BOWEL

Question 1

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

Answer 1

endometrial,
ovarian,
gastric.

Question 2

screening protocols for HNPCC recommended

Answer 2

Annual colonoscopies should begin at age 20,

and

all polyps should be removed.

Benign polyps do not necessitate a formal resection,

Question 3

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

Answer 3

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.

Question 4

low med and high output fistula defs

Answer 4

low output (500 mL/day).

Question 5

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

Answer 5

high bicarbonate loss

with

result in metabolic acidosis.

Question 6

The majority of fistulas will result in what lyte loss

Answer 6

hypokalemia due to potassium efflux.

Question 7

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

Answer 7

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

Question 8

The first steps in control of a fistula

Answer 8

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.

Question 9

Ischemic colitis most often present with

Answer 9

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.

Question 10

Patients at risk for ischemic colitis are

Answer 10

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

Question 11

The most common infectious etiologies include

Answer 11

E.coli

and

Salmonella.

Question 12

Hyperplastic polyp

Answer 12

no malignant potential!

NOT considered neoplastic!

Question 13

A polypectomy is sufficient for

Answer 13

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
    b.

    Lesions removed with margin <2 mm
    c.

    Sessile lesions removed piecemeal**
    d.

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

    Sessile lesions with lymphovascular invasion

Question 14

A polypectomy is not sufficient

Answer 14

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)

Question 15

Hyperplastic polyps

Answer 15

do not have malignant potential.

Question 16

Peutz-Jeghers syndrome polyp type

Answer 16

Hamartomas

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

Question 17

Juvenile polyposis polyp type

Answer 17

Hamartomas

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.

Question 18

Cowden’s disease polyp type

Answer 18

Hamartomas

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

Question 19

Serrated polyps

Answer 19

YES risk of cancer

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

Question 20

The McBurney point is

Answer 20

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

Question 21

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

Answer 21

careful anatomic dissection at the time of surgery.

Total mesorectal resection for rectal cancer

Question 22

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

Answer 22

NONE

Question 23

Ureteral stents or rectal cancer effect on rate of uretral injury

Answer 23

None

not proven to reduce the risk of ureteral injury.

Question 24

best treatment for adenocarcinoma of the small bowel

Answer 24

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.

T

Question 25

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

Answer 25

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.

Question 26

Gastrointestinal lymphomas

Answer 26

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.

Question 27

Hinchey

Answer 27

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

Question 28

Acute sigmoid diverticulitis is treated with

Answer 28

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.

Question 29

anastamosis created in the Billroth II procedure

Answer 29

A gastrojejunostomy anastamosis is created in the Billroth II procedure. (CAREFUL, this is not a gastro-d)

Question 30

anastamosis created in the Billroth I procedure

Answer 30

A gastroduodenostomy is created in a Billroth I procedure.

Question 31

ssx and presentation of duodenal stump complication after B II

Answer 31

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.

Question 32

Peutz-Jeghers syndrome

Answer 32

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.

Question 33

The most common types of small bowel malignancies include

Answer 33

carcinoid, adenocarcinoma, and stromal tumors.

Question 34

most common small bowel tumor

Answer 34

Carcinoid tumors look this up

Question 35

Carcinoid is treated

Answer 35

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. EXCEPT!!!! duodenal tumors less than 1cm, where endoscopic removal may be all that is necessary. OTHER EXCEPTION - 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

Question 36

laparoscopic appendectomy appears to offer significant advantages

Answer 36

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**

Question 37

Heineke-Mikulicz Strictureplasty best suited for strictures up to

Answer 37

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

Question 38

Finney strictureplasties are best suited for

Answer 38

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.

Question 39

Immune modulating drugs are are used to treat IBD when

Answer 39

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.

Question 40

hallmarks of blind loop syndrome.

Answer 40

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)

Question 41

FAP Screening

Answer 41

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.

Question 42

FAP management

Answer 42

Surgical intervention is indicated once polyps begin to appear, or 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!

Question 43

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

Answer 43

SUBmucosa 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

Question 44

tx of Adenocarcinomas of the anal canal

Answer 44

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.

Question 45

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

Answer 45

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

Question 46

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

Answer 46

Nigro protocol, 5-FU, mitomycin, radiation.

Question 47

step-wise approach to Ogilvie Syndrome

Answer 47

First, nasogastric decompression, ambulation and narcotic avoidance second, IV neostigmine third, 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.

Question 48

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

Answer 48

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.

