Bowel Obstruction And Butthole Probs (Lauren 🌭) Flashcards
1
Q
What is the difference between a partial and complete bowel obstruction?
A
Fluid and air can still pass in partial
2
Q
What are the 3 ~broad~ causes of obstruction?
A
Extrinsic- something external compresses bowel (adhesions, abscess)
Intrinsic- something within the wall of bowel compresses (strictures)
Intraluminal- something like fecal impaction that prevents passage
3
Q
What happens to the bowel that is proximal to an obstruction?
A
Bowel dilatation**
Retention of fluid**
4
Q
What happens to the bowel distal to the obstruction?
A
Bowel decompresses
5
Q
What causes the distention experienced by patients with bowel obstruction?
A
Swallowed air and gas from fermentation
6
Q
In an obstruction, edematous bowel wall leads to ___________ ________
A
Fluid sequestration
7
Q
Why are people with bowel obstruction volume depleted?
A
Due to the fluid sequestration within the edematous bowel wall
8
Q
How could excessive dilatation lead to perforation?
A
It can compromise the vascular supply causing ischemia—> Necrosis —-> Perforation
9
Q
What are the top 3 causes of small bowel obstruction?
A
ADHESIONS (65-75%)***
Hernia***
Neoplasm***
**KNOW THIS*
10
Q
What causes adhesions?
A
Prior abdominal or pelvic surgery like appendectomy, GYN surgery, colorectal
11
Q
If your patient has a small bowel obstruction, what do you most expect to learn in their history?
A
They had a previous abdominal surgery
65-75% of SBO’s are caused by adhesions compressing the bowel!!
12
Q
How do post-operative adhesions cause small bowel obstruction?
A
They are fibrous bands that press down on the bowel
13
Q
Risk of adhesions following surgery increases with _______
A
Time!!!!!
After 10 years or more, youre more likely to get adhesions
14
Q
What will you find out when you ask ROS questions of someone who has small bowel obstruction?
A
+/- fevers and chills
Intermittent periumbilical cramping that turns into constant focal pain that may indicate peritonitis (Bad sign)
Bloating/distention
Anorexia (They don’t want to take anything by mouth)
Nausea
Vomiting
+/- hematochezia
Constipation
Obstipation
15
Q
What is obstipation?
A
Inability to fart or poop
16
Q
What will you find on physical exam of someone with small bowel obstruction?
A
Vitals: +/- fever, tachycardia, hypotension, shock
General: distress, *lying motionless**
Skin: decreased turgor, dry mucous membranes (VOLUME DEPLETED)
Abdominal: high pitched tinkling bowel sounds in early phase or hypoactive/absent bowel sounds in late phase ((bad sign). Tympany on percussion.
peritoneal signs- guarding, rigidity, rebound tenderness (RED FLAG)
DRE: gross/occult blood, fecal impaction or rectal mass
17
Q
What are the RED FLAGS and BAD SIGNS in the physical exam findings for small bowel obstruction?
A
Shock
Lying motionless (Peritonitis)
Hypoactive/absent bowel sounds
Peritoneal signs- guarding, rigidity, rebound tenderness
18
Q
Which will come first in abdominal ~medical~ conditions: pain or vomiting?
A
Vomiting before pain
19
Q
Which will come first in abdominal ~surgical~ conditions: pain or vomiting?
A
Pain before vomiting
20
Q
What labs will you order for SBO?
A
CBC
CMP
Amylase/Lipase
UA
Lactate/LDH
21
Q
Why might H/H and BUN/Cr be high in someone with SBO?
A
dehydration
22
Q
What can abdominal X-rays tell you about SBO, and what can they NOT tell you?
A
They can tell you if you have a SBO
They CAN’T tell you where, what’s causing it, if it’s complete, etc. You need a CT to tell you that
23
Q
What X-Ray views do you order for SBO?
