colorectal diseases and PUD Flashcards
polyp
- benign growth of inner lining of colon
- best dx on colonoscopy
- most NOT cancerous but can become malignant
how do you describe the appearance of polyps
- pedunculated/ stalk
- sessile
- flat
- depressed
risk factors for polyps
- high fat, low fiber
- age > 50
- family hx or personal hx
- family syndromes
si/sx of polyps
- usually none
- stool occult positive
- palpable mass
- BRBPR
- rectal tenesmus
- change in bowel habits
non-neoplastic polyps
- hyperplastic
- mucosal
- inflammatory psuedopolyps
- submucosal
- hamartamous
neoplastic polyps
- adenomatous
subtypes of adenomatous polyps
- tubular
- tubovillous
- villous
hyperplastic polyps
- most common non-neoplastic polyp
- usu found in rectosigmoid
- dont have dysplasia
- dont dev into CRC
mucosal polyps
- non-neoplastic polyps
- resemble adjacent tissue
- no clinical significance
inflammatory pseudopolyps
- irregularly shaped islands of intact mucosa
- due to mucosal ulceration and regeneration
- from IBD
submucosal polyps
- non-neoplastic polyps
- lymphoid, fibromas, or lipomas
- lipomas most common
hamartamous polyps
- non-neoplastic
- grow in disorganized fashion
- can dev dysplasia and lead to CRC
- many polyposis syndromes derive from this polyp
adenomatous polyps
- neoplastic
- benign but will lead to cancer in 7-10 years if not removed
- 2/3 of all colonic polyps
- larger= more likely to be malignant
adenomatous polyp risk factors
- older age
- increased BMI, lack of physical activity
- men > women
- smoking
ways to prevent adenomatous polyps
- low fat diet, high in fruits/ veggies/ fiber
- normal body weight and exercise
- decreased EtOH, esp beer
- ASA and COX2 inhibitors
what subtype of adenomatous polyps are the worst
- villous
ways to screen for polyps
- colonoscopy*- gold std
- fecal occult blood testing
- double contrast barium enema- not common
- CT colonography
- flexible sigmoidoscopy
risks of colonoscopy procedure
- perforation
- significant bleeding
- intolerance to sedation
- dehydration or electrolyte imbalances (From prep)
pts that need colonoscopy f/u in 3-6 mo
- large polyps > 2 cm
- concern for incomplete removal
pts that need colonoscopy in f/u in 3 years
- > 1 villous adenoma
- multiple small tubular adenomas
pts that need colonoscopy f/u in 5 years
- 1-2 small tubular adenomas
pts that need colonoscopy f/u in 10 years
- no polyps
- small hyperplastic polyps
types of intestinal polyposis syndromes
- lynch syndrome
- familial adenomatous polyposis (FAP)
- hamartomatois polyposis syndromes
when would you consider polyposis syndromes as cause of polyps
- pt with family hx of CRC in more than 1 family member
- personal or family hx CRC < 50 years old
- personal or family hx of multiple polyps (> 20)
- personal or family hx of multiple extracolonic malignancies
lynch syndrome
- most common of inherited polyposis syndromes
- very likely to turn malignant
- mainly adenoma polyps
- usually involves right colon
- metachronous cancer common
typical metachronous cancer with lynch syndrome
- endometrial carcinoma
lynch syndrome treatment
- colectomy
- start monitoring with yearly colonoscopys at age 20-35
familial adenomatous polyposis (FAP)
- APC gene mutation
- > 100 adenomas
- 100% cancer prognosis, usually 20-30 years after dx
- risk of extracolonic cancers, esp duodenum
gardner syndrome
- FAP with extracolonic manifestations
- desmoid tumors common
turcot syndrome
- FAP with brain tumors
- medulloblastomas
FAP screening
- genetic testing
- yearly sigmoidoscopy at age 10-12
- yearly colonoscopy once polyp detected
FAP treatment
- colectomy
- remaining rectum and ileal pouch screened q 6 mo- 2 years
- EGD q 1-3 years
- ppx with NSAIDs and COX2
hamartomatous polyposis syndromes
- very rare
- famililal juvenile polyps
- peutz- jeghers polyps
average risk for colorectal cancer
- 50-75 years old
- no si/sx of CRC and no RF
when do you stop screening for colorectal cancer in the elderly?
