general GI surgery Flashcards
what does tinkling or high pitched bowel sounds indicate
Small bowel obstruction
Management options for acute Abdo
ABCDE approach
supportive management
conservative management
surgical management
Potential problems causing RUQ pain:
- biliary colic
- Cholecystitis/cholangitis
- duodenal ulcers
- liver abscess
- portal vein thromobsis
- acute hepatitis
- nephrolithiasis
- RLL pneumonia
Potential problems causing RLQ pain:
- acute appendicitis
- colitis
- IBD
- infectious colitis
- ureteric stone/polynephritis
- PID/ovarian torsion
- ectopic pregnancy
- malignancy
Potential problems causing Epigastrium pain:
- acute gastritis/GORD
- gastroparesis
- peptic ulcer disease/perforation
- acute pancreatitis
- mesenteric ischaemia
- AAA
- Aortic dissection
- MI
Potential problems causing suprapubic/central pain:
early appendicitis mesenteric ischaemia bowel obstruction bowel perforation constipation gastroenteritis UTI/urinary retention PiD
Potential problems causing LUQ pain:
peptic ulcer acute pancreatitis splenic abscess/ splenic infarction nephrolithiasis LLL pneumonia
Potential problems causing LLQ pain
diverticulitis colitis IBD infectious colitis ureteric stone/polynephritis PID/ovarian torsion Ectopic pregnancy Malignancy
presentation of bowel ischaemia - symptoms and signs
- sudden onset crampy abdo pain
- severity of pain depends on length and thickness of abdo affected
- Bloody, loose stool (currant jelly)
- Fever, signs of septic shock
risk factors for bowel ischaemia
age>65 cardiac arrythmias hypercoagulation/thrombophilia vasculitis sickle cell disease profound shock causing hypotension
which bowel does acute mesenteric ischaemia affecT
small
which bowel does ischaemic colitis affect
large
is acute mesenteric ischaemia occlusive/nonocclusive
usually occlusive due to thromboembol
is ischaemic colitis occlusive/nonocclusive
usually due to non-occlusive low flow states, or atherosclerosis
time onset of acute mesenteric ischaemia
sudden (presentation and severity varies)
time onset of ischaemic colitis
more mild and gradual usually
physical examination pain for acute mesenteric ischaemia
abdo pain out of proportion of clinical signs
pain rating for ischaemic colitis
moderate pain and tenderness
conservative management for mild/moderate ischaemic colitis
- IV fluid resuscitation
- bowel rest
- broad spec ABx - colonic ischaemia can result in bacterial translocation + sepsis
- NG tube for decompression: in concurrent ileus
- anticoag
- treat/manage underlying cause
- serial abdo exam + repeat imaging
indications of surgery for bowel ischaemia
any small bowel ischaemia - straight to surgery
signs of peritonitis/sepsis
haemodynamic instability
massive bleeding
fulminant colitis with toxic megacolon
who is endovascular revascularisation offered to
patient without signs of ischaemia
-> balloon angioplasty/thrombectomy
where is presenting pain in acute appendicitis
periumbilical pain that migrates -> RLQ
symptoms appendicitis associated with
anorexia!
nausea/vom
low grade fever
change in bowel habit
important signs in acute appendicitis
- Mcburney’s point
- Blumberg sign
- Rovsing sign
- Psoas sign
- Obturator sign
What is Mcburney’s point?
tenderness in the RLQ
1/3 from ASIS to umbilicus
blumberg sign
acute appendicitis
rebound tenderness in right iliac fossa
Rovsing sign
RLQ pain elicited by deep palpation of LLQ
psoas sign
RLQ pain elicited on flexion of right hip against resistance
obturator sign
RLQ pain on passive internal rotation of the hip with hip+knee flexion
imaging for acute appendicitis investigations
CT (gold standard in adults esp if age > 50)
- USS kids/preg/breastfeeding
- MRI in pregn if USS inconclusive
when would you do a diagnostic laparoscopy for acute appendicitis investigation?
persistent pain + inconclusive imaging
what score is used to determine likelihood of acute appedncitis
ALVARADO SCORE
conservative management of acute appendicitis
IV fluids, analgesia, IV antibiotics
in abscess/phlegmon/sealed perforation -> resuscitation + IV AB +/- percutaneous drainage
indications for conservative management of acute appendicitis
- ve imaging in selected patients with clinically uncomplicated appendicitis
- in delayed presentation with abscess/phlegmon formation (trying to take out appendix would be v hard)
- > CT guided drainage
- > revisit later to do interval appendicectomy
laparoscopic vs open appendicectomy
less pain lower incidence of surgical site infection decreased length hospital stay earlier return to work less overall cost better QoL scores
features used to classify mechanical intestinal obstruction
speed of onset
nature
aetiology
the two natures of mechanical bowel obstruction are:
- simple (occluded without damage to blood supply)
- strangulating (blood supply involved segment of intestine is cut off e.g. strangulated hernia, volvulus, intussusception)
luminal causes of bowel obstruction
faecal impaction
gallstone ‘ileus’
wall causes of bowel obstruction
crohn’s
tumours
diverticulitis of the colon
outside of wall causes of bowel obstruction
- strangulated hernia (ext/int)
- volvulus
- obstruction due to adhesions/bands
what is described as the restriction of normal passage of intestinal contents?
