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86 Cards in this Set
- Front
- Back
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If you vomit, you lose which ions?
What does this lead to? |
H+, Cl-, water, and Na+alkalosis and volume contraction
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CASE: patient with nausea and crampy abdominal pain. No bowel movements for days. Mild tachycardia, and orthostatic hypotension. WBC is 14,000 and Hct is 44%.
Diagnosis? After history and physical, what is the next step? |
SBO
next step is abdominal radiograph: the upright posterior-anterior and lateral chest radiograph and a flat and upright abdominal radiograph |
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In an obstructive case, what do you expect to see on XRAY?
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multiple air fluid levels in small bowel and no evidence of air in the colon or rectum
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In a SBO case, what is the person's projected fluid and electrolyte status?
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dehydration due to poor hydration through oral intake.
metabolic profile: contraction alkalosis with hypokalemia. As H+ is secreted into the stomach, bicarbonate is secreted into the plasma. To maintain neutrality, Cl- is also secreted into the stomach. With vomiting, there is a loss of H+, Na+, Cl-, and water which leads to alkalosis and volume contraction |
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What happens to the kidneys during SBO? (terms of electrolytes)
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because of the alkalosis and the volume contraction, the kidney retains sodium and H+ at the expense of K+ which is lost in the urine
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So pretty much SBO means contraction _____ and _____.
How do you correct for this? |
contraction alkalosis and hypokalemia
rehydration with fluids containing sodium and potassium IVs. The alkalosis corrects itself after rehydration. |
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NG tube, Iv fluids, and then serial PEs, lab studies, and abdominal radiography are safe... assuming that...
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the patient is NOT acidotic, absence of marked leukocytosis, fever, or localized tenderness.
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CASE: SBO patient improves over the next several days. Her pain and distention resolves, and her appetite returns.
What is your management plan? |
removal of the NG tube, and feeding should begin. If the patient tolerates the food, then discharge is appropriate. No further X-rays
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Many small bowel obstructions resolve with?
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non operative management
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Patient with SBO with a past appendectomy could be diagnosed with?
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adhesions secondary to prior appendectomy
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CASE: SBO with 1 day duration of present illness.
What would this change in your thinking? Would this deal with more or less distention of the abdomen? |
-the obstruction is likely to be more proximal than distal. This would come with less distention.
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CASE: SBO with HEME POSITIVE stool in the rectum.
What is your diagnosis? |
obstructing tumor or ischemic bowel disease
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CASE: SBO with a small amount of diarrhea.
Diagnosis? |
This might lead you to think incomplete obstruction, you should be suspicious for FECAL IMPACTION!
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CASE: SBO with a CLARK level 4 melanoma excised years ago.
Diagnosis? Treatment? |
melanoma frequently manifests as bowel obstruction and can present decades later. This is tumor related, and SURGERY is the appropriate treatment.
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CASE: SBO with an ovarian cancer that has been previously excised.
Diagnosis? Treatment? |
recurrent ovarian tumor recurring locally or via peritoneal studding, resulting in obstruction.
Even if incurable, it is beneficial to debulk tumors to improve survival. |
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What should LOCALIZED tenderness in a SBO suspected patient tell you?
Does it change your management? Name another one of these... |
should alert you that this is a potentially serious complication such as:
1. closed loop obstruction 2. perforation 3. ischemia 4. abscess YES IT DOES, it indicates that surgical exploration rather than observation is necessary. MARKED LEUKOCYTOSIS |
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CASE: SBO with metabolic acidosis.
What might be special about this? 2 next steps in management? |
this should cause you to think ISCHEMIC or necrotic bowel.
1. urgent exploration 2. mesenteric arteriography to check for arterial occlusions |
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CASE: SBO with temperature of 103F.
