Alimentary Flashcards
FAP screening recs
gene
APC
Lynch screening
MC area for FBs to impact
Esoph
What is the most common type of CBD injury
complete transection
When should stricturoplasty be performed for crohns
When concerned for short gut
Small bowel tumor with liver mets think…..
watch out for this during resection
Tx for 2nd line?
carcinoid
serotonin syndrome
octrotide
2 PE findings for obturator hernia
medial thigh paraesthesias and romberg—knees tucked
Ideal Wetzel location on small bowel
40 cm distal to LOT
Expected weight loss of excess weight at 2 years follow up?
What is excess weight calculated as
excess weight is current weight - IBW
First important SMA branch
Next?
pancreaticoduodenal
middle colic
3 possible origins of the right colic artery
SMA MCA, nothing
superior rectal artery collateralizes with …
hypogastric arteries
what is the collateral flow of the colon?
artery of Moskowitz?
Marginal artery
Arc of riolan
distal sma thrombus will show what effect pattern
jejunal sparing
3 types of mesenteric ischemia
arterial, venous and nomi
non emergent pneumatosis intestinalis
when is PI concerning
Nonemergent etiologies include asthma, chronic obstructive pulmonary disease, inflammatory bowel disease, peptic ulcer disease, bacterial and viral infections, immunosuppressive medications, collagen vascular disease, and iatrogenic causes
acute abdomen
3 findings in all mesenteric ischemia types
pain out of proportion, acute abdominal pain, metabolic acidosis
3 s/s of chronic mesenteric ischemia
food fear, postprandial pain, weight loss
Given critical CV patient, look for these 4 signs when considering NOMI
Diagnostic symptoms: high suspicion if three of four are present
Ileus or abdominal pain
Catecholamine requirement
Episode of hypotension
Gradual rise in serum transaminase level
usual suspect for NOMI
Sick CV patient
First thing to do if patient presents with Mesenteric ischemia concerns
hep ggt
4 pos prognosticators for spontaneous fistula closure
free distal flow, 2cm tract length, <1cm bowel involv, healthy surrounding bowel
at what duration does surgical intervention need to be discussed for fistula
8 weeks, but generally optimize until 6 months
MC overall cause of ECF
iatrogenic
3 imaging studies for ECF
fistulogram
CT PO
CT rectal(distal obstruction or hollwo viscus rectal connection suspected)
3 output grades for ECF
<200, 200-500, >500
agents to begin to decrease fistula out put
what helps in crohns
h2 or ppi; octreotide
infliximab
What metric do we look at for ECF considering PO vs TPN
fistula daily output, needs to be under 500cc/d
What are the basic principles of fistula management in the subacute setting
wound care(pouches?), PO v tpn, electrolyte/fluid resus
what artery supplies meckels
2 meckels tissue types
vitelline
gastric and panc
meckels scan?
technitium 99 binds to gastric mucosa
3 meckels concerning features, how does this guide us
fibrous bands, >2cm, palpable abnormalitiy
resect or not
segmental meckels removal in bleeding cases if these characteristics are present
2cm neck, narrow lumen, palp abnorm, unhealthy appearing tissues
when to consider removal of incidental meckels
why
age younger than 50 years, male sex, diverticulum length >2 cm, and ectopic tissue or palpable abnormalities.
Ca risk vs resection complication risk
what can be used for diarrhea with radiation enteriitis
Cholestyramine is commonly used to bind bile acid that is not absorbed in the ileum due to radiation damage of the small bowel, making the bile acid insoluble and osmotically inactive.
MC benign sb tumor
MC location
adenomas, Brunner gland, villous adenomas
ileum
carcinoid tumor now known as….
cell type
location in GI tract in descending order of prevalence
net
enterochromafin like
appendix>small int> colon> stomach> rectum
Mc site of SB adenoca
duo and prox j
where is malignant SB lymphoma found and why?
ileum, all the peyers patchers
2 worrisome sb adenomas and their backgrounds
villous - 50% mal risk
familial in duo – FAP
hamartomas in SB are associated with …
PJS — melanin defects
adenoca of SB accounts for __% of mal sb tumors
assoc with …
MC site
50
crohns in young age
ileum
SB lymphoma make up __% of sb malig
risk factors
MC intestinal neoplasm in this population
25
celiac and aids
younger than 10
2 mc presentations of small bowel adenomas
obstruction and bleeding
ct findings indicative of SB NET
A diagnosis of a NET of the small intestine can be confidently made based on the classic appearance of a solid mass with spiculated borders that is associated with linear strands within the mesenteric fat and kinking of the bowel on abdominal CT scan.
what imaging modality can help with identifying SB NETs
Tx for lymphoma?
dotatate
resection if symptomatic!! then systemic
SB adenoca mets to liver, tx?
