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Large Bowel Pathology Flashcards

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1
Q

How common is colorectal cancer?

A

4th most common cancer behind breast, prostate and lung

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2
Q

What is the most common classificaton of colorectal cancer?

A

Adenocarcinoma. (98%)

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3
Q

What sex is colorectal cancer more common in?

A

M > F

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4
Q

What causes colorectal cancer?

A

IBD

FH

Genetics

Alcohol

Obesity

Smoking

Diabetes

>Age

Diet

  • Decreased fibre
  • Increased red meat
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5
Q

What are the genetic causes of colorectal cancer?

A

Familial Adenomatous Polyposis

HNPCC

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6
Q

What is Familial Adenomatous Polyposis?

A

Rare autosomal dominant condition in which adenomatous polyps form in the colon epithelium due to mutation of APC gene, located on chromosome 5

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7
Q

What is HNPCC?

A

Autosomal dominant disorder of gene mutations in MSH2 and MLH1, causing mainly right-sided carcinoma

Also known as Lynch syndrome

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8
Q

How does colorectal cancer present?

A

Right

  • Weight loss
  • Iron deficiency anaemia

Left

  • Persistent rectal bleeding mixed with stools
  • Altered bowel habit, usually to loose frequent stools
  • Abdominal pain
  • Tenesmus

Both

  • Palpable lower abdominal mass
  • Cachexia
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9
Q

What investigation is used in colorectal cancer diagnosis?

A

FBC

  • Hypochromic microcytic anaemia/iron deficiency anaemia

Colposcopy with biopsy, gold standard

Biomarkers

  • CEA
  • CA19-9

CT chest, abdomen pelvis for staging

CT colonography when colonoscopy fails

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10
Q

What investigation is used in colorectal cancer screening?

A

Faecal Immunochemical Testing (FIT)

adults 50-74 every 2 years

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11
Q

What procedure can be done for those at risk of HNPCC?

A

Prophylactic Proctocolectomy

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12
Q

Name complications of colorectal cancer?

A

Acute bowel obstruction

Iron deficiency anaemia

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13
Q

What criteria is used for colorectal cancer stageing?

A

Modified Duke’s Classification

However, TNM is now more commonly used

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14
Q

Describe Duke’s stage A colorectal cancer

A

Confined to bowel wall

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15
Q

Describe Dukes stage B colorectal cancer

A

Growth through bowel wall (muscle)

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16
Q

Describe Dukes stage C colorectal cancer

A

Regional lymph node involvement

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17
Q

Describe Dukes stage D colorectal cancer?

A

Distant metastases

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18
Q

What is used to monitor disease progression in colorectal cancer?

A

CEA (carcinoembryonic antigen)

Not helpful in screening, but it may be used for predicting relapse of previously treated for bowel cancer

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19
Q

What are the locations of colorectal cancer?

A

(from most common to least common)

Rectal

Sigmoid

Ascending colon and caecum

Transverse colon

Descending colon

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20
Q

What is the most common location for colorectal cancer?

A

Rectal

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21
Q

What is HNPCC also associated with?

A

Endometrial cancer

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22
Q

What is FAP also associated with?

A

Duodenal tumours

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23
Q

What is the most common type of inherited colorectal cancer?

A

HNPCC

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24
Q

What criteria is used to help diagnose HNPCC?

