Alimentary Tract
The Esophagus
Dysphagia --> barrium swallow for diverticulum, obstruction (ring, barret, stricture, cancer), or motor disorde
Odynophagia --> infection v. inflammation, v. caustic injestion
Esophageal Cancer
Dx: Patients often present with dysphagia and weight loss.
Start with a barium swallow to identify a mass or stricture.
Upper endoscopy is used for tissue diagnosis.
Endoscopic ultrasound determines level of invasion and the need for neoadjuvant therapy.
T2 invades muscularis propria
T3 invades adventitia
Preoperative workup includes pulmonary function test and stress test as indicated.
Tx: Is based on stage.
T2, T3, or N1 gets neoadjuvant therapy followed by re-staging and resection.
Ivor-Lewis Esophagectomy versus transhiatal esophagectomy is used for resectable T1 disease. Transhiatal esophagectomy has anastamosis in the neck, which allows reopening of the cervical incision in the case of leak. It is also more difficult perform a complete en-bloc lymphadenectomy in the chest without a thoracic incision.
Chemo: 5FU, cisplain; XRT postop.
Special topics in esophageal cancer
Tracheal involvement is suspected for upper and middle third esophageal leaions and warrant bronchoscopy.
Postoperative leak is managed by opening the cervical incision at bedside for transhiatal esophagectomy. If septic in the abdomen or chest, will need operative drainage. May need a diverting esophagostomy if the leak is caught late.
Unresectable disease is determined by the presence of:
distant metastasis
paratracheal, celiac, or mediastinal lymph nodes (not paraesophageal nodes)
bronchoesophageal fistula or tracheal invasion
Neoadjuvant therapy is used for T2, T3, or N1 disease. Use 5FU, cisplatin, and XRT.
Zenker’s Diverticulum
Dx: Patients present with halitosis, regurgitation, and feeling of food sticking in neck, dysphagia.
Start with a barium swallow to identify a diverticulum versus obstruction versus motor abnormality.
Do not do endoscopy first due to risk of perforation
Tx: diverticulectomy and crycopharyngeus myotomy through a left neck incision.
Diverticuli < 2cm can have myotomy along.
Diverticuli > 2cm need diverticulectomy.
Endoscopic treatment is increasingly used for diverticuli >2cm
Special topics:
Esophageal perforation during myotomy should be closed in layers. The myotomy can be repeated in a separate area.
Leave a drain in cases of perforation.
Achalasia
Dx: Patients present with dysphagia, regurgitation, weight loss, feeling of food getting stuck.
Start with a barium swallow to identify a bird’s beak esophagus.
Endoscopy with biopsy to rule out cancer.
Mannometry reveals LES > 30mmHg, incomplete relaxation of LES, and aperistalsis.
Tx: Heller myotomy of the LES extending 2cm onto stomach and 4cm along esophagus
Include a Dor (anterior) or Toupe (posterior) partial fundoplication over a bougie
Postoperative reflux occurs up to 40% and is treated with PPI and lifestyle changes.
Postoperative dysphagia requires reimaging with an upper GI and endoscopy. Biopsy to rule out cancer. May need dilation. May need re-myomectomy if incomplete myotomy. Esophagectomy is a last resort.
Motor Disorders
Tx: ISDN, diltizem, can balloon for Hypertensive LES
Hypertensive LES= LES > 45mmHg
Diffuse esophageal spasm= high amplitude simultaneous (not peristaltic) contrastions on mannometry in > 1 of 5 swallows alternating with normal peristalsis
Nutcracker esophagus= high amplitude contractions with normal peristaltic movement
Gastroesophageal Reflux Disease (GERD)
Dx: Patients present with reflux, frequent pneumonias, voice changes.
Start with a barium swallow to look for a lesion or hiatal hernia.
Endoscopy looks for Barrett’s changes or H pylori and gives stage; biopsy multiple locations in periphery and in any ulcer base.
Stage 1= erythema
Stage 2= mild ulceration
Stage 3= extensive ulceration, cobblestoning
Stage 4= stricture, fibrosis
Manometry is diagnostic for GERD if LES < 6mmHg, LES < 2cm in length, and LES < 1cm in intraabdominal length.
