1b// Surgical Management of the GI Tract Flashcards
This scenario is typical of an acute intestinal obstruction (there is additional info).
Which would be more likely in this case, obstruction of the small or large bowel?
What would be the surgical management of a patient’s large bowel obstruction?
What does the ABX demonstrate & what is the likely diagnosis?
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
Appearances are typical of volvulus of the sigmoid colon
What conservative management is effective in treating the majority of patients with a sigmoid volvulus?
A sigmoidoscope is passed with the patient lying in the left lateral position.
A large well lubricated, soft rubber rectal tube is passed along the sigmoidoscope.
This usually untwists the volvulus, with release of vast quantities of flatus & liquid faeces.
A flatus tube was tried and left in a patient with volvulus of the sigmoid colon, but was unsuccessful. What is the risk of leaving this untreated?
Left untreated, the loop of sigmoid, with its blood supply cut off by the torsion, would undergo necrosis
What is the next step in managing a patient with volvulus of the sigmoid colon. After an unsuccessful flatus tube?
Exploratory Laparotomy & Sigmoid Colectomy with end colostomy (Hartmann’s Procedure)
What may lead to a suspicion of acute mesenteric ischaemia?
Elderly patient who is an ex-smoker – ↑ed risk of cardiovascular disease
Short history
Central pain with guarding
No previous abdominal scar or hernia
No bowel sounds
Poor general condition
↑ed serum lactate
What investigations would you order to confirm an acute mesenteric ischaemia (apart from bloods? And why?
Do you see the differences for AMI?
How would you manage a patient with acute mesenteric ischaemia?
How do you perform an exploratory laparotomy?
Midline incision
Evaluate the abdominal viscera
If obvious intestinal necrosis – resection of the affected bowel loops.
How do you conduct a damage control laparotomy?
Stapled off bowel ends may be left in discontinuity
Re-inspect after a period of continued ICU resuscitation to restore physiological balance
How do you restore blood flow in superior mesenteric artery?
Embolectomy of SMA – in embolic AMI
Endovascular management of SMA thrombus – in thrombotic AMI
Arterial bypass of SMA - in thrombotic AMI
What are the causes of arterial acute mesenteric ischaemia?
What are the causes of venous acute mesenteric ischaemia?
What is portal pyaemia?
