General Surgery (GI) Flashcards
how do you repair duodenal ulcer in pt with no prior history of ulcer disease and perforation is only several hours old
closure of perforation, using Graham patch (piece of omentum placed over perforation)
if pt with perforated ulcer has prior history of peptic ulcer disease - tx?
closure of perforation and HSV or V&P
management of patient who is laying in ICU with coffee-ground material in her NG aspirate?
- initiate H2 blockade, sucralfate or antacids w/ gastric pH monitoring
- upper GI endoscopy is not necessary for this type of bleed
- prophlyactic therapy may be given for pts at high risk of bleeding
EGD finding of duodenal ulcer with clean, white base and no active bleeding - management?
white base = has not bled recently
- can be observed w/o endoscopic tx.
- H2 blocker or PPI to maintain gastric pH > 5
EGD finding of duodenal ulcer with fresh clot adherent to the ulcer - management?
evidence of recent rebleeding
- endscopic hemostatic therapy
indications for endoscopic hemostatic therapy of bleeding ulcer
- active or recent bleeding
- large initial blood loss
- high risk of rebleeding or death from bleed
EGD finding of duodenal ulcer with fresh clot and visible artery at its base - management
visible artery - highest risk of rebleeding
- inject area around artery to attempt local control
- operate in next 24-48 hours
where is an ulcer with a visible artery presenting with massive bleeding likely found?
posterior duodenum and involves the gastroduodenal artery
EGD finding of duodenal ulcer with fresh bleeding in a patient with the onset of hypotension - management?
immediate resuscitation w/ normal saline and PRBCs; send to OR
management of duodenal ulcer in pt with ARF and creatinine of 6 mg/dL
this pt who has uremia, likely has platelet dysfunction making bleeding more likely; tx. involves dialysis and desmopressin but otherwise, management is the same as other cases
what do you do if a patient presents with bleeding gastric ulcer?
management is the same as for duodenal ulcers, but biopsy must be done once patient is stable and bleeding is resolved; if surgery is needed, excision rather than oversewing as with duodenal ulcers
management of gastric varices in setting of chronic cirrhosis pt
- do not respond to banding or sclerotherapy
- may respond to injection of cyanoacrylate glue
- if bleeding is severe, TIPs or splenectomy may be needed
management of gastric varices in setting of chronic pancreatitis
due to splenic vein thrombosis (left-sided portal HTN) –> Tx. splenectomy
what should patients with esophageal varices be treated with as prophylaxis against rebleeding?
B-blocker
what test is useful if diagnosis of GERD is uncertain?
24 hr esophageal pH monitoring
approach to patient with symptoms resembling GERD
R/O gallstones, cardiac problems, pancreatitis
- if negative, start trial of H2 blockers or PPIs –> if it helps, no W/U; if pt does not improve, order EGD
classic GERD symptoms
burning retrosternal pain - brought about by bending over, wearing tight clothes or lying flat in bed at night
antacids provide symptomatic relief
what test should be recommended to someone with long-standing GERD who was never formally diagnosed/treated?
EGD with biopsy
- assess for extent of esophagitis and possible complications
you do EGD in pt with symptoms of GERD but find nothing….
non-ulcer dyspepsia
- symptomatic tx with PPIs and h.pylori tx
tx. of Barret’s esophagus/esophagitis
medical therapy with PPIs (8-12 weeks should resolve it); behavior modification
indications for nissen fundoplication
intractable GERD symptoms despite max medical therapy
severe esophagitis
esophageal stricture
what kind of surveillance is needed in pt with diagnosed Barret’s?
EGD+biopsy every 18-24 months to monitor for dysplasia
what diagnostic tests should you do in a patient with symptoms of GERD despite max medical treatment?
EGD w/ biopsy
esophageal manometry - to demonstrate intact esophageal peristalsis before surgery
Dx. of Zenker’s diverticulum
barium swallow followed by upper endoscopy
Tx. of Zenker’s diverticulum
transection of cricopharyngeal mm
if large, excision at origin of posterior pharynx
47 yo woman complains of difficulty swallowing (liquids»_space; solids) and she has to sit up straight and wait for fluids to make it through. She occasionally regurgitates large amts of undigested food - dx?
achalasia
- poor peristaltic contractions
- increased LES tone
diagnostic test for achalasia
barium swallow first
confirm with manometry
tx of achalasia
CCBs
balloon dilation w/ endoscopy
Heller myotomy w/ surgery
older man with history of smoking and drinking presents with difficulty swallowing meats and solids that has progressed to include liquids; he has history of 30 pound weight loss - dx?
esophageal ca
- likely squamous cell ca.
