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115 Cards in this Set
- Front
- Back
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XR features of SBO? |
multiple air fluid levels, no air in colon or rectum
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Electrolyte picture in SBO?
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Contraction alkalosis + hypoK: vomiting=loss of H and water= Kidney retains H at the expense of K lost in the urine
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Symptoms and radiographic features of partial SBO?
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Flatus but no bowel mvmts, maybe some diarrhea, usual SBO findings but air in colon and rectum, more likely to resolve without surg and without complications of ischemia or perforation
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Most common tumor with mets to the small bowel?
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Melanoma
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Pt with SBO with what other signs would be more concerning?
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localized tenderness, rebound, marked WBC, metabolic acidosis, marked temp. We'd be worried about ischemia, necrosis, perforation, abscess
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If you have a closed loop obstruction and are not sure whether a segment of bowel is viable or not, what should you do?
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"Second look" operation 24 hours later
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Mgmt of SBO within a hernia?
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1. If stable, hernia repair
2. If appear sick, midline abdominal incision for exploration |
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Common sign for ischemic bowel?
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Pain level disproportionate with physical exam |
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How to manage suspected ischemic bowel?
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1. Hydrate and abx
2. If stable, colonoscopy 3. Mesenteric angiogram (should surgically revascularize b/c ischemic events will recur without repair) |
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Long term plan after bowel ischemic episode?
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ASA, eval for cardiac/peripheral vascular dz
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Can someone with necrotic bowel have low WBC? Why?
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Yes, elderly can have leukopenia with left shift as a response to overwhelming sepsis
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What does abdominal bruit suggest? What should you do?
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Stenosis of mesenteric vessel(s). Get a mesenteric angiogram
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Drug that if directly applied causes vasodilation?
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Papaverine
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What does bloody diarrhea mean?
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Ischemic segment of at least colonic mucosa: sigmoidoscopy. If just mucosal ischemia: optimize hemodynamics and abx. If full thickness necrosis: exploration and resection
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Imaging to confirm and Crohn's diagnosis?
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CT: visualize area of stenotic bowel, perforations, abscesses, fistulas, tumors
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Management of SBO secondary to Crohn's?
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NPO, TPN, hydration, observation for GI function
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Surgical options for Crohn's?
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Bowel resection or stricturoplasties
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Reoperation rate in Crohn's? Complications of terminal ileum resection?
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50%. Def. absorption of bile acids and B12, which can lead to diarrhea, depletion of bile salt pool, malabsorption, oxalate stones, gallstones, B12 def anemia
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Treatment for perianal fistula in Crohn's?
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You can open to tract for drainage, or insert seton tubes through fistula for deeper tracts. Give Metronidazole when pts have perianal problems.
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How is Crohn's in small bowel different from Crohn's in colon?
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Unfavorable, but now responsive to 5-ASA. Subtotal colectomy with ileostomy may be required if rectum involved. If not, ileorectal anastamosis.
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Most important complication of long standing UC?
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Colorectal cancer.
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Risk development rate for colorectal cancer in UC?
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2-3% for first 10 years. Increases 1-2% per year.
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Screening recommendations for those with UC pancolitis vs left colon involvement?
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Pancolitis: colonoscopy w random biopsies q year @ 8 years post onset
Left colon: colonoscopy w random biopsies q year @ 10 yeares post onset |
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Definitive surgical tx for UC?
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Total proctocolectomy with creation of ileal pouch and anastomosis with pouch to anus to restore continence
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Symptoms and tx for "pouchitis"?
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hemorrhagic mucosa with edema and small ulcerations in pouch. 1/3 of pts w/ ileal pouch will develop. Give metronidazole.
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Evaluation for suspected IBD?
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Colonoscopy or barium enema
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medical Tx for both UC and Crohn's?
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Steroids, sulfasalazine, immunosuppresives, abx
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Dangerous complication of UC? Sxs? Imaging?
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Toxic megacolon: bloody diarrhea, pain, distension, fever, tachy, tenderness. Abdominal obstructive series. Maybe a CT to rule out abscesses or perfs.
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Medical mgmt of toxic megacolon?
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NGT, NPO, TPN, IVF, abx, high dose IV steroids, close observation for worsening sxs |
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When would we do surg for toxic megacolon? Which procedure?
