Lower Gi

Front 1

symptoms of SBO without previous abdominal surgery - possible causes (3)?

Back 1

tumors (metastatic or primary) inflammatroy process, hernias

Front 2

heme-positive stool with abdominal pain, bypoactive bowel sounds x 3 days - Name the BIG 2 diagnoses.

Back 2

1. ischemic bowel
2. obstructing tumor (e.g. colon Ca)

Front 3

small amount of diarrhea or flatus, but with acute onset of abdominla pain - most likely diagnosis, others to consider?

Back 3

partial SBO
(rule out fecal impaction, gastroenteritis)

Front 4

inguinal hernia with acute abdominal pain, distended, no BMs x 3 days; manageement?

Back 4

emergent repiar due to risk of strangulation

Front 5

most common tumor that metastasizes to bowel?

Back 5

melanoma (surgery is indicated, often full rsx not possible c poor prognosis)

Front 6

post-op plan for LOA for SBO?

Back 6

IV fluids, NGT, NPO; advance diet slowly after flatus/BMs

Front 7

closed loop sbo radiogrpahically- next steps (2)?

Back 7

fluid resuscitation (ro prevent ischemic bowel) and to OR for x-lap (prevent perf)

Front 8

at initial surgery for closed loop obstruction - ?viability with edema; options (2)

Back 8

rsx and reanastamosis; 2nd look operation 24 hours day later

Front 9

SBO symptoms with free air in periteneum - diagnosis? management?

Back 9

perfoation (ischemic or overexpansion); to OR for x-lap

Front 10

incacerated inguinal hernia - surgical options dpeendent upon patient's overall condition - exaplin

Back 10

1. if stable --> hernia repair with insepction of herniated bowel
2. if ill-appearing - open hernia repair with insepction of bowel

Front 11

accidental enterotomy in OR- what post-op complications might you explanation?

Back 11

post-op leak and small bowel fistula

Front 12

symptoms of SBO, but suspected possiblility of paralytic ileus, air swallowing or constipation - what do you do to confirm SBO?

Back 12

upper GI with SBFT (can see slow transit (paralytic ileus or filled c stool in constipation); if true SBO, barium stops at obstruction

Front 13

70 yo F with 1-day hx of nausea, vomiting, inc severe abd pain. low grade fever, mild distension and tenderness, nontympanic. nonspecific ileus on KUB, pain is much more severe than suggested by KUB. VS stable with WBC of 15. Suspect what? What are two management options?

Back 13

Ischemic bowel
options: 1)to OR (if suspect bowel necrosis), or 2)further eval

Front 14

What is included in workup for suspected ischemic bowel? Initial management? Long term-management (2)?

Back 14

1. mesenteric angiogram, possible sigmoidoscopy (if suspect colon ischemia)
2. IV fluids, ?antibiotics
3. long term: revascularization procedure and/or aspirin

Front 15

75 yo F with suspicion of mesenteric ischemia (acute onset of severe abd pain, N/V)...Likely diagnosis/management of following scenarios:
1. Sig worsening pain
2. WBC count of 24
3. WBC count of 2.5
4. mod-severe met acidosis
5. atrial fibrillation
6. Hct of 55%
7. hx of CHF
8. hx of thoracic aortic dissection
9. BP 90/60
10. bloody diarrhea

Back 15

1. necrotic bowel; to OR
2. perf,necrotic; to OR
3. sepsis (leukopenia c left shift
4. marked necrosis; to OR
5. embolization; mesenteric angiogram / to OR
6. severe dehydration --> stasis,low flow,thrombosis (hypercoag state);
7. non-occlusive ischemia (low CO); mesenteric infusion of vasodilator and inotropic agents
8. dessection occluding vessel; angiogram and surgical correction
9. ischemia with sepsis/hypotension c nonocclusive ischemia (low flow); angiography/surgery
10. necrosis of at least mucosa; sigmoidoscopy to eval; to OR for rsx if full thickness necrosis

Front 16

in patient with necrotic left colon, what are the options for surgical intervention (2)? What determines which one to go with?

