Colorectal

High Yield Anatomy

• What are the dimensions of the colon?
• Approximately 5- 6 feet in length, with the rectum encompassing approximately 15 cm
• Normal caliber is 3-8 cm, cecal diameter > 9 cm is abnormal
• Which portions of the colon are retroperitoneal?
• Ascending
• Descending
• What is the blood supply to the colon?
• Superior mesenteric artery
• Terminal branch = ileocolic artery → TI, cecum
• Right and middle colic arteries → ascending and proximal 2/3rd of the transverse colon
• Inferior mesenteric artery
• Left colic → distal 1/3rd of the transverse colon and descending
• Sigmoid branches → sigmoid colon
• Superior rectal artery → proximal rectum
• Collaterals
• Marginal artery → along the colon wall connecting the SMA and IMA
• The Arc of Riolan (meandering mesenteric artery) → smaller connection between the SMA and IMA
• What are the “watershed” areas of the colon:
• Splenic flexure - SMA/IMA connection (Griffith’s point)
• Rectal/sigmoid - superior/middle rectal artery connection (Sudeck’s point)

Figure 1 - Vascular anatomy of the colon with tumor resection margins

• What is the blood supply to the rectum?
• Superior rectal (hemorrhoidal) artery - branch of IMA

• Middle rectal (hemorrhoidal) artery - branch of internal iliac (hypogastric) artery

• Inferior rectal (hemorrhoidal) artery- branch of internal pudendal → from internal iliac Remember to check groin lymph nodes for low rectal cancers .

• What is the venous drainage of the rectum?
• Superior rectal vein → IMV → portal circulation
• Middle and Inferior rectal veins → internal iliac vein → systemic circulation
• What are the proximal and distal extents of the rectum?
• Proximal extent starts where the taeniae splay
• Distal extent is the anal canal (15 cm from anal verge)
• What defines the anal canal?
• Begins at puborectalis sling (anorectal ring) → ends at anal verge = squamous mucosa blending with the perianal skin
• What defines the anal margin?
• Extends 5 cm radially from squamous mucocutaneous junction PART ONE Anal Fissure
• Where do anal fissures present?
• 90% located within posterior midline
• Females can have anterior fissures in 25% of cases
• What is the first line treatment?
• Non-operative management
• Psyllium or other bulking agent, sitz baths +/- topical anesthetic
• Topical nitrates → side effects = headaches

• Topical calcium channel blockers have similar efficacy to nitrates without the side effects

• Botulinum toxin has modest healing rates for those who fail topical therapy

Incontinence with botulinum injection is a contraindication for LIS.

• What are the surgical options?
• Lateral internal sphincterotomy
• LIS has superior efficacy to nonoperative treatments, but has a small risk of fecal incontinence
• Contraindications: women of childbearing age, prior obstetrical injuries, IBD, or history of sphincter dysfunction/ incontinence
• Anocutaneous flap
• Has inferior healing rates to LIS but lower incidence of fecal seepage/incontinence
• Can be performed in addition to LIS or botulinum injection Anorectal Abscess/Fistula-in-Ano
• Anorectal Abscess
• Where do anorectal abscesses occur?
• Defined by the anatomic space they occupy
• Intersphincteric- between the internal and external sphincter muscles
• Ischiorectal (ischioanal)- lateral to the rectal wall in the space next to the ischial tubercle
• Perirectal/Perianal - right around the anus
• Supralevator - above the levator muscle
• Submucosal - under the mucosa in the anal canal
• Deep postanal space
• Bilaterally ends in the ischiorectal fossa
• “Floor” is the anococcygeal ligament
• “Ceiling” is the levator muscle

Figure 2 - Anorectal anatomy

• What is the primary treatment?
• Drainage
• Superficial perianal and ischiorectal - external incision and drainage
• Deeper intersphincteric and supralevator - internal transanal drainage
• Who needs antibiotics after drainage?
• If there is cellulitis, systemic signs of infection, or underlying immunosuppression
• What is the risk of developing fistula in ano?

