Alimentary Tract

• 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

• 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.

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 even if found incidentally:

    • diverticulectomy for no inflammation or palpable abnormality

    • segmental resection for inflammation, perforation, palpable abnormality

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.

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

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: