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3 - GI Presentations Flashcards

1
Q

What organs cause acute abdominal pain in each of the four quadrants, the epigastrium and the suprapubic area?

A

Also consider lungs, cardiac, testicular and gynaecological pathologies, DKA

***RUQ Cholecystitis, Right flank ( pyelonephretis uretic colic ), hepatitis pancreatis
LUQ Left flank (pyelonephretis uretic colic) gastric ulcer
LLQ Diverticulitis UTI testicular gynaecological
RLQ Appendicitis Uretic olic, IBD *

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2
Q

What is an acute abdomen and
how do you assess a patient with this?

A

Sudden onset of severe abdominal pain

Need to decide if patient is critically unwell and needs surgical intervention so check observations and observe patient from bed with ABCDE

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3
Q

What are some causes of acute abdomen that require immediate urgent intervention? [6]

A
  • Ruptured AAA Weakened Wall
  • Aortic Dissection Tear
  • Perforated Bowel
  • Volvulus
  • Mesenteric Ischemia
  • Torsion Testicular
  • tests
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4
Q

Intraabdominal bleeding is a pathology that presents as acute abdomen and requires urgent intervention as it can cause hypovolemic shock.
What are some causes of this type of bleeding? [4]
How will a patient present with this?

A
  • Ruptured AAA
  • Ruptured ectopic pregnancy
  • Bleeding gastric ulcer
  • Trauma.

- Hypovolemic shock: tachycardia, hypotensive, cold to touch, clammy and pale

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5
Q

A perforated viscus is a pathology that presents as acute abdomen and requires urgent intervention as it causes peritonitis.

What are some causes of this [4]
how will a patient present with this? [5]

A
  • Peptic ulceration
  • Small or large bowel obstruction
  • Diverticular disease
  • IBD

Patients will lay **completely still **with generalised peritonitis (unlike renal colic where they will be moving to get comfortable)

Tachycardia hypotensions
Completely Rigid abdomen ( on percusssion)
Involuntary Guarding (tense when u palpate)
Reduced bowel sounds, obstructions can lead to paralytic ileus

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6
Q

Ischameic bowel (Acute Mesenteric Ischaemia) is a cause of acute abdomen that requires urgent surgical intervention.

How will this present in a patient
how is it diagnosed, definitely too?

A

Severe pain out of proportion to clinical signs has ichaemic bowel until proven otherwise

Exam often remarkable but diffuse constant pain. Often acidaemic, have a raised lactate and are physiologically compromised
Definitive diagnoses via CT with IV contrast

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7
Q

How does colic present?

A

Pain that crescendos to become very severe and then goes away completely

e.g biliary colic, ureteric colic, and bowel obstruction.

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8
Q

What is peritonism?

A

Localised inflammation of the peritoneum, usually due to inflammation of a viscus that then irritates the visceral then parietal peritoneum

Eg Appendix
Visceral pain: Early inflammation irritates the visceral peritoneum, causing diffuse, poorly localized pain (e.g., mid-abdominal pain).

Parietal pain: As inflammation spreads to the parietal peritoneum, pain becomes sharp, localized, and worse with movement (e.g., RLQ in appendicitis).

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9
Q

What labatory** tests and imaging** should you do for all cases of acute abdomen?

A

Lab Tests

- Urine dipstick ±MC&S: check for signs of infection, haematuria, pregnancy

- ABG: for bleeding or septic patients. Look at O2, rapid Hb, lactate to see perfusion of organs

- Routine bloods: FBC, U&Es, LFTs, CRP, amylase and a group and save if likely to need surgery soon

Imaging

- eCXR: for pneumoperitoneum or lower lobe lung pathology

- US: KUB Billiary tree Transvaginaly

- CT

- ECG: to rule out cardiac pathology causing referred pain

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10
Q

What may a raised serum amylase level mean in a patient with acute abdomen?

