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ABSITE > GI Tract > Flashcards

GI Tract Flashcards

1
Q

What stimulates and inhibits gastrin production?

A

Stimulates -> amino acids, ACh, Ca, EtOH, antral distention, pH > 3.0
Inhibits -> pH < 3.0, somatostatin, secretin, CCK

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2
Q

What stimulates somatostatin secretion?

A

Acid in duodenum

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3
Q

What is the effect of somatostatin?

A

Inhibits gastrin, HCl, insulin, glucagon, secretin, motilin, pancreatic and biliary output

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4
Q

Which cells secrete CCK?

A

I cells in the duodenum

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5
Q

What stimulates and inhibits secretin?

A

Stimulates: fat, bile, pH < 4.0
Inhibits: pH > 4.0, gastrin

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6
Q

What is the effect of secretin?

A

Increases pancreatic HCO3 release
Inhibits gastrin release (reversed in gastrinoma)
Inhibits HCl release

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7
Q

What is the action of VIP?

A

Increased GI secretions and motility

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8
Q

What is the effect of glucagon on motility and sphincter of Odi?

A

Decreases motility

Relaxes sphincter of Odi

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9
Q

What is the effect of Pancreatic Polypeptide?

A

Decreases pancreas and biliary output

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10
Q

What inhibits and stimulates motilin release?

A

Stimulates: duodenal acid, food, vagal input
Inhibits: somatostatin, secretin, pancreatic polypeptide, duodenal fat

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11
Q

What is the action of motilin?

A

Increased intestinal motility (Phase III peristalsis)

Erythromycin acts on this receptor

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12
Q

What is bombesin?

A

Gastrin releasing peptide. Increases motility, pancreas secretion, increases acid secretion

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13
Q

What is Peptide YY?

A

Released from TI in response to fat

Decreases HCl, stomach motility, GB and pancreatic secretions

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14
Q

What is the criminal nerve of Grassi?

A

Part of the right vagus which can cause persistently high acid levels if not divided during vagotomy

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15
Q

Where do the anterior and posterior vagus go?

A

Anterior -> liver/biliary tree

Posterior -> Celiac plexus

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16
Q

Where does thoracic duct cross from R to L?

A

T4/5

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17
Q

What are the characteristics of the UES?

A

15 cm from incisors
Resting pressure 60 mmHg
Pressure with food 15 mmHg

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18
Q

What is the most common site of esophageal perforation?

A

At the cricopharynxgeus muscle (UES)

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19
Q

What are the characteristics of the LES?

A

40cm from the incisors
Normal pressure at rest 15 mmHg
Normal pressure with food 0 mmHg

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20
Q

What is the distance from incisors to carina?

A

24-26 cm

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21
Q

What is the treatment of Zenker’s diverticulum?

A

Cricopharyngeal myotomy

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22
Q

What is a traction diverticulum?

A

A true diverticulum lying laterally usually in the mid-esphagus

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23
Q

What is an epiphanic diverticulum?

A

usually associated with motility disorders

Tx: diverticulectomy, esophageal myotome on opposite side

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24
Q

What is the Tx of diffuse esophageal spasm?

A

Calcium channel blockers and nitrates

Heller myotomy if those fail (upper and lower esophagus)

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25
Q

What does scleroderma do to esophagus?

A

Loss of LES tone, dysphagia and severe reflux resulting in fibrosis

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26
Q

What is the phrenoesophageal membrane an extension of?

A

The transversals fascia

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27
Q

What is the key move in a fundoplication?

A

Identification of the left crus

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28
Q

What is a Collis gastroplasty?

A

Creation of new esophagus by stapling along the stomach cardia when not enough esophagus can be pulled into the abdomen

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29
Q

What are the four types of Hiatal Hernias?

A

I - Sliding (most common, GERD)
II - Paraesophageal (normal GE junction)
III - combined
IV - entire stomach in chest + other organ

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30
Q

Why does type II hiatal hernia often need repair?

A

High risk of incarceration

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31
Q

What do almost all patients with a Schatzki’s ring have?

A

Sliding hiatal hernia

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32
Q

What is treatment for a Schatzki’s ring?

