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CRS by Mind Map: CRS
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CRS

Infections

Sexually transmitted

Viruses, HIV, HAART, CD4 counts optimally greater than 200, Viral load > 10000 copies / cc, Anal molluscum contagious (skin viral infection that creates bumps), Tx underlying HIV with HAART, Anal cancer screening, Annual DRE, High resolution anoscopy, ??? CARSEP seems confusing and suggests NOT using Anal Pap; but Q 245 (P 187) it reverses that thought, Anal Pap, Acetic acid directed biopsies, HPV, Condyloma, Imiquimod, 5% topical ointment X 3 hs / wk, 16 wks, Not for within anal canal, Works with adequate CD4 counts, Podophyllin, Not for use within anal canal, BCA/TCA, Fulguration, Subtypes 6 & 11, Vaccinate before sexually active, SCC, Subtypes 16 & 18, Buschke-Lowenstein, HSV, HSV - 2 = 90%, HSV -1 = 10%, Intranuclear inclusion bodies on pap smear, Positive Tzank, Positive culture, Tx, Acyclovir 400mg 5x day x 10 days

Bacteria, Chancroid / Haemophilus ducreyi, Anal papules turn to pustules turn to ulcers, Sexually transmitted, Dx by Gr stain, Gr (-) facultative anaerobe, Azithromycin 1 gm PO, Ceftriaxone 250mg IM single dose, Ciprofloxacin 500 mg BID 3 days, Emycin 500mg TID x 7 days, Chlamydia/LGV, Obligate intra-cellular, Serovars D-K non LGV Proctitis, Serovars L1-3 = LGV, Tx, Azithromycin 1 gm PO single dose, Doxycycline 100 mg bid PO X 7 days; LGV X 21 days, CARSEP : Cipro ( as a single dose?) Will treat N. Gonorrhea, at same time with single agent, Less effective, Erythromycin, Levofloxacin, Neisseria Gonnorhea, Gr (-) diplococcus, Culture in Thayer Martin, Tx, Cefixime 500mg PO single dose, Ceftriaxone 250 mg IM single dose, Cipro 500 mg PO, Ofloxacin 400mg PO, Levofloxacin 250 mg PO, Syphilis, Treponema pallidum (spirochete), Primary = chancres, painful ulcer w/o educate, Secondary stage = fever, malaise, arthralgias, maculopapular rash on palms of hands and soles of feet, Darkfield exam or Warthin- starry silver stain, F/u VDRL (positive in 75%) or RPR testing, Re-testing, If HIV (-) then, re-test in 6 months, If HIV(+) then, re-test in 3 months, FTA-ABS turns positive at 4-6 weeks for life, Granuloma inguinal ( Donovanosis), Calymmatobacterium granulomatis, Common in Africa, So. Amer., Australia, Ulcerogranulomatous form, Late can cause anal stenosis, Dx tissue smear for Donovan bodies, Tx, Doxycycline 100 mg BID Zx 7 days, Bactrim BID x 3 weeks

Colitides

Bacteria, C Diff, Most common cause of colitis in hosp'd patients, Risk Factors, Age > 60, Recurrent or current use of antibiotics, Nursing home or institutionalized patients, Dx, Stool cytotoxin assay, 2-3 day tissue culture, Sens 94-100%, Spec 99%, Stool ELISA, within a few hours, Sens 70-90%, Spec 99%, Flex Sig, Immunosuppressive risk, HIV (+), Malnourished, Chemo patients, Tx, PO or IV Metronidazole, PO Vancomycin, Gr (+) Bacillus, CARSEP : Alcohol-based foam hand soaps do not prevent C. Diff, E.Coli, Gr (-) Bacillus, Serotypes, Enteroinvasive (EIEC), Food and Water Supply, Watery to bloody diarrhea, Enterotoxigenic (ETEC), Food and Water Supply, Chloride secretory watery diarrhea, Self limited 24-48 hours, Enterohemorrhagic (EHEC), O157:H7, Hemolytic Uremic Syndrome, Microangiopathic edema, Renal Failure, Thrombocytopenia, Unwashed produce and uncooked meat, Toxins, Shiga Toxin, Secretory diarrhea, Enterohemolysin, Enterocyte invasion, Enteropathogenic (EPEC), Neonates, Diarrhea and vomiting, Enteroaggregative (EAEC), Children and HIV, Watery Diarrhea, Contaminated food and water supply, Tx, Supportive: glucose linked absorption of water and electrolytes, Antibiotics contraindicated in HUS - worsens their condition, Shigella, Gr (-) bacillus, Shiga toxin, 10 organisms can cause infection, 1-3 days incubation, Crampy abdominal pain and voluminous diarrhea, High fever, Invades enterocytes and colonocytes, Dx stool culture, Tx, Ampicillin, Cipro, TMP/SMX, Salmonella, Gr (-) bacillus, Second leading cause of foodborne illness, poultry, milk and eggs, 5 F's: flies, fingers, food, feces and fomites, Invade enterocyte and coloncyte, diarrhea to bloody diarrhea, Abdominal pain, Fever, Dx stool culture, Tx, Supportive therapy with glucose linked electrolyte replacement, Immunosuppressed and high risks may need antibiotics, Quinolones, Chloramphenicol, TMP/SMX, Campylobacter, Gr (-) bacillus, Undercooked poultry, Most frequent acute diarrhea in western world, Incubaton 48-72 hours, Abdominal pain and diarrhea, Fevers. rigors, and arthralgic aches, Dx on selected medium so must specifically ask lab for culture for Campy, Tx - self limited for 3-5 days, Supportive therapy with glucose linked electrolyte absorption, E-mycin, Flouroquinolones, Relapse 5-10%, Yersinia, Gr (-) coccobacillus, Contaminated food and water, Incubation 7 days, Mimics appendicitis, pseudo-appendicitis, Peyer's patches mesenteric adenitis, Abd pain, diarrhea, fever, N/V, Dx - stool cultures, Tx, Supportive with glucose linked electrolyte absorption, Severely septic, Ceftriaxone and gentamicin followed by oral Cipro, Spirochetosis, See sexually transmitted diseases, SAQ : Abdominal T.B., Ileocecal 85-90%, No anastomosis risk, Active pulmonary infection in 25% (less than 50% in some series), Stool culture positive in 30%, Skin testing unreliable, Great mimic for cancer or appendicitis, Tx with triples, Isoniazid, Rifampin, Pyrazinamide, 6th most common cause of extra-pulmonary TB (lymphatic, genitourinary, bone/joint, miliary, and meningeal), Not confined to lower socio-economic groups, * CT is most sensitive test (better than PPD, CXR, Sputum, Ascitic fluid and Pleural Fluid), Thick inflamed peritoneum, Peritoneal increased vascularity, Thickened bowel loops, edematous mesentery, muddy serosal studding, Omental Cake, Ascitis sample = 1 liter; spun for acid fast bacillus, Diagnostic mini-lap for peritoneal Bx, No Laparoscopy due to thick peritneum

