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GENERAL SURGERY > Common GenSurg Emergencies > Flashcards

Common GenSurg Emergencies Flashcards

1
Q

what are UGI causes of GI perforation

A
  • perforated duodenal ulcer
  • gastric/oesophageal cancer
  • Boerhaave syndrome (excessvie vomiting)
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2
Q

what are LGI causes of GI perforation

A
  • perforated diverticular disease
  • perforated tumour
  • iatrogenic
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3
Q

what is the main difference in approach to surgical repair of GI perforation

A
  • UGI perf = closed
  • LGI perf = resected

! high mortality and morbidity !

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4
Q

what are the main clinical features of GI perforation

A
  • abdo pain typically rapid onset and severe
  • associated malaise, vomiting, lethargy
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5
Q

what factors affect how unwell a patient with a GI perforation is

A
  • type of perf
  • timing of presentation
  • co-morbidities
  • functional status
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6
Q

what are the examination findings of a patient presenting with GI perforation

A
  • pt will look unwell
  • features of sepsis
  • peritonism may be local or gen (rigid abdomen)
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7
Q

what investigations are carried out in GI perforation pt

A

urgent blood tests
- FBC
- U&E
- LFTs
- CRP
- clotting

imaging

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8
Q

what would blood tests show in a patient with GI perforation

A

raised inflamm markers e.g. WCC & CRP
- may also show evidence of organ dysfunction e.g. AKI, coagulopathy secondary to sepsis

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9
Q

what is the gold standard of diagnosis of any perforation

A

CT scan with IV contrast
- confirms presece of free air and suggest location of perf

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10
Q

what imaging may be used to diagnose a suspected upper GI perforation

A

CT scan with oral contrast

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11
Q

what might an eCXR or AXR show in GI perforation

A
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12
Q

what are the 3 main requirements of managing GI perforation

A
  1. early resuscitation
  2. prompt diagnosis
  3. definitive treatment
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13
Q

describe the management plan of a patient with GI perforation

A
  • broad spectrum ABX started early
  • NBM
  • NGT if required
  • adequate IV fluid resus
  • appropriate analgesia
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14
Q

what are the 3 aspects of surgical intervention for a GI perforation

A
  1. identify underlying cause
  2. appropriate management of perf
  3. thorough washout
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15
Q

how is a peptic ulcer perforation surgically repaired

A

can be accessed typically either open or laparoscopically and a patch of omentum (termed a “Graham patch”) is tacked loosely over the ulcer

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16
Q

how is a small bowel perforation surgically repaired

A

bowel resection +/- primary anastomosis +/- stoma formation
- small perfs can be managed by oversewing defect

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17
Q

how is a large bowel perforation surgically repaired

A

can result in lots of contamination
- bowel resection +/- stoma formation

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18
Q

which type of patients with a GI perforation can be managed conservatively

A

physiologically well:
- localised diverticular perf + only localised peritonitis and tenderness, no evidence of contamination
- sealed upper GI perf, CT imaging w/out gen peritonism
- elderly frail w extensive co-morbidities who are unlikely to survive surgery

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19
Q

describe the mechanism behind a bowel obstruction

A

mechanical blockage of the bowel whereby a structural pathology physically blocks the passage of intestinal contents
- bowel segement occludes
- gross dilatation of proximal limb of bowel
- increased peristalsis of bowel
- secretion of large vol of electrolyte-rich fluid into bowel

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20
Q

what is an ileus/pseudo-obstruction

A

when the bowel is not mechanically blocked but is adnyamic and not working properly

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21
Q

what are the cardinal features of bowel obstruction (4)

