0
Q
Esophageal Neoplasms
A
-Most common is leiomyoma-benign, tx is surgical resection
- *Carcinoma**
- RFs: male, chronic alcohol and tobacco use, achalasia, caustic induced esophageal stricture, barrett’s esophagus due to GERD, reflux, radiation
- Most cases occur in distal third of esophagus
- Two main types: Squamous cell carcinoma (most common worldwide), Adenocarcinoma(due to Barretts, most common in USA)
- Sx: dysphagia (solid foods), wt loss, chest pain, back pain, hoarseness, sx from mets.
- Workup: UGI, EGD, transesophageal US, CT of chest/abdomen, CBC to look for anemia, LFTs to look for mets to liver, alkaline phosphatase to look for mets to bone
- Dx: UGI to localize tumor, EGD for bx, met workup (CXR, bone scan, CT, LFTs)
- Tx: Esophagectomy with gastric pull up or colon interposition. Nonresectable= chemo, radiaion, dilation, stent, laser, electrocoagulation, brachytherapy, photodynamic laser therapy.
1
Q
Barrett’s esophagus
A
- Can be a complication of GERD
- Metaplasia of esophageal mucosa at GE junction. Change from squamous to columnar epithelium with intestinal metaplasia.
- “Tongue like pattern” on EGD
- More common in older white males
- Sx: heartburn
- Dx: endoscopy with bx
- Tx: long term PPI use. Antacids, H2 blockers, anti-reflux surgery for GERD, surgery, endoscopic mucosal resection
- Associated with an increased risk of adenocarcinoma
2
Q
Mallory-Weiss tear
A
- Post retching, post emesis longitudinal tear of the stomach near the GE junction.
- Etiology: increased gastric pressure, often aggrevated by a hiatal hernia
- RFs: retching, alcholism, hiatal hernia
- Sx: epigastric pain, thoracic substernal pain, emesis, hematemeis
- Dx: EGD
- Classic hx: alcoholic pt after binge drinking
- Tx: room temp water lavage, electrocautery, arterial embolization, surgery if refractory bleeding (>6 u PRBCs infused).
3
Q
Esophageal Strictures
A
- Narrowing of the esophagus that causes swallowing difficulty(especially of solids)
- Etiology: GERD, esophagitis, dysfunctional LES, hiatal hernia
- Sx: solid food dysphagia, hearburn, SOB, hiccups, wt loss, hemoptysis
- Dx: endoscopy with bx
- Tx: dilation, long term PPI
4
Q
Esophageal varices
A
- Dilated submucosal veins due to the back up of portal pressure via the coronary vein to the submucosal esophageal venous plexuses secondary to portal hypertension from liver cirrhosis.
- Rule of 2/3: 2/3 of pts with portal HTN develop varices, 2/3 of pts with varices will bleed
- Sx: liver disease, portal HTN, hematemesis, caput medusa, ascites
- Dx: EGD
- Acute medical tx: lower portal pressure with somatostatin and vasopressin
- Tx: sclerotherapy or band ligation with endoscope, TIPS, liver transplant, sengstaken-blakemore balloon
5
Q
Ulcers gastric/duodenal
A
-PUD= tx H.pylori with Omeprazole, Clarithromycin, and Metronidazole/Ampicillin
- *Duodenal Ulcer**
- Age: 40-65yo, younger than gastic ulcer
- Food relieves pain
- Etiology: increased production of gastric acid
- RFs: male, smoking, ASA, NSAIDs, uremia, zollinger ellison syndrome, H. pylori, trauma, burn
- Sx: epigastric pain usually several hours after a meal, bleeding, back pain, nausea, vomiting, anorexia, decrease in appetite, guaiac positive stool, melena, hematochezia, hamatemesis
- Dx: hx, PE, EGD, UGI series
- Surgery indications: >6 u PRBC transfusions if bleeding. Intractability, hemorrhage, obstruction, perforation.
- Medical tx: PPIs, H2 agonists, tx for H. pylori.
- Surgery:
- Duodenal perforation= graham patch, truncal vagotomy and pylorplasty, graham patch with highly selective vagotomy, truncal vagotomy and antrectomy.
- Duodenal obstruction= BI or BII, truncal vagotomy and drainage procedure
- *Surgeries**
- Graham patch: piece of omentum is incorporated into the suture closure of perforation. Used in treating duodenal perforations in poor operative candidates.
- Truncal vagotomy: resection of a 1-2 cm segment of each vagal trunk as it enters the abdomen on the distal esophagus. This decreases gastric acid secretion. Need to perform a drainage procedure with it (pyloroplasty, antrectomy, or gastrojejunostomy).
- Antrectomy: remove antrum and pylorus
- BI: truncal vagotomy, antrectomy, and gastroduodenostomy. Contraindicated in stomach cancer.
- BII: truncal vagotomy, antrectomy, and gastrojejunostomy.
- *Gastric Ulcer**
- Age: 40-70yo, older than duodenal
- Less common than duodenal
- Food INCREASES pain
- Etiology: decreased cytoprotection (decrease in bicarb or mucus)
- Gastric acid production is normal or low
- RFs: smoking, alcohol, burns, trauma, CNS tumor, NSAIDs, steroids, shock, severe illness, male, advanced age
- Sx: epigastric pain, +/- vomiting, anorexia, nausea
- Dx: hx, PE, EGD with multiple bx(need to r/o gastric cancer)
- Medical tx: PPIs, H2 blockers, tx for H. pylori
- EGD: Perform for dx and 6wks postdx to confirm healing and r/o cancer
- Indications for surgery: intractability, cancer, hemorrhage, obstruction, perforation.
- Hemorrhage, obstruction, and perforation: distal gastrectomy with excision of the ulcer w/o vagotomy.
