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GI Tract Flashcards

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1
Q

What stimulates and inhibits gastrin production?

A

Stimulates -> amino acids, ACh, Ca, EtOH, antral distention, pH > 3.0
Inhibits -> pH < 3.0, somatostatin, secretin, CCK

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2
Q

What stimulates somatostatin secretion?

A

Acid in duodenum

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3
Q

What is the effect of somatostatin?

A

Inhibits gastrin, HCl, insulin, glucagon, secretin, motilin, pancreatic and biliary output

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4
Q

Which cells secrete CCK?

A

I cells in the duodenum

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5
Q

What stimulates and inhibits secretin?

A

Stimulates: fat, bile, pH < 4.0
Inhibits: pH > 4.0, gastrin

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6
Q

What is the effect of secretin?

A

Increases pancreatic HCO3 release
Inhibits gastrin release (reversed in gastrinoma)
Inhibits HCl release

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7
Q

What is the action of VIP?

A

Increased GI secretions and motility

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8
Q

What is the effect of glucagon on motility and sphincter of Odi?

A

Decreases motility

Relaxes sphincter of Odi

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9
Q

What is the effect of Pancreatic Polypeptide?

A

Decreases pancreas and biliary output

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10
Q

What inhibits and stimulates motilin release?

A

Stimulates: duodenal acid, food, vagal input
Inhibits: somatostatin, secretin, pancreatic polypeptide, duodenal fat

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11
Q

What is the action of motilin?

A

Increased intestinal motility (Phase III peristalsis)

Erythromycin acts on this receptor

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12
Q

What is bombesin?

A

Gastrin releasing peptide. Increases motility, pancreas secretion, increases acid secretion

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13
Q

What is Peptide YY?

A

Released from TI in response to fat

Decreases HCl, stomach motility, GB and pancreatic secretions

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14
Q

What is the criminal nerve of Grassi?

A

Part of the right vagus which can cause persistently high acid levels if not divided during vagotomy

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15
Q

Where do the anterior and posterior vagus go?

A

Anterior -> liver/biliary tree

Posterior -> Celiac plexus

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16
Q

Where does thoracic duct cross from R to L?

A

T4/5

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17
Q

What are the characteristics of the UES?

A

15 cm from incisors
Resting pressure 60 mmHg
Pressure with food 15 mmHg

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18
Q

What is the most common site of esophageal perforation?

A

At the cricopharynxgeus muscle (UES)

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19
Q

What are the characteristics of the LES?

A

40cm from the incisors
Normal pressure at rest 15 mmHg
Normal pressure with food 0 mmHg

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20
Q

What is the distance from incisors to carina?

A

24-26 cm

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21
Q

What is the treatment of Zenker’s diverticulum?

A

Cricopharyngeal myotomy

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22
Q

What is a traction diverticulum?

A

A true diverticulum lying laterally usually in the mid-esphagus

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23
Q

What is an epiphanic diverticulum?

A

usually associated with motility disorders

Tx: diverticulectomy, esophageal myotome on opposite side

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24
Q

What is the Tx of diffuse esophageal spasm?

A

Calcium channel blockers and nitrates

Heller myotomy if those fail (upper and lower esophagus)

