Lower G.I. 6

Question 0

68 year-old woman admitted for bright red blood per rectum. Stabilizes after resuscitation. Following day begins to bleed again. Hematocrit drops to 24 after transfusion pervious day. Management?

Answer 0

1. Resuscitation and packed RBCs
2. Locate source of bleeding - Angiography (for less stable patients) and technetium RBC scanning (for more stable patients)
3. Do not do colonoscopies during active bleed – associated with perforation
4. Consider surgical exploration when patient requires 4-6 units of blood (Left or right hemicolectomy)

Question 1

Rate of bleeding detectable by angiography versus technetium-labeled RBC scanning?

Answer 1

0.5-1.0 versus 0.1 mL/min

Question 2

Patient with significant lower G.I. bleed. Are there any situations when the patient should be surgically explored before requiring 4-6 units of blood?

Answer 2

1. Becomes unstable with bleeding (CAD, angina)

2. Hard to determine blood types, unusual antibodies

Question 3

Patient bleeding rapidly and becomes hypotensive in angiography suite. How to lessen bleeding? (Complications of interventions?)

Answer 3

1. Vasoconstrictor (vasopressin) into bleeding vessel (vasoconstricts coronaries)
2. Embolization (transmural intestinal necrosis)

Question 4

88-year-old woman presents with constipation and recent change in mental status. Tachycardic, hypotensive, with abdominal distention and tenderness. Management?

Answer 4

1. IV hydration
2. measure electrolytes, CBC
3. Obstructive radiographic series

Question 5

88-year-old woman presents with constipation and recent change in mental status. Tachycardic, hypotensive, with abdominal distention and tenderness. Management if radiograph shows:

1. Sigmoid volvulus
2. cecal volvulus
3. Massively dilated right colon up to midtransverse colon with distal colonic decompression
4. Entire colon packed with stool

Answer 5

1. Confirm with barium enema. If stable, Detorse by rigid proctosigmoidoscopy and placement of rectal tube. Otherwise sigmoid colectomy
2. Requires urgent surgical treatment (Detorsion, cecoplexy, or right colectomy)
3. If cecal diameter under 10 cm, nonoperative treatment. Over 12 cm, trial of neostigmine and endoscopic decompression. If fails, surgical decompression or right colectomy.
4. Rectal exam to rule out infection. Clear still from vault, then enema

Question 6

Causes of sigmoid volvulus? Recurrence rate after treatment?

Answer 6

Chronic laxative use, chronic illness, dementia

30%

Question 7

Acute pseudoobstruction? A.k.a.? Management? Exception to basic management protocol?

Answer 7

Acute massive dilation of cecum and right colon without evidence of mechanical obstruction.

Ogilvie’s syndrome.

1. If cecal diameter under 10 cm, nonoperative treatment.
2. Over 12 cm, trial of neostigmine and endoscopic decompression.
3. If fails, surgical decompression or right colectomy.

If immunosuppressed, surgically decompress when colonic diameter is smaller

Question 8

Why give neostigmine to patient with Ogilvie’s syndrome?

Answer 8

Parasympatholytic agent which May increase colonic tone and counteract dilation

Question 9

65-year-old woman presents with anorectal discomfort. Has trouble initiating defecation and feels protrusion from her rectum when finished moving bowels. Suspected diagnosis? Cause by? Management?

Answer 9

Rectal prolapse; Maybe related to neuromuscular deficiencies

1. If prolapse is entirely internal, high-fiber diet
2. If Prolapse is external and bleeding, need surgery (rectopexy, transabdominal rectosigmoid resection)

Question 10

30-year-old man presents with rectal pain during defecation. Ulcerated area on anal canal found on examination – suspected diagnosis? Etiology? Most common location? Management?

Answer 10

Anal fissure; trauma, IBD

Located on posterior midline

1. Conservative treatment – bulking agents, stool softeners, sitz baths
2. If deep and chronic, biopsy to rule out anal cancer and sphincterotomy

Question 11

Rationale behind sphincterotomy for anal fissure?

Answer 11

Reflex stimulation and spasm of internal anal sphincter is important for the pathogenesis of anal fissures

Question 12

Patient presents with history of persistent perianal drainage. On examination see sinus tract with granulation tissue. Suspected diagnosis? Management?

Answer 12

Fistula-in-ano, residua of previous abscess that failed to heal and formed connection to perianal skin

1. Unoof tract and drain
2. Allow tract to reepithelialize
3. If tract transverses sphincter, add seton or string to prevent incontinence

Question 13

Patient presents with severe anal pain, tender fluctulant perianal mass, fever – suspected diagnosis? Types? Management?

Answer 13

Perianal abscess

1. Perianal – perianal I&D
2. Ischioanal – perianal I&D
3. Intersphincteric (75%) – drainage from within the anal canal
4. Supralevator – Depends on location and origin

Drainage (not antibiotics)

Question 14

Patient complains of pain and drainage in sacrococcygeal area. Suspected diagnosis? Treatment?

Answer 14

Pilonidal abscess parentheses infection in hair containing sinus in sacrococcygeal area)

Unroof abscess, remove hair, leave wound open

Question 15

Mucus fistula?

If closed and dropped back into bowel? (When is this done?)

Answer 15

Distal bowel stoma

Hartmann pouch (sigmoid resection for diverticulitis when bowel cannot be safely reconnected)

Question 16

When are permanent fistulas most commonly used?

Answer 16

1 abdominoperineal resection with end sigmoid colostomy

2. Ileostomy with total proctocolectomy for ulcerative colitis
3. Ileal conduit draining the urinary system to the skin