A
Supine
Upright
CXR
24
Q
What will you see on X-Rays of Small Bowel Obstruction?
******
A
Dilated loops of bowel with air fluid levels**
Proximal bowel dilation with distal bowel collapse
CXR to look for free air consistent with perforation *****
KNOW THIS CARD*
25
If you have no idea wtf kind of imaging youre supposed to get but you have a very high suspicion for SBO or strangulated bowel, what should you do?
CALL A SURGEON AND LET THEM DECIDE ON IMAGING
Strangulated bowel is a surgical emergency!
26
How do you manage Small Bowel Obstruciton?
Admit
Surgery/GI consult
Trial of non-operative management
Serial clinical monitoring over the next 2-5 days: improvement evidenced by decreased distention, passage of gas/stool, decrease in NG output
27
How do you do a trial of non-operative management for SBO?
NPO
Volume **RESUSCITATION** (not maintenance fluid)
Electrolyte monitoring
Bowel decompression with NG tube set to suction
Anti-emetics, analgesics, antibiotics
28
What would make you do surgery for SBO?
Complications (ischemia, necrosis, perforation)
Intestinal strangulation
Worsening/unresolved symptoms with NG tube and bowel rest
29
What signs might make you think that your patient’s bowel obstruction has become ischemic, necrotic, or perforated?
Worsening abdominal pain
Fever
Tachycardia
Leukocytosis
Metabolic acidosis
Peritonitis
30
How will a patient with peritonitis present?
Looks sick
Lie still to minimize pain
Hypoactive/absent bowel sounds
Peritoneal signs
Significant pain with light palpating or bumps
************
31
If an adult has intussusception, what almost always causes it
Tumor
32
What is this:
| “Hypomotility of GI tract in absence of mechanical bowel obstruction”
Ileus
33
What are the two main situation where we see patient with paralytic ileus?
Postoperative abdominal surgery (inflammatory response to intestinal manipulation/trauma)
Use of hypomotility agents (opioids, antispasmodic, anticholinergics)
**************
34
How will a patient with ileus present?
Same presentation as Small Bowel Obstruction:
Pain, distention, bloating, gassy, NV, inability to tolerate PO, tympany,
35
What will you see on abdominal x ray of ileus?
Dilated loops of bowel BUT air present in BOTH small bowel and colon. NO air fluid levels
***************************
36
How do you manage ileus?
Similar to SBO:
IV fluids/Lyte replacement
Pain management (avoid narcotics)
Bowel rest
Bowel decompression with NG tube
Walk around
None of this was red or bolder
37
What is the most common cause of Large Bowel Obstructin?******
Adenocarcinoma, commonly colorectal ********!!!****
38
What are the other possible causes of LBO, other than adenocarcinoma?
Stricture
Volvulus
IBD
Fecal impaction
Foreign bodies 🍾
39
What questions should you ask a patient if you suspect large bowel obstruction?
Hx of hematochezia, bleeding, or change in stool caliber (cancer q’s)
Personal or FH of cancer
LLQ pain with diarrhea
Chronic opioid use or constipation?
None of this was in red
40
How will a patient with LBO present?
Similar to SBO:
+/- Fever/chills
Crampy pain
Bloating/distention
Constipation/Obstipation
+/- NV
Normal to quiet bowel sounds
Abdominal tenderness
+/- peritoneal signs
Hematochezia
DRE- occult blood, impaction, rectal mass
None of this was in red
41
What labs/imaging will you get if you suspect LBO?
Pretty much the same stuff as SBO:
CBC, CMP, UA, LDH/lactate
Plain abdominal films supine and upright
CXR
Gastrografin enema if x ray unclear
CT scan
None of this was in red
42
What will you see on X ray if your patient has a LBO?
Distended colon proximal to obstruction
43
How do you manage a ~partial~ Large Bowel obstruction?