- 76-85 provider discretion
- > 85 stop screening
what is the most common etiology of colorectal cancer
- sporadic (75% of cases)
where is colorectal cancer most commonly found
- left side of colon
where are inherited colorectal cancers most commonly found
- right side of colon
where does colorectal cancer spread to?
- LN
- liver
- lungs
- peritoneum
risk factors for colorectal cancer
- western diet- red meat, high fat
- obesity
- smoking and alcohol
- AA > caucasian
- hereditary polyposis syndromes
- family hx
- pt age
- IBD
- childhood abdominal radiation
colorectal cancer prevention
- diet rich in fruits, veggies, fiber
- limit red meat
- physical activity
- NSAIDs and low dose ASA
clinical presentation of colorectal cancer
- usually asymptomatic
- pos fecal occult blood test
- change in bowel habits, narrowing of stool
- tenesmus
- dark stool, rectal bleeding
- weight loss
- intestinal obstruction, GI bleed, peritonitis- emergencies
what is the gold standard for dx colorectal cancer
- colonoscopy with biopsy
what is CEA
- blood marker
- used as indicator of recurrence of colorectal cancer
- NOT to be used as initial screening
what type of cancer is anal cancer most often?
- squamous cell- similar to skin cancer
- very rare type of cancer
what is the most common cause of anal cancer
- HPV
risk factors for anal cancer
- HPV
- female
- life time number of partners
- warts
- smoking
- HIV infection
- receptive anal intercourse
- chronic immunosuppressive conditions
si/sx of anal cancer
- rectal bleeding, perianal itching
- anorectal pain
- rectal mass sensation
- may be asymptomatic
- mass felt on DRE
diagnosis of anal cancer
- anoscopy*
- endoscopy with biopsy
- rigid proctosigmoidoscopy
lymphatic drainage for anal cancer
- tumors above dentate line -> mesorectal and iliac nodes
- tumors below dentate line -> superficial inguinal and external iliac nodes
what is the difference between an ulcer and an erosion
- erosion- through mucosa, shallow
- ulcer- penetrates into muscularis, higher risk bleed and perforation
what are the common causes of PUD?
- h. pylori**
- NSAIDs
- alcohol
- caffeine
- smoking/ tobacco
- severe physiologic stress
- hypersecretory state (rare)
- genetics
types of PUD
- gastric ulcer
- duodenal ulcer
gastric ulcers
- pain during or shortly after eating
duodenal ulcers
- pain hours after eating or awakens pt at night
- most common type of PUD
clinical manifestations of PUD
- epigastric pain- gnawing burning s/p meals
- dyspepsia
- chest pain or heart burn
- hematemesis, coffee ground emesis, melena, hematochezia
- anemia sx
- if sudden onset either perforation or peritonitis
PE findings for PUD
- highly variable
- abdominal tenderness
- pos guaiac stool test
- orthostatic BP/ tachycardia
- chronic -> possible gastric outlet obstruction
work up for PUD
- h pylori testing*
- endoscopy*
- fasting gastrin levels to r/o hypersecretory syndromes
- upper GI contrast study- less sensitive, no biopsy
treatment for PUD
- h pylori positive -> triple therapy
- PPI 6-8 weeks or at least 1 year if pt has RF
- d/c any irritants
- endoscopy- epi injections, hemoclips, thermal coagulation
what is h pylori triple therapy
- omeprazole
- clarythromycin
- amoxicillin or flagyl
what is h pylori quadruple therapy
- alt to triple therapy
- PPI
- bismuth
- tetracycline
- flagyl
how do you test for h pylori
- urea test*
- fecal Ag testing
- serum IgG- not as sensitive if pt has been infected in last 3 years
- rapid urease test via EGD bx
