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Surgery: NMS GI Disorders
What pathophysiologic process is indicated by: gradual periumbilical pain? - ANSWER>>>>>>>visceral peritoneal irritation (e.g. appendicitis, diverticulitis, inflammatory conditions--can become localized) What pathophysiologic process is indicated by: severe, explosive pain - ANSWER>>>>>>>immediately soils parietal peritoneum (e.g. perforation of hollow viscus--can be localized or generalized) What pathophysiologic process is indicated by: progressive, severe pain - ANSWER>>>>>>>worsening intral-abdominal condition (e.g. ischemic necrosis) What pathophysiologic process is indicated by: localized pain that recurs as a generalized pain - ANSWER>>>>>>>inflamed organ has perforated (e.g. acute appendicitis has RLQ pain - > generalized) What pathophysiologic process is indicated by: crampy pain - ANSWER>>>>>>>obstruction (has crescendo then decrescendo component) Rebound tenderness is indicative of ___? - ANSWER>>>>>>>acute peritoneal irritation Dx? RUQ abdominal mass - ANSWER>>>>>>>acute cholecystitis (or complication - subhepatic or intrahepatic abscess) Dx? LLQ abdominal mass - ANSWER>>>>>>>acute diverticulitis or peridiverticular abscess Dx? RLQ abdominal mass - ANSWER>>>>>>>acute apendicitis or appendiceal abscess Dx? LUQ abdominal mass - ANSWER>>>>>>>complication of gastric or colonic malignancy, subphrenic abscess, acute inflammatory process related to spleen (e.g. infarction) Dx? midabdominal mass - ANSWER>>>>>>>pancreatic malignancy or abscess, complication of perforated ulcer, leaking AAA 3 most common causes of bowel obstruction? - ANSWER>>>>>>>post-op adhesions, colon carcinoma, inguinal hernias
Tx: sigmoid volvulus - ANSWER>>>>>>>sigmoidoscopy and decompression Dx: upper GI bleed - ANSWER>>>>>>>fiberoptic endoscopy (safe only if patient's vital signs are relatively stable) Medical treatment for upper GI bleed - ANSWER>>>>>>>NG tube (remove residual thrombus in stomach), clotting factors, H2 antagonists/PPI/antacids, vasopressin, fiberoptic endoscopy, angiography, balloon tamponade Indications for surgery for upper GI bleed - ANSWER>>>>>>>exsanguinating hemorrhage, profuse bleeding (esp assoc w/ hypotension), continued hemorrhage (despite resuscitation treatment), recurrent bleeding (after initial cessation) Dx: Lower GI bleed - ANSWER>>>>>>>anorectal exam (det source), rule out upper GI bleed (NG tube, endoscopy), colonoscopy/anoscopy (to locate lower GI bleed) Next step: lower GI bleed that stops - ANSWER>>>>>>>barium enema or colonoscopy (rule our diverticulosis or colon carcinoma) Next step: lower GI bleed that continues - ANSWER>>>>>>>angiography and radionuclide scanning (to ID bleeding site; no barium enema or colonoscopy) Indications for surgery w/ lower GI bleed - ANSWER>>>>>>>persistent bleeding Pathophysiology of Zenker's diverticulum - ANSWER>>>>>>>cricopharyngeal dysfunction (uncoordinated relaxation in UES and contraction of pharynx - > increased P) Dx? dysphagia, halitosis, regurgitation of undigested food, nocturnal aspiration, recurrent aspiration pneumonia - ANSWER>>>>>>>Zenker's diverticulum Dx: Zenker's diverticulum - ANSWER>>>>>>>H/P (usually sufficient), barium swallow, endoscopy (contraindicated if Zenker's documented on barium swallow but indicated if diverticulum NOT seen on barium swallow) Tx: Zenker's diverticulum - ANSWER>>>>>>>cricopharyngeal myotomy Dx? dysphagia followed by regurgitation and weight loss frequently w/ respiratory symptoms caused by aspiration - ANSWER>>>>>>>achalasia Dx: Achalasia - ANSWER>>>>>>>barium swallow (bird's beak), esophageal manometry (high resting LES pressure, failure relaxation during swallowing, high resting
