GI Flashcards
1
Q
Esophageal neoplasms
A
Presentation:
- solid to liquid dysphagia
- odynophagia
- wt loss, chest pain, reflux, hematemesis, Virchow’s node
- hypercalcemia in SCC
SCC (MC worldwide)
- upper 1/3rd of eso
- 50-70yo
- RF: tobacco/EtOH**, AA
Adenocarcinoma (MC US)
- GERD, BE
- lower 1/3 of eso
- RF: younger, obese, Caucasian, GERD
- poor 5y survival rate
Dx:
- upper endoscopy w/bx
- double contrast barium esophagram (solid, liquid)
- endoscopic US to stage
Mgmt:
- esophagectomy: if no spread to local tissue and no distant mets [trans-hiatal or Ivor-Lewis approach]
- radiation, chemo
2
Q
Esophageal strictures
A
Presentation:
- dysphagia (esp solids)
- often have GERD +/- BE
Eso Web: thin membrane in upper eso (congenital or acquired)
Schatzki Ring: lower eso webs/constrict at squamocolumnar junction
- MC w/hiatal hernia
Dx: barium eso (swallow)
Mgmt:
- endoscopic dilation: sx w/out reflux
- lap nissen fundoplication if reflux present
Plummer Vinson Syndrome
- dysphagia
- eso webs
- IDA
- glossitis
3
Q
GERD
A
Retrograde flow of gastric contents into esophagus
Presentation:
- heartburn - retrosternal, postprandial, worse supine
- regurgitation, dysphagia, cough
- nontypical: bronchospasm, non cardiac CP, wt loss
Et:
- transient relaxation of LES
- MC UGI disease
- esophageal motility disorder
- delayed gastric emptying
- hiatal hernia
Dx:
- clinical
- endoscopy if persistent or complicated
- eso manometry for dec LES
- 24-hr pH monitoring (gold) only indicated for persistent
Mgmt:
- lifestyle; antacid; H2Ra; PPI
- surgery: if failed medical tx; young pt; respiratory sxs or vocal cord damage
- Barrett’s: Lap nissen fundoplication to Inc LES resting pressure
Complications:
- esophagitis
- stricture
- Barrett’s (metaplasia)
- Eso adenocarcinoma
4
Q
Gastritis
A
Superficial inflammation of stomach mucosa
Presentation
- MC: asx
- Sx: epigastric pain, NV, anorexia
Et:
- MC: H. pylori
- 2nd MC: NSAIDs/Aspirin
- 3rd: acute stress
- alcohol
Dx:
- endoscopy: thick edematous erosions (<0.5cm)
- H. pylori testing
Mgmt:
- H. pylori (+): Clarithromycin, Amoxicillin, PPI
- H. pylori (-): acid suppression
IV PPI or H2Ra for prophylaxis in pt at high risk for stress-induced gastritis
5
Q
Gastric carcinomas
A
Presentation:
- dyspepsia, wt loss, early satiety
- mets: Virchow’s node, umbilical LN, ovarian
Et:
- MC: adenocarcinoma
- MC in males, >40yo
RF:
- H. pylori
- salted/cured foods w/nitrates
- pernicious anemia, smoking
Dx:
- upper endoscopy w/bx: ulcerative, polypoid, diffuse stomach wall thickening (linitis plastica), superifical spread
Mgmt:
- gastrectomy**
- radiation, chemo
- poor prognosis
Gastric lymphoma:
- stomach MC site of extranodal lymphoma
6
Q
Peptic Ulcer Disease General
A
Acid corrodes gastric epithelium
Presentation:
- dyspepsia: epigastric pain, worse at night, food often worsens GU but relieves DU
- GI bleed: PUD = MC cause of UGIB
Et:
- Gastric ulcer: dec mucosal protection
- Duodenal ulcer: inc damaging factors
- MC: H. pylori; 2nd is NSAIDs
Other causes:
- ZES: gastrin producing tumor
- EtOH, smoking, stress
RF:
- males, elderly, steroids, malignancy
Younger pt: duodenal
Older pt: equal
7
Q
Peptic Ulcer Disease Dx/Tx
A
Dx:
- endoscopy w/bx to r/o malignancy (GU)
- Upper GI series if unwilling to do endoscopy
- GU must be followed w/endoscopy to r/o malignancy and document healing (in 8-12wk)
H. pylori testing