A
  • abdo pain: colicky/cramping secondary to peristalsis
  • vomiting: early in prox obstruction
  • abdo distension
  • absolute constipation: early in distal
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22
Q

what may be present on examination of a patient with bowel obstruction

inspection, palpation, percussion, auscultation

A
  • may show evidence of underlying cause e.g. surgical scars, cachexia from malignancy or obvious hernia
  • abdominal distension
  • palpate for focal tenderness
  • percussion may give tympanic sound
  • asucultation may give tinkling bowel sounds
  • ASSESS FLUID STATUS
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23
Q

why is it important to assess a patient’s fluid status in bowel obstruction

A

significant third-spacing can occur
- too much fluid moves from the intravascular space (blood vessels) into the interstitial space
- can cause oedema, reduced CO, hypotension

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24
Q

give 4 differentials for bowel obstruction

A
  • pseudo-obstruction
  • paralytic ileus
  • toxic megacolon
  • constipation
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25
Q

give 3 common causes of SBO

A
  1. adhesions
  2. hernias
  3. tumours
  • also tumours/strictures within the wall
  • foreign bodies within the lumen
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26
Q

give 3 common causes of LBO

A
  • colorectal cancer
  • diverticular disease
  • sigmoid volvulus
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27
Q

list some clinical signs seen in bowel obstruction

A
  • distension
  • visible peristalsis
  • visible hernias/scars
  • high-pitched, tinkling bowel sounds
  • dehydration
  • tachycardia
  • hypotension
  • fever
  • tenderness
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28
Q

state 4 investigations that are appropriate in bowel obstruction

A
  • urgent routine bloods on admission (closely monitor renal function and electrolytes)
  • VBG (to evaluate for end-organ and for immediate assessment of metabolic derangement)
  • CT scan with IV contrast
  • AXR sometimes
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29
Q

what the AXR findings of SBO

A
  • dilated bowel >3cm
  • central abdo location
  • valvulae conniventes visible
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30
Q

what are the AXR findings for LBO

A
  • dilated bowel >6cm or 9cm if at caecum
  • peripheral location
  • haustral lines visible
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31
Q

what is conservative management of bowel obstruction

A
  • NBM
  • NGT
  • IVI
  • urinary catheter & fluid balance
  • analgesia + suitable anti-emetics
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32
Q

what can be performed in cases of bowel obstruction that do not resolve initially with conservative management

A

water soluble contrast study

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33
Q

when is surgical intervention indicated for bowel obstruction

A

LAPAROTOMY
- suspicion of intestinal ischaemia or closed loop bowel obstruction
- strangulated hernia or obstructing tumour
- failiure to improve after conservative management

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34
Q

what are the 2 exceptions to surgical intervention in bowel obstruction

A
  1. adhesional SBO
  2. sigmoid volvulus - endoscopic decompresison
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35
Q

what are possible complications of bowel obstruction

A
  • bowel ischaemia
  • bowel perforation –> faecal peritonitis (high mortaility)
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36
Q

define hernia

A

a condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it

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37
Q

give 4 common types of hernia

A
  1. inguinal
  2. umbilical
  3. femoral
  4. incisional
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38
Q

what are the 2 main subtypes of inguinal hernia and briefly describe it

A

direct: enters through Hesselbach’s triangle
- MEDIAL to inferior epigastric vessels
- older pt
- abdo wall laxity or inc in intra-abdo pressure

indirect: deep inguinal ring
- LATERAL to inferior epigastric vessels
- younger pt
- incomplete closure of processus vaginalis = congential

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39
Q

what are the 3 main complications of a hernia

A
  • incarceration: contents unable to return to original cavity
  • strangulation: blood supply compromised -> ischaemic bowel
  • obstruction
40
Q

what are the signs/symptoms of strangulation of a hernia

A
  • tender, painful, non-reducible lump
  • skin erythema
  • systemic upset
  • abdo distension
  • vomiting
41
Q

what are the 2 main surgical interventions for hernias and when are they used

A
  1. open mesh repair: primary inguinal hernias, Lichtenstein technique
  2. laparoscopic repair: bilateral or recurrent inguinal hernias, TEP, TAPP
42
Q

what is the ligament of Treitz

A

a thin band of peritoneum that connects and supports the end of the dudodenum and beginning of jejunum

