Term
| what part of colon is retroP? |
|
Definition
asc, desc, sig, rectum
**all except Tverse** |
|
|
Term
| parts of rectum covered by peritoneum? |
|
Definition
|
|
Term
| transverse bands that form haustra = |
|
Definition
|
|
Term
| longitudinal bands running along colon |
|
Definition
|
|
Term
|
Definition
muscularis mucosa
muscularis propria
taenia coli |
|
|
Term
|
Definition
IMA-->sup rectal art
Int iliac -->Mid rectal art
int iliac-->int pudendal-->inf rectal a |
|
|
Term
|
Definition
| Sup rectal and middle rectal junction |
|
|
Term
|
Definition
sup and middle --> IMV-->Portal system
Inf-->internal iliac --> caval system |
|
|
Term
| What makes up internal vs external anal sphincter? |
|
Definition
internal = muscularis propria
external = puborectalis muscle |
|
|
Term
| external anal sphincter innervation? |
|
Definition
-inferior rectal br of internal pudendal (sympathetic)
-perianal br of S4 |
|
|
Term
| internal anal sphincter innervation |
|
Definition
| pelvic splanchnics (parasymp only) |
|
|
Term
|
Definition
Meissner = inner
Outerbach = outer |
|
|
Term
distances from anal verge
-anal canal
-rectum
-RS junction |
|
Definition
canal = 0-5 cm
rectum = 5-15 cm
RS junction = 15-18 cm |
|
|
Term
| levator ani as anatomic landmark? |
|
Definition
| transition from anal canal to rectum |
|
|
Term
| main nutrient of colonocytes? |
|
Definition
|
|
Term
|
Definition
-inc fiber (30 gm/d) + water cures most
*subtotal colectomy w/ileo-rectal anasatomosis = last option* |
|
|
Term
Rectocele
-definition
-RF
-Tx |
|
Definition
-ant wall of rectum bulges into vag
-Multoparous F
-Kegel, +/- surg to strengthen fascia |
|
|
Term
|
Definition
1. diversion/disuse (hartmans)->SCFAcid
2. Infectious-> Cipro/Flagyl |
|
|
Term
Lymphocytic colitis
-sx
dx
tx |
|
Definition
-watery D, inflam bowel-like sxs
-normal scope, but bx: epithelial lymphocytes
-diet mod (dec caf, fat, lactose), roids, sulfasalazine |
|
|
Term
|
Definition
bloody D, pain/fever/weight loss
*Spares anus*
*bleeding @ rectal exam* |
|
|
Term
|
Definition
| -contiguous lesions, friable mucosa, |
|
|
Term
|
Definition
loss of haustra
narrow caliber, short colon,
loss of redundancy |
|
|
Term
|
Definition
5 asa (sulfasal)
Azathio/6 MCTP
Loperamide if mild dz
*not for acute exac*
low residual diet |
|
|
Term
|
Definition
continue medical mgmt
-add cipro-flagyl
-add steroids
-add inflix +/- cyclosporin |
|
|
Term
| % needing surg w/toxic megacolon? |
|
Definition
|
|
Term
| MC perf location with UC vs CD? |
|
Definition
UC = tverse colon
CD = distal ileum |
|
|
Term
|
Definition
|
|
Term
|
Definition
-hemorrhage
-refractory TMC/colitis
-obstruction/stricture
-ANY dysplasia, or CA, CA prophy if long-standing dz
- >10-12 bloody BM/day
-failed steroid wean
-perf |
|
|
Term
UC
-what operation for emergent surg? |
|
Definition
-total procto-colectomy + ileostomy
**LATER: ileoanal anast w/J-pouch** |
|
|
Term
|
Definition
1. total procto-colectomy, rectal mucosectomy, J pouch from ileum, ielo-anal anast w/loop ileostomy ...OR
2.APR w/ostomy |
|
|
Term
| UC elective pre-op considerations? |
|
Definition
if for longstanding dz..need ro RO CA w/scope
steroids + bowel prep pre-op |
|
|
Term
