1. Infections
1.1. Sexually transmitted
1.1.1. Viruses
1.1.1.1. HIV
1.1.1.1.1. HAART
1.1.1.1.2. CD4 counts optimally greater than 200
1.1.1.1.3. Viral load > 10000 copies / cc
1.1.1.1.4. Anal molluscum contagious (skin viral infection that creates bumps)
1.1.1.1.5. Anal cancer screening
1.1.1.2. HPV
1.1.1.2.1. Condyloma
1.1.1.2.2. Vaccinate before sexually active
1.1.1.2.3. SCC
1.1.1.3. HSV
1.1.1.3.1. HSV - 2 = 90%
1.1.1.3.2. HSV -1 = 10%
1.1.1.3.3. Intranuclear inclusion bodies on pap smear
1.1.1.3.4. Positive Tzank
1.1.1.3.5. Positive culture
1.1.1.3.6. Tx
1.1.2. Bacteria
1.1.2.1. Chancroid / Haemophilus ducreyi
1.1.2.1.1. Anal papules turn to pustules turn to ulcers
1.1.2.1.2. Sexually transmitted
1.1.2.1.3. Dx by Gr stain
1.1.2.1.4. Azithromycin 1 gm PO
1.1.2.1.5. Ceftriaxone 250mg IM single dose
1.1.2.1.6. Ciprofloxacin 500 mg BID 3 days
1.1.2.1.7. Emycin 500mg TID x 7 days
1.1.2.2. Chlamydia/LGV
1.1.2.2.1. Obligate intra-cellular
1.1.2.2.2. Serovars D-K non LGV Proctitis
1.1.2.2.3. Serovars L1-3 = LGV
1.1.2.2.4. Tx
1.1.2.3. Neisseria Gonnorhea
1.1.2.3.1. Gr (-) diplococcus
1.1.2.3.2. Culture in Thayer Martin
1.1.2.3.3. Tx
1.1.2.4. Syphilis
1.1.2.4.1. Treponema pallidum (spirochete)
1.1.2.4.2. Primary = chancres, painful ulcer w/o educate
1.1.2.4.3. Secondary stage = fever, malaise, arthralgias, maculopapular rash on palms of hands and soles of feet
1.1.2.4.4. Darkfield exam or Warthin- starry silver stain
1.1.2.4.5. F/u VDRL (positive in 75%) or RPR testing
1.1.2.4.6. FTA-ABS turns positive at 4-6 weeks for life
1.1.2.5. Granuloma inguinal ( Donovanosis)
1.1.2.5.1. Calymmatobacterium granulomatis
1.1.2.5.2. Common in Africa, So. Amer., Australia
1.1.2.5.3. Ulcerogranulomatous form
1.1.2.5.4. Late can cause anal stenosis
1.1.2.5.5. Dx tissue smear for Donovan bodies
1.1.2.5.6. Tx
1.2. Colitides
1.2.1. Bacteria
1.2.1.1. C Diff
1.2.1.1.1. Most common cause of colitis in hosp'd patients
1.2.1.1.2. Risk Factors
1.2.1.1.3. Dx
1.2.1.1.4. Immunosuppressive risk
1.2.1.1.5. Tx
1.2.1.1.6. Gr (+) Bacillus
1.2.1.1.7. CARSEP : Alcohol-based foam hand soaps do not prevent C. Diff
1.2.1.2. E.Coli
1.2.1.2.1. Gr (-) Bacillus
1.2.1.2.2. Serotypes
1.2.1.2.3. Tx
1.2.1.3. Shigella
1.2.1.3.1. Gr (-) bacillus
1.2.1.3.2. Shiga toxin
1.2.1.3.3. 10 organisms can cause infection
1.2.1.3.4. 1-3 days incubation
1.2.1.3.5. Crampy abdominal pain and voluminous diarrhea
1.2.1.3.6. High fever
1.2.1.3.7. Invades enterocytes and colonocytes
1.2.1.3.8. Dx stool culture
1.2.1.3.9. Tx
1.2.1.4. Salmonella
1.2.1.4.1. Gr (-) bacillus
1.2.1.4.2. Second leading cause of foodborne illness
1.2.1.4.3. Invade enterocyte and coloncyte
1.2.1.4.4. diarrhea to bloody diarrhea
1.2.1.4.5. Abdominal pain
1.2.1.4.6. Fever
1.2.1.4.7. Dx stool culture
1.2.1.4.8. Tx
1.2.1.5. Campylobacter
1.2.1.5.1. Gr (-) bacillus
1.2.1.5.2. Undercooked poultry
1.2.1.5.3. Most frequent acute diarrhea in western world
1.2.1.5.4. Incubaton 48-72 hours
1.2.1.5.5. Abdominal pain and diarrhea
1.2.1.5.6. Fevers. rigors, and arthralgic aches
1.2.1.5.7. Dx on selected medium so must specifically ask lab for culture for Campy
1.2.1.5.8. Tx - self limited for 3-5 days
1.2.1.6. Yersinia
1.2.1.6.1. Gr (-) coccobacillus
1.2.1.6.2. Contaminated food and water
1.2.1.6.3. Incubation 7 days
1.2.1.6.4. Mimics appendicitis
1.2.1.6.5. Abd pain, diarrhea, fever, N/V
1.2.1.6.6. Dx - stool cultures
1.2.1.6.7. Tx
1.2.1.7. Spirochetosis
1.2.1.7.1. See sexually transmitted diseases
1.2.1.8. SAQ : Abdominal T.B.
1.2.1.8.1. Ileocecal 85-90%
1.2.1.8.2. No anastomosis risk
1.2.1.8.3. Active pulmonary infection in 25% (less than 50% in some series)
1.2.1.8.4. Stool culture positive in 30%
1.2.1.8.5. Skin testing unreliable
1.2.1.8.6. Great mimic for cancer or appendicitis
1.2.1.8.7. Tx with triples
1.2.1.8.8. 6th most common cause of extra-pulmonary TB (lymphatic, genitourinary, bone/joint, miliary, and meningeal)
1.2.1.8.9. Not confined to lower socio-economic groups
1.2.1.8.10. * CT is most sensitive test (better than PPD, CXR, Sputum, Ascitic fluid and Pleural Fluid)
1.2.1.8.11. Ascitis sample = 1 liter; spun for acid fast bacillus
