Stomach and Small Bowel Flashcards
(138 cards)
1
Q
GIST DDX
A
- adeno, leiomyosarcoma, leiomyoma, lymphoma,NET
2
Q
GIST HPI?
A
GIB, stomach pain, obstructive sx
3
Q
GIST PE, TEST, Imaging?
A
- PE- abdominal mass, lymphadenopathy
- Test
- EGD-submucosal mass, bx (not always defines dx)
- EUS-heterogenous, cont c gastric wall, without lymphadenopathy
- FNA-spindle cells (not always necessary (bleed or spreads)however indicated for mets dz for chemo, neoadj therapy, lymphoma suspected
- Imaging
- large hypervascular, exophytic, heterogenous, central necrosis
4
Q
GIST imaging characteristics? Path?
A
- Imaging
- large hypervascular, exophytic, heterogenous, central necrosis
- Path
- IMHC-KIT rec tyrosine kinase CD117
5
Q
GIST treatment
A
Surgery for resectable gist, margin negative 1 cm, segmental resection, partial gastric resection (BII gastrojejunal recon),en bloc, GEJ then total gastrectomy with RNY, lymphadenectomy usu unneeded
6
Q
GIST Neoadj chemo?
A
Imantib (Gleevac) to downsize it if >5 cm or more 5-10 mitosis/HPF needed or sunitib if resistant
7
Q
GIST surgery?
A
- Surgery
- abdominal exploration
- enter lesser sac to eval extent
- assess wedge vs formal BII
- resect 1 cm margins
8
Q
GIST notes?
A
- Dont percutaneous Biopsy -avoid seeding or tumor rupture
- Note- mets go to liver and peritoneum
- adjuvant gleevac therapy
9
Q
What is Mallory Weiss?
A
Linear tear in mucosa of gastric cardia not painful if painful think Boarhaaves (pacnreatitis, chemo etc)
10
Q
MAllory Weiss treatment?
A
Resuscitate while doing history
11
Q
Mallory Weiss HPI, Hx, PE, Labs
A
- HPI- vomiting, retching, and hemetemesis,
- Hx-HH, binge drinking or portal HTN
- PE- check for crepitance, neck and mediastinum and check for peritonitis
- Labs- check coags, and T&C
12
Q
Dx Mallory Weiss? and Treatment?
A
- Dx- Endoscopy
- 90% self healing
- Tx
- 1st- hemoclip, heater probe, epi injection
- 2nd- Angio (Left gastric, splenic branches, inferior phrenic arteries) especially with comorbidities
- 3rd-if needed gastrostomy high and oversew with locking suture (anterior 3-0 PDS) pack anterior and posterior with lap pads to find bleeder
- if portal HTN add octreotide
- consider Vasopressin
- Note- No blakemoretube cuz this is arterial bleeding and usu associated with hiatal hernia
13
Q
Gastric ulcer ddx?
A
DDx- gastric cancer, PUD
14
Q
Gastric Ulcer HPI, Hx, PE, Labs?
A
- HPI- Epigastric pain, dyspepsia, vomiting,dark stools, anemia, weight loss
- Hx- ETOH, NSAID
- PE-Vitals, rigid abdomen, rectal exam (heme positive, Blummer’s shelf)
- Labs- CBC, serial H&H, T&C , electrolytes check for Acholorhydria (related to cancer)
15
Q
How to test for H. Pylori?
A
- How to test for H. Pylori
- biopsy antrum most accurate
- Serum Ab of h pylori
- Stool test to confirm eradication
- Urea breath test- stop PPI , pep to-bismal, abx for 2 weeks, swallow something with urea if h pylori is present converts the urea into Carbon dioxide detected from your exhaled breath after 10 minutes
16
Q
Gastric Ulcer types?
A
- Note-
- Type 1- Lesser curve
- Type 2- Included duodenum and acid
- Type 3- Prepyloric and acid
- Type 4 -GE junction
17
Q
Gastric Ulcer Dx?
A
- Dx-
- abdominal xray to r/o free air
- +/- Barium UGI
- Endoscopy biopsy center and around the edges close to 10 biopsies
- defines the ulcer
- brushings increase sensitivity of biopsies
- bx the pylorus for H. Pylori
- May need to repeat EGD in 6-8 weeks for a chronic ulcer, tx med, repeat egd if improving
18
Q
Gastric ulcer Treatment?
A
- Benign- PPI,H2 Blockers, Sulcrafate ETOH and Smoking, NSAID Cessation
- Benign with H Pylori- PPI, Amoxicillin, Clarithromycin, Pepto-Bismol
- after tx check urea breath test for eradication repeat tx if+
- Most ulcers heal with 12 weeks
- repeat endoscopy 6-12 weeks depending how large and scary it was
- Fails to heal after 8 weeks consider ZES, cancer
- check gastrin level >1000 and pH
19
Q
Gastric ulcer surgery indications?
A
- Surgery indications
- IHOP
- Intractibility >3 cm unlikely to heal, fail 24 wks to heal if bx benign the surgery based off location
- Note on tech- antrectomy is falling a little out of favor for a wedge resection and for 2-3 adding an acid reducing sx)
20
Q
Surgery type 1 gastic ulcer?
A
Type 1 - Antrectomy to include ulcer (goblet cells on duodenal side indicates adequate resection) recon with BI make sure frozens neg for malignancy. 2% recurrence
21
Q
Surgery type 2 gastic ulcer?
A
Type 2-3 -Antrectomy and Vagotomy
22
Q
Surgery type 3 gastic ulcer?
A
Type 2-3 -Antrectomy and Vagotomy
23
Q
Surgery type 4 gastic ulcer?
A
- Type 4-
- Option 1- Antrectomy and suture bx the ulcer and leaving it in situ and checking response
- Option 2- Csendes’ (subtotal gastrectomy with RNY jejunal reconstruction) remember just an ulcer, procedure to remove ulcer (long oblique line extending from the greater curvature to the right of the EGJ using free hand tech and cutting under direct vision without compromising the lumen at the EGJ, then creating a long oblique gastrojejunostomy
24
Q
Gastric ulcer with hemorrhage?
