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CRS by Mind Map: CRS

1. Infections

1.1. Sexually transmitted

1.1.1. Viruses HIV HAART CD4 counts optimally greater than 200 Viral load > 10000 copies / cc Anal molluscum contagious (skin viral infection that creates bumps) Anal cancer screening HPV Condyloma Vaccinate before sexually active SCC HSV HSV - 2 = 90% HSV -1 = 10% Intranuclear inclusion bodies on pap smear Positive Tzank Positive culture Tx

1.1.2. Bacteria Chancroid / Haemophilus ducreyi Anal papules turn to pustules turn to ulcers Sexually transmitted Dx by Gr stain Azithromycin 1 gm PO Ceftriaxone 250mg IM single dose Ciprofloxacin 500 mg BID 3 days Emycin 500mg TID x 7 days Chlamydia/LGV Obligate intra-cellular Serovars D-K non LGV Proctitis Serovars L1-3 = LGV Tx Neisseria Gonnorhea Gr (-) diplococcus Culture in Thayer Martin Tx Syphilis Treponema pallidum (spirochete) Primary = chancres, painful ulcer w/o educate Secondary stage = fever, malaise, arthralgias, maculopapular rash on palms of hands and soles of feet Darkfield exam or Warthin- starry silver stain F/u VDRL (positive in 75%) or RPR testing FTA-ABS turns positive at 4-6 weeks for life Granuloma inguinal ( Donovanosis) Calymmatobacterium granulomatis Common in Africa, So. Amer., Australia Ulcerogranulomatous form Late can cause anal stenosis Dx tissue smear for Donovan bodies Tx

1.2. Colitides

1.2.1. Bacteria C Diff Most common cause of colitis in hosp'd patients Risk Factors Dx Immunosuppressive risk Tx Gr (+) Bacillus CARSEP : Alcohol-based foam hand soaps do not prevent C. Diff E.Coli Gr (-) Bacillus Serotypes Tx Shigella Gr (-) bacillus Shiga toxin 10 organisms can cause infection 1-3 days incubation Crampy abdominal pain and voluminous diarrhea High fever Invades enterocytes and colonocytes Dx stool culture Tx Salmonella Gr (-) bacillus Second leading cause of foodborne illness Invade enterocyte and coloncyte diarrhea to bloody diarrhea Abdominal pain Fever Dx stool culture Tx Campylobacter Gr (-) bacillus Undercooked poultry Most frequent acute diarrhea in western world Incubaton 48-72 hours Abdominal pain and diarrhea Fevers. rigors, and arthralgic aches Dx on selected medium so must specifically ask lab for culture for Campy Tx - self limited for 3-5 days Yersinia Gr (-) coccobacillus Contaminated food and water Incubation 7 days Mimics appendicitis Abd pain, diarrhea, fever, N/V Dx - stool cultures Tx Spirochetosis See sexually transmitted diseases SAQ : Abdominal T.B. Ileocecal 85-90% No anastomosis risk Active pulmonary infection in 25% (less than 50% in some series) Stool culture positive in 30% Skin testing unreliable Great mimic for cancer or appendicitis Tx with triples 6th most common cause of extra-pulmonary TB (lymphatic, genitourinary, bone/joint, miliary, and meningeal) Not confined to lower socio-economic groups * CT is most sensitive test (better than PPD, CXR, Sputum, Ascitic fluid and Pleural Fluid) Ascitis sample = 1 liter; spun for acid fast bacillus Diagnostic mini-lap for peritoneal Bx

1.2.2. Viral CMV Infectious Mono type syndrome Seropositive in most homosexual men HIV 10% ileocolitis with diarrhea Tx

1.2.3. Parasites Amebiasis Entamoeba Histolytica CARSEP : Chagas disease Trypanosoma cruzi Transmission Cryptosporidia protozoan Contaminated water More lethal in children and immunocompromised Bloody diarrhea Dx with endoscopic Bx for Crypto oocysts Tx with supportive glucose linked electrolyte reabsoprtion Tx immunocompromised with parmomycin LGV Chlamydia Trachomatis Sero types L1-3 CARSEP : Enterobius vermicularis (pinworm) Mebendazole

1.2.4. Fungi Histoplasmosis In soil and bird/bat feces Typically affects lungs Immunocompromised may have GI involvement at Peyer's patches and TI Tx Ampo B, fluconazole, ketoconazole

1.3. Hepatitis

1.3.1. Occult in 70-75% of patients

1.3.2. Hep C has 60-80% Chronic

1.3.3. Hep C 10 X > Hep B

1.3.4. Hep B vaccine

1.3.5. No Hep C vaccine or effective immunoglobulin

1.4. Fournier's Gangrene

1.4.1. Controversial = role of fecal diversion

1.4.2. In debridement that leads to "floating anus" Seton may be helpful

1.4.3. CARSEP unclear on how to handle testes. Skin graft early or treat with wet-dry with delayed flap closure

2. IBD

2.1. Crohn's

2.1.1. Medication options Induce remission Sulfasalazine ( more for colitis) Other 5ASA DRUGS Steroids Maintenance Azathioprine or 6 MP Methotrexate Fistulous disease Infliximab Metronidazole Ciprofloxacillin Postop prevention/suppression 3 mos. Metronidazole

2.1.2. Vienna or Montreal classification Fistulizing Fibrosis/stenosis Genetic testing Acute inflammation

2.1.3. Scenarios Ileocolic fibrosing/stenosing Multiple stenoses & strictures Stricturoplasty Segmental colon sparing Rectal sparing Duodenal stenosing Stricturoplasty or Bypass are acceptable Anal fistulae I&D & Setons RVF See RVF above Crohn's ileo-sigmoid fistula Resect primary and repair secondary CARSEP : Exception --> phlegmonous reaction in region of recto-sigmoid. Instead perform two segmental resections. Refractory rectal Crohn's CARSEP : End colostomy and mucous fistula Proctectomy reserved: Duodenal colic fistula CARSEP : Dx with BE ( Not SBFT) Peristomal Pyoderma CARSEP : Bx leading edge Diff Dx Steroids (oral & topical)

