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Questions and Answers

What is the incidence of carcinoma for polyps larger than 2 cm?

  • 10%
  • 25%
  • 5%
  • 50% (correct)

    • Which of the following polyps is most commonly associated with neoplastic potential?

  • Hyperplastic polyp
  • Sessile polyp
  • Villous adenoma
  • Tubular adenoma (correct)

    • Which level of the Haggitt Criteria indicates that carcinoma does not invade the muscularis mucosae?

  • Level 1
  • Level 3
  • Level 0 (correct)
  • Level 2

    • What is the recommended treatment for invasive carcinoma based on the Haggitt Criteria?

    <p>Surgical resection</p> Signup and view all the answers

    What characterizes a sessile polyp with invasive carcinoma according to the guidelines?

    <p>Assumed level 4 invasion</p> Signup and view all the answers

    What is the most common cause of small bowel obstruction (SBO)?

    <p>Adhesions</p> Signup and view all the answers

    Which symptom is NOT typically associated with small bowel obstruction?

    <p>Acute chest pain</p> Signup and view all the answers

    What is the pathophysiological consequence of bowel wall edema during SBO?

    <p>Ischemia leading to necrosis</p> Signup and view all the answers

    What is the typical pattern of abdominal pain associated with SBO?

    <p>Paroxysmal crampy pain at intervals</p> Signup and view all the answers

    During the early course of SBO, what happens to gastric motility?

    <p>It increases to propel contents.</p> Signup and view all the answers

    Which of the following is a sign of dehydration in a patient with SBO?

    <p>Dry mucous membranes</p> Signup and view all the answers

    Which condition can lead to strangulation in SBO?

    <p>Bacterial overgrowth</p> Signup and view all the answers

    What complication is associated with increased abdominal pressure during SBO?

    <p>Decreased venous return</p> Signup and view all the answers

    What is the recommended timing for placing a catheter after administering low molecular weight heparin (LMWH)?

    <p>24 hours</p> Signup and view all the answers

    In cases of malignant hyperthermia, which of the following is NOT a typical sign or symptom?

    <p>Decreased heart rate</p> Signup and view all the answers

    What is the primary complication associated with conscious sedation administered by non-anesthesia personnel?

    <p>Hypoventilation</p> Signup and view all the answers

    What is the suggested treatment for malignant hyperthermia?

    <p>Dantrolene administration</p> Signup and view all the answers

    Which drug is commonly included in the regimen for conscious sedation alongside anxiolytics?

    <p>Fentanyl</p> Signup and view all the answers

    What is the most frequent major complication in postanesthesia care (PACU)?

    <p>Respiratory obstruction</p> Signup and view all the answers

    Which technique is recommended to relieve airway obstruction caused by the tongue in PACU?

    <p>Jaw thrust maneuver</p> Signup and view all the answers

    Which of the following inhalational anesthetics is known to trigger malignant hyperthermia?

    <p>Halothane</p> Signup and view all the answers

    What is the percentage of new colorectal cancer cases that occur in adults 65 years old and older?

    <p>71%</p> Signup and view all the answers

    Which stage of the Dukes Classification indicates tumors that have penetrated the bowel wall?

    <p>Stage B</p> Signup and view all the answers

    At what age does the USPSTF recommend beginning screening for colorectal cancer in adults?

    <p>45 years</p> Signup and view all the answers

    What is the most common type of colorectal cancer?

    <p>Sporadic colorectal cancer</p> Signup and view all the answers

    What is the approximate cure rate for colorectal cancer if discovered early?

    <p>90%</p> Signup and view all the answers

    Which of the following describes the epidemiology of colorectal cancer in terms of gender prevalence?

    <p>More common in women than men</p> Signup and view all the answers

    Which of the following is a recommended method for colorectal cancer screening?

    <p>Flexible sigmoidoscopy every 5 years</p> Signup and view all the answers

    What does pathologic staging (pTNM) provide for a patient diagnosed with colorectal cancer?

