General Surgery: Gastrointestinal and Nutritional (PEARLS)

The General Surgery End of Rotation Blueprint gastrointestinal and nutritional section includes 32 topics and represents 50% of your General Surgery EOR exam

Abdominal pain	EPIGASTRIC PAIN: PUD, gastritis, MI, pancreatitis, biliary colic, gastric volvulus, Mallory-Weiss RUQ PAIN: Cholecystitis, hepatitis, PUD, perforated ulcer, pancreatitis, liver tumors, gastritis, hepatic abscess, choledocholithiasis, cholangitis, pyelonephritis, nephrolithiasis, appendicitis (especially during pregnancy); thoracic causes (e.g., pleurisy/pneumonia), PE, pericarditis, MI (especially inferior MI). LUQ PAIN: PUD, perforated ulcer, gastritis, splenic injury, abscess, reflux, dissecting aortic aneurysm, thoracic causes, pyelonephritis, nephrolithiasis, hiatal hernia (strangulated paraesophageal hernia), Boerhaave’s syndrome, Mallory-Weiss tear, splenic artery aneurysm, colon disease. LLQ PAIN: Diverticulitis, sigmoid volvulus, perforated colon, colon cancer, urinary tract infection, small bowel obstruction, inflammatory bowel disease, nephrolithiasis, pyelonephritis, fluid accumulation from aneurysm or perforation, referred hip pain, gynecologic causes, appendicitis (rare). RLQ PAIN: Appendicitis! And same as LLQ; also mesenteric lymphadenitis, cecal diverticulitis, Meckel’s diverticulum, intussusception
Acute and chronic cholecystitis	A 45-year-old woman with RUQ pain for 12 hours, fever, and leukocytosis Presentation: 5 Fs: Female, Fat, Forty, Fertile, Fair (+) Murphy's sign (RUQ pain with GB palpation on inspiration) RUQ pain after a high-fat meal Diagnosis: Ultrasound is the preferred initial imaging Gallbladder wall >3 mm, pericholecystic fluid, gallstones HIDA is the best test (Gold Standard) porcelain gallbladder = chronic cholecystitis Treatment: Cholecystectomy
Acute and chronic pancreatitis	Epigastric pain radiating to back, with nausea and vomiting Acute Pancreatitis - epigastric abdominal pain with radiation to the back and elevated lipase Etiology: Cholelithiasis or alcohol abuse Diagnosis: Clinical + elevated lipase and amylase CT is required to differentiate from necrotic pancreatitis Signs: Grey Turner's sign (flank bruising), Cullen’s sign (bruising near umbilicus) This 40-year-old woman complained of worsening epigastric pain of five days duration. On examination, she had hypotension, a board-like abdomen, and extensive ecchymosis over her right loin (Grey Turner’s sign) Acute pancreatitis with Cullen’s sign Ranson’s criteria for poor prognosis: At admit: Age > 55 Leukocyte: >16,000 Glucose: >200 LDH: >350 AST: >250 At 48 hrs: Arterial PO2: <60 HCO3: <20 Calcium: <8.0 BUN: Increase by 1.8+ Hematocrit: decrease by >10% Fluid sequestration >6L Treatment: IV fluids (best), analgesics, bowel rest Complication: pancreatic pseudocyst (a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue) Chronic Pancreatitis - the classic triad of pancreatic calcification (plain abdominal x-ray), steatorrhea (high fecal fat), and diabetes mellitus Alcohol abuse Treatment: No alcohol, low-fat diet
Anal disease (fissures, abscess, fistula)	Excruciating pain with bowel movement (anal fissure) Anorectal abscess is a result of infection, whereas fistula is a chronic complication of an abscess. Produce painful swelling at the anus as well as painful defecation. Examination reveals localized tenderness, erythema, swelling, and fluctuance; fever is uncommon. Deeper abscesses may produce buttock or coccyx pain and rectal fullness; fever is more likely. Treatment of abscess requires surgical drainage, followed by warm-water cleansing, analgesics, stool softeners, and a high-fiber diet are prescribed for all patients Many abscesses can be drained as an in-office procedure; deeper abscesses may require drainage in the operating room. Antibiotics are needed for high-risk patients Anorectal fistula is an open tract between two epithelium-lined areas and is associated with deeper anorectal abscesses Fistulae will produce anal discharge and pain when the tract becomes occluded. Fistula must be treated surgically Anal fissure Tearing rectal pain and bleeding which occurs with or shortly after defecation, bright red blood on toilet paper Superficial laceration (paper cut like) Pain lasts for several hours and subsides until the next bowel movement Treatment: Sitz baths, increase dietary fiber, and water intake, stool softeners or laxatives Usually heals in 6 weeks Botulinum toxin A injection (if failed conservative treatment)
