General GI surgery Flashcards
What do we look for in the history of a patient with GI complaint?
-History of presenting complaint- SOCRATES, associated symptoms
- PMHx (past medical history)
- DHX (drug history)
- SHx (social history)
What range of investigations are there?
- Bloods
- Urinalysis + urine MC&S → check for UTI
- Imaging
- Endoscopy
What bloods can be done?
- VBG
- FBC
- CRP
- U&Es (renal profile)
- LFTs + amylase
What imaging is performed?
- Erect CXR
- AXR
- CTAP (CT of abdomen and pelvis)
- CT angiogram- when you suspect bleeding or infarction or large intraabdominal blood vessel
- USS
What are the 3 approaches to management?
- ABCDE approach
- Airways
- Breathing
- Circulation
- Disability
- Exposure
- Conservative management
- Surgical management
What diseases are associated with RUQ?
- Bilary Colic
- Cholecystitis/Cholangitis
- Duodenal Ulcer
- Liver abscess
- Portal vein thrombosis
- Acute hepatitis
- Nephrolithiasis
- RLL pneumonia
What diseases are associated with epigastrium?
- Acute gastritis/GORD
- Gastroparesis
- Peptic ulcer disease/perforation
- Acute pancreatitis
- Mesenteric ischaemia
- AAA (Abdominal Aortic Aneurysm) Aortic dissection
- Myocardial infarction
What diseases are associated with LUQ?
- Peptic ulcer
- Acute pancreatitis
- Splenic abscess
- Splenic infarction
- Nephrolithiasis
- LLL Pneumonia
What diseases are associated with RLQ?
- Acute Appendicitis
- IBD
- Colitis
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
What diseases are associated with suprapubic/ central?
- Early appendicitis
- Mesenteric ischaemia
- Bowel obstruction
- Bowel perforation
- Constipation
- Gastroenteritis
- UTI/Urinary retention
- PID
What diseases are associated with LLQ?
- Diverticulitis
- IBD (Inflammatory Bowel Disease)
- Colitis
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
Presentation of bowel ischaemia
Sudden onset crampy abdominal pain
Severity of pain depends on the length and thickness of colon affected
Bloody, loose stool (currant jelly stools)
Fever, signs of septic shock
Risk factors for bowel ischaemia
Age >65 yr
Cardiac arrythmias (mainly AF), atherosclerosis
Hypercoagulation/thrombophilia
Vasculitis
Sickle cell disease
Profound shock causing hypotension
What are the 2 types of ischaemic bowel?
Acute mesenteric ischaemia and ischaemic colitis
Differences between acute mesenteric ischaemia and ischaemic colitis
Bowel ischaemia investigations
Bloods
FBC: neutrophilic leukocytosis
VBG: Lactic acidosis
Imaging -CTAP/CTAngiogram
Detects
Disrupted flow
Vascular stenosis
‘Pneumatosis intestinalis’ (transmural ischaemia/infarction)
Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)
Endoscopy
For mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)
When is bowel ischaemia managed conservatively?
Mild to moderate cases of ischaemic colitis (not suitable for SB ischaemia)
Conservative management for bowel ischaemia?
Bowel rest
Broad-spectrum ABx - colonic ischaemia can result in bacterial translocation & sepsis
NG tube for decompression - in concurrent ileus
Anticoagulation
Treat/manage underlying cause
Serial abdominal examination and repeat imaging
Indications for surgical management of bowel ischaemia
Small bowel ischaemia
Signs of peritonitis orsepsis
Haemodynamic instability
Massive bleeding
Fulminant colitis with toxic megacolon
Surgical management of bowel ischaemia
Exploratory laparotomy:
-Resection of necrotic bowel +/-open surgicalembolectomy
or mesenteric arterial bypass
Endovascular revascularisation:
-Another technique to try prior to surgery
-Balloon angioplasty/thrombectomy
-In patients without signs of ischaemia
Presentation of acute appendicitis
Initially periumbilical pain that migrates to RLQ (within 24hours)
Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit
Important clinical signs of acute appendicitis
McBurney’s point: tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
Blumberg sign: rebound tenderness especially in the RIF
Rovsing sign: RLQ pain elicited on deep palpation of the 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
Acute Appendicitis – Investigations
Bloods
FBC: neutrophilic leukocytosis
↑ed CRP
Urinalysis: possible mild pyuria/haematuria
Electrolyte imbalances in profound vomiting
Imaging
CT: gold standard in adults esp. if age > 50
USS: children/pregnancy/breastfeeding
MRI: in pregnancy if USS inconclusive
Diagnostic Laparoscopy
In persistent pain & inconclusive imaging
What is the Alvarado score?