2.1.4. Microscopic Isolated crypt abscesses Non caseating granulomas Neuromatous hyperplasia & increased ganglion cells Longitudinal & transverse ulcers Lymphoid hyperplasia

2.1.5. Predict postop recurrence (+) SAQ : Presence of granulomas (-) Age Gender Duration disease Length of resection Blood transfusion

2.1.6. Anatomic Oral Esophageal Ileal Ileocolic Rarely mimics appendicitis Most common distribution 90% may require resection Higher recurrence rate than straight ileal Crohn's Colic Anal Gastric Duodenal

2.2. CUC

2.2.1. CARSEP : DALM Proctocolectomy 1st remove lesion and bx 4X in surrounding colon and check path results: No dysplasia then repeat scope in 6 months If dysplasia then Proctocolectomy

2.2.2. Med Tx acutely Hydrocortisone 300 mg(d) If no improvement add cyclosporine@ 7 days

2.2.3. Indeterminant colitis TAC with Ileorectal Contra-indications Surveillance

2.2.4. CARSEP: Surveillance L-sided 12-15 yrs post onset Pan-colonic 8-10 yrs post onset

2.2.5. Proctitis Tx 1st line Rowasa enemas 2nd line Cortenemas 3rd line oral steroids

2.2.6. Pouchitis 44% @ 10 yrs. CARSEP : High preop pANCA (> 100) may be predictive of pouchitis 56%; medium and low levels had 22% & 16% respectively. Lower Incidence in tobacco user Tx 1st Line Cipro / Flagyl oral Budesonide once stable : ? Probiotics

2.2.7. Microscopic Depletion of goblet cells Crypt shortening

2.2.8. Dysplasia Low grade High grade

2.3. Serum markers and genetic testing

2.3.1. Serum markers ASCA (50-80% Crohn's) pANCA (40-80% CUC) (+) pANCA correlates with post IPAA high risk of chronic pouchitis

2.3.2. Genetic testing IBD 5 (Chromosome 5) Transport proteins IBD 1(Chromosome 16) CARD 15/NOD2

2.4. Extra intestinal manifestations

2.4.1. Temporary / related to disease activity Erythema nodosum Oral aphthous ulcers Episcleritis Peripheral arthritis

2.4.2. Not temporarily related (PUPS) Pyoderma gangrenosa Uveitis Primary sclerosing cholangitis Spondyloarthropy

3. Cancer

3.1. Colon

3.1.1. Evolution of Chemo Stage II & III NSABP 1998 Duke's B and C 5FU, Vincristine, Semustine (MOF regimen) 3 Arms DFS and OS favored Postop Chemo NCCTG 5FU + Levamisole (Later Leucovorin) Advantage in only Node (+) QUASAR Complex study with 5FU, high dose and ultimately low dose folinic acid; Levamisole shifting to Leucovorin... Large recruitment, good followup Very small benefit for Stage II disease FOLFOX Stage III 5FU + Leucovorin + Oxaliplatin 12 months shrunk to 6 months Other Studies failed to show benefit in Stage II Shippinger Moertel International Multicentre Pooled Analysis of Colon Cancer Trials (IMPACT) Meta-analysis Statistical Summary showed we need 4700 patients to show significance of 4% benefit for Stage II NSABP - Mamounas Intergroup Study (Gill) Figuredo and Canada Cancer Care Ontario Program (37 trials and 11 meta-analyses) Molecular Markers for Stage II Guanylyl Cyclase C (GCC) Interleukin 1

3.1.2. High Risk Stage II Disease 5 Yr Survival Results using three factors for scoring Zero of 3 1 of 3 2 or 3 Three factors to consider CEA > 5 t Stage T4 Perineuro or lymphatic invasion Alternative s to identify high risk

3.1.3. Nodal Sampling Increased survival with nodal sampling # 12-17 nodes optimally

3.2. Rectal

3.2.1. Staging

3.2.2. Neoadjuvant Mayo / NCCTG (Two Arms) Postop XRT Chemo XRT Swedish Rectal Cancer Study (Two Arms) Surgery Preop XRT + Surgery NSABP R-03 ( closed early due to poor accrual) (Two Arms) Preop Chemo XRT + Postop 5FU Surgery + Postop 5FU + XRT Local failure was equal in 2 arms @ 10.7% Preop benefits German Rectal Cancer Study Group (Two Arms) Preop Chemo XRT Postop Chemo XRT DFS ( Preop 68% to Postop 65% ) & OS ( Preop 76% to Postop 74%) equal in 2 groups Other study aspects Conclusion: TME & Preop 5FU chemo XRT EORTC (Two Arms) Preop XRT Polish Colorectal Cancer Group (Stages T III / T IV) Preop Short Course Traditional ChemoXRT No differences in DFS, OS, sphincter preservation MRC CR07 & NCIC-CTG CO 16 demonstrates importance of CIRMCUMFERENTIAL RESECTION POSITIVE MARGINS (CRM+ive) Radiotherapy cannot rescue positive margin Mercury Study Group MRI Predictive value of CRM for TME Impact of Tumor regression from Preop XRT Complete pathologic response = pCR DFS & OS improves if tumor downstages Tumor Regression Grades GTSG (Four Arms) No Postop Tx Postop XRT (40-48 By) Postop chemo 5FU + Semustine XRT + Chemo