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25
What does scleroderma do to esophagus?
Loss of LES tone, dysphagia and severe reflux resulting in fibrosis
26
What is the phrenoesophageal membrane an extension of?
The transversals fascia
27
What is the key move in a fundoplication?
Identification of the left crus
28
What is a Collis gastroplasty?
Creation of new esophagus by stapling along the stomach cardia when not enough esophagus can be pulled into the abdomen
29
What are the four types of Hiatal Hernias?
I - Sliding (most common, GERD) II - Paraesophageal (normal GE junction) III - combined IV - entire stomach in chest + other organ
30
Why does type II hiatal hernia often need repair?
High risk of incarceration
31
What do almost all patients with a Schatzki's ring have?
Sliding hiatal hernia
32
What is treatment for a Schatzki's ring?
Dilatation of the ring and PPI | DO NOT RESECT
33
What is the treatment for severe Barrett's dysplasia?
Esophagectomy
34
Does a Nissen fix Barrett's?
No, it will prevent further metaplasia but will not prevent malignancy. Need screening EGD for life
35
What are symptoms/signs that esophageal CA is unresectable?
Hoarseness (RLN invasion), Horner's syndrome, Phrenic nerve, malignant pleural effusion, malignant fistula, airway invasion, vertebral body invasion
36
What is the blood supply for a colon interposition reconstruction?
Colon marginal vessels
37
What is the chemotherapy regimen for esophageal cancer?
5-FU and Cisplatin
38
What is the most common benign esophageal tumor?
Leiomyoma
39
What is the treatment of esophageal Leiomyoma?
Do NOT biopsy (scar) | >5 cm or symptoms -> enucleation via thoracotomy
40
What is the initial care of caustic esophageal injury?
No NG tube Nothing to drink Do Not induce vomiting CT C/A -> assess for perforation
41
What are indications for esophagectomy in a 2nd degree caustic burn?
Sepsis, peritonitis, mediastinitis, free air, mediastinal/stomach wall air, contrast extravasation, PTx, effusion
42
What is the most common cause of esophageal perforation?
EGD
43
What is the most common site of esophageal perforation?
Cervical esophagus near cricopharynxgeus muscle
44
What are the initial diagnostic tests for esophageal perforation?
CXR then gastrografin swallow
45
What is the treatment for non-contained esophageal perforations if < 24 hours?
If no major contamination primary repair with longitudinal myotomy and muscle flap interposition
46
What is the treatment for non-contained esophageal perforation if > 48 hours?
Neck -> Drains only | Chest -> Resection or Exclusion + Diversion
47
Where is the most likely site of perforation in Boerhaave's syndrome?
Left lateral wall 3-5 cm above GE junction
48
What is Hartmann's sign?
Mediastinal crunching on auscultation -> esophageal perforation
49
What is Menetrier's disease?
Mucosal cell hyperplasia, Increased rugal folds
50
What is the classic presentation of gastric volvulus?
Severe Pain | Nausea without vomiting
51
Where is the tear in Mallory Weiss usually located?
Lesser curvature near GE junction
52
Why does vagotomy increase liquid emptying?
Decreased receptive relaxation so increased gastric pressures
53
What is a truncal vagotomy?
Dividing at level of esophagus -> decreases emptying of solids
54
What is a proximal vagotomy?
Highly selective, divides individual fibers Preserves "crow's foot", Normal emptying of solids
55
What are other effects of a truncal vagotomy?
Decreased acid output, increased gastrin and G cell hyperplasia Decreased exocrine pancreas function, bile flow, increased GB volumes Diarrhea (40%) - > due to sustained MMCs forcing bile acids into colon
56
What is a Heineke-Mikulicz pyloroplasty?
Longitudinal incision and transverse closure
57
What is the diagnostic test for slow bleeds with difficulty localizing source?
Tagged RBC scan
58
What are the biggest risk factors for re-bleeding on EGD?
``` Spurting blood vessel (60% chance) Visible blood vessel (40%) Diffuse oozing (30%) ```
59
What is triple therapy for H. Pylori?
Amoxicillin Flagyl/Tetracycline Omeprazole +/- Bismuth Salts
60
What are surgical indications for duodenal ulcers?