Folfox
SB NET with carcinoid syndrome tx?
octreotide
how can duodenal adenomas be conservatively managed depending on location and anatomy
endoscopy
3 genes for colon cancer
What are the MMR genes?
KRAS
APC
TP53
MLH1, MSH2/6, PMS2
CPG island mutations for colon ca due to …..
loss of BRAF and MLH1
age of screening for colon ca
45
is a high MMR or low MMR assoc with poor colon ca prog
low
6 genetic syndromes for colon ca
FAP, HNPCC, JPS, PJS, li fraumeni, cowden
who is high risk for colon cancer
when to screen
1st degree fam hx of adv adenoma or colon ca
40 or 10 y prior to dg
screening time and finding:
5-10
5
3 then 5
8 y after onset
2ad 1cm
2 serr 1cm
3-10ad >1cm HGD
IBD
T staging for adenoca of colon
Stage 2 colon cancer T N M
who gets adjuvant?
T2-4 n0
High risk:
LVI
poorly diff
T4
<12LN
onstruction
Pos margins
S3 colon ca adjuvant reg and duration
6 months FOLFOX or CAPOX
5y survival for all colonc ca stages
90
75
50
5
surveillance schedule for all stages of colon ca
1 - 1y colonoscopy
2/3/4 - hnp and cea 6m x2 year, then 6m x 5
CT CAP 12m x 5
Colon 1 3 5
HNPCC inh pattern
gene type
7 cancers
AD
MMR
colon, endom, ovary, stomach, biliary, sb, urothelial
Op choice for HNPCC
segment or total — no diff in survivial
who needs lynch screening
3 relatives, 2 gens, 1 crc prior to 50
2 weird HNPCC skin things
sebacious adenoma and keratocanthomas
all screening for FAP
3 weird specific FAP pathologies non cancer
desmoids, jaw osteoma, epidermal cysts
who has hamartomatous disease, colon cancer syndromes
PJS, JPS
Op choice for FAP
total with end v pouch
dont leave rectum
risk of colon ca with FAP by 45yo
90%
2 dietary risk factors for diverticulosis
red meat and low fiber
what type of diverticula is a colonic diverticula
mech?
false, weak point where arteriole inserts into muscle
6 at risk populations for diverticular disease
obese, poor activity, nsaids, opiates, steroids, smoking
ideal number of attacks before colectomy for diverticulitis
4
Percent of patients with recurrent diverticular disease after first attack
20-40
Layers involved in acute ischemic colitis
mucosa and sm
dg test of choice for ischemic colitis
colonoscopy unprepped
one big long term sequelae of ischemic colitis
strictures
describe avms and their role in LGIB
With age, low-grade obstruction of submucosal veins from chronic colonic contraction can lead to arteriovenous communication and dilation in the form of angiodysplasias.
As the veins become tortuous and precapillary valves become incompetent, the resulting arteriovenous malformations (AVMs) may cause slow blood loss that frequently presents as melena or subacute anemia. AVMs represent 5% to 10% of lower GI bleeds.
The most common causes of lower GI bleeding
The most common causes of lower GI bleeding are diverticulosis (30%-65%), ischemic colitis (5%-20%), hemorrhoids (5%-20%), polyp/neoplasm (2%-15%), and angioectasias (5%-10%).
LGIB accounts for __% of all GIB
20
first step in evaluating for UGIB
Neg pred value?
NGT
only 645%
Initial dg test for LGIB
prepped colonoscopy within 24h and for reccurrence
Thoracic duct anatomy
where does the thoracic duct originate
L2 at cirstena chyli
pathophys of chylothorax
Chylothorax can cause significant systemic protein loss, which lowers oncotic pressure and can result in high-volume pleural effusions.
MCC of non trauma chylo
malig
TG level to dg chylo
what if it is indeterminate? what is the indet value?
110
50-110, chylomicron by lipoprotein elctrophereses
duration of cons mng for chylo?
poor surgical candidate next step
5-7d
embol
what cause for chylo has highest fail rate for intervention?
what extra step is taken?
malign
pleurodesis
what dietary change is made for chylo leak
medium chain
avoid long chain
