Acute care- Gastro Flashcards
Where is McBurney’s point? What is the significance of this?
2/3s of the way from umbilicus to ASIS
Site of max. pain in appendicitis
3 peritoneal signs specific for acute appendicitis
Rovsing’s Sign: palpation of LIF causes more pain in RIF
Psoas Sign: pain on extending hip (caused by retrocaecal appendix)
Obturator Sign: pain on flexion + internal rotation of hip (occurs if appendix in close proximity to obturator internus)
Which additional examinations should be considered in suspected appendicitis?
Scrotal + groin exam: ?hernia/ testicular torsion
Pelvic exam: ?ectopic
What investigations may be performed in appendicitis?
FBC: leucocytosis
CRP: high
Urine dip: r/o UTI
Pregnancy test: r/o ectopic
Which imaging modalities may be used in appendicitis?
Thin males: clinical dx
USS: r/o pelvic organ pathology in females
CT: if diagnostic uncertainty
Describe management for appendicitis
NBM
Analgesia IV
Laparoscopic appendicectomy
Prophylactic Abx: IV Ceftriaxone + Metronidazole
most common causes of SBO?
ADHESIONs
Incarcerated hernias
most common causes of LBO?
TUMOURS
Diverticular disease
Volvulus
5 symptoms of intestinal obstruction
Severe abdo pain
Abdo distension
N+V (may be bile-stained or faeculent)
Absolute constipation
Decreased/ tinkling bowel sounds
4 signs of bowel obstruction
Dehydration +/- hypovolemia (hypotension, dry mucous membranes)
Diffuse abdominal tenderness
Tympanic percussion
Tinkling/ absent bowel sounds
What is complicated bowel obstruction?
BO a/w strangulation, ischaemic necrosis or perforation
Describe initial management in suspected BO
A-E approach
Obtain IV access
IV fluid resus +/- electrolytes
NBM
NG tube with free drainage
Analgesia
Antiemetics
Obtain imaging
Describe choice of imaging modality in suspected BO
Stable: CT AP with IV contrast (definitive, GS)
Unstable: AXR
Describe imaging in SBO
Dilated bowel >3cm, predominantly central
VALVULAE CONNIVENTES (completely cross the lumen)
No gas in large bowel
Air-fluid level
Describe imaging in LBO
Dilated bowel >6cm or >9cm if at caecum
Dilated loops predominantly peripheral
HAUSTRA which don’t cross whole lumen width
Air-fluid level
Describe what management of BO depends on
Urgency of Mx depends on whether perforation is suspected
If cause of obstruction itself does not require surgery, conservative Mx for 72h can be trialled
What further management may be required in BO?
IV abx if perforation suspected/ surgery planned
Exploratory laparotomy: irrigation, resection + address underlying cause
In which cases is surgical management considered for BO?
Complicated BO
Closed loop obstruction
Strangulation
Haemodynamic instability not responding to fluids
Underlying cause necessitates e.g. tumour
Refractory to conservative Mx
Which obstructions can be managed conservatively (at least initially)?
Post-op ileus
Partial BO
What bloods should be taken in suspected intestinal obstruction?
FBC: high WCC, anaemia in Ca
CRP: HIGH
U+E’s: deranged due to vomiting
Glucose (Exclude DKA)
G+S
Mx of SBO
NBM
IV fluids
NG tube with free drainage
Some settle with conservative Mx, but otherwise will require surgery
% of LBO requiring surgery
75%
3 presenting features of upper GI bleed
Haematemesis
Melena
Raised urea (protein meal of blood)
4 oesophageal causes of upper GI bleed
Oesophageal varicies
Oesophagitis
Cancer
Mallory weiss tear
Describe upper GI bleeds due to oesophageal varicies
May have associated stigmata of chronic liver disease
Usually large vol of fresh blood.
Swallowed blood may cause melena.
Often a/w haemodynamic compromise.
May stop spontaneously but re-bleeds are common until appropriately managed.
Describe upper GI bleeds due to oesophagitis
Small vol fresh blood, often streaking vomit.
Malena rare.
Often ceases spontaneously.
Usually hx of antecedent GORD type Sx
Describe upper GI bleeds due to oesophageal cancer
Usually small vol blood, except as a pre-terminal event with erosion of major vessels.
Often associated Sx of dysphagia + constitutional Sx e.g. WL
May be recurrent until malignancy managed.
Describe upper GI bleeds due to Mallory Weiss tears
Typically brisk small-mod vol of bright red blood following a bout of repeated vomiting.
Malena rare.
Usually ceases spontaneously.
List 4 gastric causes of upper GI bleeds
Gastric ulcer
Gastric cancer
Dieulafoy lesion
Diffuse erosive gastritis
Describe upper GI bleeds due to gastric ulcers
Small low vol bleeds are more common so tend to present as IDA.
Erosion into a significant vessel may produce considerable haemorrhage + haematemesis.
Describe upper GI bleeds due to Gastric cancer
Frank haematemesis or altered blood mixed with vomit.
Prodromal features of dyspepsia + may have constitutional Sx.
Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage.
Describe upper GI bleeds due to Dieulafoy lesion
Often no prodromal features prior to haematemesis + melena
AV malformation
May produce quite a considerable haemorrhage
May be difficult to detect endoscopically
Describe upper GI bleeds due to Diffuse erosive gastritis
Haematemesis + epigastric discomfort.
Usually underlying cause e.g. recent NSAID usage.
Large vol haemorrhage may occur with considerable haemodynamic compromise
Name 2 duodenal causes of upper GI bleeds
Duodenal ulcer
Aorto-enteric fistula
Describe upper GI bleeds due to Duodenal ulcers
Usually posteriorly sited + may erode the gastroduodenal artery.
Ulcers at any site in the duodenum may present with haematemesis, melena + epigastric discomfort.
Describe upper GI bleeds due to Aorto-enteric fistulas
In those with previous AAA surgery
Rare but important cause of major haemorrhage a/w high mortality.
Describe risk assessment in upper GI bleeds
Glasgow-Blatchford score: 1st
Helps decide whether patients can be managed OP
Rockall score: AFTER endoscopy
Provides % risk of rebleeding + mortality
inc. age, features of shock, co-morbidities, aetiology of bleeding + endoscopic stigmata of recent haemorrhage
Describe resuscitation in an upper GI bleed
A-E.
Site 2x wide-bore IV cannula
Platelet transfusion if actively bleeding platelet count of <50 x 10*9/litre
FFP if fibrinogen level of <1 g/L, or PT (INR) or APTT >1.5x normal
PCC to those on warfarin + actively bleeding
Describe use of endoscopy in an upper GI bleed
Offer immediately after resus in those with a severe bleed
All should have endoscopy within 24h
Mx of non-variceal bleeding
PPIs given if stigmata of recent haemorrhage on endoscopy
If further bleeding; repeat endoscopy or IR or surgery
Mx of variceal bleeding
Terlipressin + PPX Abx at presentation (pre-endoscopy)
Band ligation for oesophageal varices
Injections of N-butyl-2-cyanoacrylate for gastric varices
Sengstaken-Blakemore tube if uncontrolled haemorrhage
Transjugular intrahepatic portosystemic shunts (TIPSS) offered if bleeding from varices is not controlled with the above
What is TIPSS? Name a common complication
Connects hepatic vein to portal vein
Cx: exacerbation of hepatic encephalopathy
What can be used for prophylaxis of variceal haemorrhage?
Propranolol
Endoscopic variceal band ligation (if cirrhosis + med-large varicies)
