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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
Classic Hx in SBO
``` Abd pain N/V No passage of flatus/stool (unless partial) Prior surgery Hx of SBO ```
26
Classic PE in SBO
Abdominal distention (stuff is building up) Abdominal tenderness
27
Labs to get in SBO
CBC w/d CHEM 7 ABG- metabolic acidosis is a late change in SBO XRAY
28
Role of a CBC in a SBO WU
Elevated WBC suggests infection & ischemia Lower Hg and MCV could suggest slow bleed and tumor
29
What to expect to see on a CHEM 7 in SBO
E- loses ARF Elevated LFT Elevated amylase if pancreatitis w/ ileus
30
Imaging to get in SBO
XRAY | CT
31
Role of CT in SBO
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
32
Evidence for STAT surg in SBO
Evidence of strangulation (peritonism, leukocytosis) Perforation Irreducible hernia
33
In what situations do we not take SBO to the OR
Postop Carcinomatosis Recurrent SBO Post radiation
34
What is carcinomatosis
When multiple carcinomas develop simultaneously due to tumor seeding. Worse than metastatic disease, this will kill them
35
Role of ABX in SBO?
Only if going to OR (ppx) or they're sick
36
NGT role in SBO
Evacuate the stomach. We're on bowel rest. This decreases N/V, distention and aspiration.
37
General Management of SBO
IVF and E- for everybody NGT if emesis Abx is going to OR or sick
38
SBO caused by intussusception management
Try out a pneumatic or barium reduction in the OR. Careful, this can cause a perf. Be ready to handle it.
39
SBO caused by adhesions special consideration
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
What is an ileus?
Postop. Obstipation and intolerance to PO intake dt a non-mechanical insult thatdisrupts normal motor activity of the GIT
41
How to tx an ileus
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
Two types of ischemic bowel disease
Mesenteric ischemia Ischemic colitis
43
Mesenteric ischemia definition
Ischemia of the small bowel. Usually secondary to SMA/SMV occlusion. Mesenteric venous thrombosis occurs in pt w/ clotting disorder
44
Ischemic colitis definition
Ischemia of the colon
45
Causes of nonocclusive mesenteric ischemia (NOMI)
ATS + shock + vasopressers
46
Classic presentation of mesenteric/ small bowel ischemia
``` PAIN OUT OF PROPORTION TO PE FINDINGS Rapid onset, periumbilical N/V Foreceful/urgent bowel evacuation RF for acute mesenteric ischemia ```
47
Labs for mesneteric ischemia
CBC | CHem 12
48
Imaging signs of mesenteric ischemia
CT- thickened/dilated bowel. Intramurl hematoma/pneumatosis XR- thumbprinting, thickened bowel. mesenteric angiograph- shows you exactly what type of acute mesenteric ischemia
49
Test of choice for mesenteric ischemia
Mesenteric angiography
50
Tx for mesenteric ischemia
Resus w/ IVF/Blood prod Anticoagulation Infusion of vasodilator, either glucagon systemically OR thru a catheter
51
Signs of mesenteric ischemia that developed into infarction
Peritoneal signs Fever. It's time to do an emergent laporatomy
52
Managment of mesenteric infarction via emergent laporatomy
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
Most frequent form of colonic ischemia? Which side of the colon does it most commonly effect?
ischemic colitis. L colon!! "WATERSHED AREAS" This is the site where the SMA changes to the IMA! It's vulnerable.
54
Causes of ischemic colitis
``` Low flow state (hypotension) Emboli (afib) Post MI (hypoten/thrombus) Post AAA reconstruction Volvulus Mesenteriv vein thrombosis (clotting person) ```
55
What are considered the two watershed areas of ischemic colitis
Rectosigmoid junction and left colon
56
Hx of pt with ischemic colitis
Abd pain N/V/D Rarely BRBPR
57
Diagnosing ischemic colitis Labs?
Largely based on clinical setting/PE. ELEVATED WBC >20,000 May be in metabolic acidosis
58
WBC in ischemic colitis?
>20,000
59
Imaging in ischemic colitis
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
Tx for ischemic colitis
Supportive (IVF, bowel rest, Abx if severe, NGT if ileus, Optimize heart and lung function) Laparotomy w/ resection
61
When to consider a laporotomy in ischemic colitis
If we see clinical deterioration despite conservative supportive therapy
62
Definition of toxic megacolon
Total or segmental non-obstuctive colonic dilation PLUS systemic toxicity
63
Causes of TMC
NOT OBSTRUCTIVE!!! IBD (CD/UC) Bacterial (Cdiff, Salmonella/shigella/campylo) Parasitic (cryptosporidium) Viral (CMV colitis)
64
Pathogenesis of TMC
Severe inflammation of the smooth muscle layer paralyzes the colonic smooth muscle, leading to dilation. Excessive NO involved.
65
Possible precipitating agents of TMC
HypoK, antimotility agents, opiates, anticholingerics, antidepressants, barium enema, colonoscopy
66
Diagnosing TMC
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
Imaging for TMC
XR/CT
68
Labs for TMC
Think about diagnosis criteria CBC CHEM7 Stool WBC (inc C diff)
69
First line of tx for TMC
Non operative!!! ``` IVF Lab abnormality correction ABX for IBD (vanco & flagyl) IVS for IBD NPO Bowel decompression w/ NGT ```
70
When do we consider surgery for TMC
Pts who do not improve on supportive non operative therapy. Subtotal colectomy with end ileostomy. This has a 50% mortality, jesus
71
RF for pancreatic cancers
Chronic pancreatitis Smoking DM FHx
72
Hx typical of pancreatic cancer
Jaundice (tumors in head of pancreas) Weight loss Pain (tumor in body or tail of pancreas) Recent onset of atypical DM
73
When does a palpable mass/ascites happen in pancreatic cancer?
Late :(
74
What is courvoisiers sign?
Nontender palpable gallbladder with jaundice. Sign of pancreatic cancer. (Usually when a gallbaldder is palpable it's cholecystitis and horribly painful)
75
Labs to get in pancreatic cancer
LFT | CA 19-9
76
Imaging to get for pancreatic cancer
CT MRI US EUS (endoscopic US)
77
Only curative approach to pancreatic canceer
Surgery. Radical Resection only really works for stages I-IIB though.
78
Role of chemo in pancreatic cancer
May improve short term survival rates, give you a couple more months at the end
79
Two types of pancreatic cancer surgery
``` Whipple (tumor in head of pancreas---jaundice!) Distal pancreatectomy (tumor in body or tail. pain) ```
80
Whipple procedures are cool as shit, what happens during them?
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
Most common kind of pancreatic cancer histology wise
Ductal adenocarcinoma (>80%).
82
Where do most ductal adenocarcinomas arise in the pancreas?
65% of the time it's the head. 15% in the body/tail. 20% the entire gland
83
Where does pancreatic cancer like to met to?
Liver, peritoneum, lungs, pleura and adrenal. At time of discovery, most have mets to peripancreatic LN
84
5 year survival for pancreatic cancer
Even at Stage I, it's only a 37% 5 year survival. This is a bad one
85
Pancreatic cancer and endocrine tumors
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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