Other GI Flashcards

Question

What is the treatment for gastric neuroendocrine tumors?

Answer 1

Nonfunctional: no carcinoid syndrome here Work up: EGD with Bx, Gastrin level, Gastric pH test - Need to stop PPI before obtaining gastrin level, otherwise will have elevated gastrin level. Ok to be on H2 blocker.

Answer 2

Type I - MC type 80%. pernicious anemia/chronic atrophic gastritis. High gastrin levels, pH >4. Tx: If < 2 cm  endoscopic resection or just follow up with EGD surveillance Tx: If > 2 cm or multifocal  antrectomy

Answer 3

Type II 5% – associated with Zollinger Ellenson. Has small risk of cancer. High gastrin levels, pH < 2. - Tx: Localize gastrinoma usually EGD resection is sufficient - Also need to work up for MEN I

Answer 4

Type III – High malignant potential. Normal gastrin level. Often present with mets. Need octreotide scan to stage. - Tx: Should be treated like gastric CA. Partial/total Gastrectomy with lymphadenectomy Biopsies should be stained for Chromogranin A and synaptophysin Get Serum gastrin and Chromogranin A Endoscopic ultrasound is preferred for assessing both tumor size and depth of penetration

Answer 5

Loss of bowel, particularly the terminal ileum, and hypersecretion of acid. -hypersecretion of acid decreases pH -> increases intestinal motility-> interferes with fat absorption -> steatorrhea Sudan red stain checks for fecal fat Complications of short gut: nephrolithiasis (hyperoxaluria), cholelithiasis (low bili reabsorption), gastric acid hypersecretion (transient), bacterial overgrowth >180 cm of SB Don’t require TPN 90 cm require TPN for at least a year generally < 60 cm require TPN for life

Answer 6

Tx: Antidiarrheal + fluid and electrolyte management + TPN = first line - Loperamide, diphenoxylate, PPI/H2blocker, b12/FOLATE - High carb, high protein, low fat diet (Medium chain fatty acid is ok) rich in glutamine - H2 blocker and PPI  b/c resection of small bowel  causes hypergastrinemia, increases acid, decreases digestion - Growth hormone and teduglutide (GLP-2 analog) has pro-absorptive effects on intestines - Octreotide use is off label used to treat diarrhea, should not be used long term. Causes steatorrhea, and gallstones - Cholestyramine tx for nephrolithiasis and helps with diarrhea, reduces fat

Answer 7

Cholestatic liver disease (cirrhosis) from TPN, repeated episodes of bacteremia from central lines, and no availability of veins for TPN (recurrent thrombosis/stenosis).

Answer 8

2nd MC tumor of appendix, #1 is carcinoid MCC of death is SBO. Causes SBO by fibrosis If there is presence of mucin outside the appendix, like mucinous ascites, this is a clinical syndrome called Pseudomyxoma peritonei Tx for Appendix mucinous neoplasm - Appendectomy is the operation of choice +/- cytoreductive surgery with HIPEC - These DO NOT need a right hemicolectomy. Does not confer survival advantage. Low risk of lymph node mets. - The question is whether the patient will need cytoreductive surgery with HIPEC or not - If just the appendix, no extra-appendiceal involvement, found incidentally on pathology with negative margins  You are done after appendectomy - If extra-appendiceal mucin present then you will need cytoreductive surgery with HIPEC - If Mucinous adenocarcinoma, this is different, (path = signet ring cells) is found  Right hemicolectomy

Answer 9

GI neuroendocrine tumor (carcinoid) T1 (<2 cm) lesions confined to the mucosa or submucosa have a low risk of metastatic spread and are amenable to local treatments. Rectal - <2 cm, T1 (submucosa)  o WLE if in low rectum (0-5 cm from anal verge) o Endoscopic resection (5-15 cm from anal verge) - > 2 cm or invades muscularis propria, T2  APR vs LAR Colon - < 1 cm, T1 – endoscopic resection - > 1 cm or invasion of muscularis propria  segmental resection with lymph nodes Small bowel - On CT this will show classic mesenteric nodes with calcification - Formal resection with lymph nodes Duodenal - Periampullary  very aggressive  whipple - < 1 cm endoscopic resection - 1-2 cm WLE with negative margin - > 2 cm formal resection with LN

