Colon, Rectum, Anus Flashcards by Clyde Silverio

What are the special features of the colon?

Haustrations
Appendices epiploicae
Taenia coli

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What are the components of taenia coli

Taenia libera
Taenia mesocolica
Taenia omentalis

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[Segment of the colon]

widest, least likely to obstruct

cecum

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[Segment of the colon]

thinnest wall, most common site of perforation

cecum

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[Segment of the colon]

what is the length of the ascending colon?

13cm

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[Segment of the colon]

Which is higher, the left or right colic flexure?

left

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[Segment of the colon]

what is the narrowest portion, most common site of obstruction

sigmoid colin

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[Segment of the colon]

most common site of volvulus

sigmoid colon

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[Segment of the colon]

Extremely mobile segment

sigmoid

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What is the embryologic origin of transverse colon?

Proximal - midgut

2. Distal - hindgut

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[Segment of the colon]

long straight “tunnel view”

Descending colon

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[Segment of the colon]

external bulging bluish mass indenting the colon, descending with respiration

splenic flexure

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[Segment of the colon]

“cathedral ceiling” appearance

Transverse colon

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[Segment of the colon]

“fool’s cecum”

Hepatic flexure

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[Segment of the colon]

spiral configuration which can cause the taenia to approximate each other

Hepatic flexure

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[Segment of the colon]

mercedes benz sign

cecum

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[Segment of the colon]

pouting lips sign

ileocecal valve

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[Segment of the colon]

bow and arrow sign

appendiceal orifice

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What are the branches of your SMA that supplies the colon?

Ileocolic
Right colic
Middle colic

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What are the branches of your IMA that supplies the colon?

Left colic
Sigmoidal branches
Superior rectal

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What are the arteries that anastomose in marginal artery of Drummond?

Terminal branches of the SMA and IMA

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What do you call the anastomosis between the middle colic artery and the SMA and the ascending branch of the left colic artery of the IMA?

Arc of Riolan or meandering artery of Moskowitz

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The inferior mesenteric vein joins this vein before draining to the portal vein

Splenic vein

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What are the foregut derivatives of the GIT?

Esophagus
Stomach
Pancreas
Liver
Duodenum

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What are the midgut derivatives of the GIT?

1. Small intestine 2. Ascending colon 3. Proximal colon 4. Transverse colon

What are the hindgut derivatives of the GIT?

1. Distal transverse 2. Descending 3. Rectum 4. Proximal anus

what do you see in the water soluble contrast enema in patients with Sigmoid volvulus?

birds beak deformity

What are the plain abdomen radiographs findings in patients with sigmoid volvulus?

1. Inverted U shaped 2. Sausage loop 3. Omega sign 4. Coffee bean sign 5. Bent inner tube sign

What is the surgical management for strangulation/unprepared bowel in patients with sigmoid volvulus?

Construction of colostomy Hartmann's pouch

What is the surgical management for patients with cecal volvulus?

Right hemicolectomy with primary ileotransverse anastomosis

[Diagnosis] loop extending from the RLQ to LUQ

Cecal volvulus

[Diagnosis] loop extending from the LLQ to the RUQ

Sigmoid volvulus

What is the standard initial therapy for acute sigmoid volvulus?

Endoscopic Detorsion / rigid proctosigmoidoscopy

What is the treatment for failed sigmoid volvulus decompression?

Emergency Laparotomy and those with peritonitis too

What are the Abdominal CT scan findings in patients with diverticulitis?

1. Sigmoid diverticula 2. Thickened colonic wall >4mm 3. Inflammation with pericolic fat with or without collection of contrast material or fluid

In patients with uncomplicated diverticulitis, how long will you administer a clear liquid diet and broad spectrum antibiotics?

7-10 days

What is the surgical management for patients with diverticulitis with abscess

drainage

What are the criteria for admission in patients with uncomplicated diverticulitis?

