Final study guide: Exam 2 content

Question 1

Diverticulitis:
1) S/Sxs?
2) Dx?

Answer 1

1) Progressive abd pain (usually LLQ), change in bowel habits, low-grade fever, +/-N/V
2) CT A/P w IV contrast (preferred initial study)
Barium enema
Scope (4-6 wks after Tx)

Question 2

List the stages of Hinchey classification (describe perforations due to diverticulitis)

Answer 2

Stage 0: mild clinical diverticulitis
Stage I: pericolic or mesenteric abscess
Stage II: walled-off pelvic abscess
Stage III: generalized purulent peritonitis
Stage IV: generalized feculent peritonitis

Question 3

Descr nonsurgical diverticulitis Tx options

Answer 3

1) Outpatient (uncomplicated): Supportive (pain control, clear liquid diet, clinical reassessment until resolved, +/- abx)
2) Inpatient (complicated): >3cm abscess, fistula, obstruction, or perforation
Meet 1 or more criteria: immunosuppressed, sepsis, sig comorbidity, etc.
IV antibiotics, IV analgesia, IV hydration, bowel rest

Question 4

Diverticulitis: Descr Emergent surgery for free/frank perforation, obstruction, & persistent symptoms (ie Hinchey III & IV)

Answer 4

1) Choice of technique depends on:
Hemodynamic stability
Extent of peritoneal contamination
Extent of colonic inflammation
Surgeon experience/preference
2) 2-stage Hartmann’s procedure (Gold standard)
MC performed for Hinchey III & IV
1st surgery get colostomy & 2nd surgery reattach bowel
3) Obstruction: resection (or fecal diversion) required to r/o cancer & relieve obstruction; endoluminal stenting
4) Persistent symptoms: surgery required for failure of medical tx & recurrent symptoms after recovery (chronic smoldering diverticulitis)

Question 5

What should you do for Localized perforation (Hinchey I & II) forming a pericolonic, mesenteric, or pelvic abscess?

Answer 5

Medical therapy +/- drained percutaneously
Abscesses >3cm evaluated for percutaneous drainage

Question 6

Descr Elective (risk reduction) surgery for diverticulitis

Answer 6

1) sigmoid colectomy (resection w/ primary anastomosis)
1-stage resection
Performed open or minimally invasive (laparoscopic or robotic)
Goal: remove diseased colon & perform primary anastomosis of healthy remaining bowel
2) Based on # episodes, severity of sx, impact on QOL, comorbidity, anatomic factors, access to medical resources, chance of recurrence, & pt preference
ie. prior episode of complicated diverticulitis and immunosuppressed
3) Typically performed 10-12 weeks after recovery

Question 7

Descr Pre/peri-operative considerations for diverticulitis

Answer 7

1) Antibiotics
MC organisms: E. coli, K. pneumoniae, and B. fragilis
2) Prophylactic abx within 1hr of surgery
3) Bowel prep: recommended for all elective resection colorectal procedures (and stable Hinchey 1 & 2 if requiring surgery)
4) Stoma marking
Stoma: surgically created opening in the abd wall connecting bowel with outside of the body
Ex. Colostomy, ileostomy, urostomy
5) Patient positioning: modified lithotomy or split-leg position

Question 8

Anorectal abscess:
1) What is it? MC form?
2) Cause?
3) S/Sx? PE?
4) Dx?

Answer 8

1) Local infection of perirectal spaces; Perianal abscess MC form
2) Cause: obstruction of anal glands & ducts
3) S&S: acute anal pain, swelling, +/-fever
PE: erythematous tender, fluctuant mass adjacent to anal canal
4) Dx: +/- MRI if no obvious PE findings or if recurrent/complex (Crohns)

Question 9

Tx for anorectal abcesses?

Answer 9

I&D for ALL abscesses
Abx for immunocompromised or septic
larger abscess: may require drain
f/u care:
Pain control
Laxatives or fiber supplements
Sitz baths
Close follow up (up to 8 weeks to heal)

Complications: anal fistula (aka fistula-in-ano)

Question 10

Descr anal fistulas

Answer 10

Definition: tissues traversed & relationship to the anal sphincter (Parks classification)
Complication of up to 50% perirectal abscesses
Suspected if persistent drainage 6-8wks after abscess drainage
PMHx: Crohn’s?

