Lower G.I. 5 Flashcards
55-year-old man presents with constipation, rectal bleeding, fatigue. Find constricting lesion 4 cm from anal verge. Biopsy shows adenocarcinoma. Further preoperative evaluation? Appropriate procedure? Complications?
- Colonoscopy for visualization
- Transrectal ultrasound to determine rectal wall invasion
- CT or MRI to determine spread to adjacent structures
- CXR and CEA
Abdominoperineal resection (excision of entire rectum with permanent colostomy)
Impotence (50%), impaired bladder function, colostomy complications
55-year-old man presents with constipation, rectal bleeding, fatigue. Find constricting lesion 4 cm from anal verge. Biopsy shows adenocarcinoma. What lymph nodes could be invaded?
Internal iliac, sacral, inferior mesenteric, inguinal
Poor prognostic factors for rectal adenocarcinoma?
#Poor histologic differentiation #elevated CEA #bowel perforation #aneuploidy
Regarding rectal cancer – distance from anal verge affects operative management how?
It’s more than 5 cm proximal to anal verge, possible to remove
If closer, abdominoperineal resection is necessary (removal results in incontinence) because margins include anal sphincter
If distal, need 2 cm margins for well/moderately differentiated lesions; 5 cm margins for poorly differentiated/anaplastic/signet cell carcinomas
When to use preoperative radiation for rectal cancer?
If lesions or large/bulky or extend outside bowel wall
How does abdominoperineal resection differ in women?
Remove posterior wall of the vagina
Patient undergoes curative resection with abdominoperineal resection. Later developed .5 cm lesion in perineum. Management?
- Biopsy
- If Biopsy shows carcinoma, repeat CT scan, CEA, colonoscopy
- Chemotherapy, radiation, and surgery
Patient with previous colon cancer resection presents with elevated CEA. Suspect metastasis. Candidate for surgical resection if?
- No extrahepatic Mets
- No local recurrence
- Lesion in surgically resectable location
- Acceptable Anastasia risk from cardiopulmonary standpoint
Some Locations of unresectable hepatic lesions?
- Multiple lesions in multiple lobes
- Lesions with vascular structures (hepatic, portal veins)
- Lesions involving diaphragm
- Lesions in cirrhotic liver (limited hepatic reserve)
Surgical Management of patients with unresectable liver metastases?
- Cryotherapy
- Injection of absolute ethanol
- Radiofrequency ablation
- Chemoembolization (catheterize hepatic artery and fill with chemotherapy)
45-year-old man presents with rectal bleeding. Find lesion; biopsy indicates most common tumor of anal canal – diagnosis? Involved regional nodes?
Squamous cell carcinoma
Inguinal lymph nodes or superior rectal lymph nodes
45-year-old man presents with rectal bleeding. Find lesion; biopsy indicates squamous cell carcinoma. Management if:
- 0.5 cm diameter lesion with no local extension and negative lymph nodes
- 4 cm lesion with no local extension and negative lymph nodes
- 8 cm lesion with positive lymph nodes
- Local excision
- Surgery not initially warranted (Nigro). Chemoradiation.
#4-6 weeks after chemoradiation do biopsy. If positive, do an Abdominoperineal resection - Chemoradiation then radical resection
70 woman presents with abdominal pain and fever (101), mild tachycardia, BPO 140/85 and tender LLQ – suspected diagnosis? Management?
Diverticulitis
- Abdominal obstructive series or CT scan
- Complete bowel rest, IV hydration, parenteral antibiotics, meperidine for pain relief (morphine increases intracolonic pressure)
- If minimal symptoms, liquid diet and outpatient antibiotics
Patient presents for diverticulitis. After management, patient becomes hungry and rapidly improves. Management? Likelihood of another episode of diverticulitis? Long-term follow-up?
High-fiber diet and outpatient treatment with broad-spectrum antibiotics 47-10 days
70% will have no further recurrences
Colonoscopy or barium enema to confirm presence of diverticula and absence of colon cancer
Patient presents with diverticulitis and gets CT scan – expected findings?
“Fat stranding” and edema of tissue near inflamed colon
Patient treated for diverticulitis six months previously returns with recurrence – management? Appropriate procedure?
- Bowel rest, IV antibiotics, analgesics
- Elective resection 4-6 weeks after inflammation resolves (to prevent perforation or abscess)
Colectomy
75-year-old woman with LLQ pain, fever, nausea. Obstructive series is unremarkable. Managed for acute diverticulitis. Patient deteriorates, continued pain, increasing fever, and increasing WBC count. Suspected problem? Appropriate evaluation? Management?
Free preparation for intra-abdominal abscess
CT scan
- CT guided insertion of catheter for sampling and drainage
- Leave in drain until drainage stops
#discharge if afebrile and tolerates food
#if does not improve with catheter drainage, Hartman procedure – resect colon with colostomy) - 4-8 weeks after information is controlled, colectomy
70-year-old woman presents with four hour history of bright red blood per rectum. Heart rate 115. Blood-pressure 105/70, pale conjunctiva, no personal edema, neurologically intact. Management?
- Two large bore IVs with 1-2 L of Ringers
- Routine blood studies and CXR
- Place Foley
- Placement of NG tube to rule out upper G.I. bleed (if positive, upper endoscopy)
- Anoscopy
Most common causes of rapid lower G.I. bleeding? Other causes?
Bleeding diverticula and Vascular ectasias
Aortoenteric fistula, ischemic colitis, IBD, hemorrhoidal disease, rectal varices
vascular ectasia? Arises from? Treatment?
AV malformations arising from degeneration of intestinal submucosal veins
Coagulation with monopolar current
Left-sided versus right-sided diverticula?
More common versus more likely to bleed
