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BRS GASTROENTEROLOGY > 1b// General Surgery in the GI tract > Flashcards

1b// General Surgery in the GI tract Flashcards

1
Q

What is SOCRATES?

A

site
onset
character
radiation
association
time course
exacerbating/ relieving symptoms
severity

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2
Q

What is an acute abdomen?

A

An acute abdomen is a condition that demands urgent attention and treatment. The acute abdomen may be caused by an infection, inflammation, vascular occlusion, or obstruction. The patient will usually present with sudden onset of abdominal pain with associated nausea or vomiting.

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3
Q

What is the general approach to an acute abdomen?

A

PC (primary care)=> pain assessment (SOCRATES), associated symptoms

PMHx, DHx, SHx=> past medical Hx, drug Hx, social Hx

Range of investigations

Management

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4
Q

What investigations would you do for an acute abdomen?

A

Bloods: VBG, FBC, CRP, U&Es (renal profile), LFTs + amylase

Urinalysis + Urine MC&S

Imaging: Erect CXR, AXR, CTAP, CT angiogram, USS

Endoscopy

*depending on presentation

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5
Q

What type of management would you provide for acute abdomen?

A

ABCDE approach
conservative management
surgical management

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6
Q

What are differential diagnoses for RUQ?

A

Biliary Colic
Cholecystitis/Cholangitis
Duodenal Ulcer
Liver abscess
Portal vein thrombosis
Acute hepatitis
Nephrolithiasis
RLL pneumonia

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7
Q

What are differential diagnoses for epigastrium?

A

Acute gastritis/GORD
Gastroparesis
Peptic ulcer disease/perforation
Acute pancreatitis
Mesenteric ischaemia
AAA (Abdominal Aortic Aneurysm) Aortic dissection
Myocardial infarction

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8
Q

What are the differential diagnoses for LUQ?

A

Peptic ulcer
Acute pancreatitis
Splenic abscess
Splenic infarction
Nephrolithiasis
LLL Pneumonia

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9
Q

What are the differential diagnoses for RLQ?

A

Acute Appendicitis
Colitis
IBD
Infectious colitis
Ureteric stone/Pyelonephritis PID/Ovarian torsion
Ectopic pregnancy
Malignancy

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10
Q

What are the differential diagnoses for suprapubic/ central?

A

Early appendicitis
Mesenteric ischaemia
Bowel obstruction
Bowel perforation
Constipation
Gastroenteritis
UTI/Urinary retention
PID

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11
Q

What are the differential diagnoses for LLQ?

A

Diverticulitis
Colitis
IBD (Inflammatory Bowel Disease) Infectious colitis
Ureteric stone/Pyelonephritis PID/Ovarian torsion
Ectopic pregnancy
Malignancy

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12
Q

What is the presentation of bowel ischaemia?

A

Sudden onset crampy abdominal pain

Severity of pain depends on the length and thickness of colon affected

Bloody, loose stool (currant jelly stools)

Fever, signs of septic shock

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13
Q

What are the risk factors for bowel ischaemia? (6)

A

Age >65 yr

Cardiac arrhythmias (mainly AF), atherosclerosis

Hypercoagulation/ thrombophilia

Vasculitis

Sickle cell disease

Profound shock causing hypotension

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14
Q

Describe acute mesenteric ischaemia?

A

Small bowel

Usually occlusive due to thromboemboli

Sudden onset (but presentation and severity varies)

Abdominal pain out of proportion of clinical signs

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15
Q

Describe ischaemia colitis?

A

Large bowel

Usually due to non-occlusive low flow states, or atherosclerosis

More mild and gradual (80-85% of the cases)

Moderate pain and tenderness

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16
Q

What investigations would you do for bowel ischaemia?

A

Bloods

Imaging- CTAP/ Angiogram

Endoscopy

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17
Q

What are you looking out for in bloods for bowel ischaemia?

A

FBC: neutrophil leukocytosis

VBG (venous blood gas): lactic acidosis

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18
Q

What would you detect in the imaging for bowel ischaemia?

A

disrupted flow
vascular stenosis
pneumatosis intestinalis
thumbprint sign

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19
Q

What would you notice in endoscopies for ischaemic colitis?

A

for mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)

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20
Q

What is the conservative management for bowel ischaemia?

A

Mild to moderate cases of ischaemic colitis (not suitable for small bowel ischaemia)

  • IV fluid resuscitation
  • Bowel rest
  • Broad-spectrum ABx - colonic ischaemia can result in bacterial translocation & sepsis
  • Nasogastric tube for decompression - in concurrent ileus
  • Anticoagulation
  • Treat/manage underlying cause

** Serial abdominal examination and repeat imaging

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21
Q

What are the indications of necessary surgery for bowel ischaemia?

