1. Benign anorectal
1.1. Anal dermatology
1.1.1. CARSEP : Lichen planus
1.1.1.1. Wickham's stria
1.1.1.2. Etio unknown
1.1.2. Psoriasis
1.1.3. Molluscum contangiosum
1.1.3.1. Viral origin
1.1.4. Pruritus ani
1.2. Hemorrhoids
1.2.1. RBL
1.2.2. Hemorrhoidectomy
1.2.2.1. Stapled
1.2.2.1.1. Less painful
1.2.2.1.2. Circumferential grade 3
1.2.2.1.3. Serious complications
1.2.2.2. Ferguson Closed
1.2.2.3. Milligan-Morgan Open
1.2.2.4. Complications
1.2.2.4.1. Urinary Retention 2-36%
1.2.2.4.2. Bleeding 0.03-6%
1.2.2.4.3. Infection 0.5-5.5%
1.2.2.4.4. Anal stenosis 0 -6%
1.2.2.5. Whitehead
1.2.2.5.1. circumferential hemorrhoidectomy
1.2.2.6. Parks
1.2.2.6.1. submucosal hemorrhoidectomy
1.2.3. Scenarios
1.2.3.1. Acute gangrenous hemorrhoids
1.2.3.2. Path specimen with melanoma
1.2.3.3. Post RBL Urinary retention & sepsis
1.2.3.4. Hemorrhoids in pregnancy
1.2.3.5. Hemorrhoids in the immunocompromised
1.2.3.5.1. Antibiotics
1.2.3.5.2. Poor wound healing
1.2.3.5.3. CARSEP : Sclerotherapy OK even with low CD4 counts
1.2.3.6. Hemorrhoids and varices in portal HTN
1.2.3.7. Hemorrhoids in IBD
1.2.3.7.1. Poor wound healing in Crohns
1.2.4. CARSEP : Sclerotherapy
1.2.4.1. 1-2 cc
1.2.4.2. Agents
1.2.4.2.1. 5% phenol in almond oil
1.2.4.2.2. 5% quinine urea
1.2.4.2.3. 5% sodium morrhuate
1.2.4.3. Used in HIV even with low CD4 counts
1.2.5. Infrared photocoagulation
1.2.6. Electro-coagulation
1.2.7. BiCap Coagulation
1.2.8. Direct Current Electrotherapy (Ultroid)
1.2.9. Monopolar Coagulation
1.2.10. Cryotherapy
1.2.11. Doppler guided hemorrhoidal arterial ligation (DGHAL)
1.2.12. Lord's procedure: anal stretch
1.3. Anal fissures
1.3.1. LIAS
1.3.1.1. 5-10% major incontinence
1.3.1.2. 30% incontinent to flatus
1.3.2. Medical Tx
1.3.2.1. Topical 0.2% nitroglycerin ointment
1.3.2.1.1. L-arginine
1.3.2.2. Topical Ca-channel blockers
1.3.2.2.1. Diltiazem 2%
1.3.2.2.2. Nifedipine 0.3%
1.3.2.3. Botulinum toxin
1.3.2.4. Other experiments
1.3.2.4.1. Alpha1 adrenal receptor antagonists (indoramin)
1.3.2.4.2. Cholinomimetic ( bethanecol)
1.3.2.4.3. Phosphodiesterase inhibitor (sildenafil(Viagra))
1.3.2.4.4. Hyperbarics
1.3.2.5. SAQ: wait eight (8) weeks to assess therapy before changing or surgery ( try not to abandon therapy as a failure until 8 weeks)
