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Clin Med III, Exam 2 (ASL) > Bowel Obstruction And Butthole Probs (Lauren 🌭) > Flashcards

Bowel Obstruction And Butthole Probs (Lauren 🌭) Flashcards

1
Q

What is the difference between a partial and complete bowel obstruction?

A

Fluid and air can still pass in partial

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2
Q

What are the 3 ~broad~ causes of obstruction?

A

Extrinsic- something external compresses bowel (adhesions, abscess)

Intrinsic- something within the wall of bowel compresses (strictures)

Intraluminal- something like fecal impaction that prevents passage

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3
Q

What happens to the bowel that is proximal to an obstruction?

A

Bowel dilatation**

Retention of fluid**

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4
Q

What happens to the bowel distal to the obstruction?

A

Bowel decompresses

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5
Q

What causes the distention experienced by patients with bowel obstruction?

A

Swallowed air and gas from fermentation

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6
Q

In an obstruction, edematous bowel wall leads to ___________ ________

A

Fluid sequestration

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7
Q

Why are people with bowel obstruction volume depleted?

A

Due to the fluid sequestration within the edematous bowel wall

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8
Q

How could excessive dilatation lead to perforation?

A

It can compromise the vascular supply causing ischemia—> Necrosis —-> Perforation

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9
Q

What are the top 3 causes of small bowel obstruction?

A

ADHESIONS (65-75%)***

Hernia***

Neoplasm***

**KNOW THIS*

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10
Q

What causes adhesions?

A

Prior abdominal or pelvic surgery like appendectomy, GYN surgery, colorectal

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11
Q

If your patient has a small bowel obstruction, what do you most expect to learn in their history?

A

They had a previous abdominal surgery

65-75% of SBO’s are caused by adhesions compressing the bowel!!

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12
Q

How do post-operative adhesions cause small bowel obstruction?

A

They are fibrous bands that press down on the bowel

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13
Q

Risk of adhesions following surgery increases with _______

A

Time!!!!!

After 10 years or more, youre more likely to get adhesions

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14
Q

What will you find out when you ask ROS questions of someone who has small bowel obstruction?

A

+/- fevers and chills

Intermittent periumbilical cramping that turns into constant focal pain that may indicate peritonitis (Bad sign)

Bloating/distention

Anorexia (They don’t want to take anything by mouth)

Nausea

Vomiting

+/- hematochezia

Constipation

Obstipation

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15
Q

What is obstipation?

A

Inability to fart or poop

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16
Q

What will you find on physical exam of someone with small bowel obstruction?

A

Vitals: +/- fever, tachycardia, hypotension, shock

General: distress, *lying motionless**

Skin: decreased turgor, dry mucous membranes (VOLUME DEPLETED)

Abdominal: high pitched tinkling bowel sounds in early phase or hypoactive/absent bowel sounds in late phase ((bad sign). Tympany on percussion.

peritoneal signs- guarding, rigidity, rebound tenderness (RED FLAG)

DRE: gross/occult blood, fecal impaction or rectal mass

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17
Q

What are the RED FLAGS and BAD SIGNS in the physical exam findings for small bowel obstruction?

A

Shock

Lying motionless (Peritonitis)

Hypoactive/absent bowel sounds

Peritoneal signs- guarding, rigidity, rebound tenderness

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18
Q

Which will come first in abdominal ~medical~ conditions: pain or vomiting?

A

Vomiting before pain

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19
Q

Which will come first in abdominal ~surgical~ conditions: pain or vomiting?

A

Pain before vomiting

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20
Q

What labs will you order for SBO?

A

CBC

CMP

Amylase/Lipase

UA

Lactate/LDH

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21
Q

Why might H/H and BUN/Cr be high in someone with SBO?

A

dehydration

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22
Q

What can abdominal X-rays tell you about SBO, and what can they NOT tell you?

A

They can tell you if you have a SBO

They CAN’T tell you where, what’s causing it, if it’s complete, etc. You need a CT to tell you that

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23
Q

What X-Ray views do you order for SBO?

A

Supine

Upright

CXR

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24
Q

What will you see on X-Rays of Small Bowel Obstruction?

