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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
Q

What would be seen on a blood test for acute appendicitis?

A

FBC: neutrophilic leukocytosis
↑ed CRP
Urinalysis: possible mild pyuria/haematuria
Electrolyte imbalances in profound vomiting

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26
Q

What is the gold standard imaging for acute appendicitis?

A

CT, espcially in adults over the age of 50
USS in children, pregnant or breastfeeding
MRI if USS inconclusive

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27
Q

What are the factors contributing to the Alvarado score?

A

RLQ tenderness
Fever >37.3
Rebound tenderness
Pain Migration
Anorexia
N&V
WCC
Neutrophillia - left shift

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28
Q

What does the conservative management of Acute Appendicitis consist of?

A

IV Fluids, Analgesia, IV or PO Antibiotics

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29
Q

When there is an abscess, plegmon or sealed perforation with acute appendicitis, what should be done?

A

Resuscitation + IV ABx +/- percutaneous drainage

Consider Interval appendicectomy

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30
Q

What are three benefits of a Laparoscopic vs Open Appendicectomy?

A
  1. Less pain
  2. Lower risk of infection
  3. reduced length of infection
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31
Q

What is meant by intestinal obstruction?

A

restriction of normal passage of intestinal contents

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32
Q

What are the two main types of bowel obstruction?

A

Paralytic (Adynamic) ileus

Mechanical

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33
Q

What is a mechanical bowel obstruction?

A

Something is physically obstructing

34
Q

What is paralytic ileus bowel obstruction?

A

Bowel not working properly, so becomes obstructed

35
Q

What is meant by a simple vs strangulated bowel obstruction?

A

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
Q

What might cause a bowel obstruction in the wall?

A

Crohn’s disease, tumours, diverticulitis of the colon

37
Q

Causes of bowel obstruction in the lumen

A

Feacal impaction or gallstone ileus

38
Q

Causes of bowel obstruction outside the walls

A

Strangulated hernia, volvulus, adhesions

39
Q

What are the common causes of a large bowel obstruction?

A

Colorectal cancer
Volvulus
Diverticulitis
Faecal impaction
Hirschsprung disease

40
Q

Common causes of small bowel obstruction

A

Adhesions, neoplasia, incarcerated hernia, crohn’s disease

41
Q

What is the difference in abdominal pain for a small vs large bowel obstruction?

A

Small = colicky and central
Large = Colicky or constant

42
Q

Describe the differences in vomiting between small and large bowel obstruction?

A

Small bowel = vomiting = late sign, and a large amount

Large bowel = late onset, progresses to faecal vomiting

43
Q

Describe the differences in absolute constipation between small and large bowel obstruction?

A

Small = Late sign
Large = Early sign

44
Q

Describe the differences in abdominal distension between small and large bowel obstruction?

A

Small = less siginificant
Large = early sign and more significant

45
Q

what is heard for an early sign of small bowel obstruction?

A

High pitched tinkling bowel sounds

46
Q

What are the three most important signs to remember when considering a bowel obstruction?

A
  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
Q

What features might suggest a strangulating bowel obstruction?

A

Change in character of pain from colicky to continuous
Tachycardia
Pyrexia
Peritonism
Bowel sounds absent or reduced
Leucocytosis
↑ed C-reactive protein

48
Q

Which type of hernia will you get no bowel obstruction?

A

Richter’s hernia

49
Q

What features will be seen on a VBG if vomiting with a bowel obstruction?

A

HypoCl-,HypoK+ metabolic alkalosis

50
Q

What is the 3 6 9 rule for bowel obstructions?

A

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
Q

What will be seen in a VBG for a strangulated bowel obstruction?

A

metabolic acidosis - lactate = METABOLIC ACIDOSIS

52
Q

What is seen on an abdominal X Ray with a small bowel obstruction

A

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
Q

What is seen on an abdominal X ray with a large bowel obstruction?

A

Distended large bowel tends to lie peripherally
Show haustrations of taenia coli - do not extend across whole width of the bowel.

54
Q

Why are CT scans useful for bowel obstructions?