Back 16

left colon rsx plus:
stable patient: reanastamosis of colon
unstable patient: colostomy and Hartmann pouch (proximal bowel colostomy, distal bowel stapled off

Front 17

24 yo woman w/ abd pain, N/V, no flatus/BMs for a few days. exam reveals abd distension, mild luekocytosis, KUB suggestive of SBO.
1. suspected diagnosis?
2. how to confirm?
3. non-operative management?
4. if non-operative management fails?

Back 17

1. SBO secondary to intraluminal stricture
2. CT abdomen (show area of stenosis, likely ileal)
3. NPO, IV fluids, careful observation - advance diet with return of flatus and BMs
4. rsx (e.g. ileal rsxn), stricturoplasty (alternative approach if mutlple strictures)

Front 18

partial ileal rsxn in Crohn's patient - post-op complications (potential symtpoms and causes)?

Back 18

1. diarrhea, malabsorption, oxalate stones (all due to bile acid absorption deficiency)
2. vit B12 deficiency (can lead to megalobastic anemia)
3. gallstone

Front 19

management for perianal fistulas in Crohn's patients (2)? what about perirectal abcesses (2)?

Back 19

1. setons + metronidazole
2. I&D + metronidazole

Front 20

when crohn's dz limited to small bowel, what differentiates it as far as management (as compared to crohn's in colon)?

Back 20

5-ASA much less effective

Front 21

currently most acceptable surgical procedure for ulcerative colitis?

Back 21

total proctocolectomy with ileoanal pouch to restore continence

Front 22

6 months post-op total proctocolectomy with blood-tinged diarrhea, fever and pain on defacation; diagnosis? what % of patients get this complication? treatment?

Back 22

pouchitis (inflammation of reservoir, unknown etiology); 1/3 of patients; metronidazole (very effective)

Front 23

patient with known UC who presents to ED actuley ill with recurrence of bloody direha, HR of 120 abdomen distended and acutely tender -
1)diagnosis?
2)evaluation (3-4)?
3) what confirms diagnosis (on imaging)
4) initial management (5-6)?

Back 23

1. toxic megacolon
2. CBC, KUB (rule out perf), CT (r/o abcess, other processes)
3. severely dilated colon with mucosal edema
4. NGT, NPO, IVF, TPN, broad spectrum abx, high dose IV steroids

Front 24

what does patient with toxic megacolon need to be closely monitored with frequent imaging?

Back 24

b/c secondary perf has high mortality (30-40%)

Front 25

toxic megacolon with free air on upright CXR or air in the wall of colon -
1. diagnosis?
2. management?

Back 25

1. perf (or impending perf);
2. to OR for total colectomy and ileostomy and Hartmann pouch (may revise later once patient is over acute illness)

Front 26

25 yo F started mid-abdomen, migrating to RLQ. +anorexia, no vomiting. mild pain on exam, no rebound or guarding. lab studies, radiographs normal, preg test negative -
1. top two on differential (borad-based)?
2. important phsyical exam (2)?
3. tests?

Back 26

1. differential: appendicitis versus gynecological problem
2. rectal (detect retrocecal appendicitis), pelvic exam (CMT)
3. ultrasound (often in women), CT-scan (to diagnose appendicitis in unclear presentation)

Front 27

25 yo F started mid-abdomen, migrating to RLQ. +anorexia, no vomiting. mild pain on exam, no rebound or guarding. lab studies, radiographs normal, preg test negative - suspect early appendicitis
1. management for early appendicitis (3);
2. what should be avoided?

Back 27

1. NPO, IVF, serial radiographs
2. avoid pain meds - may mask symptoms

Front 28

lap versus open appendectomy - advantages of either?