Question 49

AIDS related lymphomas are most commonly

Answer 49

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.

Question 50

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

Answer 50

GIST

Question 51

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

Answer 51

jejunum is the most common location.

Question 52

Carcinoids in the small intestine, most commonly in

Answer 52

ILEUM (CAREFUL, GIST is jejunum) 45% occur in small bowel all together

Question 53

Fistulas low output

Answer 53

(<200 mL/day),

Question 54

Fistulas medium output

Answer 54

moderate (200-500 mL/day)

Question 55

Fistulas high output

Answer 55

high output (>500 mL/day).

Question 56

lyte findings with fisutulas

Answer 56

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.

Question 57

spont closure rate of enterocuteanous fistulas

Answer 57

30% will close with supportive care within the first 4-6 weeks. However, mortality rate remains high as 15-25%.

Question 58

treatment of enterocuteanous fistulas

Answer 58

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.

Question 59

Massive GI bleeding with hemodynamic stability can be managed with

Answer 59

angiography and embolization when possible.

Question 60

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

Answer 60

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.

Question 61

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

Answer 61

total colectomy with end ileostomy.

Question 62

Malignant polyps are

Answer 62

adenocarcinomas that invade into the submucosa.

Question 63

Malignant polyps an be treated with

Answer 63

``` polypectomy alone if pedunculated AND 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

Question 64

GI bleed algorythm for Hematochezia

Answer 64

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 Angiography 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.

Question 65

Meckel’s diverticulum managment

Answer 65

all symptomatic diverticulum warrant a resection. uncomplicated diverticulum, a diverticulectomy is all that is necessary. ``` If it is associated with: complicated diverticulitis, GI bleeding, or has a wide base, ``` then a segmental resection is recommended.

Question 66

Rectal cancer staging compared to colon cancer,

Answer 66

SAME!

Question 67

Synchronous lesions

Answer 67

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

Question 68

T3 lesion of rectum

Answer 68

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

Question 69

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

Answer 69

shown to increase overall survival: lung or liver Isolated liver and lung metastases can be treated with wedge resection along with resection of the primary cancer.

Question 70

What colon cancers get adjuvant chemo

Answer 70

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!)

Question 71

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

Answer 71

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.

Question 72

standard of care for rectal cancers

Answer 72

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

Question 73

The criteria for a local transanal excision of rectal can cer

Answer 73

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.

Question 74

Hereditary non-polyposis colorectal cancer

Answer 74

``` (HNPCC) 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

Question 75

Amsterdam criteria

Answer 75

``` 321 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.

Question 76

percent of sporadic mutation for HNPCC

Answer 76

20% of sporadic mutation for HNPCC

Question 77

Lynch I syndrome is associated with

Answer 77

colon cancer,

Question 78

Lynch II syndrome is also associated with

Answer 78

endometrial, ovarian, GASTRIC cancers

Question 79

what medication helps close Fistulas in Crohn’s disease

Answer 79

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

Question 80

greatest absorptive activity of the colon is where

Answer 80

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

Question 81

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

Answer 81

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

Question 82

rectal prolapse Abdominal operations

Answer 82

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.

Question 83

Transperineal operations have recurrence rates of

Answer 83

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.

Question 84

A levatorplasty

Answer 84

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

Question 85

Transperineal operations

Answer 85

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.

Question 86

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

Answer 86

diverticular disease. more commonly on the right side usually self-limiting. ---- A less common cause of GI bleeding is from AV malformations,

Question 87

Surgery is indicated when for GI bleed

Answer 87

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

Question 88

AV malformations, are associated with what study should be done

Answer 88

aortic stenosis. Echocardiogram is needed for patients with arteriovenous malformations.

Question 89

Celiac asso with what kind of lymphoma

Answer 89

T-cell lymphoma is associated with disease.

Question 90

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

Answer 90

B-cell lymphoma (like AIDS)

Question 91

Neoplastic lesions of the appendix Appendectomy alone may be curative for

Answer 91

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.

Question 92

Appendiceal adenomas

Answer 92

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)

Question 93

Appendiceal carcinoids

Answer 93

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

Question 94

Nonepithelial appendiceal tumors

Answer 94

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

Question 95

Gastrointestinal stromal tumor (GIST) patho pys

Answer 95

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.

Question 96

most common sites of GISTs

Answer 96

The stomach 50% to 70% 25% small intestine (Jejunum most common SB) 5% to 15% rectum 2% of GIST esophagus.