Colorectal and Small Bowel Diseases

Colorectal and Small Bowel Diseases

High Yield Topics for the ABSITE 2022Thomas Ward, MD

Massachusetts General Hospital

December 7, 2021

Disclosures

Research support from the Olympus Corporation

Question 1A 58-year-old-woman undergoes flexible sigmoidoscopy for hematochezia, which reveals a 4 cm sigmoid mass at 40 cm, biopsy positive for adenocarcinoma. Other than occasional hematochezia, she is asymptomatic and wants to pursue surgical resection. What should her ensuing pre-operative work-up include?

A. Nothing, straight to surgery

B. CBC, chemistries, CEA, CA19-9, PET/CT chest/abdomen/pelvis, colonoscopy

C. CBC, chemistries, CEA, CA19-9, CT chest/abdomen/pelvis

D. CBC, chemistries, CEA, CT chest/abdomen/pelvis, colonoscopy

E. CBC, chemistries, CEA, Brain MRI, CT chest/abdomen/pelvis

Question 1 – Colon Cancer Pre-op WorkupA 58-year-old-woman undergoes flexible sigmoidoscopy for hematochezia, which reveals a 4 cm sigmoid mass at 40 cm, biopsy positive for adenocarcinoma. Other than occasional hematochezia, she is asymptomatic and wants to pursue surgical resection. What should her ensuing pre-operative work-up include?

A. Nothing, straight to surgery

B. CBC, chemistries, CEA, CA19-9, PET/CT chest/abdomen/pelvis, colonoscopy

C. CBC, chemistries, CEA, CA19-9, CT chest/abdomen/pelvis

D. CBC, chemistries, CEA, CT chest/abdomen/pelvis, colonoscopy

E. CBC, chemistries, CEA, Brain MRI, CT chest/abdomen/pelvis

Question 1 – Colon Cancer Pre-op WorkupPre-op you want to determine:

1. Tumor “baseline”

2. Medically operable

3. Resectable

4. Extent of resection



CBC, Chemistries, CEA

CA19-9 is not indicated



Patient’s fitness (cardiovascular, pulmonary, nutrition)


3. Resectable

? Liver or peritoneal disease -> CT abdomen/pelvis with IV contrast

? Pulmonary metastases -> CT Chest (with or without IV contrast)

PET CT is not indicated



Location of the primary tumor

?Presence of synchronous colorectal cancer -> Completion Colonoscopy

Question 2A 58-year-old-woman undergoes colonoscopy for hematochezia, which reveals a 4 cm mid rectal mass at 7 cm, biopsy positive for adenocarcinoma. Other than occasional hematochezia, she is asymptomatic and wants to pursue surgical resection. CBC, chemistries, CEA unremarkable. CT chest/abd/pelv shows no metastatic disease. What is the next best step in her care?

A. Low anterior resection

B. Chemoradiotherapy followed by Low anterior resection

C. Endorectal ultrasound

D. Transanal local excision

E. Pelvic MRI

Question 2 – Rectal Cancer Pre-op WorkupPre-op you want to determine:



3. Resectable


5. Need for neoadjuvant therapy

Same as colon cancer

Question 2 – Rectal Cancer Pre-op WorkupNeed for neoadjuvant therapy before surgery:

T3 (through the muscularis propria) or T4 (invades visceral peritoneum or adjacent organ/structure) disease

N1-2 disease (At least 1 lymph node suspicious)

Question 2 – Rectal Cancer Pre-op WorkupNeed for neoadjuvant therapy before surgery:

How to determine T and N without final pathology?

Pelvis MRI (no contrast required)

Endorectal ultrasound (inferior to MRI, use if MRI contra-indicated)

Question 3A 58-year-old-woman undergoes colonoscopy for hematochezia, which reveals a 2 cm mid rectal mass at 5 cm, biopsy positive for adenocarcinoma, no evidence of LVI nor PNI. Other than occasional hematochezia, she is asymptomatic and wants to pursue surgical resection. CBC, chemistries, CEA unremarkable. CT chest/abd/pelv shows no metastatic disease. MRI shows cT1N0 tumor. What is the next best step in her care?

A. Low anterior resectionB. Chemoradiotherapy followed by Low anterior resectionC. Endorectal ultrasoundD. Transanal local excisionE. Abdominoperineal resection

Question 3 – Rectal CancerTransanal local resection

Need all the below to be true about the lesion:

1. T1

2. N0

3. Favorable biopsy: no lymphovascular invasion (LVI), perineural invasion (PNI), well-to-moderately differentiated

4. Favorable for complete resection: < 30% of bowel lumen, < 3 cm

Question 4A 78-year-old-woman, history of 8 childbirths and occasional fecal incontinence undergoes colonoscopy for hematochezia, which reveals a 1.8 cm mid rectal mass at 2 cm, biopsy positive for adenocarcinoma, no evidence of LVI nor PNI. Other than occasional hematochezia, she is asymptomatic and wants to pursue surgical resection. CBC, chemistries, CEA unremarkable. CT chest/abd/pelv shows no metastatic disease. MRI shows cT3N1 tumor. She undergoes neoadjuvant therapy, with tumor and nodes still noted on repeat flexible sigmoidoscopy and MRI. What is the next best step in her care?

