Colorectal Ca and anal disease

low anterior resection of the rectum

+ colonic anastamosis - preserves sphincter, anorectal function

What are risk factors for colonic disease (3)

- IBD or family hx - previously resected colon ca or polyps (or family hx) -pelvic rad therapy

what is the two classifications of colorectal ca most common

- adenomatous or serrated

what are complications of perianal abscess formation

- continued expansion into adjacent spaces - sepsis - perianal fistula (common)

what are the initial lab findings in colorectal ca

- iron def anemia - elevated LFTs and Alk phos can indicate metastasis

what is pt ed for perianal abscess

- sitz bath -keep clean w handheld shower head

What are the indications for a colonoscopy with a hemorrhoids patient

-40+ year old -iron def anemia -Concening manifestations including: b symptoms, abd pain, chronic diarrhea, change in stool caliber

post tx monitoring for colorectal ca

-6m w visit and labs + CEA for 5years -if stage 2+ also do CT for visit -colonoscopy 1 year after then every 3-5 years

what test is appropriate for colorectal Ca for prognosis and monitering disease progression

-CEA; NOT for screening

Change in bowel habits that might indicate colorectal ca include

-alternating constipation/loose stool or change in stool caliber -rectal bleeding

direct visualization screening test

-colonoscopy every 10yrs - flexible sigmoidoscopy every 5 other: CT colonography, capsule colonoscopy

what would you expect to see on anoscopy of proctitis

-mucosal inflammation or friability, presence of ulcers if its HSV syphilis or LGV

when to refer to a proctologist in infectious proctitis

-no response to therapy -unclear etiology -suspected anal ca -perianal abcess/fistula

what are the complications of a hemorrhoidectomy

-severe post op pain for 2/4 weeks, risk of incontinence

Avg risk pt screening guides

-start age 45-75

colorectal ca screening is recc w colonoscopy every ______ starting at age ___

1-2 yrs, age 20-25 total colectomy once neoplasm found

Gastric ca screening w Lynch is an EGD starting at

30-35

Screening for endometrial ca w Lynch starts

30-35 and hysterectomy for age 35+

for Gc/Ch proctitis, test _____ for reinfection

3m later

what is the man age of presentation w a perianal abcess

40, M>F

RF for colorectal ca: age - risk inc after _____ and median age of dx is ____ higher incidence in ___(M/F) especially _____(race) ________hx of colorectal ca or adenomatous polyps IBD inc ___yrs after disease onset _____ due to hyperinsulinemia

45, 70 M, black males family 8 DM

what is the mean age of colon ca dx w lynch

48, some in 20's

a complete or full thickness rectal prolapse is protrusion of:

ALL 3 layers of the rectum through the anus

what is used for pre-op staging of colorectal ca

CT chest/abd/pelvis and PELVIC MRI/endorectal US if rectal ca

the empiric tx for Gc/Ch used in infectious proctitis is

Ceftriaxone + Doxy x7days *if + then extend for 3wks to cover LGV

what are the inherited genetic mutations assoc w colorectal ca

FAP, Lynch(Hnpcc)

Stool based screening tests

FIT every year - pref over fob High sensitivity FOB 3x yearly Fecal DNA every 3 years

when screening for std's w proctitis, also screen for

HIV, hep B, Hep C, preg

if you have infectious proctitis and visualize ulcers, add what to emperic treatment

HSV tx: Valacyclovir Cover for LGV if HIV pt

topical vasodilators for anal fissures include

Nitroglycerin or nifedipine x1m

if + RPR test tx w

Pen G IM

what side is most affected w lynch

R side

the test for syphilis is

RPR or VDRL - blood test

what is the surgical management of a rectal prolapse

Transabdominal Rectopexy +/- sigmoid resection

Prevention of colorectal ca

a daily 81mg aspirin can dec. over 10-20 years but isnt recc without other indications + HPV vax

1/3 of women with a rectal prolapse also have

a pelvic organ prolapse

FAP is

a rare inherited condition characterized by 100-1000's of adenomatous polyps in the colon

What is the MC colorectal Ca

adenocarcinoma

2/3 of all colon polyps are known as

adenomatous

on average, polyps develop when in FAP and colon ca by when

age 15 and colon ca by 40

Imaging is not ness for a simple perianal fistula but for a more complex/recurrent, what is recommended?

an MRI of pelvis + endosonography

which gland becomes obstructed in perianal abcess

anal crypt gland

Nonprolapsed internal hemorrhoids are usually not palpable or tender, they require____ the visualize

anoscope

on external exam, a perianal abcess would appear as:

area of erythema, fluctuant, induration/swelling

Mixed hemorrhoids are ____ to the dentate line

both proximal and distal

Rectal bleeding with a hemorrhoid will be

bright red on stool or toilet paper

dx of rectal prolapse is made:

by visualizing concentric "stacking coins" protruding through the anus

presentation of perianal fistula

chronic intermittent pain; worse w BM/sitting + pruritis -intermittent malodorous discharge - "non healing abscess" w possible induration, can drain - may have palpable cord leading from lesion to anal canal -may palpate internal opening on DRE or see on anoscopy