    <p>A basis for prognosis and consideration of further treatment</p> Signup and view all the answers

    What are the components included in the Triple Test for breast disease diagnosis?

    <p>Clinical Exam, Imaging, Sampling</p> Signup and view all the answers

    Which patient history factors are important in assessing breast disease?

    <p>Age, Reproductive history, Age at menarche, Age at menopause</p> Signup and view all the answers

    What is the significance of nipple retraction in a breast examination?

    <p>It is a specific sign of underlying cancer.</p> Signup and view all the answers

    What is the primary imaging method recommended for asymptomatic women?

    <p>Mammography</p> Signup and view all the answers

    Why is MRI considered appropriate for patients with known BRCA mutations?

    <p>It has a sensitivity of 90% for invasive cancer.</p> Signup and view all the answers

    Which of the following is TRUE about Core Needle Biopsy (CNB)?

    <p>It is preferred for diagnosing palpable lesions.</p> Signup and view all the answers

    What is a limitation of mammography in certain age groups?

    <p>It cannot be used in women &lt; 40 years due to dense breast tissue.</p> Signup and view all the answers

    What is a key characteristic of benign tumors during physical breast examination?

    <p>They are well circumscribed and movable.</p> Signup and view all the answers

    Study Notes

    Epidural Anesthesia Risks

    • Epidural anesthesia is similar to spinal anesthesia in terms of risks.
    • Epidural hematomas are a potential risk, especially when anticoagulants like low molecular weight heparin (LMWH) are used.
    • Timing is crucial:
      • Do not place epidural catheter earlier than 24 hours after LMWH treatment.
      • Do not start LMWH before 6 hours after epidural placement.

    Conscious Sedation

    • Definition: Conscious sedation or moderate sedation is a technique used to achieve a relaxed and comfortable state during medical procedures.
    • Benefits:
      • Patients are conscious and can respond to verbal or tactile stimulation.
      • They maintain airway patency without intervention.
    • Risks:
      • Hypoventilation and hypoxemia (low blood oxygen) are rare complications.
      • Common drugs used: opioids (fentanyl, morphine), anxiolytics (midazolam).
    • Hospital policies: Each hospital has specific protocols and approved drugs for conscious sedation.
    • Propofol:
      • Sometimes used, but poses a higher risk of rapid descent into deep sedation and apnea.

    Malignant Hyperthermia

    • Trigger:
      • Volatile inhalational anesthetics (halothane, enflurane, isoflurane) and succinylcholine.
    • Pathophysiology:
      • A mutated ryanodine receptor in the sarcoplasmic reticulum of skeletal muscles causes hypermetabolism, increased heat production, oxygen consumption, and carbon dioxide production, leading to metabolic and respiratory acidosis.
    • Signs and symptoms:
      • Rising temperature, tachycardia, generalized muscular rigidity, skin mottling, and elevated end-tidal carbon dioxide (ETCO2 > 100 mmHg).
    • Treatment:
      • External cooling, administration of dantrolene (inhibits calcium ion release from the sarcoplasmic reticulum).

    Postanesthesia Care Unit (PACU)

    • Respiratory complications:
      • Most frequent major complication: Respiratory/airway obstruction (usually by the tongue).
      • Causes: Oropharyngeal obstruction by tongue and soft tissue, laryngospasm, fluids/debris in the airway, glottic edema, vocal cord paralysis.
      • Treatment: Oxygen, head tilt, jaw thrust, suctioning.
      • Laryngospasm: CPAP and succinylcholine.

