GI Flashcards
0
Q
Esophageal Neoplasms
A
-Most common is leiomyoma-benign, tx is surgical resection
- *Carcinoma**
- RFs: male, chronic alcohol and tobacco use, achalasia, caustic induced esophageal stricture, barrett’s esophagus due to GERD, reflux, radiation
- Most cases occur in distal third of esophagus
- Two main types: Squamous cell carcinoma (most common worldwide), Adenocarcinoma(due to Barretts, most common in USA)
- Sx: dysphagia (solid foods), wt loss, chest pain, back pain, hoarseness, sx from mets.
- Workup: UGI, EGD, transesophageal US, CT of chest/abdomen, CBC to look for anemia, LFTs to look for mets to liver, alkaline phosphatase to look for mets to bone
- Dx: UGI to localize tumor, EGD for bx, met workup (CXR, bone scan, CT, LFTs)
- Tx: Esophagectomy with gastric pull up or colon interposition. Nonresectable= chemo, radiaion, dilation, stent, laser, electrocoagulation, brachytherapy, photodynamic laser therapy.
1
Q
Barrett’s esophagus
A
- Can be a complication of GERD
- Metaplasia of esophageal mucosa at GE junction. Change from squamous to columnar epithelium with intestinal metaplasia.
- “Tongue like pattern” on EGD
- More common in older white males
- Sx: heartburn
- Dx: endoscopy with bx
- Tx: long term PPI use. Antacids, H2 blockers, anti-reflux surgery for GERD, surgery, endoscopic mucosal resection
- Associated with an increased risk of adenocarcinoma
2
Q
Mallory-Weiss tear
A
- Post retching, post emesis longitudinal tear of the stomach near the GE junction.
- Etiology: increased gastric pressure, often aggrevated by a hiatal hernia
- RFs: retching, alcholism, hiatal hernia
- Sx: epigastric pain, thoracic substernal pain, emesis, hematemeis
- Dx: EGD
- Classic hx: alcoholic pt after binge drinking
- Tx: room temp water lavage, electrocautery, arterial embolization, surgery if refractory bleeding (>6 u PRBCs infused).
3
Q
Esophageal Strictures
A
- Narrowing of the esophagus that causes swallowing difficulty(especially of solids)
- Etiology: GERD, esophagitis, dysfunctional LES, hiatal hernia
- Sx: solid food dysphagia, hearburn, SOB, hiccups, wt loss, hemoptysis
- Dx: endoscopy with bx
- Tx: dilation, long term PPI
4
Q
Esophageal varices
A
- Dilated submucosal veins due to the back up of portal pressure via the coronary vein to the submucosal esophageal venous plexuses secondary to portal hypertension from liver cirrhosis.
- Rule of 2/3: 2/3 of pts with portal HTN develop varices, 2/3 of pts with varices will bleed
- Sx: liver disease, portal HTN, hematemesis, caput medusa, ascites
- Dx: EGD
- Acute medical tx: lower portal pressure with somatostatin and vasopressin
- Tx: sclerotherapy or band ligation with endoscope, TIPS, liver transplant, sengstaken-blakemore balloon
5
Q
Ulcers gastric/duodenal
A
-PUD= tx H.pylori with Omeprazole, Clarithromycin, and Metronidazole/Ampicillin
- *Duodenal Ulcer**
- Age: 40-65yo, younger than gastic ulcer
- Food relieves pain
- Etiology: increased production of gastric acid
- RFs: male, smoking, ASA, NSAIDs, uremia, zollinger ellison syndrome, H. pylori, trauma, burn
- Sx: epigastric pain usually several hours after a meal, bleeding, back pain, nausea, vomiting, anorexia, decrease in appetite, guaiac positive stool, melena, hematochezia, hamatemesis
- Dx: hx, PE, EGD, UGI series
- Surgery indications: >6 u PRBC transfusions if bleeding. Intractability, hemorrhage, obstruction, perforation.
- Medical tx: PPIs, H2 agonists, tx for H. pylori.
- Surgery:
- Duodenal perforation= graham patch, truncal vagotomy and pylorplasty, graham patch with highly selective vagotomy, truncal vagotomy and antrectomy.