1. High documented fever 2. Immunocompromised status 3. Severe abdominal pain 4. Significant or unstable comorbid conditions 5. Inability to tolerate oral intake

[Determine the hinchey Stage] Diverticulitis with a pericolic abscess

Stage I Tx: Percutaneous drainage of abscess, resection with primary anastomosis without diverting stoma

[Determine the hinchey Stage] diverticulitis with a distant abscess (retroperitoneal, pelvic)

Stage II Tx: percutaneous drainage of abscess, resection with primary anastomosis

[Determine the hinchey Stage] Purulent peritonitis

Stage III | Tx: Hartmann procedure, Diverting colostomy plus percutaneous draninage

[Determine the hinchey Stage] fecal peritonitis

Stage IV Tx: hartman procedure plus diverting colostomy plus percutaneous drainage

What is the preferred surgical treatment for patients with right sided diverticulitis?

Segmental ileocecal resection

What is the anatomic marker to distinguish LGIB from UGIB

Ligament of treitz

[Location of LGIB] Hematochezia

LGIB from left side of colon Rule out massive UGIB

[Location of LGIB] Maroon-colored stools

LGIB from right side of colon

[Location of LGIB] melena

Cecal bleeding BUT TYPICALLY SEEN IN UGIB

What is the rationale behind doing NGT aspiration in patients with suspected LGIB?

Determine the presence or absence of blood proximal to the ligament of treitz

What is the test of choice to identify site of LGIB (which can also be therapeutic)

Colonoscopy

What are the drug choices for vasoconstricting agents in patients with LGIB?

1. Vasopressin 2. Alcohol 3. Morrhuate sodium or Sodium tetradecyl sulfate

[Inflammatory bowel disease] Appendectomy is protective

ulcerative colitis

[Inflammatory bowel disease] smoking may prevent disease

ulcerative colitis

[Inflammatory bowel disease] affects any part of the GIT, cobblestone appearance, transmural

Crohn Disease

What is the pathognomonic feature of Crohn Disease?

Granulomas

[Inflammatory bowel disease] megacolon is frequent

ulcerative colitis

What are the indications for surgery in patients with ulcerative colitis?

1. Active disease unresponsive to medical therapy 2. Risk of CA 3. Severe bleeding

What are the indications for surgery in patients with crohn disease?

1. Management of complications | 2. Resect a segment that is grossly involved with the disease

[Colorectal CA Pathogenesis: Gene involved] Normal epithelium to Dysplastic epithelium

APC

[Colorectal CA Pathogenesis: Gene involved] Early adenoma to intermediate adenoma

KRAS

[Colorectal CA Pathogenesis: Gene involved] Late adenoma to CA

p53

[Colorectal CA Pathogenesis: Genetic pathways] chromosomal deletions and aneuploidy; tumors occur in the more distal colon, associated with a poorer prognosis

LOJ

[Colorectal CA Pathogenesis: Genetic pathways] results from errors in mismatch repair and microsatellite instability; tumors are more likely right sided with diploid DNA; better prognosis

Replication error pathway

[Colorectal CA Pathogenesis: Genetic pathways] Also called serrated methylated pathway, epigenetic alterations caused by hypo or hypermethylation of a promoter region resulting to either gene activation or silencing; observed in serrated type of polyps

CpG island methylation pathway

Most common location of colorectal polyp?

rectosigmoid area

What is the most common histologic type of colorectal polyp?

Hyperplastic polyp

Hyperplastic colorectal polyp are considered pre-malignant is its size becomes _____

>2cm

What is the histologic type of colorectal polyp that is asociated with UC and CD?

Inflammatory or pseudopolyp

Which histologic type of colorectal polyp is considered premalignant and is treated like an adenomatous polyp?

Serrated polyp

____ classification is a clinical tool used to describe the degree of invasion into a pedunculated polyp

Haggitt

[Neoplastic Polyp] Most common type

Tubular adenoma CA risk <5%

[Neoplastic Polyp] Seen throughout the large intestine

Tubulovillous adenoma CA risk 25%

[Neoplastic Polyp] predominantly in the rectum

Villous adenoma CA risk 40%

[Neoplastic Polyp] sessile, velvety, cauliflowerlike grossly

Villous adenoma CA risk 40%

What is the clinical classification used only for sessile colorectal polyp?