| best elective UC surg option to preserve bladder/sexual function? |
|
Definition
| total proctocolectomy w/J pouch better than APR |
|
|
Term
UC
% of ileoanal anastomosis that need resection and why |
|
Definition
15% (get APR and ileostomy)
-CA/dysplasia
-refractory proctitis/sepsis
-incontinence (MC reason for takedown) |
|
|
Term
| MC reason for ileoanal anast take down? |
|
Definition
|
|
Term
Ileoanal anastomosis
complications? |
|
Definition
1. leak = MC major fx
2. pouchitis
3. bladder/sexual dyfunction
4. stenosis |
|
|
Term
UC
tx total procto-colectomy /ileoanal anastomosis
--->now w/dysplasia? |
|
Definition
|
|
Term
| Contraindications to J pouch + Ileoanal ansatomosis? |
|
Definition
1. acute exacerbation
2. crohns
3. severe rectal DZ/incontinence |
|
|
Term
|
Definition
1-2% per year starting 10 years after dx
-pan colitis = highest risk
-left sided w/hx PSC are high risk |
|
|
Term
UC
scenario WITHOUT elevated CA risk |
|
Definition
NOT elevated @ pts w/isolated ulcerative proctitis
*any dysplasia = indicaton for total colectomy* |
|
|
Term
|
Definition
some argue @ 10 years
-others say 20 years esp in pts w/fam hx, early age dx, hx PSC |
|
|
Term
|
Definition
@ 8 years for pts w/pan colitis
-15 years w/isolated left side dz |
|
|
Term
UC
% with dysplasia that have CA? |
|
Definition
20% @ low grade
40% @ high grade |
|
|
Term
UC
MC extra-intestinal manifestations requiring surg? |
|
Definition
| 1. MC requiring colectomy = FTT |
|
|
Term
UC
-extra-intestinal manifestations that DO vs Dont vs 50% get better? |
|
Definition
1. does NOT-->PSC, ank spond
2. Does-->ocular sx, arthritis, anemia
3. 50% get better-Pyoderma gang
-(deep ulcers)*tx roids* |
|
|
Term
|
Definition
flagyl
diiodohydroxyquin (iodoquinol) |
|
|
Term
|
Definition
-commonly misdiagnosed..presents as a mass vs chronic fistula
-Gm pos rods w/yellow sulfer granules
-Tx = HIGH dose penicillin G
**alternate = drainage + amoxicillin** |
|
|
Term
Lymphogranuloma venerum
pres
tx |
|
Definition
-chlamydia infx-->ulcers, proctitis, tenesmus, bleeding, adenopathy, fistulas
-doxy |
|
|
Term
|
Definition
-MC = colon CA
-Divertic = #2
..sig>cecal volvulus
Ogilvies |
|
|
Term
clinical scenario
-sig volvulus |
|
Definition
| -eldrly, nursing home, using laxatives |
|
|
Term
clinical scenario
-Pseudo-obstruction |
|
Definition
| -Narcotics, very sick, in-patient |
|
|
Term
| MC place for obstruction to perf colon? |
|
Definition
|
|
Term
| 1 vs multiple stage colon resections? |
|
Definition
|
|
Term
| ddx true SBO vs Ogilvies? |
|
Definition
| air in the rectum w/Ogilvie |
|
|
Term
|
Definition
bradycardia
-have atropine ready |
|
|
Term
| Failed conservative mgmt of ogilvies? |
|
Definition
|
|
Term
sig volv
-success vs recurrence rate w/scope? |
|
Definition
80% reduce
50% recur
*sigmoid colectomy @ same admission* |
|
|
Term
|
Definition
| right hemi w/anastomosis if stable |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
colo-vesicle @ men
colo-vag @ women |
|
|
Term
| suture for bladder/vag repair @ divertic fistula? |
|
Definition
|
|
Term
| Divertic elective surg option |
|
Definition
2 stage procedure
-resection w/ostomy |
|
|
Term
| MC scenario for right sided divertic? |
|
Definition
80% found @ time of appy
