SBO/LBO, Pancreatitis, Perforated Viscus Flashcards
distended bowel- cardiac effects
-diaphragm goes up -> hyperventilation -> respiratory alkalosis -> respiratory acidosis -> MI
-can lead to perforation
-tx- NG tube to relieve distention -> otherwise can vomit and aspirate
-if distended volvulus -> NG tube prior to surgery
55 yo
epigastric pain for past 5 years and worsening
9/10 pain
N/V
sickle cell, cholelithiasis
pleural effusion
-BISAP tool
-pancreatitis
-high mortality
SBO
-step laddering
-high pitch sound -> less -> absent
volvulus
-twisting loop of bowel
-leads to necrosis and perforation
-sigmoid > cecum
-older age pts
-constipation
-distention and sudden onset
-check lactate for potential bowel ischemia
-def dx- CT = whirl sign
-x ray- coffee bean sig
-fluid resuscitation
-NG tube to decompress
-sigmoidoscope decompression
LLQ cancer
-can cause such an obstruction that pt is vomiting stool
-backflow at ileocecal valve
signs of obstruction
-high pitch
-metallic quality- change in a can sound
-ascites -> intravascular department becomes depleated -> hypotensive
-crampy abdominal pain
-no BM or flatus
-previous surgery
-hypoactive/hyperactive bowel sounds
mechanisms of fluid loss
-within bowel lumen
-within bowel wall
-weeping
-ascites
-N/V- measure its ouput via NG tube or kidney basin
obstruction: labs to order
-BUN/Creat- elevated -> prerenal azotemia (> 20:1) -> indication of bleed!
-hypernatremia
-urine lytes- low Na
-hemoconcentration- Hct can be high due to ratio
-acidosis- from anaerobic metabolism -> lactate
-leukocytosis - leukopenia can also occur if its bad
-FNa-
-if given a diuretic- Fractional excretion of urea
-US or xray if unstable
-stable- CT with IV contrast
markings go across the bowel
-this is small bowel
-small bowel > 3
-large bowel >6
-cecum >9
-air fluid levels
-step laddering
-SBO
-distended loops of bowel
-SBO
-give water soluble contrast -> high osmolality -> pt must be awake, alert, and able to swallow
-if not -> give NG tube otherwise…
-if it gets into their lungs -> pulmonary edema -> death
-barium - if it leaks in peritoneal cavity due to perforation -> chemical peritonitis -> DONT GIVE THIS
SBO approach
-Aggressive management
-IV fluids- wt in kg + 40 for maintenance
-for resuscitation- 200cc/hr, monitor BP
-“Never let the sun rise and set on a SBO”
-NPO
-NG tube
obstruction surgery
-resuscitation prior to surgery -> anesthetic are cardiopulmonary suppressors -> BP must be high enough -> FLUID
-NPO
-NG tube
-Exploratory laparotomy
-Lysis of adhesions
-Resection?
-Handle tissue carefully- adhesions form easily
-Role for conservative Tx? - pts with multiple past surgerys -> try NG tube
-ischemia, perforation, deterioration
long NG tubes
-goes down into the jejunum to decompress
-rarely used
-conservative tx
-Abbot-Miller tube!
-Radiation enteritis- you dont want to operate on this -> very friable
-Repeat offenders- multiple obstructions/surgeries
pediatric SBO
-Crohn’s disease
-Meckel’s diverticulum- lead point for RLQ intussusception, rule of 2’s (children under age 2, 2 cm, 2 ft from ileocecal valve, affects 2 layers of tissue: gastric and pancreatic )
-Pyloric outlet obstruction- projectile vomiting, olive sized mass, fixed easily via surgery
-Intussusception- sausage shaped mass -> resect it
Ogilvie’s syndrome
-acute megacolon
-Trauma
-Infection
-CHF
-distended large bowel
-no BM
-acute colonic pseudo obstruction, adynamic ileus w/out mechanical obstruction
-MASSIVE dilation of cecum & right colon
-pts have decreased propulsion of GI tract especially colon
-AIR IN RECTUM WITH DISTENDED CECUM AND RECTUM
-trauma, hip surgery, CHF, intra abdominal infection
-x-ray
-tx with neostigmine
-bowel decompression
-NG tube
-IV fluids and NPO
-surgery- ischemia or perforation
bezoar
-ball of swallowed foreign material
-eat extreme amount of fiber or objects(linens)
-buildup of solid indigestible material and causes a blockage
-hair- (Trichobezoar)→ MUST DO SURGERY
-MC dementia or psychotic pts
cathartic medication
-meds that speed up defection (bowel cleanse)- sorbitol, Mg
-never give in SBO
-perforates small bowel
-instead give mirolax, colase -> prevents stool accumulation
pancreatitis causes
-obstruction- gallstones and alcohol
-damage to pancreatic tissue- iatrogenic from ERCP, hypertriglyceridemia, or meds
-IgG4- indicates autoimmune pancreatitis
-shock
-trauma
-mumps
-scorpion
-gall stone moves down to bile duct -> zymogens (protealytic enzymes) backflow -> pancreatic inflammation -> pancreatitis
-autodigestion
pancreatitis
-relived with leaning forward
-anorexia- ingestion (even water) -> causes pain
-epigastric pain!