Answer 10

Can come from appendix, ovary or small bowel - cytoreductive surgery + HIPEC. Remove ALL tumor. - Need to debulk to < 2.0 mm !!!!! - Hyperthermic intraperitoneal chemo (mitomycin and 5FU) - Mucinous ovarian CA will need TAH-BSO HIPEC is being used for malignant peritoneal mesothelioma

Answer 11

Abdominal pain 1st! then nausea. If it’s the opposite order = gastroenteritis Periumbilical pain = visceral. RLQ pain = somatic sensory of peritoneum Children have higher rate of perforation Laparoscopic is associated with lower incisional infections however, it has increased risk with deep orgain space infection when compared to open Operate on all appendicitis in pregnancy regardless of trimester Abscess < 3 cm just do IV abx. > 3 cm  Drain If going for appendectomy, and you find normal appendix  still perform appendectomy Normal appendix < 2 mm wall and < 6 mm dilation Appendicitis with phlegmon = perforated  non-op management Perforated appendicitis  If not sick, and especially if delayed  non-op management. Most perfs will be managed non-op unless minimal inflammation, no abscess to drain, presented early If patient has perforated appendicitis  All need colonoscopy at 6 weeks at the minimum - Routine interval appendectomy is no longer recommended - If appendicolith is present, offer interval appy Stool from wound after appendectomy = cecal fistula  non-op. Usually low output. 75% close spontaneously Incidental appendectomy for: - Children undergoing chemo - Crohn’s without gross involvement of cecum - Disabled Quadriplegic - Travel to remote area without medical/surgical care Uncomplicated appendicitis = no perforation AND no appendicolith Non-op management for uncomplicated appendicitis when compared to an operation - Has about a 25% failure rate at 1 year  will ultimately require appendectomy - Complication rate of non-op is lower than appendectomy - Overall societal (includes time off work) costs are higher with an operation - Have a higher readmission rate within 1 year recurrent appendicitis - Higher length of stay

Answer 12

Acute mesenteric adenitis = ileitis Associated with MC #1 Yersinia enterocolitica, Helicobacter jejuni, Campylobacter jejuni, and Salmonella or Shigella Preceded by URI See lymphadenopathy in small bowel mesentery = key Don’t biopsy

Answer 13

Secretes K and absorbs Na (Na/K ATPase), absorbs water (mostly right colon) Retroperitoneal – ascending, descending, sigmoid, rectum

Answer 14

It connects the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). Travels near colon,

Answer 15

Arc of Riolan connection between proximal SMA and proximal IMA. Becomes enlarged with either IMA or SMA stenosis

Answer 16

Superior rectal artery - IMA Middle rectal artery - branch of internal iliac Inferior rectal artery - branch of internal pudendal, which is branch of internal iliac

Answer 17

Superior rectal vein - IMV into portal Middle rectal veins - drain into internal iliac vein Inferior rectal vein - internal iliac into caval system

Answer 18

They drain into IMA nodes.

Answer 19

Lower rectum drains into both IMA nodes and internal iliac nodes.

Answer 20

Observation unless failed 24-48 hours or if cecal diameter > 12 cm, then consider neostigmine.

Answer 21

If that fails, perform decompressive colonoscopy.

Answer 22

Go to OR for percutaneous cecostomy. If there is any ischemia or perforation, perform subtotal colectomy, NOT cecostomy.

Answer 23

Contraindicated in 2nd degree heart block, asthma, acute coronary syndrome, NOT CAD.

Answer 24

Alvimopan is an opioid antagonist. Do not give to chronic opioid users due to risk of MI.

Answer 25

Typhlitis Diagnosis made by neutropenia, abdominal pain, bowel wall thickening.

