Gastro - General Surgery Flashcards
What does PC stand for? What is it?
→ presenting complaint
→ pain assessment using SOCRATES
→ associated symptoms
What does SOCRATES stand for?
S = site O = onset C = character R = radiation A = association T = time course E = exacerbating / relieving factors S = severity
What is the general approach when a patient comes in with acute abdomen issues?
→ PC → past medical history → drug history → social history → range of investigations → manage patient
What are the range of investigations that can be done for a patient?
→ Bloods: VBG, FBC, CRP, U&Es (renal profile), LFTs +amylase
→ Urinalysis + Urine MC&S
→ Imaging: Erect CXR, AXR, CTAP, CT angiogram, USS
→ Endoscopy
What is involved in the general approach of management?
→ ABCDE management
→ Conservative management
→ Surgical management
What is ABCDE management?
A = airways B = breathing C = circulation D = disability E = exposure
What are some the differentials for pain in the RUQ?
→ Bilary Colic → Cholecystitis/Cholangitis → Duodenal Ulcer → Liver abscess → Portal vein thrombosis → Acute hepatitis → Nephrolithiasis → RLL pneumonia
What are some of the differentials of pain in the epigastrium?
→ Acute gastritis/GORD → Gastroparesis → Peptic ulcer disease/perforation → Acute pancreatitis → Mesenteric ischaemia → AAA (Abdominal Aortic Aneurysm) → Aortic dissection → Myocardial infarction
What are some of the differentials for pain in the LUQ?
→ Peptic ulcer → Acute pancreatitis → Splenic abscess → Splenic infarction → Nephrolithiasis → LLL Pneumonia
What are some of the differentials for pain in the RLQ?
→ Acute Appendicitis → Colitis → IBD → Infectious colitis → Ureteric stone/Pyelonephritis → PID/Ovarian torsion → Ectopic pregnancy → Malignancy
What are some of the differentials for pain in the suprapubic / central region?
→ Early appendicitis → Mesenteric ischaemia → Bowel obstruction → Bowel perforation → Constipation → Gastroenteritis → UTI/Urinary retention → PID (Pelvic inflammatory disease) (female reproductory organ infection)
What are some of the differentials for pain in the LLQ?
→ Diverticulitis → Colitis → IBD (Inflammatory Bowel Disease) → Infectious colitis → Ureteric stone/Pyelonephritis → PID/Ovarian torsion → Ectopic pregnancy → Malignancy
What is bowel ischaemia?
→ when the blood flow through the major arteries that supply blood to your intestines slows or stops
→ tissue in intestines begins to die
What is the clinical presentation of bowel ischaemia?
→ Sudden onset crampy abdominal pain
→ Severity of pain depends on the length and thickness of colon affected
→ Bloody, loose stool (currant jelly stools)
→ Fever, signs of septic shock
What are the risk factors for bowel ischaemia?
→ Age >65 yr → Cardiac arrythmias (mainly AF), atherosclerosis → Hypercoagulation/thrombophilia → Vasculitis → Sickle cell disease → Profound shock causing hypotension
What are the 2 different types of bowel ischaemia?
→ acute mesenteric ischaemia
→ ischaemic colitis
Where does acute mesenteric ischaemia occur?
small bowel
What usually causes acute mesenteric ischaemia?
usually occlusive, due to thromboemboli
What is the onset of acute mesenteric ischaemia?
sudden onset, but presentation + severity can vary
What is the abdominal pain caused by acute mesmeric ischaemia like?
abdo pain out of proportion of clinical signs
Where does ischaemic colitis occur?
large bowel
What usually causes ischaemic colitis?
usually due to non-occlusive low flow states or atherosclerosis
What is the onset of ischaemic colitis?
more mild + gradual (80-85% of cases)
What is the abdominal pain caused by ischaemic colitis like?
moderate pain + tenderness
What bloods should be done to investigate bowel ischaemia? What are the markers to look for?
→ FBC : look for neutrophilic leukocytosis
→ VBG : look for lactic acidosis (form of metabolic acidosis, associated with late stage mesenteric ischaemia)
What imaging should be done to investigate bowel ischaemia?