Trial of conservative therapy:
Surgical consult
NPO
IV fluids
Antibiotics
Decompression with NG tube if vomiting
Avoid narcotics and anticholinergics
44
How do you treat a ~complete~ large bowel obstruction?
Depends on the cause:
Cancer- surgical resection
Stricture- surgical resection
Cecal volvulus- surgical resection
Sigmoid volvulus- sigmoidoscopy with reduction
Intussusception- barium enema
Fecal impaction- enema
45
Which is the more common type of volvulus: sigmoid or cecal?
Sigmoid
46
What is this:
| Abnormal twisting of a portion of the GI tract, usually the intestine, which can impair blood flow
Volvulus
47
What are the mean age groups that get sigmoid volvulus vs cecal volvulus?
Sigmoid: 70 yrs, constipated
Cecal: 33-53yrs
48
What are teh risk factors for sigmoidal volvulus?
Chronic constipation
Redundant sigmoid colon
Colon dysmotility
Hypomotility agents
49
How does the management of volvulus differ between sigmoid and cecal volvuli?
Sigmoid: flex sig to decompress and de-rotate. Surgery to resect redundant sigmoid colon
Cecal: surgery
50
What is the dentate line?
Line in anus that separates area of pain and no pain
51
What are the RED FLAGS of anorectal complaints that require PROMPT REFERRAL to a GI/colorectal specialist?
Unintentional weight loss
Iron deficiency anemia
Personal or FH of IBD or colorectal cancer
Persistent anorectal bleeding or symptoms despite adequate treatment of a suspected benign condition
52
Are hemorrhoids rare or common?
Common
| Idk she put this in red
53
Does everyone technically have hemorrhoids?
Yes they are normal vascular structures that arise from a fibrovascular cushion. They protect the anal canal when you poop and help maintain continence.
They become symptomatic when the supporting structures of hemorrhoidal tissue (i.e. anal cushions) deteriorate
54
Is today the first day you have ever heard about anal cushions?
😃
55
Which is painless: internal or external hemorrhoids
```
Internal hemorrhoids (proximal to dentate line)
*******
```
56
Why are external hemorrhoids painful?
Because they are distal to the dentate line
| ******
57
What are the 4 grades of hemorrhoids?
Grade I: bulge in anal canal without prolapse
Grade II: Prolapse that reduced spontaneously
Grade III: Prolapse that requires manual reduction 🤮
Grade IV: Prolapse that is impossible to reduce
58
How will a patient with hemorrhoids present?
BLEEDING when they poop, usually bright red*** 🖍
+/- sensation of Perianal fullness (Prolapse***)
+/- PRURITUS***
+/- fecal incontinence
+/- mucoid discharge/seepage 👅
+/- acute perianal pain and palpable lump if thrombosed
First 3 things were in RED
59
What color are prolapsed internal hemorrhoids
Red
60
What color are thrombosed external hemorrhoids?
Blue
61
According to the ACG 2014 Guidelines, when do you need to do a sigmoidoscopy for a patient that presents with hemorrhoid-pattern bleeding?
Every time. Must rule out other anorectal pathology
62
If you are concerned that a hemorrhoid patient may have IBD or malignancy because they have some RED flags, what do you need to do instead of a sigmoidoscopy?
Colonoscopy
63
What is the treatment for symptomatic hemorrhoids?
Diet and lifestyle mods (ALL patients)
Conservative medical therapies
Office-based procedures
Surgery
64
What kind of dietary and Lifestyle modifications are appropriate for the management of ALL grades of hemorrhoids?
FLUID AND FIBER (dietary/bulk laxatives)***** IN RED🥬🥦🌿💧
Toilet habits (don’t strain or sit there forever like Alex)⏱
Sitz baths 🛀🏻
65
What are the “conservative medical therapies” we can do for hemorrhoids?
Stool softeners
Tucks Pads (anesthetic)
Short course of steroid creams or suppositories****** IN RED
Antispasmodics like nitroglycerin ointment
66
What are the “Office-based Procedures” we can do to treat patients with refractory hemorrhoids?
