GI

Question 1

appendicitis

Answer 1

chronic or acute inflammation of vermiform appendix - obstruction by fecalith, foreign body, neoplasm

MOST COMMON ABD SURG EMERGENCY

Question 2

appendicitis s/s

Answer 2

McBurney’s
Rovsing: RLQ pain intensified by LLQ palp

Markle: heel jar
Obturator: inward rotation of hip = kick
Psoas: lifting thigh against resistance = pain

moderate leukocytosis (10-18)

Question 3

appendicitis tx

Answer 3

NO PAIN MED UNTIL SURGICAL EVAL

cefoxitin

Question 4

cholecystitis

Answer 4

inflammation of gallbladder - 90% d/t gallstones impacted in cystic duct (inflammation behind obstruction)

acute can dev r/t infection, ex: CMV

Question 5

cholecystitis s/s

Answer 5

murphy sign: abrupt cessation of inspiration upon palpation of RUQ

referred pain to R shoulder

rebound pain, elevated WBC/AST/ALT

Question 6

cholecystitis tx

Answer 6

NPO, IVF, abx (2/3g ceph)

pain: morphine
NEVER DEMEROL

laparoscopic chole

monitor for gallbladder gangrene, post-op ileus

Question 7

pancreatitis

Answer 7

inflammation of gal bladder - assoc w dysfxn of exocrine fxn - autodigestion!

Question 8

most common abd surgical emergency

Answer 8

appendicitis

Question 9

pancreatitis s/s

Answer 9

• supine: panc makes soup out of your insides = hurts when supine (sitting = relief)
• shock
• chvostek’s: cheek spasm
• trousseau: BP cuff spasm
• cullen (bluish periumbilical)
• grey turner: bluish flanks
• pleural effusion

Question 10

pancreatitis diagnostics

Answer 10

abd xray: colon cutoff sign (gas filled transverse abruptly cut off d/t inflamed pancreas)

CT scan: DIAGNOSTIC! enlarged pancreas or pseudocyst

Question 11

diagnostic for pancreatitis

Answer 11

CT scan! enlarged or pseudocyst

Question 12

pancreatitis labs

Answer 12

↑ amylase (4x nl suggests panc)
↑ lipase (more dxic but slower)
↑ HCT (d/t hemoconcentration)
↑ PT, INR
↑  WBC 10-30
proteinuria, glycosuria, hyperglycemia
↓ serum Ca s/t ↓ albumin (3rd spacing d/t autodigestion)

Question 13

pancreatitis Ca significance

Answer 13

↓ serum Ca s/t ↓ albumin (3rd spacing d/t autodigestion)

Question 14

ischemic bowel syndrome

Answer 14

chronic: *atherosclerosis sup or inf mesenteric arts, celiac → ↓ intestinal blood flow

acute: d/t abrupt ↓ blood flow:
* shock
* embolus
* sm bowel obstruction
- trauma
- CHF (drastically diuresed)
- colon resection w reanastomosis

SURGICAL EMEGENCY

Question 15

ischemic bowel s/s

Answer 15

steady epigastric pain
elevated WBC
bloody diarrhea
abd distension
METABOLIC ACIDOSIS
hypotension

Question 16

GI surgical emergencies

Answer 16

appendicitis (most common)

ischemic bowel

Question 17

ischemic bowel tx

Answer 17

surgical emergency!!!!!!

ampicillin, aminoglycoside, clindamycin

monitor for sepsis, MODS, extension of ischemia/infarct

Question 18

2 out of 3 buys you a ticket to the OR

Answer 18

+ history
+ physical exam
+ labs, imaging

DON’T LET THE SUN RISE OR SET ON A COMPLETE SMALL BOWEL OBSTRUCTION

Question 19

GERD

Answer 19

constellation of sx r/t repeated exposure of esophageal mucosa to gastric contents → breakdown of mucosal barrier

