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Colorectal 1 Flashcards

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1
Q

large bowel obstruction MC occurs where

A

sigmoid colon

bc site where stool becomes more solid

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2
Q

LBO cecum

A

most likely to perforate if obstruction here due to thinnest wall

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3
Q

LBO etiologies

A

MC 2/2 carcinoma

can be 2/2 diverticular dz, volvulus, hernia, benign growth

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4
Q

LBO pathophysiology

A

obstruction leads to massive dilation above obstruction

causes mucosal edema and impaired venous and arterial blood flow

ischemic bowel wall loses integrity and becomes compromised = mucosal permeability

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5
Q

mucosal permeability in LBO causes

A

bacterial translocation

systemic toxicity

dehydration

electrolyte abnormalities

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6
Q

symptoms of obstruction

A

deep, cramping pain

constipation/obstipation

abdominal distention

feculent vomiting

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7
Q

signs of obstruction

A

abdominal distention and tympany

high pitched metallic tinkles, w/ rushes and gurgles on auscultation

localized tenderness

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8
Q

what indicates an emergency LBO

A

fever, peritoneal signs and abdominal rigidity

might suggests peritonitis and perforation - surgical emergency

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9
Q

TOC for LBO

A

CT Abdomen/Pelvis, with IV and Oral contrast

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10
Q

CT findings in LBO

A

haustral markings

air fluid levels and dilated colon

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11
Q

CXR in LBO

A

air under the diaphragm

can show transition point

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12
Q

tx of LBO

A

initial stabilization and prep for possible surgery

I.e. fluid resuscitation, zosyn, NG tube

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13
Q

Ogilve’s syndrome

A

colonic dilation and ileum that mimics obstruction without transition point or mechanical obstruction

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14
Q

MC site of Ogilve’s syndrome

A

right colon and cecum commonly affected

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15
Q

risk factors of Ogilve’s syndrome

A

medical or surgical illnesses such as infection, trauma, cardiac disease

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16
Q

Ogilve’s syndrome tx

A

supportive - hydration and lytes and bowel rest

colonoscopic decompression may be attempted if supportive doesn’t work but surgical intervention is not encourage

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17
Q

medications that could cause Ogilve’s syndrome

A

opioids
anticholinergics
muscle relaxants

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18
Q

rotation of intestinal segment on mesenteric axis

A

volvulus

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19
Q

volvulus results in

A

partial or complete lumen obstruction

may compromise the blood supply = closed loop obstruction

can’t back up, rapid wall extension and increased risk of perforation

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20
Q

volvulus etiologies by country

A

chronic constipation (Western)

high fiber diet (developing nations)

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21
Q

volvulus pathophysiology

A

overloaded sigmoid colonic loop

stretching of mesentery and increasing susceptibility of torsion

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22
Q

populations predisposed to volvulus

A

institutionalized pts with neuropsychiatric disorders

MS, Parkinson disease, spinal cord injury

pts in nursing homes due to prolonged recumbency and chronic constipation

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23
Q

volvulus etiologies

A

excessive use of laxatives, cathartics, enemas (increased stimulation stretches it)

pregnancy or large pelvic tumors

chagas disease

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24
Q

s/s sigmoid volvulus etiologies

A

60-70% pts present acutely with LBO symptoms (cramping, obstipation, abdominal distention)

subacute or chronic symptoms (episodic constipation, less severe abdominal pain, distention, obstipation)