A

Amsterdam criteria

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25
What is involved in the Amsterdam criteria?
At least 3 members with colorectal cancer Cases span 2 generations At least one case diagnosed before 50
26
When should an urgent 2 week colposcopy referral be offered?
Over 50 with unexplained hypochromic microcytic anaemia Over 40 years with abdominal pain and unexplained weight loss Over 50 years with unexplained rectal bleeding Over 60 years with a change in bowel habit
27
What is the management of upper rectum colorectal cancer?
Anterior resection
28
What is the management of caecal, ascending or proximal transverse colon colorectal cancer?
Right hemicoloectomy
29
What is the management of distal transverse and descending colon colorectal cancer?
Left hemicoloectomy
30
What is the management of sigmoid colon colorectal cancer?
High anterior resection
31
What is the management of anal verge colorectal cancer?
Abdominal-perineal excision of rectum
32
What is the management of lower rectum colorectal cancer?
Anterior resection
33
When is Hartmann's procedure performed?
Performed as an emergency procedure, ie perforation of rectosigmoid colon The sigmoid colon and upper rectum are removed and an end colostomy formed
34
Give complications of bowel cancer surgery
Bleeding, infection and pain Damage to nerves, bladder, ureter or bowel Post-operative ileus Anaesthetic risks Laparoscopic surgery converted during the operation to open surgery Leakage or failure of the anastomosis Requirement for a stoma Failure to remove the tumour Change in bowel habit DVT and PE Incisional hernias Low anterior resection syndrome, causing incontinence Intra-abdominal adhesions
35
How is curative bowel cancer surgery followed up?
CT chest, abdomen, pelvis CEA
36
What is appendicitis?
Inflammation of the vermiform appendix, which arises from the caecum
37
What is the peak age of appendicitis?
10-20 years
38
What causes appendicitis?
As there is a single entrance and exit to the appendix, pathogens can get trapped due to obstruction at the point where the appendix meets the bowel, leading to infection and inflammation secondary to luminal obstruction
39
How does appendicitis present?
Colicky central abdominal pain due to inflammation of the appendix, followed by localization of pain to right iliac fossa due to inflammation of overlying peritoneum McBurney'spoint/RIF tenderness N&V Low grade pyrexia Guarding on abdominal palpation Rebound tenderness (increased pain when releasing pressure), suggesting peritonitis Percussion tenderness, suggesting peritonitis Rovsing's sign
40
What is Rovsing's sign?
Palpation of LIF causes pain in RIF
41
What investigations are used in appendicitis diagnosis?
Diagnosis is mainly clinical FBC * Increased WCC * Neutrophilia \>CRP USS/CT, exclude other diagnosis B-HCG, exclude ectopic pregnancy in females Laparoscopy, diagnostic and therapeutic
42
How is appendicitis managed?
Laparoscopic/open appendicectomy Prophylactic co-amoxiclav
43
Describe the pre-operative management for an appendicectomy?
Prophylactic IV antibiotics/Co-amoxiclav
44
Give differential diagnoses of appendicitis
Ectopic pregnancy Ovarian torsion Ruptured ovarian cyst Diverticulitis PID
45
What is a complication of appendicitis?
Perforation leading to generalized peritonitis or localized appendix abscess
46
Give complications of appendicectomy
Bleeding, infection, pain and scars Damage to bowel, bladder or other organs Removal of a normal appendix Anaesthetic risks PE or DVT
47
What is ischaemic colitis?
Acute disruption in blood supply to the colon, which may lead to inflammation, ulceration and haemorrhage
48
Give risk factors for ischaemic colitis
Age AF, particularly for mesenteric colitis Other causes of emboli * Endocarditis * Malignancy CVD risk factors * Smoking * HTN * DM Cocaine
49
How does ischaemic colitis present?
Self limiting Abdominal pain * Crampy * Generalised Sudden bloating Rectal bleeding Diarrhoea Fever Dusky blue mucus
50
What investigations are used in bowel ischaemia diagnosis?
FBC * Increased WCC Increased Lactate AXR * Thumb printing in ischaemic colitis if haemorrhage or mucosal oedema CT abdomen, makes diagnosis
51
What is the first line investigation for bowel ischaemia?
Lactate
52
What is the management for ischaemic colitis?
Supportive Surgery if peritonitis, perforation or ongoing haemorrhage
53
Which part of the colon is most likely to be affected by ischaemic colitis?
Splenic flexure
54
What is sigmoid volvulus?
Describes large bowel obstruction caused by the sigmoid colon twisting on the sigmoid mesocolon
55
Where can volvulus also occur, less commonly?
Caecum (20% of cases) Due to developmental failure of peritoneal fixation of the proximal bowel
56
Give risk factors for sigmoid volvulus
Increased age Chronic constipation Chagas disease Neurological conditions * Parkinson's * DMD Psychiatric conditions * Schizophrenia
57
Give risk factors for caecal volvulus
Adhesions Pregnancy All ages
58
How does volvulus/bowel obstruction present?
Vomiting, green billious Diffuse abdominal pain Abdominal ditention Absolute constipation Tinkling bowel sounds History of malignancy/surgery
59
What investigations are used in bowel obstruction, generally?
AXR, initial investigation Contrast abdominal CT confirms diagnosis and establoshes site
60
What AXR signs are seen in volvulus?
Large bowel obstruction * Large, dilated/distended loop of colon * Often with air-fluid levels Coffee bean sign arrising from LLQ in sigmoid Embryo sign arrising from RLQ in caecal Small bowel obstruction and centrally dilated bowel may be seen in caecal
61
How is sigmoid volvulus managed?
Supportive with analgesia, fluids and NG tube insertion Rigid sigmoidoscopy with rectal tube insertion for decompression Urgent laparotomy if peritonitis or failed compression
62
How is caecal volvulus managed?
Right hemicolectomy
63
How is bowel obstruction managed, generally?
Nil by mouth IV fluids NG tube with free drainage, reducing risk of vomiting and aspiration Laparoscopy to correct underlying cause
64
Give causes of bowel obstruction
Adhesions Hernias Malignancy Volvulus Diverticular disease Strictures Intussuception
65
What anti emetic should be avoided in bowel obstruction?
Metoclopramide
66
What is diverticular disease?
Protrusion of the inner mucosal lining through to the outer muscular layer of the bowel, forming pouches/bulges
67
What causes diverticular disease?
\>50 Low fibre diet Obesity NSAIDS Congenital/Meckel's
68
Which part of the bowel is diverticular disease most common in?
Sigmoid
69
What is Meckel's diverticulum?
Congenital outpouching or bulge in lower part of the small intestine due to left over umbilical cord
70
How does diverticular disease present?
Mainly self-limiting, can be asymptomatic LLQ pain Constipation/altered bowel habit Rectal bleeding
71
What classification is used to assess the severity of diverticular disease?
Hinchey classification
72
How is diverticular disease managed?
Increase dietary fibre Bulk forming laxatives, stimulant laxatives should be avoided Surgical resection
73
Give complications of diverticular disease?
Diverticulitis Haemorrhage Fistula development Abscess development Perforation Peritonitis Ileus/obstruction
74
How does diverticulitis present?
Severe LLQ abdominal pain N&V Fever Change in bowel habit, mainly diarrhoea Rectal bleeding Reduced bowel sounds Guarding, rigidity and rebound tenderness suggests perforation Increased inflammatory markers
75
How is diverticulitis managed?
Analgesia, avoiding NSAIDS Oral co-amoxiclav for 5 days in mild disease Admitted for IV if no improvement in 72 hours Abscess drainage
76
What is melanosis coli?
Disorder of pigmentation of the bowel wall in which histology demonstrates pigment-laden macrophages, associated with laxative abuse

Gastrointestinal (14 decks)

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