A 24hr pH probe confirms the presence of reflux if pH<4 for > 1.5hrs or any reflux at night and can establish relationship between symptoms and reflux.
Tx: Surgery is indicated for persistant symptoms > 8wk despite medical treatment (double dose PPI, wt loss, elevating HOB), abnormal pH testing despite maximal PPI, hiatal hernia > 3cm, or complications (pneumonia, Barrett’s changes, strictures).
need manometry to rule out motility disorder.
Nissen improves symptoms and complications better than medication. It may also reverse Barrett’s changes but results are not definitive.
GERD with stricture should have several sessions of dilation preop. If the lesions is not able to be dilated, may need short segment esophagectomy.
Barrett’s Esophagus
5-10% of GERD can progress to low grade dysplasia.
2% of Barrett’s progress to esophageal cancer.
Dx: Patients can present with GERD symptoms.
Start with barium swallow to look for a lesion.
Endoscopy is used for biopsy diagnosis and to rule out cancer. Surveillance is q6mo EGD with biopsy; change to anually if no change twice.
Manometry and pH probe is used as for GERD.
Tx: Management depends on symptoms and pathology from endoscopy.
Symptomatic barretts not responsive to meds à Nissen.
Severe dysplasia confirmed by 2 pathologists à esophagectomy (25% have cancer).
Undilatable stricture à esophagectomy.
Perforation of Barrett’s à segmental esophagectomy, gastrostomy, cervical esophagostomy, and delayed reconstruction.
Esophageal Perforation
Dx: This often presents after endoscopy for a lesion or after dilation of a lesion. Symptoms are vague but include chest pain, tachycardia, fevers.
Start with gastrograffin swallow (less sensitive but less mediastinal inflammation if leak is present)
Can proceed to barium swallow if gastrograffin is normal.
Tx: Management depends on timing of perforation. All include antibiotics and drainage.
Early (<24 hours) perforation without shock can get esophageal repair. A mass or stricture will need resection or myotomy at the same time. The repair is bolstered with intercostals muscle flap or stomach wrap. Debride and drain mediastinum well with 2 chest tube. Use NG tube for decompression.
Late (>24 hours) will require damage control. Patients in shock will require a left posterolateral thoracotomy with drainage of perforation and chest tubes. Stable patients can undergo segmental esophagectomy, cervical esophagostomy for diversion, and feeding gastrostomy.
Esophageal Varices
Dx: Patients can present with acute bleeding, are often cirrhotic.
Tx: Surgical treatment is becoming rare, but emergency H type Mesocaval shunt (8mm prosthetic graft from IVC to IMV just distal to uncinate process) can be performed for acute bleeding.
Start with resuscitation and medical therapy (PPI, Abx, somatostatic/octreotide 50mcg then 50mcg/hr)
Next, perform EGD with sclerotherapy and banding.
If bleeding is not controlled, perform balloon tamponade and TIPS.
Consider liver transplant.
Stomach and Ulcer disease
Gastric Cancer
Dx: Patients can have risk factors like smoking, pernicious anemia, blood group A, heavy nitrate consumption, genetic predisposition. The can present with weight loss, GI bleeding, perforation.
Tissue diagnosis is with endoscopy.
CT chest / abdomen / pelvis are for staging.
Tx: Best option in the United States appears to be the gastrectomy with modified D2 lymphadenectomy (includes omentectomy, perigastric, periportal, and peripancreatic lymph nodes).
Neoadjuvent for T2 or N1.
Extent of gastrectomy depends on location of lesion. You need a 6cm margin.
Unresectable if peritoneal involvement, mets, local invasion, encasement of vessels.
Get frozen sections of the margins to ensure 6cm margin
Roux-en-y gastrojejunostomy or esophagojejunostomy is used for reconstruction. The Roux-en-y limb is ~30cm from the ligament of treitz and is a 45cm roux limb.
Adjuvent therapy for T2, N+, or R1; includes 5FU and Cisplatinand XRT
GIST (gastrointestinal stromal tumor)
Tx: wedge resection with grossly and histologically negative margins
Hiatal Hernias
Sx: 65-75yo, obstruction, bleeding, dysphagia, reflux, chest pain, iron deficency anemia, asymptomatic.