Anorexia	Think Appendicitis - Classic chronological order: 1. Periumbilical pain (intermittent and crampy) 2. Nausea/vomiting 3. Anorexia 4. Pain migrates to RLQ (constant and intense pain), usually in 24 hours Gastric ulcers: Epigastric pain, vomiting, anorexia, and nausea Duodenal ulcers: Epigastric pain—burning or aching, usually several hours after a meal (food, milk, or antacids initially relieve pain). Bleeding Back pain, Nausea, vomiting, and ↓ appetite Gastric cancer: “WEAPON”: Weight loss, Emesis, Anorexia, Pain/epigastric discomfort, Obstruction, Nausea Lower GI bleed: Hematochezia (bright red blood per rectum [BRBPR]), with or without abdominal pain, melena, anorexia, fatigue, syncope, shortness of breath, shock Carcinoma of the gallbladder: Biliary colic, weight loss, anorexia; many patients are asymptomatic until late; may present as acute cholecystitis Pancreatic carcinoma: Painless jaundice from obstruction of the common bile duct; weight loss; abdominal pain; back pain; weakness; pruritus from bile salts in the skin; anorexia; Courvoisier’s sign; acholic stools; dark urine; diabetes Thyroid disease Medications: sedatives, digoxin, laxatives, thiazide diuretics, narcotics, antibiotics
Appendicitis	The first symptom is crampy or "colicky" pain around the navel (periumbilical) There is usually a marked reduction in or total absence of appetite, often associated with nausea, and occasionally, vomiting and low-grade fever As the inflammation increases, the abdominal pain tends to move downward - begins in epigastrium → umbilicus → RLQ Right lower quadrant= "McBurney's point." This "rebound tenderness" suggests inflammation has spread to the peritoneum Signs: Rovsing – RLQ pain with palpation of LLQ Obturator sign – RLQ pain with internal rotation of the hip Psoas sign - RLQ pain with hip extension Clinical diagnosis: Imaging if atypical presentation - appy ultrasound or abdominal CT scan CBC - neutrophilia supports the diagnosis TX: surgical appendectomy
Bariatric surgery	Guidelines for bariatric surgery which include: BMI > 40 (basically, 100 pounds above ideal body weight) or BMI > 35 with a medical problem related to morbid obesity Individuals must have failed other non-surgical weight loss programs. They must be psychologically stable and able to follow post-op instructions. Obesity is not caused by a medical disease such as endocrine disorders. BMI: body weight in kg divided by height in meters squared
Bowel obstruction (small, large, volvulus)	What finding on abdominal x-ray should make you think of bowel obstruction? Air fluid levels ReelDx Virtual Rounds (Small bowel obstruction) Small bowel obstruction You are called to see a 61 y/o with acute onset severe abdominal pain and vomiting Patient Gender: Female Age: 61 Vitals Temperature: 99.4ºF/37.4ºC Heart Rate: 67 Respiratory Rate: 16 Pulse Oximetry: 99% on RA Blood Pressure: 130/79 Signs and Symptoms Acute onset severe abdominal pain and vomiting Click here to work through this patient case simulation. Small bowel obstruction (SBO) Patient with small bowel obstruction will present as → a 55-year-old male presents to the emergency department with a two-day history of severe abdominal pain, vomiting, and inability to pass stool or gas. He describes the pain as crampy and worsening, localized initially around the umbilicus but now diffused across the abdomen. His medical history is significant for an open appendectomy 20 years ago. On examination, his abdomen is distended and tender with high-pitched, tinkling bowel sounds. He is afebrile, but his heart rate is elevated. An abdominal X-ray reveals dilated loops of small bowel with air-fluid levels. You note valvulae conniventes across the full width of the bowel suggestive of a small bowel obstruction. A CT scan of the abdomen confirms the diagnosis, showing a transition point with no evidence of strangulation. The patient is admitted for nasogastric decompression, intravenous fluids, and bowel rest. Surgery is consulted for potential operative intervention, given his history of previous abdominal surgery and the likelihood of adhesive disease. The patient is closely monitored for signs of bowel ischemia or perforation. MCC: Postoperative adhesions (MC cause in adults) or hernias, cancer, IBD, volvulus, and intussusception (MC cause in children) Obstruction is typically in the ileum or jejunum History of prior abdominal surgery Symptoms include colicky abdominal pain, nausea, bilious vomiting, abdominal distention, and diarrhea High-pitched hyperactive bowel sounds (early) progressing to silent bowel sounds (hypoactive bowel sounds -late) Dehydration + electrolyte imbalances DX: Obtain plain radiographs to quickly confirm a diagnosis of bowel obstruction, and, provided the films do not have findings that indicate the need for immediate intervention, then use computed tomography (CT) of the abdomen and pelvis to further characterize the nature, severity, and potential etiologies of the obstruction KUB shows dilated small bowel loops (< 3 cm), air-fluid levels in the small bowel with valvulae conniventes visible across the full width of the bowel, string of pearls (multiple air-fluid levels), and paucity of gas in the colon TX: Treat with decompression with an NGT, surgery if a mechanical obstruction is suspected Hyperactive bowel sounds, as heard in SBO Large Bowel obstruction (LBO) Patient with large bowel obstruction will present as → a 70-year-old female presents to the emergency department with a three-day history of worsening abdominal distension, constipation, and intermittent, crampy