``` Perforation Protracted bleeding Obstruction Intractability Inability to rule out cancer If on PPI -> need acid reducing procedure as well ```
61
What are surgical options for acid reducing surgery in order of recurrence risk?
``` Truncal vagotomy + Antrectomy (2% mortality) Truncal vagotomy + Pyloroplasty (1% mortality) Proximal vagotomy (lowest complications, 10-15% recurrence) ```
62
What are reconstruction options after antrectomy?
Roux-en-Y GJ (best, less dumping and reflux gastritis) B1 (GD anastomosis) B2 (GJ anastomosis)
63
What is definition of major duo ulcer bleeding?
> 6 u pRBC in 24 hours, or hypotension despite transfusion
64
What is the surgery for bleeding duodenal ulcers?
Duodenotomy and GDA ligation Complication: CBD injury If on PPI -> need acid reducing surgery as well
65
What is the treatment for an obstructing duodenal ulcer?
PPI and serial dilations | Surgery: antrectomy and truncal vagotomy (need Bx for cancer rule out)
66
What is the definition of intractability for a duodenal ulcer?
> 3 months without relief while on escalating doses of PPI | Based on EGD mucosal findings, not symptoms
67
Where are 80% of gastric ulcers located?
Lesser curvature of the stomach
68
What are the types of gastric ulcers?
I - Lesser curvature low along body of stomach due to decreased mucosal protection II - 2 ulcers (lesser curvature and duodenal) high acid III - Pre-pyloric (high acid) IV - lesser curvature high along cardia (decreased mucosal protection) V - Associated with NSAIDs
69
Surgical indications for gastric ulcers?
Perforation, bleeding not controlled with EGD, obstruction, cannot exclude malignancy, intractability (based on EGD)
70
Why should you always resect gastric ulcers at the time of surgery?
High risk of malignancy
71
What are the two types of chronic gastritis?
``` Type A (funds) - Pernicious anemia, autoimmune dz Type B (astral) - Associated with H. Pylori ```
72
Where are the majority of gastric cancers located?
Antrum
73
What is a Krukenberg tumor?
Metastases to ovaries
74
What is the intestinal-type gastric CA?
Seen in high risk populations (old Japanese men) | Tx: Subtotal gastrectomy (10 cm margin)
75
What is the most common type of gastric cancer in the US?
Diffuse (linitis plastica) Diffuse lymphatic invasion Less favorable prognosis Tx: Total gastrectomy
76
What is the chemotherapy for gastric cancer?
5FU, doxorubicin, mitomycin C
77
What is the palliative procedure for obstructing gastric CA?
Stent proximal lesions | Bypass distal lesions with G-J
78
What is the most common benign gastric neoplasm?
GIST
79
What are the characteristics of GIST?
Hypoechoic on ultrasound with smooth edges C-KIT positive >5 cm or > 5 mitosis/50 HPF = MALIGNANT
80
What is the Tx for GIST?
Resection with 1 cm margins | Imatinib if malignant
81
What is the most common type of lymphoma in the stomach?
non-Hodgkin's lymphoma (B cell)
82
What are the treatments for gastric lymphoma?
Chemo and XRT | Surgery possible for stage I disease (confined to stomach)
83
What are the criteria for bariatric surgery?
BMI > 40 or > 35 with comorbidities Failure of nonsurgical methods Psychological stability No drug or EtOH abuse
84
What gets better after weight loss surgery?
DM, cholesterol, OSA, HTN, incontinence, GERD, venous ulcers, pseudotumor cerebri, joint pain, migraines, depression, PCOS, NAFLD
85
What are the risks of Roux-en-Y gastric bypass?
``` Marginal ulcers Leak Necrosis Fe and B12 deficiency Gallstones ```
86
What is the treatment for a leak after Roux-en-Y?
early (not contained) -> re-operation | Late (likely contained) -> perc drain, abx
87
What is the rate of marginal ulcer development?
10%
88
What are symptoms of dilation of the excluded stomach after Roux-en-Y?
Hiccoughs, large stomach bubble | Tx: G-tube
89
Why is SBO a surgical emergency in bypass patients?
High risk of small bowel herniation, strangulation, infarction, necrosis
90
What are the two phases of dumping syndrome?
Hyporsomotic fluid shift (hypotension, diarrhea, dizziness) Hypoglycemia from reactive insulin release (rare) Tx: small, low-fat, low carb meals, no liquids with meals Octreotide
91
What are surgical options for dumping syndrome?
Conversion to Roux-en-Y GJ Operations to increase gastric reservoir (j-pouch) Increase emptying time (reversed J loop)