Answer 26

Amebic colitis is caused by Entamoeba histolytica, transmitted fecal-orally, often in Mexico.

Answer 27

Stool will show trophozoites.

Answer 28

Treatment is Flagyl.

Answer 29

Placing a mesh at index operation greatly reduces risk of hernia. - Do not relocate the stoma, use the same site, just add mesh - Use prosthetic mesh - Highest in loop colostomy. Least in loop ileostomy. - No repair unless symptomatic Stoma retraction – More likely to cause symptoms in ileostomy than colostomy because of likelihood of leakage from stoma appliance

Answer 30

- Sugarbaker technique – underlay repair. Cover some distal bowel with mesh, and bowel exits laterally. Has less recurrences - Keyhole technique – keyhole Is made on mesh and encircled around bowel. MC one used

Answer 31

Candida is the most common stomal infection.

Answer 32

Diversion colitis (Hartmann’s Pouch) – due to lack of short chain fatty acids. Tx: Short chain fatty acid enema (acetate, butyrate, and propionate)

Answer 33

Ischemia is the most common cause of stenosis of stoma. Treatment is dilation if mild. Retracted and fixed stoma- will likely require surgical fixation Fistula at stoma – MCC by full thickness suture through the bowel and will need operation and place stoma at new site Abscess: Underneath stoma site, often caused by irrigation device Ostomy should go through the rectus on the lateral side

Answer 34

Ileostomy-> causes cholesterol gallstones (loss of bile salts) and uric acid kidney stones 2/2 to loss of bicarb Loop ileostomy is superior to end ileostomy, end colostomy and loop colostomy for fecal diversion e.g. protection low rectal anastomosis #1 complication following loop ileostomy take down is SBO

Answer 35

Treatment is fecal disimpaction and aggressive bowel care. If perforation occurs, never do primary repair; needs formal resection (Hartmann's) with end colostomy.

Answer 36

IR angiography: can detect bleeding at a rate > 0.5 cc/min CTA can detect bleeding at a rate > 0.3 cc/min RBC scan can detect bleeding at a rate of > 0.1 cc/min

Answer 37

Place an NGT and do gastric lavage. If you see bile only  ruled out UGI source. If you see no bile, cannot rule out UGI source colonoscopy is almost always the first step for LGIB, always try to give prep first but never delay colonoscopy just to prep, perform colonoscopy within 12 – 24 hours If patient is stable  Colonoscopy is ALWAYS the first step If patient is stable  Colonoscopy failed/inconclusive  next step is CTA then angiography CTA should always precede angiography if patient is stable, since it is better at identifying bleeds If the patient is unstable Go for angiography 1st

Answer 38

MCC of obscure GIB not found in upper and lower endoscopy is small bowel angiodysplasia. MCC of UGIB is peptic ulcer disease MCC of LGIB is #1 diverticulosis, #2 colitis #3 neoplasm #4 angiodysplasia

Answer 39

Treatment is cipro/flagyl for 7-10 days.

Answer 40

1a: pericolonic phlegmon and inflammation, no fluid collection 1b: pericolonic abscess < 4 cm 2: pelvic or inter-loop abscess OR abscess > 4 cm 3: purulent peritonitis 4: feculent peritonitis

Answer 41

Abscess < 4 cm  treat with abx. > 4 cm need drain  ALL need elective sigmoidectomy Complicated diverticulitis = perforation, abscess, stricture, obstruction - If patient has any complicated (above) diverticulitis, they need elective resection

Answer 42

Acute Diverticulitis with perforation Sigmoidectomy with primary anastomosis and diverting loop ileostomy preferred over Hartmann’s. - No difference in mortality - Higher rate of ostomy take down with loop ileostomy Need to resect all of sigmoid down to normal rectum If patient has diffuse diverticuli only resect portion that is symptomatic.  Do not perform procto-colectomy LAR = sigmoidectomy and proximal rectum. Take sigmoidal arteries +/- rectal. LEAVE IMA and left colic.

