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clin med III, exam 1 > small and large BO, anal and rectal dz > Flashcards

small and large BO, anal and rectal dz Flashcards

1
Q

vascular supply to the small intestine is primarily from

A

superior mesenteric artery

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2
Q

List the extraluminal causes of small bowel obstruction

A
  • Post-op surgical Adhesions (60%)
  • Neoplasms (20%)
  • Hernias (10%)
  • malrotation
  • intraabdominal abscess
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3
Q

What are the some intraluminal causes of small bowel obstruction

A
  • intussception
  • neoplasm
  • crohn’s
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4
Q

In a patient who presents with abd pain, why is it important to ask for a h/o abd surgery

A
  • adhesions are present in 2/3 of patients after abd surgery
  • post op surgical adhesions account for 60% of small bowel obstructions
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5
Q

small bowel obstruction leads to what volume status

A
  • hypotension
    • intravascular fluid depletion -> edematous wall leads to fluid sequestration in lumen
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6
Q

Obstipation

A
  • inability to pass either gas or stool
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7
Q

clinical presentation

  • abd pain, intermittent -> steady
  • abd distension
  • N/V
  • constipation
  • obstipation
  • high pitched or absent bowel sounds
  • typmany on percussion
A

obstruction

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8
Q

What films would you order to assess for small bowel obstruction?

A
  1. plain films: supine and upright
  2. CT scan​
    1. ​plain films are negative but high clinical suspicion
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9
Q

List the red flags when assessing for SBO -> surgery consult

A
  • pneumoperitoneum
  • retroperitoneal air
  • peritoneal signs
  • shock
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10
Q

List signs on xray/CT that are consistent with obstruction

A
  • dilated proximal bowel
  • distal collapsed loops
  • air fluid levels
  • bowel wall thickening > 3 mm
  • sub-mucosal edema
  • ascites
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11
Q

management of small bowel obstruction

A
  1. volume resuscitation, NPO, decompression with NG tube, abx
  2. consult surgeon
    • only 1/4 of patients with SBO require surgery
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12
Q

What percentage of partial small bowel obstructions resolve spontaneously

A

80%

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13
Q

Name two ways to differentiate between complete and partial small bowel obstruction

A
  1. cessation of passage of stool or gas > 12-24 hrs supports complete SBO
  2. absence of air or fluid in distal small bowel or colon supports complete SBO
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14
Q

List causes of complicated bowel obstruction

A
  • complete obstruction
  • close loop obstruction
  • incarcerated hernia: causes highest complication rate
  • bowel ischemia, necrosis, or perforation
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15
Q

List three causes of intestinal strangulation

A
  • strangulated hernia
  • volvulus
  • intussusception
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16
Q

clinical presentation

  • rebound tenderness
  • tenderness to percussion
  • pain with light palpation/bumps
  • diminished bowel sounds
A

peritonitis

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17
Q

currant jelly stools is characteristic for

A

intussusception

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18
Q

clinical presentation following abdominal surgery

  • obstipation
  • intolerance of oral intake
  • absent or hypoactive bowel sounds
A

paralytic ileus

  • certain degree is normal following surgery
    • due to anesthetics, narcotics, and manipulation
    • more likely with larger incisions
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19
Q

How can you determine (using symptoms) if an ileus is physiologic or pathologic post operatively

A
  1. no return of bowel function in 4-6 days post-op
  2. absence of flatus or stool 6 days post-op
  3. N/V requiring cessation of PO intake
  4. requirement for NGT after day 5 post-op
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20
Q

how is paralytic ileus diagnosed

A
  • plain films
    • KUB shows dilated loops and air in small bowel AND colon
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21
Q

management of paralytic ileus

A
  • fluids
  • pain managment (not narcotics)
  • NGT in some
  • PPN, TPN
  • ambulate
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22
Q

blood supply to large bowel

A
  • SMA and IMA
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23
Q

percentage of bowel obstructions in small and large bowel

A
  • small bowel 80%
  • large bowel 20%
24
Q

List the causes of large bowel obstruction

A
  1. adenocarcinoma (65%)
  2. stricture due to diverticulitis/ichemia
  3. volvulus
  4. IBD, foreign body, fecal impaction
25
Q

what films would you order when assessing for large bowel obstruction

A
  1. plain films: supine and upright
  2. CXR: look for free air under diaphragm
  3. Gastrograffin enema
    • if xrays are unclear
    • localization for surgery
  4. CT scan if diagnosis still in question
26
Q

managment of large bowel obstruction

A
  1. IV fluids, NPO
  2. abx
  3. decompression if vomiting
  4. can start bowel cleanse to prep for surgery
27
Q

what is a volvulus

A
  • abnormal twisting of a portion of the GI tract, usually intestine, which can impair blood flow
28
Q

List the two most common types of volvulus

A
  1. sigmoid volvulus
  2. cecal volvulus
29
Q

which type of volvulus is the most common? Mean age of patients who get it?