Internal roids:
Rubber band ligation (banding)***** IN RED
Infrared coagulation
Sclerotherapy
External roids:
Excision of thrombosed external hemorrhoid 🔪
67
What is the most commonly used technique for the treatment of symptomatic bleeding internal hemorrhoid ?
Rubber band ligation
68
When do you need to do surgery for hemorrhoids?
Persistent symptoms no matter what you do
Symptomatic grade III roids
Grade IV internal roids
Extensive pain from thrombosed eternal roids
69
All patients with hemorrhoids, no matter how bad they are, need to be counseled on _____ _______ _____ _____ ______
Adequate fiber and fluid intake*********RED
70
What are the three most common symptoms/signs of hemorrhoids?
Bleeding
Prolapse
Anal itching
******RED*******
71
A patient presents with painless rectal bleeding and perianal itching with evidence of a Grade II internal hemorrhoid. What recommendation is most appropriate initially?
High fiber and fluid diet
72
What is pruritus ani?
Itchy asshole
73
What are some mechanical causes of pruritus ani?
Prolapsing tissue
Fecal incontince/soiling
Inadequate hygiene
Swamp ass
Mucus or stool between buttocks
So this is what my life has come to
74
What will you see if you look at the butthole of someone with pruritus ani?
Circumferential erythematous and irritated perianal skin
75
How do you manage pruritus ani?
Eliminate offending agent
Proper hygiene: gentle cleansers, avoid aggressive wiping and overzealous hygiene, sitz baths
Keep region dry
Eliminate tight clothing
Topical astringent (witch hazel) or barrier (zinc oxide)
SHORT course of topical steroids
(None of this was in red)
76
Are perianal skin tags caused by an STI or anal sex?
No
77
What are perianal skin tags?
Outgrowth of normal skin
Can be caused by thrombosed external roids or Crohn disease
Probably the grossest picture i have seen in PA school yet
78
How do you treat perianal skin tags, even though treatment is not usually indicated?
You can refer them for excision if they interfere with hygiene or cause discomfort
79
What is this:
“Linear tear, or split, in the lining of the anal canal distal to the dentate line that causes *spasm* of the anal sphincters”
Anal fissure
| *****************
80
What is the most common cause of severe anorectal pain?
| *************
Anal fissure
| ************
81
What causes anal fissure?
Local trauma to the anal canal (passage of giant turds or dildos/negro modelo bottles)**
Crohn Disease****
Malignancy
HIV/AIDS
82
What is the reason for decreased blood flow and delayed healing of anal fissures?
Pain is so bad that it causes the sphincters to spasm, decreasing the blood flow and preventing healing
83
How will a patient describe the pain of an anal fissure?
“Like passing glass”
“Sitting on a knife” 🔪🛋
84
What is the most common location for an anal fissure?
Posterior midline************
85
Why is the posterior midline the most common place for an anal fissure?
Lowest blood supply
86
If a patient has recurrent/multiple anal fissures, or an anal fissure NOT in the posterior midline, what should you be concerned about?
Perianal Crohn’s
87
How do you manage anal fissures?
Adequate fiber/fluid
Proper hygiene
Sitz baths
Stool softeners
Topical lidocaine
Topical vasodilators to reduce spasm and increase blood flow (nifedipine or nitroglycerin ointment)
Surgery if refractory
88
What kind of surgery may be done for recurrent anal fissures?
Sphincterotomy for patients with low risk of developing fecal intcontinence
89
What kind of exams/imaging would you use to evaluate an anal fissure?
DRE/anoscopy (often too painful to tolerate)
Flex Sig/Colonoscopy if unsure/recur
90
Perianal abscess orignates from what?
Obsrtructed or infected anal crypt gland
91
Chronic perianal abscesses can progress to form ___________
Fistulas*******
92
Can Perianal abscesses be associated with Crohn’s?
