Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Year 2 - BRS > 6.13 - General surgery in the GI tract > Flashcards

6.13 - General surgery in the GI tract Flashcards

1
Q

What is acute abdomen (and what are the four types of causes)?

A

Sudden, acute onset abdominal pain, generally requiring surgery (causes: infection, inflammation, obstruction, vascular accident)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What do we look for in regards to the patient’s presenting complaint for acute abdomen?

A
  • pain assessment (SOCRATES)
  • associated symptoms (e.g. vomiting, diarrhoea, fever)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Apart from presenting complaint, what else do we ask about for acute abdomen? (3)

A
  • PMHx - past medical history
  • DHx - drug history
  • SHx - social history
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What range of investigations are there for acute abdomen? (4)

A
  • bloods (VBG, FBC, CRP, U&Es, LFTs, amylase)
  • urinalysis + urine MC&S (check for UTIs)
  • imaging (erect CXR, AXR, CTAP, CT angiogram, USS)
  • endoscopy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is CTAP?

A

CT of abdomen and pelvis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

When do you do CT angiogram?

A

When you suspect bleeding or infarction - delineates blood vessels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Why do we do erect CXR for acute abdomen?

A

A viscous perforation can cause bubbles to accumulate under the diaphragm, which is an emergency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the three approaches to management of acute abdomen?

A
  • ABCDE (airways, breathing, circulation, disability, everything else/exposure)
  • conservative management
  • surgical management
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What differential diagnoses are associated with RUQ pain? (8)

A
  • biliary colic
  • cholecystitis / cholangitis
  • duodenal ulcer
  • liver abscess
  • portal vein thrombosis
  • acute hepatitis
  • nephrolithiasis
  • RLL pneumonia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What differential diagnoses are associated with epigastric pain? (8)

A
  • acute gastritis / GORD
  • gastroparesis
  • peptic ulcer disease/perforation
  • acute pancreatitis
  • mesenteric ischaemia
  • AAA
  • aortic dissection
  • myocardial infarction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What differential diagnoses are associated with LUQ pain? (6)

A
  • peptic ulcer
  • acute pancreatitis
  • splenic abscess
  • splenic infarction
  • nephrolithiasis
  • LLL pneumonia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What differential diagnoses are associated with RLQ pain? (8)

A
  • acute appendicitis
  • colitis
  • IBD
  • infectious colitis
  • ureteric stone / pyelonephritis
  • PID / ovarian torsion
  • ectopic pregnancy
  • malignancy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What differential diagnoses are associated with suprapubic/central pain? (8)

A
  • early appendicitis
  • mesenteric ischaemia
  • bowel obstruction
  • bowel perforation
  • constipation
  • gastroenteritis
  • UTI / urinary retention
  • PID
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What differential diagnoses are associated with LLQ pain? (8)

A
  • diverticulitis
  • colitis
  • IBD
  • infectious colitis
  • ureteric stone / pyelonephritis
  • PID / ovarian torsion
  • ectopic pregnancy
  • malignancy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

How do patients with bowel ischaemia present? (3)

A
  • sudden onset crampy abdominal pain
    • severity of pain depends on length and thickness of colon affected
  • bloody, loose stool (currant jelly stools)
  • fever + signs of septic shock
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the risk factors for bowel ischaemia? (6)

A
  • age >65 years
  • cardiac arrhythmias (mainly AF), atherosclerosis
  • hypercoagulation / thrombophilia
  • vasculitis
  • sickle cell disease
  • profound shock causing hypotension
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are the two types of bowel ischaemia?

A
  • acute mesenteric ischaemia - embolic events (so look for cardiac arrhythmias), transmural ischaemia
  • ischaemic colitis - more to do with hypertension, mainly mucous
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Which bowel does acute mesenteric ischaemia vs ischaemic colitis affect?

A

Small bowel vs large bowel

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is acute mesenteric ischaemia vs ischaemic colitis caused by?

A
  • AMI - usually occlusive and secondary to thromboemboli
  • IC - usually due to non-occlusive low flow states or atherosclerosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is the onset of acute mesenteric ischaemia vs ischaemic colitis?

