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Section II General Surgery P203Surgical Recall Sixth > Colon and Rectum, C48 P308-325 > Flashcards

Colon and Rectum, C48 P308-325 Flashcards

1
Q

ANATOMY
Identify the arterial blood supply to the colon:
P308 (picture)

A
  1. Ileocolic artery
  2. Right colic artery
  3. Superior mesenteric artery (SMA)
  4. Middle colic artery
  5. Inferior mesenteric artery (IMA)
  6. Left colic artery
  7. Sigmoidal artery
  8. Superior hemorrhoidal artery
    (superior rectal)
  9. Middle hemorrhoidal artery
    10 Inferior hemorrhoidal artery
  10. Marginal artery of Drummond
  11. Meandering artery of Gonzalez
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2
Q

ANATOMY
What are the white lines of
Toldt?
P309

A

Lateral peritoneal reflections of the

ascending and descending colon

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3
Q

ANATOMY
What parts of the GI tract
do not have a serosa?
P309

A

Esophagus, middle and distal rectum

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4
Q 
ANATOMY
What are the major anatomic
differences between the
colon and the small bowel?
P309
A 
Colon has taeniae coli, haustra, and
appendices epiploicae (fat appendages),
whereas the small intestine is smooth
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5
Q 
ANATOMY
What is the blood supply to
the rectum:
Proximal?
P309
A 
Superior hemorrhoidal (or superior
rectal) from the IMA
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6
Q 
ANATOMY
What is the blood supply to
the rectum:
Middle?
P309
A 
Middle hemorrhoidal (or middle rectal)
from the hypogastric (internal iliac)
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7
Q 
ANATOMY
What is the blood supply to
the rectum:
Distal?
P309
A

Inferior hemorrhoidal (or inferior rectal)
from the pudendal artery (a branch of
the hypogastric artery)

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8
Q 
ANATOMY
What is the venous drainage
of the rectum:
Proximal?
P309
A

Via the IMV to the splenic vein, then to

the portal vein

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9
Q 
ANATOMY
What is the venous drainage
of the rectum:
Middle?
P309
A

Via the iliac vein to the IVC

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10
Q 
ANATOMY
What is the venous drainage
of the rectum:
Distal?
P309
A

Via the iliac vein to the IVC

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11
Q

COLORECTAL CARCINOMA
What is it?
P309

A

Adenocarcinoma of the colon or rectum

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12
Q

COLORECTAL CARCINOMA
What is the incidence?
P309

A 
Most common GI cancer
Second most common cancer in the
    United States
Incidence increases with age starting at
    40 and peaks at 70 to 80 years
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13
Q

COLORECTAL CARCINOMA
How common is it as a cause
of cancer deaths?
P309

A

Second most common cause of cancer

deaths

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14
Q

COLORECTAL CARCINOMA
What is the lifetime risk of
colorectal cancer?
P310

A

6%

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15
Q

COLORECTAL CARCINOMA
What is the male to female
ratio?
P310

A

≈1:1

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16
Q

COLORECTAL CARCINOMA
What are the risk factors?
P310

A 
Dietary: Low-fiber, high-fat diets
    correlate with increased rates
Genetic: Family history is important
    when taking history
    FAP, Lynch’s syndrome
IBD: Ulcerative colitis > Crohn’s
    disease, age, previous colon cancer
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17
Q

COLORECTAL CARCINOMA
What is Lynch’s syndrome?
P310

A

HNPCC = Hereditary NonPolyposis
Colon Cancer—autosomal-dominant
inheritance of high risk for development
of colon cancer

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18
Q 
COLORECTAL CARCINOMA
What are current ACS
recommendations for
polyp/colorectal screening
in asymptomatic patients
without family (first-degree)
history of colorectal
cancer?
P310
A 
Starting at age 50, at least one of the
following test regimens is recommended:
    Colonoscopy q 10 yrs
    Double contrast barium enema
       (DCBE) q 5 yrs
    Flex sigmoidoscopy q 5 yrs
    CT colonography q 5 yrs
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19
Q 
COLORECTAL CARCINOMA
What are the current recommendations
for colorectal
cancer screening if there is a
history of colorectal cancer
in a first-degree relative
less than 60 years old?
P310
A

Colonoscopy at age 40, or 10 years before
the age at diagnosis of the youngest
first-degree relative, and every 5 years
thereafter