Kikuchi Classification

[Haggitt Classification] CA invading though the muscularis mucosa but limited to the head of a peduculated polyp

Level 1

[Haggitt Classification] CA invading the neck of a pedunculated polyp

Level 2

[Haggitt Classification] CA invading the stalk of a pedunculated polyp

Level 3

[Haggitt Classification] CA invading into the submucosa of the bowel wall below the stalk of a pedunculated polyp

Level 4 Risk of LN metastasis: 12 to 25%

Oncologic resection is warranted for what Kikuchi or Haggitt Grade

Kikuchi SM 3 | Haggitt 4

[Kikuchi Classification] Superficial 1/3 of the submucosa is involved

SM 1 Nodal mets = 2%

[Kikuchi Classification] Superficial 2/3 of the submucosa is involved

SM 2 Nodal mets = 8%

[Kikuchi Classification] deep 1/3 of the submucosa is involved

SM 3 Nodal mets = 23%

Early onset colorectal CA due to HNPCC are predominantly seen in which side of the colon? (Right or left)

Right

What are the components of your Amsterdam Criteria for diagnosis of HNPCC?

3-2-1 rule 3 relatives have histologically verified colorectal CA (one must be first degree relative) 2 successive generations 1 relative must have received a diagnosis before age 50 Exclude FAP

What variant of HNPCC wherein there is an isolated early onset colorectal CA?

Lynch Syndrome 1

What variant of HNPCC wherein the colorectal CA and tumors of the endometrium, ovary, stomach, small bowel, hepatobiliary tract, pancreas, ureter, renal pelvis?

Lynch Syndrome II

____ refers to a rare hereditary, autosomal dominant cancer, affected genes are MLH1, MSH2, MSH6

Muir-Torre Syndrome

What are the findings consistent with Peutz-Jegher Syndrome?

Hamartomas

[Diagnosis] rectal bleeding, IDA, change in bowel habits, abdominal pain, intestinal obstruction

Colorectal CA

[Right or left sided colorectal CA] occult bleeding, anemia, melena, postprandial discomfort, weakness

Right side since it has large lumen, tumor must attain a large size before causing symptoms

[Right or left sided colorectal CA] goat-stool-like stools, colicky pain, alternating diarrhea, constipation, bloody stools, tenesmus

Left side Since it has a smaller lumen, symptoms can present earlier

[Colorectal CA Early Detection] When will you begin screening men an women who are at average risk for developing colorectal CA?

50 years old

[Colorectal CA Early Detection] FOBT or FIT should be done every __

Yearly

[Colorectal CA Early Detection] Flexible sigmoidoscopy should be done every

5 years

[Colorectal CA Early Detection] FOBT or FIT + Flexible Sigmoidoscopy should be done every

5 years

[Colorectal CA Early Detection] Double contrast barium enema should be done every

5 years

[Colorectal CA Early Detection] Colorectal CA should be done every ____

10 years

[Colorectal CA Early Detection] What is the best screening tool for Colorectal CA?

Colonoscopy

What screening test for colorectal CA what is both diagnostic and therapeutic?

Colonoscopy

What tumors of the colon can be reached via Digital Rectal Exam and Anoscopy?

Only mid and distal rectum

A rigid proctoscopy can only cover what length of the colon?

25cm

What is the preferred method in evaluating the rectum? (Rigid or flexible instrument)

Rigid or Flexible Fexible sigmoidoscopy gives inaccurate measurements if used at the rectum

What are the advantages of using flexible sigmoidoscopy?

1. Reaches the proximal left colon | 2. Reaches the splenic flexure

What is the role of imaging techniques like contrast enema, CT, MRI, transrectal UTZ in colorectal CA?

Important in the evaluation, staging, follow-up

CEA as a marker for colorectal CA is produced by what cells in the intestinal mucosa?

Cells originating from the primitive endoderm

What is the role of CEA monitoring in Colorectal CA?

used for treatment monitoring Its rise after successful surgical resection suggests recurrence

[Rectal UTZ finding] UT1 means that the mass invades the ___

Submucosa

[Rectal UTZ finding] UT2 means that the mass invades the ___

Muscularis propria

[Rectal UTZ finding] UT3 means that the mass invades the ___

Perirectal Fat

[Rectal UTZ finding] UT4 means that the mass invades the ___

Adjacent organs

[Colorectal CA Stage] Tumor in the submucosa Node involvement No metastasis

Stage III ANT tumor, with LN involvement, stage 3 agad

What is used in mechanical cleansing lavage solution prior to colorectal CA surgical treatment?

Polyethelyne glycol in a balanced salt solution 4 liters in 4 hours

What are the antibiotic of choice for bowel preparation prior to colorectal CA surgery?