abdominal pain. She reports her last bowel movement was four days ago, which was smaller in caliber than usual. She has a history of chronic constipation and a 20-pound unintentional weight loss over the past six months. On examination, her abdomen is markedly distended, tympanic to percussion, and tender on palpation, particularly in the lower quadrants. No bowel sounds are heard on auscultation. Her vital signs show mild tachycardia but are otherwise stable. An abdominal X-ray reveals dilated loops of large bowel with haustra and a “cut-off” sign in the sigmoid region. A CT scan of the abdomen and pelvis confirms a large bowel obstruction with a suspected mass in the sigmoid colon. The patient is admitted for nasogastric decompression, intravenous fluids, and bowel rest. Surgery and gastroenterology are consulted for further evaluation, including potential colonoscopy and biopsy of the mass. The patient is counseled about the likelihood of colorectal cancer as a potential underlying cause and the need for surgical intervention. MCC: cancer, strictures, hernias, volvulus, and fecal impaction Obstruction is typically in the colon or rectum Symptoms include gradually increasing abdominal pain with longer intervals between episodes of pain, abdominal distention, constipation, less nausea and vomiting (may be delayed) - late-onset feculent vomiting, blood in stool, more common in the elderly Patients may be febrile and tachycardic => shock may ensue Dehydration + electrolyte imbalances DX: Obtain plain radiographs to quickly confirm a diagnosis of bowel obstruction, and, provided the films do not have findings that indicate the need for immediate intervention, then use computed tomography (CT) of the abdomen and pelvis to further characterize the nature, severity, and potential etiologies of the obstruction KUB shows dilated colon (> 5 cm), air-fluid levels in the colon, haustra (small pouches caused by sacculation, which give the colon its segmented appearance) that do not transverse bowel, bird beak sign: narrowing of the lumen at the site of obstruction TX: Bowel rest, NG tube placement, surgery as directed by the underlying cause KUB in LBO demonstrates dilated loops of the large bowel with haustra (lines that don't traverse the large bowel) and air-fluid levels in the large intestine SBO vs. LBO On the physical exam: In small bowel obstruction, vomiting is more common, and the pain tends to be periumbilical, cramping, and intermittent – with bouts that last for a few minutes at a time In large bowel obstruction, vomiting is less common, and the pain is lower in the abdomen and the bouts of pain are less frequent but last a bit longer On the abdominal x-ray (KUB): Large bowel obstruction presents with haustra (small pouches caused by sacculation, which give the colon its segmented appearance) that do not transverse bowel Small bowel obstruction presents with valvulae conniventes (white lines passing across the full width of the bowel) that are only found in the small bowel
Cholangitis	RUQ pain, jaundice, and fever Cholangitis is a complication of gallstones with symptoms secondary to an infected obstruction of the common bile duct (E.coli is the #1 cause) Charcot’s triad: RUQ tenderness, jaundice, fever Reynold’s pentad: Charcot’s triad + altered mental status and hypotension ERCP is the optimal procedure both for diagnosis and for treatment
Cholelithiasis and choledocholithiasis	A precursor to cholecystitis, cholesterol stones account for > 85% of gallstones in the Western world
Colorectal carcinoma	Painless rectal bleeding and a change in bowel habits in a patient 50-80 years of age Apple core lesion on barium enema, adenoma most common type, Tumor Marker: CEA More likely to be malignant: sessile, > 1 cm, villous Less likely to be malignant: Pedunculated, < 1 cm, tubular Tx: resection and adjuvant chemotherapy Colon cancer screening for average-risk patients should begin at 45 years and end at 75 years of age Stool tests: Guaiac-based fecal occult blood (gFOBT) – once per year Fecal immunochemical test (FIT) – once per year FIT-DNA test (combines FIT with a test that detects altered DNA in stool) – once every one or three years Flexible sigmoidoscopy – once every 5 years or every 10 years with a FIT every year (serious complications occur in approximately 3.4 per 10,000 procedures) Colonoscopy: once every 10 years Perforation of the colon occurs in an estimated 3.8 per 10,000 procedures Serious complications—including perforation, major bleeding, diverticulitis, severe abdominal pain, and cardiovascular events occur in an estimated 25 per 10,000 procedures CT colonography: once every 5 years (1 additional individual per 1000 would develop cancer in his or her lifetime due to radiation exposure) USPSTF colorectal cancer screening guidelines When adequate screening colonoscopy is accomplished, intercurrent stool tests (i.e., between colonoscopy examinations) are not necessary. In addition, for patients who have had a negative colonoscopy and have been recommended to have routine screening in 10 years, screening with FIT or other screening tests is not indicated prior to the end of the 10-year period. There is adequate evidence that the benefits of detection and early intervention decline after age 75 years