43
Q

where does melena and haematemesis occur in relation to the ligament of treitz

A

usually proximal

44
Q

give 3 common causes of melena

A

1. PUD
- NSAIDs, H.Pylori, gastroduodenal artery
2. variceal bleeding
- porto-systemic anastomoses, portal HTN second. to liver cirrhosis
3. malignancy
- ulcerating oesophageal or gastric

45
Q

what should you inquire about in an assessment of a patient with melena

A
  • dysphagia
  • dyspepsia
  • weight loss
  • relevant FHx
  • colour and texture of stool
  • PMHx: smoking and alcohol
  • DHx: steroids, NSAIDs, anticoags
46
Q

what are less common causes of melena

A
  • gastritis
  • Meckel’s diverticulum
  • small bowel tumours
  • vascular malformations
47
Q

what is essential to confirm a diagnosis of melena

A

DRE
- full abdo exam to assess for peritonism, hepatomegaly or liver disease

48
Q

what investigations should all patients with SUSPECTED melena undergo

A
  • routine blood tests: FBC, U&Es, LFTs, clotting
  • G&S
49
Q

what blood test results are indicative of melena and why

A

drop in Hb & increase in urea:Cr ratio
- digested Hb produces urea as a by-product and is readily absorbed by the intestine

50
Q

what investigations must all patients with NEW ONSET melena undergo

A

OGD
- identify cause and allows for definitive interventions
- can also perform CTA or colonoscopy

urgency determined by Glasgow-Blatchford bleeding score

51
Q

what is the management of melena

A
  • blood products if haemodynamically unstable or low Hb
  • correct deranged coagulation e.g. FFP +/- platelets
  • treat underlying cause
    - PUD: adrenaline + PPI to reduce gastric acid secretion
    - oesophageal varices: urgent endoscopy + terlipression to reduce splanchnic blood flow or banding
    - malignancies: biopsies
52
Q

what is haematemesis

A

vomiting fresh blood (UGI)

53
Q

what are some DDx for haematemesis

A
  • PUD
  • Mallory-Weiss tear
  • oesophagitis
54
Q

what is a Mallory-Weiss tear

A

episodes of severe/recurrent vomiting followed by minor haematemesis
- causes tear in the epithelial lining of oesophagus at GOJ underlying oesophageal or venous plexus
- seen in alcoholics
- mostly benign and resolve spontaneously

55
Q

what are the steps of initial management of a GI bleed

A
  • A-E Assessment
  • NBM
  • Bloods + IV Cannula
  • IV Fluids (+/- Blood Transfusion)
  • +/- Stop anticoagulants
  • +/- PPI
  • +/- IV Analgesia
  • DW Senior: For OGD/Imaging
56
Q

what is haematochezia

A

rectal bleeding (LGI)

review blood supply

57
Q

what are common causes of acute lower GI bleeding

A
  • diverticulosis: outpouhcings of bowel wall composed of mucuosa mainly in the descending and sigmoid colon
  • haemorrhoids: pathologically engorged vascular cushions in the anal canal
  • ischaemic/infective colitis
  • malignancy
  • angiodysplasia
58
Q

what questions do you want to ask from a pt presenting with PR bleeding

A
  • nature of bleeding: duration, frequnecy, colour
  • pain? haematemesis/melena, previous episodes, mucus, weight loss
  • FHx
59
Q

what examinations should be carried out in pt with PR bleeding

A
  • abdo exam: localised tenderness or palpable masses
  • PR exam followed by rectal masses and ongoing presence of blood

haemodynamically unstable bleeds = A-E assessment

60
Q

how are patients presenting with lower GI bleed scored

A

Oakland score
- age
- sex
- previous admissions
- PR findings
- HR
- SBP
- Hb conc

