Abdominal Flashcards
Persistence of the Vitello-Intestinal Duct
Vitelline Fistual (meconium through umbilicus)
Proximal part only = Meckel’s Diverticulum
Does not communicate with ileum = Enterocystoma
Persistent umbilical portion of the duct, which forms a polypoidal raspberry-like tumour of the umbilicus = Entroteratoma
Meckel’s Diverticulum
Remnant of vitello-intestinal duct
Asymptomatic : ileal mucosa
Symptomatic: Gastric
Located on anti mesenteric border of the ileum
2% (of the population)
2 feet (proximal to the ileocecal valve)
2 inches (in length)
2 types of common ectopic tissue (gastric and pancreatic)
2 years is the most common age at clinical presentation
2:1 male:female ratio
Complications:
Bleeding
Obstruction
Hernia (Littre’s)
Diverticulitis
Neoplastic change
Urachus
Urachus is a fibrous remnant of the allantois, a canal that drains the urinary bladder of the fetus that joins and runs within the umbilical cord.
Runs from apex of the bladder to the umbilicus
Normally obliterated
Persistence can cause:
-Discharging umbilicus sinus
-Cyst
-Urinary fistula
Umbilical Sepsis
Neonatal
Causes serious complications:
-Portal thrombophlebitis
-Liver abscess
-Jaundice
-Portal vein thrombosis
-Liver failure
Adults
Caused by retention of sebum within folds of umbilicus or from pilonidal sinus infection of umbilicus
Erythematous
Mixed staphylococcus and streptococcus growth
Haematoma of the rectus sheath
Spontaneous rupture of a branch of the inferior epigastric artery –> haematoma in rectus sheath
Presents as abdominal pain + rigidity on one side
More common in elderly people on anticoagulation
USS used to Dx
Mx: Conservative or drainage if problematic
Desmoid Tumour
Rare tumour of fibrous intra-muscular septa in the lower rectus abdominis
More common in females CBA
Associated with Gardener’s syndrome (AD polyposis with intra colic and extra colic tumours)
Mx: excised widely as high recurrence and can undergo malignant transformation (fibrosarcoma)
Littre’s Hernia
Hernia of Meckel’s Diverticulum
Richter’s Hernia
Hernia only involving part of the circumference of the bowel wall
Do not present with usual obstructive features
May present with ileum due to peritonism caused by necrotic bowel
Amyand’s Hernia
Hernia of incarcerated appendix
Sliding inguinal hernia
Herniating viscus forms part of the of the wall of the hernia sac
Pantaloon Hernia
Direct and indirect inguinal hernia
Hernias straddle inferior epigastric artery with bulges either side
Borders of the Inguinal Canal
Anterior: External oblique aponeurosis
Lateral 1/3: +Internal oblique
Floor: Inguinal ligament
Reinforced by lacunar ligament medial end
Posterior: Transversalis fascia
Roof: Internal oblique, transversis abdominis (and transversalis fascia)
Location of Deep Inguinal Ring
1cm above the Mid-point of the inguinal ligament
1/2 way along the inguinal ligament that arises at the ASIS and inserts on the pubic tubercle
Bound medially by inferior epigastric artery
Deep ring is defect in the transversalis fascia
Location of the Superficial Inguinal Ring
Just above and medial to the pubic tubercle
Defect in external oblique aponeurosis
Reinforced by medial and lateral crura
Contents of the Inguinal Canal
M: Spermatic Cord
F: Round ligament
Ilioinguinal nerve
-Doesn’t enter through the deep ring
-At -risk during hernia repair
-Sensation to external genitalia
Genital branch of the the genitofemoral nerve
-Supplies crmaster muscle
-Anterior scrotal skin / mons pubis + labia majora
Coverings of the spermatic cord
Embryologically, takes a covering from each layer of the abdominal wall
Transversalis fascia –> Internal spermatic fascia
Internal oblique –> cremasteric muscle and fascia
External oblique –> external spermatic fascia
Contents of the spermatic cord
Spermatic cord contents “3 arteries, 3 nerves, 3 other things”:
3 arteries:
1. Testicular artery (branch of aorta on R, branch of renal artery L)
2. Deferential artery (artery to the ductus deferens)
3. Cremasteric artery (branch of inferior epigastric)
3 nerves:
