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Gi Surgery - Coggle Diagram
Gi Surgery
6.
COLON CANCER
Risk factors:
Familial adenomatous polyposis
Ulcerative colitis
Colonic adenoma
Colonic hyperplasia
Low fiber diet
CLINICAL FEATURES BY SITE
Right colon (cecum)
Iron deficiency anemia
Pallor
Fatigue
Abdominal mass
Most common symptom:
Anemia
Left colon
Altered bowel habits
Partial bowel obstruction
Dyspepsia
Most common symptom:
Alteration in bowel habits
Sigmoid colon
Altered bowel habits
Abdominal pain
Partial obstruction
Rectum
Rectal bleeding
Tenesmus
Bleeding per anus
Most common symptom:
Bleeding per anus
INVESTIGATIONS
X-ray:
Apple core appearance
CT colonography:
Initial diagnostic test
Colonoscopy:
Investigation of choice
Fecal occult blood test (FOBT):
Positive in colon cancer
Any old age patient with:
Iron deficiency anemia
Bleeding per rectum
Any GI symptom
Consider colon cancer until proven otherwise
TREATMENT OF COLON CANCER
Local metastasis:
Preoperative:
Chemotherapy + radiotherapy
Postoperative:
Chemotherapy only
FOLLOW UP AFTER COLON CANCER SURGERY
Colonoscopy:
Every year
Most important investigation
CEA:
Used in between follow ups
INTESTINAL FISTULA
Causes:
Most commonly postoperative
Crohn’s disease
Complications:
Electrolyte disturbances
Skin irritation
Treatment:
Mainly conservative
IRRITABLE BOWEL SYNDROME (IBS)
Epidemiology:
Young patients
More common under stress
Exam periods
Clinical features:
Spasmodic abdominal pain
Alternating constipation and diarrhea
Diagnosis:
Clinical
Treatment:
First step:
High fiber diet
Laxatives if constipated
Pain:
Spasmolytics
Drug of choice:
SSRI
Needs 2–4 weeks to work
Exam scenario:
Student with exam next week:
Give symptomatic treatment
Do not give SSRI
DIARRHEA
Most common causes:
Bloody diarrhea:
Campylobacter
Second most common bloody diarrhea:
Shigella
Traveler diarrhea:
E. coli
Pediatric diarrhea:
Viral
Most common virus in children:
Rotavirus
Special associations:
Diarrhea then weakness and areflexia:
Guillain–Barré syndrome
Diarrhea then renal impairment:
HUS
Bloody diarrhea then RUQ pain:
Amoeba
Diarrhea after camping:
Giardia
Chronic bloody diarrhea in young male:
IBS
Diarrhea after antibiotics:
Clostridium difficile
Diarrhea hours after meal:
Staphylococcal toxin
Bedridden with constipation and diarrhea:
Fecal impaction
Treatment principles:
Main treatment of diarrhea:
Fluids
Traveler diarrhea:
Fluids only
Staph toxin:
Fluids only
Amoeba or giardia:
Metronidazole
PSEUDOMEMBRANOUS COLITIS
Organism:
Clostridium difficile
Cause:
Recent antibiotic use
Clinical picture:
Mild diarrhea to life-threatening illness
Investigation:
Stool PCR for antigen and toxin
Treatment:
Asymptomatic carriers:
No treatment
First line:
Oral vancomycin
Severe cases:
IV metronidazole + oral vancomycin
VIRCHOW’S NODE
Definition:
Left supraclavicular lymph node
Drainage:
Abdominal lymphatics
Clinical significance:
Gastric cancer
Approach:
Treat as any neck mass
First step:
CT neck with contrast
FNAB
If malignancy confirmed:
Pan endoscopy to identify primary source
SURGICAL PEARLS
Timing of prophylactic antibiotics:
Immediately before surgery
During induction of anesthesia
HEAD INJURY
Most important sign:
Level of consciousness
3.