Viral, CMV, Infectious Mono type syndrome, Fever, Lymphadenopathy, Mild hepatitis, Seropositive in most homosexual men, HIV 10% ileocolitis with diarrhea, Tx, Medical, IV Foscarnet, Associated with irreversible renal failure and Ca metabolism problems, CARSEP : PO or IV Gancyclovir, Assoc'd with bone marrow suppression especially in AZT tx'd patients

Parasites, Amebiasis, Entamoeba Histolytica, 90% asymptomatic, Two forms, Cyst (infective), Stable and survive for months outside host, Trophozoite (invasive), Fragile and do not survive long outside host, Bloody diarrhea, Hepatic abscesses (less common), Dx, 3 stool specimens for cyst and trophozoites, Motile trophozoites with intracytoplasmic RBCs = hemocytophagia, Proctitis with ulcers with small openings (flask like ulcers), Serologic tests (may reflect carrier status or acute infection), Tx, For trophzoites use Metronidazole 750 mg TID X 10 days, For cysts use iodoquinol 650 mg TID X 3 weeks, Surgery for toxic patients - subtotal colectomy, CARSEP : Chagas disease, Trypanosoma cruzi, flagellated parasite, Transmission, Blood transfusion, Insect vector - blood sucking kissing bug, Organ transplant, Cryptosporidia, protozoan, Contaminated water, More lethal in children and immunocompromised, Bloody diarrhea, Dx with endoscopic Bx for Crypto oocysts, Tx with supportive glucose linked electrolyte reabsoprtion, Tx immunocompromised with parmomycin, LGV, Chlamydia Trachomatis Sero types L1-3, See sexually transmitted diseases, CARSEP : Enterobius vermicularis (pinworm), Mebendazole

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

Hepatitis

Occult in 70-75% of patients

Hep C has 60-80% Chronic

Hep C 10 X > Hep B

Hep B vaccine

No Hep C vaccine or effective immunoglobulin

Fournier's Gangrene

Controversial = role of fecal diversion

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

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

IBD

Crohn's

Medication options, Induce remission, Sulfasalazine ( more for colitis), Other 5ASA DRUGS, Oral, Sulfasalazine, Mesalamine, Pentasa, Asacol, Rectal, Rowasa, Steroids, Budesonide (1st line for ileocolitis), Prednisone, Adverse Rx, Short term, Moon facies, acne, HTN, hirsute, stria, psychosis, Long term, DM, infection, osteonecrosis, cataracts, glaucoma, OK in preg, Maintenance, Azathioprine or 6 MP, Adverse Rx, Pancreatitis, Drug induced hepatitis, Methotrexate, Adverse Rx, Pneumonitis, Hepatic fibrosis, Contra in preg, Fistulous disease, Infliximab, SAQ : Monoclonal antibody to TNF alpha, TNF-alpha potent mediator of host response, From monocytes/macrophages and T-cells, Adverse Rx, TB, ? Lymphoma?, Metronidazole, Ciprofloxacillin, Postop prevention/suppression, 3 mos. Metronidazole