- endoscopy w/bx
- rapid urease test
- urea breath test
- H. pylori stool antigen
- serologic ab for confirmation only
Mgmt
H. pylori Triple Therapy
- Clarithromycin
- Amoxicillin
- PPI
Quad Therapy
- PPI
- Bismuth subsalicylate
- Tetracycline
- Metronidazole
H. pylori (-)
- PPI, H2Ra, misoprostol, antacids
Refractory/Complicated PUD:
- parietal cell vagotomy and Bilroth II (a/w dumping syndrome d/t loss of pylorus; CV/GI sxs)
8
Q
PUD Other
A
Complications:
- bleeding - post surface of duodenal bulb
- perforation - mostly anterior, “free air”
- peritonitis
- posterior penetration
- pyloric obstruction d/t cycles of inflammation, edema, scarring
Nonhealing gastric ulcer: suspect GI malignancy
Alarm Sxs:
- > 50yo
- dyspepsia
- h/o GU
- anorexia
- wt loss
- anemia
- dysphagia
9
Q
Pyloric stenosis
A
Presentation
- progressive, projectile non-bilious emesis after feeding
- coffee ground emesis
- decreased urine output, poor wt gain, signs of dehydration
- “olive shaped” non-tender mobile hard mass
Et:
- hypertrophy/hyperplasia of muscular layer of pylorus
- cause: functional outlet obstruction*
- occurs first 3-12wk of life* (MC caucasian male)
- adults, a/w chronic ulcer disease
Surgical complications:
- incomplete myotomy
- duodenal perforation
Dx
- U/S: elongation, thickening of pylorus
- Upper GI contrast: string sign and delay gastric emptying
- Labs: hypochloremic, hypokalemic metabolic alkalosis
Mgmt:
- medical: correct electrolytes; rehydrate w/IVF
- surgical: open vs. lap - pyloromyotomy* definitive
10
Q
Acute cholecystitis
A
Cystic duct obstruction
Presentation:
- acute constant RUQ pain, radiates to right scapula
- NV, fever
- (+) Murphy’s sign
Complications:
- empyema
- perforation
- gangrene
Et:
- MC d/t obstruction of cystic duct by cholelithiasis impacted in Hartmann’s pouch
- E. coli (MC), klebsiella, enterococci
Dx:
- abd U/S
- elevated WBC, ALP, bilirubin
- HIDA scan
Mgmt: NPO, IVF,abx
- lap chole* w/intra-op cholangiogram to exclude common duct stones w/in 72hr
11
Q
Cholangitis
A
Bacterial infection of biliary ducts
Presentation:
- Charcot Triad: RUQ pain, fever, jaundice
- Reynold Pentad: Charcot + shock + AMS
Et:
- biliary obstruction: choledocholithiasis, biliary stricture, neoplasm
- bacteria: E coli*, klebsiella, pseudomonas, enterococci, proteus, anaerobes
Dx:
- elevated WBC, ALP, GGT, Bili
- US, CT = CBD dilation
- cholangiogram vs. ERCP/PTC
Mgmt:
- IV Abx: Amp / sulbactam, PipTazo
- Emergent ERCP w/sphincterotomy
- open surgical decompression + T-tube
12
Q
Cholelithiasis
A
Gallstones
RF: fat, fair, female, forty, fertile
Presentation:
- MC: asx
- Sxs: obstruction = biliary pain/colic, cholangitis, jaundice, pancreatitis
Dx:
- US: CBD dilation > stones
- ERCP
- elevated WBC, ALP, bilirubin
30% of pt w/cholelithiasis have surgery
Asx stones - generally left alone unless >2cm stone or calcified “porcelain” gallbladder wall
Mgmt:
- Elective lap chole w/intra-op cholangiogram (sxs)
- ursodeoxycholic acid to dissolve
13
Q
Hepatocellular carcinoma
A
MC liver neoplasm
Presentation
- early: asx
- advanced: abd pain, jaundice, weight loss
- new onset ascites, abrupt hypoalbuminemia
Et:
- RF: HBV, HCV, cirrhosis; men; 5-8th decade
- adenocarcinoma arising from hepatocytes
Dx:
- US, CT, MRI, hepatic angio
- LFTs normal or c/w advanced disease
- AFP
- HCV Ab, HBV surface ag
- needle biopsy avoid to prevent seeding
