🍔Gastro🍔 - Surgery in the GI Tract Flashcards
What is the general approach to acute abdominal issues?
Presenting complaint - SOCRATES, associated symptoms
PMHx, DHx, SHx
Range of investigations - bloods, imaging, endoscopy etc…
Management - ABCDE, conservative, surgical etc…
When does intermittent pain occur in gastro?
Obstruction of hollow viscus - when no pushing pain may go completely
What is the difference between radiation and referred pain?
How is venous blood gas (VBG) helpful in acute abdominal presentations?
Lactate is a marker of anaerobic respiration - ischaemia
What is an erect chest x-ray useful for?
Helps identify air under the diaphragm - e.g. perforation of intraabdominal viscera
What is ultrasound useful for in abdominal presentations?
Looking for liver and gall bladder pathologies
What are the common differentials for RUQ pain?
Biliary Colic
Cholecystitis/Cholangitis
Duodenal Ulcer
Liver abscess
Portal vein thrombosis
Acute hepatitis
Nephrolithiasis
RLL pneumonia
What are the common differentials for epigastric pain?
Acute gastritis/GORD
Gastroparesis
Peptic ulcer disease/perforation
Acute pancreatitis
Mesenteric ischaemia
AAA (Abdominal Aortic Aneurysm) Aortic dissection
Myocardial infarction
What are the common differentials for LUQ pain?
Peptic ulcer
Acute pancreatitis
Splenic abscess
Splenic infarction
Nephrolithiasis
LLL Pneumonia
What are the common differentials for RLQ pain?
RLQ
Acute Appendicitis
Colitis
IBD
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy
What are the common differentials or Suprapubic/central pain?
Early appendicitis
Mesenteric ischaemia
Bowel obstruction
Bowel perforation
Constipation
Gastroenteritis
UTI/Urinary retention
PID
What are the common differentials for LLQ pain?
Diverticulitis
Colitis
IBD (Inflammatory Bowel Disease)
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy
What is the presentation of bowel ischaemia?
Sudden onset crampy abdominal pain - especially after eating
Severity of pain depends on the length and thickness of colon affected
Bloody, loose stool (currant jelly stools) - shedding of mucosa
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
Compare acute mesenteric ischaemia to ischaemic colitis
What investigations should be done for suspected bowel ischaemia?
Bloods - high neutrophils, VBG - lactic acidosis
Imaging CTAP/CT angiogram - distrupted flow, vascular stenosis, Pneumatosis intestinalis, thumbprint sign
Endoscopy - mild/moderate ischaemic colitis (oedema, cyanosis, ulceration)
What is the thumb printing sign?
Disruption between layers
Parts of submucosa bulging out
What are the management options for mild/moderate ischaemic colitis?
Conservative management (not suitable for small bowel ischaemia)
IV fluids
Bowel rest
Broad-spectrum ABx
NG tube for decompression (concurrent ileus)
Anticoagulants
Serial abdominal examination and repeat imaging
Why do you give ABx in the context of ischaemic colitis?
Colonic ischaemia can result in bacterial translocation and sepsis
What are the indications for surgical management of bowel ischaemia?
Small bowel ischaemia
Signs of peritonitis orsepsis
Haemodynamic instability
Massive bleeding
Fulminant colitis with toxic megacolon
What are the surgical options for bowel ischaemia?
Exploratory laparotomy - Resection of necrotic bowel +/- open surgicalembolectomy or mesenteric arterial bypass
Endovascular revascularisation - balloon angioplasty/thrombectomy
In patients without signs of ischaemia
What is McBurney’s point?
Tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
Blumberg sign
Rebound tenderness especially in the right iliac fossa
Rovsing sign
RLQ pain elicited on deep palpation of the LLQ
Psoas sign
RLQ pain elicited on flexion of right hip against resistance
Obturator sign
RLQ pain on passive internal rotation of the hip with hip & knee flexion
What would you see in bloods for acute appndicitis?
FBC - neutrophilic leukocytosis
Eleveated CRP
Urinalysis - possible mild pyuria/haematuria
Electrolyte imbalances (if profound vomiting)
What imaging would be done for acute appendicitis?
CT - gold standard in adults (esp age >50)
Ultrasound - children, pregnancy, breastfeeding
MRI - pregnancy if USS inconclusive
When would you do a diagnostic laparoscopy in acute appendicitis?
Persistent pain and inconclusive imaging
What is the Alvarado score?
What is the conservative management for acute appendicitis?
IV fluids, analgesia, IV/PO antibiotics
What are the indications for conservative management in acute appendicitis?
After negative imaging in selected patients with clinically uncomplicated appendicitisIn IN delayed presentation with abscess or phlegmon formation - CT guided drainage
What should be considered in the case of an appendix abscess/perforation?
Consider interval appendicectomy - rate of recurrence after conservative management of abscess/perforation is 12-24%
What are the advantages of laparoscopic appendicectomy?
Less pain
Lower incidence of surgical site infection
↓ed length of hospital stay
Earlier return to work
Overall costs
Better quality of life scores
Outline the steps of laparoscopic appendicectomy
What are the classifications of bowel obstruction?