A
- Hemorrhage (3 diff vs a PUD) 1-always bx 2-angio can be attempted 3- threshold to operate is lower (4-6 uPRBC)
- 10% mortality, GDA, Visible vessels high rate of bleed
- resuscitate patient prior
- EGD + bx +/- angiogram with vasopressin
- Surgery
- if > 4u prbcs and w/in 48 hrs of endoscopic intervention or rebleed
- Type 1 - Antrectomy to include ulcer
- Type 2-3 -Antrectomy and Vagotomy
- Type 4-5 - gastrostomy bx ulcer and oversewn and biopsy antrum
- If unstable - performa wedge resection or suture/biopsy ulcer plus vagotomy/pylorplasty if 2-3
25
Gastric ulcer with obstruction?
- Obstruction from gastric ulcer
- need to treat hypokalemic hypochloremic metabolic acidosis (H/Na exchange in prox tubule and K/H in distal tubule c aciduria)
- Antrectomy and BI or BII reconstruction
26
Gastric ulcer with perforation?
- Perforation
- 24hrs and unstable
- biopsy ulcer and graham patch
27
gastric ulcer postop and follow up?
- Postop
- NPO, IVF, NGT, ABX, Foley cath, PPI, H.pylori tx
- POD 5 Gastrograffin and if negative start clears and ADAT
- Upper endoscopy in 12 weeks to reevaluate the tx
28
Gastric cancer ddx?
- ddx- benign esophagitis, gastritis, PUD, varices
| - malignant- gastric or esophageal ca, MALT, Lymphoma, GIST
29
Gastric cancer sx, RF, PE, Labs?
- ddx- benign esophagitis, gastritis, PUD, varices
- malignant- gastric or esophageal ca, MALT, Lymphoma, GIST
- Sx- epigastric pain, dysphagia, black stools, weight loss
- RF- Smoking, ETOH, Elderly, H. Pylori, Achlorhydria, Pernicious, Previous gastric resection
- PE- rectal blumers shelf node, supraclavicular/periumbilical LN, abdominal mass, surgical scars, ,
- Labs- HGB, Prealbumin
30
Gastric ulcer work up? Risk stratified? Notes?
- dx,stage, preop, tx
- Work Up
- CT
- CT- hepatic mets, lymphadenopathy, ascites, extension
- CT chest if GEJ
- EUS and FNA,
- PET (PET changes tx options 20%)
- MRI
- Laparoscopy
- Risk stratified-nutritional, cv, pulm
- Notes
- Lap dx mets catches 30% of mets not seen on CT scan, peritoneal fluid,
- R status
- RO neg margins, R1 micro residual dz, R2 gross residual dz
- Lymph nodes
- R1- imed adj perigastric LN
- R2- LN along roots of gastric vessels
- R3- Porta hepatis nodes + SMV nodes and retropanc LN
- En-bloc resection of adjacent organs (spleen, tail of pancreas, kidney except pancreas and CBD
31
Gastric ulcer treatment? Tis,TI, local regional advanced? mets?
- combined modality tx
- early Tis, T1 (mucosa) gastrectomy c D1/D2 lymphadenectomy
- Local regional advanced resectable-
- neoadjuvant and then surgery 5 cm margins
- mets-
- palliative dep on sx and functional status
- place a feeding jejunostomy in obstructing GE jxn mass
- Palliative chemo, laser recanulization, dilation, stenting
- surgical bypass has fallen out of favor
32
Gastric cancer adjuvant therapy?
adjuvant chemo RO rsxn t3,T4 positive nodes Etoposide, cisplatin, 5 FU
33
Gastric cancer treatment in proximal, middle, distal tumors?
- Location
- proximal tumors (upper 1/3)-
- total gastrectomy (nothing less) c RNY esophagojejunostomy & frozen sections
- Middle third or in corpus
- subtotal gastrectomy or total gastrectomy depending on size of tumor
- distal tumors (lower third)-
- radical subtotal gastrectomy involving 3 cm of duodenum, hepatogastricomentum, greater omentum, and DI resection (immediate adjacent perigastric LN)
- subtotal gastrectomy c B2 or RNY recon
- Palliation- total gastrectomy not gastroenterostomy!
34
Describe a subtotal gastrectomy c RNY for gastric cancer?
- Subtotal Gastrectomy c RNY DI resection (supra and infrapyloric LN and along greater and lesser curves)
- supine incase of right thoracic or cervical approach
- laparoscopy exploration catches 30% mets not seen on CT scan
- Palpate liver
- Dissect omentum from L transverse colon
- Mobilize Left colon from spleen (resect spleen if involved)
- Lift stomach and determine if involves transverse mesocolon
- Biopsy celiac node and if negative may proceed with resection for cure
- Biopsy porta hepatis
- determine if possible to resect with 5 cm margins
- Dissect along greater curvature of stomach to 5 cm margin from tumor and mobilize
- Kocherize duodenum and divide using GIA taking care to avoid retained antrum
- Dissect along port hepatic toward celiac axis to take all nodal tissue
- divide L gastric at its origin and nodal tissue is swept from crus and hiatus
- Proximal splenic artery is dissected along superior border of pancreas and nodal tissue is taken so splenic hilum
- Subtotal gastrectomy - divide proximal stomach with GIA
- Total gastrectomy - encircle esophagus with penrose, control c satinsky clamp and transect
- send proximal margins for frozen
- reconstruct c RNY gastro or esophagojejunostomy (D1 resection)
- Adjuvant chemoradiation is questionable f(5FU and (radiation decreases recurrence))
- feeding J
- drains to the stump and EJ anastomosis check amylase and bilirubin
- NGT beyond GJ anastomosis
35
Palliative gastrectomy?
Palliative gastrectomy - very controversial - if patient able to eat probably no reason, if bleeding or obstructive than consider
36
gastric cancer postop?
- Post op
- small meals, B12, iron
- No adjuvant chemo after surgery
37
gastric cancer curveballs
- Curveballs- its actually esophageal cancer- Ivor lewis resection
- hepatic mets-dont resect
38
how does gastric lymphoma present
mass or gastric folds
39
first bx of gastric lymphoma comes back and nonspecific what next?
- rescope the patient and get more bx and H.Pylori status
40
if gastric lymphoma persist after h pylori treatment?
radiation
41
gastric lymphoma work up?
Bone marrow bx and CT scans H/N/C/A
42
gastric lyphoma - Stage I or II treatment?
resect c LN,Liver should be biopsied and a splenectomy if grossly involved
43
postop gastric lymphoma?
- chemo
| - if low grade MALT - just H Pylori tx
44
Gastric Carcinoid hx, and notes?
