ICL 17.3: Appendicitis, Diverticulitis, Ischemic Collitus, Volvulus, and Traumatic/Mechanical Disorders

Question 1

13 year old female presents with loss of appetite x10 hours, vomiting, diffuse abdominal pain that became localized to the right lower quadrant, leukocytosis, and no fever.

what’s the next best step?

Answer 1

abdominal ultrasound which is almost as sensitive as a CT for detecting acute appendicitis

this can also help you rule out torsion of the ovary which can present really similarly

start IV antibiotics and laparoscopic appendectomy once acute appendicitis is confirmed

no CT because she’s young and you want to spare her radiation – only consider if the ultrasound didn’t show anything and she’s super ill

Question 2

13 year old male presents with loss of appetite x10 hours, vomiting, diffuse abdominal pain that became localized to the right lower quadrant, leukocytosis, and no fever.

what’s the next best step?

Answer 2

directly do laparoscopic appendectomy because it’s a male patient and it’s a classic presentation of acute appendicitis and he doesn’t have ovaries

abdominal US is a safe answer like if they don’t have leukocytosis and you want to confirm it isn’t constipation or anything and you could also say you need to do imaging before going to surgery

Question 3

what is acute appendicitis? who gets it?

Answer 3

acute inflammation of the appendix that causes ”nonspecific” obstruction of appendiceal lumen –> like lymph tissue inflammation from infection

it’s the most common indication for emergency abdominal surgery in children, 1-8% of kids evaluated for abdominal pain

usually happens in older children and young adults

Question 4

what are the symptoms of acute appendicitis?

Answer 4

1. loss of appetitie
2. vomiting
3. LATE fever
4. laeukocytosis
5. pain is constant but may wax-wane
6. classic abdominal findings

Question 5

what are the common causes of acute appendicitis?

Answer 5

1. fecal material
2. undigested food
3. foreign body
4. enlarged lymphoid follicle in adolescents usually after viral infection that caused lymphoid proliferation

Question 6

what are the uncommon causes of acute appendicitis?

Answer 6

1. Kink or twist of the organ (bad luck?)
2. Crohn’s granulomatous inflammation
3. appendiceal carcinoid or Burkitt lymphoma
4. cystic fibrosis

Question 7

what is the pathogenesis of acute appendicitis?

Answer 7

intermitten obstruction of the lumen of the appendix

the bacteria in the lumen then overgrows and causes distention and inflammation of the appendix

this leads to pain, perforation and peritonitis and even death

Question 8

what is peritonitis?

Answer 8

inflammation of the peritoneal cavity due to any cause like bowel obstruction, PID, appendicitis, perforated diverticulitis, etc.

peritonitis isn’t one etiology, it’s one specific clinical finding that you describe in the PE, you can’t diagnose in labs or imaging

Rosing sign, Murphy’s sign, rebound tenderness in the abdomen, obturator sign, iliopsoas sign etc. are specific signs of peritonitis

Question 9

how do you treat acute appendicitis?

Answer 9

surgery

Question 10

what symptoms are more reliable for correctly diagnosing acute appendicitis?

Answer 10

4. 5 points = tenderness in the RLQ
5. 5 points = rebound tenderness

2 points = no micturition difficulties , steady pain

1.5 points = leukocyte count elevated, under 50 years old

Question 11

what is involuntary migrating guarding?**

Answer 11

voluntary guarding is when you go up to the patient and press on the patient and they’re tensing their belly even before you touch them – the patient has abdominal pain and the anticipation of your hand makes them brace against your touch

involuntary guarding is when the patient can’t control it and they’re relaxed until you press on their belly which incites a reaction that causes an immediate pain response

Question 12

what physical exam findings/tests do you do for acute appendicitis?

Answer 12

1. involuntary migrating guarding
2. Rovsing sign
3. McBurney point
4. migrating pain

Question 13

13 year old male presents with loss of appetite x10 hours, vomiting, diffuse abdominal pain that became localized to the right lower quadrant, leukocytosis, and no fever.

if you did one, what would you expect to find on a CT scan?

