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GASTROENTEROLOGY phase 1b > 1b General Surgery in the GI Tract > Flashcards

1b General Surgery in the GI Tract Flashcards

1
Q

What is the presentation of bowel ischaemia?

A

Sudden onset crampy abdominal pain
Bloody, loose stool
Fever

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2
Q

What are the main risk factors for bowel ischaemia?

A

Age >65 yr
Cardiac arrythmias (mainly AF), atherosclerosis

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3
Q

Which part of the bowel does Acute Mesenteric Ischaemia effect?

A

Small bowel = usually transmural

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4
Q

What is the usual cause of Acute Mesenteric Ischaemia?

A

Usually occlusive due tothromboemboli

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5
Q

What part of the bowel does Ischaemic Colitis generally effect?

A

Large bowel

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6
Q

What is the usual cause of Ischaemic Colitis?

A

Usuallydue to non-occlusive low flow states, or atherosclerosis

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7
Q

What is the clinical signs of Ischaemic Colitis?

A

Moderate pain and tenderness

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8
Q

What are some differences between acute mesenteric ischaemia and ischaemic colitis?

A

Ischemic colitis has a more mild and gradual onset while the other has sudden onset
Ischemic colitis has moderate pain while in the other abdominal pain is out of proportion

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9
Q

What are the key blood signs for bowel ischaemia?

A

FBC: neutrophilic leukocytosis
VBG: Lactic acidosis – associated with high lactate

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10
Q

What imaging is most useful to do for bowel ischaemia?

A

CT angiogram

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11
Q

What would be detected on a CT angiogram for Bowel Ischaemia?

A

Disrupted flow
Vascular stenosis
‘Pneumatosis intestinalis’ (transmural ischaemia/infarction)
Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)

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12
Q

What does the prescence of lactic acid suggest?

A

That the bowel has already died = ischaemia

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13
Q

What is the conservative management for bowel ischaemia?

A

IV Fluid Resuscitation
broad spectrum anti biotics
NG tube for decompression
Anticoagulation

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14
Q

Why are broad spectrum antibiotics given for bowel ischaemia?

A

Colonic ischaemia can result in bacterial translocation & sepsis

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15
Q

What is the most important thing to do for the conservative management of bowel ischaemia?

A

Serial abdominal examination and repeat imaging to ensure that ischaemia is not occuring

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16
Q

What are the indications for surgical management of bowel ischaemia?

A

Small bowel ischaemia
Signs of peritonitis orsepsis
Haemodynamic instability
Massive bleeding
Fulminant colitis with toxic megacolon

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17
Q

What is meant by an exploratory laparotomy?

A

Open up into abdomen to see bowel - then do a resection of the necrotic bowel along with a mesenteric arterial bypass or open surgerical embolectomy

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18
Q

What is an endovascular revascularisation?

A

Balloon angioplasty/thrombectomy - balloon placed into the vessel and thrombus is removed

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19
Q

Describe the typical presentation of acute appendicitis?

A

Initially periumbilical pain that migrates to RLQ (within 24hours)

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20
Q

What are some signs and symptoms of acute appendicitis?

A

Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit

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21
Q

What is McBurney’s Point?

A

McBurney’s point: tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)

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22
Q

What is Rovsing’s sign?

A

RLQ pain elicited on deep palpation of the LLQ

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23
Q

What are the clinical signs for acute appendicitis?

A

McBurney’s
Blumberg - rebound tendernesss in the RIQ
Rovsing’s
Psoas - RLQ pain on flexion of right hip against resistance
Obturator-RLQ pain on internal rotation of hip with hip&knee flexion

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24
Q

What is the scoring system used for acute appendicitis?