3.2.3. TME Dutch Rectal Cancer Study group TME TME + Short course XRT

3.2.4. LAR

3.2.5. APR

3.2.6. Imaging PET CT MRI CARSEP : Endo-ultrasound staging T Stage N Stage CT T Stage 46-75% N Stage 56-72 %

3.2.7. Local excision Features Small Distal Mobile Exophytic Well/mod differentiated Less than 1/3 circumference Failure rates T1-2 Role of adjuvant therapy ??? Adverse features

3.3. Anal canal

3.3.1. Neoadjuvant therapy Nigro Protocol (Recommendation Level 1A) Mitomycin C 3000 cGray 5FU IMRT (Recommendation Level 2B)

3.3.2. Stage T and N stage criteria T N Stage I = T1 Stage II = T2/T3 Stage IIIa= T 1-3, N1 Stage IIIb = T 1-3, N2-N3 Stage IV = Any T, Any N, M1

3.3.3. Pre treatment Imaging CT Chest, Abdomen and Pelvis ** Head (if Symptomatic) MR Comparable to EAUS PET/CT Not routine ??? EAUS Comparable to MR

3.3.4. Measures of Success Overall Survival Rates Local Regional Survival Rates Colostomy-free Survival Rates

3.3.5. Role of APR Persistent (< 6 months from initial treatment) or Recurrent (> 6 months from initial treatment) Disease

3.3.6. Management of Lymph Node Mets Chemo radiation

3.3.7. Treatment Considerations in HIV (+) Patients CD4 > 200 = Nigro Protocol CD4 < 200 = Individualize options HAART

3.3.8. Post Treatment Surveillance Q 3 months X 2 years Biopsy if persistent lesions beyond 12 weeks Imaging Surveillance + EAUS - MRI + PET/CT

3.4. Anal margin

3.4.1. WLE

3.5. Hereditary

3.5.1. FAP & attenuated FAP (aFAP) APC Germline mutation Dominant Desmoids 10-20% of FAP Trial of sulindac or tamoxifen Score > 7 Surgery only for severe symptoms 2nd most common inherited cancer Sulindac Reduces polyps in rectum No effect on duodenal or capillary adenomas Oral or rectal Reduces expressions of ras mutation and p53 proteins

3.5.2. HNPCC Guidelines Bethesda Amsterdam II Simplified 3-2-1 Rule Dominant Most common inherited cancer CARSEP : HNPCC Cancer List Endometrial Ovarian Gastric Hepatobiliary Sm. Bowel Transitional cell of Ureters & Renal Pelvis Screening Begin at age 21 up to 40 Over 40 years

3.5.3. Myh associated polyposis (MAP) Recessive inheritance

3.5.4. MSI/ RER MSI 90% of HNPCC CARSEP : High MSI levels hMLH1 Abnormal when protein identified CARSEP : hMSH2 Normal = protein identified Abnormal= no protein identified

3.5.5. LOH CARSEP : APC First step CARSEP : p53 Polyps and cancers CUC CP Gisland methylation Sporadic cancers Infrequent in CUC CARSEP: K ras Linked to Cetuximab resistance

3.5.6. CARSEP : Peutz-Jeghers Dominant Hamartomas Buccal pigmentation Increased Ca risk

3.5.7. HNPCC assoc'd Syndromes SAQ: Muir-Torre Benign/ malignant skin lesions SAQ: Turcot's Glioblastoma

3.5.8. MMR-D = mismatch repair deficiency Stage II survival best with Surgery alone

3.6. Screening and surveillance

3.7. Special Metastatic scenarios

3.7.1. Metastatic Disease Primary CRC + Liver Mets Up-front Combination Chemotherapy Obstructing Primary Hepatic Mets 5 Yr Surv 27-58% 5 Predictors of Poor outcomes (Fong et al) Steatohepatitis caused by 5FU + Irinotecan Converting the unresectable to resectable Brain Mets 1-2 % of all colorectal cancers Most symptomatic Rectal Ca > Colon Ca (due to venous drainage) Aggressive treatment prolongs survival Ovarian Mets Incidence 1-7% Not really a Krukenberg tumor More common in pre-menopausal woman Probably hematogenous spread

3.7.2. Pelvic recurrence limitations Extensive and/ thoracic Dx Involves pelvic side walls Encased Iliac vessels Extends into sacral notch Sacral invasion above S2-3

3.7.3. Metachronous Predictor (CARSEP) Common in HNPCC Less common in Sporadic CRC Presence of synchronous neoplasia (CRC or adenoma) Increases risk Index Cancer (+) predictor (-) predictor CARSEP : Less than the risk of a recurrent CRC

3.8. Chemotherapy Factoids

3.8.1. Immunotherapy Cetuximab EGFR CARSEP : K-Ras predicts resistance to anti EGFR Tx Erbitux (Avastin) VEGF

3.8.2. FOLFOX 5FU Leucovorin Oxaliplatin

3.8.3. Capecitabine (xeloda) Single Agent for Stage III Adjuvant Therapy Reasonably well tolerated in older patients Equivalent to 5 FU + Leucovorin for 6 mos. Useful in Diabetics with peripheral neuropathy since Oxaliplatin has high incidence of peripheral neuropathy

3.8.4. Irinotecan

3.9. T Stage risk of lymph node mets

3.9.1. T1 12% Depth of submucosal invasion sm1 upper 1/3 sm2 middle 1/3 sm3 lower 1/3

3.9.2. T2 22%

3.9.3. T3 50%

3.10. CARSEP : Special

3.10.1. Melanoma

3.10.2. Pre sacral / retro rectal Chordoma Males>females 9% 10 yr surv High local recurrence Bony invasion Sacral teratoma Females>males Encapsulated Duplication cysts Anterior Meningoceles Scimitar Radiologic Sign

