1b Surgical Management in the GI Tract Flashcards
Pain, dehydrated, dry tongue, distended abdomen, no scars for previous surgery / hernias / masses. What condition?
Acute Intestinal Obstruction
What are the two most common signs of a small bowel obstruction?
previous abdominal operation
strangulated external hernias
What are key signs which would suggest large bowel obstruction over a small bowel obstruction?
No vomiting
Grossly distended Abdomen
What is the first thing to do for a patient with a large bowel obstruction?
Nasogastric tube
IV fluids
What is the typical radiological sign indicating volvulus of the sigmoid colon?
Coffee bean sign
What are key findings of an large bowel obstruction?
Enormously distended oval gas shadow, looped on itself to give typical ‘bent inner-tube sign’ OR ‘coffee bean sign’
Haustrae don’t extend across the width of the gas shadow, suggesting this is large intestine
What conservative management is effective in treating the majority of patients with a sigmoid volvulus?
Sigmoidoscope is passed with a patient lying in the left lateral position
Large, well lubricated soft rubber tube is passed along the sigmoidoscope
This usually untwists the volvus which results in the release of vast quantities of flatus and liquid faeces
What is the risk of leaving a volvulus untreated?
Left untreated, the loop of sigmoid, with its blood supply cut off by the torsion, would undergo necrosis
What is the surgical management of a volvulus?
Exploratory Laparotomy & Sigmoid Colectomy with end colostomy (Hartmann’s Procedure)
Patient with history of COPD presents with abdominal pain, nausea, breathlessness, looks pale and sweaty, abdominal distention, periumbilical gaurding, no bowel sounds. Raised lactate. What condition?
Acute Mesenteric Ischemia (AMI)
What are the key features of a patient presenting with AMI?
- some sort of cardiovascular risk
- central pain with gaurding
- increased serum lactate
What is increased serum lactate a sign of?
Late sign of bowel ischaemia
What investigations should be done for acute mesenteric ischaemia?
Computed Tomography (CT) - abdomen and pelvis with contrast
Why is a CT useful for diagnosis?
May demonstrate thrombus in the mesenteric arteries & veins.
Abnormal enhancement of bowel wall.
Presence of embolus or infarction of other organs.
What is the management of a patient with AMI?
Emergency exploratory laparotomy
Wit restoration of SMA blood flow = using a catheter with ballon, resection of the non viable bowel
What are the venous causes of AMI?
Superior mesenteric vein thrombosis
Occurs in patients with:
Portal hypertension
Portal pyaemia
Sickle cell disease
What is portal pyaemia?
Form of septic (often suppurative)
thrombophlebitis of the portal venous system
Complication of intra-abdominal sepsis
Infection and thrombosis of the portal vein
What are the sources of arterial embolism causing AMI?
From left auricle - atrial fibrillation.
A mural infarct.
Atheroma from aorta or aneurysm.
Endocarditis vegetations.
Left atrial myxoma.
What are the sources of arterial thrombosis causing AMI?
Due to atherosclerosis
Often all main splanchnic vessels—coeliac, superior & inferior mesenteric arteries
What does vasospasm in shock cause?
Non occlusive mesenteric ischaemia