A

Dilatation of the ring and PPI

DO NOT RESECT

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33
Q

What is the treatment for severe Barrett’s dysplasia?

A

Esophagectomy

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34
Q

Does a Nissen fix Barrett’s?

A

No, it will prevent further metaplasia but will not prevent malignancy. Need screening EGD for life

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35
Q

What are symptoms/signs that esophageal CA is unresectable?

A

Hoarseness (RLN invasion), Horner’s syndrome, Phrenic nerve, malignant pleural effusion, malignant fistula, airway invasion, vertebral body invasion

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36
Q

What is the blood supply for a colon interposition reconstruction?

A

Colon marginal vessels

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37
Q

What is the chemotherapy regimen for esophageal cancer?

A

5-FU and Cisplatin

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38
Q

What is the most common benign esophageal tumor?

A

Leiomyoma

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39
Q

What is the treatment of esophageal Leiomyoma?

A

Do NOT biopsy (scar)

>5 cm or symptoms -> enucleation via thoracotomy

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40
Q

What is the initial care of caustic esophageal injury?

A

No NG tube
Nothing to drink
Do Not induce vomiting
CT C/A -> assess for perforation

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41
Q

What are indications for esophagectomy in a 2nd degree caustic burn?

A

Sepsis, peritonitis, mediastinitis, free air, mediastinal/stomach wall air, contrast extravasation, PTx, effusion

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42
Q

What is the most common cause of esophageal perforation?

A

EGD

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43
Q

What is the most common site of esophageal perforation?

A

Cervical esophagus near cricopharynxgeus muscle

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44
Q

What are the initial diagnostic tests for esophageal perforation?

A

CXR then gastrografin swallow

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45
Q

What is the treatment for non-contained esophageal perforations if < 24 hours?

A

If no major contamination primary repair with longitudinal myotomy and muscle flap interposition

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46
Q

What is the treatment for non-contained esophageal perforation if > 48 hours?

A

Neck -> Drains only

Chest -> Resection or Exclusion + Diversion

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47
Q

Where is the most likely site of perforation in Boerhaave’s syndrome?

A

Left lateral wall 3-5 cm above GE junction

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48
Q

What is Hartmann’s sign?

A

Mediastinal crunching on auscultation -> esophageal perforation

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49
Q

What is Menetrier’s disease?

A

Mucosal cell hyperplasia, Increased rugal folds

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50
Q

What is the classic presentation of gastric volvulus?

A

Severe Pain

Nausea without vomiting

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51
Q

Where is the tear in Mallory Weiss usually located?

A

Lesser curvature near GE junction

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52
Q

Why does vagotomy increase liquid emptying?

A

Decreased receptive relaxation so increased gastric pressures

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53
Q

What is a truncal vagotomy?

A

Dividing at level of esophagus -> decreases emptying of solids

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54
Q

What is a proximal vagotomy?

A

Highly selective, divides individual fibers
Preserves “crow’s foot”,
Normal emptying of solids

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55
Q

What are other effects of a truncal vagotomy?

A

Decreased acid output, increased gastrin and G cell hyperplasia
Decreased exocrine pancreas function, bile flow, increased GB volumes
Diarrhea (40%) - > due to sustained MMCs forcing bile acids into colon

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56
Q

What is a Heineke-Mikulicz pyloroplasty?

A

Longitudinal incision and transverse closure

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57
Q

What is the diagnostic test for slow bleeds with difficulty localizing source?

A

Tagged RBC scan

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58
Q

What are the biggest risk factors for re-bleeding on EGD?

A 
Spurting blood vessel (60% chance)
Visible blood vessel (40%)
Diffuse oozing (30%)
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59
Q

What is triple therapy for H. Pylori?

A

Amoxicillin
Flagyl/Tetracycline
Omeprazole
+/- Bismuth Salts

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60
Q

What are surgical indications for duodenal ulcers?

A 
Perforation
Protracted bleeding
Obstruction
Intractability
Inability to rule out cancer
If on PPI -> need acid reducing procedure as well
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61
Q

What are surgical options for acid reducing surgery in order of recurrence risk?

