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Large Intestines Flashcards

1
Q

Derived from endoderm except ectoderm derived distal anal canal

A

LI

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2
Q

LI develops during

A

4th gestational week

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3
Q

Right colon

Proximal 2/3 of transverse colon

A

Midgut

SMA

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4
Q

Distal 1/3 or transverse colon

Left colon descending, sigmoid and proximal rectum

A

Hindgut derived

IMA

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5
Q

Hindgut development

A

Joining of endoderm and ectoderm at dentate line and division of urogenital sinus and rectum by urorectal septum

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6
Q

Divides endo and ectoderm

A

Dentate line

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7
Q

Retroperitoneal

A

Right and left colon

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8
Q

Intraperitoneal

A

Transverse

Sigmoid

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9
Q

Layers of colon and rectum

A

Mucosa
Submucosa (similar to SI)
Inner circular muscle: coalesce in anal canal to form internal sphincter
Outer longituginal: taenia coli (cecum to sigmoid)
In rectum, cirumferential
Serosa: midlower rectum at peritoneal reflection

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10
Q

Contiguous and inferior to pelvic floor muscle (levator ani)

A

External sphincter (voluntary striated)

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11
Q

Attaches to presacral fascia posteriorly and fasia propria of mesorectum anteriorly

A

Retrosacral Waldeyer’s fascia

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12
Q

Separates rectum from prostate and seminal vesicle from vagina

A

Denonvillier’s fascia

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13
Q

Colon differentiated from SI by

A 
appendices epiploicae (intraperitoneal fat pad) 
haustra (circumferential plicae in SI)
bands of outer longitudinal (taenia coli)
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14
Q

Largest diameter
Thinnest wall
Inc risk of perforation

A

Cecum

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15
Q

Most redundant

Inc risk of volvulus

A

Sigmoid

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16
Q

Narrowest

Inc risk of obstruction

A

Sigmoid

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17
Q

Colonic and rectal mucosa epithelium

A

Simple columnar with intestinal glands (crypts of Lieberkuhn) secreting maltase sucrase deeper than in SI

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18
Q

2cm proximal to anal verge

A

dentate

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19
Q

2 cm proximal to anal verge, epithelium

A

changes to anal transition zone with mixture of columnar, cuboidal and squamous epithelium