Neomycin + erythromycin one day beofre the operation 1pm, 2pm and 11pm

[Surgical Management] If the tumor is located in the cecum

Right hemicolectomy Extent: Terminal ileum to mid transverse colon

[Surgical Management] If the tumor is located in the ascending colon

Right hemicolectomy Extent: Terminal ileum to mid transverse colon

[Surgical Management] If the tumor is located in the hepatic flexure

extended right hemicolectomy Extent: Terminal ileum to distal transverse colon

[Surgical Management] If the tumor is located in the splenic flexure

Extended left hemicolectomy Extent: splenic flexure to rectosigmoid junction

[Surgical Management] If the tumor is located in the descending colon

left hemicolectomy Extent: splenic flexure to rectosigmoid junction

[Surgical Management] If the tumor is located in the sigmoid colon

rectosigmoid resection Extent: distal descending colon to rectosigmoid junction

What are the indications for total or subtotal colectomy with ileorectal anastomosis?

1. HNPCC 2. Attenuated FAP 3. Synchronous CA in separate colon segments 4. Acute malignant distal colon obstructions with unknown status of proximal bowel

What are the post-operative components ERAS protocol for elective colorectal surgery?

1. Early oral nutrition 2. Early ambulation 3. Early catheter removal 4. Use of chewing gum 5. Defined discharge criteria

What are the intra-operative components ERAS protocol for elective colorectal surgery?

1. Active warming 2. Use of multi-modal pain management 3. Surgical techniques 4. Avoidance or prophylactic NG tubes and drains

What are the ERAS protocol components for elective colorectal surgery that are applicable to both intra-and post-operative??

1. Use of multi-modal anti-emetic prophylaxis | 2. Use of goal directed peri-operative fluid therapy

What are the major blood vessels (artery) affected in right hemicolectomy?

1. Ileocolic 2. Right colic 3. Right branch of middle colic

What are the major blood vessels (artery) affected in extended right hemicolectomy?

1. Ileocolic 2. Right colic 3. Root of middle colic

What are the major blood vessels (artery) affected in extended left hemicolectomy?

1. Left branch middle colic 2. Left colic 3. Inferior mesenteric

What are the major blood vessels (artery) affected in left hemicolectomy?

1. Inferior mesenteric | 2. Left colic

What are the major blood vessels (artery) affected in rectosigmoid resection?

1. Inferior mesenteric | 2. Superior rectal

At what vertebral level where the sigmoid loses its mesentery and gradually becomes the rectum?

Mid sacral level

Which part of the valve of houston wherein the convexity is to the left

middle

Which of the valve od houston wherein the convexity is to the left

upper and middle

What is the eponym of the middle valve of rectum

Kohlrausch valve

What is the level corresponding the kohlraush valve?

anterior peritoneal reflection

What is the most consistent valve of the rectum

Middle valve (Kohlraush valve)

What is the anatomic landmark of proximal rectum?

Third Sacral Vertebra (S3)

What is the anatomic landmark of distal rectum?

Dentate line

What is the Surgical landmark of proximal rectum?

Sacral promontory

What is the surgical landmark of proximal rectum?

anorectal ring

What do you call the part of the anal canal that remains closed when the buttocks are gently retracted

Anal verge

What do you call the perianal skin overlying outside the anal verge?

anal margin

What do you call the longitudinal mucosal folds of the anus?

Columns of morgagni 8-14 longitudinal muscle folds

What are the borders of the anatomic canal of the rectum?

Anal verge to Dentate line Length: 1 to 1.5cm

What are the borders of the surgical canal of the rectum?

Anal verge and Anorectal line Length: 2 to 2.5cm

The external anal sphincter is a continuation of what muscle?

Puborectalis

Muscle of the anal canal that represents the distal condensation of the circular muscle layer

Internal sphincter

The conjoined longitudinal muscle of the anal canal is composed of ____

1. Outer longitudinal layer of the rectum | 2. Fibers of the levator ani muscle

What are the functions of the conjoined longitudinal muscle?

1. Attach the anorectum to the pelvis 2. Skeleton that supports and binds the internal and external sphincter complex 3. Acts as a support to prevent hemorrhoidal and rectal prolapse 4. Potentialization effect in maintaining an anal seal

What are the components of levator ani muscle?

