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Surgery Clerkship > Lower GI > Flashcards

Lower GI Flashcards

1
Q

What are common mimics of appendicitis in adults?

A 
IBD
Pancreatitis
Cholecystitis
Gastroenteritis
Nephrolithiasis
Perforated duodenal ulcer
Pyelonephritis
Cecal diverticulitis
Meckel's diverticulitis
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2
Q

What are common mimics of appendicitis in women?

A

Pelvic inflammatory disease
Ovarian torsion
Mittelschmerz: physiologic mid-cycle pain
Ruptured ectopic

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3
Q

What are mimics of appendicitis in kids?

A 
Mesenteric lymphadenitis
Yersinia enterocolitica
Pneumococcal pneumonia
Gastroenteritis
Intussusception
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4
Q

What is most important thing to do in a woman presenting with RLQ pain?

A

Test beta hCG to rule out ruptured ectopic pregnancy

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5
Q

What is the first symptom of appendicitis?

A

anorexia

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6
Q

What is typical sequence of appendicitis symptoms?

A

Anorexia
vague peri umbilical abdominal pain
vomiting
shift to RLQ pain

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7
Q

What is significance of absent bowel sounds in appendicitis?

A

Paralytic ileus secondary to inflamed/infected bowel

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8
Q

What is Rovsign’s sign?

A

RLQ pain with palpation of LLQ: stretching abdominal wall triggers pain in inflamed underlying RLQ parietal peritoneum

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9
Q

What is psoas sign?

A

RLQ on passive extension of R hip or active flexion of R hip

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10
Q

What is obturator sign?

A

RLQ pain on internal rotation of the hip

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11
Q

Where is McBurney’s point?

A

1/3 of distance between ASIS to umbilicus = incision site of open appendectomies

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12
Q

What explains shift from midline periumbilical pain to RLQ pain in appendicitis?

A

Stretching of visceral (PSNS/SNS) to parietal (somatic) nerves

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13
Q

Why is hyperesthesia of skin a sign of acute appendicitis?

A

Parietal peritoneum: spinal nerves T10-12 innervate. Area of skin supplied by those nerves on the R can become very sensitive to touch (cutaneous hyperesthesia)

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14
Q

What is a closed loop obstruction? What happens?

A
  • Loop of bowel is obstructed at 2 points: no outlet for bowel contents and pressure.
  • Bowel continues to distend until venous pressure exceeded by arterial inflow
  • Ischemia and infarction ensue
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15
Q

What causes the closed loop obstruction in acute appendicitis in kids or adults?

A

Kids: lymphoid hyperplasia
adults: fecalith

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16
Q

What is one presentation of appendicitis in kids?

A
  1. viral URI

2. true onset of acute appendicitis

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17
Q

What are the key labs to draw for suspected appendicitis?

A

1 CBC to look for WBC elevation with left shift
2 CRP
3 beta hCG to rule out pregnancy
4 UA: may show pyuria without bacteruria

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18
Q

When is imaging indicated? And what type?

A

When diagnosis is unclear
Men/non pregnant women: CT scan
Pregnant women/children: US

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19
Q

What does appendicitis look like on CT?

A

Periappendiceal fat stranding
Appendiceal diameter > 6 mm
May show free fund or phlegm

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20
Q

What is definitive treatment for appendicitis?

A

Laparoscopic or open appendectomy

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21
Q

What is role for pre- and post-op antibiotics for acute non-perforated appendicitis?

A

a single dose of pre-operative antibiotics

post-op: do not exceed 24 hours

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22
Q

What is role for antibiotics for acute perforated appendicitis?

A

IV antibiotics until fever and leukocytosis resolved (3-5 days)

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23
Q

How to proceed if doing laparoscopic appendectomy and appendix appears normal?

A

Take it out anyway EXCEPT in regional enteritis (Crohn’s) involving the cecum, because of high risk of developing a cecal fistula

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24
Q

What is the most sensitive test for appendicitis

A

CT scan

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25
Q

What is the pathophysiology of perforated appendicitis?

