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HNPCC is associated with higher risk of developing colon cancer as well some extra-colonic cancers, such as



screening protocols for HNPCC recommended

Annual colonoscopies should begin at age 20,


all polyps should be removed.

Benign polyps do not necessitate a formal resection,


Managment of HNPCC pt with completely resected polyp found to be adenoca

but if pathology shows adenocarcinoma, surgery should follow.

The recommended surgery is a total abdominal colectomy with ileorectal anastomosis.

In female patients who do not plan on further childbearing, a hysterectomy and bilateral salpingo- oophorectomy is also recommended to eradicate the risk of developing malignancy in these tissues.


low med and high output fistula defs

low output (500 mL/day).


Proximal fistulas tend to be high in with what acid base picture

high bicarbonate loss


result in metabolic acidosis.


The majority of fistulas will result in what lyte loss

hypokalemia due to potassium efflux.


With optimal care, approximately what percent close spontaneously. and what is mortality

one third

One third of fistulas will close within the first 4-6 weeks

However, mortality rate remains high as 15- 25%!

The first step in control of a fistula is control of any septic source. Additional undrained collections should be identified and controlled, with liberal use of CT scanning and percutaneous drain placement. Operative control is usually unnecessary and may worsen the problem with creation of further enterotomies or spreading septic sources. The patient must then be stabilized, resuscitated, and electrolytes repleted. Nutritional support is then begun with


The first steps in control of a fistula

control septic source.

Operative control is usually unnecessary and may worsen the problem with creation of further enterotomies or spreading septic sources.

Nutritional support is then begun with either enteral or parenteral feeding. Enteral feeding may result in increased fistula output, or simply not be tolerated due to obstructive symptoms.

If the fistula increases to high ouput levels, TPN should be used.

wound manager and agents such as psyllium, octreotide and long acting somatostatin analogues used to decrease output, with the goal of decrease output levels from high to low or moderate output.

If the fistula does not close spontaneously, the would must be closed operatively.

Aggressive nutritional support must be provided to achieve an albumin greater than 3g/dL.

After 12 weeks have passed after fistula formation, operative intervention should be considered.

The operation consists of bowel resection, anastamosis, takedown of the fistula and full thickness resection of the area of abdominal wall.

Complex abdominal reconstruction may be needed. If so, nonabsorbable mesh should be avoided.


Ischemic colitis most often present with

non-specific abdominal pain

mild hematochezia.

Even a short interval of hypotension in a patient with associated risk factors may develop ischemic colitis.

CT scans will show segmental colonic thickening.

may present with small amount of blood per rectum but a large amount favors diverticulosis or hemorrhoids.


Patients at risk for ischemic colitis are

in advanced age, have poor cardiovascular histories, or are hypercoaguable.


The most common infectious etiologies include





Hyperplastic polyp

no malignant potential!

NOT considered neoplastic!


A polypectomy is sufficient for

malignant polyps with invasion limited to the head or neck or stalk BUT NOT BASE
(unless this is IBD or HNPCC - these patients need surgery)

A repeat colonoscopy is recommended in 3 YEARS.

NEEDS formal surgery:

Pedunculated Haggitt level 4 (base) with invasion into distal third of submucosa, or pedunculated lesions with lymphovascular invasion

Lesions removed with margin <2 mm

Sessile lesions removed piecemeal**

Sessile lesions with depth of invasion into distal third of submucosa (Sm3)**

Sessile lesions with lymphovascular invasion


A polypectomy is not sufficient

polyp size greater than 3 cm

Sessile lesions removed piecemeal**

Sessile lesions with depth of invasion into distal third of submucosa (Sm3)**

angiolymphatic invasion

invasion into the base: level 4 (base) with invasion into distal third of submucosa,

poorly differentiated histology

insufficient margin of < 2 mm

(size less than 3, margin less than 2)


Hyperplastic polyps

do not have malignant potential.


Peutz-Jeghers syndrome polyp type


The risk of colon cancer is increased in these syndromes, but the hamartomas themselves are not considered premalignant.


Juvenile polyposis polyp type


Polyps with juvenile polyposis are not pre-malignant.

The risk of colon cancer is increased in these syndromes, but the hamartomas themselves are not considered premalignant.


Cowden's disease polyp type


The risk of colon cancer is increased in these syndromes, but the hamartomas themselves are not considered premalignant.


