Lecture 17 - Left Abdomen Flashcards
What are the 3 primary causes of an enlarged spleen?
Passive engorgement with blood due to vascular pressure (ex. CHF, cirrhosis, portal HTN, thrombosis of portal, hepatic or splenic veins)
Increase in size due to hemolysis/sequestration
Enlargement due to infiltration by cells or other material (ex. Infection or inflammation)
What are some sx secondary to an enlarged spleen?
LUQ pain, early satiety, abdominal fullness or distention, pain referred to chest or L shoulder
How should you treat splenomegaly?
Depends on the pt’s clinical status and the possible reasons for the splenomegaly (ranges from no Tx to splenectomy)
Stabilize pt if necessary
Treat underlying cause
Always advise pts to refrain from sports and other activities with a high risk of splenic injury
Describe intestinal ischemia
Caused by any process that reduces intestinal blood flow
Wide range of sx severity and presentation depending on degree and location of ischemia/infarction
Named differently based on location of bowel ischemia (mesenteric or colonic)
What are some risk factors for intestinal ischemia?
Any condition that reduces perfusion to the intestine
HTN, DM, HLD, smoking
Aorto-iliac surgery or instrumentation
Hemodialysis
Acquired and hereditary thrombotic conditions
Shock
Vasoconstriction medications
MI/cardiomyopathy, hypovolemia, inflammation/infection
Old age
Female
What are the sx associated with acute mesenteric ischemia?
Suddenly onset of pain
Pt appears severely ill
Abd pain is out of proportion to the exam
What are the sx associated with chronic mesenteric ischemia?
Intermittent postprandial abd pain, an aversion to eating, unintentional weight loss
What are the sx of acute colonic intestinal ischemia?
Rapid onset of mild cramping abd pain, tenderness over the affected bowel, most often involving the L abd
Pt does not appear severely ill
Rectal bleeding or bloody diarrhea often present
What are the sx for chronic intestinal ischemia?
Recurrent abdominal pain, bloody diarrhea, weight loss from protein losing enteropathy, recurrent bacteremia, persistent sepsis, or symptomatic colonic strictures
What is the test of choice for mesenteric ischemia?
CT angiogram of abd/pelvis (IV contrast only)
Order only if high degree of suspicion for mesenteric ischemia
What is the test of choice for colonic ischemia?
Colonoscopy/sigmoidoscopy
What is the general treatment for intestinal ischemia?
Initial supportive management: fluids, hemodynamic monitoring and support, correction of electrolyte abnormalities, pain and nausea control
Systemic anticoagulation under most circumstances
Initiation of broad spectrum abx
What is ulcerative colitis?
Chronic inflammation condition
Affects the mucosal layer of the colon
Almost always involves the rectum and also affects the distal colon
Inflammation is continuous usually from the rectum proximally
What is Crohn’s disease?
Mostly affects the terminal ileum and/or proximal colon, but can involve any component fo the GI tract from the mouth to the perianal area
Transmural inflammation of the bowel
May lead to fibrosis and strictures and may result in sinus tracts giving rise to microperforations and fistula formation
Smoking is a risk factor for what?
Crohn’s disease but not for UC
What are the sx for Crohn’s disease?
Crampy abd pain (RLQ) Chronic intermittent diarrhea w/ or w/o gross bleeding, fatigue, weight loss Could have signs of intestinal obstruction if there’s intestinal strictures Perianal disease (fistula, abscesses, fissures)
What is the diagnostic test of choice for Crohn’s disease?
Colonoscopy including the terminal ileum with biopsy
What are the sx associated with ulcerative colitis?
Hx of diarrhea often with blood associated with colicky (crampy) abdominal pain, FECT urgency, and tenesmus with gradual onset and progressive over weeks
What is the gold standard for diagnosis of UC?
Colonoscopy with biopsies
Is a total colectomy curative for UC?
Yes
What is diverticulosis?
Presence of diverticulum (sac like protrusions of the colonic wall)
Increases with age
What is diverticulitis?
Erosion of the diverticula wall by increased intralaminar pressure or impacted food particles
Inflammation and focal necrosis ensue, resulting in perforation
What is the MC sx for diverticulitis?
Abdominal pain
Usually LLQ
What is the imaging of choice for diverticulitis?
CT of abd/pelvis with IV and oral contrast
What is the outpatient Tx for diverticulitis?
Oral abx and close follow up (augmentin - flouroquinolone or bactrim + metronidazole)
What is the inpatient tx for diverticulitis?
Supportive care (fluids, hemodynamic support, electrolytes, pain and nausea control) IV abx (ciprofloxacin + flagyl) Surgery may be required for severe disease
What are the sx for colonic cancer?
No sx in majority of pts with early stage Hematochezia or melena Abd pain Unexplained IDA Change in bowel habits
What are the risk factors for colon cancer?
Advanced age, male gender, smoking, family history of colorectal cancer, IBD (especially UC)
What is the gold standard for imaging of colon cancer?
Colonoscopy
What is the tx for colon cancer?
Surgical resection
