(2) Flashcards
Bowel obstruction:
Define the following:
- Open loop obstruction
- Closer loop obstruction - cause?
- Strangulated obstruction
Causes:
- Luminal 4?
- Intramural - 3
- Extramural - 4
What are 2 types of volvulus?
Commonest causes of small bowel obstruction? - 2
Commonest cause of large bowel obstruction? 2 other causes?
Paralytics ileus - cause and Rx?
Pseudo-obstruction due to increased sympathetic tone. How is it Rx?
Difference between volvulus and strangulated hernia?
Volvulus and Diverticulitis
One point - no vascular compromise
2 points of obstruction - sigmoid volvulus
Distended bowel at risk of perf
Blood supply compromised ===== Faecal impaction Gallstone ileus Large polyp Foreign body
Tumour - CC
Stricture
intussusception
Adhesions IBD Volvulus - sigmoid/small bowel Compression from outside ======== SIGMOID AND SMALL BOWEL
Adhesions and strangulated hernias
Colorectal cancer
Stress from surgery - CON Rx
Volvulus - bowel twists on itself
Strangulated hernia -= bowel twists due to herniation
Bowel obstruction:
Symptoms:
- Type of pain?
- If small bowel?
- If large bowel?
Signs:
- What percussion sounds like?
- Auscultation?
- Scar?
- What part of large bowel is more likely to perf?
INV - Bloods - 6 and why?
INV - Imaging - AXR:
- What can be given to allow full view of the bowel?
What is seen in the following with barium enemas:
- Sigmoid/caecal volvulus
LARGE bowel AXR: - How big? - Markings? - Complete or incomplete? SIGMOID volvulus - sign seen? Caecal volvulus - sign seen?
SMALL bowel AXR:
- How big?
- Markings?
- Complete or incomplete?
Erect CXR - why?
Strangulated bowel won’t be able to take up the contrast. What imaging can be used then?
Constipation with no flatus or faeces
Colicky pain
Vomiting and abdo distention
Tympanic percussion - sounds like a drum
Tinkling bowel sounds
Previous surgery - adhesions
Caecum - thin walled ==== 1. FBC - WBC for infection and anaemia 2. U&E - dehydration and hypokalaemia from vomiting 3. Coagulation - surgery Group and save (crossmatch) - if surgery is needed 4. LFT - function 5. ESR/CRP - inflammation 6. Lactate - sepsis and tissue perfusion
=======
Barium enema
> 6 cm
Incomplete markings - Haustra
Coffee bean V-shape
> 4 cm - usually proximal
Valvulae conniventes - complete
Perforation
CT of abdo and pelvis
Bowel obstruction:
Management:
MED Rx:
- 1st line
- 2nd line - 2
- What drug should not be used as an anti-emetic?
SURG Rx:
- Before surgery, what can be done to decompress?
- What if unfit for surgery?
To remember bowel diameters, use 3-6-9 rules. What is it?
‘Drip and suck’ - IV fluids and NG tube
Analgesia and ABS
Metaclopamide - stimulates peristalsis and will make it worse
Rigid or flexible sigmoidoscopy with detorsion (pressure of air reduces the volvulus) and rectal tube insertion
Stent insertion - used in colorectal cancer if terminal
Remember the 3-6-9 rule to remember the normal bowel diameters:
- small bowel <3cm
- large bowel <6cm
- appendix <6cm
- caecum <9cm
so SLAC
Bowel Ischaemia:
Acute mesenteric ischaemia - main arteries - 2?
Chronic mesenteric ischaemia - above 2 are affected, which other one is affected?
Ischaemic colitis - what is it? who is it common in? where does it tend to occur?
IC less severe than mesenteric ischaemia.
AMI - they have Abdo pain - what feature would make you think it is AMI?
CMI - What is another symptoms to think about?
IC - 2 complications?
They also get PR bleeding due to necrotic surface
Exam finding?
INV - BEDSIDE - 1
- Why do ABG/vbg?
INV - BLOODS - 6 and why?
INV - IMAGING:
- AXR - sign?