Cameron lesions= linear gastric ulcers on lesser curve of stomach from trauma, acid, ischemia.
Dx: Patients can present with epigastric pain, anemia, GERD, or gastric volvulus (unlikely with sliding hernia). Determine type of hernia with endoscopy.
Type 1= GE junction is in the chest (sliding hernia).
Type 2= normal position of GE junction.
Type 3= combined type 1 & 2 where esophageal shortening brought the GE junction into the chest.
Type 4= another organ enters the chest.
Tx:
indicated for symptomatic hernias
Repair of the hernia defect, often with mesh. If stomach needs anchoring, do a stamm gastrostomy. Nissen wrap is also included. Type 3 hernia often needs Colles gastroplasty due to esophageal shortening.
Gastric Ulcer Disease
Dx: Determine location endoscopically.
Type 1= lesser curve
Type 2= body and duodenal (acid related)
Type 3= prepyloric (acid related)
Type 4= GE junction
Type 5= anywhere in stomach (NSAID related)
Tx: Can give PPI for 2 weeks, stop NSAID, treat H. pylori. Need EGD if symptoms not relived after 2 weeks.
Chronic ulcerà biopsy to look for malignancy.
If indeterminant repeat EGD in 6 weeks.
If not resolved in 6 weeks treatment, need resection.
H pylori à amoxicillin, clarithramycin, and PPI for 14 days
MALT à H. pylori treatment.
Bleeding à wedge resection, type 2 or 3 get pyloroplasty and vagotomy if stable.
Perforationà wedge resection and gram patch (can just biopsy and patch if not stable). Also consider pyloroplasty and vagotomy in type 2 or 3.
Resections:
Type 1à antrectomy and B1
Type 2/3à vagotomy and antrectomy, B1 or B2
Type 4à resection
Duodenal Ulcer Disease
Dx: Patients present with bleeding, perforation, or pain.
Free air is seen on CXR.
Endoscopy can identify and treat bleeding or H. pylori.
Tx: Management depends on presentation. All test for and treat H. pylori if present. Endoscopy is first line for bleeding if resuscitated.
Active bleeding gets 3 point U stitch to ulcer, pyloroplasty , and truncal vagotomy (need PPI if omit vagotomy). Criteria for operating on bleeding includes:
> 6 units blood transfusion in 24 hrs
Re-bleeding in the hospital
Rebleeding after endoscopic treatment
Shock
Chronic bleeding gets truncal vagotomy and antrectomy.
Perforated ulcers get Graham patch and proximal gastric vagotomy (needs PPI if omit vagotomy)
Obstructing duodenal ulcer gets NG tube for 5 days, upper GI series, PPI, electrolyte replacement, and truncal vagotomy and antrectomy once resuscitated.
Intractable ulcer gets proximal gastric vagotomy.
Difficult duodenal stump gets lateral duodenostomy.
Proximal gastric vagotomy has a 20% recurrence rate. Truncal vagotomy has a 5% recurrence rate.
Recurrent Peptic Ulcer Disease
Dx: Workup includes fasting gastrin, CMP, PTH, H. pyloi (biopsy or urea breath test for cure)
Elevated gastrin:
Secretin stim test = gastrinoma
Technetium scan = retained antrum
Protein load test = G-cell hyperplasia
Sham feeding test = incomplete vagotomy
Normal gastrin:
Hyperparathyroidism
H. pylori
Bile gastritis
NSAIDs
Small bowel
Appendicitis
Dx: RLQ pain
CT
Tx
appendectomy
nonoperative management
Overall societal costs less than surgery
reserved for uncomplicated appendicitis (no appendicolith or perforation)
49% of pts require operation at 4yrs
not more likely to have complications than with appy
Small Bowel Obstruction
Dx: Patients present with obstipation, constipation, abdominal pain, nausea, vomiting.
Look for hernias or surgical scars.
X-rays can identify dilated bowel loops, air fluid levels, or free air.
CT scan with contrast can identify sites of obstruction. Oral contrast can also help differentiate a SBO that is likely to resolve on its own versus a high grade bowel obstruction that will need surgical treatment. Free fluid > 500ml is predictor of failure of nonop tx.
