Colorectal Absite Flashcards

Front 1

what is tx for basal cell ca of anal margin?

Back 1

Basal cell carcinoma of the anal margin is appropriately treated with WLE.

Front 2

Pt presents c/ anal mass
-Bx shows cloacogenic cancer
-Next step = _

Back 2

Cloacogenic anal ca:
-variant of sq cell ca
-Tx = same as sq cell: chemo 1st line - Nigro protocol = 5-FU + mitomycin + XRT
-If inguinal adnopathy, get FNA beforehand -> extend radiation field if (+)
-80% cure rate
-Persistant or recurrent ca => APR

Front 3

pt diagnosed c/ sq cell anal ca below dentate line.
What is the tx?

Back 3

Anal cancer below dentate line - better prognosis than above:
-Sq: WLE if <3 cm, 0.5 cm margin. APR otherwise. +/- inguinal LN dissection
-Basal cell: WLE usually sufficient. APR if sphincter involved
-Bowen's dz (malignant): intraepidernal sq cell. WLE. many develop primary internal malignancies, skin cancer
-Paget's dz (rare)L: intraepidermal apocrine gland ca. Slow growing. PAS (+). WLE +/- groin dissection. Many develop rectal or colon ca.

Front 4

A 60-year-old man has rectal pain and a tender 2-cm mass at the anal canal. Sigmoidoscopy shows normal rectosigmoid mucosa. Biopsy of the mass shows squamous cell carcinoma of the anus. The most appropriate management is

Back 4

Anal canal = above dentate line, so Tx = Nigro protocol = 5-FU + mitocycin + XRT
(sq cell ca below dentate line treated surgically)

Front 5

Initial tx for anal fissure = _

Back 5

Anal fissure;
-Caused by split in anoderm
-90% in posterior midline. 73% intersphincteric, 23% transspincteric
-Pain, bleeding c/ defecation.
-Chronic fissures have sentinel pile
-Tx: Sitz baths, bulk, lidocaine jelly, stool softener, nitrate paste
-Surgery: lateral subcutaneous internal sphincterotomy
-Biggest complication from surgery = fecal incontinence
-NO surgery if pt has UC or Crohn's
-Lateral or recurrent fissures => suspect Crohn's > anal cancer (UC doesn't involve anus)

Front 6

50M c/o pain c/ defecation, blood streaks c/ BM.
-Anosocopy shows piled-up anoderm in posterior midline
-tx = _

Back 6

Anal fissure;
-Caused by split in anoderm
-90% in posterior midline. 73% intersphincteric, 23% transspincteric
-Pain, bleeding c/ defecation.
-Chronic fissures have sentinel pile
-Tx: Sitz baths, bulk, lidocaine jelly, stool softener, nitrate paste
-Surgery: lateral subcutaneous internal sphincterotomy
-Biggest complication from surgery = fecal incontinence
-NO surgery if pt has UC or Crohn's
-Lateral or recurrent fissures => suspect Crohn's > anal cancer (UC doesn't involve anus)

Front 7

Tx for anal fissue refractory to medical mgmt

Back 7

Anal fissure;
-Caused by split in anoderm
-90% in posterior midline. 73% intersphincteric, 23% transspincteric
-Pain, bleeding c/ defecation.
-Chronic fissures have sentinel pile
-Tx: Sitz baths, bulk, lidocaine jelly, stool softener, nitrate paste
-Surgery: lateral subcutaneous internal sphincterotomy
-Biggest complication from surgery = fecal incontinence
-NO surgery if pt has UC or Crohn's
-Lateral or recurrent fissures => suspect Crohn's > anal cancer (UC doesn't involve anus)

Front 8

Sq cell ca of anal canal
-Tx: _
-Indication for APR

Back 8

Sq cell ca of anal canal
-Tx: Nigro protocol (chemo-XRT), not surgery
-APR for recurrent disease

Front 9

"

Back 9

5-FU, mitomicin, XRT

SCCA of the anal canal generally presents as a mass, sometimes bleeding and pruritus.
-APR if chemo-XRT fails or if radiation contraindicated

Front 10

For a patient with normal sphincter function, appropriate treatment for a squamous cell carcinoma of the anal canal would be

Back 10

The Nigro protocol, which combines chemoradiotherapy, has been shown to have equal efficacy when compared with APR with regards to overall survival (OS), while preserving sphincter function in those that had normal function prior to undergoing treatment.
-APR for persistent or recurrent disease.

-If it were rectal carcinoma not involving the sphincter, would do LAR with TME

Front 11

what is the treatment for anal sq cell ca?

Back 11

Chemotherapy and radiation is the primary treatment for anal CANAL SCC but wide local excision is the main treatment for anal MARGIN SCC.

Front 12

patient w/ hx aortic stenosis presents c/ LGI bleed
Suspect _

Back 12

angiodysplasia bleeding:
-RIGHT colon most common
-venous bleeding. less severe than diverticular bleed but more likely to recur (80%)
-Angiogram: tufts, slow emptying
-20-30% have aortic stenosis

Front 13

what side is angiodysplasia bleeding most likely to come from?
venous or arterial?
what comorbidity is associated (which anesthesia might want to know about)?

Back 13

angiodysplasia bleeding:
-RIGHT colon most common
-venous bleeding. less severe than diverticular bleed but more likely to recur (80%)
-Angiogram: tufts, slow emptying
-20-30% have aortic stenosis

Front 14

what is the #1 cause of pediatric appendicitis?
#1 cause in adults?
general physiologic process?

Back 14

Appendicitis:
-Anorexia -> periumbilical pain -> vomiting, RLQ pain 2/2 peritonitis
-usually 20-35% y/o. can have normal WBC count.
-CT: appendix >7mm diameter or >2 mm thick, fat stranding, no contrast in appendiceal lumen
-midpoint of antimesenteric border = most likely to perforate
-Hyperplasia = #1 cause in kids. can follow a viral illness
-Fecalith = #1 cause in adults.
-Luminal obstruction -> distension -> venous congestion, thrombosis -> ischemia -> gangrene, necrosis -> rupture
-If CT shows walled-off perforated appendix => percutaneous drainage, appy at later date as long as sx improving. may need barium enema or colonoscopy to r/o perforated colon ca.