1.3.3. Pathophys
1.3.3.1. Hypertensive sphincter
1.4. Abscesses / fistula
1.4.1. Fossae
1.4.1.1. Ischioanal
1.4.1.2. Intersphincteric
1.4.1.3. Supralevator
1.4.1.4. Extrasphincteric
1.4.1.5. Peri-anal
1.4.1.6. Deep post anal
1.4.1.7. Horseshoe
1.4.1.7.1. Originates in Deep Post Anal Space
1.4.1.7.2. Trans sphincteric
1.4.2. Drain
1.4.2.1. Seton
1.4.2.2. Pezzar
1.4.3. Fistula
1.4.3.1. Fistulotomy
1.4.3.2. Fibrin Glue
1.4.3.3. Porcine collagen plugs
1.4.3.3.1. Inserted at internal opening
1.4.3.3.2. Secured at internal opening
1.4.3.4. RVF
1.4.3.4.1. See above
1.5. Levator syndrome
1.5.1. Pain in anorectum
1.5.2. (L) sided
1.5.3. Inciting events
1.5.3.1. Long rides
1.5.3.2. Childbirth
1.5.3.3. Sexual activity
1.5.3.4. Post LAR
1.5.4. Tx
1.5.4.1. NSAIDS
1.5.4.2. Muscle relaxants
1.5.4.3. Electro-galvanic stimulator
1.6. Proctalgia fugax
1.6.1. Awakens patients from sleep
1.7. Pruritus Ani
1.7.1. Substance P neuropeptide
1.7.1.1. Tx with topical capsaicin
1.7.2. C neurons get the itch
1.7.3. Intradermal injection of methylene blue
1.7.4. Intralesional corticosteroids
1.8. Anal stenosis
1.8.1. Site
1.8.1.1. Low : >0.5 cm below dentate
1.8.1.2. Dentate +/- 0.5 cm
1.8.1.3. High: > 0.5 cm above dentate
1.8.2. Severity
1.8.2.1. Mild
1.8.2.1.1. Digital exam or medium Hill Ferguson Anoscope (H-F)
1.8.2.2. Moderate
1.8.2.2.1. Forceful finger or medium H-F Scope
1.8.2.3. Severe
1.8.2.3.1. No finger or small H-F Scope
1.8.3. Surgical Tx
1.8.3.1. Y-V/ V-Y anoplasty
1.8.3.2. Diamond or House flaps
2. Colonoscopy
2.1. Flumazenil (benzodiazepine antagonist)
2.2. Virtual Colonoscopy "Failed Detection Rates"
2.2.1. 1 cm Polyp = comparable to colonoscopy for sensitivity
2.2.2. 6-9mm polyps sensitivity = 83%
2.2.3. < 5mm polyps sensivity = 53%
2.3. Malignant polyp (Haggitt Levels)
2.3.1. Circumstances for resection
2.3.1.1. Tumor in lymphatic in head of polyp
2.3.1.2. Poorly differentiated
2.3.1.3. Sessions polyp or short stalk (< 0.5cm)
2.3.2. Followup for nonoperative cases in 6 mos.
2.4. Polyp size correlated to "failed detection rates" (Differs for Virtual Colonoscopy)
2.4.1. > 1cm = 2.1%
2.4.2. 0.5-1 CM = 13%
2.4.3. < 0.5 cm = 26%
2.4.4. Sub-optimal bowel prep = 40%
2.4.5. Afternoon scopes & Physician Fatigue
2.4.5.1. Reduced detection rates
2.4.5.2. Increased poor bowel preps
2.4.5.3. Decreased cecal intubations
2.5. Withdrawal Time = > 6 minutes
2.5.1. Increases polyp detection
2.5.2. ? ? Value if 6 min timeline did increase actual large polyp/ high risk polyp detection
