General Flashcards
Explain acute abdomen due to perforated viscus
Get peritonitis
Causes of perforation: peptic ulcer, small/large bowel obstruction, diverticular disease, inflammatory bowel disease
Presentation: lying completely still, looking unwell
Examination: tachycardia, hypotension, completely rigid abdomen, involuntary guarding, reduced/absent bowel sounds
Give an overview of ischaemic bowel
Severe pain, out of proportion to clinical signs (ischaemic bowel until proven otherwise)
Acidaemia, raised lactate
Diffuse, constant pain
Need CT with contrast for diagnosis
Need early surgical involvement
What are the differentials for RUQ pain
Cholecystitis
Pyelonephritis
Ureteric colic
Hepatitis
Pneumonia
What are the differentials for LUQ pain
Gastric ulcer
Pyelonephritis
Ureteric colic
Pneumonia
What are the differentials for RLQ pain
Appendicitis
Ureteric colic
Inguinal hernia
IBD
UTI
Gynaecological
Testicular torsion
What are the differentials for LLQ pain
Diverticulitis
Ureteric colic
Inguinal hernia
IBD
UTI
Gynaecological
Testicular torsion
What are the differentials for epigastic pain
Peptic ulcer disease
Cholecystitis
Pancreatitis
MI
What are the differentials for peri-umbilical pain
Small bowel obstruction
Large bowel obstruction
Appendicitis
Abdominal aortic aneurysm
What investigations are needed for acute abdomen
Urine dip
Pregnancy test
ABG
Bloods (+ amylase for pancreatitis)
Blood cultures
Erect CXR
Ultrasound (KUG, biliary tree, gynae)
CT
ECG (rule out referred cardiac pain)
What initial management is needed for acute abdomen
Get IV access
Nil by mouth
Analgesia
Antiemetics
VTE prophylaxis
What are the emergency causes of haematemesis
Oesophageal varices
Gastric ulceration
Give an overview of oesophageal varices as a cause of haematemesis
Dilated porto-systemic venous anastomoses in oesophagus
Dilated veins are: swollen, thin-walled, prone to rupture
Can cause catastrophic haemorrhage
Common underlying cause (portal hypertension - alcoholic liver disease)
Give an overview of gastric ulceration as a cause of haematemesis
60% haematemesis cases
Erosion of blood vessels in lesser curve of stomach/posterior duodenum
May present with: known active ulcer disease, H pylori positive, NSAID use, steroid use, previous symptoms of peptic ulcer
What are the non-emergency causes of haematemesis
Mallory-Weiss tears
Oesophagitis (inflammation of intraluminal epithelial layer, mostly due to GORD)
Gastritis
Gastric malignancy
Meckel’s diverticulum
Vascular malformation
What scoring systems are used in haematemesis
Glasgow-Blatchford bleeding score (based on clinical and biochemical features, >6 = 50% risk of needing intervention)
MIN 65 score (for in-hospital mortality from upper GI bleed)
Rockall score (for GI bleed post-endoscopy)
What investigations are needed for haematemesis
Routine blood (+clotting)
VBG
Group and save
Oesophago-gastro-duodenoscopy (within 12 hrs of acute haematemesis)
Erect CXR (if suspect perforated peptic ulcer)
CT with contrast
What is the management of haematemesis due to peptic ulcer disease
Injection of adrenaline
Cauterise bleed
Give high dose PPI
H pylori eradication (if needed)
What is the management of haematemesis due to oesophageal varices
Endoscopic banding
Start somatostatin analogue or vasopressin (reduce splanchnic blood flow)
Long term management: repeat banding, long term beta blocks
Severe bleeds: Sengstaken-Blakemore tube (insert at level of varices, inflate to compress vessel)
What are the mechanical causes of dysphagia
Oesophageal/gastric malignancy
Benign oesophageal strictures
Extrinsic compression
Pharyngeal pouch
Foreign body
Oesophageal web
What are the neuromuscular causes of dysphagia
Post-stroke
Achalasia
Diffuse oesophageal spasm
Myasthenia gravis
Myotonic dystrophy
What investigations are needed in dysphagia
Endoscopy
