Surg/GI/nutrition/endo Flashcards
Virchow triad
Stasis/immobility, endothelial injury, hypercoagulability
UFH DVT prophylaxis
80U/kg bolts followed by 18U/kg infusion. Check aPTT at 6hr and q 2hr till 1.5x control achieved
LMWH DVT prophylaxis
1mg/kg SC. Bid. Therapeutic peak 0.6-1 of anti Xa
Arixta DVT prophylaxis
2.5mg SC daily go up to 10 d
Risk factors for DVT
Recent surgery Acute medical illness Immobilization Central venous cath Prior VTE Pregnant or postpartum Active malignancy Obesity Estrogen/testosterone IBD
HITT treatment
Direct thrombin inhibitor
Acova 2mvg/kg/min IV over 3hr
If PCI bivalirudin 0.75mg/kg IV Nokia then 1.75mg/kg/hr IV
SCIP abx guidelines
Abx should be administered 1hr before incision (2hr for vanco)
First or second gen cephalosporins preferred for most procedures
Dc abx 24hr post surgery
Hair not removed or cut with clippers
Cefazolin
DOC surg prophylaxis
1-2g preop
0.5-1g q6-8hr post op
Vanco
Surg abx if beta lactam sensitivity
GI/GU: 1g IV over slow 1hr infusion
Other procedures: 15mg/kg IV over 1-2hr
Metronidazole
Anaerobic coverage that should be added for colon surgery
15mg/kg IV over 30-60min followed by 7.5mg/kg IV at 6 and 12 hr
Most common locations for hemorrhoids
R anterior, R posterior, and lateral
Grade 3 internal hemorrhoid
Prolapse and manual reduction
Grade 4 hemorrhoid
Prolapse that can not be manually reduced
Most common annal carcinoma?
SCC
What is the incidence of anal cancer?
Rare (1% colon cancers)
What is paget’s dz if the anus?
Adenocarcinoma in situation of the anus
Risk factors for anal cancer?
STDs, chronic inflammation, immunosuppression, MSM, cervical/vaginal cancer, smoking
Most common sx of anal carcinoma?
Anal bleeding
Other sx include pain, mass, priritus. 25% asx
Describe lymphatic drainage of anus.
Above dentate line to pelvic chains
Below dentate line to inguinal lymph nodes
Margin cancer
Anal verge out 5cm into perianal skin
Canal cancer
Proximal to anal verge up to the border of internal sphincter
Nigro protocol
Used to to anal carcinoma
1chemo(5FU or mitomycin C)
2radiation
3postradiation scar bx at 8wk
90%response rate to protocol
Tx of anal melanoma
Wide excision with abdolominoperineal resection with possible chemo
Poor prognosis
What is Goodsall’s rule?
Anal fistula originating anterior to the transverse line Will course straight and fistula that originate posteriorly with have a curved course.
(Think of a dog nose and tail)
What percentage of perirectal abscesses develop into fistula?
About 50%
Anorectal fistula management
Marsupialization of tract, wound care, and seton if fistula through muscle
Where do perirectal abscesses originate?
Crypt glands in dentate line
What is a sentinel pile?
Thicker mucosa/skin at the distal end of an anal fissure that is often confused with a sm hemorrhoid
What dz processes must be considered with a chronic anal fissure?
IBD, STDs, and anal cancer
Treatment for perianal warts
Topical podophyllin, imiquimod
resection or ablation if not responsive to conservative methods.
Excruciating anal pain and history of hemorrhoids should make you think of this.
Thrombosis external hemorrhoid
What are the dreaded complications of hemorrhoidectomy?
Exsaguination ( bleeding pools proximally in lumen of colon without signs of bleeding), pelvic infection (may be extensive and fatal), and inconsistence from anal sphincter damage
What dz is a contraindication to a hemorroidectomy?
Crohns
Hyperplastic polyp
Usually pale benign polyp found in distal colon and rectum
Sessile polyp
Flat polyp that is more difficult to remove
Pedunculated polyp
Mushroom appearance/stalk and cap
APR
Abdominal perineal resection
Tx for low-lying rectal cancer
Rectum and anus removed leaving pt with a permanent colostomy
LAR
Low anterior resection
Tx for rectal cancer above levator muscles
Resection of rectum and lower sigmoid preserving continence
When should the average person start colorectal cancer screening?
45-50
When should a pt with FAP start getting colonoscopies?
10-12
When should an HNPCC pt start getting colonoscopies?
20-25 or 10yr before youngest relative was dx
Repeat q1-2yr
Most common colonic polyp
Tubular adenoma
Colonic polyp associated with the highest risk of cancer
Villous adenoma
*think VILLous is VILLanous
What is the most common site for colon cancer metastasis?
Liver
Most common site for lower rectal cancer metastasis?
The lungs
Colon venous drainage is portal so mets to liver but rectum venous drainage is IVC so lungs
Describe rectal blood supply
Superior rectal from IMA
Middle rectal from internal iliac
Inferior rectal branch of pudendal(off internal iliac)
What is another name for lynch syndrome?
Hereditary nonpolyposis colon cancer (HNPCC)
What does microcytic anemia on a postmenopausal woman indicate until proven otherwise?
Colon cancer
TNM stage III
Colon cancer with nodal involvement
Adjuvant chemo needed after resection
90% of colon cancers recur within…
3yrs of surgery/resection
What is the 5yr survival rate of unresectable colon cancer with liver metastasis?
