clin med second two lectures

Question 1

Complication of bowel obstruction

Answer 1

ischemia –> necrosis –> PERFORATION

Question 2

Etiology of SBO

Answer 2

ADHESIONS

Question 3

Other etiology of SBO

Answer 3

Hernia

CA

Question 4

At first periumbilical, intermittent, “cramping” pain

THEN

more focal and constant (indicate peritonitis)

Answer 4

SBO clinical presentation

Question 5

Red flag bad signs of SBO

Answer 5

fever, tachy, hypOtension

lying motionless

high pitched tinking bowel sounds –> hypoactive/absent in later stages

Peritoneal signs- guarding, rigid, rebound tenderness

Question 6

SBO Imaging

Answer 6

XRAY:
dilated loops of bowel, air fluid levels

Free air= perforation

Question 7

Tx of SBO

Answer 7

Admit (NPO, IVF, bowel decompression w NG tube, nausea, pain meds, Abx maybe, Gastrografin maybe)

TRY NON-OP first
monitor 2-5 days

Question 8

Indications for surgery in treating SBO

Answer 8

Complicated

Intestinal strangulation

Worsening/unresolved

Question 9

obstipation

Answer 9

severe or complete constipation

Question 10

What can we use to identify location, etiology, severity, and complications of SBO?

Answer 10

CT

Question 11

Ileus etiology

Answer 11

POST-OPERATIVE

Question 12

Ileus

Answer 12

an inflammatory response to recent manipulation and trauma

Question 13

Other cause of ileus

Answer 13

Hypomotility agents (opioids, anticholinergic, etc)

Question 14

Clinical presentation: abd pain, distension, bloating, “gassy”, n/v, can’t tolerate PO

Answer 14

Ileus

Question 15

Tympanic abdomen

Answer 15

air filled

found with Ileus

Question 16

X ray shows dilated loops but air is present in BOTH small and large bowel

NO AIR FLUID LEVELS

Answer 16

Ileus

Question 17

Tx of Ileus

Answer 17

Supportive- IVF, lyte replace, pain, bowel rest, bowel decompression w NG tube prn, serial X rays, ambulate

Question 18

LBO etiology

Answer 18

Adenocarcinoma

Question 19

LLQ pain w diarrhea

recent frank bloody stool w diarrhea

Answer 19

Concerning for LBO

Question 20

Crampy abd pian
Bloating
Constipation
Norm/quiet bowel sounds
Hematochezia

Answer 20

LBO

Question 21

LBO tx

Answer 21

Partial: try conservative first. NPO, IVF, Abx, Decomp w NG

Complete: depends on cause, most of the time surgical resection is the answer.

Question 22

Volvulus

Answer 22

abn twisting of GI tract, can impair blood flow

Subtypes: sigmoid, cecal

Question 23

More common subtype of Volvulus

Answer 23

SIGMOID

Question 24

Sigmoid volvulus (more common)

Answer 24

70YO
crampy abd pain, n/v, pain b4 vomiting, constipation, TTP

Tx: Flex sig and then surgery

Question 25

Cecal volvulus

Answer 25

35-53 YO, younger Episodic pain to acute abdominal catastrophe! Tx: Surgery

Question 26

Position for rectal exam

Answer 26

Left lateral decubitis

Question 27

Red flags (Anorectal complaints) that should warrant prompt GI/Colorectal referral

Answer 27

Wt loss (unintentional) Iron def anemia Personal/FH IBC or CRC Persistent anorectal bleeding or sx despite tx

Question 28

Hemorrhoid peak age

Answer 28

45-65YO

Question 29

Hemorrhoids become symptomatic when

Answer 29

supporting structures of hemorrhoidal tissue (anal cushions) deteriorate

Question 30

External hemorrhoids

Answer 30

Distal to dentate line PAINFUL

Question 31

Internal hemorrhoids

Answer 31

Proximal to dentate line, painless

Question 32

4 grades of Internal hemorrhoids

Answer 32

1: bulge without prolapse 2: prolapse that reduces spont 3: prolapse requires manual reduction 4: chronic, irreducible

Question 33

Bright red blood w BM Fullness maybe itching

Answer 33

Hemorrhoid clinical presentation

Question 34

Hemorrhoid pattern bleeding mandates AT LEAST

Answer 34

SIGMOIDOSCOPY to r/o other pathology

Question 35

If concerns of IBD or CA when thinking hemorrhoids, must get

Answer 35

Colonoscopy

Question 36

Conservative med tx for Hemorrhoids

Answer 36

Stool softener SHORT COURSE Steroids or suppositories Nitroglycerin ointmentm(antispasmodic)

Question 37

Tx for refractory hemorrhoids

Answer 37

Internal - Rubber band ligation - Infrared coag - Sclerotherapy External -Excision

Question 38

Most commonly used technique for tx of Symptomatic Bleeding Internal Hemorrhoids

Answer 38

Rubber band ligation

Question 39

When to get surgical Hemorrhoidectomy

Answer 39

Persistent despite tx Sx w/ GRADE 3 GRADE 4 internal Extensive pain

Question 40

What do we always suggest first with hemorrhoids?

