Colorectal Flashcards

Question

Survival Rates for Colon cancer

Answer 1

Overall 5yr survival rate is 60% Stage 1 approx 95% Stage 2 85% Stage 3 65% Metastatic or stage 4 colon cancer approx 10%

Answer 2

Described by Hohenberger 2009 3 main principles 1)Disection along embryological planes (keeping visceral fascial layer intact) 2)Transection of vascular pedicles (SMV -right, IMA - Left) 3) Appropriate longitudinal resection margins

Answer 3

Autosomal dominant Germline mutation of APC on 5q 20% occur due to new mutation If left untreated have CRC by 40

Answer 4

Congenital hypertrophy of retinal pigment epithelium Osteomas of skull and mandible Dental abnormalities Epidermoid cysts and firbomas Desmoid tumours Fundic glad polyps Duodenal and periampullary polyps - duodenal cancers Associated with other cancers - medulloblastoma, hepatoblastoma, thyroid cancer, gastric cancer, pancreatic cancer and adrenal caner Turcot syndrome - colonic polyps and brain tumour Gardner syndrome - dermoid, thyroid and oestomas wit colonic polyposis

Answer 5

Annual Colonoscopy and polypectomy till surgery starting at 12-15 OGD (side viewing scope) from 25 to 30 depending of spigelman stage -Stage 0-1 5yrs -stage 2 -3yrs -stage3 - 2yrs -stage4 - consider surgery

Answer 6

Occur in approx 15% of patients Benign and rarely Met but can cause compression Sulindac with Tamoxifen with intra-abdominal and abdominal call desmoid Chemo/radio for larger or rapidly growth tumours Surgery is controversial and risky

Answer 7

No guidelines Consider when large number of larger adenomas (>5mm) or adenomas with high degree of dysplasia Usually between 15-25 to avoid major disruption to life

Answer 8

Get to meet Pouch patient and specialist nurse Good function is 4-6 motions and day and 2 at night - 50% need loperamide to achieve Complications 20% have complications 25% need readmitting within 30days 1in17 need re-operatio 10-15% rate of failure at 10-25yrs Anastomotic leak 5% Pelvic sepsis 15-20% Pouchitis 10% Adhesions, strictures and SBO approx 20% (half need surgery) Reduced fertility, impotence and ED Mortality is low at <0.5%

Answer 9

Colonoscopy, anal manometry and endoanal ultrasound

Answer 10

Initially - dietary modification, bulking agents and loperamide. Can consider glycerol suppositories to empty If unsuccessful the refer to specialist nurse for pelvic floor exercise, biofeedback and consideration of rectal irrigation

Answer 11

Cochrane review 2015 - supported use for faecal incontinence Trail period - temp leads into S3 foramen each side (bellows from elevator and plantar flexion or toe). Connected to external stimulator for 5-7 days. Bowel diary is kept and compared to baseline. If >50% improvement is deemed success Complications 10% (infection, bleeding, serum, pain, nerve injury, new defacectoy problems Need to treat like a pacemaker - MRI and diathermy Follow up - every 6-12months Succesfull in around 80% of patients

Answer 12

Posterior tibial nerve stimulation - NICE approved - 12 sessions leading to 50-70% success Anal plugs Sphincter repair if defect Artificial Neo-sphincters (magnetic FENIX) Buling agents

Answer 13

Hx - possible concomitant slow transit constipation, obstructive defaecation and faecal incontinence Urinary incontience and vaginal prolapse Examination - Abdo and PR. Inspect for apparent prolapse, perianal scars, deformity and evidence of soiling Ask patient to bear down and look for rectal or mucosal prolapse and perineal decent On DRE try to assess for rectal prolapse take-off (high or low) and note if anus is patulous Assess anal tone at rest and squeezing or sphincter defects Associated vaginal prolapse Perform proctoscopic examination

Answer 14

Split into Abdominal or perineal approach Cochraine review 2008 no difference in recurrence rate and PROPSPER trail in 2013 again showed no difference in rates If young and healthy - Lap Ventral rectoplexi - Pelvic Floor Society in UK statement mesh lower risk than in transvaginal procedures If old <5cm Delormes >5cm Altemeiers (Perineal proctosigmoidectomy)

