Lower GI Disorders Flashcards
(113 cards)
1
Q
Nausea, crampy abdominal pain, abdominal distension, no BM, mildly tender abdomen w/o rebound, elevated WBC count
A
Dx = SBO; workup req’s obstructive series which demonstrates multiple air fluid levels in small bowel w/o air in the colon/rectum
2
Q
fluid/electrolyte status of pt w/SBO
A
Dehydration d/t vomiting and poor PO intake. Contraction (water loss in vomitus) alkalosis (d/t vomiting up H+) with HYPOchloremic (loss in vomitus) HYPOkalemia (kidney retains Na+ and H+ to compensate for loss in vomit and in turn results in loss of K+ into urine)
3
Q
correction of contraction alkalosis
A
Rehydration w/IV fluids containing Na+ and K+
4
Q
Mgmt for pt w/SBO
A
- NG drain
- IV fluids
- Serial PE, Labs, abdominal Xray to monitor for leukocytosis, fever, acidosis, localized tenderness
5
Q
Proximal vs. distal GI obstructions
A
Proximal obstructions have less abdominal distension on PE
6
Q
Causes of abdominal adhesions
A
- Prior surgery
- Hernia
- SB tumors
- Metastatic tumors to the bowel
- Inflammatory processes
7
Q
Pt passes flatus but not stool
A
Partial small bowel obstruction; more likely to resolve on its own w/o ischemia or perforation
8
Q
DDx for small amount of diarrhea
A
- partial small bowel obstruction
- Gastroenteritis
- Fecal impaction
- Severe constipation
- Inguinal hernia
- Metastatic melanoma to the intestines (most common tumor to met to intestine)
- Recurrent ovarian CA (peritoneal studding causes obstruction
- Metastatic breast cancer
9
Q
Localized tenderness + sx of bowel obstruction +/- marked leukocytosis
A
Requires surgical exploration DDx: 1. Closed loop obstruction 2. Perforation 3. ischemia 4. Abscess
10
Q
Metabolic acidosis + sx of bowel obstruction
A
Suspect ischemic or necrotic bowel
Workup: urgent exploration vs. mesenteric arteriography to evaluate bloodflow
11
Q
High fever + sx of bowel obstruction
A
suspect bowel perforation or ischmia
12
Q
Recurrence of abdominal distension and nausea after previous improvement on NG tube
A
If pt fails nonoperative mgmt then the next step would be ex-lap. Most likely finding = adhesive band affecting single/multiple bowel segments. Plan: lysis of adhesions to free up all of involved bowel
13
Q
Closed loop obstruction on abd Xray
A
Adhesive band occluding both the inlet AND outlet of a loop of bowel resulting in accumulation of secretions and air in the loop and distention.
Complications: blood flow obstruction d/t twisting of the blood supply or adhesive band obstructing the blood supply
14
Q
What is a “second look” operation?
A
Re-exploration of bowel 24-hrs after detecting edematous bowel from twisting
15
Q
Crampy abd pain + free air in peritoneum
A
- Ischemic perforation
2. Perforation d/t overdistention of bowel
16
Q
Small bowel obstruction + inguinal hernia
A
Suspect incarcerated inguinal hernia d/t SBO.
Treatment:
1. inguinal approach w/exploration and hernia reduction with repair
2. Abdominal approach is better for ill-appearing patients b/c it allows for thorough inspection of the entire bowel w/possible resection/reanastamosis
17
Q
Unplanned enterotomy (perforation of bowel during surgery)
A
- Small holes may be repaired via suture
2. Large or multiple holes require bowel resection
18
Q
Complications of enterotomy
A
Small bowel fistula
19
Q
Diseases mimicking SBO
A
- HF
- Sepsis
- COPD
20
Q
Study to r/o SBO
A
- Upper GI series w/small bowel follow through w/barium
21
Q
N/V, severe abd pain, low grade fever, elevated WBC count
A
Suspect ischemic bowel
- Proceed to OR if suspect necrotic bowel
- Further eval and tx prior to surgery (hydration, sigmoidoscopy, mesenteric angiogram)
If pain worsens then consider bowel necrosis and proceed directly to the OR
22
Q
Same as above but with LOW WBC count
A
Elderly pts may respond to overwhelming sepsis w/leukopenia
23
Q
Causes for polycythemia? Risks a/w polycythemia? Tx?