Answer 40

High fiber, fluid

Question 41

Pruritis Ani

Answer 41

often dev from local irritation of skin --> inflammation

Question 42

Intense itching, burning | Circumf erythematous and irritated perianal skin

Answer 42

Pruritis Ani

Question 43

Tx of Pruritis Ani

Answer 43

``` Stop offending agent Hygiene Keep dry Elim tight clothing Topical astringent or topical barrier Short course steroid cream (for severe eruptions) ```

Question 44

Perianal skin tag

Answer 44

Sequelae of thrombosed external hemorrhoids or Crohns Loose, flesh colored, pedunculated Tx usually not indicated, can excise if interefering w hygeine or causing discomfort

Question 45

Anal fissure

Answer 45

linear split or tear DISTAL to dentate line causing: Spasm of anal sphincter

Question 46

Most common cause of SEVERE Anorectal pain

Answer 46

Anal fissure

Question 47

Etiology of Anal fissure

Answer 47

Mostly: local trauma, hard stools FB Also: Crohns dz***, CA, HIV/AIDs

Question 48

Severe pain during and right after defecation "passing glass" "sitting on a knife" Bright red blood on toilet paper

Answer 48

Anal fissure

Question 49

Most common place for Anal fissure

Answer 49

Posterior midline | lowest blood supply

Question 50

Dx Anal fissure

Answer 50

DRE/Anoscopy | Flex sig/Colonoscopy if unsure

Question 51

Anal fissure tx

Answer 51

Fiber/fluid, hygeien, sitz bath, stool softener Topical analgesic (lidocaine), Topical vasodilator (reduce spasm and increase blood flow) If chronic/refractory: surgery Sphincterotomy

Question 52

Perianal abscess

Answer 52

Obstructed/infected Anal crypt gland can turn into Fistula Can be associated w CROHNs dz

Question 53

Conditions assoc w CROHNs dz

Answer 53

Peri-anal abscess | Fistula

Question 54

Fistula

Answer 54

abn communication b/w anal canal and peri-anal area chronic manifestation of abscess

Question 55

Chronic drainage of blood or pus, pain, itching, swelling, FEVER

Answer 55

Ano-rectal fistula

Question 56

Ano-rectal fistula tx

Answer 56

SURGICAL FISTULOTOMY

Question 57

Anal condyloma (HPV warts)

Answer 57

Itchy cauliflower like Anoscopy

Question 58

Tx for HPV- anal condyloma

Answer 58

Removal/desturction | Topical PODOFILOX or IMIUQUIMOD

Question 59

Office tx for HPV anal warts

Answer 59

Trichloroacetic acid can also surgically remove

Question 60

Most ANAL CA is:

Answer 60

Squamous cell

Question 61

Risk factors increasing incidence of Anal CA

Answer 61

Anal intercourse Hx of Anorectal condyloma HPV/HIV hx

Question 62

Maybe the following: rectal bleeding, pain, rectal mass, FRIABLE or ULCERATING lesions Palpate for inguinal lymphadenopathy

Answer 62

Anal CA

Question 63

Anal CA tx

Answer 63

Biopsy, scope Chemo/Radiation Surgery

Question 64

Rectal prolapse

Answer 64

Pelvic floor disorder | Rectal tissue protrudes through ANUS

Question 65

DRE shows mucosa of rectal wall FLOPPY or LOOSE w redundant tissue

Answer 65

Rectal Prolapse

Question 66

Mainstay of tx for Rectal prolapse

Answer 66

SURGICAL repair Can also increase fiber and fluid, prevent constipation/straining

Question 67

Rectocele

Answer 67

Rectum bulges INTO VAGINA cause: vaginal birth, increasing age, obesity

Question 68

On exam, Pt bears down and you see bulge of rectum into vagina

Answer 68

Rectocele

Question 69

Tx for Rectocele

Answer 69

Pelvic floor muscle training | Pessary