Carcinoma of the ColonPresentationCancer of the right colonOccult blood loss melena c iron deficiency anemiaMay have palpable mass (more often in R than L)Uncommonly n/v/dCancer of the left colonMacroscopic rectal bleeding BRBPR (hematocheia)!/"/ConstipationMay have palpable mass Cancer of the rectumRectal bleeding Obstruction #lternating diarrhea and constipation$eeling of incomplete evacuation of stool due to massPredisposing factors%!on&genetic'ietary ( lo)&fiber* high&fatUlcerative colitisCrohn+s colitisLyphogranuloma venereumVillous adenoma (polyp),enetic$amilial polyposis syndrome,ardner+s syndromeLynch syndrome'ifferential 'iagnosis #denocarcinomaCarcinoid tumorLipoma/liposarcomaLeiomyoma/ leiomyosarcoma'iverticular diseaseUlcerative colitisCrohn+sPathophysiologyColorectal carcinoma is usually adenocarcinoma-Most large bo)el cancers occur in the lo)er left side of the colon* near the rectum-Rectal cancer is more common in men- Colon cancer is more common in )omen-Right&side tumors are e.ophytic (gro)ing out)ard from an epithelial surface) / they tend to be bigger than L b/c lumen is bigger-Cancer spreads by direct e.tension (through the bo)el )all to later invade abdominoperitoneal organs)* hematogenously (portal circulation to the liver* lumbar/vertebral veins to lungs)* lymphogenously (regional spread)* transperitoneal* or intraluminal-Colon cancer is the most common cause of colonic obstruction in adults (0- diverticular disease* 1- colonic volvulus)-2or3&Up'R4 ( 567 of cancers are palpable8eme occult* C9C* barium enema* sigmoid/colonoscopyMicrocytic anemia in fol3s : ;6yoa is cancer until proven other)ise4ndorectal U< for rectal cancerC=R (lung mets)* L$>+s (liver mets)* #bdC> (liver mets)umor>6& no primary tumor>5& submucosa>0& muscularis propria>1& through muscularis propria >;& into other organs/tissues !odes!6& no node metastasis!5& 5&1 regional nodes!0& ; or more regional nodes!1& any node along named vesselor mets to 5 apical nodeMetastasisM6& no metastasisM5& distant metastasis present>reatmenthere+s a great pic on p- 0@A >)o common procedures and indications for each%#bdominal Perineal Resection (#PR) if tumor B Ccm from anal vergeLo) #nterior Resection (L#R) if tumor : Ccm from anal verge#dDuvant $or 'u3es CE&$U and levamisole chemotherapy* !O> radiation$or cancer c positive nodal mets or transmural e.tensionRadiation therapy and E&$U chemoFA67 of colorectal cancers recur )ithin 1 years of surgery ( so follo) your patientsGSmall Bowel ObstructionPresentation#bdominal discomfort* cramping* nausea#bdominal distention4mesis8igh&pitched bo)el soundsComplete ( usually no 9Ms or flatusPartial ( usually some flatusI+s>reatmentInitial H !,* I"* $oleyComplete OC84LI#H 9R9PR )ith or )ithoutM0- abdominal pain 1- melena (blac3 tar stool);- anore.iaE- fatigueN- syncope@- shortness of breathC- shoc3ICUL#R disease-#lso* a large tumor can out gro) its blood supply and begin to become necrotic and bleedOa slo)er bleed )hen compared to diverticular disease-'ilated vasculature as in hemorrhoids can become lea3y and bleed-#ny traumatic inDury can penetrate the blood supply and cause bleeding into the lumen- 'iagnostic 2or3up5- history* physical e.am* labs chec3 vital signs for hemodynamic instability and/or fever e.amine the abdomen for distension (intussusception* to.ic megacolon)* tenderness (inflammatory or infectious colitis or intussusception)* or masses (intussusception* tumors* aneurysm) chec3 the )eri*anal area for anal fissures* scratch mar3s (pruritis ani)* signs of trauma* pin)orms* s3in tags or fistula (CrohnPs disease) or peri&anal cellulitis (he high pressure area pro.imal to the stomach 3eeps food from regurgitating bac3 into esophagus/mouth-If something decreases that pressure area stomach contents don+t stay in the stomach-If a little gastric fluid travels north* a healthy esophagus can push it bac3 do)n )ith peristalsis* if esophageal motility is compromised* this mechanism does not )or3-In another situation* the normally lo) pressure in the stomach can build up so much that it overcomes the high pressure in the lo)er esophagus- 'ecreased lo)er esophageal sphincter (L4reatment/ManagementC) ( sho)s dilated ductsN- rule out pneumoperitoneum (free intraperitoneal air) that may represent perforated viscusManagement5- nothing by mouth0- I" fluids (antibiotics if suppurative)1- nasogastric