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25
Xray sigmoid volvulus findings
massively dilated single bowel loop concavity points to LLQ coffee bean sign
26
s/s cecal volvulus
severe, intermittent colicky pain in RLQ , vomiting and obstipation ensues less distention than sigmoid, more likely to have vomiting
27
cecal volvulus plain film
dilated kidney bean shaped cecum concavity pointing to RLQ cecal volvulus inadequate for diagnostics
28
tx of cecal volvulus
operative detorsion
29
sigmoid volvulus tx
no strangulation or perforation = endoscopic decompression strangulation or perforation = surgery
30
diverticulum
small finger like out-poaching of mucosa thru colonic wall at site of penetrating arteries
31
where do most diverticula occur
sigmoid colon and left sided colon due to pressure sites
32
diverticula risk factors
increase with age likely due to lack of fiber obesity
33
asymptomatic diverticula
found incidentally during C-scope or BE diagnosed with diverticulosis
34
diverticulosis tx
supplemental fiber in the diet
35
diverticulitis pathophysiology
1. erosion of the diverticular wall due to increased intraluminal pressure and thickened matter 2. outlet obstruction by fecalith or undigested food
36
diverticulitis epidemiology
mc in middle age to elderly population right sided diverticula more common in asian population
37
s/s diverticulitis
mild to moderate aching abdominal pain in LLQ n/v, constipation, diarrhea, +/- BRBPR fever symptoms are usually mild, more acute with perforation
38
diverticulitis on PE
generalized pain --> increased size causes localized pain high fever increased then decreased BP painful heel tap
39
TOC diverticulitis
CT abdomen/pelvis w/contrast
40
diverticulitis evaluation
CT scan, barium enema contraindicated Labs: CBC, chem panel, blood cultures x2 q 15 minutes +/- amylase, lipase, liver enzyme, c-diff screen
41
mild diverticulitis tx
mild symptoms and no peritoneal sings clear liquid diet, ABX 7-10 days
42
ABX used in mild diverticulitis
Cipro + Flagyl, Augmenting or Avelox
43
inpatient medical diverticulitis tx
NPO with IVF IV antibiotics (zosyn, unasyn) (3-5days switch to PO) consult if severe or septic IR percutaneous catheter
44
who gets surgical tx diverticulitis
peritonitis, large abscess, fail to improve with medical management in 2-3 days OR significant peritonitis/perforation at time of presentation
45
surgical tx diverticulitis
NOP, fluid resuscitated brand spectrum IV ABX begun abdominal laparotomy + colostomy (elective takedown)
46
repeated episodes of diverticulitis
episodes of 3+ diverticulitis consider elective colon resection (no colostomy)
47
colitis types
Infectious, ischemic, IBD RARE: microscopic, necrotizing enterocolitis, allergic colitis
48
C diff colitis
inflammation and infection of the colon typically gotten from healthcare workers and contaminated clothing and equipment and ABX use kill off other natural gut flora causing C Diff to develop
49
C diff colitis MC due to what ABX (4)
1. ampicillin 2. clindamycin 3. 3rd gen cephalosporins 4. fluorquinalones
50
risk factors for developing C diff colitis
elderly, debilitated, immunocompromised multiple abx/prolonged use entereal feeding, PPI use, DI dz, surgery
51
C diff colitis s/s
w/in 2 months of after ABX use can occur after just ONE dose of ABX watery green, foul smelling diarrhea w/mucus and cramping SIGNIFICANT LEUKOCYTOSIS
52
C diff colitis workup
Diarrheal stool samples ONLY: enzyme immunoassay (EIA) PCR assay of C diff toxin flexible sigmoidoscopy
53
tx of C diff colitis
stop abx that contribute to problem ABX 10-14days do NOT repeat
54
ABX less likely to cause C diff colitis (5)
``` vancomycin sulfonamides macrolides IV aminoglycoside tetracycline ```
55
ABX used to tx C diff colitis
Flagyl/Metronidazole (PO, IV) 500 mg q8/250q6 | Vancomycin (Oral) 125 PO
56
C diff colitis recurrence
typically occurs in 1-3 weeks repeat stool assays dont work NOT related to drug resistance so can use same drug call I&D, high chance of reoccurrence
57
severe C diff colitis if:
1. leukocytosis >15,000 2. serum creatinine >1,5x pt baseline 3. shock, hypotension
58
C diff colitis tx
VANC preferred rarely, total colectomy fecal microbiota transplant
59
fecal microbiota transplant
normal non pathogenic bacteria from donor stool can repopulate in tract of recipient and stop unchecked C Diff growth
60
ischemic colitis
low blood flow to bowel causes mucosa to become ischemic and slough typically 2/2 trauma, surgery, syncope
61
areas most vulnerable to ischemic colitis
splenic flexure | rectosigmoid junction
62
ischemic colitis s/s
LLQ pain, cramping tenderness frankly blood diarrhea following inciting event
63
ischemic colitis tx
supportive care (NPO, hydration) daily labs to monitor progress empiric ABX
64
lower GI bleed epidemiology and etiologies
mc in men, elderly 1. diverticular bleeding 2. angiodypslasia/AVM 3. benign anorectal dz 4. IBD 5. neoplasm
65
lower GI bleed painless and copious
diverticular bleed
66
lower GI bleed self limited, painless, slow and RECURRENT
AVM/angiodysplasia
67
lower GI bleed painful bloody, weight loss, mucous
inflammatory colitis
68
lower GI bleed painful, hx of event with low flow
ischemic colitis
69
lower GI bleed insidious bleeding painless
colon ca
70
lower GI bleed painful or painless, blood on toiled
anorectal disease
71
lower GI bleed management
try to qualify loss (rectal exam) lab work up: CBC, chem panel, PTT, PT/INR, T&C GI consult
72
how to determine if lower GI bleed is ongoing?
serial H&H to see rate of decline remember fluids will decrease
73
lower GI bleed workup
colonoscopy initially (tx and dx) CT scan, bleeding scan, mesenteric angiography

GI 1 (12 decks)

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