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Gastrointestinal > Large Bowel Pathology > Flashcards

Large Bowel Pathology Flashcards

1
Q

How common is colorectal cancer?

A

4th most common cancer behind breast, prostate and lung

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2
Q

What is the most common classificaton of colorectal cancer?

A

Adenocarcinoma. (98%)

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3
Q

What sex is colorectal cancer more common in?

A

M > F

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4
Q

What causes colorectal cancer?

A

IBD

FH

Genetics

Alcohol

Obesity

Smoking

Diabetes

>Age

Diet

  • Decreased fibre
  • Increased red meat
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5
Q

What are the genetic causes of colorectal cancer?

A

Familial Adenomatous Polyposis

HNPCC

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6
Q

What is Familial Adenomatous Polyposis?

A

Rare autosomal dominant condition in which adenomatous polyps form in the colon epithelium due to mutation of APC gene, located on chromosome 5

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7
Q

What is HNPCC?

A

Autosomal dominant disorder of gene mutations in MSH2 and MLH1, causing mainly right-sided carcinoma

Also known as Lynch syndrome

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8
Q

How does colorectal cancer present?

A

Right

  • Weight loss
  • Iron deficiency anaemia

Left

  • Persistent rectal bleeding mixed with stools
  • Altered bowel habit, usually to loose frequent stools
  • Abdominal pain
  • Tenesmus

Both

  • Palpable lower abdominal mass
  • Cachexia
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9
Q

What investigation is used in colorectal cancer diagnosis?

A

FBC

  • Hypochromic microcytic anaemia/iron deficiency anaemia

Colposcopy with biopsy, gold standard

Biomarkers

  • CEA
  • CA19-9

CT chest, abdomen pelvis for staging

CT colonography when colonoscopy fails

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10
Q

What investigation is used in colorectal cancer screening?

A

Faecal Immunochemical Testing (FIT)

adults 50-74 every 2 years

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11
Q

What procedure can be done for those at risk of HNPCC?

A

Prophylactic Proctocolectomy

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12
Q

Name complications of colorectal cancer?

A

Acute bowel obstruction

Iron deficiency anaemia

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13
Q

What criteria is used for colorectal cancer stageing?

A

Modified Duke’s Classification

However, TNM is now more commonly used

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14
Q

Describe Duke’s stage A colorectal cancer

A

Confined to bowel wall

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15
Q

Describe Dukes stage B colorectal cancer

A

Growth through bowel wall (muscle)

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16
Q

Describe Dukes stage C colorectal cancer

A

Regional lymph node involvement

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17
Q

Describe Dukes stage D colorectal cancer?

A

Distant metastases

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18
Q

What is used to monitor disease progression in colorectal cancer?

A

CEA (carcinoembryonic antigen)

Not helpful in screening, but it may be used for predicting relapse of previously treated for bowel cancer

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19
Q

What are the locations of colorectal cancer?

A

(from most common to least common)

Rectal

Sigmoid

Ascending colon and caecum

Transverse colon

Descending colon

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20
Q

What is the most common location for colorectal cancer?

A

Rectal

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21
Q

What is HNPCC also associated with?

A

Endometrial cancer

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22
Q

What is FAP also associated with?

A

Duodenal tumours

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23
Q

What is the most common type of inherited colorectal cancer?

A

HNPCC

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24
Q

What criteria is used to help diagnose HNPCC?

A

Amsterdam criteria

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25
Q

What is involved in the Amsterdam criteria?

A

At least 3 members with colorectal cancer

Cases span 2 generations

At least one case diagnosed before 50

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26
Q

When should an urgent 2 week colposcopy referral be offered?

A

Over 50 with unexplained hypochromic microcytic anaemia

Over 40 years with abdominal pain and unexplained weight loss

Over 50 years with unexplained rectal bleeding

Over 60 years with a change in bowel habit

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27
Q

What is the management of upper rectum colorectal cancer?

A

Anterior resection

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28
Q

What is the management of caecal, ascending or proximal transverse colon colorectal cancer?

A

Right hemicoloectomy

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29
Q

What is the management of distal transverse and descending colon colorectal cancer?