- Duodenal obstruction= BI or BII, truncal vagotomy and drainage procedure
- *Surgeries**
- Graham patch: piece of omentum is incorporated into the suture closure of perforation. Used in treating duodenal perforations in poor operative candidates.
- Truncal vagotomy: resection of a 1-2 cm segment of each vagal trunk as it enters the abdomen on the distal esophagus. This decreases gastric acid secretion. Need to perform a drainage procedure with it (pyloroplasty, antrectomy, or gastrojejunostomy).
- Antrectomy: remove antrum and pylorus
- BI: truncal vagotomy, antrectomy, and gastroduodenostomy. Contraindicated in stomach cancer.
- BII: truncal vagotomy, antrectomy, and gastrojejunostomy.
- *Gastric Ulcer**
- Age: 40-70yo, older than duodenal
- Less common than duodenal
- Food INCREASES pain
- Etiology: decreased cytoprotection (decrease in bicarb or mucus)
- Gastric acid production is normal or low
- RFs: smoking, alcohol, burns, trauma, CNS tumor, NSAIDs, steroids, shock, severe illness, male, advanced age
- Sx: epigastric pain, +/- vomiting, anorexia, nausea
- Dx: hx, PE, EGD with multiple bx(need to r/o gastric cancer)
- Medical tx: PPIs, H2 blockers, tx for H. pylori
- EGD: Perform for dx and 6wks postdx to confirm healing and r/o cancer
- Indications for surgery: intractability, cancer, hemorrhage, obstruction, perforation.
- Hemorrhage, obstruction, and perforation: distal gastrectomy with excision of the ulcer w/o vagotomy.
- Concomitant duodenal and gastric: resect and truncal vagotomy
- Pyloric gastric ulcer: truncal vagotomy and antrectomy
6
Q
Stomach Neoplasms
A
- *Benign**
- fundic gland polyps, hyperplastic polyps, adenomatous polyps(these have pre malignant potential-remove endoscopically)
- *Gastric Adenocarcinoma**
- RFs: diet(smoked meats, high nitrates, low fruits and veggies, alcohol), tobacco use, poor SES, atrophic gastritis, male, blood type A, previous partial gastrectomy, pernicious anemia, polyps, H. pylori.
- Avg age= >60yo
- Pathology: intestinal or diffuse(no glands), ulcerative or polypoid or scirrhous or superficial.
- Sx: wt loss, emesis, anorexia, epigastric pain, obstruction, nausea, hematemesis, melena, early satiety, anemia, heme occult, epigastric mass, hepatomegaly, Blumers shelf(solid peritoneal deposit anterior to the rectum), Virchows node(metastatic gastric cancer to the nodes in the left supraclavicular fossa), Sister mary joseph nodule (periumbilical LN gastric cancer mets), enlarged ovaries, axillary adenopathy.
- Most common early sx= mild epigastric discomfort and indigestion
- Most common sx overall= wt loss
- Workup: EGD with bx, endoscopic US to evaluate the level of invasion, CT of abdomen/pelvis to look for mets, CXR, CBC to look for anemia, LFTs to look for mets to liver
- More common in the lesser curvature in the proximal stomach.
- P53 genetic alteration seen in pts
- Nonoperative: distant mets, peritoneal implants
- Tx: surgical resection with wide margins and LN dissection.
- If tumor in antrum: distal subtotal gastrectomy (75% of stomach removed)
- If tumor in midbody or proximal: total gastrectomy (stomach removed and a roux en Y limb is sewn to the esophagus).
- Adjuvant tx: post op chemo and radiation for LN positive disease
- *Gastric Lymphoma**
- can develop secondary to H. pylori
- Need to treat H. pylori
- *Gastric Carcinoid**
- neuroendocrine tumor
- tx with surgical resection.
- *GIST**
- submucosal
- surgical resection, Imatinib
7
Q
Pyloric Stenosis
A
- Hypertrophy of muscular layers of pylorus,leading to obstruction
- More common in first born males
- Onset: 2-4 wks old
- Classic presentation: projectile nonbilious vomiting, palpable olive
- Dx: PE, US (cervix sign)
- Tx: correct any metabolic abnormalities first. Pyloromyotomy is curative.
