Surgery - Lower GI Flashcards Preview

Surgery > Surgery - Lower GI > Flashcards

Flashcards in Surgery - Lower GI Deck (84):
1

What can cause failure of fascia closure in ab surgery?

Infection in abdomen

Can have hernia w/ fascia open -- need to go to OR to fix ASAP

2

Most common causes of lower GI bleeding

1) Diverticulosis

2) Andiodysplasia

3

Ischemic colitis

Happens in setting of
- hypoTN
- vasculitis
- atherosclerosis

Present w/:
- ab pain (pain out of proportion of PE)
----usually pain after eating --> wt loss
- fever
- vomitting

Bleed b/c of ischemia of watershed areas of the colon

4

Acute mesenteric thrombosis

Ab pain out of proportion of physical findings
N/V
Bloody diarrhea b/c mucosal sloughing

Numerous athero risk factors

Usually SMA is occluded --> distal duodenum --> transverse colon

5

Common causes of pelvic abscesses
- male
- female

Male
- appendicitis
- rupture of appendix --> form pelvic abscess from fluid draining into rectovesical pouch

Fem:
- gyn issues

Drain these abscesses!

6

Pelvic abscess vs anorectal abscess

Pelvic
- tender fluctuant mass palpable only w/ tip of examing finger on rectal
- painful defecation
- diarrhea

Anorectal
- perineal pain
- fluctuant mass palpable on perineum
- pain w/ ambulation + defecation
- urinary retention

7

Rovsing sign

RLQ pain w/ deep palpation of LLQ

Sign of Appendicitis

8

How do you dx appendicitis?

CLinically!

Don't need further imaging to confirm dx if classic signs, sx, and lab data are present

Get CT if person has suspected appendicitis w/ atypical presentation

Need surgery ASAP
Give Abx pre and postop

9

Isolated duodenal hematoma

Mostly in kids after BAT

Usually have blood b/n submucosal and muscular layers of duodenum --> obstruction

Most will resolve by itself in 1-2 wks

Tx:
- nasogastric suction w/ TPN
- if need surgery, can do laparotomy or laparoscopic procedure

10

Uncomplicated vs complicated diverticulitis
- tx?

Uncomplicated
- colonic diverticular inflamamation
- tx: outpt, bowel rest, oral abx, observation

Complicated
- diverticulitis + abscess, perf, obstruct, or fistula formation
- if fluid collection < 3 cm, tx w/ IV abx
- if fluid > 3cm, CT guided drainage
- surgery (drainage + debridement) if drainage does not fix

11

Ab aorta operations - what is an early complication?

Bowel ischemia and infarction

12

How long do you give a pt who went under ab surgery that is now third spacing?

48-72 hrs

At this time, they will reabsorb edema and pee it all out

13

Pathophys of dumping syndrome

Rapid emptying of hypertonic gastric content into duodenum + SI

causes fluid shift from intravascular space --> SI

Then release intestinal vasoactive polypeptides and stimulation of autonomic reflexes

14

When do you use technetirum-99 labeled RBC scintigraphy?

IN cases of lower GI bleeding where source can't be ID'd by colonoscopy

15

Mesenteric ischemia

inflammation and injury of the small intestine result from inadequate blood supply

16

Different severities of hernias

Reducible
Incarcerated = not reducible
Strangulated = not reducible + ischemic

17

Minimize post op infection for elective colonic surgery

What can you use to decrease bacterial load in bowel before GI surgery?

Mechanical cleansing
Oral Abx
Periop parenteral abx (anaerobes and aerobes)

Oral nonabsorbable abx
- neomycin
- erythromycin

18

Risk factors associated with colorectal cancer

Strong risk
- advanced age
- country of birth (eg Korea, Scandanavians)
- FAP/HNPCC
- long standing UC

Moderate risk
- previous adenoma or cancer
- 1st degree relative w/ adenoma or cancer
- pelvic irradiation

19

Protector factors assoc w/ colorectal cancer

Moderate
- physical activity
- aspirin/NSAIDs (Nurses study)
- high Ca intake (Nurses study)

20

Genetics of colon cancer - what can be mutated?

Tumor suppressors
- APC
- Chr 18
- p53

Oncogenes
- k-ras

DNA repair genes
- hMLH1
- hMSH2

21

Where do adenocardionmas of colon come from?

Glandular tissue of mucosa (#1)

22

Familial adenomatous polyposis

APC gene mutation

Chromosome 5 location

AD inheritance

100% colon cancer risk

Total proctocolectomy in early 20s
- ileostomy
- or J pouch (ileoprocto anastamoses)

Still early death b/c more susceptible to other adenomas, esp in duodenum

23

What is double contrast barium enema?

2 contrasts:
- Barium
- Air

Air to disperse barium

24

Gardner's syndrome

Osteomas

variant of FAP

25

Classic for peutz-jegher's?

