(gastro) disorders of the upper gastrointestinal tract Flashcards
what are the surgical causes of upper abdominal pain?
peptic ulcer disease/GORD
pancreatitis
biliary pathology
abdominal wall pathology
vascular problems
bowel problems
what are the non-surgical causes of upper abdominal pain?
cardiac
gastroenterological
musculoskeletal
diabetes
dermatological (if you press and pain goes away, nothing to worry = as problem is usually external, but if pain remains = problem internal, more difficult to manage)
what are the four quadrants of the abdomen?
right upper quadrant (RUQ)
right lower quadrant (RLQ)
left upper quadrant (LUQ)
left lower quadrant (LLQ)
to investigate abdominal pain, which scans are most commonly used and why?
chest x-ray (CXR)
abdominal x-ray (AXR)
= easy & quick so can look for obstructions or perforations
define pyrexial
of an increased body temperature (i.e. fever)
what is a perforated viscus?
loss of gastrointestinal wall integrity with subsequent leakage of enteric contents and air
what are the classic signs of a perforated viscus on a CXR and an AXR?
free subdiaphragmatic air
Rigler’s sign
what is free subdiaphragmatic air?
air under the right and left diaphragm
what is Rigler’s sign?
free intraperitoneal air
i.e. gas within the bowel’s lumen and gas within the peritoneal cavity (on both sides of the bowel wall)
what does this CXR show?
free subdiaphragmatic air
what do the following AXRs show?
Rigler’s sign = free intraperitoneal air
what can a perforated viscus lead to?
acute peritonitis
explain how can a perforated viscus lead to acute peritonitis
intestinal/bowel perforation
= subsequent leakage of enteric contents into the peritoneal cavity
= systemic inflammatory response of peritonitis
= can lead to sepsis
what do the following abdominal CT scans show?
Rigler’s sign - air present both in the bowel and in the region outside the bowel
what is the pre-operative management of acute peritonitis?
NGT (nasogastric tube)
NBM (nil by mouth)
IV fluids
antibiotics
why is a patient with acute peritonitis given an NGT?
carries nutrients through the nose to the stomach
= placed to decompress the bowel + administer nutrition and medication to patients who cannot tolerate oral intake (i.e. will exit the GI tract via perforation)
why are patients with acute peritonitis NBM?
nil by mouth because if anything goes down their GI tract, it can exit the system via the perforation
what are the steps to the operative management of a patient with acute peritonitis?
1) identification of the aetiology of peritonitis
2) eradication of peritoneal source of contamination
3) peritoneal lavage and drainage
what is the treatment for perforated ulcers?
- conservative treatment (Taylor’s approach)
- radical surgery (vagotomy, gastrectomy)
what must you administer to a pre-op acute peritonitis patient?
loads of antibiotics and IV fluids
when is conservative management used to treat for perforated ulcer?
not clinically symptomatic
not fit enough for an operation
if perforation has sealed up itself
with clinically localised peritonitis
what is a vagatomy?
a surgical operation in which one or more branches of the vagus nerve are cut, typically to reduce the rate of gastric secretion (e.g. in treating peptic ulcers)
what is a gastrectomy?
a medical procedure where all or part of the stomach is surgically removed
why is peritoneal lavage important?
lots of fluid to wash out debris, gastric content, bacteria and contamination
what is peritoneal drainage following lavage important?
to ensure anything that needs to come out does so and no longer remains in the GI tract
what is the most common site of perforation in the GI tract in ulcerative disease?
anterior-superior surface of first part of the duodenum or pylorus
(rarely on the pre-pyloric antrum)
(less frequently in the lesser curvature and fundus of the stomach)
(rarely on the posterior surface of the first part of the duodenum/stomach)
where are perforations possible but rare in the GI tract?
pre-pyloric antrum
lesser curvature and fundus of the stomach
the posterior surface of the first part of the duodenum/stomach
how does duodenal perforation compare to gastric perforation?
duodenal is x10 more likely than gastric
how common are first-time acute ulcers?
occur in patients with no history of ulceration in 25-30% of cases
what is the most preferred form of surgery to treat perforated ulcers?
laparoscopic omental patch
how is a laparoscopic omental patch surgically placed?
take a section of the omentum
place it over the perforation with three stitches on either side
!! not too tight = omentum can become ischaemic and necrotic !!
peritoneal lavage and drainage to remove all bacterial contents and prevent infection
what must you ensure does not happen when an omental patch is placed?
