Gastroenterology

Question 1

Anal fissue etiology, RF, and sxs

Answer 1

• irritation caused by trauma to anal canal results in increased resting pressure of internal sphincter - ischemia in region of fifssure and poor healing of injury
• MC in 30-50s, M=F
• Primary: local trauma, pooping probs, anal sex, SVD
• Secondary: previous anal surgery, IBD (Crohn dz), TB, sarcoidosis, malignancy, HIV, syphilis, chlamydia
• MC site: posterior anal midline, below or distal to dentate line (where transition zone becomes squamous epithelium)
• Sxs: tearing pain with defecation, pruritis, BRB,
• signs: superficial laceration, in chronic can see external skin tags and hypertrophied anal papillae at proximal end

Question 2

Anal fissure dx and tx

Answer 2

• dx: endoscopy (if bleeding beyond 2mos tx), sigmoidoscopy if <50yo with no FH colon cancer, colonoscopy if suspician for Crohn dz
• tx: acute heals in 6wk - fiber and water, sitz baths, topical anesthetic, vasodilator (nifedipine, NTG), stool softeners or laxative
  
  • if failed tx/chronic: botox, lateral sphincterotomy (gold standard - may cause incontinence)
• Prevention: proper hygiene - keep dry and wipe with soft cotton or moist cloth, high fiber, high water, dont strain while pooping, avoid trauma to anus, prompt tx of D

Question 3

Appendicitis

Answer 3

• lumen obstructed by hyperplasia of lymphoid tissue, fecalith, or foreign body - leads to bacterial growth and inflammation - distention leads to ischemia, infarction, and necrosis
• peak incidence = mid 20s
• sxs: abd pain (epigastric → umbilicus → RLQ), anorexia, N/V, McBurney pnt (RLQ tendernes), rebound tenderness, guarding, decreased bowel sounds, low fever, Rovsing sign (LLQ TTP →RLQ referred pain), psoas sign (LQ pain w/ hip plexed against resistance or extended while lying on L side), obturator sign (LQ pain when hip and kne flexxed and hip internally rotated)
• dx: CLINICAL DX, CBC - neutrophilia (supportive), imaging if atypical presentation (CT, US)
• tx: appendectomy (lap), IVF, abx, NPO, pain mngmt

Question 4

SBO and LBO

Answer 4

• SBO: MCC = adhesions or hernias, cancer, IBD, volvulus, intussusception
  
  • sxs: abd pain, distention, V, obstipation
  • signs: dehydration + electrolyte imbalance, high-pitched bowel sounds, come in rushes
• LBO: MCC = cancer, strictures, hernias, volvulus, fecal impaction
  
  • sxs: distention, pain, complete strangulation of bowel tissue (infarction, necrosis, peritonitis, death)
  • signs: febrile, tachycardia (can lead to shock), dehydration + electrolyte imbalance
• dx both: KUB (air fluid levels, dilated bowel loops)
• tx both: NPO, nasogastric suction, IVF, pain mngmt
  
  • LBO: urgent surgery when mechanical obstruction expected

Question 5

Volvulus

Answer 5

• twisting of any portion of bowel on itself (commonly sigmoid or cecum); sigmoid is MC; MC in elderly with hx of chronic constip.
• sxs: cramping, distention, N/V, obstipation
• signs: abdominal tympany, tachycardia, fever, sever pain if ischemic (ischemia can lead to gangrene, peritonitis, sepsis)
• dx: Abd XR shows colonic distention (inverted U shape), loss of haustra, coffee bean sign (sigmoid) at midline corresponding to mesentaric root
  
  • sigmoid = loop points to RUQ
  • cecal = loop points to LUQ
  • barium enema (bird’s beak or bird of prey sign)
  • CT abd/pelvis shows whirl pattern
• ​tx: emergent endoscopic decompression - laparoscopic derotation

Question 6

acute cholecystitis

Answer 6

• obstruction of cystic duct (not infxn) - leads to inflamm of GB wall
• sxs: RUQ or epigastric pain lasts a few days, may radiate to shoulder or scap, N/V, pruritis, clay-colored stools, dark urine
• signs: RUQ TTP, rebound in RUQ, Murphy sign, hypoactive bowel sounds, low fever, leukocytosis, jaundice
• dx: RUQ US, HIDA when US inconclusive, CT scan
  
  • Labs: elevated ALK-P and GGT, elevated conjugated bili
• tx: admit, IVF, NPO, IVabx, analgesics, correct lytes, cholecystectomy (first line)
  
  • 70% recurrence if left untreated

Question 7

Choledocholithiasis, cholangitis, primary sclerosing cholangitis, primary biliary cirrhosis