A
  • AMI - sudden onset (but presentation and severity varies)
  • IC - more mild and gradual (80-85% of the cases)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is the pain like for acute mesenteric ischaemia vs ischaemic colitis?

A
  • AMI - abdominal pain out of proportion of clinical signs (often see no clinical signs at all)
  • IC - moderate pain and tenderness (generally less severe)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

How can atrial fibrillation contribute to acute mesenteric ischaemia?

A
  • if someone has AF, a small clot can get blocked in the SMA
  • if complete obstruction of the SMA, you lose all of bowel from DJ flexure to splenic flexure (all of small bowel and 3/4 of large bowel)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What three types of investigation do we do for bowel ischaemia?

A
  • bloods
  • imaging - CTAP / CT angiogram
  • endoscopy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What bloods do we do for bowel ischaemia, and what would we see? (2)

A
  • FBC - neutrophilic leukocytosis
  • VBG - lactic acidosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What does seeing lactate on VBG tell us in bowel ischaemia?

A
  • switch to anaerobic respiration
  • form of metabolic acidosis associated with late stage mesenteric ischaemia and extensive transmural intestinal infarction
  • late stage = bowel already dead (ideally want to intervene before this happens)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What do imaging (CTAP / CT angiogram) for bowel ischaemia detect? (4)

A
  • disrupted flow
  • vascular stenosis (narrowing of lumen due to extrinsic factors i.e. aneurysms, tumours)
  • pneumatosis intestinalis (transmural ischaemia/infarction) - air in bowel wall, bowel already dead
  • thumbprint sign (unspecific sign of colitis)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

When is endoscopy used for bowel ischaemia?

A

For mild or moderate causes of ischaemic colitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What do we look for on endoscopy of ischaemic bowel? (3)

A
  • oedema
  • cyanosis
  • ulceration of mucosa
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What type of bowel ischaemia can we do conservative management for?

A

Mild to moderate cases of ischaemic colitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What type of bowel ischaemia is conservative management not suitable for?

A

Small bowel ischaemia - acute mesenteric ischaemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What does conservative management of bowel ischaemia consist of? (7)

A
  • IV fluid resuscitation
  • bowel rest (NBM)
  • broad spectrum ABx (colonic ischaemia can result in bacterial translocation and sepsis)
  • NG tube for decompression (they can get concurrent ileus, where bowel does not do peristalsis)
  • anticoagulation
  • treat/manage underlying cause
  • serial abdominal examination and repeat imaging
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What are the indications for surgical management of bowel ischaemia? (5)

A
  • small bowel ischaemia (acute mesenteric ischaemia)
  • signs of peritonitis (rigid abdomen) or sepsis
  • haemodynamic instability
  • massive bleeding
  • fulminant colitis with toxic megacolon
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

How do we do exploratory laparotomy for bowel ischaemia?

A

Resection of necrotic bowel with/without open surgical embolectomy (balloon catheter in SMA to pull out thrombus) or mesenteric arterial bypass (rare)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What does dead bowel vs healthy bowel look like?

A
  • dead = purple, inflamed
  • healthy = pink
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What is endovascular revascularisation for bowel ischaemia?

A
  • another technique to try before surgery
  • balloon angioplasty/thrombectomy in patients without signs of ischaemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

How does acute appendicitis present? (5)

A
  • initially periumbilical pain that migrates to RLQ (within 24 hours)
  • anorexia (ask if they feel like eating)
  • nausea +/- vomiting
  • low grade fever
  • change in bowel habit (inflamed appendix adjacent to rectum and can irritate it)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What are some important clinical signs seen in acute appendicitis? (5)

A
  • McBurney’s point
  • Blumberg sign
  • Rovsing sign
  • Psoas sign
  • Obturator sign
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

What is McBurney’s point (acute appendicitis)?

A

Tenderness in RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What is Blumberg sign (acute appendicitis)?

