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Gastro > Bowel conditions > Flashcards

Bowel conditions Flashcards

1
Q

Define appendix

A

a prominent lymphoid tissue which regresses with age

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2
Q

What causes appendicitis

What bacteria cause appendicitis

A

Obstruction - fecalith, bezoar, filarial worms, lymphoid hyperplasia
Infection

Enterus vemicularis

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3
Q

Pathogenesis of appendicitis [5]

A
  • Fills with mucous and swell
  • eventually causing thrombosis, occlusion of small vessels and stasis of lymphatic flow.
  • Appendix becomes ischaemic and necrotic
  • Bacteria leak out through walls and pus forms around the appendix.
  • Eventual rupture
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4
Q

Presentation Appendicitis

Symptoms [3]
Signs [5]

A

Symptoms

  • Periumbilical pain that moves to RIF
  • Anorexia - pain usually proceeds any vomiting
  • Usually constipated +/- diarrhea

Signs

  • Tachycardia, fever,
  • furred tongue, foetor
  • lying still, positive cough test
  • Guarding, rebound tenderness,
  • McBurney’s point, Rovsings sign
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5
Q

What is Murphys triad

Investigations: appendicitis [5]

A

Murphys triad
- Pain, vomiting, fever

  • FBC (neutrophilic leucocytosis)
  • CRP
  • Urine test - neutrophils + leucocyte (no nitrites), pregnancy test
  • USS >6cm diameter + rule out gynae
  • CT (not routine)
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6
Q

Appendicitis management
Simple appendicitis [2]
Perforated appendicitis [2]

A

Simple appendicitis: laparoscopic appendectomy, prophylactic IV abx (metronidazole and cefuroxime)

Perforated appendicitis: copious abdominal lavage and appendectomy

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7
Q

What are the differentials for appendicitis [8]

What should you beware in elderly?

A 
Gastroenteritis
IBS, Crohns
Constipation
Peptic ulcer 
UTI 
Ectopic pregnancy
PID
Mesenteric adenitis

Beware of underlying malignancy in elderly

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8
Q

Describe an atypical presentation of appendicitis [2]

A

Retrocaecal retroperitoneal appendix > flank or RUQ pain, PR painful
Can occur in pregnancy

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9
Q

Complications of appendicitis

A
  • Perforation
  • Appendix mass - when inflamed appendix becomes covered in omentum, could also be in tumor
  • Appendix abscess
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10
Q

What is ischaemic colitis [2]

Presentation [3]

A

Ischaemic colitis describes an acute but transient compromise in the blood flow to the large bowel. This may lead to inflammation, ulceration and haemorrhage.
Bloody diarrhea + abdo pain

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11
Q

Where is common site

A

Splenic flexure

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12
Q

How do you Dx [2] and treat [2]

A

CT = 1st line
AXR

Supportive
Surgery if peritonitis / perforation / haemorrhage

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13
Q

What is mesenteric ischaemia?

Aetiology

A

Typically small bowel in contrast to ischaemic colitis

Due to embolism of SMA etc

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14
Q

What are the symptoms [4]

Mesenteric ischemia

A

Sudden onset abdo pain out of proportion of physical exam findings
Rectal bleeding
Diarrhoea
Fever

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15
Q

What are RF for bowel ischaemia / mesenteric [7]

A 
Age
Smoking, Cocaine
Hypertension, DM
Malignancy
Endocarditis, AF** (mesenteric)
Surgery 
Abdominal aneurysm
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16
Q

How do you treat mesenteric ischaemia

A

Urgent surgery - laparotomy

High mortality

17
Q

What is a volvulus [2]

A

Torsion of bowel resulting in a closed loop obstruction that can cause strangulation or incarceration

18
Q

Where is volvulus common

A

Sigmoid

Can occur gastric / caecal

19
Q

What are symptoms of volvulus [3]

Describe presentation of small intestine, caecal, sigmoid

A
  1. Absolute constipation
  2. Abdo pain + bloating
  3. N+V

Small intestine: SBO symptoms
Caecal: LBO symptoms

Sigmoid: sudden left sided abdominal pain with abdominal distention

20
Q

What is bowel volvulus associated with [5]

