DVS/Wise MD: Lower GI Flashcards
A 55 y/o male has been receiving serial U/S exams to follow his AAA. Over the past year, the aneurysm has rapidly enlarged to 5.8 cm, and he undergoes endovascular AAA repair (EVAR). The operation itself is uneventful. However, on POD1, the patient develops a low-grade fever, LLQ pain, and diarrhea that appears to be blood tinged. On exam, he has mild to moderate tenderness in the LLQ w/o rebound or guarding. What is the next step in the workup?
a. CT scan of abdomen and pelvis with oral and IV contrast
b. Ex lap
c. Formal mesenteric arteriography
d. Flexible sigmoidoscopy
e. Abdominal U/S
d. Flexible sigmoidoscopy
Ischemic colitis is one of the complications that can occur after AAA repair. The etiology is thought to be due to the fact that the IMA is ligated or occluded.
Depending on collateral blood supply, the L colon may develop mucosal or full-thickness ischemia. Ischemic colitis is confirmed by flexible sigmoidoscopy that will demonstrate inflamed, friable mucosa, or full-thickness necrosis.
Treatment begins with placing patient NPO and administering IV fluids and broad-spectrum abx. If there is evidence of sepsis and/or peritonitis, the patient will require ex lap, colonic resection, and proximal colostomy.
A 30 y/o man with colon cancer 2/2 FAP arrives to f/u after receiving a total proctocolectomy with end ileostomy. He was found to have colon cancer after presenting at the age of 27 with unexplained rectal bleeding, diarrhea, and abdominal pain. Subsequent colonscopy found multiple adenomatous polyps in his colon. He has a 5 y/o son, who is screened and is positive for the APC gene. What is the recommended screening for his son?
a. Colonoscopy starting at age 20
b. Flexible sigmoidoscopy starting at age 10
c. Colonoscopy starting at age 50
d. Annual fecal occult blood test
e. Annual barium enema
b. Flexible sigmoidoscopy starting at age 10
A child who has a parent with the APC mutation has a 50% chance of inheriting the syndrome. Thus, APC gene testing is recommended. If the child tests positive, screening with flexible sigmoidoscopy should begin at age 10.
A 66 y/o male presents with a large volume of maroon-colored stools combined with red blood. In the ED, his BP is 100/60, and HR is 120/min. Exam is unremarkable. Two large bore IVs are inserted, and 2 L NS are given, after which the patient’s VS normalize. Lab tests are sent, including a type and cross. What is the next step in the mgmt?
a. Administer 2 units O negative blood
b. Place NG tube for aspiration
c. Colonoscopy
d. Ex lap
e. Place central line
b. Place NG tube for aspiration
Need to r/o UGI first
A 27 y/o man arrives to the ER complaining of bloody diarrhea and rectal urgency. He reports a normal appetites and has not lost any significant weight. After initial workup yields no findings, he is referred to a gastroenterologist for a colonoscopy. He is found to have pseudopolyps in his colon, and subsequent biopsy results confirm UC. He is started on corticosteroids and sulfasalazine, which is able to control his symptoms. Which of the following is true regarding colon cancer and screening in patients with UC?
a. Screening for colon cancer is not necessary
b. Screening colonoscopy with random biopsies 8 years after disease onset.
c. Screening colonoscopy with biopsy only if a suspicious polyp is seen
d. Screening colonoscopy annually once dx is established.
b. Screening colonoscopy with random biopsies 8 years after disease onset.
Patients with IBD are at increased risk of colon cancer. The risk is much greater for UC than with Crohn’s and is related to the duration of illness and the extent of disease. For UC, the risk is low in the first 10 years of the disease (2-3%) but grows to 1-2% per year afterwards.
Random biopsies are necessary in patients with UC undergoing screening with colonoscopy b/c in these patients, cancers do not follow the typical progression from polyp to cancer. A proctocolectomy removes the entire rectum and colon, which prevents pts with UC from developing cancer and no further surveillance is required.
Opiate use… Pt has distended colon. What part of the large bowel is most likely to perforate?
a. Cecum
b. Transverse colon
c. Sigmoid colon
d. Rectum
a. Cecum
Ogilvie’s syndrome = pseudo-obstruction of the colon that is associated with bedridden, neurologically impaired or older pts.
A colon larger than 10 cm is at risk for perforation and requires decompression with colonoscopy and neostigmine. Due to the law of Laplace (tension=PxR), the cecum (largest diameter), is the most common site for perforation.
A 38 y/o presents with signs and sx of acute appendicitis and undergoes lap appy. At surgery, the terminal ileum and cecum appear to be red and inflamed. The appendix is removed uneventfully. Final pathology of the appendix demonstrates no evidence of acute appendicitis. Two weeks later, he presents back to the ED with feces draining from his RLQ wound. Which of the following is the most likely explanation for why the drainage may not spontaneously stop?
a. A distal colonic obstruction
b. Chronic inflammation
c. An occult intra-abdominal abscess
d. A missed malignancy
b. Chronic inflammation
A rare complication after appendectomy is a cecal fistula. The findings on laparoscopy (inflamed terminal ileum and cecum) combined with a normal appendix indicate that the patient’s actual dx is likely Crohn’s disease which can mimic appendicitis.