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20
Q

Connects terminal branches of arteries supplying the colon

A

Marginal artery of Drummond

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21
Q

Watershed area
Junction of SMA and IMA
Vulnerable to ischemia

A

Splenic flexure

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22
Q

IMV drains to

All others run parallel to artery

A

spelnic vein

All others portal vein

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23
Q

Rectal submucosal hemorrhoidal plexus drains into

A

Superior
Middle
Inferior rectal vein

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24
Q

Sympathetic inn of large intestine

A

Thoracic splanchnic T10-T12 right

L1-L3 left colon and rectum

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25
Parasympathetic inn of large intestine
Vagus right colon | S2-S4 left colon and rectum
26
Internal anal sphincter innervation
Sympa and para from pelvic plexus
27
External anal sphincter Sensation and motor function
Inferior rectal nerve S2-S4 from pudendal
28
Lymph drainage of colon
Muscularis mucosa (epicolic bowel wall, paracolic, intermediate and main SMA and IMA) nodes Rectum proximal to anal canal drains to IMA via mesorectum Proximal anal canal drains to IMA or inguinal nodes Distal anus drains to inguinal
29
Key component of radical resection for rectal cancer
Total mesorectal excision
30
Colon function
Water absortion 5L Na, K, Cl absorption Colonic bacteria: FA and NH4
31
Provide energy to colonocytectrom complex carbs
Short chain FA
32
Maintain tonic contraction at rest
Internal and external sphincter
33
Maintained by adequate sensory innervation Compliance of rectum Support from pevic floor muscle Tone from IS and ES
Anal continence
34
As feces reach rectum, pelvic dloor and IS relax and ES contracts allowing feces to approach anus and anoderm
Rectoanal reflex
35
Colon lacks
MMEC but has low and high amplitude contraction from vagal stimulation
36
Normal epithelium mutating to dysplastic epithelium
APC
37
Early adenoma to intermediate adenoma
KRAS
38
Intermediate adenoma to late adenoma
DCC/DPC4/JV18?
39
Late adenoma to carcinoma
p53
40
Carcinoma to metastasis
Other changes
41
19, F RLQ pain, febrile, hemodynamically stable RLQ rebound tenderness and guarding WBC= 13, HCG negative CT: AA without perforation OR: inflamed, attached to inflamed edematous ovary with purulence Next step in management?
PID Right oophorectomy and Appendectomy
42
Most common surgical emergency of abdomen 7% of population, W 2nd-4th decade Occlusion of lumen
Acute appendicits
43
Pain upon palpation of left lower quadrant
Rovsing’s sign
44
Pain upon hip flexion
Psoas sign
45
Pain on Internal rotation of right leg
Obturator sign
46
Atypical symptoms of AA occur in
children pregnant elderly
47
Mild leukocytosis with or without left shift
AA
48
High sensitivity 95% preferred for dx of AA
CT Scan in most populations: enlarged enhancing appendix >6mm with or without fecalith, periappendiceal fat stranding and wall thickening
49
Beneficial dx in pregnant women and children
UTZ
50
AA tx | Gold standard
Lap or open appendectomy If phlegmon, delay resection start antibiotic and perform interval appendectomy 15% negative appendectomy rate in spite of advances in imaging and technology
51
Used as landmark to find cecum and appendiceal base
Taenia coli Divide appendiceal artery, resect appendix and invert and oversew base
52
Oblique incision
McBurney
53
Transverse incision
Rocky-Davis
54
Most common malignancy of appendix
Carcinoid tumor
55
Yellow mass <2cm at appendiceal tip in association with pain or obstruction Arises from neuroendocrine enterochromaffin cells 90% in the appendix or distal ileum
Carcinoid tumor
56
``` Flushing Wheezing Edema Diarrhea Tricuspid insufficiency ```
carcinoid syndrome
57
Most conmonly found in the SI
Carcinoid
58
If tumor >2cm involves the appendiceal base or terminal ileum or is metastatic,
perform a right hemicolectomy
59
May alleviate symptoms of carcinoid syndrome
Ocreotide
60
15% of intestinal obstruction May be caused by cancer, diverticulitis, volvulus, fecal impaction, postoperative adhesions, hernias or loss of peristalsis (pseudoobstruction)