• One-third of patients with anal abscess will develop FIA

• Fistula in Ano (FIA)
• How are anal fistulae defined?
• Relationship to sphincter muscles
• Intersphincteric - most common type and runs between the internal and external sphincter muscles
• Transsphincteric - runs across both the internal and external sphincter muscles
• Can also be categorized as high (>1/3rd of the muscle complex) or low (< 1/3rd of the muscle complex)
• Suprasphincteric - runs between the muscles and up and over the external sphincter
• Extrasphincteric - runs over and above (outside) of the sphincter complex
• Submucosal
• What are the general principles of management?
• If superficial, simple fistula with minimal or no sphincter involvement discovered at the time of I&D for abscess → okay to perform fistulotomy at time of drainage
• If involves more than 25% of sphincters → drain abscess and place seton
• Seton induces fibrosis of tract
• Goal is to convert high fistula to low fistula and prepare tract for later procedures
• LIFT = Ligation of Intersphincteric Fistula Tract
• Good option for fistulas not amenable to simple fistulotomy
• Anorectal advancement flap +/- LIFT
• Always done after seton placement Avoid selecting fistula plug or fibrin glue as the answer.

Hemorrhoids

• What are hemorrhoids?
• Vascular cushions or sinusoids in the anal canal that help with gross continence
• Where is the division between internal and external hemorrhoids?
• Dentate/pectinate line
• Innervation is somatic below the dentate line and autonomic above (i .e . external hemorrhoids are painful)
• What are the common symptoms of hemorrhoidal disease?
• Bleeding, swelling, thrombosis
• Internal hemorrhoids predominately prolapse and bleed
• External hemorrhoids predominately present with pain after clotting
• What is the classification of internal hemorrhoids?
• I - internal only
• II - prolapse and spontaneously reduce
• III - prolapse and manually are reducible
• IV - prolapse and are not reducible
• How do you manage hemorrhoidal disease?
• Bowel hygiene: no prolonged sitting or straining at the toilet, fiber (25-35g/day), and plenty of fluid
• Internal hemorrhoids can be banded
• Risks- pain, bleeding, ulcer, and small risk of Fournier’s gangrene
• Symptomatic/thrombosed external hemorrhoid can be excised Never choose banding or incision and drainage for external hemorrhoids. Diverticulitis
• What is the Hinchey classification?

Table 1 - Hinchey classification of diverticulitis

• What constitutes complicated disease?
• Perforation, abscess, fistula, obstruction, stricture
• Phlegmon (contained area of inflammation) or extra-luminal gas alone does NOT constitute complicated disease
• What is the management of a clinically stable, reliable patient with uncomplicated disease who can tolerate oral hydration?
• Outpatient treatment with oral antibiotics to cover gram + and gram - (e.g. amoxicillin/clavulanate, levofloxacin/ metronidazole)
• What about a patient with complicated disease or who cannot tolerate oral hydration?
• This requires admission, IV hydration, and IV antibiotics (piperacillin/tazobactam or levofloxacin/metronidazole)

• May require operative or percutaneous intervention

• How about a patient presenting unstable and/or with diffuse peritonitis?
• OR for urgent sigmoid colectomy
• While there is literature to support primary anastomosis in select patients even in Hinchey III/IV disease, safest answer is Hartmann’s Avoid selecting laparoscopic lavage. If in the OR urgently/ emergently → resect.
• What if the patient is stable with an abscess?
• Depends on the size and somewhat controversial, but in general:
• < 3 cm generally resolve with antibiotics

• 3 cm should consider percutaneous drainage

• What if the abscess is inaccessible by IR and not resolving with medical management?
• May be candidate for laparoscopic drain placement
• Goal is to let acute phase resolve so patient may undergo elective, single stage colectomy at later date
• Patient with single episode of uncomplicated diverticulitis diagnosed on abdominal CT was successfully treated nonoperatively . What is the next step?
• If no recent colonoscopy → needs colonoscopy, typically 6 weeks after resolution of episode
• To rule out underlying ischemia, IBD, or neoplasm
• When would you recommend an elective sigmoid colectomy?
• For uncomplicated disease:
• Difficult question - used to be based on number of episodes and age; however, we now know that the 1st episode tends to be the worst and multiple uncomplicated episodes does not necessarily increase the risk of needing an emergent colectomy and stoma

• Decision for elective colectomy is now highly individualized

• Consider individual risk of surgery based on co- morbidities and general health of patient
• Effect of diverticulitis episodes on lifestyle and career
• Suspicion for neoplasm?
• Chronic symptoms (smoldering disease)?
• Complicated disease
• Elective colectomy should generally be offered to patients after recovery from a complicated episode of diverticulitis . Clostridium Difficile Infection (CDI)
• What is clostridium difficile?
• Anaerobic, gram positive rod
• What is the medical management?
• Metronidazole (500 mg TID) and vancomycin (125 mg QID) are first line oral options
• Previously, metronidazole was first line for mild to moderate disease and vancomycin was first line for severe disease
• Vancomycin is now first line with fidaxomicin as the alternative
• Vancomycin enemas are also an option
• Fidaxomicin = oral macrolide with activity against resistant strains, usually requires ID consult
• Probably not the answer on the boards
• Patients with refractory CDI can be considered for fecal transplant if conventional methods have failed
• When is surgery required?
• Surgery reserved for severe colitis that fails to respond to medical therapy
• Outside of obvious indications like perforation and generalized peritonitis, the decision to operate can be very difficult

