Casefiles 8: UC, Crohn, Diverticulitis, Anorectal disease Flashcards
surgery for UC pts with UC pan colitis (involvement extending from the rectum to the distal small bowel)
Proctocolectomy with ileal pouch reconstruction
The extracolonic manifestations of UC may include ?
skin: erythema nodosum and pyoderma gangrenosum, psoriasis stomatitis
joints: ankolysing spondylitis and sacroiliitis
eyes: uveitis, scleritis, and optic neuritis
GI: primary sclerosing cholangitis, autoimmune hepatitis, and pancreatitis
what 2 malignancies may cause appendicitis in kids?
carcinoid and lymphoma
the AGA recommends that patients with at least 1/3 of their colon involved with UC undergo initial screening colonoscopy and multiple quadrants biopsies ? after disease diagnosis, followed by subsequent surveillance colonoscopies with biopsies every ?
8 years
1 to 3 years
UC is linked to ?
GI infections (Salmonella or Campylobacter)
NSAIDs
antibiotics (tetracyclines)
Histologically, UC differs from Crohn disease in that the disease is ? as opposed to ? in Crohn disease
limited to the mucosa
transmural
anatomic extent of UC can be described as ?
anatomic extent of UC can be described as proctitis (rectal involvement only), proctosigmoiditis (rectum and sigmoid colon), left-sided disease (disease does not extend beyond the splenic flexture), extensive colitis (disease extends beyond the splenic flexture), and pancolitis (disease extends all the way to the ileal–cecal valve)
Patients with mild-to-moderate disease are often treated with ?
5-ASA, NSAIDs, Immunosuppressive agents such as thiopurines and anti-TNF antibody (infliximab)
Patients who present with fulminant colitis associated with UC are treated with ?
1/3 may not respond, tx how?
IV steroids
infliximab, intravenous cyclosporine, or surgical resection will need to be expeditiously implemented.
The main indications for surgical therapy in UC are ?
? of patients with the UC may require colectomy
fulminant colitis, toxic megacolon, dysplasia or cancer, and intractable disease
10% to 15%
UC sx
http://casefiles.mhmedical.com/ViewLarge.aspx?figid=130869547&gbosContainerID=92&gbosid=246090
new selective adhesion molecule inhibitor; blocks leukocyte migration that, which is believed to be a cause of inflammation associated with UC
vedolizumab
The most commonly performed operation for the treatment of fulminant colitis is ?
total abdominal colectomy with end ileostomy formation
the mainstay of therapy for patients with diverticulitis
broad-spectrum coverage targeting Gram-negative organisms and anaerobes:
2nd/3rd gen. cephalosporin + metronidazole, fluoroquinolone + metronidazole, or single agent such as meropenem, amoxicillin/clavulanate
diverticular phlegmon
what condition does it present like?
an inflammatory mass related to diverticulitis
diff to ddx from colorectal cancer; therefore, patients with diverticular phlegmon will need colonoscopy to evaluate the area after the acute inflammation has resolved (usually in 4 to 6 weeks)
how a colovesicular fistula presents
pneumaturia (air passage during urination), fecaluria (passage of stool in urine), or recurrent UTIs
other diverticulitis tx
oral abx rifaximin or rifaximin + fiber administration following bouts of diverticulitis improved patients’ symptoms
Mesalazine (an anti-inflammatory agent) and probiotics; associated with the reduction in symptoms recurrences
Patients who present with ? frequently require urgent operations to control the sources of sepsis. In most cases, the operations consist of ?
Hinchey class III or class IV disease segmental colon resection with formation of a temporary end-colostomy (Hartmann’s procedure) which can be reversed after pts recover from infection
new diverticulitis operation
laparoscopic peritoneal lavage with placement of drains to minimize the intraperitoneal infections
what makes diverticulitis complicated
perforation with peritonitis, abscess, obstruction, fistula
the current recommendations are to ? so that a rational decision can be made for each individual patient
discuss the pros and cons of elective resections and expectant management with patients
many surgeons elect for colectomy for patients after four episodes of diverticulitis
What is the most common cause of GI tract fistulas?