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

Scenarios, Ileocolic fibrosing/stenosing, Multiple stenoses & strictures, Stricturoplasty, H-M, Single, Double H-M, Finney, Selvaggi modified Finney, Combined H-M and a Finney, Side-to-side isoperistaltic stricturoplasties, Hurst - Michelassi, Moskel Walske Neumayer, Sasaki, Hotokezaka, Relative contraindications, Free or contained perforation, Phlegmon, Fistula involved segment, Multiple strictures in short segment, Colonic stricture, Hypoalbuminemia, Results, Sepsis 6%, Hemorrhage <4%, 2/3 of steroids, Late Reoperation @ 28%, 78 % obstruction remote from Stricturoplasty, Segmental colon sparing, Rectal sparing, Duodenal stenosing, Stricturoplasty or Bypass are acceptable, If bypass for surgical Tx, gastrojejunostomy ( +/- on role of vagotomy), Anal fistulae, I&D & Setons, RVF, See RVF above, Crohn's ileo-sigmoid fistula, Resect primary and repair secondary, CARSEP : Exception --> phlegmonous reaction in region of recto-sigmoid. Instead perform two segmental resections., Refractory rectal Crohn's, CARSEP : End colostomy and mucous fistula, Proctectomy reserved:, Symptoms refractory to diversion, Dysplasia, Duodenal colic fistula, CARSEP : Dx with BE ( Not SBFT), Peristomal Pyoderma, CARSEP : Bx leading edge, Diff Dx, Infectious, Syphilis, Necrosis from warfarin, Facilities, Steroids (oral & topical)

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

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

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

CUC

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

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

Indeterminant colitis, TAC with Ileorectal, Contra-indications, Diseased, noncompliant rectum, Rectal dysplasia, Non metastatic cancer, Peri-anal disease, Poor sphincter, Surveillance, 6% risk of Ca., Semi-annual flex Sig

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

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

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

Microscopic, Depletion of goblet cells, Crypt shortening

Dysplasia, Low grade, High grade

Serum markers and genetic testing

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

Genetic testing, IBD 5 (Chromosome 5), Transport proteins, CARSEP: OCTN1/OCTN2, Epithelial integrity, Carnitine, Transports long chain fatty acids, Lipid metabolism, Role in CD & CUC ?, IBD 1(Chromosome 16), CARD 15/NOD2, 10-30% Crohn's, Impairs bacterial defenses, CARSEP : Recognize bacterial muramyl dipeptide (MDP), NF-KB, Caucasian, CARSEP : Chronic inflammation creates fibrostenosing Crohn's, CARD 15 = Caspase Activation Recruitment Domain 15, NOD 2 = Nuclear Oligomerization domain 2

Extra intestinal manifestations

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

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

Cancer

Colon

Evolution of Chemo Stage II & III, NSABP 1998, Duke's B and C, 5FU, Vincristine, Semustine (MOF regimen), 3 Arms, Surgery Alone, Postop Chemo, Postop BCG, DFS and OS favored Postop Chemo, NCCTG, 5FU + Levamisole (Later Leucovorin), Advantage in only Node (+), QUASAR, Complex study with 5FU, high dose and ultimately low dose folinic acid; Levamisole shifting to Leucovorin..., Large recruitment, good followup, Very small benefit for Stage II disease, FOLFOX, Stage III, 5FU + Leucovorin + Oxaliplatin, 12 months shrunk to 6 months, Other Studies failed to show benefit in Stage II, Shippinger, Moertel, International Multicentre Pooled Analysis of Colon Cancer Trials (IMPACT), Meta-analysis, Statistical Summary showed we need 4700 patients to show significance of 4% benefit for Stage II, NSABP - Mamounas, C01, MOF vs Surgery alone, C02, 5FU vs. Surgery alone, C03, 5FU + Leucovorin vs. MOF, C04, 5FU + Leucovorin vs. 5FU + Levamisole vs. 5FU + Leucovorin + Levamisole, Mortality reduction, Duke's B = 30%, Duke's C = 18%, Intergroup Study (Gill), Slight DFS and OS benefit regardless of T or N stage for high risk patients, Figuredo and Canada Cancer Care Ontario Program (37 trials and 11 meta-analyses), No benefit for Tx of Stage II, Molecular Markers for Stage II, Guanylyl Cyclase C (GCC), Quantify extra-colonic (nodal) GUCY2C) mRNA, pN0 - mol (+), High risk for recurrence, Decreased DFS, Interleukin 1, Interleukin 1 Beta (IL1B), Interleukin 1 Receptor Agonist (IL1RN), VEGF -A, Adverse prognostic markers

High Risk Stage II Disease, 5 Yr Survival Results using three factors for scoring, Zero of 3, 95%, 1 of 3, 85%, 2 or 3, 57%, Three factors to consider, CEA > 5, t Stage T4, Perineuro or lymphatic invasion, Given the unreliability of LVI, the predictive usefulness of LVI comes into question, Alternative s to identify high risk

