Lower GI Tract Disorders

Question 0

What is the most common tumor that metastasizes to the intestines?

Answer 0

#1 Malignant melanoma
Ovarian cancer can recur locally with peritoneal studding -Debulking May improve survival
Recurring breast cancer may also cause obstructions

Question 1

SBO + heme positive occult stool

Answer 1

Obstructive tumor or ischemic bowel

Question 2

Small bowel obstruction with localized rebound tenderness indicates what likely disease process is occurring?

Answer 2

– potential serious complication such as a closed loop obstruction, per­ foration, ischemia, or an abscess is present.
–Localized tenderness is an indication that sur­gical exploration rather than observation is necessary.

Question 3

SBO + metabolic acidosis. What is it? What are the options for treatment?

Answer 3

Suspicion of ischemic or necrotic bowel
two options: (1) urgent exploration, or (2) mesenteric arteriography to check for an arterial occlusive lesion before exploration.

Question 4

Small bowel obstruction with a temperature of 103°F

Answer 4

Bowel perforation or ischemic process with sepsis

Question 5

A 60 year-old Man is undergoing surgery for a small bowel obstruction and lysis of adhesions. During lysis the lumen of bowel is entered. What is the biggest risk to monitor for post operatively?

Answer 5

greatest risk of an enterotomy is a postoperative leak and development of a small bowel fistula.

Question 6

Differential diagnosis for a small bowel obstruction in a patient with multiple medical conditions?

Answer 6

paralytic ileus, air swallowing, and constipation.

Question 7

If you are unsure of diagnosis for a small bowel obstruction or if NG tube offers only partial relief, how can you confirm a small bowel obstruction?

Answer 7

upper GI series with small bowel follow-through prior to the decision to explore the patient

Question 8

An elderly patient with a suspected ischemic bowel has a white blood cell count of 2500

Answer 8

overwhelming sepsis with leukopenia, often with a marked left shift is commonly seen in elderly patients

Question 9

Suspected ischemic bowel + bloody diarrhea. What is the next step?

Answer 9

ischemic segment of colon with necrosis of at least the mucosa and sub­ sequent sloughing.
The next step in evaluation is sigmoidoscopy to assess the colon. If full-thickness necrosis is present, exploration and resection are necessary. If only mucosal ischemia is present, it is possible to avoid resection by optimizing hemodynamics, an­tibiotic administration, and close observation.

Question 10

Current surgical treatment for ulcerative colitis?

Answer 10

most acceptable procedure is total proctocolec­tomy, which removes the mucosa and thus the risk of cancer, with the creation of an ileal pouch (reservoir) and anastomosis of the pouch to the anus (restores continence)

Question 11

patient with ulcerative colitis and abdominal pain, distention, fever, and bloody diarrhea

Answer 11

Toxic megacolon

Question 12

What is the treatment for toxic megacolon?

Answer 12

trial of medical therapy is indicated. Treatment consists of placement of an NG tube, NPO feeding, TPN, and IV fluids and broad­ spectrum antibiotics. Most physicians would also use high-dose IV steroids. The acute problem resolves in 50% or more patients with this therapy. Close observation for wors­ ening signs and symptoms, with frequent abdominal examinations and radiographs,

Question 13

Patient with ulcerative colitis is diagnosed with toxic megacolon. Free air is seen under the diaphragm on AXR. What is the next step?

Answer 13

ileostomy with formation of a Hartmann pouch of the rectum and to­ tal abdominal colectomy

Question 14

What signs indicate that a carcinoid tumor is malignant? What is the next step in management?

Answer 14

carcinoid tumor with a size of 2 cm or more or involvement of the base of the appendix or cecum suggests malignant behavior and is an indication to perform a right colectomy.

Question 15

What is the management for patient with previous history of carcinoid tumors?

Answer 15

CT scan of the abdomen and an octreotide scan, which localizes to neu­roendocrine tumors, is warranted.

Question 16

Colonoscopy finds a 1-cm pedunculated polyp. What is the next step in management?

Answer 16

Polypectomy
Colonoscopy in 3 to 6 months to ensure the poplyp was removed.
Follow-up colonoscopy every three years

Question 17

Colonoscopy find a 5 cm pedunculated polyps. The next step in management?

Answer 17

increased risk for developing colorectal cancers surveillance colonoscopy required

Question 18

Colonoscopy is performed and finds carcinoma in a sessile lesion. Next step in management?

Answer 18

Surgical resection is indicated

Question 19

62-year-old woman with heme positive stools + Intermittent constipation and diarrhea.

Answer 19

higher-grade obstruc­tive lesion, which is perhaps more likely on the left side of the colon

Question 20

62-year-old woman with heme positive stools and crampy abdominal pain.

Answer 20

suggests intermittent obstruction

Question 21

Colon cancer with positive lymph nodes. Treatment?

Answer 21

Stage III cancer. adjuvant chemotherapy with 5-FU and levamisole.

Question 22

Patient is recovering from a colectomy. On the third postoperative day he becomes distended and vomits feculent material.

Answer 22

1) leakage from the anastomosis has occurred, causing a per­sistent ileus, or (2) a mechanical obstruction due to adhesions, an internal hernia, or an obstructed anastomosis

CT or small bowel series

Question 23

Long term management for patient that is APC gene positive?

Answer 23

Surgery: Proctocolectomy with ileal pouch-anal anastomosis/IPAA (ileoanal reservoir)
Total proctocolectomy with ileostomy also possible
Usually done when age 18-20 is reached

Question 24

21 y/o p/w severe anal pain began 24 hours ago, worsened during past 3 hours. PE significant for tachycardia. Rectal exam can’t be completed due to pain. Diagnosis? Best next step?

Answer 24

intramuscular perirectal abscess

Exam under anesthesia in OR with consent to drain

Question 25

What is a fistula-in-ano?

Answer 25

An anal fistula - fistula between the anorectal junction and skin. Arise after drainage of perianal or perirectal abscess and represent a tube of chronic granulation tissues that fails to heal after drainage.

Question 26

Cause of anal fissure?

Answer 26

minor trauma from constipation or diarrhea. Often prominent skin tag distal that lies in anal canal.