1B general surgery in the GI tract Flashcards
1
Q
What do we look for in regards to the patient’s PC (presenting complaint)?
A
- Pain assessment (SOCRATES)
- Associated symptoms
Other things to ask about:
- PMHx (past medical history)
- DHX (drug history)
- SHx (social history)
2
Q
What range of investigations are there in general approach to acute abdomen?
A
- Bloods (VBG, FBC, CRP, U&Es (renal profile), LFTs + amylase)
- Urinalysis + urine MC&S –> check for UTI
- Imaging ( Erect CXR, AXR, CTAP, CT angiogram, USS)
- Endoscopy
3
Q
What are the 3 approaches to management of abdominal assessment?
A
- ABCDE approach
- Airways
- Breathing
- Circulation
- Disability
- Exposure
- Conservative management
- Surgical management
4
Q
What diseases are associated with RUQ pain?
A
- Bilary Colic
- Cholecystitis/Cholangitis
- Duodenal Ulcer
- Liver abscess
- Portal vein thrombosis
- Acute hepatitis
- Nephrolithiasis
- RLL pneumonia
5
Q
What diseases are associated with epigastrium pain?
A
- Acute gastritis/GORD
- Gastroparesis
- Peptic ulcer disease/perforation
- Acute pancreatitis
- Mesenteric ischaemia
- AAA (Abdominal Aortic Aneurysm) Aortic dissection
- Myocardial infarction
6
Q
What diseases are associated with LUQ pain?
A
- Peptic ulcer
- Acute pancreatitis
- Splenic abscess
- Splenic infarction
- Nephrolithiasis
- LLL Pneumonia
7
Q
What diseases are associated with RLQ pain?
A
- Acute Appendicitis
- IBD
- Colitis
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
8
Q
What diseases are associated with suprapubic/central pain?
A
- Early appendicitis
- Mesenteric ischaemia
- Bowel obstruction
- Bowel perforation
- Constipation
- Gastroenteritis
- UTI/Urinary retention
- PID
9
Q
What diseases are associated with LLQ pain?
A
- Diverticulitis
- IBD (Inflammatory Bowel Disease)
- Colitis
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
10
Q
How do patients present with bowel ischaemia?
A
- Sudden onset crampy abdominal pain
- Severity of pain depends on length and thickness of colon affected
- Bloody, loose stool (currant jelly stools)
- Fever, signs of septic shock
11
Q
What are the risk factors of bowel ischaemia?
A
- Age >65 years
- Cardiac arrythmias (mainly AF), atherosclerosis
- Hypercoagulation/thrombophilia
- Vasculitis
- Sickle cell disease
- Profound shock causing hypotension (happens to patients undergoing cardiac surgery)
12
Q
What are the 2 types of ischaemic bowel?
A
- Acute mesenteric ischaemia
- Ischaemic colitis
13
Q
Which bowel does acute mesenteric ischaemia affect?
A
Large bowel
14
Q
Which bowel does ischaemic colitis affect?
A
Large bowel
15
Q
What is acute mesenteric ischaemia caused by?
A
Usually occlusive and secondary to thromboemboli
16
Q
Who can thromboemboli happen in?
A
If someone has AF, a small clot can come and get blocked in SMA- superior mesenteric artery
If there’s complete obstruction of the SMA that’s really bad because you lose all of bowel from DJ flexure to splenic flexure- all of small bowel and 3/4 of large bowel
17
Q
What is ischaemic colitis caused by?
A
Usually due to non-occlusive low flow states, or atherosclerosis
18
Q
How is the onset for acute mesenteric ischaemia?
A
Sudden onset (but presentation and severity varies)
19
Q
How is the onset for ischaemic colitis?
A
More mild and gradual (80-85% of cases)
20
Q
What is the pain like for acute mesenteric ischaemia?
A
Abdominal pain out of proportion of clinical signs (often none at all)
21
Q
What is the pain of ischaemic colitis like?
A
Moderate pain and tenderness
22
Q
What 3 types of investigations do we do for bowel ischaemia?
A
- Bloods
- FBC - neutrophilic leukocytosis
- VBG - lactic acidosis
- Imaging
- CTAP/CT angiogram
- Endoscopy
- For mild or moderate cases of ischaemic colitis
23
Q
What is lactic acidosis?