- Fx- MEN I, Heart problems, Carcinoid Sx
| - Note- sporadic, associated c pernicious anemia, ZES
45
gastric carcinoid test?
- Test- Octreotide scan search for other lesions on GI track
- CT scans
- 24 hr urine 5HIAA, Chromogramin A sensitive
- gastrin and calcium
46
gastric carcinoid types?
- Note-Sporadic can be malignant and need 2 cm margins
- Note- pernicious anemia usually benign and are multiple small and antrectomy to reduce gastrin levels will cause regression of carcinoid usually
47
gastric carcinoid 1cm and different gastrin?
- Tumor 1 cm or normal gastrin (more aggressive) or atypical cells
- Gastrectomy with D1 dissection (cancer operation)
48
gastric carcinoid liver mets treatment?
- Liver mets- treat c chemo embolization, RFA, resectiond
49
Post gastrectomy issues, early problems, days?, sx? imaging, treatment?
- Early problems
- Leak-
- POD 3-5, Tachycardic, abd pain, SOB
- CT and UGIS
- Stable and no sepsis small fluid- perc drain, NPO, TPN, ABX
- Septic or s/o peritonitis - reexplore, oversew, place drains, feeding J tube
- Early few days post op Doudenunal stump leaks
- check tissue healthy, friable, necrotic?
- healthy- oversew hole, graham patch vs pursestrings 16 french cath doudenum
- Ischemic- - debride to healthy tissue, resuture, buttress c momentum, place catheter in duodenum laterally for decompression, widely drain area
- Friable- place lateral duodenal tube, buttress c omentum, widely drain, drain stomach with gastrojejunostomy, feed J tube
- Bleeding-
- from staple line usually stops, check coags, if doesn’t stop reexplore and suture ligation, possible arteriogram
- Obstruction
- afferent limb ( has the blind limb)- decompress endoscopically place NGT into limb
- efferent limb (Enteral limb) - NGT trial
- internal hernia- reexplore correct defect mesocolic, mesenteric, Petersons defect
- Gastroparesis- NGT, TPN, Pro motility agents give 6-8 weeks to improve
50
post gastrectomy problems that are Late?
Dumping, post vagotomy diarrhea, marginal ulcer, duodenal stump leak, gastroparesis, bile gastritis
51
Dumping syndrome dx, treatment?
- Dumping Syndrome
- Dx - gastric emptying studies, serial glucose measurements
- Octreotide, high fiber diet, decreased liquids c meals generally improves
- Roux limb recon or takedown of loop gastrojejunostomy
52
- Post vagotomy Diarrhea (not related to eating)
- cholestyramine and lomotil (usually resolves it)
| - if fails convert BI —>BII or gastrojejunostomy
53
- Doudenal stump leak POD 10 ?
- Doudenal stump leak POD 10
- usually see abscess or mass mixed c fluid in RUQ after surgery
- perc drain , NPO, TPN allow 6-12 wks to control fistula and allow hopefully to close
54
gastroparesis treatment?
- Gastroparesis
- promotility agent
- Surgery
- gastric resection (antrectomy if didn’t do before)
- subtotal gastrectomy c BII or RNY recon
55
Bile gastritis treatment?
- Bile Gastritis (confirm c hepatobiliary scan), by biopsy, alkaline drop test important that you get the dx correct
- caused by eliminating the pyloric sphincter
- post prandial, burning epigastric pain
- meds don’t really help
- if severe RNY recon c roux limb 45-60 cm in length
56
- Efferent Roux Sx treatment?
- Efferent Roux Sx
- bilious vomiting
- reglan, domperidol and erythomycin
- surgical decrease gastric remnant size or recon roux limb
57
Afferent limb obstruction treatment?
- Afferent Limb Obstruction
- CT shows a dilated afferent limb
- careful close loop obstruction
- Surgical emergency
- Balloon dilation c EGD
- LOA, reduction of internal hernia, reduction of volvulus and if too long reduce the afferent limb
- Convert BII —> RNY GJ
58
Internal hernia, long afferent limb sx, gastro-colic fistula, adenocarcinoma of gastric remnant, nutritional and metabolism issues?
- Internal hernia
- reexploration and reduction and repair of defect
- Long afferent limb sx
- take down the Gastrojejunostomy and recreating it high on the afferent limb
- Gastro-colic Fistula
- en-bloc resection of fistula an interposition of omentum b/w staple line
- Adenocarcinoma of gastric remnant
- total gastrectomy c RNY pouch
- Nutrition and metabolism issues
- weight loss,anemia, bone loss
- supplementation and multivitamins and calcium
59
Upper GI bleed broad ddx?
- Broad Ddx Varices, PUD, Neoplasms, Dieulafoy, MW, AE fistula, pancrease
60
Upper GI bleed Hx, PE?
- ABCs while resuscitate
- Hx- h/o PUD, pain, ASA, NSAID, Coumadin, Plavix, Lovenox, Pradaxia, ETOH, retching (MW), liver dz, trauma, h/o UGI surgery (marginal ulcer), h/o AAA repair
- PE- stigmata of liver dz, surgical scars, rectal exam, bruit on abdomen
61
Upper GIB algorithm?
- Algorithm
- ABCs +/-ETT
- resuscitate, T&C, Coags
- NGT
- PPI ggt
- Upper endoscopy
- Heater probe, electrocautery, epi, sclerotherapy, clips or bands ( varicose)
- visualize blood vessel
- Tagged RBC
- +/- angio
- metal coil springs, and vasopressin
- useful for gastric/doudenal ulcers and Dieulafoy lesions
- if successful initiate medical mgt
- Surgery
62
Upper GIB surgery? hemosuccspancreaticus? Aorto enteric fistula? Varices?
- Surgery
- unstable or continued bleeding (6 uprbc), complicated ulcers, massive UGIB or nonhealling ulcers
- Gastric neoplasm - see tx
- Stress gastritis- see tx
- gastric ulcer- see tx
- Dieulafoy lesion- suture ligate or excise
- Duodenal ulcer- see tx
- MW - see tx
- hemosuccuspancreaticus- distal pancreatectomy c excision of the pseudocyst and ligation of splenic artery
- Aorto enteric fistula- ctrl bleeding, resect graft, close the enteric fistula site and place a new extra-antomic graft or possible in situ graft
- Varices- see tx
63
Four-port Minnesota tube may achieve hemostats through balloon tamponade prior to initiating surgical tx
- Four-port Minnesota tube may achieve hemostats through balloon tamponade prior to initiating surgical tx
- indication- control esophageal or gastric varices
- CI - esophageal strictures, recent esophageal surgery
- ports esophageal suction, gastric suction, esophageal balloon and stomach balloon
- intubate prior to insertion 2/2 risk aspiration
- Left lateral decub
- lubricate balloons
- insert orally
- confirm placement xray
- connect both suction ports LIWS
- Inflate gastric balloon c 100 ml of air and connect pressure with within 15mmHg of initial reading (greater means in the esophagus and can perforate)
64
Peptic Ulcer Disease (gastric outlet obstruction) presentation?