Paralytic (adynamic) ileus
Mechanical
How can mechanical intestinal obstruction be classified?
Speed of onset - acute, chronic, acute-on-chronic
Site - high(vomiting, severe pain) or low(constipation)
Nature - simple vs strangulating
Aetiology
What is simple vs strangulating bowel 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)
What are the aetiologies of bowel obstruction?
Compare the aetiologies of small vs large bowel obstructions
Compare the presentation of small and large bowel obstructions
What should be considered when diagnosis bowel obstruction?
Diagnosed by the presence of symptoms
Examination should always include a search for hernias & abdominal scars, including laparoscopic portholes
Is it simple or strangulating?
What features suggest strangulating bowel obstruction
Change in character of pain from colicky to continuous
Tachycardia
Pyrexia
Peritonism
Bowel sounds absent or reduced
Leucocytosis
↑ed C-reactive protein
Why is it so important that strangulating obstructions are caught quickly?
Strangulating obstruction with peritonitis has a mortality of up to 15%
What are the common hernial sites?
What are the common types of hernias?
What are the blood tests for 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 are the imaging options for bowel obstruction?
Erect CXR/AXR
SBO: Dilated small bowel loops >3cm proximal to the obstruction (central)
LBO:Dilated large bowel >6cm (if caecum >9cm) predominantly peripheral
CT abdo/pelvis→ Transition point, dilatation of proximal loops – IV +/- oral contrast if possible
What will be seen on an abdominal x-ray in small bowel obstruction?
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 will be seen on an abdominal x-ray in large bowel obstruction?
Distended large bowel tends to lie peripherally
Show haustrations of taenia coli - do not extend across whole width of the bowel
What is a CT scan helpful for in bowel obstruction?
Can localize site of obstruction
Detect obstructing lesions & colonic tumours
May diagnose unusual hernias (e.g. obturator hernias)
When can conservative management be employed in patients with bowel obstruction?
No signs of ischaemia/no signs of clinical deterioration
What are the conservative and supportive management options for bowel obstruction?
What are the indications for surgical management of 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 are the operative options for surgical management of bowel obstructions?
Exploratory Laparotomy/Laparoscopy
Restoration of intestinal transit (depending on intra-operational findings)
Bowel resection with primary anastomosis or temporary/permanent stoma formation
(Endoscopic stenting)
What is the presentation of GI perforation?
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 the different common aetiologies of GI perforation?
Perforated peptic ulcer
Perforated diverticulum
Perforated appendix
Perforated malignancy
What are the features of a perforated peptic ulcer?
Sudden epigastric or diffuse pain
Referred shoulder pain
Hx of NSAIDs, steroids, recurrent epigastric pain
What are the features of a perforated diverticulum?
LLQ pain
Constipation
What are the features of a perforated appendix?
Migratory pain
Anorexia
Gradual worsening RLQ pain
What are the features of a perforated malignancy?
Change in bowel habit
Weight loss
Anorexia
PR Bleeding
What would the bloods look like in a patient with GI perforation?
FBC: neutrophilic leukocytosis
Possible elevation of Urea, Creatinine
VBG: Lactic acidosis
What imaging would be used in a patient with suspected GI perforation?
Erect CXR→ subdiaphragmatic free air (pneumoperitoneum)
CT abdo/pelvis→Pneumoperitoneum, free GI content,localised mesenteric fat stranding - can exclude common differential diagnoses such as pancreatitis
What are the differential diagnoses in a patient with possible GI perforation?
Acute cholecystitis, Appendicitis
Myocardial infarction, Acute pancreatitis
What is the first treatment given to a patient presenting 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
When is conservative management taken for GI perforation?
in localised peritonitis without signs of sepsis - Very rare
IR - guided drainage of intra-abdominal collection
Serial abdominal examination & abdominal imaging for assessment
What are the surgical options for a GI perforation?
Exploratory laparotomy/laparoscopy
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 biliary and pancreatic causes of acute abdominal presentations?
Biliary colic
Acute cholecystitis
Acute cholangitis
Acute pancreatitis
Outline biliary colic
Outline acute cholecystitis
Outline acute cholangitis
Outline acute pancreatitis
What does this x-ray show?
Enormously distended oval gas shadow, looped on itself to give typical “bent, inner-tube sign” or “coffee bean sign”
Volvulus
What is a volvulus?
Loop of intestine twists around itself and the mesentery that supplies it, causing a bowel obstruction
What is the conservative treatment for a volvulus?
Sigmoidoscope passed with the patient lying in the left lateral position
Large, well lubricated, soft rubber rectal tube passed along sigmoidoscope
Untwists the volvulus, release of vast quantities of flatus and liquid faeces
If a flatus tube is unsuccessful in treating volvulus, what is the risk in leaving it untreated
Left untreated, the loop of intestine would undergo necrosis
This is because its blood supply is cut off by the torsion
What is the next step (after a failed flatus tube) in managing a case of sigmoidal volvulus?
Exploratory laparotomy and sigmoid colectomy with end colostomy
Hartmann’s procedure
