Alimentary Tract Flashcards
What’s algorithm for EC Fistula?
Start TPN & PPI. Consider somatostatin analogue
Monitor electrolytes, consult dietician/nutrition/wound care
If <500mL/day then trial PO if output doesnt increase w PO intake. Otherwise NPO w TPN
If not closing spontaneously after nutritional optimization, OR
Resect ECF. Repair wall if possible but otherwise staged repair of hernia.
What’s workup for GERD/Hiatal hernia?
Symptoms: Trigger food, try avoiding them, reflux, PPI use Hx, night time cough, worse symptoms with lying down
Barium swallow, EGD, ambulatory pH study, impedance reflux study, esophageal manomatry
What’s treatment for peptic stricture?
PPI + EGD dilation
If refractory, steroid injection
If refractory, stent placement
If refractory, distal esophagectomy with esophagogastrostomy or esophagojejunostomy
Rectal prolapse workup
Colonoscopy and MRI defecography to eval for pelvic floor defect, treat constipation, anal manometry, Sitz marker studies
If manometry shows pudendal nerve injury then patient is likely to suffer from incontinence even after OR.
Sitz Marker
It involves the patient swallowing several radio-opaque markers and getting an abdominal x-ray every day for 5 days. Slow-transit colonic inertia is defined as greater than 20% retention of sitz markers after 5 days. That would be suggestive of poor peristalsis of her colon.
Constipation workup
Cancer rule out, colonoscopy, medial tx, anal manometry/balloon expulsion study/defecograrphy
If inertia refractory to meds, TAC. If refractory to TAC end ileostomy
Bailout for variceal bleed?
GE junction devascularization (Saguira-Futagawa procedure)
splenectomy, devascularization of the distal esophagus and superior two-thirds of the major and lesser gastric curve, preserving the left gastric vein.
end-to-end anastomosing stapling device transects and anastomosis the esophagus 4–6 cm above the gastroesophageal junction. This anastomosis can then be reinforced with vicryl suture. A pyloroplasty is routinely followed to facilitate gastric emptying
Management of bleeding varices?
Early intubation, mass transfusion, vasopressin for hypotension, PPI, ceftriaxone
EGD, TIPS ( R hepatic vein to portal), Blakemore tube
Transfer to transplant center
Pedunculated Polyp Evaluation
High-risk: perineural invasion, tumor budding, lymphovascular invasion,
Low or High grade/poorly differentiated or well differentiated
Polypectomy PAth eval
OK to surveil at 6 months if:
Haggitt level 1-3 or SM level 1 (1/3 of submucosa)
well differentiated histology
No lymphovascular invasion
Non-piecemeal resection with negative margin
Tx for eosinophilic esophagitis?
Steroid
What’s Polyp level?
Haggitt Level:
1 - submucosal invasion only at head
2- at neck
3 - stalk
4 - invasion beyond stalk but above muscularis
SM levels:
1 - superficial 1/3 of submucosa
2 - mid 1/3
3 - deep 1/3
What’s C diff mgmt?
If no peritonitis,
125 mg Vanc q6h or Fidaxomicin 200 mg BID x 10d
Recurrent non-severe:
Fecal transplant
Tapered pulse oral vanc or fidaxomicin
Fulminant (ileus, shock, or megacolon):
Vanc 500 q6h and flagyl iv 500 q8h
Unidentifiable GI Bleed Algorithm
Reverse AC, Check for anal bleed, start transfusion, place NGT to rule out upper GI bleed
Colonoscopy, can repeat if needed, then CTA, IR provokative study (administer heparin or vasodilator into mesentery to induce bleed)
If unstable, OR, double push enteroscopy or endoscopy via enterotomy. TAC if unable to localize.
Esophageal Perforation Mgmt
ABC, Rule out cardiac causes
CXR to look for free air or effusion
Water soluble swallow, then thin barium swallow, then full barium swallow, then CT esophagogram, then EGD
If small, contained, and non-septic, obs with possible stent
If not, OR for debridement + multilayer repair + intercostal buttress + leak test + nutrition source