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20
Q 
COLORECTAL CARCINOMA
What percentage of adults
will have a guaiac-positive
stool test?
P310
A

≈2%

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21
Q 
COLORECTAL CARCINOMA
What percentage of patients
with a guaiac-positive
stool test will have colon
cancer?
P310
A

≈10%

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22
Q 
COLORECTAL CARCINOMA
What signs/symptoms are
associated with the following
conditions:
Right-sided lesions?
P311
A 
Right side of bowel has a large luminal
    diameter, so a tumor may attain a
    large size before causing problems
Microcytic anemia, occult/melena more
    than hematochezia PR, postprandial
    discomfort, fatigue
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23
Q 
COLORECTAL CARCINOMA
What signs/symptoms are
associated with the following
conditions:
Left-sided lesions?
P311
A 
Left side of bowel has smaller lumen and
     semisolid contents
Change in bowel habits (small-caliber
    stools), colicky pain, signs of
    obstruction, abdominal mass,
    heme() or gross red blood
Nausea, vomiting, constipation
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24
Q

COLORECTAL CARCINOMA
From which site is melena
more common?
P311

A

Right-sided colon cancer

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25
Q 
COLORECTAL CARCINOMA
From which site is
hematochezia more
common?
P311
A

Left-sided colon cancer

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26
Q

COLORECTAL CARCINOMA
What is the incidence of
rectal cancer?
P311

A

Comprises 20% to 30% of all colorectal

cancer

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27
Q

COLORECTAL CARCINOMA
What are the signs/
symptoms of rectal cancer?
P311

A

Most common symptom is hematochezia
(passage of red blood ± stool) or mucus;
also tenesmus, feeling of incomplete
evacuation of stool (because of the mass),
and rectal mass

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28
Q 
COLORECTAL CARCINOMA
What is the differential
diagnosis of a colon tumor/
mass?
P311
A

Adenocarcinoma, carcinoid tumor, lipoma,
liposarcoma, leiomyoma, leiomyosarcoma,
lymphoma, diverticular disease, ulcerative
colitis, Crohn’s disease, polyps

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29
Q

COLORECTAL CARCINOMA
Which diagnostic tests are
helpful?
P311

A

History and physical exam (Note: 10%
of cancers are palpable on rectal
exam), heme occult, CBC, barium
enema, colonoscopy

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30
Q 
COLORECTAL CARCINOMA
What disease does
microcytic anemia signify
until proven otherwise in a
man or postmenopausal
woman?
P312
A

Colon cancer

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31
Q

COLORECTAL CARCINOMA
What tests help find
metastases?
P312

A 
CXR (lung metastases), LFTs (liver
metastases), abdominal CT (liver
metastases), other tests based on
history and physical exam (e.g., head
CT for left arm weakness looking for
brain metastasis)
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32
Q 
COLORECTAL CARCINOMA
What is the preoperative
workup for colorectal
cancer?
P312
A

History, physical exam, LFTs, CEA, CBC,
Chem 10, PT/PTT, type and cross 2 u
PRBCs, CXR, U/A, abdominopelvic CT

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33
Q

COLORECTAL CARCINOMA
What are the means by
which the cancer spreads?
P312

A 
Direct extension: circumferentially and
    then through bowel wall to later
    invade other abdominoperineal organs
Hematogenous: portal circulation to liver;
    lumbar/vertebral veins to lungs
Lymphogenous: regional lymph nodes
Transperitoneal
Intraluminal
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34
Q

COLORECTAL CARCINOMA
Is CEA useful?
P312

A

Not for screening but for baseline and
recurrence surveillance (but offers no
proven survival benefit)

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35
Q 
COLORECTAL CARCINOMA
What unique diagnostic test
is helpful in patients with
rectal cancer?
P312
A

Endorectal ultrasound (probe is placed
transanally and depth of invasion and
nodes are evaluated)

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36
Q

COLORECTAL CARCINOMA
How are tumors staged?
P312

A

TMN staging system

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37
Q

COLORECTAL CARCINOMA
Give the TNM stages:
Stage I
P312

A

Invades submucosa or muscularis propria

T1–2 N0 M0

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38
Q

COLORECTAL CARCINOMA
Give the TNM stages:
Stage II
P312

A

Invades through muscularis propria or
surrounding structures but with negative
nodes (T3–4, N0, M0)

