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brs (phase 1b) > (gastro) disorders of the upper gastrointestinal tract > Flashcards

(gastro) disorders of the upper gastrointestinal tract Flashcards

1
Q

what are the surgical causes of upper abdominal pain?

A

peptic ulcer disease/GORD

pancreatitis

biliary pathology

abdominal wall pathology

vascular problems

bowel problems

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2
Q

what are the non-surgical causes of upper abdominal pain?

A

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)

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3
Q

what are the four quadrants of the abdomen?

A

right upper quadrant (RUQ)
right lower quadrant (RLQ)

left upper quadrant (LUQ)
left lower quadrant (LLQ)

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4
Q

to investigate abdominal pain, which scans are most commonly used and why?

A

chest x-ray (CXR)
abdominal x-ray (AXR)

= easy & quick so can look for obstructions or perforations

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5
Q

define pyrexial

A

of an increased body temperature (i.e. fever)

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6
Q

what is a perforated viscus?

A

loss of gastrointestinal wall integrity with subsequent leakage of enteric contents and air

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7
Q

what are the classic signs of a perforated viscus on a CXR and an AXR?

A

free subdiaphragmatic air

Rigler’s sign

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8
Q

what is free subdiaphragmatic air?

A

air under the right and left diaphragm

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9
Q

what is Rigler’s sign?

A

free intraperitoneal air

i.e. gas within the bowel’s lumen and gas within the peritoneal cavity (on both sides of the bowel wall)

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10
Q

what does this CXR show?

A

free subdiaphragmatic air

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11
Q

what do the following AXRs show?

A

Rigler’s sign = free intraperitoneal air

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12
Q

what can a perforated viscus lead to?

A

acute peritonitis

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13
Q

explain how can a perforated viscus lead to acute peritonitis

A

intestinal/bowel perforation

= subsequent leakage of enteric contents into the peritoneal cavity

= systemic inflammatory response of peritonitis

= can lead to sepsis

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14
Q

what do the following abdominal CT scans show?

A

Rigler’s sign - air present both in the bowel and in the region outside the bowel

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15
Q

what is the pre-operative management of acute peritonitis?

A

NGT (nasogastric tube)
NBM (nil by mouth)
IV fluids
antibiotics

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16
Q

why is a patient with acute peritonitis given an NGT?

A

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)

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17
Q

why are patients with acute peritonitis NBM?

A

nil by mouth because if anything goes down their GI tract, it can exit the system via the perforation

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18
Q

what are the steps to the operative management of a patient with acute peritonitis?

A

1) identification of the aetiology of peritonitis
2) eradication of peritoneal source of contamination
3) peritoneal lavage and drainage

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19
Q

what is the treatment for perforated ulcers?

A
  • conservative treatment (Taylor’s approach)
  • radical surgery (vagotomy, gastrectomy)
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20
Q

what must you administer to a pre-op acute peritonitis patient?

A

loads of antibiotics and IV fluids

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21
Q

when is conservative management used to treat for perforated ulcer?

A

not clinically symptomatic

not fit enough for an operation

if perforation has sealed up itself

with clinically localised peritonitis

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22
Q

what is a vagatomy?

A

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)

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23
Q

what is a gastrectomy?

A

a medical procedure where all or part of the stomach is surgically removed

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24
Q

why is peritoneal lavage important?

A

lots of fluid to wash out debris, gastric content, bacteria and contamination

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25
Q

what is peritoneal drainage following lavage important?

A

to ensure anything that needs to come out does so and no longer remains in the GI tract

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26
Q

what is the most common site of perforation in the GI tract in ulcerative disease?

A

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)

27
Q

where are perforations possible but rare in the GI tract?

A

pre-pyloric antrum

lesser curvature and fundus of the stomach

the posterior surface of the first part of the duodenum/stomach

28
Q

how does duodenal perforation compare to gastric perforation?

A

duodenal is x10 more likely than gastric

29
Q

how common are first-time acute ulcers?

A

occur in patients with no history of ulceration in 25-30% of cases

30
Q

what is the most preferred form of surgery to treat perforated ulcers?

A

laparoscopic omental patch

31
Q

how is a laparoscopic omental patch surgically placed?