Answer 13

fecalith = remnant of your stool where over days/months some of the indigestible material in your GI tract gets compacted and crystalizes into really hard material –> they can obstruct the appendix or the colon

there shouldn’t be contrast or air in the appendix with acute appendicitis because it’s obstructed in acute appendicitis

if you can’t see the appendix on the CT scan it means it’s smaller than the CT cuts which means it’s probably 100% likely they dont have appendicitis if it’s that small

Question 14

20 year old female presents with loss of appetite x12 hours, vomiting, diffuse abdominal pain that became localized to the right lower quadrant, leukocytosis, and no fever.

which of the following could NOT be found on laparoscopy?

A. ovarian torsion

B. inflamed appendix

C. normal appendix

D. peri-appendiceal abscess

E. inflamed cecum and fecal peritonitis

F. intrauterine pregnancy

Answer 14

F. intrauterine pregnancy

you can’t see inside the uterus! you’d have to do a blood test to rule out pregnancy

in theory with the information provided, all the other things are possible

Question 15

what is diverticular disease?

Answer 15

when you strain on your belly and there’s air in your belly, the air looks for the weakest point to relieve the pressure and this is where the blood vessels come into the intestine to supply the muscular layers

so around the blood vessels you can get outpouchings called diverticuli which tend to happen most in the sigmoid colon but they can happen anywhere in the colon or other parts of the small intestine –> usually it’s the sigmoid and descending colon and it can progress proximally

Question 16

what is colonic diverticulosis?

Answer 16

increased pressure within the lumen due to low fiber diets causes diverticula where the vasa recta perforate the muscularis externa, aka where the wall is weakest

diverticula are an acquired blind pouch!

these colonic diverticuli that we’re talking about are false diverticula because only the mucosa and submucosa involved, not the muscular layer

Question 17

what is the presentation of colonic diverticulosis?

Answer 17

most commonly LLQ pain due to sigmoid involvement

but the presentation is really variable, anywhere from vague abdominal pain to peritonitis

~50% of Americans >60y have diverticulosis and it’s a disease of developed world

Question 18

what is the diverticulum?

Answer 18

a generic anatomical term for blind outpouchings anywhere in GI tract

may be false or true

Question 19

what is diverticulosis?

Answer 19

presence of colonic diverticula

no inflammation!! just the holes in the colon

Question 20

what is diverticulitis?

Answer 20

inflammation of colonic diverticula

so when the pouches become inflamed!

diverticula may bleed, this is NOT diverticulitis –> the outpouchings can erode the blood vessels and cause lower GI bleeds – inflammation only happens when there’s blockage and low blood flow to a specific diverticula and the pouch gets blocked up by stool and there’s bacterial overgrowth and inflammation just like appendicitis! this causes a lot of pressure and increased pressure on the wall which leads to perforation –> so bleeding diverticula only happens when there’s good blood flow so diverticulitis and bleeding diverticula dont happen at the same time usually

Question 21

what is uncomplicated diverticulitis?

Answer 21

acute inflammation

there’s typically a MICROperforation = NOT what is meant by “perforation”, you can’t see it unless you look at a biopsy

Question 22

what is complicated diverticulitis?

Answer 22

diverticulitis with obstruction

inflammation has become so severe that they could cause abscess, fistula, or perforation (free perforation of liquid and stool into the peritoneum)

Question 23

63 year old male presents with LLQ abdominal pain, nausea without vomiting, and has felt feverish and uncomfortable. He suffers from intermittent constipation. He has felt “something like this once before.”

which of the following are unlikely to be found on further investigation?

A. (+) hemoccult test

B. diverticula on colonoscopy

C. thickened colon wall on CT scan

D. low fiber diet

Answer 23

A. (+) hemoccult test

this person has acute diverticulitis –> when it causes the patient to get sick because the diverticula is blocked up, it’s low blood flow aka there wouldn’t be any blood in the stool

constipation = low fiber diet

CT scan would show thickened colon wall from inflammation and edema

Question 24

how do you diagnose diverticulitis?

