GI Flashcards

Question

Intussusception dx/tx

Answer 1

Dx Plain KUB: - late SBO - dance's sign: sausage shape in RUQ + no bowel gas in RLQ Enema = dx/tx - water or air; contrast should reflux through MC - ileocecal valve into terminal ileum Mgmt: - barium or air enema - surgical resection if failed enema or high suspicion of lead point Enema C.I. = perforation on KUB or clinical peritonitis

Answer 2

- chronic progressive granulomatous inflammatory disorder of GI tract (anywhere from lips to anus) - areas m/c affected = terminal ileum and right colon - peak incidence 20-40s - skip lesions occur in 15% patients, granulomatous ulcers in bowel wall in 50-75% resulting in bowel wall thickening, fissure/stricture formation - transmural depth Presentation - recurrent abd pain initiated by meals, relieved by bm - RLQ pain + constitutional sx - diarrhea - usually no blood - perianal lesions, malabsorption of Fe and Vit B12 - extra-intestinal signs = arthritis, uveitis, oral ulcers, UTIs, erythema nodosum, gallstones, etc.

Answer 3

- UGI series w/ SBFT: string sign, cobblestone - endoscopy: upper and/or lower - (+) ASCA (Ab vs Saccharomyces cerevisiae) Mgmt: - aminosalicylates, steroids, immune modifying, anti-TNF - surgical tx - preserve length and remove affected area, resection (w/ possible ileostomy/colostomy) vs. strictureplasty - surgery is NOT curative -60-75% pt will require surgery at some point to relieve sx or correct complications

Answer 4

- diffuse, contiguous mucosal inflammatory dz  begins in rectum, contiguous spread proximally - depth is mucosa and submucosa only - smoking decreases risk for UC - bimodal age distrib: 15-30, 60s-80s Presentation - LLQ pain m/c, colicky, tenesmus, urgency +/- constit sx - bloody diarrhea w/ mucus - primary sclerosing cholangitis, colon CA, toxic megacolon - extra-intestinal signs: arthritis, uveitis, oral ulcers, UTIs, erythema nodosum, gallstones, etc.

Answer 5

Dx: - Flex sigmoidoscopy test of choice in acute disease: uniform inflammation +/- ulcers, pseudopolyps - Stovepipe sign (loss of Haustra markings) on barium enema - (+) P-ANCA Mgmt: - aminosalicylates, steroids, immune modifying, anti-TNF - surgery is curative: proctolectomy (entire colon and rectum) or colectomy - colonoscopy contraindicated in acute colitis, may cause perf - barium enema CI, may cause toxic megacolon

Answer 6

- reduced intestinal blood flow (esp at splenic flexure) from arterial occlusion, venous occlu, or vasoconstrict - mortality can exceed 60% - etiology: mesenteric arterial emboli from mural thrombus in LV or clot from afib (50%), mesenteric arterial thrombosis from atherosclerotic stenosis (25%), nonocclusive (20%), OR mesenteric venous thrombosis (5%) Presentation - severe poorly localized abdominal pain (often unresponsive to opioids) - abdominal pain out of proportion to clinical findings - N/V/D, peritonitis, shock - blood in stool

Answer 7

Dx: - high lvl of susp in pt w/ RF - CT w/ absence of bowel gas, diffuse disten w/ air fluid lvls, thickened bowel wall - colonoscopy: patchy, necrotic - mesenteric CT angiography is gold standard Mgmt: - early intervention (<12 hrs s/p sx) - initial management w/ anticoagulation, pain control, abx - surgical revascularization = arterial embolectomy, angioplasty - bowel resection if not salvageable - #1 cause of short gut syndrome - often lethal d/t infarction that occurs w/ delayed dx and tx

Answer 8

-mesenteric atherosclerosis of the GI tract: inadequate perfusion (esp of splenic flex) during post-prandial studies - chronic dull abdominal pain worse after meals - intestinal angina - weight loss (anorexia) - angiogram confirms dx - colonoscopy: muscle atrophy w/ loss of villi - bowel rest - surgical revascularization (angioplasty w/ stenting or bypass)

Answer 9

- reduction in blood flow related to acute arterial occ, venous thromb, or hypoperfusion  m/c d/t systemic HTN or atherosclero involving sup & mesenteric aa - usually elderly pts - sigmoid 40% > transverse 17% > splenic flex 11% - m/c at “watershed” areas w/collaterals and splenic flexure and rectosigmoid junction - gangrenous IC: transmural, nonrevers injury rapidly fatal w/o surgery - nongangrenous: reversible, resolves w/o sequalae Presentation - LLQ pain w/ tenderness - bloody diarrhea (d/t sloughing of colon) -complications: persistent seg colitis and dev of stricture Dx - CT scan w/ contrast: thickened bowel wall - colonoscopy: segmental ischemic changes (edema, hemorrhage, friable mucosa) in areas of low perfusion Mgmt: - restore perfusion and observe for signs of perf - reversible IC (nontrasmural)  supportive care, typ resolve in 1-2 wks - irreversible IC (transmural)  resect diseased portion, possible temp colostomy

