COLORECTAL Flashcards
(220 cards)
1
Q
T-score rectal cancer
A
T1 = submucosa
T2 = muscularis propria
T3 or N1 = through MP
2
Q
Mgmt rectal CA by T-score
A
T1 = transanal excision vs. LAR or APR T2 = LAR or APR T3 = neoadjuvant CRT, then LAR or APR
3
Q
When do transanal excision instead of LAR/APR for T1 rectal CA?
A
- <30% circumference of bowel
- <3cm size
- within 8cm of anal verge
4
Q
Characteristics of polyps on colonoscopy concerning for invasive cancer - need segmental colectomy (cannot just do endoscopic removal)
A
- involved polypectomy margin (<2mm on removal)
- lymphovascular invasion, poor differentiation
- invasion of lower third submucosa
- central depression or ulceration
5
Q
Mgmt sigmoid volvulus
A
- sigmoidoscopic decompression + no evidence mucosal gangrene or bloody effluent
- then can go elective ONE STAGE (no Hartmann) sigmoid resection
6
Q
After NIGRO protocol, next steps?
A
- examined 8-12wks after completion, then at 4-6wk intervals until resolution of suspicious findings
7
Q
After NIGRO protocol, findings upon examination classified into…? subsequent f/u?
A
- complete remission -> fu exam q3-6mo for 5yrs + imaging every year for 3yrs
- persistent disease -> fu 6mo to see if further regression occurs
- progressive or persistent disease at 6mo -> w/ biopsy to confirm
8
Q
Distal margin of sigmoid for diverticulitis should be…?
A
rectum (colo-colonic anastomosis increases risk recurrent diverticulitis)
9
Q
Frequency of surveillance colonoscopy after resection of colon CA
A
- if could not evaluate entire colon (2/2 obstructing CA), then need repeat within 6mo of resection
- if entire colon surveyed at time of dx, then first surveillance colonoscopy at 1-yr postop -> 3-yr -> 5-yr
10
Q
Granular cell tumors most commonly at…? What about in GI?
A
commonly in skin + subQ, but can be in GI (tongue > esophagus > colon >anorectal)
11
Q
Mgmt granular cell tumor in GI
A
WLE (colonscopic excision)
12
Q
Anal endosonography
A
used to detect internal and external sphincter defects (external typically palp on physical exam)
13
Q
Factors that decrease likely benefit for colon CA resection (5)
A
- node + primary
- disease-free interval <12mo
- increasing # mets
- largest met >5cm
- serum CEA >200
14
Q
Alvimopan
A
= entereg
decreases time to ROBF by 15-24hr; approved for peri-op use after partial large/small bowel resection with primary anastamosis
15
Q
Painless hematochezia, think…?
A
internal hemorrhoid, AVM, UGI/small bowel bleed
16
Q
Anal fissure mgmt
A
- diet + hydration
- if failed and >4wk = chronic -> topical CCB (better than topical nitrates bc HA)
- IV botulinum toxin
- lateral internal sphincterotomy (except if have b/l incontinence)
- flap procedures
17
Q
LAR
A
low anterior resection = anterior resection of rectum
18
Q
APR
A
abdomino-perineal resection = anus + rectum + part of sigmoid + associated regional LN + end-ostomy
19
Q
total proctocolectomy
A
right/left colon + rectum
20
Q
Patho and Tx for diarrhea s/p terminal ileum resection
A
resection -> malabsorption of bile salts -> salts in colon interfere with colonic absorption of fluid/electrolytes -> diarrhea
Tx: PO cholestyramine
21
Q
Dx bacterial overgrowth in bowel? Tx?
