BOWEL Flashcards
HNPCC is associated with higher risk of developing colon cancer as well some extra-colonic cancers, such as
endometrial,
ovarian,
gastric.
screening protocols for HNPCC recommended
Annual colonoscopies should begin at age 20,
and
all polyps should be removed.
Benign polyps do not necessitate a formal resection,
Managment of HNPCC pt with completely resected polyp found to be adenoca
but if pathology shows adenocarcinoma, surgery should follow.
The recommended surgery is a total abdominal colectomy with ileorectal anastomosis.
In female patients who do not plan on further childbearing, a hysterectomy and bilateral salpingo- oophorectomy is also recommended to eradicate the risk of developing malignancy in these tissues.
low med and high output fistula defs
low output (500 mL/day).
Proximal fistulas tend to be high in with what acid base picture
high bicarbonate loss
with
result in metabolic acidosis.
The majority of fistulas will result in what lyte loss
hypokalemia due to potassium efflux.
With optimal care, approximately what percent close spontaneously. and what is mortality
one third
One third of fistulas will close within the first 4-6 weeks
However, mortality rate remains high as 15- 25%!
The first step in control of a fistula is control of any septic source. Additional undrained collections should be identified and controlled, with liberal use of CT scanning and percutaneous drain placement. Operative control is usually unnecessary and may worsen the problem with creation of further enterotomies or spreading septic sources. The patient must then be stabilized, resuscitated, and electrolytes repleted. Nutritional support is then begun with
The first steps in control of a fistula
control septic source.
Operative control is usually unnecessary and may worsen the problem with creation of further enterotomies or spreading septic sources.
Nutritional support is then begun with either enteral or parenteral feeding. Enteral feeding may result in increased fistula output, or simply not be tolerated due to obstructive symptoms.
If the fistula increases to high ouput levels, TPN should be used.
wound manager and agents such as psyllium, octreotide and long acting somatostatin analogues used to decrease output, with the goal of decrease output levels from high to low or moderate output.
If the fistula does not close spontaneously, the would must be closed operatively.
Aggressive nutritional support must be provided to achieve an albumin greater than 3g/dL.
After 12 weeks have passed after fistula formation, operative intervention should be considered.
The operation consists of bowel resection, anastamosis, takedown of the fistula and full thickness resection of the area of abdominal wall.
Complex abdominal reconstruction may be needed. If so, nonabsorbable mesh should be avoided.
Ischemic colitis most often present with
non-specific abdominal pain
mild hematochezia.
Even a short interval of hypotension in a patient with associated risk factors may develop ischemic colitis.
CT scans will show segmental colonic thickening.
may present with small amount of blood per rectum but a large amount favors diverticulosis or hemorrhoids.
Patients at risk for ischemic colitis are
in advanced age, have poor cardiovascular histories, or are hypercoaguable.
The most common infectious etiologies include
E.coli
and
Salmonella.
Hyperplastic polyp
no malignant potential!
NOT considered neoplastic!
A polypectomy is sufficient for
malignant polyps with invasion limited to the head or neck or stalk BUT NOT BASE
(unless this is IBD or HNPCC - these patients need surgery)
A repeat colonoscopy is recommended in 3 YEARS.
NEEDS formal surgery:
Pedunculated Haggitt level 4 (base) with invasion into distal third of submucosa, or pedunculated lesions with lymphovascular invasion
b.
Lesions removed with margin <2 mm
c.
Sessile lesions removed piecemeal**
d.
Sessile lesions with depth of invasion into distal third of submucosa (Sm3)**
e.
Sessile lesions with lymphovascular invasion
A polypectomy is not sufficient
polyp size greater than 3 cm
Sessile lesions removed piecemeal**
Sessile lesions with depth of invasion into distal third of submucosa (Sm3)**
angiolymphatic invasion
invasion into the base: level 4 (base) with invasion into distal third of submucosa,
poorly differentiated histology
insufficient margin of < 2 mm
(size less than 3, margin less than 2)
Hyperplastic polyps
do not have malignant potential.
Peutz-Jeghers syndrome polyp type
Hamartomas
The risk of colon cancer is increased in these syndromes, but the hamartomas themselves are not considered premalignant.
Juvenile polyposis polyp type
Hamartomas
Polyps with juvenile polyposis are not pre-malignant.
The risk of colon cancer is increased in these syndromes, but the hamartomas themselves are not considered premalignant.
Cowden’s disease polyp type
Hamartomas
The risk of colon cancer is increased in these syndromes, but the hamartomas themselves are not considered premalignant.
Serrated polyps
YES risk of cancer
were once considered hyperplastic, but are now considered to be a risk factor for developing cancer .
The McBurney point is
approximately one third of the way from the iliac spine to the umbilicus.
The only modality shown to reduce the risk of urinary and sexual disfunction complication is
careful anatomic dissection at the time of surgery.
