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
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
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
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
-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
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
-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