- Presents either as perforated (immediate), bleeding (delayed), obstructive (planned)
65
PUD ddx?
DDx MI, GB dz, pancreatitis, gastritis, aortic dissection
66
PUD H&P, initial tx, PE, Labs, Imaging and note?
- H & P - NSAID, smoking, ETOH, H.pylori (90% related, 75% related to gastric), H2 blocker hx and Ulcer Sx-det what type of operation, family h/o MEN1
- Initial treatment
- check vitals
- ABC’s 1st
- Correct hypokalemic and hypochloremic alkalosis check e-lytes don’t forget K after
- resuscitate, ABX, PPI ggt
- PE- check vitals, peritonitis, patient on steroids?
- Labs- amylase, lipase, gastrin, calcium if suspect gastrinoma
- Imaging- upright AXR, CT demo free air
- Note
- perf- always surgery better results incl elderly
67
PUD obstruction treatment? what does surgery depend on? High risk and low risk?
- Obstruction
- usually has a h/o PUD
- Correct lytes HHMA
- initial conservative -
- aggressive volume resuscitation, replace K
- NGT, PPI ggt, TPN, UGI confirm one wk and repeat one week
- Test
- Endoscopy (H. Pylori)
- CT scan (r/o malignancy)
- Treat Hypochloremic alkalosis
- Fails Conservative Mgt-
- Surgery depends on
- risk of patient
- scarring of duodenum
- tonicity of stomach (dilated thick gastric folds)
- Surgery
- high risk-
- Pyloric/duodenal edema and scarring —> GJ + vagotomy
- low risk-
- Antrectomy and Vagotomy (B1 is the best) or
- if too scarred the GJ + vagotomy (to avoid recurrence)
68
PUD perforation DDx? treatment?
- dont rush in, r/o panc, AAA, PUD ,MI, Boerhaves, gastric volvulus via history, EtOH, PPI?, reflux, RUQ pain, weight loss,
- ABC’s if s/o sepsis
- conservative mgt if after 24hrs possible if not sick depends on what caused the perf
- PPI ggt (neutralize the stomach), ABX, NGT
- Surgery (all need surgery, no role for conservative tx on boards)
69
PUD perforation surgery description?
- Surgery (all need surgery, no role for conservative tx on boards)
- Upper midline incision
- Examine entire abdomen
- irrigate and suction
- Some may have started to seal
- find it, debride it
- Mobilize tongue of omentum
- Suture repair c silk perforation if possible with long tails
- Use tails to secure omental patch over to repair
- Drain in subhepatic space
- close and continue abx and diflucan
70
PUD perforation high risk treatment?
- high risk- (elderly, >24hrs, unstable, peritonitis) omental patch and lavage
71
PUD perforation low risk treatment? options?
- low risk (young,
72
PUD giant perforations?
- giant perforations >2-3cm - no standard-omental patch (can cause stricturing), tube doudenostomy, proximal jejunal serosal patch, free mental plug, partial gastrectomy and pyloric exclusion just depends on pts status, size, contamination and experience
73
PUD perforation GE JXN?
GE jxn-subtotal gastrectomy c a RNY esophagojejunostomy or a V&A (Ivor Lewis!)
74
PUD perforation post op complication management?
- Postop Complication
- 7 days npo then study, start clears and if drain output doesn’t go up then pull, if still leak and not septic then watch until gets septic then operate
75
PUD bleeding management? Goals of surgery?
- may need to protect airway if unstable
- conservative first- EGD x2, T&C 6 units give transfusions, PPI ggt serial H&H icu
- EGD - epi injection, heater probe, hemoclips, biopsy for H. Pylori
- Tagged RBC scan if you can’t see it on EGD
- Angio of GDA is also an option if surgery is contraindicated of egd failed x2
- Goals of surgery - address the emergency bleed and + acid reducing surgery if stable and h/o PPI (didn’t respond obviously)
- Surgery
- indication -
- rebleed, >6 units/24hrs, actively bleeding vessel (visible BV is relative) HD unstable (go straight to it),
76
Description of PUD bleeding surgery? High risk? Low risk small and large ulcer?
- Oversew of ulcer and +/- anti-ulcer Surgery
- Midline Lap
- Kocher maneuver
- Incise pylorus longitudinally
- Oversew ulcer 3 point ligation of GDA prox/distal/medially
- Close pylorus in transverse Heinke Mickullicz fashion
- Vagotomy (only if taking PPI)
- dissect GEJ and expose at the hiatus
- gently mobilize esophagus
- encircle esophagus c penrose drain and use for retraction into field
- ID anterior (L vagus) and posterior (R vagus)
- place clips proximal and distal
- excise 2 cm of each vagus at trunk (frozens)
- Make sure all accessory fibers have been divided
- high risk- V/P/ and simple loop suture and if it doesn’t stop then probably the GDA involved and need a 3 point U stitch (prox& dist GDA and mid transverse pancreatic artery) avoid CBD
- low risk +small ulcer - oversew and PCV or Pyloromyotomy and vagotomy
- low risk +large ulcer (>2cm) or h/o PUD- A/V (vagotomy first sterile) frozens
- distal gastrectomy refractory ulcers and large antral ulcer
- postgastrectomy dump- small meals and octreotide - temporary
77
Postop bleeding ?
Post op H.Pylori 2 wks Omeprazole, Amox, Clarithromycin and add +6 wks omeprazole
78
PUD surgery complication? and treatments?