2.6. Quality Metrics
2.6.1. Intra-procedural
2.6.1.1. Cecal intubation
2.6.1.2. Terminal ileal intubation
2.6.1.3. Time to cecum
2.6.1.4. Time to withdrawal
2.6.1.5. # of polyps
2.6.1.6. Removal of polyps
2.6.1.7. Size of polyps
2.6.2. Patient Quality Metrics
2.6.2.1. Appropriateness
2.6.2.2. Informed consent
2.6.2.3. Safety
2.6.2.4. Comfort
2.6.2.5. Timely results
2.7. Endoscopic Mucosal Resection
2.8. Endoscopic Submucosal Resection
2.9. Flat Polyps
2.10. Sessile Serrated Adenomas (SSA)
2.10.1. 7% of all colonoscopies
2.10.2. Higher malignant potential than traditional adenomas
2.10.3. Features of hyperplastic and adenomas
2.10.4. MSI related; similar to HNPCC
2.10.4.1. BRAF Mutation
2.10.4.2. DNA Hyper- Methylation
2.10.4.2.1. Extensive methylation of the CpG Island promoter site
2.10.4.2.2. MLH1
2.10.4.2.3. MGMT (Methylations)
2.11. Chromo-endoscopy
2.11.1. indocarmine
2.11.2. Cochrane cites 5 reports
2.12. Narrow-band imaging
2.12.1. Uses blue light filters to detect angiogenesis
2.13. Polyp detection by Pit patterns
2.13.1. Several identified "pit" patterns
2.13.2. Used in Chromo endo and Narrow Band Imaging
2.14. Preps
2.14.1. Split dose preps
2.14.1.1. 1/2 prep night before
2.14.1.2. 1/2 prep 4-5 hours prior to exam
2.15. Antibiotics
2.15.1. Amp and Gent
2.15.2. Cardiac Valves and Vasc Grafts less than one year
2.16. SAQ : Hamartomatous polyps
2.16.1. Inherited
2.16.1.1. Autosomal dominant
2.16.1.1.1. Peutz-Jeghers
2.16.1.1.2. Familial juvenile polyposis
2.16.1.1.3. Cowden 's Disease
2.16.2. Acquired
2.16.2.1. Cronkite-Canada Syndrome
2.16.2.1.1. Ectodermal changes
2.16.2.1.2. GI polyps
2.16.2.1.3. 2/3rds are Japanese
2.16.2.1.4. Male:female = 2:1
2.17. Argon Plasma Coagulator - high freq monopolar current through ionized gas (not a laser)
2.18. Anticoagulation
2.18.1. Procedures with low risk of bleeding (cold biopsies)
2.18.2. Interrupt Coumadin
2.18.2.1. Stop 3-5 days prior to scope
2.18.2.2. Restart 5-10 if post polypectomy
2.18.3. Procedures with intermediate (polypectomy 1-2.5%) and high risk of bleeding (laser ablation 6%)
2.18.4. Heparin for Mechanical Heart Valves
2.18.4.1. Start when INR is sub-therapeutic
2.18.4.2. Hold heparin 4-6 hours prior to scope
2.18.4.3. Restart 2-6 hours later
2.18.5. DVT and/or atrial fibrillation
3. Laparoscopy
3.1. CRC Trials
3.1.1. Clinical outcomes of Surgical Therapy (COST)
3.1.2. Colon cancer laparoscopic or open resection (COLOR)
3.1.3. Conventional vs. laparoscopic assisted surgery in colorectal cancer (CLASICC)
3.1.4. SAQ : Conversion to Open
3.1.4.1. Most Common Reason
3.1.4.1.1. Tumor related factors
3.1.4.2. Reactive Conversions (Related to a complication)
3.1.4.3. Proactive Conversions (Prior to a complication)
3.1.5. Trial parameters
3.1.5.1. DFS & OS
3.1.5.2. LOS
3.1.5.3. Time to diet
3.1.5.4. Return of bowel function
3.1.5.5. Morbidity/mortality
3.1.5.6. circumferential radial margins
3.1.5.7. Local recurrence
3.2. CARSEP : Pneumoperitoneum or capnoperitoneum
3.2.1. 15 mm Hg causes Increase intra-abd pressure
3.2.1.1. Decrease Preload
3.2.1.2. Increase Afterload and SVR
3.2.1.3. Decrease cardiac index
3.2.1.4. Decrease pulmonary compliance
3.2.2. Low 5-7 mm Hg or Gasless Laparoscopy
3.2.3. CO 2 Embolism
3.2.3.1. Massive decrease in cardiac output due to gas-lock
3.2.3.2. Hypotension & Bradycardia
3.2.3.3. Decrease end-tidal CO2
3.2.3.4. Machinery or millwheel murmur
3.2.3.5. Central line return yields "Foamy" blood
3.2.3.6. Tx: left lateral with Trendelenburg (Durant's position)
4. Ostomies
4.1. Para stomal hernias
4.1.1. Relocate
4.1.2. Local repair
4.1.2.1. With mesh
4.2. CARSEP : Complete diversion
4.3. Ileostomies
4.3.1. Decrease output with adaption
4.3.2. Increase bacteria
4.3.3. Chronically elevated mineral corticoids
4.3.3.1. Increase H2O and Na reabsorption
4.3.3.2. Renal impact
4.3.3.2.1. Decrease urine volume
4.3.3.2.2. Decrease urine Na
4.3.3.2.3. Increase Aldosterone
4.3.3.2.4. Increase urine K
4.4. CARSEP : Emergency Stomas - higher incidence of necrosis
4.5. Pregnancy and stomas = pseudo-prolapse (resolves post delivery)
5. Rectal prolapse
5.1. Surgical treatment
5.1.1. Sacral Suspension/fixation
5.1.1.1. Ripstein (anterior)
5.1.1.2. Wells (posterior)
5.1.2. Trans abdominal Resection
5.1.2.1. LAR/Anterior resection
5.1.2.2. Proctopexy with resection (Frykman & Goldberg)
5.1.2.2.1. Reduces constipation
5.1.3. Perineal procedures
5.1.3.1. Altemeier
5.1.3.1.1. Use in young patient with incarcerated prolapse (CARSEP pg 143)
5.1.3.2. DeLorme
5.1.3.3. Thiersch
5.2. Etio
5.2.1. Diastasis of levator
5.2.2. Deep cul de sac
5.2.3. Redundant Sigmoid
5.2.4. Patulous anus
5.2.5. Loss of rectosigmoid attachments
5.2.6. +/- pudendal neuropathy
5.2.7. Constipation in 1/3-2/3
5.3. Preop transit study to ruleout colonic inertia
5.4. Urinary incontinence in 35%
5.5. Vaginal prolapse 15%
6. Anatomy & Physiology
6.1. Phys
6.1.1. Short chain fatty acids
6.1.1.1. Butyrate
6.1.1.2. Acetate
6.1.1.3. Propionate
6.1.1.4. Stimulate Na absorption
6.1.2. CARSEP: RAIR
6.1.2.1. Absent
6.1.2.1.1. Chagas
6.1.2.1.2. Hirschsprung's
6.1.2.1.3. Dermatomyositis
6.1.2.1.4. Scleroderma
6.1.2.2. Rectal distention
6.1.2.2.1. Relaxed internal sphincter
6.1.2.2.2. External sphincter contraction
6.1.2.3. Present
6.1.2.3.1. Normal patients
6.1.2.3.2. Paraplegics
6.1.3. Defecatory reflex
6.1.3.1. Rectal distension
6.1.3.2. Colonic mass movement
6.1.3.3. Spinal reflexes with cortical modulation
6.1.3.3.1. Accommodation
6.1.3.3.2. Anal canal sampling
6.1.4. CARSEP: Internal anal sphincter neuromodulation
6.1.4.1. Parasympathetic inflow
6.1.4.1.1. S2-4
6.1.4.1.2. Cholinergic (Acetylcholine)
6.1.4.1.3. Inhibitory (relaxation)
6.1.4.2. Sympathetic inflow
6.1.4.2.1. L 5
6.1.4.2.2. Alpha 1 adrenergic
6.1.4.2.3. Beta adrenergic
6.1.5. Rectal proprioceptive reflex
6.1.5.1. Location
6.1.5.1.1. Pelvic floor
6.1.5.1.2. Rectal wall
6.1.5.2. Rectal thermal thresholds
6.1.5.2.1. Correlates
6.1.6. Pudendal Neuropathy
6.1.6.1. PNTML
6.1.6.1.1. Abnormal
6.1.6.2. EMG
6.1.6.2.1. Abnormal
6.1.7. SAQ :Ileocecal valve competeency
6.1.7.1. ileocecal angulation
6.1.8. SAQ :Role of GI Anaerobes
6.1.8.1. Provide catabolic enzymes for digestion of organic compounds
6.1.8.2. Produce small amount of Vit K
6.1.8.3. Create Short Chain Fatty acid (70%)
6.1.8.4. Do not create stool bulk
6.1.9. intestinal Secretory function
6.1.9.1. Aldosterone
6.1.9.1.1. Colonic Na absorption
6.1.9.2. Angiotensin
6.1.9.2.1. Sm. Bowel Na absorption
6.1.10. CARSEP : Autonomic Dysreflexia in spinal cord injuries
6.1.10.1. Hypertension
6.1.10.2. Sweating
6.1.10.3. Headache
6.1.10.4. Hot/cold sensation
6.2. Anatomy
6.2.1. CARSEP: Haustra formed by taenia
6.2.2. CARSEP : Arc of Riolan
6.2.3. SAQ : High ligation of IMA
6.2.3.1. Increase mobilization for tension free anastomosis
7. Hidradenitis Suppurativa
8. Rectovaginal fistula
8.1. Classification
8.1.1. Simple
8.1.1.1. Low to mid rectovaginal septum
8.1.1.2. < 2.5cm
8.1.1.3. Due to trauma/infection
8.1.1.3.1. Trauma
8.1.1.3.2. Infection
8.1.2. Complex
8.1.2.1. High rectovaginal septum
8.1.2.2. >2.5cm
8.1.2.3. Due to IBD, Radiation, or neoplasia
8.1.2.3.1. Radiation induced have 33% incidence of recurrent Ca.
8.1.2.4. Failed previous repair
8.2. EUA for Detection
8.2.1. Rigid procto of rectum with water filled vagina searching for bubbles
8.2.2. Rectal methylene blue for 20 mins with vaginal tampon
8.3. Surgical Repair
8.3.1. Transanal
8.3.1.1. Endorectal Advancement Flap
8.3.1.2. Anocutaneous Advancement Flap
8.3.1.2.1. Distal fistulae when endorectal flaps would leave ectropion
8.3.1.3. Rectal Sleeve Advancement
8.3.1.3.1. In Crohns
8.3.1.3.2. Use diverting stoma
8.3.1.4. Bioprosthetics
8.3.2. Transvaginal Repair
8.3.2.1. Fistula Inversion
8.3.2.2. Vaginal Advancement Flap
8.3.2.2.1. Includes levatoroplasty
8.3.3. Transperineal techniques
8.3.3.1. Perineoproctotomy ( used by Gyn and recreates a 4th degree tear with layered closure. )
8.3.3.2. Overlapping sphincteroplasty
8.3.3.3. Tissue interposition
8.3.3.3.1. Labial Fat pad (Martius)
8.3.3.3.2. Graciloplasty
8.3.4. Trans-abdominal
8.3.4.1. Coloanal
8.3.4.2. Proctectomy
9. Peri operative
9.1. HIT
9.1.1. CARSEP : Alternative to Heparin prior to warfarin: argatroban
9.2. Blood transfusions
9.2.1. Viruses
9.2.1.1. #1 CMV
9.2.1.2. Hepatitis
9.2.1.2.1. Hepatitis C
9.2.1.3. HIV
9.3. BE trauma
9.3.1. Barium perf
9.3.1.1. Cecum overdistension
9.3.1.2. SAQ : More common thru stoma
9.3.1.3. Rectal injury
9.3.1.3.1. Catheter tip
9.3.1.3.2. Balloon overdistension
9.3.1.4. Ba Mortality 50%
9.4. TPN
9.4.1. Nonketotic, Hyperosmolar coma
9.4.2. Infection
9.4.2.1. St Epi
9.4.2.1.1. Cath tip with greater than 15 colonies
9.4.2.2. Change over wire
9.4.2.3. 12% incidence in TPN central lines (2 % in non TPN central lines)
9.4.2.4. Avoid triple lumens
9.4.3. CARSEP : Trace Elements
9.4.3.1. Zn, Se, I, Cu, Cr, and Mn
9.4.3.1.1. Zn
9.4.3.1.2. Cu
9.4.3.1.3. Cr
9.5. Serum Sodium in Hyperglycemia
9.5.1. 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.
9.5.2. Step 2 : Determine the "dilution factor" by dividing the patient glucose excess by 100. In this example, 150 / 100 = a 1.5 dilution factor
9.5.3. 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)
9.5.4. 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.
9.6. Nerve Injuries
9.6.1. Related to APR
9.6.1.1. Pudendal Nerve
9.6.1.1.1. Penile Sensory dysfunction
9.6.2. Related to sigmoid resection
9.6.2.1. Sympathetic Superior Hypogastric Plexus
9.6.2.1.1. Site @ IMA
9.6.2.1.2. Results in retrograde ejaculation
9.6.3. CARSEP: Sexual Dysfunction related to Rectal Dissection
9.6.3.1. Parasympathetics
9.6.3.2. Sympathetics
9.6.3.3. Plexi
9.6.3.3.1. Para-aortic sympathetic plexus
9.6.3.3.2. Parasympathetic Nervi Ergentes
9.6.3.3.3. Pelvic Plexus
9.6.3.3.4. Peri-postrastatic Plexus
9.6.4. Lower Extremity
9.6.4.1. CARSEP: Peroneal
9.6.4.1.1. Foot drop
9.6.4.1.2. Sensory loss over dorsum of foot and lower lateral leg
9.6.4.2. Sural
9.6.4.2.1. Sensory branch of Tibial
9.6.4.2.2. Burning pain
9.6.4.3. Tibial
9.6.4.3.1. Plantar flexion
9.6.4.3.2. Ankle inversion
9.6.4.3.3. Toe Flexion
9.6.4.4. Lateral Femoral Cutaneous
9.6.4.4.1. Thigh numbness and tingling
9.7. DVT
9.7.1. SAQ :Heparin and graded compression stockings (+) although 2012 SAQ suggests pre + post heparin and pneumatic compression stockings
9.7.2. May substitute Low molecular wt heparin
9.7.3. CARSEP: Helical CT and Role of D-Dimer testing
9.8. Cardiac Risk
9.8.1. High risk
9.8.1.1. SAQ : Aortic Stenosis
9.8.1.2. MI in 30 days
9.8.1.3. Untreated CHF
9.8.1.4. Sx in arrhythmias
9.8.2. Intermediate risk
9.8.2.1. Previous Q wave MI
9.8.2.2. CHF
9.8.2.3. DM with renal failure
9.8.3. Low risk
9.8.3.1. Abnl EKG
9.8.3.2. LVH
9.8.3.3. Low functional capacity
9.8.3.4. Hx CVA
9.8.3.5. Hx uncontrolled HTN
9.9. CARSEP : Refeeding Syndrome
9.9.1. Triad of hypokalemia, hypophosphatemia and thiamine deficiency
9.9.2. Hyper-volemia which can lead to CHF
9.9.3. For BMI of 14, start refeeding at 1200 to 1500 cal and increase by 500 q 2-3 days up to 3500.
9.10. CARSEP : SCIP
9.10.1. Appropriate peri-operative antibiotics
9.10.2. Appropriate hair removal
9.10.3. Postop normothermia
9.10.4. Continued Beta Blocker Tx
9.10.5. DVT Prophylaxis
10. Medications of Interest
10.1. Metronidazole
10.1.1. Bacteriocidal
10.1.2. Drug of choice in anaerobic sepsis
10.1.3. Also used in Trichomoniasis
10.1.4. Rare complications
10.1.4.1. Convulsive seizures
10.1.4.2. Peripheral neuropathy
10.2. Steroids
10.2.1. Short term complications
10.2.1.1. Moon facies
10.2.1.2. Psychosis
10.2.1.3. Stria
10.2.1.4. HTN
10.2.1.5. Hirsute
10.2.2. Long term complications
10.2.2.1. Osteonecrosis
10.2.2.2. DM
10.2.2.3. Infections
10.2.2.4. Cataracts/Glaucoma
10.3. Meperidine
10.3.1. CARSEP : Contra-indicated in patients seizure disorders
10.3.2. CARSEP : Used in the treatment of postop/recovery room hypothermia (25 mg)
11. Rectourinary Fistulas
11.1. Rectourethral Fistula
11.1.1. Etios
11.1.1.1. Trauma
11.1.1.1.1. Surgical Trauma
11.1.1.2. Iatrogenic
11.1.1.3. Congenital
11.1.1.4. IBD
11.1.1.5. Sepsis
11.1.1.6. Pelvic neoplasms
11.1.1.6.1. Brachytherapy
11.2. General comments
11.2.1. Localization challenge
11.2.1.1. endoscopy
11.2.1.2. fistulogram
11.2.1.3. retrograde urinary and rectal contrast studies
11.2.1.4. CT
11.2.2. Pre-existing XRT not a negative predictor to repair
11.2.3. Aggressive reoperations will resolve 90%
11.3. Surgery
11.3.1. Transperineal
11.3.2. York-Mason Trans anal layered closure
12. Notes about this Mind Map
12.1. Developed and supported by FG Opelka
12.2. To request additions or updates send email and reference material to fopelka@gmail.com
12.3. Special Terms within the map
12.3.1. SAQ refers to CRS Self Assessment Question
12.3.2. CARSEP Q refers to CRS CARSEP Question
12.4. Drag the map around to see the various aspects
12.5. Resize the map using the resizer tool
13. Medical Statistics
13.1. Clinical Equipoise
13.2. Meta-analysis
13.3. Central Tendency
13.3.1. Mean
13.3.2. Median
13.3.3. Mode
13.3.4. Range
13.4. ANCOVA - Analysis of Covariance
13.5. Relative Risk Reduction RRR
13.5.1. proportion of control group experiencing an outcome less than the intervention group experiencing the outcome
