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 are the indications for conservative management of acute appendicitis?
→ After negative imaging in selected patients with clinically uncomplicated appendicitis
→ In delayed presentation with abscess/phlegmon formation (use CT-guided drainagefirst before considering interval appendectomy)
What is the rate of recurrence for acute appendicitis after conservative management?
12-24%
What are the 2 ways in which acute appendicitis can be surgically managed?
→ laparoscopic appendectomy
→ open appendectomy
What are the advantages of laparoscopic over open appendectomy?
→ Less pain → Lower incidence of surgical site infection → ↓ed length of hospital stay → Earlier return to work → Overall costs → Better quality of life scores
What is the process of laparoscopic appendectomy?
→ Trocar placement (usually 3)
→ Exploration of RIF & identification of appendix
→ Elevation of appendix + division of mesoappendix (containing artery)
→ Based secured with endoloops and appendix is divided
→ Retrieval of appendix with a plastic retrieval bag
→ Careful inspection of the rest of the pelvic organs/intestines
→ Pelvic irrigation (wash out) + Haemostasis
→ Removal of trocars + wound closure
What is a bowel obstruction?
restriction of normal passage of intestinal contents
What are the 2 main groups of bowel obstructions?
→ paralytic (adynamic ileus)
→ mechanical
How are mechanical obstructions classified?
→ Speed of onset: acute, chronic, acute-on-chronic
→ Site: high or low
roughly synonymous with small or large bowel obstruction
→ Nature: simple vs strangulating
*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 the different groups of causes of mechanical bowel obstruction?
→ Causes in the lumen
→ Causes in the wall
→ Causes outside the wall
What can cause mechanical bowel obstruction in the lumen?
→ faecal impaction
→ gallstone ‘ileus’
What can cause mechanical bowel obstruction in the wall?
→ Crohn’s disease
→ tumours
→ diverticulitis of colon
What can cause mechanical obstruction outside of the wall?
→ Strangulated hernia (external or internal)
→ Volvulus
→ Obstruction due to adhesions or bands
What are some common causes of small bowel obstruction and their prevalences?
→ Adhesions (60%) Hx of previous abdominal surgery → Neoplasia (20%) Primary, Metastatic, Extraintestinal → Incarcerated hernia (10%) External (abdominal wall), Internal (mesenteric defect) → Crohn's Disease (5%) Acute (oedema), Chronic (strictures) → Other (5%) Intussusception, intraluminal (foreign body, bezoar)
What are some common large bowel obstructions?
→ Colorectal carcinoma → Volvulus Sigmoid, Caecal → Diverticulitis Inflammation, strictures → Faecal impaction → Hirschsprung disease commonly found in infants/children
What is the clinical presentation of vomiting in SB obstruction?
early onset
large amounts
bilious
What is the clinical presentation of constipation in SB obstruction?
late sign
What is the clinical presentation of distention in small bowel obstruction?
less significant
What kind of pain does LB obstruction present with?
colicky or constant
What is the clinical presentation of vomiting in LB obstruction?
late onset
initially billious
progresses to faecal vomiting
What is the clinical presentation of constipation in LB obstruction?
early sign
What is the clinical presentation of distention in LB obstruction?
early sign + significant
What are some other signs of bowel obstruction?
→ Dehydration
→ Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign)
→ Diffuse abdominal tenderness
What is important when diagnosing bowel obstruction?
→ diagnosed by presence of symptoms
→ examination should always include search for hernias + abdominal scars, including laparoscopic portholes
→ assess whether any hernias are simple or strangulating
What is a simple bowel obstruction compared to a strangulating one?
→ simple = bowel is still viable
→ strangulating = bowel is no longer viable
What features suggest a strangulating hernia?
→ Change in character of pain from colicky to continuous
→ Tachycardia
→ Pyrexia (fever)
→ Peritonism (localised inflammation of bowel)
→ Bowel sounds absent or reduced
→ Leucocytosis
→ increased CRP
What is the mortality rates of strangulating obstruction with peritonitis?
up to 15%
*What are some common hernial sites?
→ epigastric → umbilical → incisional → inguinal → femoral
*Why is the neck of a hernia sac important?
→ very narrow hernia sac increases chances of it being a strangulated hernia
→ larger neck = higher chances of bowel being able to slip in and out more easily
*What is a strangulated hernia?
→ bowel can’t escape the hernia
→ blood supply to + from bowel is constricted
→ bowel becomes ischaemic + is no longer viable
*What is a Richter’s hernia?
hernia that doesn’t cause bowel obstruction
What are the bloods that can be done to investigate bowel obstruction?
→ WCC/CRP usually normal (if raised suspicion of strangulation/perforation)
→ U&E: electrolyte imbalance
→ VBG if vomiting: HypoCl-,HypoK+ metabolic alkalosis
→ VBG if strangulation: Metabolic Acidosis (lactate)
What imaging can be done to investigate bowel obstruction?
→ erect CXR
→ erect + supine Abdo XR
→ CT abdo/pelvis
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 can CT scan detect in case of bowel obstruction?
→ Can localise site of obstruction
→ Detect obstructing lesions & colonic tumours
→ May diagnose unusual hernias (e.g. obturator hernias).
- What would a CT scan show in SBO?
Collapsed & dilated loops of small bowel due to transition point in the pelvis
- What would a CT scan show in LBO?
Sigmoid stricture with
proximal dilation
Can bowel obstruction patients be conservatively managed?
Yes, in patients with no signs of ischaemia/no signs of clinical deterioration
What is some supportive management for bowel obstruction?