A. Low anterior resectionB. Systemic chemotherapyC. Close clinical surveillance with repeat pelvic MRI and sigmoidoscopyD. Transanal local excisionE. Abdominoperineal resection

Question 4 – APR versus LARNeed to determine pre-operatively:

1. Extent of needed resection with respect to sphincters

2. Pre-operative continence

3. Patient preference


1. Extent of needed resection with respect to sphincters

APR needed if:

1. tumor involves the anal sphincter or levator muscles

OR

2. Distal margin required would lead loss of anal sphincter and incontinence


2. Pre-operative continence

Ask about:

Previous vaginal childbirths

Baseline gas and stool continence

Question 5A 78-year-old-man, presents with diarrhea and symptomatic anemia. CT of the abdomen and pelvis reveals a large distal transverse colon mass with evidence of peritoneal lesion and a small bowel-to-tumor fistula. Colonoscopy is positive for adenoCA, and the tumor junction was unable to be traversed with the regular colonoscope. What is the next best step in this patient’s care?

A. Diverting transverse colostomy

B. Extended right colectomy

C. Extended left colectomy

D. Systemic chemotherapy

E. Chemoradiotherapy

Question 5 – Indications for operation in unresectable/locally advanced

1. Obstruction or imminent obstruction risk

2. Significant bleeding

3. Perforation

Question 5 –Operation in obstructionAny of the below:

1. Diversion with plan for later resection

2. Resection with adequate lymphadenectomy (>=12 nodes)

3. Stent (select cases of distal lesions amenable to stenting) with plan for later resection

4. Intestinal bypass

Question 6A 45-year-old-man is taken to the OR and undergoes an appendectomy. Gross pathology reveals the following which is noted at the mid-section of the appendix and measures 2.3 cm in greatest diameter. What is the next best step?

A. Referral for port placement and chemotherapy

B. Follow-up in 6 months with CT Chest/abd/pelv

C. CT abdomen and pelvis

D. Right hemicolectomy

E. No further follow-up needed

Question 6A 45-year-old-man is taken to the OR and undergoes an appendectomy. Gross pathology reveals the following which is noted at the mid-section of the appendix and measures 2.3 cm in greatest diameter. What is the next best step?

A. Referral for port placement and chemotherapy

B. Follow-up in 6 months with CT Chest/abd/pelv

C. CT abdomen and pelvis

D. Right hemicolectomy

E. No further follow-up needed

https://upload.wikimedia.org/wikipedia/commons/b/b9/Appendiceal_carcinoid_2.JPGCC BY-SA 3.0

https://upload.wikimedia.org/wikipedia/commons/b/b9/Appendiceal_carcinoid_2.JPG

Question 6 – Appendiceal Carcinoid

Appearance, mass that is:

1. Firm

2. Yellow

3. Bulbar

https://upload.wikimedia.org/wikipedia/commons/b/b9/Appendiceal_carcinoid_2.JPGCC BY-SA 3.0

https://upload.wikimedia.org/wikipedia/commons/b/b9/Appendiceal_carcinoid_2.JPG


Treatment: Appendectomy versus R Colectomy*

Appendectomy suffices if:

1. Tumor <= 2 cm

2. No positive nodes/margins3. Incomplete resection (includes appendiceal base)

Before R colectomy: ensure the patient has resectable disease with a CT or MRI of abd/pelv with IV contrast


When to treat as colon cancer?

Pathology shows evidence of adenocarcinoma

1. “adenocarcinoid”

2. “goblet cell carcinoid”

Question 7A 75-year-old-man presents with abdominal pain and distention. Plain abdominal radiograph is shown to the right. Patient is stable with a benign exam. What is the next best step for management?

A. Sigmoidoscopy and decompressionB. Nasogastric tube placement and observationC. CecopexyD. Right hemicolectomyE. Sigmoidectomy

Question 7A 75-year-old-man presents with abdominal pain and distention. Plain abdominal radiograph is shown to the right. Patient is stable with a benign exam. What is the next best step for management?

A. Sigmoidoscopy and decompressionB. Nasogastric tube placement and observationC. CecopexyD. Right hemicolectomyE. Sigmoidectomy

https://upload.wikimedia.org/wikipedia/commons/1/17/CecalVolvulusXray.png

James Heilman, MD, CC BY-SA 4.0


Question 7 – Cecal VolvulusKnow how to identify based on plain and CT radiographs and distinguish from sigmoid volvulus

Cecal:

1. Typically LUQ to RLQ direction

2. No dilation of descending colon

3. Normal appearing sigmoid colon

Treatment: R colectomyhttps://upload.wikimedia.org/wikipedia/commons/1/17/CecalVolvulusXray.png

James Heilman, MD, CC BY-SA 4.0


Question 7 – Cecal VolvulusSigmoid

1. “Bird’s” beak if done with fluoro+contrast

2. RUQ to LLQ direction

3. Dilation of descending colon

Treatment:

Stable and no evidence of perforation: endoscopic decompression then sigmoidectomy

Unstable, evidence of perforation: sigmoidectomy

http://www.svuhradiology.ie/case-study/sigmoid-volvulus/

Question 8A 75-year-old-man presents with anal pain and blood on his toilet paper. Physical exam is shown on the right. The patient has tried fiber supplementation, regular bathing, with no relief. They would like to move to definitive management. What is the next step?

A. Closed (Ferguson) hemorrhoidectomy

B. Acyclovir

C. FistulotomyD. Lateral internal sphincterotomy

E. Hemorrhoidal artery ligation

Question 8A 75-year-old-man presents with anal pain and blood on his toilet paper. Physical exam is shown on the right. The patient has tried fiber supplementation, regular bathing, with no relief. They would like to move to definitive management. What is the next step?


B. Acyclovir

C. FistulotomyD. Lateral internal sphincterotomy

E. Hemorrhoidal artery ligation https://upload.wikimedia.org/wikipedia/commons/8/80/Anal_fissure.JPGJonathanlund, Public domain

Question 8 – Anal fissurePhysical exam

Longitudinal anoderm tear

Posterior midline (if not, suspect Crohns)

Sentinel pile

Exquisitely tender to touch

https://upload.wikimedia.org/wikipedia/commons/8/80/Anal_fissure.JPGJonathanlund, Public domain

Question 8 – Anal fissureTreatment

1. Medical1. Fiber

2. Warm baths 2-3 times a day

3. Topical agent (nifedipine, nitroglycerin)

2. Chemical sphincterotomy (botox)

3. Surgical sphincterotomy

Question 9A 89-year-old-woman, hx of CHF, CAD, COPD, presents with an anal mass. Physical exam is shown on the right. The patient has tried fiber supplementation, regular bathing, with no relief. They have no issues with constipation. The mass is 6 cm in size. They would like to move to definitive management. What is the next step?


B. Mucosal stripping + muscle plication

C. Perineal rectosigmoidectomy

D. Transabdominal rectopexy with sigmoidectomy

E. Transabdominal rectopexy

Question 9A 89-year-old-woman, hx of CHF, CAD, COPD, presents with an anal mass. Physical exam is shown on the right. The patient has tried fiber supplementation, regular bathing, with no relief. They have no issues with constipation. The mass is 6 cm in size. They would like to move to definitive management. What is the next step?


B. Mucosal stripping + muscle plication

C. Perineal rectosigmoidectomy

D. Transabdominal rectopexy with sigmoidectomy

E. Transabdominal rectopexy Dr. K.-H. Günther, Klinikum Main Spessart, Lohr am Main, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

Question 9 – Rectal prolapseDiagnosis:

Do not mistake for prolapsed hemorrhoids, which have a radial appearance shown to the right.

Have the patient bear down to determine the full extent of the prolapse, can reduce with osmotic agent (e.g., sugar)

Prof. Dr. A. Herold, End- und Dickdarm-Zentrum Mannheim, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

Question 9 – Rectal prolapseSurgical Treatment:

Candidate for abdominal procedure:

- Constipation issues: transabdominal rectopexy with sigmoidectomy

- No constipation: transabdominal rectopexy

Not a candidate for abdominal procedure:

- < 3-4 cm prolapse: Delorme (mucosal stripping + muscle plication)

- Longer: Altemeier (perineal rectosigmoidectomy)

Question 10A 58-year-old-woman with a history of Crohn’s proctocolitis undergoes a surveillance colonsoscopy. Mucosal biopsies from the proximal descending colon and sigmoid colon show dysplasia. What is the best way to manage this finding?

A. Continue with regular annual colonoscopy screenings

B. Left hemicolectomy (including splenic flexure)

C. Total abdominal colectomy with ileorectal anastomosis

D. Total proctocolectomy with ileal pouch anal anastomosis

E. Total proctocolectomy with end ileostomy

Question 10 – Colonic Crohn’s disease with dysplasia

Biopsies with dysplasia: Take out entire colon• Total colectomy (rectal sparing disease) or Total proctocolectomy

Why?• 14-40% of Crohn’s colitis patient’s who undergo segmental colorectal resection

develop metachronous colorectal cancer

• > 1/3 of specimens with “unifocal” dysplasia are found to have multifocal on final pathology

Question 10 – Colonic Crohn’s disease with dysplasia

If total proctocolectomy, why no IPAA?

Tend to avoid pouches in Crohn’s patients given higher long-term pouch failure rate

Colorectal and Small Bowel Diseases

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