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Gastro > Colon Cancer & Rectal problems > Flashcards

Colon Cancer & Rectal problems Flashcards

1
Q

What is the most common colon cancer [3]

A

Adenocarcinoma
Rectum + sigmoid
Other - HNPCC / FAP

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2
Q

Types of adenomas/polyps

A

Benign
Pre malignant
Tubular (75%)
Villous (10%)

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3
Q

What characteristics of polyps suggest high risk of malignancy [4]

A

Large (>2cm)
Numerous
High risk dysplasia
Villous architecture

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4
Q

Describe multi-step carcinogenesis in CRC [6]

A 
>  Normal cell undergoes mutation of adenomatous polyposis coli (APC) gene
> Hyperproliferation > early adenomas
> k-ras mutation then DCC mutation 
> Becomes intermediate then late adenoma
> Mutation of p53 gene
> Carcinoma
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5
Q

What are the RF for colon cancer [6]

A 
Age, Male 
Smoking, Alcohol
Diet - low fibre, high red, processed meat
Previous adenoma, Neoplastic polyps 
FH, Genetics - HNPCC / FAP
IBD
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6
Q

Criteria for urgent referral [4]

A

Always:
 >40y/o w/ unexplained weight loss AND abdo pain
 >50y/o w/ rectal bleeding with no anal symptoms
 >60y/o with iron deficiency anaemia or change in bowel habit
 FOB

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7
Q

What do high risk features automatically get

A

Colonoscopy +- barium enema + biopsy

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8
Q

What do R sided (ascending) colon cancer normally present with

A

Occult bleeding > Anaemia

Weight loss
Vague pain
Weakness

Present later as lumen can get very tight before obstruction as more liquid

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9
Q

What does L sided (descending) colon cancer present with [6]

Which is more common L or R sided colon cancer?

A

Left sided colon cancer is more common

Obstruction / stricture / perforation 
Bleeding / mucous PR due to haemorrhage
Altered bowel habit 
Weight loss / lethargy 
Tenesmus - need to evacuate 
PR mass
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10
Q

What are common symptoms in bowel cancer [7]

A 
Persistent blood
Persistent change in bowel habit
Persistent lower abdominal pain
Anaemia 
Loss of appetite
Bloating 
Mass
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11
Q

What do you do if symptoms <6 weeks + <40yo

A

Watch and review

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12
Q

What other investigations for colon cancer

Bloods [4]
Imaging [2]

Staging investigations [4]

A

FBC - hypochromic microcytic anaemia
FOB/qFIT (before colonoscopy)
Urine dip - ?haematuria
To rule out: LFT, TFT, coeliac

Colonoscopy & biopsy
Virtual CT colonoscopy

Staging 
CT
MRI if below peritoneal reflection
Liver MRI / USS 
PET if single met but chance of cure
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13
Q

What are the stages of colon cancer?

[4]

A 
Dukes classification &amp; TNM combined:
T1 A- limited to muscularis mucosa (MM)
T2 B- extension through MM 
T3 C- LN
T4 D- metastatic
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14
Q

How do you treat Dukes A [3]

A

Endoscopic resection
Remove node for analysis
DVT and Abx prophylaxis

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15
Q

How do you treat more advanced cancer [4]

A

Chemotherapy
Radiotherapy - palliation mostly or for rectal ca
Surgery = only way to cure
NSAID - reduce polyps and prevent recurrence
Biologics

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16
Q

What are the complications of surgery [11]

A 
GA issue
Bleeding 
Sepsis
Nerve or vessel damage
DVT 
Wound hernia / dehiscence
Obstruction, Post op ileus - give sugar before 
Anastomatic breakdown - day 4-5
Post-op fistula, stricture
Adhesions
High output stoma = volume deplete/ electrolyte imbalance
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17
Q

What is the screening programme for bowel cancer [4]

A

50-74
FOBT / qFIT every 2 years
If positive = colonoscopy
Recognises Hb

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18
Q

What is FAP

What is done as preventative measures to persons at risk? [2]