Front 15

what is most common reason for appendicitis in kids? in adults?

Back 15

Appendicitis:
-Anorexia -> periumbilical pain -> vomiting, RLQ pain 2/2 peritonitis
-usually 20-35% y/o. can have normal WBC count.
-CT: appendix >7mm diameter or >2 mm thick, fat stranding, no contrast in appendiceal lumen
-midpoint of antimesenteric border = most likely to perforate
-Hyperplasia = #1 cause in kids. can follow a viral illness
-Fecalith = #1 cause in adults.
-Stasis of luminal contents, then obstruction -> distension -> venous congestion, thrombosis -> ischemia -> gangrene, necrosis -> rupture
-If CT shows walled-off perforated appendix => percutaneous drainage, appy at later date as long as sx improving. may need barium enema or colonoscopy to r/o perforated colon ca.

Front 16

What tumor suppressor gene is mutated as one of the preliminary steps in the adenoma-to-carcinoma sequence in colon cancer?

Back 16

- APC gene: tumor suppressor. early mutation in 60% of sporadic colon cancer
- K-ras mutation (proto-oncogene, chromosome 12p): 65% of sporadic colon cancer. Important event in the dysplastic changes from adenoma -> carcinoma. Thought to occur after the APC mutation and in addition.
-hMSH2 (one of the HNPCC mutations, DNA repair gene)
-DCC and p53: tumor suppressor genes. occur later in the transition to carcinoma.

Front 17

During an elective resection of the sigmoid colon for a diverticular stricture in a 65-year-old woman, a solid, 6-cm right ovarian mass is found. The most appropriate management is

Back 17

Incidental ovarian mass on laparotomy:
-Post-menopausal => [oophorectomy, frozen section] -> TAH, BSO, and omentectomy
-Pre-menopausal => PARTIAL oophorectomy, frozen section -> remove tube + ovary -> if patient done with childbearing, do TAH in 2nd procedure

Front 18

During APR, the vessels located in the lateral stalks are the _ arteries

Back 18

APR anatomy:
-Exicise anal canal + rectum
-For malignant lesions not amenable to LAR: invading sphicter complex, fixed to pelvic floor, spread to adjacent organs, <6-8 cm from anal verge
-High rate of impotence 2/2 nerve disruption
-Higher risk of recurrence c/ rectal than colon ca
-MIDDLE RECTAL arteries are in lateral stalks (off the hypogastrics)
-If unresectable large liver mets found in OR, proceed c/ APR if pt was c/o bleeding or rectal pain. Otherwise place colostomy + mucus fistula to reduce morbidity.

Front 19

During metastatic w/up in preparation for APR, pt found to have unresectable large liver mets
-Proceed c/ APR only if…

Back 19

During metastatic w/up in preparation for APR, pt found to have unresectable large liver mets
-Proceed c/ APR if pt is obstructed, nearly obstructed, significant bleeding or pain

Front 20

"

Back 20

APR
Recurrent cancers usually do so within 2-3 years.
-R/o mets (CT A/P, CXR, LFTs, CEA) -> Surgery has best cure rate, should be offered when possible.

Front 21

Rectal ca metastasizes directly to spine via __

Back 21

Rectal ca metastasizes directly to spine via Batson's plexus (venous)
-colon ca rarely metastasizes to bone

Front 22

What is Bowen's disease?
-Tx = _

Back 22

Bowen's disease:
-intraepidermal squamous cell ca
only 5% invasive => wide local excision

Front 23

Apthous ulcers seen on colonoscopy => suspect infectious colitits 2/2 organism _

Back 23

Campylobacter colitis:
-may see apthous ulcers on colonoscopy

Front 24

default tx for carcinoid tumor of rectum
-have to do _ if ...

Back 24

Carcinoid tumor of rectum:
-Transanal excision = default
-Radical resection (APR/LAR) if large or doesn't fit the transanal criteria for polyp (i.e. max T1, <40% circumference, w/in 8-10 cm of anal verge, no lymphovascular invasion, not high grade)

Front 25

Carcinoid of appendix:
when is R hemicolectomy indicated?

Back 25

Carcinoid of appendix:
-if 2 cm or invading base, do R hemicolectomy
-otherwise appendectomy is sufficient

Front 26

Cecal volvulus:
-tx = _
(alternative = _)

Back 26

Cecal volvulus:
-less common than sigmoid volvulus. more prone to gangrene.
-Presentation: 20-40 y/o c/ SBO-like sx. 10% of pts are pregnant. Dilated cecum in RLQ
-only 20% decompressed by colonoscopy
-Usually needs R hemicolectomy with ileo-transverse anastomosis
-alternative = cecopexy if colon viable + pt frail

Front 27

50M presents c/ anal mass above dentate line. Bx shows cloacogenic cancer.
-next step = _

Back 27

Anal cancer above dentate line - worse prognosis than below:
Squamous, basaloid (cloacogenic), mucoepidermoid => Nigro protocol = 5FU, mitomycin, XRT +/- extend XRT to inguinal nodes
-Adenoca: APR (WLE if <3 cmm, <1/2 circumference, T1, well-diff), post-op chemo-XRT like rectal ca.
-Melanoma (#3 site for melanoma): APR c/ margins dicated by melanoma. Most tumors not heavily pigmented.

Front 28

65M presents c/ pneumoturia, Imaging shows thickened sigmoid colon, no diverticuli
-Dx most likely ...

Back 28

Colovesical fistula 2/2 colonic adenocarcinoma

Front 29

65M presents c/ pneumoturia, thickened sigmoid colon, no diverticuli
-Suspect _

Back 29

65M presents c/ pneumoturia, thickened sigmoid colon, no diverticuli => likely adenoca (since no diverticuli)

Front 30

Colon actively secretes 2 electrolytes ...

Back 30

Colon actively secretes HCO3 and K

Front 31

55M undergoing sigmoid resection for colonic adenoca and mass is incidentally found in the liver.
-Intraop US shows tumor deep in R lobe, would require R lobectomy
-What surgery should be done?

