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Surgery

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Question
Answer
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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