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BRS Year 2 > general GI surgery > Flashcards

general GI surgery Flashcards

1
Q

what does tinkling or high pitched bowel sounds indicate

A

Small bowel obstruction

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2
Q

Management options for acute Abdo

A

ABCDE approach
supportive management
conservative management
surgical management

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3
Q

Potential problems causing RUQ pain:

A
  1. biliary colic
  2. Cholecystitis/cholangitis
  3. duodenal ulcers
  4. liver abscess
  5. portal vein thromobsis
  6. acute hepatitis
  7. nephrolithiasis
  8. RLL pneumonia
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4
Q

Potential problems causing RLQ pain:

A
  1. acute appendicitis
  2. colitis
  3. IBD
  4. infectious colitis
  5. ureteric stone/polynephritis
  6. PID/ovarian torsion
  7. ectopic pregnancy
  8. malignancy
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5
Q

Potential problems causing Epigastrium pain:

A
  1. acute gastritis/GORD
  2. gastroparesis
  3. peptic ulcer disease/perforation
  4. acute pancreatitis
  5. mesenteric ischaemia
  6. AAA
  7. Aortic dissection
  8. MI
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6
Q

Potential problems causing suprapubic/central pain:

A 
early appendicitis
mesenteric ischaemia
bowel obstruction
bowel perforation
constipation
gastroenteritis
UTI/urinary retention
PiD
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7
Q

Potential problems causing LUQ pain:

A 
peptic ulcer
acute pancreatitis
splenic abscess/ splenic infarction
nephrolithiasis
LLL pneumonia
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8
Q

Potential problems causing LLQ pain

A 
diverticulitis
colitis
IBD
infectious colitis
ureteric stone/polynephritis
PID/ovarian torsion
Ectopic pregnancy
Malignancy
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9
Q

presentation of bowel ischaemia - symptoms and signs

A
  1. sudden onset crampy abdo pain
  2. severity of pain depends on length and thickness of abdo affected
  3. Bloody, loose stool (currant jelly)
  4. Fever, signs of septic shock
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10
Q

risk factors for bowel ischaemia

A 
age>65
cardiac arrythmias
hypercoagulation/thrombophilia
vasculitis
sickle cell disease
profound shock causing hypotension
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11
Q

which bowel does acute mesenteric ischaemia affecT

A

small

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12
Q

which bowel does ischaemic colitis affect

A

large

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13
Q

is acute mesenteric ischaemia occlusive/nonocclusive

A

usually occlusive due to thromboembol

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14
Q

is ischaemic colitis occlusive/nonocclusive

A

usually due to non-occlusive low flow states, or atherosclerosis

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15
Q

time onset of acute mesenteric ischaemia

A

sudden (presentation and severity varies)

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16
Q

time onset of ischaemic colitis

A

more mild and gradual usually

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17
Q

physical examination pain for acute mesenteric ischaemia

A

abdo pain out of proportion of clinical signs

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18
Q

pain rating for ischaemic colitis

A

moderate pain and tenderness

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19
Q

conservative management for mild/moderate ischaemic colitis

A
  • 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
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20
Q

indications of surgery for bowel ischaemia

A

any small bowel ischaemia - straight to surgery

signs of peritonitis/sepsis
haemodynamic instability
massive bleeding
fulminant colitis with toxic megacolon

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21
Q

who is endovascular revascularisation offered to

A

patient without signs of ischaemia

-> balloon angioplasty/thrombectomy

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22
Q

where is presenting pain in acute appendicitis

A

periumbilical pain that migrates -> RLQ

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23
Q

symptoms appendicitis associated with

A

anorexia!
nausea/vom
low grade fever
change in bowel habit

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24
Q

important signs in acute appendicitis

A
  • Mcburney’s point
  • Blumberg sign
  • Rovsing sign
  • Psoas sign
  • Obturator sign
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25
Q

What is Mcburney’s point?

A

tenderness in the RLQ

1/3 from ASIS to umbilicus

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26
Q

blumberg sign

A

acute appendicitis

rebound tenderness in right iliac fossa

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27
Q

Rovsing sign

A

RLQ pain elicited by deep palpation of LLQ

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28
Q

psoas sign

A

RLQ pain elicited on flexion of right hip against resistance

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29
Q

obturator sign

A

RLQ pain on passive internal rotation of the hip with hip+knee flexion

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30
Q

imaging for acute appendicitis investigations

A

CT (gold standard in adults esp if age > 50)

  • USS kids/preg/breastfeeding
  • MRI in pregn if USS inconclusive
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31
Q

when would you do a diagnostic laparoscopy for acute appendicitis investigation?

A

persistent pain + inconclusive imaging

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32
Q

what score is used to determine likelihood of acute appedncitis

A

ALVARADO SCORE

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33
Q

conservative management of acute appendicitis

A

IV fluids, analgesia, IV antibiotics

in abscess/phlegmon/sealed perforation -> resuscitation + IV AB +/- percutaneous drainage

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34
Q

indications for conservative management of acute appendicitis

A
  • 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
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35
Q

laparoscopic vs open appendicectomy

A 
less pain
lower incidence of surgical site infection
decreased length hospital stay
earlier return to work
less overall cost
better QoL scores
36
Q

features used to classify mechanical intestinal obstruction

A

speed of onset
nature
aetiology

37
Q

the two natures of mechanical bowel obstruction are:

A
  1. simple (occluded without damage to blood supply)
  2. strangulating (blood supply involved segment of intestine is cut off e.g. strangulated hernia, volvulus, intussusception)
38
Q

luminal causes of bowel obstruction

A

faecal impaction

gallstone ‘ileus’

39
Q

wall causes of bowel obstruction

A

crohn’s
tumours
diverticulitis of the colon

40
Q

outside of wall causes of bowel obstruction

A
  • strangulated hernia (ext/int)
  • volvulus
  • obstruction due to adhesions/bands
41
Q

what is described as the restriction of normal passage of intestinal contents?