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39
Q

COLORECTAL CARCINOMA
Give the TNM stages:
Stage III
P313

A

Positive nodes, no distant metastasis

any T, N1–3, M0

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40
Q

COLORECTAL CARCINOMA
Give the TNM stages:
Stage IV
P313

A

Positive distant metastasis (any T, any

N, M1)

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41
Q 
COLORECTAL CARCINOMA
What is the approximate
5-year survival by stage:
Stage I?
P313
A

90%

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42
Q 
COLORECTAL CARCINOMA
What is the approximate
5-year survival by stage:
Stage II?
P313
A

70%

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43
Q 
COLORECTAL CARCINOMA
What is the approximate
5-year survival by stage:
Stage III?
P313
A

50%

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44
Q 
COLORECTAL CARCINOMA
What is the approximate
5-year survival by stage:
Stage IV?
P313
A

10%

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45
Q 
COLORECTAL CARCINOMA
What percentage of
patients with colorectal
cancer have liver metastases
on diagnosis?
P313
A

≈20%

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46
Q

COLORECTAL CARCINOMA
Define the preoperative
“bowel prep.”
P313

A 
Preoperative preparation for colon/rectal
resection:
    1. Golytely colonic lavage or Fleets
       Phospho-Soda until clear effluent
       per rectum
    2. PO antibiotics (1 gm neomycin and
        1 gm erythromycin  3 doses)
Note: Patient should also receive preoperative
and 24-hr IV antibiotics
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47
Q 
COLORECTAL CARCINOMA
What are the common
preoperative IV
antibiotics?
P313
A

Cefoxitin, Unasyn®

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48
Q 
COLORECTAL CARCINOMA
If the patient is allergic (hives,
swelling), what antibiotics
should be prescribed?
P313
A

IV Cipro® and Flagyl®

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49
Q

COLORECTAL CARCINOMA
What are the treatment
options?
P313

A

Resection: wide surgical resection of

lesion and its regional lymphatic drainage

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50
Q 
COLORECTAL CARCINOMA
What decides low anterior
resection (LAR) versus
abdominal perineal
resection (APR)?
P314
A

Distance from the anal verge, pelvis size

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51
Q

COLORECTAL CARCINOMA
What do all rectal cancer
operations include?
P314

A

Total mesorectal excision—remove the
rectal mesentery, including the lymph
nodes (LNs)

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52
Q

COLORECTAL CARCINOMA
What is the lowest LAR
possible?
P314

A 
Coloanal anastomosis (anastomosis
normal colon directly to anus)
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53
Q 
COLORECTAL CARCINOMA
What do some surgeons
do with any anastomosis
less than 5 cm from the
anus?
P314
A

Temporary ileostomy to “protect” the

anastomosis

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54
Q 
COLORECTAL CARCINOMA
What surgical margins
are needed for colon
cancer?
P314
A

Traditionally >5 cm; margins must be at

least 2 cm

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55
Q

COLORECTAL CARCINOMA
What is the minimal surgical
margin for rectal cancer?
P314

A

2 cm

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56
Q 
COLORECTAL CARCINOMA
How many lymph nodes
should be resected with a
colon cancer mass?
P314
A

12 LNs minimum = for staging, and may

improve prognosis

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57
Q 
COLORECTAL CARCINOMA
What is the adjuvant
treatment of stage III colon
cancer?
P314
A

5-FU and leucovorin (or levamisole)
chemotherapy (if there is nodal
metastasis postoperatively)

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58
Q 
COLORECTAL CARCINOMA
What is the adjuvant
treatment for T3–T4
rectal cancer?
P314
A

Preoperative radiation therapy and

5-FU chemotherapy as a “radiosensitizer”

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59
Q 
COLORECTAL CARCINOMA
What is the most
common site of distant
(hematogenous) metastasis
from colorectal cancer?
P314
A

Liver

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60
Q 
COLORECTAL CARCINOMA
What is the treatment of
liver metastases from
colorectal cancer?
P314
A