- if longstanding GERD hx, think adenocarcinoma
characteristic signs/symptoms of esophageal ca.
progressive dysphagia (solids -> liquids) odynophagia constant pain regurgitation TE fistula formation hoarseness/coughing
diagnostic sequence of esophageal ca.
barium swallow first
endoscopy with biopsy
CT scan to assess extent
endoscopic USG - for staging
most accurate way to stage esophageal ca.
endoscopic ultrasound
- assess wall penetration and adjacent node involvement
pt with history of forceful or persistent vomiting followed by vomiting bright red blood - dx?
Mallory Weiss syndrome
- multiple linear erosions in gastric mucosa at GE junction
dx. and tx of Mallory Weiss tears
usually resolve on their own so w/u is conservative; if bleeding persists, consider EGD with photocoagulation
if laser coagulation is not working for a Mallory Weiss tear, what should you do next?
surgery
- oversew the laceration through anterior longitudinal gastrostomy
patient who has been vomiting repeatedly presents bc during a particularly violent episode he felt a severe, wrenching epigastric/lower sternal pain of sudden onset; on exam, he is diaphoretic, has fever, leukocytosis and looks ill - dx?
Boerhaave syndrome - transmural esophageal tear(perforation)
management of Boerhaave syndrome
gastrograffin (water soluble) swallow
followed by emergent surgery
pt who recently had upper endoscopy returns complaining of severe, constant retrosternal pain; he has a very high fever, is diaphoretic and there is a hint of subcutaneous emphysema at the base of the neck - dx?
esophageal perforation (due to instrumentation)
approach to esophageal perforation
- gastrografin swallow
- emergency surgical repair
- if < 24 hours: primary closure
- if > 24 hrs: diversion and exclusion followed by delayed reconstruction
approach to bleeding esophageal varices
endoscopic band ligation correct coagulopathy (FFP, platelets) IV octreotide or vasopressin - if pt rebleeds, repeat endoscopy and ligation
what can you consider doing if multiple attempts at endoscopic ligation of esophageal varices are unsuccessful?
portosystemic shunt - mortality of 50%
balloon tamponade - pt must be intubated; high risk of esophageal necrosis
TIPs
management of a duodenal ulcer
4-6 weeks of triple therapy for h.pylori (8-12 weeks for severe disease)
- if symptoms persist, repeat EGD: if ulcer still there or it enlarged, consider surgery (highly selective vagotomy)
what always must be done for a gastric ulcer?
biopsy
tx of linitus plastica
total gastrectomy with splenectomy
pt presents with large weight loss with a history of anorexia and vague epigastric discomfort - what do you do?
endoscopy with biopsy
- looking for cancer
if cancer, CT scan to assess for extent/operability
pt presents with colicky abdominal pain, protracted vomiting and abdominal distention; he has not had a bowel movement or passed gas for 5 days. On exam he has high-pitched, loud bowel sounds that coincide with colicky pain - what are you considering and what test should you order?
consider bowel obstruction
- order abdominal XR
XR finding in bowel obstruction
distended loops of small bowel and air-fluid levels
Management of bowel obstruction due to adhesions
NG suction, IVF and careful observation
- surgery if no improvement w/in 24 hours
pt is being tx for bowel obstruction and he develops fever, leukocytosis, abdominal tenderness and rebound tenderness - dx?
signs of peritoneal irritation in pt with bowel obstruction suggests strangulation from compression of mesenteric blood supply
- need emergency surgery
pt presents with signs and symptoms of intestinal obstruction; on physical exam you not a groin mass, the patient says he used to be able to push it back at will but for past 5 days has been unable to do so - dx?
intestinal obstruction caused by incarcerated hernia
- tx. with surgical intervention
diagnosis of carcinoid syndrome
24 hr urine 5-HIA level
CT scan to assess liver mets
characteristic symptoms of appendicitis
vague periumbilical pain that becomes severe, constant and well localized to RLQ
- abdominal tenderness, gaurding and rebound
- high fever
- elevated WBC with neutrophilia and immature forms
an older pt presents with bloody stools; the blood is visible and has been present on and off for last few weeks - he has been constipated for past 2 months with narrow calibre stools - dx?
suspect cancer of distal, left colon
diagnostic approach to distal, left-sided colon cancer
start with flexible proctosigmoidoscopy
eventual colonscopy and CT scan to assess extent
premalignant polyps
familial polyposis
familial multiple inflammatory polyps
villous adenomas
adenomatous polyps
indications for surgery in ulcerative colitis
disease > 20 years (high risk of malignancy) severe interference with nutrition multiple hospitalizations high dose steroids/immunosuppression toxic megacolon
XR findings in toxic megacolon
massively distended transverse colon
gas within wall of colon
what are the indications for emergent colectomy in a case of pseudomembranous colitis?
failure of medical management with:
WBC count > 50 000
serum lactate > 5 mmol/L
how can you differentiate between internal and external hemorrhoids?
internal - bleed but don’t hurt
external - pain (discomfort when sitting, itching), but less likely to bleed
pt presents with symptoms likely due to hemorrhoids, what must you do?
must rule out cancer!