Answer 7

• Choledocho: stones in CBD
  
  • dx: RUQ US (first line), ERCP (gold standard - dx and tx)
  • tx: ERCP with sphincterotomy and stone extract with stent placement, lap choledocholithotomy
• Cholangitis: infxn biliary tract 2ary to obstruction, CHARCOT TRIAD (RUQ pain, jaundice, fever), REYNOLD PENTAD (RUQ pain, jaundice, fever, HoTN, AMS)
  
  • dx: RUQ US (first line), CBC, bili, ERCP (definitive, but not used in acute cases)
  • tx: decompress via PTC or ERCP, bust be afeb 48h for ERCP/PTC so blood cultures, IVF, abx and decompress in the mean time
• Primary sclerosing: chonic idiopathic, likely autoimmune, strong correlation with ulcerative colitis, insidius, progressive jaundice, itching, fatigue, malaise
  
  • dx: ERCP and PTC
  • tx: liver transplant, cholestyramine - sxatic relief
• Biliary cirrhosis: chronic, intrahepatic bile duct destruction, autoimmune, similar sxs to primary sclerosing
  
  • dx: elevated alkphos, +AMA, LIVER BX CONFIRMS DX
  • tx: cholestyramin, Ca, bisphos, vitD for sxs; ursodeoxycholic acid slows progress; liver transplant curative

Question 8

Cirrhosis

Answer 8

• fibrosis, widespread nodules in liver, irreversible when advanced
• distortion of liver anatomy causes: portal HTN (dec blood flow through liver - causes ascites, periph edema, splenomeg, varicose veins), hepatocellular failure (dec albumin synth and clotting factor synth)
• Child pugh scores estimates hepatic reserve (A=mild, C=most severe)
• MCC of cirrhosis: alc liver disease
  
  • second MCC: chronic hepB and C infxn
• MCC of liver dz: nonalcoholic fatty liver dz
• chronic liver dz: ascites, varices, hemorrhoids, gynecomast, test. atrophy, palmar erythema, spider angiomas, caput medusae)
• Monitor labs q3-4mo

Question 9

Hemorrhoids

Answer 9

• varicose veins of anus and rectum
• RF: const/straining, preg, portal HTN, obesity, prolonged sitting or standing, anal intercourse
• sxs: BRBPR (painless, associated with bowel mvmnt, pruritis, fecal soilage, rectal prolapse
• dx: anoscopy if BRBPR or suspected thrombosis
• tx: sitz bath, ice, bed rest, stool softeners, high fiber/fluid, topical steroids

Question 10

external hemorrhoids

Answer 10

• dilated veins arising from inferior hemorrhoidal plexus distal to dentate
• sxs: asxatic unless thrombosed (sudden, painful swelling, lasts several days, then subsides)
• tx: conservative (sitz bath, ice, stool softeners, etc.)
  
  • rubber band ligation: if protrudes with defecation, enlargement, or bleeding - for stages 1-3 nonresponsive
  • closed hemorrhoidectomy: for permanently prolapsed (stage 3-4 chronic bleeding or stage 2 acutely thrombosed; eternal dont require surg management unless thrombosed or lare and sxatic)

Question 11

Internal hemorrhoids

Answer 11

• dilated submucosal veins above dentate line
• thrombosed: increased with def and sitting; tender, swollen, bluish ovoid mass
• sxs: painless rectal bleeding, bulging perianal mass w/ straining; when prolapsed, causes mild fecal incont, mucous d/c, wetness, sensation of fullness
• signs: bulging purplish-blue
• tx: same as external hemorrhoids

Question 12

Thrombosed hemoorhoids

Answer 12

• MC with external hemorrhoids
• sxs: painful defecation, BRBPR, pruritis
• signs: palpable mass, perianal swelling, acutely tender
• dx: anoscopy
• tx: conservative unless persistent or present w/in 72h from onset of pain
  
  • Surgery = definitive
• complications: internal hem can become prolapsed, strangulated, and develop gangrenous changes

Question 13

PUD

Answer 13

• Causes: H. pylori, NSAIDs, Zollinger-Ellison (acid hypersecretion)
  
  • other causes: smoking, ETOH, coffee, stress, dietary factors
• sxs: epigastric pain (aching, gnauwing, nocturnal sxs, effect of food variable), N/V, early satiety, wt loss
• dx: endoscopy (required for dx), barium swallow, H. pylori Ag (Abs to H. pylori can remain elevated for mos-yrs after infxn gone, false negs with PPI, pepto, abx), biopsy (GOLD STANDARD), urea breath test, gastrin measurement (zollinger)
• tx: supportive (dc NSAIDs, stop: smoking, alc, stress, eating before bed, coffee), acid suppression (H2, PPI (most effective), antacids, eradicate H. pylori infxn (amox + carith + PPI (or carith + flagyl), OR pepto + tetracyc + flagyl + PPI), cryoprotection (sucralfate, misoprostol), surgical (truncal vagotomy for hem, perf, obst, failure of meds)

