Acute GI Flashcards
What are the classical presentation of appendicitis
- young patient
- Acute onset
- umbilical pain that moves to the right iliac fossa
What are the signs of appendicitis
- Rovsing’s sign:
palpation of the LIF causes more pain in the RIF - Cope’s sign: pain of passive flexion and internal rotation of the hip
- Psoas sign: pain on extending hip
- Rebound tenderness: sign of peritonitis
What are the investigations for appendicitis
- Bloods - leukocytosis + raised CRP
- USS
- CT - very sensitive but takes time
What is the treatment of appendicitis
appendectomy
What is the surgical scar left after an appendectomy
McBurney’s incision
What are the antibiotics that are used as prophylaxis in appendicectomy
- metronidazole
2. cefuroxime
What are the complications of appendicitis
- peroforation
- appendix mass - inflamed appendix becomes covered in omentum and forms a mass
- appendix abscess
A nervous 16-year-old college student attends the local A&E department with her boyfriend, complaining of an episode of sudden onset right-sided pain in her abdomen. Physical examination of the patient is unremarkable except from a small scar located near the inguinal ligament. What is the most appropriate first line investigation in this case?
USS of the abdomen 𝞫-hCG test Full blood count CT scan of the abdomen No investigations, immediate surgery
𝞫-hCG test
A 26-year-old professional rugby player presents to the A&E department with abdominal pain in the umbilical area. On initial inspection, the gentleman is feverish with a temperature of 38C and a BP of 115/90. The admitting doctor suspects a diagnosis of appendicitis from the history and performs an abdominal physical examination and passively extends the gentleman’s right hip which elicits pain. Which eponymous sign of appendicitis is being demonstrated here and what does it represent?
Cope’s sign, and a retrocaecal appendix
Psoas sign, and a retrocaecal appendix
Psoas sign, and an appendix located next to obturator externus
Rovsing’s sign, and a retrocaecal appendix
Rovsing’s sign, and an appendix located next to obturator externus
Psoas sign, and a retrocaecal appendix
What is diverticulosis
presence of diverticulae outpouching of the colonic mucosa and submucosa throughout the large bowel
What is diverticular disease
the complications of diverticulosis
What is diverticulitis
acute inflammation and infection of diverticulae
What are the common presentation for diverticular disease
- bloody stool
- LIF pain
- fever
On general inspection, the patient is absolutely still, what does that suggest
peritonitis
What are the investigations for acute diverticular disease
- CT
2. Flexible sigmoidoscopy +/- colonoscopy
What are the investigations for chronic diverticular disease
- barium enema
2. Flexible sigmoidoscopy +/- colonoscopy
What is the management for acute diverticulosis
- IV hydration
2. bowel rest
What is the management of diverticular disease
- soluble high fibre diet
2. anti-inflammatories (mesalazine)
Diverticular disease: What is recommended if a patient has recurrent attacks or complication
Surgery
Hartmann’s
primary anastomosis
What is Hartmann’s procedure
removal of the diseased bowel and end-colostomy formation with a anorectal stump
This is used when primary anastomosis (immediate joining) is not possible
What are the complications of diverticular disease
- diverticulitis
- faecal peritonitis
- fistula
- peri-colic abscess
- colonic obstruction
- perforation
A feverish 56-year-old woman attends her GP complaining of a sudden appearance of bloody stools. She adds that she has experienced a few episodes of bloody stools before but did not seek medical attention and apart from a fever, she has had no other constitutional symptoms. The GP notes that the patient’s diet is particularly low in fibre and on physical examination, tenderness is found on pressure to the LIF. A DRE shows fresh blood upon removal of a gloved finger. What is the most likely diagnosis?
Angiodysplasia Diverticulosis Diverticulitis Mallory-Weiss tear Gastroenteritis
Diverticulitis
What are constitutional symptoms
FLAWSV Fever Lethargy Appetite changes Weight loss Night sweats Vomiting & nausea
A feverish 65-year-old is brought to the local A&E department by her daughter. She complains about nausea, LIF pain and vomiting. The attending doctor takes a full history and performs an abdominal examination and subsequently makes a diagnosis of acute diverticulitis with some associated signs of peritonism. A erect AXR is taken which shows some air under the diaphragm. What is the most appropriate surgical procedure?
Hartmann’s procedure Primary anastomosis Colectomy and end-ileostomy formation Delorme’s procedure Whipple’s procedure
Hartmann’s procedure
What are the risk factors for hernia
- age
- obesity
- constipation
- chronic cough
- heavy lifting (gym)
What are the classical presentation of a hernia
- lump in groin
- groin pain
- vomiting
- scrotal swelling
What are the features of femoral hernia
lateral & inferior to pubic tubercle More common in females more commonly strangulated surgery recommended Older patients
What are the features of inguinal hernia
superior and medial to pubic tubercle common is males less commonly strangulated can be treated without surgery younger patients
What are signs of a strangulate hernias
tender red colicky abdominal distension vomiting
How do you determine the difference between the a direct and indirect inguinal hernia
- reduce the hernia
- place finger over deep inguinal ring (just above the midpoint of the inguinal ligament)
- Ask the patient to cough and if the hernia re-appear, it cannot be an indirect hernia
What is the first investigation for hernias
USS
A 26-year-old bodybuilder attends the local day-surgical clinic upon referral from his GP due to a groin lump. The general surgical registrar suspects a hernia and so performs a simple test to ascertain the type of hernia to determine the most appropriate management. The doctor reduces the hernia and then places their finger over the deep inguinal ring. The patient is asked to cough and the hernia does not reappear. What is the most likely type of hernia?