Diarrhea, constipation, obstipation, and change in bowel habits	Constipation: Defined as less than 2 bowel movements per week Obstipation is a severe form of constipation, where a person cannot pass stool or gas Bowel obstruction Small bowel obstruction Colicky abdominal pain, nausea, bilious vomiting, obstipation, abdominal distention, hyperactive bowel sounds (early) or hypoactive bowel sounds (late), prior abdominal surgery Large bowel obstruction Gradually increasing abdominal pain with longer intervals between episodes of pain, abdominal distention, obstipation, less vomiting (feculent), more common in the elderly Illeus Hypomotility of the gastrointestinal tract in the absence of mechanical bowel obstruction Ileus that persists for more than 3 d following surgery is termed postoperative adynamic ileus or paralytic ileus Signs: Absent bowel sounds CT scan with gastrografin—must exclude mechanical obstruction Gastroparesis A condition that affects the stomach muscles and prevents proper stomach emptying MCC: Diabetes Diarrhea Pseudomembranous colitis Inflammation of the colon caused by the bacteria Clostridium difficile Occurs secondary to treatment with antibiotics with broad-spectrum antibiotics - penicillins, cephalosporins, and FQ Mild watery, foul-smelling diarrhea (> 3 but <20 stools/day) IV metronidazole OR PO vancomycin (this is the only use for oral vancomycin)
Diverticular disease	LLQ pain, tenderness, abdominal distention, fever and leukocytosis in older patients Inflammation of an abnormal pouch (diverticulum) in the intestinal wall, usually found in the large intestine. The presence of the pouches themselves is called diverticulosis. When they become inflamed, the condition is known as diverticulitis. Left-sided Appy Most common location: Sigmoid colon Fever/chills/Nausea/vomiting/left-sided abdominal pain The most common cause of massive lower gastrointestinal bleeding DX: Diagnose using abdominal and pelvic CT with oral, rectal, and IV contrast; do colonoscopy 1 to 3 months after the episode to look for cancer. CT revealing fat stranding and bowel wall thickening TX: Management depends on severity but typically includes conservative management (pain control + liquid diet x 2-3 days), sometimes antibiotics, and sometimes percutaneous or endoscopic ultrasound-guided drainage or surgical resection Recurrent attacks or the presence of perforation, fistula, or abscess require surgical removal of the involved portion of the colon Increase bulk of the diet with high-fiber foods and bulk additives such as Metamucil
Esophageal cancer	Progressive dysphagia to solid foods along with weight loss, reflux, and hematemesis Squamous cell m/c worldwide and adenocarcinoma common in the US Adenocarcinoma: A complication of Barrett's esophagus (screen Barrett's patients every 3-5 years with endoscopy) affects distal (lower) 1/3rd of the esophagus Squamous cell: Associated with smoking and alcohol use Affects the proximal (upper) 2/3rds of the esophagus Progressive dysphagia, weight loss, hoarseness Diagnostic studies: Endoscopy + biopsy Treatment: Resection
Esophageal Strictures	Solid food dysphagia in a patient with a history of GERD GERD and Scleroderma Ingestion of corrosive substances Viral or bacterial infections Symptoms Difficulty and painful swallowing, weight loss, Regurgitation of food Esophageal achalasia: primary esophageal motility disorder characterized by the absence of lower esophageal peristalsis. Difficulty swallowing caused by a failure of the LES to relax and poor peristaltic waves, producing a motor disorder signified by initial complaints of dysphagia for solids and liquids. DX: Barium swallow shows there is acute tapering at the lower esophageal sphincter and narrowing at the gastroesophageal junction, producing a "Bird’s beak" or "rat's tail" appearance - distal 2/3 most common Esophageal manometry is the best test to diagnosis shows the absence of esophageal peristalsis TX: EGD dilation of the esophagus or myotomy is the preferred treatment Esophageal web: thin membranes in the mid-upper esophagus. May be congenital or acquired Plummer-Vinson: esophageal webs + dysphagia + iron deficiency anemia A Schatzki ring is a diaphragm-like mucosal ring that forms at the esophagogastric junction (the B ring). If the lumen of this ring becomes too small, symptoms occur
Gastric cancer	Present with weight loss, abdominal fullness/pain, anemia, early satiety, melena, anorexia, guaiac-positive stool Adenocarcinoma The incidence is extremely high in Japan, Chile, and Iceland. Risk factors for gastric cancer: a family history of gastric cancer gastric ulcers Helicobacter pylori pernicious anemia SX: a loss of appetite difficulty swallowing, particularly difficulty that increases over time vague abdominal fullness nausea and vomiting weight loss abdominal fullness prematurely after meals DX: EGD (esophagogastroduodenoscopy) and biopsy showing gastric cancer a CBC showing microcytic/hypochromic anemia positive guaiac Radiation therapy and chemotherapy can be beneficial but the prognosis is poor