-tx = right hemi, primary anastomosis |
|
|
Term
| distal target of resection for sigmoidectomy? |
|
Definition
take sigmoid up to upper rectum
*where taenia coli disapear* |
|
|
Term
| pre-op imaging before colostomy take down? |
|
Definition
-Barium enema to look for distal obstruction
-CT
-consider pre-op ureteral stents |
|
|
Term
| indications for elective divertic rsxn? |
|
Definition
1. recurrent divertic
2. hospitalization < 40
3. complicated divertic (abscesses, obstruction) |
|
|
Term
| pre-op imaging before colostomy take down? |
|
Definition
-Barium enema to look for distal obstruction
-CT
-consider pre-op ureteral stents |
|
|
Term
| indications for elective divertic rsxn? |
|
Definition
1. recurrent divertic
2. hospitalization < 40
3. complicated divertic (abscesses, obstruction) |
|
|
Term
|
Definition
|
|
Term
|
Definition
sigmoid
**but 50% are proximal to sigmoid** |
|
|
Term
Colon Ca
-higher risk adenoma |
|
Definition
| -villous, sessile, > 2 cm = inc CA risk |
|
|
Term
|
Definition
1. FAP = 100% lifetime risk
2. HNPCC = 80% lifetime risk
3. Inflamm bowel dz
*red meat* |
|
|
Term
rectal CA
-best test for TN status> |
|
Definition
|
|
Term
| which rectal lesions get pre-op C-XRT> |
|
Definition
|
|
Term
Colorectal CA
-best test for M status |
|
Definition
|
|
Term
Colorectal CA
-most important prognostic factor |
|
Definition
|
|
Term
|
Definition
liver
*5% get drop mets to ovaries* |
|
|
Term
Colorectal CA w/isolated spine mets-
origin? |
|
Definition
| rectal CA via Bastons plexus |
|
|
Term
| how does Colorectal CA met to lung? |
|
Definition
|
|
Term
Colorectal CA
-better vs worse prog cellular features? |
|
Definition
better = lymphocytic penetration
worse = mucinous (signet ring cell)
..also mucoepidermoid, perf/obstruction, inc CEA, rectal tumors, ulcerative tumors, |
|
|
Term
| 4 genes involved in colorectal CA |
|
Definition
1. APC (tumor supressor, binds GSK)
2. p53 (tumor sup)
3. k-ras (oncogene, GTPase)
4. DCC (deleted in colorectal CA) |
|
|
Term
|
Definition
Tis = mucosa only
T1 = past musc mucsa, into subM
T2 = musc. propria
T3 = subserosa
T4 = through colon wall, into other organ/tissue |
|
|
Term
|
Definition
N0 = none
N1 = 1 to 3 nearby LN
N2 = 4+ nearby nodes |
|
|
Term
|
Definition
1 = T1 or T2 only
----
2A = T3 only
2B = T4 only
----
3A = T1 or T2, N1 only
3B = T3 or T4, N1 only
3C = N2 (any T)
----
4 = M1 (any T, any N) |
|
|
Term
Colorectal CA
-margins needed and exceptions? |
|
Definition
2 cm margins except...
1. T1 rectal lesions w/trans-anal excision
-->2-3 mm
2. pedunculated adenoma/sessile rectal adenoma w/small T1 focus (2-3 mm) |
|
|
Term
Extended hemi
-indications? -arteries taken? |
|
Definition
-hepatic flex tumors
-Right colic, ilio-colic, middle-colic |
|
|
Term
Right hemi
-arteries taken |
|
Definition
|
|
Term
| resection for splenic flex tumors? |
|
Definition
extended left hemi
-left colic + middle colic |
|
|
Term
| surg mgmt of left sided colon CA? |
|
Definition
| leave temporary loop ileostomy |
|
|
Term
| margins needed to safely perform LAR? |
|
Definition
2 cm margins
-2 cm from levator ani (6 cm from anal verge)
..if not--> APR |
|
|
Term
distance from verge to..
dentate
levator ani |
|
Definition
2 cm to dentate line..
