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