3.10.3. Paget's disease Intraepithelial adeno ca Synchronous GI Cancers WLE

3.10.4. Bowen's disease Intraepithelial SCC T and N stage criteria T N Nomenclature: AIN; HSIL(AIN II & III) / LSIL(AIN I); or HGAIN (AIN III) / LGAIN (AIN I & II) Low grade Squamous Intra-epithelial lesions (LSIL) = AIN I High Grade Squamous intra-epithelial lesions (HSIL) = AIN II and III Screening Procedures for LGAIN / HGAIN Treatment HPV 16 and 18 HIV (+) 50% of LGAIN progress to HGAIN

3.10.5. Buschke- Lowenstein tumor Verrucous Carcinoma of anus Locally aggressive/destructive WLE

3.10.6. GIST Interstitial cells of Cajal GI pacemaker cells C-Kit (CD117) In 98% Hematogenous ( not nodal) Mitosis / HPF Imatinib (Gleevec) for adjuvant or palliation 15% resistance Anatomic Sites #1 Stomach #2 Small Bowel #3 Rectum Less likely in colon

3.10.7. Carcinoid Forgut Midgut Hindgut Serotonin & 5HIAA

3.10.8. Appendix Adeno Ca Carcinoid < 1 cm 1-1.9 cm > 2 cm Appendices mucocele Pseudomyxoma peritonei

3.10.9. Ca risk in Ureterosigmoidoscopy (SAQ in 2005) Incidence is 2-15% Interval of 20-26 years after anastomosis to cancer Pathophysfrom urinary nitrates, endogenous amines and bacteria to produce toxic nitrosoamines Presents with pain and infections secondary to obstruction at implanted ureter (Not hematuria or bleeding) Periodic surveillance with C-scope since urine refluxes thru out entire colon

4. Benign anorectal

4.1. Anal dermatology

4.1.1. CARSEP : Lichen planus Wickham's stria Etio unknown

4.1.2. Psoriasis

4.1.3. Molluscum contangiosum Viral origin

4.1.4. Pruritus ani

4.2. Hemorrhoids

4.2.1. RBL

4.2.2. Hemorrhoidectomy Stapled Less painful Circumferential grade 3 Serious complications Ferguson Closed Milligan-Morgan Open Complications Urinary Retention 2-36% Bleeding 0.03-6% Infection 0.5-5.5% Anal stenosis 0 -6% Whitehead circumferential hemorrhoidectomy Parks submucosal hemorrhoidectomy

4.2.3. Scenarios Acute gangrenous hemorrhoids Path specimen with melanoma Post RBL Urinary retention & sepsis Hemorrhoids in pregnancy Hemorrhoids in the immunocompromised Antibiotics Poor wound healing CARSEP : Sclerotherapy OK even with low CD4 counts Hemorrhoids and varices in portal HTN Hemorrhoids in IBD Poor wound healing in Crohns

4.2.4. CARSEP : Sclerotherapy 1-2 cc Agents 5% phenol in almond oil 5% quinine urea 5% sodium morrhuate Used in HIV even with low CD4 counts

4.2.5. Infrared photocoagulation

4.2.6. Electro-coagulation

4.2.7. BiCap Coagulation

4.2.8. Direct Current Electrotherapy (Ultroid)

4.2.9. Monopolar Coagulation

4.2.10. Cryotherapy

4.2.11. Doppler guided hemorrhoidal arterial ligation (DGHAL)

4.2.12. Lord's procedure: anal stretch

4.3. Anal fissures

4.3.1. LIAS 5-10% major incontinence 30% incontinent to flatus

4.3.2. Medical Tx Topical 0.2% nitroglycerin ointment L-arginine Topical Ca-channel blockers Diltiazem 2% Nifedipine 0.3% Botulinum toxin Other experiments Alpha1 adrenal receptor antagonists (indoramin) Cholinomimetic ( bethanecol) Phosphodiesterase inhibitor (sildenafil(Viagra)) Hyperbarics SAQ: wait eight (8) weeks to assess therapy before changing or surgery ( try not to abandon therapy as a failure until 8 weeks)

4.3.3. Pathophys Hypertensive sphincter

4.4. Abscesses / fistula

4.4.1. Fossae Ischioanal Intersphincteric Supralevator Extrasphincteric Peri-anal Deep post anal Horseshoe Originates in Deep Post Anal Space Trans sphincteric

4.4.2. Drain Seton Pezzar

4.4.3. Fistula Fistulotomy Fibrin Glue Porcine collagen plugs Inserted at internal opening Secured at internal opening RVF See above

4.5. Levator syndrome

4.5.1. Pain in anorectum

4.5.2. (L) sided

4.5.3. Inciting events Long rides Childbirth Sexual activity Post LAR

4.5.4. Tx NSAIDS Muscle relaxants Electro-galvanic stimulator

4.6. Proctalgia fugax

4.6.1. Awakens patients from sleep

4.7. Pruritus Ani

4.7.1. Substance P neuropeptide Tx with topical capsaicin

4.7.2. C neurons get the itch

4.7.3. Intradermal injection of methylene blue

4.7.4. Intralesional corticosteroids

4.8. Anal stenosis

4.8.1. Site Low : >0.5 cm below dentate Dentate +/- 0.5 cm High: > 0.5 cm above dentate

4.8.2. Severity Mild Digital exam or medium Hill Ferguson Anoscope (H-F) Moderate Forceful finger or medium H-F Scope Severe No finger or small H-F Scope