-high leuks, amylase high, lipase 3x upper limit of normal!, hyponatremic
-AST and ALT can be high if alcohol is the cause
-lipase attacks surfactant -> hypoxemia
-CT with contrast- edematous pancreas with peripancreatic fat stranding -> not necessary for dx
-BUN is the most useful prognostic lab
chronic pancreatitis
-not inflamed
-its atrophic -> fibrosis
-causes- massive necrosis or repeated pancreatitis
-not enough digestive enzymes (malabsorption) or insulin (diabetes)
-pain without lipase elevation
-pancreatic insufficiency- no digestive enzymes -> fecal elastase
-CT- calcifications (past necrosis)
-MRCP- best test -> shows chain of lakes
-tx- pain control, insulin, digestive enzymes
-surgery not indicated
-different grey scaling
-fluid around it
-swollen
-edematous
-pancreatitis
-air in it
-pancreatic abscesses
-give antibiotics
pancreatitis tx
-RESUSCITATION
-IV Fluids:Aggressive hydration with normal saline.
-Pain Management:Administered opioids for severe abdominal pain.
-NPO Status: rest the pancreas or postpyloric feeding.
-Monitoring:Close monitoring of vital signs and labs
-Nutrition: As soon as feasible- titer tube -> feed pt past/distal the pancreas
-make sure have stool prep to pass stool easily
-NO ANTIBIOTICS unless complex (abscess, WBCs) -> penams
-= 30% burn pt -> suponification of Ca (hypocalcemia)
-aggressive resuscitation -> 30% x 4 = 120
-60kg x 120 = 7200 -> 7.2L fluid for resuscitation
-% area burn x 4 x wt in kg = fluid to resuscitate
LDL
-intracellular enzyme
-high -> cells are dying somewhere
BISAP score
balthazar score
-based on looking at the CT
-inflamed
-fluid inside
-irregular
-pancreas
-acute pancreas
-due to STONE
-fluid around the gallbladder
chronic pancreatitis
-no amylase, lipase
-burn out exocrine and endocrine function
-enzymes to digest food, no insulin (hyperglycemia)
-tx- pancreatic enzymes (prion)
acute vs chronic obstruction
-acute- usually small bowel, sudden onset of severe colicky pain, distention, early vomiting, and constipation
-chronic- large bowel, lower abdominal colic and absolute constipation followed by distention
-strangulation- interference to blood flow
intussusception
-episodes of screaming
-drawing up of legs in previously well male infant
-vomiting +/-
-stool is normal or blood and mucus -> currant jelly stool (dark red)
-sausage shaped mass in RUQ
-high pitch bowel
-lump that hardens on palpation - 60% of time
-emptiness in right iliac fossa - sign of dance
-rectal exam -> blood stained mucus on finger
-dx- US- target sign
-tx-
-start with NG decompression and fluids
-air enema! - pneumatic insufflation
-surgical- when pathological lead point, gangrenous or perforated bowel
LaPlace’s law
-intraluminal pressure needed to stretch wall of hollow tube is inversely proportional to its radius
colon blood supply
-SMA, IMA joined by the marginal artery
-watershed areas:
-splenic flexure (griffith’s point) - middle and left colic arteries anastomose
-rectal colic (sudek’s point) - hypogastric and left colic arteries anastomose
-these are end vessels -> ischemia if cut
colon cancer
-anal cancer- squamous cell
-colon- adenocarcinoma
-3rd MC in men
-2nd MC in women
risk factors for colonic obstruction
-prior surgery
-colon or metastatic cancer
-chronic intestinal inflammatory disease- IBD
-existing abdominal wall or inguinal hernia
-previous irradiation
-foreign body ingestion -psychiatric pts, coma