- If perforation?
- What imaging is diagnostic?
Splenic flexure
Superior mesenteric (SMA) - major duodenal papilla (of the duodenum) to the proximal 2/3 of the transverse colon.
Coeliac artery (CA) - foregut - stomach, spleen and liver
====
Inferior mesenteric artery - distal 1/3 of the transverse colon, splenic flexure, descending colon, sigmoid colon and rectum.
====
Inflammation and injury of the large intestine result from inadequate blood supply.
The elderly
Symptoms out of proportion with exam findings
*****Post-prandial pain - so fear of eating - weight loss
Necrosis and/or perforation
ECG - arrhythmia’s (AF) - cause
Metabolic acidosis - lactic acid
- FBC - WBC for infection and anaemia
- U&E - dehydration and hypokalaemia from vomiting
- Coagulation - surgery
Group and save (crossmatch) - if surgery is needed - LFT - function
- ESR/CRP - inflammation
- Lactate - sepsis and tissue perfusion
- # Amylase - pancreatitisThumb print sign
Erect CXR
Mesenteric CT angiography
Bowel Ischaemia:
Supportive Rx!
Management:
MED Rx:
- IV AB’s - why?
- Opioid antispasmodic given - why?
SURG Rx:
- 1st line - 2
- 2nd line if severe
NICE guidelines for rest
Risk of bacterial infection due to ischaemia
Vaspodilation
Arterial bypass
Embolectomy
Partial or total colectomy
Hernia:
Difference between obstructed hernia and strangulated hernia?
6 types of abdominal wall hernias
Character of pain
What makes it worse?
Risk factors:
- Increased intra-abdominal pressure - 5
- Wall weakness - 4
Inguinal hernias:
- Direct?
- Indirect?
Femoral canal - where does the small bowel travel through?
How do you know it is hernia instead of a lump? - 2
Other types of hernia? - 4
INV - Imaging - 1
CON Rx - 2
SURG Rx:
- If reducible?*****
- If unfit for surgery?*****
Bowel contents cannot pass - features of intestinal obstruction
Ischaemia occurs - the patient requires urgent surgery
Inguinal ****** Femoral Epigastric Umbilical Paraumbilical Incisional
Heavy
Dragging
Worse on straining ====== Chronic cough Constipation Urinary obstruction Ascites Heavy lifting ==== Obesity Smoking Previous surgery Connective tissue disorders ==== Protrudes through the abdo wall into the inguinal canal - basically from the side
Through deep inguinal ring and comes out at the superficial ring
The femoral canal
Hear bowel sounds
Able to reduce
Epigastric - young people Umbilical hernia Paraumbilical hernia Incisional hernia ====== USS ====== Weight loss Smoking cessation
Repair and mesh insertion **
Abdominal binders****
Hernia examination:
How to make lump visible?
How do you distinguish between direct and indirect?
Cough while standing
(1) Reduce the hernia
(2) Press down on the deep inguinal ring to occlude it
(3) Ask the patient to cough
If it comes back out, it is direct - finger not stopping it from coming back out.
If it doesn’t, it is indirect - finger stops it from coming back out.
Anorectal conditions:
Anorectal abscess:
- GI causes?
- Symptoms - 3
- When are symptoms worse?
- DRE findings? - 2
- Imaging for deeper abscesses?
- SURG Rx?
- MED Rx for pain on defecation?
- Type of bath after Rx?
Anal fistula:
- GI cause?
- Symptoms same as above. When is pain worse?
- What addition symptoms is found? *****
- Diagnosed clinically. Imaging used? - 2
- SURG Rx - 1
- What if fistula high?
- Alternative to above
Anal fissure: - GI cause? - 2 - CON Rx - 3 MED Rx: - To relieve pain on defecation? - Topical Rx? - Injection? SURG Rx - lateral anal sphincterotomy or excision and anal advancement flap.