A

Closed-loop obstruction creating an ischemic mucosal wall and not a direct result of increased intraluminal pressure

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26
Q

What to think of in a patient with signs and symptoms of appendicitis and extensive diarrhea?

A

Yersinia enterocolitica = pseudoappendicitis

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27
Q

Does an abnormal UA rule out appendicitis?

A

No! Pyuria is common in appendicitis

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28
Q

What is the differential for a lower GI bleed?

A
  • Diverticulosis
  • Neoplastic
  • Iatrogenic from biopy/colo
  • Colitis: infectious, ischemic, inflammatory, radiation
  • Angiodysplasia
  • Anorectal (hemorrhoids, fissures)
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29
Q

What is always a concern with lower GI bleed, so much so that we always do something else?

A

large upper GI bleed is the cause, so place NGT to aspirate for blood or coffee grounds

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30
Q

What is the most common cause of lower GI bleed?

A

Diverticulosis

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31
Q

What to evaluate for: watery progressing to bloody diarrhea?

A

EHEC

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32
Q

What is the pneumonic/causes for most common cause of LGIB?

A 
H-DRAIN:
Hemorrhoids
Diverticulosis
Radiation colitis
Angiodysplasia
Infectious/ischemic/IBD
Neoplasms/polyps
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33
Q

What is the most common cause of LGIB in a patient > 50?

A

diverticulosis
angiodysplasia
malignancy

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34
Q

What is the most common cause of LGIB in a younger patient?

A

Infectious
Hemorhoids
Anal fissures
IBD

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35
Q

How does diverticular bleeding present?

A

Arterial: acutely with large amounts of blood

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36
Q

How do angiodysplasia or colon cancer present with respect to bleeding?

A

Anemia or dark stools

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37
Q

What does dark maroon blood, mixed with stool, tell us about the possible location of bleeding?

A

Upper GI, small intestine, R colon

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38
Q

What does copious bright red blood (hematochezia) tell us about the possible location of the bleeding?

A

Right colon, rectum, anus, massive upper GI bleed with rapid transit

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39
Q

What does spots of blood on toilet paper or dripping after defection tell us about location of bleed?

A

rectum, anus

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40
Q

What does scant, dark red blood tell us about location of LGIB?

A

Angiodysplasia

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41
Q

What does occult blood in the stool suggest about location of bleed?

A

Polyp, colorectal cancer

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42
Q

Diverticula in the L vs. R colon are most likely to have what outcomes?

A

Right: more likely to bleed
Left: more likely to get infected

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43
Q

What is an occult bleed?

A

No blood seen per rectum: only detected by fecal occult blood testing or iron-deficiency anemia

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44
Q

What is tenesmus? When would it likely present?

A

Sense of incomplete evacuation of stool. Most often seen with UC/infectious etiology

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45
Q

Why is a past history of LGIB on prior colonoscopy important?

A

Angiodysplasia and diverticulosis patients present with chronic bleeding.
- Colon cancer arises from a polyp and takes many years to transform into a malignancy: so <5 years with normal screening colo makes cancer unlikely

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46
Q

Why is a history of pelvic radiation or prior aortic surgery important when working up LGIB?

A
  • Damage to rectal mucosa –> radiation proctitis

- Aortic surgery can erode aortic graft into duodenum –> aortoduodenal fistula

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47
Q

What medications can exacerbate GI bleeds?

A

Anticoagulants (warfarin, aspirin, clopidogrel)
NSAIDS
can both exacerbate GI bleeding

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48
Q

What is the implication of abdominal tenderness on physical examination for LGIB?

A 
Suggests colitis (IBD, ischemic or infectious).
* Unusual with diverticulosis/angodysplasia
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49
Q

What suggests upper GI bleed on history and PE?

A

Vomiting blood or coffee grounds + maroon or black stools

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50
Q

What suggests lower GI bleed on history and PE?

A

Bright red blood per rectum

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51
Q

How does ischemic colitis classically present?

A

left sided abdominal pain + bloody diarrhea in elderly patients with low flow states (dehydration, heart failure, shock, trauma)

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52
Q

What re risk factors for diverticulosis?

A
  • Older people
  • Poor diet
  • Obese
  • Connective tissue disorders
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53
Q

What is a diverticulum? What is the pathophysiology of its rupture?