1. Genital branch of the genitofemoral
2. Cremasteric nerve
3. Autonomics.
3 other things:
Ductus deferens
Pampiniform plexus
Lymphatics
Ilioinguinal nerve
Hernia passes above and medial to pubic tubercle
INGUINAL HERNIA
Hernia passes below and lateral to pubic tubercle
FEMORAL HERNIA
Hesselbach’s Triangle
Medial: lateral border of the rectus abdominis
Lateral: Inferior epigastric artery
Below: Inguinal ligament
(Above: Conjoint tendon)
Managemet of uncomplicated inguinal hernia
Neonate –> emergency
Children –> elective herniotomy
Symptomatic adults –> offered surgery
Indications for laparoscopic hernia repair
Bilateral hernias for repair
Recurrent hernia
Exploration of the groin when a symptomatic
hernia is suspected from
Age at which conservative management for umbilical hernia is switched to surgical management:
3 years
-95% resolve by then
Surgery to correct para-umbilical hernia
Mayo procedure
-Flap of rectus sheath and line alba above and below defect
Foramen of Winslow
foramen, between the greater sac (general cavity of the abdomen)
and the lesser sac
anterior: the free border of the lesser omentum, known as the hepatoduodenal ligament. This has two layers and within these layers are the common bile duct, hepatic artery, and hepatic portal vein. A useful mnemonic to remember these is DAVE: Duct, Artery, Vein, Epiploic foramen.
posterior: the peritoneum covering the inferior vena cava
superior: the peritoneum covering the caudate lobe of the liver
inferior: the peritoneum covering the commencement of the duodenum and the hepatic artery, the latter passing forward below the foramen before ascending between the two layers of the lesser omentum.
left lateral: gastrosplenic ligament and splenorenal ligament
Visceral referred pain from the abdominal cavity
Foregut: lower oesophagus to second part of duodenum –> Epigastric
Midgut: second part of duodenum to to splenic flexure –> Umbilicus
Hindgut: Splenic flexure to rectum –> Hypogastrium
Boas’s sign
In acute cholecystitis, pain radiates to the tip of the scapula and there is a tender area of skin just below the scapula, which is hyperaesthetic.
Causes of Raised Amylase
Pancreatic conditions
• Acute pancreatitis
• Pancreatic cancer
• Pancreatic trauma
Other intra-abdominal pathology
• Perforated peptic ulcer
• Acute appendicitis
• Ectopic pregnancy
• Intestinal infarction
• Acute cholecystitis
Decreased clearance of amylase
• Renal failure
• Macroamylaseaemia
Miscellaneous
• Head injury
• Diabetic ketoacidosis
• Drugs (e.g. opiates)
Causes of free sub-diaphragmatic gas
• Perforation of an intra-abdominal viscus
• Gas-forming infection
• Pleuroperitoneal fistula
• Iatrogenic: laparoscopy, laparotomy
• Gas introduced per vaginam: post-partum
• Interposition of bowel between liver and diaphragm
Common Sites for Intra-Abdominal Abscess
Subphrenic space
Subhepatic space
Pelvis
Between loops of bowel
‘pus somewhere, pus nowhere else, pus under the diaphragm’.
Anatomy of the Appendix
Blind ended tube situation on the posteromedial aspect of the caecum 2cm below the ileocaecal valve
Average 6-9cm in length
Found at the convergence of the three taenia coli
Has its own mesentry - mesoappendix
Supplied by the appendicular artery which is a branch if the ileocolic artery
Appendix Mass or Abscess
Mx Non-Operative as long as no peritonitis
Antibiotics and percutaneous drainage if abscess
Colonoscopy at 6 weeks to rule out malignancy
Appendix positions
Retrocaecal
Pelvic
Subcaecal
Paracaecal
Pre-ileal
Post-ileal
Pelvic most common on laparoscopy
Retrocaecal most common on cadaveric
Stimulants for release H2 from parietal cells
Vagus nerve acetylcholine
Gastrin
Inhibition of H2 from parietal cells
Somatostatin
Gastric inhibitory peptide
Vasoactive intestinal peptide (VIP)
Pepsin Cells
Found in body and fundus of stomach
Produce Pepsinogen
–> Pepsin
Stimulated by acteylcholine from vagus nerve
Nissen Fundoplication
Hiatus hernia reduced
Crura approximated
Fundus mobilised from underside of diaphragm
Fundus wrapped posteriorly around lower oesophagus and attached to left side of proximal stomach (360 wrap)
Others:
Toupet: 270
Watson: 180
Components of lower oesophageal sphincter
Physiological high pressure area in lower oesophagus
Mucosal rosette of the cardia
Angle of oesophagus as it meets the cardia - Angle of His
Diaphragmatic sling / crura