intubation;- parenteral analgesicsE- parenteral vitamin QN- let patient infection subside and then cholecystectomyPerforated "uodenal /lcerPresentation It )ill most li3ely be a middle aged* stressed out* smo3ing man )ith an acute abdomen-his can be associated )ith male gender* smo3ing* aspirin (!reatment$ree air )arrants an e.ploratory celiotomy (laprotomy)-If perforation is less than N hours old* the ulcer is plicated (over se)n* usually a ,raham patch& omentum is se)n over perforation) )ith an acid reducing procedure such as a Pro.imal ,astric "agotomy (only vagus branches that innervate the parietal cell mass are divided) or a >runcal "agotomy )ith antrectomy (a3a& 9illroth I or II)-If the perforation is older than N hours* only a ,raham patch isperformed- Painless $obstructi#e% 0aundicePresentationhe primary bile acids are cholic acid and chenodeo.ycholic acid* )hich are secreted as taurine and glycine conDugatesCon1u!ated #s /ncon1u!ated BilirubinUnconDugated(indirect) insoluble and tightly coupled to albumin* cannot be e.creted in urine-UnconDugated hyperbilirubinemia caused by e.cessive production of bilirubin* reduced hepatocellular upta3e* impaired conDugationConDugated (direct) )ater soluble* to.ic and loosely bound to albumin* can be e.cretedin urine-ConDugated hyperbilirubinemia caused by decreased hepatocellular upta3e and impaired bile flo)-- should test to see )hich form of bilirubin predominates in the blood to point to)ards the etiology of Daundice- bilirubin usually has to be :0&0-E for Daundice to occur* the 5st place Daundice is found is usually under the tongue'iagnostic )or3up&Labs%?/# )ill usually increase )/ obstruction but not as much as al3 phosphatase?#l3aline phosphatase )ill be elevated if obstruction?If biliary ductal system is partially obstructed (i-e- neoplasm) then serum bili may be normal but al3 phos )ill still be elevated?Prothrombin time often elevated due to malabsorption of vit Q?'irect urine bilirubin )ill be high )/ obstructive Daundice?If obstruct Daundice then urobilinogen )ill not be in the urine because e.cretion of bilirubin into the intestine )ould be bloc3ed- Imaging? 5st H UL>R#hese can either be superficial of deep-'eep venous system includes large veins* namely common femoral* superficial femoral* profunda femoral* anterior tibial* posterior tibial* and peroneal- If thin3ing about pathophys thin3 "ircho)+s triad- #nd the type of patient or scenario this state presents-If P4 thin3 clot to pulmonary artery-Most common site of origination includes Iliac* femoral and larger pelvic veins-'escription of diagnostic )or3upIf '"> I )ould begin )ith doppler ultrasound-#ccuracy of AE7->his )ill detect the variation of venous flo) due to respiration-If normal then lo)er e.tremity venous flo) )ill decrease )ith inspiration because of increased intraabdominal pressure-Other tests might include Impedance plehgysmography or I50E& labeled fibrinogen scanning->hese are not common and probably not )hat they )ant->hey )ill )ant you to order a duple. ultrasonography->his can characterie the venous blood flo) and )ill visualie the venous thrombus-#ccuracy is decreased in tibial veins due to difficulty visualiing these little veins in a muscular compartment-Might use C> for diagnosis of pelvic and vena cava thrombus-If you can+t find something )ith this techniUue might try venography-Can also do an acutect test )hich is another nuclear medicine test* binds to glycoprotein IIb/IIIa receptors on platelets and )ill detect acute but not chronic '">-If P4 thin3 ventilation and perfusion scan or pulmonary angiogram- # )edge&shaped defect on perfusion )ithout a ventilation defect indicates a P4 most often- Remember a chest .&ray is rarely diagnostic for P4* but )ill sho) if pulmonary effusion is present (it is in 167 of P4 people)* and sometimes* although rarely )ill sho) )hat is 3no)n as 2estermar3 sign* )hich is a region of atelectasis form the P4-Pulmonary angiogram is specific and sensitive (AC7)* but invasive#lso order an 4C, because you )ill see right&hearted heart problems-Understanding of principles of management>hin3 prevention first-Currently recommend )arfarin 56mg night before surgery* Emg night of surgery and then adDust the I!R to 0&1->his is called >he 8arris method-If '"> thin3 of preventing P4->hin3 anticoagulation )ith heparin and elevation of e.tremityMost appropriate prophyla.is for '"> is )arfarin* lo) molecular )eight heparins (4no.aparin* loveno.)