Colorectal Cancer/polyps/diverticula/hernias - GI Flashcards Preview

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Flashcards in Colorectal Cancer/polyps/diverticula/hernias - GI Deck (25)
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1
Q

Risk Factors - colorectal cancer

A
  • 75% no known risk factors
  • Age – 90% in people 50+ yrs
  • IBD
  • Personal or FH of CRC or polyps (3x more likely to develop)
  • FAP (familial adenomatous polyposis
  • Lynch Syndrome
  • Lack of exercise
  • Low fruit/vegetable intake
  • Low-fiber / high fat diet
  • Overweight/obesity
  • Alcohol
  • Tobacco Use
2
Q

Signs and Symptoms -Colorectal Cancer

A
  • None
  • Change in stooling for several days
  • Rectal bleeding
  • BRBPR, dark tarry stools
  • Abd pain, bloating, abd distension
  • Palpable mass, hepatomegaly, ascites
  • Fatigue, night sweats, loss of appetite, unintentional weight loss
  • Iron-deficiency anemia
3
Q

CRC Screening

A
  • decrease mortality through early diagnosis and treatment of precancerous (adenomatous) and early malignant lesions.
  • 60% of deaths could be prevented if all adults >50 had screening
  • Identifies pre-cancerous polyps
  • Detects cancer at early stage
  • 90% of early caught cancer + treatment still alive 5yrs out.
  • Normally begins at age 50
  • Flex sigmoidoscopy q5 years
  • Colonoscopy q10 years
  • Double-contrast barium enema q5 years
  • CT colonography q5 years
  • In FH of polyposis syndrome = begin screening 5 years earlier than age of diagnosis of first-degree relative.
  • Annual guaiac –based fecal occult blood test
  • Stool DNA
4
Q

Colonic Polyps

A
Adenomas – 10%
3 subtypes
-Tubular = MC (80%)
-Tubulovillous
-Villous = highest morbidity/mortality
- >1cm with high-grade dysplasia = advanced neoplasm w/ increase carcinoma risk
-Nearly all CC come from these
-However, only 5% progress to cancer
-Develops over 7-10 years

Hyperplastic

  • 90%
  • Concerning in hyperplastic polyposis syndromes
  • Familial Adenomatous Polyposis (FAP)
  • Attenuated adenomatous polyposis coli (AAPC)
  • Hereditary Nonpolyposis/Lynch Syndrome
  • Others
5
Q

Familial Adenomatous Polyposis (FAP)

A
  • Autosomal dominant in the APC gene
  • 75-80% with FH </= age 40
  • Increased risk of developing other malignancies
  • 100’s – 1000’s of adenomatous polyps
  • Develops age 16, asymptomatic
  • Untreated leads to CC by age 35-40
6
Q

Attenuated adenomatous polyposis coli (AAPC)

A
  • Fewer colonic polyps – 30-35

- Develops at later age (36yrs old)`

7
Q

Hereditary Nonpolyposis/Lynch Syndrome

A

-Autosomal dominant w/ mutations in DNA mismatch repair proteins
<100 polyps
-70-80% lifetime risk of CRC
-Age of onset = late 20’s-early 30’s

  • Symptoms: Abd pain/cramps, bloating, fatigue, loss of appetite, unintentional weight loss
  • Signs: change in bowel habits, +FOBT, black tarry stool, iron deficiency
  • FH, tumor testing, genetic testing

Associated cancers

  • Endometrial (30-40%)
  • Ovarian (10-12%)
  • Gastric (4-10%)
  • Glioblastoma (13%)
8
Q

CRC Treatment

A
  • Based on staging
  • Localized Stage I-III
  • Surgical resection (colectomy) with colostomy placement
  • Remove primary tumors + clean margins including lymphatic drainage

Common types of chemotherapy: MC – 5-Fluorouracil, others include Xelod, Tegafur, -Oxaliplatin

