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MBBS Surgery > GI > Flashcards

GI Flashcards

1
Q

List the 4 cardinal signs and symptoms of intestinal obstruction

A

Pain
Abdominal distention
Vomiting
Constipation

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2
Q

6 causes of pneumoperitoneum

A 
Perforated gastroduodenal ulcer
Perforated diverticulitis 
Post op laparoscopy 
Ruptured appendix 
Ruptured lower end of oesophagus
Anaerobic infection
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3
Q

List 8 causes of small bowel obstruction

A 
Adhesions
Hernia
Strictures
Intussception 
Meckel’s diverticulum
Gallstone ileus
Polyps
Harmatoma
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4
Q

5 etiologic factors in PUD

A 
Prolonged used  of NSAIDS 
Prolonged used of steroids 
Marijuana and cocaine used
H pylori infection
Zollinger ellision syndrome
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5
Q

6 causes of complications of diverticular disease

A
  • Diverticulitis- inflammation and possible perforation of diverticulum
  • bleeding- erosion around the edge of the pseudodiverticula
  • Perforation- Rupture of an inflamed diverticulum - free communication with the peritoneum, generalized fecal peritonitis or ruptured of a diverticular abscess- generalized purulent peritonitis
  • intestinal obstruction- inflammation swelling, compression through abscesses , ileus caused by localized irritation
  • fistula formation- colovesical most common and colovaginal in females
  • abscess- peri diverticula localization; omentum walls off pus collection
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6
Q

Causes of SBO

A 
Adhesions 
Hernias
Strictures from crohn’s and radiation 
Intussusception
Meckel’s diverticulum
Cystic fibrosis
Gallstone ileus 
Tumors - lymphoma, polyps, harmatomas
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7
Q

Ischemic bowel clinical picture

A

Sudden pain or no pain
No bowel sounds
NG tube - blood

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8
Q

Cardinal symptoms of small bowel obstruction

A

Vomiting
Abdo pain
Abdo distention
Constipation

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9
Q

Cardinal symptoms of large bowel obstruction

A

Abdo pain
Abdo distention
Constipation
Vomiting

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10
Q

SBO on X-ray

A

This is an supine abdominal X-ray, showing multiple grossly dilated >3cm loops of bowel, locates predominantly central. The dilated bowel is identified as SBO because of the presence of plicae circulares, which are hyperdense mucosal folds that extends completely across the entire width of the SB lumen

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11
Q

Investigations for any acute abdomen

A 
CBC - anemia and leucocytosis 
U&E with RFT (assess dehydration )
Group and cross match /save
Serum amylase
RBS
ABG
X-RAY (supine and erect)
Contrast ( gastrografin) enhance abdo X-ray
CT scan
Uss/MRI in pregnant women
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12
Q

LBO X-ray

A

This is an supine abdo X-ray showing multiple grossly dilated >6cm loops of bowel, located predominantly peripherally. The dilated loops of bowel is identifiable as the colon because of the presence of haustra, which are sac like pouches that do not extent completely across the entire width of the bowel lumen

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13
Q

Differential dx for LBO

A 
Colorectal cancer
Sigmoid volvulus
Diverticular disease 
Fecal impaction
Pseudo obstruction- paralytic ileus or functional obstruction (olgivie’s syndrome)
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14
Q

4 B’s that can cause peritonitis->shock

A

Bile
Blood
Bowel contents
Barium

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15
Q

5 features of a ruptured appendix on X-ray

A

Pneumo- peritoneum
Intestinal obstruction-ileus
Loss of Psoas shadow-obliterated by Pus or blood
Air around appendix-anaerobic produce gas
Faecolith

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16
Q

Types of esophageal cancer. Gross morphology and histology

A

Gross morphology: annular, exophytic and infiltrative

Histology: adenocarcinoma- lower 1/3
Squamous cell carcinoma- upper 2/3

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17
Q

Esophageal ca (adrnocarcinoma) etiology

A

GERD- Barrett esophagus
Obesity
Smoking
Achalasia

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18
Q

Esophageal ca (SCC) etiology

A 
Alcohol consumption 
Smoking
Diet low in fruits and vegetables 
Drinking hot beverage 
Achalasia 
Nitrosamines exposure
Plummer Vinson syndrome 
Structure 
Radiotherapy
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19
Q

Clinical features of esophageal ca

A

Often asymtomatic

Late stage : progressive dysphasia (from solids to liquids) with possible odynophagia
Weight loss
Retrosternal chest or back pain
Anemia

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20
Q

How would you dx esophageal ca

A 
EGD ( esophagogastroduodenoscopy)
Barium swallow ( apple core lesion)
Staging - trans esophageal endoscopic ultrasound, chest and abdo CT, bronchoscopy or laparoscopy
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21
Q

Esophageal ca tx

A 
Neoadjuvant chemoradiation
Surgical resection ( subtotal or total esophagectomy)
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22
Q

Esophageal palliative tx

A

Chemoradiation
Stent placement
Laser therapy

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23
Q

Achalasia?