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Free air on XR (perf), static or worsening sxs: ileostomy with Hartmann's pouch of rectum with total abdominal colectomy
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Initial eval for RLQ pain
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1. rectal exam for retrocecal appendicitis
2. pelvic exam for ovarian pathology 3. IVF, NPO, CBC, close observation, NO PAIN MEDS b/c it will mask sxs progression 4. Abdominal ultrasound if female to rule out gyn 5. Somtimes CT if complicated case |
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Signs of worsening appendicitis?
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Increasing pain, localized pain, rebound, guarding
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Is it ok to perform unnecessary appendectomies?
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Yes, 10-15% unnecessary appendectomies is safe.
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Can we do appendectomy on preg?
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Yes. Incision at pain site. Perf appendix carries risk for peritonitis which is a risk to the fetus.
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How does appendicitis in elderly and in children present?
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Elderly: Vague abdominal complaints, change in MS, sepsis
Children: More often present after rupture |
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What's the danger with steroids in RLQ pain?
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Steroid may be masking inflammatory sxs of ruptured appy. Don't present until septic. Must maintain high index of suspicion
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How to treat necrotic appendicits with cecal involvement?
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Depending of extent of cecal involvement, may need R hemicolectomy as to not miss perfed colon cancer
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What to do with perfed appy with abscess?
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remove appendix and drain and irrigate abscess. leave skin open b/c of danger of wound infection
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Mass at tip of appy is most likely what?
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Carcinoid
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When would you do R hemicolectomy for an appy?
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Carcinoid greater than 2cm or mass at the base w/ cecal involvement because it's evidence of malignant behavior
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Other complication of carcinoid/adenocarcinomas?
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SBO b/c they can be pedunculated masses. Resect segment of bowel and regional LNs, check for other locations cause carcinoids can be multiple.
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How to measure malignancy of carcinoids?
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Biological activity via urine 5HIAA and serotonin level
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How to visualize carcinoids?
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Octreotide scan/CT
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What do you do for pelvic abscess?
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Drainage percutaneously or open. Also do vaginal and rectal exam cause you may be able to drain it through there too.
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Colorectal cancer screening guidelines?
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Avg risk asymptomatic over 50: colonoscopy at 50 then q10
First degree relative? start at 40 or 10y before their diag, then q5 Fam hx of HNPCC? Genetic testing, colonoscopy at 20-25, then q1-2 Fam hx of FAP? Genetic counseling and yearly. 100% chance of colorectal cancer. Polyp found? recheck in 3-5 mo. Then surveillance q3y Hx of resected colorectal cancer? @1 year, then 3 years, then q5. CEA measurements q2-3 months and LFTs for mets |
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Tx of hemorrhoids?
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Sitz baths, stool softeners, fiber. If continues to bleed, surgical excision.
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How to manage extreme pain with hemorrhoids?
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Probably thrombosed hemorrhoid: I+D
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Differential for blood on rectal exam?
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Internal hemorroids, fissure, bleeding rectal/anal carcinoma, polyp. Do colonoscopy.
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What to do for anal carcinoma?
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Biopsy, transanal ultrasound to det depth of invasion
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2 types of colon polyps?
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Pedunculated and sessile
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How to take out sessile polyp?
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<2cm: inject saline under it and snare it
>2cm: surgically |
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What would you have to find on a polyp to warrant marking with tattoo and resecting segment of bowel?
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carcinoma has to be on the stalk and Margin has to be less than 2mm
Cancer poorly differentiated Vascular or lymphatic invasion Otherwise polypectomy is enough |
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What to do if carcinoma in sessile polyp? why?
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bowel resection because 15% chance of LN mets and 20% chance of local recurrence with just polypectomy
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Where in colon do most cancers occur?
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50% in rectum
20% sigmoid 15% right 10% transverse 5% left |
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Preop procedure or colon resection?
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Golytely (Mag citrate) for laxative, oral nonabsorbable abx (Gentamycin) and single preop dose of 2nd gen ceph (cefotetan)
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when you a partial colectomy, what else do you need to do/take out?
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Check for mets, do the colectomy anyway if there are cause it can cause obstruction and bleeding, take otu mesentery, regional LNs, anastamose
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Describe stages of Colorectal Ca
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TNM.
Stage I: limited to mucosa and submucosa, not thru muscularis propria Stage II: Tumor extends full thickness or adjacent structures but not regional LNs Stage III: to regional LNs Stage IV: mets |
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When would you use adjuvant chemoradiation with colon resection?