0%
What are the subtypes of neoplasticism colon polyps?
Tubular adenomas
Tubulovillous adenomas
Villous adenomas
HCl is secreted by these cells in the stomach
Parietal cells
*HCl dissolves food, activates pepsin, and kills bacteria
Pepsin is secreted by these cells in the stomach
Chief cells
*pepsin digest protein into peptides
Parietal cells are stimulated to secrete HCl by these 3 things:
Gastrin released by G cells which stimulate ECL cells to secrete
Histamine
Acetylcholine released by the vagus nerve (parasympathetic nervous system)
Somatostatin
Inhibitory hormone released by pancreatic D cells.
Decreases GI hormones
Vitamins produced by colonic bacteria (2).
Vit k
Biotin
Secretin
Hormone released by the duodenum which inhibits release of gastrin and causes the release of bicarbonate from the pancreas
Cholecytokinin (CCK)
Hormone released by the duodenum in response to fat
Stimulates pancreases to release bicarb and digestive enzymes. Also stimulates gallbladder to contract release bile
If someone has infectious esophagitis you should be looking for this?
Cause of immunocompromise
Multiple corrugated rings in the esophagus
Suggestive of eosinophilia esophagitis
What do you expect to see on EGD if pt has pull induced esophagitis?
Small well-defined ulcers of varying depths
Risk factors for pill-induced esophagitis
Prolonged supination after pill ingestion
Chronic use of NSAIDs, bisphosphonates, potassium chloride, iron pills, vit C, BB, and CCBs
GERD alarm symptoms
Dysphagia
Odynophagia
Weight loss
Bleeding
Tx options for achalasia
Botox injection
Nitrates
CCBs
Pneumatic dilation of LES
Compare achalasia and diffuse esophageal spasm esophograms
Achalasia- birds beak
Diffuse esophageal spasm - corkscrew
*both could be treated with nitrates or CCBs
2 MC causes of Boerhaave syndrome
Bulimia
Perforation on EGD
UGI bleed from longitudinal mucosal laceration of gastroesophageal junction or gastric cardia
Mallory-Weiss tear
*MC after ETOH binge with persistent retching/vomiting
What is Schatzki ring associated with?
Sliding hiatal hernias
If a child has esophageal varies you should consider this
Portal vein thrombosis - clotting disorders
These two things seen on EDG with esophageal varies are suggestive of increased bleeding risk
Red whale marking
Cherry red spots
Management of acute active esophageal varice bleed
Stabilize with 2 lrg bore IVs and fluids
Endoscopic ligation
Octreotide (DOC) or somatostatin
Balloon tamponade or TIPS in refractory cases
Preventing rebleed of esophageal varices
Nonselective BB like propranolol or nadolol is DOC
Long acting nitrates can also help
Compare squamous cell and Adenocarcinoma of the esophagus
Squamous cell: MC worldwide, upper 1/3, associated with tobacco/ETOH use, increased incidence in African Americans
Adenocarcinoma: MC in US, lower 1/3, associated with GERD, seen in younger obese caucasians
Medication that is good for preventing NSAID ulcers
Misoprostol (Cytotec)
Complete this 8-12wk after starting thx for peptic ulcer dz to document healing and r/o malignancy
EGD
Correlate sx with location of a GI ulcer
Gastric: pain for 1-2 hr after eating and weight loss (older pts ass. With malignancy)
Duodenal: pain before meals relived with food, classically associated with nocturnal sxs (4x MC, seen in younger pts)
How do you dx ZES?
Fasting gastrin levels is the best screening
Confirm with secretin test
Localized tumor with somatostatin receptor scintigraphy
Linitis plastica
Leather bottle appearance of stomach due to cancer infiltration of stomach
Associated with worse prognosis
LAD associated with GI malignancy
Virchows node- left supraclavicular
Sister many Joseph’s- umbilical
Blumer’s shelf- rectal
Irish sign - left axillary
Krukenburg tumor
Ovarian Mets from GI tumor
Compare squamous cell and Adenocarcinoma of the esophagus
Squamous cell: MC worldwide, upper 1/3, associated with tobacco/ETOH use, increased incidence in African Americans
Adenocarcinoma: MC in US, lower 1/3, associated with GERD, seen in younger obese caucasians
Medication that is good for preventing NSAID ulcers
Misoprostol (Cytotec)
Complete this 8-12wk after starting thx for peptic ulcer dz to document healing and r/o malignancy
EGD
Correlate sx with location of a GI ulcer
Gastric: pain for 1-2 hr after eating and weight loss (older pts ass. With malignancy)
Duodenal: pain before meals relived with food, classically associated with nocturnal sxs (4x MC, seen in younger pts)
How do you dx ZES?
Fasting gastrin levels is the best screening
Confirm with secretin test
Localized tumor with somatostatin receptor scintigraphy
Linitis plastica
Leather bottle appearance of stomach due to cancer infiltration of stomach
Associated with worse prognosis
LAD associated with GI malignancy
Virchows node- left supraclavicular
Sister many Joseph’s- umbilical
Blumer’s shelf- rectal
Irish sign - left axillary
Krukenburg tumor
Ovarian Mets from GI tumor
Increased bilirubin without increased LFTs should make you think of this
Familial bilirubin disorders and hemolysis
