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QUESTION NOTES > COLORECTAL > Flashcards

COLORECTAL Flashcards

1
Q

T-score rectal cancer

A

T1 = submucosa
T2 = muscularis propria
T3 or N1 = through MP

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2
Q

Mgmt rectal CA by T-score

A 
T1 = transanal excision vs. LAR or APR
T2 = LAR or APR
T3 = neoadjuvant CRT, then LAR or APR
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3
Q

When do transanal excision instead of LAR/APR for T1 rectal CA?

A
  • <30% circumference of bowel
  • <3cm size
  • within 8cm of anal verge
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4
Q

Characteristics of polyps on colonoscopy concerning for invasive cancer - need segmental colectomy (cannot just do endoscopic removal)

A
  • involved polypectomy margin (<2mm on removal)
  • lymphovascular invasion, poor differentiation
  • invasion of lower third submucosa
  • central depression or ulceration
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5
Q

Mgmt sigmoid volvulus

A
  1. sigmoidoscopic decompression + no evidence mucosal gangrene or bloody effluent
  2. then can go elective ONE STAGE (no Hartmann) sigmoid resection
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6
Q

After NIGRO protocol, next steps?

A
  • examined 8-12wks after completion, then at 4-6wk intervals until resolution of suspicious findings
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7
Q

After NIGRO protocol, findings upon examination classified into…? subsequent f/u?

A
  1. complete remission -> fu exam q3-6mo for 5yrs + imaging every year for 3yrs
  2. persistent disease -> fu 6mo to see if further regression occurs
  3. progressive or persistent disease at 6mo -> w/ biopsy to confirm
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8
Q

Distal margin of sigmoid for diverticulitis should be…?

A

rectum (colo-colonic anastomosis increases risk recurrent diverticulitis)

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9
Q

Frequency of surveillance colonoscopy after resection of colon CA

A
  • if could not evaluate entire colon (2/2 obstructing CA), then need repeat within 6mo of resection
  • if entire colon surveyed at time of dx, then first surveillance colonoscopy at 1-yr postop -> 3-yr -> 5-yr
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10
Q

Granular cell tumors most commonly at…? What about in GI?

A

commonly in skin + subQ, but can be in GI (tongue > esophagus > colon >anorectal)

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11
Q

Mgmt granular cell tumor in GI

A

WLE (colonscopic excision)

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12
Q

Anal endosonography

A

used to detect internal and external sphincter defects (external typically palp on physical exam)

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13
Q

Factors that decrease likely benefit for colon CA resection (5)

A
  • node + primary
  • disease-free interval <12mo
  • increasing # mets
  • largest met >5cm
  • serum CEA >200
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14
Q

Alvimopan

A

= entereg
decreases time to ROBF by 15-24hr; approved for peri-op use after partial large/small bowel resection with primary anastamosis

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15
Q

Painless hematochezia, think…?

A

internal hemorrhoid, AVM, UGI/small bowel bleed

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16
Q

Anal fissure mgmt

A
  • diet + hydration
  • if failed and >4wk = chronic -> topical CCB (better than topical nitrates bc HA)
  • IV botulinum toxin
  • lateral internal sphincterotomy (except if have b/l incontinence)
  • flap procedures
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17
Q

LAR

A

low anterior resection = anterior resection of rectum

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18
Q

APR

A

abdomino-perineal resection = anus + rectum + part of sigmoid + associated regional LN + end-ostomy

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19
Q

total proctocolectomy

A

right/left colon + rectum

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20
Q

Patho and Tx for diarrhea s/p terminal ileum resection

A

resection -> malabsorption of bile salts -> salts in colon interfere with colonic absorption of fluid/electrolytes -> diarrhea

Tx: PO cholestyramine

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21
Q

Dx bacterial overgrowth in bowel? Tx?

A

Dx: D-xylose breath test
Tx: Abx

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22
Q

Mgmt adult with intussusception

A

laparotomy + ileocecetomy (always)

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23
Q

Lynch syndrome defined as…? (Amsterdam/Bethesda criteria)

A
  • 3 relatives with colorectal CA
  • 2+ generations involved
  • AND at least one before 50yo
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24
Q

Cowden’s syndrome (age dx typically, associated with what CA)

A

AD juvenile polyposis syndrome

  • avg dx 18-yo
  • associated with breast + thyroid disease
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25
Q

Mgmt for small sessile lesion

A

excise using saline lift + endoscopic resection

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26
Q

Markers for goblet cell carcinoid tumors

A
  • chromogranin A

- synaptophysin (histo +)

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27
Q

SMA and IMA directly connected by…?