A

Autosomal dominant APC mutation
Annual colonoscopy from age 10
Prophylactic protocolectomy at 16

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19
Q

What do you get if you are HNPCC +Ve

A

2 year colonoscopy from 25

Endometrial / colon cancer / ovarian / pancreatic

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20
Q

What do you get if you have IBD

A

Colonoscopy 10 year post diagnosis

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21
Q

What is considered high risk FH

A

Colon cancer in 3 FDR

5 year colonoscopy at 55

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22
Q

What do you get if low risk

A

Single colonoscopy at 55

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23
Q

Where does colon cancer spread too [4]

A

Local
Lymphatic
Blood - liver, lung, bone
Transcoelomic

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24
Q

What factors play a role in whether anastomose or stoma [4]

A

Blood supply
Tissue tension
Sepsis
Unstable patient

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25
Q

Where is an ileostomy typically

A

R side

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26
Q

Where is a colostomy

A

L side
Flatter stump as not as acidic to skin - this tells you what it is rather than side
If need replaced will be on different sides

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27
Q

What are palliative options [3]

A

Chemo / RT
Diversion stoma
COlonic stenting

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28
Q

When would you do endoscopy / colonoscopy

A

Unexplained iron deficiency as risk of malignancy / bleeding / coeliac

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29
Q

What does pT3 mean in lab report

A

Pathology reports umour as stage T3

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30
Q

What does yP

A

After neoajuvant treatment

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31
Q

ANATOMY

A

SMA 2nd part of duodenum to 2/3 tranverse
IMA supplies the rest to superior rectum
Marginal artery supplies whole gut
SMA = L1
IMA = L3

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32
Q

What are the flexures of the colon

A

Hepatic

Splenic

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33
Q

What are the nodes of the colon

A

Same as arterial supply

Level of resection determined by nodes invollved

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34
Q

What is difference between end stoma or loop

A

End = irreversible

Loop is to defunction

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35
Q

What side is more likely to need temp stoma

A

L side

36
Q

What side tend to do worse

A

R side as SMA blood supply

37
Q

If person presents obstructed / perforation what do you do

A

Anastomosis is difficult
Stent = option
Loop stoma then fix at later date

38
Q

When can you anastomose even in emergency

A

Ileo-caecal

39
Q

What is Hartmanns procedure for

A

Ruptured sigmoid with colostomy

40
Q

When do you do left hemicolectomy [3]

A

Splenic
Descending
Colon to colon

41
Q

When do you do R hemicolectomy [3]

A

Caecal
Transverse
Ileo-cooln

42
Q

What tumour marker for disease progression

A

CEA

43
Q

When do you do urgent referral within 2 weeks [4]

A

> 40 weight loss and abdominal pain
50 bleed
60 anaemia or chang in bowel
+ve QFIT

44
Q

When should you consider referral [2]

A

Mass

<50 PR bleed / abdominal pain / change in bowel / weight loss / anaemia

45
Q

What is used post op for analgesia and why

A

Epidural as reduced time for normal gut transit to return

46
Q

How do you check anastomoses has worked

A

Gastrograffin enema

47
Q

How does anastomotic leak present [6]

A 
Usually day 4-5 
Septic peritonitis depending on size, Fever
Faecal / other material in drain bag 
Pain, Guarding
No bowel movement
Hypotension, Tachycardia
48
Q

How do you Dx [2]

A

Gastrograffin

CT

49
Q

How do you Rx

A

Surgery

50
Q

What do you do if wound breaks down [3]

A

Surgery
Emergency if deep and bowel showing
Can pack if superficial

51
Q

Indications for not doing colonoscopy

A

Do CT colonography if unfit for colonoscopy eg 6 months post MI / COPD

52
Q

Surgical options for colonic tumours

A

Right hemicolectomy
Left hemicolectomy
Sigmoid colectomy
Hartmann’s procedure

53
Q

Surgical options for rectal tumours [4]