Answer 15

Rome 4 Criteria (fulfilled for <3/12 with symptom onset at least 6/12 prior) 1) Two or more of the following in at least 25% of defecations: Straining during lumpy or hard stools; sensation of incomplete evacuation,; sensation of anorectal obstruction or blockage; manual manoeuvres to facilitate; Fewer than three delectations per week 2) Loose stools are rarely present without laxatives 3) Insufficient criteria for IBS

Answer 16

Bloods - FBC, UE, LFTs, Calcium, TSH Colonoscopy Colonic transit studies and defaecating proctogram (if indicated)

Answer 17

Initially - dietary fibre, fluid and laxatives Then - Specialist nurses, biofeedback and rectrograde irrigation Second line - NICE - prucalopride (failed 2 classes laxatives at highest tolerated dose for >6months and invasive tx being considered. Trial period of 4 weeks - if no better need to evaluate if to continue or if >3month period of use then need to evaluate at regular intervals

Answer 18

Highly selective 5-HT4 receptor agonist - stimulates motility Originally only approved in women as they made up approx 90% of the study population RCT in 2015 confirmed safety and efficacy in men

Answer 19

ACE - Integrate colonic enema - appendix used as stoma with washout every 1-2 days Ilestomy is an option (reversible) Subtotal and ileorectal anastomosis

Answer 20

Parks Classification 1) Intersphincteric (70%) 2) Transsphincteric (25%) 3)Suprasphincteric (5%) 4) Extrasphincteric (1%)

Answer 21

Self expanding metal stent can be using as bridge to surgery or palliative measure CREST trial showed reduced stoma formation with adverse impact on survival

Answer 22

Subtotal colectomy (47) vs segmental and primary anastomosis (44) for left sided obstructing tumours. No difference in mortality and complication rated. Bowel problems more common after segmental. Concluded that segmental resection following intra-operative irrigation is preferred option (exception of catcall perf or synchronous neoplasm)

Answer 23

Aprox 50% of patients will develop acute pouchitis during first 10yrs More common in Crohn's vs UC vs FAP Review histology (missed Crohn's), confirm diagnosis with Endo examination - inflammation and biopsies for histology and CMV. Look for cuff-its, stricture or ischaemia Stool sample to exclude infection Stop smoking Treat with 2/52 Cipro or metro, second line is budesonide enemas at bedtime (effective as metro) Probiotic VSL #3 effective in mildly active pouchitis

Answer 24

Pouch-itis Disease activity index (PDAI) - based on clinical, end and hits. Diagnosis suggested if >7

Answer 25

Symptoms lasting over 4 weeks - occurs in approx 10% of patients Discuss case at IBD MDT Remission induced in around 80% of patients with combination of 2 abxs Oral budesonide (9mg OD 8/52), oral beclomethasone and topical tacrolimus are alternatives If Chronic refractory can consider Imfliximab as effective Tx IF still ongoing can consider further medical Tx (Budesonide or azathioprine) or excision of pouch)

Answer 26

Moderate risk - 1 first degree relative <50 or 2 first degree any age - 1 off colon at 55 then follow up as per BSG guidelines High risk - cluster of at least 3 first degree relatives any age across 2 generations - 5yrly colon from 40-75

Answer 27

Screening - identifying at risk individual who may appear healthy Wilson (WHO) criteria 1) Important health problem 2) Should be a treatment 3) Facilities for diagnosis and Tx should be available 4) Should be a latent stage 5) Should be a test or examination for disease which is acceptable 6) Natural history of the disease should be understood 7) Should be a policy on whom to treat

Answer 28

Launched 2006 2yrly to men and women 55-74 Based on faecal immunochemical test (FIT) Uptake is approx 50-60% 2/100 doing test will get abnormal result - offered colonoscopy 5/10 Colons will be norma 4/10 Will have polyps 1/10 will have cancer Evidence based on 4 RCTs - Cochrane review 2007 - 16% reduction in relative risk of CRC mortality FOB - sensitivity of 50-80% and 88% specificity FIT - 92% sensivitiy and 85% specificity

Answer 29

Anatomical - Surgery (<200cm SB) Crohns disease, mesenteric ischaemia, Neoplastic disease, radiation enteritis Functional - Intra-abdoninal sepsis, enteritis, Intermittent bowel obstruction (strictures), bacterial overgrowth, recurrent disease (crohns), Medications.