intestinal obstruction
Two main groups of bowel obstruction
- paralytics (adynamic) ileus
- mechanical
causes of small bowel obstruction
1 adhesions 2 neoplasia 3 incarcerated hernia 4 crohns disease other
5 cause of large bowel obstruction
colorectal carcinoma volvulus diverticulitis faecal impaction hirschprung disease
3 points to remember about bowel obstruction
diagnosed by presence of symptoms
examination should always include a search for hernias/abdominal scars
simple or strangulating?
features suggesting strangulating bowel obstruction
change in character of pain from colicky -> continuous bowel sounds absent/reduced tachycardia pyrexia peritonism leucocytosis increased c reactive protein
what would a VBG show in a strangulated obstruction
metabolic acidosis due to lactate
imaging for bowel obstruction
erect CXR
Ct abdo/pelvis
small bowel obstruction X ray findings
dilated small bowel loops shows striations (ladder pattern)
large bowel obstruction x ray findings
dilated large bowel
usually not central
show striations only at sides of bowel not middle (tenia coli)
when to decide conservative management of bowel obstruction
patients with no ischaemia or signs of clinical deterioration
supportive management of bowel obtruction
NBM
IV access for fluids, analgesia, electrolyte balances
NG tube for decompression
urinary catheter for monitoring
conservative management of bowel obstruction caused by faecal impaction
stool evacuation - enema, endoscopic
conservative management for sigmoid volvulus causing bowel obstruction
rigid sigmoidoscopic decompression
conservative management of small bowel obstruction
oral gastrograffin for adhesions
indications for surgery for bowel obstruction
haemodynamically unstable
complete obstruction with signs of ischaemia
closed loop obstruction
persistent - over 2 days despite con management
presentation of bowel perforation
sudden onset severe abdo pain associated with distension
diffuse abdo guarding, rigidity, rebound tenderness
pain aggravated by movement
fever, tachycardia, tachypnoea, hypotension
decreased/absent bowel sounds
commonest cause of GI perforation
perforated peptic ulcers
causes of GI perforation
peptic ulcer perf
diverticulum perf
appendix perf
malignancy perf
signs of peptic ulcer perforation
sudden epigastric or diffuse pain
referred shoulder pain (phrenic nerve)
history of NSAIDs, steroids or recurrent epigastric pain
presentation of perforated diverticulum
more insidious onset
LLQ pain
constipation
presentation of perforated appendix
migratory pain
anorexia
gradually worsening RLQ pain
presentation of perforated malignancy
change in bowel habit, weight loss, anorexia in previous histories
post rectal bleeding
blood results for GI perforation
neutrophilic leucocytosis
elevated urea, creatinine
VBG = lactic acidosis
imaging for GI perforations
Erect CXR
Ct abdo/epvis
signs on X ray of GI perforation
sub-diaphragmatic free air
pneumoperitoneum
localised mesenteric fat stranding
differential Dx for GI perforation
acute cholecystitis, appendicitis
myocardial infarction
acute pancreatitis
conservative management of GI perforations
NBM, NGT IV fluids, PPI broad spectrum antibiotics parenteral analgesia and antiemetics urinary cath
surgery for perforated peptic ulcer
primary closure +/- omental patch
resection of perforated segment, primary anastamosis or temporary stoma
surgery option for perforated GI
exploratory lap
obtain intrabdominal fluid for microbiology culture and screen
surgery for perforated appendix
lap or open appendicectomy
surgery for perforated malignancy
intraoperative biopsies with primary closure
murphys sign
acute cholecystitis
pain when palpating under costal margin right hand side and asking patient to breathe deeply
signs of acute cholecystitis
acute severe RUQ pain
fever
positive murphys sign
signs of biliary colic
postprandial RUQ pain with shoulder radiation
nausea
what is charcots triad (jaundice, RUQ pain, fever) associated with
acute cholangitis
signs of acute pancreatitis
severe epigastric pain radiating to back
nausea/vom
history of gallstones or alcohol
investigation findings for biliary colic
normal bloods
ultrasound shows cholelithiasis
investigation findings for acute cholecystitis
elevated WCC and CRP
ultrsound thickened gallbladder wall
investigation findings for acute cholangitis
elevated LFTs, WCC, CRP, blood cultures positive
ultrasound biliary dilatation
management of biliary colic
analgesia
antiemetics
spasmolyitics
followup elective cholecystectomy
management for acute cholecystitis
fluids antibiotics analgesia blood cultures early or elective cholecystectomy
management of acute cholangitis
fluids
IV antibiotics
analgesia
ECRP for bile duct clearance or stenting
management for acute pancreatitis
glasgow admission score
aggressive fluid resus
analgesia, antiemetics
ICU involvement
approach to an acute abdomen
ABCDE
then SOCRATES history