Answer 43

Cowden’s syndrome – Autosomal dominant PTEN gene mutation Colonic and stomach polyps that are – hamartomas, fibromas, adenomas, lipoma, neurofibroma Multiple hamartomas of the skin, GI, bones, CNS, eye, GU, thyroid, endometrium, and breast Facial Trichilemmomas and macrocephaly = pathognomonic Screening colonoscopy at 45 years old, then q 5 years No real increase in colorectal cancer risk Highest risk of CA is thyroid, endometrium and breast

Answer 44

Uniquely autosomal recessive 10 or more synchronous polyps, usually left side, occur at age 50 80% risk of colorectal CA < 100 polyps Mutation in MYH gene, not APC

Answer 45

Sebaceous gland tumors and visceral tumors MC colorectal Considered a variant of HNPCC Sebaceous gland tumor is hallmark; presents as yellow facial papules

Answer 46

Desmoid tumors Benign, slow growing Usually found after trauma incident, previous surgical scar or during or after pregnancy - Desmoid tumors are associated with increased estrogen  OCPs and pregnancy Arises from connective tissue Female predominance Imaging: CT will show: homogenous mass arising from connective tissue. Imaging not enough to Dx: Diagnosis: with core needle/incisional biopsy Pathology will show spindle cells with abundant fibrous stroma (high collagen content) with fibroblasts (fibromatosis) Anterior abdominal wall – MC location. Intra-abdominal masses  associated with Gardner’s High risk of local recurrence, no lymphatic or distant spread - Any resection has 50% chance of recurrence Most important prognostic factor is negative margins Treatment: Abdominal wall and extra abdominal desmoid tumors - Mainstay of treatment is wide local excision with 1 cm margins, without lymph nodes - Any extra-abdominal desmoid including abdominal wall that is resectable, should be resected - Radiotherapy for those who are not surgical candidates or recurrence Intra-abdominal/retroperitoneal desmoid tumors - Treat with sulindac (FAP), tamoxifen (FAP) If desmoid tumor involving mesentery= likely Gardner’s  DO NOT RESECT  Use suldinac and tamoxifen Non-resectable or incidental, asymptomatic intra-abdominal desmoid (associated with FAP)  treat with suldinac and tamoxifen

Answer 47

Most are malignant MC malignant retroperitoneal tumor = #1 lymphoma, #2 liposarcoma Retroperitoneal sarcoma < 25% resectable, 40% recurrence

Answer 48

Gastrin – found in stomach. Secreted by G cells. Stimulated by: protein, vagal input (ACH), calcium, ETOH, antral distension, pH > 3.0 Inhibited by: pH < 3, somatostatin, secretin, CCK Target: Parietal cell and chief cell Response: Increase HCl, intrinsic factor, pepsinogen secretion (gastrin is strongest stimulator for all these),

Answer 49

Somatostatin - mainly from D cells of antrum, also small bowel and pancreas Stimulated by acid in duodenum

Answer 50

Cholecystokinin - Secreted by I Cells of duodenum. Stimulated by protein and fat in duodenum Contracts the GB, relaxation of sphincter of oddi, increase pancreatic enzyme secretion (most potent stimulus) Increases intestinal motility

Answer 51

Secretin released by S cells duodenum Stimulated by fat, bile and pH < 4 Increases pancreatic bicarb. Inhibits gastrin and HCl release High pancreatic duct output: high bicarb and low chloride Slow pancreatic output - low bicarb and high chloride (carbonic anhydrase in duct exchanges HCO3 for Cl)

Answer 52

Motilin Released by M cells in duodenum Highest concentration of receptors in gastric antrum Stimulated by duodenal acid, food Released during fasting, not while eating Erythromycin acts on this receptor

Answer 53

Pancreatic polypeptide secreted by islet cells in pancreas Causes decreased pancreatic endocrine and exocrine function Stimulated by: fasting, exercise and hypoglycemia

Answer 54

Vasoactive intestinal peptide - produced by cells in pancreas and gut Stimulated by fat and ACH Increases intestinal (water and electrolytes) secretions and motility