Obturator hernias can be difficult to diagnose, but have fluid outside the pubic ramus.
Tx: Can wait 3-5 days with NG tube and IVF if there is previous surgery, no sign of bowel ischemia, or hernias.
Gallstone ileus is treated with longitudinal incision proximal to the stone and transverse closure.
Femoral herias can be treated with a transverse incision just above the bulge under the inguinal ligament, open sac and reduce bowel if viable. Then resect the sac and close cooper ligament to inguinal ligament. If bowel is not viable, hold the bowel and do lower midline incision for bowel resection.
Inguinal hernia with ischemic bowel is repaired without mesh using the modified Bassini repair where the conjoint tendon is approximated to poupart ligament. Imbricate the transversalis fascia with continuous 2-0 prolene. Close the conjoint tendon to iliopubic tract and inguinal ligament.
Cooper / McVay repair is done through a transverse groin incision. The external oblique fibers are separated. Internal oblique and internal ring/floor are opened. The preperitoneal tissue is imbricated. The conjoint tendon is closed to cooper’s ligament. A transition stitch is used from conjoint tendon to inguinal ligament to close femoral space. The internal ring is closed by joining conjoint tendon to inguinal ligament.
Tx: can wait 2wk non operative tx for early postoperative SBO.
Enterocutaneous Fistula
Dx: Find the cause, often revealed by the history. FRIEND = foreign body, radiation, infection, epithelialization, nelplasm, distal obstruction.
Quantify output (low output is < 600ml/day)
CT abdomen / pelvis evaluates for undrained abscess.
Risk factors for failure of nonop tx: output > 500ml/d, fistula <2cm long, lateral bowel wall, multiple fistulas, inflammation.
Tx: First resuscitate, contain infection, and optimize nutrition.
Medical management includes making NPO, TPN, octreotide, antibiotics for infection, PPI/H2 blocker to decrease gastric secretion, antimotility agents.
can limit to < 1L hypotonic fluid daily if trying PO
start with PPI and loperamide; add codeine if refractory; octreotide 3rd line.
High output fistulas are unlikely to be controlled with medical management alone.
Surgery is for failure of medical management, bleeding, uncontrolled infection, complete distal obstruction, or removal of foreign body.
Radiation Enteritis
Dx: Patient present with abdominal pain, diarrhea, and a history of radiation exposure. Colonoscopy and biopsy reveals obliterative endarteristis, necrosis, and ulceration.
Tx: Surgery is used for non healing fistula or obstruction
Consider ureteral stents.
Resect / ansastamose if possible; bypass if not.
Don't do stricturoplasty if resection is possible.
Can do a frozen section prior to anastamosis.
Meckel Diverticulum
2% of general population
malignancy 5-17%
Tx
resect incidentally if patient < 50yo, male, diverticulum > 2cm long, or abnormal features in diverticulum -- leave in place if none of these features and asymptomatic.
diverticulectomy for > 2cm with simple diverticulitis, bleeding, or incidental as above
segmental or wedge resection for complicated diverticulitis or obstruction, or < 2cm with simple diverticulitis, bleeding, or incidental as above.
SMA Syndrome
Sx: nausea, vomiting, wt loss, pain to epigastrum
Dx: CT SMA-Aorta angle < 25 degrees compresses 3rd part of duodenum.
Tx
electrolyte correction
duodenal-jejunostomy
Carcinoid Tumors
Dx: Carcinoid syndrome is flushing, dermatitis, diarrhea, dementia (the 3 D’s) diagnosed with increased 24 hour urine 5HIAA and chromogranin A.
Localized with octreotide scan, MIBG, endoscopy, CT, MRI, IOUS.
Ask about MEN I symptoms
Tx:
Appediceal tumor < 2cm and not at base can get simple appendectomy. Right hemicolectomy if at base or > 2cm.
Rectal tumor <2cm can get local excision.
Rectal tumor > 2cm, invasion of muscularis mucosa, or recurrence requires APR.
Small bowel carcinoid gets resection with mesenteric lymph nodes.
Duodenal tumor < 2cm gets local resection unless it invades muscularis mucosa.
Duodenal tumor > 2cm, near the ampula, or invading muscularis mucosa requires Whipple.
