GI surgery uworld Flashcards
RUQ pain + weight loss + hx of ulcerative colitis + ct abdomen: dilated intrahepatic ducts and normal sized common bile duct + elevated CA-19-9 and CEA
ulcerative colitis + primary sclerosing cholangitis associated with cholangiocarcinoma**
elevated lipase + alk phos + u/s: multiple gallstones and a dilated common bile duct
next step
dx
ERCP**
dx: gallstone pancreatitis
if stone stays, can result in bile stasis, allowing bacteria to ascend from duodenum –> acute cholangitis (pentad: RUQ, JAUNDICE, FEVER, AMS, HYPOTENSION)
post op day 3 s/p CABG now has RUQ pain, elevated alk phos
dx?
acalculus cholecystitis
obstruction of the CYSTIC duct by a gallstone: gallbladder dissension, pericholecystic fluid, and thickened gallbladder wall and fever
next best step?
cholecystectomy within 72hrs
distended gallbladder with gas in the gallbladder wall and lumen
next step?
organisms + abx:
dx?
emergency cholecystectomy
gas forming bacteria: Clostridium + E COLI – give piperacillin-tazobactam
emphysematous cholecystitis
pt with hyperactive bowel sounds + dilated loops of small bowel and air in the intrahepatic bile ducts
mechanical bowel obstruction**
d/t gallstone ileus causing n/v and pneumobilia
vs emphysematous cholecystitis would not see the hyperactive bowel sounds
asymptomatic gallstones but has painful ureter stone that relieves pain once passed
next step?
NO TX
since asymptomatic gallstones
hollow organ contraction and outlet obstruction
severe abdominal pain after eating a fatty meal – biliary colic 2/2 gallstones
pt had percutaneous liver biopsy 5 DAYS AGO now has RUQ pain and melena
hemobilia
s/p liver biopsy usually 5 days later upper GI bleeding causing intraductal hematoma
self limited manage conservatively
ROUX en y gastric bypass - 1 week later has fever, abdominal pain, tachypnea, and tachycardia
anastomotic leak – do a CT abdominal scan**
pt undergoes distal partial gastrectomy (bypassing pyloric sphincter) now has nausea, weakness, palpitation, light headedness, diaphoresis
next step?
DUMPing syndrome
dietary modifications **
retrosternal pain, fever, crepitus in setting of protracted vomiting
esophageal perforation
chest trauma now chest tube placed – one day later has turbid green fluid right sided pleural effusion (with fluid having high content of amylase)
dx
next step
tx
esophageal perforation
WATER SOLUBLE ESOPHAGRAM
NPO, iv abx, ppi, emergency surgical consult
vatical algorithm
s/p several weeks after Nissen fundoplication for GERD with n/v/post prandial bloating, upper go series shows no obstruction
next step?
scintigraphic gastric emptying scan
(Measures the percentage of a standard meal left in the stomach after a certain number of hours) it is diagnostic of Gastroparesis in the absence of obstruction
retrocardiac air-fluid with sensation of food getting stuck in chest
gastric herniation into thoracic cavity – paraesophageal hernia
needs Nissen fundoplication surgical repair
vs
sliding hernia asymptomatic – no sx
mallory weiss tear
longitudinal mucosal tear sometimes at gastroesophageal junction
S/P roux-en y gastric bypass years later has abdominal bloating flatulence and diarrhea for three months
bacterial overgrowth
small intestinal bacterial overgrowth – SIBO
how to dx Zener diverticulum
swallow study with CONTRAST ESOPHAGOGRAPHY
GERD best diagnosis initial:
management:
when to do sx?
pH monitoring
*lifestyle modifications
antacids, H2 blockers, PPIs, sucralfate
then do endoscopy EGD *immediate if alarming symptoms
long standing symptoms not controlled with ^^
medical intractability
disease complications: ulcerations, stenosis
Nissen fundoplication
barrets esophagus
metaplasia *** doesnt need sx
if they have dysplasia and barrels –> resection required (cant do nissens won’t take barrels away)
dysphagia worse for liquids than solids
FUNCTIONAL obstruction (not anatomic)
dx
tx
achalasia (similar to hurschsprungs, functional obstruction d/t decrease in myenteric plexus)
dx: BARIUM SWALLOW +/- manometry
tx: endoscopic balloon dilation
progressive dysphagia worse with solids, now liquids, lost weight
esophageal cancer
Squamous cell carcinoma : smoking and drinking
adenocarcinoma: long standing GERD
dx: BARIUM SWALLOW (always noninvasive first) then EGD and biopsy
CT scan to assess operability
tx: surgical resection, palliative care
older pt with anorexia, weight loss, vague epigastric pain, early satiety, occasional hematemesis
dx
gastric adenocarcinoma
dx: UPPER GI STUDY SERIES *******
then endoscopy with biopsy
then CT to assess operability