Tx: Strictures secondary to reflux or esophagitis - ANSWER>>>>>>>dilation (first), antireflux operation, reconstructive procedure (if first 2 don't work) Dx: leiomyoma of esophagus (benign) - ANSWER>>>>>>>Hx dysphagia, barium swallow (localized smooth filling defect in esophageal wall), esophagoscopy (confirmatory), biopsy CONTRAINDICATED (violates mucosa - > difficult for subsequent surgery), endoscopic ultrasound (confirm location of lesion) Tx: leiomyoma of esophagus (benign) - ANSWER>>>>>>>enucleation (without violating the mucosa) Dx: benign intraluminal tumors (mucosal polyps, lipomas, fibrolipomas, myxofibromas) - ANSWER>>>>>>>radiographs (suggestive), esophagoscopy (confirmatory and rule out malignancy) Tx: benign intraluminal tumors (mucosal polyps, lipomas, fibrolipomas, myxofibromas) - ANSWER>>>>>>>esophagotomy (not endoscopy b/c of possibility of esophageal perforation) Dx: malignant esophageal tumors (SCC, adenocarcinoma) - ANSWER>>>>>>>Hx dysphagia/weightloss, contrast study (location & extent of tumor), CT (LN spread), esophagoscopy (for tissue diagnosis & det extent of tumor), EUS (assess depth & invasion of staging), bronchoscopy (assess invasion of tracheobronchial tree) Tx: malignant esophageal tumors (SCC, adenocarcinoma) - ANSWER>>>>>>>esophagectomy, RT/chemo Dx? severe chest pain crepitation in neck Hamman's sign (crunching sound over heart) septic shock can occur CXR = air in mediastinum (possibly widened mediastinum) - ANSWER>>>>>>>esophageal perforation Dx: Mallory-Weiss syndrome - ANSWER>>>>>>>endoscopy (to locate tear & rule out other causes of bleeding) Tx: Mallory-Weiss syndrome - ANSWER>>>>>>>supportive (replace blood volume, antacids, gastric lavage) Dx? middle age, edentulous women atrophic oral mucosa, anemia, dysphagia - ANSWER>>>>>>>Plummer-Vinson Syndrome
Upper esophageal webs are part of this syndrome w/ anemia, dysphagia, glossitis - ANSWER>>>>>>>Plummer-Vinson Lower esophageal webs (aka Schatzki's rings) are associated w/ this condition ____ - ANSWER>>>>>>>reflux Tx: upper & lower esophageal webs - ANSWER>>>>>>>esophageal dilation Name the type of gastric ulcer: within body of stomach usually along lesser curve at incisura angularis - ANSWER>>>>>>> Name the type of gastric ulcer: occurs in the body of stomach in combo w/ duodenal ulcers associated w/ acid oversecretion - ANSWER>>>>>>> Name the type of gastric ulcer: develop in pyloric channel associated w/ acid oversecretion - ANSWER>>>>>>> Name the type of gastric ulcer: high in the stomach adjacent to the esophagus - ANSWER>>>>>>> Name the type of gastric ulcer: secondary to chronic NSAID and aspirin use occur throughout the stomach - ANSWER>>>>>>> Dx? burning midepigastric pain stimulated by or following eating - ANSWER>>>>>>>gastric ulcer Dx: Gastric Ulcer - ANSWER>>>>>>>upper GI radiographs (show barium in ulcer crater), endoscopy, H. pylori tests (urease breath test, biopsy, Ab titer) Indications for surgery w/ gastric ulcer - ANSWER>>>>>>>intractable to medical therapy (or recurrence after medical therapy), bleeding (not controlled by endoscopy or medical therapy), perforation, gastric outlet obstruction, malignancy can't be excluded Surgical procedure for gastric ulcer type I: - ANSWER>>>>>>>hemigastrectomy (gastroduodenal anastomosis aka Billroth I = if duodenum can be mobilized, II = if duodenum can't be mobilized) Surgical procedure for gastric ulcer types II & III: - ANSWER>>>>>>>Vagotomy w/ antrectomy, excision of ulcer (decrease acid secretion)