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

Rectal

Staging

Neoadjuvant, Mayo / NCCTG (Two Arms), Postop XRT, Local recur 25%, Chemo XRT, Local recur 13.5%, Swedish Rectal Cancer Study (Two Arms), Surgery, Local recur 23%, Preop XRT + Surgery, Local recur 9%, NSABP R-03 ( closed early due to poor accrual) (Two Arms), Preop Chemo XRT + Postop 5FU, Surgery + Postop 5FU + XRT, Local failure was equal in 2 arms @ 10.7%, Preop benefits, OS=74% vs 65.6% p= 0.065, DFS= 64.7% vs 53.4% p= 0.011, German Rectal Cancer Study Group (Two Arms), Preop Chemo XRT, Local recur 6%, Postop Chemo XRT, Local recur 13% p= 0.006, DFS ( Preop 68% to Postop 65% ) & OS ( Preop 76% to Postop 74%) equal in 2 groups, Other study aspects, TME, Sphincter sparing, Postop group staging error, 18% were St I ( not St II/III), Severe % chronic toxicities less Preop group, Conclusion: TME & Preop 5FU chemo XRT, Better local control, Reduced toxicities, Sphincter preservations, Pre vs post XRT had no effect on DFS or OS, EORTC (Two Arms), Preop XRT, No chemo, Local recur 17.1%, 5FU chemo ( 3 groups), Local recur 7.6 - 9.6%, Polish Colorectal Cancer Group (Stages T III / T IV), Preop Short Course, Local recur 10.6%, Traditional ChemoXRT, Local recur 15.6%, No differences in DFS, OS, sphincter preservation, MRC CR07 & NCIC-CTG CO 16 demonstrates importance of CIRMCUMFERENTIAL RESECTION POSITIVE MARGINS (CRM+ive), Radiotherapy cannot rescue positive margin, Mercury Study Group MRI, Predictive value of CRM for TME, Specificity 98%, Negative predictive value 93%, Impact of Tumor regression from Preop XRT, Complete pathologic response = pCR, DFS & OS improves if tumor downstages, Tumor Regression Grades, TRG 0 Complete response, TRG 1 Moderate response, TRG 2 Minimal response, TRG 3 Poor response, GTSG (Four Arms), No Postop Tx, Local recurr 24%, Postop XRT (40-48 By), Local recur 20%, Postop chemo 5FU + Semustine, Local recur 26%, XRT + Chemo, Local recur 10.9%

TME, Dutch Rectal Cancer Study group, TME, Laparoscopy, TME + Short course XRT, Improvement of local failure rates 10.9% to 5.6%, Upper rectal Ca or node negatives saw no benefit from XRT

LAR

APR

Imaging, PET CT, MRI, CARSEP : Endo-ultrasound staging, T Stage, 75-95%, CARSEP Q reports 90%, uT1 = submucosa, uT2 = muscularis mucosa, uT3 = Thru wall into peri-rectal fat, uT4 = invade adjacent organs, N Stage, 80-85%, CT, T Stage 46-75%, N Stage 56-72 %

Local excision, Features, Small, Distal, Mobile, Exophytic, Well/mod differentiated, Less than 1/3 circumference, Failure rates, T1-2, Recurrence 0-25%(20%), Role of adjuvant therapy ???, Adverse features, Lymphatic invasion, Variable results across pathologists, Vascular invasion, Perineural invasion, Positive resection margin

Anal canal

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

Stage, T and N stage criteria, T, T1 < 2cm, T2: 2-5cm, T3 : > 5cm, T4 : invades adjacent organs, N, N1: perirectal nodes, CARSEP: N2: UNILATERAL internal iliac or inguinal nodes, N3 : perirectal and inguinal nodes and/or bilateral internal iliac and/or inguinal nodes, Stage I = T1, Stage II = T2/T3, Stage IIIa= T 1-3, N1, Stage IIIb = T 1-3, N2-N3, Stage IV = Any T, Any N, M1

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

Measures of Success, Overall Survival Rates, Local Regional Survival Rates, Colostomy-free Survival Rates

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

Management of Lymph Node Mets, Chemo radiation

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

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

Anal margin

WLE

Hereditary

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

HNPCC, Guidelines, Bethesda, Cancer < age 50, Synchronous/metachronous HNPCC cancer, MSI histologic test (+) in age < 60 yrs, CRC in 1st degree relative with HNPCC cancer, one cancer before age 50, CRC in 2 or more 1st/2nd degree relatives regardless of age, Amsterdam II, At least 3 family members with HNPCC related CRC, 1 of whom is 1st-degree relative of other 2, At least 2 generations with HNPCC related Ca, At least 1 individual < 50 yrs @ Dx of HNPCC related Ca, Modified criteria, 2 first degree with CRC involving 2 generations, At least 1 case before 55 yrs (or), 2 first degrees with CRC and a third relative with endometrial or another HNPCC related Ca, Simplified 3-2-1 Rule, 3 close relatives, Span 2 generations, 1 less than 50 years of age, Dominant, Most common inherited cancer, CARSEP : HNPCC Cancer List, Endometrial, Ovarian, Gastric, Hepatobiliary, Sm. Bowel, Transitional cell of Ureters & Renal Pelvis, Screening, Begin at age 21 up to 40, Every one to two years, Over 40 years, Annual