1.2.1.8.12. Diagnostic mini-lap for peritoneal Bx
1.2.2. Viral
1.2.2.1. CMV
1.2.2.1.1. Infectious Mono type syndrome
1.2.2.1.2. Seropositive in most homosexual men
1.2.2.1.3. HIV 10% ileocolitis with diarrhea
1.2.2.1.4. Tx
1.2.3. Parasites
1.2.3.1. Amebiasis
1.2.3.1.1. Entamoeba Histolytica
1.2.3.2. CARSEP : Chagas disease
1.2.3.2.1. Trypanosoma cruzi
1.2.3.2.2. Transmission
1.2.3.3. Cryptosporidia
1.2.3.3.1. protozoan
1.2.3.3.2. Contaminated water
1.2.3.3.3. More lethal in children and immunocompromised
1.2.3.3.4. Bloody diarrhea
1.2.3.3.5. Dx with endoscopic Bx for Crypto oocysts
1.2.3.3.6. Tx with supportive glucose linked electrolyte reabsoprtion
1.2.3.3.7. Tx immunocompromised with parmomycin
1.2.3.4. LGV
1.2.3.4.1. Chlamydia Trachomatis Sero types L1-3
1.2.3.5. CARSEP : Enterobius vermicularis (pinworm)
1.2.3.5.1. Mebendazole
1.2.4. Fungi
1.2.4.1. Histoplasmosis
1.2.4.1.1. In soil and bird/bat feces
1.2.4.1.2. Typically affects lungs
1.2.4.1.3. Immunocompromised may have GI involvement at Peyer's patches and TI
1.2.4.1.4. 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
2.1.1.1. Induce remission
2.1.1.1.1. Sulfasalazine ( more for colitis)
2.1.1.1.2. Other 5ASA DRUGS
2.1.1.1.3. Steroids
2.1.1.2. Maintenance
2.1.1.2.1. Azathioprine or 6 MP
2.1.1.2.2. Methotrexate
2.1.1.3. Fistulous disease
2.1.1.3.1. Infliximab
2.1.1.3.2. Metronidazole
2.1.1.3.3. Ciprofloxacillin
2.1.1.4. Postop prevention/suppression
2.1.1.4.1. 3 mos. Metronidazole
2.1.2. Vienna or Montreal classification
2.1.2.1. Fistulizing
2.1.2.2. Fibrosis/stenosis
2.1.2.2.1. Genetic testing
2.1.2.3. Acute inflammation
2.1.3. Scenarios
2.1.3.1. Ileocolic fibrosing/stenosing
2.1.3.2. Multiple stenoses & strictures
2.1.3.2.1. Stricturoplasty
2.1.3.3. Segmental colon sparing
2.1.3.4. Rectal sparing
2.1.3.5. Duodenal stenosing
2.1.3.5.1. Stricturoplasty or Bypass are acceptable
2.1.3.6. Anal fistulae
2.1.3.6.1. I&D & Setons
2.1.3.7. RVF
2.1.3.7.1. See RVF above
2.1.3.8. Crohn's ileo-sigmoid fistula
2.1.3.8.1. Resect primary and repair secondary
2.1.3.8.2. CARSEP : Exception --> phlegmonous reaction in region of recto-sigmoid. Instead perform two segmental resections.
2.1.3.9. Refractory rectal Crohn's
2.1.3.9.1. CARSEP : End colostomy and mucous fistula
2.1.3.9.2. Proctectomy reserved:
2.1.3.10. Duodenal colic fistula
2.1.3.10.1. CARSEP : Dx with BE ( Not SBFT)
2.1.3.11. Peristomal Pyoderma
2.1.3.11.1. CARSEP : Bx leading edge
2.1.3.11.2. Diff Dx
2.1.3.11.3. Steroids (oral & topical)
2.1.4. Microscopic
2.1.4.1. Isolated crypt abscesses
2.1.4.2. Non caseating granulomas
2.1.4.3. Neuromatous hyperplasia & increased ganglion cells
2.1.4.4. Longitudinal & transverse ulcers
2.1.4.5. Lymphoid hyperplasia
2.1.5. Predict postop recurrence
2.1.5.1. (+)
2.1.5.1.1. SAQ : Presence of granulomas
2.1.5.2. (-)
2.1.5.2.1. Age
2.1.5.2.2. Gender
2.1.5.2.3. Duration disease
2.1.5.2.4. Length of resection
2.1.5.2.5. Blood transfusion
2.1.6. Anatomic
2.1.6.1. Oral
2.1.6.2. Esophageal
2.1.6.3. Ileal
2.1.6.4. Ileocolic
2.1.6.4.1. Rarely mimics appendicitis
2.1.6.4.2. Most common distribution
2.1.6.4.3. 90% may require resection
2.1.6.4.4. Higher recurrence rate than straight ileal Crohn's
2.1.6.5. Colic
2.1.6.6. Anal
2.1.6.7. Gastric
2.1.6.8. Duodenal
2.2. CUC
2.2.1. CARSEP : DALM
2.2.1.1. Proctocolectomy
2.2.1.2. 1st remove lesion and bx 4X in surrounding colon and check path results:
2.2.1.2.1. No dysplasia then repeat scope in 6 months
2.2.1.2.2. If dysplasia then Proctocolectomy
2.2.2. Med Tx acutely
2.2.2.1. Hydrocortisone 300 mg(d)
2.2.2.2. If no improvement add cyclosporine@ 7 days
2.2.3. Indeterminant colitis
2.2.3.1. TAC with Ileorectal
2.2.3.1.1. Contra-indications
2.2.3.1.2. Surveillance
2.2.4. CARSEP: Surveillance
2.2.4.1. L-sided
2.2.4.1.1. 12-15 yrs post onset
2.2.4.2. Pan-colonic
2.2.4.2.1. 8-10 yrs post onset
2.2.5. Proctitis
2.2.5.1. Tx
2.2.5.1.1. 1st line Rowasa enemas
2.2.5.1.2. 2nd line Cortenemas
2.2.5.1.3. 3rd line oral steroids
2.2.6. Pouchitis
2.2.6.1. 44% @ 10 yrs.
2.2.6.2. CARSEP : High preop pANCA (> 100) may be predictive of pouchitis 56%; medium and low levels had 22% & 16% respectively.