Liver tumor can get resection or ablation
Palliation is with somatostatin, debulking, and cholecystectomy
Chemotherapy is streptozocin.
Can use XRT.
Short Bowel Syndrome
Risk with < 180cm small bowel
require permanent IV nutrition for < 60cm with colon in continuity or < 120cm without colon continuity
improved outcome if have terminal ileum
less likely to need TPN if have ileocecal valve
GLP-2 can increase likelyhood of weaning off TPN.
Crohn’s Disease
Workup: AXR, colonoscopy (cx, biopsy)
Skip lesions, granulomas
Meckel’s scan can r/o bleeding from meckel
UGI with SBFT
CT a/p
Initial tx:
Sulfasalazine 0.5mg TID, or 5ASA
Prednisone for flares
Flagyl for rectal and anal dz
AZA or 6MP for resistance (results in bone marrow suppression and pancreatitis)
Steroid enemas
Lomotil
Low residue diet, B12
Remicade
Surgery for:
Obstruction
Bleeding
Perforation
Non-healing fistula
Abscess
In surgery:
Resect grossly involved bowel
Gastrojejunostomy to bypass involved duodenum
Fistula --> take down and resect small bowel (leave colon/bladder)
For intractable colon --> proctocolectomy with permanent ileostomy
Perianal complications --> I&D and fistulotomy, rarely do proctocolectomy
Ulcerative Colitis
5% get colorectal ca; cancer causes death in 15% of US patients
Screening colonoscopy within 8yrs of dx and then every 1-3yrs
Workup= AXR, colonoscopy (cx, biopsy)
rectum always involved, continuous proximally, mucosa and submucosa only
Toxic megacolon gets ICU, abx, IVF, T&C, steroids, npo, serial exam/xray
OR if no improvement in 24-48hrs
Get subtotal colectomy and ileostomy
Less acute gets: UGI with SBFT to r/o crohns
Medical Tx:
Sulfasalazine
5ASA
Steroids
AZA
6MP
Lomotil
Surgery for acute complications:
Perforation
Non-improving toxic megacolon
Severe bleeding
all get subtotal colectomy with end ileostomy.
Surgery for chronic disease
Get anal manometry before resection
Normal anal sphincter --> total colectomy with anorectal mucosectomy and ileorectal pull through.
Complications: 5-7BM per day, loose BM, anal leakage, incontinence, pouchitis, anastamotic leak, sexual dysfunction
Rectal incontinence or severe rectal disease --> total proctocolectomy with ileostomy.
Colon
Colonoscopy surveillance
For asymptomatic average risk patients:
Low risk= any hyperplastic polyps; 1-2 adenoma < 1cm
repeat colonoscopy 10yrs
high risk= 3 adenomatous polyp, any adenoma > 1cm, high grade dysplasia, villous adenoma, serrated polyp
repeat colonoscopy 3-5yr
any adenoma removed in peicemeal should have 6mo repeat colonoscopy to verify total removal
IBD patients should have surveilance colonoscopy 8yrs after diagnosis
Colon Polyps
Colon polyps with cancer require surgery for:
<2mm margin
lymphovascular invasion
not well differentiated
sessile polyp
Rectal poylp that cannot be fully excised and <7cm from anal verge can have transrectal excision; however, if it is > T1 (submucosal invasion), it will need APR.
Transrectal excision (increased local recurrence) can be used for:
tumor < 4cm
< 1/3 the circumference
well differentiated
no lymphovascular invasion
poor surgical candidate
Colorectal Cancer
Dx: Patients present on screening exams, with blood per rectum, perforation, or obstruction.
Obtain CBC, CMP, CEA, CT abdomen/pelvis.
Complete colonoscopy for tissue diagnosis.
Transrectal ultrasound (TRUS) is required for staging rectal cancer.
Tx:
Use neoadjuvant chemo XRT for T3 or N1 rectal cancer: 5FU and XRT for 4wks, wait 4wks then surgery.
Colectomy includes 1 vessel above and 1 vessel below:
Adjuvent chemo for rectal ca --> T3 or N+ (FOLFOX)
Adjuvent chemo for colon ca --> T3/4 with obstruction, perforation, or >50yo; any N+ (FOLFOX) for 6mo; XRT for T4 or recurrant dz.