1 .Pubococcygeus 2. Iliococcygeus 3. Puborectalis

[Fascial Layers of the anorectal region] lines the rectum, part of the visceral layer of the endopelvic fascia

Fascia propria

[Fascial Layers of the anorectal region] separates the anterior rectum from the vagina in females and prostate and seminal vesicle from males

Denonvilliers fascia

[Fascial Layers of the anorectal region] fascial condensation between the fascia propria and the presacral fascia at the level of S4

Waldeyer fascia (Rectosacral fascia)

[Fascial Layers of the anorectal region] separates the posterior rectum from the sacral vessels and pelvic nerves

Presacral fascia

[Arterial supply of the rectum] From the terminal branch of the IMA

Superior rectal

[Arterial supply of the rectum] From the internal iliac artery

Middle rectal

[Arterial supply of the rectum] from the internal pudendal artery

Inferior rectal artery

What is the venous drainage of the structures above dentate line

Inferior mesenteric vein then to the portal vein

What is the venous drainage of the structures below the dentate line

Drains to the internal pudendal vein then to the internal iliac vein

[Lymphatic drainage of the rectum and anus] The upper and middle rectum

Pararectal nodes then to inferior mesenteric node

[Lymphatic drainage of the rectum and anus] lower rectum

para rectal nodes then to inferior mesenteric and internal iloac nodes

[Lymphatic drainage of the rectum and anus] anal canal above the dentate line

inferior mesenteric and internal iliac nodes

[Lymphatic drainage of the rectum and anus] anal canal below the dentate line

primarily into the medial group of superficial inguinal nodes

What is the importance of the mesorectum?

can be a metastatic site for rectal CA

What are the indications of low anterior resection?

1. Lesions in the middle and upper third of the rectum

___ is also called an anal-sparing procedure for tumors in the middle and upper third of the rectum

LAR Temporary colostomy or ileostomy might be necessary to protect anastomosis

What structures are removed in the abdominoperineal resection of Rectal tumors?

1. Sigmoid colon 2. Rectum 3. Anus APR: permanent colostomy cinstruction

What are the indcations for APR?

1. Perianal skin involvement 2. Puborectalis and sphincter involvement 3. Fecal incontinence

[Diagnosis] Abdominal discomfort, incomplete bowel evacuation, straining due to difficult defecation, digital maneuvers to help defecation, long term laxative use

Rectal proplapse Hemorrhoids has no associated SSx

[Rectal prolapse or Hemorrhoids] double rectal wall on palpation/DRE

Rectal prolapse In hemorrhoids, hemorrhoidal plexus are palpated

[Rectal prolapse or Hemorrhoids] tissue folds are radial

hemorrhoids in Rectal prolapse, the tissue folds are circumferential

What is the preferred surgical procedure for an elderly patient with multiple comorbidities with rectal prolapse?

Transperineal approach

What are examples of your transperineal approach for rectal prolapse management?

1. Anal encirclement (thiersh wire procedure) 2. Mucosal sleeve resection (delorme) 3. Perineal rectosigmoidoscopy (altemeier procedure)

What are the main hemorrhoidal complexes that traverse the anal canal

3-7-11 1. Left lateral (3 o'clock) 2. Right posterior (7 o'clock) 3. Right anterior (11 o'clock)

[External or internal hemorrhoids] itching, pain, thrombosed

External hemorrhouds

What is the most effective topical treatment for relief of symptoms of patients with hemorrhoids

Warm Sitz Bath 40 degC, soak for 15 mins

What will be the effect to the patient if the rubber band ligation for an internal hemorrhoid is done close to the dentate line?

Intense pain post procedure

What will you do if a patient with external hemorrhoid presents with intense pain <72 hours onset?

Offer excision

[management of choice: Internal Hemorrhoids] Protruding through the anal canal but not beyond the anal verge

This is Grade I Offer medical, sclerotherapy, RBL

[management of choice: Internal Hemorrhoids] protrusion but with spontaneous reduction

This is Grade II Offer medical, sclerotherapy and RBL

[management of choice: Internal Hemorrhoids] protrusion requiring manual reduction

This is grade 3 offer medical and surgical. in selected cases, sclerotherapy and RBL

[management of choice: Internal Hemorrhoids] protrusion that cannot be reduced

Medical and surgical. You cannot do sclerotherapy or RBL

What do you call (eponym) a hemorrhoidectomy technique wherein you close the dfect first after hemorrhoidectomy

Parks-Ferguson hemorrhoidectomy

What is the preferred surgical technique for patients with thrombosed hemorrhoids?