A

Saclike protrusion through the colonic wall: as it herniate: vasa recta become draped over the dome of diverticulum: separated from lumen by mucosa only! Chronic damage/stress on luminal side leads to arterial wall weakness and rupture

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54
Q

What causes a diverticulum?

A

High intraluminal pressure in the colon: mucosa and submucosa can herniate through the muscular layer of the intestinal wall (false diverticulum)

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55
Q

What is most common site for diverticula?

A

sigmoid colon

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56
Q

What is the natural history of a diverticular bleed?

A

75% stop bleeding spontaneously, but each episode of bleeding increases the risk of a future bleed

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57
Q

What is diverticulitis?

A

Micro or macroperforation of a diverticulum

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58
Q

What is angiodysplasia?

A
  • Focal submucosal areas of thin, weak and dilated vessels in the GI tract.
  • Increases with age due to weakness in vascular walls
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59
Q

What conditions is angiodysplasia associated with?

A

vWF disease
aortic stenosis
chronic kidney disease

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60
Q

What type of bleeding does angiodysplasia cause?

A
  • Small in quantity/occult
  • Results in iron deficiency anemia or heme-positive stools
  • Usually less bleeding since venous in origin
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61
Q

What causes ischemic colitis?

A
  • Decreased blood flow to colon due to ischemia, most often in watershed areas such as splenic flexure.
  • Usually not transmural
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62
Q

What factors can precipitate ischemic colitis?

A

dehydration, heart failure, shock, CV surgery, hypercoaguable states, extreme exercise, hemodialysis

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63
Q

What is the natural history of ischemic colitis?

A

Most resolve with supportive care

Minority of cases with require resection for transmural infarction

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64
Q

What are most commonly affected territories of ischemic colitis vs. acute mesenteric ischemia?

A

Ischemic colitis: watershed areas

AMIL: ligament of Treitz to mid transverse colon

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65
Q

What is the natural history of acute mesenteric ischemia?

A

Usually leads to small bowel necrosis requiring resection: high mortality

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66
Q

What layers of bowel are affected in ischemic colitis vs. acute mesenteric ischemia?

A

Ischemic: usually mucosa only
AMI: often transmural

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67
Q

How do we diagnose ischemic colitis?

A

Colonoscopy often shows mucosal changes

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68
Q

How do we diagnose acute mesenteric ischemia?

A

CT scan: small bowel wall thickening, occlusion of SMA and gas in intestinal wall

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69
Q

What are initial management steps in LGIB?

A
  • 2 large bore IVs
  • Send labs: type and cross, CBC, chemistry and INR/PTT
  • If sig blood loss: crystalloid + pRBCs as needed
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70
Q

What is next step for LGIB management after large bore IVs and fluid resuscitation?

A
  • NGT placement to rule out UGIB

- If positive for blood: EGD

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71
Q

Where should LGIB patient be admitted if hemodynamically unstable? What else should be done?

A

ICU

Do thorough workup to find source of blood

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72
Q

What is first diagnostic test for LGIB in an unstable patient? Is it effective?

A

Colonoscopy: can fail to visualize due to lack of bowel prep, but can determine general location (if colon or proximal to cecum)

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73
Q

If colonoscopy cannot identify location of LGIB, what are the other options?

A

Arteriography

Tagged red blood cell scan using technetium-99m (nuclear scintigraphy)

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74
Q

How do we look for blood in the small bowel?

A

Meckel’s nuclear scan
Capsule endoscopy
Enteroscopy

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75
Q

If a LGIB patient’s bleeding has not stopped and patient is unstable, what is the next step?

A

Emergent laparotomy + total colectomy leaving rectum and end ileostomy (assuming bleeding is in colon)

76
Q

What if arteriography localizes the source of bleeding in LGIB but is unable to stop the bleeding with embolization?

A

Surgery: resection determined by localization

77
Q

What are indications for surgery for LGIB? (3)

A

1 Hemodynamically unstable, despite resuscutation
2 Massive bleeding >6 units pRBC
3 Active bleeding with failure of embolization

78
Q

What is the differential for a change in bowel habits?