Heartburn and dyspepsia	Dyspepsia and abdominal pain are common indicators of gastritis Three causes: 1. Autoimmune or hypersensitivity reaction (e.g. pernicious anemia) Location: Body of the fundus Pernicious anemia: + Schilling test + ↓ intrinsic factor and parietal cell antibodies 2. Infection - H. pylori (most common) Location: Antrum and body Studies: Urea breath test or fecal antigen. Treatment: PPI (Ie. Omeprazole) + clarithromycin + amoxicillin +/- metronidazole 3. Inflammation of the stomach lining (NSAIDS and Alcohol) NSAIDs cause gastric injury by diminishing local prostaglandin production in the stomach and duodenum. Alcohol: a leading cause of gastritis Peptic ulcer disease Etiology: H. pylori (most common), NSAID use, Zollinger-Ellison syndrome (refractory PUD) - gastrin-secreting tumor Duodenal ulcer- pain improves with food* Gastric ulcer- pain worsens with food Diagnosis: Endoscopy with biopsy is the gold standard for diagnosis Treatment: H. pylori infection: Triple therapy PPI (Ie. Omeprazole) + clarithromycin + amoxicillin +/- metronidazole NSAIDs use: discontinue use Zollinger-Ellison syndrome: PPI and resect the tumor
Hematemesis	Peptic ulcer disease: hematemesis, abdominal discomfort, dull pain Esophageal varices: hematemesis, bleeding, difficulty swallowing Alcohol abuse: physical dependence, craving, vomiting Mallory-Weiss syndrome: a tear in the lining of the stomach just above the esophagus caused by violent retching or vomiting Coagulation disorders: characterized by a decreased ability to form a clot Esophageal cancer: progressive dysphagia to solid foods along with weight loss, reflux, and hematemesis Gastrointestinal System Neoplasms: Abdominal pain and unexplained weight loss are the most common symptoms, along with reduced appetite, anorexia, dyspepsia, early satiety, nausea and vomiting, anemia, melena, guaiac-positive stool
Hemorrhoids	Hemorrhoids are varicose veins of the anus and rectum Risk factors: Constipation/straining, pregnancy, portal HTN, obesity, prolonged sitting or standing, anal intercourse Hematochezia - rectal bleeding - bright red blood per rectum (BRPPR), painless, fecal soilage DX: Anoscopy if BRBPR or suspected thrombosis External hemorrhoids - lower 1/3 of the anus (below dentate line) *Patient with external hemorrhoids will present as →* a 35-year-old female presents with anal pain and itching, especially during sitting and following bowel movements. She recently gave birth to her second child. On examination, there are swollen, bluish, tender lumps around the anal verge, consistent with thrombosed external hemorrhoids. She is advised on warm sitz baths and is prescribed a topical anesthetic cream for symptomatic relief. She is also educated on the importance of avoiding straining and maintaining soft bowel movements through adequate hydration and fiber intake. She is informed that the thrombosed hemorrhoids may resolve spontaneously, but surgical intervention can be considered if symptoms persist or worsen. Thrombosed: Significant pain and pruritus but no bleeding Palpable perianal mass with a purplish hue Treat with excision for thrombosed external hemorrhoids Thrombosed external hemorrhoid Internal hemorrhoids - upper 1/3 of the anus (above the dentate line) *Patient with internal hemorrhoids* will present as → a 42-year-old male presents with painless rectal bleeding during bowel movements for the past week. He reports a history of chronic constipation. On examination, there is no visible perianal abnormality. Digital rectal examination is unremarkable, but there is evidence of bright red blood on the glove. An anoscopy reveals enlarged, non-prolapsing internal hemorrhoids. The patient is counseled on dietary modifications, including increased fiber intake and hydration, to alleviate constipation. He is also prescribed a topical hemorrhoidal cream with hydrocortisone and instructed on the importance of regular bowel habits to prevent straining. Bright red blood per rectum, pruritus, and rectal discomfort Treatment: Fiber, sitz bath, ice packs, bed rest, stool softeners, topical steroids Rubber band ligation If protrudes with defecation, enlargement, or intermittent bleeding Closed hemorrhoidectomy if permanently prolapsed Classification of internal hemorrhoids is based on the degree of prolapse Grade I: visualized via anoscopy; do not prolapse below the dentate line Grade II: prolapse out of the anal canal with defecation or straining but reduce spontaneously Grade III: prolapse out of the anal canal with defecation or straining and require manual reduction Grade IV:** irreducible and may strangulate Grade IV internal Hemorrhoids
Hepatic carcinoma	Abdominal pain, weight loss, right upper quadrant mass Etiology: Cirrhosis, Hepatitis B, Hepatitis C, Hepatitis D, Aflatoxin from Aspergillus Tumor Marker: ↑ alpha-fetoprotein and abnormal liver imaging Treatment: Resection, Transplant - Poor prognosis