*#dvantages of LM28 are good bioavaility* don+t bind to proteins or endothelial cells* stable dose response* no monitoring* longer half life* less thrombocytopenia and less osteoporosis->e.tboo3 says to begincontinuous infusion of heparin and to monitor the P>> until 0= normal-#fter anticoagulated )ith heparin then s)itch to )arfarin for long term-Remember that)arfarin inhibits the vitamin Q dependent factors of procoagulation>hin3 factor II* "II* I=* = and anticoagulant factor C and o dissolve an already formed thrombus thin3 of strepto3inase or uro3inase-Kou currently only use these if subclavian vein thrombus* acute renal vein thrombus* or 9he spleen is a commonly inDured organ in blunt traumas&DP" is AE7 sensitive for intraperitoneal hemorrhage-If ?* do e.ploratory laparotomy-,et 'PL if patient has abd inDury / hypotension* multiple inDuries / une.plained shoc3* potential abdominal inDury in unconscious* into.icated* or paraplegic pts-A))endicitisPresentationPain that develops in upper abd- or periumbilical region* anore.ia* nausea* vomiting* )/I ;&Nhrs pain spreads to RLS* fever* leu3ocytosis(55666&51666)* rebound tenderness and pain becomes localied to RLS* decreased or absent 9emp* C9C* U#* .&rays useful only )hen a calcified fecalith or foreign body is present* U< useful only for abscess- Usually pt- undergoes surgery based on h.* P4* and leu3ocytosis>reatment#ppendectomy* open or lapJ before surgery give fluids and electrolyte replacementJ begin#9= such as 0nd or 1rd generation cephalosporin given I"* if appendi. not ruptured ta3e off #9= )/I 0;hrs-/))er G BleedPresentationU,I bleeding commonly presents )ith hematemesis (vomiting of blood or coffee&groundli3e material) and/or melena (blac3* tarry stools))- # nasogastric tube lavage )hich yields blood or coffee&ground li3e material confirms this clinical diagnosis- 8o)ever* lavage may not be positive if bleeding has ceased or arises beyond a closed pylorus- >he presence of bilious fluid suggests that the pylorus is open and* if lavage is negative* that there is no active upper ,I bleeding distal to the pylorus- In comparison* hematocheia (bright red or maroon colored blood or fresh clots per rectum) is usually a sign of a lo)er ,I source (defined as distal to the ligament of >reit)- #lthough helpful* the distinctions based upon stool color are not absolute since melenacan be seen )ith pro.imal lo)er ,I bleeding* and hematocheia can be seen )ith massive upper ,I bleeding 'ifferential/Pathophysiology / >reatment>here are three maDor cause of Upper ,I bleeding%5% Peptic ulcer disease0%4sophagogastric varices1%Mallory 2eis tearP/"%Commonly caused by% 8&Pylori/stress/!his chronic gastritis can lead to PU'/atrophy/Metaplasia and even Ca- STR,SS%Common cause for ,I bleeding in Patients hospitalied for life threatening illnesses- 8igher mortality than those admitted for primary upper ,I bleed-Ris3 increased in patients )ith respiratory failure and coagulopathies-Prophylactic treatment )ith H%#proton pump inhibitors reduces ris3- NSA"S&Mucosal irritation / ulceration by systemic effects / prostaglandin inhibition- GASTRC AC"&$actors such as 8&Pylori/!herefore the most common causes in the U< are 4>O8 abuse and chronic active hepatitis-9leeding stops spontaneously in E67 of these patients but the mortality rate reaches C67 in those )ith continued bleeding- In those )ith advanced liver disease the bleeding may be massiveJ the only definitive treatment in these cases is li!er transplantation->reatment consists of sclerotherapy and endoscopic band ligation- MALLOR8 9,S T,AROccurs at the ,4 Dunction as a result of retching or vomiting- 9leeding ensues )hen the tear involves the underlying esophageal venous or arterial ple.us- Most tears heal uneventfully )ithin 0; to ;C hours in patients )ithout portal hypertension- #lmost all patients )ill respond to endoscopic hemostatic therapy-Gallstone Pancreatitis #cute pancreatitis from a gallstone in or passing through the ampulla of "aterPresentation%0 0&Ecm>1 :Ecm>a fi.ed>b not fi.ed>; please see pg 1@C !ode involvement!6 no suspicious a.illary adenopathy!5 nodes considered to contain gro)th!0 suspicious nodes* fi.ed to each other or another structure!1 supra& or infraclavicular nodes containing gro)thMetastasesM6 not presentM5 present#dditional studiesF