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Flashcards in Lower GI 2 Deck (21):
0

75-year-old woman presents with suspected mesenteric ischemia – When to take patients OR?

Necrotic bowel – proceed to OR

1. Significantly worsening pain after presentation
2. Leukopenia or leukocytosis
3. Metabolic acidosis

1

70-year-old woman presents with nausea vomiting and increased abdominal pain. Low grade fever and distended abdomen. Nonspecific ileus on radiograph. Sigmoidoscopy shows ischemic sigmoid colon. Angiogram shows SMA occlusion. Improves after antibiotics and hydration. Next step?

1. Given high chance of recurrence, revascularization
2. Aspirin as antiplatelet therapy

2

75-year-old woman presents with suspected mesenteric ischemia – patient also has atrial fibrillation. Suspected diagnosis? Management

Suspect ischemia, necrosis, or perforation with infection. Proceed to OR embolization

Exploration likely necessary

3

75-year-old woman presents with suspected mesenteric ischemia – hematocrit of 55%. Suspected diagnosis? Management

Polycythemia likely secondary to severe dehydration.

1. Hydration
2. Angiography

5

75-year-old woman presents with suspected mesenteric ischemia – history of thoracic aortic dissection. Suspected diagnosis? Management

Occlusion related to dissection

Angiography

6

75-year-old woman presents with suspected mesenteric ischemia – also presents with bloody diarrhea. Suspected diagnosis? Management

Ischemic segment of bowel with necrosis of mucosa

Sigmoidoscopy
1. If full thickness necrosis, exploration and resection
2. If only mucosal ischemia – antibiotics, close observation

7

75-year-old woman presents with suspected mesenteric ischemia – taken to the OR. Find necrosis of left colon. Management?

Resection with reanastomosis if patient stable (or colostomy if not )

8

75-year-old woman presents with suspected mesenteric ischemia. Taken to the OR. Find necrosis of the intestines from the ligament of Treitz to the transverse colon. Management? Complication?

Resection of majority of the bowel, leaving patients with short bowel syndrome and need for chronic TPN or transplantation

9

75-year-old woman presents with suspected mesenteric ischemia – taken to the OR. Find necrosis of 2 feet of jejunum and ischemia adjacent bowel. Management? If doubt viability?

Resection and reanastomosis

If is any doubt about the viability of bowel
1. second look procedure
2. Ileistomy to allow for direct observation if bowel

10

75-year-old woman presents with suspected mesenteric ischemia – taken to the OR. Find ischemia but no necrosis of intestines. Also find acute occlusion of SMA. Management?

1. Revascularize bowel via bypass or removal of occlusion
2. Inspect viability

11

75-year-old woman presents with suspected mesenteric ischemia – taken to the OR. Find ischemia of the intestines and small punctate areas of necrosis throughout jejunum and ileum. Patient has pulse in SMA and mild congestive heart failure. Possible causes? Management?

1. Multiple small emboli
2. Low flow state

1. Resection of necrotic segments and second look operation
2. Angiography to evaluate low flow state

12

24-year-old woman with crampy abdominal pain, nausea, vomiting. History of Crohn's disease. Obstructed series shows small bowel obstruction. No fever, no accidents, mild leukocytosis. Small bowel obstruction likely secondary to? Confirm with? Management?

Small bowel obstruction secondary to stricture due to Crohn's disease

CT of abdomen

Non-operative management the TPN, bowel rest, observation

13

24-year-old woman with crampy abdominal pain, nausea, vomiting. History of Crohn's disease. Obstructed series shows small bowel obstruction. No fever, no accidents, mild leukocytosis. CT shows internal fistula between two segments of small bowel. Management?

Non-operative management the TPN, bowel rest, observation

Management is based on patients symptoms and active problems, not radiographic findings

17

75-year-old woman presents with suspected mesenteric ischemia – history of CHF. Mechanism? Management?

Low flow nonocclusive state

Direct mesenteric onfusion of a vasodilator (Papaverine )

18

Patient with history of Crohn's disease presents with small bowel obstruction. Receives treatment for three weeks, with no signs of resolution – next step? Chance of needing reoperation?

Surgical therapy to reset strictures

Reoperation (50%)

19

Patient with Crohn's disease – surgery indicated only if? Management of superficial fistulas? Management of perianal problems?

Drain perirectal abscesses

Opening the tract or inserting setons (plastic tubes that slowly allow fistula to close)

Metronidazole

20

How does Crohn's disease in colon differ from Crohn's disease in small bowel (Regarding medical management)?

If limited to the colon – 5-ASA more effective

21

Patient with ulcerative colitis – cancer risk? Management for cancer risk?

1-2% risk of colorectal cancer per year

1. Screening colonoscopy every 1-2 tears after 10 years with the disease
2. Biopsy of strictures, lesions, plaques
3. Random biopsies

22

Patients with ulcerative colitis gets biopsy – shows severe dysplasia – management?

Removal of colon and rectum

Total proctocolectomy (removes mucosa and creates ileal pouch and anastomoses to anus to restore continence)

23

Ulcerative colitis patient undergoes total proctocolectomy and ileal pouch-anal stenosis. Returns months later with fever, blood tinged diarrhea, and pain on defecation – suspected diagnosis? Confirm diagnosis with? (Will see?) Treatment?

Pouchitis (inflammation of the reservoir from unknown cause)

EGD; Hemorrhagic mucosa with edema and small ulcerations

Metronidazole

24

Complications of terminal ileum resection?

Resection of terminal ileum may lead to diarrhea, depletion of bile salts pool, malabsorption, oxalate stones