Question 11

How do you Dx anal fistulas?

Answer 11

DRE, anoscopy (instrument used to visualize anus & lower rectum)
External opening visualized often with a palpable subcutaneous tract between the ext opening and anus
If complex tracts: MRI or endorectal US
Goodsall’s rule (predict internal opening based on where external opening is located)

Question 12

Tx for anal fistulas?

Answer 12

General surgeons (simple), colorectal surgeon (complex)
Traditional fistulotomy OR Sphincter-sparing approaches (trans-sphincteric; use of seton)
Prone (anterior) or lithotomy (posterior) position
If associated with Crohn’s: medical management (abx, biologics) only
Complications: incontinence, leakage, recurrent fistula, & abscess (rare)

Question 13

What is the main Tx for colon cancer?

Answer 13

Surgical resection +/- adjuvant chemotherapy

Question 14

Descr surgical options for colon cancer

Answer 14

Resection of the primary colonic or rectal tumor + anastomosis”
-Right hemicolectomy: tumors of the cecum and ascending colon
-Transverse colectomy: tumors of transverse colon
-Left hemicolectomy: tumors of the splenic flexure or descending colon (resection of the distal transverse, descending, and proximal sigmoid colon
-Sigmoid colectomy: tumors of the sigmoid colon (includes part of the descending colon and proximal rectum)
-Anterior resection: tumors of the rectosigmoid and upper third of the rectum

Question 15

What colon cancer pts are candidates for curative surgery?

Answer 15

Stage I-III
Stage IV with resectable mets to liver and/or lung

Question 16

Descr the surgical technique for most colon cancer pts

Answer 16

Minimally invasive technique preferred in most pts
First step: explore abdominal cavity for mets
Resection of 5 cm on each side of lesion
Adequate lymphadenectomy: 12 or more lymph nodes

Question 17

Descr surgical options if obstructing colon cancer

Answer 17

Diversion
Urgent resection with or without anastomosis
Endoscopic stenting with or without resection during same hospitalization

Question 18

Who should get adjudavent chemo for colon cancer?

Answer 18

for stage III (node-positive) disease +/- high-risk stage II
improves survival 20-25% and reduces recurrence by 40%
Start immediately upon recovery from surgery (~1 month post-op)

Question 19

Large bowel obstructions :
1) S/Sxs?
2) Etiologies?

Answer 19

1) Abd pain, distention, obstipation, nausea, vomiting (late finding)
R-sided lesions: tend to grow to a large size prior to causing obstruction bc larger diameter
2) Neoplasms (MC), diverticular disease, volvulus, IBD, ischemic or anastomotic strictures

Question 20

How do you Dx stable LBO pts?

Answer 20

plain abdominal x-ray
upright CXR
CT with rectal contrast (most useful single test for large bowel obstruction)
if concern for strangulation or perforation, use PO gastrografin (water-soluble contrast medium), barium enema, colonoscopy (for chronic symptoms)

Question 21

What is a complication of LBOs?

Answer 21

Most pts have competent valve, so reflux does not occur -> increased intraluminal pressure -> gangrene & perforation (usually in cecum)

Question 22

Descr Tx for LBOs

Answer 22

Sepsis or peritonitis: urgent surgical exploration
Mechanical obstructions almost always require intervention (extent of surgery depends on the pt’s acuity and etiology)
1) Goals of tx:
Primary: Resection of all necrotic bowel & decompression
Secondary: removal of obstructing lesion
2) Tx options:
Resection with primary anastomosis
Resection with diversion
Diversion alone
Endoscopic stent placement (bridge to surgery and/or palliative)

Question 23

How do you tx mild/mod UC?

