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General Surgery > CRC > Flashcards

CRC Flashcards

1
Q

Superior mesenteric artery

A

Ascending colon Proximal 1/2 transverse colon

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2
Q

Inferior mesenteric artery

A

Distal _ transverse colon Descending colon Sigmoid colon Upper _ rectum

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3
Q

Middle and inferior rectal artery

A

Lower 1/2 rectum Anus

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4
Q

Bowel wall layers

A

Mucosa Submucosa Muscularis Serosa (except middle and distal rectum)

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5
Q

Other structures in bowel

A

Taeniae coli Haustra Appendices epiploicae

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6
Q

Colonic motility

A

Segmentation contractions and mass contractions Movement: 18-48 h

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7
Q

Acceleration of colonic transit time

A

Emotional states Diet Disease Infection Bleeding Drugs

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8
Q

Typical defecation pattern

A

Once/24 hours May vary from 8-72 hours

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9
Q

Changes in bowel habit: Constipation

A

Ability to pass flatus but not stool

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10
Q

Changes in bowel habit: Obstipation

A

Inability to pass stool or flatus

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11
Q

Person presenting with significant change in bowel habits

A

Must be evaluated for possibility of serious disease

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12
Q

Colonic Bacteria

A

Greatest number and variety of bacteria Majority: anaerobes Also: gram + and - aerobes Degrade bile pigments and produce vitamin K Infection risk in colorectal surgery

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13
Q

Pre-op bowel prep

A

Mechanical cleansing Oral abx IV abx pre-op and 24 h

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14
Q

Dx evaluation tools

A

Digital rectal exam Rigid sigmoidoscopy Flexible fiberoptic sigmoidoscopy Fiberoptic colonoscopy Abdominal X-ray series (flat and upright) Barium enema CT scan Angiography Nuclear bleeding scan

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15
Q

Anastamosis

A

Surgical union of two hollow or tubular structures Types: End-to-end, end-to-side, side-to-end, side-to-side

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16
Q

End-to-End Anastamosis

A

Performed when 2 segments of bowel are roughly the same caliber Most often employed in rectal resections, but may be used for colocolostomy or small bowel anastamoses

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17
Q

End-to-Side Anastamosis

A

Used when one limb of bowel is larger than the other Used in chronic obstruction

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18
Q

Side-to-End Anastamosis

A

Used when proximal bowel is smaller caliber than distal bowel Ileorectal anastamosis May have less tenuous blood supply than end-to-end anastamosis

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19
Q

Side-to-Side Anastamosis

A

Allows a large, well vascularized connection to be created on the antimesenteric side of two segments of intestine Used in ileocolic and small bowel anastamoses

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20
Q

Resection

A

Operative removal of organ or gland

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21
Q

Anterior resection

A

Used to describe resection of rectum from an abdominal approach to the pelvis with no need for a perineal, sacral, or other incision

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22
Q

High anterior resection

A

Resection of distal sigmoid colon and upper rectum Used for benign lesions and disease in rectosigmoid junction (diverticulitis)

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23
Q

Low anterior resection

A

Removes lesions in the upper and mid rectum

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24
Q

Extended low anterior resection

A

Removes lesions located in distal rectum, but several cm above sphincter

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25
Q

Abdominoperineal resection (APR)

A

Involves removal of entire rectum, anal canal, and anus with construction of permanent colostomy from descending or sigmoid colon

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26
Q

-Ectomy

A

Denotes operative removal of an organ or gland

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27
Q

-Stomy

A

Denotes artificial or surgical opening -When two organs precede the suffix, the opening is between them

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28
Q

Colostomy

A

Surgically created connection between colon lumen and abdominal wall skin for diversion of fecal stream

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29
Q

Loop Colostomy

A

Also double-barrel Usually temporary Loop ileostomy

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30
Q

End colostomy

A

One lumen Most permanent stomas

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31
Q

Fistula

A

An abnormal tract between two hollow organs or an organ to the skin -Infectious -Inflammatory -Malignant -Surgical

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32
Q

Hartmann’s Procedure

A

Resect sigmoid colon Create end colostomy with L colon Close rectal stump and leave in peritoneal cavity (Hartmann’s) Alt: Bring rectal stump to abd wall (Mucous Fistula)

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33
Q

Proctum

A

Synonym for rectum

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34
Q

One stage

A

Diseased segment resected and anastamosis performed at same operation

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35
Q

Two stage

A

1st: create proximal stoma and resect diseased segment 2nd: if not already done, resect disease, then perform anastamosis and reverse colostomy