Answer 24

mild, classic cases in stable patients who will reliably follow-up and can be trusted to return for worsening symptoms:
1. blood work for leukocytosis, make sure no renal damage

2. oral antibiotics, outpatient mgmt with close follow up with PCP

all other patients with more severe symptoms like sepsis, severe pain, CKD etc, need CT scan (which should show visible diverticula), comprehensive blood tests, and probably admission

regardless of the severity of diverticulitis, all patients need colonoscopy, typically as outpatient 6w after acute episode

Question 25

63 year old male presents with LLQ abdominal pain, nausea without vomiting, and has felt warm and uncomfortable. He suffers from intermittent constipation. He has felt “something like this once before.”

what is the motivation that will guide your next steps?

A. establish a tissue diagnosis

B. exclude other causes of abdominal pain

C. get the patient to the operating room quickly

D. get the patient to the endoscopy suite quickly

E. admit the patient

Answer 25

B. exclude other causes of abdominal pain

“something like this before” means this person has had episodes of diverticulitis before but they’ve managed it at home up till now

so now you want to do confirmatory tests like a CT scan or CBC to look for leukocytosis

tissue diagnosis is for cancer or Crohn’s

endoscopy is weeks down the line once the acute episode is over

Question 26

in a patient with diverticulitis, when do you scope? who gets surgery?

Answer 26

don’t scope patients during acute episodes of diverticulitis; do it 6-8 weeks later

surgery if perforation with signs of sepsis or repeated episodes of diverticulitis that keep hospitalizing them

Question 27

are there recurrent and refractory cases of diverticulitis after an acute episode?

Answer 27

yes!

20-50% of patients have recurrent episodes because once you have diverticula they dont go away

Question 28

do seeds, popcorn, nuts, etc cause diverticulitis

Answer 28

these could in theory block the pouches but literature says nope they don’t

Question 29

what is the classic presentation of diverticulitis?

Answer 29

1. male
2. 63 years old
3. low fiber diet
4. lots of constipation or diarrhea too
5. LLQ pain
6. recurrent episodes
7. vague abdominal pain
8. fever
9. leukocytosis

severe diverticulitis might also have peritonitis

Question 30

what are the unique presentations of diverticulitis?

Answer 30

1. puffs of air when they urinate in a male
2. recurrent UTIs in males and females
3. history with diverticulitis
4. colovesical fistula

so if a question says that a 63 year old male with a h/o diverticulitis having puffs of air interrupting their urine stream? colovesical fistulae

stool from vagina = colovaginal fistula

Question 31

do you give antibiotics to patients with acute diverticulitis?

Answer 31

YES!! they ALL get antibiotics

need to cover gram (-) and anaerobe broadly

1. quinolone and metronidazole
2. bactrim + metronidazole
3. augmentin (amoxicillin + clauvanulate) + metronidazole

Question 32

how do you treat uncomplicated diverticulitis?

Answer 32

SEVERE
1. bowel rest aka NPO for days until pain free and pass flatus

2. IV resuscitation
3. early abdominal exams for 7-10 days
4. admit to hospital

MILD
send home on antibiotics and tell them to do a low fiber and liquid only diet to keep hydrated but not make the colon do work

Question 33

how do you treat complicated diverticulitis?

Answer 33

1. admit to hospital
2. IR drain
3. surgical resection

get source control = remove the infectious material; if the colon is perforated and spilled a bunch of stool cut it out, if there’s an abscess drain it

Question 34

70 year old female presents with vague, LLQ pain and fever for 3 days. She has nausea but is tolerating liquids. Her vitals are stable and she has no fever or peritonitis. She has known diverticulitis in the past. CT shows pericolonic fat stranding and no abscess or free fluid.

what is the next best step in management?

Answer 34

start oral antibiotics and ensure follow up

she can keep herself hydrated, CT doesn’t show complicated disease, no sepsis, no peritonitis, no fever, stable vitals so you can treat her outpatient and followup with PCP (make sure she has one!)

if she wasn’t able to followup because she had dementia or socioeconomic issues, just admit and manage in the hospital

Question 35

what is an intestinal obstruction?

Answer 35

contents of GI tract cannot pass from mouth to anus

this is an anatomic problems and treat physiically

they are ALWAYS an emergency so you must treat inpatient!!!

