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GI Surgery 2


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