Category: Rectum

Pouchitis Disease severity index

admin

Q) Pouchitis disease activity index includes all except (AIIMS 2019)

a)  Fever
b)  Malaise
c)  Fecal urgency
d)  Bleeding PR

Pouchitis is commonly asked in AIIMS and JIPMER MCH exams. Previous year questions are here and here 

Ans b ) Malaise, Clinical data includes Frequency, urgency and rectal bleed

Summary of the PAS

Range
I. Clinical
 1. Stool frequency(0, 2, 4, 6)
 2. Fecal urgency(0, 3)
 3. Rectal bleeding(0, 3)
Maximal clinical subscore: 12
II. Endoscopic findings
 1. Oedema(0, 1)
 2. Granularity(0, 1)
 3. Friability(0, 1, 2)
 4. Erythema(0, 2, 3)
 5. Mucosal flattening(0, 2)
 6. Ulcerations/erosions(0, 2, 3)
Maximal endoscopic subscore: 12
III. Histological Acute inflammation
 1. Polymorphonuclear infiltration(0, 1, 2, 3)
 2. Ulcerations/erosions(0, 1, 2, 3)
Chronic inflammation
 1. Mononuclear infiltration(0, 1, 2, 3)
 2. Villous atrophy(0, 1, 2, 3)
Maximal (total) histological subscore: 12
Maximal total PAS: 36

 

Cancer lower rectum

admin

Q) False statement about management of cancer rectum

a) Relative to ERUS, pelvic MRI is more accurate in its ability to detect lymph node involvement 

b) Rectal cancers located in the upper third of the rectum are exempt from neoadjuvant treatment.

c)  TME is typically performed 2-3 weeks after completion of CRT before fibrosis develop

d) ERAS  include early mobilization, transition to oral pain control, and resumption of oral food intake

Pouchitis after IPAA in ulcerative colitis

admin

Q) Which of the following is Not a risk factor for pouchitis post IPAA in ULcerative colitis

A) Smoking
B ) NSAIDs use post op
C) Elderly patients
D) UC with extra intestinal manifestation

Ans a

Pouchitis is the complication of Ileal Pouch Anal Anastomosis (IPAA) for Ulcerative colitis. The incidence of pochitis for the same proedure for familial Adenomatous polyposis is less than 10% but for ulcerative colitis can go as high as 50%.

Risk factors for development of pouchitis are

  1. Previous extra intestinal manifestations of IBD especially arthritis
  2. ANCA positive cases of UC
  3. NOD2insC  positive patients
  4. Smoking prevents the development of puchitis after IPAA in ulcerative colitis.

5. Other reported factors that may associate with pouchitis include extent of UC, thrombocytosis,and PPI use with  NSAId

Ref - https://onlinelibrary.wiley.com/doi/full/10.1111/den.12744

lymphatics of colon

admin

Q ) Which of the following group of lymph nodes do lymphatics of the colon first drain to?

a) Paracolic

b) Epicolic

c) Nodes along SMA/IMA

d) Para aortic
Answer to 37

37) b

Lymphatics first drain to epicolic group along the bowel wall

Then paracolic group along the marginal artery

Intermediate group along the named vessels SMA/IMA

Finally to par aortic 

Colon and upper 2/5 of rectum --- Para aortic

Lower 1/5 of rectum and anal canal - Superficial inguinal lymph nodes

Ref Sabiston-1317

Radiation proctitis

admin

Q) In radiation proctitis surgery is needed in all except 

a) Pain Abdomen

b) Rectal stricture

c) Haemorrhage

d) Vesical Fistula

Free Question on management of raiation proctiitis 

Ans a, NOT indicated  for pain

Acute Radiation proctitis - Occurs within 6 mths of starting the treatment

Chronic - After 6 mths, Most patients develop symptoms at a median of 8 to 12 months after completion of radiotherapy

Modified Radiation Therapy Oncology Group rectal toxicity scale

Grade 1Mild and self-limitingMinimal, infrequent bleeding or clear mucus discharge, rectal discomfort not requiring analgesics, loose stools not requiring medications
Grade 2Managed conservatively, lifestyle (performance status) not affectedIntermittent rectal bleeding not requiring regular use of pads, erythema of rectal lining on proctoscopy, diarrhea requiring medications
Grade 3Severe, alters patient lifestyleRectal bleeding requiring regular use of pads and minor surgical intervention, rectal pain requiring narcotics, rectal ulceration
Grade 4Life threatening and disablingBowel obstruction, fistula formation, bleeding requiring hospitalization, surgical intervention required

Prevention

  1. Use of newer conformal radiation therapy techniques.
  2. Amifostine is a prodrug that is metabolized to a thiol metabolite that is thought to scavenge reactive oxygen species
  3. Placebo-controlled phase III trials have detected no benefit from either topical or oral sucralfate.

Treatment  of radiation proctitis 

Medical

  1. Butyrates
  2. ASA
  3. Sucralfate
  4. Metronidazole
  5. Short chain FA
  6. Topical formalin
  7. Hyperbaric o2

Endoscopic

  1. dilatation
  2. Heater and bipolar cautrey
  3. ND YAG
  4. APC
  5. RFA

Surgery

Diverting ostomies for severe stricture - Better for incontinence, stricture and limited benefit  for bleed

Reconstruction with Flaps -  rectourethral or rectovaginal fistula with a pedunculated gracilis or a Martius flap to facilitate healing by introducing well-vascularized healthy tissue,

Proctectomy  complicated fistulous disease, especially when accompanied by significant pain and incontinence, or in cases of severe and intractable bleeding