Back 31

Sigmoid resection only (would require major liver resection)
-complete metastatic w/u in 6-8 weeks, then bring pt back for liver resection if (+)
-if mets were small, could wedge out at time of initial surgery
-25% 5-yr survival after removal of isolated liver mets
-liver mets are fed primarily by hepatic artery = route for inta-arterial chemo or embolization

Front 32

65M c/ hx T3N1M0 rectal adenoca 8 cm from anal verge undergoees XRT and Leukovorin.
-Restaged c/ imaging and biopsies, no residual tumor found
-Tx is _

Back 32

Proceed c/ LAR b/c 15-20% still have cancer on final path
-Similar strategy for APR patients, although there are some studies to just follow them non-op

Front 33

what is the most common location for colon ca?

Back 33

SIGMOID = #1 location for colon cancer

Front 34

what is the treatment for colon ca invading into adjacent organs?

Back 34

can resect colon ca growing into adjacent organs en bloc with a portion of the organ
-Since it's T3, stage 3, also needs post-op chemo

Front 35

Transformation from colon polyp -> cancer takes ~_ years

Back 35

Transformation from polyp -> cancer takes ~8 years

Front 36

Colonic AVM:
-_% of patients have aortic stenosis
-_% of patients have CAD

Back 36

Colonic AVM:
-25% of patients have aortic stenosis
-50% of patients have CAD

Front 37

_ = #1 bacterium in feces = _% of fecal bacteria
Colonic anaeobes outnumer aerobes _:1

Back 37

B. vulgatas = #1 bacterium in feces = 12% of fecal bacteria
E coli, Klebsiella, E. faecalis are ~ 0.06%
Colonic anaeobes outnumer aerobes 1000:1

Front 38

#1 location for colon ca = _

Back 38

Colorectal ca:
-#2 cause of cancer death
-Sx: anemia, constipation, bleeding
-RF: dietary fat (-> O2 radicals), Clostridium septicum infection
-Gene mutations:
-SIGMOID = #1 site for primary
-Spreads to nodes 1st
-NODAL STATUS = #1 prognostic facto

Front 39

most R colon cancers can be treated c/ _

Back 39

Most R colon cancers can be treated c/ partial colectomy, primary anastomosis, no ostomy

Front 40

Management of R colon cancer invading ~ 0.5 cm into liver

Back 40

Colorectal cancer invading into adjacent organs =>
resect en bloc (e.g. with liver wedge or partial cystectomy)

Front 41

Stage _ colorectal ca = into muscularis propria

Back 41

Stage 1 colorectal ca:
-T1: into submucosa
-T2: into muscularis propria (not through)
-N0, M0

Front 42

Stage _ colorectal ca = through muscularis propria
(defined as T_)

Back 42

Stage 2 colorectal ca:
-T3: into serosa or through muscularis propria if no serosa present
-T4: through serosa into free peritoneal cavity or adjacent organs/structures
-N0, M0

Front 43

Stage _ colorectal ca = N1
Tx is _

Back 43

Stage 3 colorectal ca = N1 = 1-3 nodes (+)
(N2 = 4 nodes (+), N3 = central nodes (+))

Front 44

Stage _ colorectal ca = M1
-Tx is _

Back 44

Stage 4 colorectal ca = M1 = distant mets
-Tx: 5FU + Leukovorin
-If rectal, add XRT +/- surgery

Front 45

Tx for colon ca that is N1

Back 45

Stage 3 colon ca = N1:
-Surgery, then post-op chemo (5-FU, leukovorin), no XRT (unlike rectal ca)

Front 46

Tx for colon ca that is M1

Back 46

Stage 4 colon ca = M1:
-5FU + Leukovorin
-Resect primary + hepatic mets only

Front 47

2 main malignancies ass'd c/ Cowden's dz

Back 47

Cowden’s Disease = hereditary hamartomatous polyposis syndrome.
-Hamartomatous polyps of the colon and stomach. Mucocutaneous lesions, thyroid adenomas and goiter, fibroadenomas and fibrocystic disease of the breast, uterine leiomyomas, and macrocephaly.
10% risk of thyroid cancer. up to 50% risk of breast adenocarcinoma in affected women.
-Hamartomatous polyps are not premalignant. no increased risk of colon cancer in these patients. No increased risk of pancreatic, lung, or small bowel cancers

Front 48

Following a 23 year history of Crohn’s disease, a 54 year old male patient presents with a history of abdominal pain, vomiting and weight loss. Upper GI study reveals a 4 cm stricture within his duodenum. What is best surgical treatment option?

Back 48

Gastrojejunostomy is a more durable repair than stricturoplasty which has a high likelihood of recurrence. Jejunal stricture maybe treated with stricturoplasty.

Front 49

If performing appendectomy and Crohns is found instead, what do you do?

Back 49

If performing appendectomy and Crohns is found instead, continue with appy unless cecum involved in inflammation
-does not increase fistula rate

Front 50

tx for perianal abscess in Crohn's is _

Back 50

tx for perianal abscess in Crohn's =
I+D just like any other abscess

Front 51

DCC (deleted in colon cancer) gene is present in _% of colon cancer

Back 51

DCC (deleted in colon cancer) gene is present in 70% of colon cancer

Front 52

The incidence of diverticulitis is about _% to _% in patients with colonic diverticula.

Back 52

Diverticulitis:
- 10-25% of pts c/ colonic diverticula get diverticulitis
-LLq pain, fever, leukocytosis.
- 2/2 infection, inflamm of colonic wall + surrounidng tissue
-Tx if uncomplicated: Flagyl + Bactrim, bowel rest x 3-4 days
-Get CT if worried about complication. F/u barium enema to r/o cancer.
-25% get complications: abscess most common (obstructive sx, fluctuant mass, peritoneal signs, temp>39, WBC>20). Percutaneously drain abcess
-Indications for surgery: recurrent dz (2nd attack has 50% recurrence rate), obstruction, perforation, abscess not amenable to drainage, can't r/o cancer
-Some argue that any patient c/ complicated diverticultis or young age should get sigmoid colectomy
-R hemicolectomy for R diverticulitis. 80% discovered on planned appendectomy

Front 53

30M presents c/ recurrent UTIs, thickened sigmoid colon, diverticula
-Suspect _

Back 53

Diverticula: in 35% of people, 80% over age 85
-Intraluminal pressure (e.g. straining) -> herniation of mucosa through colon wall @ sites where arteries enter muscular wall
-See thickening of circular muscle adjacent to diverticulum, with luminal narrowing
-Elevated elastin levels often @ colon wall sites containing diverticula.
-80% of diverticula on L (sigmoid)
-Bleeds more likely c/ R diverticula: 50% of bleeds are on R
-DiverticulITIS more likely on L. Can cause COLO-VESICAL FISTULA

Front 54

55M presents c/ an episode of bleeding 2/2 sigmoid diverticulosis confirmed by colonoscopy, resolves c/ conservative mgmt.
Bleeding recurs in 2 wks.
-Tx = _

Back 54

Diverticulosis = #1 cause of LGI bleed. Usually significant bleeding.
-75% self-limited. 25% recur
-2/2 disrupted vasa rectum -> arterial bleeding.
-Dx: colonoscopy + coagulation (or angio + vasoporessin or highly selective coil embolization if large bleed) - can be therapeutic, will localize bleed
-OR if unstable for subtotal colectomy
-Tagged RBC scan for intermittent bleed that is hard to localize. NG tube to r/o UGI source
-If recurrent bleed, resect the area if it can be localized or subtotal colectomy if not able to localize

Front 55

diverticular bleeds come from what vessels?

Back 55

Diverticulosis = #1 cause of LGI bleed. Usually significant bleeding.
-75% self-limited. 25% recur
-2/2 disrupted vasa rectum -> arterial bleeding.
-Dx: colonoscopy + coagulation (or angio + vasoporessin or highly selective coil embolization if large bleed) - can be therapeutic, will localize bleed
-OR if unstable for subtotal colectomy
-Tagged RBC scan for intermittent bleed that is hard to localize. NG tube to r/o UGI source
-If recurrent bleed, resect the area if it can be localized or subtotal colectomy if not able to localize

Front 56

External anal sphincter is innervated by __ branch and __ branch of the perineal branch.
S_ branch

Back 56

External anal sphincter is innervated by inferior rectal branch of internal pudendal nerve and perineal branch. S4

Front 57

A 30-year-old woman is admitted with obstructive symptoms and bleeding per rectum. She is found to have a 6x8 cm mesenteric mass on initial CT. She undergoes colonoscopy, and is found to have hundreds of small polyps throughout her colon. Upon further questioning, patient thinks she may indeed have a strong family history of colon cancer.
-What kind of a tumor is that?
-What is the tx for that tumor type?

Back 57

FAP with a desmoid tumor.
-mutation in the APC gene on xsome 5q.
-75% will have a family history of the disease.
-Develop 100s-1000s of polyps after puberty. ~100% cancer risk by age 50.
-1st deg relatives should be screened by flex sig starting at age 10-15yrs; EGD from age 25 due to risk for adenomas anywhere in the GI tract.

Operative options include: 1. total proctocolectomy + end ileostomy, 2. total abdominal colectomy + ileorectal anastomosis, 3. proctocolectomy + ileal pouch-anal anastomosis.
-Continued lifetime surveillence if rectum left behind.
-Desmoid tumors are responsive to tamoxifen, COX-2 inhibitors (sundilac, celecoxib), NSAIDS.

Front 58

FAP:
-__ gene
-inheritence
-Tx is __
-Don't forget to check for _
-medication _ makes polyps recede

Back 58

FAP = autosomal dominant
-2/2 mutation in APC mismatch repair gene => colon ca by age 40
-Many small polyps on LEFT colon
Therapy is total abdominal colectomy c/ mucosal procectomy + ileoanal pullthrough
-Also have upper GI polyps => survey duodenum for cancer
-Also develop desmoids - benign but difficult to manage
-Sundilac makes polyps recede

Front 59

_ = autosomal dominant dz
-2/2 mutation in mismatch repair gene _
-Many small polyps on LEFT colon
Therapy is _

Back 59

FAP = autosomal dominant
-2/2 mutation in APC mismatch repair gene => colon ca by age 40
-Many small polyps on LEFT colon
Therapy is total abdominal colectomy c/ mucosal procectomy + ileoanal pullthrough
-Also have upper GI polyps => survey duodenum for cancer
-Also develop desmoids - benign but difficult to manage - treat c/ doxorubicin, other chemo
-Sundilac makes polyps recede

Front 60

what is the treatment for FAP?

Back 60

FAP = autosomal dominant
-2/2 mutation in APC mismatch repair gene => colon ca by age 40
-Many small polyps on LEFT colon
Tx: TOTAL AB COLECTOMY + MUSCOSAL PROCTECTOMY + POUCH
-Also have upper GI polyps => survey duodenum for cancer
-Also develop desmoids - benign but difficult to manage
-Sundilac makes polyps recede

Front 61

Following total proctocolectomy for FAP, leading cause of death = _

Back 61

FAP = autosomal dominant (but 20% spontaneous)
-Mutation in APC gene (TUMOR SUPRESSOR) on xsome 5-> many small polyps on L colon by puberty -> cancer by age 40
-Flex sig for surveillance (not colonscopy)
-Tx by age 20: proctocolectomy, rectal mucosecotmy + ileoanal pouch (or total proctocolectomy + end ileostomy)
-Need surveillance of residual rectal muscosa, EGD q2 yrs for DUODENAL POLYPS
-#1 cause of death after proctocolectomy = PERIAMPULLARY DUODENAL TUMORS

Front 62

FAP is an autosomal dominant inherited disease that carries a 100% lifetime risk of colon cancer for affected individuals. What other cancer are these patients at risk for?

Back 62

Familial Adenomatous Polyposis (FAP) is an autosomally dominant inherited disease that results in a 100% lifetime risk of colorectal cancer due to a germline mutation in the APC gene located on chromosome 5. These patients are at increased risk for peri-ampullary cancers and it is recommended that they undergo routine surveillance upper-endosocopy starting when colon polyps initially appear.

Front 63

FAP:
-inheritence is __
-what type of gene is mutated?
-most tumors are R or L sided?