Question 14

duodenal vs gastric ulcers

Answer 14

• Duod: MC <40yo, 70-90% H. pylori caused, NSAIDs, relieved with eating, nocturnal pain more common
• Gast: MC >40yo, 60-70% H. pylori caused, smoking, eating can make pain worse (anorexia and wt loss)

Question 15

Gastritis

Answer 15

• Acute: NSAIDs, ASA, H. pylori, alc, smoking, caffeine, stress
  
  • sxs: asx or epigast pain, dyspepsia, abd pain
  • dx: upper GI endoscopy w/ bx, urea breath test, H. pylori Ag
  • tx: stop NSAIDs, empiric tx w/ acid suppress., 4-8wks PPI, if H pylori + tx with abx
• Chronic: MCC = H. pylori
  
  • sxs: asx, epigastric pain similar to PUD, N/V/anorexia = rare
  • dx: upper GI endoscopy w/ bx, urea breath test, H. pylori Ag
  • tx: triple tx (PPI + 2 abx) x2wks or quad tx (PPI + pepto + 2 abx) x1wk

Question 16

Gastroenteritis causes

Answer 16

• Acute viral, traveler’s D, salmonella, shigella, E. coli (enterohemorrhagic), E.coli (enteroinvasive), cholera

Question 17

acute viral gastroenteritis

Answer 17

• Causes: NORWALK, rotavirus, enterovirus
• Duration: 48-72h
• Transmission: fecal-oral
• MCC ACUTE DIARRHEA
• sxs: myalgias, malaise, low fever, HA, watery D, abd pain, N/V
• dx: fecal leuks (none), hypokalemia and met acidosis
• tx: supportive, look for similar illness in family

Question 18

Traveler’s diarrhea

Answer 18

• Cause: food/water w/ fecal matter
• Etiology: ETEC, Campylobacter, Salmonella, Shigella
• RF: travel destination, occurs in first 2 wks of travel, lasts 4d w/out tx
• sxs: 3+ unformed stools in 24h w/ at least 1 of following:
  
  • fever, N, V, abd cramps, tenesmus, bloody stools
• Complications: dehydration (MC), Guillain-Barre, Reiter syndrome
• dx: fecal leukocytes, C. diff toxin, 3 stool samples for ova and parasites, bact. stool cx, FOBT
• tx: empiric (cipro x1-3d), campylobacter and shigella = FQ (FQ resistant, children, preg = azithro), Bismuth subsalicylate (not for pts taking anticoag, causes black tongue, dark stools, tinnitus, Reye syndrome in children)
• Prophylaxis: proph with FQ = 90% effective

Question 19

Salmonella

Answer 19

• Duration: 1wk
• Transmission: food, water, fecal-oral
• Incubation: 5d-2wk (typhoid)
• sxs: inflamm D, N/V, sxs appear 24-48h after ingesting food (Salmonella typhi presents as C), possible fever
• dx: fecal leuks +, C. diff toxin and cx, 3 stool sample for ova and parasites, bact. stool cx, hypokalemia and met acidosis
• tx: cipro

Question 20

Shigella

Answer 20

• Duration: 1wk
• Transmisison: fecal-oral, MC in developing countries, children <5
• sxs: abd pain, inflamm D, mucoid and bloody stool, N/V (less common), tenesmus (feeling like u need to constantly poop), poss fever
• dx: fecal leuks +, C diff toxin, 3 stool samps for ova and parasites, bact. stool cx, hypokalmeia and met acidosis, produces largest quantity of fecal leuks than any other gastroenteritis
• tx: TMP/SMX (bactrim)​​

Question 21

E. coli

Answer 21

• Enterohemorrhagic E. coli (O157:H7)
  
  • consumption of undercooked ground beef, Shiga-like toxin
  • Onset: 12-60h; Duration: 5-10d
  • sxs: water, voluminous nonbloody D w/ N/V, can lead to dysentery (bloody)
  • dx: no fecal leuks
  • tx: abx not recommended unless severe
  • complication: hemolytic uremic syndrome
• Enteroinvasive E. coli
  
  • Source: food
  • Onset: 5-15d; Duration: 1-5d
  • sxs: cramping, watery D
  • dx: fecal leuks +
  • tx: pepto, imodium, hydration

Question 22

Cholera

Answer 22

• acute diarrheal dz, profound rapidly progressive dehydration and death
• protein enterotoxin produced by orgs as it colonizes
• consumption of contaminated shellfish
• Onset: 24-48h after consumption
• sxs: watery diarrhea “rice water stool” dt action of cholera toxin
• signs: fishy odor
• tx: tetracycline, FQs, or macrolide, oral rehydration