Routine bloods
Consider manometry and 24 hr pH studies
Consider 2ww
What are the 2ww guidelines for GI malignancy
Urgent upper GI endoscopy
For people with dysphagia or those who are > 55 and have weight loss and one of: upper abdo pain, reflux, dyspepsia
What is the management for dysphagia
Treat underlying cause
Malignancy: surgery, chemotherapy, palliation
Motility disorders: refer for swallowing therapy
If no immediate reversible cause found, refer to SALT and dieticians
What is bowel obstruction
Mechanical blockage of bowel
One bowel segment occluded, gross dilation of proximal parts, increased peristalsis, secretion of large volume of electrolyte-rich fluid into bowel (third spacing)
What is closed loop bowel obstruction
Obstruction in 2 places
Surgical emergency
Bowel wall stretches, get ischaemia or perforation
What are the causes of bowel obstruction
Small bowel: adhesions, hernia
Large bowel: malignancy, diverticular disease, volvulus
In what locations can bowel obstructions occur
Intramural (gallstone ileus, faecal impaction, foreign body)
Mural (cancer, strictures, intussusception, lymphoma)
Extramural (hernia, adhesions, volvulus)
How might bowel obstruction present
Colicky/cramping abdominal pain
Vomiting (early in proximal, late in distal)
Abdominal distension
Absolute constipation
Tinkering bowel sounds
What are the differentials for bowel obstruction
Pseudo-obstruction
Paralytic ileus
Toxic megacolon
Constipation
What investigations are needed for bowel obstruction
Urgent bloods
VBG (high lactate in ischaemia)
CT with contrast (preferred)
Abdominal X-ray
Erect CXR
Water-soluble contrast study
What are the signs of small bowel obstruction on X-ray
> 3 cm bowel
Central abdominal location
Valvulae conniventes visible (lines completely crossing bowel)
What are the signs of large bowel obstruction on X-ray
> 6 cm bowel
> 9 cm caecum
Peripheral location
Haustra lines visible
What is the management for bowel obstruction
Urgent fluid resuscitation
If ischaemia/closed loop, urgent surgery
‘Drip and suck’ (NBM, decompress bowel by sucking, start IV fluids)
Catheter
Analgesia
Antiemetics
Virgin abdomens usually need surgery
Surgery: ischaemia, closed loop, strangulated hernias, obstructing tumours, failure to improve in 48 hrs
What are the complications of bowel obstruction
Bowel ischaemia
Bowel perforation
Dehydration
Renal impairment
What are the causes of GI perforation
Peptic ulcer
Sigmoid diverticulum
Foreign body
Diverticulitis
Cholecystitis
Meckel’s diverticulum
Mesenteric ischaemia
Toxic megacolon
Trauma
Excessive vomiting
How might GI perforation present
Rapid onset sharp pain
Systemically unwell
Features of sepsis
Peritonitic
What are the differentials for GI perforation
Acute pancreatitis
Myocardial infarction
Tubo-ovarian pathology
Ruptured aortic aneurysm
What investigations are needed for GI perforation
Routine bloods
Urinalysis
Erect CXR
CT (gold standard)
Abdominal X-ray
What are the signs of GI perforation on abdominal X-ray
Rigler’s sign: both sides of bowel wall seen (intra-abdominal air acts as additional contrast)
Psoas sign: loss of sharp delineation of psoas muscle border (fluid in retroperitoneal space)
What is the management for GI perforation
Resuscitation
Start broad spectrum antibiotics early
NBM
Most will need surgery
Some may just need conservative management
What are the complications of GI perforation
Infection
Haemorrhage
What are the causes of melena
Peptic ulcer disease
Variceal bleed
Upper GI malignancy
Gastritis
Oesophagitis
Mallory-Weiss tears
Meckel’s diverticulum
Vascular malformations
What investigations are needed for melena
Routine bloods (+ clotting + group and save)
ABG
Oesophago-gastro-duodenoscopy
CT abdo with contrast
What is the management for melena
A to E
Arrange endoscopy
If haemodynamically unstable: transfuse, correct deranged coagulation