4.8.3. Surgical Tx Y-V/ V-Y anoplasty Diamond or House flaps

5. Colonoscopy

5.1. Flumazenil (benzodiazepine antagonist)

5.2. Virtual Colonoscopy "Failed Detection Rates"

5.2.1. 1 cm Polyp = comparable to colonoscopy for sensitivity

5.2.2. 6-9mm polyps sensitivity = 83%

5.2.3. < 5mm polyps sensivity = 53%

5.3. Malignant polyp (Haggitt Levels)

5.3.1. Circumstances for resection Tumor in lymphatic in head of polyp Poorly differentiated Sessions polyp or short stalk (< 0.5cm)

5.3.2. Followup for nonoperative cases in 6 mos.

5.4. Polyp size correlated to "failed detection rates" (Differs for Virtual Colonoscopy)

5.4.1. > 1cm = 2.1%

5.4.2. 0.5-1 CM = 13%

5.4.3. < 0.5 cm = 26%

5.4.4. Sub-optimal bowel prep = 40%

5.4.5. Afternoon scopes & Physician Fatigue Reduced detection rates Increased poor bowel preps Decreased cecal intubations

5.5. Withdrawal Time = > 6 minutes

5.5.1. Increases polyp detection

5.5.2. ? ? Value if 6 min timeline did increase actual large polyp/ high risk polyp detection

5.6. Quality Metrics

5.6.1. Intra-procedural Cecal intubation Terminal ileal intubation Time to cecum Time to withdrawal # of polyps Removal of polyps Size of polyps

5.6.2. Patient Quality Metrics Appropriateness Informed consent Safety Comfort Timely results

5.7. Endoscopic Mucosal Resection

5.8. Endoscopic Submucosal Resection

5.9. Flat Polyps

5.10. Sessile Serrated Adenomas (SSA)

5.10.1. 7% of all colonoscopies

5.10.2. Higher malignant potential than traditional adenomas

5.10.3. Features of hyperplastic and adenomas

5.10.4. MSI related; similar to HNPCC BRAF Mutation DNA Hyper- Methylation Extensive methylation of the CpG Island promoter site MLH1 MGMT (Methylations)

5.11. Chromo-endoscopy

5.11.1. indocarmine

5.11.2. Cochrane cites 5 reports

5.12. Narrow-band imaging

5.12.1. Uses blue light filters to detect angiogenesis

5.13. Polyp detection by Pit patterns

5.13.1. Several identified "pit" patterns

5.13.2. Used in Chromo endo and Narrow Band Imaging

5.14. Preps

5.14.1. Split dose preps 1/2 prep night before 1/2 prep 4-5 hours prior to exam

5.15. Antibiotics

5.15.1. Amp and Gent

5.15.2. Cardiac Valves and Vasc Grafts less than one year

5.16. SAQ : Hamartomatous polyps

5.16.1. Inherited Autosomal dominant Peutz-Jeghers Familial juvenile polyposis Cowden 's Disease

5.16.2. Acquired Cronkite-Canada Syndrome Ectodermal changes GI polyps 2/3rds are Japanese Male:female = 2:1

5.17. Argon Plasma Coagulator - high freq monopolar current through ionized gas (not a laser)

5.18. Anticoagulation

5.18.1. Procedures with low risk of bleeding (cold biopsies)

5.18.2. Interrupt Coumadin Stop 3-5 days prior to scope Restart 5-10 if post polypectomy

5.18.3. Procedures with intermediate (polypectomy 1-2.5%) and high risk of bleeding (laser ablation 6%)

5.18.4. Heparin for Mechanical Heart Valves Start when INR is sub-therapeutic Hold heparin 4-6 hours prior to scope Restart 2-6 hours later

5.18.5. DVT and/or atrial fibrillation

6. Laparoscopy

6.1. CRC Trials

6.1.1. Clinical outcomes of Surgical Therapy (COST)

6.1.2. Colon cancer laparoscopic or open resection (COLOR)

6.1.3. Conventional vs. laparoscopic assisted surgery in colorectal cancer (CLASICC)

6.1.4. SAQ : Conversion to Open Most Common Reason Tumor related factors Reactive Conversions (Related to a complication) Proactive Conversions (Prior to a complication)

6.1.5. Trial parameters DFS & OS LOS Time to diet Return of bowel function Morbidity/mortality circumferential radial margins Local recurrence

6.2. CARSEP : Pneumoperitoneum or capnoperitoneum

6.2.1. 15 mm Hg causes Increase intra-abd pressure Decrease Preload Increase Afterload and SVR Decrease cardiac index Decrease pulmonary compliance

6.2.2. Low 5-7 mm Hg or Gasless Laparoscopy

6.2.3. CO 2 Embolism Massive decrease in cardiac output due to gas-lock Hypotension & Bradycardia Decrease end-tidal CO2 Machinery or millwheel murmur Central line return yields "Foamy" blood Tx: left lateral with Trendelenburg (Durant's position)

7. Non IBD, Non infectious Colitides

7.1. CARSEP : Neutropenic colitis

7.1.1. Nonsurgical Tx GSF + Antibiotics + inotropes + fluids

7.1.2. R colectomy

7.1.3. CT Ominous Signs Free Air Pneumatosis coli Soft Tissue Air

7.2. CARSEP : Microscopic/ lymphocytic/ collagenous colitis

7.2.1. 1st line : diet & antidiarrheals

7.2.2. 2nd line: Mesalamine, Sulfasalazine, or cholestyramine

7.2.3. 3rd line: corticosteroids and if successful: Azathioprine / 6 MP

7.2.4. Watery diarrhea

7.2.5. Endoscopy may appear normal but Bx show non-ulcerative colitis

7.3. Eosinophilic Colitis

7.3.1. Endoscopic findings may look normal or like Crohn's - Biopsy needed

7.3.2. Tx Diarrheal symptoms

7.3.3. Severe cases may need steroids, immunosppuressive or chromoglycate

7.4. Disuse Colitis

7.4.1. See LGI Bleed

7.5. SAQ : Behcet's

7.5.1. Multi system vasculitis

7.5.2. Intestinal perforations

8. Ostomies

8.1. Para stomal hernias

8.1.1. Relocate

8.1.2. Local repair With mesh

8.2. CARSEP : Complete diversion

8.3. Ileostomies

8.3.1. Decrease output with adaption

8.3.2. Increase bacteria

8.3.3. Chronically elevated mineral corticoids Increase H2O and Na reabsorption Renal impact Decrease urine volume Decrease urine Na Increase Aldosterone Increase urine K