Resect with ≥1-cm margins and

administer chemotherapy if feasible

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61
Q

COLORECTAL CARCINOMA
What is the surveillance
regimen?
P315

A 
Physical exam, stool guaiac, CBC, CEA,
LFTs (every 3 months for 3 years, then
every 6 months for 2 years), CXR every
6 months for 2 years and then yearly,
colonoscopy at years 1 and 3 postoperatively,
CT scans directed by exam
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62
Q 
COLORECTAL CARCINOMA
Why is follow-up so
important the first 3
postoperative years?
P315
A

≈90% of colorectal recurrences are

within 3 years of surgery

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63
Q 
COLORECTAL CARCINOMA
What are the most common
causes of colonic obstruction
in the adult population?
P315
A

Colon cancer, diverticular disease,

colonic volvulus

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64
Q 
COLORECTAL CARCINOMA
What is the 5-year survival
rate after liver resection
with clean margins for colon
cancer liver metastasis?
P315
A

≈33% (28%–50%)

65
Q 
COLORECTAL CARCINOMA
What is the 5-year survival
rate after diagnosis of
unresectable colon cancer
liver metastasis?
P315
A

0%

66
Q

COLONIC AND RECTAL POLYPS
What are they?
P315

A

Tissue growth into bowel lumen, usually

consisting of mucosa, submucosa, or both

67
Q

COLONIC AND RECTAL POLYPS
How are they anatomically
classified?
P315

A

Sessile (flat)

Pedunculated (on a stalk)

68
Q 
COLONIC AND RECTAL POLYPS
What are the histologic classifications of the
following types:
Inflammatory
(pseudopolyp)?
P315
A

As in Crohn’s disease or ulcerative colitis

69
Q 
COLONIC AND RECTAL POLYPS
What are the histologic classifications of the
following types:
Hamartomatous?
P315
A

Normal tissue in abnormal configuration

70
Q 
COLONIC AND RECTAL POLYPS
What are the histologic classifications of the
following types:
Hyperplastic?
P315
A

Benign—normal cells—no malignant

potential

71
Q 
COLONIC AND RECTAL POLYPS
What are the histologic classifications of the
following types:
Neoplastic?
P316
A

Proliferation of undifferentiated cells;

premalignant or malignant cells

72
Q

COLONIC AND RECTAL POLYPS
What are the subtypes of
neoplastic polyps?
P316

A

Tubular adenomas (usually pedunculated)
Tubulovillous adenomas
Villous adenomas (usually sessile and look
like broccoli heads)

73
Q 
COLONIC AND RECTAL POLYPS
What determines malignant
potential of an adenomatous
polyp?
P316
A

Size
Histologic type
Atypia of cells

74
Q 
COLONIC AND RECTAL POLYPS
What is the most common
type of adenomatous
polyp?
P316
A

Tubular 85%

75
Q 
COLONIC AND RECTAL POLYPS
What is the correlation
between size and
malignancy?
P316
A 
Polyps larger than 2 cm have a high risk
of carcinoma (33%–55%)
76
Q 
COLONIC AND RECTAL POLYPS
What about histology and
cancer potential of an
adenomatous polyp?
P316
A

Villous > tubovillous > tubular (Think:

VILLous = VILLain)

77
Q 
COLONIC AND RECTAL POLYPS
What is the approximate percentage of carcinomas found in the following
polyps overall:
Tubular adenoma?
P316
A

5%

78
Q 
COLONIC AND RECTAL POLYPS
What is the approximate percentage of carcinomas found in the following
polyps overall:
Tubulovillous adenoma?
P316
A

20%

79
Q 
COLONIC AND RECTAL POLYPS
What is the approximate percentage of carcinomas found in the following
polyps overall:
Villous adenoma?
P316
A

40%

80
Q

COLONIC AND RECTAL POLYPS
Where are most polyps found?
P316

A

Rectosigmoid (30%)

81
Q

COLONIC AND RECTAL POLYPS
What are the signs/symptoms?
P316

A

Bleeding (red or dark blood), change in
bowel habits, mucus per rectum,
electrolyte loss, totally asymptomatic

82
Q

COLONIC AND RECTAL POLYPS
What are the diagnostic tests?
P316

A

Best = colonoscopy
Less sensitive for small polyps = barium
enema and sigmoidoscopy

83
Q

COLONIC AND RECTAL POLYPS
What is the treatment?
P317

A

Endoscopic resection (snared) if polyps;
large sessile villous adenomas should be
removed with bowel resection and lymph
node resection