- anemia- replace iron, and B12
- early recurrence with leak requires usu resection,
- uncontained leak after omental patch usu reexp with gastric resection and BII,
- check duodenal obstruction if delayed emptying
- diarrhea - usu resolves give cholestyramine and loperamide and if still not then reversed jejunal interposition placed 100 cm distal to LOT
- Dumping- dietary mod less fluid, more protein small meals usu success, octreotide prior to eating in severe cases try to really avoid corrective surgery cuz it usu resolves
- Alkaline reflux gastritis- epigastric pain and nausea postprandial, confirm c EGD, cholestyramine and reglan, then RNY GJ with afferent limb 60 cm distal to original gastrojejunostomy and TV (ulcerogenic)
- Gastroparesis- conf c UGIS, early satiety - emptying test, small meals, pro kinetic, gastric pacing, completion gastrectomy
- BII- afferent loop -postprandial pain nonbilious vomiting and relieved with bilious emesis, efferent- pain distention bilious vomiting- confirm c UGIS- surgery
79
Doudenal stump leak after PUD surgery?
- doudenal stump leak-depends if healthy, friable, necrotic
- healthy-oversew and graham patch or 16fr catheter into duodenum purse string, feeding j
- ischemic- debrided, suture, buttress c omentum, place catheter in duodenum laterally for decompression, widely drainage, feeding jejunosomy
- friable- lateral doudenal tube, buttress c omentum, widely drain, drain stomach c gastrojejunostomy, feeding jejuonostomy
- caught early reexp, doudenostomy, drainage, NPO, TPN,ABX control fistula for at least 12 wks
- caught late- CT drainage, NPO, TPN , ABX control for 12 weeks
80
Recurrent PUD DDx, HPI, Hx, W/U?
- DDx- incomplete vagotomy, retained antrum, NSAID, Gastric Outlet Obstruction, Suture granuloma at anastomosis, long afferent limb, ZES, H. pylori, hyperparathyroidism, bile gastritis, antral cell hyperplasia
- HPI- epigastric pain, nausea, melena, chest pain, vomiting
- Hx- H. Pylori, NSAID, previous bx
- check operative reports, path reports
- W/U- rule out confounders MI, pancreatitis check amylase lipase, gastrin level if equivocal do a secretin stim test
81
Recurrent PUD imaging and treatment?
- DDx- incomplete vagotomy, retained antrum, NSAID, Gastric Outlet Obstruction, Suture granuloma at anastomosis, long afferent limb, ZES, H. pylori, hyperparathyroidism, bile gastritis, antral cell hyperplasia
- HPI- epigastric pain, nausea, melena, chest pain, vomiting
- Hx- H. Pylori, NSAID, previous bx
- check operative reports, path reports
- W/U- rule out confounders MI, pancreatitis check amylase lipase, gastrin level if equivocal do a secretin stim test
82
Stress ulcer DDx?
- DDX- erosive, Curlings (Burn), Cushings (Neuro anywhere on esophagus to duodenum)
83
Stress ulcer prevention?
- prevent with H2, PPI, Carafate, Misoprostol get through NGT
84
Stress ulcer labs?
coags, T&C
85
Stress ulcer treatment?
- Treat- medically
- cold normal saline lavages via NGT
- Vasopressin, octreotide
- EGD heater probe
- Higher threshold to operate >10 uRBC than other ulcers
- Surgery if it can’t be controlled
- anterior gastrostomy away from the lesser curve and oversew major bleeders
- fails - Poor Risk- gastric devascularization ligate all except short gastrics and truncal vagotomy
- fails- Reasonable risk -total gastrectomy 30-100% mortality c RNY
86
SMA syndrome? What is it?
Wilkies Sx- rare cause frequent vomiting following rapid weight loss or VB deformities
- SMA compresses 3rd portion of duodenum
87
SMA dx? treatment?
- dx Upper GI series or CT scan dilated proximal and second portion and sharp cutoff of barium by VB
- Treatment
- TPN with gradual oral feeding
- fails then duodenojejunostomy proximal to SMA
88
Morbid obesity PE? Preop?
PE- met sx, venous stasis dz, diabetes, hernia,
Preop- EGD- r/o GERD and abdominal masses
- Cardia w/u
- Pysch consult- r/o substance abuse, bipolar,etc
- Nutritional consult
- Lose some weight prior to decrease liver size and thus operative time
89
Morbid obesity lap GB?
Lap GB
- Divide falciform
- Rotate the omentum over it
- ID LOT
- Divide at 40cm distal (blue load 60mm)
- Divide the mesentery with white load taking care not to narrow on the biliopancreatic limb or the roux side
- Counted 100cm on roux limb
- Jejunostomy anastomosis side to side functional end to end placed 2 0 silk stitch x 2 on antimesenteric border 2 enterotomies and 60 mm blue load stapler and closed with a running silk suture along with imbricating sutures
- Mesenteric defect is closed with silk pursestring
- Split the omentum at the transverse colon
- Nathanson retractor
- Open the pars flaccida to get to retrogastric space
- Remove OGT
- Serial fires 60mm blue load 60 cm cubic cm gastric pouch up towards angle of his
- Bring up roux limb and place posterior row distally of VICRYLS running and a stay stitch anteriorly
- Enterotomtomies and staple 4 cm anastomosis
- Closed enterotomies with vicryl 2-0 suture
90
Morbid Obesity sleeve?
Sleeve
- no foley
- no arms tucked
- veress
- two 5 and 12 in the upper quadrants
- liver retractor
- find lesser sac (it is an actual empty space) you start out with electrocautery and then bluntly get into it
- take down the short gastrics all the way up to the angle of his, flip the fundus posteriorly
- take the first fire
- and the egd will guide where to take the next few bites
- he usually always oversews the staple line, really just the staple line, no lemberts, just a baseball stitch
- Marlyn helps
- Postop clears
91
SBO causes?
- causes- adhesions, hernias (internal, femoral, obturator), cancer, IBD, intuss, volvulus, gallstone ileus, infections, abscess
92
SBO HPI, PE, things to think about?
- HPI- N/V/Abdominal distension, h/o surgery/cancer/IBD (crohns/UC)
- PE-distended, Hernias, abdominal masses, lymphadenopathy, Cirrhosis stigmata
- high pitched and very tympanic more distal small bowel or large bowel
- mechanical vs ileus?
- partial vs complete?
- simple or strangulating?
93
SBO work up?
- acidosis lactic acid, e-lytes
- abdominal films - dilated loops, air fluid level
- CT scan
- fluid filled stomach, transition pt, complete, pneumotosis and portal vein air, swirl si, bowel wall integrity decreased enhancement, intuss, hernia, volvulus, neoplasm
94
SBO treatment?
- Treatment/Operation
- NGT (follow outputs), fluids, NPO, +/- ABX foley
- Follow lactates!