Large bowel obstruction
61
Most common cause of LBO
Cancer
62
Pseudoobstruction
Ogilvie’s syndrome
63
Confirms LBO
CT
64
Abdominal radiograph in LBO
colonic distention SI airfluid level dilated colon without air in rectum - mechanical obstruction air in rectum - pseudoobstruction
65
Tx LBO
Fluid resuscitation Correct metabolic abnormality NGT Antibiotics if ischemic
66
First line in tx of LBO
surgery resect and anastomose
67
Pseudoobstruction tx
NGT | Neostigmine to inc motility
68
Closed loop obstruction in at least two locations by twistint of bowel >/= 180 deg Most common in sigmoid, cecum and transverse colon
Volvulus
69
Anteromedial folding of cecum on itself
Cecal bascule
70
Axial rotation of cecum around ileocolic vessel, resulting in twisting of mesentery
Cecal volvulus
71
Rf for volvulus
``` Redundant segment Megacolon Bedridden condition Chronic constipation Pregnancy ```
72
Involves rotation around mesosigmoid
Sigmoid volvulus
73
Involves rotation of ileum, cecum and ascending colon around mesentery and ileocolic vessel
Cecal volvulus
74
Volvulus may present with
sudden onset abdominal distention and pain
75
Confirms dx of volvulus
Abdominal radiograph: bent inner tube narrowing into a bird’s beak (sigmoid) coffee bean - dilated cecum
76
Dilated cecum on radiograph
Coffee bean | does not resolve with NGT
77
Loops that are interposed between liver and diaphragm at risk for volvulus
Chilaiditi’s syndrome
78
First line for nonstrangulated sigmoid volvulus
endoscopic decompression (sigmoidoscopy, colonoscopy) placement of rectal tube
79
Passage of air and feces indicate
reduction of volvulus
80
Emergent surgery
cecal volvulus | cecopexy, right colectomy
81
Associated with high recurrence and reserved for selected cases
Cecostomy
82
First line for sigmoid volvulus but not for cecal
Endoscopic decompression
83
``` 43, M Severe lower quadrant abdominal pain Denies prior nausea or vomiting Febrile but stable Slightly distended abdomen and tender B lower quadrant with guarding Leukocytosis ``` CT: diverticulosis of sigmoid with adjacent diverticular abscess on antimesenteric side of sigmoid colon No pneumoperitoneum Mx?
Admit NPO initiate IV antibiotics Consider IR drainage if abscess is in amenable location
84
Most common colonic pathology
Diverticular disease
85
Diverticulosis most affects
sigmoid 95
86
Rf for diverticulosis
Low fiber diet Sedentary lifestyle Tobacco use Chronic constipation
87
False diverticula involving herniation of mucosa and muscularis mucosa through muscularis externa at an area of weakness (ie near vessel)
Diverticulosis
88
More common in young Asian population
Right sided diverticulum
89
Multiple non inflamed lesions | Asymptomatic
Diverticulosis
90
Inflammation and infection of diverticulum (from microperforation) Complicated by abscess, gross perforation or obstruction
Diverticulitis
91
Asymptomatic or | sudden painless bright red blood per rectum (BRBPR)
Divericulosis
92
Painless bright red blood per rectum | LLQ pain, fever, leukocytosis
Diverticulitis
93
Dx of diverticulitis
Clinical with CT (identify complication)
94
Complications of diverticulosis
phlegmon abscess perforation obstruction
95
Indications for elective resection
Recurrent attack of diverticulitis Episode complicated by abscess or microperforation Diverticulitis in young or immunosuppressed patient
96
Uncomplicated diverticulosis tx
high fiber diet bowel rest oral antibiotics ir drainage if abscess is present
97
Sx for diverticulosis perforation
sigmoidectomy and Hartmann
98
After episode of complicated disease (abscess) After episode of diverticulitis in young or immunosuppressed After recurrent attack
Delayed elective resection
99
Men | Source of bleeding distal to ligament of Treitz
Lower gastrointestinal bleeding
100
LGIB is a result of
``` angiodysplasia diverticulosis Meckel’s ischemia IBD infection neoplasm hemorrhoids ```
101
Most common cause of LGIB
angiodysplasia | diverticulosis
102
Negative NGT aspirate in UGI source for GI bleeding
does not rule out UGIB
103
LGIB mx
Fluid resuscitation | Serial Hct
104
Suspected LGIB tx