Hernias (inguinal, femoral, incisional)	Inguinal hernias: Indirect (Most Common): Passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one. Direct: Passage of intestine through the external inguinal ring at Hesselbach's triangle, rarely enters the scrotum. Ventral: Often from previous abdominal surgery, obesity. Abdominal mass noted at the site of previous incision. Umbilical hernia: Very common, generally is congenital and appears at birth. Many umbilical hernias resolve on their own and rarely require intervention. Refer to surgery if an umbilical hernia persists >2 years of life. Strangulated: Hernia becomes strangulated when the blood supply of its contents is seriously impaired. Obstructed: This is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel. Incarcerated: Hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated.
Hiatal hernia	Hiatal (diaphragmatic): Involves protrusion of the stomach through the diaphragm via the esophageal hiatus. It can cause symptoms of GERD Tx: acid reduction may suffice, although surgical repair can be used for more serious cases.
Inflammatory bowel disease	Ulcerative Colitis Ulcerative colitis will present as → a 32-year-old woman comes to your office with a 6-month history of loose bowel movements, approximately eight per day. Blood has been present in many of them. She has lost 30 pounds. For the past 6 weeks, she has had intermittent fever. She has had no previous gastrointestinal (GI) problems, and there is no family history of GI problems. On examination, the patient looks ill. Her blood pressure is 130/ 70 mm Hg. Her pulse is 108 beats/ minute and regular. There is generalized abdominal tenderness with no rebound. A sigmoidoscopy reveals a friable rectal mucosa with multiple bleeding points. Isolated to the colon starts at the rectum and moves proximally Most common in the rectum Mucosal surface only Hematochezia and pus-filled diarrhea, fever, tenesmus (feeling of incomplete defecation), anorexia, weight loss Barium enema: Lead pipe appearance (loss of haustral markings) -> may lead to toxic megacolon Colonoscopy: continuous lesions in the mucosa/submucosa of rectum and colon Treatment: Colectomy is curative Medications: Prednisone and mesalamine Lead pipe appearance on Double-contrast barium enema. Image by Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA. License: CC BY 3.0 Crohn's disease Crohn’s disease will present as → a 25-year-old man with an 18-month history of chronic abdominal pain. The patient has seen several physicians and has been diagnosed as having a “nervous stomach,” irritable bowel syndrome, and “depression.” Associated with this abdominal pain for the past 3 months have been nonbloody diarrhea, anorexia, and a weight loss of 20 pounds. He has developed a painful area around the anus. On examination, the patient has diffuse abdominal tenderness. He looks thin and unwell. He has a tender, erythematous area in the right perirectal area. From mouth to anus, transmural, skip lesions, and cobblestoning! Mouth to anus Most common in the terminal ileum Skip lesions Transmural thickening Fistulas common, abscess Abdominal pain, aphthous ulcers, weight loss, nonbloody diarrhea, and cramping Barium enema: Cobblestone appearance Colonoscopy: focal ulcerations alternating with normal mucosa Treatment: Flares: Prednisone +/- Mesalamine +/- Metronidazole or Ciprofloxacin Maintenance: Mesalamine Surgery is not curative. The adjacent portion of the bowel is affected post-op Stenosis of the colon with cobblestoning particular to Crohn's disease
Jaundice	Serum bilirubin > 2.5 mg/dl Causes of postoperative jaundice: Prehepatic: Hemolysis (prosthetic valve), resolving hematoma, transfusion reaction, post cardiopulmonary bypass, blood transfusions (decreased RBC compliance leading to cell rupture) Hepatic: Drugs, hypotension, hypoxia, sepsis, hepatitis, “sympathetic” hepatic inflammation from adjacent right lower lobe infarction of the lung or pneumonia, preexisting cirrhosis, right-sided heart failure, hepatic abscess, pylephlebitis (thrombosis of portal vein), Gilbert syndrome, Crigler-Najjar syndrome, Dubin-Johnson syndrome, fatty infiltrate from TPN Posthepatic: Choledocholithiasis, stricture, cholangitis, cholecystitis, biliary-duct injury, pancreatitis, sclerosing cholangitis, tumors (e.g., cholangiocarcinoma, pancreatic cancer, gallbladder cancer, metastases), biliary stasis (e.g., ceftriaxone [Rocephin®])
Melena and hematochezia	Melena: black, tarry stool - upper GI bleed Gastric cancer, duodenal ulcers, right-sided colon cancer, portal hypertension with esophageal varices, severe erosive esophagitis, Mallory-Weiss syndrome. Hematochezia: bright red blood per rectum (BRBPR) - lower GI bleed Hemorrhoids, anal fissures, polyps, proctitis, rectal ulcers, and colorectal cancer. Diverticulosis is generally an incidental finding, since diverticular bleeding is usually of greater volume.