A

Left hemicoloectomy

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30
Q

What is the management of sigmoid colon colorectal cancer?

A

High anterior resection

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31
Q

What is the management of anal verge colorectal cancer?

A

Abdominal-perineal excision of rectum

32
Q

What is the management of lower rectum colorectal cancer?

A

Anterior resection

33
Q

When is Hartmann’s procedure performed?

A

Performed as an emergency procedure, ie perforation of rectosigmoid colon

The sigmoid colon and upper rectum are removed and an end colostomy formed

34
Q

Give complications of bowel cancer surgery

A

Bleeding, infection and pain

Damage to nerves, bladder, ureter or bowel

Post-operative ileus

Anaesthetic risks

Laparoscopic surgery converted during the operation to open surgery

Leakage or failure of the anastomosis

Requirement for a stoma

Failure to remove the tumour

Change in bowel habit

DVT and PE

Incisional hernias

Low anterior resection syndrome, causing incontinence

Intra-abdominal adhesions

35
Q

How is curative bowel cancer surgery followed up?

A

CT chest, abdomen, pelvis

CEA

36
Q

What is appendicitis?

A

Inflammation of the vermiform appendix, which arises from the caecum

37
Q

What is the peak age of appendicitis?

A

10-20 years

38
Q

What causes appendicitis?

A

As there is a single entrance and exit to the appendix, pathogens can get trapped due to obstruction at the point where the appendix meets the bowel, leading to infection and inflammation secondary to luminal obstruction

39
Q

How does appendicitis present?

A

Colicky central abdominal pain due to inflammation of the appendix, followed by localization of pain to right iliac fossa due to inflammation of overlying peritoneum

McBurney’spoint/RIF tenderness

N&V

Low grade pyrexia

Guarding on abdominal palpation

Rebound tenderness (increased pain when releasing pressure), suggesting peritonitis

Percussion tenderness, suggesting peritonitis

Rovsing’s sign

40
Q

What is Rovsing’s sign?

A

Palpation of LIF causes pain in RIF

41
Q

What investigations are used in appendicitis diagnosis?

A

Diagnosis is mainly clinical

FBC

  • Increased WCC
  • Neutrophilia

>CRP

USS/CT, exclude other diagnosis

B-HCG, exclude ectopic pregnancy in females

Laparoscopy, diagnostic and therapeutic

42
Q

How is appendicitis managed?

A

Laparoscopic/open appendicectomy

Prophylactic co-amoxiclav

43
Q

Describe the pre-operative management for an appendicectomy?

A

Prophylactic IV antibiotics/Co-amoxiclav

44
Q

Give differential diagnoses of appendicitis

A

Ectopic pregnancy

Ovarian torsion

Ruptured ovarian cyst

Diverticulitis

PID

45
Q

What is a complication of appendicitis?

A

Perforation leading to generalized peritonitis or localized appendix abscess

46
Q

Give complications of appendicectomy

A

Bleeding, infection, pain and scars

Damage to bowel, bladder or other organs

Removal of a normal appendix

Anaesthetic risks

PE or DVT

47
Q

What is ischaemic colitis?

A

Acute disruption in blood supply to the colon, which may lead to inflammation, ulceration and haemorrhage

48
Q

Give risk factors for ischaemic colitis

A

Age

AF, particularly for mesenteric colitis

Other causes of emboli

  • Endocarditis
  • Malignancy

CVD risk factors

  • Smoking
  • HTN
  • DM

Cocaine

49
Q

How does ischaemic colitis present?

A

Self limiting

Abdominal pain

  • Crampy
  • Generalised

Sudden bloating

Rectal bleeding

Diarrhoea

Fever

Dusky blue mucus

50
Q

What investigations are used in bowel ischaemia diagnosis?

A

FBC

  • Increased WCC

Increased Lactate

AXR

  • Thumb printing in ischaemic colitis if haemorrhage or mucosal oedema

CT abdomen, makes diagnosis

51
Q

What is the first line investigation for bowel ischaemia?

A

Lactate

52
Q

What is the management for ischaemic colitis?