-large ventral hernia- defects not obstruction
-umbilical hernia- obstruction -> narrow neck
signs and symptoms of colonic obstruction
-1. adhesions
-2. hernias- prior mesenteric approach surgery -> forget to close or close improperly -> obstruction
-3. cancer
-volvulus
-strictures
-foreign objects
-ogilvie syndrome - Acute colonic pseudo-obstruction -> colonic dilatation without evidence of underlying mechanical or anatomic cause
SBO vs LBO findings
-SBO
-intermittent pain
-colicky
-vomiting feels better
-frequent, larger, bilious vomiting
-focal tenderness
-LBO
-continuous pain
-intermittent and feculent vomit (incompetent ileocecal valve)
-diffuse tenderness
-constipation earlier in onset
-distention earlier and worse
ileocecal valve
-fluid builds up on both sides -> goes up through GI tract
-feculent vomitus
-cecum can perforate -> >10cm -> impending perforation -> surgery
-resection or tumor removal -> upper colostomy for good leak proof end anastomoses
evaluation
-abdominal flat plate
-CT with oral contrast (water based)
-CBC- leukocytosis
-BMP- electrolyte abn, hyponatremia, hypochloremia alkalosis from vomiting
-LFTs
-lactic acid- if really volume contracted
distended loops of bowel
sigmoid volvulus
-left
cecal volvulus
-right
distended loops of bowel
-air fluid levels
-perforation risk -> sepsis
-distended splenic flexure
-distended transverse colon
-distended bowel
-surgical intervention
-perforation risk
colon cancer risk factors
-Inflammatory bowel disease.
-personal orfamily hxof colorectal cancer or polyps.
-genetic syndrome: familial adenomatous polyposis (FAP)orhereditary non-polyposis colorectal cancer (Lynch syndrome)
-Lifestyle factorsthat may contribute to an increased risk of colorectal cancer:
-Lack of regularphysical activity
-Diet low in fruit and vegetables.
-Low-fiber and high-fatdietor a diet high in processed meats.
-Overweight andobesity
-Alcoholconsumption
-Tobacco use
colon cancer symtpoms
-change in bowel habits.
-Blood in or on your stool (bowel movement).
-Diarrhea, constipation, or feeling that the bowel does not empty all the way.
-Abdominal pain, aches, or cramps that don’t go away.
-Unexpected weight loss.
colon cancer work up
-Medical hx and physical exam -> #1 ALWAYS
-Stool tests: Fecal occult blood test (FOBT), fecal immunochemical test (FIT), and the FIT-DNA test
-Imaging tests: Chest, abdomen, and pelvic CT scans, or MRI if liver metastases are suspected
-Labs: CBC, Fe studies, a BMP (n/v), LFTs (liver mets), and Coags(fibrinogen)
-Colonoscopy: multiple bx of suspected lesion
-Molecular testing: RAS mutational testing, BRAF V600 mutational analysis, and dMMR/MSI testing
staging of colon cancer
-TMN
-you get the chart to stage someone
-dont memorize
-colon cancer
-with significant local extravasation of contents
-assoc perforation -> means its metastatic
-carcinomatosis
-studying of the peritoneal cavity from tumor cells
-lesions within liver
-metastatic colon cancer
-hematopoietic spread of cancer is drained by portal system and both the inferior and superior mesenteric veins drain into splenic or portal veins to bring blood to liver -> if malignant -> seeding in the liver
bowel prep for colon surgery
-Indications:
-Colorectal surgery was cancer (43.9%).
-Diverticulitis (30.4%).
-Inflammatory bowel disease (4.5%)
-Oral Mechanical Bowel Prep (OMBP)
-Large or reduced volume polyethylene glycol (PEG) solutions!!!