- Concomitant duodenal and gastric: resect and truncal vagotomy
- Pyloric gastric ulcer: truncal vagotomy and antrectomy
6
Q
Stomach Neoplasms
A
- *Benign**
- fundic gland polyps, hyperplastic polyps, adenomatous polyps(these have pre malignant potential-remove endoscopically)
- *Gastric Adenocarcinoma**
- RFs: diet(smoked meats, high nitrates, low fruits and veggies, alcohol), tobacco use, poor SES, atrophic gastritis, male, blood type A, previous partial gastrectomy, pernicious anemia, polyps, H. pylori.
- Avg age= >60yo
- Pathology: intestinal or diffuse(no glands), ulcerative or polypoid or scirrhous or superficial.
- Sx: wt loss, emesis, anorexia, epigastric pain, obstruction, nausea, hematemesis, melena, early satiety, anemia, heme occult, epigastric mass, hepatomegaly, Blumers shelf(solid peritoneal deposit anterior to the rectum), Virchows node(metastatic gastric cancer to the nodes in the left supraclavicular fossa), Sister mary joseph nodule (periumbilical LN gastric cancer mets), enlarged ovaries, axillary adenopathy.
- Most common early sx= mild epigastric discomfort and indigestion
- Most common sx overall= wt loss
- Workup: EGD with bx, endoscopic US to evaluate the level of invasion, CT of abdomen/pelvis to look for mets, CXR, CBC to look for anemia, LFTs to look for mets to liver
- More common in the lesser curvature in the proximal stomach.
- P53 genetic alteration seen in pts
- Nonoperative: distant mets, peritoneal implants
- Tx: surgical resection with wide margins and LN dissection.
- If tumor in antrum: distal subtotal gastrectomy (75% of stomach removed)
- If tumor in midbody or proximal: total gastrectomy (stomach removed and a roux en Y limb is sewn to the esophagus).
- Adjuvant tx: post op chemo and radiation for LN positive disease
- *Gastric Lymphoma**
- can develop secondary to H. pylori
- Need to treat H. pylori
- *Gastric Carcinoid**
- neuroendocrine tumor
- tx with surgical resection.
- *GIST**
- submucosal
- surgical resection, Imatinib
7
Q
Pyloric Stenosis
A
- Hypertrophy of muscular layers of pylorus,leading to obstruction
- More common in first born males
- Onset: 2-4 wks old
- Classic presentation: projectile nonbilious vomiting, palpable olive
- Dx: PE, US (cervix sign)
- Tx: correct any metabolic abnormalities first. Pyloromyotomy is curative.
8
Q
Acute pancreatitis
A
-Inflammation of the pancreas-digestive enzymes leak out of acinar cells and destroy the pancreas.
-Etiology: Most common are Alcohol abuse, gallstones, and idiopathic. Trauma, scorpion bite, mumps, autoimmune, steroids, hyperlipidemia, ERCP, drugs.
-Sx: epigastric pain(radiates to the back), N/V, restlessness, relief of pain by bending forward, diffuse abdominal tenderness, decreased bowel sounds, fever, dehydration/shock, tachycardia, shallow respirations, ecchymosis
-Labs: CBC(WBC will be high), LFTs, amylase(will be high), lipase(most helpful because specific to the pancreas, will be high), blood type and cross, ABG, Calcium, CMP, Coags, serum lipids, CRP
-Imaging: abdominal x-ray(sentinel loop or colon cutoff sign), US (gallstones), CT(MOST IMPORTANT)
-Ranson criteria: 1 pt for each
-Present: >35yo, WBC >16,000, Glucose >200, AST>250, LDH>350
-48hrs: base def>4, BUN increase>5, fluid sequestration>6L, serum
Ca 10%, PO2 2 may indicate drinking). Surgical consult to drain cyst or abscess.
-Complications: psudocyst, abscess, infection, vessel rupture, ascites, DM, sepsis, DIC, encephalopathy, pancreatic necrosis, hypocalcemia
9
Q
Chronic Pancreatitis
A
- Chronic inflammation of the pancreas causing destruction of parenchyma, fibrosis, and calcification, which leads to loss of endocrine and exocrine tissue.
- Most common cause is alcohol abuse. Other causes= idiopathic, hypercalcemia (hyperparathyroidism), hyperlipidemia, familial, trauma, iatrogenic, gallstones.
- Sx: epigastric pain, back pain, wt loss, steatorrhea, anorexia, N/V, constipation, flatulence, glucose intolerance
- Labs: amylase, lipase, fecal fat analysis, glucose
- Imaging: CT (greatest sensitivity), KUB, ERCP
- Tx: discontinuation of alcohol use, insulin, pancreatic enzyme replacement, narcotics, low fat diet.
- Surgery: longitudinal pancreaticojejunostomy, distal pancreaticojejunostomy, total pancreatectomy. Use surgery if severe prolonged/refractory pain.
10
Q
Pancreatic Cancer
A
- Adenocarcinoma of the pancreas arising from duct cells
- RFs: smoking, DM, alcohol use, chronic pancreatitis, diet high in fried meats, previous gastrectomy, prior abdominal radiation.
- Ave age >60yo
- Majority are in the pancreatic head-these draw attention earlier because of biliary obstruction.
- Sx of head tumor: painless jaundice, wt loss, abdominal pain, back pain, weakness, pruritis, anorexia, courcoisiers sign (palpable nontender distended gallbladder), acholic stools, dark urine, DM.
- Sx of body/tail tumor: wt loss, pain, migratory thrombophlebitis, jaundice, N/V, fatigue
- May see virchows node or sister mary josephs nodule
- Mets: liver, lungs, peritoneum
- Labs: increased direct bilirubin, increased alkaline phosphatase, increased LFTs, elevated pancreatic tumor markers (CA-19-9), elevated glucose, increased fecal fat, elevated amylase/lipase
- Imaging: abdominal CT, US, cholangiography, ERCP, endoscopic US with bx.
