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Absite 2019 > CRS/SB > Flashcards

CRS/SB Flashcards

1
Q

What is the management of prolapse?

A

Surgery. Use abdominal approach for younger patients and good surgical candidates (less recurrence) and perineal approach for poor surgical candidates.

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2
Q

Severe intractable anal pruritus =?

A

Paget’s disease of the anus

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3
Q

How many patients with Paget’s disease of the anus have an occult malignancy?

A

50% have an occult internal malignancy. Therefore colonoscopy and CT should be performed. Wide local excision with multiple perianal bx is tx of choice.

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4
Q

Describe staging of colorectal cancer..remember, STAGING or colon and rectal cancers is the same.

A

Tis- confined to mucosa, doesn’t violate basement membrane
T1 - into submucosa
T2 - into muscularis propria
T3 - thru muscularis propria or into serosa
T4 - thru serosa

Stage 0: Tis, N0, M0
Stage I: T1, N0, M0
Stage II = T3 or T4 but N0
Stage IIIA: T1-2, N1 (1-3 nodes +)
Stage IIIIB; T3-4, N1
Stage IIIC: any T, N2 (>3 nodes +)
Stage IV: M1
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5
Q

What stage of rectal cancer require preop chemo-xrt?

A

Stage II and over

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6
Q

Which way does cecal volvulus point?

A

Toward LUQ. Common in middle aged females.

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7
Q

“Coffee bean sign”

A

Sigmoid volvulus, points up or to RUQ. Common in older patients, psychotropic meds, constipation, high fiber diet.

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8
Q

Treatment for sigmoid volvulus?

A

Endoscopic detorsion unless peritoneal (80% success) and perform sigmoidectomy during same admission (50% recur)

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9
Q

Treatment for cecal volvulus?

A

Ileocolic resection with primary anastomosis (unless threatened bowel–do end ileostomy). Don’t do pexy because of high rate of recurrence.

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10
Q

What are the two most common causes of lower GI bleeding?

A

1) bleeding diverticulae 2) neoplasia or bleeding polyps

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11
Q

What is the source of bleeding from a bleeding diverticuli?

A

Either a ruptured submucosal artery or the vasa recta.

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12
Q

Hinchey classification

A

I: paracolonic
II: abscess elsewhere (pelvis, etc)
III: purulent peritonitis
IV: fecal peritonitis

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13
Q

innervation of external sphincter

A

voluntary control, internal pudendal and S4 roots

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14
Q

innervation of internal anal sphincter?

A

involuntary, via autonomic nerve fibers

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15
Q

usual location of anal fissure? location that prompts further workup?

A
  • posterior midline is usual

- lateral location should prompt Crohns, STI, or hidraadenitis workups

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16
Q

How does treatment of rectal cancer differ from colon cancer?

A

Stage II/III rectal gets neoadjuvant chemo-radiation, while colon gets surgical resection first + postop chemo, no XRT.

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17
Q

Cause of urinary retention after hemorrhoidectomy?

A

Pelvic floor muscle spasms–tx with temp foley

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18
Q

Most common cause of severe GI bleeding?

A

diverticular bleed

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19
Q

Describe Peutz-Jehger syndrome.

A

AD, characterized by intestinal hamartomas and hyperpigmented oral mucosa lesions. Colonoscopy q2 years. Increased risk of breast, cervical, thyroid, lung.

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20
Q

what rectal cancers can be excised transanally?

A

well differentiated T1 lesions, <3 cm, <30% circumference, < 8 cm from anal verge, no lymphovasc involvement or mucin production.

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21
Q

Treatment for c diff with sepsis or toxic megacolon?

A

Subtotal colectomy, ie colectomy with rectum left in place and end ileostomy

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22
Q

Management of intersphincteric abscess?

A

Internal drainage via dividing mucosa and internal sphincter

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23
Q

Describe Hereditary nonpolyposis CRC

A

Also called Lynch syndrome. AD. Tumors have high microsatellite instabiliy and defects on MLH1 and MSH2 (DNA mismatch repair). 20% risk of sporadic mutation. Need colonoscopy starting at 25 and get total proctocolectomy at first cancer operation.

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24
Q

Most common location of GIST?

A

Stomach (50%), then SB (25%)

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25
Q

What cell do GISTS derive from?

A

Interstitial cells of Cajal

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26
Q

What cells do carcinoid tumors derive from?