Total mesorectal resection for rectal cancer
Post-op radiation for rectal cancer association with increased risks of urinary and sexual dysfunction.
NONE
Ureteral stents or rectal cancer effect on rate of uretral injury
None
not proven to reduce the risk of ureteral injury.
best treatment for adenocarcinoma of the small bowel
Ideally, a segmental resection with a primary anatomosis is preferred when the tumor is found distal to the 3rd portion of the duodenum.
Tumors proximal to this location will likely need a Whipple procedure due to its close relationship with the ampulla and biliary tree.
T
best treatment for adenocarcinoma of the small bowel that are locally advanced
MINIMAL (ie, NOT the answer)
Studies have shown minimal benefit to adjuvant or neoadjuvant therapies in the treatment of small bowel adenocarcinoma.
may therefore be better suited for a palliative procedure to ensure no further intestinal obstructions.
This may include a duodenal bypass or a stent placement.
Gastrointestinal lymphomas
Small bowel lymphomas are more commonly from T-cell
(careful, AIDS, MALToma, and H pylori asso are B-cell; AND GASTRIC B-cell)
often present with vague abdominal pain and weakness.
most commonly occur in the ileum, where the Peyer’s patches lymph node basins exist, and can be diagnosed best on CT scan.
Biopsies can be useful to confirm the type and grade of lymphoma, which will help to guide the type of treatment.
Patients with a history of celiac disease are more likely to develop T-cell lymphoma of the small bowel.
T-cell lymphoma is associated with Celiac disease.
Answer D: B-cell MALTomas are associated with H.pylori infections.
Hinchey
I – Segmental colitis and pericolonic abscess
Hinchey II – Pelvic abscess - CAREFUL - still II even if giant sympomatic abscess if not perf
Hinchey III – Purulent peritonitis
Hinchey IV - Feculent peritonitis
Acute sigmoid diverticulitis is treated with
intravenous (iv) antibiotics and bowel rest initially.
Patients with diverticulitis complicated by an abscess should be percutaneously drained in addition to receiving iv antibiotics unless the abscess is small (< 3 cm).
Surgical intervention should be considered if the patient does not improve with iv antibiotics and percutaneous drainage.
Laparotomy and Hartmann’s resection should be reserved for patients with signs of sepsis or peritonitis.
anastamosis created in the Billroth II procedure
A gastrojejunostomy anastamosis is created in the Billroth II procedure.
(CAREFUL, this is not a gastro-d)
anastamosis created in the Billroth I procedure
A gastroduodenostomy is created in a Billroth I procedure.
ssx and presentation of duodenal stump complication after B II
Dehiscence of the duodenal closure fourth or fifth post- operative day.
Patients may present with no more than a sense of epigastric fullness and discomfort, may suddenly be seized with severe pain, abdominal rigidity, and fever, or may exhibit a shock-like state.
Peutz-Jeghers syndrome
This patient has which is an autosomal dominant (choice C) disease that has several identifying characteristics, such intestinal hamartomas (choice D) and hyperpigmented lesions of the oral mucosa.
These patients have an increased risk for a GI malignancy and a screening colonoscopy should be performed every 2 years (choice A).
There is no recommendation for any prophylactic surgery (choice E).
This syndrome has been shown to have an increased risk of extra-colonic cancers, such as breast, cervical, thyroid, and lung. Periodic screening for these cancers should begin at age 25 (choice B).
Bottom Line: Peutz-Jeghers syndrome is associated with intestinal hamartomas, hyperpigmented mucosal lesions, and has an increased risk of extra-colonic cancers.
The most common types of small bowel malignancies include
carcinoid,
adenocarcinoma,
and
stromal tumors.
most common small bowel tumor
Carcinoid tumors
look this up
Carcinoid is treated
surgically similar to that of adenocarcinoma,
in that it requires an en bloc surgical resection with full lymphadenectomy due to its preponderance to invade local lymph nodes.
EXCEPT!!!!
duodenal tumors less than 1cm, where endoscopic removal may be all that is necessary.
OTHER EXCEPTION -
debulk for carcinoid
Resection of metastatic disease has been shown to not only improve the symptoms of a carcinoid syndrome, but also improve overall survival if adequate debulking is achieved.
Octreotide has also been shown to treat the symptoms
laparoscopic appendectomy appears to offer significant advantages
women of childbearing age,
obese patients,
patients with an unclear diagnosis.
laparoscopic appendectomy
DECREASED wound infection
SHORTER length of stay
LESS narcotic
HIGHER incidence of postoperative intra-abdominal abscess
Heineke-Mikulicz Strictureplasty best suited for strictures up to
strictureplasties are best suited for strictures up to 5 to 7 cm long.
Finney strictureplasties are best suited for
up to 10 to 15 cm long.
The side-to-side strictureplasty is suitable for longer areas of stricture; however, this technique involves longer suture lines and is mainly considered for patients who already have, or are at high risk for, short bowel syndrome.