then another 2 cm to levator ani |
|
|
Term
| mgmt of colorectal CA s/p neo-adj chemo-XRT with complete response? |
|
Definition
still need resection
-25% have occult CA |
|
|
Term
uncontrolled sacral vein bleeding
mgmt? |
|
Definition
suture ligation, thrombin, bone wax
-->otherwise damage control and take back later |
|
|
Term
| Mgmt of local recurrence after LAR? |
|
Definition
APR
*re-stage before re-op* |
|
|
Term
|
Definition
|
|
Term
| mgmt rectal pain with rectal CA? |
|
Definition
|
|
Term
|
Definition
| remove rectum and anus w/permanent colostomy |
|
|
Term
|
Definition
| MALIGNANT lesions not amenable to LAR |
|
|
Term
| highest local recurrence risk with colon vs rectal CA? |
|
Definition
|
|
Term
|
Definition
|
|
Term
| arteries contained in "lateral stalks" |
|
Definition
|
|
Term
| Criteria for trans-anal excision of rectal CA? |
|
Definition
1. < 4 cm + < 1/3 circumf. + < 8 cm away
3. neg margins (2 mm)
4. no neuro/vasc/lymph invasion
5. well differentiated |
|
|
Term
| recurrence / survival w/trans-anal excision? |
|
Definition
| T2 = higher recurrence/lower survivial vs T1. |
|
|
Term
| which stages of CRCa get chemo/xrt? |
|
Definition
-Stg 3 + 4 COLON--> post op chemo
-----
-stg 2 + 3 RECTAL-->Neoadj CXRT + Adj chemo
-stg 4 RECTAL --> CXRT +/- surg |
|
|
Term
| which colon cancer stages get XRT? |
|
Definition
NONE!!
-stg 3 and 4 get neoadj chemo, but no XRT |
|
|
Term
|
Definition
5FU, Leucovorin, Oxaliplatin (FOLFOX 6 cycles)
-add Bevacizumab vs mets (MAb to VEGF) |
|
|
Term
| chemo med to add w/CRCA mets? |
|
Definition
| Bevacizumab (MAb to VEGF) |
|
|
Term
CRCa XRT
-benefit?
-MC site of XRT injury>? |
|
Definition
-dec local rec + inc survival
-MC = rectum (vasculitis, ulcers, strictures) |
|
|
Term
rectal CA getting pre-op CXRT?
-next step? |
|
Definition
repeat proctostocpy w/TRUS
-re-stage |
|
|
Term
| Follow up studies after CRCA surg? |
|
Definition
1. CEA q6 month x 5 years if T2 or greater
2. CT CAP qY x 3 years
3. Colonoscopy @ 1 year (unless never done, then get it 3 months post op) |
|
|
Term
CEA t 1/2?
-mgmt if cant find source? |
|
Definition
18 days
-if persistent elevation but cant find source-->2nd look lap |
|
|
Term
% CRCa recurrence?
-recurrence time-frame? |
|
Definition
20% recurrence rate
-50% w/in 6 mo
-100% w/in 3 years
**5% have another primary** |
|
|
Term
| best method for liver met detection? |
|
Definition
Intra-op US
3-5 mm resolution |
|
|
Term
| Mgmt liver met discovered at time of colon CA rsxn? |
|
Definition
1. if easy.. wedge it w/ 1 cm margins
2. if not.. send bx, finish case, re-stage 6-8 wk later..then +/- resect it |
|
|
Term
| indication for 1 vs 2 vs 3 stage colorectal CA procedure? |
|
Definition
|
|
Term
| mgmt of unresectable mets @ time of APR? |
|
Definition
| often don't need APR.. still do it if sxs were significant bleeding or pain |
|
|
Term
| unresectable CRCA w/ascites? |
|
Definition
PD dialysis w/PRN drainage
(really??) |
|
|
Term
| poor prog factors after liver met resection w/colorectal CA? |
|
Definition
1. < 1y dz free
2. > 3 tumors
3. Size > 5 cm
4. CEA> 200
5. +ve nodes
6. synchronous primary and liver mets |
|
|
Term
| outcome of formal hepatic met rsxn vs wedge? |
|
Definition
| formal rsxn improves loco-regional control. |
|
|
Term
| margins for liver met resection? |
|
Definition
1 cm
-number of tumors, size, location don't matter as long as resectable |
|
|
Term
| 5YSR after liver met resection? |
|
Definition
35%
(25 % 5YSR if lung mets) |
|
|
Term
| CRCA screening @ normal risk pt |
|
Definition
1. @ 50: Yearly FOBT, DRE qy + flex sig Q5 year OR
2. colonoscopy Q10 year
*polyp on sig requires Cscope* |
|
|
Term
| Surveillance after polypectomy? |
|
Definition
1. High risk (>3 adenoma, high grade dysp, villous, > 1 cm)--> 3y f/u scope
2. Low risk --> 5 year f/u scope |
|
|
Term
| CRCA screening @ high risk pt? |
|
Definition
1. age 40 or 10 y before..