Which scoring system is used for lower GI bleeds
Oakland score
What are the risk factors for adverse outcomes for rectal bleeding
Haemodynamic instability
Ongoing haematochezia
> 60
Serum creatinine > 150
Significant comorbidities
What are the differentials for rectal bleeding
Diverticular disease
Ischaemic colitis
Infective colitis
Haemorrhoids
Malignancy
Angiodysplasia
Crohn’s disease
Ulcerative colitis
Radiation proctitis
What investigations are needed for rectal bleeding
Routine bloods (+ clotting + group and save)
Stool culture
If unstable, stabilise then CT angiogram (localise bleed)
Fixed sigmoidoscopy/colonoscopy
OGD/MRI
What is the management for rectal bleeding
95% settle spontaneously
A to E
If Hb < 70, transfuse packed RBCs
Reverse anticoagulants
Endoscopic haemostasis: inject adrenaline, banding
Arterial embolisation
Surgery rarely needed
What is the pathophysiology of GORD
High frequency of sphincter relaxations of lower oesophageal sphincter
Get reflux of gastric contents into oesophagus
What are the risk factors for GORD
Age
Obesity
Male
Alcohol
Smoking
Caffeinated drinks
Fatty/spicy food
How might GORD present
Burning retrosternal pain
Worse on lying/bending/eating
Excessive belching
Odynophagia
Chronic cough
Nocturnal cough
Red flags: dysphagia, weight loss, early satiety, malaise, loss of appetite
What classification system is used for GORD
Los Angeles classification
Grades reflux oesophagitis
What are the differentials for GORD
Malignancy
Peptic ulcer
Oesophageal motility disorders
Oesophagitis
What investigations are needed for GORD
Usually clinical diagnosis
24 hr pH monitoring
Upper GO endoscopy
What is the management for GORD
Initial: avoid precipitants, weight loss, smoking cessation
PPIs
Surgery (in failure of PPIs/complications): fundoplication
What are the complications of GORD
Aspiration pneumonia
Barret’s oesophagus
Oesophagitis
Oesophageal strictures
Oesophageal cancer
What is Barrett’s oesophagus
Metaplasia of oesophageal epithelial lining
Stratified squamous –> simple columnar
What are the risk factors for Barrett’s oesophagus
Caucasian
Male
> 50
Smoking
Obesity
Hiatus hernia
Family history
How might Barrett’s oesophagus present
History of GORD
What investigations are needed for Barrett’s oesophagus
Take biopsy during OGD (red, velvety)
What is the management for Barrett’s oesophagus
Start PPI
Stop medications that impact stomach’s protective barrier (NSAIDs…)
Lifestyle advice
Regular endoscopies (3 months - 5 years) to monitor for progression to adenocarcinoma
What are the 2 types of oesophageal cancer
Squamous cell carcinoma
Adenocarcinoma
How might oesophageal cancer present
Dysphagia
Weight loss
Odynophagia
Hoarseness of voice
Cachexia
Dehydration
Supraclavicular lymphadenopathy
What investigations are needed for oesophageal cancer
Urgent OGD
Staging CT
Endoscopic ultrasound
Staging laparoscopy
What is the prognosis for oesophageal cancer
5 year survival 5-10%
Palliative patients have median survival of 4 months
How might oesophageal tears present
Severe, sudden-onset retrosternal pain
Respiratory distress
Subcutaneous emphysema
Following severe vomiting/retching
What investigations are needed for oesophageal tears
Routine bloods (+ clotting + group and save)
CXR
CT chest and abdo
Endoscopy
What is the management for oesophageal tears
Resuscitate
Control lead
Eradicate mediastinal/pleural contamination
Decompress oesophagus
Nutritional support
Surgery
What is achalasia
Failure of lower oesophageal sphincter to relax
Progressive failure of oesophageal smooth muscle to contract
Progressive destruction of ganglionic cells in myenteric plexus
Can get dysfunction of proximal oesophagus
How might achalasia present
Progressive dysphagia
Vomiting
Chest discomfort
Regurgitation
Coughing
Weight loss
