SBO/LBO, Pancreatitis, Perforated Viscus Flashcards

Question

pancreatitis tx

Answer 1

-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

Answer 2

-intracellular enzyme -high -> cells are dying somewhere

Answer 3

-based on looking at the CT

Answer 4

-inflamed -fluid inside -irregular -pancreas

Answer 5

-acute pancreas -due to STONE -fluid around the gallbladder

Answer 6

-no amylase, lipase -burn out exocrine and endocrine function -enzymes to digest food, no insulin (hyperglycemia) -tx- pancreatic enzymes (prion)

Answer 7

-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

Answer 8

-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

Answer 9

-intraluminal pressure needed to stretch wall of hollow tube is inversely proportional to its radius

Answer 10

-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

Answer 11

-anal cancer- squamous cell -colon- adenocarcinoma -3rd MC in men -2nd MC in women

Answer 12

-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

Answer 13

-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

Answer 14

-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

Answer 15

-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

Answer 16

-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

Answer 17

distended loops of bowel

Answer 18

sigmoid volvulus -left

Answer 19

cecal volvulus -right

Answer 20

distended loops of bowel -air fluid levels

Answer 21

-perforation risk -> sepsis -distended splenic flexure -distended transverse colon

Answer 22

-distended bowel -surgical intervention -perforation risk

Answer 23

-Inflammatory bowel disease. -personal or family hx of colorectal cancer or polyps. -genetic syndrome: familial adenomatous polyposis (FAP) or hereditary non-polyposis colorectal cancer (Lynch syndrome) -Lifestyle factors that may contribute to an increased risk of colorectal cancer: -Lack of regular physical activity -Diet low in fruit and vegetables. -Low-fiber and high-fat diet or a diet high in processed meats. -Overweight and obesity -Alcohol consumption -Tobacco use

Answer 24

-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.

Answer 25

-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

Answer 26

-TMN -you get the chart to stage someone -dont memorize

Answer 27

-colon cancer -with significant local extravasation of contents -assoc perforation -> means its metastatic -carcinomatosis -studying of the peritoneal cavity from tumor cells

Answer 28

-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

Answer 29

-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

Answer 30

-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)

Answer 31

-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

Answer 32

-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

Answer 33

-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

Answer 34

-may be permanent -resection from anus up to cure cancer -stoma -distal colon= rectum and anus -for lower lesions -colostomy bag is permanent

Answer 35

-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

Answer 36

-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

Answer 37

-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

Answer 38

-Hyperthermic during the procedure -Small bowel perforation -Anastomotic leak -monitor post op for peritonitis

Answer 39

-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

Answer 40

-“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

Answer 41

-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

Answer 42

-thickened wall- swelling -stranding is the mesentery - inflammation secondary to diverticula

Answer 43

-diverticula on the left -swelling -distended colon

Answer 44

- 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

Answer 45

-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

Answer 46

-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

Answer 47

-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

Answer 48

-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

Answer 49

-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

Answer 50

-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

Answer 51

-ulcerative colitis -crohn disease -CT enterography -MRI enterography

Answer 52

-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

Answer 53

-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

Answer 54

-FRIEND: -Foreign Body- lodged within -Radiation -Inflammation/Infection/Inflammatory Bowel Disease -Epithelization- well developed fistula -Neoplasm -Distal Obstruction- pressure on fistula

Answer 55

-MRI enterography -normal on upper left -inflammation in middle -lower right -thickened bowel -dilation - stricture -ascending and descending colon

Answer 56

-light grey around it is inflammation -surgical intervention for complications

Answer 57

-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.

Answer 58

-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

Answer 59

-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

Answer 60

-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