Femoral hernia Direct inguinal hernia Indirect inguinal hernia Spigelian hernia Hiatus hernia
Indirect inguinal hernia
What is the classical presentation of pancreatitis
- epigastric pain
- pain relieved by sitting forward
- pain radiates to the back
- pain worst on movement
What are the causes of pancreatitis
I GET SMASHED Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune disease Scorpion sting Hypertriglyceride + hypercalcaemia ERCP Drugs (thiazides)
What are the signs of pancreatitis
- epigastric tenderness
- fever
- shock, tachycardia, tachypnoea
- reduced bowel sounds
- Cullens sign
- Grey Turner’s
5 + 6 are signs of retroperitoneal bleeding
What are the investigations fr pancreatitis
- amylase
- USS - gall stones?
- Erect CXR & AXR - pleural effusion?
- CT to exclude other causes
How does the amylase present in chronic pancreatitis
normal
What scoring system is used to measure the severity of pancreatitis
Modified Glasgow Score
>3 = severe
How can the modified Glasgow score be used to measure the severity of pancreatitis
PANCREAS P = PaO2 = <7.9kPa A = age = >55y/o N = neutrophils = >15x10 9/L C = calcium = <2mmol/L R = renal function = urea >16mmol/L E = enzymes = LDH > 6000U/L or AST >200U/L A = albumin = <32g/L S = sugar = >10mmol
What is the management for acute pancreatitis
- NBM
- Drip and suck
- Catheter and NG tube if vomiting
- analgesia + glucose control
- surgical = ERCP
What are the risk factors for chronic pancreatitis
- GET SMASHED
2. mostly alcohol related 70%
What is the classical presentation of chronic bronchitis
- recurrent epigastric pain
- pain relieved by sitting forward
- Weight loss, bloating, steatorrhoea
- pain worse on movement
What are the signs of chronic pancreatitis
- epigastric tenderness
2. Cullen’s + Grey Turner’s
What are the investigations for chronic pancreatitis
- serum amylase is normal
- raise fecal elastase
- AXR pancreatic calcification
- ERCP/MRCP = early: duct dilation, late = duct strictures
Which of the following may be raised in chronic pancreatitis? Amylase Calcium Faecal elastase Albumin Haematocrit
Faecal elastase
Which of the following is not a cause of acute pancreatitis? Mumps Hypocalcaemia Thiazide drugs Trinidad scorpion bite Steroids
Hypocalcaemia
What are the risk factors for intestinal obstruction
- Malignancy
- hernia hx
- surgery hx
What is the classical presentation of intestinal obstruction
- diffuse pain
- constipation
- vomiting
- abdominal distention
What can be seen on general examination of a patient with intestinal obstruction
- abdominal distention
2. pyrexia, sweating (potential perforation or infarction)
What can be heard on auscultation in a patient with intestinal obstruction
- high pitched tinkering bowel sounds
2. absent bowel sounds
What causes bowel obstruction
- strangulated hernia
- volvulus
- inssuscepiton
How do you diagnose intestinal bowel obstruction
Plain AXR and CT
normal bowel follows 3/6/9 rule
What is the treatment for intestinal obstruction
medical treatment: Drip and suck
Surgical treatment: laparotomy
An overweight 65-year-old woman visits her general practitioner with discomfort in her right groin. On examination, the suggestion of a reducible groin lump is noted. She is routinely referred to the surgical outpatient clinic with a possible diagnosis of inguinal hernia. However, two weeks later and before her surgical appointment, she again visits her general practitioner, this time with vomiting, diarrhoea, and colicky abdominal pain. What is the next most appropriate management step?
Administer antibiotics Give IV fluids Insert an NG tube Give IV fluids and insert an NG tube Administer an enema
Give IV fluids and insert an NG tube
what is intestinal ischaemia
impaired blood transfusion to the intestine, resulting in ischaemia of the bowel wall. Also known as acute mesenteric ischaemia.
It can be acute and chronic
What are the risk factors for intestinal ischaemia
- old age
- cardiovascular disease
- AF
- hypotensive state
such as car accidents
What is the presenting symptoms of acute intestinal ischaemia
Triad
- sudden onset diffuse pain
- shock signs
- normal exam
What are the investigations for intestinal ischaemia
- AXR - perforation, megacolon
- Angiography - show blockages
- ECG - look for MI or AF
What are the risk factors for chronic intestinal ischaemia
- old age
- cardiovascular disease
- heart failure
What are the presenting symptoms of chronic intestinal ischaemia
- intermittent claudication
- post-prandial pain (after eating)
- PR bleeding
- weight loss
What are the investigation for chronic intestinal ischaemia
- blood on DRE
- normal abdominal exam
- weight loss o inspection
- AXR
- angiography - show blockages
- ECG - look for MI or AF
A 70-year-old gentleman presents to the A&E department with sudden-onset severe diffuse abdominal pain. Observations are taken in the ambulance which show an irregularly irregular pulse rate of 130 and a blood pressure of 76/60mmHg. An abdominal X-ray is performed as soon as possible which shows the Rigler sign and the physician diagnoses an acute form of mesenteric ischaemia with perforation. What is the most likely cause for the acute onset of the mesenteric ischaemia?
Atherosclerotic disease Embolism Thrombosis Polycythaemia vera Idiopathic
Embolism
