Lower GI 2 Flashcards
70-year-old woman presents with nausea vomiting and increased abdominal pain. Low grade fever and distended abdomen. Nonspecific ileus on radiograph. Sigmoidoscopy shows ischemic sigmoid colon. Angiogram shows SMA occlusion. Improves after antibiotics and hydration. Next step?
- Given high chance of recurrence, revascularization
2. Aspirin as antiplatelet therapy
75-year-old woman presents with suspected mesenteric ischemia – When to take patients OR?
Necrotic bowel – proceed to OR
- Significantly worsening pain after presentation
- Leukopenia or leukocytosis
- Metabolic acidosis
75-year-old woman presents with suspected mesenteric ischemia – patient also has atrial fibrillation. Suspected diagnosis? Management
Suspect ischemia, necrosis, or perforation with infection. Proceed to OR embolization
Exploration likely necessary
75-year-old woman presents with suspected mesenteric ischemia – hematocrit of 55%. Suspected diagnosis? Management
Polycythemia likely secondary to severe dehydration.
- Hydration
- Angiography
75-year-old woman presents with suspected mesenteric ischemia – history of thoracic aortic dissection. Suspected diagnosis? Management
Occlusion related to dissection
Angiography
75-year-old woman presents with suspected mesenteric ischemia – also presents with bloody diarrhea. Suspected diagnosis? Management
Ischemic segment of bowel with necrosis of mucosa
Sigmoidoscopy
- If full thickness necrosis, exploration and resection
- If only mucosal ischemia – antibiotics, close observation
75-year-old woman presents with suspected mesenteric ischemia – taken to the OR. Find necrosis of left colon. Management?
Resection with reanastomosis if patient stable (or colostomy if not )
75-year-old woman presents with suspected mesenteric ischemia. Taken to the OR. Find necrosis of the intestines from the ligament of Treitz to the transverse colon. Management? Complication?
Resection of majority of the bowel, leaving patients with short bowel syndrome and need for chronic TPN or transplantation
75-year-old woman presents with suspected mesenteric ischemia – taken to the OR. Find necrosis of 2 feet of jejunum and ischemia adjacent bowel. Management? If doubt viability?
Resection and reanastomosis
If is any doubt about the viability of bowel
- second look procedure
- Ileistomy to allow for direct observation if bowel
75-year-old woman presents with suspected mesenteric ischemia – taken to the OR. Find ischemia but no necrosis of intestines. Also find acute occlusion of SMA. Management?
- Revascularize bowel via bypass or removal of occlusion
2. Inspect viability
75-year-old woman presents with suspected mesenteric ischemia – taken to the OR. Find ischemia of the intestines and small punctate areas of necrosis throughout jejunum and ileum. Patient has pulse in SMA and mild congestive heart failure. Possible causes? Management?
- Multiple small emboli
- Low flow state
- Resection of necrotic segments and second look operation
- Angiography to evaluate low flow state
24-year-old woman with crampy abdominal pain, nausea, vomiting. History of Crohn’s disease. Obstructed series shows small bowel obstruction. No fever, no accidents, mild leukocytosis. Small bowel obstruction likely secondary to? Confirm with? Management?
Small bowel obstruction secondary to stricture due to Crohn’s disease
CT of abdomen
Non-operative management the TPN, bowel rest, observation
24-year-old woman with crampy abdominal pain, nausea, vomiting. History of Crohn’s disease. Obstructed series shows small bowel obstruction. No fever, no accidents, mild leukocytosis. CT shows internal fistula between two segments of small bowel. Management?
Non-operative management the TPN, bowel rest, observation
Management is based on patients symptoms and active problems, not radiographic findings
75-year-old woman presents with suspected mesenteric ischemia – history of CHF. Mechanism? Management?
Low flow nonocclusive state
Direct mesenteric onfusion of a vasodilator (Papaverine )
Patient with history of Crohn’s disease presents with small bowel obstruction. Receives treatment for three weeks, with no signs of resolution – next step? Chance of needing reoperation?
Surgical therapy to reset strictures
Reoperation (50%)