92
What causes alkaline reflux gastritis? Tx?
Bile reflux into stomach Tx: PPI, choleystramine, reglan sTx: B1 or B2 to Roux-en-Y with afferent limb 60 cm distal to GJ
93
What is chronic gastric atony? Tx?
Delayed gastric emptying Tx: reglan, prokinetics sTx: roux-en-Y
94
What causes blind-loop syndrome?
Poor motility with B2 or Roux-en-Y
95
What are the symptoms of blind-loop syndrome?
Pain Steattorehea (bacteria deconjugate bile) B12 deficiency (used by bacteria) Malabsorption
96
What causes blind loop syndrome?
Bacterial overgrowth from stasis in afferent limb
97
How do you diagnose blind loop syndrome?
EGD of afferent limb with aspirate and cultures
98
What is the tx of blind loop syndrome?
Tetracycline and flatly, reglan | sTx: re-anastomosis with shorter (< 40 cm) afferent limb)
99
What causes afferent loop obstruction?
Mechanical obstruction of afferent limb | Sx: RUQ pain, steatorrhea, nonbilios vomiting, pain relief with bilious emesis
100
What is the treatment of afferent loop obstruction?
Baloon dilation | sTx: re-anastomosis with shorter (40 cm) afferent limb)
101
What causes post-vagotomy diarrhea?
Non-conjugated bile salts in colon Casued by sustained postprandial organized MMCs Tx: cholestyramine, octrotide sTx: reversed interposition jejunal graft
102
What is the treatment of duodenal stump blow out?
Place lateral duodenostomy tube and drains
103
What is the transition point of the 3rd and 4th portion of duodenum?
Aorta/SMA
104
What is maximally absorbed in the TI?
B12 Conjugated bile acids (only site of absorption) Folate
105
How long are the jejunum and ileum?
Jejunum: 100 cm Ileum: 100 cm
106
How can you identify the jejunum from the outside?
Long vasa recta | Circular muscle folds
107
What are the four phases of migrating motor complexes?
I - Rest II - Acceleration and GB contraction III - Peristalsis IV - Deceleration
108
What does a Sudan red stain show?
Fecal fat
109
What is the Schilling test?
Checks for B12 absorption
110
How much intestine do you need to survive off of TPN?
75 cm | Maybe 50 with a competent ileocecal valve
111
What are the causes of non-healing fistulas?
``` F - Foreign Body R - Radiation I - Inflammation E - Epithelialization N - Neoplasm D - Distal obstruction S - Sepsis/infection ```
112
How do you assess for abscess in fistula with persistent fever?
Fistulogram Abdominal CT UGI with SB follow through
113
What are surgical indications for SBO?
``` Progressing pain Peritoneal signs Fever Increasing WBCs Failure to resolve ```
114
What is classic finding of gallstone ileus?
Air in biliary tree with SBO
115
What is the most common tissue found in a Meckel's?
Pancreatic tissue
116
What type of mucosa is most likely to be symptomatic in a Meckel's?
Gastric
117
When do you need a segmental bowel resection for Meckel's?
Complicated Diveticulitis (perforation) neck > 1/3 diameter of normal bowel Diveritculitis involving the base
118
What is the frequency of diverticula in the small bowel?
Duodenum > Jejunum > Ileum
119
What must be ruled out with a duodenal diverticulum?
GB-Duodenal fistula
120
How do you treat a juxta-ampullary duodenal diverticulum?
Choledocchojejunostomy for biliary sx ERCP with stent for pancreas sx AVOID WHIPPLE
121
What is the medical treatment for Crohn's?
5-ASA and Loperamide (maintenance) Steroids (flairs) Remicade -> fistulas or steroid resistance TPN may induce remission and fistula closure
122
What are indications for surgery in Crohn's disease?
``` Obstruction (conservative first) Abscess (perc drainage) Megacolon (perforation in 15%) Hemorrhage Blind loop obstruction Fissures (NO LIS) EC fistula (conservative first) Perineal fistula (unroof to r/o abscess, then let heal) Anorectovaginal fistulas (rectal advancement flap) Get 2 cm from gross disease with surgery ```
123
What is the procedure for those with diffuse colonic Crohn's?
Total proctocolectomy with ileostomy
124
What do you do with incidental IBD found on appendectomy?
Remova normal appendix if cecum not involved to r/o future confounding
125
When should you do a stricturoplasty?
If you are trying to save bowel length
126
What type of kidney stones do you get with TI resection?
