gi day 3 Flashcards by Morgan C

Acute appendicitis

cause

Unknown
Maybe obstruction of lumen with feces or lymphoid hyperplasia
E coli and bacteroides- fecal organisms

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Acute appendicitis

RLQ pain at McBurney’s point (btwn ASIS and umbilicus)
VN, anorexia
Constipation
Diarrhea if perforated

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Acute appendicitis

Low grade fever, tachycardia
RLQ tenderness with rigidity, guarding, and rebound
Rovsing’s sign- RLQ is tender when LLQ is palpated
Psoas sign- pain with extension of R leg
Obturation sign- pain on internal rotation of flexed R thigh

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Acute appendicitis

PMN leucocytosis
High CRP
UA- WBC and RBC; no bacteriuria
US and CAT scan are best

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Appendix carcinoid ?

Firm, yellow, bulbar mass usually located at the tip

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Appendix carcinoidtrmt

Less than 1cm → Benign so do appendectomy

Over 2 cm → malignant so do right colectomy

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MC site of GI carcinoid-

SI and rectum

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Adenocarcinoma of Appendix presentation

acute appendicitis

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Adenocarcinoma of Appendix trmt of choice

Trmt of choice: Right hemicolectomy

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Meckel’s Diverticulitis presentation

appendicitis

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Meckel’s Diverticulitis?

diverticulum in terminal ileum

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Meckel’s Diverticulitis

rule of 2

2% of pop
2 cm wide at base
2 ft proximal to ileocecal valve

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If you go in to take the appendix out and see it is normal but the base of the cecum is involved, check for___

crohns

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congenital Meckel’s Diverticulitis

all layers on mesenteric border

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acquired Meckel’s Diverticulitis

dt high internal pressure, located at mesenteric border

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Diverticular disease mc areas afffected and where on body

L side/ sigmoid disease MC in West like USA and canada

R side disease MC in East like Japan, China, Korea

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RARE in Africa

Diverticular disease

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MC at sigmoid colon
2nd MC at descending colon
in us

Diverticular disease

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2 types Diverticular disease

Classic- HAS muscle abnormality; in left colon of elderly; pain, inflammation, perforation, fistulae
Bleeding- NO muscle abnormality, painess

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Diverticular disease?

Outpouching of the colon
Shortening of sigmoid and wall thickening dt inc elastin content of teniae
Pericolic inflammation and fibrosis from micro and macro perforation

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Diverticular disease seen on microscope?

On microscope: inflammation with PMN leukocytes and pericolonic inflammation; mucosal and luminal hemorrhage seen

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Diverticular disease sx

Usually none
Seen by accident on Ba enema, colonoscopy, or CT scan
Vague LLQ abd pain, anorexia, nausea, constipation or diarrhea

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Diverticular disease dx

MUST get colonoscopy to r/o colon CA

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Diverticular disease trmt

High fiber diet- 25-30 grams a day
Demerol (analgesics) is agent of choice- dec intraluminal pressure
ATB to cover gram + and - bacteria

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Acute diverticulitis sx

Persistent LLQ pain Radiates to back, groun, and suprapubic region Constipation or diarrhea Low grade fever Dysuria, urgency, and frequency if near bladder Malaise in elderly pts

Acute diverticulitis pe

``` LLQ tenderness Rigidity, guarding, and rebound tenderness Vague tender mass Distension or ileus Psoas abscess- groin or thigh swelling ```

Acute diverticulitis dx

CT is best- pericolic inflammation, abscess, wall thickening, ureteric obstruction, fistulae DONT do colonoscopy in acute phase

Acute diverticulitis trmt

``` Bowel rest ATB- cover gram + and - bacteria Do frequent abd exams Drain abscesses only if over 2 cm Endoluminal colonic wall stenting if pt has no peritoneal signs and obstruction is present ```

Fistula?

Connection between 2 organs

what fistula is mc

colovesical fistula- btwn bladder and colon

Fistula | sx

Depend on type of fistula | May get frequent UTI with colovesical

Fistula | dx

Radiology

Fistula | trmt

surgery

Hemorrhage?

Chronic injury to vasa recta | Stops on its own in most pts

Hemorrhage | dx

Bleeding scan and angiography

Hemorrhage | trmt

Resection or colectomy

2 types of SBO

mechanical and ileus

BS in mechanical SBO

hyperactive

BS in ileus

no BS

when is sbo MC

post op

Small bowel obstruction cause

Usually mechanical- Most are post op adhesions Intraluminal- FB, gallstones, meconium (ileus in babies) Intramural- tumors, crohns with strictures Extrinsic- adhesions, hernias, carcinomatosis, SMA syndrome

Small bowel obstruction sx

Colicky abdominal pain, NV, obstipation | Abdominal distension

Small bowel obstruction pe

Strangulation, pain out of proportion

Small bowel obstruction dx

High WBC, acidosis AA series CT with contrast

Small bowel obstruction dx order

1. Determine if its mechanical or ileus 2. Cause? 3. Partial or complete? 4. Simple vs. closed loop vs strangulation

Small bowel obstruction trmt

NPO and NG tube Fluid Dont operate if partial SBO, early post op, crohns, carcinomatosis Operate if complete SBO, closed loop or strangulation, no improvement with non op trmt, no previous abdominal surgery

Small bowel obstruction prevention

``` Good surgical technique Careful handling tissue Minimal exposure of FB Minimally invasive technique ex: laparoscopy Hyaluronidase based agents ```

Ileus- ?

temporary motility disorder reversed after you fix what caused it

Intestinal pseudo obstruction- AKA olgivies syndrome

not temporary; irreversible intestinal dysmotility associated with chronic disorders SNS overriding PSNS

ileus cause

MC post op, infection and inflammation, electrolyte abnormalities (K and Mg), drugs

ileus sx

NV, no gas or BM

ileus dx

XRAY- diffuse SI and colonic distension

ileus trmt

Treat cause- electrolytes, infections... | Nutrition support TPN while recovering

ileus prevention pre op

U opioid receptor antagonist Alvimopan No prescription pain meds to 5 days Epidural anesthesia

ileus prevention intra op

Minimally invasive surgery such as laparoscope Careful when handling bowel Don't overload fluids

ileus prevention post op

``` Feel early Walk Epidural analgesia No excessive iv fluids Correct lytes Continue Alvimopan NSAIDS for pain ```

SI recovery after op

24 hrs

stomach recovery after op

48 hrs

colon recovery after op

3-5 days

to check for an ileus you cant just listen for bs... gotta do this too

ask about gas and bm

Colonic pseudo obstruction aka Ogilvie’s syndrome acute located here

colon only

Colonic pseudo obstruction aka Ogilvie’s syndrome | chronic lication

colon and SI

Colonic pseudo obstruction aka Ogilvie’s syndrome | sx

Abdominal distension

Colonic pseudo obstruction aka Ogilvie’s syndrome | pe

Tympanitic, nontender

Colonic pseudo obstruction aka Ogilvie’s syndrome | dx

XR- colon is over 12 cm in diameter

Colonic pseudo obstruction aka Ogilvie’s syndrome | trmt

Colonoscopy with decompression tube placement NPO, NG tube, IV fluids, correct lytes, dc all meds that inhibit bowel motility IV neostigmine- stimulates gut to contract