Gastrointestinal Presentations

Question 1

What sx would you expect with bowel obstruction?

Answer 1

• 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

Question 2

What is the difference between simple, closed loop and strangulated bowel obstruction?

Answer 2

1. Simple: one obstructing point and no vascular compromise.
2. Closed loop: obstruction at two points (eg sigmoid volvulus) forming a loop of grossly distended bowel at risk of perforation.
3. Strangulated:
   
   1. Compromised blood supply
   2. Systemic illness
   3. 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

Question 3

How can you distinguish between SBO and LBO?

Answer 3

• 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

Question 4

What are the most common causes of LBO and SBO?

Answer 4

· Small bowel: hernia, adhesions

· Large bowel: malignancy, diverticular, volvulus

Question 5

What investigations would you do to look for bowel obstruction?

Answer 5

• 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)

Question 6

What are the complications of bowel obstruction?

Answer 6

• Ischaemia
• Perforation
• Dehydration
• Renal failure

Question 7

What is closed loop obstruction? What are the complications of this?

Answer 7

• 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

Question 8

How would you manage bowel obstruction?

Answer 8

• 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)

Question 9

What is paralytic ileus?

Answer 9

• 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

Question 10

What is Pseudo obstruction/ Ogilvie sx and how is it treated?

Answer 10

• 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

Question 11

What are some of the neuromuscular vs. mechanical causes of dysphagia?

Answer 11

Question 12

What are questions should be asked to assess dysphagia?

Answer 12

1. 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).
2. Is it difficult to initiate a swallowing movement?
   
   • Yes: Suspect bulbar palsy, especially if patient coughs on swallowing.
3. Is swallowing painful (odynophagia)?
   
   1. Yes: Suspect ulceration (malignancy, oesophagitis, viral infection or Candida in immunocompromised, or poor steroid inhaler technique) or spasm.
4. 4 Is the dysphagia intermittent or is it constant and getting worse?
   
   • Intermittent: suspect oesophageal spasm.
   • Constant and worsening: suspect malignant stricture.
5. Does the neck bulge or gurgle on drinking?
   
   • Yes: Suspect a pharyngeal pouch

Question 13

What other sx should you assess for with dysphagia?

Answer 13

• Presence of regurgitation
• The sensation of food becoming ‘stuck’
• A hoarse voice
• Weight loss
• Any referred ear or neck pain.

Question 14

How would we investigate dysphagia?

Answer 14

• Endoscopy +/- biopsy
• If endoscopy normal: 24 pH test and manometry (motility tests)
• Barium swallow if pharyngeal pouch or diverticulum

Question 15

What is the criteria for upper GI endoscopy under the 2 weeks wait?

Answer 15

• 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

Question 16

What are the common causes of haematemesis?

Answer 16

Upper GI bleeds:

Common causes: peptic ulcers, mallory weiss tears, oesophageal varices, drugs (NSAIDS, aspirin, steroids, thrombolytics, anticoagulants), duodenitis, gastritis, oesophagitis.

Less common causes: Bleeding disorders, portal hypertensive gastropathy, Aorto-enteric fistula10, Angiodysplasia, Haemobilia, Dieulafoy lesion11, Meckel’s diverticulum, Peutz-Jeghers’ syndrome, Osler-Weber-Rendu syndrome.

Question 17

How would you investigate haematemesiS?

Answer 17

• Bloods: FBC, UE, CRP, LFT, clotting, crossmatch, G+S
• Imaging:
  
  • OGD within 12 hours (if acute)
  • Erect CXR – if perforated peptic ulcer. Look for pneumoperitoneum
  • CT abdo with IV contrast

Question 18

What important things do you need to ascertain when taking a hx from a pt with haematemesis?

Answer 18

• Time/ frequency
• History of dyspepsia
• Dysphagia
• Odonyphagia
• PMH
• SH: Alcohol, smoking
• DH: NSAID use, steroids, anticoags, bisphosphonates

Question 19

What scores would you be concerned about with an upper GI bleed?

Answer 19

• Rockalls - Oesphageal Varices
• Glasgow Blatchford

Question 20

When would surgery be indicated for upper GI bleeds?