Back 28

no real advantages to either; smaller incision with lap appy (but no difference in cost, hosp stay, post-op pain)

Front 29

the appendix is most often retrocecal (true/false)

Back 29

false

Front 30

25 yo F started mid-abdomen, migrating to RLQ. +anorexia, no vomiting. probably diagnosis, eval, management for following. UA following, normal pelvic exam; probably diagnosis, eval, management for following?
1. dysuria and WBC 10,000
2. minimal dysuria and WBC 8-10/hpf
3. urinary RBCs too numorous to count
4. voiding symptoms in older male?

Back 30

1. UTI; urine cx and start abx
2. consistent with appendicitis (local inf process)
3. nephrolithiasis or severe UTI; eval c IV pyelogram or CT (no contrast)
4. urinary retention secondary to BPH; percussion/U/S of distended bladder; Foley cath to relieve

Front 31

25 yo F started mid-abdomen, migrating to RLQ. +anorexia, no vomiting. what signs would be suggestive of PID (2-3) versus appendicitis?

Back 31

CMT, cervical discharge, tenderness of adnexa (?TOA), hx of PID

Front 32

IBD can mimic appendicitis in presentation, especially with ileocecal inflammation - next steps if suspect IBD (2) to confirm diagnosis?

Back 32

colonoscopy or barium enema (string sign (distal ileal stricture)

Front 33

radiographic signs of IBD (3-4)?

Back 33

inflamed ileum (string sign on barium enema), thickened wall, enlarged nodes

Front 34

retrocecal appendicitis may not present classically b/c not in contact with anterior wall (not contacting parietal peritoneum); how might be detected?

Back 34

rectal exam with pronounced tenderness

Front 35

difference in presentation of appendicitis in patients on steroids? pregnant patients?

Back 35

1. steroids - warning signs often absent until perf, sepsis (b/c body's attempt to wall off inflammation is blunted)
2. pregnancy- presentation can vary as appendix pushed up and lateral; surgery indicated for early appendicitis b/c perf poses sig risk to mother and child (appy poses low risk)

Front 36

management of operative findings with appy?
1. red, inflamed appendiceal tip with exudate
2. gangrenous appendicitis - necrosis to base of cecum
3. perforated with localized abcess
4. acute appendicitis with 1cm moveable mass
5. normal appendix

Back 36

1. ligate appendix (acute appendicitis)
2. ligate appendix and bury stump into cecum; right colectomy if cecum involved
3. ligate appendix, (I&D and irrigate abcess), JP drain, leave skin open
4. likely fecalith, normal appendectomy
5. preventive appendectomy; examine other structures

Front 37

How is carcinoid tumor on appendix managed surgically (2 answers depending on size/location)

Back 37

1. <2 cm at appendiceal tip: low malignancy risk; may do regular appendectomy
2. >2 cm or base of appendix/cecal involvement, suggestive of malignant behavior; right colectomy indicated

Front 38

appendiceal mass resected and comes back as carcinoid tumor - management (2-3)

Back 38

1. baseline 5-HIAA and serotonic levels
2. CT abdomen / octeotride scan if suspect recurrrence

Front 39

60 yo male with rupture appendic 7 days post-op with fever, chills, anorexia -
1. most likely diagnoses (2)
2. managements respectively?

Back 39

1. pelvic abcess or wound infection
2. pelvic abcess: IR perc drain (or open); wound infxn: drainage and abx

Front 40

yearly FOBT - screening for colon CA; what is its drawback?

Back 40

high false positive rate

Front 41

colonoscopy recommendation in asymptomatic patients without family hx of colorectal ca? with family hx?

Back 41

1. age 50, then every 10 years
2. age 40, or 10 years younger than youngest 1st deg relative

Front 42

screening recs and management for patient with familial adenomatous polyposis?

Back 42

yearly flex sig; once polyps discovered, colectomy indicated (cancer 100% likelihood)

Front 43

what method detects up to 80% of colon ca recurrences?

Back 43

CEA (every 2-3 months for at least 2 yrs)

Front 44

45 yo M with bright red blood streaks on stool for last few wks; hx,ROS negative; vitals, abd exam normal
1. further eval?
2. most likely diagnosis?
3. conservative management?
4. surgical management?
5. thrombosed hemorrhoid, patient in sever pain - management?

