Gastrointestinal Emergencies

Question 1

What is peritonitis?

Answer 1

Inflammation of the serosal membrane that lines the abdominal cavity

Question 2

Types of peritonitis

Answer 2

• Primary: spontaneous + not as a result of pathology in another organ
• Secondary: breakdown of the peritoneal membranes leading to foreign substances entering cavity

Question 3

What is the peritoneal cavity?

Answer 3

Space between the visceral + parietal layers of peritoneum

Question 4

What are the subdivisions of the peritoneal cavity?

Answer 4

Greater sac
Lesser sac

Question 5

What is spontaneous bacterial peritonitis?

Answer 5

• Primary peritonitis
• Infection of asitic fluid that cannot be attributed to any intra-abdominal, ongoing inflammatory or surgically correctable condition

Question 6

Presentation of spontaneous bacterial peritonitis

Answer 6

Variable
Abdominal pain
Fever
Vomiting

Question 7

Investigation of spontaneous bacterial peritonitis

Answer 7

Aspirating ascitic fluid
Neutrophil count >250 cells/mm³

Question 8

Bacterial causes of secondary peritonitis

Answer 8

• perforated peptic ulcer disease
• perforated appendicitis
• perforated diverticulitis
• post surgery

Question 9

Non bacterial causes of secondary peritonitis

Answer 9

• tubal pregnancy that bleeds (ruptured ectopic pregnancy)
• ovarian cyst

Question 10

Clinical presentation of secondary peritonitis

Answer 10

• abdominal pain
• lie very still as movement makes pain worse
• rebound tenderness
• guarding (abdominal wall muscles tense when going to exam)

Question 11

Treatment of secondary peritonitis

Answer 11

• surgery: control infectious source
• antibacterial therapy: eliminate bacteria
• intensive care: maintain organ system function

Question 12

What is acute mesenteric ischaemia?

Answer 12

Symptomatic reduction in blood supply to GI tract

Question 13

Who is acute mesenteric ischaemia more common in?

Answer 13

Females
History of peripheral vascular disease

Question 14

Types of acute mesenteric ischaemia

Answer 14

Arterial compromise:
- acute occlusion: arterial embolism in SMA or vasculitis
- non occlusive mesenteric ischaemia: low cardiac output

Venous compromise:
- mesenteric venous thrombosis

Question 15

Clinical presentation of acute mesenteric ischaemia

Answer 15

• mainly in elderly patients with CV risk factors
• abdominal pain (30mins after eating)
• nausea + vomiting
• pain often on left side

Question 16

Where is pain often located in acute mesenteric ischaemia?
Why?

Answer 16

Left sided
Blood supply to splenic flexure is most fragile
(Watershed area)

Question 17

Investigations of acute mesenteric ischaemia

Answer 17

• blood tests: metabolic acidosis + increased lactate levels
• erect chest X ray (check for perforation)
• CT angiography

Question 18

Treatment of acute mesenteric ischaemia

Answer 18

• resection of ischaemic bowel
• thrombolysis/angioplasty

Question 19

Where are peptic ulcers most common?

Answer 19

D1

Question 20

Common site of gastric ulcers

Answer 20

Lesser curve
Antrum

Question 21

What could cause a major upper GI bleed?

Answer 21

Peptic ulceration
Varices

Question 22

What vessel is at risk of damage if a duodenal ulcers perforates?

Answer 22

Gastroduodenal artery

Question 23

Why do oesophageal varices form?

Answer 23

Portal hypertension

Question 24

What is the normal pressure in the portal vein?

Answer 24

5-10 mmHg

Question 25

Venous drainage of the oesophagus

Answer 25

Upper 2/3: **oesophageal veins > azygous vein > SVC** Lower 1/3: **left gastric vein > portal vein**

Question 26

Treatment of oesophageal varices

Answer 26

- Endoscopy + band ligation - Blood transfusion if bleeding - *terlipressin*: reduces portal venous pressure

Question 27

What is abdominal aortic aneurysm?

Answer 27

Permanent pathological dilation of the aorta with diameter >1/5 x the expected diameter

Question 28

What drug is used to treat variceal bleeds?

Answer 28

*Terlipressin* Reduces portal venous pressure

Question 29

Location of most AAA

Answer 29

Below renal arteries

Question 30

How does AAA occur?

Answer 30

- Degradation of the elastin + collagen in media layer of arterial wall - lumen gradually dilates

Question 31

risk factors of AAA

Answer 31

Male Family history Increase age Smoking

Question 32

Clinical presentation of ruptured AAA

Answer 32

- asymptomatic until rupture - abdominal pain radiating to back - pulsation abdominal mass - transient hypotension > syncope

Question 33

Diagnosis + investigation of AAA

Answer 33

- **physical exam**: presence of pulsation abdominal mass - **ultrasonography** - **CT** - **X- ray** if calcified

Question 34

Treatment of AAA

Answer 34

- smoking cessation - hypertension control - surveillance of AAA (>5.5cm refer to vascular surgeons) - endovascular repair - open surgical repair

Question 35

What are the surgical treatment of AAA?

Answer 35

Endovascular repair Open surgical repair

Question 36

Outline endovascular repair of AAA

Answer 36

Relining the aorta using an endograft inserted through the femoral artery

Question 37

Outline open surgical repair of AAA

Answer 37

- Clamp aorta - Open aneurysm (remove thrombus + debris) - Suture in synthetic graft to replace diseased segment

Question 38

Who is spontaneous bacterial peritonitis most commonly seen in?

Answer 38

Patients with end stage liver disease

Question 39

What is Hirschprung’s disease

Answer 39

- congential disorder of colon where there is a lack of myenteric + submucosal plexuses - parasympathetic neuroblasts fail to migrate from neural crest to distal colon > developmental failure of meissner + Auerbach plexuses - causing hypomobility + constipation