What might be special about his? What is the management of this? |
This should make you think about bowel perforation or ischemic process with sepsis
warrants exploration surgery |
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If a patient presents with an adhesive band of scar tissue from an earlier procedure as the cause of her small bowel obstruction, which surgery are you doing to perform?
what is the post-operative plan? When do you release the patient from the hospital? |
lysis of adhesions, to free up the entire section of involved bowel.
post-operative plan = NPO with an NG tube for several days until bowel function occurs. After the patient resumes eating, you can discharge her. |
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CASE: a segment of bowel twisted on itself, AKA a closed loop obstruction, shows that upon untwisting, looks edematous and obviously injured.
What do you do now? |
The issue now is to see if the bowel is viable. If this is not definitive by observation, schedule a second surgery 24 hours later to reassess function (planned re-exploration)
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CASE: free air is seen in the PERITONEAL CAVITY along with crampy abdominal pain the patient.
What is your diagnosis? |
dx: perforation of the bowel due to ischemia or distention
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Dr. Millham is doing a lysis of adhesions procedure and then he accidentally perforates the small bowel.
What now? What problems might you have postoperatively? |
resect the affected bowel segment.
problems are: 1. postoperative leak 2. development of small bowel fistula |
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What is ileus?
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when the bowel does not undergo peristalsis.. PARALYTIC STATE.
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If you are uncertain of the diagnosis of bowel obstruction in a complex situation, is there any way you can confirm the diagnosis of SBO without an operation?
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YES; if you are uncertain and the NG tube offers only partial relief, then opt for an UPPER GI SERIES with small bowel follow-through prior to the decision to explore the patient!
Barium study! (if the barium finds it's way to the colon, then there is no obstruction and surgery will not help! |
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CASE: Patient with suspected obstruction and increasingly severe abdominal pain. Low grade fever, mild distention of the abdomen, as well as tenderness. WBC count is 15,000 and no acidosis present.
What should you be suspicious for? Management? and why!! |
ischemic bowel disease
1. either proceed to the operating room if you think the bowel is NECROTIC. 2. perform further evaluation: sigmoidoscopy and mesenteric angiogram. sigmoidoscopy this is done to establish whether there is bowel ischemia and the depth of ischemia mesenteric angiogram - warranted to allow the clinician to diagnose a VASCULAR problem and decide whether surgical revascularization was an option |
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CASE: Patient with suspected obstruction and increasingly severe abdominal pain. Low grade fever, mild distention of the abdomen, as well as tenderness. WBC count is 15,000 and no acidosis present.
You give the patient antibiotics and hydration. The patient improves. What should be in mind now about prognosis? |
this is likely to recur.
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If you want to stress your idea of a necrotic segment of bowel, what should you be confirming it with in the history?
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patient with a SIGNIFICANTLY WORSENING PAIN over a period of an hour in the ED.
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Case: What if you were presented with a 75 year old female patient with suspected mesenteric ischmia with a WBC count of 24,000 (Differential....)
2. What should be done? |
DIFFERENTIAL IS
ischemia necrosis perforation with infection 2. most surgeons would take this patient to the OR |
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Case: What if you were presented with a 75 year old female patient with suspected mesenteric ischmia with a WBC count of 2,400.
1. (Differential....) 2. What is the management of this patient? 3. Why? |
ischemia
necrosis perforation with infection 2. take patient to the OR -reasoning: elderly individuals sometimes respond to overwhelming sepsis with LEUKOPENIA, often with a marked left shift!!! |
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Patient with ischemic bowel disease undergoes revascularization therapy and is FINE now.
What medications is he or she given? |
antiplatelet therapy with aspirin
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CASE: a 75 year old woman presents to the ED with possible mesenteric ischemia. She has atrial fibrillation.
What does the last line cue about her overall condition? What study is warranted? What should be done afterward? |
Embolization to the boewl from a thrombus in the left atrium associated with AFIB should be suspected!
ANGIOGRAM study. After that, exploratory surgery. |
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What is the normal Hct in a woman? man?
What is the normal WBC? How about bands? What indicates LEFT SHIFT? |
Hematocrit (%)
41 - 50 MALE 36 - 44 FEMALE 4500-10K is normal for WBC Band forms 3 - 5% (above 8% indicates left shift) |
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What does LEFT SHIFT mean?
