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CRCA Has to know: etiology, features of right vs left colon and rectal CA, Investigations in emergency and elective,

management: dpnds on site Commonest CA in Msia (male), 3rd commonest in females 8% of all CA in Msia Chinese>Indian>Malays

Suspect CRCA in elderly presents with constitutional symptoms. And patient wif h/o or family h/o IBD. Epidemiology: Age > 50 y/o M>F (in Malaysia) western , female more common Family history FAP, Lynch Syndrome 1 (Lynch syndrome 2 a/w gastric CA, endometrial CA and urothelial CA), CRCA 85% at rectosigmoid junction 70% occurs from sporadic adenomatous polyps o Tubular adenoma with high grade dysplasia need to be f/up and do colonoscopy once every 6 months. If with low-grade dysplasia f/up colonoscopy 2-3 yearly

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30% from HNPCC 5% from FAP

If positive h/o FAP screen all family members. Rx: total colectomy with ilioanal anastomoses FAP- autosomal dominant. Defect in APC gene at chromosome 5. Scope > 100 polyps. 50% detected by 12 y/o and 95% detected by 35 y/o. Attenuated FAP: > 30 polyps but < 100 polyps. HNPCC amsterdam and Bethesda classification (not at our level but good to know) Risk factors of CRCA: 1) Increasing age > 50 y/o except in FAP and IBD 2) Low fibre diet 3) Polyps esp tubular adenoma

4) Family history 5) IBD (UC>CD). In chrohns: more on anorectal fistula, fissures, and perianal abscess. Ulcerative colitis more a/w crca. 6) Personal history of breast ca 7) DM,smoking, alcohol 8) Etccari ek

Spread: if at caecum: spread through bowel wall and Lymph nodes at rectum: coz fistula/direct organ invasion. Fistula with bladder, vagina. May invade sacral plexus and cause back pain mets to lungs and liver

most common type: adenocarcinoma. But if 1-2 cm from anus, it is squamous CA anal CA mass protrudes from anus, involve inguinal lymph nodes, may present wif bilateral lymphedema due to compression of inguinal LN. responds to radiotherapy HPE-if mucinous/signet ring poor prognosis and not respond to radiotherapy Investigations: Colonoscopy : in non obstruction case. Do not perform scope in pt presents with obstruction. To look for mass (nature, size, site, obstruct lumen, bleeding mass, extent and do biopsy for HPE) If presence of obstructed lumen or bleeding mass indication for emergency intervention Double contrast barium enema: apple core (Obstruction), polyps, diverticulum CT scan Thorax, Abdomen, Pelvis for mets MRI or endoanal ultrasound in low rectal CA to look for mesorectal involvement and rectal wall involvement. As for neo-adjuvant chemotherapy (5-Fluouracil). Adjuvant for CRCA: if Duke C, with T4, evidence of distant mets. Elective investigations: PET scan: if CEA normal and normal CT scan/MRI but pt symptomatic CEA: as baseline for f/up and check response to adjuvant/neoadjuvant therapy. Increase CEA suspects recurrence, then do scope.

Emergency: Unprepared pt and with obstruction, do barium enema and CT scan abdomen and pelvis

Treatment dpnds on stage, age and site (eg. Rectal CA: neo-adjuvant, colon: no role for neo-adjuvant except with fistula) Survival rate is higher with early stage. Survival dpnds on stage of primary tumour and mets. If patient has end-stoma, check anus, if presence means it is a Hartmanns procedure. If no anus, it is Abdomino Perineal Resection.

Further surgery: (to reduce tumour burden and to increase respond towards chemotherapy to prolong survival period) Selective liver resection Selective lung resection Selective intraabdominal CA

Duke stage: pathological staging f/up: 1) Clinical surveillance symptoms 2) CEA 3) Surveillance colonoscopy a. If pt presents emergency and no scope been done previously, do full scope after 6 months post-op b. In all post-op pt, do colonoscopy yearly for 5 years. Then if clear scope (no mass or polyps), do scope once every 3 years. 4) Liver US 5) PET CT Prevention: 1) Diet 2) Exercise

3) Surveillance in high risk group 4) Fecal occult blood in screening population, not in hosp setting 5) Colonoscopy 6) CT colonography Flexible sigmoidoscopy: in young pt with PR bleeding Easy to prepare the patient, faster and minimally invasive Can go up to transverse colon If has abnormal finding, need to prepare the pt for proper colonoscopy If previous scope revealed mass at sigmoid area, do flexible sigmoidoscopy for biopsy.

In anterior resection, margin to be resected : 10cm proximal to the mass and 5 cm distal to the mass.

Need to know about ulcerative colitis and chrohn disease. How to differentiate and extra-manisfestation of chrohn disease Colonostomy vs ileostomy. Cx stoma. How to examine stoma..for short case??.... Percentage of individual risk of CRCA with family history of CRCA MCQ