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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)
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

37
Q

give 4 common types of hernia

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

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)

GENERAL SURGERY (8 decks)

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