Myh associated polyposis (MAP), Recessive inheritance

MSI/ RER, MSI, 90% of HNPCC, CARSEP : High MSI levels, Poorly diff, Longer surv than low MSI, Chemo resist 5FU, hMLH1, Abnormal when protein identified, CARSEP : hMSH2, Normal = protein identified, Abnormal= no protein identified

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

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

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

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

Screening and surveillance

Special Metastatic scenarios

Metastatic Disease, Primary CRC + Liver Mets, Up-front Combination Chemotherapy, Obstructing Primary, Resection, Proximal Diversion, Stenting, Perfation 4%, Stent Migration 10%, Re-obstruction 10%, Hepatic Mets, 5 Yr Surv 27-58%, 5 Predictors of Poor outcomes (Fong et al), Node (+) Primary, CEA greater than 200, Disease Free Interval < 1 Year, More than one Hepatic Met, Met greater than 5 cm, CRS Scores per these five, Zero = Median Surv 74 Months, 1 = Median Surv 51 Months, 2 = Median Surv 47 Months, 3 = Median Surv 33 Months, 4 = Median Surv 20 Months, 5 = Median Surv 22 Months, Steatohepatitis caused by 5FU + Irinotecan, Mortality increased from 2% to 15%, Converting the unresectable to resectable, Induction Chemotherapy convert 16% to resectable with a 40% 5 Yr survival, Systemic Oxiplatin + Irinotecan + HAI of FUDR convert 47% to resectable; Median Survivals 35-51 months, Brain Mets, 1-2 % of all colorectal cancers, Most symptomatic, Rectal Ca > Colon Ca (due to venous drainage), Aggressive treatment prolongs survival, Ovarian Mets, Incidence 1-7%, Answer on Carsep Q = occur synchronously in less than (<) 10%, Not really a Krukenberg tumor, Features, Signet ring (intracellular mucin), Sarcoma like stroma, More common in pre-menopausal woman, Probably hematogenous spread

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

Metachronous Predictor (CARSEP), Common in HNPCC, Less common in Sporadic CRC, Presence of synchronous neoplasia (CRC or adenoma) Increases risk, Index Cancer, (+) predictor, Index CRC mucinous, Index CRC proximal colon, Germline mutation as in MSI (suggests HNPCC), (-) predictor, Index CRC stage, Index CRC degree differentiation, LOH or somatic mutation in K-ras, p53, APC or DCC, CARSEP : Less than the risk of a recurrent CRC

Chemotherapy Factoids

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

FOLFOX, 5FU, Leucovorin, Oxaliplatin

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

Irinotecan

T Stage risk of lymph node mets

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

T2, 22%

T3, 50%

CARSEP : Special

Melanoma

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

Paget's disease, Intraepithelial adeno ca, Synchronous GI Cancers, WLE

Bowen's disease, Intraepithelial SCC, T and N stage criteria, T, T1 < 2cm, T2: 2-5cm, T3 : > 5cm, T4 : invades deep extradermal structures such as bone, muscle or cartilage., N, N1: regional (+) nodes, Nomenclature: AIN; HSIL(AIN II & III) / LSIL(AIN I); or HGAIN (AIN III) / LGAIN (AIN I & II), Low grade Squamous Intra-epithelial lesions (LSIL) = AIN I, High Grade Squamous intra-epithelial lesions (HSIL) = AIN II and III, Pre-malignant, Anal Pap and High resolution microscopy, Acetic Acid or Lugol's Iodine Soln, Viz lesion, Bx and Tx with cautery, No longer recommended to do mapping biopsies., Consider HPV Vaccine, and topicals like 5FU or imiquimod, Screening Procedures for LGAIN / HGAIN, Anal Cytology (Anal Pap), Sensitivity = 69-93% (compared to HRA directed Bx), Specificity = 32%- 59%(compared to HRA directed Bx), High False (-) in Men-sex-men (MSM) risk group, HIV (-)23%, HIV (+) 45%, Colposcopy, Biopsy, High Rresoluion Anoscopy (HRA), Enhance directed Bx using Acetic acid and Lugol's iodine solution, Treatment, Observation Q 4-6 months for progression, Topical 5% Imiquimod cream, Complete response 48%, Side Effects, Irritation, Burning, Erosions, Topical 5% 5FU cream, Complete response 90%, Recurrence 50%, Side effects, Skin Irritation, Hypopigmentation, Photodynamic Therapy, Unknown Role to date, WLE and Targeted destruction, High recurrence rates 13-63%, more in HIV patients (up to 80%), HPV 16 and 18, HIV (+), 50% of LGAIN progress to HGAIN

