Diseases of the Small Bowel and Appendix Flashcards
obstruction
PATHOPHYSIOLOGY pain absolute constipation vomiting burping abdominal distension
causes for obstruction
common = within the lumen (gallstone, food, bezoar)
within the wall
outside the wall
typical presentation
depends on where in the small bowel
distension vomiting borborygmi pain faeculent vomiting presence of a cause
investigation
assessing the state of the patient (urinalysis, bloods, gases)
confirming the diagnosis (AXR, CT, gastrograffin studies)
identify those who need surgery and those who will settle
‘drip and suck’
only adhesional small bowel obstruction
up to 72 hours is standard
ABC
analgesia fluids with K+ usually hypokalaemia and alkalotic catheterise NG tube atithromboembolism measures
surgical management
laparotomy
operative principles
antibiotics
antithromboembolic measures
midline incision
can be laparoscopic
find the obstruction of following collapsed or dilated bowel
mesenteric ischaemia
dead intestine
embolus, thrombosis (arterial and venous)
CHRONIC superior mesenteric artery cramps 'angina of the guts' - pain after eating atherosclerosis
ACUTE
small bowel usually gets infarcted = dies
doesn’t have a marginal artery
colon = lives (marginal artery)
continues to get blood from surrounding arteries
causes of mesenteric ischaemia
embolus usually from AF
forms in left atrium
sticks in a narrow SMA
in situ thrombosis virchows triad dehydrated hypercoagulable compression vasocontricting drugs
diagnosis
pain out of proportion to the clinical findings
acidosis of gases (low pH, high [H=+], high BE)
lactate elevated
CRP may be normal
WCC may be up a bit
CT angiogram
laparotomy
intervene before your patient is moribund
treatment
quick
prepare the patient and family for the worst
resect if non-viable
re-anastomse or staple and planned return
if viable you can rarely perform an SMA embolectomy
sometimes we have the sad situation of an open and close
small bowel haemorrhage
ABC
exclude upper source vascular malformations ulcerations CT angiogram can often be managed by interventional radiology
meckel’d diverticulum
true diverticulum
usually incidental
remnant of the omphalomesenteric duct
complications bleed ulcerate/meckels divericulitis obstruction malignant change
appendicitis
commonest emergency operation
appendix
vestigial organ
most are retrocaecal
tip can vary in location
base constant
convergence of the three taeniae
incidence
rare in infancy
usually childhood/young adulthood
another peak in the elderly
aetiology
no unifying hypothesis
obstruction of the lumen with faecolith
bacterial
viral (clustering of cases)
parasites
pathology
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..bacterial invasion through wall
perforation
presence of inflammation in abdomen brings the greater omentum
small bowel adheres
phlegmonous mass
peritonitis can be fatal
symptoms
central pain that migrates to RIF anorexia nausea one or two vomits may not have moved bowels pelvic - vaguer pain localisation - rectal tenderness elderly
signs
mild pyrexia mild tachycardia localised pain in RIF guarding rebound
specific signs
rosvings - pressing on the left causes pain on the right
psoas - patient keeps the right hip flexed as this lifts an inflamed appendix off the psoas
obturator - appendix is touching obturator interns, flexing the hip and internally rotating will cause pain
pointing - where did it start, where is it now
special cases
retrocaecal appendix
pelvic appendix
postileal
other special cases
obese
elderly
children
pregnancy - unusual
investigation
clincial USS AXR bloods urinalysis
management
analgesia antipyretics theatre antibiotics appendicectomy
appendix mass
antibiotics first line
can operate or not
appendix abscess
usually delayed
usually has liquidised
complications
pelvic abscess wound infection intra-abdominal abscess ileus respiratory etc..