A
- A form of metabolic acidosis
- Associated with late stage mesenteric ischaemia and extensive transmural intestinal infarction
- late stage meaning bowel is already dead
24
Q
What do CTAP/CT angiograms for bowel ischaemia detect?
A
- Disrupted flow
- Vascular stenosis
- Pneumatosis intestinalis (transmural ischaemia/infarction)
- Ischaemic colitis- a thumbprint sign (unspecific sign of colitis)
Image shows blood in white next to arrow coming to a complete stop
Light grey oval bowel just to right of middle of pic is healthy, the big dark grey bowel underneath is showing it isn’t getting blood
25
What do we look for in an endoscopy for bowel ischaemia?
- Oedema
- Cyanosis
- Ulceration of mucosa
26
What type of bowel ischaemia can we do conservative management for?
Mild to moderate cases of ischaemic colitis
27
What type of bowel ischaemia is conservative management not suitable for?
Acute mesenteric ischaemia
28
What does conservative management consist of?
- V fluid resuscitation
- Bowel rest (NBM)
- Broad spectrum ABx (Colonic ischaemia can result in bacterial translocation and sepsis)
- NG tube for decompression (They can get concurrent ileus- bowel is just not peristalsing)
- Anticoagulation
- Treat/manage underlying cause
- Serial abdominal exams and repeat imaging to check for changes and e.g. if you see peritonitis you don’t want to continue conservative management
29
What are the indications for surgical management of bowel ischaemia?
- Small bowel ischaemia
- Fulminant colitis with toxic megacolon
- Signs of peritonitis or sepsis
- Haemodynamic instability
- Massive bleeding
30
What is an exploratory laparotomy?
Opening abdomen up for exploration
31
What do we do in exploratory laparotomies for ischaemic bowel?
**Resection of necrotic bowel** with or without:
- open surgical embolectomy (putting balloon catheter in SMA to pull out thrombus)
- mesenteric arterial bypass (rare)
Image shows purple dead small bowel, with pink healthy large bowel at bottom of pic and relatively healthy small bowel on right side of pic
32
What is endovascular revascularisation?
- Another technique to try prior to surgery
- Balloon angioplasty/thrombectomy
- In patients without signs of ischaemia
33
How does acute appendicitis present?
- Initially periumbilical pain that migrates to RLQ (within 24 hours)
- Anorexia
- Nausea +/- vomiting
- Low grade fever
- Change in bowel habit
34
What is a good question to ask someone who has suspected appendicitis?
Do they feel like eating a meal- they always will say absolutely not
35
Why do patients with acute appendicitis present with a change in bowel habit?
Inflamed appendix in pelvis will be adjacent to rectum and could irritate rectum to alter bowel habit
36
What are important clinical signs to look out for in acute appendicitis?
- McBurney's point
- Blumberg sign
- Rovsing sign
- Psoas sign
- Obturator sign
37
What is Mcburney's point?
Tenderness in RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
38
What is Blumberg sign?
Rebound tenderness (press down then release) especially in RIF
39
What is Rovsing sign?
RLQ pain elicited on deep palpation of the LLQ
40
What is Psoas sign?
RLQ pain elicited on flexion of right hip against resistance
41
What is obturator sign?
RLQ pain on **passive internal rotation** of the hip with hip and knee flexion
42
What 3 types of investigations are there for acute appendicitis?
- Bloods
- FBC - neutrophilic leukocytosis
- Raised CRP
- Urinalysis- possible mild pyuria (WBCs in pee)/ haematuria
- Electrolyte imbalances in profound vomiting
- Imaging
- CT: gold standard in adults esp. if age >50 → main reason is to check if nothing else is going on
- USS: children/pregnancy/breastfeeding
- MRI: in pregnancy if USS inconclusive
- Diagnostic laparoscopy
- Done when patient is in persistent pain and inconclusive imaging
43
What is the Alvarado score?
clinical scoring system for appendicitis
- RLQ tenderness- 2 points
- Rebound tenderness- 1 point
- Fever >37.3°C- 1 point
- Pain migration- 1 point
- Anorexia- 1 point
- Nausea +/- vomiting- 1 point
- WCC >10.000- 2 points
- Neutrophilia (left shift 75%)- 1 point
≤4 unlikely
5-6 possible
≥7 likely
44
What does conservative management of acute appendicitis consist of?
