance

A

HAMARTOMAS
Upper endoscopy
Small bowel radiographic study
Colonoscopy (every 2 years)
Pancreatic ultrasound (annually)
Gynecologic examination with pelvic ultrasound
Mammography annually (beginning at age 25)

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8
Q

CDH1 mutation (e-cadherin)

A

hereditary diffuse gastric cancer and increased risk for breast ca

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9
Q

when to ppx gastrectomy in hereditary diffuse gastric ca?

A

20-30 YO

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10
Q

Lynch syndrome = hereditary nonpolyposis colorectal ca

A

ADominant. DNA mismatch repair = MLH1, PMS2, MSH2, and MSH6.

A deletion in the epithelial cell adhesion molecule, which results in MSH2 promotor methylation, can also cause HNPCC.

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11
Q

how to dx HNPCC

A

AMSTERDAM CRITERIA.
3+ family members with CRC (1 first degree)
2+ generations
1 <50 YO

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12
Q

what kind of cancers pop up in HNPCC?

A

RIGHT sided colon cancer
Endometrial tumors
Ovarian tumors
Stomach ca
Urinary tract ca
Small bowel ca
CNS ca

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13
Q

APC somatic vs germline mutations

A

somatic: in more than 80% of sporadic colon cancers

germline: cause familial adenomatous polyposis (FAP).. TSG regulates intracytoplasmic B-catenin

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14
Q

HNPCC screening?

A

Colonoscopy at age 20 to 25 years (repeated every 1-3 years)
Transvaginal ultrasound or endometrial aspiration (females) at age 20 to 25 years (repeated every year)

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15
Q

colorectal met chemotherapy

A

bevacizumab, fluorouracil, and oxaliplatin/irinotecan

or FOLFOX (leukovorin, fluoro, oxali)

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16
Q

early stage rectal ca transanal excision margin

A

1cm; full thickness

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17
Q

rectal ca staging ERUS vs MRI

A

MRI is much better at detecting mesorectal fascial involvement for CRM (CIRCUMFERENTIAL MARGIN = important PROGNOSTIC indicator)

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18
Q

colon ca postop chemo indication

A

node positive or M1 AKA… .STAGE III AND ABOVE.
FOLFOX 6 mos (or 3/3)

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19
Q

primary peritoneal mesothelioma

A

2/2 asbestos
50+ YO
M>F

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20
Q

staging of primary peritoneal mesothelioma

A

The T-stage based on peritoneal cancer index (PCI) - size and distribution of the tumor

T1 is a PCI score of 1-10
T2 is a PCI score of 11-20
T3 is a PCI score of 21-30
T4 is a PCI score of 31-39.

T1N0M0 disease is classified as stage I disease
T2-3N0M0 is classified as stage II disease
stage III disease is any T4 disease, or any T1 or greater disease with the presence of node-positive or metastatic disease

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21
Q

mgmt primary peritoneal mesothelioma

A

HIPEC / CRS

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22
Q

pseudomyxoma peritonei mgmt

A

CRS HIPEC - does not travel lymphatically so can just do an appendectomy and not a R hemi
2.5mm nodules all removed; if cannot get <2.5mm, don’t do HIPEC (no survival benefit)…
NOT radiosensitive.

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23
Q

rectal carcinoid tumor mgmt

A

Transanal excision is adequate for tumors less than 2 cm in diameter

Proctectomy would be indicated with mesorectal excision for larger lesions (> 2 cm).

Invasion of the muscularis propria (T2) has been associated with lymph node metastases in up to 47% of patients.

Systemic chemotherapy is used in metastatic carcinoid lesions; however, its efficacy is limited