Back 63

FAP is Autosomal Dominant. The gene involved is the APC gene, which is a tumor suppressor gene. In HNPCC, the gene mutated is a DNA mismatch repair gene, hMLH1 or hMSH2. In FAP, most tumors are LEFT sided, whereas in HNPCC, most tumors are RIGHT sided. FAP has 100% penetrance by age 35. Even after removing the entire colon and rectum, FAP patients have a higher rate of desmoid tumors, periampullary tumors, hepatobiliary tumors and others, which reduce life expectancy versus the unaffected population

Front 64

Fissure in ano:
-_% are anterior in women
rest are located __

Back 64

Fissure in ano:
-10% are anterior in women; rest are posterior-midline
-if fissure not midline, consider IBD, TB, syphilis
-Tx: sitz baths, regular loose BM (water, fiber)
-if persists, then lateral internal sphincterotomy
-may try nitroglycerine creams (increased O2 relieves ischemia) or Botox to relax sphincter

Front 65

Fissure in ano;
treatment is ...

Back 65

Fissure in ano:
-10% are anterior in women; rest are posterior-midline
-if fissure not midline, consider IBD, TB, syphilis
-Tx: sitz baths, regular loose BM (water, fiber)
-if persists, then lateral internal sphincterotomy
-may try nitroglycerine creams (increased O2 relieves ischemia) or Botox to relax sphincter

Front 66

botox is effective in healing _% of anal fissures

Back 66

"For Fistula in Ano, Goodsall's rule states that anterior fistulas connect with rectum in a straight line, while posterior fistulas curve towards a midline internal opening in the rectum. ANAL FISSURES are linear tears in the anal mucosa. The symptoms usually include pain and bleeding. Nearly all cases occur in the posterior midline. When the rare case of anterior fissure occurs, it is prudent to looks for IBD or HIV. While the lateral internal sphincterotomy IS the surgical treatment of choice, it is unnecessary unless medical treatment is ineffective after six weeks of treatment, usually with botulinum toxin (or nitroglycerin). Botulinim toxin has been shown to be effective in healing of anal fissures in 95% of patients.

Front 67

what is Gardner's syndrome?

Back 67

Gardner's syndrome =
colon cancer (APC tumor supressor mutation like FAP) + desmoid tumors/osteomas

Front 68

A sigmoid adenocarcinoma is resected as part of a low anterior resection. The pathology report states that there is tumor invading the muscularis propria but no lymph node involvement.
What stage is it?
-5-yr survival = _-_%

Back 68

Stage I colon cancer (T2N0M0) and has a 5-year survival greater than 80 or 90%
Dukes A. Does not require adjuvant chemotherapy
2-3 cm longitudinal margins are adequate, as long as the entire mesorectal tissue radially is resected.
A resectable liver lesion is associated with a 25% 5-year survival

Front 69

48 year old female presents with a history of anemia. On CT she is found to have numerous liver masses suggestive of metastatic disease and has adeno carcinoma of the cecum on colonoscopy. The best treatment for her is:

Back 69

Right hemicolectomy, primary anastamosis and liver biopsy
Since the patient presents with anemia, she will require removal of the cause of anemia (the colon cancer) and reestablish GI continuity (primary anastamosis). If she has a solitary liver met that was amenable to wedge resection, then this would be an option. However, this patient requires control of the anemia, without a curative procedure.

Front 70

A 49 yo female underwent a left hemicolectomy for carcinoma 18 months ago, and is now found to have a 2cm mass at edge of right lobe. The most appropriate management is:

Back 70

Wedge resection of the mass. do NOT have to do an anatomic resection of the mass. A wedge resection will prolong the patients survival and there is no benefit to a formal anatomic resection.

Front 71

_ = autosomal dominant dz
-2/2 DNA mismatch repair mutations in genes hMSH2, hMLH1, hPMS1, hPMS2
Diagnostic criteria are known as…

Back 71

HNPCC aka Lynch Syndrome
= autosomal dominant dz
-2/2 DNA mismatch repair mutations in genes hMSH2, hMLH1, hPMS1, hPMS3
Amsterdam 1 criteria = 3 relatives c/ colon ca, inc. 2 generations, 1 before age 50, can't have FAP
Amsterdam 2 criteria include ca of sm bowel, stomach, ovary, pancreas, biliary tree, skin, larynx

Front 72

HNPCC:
-Cancer usually presents @ location _
-Appropriate therapy is _

Back 72

HNPCC:
-Colon cancer usually on RIGHT (70% proximal to splenic flexure)
HNPCC2 can have multiple synchronous cancers
-Total colectomy

Front 73

What are the Amterdam criteria for HNPCC?

Back 73

Hereditary non-polyposis colon cancer syndrome = Lynch syndrome:
-5% of population, autosomal D
-DNA mismatch repair gene mutation -> RIGHT-sided colon ca, multiple primaries
-Lynch 1 => colon ca only
-Lynch 2 => colon, ovarian, endometrial, bladder, stomach
-Amsterdam criteria: 3 first-deg relatives, over 2 generations, 1 with cancer <50 y/o
-Colonscopy starting @ 25, or 10 yrs before 1st relative got cancer
-50% have metachronous lesions w/in 10 yrs
-Women: annual pelvic exams, endometrial bx q3 yrs, early mammograms. consider TAH + BSO after childbearing
-Consider subtotal colectomy for 1st cancer operation

Front 74

what is the difference b/w Lynch I and Lynch II?

Back 74

Lynch I = RIGHT sided, multiple cancers
Lynch II = also ass'd c/ ca of ovary, bladder, stomach
-Both a/w DNA mismatch repair gene mutations
-Amsterdam criteria: 3 1st deg relatives over 2 generations, 1 before age 50

Front 75

A 45 year old patient is referred to your colorectal clinic following recent diagnosis of her father and grandmother with colorectal cancer. A hereditary link is suspected and she asks you a question about Lynch Syndrome. She is particularly worried about Ovarian Cancer. Lynch 1 syndrome is associated with

Back 75

Hereditary nonpolyposis colon cancer (HNPCC or Lynch's syndrome)
-1-3% but more common than FAP
-Mismatch repair defect (MSH1/2, PMS2), autosomal dominant
-70% get colorectal carcinoma, ave age 40-45
-Suspect if RIGHT sided (rare in sporadic colon ca).
-40% risk of synchronous/metachronous colorectal carcinoma
-Lynch 2 ass'd c/ ENDOMETRIAL, ovarian, stomach, bladder > pancreas, sm bowel, biliary
-Amsterdam criteria: 3 1st deg relatives c/ colon adenoca, 2 generations, 1 dx before 50 y/o

Front 76

35F presents c/ cecal cancer
-Likely to have familial syndrome _
-Other major cancer risk is located ...

Back 76

Hereditary nonpolyposis colon cancer (HNPCC or Lynch's syndrome)
-1-3% but more common than FAP
-Mismatch repair defect (MSH1/2, PMS2), autosomal dominant
-70% get colorectal carcinoma, ave age 40-45
-Suspect if RIGHT sided (rare in sporadic colon ca).
-40% risk of synchronous/metachronous colorectal carcinoma
-Lynch 2 ass'd c/ ENDOMETRIAL, ovarian, stomach, bladder > pancreas, sm bowel, biliary
-Amsterdam criteria: 3 1st deg relatives c/ colon adenoca, 2 generations, 1 dx before 50 y/o

Front 77

Pt c/ hx FAP returns to clinic 8 weeks after elective proctocolectomy + J pouch + loop ileostomy
-Must do _ before ileostomy takedown

Back 77

do BARIUM ENEMA before takeown of loop ileostomy to r/o stricture @ ileo-anal anastomosis

Front 78

In average male patient, most distal extent of a rectal cancer to still allow LAR =
_ cm from anal verge

Back 78

Low anterior resection:
-Cancer must be at least 6 cm from anal verge
(dentate line is ~2 cm from anal verge; levator ani muscles are ~2 cm from dentate line)
-Need 2 cm rectal cuff to resect c/ end-to-end stapler
-Easier to perform LAR in women b/c wider pelvic bones

Front 79

10 days after LAR, pt develops leukocytosis, mild abdominal tenderness.
CT shows 8x8 cm fluid collection near anastomosis
-Next step = _

Back 79

Anastomotic leak >7 days after APR c/ abscess formation =>
percutaneous drain if pt not clinically septic
-Bad time to operate since adhesions are starting, but not yet mature

Front 80

5 days after LAR, pt deveops large amount of feculent brown drainage from abdominal wound
-Next step = _

Back 80

Anastomotic leak <7 days after APR =>
Re-explore, take down anastomosis, place colostomy + Hartmann's
(high level of contamination)
-If leak were small, could consider primary repair of leak + diverting ileostomy

Front 81

6 hrs after LAR, pt develops fever + gray stinky drainage from wound
-Next step = _

Back 81

High fever + gray stinky drainage in early post-op period is concerning for Clostridium perfringens (gram positive rods) =>
re-explore, debride if possible
-High risk of myonecrosis, fasciitis

Front 82

10 days after LAR, pt develops clear yellow drainage from wound
-Fluid has Cr of 40
-CT abdomen shows pelvic fluid collection
-Next step = _

Back 82

Ureteral injury diagnosed >8 days after LAR =>
Percutaneous drain, then repair ureteral injury in 6-8 weeks
(if injury recongized in <7 days, might be able to repair)

Front 83

A week after low anterior resection the patient develops fever, tachycardia and severe abdominal pain. The best treatment is:

Back 83

LOOP COLOSTOMY
The point is to divert the fecal stream as easily as possible.
-Hartmann’s procedure would require a re-exploration and would make the takedown more challenging.
-Loop ileostomy might be a reasonable option, however because of it’s high output it is less convenient for the patient.
-IR drainage is not aggressive enough considering that the patient is having severe abdominal pain.

Front 84

Pt c/ hx diverticulosis presents c/ 2nd episode of lower GI bleed.
Tx is _

Back 84

Pt c/ hx diverticulosis presents c/ 2nd episode of lower GI bleed.
Tx: sigmoidectomy

Front 85

What is #2 site of colon ca mets?
-arrive via __ vein
-after resection of isolated mets, _% 5-yr survival

Back 85

Lung = #2 location for colon ca mets
-via ILIAC vein
-20% 5-yr survival if isolated lung mets resected (in selected patients)

Front 86

A 23-year-old woman with ulcerative colitis is hospitalized for severe diarrhea. She has no oral intake and receives only intravenous fluids. Over a 48-hour period, she develops muscle fasciculations and appears depressed. The most likely cause is a low serum concentration of

Back 86

magnesium

Front 87

A 70 year old male undergoes an appendectomy for a non perforated appendicitis. A wide based Meckles diverticulum is found. Should the Meckles be removed?

Back 87

The indications for removing an ASYMPTOMIC Meckles are if its base is narrow compared to its total length, and if it is thick, which might be suggestive of ectopic tissue. In this patient of advanced age, the risk of a complication is greater than any potential benefit.

Front 88

Pt is POD5 s/p open cholecystectomy, develops abdominal distension and pain
-Ab x-ray shows colon dilated to 12cm @ cecum
-Tx is _

Back 88

Ogilve's syndrome:
-Pseudo-obstruction of colon
-RFs: opiates, bedridden, old + recent surgery, infections, trauma
-Massive colon dilation
-Check electrolytes (K, Mg), d/c drugs that slow the gut
-Tx: colonoscopy + decompression, neostigmine (parasympatomimetic. cholinesterase inhibitor), +/- rectal tube -> cecostomy if that fails

Front 89

p53 is absent in _% of colon cancer

Back 89

p53 is absent in 85% of colon cancer

Front 90

what is therapy for perianal paget's dz?

Back 90

Paget's disease is intraepidermal adenocarcinoma and can be adequately treated with WLE.

Front 91

Perianal Paget's disease:
-rare intraepidermal neoplasm of _ type glands
-short or long pre-invasive phase?
-(+) or (-) PSA stain?

Back 91

Perianal Paget's disease:
-rare intraepidermal neoplasm of apocrine glands
-long pre-invasive phase
-(+) PSA stain

Front 92

What is Peutz Jeghers?

Back 92

Peutz Jeghers = hamartoma polyposis (not colon ca) + mucocutaneous pigmentation esp. oral
-Autosomal D
-2% risk of duodenal/colon ADENOcarcinoma (also est. 15x risk) =>
-endoscopic removal of polyps; no prophylactic colectomy
-also ass'd c/ SEX CORD tumors in women, SERTOLI cell tumors in men, breast ca, biliary ca
-2/2 serine/threonine kinase mutation.

Front 93

What is tx for colon polyps 2/2 Peutz Jeghers?