******

A

Dilated loops of bowel with air fluid levels**

Proximal bowel dilation with distal bowel collapse

CXR to look for free air consistent with perforation *****

KNOW THIS CARD*

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25
Q

If you have no idea wtf kind of imaging youre supposed to get but you have a very high suspicion for SBO or strangulated bowel, what should you do?

A

CALL A SURGEON AND LET THEM DECIDE ON IMAGING

Strangulated bowel is a surgical emergency!

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26
Q

How do you manage Small Bowel Obstruciton?

A

Admit

Surgery/GI consult

Trial of non-operative management

Serial clinical monitoring over the next 2-5 days: improvement evidenced by decreased distention, passage of gas/stool, decrease in NG output

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27
Q

How do you do a trial of non-operative management for SBO?

A

NPO

Volume RESUSCITATION (not maintenance fluid)

Electrolyte monitoring

Bowel decompression with NG tube set to suction

Anti-emetics, analgesics, antibiotics

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28
Q

What would make you do surgery for SBO?

A

Complications (ischemia, necrosis, perforation)

Intestinal strangulation

Worsening/unresolved symptoms with NG tube and bowel rest

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29
Q

What signs might make you think that your patient’s bowel obstruction has become ischemic, necrotic, or perforated?

A

Worsening abdominal pain

Fever

Tachycardia

Leukocytosis

Metabolic acidosis

Peritonitis

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30
Q

How will a patient with peritonitis present?

A

Looks sick

Lie still to minimize pain

Hypoactive/absent bowel sounds

Peritoneal signs

Significant pain with light palpating or bumps

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31
Q

If an adult has intussusception, what almost always causes it

A

Tumor

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32
Q

What is this:

“Hypomotility of GI tract in absence of mechanical bowel obstruction”

A

Ileus

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33
Q

What are the two main situation where we see patient with paralytic ileus?

A

Postoperative abdominal surgery (inflammatory response to intestinal manipulation/trauma)

Use of hypomotility agents (opioids, antispasmodic, anticholinergics)

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34
Q

How will a patient with ileus present?

A

Same presentation as Small Bowel Obstruction:

Pain, distention, bloating, gassy, NV, inability to tolerate PO, tympany,

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35
Q

What will you see on abdominal x ray of ileus?

A

Dilated loops of bowel BUT air present in BOTH small bowel and colon. NO air fluid levels

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36
Q

How do you manage ileus?

A

Similar to SBO:

IV fluids/Lyte replacement

Pain management (avoid narcotics)

Bowel rest

Bowel decompression with NG tube

Walk around

None of this was red or bolder

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37
Q

What is the most common cause of Large Bowel Obstructin?****

A

Adenocarcinoma, commonly colorectal **!!!**

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38
Q

What are the other possible causes of LBO, other than adenocarcinoma?

A

Stricture

Volvulus

IBD

Fecal impaction

Foreign bodies 🍾

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39
Q

What questions should you ask a patient if you suspect large bowel obstruction?

A

Hx of hematochezia, bleeding, or change in stool caliber (cancer q’s)

Personal or FH of cancer

LLQ pain with diarrhea

Chronic opioid use or constipation?

None of this was in red

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40
Q

How will a patient with LBO present?

A

Similar to SBO:

+/- Fever/chills

Crampy pain

Bloating/distention

Constipation/Obstipation

+/- NV

Normal to quiet bowel sounds

Abdominal tenderness

+/- peritoneal signs

Hematochezia

DRE- occult blood, impaction, rectal mass

None of this was in red

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41
Q

What labs/imaging will you get if you suspect LBO?

A

Pretty much the same stuff as SBO:

CBC, CMP, UA, LDH/lactate

Plain abdominal films supine and upright

CXR

Gastrografin enema if x ray unclear

CT scan

None of this was in red

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42
Q

What will you see on X ray if your patient has a LBO?

A

Distended colon proximal to obstruction

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43
Q

How do you manage a ~partial~ Large Bowel obstruction?

A

Trial of conservative therapy:

Surgical consult

NPO

IV fluids

Antibiotics

Decompression with NG tube if vomiting

Avoid narcotics and anticholinergics

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44
Q

How do you treat a ~complete~ large bowel obstruction?