A
Dx: D-xylose breath test
Tx: Abx
22
Q
Mgmt adult with intussusception
A
laparotomy + ileocecetomy (always)
23
Q
Lynch syndrome defined as…? (Amsterdam/Bethesda criteria)
A
- 3 relatives with colorectal CA
- 2+ generations involved
- AND at least one before 50yo
24
Q
Cowden’s syndrome (age dx typically, associated with what CA)
A
AD juvenile polyposis syndrome
- avg dx 18-yo
- associated with breast + thyroid disease
25
Mgmt for small sessile lesion
excise using saline lift + endoscopic resection
26
Markers for goblet cell carcinoid tumors
- chromogranin A
| - synaptophysin (histo +)
27
SMA and IMA directly connected by...?
Arc of Reolon (meandering mesenteric artery)
28
Arterial supply to rectum
- superior rectal (from IMA)
- middle rectal (from internal iliac; runs in lateral stock)
- inferior rectal (from pudendal off internal iliac)
29
Venous drainage of rectum
- superior + middle rectal -> IMV (portal)
| - inferior rectal -> internal iliac -> IVC
30
How far is rectum from anal verge?
~15cm
31
Anal canal anatomically begins/ends...?
puborectalis sling, ends at squamous mucosa (includes transition zone, dentate line)
32
If have distal rectal cancer, need to do what on physical exam to check mets?
palpable groin LN - bc unlike colon cancer, distal rectum drains to systemic iliacs -> IVC
33
single episode unCx diverticulitis, treated with Abx... next step?
colonoscopy in 6-wks to r/o CA, ischemia, or IBD
34
Main energy source for colonocytes
SCFA (butyrate)
35
Surveillance for ulcerative colitis
if colitis proximal to splenic flexure, then colonoscopy after 8 years + repeat every 1-2 years
36
If have high grade dysplasia on surveillance colonoscopy for UC?
indication for total protocolectomy w/ or wo IPAA
37
Mgmt options for ulcerative colitis
steroids, mesalamine, infliximab
38
Mgmt options Crohn's
steroids (acute), 5ASA, mesalamine, infliximab
39
Mgmt strictures Crohn's
<10cm -> Heineke Mikulicz stricturoplasty (longitudinal incision and close transversely)
10-20cm -> Finney stricturoplasty (fold stricture on itself, open bowel on either end, sew common wall)
>20cm -> Michelassi (side-to-side isoperistaltic stricturoplasty)
40
If stricture in first 2 portions of duodenum?
bypass gastroJ + highly selective vagotomy (bc pts prone to ulcerations at gastroJ stoma)
41
After stricturoplasty, make sure to do what in OR?
biopsy!
42
C/I stricturoplasty (5)
evidence of:
- malnutrition
- perforation
- inflammation
- fistula
- malignancy
43
Colon CA screening (all)
standard: 50yo q10yr
first degree before 60, or 2 relatives at any age: 40yo q5yr (or 10yr before youngest relative)
first degree after 60, or 2 second degree: 40yo q10yr
44
Colon CA screening: FAP
start 10yo, q1yr sigmoidoscopy
45
Colon CA screening: HNPCC
start 20yo, q1-2yr or 10yrs prior to youngest dx relative
46
Screening f/u if: =/<2 tubular adenomas, <10mm
repeat colonoscopy in 5-10yrs
47
Screening f/u if: 3+ tubular adenoma
repeat colonoscopy in 3yrs
48
Screening f/u if: advanced adenoma (>1cm, high grade dysplasia, villous)
repeat colonoscopy in 3yrs
49
Screening f/u if: hyperplastic polyp
normal. standard repeat colonoscopy in 10yrs
50
Endoscopic resection for polyps NOT adequate when... (5)
1. cannot remove in one piece
2. pedunculated Haggitt level 4 w/ unfavorable histology
3. sessile w/ Sm1/Sm2 depth + poor features
4. sessile q/ Sm3 depth
5. positive margins
51
T-staging colon cancer
- TIS: lamina propria
- T1: submucosa
- T2: muscularis propria
- T3: thru MP, into pericolonic tissue
- T4a: penetrates serosa
- T4b: invades/adherent to surrounding structures
52
N-staging colon cancer
pos LN = >0.2mm deposit of cancer cells
- N1 (1-3 nodes)
- N2a (4-6)
- N2b (7+)
53
TNM staging colon cancer
Stage 1: T1-T2, no nodes
Stage 2: T3-T4, no nodes
Stage 3: any T w/ nodes
Stage 4: distant mets
54
How many LN need to resect to ensure adequate lymphadenectomy for colon cancer?