A

Alvarado score

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25
What would be seen on a blood test for acute appendicitis?
FBC: neutrophilic leukocytosis ↑ed CRP Urinalysis: possible mild pyuria/haematuria Electrolyte imbalances in profound vomiting
26
What is the gold standard imaging for acute appendicitis?
CT, espcially in adults over the age of 50 USS in children, pregnant or breastfeeding MRI if USS inconclusive
27
What are the factors contributing to the Alvarado score?
RLQ tenderness Fever >37.3 Rebound tenderness Pain Migration Anorexia N&V WCC Neutrophillia - left shift
28
What does the conservative management of Acute Appendicitis consist of?
IV Fluids, Analgesia, IV or PO Antibiotics
29
When there is an abscess, plegmon or sealed perforation with acute appendicitis, what should be done?
Resuscitation + IV ABx +/- percutaneous drainage Consider Interval appendicectomy
30
What are three benefits of a Laparoscopic vs Open Appendicectomy?
1. Less pain 2. Lower risk of infection 3. reduced length of infection
31
What is meant by intestinal obstruction?
restriction of normal passage of intestinal contents
32
What are the two main types of bowel obstruction?
Paralytic (Adynamic) ileus Mechanical
33
What is a mechanical bowel obstruction?
Something is physically obstructing
34
What is paralytic ileus bowel obstruction?
Bowel not working properly, so becomes obstructed
35
What is meant by a simple vs strangulated bowel obstruction?
Simple: bowel is occluded without damage to blood supply Strangulating: blood supply of involved segment of intestine is cut off (e.g. in strangulated hernia, volvulus, intussusception)
36
What might cause a bowel obstruction in the wall?
Crohn's disease, tumours, diverticulitis of the colon
37
Causes of bowel obstruction in the lumen
Feacal impaction or gallstone ileus
38
Causes of bowel obstruction outside the walls
Strangulated hernia, volvulus, adhesions
39
What are the common causes of a large bowel obstruction?
Colorectal cancer Volvulus Diverticulitis Faecal impaction Hirschsprung disease
40
Common causes of small bowel obstruction
Adhesions, neoplasia, incarcerated hernia, crohn's disease
41
What is the difference in abdominal pain for a small vs large bowel obstruction?
Small = colicky and central Large = Colicky or constant
42
Describe the differences in vomiting between small and large bowel obstruction?
Small bowel = vomiting = late sign, and a large amount Large bowel = late onset, progresses to faecal vomiting
43
Describe the differences in absolute constipation between small and large bowel obstruction?
Small = Late sign Large = Early sign
44
Describe the differences in abdominal distension between small and large bowel obstruction?
Small = less siginificant Large = early sign and more significant
45
what is heard for an early sign of small bowel obstruction?
High pitched tinkling bowel sounds
46
What are the three most important signs to remember when considering a bowel obstruction?
1. Diagnosed through presence of symptoms 2. Examination for hernias and abdominal scars, as the presence of these increases the chances of small bowel obstruction 3. Is it simple or strangulating
47
What features might suggest a strangulating bowel obstruction?
Change in character of pain from colicky to continuous Tachycardia Pyrexia Peritonism Bowel sounds absent or reduced Leucocytosis ↑ed C-reactive protein
48
Which type of hernia will you get no bowel obstruction?
Richter's hernia
49
What features will be seen on a VBG if vomiting with a bowel obstruction?
HypoCl-,HypoK+ metabolic alkalosis
50
What is the 3 6 9 rule for bowel obstructions?
Erect CXR/AXR  SBO: Dilated small bowel loops >3cm proximal to the obstruction (central) LBO: Dilated large bowel >6cm (if caecum >9cm) predominantly peripheral
51
What will be seen in a VBG for a strangulated bowel obstruction?
metabolic acidosis - lactate = METABOLIC ACIDOSIS
52
What is seen on an abdominal X Ray with a 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.
53
What is seen on an abdominal X ray with a large bowel obstruction?
Distended large bowel tends to lie peripherally Show haustrations of taenia coli - do not extend across whole width of the bowel.