A

Depends on the cause:

Cancer- surgical resection

Stricture- surgical resection

Cecal volvulus- surgical resection

Sigmoid volvulus- sigmoidoscopy with reduction

Intussusception- barium enema

Fecal impaction- enema

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45
Q

Which is the more common type of volvulus: sigmoid or cecal?

A

Sigmoid

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46
Q

What is this:

Abnormal twisting of a portion of the GI tract, usually the intestine, which can impair blood flow

A

Volvulus

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47
Q

What are the mean age groups that get sigmoid volvulus vs cecal volvulus?

A

Sigmoid: 70 yrs, constipated

Cecal: 33-53yrs

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48
Q

What are teh risk factors for sigmoidal volvulus?

A

Chronic constipation

Redundant sigmoid colon

Colon dysmotility

Hypomotility agents

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49
Q

How does the management of volvulus differ between sigmoid and cecal volvuli?

A

Sigmoid: flex sig to decompress and de-rotate. Surgery to resect redundant sigmoid colon

Cecal: surgery

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50
Q

What is the dentate line?

A

Line in anus that separates area of pain and no pain

51
Q

What are the RED FLAGS of anorectal complaints that require PROMPT REFERRAL to a GI/colorectal specialist?

A

Unintentional weight loss

Iron deficiency anemia

Personal or FH of IBD or colorectal cancer

Persistent anorectal bleeding or symptoms despite adequate treatment of a suspected benign condition

52
Q

Are hemorrhoids rare or common?

A

Common

Idk she put this in red

53
Q

Does everyone technically have hemorrhoids?

A

Yes they are normal vascular structures that arise from a fibrovascular cushion. They protect the anal canal when you poop and help maintain continence.
They become symptomatic when the supporting structures of hemorrhoidal tissue (i.e. anal cushions) deteriorate

54
Q

Is today the first day you have ever heard about anal cushions?

A

😃

55
Q

Which is painless: internal or external hemorrhoids

A 
Internal hemorrhoids (proximal to dentate line)
*******
56
Q

Why are external hemorrhoids painful?

A

Because they are distal to the dentate line

****

57
Q

What are the 4 grades of hemorrhoids?

A

Grade I: bulge in anal canal without prolapse

Grade II: Prolapse that reduced spontaneously

Grade III: Prolapse that requires manual reduction 🤮

Grade IV: Prolapse that is impossible to reduce

58
Q

How will a patient with hemorrhoids present?

A

BLEEDING when they poop, usually bright red*** 🖍

+/- sensation of Perianal fullness (Prolapse***)

+/- PRURITUS***

+/- fecal incontinence

+/- mucoid discharge/seepage 👅

+/- acute perianal pain and palpable lump if thrombosed

First 3 things were in RED

59
Q

What color are prolapsed internal hemorrhoids

A

Red

60
Q

What color are thrombosed external hemorrhoids?

A

Blue

61
Q

According to the ACG 2014 Guidelines, when do you need to do a sigmoidoscopy for a patient that presents with hemorrhoid-pattern bleeding?

A

Every time. Must rule out other anorectal pathology

62
Q

If you are concerned that a hemorrhoid patient may have IBD or malignancy because they have some RED flags, what do you need to do instead of a sigmoidoscopy?

A

Colonoscopy

63
Q

What is the treatment for symptomatic hemorrhoids?

A

Diet and lifestyle mods (ALL patients)

Conservative medical therapies

Office-based procedures

Surgery

64
Q

What kind of dietary and Lifestyle modifications are appropriate for the management of ALL grades of hemorrhoids?

A

FLUID AND FIBER (dietary/bulk laxatives)***** IN RED🥬🥦🌿💧

Toilet habits (don’t strain or sit there forever like Alex)⏱

Sitz baths 🛀🏻

65
Q

What are the “conservative medical therapies” we can do for hemorrhoids?

A

Stool softeners

Tucks Pads (anesthetic)

Short course of steroid creams or suppositories**** IN RED

Antispasmodics like nitroglycerin ointment

66
Q

What are the “Office-based Procedures” we can do to treat patients with refractory hemorrhoids?