A 
Colorectal cancer
IBS
IBD
Celiac
INtestinal pseudoobstruciton
Thyroid disease
Drugs
Infectious diarrhea
79
Q

What are the 3 things that make you think colon cancer until proven otherwise?

A

Change in bowel habits
Weight loss
Anemia

80
Q

How does R sided colon cancer classically present?

A

Iron deficiency anemia

81
Q

How does L sided colon cancer classically present?

A

Obstructive symptoms: pencil thin stools, constipation

82
Q

How does rectal cancer classically present?

A

Hematochezia

83
Q

What is recommended screening for colon cancer?

A

Colonoscopy every 10 years: ages 50-75

84
Q

What is colon cancer screening for those with colorectal cancer in a first degree relative?

A

Colonoscopy at age 40 or 10 years prior to diagnosis in 1st degree relative

85
Q

What other screening test are there, besides colonoscopy?

A 
Flexible sigmoidoscopy (Every 5y, plus FOBT every 3y)
FOBT (Annually)
Barium enema with sigmoidoscopy (every 5y)
CT colonography (every 5y)
Capsule endoscopy (every 5y)
86
Q

What other screening test is an option, per the USPST?

A

Flexible sigmoidoscopy every 5 years + FOBT every 3 years

87
Q

How does colon cancer rank in terms of most common cancers in USA and the highest overall mortality?

A

3rd most common incidence

3rd highest mortality

88
Q

In what side of colon cancers is melena more common?

A

Right sided

89
Q

Why is rectal examination important in evaluation of suspected colorectal cancer?

A

1 May be able to feel the mass of a low rectal cancer

2 Can assess location

90
Q

What are the two types of non-neoplastic polyps?

A

Hyperplastic

Juvenile / hamartomatous

91
Q

What is the most common type of polyp?

A

Hyperplastic

92
Q

How can colon cancers develop (2 pathways)?

A
  1. Adenoma carcinoma sequence

2. Microsatellite instability

93
Q

What is the adenoma carcinoma sequence?

A
  1. Loss of APC tumor suppressor
  2. K-ras mutation
  3. loss of p53
94
Q

How does colon cancer arise?

A

Epithelial proliferation and dysplasia (adenomatous polyps)

95
Q

What features of an adenoma are associated with increased malignant risk?

A

Polyp size, architecture, severity of dysplasia

96
Q

Which types of adenoma have the highest risk of malignancy, and what are the other two types?

A

Villous and Sessile serrated

> tubulovillous > tubular

97
Q

Why do we use 10 year interval for colonoscopy screening?

A

Adenoma to carcinoma sequence takes about 10 years

98
Q

What are the most common metastatic sites for colon and rectal cancer?

A

Liver
Rectal:
- Lungs (inferior rectal to IVC via internal iliac)
- Inguinal lymph nodes (via systemic veins)
- Spine and brain (via sacral veins)

99
Q

What are the 4 heritable conditions associated with colon cancer?

A

HNPCC/Lynch syndrome
FAP
Garner’s syndrome
Turcot syndrome

100
Q

What conditions are associated with Gardner’s syndrome?

A 
Osteomas
Colonic polyps (cancer by 4th to 5th decade)
101
Q

What conditions are associated with Turcot syndrome?

A

Cafe au lait spots
Malignant CNS tumors
Neoplastic colon polyps

102
Q

At what age should first-degree family members of FAP patients begin colonoscopy screening?

A

Age 10

103
Q

What is the criteria to identify those who may have Lynch syndrome?

A

3-2-1-1
3+ relatives with cancer of colon, endometrium, small bowel or pelvis
2+ successive generations affected
1+ relatives diagnosed before 50
1+ should be a first degree relative of the other two

104
Q

What is a synchronous vs. metachronous tumor?

A
  • Synchronous is a second primary cancer present at the time of diagnosis
  • Metachronous: primary cancers that develop elsewhere in the colon 6+ months after primary resection
105
Q

How is colorectal cancer diagnosed?

A

Colonoscopy and tissue biopsy

106
Q

In a patient with suspected colon cancer, is there a role for testing blood in stool?

