Obstruction/Rectal Dz

Question 1

Divisions of small intestines? (3)

Answer 1

1) Duodenum (pylorus to ligament of Treitz)
2) Jejenum
3) Ileum

Question 2

Vascular supply of small intestines?

Answer 2

SMA

Question 3

Primary role of small intest?

Answer 3

absorption

Question 4

Components of large bowel? (8)

Answer 4

1) Cecum
2) Ascending colon
3) Hepatic Flexure
4) Transverse colon
5) Splenic flexure
6) Descending colon
7) Sigmoid
8) Rectum

Question 5

Vascular supply for large bowel?

Answer 5

SMA

IMA

Question 6

Primary role of large bowel?

Answer 6

Absorb H2O, e-

Store feces

Question 7

Causes of small bowel obstruction (SBO)? (5)

Answer 7

1) POST-OP ADHESION (primary cause, 80% self-resolve)
2) Malignancy
3) Hernia
4) Strictures (Crohn’s, NSAIDS, radiation, ischemia)
5) Tumors

Question 8

Intussusception epidemiology?

Sxs?

Answer 8

(U) kids, benign, self-limiting
Adults (U) a/w tumors

Currant jelly stool

Question 9

W/ SBO, intestinal dilation seen where?

Exacerbated by?

Answer 9

proximal to obstruction

swallowed air, intest secretion

Question 10

Dilation from SBO leads to?

Answer 10

↑ peristalsis ->

compressed lymphatics ->

swelling in lumen ->

↑pressure drives fluid into peritoneum (3rd spacing)

or

necrosis -> leaks bacteria

Question 11

SBO signs/sxs? (5)

Answer 11

1) Abd pain (intermittent initially, then constant)
2) Distention (more C w/ distal obstr)
3) N/V (more C w/ distal obstr)
4) Constipation (pass gas but not stool)
5) Obstipation (can’t pass gas or stool)

Question 12

SBO sxs that are “bad signs”? (2)

Answer 12

Constant pain

Obstipation

Question 13

Important SBO hx? (5)

Answer 13

1) Prior abd surgery?
2) Hernia?
3) CA?
4) N/V/D/C? If so, how long?
5) Pain ↓ or ↑?

Question 14

Important SBO physical exams? (3)

Answer 14

1) VITAL SIGNS (tachy w/ hypoTN = SHOCK/strangulation/sepsis)
2) Bowel sounds (Early = high-pitched w/ rushes, Late = silent)

3) Abdominal palpation (diffuse tenderness)
(Rebound + very still pt = advanced dz)

Question 15

SBO lab findings:

Electrolytes?

BUN/Cr?

WBC?

Hct?

LDH?

Answer 15

Electrolytes = altered

BUN/Cr = elevated (dehydration)

WBC = (U) elevated (late)

Hct = increased if hemoconcentration (late)

LDH = elevated if tissue breakdown (late)

Question 16

SBO imaging studies? (3)

Answer 16

1) Plain films: supine and upright
2) CT scan w/o contrast
3) UGI w/ small bowel follow through

Question 17

SBO findings on plain films?

Answer 17

Dilated bowels
Air-fluid levels
Free air if perforated
30% false negatives

Question 18

CT w/o contrast indicated for SBO when?

Answer 18

Plain films are negative

Do CT first if high clinical suspicion

Question 19

If very high suspicion for SBO, first action should be?

Answer 19

call surgeon (let him decide imaging)

Question 20

SBO management? (7)

Answer 20

1) Volume resuscitation
2) Decompress w/ nasogastric tube
3) NPO
4) Abx
5) Correct e- imbalance
6) Watch vitals
7) Reassess for next 3 days

Question 21

Paralytic Ileus is?

Answer 21

↓ bowel motility with NO obstruction

Question 22

Paralytic Ileus caused by? (6)

Answer 22

1) intra-abd surgery
2) opiates
3) bedrest
4) trauma
5) e-
6) sepsis

Question 23

Paralytic Ileus presentation? (5)

Answer 23

1) No BS
2) Less severe abd pain
3) (P) massive distention
4) N/V
5) Normal vitals

Question 24

Paralytic Ileus diagnositcs?

Findings on plain films?

Answer 24

Same as SBO (ruling this out)

Dilation of small AND large bowels

Question 25

Paralytic Ileus management? (6)

Answer 25

1) Assess for vol restriction 2) Decompress w/ NG tube if N/V 3) NO abx 4) NPO 5) AMBULATE 6) If > 4 days, (P) feeding tube?

Question 26

Large Bowel Obstruction (LBO) caused by? (4)

Answer 26

1) Adenocarcinoma (most C) 2) Stricture from diverticulitis/ischemia 3) Volvulus (malrotation) 4) IBD, FB, fecal impact

Question 27

LBO presentation? (5)

Answer 27

1) Cramping pain 2) Distention 3) Constipation/Obstipation 4) N/V 5) High-pitched bowel sounds

Question 28

Important LBO hx? (5)

Answer 28

1) Chronic rectal bleeding/black stool/∆ in caliber? (signs of CA) 2) Recent bloody stool w/ diarr? (ischemia) 3) LLQ pain w/ diarr? (diverticulitis) 4) How long? (rapid onset = volvulus) 5) Chronic narcotic use or chronic constipation? (compaction)

Question 29

LBO labs? (3)

Answer 29

CBC CMP LDH

Question 30

LBO imaging?

