General GI Surgery Flashcards
What is the general approach to acute abdominal pain?
Pain assessment (SOCRATES) PMHx, DHx, SHx
Investigations
Management
What are some investigations that could be performed for acute abdominal pain?
Bloods: VBG, FBC, CRP, U&Es (renal profile), LFTs +amylase
Urinalysis + Urine MC&S
Imaging: Erect CXR, AXR, CTAP, CT angiogram, USS
Endoscopy
What are the management approaches for acute abdominal pain?
ABCDE approach
Conservative management
Surgical management
What are the differentials for RUQ pain?
Bilary Colic Cholecystitis/Cholangitis Duodenal Ulcer Liver abscess Portal vein thrombosis Acute hepatitis Nephrolithiasis RLL pneumonia
What are the differentials for LUQ pain?
Peptic ulcer Acute pancreatitis Splenic abscess Splenic infarction Nephrolithiasis Left Lower Lobe Pneumonia
What are the differentials for epigastric pain?
Acute gastritis/GORD Gastroparesis Peptic ulcer disease/perforation Acute pancreatitis Mesenteric ischaemia AAA (Abdominal Aortic Aneurysm) Aortic dissection Myocardial infarction
What are the differentials for RLQ pain?
Acute Appendicitis Colitis IBD Infectious colitis Ureteric stone/Pyelonephritis PID/Ovarian torsion Ectopic pregnancy Malignancy
What are the differentials for LLQ pain?
Diverticulitis Colitis IBD (Inflammatory Bowel Disease) Infectious colitis Ureteric stone/Pyelonephritis PID/Ovarian torsion Ectopic pregnancy Malignancy
What are the differentials for Suprapubic pain?
Early appendicitis Mesenteric ischaemia Bowel obstruction Bowel perforation Constipation Gastroenteritis UTI/Urinary retention PID
What is important to note about these differential lists?
Not exhaustive
How do patients with bowel ischaemia present?
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
What are the 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 main features of acute mesenteric ischaemia?
Small Bowel
Usually occlusive due to thromboemboli (SMA)
Sudden onest (but presentation and severity varies)
Abdominal pain can be out of proportion of clinical signs
e.g. extreme pain + no clinical signs
major clinical signs but patient feels well
What are the two types of bowel ischaemia?
Acute mesenteric Ischaemia
Ischaemic colitis
What are the main features of Ischaemic colitis?
Large bowel
Usually due to non-occlusive low flow states or atherosclerosis
More mild and gradual (80-85% of cases)
Moderate pain and tenderness
What investigations should you to for bowel ischaemia?
FBC: neutrophilic leukocytosis
VBG: Lactic acidosis
(Venous blood gasses)
- metabolic acidosis associated with late stage ischaemia
What imaging should you to for bowel ischaemia?
CTAP/CTAngiogram
Detects
Disrupted flow
Vascular stenosis
‘Pneumatosis intestinalis’ (transmural ischaemia/infarction)
Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)
When would you used endoscopy for bowel ischaemia?
For mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)
What is the conservative management approach to bowel ischaemia?
IV fluid resuscitation
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
When would you take a more conservative approach to managing bowel ischaemia?
Mild to moderate cases of ischaemic colitis (not suitable for SB ischaemia)
When is surgical management indicated to bowel ischaemia?
Small bowel ischaemia Signs of peritonitis orsepsis Haemodynamic instability Massive bleeding Fulminant colitis with toxic megacolon
What are the two types of surgical management?
Exploratory laparotomy
Endovascualr revascularisation
What is exploratory laparotomy?
Resection of necrotic bowel +/-open surgicalembolectomy
or mesenteric arterial bypass
What is endovascular revscualrisation?
Balloon angioplasty/thrombectomy
In patients without signs of ischaemia
How does acute appendicitis present?
Initially periumbilical pain that migrates to RLQ (within 24hours)
Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit
What are the important clinical signs in 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 - moving perotineum
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
What bloods are done for acute appendicitis?
FBC: neutrophilic leukocytosis
↑ed CRP
Urinalysis: possible mild pyuria/haematuria
Electrolyte imbalances in profound vomiting
What imaging is done for acute appendcitis?
CT: gold standard in adults esp. if age > 50
USS: children/pregnancy/breastfeeding
MRI: in pregnancy if USS inconclusive
When would you do a diagnostic laparoscopy for suspected acute appendicitis?
In persistent pain & inconclusive imaging
What is the diagnostic tool used for acute appendicits?
Alvardo score
6 clinical items
What are the clinical items used on the alvardo score?
RLQ Tendereness (2) Fever (1) Rebound tenderness (1) Pain migration (1) Anorexia (1) Nausea +/- vomiting (1) WCC > 10,000 (2) Neutrophilia (left shift) (1) ≤4 Unlikely 5-6 Possible ≥7 Likely
What is the conservative management of acute appendicitis?
IV Fluids, Analgesia, IV or PO Antibiotics
In abscess, phlegmon or sealed perforation
Resuscitation + IV ABx +/- percutaneous drainage
What are the 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 must you always consider in acute appendicitis?
Consider interval appendicectomy - rate of recurrence after conservative management of abscess/perforation is 12-24%
What are the benefits of laparoscopic appenicetomy?
Less pain Lower incidence of surgical site infection ↓ed length of hospital stay Earlier return to work Overall costs Better quality of life scores
What are the steps of laparoscopic appendicetomy?
Trocar placement (usually 3)
Exploration of RIF & identification of appendix
Elevation of appendix + division of mesoappendix (containing artery)
Based 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
Define intestinal obstruction?
restriction of normal passage of intestinal contents
What are the two main groups of bowel obstruction?