13.6. Absolute Risk Reduction ARR
13.6.1. Proportion of control experiencing an event less the intervention group experiencing the event
13.7. Number Needed to Treat (NNT) = 1 / ARR
13.8. t- test
13.9. Fischer exact test
13.10. Log Regression
13.11. Mann-Whitney
13.12. Error Types
13.12.1. Null states there is no difference
13.12.2. Type I = Reject the null when the null is true
13.12.2.1. Type I states there is a difference when really there is none.
13.12.3. Type II = Accept the null when it is false
13.12.3.1. Type II states there is no difference when really there is one.
13.13. Phases of clinical trials
13.13.1. Phase I - tests safety
13.13.2. Phase II - larger groups to test efficacy and safety
13.13.3. Phase III - large groups to confirm effectiveness, monitor side effects and compare to other Tx methods
13.13.4. Phase IV - postmarketing studies, risks, benefits, and optimal use
13.14. Central Tendency
13.15. C-Statistics / Receiver Operating Characteristics
13.15.1. 5 Major points from ROC
13.15.1.1. 1. Shows trade offs between sensitivity and specificity (the more sensitive, the less specific)
13.15.1.2. 2. The closer the curve follows the sensitivity axis (the left border) and the top of the ROC space, the more accurate the test.
13.15.1.3. 3. The more the curve approaches the line draw on the 45 degree diagonal of the ROC space, the less accurate the test
13.15.1.4. 4. The slope of the tangent line to the cutpoint gives the likelihood ratio (LR) for that value of the test.
13.15.1.5. 5. The Area under the Curve (AUC) is a measure of test accuracy.