A

Internal roids:

Rubber band ligation (banding)***** IN RED

Infrared coagulation

Sclerotherapy

External roids:

Excision of thrombosed external hemorrhoid 🔪

67
Q

What is the most commonly used technique for the treatment of symptomatic bleeding internal hemorrhoid ?

A

Rubber band ligation

68
Q

When do you need to do surgery for hemorrhoids?

A

Persistent symptoms no matter what you do

Symptomatic grade III roids

Grade IV internal roids

Extensive pain from thrombosed eternal roids

69
Q

All patients with hemorrhoids, no matter how bad they are, need to be counseled on _____ _______ _____ _____ ______

A

Adequate fiber and fluid intake*******RED

70
Q

What are the three most common symptoms/signs of hemorrhoids?

A

Bleeding

Prolapse

Anal itching
**RED***

71
Q

A patient presents with painless rectal bleeding and perianal itching with evidence of a Grade II internal hemorrhoid. What recommendation is most appropriate initially?

A

High fiber and fluid diet

72
Q

What is pruritus ani?

A

Itchy asshole

73
Q

What are some mechanical causes of pruritus ani?

A

Prolapsing tissue

Fecal incontince/soiling

Inadequate hygiene

Swamp ass

Mucus or stool between buttocks

So this is what my life has come to

74
Q

What will you see if you look at the butthole of someone with pruritus ani?

A

Circumferential erythematous and irritated perianal skin

75
Q

How do you manage pruritus ani?

A

Eliminate offending agent

Proper hygiene: gentle cleansers, avoid aggressive wiping and overzealous hygiene, sitz baths

Keep region dry

Eliminate tight clothing

Topical astringent (witch hazel) or barrier (zinc oxide)

SHORT course of topical steroids

(None of this was in red)

76
Q

Are perianal skin tags caused by an STI or anal sex?

A

No

77
Q

What are perianal skin tags?

A

Outgrowth of normal skin

Can be caused by thrombosed external roids or Crohn disease

Probably the grossest picture i have seen in PA school yet

78
Q

How do you treat perianal skin tags, even though treatment is not usually indicated?

A

You can refer them for excision if they interfere with hygiene or cause discomfort

79
Q

What is this:
“Linear tear, or split, in the lining of the anal canal distal to the dentate line that causes spasm of the anal sphincters”

A

Anal fissure

*****

80
Q

What is the most common cause of severe anorectal pain?

*****

A

Anal fissure

****

81
Q

What causes anal fissure?

A

Local trauma to the anal canal (passage of giant turds or dildos/negro modelo bottles)**

Crohn Disease**

Malignancy

HIV/AIDS

82
Q

What is the reason for decreased blood flow and delayed healing of anal fissures?

A

Pain is so bad that it causes the sphincters to spasm, decreasing the blood flow and preventing healing

83
Q

How will a patient describe the pain of an anal fissure?

A

“Like passing glass”

“Sitting on a knife” 🔪🛋

84
Q

What is the most common location for an anal fissure?

A

Posterior midline****

85
Q

Why is the posterior midline the most common place for an anal fissure?

A

Lowest blood supply

86
Q

If a patient has recurrent/multiple anal fissures, or an anal fissure NOT in the posterior midline, what should you be concerned about?

A

Perianal Crohn’s

87
Q

How do you manage anal fissures?

A

Adequate fiber/fluid

Proper hygiene

Sitz baths

Stool softeners

Topical lidocaine

Topical vasodilators to reduce spasm and increase blood flow (nifedipine or nitroglycerin ointment)

Surgery if refractory

88
Q

What kind of surgery may be done for recurrent anal fissures?

A

Sphincterotomy for patients with low risk of developing fecal intcontinence

89
Q

What kind of exams/imaging would you use to evaluate an anal fissure?

A

DRE/anoscopy (often too painful to tolerate)

Flex Sig/Colonoscopy if unsure/recur

90
Q

Perianal abscess orignates from what?

A

Obsrtructed or infected anal crypt gland

91
Q

Chronic perianal abscesses can progress to form ___________

A

Fistulas***

92
Q

Can Perianal abscesses be associated with Crohn’s?

A

Yes *******

93
Q

How will a patient with a perianal abscess present?