- IV fluids
- Analgesia
- IV or PO antibiotics
- In abscess, phlegmon or sealed perforation, we do resuscitation + IV ABx +/- percutaneous drainage (if there’s a collection)
45
What are the indications for conservative management of acute appendicitis?
- After **negative imaging** in selected patients with **clinically uncomplicated appendicits**
- In **delayed presentation** with abscess/phlegmon formation and then you do CT guided drainage
46
What do we consider after conservative management of acute appendicitis?
Interval appendicectomy because rate of recurrence after conservative management of abscess/perforation is 12-24%
47
Why is laparoscopic better than open appendicectomy?
- Less pain
- Lower incidence of surgical site infection
- Decreased length of hospital stay
- Earlier return to work
- Overall costs
- Better QoL scores
48
What are the steps to a laparoscopic appendicectomy?
1) Trocar placement (usually 3 port sites)
2) Exploration of RIF and identification of appendix
3) **Elevation** of appendix and **division** of mesoappendix (containing artery)
4) **Base secured with endoloops** (like a lasso) and **appendix divided**
5) Retrieval of appendix with a plastic retrieval bag
6) Careful **inspection** of the rest of the pelvic organs/intestines
7) Pelvic **irrigation** (wash out) + haemostasis
8) Removal of trocars + wound closure
49
What is the definition of intestinal obstruction?
Restriction of normal passage of intestinal contents
50
What are the 2 main groups of intestinal obstruction?
- **Paralytic (adynamic) ileus** e.g. someone with abdomen full of pus, this irritates bowel and bowel stops peristalsis (this is an ileus) and doesn’t stop til irritation gone
- **Mechanical** e.g. mechanically a bit of the bowel closes off
51
What are the 4 different ways to classify a mechanical intestinal obstruction?
- Speed of onset (acute, chronic, acute-on-chronic)
- Site (High/low/synonymous with small or large bowel obstruction)
- Nature (simple vs strangulating)
- Aetiology (what are the causes?)
52
What does simple bowel obstruction mean?
Bowel is occluded without damage to blood supply
53
What does strangulating bowel obstruction mean (+ give 3 causes)?
blood supply of involved segment of intestine is cut off e.g. in
- strangulated hernia
- volvulus
- intussusception
54
What is volvulus?
Imagine a party balloon being twisted giving you a closed loop
55
What is intussusception?
When a bit of a bowel slides into the next bit
56
What are the causes of bowel obstruction?
- **Causes in the lumen** e.g. faecal impaction, gallstone ‘ileus’ where gallstone erodes through gallbladder into bowel then gets wedged in it
- **Causes in the wall**- Crohn’s disease (thickening of small bowel wall), tumours, colon diverticulitis
- **Causes outside the wall**- strangulated hernia (external or internal), volvulus, obstruction due to adhesions or bands (this one is the commonest)
57
What are the causes of small bowel obstruction?
58
What are the causes of large bowel obstruction?
59
What are the 4 main signs/symptoms of presentationfor both small and large bowel obstruction?
- Abdominal pain
- Vomiting
- Absolute constipation
- Abdominal distention
60
What are the 3 important things to remember about diagnosing bowel obstruction?
- Diagnosed by the presence of symptoms
- Examination should always include a search for hernias and abdominal scars, including laparoscopic portholes
- Is it simple or strangulating?
61
What are features suggesting strangulation?
- Change in character of pain from colicky to continuous
- Peritonism (symptom complex of vomiting, pain/abdo tenderness and shock)
- Tachycardia
- Pyrexia
- Leukocytosis
- Increased CRP
- Bowel sounds absent or reduced
62
Why is checking for strangulation important?
Strangulating obstruction with peritonitis has mortality of up to 15%
63
Describe common hernia sites
- **Inguinal and femoral hernias** in groin are due to defects in abdominal wall
- Can get **incisional hernia** where you’ve had operation where skin has healed but underneath muscle has defect so bowel can come through that
- **Umbilical hernias** happen around umbilicus
- **Epigastric hernias** happen around epigastrium
64
Why is the neck of the hernia sac important?