Answer 23

Sulfasalazine or 5-aminosalicylates (induce & maintain remission in mild- moderate disease)
If no response, add… Corticosteroids
Still no response, add…
Immunomodulators (ie, azathioprine, 6-MP) (induce & maintain remission)
Biologics (ie, infliximab, adalimumab) (moderate-severe disease)

Question 24

How do you Tx severe UC?

Answer 24

Corticosteroids (in severe dz, this is 1st step; induce remission, treat exacerbations)
If good response, maintenance therapy initiated
If no response, add immunomodulators or biologics; surgery considered.

Question 25

Surgical UC Tx?

Answer 25

1) Urgent or emergency surgery For complications such as toxic megacolon, fulminant colitis, or uncontrolled hemorrhage managed medically first & if deteriorates/no improvement -> total colectomy + ileostomy 2) Chronic intractable disease, medication intolerance, or inability to wean from steroids Children may present with growth retardation; adults with poor QOL Severe extraintestinal manifestations 3) Treatment for dysplasia or carcinoma Total proctocolectomy with end-ileostomy (in emergent setting) proctocolectomy with ileal pouch-anal anastomosis (J-pouch)(IPAA)- in elective setting Guided by preop sphincter function, presence of low rectal cancer, age, general health and preferences IPAA contraindicated: poor baseline sphincter tone or Chrons dx not excluded

Question 26

Postop UC complications?

Answer 26

Small bowel obstruction, bleeding, infection (sepsis 25% of pts, MC cause of pouch failure), injury to pelvic nerves controlling sexual & bladder function, infertility, anastomotic leak Pouchitis (inflammation of ileal pouch): ~50% post-IPAA Increased stool frequency, crampy abdominal pain, bleeding Tx: antibiotics, probiotics

Question 27

Descr SBO causes

Answer 27

extraluminal/extrinsic causes: adhesions (MC), hernias, carcinomas, abscesses intrinsic to the bowel wall (intramural): primary tumors Intraluminal obstruction: gallstones, enteroliths, FB 3 MC causes (U.S.): adhesions, hernias (if no hx of abd surgery), neoplasms

Question 28

S/Sxs of SBOs

Answer 28

N/V, colicky abdominal pain, distention, obstipation, high-pitched or absent bowel sounds As it worsens: tachycardia w/ dehydration, fever, localized pain or peritonitis, leukocytosis Based on location: High: frequent vomiting Middle: mod vomiting & distention, intermittent pain w/ free intervals Low: marked distention, variable pain

Question 29

DX for SBOs?

Answer 29

1) XR (1st line imaging in pt w/ abd pain): dilated loops of bowel, air fluid levels, no gas beyond obstruction Note: Normal caliber of small bowel on abd XR is <3 cm 2) CT w/ IV & oral contrast: both diagnostic & therapeutic Gastrographin may speed resolution Sensitive for complete or high-grade SBO & for determining location & etiology (less sensitive for partial SBO) 3) Can also consider additional tests: Barium upper GI tract series with SBFT (small bowel follow through) US: if pregnant MRI: no better than CT

Question 30

SBO Tx?

Answer 30

Usually non-operative (most pts w/ adhesions resolve w/out surgery) Medical management (do this 1st unless CT indicates need for immediate surgery) NPO, IVF resuscitation Correction of electrolyte abnormalities NGT: allows for GI decompression to relieve symptoms, prevent further gas and fluid accumulation proximally, decreases risk of aspiration & urinary catheter +/- TPN Foley catheter to monitor fluid output If failure to improve after 8-24hrs -> abd XR + gastrografin unless pregnant or had abdominal surgery ≤6wks ago

Question 31

Operative SBO options?

Answer 31

Lysis of adhesions (LOA): ~10 % recurrence Resection of nonviable or diseased bowel with anastomosis Intestinal bypass +/- stoma

Question 32

Crohn's complications?