A

Rebound tenderness especially in right iliac fossa (pain on pressure removal rather than application)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

What is Rovsing sign (acute appendicitis)?

A

RLQ pain elicited on deep palpation of the LLQ

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

What is Psoas sign (acute appendicitis)?

A

RLQ pain elicited on flexion of right hip against resistance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

What is Obturator sign (acute appendicitis)?

A

RLQ pain on passive internal rotation of the hip with hip & knee flexion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

What three types of investigations are there for acute appendicitis?

A
  • bloods
  • imaging
  • diagnostic laparoscopy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

What bloods are done for acute appendicitis, and what would you see? (4)

A
  • FBC - neutrophilic leukocytosis
  • raised CRP
  • urinalysis - possible mild pyuria (WBCs present) / haematuria
  • electrolyte imbalances in profound vomiting
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

What imaging tests are done for acute appendicitis? (3)

A
  • CT - gold standard in adults especially if age>50
  • USS - children/pregnancy/breastfeeding (radiation)
  • MRI - in pregnancy if USS inconclusive
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

When is diagnostic laparoscopy done for acute appendicitis?

A

In persistent pain and inconclusive imaging

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

What is the Alvarado score for acute appendicitis?

A

Clinical scoring system for appendicitis:

  • RLQ tenderness = 2
  • fever (>37.3) = 1
  • rebound tenderness = 1
  • pain migration = 1
  • anorexia = 1
  • nausea +/- vomiting = 1
  • WCC > 10.000 = 2
  • neutrophilia (left shift 75%) = 1

</=4 unlikely, 5-6 possible, >/=7 likely

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

What does conservative management of acute appendicitis consist of? (4)

A
  • IV fluids
  • analgesia
  • IV or PO antibiotics
  • in abscess, phlegmon (inflammation of soft tissue that spreads under skin/inside body) or sealed perforation:
    • resuscitation + IV ABx +/- percutaneous drainage
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

What are the indications for conservative management of acute appendicitis? (2)

A
  • after negative imaging in selected patients with clinically uncomplicated appendicitis
  • in delayed presentation with abscess/phlegmon formation –> do CT-guided drainage
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

What do we consider after conservative management of acute appendicitis?

A

Interval appendicectomy as rate of recurrence after conservative management of abscess/perforation is 12-24%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Why is laparoscopic surgery better than open appendicectomy? (6)

A
  • less pain
  • lower incidence of surgical site infection
  • decreased length of hospital stay
  • earlier return to work
  • overall costs
  • better QoL scores
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

What are the steps of a laparoscopic appendicectomy? (Do not need to know?)

A
  1. trocar placement (usually 3)
  2. exploration of RIF + identification of appendix
  3. elevation of appendix + division of mesoappendix (containing artery)
  4. base secured with endoloops and appendix divided
  5. retrieval of appendix with a plastic retrieval bag
  6. careful inspection of the rest of the pelvic organs/intestines
  7. pelvic irrigation (wash out) + haemostasis
  8. removal of trocars + wound closure
52
Q

What is the definition of intestinal obstruction?

A

Restriction of normal passage of intestinal contents

53
Q

What are the two main groups of intestinal obstruction?

A
  • paralytic (adynamic) ileus - pus etc irritates bowel which stops peristalsis until irritation gone
  • mechanical
54
Q

What are the four different ways to classify a mechanical intestinal obstruction?

A
  • speed of onset - acute, chronic, acute-on-chronic
  • site - high or low (roughly synonymous with small or large bowel obstruction)
  • nature - simple vs strangulating
  • aetiology
55
Q

What is the difference between a simple vs strangulating 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)
56
Q

What is a volvulus?

A

Imagine a party balloon being twisted giving you a closed loop - but with intestines twisting

57
Q

What is an intussusception?