  • Metastatic Disease
  • Stage III and some Stage II = 5-fluorouracil + adjuncts
  • Short Term: N/V/diarrhea, hair loss, anorexia, fatigue fever, sores, pain, constipation, easy bruising
  • Long Term: Lung tissue damage, heart damage, infertility, renal problems, peripheral neuropathy, risk of a second cancer
9
Q

Treatment Follow-up - CRC

A
  • 85% recurrence within 3 years after resection of primary tumor (Stage II-III)
  • Regular surveillance
  • Serum CEA every 3 months Stage III or III x 3 years, every 6 months years 4-5
  • Annual CT of chest and abdomen x 3 years
  • In the absence of high-risk pathology with postoperative colonoscopy, needs colonoscopy in 3 years, then every 5 years
10
Q

Diverticula

A

-multiple, mucosal, saclike herniations through weak points in intestinal wall (sites were mesenteric vessels penetrate small bowel)

11
Q

Diverticulosis

A

-Cause = unknown
-Risk factors – generally unknown
-Epidemiology
-Equal in men/women/across all races
-Age >50
-Most are asymptomatic (diverticulosis)
-Symptoms = complications (diverticulitis)
-Rectal bleeding (hematochezia, melena, minimal bleeding leads to iron deficiency)
-Abdominal pain, LLQ tenderness (RLQ more common in Asians), guarding
-Fever, elevated WBC?
-Labs – WBC, UA, electrolytes
-Imaging: abd xray (flat/upright), CT is gold standard
Treatment
-Inpatient vs outpatient
-2 antibiotics (metronidazole + levaquin or amoxicillin-clavulanate/TMP-SMX+ metronidazole)
-Surgery consult for repeat attacks

12
Q

Hernia

A

-Cause = unknown
-Risk factors – generally unknown
-Epidemiology
-Equal in men/women/across all races
-Age >50
May be:
-Reducible: pop back in
-Incarcerated (irreducible) - cant get in
-Strangulated: incarcerated hernia with vascular compromise, may lead to bowel gangrene
Treatment
-Attempt reduction of recently incarcerated hernias
-If strangulation: NPO, NG tube, IV fluids, broad-spectrum antibx., immediate surgery

13
Q

Types of hernias

A
  • Umbilical
  • Ventra wall/incisional
  • Femoral
  • Inguinal
14
Q

Umbilical

A
  • Congenital
  • Weakness or opening in the muscle deep to the umbilicus
  • Caused by incomplete closing of the umbilical ring
  • Small protrusion through the umbilicus
  • Worsened by coughing, crying, straining, stooling
  • Soft, reduces easily, occasionally stays protruded
  • May resolve on own
  • Up to 80% resolve on own
  • Surgery later age 5-6
15
Q

Incisional/Ventral Hernia

A

-Associated with prior surgery due to weakened scar tissue
-More likely in obese patients and pregnant women
-Other risk factors: Surgery, Persistent straining/lifting, Severe vomiting or coughing
-Soft, usually non-tender bulge
-Can be worse with increase abdominal pressure (straining/lifting)
-May or may not reduce
Diagnosis
-Made on H&P
-Hard to image since better seen when supine
Treatment
-Avoid worsening activities, support bands, surgery consult

16
Q

Inguinal Hernia

A

3 types

  • Direct
  • Indirect
  • Femoral
  • Common surgery referral
  • 75% hernias are inguinal
  • Inguinal: 25% lifetime risk in males vs. 2% in female
  • 2/3 indirect vs. 1/3 direct inguinal
  • Femoral – most common in females
  • Surgery
  • Incarceration – non-reducible, stuck
  • Strangulation
  • Incarcerated hernia w/ compromised blood flow leading to gangrene
  • Painful, N/V, surgical emergency
17
Q

Indirect Hernia

A

-Most Common
-Passage of intestine through the internal inguinal ring down the inguinal canal
-Into the scrotum because it follows the spermatic cord
-Can be congenital
Risk Factors
-Repeated lifting, straining, climbing
-H/of prior hernia repair
Presenting Symptoms
-Bulge
-Pain – aching, pulling, sharp pain
-Worse with increased groin pressure
-Surgery
-Recurrence likely especially in trade workers