A

Pain +/- drainage, constitutional symptoms

Red, palpable, fluctuant mass with surrounding edema

94
Q

What kind of imaging may be done for a perianal abscess>

A

CT or MRI pelvis to determine extent

95
Q

How do you manage a perianal abscess?

A

Incision and drainage

+/- antibiotics

Postoperatively: sitz baths and adequate fluid and fiber

96
Q

Fistulas/abscesses/fissures that recur should always make you think about WHAT

A

CROHNS*******

97
Q

What is an anorectal fistula?

A

Abnormal communication between anal canal and the perianal area.

It is a chronic manifestation of a perianal abscess

98
Q

What other conditions can be associated with anorectal fistulas?

A

Crohn Disease**

Radiation proctitis

Diverticulitis

99
Q

How will someone with an anorectal fistula present?

A

Chronic drainage of blood/pus/stool from fistula, rectal pain, itching, swelling, fever

Perianal skin may be excoriated or inflamed

Palpable cord beneath the skin between anus and abscess opening

100
Q

If someone shows up with an anorectal fistula and you are concerned about IBD, what should you do?

A

COLONOSCOPY

****

101
Q

What kind of imaging may be done to evaluate a complex or recurrent anorectal fistula?

A

MRI pelvis

102
Q

What is the mainstay therapy for an anorectal fistula?

A

Surgical Fistulotomy (unroofing the fistula tract to allow healing)

103
Q

What are anal condyloma?

A

Anal warts

104
Q

What virus causes anal condyloma?

A

HPV *******

105
Q

“Cauliflower like appearance, in clusters of single entities”

A

Anal condyloma

106
Q

Are anal condylomas that bad?

A

Not really, but may be risk for anal cancer.

107
Q

What are your options for removing anal condylomas?

A

Topical podofilox

Topical imiquimod

Trichloroacetic acid

Surgical removal

(This is probably not on the test)

108
Q

Most anal cancers are (columnar/squamous) cell cancers

A

Squamous cell *******

109
Q

What populations of people are at an increased risk of Anal Cancer?

A
  • have receptive anal sex
  • history of anal condyloma
  • history of HPV or HIV
110
Q

How will anal cancer present?

A

+/- rectal bleeding, anorectal pain, sensation of rectal mall

+/- anal warts, perianal skin irritation, hard, friable or ulcerating lesions

+/- inguinal lymphadenopathy**

111
Q

What do you need to check for if you have a patient walk in with some anal warts

A

Inguinal lymphadenopathy

112
Q

How do you manage anal cancer?

A

REFER

113
Q

What is the pathophysiology of Rectal Prolapse?

A

Pelvic flor disorder

Rectal tissue protrudes through anus

May come along with chronic constipation, straining, multiple vaginal births, or prior pelvic surgery

114
Q

How will a patient with rectal prolapse present?

A

Constipation or fecal incontincenc

Incomplete bowel evacuation

Seepage

“Mass” protruding through anus

On DRE, mucosa of rectal wall may feel floppy or loose with redundant tissue

115
Q

What is defecography?

A

You literally look at their asshole while they take a shit

116
Q

What two diagnostic studies may be done to diagnose rectal prolapse?

A

Defecography

Anorectal manometry

Ew

117
Q

What is the treatemnt for rectal prolapse?

A

Prevent constipation-increase fiber and fluid

Surgical repair is mainstay

118
Q

What is a rectocele?

A

Weakened fascia allows the rectum to bulge into vagina

119
Q

What can cause rectocele?

A

Vaginal delivery

Increasing age

Fat

120
Q

What might a patient tell you if she has a rectocele?

A

That she needs to apply pressure on her vagina, rectum, or perineum in order to defecate

121
Q

What is a rectovaginal examination?

A

Asking a patient to bear down and looking for a bulge of rectum into vagina

122
Q

A 67 year old female with a history of multiple vaginal births present with chronic constipation and complaints of fecal incontinenece. What may you find on physical exam?

A

Rectal prolapse

123
Q

Anorectal symptoms require a _______history and _______exam

A

Thorough

Focused

124
Q

If unsure of diagnosis, _______ to gastroenterologist/colorectal surgeon

A

Refer

Clin Med III, Exam 2 (ASL) (3 decks)

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