Nausea and vomiting	Postoperative nausea and vomiting (PONV) is an unpleasant complication affecting 30 percent of children and adults after anesthesia Vomiting or retching can result in wound dehiscence, esophageal rupture, aspiration, dehydration, increased intracranial pressure, and pneumothorax. Nausea can have causes that aren't due to underlying disease. Examples include motion such as from a car and plane, taking pills on an empty stomach, eating too much or too little, or drinking too much alcohol Gastroenteritis: nausea, vomiting, diarrhea, stomach cramps Common cold: nausea, vomiting, runny nose Migraine headache: nausea, vomiting, headache Food poisoning: nausea, vomiting, malaise Influenza virus: nausea, vomiting, cough with phlegm Pyloric Stenosis: Infant with projectile vomiting Peptic ulcer disease: upper abdominal pain, may have nausea or vomiting Hiatal hernia: symptoms of GERD
Pancreatic carcinoma	An elderly man with large nontender palpable gallbladder (Courvoisier's sign) Painless jaundice is pathognomonic The 4th leading cause of death from cancer in the U.S. The disease is slightly more common in men than in women and risk increases with age. The cause is unknown, but the incidence is greater in smokers. Almost one-third of cases of pancreatic carcinoma can be attributed to cigarette smoking and ETOH abuse. Most commonly ductal adenocarcinoma located at the pancreatic head Presentation: weight loss/epigastric abdominal pain, clay-colored stools Jaundice + palpable non-tender gallbladder (Courvoisier’s sign) Virchow's node (or signal node) is a lymph node in the left supraclavicular fossa (the area above the left clavicle) that is associated with pancreatic cancer DX: ERCP abdominal CT scan: 75% show tumor at the head of the pancreas, 25% at the tail pancreatic Bx abdominal MRI elevated serum bilirubin abnormal liver function tests CA 19-9 is present in about 80% of patients who have pancreatic cancer TX: At the time of diagnosis, only about 20% of pancreatic tumors can be removed by the standard procedure is called a pancreaticoduodenectomy (Whipple procedure). When the tumor is confined to the pancreas but cannot be removed, a combination of radiation therapy and chemotherapy may be recommended The Whipple procedure involves removing the antrum of the stomach, part of the duodenum, the head of the pancreas, and gallbladder CT with IV contrast showing pancreatic adenocarcinoma at the head of the pancreas.
