Lecture 17 - Left Abdomen

Question 1

What are the 3 primary causes of an enlarged spleen?

Answer 1

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)

Question 2

What are some sx secondary to an enlarged spleen?

Answer 2

LUQ pain, early satiety, abdominal fullness or distention, pain referred to chest or L shoulder

Question 3

How should you treat splenomegaly?

Answer 3

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

Question 4

Describe intestinal ischemia

Answer 4

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)

Question 5

What are some risk factors for intestinal ischemia?

Answer 5

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

Question 6

What are the sx associated with acute mesenteric ischemia?

Answer 6

Suddenly onset of pain
Pt appears severely ill
Abd pain is out of proportion to the exam

Question 7

What are the sx associated with chronic mesenteric ischemia?

Answer 7

Intermittent postprandial abd pain, an aversion to eating, unintentional weight loss

Question 8

What are the sx of acute colonic intestinal ischemia?

Answer 8

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

Question 9

What are the sx for chronic intestinal ischemia?

Answer 9

Recurrent abdominal pain, bloody diarrhea, weight loss from protein losing enteropathy, recurrent bacteremia, persistent sepsis, or symptomatic colonic strictures

Question 10

What is the test of choice for mesenteric ischemia?

Answer 10

CT angiogram of abd/pelvis (IV contrast only)

Order only if high degree of suspicion for mesenteric ischemia

Question 11

What is the test of choice for colonic ischemia?

Answer 11

Colonoscopy/sigmoidoscopy

Question 12

What is the general treatment for intestinal ischemia?

Answer 12

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

Question 13

What is ulcerative colitis?

Answer 13

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

Question 14

What is Crohn’s disease?

Answer 14

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

Question 15

Smoking is a risk factor for what?

Answer 15

Crohn’s disease but not for UC

Question 16

What are the sx for Crohn’s disease?

Answer 16

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)

Question 17

What is the diagnostic test of choice for Crohn’s disease?

Answer 17

Colonoscopy including the terminal ileum with biopsy

Question 18

What are the sx associated with ulcerative colitis?

Answer 18

Hx of diarrhea often with blood associated with colicky (crampy) abdominal pain, FECT urgency, and tenesmus with gradual onset and progressive over weeks

Question 19

What is the gold standard for diagnosis of UC?

Answer 19

Colonoscopy with biopsies

Question 20

Is a total colectomy curative for UC?

Answer 20

Yes

Question 21

What is diverticulosis?

Answer 21

Presence of diverticulum (sac like protrusions of the colonic wall)
Increases with age

Question 22

What is diverticulitis?

Answer 22

Erosion of the diverticula wall by increased intralaminar pressure or impacted food particles
Inflammation and focal necrosis ensue, resulting in perforation

Question 23

What is the MC sx for diverticulitis?

Answer 23

Abdominal pain

Usually LLQ

Question 24

What is the imaging of choice for diverticulitis?

Answer 24

CT of abd/pelvis with IV and oral contrast

Question 25

What is the outpatient Tx for diverticulitis?

Answer 25

Oral abx and close follow up (augmentin - flouroquinolone or bactrim + metronidazole)

Question 26

What is the inpatient tx for diverticulitis?

Answer 26

Supportive care (fluids, hemodynamic support, electrolytes, pain and nausea control) 
IV abx (ciprofloxacin + flagyl)
Surgery may be required for severe disease

Question 27

What are the sx for colonic cancer?

Answer 27

No sx in majority of pts with early stage 
Hematochezia or melena 
Abd pain 
Unexplained IDA 
Change in bowel habits

Question 28

What are the risk factors for colon cancer?

Answer 28

Advanced age, male gender, smoking, family history of colorectal cancer, IBD (especially UC)

Question 29

What is the gold standard for imaging of colon cancer?

Answer 29

Colonoscopy

Question 30

What is the tx for colon cancer?

Answer 30

Surgical resection