A

intestinal obstruction

42
Q

Two main groups of bowel obstruction

A
  • paralytics (adynamic) ileus

- mechanical

43
Q

causes of small bowel obstruction

A 
1 adhesions
2 neoplasia
3 incarcerated hernia
4 crohns disease
other
44
Q

5 cause of large bowel obstruction

A 
colorectal carcinoma
volvulus
diverticulitis
faecal impaction
hirschprung disease
45
Q

3 points to remember about bowel obstruction

A

diagnosed by presence of symptoms
examination should always include a search for hernias/abdominal scars
simple or strangulating?

46
Q

features suggesting strangulating bowel obstruction

A 
change in character of pain from colicky -> continuous
bowel sounds absent/reduced
tachycardia
pyrexia
peritonism
leucocytosis
increased c reactive protein
47
Q

what would a VBG show in a strangulated obstruction

A

metabolic acidosis due to lactate

48
Q

imaging for bowel obstruction

A

erect CXR

Ct abdo/pelvis

49
Q

small bowel obstruction X ray findings

A 
dilated small bowel loops 
shows striations (ladder pattern)
50
Q

large bowel obstruction x ray findings

A

dilated large bowel
usually not central
show striations only at sides of bowel not middle (tenia coli)

51
Q

when to decide conservative management of bowel obstruction

A

patients with no ischaemia or signs of clinical deterioration

52
Q

supportive management of bowel obtruction

A

NBM
IV access for fluids, analgesia, electrolyte balances
NG tube for decompression
urinary catheter for monitoring

53
Q

conservative management of bowel obstruction caused by faecal impaction

A

stool evacuation - enema, endoscopic

54
Q

conservative management for sigmoid volvulus causing bowel obstruction

A

rigid sigmoidoscopic decompression

55
Q

conservative management of small bowel obstruction

A

oral gastrograffin for adhesions

56
Q

indications for surgery for bowel obstruction

A

haemodynamically unstable
complete obstruction with signs of ischaemia
closed loop obstruction
persistent - over 2 days despite con management

57
Q

presentation of bowel perforation

A

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

58
Q

commonest cause of GI perforation

A

perforated peptic ulcers

59
Q

causes of GI perforation

A

peptic ulcer perf
diverticulum perf
appendix perf
malignancy perf

60
Q

signs of peptic ulcer perforation

A

sudden epigastric or diffuse pain
referred shoulder pain (phrenic nerve)
history of NSAIDs, steroids or recurrent epigastric pain

61
Q

presentation of perforated diverticulum

A

more insidious onset
LLQ pain
constipation

62
Q

presentation of perforated appendix

A

migratory pain
anorexia
gradually worsening RLQ pain

63
Q

presentation of perforated malignancy

A

change in bowel habit, weight loss, anorexia in previous histories
post rectal bleeding

64
Q

blood results for GI perforation

A

neutrophilic leucocytosis
elevated urea, creatinine
VBG = lactic acidosis

65
Q

imaging for GI perforations

A

Erect CXR

Ct abdo/epvis

66
Q

signs on X ray of GI perforation

A

sub-diaphragmatic free air
pneumoperitoneum
localised mesenteric fat stranding

67
Q

differential Dx for GI perforation

A

acute cholecystitis, appendicitis
myocardial infarction
acute pancreatitis

68
Q

conservative management of GI perforations

A 
NBM, NGT
IV fluids, PPI
broad spectrum antibiotics
parenteral analgesia and antiemetics
urinary cath
69
Q

surgery for perforated peptic ulcer

A

primary closure +/- omental patch

resection of perforated segment, primary anastamosis or temporary stoma

70
Q

surgery option for perforated GI

A

exploratory lap

obtain intrabdominal fluid for microbiology culture and screen

71
Q

surgery for perforated appendix

A

lap or open appendicectomy

72
Q

surgery for perforated malignancy

A

intraoperative biopsies with primary closure

73
Q

murphys sign

A

acute cholecystitis

pain when palpating under costal margin right hand side and asking patient to breathe deeply

74
Q

signs of acute cholecystitis

A

acute severe RUQ pain
fever
positive murphys sign

75
Q

signs of biliary colic

A

postprandial RUQ pain with shoulder radiation

nausea

76
Q

what is charcots triad (jaundice, RUQ pain, fever) associated with

A

acute cholangitis

77
Q

signs of acute pancreatitis

A

severe epigastric pain radiating to back
nausea/vom
history of gallstones or alcohol

78
Q

investigation findings for biliary colic

A

normal bloods

ultrasound shows cholelithiasis

79
Q

investigation findings for acute cholecystitis

A

elevated WCC and CRP

ultrsound thickened gallbladder wall

80
Q

investigation findings for acute cholangitis

A

elevated LFTs, WCC, CRP, blood cultures positive

ultrasound biliary dilatation

81
Q

management of biliary colic

A

analgesia
antiemetics
spasmolyitics
followup elective cholecystectomy

82
Q

management for acute cholecystitis

A 
fluids
antibiotics
analgesia
blood cultures
early or elective cholecystectomy
83
Q

management of acute cholangitis

A

fluids
IV antibiotics
analgesia
ECRP for bile duct clearance or stenting

84
Q

management for acute pancreatitis

A

glasgow admission score
aggressive fluid resus
analgesia, antiemetics
ICU involvement

85
Q

approach to an acute abdomen

A

ABCDE

then SOCRATES history

BRS Year 2 (67 decks)

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