Buccal pigmentation

26

HNPCC (Lynch syndrome)

AD inheritance

Not hundreds of adenomas like FAP but will still get polyps

Mismatch repair gene mutation

Higher risk for other cancers:
- stomach
- SI
- renal
- ovarian
- pancreatic

27

Where are most hereditary colon cancers?

R side

28

Watershed areas of Colon

Lives off collateralization of arteries for supplying area

Griffith's point = splenic flexture
- Arch of Reiling
- SMA - marginal A branch of IMA

Sudek's point
- superior hemorrhoidal A (IMA) - middle and inferior rectal A (internal iliac)
- mets to lung and liver for rectal cancer

29

Microsatellite instability

When 2 bases don't line up, you get a break = MI

condition of genetic hypermutability that results from impaired DNA Mismatch Repair (MMR).

30

Microsatellite stable vs. unstable - which has better prognosis?

Microsatellite unstable cancer has better prognosis!
- less biologically active

But more resistant to 5-flurouracil chemo

31

Molecular pathogenesis of colorectal cancer

MIcrosatellite stable cancer:
Loss of APC gene --> k-ras mutation --> DCC deletion --> p53 deletion

Microsatellite unstable cancer:
MSH2/ MLH1 abnormality --> k-ras mutation --> DCC deletion --> p53 deletion

32

What do you look for in FOBT?

Iron!

THIS IS NOT SPECIFIC OR SENSITIVE!

Guiaic test:
- 3 separate stool samples collected by patients and tested for blood

33

Screening recommendations for CRC
- what tests do you do?

Annual FOBT + sigmoidoscopy / 5 years

Colonoscopy every 10 years
Double contrast barium enema every 10 years

34

Post op, when does bowel function come back?

SI - 4h
Stomach - 24h
Colon - 3d

35

Abx for GI surgery ppx if will cause significant trauma

Ampicillin + gentamicin

- fights enterococci

36

Intestinal atresia usually due to

vascular accidents in utero

Ileum #1 affected

Duodenum is a failure to recannalize rather than a vascular accident in utero

37

Whipple's disease manifestations

PAS + macrophages (foamy)
Cardiac sympoms
Arthralgias
Neurologic symptoms

38

Diverticulosis

Most in sigmoid colon
- smaller diameter, more pressure
- more formed stool

Occur esp where vasa recta perforate muscularis externa

39

Volvulus

Twisting of portion of bowel around redundant mesentery in colon

Cecum (young)
Sigmoid (old)

40

Meconium ileus
- pathophys
- tx

In cystic fibrosis

Meconium plug obstructs intestine (terminal ileum) preventing stool passage at birth

Tx:
Gastrografin enema to dx
Gastrografin enema can also tx (draws fluids in and dissolves pellets of meconium)
NO SURGERY!

41

Necrotizing enterocolitis
- what is it?
- tx?

Necrosis of intestinal mucosa
Possible perf

Colon is usually involved

More common in preemies
- common when baby begins solids foods or formula


IVF + IV abx

Surgery if have pneumoperitoneum, ab wall erythema, air in portal v, or intestinal pneumotosis

42

Dx carcinoid
Tx carcinoid

Dx:
- urinary 5-hydroxyindoleacetic acid
- not blood levels b/c it is waxing and waning symptoms. levels only high at time of attack; otherwise, levels will be normal

Tx:
Tumor excision is 1st line
Use octreotide if can't resect/too advanced

43

Bacterial overgrowth syndrome in intestine
- symptoms
- clinical manifestations

Sx:
Ab pain
Watery diarrhea
Dyspepsia
Wt loss

Severe:
Tetany (hypo Ca b/c vit D deficiency)
night blindness (vit A def)
neuropathy (B12 def)
dermatitis
arthritis
hepatic injury

PE:
secussion splash (from fluid filled loops of bowels)

Upper GI w/ small bowel follow through to dx by showing hypomotility, partial obstruction, dilation w/ delayed GI motility

44

Usual Causes of ileus

UTI
PNA

45

Tx ogilvie’s syndrome

1st make sure there is no actual intestinal blockage

neostigmine + monitor cardiac function

46

Tx Volvulus
Dx volvulus

rigid sigmoid + rectal tube (keep from twisting on itself and do on a bowel perp) so you can do a sigmoid resection

Can dx w/ xray

47

Tx Gallstone ileus

go in and slit in the ileum and milk out the stone. Go back and fix the gallstone duodenum fistula later

48

Ab pain + high amylase + normal lipase
What happened?

Bowel can release amylase.

If have ab pain and only high amylase without corresponding rise in lipase, not pancreatitis and can be bowel ischemia

49

Most common causes of C Dif colitis
- when do you need surgery

CLindamycin
Cephalosporins

Surgery when WBC > 50, serum lacate > 5

50

Fissure or fistula that doesn't heal well - what does this suggest?

Crohns

Anal area has good blood supply and usually these things heal. If not, suggests Crohns

51

Generally, GI bleeding is from where?