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The term 'left shift' indicates that the neutrophils present in the blood are at a slightly earlier stage of maturation than usual. This is often seen in acute infections, when toxic granulation and 'Dohle Bodies' may also be seen. Early neutrophils are often referred to as 'band cells', because of the unsegmented nucleus
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In severe dehydration, what happens to the blood cell counts?
How would you correct this? |
polycythemia
rehydration! |
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How do you treat polycythemia?
This can occur secondary to? Give the patient a ___ evaluation. |
phlebotomy and hydration
dehydration and COPD. pulmonary evaluation |
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What is the hartmann procedure?
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the proximal bowel is brought out as a colostomy and the distal bowel is stapled and closed and left in the abdomen.
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Why might there be BLOODY diarrhea in some cases of ischemic bowel disease?
What is the next step in management? |
an ischemic event in the colon with necrosis of the mucosa and submucosa, and these portions of the colon slough off.
sigmoidoscopy! |
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CASE: you open up a patient and find that there is NECROSIS of the LEFT COLON.
What would you do? |
resect the colon back to well-perfused regions!
If the patient is stable, then reanastomosis of the colon is appropriate. If the patient is not stable, then do a colostomy and a hartmann pouch procedure (stapling the distal colon and placement back into the abdomen). |
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CASE: you open up a patient and find that there is NECROSIS of the INTESTINES from the ligament of treitz to the transverse colon.
What would you do? |
close the patient up after resecting the majority of bowel, this is a hopeless situation.
Patients will come down with SHORT BOWEL SYNDROME and then, -transplant of bowel -give chronic TPN |
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What is a colostomy?
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A colostomy is a reversible surgical procedure in which a stoma is formed by drawing the healthy end of the large intestine or colon through an incision in the anterior abdominal wall and suturing it into place. This opening, in conjunction with the attached stoma appliance, provides an alternative channel for feces to leave the body.
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CASE: suspected diagnosis of SBO due to crohn's disease.
What could you do to confirm the diagnosis? Why? |
CT scan of the abdomen.
Because it might demonstrate the area of stenotic bowel in the terminal ileum and it could help determine the existence of any complications such as a perforation, abscess, or fistula. |
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What are the normal lab values of HEMOGLOBIN in males and females?
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Hemoglobin (g/dl)
13.5 - 16.5 MALES 12.0 - 15.0 FEMALES |
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CASE: suspected diagnosis of SBO due to crohn's disease. CT scan reveals a stenotic portion of bowel in the TERMINAL ILEUM region and no other suggestions of complications.
What is your management plan? |
most surgeons would manage this patient with TPN, bowel rest, and careful observation.
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CASE: suspected diagnosis of SBO due to crohn's disease. CT scan reveals an internal fistula between two segments of small bowel!
What is your management? |
Treat this patient with TPN, Bowel rest, and careful observation.
NMS - "management is based on patient symptoms and active problems, not radiologic findings" Treatment remains the same as stenotic segment of bowel in the terminal ileum region. |
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CASE: suspected diagnosis of SBO due to crohn's disease. CT scan reveals a stenotic portion of bowel in the TERMINAL ILEUM region and no other suggestions of complications.
You treat her like you are supposed to, but she does not improve! Now what? |
if the obstruction fails to resolve after medical treatment, consider surgical therapy.
-relieve the obstruction -preserve as much normal bowel as possible |
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What is a technique to prevent recurrent strictures?
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STRICTUROPLASTIES; opening of a structured area by cutting the stricture and repairing it transversely to dilate the lumen!
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What obvious problems will result if you resect the ileum?
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cannot absorb bile acids and B12.
Impaired bile acid resorption leads to diarrhea, depletion of bile salt pool, and malabsorption as well as oxalate stones. Don't forget gallstones and vitamin B12 deficiency. |
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There is a woman with crohn's disease and perianal disease in your service. On PE you notice a tender perineum and inflammation. How will you take care of her?