A

Small bowel ischaemia

Signs of peritonitis or sepsis

Haemodynamic instability

Massive bleeding

Fulminant colitis with toxic megacolon

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22
Q

What are the surgeries you could do for bowel ischaemia?

A

exploratory laparotomy

endovascular revascularisation

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23
Q

What is exploratory laparotomy?

A

Resection of necrotic bowel +/- open surgical embolectomy or mesenteric arterial bypass

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24
Q

What is an embolectomy?

A

also sometimes called thrombectomy — is the removal of a blood clot (thrombus) that’s keeping blood from flowing through a blood vessel normally

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25
What is endovascular revascularisation and when would you do it?
balloon angioplasty/ thrombectomy in patients without signs of ischaemia
26
How does acute appendicitis present?
Initially periumbilical pain that migrates to RLQ (within 24hours) Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit
27
What are the important clinical signs of acute appendicitis? (5)
McBurney’s point Blumberg sign Rovsing sign Psoas sign Obturator sign
28
What is McBurney's point?
tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
29
What is Blumber sign?
rebound tenderness especially in the RIF
30
What is Rovsing sign?
RLQ pain elicited on deep palpation of the LLQ
31
What is Psoas sign?
RLQ pain elicited on flexion of right hip against resistance
32
What is obturator sign?
RLQ pain on passive internal rotation of the hip with hip & knee flexion
33
What are the investigations for acute appendicitis?
Bloods Imaging Diagnostic laparoscopy
34
What do you look out in bloods for acute appendicitis?
FBC: neutrophilic leukocytosis increased CRP Urinalysis: possible mild pyuria/ haematuria electrolyte imbalances in profound vomiting
35
What is pyuria?
a condition in which you have high levels of white blood cells (leukocytes) or pus in your urine (pee)
36
What type of imaging do you use for different patients for acute appendicitis?
CT: adults esp over 50 USS: children/ pregnancy/ breastfeeding MRI: in pregnancy if USS inconclusive
37
When do you use diagnostic laparoscopy for acute appendicitis?
in persistent pain and inconclusive imaging
38
What score do you use to measure likeliness of acute appendicitis and what does it include?
39
What does the conservative management of acute appendicitis consist of?
IV Fluids, Analgesia, IV or PO Antibiotics In abscess, phlegmon or sealed perforation - Resuscitation + IV ABx +/- percutaneous drainage
40
What are the indications for conservative management for acute appendicitis? And what treatment should you consider?
After negative imaging in selected patients with clinically uncomplicated appendicitis In delayed presentation with abscess/phlegmon formation - CT-guided drainage Consider interval appendicectomy - rate of recurrence after conservative management of abscess/perforation is 12-24%
41
Laparoscopic vs Appendectomy. (6)
Less pain Lower incidence of surgical site infection Decreased length of hospital stay Earlier return to work Overall costs Better quality of life scores
42
What are the steps of laparoscopic appendicectomy?
43
What is the classification of bowel/ intestinal obstruction?
2 main groups: Paralytic (Adynamic) ileus Mechanical
44
What is intestinal obstruction?
restriction of normal passage of intestinal contents
45
How is mechanical intestinal obstruction classified by?
Speed of onset Site Nature Aetiology
46
What is the small bowel obstruction aetiology?
47
What is the large bowel obstruction aetiology?
48
Small bowel vs Large bowel signs and symptoms: Abdominal pain?
small=> colicky, central large=> colicky or constant
49
Small bowel vs Large bowel signs and symptoms: Vomiting?
small=> early onset, large amount, bilious large=> late onset, initially bilious, progresse to faecal vomiting
50
Small bowel vs Large bowel signs and symptoms: absolute constipation?
small=> late sign large=> early sign
51
Small bowel vs Large bowel signs and symptoms: abdominal distention?
small=> less significant large=> early sign and significant
52
What are other signs of both small and large bowel obstruction?
Dehydration Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign) Diffuse abdominal tenderness
53
What type of obstruction has a mortality of up to 15%?
strangulating obstruction with peritonitis
54
How is bowel obstruction diagnosed?
diagnosed by the presence of symptoms
55
What should the examination of bowel obstruction always include?
search for hernias and abdominal scars, including laparoscopic portholes
56
If the bowel obstruction is not simple what is it?
strangulating
57
What are the features that suggest strangulation obstruction?
Change in character of pain from colicky to continuous Tachycardia Pyrexia Peritonism Bowel sounds absent or reduced Leucocytosis ↑ed C-reactive protein
58
What is paralytic ileus?
Paralytic ileus is the condition where the motor activity of the bowel is impaired