Calcium oxalate (increased oxalate absorption 2/2 decreased fat absorption and fat binding calcium)
127
What are the hallmark symptoms of carcinoid syndrome?
``` Intermittent flushing (from bradykinin) Diarrhea (from serotonin) ```
128
What are the diagnostic tests for carcinoid?
``` Chromogranin A level (highest sensitivity) Octreotide scan (localizing tumor) ```
129
What are the most common sites for carcinoid?
Appendix > ileum > rectum
130
What is the treatment for appendices carcinoid?
< 2 cm = Appendectomy | > 2 cm or involving base = right hemicolectomy
131
What is the treatment for small bowel carcinoid?
Segmental resection with lymphadenectomy
132
What ist he chemotherapy for carcinoid?
Streptozocin and 5-FU
133
What are the treatments for carcinoid syndrome symptoms?
Octreotide (global) Aprotinin - for bronchospasm alpha blockers - for flushing
134
What is a the presentation of a small bowel adenoma?
Bleeding, obstruction | Tx: resection (often endoscopic)
135
What is the most common extra-intestinal malignancy in Peutz-Jeghers syndrome?
Breast cancer
136
What are risk factors for duodenal cancer?
FAP Gardner's syndrome Polyps and adenomas von Recklinghausen's disease (NF1)
137
What is the most common site of small bowel adenocarcinoma?
Duodenum
138
Where are leiomyosarcomas found in the small bowel?
Jejunum and ileum, extraluminal
139
Where is lymphoma usually found in the small bowel?
Ileum
140
What is small bowel lymphoma usually associated with?
``` Wegner's SLE AIDS Crohn's Celiac dz Post-transplantation ```
141
What is the treatment for small bowel lymphoma?
Wide en-bloc resection (including nodes) | 1st or 2nd portion of Duo -> XRT (no whipple)
142
What is the most common stoma infection?
Candida
143
What is diversion colitis caused by?
Lack of short-chain fatty acids (tx SCFA enemas)
144
What is the most common cause of stenosis of stoma?
Ischemia
145
What types of stones are increased with ileostomy?
Gallstones | Uric acid kidney stones
146
What are CT findings of appendicitis?
Diameter > 7 mm Wall thickness > 2 mm (bulls eye) Fat stranding No contrast in lumen
147
What area of the appendix is most likely to perforate?
Midpoint of the anti-mesenteric border
148
What should you consider in an elderly person with perforated appendicitis?
Perforated cecal colon cancer
149
What is different about appendicitis in pregnancy?
Need to make incision where the pain is as appendix is displaced cephalad
150
What is the fetal mortality with appendices rupture?
35%
151
What must be tested on women with suspected appendicitis?
HcG and abdominal U/S to rule out appendicitis
152
What is treatment for appendix mucocele?
Open appendectomy to avoid spillage | Right hemicolectomy if malignant
153
What is the most common cause of death with appendix mucocele?
SBO from peritoneal tumor spread
154
What can mimic appendicitis?
Regional ileitis -> 10% go on to get Crohn's
155
What if you operate and do not find appendicitis?
Generally remove appendix except of there is cecal enteritis
156
What is the defining radiographic feature of ileus?
Uniform dilatation of stomach, small bowel, colon and rectum without decompression
157
What are the signs of typhoid enteritis (salmonella)?
RLQ pain, diarrhea, fever, headaches Maculopapular rash Leukopenia Tx; Bactrim
158
What happens to the Taenia at the rectosigmoid junction?
They become broad and completely encircle bowel
159
How far is the dentate line from the anal verge?
2 cm
160
Where does the inferior rectal artery branch from?
Internal Pudendal
161
What is lymphatic and venous drainage of the rectum?
Superior and middle -> IMV and IMA nodes | Lower rectum -> Internal Iliac Vein, IMA nodes and iliac nodes
162
What are the two watershed areas?
Griffith's Point at the splenic flexure | Sudan's point in the rectum
163
What innervates the external sphincter?
Inferior rectal branch of the internal pudendal nerve
164
What are some important distances from the anal verge?
0-5 cm - Anal Canal 5-15 cm - Rectum 15-18 cm - Rectosigmoid Junction
165
What are Denonvilliers and Waldeyer's fascia?
Denonvilliers -> rectovaginal or rectovesicular | Waldeyer's -> rectosacral
166
What increases cancer risk in a polyp?
