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BTK Review 2024 > Colorectal > Flashcards

Colorectal Flashcards

1
Q

What is the Arc of Riolan?

A

a smaller arcade between the SMA and IMA that provides collateralization to the colon

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1
Q

What defines the proximal anal canal?

A

the puborectalis sling

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2
Q

What are the medical treatments for anal fissures?

A
  • fiber and other bulking agents
  • sitz baths
  • topical anesthetics/nitrates/CCB
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3
Q

What are the procedural treatment options for anal fissures?

A
  • botox injection
  • lateral internal sphincterotomy
  • an-cutaneous flap
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4
Q

What are the contraindications for lateral internal sphincterotomy for anal fissure?

A
  • incontinence with botox injection
  • women of childbearing age or with prior obstetrical injuries
  • inflammatory bowel disease
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5
Q

What is the rule for the course that an anorectal fistula takes?

A
  • anteriorly they take linear tracts unless > 3cm from the anus
  • posterior they take curvilinear tracts
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6
Q

Which perirectal abscesses should be drained trans-anally?

A

deeper intersphincteric and supralevator

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7
Q

What is the proper procedure for draining a horseshoe abscess?

A

posterior mildline trans-anal incision with bilateral counter incisions

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8
Q

Which patients with peri-rectal abscesses should be treated with antibiotics?

A

those with cellulitis, systemic signs of infection, or with underlying immunosuppression

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9
Q

How does a seton work?

A

it induces fibrosis of the tract

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10
Q

When can you perform a fistulotomy?

A

if there is < 25% involvement of the sphincter

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11
Q

What is the physiologic function of hemorrhoids?

A

they provide volume to assist with continence

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12
Q

What procedure is the preferred intervention for acute symptomatic external hemorrhoids?

A

excision (not I&D)

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13
Q

Which hemorrhoids can be banded?

A

only internal since they have no somatic innervation

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14
Q

When should perc drain placement be pursued for those with diverticular abscess?

A

when the abscess is accessible and > 3cm

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15
Q

When should colonoscopy be performed after diverticulitis? Why?

A
  • typically 6 weeks after resolution of the episode
  • rule out ischemia, IBD, and neoplasm
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16
Q

What is the natural history of diverticulitis?

A

the first episode tends to be the worst

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17
Q

What class of bacteria is C. diff?

A

an anaerobic, gram-negative rod

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18
Q

For C. diff, how are the following treated:
- non-severe disease
- severe disease
- fulminant
- recurrent (1st)
- recurrent (2nd)

A
  • PO vanco or flagyl
  • PO vanco or PO fidaxomicin
  • PO vanco and IV flagyl
  • PO fidaxomicin
  • longer course of vanco or fixaxomicin
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19
Q

What is the operative procedure of choice for C. diff colitis?

A

subtotal colectomy with ileostomy

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20
Q

What is the next step for a patient with suspected sigmoid volvulus on KUB?

A

CT scan to confirm diagnosis and assess colonic viability

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21
Q

When should you consider sigmoid colectomy for volvulus?

A
  • on presentation if there is ischemic bowel
  • otherwise during index admission given high risk for recurrence
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22
Q

What is the important difference between management of sigmoid v cecal volvulus?

A

there is no role for endoscopic management of cecal volvulus

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23
Q

What are risk factors for perforation in Ogilvie’s?

A

cecum > 12cm, fever, leukocytosis, abdominal tenderness

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24
Q

What medication can be given to decompress the colon in someone with Ogilvie’s? How does it work?

A

neostigmine, an acetylcholinesterease inhibitor

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25
Q

What is the most common side effect of neostigmine?

A

bradycardia

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26
Q

If someone with a dilated colon does not respond to neostigmine, what is the next step?

A

endoscopic decompression

27
Q

What lifestyle modification can be used to help manage rectal prolapse?

A

a high fiber diet, but surgery remains the mainstay of treatment

28
Q

What is the first line therapy for a relatively healthy patient with rectal prolapse?

A
  • rectopexy is the key component
  • LAR or sigmoid colectomy is added if the patient has constipation
29
Q

What is the key difference between a Delorme and an Altemeier procedure?

A
  • both are perineal approaches for rectal prolapse
  • Delorme is a partial thickness resection while an Altemeier is full thickness
30
Q

Which study has the highest sensitivity for bleeding?

A

a tagged RBC scan > CT angio > angio

31
Q

What are the classic pathology findings for UC and Crohn’s?

A
  • UC: pseudopolyps and crypt abscesses
  • Crohn’s: creeping fat and transmural inflammation
32
Q

How is UC medically managed?

A
  • mesalamine enemas for maintenance
  • infliximab added if resistant
  • steroids for flares
33
Q

What is the recommended surveillance for those with UC?

A
  • endoscopy every 1-2 years, beginning 8 years after diagnosis
  • make sure to take 4 quadrant random biopsies every 10cm
34
Q

What is the best next step for a patient with high-grade dysplasia on a random biopsy?

A

total proctocolectomy with or without IPAA

35
Q

What is the preferred emergency operation for those with UC?

A
  • total or subtotal colectomy with end ileostomy
  • can perform completion proctectomy later
36
Q

Which UC patients are a candidate for TAC with ileorectal anastomosis? What surveillance do they still need?

A
  • can perform if they have an uninvolved rectum (rare)
  • should have annual endoscopic surveillance of rectal cuff
37
Q

What are the three kinds of stricturoplasties?