2.2.6.3. Lower Incidence in tobacco user
2.2.6.4. Tx
2.2.6.4.1. 1st Line Cipro / Flagyl
2.2.6.4.2. oral Budesonide
2.2.6.4.3. once stable : ? Probiotics
2.2.7. Microscopic
2.2.7.1. Depletion of goblet cells
2.2.7.2. Crypt shortening
2.2.8. Dysplasia
2.2.8.1. Low grade
2.2.8.2. High grade
2.3. Serum markers and genetic testing
2.3.1. Serum markers
2.3.1.1. ASCA (50-80% Crohn's)
2.3.1.2. pANCA (40-80% CUC)
2.3.1.2.1. (+) pANCA correlates with post IPAA high risk of chronic pouchitis
2.3.2. Genetic testing
2.3.2.1. IBD 5 (Chromosome 5)
2.3.2.1.1. Transport proteins
2.3.2.2. IBD 1(Chromosome 16)
2.3.2.2.1. CARD 15/NOD2
2.4. Extra intestinal manifestations
2.4.1. Temporary / related to disease activity
2.4.1.1. Erythema nodosum
2.4.1.2. Oral aphthous ulcers
2.4.1.3. Episcleritis
2.4.1.4. Peripheral arthritis
2.4.2. Not temporarily related (PUPS)
2.4.2.1. Pyoderma gangrenosa
2.4.2.2. Uveitis
2.4.2.3. Primary sclerosing cholangitis
2.4.2.4. Spondyloarthropy
3. Cancer
3.1. Colon
3.1.1. Evolution of Chemo Stage II & III
3.1.1.1. NSABP 1998
3.1.1.1.1. Duke's B and C
3.1.1.1.2. 5FU, Vincristine, Semustine (MOF regimen)
3.1.1.1.3. 3 Arms
3.1.1.1.4. DFS and OS favored Postop Chemo
3.1.1.2. NCCTG
3.1.1.2.1. 5FU + Levamisole (Later Leucovorin)