- bowel rest if PSBO if 2/2 to adhesions give it 48hrs and if no improvement
- If patient without h/o surgery or trauma sugg of duodenal HTA then likely pt will require surgery
- get a contrast study to evaluate progression
- can follow with serial films watching the contrast hopefully makes it to the end of colon in 24hrs
- or if worsens F, tacky, pain out of proportion to PE
- 65-80% resolve without surgery
- OR if complete, LBO or strangulating
95
Post op obstructions?
- Note- Remember bariatric patients high risk fro internal hernias
- Note- post op obstructions
- usually resolve w/in 14 days NPO, NGT, TPN w/in first 7 days of NPO
- If worsens before 14 days —>OR
- after 14 days adhesions are dense, poorly defined, highly vascular
- If low grade partial obstruction wait 3-4 wks then go back and do complete
- post operative
- SBO give 14 days to resolve if worsens then go to OR before.
- Note-
- after 14 days the adhesions are dense, poorly defined, highly vascular.
- if low grade psbo then go to the OR in 3-4weeks and do a complete LOA
- Postop laparoscopic surgery SBO needs immediate exploration 2/2 port site herniation or internal hernias
- Look out for obturator hernias (CT scan fluid filled structure behind pubic ramus)
96
SBO surgery?
- Surgery
- eval bowel with doppler US mesenteric side of the bowel and rare cases flourescein dyes eval
- reduce intussusception with gentle traction
- crohns stricturoloplasty rather than resection
- Check for gallstone ileus
- XRAY- showing air in biliary tree or large stone in RLQ
- No point in waiting 2-3 days
- Obstruction in the pylorus or MC is ileocecal jxn.
- ID point of obstruction and milking the stone proximal to an area not inflamed and remove via enterotomy
- palpate entire bowel r/o other stones
- usually really elderly and sick so 2nd procedure is probably best
- 1st remove stone, close transversely
- 2nd 6-8wks later if even at all for cholecystectomy /TD and 2 layer closure and cholangiogram
- Hernia- see section
- run entire bowel
- Questionable bowel
- intraoperative doppler on antimesenteric border
- warm moist lap sponges
- IV flourascein and woods lamp
97
Incarcerated femoral hernia presentation? where is it? Work up?
- Obese 50 yo female with SBO and a lump in right groin
- Lump above or below the inguinal ligament
- How long? Peritonitis? Fever or WBC?
- Preop, IVF, NGT, ABX etc
98
Femoral hernia surgery?
- Preop, IVF, NGT, ABX etc
- Incision through the inguinal like normal and stress gaining control on the neck of the sac in order to prevent dropping the bowel into th operational cavity before complete inspection
- if drops back in prior, perform a diagnostic laparoscopy in same setting if you want to avoid a laparotomy
- Find coopers ligament
- reduce the hernia
- divide the ligament if needed
- place a mesh suture it to coopers and transition to the inguinal ligament and then to the transversus as normally
- If needed can divide the inguinal ligament
- Ok to perform a coopers repair vs mesh
99
Cholecystodoudenal Fistula presentation?
usually old frail elderly with bowel obstruction symptoms
100
Cholecystodoudenal Fistula triad?
rigors triad (pneumobilia, evidence of obstruction, ectopic gallstone) only in 50%
101
Cholecystodoudenal Fistula imaging and initial treatment?
- Imgaing
- X-ray only shows 15% of stones 2/2 most are radiolucent
- U/S and CT scan
- Initial treatment
- Resuscitate, ABX, airway,e-lytes, NGT
102
Cholecystodoudenal Fistula surgery? Note?
| Postop?
- Surgery
- Primary goal is remove obstruction quickly and safely (sites are distal ileum, jejunum, gastric outlet) vast majority of patients
- usually midline laparotomy
- proximal! longitudinal enterotomy on anti mesenteric border distal to the stone and retrograde retrieval (ante grade causes more mucosal damage) sometimes bowel resection is necessary
- run the entire bowel
- really try to avoid cholecystectomy (lot of inflammation) and fistula takedown (depending on size primary repair, omental patch, pyloric exclusion) significant increase in operative time and increases risk of morbidity and mortality. may consider in patient very stable, minimal comorditiies. not to mention possible leaks after repairs which could be disastrous. if you do repair it get an UGI postop
- Note-
- Risk of recurrent gallstone ileus or comp to fistula is very low. generally closes spontaneously without stones
- Postop
- NGT, IVF, bowel rest
- may consider interval cholecystectomy who recovers fully and good operative candidate at least 4-6 wks out
103
ECF HPI?
- HPI- crohns, previous surgery, notable weight loss
104
ECF PE?
- PE- Overall appearance, stability, wound care, peritonitis and signs of systemic infection
- just because there is fluid leaving the wound doesn’t mean there is a ECF
- Serosanguinous fluid can signify dehiscence needs to be evaluated at bedside or OR
105
ECF dx?
- Diagnosis
- std fever w/u
- CT scan r/o abscess anything percutaneous drainable
- Check fistula out put
- High >500 cc/day
- Mod 200-500 cc/day
- Low
106
ECF phases and treatments?
- Treatment
- 1st Phase
- fluid resuscitation (e-lytes low K and Cl), NGT, Foley, NPO, Central Venous Access TPN
- ABX (if signs of infection), PPI, or H2 blockers (decreases gastric and intestinal secretions and reduces stress ulcers)
- wound vac, appliance, skin barriers
- Consider Octreotide (can decrease output not closure)
- Note- nutrition adjust TPN (TPN %25 glucose 4%AA 10%FFA (50% non -protein cal to be glucose and 50%FFA 1 g/kg/day protein, 25 Kcal/kg/day carb))
- 2nd phase
- Will not heal if FRIENDS
- after 7-10 days fistula track is matured enough to place a catheter to fistula delineation -fistulogram r/o leak or UGI
- tracks longer than 2 cm more likely to heal, site of bowel injury, intestinal continuity and distal obstruction
- 3rd Phase
- need to decide when to operate based on location
- Unlikely to heal 50%
- Oropharynx, esophagus, duodenal stump, pancreatic-biliary and jejunum
- 5-6 weeks if nutrition is ok and fistula is unlikely to heal consider surgery
- Uncontrolled sepsis - need to operate sooner if you can’t find an abscess that can be perc drained
- If patients situation is extremes, then divert the bowel and repair the fistula later
107
ECF definitive treatment?
