Gastrointestinal - Level 2.2 Flashcards
Definition of inguinal hernia?
- Protrusion of abdominal or pelvic contents into inguinal canal
Types of inguinal hernia?
o Indirect hernias (80%) pass through internal inguinal ring and out of external if large enough
o Direct hernias (20%) push through posterior wall of canal into Hesselbach’s triangle (medial to inferior epigastric and lateral to rectus abdominis)
Anatomy of inguinal canal?
o Deep ring – mid-point of inguinal ligament
o Superficial ring – split in EO aponeurosis superior and medial to pubic tubercle
Borders of inguinal canal?
o Floor – Inguinal ligament, lacunar ligament medially
o Roof – Transversalis and Internal oblique
o Anterior – External oblique aponeurosis + internal oblique for lateral 1/3
o Posterior – lateral – transversalis fascia, medial – conjoint tendon
Contents of inguinal canal?
o External spermatic fascia (from IO), cremasteric fascia (from TA), internal spermatic fascia (from TF) covers cord
Cord contents running through inguinal hernia?
o Vas deferens o Obliterated processus vaginalis o Arteries to vas, cremaster, testis o Genital branch of genitofemoral nerve/sympathetic o Ilioinguinal nerve
Epidemiology of inguinal hernia?
- Most common hernia
- Men 8x more common
Risk factors of inguinal hernia?
o Male, older age, smoking, FHx, constipation, chronic cough, pregnancy, heavy lifting, obesity
Symptoms of inguinal hernia?
o Visible lump in groin
Pain during strenuous exercise or heavy lifting
Dragging sensation
Inguinal = superomedial to pubic tubercle
Femoral = inferolateral to pubic tubercle
o Worse on standing/coughing
o Sometimes reducible
Diagnostic examination of inguinal hernia?
- Examination diagnostic usually
o Done lying down and standing
o Ask patient to reduce it and cough impulse
o Palpate coughing impulse – insert finger through top of scrotum
o Determining between direct and indirect hernia – reduce hernia and ask patient to cough, if not restrained and appears then direct hernia
Management of inguinal hernia - referral?
o If features of strangulation or obstruction – admit immediately
o If no features – refer urgently to surgeon if child and routine if adult (urgent if irreducible)
Management of inguinal hernia -general measures?
o Analgesia
o Fluids
o Stop smoking
o Weight loss
Management of inguinal hernia - if small and asymptomatic?
o Watchful waiting
Management of inguinal hernia - if large or symptomatic?
o Surgery Open/Laparoscopic surgery • Mesh repairs – Lichtenstein repair • Methods either transabdominal pre-peritoneal (TAPP) and totally extraperitoneal (TEP) o Prophylactic antibiotics
Management of inguinal hernia - if incarcerated or strangulated?
o Urgent surgical repair and prophylactic antibiotics
Definition of femoral hernia?
- Bowel enters femoral canal presenting as mass in upper thigh or above inguinal ligament where it points down the leg
- Likely irreducible and strangulated
Boundaries of femoral canal?
o Anterior – inguinal ligament
o Posterior – pectineus, pectineal ligament
o Medial – lacunar ligament
o Lateral – femoral vein, iliopsoas
Epidemiology of femoral hernia?
- More in females
- Incidence increases with age
Aetiology of femoral hernia?
o Increased abdominal pressure
Pregnancy, chronic cough, GI obstruction, straining
o Laxity of tissue
Pregnancy, weight loss, previous repair
Symptoms of femoral hernia?
o Lump in groin Neck of hernia is inferior and lateral to pubic tubercle Worse on coughing and straining Reduces when supine o Dragging, aching feeling o May be asymptomatic
Diagnosis of femoral hernia?
- Examination
- USS
Management of femoral hernia?
- All Surgical – elective but within 2 weeks as risk of strangulation
o Herniotomy – ligation and excision of sac
o Herniorrhaphy – repair of hernial defect
Complications of femoral hernia?
o Strangulation
o Obstruction
Definition of incisional hernia?
- Protrusion of contents of a cavity through a previously made incision due to breakdown of muscle closure
Epidemiology of incisional hernia?