A

CT
Can localize site of obstruction
Detect obstructing lesions & colonic tumours
May diagnose unusual hernias (e.g. obturator hernias).

55
Q

What is the supportive management of a bowel obstruction in patients with no sign of clinical deterioration?

A

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
Q

What is the conservative management of a small bowel obstruction?

A

Feacal impaction: stool evacuation
Sigmoid volvulus: rigid sigmoidoscopic decompression
SBO: ora; gastrograffin (highly osmolar iodinated contrast agent)

57
Q

What are the indications for surgery with a bowel obstruction?

A

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
Q

Describe the typical presentation of a GI perforation?

A

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
Q

Describe the typical presentation of a perforated peptic ulcer?

A

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
Q

Describe the typical presentation of a perforated diverticulum?

A

LLQ pain
Constipation

61
Q

Describe the typical presentation of a perforated appendix?

A

Migratory pain
Anorexia
Gradual worsening RLQ pain

62
Q

Describe the typical presentation of a perforated malignancy?

A

Change in bowel habit
Weight loss
Anorexia
PR Bleeding

63
Q

What is seen on an X ray in patients with a GI perforation?

A

air under the diaphragm = pneumoperitoneum

64
Q

What is seen on blood investigations for a GI perforation?

A

FBC: neutrophilic leukocytosis
Possible elevation of Urea, Creatinine
VBG: Lactic acidosis

65
Q

What are the differentials for a GI perforation?

A

Differential Diagnosis
Acute cholecystitis, Appendicitis.
Myocardial infarction, Acute pancreatitis

66
Q

What is the conservative management for a GI perforation?

A

NBM & NG tube
IV peripheral access with large bore cannula -IV Fluid resuscitation
Broad spectrum Abx
IV PPI
Parenteral analgesia & antiemetics
Urinary catheter

67
Q

Describe the conservative management of localised peritonitis without signs of sepsis?

A

IR - guided drainage of intra-abdominal collection
Serial abdominal examination & abdominal imaging for assessment

68
Q

Surgicalm management of generalised peritonitis

A

Exploratory laparotomy
Primary closure of perforation with or withoutomental patch (most common in perforated pepticulcer)
Resection, lavage

69
Q

What are the symptoms of biliary colic?

A

PostprandialRUQ pain with radiation to the shoulder.
Nausea

70
Q

What are the symptoms of Acute Cholecystitis?

A

Acute, severe RUQ pain
Fever
Murphy’s sign

71
Q

What are the symptoms of Acute Cholangitis?

A

Acute Cholangitis
*Charcot’s triad: jaundice, RUQ pain, fever
*Bile stuck in bile ducts

72
Q

What are the symptoms of acute pancreatitis?

A

Severe epigastric pain radiating to the back
Nausea +/- vomiting
Hx of gallstones or EtOH use

73
Q

What is seen on an ultrasound of a patient with acute cholecystitis?

A

Thickened gall bladder wall

74
Q

What is seen on investigation of a patient with acute cholangitis?

A

Elevated LFTs, WCC, CRP, Blood MCS (+ve)
USS: bilary dilatation

75
Q

What is seen on investigation of a patient with biliary colic?

A

Normal blood results
USS: cholelithiasis

76
Q

What is seen on investigations are done for acute pancreatitis?

A

Raised amylase/lipase
High WCC/Low Ca2+
CT and US to assess for complications/cause

77
Q

What is the management of biliary colic?

A

Analgesia, Antiemetics, Spasmolytics
Follow up for elective cholecystectomy

78
Q

What is the management of acute cholecystitis?

A

Fluids, ABx, Analgesia, Blood cultures
Early (<72 hours) or elective cholecystectomy (4-6 weeks)

79
Q

What is the management of Acute Cholangitis?

A

Fluids, IV Abx, Analgesia
ERCP (within 72hrs) for clearance of bile duct or stenting

80
Q

What is the management for acute pancreatitis?

A

Admission score (Glasgow-Imrie)
Aggressive fluid resuscitation, O2
Analgesia, Antiemetics
ITU/HDU involvement

GASTROENTEROLOGY phase 1b (12 decks)

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