Answer 30

1) Plain films: supine, upright 2) CXR (for perf air) 3) Gastrograffin Enema 4) CT (only if dx still unclear)

Question 31

Possible LBO findings: Plain films? (5)

Answer 31

1) Proximal colon distention 2) Rectal air = ileus or PSBO (partial sm bowel) 3) Intraluminal air = ischemia 4) Competent ileocecal valve = higher chance of perf 5) Loss of haustral markings = volvulus

Question 32

Possible LBO findings/uses: Gastrograffin Enema?

Answer 32

Uses: X-Ray unclear, Identify PSBO vs Obstruction Localization for surgery Findings: "bird beaks" = volvulus

Question 33

Partial LBO management? (5) If Pseudo-obstruction?

Answer 33

1) IV fluids, NPO 2) ABX 3) Decompress if vomiting 4) Slow bowel cleanse 5) No narcotics or anticholinergics If pseudo-obstr: neostigmine + decompression

Question 34

Complete LBO management: Cancer? Complete Stricture? Sigmoid Volvulus? Cecal Volvulus? Fecal Impaction? Intussusception?

Answer 34

Depends on cause: Cancer = resection Complete Stricture = resection Sigmoid Volvulus = sigmoidoscopy w/ reduction Cecal Volvulus = resection Fecal Impaction = H2O/mineral oil enema Intussusception = barium enema

Question 35

Rectum anatomy?

Answer 35

Dentated line at anorectal jxn: Above = insensate Below = sensate Super/Inferior hemorrhoidal veins

Question 36

Hemorrhoids are? Normal hemorrhoid plexus important for?

Answer 36

swollen cluster of vv, aa, CT protection of vasculature, sensory (e.g. liquid vs gas)

Question 37

Hemorrhoids (P) cause what? (3)

Answer 37

1) allows fecal leakage -> pruritis ani 2) exposes vasculature 3) tissue prolapse

Question 38

Hemorrhoid presentation?

Answer 38

bright red blood per rectum, pain, itching

Question 39

Important Hemorrhoid hx? (6)

Answer 39

R/O other rectal path: 1) qty of blood? 2) color of blood? 3) blood mixed w/ stool? (IBD) 4) recent diar/constip? 5) severe pain w/ BMs? (fissure) 6) d/c or mucus? (IBD, infection)

Question 40

Hemorrhoid diagnostics? (4)

Answer 40

1) Rectal (feel for ulcers, fissures, abscess) 2) CBC to eval bleeding 3) Anoscope (visualize) 4) Flexible Sigmoidoscopy (standard of care)

Question 41

Perianal Infections caused by?

Answer 41

Obstruction of perianal glands -> stasis -> infection (common a/w fistulas) (U) e coli, anaerobes

Question 42

Perianal infection presentation? Locations?

Answer 42

rectal pain, fullness, fever/chills Perianal (most C) Ischiorectal Intersphincteric Supralevator

Question 43

Perianal infection diagnostics?

Answer 43

Digital rectal | (P) CT/MRI

Question 44

Perianal infection management?

Answer 44

I & D w/ anesthesia (P) drain placement (P) abx based on culture

Question 45

Fistulas related to rectal dz are?

Answer 45

inflammatory tracts connecting abscesses to the skin

Question 46

Fistulas caused by? (3)

Answer 46

1) Open/ruptured abscesses 2) Crohn's 3) Diverticulitis

Question 47

Fistula in Ano is?

Answer 47

connection b/w anal canal and skin

Question 48

Fistula presentation?

Answer 48

chronic drainage of pus and (P) stool from opening in skin

Question 49

Fistula diagnostics?

Answer 49

Exam under anesthesia MRI if complex/recurrent Colonoscopy if IBD possible

Question 50

Fistula management?

Answer 50

unroofing of fistula tract to allow healing

Question 51

Anal Fissures are?

Answer 51

trauma-caused linear tears in lining of anal canal BELOW dentate line (U) on posterior wall (lowest blood supply here)

Question 52

Anal Fissures are concerns why?

Answer 52

Tear causes mm spasm -> ↓ blood flow -> poor healing Repeat injury from BMs

Question 53

Anal Fissure presentation?

Answer 53

1) Severe rectal pain w/o BM 2) Fear of having BM 3) Rectal bleeding

Question 54

Anal Fissure diagnostics?

Answer 54

(U) felt on digital rectal | (P) flex sig/colonoscopy

Question 55

Anal Fissure management?

Answer 55

``` Stool softener Sitz baths Nitroglycerine ointment (↓spam/↑blood flow) Botox Surgery if not healed in 3 wks ```

Question 56

Rectal Prolapse is?

Answer 56

protrusion of rectal tissue through anus

Question 57

Rectal Prolapse caused by?

Answer 57

Unknown | (P) a/w chronic straining, neuro dz, preggos

Question 58

Rectal Prolapse presentation?

Answer 58

mass protruding thru anus, | may start w/ BM and retract

Question 59

Rectal Prolapse exam?

Answer 59

Pt strain on toilet to reproduce

Question 60

Rectal Prolapse diagnostics?

Answer 60

Defecography (X-ray to see shape/position of emptying rectum) Anal Manometry if unclear (measure of strength of anal mm)

Question 61

Rectal Prolapse management?

Answer 61

all need surgery

Question 62

Rectocele is?

Answer 62

rectum bulges into/against vagina