- Tx: in head= whipple(cholecystecomy, truncal vagotomy, antrectomy, pancreaticoduodenectomy(remove head of pancreas and duodenum), choledochojejunostomy( anastomosis of common bile duct to jejunum), pancreaticojejunostomy(anastomosis of distal pancreas remnant to jejunum), gastrojejunostomy(asastomosis of stomach to jejunum). In body/tail= distal resection.
- Inoperable: vascular encasement, liver mets, peritoneal implants, distant LN mets, distant mets, malignant ascites.
- Post op= chemo +/- radiation
- Palliative: PTC or ERCP and placement of stent.
11
Q
Pancreatic pseudocyst
A
- Encapsulated collection of pancreatic fluid. Wall is formed by inflammatory fibrosis.
- RFs: chronic alcoholic pancreatitis
- Sx: epigastric pain, emesis, mild fever, wt loss, palpable mass, ileus
- Labs: amylase(high), lipase, bilirubin(high), CBC(leukocytosis)
- Imaging: US(fluid filled mass), CT (fluid filled mass), ERCP
- Complications: infection, bleeding, fistula, ascites, gastic outlet obstruction, biliary obstruction
- Tx: drainage or observation (50% will resolve spontaneously). If bleeding, need angiogram and embolization. If infected, need percutaneous external drainage with IV abx. Needs to be drained if >5cm, calcified wall, or thick wall. Can drain with: percutaneous aspiration, operative drain, or transpapillary stent via ERCP. If using surgical drainage, need to bx.
12
Q
Liver Neoplasms
A
- Most common liver cancer is metastatic disease.
- Most common primary malignant tumor= hepatocellular carcinoma
- Most common primary benign tumor= hemangioma
- Imaging studies: CT, US, angiogram
- Benign*
- 3 Types: hemangioma, hepatocellular adenoma, focal nodular hyperplasia
- *Hemangioma**
- Vascular tumor
- Most common primary benign tumor of liver
- Sx: RUQ pain/mass, bruits
- Complications: pain, CHF, coagulopathy, obstructive jaundice, gastric outlet obstruction, Kasaback merritt syndrome(hemangioma and thrombocytopenia and fibrinogenopenia), hemorrhage.
- Dx: CT with contrast, tagged red blood scan, MRI, US
- Tx: observation. Resect if symptomatic or hemorrhage.
- *Hepatocellular Adenoma**
- Normal hepatocytes w/o bile ducts
- RFs: women, birth control pills, anabolic steroids, glycogen storage disease
- Avg age= 30-35yo
- Sx: RUQ pain/mass, bleeding
- Complications: rupture with bleeding, necrosis, pain, risk of cancer
- Dx: CT, US, bx
- Tx: small=stop birth control pills, surgical resection. large= surgical resection.
- *Focal Nodular Hyperplasia**
- Normal hepatocytes and bile ducts
- RFs: female, birth control(but not as great a risk as adenoma)
- Avg age= 40yo
- Dx: nuclear technetium 99 study, US, CT, angiogram, bx
- Complications: pain
- No increased risk for cancer
- Tx: resection or embolization if symptomatic, stop birth control pills, observation.
- Malignant*
- 4 Types: hepatocellular carcinoma, cholangiocarcinoma, angiosarcoma, hepatoblastoma.
- *Hepatocellular carcinoma**
- RFs: Hep B, cirrhosis, alfatoxin
- Sx: dull RUQ pain, hepatomegaly, abdominal mass, wt loss, paraneoplastic syndromes, signs of portal HTN, ascites, jaundice, fever, anemia, splenomegaly
- Labs: US, CT, angiography, elevated alpha-fetoprotein(tumor marker)
- Dx: needle bx with CT/US/laproscopic guidance
- Mets: lungs
- Tx: surgical resection, transplant
- Non-operable: percutaneous ethanol tumor injection, cryotherapy, intra-arterial chemo
13
Q
Portal hypertension
A
- Elevated portal pressure resulting from resistance to portal flow
- Normal portal pressure is <10 mmHg
- Etiology: Prehepatic- thrombosis of portal vein, atresia. Hepatic- cirrhosis, hepatocellular carcinoma, fibrosis. Posthepatic- budd chiari syndrome, thrombosis of hepatic veins.
- Most common cause is cirrhosis.
- Associated clinical findings: esophageal varices, splenomegaly (most common finding), caput medusa, hemorrhoids. Also spider angioma, palmar erythema, truncal obesity, peripheral wasting, encephalopathy, asterixis, gynecomastia, jaundice.
- Most feared complication= bleeding from esophageal varices.
- If bleeding, use EGD.
14
Q
Rectal Cancer
A
- Adenocarcinoma of the rectum
- 20-30% of all colorectal cancer
- Sx: hematochezia, mucus, tenesmus, felling of incomplete evacuation of stool, rectal mass
- Dx: hx, PE, heme occult, CBC, barium enema, colonoscopy
- CXR, LFTs, and abdominal CT to look for mets
- Preop workup: hx, PE, LFTs, CEA, CBC, CMP, PT/PTT, type and cross, CXR, UA, abdominopelvic CT
- Endorectal US is used for rectal cancer
- Tx: resection of the lesion and its regional lymphatic drainage. All rectal cancer operations include a total mesorectal excision(remove the rectal mesentery and LNs). Minimal surgical margin is 2cm.
- Adjuvant tx: pre-op radiation and 5-FU chemo.
15
Q
Anal fissure
A
- Tear in anal epithelium
- Most commonly occurs in posterior midline
- Etiology: hard stool passage, hyperactive sphincter, disease process (crohns disease).
- Sx: pain, painful bowel movements, rectal bleeding, sentinel tag, tear in anal skin, sentinel pile, hypertrophic papilla
- Tx: sitz baths, stool softeners, high fiber diet, topical nifedipine, botox. Surgery if refractive to treatment-lateral internal sphincterotomy(cut the internal sphincter to release it from spasm)
- Need to consider crohns disease, anal cancer, STD, UC, and AIDS if the fissure is off midline.
