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GI Remediation > Misc GI > Flashcards

Misc GI Flashcards

1
Q

Where is the appendix

A

Located where tenia joins at cecum (distal) LRQ. Remember the cecum is where the ileum meets the bowel. It;s 7-10cm long

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2
Q

Common cause of appendicitis

A

Obstructed process at the lumen

a) Fecolith, stricture, FB
b) Dietary factors (low fiber)
c) Bacteria proliferation
d) Tumor obstruction
e) Lymphoid hyperplasia

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3
Q

Common bugs involved w/ gangrenous/perfed appy

A

E coli
Pepto strepto
B frag
Pseudo

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4
Q

Pain presentation of the migratory pain of appendicitis

A

When it’s periumbilical pain it tends to be colicky, whereas the right iliac fossa pain is more of a dull, constant pain

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5
Q

Progression of appy sx

A

First comes the periumbilical pain

Second one or two episodes of vomiting

Third Right iliac fossa pain. Buy the time the fossa pain comes about, that’s when the anorexia and nausea really starts to settle in.

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6
Q

WU of appy

A

1) Fever

2) Physical (Mcburneys point, Psoas sign, Obsturator sign, pointing sign)

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7
Q

Psoas sign

A

RLQ pain w/ passive R hip extension

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8
Q

Obturator sign

A

Pt R hip and knee is flexed followed by internal rotation of R hip. Elicits RLQP.

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9
Q

Rovsings

A

Palpation of LLQ causes pain in RLQ

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10
Q

Lab WU of appy

A

CBC
E-
LFT
UA

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11
Q

Imaging WU of appy

A

US
CT
Xray technically but we don’t really use it so much anymore

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12
Q

IN WHAT CASES DO WE NOT OPERATE ON AN APPENCITIS

A

1) Signs of peritonitis
2) Presence of an appendicular mass/tumor (think seeding)
3) It’s resolved w/ abx. Just do it electively later on

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13
Q

ABX for preop appendicitis

A

Broad spectrum to cover aerobic/anaerobic

3rd gen ceph or gent + flagyl

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14
Q

Most common complication of appy surg

A

Wound infection

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15
Q

When does the gut arterial supply switch from the SMA to the IMA

A

The distal 1/3 of the transverse colon.

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16
Q

Hallmark signs of a SBO

A

Distension

High pitched Tinkering bowel sounds

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17
Q

Potential causes of a SBO

A 
Postop adhesions (most common cause) 
Hernias (most common cause in developing world)
Abdominal Mass
CD
Gallstones
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18
Q

Evidence of SBO strangulation/ischemia/perforation

A

Peritonism

Fever

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19
Q

SBO on abdominal XR

A

Multiply loops of small bowel. Cannot see rectum.

These guys are 80% sensitive

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20
Q

Three types of obstruction

A

1) Intraluminal –> Something is inside the gut
2) Intramural –> Something is making the wall of the gut bigger & compress (stricture, intussuseption)
3) Extramural –> Something is pushing on the gut

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21
Q

Stricture definition

A

Abnormal narrowing of a tube/canal

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22
Q

In a simple obstruction, what happens to the bowel above and below the problem site?

A

Above- Peristalsis increases, the intestine dilates and this weakens the peristalsis. This results in exhausted flaccidity and paralysis.

Below: Normal peristalsis and absorption, it’s just doing its thing. But once it’s empty it contracts and becomes immobile

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23
Q

What happens to the bowel in a strangulated obstruction (volvulus)

A

Impaired venous return and inc congestion. The arterial blood supply is all effed up.

We start to see free peritoneal fluid, edema, ischemia and gangrene.

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24
Q

What is distention?

A

Accumulation of gas and fluids.

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25
Q

Classic Hx in SBO

A 
Abd pain
N/V
No passage of flatus/stool (unless partial)
Prior surgery
Hx of SBO
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26
Q

Classic PE in SBO

A

Abdominal distention (stuff is building up)

Abdominal tenderness

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27
Q

Labs to get in SBO

A

CBC w/d
CHEM 7
ABG- metabolic acidosis is a late change in SBO
XRAY

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28
Q

Role of a CBC in a SBO WU

A

Elevated WBC suggests infection & ischemia

Lower Hg and MCV could suggest slow bleed and tumor

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29
Q

What to expect to see on a CHEM 7 in SBO

A

E- loses
ARF
Elevated LFT
Elevated amylase if pancreatitis w/ ileus

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30
Q

Imaging to get in SBO

A

XRAY

CT

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31
Q

Role of CT in SBO

A

Only do water soluble contrast in case you perf and it gets everywhere.

