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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
Q

Postop surveillance after oncologic colon cancer resection?

A

CEA every 3 to 6 months
CT chest/abdomen/pelvis every 6 to 12 months
Colonoscopy at 12 months

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26
Q

indications for proctocolectomy with or without IPAA in ULCERATIVE COLITIS

A

colorectal cancer, a non–adenoma-like dysplasia-associated lesion or mass (DALM), or high-grade dysplasia

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27
Q

which sx get better after colectomy in UC?

A

anemia, uveitis, arthritis, episcleritis improve

50% pyoderma gangrenosum, erythema nodosum

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28
Q

which sx do not get better after colectomy in UC?

A

PSC and ankylosing spondylitis

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29
Q

how long should an ileal J pouch be?

A

15-20 cm

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30
Q

what mutation associated with IBD

A

NOD2, HLA B27

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31
Q

pelvic floor dysfunction causing constipation
dx and mgmt

A

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.

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32
Q

mgmt of toxic megacolon in UC

A

total colectomy without proctectomy (damage control) with end ileostomy

(can trial medicien first (NGT, fluds, steroid, bowel rest, CTX/Flagyl))

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33
Q

UC presentation

A

bloody diarrhea, pain, weight loss (less than Crohns)

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34
Q

UC dx

A

path colonoscopy = pseudopolyps, collar button ulcer, crypt abscesses, anal sparing

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35
Q

UC screening
8 years after dx, every 1-2 years

A

All abnormal lesions must be biopsied along with random biopsies performed in 4 quadrants every 10 cm along the colon and rectum

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36
Q

Crohns screening
8 yrs after dx q1yr

A

Surveillance should be performed using either random biopsies or chromoendoscopy every 1 to 3 years or more frequently if mandated by findings

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37
Q

MC site of perforation UC vs Crohns

A

transverse colon vs distal ieum

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38
Q

2cm+ mass on appendectomy

A

hemi

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39
Q

MC extraintestinal manifestation of UC requiring colectomy

A

FTT

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40
Q

mgmt of colovesical fistula with fecaluria presentation

A
  1. abx
  2. let all inflammation subside
  3. colectomy with fistula takedown, bladder closure, omentum interposition between colon and bladder
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41
Q

Gardner (desmoids and polyposis) encounter mesenteric desmoid during colectomy

A

core bx it; don’t resect (will end up resecting more than you should… short gut)

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42
Q

Crohn’s disease pathology on Bx

A

transmural involvement, segmental disease (skip lesions), cobblestoning, narrow ulcers, creeping at, GRANULOMAS

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43
Q

mgmt of Crohn’s maintenance

A

sulfasalazine, loperamide

refractory: remicade/infliximab (TNF-a inhibitor) good for fistulas

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44
Q

mgmt of Crohn’s acute

A

steroids

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45
Q

surgery in Crohn’s

A

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)

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46
Q

if resecting in Crohn’s, margins?

A

2 cm away from gross disease

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47
Q

severe colonic disease in Crohn’s necessitating surgery

A

proctocolectomy and ileostomy is procedure of choice
NO POUCHES/IPAA In CROHNS

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48
Q

incidental Crohn’s disease when suspected appy

A

take out appy (will confound in future)

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49
Q

stricture disease in Crohn’s

A

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

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50
Q

MC complication after stricturoplasty?

A

bleeding! not perf/restricture interestingly

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51
Q

;.;;oxalate stones in Crohn’s s/p TI resection

A

decrease oxalate binding to Ca 2/2 increased intraluminal fat
oxalate goes into colon
released in urine
ca-oxalate kidney stones

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52
Q

Rectal prolapse management

A

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.

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53
Q

What is positive node

A

0.2 mm of cancer deposit

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54
Q

circular layer of muscle in colon?

A

muscularis PROPRIA

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55
Q

what is haustra?