16
Q
Hemorrhoids
A
- Engorgement of the venous plexuses of the rectum, anus or both with protrusion of the mucosa, anal margin or both.
- Sx: anal mass/prolapse, bleeding, itching, pain(external only)
- If excruciating pain= thrombosed external hemorrhoid
- Dentate line separates internal from external
- 1st degree internal: does not prolapse
- 2nd degree internal: prolapses with defecation, returns on own
- 3rd degree internal: prolapses w/ defecation and any type of valsalva, requires active manual reduction
- 4th degree internal: cannot be reduced
- Tx: high fiber diet, anal hygiene, topical steroids, sitz baths, rubber band ligation, surgical resection.
- Complications of hemorrhoidectomy: exsanguination, pelvic infection, incontinence, anal stricture
- Crohns disease is contraindication to hemorrhoidectomy.
17
Q
Pilonidal disease
A
- Draining sinus or acute abscess in sacrococcygeal area
- Infection/irritation and trapping of foreign material in deep tissues
- Surgical drainage-I&D
- No abx unless signs of cellulitis
18
Q
Anorectal abscess/fistula
A
- *Perianal abscess**
- Abscess formation around the anus/rectum
- Etiology: crypt abscess in dentate line with spread
- Sx: rectal pain(throbbing), drainage of pus, fever, perianal mass
- Dx: PE, DRE
- Tx: drainage(I&D, surgical drainage if ischiorectal abscess), sitz bath, anal hygiene, stool softeners.
- Indication for post-op IV abx: cellulitis, immunosuppression, DM, heart valve abnormality
- 50% of pts will have fistula in ano
- *Fistula in Ano**
- Anal fistula from rectum to perianal skin
- Etiology: anal crypt/gland infection
- Sx: perianal drainage, perirectal abscess, recurrent perirectal abscess, diaper rash, itching
- Dx: PE, proctoscope
- Goodsalls rule: originate anteriorly=course straight ahead and exit anteriorly. originate posteriorly=curved tract
- Management: marsupialization of fistula tract(fillet tract open), wound care(sitz baths and dressing changes), seton placement(thick suture placed through fistula tract to allow slow transection of sphincter muscle-scar tissue formed will hold muscle in place)
19
Q
Fecal impaction
A
- Leads to large bowel obstruction
- RFs: medications(opioids), severe psychiatric disease, prolonged bed rest, neurogenic disorders of the colon, spinal cord disorders
- Sx: decreased appetite, N/V, abdominal pain/distension, paradoxical diarrhea
- Dx: DRE
- Tx: enema, digital/manual evacuation.
20
Q
Penetrating GI trauma
A
- Most common penetrating injury is the small bowel
- Tx of rectal penetrating injury: diverting proximal colostomy, closure of perforation
- Tx of bladder rupture: bladder cath drainage and observation, may require surgical closure if large or intraperitoneal
- Tx of colon injury: if in shock=resection and colostomy. if stable= primary anastomosis/repair
21
Q
Blunt GI trauma
A
- Associated with seat belt use-small bowel injuries, L2 fx, pancreatic injury
- Most common blunt abdominal trauma is to the liver
- Dx:abdominal sonogram, CT, LFTs
- Lethal triad: acidosis, coadulopathy, hypothermia
- Tx pelvic fx: pelvic binder until external fixator placed, IVF, blood, angiogram to embolize bleeding pelvic vessels
- Tx irreparable biliary duodenal and pancreatic head injury: whipple
- Tx small bowel injury: primary closure or resection and primary anastomosis
- Tx minor pancreatic injury: drainage
- Tx significant duodenal injury: pyloric exclusion
- Tx pancreas tail injury: distal pancreatectomy
- Damage control surgery: stop major hemorrhage and GI soilage, pack and get out of OR asap to bring pt to ICU to warm, correct coags and resuscitate, return pt to OR when stable warm and not acidotic
- Exploratory lap is required when free air is found on ABD/pelvic CT
22
Q
Apendicitis
A
- Inflammation of the appendix caused by obstruction of the appendiceal lumen producing a closed loop with resultant inflammation that can lead to necrosis and perforation.
- Etiology: lymphoid hyperplasia, fecalith
- Classic presentation: periumbilical pain, N/V, anorexia, pain migrates to RLQ
- Sx: guarding, muscle spasm, rebound tenderness, obturator sign(pain on internal rotation of leg with hip and knee flexed), psoas sign(pain on extenstion of hip with knee in full extension or by flexing the hip against resistance), rovsings sign(rebound tenderness to RLQ when LLQ is touched), low grade fever, hyperesthesia.
- McBurneys point: 1/3 from the anterior superior iliac spine to the umbilicus.
- Labs: CBC (WBW increased with left shift), UA(may see mild hematuria and pyuria), spiral CT, US, AXR(fecalith, sentinel loops)
- Pre-op prep: rehydration with IVF, abx with anaerobic coverage.
- Tx non-perforated: prompt appendectomy, 24hrs abx, d/c POD1
- Tx perforated: IVF resuscitation, prompt appendectomy, drain all pus, post-op abx for 3-7 days, leave wound open.
- Abx non-perforated: cefoxitin, cefotetan, unasyn, cipro, flagyl
- Abx perforated: BROAD SPECTRUM- ampicillin, cipro, clindamycin, penicillin
- Complications: pelvic abscess, liver abscess, perforation, portal pylethrombophlebitis
- Complications of appendectomy: SBO, enterocutaneous fistula, wound infection, infertility, right inguinal hernia
- Lap appy: identify appendix, staple mesoappendix, staple and transect appendix at base, remove appendix, irrigate and aspirate.
23
Q
Diverticulosis
A
- Outpouching of the colonic musculature caused by thickening and hypertrophy.