This is helpful for complicated SBO that wont respond to normal measures.

If the contrast fails to reach the cecum by 4 hrs, it indicates that we’re probably doing surgery.

Can even be therapeutic in adhesional SBO, some osmolar effect

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32
Q

Evidence for STAT surg in SBO

A

Evidence of strangulation (peritonism, leukocytosis)
Perforation
Irreducible hernia

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33
Q

In what situations do we not take SBO to the OR

A

Postop
Carcinomatosis
Recurrent SBO
Post radiation

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34
Q

What is carcinomatosis

A

When multiple carcinomas develop simultaneously due to tumor seeding. Worse than metastatic disease, this will kill them

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35
Q

Role of ABX in SBO?

A

Only if going to OR (ppx) or they’re sick

36
Q

NGT role in SBO

A

Evacuate the stomach. We’re on bowel rest. This decreases N/V, distention and aspiration.

37
Q

General Management of SBO

A

IVF and E- for everybody
NGT if emesis
Abx is going to OR or sick

38
Q

SBO caused by intussusception management

A

Try out a pneumatic or barium reduction in the OR. Careful, this can cause a perf. Be ready to handle it.

39
Q

SBO caused by adhesions special consideration

A

Try conservative treatment first. Adhesions are caused by prior surgery and if you go in there, you may fix the problem today but you’re screwing them over in the end.

40
Q

What is an ileus?

A

Postop. Obstipation and intolerance to PO intake dt a non-mechanical insult thatdisrupts normal motor activity of the GIT

41
Q

How to tx an ileus

A

It depends on how the ileus was caused (what disease/surgery).

Start with correcting underlying conditions, E- and acid/base abnormalities

NGT for decompression if emesis/distention

DC gut slowing Rx (opiates)

Consider NSAIDS for pain and infl

Consider CT for mechanical obstruction if not improving

42
Q

Two types of ischemic bowel disease

A

Mesenteric ischemia

Ischemic colitis

43
Q

Mesenteric ischemia definition

A

Ischemia of the small bowel. Usually secondary to SMA/SMV occlusion. Mesenteric venous thrombosis occurs in pt w/ clotting disorder

44
Q

Ischemic colitis definition

A

Ischemia of the colon

45
Q

Causes of nonocclusive mesenteric ischemia (NOMI)

A

ATS + shock + vasopressers

46
Q

Classic presentation of mesenteric/ small bowel ischemia

A 
PAIN OUT OF PROPORTION TO PE FINDINGS
Rapid onset, periumbilical
N/V
Foreceful/urgent bowel evacuation
RF for acute mesenteric ischemia
47
Q

Labs for mesneteric ischemia

A

CBC

CHem 12

48
Q

Imaging signs of mesenteric ischemia

A

CT- thickened/dilated bowel. Intramurl hematoma/pneumatosis
XR- thumbprinting, thickened bowel.
mesenteric angiograph- shows you exactly what type of acute mesenteric ischemia

49
Q

Test of choice for mesenteric ischemia

A

Mesenteric angiography

50
Q

Tx for mesenteric ischemia

A

Resus w/ IVF/Blood prod
Anticoagulation
Infusion of vasodilator, either glucagon systemically OR thru a catheter

51
Q

Signs of mesenteric ischemia that developed into infarction

A

Peritoneal signs
Fever.

It’s time to do an emergent laporatomy

52
Q

Managment of mesenteric infarction via emergent laporatomy

A

Resotre blood flow w/ arteriotomy or bypass graft
Resect infarcted bowel
Second look 24-48 hours
Vasodilators and CAEFUL pressor use to restore flow

53
Q

Most frequent form of colonic ischemia? Which side of the colon does it most commonly effect?

A

ischemic colitis. L colon!! “WATERSHED AREAS” This is the site where the SMA changes to the IMA! It’s vulnerable.

54
Q

Causes of ischemic colitis

A 
Low flow state (hypotension)
Emboli (afib)
Post MI (hypoten/thrombus)
Post AAA reconstruction
Volvulus
Mesenteriv vein thrombosis (clotting person)
55
Q

What are considered the two watershed areas of ischemic colitis

A

Rectosigmoid junction and left colon

56
Q

Hx of pt with ischemic colitis

A

Abd pain
N/V/D
Rarely BRBPR

57
Q

Diagnosing ischemic colitis

Labs?

A

Largely based on clinical setting/PE.

