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Surgery Shelf > Diseases of the GI System > Flashcards

Diseases of the GI System Flashcards

1
Q

Gastroesophageal Reflux

A

Vague sx difficult to distinguish from other causes of epigastric pain
pH monitoring dx reflux and correlate to sx
Complain of retrosternal burning/heartburn
Brought on by bending over, tight clothes or lying flat in bed
Improved w/ OTC antacids or H2 blockers
Concern of peptic esophagitis and Barrett esophagus
Endoscope w/ biopsy to r/o Barrett
Surgery if cannot control w/ meds- Nissan fundoplication
If severe dysplasia, resection

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2
Q

Diffuse esophageal spasm

A

Crushing pain with swallowing
Uncoordinated massive contraction
Seen as corkscrew esophagus on manometry

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3
Q

Achalasia

A

More common in women
Dysphagia worse for liquids
Must sit straight up and wait for liquids to get past sphincter
Occasional regurgitation of undigested food
Xray shows megaesophagus; manometry dx
Tx- balloon dilation by endoscope

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4
Q

Esophageal cancer

A

Progressive dysphagia- meat, then other solids, then soft food, liquids, then finally saliva
Significant weight loss always seen
Squamous cell carcinoma seen in men who smoke and drink- higher incidence in blacks
Adenocarcinoma w/ hx of GERD
Dx w/ endoscopy and biopsy after barium study
CT determines surgery- usually only palliative

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5
Q

Mallory-Weiss Tear

A

Prolonged, forceful vomiting
Bright red blood
Endoscope dx and allows photocoagulation

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6
Q

Boerhaave syndrome

A

Prolonged forceful vomiting leading to esophageal perforation
Continuous severe wrenching and low sternal pain of sudden onset
Followed by fever, leukocytosis, and looks sick
Contrast swallow (gastrografin then barium if neg)
Emergency surgery

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7
Q

Instrument perforation of esophagus

A

Most common cause of perforation
Continuous severe wrenching and low sternal pain of sudden onset
Followed by fever, leukocytosis, and looks sick
May have emphysema in lower neck
Contrast studies and prompt repair

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8
Q

Gastric adenocarcinoma

A 
More common in elderly
Weight loss, anorexia, vague epigastric distress, and early satiety
Occasional hematemasis
Endoscopy and biopsy dx
CT determines surgery- best tx
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9
Q

Gastric lymphoma

A

Now as common as adenocarcinoma
Weight loss, anorexia, vague epigastric distress, and early satiety
Occasional hematemasis
Endoscopy and biopsy dx
Tx: chemo or radiation, surgery if perforation
Low grade MALTOMA can be reversed by eradicating H. pylori

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10
Q

Mechanical intestinal obstruction

A

Typically caused by adhesions from prior abdominal surgery
Colicky abdominal pain, protracted vomiting, progressive distention, and no gas or poop
Early, high pitched BS coincides with pain
Xray shows distended loops w/ air-fluid levels
Tx: NPO, NG suction, IV fluids
Surgery if no response in 24h (complete) or days if partial

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11
Q

Strangulated obstruction

A

Compromised blood supply
Starts as any SBO
Eventually fever, leukocytosis, constant pain, and peritoneal irritation And ultimately sepsis
Emergency surgery required

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12
Q

Mechanical intestinal obstruction from incarcerated hernia

A

Compromised blood supply
Starts as any SBO
Eventually fever, leukocytosis, constant pain, and peritoneal irritation And ultimately sepsis
Physical exam finds irreducible hernia
Surgical repair of hernia: emergent if cannot reduce, elective if manual reduction successful

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13
Q

Carcinoid Syndrome

A

Small bowel carcinoid tumor that mets to liver
Flush face, diarrhea, wheezing and RT side valve damage (prominent JVP)
Dx: 24h urine for 5-hydroxyindoleacetic acid

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14
Q

Classic acute appendicitis

A

Anorexia, vague periumbilical pain that becomes severe, constant, in RLQ
Tenderness, guarding, rebound in RLQ and below umbilicus
Modest fever, leukocytosis, neutrophila & bands
If doubtful, CT to confirm
Emergency appendectomy

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15
Q

Cancer of RT colon

A

Typically w/ unexplained anemia in elderly
Stool 4+ occult blood
Dx: colonoscopy w/ biopsy
Right hemicolectomy to treat

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16
Q

Cancer of LT colon

A

Bloody bowel movements w/ blood coating stool
Constipation w/ change in stool caliber
Flex sig and biopsy to dx w/ full colonoscopy to rule out synchronous second primary
Pre-op chemo/radiation to shrink
Surgery to tx