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This is a difficult disease to treat.
Surgery is indicated if there is a perianal abscess. Metronidazole is useful in the management of the majority of patients with perianal problems. |
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Crohn's diease:
If the disease is limited to the colon, which medical treatment works? How about the small bowel? |
5 acetyl salicylic acid! (5-ASA)
if the small bowel, then 5 ASA has little effect. Seek surgical repair. the ileum can be anastomosed to the sigmoid colon or rectum. if there are surgical complications, then subtotal colectomy and ileostomy if the rectum is involved |
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What is the risk of cancer in UC?
What kind of cancer? |
2-3%, but the catch is that it increases 1-2% per year!!!!!!!!
CRC |
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What is the risk of cancer in a patient who had UC for 20 years?
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over 20% risk of CRC
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How do people with UC monitor their cancers or occurrence of such?
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patients with pancolitis must undergo colonoscopy every 1-2 years beginning after 8 years of having the disease.
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Today, what is the surgical procedure of choice for UC?
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total proctocolectomy, which removes the mucosa and thus the risk of cancer, with a creation of an ileal pouch (reservoir) and anastomosis of the pouch to the anus (restores continence)
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Patient received the top surgical treatment for UC which is ? but then she returns 6 months later with fever, blood tinged diarrhea, and pain on defectation. Diagnosis?
What is the treatment? |
treatment: total proctocolectomy
pouchitis; inflammation of the reservoir from an unknown cause metronidazole |
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What is the medical treatment of pouchitis?
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metronidazole
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What diagnosis should you be thinking about in terms of ulcerative colitis and ABDOMINAL PAIN, DISTENTION, FEVER, and BLOODY DIARRHEA?
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toxic megacolon!
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CASE: 29 year old woman presents with a several month history of abdominal cramps, diarrhea, and 5 lb. weight loss of several month's duration. Bloody diarrhea began this morning. The rest of the history is unremarkable. What is your diagnosis?
How would you evaluate further? |
inflammatory bowel disease
you would get a clonoscopy or barium enema to determine whether disease is ulcerative colitis, crohn's disease, or other. |
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Ulcerative colitis occurs in which population?
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occurs among young people
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"crypt abscesses and ulcerations" should make you think?
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ulcerative colitis
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What is the distribution of crohns colitis?
In what pattern? Severe ____ disease, especially ____ can occur. |
anywhere from the mouth to the anus
skip lesions perianal disease fistula |
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Once you are concerned about toxic megacolon, what tests might you run?
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routine blood studies an abdominal obstructive series (radiograph?) to rule out an bowel perforation.
Also run a CT. |
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What is the management of a patient who has free air in a chest X-ray?
Why is this? What procedure should be done afterward? |
patient should be taken immediately to an operating room; this is evidence of a perforation.
procedure: ileostomy with a hartmann pouch |
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Patient presents with 29 year old woman presents with a several month history of abdominal cramps, diarrhea, and a 5lb weight loss of several months' duration.
Her radiographs show a very dilated colon with mucosal edema, and no signs of abscess or perforation. What is your management now? (4) |
Provided that the patient is stable it is best to do a trial of medical therapy!
-NG tube -NPO feeding -TPN and IV fluids sometimes they are given IV steroids (most surgeons do this) |
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Patient presents with 29 year old woman presents with a several month history of abdominal cramps, diarrhea, and a 5lb weight loss of several months' duration.
Her radiographs show a very dilated colon with mucosal edema, and no signs of abscess or perforation. 3-6 days go by, there is no improvement of symptoms. What is done now? |
surgery. if the patient's condition is worsened, surgery is also the answer.
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With a classic case of appendicitis, there are two surgical options:
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1. laparoscopy and visualization of the appendix, with removal of the appendix
2. exploration through a Mcburney incision to visualize the appendix |
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Where is the incision made for an appendectomy?