8
Q
Acute pancreatitis
A
-Inflammation of the pancreas-digestive enzymes leak out of acinar cells and destroy the pancreas.
-Etiology: Most common are Alcohol abuse, gallstones, and idiopathic. Trauma, scorpion bite, mumps, autoimmune, steroids, hyperlipidemia, ERCP, drugs.
-Sx: epigastric pain(radiates to the back), N/V, restlessness, relief of pain by bending forward, diffuse abdominal tenderness, decreased bowel sounds, fever, dehydration/shock, tachycardia, shallow respirations, ecchymosis
-Labs: CBC(WBC will be high), LFTs, amylase(will be high), lipase(most helpful because specific to the pancreas, will be high), blood type and cross, ABG, Calcium, CMP, Coags, serum lipids, CRP
-Imaging: abdominal x-ray(sentinel loop or colon cutoff sign), US (gallstones), CT(MOST IMPORTANT)
-Ranson criteria: 1 pt for each
-Present: >35yo, WBC >16,000, Glucose >200, AST>250, LDH>350
-48hrs: base def>4, BUN increase>5, fluid sequestration>6L, serum
Ca 10%, PO2 2 may indicate drinking). Surgical consult to drain cyst or abscess.
-Complications: psudocyst, abscess, infection, vessel rupture, ascites, DM, sepsis, DIC, encephalopathy, pancreatic necrosis, hypocalcemia
9
Q
Chronic Pancreatitis
A
- Chronic inflammation of the pancreas causing destruction of parenchyma, fibrosis, and calcification, which leads to loss of endocrine and exocrine tissue.
- Most common cause is alcohol abuse. Other causes= idiopathic, hypercalcemia (hyperparathyroidism), hyperlipidemia, familial, trauma, iatrogenic, gallstones.
- Sx: epigastric pain, back pain, wt loss, steatorrhea, anorexia, N/V, constipation, flatulence, glucose intolerance
- Labs: amylase, lipase, fecal fat analysis, glucose
- Imaging: CT (greatest sensitivity), KUB, ERCP
- Tx: discontinuation of alcohol use, insulin, pancreatic enzyme replacement, narcotics, low fat diet.
- Surgery: longitudinal pancreaticojejunostomy, distal pancreaticojejunostomy, total pancreatectomy. Use surgery if severe prolonged/refractory pain.
10
Q
Pancreatic Cancer
A
- Adenocarcinoma of the pancreas arising from duct cells
- RFs: smoking, DM, alcohol use, chronic pancreatitis, diet high in fried meats, previous gastrectomy, prior abdominal radiation.
- Ave age >60yo
- Majority are in the pancreatic head-these draw attention earlier because of biliary obstruction.
- Sx of head tumor: painless jaundice, wt loss, abdominal pain, back pain, weakness, pruritis, anorexia, courcoisiers sign (palpable nontender distended gallbladder), acholic stools, dark urine, DM.
- Sx of body/tail tumor: wt loss, pain, migratory thrombophlebitis, jaundice, N/V, fatigue
- May see virchows node or sister mary josephs nodule
- Mets: liver, lungs, peritoneum
- Labs: increased direct bilirubin, increased alkaline phosphatase, increased LFTs, elevated pancreatic tumor markers (CA-19-9), elevated glucose, increased fecal fat, elevated amylase/lipase
- Imaging: abdominal CT, US, cholangiography, ERCP, endoscopic US with bx.
- Tx: in head= whipple(cholecystecomy, truncal vagotomy, antrectomy, pancreaticoduodenectomy(remove head of pancreas and duodenum), choledochojejunostomy( anastomosis of common bile duct to jejunum), pancreaticojejunostomy(anastomosis of distal pancreas remnant to jejunum), gastrojejunostomy(asastomosis of stomach to jejunum). In body/tail= distal resection.
- Inoperable: vascular encasement, liver mets, peritoneal implants, distant LN mets, distant mets, malignant ascites.
- Post op= chemo +/- radiation
- Palliative: PTC or ERCP and placement of stent.
11
Q
Pancreatic pseudocyst
A
- Encapsulated collection of pancreatic fluid. Wall is formed by inflammatory fibrosis.
- RFs: chronic alcoholic pancreatitis
- Sx: epigastric pain, emesis, mild fever, wt loss, palpable mass, ileus
- Labs: amylase(high), lipase, bilirubin(high), CBC(leukocytosis)
- Imaging: US(fluid filled mass), CT (fluid filled mass), ERCP
- Complications: infection, bleeding, fistula, ascites, gastic outlet obstruction, biliary obstruction
- Tx: drainage or observation (50% will resolve spontaneously). If bleeding, need angiogram and embolization. If infected, need percutaneous external drainage with IV abx. Needs to be drained if >5cm, calcified wall, or thick wall. Can drain with: percutaneous aspiration, operative drain, or transpapillary stent via ERCP. If using surgical drainage, need to bx.
12
Q
Liver Neoplasms
A
- Most common liver cancer is metastatic disease.
- Most common primary malignant tumor= hepatocellular carcinoma
- Most common primary benign tumor= hemangioma
- Imaging studies: CT, US, angiogram
- Benign*
- 3 Types: hemangioma, hepatocellular adenoma, focal nodular hyperplasia
- *Hemangioma**
- Vascular tumor
- Most common primary benign tumor of liver
- Sx: RUQ pain/mass, bruits
- Complications: pain, CHF, coagulopathy, obstructive jaundice, gastric outlet obstruction, Kasaback merritt syndrome(hemangioma and thrombocytopenia and fibrinogenopenia), hemorrhage.
- Dx: CT with contrast, tagged red blood scan, MRI, US
- Tx: observation. Resect if symptomatic or hemorrhage.
- *Hepatocellular Adenoma**
- Normal hepatocytes w/o bile ducts
- RFs: women, birth control pills, anabolic steroids, glycogen storage disease
- Avg age= 30-35yo
- Sx: RUQ pain/mass, bleeding
- Complications: rupture with bleeding, necrosis, pain, risk of cancer
- Dx: CT, US, bx
- Tx: small=stop birth control pills, surgical resection. large= surgical resection.
- *Focal Nodular Hyperplasia**
- Normal hepatocytes and bile ducts
- RFs: female, birth control(but not as great a risk as adenoma)
- Avg age= 40yo
- Dx: nuclear technetium 99 study, US, CT, angiogram, bx
- Complications: pain
- No increased risk for cancer
- Tx: resection or embolization if symptomatic, stop birth control pills, observation.
- Malignant*
- 4 Types: hepatocellular carcinoma, cholangiocarcinoma, angiosarcoma, hepatoblastoma.
- *Hepatocellular carcinoma**
- RFs: Hep B, cirrhosis, alfatoxin
- Sx: dull RUQ pain, hepatomegaly, abdominal mass, wt loss, paraneoplastic syndromes, signs of portal HTN, ascites, jaundice, fever, anemia, splenomegaly
- Labs: US, CT, angiography, elevated alpha-fetoprotein(tumor marker)
- Dx: needle bx with CT/US/laproscopic guidance
- Mets: lungs
- Tx: surgical resection, transplant
- Non-operable: percutaneous ethanol tumor injection, cryotherapy, intra-arterial chemo
13
Q
Portal hypertension
A
- Elevated portal pressure resulting from resistance to portal flow
- Normal portal pressure is <10 mmHg
- Etiology: Prehepatic- thrombosis of portal vein, atresia. Hepatic- cirrhosis, hepatocellular carcinoma, fibrosis. Posthepatic- budd chiari syndrome, thrombosis of hepatic veins.
- Most common cause is cirrhosis.
- Associated clinical findings: esophageal varices, splenomegaly (most common finding), caput medusa, hemorrhoids. Also spider angioma, palmar erythema, truncal obesity, peripheral wasting, encephalopathy, asterixis, gynecomastia, jaundice.
- Most feared complication= bleeding from esophageal varices.