-MiraLAX, GoLYTELY, NuLYTELY) or bisacodyl (HalfLytely)
-not used as often bc they dont guarantee no infection
-NPO 1 day prior
-volume contracted pts -> give IV fluids before anesthesia -> risk for hypotension
-Addition of oral antibiotics:
-Neomycin and erythromycin given day before surgery -> not absorbed by GI tract
-Metronidazole (500 mg) has been substituted for erythromycin because increased effectiveness against anaerobics
pre/perioperative antibiotics for colon cancer surgery
-prevent wound infection
-emergent has no bowel prep
-urgent- some bowel prep
-cefuroxime (Ceftin) + metronidazole (Flagyl)
-cefoxitin (Mefoxin) + metronidazole (Flagyl).
-ceftriaxone (Rocephin) + metronidazole (Flagyl).
-ciprofloxin (Cipro) + metronidazole (Flagyl)
resection of colon with anastomosis
-tumor in transverse colon -> remove it with surgical margins -> edges are put together
-depends on surgery
-left sided resection -> 2 stage procedure -> Hartman’s operation- resection and create colostomy -> leave distal part ofq colon in as pouch
-bloody, pencil thin stool
-cecal cancer - anemia and palpable mass -> grows large before detection -> Hypochromic microcytic anemia
hartmanns operation
-resection
-pouch is closed and left inside
-proximal part is brought out as colostomy
-allows for edema and swelling to go down
-distention proximally and collapse distally -> opportunity to rest
-go back and REVERSE this in 3-6 months
-laparoscopically or robotics
-ostomy can be done throughout the GI tract
ostomies
-ileostomy- allows diversion flow of liquid stool away from anastomoses
-more problematic - fluid loss of 3-4L a day sometimes
-ostomies can be almost anywhere
-post op complications- ischemia especially was watershed area
end colostomy
-may be permanent
-resection from anus up to cure cancer
-stoma
-distal colon= rectum and anus
-for lower lesions
-colostomy bag is permanent
adjuvant chemotherapy
-for stage 2 and 3, large tumors, presence of nodes
-DONT NEED TO KNOW ALL NAMES
-Stage II colon cancer
-High-risk stage II colon cancer 5-FU or capecitabine.
-Oxaliplatin may also be an option.
-Stage III colon cancer
-Surgery to remove the cancer and nearby lymph nodes.
-Adjuvant chemotherapy: FOLFOX (5-FU, leucovorin, and oxaliplatin).
CapeOx (capecitabine and oxaliplatin)
-Length of tx depends on pts risk of recurrence and regimen used:
-Low-risk stage III:Pts with low-risk stage III disease (T1-3, N1) may be able to complete tx in 3 months.
-High-risk stage III:Pts with high-risk stage 3 ds (T4 and/or N2) typically receive 6 months of tx
Cytoreductive Surgery + HIPEC for Colon Cancer
-Hyperthermia Classification:
-Fever hyperthermia (39-40 °C).
-Mild hyperthermia (heat shock temperature 41-43 °C).
-Thermal ablation (cytotoxic temperature, > 43 °C).
-Can be utilized in colon cancer pts with carcinomatosis.
-heat Bypasses the “peritoneal-plasma barrier” but putting it directly there -> need less of dose -> less toxic
-Debulking of tumor by stripping peritoneum and/or involved organs
-Hyperthermic Intraperitoneal chemotherapy:
-Utilizes Mitomycin-C (MMC) +/- Cisplatin.
-Temperature causes vasodilatation and increased chemo uptake locally.
-Allows for extension of life expectancy
-go in abdomen
-take out cancer
-take out peritoneal studying
-take out other organs that are affected
-use hyperthermic intraperitoneal chemotherapy bc cytotoxic affect of thermoablation of cells at 40 degree Celsius or higher
-heated chemo into peritoneal cavity
-leave for few hours
-vasodilation -> high doses of chemo locally
Heat Shock Response and Cytoreductive Temperature
-Heat Shock Response:
-Directly killing or inhibiting growth of pathogens.
-inducing cytoprotective heat shock proteins (Hsps) in host cells.
-Inducing expression of pathogen Hsps, an activator of host defenses.
-Modifying and orchestrating host defenses.
-Cytoreductive Temperature:
-Hyperthermia-induced increased permeability of CTX into tumor cells.
-Increased drug-induced DNA damage.
-Inhibition of the repair of drug-induced DNA damage.