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

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

Carcinoid, Forgut, Midgut, Hindgut, Serotonin & 5HIAA

Appendix, Adeno Ca, Carcinoid, < 1 cm, Appendectomy, 1-1.9 cm, Tx depends on features, > 2 cm, Right colectomy, Appendices mucocele, Pseudomyxoma peritonei, CT, Ascites, Visceral scalloping, Open cecectomy/ right colectomy, If perf'd, Early postoperative intraperitoneal chemo, Cytoreductive surgery + omentectomy, Heated (107.5) intraoperative, intraperitoneal chemo, Mitomycin C & cis-platinum, 5 FU

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

Benign anorectal

Anal dermatology

CARSEP : Lichen planus, Wickham's stria, Etio unknown

Psoriasis

Molluscum contangiosum, Viral origin

Pruritus ani

Hemorrhoids

RBL

Hemorrhoidectomy, Stapled, Less painful, Circumferential grade 3, Serious complications, Pelvic sepsis, Rectal perforation, Retroperitoneal air, Sx Fever, urinary retention and abdominal pain, SAQ : broad spectrum antibiotics, Ferguson Closed, Milligan-Morgan Open, Complications, Urinary Retention 2-36%, Bleeding 0.03-6%, Infection 0.5-5.5%, Anal stenosis 0 -6%, Whitehead, circumferential hemorrhoidectomy, Parks, submucosal hemorrhoidectomy

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

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

Infrared photocoagulation

Electro-coagulation

BiCap Coagulation

Direct Current Electrotherapy (Ultroid)

Monopolar Coagulation

Cryotherapy

Doppler guided hemorrhoidal arterial ligation (DGHAL)

Lord's procedure: anal stretch

Anal fissures

LIAS, 5-10% major incontinence, 30% incontinent to flatus

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

Pathophys, Hypertensive sphincter

Abscesses / fistula

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

Drain, Seton, Pezzar

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

Levator syndrome

Pain in anorectum

(L) sided

Inciting events, Long rides, Childbirth, Sexual activity, Post LAR

Tx, NSAIDS, Muscle relaxants, Electro-galvanic stimulator

Proctalgia fugax

Awakens patients from sleep

Pruritus Ani

Substance P neuropeptide, Tx with topical capsaicin

C neurons get the itch

Intradermal injection of methylene blue

Intralesional corticosteroids

Anal stenosis

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

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

Surgical Tx, Y-V/ V-Y anoplasty, Diamond or House flaps

Colonoscopy

Flumazenil (benzodiazepine antagonist)

Virtual Colonoscopy "Failed Detection Rates"

1 cm Polyp = comparable to colonoscopy for sensitivity

6-9mm polyps sensitivity = 83%

< 5mm polyps sensivity = 53%

Malignant polyp (Haggitt Levels)

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

Followup for nonoperative cases in 6 mos.

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

> 1cm = 2.1%

0.5-1 CM = 13%

< 0.5 cm = 26%

Sub-optimal bowel prep = 40%

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

Withdrawal Time = > 6 minutes

Increases polyp detection

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

Quality Metrics

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

Patient Quality Metrics, Appropriateness, Informed consent, Safety, Comfort, Timely results

Endoscopic Mucosal Resection

Endoscopic Submucosal Resection

Flat Polyps

Sessile Serrated Adenomas (SSA)

7% of all colonoscopies

Higher malignant potential than traditional adenomas

Features of hyperplastic and adenomas

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

Chromo-endoscopy

indocarmine

Cochrane cites 5 reports

Narrow-band imaging

Uses blue light filters to detect angiogenesis

Polyp detection by Pit patterns

Several identified "pit" patterns

Used in Chromo endo and Narrow Band Imaging

Preps

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

Antibiotics

Amp and Gent

Cardiac Valves and Vasc Grafts less than one year

SAQ : Hamartomatous polyps

Inherited, Autosomal dominant, Peutz-Jeghers, Familial juvenile polyposis, Cowden 's Disease, Skin, Trichilemmoma, Breast, Intestine, Thyroid

Acquired, Cronkite-Canada Syndrome, Ectodermal changes, Alopecia, onychodystrophy, Skin hyperpigmentation, GI polyps, 2/3rds are Japanese, Male:female = 2:1

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

Anticoagulation

Procedures with low risk of bleeding (cold biopsies)

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

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

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

DVT and/or atrial fibrillation

Laparoscopy

CRC Trials

Clinical outcomes of Surgical Therapy (COST)

Colon cancer laparoscopic or open resection (COLOR)

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

SAQ : Conversion to Open, Most Common Reason, Tumor related factors, Size, Fixation, Local tumor infiltration, Reactive Conversions (Related to a complication), Proactive Conversions (Prior to a complication)