Question 36

what is the clinical presentation of intestinal obstructions?

Answer 36

1. nausea/vomiting
2. abdominal pain
3. sepsis
4. distended abdomen
5. tympanic
6. may impair respiration because the bowels get so big they’re trapping the lungs

you need to ask them if they’re passing gas!! patients with bowel obstruction may still pass stool from weeks ago but there won’t be gas because you swallow that every day

Question 37

what are the causes of small bowel obstructions?**

Answer 37

1. adhesions due to scar tissue from previous surgery
2. cancer
3. hernias
4. Crohn’s
5. radiation
6. intussusception
7. gallstones
8. volvulus (twisting of intestine)

Question 38

what are the causes of large bowel obstructions?**

Answer 38

1. rectosigmoid, rectal or anal cancers
2. volvulus (common in elderly patients because bowels get floppy and can twist)
3. stricture
4. hernia

Question 39

what is the pathology common to all obstructions?

Answer 39

intraluminal contents accumulate and intestine distends -> Laplace’s law, tension and pressure in intestinal wall rises due to stuff getting compacted

• > venous outflow collapses since it’s low pressure and the pressure in the intestines is getting really high –> capillary transit stops since veins can’t drain the blood in the capillaries-> O2 delivery and CO2 export ceases
• > anaerobic metabolism, ischemia, acidosis, necrosis set in

if untreated, becomes irrevocable, perforation, peritonitis

Question 40

57 year old female presents to ED with bilious emesis x3 days. She has not passed flatus recently. Her PSH included appendectomy age 14, c-section age 22, cholecystectomy age 40. She is afebrile, tachycardic, normotensive, with shallow rapid breaths (>30/min) and a distended, tympanic abdomen.

what is your next best step in management?

Answer 40

you should insert NG tube and decompress stomach and intestines first which will help improve her respirations!

x-ray to see intestine

if you lay her flat and intubate and giver her a paralytic she will aspirate and die so do NOT intubate

highly suspicious for bowel obstruction

Question 41

what are safe answer to the “next best step” to someone who has a bowel obstruction?**

Answer 41

1. decompress the lumen – break the cycle – NG tube by hand and rectal tube by EGD
2. IV fluids
3. foley
4. admit to ICU
5. vasopressors
6. may need to be ventilated

Question 42

how do you diagnose a bowel obstruction?

Answer 42

1. Clinical history + Imaging
2. may have elevated lactate because venous outflow can be impaired from bowel obstructions so if it is, then lactate will be elevated –> but because lactate being released from the GI tract would have to get to the heart via venous system and back out to the peripheral circulation before it’s detected in blood tests, sometimes it looks normal which is why normal lactate doesn’t exclude bowel obstructions
3. may have metabolic derangements 2/2 sepsis like low bicarb = metabolic acidosis or acute kidney injury from dehydration

Question 43

what is air fluid level?**

Answer 43

bad bowel obstruction!!

the intestines are blocked up and the air and fluids aren’t moving past the blocked point so you see air above and fluid below from them pooling in the intestines when a patient is standing up

Question 44

how do you treat large bowel obstructions?

Answer 44

sigmoid volvulus may be decompressed endoscopically, but should be resected “semi-electively” because the floppy colon will probably retwist

ALL other large bowel obstructions go to the operating room urgently

Question 45

how do you treat small bowel obstructions?

Answer 45

try to manage “conservatively” with NG tube, IV fluids, bowel rest for 2-5 days –> you can also do GI contrast study where you give them contrast down NG tube and take x-rays to see where the blockage is; also the contrast is hyerptonic and can pull water from the intestinal wall which decreases edema and can un-kink the bowel tissue without going to the OR

”Free air” outside the intestine, “pneumatosis intestinalis = gas bubbles in wall of intestines “portal-venous gas,” ”closed loop” = radiographic terms that virtually mandate surgery

pneumatosis intestinal and portal venous gas are signs there’s no blood flow and gas forming bacteria have overtaken the bowel while closed loop means there’s scare tissue on both sides of the bowel and putting an NG tube in won’t help decompress

many nonspecific signs may indicate need for operation

Question 46

what is the definition of an obstruction?