3.1.1.2.2. Advantage in only Node (+)
3.1.1.3. QUASAR
3.1.1.3.1. Complex study with 5FU, high dose and ultimately low dose folinic acid; Levamisole shifting to Leucovorin...
3.1.1.3.2. Large recruitment, good followup
3.1.1.3.3. Very small benefit for Stage II disease
3.1.1.4. FOLFOX
3.1.1.4.1. Stage III
3.1.1.4.2. 5FU + Leucovorin + Oxaliplatin
3.1.1.4.3. 12 months shrunk to 6 months
3.1.1.5. Other Studies failed to show benefit in Stage II
3.1.1.5.1. Shippinger
3.1.1.5.2. Moertel
3.1.1.5.3. International Multicentre Pooled Analysis of Colon Cancer Trials (IMPACT)
3.1.1.6. Meta-analysis
3.1.1.6.1. Statistical Summary showed we need 4700 patients to show significance of 4% benefit for Stage II
3.1.1.6.2. NSABP - Mamounas
3.1.1.6.3. Intergroup Study (Gill)
3.1.1.6.4. Figuredo and Canada Cancer Care Ontario Program (37 trials and 11 meta-analyses)
3.1.1.7. Molecular Markers for Stage II
3.1.1.7.1. Guanylyl Cyclase C (GCC)
3.1.1.7.2. Interleukin 1
3.1.2. High Risk Stage II Disease
3.1.2.1. 5 Yr Survival Results using three factors for scoring
3.1.2.1.1. Zero of 3
3.1.2.1.2. 1 of 3
3.1.2.1.3. 2 or 3
3.1.2.2. Three factors to consider
3.1.2.2.1. CEA > 5
3.1.2.2.2. t Stage T4
3.1.2.2.3. Perineuro or lymphatic invasion
3.1.2.3. Alternative s to identify high risk
3.1.3. Nodal Sampling
3.1.3.1. Increased survival with nodal sampling #
3.1.3.2. 12-17 nodes optimally
3.2. Rectal
3.2.1. Staging
3.2.2. Neoadjuvant
3.2.2.1. Mayo / NCCTG (Two Arms)
3.2.2.1.1. Postop XRT
3.2.2.1.2. Chemo XRT
3.2.2.2. Swedish Rectal Cancer Study (Two Arms)
3.2.2.2.1. Surgery
3.2.2.2.2. Preop XRT + Surgery
3.2.2.3. NSABP R-03 ( closed early due to poor accrual) (Two Arms)
3.2.2.3.1. Preop Chemo XRT + Postop 5FU
3.2.2.3.2. Surgery + Postop 5FU + XRT
3.2.2.3.3. Local failure was equal in 2 arms @ 10.7%
3.2.2.3.4. Preop benefits
3.2.2.4. German Rectal Cancer Study Group (Two Arms)
3.2.2.4.1. Preop Chemo XRT
3.2.2.4.2. Postop Chemo XRT
3.2.2.4.3. DFS ( Preop 68% to Postop 65% ) & OS ( Preop 76% to Postop 74%) equal in 2 groups
3.2.2.4.4. Other study aspects
3.2.2.4.5. Conclusion: TME & Preop 5FU chemo XRT
3.2.2.5. EORTC (Two Arms)
3.2.2.5.1. Preop XRT
3.2.2.6. Polish Colorectal Cancer Group (Stages T III / T IV)
3.2.2.6.1. Preop Short Course
3.2.2.6.2. Traditional ChemoXRT
3.2.2.6.3. No differences in DFS, OS, sphincter preservation
3.2.2.7. MRC CR07 & NCIC-CTG CO 16 demonstrates importance of CIRMCUMFERENTIAL RESECTION POSITIVE MARGINS (CRM+ive)
3.2.2.7.1. Radiotherapy cannot rescue positive margin
3.2.2.8. Mercury Study Group MRI
3.2.2.8.1. Predictive value of CRM for TME
3.2.2.9. Impact of Tumor regression from Preop XRT
3.2.2.9.1. Complete pathologic response = pCR
3.2.2.9.2. DFS & OS improves if tumor downstages
3.2.2.9.3. Tumor Regression Grades
3.2.2.10. GTSG (Four Arms)
3.2.2.10.1. No Postop Tx
3.2.2.10.2. Postop XRT (40-48 By)
3.2.2.10.3. Postop chemo 5FU + Semustine
3.2.2.10.4. XRT + Chemo
3.2.3. TME
3.2.3.1. Dutch Rectal Cancer Study group
3.2.3.1.1. TME
3.2.3.1.2. TME + Short course XRT
3.2.4. LAR
3.2.5. APR
3.2.6. Imaging
3.2.6.1. PET CT
3.2.6.2. MRI
3.2.6.3. CARSEP : Endo-ultrasound staging
3.2.6.3.1. T Stage
3.2.6.3.2. N Stage
3.2.6.4. CT
3.2.6.4.1. T Stage 46-75%
3.2.6.4.2. N Stage 56-72 %
3.2.7. Local excision
3.2.7.1. Features
3.2.7.1.1. Small
3.2.7.1.2. Distal
3.2.7.1.3. Mobile
3.2.7.1.4. Exophytic
3.2.7.1.5. Well/mod differentiated
3.2.7.1.6. Less than 1/3 circumference
3.2.7.2. Failure rates
3.2.7.2.1. T1-2
3.2.7.2.2. Role of adjuvant therapy ???
3.2.7.2.3. Adverse features
3.3. Anal canal
3.3.1. Neoadjuvant therapy
3.3.1.1. Nigro Protocol (Recommendation Level 1A)
3.3.1.1.1. Mitomycin C
3.3.1.1.2. 3000 cGray
3.3.1.1.3. 5FU
3.3.1.2. IMRT (Recommendation Level 2B)
3.3.2. Stage
3.3.2.1. T and N stage criteria
3.3.2.1.1. T
3.3.2.1.2. N
3.3.2.2. Stage I = T1
3.3.2.3. Stage II = T2/T3
3.3.2.4. Stage IIIa= T 1-3, N1
3.3.2.5. Stage IIIb = T 1-3, N2-N3
3.3.2.6. Stage IV = Any T, Any N, M1
3.3.3. Pre treatment Imaging
3.3.3.1. CT
3.3.3.1.1. Chest, Abdomen and Pelvis
3.3.3.1.2. ** Head (if Symptomatic)
3.3.3.2. MR
3.3.3.2.1. Comparable to EAUS
3.3.3.3. PET/CT
3.3.3.3.1. Not routine ???
3.3.3.4. EAUS
3.3.3.4.1. Comparable to MR
3.3.4. Measures of Success
3.3.4.1. Overall Survival Rates
3.3.4.2. Local Regional Survival Rates
3.3.4.3. Colostomy-free Survival Rates
3.3.5. Role of APR
3.3.5.1. Persistent (< 6 months from initial treatment) or Recurrent (> 6 months from initial treatment) Disease
3.3.6. Management of Lymph Node Mets
3.3.6.1. Chemo radiation
3.3.7. Treatment Considerations in HIV (+) Patients