A
- Dehydration
- Polycythemia vera
- COPD or other hypoxemic states
Complications = hypercoagulable state and may cause stasis/low flow/thrombosis in vascular beds
Tx = phlebotomy + hydration
24
Q
Causes of bloody diarrhea? Workup?
A
Dx = colonic ischemia w/necrosis of the mucosa and subsequent sloughing
Sigmoidoscopy to assess colon. Mucosal ischemia tx includes optimizing hemodynamics, ABx, and observation. Full thickness neecrosis requires exploration +/- resection
25
Necrosis extending from ligament of Treitz to transverse colon
Most likely hopeless situation. Surgical resection + reanastamosis in younger pts is ok. most likely results in short bowel syndrome.
26
Necrosis of 2ft of jejunum and ischmia of adjacent bowel
1. Resection + reanastamosis
2. Second look
3. Ileostomy (avoids risk of anastomotic breakdown)
27
Ischemia w/o necrosis d/t acute occlusion of the SMA
SMA should be exposed and the occlusion removed or bypassed
28
Crampy abd pain, N/V, hx of Crohn's of terminal ileum s/p steroid infusion 6mo ago, now presenting w/SBO
SBO 2/2 stricture of the involved bowel w/Crohn's disease
29
Workup for Crohn's diasease
1. CT abdomen demonstrates stenotic bowel in the terminal ileum may reveal stenotic bowel, perforation, abscess/fistula formation
30
Tx for Crohn's stricture
1. TPN
2. Bowel rest
3. Observation
31
If Crohn's stricture/SBO does not resolve or recurs then surgery is indicated
1. Relieve the obstruction by bowel resection
2. Resect strictures and involved bowel back to grossly normal appearing bowel
3. Stricturoplasties (cut strictures axiailly and repair them transversely to dilate the lumen
32
Complications of surgical intervention for Crohn's
1. Reoperation in the future
2. B12 deficiency
3. Impaired reabsorption of bile salts
4. Malabsorption d/t deplection of bile salt pool
5. Diarrhea d/t inability to digest fats.
33
Perianal dz in Crohn's
1. Surgery indicated to drain perirectal abscesses
2. Mgmt of superficial fistulas
3. Seton insertion - plastic tubes that facilitate fistula closure
4. Metronidazole
34
Crohn's dz in colon vs. Crohn's dz in small bowel
Rectal involvement is NOT favorable. If dz is limited to colon then 5-ASA+ steroids. If surgical complications evolve then subtotal colectomy and ileostomy may be performed if rectum is involved. If dz is limited to small bowel then the 5-ASA is not effective. If rectum spared then a reanastamosis may be performed to the sigmoid or rectum
35
Screening for CRC in pts with UC
1. Pancolitis = colonoscopy q1-2yrs after 8yrs of dz
2. Left colitis = colonoscopy q1-2yrs after 10yrs of dz
3. Suspicious lesions (strictures, polypoid lesions, and mucosal plaques) warrant biopsy
4. Random biopsy is also reqd b/c CRC doesnt always follow pathway of polyp to CA
5. Colectomy + rectum removal in the case of severe dysplasia
36
Goals of surgical intervention for CRC
1. Remove entire colonic and rectal mucosa
2. Restore anal continence
3. Establish a reservoir function to allow controlled defecation
e. g. total proctocolectomy (removes mucosa i.e. risk of CA) with ileorectal anastamosis
37
Pt is s/p total proctocolectomy w/ileal pouch anal anastamosis p/w fever, bloody diarrhea, and pain w/defecation
Pouchitis resulting in hemorrhagic mucosa w/edema and small ulcerations. Tx = Metronidazole
38
Several mo of abd cramps, diarrhea, 5lb weight loss, bloody diarrhea x1day
IBD
Workup: colonoscopy or barium enema. Ulcerative colitis affects only the mucosa, begins in distal colon and rectum and has crypt abscesses and raised ulcerations
39
Bloody diarrhea, abd pain, distention, fever, tachycardia. Workup for DDx