61
Q

what investigations should all patients presenting with rectal bleeding undergo

A
  • routine bloods
  • G&S
  • stool cultures
62
Q

what might blood tests show in a pt with rectal bleeding

A
  • acute bleeds may not initially show reduced Hb level due to haemoconcentration
  • ongoing bleeding will show a reduced Hb
  • elevated serum urea to creatinine ratio suggests an upper GI source of bleeding being more likely
63
Q

what is a right hemicolectomy

A

removal of terminal ileum, caecum, appendix, ascending colon and hepatic flexure

64
Q

briefly describe how a R hemicolectomy is carried out

A

open or lap
- majority of cases = anastomosis from the ileum to the transverse colon is formed

64
Q

when is a R hemicolectomy indicated

A

most commonly due to bowel malignancy
- diverticular disease
- bowel ischaemia
- bowel perf.

65
Q

in what cases is a stoma created over an anastomoses

A

if there are abscesses, fistulae, poor nutrition or lack of blood supply then it is not suitable for anastomosis as there is a higher chance of leak!

66
Q

why is a colonoscopy indicated in diverticulitis and when should it be carried out

A

cancer can mimic symptoms of diverticulitis so carry out a colonoscopy ~4 weeks AFTER inflammation has settled

67
Q

give mechanical and non-mechanical causes of bowel obstruction

A

mechanical
- extramural: hernias, ahdesions, volvulus
- mural: cancer, inflamm strictyures, intussuscpetion, lymphoma
- intraluminal: gallstone ileus, ingested foreign body, faecal implantation

non-mechanical
- infection
- ILEUS
- pesudo-obstruction

68
Q

how does gastrografin work in adhesive bowel obstruction

A

it is a hypertonic solution that causes fluid to be drawn into the lumen
- this reduces intestinal wall oedema and stimulates peristalsis

69
Q

what is peptic ulcer disease and how does it present

A

imbalance between damaging and protective factors of mucosa
- abdo pain, N&V, haematemesis/melena

70
Q

classify causes of PUD

A

↑ acid production
- Zollinger Ellison syndrome
- hyperparathryoidism
- chronic renal failure
- inc Ca2+ stimulates GO cells to secrete acid

↓ mucosal defence
- H.pylori (inflammation)
- NSAIDs (↓ PG & mucus)
- cigarette smoking
- corticosteroids (↓ wound healing)

71
Q

what is the mechanism of stress ulcers

A

vagal stimulation leads to acid hypersecretion
- systemic acidosis - muscosal injury
- splanchnic vasoconstriction causes hypoxia due to reduced blood flow - acute ulcer

72
Q

what are uncommon causes of haematemesis

A
  • Dieulafoy’s lesion
  • watermelon stomach/ gastric antral vascular ectasia
  • aorto-enteric fistula
73
Q

what is Dieulafoy’s lesion

A

a dilated aberrant submucosal vessel that erodes the overlying epithelium and not associated with a primary ulcer

73
Q

where is Dieulafoy’s lesion most commonly seen

A

in lesser curvature 6cm from the GOJ

74
Q

how is diagnosis of Dieulafoy’s lesion best made and what does it show

A

endoscopy reveals active arterial pumping from site

75
Q

what is watermelon stomach or GAVE

A

gastric antral vascular ectasia
- characteristic endoscopic appearance of tudinal rows of erythematous mucosa radiating from pylorus to antrum
- ectatic or sacculated mucosal vessels seen in endoscopy

76
Q

how does watermelon stomach present

A
  • chronic bleeding
  • occult blood positive stool
  • IDA
77
Q

what is an aorto-enteric fistula

A

direct communication between the aorta and the GI tract

78
Q

what is the most common cause of an aortic-enteric fistula

A

infected prosthetic aortic graft eroding into the intestine
- other causes: penetrating ulcer, tumour invasion

