Lower GI 4

Question 1

45-year-old man presents with bright red blood streaks on stool for last three weeks. Otherwise normal caliber and color, occasional constipation. Rectal examination shows bright red blood on glove. Next step? Ddx?

Answer 1

Anoscopy or sigmoidoscopy

Internal hemorrhoids, fissure, bleeding rectal/adenocarcinoma, polyp

Question 2

45-year-old man presents with bright red blood streaks on stool for last three weeks. Otherwise normal caliber and color, occasional constipation. Rectal examination/sigmoidoscopy shows thrombosis hemorrhoid. Management?

Answer 2

1. Sitz baths, stool softeners

2. If extreme pain, I&D of overlying skin and tissue

Question 3

45-year-old man presents with bright red blood streaks on stool for last three weeks. Otherwise normal caliber and color, occasional constipation. Rectal examination/sigmoidoscopy shows hemorrhoids. General Management? Specific management of external versus internal?

Answer 3

1. Sits baths, stool softeners, fiber
2. If continue to bleed, removal in OR

Surgical excision versus excision/banding

Question 4

45-year-old man presents with bright red blood streaks on stool for last three weeks. Otherwise normal caliber and color, occasional constipation. Rectal examination/sigmoidoscopy shows 5 cm perianal fungating mass. Suspected diagnosis? Initial step? Best imaging?

Answer 4

Anal carcinoma

Biopsy
Transanal ultrasound

Question 5

60-year-old woman reports red blood in stool. Colonoscopy finds polyp. Management if find:

1. 1 cm pedunculated polyps
2. 5 cm pedunculated polyps
3. 4 cm flat, sessile lesion

Answer 5

1. Polypectomy and send for pathology. Repeat colonoscopy after 3-6 months and surveillance colonoscopy every three years
2. Removal in piecewise fashion or more than one endoscopic session. Surveillance colonoscopy afterwards
3. If over 2 cm, may require surgical resection

Question 6

60-year-old woman with polyps. Polyps removed and sent for histology. Management if Histology shows:

1. Severe atypia
2. Carcinoma in situ and head of pedunculated polyp, with no extension to stalk
3. Carcinoma in stalk of pedunculated polyp
4. Carcinoma in sessile the

Answer 6

1. Follow up with colonoscopy
2. Colonoscopy in 3-6 months and then yearly. (Polypectomy was sufficient therapy alone)
3. Polypectomy sufficient if margins greater than 2 mm, not poorly differentiated, no vascular/lymphocytic lesion. Otherwise resect segment of bowel.
4. Bowel section

Question 7

55-year-old man with fatigue. Find pale conjunctiva and black, guaiac positive stool. Suspected diagnosis? Key initial Management?

Answer 7

Cancer

Colonoscopy, and CXR, CEA, LFTs to check for metastases.

Question 8

Patient presents with microcytic anemia and melena. Colonoscopy shows 5 cm exophytic mass in cecum. Biopsy shows moderately differentiated adenocarcinoma of cecum. Management?

Answer 8

Surgery and Fe supplements

Question 9

Areas of colon typically involved with cancer (from greatest to least?)

Answer 9

Rectum (50%) > cecum (20%) > Ascending colon (15%) > transverse colon (10%) >descending colon (5%)

Question 10

Pt Preparation before colon surgery?

Answer 10

1. Magnesium citrate or GoLYTELY
2. Oral, nonabsorbent antibiotics to decrease colonic bacteria
3. Single preoperative dose of second generation cephalosporin to diminishment infections

Question 11

Patient with colon tumor. Necessary steps during surgery?

Answer 11

1. Remove tumor, partial colectomy
2. Remove mesenteric tissue and regional lymph nose
3. anastomosis

Question 12

Patient undergoes right colectomy and excision of mesenteric lymph nodes. Remainder of abdomen is normal. Post operative management?

Answer 12

1. NPO and IV fluids until the bowel function returns

2. Once patient can tolerate food, discharge

Question 13

Stages of colon cancer?