A

- 3x normal limit: pancreatitis

- Raised but not 3x: perforated bowel, ectopic pregnancy, or diabetic ketoacidosis (DKA)

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11
Q

How is acute abdomen managed generally before a diagnosis is made? [7]

A
  • IV access +/- fluids
  • Nil by mouth (prep for surgery)
  • Analgesics
  • Antiemetics
  • Initial imaging, bloods and urine dip
  • VTE prophylaxis
  • Consider NG tube and catheter if unwell to monitor fluid balance
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12
Q

What are the key principles of making surgical incisions?

A
  • Incisions should follow Langer’s lines where possible, for maximal wound strength with minimal scarring
  • Muscles should be split and not cut (where possible)
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13
Q

What are the incisions used for an appendectomy? [2] and where

A

Made at McBurney’s point (2/3 from umbilicus to ASIS). Passes through passing through all of the abdominal muscles, transversalis fascia, and then the peritoneum to the abdominal cavity

Lanz Incision: transverse incision that follows Langer lines so more aesthetically pleasing and less scarring

Gridiron incision: oblique (superolateral to inferomedial)

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14
Q

What are the names of the following incisions?

A
  1. Midline
  2. Paramedian
  3. Kocher
  4. Chevron / rooftop incision or modification
  5. Mercedes Benz incision or modification
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15
Q

What is a midline incision used for?

A

Anywhere from the xiphoid process to the pubic symphysis, passing around the umbilicus

Will cut through skin, subcutaneous tissue, fascia, linea alba and tranversalis fascia, peritoneum before reaching the abdominal cavity

Can be used for emergency procedures as good visualisation. Also minimal blood loss and nerve damage. However bad scarring

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16
Q

What is a paramedian incision?

A

Rarely used but when used it is to get to lateral viscera like kidneys and spleen

2-5cm lateral to the midline, anterior rectus sheath is separated and moved laterally, before the excision is continued through the posterior rectus sheath (if above the arcuate line) and the transversalis fascia, reaching the peritoneum and abdominal cavity

Takes a long time but prevents division of rectus muscle. However can damage lateral muscle blood and nerve supply causing atrophy of muscle medially

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17
Q

What is a Kocher incision and what is it used to gain access to?

A

Subcostal incision used to gain access to gall bladder for the biliary tree.

Runs parallel to the costal margin, starting below the xiphoid and extending laterally.

Pass through all the rectus sheath and rectus muscles, internal oblique and transversus abdominus, before passing through the transversalis fascia and then peritoneum to enter the abdominal cavity.

Heals well

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18
Q

What are two modifications of the Kocher incision and what are they used for?

A

Chevron / rooftop incision

  • Extension of Kosher to the other side
  • May be used for oesophagectomy, gastrectomy, bilateral adrenalectomy, hepatic resections, or liver transplantation

Mercedes Benz incision

  • Liver transplantation
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19
Q

What laparoscopic port site is almost always the same in every surgery?

A

Umbilicus for camera port

Common instruments include camera, cutting and dissecting scissors, and grippers

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20
Q

What are some of the causes of haematemesis?

A

Emergency (due to haemorraghe)

- Oesophageal varices: often due to portal hypertension from alcohol abuse. Needs urgent OGD

- Gastric ulceration: erosion into blood vessels, usually lesser curve of stomach and posterior duodenum. May have history of epigastric pain, NSAIDs, H.Pylori

Non-emergency

- Mallory-Weiss Tear: just needs reassurance and monitoring. If severe or prolonged this warrants OGD (oesophagogastroduodenoscopy)

MUCOUSAL TEAR

- Oesophagitis: due to GORD, infections such as candidiasis, radiotherapy, Crohn’s, ingestion of toxic substances

  • Gastritis, Gastric malignancy, Meckel’s di sverticulum
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21
Q

When a patient presents with haematemesis, what do you need to find out in the history? [4]

A

See image but also check for peritonism, epigastric tenderness, evidence of underlying cause e.g liver stigmata

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22
Q

What investigations are done when a patient has haematemesis? [5]

A

- Routine bloods (FBC, U&Es, LFTs, and clotting) and VBG

- Group and Save and crossmatch 4 units of blood

  • OGD is definitive, within 12 hours

- Erect CXR if suspect perforated peptic ulcer

- CT abdomen with IV contrast if too unwell for OGD or if OGD is unremarkable

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23
Q

What is the Glasgow-Blatchford Bleeding Score?

and then what do u use

A

Decide whether Upper GI bleed can be managed as outpatient or inpatient with endoscopy

Rockall Score (severity score for GI bleeding post-endoscopy)

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24
Q

What is the best imaging for acute abdomen and haematemesis?

A

Acute Abdomen: CT with IV contrast

Haematemesis: OGD

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25
How is haematemesis due to peptic ulcer disease and oesophageal varices managed?
**- Initial:** 2 large bore IV cannulas, start fluid resuscitation if needed, and crossmatch blood **_Endoscopy:_** **- Peptic ulcer disease:** Injection of adrenaline and cauterisation or embolisation of gastroduodenal artery. High dose IV PPI +/- eradication therapy **- Oesophageal varices:** prophylactic antibiotics and Terlipressin. Endoscopic banding, Somatostatin analogues (e.g. octreotide) or vasopressors (e.g. terlipressin), Long-term repeated banding and long term beta blockers
26
In eosophageal varices what meds do u give? and why
terlipressin and octreotide, prophylatic antibitotics vasopressor and somatostatin analouge ( both cause splanchnic vasocontrction reducing portal hypertension) Antibiotics to reduce chacnes of bacterial peritonitis. Ceftriaxone (IV) 1st Ciprofloxanin 2nd line
27
What is the aetiology of dysphagia and what are some questions you should ask someone with this?
- Is there difficulty in initiating the swallowing action? - Do you cough after swallowing? - Do you have to swallow a few times to get the food to pass your throat? Ask about regurgitation, the sensation of food becoming ‘stuck’, hoarse voice, weight loss, referred ear or neck pain
28
How is a dysphagia presentation investigated? [4]
**- URGENT OGD** and **biopsy** to rule out malignancy - FBC If endoscopy normal * **manometry and 24hr pH studies** to look for motilitity disorders, * barium swallow to look for pharyngeal pouch *Manometry: Measures pressure and coordination of muscle contractions in the oesophagus to diagnose motility disorders (e.g., achalasia). 24-hour pH Study: Monitors acid levels in the oesophagus over 24 hours to assess for GORD (gastro-oesophageal reflux disease).**
29
How is dysphagia managed? [2]
- Treat underlying cause e.g excision/palliation for malignancy - Involve speech therapists and dieticians early if ongoing
30
What is a closed loop obstruction?
31
Why is urgent fluid resuscitation required in a bowel obstruction?
Once the bowel segment has become occluded, **dilatation of the proximal limb** of bowel occurs, resulting in an **increased peristalsis of the bowel.** This leads to **secretion of large volumes of electrolyte-rich fluid into the bowel** (often terme**d ‘third spacing’).**
32
What is the aetiology of small and large bowel obstructions?
**Small bowel** – adhesions and hernia **Large bowel** – malignancy, diverticular disease, and volvulus SURGICAL SIEVE: outside, within the wall, within the lumen
33
What are some clinical features of a bowel obstruction?
- See image for features **- Examination:** abdominal distension, focal tenderness, tinkling bowel sounds on auscultation, tympanic sound on percussion - Patients develop **guarding** and **rebound tenderness** with abdominal tenderness when **ischaemia** of the bowel is starting
34
What are some differential diagnoses for bowel obstruction?
- Pseudo-obstruction - Paralytic ileus - Toxic megacolon - Constipation
35
What investigations are done if you suspect a bowel obstruction?
**- Urgent bloods** and a **G+S** due to third spacing **- VBG** to look for raised lactate (ischaemia) or metabolic derangement due to vomiting/dehydration **- CT with IV contrast** is imaging of choice **- AXR** **- Water soluble contrast stud**y (gastrograffin) in small bowel obstruction from adhesions from surgery
36
Why is CT imaging better than AXR for bowel obstructions?
(1) more sensitive (2) can differentiate between mechanical obstruction and pseudo-obstruction (3) can find site and cause of obstruction so good for operative planning (4) presence of metastases if caused by a malignancy
37
What would you see on an AXR of a bowel obstruction?
38
How is a bowel obstruction managed conservatively?
- If closed loop or signs of ischaemia need **urgent surgery** - If no signs of ischaemia **DRIP AND SUCK** (see image) **- Water soluble contrast study** if does not resolve within 24 hours conservative management.
39
What is the surgical management of a bowel obstruction?
- Indications of surgery (see image) plus virgin abdomen **- Laparotomy** **- Resection of bowel if ischaemic** and **anastomose** or **stoma**
40
What are some complications of bowel obstruction?
- Bowel ischaemia - Bowel perforation leading to faecal peritonitis (high mortality) - Dehydration and renal impairment
41
What is a red flag that ischaemia may be developing in a suspected bowel obstruction?
- Colicky pain that becomes constant in nature or worse on movement - Guarding and rebound tenderness
42
What is the first diagnosis you should consider with an acute abdomen?
GI perforation as delay in resuscitation and surgery can lead to septic shock, multi-organ dysfunction and death
43
What is the aetiology of GI perforations?
**- Most common:** peptic ulcers and sigmoid diverticulum **- Others:** sigmoid volvulus, colorectal cancer, appendicits, colonoscopy, UC in toxic megacolon - Inflammatory, Ischaemic, Trauma
44
What are some of the features of a GI perforation?
- Rapid onset sharp pain - Systemically unwell with septic features - May have signs of peritonism, if generalised needs surgery (rigid abdomen) - If ***thoracic perforation*** (e.g oesophageal rupture) may have ***chest or neck pain radiating to back***, worsening on inspiration. May be ***vomiting*** and ***respiratory symptoms*** (signs of pleural effusion or palpable crepitus)
45
What are some investigations you should do if you suspect a GI perforation?
**- Baseline bloods with G+S:** raised CRP and WCC` **- Urinalysis:** to rule out renal and tubo-ovarian pathology **- CT scan:** gold standard, shows free air and site of perforation - Possible **AXR** and **eCXR**
46
What would you see on an AXR and eCXR with a GI perforation?
**_AXR_** - Rigler sign - Psoas sign (loss of the sharp delineation of the psoas muscle border due to fluid in the retroperitoneum) **_eCXR (only 70% sensitivity so use CT)_** - Cupola sign (look under right diaphragm) - Pneumomediastinum or widened mediastinum if thoracic perforation
47
How are GI perforations managed?
**_Initially:_** broad spectrum abx, NBM, NG tube, IV fluid support, analgesia **_Surgical:_** - Identify underlying cause - Repair underlying cause (***omental/Graham patch*** for peptic ulcer or ***Hartmann's procedure*** for perforated diverticular) - Thorough washout **_Conservative:_** - Initial treatment if: - elderly with comorbidities unlikely to survive surgery - if sealed upper GI perforation on CT scan with no generalised peritonism - localised diverticular abscess / perforation (\<5cm) with only localised peritonitis and tenderness, and no evidence of generalised contamination on CT imaging
48
What are the surgical incisions needed to gain access to the following perforations: - Stomach/duodenal - Small bowel - Large bowel
**- Stomach/duodenum:** upper midline incision with omental patch (Graham's) and take a biopsy for malignancy **- Small bowel:** midline laparotomy, oversew if bowel is viable, if not resect and anastomose or stoma **- Large bowel:** midline laparotomy, do not anastomose if faecal content just stoma
49
What are some causes of melaena?
**- Peptic ulcer disease** **- Oesophageal varices** **- Upper GI malignancy** - Gastritis or Oesophagitis - Mallory–Weiss tear - Meckel’s diverticulum
50
What questions in the history should you ask if a patient has melaena?
**Colour and texture of the stool–** jet black, tar-like, and sticky **Associated symptoms –** including haematemesis, abdominal pain, or a history of dyspepsia, dysphasia or odynophagia **PMH** – including smoking and alcohol status, and inflammatory bowel disease **DHx–** use of steroids, NSAIDs, anticoagulants, or iron tablets **ALWAYS DO DRE** TO CONFIRM AND **ABDOMINAL EXAM** TO LOOK FOR EPIGASTRIC TENDERNESS, HEPATOMEGALY OR STIGMATA OF LIVER DISEASE
51
What investigations should you do if a patient has melaena?
**_- Routine bloods:_** Hb might not have dropped with acute bleed. LFTs may show underlying liver pathology. ***Any drop in Hb and rise in urea:creatinine ratio is indicative of upper GI bleed*** **_- G+S:_** 4 units crossmatched **_- ABG:_** pH, Base Excess, and Lactate, for signs of tissue hypoperfusion **_- OGD:_** definitive imagine **_- CT with IV contrast:_** if OGD unremarkable
52
How is malaena managed?
**- A to E approach** to stabilise **- OGD** once stable and resuscitated **- Tranfuse blood products** if haemodynamically unstable or with a low Hb (\<70g/L). **- Correct any deranged coagulation** as, use reversal agents if patient on anti-coagulants or FFP +/- platelets with impaired liver function
53
What are some causes of rectal bleeding?
- If haemodynamically unstable then suspect upper GI bleed until proven otherwise - Diverticular disease - Ischaemic or infective colitis - Haemorrhoids - Malignancy (ALWAYS SUSPECT) - Angiodysplasia - Crohn’s disease or Ulcerative colitis - Radiation proctitis.
54
What are some questions you need to ask in a history if a patient has PR bleeding?
**- Nature of bleeding:** duration, frequency, colour of the bleeding, relation to stool and defecation **- Associated symptoms:** pain (especially association with defaecation), haematemesis, PR mucus, or previous episodes **- FHx** of bowel cancer or inflammatory bowel disease **- Do PR and abdomen exam** for rectal or abdominal masses
55
What is the Oakland score?
]Score to stratify patients presenting with a **lower GI bleed** to determine if **outpatient management** is feasible
56
What investigations are done when a patient has PR bleeding?
- Routine bloods and G+S (may not initially show anaemia) (FBC, Clotting, LFTs, Faecal calprotectin, Ferritin and Iron studies) - Stool culture to rule out infective causes - If haemodynamically unstable then **urgent CT angiogram** (before any endoscopic therapy) to locate bleed - If stable then **flexible sigmoidoscopy** and **OGD**
57
What are some risk factors for adverse outcomes from acute rectal bleeding?
58
How is PR bleeding managed?
**_- Low risk score:_** can be sent home for outpatient treatment as will often settle spontaneously **_- High risk/Unstable:_** A to E, IV fluids, Blood transfusion, reverse any anticoagulants then: * **Endoscopic haemostasis methods:** e.g adrenaline injection, band ligation, bipolar electrocoagulation * **Arterial embolisation:** if blush of sufficient size on angiogram * Surgery if above fails
59
What are some of the causes of jaundice?
High levels of bilirubin (breakdown product of haem that is conjugated in the liver) ## Footnote **- Prehepatic:** excessive breakdown of RBC **- Hepatic:** dysfunction of hepatic cells so mixture of conjugated/unconjugated - **Post-hepatic:** obstruction of biliary drainage
60
What is bilirubinuria?
Dark coca cola coloured urine when there is lots of conjugated bilirubin so either hepatic or post hepatic cause. Also pale stools If normal colour urine likely pre-hepatic jaundice as unconjugated
61
What labatory investigations can be done if a patient presents with jaundice?
- LFTs - Coagulation studies (PT is marker of liver synthesis function) - FBC (anaemia, raised MCV, and thrombocytopenia all seen in liver disease) and U's and E's - Liver screen
62
What is a liver screen?
Performed on patients where there is whereby there is no initial cause for liver dysfunction
63
What imaging can be done if a patient presents with jaundice?
**- US abdomen:** first line for obstructive jaundice and liver pathology **- MRCP:** to look for obstructive jaundice in the biliary tree if nothing on US **- Liver biopsy**
64
How is jaundice managed?
**- Treat underlying cause** e.g ERCP if gallstone causing obstructive jaundice - To treat itching give **antihistamines** or **cholestyramine** if obstructive jaundice - Monitor for **coagulopathy**, treating promptly (either **vitamin K** or **FFP**) **- Oral glucose** for hypoglycaemia - If confused due to decompensating liver disease (hepatic encephalopathy) give **laxatives (lactulose or senna) +/- neomycin or rifaximin** to reduce the number of ammonia-producing bacteria
65
