Diseases of the small bowel and appendix Flashcards by K M

What are the symptoms of obstructed bowel?

Pain (colicky)
Absolute constipation
Vomiting
Burping
Abdominal distension

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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

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What do patients with small bowel obstruction present with?

Distension
Vomiting
Borborygmi
Pain
Faeculent vomiting
Presence of a cause - scars

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When no scar is present on the stomach and small bowel is obstructed what should be checked for?

Hernias

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What investigations are done for small bowel obstruction?

Urinalysis
Bloods
Gases
AXR
Contrast CT of abdomen
Gastrogaffin studies

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What is the treatment of small bowel obstruction that is down to adhesions?

Drip and suck

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What are the steps of ‘Drip and suck’

ABC
Analgesia
Fluids with potassium
Catheterise
NG Ryles tube
Antithromboembolism measures
TED stockings

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How long do you do drip and suck?

72 hours

Should be stopped earlier if Strangulation, Perforation or Ischaemia

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What is the surgical management of small bowel obstruction?

Laparotomy

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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

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What is mesenteric ischeamia?

Dead gut

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How is the small bowel different from the large bowel?

There is not Marginal artery in the small bowel

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What are the symptoms of chronic mesenteric ischaemia?

SMA
Cramps
Like angina of the gut
Atherosclerosis

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What are the consequences of acute mesenteric ischaemia?

Small bowel infarcts

Colon lives

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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

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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

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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

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How much small bowel is required to live?

At least 30cm

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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 ```