What investigations are needed for achalasia
MRI (bird beak image)
OGD (exclude oesophageal cancer)
Oesophageal manometry (measures pressure in oesophageal sphincter)
What is the management of achalasia
Sleep with many pillows
Eat slowly
CCBs
Botox injections (into lower oesophageal sphincter)
Endoscopic balloon dilation
Laparoscopic Heller myotomy (division of fibres of the sphincter that is not relaxing)
Give an overview of diffuse oesophageal spasms
Multi-focal high amplitude contractions of oesophagus
Presentation: severe dysphagia, chest pain
Investigations: oesophageal manometry, barium swallow (corkscrew appearance)
Management: CCBs/nitrates (relaxation of oesophageal smooth muscle), pneumatic dilation, myotomy
What is a hiatus hernia
Protrusion of an organ from abdominal cavity into thorax through oesophageal hiatus
Stomach usually herniates
What are the 2 types of hiatus hernia
Sliding (organ slides up through diaphragmatic hiatus)
Rolling (creates a ‘bubble’ of stomach in thorax)
What are the risk factors for hiatus hernia
Age
Pregnancy
Obesity
Ascites
How might hiatus hernia present
Most asymptomatic
GORD
Vomiting
Weight loss
Bleeding
Hiccups
Palpitations
Dysphagia
Might hear bowel sounds in chest (if hernia very large)
What are the differentials for hiatus hernia
Cardiac chest pain
Malignancy (gastric, pancreatic)
GORD
What are the investigations for hiatus hernia
OGD (gold standard, see upward displacement of gastro-oesophageal junction)
Incidental finding on CT/MRI
What is the management for hiatus hernia
PPIs
Lifestyle modification (weight loss, sleep with head raised)
Cruroplasty (hernia reduced from thorax into abdomen, may need mesh)
Fundoplication (fundus wrapped around lower oesophageal sphincter)
What are the complications of hiatus hernia
Incarceration/strangulation
Gastric volvulus (stomach twists on itself, get necrosis)
Complications of surgery: recurrence, bloating, dysphagia (fundoplication too tight), fundal necrosis
What is Borchardt’s triad
Seen in gastric volvulus
Severe epigastric pain
Retching without vomiting
Inability to pass NG tube
What is peptic ulcer disease commonly related to
H pylori infection
NSAID use
What are the risk factors for peptic ulcer disease
H pylori infection
Prolonged NSAID use
Corticosteroid use
Previous gastric bypass
Physiological stress
Head trauma
Zollinger-Ellison syndrome (severe peptic ulcer disease, gastric acid hypersecretion, gastrinoma)
How might peptic ulcer disease present
Epigastric pain
Retrosternal pain
Nausea
Bloating
Post-prandial discomfort
Early satiety
Complications of ulcer: bleeding, perforation, gastric outlet obstruction
What are the differentials for peptic ulcer disease
Acute coronary syndrome
GORD
Gallstones
Gastric malignancy
Pancreatitis
What investigations are needed for peptic ulcer disease
Routine bloods
H pylori testing (urea breath test, serum antibodies, stool antiges)
OGD
Biopsy
What are the NICE guidelines for investigating peptic ulcer disease
All identified ulcers should be biopsied (malignant potential)
Repeat endoscopy towards end of PPI therapy (check for resolution)
What is the management for peptic ulcer disease
Lifestyle advice
PPI
Have H pylori: PPI + amoxicillin + clarithromycin/metronidazone
Surgery rarely needed (only in perforations or very severe disease)
What are the complications of peptic ulcer disease
Perforation
Haemorrhage
Pyloric stenosis
What are the risk factors for gastric cancer
Male
H pylori infection
Increasing age
Smoking
Alcohol
Salty diet
Family history
Pernicious anaemia
How might gastric cancer present
Dyspepsia
Dysphagia
Early satiety
Vomiting
Melena
Anorexia
Weight loss
Anaemia
Epigastric mass
Virchow’s node
Hepatomegaly
Ascites
Jaundice
What are the differentials for gastric cancer
Peptic ulcer disease
GORD
Gallstones
Pancreatic cancer