Serrated polyps

YES risk of cancer

were once considered hyperplastic, but are now considered to be a risk factor for developing cancer .


The McBurney point is

approximately one third of the way from the iliac spine to the umbilicus.


The only modality shown to reduce the risk of urinary and sexual disfunction complication is

careful anatomic dissection at the time of surgery.

Total mesorectal resection for rectal cancer


Post-op radiation for rectal cancer association with increased risks of urinary and sexual dysfunction.



Ureteral stents or rectal cancer effect on rate of uretral injury


not proven to reduce the risk of ureteral injury.


best treatment for adenocarcinoma of the small bowel

Ideally, a segmental resection with a primary anatomosis is preferred when the tumor is found distal to the 3rd portion of the duodenum.

Tumors proximal to this location will likely need a Whipple procedure due to its close relationship with the ampulla and biliary tree.



best treatment for adenocarcinoma of the small bowel that are locally advanced

MINIMAL (ie, NOT the answer)

Studies have shown minimal benefit to adjuvant or neoadjuvant therapies in the treatment of small bowel adenocarcinoma.

may therefore be better suited for a palliative procedure to ensure no further intestinal obstructions.

This may include a duodenal bypass or a stent placement.


Gastrointestinal lymphomas

Small bowel lymphomas are more commonly from T-cell

(careful, AIDS, MALToma, and H pylori asso are B-cell; AND GASTRIC B-cell)

often present with vague abdominal pain and weakness.

most commonly occur in the ileum, where the Peyer’s patches lymph node basins exist, and can be diagnosed best on CT scan.

Biopsies can be useful to confirm the type and grade of lymphoma, which will help to guide the type of treatment.

Patients with a history of celiac disease are more likely to develop T-cell lymphoma of the small bowel.

T-cell lymphoma is associated with Celiac disease.

Answer D: B-cell MALTomas are associated with H.pylori infections.



I – Segmental colitis and pericolonic abscess

Hinchey II – Pelvic abscess - CAREFUL - still II even if giant sympomatic abscess if not perf

Hinchey III – Purulent peritonitis

Hinchey IV - Feculent peritonitis


Acute sigmoid diverticulitis is treated with

intravenous (iv) antibiotics and bowel rest initially.

Patients with diverticulitis complicated by an abscess should be percutaneously drained in addition to receiving iv antibiotics unless the abscess is small (< 3 cm).

Surgical intervention should be considered if the patient does not improve with iv antibiotics and percutaneous drainage.

Laparotomy and Hartmann’s resection should be reserved for patients with signs of sepsis or peritonitis.


anastamosis created in the Billroth II procedure

A gastrojejunostomy anastamosis is created in the Billroth II procedure.

(CAREFUL, this is not a gastro-d)


anastamosis created in the Billroth I procedure

A gastroduodenostomy is created in a Billroth I procedure.


ssx and presentation of duodenal stump complication after B II

Dehiscence of the duodenal closure fourth or fifth post- operative day.

Patients may present with no more than a sense of epigastric fullness and discomfort, may suddenly be seized with severe pain, abdominal rigidity, and fever, or may exhibit a shock-like state.


Peutz-Jeghers syndrome

This patient has which is an autosomal dominant (choice C) disease that has several identifying characteristics, such intestinal hamartomas (choice D) and hyperpigmented lesions of the oral mucosa.
These patients have an increased risk for a GI malignancy and a screening colonoscopy should be performed every 2 years (choice A).
There is no recommendation for any prophylactic surgery (choice E).
This syndrome has been shown to have an increased risk of extra-colonic cancers, such as breast, cervical, thyroid, and lung. Periodic screening for these cancers should begin at age 25 (choice B).
Bottom Line: Peutz-Jeghers syndrome is associated with intestinal hamartomas, hyperpigmented mucosal lesions, and has an increased risk of extra-colonic cancers.


The most common types of small bowel malignancies include

stromal tumors.


most common small bowel tumor

Carcinoid tumors

look this up


Carcinoid is treated

surgically similar to that of adenocarcinoma,

in that it requires an en bloc surgical resection with full lymphadenectomy due to its preponderance to invade local lymph nodes.

duodenal tumors less than 1cm, where endoscopic removal may be all that is necessary.

debulk for carcinoid
Resection of metastatic disease has been shown to not only improve the symptoms of a carcinoid syndrome, but also improve overall survival if adequate debulking is achieved.