Dx: gastric adenocarcinoma - ANSWER>>>>>>>Upper GI series (suggests Dx), upper endoscopy w/ biopsy (confirmatory) Dx: gastric lymphoma - ANSWER>>>>>>>endoscopy w/ biopsy, endoscopic ultrasound (for staging), bone marrow biopsy (assess for distant disease), CT (chest, abdomen, pelvis), upper airway exam, H. pylori testing immunohistochemical staining for GIST - ANSWER>>>>>>>CD 117 Tx: gastric lymphoma - ANSWER>>>>>>>RT/chemo (first line = CHOP cyclophosphamide, hydroxydaunomycin, oncovin, prednisone) Tx: GIST - ANSWER>>>>>>>surgical resection Dx? sudden onset of massive upper GI bleeding w/ associated hypotension - ANSWER>>>>>>>dieulafoy's gastric lesion (from abnormally large tortuous artery in submucosa) Dx: dieulafoy's gastric lesion - ANSWER>>>>>>>endoscopy (Dx and Tx) Tx: dieulafoy's gastric lesion - ANSWER>>>>>>>endoscopy (Dx and Tx) Dx? Borchardt's triad: sudden onset of constant, severe abdominal pain wretching without vomitus inability to pass NG tube - ANSWER>>>>>>>gastric volvulus Dx? vomiting & post-prandial pain in young, thin women associated w/ lack of retroperitoneal fat cushion, prolonged immobilization, pressure - ANSWER>>>>>>>SMA syndrome (aka cast syndrome = 3rd portion of duodenum obstructed by SMA) 4 postgastrectomy syndromes - ANSWER>>>>>>>alkaline reflux gastritis, afferent loop syndrome, dumping syndrome, postvagotomy diarrhea Dx? post-gastrectomy postprandial epigastric pain, nausea, vomiting, weight loss endoscopy demonstrates gastritis & free reflux of bile - ANSWER>>>>>>>alkaline reflux gastritis
Tx: alkaline reflux gastritis - ANSWER>>>>>>>conversion of a Billroth - > Roux-en Y anastomosis Dx? post-gastrectomy early postprandial distention, pain, nausea relieved by vomiting of bilious material not mixed w/ food - ANSWER>>>>>>>afferent loop syndrome Tx: afferent loop syndrome - ANSWER>>>>>>>good drainage of afferent loop, conversion to Roux-en Y anastomosis Dx? post-gastrectomy epigastric fullness or pain nausea, palpitations, dizziness, diarrhea, tachycardia, elevated BP - ANSWER>>>>>>>dumping syndrome (can be early or late) Tx: dumping syndrome - ANSWER>>>>>>>octreotide (symptomatic control), avoid high carb diets/no fluids w/ meals, surgical (interposition of an antiperistaltic jejunal loop btwn stomach & small bowel or conversion to long limb Roux-en Y reconstruction) Most common cause of small bowel obstruction? - ANSWER>>>>>>>adhesions Dx? crampy abdominal pain, nausea, vomiting, abdominal distention
- usually do not pass flatus or bowel movements - ANSWER>>>>>>>small bowel obstruction Dx: small bowel obstruction - ANSWER>>>>>>>abdominal X ray (dilated loops of small bowel on flat plate & air fluid levels on upright), CT (to localize point of obstruction) Tx: small bowel obstruction - ANSWER>>>>>>>resuscitation w/ IV fluids, NG tube decompression, urinary catheter, abdominal exploration (w/ peritoneal signs, leukocytosis, fever, or failure or resolution of obstructive symptoms) Tx: GIST in small intestine - ANSWER>>>>>>>wide surgical resection, imatinib (for unresectable or metastatic GIST) Tx: adenocarcinoma of 1st and 2nd portions of duodenum - ANSWER>>>>>>>whipple (pancreaticoduodenectomy; unresectable tumors should e palliated by gastrojejeunostomy or stens) Tx: adenocarcinoma of distal duodenum and small bowel - ANSWER>>>>>>>wide local resection (of bowel & intervening mesentary) Dx?