- Diverticula can be found in the colon, especially in the sigmoid colon
- Pathophysiology: weakness in the bowel wall develops where nutrient blood vessels enter bt antimesenteric and mesenteric taenia.
- RFs: low fiber diets, chronic constipation, FH, age
- Sx: bleeding
- Dx: If bleeding=colonoscopy. If pain and inflammation= CT
- Tx: high fiber diet.
- Indication for operation: complications of diverticulitis(fistula, obstruction, stricture), recurrent episodes, hemorrhage, suspected carcinoma, prolonged sx, abscess not drainable
- Obtain colonoscopy 6 wks after inflammation resolves to r/o colon cancer.
24
Diverticulitis
-Infection or perforation of a diverticulum
-Pathophysiology: obstruction of diverticulum by a fecalith leading to inflammation and microperforation.
-Sx: LLQ pain, change in bowel habits, fever, chills, anorexia, LLQ mass, N/V, dysuria
-Labs: increased WBCs
-Imaging: x-ray= ileus, partially obstructed colon, air fluid levels, free air if perforated. CT(best test)= swollen edematous bowel wall. Avoid barium enema and colonoscopy.
Complications: abscess, diffuse peritonitis, fistula, obstruction, perforation, stricture
-Tx: Initial: IVF, NPO, broad spectrum abx(ciprofloxacin 500mg PLUS metronidazole 500mg TIDx7-10days), NG suction. Clear liquids to low residue diet.
-Surgery warranted if obstruction, fistula, free perforation, abscess not amedable to percutaneous drainage, sepsis. For acute case with complication= Hartmann's procedure(resection of involved segment with and end colostomy and stapled rectal stump).
25
Obstruction
* *Small bowel**
- Etiology: adhesions(#1 cause in adults), hernias(#1 cause in kids), cancer, Crohn's, volvulus, foreign bodies, intestinal atresia, strictures, superior mesenteric artery syndrome, intussusception.
- Sx: abdominal discomfort, cramping, N/V, distension, high pitched bowel sounds, inability to pass gas, dehydration
- Labs: electrolytes, CBC, type and screen, UA
- Imaging: CT with oral contrast, small bowel follow through
- Classic findings: hypovolemic, hypochoremic, hypokalemia, alkalosis
- Need to r/o incarcerated hernia
- AXR: distended loops of small bowel, air fluid levels on upright film
- At risk for closed loop strangulation of the bowel leading to bowel necrosis(signs= fever, severe continuous pain, shock, peritoneal signs, acidosis).
- Tx: initial management: NPO, NGT, IVF, foley. Complete= laparotomy and lysis of adhesions. Incomplete= conservative tx with close observation and NGT decompression.
* *Large Bowel**
- Etiology: neoplasms, hernias, IBD, colonic volvulus, adhesions, constipation, fecal impaction, benign strictures, endometriosis.
26
Toxic Megacolon
- Etiology: crohns, UC, infectious colitis, ischemic colitis, volvulus, diverticulitis, colon cancer
- Sx: sepsis, fever, abdominal pain, severe bloody diarrhea is the most common presenting sx
- Dx: AXR
- Tx: Medical= fluid resuscitation, broad spectrum abx, IV corticosteroids, complete bowel rest, bowel decompression with nasogastric or long bowel tube. Surgical= emergent colectomy
27
Ischemic Bowel disease
* *Acute mesenteric ischemia**
- Occlusive(thrombus or embolus) vs nonocclusive(cardiac failure, hypotension)
- Sx: severe epigastric and peri-umbilical pain, pain is out of proportion to PE, N/V, hypotension
- Dx: CTA, MRA, mesenteric arteriography is gold standard
- Labs: leukocytosis, metabolic acidosis, elevated serum lactate
- Tx: hemodynamic monitoring and support, correct metabolic acidosis, broad spectrum abx, NGT for gastric decompression, systemic anticoagulation(heparin), aggressive fluid resuscitation, vasopressor(dobutamine), arteriography with vasodilator, stent placement, surgical laparotomy with embolectomy, mesenteric artery bypass, small bowel resection.
* *Chronic mesenteric ischemia**
- Caused by stenosis or atherosclerosis of celiac artery, SMA or IMA (2 need to be affected)
- Sx: postprandial epigastric abdominal pain, wt loss secondary to anorexia
- Dx: CTA or MRA
- Tx: angioplasty or stenting, mesenteric artery bypass, visceral artery endarterectomy
* *Ischemic colitis**
- Sx: crampy, LLQ pain, mild bloody diarrhea
- Dx: colonoscopy, CT
- Tx: conservative(NPO, IVF, abx, bowel rest) Surgery may be needed in progressive disease.
28
Colorectal Cancer
-Adenocarcinoma
-Most common GI cancer, 2nd most common cancer in US, 2nd most common cause of cancer deaths.
-Incidence increases with age.
-RFs: dietary(low fiber high fat diet), genetic(FH, FAP, HNPCC), IBD(UC>crohns)
-Screening recommendations: NO FH: start at age 50; colonoscopy q10yrs or double contrast barium enema q5yrs or flex sigmoidoscopy q5yrs or CT colonography q5yrs. +FH: Colonoscopy at age 40 or 10 yrs prior to age of dx, then colonoscopy q5yrs.
Sx right sided lesions: tumor may attain large size, microcytic anemia, occult melena, postprandial discomfort, fatigue
Sx left sided lesions: change in bowel habits, colicky pain, signs of obstruction, abdominal mass, heme+, hematochezia, N/V, constipation.
-Dx: hx, PE, heme occult, CBC, barium enema, colonoscopy
-Mets: look with CXR, LFTs, and abdominal CT. most common site is liver-treat with resection and chemo.
-Pre-op workup: hx, PE, LFTs, CEA, CBC, Chem 10, PT/PTT, type and cross, CXR, UA, CT.