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24
Q

colon carcinoid mgmt

A

<1cm polypectomy
>1cm formal resection

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25
Postop surveillance after oncologic colon cancer resection?
CEA every 3 to 6 months CT chest/abdomen/pelvis every 6 to 12 months Colonoscopy at 12 months
26
indications for proctocolectomy with or without IPAA in ULCERATIVE COLITIS
colorectal cancer, a non–adenoma-like dysplasia-associated lesion or mass (DALM), or high-grade dysplasia
27
which sx get better after colectomy in UC?
anemia, uveitis, arthritis, episcleritis improve 50% pyoderma gangrenosum, erythema nodosum
28
which sx do not get better after colectomy in UC?
PSC and ankylosing spondylitis
29
how long should an ileal J pouch be?
15-20 cm
30
what mutation associated with IBD
NOD2, HLA B27
31
pelvic floor dysfunction causing constipation dx and mgmt
Sitzmarker study (distal accumulation) combined with an abnormal defecography or functional MRI physical therapy and biofeedback training to retrain the pelvic floor muscles to relax properly to allow for normal defecation.
32
mgmt of toxic megacolon in UC
total colectomy without proctectomy (damage control) with end ileostomy (can trial medicien first (NGT, fluds, steroid, bowel rest, CTX/Flagyl))
33
UC presentation
bloody diarrhea, pain, weight loss (less than Crohns)
34
UC dx
path colonoscopy = pseudopolyps, collar button ulcer, crypt abscesses, anal sparing
35
UC screening 8 years after dx, every 1-2 years
All abnormal lesions must be biopsied along with random biopsies performed in 4 quadrants every 10 cm along the colon and rectum
36
Crohns screening 8 yrs after dx q1yr
Surveillance should be performed using either random biopsies or chromoendoscopy every 1 to 3 years or more frequently if mandated by findings
37
MC site of perforation UC vs Crohns
transverse colon vs distal ieum
38
2cm+ mass on appendectomy
hemi
39
MC extraintestinal manifestation of UC requiring colectomy
FTT
40
mgmt of colovesical fistula with fecaluria presentation
1. abx 2. let all inflammation subside 3. colectomy with fistula takedown, bladder closure, omentum interposition between colon and bladder
41
Gardner (desmoids and polyposis) encounter mesenteric desmoid during colectomy
core bx it; don't resect (will end up resecting more than you should... short gut)
42
Crohn's disease pathology on Bx
transmural involvement, segmental disease (skip lesions), cobblestoning, narrow ulcers, creeping at, GRANULOMAS
43
mgmt of Crohn's maintenance
sulfasalazine, loperamide refractory: remicade/infliximab (TNF-a inhibitor) good for fistulas
44
mgmt of Crohn's acute
steroids
45
surgery in Crohn's
NOT curative (unlike UC)... no LIS for fissure, no takedown of fistulas I.e. rly only indication: blind loop obstruction anorectal advancement flap vs colostomy in anorectovaginal fistulas strictures (see other card)
46
if resecting in Crohn's, margins?
2 cm away from gross disease
47
severe colonic disease in Crohn's necessitating surgery
proctocolectomy and ileostomy is procedure of choice NO POUCHES/IPAA In CROHNS
48
incidental Crohn's disease when suspected appy
take out appy (will confound in future)
49
stricture disease in Crohn's
MC is resection if SHORT ISOLATED SEGMENT consider stricturoplasty if impending short gut <10cm: (longitudal incision close transversely = Heineke-Mikulicz) 10-20cm: FINNEY (fold stricture segment and make common channel >20cm: MICHELASSI: same as finney but longer Make sure to Bx if stricturoplastying CI to stricturoplasty: malnutrition, presence of inflammatuion/fistula, malignancy
50
MC complication after stricturoplasty?
bleeding! not perf/restricture interestingly
51
;.;;oxalate stones in Crohn's s/p TI resection
decrease oxalate binding to Ca 2/2 increased intraluminal fat oxalate goes into colon released in urine ca-oxalate kidney stones
52
Rectal prolapse management
high fiber diet if old/sick: Altemeier = perineal rectosigmoid resection transanally - HIGHER RECURRENCE, LESS DURABLE if can tolerate: transabdominal rectopexy (open vs lap) +/- LAR or sigmoidectomy if CONSTIPATION concurrent.
53
What is positive node
0.2 mm of cancer deposit
54
circular layer of muscle in colon?
muscularis PROPRIA
55
what is haustra?
transverse bands made up of plicae semilunares
56
taenia coli
3 bands; splay at rectosigmoid junction
57
quick measurements from verge dentate end of rectum \every 1/3 of rectum top of rectum
dentate 2 cm end of rectum 4 cm (where levator ani is) thirds of rectum split by 4 cm16 cm