A

enterochromaffin cells at the base of the crypts of Leiberkuhn

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27
Q

5 types of hemorrhoidectomy?

A

open, closed, circumferential, stapled, transanal hemorrhoidal dearterialization (Doppler guided ligation of the arterial inflow of hemorrhoids)

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28
Q

What bacterial infections are associated with colon Ca?

A

Clostridium septicum, strep bovis/gallolyticus

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29
Q

Genes associated with colorectal ca?

A

APC, DCC, p53, kras

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30
Q

Number 1 and 2 sites of mets?

A

1) Liver, 2) Lung

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31
Q

How can rectal ca metastasize to spine?

A

Batson’s venous plexus

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32
Q

What marks transition between anal canal and rectum?

A

Levator ani

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33
Q

3 types of polyps

A

Hyperplastic = no cancer risk
Tubular adenoma = most common neoplastic polyp, usually pedunculated
Villous adenoma = usually sessile, 50% have cancer

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34
Q

Margins generally needed for colorectal cancer?

A

5-7 cm (ensures adequate nodal resection–need 12 nodes)

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35
Q

When do you need an APR?

A

If lesion is closer than 2 cm to levator ani muscles

36
Q

Types of chemo from colorectal cancer?

A

5FU + oxiplatin + leucovorin=FOLFOX for 6 mos

37
Q

What percentage of patients have recurrence of colorectal cancer?

A

20%–> need 1 yr colonoscopy

38
Q

Describe Familial Adenomatous Polyposis

A

AD, although 20% are spontanous. All have Ca by age 40. APC gene on chromosome 5. Tx to get total proctocolectomy with J pouch at age 20 (polyps start at puberty), also need to check for duodenal polyps q2 years.

39
Q

APC gene related syndromes?

A

FAP, Gardner (colon Ca + desmoid tumors), Turcot’s (Colon ca + brain ca)

40
Q

What is the Amsterdam criteria for Lynch Syndrome?

A

“3,2,1” = 3 first degree relatives over 2 generations, 1 with cancer before age 50

41
Q

What do you find on colonoscopy in patient with ulcerative colitis?

A

involves mucosa and submucosa–starts in rectum and is contiguous, has mucosal friability, pseudopolyps, and collar button ulcers

42
Q

Medical tx for maintenance and flares of UC?

A

Maintenance: 5-ASA or sulfasalazine

Steroids for flares

43
Q

Tx for infectious vs stump pouchitis?

A

infectious: flagyl
stump: short chain fatty acids

44
Q

1 and 2 causes of colonic obstruction

A

1) cancer 2) diverticulitis

45
Q

What percentage of patients develop a fistula after perianal abscess?

A

30%

46
Q

Define simple vs complex fistula in ano

A

Simple: superficial (perianal), intersphincteric, low lying transphincteric (<30% sphincter involvement).
Complex: high transphincteric, suprasphincteric, horseshoe, recurrent

47
Q

Tx for simple fistula?

A

If no incontinence, then primary fistulotomy and curettage.

48
Q

Tx for complex fistula?

A

Sphincter sparing approaches 2/2 high risk of incontinence–endoanal advancement flap, modified Hanley procedure, ligation of the intersphincteric fistula tract (LIFT), diversion. Place seton FIRST.

49
Q

What tx for fistula are contraindicated with incontinence?

A

fistulotomy, endoanal/endorectal andvancement flaps

50
Q

Tx for anal cancer?

A

T1 lesion (well differentiated): wide local excision
Locally advanced: Nigro protocol (5-Fu, mitomycin C, 3000 Gy radiation) prior to excision and LAD
Recurrence: re-excision or APR

51
Q

Workup of rectal mass?

A

CEA, LFTs, proctoscopy for distance from anal verge, full colonoscopy to rule out synchronous lesion,CT for mets, MRI or EUS for depth and nodal envolvement

52
Q

What does colon absorb and secrete?

A

Absorbs: water, sodium, chloride. Secretes: bicarb + potassium. Fuel source is short chain fatty acids (butyrate, acetate, propionate).

53
Q

What extracolonic manifestations of UC improve with colectomy?

A

Arthritis, pyoderma gangrenosum, erythema nodosum resolves, AS improves. Remember, PSC is unaffected.

54
Q

What subtypes of HPV cause anal condyloma, and which can progress to dysplasia or carcinoma?

A

HPV 6 + 11 = condyloma

HPV 16 + 18 = more aggressive, can cause cancer

55
Q

Describe characteristics of solitary rectal ulcer syndrome.