Back 44

1. rectal exam, colonoscopy (r/o ca)
2. hemorrhoids
3. conservative: sitz baths, stool softeners, fiber
4. surgical (external: excision; internal: banding or excision
5. I&D

Front 45

patient in for yearly exam mentions recent bright red blood in stool with some pain - rectal exam also reveals bright red blood
1. further evaluation
2. highest on differential?

Back 45

1. anoscopy or sigmoidoscopy
2. hemmorhoids, fissure, rectal/anal polyp or ca

Front 46

60 yo F with screening colonoscopy found to have following findings - what is initial and future management?
1. 1cm pedunculated polyp
2. 5cm predunculated polyp
3. 4cm, flat sessile lesion
4. carcinoma at head or stalk (>2mm margin), no lymphatic/vascular invasion
5. carcinoma in sessile lesion

Back 46

1. polypectomy with pathology; repeat colonoscopy 3-6 mo, continued surveillence every 3 yrs
2. 5cm pedunculated mass; piecemeal polypectomy; surveillence screening
3. seg colon rsx (<2 cm sessile lesions can be resected)
4. polpyectomy sufficient
5. bowel rsx; repeat colonoscopy after 1 year

Front 47

55 yo male referred from PCP, 5lb weight loss, no other symptoms or family hx; physical exam significant for black, guiac + stool.
1. Evaluation (4-5)
2. Preop instructions? (2)
3. important perioperative steps/goals (3-4)
4. post-op orders (2-3)?

Back 47

1. CBC, CEA, colonoscopy, CXR and LFTs (to check for evidence of mets)
2. bowel prep (e.g. golytely), single dose abx (e.g. keflex) for wound infection prevention
3. partial colectomy, assess for metastases (e.g. liver), remove mesenteric tissue and regional lymph nodes
4. NPO, IVF, +/-NGT

Front 48

give description of stages of colon ca? Stages 0-4?

Back 48

Stage 0: CIS
Stage 1: limited to mucosa (not thru muscularis propria)
Stage 2: thru full thickness of bowel wall / adjacent structures
Stage 3: regional lymph nodes
Stage 4: mets

Front 49

5 year survival of colon CA for each stage?

Back 49

I: >90
II: 60-80
III: 20-50
IV: <5

Front 50

After colon cancer rsx, what is appropriate follow-up?

Back 50

check for recurrence by surveillence colonoscopies, CEA, LFTs, CXR
Note: if CEA up, do CT abdomen

Front 51

for primary colon ca, explain how planned therapy may vary with follownig pathologic findings:
1. penetration of tumor to abdominal wall
2. + lymph nodes at surgery
3. + lymph node by pathology post-op
4. 1cm lesion on liver at surgery
5. 8 cm liver lesion at surgery
6. 2cm nodule on CXR

Back 51

1. colon rsxn plus radical abd wall rsxn
2. operation unchanged--> followed by chemo
3. add adjuvant chemo post-op
4. excision of lesion
5. biopsy of lesion (excision inc risk of bleeding)
6. chect CT, needle biopsy, colectomy remains unchanged

Front 52

reddened, fluctuant area develops as posterior aspect of wound post-colectomy; diagnosis and management?

Back 52

wound infection; opening and drainage

Front 53

feculent material draining from inferior aspect of wound post-colectomy; diagnosis and management?

Back 53

anastamotic leak with fistula (enterocutaneous fistula); IV fluids and NPO

Front 54

patient comes to hospital 12 days post-op sigmoid rxs with primary anastamosis with temp of 104 and LLQ pain. Most likely diagnosis and management?

Back 54

abcess (likely pelvic or paracolic); perc drainage and antibiotics

Front 55

suspect rectal cancer in patient with constipation, rectal bleeding and constricting hard lesion 4cm from anal verge. after colonoscopym what is next test to determine rectal wall invasion?

Back 55

transrectal ultrasound (CT scan also indicated)

Front 56

What is the surgical management of rectal cancer? How does it depend upon location? nodal spread?