58
middle rectal artry origin
internal iliacs** but follows portal venous flow
59
inferior rectal artery origin
pudendal from internal iliac
60
superior/middle rectal VEINS drain into
IMV to portal
61
inferior rectal vein drains into
internal iliacs and then cava system
62
superior and middle rectum VS inferior rectum nodal drainage
superior/middle = IMA nodes inferior = IMA and internal iliacs below dentate = internal iliacs
63
external sphincter muscle & innervation
puborectalis (continuation of levator ani) mm AND internal pudendal nerve (voluntary)
64
internal sphincter muscle and innervation
smooth muscle cotinuation of muscularis propria... AND pelvic splanchnic nerves (involuntary)
65
plexus of colon wall
Meissners plexus INNER Auerbachs plexus OUTER
66
pelvic splanchnics para vs sympa?
PARA.
67
crypts of Lieberkuhn
mucin secreting goblet cells in rectum
68
pouchitis abx of choice
flagyl (and cipro), consider budesonide enema if persistent if intractable, consider Crohns; and resect. end ileostomy 4 life.
69
denonvilliers fascia
ANTERIOR fascia; rectovesicular/rectoprostatic/rectovagial fascia
70
waldeyers fascia
POSTERIOR fascia; rectoSACRAL
71
cancer risk with villous adenoma
50% have cancer
72
polyp high risk features
>2cm villous sessile
73
carcinoma in situ vs high grade dysplasia? in colonic polyp
THE SAME THING.
74
definition of invasive colon cancer
invades submucosa (T1)
75
COLON CANCER screening recommendations
@50, q10yr - colonoscopy or @50, q5yr sigmoid + FOBT or @40 q5yr or 10 yr before earliest dx if first degree family hx* Or @40 q10yr if first degree > 60YO or two 2nd degree Or @10-12 YO q1yr sigmoidoscopy FAP Or @20-25 YO q1-2 yrs or 10 yrs before dx HNPCC
76
alternative to colonoscopy surveillance
fecal occult blood test q3yr with flex sig q5yr OR fecal occult blood test q1yr
77
polypectomy shows T1 lesions (villous or nonvillous)
all good! as long as 2mm margin & well differentiated
78
low rectal villous polyp that shows T2 lesion*
APR or LAR
79
colon ca bacterial association
Clostridium septicum
80
genetic mutations with colon ca
APC DCCC p53 KRAS
81
most important prognostic factor colon ca
NODAL STATUS
82
batsons plexus
in breast AND rectum (spine mets... but colon doesn't rly go to spine)
83
lymphocytic penetration in colon ca
better** prognosis
84
worst prognosis type of colon ca
mucoepidermoid type
85
rectal cancer resection goals
2 cm margin
86
rectal ca mgmt
T1: excise if <3cm, <1/3 circumference, close to verge; otherwise APR/LAR otherwise surgerize NEOADJUVANT: Stage II and III: chemoXRT 5000 cGy with 5-Fu to make radiosensitive x 5-6 wks Re-image for response. SURGERY: Upper 1/3: mesorectal excision with 5cm distal margin (like colon) Lower 2/3: total mesorectal excision with LAR or APR, 2 cm distal margin; 1cm if very distal otherwise need APR ADJUVANT: FOLFOX for Stage III or higher who did not get NEO (were understaged) for high risk Stage II (high grade) Stage IV: chemoXRT +/- SURGERY (maybe just colostomy)
87
TNM staging colon and rectal ca
T1: into submucosa T2: into muscularis propria T3: into subserosa or thru propria if no serosa present T4: through serosa into free cavity/adjacent organs if no serosa present N0: none N1: 1-3 positive (0.2mm deposit of cancer cells) N2: 4+ N3: central nodes positive M1: distant metss
88
staging based off TNM
0: TisN0M0 I: T1-2N0M0 IIA: T3N0M0 IIB: T4N0M0 IIIA T1-2N1M0 IIIB T3-4N1M0 IIIC anyTN2M0 IV M1
89
colon ca mgmt
All resectable: 3 mo FOLFOX then surgery then 3 mo FOLFOX III and IV: adjuvant chemotherapy (NO RADIATION) 5 cm margin, 12 nodes
90
f/u colonoscopy after cancer resection?
1 yr to look *for another primary
91
Amsterdam criteria for Lynch syndrome 321
3 first degree relatives 2 generations 1 cancer < 50 YO
92
surveillance start in Lynch
@25 YO or 10 years before relative
93
mgmt Lynch
total proctocolectomy
94
sigmoid volvulus dx and mgmt
XR RUQ pointed decompress with colonoscopy if not peritonitic - leave tube 1-3 days (high rate recurrence) perform OPEN sigmoid colectomy primary anastomosis same admission If unstable: HARTMANNS
95
cecal volvulus dx and mgmt
XR LUQ pointed 20-30 YO just go to OR for R hemi or ileocecectomy > pexy Do not decompress!
96
Ogilvies mgmt
if colon > 12 cm or >6 days (high perforation risk) tx: 1. fluid resuscitation, correct lytes, NGT decompression 2. neostigmine (AE: bradycardia) 3. cscope decompression if neo fails 4. if no improvement @ 6 days, R hemi vs subtotal If just failed obs, just tube cecostomy vs resection If ischemia/perforation: OR resection (anast can be considered)