resuscitation, multiple organ support correct coagulopatht/thrombocytopenia ET for shock Surgical consultation
105
+ aspirate NGT or risk factors for UGIB
Urgent EGD
106
- aspirate and low risk for UGIB
Urgent colonoscopy | after oral PEG purge
107
Visualization of LGI source
thermal/injection therapy
108
Nonvisualization of LGI source | Severe bleeding preventing endoscopic visualization
Angiography (+/- prior TRBC scan) with possible angiographic therapy
109
NEC affecting terminal ileum, cecum and right colon
Typhilitis
110
Typhilitis rf
leukemia | immunosupression (AIDS, chemo, transplant)
111
Confirms dx of typhilitis
CT: dilation of bowel, wall thickening, mesenteric stranding, pneumatosis intestinalis if ischemic)
112
Typhilitis mx
``` Medical Immediately instituted NPO NGT fluid resuscitation broad spec antibiotics ```
113
Resection in typhilitis if
``` hemodynamically unstable perforation hemorrhage complete bowel obstruction sepsis ```
114
15% of IBD cases have
indeterminate cause
115
Active form of sulfasalazine
5-ASA
116
Extra intesinal manifestation of IBD
``` Primary sclerosing cholangitis (UC) Erythema nodosum Pyoderma gangrenosum Arthritis Sacroileitis Anemia Pancreatic insufficiency Pericarditis Ankylosing spondyltitis Uveitis Scleritis ```
117
Patients with IBD should have
annual colonoscopy after disease has been diagnosed for 8-12 years due to risk of colorectal cancer
118
Indications for emergent surgery UC
toxic megacolon fulminant/steroid resistant disease severe bleeding perforation
119
Indications for elective surgery UC
``` Dysplasia or malignancy Stricture Intractable symptoms Inability to tolerate medical management Extra intestinal disease Growth retardation ```
120
Second leading cause of cancer deaths | No gender predominance
Colorectal cancer
121
Rf for CRC
>50 yrs hx of colon adenoma IBD (UC) fmx of colorectal cancer HCCS
122
Premalignant
Adenoma
123
Most common adenoma
Tubular
124
Adenoma with inc risk for cancer
villous
125
May present with asymptom, obstruction, rectal bleeding, changes in stool pattern or caliber, tenesmus or anemia Exam: guaiac + stool, palpable rectal mass or signs of LBO
CRC
126
Indications for surgery Crohn’s
``` Fistula Abscess Strictures/obstruction/failed medical management Perforation Hemorrhage Dysplasia/malignancy Growth retardation ```
127
CRC may reveal
Anemia | Inc CEA
128
Screening for CRC
``` DRE FOBT Flexible sigmoidoscopy Air contrast barium enema CT colonography (virtual colonoscopy) Colonoscopy (preferred) ```
129
Staging for CRC
``` endoscopic ultrasound pelvic MRI (assess depth of local invasion) CT (distant metastases) ```
130
Tx for CRC
CIS (adenoma with high grade dysplasia) endoscopic resection Invasive cancer in polyp (cancer invading through muscularis mucosa) segmental resection if lymphatic or vascular invasion + margin or poorly diff histology Endoscopic resection if criteria are absent All other invasive colon cancers: segmental resection add postoperative chemo (5-FU, oxaliplatin, leucovorin) if + lymph node
131
CRC screening guidelines for average risk patients starting 50
Annual FOBT and flexible sigmoidoscopy every 5 years Colonoscopy every 10 years Air contrast barium enema every 5 years Opinion favors colonoscopy
132
Outcomes for stage IV disease with hepatic metastases are
improved if hepatic disease is resected
133
Resection should include at least
12 lymph nodes for optimal staging If tumor is perforated or obstructing, surgery is directed at removal of malignancy although bypass or colostomt may be all that is possible
134
Treatment for rectal cancer
May include radiation with chemotherapy
135
Carcinoma in situ rectal tx
Endoscopic resection or transanal local excision
136
T1 rectal disease
Radical resection or for small accessible lesions, transanal, full thickness local excision
137
T2 or higher stage rectal disease tx
Radical resection including at least 5cm distal margin of rectum and mesorectum (for upper rectum and rectosigmoid) or TME 1-2 cm distal margin of rectal wall (for mid to low rectal cancer)
138
For very low rectal cancers near canal or sphincter tx
APR
139
T3 or node + rectal disease