• Multisystem organ failure is an ominous sign - you’ve waited too long; perforation is also associated with high mortality

• Consider early operative intervention in patients requiring vasopressors or signs of impending sepsis
• What is the procedure of choice?
• Subtotal colectomy with ileostomy A diverting loop ileostomy with colonic lavage and antegrade vancomycin enemas is another surgical option, but not on the exam.

Colonic Volvulus

• Sigmoid volvulus
• What is the radiographic finding on plain films?
• Bent inner tube sign - apex points to RUQ
• What are your next steps?
• Contrast enhanced CT to confirm diagnosis and assess colon viability
• If no colonic ischemia or perforation on CT → endoscopic detorsion with decompression tube left in place for 1-3 days
• High long-term recurrence rate after initial endoscopic detorsion → consider sigmoid colectomy during index admission in appropriate patients
• What operation do you perform if emergent indications?
• Safest answer = open sigmoidectomy with end colostomy (Hartmann)
• What operation do you perform in the semi-elective setting after successful detorsion?
• Open sigmoid colectomy with anastomosis Case scenario is usually an elderly, nursing home patient on antipsychotics with history of constipation.
• Cecal volvulus

• What is the radiographic finding?

• Coffee bean pointing to the left upper quadrant
• How do you manage this?
• Endoscopic reduction is NOT recommended - rarely successful with high recurrence
• These patients need to go to OR → resect if dead bowel
• How do you decide on resection vs pexy?
• Data is limited - resection has lower recurrence but may have higher procedure-related morbidity than pexy
• Both are acceptable answers
• Safest answer = resection (ileocecectomy or right hemicolectomy) with primary anastomosis Never choose cecostomy, endoscopic detorsion, or operative detorsion alone. Figure 3 - Appearance of colonic volvulus on plain film

Acute Colonic Pseudo-Obstruction (Ogilvie’s)

• What are the risk factors for Ogilvie’s?
• High dose opiates, electrolyte abnormalities, etc .
• What are the risk factors for perforation?
• Cecum > 12 cm or duration > 6 days
• What is the initial treatment if no signs of ischemia and cecum < 12 cm?
• Supportive care and correct underlying cause: correct electrolytes, fluid resuscitation, minimize narcotics and anticholinergic medications, treat infection, bowel rest and decompression
• What if patient is not improving with supportive care?
• Neostigmine = anti-acetylcholinesterase, promotes colonic transit
• What is the most common side effect?
• Bradycardia → need to give in a monitored setting
• What if the patient is not responsive to neostigmine or neostigmine is contraindicated?
• Endoscopic decompression
• How do you manage ischemia or perforation?
• OR for resection (ostomy vs anastomosis +/- diversion on case by case basis) Rectal Prolapse
• How do you diagnose rectal prolapse?
• Full thickness intussusception of the rectal wall with visible concentric rings (important to differentiate from prolapsed hemorrhoids)
• What is the common patient presentation?
• Higher incidence in elderly females, developmentally delayed, and psychiatric co-morbidities with multiple meds, straining and chronic diarrhea

• What are the goals of surgery?

• Eliminate prolapse through either resection or restoration of normal anatomy
• Correct associated functional abnormalities
• Avoid creation of de novo bowel dysfunction
• What is the mainstay of treatment?
• Surgery
• Low risk- Transabdominal rectal fixation (rectopexy)
• Open vs laparoscopic have equivalent recurrence rates, improved morbidity with laparoscopic approach
• Rectopexy is the key component
• If patient has constipation → add LAR or sigmoid resection to rectopexy
• High risk (older, multiple co-morbidities, cannot tolerate general anesthetic) - Perineal proctosigmoidectomy (Altemeier procedure)
• Lower morbidity but higher recurrence and less durable
• High fiber diet Quick Hits
• What is the main nutrient of colonocytes?
• Butyrate (short chain fatty acids) Glutamine is the primary source for small bowel enterocytes.
• Patient with sigmoid volvulus on CT → on endoscopy mucosa is dusky with ulceration . Next step?
• Abort endoscopy → OR for urgent sigmoidectomy