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

CARSEP : Pneumoperitoneum or capnoperitoneum

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

Low 5-7 mm Hg or Gasless Laparoscopy

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

Non IBD, Non infectious Colitides

CARSEP : Neutropenic colitis

Nonsurgical Tx, GSF + Antibiotics + inotropes + fluids

R colectomy

CT Ominous Signs, Free Air, Pneumatosis coli, Soft Tissue Air

CARSEP : Microscopic/ lymphocytic/ collagenous colitis

1st line : diet & antidiarrheals

2nd line: Mesalamine, Sulfasalazine, or cholestyramine

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

Watery diarrhea

Endoscopy may appear normal but Bx show non-ulcerative colitis

Eosinophilic Colitis

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

Tx Diarrheal symptoms

Severe cases may need steroids, immunosppuressive or chromoglycate

Disuse Colitis

See LGI Bleed

SAQ : Behcet's

Multi system vasculitis

Intestinal perforations

Ostomies

Para stomal hernias

Relocate

Local repair, With mesh

CARSEP : Complete diversion

Ileostomies

Decrease output with adaption

Increase bacteria

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

CARSEP : Emergency Stomas - higher incidence of necrosis

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

GI Bleeds

Massive LGI Bleed

Diverticulosis

Vascular ecstasias

Ischemic colitis

IBD

Dx & Tx, Technetium labeled RBC scan, Colonoscopy, Selective mesenteric angiogram

CARSEP : Dieulafoy's lesion of rectum

Visible vessel >>> oversew or ligate

Radiation enteritis

SAQ : Formaldehyde 4% for 30 sec to 3 min

Disuse colitis

Tx with short chain fatty acid enemas

CARSEP : Endometriosis

Disc excision with transverse closure

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

Rectal varices

Tx underlying portal HTN

SRUS

CARSEP Q - Asymptomatic = Tx with fiber

Technetium versus sulfur colloid

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

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

Rectal prolapse

Surgical treatment

Sacral Suspension/fixation, Ripstein (anterior), Wells (posterior)

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

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

Etio

Diastasis of levator

Deep cul de sac

Redundant Sigmoid

Patulous anus

Loss of rectosigmoid attachments

+/- pudendal neuropathy

Constipation in 1/3-2/3

Preop transit study to ruleout colonic inertia

Urinary incontinence in 35%

Vaginal prolapse 15%

Diverticulitis

Hinchey classification of peritonitis

Hinchey I: paracolonic abscess

Hinchey II: pelvic abscess

Hinchey III purulent peritonitis

Hinchey IV: feculent peritonitis

When to operate?

CT documented severity

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

When Complications develop?

Giant Diverticulum

Rare

Sx: Pain in 70% ; 10% Asx

Most common presentation - Sign: Abdominal Mass

70% demonstrate communication to colon

Attacks and recurrences

1st attack has 33% recurrence

2nd attack has 50% recurrence

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

Role of delayed resection with initial washout laparoscopically ??

SAQ : Right sided Diverticultitis - Rare

May look like CRC or acute Appy

Anatomy & Physiology

Phys

Short chain fatty acids, Butyrate, Acetate, Propionate, Stimulate Na absorption

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

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

CARSEP: Internal anal sphincter neuromodulation, Parasympathetic inflow, S2-4, Cholinergic (Acetylcholine), Agonist, Bethanecol, Relaxation, Antagonist, Atrophine, Increase resting pressure/ prevents relaxation, Inhibitory (relaxation), Sympathetic inflow, L 5, Alpha 1 adrenergic, Excitation/contraction, Beta adrenergic, Relaxation

Rectal proprioceptive reflex, Location, Pelvic floor, Rectal wall, Rectal thermal thresholds, Correlates, Balloon manometrics, Defecatory desire, Max tolerable volume

Pudendal Neuropathy, PNTML, Abnormal, Prolonged, EMG, Abnormal, Denervation-renervation, Increased single fiber density

SAQ :Ileocecal valve competeency, ileocecal angulation

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

intestinal Secretory function, Aldosterone, Colonic Na absorption, Na absorption continues until luminal concentration 15-25 mMols/liter, K excretion continues until luminal concentration of > 15mmol/liter, Angiotensin, Sm. Bowel Na absorption

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

Anatomy

CARSEP: Haustra formed by taenia

CARSEP : Arc of Riolan

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

Functional bowel disorders

IBS

Constipation, Tx with lubiprostone ( Cl channel activator), Tx with tegaserod

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

Slow transit constipation/ colonic inertia

Obstructive defecation

Dx, CARSEP : Anal manometry & defecography

STARR (Stapled Transanal Rectal Resection)

Ogilvie's

Autonomic imbalance: sympathetic>parasympathetics

Colonoscopic decompression

CARSEP: 1st line of Tx Neostigmine

Epidural sympathetic block

Chagas

Colonic volvulus

Sigmoid

Cecal

SAQ = Nonoperative reduction is typically successful

High recurrence rates

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

Pilonidal sinus

Acute

Chronic

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

Phenol injection forms eschar in track

Hidradenitis Suppurativa

Rectovaginal fistula

Classification

Simple, Low to mid rectovaginal septum, < 2.5cm, Due to trauma/infection, Trauma, Obstetric Injury # 1 cause, fourth degree lacerations, Primiparity, High birth weight newborns, Prolonged second stage delivery (developing countries), Midline episiotomy, Vaginal forceps, Anorectal complications, PPH, STARR, Less than 0.1% of all vaginal deliveries, Infection, TB, LGV, Schistosomiasis