79
Q

what is the most common site of an aortic-enteric fistula

A

D3/D4

80
Q

what are the 2 types of diverticula

A

false: herniation of colonic mucosa & submucosa through muscular layers

true: involves all layers

81
Q

what is the most common manifestation of colon cancer

A

painless occult bleed
+ IDA

82
Q

what are the 3 progressive phases of ischaemic colitis

A
  1. hyperactive: severe abdo pain + bloody stools
  2. paralytic: ischaemia continues, tender abdomen, dec bowel motility, absent bowel sounds
  3. shock: fluids leak through damaged colon lining - metabolic acidosis + dehydration, hypotension, tachycardia
83
Q

what is the rule of 2s for Meckels diverticulum

A
  • 2% of population
  • under 2s
  • 2ft proximal to ileo-caecal valve
  • 2 inches
  • 2 types of tissue (gastric and pancreatic)
84
Q

what is a hiatus hernia

A

protrusion of an organ from abdo cavity into thorax through oesophageal hiatus typically stomach

85
Q

what is the anatomical classification of hiatus hernias

A
  • Type I, Sliding Hernia (90%) – the GOJ and frequently cardia of the stomach move (or “slides”) upwards through the diaphragmatic hiatus into the thorax
  • Type II, Rolling Hernia (or para-oesophageal) – an upward movement of the gastric fundus occurs to lie alongside a normally positioned GOJ, which creates a ‘bubble’ of stomach in the thorax; a true hernia with a peritoneal sac
  • Type III, Mixed Type– both the gastric fundus and the GOJ herniate above the hiatus, with the fundus lying above the GOJ
  • Type IV, Other Structures – other structures apart from the stomach herniating through the oesophageal hiatus
86
Q

what are risk factors of hiatus hernias

A
  • age due to age-related loss of diaphragmatic tone, ↑intra-abdo pressure and ↑size of diaphragmatic hiatus
  • also pregnancy, obesity and ascites
  • previous oesophageal and stomach surgery
87
Q

how do hiatus hernias present

A
  • majority are asymptomatic
  • symptomatic: mainly epigastric pain worse on lying flat, hiccups, palps, vomiting, dysphagia, anaemia
  • normal clinical exam
88
Q

what can large hiatus hernias lead to

A

gastric outflow obstruction: presenting with early satiety, vomiting and severe chest pain

89
Q

what are complications of fundoplication

A
  • recurrence of hernia due to failure of cruroplasty
  • abdo bloating or ↑ flatulence
  • dysphagia if the wrap is too tight or crural repair too narrow
  • fundal necrosis if blood supply via left gastric and short gastrics is disrupted
90
Q

how are the majority of hiatus hernias diagnosed

A

OGD
- can show an upward displacement of the GOJ (‘Z-line’), as well as any oesophagitis, gastritis, or Barrett’s oesophagus present
- exclude any malignancy

91
Q

for patients being considered for surgical management with hiatus hernias, what investigations are indicated (3)

A
  • Oesophageal manometry – measures the pressure within the oesophagus during swallowing, useful for assessment of oesophageal motility disorders, such as achalasia
  • Ambulatory 24-hour oesophageal pH monitoring – quantifies the level of reflux and assess the relationship between the reflux episodes and patient symptoms
  • Contrast swallow or meal – can be used to diagnose a hiatus hernia and rule out other structural disorders such as strictures or motility disorders
92
Q

what is the conservative management of hiatus hernias

A
  • Proton Pump Inhibitors (PPIs), acting to reduce gastric acid secretion and aiding in symptom control.
  • lifestyle modification, such as weight loss and alteration of diet (low fat, avoidance of meals 2-3 hours before bedtime, smaller portions).
  • Smoking cessation and reduction in alcohol intake should be advised, as both nicotine and alcohol are thought to inhibit lower oesophageal sphincter function worsening symptoms
93
Q

how can hiatus hernias be repaired surgically

A
  • Cruroplasty – The hernia is reduced from the thorax into the abdomen and the hiatus re-approximated to the appropriate size, usually with sutures; a mesh can be placed
  • Fundoplication - gastric fundus is wrapped around the lower oesophagus and stitched in place to strengthen the lower oesophageal sphincter and keep the GOJ in place below the diaphragm (can be full Nissen or partial Toupet)

GENERAL SURGERY (10 decks)

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