Octreotide has also been shown to treat the symptoms


laparoscopic appendectomy appears to offer significant advantages

women of childbearing age,
obese patients,
patients with an unclear diagnosis.

laparoscopic appendectomy
DECREASED wound infection
SHORTER length of stay
LESS narcotic

**HIGHER incidence of postoperative intra-abdominal abscess**


Heineke-Mikulicz Strictureplasty best suited for strictures up to

strictureplasties are best suited for strictures up to 5 to 7 cm long.


Finney strictureplasties are best suited for

up to 10 to 15 cm long.

The side-to-side strictureplasty is suitable for longer areas of stricture; however, this technique involves longer suture lines and is mainly considered for patients who already have, or are at high risk for, short bowel syndrome.


Immune modulating drugs are are used to treat IBD when

Immune modulating drugs are only available in IV form

better served for long term remission.

Azathioprine can be used for long term remission treatment of Crohn's but takes several weeks for desired effect so it is not a good choice in the acute setting.


hallmarks of blind loop syndrome.

Steatorrhea, diarrhea, megaloblastic anemia, and malnutrition are the

Hypocalcemia (choice C) occurs because calcium is bound to unabsorbed fatty acids in the intestinal lumen.

Macrocytic anemia (choice E) is due to malabsorption of vitamin B12, because of binding of the vitamin by anaerobic bacteria.

can be seen with Crohns with enteroenteric fistula (NOT JUST BII)


FAP Screening

FAP Screening starts with EVERY YEAR proctosigmoidoscopies as teenagers.

UPPER endoscopy screening for duodenal polyps should be started once the colonic polyps appear

screened for rectal polyps EVERY 6 MONTHS! if ileorectal anastomosis.


FAP management

Surgical intervention is indicated once polyps begin to appear,


before the age of twenty

The recommended surgery is a total abdominal proctocolectomy with ileal J-pouch and anal anastomosis.

If the rectum is minimally involved, a mucosectomy with ileorectal anastomosis can be performed, but this confers a high risk of developing rectal cancer. Therefore, these patients need to be screened for rectal polyps EVERY 6 MONTHS!


what is layer for sewing on bowel and why is it the best


Tensile strength is mainly determined by collagen cross linking.

The submucosal layer has a high content of collagen fibers and is where the tensile strength of the bowel


tx of Adenocarcinomas of the anal canal

have a very poor prognosis

treated with surgical resection (CAREFUL, don't confuse with squamous anal canal nigro)

less than 3 cm that are limited to the submucosa can be removed by wide local excision. (Small, T1 )

Larger lesions that are more invasive will require an APR.


Squamous cell cancers of the anus that occur below the dentate line at the anal margin are best treated with

Squamous cell cancers less than 3 cm in size at the anal margin are treated with wide local excision and clear margins.


Squamous cell cancers of the anus that are above the dentate line are treated with

Nigro protocol,





step-wise approach to Ogilvie Syndrome


nasogastric decompression, ambulation and narcotic avoidance

IV neostigmine

colonoscopic decompression

If all else fails surgical intervention is warranted.

unable to tolerate a major operation,

percutaneous cecostomy for decompression.

Total colectomy and Hartmann’s procedures have also been recommended.


free air with peritonitis secondary to diverticulitis ith purulent peritonitis is managed how

Even with purulent peritonitis, a primary anastomosis can be performed with a diversion as long as the tissue is viable and there is no tension.

Due to the higher risk of leak, a diversion is indicated to allow ample time for the anastomosis to heal. This helps avoid having to operate in this contaminated field at a later date for reversal.

A primary anastomosis with diverting ileostomy can be safely performed in patients with purulent peritonitis

A primary anastomosis without diversion is contraindicated with purulent peritonitis.


AIDS related lymphomas are most commonly

B CELL (Like MALToma and H pylori asso!)

aggressive, high-grade
lymphoms of B-cell origin

other LESS common:

Hodgkin lymphoma appears to occur 2.5–8.5 fold higher in the HIV positive population. The clinical setting is typically more advanced with mixed cellularity subtype.