• Patient with anal fissure lateral or multiple fissures. What do you worry about? - Crohn’s disease, HIV, syphilis, tuberculosis

• You take septic patient with fulminant C diff colitis to ex lap for planned total abdominal colectomy but upon opening the colon looks normal . What do you do?
• C diff is mucosal disease → proceed with TAC and end ileostomy
• What is the management of a lower GI bleed?
• 1st steps - Resuscitate - 2 large bore IVs, type and cross, transfuse, admit to ICU for monitoring
• Localize the source -
• R/o upper GI source - NG lavage
• Colonoscopy, angiography, and/or tagged RBC scan
• Recommendations of which to perform first vary and are institution specific - would say colonoscopy on test if it’s an option
• Most will stop spontaneously → If stops initially and then rebleeds can try 2nd attempt at localization as long as patient is stable
• If patient unstable and/or ongoing transfusion requirement
• Segmental colectomy if bleeding source localized by colonoscopy, angiography, or tagged RBC scan
• TAC if unable to localize

Figure 4 - Management approach for lower GI bleed PART TWO Ulcerative Colitis

• How is UC defined?
• Chronic inflammatory condition affecting rectum and extending proximally (spares anus)
• Buzzwords: mucosal disease, contiguous, characteristic crypt abscesses and pseudopolyps
• What is the management?
• Most can be managed medically with 15-30% eventually requiring surgery
• Steroids for acute flares, mesalamine maintenance, infliximab added if resistant
• What are indications for surgical intervention?

• Medical intractability (most common), malignancy, and other complications from colitis (stricture, perforation, fulminant/ toxic colitis)

• What constitutes “medical intractability?”
• Growth failure in children
• Condition worsens while on medical therapy
• Condition is insufficiently controlled with maximal medical therapy - somewhat vague, but essentially patient can’t achieve adequate quality of life
• Risk of chronic medical therapy is not tolerated (e .g . chronic steroids)
• Disabling extra-intestinal manifestations that may respond to colectomy (e .g . large joint arthropathy, erythema nodosum, episcleritis)
• What about hepatobiliary manifestations?
• Typically, do NOT respond to colectomy (e .g . primary sclerosing cholangitis)
• What is the association between UC and malignancy?
• Increased risk of malignancy associated with prolonged inflammation
• Surveillance recommendations;
• Patients with extensive colitis (proximal to splenic flexure)
• Endoscopy after 8 years of disease and then every 1-2 years
• 4 quadrant random biopsy should be performed at 10 cm intervals throughout involved segment of colon - along with directed biopsies of suspicion lesions
• What do you do if there is malignancy or high-grade dysplasia?
• Total proctocolectomy with or without IPAA
• What are the surgical options?
• If emergent (toxic colitis, perforation, etc .) → total or subtotal colectomy with end ileostomy

• Later may perform completion proctectomy and IPAA

• Elective options
• Total proctocolectomy with end ileostomy = curative, removes all pathologic tissue
• Commits patient to lifelong ileostomy
• Total proctocolectomy with IPAA - MC procedure in elective setting
• Advantage of no stoma, but may have complications related to pouch (e .g . pouchitis)
• Must have good baseline continence prior to IPAA
• Must be sure it’s UC and not Crohn’s (Distal ileum used for ileal pouch)
• TAC with ileorectal anastomosis
• Only used in highly select cases
• Must have uninvolved rectum (rare)
• Rectum still at risk for ongoing disease and risk of CA → Needs annual surveillance of residual rectal cuff

Figure 5 - Operative options for ulcerative colitis Crohn’s Disease

• How is Crohn’s disease described?

• Chronic, incurable, inflammatory disorder that can affect any segment of the intestinal tract (TI most common, usually spares rectum)
• Bimodal distribution (20-30s; 50-60s)
• Buzzwords: transmural involvement, segmental, characteristic creeping fat UC is limited to the mucosa and affects the colon continuously.
• Phenotypes: inflammatory, fibrostenotic, penetrating (can overlap and change)
• Extraintestinal manifestations - arthritis/arthralgias, megaloblastic anemia (2/2 malabsorption of B12 in TI), uveitis, erythema nodosum
• What is the medical treatment?
• Steroids for acute flares, 5-ASA/mesalamine for maintenance, infliximab for resistant disease
• When is surgery indicated?
• Surgery is not curative unlike UC
• Reserved for complications of disease - stricturing, obstruction, malignancy, perforation, fistula
• Preserve as much small bowel as possible (often need multiple resections over course of lifetime)
• What is the management of symptomatic strictures?
• If able to reach endoscopically - can try endoscopic dilation first
• Otherwise - resection or stricturoplasty
• Resection is most commonly performed - especially if isolated short segment disease
• Stricturoplasty is useful for preserving bowel length if there is concern for existing or impending short gut
• Type of stricturoplasty depends on length of stricture:

• Short strictures (< 10 cm) - Heineke-Mikulicz stricturoplasty

• Longitudinal incision on stricture and close transversely
• Medium-length strictures (10-20 cm) - Finney stricturoplasty
• Fold strictured segment on itself and make a common channel in the loop
• Long strictures (> 20 cm) - Michelassi
• Similar to Finney - side-to-side isoperistaltic stricturoplasty
• Perform biopsies of strictured segment - Don’t inadvertently leave a malignancy behind for the sake of preserving bowel length
• Malnutrition, presence of inflammation/ perforation/fistula, and suspicion for malignancy are contraindications for stricturoplasty Colon Cancer
• What are the screening recommendations? Table 2 - Colorectal cancer screening recommendations
• If patient has a personal history of adenomas what is the recommended surveillance interval?

Table 3 - Colonoscopy surveillance recommendations

• What if a malignant polyp was found?
• Malignant pedunculated or sessile polyps may be managed endoscopically if the following criteria are met:
• Polyp can be removed in 1 piece
• Resection margins free of dysplasia or cancer
• Lesion is well or moderately differentiated and no angiolymphatic invasion
• Limited submucosal invasion (cancer cells 2mm or less past muscularis mucosa)
• Malignant polyps that do not meet low-risk criteria or cannot be adequately removed via endoscopic techniques → oncologic resection
• One of the few cancers that you absolutely need to know the staging . What is the TNM staging?

Table 4 - Colon cancer staging

• Positive lymph node defined as 0.2 mm deposit of cancer cells
• What extent of proximal and distal margin is required?
• Ideally 5-7 cm to ensure adequate lymphadenectomy
• How many nodes are needed?
• At least 12
• What is the management of Stage IV disease?
• Should classify as 1) resectable, 2) potentially resectable (if able to downstage with standard chemotherapy regimens), or 3) unresectable
• Resectable
• In medically fit patients, curative resection of hepatic and/ or pulmonary metastases can be performed
• Sequence of chemotherapy, resection of primary tumor, and resection of metastasis varies widely by surgeon, institution, and individual patient/tumor characteristics

• Safe answer if given resectable colon CA with hepatic metastasis: 3 months of preoperative FOLFOX → surgery → 3 months of postop FOLFOX

• Potentially resectable disease should receive preoperative FOLFOX → re-evaluate resectability based on response
• Unresectable
• Surgery only for palliation (obstruction, bleeding, perforation)
• If obstruction → stenting is preferable to colectomy or diversion
• Adjuvant therapy
• Who gets adjuvant therapy?
• In general, Stage III and above (positive nodes or M1) Adjuvant therapy for “high-risk” stage II disease (T4 primary, perforation/obstruction, poorly differentiated, <12 nodes harvested) is not standard of care.
• What is the regimen?
• FOLFOX for 6 months (or 3 mo preop + 3 mo postop)
• Folinic acid (leucovorin)
• Fluorouracil (5-FU)
• Oxaliplatin
• Radiation is not indicated for colon cancer Rectal Cancer
• What is the workup for newly diagnosed rectal cancer?
• Labs including CEA
• Rigid proctoscopy to document level of tumor
• CT chest/abdomen/pelvis to evaluate metastatic disease
• Endorectal U/S (EUS) or Rectal MRI for T and N stage
• MRI is particularly helpful in determining tumor circumferential margin (CRM)
• CRM = total distance between tumor and mesorectal fascia