3.3.7.1. CD4 > 200 = Nigro Protocol
3.3.7.2. CD4 < 200 = Individualize options
3.3.7.2.1. HAART
3.3.8. Post Treatment Surveillance
3.3.8.1. Q 3 months X 2 years
3.3.8.2. Biopsy if persistent lesions beyond 12 weeks
3.3.8.3. Imaging Surveillance
3.3.8.3.1. + EAUS
3.3.8.3.2. - MRI
3.3.8.3.3. + PET/CT
3.4. Anal margin
3.4.1. WLE
3.5. Hereditary
3.5.1. FAP & attenuated FAP (aFAP)
3.5.1.1. APC
3.5.1.2. Germline mutation
3.5.1.3. Dominant
3.5.1.4. Desmoids
3.5.1.4.1. 10-20% of FAP
3.5.1.4.2. Trial of sulindac or tamoxifen
3.5.1.4.3. Score > 7
3.5.1.4.4. Surgery only for severe symptoms
3.5.1.5. 2nd most common inherited cancer
3.5.1.6. Sulindac
3.5.1.6.1. Reduces polyps in rectum
3.5.1.6.2. No effect on duodenal or capillary adenomas
3.5.1.6.3. Oral or rectal
3.5.1.6.4. Reduces expressions of ras mutation and p53 proteins
3.5.2. HNPCC
3.5.2.1. Guidelines
3.5.2.1.1. Bethesda
3.5.2.1.2. Amsterdam II
3.5.2.1.3. Simplified 3-2-1 Rule
3.5.2.2. Dominant
3.5.2.3. Most common inherited cancer
3.5.2.4. CARSEP : HNPCC Cancer List
3.5.2.4.1. Endometrial
3.5.2.4.2. Ovarian
3.5.2.4.3. Gastric
3.5.2.4.4. Hepatobiliary
3.5.2.4.5. Sm. Bowel
3.5.2.4.6. Transitional cell of Ureters & Renal Pelvis
3.5.2.5. Screening
3.5.2.5.1. Begin at age 21 up to 40
3.5.2.5.2. Over 40 years
3.5.3. Myh associated polyposis (MAP)
3.5.3.1. Recessive inheritance
3.5.4. MSI/ RER
3.5.4.1. MSI
3.5.4.1.1. 90% of HNPCC
3.5.4.1.2. CARSEP : High MSI levels
3.5.4.2. hMLH1
3.5.4.2.1. Abnormal when protein identified
3.5.4.3. CARSEP : hMSH2
3.5.4.3.1. Normal = protein identified
3.5.4.3.2. Abnormal= no protein identified
3.5.5. LOH
3.5.5.1. CARSEP : APC
3.5.5.1.1. First step
3.5.5.2. CARSEP : p53
3.5.5.2.1. Polyps and cancers
3.5.5.2.2. CUC
3.5.5.3. CP Gisland methylation
3.5.5.3.1. Sporadic cancers
3.5.5.3.2. Infrequent in CUC
3.5.5.4. CARSEP: K ras
3.5.5.4.1. Linked to Cetuximab resistance
3.5.6. CARSEP : Peutz-Jeghers
3.5.6.1. Dominant
3.5.6.2. Hamartomas
3.5.6.3. Buccal pigmentation
3.5.6.4. Increased Ca risk
3.5.7. HNPCC assoc'd Syndromes
3.5.7.1. SAQ: Muir-Torre
3.5.7.1.1. Benign/ malignant skin lesions
3.5.7.2. SAQ: Turcot's
3.5.7.2.1. Glioblastoma
3.5.8. MMR-D = mismatch repair deficiency
3.5.8.1. Stage II survival best with Surgery alone
3.6. Screening and surveillance
3.7. Special Metastatic scenarios
3.7.1. Metastatic Disease
3.7.1.1. Primary CRC + Liver Mets
3.7.1.1.1. Up-front Combination Chemotherapy
3.7.1.1.2. Obstructing Primary
3.7.1.2. Hepatic Mets
3.7.1.2.1. 5 Yr Surv 27-58%
3.7.1.2.2. 5 Predictors of Poor outcomes (Fong et al)
3.7.1.2.3. Steatohepatitis caused by 5FU + Irinotecan
3.7.1.2.4. Converting the unresectable to resectable
3.7.1.3. Brain Mets
3.7.1.3.1. 1-2 % of all colorectal cancers
3.7.1.3.2. Most symptomatic
3.7.1.3.3. Rectal Ca > Colon Ca (due to venous drainage)
3.7.1.3.4. Aggressive treatment prolongs survival
3.7.1.4. Ovarian Mets
3.7.1.4.1. Incidence 1-7%
3.7.1.4.2. Not really a Krukenberg tumor
3.7.1.4.3. More common in pre-menopausal woman
3.7.1.4.4. Probably hematogenous spread
3.7.2. Pelvic recurrence limitations
3.7.2.1. Extensive and/ thoracic Dx
3.7.2.2. Involves pelvic side walls
3.7.2.3. Encased Iliac vessels
3.7.2.4. Extends into sacral notch
3.7.2.5. Sacral invasion above S2-3
3.7.3. Metachronous Predictor (CARSEP)
3.7.3.1. Common in HNPCC
3.7.3.2. Less common in Sporadic CRC
3.7.3.3. Presence of synchronous neoplasia (CRC or adenoma) Increases risk
3.7.3.4. Index Cancer
3.7.3.4.1. (+) predictor
3.7.3.4.2. (-) predictor
3.7.3.5. CARSEP : Less than the risk of a recurrent CRC
3.8. Chemotherapy Factoids
3.8.1. Immunotherapy
3.8.1.1. Cetuximab
3.8.1.1.1. EGFR
3.8.1.1.2. CARSEP : K-Ras predicts resistance to anti EGFR Tx
3.8.1.2. Erbitux (Avastin)
3.8.1.2.1. VEGF
3.8.2. FOLFOX
3.8.2.1. 5FU
3.8.2.2. Leucovorin
3.8.2.3. Oxaliplatin
3.8.3. Capecitabine (xeloda)
3.8.3.1. Single Agent for Stage III Adjuvant Therapy
3.8.3.2. Reasonably well tolerated in older patients
3.8.3.3. Equivalent to 5 FU + Leucovorin for 6 mos.
3.8.3.4. 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
3.9.1.1. 12%
3.9.1.2. Depth of submucosal invasion
3.9.1.2.1. sm1 upper 1/3
3.9.1.2.2. sm2 middle 1/3
3.9.1.2.3. sm3 lower 1/3
3.9.2. T2
3.9.2.1. 22%
3.9.3. T3
3.9.3.1. 50%
3.10. CARSEP : Special
3.10.1. Melanoma
3.10.2. Pre sacral / retro rectal
3.10.2.1. Chordoma
3.10.2.1.1. Males>females
3.10.2.1.2. 9% 10 yr surv
3.10.2.1.3. High local recurrence
3.10.2.1.4. Bony invasion
3.10.2.2. Sacral teratoma
3.10.2.2.1. Females>males
3.10.2.2.2. Encapsulated
3.10.2.3. Duplication cysts
3.10.2.4. Anterior Meningoceles
3.10.2.4.1. Scimitar Radiologic Sign