Answer 30

Travis (Oxford) criteria At day 3 of IV steroids -Opening bowels >8x a day -3-8 motions + CRP >45 Positive predictive valuue for colectomy is 85%

Answer 31

Initially 100mg IV hydrocortisone QDS If fails Cyclosporin (2mg/Kg/day) - 80% will respond but approx 50% will need colectomy in 1yr at 8% at 7yrs - SE seizure, HTN, renal impairment Infliximab (5mg/Kg) - repeated at 2 and 6 weeks. 3yr colectomy rate of 50% SE Severe infection, demyelination, non- Hodgkins lymphoma

Answer 32

BSG/ACPGBI Annual endoscopic surveillance if high risk features (Previous dysplasia (rectal) or cancer at time of pouch surgery, PSC, Type C mucosa (permanent persistent atrophy and severe inflammation) Otherwise 5yrly Surveillance

Answer 33

BSG 2019 Assess to stable vs unstable using Shock index (HR/systolic) <1 = stable Catagorise to major or minor using Oaklands score <10 safe to discharge and organise OP investigations.

Answer 34

Diverticular Vascular malformations (angiodysplasic) ISchaemic coltiis haemorrhoids IBD Neoplasia Radation Approx 15% will be UGI source - need OGD

Answer 35

BSG guidelines 2019 Primary prophylaxis - Permanently discontinued Secondary previous should not be routinely stopped - if stopped should be re-commenced as soon as haemostats achieved

Answer 36

Not indicated European society of Gastrointestinal Endoscopy 2021 guideline essay no HALT-IT large multi-national RCT 2020 showed no reduction in deaths but increased VTE events

Answer 37

1) Noting 2) Belt support 3)Restore continuity if possible and repair defect 4) Repair parastomal hernia (Suture - high recurrent risk, Mesh - Keyhole or sugar baker) 5) Relocate stoma

Answer 38

Obliteration of the lamina proprietor by fibrosis and smooth muscle fibre extension from the muscular mucosa to the lumen

Answer 39

Defaecting proctogram - Look for rectocele/intussusection Colonic transit study. - slow transit constipation and obstructive patterns Anorectal manometry and physiology studies - assess rectal sensation and inhibitory reflex and paradoxical contractions and animus Endoanal US can demonstrate thickening of internal anal sphincter (limited significance)

Answer 40

Oxford grading system Grade 1 - High rectal - descends no lower than proximal limit of rectocele Grade 2 Low rectal - descends into level of the rectocele but not onto sphincter/canal Grade 3 High anal - descends onto sphincter/anal canal Grade 4 Low Anal - Descends into sphincter/anal canal Grade 5 Overt rectal prolapse

Answer 41

1) Conservative treatment - Dietary modifications (high fibre, bulking laxatives), pelvic floor rehab, biofeedback 2) Mediations - Steroids, 5 ASA sucralfate 3) Surgery - STARR, LVMR - both have limited roles as correcting anatomy my not correct physiology. Only contemplate when failed all else, significant symptoms and high grade rectal intusseception with outlet obstructive pattern and animus ruled out.

Answer 42

3 main groups 1_ Inflammatory (mucosal oedema, erythema/pallor, ulceration) 2- Haemorrhagic (friable mucosa which bleeds spontaneously and/or telangiectasia 3- Mixture of both Biopsy not required unless uncertain (then take from back wall) - risk of non-healing ulceration or fistula formation

Answer 43

Radiation related - Volume of rectum irradiated, total dose and dose per fraction and technique (Spaces and balloons not routinely used) Patient related - Vascular disease, DM, IBD, connective tissue disease, Chemo, smoking, anticoagulants/HTN/hormonal Tx, Previous CRC section

Answer 44

Conservative - mild symptoms (Do nothing, diet, loperamide) Medical Bleeding predominant - sucralfate enemas (2g Bd for up to 24/52) Inflammatory - corticosteroids or metronidazole in combination oral mesalazine and betamethasone enemas for 4/52 Endoscopic - Argon plasma coagulation, topical formalin applications, laser, RFA bipolar