How do you do a hernia examination?
**- Introduction:** wash hands, gain consent, introduce, chaperone **- Inspect:** get them to stand and look for asymmetry, scars, skin changes, lumps. Ask them to cough to protrude hernia **- Palpate**: decide if scrotal (can get above) or groin swelling, decide if femoral or inguinal, ask patient to lie down and if reduces it is likely hernia, cough impulse. Examine other side as often bilateral **- Complete:** say you would assess genitalia for lymph nodes and any hernia into the scrotum.
66
How do you decide whether a hernia is femoral, direct inguinal or indirect inguinal?
**- Above and medial pubic tubercle** = inguinal hernia **- Below and lateral** **pubic tubercle** = femoral hernia
67
How do you do a stoma examination?
**Introduction:** usual, put patient at 45 degrees, ask about any pain or output issues with stoma **Inspection:** ask to remove stoma bag, inspect stoma, look for any complications like parastomal hernia (common with colostomies), prolapse, retraction, or infarction (black). Check skin for any erythema, ulceration or fistulas **Palpate:** feel around stoma for any tenderness, ask patient to cough and see if cough impulse for parastomal hernia, digitate the stoma to assess for any stenosis and check patency
68
How do you do a digital rectal examination?
**Introduction:** usual, ask if any pain and tell them if any pain you can stop, chaperone **Preparation:** position on their left side and bring their knees to their chest, positioning the buttocks at the edge of the couch, chaperone at their front side. get adequate lighting **Inspection:** part buttocks and inspect perianal area e.g haemorrhoids, rectal prolapse, pilonidal sinus, skin disease **Palpation:** (see image) **Complete:** clean patient with towel, wash hands, offer to perform abdominal exam, clockface findings
69
What are some causes of acute epigastric pain?
- Perforated stomach ulcer - Gastritis - Pancreatitis - Gallbladder pathology - MI - Pneumoa - Oesophagitis (also retrosternal pain) Ask about pain distribution, onset, character, timing, exacerbating factors, severity and radiation to work out cause of the epigastric pain
70
Once you have characterised acute epigastric pain with SOCRATES, what are some questions to ask in the history?
71
What is Boerhaave syndrome?
Spontaenous rupture of the oesophagus that presents with Mackler's triad (vomiting, chest pain, subcutaneous emphysema)
72
What is the difference between acute and chronic pancreatitis?
- Acute pancreatitis is a life threatening inflammatory process. Usually due to gall stones or binge drinking - Chronic pancreatitis develops insidiously over a long period of time and is characterised by progressive fibrosis and destruction of endo and exocrine glands. Usually due to chronic alcohol ingestion
73
What are the two commonest causes of upper GI haemorraghe?
Duodenal and Gastric ulceration
74
What are some differentials for a groin lump?
- Inguinal hernia (reducible) - Inguinal lymphadenopathy - Femoral artery pseudoaneurysm - Undescended testes - Saphena Varix (reducible)
75
What are some differentials for RIF pain?
- Appendicitis - Bowel obstruction - IBD - Testicular torsion - Gynaecological (ectopic/endometriosis) - Inguinal hernia - UTI - Ureteric colic
76
How can diverticulitis cause a large bowel obstruction?
Scarring from acute inflammation forming a stricture
77
How is a small bowel obstruction due to adhesions managed?
Conservatively unless strangulation
78
What is the difference between a loop and end stoma?
**_Loop:_** used in emergencies and is only temporary, a loop of bowel is held out and held by an external device, two openings are made one for stool and one for mucus **_End:_** stoma created from one end of the bowel, the other portion of bowel is either removed or sewn shut
79