clinical scoring system for appendicitis
- RLQ tenderness- 2 points
- Rebound tenderness- 1 point
- Fever >37.3°C- 1 point
- Pain migration- 1 point
- Anorexia- 1 point
- Nausea +/- vomiting- 1 point
- WCC >10.000- 2 points
- Neutrophilia (left shift 75%)- 1 point
≤4 unlikely
5-6 possible
≥7 likely
Conservative management for acute appendicitis
IV Fluids, Analgesia, IV or PO Antibiotics
In abscess, phlegmon or sealed perforation
Resuscitation + IV ABx +/- percutaneous drainage
Indications for conservative management for acute appendicitis
After negative imaging in selected patients with clinically uncomplicated appendicitis
In delayed presentation with abscess/phlegmon formation
CT-guided drainage
What do we consider after conservative management?
interval appendicectomy - rate of recurrence after conservative management of abscess/perforation is 12-24%
Laparoscopic vs Open appendicectomy benefits
Less pain
Lower incidence of surgical site infection
↓ed length of hospital stay
Earlier return to work
Overall costs
Better quality of life scores
Steps of Laparoscopic Appendicectomy
Trocar placement (usually 3)
Exploration of RIF & identification of appendix
Elevation of appendix + division of mesoappendix (containing artery)
Base secured with endoloops and appendix is divided
Retrieval of appendix with a plastic retrieval bag
Careful inspection of the rest of the pelvic organs/intestines
Pelvic irrigation (wash out) + Haemostasis
Removal of trocars + wound closure
What is intestinal obstruction?
What are the 2 types?
Intestinal obstruction - restriction of normal passage of intestinal contents.
Two main groups:
Paralytic (Adynamic) ileus
Mechanical.
How is mechanical intestinal obstruction classified?
Speed of onset: acute, chronic, acute-on-chronic
Site: high or low
roughly synonymous with small or large bowel obstruction
Nature: simple vs strangulating
Simple: bowel is occluded without damage to blood supply.
Strangulating: blood supply of involved segment of intestine is cut off (e.g. in strangulated hernia, volvulus, intussusception)
Aetiology:
Causes in the lumen - faecal impaction, gallstone ‘ileus’
Causes in the wall - Crohn’s disease, tumours, diverticulitis of colon
Causes outside the wall –
Strangulated hernia (external or internal)
Volvulus
Obstruction due to adhesions or bands.
What are the causes of small bowel obstruction?
- Adhesions (60%)- Hx of previous abdominal surgery
- Neoplasia (20%)- primary (rare), metastatic, extraintestinal- can happen in ovarian peritoneal disease
- Incarcerated hernia (10%)- external (abdominal wall), internal (mesenteric defect)
- Crohn’s Disease (5%)- acute (oedema), chronic (strictures)
- Other (5%)- intussusception, intraluminal (foreign body, bezoar)
What are the causes of large bowel obstruction?
- Colorectal cancer- commonest cause- usually obstructs on left hand side because on right the bowel can expand and compensate
- Volvulus- sigmoid, caecal
- Diverticulitis- inflammation, strictures
- Faecal impaction
- Hirschsprung disease- commonly found in infants/children (lack of nerve ganglions means bowels can’t do peristalsis)
Presentation of bowel obstruction
What are the 3 important things to remember about diagnosing bowel obstruction?
- Diagnosed by the presence of symptoms
- Examination should always include a search for hernias and abdominal scars, including laparoscopic portholes
- Is it simple or strangulating?