13.15.2. Area under Curve (AUC)
13.15.2.1. Excellent 0.9 - 1.0
13.15.2.2. Good 0.8 - 0.9
13.15.2.3. Fair 0.7 - 0.8
13.15.2.4. Poor 0.6 - 0.7
13.15.2.5. Fail 0.5 - 0.6
13.16. Power
13.16.1. Sample size
13.16.2. Size of the difference to be detected
13.16.3. Risk of error
14. Infections
14.1. Sexually transmitted
14.1.1. Viruses
14.1.1.1. HIV
14.1.1.1.1. HAART
14.1.1.1.2. CD4 counts optimally greater than 200
14.1.1.1.3. Viral load > 10000 copies / cc
14.1.1.1.4. Anal molluscum contagious (skin viral infection that creates bumps)
14.1.1.1.5. Anal cancer screening
14.1.1.2. HPV
14.1.1.2.1. Condyloma
14.1.1.2.2. Vaccinate before sexually active
14.1.1.2.3. SCC
14.1.1.3. HSV
14.1.1.3.1. HSV - 2 = 90%
14.1.1.3.2. HSV -1 = 10%
14.1.1.3.3. Intranuclear inclusion bodies on pap smear
14.1.1.3.4. Positive Tzank
14.1.1.3.5. Positive culture
14.1.1.3.6. Tx
14.1.2. Bacteria
14.1.2.1. Chancroid / Haemophilus ducreyi
14.1.2.1.1. Anal papules turn to pustules turn to ulcers
14.1.2.1.2. Sexually transmitted
14.1.2.1.3. Dx by Gr stain
14.1.2.1.4. Azithromycin 1 gm PO
14.1.2.1.5. Ceftriaxone 250mg IM single dose
14.1.2.1.6. Ciprofloxacin 500 mg BID 3 days
14.1.2.1.7. Emycin 500mg TID x 7 days
14.1.2.2. Chlamydia/LGV
14.1.2.2.1. Obligate intra-cellular
14.1.2.2.2. Serovars D-K non LGV Proctitis
14.1.2.2.3. Serovars L1-3 = LGV
14.1.2.2.4. Tx
14.1.2.3. Neisseria Gonnorhea
14.1.2.3.1. Gr (-) diplococcus
14.1.2.3.2. Culture in Thayer Martin
14.1.2.3.3. Tx
14.1.2.4. Syphilis
14.1.2.4.1. Treponema pallidum (spirochete)
14.1.2.4.2. Primary = chancres, painful ulcer w/o educate
14.1.2.4.3. Secondary stage = fever, malaise, arthralgias, maculopapular rash on palms of hands and soles of feet
14.1.2.4.4. Darkfield exam or Warthin- starry silver stain
14.1.2.4.5. F/u VDRL (positive in 75%) or RPR testing
14.1.2.4.6. FTA-ABS turns positive at 4-6 weeks for life
14.1.2.5. Granuloma inguinal ( Donovanosis)
14.1.2.5.1. Calymmatobacterium granulomatis
14.1.2.5.2. Common in Africa, So. Amer., Australia
14.1.2.5.3. Ulcerogranulomatous form
14.1.2.5.4. Late can cause anal stenosis
14.1.2.5.5. Dx tissue smear for Donovan bodies
14.1.2.5.6. Tx
14.2. Colitides
14.2.1. Bacteria
14.2.1.1. C Diff
14.2.1.1.1. Most common cause of colitis in hosp'd patients
14.2.1.1.2. Risk Factors
14.2.1.1.3. Dx
14.2.1.1.4. Immunosuppressive risk
14.2.1.1.5. Tx
14.2.1.1.6. Gr (+) Bacillus
14.2.1.1.7. CARSEP : Alcohol-based foam hand soaps do not prevent C. Diff
14.2.1.2. E.Coli
14.2.1.2.1. Gr (-) Bacillus
14.2.1.2.2. Serotypes
14.2.1.2.3. Tx
14.2.1.3. Shigella
14.2.1.3.1. Gr (-) bacillus
14.2.1.3.2. Shiga toxin
14.2.1.3.3. 10 organisms can cause infection
14.2.1.3.4. 1-3 days incubation
14.2.1.3.5. Crampy abdominal pain and voluminous diarrhea
14.2.1.3.6. High fever
14.2.1.3.7. Invades enterocytes and colonocytes
14.2.1.3.8. Dx stool culture
14.2.1.3.9. Tx
14.2.1.4. Salmonella
14.2.1.4.1. Gr (-) bacillus
14.2.1.4.2. Second leading cause of foodborne illness
14.2.1.4.3. Invade enterocyte and coloncyte
14.2.1.4.4. diarrhea to bloody diarrhea
14.2.1.4.5. Abdominal pain
14.2.1.4.6. Fever
14.2.1.4.7. Dx stool culture
14.2.1.4.8. Tx
14.2.1.5. Campylobacter
14.2.1.5.1. Gr (-) bacillus
14.2.1.5.2. Undercooked poultry
14.2.1.5.3. Most frequent acute diarrhea in western world
14.2.1.5.4. Incubaton 48-72 hours
14.2.1.5.5. Abdominal pain and diarrhea
14.2.1.5.6. Fevers. rigors, and arthralgic aches
14.2.1.5.7. Dx on selected medium so must specifically ask lab for culture for Campy
14.2.1.5.8. Tx - self limited for 3-5 days
14.2.1.6. Yersinia
14.2.1.6.1. Gr (-) coccobacillus
14.2.1.6.2. Contaminated food and water
14.2.1.6.3. Incubation 7 days
14.2.1.6.4. Mimics appendicitis
14.2.1.6.5. Abd pain, diarrhea, fever, N/V
14.2.1.6.6. Dx - stool cultures
14.2.1.6.7. Tx
14.2.1.7. Spirochetosis
14.2.1.7.1. See sexually transmitted diseases
14.2.1.8. SAQ : Abdominal T.B.
14.2.1.8.1. Ileocecal 85-90%
14.2.1.8.2. No anastomosis risk
14.2.1.8.3. Active pulmonary infection in 25% (less than 50% in some series)
14.2.1.8.4. Stool culture positive in 30%
14.2.1.8.5. Skin testing unreliable
14.2.1.8.6. Great mimic for cancer or appendicitis
14.2.1.8.7. Tx with triples
14.2.1.8.8. 6th most common cause of extra-pulmonary TB (lymphatic, genitourinary, bone/joint, miliary, and meningeal)
14.2.1.8.9. Not confined to lower socio-economic groups
14.2.1.8.10. * CT is most sensitive test (better than PPD, CXR, Sputum, Ascitic fluid and Pleural Fluid)
14.2.1.8.11. Ascitis sample = 1 liter; spun for acid fast bacillus
14.2.1.8.12. Diagnostic mini-lap for peritoneal Bx
14.2.2. Viral
14.2.2.1. CMV
14.2.2.1.1. Infectious Mono type syndrome
14.2.2.1.2. Seropositive in most homosexual men
14.2.2.1.3. HIV 10% ileocolitis with diarrhea
14.2.2.1.4. Tx
14.2.3. Parasites
14.2.3.1. Amebiasis
14.2.3.1.1. Entamoeba Histolytica
14.2.3.2. CARSEP : Chagas disease
14.2.3.2.1. Trypanosoma cruzi
14.2.3.2.2. Transmission
14.2.3.3. Cryptosporidia
14.2.3.3.1. protozoan
14.2.3.3.2. Contaminated water
14.2.3.3.3. More lethal in children and immunocompromised
14.2.3.3.4. Bloody diarrhea
14.2.3.3.5. Dx with endoscopic Bx for Crypto oocysts
14.2.3.3.6. Tx with supportive glucose linked electrolyte reabsoprtion
14.2.3.3.7. Tx immunocompromised with parmomycin
14.2.3.4. LGV
14.2.3.4.1. Chlamydia Trachomatis Sero types L1-3
14.2.3.5. CARSEP : Enterobius vermicularis (pinworm)
14.2.3.5.1. Mebendazole
14.2.4. Fungi
14.2.4.1. Histoplasmosis
14.2.4.1.1. In soil and bird/bat feces
14.2.4.1.2. Typically affects lungs
14.2.4.1.3. Immunocompromised may have GI involvement at Peyer's patches and TI
14.2.4.1.4. Tx Ampo B, fluconazole, ketoconazole
14.3. Hepatitis
14.3.1. Occult in 70-75% of patients
14.3.2. Hep C has 60-80% Chronic
14.3.3. Hep C 10 X > Hep B
14.3.4. Hep B vaccine
14.3.5. No Hep C vaccine or effective immunoglobulin
14.4. Fournier's Gangrene
14.4.1. Controversial = role of fecal diversion
14.4.2. In debridement that leads to "floating anus" Seton may be helpful
14.4.3. CARSEP unclear on how to handle testes. Skin graft early or treat with wet-dry with delayed flap closure
15. IBD
15.1. Crohn's
15.1.1. Medication options
15.1.1.1. Induce remission
15.1.1.1.1. Sulfasalazine ( more for colitis)
15.1.1.1.2. Other 5ASA DRUGS
15.1.1.1.3. Steroids
15.1.1.2. Maintenance
15.1.1.2.1. Azathioprine or 6 MP
15.1.1.2.2. Methotrexate
15.1.1.3. Fistulous disease
15.1.1.3.1. Infliximab
15.1.1.3.2. Metronidazole
15.1.1.3.3. Ciprofloxacillin
15.1.1.4. Postop prevention/suppression
15.1.1.4.1. 3 mos. Metronidazole
15.1.2. Vienna or Montreal classification
15.1.2.1. Fistulizing
15.1.2.2. Fibrosis/stenosis
15.1.2.2.1. Genetic testing
15.1.2.3. Acute inflammation
15.1.3. Scenarios
15.1.3.1. Ileocolic fibrosing/stenosing
15.1.3.2. Multiple stenoses & strictures
15.1.3.2.1. Stricturoplasty
15.1.3.3. Segmental colon sparing
15.1.3.4. Rectal sparing
15.1.3.5. Duodenal stenosing
15.1.3.5.1. Stricturoplasty or Bypass are acceptable
15.1.3.6. Anal fistulae
15.1.3.6.1. I&D & Setons
15.1.3.7. RVF
15.1.3.7.1. See RVF above
15.1.3.8. Crohn's ileo-sigmoid fistula
15.1.3.8.1. Resect primary and repair secondary
15.1.3.8.2. CARSEP : Exception --> phlegmonous reaction in region of recto-sigmoid. Instead perform two segmental resections.
15.1.3.9. Refractory rectal Crohn's
15.1.3.9.1. CARSEP : End colostomy and mucous fistula
15.1.3.9.2. Proctectomy reserved:
15.1.3.10. Duodenal colic fistula
15.1.3.10.1. CARSEP : Dx with BE ( Not SBFT)
15.1.3.11. Peristomal Pyoderma
15.1.3.11.1. CARSEP : Bx leading edge
15.1.3.11.2. Diff Dx
15.1.3.11.3. Steroids (oral & topical)
15.1.4. Microscopic
15.1.4.1. Isolated crypt abscesses
15.1.4.2. Non caseating granulomas
15.1.4.3. Neuromatous hyperplasia & increased ganglion cells
15.1.4.4. Longitudinal & transverse ulcers
15.1.4.5. Lymphoid hyperplasia
15.1.5. Predict postop recurrence
15.1.5.1. (+)
15.1.5.1.1. SAQ : Presence of granulomas
15.1.5.2. (-)
15.1.5.2.1. Age
15.1.5.2.2. Gender
15.1.5.2.3. Duration disease
15.1.5.2.4. Length of resection
15.1.5.2.5. Blood transfusion
15.1.6. Anatomic
15.1.6.1. Oral
15.1.6.2. Esophageal
15.1.6.3. Ileal
15.1.6.4. Ileocolic
15.1.6.4.1. Rarely mimics appendicitis
15.1.6.4.2. Most common distribution
15.1.6.4.3. 90% may require resection
15.1.6.4.4. Higher recurrence rate than straight ileal Crohn's
15.1.6.5. Colic
15.1.6.6. Anal
15.1.6.7. Gastric
15.1.6.8. Duodenal
15.2. CUC
15.2.1. CARSEP : DALM
15.2.1.1. Proctocolectomy
15.2.1.2. 1st remove lesion and bx 4X in surrounding colon and check path results:
15.2.1.2.1. No dysplasia then repeat scope in 6 months
15.2.1.2.2. If dysplasia then Proctocolectomy
15.2.2. Med Tx acutely
15.2.2.1. Hydrocortisone 300 mg(d)
15.2.2.2. If no improvement add cyclosporine@ 7 days
15.2.3. Indeterminant colitis
15.2.3.1. TAC with Ileorectal
15.2.3.1.1. Contra-indications
15.2.3.1.2. Surveillance
15.2.4. CARSEP: Surveillance
15.2.4.1. L-sided
15.2.4.1.1. 12-15 yrs post onset
15.2.4.2. Pan-colonic
15.2.4.2.1. 8-10 yrs post onset
15.2.5. Proctitis
15.2.5.1. Tx
15.2.5.1.1. 1st line Rowasa enemas
15.2.5.1.2. 2nd line Cortenemas
15.2.5.1.3. 3rd line oral steroids
15.2.6. Pouchitis
15.2.6.1. 44% @ 10 yrs.
15.2.6.2. CARSEP : High preop pANCA (> 100) may be predictive of pouchitis 56%; medium and low levels had 22% & 16% respectively.
