Surgery
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Areas of colon most likely injured by ischemia | Splenic flexure & sigmoid colon:
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Most likely spot in colon for perforation | Cecum
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colon: 2 nerve plexi | Meissner’s (submucosal); Auerbach’s (myenteric) plexus
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colon: NS (symp & parasymp): | Symp: from sup mesenteric ganglion; Para: from vagus
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colon flora | 99% anaerobe (bacteroides); aerobes = E coli / Klebs; colon much more bac than ileum
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Diverticulitis etiology: | Outpouching of the wall of a hollow viscus; type I (pseudo; herniation thru circular mx); type II (all layers of colon wall; rare/congenital)
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Diverticulitis dx | fever, LLQ pain / tender; palpable mass; abscess, colon obstructn?; dx w/ CT
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Bleeding: diverticulosis vs diverticulitis | diverticulosis will bleed
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Diverticulitis mgmt | usu in hosp; resection (w/ diversion?); return for colostomy takedown
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etiology: colovesical fistula | complicn of diverticulitis, ca, * IBD (men); fistula) btw colon & bladder (or colovaginal)
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dx: colovesical fistula | pneumaturia/ fecaluria; dx w/ CT +/- cystogram
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mgmt: colovesical fistula | Etiology specific; bowel rest +/- surgery
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etiology: lower GI hemorrhage | Diverticular; AV malform; post-procedure; ca; colitis; upper GI
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dx: lower GI hemorrhage | proctoscopy, colonoscopy, tagged RBC scan
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lower GI hemorrhage: s/s of Hypovolemia | Tachycardia, Hypotension, Orthostatic Hypotension
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mgmt: lower GI hemorrhage | 2 lg bore IV, LR +/- PRBC; if persists: Total Abdominal Colectomy
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etiology: colon volvulus | Torsion of redundant sigmoid colon on itself (elder constip pt)
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dx: colon volvulus | abd distension, N&V, pain; obstructn / ischemia? Dx w/ KUB, gastrograffin enema (shows bird beak)
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mgmt: colon volvulus | if peritonitis: explor laparotomy & resect w/ colostomy; if stable: colonic decompression, bowel rest; prep for sigmoid colectomy / anastomosis
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etiology: Crohn’s colitis | non-caseating granulomas in submucosa; skip lesions; transmural inflam; anywhere in GI
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dx: Crohn’s colitis | abd pain, diarrhea, distension, wt loss
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mgmt: Crohn’s colitis | sulfasalazine; steroids
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etiology: ulcerative colitis | Superficial inflam process involving colon mucosa; usu rectum; Crypt abscesses and inflammatory pseudopolyps
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dx: ulcerative colitis | abd pain, wt loss, bloody diarrhea; dx w/ colonoscopy & bx
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mgmt: ulcerative colitis | sim to Crohn dz; removal of entire colonic mucosa is curative
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etiology: ischemic colitis | Acute: often post-AAA repair;
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dx: ischemic colitis | acute: bloody diarrhea d/t mucosal slough; Dx: Emergent Flexible Sigmoidoscopy; chronic: episodic LLQ pain
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mgmt: ischemic colitis | Maximize O2 Delivery; bowel rest; surg: tx comps only (perf / peritonitis)
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etiology: hemorrhoids | sliding downward of anal cushions; external: below dentate & squamous epi; internal: above dentate & columnar epithelium
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dx: hemorrhoids | 1st – 4th degree
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mgmt: hemorrhoids | Tx only sx / int hemorrhoids; pt >40 eval by colonoscopy to r/o proximal dz; acute: poss topical hydrocortisone; surg if persists: banding or hemorrhoidectomy
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etiology: anal fissure | elliptical ulcer or tear in anal canal; tearing of anoderm
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dx: anal fissure | dx on PE (anoscope); always close to midline (usu posterior) of anal canal
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mgmt: anal fissure | usu heal themselves; Botox; surg: lateral internal sphincterotomy
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etiology: perianal abscess | Obstructed anal crypts leads to bac overgrowth in anal glands; M > F
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dx: perianal abscess | pain, swelling, fever, pus: EUS & CT, needle aspirate
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mgmt: perianal abscess | Abx; suspect gas-forming bac (esp w/ prosthetic / imm’compromised); I&D
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Intersphincteric abscess: most common: | perianal (2nd most common: ischiorectal / lateral)
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colorectal cancer prevalence | 60,000 d/yr; 3d leading COD
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colorectal cancer risk factors | Smoking, EtOH, diet, obesity. Genetic: FAP, Gardner syndrome. IBD/UC, neoplastic polyps. HPV is RF for anal ca
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Colon polyp types | Submucosal; Hyperplastic; Hamartomatous; Adenomatous (premalignant lesion)
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Polyps: tx | Larger polyps or sessile polyps must be surgically resected as if early cancer
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colorectal cancer: dx | CT (staging); CXR; Endo US; CEA
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colorectal cancer screening | Annual DRE / FOBT at age 50 (or flex sigmoid q3-5 yr at 50; or colonoscopy q10 y)
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Most common bowel prep used | Golytely
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Pelvic floor mx | Iliococcygeous; Pubococcygeus; Puborectalis (most important): dysfn is assoc w/ fecal incontinence
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General Layers of GI tract (4): | Serosa (outermost), Muscularis Propria, Submucosa, Mucosa (luminal / innermost)
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Muscularis Propria contains: | [from outer to inner] - Longitudinal muscle, Auerbach (myenteric) plexus, Circula muscle
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Submucosa contains: | Meissner (Submucosal) Plexus
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GI Mucosa consists of: | Epithelium, lamina propria, muscularis mucosa
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SBO clinical features | N/V, obstipation, crampy abd pain with crescendo-decrescendo pattern. Distention, high pitched metallic bowel sounds.
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Ileus etiologies | Peritonitis, lyte imbalance, opioids, dysmotility disorders.
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Carcinoid tumor locations | Tumors arise from neuroendocrine cells. Appendix is most common site; terminal ileus (no. 2)
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Bronchospasm, flushing, diarrhea, right sided HF are clinical features of: | carcinoid tumor
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SMA syndrome = | extensive ischemia/necrosis of small / lg intestines, from ligament of Trietz to mid-transverse colon
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IMA syndrome = | extensive ischemia/necrosis of small / lg intestines, in left colon and sigmoid, Celiac artery is usually narrow or occluded (as in SMA syndrome)
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