RELAXATION OF ESOPHAGEAL SPHINCTER

Question 20

GERD mgmt

Answer 20

lifestyle modification, Nissen fundoplication

• PPI: -prazoles, Protonix, Prevacid, Nexium etc
• eliminate/reduce sx

Question 21

peptic ulcer disease

Answer 21

gastric & duodenal ulcers - break in surface mucosa of stomach/duodenum → exposes tissue to damaging effects of acid & pepsin
usually consider an area > 5mm

H. PYLORI IS A BIGGY! NSAIDS, syndromes

Question 22

PUD sx both v gastric v duodenal

Answer 22

both: burning/gnawing pain, epigastric region dyspepsia, sx clusters/free periods

gastric - eating may ↑ pain

duodenal - ↓ pain after eating, ⅔ nocturnal pain

Question 23

PUD tx

Answer 23

sx controlled, assess for GIB

Question 24

dumping syndrome

Answer 24

20% PUD - hyperosmolar chyme (CHO) enters sm int, ↑ osmotic gradient & pulling fluid into the gut

GI discomfort, n, v, d, cramps

vasomotor response: diaphoresis, palpitations, flushing

Question 25

diverticulitis

Answer 25

inflammatory changes w/in diverticular mucosa - diverticuli in DESCENDING & SIGMOID pouch-like protrusions of intestinal mucosa in descending & sigmoid colon MOST ASX!! / sxatic if: inflamed, bleed, perforate

Question 26

diverticulitis presentation

Answer 26

mild LLQ tenderness, rebound tenderness, + stool guaiac!!! older folks MILD MILD MILD

Question 27

diverticulitis dx

Answer 27

CT scan: diverticuli or fistula colonoscopy: not definitive but can r/o other causes

Question 28

diverticulitis tx

Answer 28

abx: keflex, flagyl, cipro, bactrim spasms: bentyl, buspar pain relief: avoid morphine (increased intraluminal pressure in colon can lead to perf)

Question 29

avoid morphine in diverticulitis why?

Answer 29

increased intraluminal pressure in colon can lead to perf

Question 30

ulcerative colitis

Answer 30

colon(ly) - diffuse mucosal inflamation aka regional enteritis

Question 31

clinical hallmark of ulcerative colitis

Answer 31

BLOODY DIARRHEA! may present with urgency

Question 32

UC work up

Answer 32

colonoscopy with biopsy or sigmoidoscopy

Question 33

UC dx based on

Answer 33

``` hx blood diarrhea! lower abd cramps w urgency microcytic anemia ↓ serum albumin - stool cultures + colonoscopy or sigmoidoscopy ```

Question 34

UC tx

Answer 34

prednisone!! avoid prolonged | sulfasalazine (also anti-inflammatory)

Question 35

beware toxic megacolon

Answer 35

UC & Crohn's

Question 36

Crohn's disease

Answer 36

bow-all. any or all layers of the bowel, not just the colon - transmural

Question 37

Crohn's visualization

Answer 37

- mucosal inflammation ulceration (peyer’s patches) - x-ray “cobblestone appearance” - develop strictures & subsequent obstrctn narrowing of lumen, loops adhering to each other - high risk for bowel obstruction (50% dx req surgery)

Question 38

Crohn's clinical presentation

Answer 38

RLQ pain/mass | semiliquid stool/diarrhea, fistulas, flatulence

Question 39

Crohn's labs

Answer 39

CBC, CMP - anemia (iron or B12) which also presents as neuropathy - hypoalbuminemia - leukocytosis

Question 40

IBS

Answer 40

3mo+ lower abd sx & bowel complaints (Δ freq or characteristics) may be continuous or intermittent also called “spastic colon” POO'D = GOOD

Question 41

IBS H&P shows no

Answer 41

fever, bloody diarrhea, leukocytosis

Question 42

IBS tx

Answer 42

antispasmodic: bentyl lomotil, imodium assess for relief of sx

Question 43

C Diff

Answer 43

``` abx associated colitis: FACC'd up bowels fluoroquinolone ampicillin cephs clindamycin ```

Question 44

difficult to differentiate until OR...

Answer 44

Crohn's & UC

Question 45

C Diff tx

Answer 45

Flagyl (metronidazole), vanc, colectomy, hand washing!!!