Answer 10

- 4th m/c CA, 3nd m/c cause of CA-related death in US - 90% of cases occur > age 50, 95% adenoCA - m/c site of metastatic spread is the liver - RFs  familial adenomatous polyposis (APC gene mutation), lynch syndrome, Peutz-Jehgers (autosomal dominant, hamartomatous polyps, mucocutaneous hyperpigmentation), UC > Crohn’s, adenomatous polyps, low-fiber high processed/red meat diet, smoking, ETOH, AA, FH - spreads through regional LN mets, direct extension (forms apple core circum), or hematogenous mets - doubling time 130 days - complications = perf, hemorrhage, obstruct

Answer 11

- iron deficiency anemia, rectal bleeding, abdominal pain, change in bowel habits - CRC m/c cause of large bowel obstruction in adults - right-sided lesions tend to bleed (anemia and fecal occult), diarrhea, fatigue, weight loss - left-sided lesions present later w/ bowel obstruction, change in bowel habits (rectal lesions cause hematochezia) Dx - colonoscopy w/ bx = test of choice - barium enema = apple core lesion classic - Stool based tests = gFOBT, FIT, stool DNA testing - CT chest/abd/pelvis to w/u - CEA = lvls also monitored during tx - CBC = iron deficiency classic

Answer 12

- simple polypectomy or local excision for tumors limited to colonic mucosa - localized (stage I-II) = wide surgical resection of affecter area - stage III and metastatic = chemo mainstay of tx (ex. 5FU) - palliative interventions = diverting colostomy, electrocoagulation, endoluminal stents -colon CA screening if avg risk: FOBT annually at 50yo, colonoscopy q10y or flex sig q5y (w/ FOBT q3y) up to 75yo

Answer 13

- <10% of all GI tumors - 1/3rd benign: adenomas and leiomyomas - 2/3rds malignant: adenocarcinoma (45%), carcinoid (30%), lymphoma (15%), stromal and sarcoma (10%) Presentation - benign tumor: typically asx, intermittent abd cramp, chronic bleed w/ iron def anemia - malig: weight loss, sx depending on location, sx secondary to hormone production Dx: - CT scan abd/pelvis w/ contrast - upper GI study - endoscopy: usually for eval of duodenum Mgmt: - most tx w/ surgical excision - chemo, radiation pending specific pathology - octreotide useful in improving sx in neuroendocrine tumors

Answer 14

General - post-surgical adhesions m/c, incarcerated hernia 2nd m/c cause of SBO - closed loop vs. open loop, complete vs. partial, distal vs. partial Presentation - cramping abd pain, abd distent, vomiting, obstipation (CAVO) - hyperactive BS early (high-pitched tinkles on auscultation and visible peristalsis), hypoactive BS late in obstruct Dx - abdominal series: air fluid lvls in step ladder pattern, dilated bowel loops - CT abdomen pelvis w/ IV and PO contrast to ID site and severity of obstruction Mgmt - non-strangulated/partial  NPO, IV fluids, bowel decompress - strangulated/closed loop  surgery (laparotomy, LOA, eval of whole SB, resection of nonviable segment) -if + peritonitis, free air, or closed loop obstruction, take to OR

Answer 15

General - malignancy m/c cause of large bowel obstruction, strictures, volvulus (m/c cause of benign obstruct), incarcerated hernia, FB impaction - blockage resulting in distension and risk for perf - 15% of all intestinal obstruction, sigmoid m/c Presentation - deep visceral crampy pain, referred to hypogastrium - constipation, obstipation - abd distention & tympany Dx - plain films w/ distended colon - barium enema: obs location - CT w/ oral and IV contrast best test Mgmt - surgery almost always required: resect necrotic bowel, decompress obstructed area, remove obstructing lesion - flex sigmoidoscopy to reduce sigmoid volvulus