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17
Q

Colonic polyps

A

May be premalignant
familial polyposis>familial multiple inflammatory polyps>villous adenoma>adenomatous polyp
Not premalignant: juvenile polyps, Peutz-Jeghers, isolated inflammatory, and hyperplastic

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18
Q

Chronic ulcerative colitis

A

Managed medically
Surgical intervention after 20yrs (cancer risk), nutritional interference, high dose steroids, or toxic megacolon
Toxic megacolon: fever, leukocytosis, epigastric tenderness, massively distended transverse colon
Surgical removal of affected colon including all rectal mucosa

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19
Q

Pseudomembraneous enterocolitis

A

Over growth of C. diff in pt on antibiotics
Clindamycin historically, cephalosporins common
Profuse watery diarrhea, crampy abdominal pain, fever, and leukcytosis
ID toxin in stool
Cultures take too long and pseudomembranes not always seen on endoscopy
Antibiotics stopped, no antidiarrheals
Tx w/ Metronidazole or Vancomycisn
Virulent form unresponsive to tx w/ WBC >50000 and serum lactate >5 req colectomy

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20
Q

Hemorrhoids

A

Internal bleed; prolapsed can hurt and itch
External hurt and can thrombose
Internal can have band ligation
External conservative, then surgery

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21
Q

Anal Fissure

A

Young women
Pain pooping w/ blood covering stools
Avoid BM and get constipated b/c fear of pain
Refuse physical exam (may need EUA)
Caused by tight internal sphincter
Tx w/ stool softeners, topical nitroglycerin, botulinum toxin, calcium channel blockers, forced dilations, or lateral internal sphincterotomy
CCBs most successful

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22
Q

Crohn Disease

A

Starts as fissure, fistula, or ulcer but fails to heal
Suspected if fails to improve with surgery
Fistula could be drained with setons
Ramicade helps healing

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23
Q

Ishiorectal abscess

A

Very common
Febrile w exquisite perirectal pain- can’t sit or shit
Red, pain, hot, swollen b/t anus and ischial tuberocity
I&D to tx
Cancer should be ruled out
Severe diabetics can get necrotizing soft tissue infection

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24
Q

Fistula in ano

A

Develops after draining ischiorectal abscess
Epithelial migration from anal crypts and perineal skin forms permanent tract.
Fecal soiling and perineal discomfort
Openings lateral to anus and cordlike tract
Discharge may be expressed
R/o necrotic and draining tumor
Tx w fistulotomy