Mgmt:
- surgical resection if confined to a lobe and not a/w cirrhosis
- transplant: only curative
- ablative techiques
- chemo for palliative care
14
Q
Metastatic liver neoplasm
A
Constitutional sxs
18x more common than primary liver tumors
2nd leading organ of mets after LN
Dx: CT/MRI or PET
Mgmt: chemo usually the only option
15
Q
Benign hepatic lesions
A
Asx
MC: hemangiomas
2nd MC: simple or complex cysts
Other: focal nodular hyperplasia, hepatic adenomas
Often found incidentally on abdominal imaging (CT)
Mgmt:
- all non-malignant tumors except adenoma managed conservatively with serial abdominal CT
- if resection consider, main decision point is status of liver
16
Q
Pancreatic pseudocysts
A
Presentation:
- acute pancreatitis not resolving after 1wk
- abd pain, duodenal/biliary obstruction, vascular occlusion, palpable mass w/expansion of cyst
Et:
- maturing collection of pancreatic juice encased by reactive tissue, consequence of inflammation or ductal leakage
- lined by fibrous tissue: lack of epithelial lining**
- acute pancreatitis MC cause
Complications:
- infection
- pseudoaneurysm
- ascites
Dx: amylase/lipase; CBC; CT scan
Mgmt:
- 40% resolve w/out intervention
- percutaneous drainage
- endoscopic drainage if >6wk old, >6cm, adherent to stomach/duodenum
- surgical drainage/debridement if infected
17
Q
Pancreatic cystic neoplasms
A
May have malignant potential*
Subtypes:
- serous cystic tumor
- mucinous cystic neoplasm
- intraductal papillary mucinous neoplasms
- solid pseudopapillary neoplasms
Mgmt:
- surveillance vs. resection based on risk of malignancy
18
Q
Pancreatic cancer
A
3rd leading cause of death from CA
90% adenocarcinoma
- 70% in pancreatic head
RF:
- age > 60yo
- smoking, male, obesity, AA, chronic pancreatitis, DM, EtOH
Presentation:
- painless jaundice and wt loss*
- abd pain to back
PE:
- Trousseau’s malignancy sign: migratory phlebitis
- Courvoisier’s sign: palpable, nontender distended gallbladder a/w jaundice
19
Q
Pancreatic cancer Dx/Tx
A
Dx:
- LFTs
- Tumor markers: CA 19-9, CEA
- CT scan abd/pelvis w/pancreas protocol
- ERCP, EUS w/FNA biopsy
Mgmt:
- chemo/radiation
“Curative” surgery only considered if:
- non-metastatic
- resectable by surgeon’s standards
“Curative” surgery = Pancreaticoduodenectomy
- Whipple: mass in head
- distal pancreatectomy: mass in tail
- Total pancreatectomy
Palliative:
- biliary stent via ERCP, PTC, duodenal stent
20
Q
Appendicitis general/presentation
A
General
- inflammation /distention of appendix d/t obstruction of lumen -> thrombosis of vessels -> ischemia/necrosis or infection of appendiceal wall
- Epi: 20s-30s
- MC non-Ob surgical disease of abdomen during pregnancy
Presentation
- Nausea, anorexia, fever
- vague periumbilical pain eventually migrating to RLQ w/increasing intensity
PE:
- rebound tenderness
- Psoas or obturator sign
- McBurney pain
Complications
- perforation
- peritonitis
- appendiceal abscess
21
Q
Appendicitis dx/tx
A
Dx:
- plain film generally not helpful
- U/S = peds**
adult: CT abd/pelvis w/contrast = Gold
- wall thickening
- enlarged
- occluded lumen
- peri-append fat strands
- appendicolith
Leukocytosis
Mgmt:
- surgical appendectomy ASAP
- broad spectrum abx initiated at time of diagnosis
22
Q
Diverticular disease general
A
Diverticulosis:
- asx
- MC cause of acute lower GI bleed
- bleed stops in 90% w/high fiber diet
