GI: Small Intestine and Colorectal

Question 1

Duodenal Atresia
RF
CM
Diagnosis

Answer 1

RF
-polyhydraminos, down syndrome

CM
*neonatal intestinal obstruction s/s: after birth (w/in first 24-38 hrs of life) BILIOUS vomiting (but can be nonbilious), with abdominal distention

Diagnosis:

• Abd xray: double bubble sign– distended air filled stomach + smaller distended duodeunm spe by pyloric valve
• can also diagnose in utero if mom has polyhydraminos
• upper GI series

TX:

• decompression of GI tract, electroylte and fluid replacement
• duodenoduodenostomy

Question 2

Intestinal Malrotation

• CM
• Diagnosis
• tx

Answer 2

• Intermittnet or persistent bile-stained vomiting
• dehydration and electrolyte imbalances
• fever, pain, scanty stools, diarrhea and blood stool

Eval:

• clinical
• x-rays–coffee bean sign– sigmoid volvulus

Question 3

Volvulus 
RF 
CM 
Diagnosis 
Tx-intial TOC?

Answer 3

RF 
*chronic illness 
*age 
*CNS dz 
*chronic constipation 
*laxative abuse (esp the stimulant ones) 
*antimotility drugs 
prior abdominal surgery 

CM//PE

• Obstruction s/s: crampy abdominal pain, distention, N/V/C, tympanic abdomen with tenderness to palpation
• bilious vomit**
• Impaired vascular supply s/s: fever, tachy, peritonitits

*neonates: bilious vomiting within first week of life + colicky pain

Diagnosis:

• Abd CT: dilated sigmoid “bird beak” apperance at the site of volvulus
• abd xray: bent inner tube appearance (dilated sigmoid colon) or coffee bean sign (large air-filled levels in RLQ)

TX:
-endoscopic decompression via proctosigmoidoscopy– initial TOC

• rectal tube is left in place to decrease acute reccurence/decr distention
• decompression often followed by elective surgery due to high rate of reccurence
• immediate surgical correction in PTs with +peritonititis +gangrene or endoscopic decompress unsuccessful

Question 4

Meckel Diverticulum
CM
diagnosis:

Answer 4

CM:

• usually asympto–often found incidentialy
• painless rectal bleeding or ulceration (if +pain…. usually periumbilical)
• can cause intussusception, volvulus, obstruction
• can cause diverticulitis in adults

Diagnosis:

• Meckel Scan (nuclear medicine) looks for ectopic gastric tissue in the ileal area
• mesenteric arteriography or abdominal exploration

TX:
-surgical incision is symptomatic

Question 5

Intussusception 
RF 
etiology 
CM 
PE 
diagnosis-- TOC? 
management

Answer 5

RF

• children (6-18MO) and males
• incr risk with Meckel Diverticulum, tumors, FBs

Etilogy:
MC is idiopathic

CM:

• TRAID: vomiting, abdominal pain and passage of currant jelly stools (stool+mucus+blood)
• colciky abdominal pain

PE:
*sausage shaped mass in RUQ or hypochondrium + emptiness in the right lower quadrant due to telescoping

Diagnosis:

• US best inital TOC
• ABxray: lack of gas in bowels
• air or contrast enemia=diagnostic and therapeutic
• air enemoa more commonly used (if contrast needed–gastrografin vs barium)

Maagment:

1. fluid and electrolyte replacement most imp initial steps
2. NG decompression
3. Intussusception reduction: pneumati (air) or hydrostatic (saline or gastrografin) decompression
4. admitted for observation—10% recurrance in 1st 24 hrs of tx
5. Surgical resection if refractory to above

Question 6

Anorectcal abscess and fistuals

ABSCESS:
MCC
MC site
CM

FISTULA:
CM

Answer 6

ABSCESS
MC=staph A
MC site=posterior rectcal wall
CM: swelling, rectal pain– worse with sitting coughing and pooping,+/- fever, induration and fluctuance

FISTULA:
CM: can cause discharge and pain

TX: 
I/D: mainstay of tx followed by WASH 
W: warm water cleaning
A: analgesics
S: sitz bath
H: high fiber diet 

ABX not usually requried in simple cases

Question 7

anal fissures

-etiologies

Answer 7

etiologies:
- low fiber diets
- passage of large stools
- trauma
- constipation

CM:

• severe rectcal pain and BMs
• causing PT to refrain from BM
• BRBPR—bright red blood per rectum

tx:
-most resolve. on own
-supportive:
1st line: warm water sitz bath, analgesics, high fiber diet, incr water intake, stool sofeners, laxatives, mineral oils,

2nd line: topical vasodilators—Nitroglycerin or nifedipine ointment

others:
- botox injection to help spasms
- surgery: lateral internal sphincterotomy for refractory

Question 8

Hemorrhoids

• enlargement of>
• internal vs external: origin, locations and pain/painless +/- bleeding

Answer 8

engorgement of venous plexsus

Internal:

• orig: superior hemorrhoid vein
• proximal to the dentate line
• PAINLESS bleeding

External:

• orig: inferior hemorrhoid vein
• distal to the dentate line
• painful and dont usually bleed

Etiologies:

• straining
• preg
• obesity
• prolong sitting
• cirrhosis w/ PHTN

CM:
INTERNAL
*painless bright red blood per rectum
*hematochezia–seen on TP, coating the stool or dispered in the toilet water
*usually not tender if not uncomplicated

External:
-perianal pain aggravated w. defecation
+/- skin tags

TX:
-Conservative = high fiber diet, increased fluids, warm Sitz baths & topical rectal corticosteroids & analgesics to help pruritis and discomfort or thrombosis.
-If refractory to conservative management or debilitating pain or strangulation:
-Rubber band ligation is MC; sclerotherapy or infrared coagulation
-Excision of thrombosed external hemorrhoids
Hemorrhoidectomy - for stage IV or refractory

Question 9

diverticulosis
MC of what?
MC location for bleeding?
MC location for incidence in general

MC location?

Answer 9

MCC of painless LGIB

Right colon MC for bleeding
Left colon MC for incidence
MC location=sigmoid

CM

• usually asympto
• LGIB: painless
  vague: LLQ discomfort, bloating, constipation/diarrhea

TX:
-In most cases, the bleeding stops spontaneously
If serious bleeding, resuscitation may be needed
Endoscopic therapy can be utilized to help control bleeding (epinephrine injection, tamponade)

Asymptomatic diverticulosis can be followed - recommend high fiber diet, use bran or psyllium.

Question 10

diverticulitis 
MC area? 
CM
diagnosis 
tx

Answer 10

sigmoid colon MC location (high intraluminal pressure here)

CM:

• LLQ abdominal pain (MC)
• LLQ tenderness
• low grade fever
• /+ N/V/C/D
• flatulence
• bloating
• changes in bowel habits

Diagnosis:
CT scan–TOC–
NO colonoscopy high risk for perf

Labs: leukocytosis

tx:
1) uncomplicated: tx as outpatient– with PO Metronidazole + ciprofloxacin or levofloxacin
- clear diet

2) surgery for complicated:

Question 11

how do we diagnose IBS

Answer 11

Diagnosis of exlusion– need to make sure there is no other pathology before diagnosing PT with IBS

ROME IV Criteria:

• recurrent abdominal pain on avg at least 1 day/week in the last 3 MO associated w/ 2 of the 3:
  1) relation to defication
  2) onset assoc with change in stool frequency
  3) onset assoc with change in stool form (apperance)