59
What are the common sites for hernias?
epigastric umbilical incisional inguinal femoral
60
What are the types of hernias?
neck of sac strangulated hernia Richter's hernia
61
What investigations do you do for bowel obstruction?
Bloods Imaging
62
What do you look out for in bloods for bowel obstruction?
WCC/CRP usually normal (if raised suspicion of strangulation/perforation) U&E: electrolyte imbalance VBG if vomiting: HypoCl-,HypoK+ metabolic alkalosis VBG if strangulation: Metabolic Acidosis (lactate)
63
What imaging do you do for bowel obstruction?
Erect CXR/AXR - SBO: Dilated small bowel loops >3cm proximal to the obstruction (central) - LBO: Dilated large bowel >6cm (if caecum >9cm) predominantly peripheral - 3cm for small, 6cm for large, 9cm for caecum (3,6,9 rule) CT abdo/pelvis → Transition point, dilatation of proximal loops – IV +/- oral contrast if possible
64
What does an abdominal x-ray look like for small bowel obstruction?
Ladder pattern of dilated loops & their central position Striations that pass completely across the width of the distended loop produced by the circular mucosal folds.
65
What does an abdominal x-ray look like for large bowel obstruction?
Distended large bowel tends to lie peripherally Show haustrations of taenia coli - do not extend across whole width of the bowel
66
What does CT scans do for bowel obstructions?
Can localize site of obstruction Detect obstructing lesions & colonic tumours May diagnose unusual hernias (e.g. obturator hernias).
67
What do CT scans look like for bowel obstructions?
68
When do you give supportive/ conservative management for bowel obstruction?
In patients with no signs of ischaemia/no signs of clinical deterioration
69
What is the supportive treatment for bowel obstruction? (4)
70
What is the conservative treatment for bowel obstruction?
Faecal impaction: stool evacuation (manual, enemas, endoscopic) Sigmoid volvulus: rigid sigmoidoscopic decompression SBO: oral gastrografin (highly osmolar iodinated contrast agent) can be used to resolve adhesional small bowel obstruction
71
What are the indications to give surgical management for bowel obstruction?
Haemodynamic instability or signs of sepsis Complete bowel obstruction with signs of ischaemia Closed loop obstruction Persistent bowel obstruction >2 days despite conservative management
72
What are the possible operations for bowel obstruction?
Exploratory Laparotomy/Laparoscopy Restoration of intestinal transit (depending on intra-operational findings) Bowel resection with primary anastomosis or temporary/permanent stoma formation (Endoscopic stenting)
73
What is endoscopic stenting?
Endoscopic stenting is a medical procedure by which a stent, a hollow device designed to prevent constriction or collapse of a tubular organ, is inserted by endoscopy
74
What is the presentation of GI perforation?
Sudden onset severe abdominal pain associated with distention Diffuse abdominal guarding, rigidity, rebound tenderness Pain aggravated by movement Nausea, vomiting, absolute constipation Fever, Tachycardia, Tachypnoea, Hypotension Decreased or absent bowel sounds
75
What is the presentation of perforated peptic ulcer?
76
What is the presentation of perforated diverticulum?
77
What is the presentation of perforated appendix?
78
What is the presentation of perforated malignancy in GI?
79
What investigations do you do for GI perforation?
Bloods Imaging
80
What are the differential diagnoses for GI perforations?
Acute cholecystitis, Appendicitis. Myocardial infarction, Acute pancreatitis
81
What do you look out for in bloods of GI perforation?
FBC:> neutrophilic leukocytosis Possible elevation of Urea, creatinine VBG: lactic acidosis
82
What will you see in imaging for GI perforation?
Erect CXR → subdiaphragmatic free air (pneumoperitoneum) CT abdo/pelvis → Pneumoperitoneum, free GI content, localised mesenteric fat stranding - can exclude common differential diagnoses such as pancreatitis
83
What is the supportive management on presentation of GI perforation?
NBM & NG tube IV peripheral access with large bore cannula - IV Fluid resuscitation Broad spectrum Abx IV PPI Parenteral analgesia & antiemetics Urinary catheter
84
What is PPI?
proton pump inhibitor
85
When do use conservative management for GI perforation and what is included?
Conservative management in localised peritonitis without signs of sepsis Very rare IR - guided drainage of intra-abdominal collection Serial abdominal examination & abdominal imaging for assessment
86
When do you use surgical management for GI perforation and what is included?
87
What are the symptoms, investigations and management of biliary colic?
88
What are the symptoms, investigations and management of acute cholecystitis?
89
What are the symptoms, investigations and management of acute cholangitis?
90
What are the symptoms, investigations and management of acute pancreatitis?
91
Do you understand all of these concepts?
Y/ N

BRS GASTROENTEROLOGY (25 decks)

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