Sitz bath
IBD = Crohn’s
Diverticulitis
Perianal pain and itch
Constipation due to pain *****
Perianal swelling
Purulent/bloody discharge
Endoanal US or MRI
Incision and Drainage
Laxative - so stool softners
Crohn’s
Discharge and soiling ****
Endoanal USS
MRI
Fistulotomy - fistula is opened by and allowed to heal by secondary intention
Same as above but seton cord left in to allow drainage during healing
IBD
Straining constipation
- Avoid straining
- Increase fibre and fluid intake
- Immense anus warm water with swallow bath (Sitz birth kit 2 - 3 days daily)
Consider laxative
Topical GTN basically - causes relaxation of sphincter - increased blood flow - aids healing
Botox
Anorectal conditions:
Haemorrhoids: - GI cause? - When does it become external? - 2 main symptoms - When may it be painful? - 2 - INV - BEDSIDE - 1 - What device can be used? - What needs to be ruled out and how? - CON Rx - 1 - MED Rx - to avoid strain? SURG Rx - Excision for: - For internal? - For external? - Alternative for both - doesn't last as long?
Rectal prolapse:
- 3 types?
- One sign patients may notice
- Key group of people it affects
- CON Rx for mucosa only
- SURG Rx for mucosa only
- CON Rx for full thickness - same as above!
- SURG Rx for full thickness - 2
- A abdominal approach?
Colorectal cancer - colonoscopy
Constipation
Below dentate line
Bright red blood - PAINLESS
Itch
Clot in external H
Strangulated prolapsed internal H
DRE
Proctoscope
Increased fibre and fluids
Soften stools - laxatives, fibre and fluids
Rubber band ligation via endoscopy - haemorrhoids fall off
Excision
Stapling or haemorrhoid arterial ligation ================ Partial - mucosa only Complete - Full thickness of the rectum Internal - intussusception
Mass appears on defecation
Avoid straining
- Rubber band ligation or stapling ****
======
DeLorme’s procedure - The mucosa is removed close to the dentate line and the mucosal boundaries are sutured together
Altemieier’s procedure - Full-thickness rectal resection
Laparoscopic ventral rectoplexy - rectum stitched to wall
Anorectal conditions:
Faecal incontinence:
Causes:
- 3 obstetric causes?
- GI causes? - 2
INV - BEDSIDE - 1
INV - SPECIAL TEST - 1
TREAT underlying cause!
CON Rx - 1 product that can be bought
MED Rx - prevent diarrhoea? - 2
SURG Rx - 3 options
Anal itching - 4 bits of patient advice
Flexible sigmoid colonoscopy
High parity
Instrumental delivery
Episiotomy
Cancer or fistula (Crohn’s)
DRE
Anal plug
Loperamide and codeine
Sphincter repair
Sacral nerve stimulation
Stoma
======
Avoid itching and excess wiping
Washing with plain water
Gently patting dry
Identify and avoid triggers (e.g. soaps, detergents, fabrics)
Gallbladder Disease:
Choledocholithiasis (Gallstones in CBD) - 3 presentations?
Risk factors - 5 F’s?
Biliary colic:
- What is it?
- Why do you get pain?
- Where is the obstruction?
- Symptoms - 2
- How long does it take for symptoms to resolve?
- INV - BLOODS - 1
- INV - IMAGING - 1
- INV - SPECIAL - 1
- CON Rx - what should be avoided?
- MED Rx - symptomatic relief
- SURG Rx -
Obstructive jaundice
Acute cholangitis
Acute pancreatitis
Fat or rapid weight loss Female Forty (age) - due to premenopausal oestrogen increases risk Fair - white ethnicity Fertile - multiparity ======== Biliary obstruction without infection
Gallbladder contracts against the obstruction
Stone impaction in the gallbladder neck or cystic duct.****
Pain - RUQ, epigastric, worse after fatty meal **
N&V
<6hrs ======= LFT's USS MRCP ======= Triggering food (avoid high fat food)
Analgesia - diclofenac -NSAID
(1) ERCP - clearance
(2) Laparoscopic Cholecystectomy
Gallbladder Disease:
Acute Cholecystitis: - What may it come after? - 2 symptoms? - Where is the obstruction? - Big difference between patient comfort between AC and BC? - 2 signs seen on examination? - INV - BEDSIDE - Obs - INV - BLOOD - 3 and why? INV - IMAGING - USS: - Over how many cm's suggest dilated CBD? - Other USS findings - 2 - GOLD standard? - MED Rx - 2 - SURG Rx - 2
Chronic C basically the same but not acute!