ELEVATED WBC >20,000
May be in metabolic acidosis

58
Q

WBC in ischemic colitis?

A

> 20,000

59
Q

Imaging in ischemic colitis

A

CT- this may be normal initially but eventually we will see thickening of bowel wall in segmental pattern, as well as pneumatosis as it gets more adv.

Role for endoscopy as well

60
Q

Tx for ischemic colitis

A

Supportive (IVF, bowel rest, Abx if severe, NGT if ileus, Optimize heart and lung function)

Laparotomy w/ resection

61
Q

When to consider a laporotomy in ischemic colitis

A

If we see clinical deterioration despite conservative supportive therapy

62
Q

Definition of toxic megacolon

A

Total or segmental non-obstuctive colonic dilation PLUS systemic toxicity

63
Q

Causes of TMC

A

NOT OBSTRUCTIVE!!!

IBD (CD/UC)
Bacterial (Cdiff, Salmonella/shigella/campylo)
Parasitic (cryptosporidium)
Viral (CMV colitis)

64
Q

Pathogenesis of TMC

A

Severe inflammation of the smooth muscle layer paralyzes the colonic smooth muscle, leading to dilation. Excessive NO involved.

65
Q

Possible precipitating agents of TMC

A

HypoK, antimotility agents, opiates, anticholingerics, antidepressants, barium enema, colonoscopy

66
Q

Diagnosing TMC

A

1) Abdominal distention and diarrhea (acute or chronic)
2) Radiographic evidence of colonic distention
3) 3 of the following: Fever, Tachy>120, WBC >10,500, anemia

4) One of the following: Dehydration, AMS, E-, hypotension

67
Q

Imaging for TMC

A

XR/CT

68
Q

Labs for TMC

A

Think about diagnosis criteria

CBC
CHEM7
Stool WBC (inc C diff)

69
Q

First line of tx for TMC

A

Non operative!!!

IVF
Lab abnormality correction
ABX for IBD (vanco & flagyl)
IVS for IBD
NPO
Bowel decompression w/ NGT
70
Q

When do we consider surgery for TMC

A

Pts who do not improve on supportive non operative therapy.

Subtotal colectomy with end ileostomy. This has a 50% mortality, jesus

71
Q

RF for pancreatic cancers

A

Chronic pancreatitis
Smoking
DM
FHx

72
Q

Hx typical of pancreatic cancer

A

Jaundice (tumors in head of pancreas)
Weight loss
Pain (tumor in body or tail of pancreas)
Recent onset of atypical DM

73
Q

When does a palpable mass/ascites happen in pancreatic cancer?

A

Late :(

74
Q

What is courvoisiers sign?

A

Nontender palpable gallbladder with jaundice. Sign of pancreatic cancer.

(Usually when a gallbaldder is palpable it’s cholecystitis and horribly painful)

75
Q

Labs to get in pancreatic cancer

A

LFT

CA 19-9

76
Q

Imaging to get for pancreatic cancer

A

CT
MRI
US
EUS (endoscopic US)

77
Q

Only curative approach to pancreatic canceer

A

Surgery. Radical Resection only really works for stages I-IIB though.

78
Q

Role of chemo in pancreatic cancer

A

May improve short term survival rates, give you a couple more months at the end

79
Q

Two types of pancreatic cancer surgery

A 
Whipple (tumor in head of pancreas---jaundice!)
Distal pancreatectomy (tumor in body or tail. pain)
80
Q

Whipple procedures are cool as shit, what happens during them?

A

They basically take out half the stomach and the head of the pancreas. Then, the duodenumbecomes this looop where half of it finishes off the stomach and the remaining bit becomes this type for pancreatic enzymes and the biliary tree.

81
Q

Most common kind of pancreatic cancer histology wise

A

Ductal adenocarcinoma (>80%).

82
Q

Where do most ductal adenocarcinomas arise in the pancreas?

A

65% of the time it’s the head.
15% in the body/tail.
20% the entire gland

83
Q

Where does pancreatic cancer like to met to?

A

Liver, peritoneum, lungs, pleura and adrenal.

At time of discovery, most have mets to peripancreatic LN

84
Q

5 year survival for pancreatic cancer

A

Even at Stage I, it’s only a 37% 5 year survival. This is a bad one

85
Q

Pancreatic cancer and endocrine tumors

A

Think paraneoplastic syndrome. These guys can pump the body full of hormones like gastrin, insulin, VIP, glucagon and somatostatin.

GI Remediation (6 decks)

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