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Surgery Shelf Study Guide > Lower GI Surgery > Flashcards

Lower GI Surgery Flashcards

0
Q

What is the most common cause of small bowel obstruction?

A

The most common causes are adhesions from a previous surgery and hernias.

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1
Q

How does a small bowel obstruction present?

A

Presents as colicky abdominal pain, nausea/vomiting, and constipation

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2
Q

How do you manage and treat a small bowel obstruction?

A

Get a KUB, diagnosis is by air fluid levels and dilated loops; tx NPO, NG suction, IVF, and initially observation

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3
Q

What is the electrolyte imbalance caused by small bowel obstruction?

A

Hypokalemic hypochloremic metabolic alkalosis due to emesis

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4
Q

What does bloody diarrhea and a small bowel obstruction indicate?

A

Obstructive tumor or ischemic bowel

dx: sigmoidoscopy –> observe if mucosal, resection if full thickness

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5
Q

What does a SBO + flatus indicate?

A

Indicates partial SBO since gas can get through, more likely to resolve without surgery

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6
Q

What does SBO + diarrhea indicate?

A

Indicates partial SBO due to fecal impaction and severe constipation

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7
Q

What does SBO + inguinal hernia indicate?

A

Requires urgent hernia repair to relieve strangulation

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8
Q

What does SBO with melanoma indicate?

A

Melanoma is the most common tumor that metastasizes to the intestine, surgery is indicated since these don’t resolve spontaneously

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9
Q

What does SBO + peritonitis present as?

A

Presents as rebound tenderness, increased WBC, fever, or metabolic acidosis due to necrotic bowel; indicated for ex lap

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10
Q

How do you manage SBO + adhesions?

A

Indicated for ex lap –> lysis of adhesions

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11
Q

What causes SBO and closed loop obstruction?

A

Usually due to an adhesive band occluding two segments of bowel; indicated for x lap –> lysis of adhesions, resection of any dead bowel, and “second look” operation if bowel viability is indeterminate

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12
Q

What does SBO + pneumoperiotneum indicate?

A

Indicates perforation due to ischemic or overdistended bowel; indicated for ex lap and dead bowel resection

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13
Q

What are you at risk for if there is a nicked bowel during LOA?

A

Small hole –> primary repair

Large or multiple holes –> bowel resection; high risk of leakage or EC fistula formation

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14
Q

What do you do if you are uncertain about an SBO?

A

Get an upper GI series with small bowel follow-through, barium contrast will stop at site of obstruction if SBO exists

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15
Q

How does mesenteric ischemia present?

A

Presents as postprandial abdominal pain, weight loss, SBO, and multiple abdominal bruits usually due to atherosclerosis of celiac trunk or SMA

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16
Q

How do you manage mesenteric ischemia?

A

Dx by mesenteric angiogram
Tx revascularization
follow up with aspirin and evaluation for other atherosclerotic diseases

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17
Q

How does mesenteric ischemia + peritonitis present?

A

Presents as rebound tenderness, increased WBC, fever, or metabolic acidosis due to necrotic bowel; ex lap indicated

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18
Q

What does mesenteric ischemia with afib indicate?

A

Indicates emboli shooting from left atrium to celiac trunk or SMA

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19
Q

What does mesenteric ischemia with an increased hct indicate?

A

Polycythemia due to severe dehydration

Requires IV fluid resuscitation

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20
Q

What does mesenteric ischemia + CHF indicate?

A

Ischemia may be secondary to low-flow, nonocclusive state; indicated for mesenteric vasodilation and improve cardiac output

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21
Q

How can an aortic dissection cause mesenteric ischemia?

A

The dissected aorta can occlude mesenteric vessels;
dx angiography
tx surgical repair

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22
Q

What are you concerned about with mesenteric ischemia with a decrease in blood pressure?

A

Either ischemic bowel causing septic shock or hypotension causing low-flow, non occlusive ischemia

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23
Q

How do you treat left colon necrosis?

A

Bowel resection –> anastomosis

If stable, otherwise colostomy and Hartmann pouch

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24
Q

How do you treat long segment necrosis?

A

Bowel resection –> small bowel syndrome requiring chronic TPN or transplant

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25
Q

How do you treat short segment necrosis?

A

Bowel resection –> anastomosis, “second look” operation if bowel viability is indeterminate

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26
Q

What does small punctate necroses indicate and how do you treat it?

A

Indicates multiple small emboli or low-flow state

Tx bowel resection –> anastomosis, “second look” operation if bowel viability is indeterminate

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27
Q

How do you treat bowel ischemia without necrosis?