Question 23

Acute pancreatitis

Answer 23

• inflamm from prematurely activated enzymes (autodigestion)
• Causes: ETOH, gallstones, post ERCP, viral inxn, drugs, scorpion, pancreatic CA, hyperTG, hyperCa, uremia, blunt trauma (MC in kids)
• Mild (MC): abd pain, epigastric, radiates to back, steady, dull, severe, worse supine and after meals, N/V/anorexia
• signs: fever, tachycard, HoTN, leuks, epigast TTP, abd distention, dec bowel sounds,
  
  • hemorrhagic pancreatitis: Gray turner sign (flank), cullen sign (periumbilical), fox sign (inguinal ligament)
• dx: serum amylase - nonspec, absence dosnt ro, 5xULN, norm 48-72h after, serum lipase (more spec: 5xULN), LFTs, hyperglycemia, hypoxemia, leuks, Ranson criteria (gluc, Ca, hematocrit, BUN, ABG, LDH, AST, WBC), KUB, abd US, CT scan (confirmatory), ERCP
• tx: bowel rest, IVF, pain control
  
  • if severe: ICU admit, enteral nutrition in first 72hrs through NJ tube
• Complicaitons: pancreatic necrosis, pancreatic pseudocyst

Question 24

Inflammatory bowel disease

Answer 24

• Ulcerative colitis, Crohn dz, Ischemic colitis

Question 25

Ulcerative colitis

Answer 25

• Chronic inflamm of colon or rectal mucosa (muc . and submuc involvment only), any age, MC = rectum and L colon
• SMOKING IS PROTECTIVE​
• sxs: gradual or abrupt onset LLQ pain, tenesmus (MC), hematochezia w/ pus, frequent small BMs, fever, wt loss
  
  • extraintest sxs: scleritis, episcleritis, 1ary sclerosing cholang., erythema nodosum, pyoderma gangrenosum, ankylosing spond.
• dx: anemia, inc ESR, low serum albumin, ANCA + (60-70%), KUB, cx for c. diff, O and P, fecal leuks + (in UC, ischem colitis, infxs D), colonoscopy (no skip lesions, avoid in acute dz dt risk perf or toxic megacolon), sigmoidoscopy
• tx: topical or PO sulfasalazine, 5-ASA enema, steroids, immunosuppress, Proctocolectomy (curative, indicated in severe dz, toxic mega, obst, hemorrhage, etc.)
• complications: IDA, hemorrhage, lyte imbalance, colon cancer, PSC, toxic mega (leading COD)

Question 26

Crohn Dz

Answer 26

• inflamm affecting ANY PART of GI (mouth-anus), MC is small bowel. Unpredictable flares, chronic granulomatous inflamm, transmural inflamm - lead to fistulization, submucosal inflamm
• MC = terminal ileum and cecum
• Gradual onset: D (no blood), wt loss dt malabs, RLQ pain, N/V, aphthous oral ulcers, uveitis, arthiritis, erythema nodosum, cholelith, nephrolith
• Complications: fistula, abscess, transmural thickening and inflamm
• dx: abd CT (inflamm through wall at ileocecal junction, mesenteric fat wrapping, colonoscopy with bx, cobblestone appearance, skip lesions, RECTAL SPARING
• tx: Sulfasalazine (mesalamine, 5-ASA), prednisone for acute exacerbations, metronidazole, immunosuppression, cholestyramine
  
  • Surgery: dt complications (SBO MC, fistulae, perf, abscess)
  • IV nutrition
  • supplement with B12, folate, and vitD
  • stop smoking
  • tx efficacy dec w/ advancing dz, recurrence common after surg

Question 27

Upper GI bleed

Answer 27

• bleeding originates proximal to lig of treitz
• ddx: peptic ulcer, esophageal varices, gastric bleeding from portal HTN, gastritis, AVM, tumor, Mallory-Weiss tear
• RF: NSAIDs, ASA, anticoag, antiplatelet, ETOH, prev GI bleed, liver dz, coagulopathy
• sxs: Hematemesis (blood or coffee ground), Melena, hematochezia (massive upper GI bleed)
• signs: orthostatic HoTN, tachycard, abdominal TTP
• dx: type and screen, Hgb, plt count, coag studes, liver enzymes, albumin, BUN/Cr, NG lavage + for blood = confirmatory
  
  • endoscopy once stabilized (give erythromycin before exam), abx prophylactically for cirrhotics
• tx: supportive (NPO, IV access, O2, IVF, IV PPI until confirmation of cause of bleeding, consult GI and interventional radiology or surg, tx underlying cause, surg (duodenotomy or gastroduodenotomy, ligation of bleeding)

Question 28

Lower GI bleed

Answer 28

• bleeding from site distal to ligament of Treitz
• ddx: diverticulosis (MC), angiodysplasia, colitis, colon CA, proctitis
• sxs: hematochezia, melena (seen w/ bleeding from R colon or small intest), orthostatic HoTN or shock
• dx: CBC, liver test, coag studies, Hgb q2-8hrs, BP, O2, EKG, colonoscopy (only if upper bleed ruled out), CT or mesenteric angiography (requires active bleed to identify source)
• tx: supportive care (O2, IV, fluid and blood resuscitation, managment of coagulopathies, antiplatelets, anticoags)