Answer 55

Peptide YY – released from terminal ileum following fatty meal; inhibits acid secretion and stomach contraction, inhibits GB contraction

Answer 56

Appendiceal carcinoid - < 2 cm, not near the base, mesoappendix not involved, no nodes or mets, and it is T1  appendectomy. All others require a RHC (including lymphovascular invasion, mod-high grade, goblet cell)

Answer 57

Enterocutaneous/colocutaneous fistula <200 cc/day = low output >500 cc/day = high output Enterocutaneous fistula treatment algorithm: * Restrict oral intake of hypotonic fluids < 1 liter a day  NPO and TPN if still high output * Initial therapy: Loperamide + PPI * If refractory  next to add is Codeine * Then you can consider octreotide. Octreotide is not first line Must wait 12 weeks or 3 months before considering an operation

Answer 58

Actinomyces – can occur in cecum; penicillin or tetracycline

Answer 59

Anorexia – mediated by hypothalamus

Answer 60

Bombesin (gastrin-releasing peptide) – increases intestinal motility, pancreatic enzyme secretion, and gastric acid secretion

Answer 61

Fallen out of favor, high rates of morbidity No increase rates of operation Are at increased risk of requiring additional drainage of abscesses Decreased risk of having a colostomy at 12 months Decreased length of stay

Answer 62

Inpatient admission: - any complicated diverticulitis. (abscess, fistula, perforation, obstruction) - If CT shows uncomplicated diverticulitis, but shows o Microperforation o Any sign of SEPSIS o Failed outpatient tx o Age >70 All others can be treated outpatient

Answer 63

Colovesicular fistula – MC fistula in men. MCC is diverticulitis in men and women. Dx: CT with oral or rectal contrast WITHOUT IV contrast!!!! BEST TEST!! - All need colonoscopy prior to surgery to rule out cancer - Tx: If due to diverticulitis  resect involved segment of colon, primary anastomosis, close bladder, without diversion - Tx: if due to cancer  need en block resection Colo-vaginal fistula – MC fistula in women from diverticulitis

Answer 64

Diverticula. Caused by disrupted vasa recta arterial bleed

Answer 65

MC in right colon. -> venous bleeding. Angiogram shows tufts and slow emptying -Forms due ot progressive submucosal blood vessel dilation; can be cause of occult lower GI bleeding -Flat, bright red, stellate shape -Tx: endoscopic thermal coagulation= argon plasma coagulation ablation

Answer 66

middle and lower rectum is spared Dx: Endoscopy with argon beam coagulation

Answer 67

GI polyps Associated with alopecia, cutaneous pigmentation, atrophy of fingernails and toenails Diarrhea is a prominent symptom

Answer 68

Peutz-Jeghers – autosomal dominant * Hamartomatous polyps through all of GI. MC jejunum and ileum * Harmatomatous polyps + mucocutaneus lesions = make the diagnosis * Mutation is SKT11 * Sx: MC obstruction  intussusception * Hyperpigmentation mucous membranes and hands, feet * Significantly increased risk of many extra GI CA- MC is breast, other common colorectal, pancreatic and testicular * Screening: EGD and colonoscopy yearly starting at 10 years old. Then q 3 years * Yearly screening for uterus, ovary, cervix, breast, testicles starting at 25 years

Answer 69

Familial Juvenile polyposis – Autosomal dominant More than 10 polyps Hamartomatous Polyps – upper GI and COLON – before 20 Colon affected 100% of the time 50% rate of colorectal CA Has significant risk of GI cancer, not as high as FAP **MOSTLY RIGHT SIDED POLYPS Need colonoscopy starting at age 15 then q 3 years Need EGD Q1 year by age 25 No prophylactic resection. MADH4 germ line mutation

Answer 70

liposarcoma

Answer 71

First line treatment PO fidaxomicin

Answer 72

Prone position with head turned right; ease of visulaization/ cannulation of ampulla of vater; better pancreaticobiliary anatomuy image; prevent aspiration

Other GI Flashcards

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