A 
Truncal vagotomy + Antrectomy (2% mortality)
Truncal vagotomy + Pyloroplasty (1% mortality)
Proximal vagotomy (lowest complications, 10-15% recurrence)
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62
Q

What are reconstruction options after antrectomy?

A

Roux-en-Y GJ (best, less dumping and reflux gastritis)
B1 (GD anastomosis)
B2 (GJ anastomosis)

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63
Q

What is definition of major duo ulcer bleeding?

A

> 6 u pRBC in 24 hours, or hypotension despite transfusion

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64
Q

What is the surgery for bleeding duodenal ulcers?

A

Duodenotomy and GDA ligation
Complication: CBD injury
If on PPI -> need acid reducing surgery as well

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65
Q

What is the treatment for an obstructing duodenal ulcer?

A

PPI and serial dilations

Surgery: antrectomy and truncal vagotomy (need Bx for cancer rule out)

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66
Q

What is the definition of intractability for a duodenal ulcer?

A

> 3 months without relief while on escalating doses of PPI

Based on EGD mucosal findings, not symptoms

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67
Q

Where are 80% of gastric ulcers located?

A

Lesser curvature of the stomach

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68
Q

What are the types of gastric ulcers?

A

I - Lesser curvature low along body of stomach due to decreased mucosal protection
II - 2 ulcers (lesser curvature and duodenal) high acid
III - Pre-pyloric (high acid)
IV - lesser curvature high along cardia (decreased mucosal protection)
V - Associated with NSAIDs

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69
Q

Surgical indications for gastric ulcers?

A

Perforation, bleeding not controlled with EGD, obstruction, cannot exclude malignancy, intractability (based on EGD)

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70
Q

Why should you always resect gastric ulcers at the time of surgery?

A

High risk of malignancy

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71
Q

What are the two types of chronic gastritis?

A 
Type A (funds) - Pernicious anemia, autoimmune dz
Type B (astral) - Associated with H. Pylori
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72
Q

Where are the majority of gastric cancers located?

A

Antrum

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73
Q

What is a Krukenberg tumor?

A

Metastases to ovaries

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74
Q

What is the intestinal-type gastric CA?

A

Seen in high risk populations (old Japanese men)

Tx: Subtotal gastrectomy (10 cm margin)

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75
Q

What is the most common type of gastric cancer in the US?

A

Diffuse (linitis plastica)
Diffuse lymphatic invasion
Less favorable prognosis
Tx: Total gastrectomy

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76
Q

What is the chemotherapy for gastric cancer?

A

5FU, doxorubicin, mitomycin C

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77
Q

What is the palliative procedure for obstructing gastric CA?

A

Stent proximal lesions

Bypass distal lesions with G-J

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78
Q

What is the most common benign gastric neoplasm?

A

GIST

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79
Q

What are the characteristics of GIST?

A

Hypoechoic on ultrasound with smooth edges
C-KIT positive
>5 cm or > 5 mitosis/50 HPF = MALIGNANT

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80
Q

What is the Tx for GIST?

A

Resection with 1 cm margins

Imatinib if malignant

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81
Q

What is the most common type of lymphoma in the stomach?

A

non-Hodgkin’s lymphoma (B cell)

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82
Q

What are the treatments for gastric lymphoma?

A

Chemo and XRT

Surgery possible for stage I disease (confined to stomach)

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83
Q

What are the criteria for bariatric surgery?

A

BMI > 40 or > 35 with comorbidities
Failure of nonsurgical methods
Psychological stability
No drug or EtOH abuse

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84
Q

What gets better after weight loss surgery?

A

DM, cholesterol, OSA, HTN, incontinence, GERD, venous ulcers, pseudotumor cerebri, joint pain, migraines, depression, PCOS, NAFLD

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85
Q

What are the risks of Roux-en-Y gastric bypass?

A 
Marginal ulcers
Leak
Necrosis
Fe and B12 deficiency
Gallstones
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86
Q

What is the treatment for a leak after Roux-en-Y?