Question 29

Jaundice

Answer 29

• yellow discoleration of skin, sclera, mucous membranes from bilirubin in tissues (indicates serum bili >3mg/dL)
• if suspect scleral icterus, second site to examine is under tongue
• sxs: yellow, wt loss, fever, chills, abd pain, flulike sxs, itching
• signs: icterus, pallor, abd mass, palpable GB, oliguria, spider angioma, muscle wasting, ecchymosis, parotid enlargement, gynecomastia, HSM, +/- ascites
• dx: urinary bili, CBC< LFTs, GGT, alkphos, hep panel, abd US or CT abd, liver bx (definitive)
• tx: tx underlying cause
• Conjugated bili is water soluble and excreted in urine

Question 30

Crytosporidiosis, Amebiasis, Giardiasis

Answer 30

• Crytposporidiosis: spore-forming protozoa
  
  • Trans: fecal-oral
  • sxs: watery D
  • dx: stool sample (oocytes)
  • tx: supportive
• Amebiasis: Entamoeba histolytica (protozoa)
  
  • trans: fecal-oral, food/H2O, anal-oral
  • sxs: bloody D, tenesmus, abd pain, +/- liver abscess
  • dx: stool sample (trophozoites)
  • tx: Iodoquinol or paromomycin, Flagyl for liver abscess
• Giardiasis: Giardia lamblia (protozoa)
  
  • Trans: fecal-oral, food/H2O, anal-oral
  • Incubation: 1-3wk“foul smelling D”
  • sxs: fatty D, D w/ cramps, N, malaise, anorexia, flatulence, bloating
    
    • hx: daycare, recent camping trip, watery D, chonic infxn w/ wt loss
  • dx: stool sample (cysts or trophozoites)
  • tx: supportive, abx (tinidazole, nitaxonide, Flagyl (metro))

Question 31

Hiatal hernia

Answer 31

• Sliding (type I): >90%, GE junction and stomach herniate into thorax through esophageal hiatus, associated with GERD
  
  • sxs: asx, heartburn, CP, dysphagia
  • dx: barium upper GI, upper endosc.
  • tx: antacids, small meals, elevation of head of bed
  • complications: GERD, reflux esophagitis, aspiration
• Paraesophageal (type II): <5%, stomach herniates into thorax through esophageal hiatus, but GE junction does not
  
  • sxs: can be strangulated, enlarge with time, does NOT cause GERD
  • tx: elective surg
  • complications: obstruction, hemorrhage, incarceration, strangulation (life threatening)

Question 32

Mallory Weiss vs Boerhaave syndrome

Answer 32

• Mallory-Weiss: mucosal tear at (or just below) GE junciton dt vomiting (like in binge drinkers)
  
  • sxs: after repeated episodes of vom., hematemesis, painful
  • dx: upper endoscopy
  • tx: surgery or angiographic embolization
  • Most resolve spontaneously (90%)
• Boerhaave: transmural ruptured esophagus dt vomiting
  
  • sxs: retrosternal CP, odynophagia, fever, HoTN, tachypnea, Hamman’s sign (mediastinal crackling)
  • dx: gastrografin swallow (water soluble contrast preferred when perf suspected)
  • tx: surgery for thoracic perf, abx for cervical perf

Question 33

GERD

Answer 33

• inappropriate relaxation of LES (decreased tone), retrograde flow of stomach contents into esophagus, dec esoph motility, gast outlet obst., hiatal hernia (common)
• dietary RF: ETOH, tobacco, choc, high fat foods, coffee
• Complications: barretts esophagus (squamous ep → columnar), dental erosion, laryngitis, pharyngitis, recurrent PNA, esophageal stricture
• sxs: heartburn, dyspepsia - retrosternal pain, burning shortly after eating, worse with lying down after meals, mimics cardiac CP, regurg, waterbrash (reflex salivary hypersec.), hoarseness, sore throat, globus sensation, early satiety
• dx: barium study (IDs complications, but not dx), endoscopy w bx (if refractory to tx), 24-h pH monitor (GOLD STANDARD), manometry
• tx: diet changes (no fat, orange juice, coffee, ETOH, choclate, large meals, smoking), antacids after meals and @ bedtime
  
  • phase II: add H2 blocker
  • phase III: switch to PPI
  • phase IV: add promotility (metoclop or regland, bethanechol)
  • phase V: H2 + promotility + PPI
  • phase VI: antireflux surg

Question 34

Infectious, pill induced, eosinophilic, radiation, corrosive esophagitis

Answer 34

• infectious: AIDS, organ transplant, leukemia, lymphoma; MC pathogens = candida albicans, herpes, CMV
  