84
Q 
POLYPOSIS SYNDROMES
FAMILIAL POLYPOSIS
What is another name for
this condition?
P317
A

Familial adenomatous polyposis (FAP)

85
Q

POLYPOSIS SYNDROMES
FAMILIAL POLYPOSIS
What are the characteristics?
P317

A

Hundreds of adenomatous polyps within
the rectum and colon that begin developing
at puberty; all undiagnosed; untreated
patients develop cancer by ages 40 to 50

86
Q 
POLYPOSIS SYNDROMES
FAMILIAL POLYPOSIS
What is the inheritance
pattern?
P317
A 
Autosomal dominant (i.e., 50% of
offspring)
87
Q

POLYPOSIS SYNDROMES
FAMILIAL POLYPOSIS
What is the genetic defect?
P317

A

APC (adenomatous polyposis coli) gene

88
Q

POLYPOSIS SYNDROMES
FAMILIAL POLYPOSIS
What is the treatment?
P317

A

Total proctocolectomy and ileostomy
Total colectomy and rectal mucosal
removal (mucosal proctectomy) and
ileoanal anastomosis

89
Q 
POLYPOSIS SYNDROMES
GARDNER’S SYNDROME
What are the
characteristics?
P317
A

Neoplastic polyps of the small bowel
and colon; cancer by age 40 in 100% of
undiagnosed patients, as in FAP

90
Q 
POLYPOSIS SYNDROMES
GARDNER’S SYNDROME
What are the other
associated findings?
P317
A

Desmoid tumors (in abdominal wall or
cavity), osteomas of skull (seen on x-ray),
sebaceous cysts, adrenal and thyroid
tumors, retroperitoneal fibrosis, duodenal
and periampullary tumors

91
Q 
POLYPOSIS SYNDROMES
GARDNER’S SYNDROME
How can the findings
associated with Gardner’s
syndrome be remembered?
P317
A

Think of a gardener planting “SOD”:
Sebaceous cysts
Osteomas
Desmoid tumors

92
Q

POLYPOSIS SYNDROMES
GARDNER’S SYNDROME
What is a desmoid tumor?
P318

A

Tumor of the musculoaponeurotic sheath,
usually of the abdominal wall; benign, but
grows locally; treated by wide resection

93
Q 
POLYPOSIS SYNDROMES
GARDNER’S SYNDROME
What medications may
slow the growth of a
desmoid tumor?
P318
A

Tamoxifen, sulindac, steroids

94
Q 
POLYPOSIS SYNDROMES
GARDNER’S SYNDROME
What is the inheritance
pattern?
P318
A

Varying degree of penetrance from an

autosomal-dominant gene

95
Q 
POLYPOSIS SYNDROMES
GARDNER’S SYNDROME
What is the treatment of
colon polyps in patients with
Gardner’s syndrome?
P318
A

Total proctocolectomy and ileostomy
Total colectomy and rectal mucosal
removal (mucosal proctectomy) and
ileoanal anastomosis

96
Q 
POLYPOSIS SYNDROMES
PEUTZ-JEGHERS’ SYNDROME
What are the
characteristics?
P318
A

Hamartomas throughout the GI tract

jejunum/ileum > colon > stomach

97
Q 
POLYPOSIS SYNDROMES
PEUTZ-JEGHERS’ SYNDROME
What is the associated
cancer risk from polyps?
P318
A

Increased

98
Q 
POLYPOSIS SYNDROMES
PEUTZ-JEGHERS’ SYNDROME
What is the associated
cancer risk for women with
Peutz-Jeghers?
P318
A 
Ovarian cancer (granulosa cell tumor is
most common)
99
Q 
POLYPOSIS SYNDROMES
PEUTZ-JEGHERS’ SYNDROME
What is the inheritance
pattern?
P318
A

Autosomal dominant

100
Q

POLYPOSIS SYNDROMES
PEUTZ-JEGHERS’ SYNDROME
What are the other signs?
P318

A

Melanotic pigmentation (black/brown)
of buccal mucosa (mouth), lips, digits,
palms, feet (soles)
(Think: Peutz = Pigmented)

101
Q

POLYPOSIS SYNDROMES
PEUTZ-JEGHERS’ SYNDROME
What is the treatment?
P318

A 
Removal of polyps, if symptomatic (i.e.,
bleeding, intussusception, or obstruction)
or large (>1.5 cm)
102
Q

