Gastro Flashcards
what are the indications of an NG tube?
Diagnostic and Therapeutic indications:
Diagnostic:
- Evaluation of upper GI bleeding
- Aspiration of gastric fluid content
- Identification of the esophagus and stomach on a chest radiograph
- Giving radiographic contrast to the GI tract
Therapeutic:
- Gastric decompression
- Feeding
- Bowel irrigation
- Medication administration
If a patient with acute abdomen needs surgical input after your assessment, what are some mx things you need to include after those in A-E?
- intravenous access, nil-by-mouth (NBM) status set,
- analgesia +/- antiemetics,
- initial imaging (as discussed above),
- VTE prophylaxis,
- urine dip, bloods (including amylase).
- If the patient is unwell, consider a urinary catheter and/or nasogastric tube if necessary, monitor fluid balance.
what is peritonism? how does it present?
Peritonism (not peritonitis) refers to the localised inflammation of the peritoneum, usually due to inflammation of a viscus that then irritates the visceral (and subsequently, parietal) peritoneum.
This leads to patients stating that their abdominal pain starts in one place (irritation of the visceral peritoneum) before localising to another area* (irritation of the parietal peritoneum) or becoming generalised.
The classic example of this is acute appendicitis, with the pain migrating from the umbilical region to the right iliac fossa
describe colicky pain and give examples
Colic is an abdominal pain that crescendos to become very severe and then goes away completely. The most common types of colic are seen in biliary colic, ureteric colic, and bowel obstruction.
how does an ischaemic bowel disease present?
3 types: acute mesenteric ischaemia, chronic mesenteric ischaemia, and colonic ischaemia.
Any patient who has severe pain out of proportion to the clinical signs has ischaemic bowel until proven otherwise.
Patients will often complain of a diffuse and constant pain, however the examination can often otherwise be unremarkable.
The clinical course may range from transient and reversible to fulminant.
Can present post MI or similar event
what are ivx findings of ischaemic bowel?
FINISH
They are often acidaemic with a raised lactate and physiologically compromised.
what is the aetiology of ischaemic bowel disease?
Arterial:
emboli, thrombosis, vasculitis
Venous:
Thrombosis
Hypoperfusion:
shock (heart failure, dialysis), infection, trauma, drugs
Complications of iscahemic bowel?
- Fear of food, Short bowel syndrome, Stricture
- Perforation, infarction, peritonitis
Mx of ischaemic bowel?
Imaging:
Definitive diagnosis is via a CT scan with IV contrast.
Rx:
Refer to surgical team
- If evidence of complications; perforation, infarction, peritonitis
A. Resuscitation + supportive
B. Empirical abx
C. Correct cause / surgery- embolectomy / bowel resection
D. Post op Anticoagulation - heparin - No evidence of complications
A. Resuscitation + supportive
C. Correct cause / surgery- embolectomy / bowel resection
D. Post op Anticoagulation - heparin
how does peritonitis present?
Patients with a generalised peritonitis present will often lay completely still (not to move their abdomen) and look unwell; this is especially important when compared to a renal colic, whereby patients are constantly moving and cannot get comfortable.
On examination, they will show signs of:
Tachycardia and potential hypotension
A completely rigid abdomen with percussion tenderness
Involuntary guarding – the patient involuntarily tenses their abdominal muscles when you palpate the abdomen
Reduced or absent bowel sounds, suggesting the presence of a paralytic ileus
what is a paralytic Ileus?
Paralytic ileus is the condition where the motor activity of the bowel is impaired. Neuromuscular failure involving the myenteric (Auerbach’s) and submucous (Meissner’s) plexus.
The intestine fails to transmit peristaltic waves, resulting in a functional obstruction, allowing fluid and gas to collect in the intestine.
It is the small intestine that is predominantly affected, but the colon and stomach could also be involved.
Although the condition may be self‐limiting, it is serious and if prolonged and untreated will result in death
how does ileus presnt?
The resultant stasis leads to accumulation of fluid and gas within the bowel with associated distension, vomiting, decrease of bowel sounds, and absolute constipation.
peritonitis can cause Ileus
ivx findings in ileus?
AXR:
- Generalised distension of small and large bowel
- Air fluid levels in bowel
causes of peritonitis?
perforation of an abdominal viscus.
The causes of perforation are broad but include peptic ulceration, small or large bowel obstruction, diverticular disease, and inflammatory bowel disease.
Which acute abdomen causes require most urgent intervention?
Bleeding: Ruptured AAA Ectopic pregnancy Trauma Gastric ulcer
what are the forms of bowel obstruction?
Small bowel obstruction:
- Partial: partial passage of flatus and occasionally stool. This is not a surgical emergency and it may resolve with non-operative therapy
- Complete: cannot pass flatus or stool.
- complicated: with perforation or ischaemia or necrosis
aetiology of bowel obstruction?
Previous surgery with the formation of intra-abdominal adhesions, including colorectal/gynaecological surgery, resection of intra-abdominal tumours, laparotomy for trauma
Inguinal hernia with incarceration; ventral, incisional, umbilical, and parastomal hernias
Crohn’s disease
Intestinal malignancy
Appendicitis.
signs of small bowel obstruction ?
No flatus or stool - constipation
Abdominal pain - intermittent,cramping,severe
Vomiting - billous (if faecolent: wont improve w/o surgical intervention)
Abdominal distension
Abdominal tenderness
Guarding - localised or generalised (this indicates peritonitis!)
often fever and tacchy is present
whta tests do we do for SBO - small bowel obstruction?
- ABG + Lactate - for poor tissue perfusion. metabolic alkalosis
2. Bloods: FBC - wcc + cup increased U&Es - dehydration amylase - rule out pancreatitis glucose - rule out dka G&S, Xmatch, clotting - ahead of surgery
- CT Abdo:
- identify cause
how do we mx SBO?
Surgery needed:
- Supportive - fluid resus, analgesia (morphine)
- NG tube decompression
- Surgery - general surgeons v. urgent
No Surgery needed:
steps 1+2 + treat underlying cause
Stomas teaching
Okay
Types of stomas?
Colostomy
Ileostomy
Urostomy
Jejunostoym - rare
Define stoma
Surgically created opening between a hollow viscus and abdominal wall
Types of stoma
End stoma
Defubctionung stoma - to give rest to bowel when distal bowel healing in anastamosis
How to tell ielostomy and colostomy apart
Ileostomy ;
Iliac fossa - rif
Usually spouted (extended away from skin) due to irritation to skin from enzymes from output
Closer to stomach so output is loose fluid
Colostomy:
Lif
Output looks more faecal especially the more distal it is (sigmoid colostomy)
See slides AND GEEKY MEDICS
Complications of stoma?
Infection Dehiscense Prolaspe and perforation High output -> dehydration Necrosis
Where do we site stomas?
Above waistline so dorsnt catch on clothes
Anterior aspect so pt can care for stoma
When presenting a patient with a stoma, how do you describe the stoma?
See notes
Purpose of surgical f drain
Slides
what is an ileal conduit?
a loop of bowel that has been connect to the ureters.
Done after bladder removal eg due to cancers!
the product is urine.
dont confuse for ileostomy - check contents of bag.
What are the 3 criteria for NG to be satisfactory?
Has to bifurcate the carina
Has to pass the diaphrgam margin
Has to be on left side of abdomen or body