8.4. CARSEP : Emergency Stomas - higher incidence of necrosis

8.5. Pregnancy and stomas = pseudo-prolapse (resolves post delivery)

9. GI Bleeds

9.1. Massive LGI Bleed

9.1.1. Diverticulosis

9.1.2. Vascular ecstasias

9.1.3. Ischemic colitis

9.1.4. IBD

9.1.5. Dx & Tx Technetium labeled RBC scan Colonoscopy Selective mesenteric angiogram

9.2. CARSEP : Dieulafoy's lesion of rectum

9.2.1. Visible vessel >>> oversew or ligate

9.3. Radiation enteritis

9.3.1. SAQ : Formaldehyde 4% for 30 sec to 3 min

9.4. Disuse colitis

9.4.1. Tx with short chain fatty acid enemas

9.5. CARSEP : Endometriosis

9.5.1. Disc excision with transverse closure

9.5.2. Segmental resection Circumferential lesion Obstruction Lesion > 3 cm Inability to exclude malignancy

9.6. Rectal varices

9.6.1. Tx underlying portal HTN

9.7. SRUS

9.7.1. CARSEP Q - Asymptomatic = Tx with fiber

9.8. Technetium versus sulfur colloid

9.8.1. Tc RBC 24-48 Hr allows for rescanning detects 0.5 cc/min

9.8.2. Sulfur Colloid Immediate, no rescanning detects 0.1 cc/min

10. Rectal prolapse

10.1. Surgical treatment

10.1.1. Sacral Suspension/fixation Ripstein (anterior) Wells (posterior)

10.1.2. Trans abdominal Resection LAR/Anterior resection Proctopexy with resection (Frykman & Goldberg) Reduces constipation

10.1.3. Perineal procedures Altemeier Use in young patient with incarcerated prolapse (CARSEP pg 143) DeLorme Thiersch

10.2. Etio

10.2.1. Diastasis of levator

10.2.2. Deep cul de sac

10.2.3. Redundant Sigmoid

10.2.4. Patulous anus

10.2.5. Loss of rectosigmoid attachments

10.2.6. +/- pudendal neuropathy

10.2.7. Constipation in 1/3-2/3

10.3. Preop transit study to ruleout colonic inertia

10.4. Urinary incontinence in 35%

10.5. Vaginal prolapse 15%

11. Diverticulitis

11.1. Hinchey classification of peritonitis

11.1.1. Hinchey I: paracolonic abscess

11.1.2. Hinchey II: pelvic abscess

11.1.3. Hinchey III purulent peritonitis

11.1.4. Hinchey IV: feculent peritonitis

11.2. When to operate?

11.2.1. CT documented severity

11.2.2. Age? 7th & 8th decades 5-10% less than 50 years old

11.2.3. When Complications develop?

11.3. Giant Diverticulum

11.3.1. Rare

11.3.2. Sx: Pain in 70% ; 10% Asx

11.3.3. Most common presentation - Sign: Abdominal Mass

11.3.4. 70% demonstrate communication to colon

11.4. Attacks and recurrences

11.4.1. 1st attack has 33% recurrence

11.4.2. 2nd attack has 50% recurrence

11.5. SAQ - in the case of surgery, a primary resection is preferred rather than diversion. Resection is almost always possible.

11.6. Role of delayed resection with initial washout laparoscopically ??

11.7. SAQ : Right sided Diverticultitis - Rare

11.7.1. May look like CRC or acute Appy

12. Anatomy & Physiology

12.1. Phys

12.1.1. Short chain fatty acids Butyrate Acetate Propionate Stimulate Na absorption

12.1.2. CARSEP: RAIR Absent Chagas Hirschsprung's Dermatomyositis Scleroderma Rectal distention Relaxed internal sphincter External sphincter contraction Present Normal patients Paraplegics

12.1.3. Defecatory reflex Rectal distension Colonic mass movement Spinal reflexes with cortical modulation Accommodation Anal canal sampling

12.1.4. CARSEP: Internal anal sphincter neuromodulation Parasympathetic inflow S2-4 Cholinergic (Acetylcholine) Inhibitory (relaxation) Sympathetic inflow L 5 Alpha 1 adrenergic Beta adrenergic

12.1.5. Rectal proprioceptive reflex Location Pelvic floor Rectal wall Rectal thermal thresholds Correlates

12.1.6. Pudendal Neuropathy PNTML Abnormal EMG Abnormal

12.1.7. SAQ :Ileocecal valve competeency ileocecal angulation

12.1.8. SAQ :Role of GI Anaerobes Provide catabolic enzymes for digestion of organic compounds Produce small amount of Vit K Create Short Chain Fatty acid (70%) Do not create stool bulk

12.1.9. intestinal Secretory function Aldosterone Colonic Na absorption Angiotensin Sm. Bowel Na absorption