POLYPOSIS SYNDROMES
PEUTZ-JEGHERS’ SYNDROME
What are juvenile polyps?
P318

A

Benign hamartomas in the small bowel
and colon; not premalignant; also known
as “retention polyps”

103
Q 
POLYPOSIS SYNDROMES
PEUTZ-JEGHERS’ SYNDROME
What is Cronkhite-Canada
syndrome?
P319
A

Diffuse GI hamartoma polyps (i.e., no
cancer potential) associated with
malabsorption/weight loss, diarrhea, and
loss of electrolytes/protein; signs include
alopecia, nail atrophy, skin pigmentation

104
Q

POLYPOSIS SYNDROMES
PEUTZ-JEGHERS’ SYNDROME
What is Turcot’s syndrome?
P319

A

Colon polyps with malignant CNS

tumors (glioblastoma multiforme)

105
Q

DIVERTICULAR DISEASE OF THE COLON
DIVERTICULOSIS
What is diverticulosis?
P319 (picture)

A 
Condition in which diverticula can be
found within the colon, especially the
sigmoid; diverticula are actually false
diverticula in that only mucosa and
submucosa herniate through the bowel
musculature; true diverticula involve all
layers of the bowel wall and are rare in
the colon
106
Q

DIVERTICULAR DISEASE OF THE COLON
DIVERTICULOSIS
Describe the pathophysiology
P319

A

Weakness in the bowel wall develops at
points where nutrient blood vessels enter
between antimesenteric and mesenteric
taeniae; increased intraluminal pressures
then cause herniation through these areas

107
Q

DIVERTICULAR DISEASE OF THE COLON
DIVERTICULOSIS
What is the incidence?
P319

A

≈50% to 60% in the United States by
age 60, with only 10% to 20% becoming
symptomatic

108
Q

DIVERTICULAR DISEASE OF THE COLON
DIVERTICULOSIS
What is the most common site?
P319

A

95% of people with diverticulosis have

sigmoid colon involvement

109
Q

DIVERTICULAR DISEASE OF THE COLON
DIVERTICULOSIS
Who is at risk?
P320

A

People with low-fiber diets, chronic
constipation, and a positive family
history; incidence increases with age

110
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULOSIS
What are the symptoms/
complications?
P320
A

Bleeding: may be massive

Diverticulitis, asymptomatic (80% of cases)

111
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULOSIS
What is the diagnostic approach:
Bleeding?
P320
A

Without signs of inflammation: colonoscopy

112
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULOSIS
What is the diagnostic approach:
Pain and signs of
inflammation?
P320
A

Abdominal/pelvic CT scan

113
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULOSIS
What is the treatment of
diverticulosis?
P320
A

High-fiber diet is recommended

114
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULOSIS
What are the indications
for operation with
diverticulosis?
P320
A

Complications of diverticulitis (e.g.,
fistula, obstruction, stricture); recurrent
episodes; hemorrhage; suspected carcinoma;
prolonged symptoms; abscess not
drainable by percutaneous approach

115
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULOSIS
When is it safe to get a
colonoscopy or barium
enema/sigmoidoscopy?
P320
A

Due to risk of perforation, this is
performed 6 weeks after inflammation
resolves to rule out colon cancer

116
Q

DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What is it?
P320

A

Infection or perforation of a diverticulum

117
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What is the
pathophysiology?
P320
A

Obstruction of diverticulum by a
fecalith leading to inflammation and
microperforation

118
Q

DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What are the signs/symptoms?
P320

A 
LLQ pain (cramping or steady), change in
bowel habits (diarrhea), fever, chills, anorexia,
LLQ mass, nausea/vomiting, dysuria
119
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What are the associated lab
findings?
P320
A

Increased WBCs

120
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What are the associated
radiographic findings?
P320
A

On x-ray: ileus, partially obstructed colon,
air-fluid levels, free air if perforated
On abdominal/pelvic CT scan: swollen,
edematous bowel wall; particularly
helpful in diagnosing an abscess

121
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What are the associated
barium enema findings?
P321
A

Barium enema should be avoided in

acute cases

122
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
Is colonoscopy safe in an
acute setting?
P321
A

No, there is increased risk of perforation

123
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What are the possible
complications?
P321
A

