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SUM: Intro To Surgery I & II Surgical Cases > Gastro: intestinal perforation - causes > Flashcards

Gastro: intestinal perforation - causes Flashcards

1
Q

Causes of Gastrointestinal perforation

A

Appendicitis

Gastrointestinal cancer

Diverticulitis

Inflammatory bowel disease

Superior mesenteric artery syndrome

Trauma

Non-steroidal anti-inflammatory drugs

Ingestion of corrosives

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2
Q

What is Diverticulitis?

A
  • involves the formation of pouches (diverticula) within the bowel wall
  • this process is known as diverticulosis and typically occurs within the large intestine
  • Ddiverticulitis results when one of these diverticula becomes inflamed
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3
Q

Diverticulosis – false diverticula

A

•Without circular muscular layer

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4
Q

Risk factors

A
  • increasing age
  • constipation
  • a diet that is low in dietary fiber (contradicted by the latest study)
  • connective tissue disorders (such as Marfan syndrome and Ehlers Danlos Syndrome) that may cause weakness in the colon wall
  • hereditary or genetic predisposition
  • and extreme weight loss
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5
Q

What is Size of diverticula?

What is asymptomatic diverticulosis?

A

•pouches are usually very small (5 to 10 millimeters) in diameter but can be larger.

In diverticulosis, the pouches in the colon wall do not cause symptoms

•Diverticulosis may not be discovered unless symptoms occur, such as in painful diverticular disease or in diverticulitis.

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6
Q

How rare is Diverticulosis?

A
  • 80 % of people who have diverticulosis never get diverticulitis
  • In many cases, diverticulosis is discovered only when tests are done to find the cause of a different medical problem or during a screening exam.
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7
Q

What causes diverticulosis?

A
  • Causes are not completely understood
  • High pressure inside the colon in constipation but not only
  • When diet is low in fiber, the colon must exert more pressure than usual to move small, hard stool
  • Genetic
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8
Q

How is diverticulosis diagnosed?

A
  • barium enema X-ray
  • colonoscopy

CT

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9
Q

What are the symptoms of diverticulosis?

A

•Most people don’t have symptoms. You may have had diverticulosis for years by the time symptoms occur (if they do). Over time, some people get an infection in the pouches (diverticulitis).

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10
Q

What are the symptoms of diverticulitis?

A
  • abdominal bloating
  • pain
  • tenderness, typically in the left lower abdomen
  • diarrhea
  • chills
  • a low-grade fever.
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11
Q

Superior mesenteric artery syndrome?

A

•caused by an angle of 6°-25° between the AA and the SMA, in comparison to the normal range of 38°-56°, due to a lack of retroperitoneal and visceral fat (mesenteric fat).

•the aortomesenteric distance is 2-8 millimeters, as opposed to the typical 10-20

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12
Q

Superior mesenteric artery syndrome?

A

•SMA syndrome is also known as Wilkie’s syndrome, cast syndrome, mesenteric root syndrome, chronic duodenal ileus and intermittent arterio-mesenteric occlusion

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13
Q

Symptoms of superior mesenteric artery syndrome?

A

•nausea, vomiting, abdominal pain (due to both the duodenal compression and the compensatory reversed peristalsis), abdominal distention, tenderness of the abdominal area, diarrhea, reflux, and heartburn.

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14
Q

Symptoms of superior mesenteric artery syndrome

A

•In infants, feeding difficulties and poor weight gain are also frequent symptoms.

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15
Q

Symptoms of superior mesenteric artery syndrome

A

•”Food fear” is a common development among patients with the chronic form of SMA syndrome.

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16
Q

Treatment of SMA syndrome

A

Duodenojejunostomy

bypassing the compression

caused by the AA and the SMA

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17
Q

Epidemiology

A

SMA syndrome is extremely rare, evident in only 0.3% of upper-gastrointestinal-tract barium studies

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18
Q

Superior mesenteric artery syndrome

A

•It is distinct from Nutcracker syndrome, which is the entrapment of the left renal vein between the AA and the SMA

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19
Q

Loss of weight – maybe cause of SMA syndrome, but mostly because of?

