Colon, Rectum, Anus Flashcards
How does appendiciits happen?
Fecalith obstructs (adults)/lymphoid aggregates post diarrhea (kids)–> obstruction distention–>edema and inflammation–>irritation of parietal peritoneum–> ischema,infarct–>perforation
Periumbilical abdominal pain moves to RLQ
Appendicits
Why is it that if there distention in the colon due to irritation/infection, then why doesnt it extend to the intestines?
Ileocecal valve prevents reflux of air
Most common causes of a large bowel obstruction?
In US: Colorectal cancer
Global: sigmoid volvulus
How do you work up a large bowel obstruction?
xray to look for distention and air
then CT w/IV contrast
Whorl sign
Swirling appearence of mesentary suggestive of a volvulus
Coffee bean on xray
sigmoid volvulus
Internal or External Hemerroids: Bleed but do not hurt
Internal! No somatic innervation above the pectinate line
Internal or External Hemerroids: Bleed and hurt
External!
Problem for hairy ass’d people
pilonidal disease
Infection of sinus tracts on butt
pilonidal disease
HPVs that are associated w/anal sex
16, 18, and other
What are some major risk factors for anal cancer?
HIV+ and anal receptive sex
What is this characteristic of?
“There are subcutaneous sinuses that open onto pits found midline in the intergluteal fold. These pits, sinuses, and tracts (all the same thing) can have hair grow into them. There can also be skin, debris, and fluid. These sinuses chronically drain and can become acutely infected. The pits go unnoticed and unseen until an abscess forms. The abscess is treated like any other, with incision and drainage.”
Pilonidal disease
What medical therapies help with anal fissures?
Dietary changes and regular defecationwill prevent the fissure from worsening. Then, it is all about relaxation of the anal sphincter. Medical therapy, including topical nitroglycerin, calcium-channel blockers (nifedipine), and botulinum toxin injections (try topical agents first), should be exhausted before going to surgery.
diverticulitis
Autoimmune disease that causes shallow, broad-based ulcers starting in colon and are continuous through the proximal colon Pt presents w/ Abdominal pain, bloody diarrhea, no malabsorption
Dx:Colonoscopy = Broad-based ulcers, pseudopolypsBiopsy = Crypt abscesses
Ulcerative colitis
How does the presentation differ in left versus right sided colon cancer?
Left-sided colon cancer obstructs, and stricture causes pencil-thin stools, alternating constipation with diarrhea
Right-sided colon cancer bleeds
How do we make sure dx before rushing domone off for an appendectomy?
Though point-of-care ultrasound may eventually replace CT for the diagnosis of acute appendicitis, CT remains the best radiological test to diagnose and stage the disease (just use low-dose radiation CTs).
What are the hichney stages?
Its used to assess diverticulitis
Which hichney stage gets you to the OR?
3 and 4
Hinchey stage 0 does not need treatment, Hinchey stage 1 needs antibiotics and bowel rest, Hinchey stage 2 needs IV antibiotics and a drain, and Hinchey stages 3 and 4 need sigmoidectomy.
What is the process for treating anal fissures?
Anal fissures are treated first by getting the stool soft and bowel movements frequent;
second by relaxing the anal sphincter with topical medications or botulinum injections;
finally by performing a lateral internal sphincterotomy.
How can you discern an ileocecal volvulus on XR?
There is distension of the proximal colon (the dilation is on the left side of the image, right side of the patient) without gas patterns for the transverse, descending, or sigmoid colon, indicating that this is an ileocecal volvulus (cecal volvulus)
deep palpation of the LLQ leading to RLQ pain . . . which is a more brutal version of the rebound method described in Approach to Abdominal Pain; do not perform a maneuver to elicit this sign
Rovsings sign
appendicitis
elicited by passive extension of the hip
psoas sign
appendicitis
passive internal rotation of a flexed hip elicits pain
obturator sign
Uncomplicated appendicits doesnt need surgery. What do we mean by uncomplicated?
Uncomplicated appendicitis is inflamed and swollen but without necrosis/perf
What are the theorized causes of anal fissures?
The cause is unknown, but several theories exist. The initial tear is likely a result of antecedent constipation. A big, hard stool is passed through the sphincter and the sphincter tears. However, because so many successful medical therapies involve relaxation of the sphincter muscle, another potential cause is a hypertonic anal sphincter (insert inappropriate tight ass joke here). The patient will complain of intense pain with defecation that lasts for hours. These patients tend to associate defecation with pain, so they voluntarily withhold stool, making constipation—and the fissure—worse.
Where is UC lesions vs crohn?
UC= COLON
Crohn=ANYWHERE mouth to anus
Depth of invasion: UC v crohn
UC= mucosa only
crohn=transmural
Diffuse continuous lesions: UC or crohn
Diffuse=UC
Crypt abscesses
UC
Skip lesions
crohn
When is cancer a problem in IBD?
when it involves the colon, so in all UC and in some CROHN
REctal exam shows an exquisitely tender, purple mass just below the dentate line. What is your next step in managment?
hemorrhoidectomy (not rubber band ligation)
this is a thrombosed external hemorrhoid
Right-sided colon cancers _______________, left-sided colon cancers ______________.
R bleed, L obstruct
L or R sided colon cancer: iron deficiency anemia
R sided bleeds, bleeding causes iron-deficiency anemia in a man or postmenopausal woman.
L or R sided colon cancer: pencil thin stools
Obstruction alters the caliber of stools (pencil thin)
First line medical management of UC
UC (Ulcerative colitis)
Salicylates (5-asa, mesalamine)
When do we start screening with a colonoscopy in a person with UC?
In a person with ulcerative colitis, we start 8 years after dx and q1yr until soemthing bad is found
Most common site of colon volvulus
sigmoid colon
Coffee bean on xr
Diverticula appear where luminal pressures are highest, in the _____________________
sigmoid colon
What is the approach for treating diverticulitis
If there are only microperforations (the peritoneum is not perforated and infection is contained), as evidenced by the absence of free air under the diaphragm or diffuse peritonitis, the patient can be treated with IV Abx alone if there is no abscess, and IV Abx + perc drain if there is an abscess. If macroperforations are present(diffuse peritonitis) then IV Abx with sigmoid resection is preferred.
Anal cancer can be screened for with
Anal cancer can be screened for with an anal Pap test.
How do we treat anal fissures?
FIBER is for starters
Medical therapy, including topical nitroglycerin, calcium-channel blockers (nifedipine), and botulinum toxin injections (try topical agents first), should be exhausted before going to surgery. When medical therapy fails, anoscopy with biopsy is performed to make sure the diagnosis is correct. Ultimately, a lateral internal sphincterotomy is performed.