Boas sign - extreme tenderness in the area of back pain below the scapula
Biliary colic pain
Pain - RUQ, epigastric, worse after fatty meal **
N&V
Stone impaction in the gallbladder neck or cystic duct.***
AC - lying still BC - can't get comfortable ======= Murphy's sign: (1) With 2 fingers pressed on RUQ (2) There is pain on inspiration (3) Patient stops breathing (4) Positive if negative in LUQ
FBC (Raised WBC)
CRP/ESR
LFT’s - raised liver enzymes (e.g. ALP, BR and GGT)
> 6 mm
Distended GB
Thick walled GB
Fluids and analgesia
ERCP for CBD stones (stenting, clearance)
Laparascopic Cholecy…..
Acute Cholangitis:
Iatrogenic cause?
How do you know it is not A Cholecystitis?
Charcot’s triad?
INV - BLOOD - 2 and why?
INV - IMAGING - 2
MED Rx - 2
SURG Rx:
- 2 ways ERCP can help?
- Permenant?
ERCP
No Murphy’s sign - there is no tenderness
Jaundice - obstructive
Abdo pain - RUQ
Rigors
JAR!!!
FBC - raised WBC
LFTs - Raised BR, alk phosphate and GGT
USS
MRCP
IV fluids and analgesia
ERCP - Sphincterotomy and stone clearance/stenting
Laparascopic Cholecy…..
Gallstones ileus:
What is it?
CLUE - stone that pass through the sphincter of Odi unlikely to….
Where does it happen?
What would you see on AXR? - 2
A large gallstone that erodes through the gallbladder into the duodenum causing small bowel obstruction
The narrowest point in small bowel - 2 feet proximal to the ileocecal valve
Dilated loops of bowel and air in the biliary tree (entered through the fistula
Acute Pancreatitis:
3 manifestations of inflammation systemically?
How can it lead to abdominal bleeding?
I GET SMASHED?
Symptoms - 3
Why do they get the following:
- Pleural effusion - 2
- Ascites
They can also get pleural effusion due to blockage of lymphatic drainage or fistula.
2 signs on exam and what they mean?
INV - BEDSIDE - OBS
INV - BLOODS - 6 and why?
- What is seen on ABG/VBG?
- What 2 electrolytes should you keep an eye on?
Erosion of vessel wall and intra-abdominal bleeding
Oedema
Fluid shifts
Hypovolaemia
Idiopathic
Gallstones - more common in women
Ethanol - alcohol - more common in men
Trauma
Steroids Mumps and malignancy Autoimmune Scorpion sting Hyperlipidaemia and hypercalcaemia ERCP Drugs e.g. valproate, azathioprine, thiazides ====== Severe Epigastric or LUQ (may radiate to back) N&V ====== - Due to blockage of lymphatic drainage or fistula. - Pancreaticopleural fistula
Cullens - bruising umbilical
Grey-turner - bruising flanks
HAEMORRHAGIC PANCREATITIS ====== 1. FBC - WBC for infection 2. U&E - dehydration and hypokalaemia from vomiting 3. Coagulation - surgery Group and save (crossmatch) - if surgery is needed 4. LFT - gallstones 5. ESR/CRP - inflammation 6. Lactate - sepsis and tissue perfusion 7. Amylase/lipase - LIPASE BETTER!!
Metabolic (LACTIC) acidosis can occur in acute pancreatitis for multiple reasons that include lactic acidosis resulting from shock, renal failure, or late in the course of disease because of loss of bicarbonate-rich pancreatic secretions due to pancreatic duct disruption.
Hypokalaemia - vomiting
Hypokalaemia - tetany - severe P