-FOBT x 3 + DRE qY + C-scope q2-3Y |
|
|
Term
| When NOT to do colonoscopy for screening? |
|
Definition
| 1. recent MI, splenomegaly, pregnancy if fluoro is planned |
|
|
Term
| efficacy of FOBT screening? |
|
Definition
| Dec mortality by 1/3 due to earlier dx |
|
|
Term
|
Definition
APC tumor supressor mutation
*20% spont w/no fam Hx* |
|
|
Term
|
Definition
|
|
Term
|
Definition
duodenal and periampullary polyps/adenoCA
*EGD q 1-2 years |
|
|
Term
|
Definition
Total proctocolectomy + rectal mucosectomy + ileoanal pouch
-lifetime surveillance of residual rectum
*can also do totalproctocolectomy w/end ileostomy* |
|
|
Term
| MCC death with FAP after colectomy? |
|
Definition
duodenal periampullary CA
*whipple* |
|
|
Term
|
Definition
|
|
Term
|
Definition
bloody D, urgency
Colonoscopy, friable pouch
-cipro flagyl
*might need APR if refractory or ANY dysplasia* |
|
|
Term
|
Definition
Colon CA (APC gene)
Osteomas (forehead bumps)
Desmoid tumors (benign, locally invasive) |
|
|
Term
|
Definition
WLE +/- NSAIDs, anti-estroges, CXRT
*if involving significant SB, dont resect it..cang et worse* |
|
|
Term
|
Definition
|
|
Term
|
Definition
DNA mismatch repair genes
-MSH, MLH, PMS1, PMS2 |
|
|
Term
|
Definition
AD, < 100 polyps, 80% lifetime risk Colon CA
-inc right sided CA, multiple colon CAs |
|
|
Term
|
Definition
type 1 = just colon CA
type 2 = + ovarian, endometrial, bladde,r stomach, panc CA |
|
|
Term
|
Definition
"3-2-1"
-3 relatives, over 2 gen
-1 relative w/colon Ca before 50
*Amsterdam 2 criteria includes any combination of CA* |
|
|
Term
|
Definition
Cscop..
1. q2 year @ 21 or 10 years before..until 40 then yearly |
|
|
Term
|
Definition
| total colectomy @ time of first CA operation |
|
|
Term
|
Definition
1. yearly..pelvic/trans-vag/CA-125 @ age 25
-->+/- endometrial bx
2. Breast: yearly mammo @ 30, breast exam @ 20
*consider TAH/BSO after child-bearing years* |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
colon polyp showing T1 lesion after polypectomy..
when is polypectomy adequate> |
|
Definition
-clear 2-3 mm margins
-well dif
-no vascular/lymph/neuro invasion
*o/w get formal rsxn* |
|
|
Term
mgmt:
-low rectal villous adenoma w/atypia |
|
Definition
trans-anal excision
-no ARP unless CA is present |
|
|
Term
trans anal adenoma excision showing T1 lesion
-mgmt |
|
Definition
| adequate if well diff, clear 2-3mm margins, no invasion |
|
|
Term
| trans-anal excision of rectal polyp showing T2 lesion.. mgmt |
|
Definition
APR or LAR
*pre-op CXRT if t3 or t4 |
|
|
Term
| MC intestinal neoplastic polyp? |
|
Definition
|
|
Term
Juvenile polyposis
-CA risk
-p/w
-why CA risk? |
|
Definition
1-% lifetime CRCA risk (inc polyps = inc rsk)
-p/w painless rectal bleed. anemia, FTT
-hamartomas (risk for adenomatous change) |
|
|
Term
Juvy polyposis
-surveillance |
|
Definition
|
|
Term
Cronkite-Canada
-features |
|
Definition
hamartomas->chronic D, enteropathy
-nail/hair atrophy, hypopigmentation
-stomach and colon polyps
-10% lifetime CA risk 2/2 adenomatous change |
|
|
Term
|
Definition
< 2 cm = WLE w/neg margins
**colon or high rectal = formal rsxn + adenectomy**
> 2 cm OR musc propria invasion = APR |
|
|
Term
Neutropenic typhitis
-pres/tx |
|
Definition
after chemo..cecal inflammation
-no OR unless perf
