Colorectal 2 Flashcards
Acute Mesenteric Ischemia
mesenteric vessel occlusion causing loss of blood flow to a region of the bowel
can be in both large and small intestine
s/s of Acute Mesenteric Ischemia
severe steady epigastric/periumbilical pain
minimal PE findings
Acute Mesenteric Ischemia work up + tx
Work Up: Lactic acid levels, CBC, angiography
tx: restore blood flow and remove dead bowel
chronic mesenteric ischemia
arteriosclerotic lesions in gut cause inability to supply blood after eating
who gets chronic mesenteric ischemia
pts with RF for CAD/PVD
pts who have ASD elsewhere
smoking, HTN, hyperlipidemia, DM
s/s of chronic mesenteric ischemia
epigastric or periumbilical postprandial pain
lose weight due anorexia 2/2 pain
tx of chronic mesenteric ischemia
identification of lesion and stent placement
Toxic Megacolon/Toxic Colitis
actue toxic colitis with dilation of colon
typically associated with IBD flare
Toxic Megacolon/Toxic Colitis H&P
acutely ill (may be masked by steroids)
diarrhea, abdominal pain, high fever, vomiting, symptoms of systemic toxicity
rebound, peritoneal signs, abdominal rigidity
Toxic Megacolon/Toxic Colitis
diagnostic criterion
radiographic evidence of colonic dilation (>6cm + loss of haustra)
3 of:
- Fever >101.5
- Tachycardia >120 bpm
- Leukocytosis >10.5
- Anemia
Toxic Megacolon/Toxic Colitis
radiograph req
plain film X Ray - do serially to asses progress
avoid contrast (increase perforation)
GI and surgery consult
Toxic Megacolon/Toxic Colitis tx
- NG tube, bowel rest (reduce colonic distention)
- correct fluid and electrolyte disturbances
- treat toxemia and precipitating disease (IV ABX)
+/- emergent colectomy
indications for surgery Toxic Megacolon/Toxic Colitis
free perforation (air under diapragham)
massive hemorrhage
increased toxicity (HoTN)
progression of colonic dilation
persistent dilation (24-72 hrs)
constipation manifestations
few or very hard BM
excessive straining
feeling rectum doesn’t completely empty
primary constipation etiologies
structural GI tract/pelvic floor abnormalities (slow transit, difficulty relaxing anal sphincter)
psychosocial issues or sexual abuse
secondary constipation etiologies
systemic disorders (sicca, DM, MS, Parkinson’s, pregnancy)
medications (anticholinergics, opitates)
structureal
evaluation and management of constipation
<50
NO alarming H & P
empiric therapy, address diet and lifestyle (hydration, exercise, fiber)
e&M constipation >50 alarming
unexplained weight loss, GI bleed
other disease suggestions (DM, Parkinson’s etc)
colonoscopy, lung CA, PSA, ovarian screen
initial agents in constipation tx
decusate (colace)
fiber, blue lazativitys
glycerin suppository (fleets)
osmotic agents constipation tx
draw water into bowel, act w.in 24 hrs
PEG (Miralax, GoLYTELY) (no go in stroke)
lactulose (enulose) or sorbitol (lg osmotic load)
MOM and mg citrate (acts right away)
bowel stimulants constipation tx
bisacodyl (Dulcolax) and Senna
may cause hypokalemia, protein loss
tx of constipation (line up)
Daily: PEG, Colace, Fiber
PRN: Senna, ducolax, sorbitol
emergent: Mg citrate, MOM
tx of opiate induced constipation
antagonist peripheral opioid receptor
Methylnatrexone (Relistor) Naloxegol (Movantik) Alvimopan (Entereg) Tegaserod (Zelnorm) Lubiprostone (Amitiza) Linaclotide (Linzess)
Methylnatrexone
brand + indication
(Relistor)
injection Sub Q
CA and non CA opioid use
Naloxegol brand + indication
(Movantik)
schedule II
non-CA opioid use
Alvimopan
brand + indication
(Entereg)
post op ileus
Tegaserod brand + indication + moa
(Zelnorm)
serotonin receptors stimulative GI peristalsis
women <55 who have IBS or chronic idiopathic constipation
Lubiprostone brand + moa
(Amitiza)
opens intestinal Cl channels
Linaclotide brand + MOA
(Linzess)
activates cGMP
fecal impaction
occurs when stool causes LBO
confirmed with DRE - copious amounts of stool in rectum
when is DRE non diagnostic in fecal impaction
proximal rectum or sigmoid colon
fecal impaction s/s/
obstipation
loud, hyperactive bowel
abdominal distention
abdominal pain
may have loose stools (GI more mobile and pushes loose around impaction
fecal impaction tx
multiple enema preparations to soften stool and manual disimpaction
prevent by placing on bowel regimen
fecal incontinence tx
padding undergarments
avoid caffeine
adequate fiber
Kegel exercises
these are therapies for MOBILE pts