A

transverse bands made up of plicae semilunares

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56
Q

taenia coli

A

3 bands; splay at rectosigmoid junction

57
Q

quick measurements from verge
dentate
end of rectum
\every 1/3 of rectum
top of rectum

A

dentate 2 cm
end of rectum 4 cm (where levator ani is)
thirds of rectum split by 4 cm16 cm

58
Q

middle rectal artry origin

A

internal iliacs** but follows portal venous flow

59
Q

inferior rectal artery origin

A

pudendal from internal iliac

60
Q

superior/middle rectal VEINS drain into

A

IMV to portal

61
Q

inferior rectal vein drains into

A

internal iliacs and then cava system

62
Q

superior and middle rectum VS inferior rectum nodal drainage

A

superior/middle = IMA nodes
inferior = IMA and internal iliacs
below dentate = internal iliacs

63
Q

external sphincter muscle & innervation

A

puborectalis (continuation of levator ani) mm AND internal pudendal nerve (voluntary)

64
Q

internal sphincter muscle and innervation

A

smooth muscle cotinuation of muscularis propria… AND pelvic splanchnic nerves (involuntary)

65
Q

plexus of colon wall

A

Meissners plexus INNER
Auerbachs plexus OUTER

66
Q

pelvic splanchnics para vs sympa?

A

PARA.

67
Q

crypts of Lieberkuhn

A

mucin secreting goblet cells in rectum

68
Q

pouchitis abx of choice

A

flagyl (and cipro),

consider budesonide enema if persistent
if intractable, consider Crohns; and resect. end ileostomy 4 life.

69
Q

denonvilliers fascia

A

ANTERIOR fascia; rectovesicular/rectoprostatic/rectovagial fascia

70
Q

waldeyers fascia

A

POSTERIOR fascia; rectoSACRAL

71
Q

cancer risk with villous adenoma

A

50% have cancer

72
Q

polyp high risk features

A

> 2cm
villous
sessile

73
Q

carcinoma in situ vs high grade dysplasia? in colonic polyp

A

THE SAME THING.

74
Q

definition of invasive colon cancer

A

invades submucosa (T1)

75
Q

COLON CANCER screening recommendations

A

@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
Q

alternative to colonoscopy surveillance

A

fecal occult blood test q3yr with flex sig q5yr

OR

fecal occult blood test q1yr

77
Q

polypectomy shows T1 lesions (villous or nonvillous)

A

all good! as long as 2mm margin & well differentiated

78
Q

low rectal villous polyp that shows T2 lesion*

A

APR or LAR

79
Q

colon ca bacterial association

A

Clostridium septicum

80
Q

genetic mutations with colon ca

A

APC
DCCC
p53
KRAS

81
Q

most important prognostic factor colon ca

A

NODAL STATUS

82
Q

batsons plexus

A

in breast AND rectum (spine mets… but colon doesn’t rly go to spine)

83
Q

lymphocytic penetration in colon ca

A

better** prognosis

84
Q

worst prognosis type of colon ca

A

mucoepidermoid type

85
Q

rectal cancer resection goals

A

2 cm margin

86
Q

rectal ca mgmt

A

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
Q

TNM staging colon and rectal ca

A

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
Q

staging based off TNM

A

0: TisN0M0
I: T1-2N0M0
IIA: T3N0M0
IIB: T4N0M0
IIIA T1-2N1M0
IIIB T3-4N1M0
IIIC anyTN2M0
IV M1

89
Q

colon ca mgmt

A

All resectable: 3 mo FOLFOX then surgery then 3 mo FOLFOX

III and IV: adjuvant chemotherapy (NO RADIATION)

5 cm margin, 12 nodes

90
Q

f/u colonoscopy after cancer resection?

A

1 yr to look *for another primary

91
Q

Amsterdam criteria for Lynch syndrome 321

A

3 first degree relatives
2 generations
1 cancer < 50 YO

92
Q

surveillance start in Lynch

A

@25 YO or 10 years before relative

93
Q

mgmt Lynch

A

total proctocolectomy

94
Q

sigmoid volvulus dx and mgmt

A

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
Q

cecal volvulus dx and mgmt

A

XR LUQ pointed
20-30 YO
just go to OR for R hemi or ileocecectomy > pexy

Do not decompress!

96
Q

Ogilvies mgmt

A

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
Q

travel to Mexico presents with bloody diarrhea

A

dx: endoscopy with ulceration/trophozoites, 90% have E.histolytica Abs

mgmt: Flagyl, diiodohydroxyquin

98
Q

azotemia after GIB

A

urea from bacterial action on intraluminal blood. increase BUN and Total BILi

99
Q

arteriography speed of bleeding

A

at least 0.5 cc/min

100
Q

Tagged RBC study speed of bleeding

A

at least 0.1 cc/min (so wont see it on CTA again. just embolize)

101
Q

divertiular bleeding cause

A

vasa recta (arterial bleeding) disruption

102
Q

angiodysplasia in colona

A

mostly RIGHT
associated with aortic stenosis (improves after valve surgery)

103
Q

cold vs hot snare polypectomy

A

cold in general… push in and pull
hot if: 1cm+ sessile/pedunculated polyp
otherwise use cold.