Abscess, diffuse peritonitis, fistula,

obstruction, perforation, stricture

124
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What is the most common
fistula with diverticulitis?
P321
A

Colovesical fistula (to bladder)

125
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What is the best test for
diverticulitis?
P321
A

CT scan

126
Q

DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What is the initial therapy?
P321

A

IV fluids, NPO, broad-spectrum
antibiotics with anaerobic coverage,
NG suction (as needed for emesis/ileus)

127
Q

DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
When is surgery warranted?
P321

A

Obstruction, fistula, free perforation,
abscess not amenable to percutaneous
drainage, sepsis, deterioration with initial
conservative treatment

128
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What is the lifelong risk of recurrence after:
First episode?
P321
A

33%

129
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What is the lifelong risk of recurrence after:
Second episode?
P321
A

50%

130
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What are the indications for
elective resection?
P321
A

Two episodes of diverticulitis; should be
considered after the first episode in a
young, diabetic, or immunosuppressed
patient

131
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What surgery is usually
performed ELECTIVELY
for recurrent bouts?
P321
A

One-stage operation: resection of involved
segment and primary anastomosis (with
preoperative bowel prep)

132
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What type of surgery is
usually performed for an
acute case of diverticulitis
with a complication (e.g.,
perforation, obstruction)?
P321
A 
Hartmann’s procedure: resection of
involved segment with an end colostomy
and stapled rectal stump (will need
subsequent reanastomosis of colon
usually after 2–3 postoperative months)
133
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What is the treatment of
diverticular abscess?
P322
A

Percutaneous drainage; if abscess is not
amenable to percutaneous drainage, then
surgical approach for drainage is necessary

134
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
How common is massive
lower GI bleeding with
diverticulitis?
P322
A

Very rare! Massive lower GI bleeding is

seen with diverticulosis, not diverticulitis

135
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What are the most common
causes of massive lower GI
bleeding in adults?
P322
A

Diverticulosis (especially right sided),

vascular ectasia

136
Q 
DIVERTICULAR DISEASE OF THE COLON
DIVERTICULITIS
What must you rule out in
any patient with diverticulitis/
diverticulosis?
P322
A

Colon cancer

137
Q

DIVERTICULAR DISEASE OF THE COLON
COLONIC VOLVULUS
What is it?
P322

A

Twisting of colon on itself about its
mesentery, resulting in obstruction and, if
complete, vascular compromise with
potential necrosis, perforation, or both

138
Q 
DIVERTICULAR DISEASE OF THE COLON
COLONIC VOLVULUS
What is the most common
type of colonic volvulus?
P322
A 
Sigmoid volvulus (makes sense because the
sigmoid is a redundant/“floppy” structure!)
139
Q

DIVERTICULAR DISEASE OF THE COLON
SIGMOID VOLVULUS
What is it?
P322 (picture)

A

Volvulus or “twist” in the sigmoid colon

140
Q

DIVERTICULAR DISEASE OF THE COLON
SIGMOID VOLVULUS
What is the incidence?
P323

A

≈75% of colonic volvulus cases (Think:

Sigmoid = Superior)

141
Q 
DIVERTICULAR DISEASE OF THE COLON
SIGMOID VOLVULUS
What are the etiologic
factors?
P323
A 
High-residue diet resulting in bulky stools
and tortuous, elongated colon; chronic
constipation; laxative abuse; pregnancy;
seen most commonly in bedridden elderly
or institutionalized patients, many of
whom have history of prior abdominal
surgery or distal colonic obstruction
142
Q

DIVERTICULAR DISEASE OF THE COLON
SIGMOID VOLVULUS
What are the signs/symptoms?
P323

A

Acute abdominal pain, progressive
abdominal distention, anorexia,
obstipation, cramps, nausea/vomiting

143
Q 
DIVERTICULAR DISEASE OF THE COLON
SIGMOID VOLVULUS
What findings are evident
on abdominal plain film?
P323
A

Distended loop of sigmoid colon, often in
the classic “bent inner tube” or “omega”
sign with the loop aiming toward the RUQ

144
Q 
DIVERTICULAR DISEASE OF THE COLON
SIGMOID VOLVULUS
What are the signs of necrotic
bowel in colonic volvulus?
P323
A

Free air, pneumatosis (air in bowel wall)

