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Flashcards in COLON Deck (41)
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Embryology of large bowel

Derives from midgut- up to 2/3 mid-transverse colon. Derives from hindgut up to proximal anus. Distal anus forms from ectoderm


What marks the part of anus that formed from hindgut vs. ectoderm?

Dentate line


Blood supply to large bowel

Follow embryologic origins: midgut (SMA), hindgut (IMA), distal anus (internal pudendal artery branches). Rectum: internal iliac artery via middle rectal and inferior rectal arteries


Why do L and R sided colon cancers present so differently?

Colon progressively narrows distally, so L sided more likely to present with change in bowel habits/obstruction/hematochezia; R sided more likely to present indolently with anemia/fatigue/melena.


Normal flora of colon

Sterile at birth. Once colonized 99% anaerobic (mostly B fragilis) and 1% aerobic (mostly E coli)


Difference between constipation and obstipation

Constipation you can pass flatus, obstipation you can't


What is the cause of postvagotomy diarrhea?

After a truncal vagotomy, denervation of extrahepatic biliary tree -> rapid transit of uncon bile salts into colon, impeding water absorption -> diarrhea. Tx: cholestyramine. If that fails, surgical reversal of small intestine to prolong transit time.


Treatment of C diff

Flagyl first line (PO, IV if can' take PO). Second line is PO vancomycin


Actinomycosis [Actinomyces Israelii)

Infection of the GI tract (usu the ileocecal region) with A. israelii, classically after appendectomy. Presents with weight loss, night sweats, draining fistulae, abdominal mass. Dx: "sunburst" pattern of sulfur granules of pathology, culture. Tx: drainage + abx (tetracycline or penicillin)


Neutropenic colitis

Diffuse mucosal ulceration, invasive infection with enteric organisms, can lead to sepsis; In patients with ANC


Radiation induced colitis

Dose dependent. Early (during course of XRT) = N/V, cramps, diarrhea, mucosal edema/ulceration. Late (weeks to up to 20 yrs later) = tenesmus, bleeding, abscess, fistula involving rectum, increased frequency of BMs.


How to treat late radiation induced colitis?

Stool softener, topical 5-ASA, steroid enema. Dilation for strictures, colostomy + fistula repair


What watershed part of bowel is most vulnerable to ischemic colitis?

Splenic flexure


What is the most common clinical setting for ischemic colitis?

Classically, after AAA repair (impaired blood flow through the IMA)


UC colon cancer risk

10% at 10 yrs, 2% per year thereafter


Pathophys of diverticulitis

Inflammation caused by (usu tiny) perforationi of the diverticulum secondary to increased pressure or osbtruction by inspissated feces -> feces extravasate onto serosal surface but infection usu well contained in immunocompetent patient


Imaging of choice for diverticulitis

CT scan (don't do colonoscopy or barium enema bc can cause perf, but do them in follow up)


What are the most common causes of lower GI bleed (LGIB)?

Diverticulosis (brisk bleed) and angiodysplasia (slow bleed)


What causes LGIB in angiodysplasia?

Chronic intermittent obstructiton of submucosal veins 2/2 repeated muscular contractions -> dilated venules and dilation of the venules and arteriolar capillary units feeding them -> AV communication


Why does angiodysplasia occur more commonly in cecum/right colon?

LaPlace law: greater diameter of right colon = more wall tension


Large bowel obstruction

Less common than SBO. Make sure it is a complete obstruction (not passing any gas or stool for 8-12 hrs), since partial obstruction does not require surgery, while complete large bowel obstruction is a surgical emergency (since NGT will not decompress in this case)


Most common place for volvulus

Sigmoid colon (70%), cecum (30%)


Management of cecal volvulus

Right hemicolectomy if vascular compromise. Cecopexy otherwise adequate


Management of sigmoid volvulus

Firs try to decompress with sigmoidoscopy. [Once resolved, will want to do elective resection to prevent high risk of recurrence]. If this fails, or if strangulation/perf present -> emergent laparotomy.


Histologic types of colonic polyps

Inflammatory (UC), lymphoid, hyperplastic (no malign potential), adenomatous (premalignant), hamartomatous (Peutz-Jeghers, juvenile polyps)


Familial adenomatous polyposis

Autosomal dominant. 100% chance of colon cancer w/o colectomy (get it once polyps present).


Gardner's syndrome

Autosomal dominant. Innumerable polyps + osteomas, epidermal cysts, fibromatosis. 100% chance of colon cancer w/o colectomy


Turcot's syndrome

Autosomal recessive. Adenomatous colonic polyps + CNS tumors, esp gliomas


Hereditary nonpolyposis colon cancer syndrome (HNPCC) aka Lynch syndrome

Autosomal dominant. Lynch syndrome I: pts w/o multiple polyps who devel R sided colon cancer. Lynch syndrome II: same as I plus risk of extracolonic adenocarcinomas of uterus, ovary, cervix, breast


Peutz-Jeghers syndrome

Autosomal dominant. Hamartomatous polyps + melanotic pigmentation of face/lips/palms. Increased risk of pancreatic, breast, lung, ovarian, uterine cancer


CEA (carcioembryonic antigen)

CEA mainly used as a tumor marker to monitor CRC tx, to identify recurrences after surgical resection, for staging or to localize cancer spread through measurement of biological fluids. CEA levels may also be raised in gastric carcinoma, pancreatic carcinoma, lung carcinoma, breast carcinoma, and medullary thyroid carcinoma, as well as some non-neoplastic conditions like ulcerative colitis, pancreatitis, cirrhosis, COPD, Crohn's disease, hypothyroidism as well as in smokers.


Apple core filling defect

XRay sign for colon cancer


Treatment of hemorrhoids

Depends on severity (from protrusion into lumen with no prolapse to prolapse that cannot be reduced). Nonresectional (only for nonsensate areas, aka above dentate line): band ligation, coagulation, sclerotherapy. Excision required for severe.


Anal fissure treatment

Sitz baths, fiber supplement, more fluids. If this fails, can do lateral internal sphincterotomy or forceful anal dilation


What is a seton?

Heavy suture loop through anal tract to keep it patent for drainage and stimulate fibrosis


Paget's disease of perianal skin

Adenocarcinoma in situ


Bowen's disease of perianal skin

Squamous carcinoma in situ


Anal canal tumor types

SCC or transitional cell/cloacogenic carcinoma, or malignant melanoma (worst prognosis)


Anal cancer treatment

Primary treatment is combo of chemo and radiation


Rectal cancer

Responds to radiation therapy, whereas colon cancers do not. High risk of local recurrence at site of resection for rectal cancer


What improves survival in stage III colon cancer?

Adjuvant chemo after surgery