3/4 cases before ligament of Treitz (upper GI)

1/4 in colon or rectum

52

BRBPR in child - what is it most likely?

What do you do next?

Meckel's diverticulum

Technetium scan looking for ectopic gastric mucosa

53

Omphalocele vs. gastroschisis repair

Omphalocele = reduce day by day

Gastrochisis = need TPN b/c bowel will not work for about 1 mo

54

Tx imperforate anus in newborn

If there is a fistula, can delay until before potty training time

If no fistula, do colostomy for high rectal pouches or do primary repair asap

Find where blind pouch is with xrays taken upside down

55

Dx Hirschsprung disease

Full thickness bx of rectal mucosa

Manometrics usually for older kids

56

SCC of anus

more common in HIV+ and homosexuals

fungating mass growing out of anus

tx:
nigro chemorad (90% success)
surgery if there is residual

57

All hernias should be electively repaired except

umbilical hernias in kids < 2-5 yo

esophageal sliding hernia

58

Anal fissure

Usually in young women

lots of pain w/ defecation + blood streaks covering stools

Can get constipated because fear defecation

Tx:
- stool softners
- topical nitro
- local botox
- forceful dilatation
- CCB (dilitazem)

59

Thumb print sign on KUB/Ab XRAY

Bowel wall edema

On an unremarkable abdominal radiograph of a patient with normal colon wall thickness, you see only the inner wall of the bowel because it is outlined by the gas in the lumen of the bowel; you don't normally see outer wall of normal bowel wall.

If the bowel wall is thickened, it protrudes into gas-filled lumen, and on radiographs, these protrusions appear as focal areas of soft tissue thickening along the colon wall that look like somebody is pressing a thumb into the air-filled lumen

60

SBO in man w/o previous ab surgeries + aerobilia - what do you suspect?

Aerobilia = air in the biliary tract

This is gallstone ileus!!!

Tx: ileotomy + extraction; later cholecystectomy
- do not operate on the biliary fistula now

61

Tx Hirschprung's disease

Initial = colostomy decompression

Wait for definite repair until nutritional status is ok and nontdistended bowel

62

Umbilical hernia in newborn + no incarceration - tx?

Wait

Most close by age 4

63

Is more water absorbed in R or L colon?

Both same!

64

How best to stage rectal wall and pararectal lymph nodes in rectal cancer?

US

65

Do you do a resection for rectal cancer if it invades muscularis mucosa?

Not needed - if taking out cancer has clear gross adn microscopic margins, tumor is well differentiated, and stalk not invaded

66

Ach - + or - motility of GI?

Causes motility!!

Anything that simulates PSNS activity stimulates motility

67

Places where hemorrhoids arise

L lateral
R anterior
R posterior

68

Tx external hemorrhoids, thrombosed

If < 72 hrs old - remove clot

If > 72 hrs old - don't do anything, warm bath. body is resorbing the clot

69

Where do you cut to do I&D for anal abscess?

Near anus as possible b/c may make fistula so want to go as close to opening as possible

70

anal fissure characteristics

Will have a skin tag usually with it

71

Coincentric rings indicative of

Rectal prolapse

72

Causing anal pain

Abscess
Herpes
Fissure
Thrombosed external hemorrhoids

73

Mass on outside of anus/abnormalities around anus that are not painful

Skin tags
Internal hemrrhoids
Pruritus ani
Tumor

74

Crohns vs regular fissure

Crohns usually lateral

Conventional fissures usually posteriorly

75

Howship Romberg sign

Obturator neuralgia from nerve compression by obturator hernia

Thigh extension, adduction and medial rotation

76

.Fat absorption

Short _ medium chain = transport directly from jejunal mucosa --> portal venous system

Larger triglycerides --> chylomicrons --> lymphatics

77

Regional enteritis aka crohns in kid can mimic appendicitis - what do you do when you do surgery and the appendix looks normal?

Appendectomy if cecum at base of appendix is not involved

78

Anal cancer 1st therapeutic approach should be

Radiation + chemo

Surgery has been shown to have not great results

79

Indications for surgery in crohns

Free perforation
Stricture if it compromises nutritional status
Fistula w/ symptoms

80

Carcinoid tumor in appendix tx

< 2 cm - appendectomy

>2cm - R hemicolectomy

81

Tx complicated diverticulitis
- abscess
- perforation
- obstruction
- fistula formation

Abscess:
CT guided percutaneous drainage --> if doesn't resolve, surgical drainage and debridement

Fistula, perforation, peritonitis, obstruction, recurrent attacks:
- sigmoid resection

82

GI complaints followed by periorbital edema + myositis + eosinophilia + splinter hemorrhages

Trichinellosis!!!

83

What should you always look for as a source of constipation?

Hyper Ca

Watch out for MM, cancers causing this, esp if pt has bone pain

84

Difference between ileus vs pseudoobstruction

ileus has NO BS
- will have both SI and colon distention

Pseudoobstruction has hyperactive bowel sounds
- most colon distention w/o much SI distention