SSAT: ABSITE Prep Upper and Lower GI

Lisa A. Cunningham, MD Achalasia

• Symptoms: dysphagia, regurgitation of undigested food, cough • No peristalsis, LES does not relax • Destruction of ganglion cells in muscle wall • Esophogram: tortuous dilated esophagus, bird’s beak • Manometry: high pressure, no relaxation • EGD to rule out esophageal CA – Can developed due to chronic irritation (SCC) • Tx: Balloon dilation, botox injection into LES, nitrates, Ca channel blockers • if above fails: with wrap Hiatal

• Symptoms: chest pain, N/V, difficulty passing NG, bleeding from Cameron’s lesions – Type 1: sliding from dilation of the hiatus – Type 2: paraesophageal – Type 3: combined – Type 4: entire plus one additional organ in the chest • Type 2-4 at risk for incarceration and strangulation • Perform wrap +/- G tube/ to anchor stomach at time of repair • Associated with Schatzki’s rings – tx with dilation not resection Esophageal Perforation

• Symptoms: CP, back pain, dysphagia • Boerhaave’s: forceful vomiting followed by severe chest pain – Most common location: left lateral wall 3-5 cm above the GE junction – Highest mortality of all perforations • Iatrogenic Perforations: Commonly from EGD – Most common location: cervical esophagus near cricopharyngeus muscle • Other causes: trauma, FB ingestion, CA • Diagnosis: Gastrograffin swallow Esophageal Perforation

• Treatment: – Contained on swallow with no signs of systemic illness: • NPO, IVF, antibiotics – Not contained: • Early: – Primary repair with drains » complete longitudinal myotomy » intercostal muscle flaps to buttress • Late: – : Drainage only – will heal – Chest: Resection () or exclusion and diversion (esophagostomy) Caustic Esophageal Injury • Types: – Alkali: deep liquefactive necrosis – Acid: coagulative necrosis • Do NOT place NG or induce vomiting • Evaluation: – CT scan to evaluate for perforation – to assess injury • Do not perform if CT reveals perforation • Treatment: – Superficial: NPO, IVF, antibiotics, serial exams – Deep: starts same as above, but likely esophagectomy GERD

• Heartburn, worse with lying down, cough • Reflux of acid into the distal esophagus • Medical Tx: PPI, lifestyle modifications – If fails escalating doses, need further studies • Dx: pH probe, endoscopy, manometry • Surgery: Barrett’s Esophagus • Long standing reflux • Tongues of raised, salmon colored tissue extending up from GE junction – Columnar metaplasia • Medical Tx: PPI • High grade dysplasia requires frequent (q3 monthly) with 4 quadrant biopsies – Consider radiofrequency ablation – destroys superficial tissue • Decreases rate of progression to cancer compared to surveillance alone – Cryotherapy (cold) – EMR – resection down to submucosa, can obtain depth of invasion • Esophagectomy considered for persistent HGD or if progresses to CA

• Adenocarcinoma most common in US – lower 1/3 • Spreads quickly along lymphatic channels – Nodal status most important prognostic factor • Symptoms that indicate likely unresectability: – Hoarseness, Horner’s syndrome, phrenic nerve invasion, pleural effusions, fistulas • Dx: Endoscopy • Tx: – Pre-op chemo-XRT can downstage tumors and make them resectable, post-op chemo for node positive disease – Esophagectomy • Right gastroepiploic artery – primary blood supply to gastric conduit • Complications: Leaks, strictures, chylothorax Stomach Ulcer Disease

• Duodenal Ulcers: – Anterior: perforate – Posterior: bleed (GDA) • Gastric Ulcers: – Commonly on the lesser curvature • Tx: H. pylori, PPI, lifestyle modifications • Surgery indicated when there is perforation, continued bleeding, obstruction, resistance to medical therapy, inability to rule out CA – Proximal : low complications but high recurrence – Truncal vagotomy with pyloroplasty – Truncal vagotomy with antrectomy: lowest recurrence • Reconstruction with Roux-en-Y gastrojejunostomy, B1 or B2 Gastric Cancer

• Symptoms: pain, weight loss, GOO • Risk factors: adenomatous polyps, smoking, previous , gastritis • Dx: EGD with biopsies • Treatment: – Chemo: 5FU, doxorubicin, mitocycin – XRT: Pain or bleeding palliation – Surgery: • Intestinal type: subtotal with 10 cm margins • Linitis plastic (diffuse): total gastrectomy Other Cancers

• GISTs – Commonly benign, usually asymptomatic but can cause obstructive symptoms • Malignant if >5 cm or >5 mitoses per HPF – C-KIT positive – Tx: Imatinib (Gleevec), resection with 1 cm margins • MALT Lymphoma – Associated with H. pylori and regresses with tx – XRT if doesn’t regress • Gastric Lymphomas – Stomach is the most common location for extra-nodal lymphoma – Tx: chemo and XRT, surgery for complications (perforation) or very low stage disease and Colon Meckel’s Diverticulum

• True diverticulum from failure of closure of the omphalomesenteric duct • Rule of 2s: 2 ft from ileocecal valve, 2% of population, 1st 2 years of life, 2 types of tissue – Pancreatic: most common – Gastric: can produce acid that leads to bleeding • Presentation: bleeding in kids, obstruction in adults • Treatment: – Diverticulectomy for uncomplicated diverticulitis or bleeding – Segmental resection if complicated, large neck or base involved Crohn’s Disease vs. Ulcerative Colitis