12
55
Negative margin criteria for colon cancer
5-7cm (bc need adequate lymphadenectomy + removal of vascular supply)
56
Folfox chemotherapy is a combination of...?
cisplatin + 5FU + folinic acid chemotherapy
57
What does a circumferential resection margin (CRM) indicate for rectal cancer?
total distance btwn tumor and mesorectal fascia - good prognostic indicator
58
How to evaluate CRM of rectal cancer?
Endorectal US or MRI
59
Neoadjuvant regimen for rectal cancer
500 centagrade + 5-FU (5-6wks) -> resection 2-3mo following neoadjuvant
*5FU is a sensitizer for radiation
60
Patients that get neoadjuvant upfront for rectal cancer
- locally advanced of middle or distal rectum
- T3 or greater
- any node pos disease
61
When can do local excision for rectal cancer?
T1 lesions wo high risk features:
- well-mod differentiated
- no lymph/vasc/perineural invasion
- tumor <3cm
- clear margins >3mm
- <1/3 circumference of bowel lumen
- mobile, not-fixed
- tumor within 8cm anal verge
- no muccin production
62
Disadvantages of local excision of rectal cancer
- not able to pathologically examine regional LN
| - up to 20% local recurrence
63
Mgmt rectal cancer in upper 1/3 rectum
LAR w/ tumor specific mesorectal excision w/ 5cm margin + anastamosis (want to preserve rectum and continence)
64
Mgmt rectal cancer in mid-lower third of rectum
APR + total mesorectal excision; ideally want 2cm margins, but if very distal can do 1cm to avoid excising sphincter
65
Types of anal squamous neoplasm (4)
- cloacogenic
- basaloid
- epidermoid
- mucoepidermoid
66
Mgmt anal canal SCC
NIGRO protocol: 5FU + mitomycin C + 3000 centigrade XRT (no surgery)
67
f/u for AIN 1, 2, 3
low dysplasia = 1, 2
high dysplasia = 3
low conversion rate for immmunocompetent; surveillance q4mo
68
local therapy AIN
topical iniquimad + topical 5FU
69
What is the anal margin?
perianal skin
70
Mgmt anal melanoma
WLE if possible (avoid APR bc high morbidity procedure for likely metastatic disease)
71
Preoperative evaluation for rectal cancer needs to include...?
- CEA
- rigid proctoscopy
- CT C/A/P
- Endorectal US or rectal MRI (CRM)
72
Second MCC of death in FAP pts
duodenal adenomas
73
Gardner's syndrome also associated with
- desmoid tumors
- epidermoid tumors
- osteomas
74
Turcot's syndrome also associated with
- brain tumors (2/3 also have APC mutation)
75
When do colectomy for FAP?
typically 20-yo
76
Do desmoid tumors metastasize?
no - locally invasive
77
Third MCC of death in FAP pts
desmoid tumors
78
If during screening EGD in FAP pt, and find high-risk dysplasia in duodenum... then need...?
If stage 4 Spigelman classification, then Whipple (duodenal adenoma in FAP 2nd MCC death)
79
Lynch syndrome patho
(AD) - defect in mismatch repair genes (MLH1, MSH2/6, PMS2) -> DNA buildup of microsatellite -> instability
- non-polyposis
- typically right colon, mucinous, poor-differentiation
80
Endometrial cancer in pt <50yo, suspect...?
Lynch II syndrome
81
Cecal bascule
- type of cecal volvulus
| - folding of cecum anteriorly over ascending colon -> large bowel obstruction
82
rectal prolapse vs. hemorroids
rectal prolapse is full-thickness, is also appear and concentric rings of tissue (hemorrhoids appear radial pattern)
83
MC nonintestinal viscera involved w/ internal fistula from Crohn's
bladder
84
Mgmt most internal fistulas 2/2 Crohn's
limited or no resection (only resection if both segments involved with Crohn's) w/ tension-free closure
85
Chilaiditi sign
transposition of a loop of large intestine (usually transverse colon) in between the diaphragm and the liver. NTD unless symptomatic.
86
F/u for FAP pts s/p total colectomy w/ ileorectal anastomosis
annual endoscopy of remnant rectum
87
MCC anal fistula
cryptoglandular disease (inflammation of protodeal glands in intersphincteric space)
88
Mgmt horseshoe abscess of anus
Hanley procedure = incision made in internal sphincter posterior to enter deep postanal space w/ b/l elliptical incisions for drainage bilaterally
89
What is anal horseshoe abscess?
bilateral fluid collections of ischiorectal space that communicates via deep postanal space behind anococcygeal ligament
90
What is LIFT procedure?
ligation of internal fistula tract = definitive mgmt for transsphincteric fistula control w/o risk incontinence
91
When try endorectal advancement flap?
for complex transsphincteric fistula, but higher risk incontinence (20%) - can be attempted if LIFT fails
92
Non-op mgmt of pilonidal disease
shaving
93
abd pain + hematochezia + colonoscopy w/ erythematous and edematous mucosa w/ small ulcerations... think?
ischemic colitis - mgmt: IVF, Abx, bowel rest (if transmural ischemia, then need ex-lap)
94
Krukenberg tumor
metastatic GI adenoCA to ovary (via retrograde lymphatic spread)
95
Mgmt obstructing descending colonic mass
transverse loop colectomy - colonic obstruction is a surgical emergency; resection of mass can be done after appropriate staging
96
Signet-ring cell CA of colon MC associated with what gene defect?
microsatellite instability (MSI)
97
What is Sitzmark study?
colon transit study (ingest radiopaque markers, then daily XR)
98
Intermittent, crampy abd pain and alternating constipation/diarrhea s/p Rx of ischemic colitis... think?
colonic stricture after ischemic colitis -> need dx colonoscopy
99
Loop vs. end colostomies more prone to prolapse?
loop
100
MCC acute LGI hemorrhage
diverticulosis > colitis > neoplasm > angiodysplasia
101
MC site for bowel perf if obstructing cancer
if ileocecal valve competent -> cecum; if not -> perf at tumor site
102
MC sxs colorectal cancer <40yo
rectal bleeding > abd pain
103
Total colectomy w/ end colostomy for severe UC, need to preserve...?
- superior rectal artery (supplies rectal stump needed to heal rectal staple line)
- terminal branches of IMA (until proctectomy)
- ileocolic artery (collateral blood flow to future J-pouch)
- rectum should be divided ABOVE posterior peritoneal reflection above level of sacral promontory (easier completion proctectomy later)
104
Elective proctectomy w/ or wo IPAA at later date for severe UC... do not perform where?
do not perform in total mesorectal excision plane bc risk injury to hypogastric plexus and pelvic nerves -> bladder and sexual dysfxn
105
MC Cx cholecystostomy tube placement or removal
bile leak (3%) - most self-limited
106
Mgmt anal margin SCC
mapping biopsies followed by WLE with 1-cm microscopic margins - for stage 1 and 2A disease
107
Location for rubber band ligation of internal hemorrhoids
2cm above dentate line (so no pain)
108
Life-threatening Cx s/p rubber band ligation for internal hemorrhoids
perianal sepsis
109
Proximal vs. distal rectal anastomoses, which more likely to leak?
distal > proximal
110
Mgmt refractory strictures from Crohn's: duodenum vs. jejunum/ileum
1st/2nd duo -> gastrojejunostomy + vagotomy (avoid marginal ulcers)
3rd/4th duo -> duodenoJ
short strictures jejunum/ileum -> stricturoplasty
111
High ileostomy output defined as...?