Answer 20

• Severe bleeding/ bleeding despite transfusing if pt is >60 y
• Active or uncontrollable bleeding at endoscopy
• Initial rockall > 3 (or final 6)

Question 21

How would you generally manage an upper GI bleed?

Answer 21

• A-E:
  
  • High flow oxygen
  • 2 wide bore cannulae, IV fluids: take bloods: FBC, UE, LFT, clotting, group+ save + crossmatch
  • Urinary catheter + UO
• Imaging: CXR, ECG, ABG, OGD urgently (when bleeding settles)
• Transfuse blood if needed
• Further management: daily bloods, NBM for 24hrs
• IVI Omeprazole 80mg
• Tell surgeons: to determine specific management depending on cause

Question 22

How do you specifically manage a perforated peptic ulcer?

Answer 22

• • Adrenaline
• Cauterisation
• Omeprazole 40mg PPI IVI
• Angioembolisation
• H.Pylori triple eradication

Question 23

How do you manage a burst oesophageal varices?

Answer 23

• Pharmacological:
  
  • Prophylactic abx therapy: ceftriaxone
  • Vasopressors (terlipressin) – reduce splanchnic blood flow
  • Somatostatin analogues (octreotide) - less common
• Surgical:
  
  • Definitive: Endoscopic banding
  • Angio-embolisation of bleeding vessel: e.g. gastroduodenal artery
  • Severe: Sengstaken-Blakemore tube - for balloon dilatation
• Long term: beta blocker e.g. propanolol
• 2ndary: if they rebleed - transjugular intrahepatic porto-systemic shunt

Question 24

What are some of the causes of GI perforation?

Answer 24

Question 25

What other causes of GI perforation can you get?

Answer 25

* **Ischaemic/ inflammatory:** chemical or foreign body * **Infection**: diverticulitis, cholesystitis, meckels diverticulum * **Ischaemic**: mesenteric ischaemia, colitis – toxic megacolon * **Trauma**: iatrogenic –recent surgery, anastomotic leak, endoscopy or incorrect NG tube insertion, penetrating or direct trauma, direct rupture – excessive vomiting

Question 26

How do you manage GI perforations?

Answer 26

* **General**: * Broad spectrum AB * NBM / NG tube * IV fluids * Analgesia * **Surgical**: treat pathology and washout * **Perforated peptic ulcer:** omental patct * **Sigmoid diverticulitis**: resection via hartmans procedure * Accessing the site: * Any stomach or duodenal perforations- upper midline incision/ laparoscopic * Small bowel: midline laparotomy * Large bowel perf: midline laparotomy

Question 27

What are the most common causes of GI perforation?

Answer 27

Peptic ulcer burst Sigmoid diverticulum

Question 28

What is the most common cause of rectal bleeding?

Answer 28

Diverticulosis

Question 29

What are some of the other causes of rectal bleeding?

Answer 29

Diverticulosis, ischaemia, infective colitis, haemorrhoids, malignancy, IBD

Question 30

What investigations would you do for rectal bleeding?

Answer 30

Bloods + group & save, upper GI source of bleeding, 1. **Endoscope**: flexible sigmoidoscopy (if haemadynamically stable) , importantly to exclude . 2. **Full colonoscopy** if sigmoidoscopy inconclusive 3. **CT angiography** – identify culprit bleeding vessels. Therapeurtic intervention via arterial embolization

Question 31

How is rectal bleeding managed?

Answer 31

* Most cases will settle * Discharge / outpatient – if settled bleeding / Normal Hb * Haemodynamically stable: * **Endoscopic haemostasis** – adrenaline, bipolar electrocoagulation, argon plasma coag, endoscopic clips, band ligation * **Arterial embolization** * **Surgical intervention** – ongoing lower GI bleed / haemodynamically unstable *

Question 32

How would you investigate a suspected GI perforation? What would you expect to see?

Answer 32

* Bloods: FBC, UE, LFT, CRP (raised CRP/ WCC), * Imaging: * **Erect CXR** – free air under diaphragm (pneumoperitoneum) * **CT scan** * **AXR:** * **Riglers sign** – both sides of the bowel wall can be seen dueto the air acting as additional contrast – shows pneumoperitoneum * **Psoas sign** – loss of delineation of the psoas muscle border