A

When a bit of bowel slides into the next bit

58
Q

What are the causes of mechanical intestinal obstruction? (3)

A
  • causes in the lumen e.g. faecal impaction, gallstone ileus (fistula)
  • causes in the wall - Crohn’s disease (thickening of SB wall), tumours, colon diverticulitis
  • causes outside the wall - strangulated hernia (external or internal), volvulus, obstruction due to adhesions or bands
59
Q

What are the causes of small bowel obstruction? (5)

A
  • adhesions (60%) - Hx of previous abdominal surgery
  • neoplasia (20%) - primary, metastatic, extraintestinal
  • incarcerated hernia (10%) - external (abdominal wall), internal (mesenteric defect)
  • Crohn’s disease (5%) - acute (oedema), chronic (strictures)
  • other (5%) - intussusception, intraluminal (foreign body, bezoar)
60
Q

What are the causes of large bowel obstruction? (5)

A
  • colorectal carcinoma (usually LHS since RHS can expand and compensate)
  • volvulus - sigmoid, caecal
  • diverticulitis - inflammation, strictures
  • faecal impaction
  • Hirschsprung disease - commonly in infants/children (lack of nerve ganglions means no peristalsis)
61
Q

What are the 4 main signs/symptoms (and three other signs/symptoms) of bowel obstruction?

A
  • abdominal pain
  • vomiting
  • absolute constipation
  • abdominal distention

Other signs:

  • dehydration
  • increased high pitch tinkling bowel sounds AKA borborygmi (early sign)
    • or absent bowel sounds (late sign and bad as peristalsis has stopped, may have ischaemic bowel)
  • diffuse abdominal tenderness (worrying)
62
Q

How does abdominal pain differ between small and large bowel obstruction?

A
  • SBO - colicky, central
  • LBO - colicky or constant
63
Q

How does vomiting differ between small and large bowel obstruction?

A
  • SBO - early onset, large amount, bilious (with bile)
  • LBO - late onset, initially bilious, progresses to faecal vomiting (looks like faeces)
64
Q

How does absolute constipation differ between small and large bowel obstruction?

A
  • SBO - late sign
  • LBO - early sign
65
Q

How does abdominal distention differ between small and large bowel obstruction?

A
  • SBO - less significant
  • LBO - early sign and significant
66
Q

What are 3 important points to remember about diagnosing intestinal bowel obstruction?

A
  • diagnosed by the presence of symptoms
  • examination should always include a search for hernias and abdominal scars, including laparoscopic potholes
  • is it simple or strangulating? (hernia)
67
Q

What are features suggesting strangulation (hernia)? (7)

A
  • change in character of pain from colicky to continuous
  • tachycardia
  • pyrexia
  • peritonism (rigid abdomen)
  • bowel sounds absent or reduced (initially increased)
  • leucocytosis
  • increased CRP
68
Q

Why is checking for strangulation (of hernia) important?

A

Strangulating obstruction with peritonitis has mortality of up to 15%

69
Q

What is a hernia?

A

Contents of bowel protrude outside its sac/cavity

70
Q

What are some common sites of hernias? (5)

A
  • inguinal - due to defects in abdominal wall
  • femoral - due to defects in abdominal wall
  • incisional hernia - skin healed but muscle underneath has defect so bowel protrudes through
  • umbilical hernias - around umbilicus
  • epigastric hernias - around epigastrium
71
Q

Why is the neck of the hernia sac important?

A
  • if it is large, the bowel can get in/out easily
  • smaller the hole, the greater the chance of the hernia obstructing and strangulating
72
Q

Describe the loss of blood supply in a strangulated hernia.

A
  • first venous return stops
  • bowel becomes oedematous as blood still coming in but cannot leave
  • then arterial supply stops which causes ischaemic bowel
73
Q

What is a Richter’s hernia?

A
  • not all hernias are associated with obstruction
  • this is a knuckle of bowel getting caught in a hernia, but there is still continuity of bowel
  • you still have some dead bowel but without proper bowel obstruction
74
Q

What are the two types of investigations done for bowel obstruction?