-Pre-op bowel prep: Golytely colonic lavage or Fleets Phospho Soda until clear effulent per rectum, PO antibiotics (cefoxitin, unasyn. cipro and flagyl if allergic).
-Tx: resection- wide surgical resection (>5cm margins) of lesion and its regional lymphatic drainage. 12 LN minimum should be resected. With anastomosis less than 5cm from anus do temporary ileostomy to protect the anastomosis.
-Adjuvant tx: 5-FU and leucovorin chemo.
-Surveillance: PE, stool guaiac, CBC, CEA, and LFTs q3mos for 3yrs, then q6mos for 2yrs. CXR q6mos for 2 yrs and then yearly. Colonoscopy at years 1 and 3 postoperatively.
29
Small intestine cancer
- Sx: abdominal pain, wt loss, obstruction, perforation
- Most common benign tumor: leiomyoma
- Most common malignant tumor: adenocarcinoma
- Workup: UGI with small bowel follow through, enteroclysis, CT, enteroscopy
- Tx: resection and removal of mesenteric draining LNs
- Melanoma classically metastasizes to SI
30
Ulcerative Colitis
- Extraintestinal Manifestations: anklylosing spondylitis, aphthous ulcers, iritis, pyodermal gangrenosum, erythema nodosum, finger clubbing, sclerosing cholangitis, arthritis, kidney disease.
- Male>female, high in jewish populations, 20-35yo and 50-65yo
- Sx: bloody diarrhea, fever, wt loss, rectal bleeding
- Distribution: colon only with rectal involvement; spreads proximally
- Involves mucosa and submucosa only
- Anal involvement in uncommon.
- Crypt abscesses, ulcers, pseudopolyps, lead pipe appearance on barium enema.
- Dx: colonoscopy, barium enema, UGI with small bowel follow through, stool cultures
- Complications: cancer, toxic megacolon, colonic perforation, hemorrhage, strictures, obstruction, complications of surgery.
- Higher risk of developing colon cancer and toxic megacolon compared to Crohn's disease.
- Indications for surgery: toxic megacolon, cancer prophylaxis, massive bleeding, failure of child to mature, perforation, suspicion of cancer, sx refractory to treatment, obstruction, dysplasia, stricture
- Surgical options: 1)total proctocolectomy, distal rectal mucosectomy, and ileoanal pull through. 2) Total proctocolectomy and brooke ileostomy.
- Medications: sulfasalazine, mesalamine, steroids, metronidazole, azathioprine, 6-mercap, inflizimab. 6-mercap, azathioprine, and mesalamine are used for long term remission. Steroids are used for flare ups.
- Unique medication route for UC is enema.
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Crohn's Disease
- Extraintestinal Manifestations: anklylosing spondylitis, aphthous ulcers, iritis, pyodermal gangrenosum, erythema nodosum, finger clubbing, sclerosing cholangitis, arthritis, kidney disease.
- Female>male, high in jewish populations, 25-40yo and 50-65yo.
- Sx: abdominal pain, diarrhea, fever, wt loss, anal disease
- Distribution: mouth to anus, skip lesions, anal involvement, full thickness of the colon wall.
- Dx: colonoscopy with bx, barium enema, UGI with small bowel follow through, stool cultures
- Complications: fistulas, abscesses, strictures, toxic megacolon, hemorrhage, obstruction, cancer.
- Indications for surgery: obstruction, massive bleeding, fistula, perforation, suspicion of cancer, abscess, toxic megacolon, strictures, dysplasia.
- Medications: sulfasalazine, mesalamine, steroids, metronidazole, azathioprine, 6-mercap, inflizimab. 6-mercap, azathioprine, and mesalamine are used for long term remission. Steroids are used for flare ups.
- Medication of choice for perianal involvement: PO metronidazole
- See cobblestoning on endoscopic exam.
- Most common indication for surgery is SBO.
- Intraoperative findings: mesenteric fat creeping, shortened mesentery, thick bowel wall, fistula, abscess.
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Intussusception
- Telescoping of proximal part of bowel into distal part
- Most common in ileocolic
- 6-12mos old, males>females
- Sx: colicky abdominal pain, red currant jelly stool
- Tx: reduction with barium or pneumatic enema. Surgery may be needed if reduction is unsuccessful.
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Meckel's Diverticulum
- Most common small bowel congenital abnormality
- Location: w/i 2 feet of the ileocecal valve on the antimesenteric border of the bowel
- More common in men and in the first 2 years of life, most are 2 inches long
- Complications: intestinal hemorrhage, intestinal obstruction, inflammation
- Sx: lower GI bleeding, abdominal pain, SBO
- Tx if bleeding and obstruction: surgical resection with small bowel resection.
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Spleen Trauma
- Delayed splenic rupture: subscapular hematoma or pseudoaneurysm may rupture some time after blunt trauma. Rupture classically occurs about 2 wks after the injury and presents with shock/abdominal pain
- Sx: hemoperitoneum, kehrs sign(left shoulder pain seen with splenic rupture), LUQ abdominal pain, ballance's sign(LUQ dullness to percussion), seagesser's sign(phrenic nerve compression causing neck tenderness in splenic rupture).
- Dx: Abdominal CT if the pt is stable. FAST exam (focused assessment with sonography for trauma) or DPL(diagnostic peritoneal lavage) if the pt is unstable.
- Tx: Nonoperative in a stable pt with an isolated splenic injury without hilar involvement/complete rupture. If pt is unstable, DPL/FAST laparotomy with splenorrhaphy(splenic salvage operation) or splenectomy. Embolization in certain pts.
- Post-op complications: Thrombocytosis, subphrenic abscess, atelectasis, pancreatitis, gastric dilation, and overwhleming postsplenectomy sepsis (OPSS)
- OPSS:Caused by increased susceptibility to fulminant bacteremia, meningitis, or pneumonia because of loss of splenic function). Presents as fever, lethargy, common cold, sore throat, URI followed by confusion, shock, and coma with death ensuing in 24hrs in up to 50% of pts). Caused by encapsulated bacteria(strep pneumoniae, n. meningititdes, H. influenzae). S. pneumoniae is the most common. Preventive treatment is vaccinations for pneumococcus, H. influenzae, and meningococcus and prophylactic penicillin.