Answer 32

Repeated small bowel resections may lead to short-bowel/gut syndrome (~<200 cm) Cigarette smoking is an independent risk factor for recurrence of CD after resection

Question 33

Descr the role of endoscopy and CTs in esophageal conditions

Answer 33

1) Endoscopy: Visualize the mucosal surface & biopsy Commonly indicated for dysphagia High sensitivity & specificity for functional & structural lesions 2) CT scan: Useful for evaluating esophageal tumor invasion into surrounding structures, metastatic disease, regional lymphadenopathy

Question 34

Descr barium swallow and esophageal manometry

Answer 34

1) Barium swallow (esophagogram): Part of Upper GI series (UGIS) Provides functional & structural information (hiatal hernia, esophageal stricture) Useful to identify aspiration after swallowing, peristalsis, reflux 2) Esophageal manometry: Measures contractility & resting pressures Indicated with suspected motor abnormality after barium swallow or endoscopy fails to show clear structural defect Mostly used with pH monitoring in dx of GERD

Question 35

Descr 1) High-resolution manometry (HRM) 2) 24 hour pH monitoring

Answer 35

1) High-resolution manometry (HRM): Manometry with increased number of pressure sensors Primary method to evaluate esophageal motor function Data visualized on Esophageal Pressure Topography (EPT) 2) 24-hour pH monitoring: Measures severity & duration of acid exposure Correlates pt sx with acid exposure (symptom diary) Gold standard for GERD diagnosis Indications: Reflux symptoms with failure of 12-weeks acid suppression Pre-operative evaluation for anti-reflux procedures

Question 36

Descr Esophageal perforation treatment

Answer 36

Operative management: TOC for pts with systemic toxicity (usually shows w/in 24hrs) Immediate broad-spectrum abx given & continued for 7-10 days Goal: within 24hrs Primary closure has high incidence of failure >24hrs Goals: debridement, primary repair, adequate drainage

Question 37

Descr nonop mgmt for esophageal perforation

Answer 37

General criteria: Minimal symptoms & no systemic signs of infection No pathology (malignancy, stricture, motility disorder) Management: Fluid resuscitation broad-spectrum abx NPO 7-10 days, NGT, TPN repeat contrast study

Question 38

Achalasia: 1) S/Sxs 2) Dx

Answer 38

1) progressive dysphagia, occasional regurgitation, wt loss, heartburn, CP due to esophageal distention at time of a meal 2) Dx: Endoscopy to r/o mechanical obstruction (stricture or cancer) CXR: widened mediastinum due to dilated esophagus Barium esophagram: “bird’s beak” taper at GE junction and slow emptying of contrast Esophageal manometry (gold standard)

Question 39

Descr the 3 groups of Tx options for achalasia

Answer 39

1) Medical tx: nitrates, CCBs, antimuscarinic agents to relax the esophageal smooth muscle 2) Endoscopic tx options: Intra-sphincteric Botulinum toxin injection (short term help) Pneumatic dilation Peroral endoscopic myotomy (POEM) cutting inner circular muscle layer of the esophagus (myotomy) 3) Surgical tx options: more invasive & not as common compared to POEM Laparoscopic Heller myotomy (LHM) & Dor fundoplication myotomy (cutting lower esophageal sphincter muscle) AND partial anterior fundoplication (fundus wrapped around lower esophagus, creating a new “valve” that reinforces LES to protect from acid reflux)

Question 40

GERD: 1) S/Sxs 2) Dx

Answer 40

1) S&S: heartburn, regurgitation, dysphagia, chest pain, odynophagia, extraesophageal symptoms (cough, hoarseness, wheezing), nausea 2) EGD (look for any pathology) Barium swallow: for info on hiatal hernia or strictures (but not to dx reflux) 24hr pH monitoring (gold standard for GERD dx)

Question 41

GERD Tx?

Answer 41

1) Non-surgical (MC): lifestyle changes & acid-suppression therapy 2) Surgical: Ideal pt: ambulatory pH monitoring shows abnormal GER and whose heartburn is well controlled by PPIs Goal = restore competence of LES POC= laparoscopic Nissen fundoplication fundus is wrapped around lower esophagus, creating a new “valve” that reinforces the LES Increases resting pressure and length of the LES, decrease # of transient relaxations, & improves quality of esophageal peristalsis