A
  • bloods
  • imaging
75
Q

What bloods are done for bowel obstruction and what would we see? (4)

A
  • WCC/CRP - usually normal (if raised, suspicion of strangulation/perforation)
  • U&E - electrolyte imbalance e.g. vomiting
  • VBG if vomiting - hypoCl-, hypoK+ metabolic alkalosis
  • VBG if strangulation - metabolic acidosis (lactate)
76
Q

What imaging modalities are done for bowel obstruction? (2)

A
  • erect CXR / AXR
  • CT abdo/pelvis
77
Q

What do we see in erect CXR/AXR for small bowel obstruction?

A
  • ladder pattern of dilated small bowel loops >3cm proximal to the obstruction (central position)
  • striations that pass completely across the width of the distended loop produced by circular mucosal folds
78
Q

What do we see in erect CXR/AXR for large bowel obstruction?

A
  • dilated large bowel >6cm (if caecum >9cm), tends to lie predominantly peripherally
  • show haustrations of taenia coli that do not extend across the whole width of the bowel
79
Q

Why do we do CT pelvis/abdo for bowel obstruction? (5)

A
  • can see transition point (helps with surgery)
  • can see dilatation of proximal loops - give IV or oral contrast if possible
  • can localise site of obstruction
  • can detect obstructing lesions and colonic tumours
  • may diagnose unusual hernias (e.g. obturator hernia)
80
Q

When can we do supportive/conservative treatment for patients with bowel obstruction?

A

When they have no signs of ischaemia / clinical deterioration

81
Q

What supportive management is there for bowel obstruction? (4)

A
  • NBM, IV peripheral access with large bore cannula - IV fluid resuscitation
  • IV analgesia, IV antiemetics, correction of electrolyte imbalances
  • NG tube for decompression (also removes problem of aspiration pneumonia), urinary catheter for monitoring output
  • introduce gradual food intake if abdominal pain and distension improve
82
Q

What conservative treatment is there for bowel obstruction? (3)

A
  • faecal impaction - stool evacuation (manual, enemas, endoscopic)
  • sigmoid volvulus - rigid sigmoidoscopic decompression
  • small bowel obstruction - oral gastrograffin (highly osmolar iodinated contrast agent) can be used to resolve adhesional small bowel obstruction
    • when you have small bowel adhesion the more fluid you pump in the more it twists so if you decompress and suck fluid out it has a chance to straighten itself out
83
Q

What are the indications for surgical management of bowel obstruction? (4)

A
  • haemodynamic instability or signs of sepsis
  • complete bowel obstruction with signs of ischaemia
  • closed loop obstruction (intervene before ischaemic)
  • persistent bowel obstruction >2 days despite conservative management
84
Q

What operations are there for bowel obstruction? (3)

A
  • exploratory laparotomy/laparoscopy
  • restoration of intestinal transit (depending on intra-operational findings)
  • bowel resection with primary anastomosis or temporary/permanent stoma formation
85
Q

What do we do with patients with bowel obstruction that are unwell, especially those with tumours?

A

Endoscopic stenting (especially if distal obstruction)

86
Q

How do patients with GI perforation present? (6)

A
  • sudden onset severe abdominal pain associated with distention
  • pain aggravated by movement (lie very still)
  • diffuse abdominal guarding, rigidity, rebound tenderness
  • nausea, vomiting, absolute constipation (ileus of chemical irritation)
  • fever, tachycardia, tachypnoea, hypotension
  • decreased or absent bowel sounds
87
Q

What are the four causes/types of GI perforation?

A
  • perforated peptic ulcer
  • perforated diverticulum
  • perforated appendix
  • perforated malignancy
88
Q

How does perforated peptic ulcer present? (3)

A
  • sudden epigastric or diffuse pain
  • referred shoulder pain (phrenic nerve innervates diaphragm and right shoulder)
  • Hx of NSAIDs, steroids, recurrent epigastric pain
89
Q

How does perforated diverticulum present? (2)

A
  • LLQ pain (insidious onset)
  • constipation
90
Q

How does perforated appendix present? (3)

A
  • migratory pain
  • anorexia
  • gradual worsening RLQ pain
91
Q

How does perforated malignancy present? (4)

A
  • change in bowel habit
  • weight loss
  • anorexia
  • PR bleeding
92
Q

What are the two types of investigations we do for GI perforation?