Back 93

Peutz Jeghers = hamartoma polyposis (not colon ca) + mucocutaneous pigmentation esp. oral
-Autosomal D
-2% risk of duodenal/colon ADENOcarcinoma (also est. 15x risk) =>
-endoscopic removal of polyps; no prophylactic colectomy
-also ass'd c/ SEX CORD tumors in women (granulosa cell), SERTOLI cell tumors in men (testosterone producing), breast ca, biliary ca
-2/2 serine/threonine kinase mutation.

Front 94

What is the treatment for pouchitis?

Back 94

Pouchitis: treat c/ Flagyl or short-chain fatty acid enemas

Front 95

"

Back 95

Primary sclerosing cholangitis (PSC)
-Temporary therapies: ERCP, choledochojejunostomy, PTC
-Nearly all patients progress to cirrhosis and eventual liver failure even with treatment
-Liver transplant= best treatment for long-term cure

Front 96

Pyoderma gangrenosum: Tx is _

Back 96

Pyoderma gangrenosum: tx = Dapson and/or topical or systemic steroids
Thought to be 2/2 defective neutrophil function

First-line therapy for disseminated or localized instances of pyoderma gangrenosum is systemic treatment by corticosteroids and cyclosporine. If ineffective, alternative therapeutic procedures include systemic treatment with corticosteroids and mycophenolate mofetil; mycophenolate mofetil and cyclosporine; tacrolimus; thalidomide; infliximab; or plasmapheresis

Front 97

Pt undergoes LAR then chemo-XRT
6 weeks after chemo, he c/o severe proctitis, rectal bleeding requiring transfusion
-Best therapy is _

Back 97

Radiation proctitis:
-Vasculitis, thrombosis, ulcers, strctures
-If severe bleeding, treat c/ formalin fixation of rectum

(XRT indicated for rectal ca if T3 or N1 = stage 2. decreases local recurrence, improves survival)

Front 98

_% of colon cancer has the ras mutation

Back 98

50% of colon cancer has the ras mutation

Front 99

Rectal ca can metastasize directly to _ via Batson's plexus

Back 99

Colorectal ca mets:
#1: Portal vein -> Liver, 25% 5-yr survival if resectable c/ adequate liver fx
#2: Iliac vein -> Lung, 20% 5-yr survival
-Resect isolated liver, lung mets
-5% get drop mets to ovaries
-Recal ca metastasized directly to spine via veins of BATSON'S PLEXUS
-Colon ca rarely goes to bone

Front 100

treatment for rectal cancer c/ pain

Back 100

rectal ca c/ pain => APR

Front 101

P thas T3N1M0 rectal ca ->
undergoes preop chemo-XRT
-Restaging (biopsies of rectum and previous node), and no residual tumor found
-Next step = _

Back 101

P thas T3N1M0 rectal ca ->
undergoes preop chemo-XRT
-Restaging (biopsies of rectum and previous node), and no residual tumor found
-PROCEED C/ LAR (OR APR) AS PLANNED => 15-20% have cancer on final path

Front 102

Rectal ca:
-Transanal excision if ...
-Chemo-XRT if ...

Back 102

-T1 (limited to submucosa) rectal adenoca can be excised transanally
-Stage 2 or 3 => chemo-XRT

Front 103

50 yo male is diagnosed with rectal carcinoma that was determined to be 6cm from the dentate line. A Low Anterior Resection (LAR) was planned for this patients. What is the distance required from anal verge for this operation and what would be margin of resection?

Back 103

8 cm from anal verge and 2 cm margin.
Rectal cancers 8-12cm (middle third) from anal verge (6-10cm from dentate line), as in this case, can be managed by LAR. A 2cm margin of resection from the tumor should be sufficient

Front 104

Compared with postoperative chemotherapy and radiation therapy, preoperative chemotherapy and radiation therapy for treatment of rectal cancer may be associated with lower rates of

Back 104

lower rates of APR

Front 105

A 58-year-old man undergoes low anterior resection of a rectal adenocarcinoma 5 cm from the anal verge. Pathologic examination shows the well-differentiated tumor invades but does not penetrate the muscularis propria and that four of 15 lymph nodes contain metastatic tumor. There are no liver metastases. The most appropriate postoperative management is

Back 105

Stage 3 rectal ca => resect (if possible) then radiation therapy to the pelvis and chemotherapy (5-fluorouracil and levamisole)
-Chemo (5-FU, levamisole) for stage 2 rectal ca = T3-4N0
-XRT for stage 3 rectal ca = T3 and/or N1

Front 106

How is rectal adenocarcinoma staged?
-what modality is most sensitive for T and M?
-what modality is used for radial tumor eval (local invasion)?

Back 106

Rectal adenoca staging by EUS, CT
-EUS most sensitive for T, N
-CT for radial tumor eval (local invasion), distant mets

Front 107

Preop chemo/XRT is indicated for rectal adenocarcinoma if... 2 things

Back 107

pre-op chemo/XRT for rectal adenoca if T3/4 (through muscularis propria) or N+
(T1/2 managed by surgery primarily; need 2 cm distal margin)

Front 108

Stage _ rectal ca = M1
-Tx is _

Back 108

Stage 4 rectal ca = M1
-Tx: chemo-XRT +/- surgery (usually just colosotmy)

Front 109

Stage _ rectal ca = through muscularis propria
-Tx is _

Back 109

Stage 2 rectal ca:
-T3: into serosa or through muscularis propria if no serosa present
-T4: through serosa into free peritoneal cavity or adjacent organs/structures
-N0, M0
-Tx: Preop or postop chemo-XRT (same for stage 3 rectal ca)

Front 110

Tx for low rectal cancer invading into muscularis propria

Back 110

Rectal ca:
-T2 (or higher) = into muscularis propria
-Tx: APR or LAR

Front 111

Tx for rectal cancer invading into serosa or past muscularis propria or N1

Back 111

Rectal ca:
-if T3 or N1, need LAR/APR and post-op XRT
-Can do XRT pre-op to allow LAR instead of APR