Answer 46

*complete anatomic blockage

Question 47

what is a partial obstruction?

Answer 47

often the same pathology as complete obstruction, and patient will have similar presentation, except:

1. typically chronic
2. usually a focal segment of intestine is narrowed – if you decompress stomach and give that small segment a chance to unkink or pass food, then the obstruction can be relieved
3. often less sick at presentation

Question 48

what is ileum?

Answer 48

a patient doesn’t pass their intestinal contents as quickly as you’d expect but it’s not due to a physical or anatomic obstruction

things that can cause this are medication S/E, electrolyte disturbance, due to handling in OR (postop) or inflammation, neural or hormonal effects

Question 49

80F presents with progressive onset of abdominal distention, change in stool caliber, weight loss, and fatigue. Her vitals are normal. Her abdomen is mildly distended, digital rectal exam reveals no blood, no masses. She has had no surgeries in her lifetime.

which of the following is likely to be found on CT scan with oral contrast?

A. sigmoid volvulus

B. gallstone Ileus

C. pneumatosis of the small bowel

D. free air

E. rectosigmoid Mass

Answer 49

E. rectosigmoid Mass

this would explain the change in stool caliber! this happens because the rectum is being taken up by a cancerous mass which is why the stool is pencil like

she’s an elderly person with weight loss too…

sigmoid volvulus wouldn’t be a progressive onset over days, it would be sudden kink

gallstone illeus is more common in small intestines

Question 50

60F presents with sudden onset of abdominal distention, nausea with bilious vomiting. She has had right upper quadrant pain for 48 hours but it worsened suddenly overnight. She is passing no flatus. She has had no surgeries in her lifetime. Her vitals are stable.

which of the following is likely to be found on CT scan with oral contrast?

A. sigmoid Volvulus

B. gallstone Ileus

C. pneumatosis of the small bowel

D. free air

E. rectosigmoid Mass

Answer 50

B. gallstone Ileus

small bowel obstruction

RUQ pain is where the gallbladder is! and she hasn’t had surgery so it hasn’t been removed

bilious vomiting = not a blockage between small intestine and gall bladder

not passing gass = obstruction

Question 51

A 50y, paranoid schizophrenic male is brought in by his family. He has had nausea, vomiting, and abdominal pain for 5 days but refused to come to the ER. He appears toxic, febrile, drowsy, and resists your abdominal exam. When you bump the bed, he winces in pain.

which of the following is likely to be found on CT scan with oral contrast?

A. sigmoid volvulus

B. gallstone Ileus

C. pneumatosis of the small bowel

D. free air

E. rectosigmoid Mass

Answer 51

C. pneumatosis of the small bowel or D. free air

late presentation of a bowel obstruction which has worsened to the point of sepsis

Question 52

A 90 year old woman with dementia presents to the ER with LLQ pain. She cannot provide her own history, but the chart from the facility documents years of weight loss. She is mildly tachycardic and tender in the LLQ.

which of the following is likely to be found on CT scan with oral contrast?

A. sigmoid volvulus

B. gallstone Ileus

C. pneumatosis of the small bowel

D. free air

E. rectosigmoid Mass

Answer 52

A. sigmoid volvulus

many years of progressive weight loss and 90 years old leave her with a floppy mesentery that’s easy to twist/kink

it could also be a rectosigmoid mass but sigmoid volvulus is better answer but you’d probably have to do imaging to confirm

Question 53

2 day old male infant who has failed to pass meconium presents with bilious emesis and abdominal distention.

differential diagnosis?

Answer 53

Hirschsprung Disease = congenital megacolon)

Question 54

what is Hirschsprung disease?

Answer 54

functional bowel obstruction due to the absence of nerves within the wall of the distal colon

due to failure of craniocaudal neural crest migration –> aganglionic (no Meissner or Auerbach plexuses) segment of the distal colon –> associated w/ RET mutation

newborn will have failure to pass meconium (first poop) in the first 48 hours of life, abdominal distention, bilious emesis, chronic constipation and failure to thrive

Question 55

how do you diagnose Hirschsprung disease?