A

No

107
Q

What is the role of CEA?

A

An adjunct to other modalities to look for tumor recurrence: NOT for screening

108
Q

Once we establish diagnosis of colon cancer, what labs to draw?

A 
CEA
Liver enzymes (look for mets)
109
Q

What conditions can elevate CEA?

A

Colon cancer + MANY GI and other inflammatory conditions (+ smoking)

110
Q

Once we establish diagnosis of colon cancer, what imaging should be done?

A

CT abdomen, chest and pelvis to look for mets

111
Q

Once we establish diagnosis of rectal cancer, what imaging should be done?

A
  1. Transrectal ultrasound
  2. MRI
    Better for staging
112
Q

In a locally advanced rectal cancer, what neoadjuvant therapy is pursued and why?

A

Chemo and radiation to shrink tumor/downstage it and increase the chance for sphincter preservation, reduce recurrence rate

113
Q

What is the staging system for colon cancer?

A

TNM

114
Q

What is the operation and artery ligation for right sided colon cancer?

A

R colectomy

Ligation of ileocolic artery

115
Q

What is the operation and artery ligation for transverse colon cancer?

A

Transverse colectomy or extended R colectomy with location of ileocolic and middle colic arteries

116
Q

What is the operation and artery ligation for descending colon cancer?

A

Left colectomy with ligation of IMA

117
Q

What is the operation and artery ligation for sigmoid colon cancer?

A

Left colectomy with ligation of IMA

118
Q

What is the management of benign polyps?

A

Polypectomy and reassess in 1-5 years

119
Q

What is the management for colon cancer (3)?

A
  1. R/L colectomy
  2. Bowel prep before colectomy
  3. Post op chemo for locally advanced disease and/or positive lymph nodes
120
Q

What is bowel prep and why is it done?

A

Prepares colon for surgery

  • Removes all stool - prevents stool spillage into peritoneum during surgery
  • Provides better visualization of colon
121
Q

When should bowel prep NOT be used?

A

Patient suspected of having an obstruction

122
Q

what is the management of rectal cancer?

A
  • w/in 3cm dentate: abdominal perineal resection: remove entire distal rectum including sphincter (colostomy)
  • > 3cm from dentate: low anterior resection removing part of rectum through abdomen
123
Q

How many lymph nodes should be resected?

A

12 minimum

124
Q

why is radiation used for rectal cancer and not colon?

A

Colon is too large: would have to irradiate organs that often cause complications

125
Q

What are the major complications of R colectomy?

A

Injury to ureters
Injury to duodenum
Anastomotic leak

126
Q

How does anastomotic leak present?

A

w/in 1st week of surgery: fever, abdominal pain, tenderness, ileus and leukocytosis

127
Q

What is treatment for suspected anastomotic leak?

A

CT scan or OR urgently with exploration, washout and stony diversion

128
Q

What are the major complications of L colectomy?

A

Injury to ureters
Injury to spleen
Anastomotic leak

129
Q

Is it useful to follow CEA levels after surgery?

A

Yes: every 3 months for first 3 years after surgery

130
Q

What is the difference between obstipation and constipation?

A

Constipation: infrequent stools < 3 per week, usually hard
Obstipation: complete absence of gas or stool per rectum

131
Q

What clues on history and physical distinguish between SBO and LBO?

A

SBO: vomiting, hyperactive bowel sounds
LBO: Pronounced distention, less or late onset vomiting, decreased bowel sounds

132
Q

Why is history of neurologic or psychiatric disorders important in evaluation of abdominal disease?

A

Drugs used to treat can affect colonic motility and predispose to chronic constipation, elongation of sigmoid and volvulus + colonic pseudoobstruction

133
Q

What is the presentation of Ogilvie’s syndrome?

A
  • Massive abdominal distention over several days
  • N /V
  • UNLIKE LBO: classic in someone already hospitalized in post-op setting
134
Q

What are the 5 F causes of abdominal distention?

A 
Fat
Feces (impaction)
Fetus
Flatus (ileus/obstruction)
Fluid (ascites)
135
Q

How do we tell between flatus and fluid?