A

early (not contained) -> re-operation

Late (likely contained) -> perc drain, abx

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87
Q

What is the rate of marginal ulcer development?

A

10%

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88
Q

What are symptoms of dilation of the excluded stomach after Roux-en-Y?

A

Hiccoughs, large stomach bubble

Tx: G-tube

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89
Q

Why is SBO a surgical emergency in bypass patients?

A

High risk of small bowel herniation, strangulation, infarction, necrosis

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90
Q

What are the two phases of dumping syndrome?

A

Hyporsomotic fluid shift (hypotension, diarrhea, dizziness)
Hypoglycemia from reactive insulin release (rare)
Tx: small, low-fat, low carb meals, no liquids with meals
Octreotide

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91
Q

What are surgical options for dumping syndrome?

A

Conversion to Roux-en-Y GJ
Operations to increase gastric reservoir (j-pouch)
Increase emptying time (reversed J loop)

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92
Q

What causes alkaline reflux gastritis? Tx?

A

Bile reflux into stomach
Tx: PPI, choleystramine, reglan
sTx: B1 or B2 to Roux-en-Y with afferent limb 60 cm distal to GJ

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93
Q

What is chronic gastric atony? Tx?

A

Delayed gastric emptying
Tx: reglan, prokinetics
sTx: roux-en-Y

94
Q

What causes blind-loop syndrome?

A

Poor motility with B2 or Roux-en-Y

95
Q

What are the symptoms of blind-loop syndrome?

A

Pain
Steattorehea (bacteria deconjugate bile)
B12 deficiency (used by bacteria)
Malabsorption

96
Q

What causes blind loop syndrome?

A

Bacterial overgrowth from stasis in afferent limb

97
Q

How do you diagnose blind loop syndrome?

A

EGD of afferent limb with aspirate and cultures

98
Q

What is the tx of blind loop syndrome?

A

Tetracycline and flatly, reglan

sTx: re-anastomosis with shorter (< 40 cm) afferent limb)

99
Q

What causes afferent loop obstruction?

A

Mechanical obstruction of afferent limb

Sx: RUQ pain, steatorrhea, nonbilios vomiting, pain relief with bilious emesis

100
Q

What is the treatment of afferent loop obstruction?

A

Baloon dilation

sTx: re-anastomosis with shorter (40 cm) afferent limb)

101
Q

What causes post-vagotomy diarrhea?

A

Non-conjugated bile salts in colon
Casued by sustained postprandial organized MMCs
Tx: cholestyramine, octrotide
sTx: reversed interposition jejunal graft

102
Q

What is the treatment of duodenal stump blow out?

A

Place lateral duodenostomy tube and drains

103
Q

What is the transition point of the 3rd and 4th portion of duodenum?

A

Aorta/SMA

104
Q

What is maximally absorbed in the TI?

A

B12
Conjugated bile acids (only site of absorption)
Folate

105
Q

How long are the jejunum and ileum?

A

Jejunum: 100 cm
Ileum: 100 cm

106
Q

How can you identify the jejunum from the outside?

A

Long vasa recta

Circular muscle folds

107
Q

What are the four phases of migrating motor complexes?

A

I - Rest
II - Acceleration and GB contraction
III - Peristalsis
IV - Deceleration

108
Q

What does a Sudan red stain show?

A

Fecal fat

109
Q

What is the Schilling test?

A

Checks for B12 absorption

110
Q

How much intestine do you need to survive off of TPN?

A

75 cm

Maybe 50 with a competent ileocecal valve

111
Q

What are the causes of non-healing fistulas?

A 
F - Foreign Body
R - Radiation
I - Inflammation
E - Epithelialization
N - Neoplasm
D - Distal obstruction
S - Sepsis/infection
112
Q

How do you assess for abscess in fistula with persistent fever?

A

Fistulogram
Abdominal CT
UGI with SB follow through

113
Q

What are surgical indications for SBO?

A 
Progressing pain
Peritoneal signs
Fever
Increasing WBCs
Failure to resolve
114
Q

What is classic finding of gallstone ileus?

A

Air in biliary tree with SBO

115
Q

What is the most common tissue found in a Meckel’s?