Front 112

Stage 2 or 3 rectal ca.
Tx is_

Back 112

Stage 2 or 3 rectal ca => chemo + XRT

Front 113

XRT is indicated in rectal cancer if T_ or N_

Back 113

XRT for rectal ca:
-T3 (into serosa or through muscularis propria) - i.e. Stage 2
-N1 (1-3 nodes positive) - i.e. Stage 3
-Decreases local reccurence, increases suvival when combined c/ chemo
-Ses: rectal vasculitis, thrombosis, ulcers, strictures
-Pre-op chemo-XRT may shrink tumor -> downstage, possibly allow LAR (vs. APR)

Front 114

Pt returns to clinic 6 mo s/p LAR for low rectal ca, c/o constipation
-Found to have mass @ suture line.
Metatstatic w/up negative (CT A/P, CXR, LFTs, CEA)
-Next step = _

Back 114

Rectal ca local recurrence after LAR:
-Do APR unless pt also has mets that preclude surgery

Front 115

Rectal ca:
-T1 = limited to __. Tx = _
T2: __% are node (+)
No transanal excision if __

Back 115

Rectal ca:
T1 (limited to submucosa) => can be excised transanally
T2: 20% of node (+), rec APR
NO transanal if poorly diff, neuro/vasc invasion

Front 116

main source of nutrition for colonocytes = _

Back 116

main source of nutrition for colonocytes = short chain fatty acids, e.g. butyrate

Front 117

Elderly pt presents c/ abdominal pain, distension.
Ab x-ray shows distended colon, "ace of spades" shape pointing to LLQ. No peritoneal signs
-Suspect _
-Tx is _ -> _% resolve, but _% of those recur

Back 117

Sigmoid volvulus:
-More common c/ high-fiber diets (Iran, Iraq)
-Debilitated psych pts, neurologic dysfx, laxative abuse
-Closed loop obstruction -> pain, distension, obstipation Ab x-ray: bent inner tube sign
-Gastrograffin enema: bird's beak sign = tapered colon
-No peritoneal signs => colonscopy for decompression (80% reduce, 50% will recur), give bowel prep and perform sigmoid colectomy during same admission
-Peritoneal signs, gangrenous bowel => to OR for sigmoidectomy OR detorse + return for resection in 2 days

Front 118

Sigmoid volvulus:
Tx is _

Back 118

Sigmoid volvulus:
-More common c/ high-fiber diets (Iran, Iraq)
-Debilitated psych pts, neurologic dysfx, laxative abuse
-Closed loop obstruction -> pain, distension, obstipation Ab x-ray: bent inner tube sign
-Gastrograffin enema: bird's beak sign = tapered colon
-No peritoneal signs => colonscopy for decompression (80% reduce, 50% will recur), give bowel prep and perform sigmoid colectomy during same admission
-Peritoneal signs, gangrenous bowel => to OR for sigmoidectomy

Front 119

superior rectal artery = off _ artery
middle rectal artery = off __
-inferior rectal artery = off __ (which is off __)

Back 119

superior rectal artery = off IMA
middle rectal artery = off internal iliac
-inferior rectal artery = off pudendal (off internal iliac)

Front 120

Tagged RBC scan:
requires bleed of _ cc/min

Back 120

Tagged RBC scan:
requires bleed of 0.1 cc/min
-good for localizing intermittent slow bleed

Front 121

Criteria for transanal excision of polyp:
-no greater than T_
-<_% circumferential of rectum
-W/in _ to _ cm of anal verge
-If invasive, no lymphovascular invasion, not poorly differentiated (i.e. low risk of LN mets)

Back 121

Criteria for transanal excision of polyp:
-no greater than T1
-<40% circumferential of rectum
-W/in 8-10 cm of anal verge
-If invasive, no lymphovascular invasion, not poorly differentiated (i.e. low risk of LN mets)

Front 122

What is Turcot's syndrome?

Back 122

Turcot's syndrome:
colon cancer (2/2 APC tumor supressor mutation like FAP) + brain tumors

Front 123

UC: what is the effect of proctocolectomy on extra-colonic manifestations?

Back 123

Proctocolectomy for UC:
-improves pyoderma gangrenosum, erythema nodosum, arthritis, ocular problems
-Does not help with sclerosing cholangitis, ankylosing spondylitis.
-HLA B27 ass'd c/ sacroileitis

Front 124

A patient with known ulcerative colitis is admitted with a fever, leukocytosis, tachycardia, and abdominal pain with distention. On exam she demonstrates signs of peritonitis. An abdominal XR shows dilated colon throughout. What is next best treatment for this patient?

Back 124

The best procedure in this non-elective case is a staged procedure with total abdominal colectomy and end ileostomy done initially. Eventually the patient can be brought back for completion proctectomy and ilial pouch-anal anastomsis (IPAA).

Front 125

#1 location for bowel perforation in UC

Back 125

transverse colon = #1 place for perforation in UC
(distal ileum most common in Crohns)

Front 126

60 year old male 5 days after hemicolectomy with extensive lysis of adhesions develops left flank pain and a palpable mass. On physical exam the patient has decreased breath sounds and severe pain. The WBC=13,000. CT scan shows fluid in the left retroperitoneum. The next step should be:

Back 126

Placement of a percutaneous nephrostomy tube
This is a post-op uroma. The key concept is to allow the patient to heal while you drain the urine as simply as possible and then worry about connecting the ureter later with the help of a urologist.

Front 127

Patient has large, symptomatic, sessile colon polyp removed.
-Path: fingerlike projections of epithelium over lamina propria
-Most likely it is _ type of polyp
-This polyp type has _% rate of cancer inside

Back 127

Villous adenoma:
-only 10% of polyps, but most likely to produce sx
-50% (+) FOR CANCER
-usually sessile, larger than tubular adenomas
-Path: fingerlike projections of epithelium over lamina propria

Front 128

GI tract = 2nd most radiosensitive organ (_ = #1)
-Damage @ 3000 rads

Back 128

GI tract = 2nd most radiosensitive organ (kidney = #1)
-Damage @ 3000 rads

Front 129

what is the treatment for anal sq cell ca?

Back 129

Chemotherapy and radiation is the primary treatment for anal CANAL SCC but wide local excision is the main treatment for anal MARGIN SCC.

Front 130

_ = intraepidermal SCC.
Can be adequately treated with WLE in most cases

Back 130

Bowen's disease is intraepidermal SCC and can be adequately treated with WLE in most cases.

Front 131

treatment for rectal cancer c/ pain

Back 131

rectal ca c/ pain => APR