- Definitive treatment
- open abdomen and TD all adhesions
- small bowel segment c fistula needs to be resected
- Place feeding tube
- cont 5-10 days of TPN after
108
ECF wait period? Note?
- Note- some wait 6mo-12 mo for bowel adhesions to soften and optimize patients infxn, nutrition,wound status
- Note- surgery new site entrance and extensive LOA if possible to avoid recurrence, drain abscess, ostomy to protect resection anastomosis if necessary depending and not a simple closure of fistula site which has a high risk of recurrence
109
Small bowel tumors DDX?
DDx- adenomas (FAP), hemangiomas (bleed), hamartomas (risk dev adenocarcinoma), adenocarcinoma (MC), carcinoid, lymphoma
110
Small bowel tumors H&P? Dx?
- H&P- abdominal pain, obstruction, bleed, weight loss, perforation, jaundice, feel for masses, hernias, LN
- Diagnosis-
- r/o other causes of obstruction - hernias or bleeding (EGD, C-Scope, capsule endoscopy
- UGI and SBFT id most lesions and tumors and id the location
- CT scan - evaluate extent of tumor, LN and mets
111
Small bowel tumors treatment of the various areas and types? Obstruction, bleeding, malignant, duodenum, TI, GIST?
- Treatment
- Obstruction- see SBO
- Bleeding - Stabilized and EGD r/o esophageal and stomach causes
- angiogram and Tagged RBC and capsule endoscopy
- Malignant tumor- proper staging, resect with 6 cm margins both sides with en bloc lymphadenectomy
- Duodenum- Whipple
- TI- Right Hemicolectomy
- Postop chemo
- Lymphoma- usually ileum - stage1-2 segmental resection c mesentery
- Stage 3-4 chemo and XRT
- GIST- segmental resection c 1-2 cm margins no need for mesenteric resection (rarely spread via LN usually blood route)
- Postop Gleevac
112
Carcinoid Tumors DDx, Note, H&P, Labs?
- DDx- IBD, Pheochromocytoma, Hyperthyroidism
- Note-Usually malignant slow growing c mets preference to LN, Liver, R heart chamber
- H&P- abdominal pain, obstruction, diarrhea, flushing or palpitations, check for abdominal masses
- Labs- urinary 5-HIAA (100% for carcinoid syndrome not tumor)
- Chromogranin A is more sensitive for tumor
113
Carcinoid Tumors imaging?
- Imaging- CT scan A/P best initial test - can find mesenteric shortening and fibrosis and possible mets to liver
- Somatostatin Receptor Scintagraphy- may localize a primary and mets better than other imaging modalities
- useful for staging
114
Carcinoid Tumors treatment location?
- Treatment
- depends on location and size of tumor (2 cm is magical!) Beyond it becomes malignant and mets
- duodenum - 2 cm whipple
- if hepatic mets then locally debunk (to help c symptoms ) and post operative medical tx
- ileum and jejunum - wide local resection c en bloc mesentery resection, hepatic mets debulk
- Appendix- >2 cm or at the base (may extend further then you think —> right hemicolectomy
- Tip and 2cm or invade the muscularis propria —> APR
- Mets to liver-
- only wedge resection at original surgery don’t do extensive resection
- remove primary lesion, get baseline 5-HIAA and observe patients symptoms
- plan resection or ablation of these lesions after there is clear assessment of the disease
115
Carcinoid Tumors crisis?
- Carcinoid Syndrome
- treat medically c Octreotide 150 mcg sq BID
- lantreotide IM q 1wk
- Sandostatin LAR IM q 1mo
- S/E glucose intolerance, steatorrhea, gallstones
116
Carcinoid syndrome?
- Carcinoid Crisis
- cardiac arrythmias and can become HD unstable and cardiac arrest
- ACLS and octreotide 50 mcq TID
117
Non resectional tumors refractory to meds?
- Non-resectional tumors are refractory to meds
| - TACE c doxorubicin, RFA
118
Small bowel diverticular dz HPI, PE, Dx?
- HPI-h/o diverticulitis, perforation, abscess formation, UGIB, obstruction, jaundice
- PE- unremarkable
- Dx
- EGD to r/o foregut diverticulum
- UGI c SBFT or capsule endo to r/o midgut diverticulum
119
Small bowel diverticular dz treatment different types, meckels adults vs children?
- Treatment
- depends on location
- Asx duodenum tic - nothing
- Sx duodenum tic (inflamed or perf)- kocherize , close the hole and drain area (+/- pyloric exclusion)
- Peri-vaterian lesion - choledochojejunostomy and cholecystectomy
- UGIB- see other notes
- Asx Jejunoileal lesions- nothing
- Sx jejunoileal lesions - inflamed or perforated- will require resection with primary anastomosis
- Bleeding- angio c embolization or resection
- Meckels Adults
- Asymtomatic - nothing
- Symptomatic- resect
- Meckels Children
- always resect when found
120
Short bowel syndrome Hx, and treatment? things to remember?
- Hx- Crohns, radiation enteritis, and multiple bowel resections
- diarrhea, weight loss, dehydration, malnutrition, steatorrhea
- Hx - main way of dx
- Treatment
- Resuscitate
- Correct e-lytes and trace elements
- PPI and TPN
- Treat Diarrhea - Lomotil
- Start enteral feeds
- Note if
121
Small Bowel Crohns Disease scenario? note?
- cenario- “A young patient with few months history of intermittent abdominal pain, low grade fever, mucoid/slightly bloody diarrhea, losing weight or slightly anemic"
- Note- abdominal pain > bleeding (UC), skip lesions, transmural, granulomas, small bowel and perianal dz
122
Small Bowel Crohns Disease H&P, PE
- H&P- Pain, previous episodes, FHx, bowel habits, N/V, previous perirectal abscess, rectal bleeding
- PE- examine anus and perineum, stool guiac, skin exam pyoderma gangrenosum, anal skin tag
123
Small Bowel Crohns Disease w/u?
- Invasive/ Radiology (eval for IHOP)
- Flat and upright XRAY r/o obstruction
- sigmoidoscopy un prepped r/o UC (starts at rectum and progresses proximal no skip) and bx abnormal tissue, perianal fistula
- Meckels if strong “bleeding picture"
- If no obstruction on X-ray and sigmoidoscopy is negative and no peritonitis
- Barium UGIS c SBFT look for crohns stigmata (strictures, TI (almost always involved) extent of disease
- BE to look for colon involvement
- Colonoscopy if colon involved c biopsies
- CT A/P r/o path - small bowel wall thickening and mesenteric inflammation, fistula, transition points, masses, to look for relationship of disease segments and adjacent organs
124
Small Bowel Crohns Disease treatment and operation?