A
  • bloods
  • imaging
93
Q

What bloods do we do for GI perforation and what would we see? (3)

A
  • FBC - neutrophilic leukocytosis
  • possible elevation of urea and creatinine
  • VBG - lactic acidosis
94
Q

What imaging do we do for GI perforation? (2)

A
  • erect CXR - subdiaphragmatic free air (pneumoperitoneum) = perforation!!
  • CT abdo/pelvis - pneumoperitoneum, free GI content, localised mesenteric fat stranding, can exclude common differentials like pancreatitis
95
Q

What differentials are there with the same symptoms as GI perforation? (4)

A
  • acute cholecystitis
  • acute pancreatitis
  • acute appendicitis
  • MI
96
Q

What supportive management (on presentation) is there for GI perforation? (6)

A
  • NBM and NG tube
  • IV peripheral access with large bore cannula - IV fluid resuscitation
  • broad spectrum Abx
  • IV PPIs
  • parenteral analgesia & antiemetics
  • urinary catheter
97
Q

Which patients with GI perforation do we do conservative management in?

A

In patients with localised peritonitis without signs of sepsis - very rare, most patients will need surgery

98
Q

What conservative management is there for GI perforation? (2)

A
  • interventional radiography (IR) - guided drainage of intra-abdominal collection
  • serial abdominal exams and abdominal imaging for assessment to look at changes
99
Q

What patients with GI perforation do we do surgical management in?

A

Patients with generalised peritonitis +/- signs of sepsis

100
Q

What surgical management options are there for GI perforation? (6)

A
  • exploratory laparotomy/laparoscopy
  • primary closure of perforation +/- omental patch (most common in perforated peptic ulcer)
  • resection of the perforated segment of the bowel with primary anastomosis or temporary stoma
  • obtain intra-abdominal fluid for MC&S, peritoneal lavage ++++
  • if perforated appendix - lap or open appendicectomy
  • if malignancy - intra-operative biopsies if possible
101
Q

What are the symptoms of biliary colic? (2)

A
  • post prandial RUQ pain with radiation to shoulder
  • nausea
102
Q

What are the investigations for biliary colic? (2)

A
  • normal blood results
  • USS - cholelithiasis
103
Q

What is the management for biliary colic? (2)

A
  • conservative - analgesia, anti-emetics, spasmolytics
  • follow up for elective cholecystectomy
104
Q

What are the symptoms of acute cholecystitis? (3)

A
  • acute, severe RUQ pain
  • fever
  • Murphy’s sign
105
Q

What are the investigations for acute cholecystitis? (2)

A
  • elevated WCC/CRP
  • USS - thickened gallbladder wall
106
Q

What is the management for acute cholecystitis? (2)

A
  • fluids, Abx, analgesia, blood cultures
  • early (<72h) or elective cholecystectomy (4-6 weeks)
107
Q

What are the symptoms of acute cholangitis?

Stone –> CBD (blocks liver outflow)

A

Charcot’s triad - jaundice, RUQ pain, fever

108
Q

What are the investigations for acute cholangitis? (2)

A
  • elevated LFTs, WCC, CRP, blood MC&S (+ve)
  • USS - biliary dilatation
109
Q

What is the management for acute cholangitis? (2)

A
  • fluids, IV Abx, analgesia
  • ERCP (within 72h) for clearance of bile duct or stenting
110
Q

What are the symptoms of acute pancreatitis? (3)

A
  • severe epigastric pain radiating to the back
  • nausea +/- vomiting
  • Hx of gallstones or alcohol use
111
Q

What are the investigations for acute pancreatitis? (3)

A
  • raised amylase/lipase
  • high WCC/low Ca2+
  • CT and US to assess for complications/cause
112
Q

What is the management for acute pancreatitis? (4)

A
  • admission score (Glasgow-Imrie)
  • aggressive fluid resuscitation, O2
  • analgesia, antiemetics
  • ITU/HDU involvement
113
Q

What are the two commonest causes of small bowel obstruction?