3 main reasons.

A

•Anatomic anomalies: Abnormally high and fixed position of the ligament of Treitz with an upward displacement of the duodenum and unusually low origin of the SMA.

also •use of body cast in the surgical treatment of scoliosis or vertebral fractures. SMA cases after corrective spine surgery is due to the result of spinal elongation, which decreases the superior mesenteric/aortic angle

•such as tall thin body build which is reported in 80% of patients, exaggerated lumbar lordosis, visceroptosis, and rapid linear growth without compensatory weight gain, particularly during adolescence

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20
Q

Nutcracker syndrome

A

•called nutcracker phenomenon, renal vein entrapment syndrome, or mesoaortic compression of the left renal vein.

•The name derives from the fact that, in the sagittal plane and/or transverse plane, the SMA and AA (with some imagination) appear to be a nutcracker crushing a nut (the renal vein).

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21
Q

Symptoms of nutcracker syndrome

A
  • hematuria (which can lead to anemia)
  • abdominal pain (classically left flank or pelvic pain)
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22
Q

Symptoms of nutcracker syndrome

A

if left gonad drains via the left renal vein it can also result in left testicular varicocele and pain in scrotum or left lower quadrant pain in women.

•Nausea and vomiting can result due to compression of the splanchnic veins

can also lead to varicocele formation and varicose veins in the lower limbs.

•Nutcracker syndrome is an often finding in varicocele-affected patients and possibly, nutcracker syndrome should be routinely excluded as a possible cause of varicocele

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23
Q

NCS Treatments include

A
  • Endovascular stenting
  • Renal vein re-implantation
  • Gonadal vein embolization
24
Q
  • Appendicitis commonly presents with right lower abdominal pain
  • Pain is located where appnedix is located

App symptoms are:

A
  • Nausea
  • Vomiting
  • Decreased appetite
25
Q

Perforation in app

A

•Severe complications of a perforation appendix include widespread, painful inflammation of the inner lining of the abdominal wall and sepsis.

26
Q

Cause of app

A
  • Fecal stone in the orifice to the app
  • Inflamed lymphoid tissue from a viral infection
  • Parasites
  • Gallstone

Tumors

27
Q

Diagnosis of App

A
  • Natural history of the app
  • Physical examination
  • Diagnostic imaging
  • Laboratory examinations – WBC, CRP, Procalcitonin – markers of inflammation state
28
Q

Medical treatment of App is done by

A

Surgery

29
Q

What is thickness in the Ultrasound of a APP?

What age group is most common?

A

•Border of thickness of the app wall – 6 mm

•Appendicitis is most common between the ages of 5 and 40

30
Q

Diagnostic imaging for App

A

•CT scan has been shown to be more accurate than ultrasound in detecting acute appendicitis.However, ultrasound may be preferred as the first imaging test in children and pregnant women because of the risks associated with radiation exposure from CT scans.

31
Q

The Alvarado score and pediatric appendicitis score are okay but not definitive.

What do scores mean?

Whats the total score?

A

A score below 5 suggests against a diagnosis of appendicitis, whereas a score of 7 or more is predictive of acute appendicitis. In a person with an equivocal score of 5 or 6, a CT scan or ultrasound exam may be used to reduce the rate of negative appendectomy.

10

32
Q

Alvarado score given on which different items?

A

Migratory right iliac fossa pain – 1 point

Anorexia – 1 point

Nausea and vomiting – 1 point

Right iliac fossa tenderness – 2 points

Rebound abdominal tenderness – 1 point

Fever – 1 point

High white blood cell count (leukocytosis) 2 points

Shift to left (segmented neutrophils) 1 point

33
Q

Differential diagnosis- children to get Perforation?

  • New-onset Crohn’s disease
  • New-onset ulcerative colitis
  • Pancreatitis
  • Abdominal trauma from child abuse
  • Distal intestinal obstruction in children with cystic fibrosis

Typhlitis in children with leukemia.

A
  • Gastroenteritis
  • Mesenteric adenitis
  • Meckel’s diverticulitis
  • Intussusception
  • Henoch-Schönlein purpura
  • Lobar pneumonia
  • Urinary tract infection
34
Q

What is Typhlitis?