- Treatment/Operation
- initially mostly medical
- acute flare up
- Prednisone 40 mg/d (is tapered over 4 weeks)
- Sulfasalazine 0.5mg/d or mesalamine (dz modifier)
- Flagyl for perianal dz
- may consider Remicade-anti-TNF ab to establish remission in refractory patients
125
Small Bowel Crohns Disease indications for surgery?
- Indications for surgery
- Severe symptoms as surgery doesn’t cure
- Obstruction
- Intraabdominal abscess
- Symptomatic fistula (enterovesical, enterocutaneous - enteroentero may not need sx)
- Intractable bleeding
- Cancer (increase risk)
- FTT in children
- Failed medical control of symptoms (toxic megacolon Wbc>12.5, HR>100 temp>38.5, traverse colon >5cm)
- Perianal dz
126
```
Small Bowel Crohns Disease surgery?
IA abscess?
Fistula?
Appy?
fistula?
intractable colon involvement?
```
- Surgery
- nutritional optimized
- preserve small bowel length, least amount of surgery possible, no frozens for margins, just grossly, stricturoplasty if extensive
- contraindications
- perforation, mult strictures in a short segment, colonic stricture, suspect cancer and a stricture close to the proposed area to resect
- grossly involved bowel- resect c primary anastomosis
- if duodenum involved - then bypass with gastrojejunostomy c truncal vagotomy if there is a fistula
- fistula- usually aggressive and requires a “cool-down” period, on third need to be taken down and resect involved small bowel and repair bladder c omentum interposed
- IA abscess- perc drain abx and plan surgery after inflammation decreased 4 weeks later should be kept NPO and TPN in the meantime
- If during appy- perform appy if base not involved, if its involved forego the appy for fear of fistula formation
- Distal anal stricture- dilate vs permanent diversion
- Anal fistula - setons, try to minimize surgery here to avoid injury to the sphincter
- If extensive colonic involvement and rectum with incontinence - can consider total proctocolectomy with end ileostomy (lowest recurrence rate)
- Intractable colon involvement- proctocolectomy with permanent ileostomy (poor results c high recurrence rates)
127
Bowel Ischemia hx?
Hx- A. Fib, post op from heart surgery or MI, c/o acute severe epigastric pain or periumbilical pain disproportionate findings
128
Bowel Ischemia initial tx?
- Initial treatment
- ABC
- Labs
- cbc, renal, lactate, amylase and lipase, check for met acidosis
- EKG, cardiac enzymes, rectal exam and guaiac
129
Bowel Ischemia PE?
PE- check for hernias
130
Bowel Ischemia imaging/testing?
- Imaging/ testing
- if stable perform extended sigmoidoscopy (look for ischemic changes in colonic mucosa)
- if suspect ischemia order a CTA or arteriogram (with papaverine drip good for non-occlusive dz)
- Dx laparoscopy
- If normal consider colonoscopy
131
Bowel Ischemia preop?
- Preop
- IVF optimize CVP and UOP
- ABX (Imipenem)
- Heparin (10,000 bolus and 1000 u/h)
- Consider dopamine and bicarb possibly post op to restore blood to bowel
132
Bowel Ischemia SMA embolus ?
- SMA embolus (patent proximal 3-8 cm from SMA origin)
- Laparotomy and embolectomy
- Expose SMA
- transverse colon is reflected upward and the bowel is packed laterally
- exposing root of mesentery crossing the third portion of duodenum
- follow the middle colic artery in the transverse mesocolon
- small longitudinal incision is made in posterior peritoneum
- artery is ID medial to SMV
- Transverse arteriotomy
- flush c heparin and repair it
- watch the bowel
- use intraoperative doppler
- viable bowel will have clear doppler signal on its mesenteric border
- IV fluorescein with woods lamp
- If segments are clearly not viable then resect
- if questionable consider 2nd look the next day
- Keep heparin ggt postop
133
Bowel Ischemia SMA thrombosis?
- SMA thrombosis (occlusion at origin of SMA)
- laparotomy and embolectomy to SMA
- poor flow
- Harvest saphenous vein graft b/w soft spot in infrarenal aorta and the SMA
- if no soft soft infrarenal then suprarenal aorta
- approach through gastrohepatic omentum above the celiac trunk and passed behind the pancreas to SMA
134
Bowel Ischemia NOMI?
- Non-occlusive mesenteric ischemia (normal prox mesenteric vessels but gradual tapering and spasm)
- Associated with low flow state (acute heart failure, dehydration)
- Heparinization
- papaverine infusion through the angiocatheter
- correct underlying condition (opt intravascular volume and CO)
- If improves repeat angiogram to confirm normal blood flow to bowel
- if develops peritonitis then laparotomy and bowel resection
135
Bowel ischemia arteriogram?
- Arterial phase of arteriogram is normal but delayed, and a venous occlusion is noted on venous phase
- also consider spiral CT delineate
- associated with hypercoagulopathy
- Tx
- heparin
- optimized medical condition and repeated exam
- possible laparoscopy
- possible laparotomy and bowel resection
- ostomies and MF
- or second look laparoscopy to check anastomosis
136
Intestinal Angina hx?
- Hx- postprandial pain, loss of weight, negative exam and neg GI w/u
- Mild intermittent claudication or a smoker
137
Intestinal Angina imaging/ testing surgery?
- Imaging/testing
- duplex scan to celiac artery, SMA, IMA
- and if positive perform a CTA
- will show two or more of three vessels
- candidate for re-vascularization procedure
- priority is celiac >SMA>IMA
- Angioplasty with or without stent treatment of choice
- if unavailable then surgery
- transabdominally or retro
- autologous graft b/w supraceliac aorta via gastrohepatic omentum and both celiac and SMA
- the limb to SMA passed behind pancreas to prevent kinking near duodenum
- other option is if infrarenal aorta is healthy then straight short graft b/w infrarenal aorta and SMA distal to its occluded segment
138
intestinal angina postop?
- Postop
- re-vascularization syndrome
- abdominal pain, tachy, wbc and intestinal edema
- concerned about re-vascularization repeat angiography