A
  • previous abdominal operation
  • strangulated external hernia
114
Q

What is obstruction of small bowel usually accompanied by (compared to large bowel)?

A

Early and profuse vomiting (tends to be late or absent in large bowel obstruction)

115
Q

What is a feature of large bowel obstruction that may not be present in small bowel obstruction?

A

Grossly distended abdomen due to size of the large bowel therefore distension is usually marked

116
Q

What appearances on chest X-ray are typical of volvulus of the sigmoid colon? (2)

A
  • enormously distended oval gas shadow, looped on itself to give typical ‘bent inner-tube sign’ or ‘coffee bean sign’
  • haustrae do not extend across the width of the gas shadow, suggesting large intestine
117
Q

What conservative management is effective in treating the majority of patients with a sigmoid volvulus?

A
  • 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 and liquid faeces
118
Q

What is the risk of leaving sigmoid volvulus untreated?

A

The loop of sigmoid, with its blood supply cut off by torsion, can undergo necrosis

119
Q

For sigmoid volvulus, what is the next step if a flatus tube fails?

A

Exploratory laparotomy and sigmoid colectomy with end colostomy (Hartmann’s procedure)

120
Q

What in the history/exam can indicate acute mesenteric ischaemia? (7)

A
  • elderly patient who is an ex-smoker (increased risk of CVD)
  • short history (e.g. 1 day Hx)
  • central pain with guarding
  • no previous abdominal scar or hernia
  • no bowel sounds
  • poor general condition
  • increased serum lactate
121
Q

What can CTAP with contrast show in acute mesenteric ischaemia? (3)

A
  • thrombus in mesenteric arteries and veins (normal flow white, thrombus grey)
  • abnormal enhancement of bowel wall
  • presence of embolus or infarction of other organs
122
Q

How would you manage a patient with acute mesenteric ischaemia and what are the goals of this?

A

Emergency exploratory laparotomy

  • restoration of SMA blood flow
  • resection of non-viable bowel
123
Q

What is done in an exploratory laparotomy for acute mesenteric ischaemia?

A
  • midline incision
  • evaluate the abdominal viscera
  • if obvious intestinal necrosis - resection of the affected bowel loops
124
Q

What is done in a damage control laparotomy for acute mesenteric ischaemia?

A
  • stapled off bowel ends may be left in discontinuity
  • re-inspect after a period of continued ICU resuscitation to restore physiological balance
125
Q

How do we restore blood flow to the SMA in acute mesenteric ischaemia? (3)

A
  • embolectomy of SMA - in embolic AMI
  • endovascular management of SMA thrombus - in thrombotic AMI
  • arterial bypass of SMA - in thrombotic AMI
126
Q

What are the arterial causes of acute mesenteric ischaemia? (3 main types)

A
  • embolism (50%) - sources:
    • from left auricle - atrial fibrillation
    • mural infarct
    • atheroma from aorta or aneurysm
    • endocarditis vegetations
    • left atrial myxoma
  • thrombosis (20-35%)
    • blocks origin of SMA and can cause ischaemia of full length of small bowel
    • due to atherosclerosis - often all main splanchnic vessels - coeliac, superior and inferior mesenteric arteries
  • nonocclusive (<5%)
    • due to hypotension/hypoperfusion
    • due to vasospasm in shock –> nonocclusive mesenteric ischaemia (NOMI)
    • critically ill patients with vasopressor requirements
    • those undergoing dialysis with large volume fluid removal
127
Q

What are the venous causes of acute mesenteric ischaemia?

A

Superior mesenteric vein thrombosis:

  • occurs in patients with:
    • portal hypertension
    • portal pyaemia
    • sickle cell disease
  • related to the presence of an underlying hypercoagulable state
128
Q

What is portal pyaemia (pylephlebitis)?

A
  • form of septic (often suppurative) thrombophlebitis of the portal venous system
  • complication of intra-abdominal sepsis
    • diverticulitis
    • appendicitis

Year 2 - BRS (84 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions