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Surgery - Lower GI Flashcards

1
Q

What can cause failure of fascia closure in ab surgery?

A

Infection in abdomen

Can have hernia w/ fascia open – need to go to OR to fix ASAP

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2
Q

Most common causes of lower GI bleeding

A

1) Diverticulosis

2) Andiodysplasia

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3
Q

Ischemic colitis

A

Happens in setting of

  • hypoTN
  • vasculitis
  • atherosclerosis

Present w/:

  • ab pain (pain out of proportion of PE)
  • —usually pain after eating –> wt loss
  • fever
  • vomitting

Bleed b/c of ischemia of watershed areas of the colon

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4
Q

Acute mesenteric thrombosis

A

Ab pain out of proportion of physical findings
N/V
Bloody diarrhea b/c mucosal sloughing

Numerous athero risk factors

Usually SMA is occluded –> distal duodenum –> transverse colon

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5
Q

Common causes of pelvic abscesses

  • male
  • female
A

Male

  • appendicitis
  • rupture of appendix –> form pelvic abscess from fluid draining into rectovesical pouch

Fem:
- gyn issues

Drain these abscesses!

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6
Q

Pelvic abscess vs anorectal abscess

A

Pelvic

  • tender fluctuant mass palpable only w/ tip of examing finger on rectal
  • painful defecation
  • diarrhea

Anorectal

  • perineal pain
  • fluctuant mass palpable on perineum
  • pain w/ ambulation + defecation
  • urinary retention
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7
Q

Rovsing sign

A

RLQ pain w/ deep palpation of LLQ

Sign of Appendicitis

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8
Q

How do you dx appendicitis?

A

CLinically!

Don’t need further imaging to confirm dx if classic signs, sx, and lab data are present

Get CT if person has suspected appendicitis w/ atypical presentation

Need surgery ASAP
Give Abx pre and postop

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9
Q

Isolated duodenal hematoma

A

Mostly in kids after BAT

Usually have blood b/n submucosal and muscular layers of duodenum –> obstruction

Most will resolve by itself in 1-2 wks

Tx:

  • nasogastric suction w/ TPN
  • if need surgery, can do laparotomy or laparoscopic procedure
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10
Q

Uncomplicated vs complicated diverticulitis

- tx?

A

Uncomplicated

  • colonic diverticular inflamamation
  • tx: outpt, bowel rest, oral abx, observation

Complicated

  • diverticulitis + abscess, perf, obstruct, or fistula formation
  • if fluid collection < 3 cm, tx w/ IV abx
  • if fluid > 3cm, CT guided drainage
  • surgery (drainage + debridement) if drainage does not fix
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11
Q

Ab aorta operations - what is an early complication?

A

Bowel ischemia and infarction

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12
Q

How long do you give a pt who went under ab surgery that is now third spacing?

A

48-72 hrs

At this time, they will reabsorb edema and pee it all out

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13
Q

Pathophys of dumping syndrome

A

Rapid emptying of hypertonic gastric content into duodenum + SI

causes fluid shift from intravascular space –> SI

Then release intestinal vasoactive polypeptides and stimulation of autonomic reflexes

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14
Q

When do you use technetirum-99 labeled RBC scintigraphy?

A

IN cases of lower GI bleeding where source can’t be ID’d by colonoscopy

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15
Q

Mesenteric ischemia

A

inflammation and injury of the small intestine result from inadequate blood supply

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16
Q

Different severities of hernias

A

Reducible
Incarcerated = not reducible
Strangulated = not reducible + ischemic

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17
Q

Minimize post op infection for elective colonic surgery

What can you use to decrease bacterial load in bowel before GI surgery?

A

Mechanical cleansing
Oral Abx
Periop parenteral abx (anaerobes and aerobes)

Oral nonabsorbable abx

  • neomycin
  • erythromycin
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18
Q

Risk factors associated with colorectal cancer

A

Strong risk

  • advanced age
  • country of birth (eg Korea, Scandanavians)
  • FAP/HNPCC
  • long standing UC

Moderate risk

  • previous adenoma or cancer
  • 1st degree relative w/ adenoma or cancer
  • pelvic irradiation
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19
Q

Protector factors assoc w/ colorectal cancer

A

Moderate

  • physical activity
  • aspirin/NSAIDs (Nurses study)
  • high Ca intake (Nurses study)
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20
Q

Genetics of colon cancer - what can be mutated?

A

Tumor suppressors

  • APC
  • Chr 18
  • p53

Oncogenes
- k-ras

DNA repair genes

  • hMLH1
  • hMSH2
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21
Q

Where do adenocardionmas of colon come from?

A

Glandular tissue of mucosa (#1)

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22
Q

Familial adenomatous polyposis

A

APC gene mutation

Chromosome 5 location

AD inheritance

100% colon cancer risk

Total proctocolectomy in early 20s

  • ileostomy
  • or J pouch (ileoprocto anastamoses)

Still early death b/c more susceptible to other adenomas, esp in duodenum

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23
Q

What is double contrast barium enema?

