Other GIT Disease

Acute mesenteric ischemia rapid onset of intestinal hypoperfusion that can lead to mucosal sloughing within 3 hours of onset and to intestinal infarction 6 hours of her onset Can be SMA Embolism SMA thrombosis non occlusive 20-30% Venous obstructionMC 15-25% low flow state 5%50% Due to emboli by microvascular Due to thrombioriginates in the heart vasospasm in response or strangulation(left atrial or ventricle) to systemic physiologic or idiopathicaffecting Distal ileum stress in otherwise normal& Proximal colon vasculature Hx of cardiac disease mc atrial fibrillation Drugs digitals &-MI -vasopressin Risk factors: Cardiac: ↓ CO, Cardiac arrhythmias, Severe Cardiac Valvular disease, Recent MI Age Atherosclerosis hyper coagulable state Notes & prognosis: Acute arterial mesenteric ischemia mortality rate 59-93% Sign & symptoms Abdominal pain out of proportion to tenderness on physical exam (hallmark) Colicky, diffuse, typically mid abdominal associated with nausea, vomiting, diarrhea following infarction: Peritonitis (Rebound tenderness, abdominal distention and rigidity) full thickness bloody stool SIRS Diagnosis Suspicious with heart disease or hypercoagulable state Diagnostic: mesenteric angiography other: CT with IV contrast (Sensitive in Venous thrombosis not artery) Pneumatosis intestinalis - Bowel wall Dark (Dend) - & perforation free air Treatment: hemodynamically monitor IV fluid correct electrolyte abnormality (acidosis) Ab for bacteria translocation NGIT for gastric decompression Exploratory laparotomy (assessment for intestinal viability) Peritoneal signs → Emergency laparotomy (assessment for intestinal viability) Embolic Cause → Intraoperative embolectomy → Resect dead bowel → Leave viable bowel Venous thrombosis → Bypass of site of obstruction using saphenous vein graft Therapy via angiography include: intra arterial vasodilator or thrombotic agent angioplasty or stent placement and embolectomy serial abdominal exam → surgery if needed Diagnosis: CBC iron - B12 folate deficiency Serology p-ANCA ASCA calprotectin antisaccharomyces cerevisiae antinuclear cytoplasmic antibody Colonoscopy with biopsy Cobblestone appearance (linear ulcers produce transverse clefts & sinus) mucosal findings aphthous ulcers - granulomas linear ulcers transverse fissure swollen mucosa full thickness wall involvement others & Small bowel Contrast study (length of involvement & area of stricture) Radiographic finding include mucosal nodularity - narrowed lumen - ulceration String sign - abcess or fistula if present. Treatment medical corticosteroids aminosalicylate - Immune modulators infliximab - metionidazole Should be avoided if possible, (not curative and can move from mouth to anus) Surgery Surgery indications Failed medical therapy Intra operative findings mesentery (fat grouping) of small intestine short & thick mesentery thick bowel wall fistulas abscess Acute: obstruction → fistula, hemorrhage → perforation abscess, toxic colitis s Chronic: Extra intestinal manifestations, growth retardation (eye + perineal) cancer (bad ↑ in uc) (if long standing > 10y) Surgery Intestinal resection, staculoplasty Small bowel resection fistula Seton placement & drain Fistulotomy Fistulectomy advanced disease → total colectomy with ileostomy Toxic Colitis (w/megacolon) Topic colitis - clinical diagnosis May be associated with megacolon Dilation of colon can occur without toxicity and toxicity can occur without dilation of colon DDX Infectious colitis (bacterial - viral - fungal - parasitic) Inflammatory colitis (IBD-CD) Ischemic colitis Radiation colitis Microscopic colitis (collagenous, lymphatic) Toxicity Fever > 101.5 Tachycardia > 120 /min Leukocytosis > 15000 sepsis Anemia Diarrhea - abdominal pain Rectal bleeding, vomiting Dehydration Altered mental state Hypotension Treatment: NPO NGT Fluid replacement IV Steroids Antibiotics Biologics / cyclosporine If there is no improvement in 48-72 h → total or subtotal colectomy (Risk of perforation) Notes In the presence of steroids physical signs of perforation may be absent Prognosis 4-5% mortality w/o perforation 20% with perforation Megacolon Dilation of transverse colon with at least 6 cm (say) Thumb printing from submucosal infiltration Free air Barium enema should Not be preferred DDX Infectious colitis (bacterial - viral - fungal - parasitic) Inflammatory colitis (IBD-CD) Ischemic colitis Radiation colitis Microscopic colitis (collagenous, lymphatic) Toxicity Fever > 101.5 Tachycardia > 120 /min Leukocytosis > 15000 sepsis Anemia Diarrhea - abdominal pain Rectal bleeding, vomiting Dehydration Altered mental state Hypotension Treatment: NPO NGT Fluid replacement IV Steroids Antibiotics Biologics / cyclosporine If there is no improvement in 48-72 h → total or subtotal colectomy (Risk of perforation) Notes In the presence of steroids physical signs of perforation may be absent Prognosis 4-5% mortality w/o perforation 20% with perforation Toxic Colitis (w/megacolon) Topic colitis - clinical diagnosis May be associated with megacolon Dilation of colon can occur without toxicity and toxicity can occur without dilation of colon DDX Infectious colitis (bacterial - viral - fungal - parasitic) Inflammatory colitis (IBD-CD) Ischemic colitis Radiation colitis Microscopic colitis (collagenous, lymphatic) Toxicity Fever > 101.5 Tachycardia > 120 /min Leukocytosis > 15000 sepsis Anemia Diarrhea - abdominal pain Rectal bleeding, vomiting Dehydration Altered mental state Hypotension Treatment: NPO NGT Fluid replacement IV Steroids Antibiotics Biologics / cyclosporine If there is no improvement in 48-72 h → total or subtotal colectomy (Risk of perforation) Notes In the presence of steroids physical signs of perforation may be absent Prognosis 4-5% mortality w/o perforation 20% with perforation Megacolon Dilation of transverse colon with at least 6 cm (say) Thumb printing from submucosal infiltration Free air Barium enema should Not be preferred DDX Infectious colitis (bacterial - viral - fungal - parasitic) Inflammatory colitis (IBD-CD) Ischemic colitis Radiation colitis Microscopic colitis (collagenous, lymphatic) Toxicity Fever > 101.5 Tachycardia > 120 /min Leukocytosis > 15000 sepsis Anemia Diarrhea - abdominal pain Rectal bleeding, vomiting Dehydration Altered mental state Hypotension Treatment: NPO NGT Fluid replacement IV Steroids Antibiotics Biologics / cyclosporine If there is no improvement in 48-72 h → total or subtotal colectomy (Risk of perforation) Notes In the presence of steroids physical signs of perforation may be absent Prognosis 4-5% mortality w/o perforation 20% with perforation Pseudomembranous Colitis acute colitis characterized by formation of an adherent inflammation & Exudate (psudo membranous) overlying site of mucosal injury MC due to overgrowth of C. difficile (gram +ve anerobs, Spore forming bacilli) typically after broad spectrum antibiotic Due to eradication of normal flora (Clindamycin, ampicillin Cephalosporin) 585 -Self limited diasited illness Invasive Colitis with megacolon Diagnosis: Detection C. difficile teixin in stool Proctoscopy or colonoscopy if unclear Treatment: stop offending Ab give flagyl or Vancomycin po note high rate of recurrance 20% despite responce to treatment Radiation induced colitis in > 6000 Gy mostly to pelvis endometrial-Cerrical-prostate bladder rectal cancer- RF: atheroscelensis -DM-H.TV old age - adhesions from previous surgery Ecully (During XRT treatment Can be late (weeks years later)) ss: nausia, Vomiting, Crampy diaciken [585] tenesmus, bicading, abcess, fistula involving reclum tenesmus, rectal bleeding nous plain film- barium enema Tulogy submucosal edema, hyperemu acute ulceration Baiun enema CT Scan (Shad per vagira-rectal pin) Submucosal astericlar Vasculitis, microvascular thrombosis wall thickening strucosed ulceration, stricture, perforation redment, trend symptoms •steel softner-topical 5 ASA If didnt improve dese Steroid enema -Structure Grente dialation or diverting Colostrony Stoma Can be permanent or temporary Indicators (uses) Obstruction: Congenital malformation, inflammation, ischemia, Radiation Complication of inflammation process: Perforation, fistula, obstruction, Diverticulitis, chores, uc Injury: iatrogenic - Traumatic Operations: primary or secondary (eg Diversion) Miscellaneous: Volvulus, colonic dysmotility, Incontinence and disease, paralysis burn, Perineal inf, Decubitus ulcer Types Loop End Double barrel Complications: Parasternal hernia (leave unless complicated) Dehydration & electrolyte disturbance the more proximal the stoma the worse Prolapse (Clavicle it unless complicated) Retraction (Repair) Stricture (Constipation) → Do another stoma Ischemia superficial on skin → leave it → it will fall alone more deep OR skin incision MC ileostomy 2 cm above skin Chronic mesenteric ischemia not common Insidious, episodic or constant state of intestinal hypoperfusion Chronic atherosclerosis of 2 of the 3 main visceral arteries Celiac SMA IMA Supported of large number of collaterals rarely lead to infarction Can be Arterial ischemia MC: associated with atherosclerosis of more than 1 mesenteric and splanchnic vessels Venous thrombosis: thrombosis of part of splenic vein leading to portal HTN with subsequent development of esophageal varices & splenomegaly Risk factors: Atherosclerosis (50% of pt have Hx of peripheral vascular disease or Coronary artery Disease) Smoking Sx: Intestinal angina: post prandial abdominal pain (30-60 min) Dull and crampy leading to food aversion wt loss Hallmark Chronic venous thrombosis mostly asymptomatic due to collateral formation or present with esophageal varices bleeding Diagnosis CT or MR angiography high grade stenosis in multiple mesenteric vessels angiography is Golden Standard other mesenteric doppler US screening for stenoses in Celiac & SMA Treatment: Arterial CMI Surgical revascularization By aortomesenteric bypass graft or mesenteric endarterectomy Percutaneous transluminal angioplasty w/o stent Relied symptoms Easier than surgery Chronic venous mesenteric thrombosis Anticoagulant therapy Heparin Prognosis: Perioperative mortality rate 0-16% Surgery relieved symptoms by 90% Recurrence rate After surgery < 10% Following PTA 10-67% Angiodysplasia & artero venus mal formation (vascular ectasias - angioma) Chronic intermittent obstruction of submucosal veins secondary to repeated muscular Contractions results in dilated venules with incomplete precapillary sphincters and thus arteriovenous Communication. MC in cecum & ascending Colon ≈ Rt colon Q 25-60 y male > women Causes Slow chronic, intermittent Bleeding * melena or hematochezia often with symptoms of orthostasis Diagnosis: Colonoscopy angiography (better) s-selective mesenteric angiography is best method. *Treatment & 85%-90% stop spontaneously Surgical treatment for massive acute bleeding or chronic intermittent hard bleeding segmental resection of localized segment is preferred -other options if site is identified's octreotide - embolization - Vasoconstriction with epinephrine vasoconstriction with alcohol or sodium Compounds - Coagulation or Cautery