A

Inadequate relaxation of the lower esophageal sphincter

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24
Q

Achalasia causes

A 
Primary ( unknown )
Secondary : esophageal cancer 
Stomach cancer 
Chagas diseases 
Amyloidosis
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25
Q

Pathophysiology of achalasia

A

Atrophy of inhibitory neurons in the Auerbach plexus

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26
Q

Achalasia clinical features

A 
Dysphasia 
Regurgitation
Retrosternal pain and cramps
Weight loss 
Progressive dysphasia to solids and liquids
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27
Q

Achalasia dx

A

Initially upper endoscopy to rule out pseudo achalasia
esophageal barium swallow ( bird beak sign)
Esophageal manometry ( evaluates the peristaltic function of the esophagus during swallowing)
Chest X-ray (widened mediastinum, air fluid level in lateral view, possible absence of gastric air bubble)

28
Q

Achalasia tx

A 
Low surgical risk : pneumatic dilation,
LES myotomy (heller myotomy)- fundoplication : nissen 360 , toupees 270

High surgical risk : botulinum toxin injection in the LES , nitrates or CCB

29
Q

Define diverticular disease

A

Outpouching of the colonic mucosa and underlying connective tissue through the colon wall

It is an acquired disease - false diverticula

30
Q

Diverticulum define

A

One outpouching

31
Q

Diverticula

A

Multiple outpouching

32
Q

Diverticulitis

A

Inflammation of diverticula

33
Q

Diverticulosis

A

Diverticula with no symptoms

34
Q

Diverticular disease

A

Symptomatic diverticulosis

35
Q

Hinchey classification

A

1 Diverticulitis with confines pericolic abscess

2 diverticulitis with distant abscess formation (pelvic abscess)

3 perforated diverticulitis with generalized purulent peritonitis

4 perforated diverticulitis with free communication with the peritoneum, Generalized fecal peritonitis

36
Q

Hartmann procedure

A

Resection of rectosigmoid colon with closure of the anorectal stump and formation of an end colostomy

37
Q

Forms of fistulas by diverticula

A

Colovesical
Colovaginal
Coloenteric
Colocutaneous

38
Q

Colovesical- symptoms, dx and tx

A

Symptoms: pneumaturia (passage of air in the urine)
Fecaluria ( passage of fecal content in the urine)

Dx: CT with oral contrast

Tx: primary anastomosis

39
Q

Diverticulitis mode of presentation, Tx , dx

A

Presents like a left sides appendicitis
Tx: conservatively with bowel rest and antibiotics
Confirm dx : by barium enema or colonoscopy after waiting for at least 6 weeks
Elective surgery (only if after 2nd attack if diverticulitis)

40
Q

Diverticular abscess (Hinchey 1 &2) tx

A 
Drain abscess percutaneously under radiological guidance 
Elective surgery (colectomy) following interval of 6 weeks
41
Q

Diverticular free perforation (Hinchey 3&4) tx

A

Resuscitate

Emergency surgery- Hartmann procedure

42
Q

Diverticula bleeding mode of presentation and tx , dx

A

Sudden onset , massive painless bleed (similar to Angiodysplasia)

Resuscitate -IV, foley, NG tube (rule out UGI Bleed)

Most resolve spontaneously- elective colonoscopy to confirm dx

43
Q

Diverticula bleeding - bleeding continues after conservative tx , what now

A

Colonoscopy if slow bleed (not effective for high rates of bleeding for to poor visualization)

Diagnostic and therapeutic 
Vasoconstrictive agents (adrenaline)
Vasoablative agents ( alcohol)
Thermal therapy (electrocoagulatiin, photocoagulation)

If high bleed
Nuclear scan with TC 99 (rate of .1-.5ml/min)

Mesenteric angiogram
Dx and therapeutic
Rate of 1ml/min
Vasopressin infusion via catheter

Laparotomy with total colectomy

44
Q

Causes of massive PR bleed

A 
Diverticular disease
Massive upper GI bleed
Angiodysplasia 
Colorectal carcinoma
Colorectal polyps 
Meckel’s diverticulum
Gastrointestinal stromal tumor
Ischemic colitis 
Uremic colitis 
Ulcerative colitis 
Haemorrhoids
45
Q

Px presents with ruptured spleen. What are the X-ray findings

A

Above the diaphragm: rib fractures
Raised hemi diaphragm
Pneumothorax
Haemothorax

Below the diaphragm: gastric bubble pushed medially
Colon pushed inferiorly
Loss of Psoas shadow
Blood around the spleen (radio opaque)

46
Q

Ogilvie syndrome

A

Colonic pseudo obstruction
Ileus of colon occurring in bed ridden patients
Presents with sudden onset of distention and constipation