104
Q

Length of colon and rectum

A

5-6 ft, 15cm rectum

105
Q

Arc of riolan vs marginal; which is closest to the colon WALL (SMA IMA connection)

A

Marginal is closer.

106
Q

Middle colic artery vs RIGHT/LEFT

A

Middle colic perfuses 2/3 of transverse; left takes over distal 1/3 to descending.

107
Q

Watershed areas

A

Splenic = GRIFFITHS SMA/IMA connection
Rectosigmoid = SUDECKS Sup/middle rectal aa

108
Q

Rectum boundaries

A

Prox: where taenia SPLAY [colaesce at the cecum]
Distal: ANAL CANAL (15cm from verge)

109
Q

Anal canal boundaries (15 cm, like rectum)

A

Prox: puborectalis sling (anorectal ring)
Distal: the verge

110
Q

Define the anal margin

A

5cm radially from VERGE (squamous mucocutaneous junction)

111
Q

Diverticulitis - Hinchey classification

A

I: Pericolic abscess < 4 cm
II: >4 cm
III: Purulent peritonitis
IV: Feculent peritonitis

112
Q

“Complicated” diverticulitis

A

Perforation (not just extraluminal gas or phlegmonous changes)
Abscess
Fistula
Obstruction
Stricture

So… Hinchey Ib or higher.

113
Q

Treatment of complicated diverticulitis?

A

II: perc drainage
III, IV: Hartmann’s

114
Q

Timing of colonoscopy (if not recent) after resolution of uncomplicated divertiulitis?

A

6 wks - to r/o underlying ischemia, IBD or neoplasm

115
Q

Elective colectomy in diverticulitis?

A

Complicated - resolved: Yes. Offer.
Uncomplicated: not necessarily higher risk of emergent colectomy/stoma so can consider individual basis.

116
Q

C. diff dx

A

send stool PCR: Ag and toxin B

117
Q

C. Diff treatment

A

PO vanc, alt: fidaxomicin, flagyl

Fidaxomicin: PO marolide

118
Q

How to change surveillance based on scope findings?

A

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
Q

How to change surveillance based on scope findings?

A

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
Q

Colon cancer resection goals?

A

5-7cm margins, 12 nodes

121
Q

high quality colonoscopy

A

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
Q

postpolypectomy syndrome

A

full thickness without perforation after thermal injury

return with fever and pain

tx: obs, exams, bowel rest, IVF, abx

123
Q

colonic lipoma

A

pillow sign
resect if sx or > 2 cm

124
Q

abx ppx to prevent SSI in SCIP for elective colon surgery
(clean contaminated)

A

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
Q

amifostine

A

IV infusion to prevent radiation enteritis

126
Q

fecal incontinence from babies

A

probably sphincter defect; get ENDOANAL US FIRST TO DX

tx: overlapping sphincteroplasty

127
Q

clinical presentation radiation enteritis/proctitis

A

ACUTE: n/v, pain, diarrhea within 6 wks

CHRONIC: obstruction, pain, diarrhea, bleeding in 8-12 mos

128
Q

mgmt radiation enteritis/proctitis

A

ACEi, statins, AMIFOSTINE********

129
Q

hnpcc with sebaceous gland tumors + GU cancers

A

MUIR-TORRE SYNDROME

130
Q

hnpcc screening

A

20 YO c scope
30-35 EGD and UA
25 endometrial vacuum curettage

131
Q

appendiceal carcinoid (NET) mgmt

A

> 2 cm needs hemi
positive margin
LV invasion
positive margin
3 mm mesoappendix invasion

ALL NEED HEMI

132
Q

appendiceal ADENOcarcinoma mgmt

A

hemi

133
Q

serosa

A

not on rectum; yes on colon

134
Q

typhlitis dx

A

WBC < 3…. can mimic surgical emergency with pneumatosis intestinalis (not an indication alone for OR!!!!!!0

135
Q

typhlitis tx

A

Abx… get WBC up…. surgery ONLY for free perforation

136
Q

what GI bug looks like appendicitis

A

Yersinia

137
Q

Yersinia tx

A

tetracycline or Bactrim

138
Q
A

ABSITE (37 decks)

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