→ CTAP / CT angiogram
→ endoscopy
Why use CTAP / CT angiogram to investigate bowel ischaemia?
to look for + detect:
→ vascular stenosis
→ disrupted flow
→ pneumatosis intestinalis (transmural ischaemia / infarction)
→ ischaemic colitis (looks like a thumbprint)
Why do an endoscopy for bowel ischaemia?
for mild + moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)
What kind of bowel ischaemia can be managed conservatively?
mild to moderate cases of ischaemic colitis
How is mild to moderate ischameic colitis managed conservatively?
→ IV fluid resuscitation
→ Bowel rest
→ Broad-spectrum ABx - colonic ischaemia can result in bacterial translocation & sepsis
→ NG tube for decompression - in concurrent ileus (no peristalsis)
→ Anticoagulation
→ Treat/manage underlying cause
→ Serial abdominal examination and repeat imaging
What are the indications that bowel ischaemia should be managed surgically?
→ Small bowel ischaemia → Signs of peritonitis orsepsis → Haemodynamic instability → Massive bleeding → Fulminant colitis with toxic megacolon
What are the two ways in which bowel ischaemia is surgically managed?
→ exploratory laparotomy
→ endovascular revascularisation
What is the process of exploratory laparotomy?
→ resection of necrotic bowel
→ +/- open surgical embolectomy or mesenteric arterial bypass
What is the process of endovascular revascularisation?
→ done before going into theatre
→ more common in choleric ischaemic patients
→ Balloon angioplasty / thrombectomy
→ In patients without signs of ischaemia
What is the clinical presentation of acute appendicitis?
→ Initially periumbilical pain that migrates to RLQ (within 24hours) → Anorexia → nausea +/- vomiting → low grade fever → change in bowel habit
What are some important clinical signs of acute appendicitis?
→ McBurney’s point → Blumberg sign → Rovsing sign → Psoas sign → Obturator sign
What is McBurney’s point or sign?
→ tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
→ where the appendix is
What is the Blumberg sign?
rebound tenderness especially in the RIF
What is the Rovsing sign?
RLQ pain elicited on deep palpation of the LLQ
What is the Psoas sign?
RLQ pain elicited on flexion of right hip against resistance
What is the Obturator sign?
RLQ pain on passive internal rotation of the hip with hip & knee flexion
What bloods should be done to investigate acute appendicitis?
→ FBC : look for neutrophilic leukocytosis and increased CRP
→ Urinalysis : possible mild pyuria/haematuria
→ Electrolyte imbalances in profound vomiting
What imaging should be done for acute appendicitis?
→ CT : gold standard in adults esp. if age > 50
→ USS: children /pregnancy /breastfeeding
→ MRI : in pregnancy if USS inconclusive
What can be done for acute appendicitis if imaging is inconclusive but patient still in persistent pain?
→ diagnostic laparoscopy
*What is the Alvarado scoring criteria?
→ RLQ tenderness → fever → rebound tenderness → pain migration → anorexia → nausea +/- vomiting → WCC > 10 → Nuetrophilia
What is the conservative management for acute appendicitis?
→ IV Fluids
→ Analgesia
→ IV or PO Antibiotics
→ In abscess, phlegmon or sealed perforation, Resuscitation + IV Antibiotics +/- percutaneous drainage
*What is a simple obstruction vs. a strangulating obstruction?
→ Simple: bowel is occluded without damage to blood supply.
→ Strangulating: blood supply of involved segment of intestine is cut off (e.g. in strangulated hernia, volvulus, intussusception (in picture))
*What are some common hernial sites?
→ epigastric → umbilical → incisional → inguinal → femoral
*What is a Richter’s hernia?
hernia that doesn’t cause bowel obstruction
What does an SBO CXR look like?
Dilated small bowel loops >3cm proximal to the obstruction (central)
What does an LBO CXR look like?
Dilated large bowel >6cm (if caecum >9cm) predominantly peripheral
What makes a SBO from an LBO on X-rays?
→ Ladder pattern of dilated loops & their central position
→ Striations that pass completely across the width of the distended loop produced by the circular mucosal folds.
*What makes an LBO AXR distinct from a SBO AXR?
→ Distended large bowel tends to lie peripherally
→ Show haustrations of taenia coli - do not extend across whole width of the bowel.
*What imaging can be done to investigate GI perforations?
→ Erect CXR: subdiaphragmatic free air (pneumoperitoneum)
→ CT abdo/pelvis: Pneumo-peritoneum, free GI content,localised mesenteric fat stranding, can exclude common differential diagnoses such as pancreatitis