Add chemoradiation to radical surgery preferably preoperatively Dec morbidity compared to postoperative chemoradiation Also add postoperative chemotherapy for any node + rectal cancer (as for colon cancer)
140
Surgery for CRC involves
segmental resection including involved portion of colon and lymphatic drainage to the root of associated mesentery
141
Amsterdam Criteria for HNPCC (3,2,1 rule)
>/= 3 relatives, 1 of whom is a first degree relative with HNPCC related cancer >/= 2 generations affected >/= 1 person affected <50 years Confirmation that pathologic tumors are not FAP related
142
Most common surgery for UC
Total proctocolectomy
143
Most common complication of total proctocolectomy
Pouchitis
144
Curative for UC but not for Crohn’s disease
Surgery
145
3rd and 7th decase Inc risk Ashkenazi Jew Dec risk with tobacco Colon (left and rectum) Diarrhea, hematochezia, abdominal pain (crampy), fever Colonoscopy, biopsy Mucosa and submucosa Continuous, friable mucosa, crypt abscess, pseudopolyp Fulminanct UC, hemorrhage, toxic megacolon, CRC, extra-intestinal manifestation For maintenance: Sulfasalazine or 5-ASA 6-mercaptopurine or azathioprine For acute attack: steroid, sulfa, 5-ASA
Ulcerative colitis
146
For severe UC tx
Infliximab
147
For fulminant steroid-refractory UC tx
Cyclosporine
148
2nd and 6th decase Inc risk with Ashkenazi Jew Inc risk with tobacco Anywhere in GI: most common terminal ileum Diarrhea, obstruction, abdominal pain, weight loss, hematochezia, fever Colonoscopy with biopsy, small bowel follow through CT scan Transmural Skip lesion (ulceration with interspersed normal mucosa), noncaseating granuloma, fistula perianal, abscess, cobblestoning, stricture Fulminant colitis, toxic megacolon, extra-intestinal manifestation, colorectal and small bowel cancer Metronidazole for maintenance of perianal disease
Crohn’s disease
149
AD Hamartomatous polyp throughout GI tract Inc risk of CRC
Juvenile polyposis
150
AD Hamartomatous polyp most often located within jejunum/ileum and possibly rectum Concurrent hyperpigmentation of buccal mucosa Slightly inc risk of adenomatous degeneration Inc risk of extra intestinal cancer (breast, gonad, pancreaticobiliary)
Peutz-Jeghers syndrome
151
AD PTEN mutation GI polyp, mucocutaneous lesion, uterine leiomyoma, thyroid and breast tumor
Cowden syndrome
152
Sporadic GI polyposis Epidermal changes including alopecia, nail plate dystrophy, hyperpigmentation
Cronkite-Canada syndrome
153
APC mutation ch5q Colonic adenoma with 100% lifetime CRC risk Inc risk of periampullary, thyroid, adrenocortical cancer If + APC = flexible sigmoidoscopy annually at 10-15 yrs Upper GI endoscopy every 1-3 years from 25 years
FAP
154
``` APC mutation ch5q Colonic adenoma with inc risk of CRC Desmoid tumor Osteoid tumor Epidermoid skin cyst ``` As for FAP
Gardner
155
APC mutation ch5q Colonic adenoma with inc risk of CRC, brain tumors As for FAP
Turcot’s syndrome
156
hMLH1, hMSH2 mutation (DNA mismatch repair genes) 85% lifetime risk of CRC Screening colonoscopy annually starting at 20-25 years or 10 years earlier than the youngest CRC diagnosis Endometrial biopsy or transvaginal ultrasound annually starting at 25-35 years
HNPCC (Lynch)
157
Early onset CRC
Lynch I
158
Inc risk of brain, stomach, SI, pancreaticobiliary, genitourinary, endometrial malignancy
Lynch II
159
Engorged anal submucosal cushion | (CT, arteriole and venule) not varicose
Hemorrhoid
160
Hemorrhoids rf
``` inc intraabdominal pressure obesity pregnancy staining with defacation most common location are right anterolateral, right posterolateral and left lateral ```
161
Internal hemorrhoid Insensatr Transitional/columnar epithelium
superior to dentate line
162
First degree hemorrhoid
Prolapse
163
Second degree hemorrhoid
+ spontaneous reducing prolapse
164
Third degree hemorrhoid
+ prolapse requiring manual reduction
165
fourth degree hemorrhoid
+ nonreducible prolapse
166
Inferior to dentate line Squamous epithelium Innervated anoderm hence sensitive
External hemorrhoid
167
Most common cause of acute anal pain
thrombosis of external hemorrhoid perianal abscess anal fissure
168
Cause bothersome swelling and diffuclty with hygiene
External hemorrhoid
169