What investigations are needed for gastric cancer
Bloods
OGD
Staging CT
What are the 2 types of inguinal hernia
Direct: bowel goes directly into inguinal canal, through weakness in Hesselbach’s triangle, more in older people, medial to inferior epigastric vessel
Indirect: bowel enters inguinal canal through deep inguinal ring, due to incomplete closure of processus vaginalis, lateral to inferior epigastric vessel
What are the risk factors for inguinal hernia
Male
Increasing age
Raised intra-abdominal pressure: chronic cough, heavy lifting, chronic constipation
Obesity
How might inguinal hernia present
Lump in groin
In incarcerated: painful, tender, erythematous
If strangulated: blood supply compromised, irreducible, tender, pain out of proportion to clinical signs
Features of bowel obstruction
How do you differentiate between direct and indirect inguinal hernias
Reduce hernia
Press over inguinal ring
Ask patient to cough
If protrudes, direct
If doesn’t protrude, indirect
Only definitive way is to look during surgery
What are the differentials for inguinal hernia
Femoral hernia
Saphena varix
Inguinal lymphadenopathy
Lipoma
Groin abscess
Internal iliac aneurysm
If extends into scrotum: hydrocele, varicocele, testicular mass
What is the management for inguinal hernia
Indications: irreducible, incarcerated, obstructed, strangulated
Open/laparoscopic repair
What are the complications of inguinal hernias
Incarceration
Strangulation
Obstruction
Post-op: pain, bruising, haematoma, infection, urinary retention, recurrence, chronic pain, damage to vas deferens/testicular vessels
What are the risk factors for femoral hernia
Female
Pregnancy
Raised intra-abdominal pressure
Increasing age
How might femoral hernia present
Small lump in groin
Infero-lateral to pubic tubercle (medial to femoral pulse)
What are the differentials for femoral hernia
Inguinal hernia
Femoral canal lipoma
Saphena varix
Femoral artery aneurysm
Athletic pubalgia (small tear in rectus sheath, impingement of abdominal wall muscles)
What investigations are needed for femoral hernia
Clinical diagnosis
May need ultrasound/CT
What is the management for femoral hernia
Usually need surgery within 2 weeks of presentation (high strangulation risk)
Can have low or high surgical approach (below/above inguinal ligament)
What is an epigastric hernia
Hernia in upper midline
Through fibres of linea alba
Due to chronic raised intraabdominal pressure
Mostly middle ages men
Usually asymptomatic
Disappears on lying flat
What is a paraumbilical hernia
Herniation through linea alba, around umbilical region (not through umbilicus)
Due to chronic raised intraabdominal pressure
Contain pre-peritoneal fat
Do not usually strangulate
What is a spigelian hernia
In semilunar line, around level of arcuate line
Small tender mass on lower lateral edge of rectus abdominis
High risk of strangulation
What is an obturator hernia
Hernia of pelvic floor
Through obturator foramen, into obturator canal
Usually in elderly women
Mass in upper medial thigh
Features of small bowel obstruction
Positive Howship-Romberg sign (compression of obturator nerve)
What is Littre’s hernia
Herniation of Meckel’s diverticulum
Mostly in inguinal canal
What is a lumbar hernia
Rare
Posterior mass
Associated with back pain
What is a Richter’s hernia
At any site
Partial herniation of bowel (anti-mesenteric border strangulated)
Tender, irreducible mass
Symptoms of obstruction
Surgical emergency
What is hospital-acquired gastroenteritis
Usually C diff
Following broad spectrum antibiotics (disrupt normal microbiota)
Large amounts of enterotoxin A and B produced
Present with severe bloody diarrhoea
Can get toxic megacolon
Investigations: stool culture, C diff toxin test
Management: IV fluid rehydration, oral metronidazole. Start vancomycin if severe disease/no improvement after 72 hrs