    Small Bowel Obstruction (SBO)

    • Pathophysiology:
      • Early: Increased gastric motility to propel luminal contents. This can lead to diarrhea.
      • Later: Bowel fatigue, slowing, and dilation. This explains the change in bowel sounds (increased initially, then decreased/absent).
      • Bowel dilation: Water and electrolytes accumulate intraluminally and in the bowel wall (third spacing), causing dehydration and hypovolemia.
      • Other complications: Increased abdominal pressure, decreased venous return, elevated diaphragm compromising ventilation.
      • Progressive bowel wall edema and increased intraluminal pressure: Decreased blood flow, ischemia, necrosis, perforation, and peritonitis.

    SBO: Causes

    • Most common cause: Adhesions.
    • Intrinsic causes: Primary tumors within the bowel wall.
    • Intraluminal causes: Gallstones, enteroliths, foreign bodies, bezoars.
    • Other causes:
      • Crohn's disease (5%): Inflammation, edema, strictures (creeping fat sign).
      • Intra-abdominal abscess: Commonly seen with ruptured appendix, diverticulum, dehiscence of an intestinal anastomosis.
      • Miscellaneous causes: Intussusception (in adults, usually secondary to a pathologic lead point, like a polyp or tumor).
    • Most common cause of large bowel obstruction (LBO): Colon cancer.

    SBO: Diagnosis

    • History:
      • Colicky abdominal pain: Crampy pain occurring in paroxysms at 4-5 minute intervals, less frequent with more distal obstructions.
      • Nausea and vomiting: Vomiting may become feculent late in the process.
      • Abdominal distention:
      • Failure to pass flatus/feces (obstipation).
    • Physical examination:
      • General: Fever and tachycardia suggest strangulation/bacterial overgrowth. Tachycardia, oliguria, dry mucous membranes, and hypotension indicate dehydration.
      • Abdominal: Inspect for distention, hernias, and surgical scars. Auscultation: High-pitched or hypoactive bowel sounds suggest an SBO. Percussion: Tympani and tenderness further support the diagnosis.

    Colorectal Polyps

    • Size matters:
      • Smaller than 1 cm: 5% incidence of carcinoma.
      • Larger than 2 cm: 50% incidence of cancer.
    • Most common polyp without neoplastic potential: Hyperplastic polyp (histology: serrated).
    • Most common benign polyp with neoplastic potential: Tubular adenoma (pedunculated).
    • Worst type of polyp: Sessile, > 2 cm, villous > tubulovillous > tubular.
    • Invasive carcinoma: Malignant cells penetrate the muscularis mucosa.
    • Treatment of polyps: Removal, usually by colonoscopy.
    • Treatment of invasive carcinoma: Based on Haggitt criteria.

    Haggitt Criteria (Colorectal Cancer)

    • Level 0: Carcinoma does not invade the muscularis mucosae (carcinoma-in-situ or intramucosal carcinoma).
    • Level 1: Carcinoma invades the submucosa, limited to the polyp head.
    • Level 2: Carcinoma invades the neck of the polyp (junction between head and stalk).
    • Level 3: Carcinoma invades any part of the stalk.
    • Level 4: Carcinoma invades the submucosa below the stalk but above the muscularis propria.
    • All sessile polyps with invasive carcinoma are Level 4!
    • Sessile polyps: Require aggressive treatment.
    • Level 1-3: Low risk of metastasis/recurrence. Treatment: Complete excision. Repeat colonoscopy in 3-6 months.
    • Lymphovascular space involvement: Aggressive treatment as metastasis occurs in 10% of cases.

    Hereditary Cancer Syndromes

    • All are autosomal dominant, tumor suppressor genes.
    • Increased risk of colorectal cancer and other cancers.
    • Strong family history: Multiple first-degree relatives with colorectal cancer, or a single first-degree relative (father) with cancer diagnosed before 60 years of age.
    • Increased risk of 3-4 times the average.

    Dukes Classification (Colorectal Cancer)

    • Stage A: Confined to the bowel wall/mucosa.
    • Stage B: Penetrates the bowel wall.
      • B1: Partial penetration of the muscularis propria.
      • B2: Full penetration of the muscularis propria.
    • Stage C: Lymph node metastases.
      • C1: Tumors invading lymph nodes, but not penetrating the entire bowel wall.
      • C2: Tumors invading lymph nodes and penetrating the entire bowel wall.
    • Stage D: Distant metastases.