  • sxs: odynophagia, dysphagia, substerna CP, oral thrush, CMV infxn at other sites, oral ulcers
  • dx: endoscopy w/bx
  • tx: fluconazole (candida), Ganciclovir (CMV), HAART (AIDS), sxatic tx or acyclovir (herp)
• pill induced: MC = alendronate, clinda, doxy, iron, NSAIDs, KCl, quinidine, tetracycline, bactrim, vitC
  
  • sxs: odynophagia, dysphagia, severe retrosternal CP
  • dx: endoscopy (shallow or deep ulcers)
  • prevention: take with water, remain upright x30mins
• eosinophilic: hx food allergies, asthma, atopic derm
  
  • sxs: dysphagia, impaction (food stuck @ lower esoph.)
  • dx: upper endosc., bx (eosinophil inflamm)
  • tx: topical steroids (budesonide)
• radiation: radiosensitizing drugs = doxorubicin, bleomycin, cyclophosphamide, cisplatin; radiation exposure 5000 cGy assoc. increased risk of stricture
  
  • sxs: dysphagia, odynophagia
  • tx: supportive tx, dilation
• corrosive: ingestion of alkali or acid from attempted suicide
  
  • tx: steroids

Question 35

Zenker diverticulum

Answer 35

• older pts, outpouching of posterior pharyngeal wall above upper esophageal sphincter in area of weakness bw 2 parts of inf post constrictor, stores undigested food and pushes on lumen of esophagus
• sxs: dysphagia, halitosis, regurg of undigested food, globus sensation, coughing after eating, wt loss, borborygmi in neck
• dx: barium swallow, manometry
• tx: requres only if sxatic cricophayngeus myotomy, no intervention if small (<2cm), botulinum toxin for temporary relief
• complications: aspiration and PNA

Question 36

Mechanical (intestinal) obstruction

Answer 36

• postop adhesions or internal (mesenteric) ischemia
• sxs: short period of normal intestinal fn before obstructive sxs, cramping, abd distension
• signs: high-pitched hyperactive bowel sounds, visible peristalsis, minimal tenderness
• dx: XR - air fluid levels in loops of small bowel
• tx: NG suction for several days, invasive hemodynamic monitoring if cardiac, pulm, or renal dz, if no resolution in 24-48h or peritoneal signs, laparotomy (abx for surg)

Question 37

anorectal fistulas etiology and sxs

Answer 37

• 10% associated with IBD, tuberculosis, malignancy, radiation
• communication of abscess cavity with an identifiable internal opening within anal canal, most commonly located at dentate line where anal glands enter the canal
• arise through obstruction of anal crypts or glands
  
  • intersphincteric (70%), transsphincteric, extrasphincteric, suprashpincteric
• 40% are + for intestinal bacteria, male 2x > F, MCC = anorectal abscess
• sxs: nonhealing anorectal abscess folowing drainage or chronic purulent drainage and pustule-like firm mass in perianal or buttock area, intermittent rectal pain (worse with defecation, sitting, and activity), malodorous perianal drainage, pruritus
• signs: excoriation and inflammation of perianal skin, inflamed, tender, draining, external opening

Question 38

anorectal fistulas dx and tx

Answer 38

• dx: all require anoscopy with diluted hydrogen peroxide to look for internal opening, imaging not required, drain with Mallenkot catheter, then fistulagram to search for an occult fistula tract, parks classification system
• tx:
  
  • simple: fistulotomy with probing (preferred) - decreased risk of incontinence and recurrence, shorter healing time; simple ligation of internal fistula tract procedure, fistulectomy (larger wound, prolonged healing time, higher risk of incontinence
  • complex: seton (vessel loop r silk tie placed through fistula tract - reduces risk of incontinence in cases where poor would healing expected, can be initial temporary intervention or for complex fistulas who fail initial tx), can also do fistulotomy

Question 39

anorexia nervosa

Answer 39

• MC F 14-21yo, F:M (3:1), homosexual men, child sex abuse, OCD, childhood/parental obesity
• starvation induces protein and fat catabolism → loss of cellular volume and atrophy in kidneys, brain, heart, liver, intestines, and muscles
• restriction of energy intake, intense fear of gaining weight, distorted perception of body weight and shape, palpitations, dizziness, weakness, exertional fatigue, cold intolerance, amen, abd pain or bloating, early satiety, const, swelling of feet
• signs: bradycardia, ortho hoTN, BMI <17.5, hypotherm, hypoactive bowel sounds, brittle hair, hair loss, xerosis (dry skin), lanugo, abd distention
• dx: EKG (inc PR interval, 1st def heart block, ST-T wave abnl, QT prolong.), CBC (anem leukopen, thrombocytopen), hypoK, hypoMg, hypophosph, hypoNa, Cr low, elevated bili/alkphos/AST/ALT, low T3/T4, low FSH/LH, high cholesterol
• tx: psychotherapy, nutritional . rehab, avoid bupropion