Answer 16

General - acute pseudoobstruction of colon w/o mech lesion  imbalance in autonomic tone w/ absence of peristalsis - m/c in ill elderly (>60), men, s/p trauma/ meds - m/c in cecum and right hemicolon Presentation - abdominal pain and distention - vomiting, obstipation, diarrhea - tympany w/ normal BS Dx - plain films w/ gaseous disten, barium enema w/o obstruction - CT abd/pelvis: proximal right colon dilation Mgmt - conservative tx: supportive care, remove precipitant drugs - neostigmine (to increase Ach lvls and bowel compress), colonic decompression w/ rectal tube if cecum >12cm diameter - surgery is last resort if unresp. and sig risk for perf or ischemia

Answer 17

- pseudopolyps/inflammatory: d/t IBD, not considered cancerous - hyperplastic  low risk for malignancy - adenomatous polyps  avg is 10-20yr before becoming cancerous (esp >1cm) – tubular polyps (m/c & least risk), tubulovillous (intermed risk), villous adenoma (highest risk) Dx -direct visualization of polyps and CA= flex sig, colonoscopy, CT colonography Mgmt -removal during colonoscopy and pathology

Answer 18

General - nonobstructive extreme colon dilation >6cm + signs of systemic toxicity - etiologies = UC, Crohn, pseudomembranous colitis, infections, radiation, ischemic Presentation: - fever, abd pain, N/V/D, rectal bleeding, tenesmus, electrolytes - abd tenderness, rigidity, tachycardia, dehydration, hypotension, AMS Dx: -abd radiographs w/ large dilated colon >6cm Mgmt - bowel decompression, bowel rest, NG tube - broad spectrum abx - electrolyte repletion - colostomy reserved for severe cases

Answer 19

General - bacterial infection and blockage of anal ducts/glands - m/c S. aureus, E. coli, Bacteroides, Proteus, Strep - m/c in posterior rectal wall Presentation - anorectal swelling, rectal pain worse w/ sitting, coughing, defecation - systemic dx of infxn possible Dx - CBC - CT abd/pelvis w/ contrast to eval extent of abscess prn Mgmt - I & D followed by warm-water cleansing, analgesics, sitz baths, high-fiber diet (WASH) - abx - surgical removal

Answer 20

General -open tract btw two epithelium-lined areas, seen especially w/ deeper abscesses Presentation -may cause anal discharge & pain Mgmt - I & D followed by warm-water cleansing, analgesics, sitz baths, high-fiber diet (WASH) - abx - surgical removal

Answer 21

General - blood vessels in lower rectum and anal canal become engorged d/t increase in intraabdominal pressure - RF = venous pressure, straining, pregnancy, obesity, prolonged sitting, cirrhosis w/ portal HTN - internal  originate above dentate line, generally painless, 1st- 4th degree - external  originate below dentate line, sx occur w/ thrombosis, presents as severe perianal pain Presentation - internal  intermittent BRBPR, mucous discharge, rectal fullness, edema/incarcer - external  acute intravascular thrombosis w/ severe pain, purple-black perianal mass Dx - clinical dx w/ visualization of prolapsed or thrombosed hemorrhoids on exam - DRE, FOBT - anoscopy for eval of internal hemorrhoids - proctosigmoidoscopy, colonoscopy in pt w/ BRBPR Mgmt - initially conservative w/ diet (add fiber, stool softener) and exercise, sitz baths, topical rectal steroids - office-based procedure  injection sclerotherapy, elastic band ligation - surgical  stapled hemorrhoidectomy, excisional

Answer 22

General - tender abscess w/ drainage on or near gluteal cleft near midline of coccyx or sacrum w/ midline pits - likely congenital anomaly - m/c in white males, obese, hirsute pt, prolonged sitting, local trauma Presentation - asx - acute abscess = sudden onset sev pain/swell, inflamed mass overlying sacrum or coccyx - chronic dz = persist drainage Clinical diagnosis Mgmt: - I&D - requires curative surgical excision of pilonidal sinus and tracts w/ possible plastic surgery closure of muscle

Answer 23

-rectal lesions cause hematochezia Dx -rectal bleeding in middle-aged person, even in presence of hemorrhoids  must r/o CA Mgmt - recto-sigmoid colon lesion  Low anterior resection of rectum (LAR) - middle rectal lesion  colo-anal anastomosis w/ J-pouch construct - distal rectal lesion  abdomino-perineal resection of rectum w/ end colostomy -Hartmann’s procedure = temp colostomy

Answer 24

General - herniation through abd wall at or near umbilicus, usually contains omentum or preperitoneal fat - common, usually acquired in adults d/t  in intraabd pressure, female > male - congenital in children d/t fail of umbilical ring closure - freq coexist w/ rectus abdominus diastasis Presentation - soft protuberance at umbilicus - often asx unless incarceration or strangulation - tenderness may be elicited w/ pressure & palpation Clinical diagnosis Mgmt - don’t req tx if small/asx  observation, usually resolves by 2yo - surgical repair if sx or still persist >5 yo open vs laparoscopic - mesh used for large defects and fascial edges w/ sig tension (possibility for mesh infection, erosion, migration)