Answer 55

1. squirt sign = explosive expulsion of feces followed by empty rectum on digital exam
2. absence of ganglionic cells on rectal suction biopsy is diagnostic

Question 56

how do you treat Hirschsprung disease?

Answer 56

resection of the parts of the colon that are affected

Question 57

2 day old male infant who has failed to pass meconium presents with bilious emesis and abdominal distention.

diagnosis?

Answer 57

meconium ileus

looks just like Hirschsprung disease but when you do a biopsy the colon is normal

Question 58

what is meconium ileus?

Answer 58

intraluminal intestinal obstruction, often at the terminal ileum, due to abnormal meconium

90% of cases seen in patients with CF, earliest finding

symptoms = failure to pass meconium, abdominal distention, bilious emesis, failure to thrive

Question 59

what are the complications associated with meconium ileus?

Answer 59

1. volvulus
2. perforation
3. ischemic necrosis
4. periotnitis

Question 60

what is the pathogenesis of meconium ileus?

Answer 60

Abnormal chloride ion transport across epithelial cells of the intestine –> hyperviscous secretions from intestinal mucus glands –> dry, sticky meconium which adheres to the walls of the mucosa –> meconium plug

Question 61

how do you treat meconium ileus?

Answer 61

radiographic contrast enema w/ N-acetylcysteine which helps break up mucoid plug

if the enema fails, surgical resection is required

Question 62

1 mo male presents with persistent bilious emesis, blood stained stool, and abdominal distention

diagnosis?

Answer 62

malrotation

Question 63

what is malrotation?

Answer 63

defective rotation during embryogenesis of the primitive bowel loop around the axis of the SMA –> abnormal positioning of intestinal loops within the peritoneal cavity

usually asymptomatic (until a twist happens)

Question 64

what is malrotation with midgut volvus?

Answer 64

abnormally short mesenteric root that results from defective embryogenic rotation leads to a short mesenteric root

symptoms of malrotation appear when the bowel twists around this short mesenteric loop leading to a midgut volvulus

the twisting will lead to necrosis so they’ll have to go to the operating room to save the intestine

clinical presentation mirrors intestinal obstruction, i.e. bilious emesis and abdominal distention

colon will be all on the left and small intestine all on the right on x-ray and CT imaging! you’ll see a whirl sign on ultrasound

Question 65

what is a complication of malrotation with midgut volvus?

Answer 65

ischemic necrosis

twisting of the midgut cuts off blood supply to the intestines leading to necrosis

common presentations:
1. abdominal obstruction

2. bloody stool
3. severe abdominal pain

Question 66

how do you treat malrotation with midgut volvus?

Answer 66

emergency surgery

Ladd’s procedure, often with an appy due to abnormal location of cecum

Question 67

what is Meckel’s diverticulum?

Answer 67

rule of 2’s

2 years age

2 feet of ileocecal valve

2 inches

2 types tissue – pancreatic and gastric

2% population

2:1 male to female

“2rue” (true) diverticulum

Question 68

what is intusseception?

Answer 68

kids get viral infection and lymphatics swell up which leads to telescoping of intestines within themselves –> give enema

in adults, intussusception, it could mean cancer

Question 69

64 yo female with sudden onset severe diffuse abdominal pain out of proportion to physical exam, nausea, vomiting, and diarrhea.

diagnosis?

Answer 69

mesenteric ischemia

Question 70

what is mesenteric ischemia?

Answer 70

inadequate blood flow to the small intestine

Question 71

what is the classic presentation of mesenteric ischemia?

Answer 71

1. > 50 yo
2. sudden onset very severe abdominal pain
3. N/V/D because intestines aren’t moving things through and there’s malabsorption
   initially: pain is severe, diffuse, w/o localization, and out of proportion to exam (patient is writhing in pain but abdomen is soft w/ no guarding or rebound tenderness

as disease progresses, bowel infarcts leading to abdominal distention, guarding, rebound, and absence of bowel sounds

bloody diarrhea and heme positive stools seen after bowel has infarcted

Question 72

what are the 4 causes of mesenteric ischemia?

Answer 72

1. mesenteric artery embolus
2. mesenteric artery thrombosis
3. mesenteric vein thrombosis
4. non-occlusive ischemia

Question 73

what is a mesenteric artery embolus?