Suspect Toxic megacolon
Workup:
1) Abdominal obstructive series to r/o perforation
2) Abdominal CT to r/o abscess or perforation
40
Mgmt of UC/toxic megacolon
1) NG tube
2) NPO
3) TPN
4) IV fluids
5) Broad-spec ABx
6) High dose IV steroids
7) Close observation for worsening s/s with frequent abd examinations and radiographs to r/o toxic megacolon
41
Free air on upright CXR or air in the wall of the colon
Operate immediately as these are signs of perforation. Perform ileostomy w/Hartmann pouch of the rectum
42
Pain in middle abdomen-->lower right abdomen. Anorexia. No guarding or rebound tenderness in RLQ
```
Dx: Appendicitis
Workup:
1) Rectal exam to r/o retroceal appendicitis
2) Pelvic exam to r/o ovarian dz and PID
Mgmt:
1) NPO
2) Hydration
3) Observation + serial exams
4) Repeat CBC
5) AVOID PAIN MEDS B/C THEY MASK SX
```
43
abdominal pain, anorexia, no guarding/rebound, dysuria and urinary WBC >10000/hpf
UTI may also occur with appendicitis d/t appendiceal abscess in continuity with the bladder
44
same as above but with only few WBC detected and only minimal dysuria
Local inflammatory processs results in inflammation of urinary tract d/t local inflammatory process
45
If a pt has suspected IBD d/t significant FHx
consider CT imaging before exploration. CT may show thickened loop of bowel or enlarged nodes in the terminal ileum in the case of IBD. But remember that appendicitis may still occur in pt with IBD
46
Terminal ileitis. Workup.
1) Inflammation of fat wrapping around the intesting
2) Thickened intestinal wall
3) Enlarged nodes
Workup: Do not biopsy b/c of risk of anastomotic breakdown and GI fistula. Biopsy of local node is okay (may show granulomas which is diagnostic)
47
Retrocecal appendix diagnosis
Tenderness with rectal examination rather than on anterior abdominal wall
48
Detection of appendicitis in pt on steroids
Steroids mask all s/s of inflammation and disrupt the body's ability to wall off inflammation to form an abscess
49
Red inflamed appendiceal tip with exudate
Sx of acute appendicitis requiring ligation and amputation of the appendix
50
Necrotic base to the appendix
Ligation and amputation of the appendix with sutures and burial of the base of the appendix into the cecum to prevent blowout. If cecum is involved then a right colectomy is appropriate
51
Perforated appendix with localized abscess
1. Incise, drain, and irrigate the abscess
2. Leave closed drain in the abscess to drain
3. Leave skin open to reduce risk of infection
52
1cm, yellow, firm mass on TIP of appendix
Dx = small carcinoid tumor
53
2cm yellow firm mass on the BASE of the appendix
Dx = larger carcinoid tumor involving the base of the cecum requiring EXCISION. these are generally malignant and require right collectomy
54
3cm round, pedunculated mass in terminal ileum causing obstruction of the lumen
Pedunculated masses of carcinoid tumors or adenoCA may cause SBO and mimic appendicitis. Must remove involved ileum and regional LN's
55
Assessing carcinoid tumors and devising treatment
1. Measure 5-HIAA
| 2. Measure serum serotonin level
56
Fever, chills, anorexia, and malaise 1wk after ruptured appendix
Pelvic abscess or wound infection requiring wound drainage. Abscess may be palpated on rectal exam.
57
Avg risk pt for CRC
Asymptomatic patient >50yo w/o other risk factors
58
Mgmt of hemorrhoids
1. Sitz baths
2. Stool softeners
3. Fiber diet
4. Surgical removal of persistent bleeding hemorrhoids
59
Mgmt for thrombosed hemorrhoids
1. Sitz baths + stool softeners
| 2. Incision and drainage if pain is extreme (remove skin and SC tissue to remove all underlying BV's.