Paralytic (Adynamic) ileus
Mechanical.
How do you classify mechanical intestinal obstruction?
Speed of onset
Site
Nature
Aetiology
What are the different speeds of onset for bowel obstruction?
acute, chronic, acute-on-chronic
What are the different sites of bowel obstruction?
high or low
roughly synonymous with small or large bowel obstruction
What are the different natures of bowel obstruction?
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)
What are the causes of bowel obstruction?
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 main causes of small bowel obstruction?
Adhesions (60%) Neoplasia (20%) Incarcerated hernia (10%) Crohn's disease (5%) Other (5%)
What are the main causes of large bowel obstruction?
Colorectal cancer Volvulus Diverticulitis Faecal impaction Hirschsprung's disease
How does small bowel obstruction present?
Colicky, central pain
Early onset vomiting - large amount and bilious
Constipation - late sign
Abdominal distention is less significant
How does large bowel obstruction present?
Colicky or constant pain
Vomitting is late onset - initally billous progress to faecal vomiting
Constipation is early sign
Abdominal distention is early and significant
What are other signs of bowel obstruction that are present in both?
Dehydration
Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign)
Diffuse abdominal tenderness
What are the three important things about diagonisisng bowel obstruction?
Diagnosed by the presence of symptoms
Examination should always include a search for hernias & abdominal scars, including laparoscopic portholes
Is it simple or strangulating?
What features suggest strangulation?
Change in character of pain from colicky to continuous Tachycardia Pyrexia Peritonism Bowel sounds absent or reduced Leucocytosis ↑ed C-reactive protein
What are common hernial sites?
Epigastric Ubmilical Incscional Inguinal Feomral
What are the different types of hernia?
Neck of sac
Strangulated
Richter’s
What are the blood results for bowel obstruction?
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)
What imaging is done for bowel obstruction?
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 is seen on AXR for small bowel obstruction?
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 is seen on AXR for large bowel obstruction?
Distended large bowel tends to lie peripherally
Show haustrations of taenia coli - do not extend across whole width of the bowel.
What can CT scans do re bowel obstruction?
Can localize site of obstruction
Detect obstructing lesions & colonic tumours
May diagnose unusual hernias (e.g. obturator hernias).
What is the supportive mangement for 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
What is the conservative treatment for bowel obstruction?
Faecal impaction: stool evacuation (manual, enemas, endoscopic)
Sigmoid volvulus: rigid sigmoidoscopic decompression - pass tube through bowel to straighten it out
SBO: oral gastrograffin (highly osmolar iodinated contrast agent)can be used to resolve adhesionalsmall bowel obstruction
What are the indications of surgical management for 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
What is the surgical process for bowel obstruction?
Exploratory Laparotomy/Laparoscopy
Restoration of intestinal transit (depending on intra-operational findings)
Bowel resection with primary anastomosis or temporary/permanent stoma formation
How does GI perforation present?
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 the features of perforated peptic ulcer?
Sudden epigastric or diffuse pain
Referred shoulder pain - diaphragm irritation Phrenic nerve innervates shoulder
Hx of NSAIDs, steroids, recurrent epigastric pain
What are the features of perforated diverticulum?
LLQ pain
Constipation
What are the features of perforated appendix?
Migratory pain
Anorexia
Gradual worsening RLQ pain
What are the features of perforated malignancy?
Change in bowel habit
Weight loss
Anorexia
PR Bleeding
What bloods are done for GI perforations?
Change in bowel habit
Weight loss
Anorexia
PR Bleeding
What imaging are done for GI perforations?
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
What is the supportive management for GI perforation?
NBM & NG tube IV peripheral access with large bore cannula -IV Fluid resuscitation Broad spectrum Abx IV PPI Parenteral analgesia & antiemetics Urinary catheter
What is the conservative management for GI perforation?
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
What are the stages of surgical management for GI Perforation?
Exploratory laparotomy/laparascopy
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
What are the stages of surgical management for GI Perforation?
Exploratory laparotomy/laparascopy
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
What are the symptoms of biliary collic?
PostprandialRUQ pain with radiation to the shoulder.
Nausea
What are the investigations for biliary collic?
Normal blood results
USS: cholelithiasis
How do you manage biliary collic?
Analgesia, Antiemetics, Spasmolytics
Follow up for elective cholecystectomy
What are the symptoms of acute cholycystisis?
Acute, severe RUQ pain
Fever
Murphy’s sign
What are the investigations for acute cholycystisis?
Elevated WCC/CRP
USS: thickened gallbladder wall
What is the management for acute cholycystisis?
Fluids, ABx, Analgesia, Blood cultures
Early (<72 hours) or elective cholecystectomy (4-6 weeks)
What are the symptoms of acute cholangitis?
Charcot’s triad: jaundice, RUQ pain, fever
What are the investigations for acute cholangitis?
Elevated LFTs, WCC, CRP, Blood MCS (+ve)
USS: bilary dilatation
What is the management for acute cholangitis?
Fluids, IV Abx, Analgesia
ERCP (within 72hrs) for clearance of bile duct or stenting
What are the symptoms of acute pancreatitis?
Severe epigastric pain radiating to the back
Nausea +/- vomiting
Hx of gallstones or EtOH use
What are the investigations for acute pancreatitis?
Raised amylase/lipase
High WCC/Low Ca2+
CT and US to assess for complications/cause
What is the management for acute pancreatitis?
Admission score (Glasgow-Imrie)
Aggressive fluid resuscitation, O2
Analgesia, Antiemetics
ITU/HDU involvement