→ NBM
→ IV peripheral access with large bore cannula with IV Fluid resuscitation
→ IV analgesia, IV antiemetics, correction of electrolyte imbalances
→ NG tube for decompression, urinary catheter for monitoring output
→ Introduce gradual food intake if abdominal pain and distention improve
What is some conservative management for bowel obstruction?
→ Faecal impaction: stool evacuation (manual, enemas, endoscopic)
→ Sigmoid volvulus: rigid sigmoidoscopic decompression (tube that straightens out colon)
→ SBO: oral gastrograffin (highly osmolar iodinated contrast agent)can be used to resolve adhesionalsmall bowel obstruction
What are the indications for surgical management in bowel obstruction?
→ Haemodynamic instability or signs of sepsis
→ Complete bowel obstruction with signs of ischaemia
→ Closed loop obstruction
→ Persistent bowel obstruction >2 days despite conservative management
What surgeries can be done for bowel obstruction?
→ Exploratory Laparotomy / Laparoscopy
→ Restoration of intestinal transit (depending on intra-operational findings)
→ Bowel resection with primary anastomosis or temporary/permanent stoma formation
What symptoms does GI perforation clinically present with?
→ Sudden onset severe abdominal pain associated with distention
→ Diffuse abdominal guarding, rigidity, rebound tenderness
→ Pain aggravated by movement
→ Nausea, vomiting, absolute constipation
→ Fever, Tachycardia, Tachypnoea, Hypotension
→ Decreased or absent bowel sounds
What are 4 common + distinct GI perforations?
→ perforated peptic ulcer
→ perforated diverticulum
→ perforated appendix
→ perforated malignancy
What is distinct in clinical perforation of a perforated peptic ulcer?
→ Sudden epigastric or diffuse pain
→ Referred shoulder pain
→ Hx of NSAIDs, steroids, recurrent epigastric pain
What is distinct in clinical perforation of a perforated diverticulum?
→ LLQ pain
→ Constipation
What is distinct in clinical perforation of a perforated appendix?
→ Migratory pain
→ Anorexia
→ Gradual worsening RLQ pain
What is distinct in clinical perforation of a perforated malignancy?
→ Change in bowel habit
→ Weight loss
→ Anorexia
→ PR Bleeding
What bloods can be done to investigate GI perforation? What is being looked for?
→ FBC: neutrophilic leukocytosis
→ Possible elevation of Urea, Creatinine
→ VBG: Lactic acidosis
*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
What are the differential diagnosis for GI perforation?
→ Acute cholecystitis
→ Appendicitis
→ Myocardial infarction
→ Acute pancreatitis
What is the supportive management given to patient on presentation with GI perforation?
→ NBM & NG tube → IV peripheral access with large bore cannula -IV Fluid resuscitation → Broad spectrum Abx → IV PPI → Parenteral analgesia & antiemetics → Urinary catheter
Can GI perforations be conservatively managed?
only in localised peritonitis without signs of sepsis - very rare
What is conservative management for GI perforations?
→ IR - guided drainage of intra-abdominal collection
→ Serial abdominal examination & abdominal imaging for assessment
What is the surgical management for generalised peritonitis +/- signs of sepsis?
→ Exploratory laparotomy/laparascopy
→ Primary closure of perforation with or withoutomental patch (most common in perforated pepticulcer)
→ Resection of theperforated segment of the bowelwith primary anastomosis or temporary stoma
→ Obtainintra-abdominal fluid for MC&S, peritoneal lavage
→ If perforated appendix: Lap or open appendicectomy
→ If malignancy: intraoperative biopsies if possible
What are the symptoms of biliary colic?
→ PostprandialRUQ pain with radiation to the shoulder.
→ Nausea
What are the investigations for biliary colic, and what results indicate biliary colic?
→ Normal blood results
→ USS: cholelithiasis (presence of gall stones)
What is the management for biliary colic?
→ Analgesia
→ Antiemetics (drugs to help with nausea + vomiting)
→ Spasmolytics (drugs to relieve spasming of the smooth muscle)
→ Follow up for elective cholecystectomy
What are the symptoms of acute cholecystitis?
→ Acute, severe RUQ pain
→ Fever
→ Murphy’s sign
What are the investigations for acute cholecystitis, and what results indicate acute cholecystitis?
→ Elevated WCC/CRP
→ USS: thickened gallbladder wall
What is the management for acute cholecystitis?
→ Fluids, ABx, Analgesia, Blood cultures
→ Early (<72 hours) or elective cholecystectomy (4-6 weeks)
What are the symptoms of acute cholangitis?
Charcot’s triad:
→ jaundice,
→ RUQ pain,
→ fever
What are the investigations for acute cholangitis, and what results indicate acute cholangitis?
- Elevated LFTs, WCC, CRP, Blood MCS (blood culture) (+ve)
* USS: bilary dilatation
What is the management for acute cholangitis?
- Fluids, IV Abx, Analgesia
* ERCP (endoscopic retrograde cholangio pancreatography) (within 72hrs) for clearance of bile duct or stenting
What are the symptoms of acute pancreatitis?
→ Severe epigastric pain radiating to the back
→ Nausea +/- vomiting
→ Hx of gallstones or alcohol use
What are the investigations for acute pancreatitis, and what results indicate acute pancreatitis?
→ Raised amylase/lipase
→ High WCC/Low Ca2+
→ CT and US to assess for complications/cause
What is the management for acute pancreatitis?
→ Admission score (Glasgow-Imrie)
→ Aggressive fluid resuscitation, O2
→ Analgesia, Antiemetics
→ ICU/HDU involvement