- uninflamed herniations of mucosa through colon wall d/t intraluminal pressure
Diverticulitis
- fever
- LLQ abd pain* (MC)
- NVD, constipation, flatulence, bloating
- inflamed diverticula secondary to obstruction or infection
- MC: sigmoid colon
- increased prevalence w/age
- a/w low fiber diet, constipation, obesity
23
Q
Diverticular disease dx/tx
A
Dx:
- CT abd/pelvis w/IV contrast: peri-colic fat stranding, abscess, fistula
- inc WBC, + guiac
Mgmt:
Diverticulosis: high fiber diet, fiber supplement
Diverticulitis:
- admit for significant pain, anorexia, or systemic disease
- bowel rest: NPO, NG decompression
- broad spec abx: Cipro or TMP/SMX + Metro
- IVF
Surgery:
- urgent if partial colectomy if perforation w/peritonitis
- elective if recurrent or complicated disease, inability to r/o CA
- primary resection w/out anastomosis (risk for leak) or temporary colostomy (Hartmann procedure) w/anastomoses in 1-2 mo
24
Q
Intussusception general
A
General
- intestinal segment telescopes into adjoining intestinal lumen causing bowel obstruction
- MC acute abd pain in kids <5y (more common in M)
- MC idiopathic and MC ileocecal junction
Presentation
- colicky abd pain: attacks up to 15-30min, knees drawn up
- currant jelly stool
- Triad: vomit, abd pain, passage of blood per rectum*
- abd distension
- palpable mass in RLQ
- blood on rectal exam
Complications:
- perforation secondary to enema
- recurrent intussusception
25
Q
Intussusception dx/tx
A
Dx
Plain KUB:
- late SBO
- dance’s sign: sausage shape in RUQ + no bowel gas in RLQ
Enema = dx/tx
- water or air; contrast should reflux through
MC - ileocecal valve into terminal ileum
Mgmt:
- barium or air enema
- surgical resection if failed enema or high suspicion of lead point
Enema C.I. = perforation on KUB or clinical peritonitis
26
Q
Crohn’s disease general
A
- chronic progressive granulomatous inflammatory disorder of GI tract (anywhere from lips to anus)
- areas m/c affected = terminal ileum and right colon
- peak incidence 20-40s
- skip lesions occur in 15% patients, granulomatous ulcers in bowel wall in 50-75% resulting in bowel wall thickening, fissure/stricture formation
- transmural depth
Presentation
- recurrent abd pain initiated by meals, relieved by bm
- RLQ pain + constitutional sx
- diarrhea - usually no blood
- perianal lesions, malabsorption of Fe and Vit B12
- extra-intestinal signs = arthritis, uveitis, oral ulcers, UTIs, erythema nodosum, gallstones, etc.
27
Q
Crohn’s dx/tx
A
- UGI series w/ SBFT: string sign, cobblestone
- endoscopy: upper and/or lower
- (+) ASCA (Ab vs Saccharomyces cerevisiae)
Mgmt:
- aminosalicylates, steroids, immune modifying, anti-TNF
- surgical tx - preserve length and remove affected area, resection (w/ possible ileostomy/colostomy) vs. strictureplasty
- surgery is NOT curative
-60-75% pt will require surgery at some point to relieve sx or correct complications
28
Q
Ulcerative colitis general
A
- diffuse, contiguous mucosal inflammatory dz begins in rectum, contiguous spread proximally
- depth is mucosa and submucosa only
- smoking decreases risk for UC
- bimodal age distrib: 15-30, 60s-80s
Presentation
- LLQ pain m/c, colicky, tenesmus, urgency +/- constit sx
- bloody diarrhea w/ mucus
- primary sclerosing cholangitis, colon CA, toxic megacolon
- extra-intestinal signs: arthritis, uveitis, oral ulcers, UTIs, erythema nodosum, gallstones, etc.