15.2.6.3. Lower Incidence in tobacco user
15.2.6.4. Tx
15.2.6.4.1. 1st Line Cipro / Flagyl
15.2.6.4.2. oral Budesonide
15.2.6.4.3. once stable : ? Probiotics
15.2.7. Microscopic
15.2.7.1. Depletion of goblet cells
15.2.7.2. Crypt shortening
15.2.8. Dysplasia
15.2.8.1. Low grade
15.2.8.2. High grade
15.3. Serum markers and genetic testing
15.3.1. Serum markers
15.3.1.1. ASCA (50-80% Crohn's)
15.3.1.2. pANCA (40-80% CUC)
15.3.1.2.1. (+) pANCA correlates with post IPAA high risk of chronic pouchitis
15.3.2. Genetic testing
15.3.2.1. IBD 5 (Chromosome 5)
15.3.2.1.1. Transport proteins
15.3.2.2. IBD 1(Chromosome 16)
15.3.2.2.1. CARD 15/NOD2
15.4. Extra intestinal manifestations
15.4.1. Temporary / related to disease activity
15.4.1.1. Erythema nodosum
15.4.1.2. Oral aphthous ulcers
15.4.1.3. Episcleritis
15.4.1.4. Peripheral arthritis
15.4.2. Not temporarily related (PUPS)
15.4.2.1. Pyoderma gangrenosa
15.4.2.2. Uveitis
15.4.2.3. Primary sclerosing cholangitis
15.4.2.4. Spondyloarthropy
16. Cancer
16.1. Colon
16.1.1. Evolution of Chemo Stage II & III
16.1.1.1. NSABP 1998
16.1.1.1.1. Duke's B and C
16.1.1.1.2. 5FU, Vincristine, Semustine (MOF regimen)
16.1.1.1.3. 3 Arms
16.1.1.1.4. DFS and OS favored Postop Chemo
16.1.1.2. NCCTG
16.1.1.2.1. 5FU + Levamisole (Later Leucovorin)
16.1.1.2.2. Advantage in only Node (+)
16.1.1.3. QUASAR
16.1.1.3.1. Complex study with 5FU, high dose and ultimately low dose folinic acid; Levamisole shifting to Leucovorin...
16.1.1.3.2. Large recruitment, good followup
16.1.1.3.3. Very small benefit for Stage II disease
16.1.1.4. FOLFOX
16.1.1.4.1. Stage III
16.1.1.4.2. 5FU + Leucovorin + Oxaliplatin
16.1.1.4.3. 12 months shrunk to 6 months
16.1.1.5. Other Studies failed to show benefit in Stage II
16.1.1.5.1. Shippinger
16.1.1.5.2. Moertel
16.1.1.5.3. International Multicentre Pooled Analysis of Colon Cancer Trials (IMPACT)
16.1.1.6. Meta-analysis
16.1.1.6.1. Statistical Summary showed we need 4700 patients to show significance of 4% benefit for Stage II
16.1.1.6.2. NSABP - Mamounas
16.1.1.6.3. Intergroup Study (Gill)
16.1.1.6.4. Figuredo and Canada Cancer Care Ontario Program (37 trials and 11 meta-analyses)
16.1.1.7. Molecular Markers for Stage II
16.1.1.7.1. Guanylyl Cyclase C (GCC)
16.1.1.7.2. Interleukin 1
16.1.2. High Risk Stage II Disease
16.1.2.1. 5 Yr Survival Results using three factors for scoring
16.1.2.1.1. Zero of 3
16.1.2.1.2. 1 of 3
16.1.2.1.3. 2 or 3
16.1.2.2. Three factors to consider
16.1.2.2.1. CEA > 5
16.1.2.2.2. t Stage T4
16.1.2.2.3. Perineuro or lymphatic invasion
16.1.2.3. Alternative s to identify high risk
16.1.3. Nodal Sampling
16.1.3.1. Increased survival with nodal sampling #
16.1.3.2. 12-17 nodes optimally
16.2. Rectal
16.2.1. Staging
16.2.2. Neoadjuvant
16.2.2.1. Mayo / NCCTG (Two Arms)
16.2.2.1.1. Postop XRT
16.2.2.1.2. Chemo XRT
16.2.2.2. Swedish Rectal Cancer Study (Two Arms)
16.2.2.2.1. Surgery
16.2.2.2.2. Preop XRT + Surgery
16.2.2.3. NSABP R-03 ( closed early due to poor accrual) (Two Arms)
16.2.2.3.1. Preop Chemo XRT + Postop 5FU
16.2.2.3.2. Surgery + Postop 5FU + XRT
16.2.2.3.3. Local failure was equal in 2 arms @ 10.7%
16.2.2.3.4. Preop benefits
16.2.2.4. German Rectal Cancer Study Group (Two Arms)
16.2.2.4.1. Preop Chemo XRT
16.2.2.4.2. Postop Chemo XRT
16.2.2.4.3. DFS ( Preop 68% to Postop 65% ) & OS ( Preop 76% to Postop 74%) equal in 2 groups
16.2.2.4.4. Other study aspects
16.2.2.4.5. Conclusion: TME & Preop 5FU chemo XRT
16.2.2.5. EORTC (Two Arms)
16.2.2.5.1. Preop XRT
16.2.2.6. Polish Colorectal Cancer Group (Stages T III / T IV)
16.2.2.6.1. Preop Short Course
16.2.2.6.2. Traditional ChemoXRT
16.2.2.6.3. No differences in DFS, OS, sphincter preservation
16.2.2.7. MRC CR07 & NCIC-CTG CO 16 demonstrates importance of CIRMCUMFERENTIAL RESECTION POSITIVE MARGINS (CRM+ive)
16.2.2.7.1. Radiotherapy cannot rescue positive margin
16.2.2.8. Mercury Study Group MRI
16.2.2.8.1. Predictive value of CRM for TME
16.2.2.9. Impact of Tumor regression from Preop XRT
16.2.2.9.1. Complete pathologic response = pCR
16.2.2.9.2. DFS & OS improves if tumor downstages
16.2.2.9.3. Tumor Regression Grades
16.2.2.10. GTSG (Four Arms)
16.2.2.10.1. No Postop Tx
16.2.2.10.2. Postop XRT (40-48 By)
16.2.2.10.3. Postop chemo 5FU + Semustine
16.2.2.10.4. XRT + Chemo
16.2.3. TME
16.2.3.1. Dutch Rectal Cancer Study group
16.2.3.1.1. TME
16.2.3.1.2. TME + Short course XRT
16.2.4. LAR
16.2.5. APR
16.2.6. Imaging
16.2.6.1. PET CT
16.2.6.2. MRI
16.2.6.3. CARSEP : Endo-ultrasound staging
16.2.6.3.1. T Stage
16.2.6.3.2. N Stage
16.2.6.4. CT
16.2.6.4.1. T Stage 46-75%
16.2.6.4.2. N Stage 56-72 %
16.2.7. Local excision
16.2.7.1. Features
16.2.7.1.1. Small
16.2.7.1.2. Distal
16.2.7.1.3. Mobile
16.2.7.1.4. Exophytic
16.2.7.1.5. Well/mod differentiated
16.2.7.1.6. Less than 1/3 circumference
16.2.7.2. Failure rates
16.2.7.2.1. T1-2
16.2.7.2.2. Role of adjuvant therapy ???
16.2.7.2.3. Adverse features
16.3. Anal canal
16.3.1. Neoadjuvant therapy
16.3.1.1. Nigro Protocol (Recommendation Level 1A)
16.3.1.1.1. Mitomycin C
16.3.1.1.2. 3000 cGray
16.3.1.1.3. 5FU
16.3.1.2. IMRT (Recommendation Level 2B)
16.3.2. Stage
16.3.2.1. T and N stage criteria
16.3.2.1.1. T
16.3.2.1.2. N
16.3.2.2. Stage I = T1
16.3.2.3. Stage II = T2/T3
16.3.2.4. Stage IIIa= T 1-3, N1
16.3.2.5. Stage IIIb = T 1-3, N2-N3
16.3.2.6. Stage IV = Any T, Any N, M1
16.3.3. Pre treatment Imaging
16.3.3.1. CT
16.3.3.1.1. Chest, Abdomen and Pelvis
16.3.3.1.2. ** Head (if Symptomatic)