• Very important prognostic indicator

• Who gets neoadjuvant chemoradiotherapy?
• Locally advanced tumors of mid-distal rectum (T3 or greater or any N+ disease)
• What is the regimen?
• 5000 cGy radiotherapy delivered concurrently with 5-FU chemotherapy delivered over 5-6 weeks → surgery to follow roughly 8-12 weeks after
• 5-FU is a radiosensitizer
• Surgical Management
• When is local excision an option?
• Consider for T1 lesions without high-risk features
• Well to moderately differentiated lesions, no lymphovascular or perineural invasion, < 3 cm, and < 1/3rd of circumference of bowel lumen
• Big issue here is not able to pathologically examine regional lymph nodes
• Patient counseling is key: up to 20% local recurrence rate for T1 lesions
• If good surgical candidate wound lean toward resection Local excision can be performed for T2 lesions in poor surgical candidates but is likely not the correct answer for the exam.
• How do you manage tumors of upper 3rd of rectum?
• Tumor specific mesorectal excision with 5 cm distal margin
• What about tumors of the mid to lower 3rd of rectum?
• Total mesorectal excision (TME) as part of LAR or APR
• With TME - 2 cm distal margins are ideal, 1 cm okay if very distal

• If can’t get this margin with sphincter preservation → needs APR

• What is the adjuvant therapy?
• FOLFOX recommended for:
• Stage III or greater who did not receive neoadjuvant (in other words, patient was understaged during preop w/u)
• High-risk stage II or greater who received neoadjuvant therapy
• In this case, we assume that pathologic high-grade stage II disease is the result of downstaging by neoadjuvant therapy Anal Squamous Neoplasms
• How will these be described?
• Histologic variants: cloacogenic, basaloid, epidermoid, mucoepidermoid
• You need to know these because they will try to trick you by giving you a patient with an anal mass that was biopsied, and path returns as one of these variants . Recognize that you are dealing with anal SCC
• They try to get you to do an APR when what the patient needs is primary chemoradiotherapy (Nigro) .
• What HPV serotypes are associated with anal SCC?
• 16 and 18
• Who has a higher incidence of anal SCC?
• Immunosuppressed patients
• What is anal intraepithelial neoplasm (AIN)
• Precursor lesion to SCC
• Many confusing classification systems exist
• Know this:
• AIN I, II, and III correspond to low-moderate-high grade dysplasia, respectively
• Low grade AIN (LGAIN) = AIN I/II
• High grade AIN (HGAIN) = AIN III

• What is the primary treatment for SCC of anal canal?

• Chemoradiotherapy (Nigro Protocol)
• 5-FU, Mitomycin C, and 3000 cGy XRT
• What do you do with persistent or recurrent SCC of anal canal after primary CRT?
• APR
• How do you manage SCC of the anal margin?
• Treat like skin CA → WLE The anal margin extends 5 cm radially from the squamous mucocutaneous junction.
• What is the treatment of HGAIN/LGAIN?
• Overall low rate of conversion to SCC (higher in immunosuppressed)
• Several local treatments can be used:
• Topical 5% imiquimod
• Topical 5% 5-FU
• Photodynamic therapy
• Targeted destruction
• Probably most important part of any of above treatments is close clinical f/u with surveillance every 4-6 months
• Some advocate observation with surveillance alone
• Anal melanoma is treated with APR Quick Hits
• Transverse colon cancer with local invasion of head of pancreas, no evidence of metastatic disease . How do you treat?
• Resect en bloc: Whipple + extended hemicolectomy
• Treatment of isolated peritoneal carcinomatosis 2/2 colon CA?

• Carcinomatosis often associated with widespread metastasis . However, if isolated → cytoreductive surgery with intraperitoneal chemotherapy

• What do you do with rectal cancer with apparent complete clinical response to neoadjuvant therapy?
• Current imaging (CT, MRI, PET) cannot reliably predict complete clinical response → this patient still requires resection
• Patient referred for “hemorrhoid.” On exam has 1 cm palpable mass of anal canal . Biopsy performed in clinic returns epidermoid carcinoma . Management?
• Primary chemoradiotherapy (Nigro protocol)
• This is a variant of SCC
• Patient with prior proctocolectomy and IPAA for UC presents with fever, pelvic pain, and increased frequency of stools. Flexible endoscopy shows mucosal inflammation of ileal pouch . Diagnosis?
• Pouchitis
• Treatment?
• Antibiotics (ciprofloxacin/metronidazole), supportive care
• Budesonide enemas if not responsive to antibiotics
• Chronic pouchitis → suspect Crohn’s
• Severe refractory pouchitis may require pouch excision and ileostomy
• During laparoscopic exploration for presumed acute appendicitis, appendix appears normal, but TI inflamed. What do you do?
• Suspect Crohn’s
• If cecum uninvolved → appendectomy to prevent future diagnostic confusion
• If cecum inflamed → leave appendix in place
• Either way, treat medically for acute Crohn’s flare.

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