3.10.3. Paget's disease
3.10.3.1. Intraepithelial adeno ca
3.10.3.2. Synchronous GI Cancers
3.10.3.3. WLE
3.10.4. Bowen's disease
3.10.4.1. Intraepithelial SCC
3.10.4.2. T and N stage criteria
3.10.4.2.1. T
3.10.4.2.2. N
3.10.4.3. Nomenclature: AIN; HSIL(AIN II & III) / LSIL(AIN I); or HGAIN (AIN III) / LGAIN (AIN I & II)
3.10.4.3.1. Low grade Squamous Intra-epithelial lesions (LSIL) = AIN I
3.10.4.3.2. High Grade Squamous intra-epithelial lesions (HSIL) = AIN II and III
3.10.4.3.3. Screening Procedures for LGAIN / HGAIN
3.10.4.3.4. Treatment
3.10.4.4. HPV 16 and 18
3.10.4.5. HIV (+)
3.10.4.5.1. 50% of LGAIN progress to HGAIN
3.10.5. Buschke- Lowenstein tumor
3.10.5.1. Verrucous Carcinoma of anus
3.10.5.2. Locally aggressive/destructive
3.10.5.3. WLE
3.10.6. GIST
3.10.6.1. Interstitial cells of Cajal
3.10.6.2. GI pacemaker cells
3.10.6.3. C-Kit (CD117)
3.10.6.3.1. In 98%
3.10.6.4. Hematogenous ( not nodal)
3.10.6.5. Mitosis / HPF
3.10.6.6. Imatinib (Gleevec) for adjuvant or palliation
3.10.6.6.1. 15% resistance
3.10.6.7. Anatomic Sites
3.10.6.7.1. #1 Stomach
3.10.6.7.2. #2 Small Bowel
3.10.6.7.3. #3 Rectum
3.10.6.7.4. Less likely in colon
3.10.7. Carcinoid
3.10.7.1. Forgut
3.10.7.2. Midgut
3.10.7.3. Hindgut
3.10.7.4. Serotonin & 5HIAA
3.10.8. Appendix
3.10.8.1. Adeno Ca
3.10.8.2. Carcinoid
3.10.8.2.1. < 1 cm
3.10.8.2.2. 1-1.9 cm
3.10.8.2.3. > 2 cm
3.10.8.3. Appendices mucocele
3.10.8.3.1. Pseudomyxoma peritonei
3.10.9. Ca risk in Ureterosigmoidoscopy (SAQ in 2005)
3.10.9.1. Incidence is 2-15%
3.10.9.2. Interval of 20-26 years after anastomosis to cancer
3.10.9.3. Pathophysfrom urinary nitrates, endogenous amines and bacteria to produce toxic nitrosoamines
3.10.9.4. Presents with pain and infections secondary to obstruction at implanted ureter (Not hematuria or bleeding)
3.10.9.5. 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
4.1.1.1. Wickham's stria
4.1.1.2. Etio unknown
4.1.2. Psoriasis
4.1.3. Molluscum contangiosum
4.1.3.1. Viral origin
4.1.4. Pruritus ani
4.2. Hemorrhoids
4.2.1. RBL
4.2.2. Hemorrhoidectomy
4.2.2.1. Stapled
4.2.2.1.1. Less painful
4.2.2.1.2. Circumferential grade 3
4.2.2.1.3. Serious complications
4.2.2.2. Ferguson Closed
4.2.2.3. Milligan-Morgan Open
4.2.2.4. Complications
4.2.2.4.1. Urinary Retention 2-36%
4.2.2.4.2. Bleeding 0.03-6%
4.2.2.4.3. Infection 0.5-5.5%
4.2.2.4.4. Anal stenosis 0 -6%
4.2.2.5. Whitehead
4.2.2.5.1. circumferential hemorrhoidectomy
4.2.2.6. Parks
4.2.2.6.1. submucosal hemorrhoidectomy
4.2.3. Scenarios
4.2.3.1. Acute gangrenous hemorrhoids
4.2.3.2. Path specimen with melanoma
4.2.3.3. Post RBL Urinary retention & sepsis
4.2.3.4. Hemorrhoids in pregnancy
4.2.3.5. Hemorrhoids in the immunocompromised
4.2.3.5.1. Antibiotics
4.2.3.5.2. Poor wound healing
4.2.3.5.3. CARSEP : Sclerotherapy OK even with low CD4 counts
4.2.3.6. Hemorrhoids and varices in portal HTN
4.2.3.7. Hemorrhoids in IBD
4.2.3.7.1. Poor wound healing in Crohns
4.2.4. CARSEP : Sclerotherapy
4.2.4.1. 1-2 cc
4.2.4.2. Agents
4.2.4.2.1. 5% phenol in almond oil
4.2.4.2.2. 5% quinine urea
4.2.4.2.3. 5% sodium morrhuate
4.2.4.3. 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
4.3.1.1. 5-10% major incontinence
4.3.1.2. 30% incontinent to flatus
4.3.2. Medical Tx
4.3.2.1. Topical 0.2% nitroglycerin ointment
4.3.2.1.1. L-arginine
4.3.2.2. Topical Ca-channel blockers
4.3.2.2.1. Diltiazem 2%
4.3.2.2.2. Nifedipine 0.3%
4.3.2.3. Botulinum toxin
4.3.2.4. Other experiments
4.3.2.4.1. Alpha1 adrenal receptor antagonists (indoramin)
4.3.2.4.2. Cholinomimetic ( bethanecol)
4.3.2.4.3. Phosphodiesterase inhibitor (sildenafil(Viagra))
4.3.2.4.4. Hyperbarics
4.3.2.5. 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
4.3.3.1. Hypertensive sphincter
4.4. Abscesses / fistula
4.4.1. Fossae
4.4.1.1. Ischioanal
4.4.1.2. Intersphincteric
4.4.1.3. Supralevator
4.4.1.4. Extrasphincteric
4.4.1.5. Peri-anal
4.4.1.6. Deep post anal
4.4.1.7. Horseshoe
4.4.1.7.1. Originates in Deep Post Anal Space
4.4.1.7.2. Trans sphincteric
4.4.2. Drain
4.4.2.1. Seton
4.4.2.2. Pezzar
4.4.3. Fistula
4.4.3.1. Fistulotomy
4.4.3.2. Fibrin Glue
4.4.3.3. Porcine collagen plugs
4.4.3.3.1. Inserted at internal opening
4.4.3.3.2. Secured at internal opening
4.4.3.4. RVF
4.4.3.4.1. See above
4.5. Levator syndrome
4.5.1. Pain in anorectum
4.5.2. (L) sided
4.5.3. Inciting events
4.5.3.1. Long rides
4.5.3.2. Childbirth
4.5.3.3. Sexual activity
4.5.3.4. Post LAR
4.5.4. Tx
4.5.4.1. NSAIDS
4.5.4.2. Muscle relaxants
4.5.4.3. Electro-galvanic stimulator
4.6. Proctalgia fugax
4.6.1. Awakens patients from sleep
