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Surgery (bpa) > GI > Flashcards

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
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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
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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
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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

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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

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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

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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

  1. Clarithromycin
  2. Amoxicillin
  3. PPI

Quad Therapy

  1. PPI
  2. Bismuth subsalicylate
  3. Tetracycline
  4. 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)

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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
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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
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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

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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
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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
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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
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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

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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
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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
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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

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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
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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

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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
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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
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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
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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

Surgery (bpa) (19 decks)

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