HERNIA
Predisposing factors:
Constipation
Chronic cough
TYPES OF HERNIA
1. Femoral hernia
Sex:
More common in multiparous females
Site:
Below inguinal ligament
Medial to femoral vessels
Lateral to pubic tubercle
Key points:
Most common hernia to complicate
Requires immediate referral to surgery
Female with inguinal swelling = femoral hernia until proven otherwise
2. Incisional hernia
Definition:
Hernia through an incompletely healed surgical wound
Most common predisposing factor:
Hematoma
Clinical picture:
Abdominal bulge with a scar
Examination:
Patient standing
Ask patient to cough important
Treatment:
Surgery
3. Epigastric hernia
Obese adult with large epigastric hernia:
Surgery
Child with epigastric hernia:
Reassurance
4. Acquired diaphragmatic hernia
Cause:
Blunt trauma from traffic accidents
Symptoms:
Dyspnea
Tachypnea
Bowel sounds in chest
Investigation:
X-ray showing bowel loops in chest
Treatment:
Surgery
HERNIA IN PEDIATRICS
1. Inguinal hernia
Management:
Obstruction or strangulation:
Immediate surgery
Irreducible:
Surgery as soon as possible
Reducible:
Rule of 6–2:
Birth to 6 weeks: surgery in 2 days
6 weeks to 6 months: surgery in 2 weeks
More than 6 months: surgery in 2 months
Important association:
Exclude congenital hypothyroidism
2. Umbilical hernia
Less than 4 years:
Observation
More than 4 years:
Surgery
IMPORTANT RULES IN HERNIA
Most common hernia:
Inguinal
Most common hernia to complicate:
Femoral
Once femoral hernia diagnosed:
Surgery
Irreducible hernia or absent cough impulse:
Immediate X-ray
Do not choose US or CT
Proceed to surgery
Incisional hernia:
Occurs at site of previous surgery
HOW TO SUSPECT COMPLICATED HERNIA
No cough impulse
Symptoms of intestinal obstruction:
Vomiting
Constipation
Abdominal distension
Investigation if intestinal obstruction suspected:
X-ray is investigation of choice
HERNIA TREATMENT PRINCIPLES
Treatment of choice:
Surgery
Preferred technique:
Hernioplasty with mesh
When to treat based on defect size:
Umbilical hernia > 2 cm
Inguinal hernia > 2 cm
Adult inguinal hernia with newly discovered 1 cm defect:
No treatment
TYPES OF HERNIA SURGERY
Pediatrics:
Herniotomy
Adults:
Laparoscopic mesh repair (hernioplasty)
CLINICAL SCENARIOS
6-month-old infant with history of inguinal swelling:
Even if exam is normal
Immediate referral to surgery for evaluation
2.
GASTRIC BAND COMPLICATIONS
Band slip:
Stomach prolapses upward through band
Symptoms:
Severe GERD
Abdominal pain
Nausea
Vomiting
Investigation:
Barium meal
Treatment:
Surgery definitive
ANASTOMOTIC LEAKAGE
Cause:
Bariatric surgery
Anastomotic surgery
Timing:
Usually 3 to 10 days
Can occur weeks later
Symptoms:
Fever
Abdominal pain
Nausea and vomiting
Left shoulder pain
Pleural effusion
Diagnosis:
Immediate CT scan
Treatment:
Stop oral intake
Antibiotics
Surgery
Rule:
Low-grade fever + abdominal pain + pleural effusion after surgery = leak until proven otherwise
AFFERENT LOOP OBSTRUCTION
Definition:
Obstruction of afferent limb after bypass
Pathophysiology:
Fluid pressure buildup
Clinical picture:
Marked vomiting
Abdominal pain
Can occur any time post surgery
Investigation:
CT scan of choice
Treatment:
Surgery
ESOPHAGEAL VARICES
Investigation:
Endoscopy
Management:
Fluid resuscitation priority
Non-bleeding:
Beta blockers
Bleeding:
Endoscopic ligation
Very low Hb:
Packed RBCs
After resuscitation:
Sengstaken-Blakemore tube balloon tamponade
PILES (HEMORRHOIDS)
Risk factors:
Constipation
Pregnancy
Clinical picture:
Painless bleeding
Mucous discharge
Bleeding with or without defecation
Pain occurs only if:
Thrombosed
Infected
Investigation:
Colonoscopy in old age to rule out cancer
Treatment:
Step 1:
Diet
Stool softeners
Step 2:
Band ligation
Severe:
Surgery
Thrombosed piles:
Incision and evacuation
PERIANAL HEMATOMA
Clinical picture:
Painful anal swelling
Management:
Within 24 hours:
Simple aspiration
24 hours to 5 days:
Incision under local anesthesia
More than 5 days:
Leave it to resolve spontaneously
Key difference:
Perianal hematoma: painful
Piles: painless
Most common symptom:
Piles: bleeding
Perianal hematoma: pain
PILONIDAL SINUS
Typical patient:
Young male
Dark dense hair
Symptoms:
Pain
Redness
Pus or blood discharge
Treatment:
Radical excision of sinus and tract
Advice:
Shaving
Keep area clean
ANAL FISTULA
Most common cause:
Perianal abscess
Recurrent or multiple fistulae:
Crohn’s disease
Symptom:
Persistent purulent discharge
Investigation:
Proctoscopy main
Fistulography
Treatment:
Surgery
ANAL FISSURE
Most common cause:
Constipation
Multiple fissures:
Crohn’s disease
Old age:
Always consider cancer
Main symptom:
Severe pain during defecation
Examination:
Inspection only
DRE contraindicated in acute fissure
Investigation:
Anoscopy
Management:
Step 1:
Increase fluids
Vegetables
Stool softeners
First-line:
GTN ointment
Other:
Local anesthetic
Corticosteroid cream
Severe:
Lateral sphincterotomy
Crohn’s-related fissure:
Infliximab
BLEEDING PER RECTUM
Most common overall:
Piles
Anal fissure
Infancy:
Anal fissure most common
Old age:
Diverticulosis most common
Always rule out colon cancer first
Bleeding + AF:
Ischemic colitis
First step:
Fluid resuscitation
Melena with negative endoscopy and colonoscopy:
Capsule endoscopy next
Rule:
Old age + bleeding per rectum = colon cancer until proven otherwise
Note:
Most rectal bleeding stops spontaneously after resuscitation
4.
DIVARICATION OF RECTI (DIASTASIS RECTI)
How to examine:
Ask patient to raise head without support
Management:
Pregnancy and children:
No treatment
Mild cases:
Physiotherapy
Severe cases:
Surgery
ESOPHAGUS
1. Corrosive injury of the esophagus
Cause:
Alkali agents
Detergents
Washing powder
First aid:
Milk no longer used
Gastric lavage contraindicated
Key investigation:
Endoscopy
Timing of endoscopy:
Within 24 hours
2. Achalasia
Cause:
Failure of lower esophageal sphincter relaxation
Epidemiology:
More common in females
Symptoms:
Dysphagia to solids and liquids
More to liquids
Regurgitation
Investigations:
Barium meal:
Dilated esophagus
Narrow distal end
Rat tail appearance
Manometry:
Best test
Weak peristaltic waves
Endoscopy:
Rule out malignancy in elderly
Treatment:
Treatment of choice:
Heller’s myotomy
Elderly or poor surgical candidates:
Dilatation
Botulinum toxin injection
3. Esophageal spasm
Symptoms:
Retrosternal pain
Triggered by hot or cold drinks
Dysphagia
Investigation:
Barium swallow showing corkscrew appearance
Treatment:
Calcium channel blockers
Nitroglycerin
4. Eosinophilic esophagitis
Definition:
Allergic inflammatory condition due to food allergy
Symptoms:
Dysphagia
Food impaction
Heartburn
Associations:
Asthma
Celiac disease
Other autoimmune and allergic diseases
Endoscopic findings:
Rings
Furrows
Ridges
Diagnosis:
Persistent esophageal eosinophilia
After 8 weeks of PPI therapy
Treatment:
Step 1:
Dietary modification
Avoid eggs, soy, nuts, seafood
First-line:
Swallowed steroids
Budesonide
Fluticasone
HIATUS HERNIA
Clinical picture:
Retrosternal discomfort
Regurgitation
Same as GERD
Treatment:
Same as GERD
Weight reduction
Head elevation during sleep
Small frequent meals
PPI best drug
ESOPHAGEAL STRICTURE
Pathophysiology:
Long history of GERD
GERD symptoms disappear
Dysphagia becomes main symptom
Investigation:
Endoscopy
Treatment:
PPI
Dilatation
BARRETT’S ESOPHAGUS
Cause:
Long-standing GERD
Risk:
Adenocarcinoma of esophagus
Investigation:
Endoscopy with biopsy
Poor prognostic factors:
Length of affected segment
Presence of dysplasia
Surveillance:
No dysplasia:
Endoscopy every 3 to 5 years
Low-grade dysplasia:
Endoscopy every 6 months
High-grade dysplasia:
Surgery or ablation
Treatment:
High-dose PPI up to twice daily
ESOPHAGEAL CANCER
Risk factors:
Old age
Male sex
Smoking
Alcohol
Symptoms:
Dysphagia
Weight loss
Investigation:
Endoscopy with biopsy
5.