Manifestation Crohn’s Disease Ulcerative Colitis Fissures ++ + Fistulas +++ + Perianal Disease ++ - Ulcers + - Small Bowel +++ - Involvement Rectal - +++ Involvement Bleeding - +++ Crohn’s Disease

• Abdominal pain, diarrhea, fistulas • Terminal ileum most commonly involved • Medical Tx: – Maintenance: sulfasalazine or 5-ASA – Immunomodulators for resistant disease – Steroids +/- cipro/flagyl for flares • Surgical Tx: – Try not to perform surgery to decrease risk of short gut – If necessary, resect involved segment only Ulcerative Colitis • Bleeding, abdominal pain • Spares anus • Extra-intestinal manifestations that get better after : – arthritis, anemia, uveitis, pyoderma gangrenosum • BE: loss of haustra, narrow caliber – lead pipe colon • Medical Tx: – Maintenance: sulfasalazine or 5-ASA – Immunomodulators for resistant disease – Steroids +/- cipro/flagyl for flares • Surgical Tx: Total proctocolectomy with end or J pouch, APR with ileostomy – Performed electively with long-standing disease or CA, emergently with toxic colitis or megacolon Familial Adenomatous Polyposis (FAP)

• Autosomal dominant, small amount are spontaneous – APC gene • Gardner’s syndrome: FAP + desmoid tumors • Turcot’s syndrome: FAP + brain tumors • Associated with duodenal polyps – Requires EGD surveillance – Most common cause of death in FAP after colectomy: periampullary cancers • Flex sig to check for polyps – carpet the entire colon • Surgery: Total proctocolectomy by age 20 Hereditary Nonpolyposis Colon Cancer (HNPCC)

• Autosomal dominant transmission – DNA mismatch repair • Associated cancers: ovarian, endometrial, bladder, stomach • Amsterdam Criteria: – 3 first degree relative – Over 2 generations – With at least 1 having cancer before age 50 • Start surveillance at age 25 or 10 years before youngest affected family member • Surgery: total proctocolectomy Volvulus

• Cecal volvulus – Presents as SBO with dilated cecum – unlikely to be successful – Surgery: Right hemicolectomy best, cecopexy an option • Sigmoid volvulus – More common – Presents as LBO – Colonoscopy to evaluate bowel, decompression highly successful but can recur – Needs sigmoid colectomy during same admission even if colonoscopy successful or bowel gangrenous Diverticulitis • Perforation of colonic diverticulum – Left side predominance • Symptoms: LLQ pain, fever, leukocytosis • Hinchey Score: – 1: localized abscess/phlegmon - 3: purulent peritonitis – 2: pelvic abscess - 4: feculent peritonitis • Treatment: – Antibiotics and bowel rest for Hinchey 1 – IR or surgical drainage + above for Hinchey 2 – Hartmann’s for Hinchey 3 or 4 - controversy about laparoscopic washout • Complications: recurrent abscess, colovesical/vaginal fistulas • Need follow-up colonoscopy after attack to rule out CA Colorectal Cancer

• Symptoms: anemia, constipation, bleeding (MC in young patients) • Associated with C. septicum infection • Associated genes: APC, DCC, p53, k-ras • Spreads to nodes, via portal system and hematogenously – Nodal status most important prognostic factor – Resect isolated lung/liver mets • Dx: Colonoscopy to asses entire colon (rule out synchronous lesions) Colorectal Cancer

• Surgery: – Segmental resections for colonic lesions from cecum to sigmoid – APR for low rectal lesions, can do LAR if 2 cm margins – Transanal excision of T1 rectal lesions can be considered if small and no invasion on TRUS • Chemo: – For node positive and metastatic disease – FOLFOX and FOLFIRI • XRT: – Can be used preop with chemo to downstage rectal cancers Anorectal Fissures

• Split in the anoderm – Straining, constipation • Vast majority in the posterior midline – If lateral or recurrent, concern for IBD • Pain and bleeding with defecation • Medical tx first: Sitz baths, fiber with stool softeners, topical lidocaine, nitro cream • Surgical tx if fails: lateral subcutaneous sphincterotomy – Anal incontinence – Contraindicated with IBD Fistulas

• Common complication of perirectal/anal abscess • Goodsall’s Rule: – Anterior fistulas connect in a straight line – Posterior fistulas go toward a midline internal opening • Treatment: – Lower 1/3: Seton vs fistulotomy – Upper 2/3: Seton, then consider advancement flap • No fistulotomy due to risk of injuring external anal sphincter Anal Cancer

• Highly associated with HPV and XRT • lesions (above dentate): – SSC: tx with Nigro protocol (chemo-XRT, 5FU and mitomycin), APR if fails or recurs – Adeno: tx with APR, WLE if small and limited in extent – Melanoma: 3rd most common site, very early spread, tx with APR with standard melanoma depth criteria • Anal margin lesions (below dentate): – SCC: Mets to inguinal nodes, tx with WLE if less than 5 cm, chemo-XRT for >5 cm or if sphincter involvement, node dissection Citations

• Information taken liberally from Fiser, 5th edition and Sabiston’s Textbook 20e and The ASCRS Textbook of Colon and Rectal Surgery 3e, accessed via Score