Diseases of the small bowel and appendix Flashcards
What are the symptoms of obstructed bowel?
Pain (colicky) Absolute constipation Vomiting Burping Abdominal distension
What are the three sites of bowel obstruction and what causes these?
Lumen - gallstone, food, bezoar
Within the wall - tumour, Crohn’s, Radiation
Outside the wall - Adhesions (previous surgery), Herniation
What do patients with small bowel obstruction present with?
Distension Vomiting Borborygmi Pain Faeculent vomiting Presence of a cause - scars
When no scar is present on the stomach and small bowel is obstructed what should be checked for?
Hernias
What investigations are done for small bowel obstruction?
Urinalysis Bloods Gases AXR Contrast CT of abdomen Gastrogaffin studies
What is the treatment of small bowel obstruction that is down to adhesions?
Drip and suck
What are the steps of ‘Drip and suck’
ABC Analgesia Fluids with potassium Catheterise NG Ryles tube Antithromboembolism measures TED stockings
How long do you do drip and suck?
72 hours
Should be stopped earlier if Strangulation, Perforation or Ischaemia
What is the surgical management of small bowel obstruction?
Laparotomy
What are the operative principles of laparotomy?
Antibiotics Antithromboembolic measures Usually a midline incision Can be laparoscopic Find the obstruction by following collapsed or dilated bowel
What is mesenteric ischeamia?
Dead gut
How is the small bowel different from the large bowel?
There is not Marginal artery in the small bowel
What are the symptoms of chronic mesenteric ischaemia?
SMA
Cramps
Like angina of the gut
Atherosclerosis
What are the consequences of acute mesenteric ischaemia?
Small bowel infarcts
Colon lives
What are the causes of mesenteric ischaemia?
Embolus usually from AF - forms in left atrium, sticks in narrow SMA In situ thrombosis Virchows triad -Dehydrated -Hypercoagulable -Compression -Vasoconstricting drugs
How is mesenteric ischaemia diagnosed?
Pain out of proportion with clinical findings Acidosis of gases Lactate elevated CRP may be normal WCC may be elevated CT angiogram At Laparotomy Intervene before your patient is moribound
How is mesenteric ischaemia treated?
QUICKLY
Prepare the patient and family for the worst
Resect if non-viable
Re-anastomise and planned return
If viable you can rarely perform an SMA embolectomy
How much small bowel is required to live?
At least 30cm
How much of an icon is this lecturer?
A massive icon
How is small bowel haemorrhage diagnosed?
ABC Exclude upper source Vascular malformation Ulceration CT angiogram Interventional radiology
How is small bowel haemorrhage managed?
Interventional radiology
Describe Meckels Diverticulum
60cm from IC valve (2 feet) 2% of population Present before 2 years of age Usually incidental Remnant of the omphalomesenteric duct Complications Bleed (haematochezia) Ulcerate/meckels diverticulitis Obstruction Malignant change (0.5%)
What is the appendix and where are they found?
Vestigal organ
Most are retrocaecal
Tip can vary in location
Base in constant at the convergence of the 3 taeni coli
Which artery supplies the appendix and what type of artery is it?
Apendicular Artery
End artery
When does appendicitis usually occur?
Usually in childhood/young adulthood
Rare in infancy
Peak in elderly
What are the 5 causes of appendicitis?
No unifying hypothesis Obstruction of the lumen with faecolith Bacterial Viral Parasites
What is the pathology of appendicitis?
Huge variation in macroscopic disease Lumen may or may not be occluded Mucosal inflammation Lymphoid hyperplasia Obstruction Build up of mucus and exudate Venous obstruction Ischaemia - bacteria invasion through wall Perforation Presence of inflammation in the abdomen Small bowel adheres Phlegmonous mass Peritonitis can be fatal
What are the characteristics of appendicular related pain?
Midgut colicky pain that moves to the right iliac fossa becoming sharp and localised
What are the risk factors for peritonitis?
Age
Immunosuppression
Diabetes
Absence of omentum
What are the symptoms 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 signs of appendicitis?
Mild pyrexia - never over 39/40 Mild tachycardia Localised pain in RIP Guarding Rebound
What are the specific signs of appendicitis?
Rosving’s - pressing on the left hurts the right
Psoas - patient keeps right hip flexed as this lifts an inflamed 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 is it now?
What are three special cases of appendicitis that do not follow classic signs?
Retrocaecal appendix - may have few signs
Pelvic appendix - Diarrhoea, frequency of micturation
Postileal - rare diarrhoea, vomiting
What are 4 groups of people that present with cases of appendicitis that don’t present with normal signs?
Obese - difficult, will still claim hunger
Elderly - gangrene and perforate more frequently, usually have co-morbidities
Children - don’t sleep, wont eat
Pregnancy - appendix moves up and out, foetal loss in 3-5%. 20% if perforation, operate early, MRI useful
What are the differential diagnoses of RIF pain in children?
Gastroenteritis Mesenteric adenitis Meckel’s diverticulum Intususseption Henoch-Schonlein Purpura Lobar pneumonia
What are the differential diagnoses of RIF pain in Adults?
Terminal ileitis Ureteric colic Acute pyelonephritis Perforated ulcer Pancreatitis Rectus sheath haemotoma
What are the differential diagnoses of RIF pain in Women?
Mittelschmerz
Ovarian cyst
Salpingitis
Ectopic pregnancy
What are the differential diagnoses of RIF pain in the Elderly?
Sigmoid diverticulitis
Intestinal obstruction
Carcinoma of the caecum
What are the differential diagnoses of RIF pain in Strange cases?
Pophyria
Diabetic ketoacidosis
typhilitis
What are the investigations for appendicitis?
CLINICAL diagnosis USS useful in women and kids AXR to exclude other causes Bloods (important CRP, WCC) Urinalysis
What scoring system is used for appendicitis?
Alvarado score MANTRELS PNEUMONIC -sore to move/cough -Flushed red face -Foeter oris
What is the management of appendicitis?
Analgesia Antipyretics Theatre Antibiotics Appendicectomy Laparascopic (best) Convert to open sometimes (not first line) Laparotomy sometimes
What is the treatment of appendicular mass?
Antibiotics first line
Can operate or not
Theatre if fails or complicated
What are the symptoms of appendix mass?
Tachycardia Worsening pain Increase in size Vomiting Copious NG aspirates
What are the complications of appendicitis?
Pelvic abscess Wound infection Intra-abdominal abscess Ileus Respiratory DVT/PE Portal pyaemia Faecal fistula Adhesions Right sided inguinal hernia
What is an appendix abscess?
Not an appendix mass
Usually delayed
Usually has liquidised
Radiological drains
What is a carcinoid of the appendix and what is their epidemiology>
1 in every 300 to 400 appendixes Crypts of Lieberkuhn Stains for chromagrannin Metastatic risk relates to size 92% 5 year survival for local disease If less than 1cm appendicectomy alone If greater than 2cm completion right hemi