A

Pancreatic tissue

116
Q

What type of mucosa is most likely to be symptomatic in a Meckel’s?

A

Gastric

117
Q

When do you need a segmental bowel resection for Meckel’s?

A

Complicated Diveticulitis (perforation)
neck > 1/3 diameter of normal bowel
Diveritculitis involving the base

118
Q

What is the frequency of diverticula in the small bowel?

A

Duodenum > Jejunum > Ileum

119
Q

What must be ruled out with a duodenal diverticulum?

A

GB-Duodenal fistula

120
Q

How do you treat a juxta-ampullary duodenal diverticulum?

A

Choledocchojejunostomy for biliary sx
ERCP with stent for pancreas sx
AVOID WHIPPLE

121
Q

What is the medical treatment for Crohn’s?

A

5-ASA and Loperamide (maintenance)
Steroids (flairs)
Remicade -> fistulas or steroid resistance
TPN may induce remission and fistula closure

122
Q

What are indications for surgery in Crohn’s disease?

A 
Obstruction (conservative first)
Abscess (perc drainage)
Megacolon (perforation in 15%)
Hemorrhage
Blind loop obstruction
Fissures (NO LIS)
EC fistula (conservative first)
Perineal fistula (unroof to r/o abscess, then let heal)
Anorectovaginal fistulas (rectal advancement flap)
Get 2 cm from gross disease with surgery
123
Q

What is the procedure for those with diffuse colonic Crohn’s?

A

Total proctocolectomy with ileostomy

124
Q

What do you do with incidental IBD found on appendectomy?

A

Remova normal appendix if cecum not involved to r/o future confounding

125
Q

When should you do a stricturoplasty?

A

If you are trying to save bowel length

126
Q

What type of kidney stones do you get with TI resection?

A

Calcium oxalate (increased oxalate absorption 2/2 decreased fat absorption and fat binding calcium)

127
Q

What are the hallmark symptoms of carcinoid syndrome?

A 
Intermittent flushing (from bradykinin)
Diarrhea (from serotonin)
128
Q

What are the diagnostic tests for carcinoid?

A 
Chromogranin A level (highest sensitivity)
Octreotide scan (localizing tumor)
129
Q

What are the most common sites for carcinoid?

A

Appendix > ileum > rectum

130
Q

What is the treatment for appendices carcinoid?

A

< 2 cm = Appendectomy

> 2 cm or involving base = right hemicolectomy

131
Q

What is the treatment for small bowel carcinoid?

A

Segmental resection with lymphadenectomy

132
Q

What ist he chemotherapy for carcinoid?

A

Streptozocin and 5-FU

133
Q

What are the treatments for carcinoid syndrome symptoms?

A

Octreotide (global)
Aprotinin - for bronchospasm
alpha blockers - for flushing

134
Q

What is a the presentation of a small bowel adenoma?

A

Bleeding, obstruction

Tx: resection (often endoscopic)

135
Q

What is the most common extra-intestinal malignancy in Peutz-Jeghers syndrome?

A

Breast cancer

136
Q

What are risk factors for duodenal cancer?

A

FAP
Gardner’s syndrome
Polyps and adenomas
von Recklinghausen’s disease (NF1)

137
Q

What is the most common site of small bowel adenocarcinoma?

A

Duodenum

138
Q

Where are leiomyosarcomas found in the small bowel?

A

Jejunum and ileum, extraluminal

139
Q

Where is lymphoma usually found in the small bowel?

A

Ileum

140
Q

What is small bowel lymphoma usually associated with?

A 
Wegner's
SLE
AIDS
Crohn's
Celiac dz
Post-transplantation
141
Q

What is the treatment for small bowel lymphoma?

A

Wide en-bloc resection (including nodes)

1st or 2nd portion of Duo -> XRT (no whipple)

142
Q

What is the most common stoma infection?

A

Candida

143
Q

What is diversion colitis caused by?

A

Lack of short-chain fatty acids (tx SCFA enemas)

144
Q

What is the most common cause of stenosis of stoma?

A

Ischemia

145
Q

What types of stones are increased with ileostomy?