- The best time to give immunizations to pts is preoperatively or 2 wks post op.
- Lab abnormalities after splenectomy: WBC count increases, thrombocytosis, RBC smear abnormal ( pappenheimer bodies, howell jolly bodies, heinz bodies)
- Treat thrombocytosis when platelet count >1million- treat with ASA
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Splenomegaly
- Most common physical finding of portal hypertension.
- Etiology: cirrhosis, heart failure, thrombosis of portal, hepatic, or splenic veins, lymphoma, leukemias, polycythemia vera, essential thrombocytemia, myeloid metaplasia, primary splenic tumors, metastatic solid tumors, infections, infective endocarditis, sarcoid, serum sickness, SLE, RA, sickle cell anemia.
- Sx: hyperfunctioning spleen( loss of blood elements(WBC, Hct, platelets), hyperactive bone marrow to keep up with loss of blood elements), pain, fullness, or discomfort in the LUQ, pain referred to left shoulder, early satiety
- Dx: AXR, US, CT(most useful), radionucleotide scans, angiography
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Acute cholecystistis
- Obstruction of cystic duct leads to inflammation of the gallbladder.
- Etiology: 95% of cases due to stones. Can be associated with infection of bile.
- RFs: gallstones, recent fatty meal
- Sx: unrelenting RUQ pain/tenderness, fever, N/V, painful palpable gallbladder, Murphy's sign, right subscapular pain, epigastric discomfort, guarding, lie still on the exam table.
- Complications: abscess, perforation, choledocholithiasis, cholecystenteric fistula formation, gallstone ileus
- Labs: increased WBC, slight elevation in alkaline phosphatase, LFTs, amylase, and bilirubin.
- Dx: US (test of choice)- will show thickened gallbladder wall, pericholecystic fluid, distended gallbladder, gallstones. HIDA scan- + if the GB does not visualize because cystic duct not patent so label cant get in.
- Tx: IVFs, electrolytes, NPO, abx(cephalosporins), analgesics(ketorlac) cholecystectomy
- Lap chole: 1)Dissection of peritoneum overlying the cystic duct and artery. 2) Clipping of cystic artery and transect. 3)Division of cystic duct b/t clips 4) Dissection of gallbladder from the liver bed 5)Cauterization, irrigation, suction 6)Remove gallbladder.
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Chronic Cholecystitis
-Repeated episodes or chronic irritation of gallbladder wall by stones.
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Cholelithiasis
- Formation of gallstones
- RFs: 4 F's= female, fat, forty, fertile
- Types: Cholesterol and pigment stones
- Pathogenesis of cholesterol stones: secretion of bile supersaturated with cholesterol then cholesterol precipitates out and forms solid crystals and then gallstones
- Sx: biliary colic, cholangitis, choeldocholithiasis, gallstone, pancreatitis. Most pts are asx. Boas sign(referred right subscapular pain of biliary colic). N/V. May be precipitated by a large fatty meal.
- Cause of biliary colic: gallbladder contraction against a stone temporarily at the gallbladder/cystic duct junction.
- Complications: acute cholecystitis, choledocholithiasis, gallstone pancreatitis, gallstone ileus, cholangitis.
- Dx: hx, PE, US(best test to detect)
- Symptomatic and complicated cases are treated with cholecystectomy
- Complications of lap chole: common bile duct injury, right hepatic duct/artery injury, cystic duct leak, biloma.
- Indications for cholecystectomy in asx pt: sickle cell disease, calcified gallbladder, child
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Choledocholithasis
- Gallstones in the common bile duct
- Sx: colicky RUQ pain, intermittent, jaundice
- Labs: WBC, bilirubin(rise correlates with obstruction), alkaline phosphatase
- Dx test of choice: cholangiography (ERCP)
- US is not a good diagnostic test for this, compared to cholelithiasis
- Management: 1)ERCP with papilotomy and basket/balloon retrieval of stones 2) laparoscopic transcystic duct or trans common bile duct retrieval 3) open common bile duct exploration.
- Major complication of ERCP: pancreatitis. Give pre-op or post-op antibiotics (penicillin, 3rd gen ceph).
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Cholangitis
- Bacterial infection of the biliary tract from obstruction
- Potentially life threatening-can lead to liver damage or cirrhosis.
- Etiology: choeldocholithiasis(most common cause), stricture, neoplasm, extrinsic compression, instrumentation of the bile ducts, biliary stent
- Sx: Charcot's triad (fever, RUQ pain, jaundice), Raynold's pentad(Charcot's triad plus altered mental status and shock/hypotension)
- Labs: increased WBCs, increased bilirubin, increased alkaline phosphatase, positive blood cultures, elevated LFTs
- Organisms: Mostly gram neg
- Dx: US and contrast study (ERCP or IOC)
- Suppurative cholangitis: severe infection with sepsis
- Management nonsuppurative: IVF and Abx, definitive treatment comes later.
- Management suppurative: IVF, abx, decompression(ERCP with papillotomy, PTC with catheter drainage, or laparotomy with T tube placement).
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Biliary Obstruction
- Alkaline phosphatase will be elevated in bile duct obstruction because it is made in bile duct epithelium
- Etiology: cysts of common bile duct, enlarged LNs, gallstones, inflammation of bile ducts, trauma, tumors
- Sx: RUQ pain, jaundice, fever, itching, dark urine, N/V, pale colored stools
- Labs: increased bilirubin, increased alkaline phosphatase, increased LFTs
- Dx: ERCP, US, CT
- Tx: remove stones with endoscope during ERCP
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Hernias General
- Protrusion of a peritoneal sac through a musculouaponeuroitc barrier, a fascial defect
- Precipitating factors: increased intra-abdominal pressure, straining at defecation or urination, obesity, pregnancy, ascites, valsavagenic, COPD, abnormal congenital anatomic route
- Repair hernias to avoid complications of incarceration, strangulation, bowel necrosis, SBO, and pain.