16.3.3.2. MR
16.3.3.2.1. Comparable to EAUS
16.3.3.3. PET/CT
16.3.3.3.1. Not routine ???
16.3.3.4. EAUS
16.3.3.4.1. Comparable to MR
16.3.4. Measures of Success
16.3.4.1. Overall Survival Rates
16.3.4.2. Local Regional Survival Rates
16.3.4.3. Colostomy-free Survival Rates
16.3.5. Role of APR
16.3.5.1. Persistent (< 6 months from initial treatment) or Recurrent (> 6 months from initial treatment) Disease
16.3.6. Management of Lymph Node Mets
16.3.6.1. Chemo radiation
16.3.7. Treatment Considerations in HIV (+) Patients
16.3.7.1. CD4 > 200 = Nigro Protocol
16.3.7.2. CD4 < 200 = Individualize options
16.3.7.2.1. HAART
16.3.8. Post Treatment Surveillance
16.3.8.1. Q 3 months X 2 years
16.3.8.2. Biopsy if persistent lesions beyond 12 weeks
16.3.8.3. Imaging Surveillance
16.3.8.3.1. + EAUS
16.3.8.3.2. - MRI
16.3.8.3.3. + PET/CT
16.4. Anal margin
16.4.1. WLE
16.5. Hereditary
16.5.1. FAP & attenuated FAP (aFAP)
16.5.1.1. APC
16.5.1.2. Germline mutation
16.5.1.3. Dominant
16.5.1.4. Desmoids
16.5.1.4.1. 10-20% of FAP
16.5.1.4.2. Trial of sulindac or tamoxifen
16.5.1.4.3. Score > 7
16.5.1.4.4. Surgery only for severe symptoms
16.5.1.5. 2nd most common inherited cancer
16.5.1.6. Sulindac
16.5.1.6.1. Reduces polyps in rectum
16.5.1.6.2. No effect on duodenal or capillary adenomas
16.5.1.6.3. Oral or rectal
16.5.1.6.4. Reduces expressions of ras mutation and p53 proteins
16.5.2. HNPCC
16.5.2.1. Guidelines
16.5.2.1.1. Bethesda
16.5.2.1.2. Amsterdam II
16.5.2.1.3. Simplified 3-2-1 Rule
16.5.2.2. Dominant
16.5.2.3. Most common inherited cancer
16.5.2.4. CARSEP : HNPCC Cancer List
16.5.2.4.1. Endometrial
16.5.2.4.2. Ovarian
16.5.2.4.3. Gastric
16.5.2.4.4. Hepatobiliary
16.5.2.4.5. Sm. Bowel
16.5.2.4.6. Transitional cell of Ureters & Renal Pelvis
16.5.2.5. Screening
16.5.2.5.1. Begin at age 21 up to 40
16.5.2.5.2. Over 40 years
16.5.3. Myh associated polyposis (MAP)
16.5.3.1. Recessive inheritance
16.5.4. MSI/ RER
16.5.4.1. MSI
16.5.4.1.1. 90% of HNPCC
16.5.4.1.2. CARSEP : High MSI levels
16.5.4.2. hMLH1
16.5.4.2.1. Abnormal when protein identified
16.5.4.3. CARSEP : hMSH2
16.5.4.3.1. Normal = protein identified
16.5.4.3.2. Abnormal= no protein identified
16.5.5. LOH
16.5.5.1. CARSEP : APC
16.5.5.1.1. First step
16.5.5.2. CARSEP : p53
16.5.5.2.1. Polyps and cancers
16.5.5.2.2. CUC
16.5.5.3. CP Gisland methylation
16.5.5.3.1. Sporadic cancers
16.5.5.3.2. Infrequent in CUC
16.5.5.4. CARSEP: K ras
16.5.5.4.1. Linked to Cetuximab resistance
16.5.6. CARSEP : Peutz-Jeghers
16.5.6.1. Dominant
16.5.6.2. Hamartomas
16.5.6.3. Buccal pigmentation
16.5.6.4. Increased Ca risk
16.5.7. HNPCC assoc'd Syndromes
16.5.7.1. SAQ: Muir-Torre
16.5.7.1.1. Benign/ malignant skin lesions
16.5.7.2. SAQ: Turcot's
16.5.7.2.1. Glioblastoma
16.5.8. MMR-D = mismatch repair deficiency
16.5.8.1. Stage II survival best with Surgery alone
16.6. Screening and surveillance
16.7. Special Metastatic scenarios
16.7.1. Metastatic Disease
16.7.1.1. Primary CRC + Liver Mets
16.7.1.1.1. Up-front Combination Chemotherapy
16.7.1.1.2. Obstructing Primary
16.7.1.2. Hepatic Mets
16.7.1.2.1. 5 Yr Surv 27-58%
16.7.1.2.2. 5 Predictors of Poor outcomes (Fong et al)