A

Try to revascularize the bowel by removing or bypassing the occlusion

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28
Q

How does inflammatory bowel disease present?

A

Crohn’s disease and UC present as crampy abdominal pain, bloody diarrhea, and recent weight loss

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29
Q

How do you manage IBD?

A

Colonoscopy to determine if it’s UC, Crohn’s, or something else
Abdominal CT scan for confirmation

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30
Q

What is Crohn’s disease?

A

Inflammatory disease involving full GI tract with skip lesions (terminal ileum is the most common site)
bx shows full thickness + noncaseating granulomas + creeping fat
dx terminal ileum string sign on CT scan

31
Q

How do you manage Crohn’s disease?

A

IV steroids and 5-ASA for acute flare-ups

32
Q

What causes SBO in Crohn’s? How do you manage it?

A

Due to stenotic terminal ileum

Manage with NPO, TPN, and observation–> if it fails to resolve, surgical stricturoplasty is indicated

33
Q

How do you treat Crohn’s with rectal disease?

A

Rare, indicated for subtotal colectomy and ileostomy

34
Q

What is ulcerative colitis?

A

Inflammatory disease involving the rectum and continuous proximal extension
bx shows mucosal involvement + crypt abscesses + pseudopolyps
dx lead pipe sign on CT scan

35
Q

How do you manage UC?

A

IV steroids and 5-ASA for acute flare-ups, annual colonoscopy for possibility of cancer

36
Q

How do you treat UC with severe dysplasia?

A

Total proctocolectomy, ileal pouch formation, and ileo-anal anastomosis; no further cancer surveillance needed

37
Q

What is pouchitis? How do you treat it?

A

Presents as fever, bloody diarrhea, and pain on defecation s/p ileal pouch formation for UC
Tx: metronidazole

38
Q

How does toxic megacolon present?

A

Presents as fever, bloody diarrhea, pain, and abdominal distention in a patient with UC

39
Q

How do you manage toxic megacolon?

A

Get KUB for confirmation, then NPO, IVF, NG suction, IV steroids and abx
If it improves, then surgery is not necessary
Otherwise surgery is needed

40
Q

What do you see if there is perforation of toxic megacolon?

A

Shows free air on upright CXR, indicated for total colectomy and ileostomy with Hartmann pouch

41
Q

How does appendicitis present?

A

Presents as RLQ pain, low grade fever and leukocytosis; MCC is lymphoid hyperplasia

42
Q

How do you manage appendicitis?

A 
Get CT scan or U/S; if uncomplicated, the appendectomy
if abscess (fever and increased WBC) --> perc drain, interval appendectomy
43
Q

How does appendicitis present in children, the elderly, and in pregnant women?

A

Children: appendicitis more often ruptured appendix
Elderly: usually don’t have classic presentation of appendicitis, but rather vague abdominal complaints, sepsis, AMS, or FTT
Pregnancy: enlarged uterus can push appendix upwards –> RUQ pain, appendectomy can be performed safely

44
Q

What is the differential for RLQ pain and dysuria?

A

Indicates appendicits, UTI, PID, gastroenteritis, or appendiceal abscess next to bladder

45
Q

What is the likely cause of RLQ pain and BPH symptoms?

A

Bladder outlet obstruction due to an enlarged prostate, tx with Foley

46
Q

What are the possible appendectomy findings?

A

Inflamed appendix, perforated appendix, normal appendix, inflamed cecum, fecalith, carcinoid tumor, other tumors

47
Q

How do you manage an appendiceal carcinoid?

A

2 cm hemicolectomy

Can present with carcinoid syndrome due to liver metastasis

48
Q

How does diverticulosis present?

A

Presents as LGIB, 85% stop spontaneously, may develop into diverticulitis
Presents like left-sided appendicitis, get CT scan and manage non-op if possible even with signs of LLQ peritonitis

49
Q

What are the surgical indications of diverticulitis?

A

Uncontained perforation that presents as 4 quadrant peritonitis or pneumoperitoneum, occurs more than 4 times
Follow up with colonoscopy to confirm presence of diverticula and absence of cancer

50
Q

What are the complications of diverticulitis?

A

Abscess, obstructions, fistula (pneumaturia or fecaluria)

51
Q

How and when should you screen for colon cancer?

A

Anyone above 50 y/o should get yearly fecal occult blood test (flex sig and colonoscopy also used, but less commonly)

52
Q

What are colon polyps? How do you manage them?

A

Tubular/pedunculated and have a stalk
Sessile/villous are flattened
Progression from polyp to cancer takes about 10 years
If these are dysplastic, then segmental colectomy

53
Q

How do you diagnose colon cancer?

