Disease of small bowel and appendix Flashcards
what can cause obstruction inside the lumen?
gallstones
food
bezoar
what can cause obstruction within the wall?
tumour
crohns
radiation
what can cause obstruction outside the wall?
adhesions (most common, can be post surgery or congenital which presents late in life)
herniation
what are the symptoms of small bowel obstruction?
pain (colicky, central) absolute constipation vomiting burping abdominal distension
what is the typical presentation of small bowel obstruction?
distension vomiting borborygmi pain faeculent vomiting presence of a cause (eg scar, hernias)
how is the state of the patient assessed in small bowel obstruction?
urinalysis
bloods
gases
how is small bowel obstruction diagnosed?
AXR
contrast CT
gastrograffin studies
what does small/large bowel obstruction look like on XR?
small = multiple thickened loops large = big distended large intestine
what is drip and suck?
treatment for small bowel obstruction due to adhesions
1) ABC
2) analgesia
3) fluids with potassium
4) they are usually hypokalaemic and alkalotic
5) catheterise
6) NG tube (ryles tube not a feeding)
7) antithromboembolism measures (eg TED stockings)
how long do you drip and suck for?
up to 72 hours usually intervene earlier if - strangulation - perforation - ishcaemia
how can small bowel obstruction be surgically managed?
laparotomy
what are the principles of a laparotomy?
antibiotics antithrombotic measures usually a midline incision can be laparoscopic find the obstruction by following collapsed or dilated bowel
what is mesenteric ischaemia?
dead gut
what is the difference between small/large bowel?
small bowel doesn’t have a marginal artery
what can cause mesenteric ischaemia?
embolus (usually from AF, forms in left atrium, sticks in a narrow SMA)
thrombosis (virchows triad)
atherosclerosis
what are the symptoms of mesenteric ischaemia?
Cramps, like angina of the gut
pain out of proportion with clinical findings
why might the colon live when the small bowel is infarcted and dies?
colon has supply from marginal artery
who is the typical patient for mesenteric ischaemia?
old lady on lots of morphine
how is mesenteric ischaemia diagnosed?
acidosis on ABGs (low pH, high H+, high BE) elevated lactate CRP may be normal WCC will be up (around 15) CT angiogram At laparotomy Intervene before patient is moribund
how is mesenteric ischaemia treated?
Must act quickly
Resect if non-viable
Re-anastamose or staple and planned return
If viable you can rarely perform an SMA embolectomy
Sometimes have to “open and close” = open up to find gangrene and tell them they are going to die slowly and painfully
how much bowel do you need to survive?
30cm
so can only perform resection if 30cm or more is left
how is small bowel haemorrhage diagnosed?
CT angiogram ABC exclude upper source vascular malformations ulcerations
how is a small bowel haemorrhage usually managed?
interventional radiology
what and where is a meckels diverticulum?
remnant of omphalomesenteric duct
60cm above IC valve
how does meckels diverticulum present?
usually before age 2
usually incidental
what are the possible complications of meckels diverticulum?
Bleed (haematochezia)
Ulcerate/meckels diverticulitis
Obstruction
Malignant change (0.5%)
where is the appendix?
most are retrocaecal
base always at converegence of the 3 taenai coli
tip can vary
what artery supplies the appendix?
appendicular artery end artery (stops at appendix)
describe the incidence of appendicitis?
declining incidence rare in infancy usually in childhood/young adults another peak in elderly more common in males before age 25, then the same
what causes appendicitis?
no real underlying hypothesis
faecolith obstruction
viral (in clustering of cases)
bacterial
describe the pathology of appendicitis?
lumen may/may not be occluded mucosal inflammation lymphoid hyperplasia obstruction mucus/exudate build up venous obstruction ischaemia perforation presence of inflammtions in abdomen brings the greater omentum down, small bowel adheres, phlegmonous mass peritonitis can be fatal (if appendix bursts)
who is a ruptured appendix more likely in?
elderly
immunosuppressed
diabetes
absence of omentum (ie. surgery)
what is the classic picture of appendicitis?
Central pain that migrates to RIF Anorexia Nausea One or two vomits May not have moved bowels Pelvic: vaguer pain localisation: rectal tenderness Elderly
what are the classical signs of appendicitis?
mild pyrexia (not too high, <40) mild tachycardia localised pain in RIF guarding rebound
what are some specific signs of appendicitis?
Rosving’s = Pressing on the left causes pain on the right Psoas = Patient keeps the right hip flexed as this lifts an infmaled appendix off the psoas Obturator = If appendix is touching obturator internus, flexing the hip and internally rotting will cause pain Pointing = Where did it start, where it is now?
what are some special cases that might not present with classical signs?
retrocaecal appendix = few signs
pelvic appendix = diarrhoea, frequent micturition
Postileal = rare, diarrhoea, vomiting
name 4 groups of people that can present with special cases/symptoms of appendicitis?
obese (still claim hunger)
elderly (more gangrene/perforation)
children (don’t sleep/eat)
pregnancy (appendix moves up and out, MRI useful, operate early - lap is safe and feasible)
what might the differential diagnosis be in children?
Gastroenteritis Mesenteric adenitis Meckel’s diverticulum Intususseption Henoch-Schonlein Purpura Lobar pneumonia
what might the differential diagnosis be in women?
Mittelschmerz
Ovarian cyst
Salpingitis
Ectopic pregnancy
how is appendicitis investigated?
clinical diagnosis Ultrasound useful in women/kids AXR to exclude other cause (not first line) Bloods (CRP< WCC) Urinalysis (check pregnancy etc)
what is alvadro score?
uses mantrels scoring system to determine appendicitis
- score to move/cough/laugh
- flushed red face
- foetor oris
how is appendicitis treated?
analgesia antipyretics theatre antibiotics appendicectomy - laparascopic (best) - open (not first line) - laparotomy sometimes
what is appendix mass?
late presentation of appendicitis
inflamed
how is appendix mass treated?
antibiotics first line
don’t often operate, only if treatment fails or complicated
what is an appendix abscess?
delayed presentation
liquidised
treated with radiological drain
what are some complications of appendix abscess?
Pelvic abscess Wound infection Intra-abdominal abscess Ileus Respiratory DVT/PE Portal pyaemia Faecal fistula Adhesions Right sided inguinal hernia
what is carcinoid of the appendix?
cancer in crypts of lieberkuhn
metastatic risk
stains for chromagrannin
how is carcinoid of the appendix treated?
appenicectomy if <1cm
completion right hemi if >2cm