Milligan-Morgan Method DO NOT SUTURE THE DEFECT

Where is the tear located in patients with anal fissure?

distal to the dentate line

How will you drain a supralevator abscess that is a result from an upward extension of an inter-sphincteric abscess?

Drain transrectally Remember: intersphincteric between sphincters

Why will you not do a transperineal drainage for a supralevator abscess from an upward extension of an intersphincteric abscess?

It can cause a suprasphincteric fistula Remember: intersphincteric = between 2 sphincters

How will you drain a supralevator abscess that is a result of upward extension of a trans-sphincteric fistula or an ischiorectal abscess?

Drain transperineally If drained transrectally, extra sphincteric fistula will be the result

What is the surgical treatment of choice for superficial fistula-in-ano?

Fistulotomy

What is the surgical treatment of choice for intersphincteric tract?

Ligation of intersphincteric fistula tract

A fistula that originates anterior to the tranverse line will course ____

Anteriorly in a direct or radial route Except if the anterior fistula lies more than 3cm from the anus can have a curvilinear tract draining to the posterior midline

A fistula that originate posterior to the transverse line will have a ))))

curved path; the internal opening is at the posterior midline

[Crohn or UC] which is associated with perianal fistula?

Crohn's

[Anal canal/anal margin tumors] lesions that cannot be visualized at all while gentle traction is placed on the buttocks

Anal canal tumor above the dentate line

[Anal canal/anal margin tumors] lesion completely visible when gentle traction is placed in the buttocks

Anal margin tumors below the dentate line

Tumors that fall more than 5cm from the radius of the anal opening is classified as?

skin tumor not anal canal/margin tumor

Where is the usual location of more advance anal region neoplasm?

distal anal canal

What are the components of staging workup for anal CA?

1. CT of the chest, abdomen, pelvis | 2. Trans anal UTZ to assess depth of invasion and establish size of tumor

What is the medical management for anal canal CA?

Nigro Protocol 5FU, Mitomycin C, Radiotherapy

What is the surgical management of choice for patients with <1cm, well differentiated anal canal SCCA?

1Wide local excision

What is the surgical management of choice for anal SCCA sessile lesions?

Remove via piecemeal tecnhique

What is the surgical management for an anal margin SCC with no sphincter invasion?

Wide local excision to negative margins

What is the surgical management for an anal margin SCC with sphincter invasion or a significantly large mass?

Chemotherapy + radiotherapy

What is the surgical management for an anal margin SCC that is <2cm, well-differentiated, without evidence of nodal spread

Anal margin SCC

What is the surgical management for an anal margin SCC if adequate excision compromises sphincter?

Do APR

In patients with Hirschsprung disease, what will be the use of doing Barium enema?

Demonstrate transition zone

What will be demonstrated in suction rectal biopsy for patients with hirschsprung disease>

1. Absence of ganglion cells in the myenteric and submucosal plexus 2. Increased acetylcholinesterase positive nerve fibers 3. Hypertrophied nerve bundles

[Surgical Options for hirschsprung] side to side anastomosis; residual pouch of aganglionic bowel left intact with the ganglionic bowel attached behind

Duhamel Duha = side to side

[Surgical Options for hirschsprung] Resection of aganglionic segment with end to end anastomosis

Swenson simple connection lang

[Surgical Options for hirschsprung] mucosa of aganglionic segment stripped but the outer muscular cuff is left, and anastomosis is done

Soave strip aganglionic segment

What is the anatomic marker to distinguish a high vs low type imperforate anus?

Levator ani

What do you call an x-ray imaging technique specifically used to assess imperforate anus?

Rice Wangensteen X-ray Cross table lateral

What is the surgical management for low type imperforate anus?

Perineal approach without colostomy

What will be the surgical technique for a high type imperforate anus?

Colostomy then pull-through

What are the anatomic markers seen in rice wangensteen x-ray that used to classify imporforate anus

Pubococcygeus (PC) Ischial Spine (I line) M line

[Classify the imperforate anus] gas bubble is above the PC line

High anomaly imperforate anus

Colon, Rectum, Anus Flashcards

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