Endocarditis 2/2 which of the following organisms is associated with colon cancer?
a. S. bovis
b. Clostridia septicum
c. S. bovis + Clostridia septicum
d. Diphyllobothrium latum
e. Cryptococcus neoformans
c. S. bovis (endocarditis) + Clostridia septicum (hematogenous spread)
An 80-year-old woman who resides in a nursing home is brought to the emergency department for a 2-day history of abdominal distention and obstipation. She has no history of previous surgeries. Her current medications are ibuprofen and omeprazole.
On physical examination, her temperature is 98.6°F (37.0°C), pulse is 80/min and regular, respirations are 24/min, and blood pressure is 149/80 mm Hg. No murmurs are heard, and the lungs are clear to auscultation and percussion. The abdomen is markedly distended and tympanitic with diffuse tenderness but no rebound. Rectal examination shows no stool.
Plain abdominal x-ray shows a markedly distended, coffee bean–shaped loop of bowel with haustral markings in the right upper quadrant.
Which of the following is the most likely diagnosis?
a. Ogilve’s pseudo-obstruction
b. Small bowel obstruction
c. Diverticulitis
d. Sigmoid volvulus
e. Gallstone ileus
d. Sigmoid volvulus
The clinical picture and exam are most consistent with a bowel obstruction. The markedly distended abdomen is typically seen when a large bowel obstruction is present, but small bowel obstruction is still possible. The radiological workup (x-rays) are classic for a large bowel obstruction due to sigmoid volvulus. The clinical and x-ray picture are not consistent with ogilve’s pseudo-obstruction.
If a pt is found to have a sigmoid volvulus, what is the next best step in mgmt?
a. Nasogastric tube with intravenous hydration
b. Mesenteric angiography
c. Computed tomography of the abdomen
d. Sigmoidoscopy
e. Saline enema
d. Sigmoidoscopy
Sigmoid volvulus is a form of large bowel obstruction that is ideally decompressed prior to definitive management (surgery to avoid recurrence). While decompression has been demonstrated with barium enema examination, sigmoidsocopy (rigid or flexible) has the best chance of decompression. Decompression allows for time to resuscitate, and possibly bowel prep the patient, but surgical management is still recommended (preferably during the same hospitalization) since eventual recurrence of the volvulus is high.
A 63-year-old woman comes to the emergency department because of a 2-day history of increasing abdominal distention and obstipation. She has vomited twice in the past 8 hours. She has a 2-month history of diffuse, dull lower abdominal pain. She has noted a recent change in bowel habits, characterized by passing hard, pellet-like stools alternating with loose stools. She has lost 5 lb (2.2 kg) over the past 2 months. She has osteoarthritis and frequent episodes of heartburn. Her current medications are ibuprofen and omeprazole.
On physical examination, her temperature is 98.6°F (37.0°C), pulse is 90/min and regular, respirations are 18/min, and blood pressure is 118/80 mm Hg. No murmurs are heard. The lungs are clear to auscultation and percussion. Abdominal examination shows distention with high-pitched, tinkling bowel sounds and diffuse, mild tenderness.
Which of the following is the most likely diagnosis?
a. Sigmoid volvulus
b. Small bowel obstruction
c. Colon cancer
d. Colonic Crohn’s disease
e. Fecal impaction
c. Colon cancer
Of the five options, colon cancer is the most likely. The clinical picture (specifically the physical examination) is not consistent with small bowel obstruction, impaction, or volvulus. The pt’s age and presentation are not consistent with crohn’s.
A 45-year-old woman comes to the emergency department because of a 2-day history of severe periumbilical, colicky pain and abdominal distention. She is nauseated and has vomited light green vomitus 6 times in the past 24 hours. She has not passed stools or flatus for 48 hours. Her medical history is remarkable only for appendectomy at the age of 14 years.
On physical examination, her temperature is 100.4°F (38.0°C), pulse is 100/min and regular, respirations are 24/min, and blood pressure is 120/90 mm Hg. No murmurs are heard. The lungs are clear to auscultation and percussion. The abdomen is distended and mildly tender with rebound on deep palpation. Bowel sounds are rare and high pitched.
Laboratory studies show a leukocyte count of 15,000/mm3. Plain films of the abdomen show dilated proximal small bowel with pneumatosis.
A nasogastric tube is placed and intravenous fluids are begun. Which of the following is the best next step in management?
a. Computed tomography of the abdomen
b. Exploratory laparotomy
c. Observation only
d. Barium enema
e. Upper gastrointestinal series with water-soluble contrast
a. Ex lap
The presence of peritoneal signs and pneumoatosis on x-rays are concerning for compromised or dead bowel. Especially in light of the leukocytosis and low grad temperature. In this setting, further workup would not alleviate this concern and thus exploratory laparotomy is the correct next step.