29
Q
Ulcerative colitis dx/tx
A
Dx:
- Flex sigmoidoscopy test of choice in acute disease: uniform inflammation +/- ulcers, pseudopolyps
- Stovepipe sign (loss of Haustra markings) on barium enema
- (+) P-ANCA
Mgmt:
- aminosalicylates, steroids, immune modifying, anti-TNF
- surgery is curative: proctolectomy (entire colon and rectum) or colectomy
- colonoscopy contraindicated in acute colitis, may cause perf
- barium enema CI, may cause toxic megacolon
30
Q
Acute mesenteric ischemia general
A
- reduced intestinal blood flow (esp at splenic flexure) from arterial occlusion, venous occlu, or vasoconstrict
- mortality can exceed 60%
- etiology: mesenteric arterial emboli from mural thrombus in LV or clot from afib (50%), mesenteric arterial thrombosis from atherosclerotic stenosis (25%), nonocclusive (20%), OR mesenteric venous thrombosis (5%)
Presentation
- severe poorly localized abdominal pain (often unresponsive to opioids)
- abdominal pain out of proportion to clinical findings
- N/V/D, peritonitis, shock
- blood in stool
31
Q
Acute mesenteric ischemia
A
Dx:
- high lvl of susp in pt w/ RF
- CT w/ absence of bowel gas, diffuse disten w/ air fluid lvls, thickened bowel wall
- colonoscopy: patchy, necrotic
- mesenteric CT angiography is gold standard
Mgmt:
- early intervention (<12 hrs s/p sx)
- initial management w/ anticoagulation, pain control, abx
- surgical revascularization = arterial embolectomy, angioplasty
- bowel resection if not salvageable
- # 1 cause of short gut syndrome
- often lethal d/t infarction that occurs w/ delayed dx and tx
32
Q
Chronic mesenteric ischemia
A
-mesenteric atherosclerosis of the GI tract: inadequate perfusion (esp of splenic flex) during post-prandial studies
- chronic dull abdominal pain worse after meals
- intestinal angina
- weight loss (anorexia)
- angiogram confirms dx
- colonoscopy: muscle atrophy w/ loss of villi
- bowel rest
- surgical revascularization (angioplasty w/ stenting or bypass)
33
Q
Ischemic colitis
A
- reduction in blood flow related to acute arterial occ, venous thromb, or hypoperfusion m/c d/t systemic HTN or atherosclero involving sup & mesenteric aa
- usually elderly pts
- sigmoid 40% > transverse 17% > splenic flex 11%
- m/c at “watershed” areas w/collaterals and splenic flexure and rectosigmoid junction
- gangrenous IC: transmural, nonrevers injury rapidly fatal w/o surgery
- nongangrenous: reversible, resolves w/o sequalae
Presentation
- LLQ pain w/ tenderness
- bloody diarrhea (d/t sloughing of colon)
-complications: persistent seg colitis and dev of stricture
Dx
- CT scan w/ contrast: thickened bowel wall
- colonoscopy: segmental ischemic changes (edema, hemorrhage, friable mucosa) in areas of low perfusion
Mgmt:
- restore perfusion and observe for signs of perf
- reversible IC (nontrasmural) supportive care, typ resolve in 1-2 wks
- irreversible IC (transmural) resect diseased portion, possible temp colostomy
34
Q
Colorectal cancer general
A
- 4th m/c CA, 3nd m/c cause of CA-related death in US
- 90% of cases occur > age 50, 95% adenoCA
- m/c site of metastatic spread is the liver
- RFs familial adenomatous polyposis (APC gene mutation), lynch syndrome, Peutz-Jehgers (autosomal dominant, hamartomatous polyps, mucocutaneous hyperpigmentation), UC > Crohn’s, adenomatous polyps, low-fiber high processed/red meat diet, smoking, ETOH, AA, FH
- spreads through regional LN mets, direct extension (forms apple core circum), or hematogenous mets
- doubling time 130 days
- complications = perf, hemorrhage, obstruct
35
Q
CRC presentation/dx
A
- iron deficiency anemia, rectal bleeding, abdominal pain, change in bowel habits
- CRC m/c cause of large bowel obstruction in adults
- right-sided lesions tend to bleed (anemia and fecal occult), diarrhea, fatigue, weight loss
- left-sided lesions present later w/ bowel obstruction, change in bowel habits (rectal lesions cause hematochezia)
Dx
- colonoscopy w/ bx = test of choice
- barium enema = apple core lesion classic
- Stool based tests = gFOBT, FIT, stool DNA testing
- CT chest/abd/pelvis to w/u