Question 40

anorectal abscess

Answer 40

• Goodsall’s rule: all fistula tracts with external opening within 3cm of the anal verge and post to a line drawn through ischial spines travel in a curvilinear fashion to the posterior midline; all tracks with external openings anterior to this line enter anal canal in a radial fashion
• complex fistulas: extrasphincteric or high fistulas proximal to dentate line; women with ant fistulas; fistulas with multiple tracts; recurrent fistulas; fistuals related to IBD, TB, HIV, or radiation tx; hx or anal incont; rectovag fistulas
• Parks described four types that originate from cryptoglandular infxns
  
  • type 1: intersphincteric fistula that travels along the intersphincteric plane
  • type 2: transsphincteric fistula that encompasses a portion of internal and external sphincter
  • type 3: suprasphincteric fistula that encompasses the entire spincter apparatus
  • type 4: extrasphincteric fistula that extends from primary opening in rectum, encompasses the entire sphincter apparatus, and opens onto skin overlying the buttock

Question 41

diverticulosis

Answer 41

• MOA: inc luminal pressure
• RF: low fiber diet, + family hx, prevalence (inc age >60)
• MC location = sigmoid colon
• presence of diverticula - constipation leads to expulsion of diverticula in sigmoid colon
• hx of constipation: asxsatic - discovered incidentally, only 20% sxatic (LLQ discomfort, bloating, constipation, diarrhea, lower GI bleed)
• dx: KUB (ro free air), CT if pt doesnt respond to tx, barium enema - avoid during acute eps, leads to perforation and peritonitis, colonoscopy (avoid during acute eps)
• tx: high-fiber diet (bran) to bulk up stool, psyllium
• complicaitons: painless rectal bleeding with sudden-onset large volume hematochezia; spontaneously resolves - if continuous or recurrent go to surg, diverticulitis

Question 42

acute diverticulitis

Answer 42

• defined as inflammation and/or infxn of diverticulum, feces impacted in diverticulum = erosion + microperf
• mean age = 63; gram neg rods and anaerobes (E. coli, B. fragilis)
• sxs: sudden onset abd pain in LLQ or suprapubic region (constant over several days, 50% w/ previous episode, N/V/C/D, +/- fever
• signs: painful mass on rectal exam
• dx: abd CT with contrast: localized bowel wall thickening (>4mm), increase soft tissue density in pericolonic fat, colonic diverticula, FOBT +, CBC (leukocytosis), avoid colonoscopy and barium enemas during acute eps
• complications: diverticular abscess, colovesical fistula, bowel obst, perf

Question 43

treatment of diverticulitis

Answer 43

• outpt: PO abx x7-10d (cipro + flagyl; bactrim + flagyl; augmentin)
  
  • consume clear liquids only until reassessed after 2-3d
  • repeat imaging not necessary if clinically improved
• prophylaxis: do NOT need to avoid nuts, seeds, popcorn; high fiber diet
• inpt:
  
  • uncomp: IVF (LR or NS), pain meds (morphine, tylenol, hydromorphone), NPO (bowel rest) or clear liquid diet; IV abx until abd pain resolves (3-5d) - PO abx x10-14d (flagyl PLUS: cefazolin, cefuroxime, ceftriaxone, cefotaxime, ciprofloxacin, levofloxacin; OR single-agent (ertapenem, piperacillin/tazobactam); repeat imaging (ro abscess, perf), after 6wk pt needs colonoscopy to ro colon CA
  • comp or recurrent sx: bowel resection

Question 44

toxic megacolon

Answer 44

• extreme dilation and immobility of the colon, true emergency
• presents as a complicaiton of UC, Crohn dz, pseudomembranous colitis, infxns (amebiasis, Shigella, campylobacter, clostridium difficile)
• sxs: fever, prostration, severe cramps, abd distention
• signs: rigid abd, diffuse rebound abd tenderness
• dx: abd XR (colonic dilation)
• tx: decompression of colon, in some cases colostomy or complete colonic resection, monitor fluid and electrolytes

Question 45

ranson criteria

Answer 45

• GA LAW - prognosis and mortality rates of pancreatitis
  
  • Glucose >200
  • Age >55
  • LDH > 350
  • AST >250
  • WBC >16k

Question 46

nausea/vomiting

Answer 46

• migraine: dop (probably primary mediator)
  
  • antiemetic for HA and N - metoclopramide or prochlorperazine
  • antiemetic for N: oral antiemetics, metoclop, prochlor, serotonin antags
• vestibular nausea: histamine, acetylcholine
  
  • antiemetic; antihist and antichol (equally effective)
• preg-induced: unkown
  
  • antiemetic for N: ginger, vitB6
  • for hyperemesis gravidarum: prometh (first line), serotonin antag and corticosteroids (second line)
• gastroenteritis: dop and serotonin
  
