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CRS by Mind Map: CRS

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 [email protected] 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