When is it necessary to form a stoma?
**1. Part of the colon has been removed** so faeces can no longer pass through the anus e.g colon cancer, diverticulitis **2. A part of the colon has been operated on** and needs to rest and heal, temporary **3. Faecal incontinence** that is not responsive to other treatments
80
What are the differences between an ileostomy and a colostomy?
**- Ileostomy** is small bowel and is spouted and in the RIF. Often liquid that comes out **- Colostomy** is large bowel, adhered to skin, can be anywhere on the abdomen and stool is solid
81
What is a Hartmann's procedure?
Surgical **resection of the rectosigmoid colon** with **closure of the rectal stump** and **formation of an end colostomy** with a stoma bag Done as a primary anastomosis is too risky at the time and may cause an anastomotic leak
82
How can you split the causes of PR bleeding into a surgical sieve and give some examples of causes?
Split anatomically
83
A patient presents to DASU with PR bleeding. An initial ABCDE assessment is done to check the patient is haemodynamically stable. What questions in the history should you ask about the bleeding?
- How much blood? - How long has this been going on? - Relationship of blood with stool? - Any pain (usually painless) or prolapse when opening bowels? - Any tenesmus (rectal cancer)? - Any change in bowel habit? - Any weight loss? - Any symptoms of anaemia? - Any drugs that could cause peptic ulcers?
84
If a patient presents to the GP with a diverticulitis flare, what is the most appropriate management?
- Send home with oral abx - If no improvement within 72 hours go to A+E for IV Ceftriaxone and Metronidazole
85
How is a bowel obstruction managed?
- NBM - NGT - IVI, Catheter - Analgesia - AXR + CT + eCXR to diagnose - Surgery
86
What are two causes of bowel obstruction that may not need surgery to manage?
- Adhesional small bowel obstruction (conservative) - Sigmoid volvulus (endoscopic decompression)
87
What are Cushing's and Curling's tumours?
**Cushing's:** gastric ulcer due to head injury, increased ICP causes vagal overactivity, prone to perforation **Curling's:** often seen in the stomach after intensive burns
88
What should you do when you are managing a GI perforation due to a gastric ulcer?
Always biopsy the ulcer to see if underlying malignancy
89
What is the main imaging investigation for acute abdomen?
CT scan with IV contrast if eGFR fine, not pregnant and no allergy to contrast
90
How can you split the causes of an acute abdomen into a surgical sieve?
91
When a patient presents with an acute abdomen, apart from an abdominal examination what other examinations and investigations should you do?
- Groin - PR - PV/Scrotal
92
What is the general management for anyone presenting with an acute abdomen?
- NBM - IV fluids - Tubes (Catheter and NG) - Thromoprophylaxis - Analgesia/Antiemetics - Inform seniors
93
What are some electrolyte imbalances that can cause paralytic ileus?
- HypoK - HypoNa - Hypo/Hyper Mg
94
What is the difference between guarding and rigidity?
95
What is an important non-abdominal investigation to do when a patient presents with upper abdominal pain?
- CXR to rule out lower lobe pneumonia - ECG to rule out MI
96
What type of bowel obstruction cannot be seen on AXR?
Adhesional
97
When deciding if a surgery is Cat 1 (within 1 hour), what principle do you use?
Limb or life threatening (e.g closed loop obstruction is lifethreatening but open loop isn't)
98
How may lower lobe pneumonia present atypically?
RIF pain due to referred pain
99
What are some medical causes of an acute abdomen?
* DKA * Sickle cell crisis * Hyperca
100
When should you image if you are suspecting pancreatitis?
48 hours later to look for necrosis
101
How should you think about the causes of bowel obstruction and obstructive jaundice? (IMPORTANT FOR OSCES)
* Extraluminal * Luminal * Intraluminal

Y3 SURG (21 decks)

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