A

Gallstones

Uric acid kidney stones

146
Q

What are CT findings of appendicitis?

A

Diameter > 7 mm
Wall thickness > 2 mm (bulls eye)
Fat stranding
No contrast in lumen

147
Q

What area of the appendix is most likely to perforate?

A

Midpoint of the anti-mesenteric border

148
Q

What should you consider in an elderly person with perforated appendicitis?

A

Perforated cecal colon cancer

149
Q

What is different about appendicitis in pregnancy?

A

Need to make incision where the pain is as appendix is displaced cephalad

150
Q

What is the fetal mortality with appendices rupture?

A

35%

151
Q

What must be tested on women with suspected appendicitis?

A

HcG and abdominal U/S to rule out appendicitis

152
Q

What is treatment for appendix mucocele?

A

Open appendectomy to avoid spillage

Right hemicolectomy if malignant

153
Q

What is the most common cause of death with appendix mucocele?

A

SBO from peritoneal tumor spread

154
Q

What can mimic appendicitis?

A

Regional ileitis -> 10% go on to get Crohn’s

155
Q

What if you operate and do not find appendicitis?

A

Generally remove appendix except of there is cecal enteritis

156
Q

What is the defining radiographic feature of ileus?

A

Uniform dilatation of stomach, small bowel, colon and rectum without decompression

157
Q

What are the signs of typhoid enteritis (salmonella)?

A

RLQ pain, diarrhea, fever, headaches
Maculopapular rash
Leukopenia
Tx; Bactrim

158
Q

What happens to the Taenia at the rectosigmoid junction?

A

They become broad and completely encircle bowel

159
Q

How far is the dentate line from the anal verge?

A

2 cm

160
Q

Where does the inferior rectal artery branch from?

A

Internal Pudendal

161
Q

What is lymphatic and venous drainage of the rectum?

A

Superior and middle -> IMV and IMA nodes

Lower rectum -> Internal Iliac Vein, IMA nodes and iliac nodes

162
Q

What are the two watershed areas?

A

Griffith’s Point at the splenic flexure

Sudan’s point in the rectum

163
Q

What innervates the external sphincter?

A

Inferior rectal branch of the internal pudendal nerve

164
Q

What are some important distances from the anal verge?

A

0-5 cm - Anal Canal
5-15 cm - Rectum
15-18 cm - Rectosigmoid Junction

165
Q

What are Denonvilliers and Waldeyer’s fascia?

A

Denonvilliers -> rectovaginal or rectovesicular

Waldeyer’s -> rectosacral

166
Q

What increases cancer risk in a polyp?

A

> 2 cm
Sessile
Villous

167
Q

What is intramucosal cancer?

A

Still in situ, has gone into muscularis mucosa but not basement membrane

168
Q

When is a polypectomy adequate for a T1 lesion?

A

If margins are clear (2 mm), well differentiated, no vascular/lymphatic invasion

169
Q

What is the tx for low rectal villous adenomas with atypic?

A

Transanal excision

APR only if true cancer is present

170
Q

What if pathology shows T1 or T2 lesion after transanal excision?

A

T1 -> if 2 mm, well differentiated, no invasion, nothing further
T2 -> APR or LAR

171
Q

How does rectal CA metastasize to the spine?

A

Directly via Batson’s plexus (venous)

172
Q

What histologic features of colon CA have a better and worse prognosis?

A

Lymphocytic -> improved

Mucoepidermoid -> worst prognosis

173
Q

What is the implication of rectal pain with a rectal CA?

A

Needs APR

174
Q

What margins are needed with colon cancer?

A

2 cm

175
Q

What is the best method for assessing hepatic mets?

A

Intraoperative U/S (resolution 3-5 mm vs. 10 mm for transabdominal)

176
Q

What is the role of pre-op Chemo/XRT in rectal cancer?

A

Can produce response and preserve sphincter function in some

177
Q

What is the N staging for colorectal cancer?

A

N1: 1-3 nodes
N2: >4 nodes
N3: central nodes

178
Q

When is chemo/XRT used in colorectal cancer?

