Disease of small bowel and appendix

Question 1

what can cause obstruction inside the lumen?

Answer 1

gallstones
food
bezoar

Question 2

what can cause obstruction within the wall?

Answer 2

tumour
crohns
radiation

Question 3

what can cause obstruction outside the wall?

Answer 3

adhesions (most common, can be post surgery or congenital which presents late in life)
herniation

Question 4

what are the symptoms of small bowel obstruction?

Answer 4

pain (colicky, central)
absolute constipation
vomiting
burping
abdominal distension

Question 5

what is the typical presentation of small bowel obstruction?

Answer 5

distension
vomiting
borborygmi
pain
faeculent vomiting
presence of a cause (eg scar, hernias)

Question 6

how is the state of the patient assessed in small bowel obstruction?

Answer 6

urinalysis
bloods
gases

Question 7

how is small bowel obstruction diagnosed?

Answer 7

AXR
contrast CT
gastrograffin studies

Question 8

what does small/large bowel obstruction look like on XR?

Answer 8

small = multiple thickened loops
large = big distended large intestine

Question 9

what is drip and suck?

Answer 9

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)

Question 10

how long do you drip and suck for?

Answer 10

up to 72 hours usually
intervene earlier if
- strangulation
- perforation
- ishcaemia

Question 11

how can small bowel obstruction be surgically managed?

Answer 11

laparotomy

Question 12

what are the principles of a laparotomy?

Answer 12

antibiotics
antithrombotic measures
usually a midline incision
can be laparoscopic
find the obstruction by following collapsed or dilated bowel

Question 13

what is mesenteric ischaemia?

Answer 13

dead gut

Question 14

what is the difference between small/large bowel?

Answer 14

small bowel doesn’t have a marginal artery

Question 15

what can cause mesenteric ischaemia?

Answer 15

embolus (usually from AF, forms in left atrium, sticks in a narrow SMA)
thrombosis (virchows triad)
atherosclerosis

Question 16

what are the symptoms of mesenteric ischaemia?

Answer 16

Cramps, like angina of the gut

pain out of proportion with clinical findings

Question 17

why might the colon live when the small bowel is infarcted and dies?

Answer 17

colon has supply from marginal artery

Question 18

who is the typical patient for mesenteric ischaemia?

Answer 18

old lady on lots of morphine

Question 19

how is mesenteric ischaemia diagnosed?

Answer 19

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

Question 20

how is mesenteric ischaemia treated?

Answer 20

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

Question 21

how much bowel do you need to survive?

Answer 21

30cm

so can only perform resection if 30cm or more is left

Question 22

how is small bowel haemorrhage diagnosed?

Answer 22

CT angiogram
ABC
exclude upper source
vascular malformations
ulcerations

Question 23

how is a small bowel haemorrhage usually managed?

Answer 23

interventional radiology

Question 24

what and where is a meckels diverticulum?

Answer 24

remnant of omphalomesenteric duct

60cm above IC valve

Question 25

how does meckels diverticulum present?

Answer 25

usually before age 2

usually incidental

Question 26

what are the possible complications of meckels diverticulum?

Answer 26

Bleed (haematochezia)
Ulcerate/meckels diverticulitis
Obstruction
Malignant change (0.5%)

Question 27

where is the appendix?

Answer 27

most are retrocaecal
base always at converegence of the 3 taenai coli
tip can vary

Question 28

what artery supplies the appendix?

Answer 28

appendicular artery
end artery (stops at appendix)

Question 29

describe the incidence of appendicitis?

Answer 29

declining incidence
rare in infancy
usually in childhood/young adults
another peak in elderly
more common in males before age 25, then the same

Question 30

what causes appendicitis?

Answer 30

no real underlying hypothesis
faecolith obstruction
viral (in clustering of cases)
bacterial

Question 31

describe the pathology of appendicitis?

Answer 31

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)

Question 32

who is a ruptured appendix more likely in?

Answer 32

elderly
immunosuppressed
diabetes
absence of omentum (ie. surgery)

Question 33

what is the classic picture of appendicitis?

Answer 33

Central pain that migrates to RIF
Anorexia
Nausea
One or two vomits
May not have moved bowels
Pelvic: vaguer pain localisation: rectal tenderness
Elderly

Question 34

what are the classical signs of appendicitis?

Answer 34

mild pyrexia (not too high, <40)
mild tachycardia
localised pain in RIF
guarding
rebound

Question 35

what are some specific signs of appendicitis?

Answer 35

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?

Question 36

what are some special cases that might not present with classical signs?

Answer 36

retrocaecal appendix = few signs
pelvic appendix = diarrhoea, frequent micturition
Postileal = rare, diarrhoea, vomiting

Question 37

name 4 groups of people that can present with special cases/symptoms of appendicitis?

Answer 37

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)

Question 38

what might the differential diagnosis be in children?

Answer 38

Gastroenteritis
Mesenteric adenitis
Meckel’s diverticulum
Intususseption
Henoch-Schonlein Purpura
Lobar pneumonia

Question 39

what might the differential diagnosis be in women?

Answer 39

Mittelschmerz
Ovarian cyst
Salpingitis
Ectopic pregnancy

Question 40

how is appendicitis investigated?

Answer 40

clinical diagnosis
Ultrasound useful in women/kids
AXR to exclude other cause (not first line)
Bloods (CRP< WCC)
Urinalysis (check pregnancy etc)

Question 41

what is alvadro score?

Answer 41

uses mantrels scoring system to determine appendicitis

• score to move/cough/laugh
• flushed red face
• foetor oris

Question 42

how is appendicitis treated?

Answer 42

analgesia
antipyretics
theatre
antibiotics
appendicectomy
- laparascopic (best)
- open (not first line)
- laparotomy sometimes

Question 43

what is appendix mass?

Answer 43

late presentation of appendicitis

inflamed

Question 44

how is appendix mass treated?

Answer 44

antibiotics first line

don’t often operate, only if treatment fails or complicated

Question 45

what is an appendix abscess?

Answer 45

delayed presentation
liquidised
treated with radiological drain

Question 46

what are some complications of appendix abscess?

Answer 46

Pelvic abscess
Wound infection
Intra-abdominal abscess
Ileus
Respiratory
DVT/PE
Portal pyaemia
Faecal fistula
Adhesions
Right sided inguinal hernia

Question 47

what is carcinoid of the appendix?

Answer 47

cancer in crypts of lieberkuhn
metastatic risk
stains for chromagrannin

Question 48

how is carcinoid of the appendix treated?

Answer 48

appenicectomy if <1cm

completion right hemi if >2cm