- CEA = lvls also monitored during tx
- CBC = iron deficiency classic
36
Q
CRC mgmt
A
- simple polypectomy or local excision for tumors limited to colonic mucosa
- localized (stage I-II) = wide surgical resection of affecter area
- stage III and metastatic = chemo mainstay of tx (ex. 5FU)
- palliative interventions = diverting colostomy, electrocoagulation, endoluminal stents
-colon CA screening if avg risk: FOBT annually at 50yo, colonoscopy q10y or flex sig q5y (w/ FOBT q3y) up to 75yo
37
Q
Small intestine tumors
A
- <10% of all GI tumors
- 1/3rd benign: adenomas and leiomyomas
- 2/3rds malignant: adenocarcinoma (45%), carcinoid (30%), lymphoma (15%), stromal and sarcoma (10%)
Presentation
- benign tumor: typically asx, intermittent abd cramp, chronic bleed w/ iron def anemia
- malig: weight loss, sx depending on location, sx secondary to hormone production
Dx:
- CT scan abd/pelvis w/ contrast
- upper GI study
- endoscopy: usually for eval of duodenum
Mgmt:
- most tx w/ surgical excision
- chemo, radiation pending specific pathology
- octreotide useful in improving sx in neuroendocrine tumors
38
Q
SBO
A
General
- post-surgical adhesions m/c, incarcerated hernia 2nd m/c cause of SBO
- closed loop vs. open loop, complete vs. partial, distal vs. partial
Presentation
- cramping abd pain, abd distent, vomiting, obstipation (CAVO)
- hyperactive BS early (high-pitched tinkles on auscultation and visible peristalsis), hypoactive BS late in obstruct
Dx
- abdominal series: air fluid lvls in step ladder pattern, dilated bowel loops
- CT abdomen pelvis w/ IV and PO contrast to ID site and severity of obstruction
Mgmt
- non-strangulated/partial NPO, IV fluids, bowel decompress
- strangulated/closed loop surgery (laparotomy, LOA, eval of whole SB, resection of nonviable segment)
-if + peritonitis, free air, or closed loop obstruction, take to OR
39
Q
Large bowel obstruction
A
General
- malignancy m/c cause of large bowel obstruction, strictures, volvulus (m/c cause of benign obstruct), incarcerated hernia, FB impaction
- blockage resulting in distension and risk for perf
- 15% of all intestinal obstruction, sigmoid m/c
Presentation
- deep visceral crampy pain, referred to hypogastrium
- constipation, obstipation
- abd distention & tympany
Dx
- plain films w/ distended colon
- barium enema: obs location
- CT w/ oral and IV contrast best test
Mgmt
- surgery almost always required: resect necrotic bowel, decompress obstructed area, remove obstructing lesion
- flex sigmoidoscopy to reduce sigmoid volvulus
40
Q
Ogilvie’s Syndrome
A
General
- acute pseudoobstruction of colon w/o mech lesion imbalance in autonomic tone w/ absence of peristalsis
- m/c in ill elderly (>60), men, s/p trauma/ meds
- m/c in cecum and right hemicolon
Presentation
- abdominal pain and distention
- vomiting, obstipation, diarrhea
- tympany w/ normal BS
Dx
- plain films w/ gaseous disten, barium enema w/o obstruction
- CT abd/pelvis: proximal right colon dilation
Mgmt
- conservative tx: supportive care, remove precipitant drugs
- neostigmine (to increase Ach lvls and bowel compress), colonic decompression w/ rectal tube if cecum >12cm diameter
- surgery is last resort if unresp. and sig risk for perf or ischemia
41
Q
Polyps
A
- pseudopolyps/inflammatory: d/t IBD, not considered cancerous
- hyperplastic low risk for malignancy
- adenomatous polyps avg is 10-20yr before becoming cancerous (esp >1cm) – tubular polyps (m/c & least risk), tubulovillous (intermed risk), villous adenoma (highest risk)
Dx
-direct visualization of polyps and CA= flex sig, colonoscopy, CT colonography
Mgmt
-removal during colonoscopy and pathology
42
Q
Toxic megacolon
A
General
- nonobstructive extreme colon dilation >6cm + signs of systemic toxicity
- etiologies = UC, Crohn, pseudomembranous colitis, infections, radiation, ischemic
Presentation:
- fever, abd pain, N/V/D, rectal bleeding, tenesmus, electrolytes
- abd tenderness, rigidity, tachycardia, dehydration, hypotension, AMS
Dx:
-abd radiographs w/ large dilated colon >6cm
Mgmt
- bowel decompression, bowel rest, NG tube
- broad spectrum abx