Follow CEA postoperative every 6 months for 5yrs. If elevated CEA:
Repeat CEA in 2 weeks, check CT chest / abdmen / pelvis, colonoscopy, PET.
Unresectable disease needs chemotherapy.
If unable to localize, do exploratory laparotomy and look at liver, lymph nodes, retroperitoneum, and all surfaces.
Unresectable disease found during re-exploration needs intraoperative brachytherapy or intraoperative tumor marking for future XRT.
Avastin for metastatic or recurrent (do not operate on avastin for 4 weeks due to bleeding and poor healing)
Cecal Volvulus
Dx: Patient present with colonic obstruction, abdominal pain, and distention.
Abdominal series or CT scan can show volvulus
Colonoscopy can occasionally be used to de-tourse
Tx: Right hemicolectomy is standard treatment after resuscitation.
Colonoscopic de-toursion alone has high recurrence
Cecopexy or cecostomy can be used in high risk patients.
Sigmoid Volvulus
Dx: AXR, CT
Tx:
1- start with endoscopic decompression (immediate resection has higher morbidity)
2- emergent resection for failure to decompress, perforation
3- non-emergent resection once decompressed and resuscitated
Diverticulitis
Dx: Hx, labs, Px, CT
CRP > 150 is suggestive of complicated diverticulitis.
Hinchey
0= mild; CT with colonic thickening and divertics
Ia= pericolic phlegmon
Ib= pericolic abscess
II= deep pelvic/retroperitoneal abscess
III= pneumo, purulent peritonitis
IV= fecal peritonitis
Tx:
Hinchey 1 may not need abx
IR drain for abscess > 3cm
evaluate colon after sucessful non-op tx
elective colectomy for fistula, obstruction, stricture complications
immunosuppression does not increase risk of recurrence but does increase risk of surgery
emergent resection for diffuse peritonitis or failure of non-op. Rsxn should include entire sigmoid.
Hartman
primary anastamosis with loop ileostomy
primary anastamosis
Anaorectal
Anal Cancer
Dx: Patients may be immunosuppressed, presenting with trismus, bleeding, or a mass.
Perform a skin and lymph node exam.
Anoscopy, proctoscopy, and colonoscopy to define lesion, get tissue, and fully evaluate the colon.
FNA of any suspicious inguinal nodes.
Tx: Management depends on location.
Anal margin (intersphincteric groove to 5cm around perineum - or approximatly distal to dentate line) cancer needs a 0.5cm margin wide local excision
Anal canal (proximal to dentate line) gets Nigro protocol (XRT flanked with 5FU & mitomycin C).
Re-examine and biopsy and suspicious areas.
Can repeat Nigro once.
Re-examine and if biopsy is positive, will need APR. If inguinal nodes remain positive, will need lymph node dissection.
Superficial groin dissection:
Raise flaps just deep to scarpa's fascia.
lateral to sartorius.
medial to aductor magnus.
Inferior to apex above muscles and divide saphenous vein.
Superior above inguinal ligament.
Excise fatty tissue above the SFA adventitia.
Work inferior to superior, then lateral to medial.
Divide saphenofemoral junction.
Reach cloque's node under inguinal ligament.
Deep groin dissection:
Retroperitoneal dissection
Circumferential dissection of nodes off external iliac to common iliac artery.
Rectovaginal Fistula
Dx: Patients present with stool in the vagina.
Low fistulas are usually obstetric injury and less complicated.
High fistulas can be from diverticulitis, cancer, crohns, and are more complex
Workup includes CT abdomen / pelvis with rectal contrast, colonoscopy, and evaluation of internal sphincter function.
Tx: Management depends on location.
High fistulas likely need sigmoid colectomy.
Low fistulas can be treated with an advancement flap:
prone position, prep anus and vagina
elevated trapezoidal flap with the apex at the fistula to include mucosa, submucosa, and circular muscle (internal sphincter).
Mobilize surrounding internal sphincter to close longitudinally with 2-0 dexon (plication sphincteroplasty).
Excise flap excess including fistula and close with 3-0 dexon.
Anal Incontinence
Dx: Evaluate internal sphincter function.
Anal manometry.