avoid endoscopy |
|
|
Term
|
Definition
first few weeks after XRT
-p/w D and tenesmus
-Tx w/ roid enema
*avoid scopes due to perf risk* |
|
|
Term
Late XRT proctitis
-pres/tx |
|
Definition
a. bleeding-->formalin fixation = best
b. obstruction 2/2 stricture--> 6-8 wks conservative mgmt +/- roids
*+/- dilation or trans anal excision +/- ostomy diversion* |
|
|
Term
late radiation proctitis w/fistula
-mgmt |
|
Definition
bx to R/O CA recurrence
**Avoid APR** |
|
|
Term
late radiation colitis
mgmt |
|
Definition
-bx to r/o ca
-likely ostomy / bypass |
|
|
Term
|
Definition
NGT lavage showing BILE
-clear fluid could mean closed pylorus w/blood just beyond it |
|
|
Term
| mgmt hard to find GI bleed? |
|
Definition
-arteriography (>0.5 cm/min bleeds)
-tagged RBC (most sensitive: >0.1 cc/m) |
|
|
Term
LGIB
-meds to slow the bleed? |
|
Definition
|
|
Term
|
Definition
diverticulosis
*MC right side, but higher proportion of right sided -osis have bleeding*
-75% stop spontaneously |
|
|
Term
| MC location of angiodysplasia bleeding? |
|
Definition
MC right side colon
-venous bleeding
(Diverticulosis is arterial bleeding)
*more likley to recur vs Dosis* |
|
|
Term
| assoc condition w/angiodysplasia? |
|
Definition
|
|
Term
|
Definition
1. scope
2. amicar if diffuse
3. resection if recurrent |
|
|
Term
|
Definition
|
|
Term
|
Definition
-IMA ligation / thrombosis
-low flow state |
|
|
Term
|
Definition
1. Splenic (Griffith) = SMA (middle colic) & IMA (left colic) =
2. Rectal (Sudeck)= Sup rectal (IMA) & middle rectal (int iliac) |
|
|
Term
| area spared with low flow state ischemic colitis? |
|
Definition
middle and lower rectum
*middle rectual (int iliac) and inf rectal (int pudendal) |
|
|
Term
| Embolic mesenteric ischemia RF |
|
Definition
| -recent agnio, CABG, A fib, endocarditis, MI |
|
|
Term
|
Definition
1. arterial embo (50% = MCC)
2. arterial thrombosis (25%)
3. NOMI (15%)
4. venous thrombosis (5%) |
|
|
Term
| imaging findings of SMA embolic mesenteric ischemia vs thrombotic> |
|
Definition
embolic: meniscus 5 cm down the SMA, near origin of SMA
**Spares Jej**
thrombotic: involves jejunum |
|
|
Term
| criteria for intra-art thrombolysis of embolic acute mesenteric ischemia |
|
Definition
|
|
Term
|
Definition
atherosclerosis
-hx chronic problems |
|
|
Term
| surg approach of embolic vs thrombotic arterial mesenteric ischemia? |
|
Definition
1. embolic = fogarty
2. thrombotic = usually bypass |
|
|
Term
| meds to inc blood flow in NOMI? |
|
Definition
glucagon
papavarine
nitrates |
|
|
Term
mesenteric VEIN thrombosis
-usual pattern seen |
|
Definition
| short segment of bowel involved |
|
|
Term
| SMA to celiac colaterals = ? |
|
Definition
|
|
Term
chronic mesenteric angina
-best tx |
|
Definition
|
|
Term
Median Arcuate Lig syndrome
-pphys
-pres
-tx |
|
Definition
-celiac compression
-bruit near epigastrium, chronic pain/WL/D
-transect median arcuate lig |
|
|
Term
MC org causing mesenteric lymphadenitis
-pt pop?
-tx? |
|
Definition
yersinia
*MC kids*
-tetracycline or bactrim |
|
|
Term
| MC area affected by Hirschsprung dz? |
|
Definition
-rectosigmoid MC
*dx rectal bx* |
|
|
Term
|
Definition
-2/2 trypanosome cruzi
*Auerbach plexus nerve destruction* |
|
|
Term
|
Definition
loop of colon above liver
-confused w/free air |
|
|
