GI Flashcards
1
Q
List the 4 cardinal signs and symptoms of intestinal obstruction
A
Pain
Abdominal distention
Vomiting
Constipation
2
Q
6 causes of pneumoperitoneum
A
Perforated gastroduodenal ulcer Perforated diverticulitis Post op laparoscopy Ruptured appendix Ruptured lower end of oesophagus Anaerobic infection
3
Q
List 8 causes of small bowel obstruction
A
Adhesions Hernia Strictures Intussception Meckel’s diverticulum Gallstone ileus Polyps Harmatoma
4
Q
5 etiologic factors in PUD
A
Prolonged used of NSAIDS Prolonged used of steroids Marijuana and cocaine used H pylori infection Zollinger ellision syndrome
5
Q
6 causes of complications of diverticular disease
A
- Diverticulitis- inflammation and possible perforation of diverticulum
- bleeding- erosion around the edge of the pseudodiverticula
- Perforation- Rupture of an inflamed diverticulum - free communication with the peritoneum, generalized fecal peritonitis or ruptured of a diverticular abscess- generalized purulent peritonitis
- intestinal obstruction- inflammation swelling, compression through abscesses , ileus caused by localized irritation
- fistula formation- colovesical most common and colovaginal in females
- abscess- peri diverticula localization; omentum walls off pus collection
6
Q
Causes of SBO
A
Adhesions Hernias Strictures from crohn’s and radiation Intussusception Meckel’s diverticulum Cystic fibrosis Gallstone ileus Tumors - lymphoma, polyps, harmatomas
7
Q
Ischemic bowel clinical picture
A
Sudden pain or no pain
No bowel sounds
NG tube - blood
8
Q
Cardinal symptoms of small bowel obstruction
A
Vomiting
Abdo pain
Abdo distention
Constipation
9
Q
Cardinal symptoms of large bowel obstruction
A
Abdo pain
Abdo distention
Constipation
Vomiting
10
Q
SBO on X-ray
A
This is an supine abdominal X-ray, showing multiple grossly dilated >3cm loops of bowel, locates predominantly central. The dilated bowel is identified as SBO because of the presence of plicae circulares, which are hyperdense mucosal folds that extends completely across the entire width of the SB lumen
11
Q
Investigations for any acute abdomen
A
CBC - anemia and leucocytosis U&E with RFT (assess dehydration ) Group and cross match /save Serum amylase RBS ABG X-RAY (supine and erect) Contrast ( gastrografin) enhance abdo X-ray CT scan Uss/MRI in pregnant women
12
Q
LBO X-ray
A
This is an supine abdo X-ray showing multiple grossly dilated >6cm loops of bowel, located predominantly peripherally. The dilated loops of bowel is identifiable as the colon because of the presence of haustra, which are sac like pouches that do not extent completely across the entire width of the bowel lumen
13
Q
Differential dx for LBO
A
Colorectal cancer Sigmoid volvulus Diverticular disease Fecal impaction Pseudo obstruction- paralytic ileus or functional obstruction (olgivie’s syndrome)
14
Q
4 B’s that can cause peritonitis->shock
A
Bile
Blood
Bowel contents
Barium
15
Q
5 features of a ruptured appendix on X-ray
A
Pneumo- peritoneum
Intestinal obstruction-ileus
Loss of Psoas shadow-obliterated by Pus or blood
Air around appendix-anaerobic produce gas
Faecolith
16
Q
Types of esophageal cancer. Gross morphology and histology
A
Gross morphology: annular, exophytic and infiltrative
Histology: adenocarcinoma- lower 1/3
Squamous cell carcinoma- upper 2/3
17
Q
Esophageal ca (adrnocarcinoma) etiology
A
GERD- Barrett esophagus
Obesity
Smoking
Achalasia
18
Q
Esophageal ca (SCC) etiology
A
Alcohol consumption Smoking Diet low in fruits and vegetables Drinking hot beverage Achalasia Nitrosamines exposure Plummer Vinson syndrome Structure Radiotherapy
19
Q
Clinical features of esophageal ca
A
Often asymtomatic
Late stage : progressive dysphasia (from solids to liquids) with possible odynophagia
Weight loss
Retrosternal chest or back pain
Anemia
20
Q
How would you dx esophageal ca
A
EGD ( esophagogastroduodenoscopy) Barium swallow ( apple core lesion) Staging - trans esophageal endoscopic ultrasound, chest and abdo CT, bronchoscopy or laparoscopy
21
Q
Esophageal ca tx
A
Neoadjuvant chemoradiation Surgical resection ( subtotal or total esophagectomy)
22
Q
Esophageal palliative tx
A
Chemoradiation
Stent placement
Laser therapy
23
Q
Achalasia?