>1200 cc/day
112
Min period of time btwn formation and closure of stoma
12 weeks
113
Transverse folds of rectum are...?
"valves of Houston" - hold fecal matter and prevent its urge towards the anus, which would produce strong urge to defecate - there are 3 (upper+lower to right, and middle to left)
114
What direction does arterial supply for rectum come?
posteriorly
115
What is: postpolypectomy coagulation syndrome? Mgmt?
thermal energy to remove polyps -> full-thickness injury to bowel wall -> present similar to perforation, but if CT r/o free air and HDS, then can Tx IV Abx, bowel rest, and serial exams
116
Strictures more common in Crohn's vs. UC?
MC Crohn's. Uncommon in UC.
117
Why is 5-ASA not used for Crohn's?
bc primarily intraluminal - acts on mucosal changes of UC, but does not affect transmural inflam of Crohn's
118
Most important predictor of survival for colorectal CA
staging at presentation (90% stage 1; 10% stage 4)
119
FAP also associated with what cancers?
colorectal (100%), thyroid cancer, desmoid tumors, hepatoblastomas, osteomas
120
Mgmt prolapsed stoma
stoma revision (usually local procedure -> resection of redundant bowel and rematuration)
121
If sessile polyp is removed piecemeal, when should pt have follow-up colonoscopy?
2-6 month intervals
122
Haggitt classification
describes level of invasion of malignant polyps
Lvl 1 -> invade head
Lvl 2 -> invade neck
Lvl 3 -> invade stalk (muscularis mucosa)
Lvl 4 -> invade base (submucosa), or are involved in a sessile polyp (req. formal segmentectomy)
123
Rate of sporadic mutation for HNPCC?
20%
124
Lynch II syndrome assoicated with...
colon, endometrial, gastric, ovarian cancers
125
Preferred Abx for C.diff in pregnancy
PO vanc
126
Cancer screening for Peutz-Jeghers syndrome should begin at what age? For what CA?
25-yo for colon (q2y), breast, cervical, thyroid, lung cancer
127
MCC lower GI bleeding
diverticulosis
128
Bleeding from diverticulosis 2/2...?
arterial rupture of submucosal artery or from vasa recta
129
Mgmt stage 3 colon cancer
FOLFOX neoadjuvant + resection
130
Mgmt T1 rectal adenocarcinoma NOT within 8cm anal verge, but favorable features
polypectomy (upper rectal CA treated like colon cancer)
131
W/u low rectal cancer (palpable on DRE)
- CEA level
- LFTs
- colonoscopy to r/o synchronous lesion
- CT scan to eval mets
- MRI or EUS to stage depth of tumor and nodal involvement
132
Treatment of choice for colorectal liver mets (best prognostic factor)
margin-negative (R0) resection
133
Poor prognostic factors for colorectal mets
- >3 mets
- CEA >300 ng/mL
- mets >5cm
- LN positive primary disease
- positive margins
134
Independent predictors of need for operative invention for pneumatosis intestinalis
- lactic acid >2 mmol/L
- hypotension or pressure req
- peritonitis
- AKI
- mechanical ventilation
- absent bowel sounds
135
Cecal bascule
variant of cecal volvulus - anterosuperior folding of cecum wo axial rotation -> less likely to cause vascular compromise and intestinal ischemia
136
Is PET/CT indicated for rectal cancer?
NO
137
In pts with lower GI bleeding, but stable... first step dx?
colonoscopy with rapid lavage bowel prep
138
Risk of LN mets related to what of colorectal polyps?
depth of invasion
139
Risk of LN mets in Haggitt level 1,2,3 polyps without aggressive features is...?