60
DDx for bright red blood on glove on rectal exam
1. Internal hemorrhoids
2. Fissure
3. Bleeding rectal/anal CA or polyp
Workup:
Anoscopy/sigmoidoscopy/colonoscopy depending on where lesion may be visualized
61
Recent onset fatigue, wt loss, pale conjunctiva, black guiac positive stools
Workup: colonoscopy + CXR, CEA level, LFT's to r/o mets. If LFT's are abnormal then a liver CT is indicated
62
Pre-op procedures for a colectomy in case of CRC
1. Bowel prep w/GoLYTELY, Mg-Citrate, laxatives
| 2. Oral NONABSORBED Abx +single pre-op dose of 2nd gen cephalosporin to diminish wound infection
63
Post-op procedures after colectomy w/removal of involved mesentary and LN's
1. NPO
2. IVF
3. NG tube placement
4. Once pt is able to tolerate food they may be discharged
64
Stage II T3NOMO CRC indications for adjuvent CTX
1. mucus-producing tumors
2. Signet ring cell tumors
3. Tumors presenting w/bowel perforation
4. Tumors w/venous or perineural invasion
CTX for Stage III includes 5FU + leucovorin/5FU and levamisole
65
Following up on recurrence of CRC
1. local recurrence at anastamosis
2. Mets to liver
3. Distant mets
4. Occurrence of 2nd primary colon CA
Monitor w/CXR, CEA, LFT's +/- CT abdomen
66
CRC w/intermittent constipation and diarrhea
L>R side bowel obstruction. Necessitates urgent surgical treatment +/- bowel prep
67
Large liver metastatic mass is detected during surgery
DO NOT resect the mass b/c of risk of intraoperative bleeding. Most surgeons are not experienced hepatic surgeons. Risk of infection and bile leakage. Rather, simply biopsy the liver lesion and plan for later resection after further eval
68
Lung nodule detected on CXR preoperatively
Lung mets make cure unlikely and thus a more conservative bowel resection should be performed. Colectomy goal should be to remove the primary tumor to manage it locally and prevent further blood loss or bowel obstruction
69
Vomiting feculent material post-op
Postoperative ileus or mechanical obstruction resulting in bacterial overgrowth in stomach and proximal small bowel. and failure to propel food forward. Must obtain obstructive series to r/o leakage from anastomosis causing persistent ileus or mechanical obstruction d/t adhesions, an internal hernia, or obstruction anastomosis
70
Reddening and fluctuance at the wound
Wound infection requiring reopening the infected area down to the involved fascia
71
Feculent material draining from wound
Anastomotic leak that has drained to the skin via colon fistula.
Mgmt:
-NPO feedings
-IV fluids
-Abd CT to r/o collection of undrained fecalus.
-Immediate surgical intervention as a distal obstruction may prevent the fistula from resolving
72
High post-op fever and abd pain in the RLQ
Abscess formation in the right paracolic gutter or pelvis. Confirm dx by CT and percutaneous drainage
73
Crampy abd pain, constipation, and decreased stool caliber
Anastomotic recurrence of CA and stricture formation at the anastomosis d/t excessive scar formation d/t inadequate blood supply to the site of anastamosis
74
Constipation, rectal bleeding, fatigue, constricting hard lesion 4cm from the anal verge. Workup for adenoCA of the rectum
1. Colonoscopy to r/o multiple synchronous lesions
2. Transrectal US to determine depth of invasion
3. CT/MRi to determine involvement of adjacent structures AND distant structures such as the liver and LN's.
4. Abdominoperineal resection (excision of entire rectum w/creation of permanent colostomy
75
LN spread of rectal CA
1. Internal iliac nodes
2. Sacral nodes
3. Inferior mesenteric nodes
76
Risks a/w abdominoperineal resection
1. Damage to sympathetic pleux of nerves near rectum resulting in impotence
2. Impairment of bladder function
3. Massive venous bleeding from presacral space
4. Injury to ureter
77
Poor prognostic factors of a primary rectal CA tumor
1. High CEA level
2. Poor histological differentiation
3. Bowel perforation
4. Aneuploidy
78
Rectal CA within 5cm of anal verge
Requires abdominoperineal resection b/c lateral margins of resection include the anal sphincter mechanism. Removal/disabling this mechanism results in incontinence
79
Indications for pre-op radiation therapy to reduce local recurrence
1. Large bulky masses
| 2. Extension of mass outside the bowel wall into the surrounding tissue
80
In women undergoing abdominoperineal resection of anterior rectal mass what structure is at risk of damage
1. Posterior wall of the vagina will most likely be resected
| 2. Female urethra
81
After curative resection for CRC, the CEA begins to rise again. Workup.