Answer 45

Precursor lesions to serrated neoplasm resulting in cancers with B-RAF mutation, methylation of DNA repair genes, CpG island methylation phenotype and high levels of microsateliitle instability Adenocarcinoma sequence can proceed after in them than APC mutation and higher risk of lymphatic invasion and mets Can occur with our without dysplasia Difficult to detect - may be related to failure of colonoscopy to reduced R sided cancers

Answer 46

Standard biopsy forceps 8mm open and 2.5mm closed

Answer 47

Reduction of gut function to below the minimum level required to absorb macronutrients and/or water and electrolytes such that IV supplimentation is required

Answer 48

European Society for clinical nutrition and metabolism Type 1 - Acute and short term - usually self limiting (grade1 )short duration)- no intervention, Grade 2 - may require intervention) Type 2 Prolonged acute condition - often unstable patient requiring complex care and IV supplementation over months or years (reversible or irreversible) Type 3 - Chronic condition, stable patient requires IV supplementation over months/years - may be reversible

Answer 49

TPN IV fluids and electrolytes Surgery to correct fisulta or revese stoma Type 3 patients may be appropriate for GLP2 drugs or experimental bowel lengthening procedures Very selective patients may be eligible for SB transplant

Answer 50

Full obsteritic history including prolonged second stage, instrumentation, episiotomy or tears Onset of symptoms and nature and quality of incontinence Relavent PMH and PSH Incontinece score (St Marks or Wexner score) to classify severity Conduct a perineal examination and PR to assess sphincter complex

Answer 51

Sultan Classification system 1st Degree - skin or vaginal mucosa 2nd Degree - perineum involving muscles but not sphincters 3rd Degree - perineum involving sphincter complex -3a) <50% external anal sphincter form 3b) >50% external anal sphincter 3c Both external and internal torn 4th Degree Perineum involving sphincter complex and anal epithelium

Answer 52

Resting pressure and involuntary squeeze reflex - measure of function of internal anal sphincter Peak Squeeze and 5 second squeeze - measure of external anal sphincter

Answer 53

1- Asymptomatic 2 - Plans for further vaginal deliveries 3 - Late onset faecal incontinence 4- Non-contracting external anal sphincter 5- Partial external anal sphincter tear 6- Obese - risk of wound infection, breakdown and fistula formation

Answer 54

Result from anastomosis of the lateral and median sacral veins and courses into the pelvic fascia covering the anterior aspect of the body of the sacrum The medial sacral vein drains into the Left common iliac The lateral veins drain into the internal iliac veins The plexus receives contributions from the lumbar veins of the posterior abdo wall and the base-verebral veins that pass through the sacral foramen

Answer 55

Sepsis 6 Investigate - CT with contrast +/- chest Reassess with the imagine - if stable and subtle signs of possible early leak can attempt conservative management Some units may have protocoled management where high inflammatory markers and suspension of CT would prompt operative re-intervention. The ongoing Tentacle Study and IMARI trial will provide more detailed data on identifying which approach is best

Answer 56

1) Surveillance - may wish to retain rectum or avoid surgery - Stump surveillance in accordance with BSG and ACPGBI guidelines - low risk start 10yrs from start of symptoms and every 5 yrs or yearly if high risk 2) Completion proctectomy and end ileostomy 3) Ileoanal pouch 4) Ileorectal anastomosis - highly selective patients and careful counselling. Need to have minimal rectal disease and preserved complaint and capacity and good sphincter tome. Avoids pelvic dissection and risk of sexual and urinary dysfunction. Still has impact go fecundity. Will need ongoing surveillance of stump as per BSG . May still fail and need ileoanal pouch or end ileostomy

Answer 57

Explain to patient EUA and biopsy and seton Future management depends of cause - leak, crypto glandular, Crohns or malignancy At EUA - attempt to delineate anatomy, drain sepsis, take biopsy of anastomosis, body of pouch and pre-pouch ileum and place seton Discuss at IBD MDT If Crohns - may need anti-TNF biologic agent and Gastro input - ACCENT 2 trial - 50% closure

Answer 58

Need full clinical and radiological work up Referral to tertiary centre with relevant expertise Sphincter preserving approach desirable Advancement flap or a LIFT (Ligation of intersphincteric fistula tract) proceedure Need to council risk of failure to heal, prolonged healing, wound related issues, recurrence and worsening pouch function.