A

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

32
Q

what must you ensure does not happen when an omental patch is placed?

A

do not suture the omental patch too tightly

= omentum can become ischaemic and necrotic

33
Q

why must you do after placing a laparoscopic mental patch and why?

A

peritoneal lavage and drainage to remove all bacterial contents and prevent infection

34
Q

what does the following CXR show?

A

pneumonia

35
Q

what is the most common cause of infection in upper abdo surgery patients?

A

pneumonia

= particularly prone to chest infections

36
Q

are leaks from omental patch sites common?

A

not really

37
Q

what is an intra-abdominal collection?

A

small pocket of fluid remains due to inefficient/lack of peritoneal lavage and drainage

becomes contaminated and bacteria proliferate

38
Q

how is persistent pneumonia prevented?

A

extensive lavage to prevent bacterial contents from leaking everywhere forming pockets of pus and leaking

39
Q

how is an intra-abdominal collection treated?

A

percutaneous drainage

40
Q

which blood results are commonly seen in a patient with gallstone pancreatitis?

A

elevated serum amylase

raised CRP (due to pancreatic inflammation)

may have abnormal LFTs are well

41
Q

how is the severity of acute pancreatitis assessed?

A

modified Glasgow criteria

(or Ranson’s criteria = uncommon)

42
Q

what is the modified Glasgow criteria?

A

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

43
Q

what is an alternative to the modified Glasgow criteria for assessing the severity of acute pancreatitis?

A

Ranson’s criteria (only takes into account age, WCC, enzyme levels and sugar)

44
Q

what score on the modified Glasgow criteria indicates severe pancreatitis?

A

score of 3 or >3 within 48 hours of onset

= severe pancreatitis

45
Q

what do patients with severe pancreatitis require?

A

referral to HDU or intensive care

46
Q

why is CRP important in assessing the severity of pancreatitis?

A

independent predictor of severity (but should be interpreted in context)

>200 = severe pancreatitis

47
Q

how is acute pancreatitis managed?

A

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

48
Q

what are the four principles of management for acute pancreatitis?

A

fluid resuscitation (IV fluids, urinary catheter, strict fluid balance monitoring)

analgesia

pancreatic rest (+/- nutritional support if prolonged recovery = NJ feeding)

determining underlying cause

49
Q

are antibiotic used to treat pancreatitis?

A

only if pancreatitis = necrotic or infected

but not usually otherwise as the acute inflammatory reaction can have other causes apart from infection

50
Q

what is the best imaging investigation for gallstones?

A

ultrasound scan

51
Q

what is an MRCP and when is it used?

A

specialised MRI exam that evaluates the hepatobiliary and pancreatic systems

  • to produce pictures of the liver, gallbladder, pancreas and bile ducts
52
Q

are CT scans used to visualise gallstones?

A

no - they cannot visualise gallstones very well

53
Q

why must an MRCP be done before an ERCP can be done?

A

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

54
Q

what is colicky pain?

A

pain that comes and goes (i.e. is not constant)

55
Q

what is Murphy’s sign?

A

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)

56
Q

explain how a patient is examined for Murphy’s sign

A

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

57
Q

what does a positive Murphy’s sign indicate?

A

acute cholecystitis (inflammation of the gallbladder)

58
Q

how is cholecystitis treated?

A

usually a laparoscopic cholecystectomy (keyhole surgery for removal of gallbladder)

or conservatively (IV antibiotics and fluid resuscitation)

59
Q

which two structures need to be identified and divided during a laparoscopic cholecystectomy?

A

cystic duct (differentiated from the common bile duct) and cystic artery (differentiated from the hepatic artery)

60
Q

what kind of scan is this and what does it show?

A

ultrasound scan

= confirms presence of gallstones (w an ‘acoustic shadow’)

61
Q

what kind of scan is this and what does it show?

A

MRCP

= confirms the presence of gallstones: here, in the common bile duct

62
Q

what is the following procedure and why is it carried out?

A

ERCP

= used to diagnose and treat problems in the liver, gallbladder, bile duct and pancreas (e.g. remove gallstones from CBD)

63
Q

what is the following scan and what does it show?

A

abdominal CT

= shows an inflamed gallbladder in the top left quadrant

brs (phase 1b) (71 decks)

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