4.7. Pruritus Ani
4.7.1. Substance P neuropeptide
4.7.1.1. 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
4.8.1.1. Low : >0.5 cm below dentate
4.8.1.2. Dentate +/- 0.5 cm
4.8.1.3. High: > 0.5 cm above dentate
4.8.2. Severity
4.8.2.1. Mild
4.8.2.1.1. Digital exam or medium Hill Ferguson Anoscope (H-F)
4.8.2.2. Moderate
4.8.2.2.1. Forceful finger or medium H-F Scope
4.8.2.3. Severe
4.8.2.3.1. No finger or small H-F Scope
4.8.3. Surgical Tx
4.8.3.1. Y-V/ V-Y anoplasty
4.8.3.2. 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
5.3.1.1. Tumor in lymphatic in head of polyp
5.3.1.2. Poorly differentiated
5.3.1.3. 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
5.4.5.1. Reduced detection rates
5.4.5.2. Increased poor bowel preps
5.4.5.3. 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
5.6.1.1. Cecal intubation
5.6.1.2. Terminal ileal intubation
5.6.1.3. Time to cecum
5.6.1.4. Time to withdrawal
5.6.1.5. # of polyps
5.6.1.6. Removal of polyps
5.6.1.7. Size of polyps
5.6.2. Patient Quality Metrics
5.6.2.1. Appropriateness
5.6.2.2. Informed consent
5.6.2.3. Safety
5.6.2.4. Comfort
5.6.2.5. 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
5.10.4.1. BRAF Mutation
5.10.4.2. DNA Hyper- Methylation
5.10.4.2.1. Extensive methylation of the CpG Island promoter site
5.10.4.2.2. MLH1
5.10.4.2.3. 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
5.14.1.1. 1/2 prep night before
5.14.1.2. 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
5.16.1.1. Autosomal dominant
5.16.1.1.1. Peutz-Jeghers
5.16.1.1.2. Familial juvenile polyposis
5.16.1.1.3. Cowden 's Disease
5.16.2. Acquired
5.16.2.1. Cronkite-Canada Syndrome
5.16.2.1.1. Ectodermal changes
5.16.2.1.2. GI polyps
5.16.2.1.3. 2/3rds are Japanese
5.16.2.1.4. 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
5.18.2.1. Stop 3-5 days prior to scope
5.18.2.2. 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
5.18.4.1. Start when INR is sub-therapeutic
5.18.4.2. Hold heparin 4-6 hours prior to scope
5.18.4.3. 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
6.1.4.1. Most Common Reason
6.1.4.1.1. Tumor related factors
6.1.4.2. Reactive Conversions (Related to a complication)
6.1.4.3. Proactive Conversions (Prior to a complication)
6.1.5. Trial parameters
6.1.5.1. DFS & OS
6.1.5.2. LOS
6.1.5.3. Time to diet
6.1.5.4. Return of bowel function
6.1.5.5. Morbidity/mortality
6.1.5.6. circumferential radial margins
6.1.5.7. Local recurrence
6.2. CARSEP : Pneumoperitoneum or capnoperitoneum
6.2.1. 15 mm Hg causes Increase intra-abd pressure
6.2.1.1. Decrease Preload
6.2.1.2. Increase Afterload and SVR
6.2.1.3. Decrease cardiac index
6.2.1.4. Decrease pulmonary compliance
6.2.2. Low 5-7 mm Hg or Gasless Laparoscopy
6.2.3. CO 2 Embolism
6.2.3.1. Massive decrease in cardiac output due to gas-lock
6.2.3.2. Hypotension & Bradycardia
6.2.3.3. Decrease end-tidal CO2
6.2.3.4. Machinery or millwheel murmur
6.2.3.5. Central line return yields "Foamy" blood
6.2.3.6. Tx: left lateral with Trendelenburg (Durant's position)
7. Non IBD, Non infectious Colitides
7.1. CARSEP : Neutropenic colitis
7.1.1. Nonsurgical Tx
7.1.1.1. GSF + Antibiotics + inotropes + fluids
7.1.2. R colectomy
7.1.3. CT Ominous Signs
7.1.3.1. Free Air
7.1.3.2. Pneumatosis coli
7.1.3.3. 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:
7.2.3.1. 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
8.1.2.1. 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
8.3.3.1. Increase H2O and Na reabsorption
8.3.3.2. Renal impact
8.3.3.2.1. Decrease urine volume
8.3.3.2.2. Decrease urine Na
8.3.3.2.3. Increase Aldosterone
8.3.3.2.4. 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
9.1.5.1. Technetium labeled RBC scan
9.1.5.2. Colonoscopy
9.1.5.3. 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
9.5.2.1. Circumferential lesion
9.5.2.2. Obstruction
9.5.2.3. Lesion > 3 cm
9.5.2.4. 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
9.8.1.1. 24-48 Hr allows for rescanning
9.8.1.2. detects 0.5 cc/min
9.8.2. Sulfur Colloid
9.8.2.1. Immediate, no rescanning
9.8.2.2. detects 0.1 cc/min
10. Rectal prolapse
10.1. Surgical treatment
10.1.1. Sacral Suspension/fixation
10.1.1.1. Ripstein (anterior)
10.1.1.2. Wells (posterior)
10.1.2. Trans abdominal Resection
10.1.2.1. LAR/Anterior resection
10.1.2.2. Proctopexy with resection (Frykman & Goldberg)
10.1.2.2.1. Reduces constipation
10.1.3. Perineal procedures
10.1.3.1. Altemeier
10.1.3.1.1. Use in young patient with incarcerated prolapse (CARSEP pg 143)
10.1.3.2. DeLorme
10.1.3.3. 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?