- do proctosigmoidoscopic exam with DRE, anoscopy and flexible sigmoidoscope
tx. of hemorrhoids
internal - rubber band ligation
external or prolapsed - surgery
young woman complains for exquisite pain with defection and blood streaks on outside of stool; she avoids having bowel mvts due to pain and when she does they are hard and even more painful
anal fissure
- usually posterior, in midline
management approach to anal fissures
physical exam is diagnostic but cancer must be ruled out
- in young pts with no risk factors: do flexible sigmoidoscopy
- all others do colonscopy (esp. if unusual location - anterior/lateral or symptoms of Crohns)
tx. of anal fissures
sitz baths, fibre/stool softeners
topical anesthetic agents
topical nitroglycerin
tx of chronic anal fissure that is not responding/healing
surgery - lateral internal sphincterectomy
man comes in with exquisite perianal pain; he cannot sit down, bowel mvts are very painful and he has been having chills/fever. On exam there is a hot, tender, red fluctuant mass between anus and ischial tuberosity - dx?
ischiorectal abscess
management of ischiorectal abscess
drainage of abscess
must r/o cancer
62 yo man complains of perianal discomfort and reports fecal streaks soiling his underwear. 4 months ago he had a perirectal abscess drained surgically. On exam, there is a perianal opening in the skin and a cord-like tract going from the opening toward the inside of the anal canal; brownish purulent discharge can be expressed from the tract -dx?
fistula in ano
- only develops in pts with previous anorectal fistula
management of fistula in ano
R/O cancer with proctosigmoidoscopy - necrotic tumors can drain
- elective fistulotomy
HIV positive man has a fungating mass growing out of anus and rock-hard enlarged LN in both groins; he has lost a lot of weight and looks emaciated and ill - dx?
squamous cell carcinoma of anus
- take a biopsy of mass
management of squamous cell ca. of anus
Nigro protocol (tumors < 5 cm) - preop chemotherapy (5FU and mitomycin) and radiation followed by surgery
indications for surgery in GI bleed
- failure of medical tx
- hemodynamic instability despite > 3U of blood transfused
- recurrent bleed despite 2x endoscopic hemostasis attempts
- hypovolemic shock
- > 3U/day of blood needed
pt vomits large amt of bright red blood
upper GI bleed
- above the ligament of Treitz
first test to do in upper GI bleed?
endoscopy
what is the next step in assessment of a dark red bowel movement?
place NGT with aspiration
NG tube aspirate returns copious amts of bright red blood - next steps in management?
defines upper GI bleed
- establish IV access
- give H2 blockers and monitor pH
- when stable, proceed with endoscopy
NG tube aspirate returns clear, green fluid without blood
R/O upper GI bleed - must be distal to Ligament of Treitz
diagnostic approach to a lower GI bleed
always do anoscopy to look for hemorrhoids first
tagged red cell study (0.5-2.0 ml/min)
angiogram (> 2 ml/min i.e. 1 U blood every 4 hrs)
colonscopy (wait; < 0.5 m/min)
a pt comes in bc they had dark bloody stools 2 days ago; they are not currently bleeding and NG tube shows clear fluid - dx?
young pt - EGD
older pt - EGD and colonoscopy
management of stress ulcer in ICU pt
keep pH > 4-5 with H2 blockers, antacids or both
- if bleeding happens, endoscopy and angiographic embolization of L.gastric aa may be needed
pt with liver cirrhosis and ascites presents with generalized abdominal pain; moderate tenderness, some guarding and rebound with mild fever and leukocytosis - dx?
in pt with ascites and history of cirrhosis, think of SBP –> do NOT do surgery
tx of SBP
culture of ascitic fluid and antibiotics
sudden onset excruciating abdominal pain; pt has rigid abdomen, is laying motionless, there are no bowel sounds. XR shows air under diaphragm - dx?
perforated viscus (most likely duodenal ulcer) - emergent laparotomy
diagnosis of acute pancreatitis
serum amylase or lipase (more specific)
who should receive a CT scan in acute pancreatitis?
- pts who do not improve on conservative tx
- pts suspected of having complications
- unclear diagnosis
diagnostic test for ureteral colic
CT scan
older woman with LLQ pain, tenderness and vaguely palpable mass; she has fever and leukocytosis - dx? and test?
acute diverticulitis
test - CT scan
82 yo man develops severe abdominal distention, NV and colicky abdominal pain; he has not passed any gas or stool; XR shows very large gas shadow in RUQ that tapers toward LLQ with shape of a parrots beak - dx?
sigmoid volvulus
tx. of sigmoid volvulus
proctosigmoidoscopy
- leave rectal tube in place