causes of fecal incontinence
loss of central awareness (CVA, dementia)
peripheral n. injury (spinal cord, cauda equina, pudenal n damage)
sphincter damage (ob trauma, anal surgery, physical trauma)
fecal incontinence evaluation
inspect sphincter, DRE relaxation, evaluation rectal tone
sigmoidoscopy, anoscopy, imaging studies
anorectal abscess
obstruction of the anal crypt gland by inspissated debris causes bacterial growth and abscess formation
+/- fistula formaiton
will spread to adjacent structures
common organisms causing anorectal abscess
E. coli (enteric gram neg)
bacteroides (anaerobic)
staphylococcal species
locations most likely for anorectal abscess
perianal
ischiorectal
interspinteric and supralevatior (hard to ID)
anorectal abscess epidemiology
male predominance
20-30s
summer and spring
symptoms anorectal abscess
severe pain (dull, constant, worse with BM)
Pruritus, anal fullness
constitutional symptoms (fever, malaise)
purulent rectal drainage
signs of anorectal abscess
area of fluctuant, erythematous indurated skin
fluctuant indurated mass on DRE
deep abscess: no physical exam findings other then systemic toxicity
work up of anorectal abscess
CT scan w/IV contrast
pus collection and culture
anorectal abscess tx
incision and drainage + abx
pack with iodophor gauze
must be done immediately (can cause sphincter malfunction)
complication of anorectal abscess
fistula formation
MC 2/2 infections caused by GNR
Anorectal Fistula s/s
non healing abscess following I&D
pain during defecation
excoriation of perianal skin
diarrhea, abdominal pain
Anorectal Fistula etiologies
PERIANAL ABSCESS Crohn's/UC Anorectal malignancy radiation proctitis rectal foreign bodies, leukemia, diverticulitis
Anorectal Fistula tx
surgery
underlying cause
referral to colorectal surgeon
Anorectal Fistula- who gets surgery?
symptomatic fistula in pts w/o IBD
Anorectal Fistula IBD
treatment of underlying dz
surgery can exacerbate fistula formation and worsen disease
surgical management of Anorectal Fistula depends on
location of fistula
how much of sphincter complex is involved
Anal Fissure
tear in lining of anal canal distal to dentate line
local trauma to anal canal
accompanied by sentinel pile
location of Anal Fissure
12 o clock and 6 o clock position
*if not in these spots, consider other underlying pathology (IBD, HIV, TB, CA, syphilis)
Anal Fissure symptoms
exquisite pain during BM (lasts minutes to hrs from passage of stool, occurs with every BM)
bright red blood on TP or streaking stool
Anal Fissure exam
found at posterior midline or anterior midline
too much pain for DRE
acute: fresh lesion
chronic: raised edges, white and horizontal fibers
Anal Fissure tx
fiber supplement, sitz bath, EMLA
referral to GI if no improvement in 2 mo
how do you determine if hemorrhoid is internal or external?
based on location above or below dentate line
pathophys of EXTERNAL hemorrhoid
advanced age
pregnancy
pelvic tumors
prolonged sitting on toiled
s/s of hemorrhoids
painless rectal bleeding (BRIGHT RED)
rectal pain if associated with thrombosis
prolapse
pruritus
fecal soilage
diagnosis of hemorrhoids
physical examination (can see external)
flexible sigmoidoscopy, anoscopy or colonoscopy (bleeding only)
*if pt is bleeding, this might not be due to hemorrhoids but something much more serious, so be diligent
tx hemorrhoids
conservative
treat symptomatic pts only
bleeding- fiber supplement
pruritus/Irritation - analgesic creams
tx of painful hemorrhoids
w/in 72 hrs
excision of entire hemorrhoid
lancing and evacuation of clot
tx of painful hemorrhoids
NOT w/in 72 hrs
oral and topical analgesics
stool softeners
sitz bath
pilonidal cysts
young adults in their 30s (mc in men)
cyst or abscess in part of natal cleft
pilonidal cysts asymptomatic presentation
painless cystic lesion or sinus opening at top of cleft
pilonidal cysts acute abscess
sudden onset of severe pain and swelling
acutely inflamed mass
overlying sacrum or coccyx
rare: fever
chronic pilonidal cysts
persistent drainage from sinus
one or more opening seen and drainage of mucoid or purulent material present
diagnosis of pilonidal cysts
clinical diagnoses
esp. if patient presents with acute inflamed mass at top of natal cleft
tx of pilonidal cysts
I and D
ABX not indicated unless there is significant cellulite
metronidazole and first gen cephalosporin (G+ and anaerobes)