A previously healthy 22-month-old boy is brought to the emergency department because of paroxysms of severe colicky abdominal discomfort that has persisted for 24 hours. His mother reports that he passed maroon-colored stool earlier today. He has not had fever.
The patient’s temperature is 98.6°F (37.0°C), pulse is 90/min, respirations are 24/min, and blood pressure is 105/80 mm Hg. On cardiac examination, S1 and S2 are normal, and no murmurs are heard. The lungs are clear to auscultation. Abdominal examination shows distention and right-sided fullness. Laboratory studies show a leukocyte count of 7800/mm3. An abdominal radiograph shows dilated loops of small bowel.
a. Barium enema
b. Surgical exploration
c. Upper gastrointestinal series with water-soluble contrast
d. Colonoscopy
e. Computed tomography of the abdomen
Which of the following is the best next step in diagnosis?
a. Barium enema
The 22 month old boy’s symptoms are most consistent with intussusception. These include colicky pain, marron-colored stools, and paroxysmal nature of pain. Of the diagnostic tests listed, barium enema is the most successful in achieving the diagnosis, but also can be therapeutic as well.
A 60-year-old man is evaluated for a 5-day history of lower abdominal pain and tenesmus. For the past 2 days, the abdominal pain has increased, and he has had nausea without vomiting. He has 2 previous episodes of similar symptoms that were treated on an outpatient basis. The patient has a history of chronic constipation that he manages with magnesium hydroxide.
On physical examination, his temperature is 100.8°F (38.2°C), pulse is 90/min and regular, respirations are 16/min, and blood pressure is 140/90 mm Hg. No murmurs are heard. The lungs are clear to auscultation and percussion. The abdomen is distended with high-pitched tinkling bowel sounds. There is significant tenderness in the left lower quadrant with guarding but no rebound. Laboratory studies show a leukocyte count of 12,400/mm3 and hemoglobin of 12 g/dL.
A nasogastric tube is placed and intravenous fluids are begun. Which of the following is the most appropriate next step in management?
a. Mesenteric angiography
b. Exploratory laparotomy
c. Computed tomography of the abdomen
d. Barium enema
e. Colonoscopy
c. Computed tomography of the abdomen
The patient is most likely presenting with diverticulitis. Diverticulitis often presents with low grade temps, left lower quadrant pain and tenderness, and leukocytosis. The history of previous similar symptoms treated as an outpatient is also consistent with the diagnosis of diverticulitis. The next step in the management and to confirm the diagnosis (and rule out other possible diagnosis) is to obtain a CT scan of the abdomen. CT will also help to determine if the nature of the diverticulitis is complicated (such as perforation or abscess).
An 80-year-old woman is evaluated for a 2-day history of nausea, vomiting, and abdominal distention and pain. Her medical history is remarkable for type 2 diabetes mellitus treated with metformin. She resides in an assisted living facility where she has fallen 3 times in the past year.
On physical examination, her temperature is 98.6°F (37.0°C), pulse is 70/min and regular, respirations are 16/min, and blood pressure is 140/60 mm Hg. The abdomen is distended with diffuse tenderness and tympany on percussion. While internally rotating the flexed right hip, she complains of pain extending down the medial aspect of the right thigh.
Which of the following is the most likely diagnosis?
a. Psoas abscess
b. Obturator hernia
c. Acute appendicitis
d. Cecal carcinoma
e. Pelvic fracture
b. Obturator hernia
The patient is presenting with a bowel obstruction. In a patient with no an abdominal surgical history, adhesions are uncommon cases should be entertained. The physician exam is consistent with a strangulated hernia, obturator hernia in this case.
A 65-year-old man with recently diagnosed unresectable gastric cancer presents to the emergency department because of a 4-day history of nausea, non-bilious emesis, and epigastric pain. The patient has elected to not pursue chemotherapy treatment at this time.
On physical examination, his temperature is 98.0°F (36.7°C), pulse is 130/min, respirations are 28/min, and blood pressure is 100/55 mm Hg. The mucus membranes are dry. Abdominal examination shows upper abdominal distention with tympany. No peritoneal signs are noted.
Results of laboratory studies are most likely to show which of the following?
a. Aciduria
b. Hyperchloremia
c. Lactic acidosis
d. Unconjugated hyperbilirubinemia
e. Hyperkalemia
a. Aciduria
This patient has gastric outlet obstruction. The result is non-bilious vomiting which depletes hydrochloric acid from the stomach. This depletion of hydrochloric acid causes a hypocholemic metabolic alkalosis and dehydration because of the loss of H+ and Cl- ions in addition to fluid. The loss of protons triggers the kidney to preserve protons at the expense of potassium and thus hypokalemia ensues and the result is hypochloremic, hypokalemic metabolic alkalosis.
With time, the renal compensation will continue and H+ will continue to be excreted in the urine, thus result in a “paradoxical aciduria”.
E. Laparotomy
Cecal volvulus