    Colorectal Cancer Epidemiology

    • Incidence: Directly associated with age, 71% of new cases occur in adults 65 years and older.
    • Prevalence: 3rd most common new cancer in both men and women, slightly more common in women.
    • Mortality: 2nd leading cause of cancer death in the USA.
    • Cure rate: 90% if discovered early.
    • Origin: Most arise from benign polyps.
    • General population risk: 6% for colorectal cancer. Family history increases risk 1.5-4 fold.
    • Sporadic colorectal cancer:
      • Most common type.
      • Generally affects older adults (60-80 years old).
      • Usually an isolated colon or rectal lesion, often in the left colon.
    • Lynch syndrome: More common than familial adenomatous polyposis (FAP).

    Screening Colonoscopy

    • Importance: Decreases colorectal cancer mortality.
    • USPSTF recommendations: Screening for colorectal cancer in adults starting at age 45 and continuing until age 75.
    • Screening methods:
      • Annual fecal occult blood testing (FOBT).
      • Flexible sigmoidoscopy every 5 years.
      • Full colonoscopy if FOBT is positive or adenomatous polyps are found on flexible sigmoidoscopy. Colonoscopy every 10 years.
      • Double contrast barium enema (DCBE) every 5 years (alternative to colonoscopy).

    Colorectal Cancer: Preoperative Workup

    • Staging: Pathologic staging of the resected specimen (pTNM) provides information for prognosis and adjuvant treatment decisions.
    • Non-obstructing tumors: Thorough evaluation for metastatic disease: Chest X-ray (CXR) and carcinoembryonic antigen (CEA) level.

    Breast Disease Diagnosis

    • Triple Test: Clinical exam, diagnostic mammography, and sampling (core needle biopsy).
    • Patient history: Age, reproductive history, age at menarche, age at menopause, pregnancy history, obstetrical surgical history.
    • Specific breast complaints: Masses, discharge, skin changes.
    • Physical examination: Inspect for masses, asymmetries, and skin changes.
      • Look for nipple inversion, excoriation of the epidermis, or retraction.
      • Assess skin for edema ("peau d'orange").
      • Palpate breasts for underlying masses with the patient supine and arms stretched above the head.
        • Benign masses: Well-circumscribed and movable.
        • Carcinoma: Less circumscribed and drag surrounding tissue.
    • Dimpling or nipple retraction: Specific and sensitive sign of underlying cancer.

    Breast Imaging

    • Fine needle aspiration (FNA): 22-gauge needle inserted into mass for immediate cell fixation on a slide.
      • Differentiates solid from cystic masses.
      • Mostly replaced by ultrasound.
      • Proceed to core needle biopsy if blood is present or the mass does not fully resolve after FNA.
    • Core needle biopsy (CNB): Preferred for diagnosing palpable lesions.
      • Skin incision with insertion of an 11-gauge needle to obtain a sample.
      • Excisional biopsy should only be performed if CNB is not feasible.
    • Mammography: Primary imaging for asymptomatic women.
      • Two views: Mediolateral oblique (visualizes the tail of Spence) and craniocaudal.
      • Not used in women under 40 due to breast tissue density.
    • Sonography (Ultrasound):
      • Useful for determining solidity or cystic nature of lesions detected on mammography, particularly in patients with dense breasts and young women.
      • Not a good screening tool due to operator dependence.
    • Magnetic Resonance Imaging (MRI):
      • Useful for locating primary tumors when there are axillary lymph node metastases without evidence of a breast tumor on mammography.
      • Screening tool for patients with known BRCA mutations.
      • High sensitivity for invasive cancer (90%) and ductal carcinoma in situ (DCIS) (60%).

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