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

EUA for Detection

Rigid procto of rectum with water filled vagina searching for bubbles

Rectal methylene blue for 20 mins with vaginal tampon

Surgical Repair

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

Transvaginal Repair, Fistula Inversion, Vaginal Advancement Flap, Includes levatoroplasty

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

Trans-abdominal, Coloanal, Proctectomy

Embryology

Hirschsprung's

Failure migration of neural crest

Absence of ganglion cells

Thick non-myelinated nerves

Pre/post ganglionic fibers w/o synapses

CARSEP: Prominent adrenergic and cholinergic fibers

SAQ = Increase staining for Ach

Absence of RAIR

VACTERL Anomalies

Vertebral

Anal atresia

Cardiac

Trach-esophageal

CARSEP : Renal

Limbs

Trauma

Colon

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

Rectum

Anus/sphincter

Peri operative

HIT

CARSEP : Alternative to Heparin prior to warfarin: argatroban

Blood transfusions

Viruses, #1 CMV, Hepatitis, Hepatitis C, HIV

BE trauma

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

TPN

Nonketotic, Hyperosmolar coma

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

CARSEP : Trace Elements, Zn, Se, I, Cu, Cr, and Mn, Zn, Acrodermatitis enteropathica, immune deficiency, Loss of taste, Night blindness, Alopecia, Impotence and hypogonadism, Cu, Bone marrow, Hypochromic anemia unresponsive to Fe, Neutropenia, Osteoporosis, Cr, Glucose Intolerance

Serum Sodium in Hyperglycemia

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.

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

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)

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.

Nerve Injuries

Related to APR, Pudendal Nerve, Penile Sensory dysfunction

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

CARSEP: Sexual Dysfunction related to Rectal Dissection, Parasympathetics, Sympathetics, Plexi, Para-aortic sympathetic plexus, Coalesce to form hypogastric plexus, Parasympathetic Nervi Ergentes, SAQ : Forceful Traction on Rectum, Pelvic Plexus, Hypogastric Plexus (Sympathetic) + Nervi Ergentes (Parasympathetic), Peri-postrastatic Plexus

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

DVT

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

May substitute Low molecular wt heparin

CARSEP: Helical CT and Role of D-Dimer testing

Cardiac Risk

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

Intermediate risk, Previous Q wave MI, CHF, DM with renal failure

Low risk, Abnl EKG, LVH, Low functional capacity, Hx CVA, Hx uncontrolled HTN

CARSEP : Refeeding Syndrome

Triad of hypokalemia, hypophosphatemia and thiamine deficiency

Hyper-volemia which can lead to CHF

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

CARSEP : SCIP

Appropriate peri-operative antibiotics

Appropriate hair removal

Postop normothermia

Continued Beta Blocker Tx

DVT Prophylaxis

Medications of Interest

Metronidazole

Bacteriocidal

Drug of choice in anaerobic sepsis

Also used in Trichomoniasis

Rare complications, Convulsive seizures, Peripheral neuropathy

Steroids

Short term complications, Moon facies, Psychosis, Stria, HTN, Hirsute

Long term complications, Osteonecrosis, DM, Infections, Cataracts/Glaucoma

Meperidine

CARSEP : Contra-indicated in patients seizure disorders

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

Rectourinary Fistulas

Rectourethral Fistula

Etios, Trauma, Surgical Trauma, Iatrogenic, Congenital, IBD, Sepsis, Pelvic neoplasms, Brachytherapy

General comments

Localization challenge, endoscopy, fistulogram, retrograde urinary and rectal contrast studies, CT

Pre-existing XRT not a negative predictor to repair

Aggressive reoperations will resolve 90%

Surgery

Transperineal

York-Mason Trans anal layered closure

Miscellaneous

Colonic J Pouch

Shorter pouches evacuate better than long pouches

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

Portal Vein Thrombosis

Assoc'd with IBD patients

Sx and Signs, Abd pain, Fever, Leukocytosis, Delayed bowel function

CARSEP : Tx with Heparin

Notes about this Mind Map

Developed and supported by FG Opelka

To request additions or updates send email and reference material to fopelka@gmail.com

Special Terms within the map

SAQ refers to CRS Self Assessment Question

CARSEP Q refers to CRS CARSEP Question

Drag the map around to see the various aspects

Resize the map using the resizer tool

Medical Statistics

Clinical Equipoise

Meta-analysis

Central Tendency

Mean

Median

Mode

Range

ANCOVA - Analysis of Covariance

Relative Risk Reduction RRR

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

Absolute Risk Reduction ARR

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

Number Needed to Treat (NNT) = 1 / ARR

t- test

Fischer exact test

Log Regression

Mann-Whitney

Error Types

Null states there is no difference

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

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

Phases of clinical trials

Phase I - tests safety

Phase II - larger groups to test efficacy and safety

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

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

Central Tendency

C-Statistics / Receiver Operating Characteristics

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

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

Power

Sample size

Size of the difference to be detected

Risk of error