Answer 73

most common cause of acute mesenteric ischemia

acute d/t embolus lodging in and occluding an artery with little to no time for collateral circulation to form

most common location is SMA

Question 74

what are the risk factors for a mesenteric artery embolus?

Answer 74

1. arrhythmias (AFib)
2. mural thrombus
3. valvular heart disease
4. structural heart defects

Question 75

what is a mesenteric artery thrombosis?

Answer 75

atherosclerosis of mesenteric vasculature slowly forms over time until occlusion occurs and causes acute ischemia once plaque ruptures

h/o undiagnosed chronic mesenteric ischemia – vague Sx such as weight loss, abdominal angina (pain after meals), and fear of food

celiac trunk is most common followed by SMA

90% mortality due to extensive bowel necrosis

Question 76

what is a mesenteric vein thrombosis?

Answer 76

least common cause of mesenteric ischemia; can be acute or chronic

seen in relatively younger populations

most commonly in SMV

Question 77

what are the risk factors for a mesenteric vein thrombosis?

Answer 77

1. hypercoagulable states (Factor V Leiden, protein c deficiency),
2. h/o DVT
3. recent surgery
4. malignancy
5. cirrhosis

Question 78

what is non-occlusive ischemia?

Answer 78

occurs in low flow states, i.e. decreased cardiac output d/t cardiogenic shock, CHF, arrhythmias, sepsis, HoTN, and drugs.

not associated with arterial or venous occlusion

angiography is the gold standard for diagnosis and treatment

Question 79

what is ischemic colitis?

Answer 79

ischemia of the colon due to a comorbidity

edema, ischemia, campy bloody diarrhea without arterial blockage with colonic thickening due to a comorbidity – treat with IV fluids, bowel rest, get blood sugar under control etc.

1. age > 60
2. crampy pain, bloody diarrhea
3. DM, HTN, ESRD comorbidities
4. constipating medicines
5. low albumin

diagnose with clinical picture plus CT, c-scope if unclear and NO perforation

treat supportively

Question 80

what is a handlebar trauma?

Answer 80

duodenal hematoma in a kid!

the bruise pattern (appearance of handlebar) and history are most important

present after injury in mild pain, stable

initial CT often normal despite pain so it’s hard to diagnose other than clinical suspicioun

require serial abdominal examinations, if worsen, repeat CT scan and look for hematoma around the duodenum which could be impairing their ability to eat and drink

Question 81

what are the clinical signs of retroperitoneal bleeding?

Answer 81

1. Cullen sign

bluish discoloration around umbilicus –> due to intraperitoneal bleeding, often pancreas

2. Grey-Turner sign

greyish-blue discoloration of flanks and lower back –> often due to retroperitoneal bleeding from kidneys, pancreas, or pelvic fractures into contained space

Question 82

what is the seatbelt sign?

Answer 82

nonspecific sign

pattern of bruising from deceleration

this should heighten your suspicion for a visceral injury

Question 83

why do you do gastric bypass surgery?

Answer 83

1. diabetes
2. HTN
3. GERD
4. cardiac risk factors
5. lose weight

Question 84

what are some of the side effects of bypass surgery?

Answer 84

you’ve taken away the pylorus and the ability of the pancreas and duodenum to neutralize stomach acid when you do bypass, you may see an ulcer form = marginal ulcer

this procedure is designed to be maladsorptive so they might have diarrhea so watch out for diarrhea

Question 85

what is dumping syndrome?

Answer 85

diet high in simple sugars transits fast, increases osmolality which pulls water into lumen

leads to hypotension, sympathetic response, diarrhea and crampy abdominal pain

often ~15 minutes after ingesting

treat by improving diet

Question 86

what is a marginal ulcer?

Answer 86

ulcer formation at the site of the gastro-jejunal anastamosis after bypass surgery

may present as any other ulcer with pain, perforation, or bleeding

high risk in patients who smoke, drink, use NSAIDs, have history of H. pylori

treat with acid supression (PPI +/- sucralfate), endoscopy to diagnose and then to confirm healing