Gastrointestinal Presentations Flashcards
1
Q
What sx would you expect with bowel obstruction?
A
- Abdominal pain – colicky or cramping (secondary to bowel obstruction)
- Distension -
- Constipation – failure to pass flatus or faecaes
- Vomiting – gastric contents, then bilious and then faeculent (like shit – dark brown and smelly
2
Q
What is the difference between simple, closed loop and strangulated bowel obstruction?
A
- Simple: one obstructing point and no vascular compromise.
- Closed loop: obstruction at two points (eg sigmoid volvulus) forming a loop of grossly distended bowel at risk of perforation.
-
Strangulated:
- Compromised blood supply
- Systemic illness
- and the patient is iller than you would expect. There is sharper, more constant, and localized pain. Peritonism is the cardinal sign. There may be fever + ↑wcc with other signs of mesenteric ischaemia
3
Q
How can you distinguish between SBO and LBO?
A
- SBO: vomiting occurs early, distension is less, and pain is higher in the abdomen
- LBO: pain is more constant. The axr plays a key role
4
Q
What are the most common causes of LBO and SBO?
A
· Small bowel: hernia, adhesions
· Large bowel: malignancy, diverticular, volvulus
5
Q
What investigations would you do to look for bowel obstruction?
A
- Bedside: urine dip, pregnancy test
- Bloods: Urgent (FBC, CRP, U&Es, LFTs, amylase/ lipase and a Group and Save (G&S)), VBG (look for signs of ischaemia e.g. raised lactate)
-
Images:
- CT with IV contrast;
- AXR (remember rule of 3,6, 9)
- LARGE BOWEL – dilated bowel (6cm, 9 if at caecum), peripheral location and haustral lines
- SMALL BOWEL – dilated bowel beyond 3cm, central abdominal location, visible plicae circulares
- Erect CXR (look for perforation)
6
Q
What are the complications of bowel obstruction?
A
- Ischaemia
- Perforation
- Dehydration
- Renal failure
7
Q
What is closed loop obstruction? What are the complications of this?
A
- Second obstruction proximally (such as in a volvulus or in large bowel obstruction with a competent ileocaecal valve)
- Two points along the course of a bowel are obstructed
- Surgical emergency: bowel will continue to distend, stretching the bowel wall until it becomes ischaemic or perforates
8
Q
How would you manage bowel obstruction?
A
- A-E: Fluid resuscitation, surgery if closed loop bowel obstruction/ ischaemia
- Investigations: bloods (FBC, UE, CRP, LFT, amylase), AXR, erect CXR, ECG, CT
-
Pharmacological (Sx management): (if no strangulation or ischaemia): ‘
- Drip and suck’ NG tube/ NBM, IV fluids,
- Catheter and fluid balance
- Analgesia
- High flow oxygen
- Suitable anti emetics (cyclizine/ metacloperamide)
-
Surgical: laparotomy
- Intestinal ischaemia of closed loop obstruction
- Surgical correction needed: hernia or tumour
- Strangulation
- SBO - rarely needs surgery
- LBO - usually needs surgery. If patients fail to improve with conservative measures (≥48h)
9
Q
What is paralytic ileus?
A
- Adynamic bowel due to the absence of normal peristaltic contractions.
- Contributing factors: abdominal surgery, pancreatitis (or any localized peritonitis), spinal injury, hypokalaemia, hyponatraemia, uraemia, peritoneal sepsis and drugs (eg tricyclic antidepressants).
- Diagnosis: absent bowel sounds, no pain
10
Q
What is Pseudo obstruction/ Ogilvie sx and how is it treated?
A
- Dilatation of the colon due to an adynamic bowel, in the absence of mechanical obstruction
- Causes: Electrolyte imbalance or endocrine disorders, Medication (opioids, CCBs, or anti-depressants), Recent surgery, severe illness, or trauma, Neurological disease
- Treatment: neostigmine
11
Q
What are some of the neuromuscular vs. mechanical causes of dysphagia?
A
12
Q
What are questions should be asked to assess dysphagia?
A
- Was there difficulty swallowing solids and liquids from the start?
- Yes: motility disorder (eg achalasia, cns, or pharyngeal causes).
- No: Solids then liquids: suspect a stricture (benign or malignant).
- Is it difficult to initiate a swallowing movement?
- Yes: Suspect bulbar palsy, especially if patient coughs on swallowing.
- Is swallowing painful (odynophagia)?
- Yes: Suspect ulceration (malignancy, oesophagitis, viral infection or Candida in immunocompromised, or poor steroid inhaler technique) or spasm.
- 4 Is the dysphagia intermittent or is it constant and getting worse?
- Intermittent: suspect oesophageal spasm.
- Constant and worsening: suspect malignant stricture.
- Does the neck bulge or gurgle on drinking?
- Yes: Suspect a pharyngeal pouch
13
Q
What other sx should you assess for with dysphagia?
A
- Presence of regurgitation
- The sensation of food becoming ‘stuck’
- A hoarse voice
- Weight loss
- Any referred ear or neck pain.
14
Q
How would we investigate dysphagia?
A
- Endoscopy +/- biopsy
- If endoscopy normal: 24 pH test and manometry (motility tests)
- Barium swallow if pharyngeal pouch or diverticulum
15
Q
What is the criteria for upper GI endoscopy under the 2 weeks wait?
A
- 55 y/o with weight loss +
- ALARMS sx: Anaemia (iron deficiency), Loss of weight, Anorexia, Recent onset of progressive symptoms, Melaena / haematemesis, Swallowing difficulty
- Or dyspepsia
19
Q
What scores would you be concerned about with an upper GI bleed?
A
- Rockalls - Oesphageal Varices
- Glasgow Blatchford
24
Q
What are some of the causes of GI perforation?
A