Pancreatic pseudocyst	Pancreatitis and a palpable epigastric mass Cystic collection of tissue, fluid, and necrotic debris surrounding the pancreas Classically occur 2-3 weeks after acute pancreatitis Presents with abdominal pain and a palpable epigastric mass CT scan is the study of choice Treatment - if pseudocyst persists for 4 to 6 weeks or continues to enlarge Surgical decompression (pancreaticogastrostomy) Percutaneous drainage Can become infected and lead to peritonitis
Peptic ulcer disease	PUD is an ulcer of the upper GI tract mucosa involving the proximal duodenum (90%) and distal stomach (10%). There are 2 main types of ulcers duodenal and gastric Duodenal ulcer (food classically decreases pain think Duodenum = Decreased pain with food) Duodenal ulcers are more than twice as common as gastric ulcers Duodenal ulcers are most commonly caused by H. pylori (95%) Pts typically present with epigastric pain that is better postprandial Gastric ulcer (food classically causes pain) Gastric ulcers are most commonly caused by H. pylori. Can also be caused by NSAIDs, acid reflux, smoking Pain is described as gnawing or burning and usually radiates to the back Pts typically present with epigastric pain that is worse postprandial Bleeding — Acute upper gastrointestinal hemorrhage is the most common complication of peptic ulcer disease DX: Upper endoscopy is the most accurate diagnostic test for peptic ulcer disease Biopsy for H. pylori should be obtained in all patients undergoing upper endoscopy for PUD unless contraindicated Ulcer biopsy of benign-appearing duodenal ulcers is not recommended All ulcers with malignant features should be biopsied TX: All patients with peptic ulcers should receive antisecretory therapy with a proton pump inhibitor (PPI) (eg, omeprazole 20 to 40 mg daily or equivalent) for 4-8 weeks Patients with evidence of H. pylori on biopsy should receive eradication therapy Treatment for H.Pylori ⇒ think Baseball "CAP" = clarithromycin + amoxicillin + PPI In patients with active bleeding, a negative biopsy result does not exclude H. pylori, and a breath test or a stool antigen test for H. pylori should be performed to confirm a negative result In patients who receive treatment for H. pylori, eradication should be confirmed four or more weeks after the completion of therapy Discontinue nonsteroidal anti-inflammatory drugs (NSAIDs) Patients with duodenal ulcers who have been treated do not need further endoscopy unless symptoms persist at four weeks or recur
Pyloric stenosis	An infant with projectile vomiting ReelDx Virtual Rounds (Pyloric stenosis) Pyloric stenosis You are called to see a 6-week-old with two weeks of projectile vomiting and an olive-sized abdominal mass Patient Gender: Male Age: 6 weeks Weight: 6.2 lb./2.8 kg Signs and Symptoms 2 weeks projectile vomiting; olive-sized abdominal mass; afebrile. Click here to work through this patient case simulation. Pyloric stenosis is a congenital condition where a newborn’s pylorus undergoes hyperplasia and hypertrophy, leading to obstruction of the pyloric valve which causes vomiting (that might be projectile), as well as dehydration and metabolic alkalosis Projectile vomiting occurs shortly after feeding in an infant < 3 mo. old with a palpable “olive-like” mass at the lateral edge of the right upper quadrant Pediatric patients < 3 months old Nonbilious projectile vomiting after most or every feeding Physical exam - palpable epigastric olive-shaped mass (is pathognomonic for the disorder) DX: Diagnosis is by ultrasound On ultrasound, you will see a “double-track” Barium studies will reveal a “string sign” or “shoulder sign” Labs: Hypochloremic, hypokalemic metabolic alkalosis (secondary to dehydration) TX: surgical correction - pyloromyotomy (Ramstedt's procedure) Pyloric stenosis as seen on ultrasound in a 6-week-old. Notice the "double track" (red arrow)
Small bowel carcinoma	The most common presenting symptom of a small bowel tumor is abdominal pain- typically intermittent and crampy in nature Adenocarcinomas represent from 25 to 40 percent of small bowel cancers - highest in the duodenum Crohn's disease predisposes to adenocarcinoma within the involved area of the small intestine Diagnosis includes radiographic (computed tomography [CT] scan, small bowel series, enteroclysis) or endoscopic (wireless capsule endoscopy, push enteroscopy, double-balloon endoscopy) Treatment is surgery — Localized adenocarcinomas of the small bowel are best managed with wide segmental surgical resection Adjuvant chemotherapy to patients with lymph node-positive
Toxic megacolon	Patient will present as → a 24-year-old man with ulcerative colitis who receives Lomotil for excessive diarrhea and develops a fever, abdominal pain, and tenderness, and a massively dilated colon on abdominal x-ray. A complication of ulcerative colitis (most common), Crohn’s, Hirschsprung’s, pseudomembranous colitis, enteritis Life-threatening form of colon distention Pt will present with FEVER, rigid and markedly distended abdomen with peritonitis and shock Common in patients with Ulcerative Colitis and Crohn's disease DX: Toxic megacolon is diagnosed based on clinical signs of systemic toxicity combined with radiographic evidence of colonic dilatation (diameter >6 cm) The most widely used criteria for the clinical diagnosis of toxic megacolon are: Radiographic evidence of colonic distension PLUS at least three of the following: Fever >38ºC Heart rate >120 beats/min Neutrophilic leukocytosis >10,500/microL Anemia PLUS at least one of the following: Dehydration Altered sensorium Electrolyte disturbances Hypotension TX: Decompression of the colon is required In some cases, colostomy or even complete colonic resection may be required Toxic Megacolon seen in ulcerative colitis. The patient underwent a colectomy.