Back 56

1. If tumor is within 5cm of anal verge: APR c creation of permanent colostomy and removal of local LN

2. If tumor is >5cm from anal verge, do Low Anterior Resection c primary reanastamosis

3. If regional LN involved (stage III) or high-risk stage II cancers--> adjuvant chemo

4. If large, bulky tumor or extend outside bowel wall into surrounding tissue --> pre-op RT

Front 57

complications related to abdominoperineal rsx (4)?

Back 57

impotence (50%), bladder fnxn, massive venous bleeding, ureter injury

Front 58

what is a very important feature in surgical rsx of rectal cancer?

Back 58

clear margins (>2cm or >5c relative to differentiation) to prevent recurrence

Front 59

curative rsxn of colon cancer in 49 yo man who has stage II cancer - At 3 yrs, bump in CEA level - next steps (3)?

Back 59

CT scan, CXR (to look for metastatic disease), colonoscopy

Front 60

Patient with recurrent primary colon CA has resectable liver mass (not in region of vascular structures, solitary lesion) - management and survival?

Back 60

resect liver lesion; solitary lesion rsx survival high as 33% at 5 yrs

Front 61

what are contraindications to resecting hepatic lesion in metastatic CA (3)?

Back 61

unresectable location, multiple liver lesions, metastatic dz outside liver

Front 62

what can be done for metastatic liver lesions that are unresectable surgically?

Back 62

cryotherapy or radio-frequency (R-F) ablation; angiographically by chemoembolization

Front 63

must common tumor of anal canal? What is difference in management of 0.5 cm versus 4 cm lesion (both with no local extension, neg lymph nodes)?

Back 63

Sq cell CA
0.5 cm: local excision
4cm lesion: NIGRO PROTOCOL: chemo and radiation --> THEN abdominoperineal rex 4-6 wks later ONLY IF residual cancer by biopsy

Hint 63

surgical versus non-surgical??

Front 64

70 yo woman to ED with abd pain and fever. fever of 101, mildly tachy, abd TTP in LLQ. probable diagnosis? management (minimal symptoms, stable patient versus more severe course)?

Back 64

1. diverticulitis;
2.
-uncomplicated case: KUB/upright, liquid diet, outpatient abx treatment versus
-complicated: admission with IV fluids, IV abx, NPO, CT abdomen

Front 65

diverticulitis patient at discharge - short-term versus long term management

Back 65

short term: fiber, finish up abx
long term: colonosopy to confirm diverticula, r/o colon CA

Front 66

recurrence of diverticulitis, and patient recovers after IV abx, bowel rest, and analgesics - what follow-up is indicated on discharge? why?

Back 66

elective rsx after inflammation has settled (4-6 weeks); reason is b/c of risk of perf or abcess

Front 67

what is usual surgical procedure for diverticulitis?

Back 67

rsx of small colonic segment with diverticula (often sigmoid) with primary anastamosis

Front 68

75 yo F with LLQ pain, fever, nausea with presumptive diagnosis of acute dverticultiis. WBC 15, therapy with abx, iv fluid, and bowel rest is initiated, but patient's condition worsens, inc fever and WBC count.
1. what is differential diagnosis (2)?
2. evaluation?
3. management (if abcess)?

Back 68

1. bowel perf or IA abcess
2. CT scan
3. perc drainage, followed by single-stage colectomy of affected colon 4-8 weeks post-infection

Front 69

sensation of voiding air with urinating, hx of diverticulitits, what is going on?

Back 69

pneumaturia (from colovesicular fistula) (colon-bladder)

Front 70

70 yo woman with large amts of BRBPR x 4 hrs. HR 115, BP 105/70, tired, but alert, dry MMs and pale conjunctiva.
Initial eval and management of this issue (4-5)? differential (5)?