A

Supportive

Surgery if peritonitis, perforation or ongoing haemorrhage

53
Q

Which part of the colon is most likely to be affected by ischaemic colitis?

A

Splenic flexure

54
Q

What is sigmoid volvulus?

A

Describes large bowel obstruction caused by the sigmoid colon twisting on the sigmoid mesocolon

55
Q

Where can volvulus also occur, less commonly?

A

Caecum (20% of cases)

Due to developmental failure of peritoneal fixation of the proximal bowel

56
Q

Give risk factors for sigmoid volvulus

A

Increased age

Chronic constipation

Chagas disease

Neurological conditions

  • Parkinson’s
  • DMD

Psychiatric conditions

  • Schizophrenia
57
Q

Give risk factors for caecal volvulus

A

Adhesions

Pregnancy

All ages

58
Q

How does volvulus/bowel obstruction present?

A

Vomiting, green billious

Diffuse abdominal pain

Abdominal ditention

Absolute constipation

Tinkling bowel sounds

History of malignancy/surgery

59
Q

What investigations are used in bowel obstruction, generally?

A

AXR, initial investigation

Contrast abdominal CT confirms diagnosis and establoshes site

60
Q

What AXR signs are seen in volvulus?

A

Large bowel obstruction

  • Large, dilated/distended loop of colon
  • Often with air-fluid levels

Coffee bean sign arrising from LLQ in sigmoid

Embryo sign arrising from RLQ in caecal

Small bowel obstruction and centrally dilated bowel may be seen in caecal

61
Q

How is sigmoid volvulus managed?

A

Supportive with analgesia, fluids and NG tube insertion

Rigid sigmoidoscopy with rectal tube insertion for decompression

Urgent laparotomy if peritonitis or failed compression

62
Q

How is caecal volvulus managed?

A

Right hemicolectomy

63
Q

How is bowel obstruction managed, generally?

A

Nil by mouth

IV fluids

NG tube with free drainage, reducing risk of vomiting and aspiration

Laparoscopy to correct underlying cause

64
Q

Give causes of bowel obstruction

A

Adhesions

Hernias

Malignancy

Volvulus

Diverticular disease

Strictures

Intussuception

65
Q

What anti emetic should be avoided in bowel obstruction?

A

Metoclopramide

66
Q

What is diverticular disease?

A

Protrusion of the inner mucosal lining through to the outer muscular layer of the bowel, forming pouches/bulges

67
Q

What causes diverticular disease?

A

>50

Low fibre diet

Obesity

NSAIDS

Congenital/Meckel’s

68
Q

Which part of the bowel is diverticular disease most common in?

A

Sigmoid

69
Q

What is Meckel’s diverticulum?

A

Congenital outpouching or bulge in lower part of the small intestine due to left over umbilical cord

70
Q

How does diverticular disease present?

A

Mainly self-limiting, can be asymptomatic

LLQ pain

Constipation/altered bowel habit

Rectal bleeding

71
Q

What classification is used to assess the severity of diverticular disease?

A

Hinchey classification

72
Q

How is diverticular disease managed?

A

Increase dietary fibre

Bulk forming laxatives, stimulant laxatives should be avoided

Surgical resection

73
Q

Give complications of diverticular disease?

A

Diverticulitis

Haemorrhage

Fistula development

Abscess development

Perforation

Peritonitis

Ileus/obstruction

74
Q

How does diverticulitis present?

A

Severe LLQ abdominal pain

N&V

Fever

Change in bowel habit, mainly diarrhoea

Rectal bleeding

Reduced bowel sounds

Guarding, rigidity and rebound tenderness suggests perforation

Increased inflammatory markers

75
Q

How is diverticulitis managed?

A

Analgesia, avoiding NSAIDS

Oral co-amoxiclav for 5 days in mild disease

Admitted for IV if no improvement in 72 hours

Abscess drainage

76
Q

What is melanosis coli?

A

Disorder of pigmentation of the bowel wall in which histology demonstrates pigment-laden macrophages, associated with laxative abuse

Gastrointestinal (14 decks)

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