<1% - no need for radical lymphadenectomy
140
Risk of LN mets in sessile polyp (Haggitt 4) removed with >2-mm deep margin is...? Mgmt?
negligible - oncologic formal resection not necessary
141
fu surveillance colonoscopy after endoscopic removal of potentially malignant polyp
3-mo
142
MCC large bowel obstruction
malignancy`
143
In elderly pt with amp dominant hand presenting with malignant large bowel obstruction, intervention of choice?
endoscopic stent placement -> allow for colon decompression, pt optimization, and proper bowel prep for elective -> 1-stage colectomy with primary anastomosis
*no ex-lap and ostomy bc high Cx rate in elderly, and would be unable to care of ostomy
144
Type 1 vs. Type 2 enterocutaneous fistula
Type 1 - not associated with active disease (ie. Crohn's)
| Type 2 - associated with intra-abdominal abscess; will not close with conservative mgmt
145
Mesh of choice for parastomal hernia repair
synthetic polypropylene (PTFE disfavored)
146
Dx and therapeutic, non-op mgmt for small bowel obstruction?
water-soluble contrast study - presence of contrast in colon within 24hrs also predicts resolution
147
Patho distal intestinal obstructive syndrome (DIOS) in cystic fibrosis adults
decreased Cl- and fluid secretion into both small airways and GI tract 2/2 defective cystic fibrosis transmembrane conductance regulator
148
MC location of fecal obstruction in distal intestinal obstructive syndrome
ileocecum
149
Mgmt AIN (dx + tx)
high-resolution anoscopy (analogous to colposcopy for cervical cancer screening) + directed biopsy/treatment (local ablative therapy: ie. electrocautery, cyrotherapy, topical imiquimod)
150
Mgmt pt s/p successful endoscopic decompression, presenting again with sigmoid volvulus
Hartmann procedure with end colostomy vs. sigmoidectomy with primary anastomosis
151
Mgmt pt s/p successful endoscopic decompression, presenting again with sigmoid volvulus
Hartmann procedure with end colostomy vs. sigmoidectomy with primary anastomosis
152
Measures of quality screening colonoscopy
- adequacy of bowel prep >90%
- withdrawal times >6 min
- post procedure discomfort <10%
- greater % complete colonoscopy, less risk post-colonoscopy colorectal cancer
153
Mgmt Stage 2B anal margin cancer
- has associated invasive component or anorectal carcinoma
| - APR
154
Mgmt Stage 3 anal margin cancer
- anorectal carcinoma that has mets to regional LN
| - APR w/ inguinal LN dissection
155
Congenital hypertrophy of the retinal pigmented epithelium is pathnognomonic for...?
FAP
156
MCC diarrhea in immunocompromised CD4<50
C.diff
157
Kudo classification system
recognizes that risk of LN mets in each Haggitt level 4 lesion is not the same - submucosal invasion into 3rds (Sm1, Sm2, Sm3)
158
How do you differentiate sigmoid vs. rectum intra-op?
rectum has convergence of taenia coli
159
Mgmt anal margin vs. anal canal SCC
anal margin = WLE
| anal canal = nigro
160
Desmoid (aggressive fibromatosis) vs. sarcoma characteristic on imaging
desmoid/AF: infiltrate deep tissue and muscles
| sarcoma: pushes adjacent tissue
161
MC solid neoplasm of the mesentery
lymphoma
162
CT characteristic: "sandwich sign"
lymphoma of mesentery: associated with bulky adenopathy w/ preservation of fat around mesenteric vessels
163
Ideal Abx prophylaxis (against SSI) for colorectal procedures
combination oral AND IV cefazolin and metroniadazole
164
Most reliable method to detect small liver mets (<1cm) from colorectal carcnioma is...?
contrast-enhanced MRI (but costly, so not used for screening)
165
Mgmt unresectable and asymptomatic desmoid tumors
First-line: NSAID (ie. sulindac) + antiestrogen (ie. tamoxifen)
166
Is local recurrence equivocal for transanal excision vs. formal resection for T1 rectal cancers?