A

2 contrasts:

  • Barium
  • Air

Air to disperse barium

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24
Q

Gardner’s syndrome

A

Osteomas

variant of FAP

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25
Classic for peutz-jegher's?
Buccal pigmentation
26
HNPCC (Lynch syndrome)
AD inheritance Not hundreds of adenomas like FAP but will still get polyps Mismatch repair gene mutation Higher risk for other cancers: - stomach - SI - renal - ovarian - pancreatic
27
Where are most hereditary colon cancers?
R side
28
Watershed areas of Colon
Lives off collateralization of arteries for supplying area Griffith's point = splenic flexture - Arch of Reiling - SMA - marginal A branch of IMA Sudek's point - superior hemorrhoidal A (IMA) - middle and inferior rectal A (internal iliac) - mets to lung and liver for rectal cancer
29
Microsatellite instability
When 2 bases don't line up, you get a break = MI condition of genetic hypermutability that results from impaired DNA Mismatch Repair (MMR).
30
Microsatellite stable vs. unstable - which has better prognosis?
Microsatellite unstable cancer has better prognosis! - less biologically active But more resistant to 5-flurouracil chemo
31
Molecular pathogenesis of colorectal cancer
MIcrosatellite stable cancer: Loss of APC gene --> k-ras mutation --> DCC deletion --> p53 deletion Microsatellite unstable cancer: MSH2/ MLH1 abnormality --> k-ras mutation --> DCC deletion --> p53 deletion
32
What do you look for in FOBT?
Iron! THIS IS NOT SPECIFIC OR SENSITIVE! Guiaic test: - 3 separate stool samples collected by patients and tested for blood
33
Screening recommendations for CRC | - what tests do you do?
Annual FOBT + sigmoidoscopy / 5 years Colonoscopy every 10 years Double contrast barium enema every 10 years
34
Post op, when does bowel function come back?
SI - 4h Stomach - 24h Colon - 3d
35
Abx for GI surgery ppx if will cause significant trauma
Ampicillin + gentamicin - fights enterococci
36
Intestinal atresia usually due to
vascular accidents in utero Ileum #1 affected Duodenum is a failure to recannalize rather than a vascular accident in utero
37
Whipple's disease manifestations
PAS + macrophages (foamy) Cardiac sympoms Arthralgias Neurologic symptoms
38
Diverticulosis
Most in sigmoid colon - smaller diameter, more pressure - more formed stool Occur esp where vasa recta perforate muscularis externa
39
Volvulus
Twisting of portion of bowel around redundant mesentery in colon Cecum (young) Sigmoid (old)
40
Meconium ileus - pathophys - tx
In cystic fibrosis Meconium plug obstructs intestine (terminal ileum) preventing stool passage at birth Tx: Gastrografin enema to dx Gastrografin enema can also tx (draws fluids in and dissolves pellets of meconium) NO SURGERY!
41
Necrotizing enterocolitis - what is it? - tx?
Necrosis of intestinal mucosa Possible perf Colon is usually involved More common in preemies - common when baby begins solids foods or formula IVF + IV abx Surgery if have pneumoperitoneum, ab wall erythema, air in portal v, or intestinal pneumotosis
42
Dx carcinoid | Tx carcinoid
Dx: - urinary 5-hydroxyindoleacetic acid - not blood levels b/c it is waxing and waning symptoms. levels only high at time of attack; otherwise, levels will be normal Tx: Tumor excision is 1st line Use octreotide if can't resect/too advanced
43
Bacterial overgrowth syndrome in intestine - symptoms - clinical manifestations
``` Sx: Ab pain Watery diarrhea Dyspepsia Wt loss ``` ``` Severe: Tetany (hypo Ca b/c vit D deficiency) night blindness (vit A def) neuropathy (B12 def) dermatitis arthritis hepatic injury ``` ``` PE: secussion splash (from fluid filled loops of bowels) ``` Upper GI w/ small bowel follow through to dx by showing hypomotility, partial obstruction, dilation w/ delayed GI motility
44
Usual Causes of ileus
UTI | PNA
45
Tx ogilvie’s syndrome
1st make sure there is no actual intestinal blockage neostigmine + monitor cardiac function
46
Tx Volvulus | Dx volvulus
rigid sigmoid + rectal tube (keep from twisting on itself and do on a bowel perp) so you can do a sigmoid resection Can dx w/ xray
47
Tx Gallstone ileus
go in and slit in the ileum and milk out the stone. Go back and fix the gallstone duodenum fistula later
48
Ab pain + high amylase + normal lipase | What happened?
Bowel can release amylase. If have ab pain and only high amylase without corresponding rise in lipase, not pancreatitis and can be bowel ischemia
49
Most common causes of C Dif colitis | - when do you need surgery
CLindamycin Cephalosporins Surgery when WBC > 50, serum lacate > 5
50
Fissure or fistula that doesn't heal well - what does this suggest?
Crohns Anal area has good blood supply and usually these things heal. If not, suggests Crohns
51
Generally, GI bleeding is from where?
3/4 cases before ligament of Treitz (upper GI) 1/4 in colon or rectum
52