MALLORY–WEISS SYNDROME
Definition:
Partial mucosal tear at gastroesophageal junction
Risk factors:
Alcoholism
Severe vomiting
Retching
Coughing
Clinical picture:
Hematemesis after violent vomiting
Diagnosis:
Endoscopy
Treatment:
Supportive
Endoscopic cauterization
Epinephrine injection if bleeding
BOERHAAVE SYNDROME
Definition:
Full-thickness rupture of esophageal wall
History:
Severe vomiting
Retching
Alcoholism
Key:
High suspicion clinically
Management:
Emergency diagnosis and treatment
PREMALIGNANT LESIONS OF COLON CANCER
1. Familial polyposis coli
Genetics:
Autosomal dominant
Features:
Numerous polyps in colon and rectum
Natural history:
Colon cancer inevitable
Timing:
Polyps appear by age 10 to 15
Screening:
Colonoscopy
Treatment:
Surgery once polyps appear
2. Gardner syndrome
Variant of FPC
Features:
Desmoid tumors
Osteomas
Epidermoid cysts
3. Peutz–Jeghers syndrome
Features:
Mucocutaneous pigmentation
Risk:
Increased colon cancer risk
Complication:
Severe abdominal pain suggests intussusception
4. Lynch syndrome (HNPCC)
Genetics:
Autosomal dominant
Associated malignancies:
Colorectal cancer
Endometrial cancer
Ovarian cancer
Other GI cancers
Colon findings:
Multiple polyps with dysplasia
Management:
Surgical resection
COLONIC ADENOMAS
Villous adenoma:
Most common adenoma causing electrolyte disturbances
Highest malignant potential
1.
HEMATEMESIS
Definition: Vomiting blood
Causes:
Peptic ulcer disease most common
Reflux esophagitis
Esophageal varices
Mallory-Weiss tear
Esophageal cancer
Gastric cancer
Management sequence:
Step 1: Fluid resuscitation
Packed RBCs if needed
After stabilization: Upper endoscopy is investigation of choice
ACQUIRED PYLORIC STENOSIS
Most common cause:
Fibrosed peptic ulcer
Clinical picture:
Recurrent vomiting
Vomiting occurs 1 hour after meals important
Succussion splash important sign
Imaging:
Dilated stomach on X-ray
Treatment:
Surgery
PEPTIC ULCER DISEASE
Site:
Duodenum more common than stomach
Risk factors:
Helicobacter pylori most common
Smoking
Alcohol
Stress
NSAIDs
Clinical picture:
Epigastric pain
Nausea and vomiting
Hematemesis in severe cases
Iron deficiency anemia
H. pylori investigations:
Urea breath test
Stool antigen test
Serology IgG
Endoscopy with biopsy
Treatment:
Triple therapy:
Amoxicillin
Clarithromycin
Omeprazole
Duration: 10 to 14 days optimal
Old regimen:
Amoxicillin + metronidazole + omeprazole
No longer used due to metronidazole resistance
If failure with triple therapy:
Omeprazole
Bismuth
Tetracycline
Metronidazole
If penicillin allergy:
Omeprazole
Bismuth
Metronidazole
Tetracycline
Follow-up after treatment:
Urea breath test
Stop antibiotics 4 weeks before
Stop PPI 2 weeks before
Persistent symptoms after therapy:
Step 1: Urea breath test
Step 2: Quadruple therapy
Best advice to avoid peptic ulcer:
Avoid smoking
GERD MANAGEMENT
Step 1:
PPI once daily
If symptoms persist:
PPI twice daily
Red flag signs requiring endoscopy:
Age > 55
Weight loss
Recurrent vomiting
Hematemesis
Dysphagia
High malignancy risk:
Old age
Weight loss
Smoking
Alcohol use
If biopsy negative for malignancy:
Repeat biopsy if suspicion remains
COMPLICATIONS OF PEPTIC ULCER
Bleeding
Confused patient:
Protect airway
Intubate first
Not confused:
Fluid resuscitation first
Blood transfusion:
Packed RBCs if needed
Medical:
IV omeprazole
Diagnostic:
Endoscopy
Endoscopic therapy:
Adrenaline injection
Heat probe
If uncontrolled:
Surgery
Perforation
Emergency
Clinical picture:
Severe abdominal pain radiating to back
Abdominal rigidity
Nausea and vomiting
Hypotension
Investigation:
Erect chest X-ray showing free air under diaphragm first step
Treatment:
Resuscitation first
Surgery