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No radiation
Only adjuvant chemo with stage III with 5FU +Leucovorin Also mucous producing tumors and signet cell tumors, tumors with bowel perf, and those with venous or perineural invasion may require adjuvant chemo. |
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How long does the progression from polyp to cancer take?
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10 years
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What do you do with a small liver met?
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Wedge resection unless its contiguous with a vessel like the hepatic vein. the you just biopsy
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What do you do with a large liver met?
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Don't resect at the time of colectomy. Risks: bleeding, infection, bile leakage. just biopsy, save resection for later
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What factors about colorectal cancers have poor prognosis?
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poorly differentiated
mucin producing signet cell tumors venous or perineural invasion tumors that present with bowel perf |
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What do you do with a CXR nodule with suspected colon cancer?
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biopsy, CT, still do the colectomy to prevent obstruction and bleeding
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Postop complications of colectomy?
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Postop ileus, mech obstruction, anastamotic leakage causing ileus, adhesions, internal hernia, obstructed anastamosis, wound infection, anastomotic leak fistulizing to skin, abscess, anastamotic stricture, recurring cancer
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Will a fistula with a downstream obstruction close on its own?
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No. needs surgical repair
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How do you work up rectal cancer?
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transrectal US for staging, CT/MRI for mets to prostate, bladder, ureters, liver, LNs, CXR, baseline CEA for monitoring
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Tx for rectal cancer?
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Abdominoperineal resection w/ complete excision of rectum and permanent colostomy with removal of LNs
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which nodes to rectal cancers met to?
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Internal iliac nodes, Sacral nodes, inf mesenteric nodes, inguinal nodes if <5cm from anal verge
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Risks of abdominoperineal resection?
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Impotence 50% (sympathetic plexus of nerves around rectum), bladder dysfunc, massive venous bleeding from presacral space, ureter injury, colostomy complications such as stricture, prolapse, retraction, obstruction
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When do we perform abdominoperitoneal resection vs low anterior resection?
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When tumor is less than 5cm to the anal verge: to avoid anal sphincter mechanism, and because with higher risk cancers you want a 5cm margin.
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When's the only time to use radiation in colorectal cancer?
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When it's a large and bulky rectal tumor extending outside the bowel wall into surrounding tissues. Use to reduce size for several weeks before resection
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2 alternatives to abdominoperineal resection are?
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1. sphincter preserving proctectomy
2. local resection of small tumors transanally or transsacrally |
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What do you do when you have elevated CEA on follow up long after surgery?
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CXR and CT for mets. repeat colonoscopy if necessary.
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What do you do with a colon cancer met to liver that's small?
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resect if solitary. Need at least 1cm margin
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When is a liver met non-resectable?
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mutiple in both lobes, intimate with vascular structures like hepatic/portal veins, invasion of other local structures like diaphragm, cirrhotic livers (limited hepatic reserve)
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Most common tumor of anal canal?
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Sqamous cell carcinoma
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Anal cancer drains to what LNs?
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Inguinal LNs, but also Superior rectal LNs in half of pts.
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How do you stage anal cancer?
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TNM, CT, transrectal US
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What do you do with a large anal cancer with no local extension or LNs?
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Nigro protocol: radiation plus 5FU and Mitomycin C regiment, then abdominoperineal resection
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What do you do with a large anal cancer with local extension or LNs?
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Nigro protocol with resection. Same as without local extension or LNs. LNs worsen prognosis.
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Mgmt of diverticulitis?
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1. liquid diet/NPO/NGT if nausea
2. broad spec abx PO or IV 3. IV hydration 4. avoid morphine as it increases intracolonic pressure 5. Consider CT to confirm diag if complicated. Id prolly do obstructive series to check for air and other problems 6. serial abd exams 7. F/u with abx for 7-10d |
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Recurrence rate for diverticulitis?
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>70% have no recurrences
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Long term f/u after diverticulitis?
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colonoscopy or barium enema for conf presence of tics and to r/o colon cancer
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When do you operate on diverticulitis?
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Elective resection 4-6 wks after first recurrence resolves b/c of risk of perf or abscess increases with recurrence
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How do you preop and operate on tics?
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Colonoscopy to locate, bowel prep, resection and anastamosis. no colostomy usually needed.
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What to suspect with worsening condition despite tic tx?
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Perfed bowel or intra abdominal abscess: CT!