18
Q

Direct Inguinal Hernia

A
  • Passage of intestine through the external inguinal ring through Hesselbach’s Triangle
  • Lateral boundary: inferior epigastric artery
  • Medial boundary: rectus muscle
  • Inferior boundary: inguinal ligament
  • Rarely enters scrotum
  • Surgery
  • Recurrence likely especially in trade workers
19
Q

Femoral Hernia

A

-Least common
-Passage through the femoral ring
-Can involve fat or pre-peritoneal tissue
-Caused by intra-abdominal pressure
-Obesity
-Pregnancy
-Bulge – quite obvious at times
-Worse with straining or supine position
Diagnosis and Treatment
-H&P
-Imaging
-Surgery Consult

20
Q

Intussusception

A

-Due to imbalances in the force of the intestinal walls
-Invagination and telescoping
Stats
-1:2000 live births
-2/3 occur in age sloughing infarcted mucosa -> “currant jelly stools” (sloughed mucosa, blood, mucus) -> gangrene
Presenting symptoms
-Classic Triad in 1/3 patient
-Abdominal pain, vomiting, blood in stool (”currant jelly stools”)
-Pain (colicky, severe, intermittent), drawing up legs to abdomen and kicking legs in the area, calm in between attacks
-Lethargy – can be only sign
-Palpable abdominal mass
-Preceding URI
-PE: chubby, cycling episodes every 15-30 mins, peritonitis (if gangrene), pale
Diagnosis
-CONTRAST ENEMA (quick & therapeutic)
leukocytosis, vitals, flat/upright abdominal xrays, US
-Surgery – if suspect gangrene or perforation
Tx: Nonsurgical
-Air enema vs. barium enema
-Fluid resuscitation
TX: Surgery
-Prognosis based on timing of intervention
-Early detection/treatment = 1% mortality rate
-Untreated = uniformly fatal in 2-5 days

21
Q

Toxic Megacolon

A
  • Acute toxic colitis with dilation of the colon
  • Radiographic evidence of >6cm in transverse colon, loss of haustra in UC
  • Any 3 of the following : Fever >101.5, tachycardia >120bpm, leukocytosis
  • 1 of the following: dehydration, AMS, electrolyte abnormality, hypotension
  • Worst complication is perforation
22
Q

TMC - Causes

A
  • Inflammatory: UC, Crohns, Pseudomembranous colitis
  • Infection: Salmonella, Shigella, Campylobacter, Yersinia, C. dif, CMV, rotavirus
  • Other: chemo, radiation, ischemic
  • Rapid tapering/abrupt DC of steroids, sulfasalazine, 5-aminosalicycic acid
  • Medications negatively impacting motility: anticholinergics, anti-diarrheals, antidepressants, opiods

Prognosis

  • No perforation = 4% mortality rate
  • Perforation = 20% mortality rate
  • Best prognosis with surgery (need ostomy)

-Many present w/ TMC during firsts IBD flare

23
Q

TMC –Physical Exam

A

-Symptoms of colitis: diarrhea, abd pain, rectal bleeding, tenesmus, vomiting, fever
-History: recent travel, abx use, chemo, immunosuppression
Ill, toxic (high fever, abdom pain, tachycardia,dehydration)
-Perforation: peritonitis (rebound, rigidity)

24
Q

TMC - Diagnosis

A

Labs
-CBC (leukocytosis with left shift, anemia)
-Electrolyte disturbances
-ESR and CRP elevated
Imaging
-Serial plain abdominal xrays
-CT scan – if TM is suspected – may find perforation

25
Q

TMC- Treatmet

A
  • Reduce distention to prevent perforation
  • Bowel rest, NG tube for decompression
  • All narcotics, antidiarrheals, anticholinergic meds stopped
  • Correct fluid/electrolyte disturbances
  • Treat toxemia
  • Broad-spectrum IV antibiotics
  • IV steroids
  • Repeat abdominal plain films
  • Cyclosporine
  • Colectomy/proctolectomy