- Small defects are more dangerous more likely to strangulate if incarcerated.
- Reducible: can return displaced contents to usual site.
- Incarcerated: swollen or fixed within the hernia sac; may cause intestinal obstruction.
- Strangulated: incarcerated hernia with resulting ischemia-can result in intestinal obstruction or bowel necrosis.
- Complete: hernia sac and its contents protrude all the way through the defect
- Incomplete: defect present without sac or contest protruding completely through it.
- Layers of abdominal wall: skin-subcutaneous fat-scarpas fascia-external oblique-internal oblique-transversus abdominus-transversalis fascia-preperitoneal fat-peritoneum.
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Femoral Hernia
- Hernia medial to femoral vessels(under inguinal ligament)
- RFs: women, pregnancy, exertion
- Complications: very prone to incarceration
- Tx: McVay repair (Cooper's ligament sutured to transversus abdominus aponeurosis/conjoint tendon), mesh plug repair(place plug of mesh in hernia defect and then overlaying a patch of mesh over inguinal floor).
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Hiatal Hernia
- 2 Types: sliding and paraesophageal
* *Sliding**
- Both the stomach and GE junction herniate into the thorax via esophageal hiatus
- Majority of hiatal hernias (>90%)
- Sx: most pts asx, reflux, dysphagia, esophagitis, pulmonary problems due to aspiration.
- Dx: UGI series, monometru, EGD with bx
- Complications: reflux->esophagitis->Barrett's esophagus->cancer and stricture formation, aspiration pneumonia, UGI bleeding
- Tx: antacids, H2 blockers, PPIs, head elevation after meals, small meals, and no food prior to sleeping. Surgery if persistent sx.
- Surgery: laparoscopic nissen fundoplication(wrap the fundus around the LES and suture it in place)
* *Paraesophageal**
- Herniation of all or part of the stomach through the esophageal hiatus into the thorax without displacement of the GE junction.
- Sx: asx, dysphagia, stasis gastric ulcer, strangulation
- Complications: hemorrhage, incarceration, obstruction, strangulation
- Tx: surgery
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Incisional Hernia
- Hernia through an incisional site
| - Most common cause is wound infection
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Inguinal Hernia
* *Direct**
- Hernia within the floor of Hesselbach's triangle
- Hernia sac does not traverse the internal ring
- Etiology: acquired
- Frequency increases with advanced age
* *Indirect**
- Hernial through the internal ring of the inguinal canal; may enter scrotum
- Etiology: patent process vaginalis(congenital)
- Most common hernia in men and women
- Dx: hx, PE(index finger invaginated into the external ring and palpation of hernia)
- Higher risk of strangulation than direct, but not has high a risk as femoral.
- Tx: emergent herniorrhaphy is indicated if strangulaiton is suspected or acute incarceration is present. If not, elective heniorrhaphy to prevent chance of incarceration/strangulation.
* *Inguinal Hernia Repairs**
- Bassini: sutures approximate reflection of inguinal ligament to the transversus abdominis aponeurosis/conjoint tendon.
- McVay: Cooper's ligament sutured to transversus abdominus aponeurosis/conjoint tendon.
- Lichtenstein: Use mesh
- Shouldice: Imbrication of the floor of the inguinal canal
- Plug and patch: place plug of mesh in hernia and overlay mesh over inguinal floor.
- High ligation: ligation and transection of indirect hernia sac without repair of inguinal floor
- TAPP: trans abdominal pre-peritoneal inguinal hernia repair
- TEPA: totally extra-peritoneal approach
- Laparoscopic if b/l, recurring, and pt needs to resume activity asap.
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Umbilical Hernia
- Hernia through the umbilical ring
| - Associated with ascites, pregnancy, and obesity
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Ventral Hernia
-Incisional hernia in the ventral abdominal wall
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Bariatric Surgery
- Wt reduction surgery for morbidly obese
- BMI >40 or >35 if medical problems related to obesity
- 2 options: gastric bypass and vertical banded gastroplasty (lap band)
- Gastric Bypass: stapling off of small gastric pouch, roux-en-Y limb to gastric pouch
- Creates a small gastric reservoir, causes dumping sx when pt eats too much or high calorie foods(the food is dumped into the roux-en-Y limb), bypass of small bowel.
- This operation works the best
- Complications: gallstones, asastomotic leak (will see tachycardia), marginal ulcer, stenosis of pouch/anastomosis, malnutrition, incisional hernia, spleen injury, iron def, B12 def.
-Lap-band: laparoscopically placed band around stomach with a subcutaneous port to adjust constriction, results in smaller gastric reservoir.
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Constipation
- Most common digestive complaint
- Straining, incomplete evacuation, manual maneuvers, hard or lumpy stool 25% of the time.
- RFs: female, >60yo, non-white pts, minimal physical activity, low income, less education, psychosocial issues
- Sx: straining, feeling of obstruction, incomplete evacuation, infrequent BMs.
- Alarm sx: FH of colon cancer or IBD, >50yo, wt loss, IDA, blood in stool.
- Evaluation: hx, PE, DRE. If alarm sx: CBC, CMP, TSH, and colonoscopy.
- Tx: optimize toilet habits, evaluate meds, address psychosocial issues, increase physical activity, increase water intake, increase fiber(20-25g/day for women, 30-38g/day for men). Osmotic laxatives (polyethylene glycol, milk of magnesia/magnesium hydroxide), stimulant laxatives (bisacodul, senna, cascara, lubiprostone), mineral oil, suppositories, linaclotide, enemas, magnesium citrate.
Surgery Rotation
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