Components of small bowel
DJ-I; ileum is the longests
SMA/SMV
J and I
Where does lymph drain?
cisterna chyli
What supplies the appendix?
ileocolic artery
Where does most of absorption occur?
jejunum; passive
Where is B12 absorbed?
ileum
Excitatory neurotransmitter
acetyl choline
What is the MCC of acute abdomen?
acute appendicitis
The appendix is primarily composed of what?
lymph
N/V; Pain usually at the umbilicus then moves later to RLQ
appendicitis
Rovsig's tenderness
palpation on LLQ radiates to RUQ
What is the best diagnostics for appendicitis?
CT
Alvarado Score
What is the preferred approach of appendicitis?
Interventional radiology drainage
Appendicitis Abx
Cefoxitin (Mefoxin), PIP-TZN (Zosyn), cipro/flagyl
Two most common microbes assoc. with appendicits?
E. coli and B. fragilis
What is the MC tumor in the appendix?
carcinoid
2nd MC appendix tumor
adenocarcinoma; Right hemicolectomy
Obstruction
MC due to adhesion from prior surgery; hyperactive BS; pain is colicky
Paralytic Illeus
non mechanical;
Intussusception
< 2 yrs; jelly stool; tx is barium enema
Adult Intuss
target sign on CT
What is the MC small bowel tumor?
leiomyoma
SBO therapy
Laparoscopy vs open technique
SBO tx
NGT placement�decompress the small bowel and stomach
LBO
preop abx- mefoxin
Left sided colon CA
cause obstruction
diverticulitis
-Antibiotics
-Bowel Rest
-NGT if vomiting severe
-Drainage of abscess
Dementia
Ogilvie's Syndrome: Colonic Pseudo-Obstruction
Peritoneal signs
could indicate perforation
Sigmoid Volvulus
proctoscopy or colonoscopy
Coffee bean sign
comma sign; haustra in LUQ; indicates LBO
Cecal Volvulus
ileostomy if peritonitis
Dentate line
divides the rectal mucosa; columnar and squamous mucosa
Internal sphincter
involuntary control
External sphincter
voluntary control
4 areas of anorectum
-Peri-anal
- Ischioanal
- Supralevator
- Intersphincteric (intermuscular)
Internal hemorrhoids
painless bleeding, chronic straining; engorgement and bleeding, as well as hemorrhoidal prolapse
Grades of Internal Hemorrhoids
Grade 1 Bleeding without prolapse
Grade 2 prolapse that spontaneously reduce
Grade 3 prolapse necessitating manual reduction
Grade 4 irreducible prolapse
Internal hemorrhoids dz- nonoperative
Rubber band ligation; Infrared coagulation
External Hemorrhoids
painful
External hemorrhoid tx
completely excise
Anal Fissure
split in andoderm; passage of large stools; posterior midline
Anal Fissure Classic triad
-Hypertrophy of anal papilla
- Anal fissure
- Sentinel skin tag
Anal Fissure tx
- Fiber supplement
- Stool softeners
- Generous water intake
- Sitz bath
- Local anesthetic ointment
Anal Fissure management
lateral internal anal sphintrotomy
Anal Fissure Therapeutic alternatives
topical nitro, topical CCB, B toxin
Most anorectal abscess are
cryptogenic; perianal abscess is MC
MC location of Ano fistula
internal and external sphincters
Pilondial sinus dz
Excision and primary closure
Pruritus Ani
lichenification
Seven layers of abd wall
Skin, camper's fascia, scarpa's fascia, external oblique fascia, internal oblique fascia, transversalis fascia and peritoneum
MC hernia
inguinal hernia
Inguinal
indirect; MC passage of intestines through internal inguinal ring down inguinal canal, most common at right side, may pass into scrotum; direct hernia; passage of intestines through external inguinal ring through hesselbach triangle; rarely enters the scr
Inguinal hernal repair
lichenstein or tension free repair
McVay repair
Sewing the conjoined tendon to the Cooper's ligament
Hesselbach's Hernia
Protrudes onto the thigh BENEATH the inguinal ligament
Courses LATERAL to the femoral vessels