- 10-20% occurrence after surgery
- More commonly following open surgery
Risk factors of incisional hernia?
- Smoking
- BMI >25
- Midline incision
- Infection
- Increased abdominal pressure – pregnancy, coughing, straining, weight lifting
Symptoms of incisional hernia?
o Non-pulsatile reducible, soft and non-tender swelling at or near site of previous surgical wound
o If incarcerated – painful, tender, erythema
Signs of incisional hernia?
o Mass is palpable which may be reducible
Diagnosis of incisional hernia?
- Clinical Examination
- USS or CT may help
Management of incisional hernia - asymptomatic?
- If asymptomatic – can be managed conservatively
Management of incisional hernia symptomatic
- Surgery
o Reinforcing mesh repair
o Sutures
Complications of incisional hernia?
o Incarceration
o Strangulation
o Bowel Obstruction
Definition of umbilical hernia??
Occur just above or below umbilicus – defect in anterior abdominal wall fascia that occurs when the umbilical ring fails to close
o Ring continues to close over time when occurs in childhood
Omentum or bowel herniates through the defect
Types of umbilical hernia??
o Adult Umbilical Hernia – 90% are acquired
o Congenital (omphalocele, gastroschisis)
o Infantile – associated with prematurity
Epidemiology of umbilical hernia??
10-30% of all hernias
Risk factors of umbilical hernia??
o Obesity
o Ascites
o Low birth weight
o Pregnancy
Symptoms of umbilical hernia??
- Lump enlarges and may be multi-loculated
o Easily reducible - Pain on coughing or straining
- Ache or dragging sensation
Diagnosis of umbilical hernia??
- Clinical Examination
Management of umbilical hernia??
- Surgery (if large enough >1.5cm or child >5)
o Mayo repair – repair of rectus sheath
Definition of bile?
- Bile contains cholesterol, bile pigments and phospholipids
- Majority of biliary emergencies caused by gallstones – acute and chronic cholecystitis, biliary colic, ascending cholangitis
Definition of biliary colic?
Definition of acute cholecystitis?
o Temporary obstruction of cystic or CBD by stone
o Follow impaction of stone in cystic duct or neck of bladder
Definition of acute cholangitis?
o Infection of biliary tree and often secondary to CBD stones
Epidemiology of biliary tract infections?
- 8% of those over 40 years
- 90% remain asymptomatic
Risk factors for biliary tract infection?
o Female o Fat o > Forty o Fair – Caucasian o Fertile – parity o Smoking o DM
Types of gallstones?
o Pigment stones (10%) – small friable and irregular – caused by hereditary spherocytosis, malaria and haemolytic anaemia
o Cholesterol stones (90%) – Large, often solitary – causes female, obesity, age
o Mixed stones – faceted
Symptoms of biliary colic?
o Short-lived recurrent episodes of epigastric/RUQ pain with radiation to back and right shoulder
o May have vomiting
Symptoms of acute cholecystitis?
Continuous epigastric/RUQ pain radiating to right shoulder and back
Fever, vomiting and local peritonism
Signs of acute cholecystitis?
Fever, RUQ tenderness
Murphy’s sign positive (pain and arrest of inspiration when palpating liver)
May be palpable mass – suggestive of empyema and mucocele
Septic shock
Symptoms of chronic cholecystitis?
Chronic RUQ pain
Flatulent dyspepsia
Abdominal discomfort and distention
Fat intolerance
Common bile duct stones can cause what>
o Acute pancreatitis
o Obstructive jaundice
Symptoms
• Jaundice with pale stools and dark urine
• May have pain
• Courvoiser’s law – in presence of jaundice, if the gallbladder is palpable cause is likely to be a stone
Symptoms of acute cholangitis?