A

Sxs are rectal bleeding, copious mucus discharge, anorectal pain, diffuculty passing stool. Patients can have one, multiple, or no rectal ulcers. It is a benign condition. Treat conservatively first.

56
Q

Describe Haggitt classification

A

Classification system for malignant polyps. Level 1- invade head of polyp, 2 invade neck, 3 invade stalk, 4 invade base or involve sessile polyp. Usually Haggitt 4 need segmentectomy.

57
Q

Which side of the colon is most common for diverticular bleed. Which percentage of bleeds stop on their own; how many recur?

A

Although divertiucli are most common on LEFT side, BLEEDING from them is most common on the RIGHT. 75% of bleeding will stop, 25% will recur.

58
Q

When to give blood in trauma patients, acute phase? Resusc goals?

A

After 2L XL. Resusc to SBP >90, LA <2.5. UOP >0.5cc/kg/hr

59
Q

Most common bacteria in colon?

A

Bacteroides fragilis

60
Q

Mechanism of diverticulitis?

A

obstruction of tic, leading to venous obstruction/congestion

61
Q

What is management of contained anastomotic leak?

A

IV abx alone. Perc drain if abscess. Only operate for pelvic sepsis.

62
Q

What is the treatment for recurrent anal SCC?

A

APR

63
Q

How to handle bleeding in the first 24h following hemorrhoidectomy??

A

Re-explore, likely 2/2 poor suturing technique

64
Q

Most common location to perforate with UC? With Crohns?

A 
UC = transverse colon
Crohn's = terminal ileum
65
Q

Tx for low rectal carcinoid tumors?

A

If <2cm–wide local excision with negative margins. If >2 cm or invading musclaris propria then APR.

66
Q

How do you dx amoebic colitis?

A

endoscopy shows ulceration and trophozoites. 90% of patients have anti-amebic antibodies.

67
Q

What is the tx for amoebic colitis?

A

Flagyl, dioodohydroxyquin

68
Q

Where is the primary and secondary infection of Entamoeba histolytica?

A 
Primary = colon
secondary = liver
69
Q

How does actinomyces present in the colon and what is the tx?

A

Can be mass, abscess, fistula or induration. Path shows yellow-white sulfur granules

70
Q

Tx of actinomyces in the colon?

A

Penicillin or tetracycline, drainage of abscess.

71
Q

How long will Guiac stay + after GI bleed?

A

Up to 3 weeks

72
Q

What rate of bleeding can arteriography detect?

A

> 0.5 cc/min

73
Q

what rate of bleeding can tagged RBC scan detect?

A

> 0.1 cc/min

74
Q

Why do you get uremia after GI bleed?

A

From bacteria eating the blood in the colon and producing more urea. Can also get elevated Tbili.

75
Q

Tx for right sided diverticulitis?

A

right hemicolectomy

76
Q

What is the best dx test for colovesicular fistula?

A

cystoscopy

77
Q

Angiodysplasia in GI tract is assoc with what?

A

aortic stenosis–improves after AVR

78
Q

Which areas of the colon are most vulnerable to low flow state?

A

Splenic flexure (Griffiths point–SMA and IMA junction) and upper rectum (Sudeck’s point–superior rectal and middle rectal artery junction)

79
Q

What is neutropenic typhilitis and what is the tx?

A

It is an enterocolitis that occurs after chemo at the nadir of WBC. Tx is abx. Do not operate for pneumatosis, only for free perforation.

80
Q

What is the venous drainage of the rectum?

A

Superior and middle rectal veins drain to IMV and into portal system. Inferior drains to iliac vein and into IVC.

81
Q

Which patients need abx after perirectal abscess tx?

A

extensive cellulitis, DM, immunosuppressed, prosthetic hardware

82
Q

What are anorectal problems associated with AIDS?

A
  • Kaposi sarcoma–nodule with ulceration
  • CMV- shallow ulcers, tx ganciclovir
  • HSV- rectal ulcer
  • B cell lymphoma- can present as abscess or ulcer
83
Q

What nodes do anal margin cancers go to?

A

inguinal

84
Q

What nodes do upper 2/3 of anal canal go to?

A

internal iliac

85
Q

When does sloughing of eschar usually occur after hemorrhoidectomy?

A

After pod5

86
Q

Most common location for SB lymphoma?

A

ileum because that is where the most lymphoid tissue is

Absite 2019 (18 decks)

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