do not suture the omental patch too tightly
= omentum can become ischaemic and necrotic
why must you do after placing a laparoscopic mental patch and why?
peritoneal lavage and drainage to remove all bacterial contents and prevent infection
what does the following CXR show?
pneumonia
what is the most common cause of infection in upper abdo surgery patients?
pneumonia
= particularly prone to chest infections
are leaks from omental patch sites common?
not really
what is an intra-abdominal collection?
small pocket of fluid remains due to inefficient/lack of peritoneal lavage and drainage
becomes contaminated and bacteria proliferate
how is persistent pneumonia prevented?
extensive lavage to prevent bacterial contents from leaking everywhere forming pockets of pus and leaking
how is an intra-abdominal collection treated?
percutaneous drainage
which blood results are commonly seen in a patient with gallstone pancreatitis?
elevated serum amylase
raised CRP (due to pancreatic inflammation)
may have abnormal LFTs are well
how is the severity of acute pancreatitis assessed?
modified Glasgow criteria
(or Ranson’s criteria = uncommon)
what is the modified Glasgow criteria?
P - PO2 < 8kPa
A - age > 55 years
N - WCC > 15
C - calcium < 2mmol/L
R - renal:urea > 16mmol/L
E - enzymes: AST > 200iu/L, LDH > 600 iu/L
A - albumin < 32 g/L
S - sugar > 10mmol/L
what is an alternative to the modified Glasgow criteria for assessing the severity of acute pancreatitis?
Ranson’s criteria (only takes into account age, WCC, enzyme levels and sugar)
what score on the modified Glasgow criteria indicates severe pancreatitis?
score of 3 or >3 within 48 hours of onset
= severe pancreatitis
what do patients with severe pancreatitis require?
referral to HDU or intensive care
why is CRP important in assessing the severity of pancreatitis?
independent predictor of severity (but should be interpreted in context)
>200 = severe pancreatitis
how is acute pancreatitis managed?
most cases of pancreatitis will settle with conservative management (i.e. fluid resuscitation)
can try four principles of management (fluid resuscitation, analgesia, pancreatic rest - with nutritional support, determining the underlying cause)
if severe pancreatitis on scoring = HDU
surgery very rarely required
what are the four principles of management for acute pancreatitis?
fluid resuscitation (IV fluids, urinary catheter, strict fluid balance monitoring)
analgesia
pancreatic rest (+/- nutritional support if prolonged recovery = NJ feeding)
determining underlying cause
are antibiotic used to treat pancreatitis?
only if pancreatitis = necrotic or infected
but not usually otherwise as the acute inflammatory reaction can have other causes apart from infection
what is the best imaging investigation for gallstones?
ultrasound scan
what is an MRCP and when is it used?
specialised MRI exam that evaluates the hepatobiliary and pancreatic systems
- to produce pictures of the liver, gallbladder, pancreas and bile ducts
are CT scans used to visualise gallstones?
no - they cannot visualise gallstones very well
why must an MRCP be done before an ERCP can be done?
endoscopic procedure can increase the risk of endoscopic perforation
= so no ERCP until you can prove there is definitely a stone to remove via an MRCP
what is colicky pain?
pain that comes and goes (i.e. is not constant)
what is Murphy’s sign?
elicited in patients with acute cholecystitis
(elicited by asking the patient to take in and hold a deep breath while palpating the right subcostal area)
(if pain occurs when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive)
explain how a patient is examined for Murphy’s sign
asking the patient to take in and hold a deep breath while palpating the right subcostal area
if pain occurs when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive
what does a positive Murphy’s sign indicate?
acute cholecystitis (inflammation of the gallbladder)
how is cholecystitis treated?
usually a laparoscopic cholecystectomy (keyhole surgery for removal of gallbladder)
or conservatively (IV antibiotics and fluid resuscitation)
which two structures need to be identified and divided during a laparoscopic cholecystectomy?
cystic duct (differentiated from the common bile duct) and cystic artery (differentiated from the hepatic artery)
what kind of scan is this and what does it show?
ultrasound scan
= confirms presence of gallstones (w an ‘acoustic shadow’)
what kind of scan is this and what does it show?
MRCP
= confirms the presence of gallstones: here, in the common bile duct
what is the following procedure and why is it carried out?
ERCP
= used to diagnose and treat problems in the liver, gallbladder, bile duct and pancreas (e.g. remove gallstones from CBD)
what is the following scan and what does it show?
abdominal CT
= shows an inflamed gallbladder in the top left quadrant