A

Neutropenic enterocolitis, also known as typhlitis or typhlenteritis, and less commonly called caecitis or cecitis, is inflammation of the cecum

It is particularly associated with neutropenia in leukemia.

35
Q

Differential diagnosis - woman who get perforation is caused by?

A
  • Ectopic pregnancy
  • Pelvic inflammatory disease
  • Ovarian torsion
  • Endometriosis
36
Q

Differential diagnosis - man who get perforation is caused by?

A

Testicular torsion

37
Q

Differential diagnosis - adults to get perforation is caused by?

A
  • New-onset Crohn’s disease and ulcerative colitis
  • Regional enteritis,
  • Renal colic
  • Perforated peptic ulcer
  • Pancreatitis
38
Q

Differential diagnosis - elderly in getting perforation by?

A
  • Diverticulitis
  • Intestinal obstruction
  • Colonic carcinoma
  • Mesenteric ischemia
  • Leaking aortic aneurysm
39
Q

What is Meckel’s diverticulitis?

Where is it located?

Why is the Yolk sac important to neonatal?

A

A Meckel’s diverticulum, a true congenital diverticulum, is a slight bulge in the small intestine present at birth and a vestigial remnant of the omphalomesenteric duct (also called the vitelline duct or yolk stalk).

– between yolc sac and first midgut and when in adult – about 60 cm from ileocecal valve.

-important in early embryonic blood supply and nutrition. Degenerates to 7th gestational week.

40
Q

Meckel’s Diverticulum

How freqeunt?

Whats the rule of 2s?

A

2% with more males effected.

  • 2% (of the population)
  • 2 feet (proximal to the ileocecal valve)
  • 2 inches (in length)
  • 2 types of common ectopic tissue (gastric and pancreatic)
  • 2 years is the most common age at clinical presentation
  • 2:1 male:female ratio
41
Q

Symptoms of Meckels diverticulum?

How is it managed?

A

•The majority of people with a Meckel’s diverticulum are asymptomatic. An asymptomatic Meckel’s diverticulum is called a silent Meckel’s diverticulum.

•Treatment is surgical, potentially with a laparoscopic resection

42
Q

Esophageal perforation causes and risks

A
  • The contents of the esophagus can pass into the area surrounding area in the chest (mediastinum), when there is a hole in the esophagus. This often results in infection of the mediastinum (mediastinitis).
  • The most common cause of an esophageal perforation is injury during a medical procedure. However, the use of flexible instruments has made this problem rare.

Other causes are tumor, swalling object, violent vomiting and trauma.

43
Q

Esophageal perforation Symptoms are?

A
  • The main symptom is pain when the problem first occurs.
  • A perforation in the middle or lower most part of the esophagus may cause:
  • Swallowing problems
  • Chest pain
  • Breathing problems
44
Q

Esophagus perforation exams and tests

Diagnosis is done by?

A

•Fast breathing, Fever, Low blood pressure, Rapid heart rate, and Neck pain or stiffness and air bubbles underneath the skin if the perforation is in the top part of the esophagus.

You may have a chest x-ray to look for: Air in the soft tissues of the chest, Fluid that has leaked from the esophagus into the space around the lungs.

Collapsed lung. X-rays taken after you drink a non-harmful dye can help pinpoint the location of the perforation.

You may also have chest CT scan look for an abscess in the chest or esophageal cancer.

45
Q

Esophagus perforation Treatment

To avodi surgery, what can be placed?

A

Surgery will depend on the location and size of the perforation. If surgery is needed, it is best done within 24 hours. Fluids given through a vein (IV), IV antibiotics to prevent or treat infectionDraining of fluid around the lungs with a chest tube.

A stent may be placed in the esophagus if only a small amount of fluid has leaked. This may help avoid surgery.

46
Q

A perforation in the uppermost (neck region) part of the esophagus may heal by itself if you do not eat or drink for a period of time. In this case, you will need a stomach feeding tube or another way to get nutrients.

Surgery is often needed to repair which area?