A

Elderly, Constipation
Neuro: Duchennes / PD
Schizophrenia
Chagas disease

Caecal - preg / adhesions / fistula, Crohns

21
Q

How do you Dx and Rx [3]

A

AXR

Central distended bowel in cecum

22
Q

Tx of volvulus
Caecal [2]
Sigmoid [2]

A

Caecal

  • Laparotomy for resection of affected segment
  • +/- anastomosis

Sigmoid

  • Emergency sigmoidoscopy, rectal tube insertion and
  • Laparotomy for sigmoidectomy +/- anastomosis
23
Q

Gastric volvulus
Aetiology
Risk factors [2]

A

Aetiology: twisting of stomach more than 180 degrees
Risk factors:
- Congenital eg pyloric stenosis
- Acquired (surgery)

24
Q

Gastric volvulus
Symptoms [3]
Ix [2]
Mx [2]

A

Symptoms:

  • Vomiting, pain, failure to pass NGT
  • saliva regurgitation
  • dysphagia

Ix: erect CXR, AXR (gastric dilation, double fluid level)

Mx: resuscitation, laparotomy

25
Q

What is a diverticulum

A

Outpouching of gut wall
Usually at site of entry of arteries
Intraluminal pressure forces mucosa to herniate through gut at weak points

26
Q

Where is common site for diverticulum

A

Sigmoid colon as this is where the luminal pressures are highest

27
Q

What is diverticular disease

What is diverticulosis

A

Symptomatic diverticulum

The state of having diverticula which are asymptomatic

28
Q

What are the symptoms of diverticular disease [7]

A

Pain LLQ
Relieved by defecation
N+V, bloating, flatulence
Altered bowel habit
Dysuria - bladder irritation due to inflamed bowel
PR bleeding
Pneumaturia or faecaluria may suggest colovesical fistula while vaginal passage of faeces or flatus may suggest a colovaginal fistula.

29
Q

What are RF for diverticular disease [5]

A 
Lack of fibre
Age
Obesity
Smoking
NSAID
30
Q

How do you Dx diverticular disease [6]

A

FBC: raised WCC
CRP: raised
Erect CXR: may show pneumoperitoneum in cases of perforation
AXR: may show dilated bowel loops, obstruction or abscesses
CT: this is the best modality in suspected abscesses
Colonoscopy: should be avoided initially due to increased risk of perforation in diverticulitis

31
Q

How do you treat diverticular disease in the community [4]

A

Antibiotics (oral)
Liquid diet
Analgesia

32
Q

What are complications of diverticular disease [5]

A 
Diverticulitis
Haemorrhage
Fistula (colovesical)
Perforation
Peritonitis, Abscess
33
Q

What is diverticulitis

A

Inflammation of a diverticulum

Beware in immunocompromised who present late

34
Q

What are signs of diverticulitis [5]

A
  • Low grade pyrexia
  • Tachycardia
  • Tender LIF: in 20% there will be a tender palpable mass due to inflammation or an abscess
  • Possibly reduced bowel sounds
  • Guarding, rigidity and rebound tenderness may suggest complicated diverticulitis with perforation
35
Q

How long should you wait before you admit patients with diverticulitis?

A 
If no improvement in 72h:
Admit
Analgesia
NBM
Iv fluid
Abx: IV ceftriaxone, metronidazole
Surgery for peritonitis / perforation
36
Q

2 investigations you should not do in acute diverticulitis as risk of perforation?

A

Colonoscopy

Barium enema

37
Q 
Management of
Abscess [2]
Perforation [2]
Hemorrhage [2]
Fistulae [1]
A

Abscesses: abx +/- US or CT guided drainage

Perforation: laparotomy and Hartmann’s procedure (temporary colostomy and partial colectomy)

Haemorrhage:

  • mx as per any rectal bleed; may require transfusion and elective embolization (diathermy and local adrenaline)
  • or colonic resection after colonoscopy or angiography

Fistulae: elective colonic resection

Gastro (17 decks)

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