Features suggesting strangulation
Change in character of pain from colicky to continuous
Tachycardia
Pyrexia
Peritonism
Bowel sounds absent or reduced
Leucocytosis
↑ed C-reactive protein
Types of hernias
Bowel Obstruction - Investigations
Bloods
WCC/CRP usually normal (if raised suspicion of strangulation/perforation)
U&E: electrolyte imbalance
VBG if vomiting: HypoCl-,HypoK+ metabolic alkalosis
VBG if strangulation: Metabolic Acidosis (lactate)
Imaging
Erect CXR/AXR
SBO: Dilated small bowel loops >3cm proximal to the obstruction (central)
LBO:Dilated large bowel >6cm (if caecum >9cm) predominantly peripheral
CT abdo/pelvis→ Transition point, dilatation of proximal loops – IV +/- oral contrast if possible
What does SBO abdominal Xray show?
Ladder pattern of dilated loops & their central position
Striations that pass completely across the width of the distended loop produced by the circular mucosal folds
What does LBO abdominal Xray show?
Distended large bowel tends to lie peripherally
Show haustrations of taenia coli - do not extend across whole width of the bowel.
What can CT show in bowel obstruction?
Can localize site of obstruction
Detect obstructing lesions & colonic tumours
May diagnose unusual hernias (e.g. obturator hernias).
When are patients with bowel obstruction conservatively managed?
In patients with no signs of ischaemia/no signs of clinical deterioration
Supportive managementfor bowel obstruction
NBM, IV peripheral access with large bore cannula -IV Fluid resuscitation
IV analgesia, IV antiemetics, correction of electrolyte imbalances
NG tube for decompression, urinary catheter for monitoring output
Introduce gradual food intake if abdominal pain and distention improve
Conservative managementfor bowel obstruction
Faecal impaction: stool evacuation (manual, enemas, endoscopic)
Sigmoid volvulus: rigid sigmoidoscopic decompression
SBO: oral gastrograffin (highly osmolar iodinated contrast agent)can be used to resolve adhesionalsmall bowel obstruction
Indications for surgical management of bowel obstruction
Haemodynamic instability or signs of sepsis
Complete bowel obstruction with signs of ischaemia
Closed loop obstruction
Persistent bowel obstruction >2 days despite conservative management
Surgical management of bowel obstruction
Exploratory Laparotomy/Laparoscopy
Restoration of intestinal transit (depending on intra-operational findings)
Bowel resection with primary anastomosis or temporary/permanent stoma formation
(Endoscopic stenting)
GI Perforation – Presentation
Sudden onset severe abdominal pain associated with distention
Diffuse abdominal guarding, rigidity, rebound tenderness
Pain aggravated by movement
Nausea, vomiting, absolute constipation
Fever, Tachycardia, Tachypnoea, Hypotension
Decreased or absent bowel sounds
What are 4 causes of GI perforation and how do they present?
GI Perforation – Investigations
Bloods
FBC: neutrophilic leukocytosis
Possible elevation of Urea, Creatinine
VBG: Lactic acidosis
Imaging
Erect CXR→ subdiaphragmatic free air (pneumoperitoneum)
CT abdo/pelvis→Pneumoperitoneum, free GI content,localised mesenteric fat stranding
can exclude common differential diagnoses such as pancreatitis
GI Perforation – Conservative Management
Supportive management on presentation
NBM & NG tube
IV peripheral access with large bore cannula -IV Fluid resuscitation
Broad spectrum Abx
IV PPI
Parenteral analgesia & antiemetics
Urinary catheter
Conservative management in localised peritonitis without signs of sepsis
Very rare
IR - guided drainage of intra-abdominal collection
Serial abdominal examination & abdominal imaging for assessment
When would a GI perforation be surgically managed
Generalised peritonitis +/- signs ofsepsis
GI Perforation – Surgicalmanagement
Exploratory laparotomy/laparoscopy
Primary closure of perforation with or withoutomental patch (most common in perforated pepticulcer)
Resection of theperforated segment of the bowelwith primary anastomosis or temporary stoma
Obtainintra-abdominal fluid for MC&S, peritoneal lavage ++++
If perforated appendix: Lap or open appendicectomy
If malignancy: intraoperative biopsies if possible
Biliary & Pancreatic Causes of Acute Abdomen
Biliary Colic
Acute Cholecystitis
Acute Cholangitis
Acute Pancreatitis
Symptoms, investigations and management for biliary colic
Symptoms, investigations and management for Acute Cholecystitis
Symptoms, investigations and management for Acute Cholangitis
Symptoms, investigations and management for Acute Pancreatitis