12.1.10. CARSEP : Autonomic Dysreflexia in spinal cord injuries Hypertension Sweating Headache Hot/cold sensation

12.2. Anatomy

12.2.1. CARSEP: Haustra formed by taenia

12.2.2. CARSEP : Arc of Riolan

12.2.3. SAQ : High ligation of IMA Increase mobilization for tension free anastomosis

13. Functional bowel disorders

13.1. IBS

13.1.1. Constipation Tx with lubiprostone ( Cl channel activator) Tx with tegaserod

13.1.2. Diarrhea CARSEP : Tx with Alosetron (assoc'd with ischemic colitis)

13.2. Slow transit constipation/ colonic inertia

13.3. Obstructive defecation

13.3.1. Dx CARSEP : Anal manometry & defecography

13.3.2. STARR (Stapled Transanal Rectal Resection)

13.4. Ogilvie's

13.4.1. Autonomic imbalance: sympathetic>parasympathetics

13.4.2. Colonoscopic decompression

13.4.3. CARSEP: 1st line of Tx Neostigmine

13.4.4. Epidural sympathetic block

13.5. Chagas

14. Colonic volvulus

14.1. Sigmoid

14.2. Cecal

14.3. SAQ = Nonoperative reduction is typically successful

14.3.1. High recurrence rates

14.3.2. For megacolon patients - post successful reduction --> consider a subtotal colectomy

15. Pilonidal sinus

15.1. Acute

15.2. Chronic

15.2.1. Surgery Open wound Closed - Off Midline - Flaps Bascom Excision and Z-plasty Karydakis procedure

15.2.2. Phenol injection forms eschar in track

16. Hidradenitis Suppurativa

17. Rectovaginal fistula

17.1. Classification

17.1.1. Simple Low to mid rectovaginal septum < 2.5cm Due to trauma/infection Trauma Infection

17.1.2. Complex High rectovaginal septum >2.5cm Due to IBD, Radiation, or neoplasia Radiation induced have 33% incidence of recurrent Ca. Failed previous repair

17.2. EUA for Detection

17.2.1. Rigid procto of rectum with water filled vagina searching for bubbles

17.2.2. Rectal methylene blue for 20 mins with vaginal tampon

17.3. Surgical Repair

17.3.1. Transanal Endorectal Advancement Flap Anocutaneous Advancement Flap Distal fistulae when endorectal flaps would leave ectropion Rectal Sleeve Advancement In Crohns Use diverting stoma Bioprosthetics

17.3.2. Transvaginal Repair Fistula Inversion Vaginal Advancement Flap Includes levatoroplasty

17.3.3. Transperineal techniques Perineoproctotomy ( used by Gyn and recreates a 4th degree tear with layered closure. ) Overlapping sphincteroplasty Tissue interposition Labial Fat pad (Martius) Graciloplasty

17.3.4. Trans-abdominal Coloanal Proctectomy

18. Embryology

18.1. Hirschsprung's

18.1.1. Failure migration of neural crest

18.1.2. Absence of ganglion cells

18.1.3. Thick non-myelinated nerves

18.1.4. Pre/post ganglionic fibers w/o synapses

18.1.5. CARSEP: Prominent adrenergic and cholinergic fibers

18.1.6. SAQ = Increase staining for Ach

18.1.7. Absence of RAIR

18.2. VACTERL Anomalies

18.2.1. Vertebral

18.2.2. Anal atresia

18.2.3. Cardiac

18.2.4. Trach-esophageal

18.2.5. CARSEP : Renal

18.2.6. Limbs

19. Trauma

19.1. Colon

19.1.1. Primary repair except: Severe contamination 6 hr surgical delay > 6 unit transfusion

19.2. Rectum

19.3. Anus/sphincter

20. Peri operative

20.1. HIT

20.1.1. CARSEP : Alternative to Heparin prior to warfarin: argatroban

20.2. Blood transfusions

20.2.1. Viruses #1 CMV Hepatitis Hepatitis C HIV

20.3. BE trauma

20.3.1. Barium perf Cecum overdistension SAQ : More common thru stoma Rectal injury Catheter tip Balloon overdistension Ba Mortality 50%

20.4. TPN

20.4.1. Nonketotic, Hyperosmolar coma

20.4.2. Infection St Epi Cath tip with greater than 15 colonies Change over wire 12% incidence in TPN central lines (2 % in non TPN central lines) Avoid triple lumens

20.4.3. CARSEP : Trace Elements Zn, Se, I, Cu, Cr, and Mn Zn Cu Cr

20.5. Serum Sodium in Hyperglycemia

20.5.1. Step 1: Subtract 200 - the upper limit of normal blood glucose - from the patient blood glucose reading. For example, if reading is 350, then 350 - 200 = 150.

20.5.2. Step 2 : Determine the "dilution factor" by dividing the patient glucose excess by 100. In this example, 150 / 100 = a 1.5 dilution factor

20.5.3. Step 3 : Multiple the dilution factor (X) by 1.6. Again, 1.5 in our example is (X) by 1.6 to = 2.4. (serum sodium deficit)

20.5.4. Step 4 : In the final step, add the serum sodium deficit to the measured serum sodium level to get the corrected sodium level. In this case, the measured sodium was 135. Add: 2.4 + 135 = 137.4 as the corrected value.