-Expression of heat shock proteins by tumor cells which ultimately potentiates the effect of Natural Killer cells (antitumor response)
-risk of hyperthermia
-generate inhibitory growth factors for tumors -> increase permeability of chemo into the cells
-DNA damage to bad cells
-inhibits and repair drug induced DNA damage
-heat shock proteins make NKC work better
-positive affect on antimetabolism of tumors
Cytoreductive + HIPEC Postoperative Complications
-Hyperthermic during the procedure
-Small bowel perforation
-Anastomotic leak
-monitor post op for peritonitis
diverticulosis
-no muscle in the wall itself
-diverticulum forms where vessels come into the wall cause areas of weakness
-A Western Hemisphere “epidemic”- high fat and low fiber diet
-Found in 60% of pts > 60 yo have diverticulosis
-colonoscopy
-88% of diverticular/diverticulitis disease is uncomplicated.
-12% is diverticular/diverticulitis disease is complicated:
-Abscess
-Fistula
-Obstruction
-local perforations
diverticulitis symptoms
-“Left-sided” appendicitis
-Fever
-Nausea/Vomiting
-Changes in bowel habit- constipation or diarrhea
-Urinary symptoms
-bloating
-possible tender, palpable mass
-Flatulence.
-Weakness.
-anemia
-leukocytosis, fever, LLQ pain
diverticulitis workup
-History & Physical Exam. #1
-Labs: CBC (anemia), BMP (electrolytes), U/A (blood), and CRP
-leukocytosis
-imaging: CT scan abdomen & pelvis with contrast, abdominal US (barium enema- not really anymore)
-Abdominal U/S:Can accurately dx acute diverticulitis
-thickened wall
-Colonoscopy:Examine lining of entire for diverticula, inflammation, or bleeding -> contraindicated during acute episode
-colonoscopy 6-8 weeks after resolution to assess and r/o malignancy
-thickened wall- swelling
-stranding is the mesentery - inflammation secondary to diverticula
-diverticula on the left
-swelling
-distended colon
classification of diverticular disease: Hinchey classification
- 2, 3, 4 -> surgery
-1a and 1b -> monitor closely
-Hinchey I and II:
-Conservative management.
-Percutaneous catheter drainage may be used for abscesses > 2–3 cm
-Hinchey III:
Laparoscopic lavage and drainage (LLD) alternative to surgical resection
-Hinchey IV:
-Emergency surgery is usually required
-Hartmann procedure is the preferred- end colostomy with distal stub left inside for later reversal
-Significant morbidity and mortality
diverticulitis antibiotics
-key to management - oral
-1st line- Ciprofloxacin (Cipro) + metronidazole (Flagyl)
-TMP + Metronidazole
-single dose: better compliance
-Amoxicillin-Clavulanate
-moxifloxacin (Avelox)
-complicated:
-broad spectrum IV
-CT guided percutaneous drainage for abscesses >4cm
-emergency colectomy for perforated peritonitis
-elective colectomy after resolved complicated diverticulitis is acceptable
causes of massive lower GI bleed
-1# cause of GI bleeding -> hemorrhoids
-#1 cause of MASSIVE GI bleeding
-diverticulosis!
-angiodysplasia
-upper GI bleed 1/3rd of pts as a mimic due to rapid transit time
-21% mortality especially in pts with comorbidities
->50yo with massive GI bleed -> cardiac enzymes, EKG -> low blood count causes cardiac ischemia -> coronary arteries are massively compensated -> MI
-airway and breathing
-scope from above to see if upper cause
-then try to bowel prep and check lower
-resuscitation
-signs of shock or significant amount of melena -> intubation
Approach to the GI Bleed Patient: Initial Eval and Triage
-O2
-2 large-bore peripheral IV drip -> normal saline, ringers lactate, plasmolytes
-Place on a cardiopulmonary monitor.
-IV infusion of crystalloid started immediately to resuscitate the pt
-transfuse if -> hmg 7 and 21 or 8 and 24 if ACS
-TEG
diagnostics for massive GI bleed
-CBC
-BMP
-LFTs
-lactic Acid- base deficit >4 -> transfer to ICU for arterial line for ABGs acidosis
-Coags
-Type & Crossmatch
-if > 50yo -> Cardiac Enzymes* and EKG*
-CXR- air under diaphragm
-CT Abdomen/CTA Abdomen (If hemodynamically Stable)- embolize and identify bleed
BLEED criteria
-Bleeding: bright red blood.