145
Q

DIVERTICULAR DISEASE OF THE COLON
SIGMOID VOLVULUS
How is the diagnosis made?
P323

A

Sigmoidoscopy or radiographic exam with

gastrografin enema

146
Q 
DIVERTICULAR DISEASE OF THE COLON
SIGMOID VOLVULUS
Under what conditions is
gastrografin enema useful?
P323
A

If sigmoidoscopy and plain films fail to
confirm the diagnosis; “bird’s beak” is
pathognomonic seen on enema contrast
study as the contrast comes to a sharp end

147
Q 
DIVERTICULAR DISEASE OF THE COLON
SIGMOID VOLVULUS
What are the signs of
strangulation?
P323
A 
Discolored or hemorrhagic mucosa on
sigmoidoscopy, bloody fluid in the
rectum, frank ulceration or necrosis at
the point of the twist, peritoneal signs,
fever, hypotension, ↑ WBCs
148
Q 
DIVERTICULAR DISEASE OF THE COLON
SIGMOID VOLVULUS
What is the initial
treatment?
P323
A 
Nonoperative: If there is no strangulation,
sigmoidoscopic reduction is successful
in ≈85% of cases; enema study will
occasionally reduce (5%)
149
Q 
DIVERTICULAR DISEASE OF THE COLON
SIGMOID VOLVULUS
What is the percentage
of recurrence after
nonoperative reduction
of a sigmoid volvulus?
P323
A

≈40%!

150
Q 
DIVERTICULAR DISEASE OF THE COLON
SIGMOID VOLVULUS
What are the indications for
surgery?
P324
A 
Emergently if strangulation is suspected
or nonoperative reduction unsuccessful
(Hartmann’s procedure); most patients
should undergo resection during same
hospitalization of redundant sigmoid after
successful nonoperative reduction
because of high recurrence rate (40%)
151
Q

DIVERTICULAR DISEASE OF THE COLON
CECAL VOLVULUS
What is it?
P324

A

Twisting of the cecum upon itself and the

mesentery

152
Q 
DIVERTICULAR DISEASE OF THE COLON
CECAL VOLVULUS
What is a cecal “bascule”
volvulus?
P324
A

Instead of the more common axial
twist, the cecum folds upward (lies on the
ascending colon)

153
Q

DIVERTICULAR DISEASE OF THE COLON
CECAL VOLVULUS
What is the incidence?
P324

A

≈25% of colonic volvulus (i.e., much less

common than sigmoid volvulus)

154
Q

DIVERTICULAR DISEASE OF THE COLON
CECAL VOLVULUS
What is the etiology?
P324

A

Idiopathic, poor fixation of the right
colon, many patients have history of
abdominal surgery

155
Q 
DIVERTICULAR DISEASE OF THE COLON
CECAL VOLVULUS
What are the signs/
symptoms?
P324
A 
Acute onset of abdominal or colicky pain
beginning in the RLQ and progressing to
a constant pain, vomiting, obstipation,
abdominal distention, and SBO; many
patients will have had previous similar
episodes
156
Q

DIVERTICULAR DISEASE OF THE COLON
CECAL VOLVULUS
How is the diagnosis made?
P324

A 
Abdominal plain film; dilated, ovoid
colon with large air/fluid level in the
RLQ often forming the classic “coffee
bean” sign with the apex aiming toward
the epigastrium or LUQ (must rule out
gastric dilation with NG aspiration)
157
Q 
DIVERTICULAR DISEASE OF THE COLON
CECAL VOLVULUS
What diagnostic studies
should be performed?
P324
A

Water-soluble contrast study (gastrografin),

if diagnosis cannot be made by AXR

158
Q

DIVERTICULAR DISEASE OF THE COLON
CECAL VOLVULUS
What is the treatment?
P324

A

Emergent surgery, right colectomy with
primary anastomosis or ileostomy and
mucous fistula (primary anastomosis may
be performed in stable patients)

159
Q 
DIVERTICULAR DISEASE OF THE COLON
CECAL VOLVULUS
What are the major
differences in the
EMERGENT management
of cecal volvulus versus
sigmoid?
P325
A 
Patients with cecal volvulus require
surgical reduction, whereas the vast
majority of patients with sigmoid volvulus
undergo initial endoscopic reduction of
the twist

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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