A

Surgery:

  • Anterior resection
  • Abdominal perineal resection
  • Defunctioning loop colostomy

+/- neoadjuvant RT

54
Q

Advanced cancer [5]

A 
Stents
Surgical bypass
Diversion stoma
Palliative RT, chemo
Cetuximab, pantitumumab (anti-EGFR agents)
55
Q

What are the symptoms of haemorrhoids [4]

Symptoms of acutely thrombosed external hemorrhoids [3]

A

Fresh painless bleeding after defaecation (on stool, tissue dripping)
Itchy
Mucous discharge
Lump in anus

Acutely thrombosed external hemorrhoids:
Signifcant pain
Purple / oedematous
Tender subcutaneous perianal mass

56
Q

What are the RF for haemorrhoids [5]

What are anal cushions? [3]

A 
Obese, Pregnant
Age
Weight lifting
Excessive straining due to constipation 
Lack of fibre

Anal cushions

  • 3 discontinuous patches of spongy vascular tissue
  • Major arteries feed into at 3, 7, 11 o’clock (lithotomy)
  • Cushions are prone to trauma so blood loss is from capillaries below lamina propria of anal cushion
57
Q

How do you Dx haemorrhoids
Outline the 4 degrees of hemorrhoids
What are differentials for haemorrhoids? [3]

A 
Digital rectal exam
1 = not out of canal
2 = spontaneously reducible
3 = manually reducible
4 = cannot reduce

Differentials:
Colitis
Cancer
Unlikely to be abscess or fissure as painful

58
Q

Management of haemorrhoids
1st degree [3]
2-3rd degree [4]
4th degree [2]

A

1st degree:

  • Increase fluid and fibre
  • Topical LA
  • Topical steroids

2nd-3rd degree:

  • Rubberband ligation
  • Injection sclerotherapy
  • Infra-red coagulation
  • Doppler guided hemorrhoidal artery ligation

4th degree:

  • Excisions haemorrhoidectomy
  • Stapled hemorrhoidopexy
59
Q

Pathogenesis hemorrhoids

What differentiates between internal and external? [4]

A

Disruption and dilation of anal vascular cushions, may strangulate

  • Internal: above dentate line (no sensory supply) so not generally painful
  • External: below dentate line and prone to thrombosis which can be painful
60
Q

Investigations [2]

What is excisions hemorrhoidectomy? [2]

Comparison between stapled vs excisions [2]

A

Proctoscopy to view internal hemorrhoids
Sigmoidoscopy to identify pathology higher up

 Excisional haemorrhoidectomy:

  • excision of piles +/- ligation of vascular pedicles
  • day case but need 2w off work

Stapled hemorrhoidpexy is…

  • less pain and quicker return to normal activities
  • increased risk of recurrence and prolapse
61
Q

What causes anal fissure [5]

A 
Hard feces*
Trauma
Crohns
Anal cancer
Syphilis
62
Q

What are the symptoms of anal fissure [3]

A
  1. Pain
  2. Bleeding after defection typically in posterior midline ie 6 o’clock position when patient in lithotomy
  3. Itching
63
Q

How do you Dx fissure

A

Digital rectal exam

64
Q

Treatment:
Acute fissure [4]
Chronic fissure
3rd line treatment? [2]

A

Acute <6w:

  • Laxatives
  • High fibre diet
  • Lubricants before defecation
  • Ointment, Topical anaesthetic

Chronic >6w:
- Topical NO / GTN / CCB (relaxes anal sphincter)

If no improvement by 8w:

  • Botulinum toxin
  • Internal Sphincterotomy
65
Q

Internal Sphincterotomy complications [2]

A

Flatus incontinence in 30%

Faecal incontinence can occur in females if previous pregnancy or pelvic floor damage

66
Q

What causes peri-anal abscess [4]

Types of peri-anal abscess [4]

A

Causes:

  • IBD
  • STI
  • Blocked anal gland
  • E.coli / S.Aureus

Types

  • Perianal
  • ischiorectal
  • Intersphincteric
  • Supralevator
67
Q

What are the symptoms of abscess [4]

A

Perianal pain - worse sitting
Swelling
Perianal erythema

Fever + severe pain differentiate from fissure

68
Q

What are the RF for abscess [4]

A

IBD, DM, Steroids
Diverticulitis
PID
Malignancy

69
Q

Investigations for abscess [5]

A

(usually not required)

Digital rectal exam 
Blood cultures, CRP
Colonoscopy for underlying cause
MRI
Transperineal USS
70
Q

How do you treat abscess [3]

A

Drain abscess
Pain relief
Abx not usually needed

71
Q

What are the complications of abscess

A

Fistula

72
Q

What causes fistula in ano [7]

A 
Perianal sepsis
Crohns
Abscess
TB
Diverticular disease
Rectal ca
Immunocompromised
73
Q

What are the symptoms of fistula [4]

A

Pain, Skin irritation
Smelly discharge
Passing pus or blood in stool
Bowel incontinence

74
Q

How do you Dx fistula [5]

A 
Digital rectam exam
Proctoscopy
Endoanal USS
MRI/CT
Infection screen
75
Q

Fistula in ano treatment

  • Conservative: when is it indicated? [2], describe 3 components of conservative
  • What are 2 interventions you can do?
  • What would you do for Crohn’s with fistula?
A

Conservative if low and no sphincter involvement, no IBD

  • TPN / nutrition if high volume
  • Octreoide - reduce volume of pancreatic secretions
  • Permacol paste
  • Fistulotomy
  • Excision
  • Crohns: draining Seton suture prevents recurrent sepsis
76
Q

What are the symptoms of anorectal cancer? [4]

What type of cancer is it most commonly?

Describe tendency to metastasize [2]

(if neglected can present as a rectovaginal fistula in women)

A

Subacute onset

  • perianal pain
  • bleeding or ulcer
  • palpable lesion or faecal incontinence

Squamous cell carcinoma makes up 80%

Local lymphatic spread common
Distant spread rar

77
Q

How do you investigate anorectal cancer [6]

Staging [4]

A

DRE
Procotscopy / sigmoidoscopy
Biopsy
HIV serology

CT / MRI to stage
Endoanal USS and PET

78
Q

How do you treat squamous anorectal cancer [2]

A

Chemo - 5-FU, cisplatin

Radiotherapy

79
Q

How do you treat adenocarcinoma [3]

A

Chemo + RT

Laparoscopic resection

80
Q

What are the RF for anorectal cancer [6]

A 
HPV 16, 18 
Cervical cancer or CIN
Smoking 
Weakened immune system
MSM
PID infection
81
Q

Anterior [1] vs abdominal perineal resection [3]

Indications

A

Abdominal perineal if

  • Sphincter invovled
  • Very low
  • 2cm clearance margin

If upper rectum = anterior resection (colorectal)

Often temp stoma to allow time to heal

82
Q

What causes solitary rectal ulcer [3]

A

Constipation
Straining
Ulceration

83
Q

Pruritus Ani
Ax [5]
Mx [3]

A

Causes:

  • Fissures, fistula
  • Incontinence, poor hygiene
  • Tight pants
  • Threadworm
  • Dermatoses, lichen sclerosis

Mx

  • Careful hygiene
  • Anaesthetic cream
  • Moist wipe after defecation
84
Q

Complications of anorectal cancer

A

Recto-vaginal fistula

85
Q

What do you do if presents obstructed in anorectal cancer [2]

A

De-function stoma until can stage cancer

Don’t resect as won’t be able to anastomose

86
Q

Acutely thrombosis of external hemorrhoids mx

Natural course?

A
  • If presents within 72h, consider referral for excision
  • Otherwise manage with stool softeners, ice packs, analgesia
  • Symptoms usually settle within 10 days

Gastro (17 decks)

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