Lower G.I. 5

Question 0

55-year-old man presents with constipation, rectal bleeding, fatigue. Find constricting lesion 4 cm from anal verge. Biopsy shows adenocarcinoma. Further preoperative evaluation? Appropriate procedure? Complications?

Answer 0

1. Colonoscopy for visualization
2. Transrectal ultrasound to determine rectal wall invasion
3. CT or MRI to determine spread to adjacent structures
4. CXR and CEA

Abdominoperineal resection (excision of entire rectum with permanent colostomy)

Impotence (50%), impaired bladder function, colostomy complications

Question 1

55-year-old man presents with constipation, rectal bleeding, fatigue. Find constricting lesion 4 cm from anal verge. Biopsy shows adenocarcinoma. What lymph nodes could be invaded?

Answer 1

Internal iliac, sacral, inferior mesenteric, inguinal

Question 2

Poor prognostic factors for rectal adenocarcinoma?

Answer 2

#Poor histologic differentiation
#elevated CEA
#bowel perforation
#aneuploidy

Question 3

Regarding rectal cancer – distance from anal verge affects operative management how?

Answer 3

It’s more than 5 cm proximal to anal verge, possible to remove

If closer, abdominoperineal resection is necessary (removal results in incontinence) because margins include anal sphincter

If distal, need 2 cm margins for well/moderately differentiated lesions; 5 cm margins for poorly differentiated/anaplastic/signet cell carcinomas

Question 4

When to use preoperative radiation for rectal cancer?

Answer 4

If lesions or large/bulky or extend outside bowel wall

Question 5

How does abdominoperineal resection differ in women?

Answer 5

Remove posterior wall of the vagina

Question 6

Patient undergoes curative resection with abdominoperineal resection. Later developed .5 cm lesion in perineum. Management?

Answer 6

1. Biopsy
2. If Biopsy shows carcinoma, repeat CT scan, CEA, colonoscopy
3. Chemotherapy, radiation, and surgery

Question 7

Patient with previous colon cancer resection presents with elevated CEA. Suspect metastasis. Candidate for surgical resection if?

Answer 7

1. No extrahepatic Mets
2. No local recurrence
3. Lesion in surgically resectable location
4. Acceptable Anastasia risk from cardiopulmonary standpoint

Question 8

Some Locations of unresectable hepatic lesions?

Answer 8

1. Multiple lesions in multiple lobes
2. Lesions with vascular structures (hepatic, portal veins)
3. Lesions involving diaphragm
4. Lesions in cirrhotic liver (limited hepatic reserve)

Question 9

Surgical Management of patients with unresectable liver metastases?

Answer 9

1. Cryotherapy
2. Injection of absolute ethanol
3. Radiofrequency ablation
4. Chemoembolization (catheterize hepatic artery and fill with chemotherapy)

Question 10

45-year-old man presents with rectal bleeding. Find lesion; biopsy indicates most common tumor of anal canal – diagnosis? Involved regional nodes?

Answer 10

Squamous cell carcinoma

Inguinal lymph nodes or superior rectal lymph nodes

Question 11

45-year-old man presents with rectal bleeding. Find lesion; biopsy indicates squamous cell carcinoma. Management if:

1. 0.5 cm diameter lesion with no local extension and negative lymph nodes
2. 4 cm lesion with no local extension and negative lymph nodes
3. 8 cm lesion with positive lymph nodes

Answer 11

1. Local excision
2. Surgery not initially warranted (Nigro). Chemoradiation.
   #4-6 weeks after chemoradiation do biopsy. If positive, do an Abdominoperineal resection
3. Chemoradiation then radical resection

Question 12

70 woman presents with abdominal pain and fever (101), mild tachycardia, BPO 140/85 and tender LLQ – suspected diagnosis? Management?

Answer 12

Diverticulitis

1. Abdominal obstructive series or CT scan
2. Complete bowel rest, IV hydration, parenteral antibiotics, meperidine for pain relief (morphine increases intracolonic pressure)
3. If minimal symptoms, liquid diet and outpatient antibiotics

Question 13

Patient presents for diverticulitis. After management, patient becomes hungry and rapidly improves. Management? Likelihood of another episode of diverticulitis? Long-term follow-up?

Answer 13

High-fiber diet and outpatient treatment with broad-spectrum antibiotics 47-10 days

70% will have no further recurrences

Colonoscopy or barium enema to confirm presence of diverticula and absence of colon cancer

Question 14

Patient presents with diverticulitis and gets CT scan – expected findings?

Answer 14

“Fat stranding” and edema of tissue near inflamed colon

Question 15

Patient treated for diverticulitis six months previously returns with recurrence – management? Appropriate procedure?

Answer 15

1. Bowel rest, IV antibiotics, analgesics
2. Elective resection 4-6 weeks after inflammation resolves (to prevent perforation or abscess)

Colectomy

Question 16

75-year-old woman with LLQ pain, fever, nausea. Obstructive series is unremarkable. Managed for acute diverticulitis. Patient deteriorates, continued pain, increasing fever, and increasing WBC count. Suspected problem? Appropriate evaluation? Management?

Answer 16

Free preparation for intra-abdominal abscess

CT scan

1. CT guided insertion of catheter for sampling and drainage
2. Leave in drain until drainage stops
   #discharge if afebrile and tolerates food
   #if does not improve with catheter drainage, Hartman procedure – resect colon with colostomy)
3. 4-8 weeks after information is controlled, colectomy

Question 17

70-year-old woman presents with four hour history of bright red blood per rectum. Heart rate 115. Blood-pressure 105/70, pale conjunctiva, no personal edema, neurologically intact. Management?

Answer 17

1. Two large bore IVs with 1-2 L of Ringers
2. Routine blood studies and CXR
3. Place Foley
4. Placement of NG tube to rule out upper G.I. bleed (if positive, upper endoscopy)
5. Anoscopy

Question 18

Most common causes of rapid lower G.I. bleeding? Other causes?

Answer 18

Bleeding diverticula and Vascular ectasias

Aortoenteric fistula, ischemic colitis, IBD, hemorrhoidal disease, rectal varices

Question 19

vascular ectasia? Arises from? Treatment?

Answer 19

AV malformations arising from degeneration of intestinal submucosal veins

Coagulation with monopolar current

Question 20

Left-sided versus right-sided diverticula?

Answer 20

More common versus more likely to bleed