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Colorectal 2 Flashcards

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1
Q

Acute Mesenteric Ischemia

A

mesenteric vessel occlusion causing loss of blood flow to a region of the bowel

can be in both large and small intestine

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2
Q

s/s of Acute Mesenteric Ischemia

A

severe steady epigastric/periumbilical pain

minimal PE findings

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3
Q

Acute Mesenteric Ischemia work up + tx

A

Work Up: Lactic acid levels, CBC, angiography

tx: restore blood flow and remove dead bowel

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4
Q

chronic mesenteric ischemia

A

arteriosclerotic lesions in gut cause inability to supply blood after eating

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5
Q

who gets chronic mesenteric ischemia

A

pts with RF for CAD/PVD

pts who have ASD elsewhere

smoking, HTN, hyperlipidemia, DM

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6
Q

s/s of chronic mesenteric ischemia

A

epigastric or periumbilical postprandial pain

lose weight due anorexia 2/2 pain

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7
Q

tx of chronic mesenteric ischemia

A

identification of lesion and stent placement

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8
Q

Toxic Megacolon/Toxic Colitis

A

actue toxic colitis with dilation of colon

typically associated with IBD flare

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9
Q

Toxic Megacolon/Toxic Colitis H&P

A

acutely ill (may be masked by steroids)

diarrhea, abdominal pain, high fever, vomiting, symptoms of systemic toxicity

rebound, peritoneal signs, abdominal rigidity

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10
Q

Toxic Megacolon/Toxic Colitis

diagnostic criterion

A

radiographic evidence of colonic dilation (>6cm + loss of haustra)

3 of:

  • Fever >101.5
  • Tachycardia >120 bpm
  • Leukocytosis >10.5
  • Anemia
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11
Q

Toxic Megacolon/Toxic Colitis

radiograph req

A

plain film X Ray - do serially to asses progress

avoid contrast (increase perforation)

GI and surgery consult

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12
Q

Toxic Megacolon/Toxic Colitis tx

A
  1. NG tube, bowel rest (reduce colonic distention)
  2. correct fluid and electrolyte disturbances
  3. treat toxemia and precipitating disease (IV ABX)

+/- emergent colectomy

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13
Q

indications for surgery Toxic Megacolon/Toxic Colitis

A

free perforation (air under diapragham)

massive hemorrhage

increased toxicity (HoTN)

progression of colonic dilation

persistent dilation (24-72 hrs)

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14
Q

constipation manifestations

A

few or very hard BM
excessive straining
feeling rectum doesn’t completely empty

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15
Q

primary constipation etiologies

A

structural GI tract/pelvic floor abnormalities (slow transit, difficulty relaxing anal sphincter)

psychosocial issues or sexual abuse

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16
Q

secondary constipation etiologies

A

systemic disorders (sicca, DM, MS, Parkinson’s, pregnancy)

medications (anticholinergics, opitates)

structureal

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17
Q

evaluation and management of constipation

<50

A

NO alarming H & P

empiric therapy, address diet and lifestyle (hydration, exercise, fiber)

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18
Q

e&M constipation >50 alarming

A

unexplained weight loss, GI bleed
other disease suggestions (DM, Parkinson’s etc)

colonoscopy, lung CA, PSA, ovarian screen

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19
Q

initial agents in constipation tx

A

decusate (colace)
fiber, blue lazativitys
glycerin suppository (fleets)

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20
Q

osmotic agents constipation tx

A

draw water into bowel, act w.in 24 hrs

PEG (Miralax, GoLYTELY) (no go in stroke)
lactulose (enulose) or sorbitol (lg osmotic load)

MOM and mg citrate (acts right away)

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21
Q

bowel stimulants constipation tx

A

bisacodyl (Dulcolax) and Senna

may cause hypokalemia, protein loss

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22
Q

tx of constipation (line up)

A

Daily: PEG, Colace, Fiber

PRN: Senna, ducolax, sorbitol

emergent: Mg citrate, MOM

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23
Q

tx of opiate induced constipation

A

antagonist peripheral opioid receptor

Methylnatrexone (Relistor) 
Naloxegol (Movantik) 
Alvimopan (Entereg) 
Tegaserod (Zelnorm) 
Lubiprostone (Amitiza) 
Linaclotide (Linzess)
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24
Q

Methylnatrexone

brand + indication

A

(Relistor)

