Gastrointestinal Post-Op Complications

Question 1

what are the common early post-op GI complications?

Answer 1

• ileus
• malabsorption
• post-op nausea and vomiting

Question 2

what is an ileus?

Answer 2

decrease or complete arrest in gut motility following surgery

Question 3

what are the risk factors for an ileus?

Answer 3

• intra-abdominal surgery
• opioid analgesia
• stress response
• sepsis

Question 4

what are the clinical presentation of a post-operative ileus?

Answer 4

• failure to pass flatus or faeces
• sensation of bloating or distension
• nausea and vomiting

Question 5

what are the clinical findings of a post-operative ileus?

Answer 5

• abdominal distension

- absent bowel sounds

Question 6

what investigations can be done in a suspected post-op ileus?

Answer 6

• routine bloods

- CT scan of the abdo pelvis to confirm diagnosis

Question 7

what is the management for a post-op ileus?

Answer 7

• encourage mobilisation
• reduce opiate analgesia
• using an NG tube to drain bowel contents

Question 8

what can be done to prevent a post-op ileus?

Answer 8

• minimise intra-operative intestinal handling
• avoid fluid overload as can cause intestinal oedema
• minimise opiate use
• encourage early mobilisation

Question 9

what is an anastomotic leak?

Answer 9

a leak of luminal contents from a surgical join

Question 10

why is it so important to identify an anastomotic leak?

Answer 10

the longer it is left untreated, the more chance of contamination of the abdomen by the luminal contents

Question 11

what is the worst complication of an anastomotic leak?

Answer 11

sepsis

Question 12

true or false: a patient who is deteriorating after surgery is considered to have an anastomotic leak until proven otherwise

Answer 12

true.

Question 13

what are the patient risk factors for an anastomotic leak?

Answer 13

• immunosuppressed
• smoking or alcohol excess
• diabetic
• obesity or malnutrition

Question 14

what are the surgical risk factors for an anastomotic leak?

Answer 14

• emergency surgery
• loner intra-operative time
• peritoneal contamination
• oesophageal-gastric or rectal anastomoses

Question 15

what are the clinical features of an anastomotic leak?

Answer 15

abdominal pain and fever presenting 5 to 7 days post operatively

Question 16

what are the clinical signs of an anastomotic leak?

Answer 16

pyrexia
tachycardia
signs of peritonism (severe pain and swelling of the abdomen)

Question 17

what investigations should be done in a patient with a suspected anastomotic leak?

Answer 17

CT abdo-pelvis which will show if there are any extra-luminal contents
Blood test: FBC, U&Es, CRP, LFTs, clotting screen, G&S and X-match

Question 18

how would you initially manage a patient with an anastomotic leak?

Answer 18

put the patient on NBM status and begin broad spectrum antibiotic cover
begin IV fluid therapy and monitor fluid balance with catheter insertion

Question 19

what is considered the definitive management of a minor anastomotic leak?

Answer 19

can be managed conservatively:
using IV antibiotics if small
percutaneous drainage if leak is >5cm

Question 20

what is considered definitive management of a major anastomotic leak?

Answer 20

if the patient is septic or has multiple collections then an exploratory laparotomy is done - to washout with drain insertion

Question 21

true or false: a colo-rectal anastomosis should be treated with a stoma

Answer 21

true.

Question 22

what are bowel adhesions?

Answer 22

fibrous bands of scar tissue, most commonly due to previous surgery or intra-abdo inflammation

Question 23

true or false: bowel adhesions are the most common cause of small bowel obstruction

Answer 23

true.

Question 24

true or false: bowel adhesions tend to asymptomatic

Answer 24

true.

Question 25

what are the major complications of bowel adhesions?

Answer 25

obstruction, female infertility, chronic pelvic pain

Question 26

what is the management for bowel obstruction caused by adhesions?

Answer 26

if uncomplicated: treat conservatively using an NG tube to decompress patient is also kept NBM and given IV fluids and analgesia

Question 27

what is the surgical management for bowel obstruction caused by adhesions?

Answer 27

adhesiolysis is only done if patient shows signs of ischaemia or perforation, or if conservative treatment failed. it is also only done on adhesions causing the obstruction

Question 28

what is an incisional hernia?

Answer 28

protrusion of the contents of the abdominal cavity through a previously made incision

Question 29

why does an incisional hernia occur?

Answer 29

disruption of the continuity of the anterior abdominal wall muscles by a surgical incision results in structural weakness. an increase in intra-abdominal pressure allows the abdominal contents to herniate through this weakness

Question 30

what are the risk factors for an incisional hernia?

Answer 30

- emergency surgery - wound and incision (midline) type - obesity - wound infection - age - pregnancy - smoking - connective tissue disorders

Question 31

what are the clinical features of an incisional hernia?

Answer 31

non pulsatile, reducible, soft and non-tender swelling at or near the site of a previous surgical wound

Question 32

what are the clinical features of an incarcerated incisional hernia?

Answer 32

painful, tender and erythematous

Question 33

what would you find on examination of an incisional hernia?

Answer 33

palpable mass which may be reducible | if ischaemic: there may be rebound tenderness or guarding

Question 34

what investigations would you do in a patient with a suspected incisional hernia?

Answer 34

diagnosis is made on clinical basis however USS or CT can be used to investigate

Question 35

how would you manage an incisional hernia?

Answer 35

if asymptomatic: manage conservatively | if symptomatic: surgery is indicated

Question 36

what is the clinical definition of constipation?

Answer 36

< 3 bowel movements a week, often with hard, dry stool, that may be difficult to pass

Question 37

what are the causes of post-op constipation?

Answer 37

- physiological e.g. low fibre diet, low fluid intake - iatrogenic e.g. medications like opioids - pathological such as bowel obstruction - functional such as painful defecation

Question 38

what are the clinical presentation of post-op constipation?

Answer 38

lower abdominal pain | if severe can present with abdo distension, nausea and vomiting, loss of appetite

Question 39

what are the clinical signs of post-op constipation?

Answer 39

a DRE is done to assess degree of faecal impaction

Question 40

what investigations are done in a suspected post-op constipation?

Answer 40

usually made on a clinical diagnosis | imaging is only done if bowel obstruction is suspected

Question 41

what is the management for a post-op constipation?

Answer 41

conservatively managed with laxatives | if resistant additional therapy can be done as manual evacuation or an enema

Question 42

what preventative measures can be given for post-op constipation?

Answer 42

- opioid analgesia should be avoided | - prophylactic stimulant laxatives should be used if needed