  • first line antiem: dop antag
  • second line antiem: serotonin antag
  • use in children is controversial
• postop N/V: dop and serotonin
  
  • prevent: serotonin antag, droperidol, dexameth
  • tx: dop antag, serotonin antag, dexameth
• serotonin antag = prochlorperazine
• dop antag = metoclop
• 1st gen antihist = prometh

Question 47

indirect and direct inguinal hernias etiology and sxs

Answer 47

• indirect: obliteration of processus vaginalis (peritoneal extension accompanying testis in its descent into the scrotum) fails to occur, hernial sac passes through internal inguinal ring, a defect in trans fasc half-way between ASIS and pubic tubercle, sac located anteromedially to sperm cord, descends into scrotum
• direct: weakness or defect in trans fasc, funicular type more likely to become incarcerated dt distinct borders
• sxs of both: asxatic, lump or swelling in groin with sudden pain and bulge that occurs while lifting or straining, “draggin” sensation, radiation of pain into scrotum, with enlargement - discomfort, aching pain, must lie down to reduce

Question 48

indirect and direct inguinal hernias dx and tx

Answer 48

• indirect dx: mass may or may not be reducible, examin supine and standing with cough and strain, finger directed laterally and upward into inguinal canal - protrudes against tip of finger; tissue must be felt protruding the inguinal canal during coughing in order for diagnosis (posterior wall of inguinal canal is firm and resistant)
• direct: appears symmetrically, circular swelling at external ring with standing and straining, finger directed laterally and upward into inguinal canal - protrudes against side of finger (bulges forward through hesselbach triangle), disappears when lying supine (posterior wall of inguinal canal is relaxed or absent)
• tx: all sxatic hernias should be repaired if pt can tolerate surg
  
  • nonsurg tx: TRUSS, use if pt refuses operative repair or when absolute CI to operation, external compression over defect, take off at night

Question 49

femoral hernia

Answer 49

• acquired protrusion of a peritoneal sac through the femoral ring, passes beneath the iliopubic tract and inguinal ligament into upper thigh
• predisposing factor: small empty space between lacunar ligament medially and femoral vein laterally
• sxs: bulge near groin or thigh
• prognosis: highest incidence of strangulation and incarceration

Question 50

incisional hernia

Answer 50

• 10% of operations
• sxs: asymptomatic, s/sx of small bowel obstruction
• tx: small (early repair dt obstruction) - if unwilling or poor surg risk use eleastic binder
  
  • large: may be left if asxatic, less likely to incarcerate (considered large if fascial edges cannot be approximated without tension, mesh > primary suture repair, even if small, recurrence rate increases with each sub reoperation
• factors that in recurrence: wound infxn, abd aneurysms, smoking, poor nutrition

Question 51

hernia (incarcerated/strangulated)

Answer 51

• reducible hernia is one in which contents of sac return to abdomen sponatneously or with manual pressure
• irreducible hernia (incarcerated) is one whose contents cant be returned to abdomen becuase they are trapped by narrow neck
• compromise to the blood supply of the contents of the sac results in a strangulated hernia in which gangrene of the contents of the sac has occurred.

Question 52

ischemic bowel disease

Answer 52

• can be acute or chronic AMI: arterial embolus/thrombus, venous thrombosis; >50y, other CV or collagen vascular dz
• sxs:
  
  • AMI - sudden onset severe abdominal pain
  • CMI - abdominal angina, pain occurs 10-30min after eating, relieved by squatting or lying down, intestinal infarction more common in small bowel than large
• signs:
  
  • CMI: normal physical exam
  • AMI: pain out of proportion to examination findings - involuntary guarding, reb ound, heme + stool
• dx: plain film radiography and CT - ro other causes, duplex US of mesenteric arteries, confirmed by CT angio
• tx: AMI - emergency, high mortality
  
  • abdominal laparotomy

Question 53

acute mesenteric ischemia

Answer 53

• SMA supplies small bowel and ascending and proximal 2/3 of transverse colon
• IMA supplies; distal 1/3 of colon, descending and sigmoid
• consider with a pt with afib - watershed area = splenic flexure most vulnerable to ischemia during systemic hypoperfusion
• sxs: diffuse abd pain, severe and out of proportion to exam (visceral in nature, poorly localized, worse after eating), bowe, distention, bloody diarrhea, nausea, vom
• signs: rebound tenderness, bowel sounds absent
• dx:CBC - neutrophilic leukocytosis +/- left shift, serum amylase high, CT angio = gold standard (diagnostic and therapeutic, distinguishes between arterial embolic and thrombotic causes, KUB (air fluid levels), widespread edema
• tx: mesenteric angiogram (vasodilator tx, thrombectomy, and embolectomy), emergent laparotomy (remove bowel with infarction, anastomosis of healthy tissue)