- Charcot’s triad – RUQ pain, jaundice, fever/rigors
- Shock
- Urine dark and stools pale
Investigations in biliary colic?
o If pain gone and no asymptomatic – discharge and rearrange GP follow-up
o If symptoms – LFTs (raised ALP and bilirubin) and USS shows stones
MRCP if US not detected stones but bile duct dilated and/or LFT abnormal
Initial investigations in cholecystitis?
o Abdominal USS
o Bloods
FBC (Raised WCC, ALP and bilirubin), U&Es, glucose, amylase, LFTs (post hepatic – raised ALP, bilirubin)
Management of gallstones - if asymptomatic?
NONE
If asymptomatic common bile duct stones – offer bile duct clearance and laparoscopic cholecystectomy
Management of gallstones - if symptomatic?
General Advice
• Avoid food and drink which trigger symptoms
• Low fat diet
Analgesia
Elective laparoscopic cholecystectomy
• +/- bile duct clearance (if common bile duct stones)
Management of acute cholecystitis?
o NBM
o IV analgesia (diclofenac75mg IM if severe) and antiemetic
o IV Fluids if needed
o Bloods – FBC (Raised WCC, ALP and bilirubin), U&Es, glucose, amylase, LFTs (post hepatic – raised ALP, bilirubin)
o CXR, ECG (atypical MI)
o USS confirm diagnosis (tenderness on pressing USS transducer over area of thickened gallbladder containing stones called ultrasonic Murphy’s sign)
o IV Abx (co-amoxiclav + metronidazole)
o Refer to surgery
Laparoscopic cholecystectomy (within 1 week or after acute episode subsided - 4 weeks)
Management of chronic cholecystitis?
o USS – small shrunken gall bladder, measure CBD diameter
o Cholecystectomy if dilated CBD with stones
o If symptoms persist then consider other causes
Management of acute cholangitis?
o NBM o IV analgesia and antiemetic o IV fluids o Bloods – FBC (Increased WCC), LFTs (Raised bilirubin, ALP) o USS – dilated CBD o IV Abx (Co-amoxiclav and Metronidazole) o ERCP – biopsy, drainage, stenting o May need laparoscopic cholecystectomy
Complications of biliary tract infections?
o Mucocele o Empyema o Carcinoma o Mirizzis’s Syndrome Stone on GB presses on bile duct causing jaundice o Pancreatitis o Gallstone Ileus
Definition of portal hypertension?
- Abnormally high pressure in hepatic portal vein
- Hepatic venous pressure gradient >10mmHg
Pathophysiology of portal hypertension?
o Increased vascular resistance in portal venous system contributes to abnormal blood flow patterns
o Increased blood flow in portal veins – vasodilatation
o Raised pressure opens up collateral vessels:
GOJ – producing varices
Anterior abdominal wall – via umbilical vein – caput medusae
o Hypervolaemia and salt and water retention
Causes of portal hypertension - pre-hepatic?
Thrombosis (portal or splenic vein)
Causes of portal hypertension - intra-hepatic?
Cirrhosis (80%) Schistosomiasis Sarcoid Myeloproliferative diseases Congenital hepatic fibrosis
Causes of portal hypertension - post-hepatic?
Budd-Chiari syndrome
RHF
Constrictive pericarditis
Veno-occlusive disease
Symptoms of portal hypertension?
o Dilated veins in anterior abdominal wall – caput medusae
o Splenomegaly
o Ascites
Signs of liver failure?
o Jaundice o Spider naevi o Palmar erythema o Liver flap o Fetor hepaticus o Low BP o Enlarged liver o Gynaecomastia
Complications of portal hypertension?
o Haematemesis – bleeding varices
o Lethargy, irritability – encephalopathy
o Increased weight, abdomen – ascites
o Abdominal pain and fever - SBP
Investigations of portal hypertension?
o LFT o U&E o Glucose o FBC o Clotting o If liver disease not known – ferritin, hepatitis serology, autoantibodies, alha-1-antitrypsin, ceruloplasmin
Imaging of portal hypertension?
o Abdominal USS
o Doppler US
o Spiral CT scan if US inconclusive
- Endoscopy – for oesophageal varices
- Portal pressure by hepatic venous pressure gradient
Management of portal hypertension - drug treatment?
o Beta-blockers
o Nitrates
o Terlipressin and octreotide – acute variceal bleeding