Colorectal 4 (685-703)

Question 1

What test is used in the current bowel screening programme?;

Answer 1

FIT test every 2 years over age of 50 (men and women)

Question 2

Name some risk factors for colorectal cancers;

Answer 2

Non-modifiable- increasing age, male, family history. Genetic syndromes- FAP, cowdens, Pzeutz-Jegher, lynch syndrome. Modifiable- obesity, low fibre diet, smoking, alcohol, high processed meat.

Question 3

What symptoms would a patient with right side colorectal cancer present with?;

Answer 3

Abdominal pain, iron-deficiency anaemia, palpabale mass in right iliac fossa, often present late.

Question 4

What symptoms would a patient with a left side colorectal cancer present with?;

Answer 4

Rectal bleedin, change in bowel habit, tenesmus, palpable mass in left iliac fossa or on PR exam.

Question 5

What examination would you expect in a patient with colorectal malignancy?;

Answer 5

Abdo exam- abdo tender, palbable mass, cachexia (weight loss). PR exam- palpable mass, blood, mucous, loose stool. If mets- jaundice (liver), breathless (lung), confusion (brain)

Question 6

What is Duke’s classification (Astler-Coller modification) for colorectal cacner?;

Answer 6

Stage A- mucosa and submucosa (confined beneath muscularis propria). Satge B - extension through the muscularis propria. Stage C - Lymph nodes involvment Stage D - Distant metastasis.

Question 7

What is the TMN classification for colorectal cancers?;

Answer 7

T1 - mucosa & submucsa. T2 - muscularis propria. T3 - beyond muscularis propria into mesorectal or pericolic fat. T4 - tumour invades adjacent organs or perforates peritoneum. N1 - 1-3 lymph nodes. N2 - 4 or more. M1 - distant mets.

Question 8

Describe the mechanism of metastatic spread of colorectal cancers;

Answer 8

5 stages of metastasis- 1. detachment and migration from the primary tumour (cells need to undergo epitheal cell to mesenchymal cell transition by E cadherins). 2. Intravastation (enters the blood ciculation system). 3. Transport. 4. Extravasation (exciting blood circulation system). 5. Growth at the site of metastasis.

Question 9

Describe the principles of managing cancers in the ascending and descending colon;

Answer 9

Removal of tumour & bowel depends on location, regional colectomy to ensure the removal of the primary tumour with adequate margins and lymphatic drainage. Left colon = left hemi, right colon = right hemi. Remove appropriate mesentery and blood vessel. No role for radiotherapy (only in rectal cancer).

Question 10

What are the indications for chhemotherapy in colon cancers?;

Answer 10

Patients with advanced disease (Dukes C or D) after discussion at colorectal MDT, an example is Flurouracil (5-FU). Palliative chemotherapy can be given for symptom control.

Question 11

Describe the principles of managing rectal cancers;

Answer 11

Bloods- FBC, LFTs and clotting (CEA not diagnostic but can be used to monitor disease progression). Imaging- colonscopy with biopsy (gold standard), CT CAP (mets), MRI rectum (assess depth of invasion and potential need for pre-operative chemotherapy), Endo-anal ultrasound (for early rectal cancer T1 or T2) to assess suitability for trans-anal resection. All patient need to be discussed at MDT. More options for treatment compared to colon cancer. Radiotherapy can be used in rectal cacner as neo-adjuvant treatment and can be given alongside chemo. Some cases achieve complete response with chemo-radiotherapy,

Question 12

What are the indications for chemotherapy and radiotherapy in rectal cancers?;

Answer 12

Most cases undergo pre-operative long course of chemo-radiotherapy to skink the tumour, thereby increasing chance of complete resection and cure (particularly useful in rectal cancers who have a “threatened” circumferential resection on MRI. Some have complete response to chemo-radiotherapy and can opt for close surviallance instead of radical surgery.

Question 13

How is acute diverticulitis classified?;

Answer 13

Hinchey classification. Stage 1- Phlegmon (localised area of inflammation) (1a) or diverticulitis with pericolic or mesenteric abscess (1b). Stage 2- Diverticulitis with walles off pelvic abscess. Stage 3- Diverticulitis with generalised purulent peritonitis. Stage 4- Diverticulitis with generalised faecal peritonitis.

Question 14

How are Hinchey III and Hinchey IV diverticular disease managed?;

Answer 14

A-E management including sepsis bundle (antibiotics, IVIs and analgesia). Surgical intervention is required for peritonitis or sepsis. Procedure usually Hartmann’s procedure.

Question 15

What is Hartmanns procedure and what are the indications?;

Answer 15

A sigmoid colectomy with formation of end colostomy (reversal may be possible at later date but only happens in 50%). Typically performed in emergency setting for sigmoid perforation (e.g. secondary to diverticulitis) or sigmoid malignancy causing bowel obstruction. Other indications include anastomotic complications, ischaemic colitis, abdominal trauma, left-side colonic volvulus.

Question 16

Name some indications for performing a loop ileostomy;

Answer 16

Where faecal diversion is required to protect and defunction down-stream bowel. Common examples is a loop ileostomy as part of an anterior resection of the rectum (reduces morbidity of an anastomotic leak).

Question 17

Name some indications for performing an end colostomy;

Answer 17

Abdominal perineal excision of rectum performed for a low rectal cancinoma or Hartmann’s procedure for treatment of diverticulitis or large bowel obstruction from sigmoid tumour or anastomotic complication.

Question 18

Name are the indications for a panproctocolectomy?;

Answer 18

Most commonly for Ulcerative colitis and FAP. May also be done for Crohn’s or some colorectal cancers. Ileostomy constructed in permanent.

Question 19

What complications can arise in a pouch?;

Answer 19

Pouchitis, pouch fistula, pelvic abscess, anastomotic leak, anastomic stricture, pouch prolapse or twisting, Crohn’s disease of pouch, proximal small bowel bacterial overgrowth, infertility and sexual dysfunction.