A

Tympanitic (gas) or dull (fluid) to percussion

136
Q

What are the most common causes of LBO in USA?

A
  1. Colon cancer
  2. Diverticulitis
  3. Volvulus
137
Q

How does LBO present?

A

gradual and severe abdominal distention
obstipation
vomiting

138
Q

How does uncomplicated vs. complicated volvulus present?

A

Non: Normal vitals, mental status and non-tender abdomen
Complicated: severe abdominal pain, fever, tachycardia, toxic appearance, peritoneal signs and leukocytosis

139
Q

What are important things to look for in H&P for patient with suspected LBO?

A

Abdominal scars
Hernias
Rectal exam
* Need to assess for other differentials!

140
Q

What causes sigmoid volvulus?

A

Acquired stretching of the sigmoid

  • Neuropsychiatric disease
  • Institutionalization
  • Chronic constipation
  • Long term anticholinergic use
  • High fiber diet
  • Pregnancy
141
Q

Where in colon is cancer most likely to cause LBO?

A

Left due to smaller diameter

142
Q

What is the difference between malrotation and volvulus?

A

Malrotation: congenital: bowel not in the normal position or properly attached: prone to twisting and obstruction. Asymptomatic if bowel/mesentery don’t twist
Volvulus: manifestation of malrotation if the small bowel twists, or w/out malrotation

143
Q

What is etiology of cecal vs. sigmoid volvulus?

A

Cecal: congenital partial malrotation: cecum and R colon are not fixed
Sigmoid: acquired due to progressive stretching and redundancy of sigmoid colon (twisting on narrow mesentery)

144
Q

What are risk factors for sigmoid volvulus?

A

Anticholinergic (impair motility)
Neurologic/psych diseases (chronic constipation and stool retention)
CF
Chagas disease
High fiber diet (bulky stools that stretch colon)

145
Q

What is complicated volvulus?

A

Bowel ischemia and sequelae like gangrenous bowel and sepsis

146
Q

What are the symptoms/signs of complicated volvulus?

A 
Severe diffuse abdominal pain
Fever
Tachycardia
AMS
Marked tenderness to palpation with peritoneal signs
Labs: infection
147
Q

What are the first steps in workup of suspected LBO?

A

Labs: CBC, lactate, chemistries

148
Q

What labs suggest LBO in appropriate clinical context?

A

Leukocytosis with left shift

Lactic acidosis

149
Q

What is the first imaging recommended for suspect LBO?

A

Plain abdominal (supine and upright) and upright CXR (free air under diaphragm)

150
Q

What signs on XR suggest sigmoid volvulus?

A

Coffee bean sign or omega, bent inner tube, kidney bean sign

151
Q

What signs on XR suggest cecal volvulus?

A

Comma or kidney bean sign

152
Q

If LBO diagnosis is unclear with plain X-ray, what is the next step?

A

CT with oral and IV contrast: volvulus will show whirl sign with mesenteric twisting and dilated colon

153
Q

What are the initial steps in management of LBO after diagnosis has been made?

A

IVF resuscitation
Place Foley to monitor urine output
NGT for symptomatic relief if vomiting

154
Q

What is the definitive treatment for uncomplicated sigmoid volvulus?

A
  1. Detorsion of volvulus with endoscopy: gradual advanced through the closed loop by decompressing with gas
  2. Semi-elective resection
155
Q

What is the definitive treatment for complicated sigmoid volvulus?

A

Emergent laparotomy with resection due to suspicion for colonic ischemia and/or perforation. DO NOT attempt endoscopic detorsion

156
Q

What is the definitive treatment for cecal volvulus?

A
  • No detorsion attempted due to higher rates of failure and bowel necrosis
  • Take to OR for R colectomy
157
Q

What is an alternative option to reduce volvulus (vs. endoscopic detorsion)?

A

Contrast enema, but does not offer mucosal inspection benefit

158
Q

What are the complications of surgery for volvulus treatment?

A

Wound infection
Anastomotic leak
Recurrence
W/o detorsion/resection: ischemia, perforation and sepsis

159
Q

What signs suggest ischemic bowel?