A
Inadequate relaxation of the lower esophageal sphincter
24
Q
Achalasia causes
A
Primary ( unknown ) Secondary : esophageal cancer Stomach cancer Chagas diseases Amyloidosis
25
Pathophysiology of achalasia
Atrophy of inhibitory neurons in the Auerbach plexus
26
Achalasia clinical features
```
Dysphasia
Regurgitation
Retrosternal pain and cramps
Weight loss
Progressive dysphasia to solids and liquids
```
27
Achalasia dx
Initially upper endoscopy to rule out pseudo achalasia
esophageal barium swallow ( bird beak sign)
Esophageal manometry ( evaluates the peristaltic function of the esophagus during swallowing)
Chest X-ray (widened mediastinum, air fluid level in lateral view, possible absence of gastric air bubble)
28
Achalasia tx
```
Low surgical risk : pneumatic dilation,
LES myotomy (heller myotomy)- fundoplication : nissen 360 , toupees 270
```
High surgical risk : botulinum toxin injection in the LES , nitrates or CCB
29
Define diverticular disease
Outpouching of the colonic mucosa and underlying connective tissue through the colon wall
It is an acquired disease - false diverticula
30
Diverticulum define
One outpouching
31
Diverticula
Multiple outpouching
32
Diverticulitis
Inflammation of diverticula
33
Diverticulosis
Diverticula with no symptoms
34
Diverticular disease
Symptomatic diverticulosis
35
Hinchey classification
1 Diverticulitis with confines pericolic abscess
2 diverticulitis with distant abscess formation (pelvic abscess)
3 perforated diverticulitis with generalized purulent peritonitis
4 perforated diverticulitis with free communication with the peritoneum, Generalized fecal peritonitis
36
Hartmann procedure
Resection of rectosigmoid colon with closure of the anorectal stump and formation of an end colostomy
37
Forms of fistulas by diverticula
Colovesical
Colovaginal
Coloenteric
Colocutaneous
38
Colovesical- symptoms, dx and tx
Symptoms: pneumaturia (passage of air in the urine)
Fecaluria ( passage of fecal content in the urine)
Dx: CT with oral contrast
Tx: primary anastomosis
39
Diverticulitis mode of presentation, Tx , dx
Presents like a left sides appendicitis
Tx: conservatively with bowel rest and antibiotics
Confirm dx : by barium enema or colonoscopy after waiting for at least 6 weeks
Elective surgery (only if after 2nd attack if diverticulitis)
40
Diverticular abscess (Hinchey 1 &2) tx
```
Drain abscess percutaneously under radiological guidance
Elective surgery (colectomy) following interval of 6 weeks
```
41
Diverticular free perforation (Hinchey 3&4) tx
Resuscitate
| Emergency surgery- Hartmann procedure
42
Diverticula bleeding mode of presentation and tx , dx
Sudden onset , massive painless bleed (similar to Angiodysplasia)
Resuscitate -IV, foley, NG tube (rule out UGI Bleed)
Most resolve spontaneously- elective colonoscopy to confirm dx
43
Diverticula bleeding - bleeding continues after conservative tx , what now
Colonoscopy if slow bleed (not effective for high rates of bleeding for to poor visualization)
```
Diagnostic and therapeutic
Vasoconstrictive agents (adrenaline)
Vasoablative agents ( alcohol)
Thermal therapy (electrocoagulatiin, photocoagulation)
```
If high bleed
Nuclear scan with TC 99 (rate of .1-.5ml/min)
Mesenteric angiogram
Dx and therapeutic
Rate of 1ml/min
Vasopressin infusion via catheter
Laparotomy with total colectomy
44
Causes of massive PR bleed
```
Diverticular disease
Massive upper GI bleed
Angiodysplasia
Colorectal carcinoma
Colorectal polyps
Meckel’s diverticulum
Gastrointestinal stromal tumor
Ischemic colitis
Uremic colitis
Ulcerative colitis
Haemorrhoids
```
45
Px presents with ruptured spleen. What are the X-ray findings
Above the diaphragm: rib fractures
Raised hemi diaphragm
Pneumothorax
Haemothorax
Below the diaphragm: gastric bubble pushed medially
Colon pushed inferiorly
Loss of Psoas shadow
Blood around the spleen (radio opaque)
46
Ogilvie syndrome
Colonic pseudo obstruction