A

Stage III and IV colon CA -> post-op chemo only
Stage II and III rectal -> Preop chemo+XRT
Stage IV rectal -> chemo/xrt +/- surgery

179
Q

What is the chemotherapy for colorectal cancer?

A

FOLFOX = 5FU, leucovorin, oxaliplatin

180
Q

What is recurrence rate on colorectal cancer?

A

20%

5% get a second primary (follow up colonoscopy at 1 year)

181
Q

What is the surveillance for FAP?

A

Flexible sigmoidoscopy

182
Q

Where else do those with FAP get polyps?

A

Duodenum

183
Q

What is Gardner’s syndrome?

A

Colon CA and Desmoid Tumors/Osteoms

184
Q

What is Turcot’s syndrome?

A

Colon cancer and brain tumors

185
Q

What are the two types of Lynch syndrome?

A

Lynch I -> just colon cancer

Lynch II -> also increased ovarian, endometrial, bladder, gastric cancers

186
Q

What are the Amsterdam Criteria for Lynch syndrome?

A

“3-2-1”

3 first degree relatives over two generations with one cancer prior to age 50

187
Q

What is the treatment for HNCC?

A

Total proctocolectomy with the first cancer diagnosis

188
Q

What are risk factors for sigmoid volvulus?

A

High fiber diets (middle east)
Psychiatric patients
Neurologic dysfunction
Laxative abuse

189
Q

What are the findings for sigmoid volvulus on AXR?

A

Bent inner tube sign

Bird’s beak with gastrograffin enema

190
Q

What is the Tx for sigmoid volvulus?

A

Peritoneal signs -> Sigmoidectomy

Decompression with colonoscopy (80% reduce, 50% recur) -> sigmoid colectomy during same admission

191
Q

What are the characteristics of cecal volvulus?

A

younger patients in 20s-30s

see a dilated cecum in the RLQ

192
Q

What are the findings of the mucosa with UC?

A

Mucosal friability

Pseudopolyps and collar-button ulcers

193
Q

What is definition of toxic colitis?

A 
> 6 blood stools/d
Fever
Tachycardia
Drop in Hgb
Leukocytosis
194
Q

What is toxic megacolon?

A

Toxic colitis + distention, abd pain, tenderness

195
Q

What is the initial treatment of toxic colitis and toxic megacolon?

A

NG tube, IVF, steroids, bowel rest, abx
Treats 50%
Avoid: barium enemas, narcotics, anti-diarrheal agents, anti-cholinergics

196
Q

What are absolute indications for surgery with toxic colitis/megacolon?

A 
Pneumoperitoneum
Diffuse peritonitis
Localied peritonitis with increased pain/distention
Uncontrolled sepsis
Major hemorrhage
197
Q

What are relative indictions for surgery with toxic megacolon/colitis?

A 
Inability to promptly control sepsis
Increasing
Failure to improve in 24-48 hours
Increasing toxicity or signs of deterioration
Continued transfusion requirements
198
Q

What are the common sites of perforation for UC and Crohn’s?

A

UC - T colon

Crohn’s - TI

199
Q

What are surgical indications fur UC?

A 
Massive hemorrhage
Refractory toxic megacolon
Acute fulminant UC 
Obstruction
Any dysplasia or cancer
Intractability and systemic complications
FTT
Long-standing disease
200
Q

What is done for elective resections for UC?

A

Ileoanal anastomosis with rectal mucosectomy and J-pouch with temporary diverting ileostomy

201
Q

What is the cancer risk with UC?

A

1% per year starting 10 years after initial diagnosis

202
Q

What manifestations of UC do and do not get better with colectomy?

A

Get better: ocular problems, arthritis, anemia
Do not: PSC, ankylosing spondolytis
50% get better: Pyoderma gangrenosum

203
Q

What is the treatment for low rectal carcinoids?

A

< 2 cm -> WLE with negative margins

> 2 cm or invasion of muscular -> APR

204
Q

Where is colonic perforation most likely to occur in setting of obstruction?

A

In the cecum

205
Q

What is the treatment for Ogilvie’s syndrome?