What is angiodysplasia
Most common vascular abnormality in GI tract
Formation of arteriovenous malformations between previously healthy blood vessels (often due to reduced submucosal venous drainage of colon)
How might angiodysplasia present
Asymptomatic (diagnosed during colonoscopy)
Painless occult PR bleeding
Acute haemorrhage
What are the differentials for angiodysplasia
Oesophageal varices
GI malignancy
Diverticular disease
Coagulopathies
What investigations are needed for angiodysplasia
Routine bloods (+ clotting + group and save)
Upper GI endoscopy/colonoscopy (exclude malignancy)
Mesenteric angiography (to confirm diagnosis)
What is the management for angiodysplasia
Conservative
Endoscopic argon plasma coagulation
Laser photoablation
Sclerotherapy
Band ligation
Surgery: resection and anastomosis of affected bowel segment (in severe bleeds or repeat recurrence)
What are the complications of angiodysplasia treatment
Re-bleeding
Bowel perforation
Haematoma formation
Arterial dissection
Thrombosis
Bowel ischaemia
What are gastroenteropancreatic neuroendocrine tumours (GEP-NETs)
Neuroendocrine tumours from neuroendocrine cells in tubular GI tract and pancreas
Classified grade 1 - 3: based on mitotic count
Also classified as functioning or non-functioning, based on whether there is hormone hypersecretion
What are the risk factors for gastroenteropancreatic neuroendocrine tumours (GEP-NETs)
Multiple endocrine neoplasia type 1
Von Hipple-Lindau disease
Neurofibromatosis
Tuberous sclerosis
How might gastroenteropancreatic neuroendocrine tumours (GEP-NETs) presents
Vague abdominal pain
Nausea and vomiting
Abdominal distension
Features of bowel obstruction
Weight loss
Palpable abdominal mass
What investigations are needed for gastroenteropancreatic neuroendocrine tumours (GEP-NETs)
Chromogranin A and 5-HIAA levels
Routine bloods
Pancreatic peptides
Genetic testing
Endoscopy
What is carcinoid crisis
Overwhelming release of hormones from gastroenteropancreatic neuroendocrine tumours (GEP-NETs)
Get resistant severe hypotension
Treat with somatostatin analogues
What are the risk factors for acute appendicitis
Family history
Caucasian
Summer time
How might acute appendicitis present
Acute abdominal pain (initially dull poorly localised, then sharp right iliac fossa)
Nausea and vomiting
Anorexia
Diarrhoea/constipation
Tachycardia, tachypnoea, pyrexia
Rebound tenderness over McBurney’s point (2/3 distance between umbilicus and asis)
Rovsing’s sign
Psoas sign
What is Rovsing’s sign
Due to acute appendicitis
Right iliac fossa pain on palpation of left iliac fossa
What is psoas sign
Due to acute appendicitis
Right iliac fossa pain extending to right hip
What investigations are needed for acute appendicitis
Urinalysis
Routine bloods
Ultrasound
CT
What is the management for acute appendicitis
Laparoscopic appendicectomy: definitive
If simple: antibiotics alone (high failure rates)
What are the complications of acute appendicitis
Perforation
Surgical site infection
Appendix mass (omentum and small bowel adhere to appendix)
Pelvic abscess
What is diverticular disease
Outpouching of bowel wall
Usually in sigmoid colon
Diverticulosis - presence of diverticula
Diverticular disease - symptoms from diverticula
Diverticulitis - inflammation of diverticula
Diverticula bleeding - diverticulum erodes into vessels (large volume, painless bleeding)
What is the pathophysiology of diverticular disease
Weakened bowel
Movement of stool causes increased luminal pressure
Outpouching of mucosa through weakened area
Bacteria can grow in outpouchings
Diverticulum can perforate
What are the differentials for diverticular disease
Age
Low fibre diet
Obesity
Smoking
Family history
NSAID use
M>F
How might diverticular disease present
Intermittent colicky lower abdominal pain
Altered bowel habits
Nausea
Flatulence