16.7.1.2.3. Steatohepatitis caused by 5FU + Irinotecan
16.7.1.2.4. Converting the unresectable to resectable
16.7.1.3. Brain Mets
16.7.1.3.1. 1-2 % of all colorectal cancers
16.7.1.3.2. Most symptomatic
16.7.1.3.3. Rectal Ca > Colon Ca (due to venous drainage)
16.7.1.3.4. Aggressive treatment prolongs survival
16.7.1.4. Ovarian Mets
16.7.1.4.1. Incidence 1-7%
16.7.1.4.2. Not really a Krukenberg tumor
16.7.1.4.3. More common in pre-menopausal woman
16.7.1.4.4. Probably hematogenous spread
16.7.2. Pelvic recurrence limitations
16.7.2.1. Extensive and/ thoracic Dx
16.7.2.2. Involves pelvic side walls
16.7.2.3. Encased Iliac vessels
16.7.2.4. Extends into sacral notch
16.7.2.5. Sacral invasion above S2-3
16.7.3. Metachronous Predictor (CARSEP)
16.7.3.1. Common in HNPCC
16.7.3.2. Less common in Sporadic CRC
16.7.3.3. Presence of synchronous neoplasia (CRC or adenoma) Increases risk
16.7.3.4. Index Cancer
16.7.3.4.1. (+) predictor
16.7.3.4.2. (-) predictor
16.7.3.5. CARSEP : Less than the risk of a recurrent CRC
16.8. Chemotherapy Factoids
16.8.1. Immunotherapy
16.8.1.1. Cetuximab
16.8.1.1.1. EGFR
16.8.1.1.2. CARSEP : K-Ras predicts resistance to anti EGFR Tx
16.8.1.2. Erbitux (Avastin)
16.8.1.2.1. VEGF
16.8.2. FOLFOX
16.8.2.1. 5FU
16.8.2.2. Leucovorin
16.8.2.3. Oxaliplatin
16.8.3. Capecitabine (xeloda)
16.8.3.1. Single Agent for Stage III Adjuvant Therapy
16.8.3.2. Reasonably well tolerated in older patients
16.8.3.3. Equivalent to 5 FU + Leucovorin for 6 mos.
16.8.3.4. Useful in Diabetics with peripheral neuropathy since Oxaliplatin has high incidence of peripheral neuropathy
16.8.4. Irinotecan
16.9. T Stage risk of lymph node mets
16.9.1. T1
16.9.1.1. 12%
16.9.1.2. Depth of submucosal invasion
16.9.1.2.1. sm1 upper 1/3
16.9.1.2.2. sm2 middle 1/3
16.9.1.2.3. sm3 lower 1/3
16.9.2. T2
16.9.2.1. 22%
16.9.3. T3
16.9.3.1. 50%
16.10. CARSEP : Special
16.10.1. Melanoma
16.10.2. Pre sacral / retro rectal
16.10.2.1. Chordoma
16.10.2.1.1. Males>females
16.10.2.1.2. 9% 10 yr surv
16.10.2.1.3. High local recurrence
16.10.2.1.4. Bony invasion
16.10.2.2. Sacral teratoma
16.10.2.2.1. Females>males
16.10.2.2.2. Encapsulated
16.10.2.3. Duplication cysts
16.10.2.4. Anterior Meningoceles
16.10.2.4.1. Scimitar Radiologic Sign
16.10.3. Paget's disease
16.10.3.1. Intraepithelial adeno ca
16.10.3.2. Synchronous GI Cancers
16.10.3.3. WLE
16.10.4. Bowen's disease
16.10.4.1. Intraepithelial SCC
16.10.4.2. T and N stage criteria
16.10.4.2.1. T
16.10.4.2.2. N
16.10.4.3. Nomenclature: AIN; HSIL(AIN II & III) / LSIL(AIN I); or HGAIN (AIN III) / LGAIN (AIN I & II)
16.10.4.3.1. Low grade Squamous Intra-epithelial lesions (LSIL) = AIN I
16.10.4.3.2. High Grade Squamous intra-epithelial lesions (HSIL) = AIN II and III
16.10.4.3.3. Screening Procedures for LGAIN / HGAIN
16.10.4.3.4. Treatment
16.10.4.4. HPV 16 and 18
16.10.4.5. HIV (+)
16.10.4.5.1. 50% of LGAIN progress to HGAIN
16.10.5. Buschke- Lowenstein tumor
16.10.5.1. Verrucous Carcinoma of anus
16.10.5.2. Locally aggressive/destructive
16.10.5.3. WLE
16.10.6. GIST
16.10.6.1. Interstitial cells of Cajal
16.10.6.2. GI pacemaker cells
16.10.6.3. C-Kit (CD117)
16.10.6.3.1. In 98%
16.10.6.4. Hematogenous ( not nodal)
16.10.6.5. Mitosis / HPF
16.10.6.6. Imatinib (Gleevec) for adjuvant or palliation
16.10.6.6.1. 15% resistance
16.10.6.7. Anatomic Sites
16.10.6.7.1. #1 Stomach
16.10.6.7.2. #2 Small Bowel
16.10.6.7.3. #3 Rectum
16.10.6.7.4. Less likely in colon
16.10.7. Carcinoid
16.10.7.1. Forgut
16.10.7.2. Midgut
16.10.7.3. Hindgut
16.10.7.4. Serotonin & 5HIAA
16.10.8. Appendix
16.10.8.1. Adeno Ca
16.10.8.2. Carcinoid
16.10.8.2.1. < 1 cm
16.10.8.2.2. 1-1.9 cm
16.10.8.2.3. > 2 cm
16.10.8.3. Appendices mucocele
16.10.8.3.1. Pseudomyxoma peritonei
16.10.9. Ca risk in Ureterosigmoidoscopy (SAQ in 2005)
16.10.9.1. Incidence is 2-15%
16.10.9.2. Interval of 20-26 years after anastomosis to cancer
16.10.9.3. Pathophysfrom urinary nitrates, endogenous amines and bacteria to produce toxic nitrosoamines
16.10.9.4. Presents with pain and infections secondary to obstruction at implanted ureter (Not hematuria or bleeding)
16.10.9.5. Periodic surveillance with C-scope since urine refluxes thru out entire colon
17. Non IBD, Non infectious Colitides
17.1. CARSEP : Neutropenic colitis
17.1.1. Nonsurgical Tx
17.1.1.1. GSF + Antibiotics + inotropes + fluids
17.1.2. R colectomy
17.1.3. CT Ominous Signs
17.1.3.1. Free Air
17.1.3.2. Pneumatosis coli
17.1.3.3. Soft Tissue Air
17.2. CARSEP : Microscopic/ lymphocytic/ collagenous colitis
17.2.1. 1st line : diet & antidiarrheals
17.2.2. 2nd line: Mesalamine, Sulfasalazine, or cholestyramine
17.2.3. 3rd line: corticosteroids and if successful:
17.2.3.1. Azathioprine / 6 MP
17.2.4. Watery diarrhea
17.2.5. Endoscopy may appear normal but Bx show non-ulcerative colitis
17.3. Eosinophilic Colitis
17.3.1. Endoscopic findings may look normal or like Crohn's - Biopsy needed
17.3.2. Tx Diarrheal symptoms
17.3.3. Severe cases may need steroids, immunosppuressive or chromoglycate
17.4. Disuse Colitis
17.4.1. See LGI Bleed
17.5. SAQ : Behcet's
17.5.1. Multi system vasculitis
17.5.2. Intestinal perforations
18. GI Bleeds
18.1. Massive LGI Bleed
18.1.1. Diverticulosis
18.1.2. Vascular ecstasias
18.1.3. Ischemic colitis
18.1.4. IBD
18.1.5. Dx & Tx
18.1.5.1. Technetium labeled RBC scan
18.1.5.2. Colonoscopy
18.1.5.3. Selective mesenteric angiogram
18.2. CARSEP : Dieulafoy's lesion of rectum
18.2.1. Visible vessel >>> oversew or ligate
18.3. Radiation enteritis
18.3.1. SAQ : Formaldehyde 4% for 30 sec to 3 min
18.4. Disuse colitis
18.4.1. Tx with short chain fatty acid enemas
18.5. CARSEP : Endometriosis
18.5.1. Disc excision with transverse closure
18.5.2. Segmental resection
18.5.2.1. Circumferential lesion
18.5.2.2. Obstruction
18.5.2.3. Lesion > 3 cm
18.5.2.4. Inability to exclude malignancy
18.6. Rectal varices
18.6.1. Tx underlying portal HTN
18.7. SRUS
18.7.1. CARSEP Q - Asymptomatic = Tx with fiber
18.8. Technetium versus sulfur colloid
18.8.1. Tc RBC
18.8.1.1. 24-48 Hr allows for rescanning
18.8.1.2. detects 0.5 cc/min
18.8.2. Sulfur Colloid
18.8.2.1. Immediate, no rescanning
18.8.2.2. detects 0.1 cc/min
19. Diverticulitis
19.1. Hinchey classification of peritonitis
19.1.1. Hinchey I: paracolonic abscess
19.1.2. Hinchey II: pelvic abscess
19.1.3. Hinchey III purulent peritonitis
19.1.4. Hinchey IV: feculent peritonitis
19.2. When to operate?
19.2.1. CT documented severity
19.2.2. Age?
19.2.2.1. 7th & 8th decades
19.2.2.2. 5-10% less than 50 years old
19.2.3. When Complications develop?
19.3. Giant Diverticulum
19.3.1. Rare
19.3.2. Sx: Pain in 70% ; 10% Asx
19.3.3. Most common presentation - Sign: Abdominal Mass
19.3.4. 70% demonstrate communication to colon
19.4. Attacks and recurrences
19.4.1. 1st attack has 33% recurrence
19.4.2. 2nd attack has 50% recurrence
19.5. SAQ - in the case of surgery, a primary resection is preferred rather than diversion. Resection is almost always possible.
19.6. Role of delayed resection with initial washout laparoscopically ??
19.7. SAQ : Right sided Diverticultitis - Rare
19.7.1. May look like CRC or acute Appy
20. Functional bowel disorders
20.1. IBS
20.1.1. Constipation
20.1.1.1. Tx with lubiprostone ( Cl channel activator)
20.1.1.2. Tx with tegaserod
20.1.2. Diarrhea
20.1.2.1. CARSEP : Tx with Alosetron (assoc'd with ischemic colitis)
20.2. Slow transit constipation/ colonic inertia
20.3. Obstructive defecation
20.3.1. Dx
20.3.1.1. CARSEP : Anal manometry & defecography
20.3.2. STARR (Stapled Transanal Rectal Resection)
20.4. Ogilvie's
20.4.1. Autonomic imbalance: sympathetic>parasympathetics
20.4.2. Colonoscopic decompression
20.4.3. CARSEP: 1st line of Tx Neostigmine
20.4.4. Epidural sympathetic block
20.5. Chagas
21. Colonic volvulus
21.1. Sigmoid
21.2. Cecal
21.3. SAQ = Nonoperative reduction is typically successful
21.3.1. High recurrence rates
21.3.2. For megacolon patients - post successful reduction --> consider a subtotal colectomy
22. Pilonidal sinus
22.1. Acute
22.2. Chronic
22.2.1. Surgery
22.2.1.1. Open wound
22.2.1.2. Closed - Off Midline - Flaps
22.2.1.2.1. Bascom
22.2.1.2.2. Excision and Z-plasty
22.2.1.2.3. Karydakis procedure
22.2.2. Phenol injection forms eschar in track
23. Embryology
23.1. Hirschsprung's
23.1.1. Failure migration of neural crest
23.1.2. Absence of ganglion cells
23.1.3. Thick non-myelinated nerves
23.1.4. Pre/post ganglionic fibers w/o synapses
23.1.5. CARSEP: Prominent adrenergic and cholinergic fibers
23.1.6. SAQ = Increase staining for Ach
23.1.7. Absence of RAIR
23.2. VACTERL Anomalies
23.2.1. Vertebral
23.2.2. Anal atresia
23.2.3. Cardiac
23.2.4. Trach-esophageal
23.2.5. CARSEP : Renal
23.2.6. Limbs
24. Trauma
24.1. Colon
24.1.1. Primary repair except:
24.1.1.1. Severe contamination
24.1.1.2. 6 hr surgical delay
24.1.1.3. > 6 unit transfusion
24.2. Rectum
24.3. Anus/sphincter
25. Miscellaneous
25.1. Colonic J Pouch
25.1.1. Shorter pouches evacuate better than long pouches
25.1.2. SAQ: Vol 50, No. 8 reports lower leak rate in J pouches than straight coloanals.
25.2. Portal Vein Thrombosis
25.2.1. Assoc'd with IBD patients
25.2.2. Sx and Signs
25.2.2.1. Abd pain
25.2.2.2. Fever
25.2.2.3. Leukocytosis
25.2.2.4. Delayed bowel function
25.2.3. CARSEP : Tx with Heparin