- If bleeding, use EGD.
14
Q
Rectal Cancer
A
- Adenocarcinoma of the rectum
- 20-30% of all colorectal cancer
- Sx: hematochezia, mucus, tenesmus, felling of incomplete evacuation of stool, rectal mass
- Dx: hx, PE, heme occult, CBC, barium enema, colonoscopy
- CXR, LFTs, and abdominal CT to look for mets
- Preop workup: hx, PE, LFTs, CEA, CBC, CMP, PT/PTT, type and cross, CXR, UA, abdominopelvic CT
- Endorectal US is used for rectal cancer
- Tx: resection of the lesion and its regional lymphatic drainage. All rectal cancer operations include a total mesorectal excision(remove the rectal mesentery and LNs). Minimal surgical margin is 2cm.
- Adjuvant tx: pre-op radiation and 5-FU chemo.
15
Q
Anal fissure
A
- Tear in anal epithelium
- Most commonly occurs in posterior midline
- Etiology: hard stool passage, hyperactive sphincter, disease process (crohns disease).
- Sx: pain, painful bowel movements, rectal bleeding, sentinel tag, tear in anal skin, sentinel pile, hypertrophic papilla
- Tx: sitz baths, stool softeners, high fiber diet, topical nifedipine, botox. Surgery if refractive to treatment-lateral internal sphincterotomy(cut the internal sphincter to release it from spasm)
- Need to consider crohns disease, anal cancer, STD, UC, and AIDS if the fissure is off midline.
16
Q
Hemorrhoids
A
- Engorgement of the venous plexuses of the rectum, anus or both with protrusion of the mucosa, anal margin or both.
- Sx: anal mass/prolapse, bleeding, itching, pain(external only)
- If excruciating pain= thrombosed external hemorrhoid
- Dentate line separates internal from external
- 1st degree internal: does not prolapse
- 2nd degree internal: prolapses with defecation, returns on own
- 3rd degree internal: prolapses w/ defecation and any type of valsalva, requires active manual reduction
- 4th degree internal: cannot be reduced
- Tx: high fiber diet, anal hygiene, topical steroids, sitz baths, rubber band ligation, surgical resection.
- Complications of hemorrhoidectomy: exsanguination, pelvic infection, incontinence, anal stricture
- Crohns disease is contraindication to hemorrhoidectomy.
17
Q
Pilonidal disease
A
- Draining sinus or acute abscess in sacrococcygeal area
- Infection/irritation and trapping of foreign material in deep tissues
- Surgical drainage-I&D
- No abx unless signs of cellulitis
18
Q
Anorectal abscess/fistula
A
- *Perianal abscess**
- Abscess formation around the anus/rectum
- Etiology: crypt abscess in dentate line with spread
- Sx: rectal pain(throbbing), drainage of pus, fever, perianal mass
- Dx: PE, DRE
- Tx: drainage(I&D, surgical drainage if ischiorectal abscess), sitz bath, anal hygiene, stool softeners.
- Indication for post-op IV abx: cellulitis, immunosuppression, DM, heart valve abnormality
- 50% of pts will have fistula in ano
- *Fistula in Ano**
- Anal fistula from rectum to perianal skin
- Etiology: anal crypt/gland infection
- Sx: perianal drainage, perirectal abscess, recurrent perirectal abscess, diaper rash, itching
- Dx: PE, proctoscope
- Goodsalls rule: originate anteriorly=course straight ahead and exit anteriorly. originate posteriorly=curved tract
- Management: marsupialization of fistula tract(fillet tract open), wound care(sitz baths and dressing changes), seton placement(thick suture placed through fistula tract to allow slow transection of sphincter muscle-scar tissue formed will hold muscle in place)
19
Q
Fecal impaction
A
- Leads to large bowel obstruction
- RFs: medications(opioids), severe psychiatric disease, prolonged bed rest, neurogenic disorders of the colon, spinal cord disorders
- Sx: decreased appetite, N/V, abdominal pain/distension, paradoxical diarrhea
- Dx: DRE
- Tx: enema, digital/manual evacuation.