NO - transanal excision is better tolerated, but higher recurrence rate even for T1 rectal cancers with appropriate criteria
167
Presenting with bleeding cecal mass + incidental 5.5cm aneurysm, what is appropriate mgmt?
fix most life-threatening first (bleeding mass) first. in addition, should not fix aneurysm first bc do not know stage of cecal mass - if poor prognosis, then should not fix aneurysm if life expectancy short.
168
Why would you not do colon resection and endovascular aortic graft repair at the same time?
risk graft contamination
169
APR vs. LAR for rectal cancers?
APR if tumor invades sphincters or would compromise sphincter muscles for adequate margins
170
Mgmt cecal volvulus? Exception?
ileocolic resection + primary anastomosis
| Exception: if gangrenous bowel or perf, then safer to place end ileostomy (no anastomosis)
171
What is definitive mgmt for rectal prolapse?
surgical (abdominal vs. perineal approach)
172
Preferred approach for rectal prolapse in elderly?
perineal approach - higher recurrence rate compared to abdominal approach, but better tolerated in elderly population
173
Young female with multiple vaginal deliveries and constipation presenting with "something falling out of anus" - what is it?
likely rectal prolapse
174
RF colonic volvulus
- high fiber diet ("volvulus belt" of Africa and Asia)
- chronic constipation
- psychotropic drugs
- sedentary lifestyle
175
Frequency of colonic volvuli in descending order
sigmoid > cecum > transverse > splenic flexure
176
Describe Hinchy classification
1: pericolic abscess
2: abscess away from colon (ie. pelvic)
3: purulent peritonitis
4: fecal peritonitis
177
External anal sphincter is under control of what nerves?
voluntary - internal pudendal nerves + S4 roots
178
MC bacterial in normal flora colon
Bacteroides fragilis (anaerobic) - NOT E.coli, which is MC aerobic
179
Prior to undergoing sigmoidectomy for colovesicular fistula, need to first do what screening procedure?
colonoscopy - to confirm diverticular disease as etiology for fistula, and not tumor (bc if tumor, then will also need en-block resection of bladder)
180
Why no primary anastomosis after total abdominal colectomy for not-localized severe GI bleed?
bc may have further bleeding -> hypotension -> high risk for leak
181
What extraintestinal conditions of UC will improve after colectomy?
- pyoderma gangrenosum
- arthritis
- erythema nodosum
182
What extraintestinal conditions of UC will NOT improve after colectomy?
- PSC
| - ankylosing spondylitis
183
First-line Tx GI CMV in transplant pt
ganciclovir (IV) - opposed to valganciclovir (PO) which is for milder diseases
184
How many LN do you need for appropriate staging for colorectal CA?
12
185
If do not have sufficient LN harvest for colon CA, then must do what for treatment?
Adjuvant chemotherapy
186
What is NIGRO protocol
5FU + 60Gy radiation + mitomycin
187
Internal vs. external hemorrhoids arise from ? hemorrhoidal plexus
Internal: arise from superior hemorrhoidal plexus
External: from inferior “”
188
Mgmt acute thrombosis of external hemorrhoids
if <4d: excision
| if after, pain tend to be resolving.