A
  • Heineke-Mikulicz: longitudinal incision with transverse closure
  • Finney: fold structured segment on itself and make a common channel
  • Michelassi: side-to-side isoperistaltic anastamosis
38
Q

What is the most common complication after stricturoplasty?

A

bleeding

39
Q

What is the standard recommendation for colon cancer screening?

A
  • colonoscopies every 10 years starting at 45 years old
  • alternative is sigmoidoscopy with FOBT every 5 years
40
Q

What is the screening recommendation for those with FAP? For hereditary non-polyposis CRC?

A
  • FAP: colonoscopy every 1-2 years for those age 10-12
  • HNPCC: colonoscopy every 1-2 years for those age 20-25
41
Q

What is the screening recommendation for those with the following:
- 1st degree relative with CRC or adenomas
- 2nd degree relative with CRC

A
  • 1st: age 40 or 10 years before the youngest relative’s diagnosis, every 5 years
  • 2nd: age 45 and every 10 years
42
Q

What is the surveillance interval for the following colonoscopy findings:
- 1-2 tubular adenomas < 10mm
- 3-4 tubular adenomas < 10mm
- > 10 tubular adenomas
- adenoma > 10mm
- adenoma with HGD
- piecemeal resection
- hyperplastic polyps < 10mm
- hyperplastic polyps > 10mm

A
  • 7-10 years
  • 3-5 years
  • 1 year
  • 3 years
  • 3 years
  • 6 months
  • 10 years
  • 3-5 years
43
Q

Which malignant colon polyps can be managed endoscopically?

A

those that meet these criteria:
- able to remove in 1 piece
- margins free of dysplasia/cancer
- well or moderately differentiated
- without angiolymphatic invasion
- limited submucosal invasion less than 2mm past the muscularis mucosa

44
Q

Describe the TNM staging for colorectal cancer.

A

T1: invades submucosa
T2: invades muscularis propria
T3: invades into pericolonic tissue
T4a: penetrates serosa
T4b: invades surrounding structures
N1: 1-3 nodes
N2a: 4-6 nodes
N2b: 7+ nodes

stage 1: T1-T2
stage 2: T3-T4
stage 3: any N
stage 4: any M

45
Q

What is the standard margin for colon cancer resection? How many nodes are required?

A

5-7cm proximally and distally to ensure adequate lymphadenectomy (12 nodes)

46
Q

How should you manage colon cancer with isolated, resectable, hepatic metastases?

A
  • 3 months neoadjuvant therapy (FOLFOX)
  • surgery
  • 3 months adjuvant therapy (FOLFOX)
47
Q

Which patients are eligible for adjuvant chemotherapy for colon cancer? What regimen is used?

A

those with stage III disease (FOLFOX for 6 months; folinic acid, 5-FU, oxaliplatin)

48
Q

What is tumor circumferential margin in those with rectal cancer?

A

the total distance between the tumor and mesorectal fascia

49
Q

Which patients with rectal cancer should receive neoadjuvant chemotherapy? What is the typical regimen?

A
  • locally advanced tumors of the mid-distal rectum (T3 or any N)
  • give 5000Gy radiotherapy concurrently with 5-FU over 5-6 weeks
  • surgery follows another 8-12 weeks after
50
Q

When is local excision an option for rectal cancer?

A

must meet the following criteria:
- T1 lesions without high risk features
- well-to-moderately differentiated
- no lymph vascular or perineural invasion
- < ⅓ circumference of the bowel lumen

big consideration is that you can’t assess lymph nodes and has up to 20% recurrence

51
Q

What is the adjuvant therapy for rectal cancer? Who is it recommended for?

A
  • FOLFOX is the regimen
  • should give to stage II that received neoadjuvant therapy (assume they were downstage) or stage III disease (upstaged at time of excision)
52
Q

Name four histologic variants of anal SCC.

A
  • cloacogenic
  • basaloid
  • epidermoid
  • mucoepidermoid
53
Q

What HPV serotypes are associated with anal SCC?

A

16 and 18

54
Q

What is anal intra-epithelial neoplasm?

A

a precursor lesion to SCC

55
Q

What is the primary treatment for SCC of the anal canal?

A

nigro protocol chemoradiotherapy (5-FU, mitomycin C, and 3000 cGy XRT)

56
Q

What is the appropriate management of residual SCC of the anal canal after nigro protocol?

A

APR

57
Q

How do you manage SCC of the anal margin?

A

like a skin cancer with WLE

58
Q

How do you manage anal melanoma?

A

with APR

59
Q

What is the appropriate management of an AIN lesion?

A

local treatment (photodynamic, imiquimod, topical 5-FU) with surveillance every 4-6 months

60
Q

What is the main nutrient of colonocytes? Enterocytes?

A
  • short chain fatty acids, particularly butyrate
  • glutamine
61
Q

What should you do with rectal cancer that had a complete clinical response to neoadjuvant therapy?

A

proceed with resection

62
Q

Chronic pouchitis in a patient with UC should prompt a suspicion for what?

A

Crohns

63
Q

What is the treatment of pouchitis?

A
  • antibiotics
  • supportive care
  • budesonide enemas
64
Q

During laparoscopy of appendicitis, the appendix looks normal with inflamed TI. What do you do next?

A
  • lap appy if cecum is uninvolved
  • otherwise, close and workup for Crohns
65
Q
A

BTK Review 2024 (19 decks)

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