- electrolyte repletion
- colostomy reserved for severe cases
43
Q
Abscess
A
General
- bacterial infection and blockage of anal ducts/glands
- m/c S. aureus, E. coli, Bacteroides, Proteus, Strep
- m/c in posterior rectal wall
Presentation
- anorectal swelling, rectal pain worse w/ sitting, coughing, defecation
- systemic dx of infxn possible
Dx
- CBC
- CT abd/pelvis w/ contrast to eval extent of abscess prn
Mgmt
- I & D followed by warm-water cleansing, analgesics, sitz baths, high-fiber diet (WASH)
- abx
- surgical removal
44
Q
Fistula
A
General
-open tract btw two epithelium-lined areas, seen especially w/ deeper abscesses
Presentation
-may cause anal discharge & pain
Mgmt
- I & D followed by warm-water cleansing, analgesics, sitz baths, high-fiber diet (WASH)
- abx
- surgical removal
45
Q
Hemorrhoids
A
General
- blood vessels in lower rectum and anal canal become engorged d/t increase in intraabdominal pressure
- RF = venous pressure, straining, pregnancy, obesity, prolonged sitting, cirrhosis w/ portal HTN
- internal originate above dentate line, generally painless, 1st- 4th degree
- external originate below dentate line, sx occur w/ thrombosis, presents as severe perianal pain
Presentation
- internal intermittent BRBPR, mucous discharge, rectal fullness, edema/incarcer
- external acute intravascular thrombosis w/ severe pain, purple-black perianal mass
Dx
- clinical dx w/ visualization of prolapsed or thrombosed hemorrhoids on exam
- DRE, FOBT
- anoscopy for eval of internal hemorrhoids
- proctosigmoidoscopy, colonoscopy in pt w/ BRBPR
Mgmt
- initially conservative w/ diet (add fiber, stool softener) and exercise, sitz baths, topical rectal steroids
- office-based procedure injection sclerotherapy, elastic band ligation
- surgical stapled hemorrhoidectomy, excisional
46
Q
Pilonidal cyst
A
General
- tender abscess w/ drainage on or near gluteal cleft near midline of coccyx or sacrum w/ midline pits
- likely congenital anomaly
- m/c in white males, obese, hirsute pt, prolonged sitting, local trauma
Presentation
- asx
- acute abscess = sudden onset sev pain/swell, inflamed mass overlying sacrum or coccyx
- chronic dz = persist drainage
Clinical diagnosis
Mgmt:
- I&D
- requires curative surgical excision of pilonidal sinus and tracts w/ possible plastic surgery closure of muscle
47
Q
Rectal cancer
A
-rectal lesions cause hematochezia
Dx
-rectal bleeding in middle-aged person, even in presence of hemorrhoids must r/o CA
Mgmt
- recto-sigmoid colon lesion Low anterior resection of rectum (LAR)
- middle rectal lesion colo-anal anastomosis w/ J-pouch construct
- distal rectal lesion abdomino-perineal resection of rectum w/ end colostomy
-Hartmann’s procedure = temp colostomy
48
Q
Umbilical hernia (ventral)
A
General
- herniation through abd wall at or near umbilicus, usually contains omentum or preperitoneal fat
- common, usually acquired in adults d/t in intraabd pressure, female > male
- congenital in children d/t fail of umbilical ring closure
- freq coexist w/ rectus abdominus diastasis
Presentation
- soft protuberance at umbilicus
- often asx unless incarceration or strangulation
- tenderness may be elicited w/ pressure & palpation
Clinical diagnosis
Mgmt
- don’t req tx if small/asx observation, usually resolves by 2yo
- surgical repair if sx or still persist >5 yo open vs laparoscopic
- mesh used for large defects and fascial edges w/ sig tension (possibility for mesh infection, erosion, migration)
49
Q
Incisional hernia (ventral)
A
General
- dev in sites where incision has been made for some prior abd procedure d/t failure of fascial tissues to heal
- emergency surgery or any condition which inhib wound healing risk (obesity m/c)
- occurs in 10-15% of abd incisions, midline m/c, typically dev in early post-op period
Presentation
- bulge in abd wall originating deep to skin scar, edges of fascial defect often defined
- sx vary, aggravated by coughing or straining
Clinical diagnosis
Mgmt
- expectant vs operative
- mandatory surgical tx if bowel involved
- simple sutured vs. mesh repair, open vs. laparoscopic sutured w/ recurrence