20.6. Nerve Injuries

20.6.1. Related to APR Pudendal Nerve Penile Sensory dysfunction

20.6.2. Related to sigmoid resection Sympathetic Superior Hypogastric Plexus Site @ IMA Results in retrograde ejaculation

20.6.3. CARSEP: Sexual Dysfunction related to Rectal Dissection Parasympathetics Sympathetics Plexi Para-aortic sympathetic plexus Parasympathetic Nervi Ergentes Pelvic Plexus Peri-postrastatic Plexus

20.6.4. Lower Extremity CARSEP: Peroneal Foot drop Sensory loss over dorsum of foot and lower lateral leg Sural Sensory branch of Tibial Burning pain Tibial Plantar flexion Ankle inversion Toe Flexion Lateral Femoral Cutaneous Thigh numbness and tingling

20.7. DVT

20.7.1. SAQ :Heparin and graded compression stockings (+) although 2012 SAQ suggests pre + post heparin and pneumatic compression stockings

20.7.2. May substitute Low molecular wt heparin

20.7.3. CARSEP: Helical CT and Role of D-Dimer testing

20.8. Cardiac Risk

20.8.1. High risk SAQ : Aortic Stenosis MI in 30 days Untreated CHF Sx in arrhythmias

20.8.2. Intermediate risk Previous Q wave MI CHF DM with renal failure

20.8.3. Low risk Abnl EKG LVH Low functional capacity Hx CVA Hx uncontrolled HTN

20.9. CARSEP : Refeeding Syndrome

20.9.1. Triad of hypokalemia, hypophosphatemia and thiamine deficiency

20.9.2. Hyper-volemia which can lead to CHF

20.9.3. For BMI of 14, start refeeding at 1200 to 1500 cal and increase by 500 q 2-3 days up to 3500.

20.10. CARSEP : SCIP

20.10.1. Appropriate peri-operative antibiotics

20.10.2. Appropriate hair removal

20.10.3. Postop normothermia

20.10.4. Continued Beta Blocker Tx

20.10.5. DVT Prophylaxis

21. Medications of Interest

21.1. Metronidazole

21.1.1. Bacteriocidal

21.1.2. Drug of choice in anaerobic sepsis

21.1.3. Also used in Trichomoniasis

21.1.4. Rare complications Convulsive seizures Peripheral neuropathy

21.2. Steroids

21.2.1. Short term complications Moon facies Psychosis Stria HTN Hirsute

21.2.2. Long term complications Osteonecrosis DM Infections Cataracts/Glaucoma

21.3. Meperidine

21.3.1. CARSEP : Contra-indicated in patients seizure disorders

21.3.2. CARSEP : Used in the treatment of postop/recovery room hypothermia (25 mg)

22. Rectourinary Fistulas

22.1. Rectourethral Fistula

22.1.1. Etios Trauma Surgical Trauma Iatrogenic Congenital IBD Sepsis Pelvic neoplasms Brachytherapy

22.2. General comments

22.2.1. Localization challenge endoscopy fistulogram retrograde urinary and rectal contrast studies CT

22.2.2. Pre-existing XRT not a negative predictor to repair

22.2.3. Aggressive reoperations will resolve 90%

22.3. Surgery

22.3.1. Transperineal

22.3.2. York-Mason Trans anal layered closure

23. Miscellaneous

23.1. Colonic J Pouch

23.1.1. Shorter pouches evacuate better than long pouches

23.1.2. SAQ: Vol 50, No. 8 reports lower leak rate in J pouches than straight coloanals.

23.2. Portal Vein Thrombosis

23.2.1. Assoc'd with IBD patients

23.2.2. Sx and Signs Abd pain Fever Leukocytosis Delayed bowel function

23.2.3. CARSEP : Tx with Heparin

24. Notes about this Mind Map

24.1. Developed and supported by FG Opelka

24.2. To request additions or updates send email and reference material to [email protected]

24.3. Special Terms within the map

24.3.1. SAQ refers to CRS Self Assessment Question

24.3.2. CARSEP Q refers to CRS CARSEP Question

24.4. Drag the map around to see the various aspects

24.5. Resize the map using the resizer tool

25. Medical Statistics

25.1. Clinical Equipoise

25.2. Meta-analysis

25.3. Central Tendency

25.3.1. Mean

25.3.2. Median

25.3.3. Mode

25.3.4. Range

25.4. ANCOVA - Analysis of Covariance

25.5. Relative Risk Reduction RRR

25.5.1. proportion of control group experiencing an outcome less than the intervention group experiencing the outcome

25.6. Absolute Risk Reduction ARR

25.6.1. Proportion of control experiencing an event less the intervention group experiencing the event

25.7. Number Needed to Treat (NNT) = 1 / ARR

25.8. t- test

25.9. Fischer exact test

25.10. Log Regression

25.11. Mann-Whitney

25.12. Error Types

25.12.1. Null states there is no difference

25.12.2. Type I = Reject the null when the null is true Type I states there is a difference when really there is none.

25.12.3. Type II = Accept the null when it is false Type II states there is no difference when really there is one.

25.13. Phases of clinical trials

25.13.1. Phase I - tests safety

25.13.2. Phase II - larger groups to test efficacy and safety

25.13.3. Phase III - large groups to confirm effectiveness, monitor side effects and compare to other Tx methods

25.13.4. Phase IV - postmarketing studies, risks, benefits, and optimal use

25.14. Central Tendency

25.15. C-Statistics / Receiver Operating Characteristics

25.15.1. 5 Major points from ROC 1. Shows trade offs between sensitivity and specificity (the more sensitive, the less specific) 2. The closer the curve follows the sensitivity axis (the left border) and the top of the ROC space, the more accurate the test. 3. The more the curve approaches the line draw on the 45 degree diagonal of the ROC space, the less accurate the test 4. The slope of the tangent line to the cutpoint gives the likelihood ratio (LR) for that value of the test. 5. The Area under the Curve (AUC) is a measure of test accuracy.

25.15.2. Area under Curve (AUC) Excellent 0.9 - 1.0 Good 0.8 - 0.9 Fair 0.7 - 0.8 Poor 0.6 - 0.7 Fail 0.5 - 0.6

25.16. Power

25.16.1. Sample size

25.16.2. Size of the difference to be detected

25.16.3. Risk of error