> 2 cm Sessile Villous
167
What is intramucosal cancer?
Still in situ, has gone into muscularis mucosa but not basement membrane
168
When is a polypectomy adequate for a T1 lesion?
If margins are clear (2 mm), well differentiated, no vascular/lymphatic invasion
169
What is the tx for low rectal villous adenomas with atypic?
Transanal excision | APR only if true cancer is present
170
What if pathology shows T1 or T2 lesion after transanal excision?
T1 -> if 2 mm, well differentiated, no invasion, nothing further T2 -> APR or LAR
171
How does rectal CA metastasize to the spine?
Directly via Batson's plexus (venous)
172
What histologic features of colon CA have a better and worse prognosis?
Lymphocytic -> improved | Mucoepidermoid -> worst prognosis
173
What is the implication of rectal pain with a rectal CA?
Needs APR
174
What margins are needed with colon cancer?
2 cm
175
What is the best method for assessing hepatic mets?
Intraoperative U/S (resolution 3-5 mm vs. 10 mm for transabdominal)
176
What is the role of pre-op Chemo/XRT in rectal cancer?
Can produce response and preserve sphincter function in some
177
What is the N staging for colorectal cancer?
N1: 1-3 nodes N2: >4 nodes N3: central nodes
178
When is chemo/XRT used in colorectal cancer?
Stage III and IV colon CA -> post-op chemo only Stage II and III rectal -> Preop chemo+XRT Stage IV rectal -> chemo/xrt +/- surgery
179
What is the chemotherapy for colorectal cancer?
FOLFOX = 5FU, leucovorin, oxaliplatin
180
What is recurrence rate on colorectal cancer?
20% | 5% get a second primary (follow up colonoscopy at 1 year)
181
What is the surveillance for FAP?
Flexible sigmoidoscopy
182
Where else do those with FAP get polyps?
Duodenum
183
What is Gardner's syndrome?
Colon CA and Desmoid Tumors/Osteoms
184
What is Turcot's syndrome?
Colon cancer and brain tumors
185
What are the two types of Lynch syndrome?
Lynch I -> just colon cancer | Lynch II -> also increased ovarian, endometrial, bladder, gastric cancers
186
What are the Amsterdam Criteria for Lynch syndrome?
"3-2-1" | 3 first degree relatives over two generations with one cancer prior to age 50
187
What is the treatment for HNCC?
Total proctocolectomy with the first cancer diagnosis
188
What are risk factors for sigmoid volvulus?
High fiber diets (middle east) Psychiatric patients Neurologic dysfunction Laxative abuse
189
What are the findings for sigmoid volvulus on AXR?
Bent inner tube sign | Bird's beak with gastrograffin enema
190
What is the Tx for sigmoid volvulus?
Peritoneal signs -> Sigmoidectomy | Decompression with colonoscopy (80% reduce, 50% recur) -> sigmoid colectomy during same admission
191
What are the characteristics of cecal volvulus?
younger patients in 20s-30s | see a dilated cecum in the RLQ
192
What are the findings of the mucosa with UC?
Mucosal friability | Pseudopolyps and collar-button ulcers
193
What is definition of toxic colitis?
``` > 6 blood stools/d Fever Tachycardia Drop in Hgb Leukocytosis ```
194
What is toxic megacolon?
Toxic colitis + distention, abd pain, tenderness
195
What is the initial treatment of toxic colitis and toxic megacolon?
NG tube, IVF, steroids, bowel rest, abx Treats 50% Avoid: barium enemas, narcotics, anti-diarrheal agents, anti-cholinergics
196
What are absolute indications for surgery with toxic colitis/megacolon?
``` Pneumoperitoneum Diffuse peritonitis Localied peritonitis with increased pain/distention Uncontrolled sepsis Major hemorrhage ```
197
What are relative indictions for surgery with toxic megacolon/colitis?
``` Inability to promptly control sepsis Increasing Failure to improve in 24-48 hours Increasing toxicity or signs of deterioration Continued transfusion requirements ```
198
What are the common sites of perforation for UC and Crohn's?
UC - T colon | Crohn's - TI
199
What are surgical indications fur UC?
``` Massive hemorrhage Refractory toxic megacolon Acute fulminant UC Obstruction Any dysplasia or cancer Intractability and systemic complications FTT Long-standing disease ```
200
What is done for elective resections for UC?
Ileoanal anastomosis with rectal mucosectomy and J-pouch with temporary diverting ileostomy
201
What is the cancer risk with UC?