A

Electrolyte repletion
Discontinue drugs that slow colon
NGT
If colon > 10 cm -> decompression with colonoscopy and neostigmine

206
Q

Where is the most common colonic site of actinomycetes infection?

A

Cecum
Yellow-White sulfur granules
Tx: penicillin or tetracycline

207
Q

Where are bleeding diverticula most likely to be located?

A

On the right side

208
Q

What is the limit of detection for for LGIB for arteriography and tRBC scans?

A

Arteriography > 0.5 cc/min

tRBC > 0.1 cc/min

209
Q

What do you need after an episode of diverticulitis?

A

Follow up colonoscopy to r/o cancer

210
Q

What are signs of complicated diverticulitis?

A 
Obstruction
Fluctuant mass
Peritoneal signs
Temp > 39
WBCs > 20
211
Q

What is treatment for R sided diverticulitis?

A

Right hemicolectomy

212
Q

What is the Dx algorithm for LGIB?

A

NGT to r/o UGI
Colonoscopy
Angio first if massive bleed
OR if hypotensive and not responding to resuscitation (colectomy vs subtotal colectomy if site is localized)

213
Q

What are the characteristics of angiodysplasia bleeds?

A

Less severe than diverticular but more likely to recur

214
Q

What cardiac finding is associated with colonic angiodysplasia?

A

Aortic stenosis

215
Q

What are the key findings in C. Diff colitis?

A

PMH inflammation of mucosa and submucosa

216
Q

What is the treatment for neutropenic typhlitis?

A

Antibiotics

surgery ONLY for free perforation

217
Q

What is the venous drainage of the anus?

A

Above dentate -> internal hemorrhoid plexus

Below dentate -> external hemorrhoid plexus

218
Q

What are the grades of hemorrhoids?

A

I - Slides below dentate with strain
II - prolapse and spontaneous reduction
III - manual reduction required
IV - incarcerated

219
Q

What causes rectal prolapse?

A

Pudendal neuropathy and laxity of sphincters

220
Q

What are the treatments for rectal prolapse?

A

Medical: High fiber diet
Surgical: Perineal rectosigmoid resection (Altemeir) or LAR and pexy of residual colon

221
Q

What do you worry about with lateral or recurrent fissures?

A

IBD

222
Q

Which perianal abscesses can be drained through the skin?

A

Perianal
Intersphincteric
Ischiorectal
All are below levators

223
Q

When are antibiotics needed for anorectal abscess?

A

Cellulitis
DM
Immunosuppressed
Prosthetic hardware

224
Q

What is Goodsall’s rule?

A

Anterior fistulas connect with anus/rectum in a straight line
Posterior go towards the midline internal opening in the anus

225
Q

What is the treatment for rectovaginal fistula?

A

Simple - trans-anal rectal mucosa advancement flap

Complex -> abdominal approach with resection, closure, interposition and temporary ileostomy

226
Q

What is the tx for anal incontinence from abdominoperinal descent?

A

high-fiber diet, reduced BMs

2/2 chronic damage to levator and pudendal nerves

227
Q

What is the treatment for anal incontinence from obstetrical trauma?

A

Anterior Anal Sphincteroplasty

228
Q

What are the various anorectal findings in AIDS?

A

Nodule with ulceration = Kaposi’s
Shallow ulcers = CMV (presents like appendicitis)
Rectal Ulcer = HSV
Abscess/ulcer = B cell lymphoma

229
Q

What is the treatment for Squamous CA of the anal canal?

A 
Nigro Protocol (chemo-XRT with 5FU and mitomycin)
APR for treatment failures
230
Q

What is the treatment for adenocarcinoma of the anal canal?

A

APR

WLE if < 3 cm and < 1/3 circumference and T1 and no invasion. Needs 1 cm margin

231
Q

What is the characteristics of anal melanoma?

A

3rd most common site
Sx: rectal bleeding
Most not pigmented at all
APR

232
Q

What is the treatment for Squamous cell CA of anal margin (below dentate line)

A

WLE < 5 cm
Chemo-XRT (5FU and cisplatin) for > 5 cm if involving sphincter or positive nodes
Need inguinal node dissection if clinically positive

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