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25
Squamous cell carcinoma of anus
More common in HIV+ and anoreceptive sex Fungating mass out of anus Metastatic inguinal nodes often present Biopsy dx Tx: Nigro chemoradiation followed by surgery if residual tumor Currently 5wk chemo-radiation 90% successful so surgery rarely needed
26
GI bleed statistics
3/4 from upper GI 1/4 rectum or colon Very few from jejunum and ileum Colon bleed: angiodysplasia, polyps, diverticulosis, or cancer Young people usually upper; older can be any Always upper if vomiting blood
27
Vomiting blood
Always upper GI bleed Also if blood in NG suction Upper GI endoscopy Look at mouth and nose
28
Melena
Black, tarry stools Indicated digested blood from upper GI Start workup with upper GI endoscopy
29
Red blood per rectum
Could be from anywhere in GI Upper if passes too fast for digestion Put in NG tube: if bloody then upper GI; if white fluid then may still be duodenum; if green then upper GI is clear must be lower
30
Active bleeding per rectum when upper GI cleared
Exclude hemorrhoids w anoscopy Colonoscopy not helpful if active b/c obscured If >2ml/min angiogram If <0.5ml/min wait for it to stop then colonoscpy In between: tagged red cell study shows puddling and an area where angio can be done, Tagged red cell is a slow test & may stop bleeding before done; can allow blind hemicolectomy If bleeding not found in colon, capsule endoscopy to see small bowel
31
Patient w history of blood per rectum but not actively bleeding
Start workup w/ upper endoscopy if young | Both ends if old
32
Blood per rectum in child
Should be from Meckel diverticulum | Start workup w/ technetium scan looking for ectopic gastric mucosa
33
Massive upper GI bleeding in stressed multi trauma
Likely stress ulcer Endoscopy to confirm Angiographic embolization best therapy Avoid by maintaining gastric pH above 4
34
Acute abdominal pain caused by perforation
Sudden onset constant, generalized, severe pain Reluctant to move, protective of abdomen Generalized peritoneal signs except in old/sick Tenderness, guarding, rebound, silent abdomen Free air under diaphragm in upright xray Perforated peptic ulcer most common example Urgent surgery needed
35
Acute abdomen caused by obstruction of narrow duct
``` Ureter, cystic duct, common duct Sudden onset colicky pain Patient moves constantly trying to get comfortable Location/radiation according to source Few physical findings ```
36
Acute abdomen caused by inflammatory process
Gradual onset/slow build up over 6-12hrs Constant pain starting as ill defined then localizing Often has typical radiation patterns Physical findings of peritoneal irritation in affected area (except pancreatitis) Systemic signs: fever & leukocytosis
37
Ischemic process in bowel
Only thing with sever abdominal pain and blood in the lumen of the gut
38
Primary peritonitis
Should be suspected in child w/ nephrosis and ascites or adult with ascites and equivocal findings Cultures of ascitic fluid yields single organism Treat with antibiotics no surgery
39
Generalized acute abdomen treatment
Exploratory laparotomy; no need for specific diagnosis r/o myocardial ischemia w/ EKG r/o lower lobe pneumonia w/ CXR r/o PE in immobilized patient r/o pancreatitis w/ amylase/lipase b/c no surgery r/o urinary stones w/ CT b/c no surgery
40
Acute pancreatitis
Suspected in alcoholic w/ upper acute abdomen Onset over several hrs Constant epigastric pain radiating thru to back Nausea, vomiting, retching Dx w/ serum/urine amylase or lipase CT if not clear Tx: NPO, NG suction, IV fluids
41
Biliary tract disease
Fat female, 40s fertile w/ RUQ pain
42
Ureteral stones
Sudden onset flank pain radiating to inner thigh and scrotum/labia Sometimes w/ urinary sx- urgency/frequency CT scan best test
43
Acute diverticulitis
One of few inflammatory processes causing acute abdominal pain in LLQ Middle age or older Fever, leukocytosis, peritoneal irritation in LLQ CT is diagnositic Start NPO, IV fluids, antibiotics- most cool down Emergency surgery if unimproved
44
Sigmoid volvulus
Seen in old people Signs of obstruction & severe abdominal distention Xray-air-fluid levels, distending colon, air filled loop in RUQ that tapers toward LLQ-Parrots beak Proctosigmoidscope resolves acute problem Rectal tube left in Recurrent cases need elective sigmoid resection
45
Mesenteric ischemia
Seen in elderly, atrial fibrillation, or recent MI Old peeps have less acute abdomen often dx late with blood in lumen, with acidosis & sepsis If very early, arteriogram and embolectomy Late, colectomy
46
Primary hepatoma/ hepatocellular carcinoma
``` In US, caused by cirrhosis or HBV Vague RUQ discomfort and weight loss Blood marker alpha fetoprotein CT shows location and extent Surgery if possible ```
47
Mets to liver
Outnumbers primary cancer 20:1 Found on CT or rising carcinoembryonic antigen If primary slow growing and mets only in one lobe, can resect or radioablation
48
Hepatic adenoma
Complication of OCP Risk of rupture with massive bleeding CT diagnostic emergency surgery
49
Pyogenic liver abscess
``` Complication of biliary tract disease Especially acute ascending cholangitis Fever, leukocytosis, tender liver U/S or CT dx Percutaneous drainage required ```
50
Amebic abscess of liver
Favors men with Mexico connection Fever, leukocytosis, tender liver U/S or CT dx; definitive w/ serology Treated with metronidazoe and seldom req drainage
51
Hemolytic jaundice
