GI goljan bowel obstruction, hernias

Question 1

What is the most common site for obstruction?

Answer 1

small bowel

Question 2

Radiographic findings in bowel obstruction

Answer 2

bowel distention;
air-fluid levels w/ step ladder appearance;
absence of air distal to obstruction

Question 3

general Clinical findings in bowel obstruction

Answer 3

Colicky pain (pain-pain free intervals);
abdominal distention;
no rebound tenderness;
tympanitic to percussion
high-pitched tinkling sounds

Question 4

Tx for bowel obstruction

Answer 4

surgery

Question 5

most common cause of small bowel obstruction?

Answer 5

adhesions from previous surgery (most common);
endometriosis;
radiation

Question 6

How does Crohn’s disease cause bowel obstruction?

Answer 6

lumen in terminal ileum narrowed due to full-thickness inflammation of bowel wall;
bowel-bowel serosal adhesions

Question 7

Define duodenal atresia and what is it associated w/?

Answer 7

atresia distal to entry of common bile duct;

assoc w/ down syndrome

Question 8

Duodenal atresia is a bowel obstruction disorder. How does it present?

Answer 8

Hx of maternal polyhydramnios;
vomiting of bile stained fluid at birth;
Double bubble sign=> air in stomach and prox duodenum

Question 9

who is gallstone ileus likely to present in?

Answer 9

most common in elderly women w/ chronic cholecystitis and cholelithiasis

Question 10

What is the mechanism for obstruction in gallstone ileus?

Answer 10

fistula develops bw gallbladder and small bowel => stone passes into small bowel & lodges at ileocecal valve causing obstruction

Question 11

Radiographic presentation of gallstone ileus?

Answer 11

air in biliary tree

Question 12

Define Hirschsprung’s disease and how it causes obstruction

Answer 12

absence of ganglion cells in Meissner’s submucosal plexus and Auerbach’s myenteric plexus causing localized aperistalsis => NO sympa neurons in aganglionic segment => constant contraction w/o relaxation => obstruction

Question 13

How may Hirschsprung’s disease be acquired?

Answer 13

Chagas’ disease and destruction of ganglion cells by amastigotes

Question 14

What does Hirschsprung’s disease involve?

Answer 14

distal sigmoid and rectum => may involve entire rectum and descending colon => proximal uninvolved bowel is dilated but HAS PERISTALSIS

Question 15

How does Hirschsprung’s disease present?

Answer 15

abdominal pain;
chronic constipation w/o large stools of retentive encopresis;
alternating signs of obstruction w/ diarrhea

Question 16

Describe physical exam for Hirschsprung’s disease

Answer 16

absent stool on examining finger bc NO stool in rectal vault (different from other chronic constipation)

Question 17

any associations w/ Hirschsprung’s?

Answer 17

down syndrome

Question 18

Complications w/ Hirschsprung’s?

Answer 18

enterocolitis of dilated bowel (danger of perforation)

Question 19

What is most common cause of death in Hirschsprung’s?

Answer 19

perforation of dilated bowel

Question 20

How to Dx and Tx Hirschsprung’s?

Answer 20

rectal biopsy;

surgical resection of affected segment

Question 21

What is the 2nd most common cause of small bowel obstruction? How does it do this?

Answer 21

indirect hernia;

bowel becomes trapped in inguinal canal

Question 22

What bowel obstruction leads to highest rate of bowel incarceration?

Answer 22

femoral hernia

Question 23

Who is most likely to have intussusception causing bowel obstruction?

Answer 23

children ages 1-5

Question 24

In children, what is the nidus for intussusception?

Answer 24

terminal ileum invaginates into cecum leading to mound of hyeprplastic lymphid tissue in Peyer’s patches leading to combo of obstruction and ischemia

Question 25

How will a child w/ intussusception present? physical exam?

Answer 25

colicky pain w/ bloody diarrhea; | oblong mass palpated in midepigastrum (Dance's)

Question 26

What is the Tx for a child w/ intussusception?

Answer 26

usually self-reduces but may require air reduction under fluoroscopy or ultrasound

Question 27

What vaccine may intussusception be associated with?

Answer 27

rotavirus oral vaccine

Question 28

In adults, what is the common nidus for intussusception?

Answer 28

polyp or cancer

Question 29

Describe who and how a meconium ileus leads to bowel obstruction

Answer 29

complication of newborn w/ CF; | meconium lacks NaCl and obstructs bowel lumen

Question 30

Define volvulus

Answer 30

bowel twists around mesenteric root producing obstruction and strangulation of bowel

Question 31

Depending on age, where does volvulus likely occur?

Answer 31

elderly=> sigmoid colon | young adults=> cecum

Question 32

Risk factors for volvulus

Answer 32

chronic constipation (most common); pregnancy; laxative abuse

Question 33

What are mechanisms predisposing to acquired hernias?

Answer 33

increased intra-abdominal pressure (coughing, heavy weight lifting); weakness in abdominal wall

Question 34

What are the 5 types of hernias?

Answer 34

``` direct; indirect; femoral; umbilical; ventral ```

Question 35

What are the borders to Hesselback's triangle?

Answer 35

medial=> rectus sheath lateral=> inferior epigastric artery inferior=> inguinal ligament

Question 36

What covers a direct hernia and where does it bulge to?

Answer 36

single layer of transversalis is stretched in floor of Hesselbach's triangle w/ bulge there

Question 37

Does direct hernia lead to obstruction or incarceration? Why?

Answer 37

no=> small bowel cannot enter scrotal sac so no obstruction or incarceration

Question 38

How can a direct hernia be Dx on physical exam?

Answer 38

when patient reclines, the bulge goes away

Question 39

Tx for direct hernia

Answer 39

sutured mesh covering inguinal canal and Hesselbach's triangle

Question 40

What is the most common hernia?

Answer 40

indirect hernia

Question 41

Pathogenesis of indirect hernia in children?

Answer 41

persistence of peritoneal connection bw inguinal canal and tunica vaginalis

Question 42

pathogenesis of indirect hernia in adults?

Answer 42

protrusion of new peritoneal process into inguinal canal

Question 43

How can indirect hernia be diagnosed?

Answer 43

physical exam=> small bowel passes through internal inguinal ring and may enter scrotal sac thus hitting the examining finger w/in inguinal canal

Question 44

complications of indirect hernia

Answer 44

entrapped inguinal canal leading to incarceration; | strangulated obstruction causing hemorrhagic infarction

Question 45

Tx of indirect hernia in children

Answer 45

high ligation of hernia sac at level of internal inguinal ring and tightening of internal inguinal ring

Question 46

Tx of indirect hernia in adults

Answer 46

sutured mesh covering inguinal canal and Hesselbach's triangle

Question 47

Where does the most common hernia in women present?

Answer 47

femoral hernia will have bulge located below inguinal ligament

Question 48

Tx for femoral hernia

Answer 48

transversalis fascia and conjoined tendon are sutured to Cooper's ligament

Question 49

Who is an umbilical hernia most common in?

Answer 49

adults w/ ascites, pregnancy, obesity; | black newborns

Question 50

Define umbilical hernia

Answer 50

peritoneal protrusion extending into fascial defect contain remnants of umbilical cord

Question 51

How is an umbilical hernia typically treated?

Answer 51

most close spontaneously w/in 2nd year or can be treated by surgery

Question 52

Who is most likely to suffer from incarceration of the bowel in umbilical hernias?

Answer 52

adults >> children

Question 53

What is a hernia where obesity is common cause? How does it develop?

Answer 53

Ventral hernia; | develops in weakened area of previous surgical excision