Bowel conditions Flashcards
Define appendix
a prominent lymphoid tissue which regresses with age
What causes appendicitis
What bacteria cause appendicitis
Obstruction - fecalith, bezoar, filarial worms, lymphoid hyperplasia
Infection
Enterus vemicularis
Pathogenesis of appendicitis [5]
- 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
Presentation Appendicitis
Symptoms [3]
Signs [5]
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
What is Murphys triad
Investigations: appendicitis [5]
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)
Appendicitis management
Simple appendicitis [2]
Perforated appendicitis [2]
Simple appendicitis: laparoscopic appendectomy, prophylactic IV abx (metronidazole and cefuroxime)
Perforated appendicitis: copious abdominal lavage and appendectomy
What are the differentials for appendicitis [8]
What should you beware in elderly?
Gastroenteritis IBS, Crohns Constipation Peptic ulcer UTI Ectopic pregnancy PID Mesenteric adenitis
Beware of underlying malignancy in elderly
Describe an atypical presentation of appendicitis [2]
Retrocaecal retroperitoneal appendix > flank or RUQ pain, PR painful
Can occur in pregnancy
Complications of appendicitis
- Perforation
- Appendix mass - when inflamed appendix becomes covered in omentum, could also be in tumor
- Appendix abscess
What is ischaemic colitis [2]
Presentation [3]
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
Where is common site
Splenic flexure
How do you Dx [2] and treat [2]
CT = 1st line
AXR
Supportive
Surgery if peritonitis / perforation / haemorrhage
What is mesenteric ischaemia?
Aetiology
Typically small bowel in contrast to ischaemic colitis
Due to embolism of SMA etc
What are the symptoms [4]
Mesenteric ischemia
Sudden onset abdo pain out of proportion of physical exam findings
Rectal bleeding
Diarrhoea
Fever
What are RF for bowel ischaemia / mesenteric [7]
Age Smoking, Cocaine Hypertension, DM Malignancy Endocarditis, AF** (mesenteric) Surgery Abdominal aneurysm
How do you treat mesenteric ischaemia
Urgent surgery - laparotomy
High mortality
What is a volvulus [2]
Torsion of bowel resulting in a closed loop obstruction that can cause strangulation or incarceration
Where is volvulus common
Sigmoid
Can occur gastric / caecal
What are symptoms of volvulus [3]
Describe presentation of small intestine, caecal, sigmoid
- Absolute constipation
- Abdo pain + bloating
- N+V
Small intestine: SBO symptoms
Caecal: LBO symptoms
Sigmoid: sudden left sided abdominal pain with abdominal distention
What is bowel volvulus associated with [5]
Elderly, Constipation
Neuro: Duchennes / PD
Schizophrenia
Chagas disease
Caecal - preg / adhesions / fistula, Crohns
How do you Dx and Rx [3]
AXR
Central distended bowel in cecum
Tx of volvulus
Caecal [2]
Sigmoid [2]
Caecal
- Laparotomy for resection of affected segment
- +/- anastomosis
Sigmoid
- Emergency sigmoidoscopy, rectal tube insertion and
- Laparotomy for sigmoidectomy +/- anastomosis
Gastric volvulus
Aetiology
Risk factors [2]
Aetiology: twisting of stomach more than 180 degrees
Risk factors:
- Congenital eg pyloric stenosis
- Acquired (surgery)
Gastric volvulus
Symptoms [3]
Ix [2]
Mx [2]
Symptoms:
- Vomiting, pain, failure to pass NGT
- saliva regurgitation
- dysphagia
Ix: erect CXR, AXR (gastric dilation, double fluid level)
Mx: resuscitation, laparotomy
What is a diverticulum
Outpouching of gut wall
Usually at site of entry of arteries
Intraluminal pressure forces mucosa to herniate through gut at weak points
Where is common site for diverticulum
Sigmoid colon as this is where the luminal pressures are highest
What is diverticular disease
What is diverticulosis
Symptomatic diverticulum
The state of having diverticula which are asymptomatic
What are the symptoms of diverticular disease [7]
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.
What are RF for diverticular disease [5]
Lack of fibre Age Obesity Smoking NSAID
How do you Dx diverticular disease [6]
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
How do you treat diverticular disease in the community [4]
Antibiotics (oral)
Liquid diet
Analgesia
What are complications of diverticular disease [5]
Diverticulitis Haemorrhage Fistula (colovesical) Perforation Peritonitis, Abscess
What is diverticulitis
Inflammation of a diverticulum
Beware in immunocompromised who present late
What are signs of diverticulitis [5]
- 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
How long should you wait before you admit patients with diverticulitis?
If no improvement in 72h: Admit Analgesia NBM Iv fluid Abx: IV ceftriaxone, metronidazole Surgery for peritonitis / perforation
2 investigations you should not do in acute diverticulitis as risk of perforation?
Colonoscopy
Barium enema
Management of Abscess [2] Perforation [2] Hemorrhage [2] Fistulae [1]
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