T-cell -large granular lymphocyte disease, large-cell, or anaplastic T-cell lymphoma have been reported (choice B). HTLV-1 virus infection has been associated with some cases of T-cell lymphomas in patients with AIDS.


patient presents with a several week history of poor oral intake and bloating. An upper GI series is performed which shows a smoothly contoured submucosal mass causing a gastrointestinal obstruction. what is diagnosis



GIST’s in the small bowel are most commonly found where

jejunum is the most common location.


Carcinoids in the small intestine, most commonly in

ILEUM (CAREFUL, GIST is jejunum)

45% occur in small bowel all together


Fistulas low output

(<200 mL/day),


Fistulas medium output

moderate (200-500 mL/day)


Fistulas high output

high output (>500 mL/day).


lyte findings with fisutulas

The majority of fistulas will result in hypokalemia due to potassium efflux.

Proximal fistulas tend to be high in bicarbonate and result in metabolic acidosis.


spont closure rate of enterocuteanous fistulas

30% will close with supportive care within the first 4-6 weeks.

However, mortality rate remains high as 15-25%.


treatment of enterocuteanous fistulas

After 12 weeks have passed after fistula formation, operative intervention should be considered.

The operation consists of bowel resection, anastamosis, takedown of the fistula and full thickness resection of the area of the abdominal wall.

Complex abdominal reconstruction may be needed.


Massive GI bleeding with hemodynamic stability can be managed with

angiography and embolization when possible.


Massive GI bleeding requiring more than 6 units of blood or having ongoing hemodynamic instability management is

surgical (CAREFUL - angio for possible hypotensive bleeding pelvis - but not bowel..)

Without localization, the operation of choice is:
a total abdominal colectomy.

Providing a stoma is preferred to a primary anastomosis in case the patient rebleeds.

On-table colonoscopies are another useful tool, but should only be used if the patient is more stable.


The surgical treatment for a massive lower GI bleed of unknown origin is

total colectomy with end ileostomy.


Malignant polyps are

adenocarcinomas that invade into the submucosa.


Malignant polyps an be treated with

polypectomy alone if
do not involve the base (CAREFUL, stalk is OK)
do NOT invade lymphovasculature.

At least a 2 mm margin is necessary for cure with polypectomy.

If these criteria are not met,
formal resection.

Things that sound shady but can still just take out the polyp:

High grade dysplasia that does not invade into the submucosa can be treated with polypectomy alone.

Invasion into the stalk is ok


GI bleed algorythm for Hematochezia

differential that includes bleeding from the upper or lower GI tract.

If the patient is hemodynamically unstable: resuscitation is the first step of treatment.

Once stabilized, these procedures can be performed

NG lavage to rule out an upper GI source

If the NG lavage is negative:
lower GI problem.

If the bleeding is intermittent and the patient is stable:
formal colonoscopy can be scheduled to evaluate the colon.

If the brisk bleeding:
localization study

requires a bleeding rate of at least 0.5 mL/min for detection - and can treat the source of bleeding,

A tagged RBC scan
requires bleeding rate of 0.1mL/min
no therapeutic option.


Meckel’s diverticulum managment

all symptomatic diverticulum warrant a resection.

uncomplicated diverticulum, a diverticulectomy is all that is necessary.

If it is associated with:
complicated diverticulitis,
GI bleeding,
has a wide base,

then a segmental resection is recommended.


Rectal cancer staging compared to colon cancer,



Synchronous lesions

may represent a second primary and is not necessarily metastatic disease.


T3 lesion of rectum

If the tumor migrates through the muscle and into the perirectal tissue


The role for surgical resection of colon cancer along with metastatectomy with mets where

shown to increase overall survival:

Isolated liver and lung metastases can be treated with wedge resection along with resection of the primary cancer.


What colon cancers get adjuvant chemo

All stage III and IV colon cancers are recommended to have adjuvant chemotherapy.

Stage III any node positive.

(Careful, invasion into another organ T4 - is still Stage IIc!)


T3N0M0 rectal cancer which is designated as what Stage and what is treatment

T3 through the muscularis propria and into the perrectal tissue possible even invasion of vieral peritoneum of other organ but NOT invasion into parenchima

Stage II and over rectal cancers should be treated with preoperative chemoradiation therapy followed by a formal resection.


standard of care for rectal cancers

Formal surgical resection

However, there is a subset of patients that are candidates for a local transanal excision.


The criteria for a local transanal excision of rectal can cer

well differentiated
T1 mass
less than 4cm
involving less than 40% of the circumference
distance less than 8cm from the anal verge,
no lymphovascular involvement
no mucin production.