Positive intra-abdominal pressure at lower end of oesophagus
Hiatus hernia
Sliding: 90%
Stomach slides through diaphragmatic hiatus, grastro-oesophageal junction lies in thorax
–> Lower sphincter incompetent
Rolling: 10%
Para-oesophageal
Cardia remains below diaphragm: sphincter competent
Stomach rolls up anteriorly through hiatus
(Mixed)
Ivor Lewis Oesophagectomy
Two stages
Laparotomy
Stomach fully mobilised on vascular pedicle
Left gastroepiploic and gastric artery divided
Right thoracotomy
Oesophagectomy
Bring up stomach
Anastomasois
Feeding jejunostomy
Trans-hiatal Oesophagectomy
Abdominal incision
Mobilise oesophagus through hiatus
Cervical oesophagus by left neck incision
Pharyngeal Pouch
Killian’s Dehiscence
Between thyropharyngeus and cricopharyngeus
Posterior pharyngeal pouch
Mx: Endoscopic stapling
Heller’s Myomotomy
Lower oesophageal sphincter divided 5c, above junction and 3cm below
+Anterior partial fundoplication to reduce subsequent GORD
Achalasia
Failure of relaxation of lower oesophageal sphincter and associated ineffective peristalsis
Degeneration of myenteric plexus of Auerbach
Mx
Balloon dilatation
Surgical: Heller’s
Management of diffuse oesophageal spasm
Calcium channel blockers
Sublingual GTN
PPI
Causes of peptic ulcers
H.Pylori
NSAIDs
Smoking
Zollinger-Ellison syndrome
Hyperparathyroidism –> hypercalcaemia
Blood group O
Surgical management of gastric ulcers
Failure to heal with medical therapy –> indication for surgery
Benign distal ulcers: Billroth I gastrectomy
-Distal stomach removed and proximal stump anastomosed with duodenum
Proximal ulcers: Polya-Type reconstruction
- Anastomosis of gastric remnant to jejunum
Complications of Gastrectomy
Dumping
-Early
-Late
Diarrhoea
Anaemia
Osteoporosis + Osteomalacia
Nutritional deficiencies
Carcinoma
-Reflux of bile salts
-Should be offered endoscopic surveillance
GIST
Dx: EUS
<2cm –> discharge
2-5cm –> surveillance
> 5cm –> resect
Meneteriers Disease
Gastric mucosal hypertrophy
Mucosal folds in body and fungus grossly enlarged
Leads to over-secretion of acid and mucus
Increased risk of malignancy –> prophylactic gastrectomy
Dumping
Early: True
15-30 minutes post meal
Vasomotor symptoms
Tachycardia
Flushing
Light-headedness
Sweating
–> Rapid emptying of hyperosmolar (mainly carbohydrates) into small bowel
–> Influx of fluids down osmotic gradient
Late
4 hours
–>Reactive hypoglycaemia
Zollinger-Ellison Syndrome
Gastrinoma
Normally in pancreas but can be in duodenum or stomach
MEN 1: 30%
Present with diarrhoea and pain
–> Peptic ulceration
Liver surface anatomy
5th intercostal down to right costal margin
Extends to left mid-clavicle
Bilirubin level of clinical jaundice
50
Right Hepatic and Right portal vein supply
Right hemiliver
Lobes V - VIII
Left Hepatic and Left portal vein supply
Left hemiliver
I –> Caudate
II and III –> Left lobe
IV –> Quadrate
Causes of portal hypertension
Pre-Hepatic
Congenital atresia of portal vein
Portal vein thrombosis: Neonatal Sepsis, Pyelophlebitis, Trauma, Tumour
Extrinsic compression: Pancreatic, Biliary
Hepatic:
Cirrhosis
Schistosomiasis
Post-Hepatic:
Budd-Chiari syndrome
Cosntrictive pericarditis
(Increased blood flow due to arteriovenous fistula or hyperspenlism)
Hydatid Cyst
Tapeworm infection:
Echinococcus granulosus
E. Multiocularis
Adult tapeworm lives in intestine of dog
Ingested ova hatch in duodenum –> portal venous sytem
Leads to cyst with a surrounding fibrosis of the adventitial layer
Rupture can lead to anaphylaxis
Eosinophilia
Mx: Mebendazole
Pyogenic liver abscess pathogens
Strep milleri
E.coli
Strep faecalis
Staph aureus
Anaerobes
Amoebic liver abscess
Entamoeba histolytica
Intestine –> trophozoites –> portal vein –> Liver
Right lobe ascess with thin-walles
Solitary
Stool: Ameobae cysts
Mx of Acites
Spironolactone
Fluid restriction and Salt restriction
+/- LeVeen shunt for refractory ascotes
Peritoneum –> external jugular
Budd Chiari
Portal HTN
Caudate hypertrophy
Liver failure
Gross ascites
Compenents of Child Score
Encephalopathy
Ascites
Bilirubin
Albumin
Prothrombin ratio
Antibiotic prophylaxis in Varices
Ciprofloxacin 500mg BD
Diagnosis of HCC
If resection planned do NOT biopsy
Diagnosis
Two imaging modalities showing arterial hypervascularisation (regardless of AFP)
OR
Single modality showing lesion + AFP >400
OR
Histological diagnosis <2cm