A

Arc of Reolon (meandering mesenteric artery)

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28
Q

Arterial supply to rectum

A
  • superior rectal (from IMA)
  • middle rectal (from internal iliac; runs in lateral stock)
  • inferior rectal (from pudendal off internal iliac)
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29
Q

Venous drainage of rectum

A
  • superior + middle rectal -> IMV (portal)

- inferior rectal -> internal iliac -> IVC

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30
Q

How far is rectum from anal verge?

A

~15cm

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31
Q

Anal canal anatomically begins/ends…?

A

puborectalis sling, ends at squamous mucosa (includes transition zone, dentate line)

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32
Q

If have distal rectal cancer, need to do what on physical exam to check mets?

A

palpable groin LN - bc unlike colon cancer, distal rectum drains to systemic iliacs -> IVC

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33
Q

single episode unCx diverticulitis, treated with Abx… next step?

A

colonoscopy in 6-wks to r/o CA, ischemia, or IBD

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34
Q

Main energy source for colonocytes

A

SCFA (butyrate)

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35
Q

Surveillance for ulcerative colitis

A

if colitis proximal to splenic flexure, then colonoscopy after 8 years + repeat every 1-2 years

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36
Q

If have high grade dysplasia on surveillance colonoscopy for UC?

A

indication for total protocolectomy w/ or wo IPAA

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37
Q

Mgmt options for ulcerative colitis

A

steroids, mesalamine, infliximab

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38
Q

Mgmt options Crohn’s

A

steroids (acute), 5ASA, mesalamine, infliximab

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39
Q

Mgmt strictures Crohn’s

A

<10cm -> Heineke Mikulicz stricturoplasty (longitudinal incision and close transversely)
10-20cm -> Finney stricturoplasty (fold stricture on itself, open bowel on either end, sew common wall)
>20cm -> Michelassi (side-to-side isoperistaltic stricturoplasty)

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40
Q

If stricture in first 2 portions of duodenum?

A

bypass gastroJ + highly selective vagotomy (bc pts prone to ulcerations at gastroJ stoma)

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41
Q

After stricturoplasty, make sure to do what in OR?

A

biopsy!

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42
Q

C/I stricturoplasty (5)

A

evidence of:

  • malnutrition
  • perforation
  • inflammation
  • fistula
  • malignancy
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43
Q

Colon CA screening (all)

A

standard: 50yo q10yr
first degree before 60, or 2 relatives at any age: 40yo q5yr (or 10yr before youngest relative)
first degree after 60, or 2 second degree: 40yo q10yr

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44
Q

Colon CA screening: FAP

A

start 10yo, q1yr sigmoidoscopy

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45
Q

Colon CA screening: HNPCC

A

start 20yo, q1-2yr or 10yrs prior to youngest dx relative

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46
Q

Screening f/u if: =/<2 tubular adenomas, <10mm

A

repeat colonoscopy in 5-10yrs

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47
Q

Screening f/u if: 3+ tubular adenoma

A

repeat colonoscopy in 3yrs

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48
Q

Screening f/u if: advanced adenoma (>1cm, high grade dysplasia, villous)

A

repeat colonoscopy in 3yrs

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49
Q

Screening f/u if: hyperplastic polyp

A

normal. standard repeat colonoscopy in 10yrs

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50
Q

Endoscopic resection for polyps NOT adequate when… (5)

A
  1. cannot remove in one piece
  2. pedunculated Haggitt level 4 w/ unfavorable histology
  3. sessile w/ Sm1/Sm2 depth + poor features
  4. sessile q/ Sm3 depth
  5. positive margins
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51
Q

T-staging colon cancer

A
  • TIS: lamina propria
  • T1: submucosa
  • T2: muscularis propria
  • T3: thru MP, into pericolonic tissue
  • T4a: penetrates serosa
  • T4b: invades/adherent to surrounding structures
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52
Q

N-staging colon cancer

A

pos LN = >0.2mm deposit of cancer cells

  • N1 (1-3 nodes)
  • N2a (4-6)
  • N2b (7+)
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53
Q

TNM staging colon cancer

A

Stage 1: T1-T2, no nodes
Stage 2: T3-T4, no nodes
Stage 3: any T w/ nodes
Stage 4: distant mets

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54
Q

How many LN need to resect to ensure adequate lymphadenectomy for colon cancer?

A

12

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55
Q

Negative margin criteria for colon cancer

A

5-7cm (bc need adequate lymphadenectomy + removal of vascular supply)

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56
Q

Folfox chemotherapy is a combination of…?

A

cisplatin + 5FU + folinic acid chemotherapy

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57
Q

What does a circumferential resection margin (CRM) indicate for rectal cancer?

A

total distance btwn tumor and mesorectal fascia - good prognostic indicator

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58
Q

How to evaluate CRM of rectal cancer?

A

Endorectal US or MRI

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59
Q

Neoadjuvant regimen for rectal cancer

A

500 centagrade + 5-FU (5-6wks) -> resection 2-3mo following neoadjuvant

*5FU is a sensitizer for radiation

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60
Q

Patients that get neoadjuvant upfront for rectal cancer

A
  • locally advanced of middle or distal rectum
  • T3 or greater
  • any node pos disease
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61
Q

When can do local excision for rectal cancer?

A

T1 lesions wo high risk features:

  • well-mod differentiated
  • no lymph/vasc/perineural invasion
  • tumor <3cm
  • clear margins >3mm
  • <1/3 circumference of bowel lumen
  • mobile, not-fixed
  • tumor within 8cm anal verge
  • no muccin production
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62
Q

Disadvantages of local excision of rectal cancer

A
  • not able to pathologically examine regional LN

- up to 20% local recurrence

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63
Q

Mgmt rectal cancer in upper 1/3 rectum

A

LAR w/ tumor specific mesorectal excision w/ 5cm margin + anastamosis (want to preserve rectum and continence)

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64
Q

Mgmt rectal cancer in mid-lower third of rectum

A

APR + total mesorectal excision; ideally want 2cm margins, but if very distal can do 1cm to avoid excising sphincter

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65
Q

Types of anal squamous neoplasm (4)

A
  • cloacogenic
  • basaloid
  • epidermoid
  • mucoepidermoid
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66
Q

Mgmt anal canal SCC

A

NIGRO protocol: 5FU + mitomycin C + 3000 centigrade XRT (no surgery)

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67
Q

f/u for AIN 1, 2, 3

A

low dysplasia = 1, 2
high dysplasia = 3
low conversion rate for immmunocompetent; surveillance q4mo

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68
Q

local therapy AIN

A

topical iniquimad + topical 5FU

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69
Q

What is the anal margin?

A

perianal skin

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70
Q

Mgmt anal melanoma

A

WLE if possible (avoid APR bc high morbidity procedure for likely metastatic disease)

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71
Q

Preoperative evaluation for rectal cancer needs to include…?

A
  • CEA
  • rigid proctoscopy
  • CT C/A/P
  • Endorectal US or rectal MRI (CRM)
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72
Q

Second MCC of death in FAP pts

A

duodenal adenomas

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73
Q

Gardner’s syndrome also associated with

A
  • desmoid tumors
  • epidermoid tumors
  • osteomas
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74
Q

Turcot’s syndrome also associated with

A
  • brain tumors (2/3 also have APC mutation)
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75
Q

When do colectomy for FAP?

A

typically 20-yo

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76
Q

Do desmoid tumors metastasize?

A

no - locally invasive

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77
Q

Third MCC of death in FAP pts

A

desmoid tumors

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78
Q

If during screening EGD in FAP pt, and find high-risk dysplasia in duodenum… then need…?

A

If stage 4 Spigelman classification, then Whipple (duodenal adenoma in FAP 2nd MCC death)

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79
Q

Lynch syndrome patho

A

(AD) - defect in mismatch repair genes (MLH1, MSH2/6, PMS2) -> DNA buildup of microsatellite -> instability

  • non-polyposis
  • typically right colon, mucinous, poor-differentiation
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80
Q

Endometrial cancer in pt <50yo, suspect…?

A

Lynch II syndrome

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81
Q

Cecal bascule

A
  • type of cecal volvulus

- folding of cecum anteriorly over ascending colon -> large bowel obstruction

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82
Q

rectal prolapse vs. hemorroids

A

rectal prolapse is full-thickness, is also appear and concentric rings of tissue (hemorrhoids appear radial pattern)

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83
Q

MC nonintestinal viscera involved w/ internal fistula from Crohn’s

A

bladder

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84
Q

Mgmt most internal fistulas 2/2 Crohn’s

A

limited or no resection (only resection if both segments involved with Crohn’s) w/ tension-free closure

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85
Q

Chilaiditi sign

A

transposition of a loop of large intestine (usually transverse colon) in between the diaphragm and the liver. NTD unless symptomatic.

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86
Q

F/u for FAP pts s/p total colectomy w/ ileorectal anastomosis

A

annual endoscopy of remnant rectum

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87
Q

MCC anal fistula

A

cryptoglandular disease (inflammation of protodeal glands in intersphincteric space)

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88
Q

Mgmt horseshoe abscess of anus

A

Hanley procedure = incision made in internal sphincter posterior to enter deep postanal space w/ b/l elliptical incisions for drainage bilaterally

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89
Q

What is anal horseshoe abscess?

A

bilateral fluid collections of ischiorectal space that communicates via deep postanal space behind anococcygeal ligament

90
Q

What is LIFT procedure?

A

ligation of internal fistula tract = definitive mgmt for transsphincteric fistula control w/o risk incontinence

91
Q

When try endorectal advancement flap?

A

for complex transsphincteric fistula, but higher risk incontinence (20%) - can be attempted if LIFT fails

92
Q

Non-op mgmt of pilonidal disease

A

shaving

93
Q

abd pain + hematochezia + colonoscopy w/ erythematous and edematous mucosa w/ small ulcerations… think?

A

ischemic colitis - mgmt: IVF, Abx, bowel rest (if transmural ischemia, then need ex-lap)

94
Q

Krukenberg tumor

A

metastatic GI adenoCA to ovary (via retrograde lymphatic spread)

95
Q

Mgmt obstructing descending colonic mass

A

transverse loop colectomy - colonic obstruction is a surgical emergency; resection of mass can be done after appropriate staging

96
Q

Signet-ring cell CA of colon MC associated with what gene defect?

A

microsatellite instability (MSI)

97
Q

What is Sitzmark study?

A

colon transit study (ingest radiopaque markers, then daily XR)

98
Q

Intermittent, crampy abd pain and alternating constipation/diarrhea s/p Rx of ischemic colitis… think?

A

colonic stricture after ischemic colitis -> need dx colonoscopy

99
Q

Loop vs. end colostomies more prone to prolapse?

A

loop

100
Q

MCC acute LGI hemorrhage

A

diverticulosis > colitis > neoplasm > angiodysplasia

101
Q

MC site for bowel perf if obstructing cancer

A

if ileocecal valve competent -> cecum; if not -> perf at tumor site

102
Q

MC sxs colorectal cancer <40yo

A

rectal bleeding > abd pain

103
Q

Total colectomy w/ end colostomy for severe UC, need to preserve…?

A
  • superior rectal artery (supplies rectal stump needed to heal rectal staple line)
  • terminal branches of IMA (until proctectomy)
  • ileocolic artery (collateral blood flow to future J-pouch)
  • rectum should be divided ABOVE posterior peritoneal reflection above level of sacral promontory (easier completion proctectomy later)
104
Q

Elective proctectomy w/ or wo IPAA at later date for severe UC… do not perform where?

A

do not perform in total mesorectal excision plane bc risk injury to hypogastric plexus and pelvic nerves -> bladder and sexual dysfxn

105
Q

MC Cx cholecystostomy tube placement or removal

A

bile leak (3%) - most self-limited

106
Q

Mgmt anal margin SCC

A

mapping biopsies followed by WLE with 1-cm microscopic margins - for stage 1 and 2A disease

107
Q

Location for rubber band ligation of internal hemorrhoids

A

2cm above dentate line (so no pain)

108
Q

Life-threatening Cx s/p rubber band ligation for internal hemorrhoids

A

perianal sepsis

109
Q

Proximal vs. distal rectal anastomoses, which more likely to leak?

A

distal > proximal

110
Q

Mgmt refractory strictures from Crohn’s: duodenum vs. jejunum/ileum

A

1st/2nd duo -> gastrojejunostomy + vagotomy (avoid marginal ulcers)
3rd/4th duo -> duodenoJ
short strictures jejunum/ileum -> stricturoplasty

111
Q

High ileostomy output defined as…?

A

> 1200 cc/day

112
Q

Min period of time btwn formation and closure of stoma

A

12 weeks

113
Q

Transverse folds of rectum are…?

A

“valves of Houston” - hold fecal matter and prevent its urge towards the anus, which would produce strong urge to defecate - there are 3 (upper+lower to right, and middle to left)

114
Q

What direction does arterial supply for rectum come?

A

posteriorly

115
Q

What is: postpolypectomy coagulation syndrome? Mgmt?

A

thermal energy to remove polyps -> full-thickness injury to bowel wall -> present similar to perforation, but if CT r/o free air and HDS, then can Tx IV Abx, bowel rest, and serial exams

116
Q

Strictures more common in Crohn’s vs. UC?

A

MC Crohn’s. Uncommon in UC.

117
Q

Why is 5-ASA not used for Crohn’s?

A

bc primarily intraluminal - acts on mucosal changes of UC, but does not affect transmural inflam of Crohn’s

118
Q

Most important predictor of survival for colorectal CA

A

staging at presentation (90% stage 1; 10% stage 4)

119
Q

FAP also associated with what cancers?

A

colorectal (100%), thyroid cancer, desmoid tumors, hepatoblastomas, osteomas

120
Q

Mgmt prolapsed stoma

A

stoma revision (usually local procedure -> resection of redundant bowel and rematuration)

121
Q

If sessile polyp is removed piecemeal, when should pt have follow-up colonoscopy?

A

2-6 month intervals

122
Q

Haggitt classification

A

describes level of invasion of malignant polyps
Lvl 1 -> invade head
Lvl 2 -> invade neck
Lvl 3 -> invade stalk (muscularis mucosa)
Lvl 4 -> invade base (submucosa), or are involved in a sessile polyp (req. formal segmentectomy)

123
Q

Rate of sporadic mutation for HNPCC?

A

20%

124
Q

Lynch II syndrome assoicated with…

A

colon, endometrial, gastric, ovarian cancers

125
Q

Preferred Abx for C.diff in pregnancy

A

PO vanc

126
Q

Cancer screening for Peutz-Jeghers syndrome should begin at what age? For what CA?

A

25-yo for colon (q2y), breast, cervical, thyroid, lung cancer

127
Q

MCC lower GI bleeding

A

diverticulosis

128
Q

Bleeding from diverticulosis 2/2…?

A

arterial rupture of submucosal artery or from vasa recta

129
Q

Mgmt stage 3 colon cancer

A

FOLFOX neoadjuvant + resection

130
Q

Mgmt T1 rectal adenocarcinoma NOT within 8cm anal verge, but favorable features

A

polypectomy (upper rectal CA treated like colon cancer)

131
Q

W/u low rectal cancer (palpable on DRE)

A
  • CEA level
  • LFTs
  • colonoscopy to r/o synchronous lesion
  • CT scan to eval mets
  • MRI or EUS to stage depth of tumor and nodal involvement
132
Q

Treatment of choice for colorectal liver mets (best prognostic factor)

A

margin-negative (R0) resection

133
Q

Poor prognostic factors for colorectal mets

A
  • > 3 mets
  • CEA >300 ng/mL
  • mets >5cm
  • LN positive primary disease
  • positive margins
134
Q

Independent predictors of need for operative invention for pneumatosis intestinalis

A
  • lactic acid >2 mmol/L
  • hypotension or pressure req
  • peritonitis
  • AKI
  • mechanical ventilation
  • absent bowel sounds
135
Q

Cecal bascule

A

variant of cecal volvulus - anterosuperior folding of cecum wo axial rotation -> less likely to cause vascular compromise and intestinal ischemia

136
Q

Is PET/CT indicated for rectal cancer?

A

NO

137
Q

In pts with lower GI bleeding, but stable… first step dx?

A

colonoscopy with rapid lavage bowel prep

138
Q

Risk of LN mets related to what of colorectal polyps?

A

depth of invasion

139
Q

Risk of LN mets in Haggitt level 1,2,3 polyps without aggressive features is…?

A

<1% - no need for radical lymphadenectomy

140
Q

Risk of LN mets in sessile polyp (Haggitt 4) removed with >2-mm deep margin is…? Mgmt?

A

negligible - oncologic formal resection not necessary

141
Q

fu surveillance colonoscopy after endoscopic removal of potentially malignant polyp

A

3-mo

142
Q

MCC large bowel obstruction

A

malignancy`

143
Q

In elderly pt with amp dominant hand presenting with malignant large bowel obstruction, intervention of choice?

A

endoscopic stent placement -> allow for colon decompression, pt optimization, and proper bowel prep for elective -> 1-stage colectomy with primary anastomosis

*no ex-lap and ostomy bc high Cx rate in elderly, and would be unable to care of ostomy

144
Q

Type 1 vs. Type 2 enterocutaneous fistula

A

Type 1 - not associated with active disease (ie. Crohn’s)

Type 2 - associated with intra-abdominal abscess; will not close with conservative mgmt

145
Q

Mesh of choice for parastomal hernia repair

A

synthetic polypropylene (PTFE disfavored)

146
Q

Dx and therapeutic, non-op mgmt for small bowel obstruction?

A

water-soluble contrast study - presence of contrast in colon within 24hrs also predicts resolution

147
Q

Patho distal intestinal obstructive syndrome (DIOS) in cystic fibrosis adults

A

decreased Cl- and fluid secretion into both small airways and GI tract 2/2 defective cystic fibrosis transmembrane conductance regulator

148
Q

MC location of fecal obstruction in distal intestinal obstructive syndrome

A

ileocecum

149
Q

Mgmt AIN (dx + tx)

A

high-resolution anoscopy (analogous to colposcopy for cervical cancer screening) + directed biopsy/treatment (local ablative therapy: ie. electrocautery, cyrotherapy, topical imiquimod)

150
Q

Mgmt pt s/p successful endoscopic decompression, presenting again with sigmoid volvulus

A

Hartmann procedure with end colostomy vs. sigmoidectomy with primary anastomosis

151
Q

Mgmt pt s/p successful endoscopic decompression, presenting again with sigmoid volvulus

A

Hartmann procedure with end colostomy vs. sigmoidectomy with primary anastomosis

152
Q

Measures of quality screening colonoscopy

A
  • adequacy of bowel prep >90%
  • withdrawal times >6 min
  • post procedure discomfort <10%
  • greater % complete colonoscopy, less risk post-colonoscopy colorectal cancer
153
Q

Mgmt Stage 2B anal margin cancer

A
  • has associated invasive component or anorectal carcinoma

- APR

154
Q

Mgmt Stage 3 anal margin cancer

A
  • anorectal carcinoma that has mets to regional LN

- APR w/ inguinal LN dissection

155
Q

Congenital hypertrophy of the retinal pigmented epithelium is pathnognomonic for…?

A

FAP

156
Q

MCC diarrhea in immunocompromised CD4<50

A

C.diff

157
Q

Kudo classification system

A

recognizes that risk of LN mets in each Haggitt level 4 lesion is not the same - submucosal invasion into 3rds (Sm1, Sm2, Sm3)

158
Q

How do you differentiate sigmoid vs. rectum intra-op?

A

rectum has convergence of taenia coli

159
Q

Mgmt anal margin vs. anal canal SCC

A

anal margin = WLE

anal canal = nigro

160
Q

Desmoid (aggressive fibromatosis) vs. sarcoma characteristic on imaging

A

desmoid/AF: infiltrate deep tissue and muscles

sarcoma: pushes adjacent tissue

161
Q

MC solid neoplasm of the mesentery

A

lymphoma

162
Q

CT characteristic: “sandwich sign”

A

lymphoma of mesentery: associated with bulky adenopathy w/ preservation of fat around mesenteric vessels

163
Q

Ideal Abx prophylaxis (against SSI) for colorectal procedures

A

combination oral AND IV cefazolin and metroniadazole

164
Q

Most reliable method to detect small liver mets (<1cm) from colorectal carcnioma is…?

A

contrast-enhanced MRI (but costly, so not used for screening)

165
Q

Mgmt unresectable and asymptomatic desmoid tumors

A

First-line: NSAID (ie. sulindac) + antiestrogen (ie. tamoxifen)

166
Q

Is local recurrence equivocal for transanal excision vs. formal resection for T1 rectal cancers?

A

NO - transanal excision is better tolerated, but higher recurrence rate even for T1 rectal cancers with appropriate criteria

167
Q

Presenting with bleeding cecal mass + incidental 5.5cm aneurysm, what is appropriate mgmt?

A

fix most life-threatening first (bleeding mass) first. in addition, should not fix aneurysm first bc do not know stage of cecal mass - if poor prognosis, then should not fix aneurysm if life expectancy short.

168
Q

Why would you not do colon resection and endovascular aortic graft repair at the same time?

A

risk graft contamination

169
Q

APR vs. LAR for rectal cancers?

A

APR if tumor invades sphincters or would compromise sphincter muscles for adequate margins

170
Q

Mgmt cecal volvulus? Exception?

A

ileocolic resection + primary anastomosis

Exception: if gangrenous bowel or perf, then safer to place end ileostomy (no anastomosis)

171
Q

What is definitive mgmt for rectal prolapse?

A

surgical (abdominal vs. perineal approach)

172
Q

Preferred approach for rectal prolapse in elderly?

A

perineal approach - higher recurrence rate compared to abdominal approach, but better tolerated in elderly population

173
Q

Young female with multiple vaginal deliveries and constipation presenting with “something falling out of anus” - what is it?

A

likely rectal prolapse

174
Q

RF colonic volvulus

A
  • high fiber diet (“volvulus belt” of Africa and Asia)
  • chronic constipation
  • psychotropic drugs
  • sedentary lifestyle
175
Q

Frequency of colonic volvuli in descending order

A

sigmoid > cecum > transverse > splenic flexure

176
Q

Describe Hinchy classification

A

1: pericolic abscess
2: abscess away from colon (ie. pelvic)
3: purulent peritonitis
4: fecal peritonitis

177
Q

External anal sphincter is under control of what nerves?

A

voluntary - internal pudendal nerves + S4 roots

178
Q

MC bacterial in normal flora colon

A

Bacteroides fragilis (anaerobic) - NOT E.coli, which is MC aerobic

179
Q

Prior to undergoing sigmoidectomy for colovesicular fistula, need to first do what screening procedure?

A

colonoscopy - to confirm diverticular disease as etiology for fistula, and not tumor (bc if tumor, then will also need en-block resection of bladder)

180
Q

Why no primary anastomosis after total abdominal colectomy for not-localized severe GI bleed?

A

bc may have further bleeding -> hypotension -> high risk for leak

181
Q

What extraintestinal conditions of UC will improve after colectomy?

A
  • pyoderma gangrenosum
  • arthritis
  • erythema nodosum
182
Q

What extraintestinal conditions of UC will NOT improve after colectomy?

A
  • PSC

- ankylosing spondylitis

183
Q

First-line Tx GI CMV in transplant pt

A

ganciclovir (IV) - opposed to valganciclovir (PO) which is for milder diseases

184
Q

How many LN do you need for appropriate staging for colorectal CA?

A

12

185
Q

If do not have sufficient LN harvest for colon CA, then must do what for treatment?

A

Adjuvant chemotherapy

186
Q

What is NIGRO protocol

A

5FU + 60Gy radiation + mitomycin

187
Q

Internal vs. external hemorrhoids arise from ? hemorrhoidal plexus

A

Internal: arise from superior hemorrhoidal plexus
External: from inferior “”

188
Q

Mgmt acute thrombosis of external hemorrhoids

A

if <4d: excision

if after, pain tend to be resolving.

189
Q

Grade of prolapse of internal hemorrhoids

A 
1 = prolapse into anal canal
2 = extend outside anal canal, but reduces spontaneously
3 = requires manual reduction
4 = irreducible
190
Q

Mgmt of grades of internal hemorrhoid prolapse

A 
1/2 = injection sclerotherapy, infrared coagulation
2/3 = rubber band ligation
3/4 = OR hemorrhoidectomy (can also do stapled hemorrhoidopexy, which is less painful, but higher recurrence rate)
191
Q

Mgmt rectal carcinoid

A

<1cm = local endoscopic excision
>2cm (most will have mets at time of dx) = proctectomy

*tumor size correlates with likelihood of mets

192
Q

MC procedure for anal incontinence (ie. 2/2 obstetrics trauma)

A

Wrap around sphincteroplasty - mobilize and reapprox sphincter without tension

193
Q

Methods for internal hemorrhoidectomy

A
  • open (Miligan-Morgan) technique
  • closed (Ferguson) technique
  • circumferential (Whitehead) technique
  • stapled hemorrhoidectomy
  • transanal hemorrhoidal dearterialization
194
Q

Steps: transanal hemorrhoidal dearterialization

A

doppler-guided ligation of arterial inflow to hemorrhoids (superior hemorrhoidal arteries) + suture rectopexy

195
Q

Steps: circumferential (Whitehead) hemorrhoidectomy

A

circumferential excision of internal hemorrhoids just proximal to dentate line

196
Q

Mgmt of incidentally found retrorectal tumor

A

resection (even if asymptomatic)

197
Q

Solitary rectal ulcer syndrome (SRUS)

A

sxs: rectal bleeding, copious mucous discharge, anorectal pain, difficulty passing stool
exam: ulcer(s) on anterior rectal wall just above anorectal ring
mgmt: conservative

198
Q

C/I fistulotomy and curettage for anal fistula

A

pt with hx incontinence

199
Q

Preferred mgmt low-lying (<30% sphincter complex) simple anal fistula if no hx incontinence

A

primary fistulotomy and curettage

200
Q

Preferred mgmt anal fistulas transversing external anal sphincter

A

setons to obliterate tract over period of time

201
Q

Dx of anal fissure based off on…

A

hx of pain and bleeding with defecation in association with hx constipation + gentle inspection by parting anus (do not need DRE or proctoscopy bc ouch!)

202
Q

When need lymphadenectomy for anal margin SCC?

A

rare - only if inguinal LN involvement (which is poor prognosis indicator)

203
Q

Cx of urinary retention after hemorrhoidectomy 2/2…?

A

muscle spasms of pelvic floor musculature

204
Q

Bleeding within 24hrs after hemorrhoidectomy due to…?

A

likely surgical error that will need be be corrected in the OR

205
Q

Bleeding at POD#5 s/p hemorrhoidectomy due to…?

A

likely sloughing of eschar - should resolve

206
Q

Hemorrhoids are located in what “cushions?”

A
  • when pt in lithotomy, located at 3’, 7’, 11’oclock
  • left lateral
  • right anterior
  • right posterior
207
Q

Surgical mgmt for rectal prolapse

A

abdominal and perineal approach.

  • abdominal rec for younger pts
  • perineal has higher rate of recurrence; rec for elderly bc less invasive
208
Q

Mgmt contained colonic anastomotic leaks without evidence pelvic sepsis (s/p surgery)

A

IV Abx alone (95% will heal spontaneously) - only perQ drain if abscess

209
Q

Screening surveillance for Peutz-Jeghers syndrome

A

colonoscopy starting 25yo q2y

210
Q

Mgmt recurrent C.diff

A

combined IV flagyl + PO vanc

211
Q

Mgmt C.diff in pregnant females or breast-feeding mothers

A

PO vanc (no flagyl)

212
Q

Perirectal abscesses MC due to …?

A

obstructed anal glands

213
Q

Where do anal fistulas tract?

A

will track back to anal canal (Goodsall’s rule)
anterior -> track in linear fashion
posterior -> track in curvilinear fashion
ischiorectal -> track around rectum to form “horseshoe abscess”

214
Q

When can you do primary repair of colonic injury?

A

If <50% colon circumference

215
Q

Pathophys of diverticular bleed

A

arterial rupture of submucosal artery or from vasa recta

216
Q

MCC lower GI bleeding (#1 and #2)

A 
#1: diverticulosis
#2: neoplasia or bleeding polyps
217
Q

Which extracolonic UC Cx will not resolve after colectomy?

A
  • PSC

- ankylosing spondylitis

218
Q

Mgmt rectal carcinoid? If unresectable mets?

A

(same as appendix)
<1cm (low likelihood mets) = local endoscopic excision
>2cm (likely mets) = proctectomy
widespread, unresectable mets = octreotide

219
Q

Anastomotic leak rate:

  • ileocolic
  • colocolonic
  • coloanal
A
  • ileocolic: <1%
  • colocolonic: 1-10%
  • coloanal: 10-20%
220
Q

MC site iatrogenic perforation 2/2 colonoscopy

A

sigmoid colon

QUESTION NOTES (28 decks)

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