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125 Cards in this Set
- Front
- Back
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colorectal tumor types
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adenocarcinomas
rarely: -- carcinoids -- lymphomas -- Kaposi's |
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pts with + FOBT need
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colonoscopy
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how many colorectal cancer pts have distant metastases at presentation
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20%
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risk factors for colorectal cancer
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age > 50 yrs
adenomatous polyps, esp: --villous -- ^ size -- ^ number personal history of CRC or polyps IBD family hx --multiple relatives c CRC --1st deg. relative dx < 60 polyposis syndromes |
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one polyposis syndrome is dominant, another is recessive
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dominant
familial adenomatous polyposis |
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FAP affects what anatomy
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colon always
duodenum in 90% |
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FAP genetics
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dominant
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FAP risk and timing of CRC
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100% by 3rd or 4th decade
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Gardner's syndrome
full description |
polyps --> 100% CRC by age 40
osteomas dental benign soft tissue tumors desmoid tumors sebaceous cysts |
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turcot's
full description of pathophysiological effects |
polyps
cerebellar medulloblastoma glioblastoma multiforme |
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turcot's genetics
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recessive
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peutz jeghers
manifestations |
single or multiple hamartomas @
small bowel colon stomach pigmented spots @ lips, face, genitals, palms |
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peutz jeghers CRC risk
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hamartomas have very low malignant potential
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acute complications of peutz-jeghers
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intussusception
GI bleeding |
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hereditary nonpolyposis CRC includes...
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lynch syndrome I
lynch syndrome II |
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lynch syndrome I
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early onset CRC
absence of polyposis |
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lynch syndrome II --> CRC, yes, but what other associated cancers
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female genital
breast stomach pancreas biliary tract skin brain |
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most common presenting symptom of CRC
cause? |
abdominal pain
2^ obstruction peritoneal dissemination |
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CRC is the most common cause of
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large bowel obstruction in adults
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_ is the most common cause of large bowel obstruction in adults
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CRC
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the most life-threatening complication of CRC
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perforation --> peritonitis
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sxs
right side CRC vs left side CRC |
right:
melena iron deficiency anemia weakness left CRC obstruction change in bowel habits: --alternating constipation/diarrhea --pencil stools hematochezia |
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why is obstruction unusual in r sided crc
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larger luminal diameter
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right CRC manifestations
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melena
iron deficiency anemia weakness |
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left CRC manifestations
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obstruction
change in bowel habits: --alternating constipation/diarrhea --pencil stools hematochezia |
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rectal cancer's most common symptom
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hematochezia
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rectal cancer sxs
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hematochezia
tenesmus rectal mass, feeling of incomplete evacuation of stool |
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radiation therapy in which CRCs....
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Radiation is used in Rectal ca
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most polyps are found in ___ region
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rectosigmoid
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most pts with polyps have what sxs most commonly?
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most are asymptomatic
rectal bleeding is most common symptom |
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___ lab test in CRC should be obtained before surgery
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CEA level
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follow-up after CRC surgery
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stool guaiac
annual CT abd/pelvis and CXR x 5 yrs colonoscopy @ 1 yr then every 3 yrs CEA levels q 3-6 mo |
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90% of recurrences of CRC occur
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within 3 yrs of surgery
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very high levels of CEA suggest
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liver involvement
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non-neoplastic polyps include
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hyperplastic
juvenile inflammatory (pseudopolyps) of UC |
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histology and shape of polyps with higher malignant potential
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atypia
sessile (flat) |
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diverticulosis happens how
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inner layer of colon bulges through
focal area of weakness usu @ blood vessel penetration |
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risk factors for diverticulosis
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low-fiber diet
family hx age |
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most common location of diverticuli
possible locations |
sigmoid
may occur anywhere |
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complications of diverticulosis
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painless rectal bleeding
diverticulitis |
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complications of diverticulitis
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obstruction
abscess fistulas perforation --> peritonitis |
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complications of diverticulosis vs. diverticulitis
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painless rectal bleeding
diverticulitis obstruction abscess fistulas perforation --> peritonitis |
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diverticulosis sxs
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usu asymptomatic
vague LLQ discomfort bloating constipation/diarrhea |
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diverticulosis test of choice
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barium enema
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treatment for painless rectal bleeding of diverticulosis
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usually clinically insignificant, stops spontaneously, no rx
- - - - - - - - - - severe in 5%. often stops spontaneously. may perform colonoscopy (sometimes mesenteric angiography) to locate site of bleeding. persistent / recurrent bleeding, surgery (segmental colectomy) |
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treatment for diverticulosis
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bran
psyllium |
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diverticulitis pathophys
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feces become impacted in the diverticulum -->
erosion and microperforation |
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lower GI bleeding in
diverticulitis vs. diverticulosis |
rare in diverticulitis
common in diverticulosis |
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diverticulitis triad sxs
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*fever
*LLQ pain *leukocytosis |
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diverticulitis misc possible sxs
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constipation / diarrhea
vomiting painful mass on rectal exam |
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colovesical fistula in diverticulitis prognosis
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50% close spontaneously
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diverticulosis test of choice
diverticulitis test of choice one of them: tests NOT to do |
diverticulosis: barium enema
diverticulitis: CT scan with oral and IV contrast barium enema and colonoscopy are contraindicated |
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disease association:
25% of pts with bleeding arteriovenous malformations of the colon have _______ |
aortic stenosis
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aortic stenosis is associated with this GI problem
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arteriovenous malformations aka angiodysplasia
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colon angiodysplasia is aka
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arteriovenous malformations
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arteriovenous malformations are aka
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angiodysplasia
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a test _____ that may be useful in diverticulitis to exclude other stuff _________
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abd x-ray
other causes of LLQ pain ileus obstruction perforation |
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perforation on abd xray
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free air
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ileus or obstruction on abd xray
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air-fluid levels
distension |
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medical treatment of diverticulitis
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if uncomplicated:
-- IV abx -- NPO -- IV fluids mild episodes rx outpt |
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surgical rx of diverticulitis may be needed in what situations?
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symptoms > 3-4 days
resection of segment for recurrent episodes complicated diverticulitis |
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angiodysplasia
the gist of its presentation |
common cause of GI bleeding
pts > 60 yrs |
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how severe is bleeding in angiodysplasia
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usu low grade
15% massive hemorrhage |
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angiodysplasia dx
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colonoscopy
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course of pts in angiodysplasia
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90% bleeding stops spontaneously
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angiodysplasia rx
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colonoscopic coagulation
if persists: right hemicolectomy |
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which is more common, acute or chronic mesenteric ischemia?
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acute
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pts with acute mesenteric ischemia often have _____
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preexisting heart disease
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acute mesenteric ischemia
embolic presentation |
sudden and painful
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acute mesenteric ischemia
arterial presentation why? |
more gradual, less severe
collaterals have developed |
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acute mesenteric ischemia
nonocclusive presentation |
critically ill pts
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acute mesenteric ischemia
venous thrombosis |
sxs for several days or weeks
with gradual worsening |
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signs of intestinal infarction
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hypotension
tachypnea lactic acidosis altered mental status shock |
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check ___ lab if acute mesenteric ischemia is suspected
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lactate level
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acute mesenteric ischemia
pathophys |
blood flow compromise, usu @ superior mesenteric
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four types of acute mesenteric ischemia in order of frequency
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arterial embolism 50%
arterial thrombosis 25% nonocclusive 20% venous thrombosis < 10% |
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acute mesenteric ischemia
embolic -- almost all emboli are from.... |
heart:
afib MI valvular dz |
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acute mesenteric ischemia
arterial thrombosis pathophys |
most of these pts have atherosclerotic dz
acute occlusion over preexisting atherosclerotic dz may be from v in CO 2^ MI, CHF, or plaque rupture |
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acute mesenteric ischemia
nonocclusive pathophys |
vasoconstriction 2^ low CO
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predisposing factors for venous thrombosis in acute mesenteric ischemia
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infection
hypercoagulability oral contraceptives portal HTN malignancy pancreatitis |
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prognosis in acute mesenteric ischemia
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60-70% mortality
if bowel infarction, can be > 90% |
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acute mesenteric ischemia
clinical presentation: very important sxs misc sxs |
*severe abd pain disproportionate to physical findings*
anorexia vomiting GI bleeding (mild) peritonitis, sepsis, shock |
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dx test of choice for acute mesenteric ischemia
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mesenteric angiography
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misc tests for acute mesenteric ischemia
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abd xray to exclude other causes of abd pain
thumbprinting on barium enema |
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acute mesenteric ischemia
rxs relevant to all causes |
IV fluids
broad-spectrum antibiotics |
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acute mesenteric ischemia
rx in arterial causes |
intra-arterial infusion of papaverine (vasodilater) into superior mesenteric during arteriography
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acute mesenteric ischemia
rx for embolic |
intra-arterial infusion of thrombolytics
or embolectomy |
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acute mesenteric ischemia
rx for venous thrombosis |
heparin
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acute mesenteric ischemia
if signs of peritonitis develop |
surgical resection
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chronic mesenteric ischemia
pathophys |
atherosclerotic occlusive dz
@ celiac superior and inferior mesenteric |
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chronic mesenteric ischemia
presentation |
dull pain
postprandial weight loss |
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chronic mesenteric ischemia
dx |
mesenteric arteriography
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chronic mesenteric ischemia
rx |
surgical revascularization
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avoid ___ drug in mesenteric ischemia b/c
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worsen the ischemia
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ogilvie's syndrome gist
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signs, symptoms, radiographic evidence of large bowel obstruction
but there's no mechanical obstruction |
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what type of pts get ogilvie's syndrome
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usually ill
hx of recent surgery or medical illness |
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common causes of ogilvie's
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recent surgery, trauma
medical illness e.g. sepsis, malignancy meds: narcotics, psychotropics, anticholinergics |
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ogilvie's
rx |
stop any offending agent (e.g. narcotics)
IV fluids electrolyte repletion decompression with: -- enemas -- nasogastric suction if that fails: colonoscopy last resort: surgical decompression |
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how do you know that you'd better decompress colon immediately
why? |
distension
diameter > 10 cm rupture --> peritonitis |
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abx often responsible for pseudomembranous colitis
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clindamycin
ampicillin cephalosporins |
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timing of onset of pseudomembranous colitis in relation to abx given that caused it
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usu in 1st wk of abx
but up to 6 wks may elapse before sxs |
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complications of pseudomembranous colitis
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toxic megacolon with risk of perforation
anasarca electrolyte disturbances |
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anasarca wikipedia definition
usual suspects |
Anasarca, or extreme generalized edema,
widespread swelling of the skin due to effusion of fluid into the extracellular space.[1] It is usually caused by liver failure (cirrhosis of the liver) or renal failure/disease and severe malnutrition/protein deficiency. The increase in salt and water retention caused by low cardiac output can also result in anasarca as a long term maladaptive response. |
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pseudomembranous colitis clinical features
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profuse watery diarrhea
crampy abd pain |
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pseudomembranous colitis
diagnosis |
toxins in stool
flexible sigmoidoscopy abd xray leukocytosis |
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a very common lab finding in pseudomembranous colitis
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leukocytosis
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role of abd xray in pseudomembranous colitis
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to r/o toxic megacolon --> perforation
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role of flexible sigmoidoscopy in pseudomembranous colitis
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flexible sigmoidoscopy
-- rapid -- diagnostic --discomfort/expense-->rarely used |
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in pseudomembranous colitis a test frequently used and its characteristics
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toxins in stool
-- 95% sensitive -- 24 hrs |
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pseudomembranous colitis rx
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discontinue abx causing it
metronidazole [oral vancomycin] cholestyramine to improve diarrhea |
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when might you use oral vancomycin in pseudomembranous colitis
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resistant to metronidazole
can't tolerate metronidazole infants pregnant women |
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volvulus may --> bad sequelae
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obstruction
vascular compromise necrosis perforation |
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volvulus
most common sites |
sigmoid colon (75%)
cecum (25%) |
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risk factors for volvulus
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chronic illness
age institutionalization CNS dz chronic constipation laxative abuse antimotility drugs prior abd surgery |
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cecal volvulus is due to _____
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congenital lack of fixation of the right colon
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___ volvulus tends to occur in younger pts
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cecal
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volvulus
clinical features |
acute onset colicky pain
obstipation abd distension [anorexia, nausea, vomiting] |
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obstipation =
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severe constipation
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volvulus
dx tests |
plain abd films
sigmoidoscopy barium enema |
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volvulus
plain abd films in sigmoid volvulus shows |
-- omega loop sign
-- bent inner-tube shape indicates dilated sigmoid colon |
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volvulus
plain abd films in cecal volvulus shows |
-- coffee bean sign indicates large air-fluid level in RLQ
-- distension of cecum and small bowel |
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preferred diagnostic and therapeutic test for sigmoid volvulus
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sigmoidoscopy
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volvulus
barium enema shows |
narrowing "bird's beak"
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volvulus
rx |
sigmoid:
decompression via sigmoidoscopy succeeds in 70% recurrence is high, so elective sigmoid resection is recommended cecum: emergent surgery |
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volvulus
do not perform _____ diagnostic test if ____ is suspected |
barium enema
strangulation |