1. Repeat CXR to look for mets
2. CT of abdomen to look for mets
3. Repeat colonoscopy
82
Rectal bleeding, hard lesion of the anal verge, pain, pruritis
SCC of the anus
83
Nodes to which SCC of anus metastasizes to
Inguinal lymph nodes and superior rectal lymph nodes
84
Tx of small diameter rectal tumor w/o LN extension
Local excision of superficial small mobile masses
85
Tx of medium sized rectal tumor w/o LN extension
Nigro protocool - CTX + RadTx followed by abdominoperineal resection
86
Tx of large rectal tumor with LN extension
Chemoradiation
87
Abdominal pain in LLQ, fever, ocassional constipation, tachycardia, Mgmt. Workup.
Diverticulitis. Mgmt includes bowel rest, IV hydration, parenteral ABx. AVOID morphine for pain control b/c it increases intracolonic pressure. Rather, use meperidine. NG tube may be used. HIGH-fiber diet to soften stools.
Obstructive series to r/o inflammation, abscess diverticula, thickened sigmoid bowel. Colonoscopy after recovery from episode in order to confirm diverticula and r/o CRC
88
Tx of recurrent episodes of diverticulitis
Elective resection 4-6wks after inflammation has resolved. (Increased risk of perforation or abscess w/each attack). Must ID involved segment of colon via preop/intraop colonoscopy
89
LLQ pain, fever, nausea, and WBC count of 15,000 (and rising...). Workup. Tx.
Free perforation of intrabdominal abscess. CT scan demonstrates abscess, perforation, diverticula, "loculated fluid collection in the pericolic gutter". Tx = CT guided needle insertion of a catheter into the fluid collection to be sampled and drained.
90
Drained fluid from intraabdominal abscess reveals gram negative bacilli. Mgmt.
If pt tolerates food and remains afebrile they may be discharged. If pt has persistent ileus or functional obstruction from edema the pt may req TPN nutrition. If the pt does NOT improve with catheter drainage then a Hartman's procedure is necessary.
91
Hx of acute diverticulitis, colonoscopy shows sigmoid diverticula w/scarring and stricture. Voided air in urine.
Pneumaturia d/t fistula formation in diverticulosis.
92
Bright red blood per rectum, tachycardia, pale conjunctiva, dry mucous membranes. Tx.
Bleeding diverticula OR vascular ectasia resulting in hypovolemia. Tx = isotonic fluid resuscitation by placing two large borre IV's and 1-2 liters of lactated Ringer's solution OR 0.9L normal saline.
93
Mgmt of hypovolemia
1. Routine blood studies
2. CXR
3. Coagulation evaluation
4. Blood transfusion if necessary
5. Placement of foley catheter to eval the adequacy of resuscitation.
6. Place NG tube for lavage and r/o UGI bleed w/upper endoscopy and anoscopy to r/o hemorrhoids, rectal varices, or other anorectal dz
94
causes of bright red blood per rectum
1. Meckel's diverticulum
2. Aortoenteric fistula
3. Ischemic colitis
4. IBD
5. Hemorrhoidal disease
6. Rectal varices
7. Colon CA
95
What is important to keep in mind with hematocrit measurement?
Hematocrit takes several hours to equilibrate before it is an accurate indicator of blood cell volume.
96
Workup to determine cause of bright rectal bleeding. Tx of different causes of bleeding.
1. Colonoscopy is reqd.
2. Endoscopic tx allows for localization of bleeding
Vascular ectasia tx = coagulation with monopolar current.