A

Bowel wall thickening
Mesenteric edema
Pneumatosis
Portal venous gas

160
Q

What are the key features of diverticulitis?

A

LLQ pain/tenderness on exam
Fever
Leukocytosis

161
Q

What are the risk factors for diverticulitis?

A

Obesity
Advanced age
Diet low in fiber, high in fat and high in red meat

162
Q

How is diverticulitis diagnosed?

A

Clinically: LLQ pain/tenderness, fever, leukocytosis

163
Q

Where are diverticula most frequently located? Where are they more prone to infection? More likely to bleed?

A

Frequent: Sigmoid
Infected: Left/sigmoid
Bleed: Right

164
Q

Do diverticula occur in the rectum? Why or why not?

A

No: because taenia coli coalesce into circumferential band

165
Q

Are sigmoid diverticula true or false diverticula? which layers?

A

False: only mucosa and submucosa

166
Q

What are the complications of diverticulitis?

A

Abscess, perforation, fistula, stricture, LBO

167
Q

What are the etiologies of fistula?

A 
FRIEND:
Foreign body
Radiation
Infection/inflammation
Epithelialization
Neoplasm
Distal obstruction
168
Q

What is uncomplicated vs. complicated diverticulitis?

A

Diverticulitis with complications = complicated. Abscess, obstruction, peritonitis, fistulization

169
Q

Why might sigmoid diverticulitis present with RLQ pain?

A

Especially long or redundant sigmoid colon on the right side of the abdomen

170
Q

What imaging is recommended for diverticulitis? Is it needed for diagnosis?

A

CT scan, and no

171
Q

What imaging is containdicated in the setting of diverticulitis? Why?

A

Barium enema
Colonoscopy
Due to increased risk of new perforation or exacerbation of existing perf

172
Q

What is the first management step of suspected acute diverticulitis?

A

Is it complicated or not: assess for SIRS criteria.

173
Q

What is the management of uncomplicated diverticulitis without SIRS?

A

Discharge home on oral antibiotics and clear liquid diet

174
Q

What is the management of uncomplicated diverticulitis with SIRS?

A

Admit, placed NPO and given IV antibiotics, fluids and analgesia

175
Q

In a patient with uncomplicated diverticulitis and SIRS, what is the subsequent management after admission if there are no complications?

A

No complication: d/c with dietary modification

176
Q

In a patient with uncomplicated diverticulitis and SIRS, what is the subsequent management if she fails to improve?

A

Failure to improve: repeat CT scan to look for abscess, or take to OR for colon resection

177
Q

In a patient with uncomplicated diverticulitis and SIRS, what is necessary 4-6 weeks after discharge and why?

A

Colonoscopy to rule out malignancy and IBD

178
Q

What is the management for complicated diverticulitis?

A

Depending on complication

  • Urgent surgery
  • CT guided drainage
  • Delayed surgery
179
Q

Which complicated diverticulitis patients need urgent surgery? What type?

A
  • Diffuse peritonitis due to free colonic perforation
  • Diseased colon removed and end colostomy performed
  • Reverse colostomy 12 weeks later
180
Q

How do we treat diverticulitis complicated by a localized abscess <4cm?

A

<4cm: bowel rest + antibiotics

181
Q

How do we treat diverticulitis complicated by a colovesical fistula?

A

IV antibiotics followed by:

  • Resect affected colon segment
  • Repair bladder
182
Q

How do we treat diverticulitis complicated by a localized abscess >4cm?

A

> 4cm: CT-guided percutaneous drainage (to stabilize/reduce inflammation before surgery down the line)

183
Q

How do we treat diverticulitis complicated by free perforation with diffuse peritonitis?

A

Emergent colectomy with end colostomy

184
Q

How do we treat diverticulitis complicated by LBO?

A

Urgent colectomy with end colostomy

185
Q

How is elective surgery for sigmoid diverticulitis different than urgent or emergent?

A

Elective: primary anastomosis

Emergent/urgent: no anastomosis (temporary end colostomy) followed by anastomosis at a later date

186
Q

What structure is at great risk of damage during sigmoid colon resection?

A

Ureters!

Surgery Clerkship (16 decks)

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