Back 70

1. Hypovolemia from GI bleed
2. 1-2 L NS/LR via 2 large bore IVs, telemetry, CBC, coags, Foley (assessed resuscitation adequacy)
Differential: diverticular bleeds, vasular ectasia, Mcekel's, ischemic colitis, hemorrhoidal dz, rectal varices

Front 71

acute GI bleed (bright red blood) x 4 hours with hypovolemia?
Eval includes what tests (if subsequent one is negative)?

Back 71

1. NGT (if blood, then EGD) (r/o upper GI)
2. colonoscopy (now or later if GI bleed stops)

Front 72

patients with diverticular bleeds usually will stop bleeding spontaneously, but vascular ectasias (A-V malformations) usually require intervention before bleeding stops (true/false)?

Back 72

false; majority of both diverticular and vascular ectasia bleeds stop spontaneously

Front 73

On day 2 of admission post acute GI bleed with resuscitation and 2 units pRBCs, Hct drops to 24% (from 35% night before) with continued bleeding. Site of bleeding unclear - what can be done for eval, what is contraindicated?

Back 73

1. technetium-labeled RBC scan, mesenteric angography
2. contraindicated - colonoscopy (risk of perf)

Front 74

technetium-labeled RBC scan can find slow bleeds in stable patients at rate above what?

Back 74

0.5-1 ml/min

Front 75

when is surgery indicated in a GI bleed and what should be done preoperatively?

Back 75

active bleed with cardiovascular instability despite resuscitative measures, most notably 4-6 units pRBCs; preoperative angiogram to determine probable site of bleeding

Front 76

angiogram preop for active colonic bleed to determine site of bleed - therapeutic modality that can be executed to control bleeding with angiogram?

Back 76

vasopressin (vasoconstrictor)

Front 77

88 yo nursing home patient in ED with hx of constipation, deteriorating mental status. BP 100/60, HR 120; abdomen distended with moans to palpation. Diagnosis and management (nonoperative and operative)? Difference if is cecal volvlus?

Back 77

sigmoid volvulus; nonoperative: proctosigmoidoscopy c placement of rectal tube
operative: sigmoid colectomy

Front 78

massive dilation of cecum and right coon without evidence of mechanical obstruction due to imbalance of sympathetic and parasympathetic - treated with endoscopic decompression, what is diagnosis?

Back 78

Ogilvis syndrome (or acute pseudoobstruction)

Front 79

entire colon packeed with stool in constipated patient - evaluation and management?

Back 79

1. rectal exam (make sure not impacted)
2. management: enemas (before any oral tretment such as laxative)

Front 80

operative options for rectal prolapse (3)?

Back 80

rectopexy (rectum pinned to sacrum), rectum and distal smgoid rsx (anterior and perineal approaches)

Front 81

30 yo m with rectal pain particularly severe with defacation - ulcerated area in anal canal on rectal exam that is severely painful - diagnosis? management (conservative management versus surgical)?

Back 81

1. diagnosis - anal fissure
2. conservative: stool softeners, fiber, sitz baths;
surgical: sphincterotomy

Front 82

most cases of anal fissures where anatomically?

Back 82

posterior midline

Front 83

persistent perioanal drainage with graunulation tissue with sinus tract found on exam - diagnosis and management?

Back 83

fistula-in-ano (residual abcess), management: unroofing and draining, +/- seton or string

Front 84

anal pain, fluctuant perianal mass, and fever - diagnosis and management?

Back 84

perianal abcess; depending upon location, perianal incision/drainage versus drainage in ana canal;
NOTE: drainage, not antibiotcs

Front 85

painful abcess in sacrococcygeal area? treatment?

Back 85

pilonidal abcess; unroofing, drainage and leaving open (secondary intention healing)

Front 86

colonic rsx with distal bowel closed and dropped back into pelvis?

Back 86

Hartmann pouch

Front 87

distal bowel stomas (with proximal colostomy as well)

Back 87

mucous fistulas

Front 88

two situations where end stomas are commonly seen?

Back 88

1. abdominoperineal rxs (with end sigmoid colostomy)
2. ileostomy (post-proctocolectomy in UC patients)