Answer 13

Stage 1 – tumor limited to mucosa/submucosa OR deeper but not extending through muscularis propria

Stage 2 – Full thickness invasion of bowel wall OR into a adjacent structures, but does not involve regional lymph nodes

Stage 3 – tumor metastasized to regional lymph nodes

Stage 4 – Distant metastases

Question 14

When to use adjuvant chemotherapy for colon cancer? Specific drugs?

Answer 14

Stage III cancer;

5-FU + leucovorin
Or 5-FU + levamisole

Question 15

Follow-up for patient after colon cancer resection?

Answer 15

1. Repeat colonoscopy six months and then yearly

2. Frequent monitoring of CXR, CEA, and LFTs

Question 16

62-year-old woman with him positive stools. Suspect colon cancer. How do the following change evaluation of the patient:

1. RLQ mass
2. Intermittent constipation and diarrhea
3. Crampy abdominal pain
4. Family History of colon cancer - consider?
5. Previous colonoscopy showed polyps
6. Scleral icterus
7. Patient is 22 instead of 62

Answer 16

1. Large tumor – CT to assess involved structures
2. High-grade obstructive lesion (Usually on left side). Patients may not be able to undergo bowel prep.
3. Also high-grade obstructive lesion
4. Consider Lynch’s syndrome or Gardener’s syndrome
5. Still should undergo repeat colonoscopy
6. Consider metastases to liver or metastatic obstruction of bile duct. Get ultrasound or CT
7. More likely to be inflammatory condition

Question 17

Perform colectomy for colon cancer and 58-year-old man. Changes in management if:

1. Penetration of tumor into abdominal wall
2. Positive lymph nodes noted at surgery
3. Positive lymph nodes noted by pathologist days later
4. 1 cm palpable lesion of liver noted during surgery
5. 8 cm palpable lesion on liver during surgery
6. Poorly differentiated tumor histology obtained preoperatively
7. 2 cm nodule on CXR

Answer 17

1. Resect portion of abdominal wall. Significantly worsens prognosis
2. Remove all involved nodes
3. No further operative procedures. If stage III disease, adjuvant chemotherapy
4. Removal unless contiguous with vital structures (hepatic vein). If cannot remove, biopsy
5. Complete colectomy, biopsy liver lesion, plan resection at later date after further evaluation
6. No changes
7. CT and biopsy by percutaneous Neil biopsy. Decreases chance of curative operation, so cholectomy does not need to be as extensive

Question 18

Colon Cancer – types of tumors with worse prognosis?

Answer 18

1. Poorly differentiated tumors (Mucin producing and signet cell tumors)
2. Tumors with Venus or perineural invasion
3. Tumors presenting with perforation

Question 19

Post colectomy, diagnosis and management if:

1. Patient becomes distended and vomits feculent material on POD3
2. Reddening, fluctuant area develops on inferior aspect wound
3. Feculent material drains from inferior aspect of wound
4. Patient returns to hospital on POD10 with a temperature of 104 and RLQ pain
5. Patient returns in six months with crampy, abdominal pain, decreased stool caliber, constipation

Answer 19

1. Leakage from anastomoses causing persistent ileus OR mechanical obstruction from adhesions/hernia/obstructed and a stenosis. Feculent vomiting suggests bacterial overgrowth in stomach. NPO and IV fluids with NG tube.
2. Wound infection. Open wound and ensure fascia intact
3. Wound infection caused by anastomotic leak. Most will close with NPO and IV fluids. CT scan to look for undrained collection. Gastrografin enema or colonoscopy if doubt patency of anastomosis.
4. Abscess. CT scan and percutaneous drainage
5. Anastomotic recurrence of cancer or stricture at anastomoses. Colonoscopy

Question 20

Post colectomy – feculent material drains from inferior aspect of wound. Will need operative revision if?

Answer 20

Fistula with distal obstruction due to nonpatent anastomoses (will not close with IV fluids and NPO)