54
Why are CT scans useful for bowel obstructions?
CT Can localize site of obstruction Detect obstructing lesions & colonic tumours May diagnose unusual hernias (e.g. obturator hernias).
55
What is the supportive management of a bowel obstruction in patients with no sign of clinical deterioration?
NBM, IV peripheral access with large bore cannula - IV Fluid resuscitation IV analgesia, IV antiemetics, correction of electrolyte imbalances NG tube for decompression, urinary catheter for monitoring output Introduce gradual food intake if abdominal pain and distention improve
56
What is the conservative management of a small bowel obstruction?
Feacal impaction: stool evacuation Sigmoid volvulus: rigid sigmoidoscopic decompression SBO: ora; gastrograffin (highly osmolar iodinated contrast agent)
57
What are the indications for surgery with a 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 
58
Describe the typical presentation of a 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,absent bowel sounds
59
Describe the typical presentation of a perforated peptic ulcer?
Sudden epigastric or diffuse pain Referred shoulder pain Hx of NSAIDs, steroids, recurrent epigastric pain perforated peptic ulcers can be found in the stomach or the duodenum
60
Describe the typical presentation of a perforated diverticulum?
LLQ pain Constipation
61
Describe the typical presentation of a perforated appendix?
Migratory pain Anorexia Gradual worsening RLQ pain
62
Describe the typical presentation of a perforated malignancy?
Change in bowel habit Weight loss Anorexia PR Bleeding
63
What is seen on an X ray in patients with a GI perforation?
air under the diaphragm = pneumoperitoneum
64
What is seen on blood investigations for a GI perforation?
FBC: neutrophilic leukocytosis Possible elevation of Urea, Creatinine VBG: Lactic acidosis
65
What are the differentials for a GI perforation?
Differential Diagnosis Acute cholecystitis, Appendicitis. Myocardial infarction, Acute pancreatitis
66
What is the conservative management for a 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 
67
Describe the conservative management of localised peritonitis without signs of sepsis?
IR - guided drainage of intra-abdominal collection Serial abdominal examination & abdominal imaging for assessment
68
Surgicalm management of generalised peritonitis
Exploratory laparotomy Primary closure of perforation with or without omental patch (most common in perforated peptic ulcer) Resection, lavage
69
What are the symptoms of biliary colic?
Postprandial RUQ pain with radiation to the shoulder. Nausea
70
What are the symptoms of Acute Cholecystitis?
Acute, severe RUQ pain Fever Murphy's sign
71
What are the symptoms of Acute Cholangitis?
Acute Cholangitis *Charcot's triad: jaundice, RUQ pain, fever *Bile stuck in bile ducts
72
What are the symptoms of acute pancreatitis?
Severe epigastric pain radiating to the back Nausea +/- vomiting Hx of gallstones or EtOH use
73
What is seen on an ultrasound of a patient with acute cholecystitis?
Thickened gall bladder wall
74
What is seen on investigation of a patient with acute cholangitis?
Elevated LFTs, WCC, CRP, Blood MCS (+ve) USS: bilary dilatation
75
What is seen on investigation of a patient with biliary colic?
Normal blood results USS: cholelithiasis
76
What is seen on investigations are done for acute pancreatitis?
Raised amylase/lipase High WCC/Low Ca2+ CT and US to assess for complications/cause
77
What is the management of biliary colic?
Analgesia, Antiemetics, Spasmolytics Follow up for elective cholecystectomy
78
What is the management of acute cholecystitis?
Fluids, ABx, Analgesia, Blood cultures Early (<72 hours) or elective cholecystectomy (4-6 weeks)
79
What is the management of Acute Cholangitis?
Fluids, IV Abx, Analgesia ERCP (within 72hrs) for clearance of bile duct or stenting
80
What is the management for acute pancreatitis?
Admission score (Glasgow-Imrie) Aggressive fluid resuscitation, O2 Analgesia, Antiemetics ITU/HDU involvement

GASTROENTEROLOGY phase 1b (12 decks)

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