Transanal ultrasound= can identify sphincter defects.
Pudendal nerve studies.
Tx: Use fiber (30g/day), caffeine avoidance, antidiarrheals, regular enemas prior to surgical therapy. Use surgery if a sphincter abnormality is found.
Plication sphincteroplasty:
Lithotomy position.
Semicircular incision anterior to anus.
Elevate anoderm in the submucosal plane.
Deep - Identify the internal sphincter.
Laterally - identify transverse perineal muscle.
Deep to intenal sphincters - identify levators.
Plicate levators.
Plicate transverse perineal muscle.
Plicate internal sphincter.
Rectal Prolapse
Dx: Patient present with tenesmus, prolapse, incontinance, possibly constipation.
Physical exam give type of prolapse
Type I
Type II
Type III
prolapsed mucosa only
full thickness prolapse
full thickness with perineal hernia
Colonoscopy to ensure no other lesions.
Anoretal manometry.
colonic transit study.
Dx: Start with medical treatment including biofeedback and fiber.
Surgical treatment is based on type of prolapse:
Type I = hemorrhoidectomy
Type II = transabdominal rectopexy, may need sigmoidectomy for redundant sigmoid
Type III = modified altmeyer procedure
Modified Altmeyer procedure:
Prone jack-knife position.
Lone star retractor.
Full thickness incision 1cm above dentate line.
Open hernia sac anteriorly and free rectum circumferentially
Transect rectum / sigmoid when redundancy ends.
Plicate levator muscles.
Hand sewn anastamosis.
** Can't do this after prior sigmoidectomy due to blood supply **
Radiation enteritis
Sx: diarrhea, abdominal pain/cramps
Dx: rule out infection, cancer, or obstruction
Tx: loperamide (improves bile acid absorption and slows transit time)
Special topics
Sengstaken-blakemore tube= for bleeding varicees. Inflate gastric baloon in stomach with 250ml air after check CXR to confirm placement. Apply 1kg traction. Inflate esopageal tube to 45mmHg for additional bleeding. Deflate esopageal 5min every 6hrs, can leave in for 24hrs.
Management of ureteral injury:
Below pelvic brim --> reimplant with a stent
Mid ureter --> repair over a stent; reimplant with psoas hitch and stent
Upper ureter --> transureteroureterostomy; nephrostomy, and wait for urology
Lower GI bleeding
Dx:
Colonoscopy
CTA detects bleeding 0.3ml/min, should be used prior to angiogram (does not increase risk if CIN and increases therapeutic yield).
angiogram, detects 0.5ml/min bleeding and used for therapy after CTA locates bleeding
Technetium 99m labeled RBC scan detecs 0.1ml/min bleeding but is poor at localization
Macrocytic anemia
from lack of intrinsic factor (vitamin B12 deficency)
caused by gastrectomy, chronic gastritis, autoimmune disease
Bariatric induced vitamin deficency
Protein
B12 (cyanocobalamine) deficency= megaloblastic anemia, neuropathy, spastic paresis
B1 (thiamine) deficency= Beriberi
Wet Beriberi Sx: tachycardia, right heart failure, hypertension, vasodilatory edema, respiratory problems
Dry Beriberi Sx: neuropathy, myalgia, atrophy, paraplegia
Wernicke-Korsakoff syndrome Sx: ataxia, oculmotor problems, coma with 20% mortality
Vitamin D
Vitamin A deficency= opthalmic problems
Iron deficency= microcytic anemia
Calcium
Antibiotic Duration
Familial adenomatous polyposis (FAP)
APC gene defect
autosomal dominant
Sx: have innumerable polyps in colon/rectal, can have rectal sparing
100% risk of colon cancer if not resected
also increased risk of gastric, duodenal, small bowel, and desmoid tumors
Tx:
prophylactic surgery in 20s to prevent cancer
Total proctocolectomy with ileal pouch anal anastamosis (IPAA)
total colectomy with ileal rectal anastamosis if rectal sparing.
Lynch Syndrome
Colon cancer, uterine cancer
Peutz-Jegher Syndrome
Sx:
hamartomatous and adenomatous polyps in GI tract
increased gastric, small bowel, colon cancers
High risk for for small bowel cancer