BRBPR in child - what is it most likely? What do you do next?
Meckel's diverticulum Technetium scan looking for ectopic gastric mucosa
53
Omphalocele vs. gastroschisis repair
Omphalocele = reduce day by day Gastrochisis = need TPN b/c bowel will not work for about 1 mo
54
Tx imperforate anus in newborn
If there is a fistula, can delay until before potty training time If no fistula, do colostomy for high rectal pouches or do primary repair asap Find where blind pouch is with xrays taken upside down
55
Dx Hirschsprung disease
Full thickness bx of rectal mucosa Manometrics usually for older kids
56
SCC of anus
more common in HIV+ and homosexuals fungating mass growing out of anus tx: nigro chemorad (90% success) surgery if there is residual
57
All hernias should be electively repaired except
umbilical hernias in kids < 2-5 yo esophageal sliding hernia
58
Anal fissure
Usually in young women lots of pain w/ defecation + blood streaks covering stools Can get constipated because fear defecation Tx: - stool softners - topical nitro - local botox - forceful dilatation - CCB (dilitazem)
59
Thumb print sign on KUB/Ab XRAY
Bowel wall edema On an unremarkable abdominal radiograph of a patient with normal colon wall thickness, you see only the inner wall of the bowel because it is outlined by the gas in the lumen of the bowel; you don't normally see outer wall of normal bowel wall. If the bowel wall is thickened, it protrudes into gas-filled lumen, and on radiographs, these protrusions appear as focal areas of soft tissue thickening along the colon wall that look like somebody is pressing a thumb into the air-filled lumen
60
SBO in man w/o previous ab surgeries + aerobilia - what do you suspect?
Aerobilia = air in the biliary tract This is gallstone ileus!!! Tx: ileotomy + extraction; later cholecystectomy - do not operate on the biliary fistula now
61
Tx Hirschprung's disease
Initial = colostomy decompression Wait for definite repair until nutritional status is ok and nontdistended bowel
62
Umbilical hernia in newborn + no incarceration - tx?
Wait Most close by age 4
63
Is more water absorbed in R or L colon?
Both same!
64
How best to stage rectal wall and pararectal lymph nodes in rectal cancer?
US
65
Do you do a resection for rectal cancer if it invades muscularis mucosa?
Not needed - if taking out cancer has clear gross adn microscopic margins, tumor is well differentiated, and stalk not invaded
66
Ach - + or - motility of GI?
Causes motility!! Anything that simulates PSNS activity stimulates motility
67
Places where hemorrhoids arise
L lateral R anterior R posterior
68
Tx external hemorrhoids, thrombosed
If < 72 hrs old - remove clot If > 72 hrs old - don't do anything, warm bath. body is resorbing the clot
69
Where do you cut to do I&D for anal abscess?
Near anus as possible b/c may make fistula so want to go as close to opening as possible
70
anal fissure characteristics
Will have a skin tag usually with it
71
Coincentric rings indicative of
Rectal prolapse
72
Causing anal pain
Abscess Herpes Fissure Thrombosed external hemorrhoids
73
Mass on outside of anus/abnormalities around anus that are not painful
Skin tags Internal hemrrhoids Pruritus ani Tumor
74
Crohns vs regular fissure
Crohns usually lateral Conventional fissures usually posteriorly
75
Howship Romberg sign
Obturator neuralgia from nerve compression by obturator hernia Thigh extension, adduction and medial rotation
76
.Fat absorption
Short _ medium chain = transport directly from jejunal mucosa --> portal venous system Larger triglycerides --> chylomicrons --> lymphatics
77
Regional enteritis aka crohns in kid can mimic appendicitis - what do you do when you do surgery and the appendix looks normal?
Appendectomy if cecum at base of appendix is not involved
78
Anal cancer 1st therapeutic approach should be
Radiation + chemo Surgery has been shown to have not great results
79
Indications for surgery in crohns
Free perforation Stricture if it compromises nutritional status Fistula w/ symptoms
80
Carcinoid tumor in appendix tx
< 2 cm - appendectomy >2cm - R hemicolectomy
81
Tx complicated diverticulitis - abscess - perforation - obstruction - fistula formation
Abscess: CT guided percutaneous drainage --> if doesn't resolve, surgical drainage and debridement Fistula, perforation, peritonitis, obstruction, recurrent attacks: - sigmoid resection
82
GI complaints followed by periorbital edema + myositis + eosinophilia + splinter hemorrhages
Trichinellosis!!!
83
What should you always look for as a source of constipation?
Hyper Ca Watch out for MM, cancers causing this, esp if pt has bone pain
84
Difference between ileus vs pseudoobstruction
ileus has NO BS - will have both SI and colon distention Pseudoobstruction has hyperactive bowel sounds - most colon distention w/o much SI distention

Surgery (12 decks)

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