-Low SBP < 100 or orthostatic changes
-Elevated prothrombin, > 1.2 x normal.
-Erratic mental status.
-unstable comorbid Disease
-need transfusion sooner rather than later
reversal of anticoagulants
tx for massive GI bleed
-Reversal of anticoagulants if applicable.
-Upper endoscopy is usually done 1st -> doesnt require prep
-CTA to detect bleeds 0.3 ml/min – 0.5 ml/min.
-Bleeding Scan to detect bleeds 0.01 ml/min – 0.36 ml/min -> nuclear
-Colonoscopy within 24 hours, after prep if stable
-6U blood in a 24 hour period -> surgical intervention to find out whats happening!
-mesenteric angiogram
-catheter angiography with angioembolization
-endoscopic hemostasis
inflammatory bowel disease
-ulcerative colitis
-crohn disease
-CT enterography
-MRI enterography
surgical management of ulcerative colitis
-colon to rectum
-sometimes can see backwash ileitis
-Elective:
-Tx aimed at complications, dysplastic polyps or adenomatous colorectal polyps
-Presence of disease for 10 years (cancer risk increase) -> surgery !
-Failure of medical management -> surgery
-Emergency/Urgent:
-Colonic perforation
-GI hemorrhage
-Toxic Megacolon- significant distended (usually transverse)- pneumatosis or ischemia
surgical management of crohns disease
-mouth to anus disease.
-Primary tx is medical.
-Surgery reserved for COMPLICATIONS or refractory to medical treatment
-Optimization Priority:
-Correcting severe anemia.
-Replete fluid deficits.
-Correct electrolyte imbalances
-anemic
-Address nutrition
-may be on immune suppression -> poor wound healing
-complications:
-Perforation.
-Abscess.
-Fistula- perirectal
-strictures.
-Malignancy.
-Hemorrhage.
-Inflammation.
-Toxic Megacolon
what keeps fistulas open
-FRIEND:
-Foreign Body- lodged within
-Radiation
-Inflammation/Infection/Inflammatory Bowel Disease
-Epithelization- well developed fistula
-Neoplasm
-Distal Obstruction- pressure on fistula
-MRI enterography
-normal on upper left
-inflammation in middle
-lower right -thickened bowel
-dilation - stricture
-ascending and descending colon
-light grey around it is inflammation
-surgical intervention for complications
acute vs chronic obstruction
-Acute
-Acute on Chronic
-Chronic
-Acute obstruction -SBO , with sudden onset of severe colicky central abdominal pain, distension and early vomiting and constipation
-Chronic obstruction- LBO, with lower abdominal colic and absolute constipation followed by distension.
-Presentation will be further influenced by whether the obstruction is simple.
-Strangulating/strangulated – in which there is interference to blood flow.
cirrhosis
-portal HTN
-bile
-pruritus
-jaundice
-xanthoma
-ascites
-esophageal varices
-hepatic encephalopathy
-anorexia, wt loss
-clubbing
-petechiae
-telangiectasia
-clubbing
-ALT and AST
-hyperestrogenism
-decrease HGB and platelets
-thrombocytopenia
-anemia
-US- best test
-bx- gold standard
-tx- liver transplant is the only curative option
bowel obstruction
-obstipation- compete bowel obstruction
-pain, distension, vomiting, absolute constipation
-dehydration, hypokalemia (not common), pyrexia
-tympanic percussion
-increase high pitched bowel sounds (early) or absence of bowel sounds (late)
-collapsed empty rectum on rectal exam -> complete obstruction or impacted feces
obstruction complications
-Bowel perforation: pneumoperitoneum
-Bowel ischemia
-Decreased or abnormal contrast-enhancement of the bowel wall on contrast imaging
-Bowel wall thickness increased to > 3 mm on CT, US, or MRI
-Pneumatosis intestinalis: gas in mesenteric veins
-Free fluid between dilated loops
-Nonspecific: focal mesenteric edema and fat stranding
-Whirl sign in volvulus
-Target sign/doughnut/bulls eye in intussusception
-Intraabdominal malignancy
-Diverticuli
