clin med second two lectures Flashcards
Complication of bowel obstruction
ischemia –> necrosis –> PERFORATION
Etiology of SBO
ADHESIONS
Other etiology of SBO
Hernia
CA
At first periumbilical, intermittent, “cramping” pain
THEN
more focal and constant (indicate peritonitis)
SBO clinical presentation
Red flag bad signs of SBO
fever, tachy, hypOtension
lying motionless
high pitched tinking bowel sounds –> hypoactive/absent in later stages
Peritoneal signs- guarding, rigid, rebound tenderness
SBO Imaging
XRAY:
dilated loops of bowel, air fluid levels
Free air= perforation
Tx of SBO
Admit (NPO, IVF, bowel decompression w NG tube, nausea, pain meds, Abx maybe, Gastrografin maybe)
TRY NON-OP first
monitor 2-5 days
Indications for surgery in treating SBO
Complicated
Intestinal strangulation
Worsening/unresolved
obstipation
severe or complete constipation
What can we use to identify location, etiology, severity, and complications of SBO?
CT
Ileus etiology
POST-OPERATIVE
Ileus
an inflammatory response to recent manipulation and trauma
Other cause of ileus
Hypomotility agents (opioids, anticholinergic, etc)
Clinical presentation: abd pain, distension, bloating, “gassy”, n/v, can’t tolerate PO
Ileus
Tympanic abdomen
air filled
found with Ileus
X ray shows dilated loops but air is present in BOTH small and large bowel
NO AIR FLUID LEVELS
Ileus
Tx of Ileus
Supportive- IVF, lyte replace, pain, bowel rest, bowel decompression w NG tube prn, serial X rays, ambulate
LBO etiology
Adenocarcinoma
LLQ pain w diarrhea
recent frank bloody stool w diarrhea
Concerning for LBO
Crampy abd pian Bloating Constipation Norm/quiet bowel sounds Hematochezia
LBO
LBO tx
Partial: try conservative first. NPO, IVF, Abx, Decomp w NG
Complete: depends on cause, most of the time surgical resection is the answer.
Volvulus
abn twisting of GI tract, can impair blood flow
Subtypes: sigmoid, cecal
More common subtype of Volvulus
SIGMOID
Sigmoid volvulus (more common)
70YO
crampy abd pain, n/v, pain b4 vomiting, constipation, TTP
Tx: Flex sig and then surgery
Cecal volvulus
35-53 YO, younger
Episodic pain to acute abdominal catastrophe!
Tx: Surgery
Position for rectal exam
Left lateral decubitis
Red flags (Anorectal complaints) that should warrant prompt GI/Colorectal referral
Wt loss (unintentional)
Iron def anemia
Personal/FH IBC or CRC
Persistent anorectal bleeding or sx despite tx
Hemorrhoid peak age
45-65YO
Hemorrhoids become symptomatic when
supporting structures of hemorrhoidal tissue (anal cushions) deteriorate
External hemorrhoids
Distal to dentate line
PAINFUL
Internal hemorrhoids
Proximal to dentate line, painless
4 grades of Internal hemorrhoids
1: bulge without prolapse
2: prolapse that reduces spont
3: prolapse requires manual reduction
4: chronic, irreducible
Bright red blood w BM
Fullness
maybe itching
Hemorrhoid clinical presentation
Hemorrhoid pattern bleeding mandates AT LEAST
SIGMOIDOSCOPY to r/o other pathology
If concerns of IBD or CA when thinking hemorrhoids, must get
Colonoscopy
Conservative med tx for Hemorrhoids
Stool softener
SHORT COURSE Steroids or suppositories
Nitroglycerin ointmentm(antispasmodic)
Tx for refractory hemorrhoids
Internal
- Rubber band ligation
- Infrared coag
- Sclerotherapy
External
-Excision
Most commonly used technique for tx of Symptomatic Bleeding Internal Hemorrhoids
Rubber band ligation
When to get surgical Hemorrhoidectomy
Persistent despite tx
Sx w/ GRADE 3
GRADE 4 internal
Extensive pain
What do we always suggest first with hemorrhoids?
High fiber, fluid
Pruritis Ani
often dev from local irritation of skin –> inflammation
Intense itching, burning
Circumf erythematous and irritated perianal skin
Pruritis Ani
Tx of Pruritis Ani
Stop offending agent Hygiene Keep dry Elim tight clothing Topical astringent or topical barrier Short course steroid cream (for severe eruptions)
Perianal skin tag
Sequelae of thrombosed external hemorrhoids or Crohns
Loose, flesh colored, pedunculated
Tx usually not indicated, can excise if interefering w hygeine or causing discomfort
Anal fissure
linear split or tear DISTAL to dentate line causing: Spasm of anal sphincter
Most common cause of SEVERE Anorectal pain
Anal fissure
Etiology of Anal fissure
Mostly: local trauma, hard stools FB
Also: Crohns dz***, CA, HIV/AIDs
Severe pain during and right after defecation
“passing glass” “sitting on a knife”
Bright red blood on toilet paper
Anal fissure
Most common place for Anal fissure
Posterior midline
lowest blood supply
Dx Anal fissure
DRE/Anoscopy
Flex sig/Colonoscopy if unsure
Anal fissure tx
Fiber/fluid, hygeien, sitz bath, stool softener
Topical analgesic (lidocaine), Topical vasodilator (reduce spasm and increase blood flow)
If chronic/refractory: surgery
Sphincterotomy
Perianal abscess
Obstructed/infected Anal crypt gland
can turn into Fistula
Can be associated w CROHNs dz
Conditions assoc w CROHNs dz
Peri-anal abscess
Fistula
Fistula
abn communication b/w anal canal and peri-anal area
chronic manifestation of abscess
Chronic drainage of blood or pus, pain, itching, swelling, FEVER
Ano-rectal fistula
Ano-rectal fistula tx
SURGICAL FISTULOTOMY
Anal condyloma (HPV warts)
Itchy
cauliflower like
Anoscopy
Tx for HPV- anal condyloma
Removal/desturction
Topical PODOFILOX or IMIUQUIMOD
Office tx for HPV anal warts
Trichloroacetic acid
can also surgically remove
Most ANAL CA is:
Squamous cell
Risk factors increasing incidence of Anal CA
Anal intercourse
Hx of Anorectal condyloma
HPV/HIV hx
Maybe the following:
rectal bleeding, pain, rectal mass, FRIABLE or ULCERATING lesions
Palpate for inguinal lymphadenopathy
Anal CA
Anal CA tx
Biopsy, scope
Chemo/Radiation
Surgery
Rectal prolapse
Pelvic floor disorder
Rectal tissue protrudes through ANUS
DRE shows mucosa of rectal wall FLOPPY or LOOSE w redundant tissue
Rectal Prolapse
Mainstay of tx for Rectal prolapse
SURGICAL repair
Can also increase fiber and fluid, prevent constipation/straining
Rectocele
Rectum bulges INTO VAGINA
cause: vaginal birth, increasing age, obesity
On exam, Pt bears down and you see bulge of rectum into vagina
Rectocele
Tx for Rectocele
Pelvic floor muscle training
Pessary