In stage 1,2,3 _____ is indicated and can be curative; it is able to restore bowl continuity in most w anastamosis

colectomy

discrete mass lesions that protrude into the intestinal lumen are known as

colon polyps

what is the most sensitive test for colon polyps

colonoscopy, allows for detection and resection

What is the method of dx for colorectal ca

colonoscpty

Lynch associated cancers

colorectal gastric endometrial/overian sm intestine urinary tract prostate pancreatic

what is the mcc of a perianal fistula

concomitant or preceding perianal abscess

Internal hemorrhoid stage 1

confined to anal canal

what are less common causes of a perianal fistula

crohn's obstetric trauma infectious disease

External hemorrhoids are ____ to the dentate line

distal

an anal fistula is ____ to the dental line while a rectal fistula is _____ to the dentate line

distal; proximal

what is the mc extracolonic ca w lynch

endometrial

For a thromboses external hemorrhoid - you can ______ within the first 3 days for sx relief and use : (3 options)

excise the clot -sitz bath, analgesics, ointment

There is a palpable mass if hemorrhoids are

external or prolapsed

What is the management of a perianal fistula

fistulotamy: incision/excision for simple if comp: I/D then later do fistulotamy

when would a hemorrhoidectomy be preformed?

for chronic severe bleeding due to stage 3/4 hemorrhoids

how is Lynch dx

genetic testing

What is the MCC of proctitis

gonnorrhea

Colorectal ca exam is usually normal but _____+, and _______can indicate metastatic spread

guaic hepatomegally

MC non-neoplastic polyp in colon

hyperplastic

chronic anal fissures may present as:

hypertrophied skin tag/ papillae

High risk pt screening guides

if first degree relative dx >60: start at 40 w colonoscopy if first deg relative dx 60< or 2+ - age 40 or 10 yrs younger than dx, colonoscopy q5 yrs

why are anal fissures so painful

it exposes the internal sphincter muscle which frequently spasms and causes the pain as well as restricted blood flow and slow healing

what causes colorectal ca and what does it look like

it is a bulky exophytic mass or annular constricting lesion that comes from malignant transformation of a polyp

____ and ____ is common sx w hemorrhoids

itching and irritation

What is the preferred management for chronic anal fissures and what are the risks

lateral internal sphincterotomy; incontinence

topical analgesics for anal fissures include:

lidocaine

anal fissures are _____ tears in the ______ <__ mm in lenght

liner; anoderm; 5

1 in 5 colorectal pts present w metastasis. Where are the mc locations:

liver lungs peritoneaum regional lymph nods

what are pros and cons w inferred coagulation

more recurrences, fewer complications, less post op discomfort

a partial rectal prolapse is the _____ only

mucosa

when would you avoid a lateral internal sphincterotomy

multiparous women, older patients

are rectal prolapses usually painful

no

There is usually (pain/no pain) with hemorrhoids

no pain

chemo improves outcome in what stage of colorectal ca

node + stage 3

what is a Transabd rectopexy

pararectal tissue affixed w suture/mesh to the presacral fascia or sacral periosteum

which is more complex? perianal or perirectal

perirectal

with proctitis you want to check a NAAT anal swab as well as which two locations?

pharyngeal, urine/cervical

vasoactive agents like _____ provide temp relief due to vasoconrtsiction in hemorrhoids

phenylephrine ointment/suppository

who to perform genetic testing for FAP

potions w >10 adenomas fam hx of FAP or strong family hx of colon ca

Stage 3 internal hemorrhoid

prolapse requires manual reduction after BM

interanal hemorrhoid stage 2

prolapse w straining, reduces spontaneously

what is the management of FAP

prophylactic total colectomy pref + EGD to screen for stomach/duodenum + cox 2 inhibitors

External hemorrhoids are visible on inspection while prolapsed internal hemorrhoids may appear as:

protruding purple nodules

Internal hemorrhoids are ____ to the dentate line

proximal

An occult rectal prolapse is

rectal intussusception, telescoping of the bowel on itself without protruding through the anus

Bot tox injections have a higher ____ _rate vs lateral sphincterotomy

recurrence rate

Stage 4 internal hemorrhoid

remains chronically protruding; causes a sense of fullness and mucoid discharge or leakage of fecal matter

Stage IV colorectal ca managememnt

resection of mets if can be isolated can be curative, current therapy can extend from 12m-30m

what is the preferred method of proctology management for stage 2/3 internal hemorrhoids

rubber band ligation

What is the management of a perianal abscess

surgical I/D then wont packing + emperic ABX to reduce risk of fistula -augmentin OR cipro + metronidazole

what are the 3 signs of colorectal ca

tenesmus, urgency, recurrent hematochezia

complications of hemorrhoids include ______ external hemorrhoids and _______ or _____ internal hemorrhoids

thrombosed strangulated; gangrenous

a DRE must be done w a perianal fistula why?

to asses for indolent abcess

majority of rectal ca patients require:

trans abdominal excision + pre/post op chemo or rad

abdominoperineal recection w colostomy is necessary for

tumors in lower rectum, cannot preserve sphincter

Hemorrhoids are symptomatic when distended or engorged, caused by activities that increase ______. Such as:

venous pressure -straining, constipation/diarrhea, prolonged sitting, preg, obesity

the test for HSV is swab of ______

vesicular fluid (PCR)