Cause bright red bleeding BRBPR and mucous discharge
Internal hemorrhoid
170
Family hx of CRC >40 years Suspicious symptom With hemorrhoid
Perform flexible sigmoidoscopy or colonoscopy
171
Complication of stapled and traditional hemorrhoidectomy
Pain Bleeding Urinary retention
172
Tear or ulcer in anoderm distal to the dentate line usually midline
Anal fissure
173
Anal fissures are caused by
Hypertonic internal anal sphincter muscle from insufficient dietary fiber
174
Small longitudinal ulcer in anoderm with sentinel pile distally or hypertrophic anal papilla proximally
Anal fissure
175
Best way to diagnose anal fissure
inspection
176
DRE of anal fissure
internal sphincter spasm and tenderness
177
Dx for anal fissure
Anoscopy | Sigmoidoscopy
178
Anal fissure tx
Stool softener Sitz bath Nifedipine ointment
179
Failure of medical management in anal fissure:
lateral internal sphincterotomy
180
Relaxes internal sphincter
Nifedipine
181
Occasional complication of lateral internal sphincterotomy
Minor incontinence
182
Fistula between anal canal and perineal skin
Fistula-in-ano
183
Anterior or anterolateral external opening track
directly radially to anal canal
184
Posterior or posterolateral opening tracks
curvilinearly to posterior midline in anal canal
185
Fistula in ano tx
fistulotomy
186
Complication if sphincter is divided
Fecal incontinence
187
Proper evaluation for any anorectal complaint
Careful anal inspection Rectal exam Anoscopy Sigmoidoscopy and sometimes colonoscopy
188
Infected hair containing sinus in gluteal cleft Hirsute men 15-40 Pain superior to gluteal cleft Dx: clinical, abscess or multiple pits or sinuses with hair Sx: excision, marsupialization
Pilonidal cysy
189
Inflammation of anorectum Syphilis, gonorrhea, herpes, HPV, CMV, Chlamydia, chancroid, UC, Crohn’s Rectal pain, urgency, BRBPR mucuous discharge Treatment is etiology spec
Proctitis
190
Protrusion of entire rectal wall through anus | W >60
Rectal prolapse
191
True rectal prolapse present
circumferential mucosal fold
192
Mucosal prolapse present with
radial fold in mucosal prolapse
193
Rectal prolapse dx
Colonoscopy Contrast enema Defecography
194
Rectal prolapse procedure (less invasive)
Delorme’s | Perineal rectosigmoidoscopy
195
Good operative candidates for rectal prolapse
Laparotomy | Rectopexy with or without rectosigmoid resection
196
Anal cancer most commonly is
SCC by HPV
197
Pain, pruritus, sense of anal fullness, rectal bleeding Anal mass occasionally with lymphadenopathy
Rectal cancer
198
Confirms dx of rectal ca
Biopsy
199
Wide locsl excision
small lesion or on perianal skin ca
200
Chemoradiation
Large lesions and anal canal (Nigro protocol)
201
Nigro protocol
5-FU | Mitomycin
202
Recurrent or persistent disease after chemoradiation is treated with
APR
203
Appendectomy 3cm yellow mass at tip of nonperforated appendix Mx?
Because tumor is >2 cm | right colectomy indicated for carcinoid tumor
204
70 diagnosed with colon cancer What is the incidencr of a synchronous lesion?
5-10% synchronous cancer | 20-50% synchronous adenoma
205
Next step in eval of LGIB if UGI snd LGI endoscopies are negative Px is hemodynamically stable
Tagged red cell scan Angiography Capsule endoscopy
206
Traits of T1 colon cancer necessitate segmental resection rather than endoscopic resection
Lymphovascular invasion <1mm margin | Poorly differentiated lesion
207
25, F Lynch II Screening recommendation
Anually starting at 20-25 yrd of age 10 yrs earlier than youngest CRC dx Endometrial biopsy or transv UTZ anually starting 25-35 yrs
208
Adjuvant chemo regimen for stage III colon cancer Indications for adjuvant chemotherapy in stage II disease
STAGE III: FOLFOX Stage II: perforation, obstruction, high-grade lesion, lymphovascular invasion <12 lymph node in resected specimen
209
Highly sensitive and specific marker for detecting INTESTINAL INFLAMMATION
Lactoferrin
210
Level correlates well with histologic inflammation, predict relapses and detect pouchitis
Fecal calprotectin
211
Earliest radiologic change of UC in barium enema
Fine mucosal granularity
212
Earliest lesion of Crohn’s
Apthuous ulcer

Surgery (17 decks)

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