189
Grade of prolapse of internal hemorrhoids
```
1 = prolapse into anal canal
2 = extend outside anal canal, but reduces spontaneously
3 = requires manual reduction
4 = irreducible
```
190
Mgmt of grades of internal hemorrhoid prolapse
```
1/2 = injection sclerotherapy, infrared coagulation
2/3 = rubber band ligation
3/4 = OR hemorrhoidectomy (can also do stapled hemorrhoidopexy, which is less painful, but higher recurrence rate)
```
191
Mgmt rectal carcinoid
<1cm = local endoscopic excision
>2cm (most will have mets at time of dx) = proctectomy
*tumor size correlates with likelihood of mets
192
MC procedure for anal incontinence (ie. 2/2 obstetrics trauma)
Wrap around sphincteroplasty - mobilize and reapprox sphincter without tension
193
Methods for internal hemorrhoidectomy
- open (Miligan-Morgan) technique
- closed (Ferguson) technique
- circumferential (Whitehead) technique
- stapled hemorrhoidectomy
- transanal hemorrhoidal dearterialization
194
Steps: transanal hemorrhoidal dearterialization
doppler-guided ligation of arterial inflow to hemorrhoids (superior hemorrhoidal arteries) + suture rectopexy
195
Steps: circumferential (Whitehead) hemorrhoidectomy
circumferential excision of internal hemorrhoids just proximal to dentate line
196
Mgmt of incidentally found retrorectal tumor
resection (even if asymptomatic)
197
Solitary rectal ulcer syndrome (SRUS)
sxs: rectal bleeding, copious mucous discharge, anorectal pain, difficulty passing stool
exam: ulcer(s) on anterior rectal wall just above anorectal ring
mgmt: conservative
198
C/I fistulotomy and curettage for anal fistula
pt with hx incontinence
199
Preferred mgmt low-lying (<30% sphincter complex) simple anal fistula if no hx incontinence
primary fistulotomy and curettage
200
Preferred mgmt anal fistulas transversing external anal sphincter
setons to obliterate tract over period of time
201
Dx of anal fissure based off on...
hx of pain and bleeding with defecation in association with hx constipation + gentle inspection by parting anus (do not need DRE or proctoscopy bc ouch!)
202
When need lymphadenectomy for anal margin SCC?
rare - only if inguinal LN involvement (which is poor prognosis indicator)
203
Cx of urinary retention after hemorrhoidectomy 2/2...?
muscle spasms of pelvic floor musculature
204
Bleeding within 24hrs after hemorrhoidectomy due to...?
likely surgical error that will need be be corrected in the OR
205
Bleeding at POD#5 s/p hemorrhoidectomy due to...?
likely sloughing of eschar - should resolve
206
Hemorrhoids are located in what "cushions?"
* when pt in lithotomy, located at 3', 7', 11'oclock
- left lateral
- right anterior
- right posterior
207
Surgical mgmt for rectal prolapse
abdominal and perineal approach.
- abdominal rec for younger pts
- perineal has higher rate of recurrence; rec for elderly bc less invasive
208
Mgmt contained colonic anastomotic leaks without evidence pelvic sepsis (s/p surgery)
IV Abx alone (95% will heal spontaneously) - only perQ drain if abscess
209
Screening surveillance for Peutz-Jeghers syndrome
colonoscopy starting 25yo q2y
210
Mgmt recurrent C.diff
combined IV flagyl + PO vanc
211
Mgmt C.diff in pregnant females or breast-feeding mothers
PO vanc (no flagyl)
212
Perirectal abscesses MC due to ...?
obstructed anal glands
213
Where do anal fistulas tract?
will track back to anal canal (Goodsall's rule)
anterior -> track in linear fashion
posterior -> track in curvilinear fashion
ischiorectal -> track around rectum to form "horseshoe abscess"
214
When can you do primary repair of colonic injury?
If <50% colon circumference
215
Pathophys of diverticular bleed
arterial rupture of submucosal artery or from vasa recta
216
MCC lower GI bleeding (#1 and #2)
```
#1: diverticulosis
#2: neoplasia or bleeding polyps
```
217
Which extracolonic UC Cx will not resolve after colectomy?
- PSC
| - ankylosing spondylitis
218
Mgmt rectal carcinoid? If unresectable mets?
(same as appendix)
<1cm (low likelihood mets) = local endoscopic excision
>2cm (likely mets) = proctectomy
widespread, unresectable mets = octreotide
219
Anastomotic leak rate:
- ileocolic
- colocolonic
- coloanal
- ileocolic: <1%
- colocolonic: 1-10%
- coloanal: 10-20%
220
MC site iatrogenic perforation 2/2 colonoscopy
sigmoid colon