1% per year starting 10 years after initial diagnosis
202
What manifestations of UC do and do not get better with colectomy?
Get better: ocular problems, arthritis, anemia Do not: PSC, ankylosing spondolytis 50% get better: Pyoderma gangrenosum
203
What is the treatment for low rectal carcinoids?
< 2 cm -> WLE with negative margins | > 2 cm or invasion of muscular -> APR
204
Where is colonic perforation most likely to occur in setting of obstruction?
In the cecum
205
What is the treatment for Ogilvie's syndrome?
Electrolyte repletion Discontinue drugs that slow colon NGT If colon > 10 cm -> decompression with colonoscopy and neostigmine
206
Where is the most common colonic site of actinomycetes infection?
Cecum Yellow-White sulfur granules Tx: penicillin or tetracycline
207
Where are bleeding diverticula most likely to be located?
On the right side
208
What is the limit of detection for for LGIB for arteriography and tRBC scans?
Arteriography > 0.5 cc/min | tRBC > 0.1 cc/min
209
What do you need after an episode of diverticulitis?
Follow up colonoscopy to r/o cancer
210
What are signs of complicated diverticulitis?
``` Obstruction Fluctuant mass Peritoneal signs Temp > 39 WBCs > 20 ```
211
What is treatment for R sided diverticulitis?
Right hemicolectomy
212
What is the Dx algorithm for LGIB?
NGT to r/o UGI Colonoscopy Angio first if massive bleed OR if hypotensive and not responding to resuscitation (colectomy vs subtotal colectomy if site is localized)
213
What are the characteristics of angiodysplasia bleeds?
Less severe than diverticular but more likely to recur
214
What cardiac finding is associated with colonic angiodysplasia?
Aortic stenosis
215
What are the key findings in C. Diff colitis?
PMH inflammation of mucosa and submucosa
216
What is the treatment for neutropenic typhlitis?
Antibiotics | surgery ONLY for free perforation
217
What is the venous drainage of the anus?
Above dentate -> internal hemorrhoid plexus | Below dentate -> external hemorrhoid plexus
218
What are the grades of hemorrhoids?
I - Slides below dentate with strain II - prolapse and spontaneous reduction III - manual reduction required IV - incarcerated
219
What causes rectal prolapse?
Pudendal neuropathy and laxity of sphincters
220
What are the treatments for rectal prolapse?
Medical: High fiber diet Surgical: Perineal rectosigmoid resection (Altemeir) or LAR and pexy of residual colon
221
What do you worry about with lateral or recurrent fissures?
IBD
222
Which perianal abscesses can be drained through the skin?
Perianal Intersphincteric Ischiorectal All are below levators
223
When are antibiotics needed for anorectal abscess?
Cellulitis DM Immunosuppressed Prosthetic hardware
224
What is Goodsall's rule?
Anterior fistulas connect with anus/rectum in a straight line Posterior go towards the midline internal opening in the anus
225
What is the treatment for rectovaginal fistula?
Simple - trans-anal rectal mucosa advancement flap | Complex -> abdominal approach with resection, closure, interposition and temporary ileostomy
226
What is the tx for anal incontinence from abdominoperinal descent?
high-fiber diet, reduced BMs | 2/2 chronic damage to levator and pudendal nerves
227
What is the treatment for anal incontinence from obstetrical trauma?
Anterior Anal Sphincteroplasty
228
What are the various anorectal findings in AIDS?
Nodule with ulceration = Kaposi's Shallow ulcers = CMV (presents like appendicitis) Rectal Ulcer = HSV Abscess/ulcer = B cell lymphoma
229
What is the treatment for Squamous CA of the anal canal?
``` Nigro Protocol (chemo-XRT with 5FU and mitomycin) APR for treatment failures ```
230
What is the treatment for adenocarcinoma of the anal canal?
APR | WLE if < 3 cm and < 1/3 circumference and T1 and no invasion. Needs 1 cm margin
231
What is the characteristics of anal melanoma?
3rd most common site Sx: rectal bleeding Most not pigmented at all APR
232
What is the treatment for Squamous cell CA of anal margin (below dentate line)
WLE < 5 cm Chemo-XRT (5FU and cisplatin) for > 5 cm if involving sphincter or positive nodes Need inguinal node dissection if clinically positive

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