A
  • sigmoid volvulus
  • 70 yo
30
Q

imaging is suggestive of

  • KUB/upright: U shaped “bent inner tube” sign
  • CT scan: whirl pattern and birds beak
A

sigmoid volvulus

31
Q

tx of sigmoid volvulus

A
  • reduction
    • flexible sig to decompress and de-rotate
  • interval surgery to resect redundant sigmoid and fix colon so it can not rotate again
32
Q

cecal volvulus commonly affects what age group

A

mean age 33-53 yo

33
Q

imaging suggestive of

  • KUB/upright: comma or coffee bean sign with air fluid levels
A

cecal volvulus

34
Q

tx of cecal volvulus

A
  1. right colectomy
  2. cecopexy with cecostomy tube: if pt unstable
  3. cecostomy tube alone in debilitated pt
35
Q

What line seperates innervation of anus? Where is somatic innervation?

A
  • pectinate or dentate line
  • somatic innervation is below line: pt feels pain here
36
Q

causes of hemorrhoids

A
  • prlonged sitting, straining, pregnancy, advanced age
37
Q

why do hemorrhoids itch

A
  • swelling in the tissue allows fecal mattter to infiltrate and cause localized dermatitis
38
Q

clinical presentation

  • bright red blood per rectum - on toilet paper or stool (not mixed in)
  • pruritus
A

hemorrhoids

39
Q

what is the most common cause of rectal bleeding

A
  • internal hemorrhoids
40
Q

differentiate between internal and external hemorrhoids

A
  1. internal: above dentate line
    • not painful
    • may bleed and prolapse
  2. external: below dentate line
    • do not bleed
    • May thrombose
    • pain, itching
41
Q

diagnostic evaluation of hemorrhoids

A
  1. rectal exam
  2. CBC
  3. anoscope
  4. if in doubt, flexible sigmoidoscopy vs colonoscopy
42
Q

differentiate between the 4 classes of internal hemorrhoids

A
  • 1st degree: bulge in anal canal
  • 2nd degree: protrude with defecation, spontaneous reduction
  • 3rd degree: require manual reduction
  • 4th degree: permanently protruded
43
Q

list the two options for hemorrhoid treatment

A
  1. non-operative symptomatic relief
    • rubber band ligation of grade II and II internal hemorrhoids
      • will cause necrosis
  2. surgical hemorrhoidectomy
    • internal or external hemorrhoids with extensive thrombosis, pain, and persistent bleeding
44
Q

List the 4 types of anorectal abscesses due to obstruction of perianal crypt glands

A
  1. perianal (60%)
  2. ischiorectal
  3. intersphincteric
  4. supralevator
45
Q

causative organisms of anorectal abscess

A
  • e-coli
  • proteus
  • strep bacteriodes
46
Q

tx of anorectal abscess

A
  1. surgical drainage: all require I&D
  2. possible broad spectrum abx
  3. wound care
47
Q

untreated perianal infections can lead to

A

Fournier’s gangrene

48
Q

what is a anal fistula

A
  • abnormal connection between anal canal (internal opening) and the perianal skin (external opening)
    • 50% chance after abscess
49
Q

List the causes of fistula

A
  • opened or ruptured abscess
  • crohns disease
  • diverticulitis
  • fistula in ano
50
Q

managment of fistula

A
  • fistulotomy: unroofing the fistula tract to allow healing
51
Q

tx for fistula in ano

A
  • delineation of fistula tract
  • drainage and curettage of fistula tract
  • placement of seton
52
Q

what are anal fissues

A
  • linear tears in the lining of the anal canal below the level of the dentate line
53
Q

causes of anal fissues

A
  • foreign body
  • very hard bowel movement
54
Q

anal fissues are most common where

A
  • posterior wall
  • lowest blood supply
55
Q

clinical presentation

  • severe rectal pain with BM
  • afraid to have a BM
  • rectal bleeding
A

anal fissues

56
Q

how is anal fissues diagnosed

A
  • felt on DRE
  • if unsure, get flex sig or colonoscopy
57
Q

tx of anal fissues

A
  • aim for soft, formed BM
  • nitroglycerin ointment
    • reduced spasm and increases blood flow
  • if not healed in 3-4 weeks, needs surgery

clin med III, exam 1 (5 decks)

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