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36
Q

Three stage

A

3rd: reverse colostomy

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37
Q

Ulcerative Colitis

A

Only affects colon/rectum Long standing: colon is foreshortened and lacks haustral markings (“Lead pipe” colon) Cure: remove affected intestinal segment (colon and rectum)

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38
Q

Thumb Printing

A

Similar appearance of thumbs protruding into intestinal lumen Caused by thickened haustral mucosal folds Abd thumb printing is sign of intestinal ischemia Observed in exacerbations of conditions like UC

39
Q

UC: Emergency surgery

A

Massive life-threatening hemorrhage -Proctectomy and creation of permanent ileostomy or ileal pouch-anal anastamosis

40
Q

Complications of UC

A

Toxic megacolon Fulminant colitis -Total abdominal colectomy with end ileostomy (with or without mucus fistula)

41
Q

UC: Elective surgery

A

Intractability despite max medical therapy High-risk development of major complications (aseptic necrosis of joints from chronic steroid use) At risk of developing colorectal carcinoma

42
Q

UC: Elective resection procedure

A

Total proctocolectomy with end ileostomy TREATMENT OF CHOICE: Restorative proctocolectomy with ileal pouch-anal anastamosis

43
Q

Crohn’s Disease: Areas affected

A

Any portion of the intestinal tract, from mouth to anus -Skip lesions -Rectal sparing (40%) -Terminal ileum and cecum involved in 41% -Small intestine involved in 35%

44
Q

Crohn’s Disease: When to do surgery

A

Complications of the disease

45
Q

String sign

A

Narrowing of loop of bowel– thin stripe of contrast within the lumen looks like a string Observed in Crohn’s

46
Q

Crohn’s: Internal fistulae and/or intra-abdominal abscess

A

CT guided drainage of abscess Resection of fistulae with segment of bowel

47
Q

Crohn’s: Strictures/Obstruction

A

Tx: resection or stricturoplasty

48
Q

Crohn’s: creation of stroma

A

Consider if patient is: -Hemodynamically stable -Septic -Malnourished -Receiving high-dose immunosuppressive therapy -Extensive intra-abdominal contamination

49
Q

Diverticular Disease

A

Mucosal herniation through muscular wall usually at penetration of marginal artery (false diverticula) 5th – 8th decade Low-fiber diet Chronic constipation Sigmoid colon

50
Q

Diverticulosis

A

Multiple colonic diverticuli 80% asx finding on exam Sx: recurrent abd pain, usually LLQ. Constipation, diarrhea, or alternating Tx: high fiber diet

51
Q

Diverticulitis

A

Infection or perf of diverticulum, leading to infection/inflammation of peridiverticular tissue Abscess formation or generalized peritonitis -LLQ pain and tenderness -Alteration in bowel habits -Fever, chills -Leukocytosis -LLQ “mass”

52
Q

Contraindicated tests in diverticulitis acute stage

A

Barium enema Colonoscopy

53
Q

Initial tx of diverticulitis

A

NPO, IVF IV Abx (cipro/flagyl) -Sick patients need most aggressive therapy

54
Q

Diverticulitis: perforation tx

A

Emergent surgery Resect perforated segment and create proximal colostomy (Hartmann) Post-op: treat infection aggressively Delay 2nd stage 6-12 weeks

55
Q

Diverticulitis: Abscess tx

A

Emergent drainage: open or image guided Treat infection Many can undergo one-stage procedure electively If fail: treat as perf

56
Q

Diverticulitis: Obstruction tx

A

Incomplete: prep bowel; 1 stage operation Complete: unprepped bowel; 2-3 stage operation CA is a cause of obstruction

57
Q

Diverticulitis: Fistula

A

Colovesicular, colovaginal, coloenteric -If no sepsis or abscess: one stage repair. -Sepsis or abscess: two stage repair.

58
Q

Hemorrhoids: etiology

A

Cushions of submucosal tissue consisting of venules and smooth muscle fibers located in the upper anal canal become displaced downward during straining at defecation causing dilation of venules

59
Q

Location of hemorrhoids

A

Left lateral: 3:00 Right posterior: 7:00 Right anterior: 11:00

60
Q

Internal hemorrhoids

A

Above dentate line Covered by insensitive rectal mucosa S/S: discomfort, bleeding, prolapse

61
Q

External hemorrhoids

A

Below dentate line Covered by well innervated anoderm S/S: severe pain from thrombosis

62
Q

Grading of hemorrhoids

A

I. Remain above dentate line II. Prolapse through anus with straining but reduce spontaneously III. Prolapse through anus with minimal strain and/or require manual reduction IV. Continuous prolapse and/or cannot be manually reduced

63
Q

Treatment of hemorrhoids: I, II

A

Diet and lifestyle

64
Q

Treatment of hemorrhoids: I, II– unresponsive

A

Rubber band ligation Alt: infrared photocoagulation, sclerotherapy,

65
Q

Treatment of hemorrhoids: III, IV

A

Hemorrhoidectomy

66
Q

Treatment of hemorrhoids: thrombosed external

A

Excise thrombus

67
Q

Treatment of hemorrhoids: Strangulated

A

Hemorrhoidectomy

68
Q

What is the most common GI cancer?