Answer 59

Obstetric trauma Pelvic surgery (hysterectomy, rectal surgery, stapling devices, anastomitic leak, mesh Neoplasm Crohns diseas Radiation injury Infection (cyrptoglandular) Trauma, including sexual truma Medications

Answer 60

Variety of systems exist Ano-vaginal fistula - below dentate line True recto-vaginal - proximal to dentate line (High, mid or low) Low - occur through sphincter complex but proximal to dentate Mid - lower 1/3 of vagina high mid rectum to posterior fornix Also classified based on complexity: Simple small, distal, caused by trauma or infection. Complex large , proximal caused by IBD, cancer, radiation

Answer 61

mrTRG (MR tumour regression Grade (MERCURY group and ESGAR) Grade 1 - Complete response with linear/cresectric 1-2mm scar in mucosa or submucosa Grade 2 - Good response. MRI - dense fibrosis without obvious residual tumour Grade 3 - Moderal response >50% areas with fibrosis or mucin and visible intermediate tumour signal Grade 4 - slight response.- few areas with fibrosis or mucin and mostly tumour derived signal Grade 5 - No response to theatre. Similar to baseline or significant regrowth

Answer 62

Clinical response - team find no clinical evidence of cancer (may still be residual disease microscopically 3 criteria: Normal DRE Endoscopic - Flat white scar, telangiectasia (no ulcer or modularity) MR - mrTRG Grade1/2 Pathological response - Post neoadjuvent and surgery - pathologist cannot find evidence of cancer cells

Answer 63

1) - Surgery - gold standard - risk of no cancer in specimen and 2% risk of mortality - 6vs12 trial - op traditionally 6 weeks post Chemorad but larger effect at 12 2) Watch and wait - ACPGBI support this -Involves 3/12 follow up for 2yrs with clinical, end and MRI and CT imagine and CEA. Then 6/12 for 3yrs. OnCoRE registry shows approx 1/3 with have local regrowth in first 3yrs with 88% undergoing successful salvage surgery. 8% will develop mets with no regrowth. 93.5% 3yr survival

Answer 64

Absence of viable adenocarcinoma in surgical specimen or presence of lakes of mucus without tumour cells Mansard TRG classification TRG1- No viable cells - complete clinical response TRG2 Fibrosis with scattered tumour cells TRG3 - Fibrosis and tumour cells with a preponderance of fibrosis TRG4 Fibrosis and tumour cells with preponderance of tumour cells TRG5 - Tumour without changes of regression

Answer 65

LCRT with induction or consolidation Chemo - OPRA protocol SCRT followed by consolidation chemotherapy - RAPIDO protocol

Answer 66

R0 resection key surgical objective and achieved in approx 70% with BeyondTME disease PelvEx registry 3yr survival with R0 is approx 56%

Answer 67

Royal college of Pathologists define positive R1 margin as presence of viable tumour cells within 1mm of any section margin

Answer 68

Each case needs discussing with oncologist and MDT Generally no evidence for adjuvant chemotherapy after complete pathological response

Answer 69

Propensity - score matched cohort analysis of watcha nd wait vs surgery for cCR after Chemorad Showed substantial proportion of rectal cancer managed with watch and wait avoided major surgery and colostomy without loss of oncological safety at 3yrs High proportion of local regrowths amenable to salvage surgery with high R0 resection rate and no evidence of pathological upward stage migration

Answer 70

SIGGAR trials - no difference between pick ups

Answer 71

Invasion beyond muscular proprietor - cutoff at 5mm a<1mm b 1-5mm invasion c5-15mm d>15

Answer 72

Anal cancel - extends from the anorectal junction to the anal margin - includes transition zone (some cancers can be adenoids) Anal margin - extends from anal verge to pigmented area - approx 5cm Proximal anal cana; - drains into perirectal and paravetebral Tumours about the dentate-internal iliac and internal pudendal LN Below the dentate and anal margin - inguinal, external iliac and femoral LN

Answer 73

T1 - <2cm T2 - 2-5cm T3 - >5cm T4 - invading other structures

Answer 74

Montreal or Paris Looks at age of diagnosis, location of lesions, behaviour of disease (penetrating or stricturing) Paris classification similar but loos at associated growth delay

Answer 75

Crohns Disease Activity index (trials) Harvey Bradshaw index (weighted towards diarrhoea IBD tarted PROMS