Ileus of colon occurring in bed ridden patients
Presents with sudden onset of distention and constipation
Tx
Rectal tube
Colonoscopic decompression
Neostigmine
47
Colorectal cancer hx presentations
Depends on the site if the tumor
Left sided : alteration of bowel habits (constipation) , Pr bleed, intestinal obstruction
Right sides : anaemia, mass
Rectal: tenesmus (incomplete evacuation) , spurious diarrhea, bleeding
48
3 true things about colorectal cancer
Most in rectosigmoid region (then caecum)
Most are sporadic ( adenoma- carcinoma sequence)
Inherited: ( familial adenomatous polyposis (mutation in APC gene)) , HNPCC (Lynch syndrome) (mutation in mismatch repair gene
49
Colorectal cancer : family hx - HNPCC Amsterdam criteria
>/= 3 relatives
At least one 1st degree
>/= 2 generations
At least one < 50 years
50
Colorectal cancer examination- general, abdominal, DRE
General: wt loss, anemia, virchow lymph node
Abdomen : distended (obstructed or Ascites ), hepatomegaly, Mass
DRE: palpable tumor (location from AV , mobility) , sphincter tone, blood on glove
51
Colorectal cancer investigations
Blood: hb, LFT, CEA (carcinoembryonic antigen)
Colonoscopy: dx and therapeutic (polypectomy) , synchronous lesions
Barium enema( if colonoscopy not available)
52
Once colorectal cancer confirmed in histology ( adenocarcinoma ) , now what
Staging : CXR , CT scan abdomen, chest pelvic
53
Rectal cancer investigations (imagining )
Endorectal US
MRI with endorectal coil
54
Colon cancer tx
Right colon - right hemicolectomy
Left colon - left hemicolectomy
Lymphadenectomy - minimum of 12 nodes for adequate staging
55
Rectal cancer tx
Anterior resection
Abdomino-perineal resection (APR)
Refer to stoma therapist
Total mesorectal excision (TME)
56
TNM staging for colorectal cancer
T0 no evidence of primary tumor
T1 tumor invades submucosa
T2 tumor invades muscularis propria
T3 tumor invades through the muscularis propria into the subserosa
T4 tumor directly invades other organs or structures
N0 no regional lymph nodes can’t be assessed
N1 Mets in 1-3 regional lymph nodes
N2 Mets in 4 or more regional lymph nodes
M0 no distant met
M1 distant met
57
At what stage do you start adjuvant therapy in colorectal cancers
Stage 2b and greater - T4N0M0
58
Adjuvant therapy for rectal and colon cancer
Rectum lacks serosa therefore increase in local recurrence- Chemo and radiotherapy for rectal cancer
Chemo only for colon cancer
NB: chemo - works in systemic disease
: radiotherapy- works against local recurrence
59
Types of chemotherapy and radiotherapy for colorectal cancer
Chemo: FOLFOX (FOLinic acid, 5-Flourouracil OXaliplatin
Immunotherapy: Bevazicumab (VEGFR) , Cetuximab (EGFR)
60
Inflammatory bowel disease, 8 things for each
Ulcerative colitis
1. Bloody diarrhea
2. starts in rectum and extends proximally
3. Continuous
4. Mucosal
5. Macro: pseudo polyps
6. Micro: Crypt abscesses
7. Perianal disease -rare
8. Cancer risk ⬆️⬆️
Crohn’s disease
1. Pain, wt loss
2. Anywhere in GIT from mouth to anus
3. Skip lesions
4. Transmural
5. Macro: cobblestone
6. Micro: granulomas
7. Perianal disease - common
8. Cancer risk ⬆️
61
Inflammatory bowel disease extra intestinal manifestations
Uveitis, iritis
Arthritis, ankylosing spondylitis
Sclerosing cholangitis
Erythema nodosum, pyoderma grangrenosum
62
Inflammatory bowel disease dx investigations
Blood : normocytic anaemia, ⬆️CRP , ⬆️ESR
Barium meal and follow through in Crohn’s
Colonoscopy or Barium enema in non acute state (risk of perforation)
63
Inflammatory bowel disease tx
Acute attack:
- Steroids (oral, IV , rectal)
- Azathioprine
- cyclosporine
Maintenance:
- Aminosalicylates (Sulfasalazine)
64
Inflammatory bowel disease indications for surgery
Emergency :
- Pr bleed
- toxic megacolon
Elective:
- carcinoma
- failure of medical therapy
65
Inflammatory bowel disease surgical name
Proctocolectomy with ileal pouch
