Casefiles 8: UC, Crohn, Diverticulitis, Anorectal disease

Question 1

surgery for UC pts with UC pan colitis (involvement extending from the rectum to the distal small bowel)

Answer 1

Proctocolectomy with ileal pouch reconstruction

Question 2

The extracolonic manifestations of UC may include ?

Answer 2

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

Question 3

what 2 malignancies may cause appendicitis in kids?

Answer 3

carcinoid and lymphoma

Question 4

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 ?

Answer 4

8 years

1 to 3 years

Question 5

UC is linked to ?

Answer 5

GI infections (Salmonella or Campylobacter)
NSAIDs
antibiotics (tetracyclines)

Question 6

Histologically, UC differs from Crohn disease in that the disease is ? as opposed to ? in Crohn disease

Answer 6

limited to the mucosa

transmural

Question 7

anatomic extent of UC can be described as ?

Answer 7

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)

Question 8

Patients with mild-to-moderate disease are often treated with ?

Answer 8

5-ASA, NSAIDs, Immunosuppressive agents such as thiopurines and anti-TNF antibody (infliximab)

Question 9

Patients who present with fulminant colitis associated with UC are treated with ?
1/3 may not respond, tx how?

Answer 9

IV steroids

infliximab, intravenous cyclosporine, or surgical resection will need to be expeditiously implemented.

Question 10

The main indications for surgical therapy in UC are ?

? of patients with the UC may require colectomy

Answer 10

fulminant colitis, toxic megacolon, dysplasia or cancer, and intractable disease
10% to 15%

Question 11

UC sx

Answer 11

http://casefiles.mhmedical.com/ViewLarge.aspx?figid=130869547&gbosContainerID=92&gbosid=246090

Question 12

new selective adhesion molecule inhibitor; blocks leukocyte migration that, which is believed to be a cause of inflammation associated with UC

Answer 12

vedolizumab

Question 13

The most commonly performed operation for the treatment of fulminant colitis is ?

Answer 13

total abdominal colectomy with end ileostomy formation

Question 14

the mainstay of therapy for patients with diverticulitis

Answer 14

broad-spectrum coverage targeting Gram-negative organisms and anaerobes:
2nd/3rd gen. cephalosporin + metronidazole, fluoroquinolone + metronidazole, or single agent such as meropenem, amoxicillin/clavulanate

Question 15

diverticular phlegmon

what condition does it present like?

Answer 15

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)

Question 16

how a colovesicular fistula presents

Answer 16

pneumaturia (air passage during urination), fecaluria (passage of stool in urine), or recurrent UTIs

Question 17

other diverticulitis tx

Answer 17

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

Question 18

Patients who present with ? frequently require urgent operations to control the sources of sepsis. In most cases, the operations consist of ?

Answer 18

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

Question 19

new diverticulitis operation

Answer 19

laparoscopic peritoneal lavage with placement of drains to minimize the intraperitoneal infections

Question 20

what makes diverticulitis complicated

Answer 20

perforation with peritonitis, abscess, obstruction, fistula

Question 21

the current recommendations are to ? so that a rational decision can be made for each individual patient

Answer 21

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

Question 22

What is the most common cause of GI tract fistulas?

Answer 22

Diverticulitis

Question 23

only ? of patients with diverticulitis ultimately require surgical therapy

Answer 23

10% to 15%

Question 24

the most common anorectal-related complaints

Answer 24

Anal fissure, hemorrhoids, fistula-in-ano, perirectal abscess, and anorectal neoplasms

Question 25

underlying problem causing anal fissures

Answer 25

non-healing of the skin or mucosal tear at the anal verge secondary to hypertonic (spasms) anal sphincter muscles

Question 26

what are hemorrhoids?

Answer 26

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

Question 27

Abnormal enlargement of the hemorrhoidal venous plexus can occur due to ?
symptoms?

Answer 27

diarrhea, constipation, obesity, and increased abdominal pressure
itching, pain (mostly associated with thrombosis), bleeding, and prolapse

Question 28

anorectal/perirectal abscess originate ?

Answer 28

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)

Question 29

fistula-in-ano types

Answer 29

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

Question 30

A loop of plastic or silicone (commonly a “vessel loop”) that can be placed into the fistula-in-ano

Answer 30

Seton
can be helpful as mechanism of drainage or it can serve as a marker or to cause chronic granulation/fibrosis along the fistula

Question 31

LIFT procedure

Answer 31

ligation of intersphincteric fistula tract

Question 32

banding or ablation can be used for what type of hemorrhoids?
alternative techniques ?

Answer 32

internal

can also be ablated with injections of sclerosant agents or application of infrared energy

Question 33

pulsion diverticula happen where in the esophagus vs traction diverticula

Answer 33

top and bottom 1/3 of esophagus

middle 1/3 esophagus

Question 34

anal fissure treatment

Answer 34

Sitz baths, stool softeners, suppositories, increase dietary fiber intake, stool bulking agents
Topical nitroglycerine ointment or topical nifedipine ointment

Question 35

chronic anal fissure treatment (greater than 6-8 weeks)

Answer 35

botulinum toxin injection or lateral internal sphincterotomy can be helpful

Question 36

? are almost never palpable on digital rectal examination (DRE), and everything palpable on DRE is a ? until proven otherwise

Answer 36

Hemorrhoids

neoplasm

Question 37

A thrombosed external hemorrhoid not responding to medical therapy should be treated by ?

Answer 37

excision rather than incision and drainage because drainage alone is associated with a high rate of recurrence

Question 38

poor fascial/wound healing is associated with ?

Answer 38

smoking, diabetes, COPD, CAD, malnutrition, infection, immunosuppression, low serum albumin, chronic steroid use, obesity, and advanced age

Question 39

care of pt with enterocutaneous fistula

Answer 39

(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)

Question 40

“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

Answer 40

7 days to 28 days

Question 41

CDC surgical wound classification

Answer 41

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%)

Question 42

phases of wound healing

Answer 42

inflammatory
proliferation
remodeling (maturation)

Question 43

primary repair of fascial defects greater than ? in diameter is associated with high recurrences

Answer 43

2 cm
therefore, placement of either prosthetic material, biologic material, or component separations are recommended for the larger hernias

Question 44

don’t use what type of suture in heavily infected operative field

Answer 44

braided, nonabsorbable suture material

it is associated with the trapping of tissue debris within the suture material

Question 45

FAST looks at what areas in the abdomen?

Answer 45

sub-xiphoid, RUQ, LUQ, pelvis

can see above 250cc