Bleeding polyps tx = esnaring the polyps
Tattooing the bleeding site with methylene blue or india ink allows for precise localization
97
MOA of bleeding in diverticulitis
Underlying vasa recta artery penetrates bowel wall through the neck or apex of a diverticulum and becomes eroded. Bleeding is more likely in R>L side diverticuli
98
Vascular ectasia
Arteriovenous malformations arising from degeneration of intestinal submucosal veins and overlying mucosal capillaries resulting in communication btwn submucosal arteries and veins
99
Defining the source of an unknown active bleed
1. Technetium-labled RBC scan: better for more stable patients with slow bleeds. Cannot precisely localize bleeding, making results difficult to interpret
2. Mesenteric angiography: better open for a less stable patient b/c there is better monitoring and resuscitation capability in the angiography suite
100
Blood is a cathartic. What does this mean?
It has the effect of cleaning out the colon when there is a GI bleed and thus no need for a bowel prep.
101
Methods for quidkly controlling bleeding
1. Vasopressin (risk of coronary vasocontriction and rebleeding after 12hrs)
2. Embolization of arteries (risk of transmural bowel necrosis)
102
Constipation, deteriorating mental status, tachycardia, abdominal distention, painful abdomen, no stool in rectum. Workup.
1. Electrolytes
2. CBC
3. Abdominal obstructive series
103
Cause of sigmoid volvulus. workup. Tx.
1. chronic laxative use
2. chronic illness
3. dementia
Dx via barium enema study.
Tx via rigid proctosigmoidoscopy and placemnt of rectal tube OR sigmoid colectomy w/diverting colostomy OR resection w/primary anastomosis
104
Cecal volvulus tx.
1. Detorsion
2. Cecopexy
3. Right colectomy w/primary anastomosis (#1 tx choice)
105
Dilated right colon to the level of the midtransverse colon w/distal colonic decompression. Mgmt.
Acute pseudoobstruction (Ogilvie's syndrome) = acute massive dilation of cecum and right colon w/o evideence of mechanical obstruction (common in hospitalized intubated ICU pts). If the cecal diameter is 11-12cm then endoscopic decompression is indicated. First try neostigmine (Cholinergic agent to increase colonic tone)
106
Entire colon packed with stool
Constipation with stool throughout the colon.
Perform rectal exam to ensure that stool is NOT impacted and THEN perform enema.
107
Difficulty initiating defecation, sensation of protrusion through the rectum, patulous anus
Rectal prolapse. May occur w/defecation. Often d/t neuromuscular deficiencies and decreased rectal sensation. If the prolapse is entirely internal then a high fiber diet may be sufficient and no surgery necessary. If prolapse is external and causes rectal bleeding then surgery is indicated.
108
Surgical tx of rectal prolapse
1. Rectopexy (fixation to the sacrum)
2. Low anterior resection to remove the upper and midldle portions of the rectum as well as redundant sigmoid colon
3. Perineal appraoch to remove prolapsed rectum and sigmoid colon w/proximal sigmoid colon anastamosis to transitional zone 1-2cm above the dentate line
109
Rectal pain worse w/defection. Ulceration of anal canal sensitive to palpation. Blood in stool.
Anal fissures d/t trauma caused by passage of hard stools OR d/t IBD. Anal fissures are usually found in the posterior midline
110
Tx of anal fissures
Conservative tx = bulk agents, stool softeners, sitz baths.
Deep and chronic fissures require lateral spincterectomy
Biopsy of suspicious chronic fissures is indicated to r/o CA
111
Persistent perianal drainage a/w sinus tract w/granulation tissue. Tx
Fistula-in-ano: residual of incompletely healed abscess. Tx = unroofing the tract, draining any undrained collection and the nallowing reepithelialization
112
Severe anal pain, perianal mass, fever
Perianal abscess resulting from infection in anal crypts and glands at the dentate line. there are 4 types of abscesses: perianal ischioanal, interspincteric, supralevator. The first two require perianal incision drainage. Intersphincteric abscess causes pain and requires drainage within the canal. Supralevator abscess drainage depends on location.
113
Sacrococcygeal abscess with pain and drainage
Pilonidal abscess = infection of hair-containing sinus. Tx = unroofing the abscess, removing the hair, leaving wound open to heal by 2ndary intention