injection Sub Q

CA and non CA opioid use

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25
Naloxegol brand + indication
(Movantik) schedule II non-CA opioid use
26
Alvimopan | brand + indication
(Entereg) | post op ileus
27
Tegaserod brand + indication + moa
(Zelnorm) serotonin receptors stimulative GI peristalsis women <55 who have IBS or chronic idiopathic constipation
28
Lubiprostone brand + moa
(Amitiza) opens intestinal Cl channels
29
Linaclotide brand + MOA
(Linzess) activates cGMP
30
fecal impaction
occurs when stool causes LBO confirmed with DRE - copious amounts of stool in rectum
31
when is DRE non diagnostic in fecal impaction
proximal rectum or sigmoid colon
32
fecal impaction s/s/
obstipation loud, hyperactive bowel abdominal distention abdominal pain may have loose stools (GI more mobile and pushes loose around impaction
33
fecal impaction tx
multiple enema preparations to soften stool and manual disimpaction prevent by placing on bowel regimen
34
fecal incontinence tx
padding undergarments avoid caffeine adequate fiber Kegel exercises these are therapies for MOBILE pts
35
causes of fecal incontinence
loss of central awareness (CVA, dementia) peripheral n. injury (spinal cord, cauda equina, pudenal n damage) sphincter damage (ob trauma, anal surgery, physical trauma)
36
fecal incontinence evaluation
inspect sphincter, DRE relaxation, evaluation rectal tone sigmoidoscopy, anoscopy, imaging studies
37
anorectal abscess
obstruction of the anal crypt gland by inspissated debris causes bacterial growth and abscess formation +/- fistula formaiton will spread to adjacent structures
38
common organisms causing anorectal abscess
E. coli (enteric gram neg) bacteroides (anaerobic) staphylococcal species
39
locations most likely for anorectal abscess
perianal ischiorectal interspinteric and supralevatior (hard to ID)
40
anorectal abscess epidemiology
male predominance 20-30s summer and spring
41
symptoms anorectal abscess
severe pain (dull, constant, worse with BM) Pruritus, anal fullness constitutional symptoms (fever, malaise) purulent rectal drainage
42
signs of anorectal abscess
area of fluctuant, erythematous indurated skin fluctuant indurated mass on DRE deep abscess: no physical exam findings other then systemic toxicity
43
work up of anorectal abscess
CT scan w/IV contrast | pus collection and culture
44
anorectal abscess tx
incision and drainage + abx pack with iodophor gauze must be done immediately (can cause sphincter malfunction)
45
complication of anorectal abscess
fistula formation MC 2/2 infections caused by GNR
46
Anorectal Fistula s/s
non healing abscess following I&D pain during defecation excoriation of perianal skin diarrhea, abdominal pain
47
Anorectal Fistula etiologies
``` PERIANAL ABSCESS Crohn's/UC Anorectal malignancy radiation proctitis rectal foreign bodies, leukemia, diverticulitis ```
48
Anorectal Fistula tx
surgery underlying cause referral to colorectal surgeon
49
Anorectal Fistula- who gets surgery?
symptomatic fistula in pts w/o IBD
50
Anorectal Fistula IBD
treatment of underlying dz surgery can exacerbate fistula formation and worsen disease
51
surgical management of Anorectal Fistula depends on
location of fistula | how much of sphincter complex is involved
52
Anal Fissure
tear in lining of anal canal distal to dentate line local trauma to anal canal accompanied by sentinel pile
53
location of Anal Fissure
12 o clock and 6 o clock position *if not in these spots, consider other underlying pathology (IBD, HIV, TB, CA, syphilis)
54
Anal Fissure symptoms
exquisite pain during BM (lasts minutes to hrs from passage of stool, occurs with every BM) bright red blood on TP or streaking stool
55
Anal Fissure exam
found at posterior midline or anterior midline too much pain for DRE acute: fresh lesion chronic: raised edges, white and horizontal fibers
56
Anal Fissure tx
fiber supplement, sitz bath, EMLA referral to GI if no improvement in 2 mo
57
how do you determine if hemorrhoid is internal or external?
based on location above or below dentate line
58
pathophys of EXTERNAL hemorrhoid
advanced age pregnancy pelvic tumors prolonged sitting on toiled
59
s/s of hemorrhoids
painless rectal bleeding (BRIGHT RED) rectal pain if associated with thrombosis prolapse pruritus fecal soilage
60
diagnosis of hemorrhoids
physical examination (can see external) flexible sigmoidoscopy, anoscopy or colonoscopy (bleeding only) *if pt is bleeding, this might not be due to hemorrhoids but something much more serious, so be diligent
61
tx hemorrhoids | conservative
treat symptomatic pts only bleeding- fiber supplement pruritus/Irritation - analgesic creams
62
tx of painful hemorrhoids | w/in 72 hrs
excision of entire hemorrhoid | lancing and evacuation of clot
63
tx of painful hemorrhoids | NOT w/in 72 hrs
oral and topical analgesics stool softeners sitz bath
64
pilonidal cysts
young adults in their 30s (mc in men) cyst or abscess in part of natal cleft
65
pilonidal cysts asymptomatic presentation
painless cystic lesion or sinus opening at top of cleft
66
pilonidal cysts acute abscess
sudden onset of severe pain and swelling acutely inflamed mass overlying sacrum or coccyx rare: fever
67
chronic pilonidal cysts
persistent drainage from sinus one or more opening seen and drainage of mucoid or purulent material present
68
diagnosis of pilonidal cysts
clinical diagnoses esp. if patient presents with acute inflamed mass at top of natal cleft
69
tx of pilonidal cysts
I and D ABX not indicated unless there is significant cellulite metronidazole and first gen cephalosporin (G+ and anaerobes)

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