Transanal excision is better tolerated by the patient, but comes with a higher risk of recurrence.

NO T2 lesions
have an even higher risk of recurrence and should only be excised locally if the patient is a poor surgical candidate.


Hereditary non-polyposis colorectal cancer

lynch syndrome
autosomal dominant
high incidence of colon cancer
high microsatellite instability
defects on the MLH1 and MSH2 genes, which are responsible for DNA mismatch repair.

Screening genetic associations recommended for patients who fit the Amsterdam criteria


Amsterdam criteria

3 firsts
2 gens
1 50
three or more first-degree relatives with colon cancer,

across two generations,

one member diagnosed prior to the age of 50.


percent of sporadic mutation for HNPCC

20% of sporadic mutation for HNPCC


Lynch I syndrome is associated with

colon cancer,


Lynch II syndrome is also associated with

GASTRIC cancers


what medication helps close Fistulas in Crohn’s disease

Infliximab can be used to facilitate closure of fistulas in Crohn’s disease of the small bowel.


greatest absorptive activity of the colon is where

The proximal colon

Over one liter of water a day is absorbed through the proximal colon.


The surgical treatment for duodenal obstruction in Crohn’s patients is

a gastrojejunostomy

strictureplasty procedures are difficult in the duodenum and are only anatomically achievable in select patients.


rectal prolapse Abdominal operations

recurrence rates less than 10% and are used in fit patients.

by rectopexy (open or laparoscopic, with or without a concomitant sigmoid resection)

Transabdominal rectopexy
full mobilization of the rectum to the level of the pelvic floor musculature with suture fixation of the mesorectum to the presacral fascia below the sacral promontory.


Transperineal operations have recurrence rates of

15% to 20% (or more in some series)

and are most appropriate in elderly patients or patients at high risk for complications of abdominal surgery.


A levatorplasty

(anterior, posterior, or both) can be performed to help recreate the anorectal angle as part of the Altemeier operation.


Transperineal operations

Bottom Line: Methods of repair of rectal prolapse are abdominal and perineal, the former represented

and the latter represented by the Altemeier perineal proctectomy and Delorme plication.


The 2 most common cause of severe GI bleeding in the older populations is from

diverticular disease.

more commonly on the right side

usually self-limiting.


A less common cause of GI bleeding is from AV malformations,


Surgery is indicated when for GI bleed

hemodynamically unstable
more than 4 units of blood are needed for resuscitation.


AV malformations, are associated with what study should be done

aortic stenosis.

Echocardiogram is needed for patients with arteriovenous malformations.


Celiac asso with what kind of lymphoma

T-cell lymphoma is associated with disease.


MALTomas are associated with H.pylori infections are associated with what kind of lymphoma

B-cell lymphoma (like AIDS)


Neoplastic lesions of the appendix Appendectomy alone may be curative for

appendiceal mucocele,
localized pseudomyxoma peritonei (rare to be localized)
most appendiceal carcinoids (less than 2cm)

Benign neoplasms of the appendix include mucosal hyperplasia or metaplasia, leiomyomas, neuromas, lipomas, angiomas, and other rare lesions.


Appendiceal adenomas

tend to be diffuse
predominant villous character.

Mucus-producing cystadenomas predispose to appendiceal mucocele, sometimes accompanied by localized pseudomyxoma peritonei.

If the base of the appendix is free of disease, appendectomy alone is sufficient treatment (this does not apply to adenoCARCINOMA)


Appendiceal carcinoids

predominantly of neural cellular origin

have a better prognosis than all other intestinal carcinoid tumors, which typically are of mucosal cellular origin.


Nonepithelial appendiceal tumors

are extremely rare. Such lesions include malignant and Burkitt lymphomas, smooth muscle tumors, granular cell tumors, ganglioneuromas, and Kaposi sarcoma


Gastrointestinal stromal tumor (GIST) patho pys

most common sarcoma of the GI tract,

interstitial cells of Cajal, between the intramural neurons and the smooth muscle cells.

c-kit mutations, a transmembrane receptor tyrosine kinase involved in the regulation of cellular proliferation, apoptosis, and differentiation.


most common sites of GISTs

The stomach 50% to 70%

25% small
intestine (Jejunum most common SB)

5% to 15% rectum

2% of GIST esophagus.