- If it’s a large one, the bowel can get in and out easily
- The smaller the hole, the greater the chance there is of the hernia obstructing and strangulating
- e.g. in strangulated hernia pic, first venous return goes then bowel becomes oedematous then blood stops coming out which compresses arterial blood coming in causing ischaemic bowel
65
What is a Richter’s hernia?
- Not all hernias are associated with obstruction
- This is a knuckle of bowel getting caught in a hernia but there’s still continuity of the bowel so you still have dead bowel without proper bowel obstruction
66
What are the 2 types of investigations done for bowel obsctruction?
- Bloods
- WCC/CRP usually normal (if raised then suspicion of strangulation/perforation)
- U&E: electrolyte imbalance e.g. if vomiting
- VBG if vomiting: HypoCl-, HypoK+ metabolic alkalosis
- VBG if strangulation: metabolic acidosis (lactate)
- Imaging
- Erect CXR/AXR
- CT abdo/pelvis
67
Describe the signs of SBO on an erect CXR/AXR
- Ladder pattern of dilated small bowel loops >3cm central to obstruction
- Striations that pass completely across the width of the distended loop produced by the circular mucosal folds
68
Describe signs of LBO on an erect CXR/AXR
- Distended (dilated) large bowel tends to lie peripherally
- Show haustrations of taenia coli that don’t extend across the whole width of the bowel
69
Why is CT abdo/pelvis done to investigate bowel obstruction?
- Can see **transition point**- helps with surgery
- can see **dilatation of proximal loops**- give IV or oral contrast if possible
70
When can we do supportive/conservative treatment for patients with bowel obstruction?
When they have no signs of ischaemia/clinical deterioration
71
What supportive management is there for bowel obstruction?
- **NBM**, IV peripheral access with large bore cannula- **IV fluid resuscitation**
- **IV analgesia, IV antiemetics, correction of electrolyte imbalances**
- **NG tube** for decompression (also removes problem of aspirational pneumonia), **urinary catheter** for monitoring so we can base fluid input on pee output
- Introduce **gradual food intake** if abdominal pain and distention improve
72
What conservative treatment of bowel obstruction is there?
- Faecal impaction- stool evacuation (manual, enemas, endoscopic)
- Sigmoid volvulus- rigid sigmoidoscopic decompression
- SBO- oral gastrogaffin (highly osmolar iodinated contrast agent) can be used to resolve adhesional small bowel obstruction
- When you have small bowel adhesion the more fluid you pump in the more it twists so if you decompress and suck fluid out it has a chance to straighten itself out
73
What indications are there for surgical management of bowel obstruction?
- **Haemodynamic instability** or signs of **sepsis**
- **Closed loop obstruction** (intervene quickly before it becomes ischaemic)
- **Complete bowel obstruction** with ischaemic signs
- **Persistent bowel obstruction >2 days** despite conservative management
74
What operations are there for bowel obstruction?
- **Exploratory laparotomy/laparoscopy** to find what’s going wrong so we can remove it
- **restoration of intestinal transit** (depending on intra-operational findings)
- **Bowel resection** with primary anastomosis or temporary/permanent stoma formation
75
What do we do with patients that are unwell (especially those with tumours)?
- Give them endoscopic stenting
- Especially if obstruction is distal
76
How do patients with GI perforations present?
- Sudden onset severe abdominal pain associated with distention
- Pain aggravated by movement
- Diffuse abdominal guarding, rigidity, rebound tenderness
- Nausea, vomiting, absolute constipation (due to ileus of chemical irritation rather than mechanical obstruction)
- Decreased or absent bowel sounds (because of ileus)
- Fever, tachycardia, tachypnoea, hypotension
77
What are the four causes of GI perforation?
- Perforated peptic ulcer
- Perforated diverticulum
- Perforated appendix
- Perforated malignancy
78
How does perforated peptic ulcer present?
- Sudden epigastric or diffuse pain
- Referred shoulder pain- due to irritation of diaphragm (innervated by phrenic nerve which also innervated right shoulder)
- Hx of NSAIDs, steroids, recurrent epigastric pain
79
How does perforated diverticulum present?
- LLQ pain- insidious onset
- Constipation
80
How does perforated appendix present?