A

Carcinoma of the colon and rectum -40s, 70s-80s -Male = female -RF: genetics, diet, IBD

69
Q

Sx: right colon cancer

A

Weight loss Mass Virchow’s node Blummer’s shelf Anemia

70
Q

Sx: left colon cancer

A

+/- weight loss Rectal bleeding Blummer’s shelf Obstruction

71
Q

Sx: Rectum cancer

A

Rectal bleeding Tympany Obstruction

72
Q

ACS recommendations: no first degree family hx

A

Annual DRE starting age 40 Annual fecal occult blood starting age 40 Sigmoidoscopy age 50 and q 3-5 years

73
Q

ACS recommendations: positive CRC in first degree relative

A

Colonoscopy or BE starting age 35-40 and q 5 years

74
Q

Pre-malignant polyps

A

Adenomatous polyps Subdivisions: -Tubular -Tubovillous -Villous adenoma (> 2 cm in size, most commonly malignant) Can be: sessile or pedunculated Tx: colonoscopic polypectomy

75
Q

Large bowel CA

A

Most common source of large bowel obstruction in adults Sx depend on site TEST OF CHOICE: ENDOSCOPY Tx: Biopsy, CEA, CT scan of abdomen (staging)

76
Q

Classic sign of large bowel CA

A

Apple core lesion

77
Q

Tx: CRC

A

Wide surgical resection of lesion Include venous and lymphatic drainage Minimum 2 cm margin (usually 5 cm or more) Chemo for nodal mets Radiation for RECTAL (not colon)

78
Q

Who needs total or subtotal colectomy?

A

Patients with fulminant colitis, attenuated FAP, or synchronous colon carcinomas

79
Q

CRC Staging: A

A

Confined to mucosa 5 year survival: 85-90%

80
Q

CRC Staging:B1

A

Negative nodes; extension into, but not through, the muscularis propria 5 yr survival: 70-75%

81
Q

CRC Staging: B2

A

Negative nodes; extension through the muscularis propria 5 yr survival: 60-65%

82
Q

CRC Staging: C1

A

Same level of penetration as B1 but with positive nodes 5 yr survival: 30-35%

83
Q

CRC Staging: C2

A

Same level of penetration as B2 but with positive nodes 5 yr survival: 25%

84
Q

Rectal carcinoma

A

Adenocarcinoma Tx: APR (abdominoperineal resection) or LAR (low anterior resection) Fulguration– used in stage A Adjuvant chemo

85
Q

Anal Carcinoma

A

Squamous cell type Tx: Nigro protocol (5 fluorouracil and mitomycin and medical radiation if

86
Q

What is the most common cause of large bowel obstruction?

A

Colon cancer (65%) Other: diverticular stricture (20%), volvulus (5%), other (10%; IBD, benign tumors, FB, fecal impaction)

87
Q

Sx of obstruction

A

Crampy intermittent abdominal pain Abd distension No BM No flatus Previous surgery Hypo/hyperactive bowel sounds Metallic quality Ascites–intravascular volume depleted Severe, persistent pain = strangulation or perforation

88
Q

Large Bowel Obstruction: lab values

A

BUN/CR: > 20:1 Hypernatremia Urine electrolytes Hemoconcentration Acidosis Leukocytosis

89
Q

Possible locations of obstruction

A

Proximal Mid-gut Distal

90
Q

Obstruction: Radiology

A

Supine and erect abd x-ray Erect CXR (including diaphragm) Single-contrast barium enema CT scan

91
Q

Colon cut-off sign

A

Abrupt termination of gas in proximal colon at level of splenic flexure Most common = acute pancreatitis

92
Q

Tx of bowel obstruction

A

Fluid resuscitation and monitoring NG tube for decompression Pre-op abx Exploratory laparotomy

93
Q

Bowel obstruction complications

A

Fluid and electrolyte imbalance Dehydration… hypovolemic shock Ischemia of bowel leading to strangulation, necrosis, perforation Peritonitis Sepsis Death

General Surgery (8 decks)

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