Answer 76

Crohns disease endoscopic index of severity Simplified Endoscopic activity score for Crohns Look at size of ulcers, surface Ulceration, Proportion of affected surface, presence of strictures

Answer 77

Medical management of Crohns stricture suceesful up to 12cm

Answer 78

For stricutres small than 10cm - Heineken-Mikulicz procedure Medium length strictures - Finney procedure Entero-enterostomy for larger strictures

Answer 79

Lynch - autosomal dominant - Hereditary non-polyposis Diagnosed using Amsterdam 2 criteria Formal diagnosis mutation in MMR MLH1, MSH 2,6 PMS2 Average age of onset 42 Lynch like Syndrome -Patients who are MMR deficient without obvious genetic mutation

Answer 80

At lease 3 first degree relatives across 2 generations with an associated cancer At lease 1 should be under 50yrs old

Answer 81

Average risk - no family HX Moderate - 1 first degree relative under 50 or 2 first degree relative (any age) High - at least 3 first degree relatives at any age across 2 generations Average - 2yrly FIT(National screening) Moderate risk - Colonsopy at 55 then following National guidelines depending on findins High risk - 5yrly colons starting at 40

Answer 82

Lifestyle measures BSG guidelines - aspirin - CAPP2 trial - reduced risk of cancer by 50% for 2yrs) Aspirin thought to affect by reducing or inhibiting COX1 and 2 also affect Gut microbiome as well as aspirin metabolites which inhibit CDKs thus cell growth

Answer 83

MLH1 and MSH2 (and no obvious mutation) - 2yrs COlon from 25-75 MSH6 and PMS 2 - 2yr colon from 35-75 H Pylori testing as increases risk of Gastric cancer Hysterectomy (not PSM 2) 35-40 - first of endometrial caner

Answer 84

Familial adenomatous polyposis Mutation in APC gene on 5q, 21/22 Chromosome Autosomal dominant - near complete penetrance 25% de-novo mutation Surveillance as per BSG guidelines -If mutation - Colon starting 12-14 ever 1-3yrs. OGD when 25 and surveillance depending on Spiegelman criteria If no mutation 5yrly colon from 12-14. OGD not required unless polyps present on index colon

Answer 85

Score based on Number of polyps Size of polyps histology Degree of dysplasia Interval of OGD based on score 6mnthly to 5yrly

Answer 86

Absolute - presence or high suspicion of cancer or symptoms related to polyps Relative - polyps >1cm, high grade dysplasia, significant increase in number of polyps

Answer 87

Peutz Jeghers (STK11) Juvenile Polyposis (SMAD4/BMPR1A mutation) MUTYH- associated syndrome

Answer 88

Brown mucocutaneoux lesions with multiple hamartomas Autosomal dominant Mainly affects small bowel Associated with STK11 gene mutation Diagnosed - >1 GI hamartoma, mucocutaneuous lesion with family Hx or any hamartoma in someone with 1st degree PJS relative Surveillance - BSG guidlines - commence at 8 - every 3 yrs 3yrly small bowel video capsule Baseline OGD and colon - if normal surveillance of upper and lower postpones to 18yrs Normally offer resection of Small bowel hamatoma as likely to lead to intersuspection

Answer 89

Screening depends on mutation SMAD4 only - OGD from 18 at 1-3yrs BMPR!A mutation - OGD from 25 1-3yrs Both should have Colonoscopy from 15 every 103yrs

Answer 90

Colonoscopy from 18 every year OGD from 35 and interval based on Spiegelman criteria

Answer 91

1- Round pits - Normal 2 - Asteroid or papillary pits - Hyperplasia 3 - Tubular - Adenoma (s - smaller , L larger) 4- Branch like or gyrus like - Adenoma 5 - Non structural - Carcinoma

Answer 92

Classification of depth of invasion of T1 cancers SM1-3 1 - superficial 1/3 of submucosa (a-c) based on level of invasion into second 1/3 2 - intermediate 1/3 of submucosa 3extending into inner surface of musclaris proprietor Related to likelihood of LN mets

Answer 93

Level 0 - Carcinoma in situ Level 1 - Invasion into head Level 20 Invades into Neck Level 3 - invades into stalk Level 4 0 invaded the submucosa below level of mucosa - (all Kikuchi are level 4)

Colorectal Flashcards

(117 cards)