A

a perforation in the middle or bottom portions of the esophagus. The leak may be treated by simple repair or by removing the esophagus depending on the extent of the problem.

47
Q

Perforation Esophagus prognosis

•The condition can progress to shock, even death, if untreated. However the outlook is good if:

A

the problem is found within 24 hours of it occurring. Most people survive when surgery is done within 24 hours. Survival rate goes down if you wait longer.

48
Q

Esophagus perforation Complications may include:

A
  • Permanent damage to the esophagus (narrowing or stricture)
  • Abscess formation in and around the esophagus
  • Infection in and around the lungs
49
Q

•The frequency of esophageal perforation is 3 in 100,000 in the United States. The distribution by location is as follows:

A
  • Cervical - 27%
  • Intrathoracic - 54%
  • Intra-abdominal - 19%
50
Q

Esophagogastroduodenoscopy (EGD) is the most common procedure for instrumentation of the esophagus. The irsk is .03% but goes up depending on the procedure being done.

What are those levels?

A
  • Esophageal dilation - 0.5%
  • Esophageal dilation for achalasia - 1.7%
  • Endoscopic thermal therapy - 1-2%
  • Endoscopic variceal sclerotherapy - 1-6%
  • Endoscopic laser therapy - 5%
  • Photodynamic therapy - 4.6%
  • Esophageal stent placement - 5-25%
51
Q

Where and what kind of perforation is most likely in the Esophagus when caused by instrumentation?

By spontaneous rupture?

How large are the perforations and which side is more prevalent?

A

Instrumental perforation is common in the pharynx or distal esophagus.

Spontaneous rupture may occur just above the diaphragm in the posterolateral wall of the esophagus.

Perforations are usually longitudinal (0.6-8.9 cm long), with the left side more commonly affected than the right (90%).

52
Q

Esophageal perforation remains a highly morbid condition. Mortality rates are reported from 25-89% and are based predominantly on time of presentation and etiology of perforation.

Whats the mortality rate?

A

Within 24hrs, chanes are 25% of mortality. If longer than 24hrs, then 65% can go up to 75-89% after 48 hrs.

53
Q

What is Boerhaave’s syndrome and how does it cause Spontaneous perforation?

A

•Spontaneous perforation of the esophagus most commonly results from a full-thickness tear in the esophageal wall due to a sudden increase in intraesophageal pressure combined with relatively negative intrathoracic pressure caused by straining or vomiting (effort rupture of the esophagus or Boerhaave’s syndrome).

54
Q

In most cases of Boerhaave’s syndrome, where does the tear happen?

Summary of steps of treamtent for Boerhaave syndrome?

What are the 3 signs that are called Mackler’s triad?

A

at the left postero-lateral aspect of the distal esophagus and extends for several centimeters.

the mortality of untreated Boerhaave syndrome is nearly 100%. Its treatment includes immediate antibiotic therapy to prevent mediastinitis and sepsis, surgical repair of the perforation, and if there is significant fluid loss it should be replaced with IV fluid therapy since oral rehydration is not possible. Even with early surgical intervention (within 24 hours) the risk of death is 25%.

chest pain, vomiting, and subcutaneous emphysema.

55
Q

What is Mallory–Weiss syndrome or gastro-esophageal laceration syndrome

A

bleeding from a laceration in the mucosa at the junction of the stomach and esophagus. This is usually caused by severe vomiting because of alcoholism or bulimia, but can be caused by any conditions which causes violent vomiting and retching such as food poisoning. The syndrome presents with painful hematemesis.

56
Q

Mallory–Weiss syndrome or gastro-esophageal laceration Diagnosis?

What are the treatments?

If all other methods fail?

A

Endoscopy

Cauterization or injection of epinephrine to stop the bleeding may be undertaken during the index endoscopy procedure.

Very rarely, embolization of the arteries supplying the region may be required to stop the bleeding.

high gastrostomy can be used to ligate the bleeding vessel. It is to be noted that the tube will not be able to stop bleeding as here the bleeding is arterial and the pressure in the balloon is not sufficient to overcome the arterial pressure.

SUM: Intro To Surgery I & II Surgical Cases (8 decks)

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