Yes ***************
93
How will a patient with a perianal abscess present?
Pain +/- drainage, constitutional symptoms
Red, palpable, fluctuant mass with surrounding edema
94
What kind of imaging may be done for a perianal abscess>
CT or MRI pelvis to determine extent
95
How do you manage a perianal abscess?
Incision and drainage
+/- antibiotics
Postoperatively: sitz baths and adequate fluid and fiber
96
Fistulas/abscesses/fissures that recur should always make you think about WHAT
CROHNS***************
97
What is an anorectal fistula?
Abnormal communication between anal canal and the perianal area.
It is a chronic manifestation of a perianal abscess
98
What other conditions can be associated with anorectal fistulas?
Crohn Disease********
Radiation proctitis
Diverticulitis
99
How will someone with an anorectal fistula present?
Chronic drainage of blood/pus/stool from fistula, rectal pain, itching, swelling, fever
Perianal skin may be excoriated or inflamed
Palpable cord beneath the skin between anus and abscess opening
100
If someone shows up with an anorectal fistula and you are concerned about IBD, what should you do?
COLONOSCOPY
| ******************
101
What kind of imaging may be done to evaluate a complex or recurrent anorectal fistula?
MRI pelvis
102
What is the mainstay therapy for an anorectal fistula?
Surgical Fistulotomy (unroofing the fistula tract to allow healing)
103
What are anal condyloma?
Anal warts
104
What virus causes anal condyloma?
HPV *********
105
“Cauliflower like appearance, in clusters of single entities”
Anal condyloma
106
Are anal condylomas that bad?
Not really, but may be risk for anal cancer.
107
What are your options for removing anal condylomas?
Topical podofilox
Topical imiquimod
Trichloroacetic acid
Surgical removal
(This is probably not on the test)
108
Most anal cancers are (columnar/squamous) cell cancers
Squamous cell ***************
109
What populations of people are at an increased risk of Anal Cancer?
- have receptive anal sex
- history of anal condyloma
- history of HPV or HIV
110
How will anal cancer present?
+/- rectal bleeding, anorectal pain, sensation of rectal mall
+/- anal warts, perianal skin irritation, hard, friable or ulcerating lesions
+/- inguinal lymphadenopathy**
111
What do you need to check for if you have a patient walk in with some anal warts
Inguinal lymphadenopathy
112
How do you manage anal cancer?
REFER
113
What is the pathophysiology of Rectal Prolapse?
Pelvic flor disorder
Rectal tissue protrudes through anus
May come along with chronic constipation, straining, multiple vaginal births, or prior pelvic surgery
114
How will a patient with rectal prolapse present?
Constipation or fecal incontincenc
Incomplete bowel evacuation
Seepage
“Mass” protruding through anus
On DRE, mucosa of rectal wall may feel floppy or loose with redundant tissue
115
What is defecography?
You literally look at their asshole while they take a shit
116
What two diagnostic studies may be done to diagnose rectal prolapse?
Defecography
Anorectal manometry
Ew
117
What is the treatemnt for rectal prolapse?
Prevent constipation-increase fiber and fluid
Surgical repair is mainstay
118
What is a rectocele?
Weakened fascia allows the rectum to bulge into vagina
119
What can cause rectocele?
Vaginal delivery
Increasing age
Fat
120
What might a patient tell you if she has a rectocele?
That she needs to apply pressure on her vagina, rectum, or perineum in order to defecate
121
What is a rectovaginal examination?
Asking a patient to bear down and looking for a bulge of rectum into vagina
122
A 67 year old female with a history of multiple vaginal births present with chronic constipation and complaints of fecal incontinenece. What may you find on physical exam?
Rectal prolapse
123
Anorectal symptoms require a _______history and _______exam
Thorough
Focused
124
If unsure of diagnosis, _______ to gastroenterologist/colorectal surgeon
Refer