What should the patient be in terms of nutrition provisional status |
from ASIS to the umbilicus, 1/3 of the way towards the umbilcus from the ASIS
as soon as the patient can tolderate feeding, it should begin. |
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CASE: female patient presents with RLQ pain, dysuria, and a white count of 10,000/hpf.
What is your differential? |
UTI
appendiceal abscess in continuity with the bladder. appendicitis |
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CASE: female patient presents with RLQ pain, dysuria, and a white count of 10,000/hpf. History of pelvic inflammatory disease.
What is your differential? |
UTI
pelvic inflammatory disease (this tends to recur!) appendiceal abscess in continuity with the bladder appendicitis |
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CASE: female patient presents with RLQ pain, dysuria, and a white count of 10,000/hpf. Patient has cervical discharge.
What is your diagnosis, and what are two things you do next? |
dx: pelvic inflammatory disease
1. culture the discharge 2. obtain gynecologic consult |
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CASE: 65 year old male patient presents with RLQ pain, and voiding symptoms
Treatment? (2) |
1. insertion of a foley catheter
2. re-examination |
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CASE: female patient presents with RLQ pain, dysuria, and a white count of 10,000/hpf. Family history of inflammatory bowel disease.
What tests might you run after a physical? If this is true, what might be 2 drugs you will treat with? |
1. CT scan
2. colonoscopy 3. barium enema 1. initial treatment: steroids 2. maintenance: 5 ASA |
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A "string sign" is what?
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a typical distal ileal stricture due to crohn's disease
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Name 3-4 gross findings of an inflamed ileum!!!
These are diagnostic findings of inflammatory bowel disease. |
1. fat wrapping around the intestine
2. a thickened wall 3. enlarged nodes |
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What is the incidence of appendicitis (you got this wrong!)??
What are the symptoms for the patients? |
the incidence is BIMODAL, which peaks in incidence in 25 years and then 65 years.
Classic symptoms for the 25 year olds, while the 65 year patients will have vague abdominal complaints, sepsis, altered consciousness, or failure to thrive. |
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What is a tip about children and appendicitis?
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children more often present with appendicitis in which the appendix is ruptured.
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In patients who are taking steroids and with abdominal pain, what should you be thinking?
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steroids can mask most or all signs of any inflammatory process. In addition, the body, attempt to WALL OFF inflammation and abscesses is blunted with steroids.
Therefore, in many cases, the warnings signs are absent until perforation occurs and sepsis develops. |
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How do you treat a localized abscess from a perforated appendix?
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remove the appendix and to incise, drain, and irrigate the abscess. You can put a drain in the abscess draining to the outside.
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Describe the appearance of the appendix in acute appendicitis.
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A red, inflamed appendiceal tip with exudate
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CASE: a 34 year old man has suspected appendicitis. On exploration you find a firm, yellow mass at the tip of the appendix?
How about if the mass was movable and round? |
carcinoid tumor
fecalith |
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A carcinoid tumor with what features suggests malignancy?
What is the treatment if things turn out this way? |
-2cm or more in size
-pedunculated -involvement at the base of the appendix or cecum perform a right colectomy |
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Carcinoid tumors and adenocarcinomas of the small intestine may manifest as ? that cause ?
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pedunculated masses
intermittent small bowel obstruction |
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What is the principal determinant out of the others that indicates whether a carcinoid tumor is MALIGNANT?
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biological behavior! rather than histo, location, and size!!!!
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What is looked for in the urine with a carcinoid tumor case?
serum? |
5 HIAA (5-hydroxyindolacetic acid)
serum serotonin level |
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How would you track caricnoid tumors for recurrence?
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1. CT scan!
2. octreotide scan |
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CASE: 60 year old man with an ruptured appendix recovers from surgery and is discharged. One week later, he presents with fever, chills, and malaise.
What is on your mind? |
this could be a pelvic abscess or a wound infection
1. evaluate for a wound infection. If there is one then drain it 2. if there is no wound infection, then get a Ct or an ultrasound study |
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What should a pelvis abscess feel like in a PE?
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rectal examination reveals a tender mass
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