Emma Holliday for Surgery: Part VI Flashcards
If we see an inflammatory bowel issue involving the terminal ileum, think:
Crohn’s Disease.
Crohn’s disease most closely mimics
Appendicitis
We see this lab finding most readily with Crohn’s patients
Fe deficiency anemia
Inflammatory bowel disease continuously involving the rectum =
UC
RARELY get some ileal backwash, but never any higher than that
UC causes an increased risk for:
Primary Sclerosing Cholangitis
PSC leads to increased chance of
Cholangial CA
Crohn’s is likely to cause a ______. Tx with _____.
Fistula. Give Metronidazole
Granulomas on bx =
Crohn’s
Tramnsmural inflammation
Crohn’s
Cure for UC
Colectomy
Smokers have a lower risk of developing _____ and a higher risk for ______.
UC. Smokers have a higher risk for Crohn’s
Highest risk of Colon CA seen in _____ patients
UC. Another reason to get a colectomy!
UC is associated with this lab finding
p-ANCA
How do we treat IBD
ASA, sulfasalazine to maintain remission. Corticosteroids to induce remission. For Crohn’s, give Metro for ANY ulcers or abscess to prevent fistula. Give Azathrioprine for Crohn’s, and 6MP with methotrexate for severe symptomatic disease
Are the diverticula seen in diverticulitis false or true diverticulae?
False, believe it or not.
Only outpocketings of the mucosa
Cause of diverticulae
2/2 low fiber diet in areas of weakness where blood vessels penetrate and leads to bleeding
What makes diverticulitis?
Diverticulum becomes obstructed and forms abscess/perforates
Sx’s of diverticulitis
LLQ pain, constipation, diarrhea
Imaging for diverticulitis
Look for free air, CT is best to evaluate for abscess. NO BARIUM ENEMA
Tx for diverticulitis
NPO, NG suction, IVF, broad spectrum abx, and pain management
Do we do a colonoscopy for diverticulitis?
Yes, 4-6 weeks later
When is surgery indicated for diverticulitis?
Multiple episodes, age over 50.
Elective better than emergency so we can do a primary anastamosis!
Risk factors for colorectal cancer
Genetics
UC
Genetic risk factors for colorectal CA
AFP Lynch HNPCC Gardners Cowdens
GI symptoms of Colorectal cancer based on location
Right sided = bleeding
Left sided = obstruction
Rectal Cancer = Pain/fullness, bleeding, obstruction
Workup for colorectal cancer
DRE, transrectal US (depth of invasion), COLONOSCOPY
CEA to measure recurrance, CT for staging
Treatment for colon cancer
Remove affected segment and chemo if node +
Treatment for rectal cancer
Upper/Middle 1/3 = Resect area
Lower 1/3 = APR = Remove sphincter and give permanent colostomy
Do we screen for AAA?
Yes.
Men 65-75 who have EVER smoked. Do abdominal U/S
Symptoms of AAA
Pulsatile abdominal mass
Treatment for AAA
Conservatively if less than 5cm and asymptomatic. Monitor every 3-12 months.
Surgery if greater than 5 cm or after observing you notice it growing 4mm per year
Symptoms of ruptured AAA
Severe sudden abdominal flank or back pain, shock, tender pulsatile mass
50% will die before getting to hospital
1 cause of death post-op from AAA
MI
Other post-op complications and symptoms from AAA
Bloody diarrhea = ischemic colitis
Weakness, decreased pain with preserved vribration and position - ASA syndrome
1-2 years later with brisk bleeding GI - Aortoenteric fistula
When do I suspect an acute mesenteric ischemia?
Acute Abd pain in a pt with A-Fib, subtherapeutic on warfarin, or pt s/p high dose vasoconstrictors (shock, bypass)
What do I do if suspecting mesenteric ischemia?
Angiography of SMA/IMA
Tx with embolectomy. If thrombus or aortomesenteric, do a bypass.
What defines a chronic mesenteric ischemia?
Slow progressing stenosis of 2.5 vessels (Celiac, SMA, or IMA)
Sxs of chronic mesenteric ischemia
Severe mid-epigastric pain after eating, food fear and weight loss. “Pain out of proportion to exam”
How do we diagnose chronic mesenteric ischemia
Duplex or angiography
How do we treat chronic mesenteric ischemia
Aortomesenteric bypass or transaortic mesenteric endarterectomy
5 P’s of arterial occlsuion
Pain Pallor Pulseless Paresthesia Paralysis
Treatment for arterial occlusion
–Tx w/ immediate heparin + prepare for surgery.
–Surgery (embolectomy or bypass) done w/in 6hrs to avoid loss.
–Thrombolytics may be possible if: no surg in last 2wks, hemorrhagic stroke.
Complications of repairing occlusion
–Complications = compartment syndrome during reperfusion period –> do fasciotomy watch for myoglobinuria.
What is claudication?
Pain in the butt, calf, thigh upon exertion, improved with rest
What is the best test for claudication
Ankle-Brachial index. More than 1 is normal.
- Claudication and ulcers: 0.4-0.8, use medical management
- Limb ischemia - 0.2-0.4, surgery is indicated
- Gangrene Less than 0.2 may require amputation
How do we diagnose a DVT?
Duplex U/S and check for PE
How do we treat a DVT
Heparin, then overlap with Warfarin for 5 days, then continue warfarin for 3-6 months
Complications of DVT
Post-phlebotic syndrome = chronic valvular incompetence, cyanosis and edema
PE indications
Random signs = right heart strain on EKG, sinus tach, decr vascular markings on CXR, wedge infarct, ABG w/ low CO2 and O2.
Treatment for PE
If suspected, give heparin 1st! Then work up w/ V/Q scan, then spiral CT. Pulmonary angiography is gold standard.
Tx w/ heparin warfarin overlap. Use thrombolyticsif severe but NOT if s/p surgery or hemorrhagic stroke. Surgical thrombectomy if life threatening.
When do we use an IVC filter for PE
IVC filter if contraindications to chronic coagulation.