A

Left side obstructs, right side bleeds
“apple core” lesion on barium enema
Tx with colectomy unless stage IV, then palliative care only

54
Q

What are the worrisome post-op complications of a colectomy?

A

Wound infection
Feculent leak : indicated anastomotic leak, get abd CT scan to check for undrained collection, then NPO/IVF
Feculent vomit: indicates either post-op ileus or mechanical obstruction, treat NPO?IVF and NG tube
Abscesses: CT scan, perc drain
Constipation: stricture or cancer recurrence, dx with colonoscopy

55
Q

What is FAP? How is it treated?

A

Delta APC on chromosome 5p
autosomal dominant
presents as >100 polyps in colon
tx either total proctocolectomy or total abdominal colectomy + strip anal mucosa + ileoanal anastomosis

56
Q

What is Gardner syndrome?

A

FAP + polyps in stomach (not premalignant) and duodenum (malignant)
FAP patients should get upper endoscopy and remove the duodenal polyps

57
Q

What is HNPCC? How do you treat it?

A

Delta MLH or delta MSH mismatch repair genes
Leads to microsatellite instability
tx total abdominal colectomy + ileorectal anastomosis

58
Q

How do you prevent recurrence of colon cancer?

A

Colonoscopy, CEA markers, CXR for lung metastasis, LFTs for liver metastasis

59
Q

What is the first step in management of all anorectal disease?

A

Scope and rule out cancer

60
Q

How do hemorrhoids present?

A

Present as blood streaks in stool and extreme pain (external)
Tx scope to rule out cancer, fiber/stool softeners
if it keeps bleeding, excision or banding

61
Q

What do non healing hemorrhoids indicate?

A 
anal canal cancer
tx chemoradiation (5-FU) --> APR if it persists or recurs
62
Q

What is LAR vs. APR?

A

LAR: low anterior resection (high in rectum)
APR: abdominoperineal resection (low in rectum)

63
Q

How does anal cancer present? How do you treat it?

A

Anal cancer presentation is non-specific (bleeding, pain, drainage, itching) and requires biopsy
Small anal cancer: tx resection with negative margins
Large anal cancer: often mistaken as “non healing hemorrhoids” tx chemoradiation and APR if it persists or recurs

64
Q

What is the common consequence of a perirectal abscess?

A

40% will develop a fistula, tx with fistulotomy

65
Q

What is an anal fissure?

A

Presents as pain and blood with BM due to increased sphincter tone
tx with fiber/stool softeners
if it won’t heal, botox
recurring anal fissure is suggestive of Crohn’s

66
Q

How does rectal prolapse present?

A

Rectal protrusion following defecation

Internal prolapse –> high fiber diet to normalize BM, external/bleeding prolapse –> rectopexy or LAR

67
Q

What is melena?

A

Coffee ground blood in stool, usually UGIB but can also be from ascending colon

68
Q

What is hematochezia?

A

BRBPR, can either UGIB or LGIB;
NG tube aspirate/lavage
LGIB if -blood/+bile
UGIB if +blood

69
Q

What is UGIB?

A

GI bleeding proximal to Ligament of Treitz, management is EGD

70
Q

What is LGIB?

A

GI bleeding distal to Ligament of Treitz, 85% stop spontaneously
MCC are AVM, diverticulosis, and colon cancer

71
Q

How do you manage a LGIB?

A

Must localize site of bleeding with tagged RBCs or angiography; if not currently bleeding, get upper and lower endoscopy

72
Q

What does LGIB indicated in kids?

A

Meckel’s diverticulum

Dx with technetium uptake into ectopic gastric mucosa

73
Q

What are tagged RBCs and angiograms good for?

A

Tagged RBCs: sensitive for LGIB at 0.1 cc/min, but not specific for localizing site of LGIB
Angiogram: less sensitive for LGIB at 1.0 cc/min, but more specific for localizing site of LGIB, allows for smaller LGI resection in surgery if necessary

74
Q

What is sigmoid volvulus?

A

Twisting of sigmoid colon around mesentery resulting in closed-loop obstruction; tx is “detorsing” the colon via rigid scope and rectal tube, then elective sigmoid colectomy

75
Q

What is cecal volvulus?

A

Twisting of cecum; tx right colectomy since detorsion doesn’t work

76
Q

What is Ogilvie’s syndrome?

A

Pseudoobstruction and massive colon dilation without mechanical obstruction
tx endoscopic decompression or neostigmine if >11 cm due to possibility of cecal perforation

Surgery Shelf Study Guide (13 decks)

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