How might acute diverticulitis present
Acute sharp abdominal pain
Localised to left iliac fossa
Worse on movement
Systemic features
How might perforated diverticulum present
Localised peritonitis
Generalised peritonitis
Extremely unwell
What are the differentials for diverticular disease
Inflammatory bowel disease
Bowel cancer
Mesenteric ischaemia
Gynae causes
Renal stones
What investigations are needed for diverticular disease
CT abdo-pelvis
Flexible sigmoidoscopy
What are the CT findings in diverticular disease
Thickening of colonic wall
Pericolonic fat stranding
Abscess
Localised air bubble
Free air
What classification system is used for diverticular disease
Hinchey classification
How is diverticular disease managed
Analgesia, fluids, self-limiting bleeding
Acute diverticulitis: antibiotics, IV fluids, analgesia
Surgery: for perforation/faecal peritonitis/overwhelming sepsis, use Hartmann’s procedure
What are the complications of diverticular disease
Recurrent diverticulitis
Diverticular stricture
Fistula formation
What is pseudo-obstruction
Oglivie syndrome
Dilation of colon due to adynamic bowel, in absence of mechanical obstruction
Common in caecum and ascending colon
What are the causes of pseudo-obstruction
Electrolyte imbalance
Endocrine disorder
Medications (opioids, CCBs, antidepressants)
Recurrent surgery
Severe illness
Trauma
Neurological disease (Parkinson’s, multiple sclerosis, Hirschsprung’s disease)
How might pseudo-obstruction present
Abdominal pain
Abdominal distension
Constipation
Vomiting (late feature)
What are the differentials for pseudo-obstruction
Mechanical obstruction
Paralytic ileus
Toxic megacolon
What investigations are needed for pseudo-obstruction
Routine bloods
Abdominal X-ray (shows distension)
Abdominal CT (gold standard)
Motility studies
Consider biopsy
What is the management for pseudo-obstruction
NBM
IV fluids
NG tube if vomiting
Usually recover in 24-48 hrs
Endoscopic decompression (insert flatus tube)
IV neostigmine (anticholinesterase)
Surgery: for perforation/ischaemia/not responding, segmental resection and anastomosis
What is a volvulus
Twisting of loop of intestines around mesentery
Compromises bloods supply (get ischaemia, necrosis, perforation)
Mostly in sigmoid colon (longest mesentery)
What are the risk factors for volvulus
Increasing age
Neuropsychiatric disorders
Nursing home residents
Chronic constipation
Chronic laxative use
M>F
Previous abdominal surgery
How might volvulus present
Clinical features of bowel obstruction
Colicky pain
Abdominal distension
Absolute constipation
Vomiting (late sign)
Rapid onset
What are the differentials for volvulus
Severe constipation
Pseudo-obstruction
Sigmoid diverticular disease
What investigations are needed for volvulus
Routine bloods
CT abdo-pelvis (whirl sign)
Abdo X-ray (coffee-bean sign)
What is the management for volvulus
Decompression by sigmoidoscopy
Insert flatus tube
Surgery (ischaemia, perforation, repeated failed decompressions, necrosis)
What are the complications of volvulus
Bowel ischaemia
Perforation
Risk of recurrence
Complications of stoma
High mortality from surgery
Give an overview of caecal volvulus
Bimodal age: 10-29, 60-79
Diagnosed via CT
Management: laparotomy and ileocaecal resection
What are the 4 degrees of haemorrhoids
1st: remain in rectum
2nd: prolapse through anus on defecation, spontaneously reduce
3rd: prolapse through anus on defecation, need digital reduction
4th: remain persistently prolapsed
What are the risk factors for haemorrhoids
Excessive straining
Increasing age
Raised intra-abdominal pressure
Pelvic/abdominal mass
Family history
Cardiac failure
Portal hypertension
How might haemorrhoids present
Painless bright red PR bleeding
Itching
Rectal fullness
Anal lump
Soiling
Large can thrombose: painful
What is the management for haemorrhoids
Lifestyle advice
Topical analgesia (lignocaine gel)
Rubber band ligation
Haemorrhoidal artery ligation
Haemorrhoidectomy
What are the complications of haemorrhoids
Thrombosis
Ulceration
Gangrene
Skin tags
Perianal sepsis
What is pilonidal sinus disease
Disease of inter-gluteal region
Formation of sinus in cleft of buttocks
Mostly males 16-30
What is the pathophysiology of pilonidal sinus disease
Hair follicles in inter-gluteal cleft become infected and inflamed
Obstruction of follicle, extends inwards, forms pit
Foreign-body reaction causes formation of cavity
Connection of cavity to skin surface via epithelialised sinus tract
What are the risk factors for pilonidal sinus disease
Caucasian males
Coarse dark body hair
Sitting for long periods
Increased sweating
Buttock friction
Obesity
Poor hygiene
Local trauma
How might pilonidal sinus disease present
Mass in sacrococcygeal region
Intermittently red, painful, swollen
Discharge from sinus
Systemic features of infection
What is the management for pilonidal sinus disease
Shave affected region
Wash sinus
Use antibiotics in septic episodes
Surgical: abscess incision, drainage and washout. In chronic disease, can remove pilonidal sinus tract (can leave open or do primary closure)
What is perianal fistula
Abnormal connection between anal canal and perianal skin
Associated with anorectal abscess formation
What are the risk factors for perianal fistula
Perianal abscess
Inflammatory bowel disease
Systemic disease (TB, diabetes, HIV)
History of trauma
Previous radiation therapy to anus
How might perianal fistula present
Recurrent perianal abscesses
External opening of perineum
Fibrous tract underneath skin on DRE
What is Park’c classification system for perianal fistula
Inter-sphincteric
Trans-sphincteric
Supra-sphincteric
Extra-sphincteric
What investigations are needed for perianal fistula
Proctoscopy
MRI (for complex fistulas)
What is the management for perianal fistula
Conservative
Surgical: fistulotomy (leave tract open), placement of seton (for high tract disease)
What is the pathophysiology of anorectal abscess
Plugging of anal duct
Fluid stasis
Infection
What are the categories of anorectal abscess
Perianal
Ischiorectal
Intersphincteric
Supralevator
How might anorectal abscess present
Pain in perianal region
Worse on sitting down
Localised swelling
Itching
Discharge
Systemic features
Perianal mass
Surrounding cellulitis
What is the management for anorectal abscess
Antibiotics
Analgesia
Incision and drainage (leave to heal by secondary intention)
What is an anal fissure
Tear in mucosal lining of anal canal
Acute < 6 weeks
Chronic > 6 weeks
What are the risk factors for anal fissure
Constipation
Dehydration
Inflammatory bowel disease
Chronic ischaemia
How might anal fissure present
Intense pain on defecation
Bleeding
Itching
Visible fissure
DRE very painful (may need to examine under anaesthesia)
What is the management for anal fissure
Laxatives
Analgesia
Topical anaesthetics
GTN/diltiazem cream (increase blood supply, relax internal anal sphincter)
Botox injections (relax internal anal sphincter)
Lateral sphincterotomy (division of internal sphincter)
What is rectal prolapse
Protrusion of mucosal or full-thickness layer of rectal tissue out of anus
Partial thickness: rectal mucosa protrudes out of anus (stretching of connective tissue)
Full thickness: rectal wall protrudes out of anus (a form of sliding hernia)
What are the risk factors for rectal prolapse
Increasing age
F>M
Multiple vaginal deliveries
Straining
Anorexia
Previous traumatic vaginal delivery
How might rectal prolapse present
Rectal mucus discharge
Faecal incontinence
PR bleeding
Visible ulceration
Rectal fullness
Tenesmus
Repeated defecations
What is the management for rectal prolapse
Increase fibre and fluids
Banding
Surgery: perianal of abdominal approach