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How to tx intraabdominal abscess?
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CT guided catheter drainage. leave catheter in to drain continuously. Examine sample for organisms. 4-8 wks after symptom improvement, do single stage colectomy
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What to do if tic/abscess sxs do not improve with drainage?
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Hartmann's procedure with colectomy of inflammatory mass with colostomy
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Complications of diverticulitis?
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Bowel perf, fistula with bladder gives you pneumaturia. both need surgery
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What do you do when you suspect massive lower GI bleed?
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1. 2 line insertion, fluids
2. type and cross, CBC, coags 3. CXR 4. Foley to evaluate fluid resuscitation 5. NG tube to r/o UGIB 6. Anoscopy to look for hemorrhoids or other sources of bleeding like rectal varices |
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Most common causes of LGIB?
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Bleeding tic, vascular ectasias, Meckel's, aortoenteric fistula, ischemic colitis, IBD, hemorrhoids, rectal varices
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what usually happens with bleeding tics and ectasias (A/V malformations)?
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spontaneously stop bleeding. But you have to get a colonoscopy at some point cause you don't wanna miss colon cancer.
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Why do tics bleed?
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Vasa recta penetrate bowel wall. become eroded with tics.
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Where do most tics occur?
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Sigmoid. But R sided tics more likely to bleed
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What do you do for a persistent massive LGIB?
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Technetium labeled RBC scan for slow bleeders or mesenteric angiography for fast bleeders (preoperative). RBC scan not that precise but very sensitive to .1ml/min. Can't see anything with active bleeding on colonoscopy.
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When do we wanna explore a bleed?
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After 4-6 units of blood given. OR before that if unstable, have CAD, hard to determine blood types or unusual Abs, Jehovah's witnesses
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How to surgically treat peristent bleeder?
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Colectomy with primary anastamosis since blood is cathartic to colon.
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What can we do for bleeders in angiography suite?
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Local vasopressin (coronary vasoconstrictor if prolonged) and half rebleed after 12h, embolization for poor surgical candidates
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What if you can't localize the bleed in the OR?
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total abdominal colectomy. a blind left or right colectomy is assoc w/ rebleeding and high mortality.
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How to treat sigmoid volvulus?
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If stable, detorse by rigid sig and placement of rectal tube. Then resect with primary anastamosis or colostomy. Recurrence rate is 30%
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How to treat Cecal volvulus?
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R colectomy with primary anastamosis. Detorsion or cecopexy usually not successful
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How to treat Ogilvie's syndrome?
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Acute massive dilation of R colon and cecum without evidence of mechanical obstruction. ICU pts. Cecal diameter 9-10cm: conservative tx. Follow with serial films. 11-12 cm: endoscopic decompression/neostigmine/surgical decompression by cecostomy
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How to treat colon packed with stool?
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Disimpaction, enema. Treat from below before above.
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How to tx rectal prolapse?
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Internal: fiber and avoid surgery
External and bleeding: rectopexy fixes rectum to sacrum/ low anterior resection with removal of upper and middle rectum and redundant sigmoid/perineal resection of prolapsed rectum and sigmoid with prox sigmoid anastamosed to transitional zone 1-2 cm above dentate line |
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What are anal fissures assoc w/?
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IBD
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Where are anal fissures usually located?
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posterior midline of anal canal
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Mgmt of anal fissures?
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Conservative: bulk agents, stool softeners, sitz baths
Deep and chronic: lateral sphincterotomy. biopsy to r/o anal ca |
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What causes anal fistula?
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previous abscesses that failed to completely heal
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Tx for anal fistulas?
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1. cut and lay open not appropriate if fistula crosses anal sphincter
2. cutting seton 3. seton stitch 4. fibrin glue injection 5. Fistula plug with small amount of intestinal submucosa |
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Where does perianal abscess occur?
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Infection anal crypts and glands at dentate line
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4 types of perianal abscesses?
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perianal, ischioanal, intersphicteric, supralevator. all require drainage
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What is abscess at sacrococcygeal area? tx?
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Pilonidal abscess: unroof, remove hair, and leave open to heal by secondary intention
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Complications of stomas?
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leakage (don't put it in a skin fold), herniation, bowel obstruction due to abscess, fistula formation
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When do you perform permanent stoma?
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abdominoperineal resection, ileal conduit drining urinary system to skin after bladder removal
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How to treat pouchitis?
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Metronidazole
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