97
travel to Mexico presents with bloody diarrhea
dx: endoscopy with ulceration/trophozoites, 90% have E.histolytica Abs mgmt: Flagyl, diiodohydroxyquin
98
azotemia after GIB
urea from bacterial action on intraluminal blood. increase BUN and Total BILi
99
arteriography speed of bleeding
at least 0.5 cc/min
100
Tagged RBC study speed of bleeding
at least 0.1 cc/min (so wont see it on CTA again. just embolize)
101
divertiular bleeding cause
vasa recta (arterial bleeding) disruption
102
angiodysplasia in colona
mostly RIGHT associated with aortic stenosis (improves after valve surgery)
103
cold vs hot snare polypectomy
cold in general... push in and pull hot if: 1cm+ sessile/pedunculated polyp otherwise use cold.
104
Length of colon and rectum
5-6 ft, 15cm rectum
105
Arc of riolan vs marginal; which is closest to the colon WALL (SMA IMA connection)
Marginal is closer.
106
Middle colic artery vs RIGHT/LEFT
Middle colic perfuses 2/3 of transverse; left takes over distal 1/3 to descending.
107
Watershed areas
Splenic = GRIFFITHS SMA/IMA connection Rectosigmoid = SUDECKS Sup/middle rectal aa
108
Rectum boundaries
Prox: where taenia SPLAY [colaesce at the cecum] Distal: ANAL CANAL (15cm from verge)
109
Anal canal boundaries (15 cm, like rectum)
Prox: puborectalis sling (anorectal ring) Distal: the verge
110
Define the anal margin
5cm radially from VERGE (squamous mucocutaneous junction)
111
Diverticulitis - Hinchey classification
I: Pericolic abscess < 4 cm II: >4 cm III: Purulent peritonitis IV: Feculent peritonitis
112
“Complicated” diverticulitis
Perforation (not just extraluminal gas or phlegmonous changes) Abscess Fistula Obstruction Stricture So… Hinchey Ib or higher.
113
Treatment of complicated diverticulitis?
II: perc drainage III, IV: Hartmann’s
114
Timing of colonoscopy (if not recent) after resolution of uncomplicated divertiulitis?
6 wks - to r/o underlying ischemia, IBD or neoplasm
115
Elective colectomy in diverticulitis?
Complicated - resolved: Yes. Offer. Uncomplicated: not necessarily higher risk of emergent colectomy/stoma so can consider individual basis.
116
C. diff dx
send stool PCR: Ag and toxin B
117
C. Diff treatment
PO vanc, alt: fidaxomicin, flagyl Fidaxomicin: PO marolide
118
How to change surveillance based on scope findings?
1-2 tubular adenoma: 5 years >3 tubular adenomas: 3 years ANY Advanced (>1 cm, HIGH GRADE, dysplasia, VILLOUS): 3 years Hyperplastic polyps: 10 years (average risk)
119
How to change surveillance based on scope findings?
1-2 tubular adenoma: 5 years >3 tubular adenomas: 3 years ANY Advanced (>1 cm, HIGH GRADE, dysplasia, VILLOUS): 3 years Hyperplastic polyps: 10 years (average risk)
120
Colon cancer resection goals?
5-7cm margins, 12 nodes
121
high quality colonoscopy
90%+ CECUM INTUBATED 6 MINUTES withdrawal perforation rate <.1 in 1000 screening, <1 in 500 overall <1% post polypectomy bleeding post polypectomy bleeding is ok nonop in 90+% cases
122
postpolypectomy syndrome
full thickness without perforation after thermal injury return with fever and pain tx: obs, exams, bowel rest, IVF, abx
123
colonic lipoma
pillow sign resect if sx or > 2 cm
124
abx ppx to prevent SSI in SCIP for elective colon surgery (clean contaminated)
cefoxitin/erta/ancef+flagyl within 1 hour PREP = 1 g neomycin + 1 g erythromycin (or 500 flagyl) PO 18 hr, 17 hr, and 10 hrs
125
amifostine
IV infusion to prevent radiation enteritis
126
fecal incontinence from babies
probably sphincter defect; get ENDOANAL US FIRST TO DX tx: overlapping sphincteroplasty
127
clinical presentation radiation enteritis/proctitis
ACUTE: n/v, pain, diarrhea within 6 wks CHRONIC: obstruction, pain, diarrhea, bleeding in 8-12 mos
128
mgmt radiation enteritis/proctitis
ACEi, statins, AMIFOSTINE********************************
129
hnpcc with sebaceous gland tumors + GU cancers
MUIR-TORRE SYNDROME
130
hnpcc screening
20 YO c scope 30-35 EGD and UA 25 endometrial vacuum curettage
131
appendiceal carcinoid (NET) mgmt
>2 cm needs hemi positive margin LV invasion positive margin >3 mm mesoappendix invasion ALL NEED HEMI
132
appendiceal ADENOcarcinoma mgmt
hemi
133
serosa
not on rectum; yes on colon
134
typhlitis dx
WBC < 3.... can mimic surgical emergency with pneumatosis intestinalis (not an indication alone for OR!!!!!!0
135
typhlitis tx
Abx... get WBC up.... surgery ONLY for free perforation
136
what GI bug looks like appendicitis
Yersinia
137
Yersinia tx
tetracycline or Bactrim
138

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