- **Migratory pain**
- Anorexia
- Gradual worsening RLQ pain
81
How does perforated malignancy present?
- Change in bowel habit
- PR bleeding
- Weight loss
- Anorexia
82
What are the two types of investigations we do?
- Bloods
- FBC: neutrophilic leukocytosis
- VBG: lactic acidosis
- Possible elevation of urea, creatinine
- Imaging (help up localise perforation)
- Erect CXR- subdiaphragmatic free air (pneumoperitoneum)
- CT abdo/pelvis → pneumoperitoneum, free GI content, localised mesenteric fat stranding- can exclude common differentials like pancreatitis
83
What differentials are there with the same symptoms as GI perforation?
- Acute cholecystitis
- Acute pancreatitis
- Appendicitis
- MI
so always check amylase before sending someone off for surgery
84
What supportive management is there for GI perforation?
- IV peripheral access with large bore cannula- **IV fluid resuscitation**
- **NBM and NG tube** (to decompress)
- **Broad spectrum Abx**
- **Parenteral analgesia and antiemetics**
- **IV PPI**
- **Urinary catheter**
85
Which patients do we do conservative management in for GI perforation?
In patients with localised peritonitis without signs of sepsis (not generalised peritonitis)
This is very rare though, most patients will need surgery
86
What conservative management is there for GI perforation?
- **Interventional radiography (IR)**- guided drainage of intra-abdominal collection
- **Serial abdominal exams** and **abdominal imaging** for assessment to look for changes
87
Which patients do we do surgical management in for GI perforation?
Patients with generalised peritonitis +/- signs of sepsis
88
What surgical management options are there for patients with GI perforation?
- Exploratory laparotomy/laparoscopy- find hole and deal with it
- Primary closure of perforation +/- omental patch e.g. A in pic (most common in perforated peptic ulcer)
- Resection of the perforated segment of the bowel with primary anastomosis or temporary stoma
- Obtain intra-abdominal fluid for MC&S (microscopy culture and sensitivity), peritoneal lavage
89
What do we do for GI perforation if there’s a perforated appendix?
Lap or open appendicectomy
90
What do we do for GI perforation if there's a malignancy?
Intraoperative biopsies if possible
91
What are symptoms of Biliary colic?
- Post prandial RUQ pain with radiation to shoulder
- Nausea
92
What investigations are done for biliary colic?
- Normal bloods
- Cholelithiasis (gallstone) on USS
93
What is the management for biliary colic?
- Conservative- analgesia, antiemetics, spasmolytics
- Follow up for elective cholecystectomy
94
What are symptoms of acute cholecystitis?
This is infection of gallbladder
- Acute, severe RUQ pain
- Fever
- Murphy's sign
95
How is Murphy's sign different from pleuritic chest pain?
- Murphy’s sign is placing hand in RUQ and it may feel non tender, then ask patient to take deep breath in and liver pushes gallbladder down which touches hand and patient yelps
- Pleuritic chest pain is when you take deep breath in and you feel sharp pain in chest wall, not abdomen
96
What investigations are done for acute cholecystitis?
- Elevated WCC/CRP
- USS- thickened gallbladder wall
97
What treatment is given for acute cholecystitis?
- Fluids, ABx, analgesia, blood cultures
- Early (<72 hours) or elective cholecystectomy (4-6 weeks)
98
What are symptoms and causes of acute cholangitis?
- Charcot’s triad- jaundice, RUQ pain, fever
- Usually is obstruction of biliary tree
99
What investigations are done for acute cholangitis?
- Elevated LFTs, WCC, CRP, blood MCS (+ve)
- USS- biliary dilatation
100
What treatment is given for acute cholangitis?
- Fluids, IV Abx, analgesia
- ERCP (within 72 hours) for clearance of bile duct or stenting
101
What are the symptoms of acute pancreatitis?
- Severe epigastric pain radiating to back
- Nausea +/- vomiting
- Hx of gallstones or EtOH use
102
What are the investigations for acute pancreatitis?
- Raised amylase/lipase
- High WCC/low Ca2+
- CT and US to assess for complications/cause
103
What treatment is given to patients with acute pancreatitis?
- Glasgow-Imrie admission score
- Analgesia, antiemetics
- Aggressive fluid resuscitation, O2
- ITU/HDU involvement
