NMS GI Flashcards
What 2 types of gallbladder pathology predispose to gallbladder cancer
- polyps > 2cm
2. calcified (porcelain) gallbladder
how to work up pancreatitis (imaging)
obstructive series imaging;
CT not indicated unless complicated! (really?)
Treatment for pancreatitis
palliative: NPO, IVF, pain meds, observation, +/- TPN
how to treat gallstone pancreatitis
palliative treatment (npo, ivf, pain meds, observation, +/- TPN) until resolution of pancreatitis symptoms (usually 48h) followed by cholecystectomy and CBD stone removal (ERCP?)
if patient with acute pancreatitis begins to worsen and look ill, what are you worried about? how do you work up and treat it?
severe necrotizing pancreatitis with SIRS and thirdspacing of fluid –> need CT to look for other causes of decompensation (Unlike complicated pancreatitis) –> FLUID RESUSCITATION is essential, ventilation if devt of ARDS
correlation of amylase levels and pancreatitis
NONE
indications to intubate
ABGs (PaO2 45) and CLINICAL STATUS
treatment of pancreatic abscess
aspirate and culture for abx, then drain
specificity of amylase for pancreatitis
poor –> can be elevated in peripancreatic inflammation eg mesenteric ischemia, volvulus, etc.
How do you treat a pancreatic pseudocyst
manage expectantly for 6 weeks: NPO, IVF, TPN; if no improvement after 6 weeks, need to DRAIN surgically
Why wait 6 weeks to operate on pancreatic pseudocyst (2 reasons)
1) often resolve spontaneously
2) in 6 wks, enough fibrous tissue has formed to facilitate surgical closure
Are hepatic lesions usually benign or malignant? what are common types of each
usually BENIGN
1) benign: cystic (simple cyst) or solid (hemangioma)
2) malignant: HCC, mets, cholangiocarcinoma
what are 3 types of hepatic collections and their treatment
1) simple cyst: ntd?
2) multiloculated cyst: operative sterilization and excision
3) abscess: if pyogenic, IV abx + drainage; if amebic, tx with metronidazole (no drainage)
Differential of solid hepatic masses (benign and malignant)
1) benign: hemangioma, focal nodular hyperplasia, hepatic adeonoma (+/-)
2) malignant: HCC, metastatic cancer
most common solid hepatic mass
hemangioma (benign)
dx of hemangioma in liver
RBC scan (inc uptake) or CT with CONTRAST (out –> in enhancement); avoid bx if possible –> risk of bleeding
tx of hemangioma, focal nodular hyperplasia, and hepatic adenoma
HEMANGIOMA: none (unless symptomatic)
FOCAL NODULAR HYPERPLASIA: non
HEPATIC ADENOMA: resection if large/persistent (risk of rupture or devt of HCC)
dx of focal nodular hyperplasia. how do you tell its not hepatic adenoma or cancer
often see CENTRAL STELLATE SCAR on imaging; hard to distinguish from more dangerous pathology, so BIOPSY necessary
which hepatic lesion is a/w oral contraceptive use/pregnancy
hepatic adenoma
tx of HCC
if nonmetastatic (do CT first), surgical
tx of hepatic abscess
if pyogenic, small/multiple –> IV abx x 6 wk; large/singular –> need to drain + abx; if AMEBIC: just metronidazole (no surg)
mgmt of small bowel obstruction
KUB (kidneys, ureter, bladder), NPO, IVF, NG tube; watch for a couple of days (most RESOLVE SPONTANEOUSLY); take to OR if worsened or new indications
indications to take SBO to OR
- high fever
- high WBC
- decreased pH (suggests ischemia)
- peritonitis/local tenderness
- failed medical mgmt (dont improve while observed)
definition and treatment of closed loop obstruction
def: inlet and outlet of loop of bowel is obstructed –> tx: operate
operative mgmt of closed loop obstruction
assess viability of bowel; if dead, cut it out; if possibly viable, two options:
- resect, reanastomose
- close, observe, reexplore in 24 h
how to confirm dx of SBO if question of SBO vs. ileus
upper GI with SBFT (small bowel follow through:
radiologic examination of the small intestine from the distal duodenum/duodenojejunal junction to the ileocecal valve.
An X-ray examination of the most proximal small bowel (duodenum) is typically done together with an examination of the esophagus and stomach and is called an upper GI series.
- Patient drinks radio-opaque contrast, most often barium
2. X-ray images of abdomen are made at timed intervals.
What post op risks a/w accidental enterotomy (surgical incision into intestine);
(2 things)
- post op leak
2. small bowel fistula
how to work up and manage stable patient with (possible) ischemic bowel
INITIALLY, need dx:
1) sigmoidoscopy (should see ischemic colon) or if negative
2) angiography (gold standard); if no evidence of NECROSIS, medical mgmt : fluids, npo, abx
LATER can do prophylactic revascularization and longterm ASA
What operative risks a/w polycythemia? how do you manage them?
polycythemia –> hypercoagulable state; need to correct prior to procedure (phlebotomy, hydration)
what does bloody diarrhea suggest in ischemic bowel? mgmt
suggests NECROSIS ; do SIGMOIDOSCOPY –> if just mucosa, can manage medically; if involves full thickness, requires SURGERY
difference in etiology of colonic vs. small bowel ischemia
colonic is rarely 2/2 an arterial obstruction (more likely low flow state) –> less likely to benefit from or be diagnosed by angiography
(check this)
Most common causes of SBO in patient with Crohn’s disease
stricture
mgmt of fistula or stricture a/w crohns
NONOPERATIVE: npo, tpn, bowel rest, observation;
if no resolution tx surgically
how to manage perianal problems in crohns
metronidazole; surgery if abscess
timeline of increased cancer risk with ulcerative colitis? what are implications for surveillance frequency?
minimal inc in cancer risk for first 10 years, then increases steadily. after 8 yrs need colonoscopy every 1-2 years –> resection if severe dysplasia on biopsy
what is pouchitis? how do you treat it
inflammation of ileal pouch after colectomy; seen in 1/3 of patients with ileal pouch; treat with metronidazole (like perianal problems in Crohn’s)
treatment of toxic megacolon
MEDICAL management: bowel rest, decompression (NG tube), IV steroids –> if no improvement in a few days or new findings (free air, peritonitis, fever, etc.). SURGERY
What does air in wall of colon suggest
IMPENDING PERFORATION –> operative intervention
how to interpret pyuria in workup of appendicitis
could be UTI/pyelonephritis, or peri-appendiceal abscess; if not gross pyuria, could STILL BE APPENDICITIS (periappendiceal inflammation)
radiographic sign of crohns’ disease
string sign
how to elicit tenderness with retrocecal appendicitis
rectal exam!
most common ages for appendicitis
BIMODAL (25 and 65)
why is appendicitis bad in the very young and very old
very young: often present after perf
very old: present with vague, nonspecific symptoms
what to do if appendicitis in pregnant woman
OPERATE: peritonitis much more dangerous than appendectomy
what does carcinoid tumor look like? where is it found? how do you test for it?
yellow mass, often in appendix or small bowel; more common in appendix, but more likely to met from small bowel (esp ileum); check for 5-HT and 5-HIAA levels in urine
management of carcinoid tumor in appendix-how do size and location affect mgmt?
if > 2cm or in base of appendix, need to perform RIGHT HEMICOLECTOMY;
if < 2 cm and at tip, can get away with SIMPLE APPENDECTOMY
mgmt of carcinoid tumor in small bowel
RESECTION, esp of ileum and lymph nodes (high rate of metastasis to liver)
what is recommended for screening of CRC
if NORMAL RISK: starting at age 50 y, get
1) colonoscopy q 10y
OR
2) sigmoidoscopy q 5y and FOBT (fecal occult blood test) q 1y
what pmh increases recommended screening of crc? how?
CHECK THESE
1) FAP: sigmoidoscopy q 1y (will see polyps in sigmoid);
2) HNPCC (Lynch): colonoscopy q 1-2y (few polyps, might be in nonsigmoid)
3) adenomatous polyp or CRC resection: colonoscopy 3y after removal, then q 5y. CEA q 3m for CRC resection
initial treatment for hemorrhoids; treatment if refractory
INITIAL: sitz baths, stool softeners, increased fiber; REFRACTORY: depends on location; internal: endoscopic banding/ligation; external: surgical excision; COLONOSCOPY/SIGMOIDOSCOPY to r/o cancer
types and treatment of polyps (2)
1) PEDUNCULATED: usually can excise with snare (polypectomy) –> partial colectomy, else scope every 3 years;
2) SESSILE: excise (2 cm surgically); need f/u surveillance colonoscopies
tx of colon cancer
SURGICAL RESECTION +/- adjuvant chemotherapy (5-FU, levamisole); NOT radiation
what labs to follow with colon cancer
CEA (for recurrence) and LFTs (for liver mets)
what histology suggests poor prognosis with CRC (3)
1) poorly differentiated
2) mucin-producing
3) signet-cell
potential causes of obstruction following colectomy (2 big categories)
- LEAK: from anastomosis –> inflammatory ileus
- MECHANICAL: adhesions, internal hernia, obstructed anastamosis; late complications include cancer recurrence and stricture
workup and treatment of anastamotic leak
WORKUP: often see feculant matter from wound –> CT to see if drainable collection, gastrograffin enema or colonoscopy if unsure about patency of anastomosis; TREATMENT: observation (npo, ivf) –> most will close (unless distally obstructed –> operate)
how does location affect tx of rectal cancer
if within 5 cm of anal verge: need to abdominoperineal resection (cant keep margins clean without destroying anal sphincter) –> permanent ostomy;
if > 5 cm from anal verge, can do low anterior repair
how does rectal cancer spread? to where
DIRECT EXTENSION (anterior structures include bladder, ureter, prostate, seminal vesicles) and LYMPHATICS (internal iliac nodes, sacral nodes, inferior mesenteric nodes_
what to do with large, bulky rectal cancer
PREOP RADIATION (often effective enough to not require surgery!_
tx of anal cancer
NIGRO PROTOCOL: chemo, radiation, NO SURGERY
tx of diverticulitis (depending on patient)
HEALTHY patient: liquid diet, abx x 7-10d;
ELDERLY: IVF, NPO, bowel rest, IV abx;
if >1 episode or COMPLICATIONS (perf, abscess): ELECTIVE RESECTION (in 4-8 weeks after colonoscopy to rule out cancer)
initial workup upper GI bleed
NG lavage to make sure not upper GI bleed –> if positive, get upper endoscopy; else get anoscopy
Most common causes lower GI bleed
1) AVM
2) diverticulosis
does lower GI bleed need to be admitted if bleeding stops
YES; need to observe and determine etiology (make sure not cancer); colonoscopy when stable
why not perform colonoscopy while pt is actively bleeding
1) cant see anything
2) higher perf risk (cant see wall)
how to stop diverticular/AVM bleeding?
vast majority stop by themselves-just manage expectantly; if dont stop, can try colonoscopic or operate
what to do if persistent lower GI bleeding
can try colonoscope for tx of AVM or polyps; if persistent bleeding and 4-6 units of blood given, need to ID source (angiogram if stable, RBC scan if unstable) and go to OR
dx and mgmt of sigmoid volvulus
dx by barium enema; tx: 1) “detorsing” by rigid proctoscope if STABLE; or 2) sigmoid colectomy with colostomy/anastomosis depending on patient stability
tx of cecal volvulus? how does it differ from sigmoid volvulus?
URGENT SURGERY : detorsion , colectomy, cecopexy; (nonoperative tricks used for sigmoid volvulus don’t work)
what is oglvie syndrome, and how is it treated
pseudo-obstruction, esp of cecum/rectum; if colon < 8 cm, just watch; if colon > 10 cm decompress endoscopically or surgically
most common location and treatment of anal fissure
most common location: posteromedial; tx: sitz baths, high fiber diet, stool softeners (like hemorrhoids)
name 2 types of esophageal diverticula. where are they located? how do they form? how do you treat them ?
1) ZENKER’s (above cricothyroid muscle)
2) epiphrenic (above LES);
form 2/2 inappropriate muscle tone –> increased pressure –> forced diverticulum out; sx include choking, regurgitation of unswallowed food, bad mouth odor; tx by cutting muscle + excising diverticulum
tx of achalasia
calcium channel blockers + surgical release of lower esophagus (open or endoscopically)
how to treat esophageal tumors
depends on locations:
lower 1/3 –> surgery
mid 1/3 –> surg vs. chemo/rads
upper 1/3 –> chemorads