Tx
Rectal tube
Colonoscopic decompression
Neostigmine

47
Q

Colorectal cancer hx presentations

A

Depends on the site if the tumor

Left sided : alteration of bowel habits (constipation) , Pr bleed, intestinal obstruction

Right sides : anaemia, mass

Rectal: tenesmus (incomplete evacuation) , spurious diarrhea, bleeding

48
Q

3 true things about colorectal cancer

A

Most in rectosigmoid region (then caecum)

Most are sporadic ( adenoma- carcinoma sequence)

Inherited: ( familial adenomatous polyposis (mutation in APC gene)) , HNPCC (Lynch syndrome) (mutation in mismatch repair gene

49
Q

Colorectal cancer : family hx - HNPCC Amsterdam criteria

A

> /= 3 relatives

At least one 1st degree

> /= 2 generations

At least one < 50 years

50
Q

Colorectal cancer examination- general, abdominal, DRE

A

General: wt loss, anemia, virchow lymph node

Abdomen : distended (obstructed or Ascites ), hepatomegaly, Mass

DRE: palpable tumor (location from AV , mobility) , sphincter tone, blood on glove

51
Q

Colorectal cancer investigations

A

Blood: hb, LFT, CEA (carcinoembryonic antigen)

Colonoscopy: dx and therapeutic (polypectomy) , synchronous lesions

Barium enema( if colonoscopy not available)

52
Q

Once colorectal cancer confirmed in histology ( adenocarcinoma ) , now what

A

Staging : CXR , CT scan abdomen, chest pelvic

53
Q

Rectal cancer investigations (imagining )

A

Endorectal US

MRI with endorectal coil

54
Q

Colon cancer tx

A

Right colon - right hemicolectomy

Left colon - left hemicolectomy

Lymphadenectomy - minimum of 12 nodes for adequate staging

55
Q

Rectal cancer tx

A

Anterior resection

Abdomino-perineal resection (APR)

Refer to stoma therapist

Total mesorectal excision (TME)

56
Q

TNM staging for colorectal cancer

A

T0 no evidence of primary tumor
T1 tumor invades submucosa
T2 tumor invades muscularis propria
T3 tumor invades through the muscularis propria into the subserosa
T4 tumor directly invades other organs or structures

N0 no regional lymph nodes can’t be assessed
N1 Mets in 1-3 regional lymph nodes
N2 Mets in 4 or more regional lymph nodes

M0 no distant met
M1 distant met

57
Q

At what stage do you start adjuvant therapy in colorectal cancers

A

Stage 2b and greater - T4N0M0

58
Q

Adjuvant therapy for rectal and colon cancer

A

Rectum lacks serosa therefore increase in local recurrence- Chemo and radiotherapy for rectal cancer

Chemo only for colon cancer

NB: chemo - works in systemic disease

: radiotherapy- works against local recurrence

59
Q

Types of chemotherapy and radiotherapy for colorectal cancer

A

Chemo: FOLFOX (FOLinic acid, 5-Flourouracil OXaliplatin

Immunotherapy: Bevazicumab (VEGFR) , Cetuximab (EGFR)

60
Q

Inflammatory bowel disease, 8 things for each

A

Ulcerative colitis

  1. Bloody diarrhea
  2. starts in rectum and extends proximally
  3. Continuous
  4. Mucosal
  5. Macro: pseudo polyps
  6. Micro: Crypt abscesses
  7. Perianal disease -rare
  8. Cancer risk ⬆️⬆️

Crohn’s disease

  1. Pain, wt loss
  2. Anywhere in GIT from mouth to anus
  3. Skip lesions
  4. Transmural
  5. Macro: cobblestone
  6. Micro: granulomas
  7. Perianal disease - common
  8. Cancer risk ⬆️
61
Q

Inflammatory bowel disease extra intestinal manifestations

A

Uveitis, iritis

Arthritis, ankylosing spondylitis

Sclerosing cholangitis

Erythema nodosum, pyoderma grangrenosum

62
Q

Inflammatory bowel disease dx investigations

A

Blood : normocytic anaemia, ⬆️CRP , ⬆️ESR

Barium meal and follow through in Crohn’s

Colonoscopy or Barium enema in non acute state (risk of perforation)

63
Q

Inflammatory bowel disease tx

A

Acute attack:

  • Steroids (oral, IV , rectal)
  • Azathioprine
  • cyclosporine

Maintenance:
- Aminosalicylates (Sulfasalazine)

64
Q

Inflammatory bowel disease indications for surgery

A

Emergency :

  • Pr bleed
  • toxic megacolon

Elective:

  • carcinoma
  • failure of medical therapy
65
Q

Inflammatory bowel disease surgical name

A

Proctocolectomy with ileal pouch

MBBS Surgery (11 decks)

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