11.2.2.1. 7th & 8th decades
11.2.2.2. 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
12.1.1.1. Butyrate
12.1.1.2. Acetate
12.1.1.3. Propionate
12.1.1.4. Stimulate Na absorption
12.1.2. CARSEP: RAIR
12.1.2.1. Absent
12.1.2.1.1. Chagas
12.1.2.1.2. Hirschsprung's
12.1.2.1.3. Dermatomyositis
12.1.2.1.4. Scleroderma
12.1.2.2. Rectal distention
12.1.2.2.1. Relaxed internal sphincter
12.1.2.2.2. External sphincter contraction
12.1.2.3. Present
12.1.2.3.1. Normal patients
12.1.2.3.2. Paraplegics
12.1.3. Defecatory reflex
12.1.3.1. Rectal distension
12.1.3.2. Colonic mass movement
12.1.3.3. Spinal reflexes with cortical modulation
12.1.3.3.1. Accommodation
12.1.3.3.2. Anal canal sampling
12.1.4. CARSEP: Internal anal sphincter neuromodulation
12.1.4.1. Parasympathetic inflow
12.1.4.1.1. S2-4
12.1.4.1.2. Cholinergic (Acetylcholine)
12.1.4.1.3. Inhibitory (relaxation)
12.1.4.2. Sympathetic inflow
12.1.4.2.1. L 5
12.1.4.2.2. Alpha 1 adrenergic
12.1.4.2.3. Beta adrenergic
12.1.5. Rectal proprioceptive reflex
12.1.5.1. Location
12.1.5.1.1. Pelvic floor
12.1.5.1.2. Rectal wall
12.1.5.2. Rectal thermal thresholds
12.1.5.2.1. Correlates
12.1.6. Pudendal Neuropathy
12.1.6.1. PNTML
12.1.6.1.1. Abnormal
12.1.6.2. EMG
12.1.6.2.1. Abnormal
12.1.7. SAQ :Ileocecal valve competeency
12.1.7.1. ileocecal angulation
12.1.8. SAQ :Role of GI Anaerobes
12.1.8.1. Provide catabolic enzymes for digestion of organic compounds
12.1.8.2. Produce small amount of Vit K
12.1.8.3. Create Short Chain Fatty acid (70%)
12.1.8.4. Do not create stool bulk
12.1.9. intestinal Secretory function
12.1.9.1. Aldosterone
12.1.9.1.1. Colonic Na absorption
12.1.9.2. Angiotensin
12.1.9.2.1. Sm. Bowel Na absorption
12.1.10. CARSEP : Autonomic Dysreflexia in spinal cord injuries
12.1.10.1. Hypertension
12.1.10.2. Sweating
12.1.10.3. Headache
12.1.10.4. 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
12.2.3.1. Increase mobilization for tension free anastomosis
13. Functional bowel disorders
13.1. IBS
13.1.1. Constipation
13.1.1.1. Tx with lubiprostone ( Cl channel activator)
13.1.1.2. Tx with tegaserod
13.1.2. Diarrhea
13.1.2.1. CARSEP : Tx with Alosetron (assoc'd with ischemic colitis)
13.2. Slow transit constipation/ colonic inertia
13.3. Obstructive defecation
13.3.1. Dx
13.3.1.1. 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
15.2.1.1. Open wound
15.2.1.2. Closed - Off Midline - Flaps
15.2.1.2.1. Bascom
15.2.1.2.2. Excision and Z-plasty
15.2.1.2.3. Karydakis procedure
15.2.2. Phenol injection forms eschar in track
16. Hidradenitis Suppurativa
17. Rectovaginal fistula
17.1. Classification
17.1.1. Simple
17.1.1.1. Low to mid rectovaginal septum
17.1.1.2. < 2.5cm
17.1.1.3. Due to trauma/infection
17.1.1.3.1. Trauma
17.1.1.3.2. Infection
17.1.2. Complex
17.1.2.1. High rectovaginal septum
17.1.2.2. >2.5cm
17.1.2.3. Due to IBD, Radiation, or neoplasia
17.1.2.3.1. Radiation induced have 33% incidence of recurrent Ca.
17.1.2.4. 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
17.3.1.1. Endorectal Advancement Flap
17.3.1.2. Anocutaneous Advancement Flap
17.3.1.2.1. Distal fistulae when endorectal flaps would leave ectropion
17.3.1.3. Rectal Sleeve Advancement
17.3.1.3.1. In Crohns
17.3.1.3.2. Use diverting stoma
17.3.1.4. Bioprosthetics
17.3.2. Transvaginal Repair
17.3.2.1. Fistula Inversion
17.3.2.2. Vaginal Advancement Flap
17.3.2.2.1. Includes levatoroplasty
17.3.3. Transperineal techniques
17.3.3.1. Perineoproctotomy ( used by Gyn and recreates a 4th degree tear with layered closure. )
17.3.3.2. Overlapping sphincteroplasty
17.3.3.3. Tissue interposition
17.3.3.3.1. Labial Fat pad (Martius)
17.3.3.3.2. Graciloplasty
17.3.4. Trans-abdominal
17.3.4.1. Coloanal
17.3.4.2. 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:
19.1.1.1. Severe contamination
19.1.1.2. 6 hr surgical delay
19.1.1.3. > 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
20.2.1.1. #1 CMV
20.2.1.2. Hepatitis
20.2.1.2.1. Hepatitis C
20.2.1.3. HIV
20.3. BE trauma
20.3.1. Barium perf
20.3.1.1. Cecum overdistension
20.3.1.2. SAQ : More common thru stoma
20.3.1.3. Rectal injury
20.3.1.3.1. Catheter tip
20.3.1.3.2. Balloon overdistension
20.3.1.4. Ba Mortality 50%
20.4. TPN
20.4.1. Nonketotic, Hyperosmolar coma
20.4.2. Infection
20.4.2.1. St Epi
20.4.2.1.1. Cath tip with greater than 15 colonies
20.4.2.2. Change over wire
20.4.2.3. 12% incidence in TPN central lines (2 % in non TPN central lines)
20.4.2.4. Avoid triple lumens
20.4.3. CARSEP : Trace Elements
20.4.3.1. Zn, Se, I, Cu, Cr, and Mn
20.4.3.1.1. Zn
20.4.3.1.2. Cu
20.4.3.1.3. 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
20.6.1.1. Pudendal Nerve
20.6.1.1.1. Penile Sensory dysfunction
20.6.2. Related to sigmoid resection
20.6.2.1. Sympathetic Superior Hypogastric Plexus
20.6.2.1.1. Site @ IMA
20.6.2.1.2. Results in retrograde ejaculation
20.6.3. CARSEP: Sexual Dysfunction related to Rectal Dissection
20.6.3.1. Parasympathetics
20.6.3.2. Sympathetics
20.6.3.3. Plexi
20.6.3.3.1. Para-aortic sympathetic plexus
20.6.3.3.2. Parasympathetic Nervi Ergentes
20.6.3.3.3. Pelvic Plexus
20.6.3.3.4. Peri-postrastatic Plexus
20.6.4. Lower Extremity
20.6.4.1. CARSEP: Peroneal
20.6.4.1.1. Foot drop
20.6.4.1.2. Sensory loss over dorsum of foot and lower lateral leg
20.6.4.2. Sural
20.6.4.2.1. Sensory branch of Tibial
20.6.4.2.2. Burning pain
20.6.4.3. Tibial
20.6.4.3.1. Plantar flexion
20.6.4.3.2. Ankle inversion
20.6.4.3.3. Toe Flexion
20.6.4.4. Lateral Femoral Cutaneous
20.6.4.4.1. 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
20.8.1.1. SAQ : Aortic Stenosis
20.8.1.2. MI in 30 days
20.8.1.3. Untreated CHF
20.8.1.4. Sx in arrhythmias
20.8.2. Intermediate risk
20.8.2.1. Previous Q wave MI
20.8.2.2. CHF
20.8.2.3. DM with renal failure
20.8.3. Low risk
20.8.3.1. Abnl EKG
20.8.3.2. LVH
20.8.3.3. Low functional capacity
20.8.3.4. Hx CVA
20.8.3.5. 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
21.1.4.1. Convulsive seizures
21.1.4.2. Peripheral neuropathy
21.2. Steroids
21.2.1. Short term complications
21.2.1.1. Moon facies
21.2.1.2. Psychosis
21.2.1.3. Stria
21.2.1.4. HTN
21.2.1.5. Hirsute
21.2.2. Long term complications
21.2.2.1. Osteonecrosis
21.2.2.2. DM
21.2.2.3. Infections
21.2.2.4. 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
22.1.1.1. Trauma
22.1.1.1.1. Surgical Trauma
22.1.1.2. Iatrogenic
22.1.1.3. Congenital
22.1.1.4. IBD
22.1.1.5. Sepsis
22.1.1.6. Pelvic neoplasms
22.1.1.6.1. Brachytherapy
22.2. General comments
22.2.1. Localization challenge
22.2.1.1. endoscopy
22.2.1.2. fistulogram
22.2.1.3. retrograde urinary and rectal contrast studies
22.2.1.4. 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
23.2.2.1. Abd pain
23.2.2.2. Fever
23.2.2.3. Leukocytosis
23.2.2.4. 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
25.12.2.1. Type I states there is a difference when really there is none.
25.12.3. Type II = Accept the null when it is false
25.12.3.1. 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
25.15.1.1. 1. Shows trade offs between sensitivity and specificity (the more sensitive, the less specific)
25.15.1.2. 2. The closer the curve follows the sensitivity axis (the left border) and the top of the ROC space, the more accurate the test.
25.15.1.3. 3. The more the curve approaches the line draw on the 45 degree diagonal of the ROC space, the less accurate the test
25.15.1.4. 4. The slope of the tangent line to the cutpoint gives the likelihood ratio (LR) for that value of the test.
25.15.1.5. 5. The Area under the Curve (AUC) is a measure of test accuracy.
25.15.2. Area under Curve (AUC)
25.15.2.1. Excellent 0.9 - 1.0
25.15.2.2. Good 0.8 - 0.9
25.15.2.3. Fair 0.7 - 0.8
25.15.2.4. Poor 0.6 - 0.7
25.15.2.5. 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