50
Q
Spigelian hernia (ventral)
A
General
- herniation through linea semilunaris (line where sheaths of lateral abd muscles fuse to form lateral rectus sheath)
- extremely rare, but high incidence of incarceration
Presentation
-swelling and sharp pain / tenderness in mid to lower abd just lateral to rectus muscle
Diagnosis
- clinical dx bulge present when pt standing and straining
- US, CT
Mgmt
- surgical repair w/open or lap
51
Q
Epigastric hernia (ventral)
A
General
- defects in abdominal midline btw umbilicus & xiphoid, usually at sites of congenital weakness in linea alba, incarceration/strangulation rare
- men > women, usually middle age
- RF = ext physical training or coughing, obesity, smoking, chronic steroid use, DM, old age
Presentation
- small uncomfortable mass b/s umbilicus and xiphoid, <1 cm in diameter
- can be asx
Clinical diagnosis
Mgmt
- repair only sx hernias
- usually performed under local anesthesia w/ open approach
- low recurrence rate after repair
52
Q
Parastomal hernia (ventral)
A
General
- type of incisional hernia protrusion of abd contents through abd wall defect created during ostomy
- most freq complication s/p colostomy/ileostomy (50%), typically w/in 1st 2 yrs of creation
Presentation
- bulge at stoma site or adjacent
- may have pain
Dx
-removal of ostomy device req for exam digitization of ostomy allows for identification
Mgmt
- conservative management for asx
- surgical options open vs. lap, primary vs. mesh
53
Q
Inguinal hernia General (groin)
A
General
- protrusion of abd contents through inguinal canal d/t weakness/defect in transversalis fascia, male > female
- 95% of groin hernias are inguinal (indirect > direct)
- accounts for most hernias in infants, kids, YA
- indirect herniation at internal inguinal ring (spermatic cord or round lig), origin lateral to inferior epigastric vessels, most are congenital d/t patent process vaginalis, R>L, m/c overall type in both sexes
- direct herniation medial to inferior epigastric vessels d/t weakness in floor of inguinal canal (Hesselbach’s triangle), does not reach scrotum
- pantaloon combined direct and indirect hernia, result of untreated indirect hernia
Presentation
- most asx until pt notices lump or swelling in groin (may have scrotal swelling in indirect)
- sx more likely as hernia enlarges m/c is heaviness or dull discomfort w/ strain or lift
- incarcerated painful, enlargement of irreducible hernia, N/V if bowel obstructed
- strangulated ischemic incarcerated hernia w/ systemic tox, severe painful bm
54
Q
Inguinal hernia dx/tx
A
Dx
- most dx w/ H&P
- examine visually for bulge
- in males, index finger invaginates scrotum adj to external ring pt to cough
- in females, place fingers across inguinal canal pt bear down
Mgmt
- definitive tx is surgical repair open Lichtenstein (w/ mesh), open 1, laparoscopic (TEP vs TAPP)
- urgent repair if strangulation or bowel obstruct no contraindications
- bilateral best tx w/ laparoscopic, open best for pt w/ prior abd surg
- expectant management can be considered in asx pt Truss can provide ext compress over defect
- inguinal hernia repair is m/c general surgical procedure performed
- difficult to separate direct vs. indirect on exam
55
Q
Femoral hernia
A
- protrusion of contents of abd cavity through the femoral canal below inguinal ligament (medial to femoral vein)
- m/c seen in women
- commonly present as bowel obstruction often become strangulated c/t inguinal hernia
-surgical repair McVay (open w/ no mesh), open bilayer mesh repair, laparoscopic repair
56
Q
Obturator hernia
A
General
- rare hernia through pelvic floor in which pelvic or abd contents protrude through obturator foramen
- m/c in women (multiparous or sig weight loss)
- mortality rate 10-40% most lethal abd wall hernia
Presentation
- often presents as SBO
- lancinating pain in medial thigh/obturator distrib extend to knee c/b compress of obt nerve
Mgmt
- surgical tx urgent if incarcerated and causing SBO
- consider in any elderly debilitated women w/o prior abd surgery who presents w/ SBO