Usually low level (bilirubin 6-8 not in 30-40) All bilirubin is unconjugated No bile in urine Must determine what chewing up red cells
52
Hepatocellular jaundice
Elevation of both fractions of bilirubin Very high levels transaminase Modest elevation alk phos Hepatitis most common example- look at serology
53
Obstructive jaundice
Elevation of both bilirubin fractions Modest elevations of transaminase Very high levels alk phos Get U/S first Obstruction may be stones- may not see; no gallbladder dilation Malignant obstruction gets distended gallbladder
54
Obstructive jaundice caused by stones
Suspect in 40 female fertile fat High alk phos, dilated ducts, nondilated GB w stones ERCP to confirm and sphincterotomy Cholecystectomy to follow
55
Obstructive jaundice caused by tumor
``` Adenocarcinoma of pancreas head Adenocarcinoma of ampulla Cholangiocarcinoma of common bile duct U/S shows distended GB- get CT Percutaneous biopsy to follow If CT negative get ERCP ```
56
Ampullary cancers
Suspect when malignant obstructive jaundice coincides w/ anemia and blood in stools Can bleed into lumen & also obstruct Endoscopy first dx test
57
Pancreatic cancer
Seldom cured even with whipple | Ampullary cancer and cancer of common duct have better prognosis 40%
58
Gallstones
Vast majority of biliary tract pathology Fat female fertile 40 Also in Mexican and Native americans Asymptomatic stones left alone
59
Biliary colic
Occurs when stone temporarily occludes the duct Colicky RUQ pain radiating to shoulder & back Often triggered by fatty food Nausea and vomiting w/o peritoneal signs or inflammatory process Self limited 10-30min Easily aborted by anticholinergics If u/s shows gallstones then elective cholecystectomy
60
Acute cholecystitis
Stone in duct and inflammation occurs in obstructed gallbladder Pain is constant, low fever, leukocytosis & RUQ peritoneal irritation LFTs usually normal U/S dx-GB wall thickening, pericholecystic fluid, and stones HIDA will show uptake in liver, common duct, and duodenum but NOT in the GB NG suction, NPO, IV fluids, & abx Cool down w/ elective cholecystectomy to follow, but usually in same admission If not cooling down (often men w/ diabetes) then emergency cholecystectomy Emergency percutaneous transhepatic cholecystectomy may temporize in old/very sick
61
Acute ascending cholangitis
Very deadly; stone blocks common duct and leads to ascending infection Temp to 104-105, chills, very high WBC count Hyperbilirubinemia and extremely high alk phos IV abx and emergency decompression of common bile duct (usually ERCP or PTC but rarely surgery) Eventually cholecystectomy to follow
62
Obstructive Jaundice
Without ascending cholangitis Occurs when stones produce complete biliary obstruction rather than partial Elevation of both bilirubin fractions Modest elevations of transaminase Very high levels alk phos Get U/S first Obstruction may be stones- may not see; no gallbladder dilation Malignant obstruction gets distended gallbladder
63
Biliary Pancreatitis
Seen when stones impacted distally in ampulla temporarily obstruct both pancreatic & biliary ducts May pass spontaneously Produces transient cholangitis and pancreatitis (elevated amylase & lipase) U/S shows stones in GB NPO, NG suction, IV fluids often improves w/ later cholecystectomy If not, ERCP w/ sphincterotomy
64
Acute pancreatits
Complication of gallstones, or in alcoholics May be edematous, hemorrhagic, or suppurative Late complications: pancreatic pseudocyst, and chronic pancreatitis
65
Acute edamatous pancreatits
Alcoholics or gallstones Epigastric & midabdominal pain after heavy meal or booze Constant pain radiating to back w/ nausea & vomiting Tenderness & mild rebound in upper abdomen Elevated amylase and lipase w/ elevated hematocrit Resolution after pancreatic rest-NPO, NG suction and IV fluids
66
Acute hemorrhagic pancreatitis
Much more deadly Starts as edmatous, but has lower hematocrit Ranson criteria: elevated WBC, elevated glucos, low serum Ca2+ at presentation; Next day lower hct, low Ca2+ increased BUN & metabolic acidosis Terrible outcome; ICU needed Death follows multiple pancreatic abscesses; have daily CT to drain if forming
67
Necrosectomy
Best way to deal with necrotic pancreas Wait for necrotic tissue to delineate Best to wait 4wks
68
Pancreatic abscess (acute suppurative pancreatitis)
Persistent fever & leukocytosis about 10 days after onset of pancreatitis CT shows collections of pus Percutaneous drainage or necrosectomy
69
Pancreatic pseudocyst
Late sequela of acute pancreatitis or trauma 5wks after initial presentation Collection of pancreatic juice outside pancreatic duct-usually lesser sac Pressure symptoms-early satiety, vague discomfort and deep palpable mass Dx w/ CT or U/S 6cm or >6wk more likely to rupture/bleed so req drainage- percutaneous, surgically into GI or endoscopically into stomach
70
Chronic pancreatitis
Repeat episodes of pancreatitis (usually alcohol) Develop calcified burned out pancreas Steatorrhea, diabetes, and constant epigastric pain Diabetes & steatorrhea controlled w/ insulin & enzymes Pain cannot be controlled If ERCP shows specific point of obstruction & dilation, surgery to drain that duct
71
Abdominal hernias
All abdominal hernias should be electively repaired to prevent obstruction/strangulation Except: umbos pt 2-5 (may close themselves) or esophageal sliding hiatal hernia (not true hernia) Hernias that become irreducible req emergency surgery to prevent strangulation

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