Diverticulitis
only ? of patients with diverticulitis ultimately require surgical therapy
10% to 15%
the most common anorectal-related complaints
Anal fissure, hemorrhoids, fistula-in-ano, perirectal abscess, and anorectal neoplasms
underlying problem causing anal fissures
non-healing of the skin or mucosal tear at the anal verge secondary to hypertonic (spasms) anal sphincter muscles
what are hemorrhoids?
fibrovascular cushions that are normal parts of the anal canal near the dentate line.
The 3 cushions are located right-anterior, right-posterior, and left-lateral
Abnormal enlargement of the hemorrhoidal venous plexus can occur due to ?
symptoms?
diarrhea, constipation, obesity, and increased abdominal pressure
itching, pain (mostly associated with thrombosis), bleeding, and prolapse
anorectal/perirectal abscess originate ?
originate in the cryptoglandular area above the dentate line, within the rectum
perianal (superficial at the anal verge)
submucosal (just under the mucosa in the rectum)
intersphincteric (between the internal and external sphincters)
ischiorectal (lateral to the rectal sphincter muscles and in the ischiorectal fat)
supralevator (deep above the levator muscles)
fistula-in-ano types
Intersphincteric: btw the internal and external sphincters
Transphincteric: through the internal and external sphincter muscles
Extrasphincteric (suprasphincteric): this can be a rectal opening above the sphincter muscles to an opening lateral to the sphincters
A loop of plastic or silicone (commonly a “vessel loop”) that can be placed into the fistula-in-ano
Seton
can be helpful as mechanism of drainage or it can serve as a marker or to cause chronic granulation/fibrosis along the fistula
LIFT procedure
ligation of intersphincteric fistula tract
banding or ablation can be used for what type of hemorrhoids?
alternative techniques ?
internal
can also be ablated with injections of sclerosant agents or application of infrared energy
pulsion diverticula happen where in the esophagus vs traction diverticula
top and bottom 1/3 of esophagus
middle 1/3 esophagus
anal fissure treatment
Sitz baths, stool softeners, suppositories, increase dietary fiber intake, stool bulking agents
Topical nitroglycerine ointment or topical nifedipine ointment
chronic anal fissure treatment (greater than 6-8 weeks)
botulinum toxin injection or lateral internal sphincterotomy can be helpful
? are almost never palpable on digital rectal examination (DRE), and everything palpable on DRE is a ? until proven otherwise
Hemorrhoids
neoplasm
A thrombosed external hemorrhoid not responding to medical therapy should be treated by ?
excision rather than incision and drainage because drainage alone is associated with a high rate of recurrence
poor fascial/wound healing is associated with ?
smoking, diabetes, COPD, CAD, malnutrition, infection, immunosuppression, low serum albumin, chronic steroid use, obesity, and advanced age
care of pt with enterocutaneous fistula
(1) control sepsis; (2) stabilize fluid/electrolyte abnormalities; (3) nutritional support (given as enteral, parenteral, or combined); (4) control of spillage including wound care, skin care, and pharmacologic control; (5) definitive repair (if necessary)
“hostile abdomen” occurs between ? to ? after an abdominal operation, there are a combination of inflammatory changes and fibrosis in the peritoneal cavity, and as the result of these processes, surgical dissections tend to be bloody and injuries to intestines can occur more easily
7 days to 28 days
CDC surgical wound classification
Class I: clean (wound infection rate of 1%-5%)
Class II: clean-contaminated (wound infection rate of 3%-11%)
Class III: contaminated (wound infection rate of 10%-17%
Class IV: dirty or infected (wound infection rate of 27%)
phases of wound healing
inflammatory
proliferation
remodeling (maturation)
primary repair of fascial defects greater than ? in diameter is associated with high recurrences
2 cm
therefore, placement of either prosthetic material, biologic material, or component separations are recommended for the larger hernias
don’t use what type of suture in heavily infected operative field
braided, nonabsorbable suture material
it is associated with the trapping of tissue debris within the suture material
FAST looks at what areas in the abdomen?
sub-xiphoid, RUQ, LUQ, pelvis
can see above 250cc