Answer 25

General - dev in sites where incision has been made for some prior abd procedure d/t failure of fascial tissues to heal - emergency surgery or any condition which inhib wound healing  risk (obesity m/c) - occurs in 10-15% of abd incisions, midline m/c, typically dev in early post-op period Presentation - bulge in abd wall originating deep to skin scar, edges of fascial defect often defined - sx vary, aggravated by coughing or straining Clinical diagnosis Mgmt - expectant vs operative - mandatory surgical tx if bowel involved - simple sutured vs. mesh repair, open vs. laparoscopic  sutured w/  recurrence

Answer 26

General - herniation through linea semilunaris (line where sheaths of lateral abd muscles fuse to form lateral rectus sheath) - extremely rare, but high incidence of incarceration Presentation -swelling and sharp pain / tenderness in mid to lower abd just lateral to rectus muscle Diagnosis - clinical dx  bulge present when pt standing and straining - US, CT Mgmt - surgical repair w/open or lap

Answer 27

General - defects in abdominal midline btw umbilicus & xiphoid, usually at sites of congenital weakness in linea alba, incarceration/strangulation rare - men > women, usually middle age - RF = ext physical training or coughing, obesity, smoking, chronic steroid use, DM, old age Presentation - small uncomfortable mass b/s umbilicus and xiphoid, <1 cm in diameter - can be asx Clinical diagnosis Mgmt - repair only sx hernias - usually performed under local anesthesia w/ open approach - low recurrence rate after repair

Answer 28

General - type of incisional hernia  protrusion of abd contents through abd wall defect created during ostomy - most freq complication s/p colostomy/ileostomy (50%), typically w/in 1st 2 yrs of creation Presentation - bulge at stoma site or adjacent - may have pain Dx -removal of ostomy device req for exam  digitization of ostomy allows for identification Mgmt - conservative management for asx - surgical options  open vs. lap, primary vs. mesh

Answer 29

General - protrusion of abd contents through inguinal canal d/t weakness/defect in transversalis fascia, male > female - 95% of groin hernias are inguinal (indirect > direct) - accounts for most hernias in infants, kids, YA - indirect  herniation at internal inguinal ring (spermatic cord or round lig), origin lateral to inferior epigastric vessels, most are congenital d/t patent process vaginalis, R>L, m/c overall type in both sexes - direct  herniation medial to inferior epigastric vessels d/t weakness in floor of inguinal canal (Hesselbach’s triangle), does not reach scrotum - pantaloon  combined direct and indirect hernia, result of untreated indirect hernia Presentation - most asx until pt notices lump or swelling in groin (may have scrotal swelling in indirect) - sx more likely as hernia enlarges  m/c is heaviness or dull discomfort w/ strain or lift - incarcerated  painful, enlargement of irreducible hernia, N/V if bowel obstructed - strangulated  ischemic incarcerated hernia w/ systemic tox, severe painful bm

Answer 30

Dx - most dx w/ H&P - examine visually for bulge - in males, index finger invaginates scrotum adj to external ring  pt to cough - in females, place fingers across inguinal canal  pt bear down Mgmt - definitive tx is surgical repair  open Lichtenstein (w/ mesh), open 1, laparoscopic (TEP vs TAPP) - urgent repair if strangulation or bowel obstruct  no contraindications - bilateral best tx w/ laparoscopic, open best for pt w/ prior abd surg - expectant management can be considered in asx pt  Truss can provide ext compress over defect - inguinal hernia repair is m/c general surgical procedure performed - difficult to separate direct vs. indirect on exam

Answer 31

- protrusion of contents of abd cavity through the femoral canal below inguinal ligament (medial to femoral vein) - m/c seen in women - commonly present as bowel obstruction  often become strangulated c/t inguinal hernia -surgical repair  McVay (open w/ no mesh), open bilayer mesh repair, laparoscopic repair

Answer 32

General - rare hernia through pelvic floor in which pelvic or abd contents protrude through obturator foramen - m/c in women (multiparous or sig weight loss) - mortality rate 10-40%  most lethal abd wall hernia Presentation - often presents as SBO - lancinating pain in medial thigh/obturator distrib extend to knee c/b compress of obt nerve Mgmt - surgical tx  urgent if incarcerated and causing SBO - consider in any elderly debilitated women w/o prior abd surgery who presents w/ SBO

GI Flashcards

(56 cards)