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Year 2 Gastro > General GI Surgery > Flashcards

General GI Surgery Flashcards

1
Q

What is the general approach to acute abdominal pain?

A 
Pain assessment (SOCRATES)
PMHx, DHx, SHx

Investigations

Management

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2
Q

What are some investigations that could be performed for acute abdominal pain?

A

Bloods: VBG, FBC, CRP, U&Es (renal profile), LFTs +amylase

Urinalysis + Urine MC&S

Imaging: Erect CXR, AXR, CTAP, CT angiogram, USS

Endoscopy

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3
Q

What are the management approaches for acute abdominal pain?

A

ABCDE approach
Conservative management
Surgical management

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4
Q

What are the differentials for RUQ pain?

A 
Bilary Colic
Cholecystitis/Cholangitis
Duodenal Ulcer
Liver abscess
Portal vein thrombosis
Acute hepatitis
Nephrolithiasis
RLL pneumonia
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5
Q

What are the differentials for LUQ pain?

A 
Peptic ulcer
Acute pancreatitis
Splenic abscess
Splenic infarction
Nephrolithiasis
Left Lower Lobe Pneumonia
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6
Q

What are the differentials for epigastric pain?

A 
Acute gastritis/GORD
Gastroparesis
Peptic ulcer disease/perforation
Acute pancreatitis
Mesenteric ischaemia
AAA (Abdominal Aortic Aneurysm) Aortic dissection
Myocardial infarction
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7
Q

What are the differentials for RLQ pain?

A 
Acute Appendicitis
Colitis
IBD
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy
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8
Q

What are the differentials for LLQ pain?

A 
Diverticulitis
Colitis
IBD (Inflammatory Bowel Disease)
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy
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9
Q

What are the differentials for Suprapubic pain?

A 
Early appendicitis
Mesenteric ischaemia
Bowel obstruction
Bowel perforation
Constipation
Gastroenteritis
UTI/Urinary retention
PID
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10
Q

What is important to note about these differential lists?

A

Not exhaustive

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11
Q

How do patients with bowel ischaemia present?

A

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

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12
Q

What are the risk factors for bowel ischaemia?

A 
Age >65 yr
Cardiac arrythmias (mainly AF), atherosclerosis
Hypercoagulation/thrombophilia
Vasculitis
Sickle cell disease
Profound shock causing hypotension
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13
Q

What are the main features of acute mesenteric ischaemia?

A

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

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14
Q

What are the two types of bowel ischaemia?

A

Acute mesenteric Ischaemia

Ischaemic colitis

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15
Q

What are the main features of Ischaemic colitis?

A

Large bowel

Usually due to non-occlusive low flow states or atherosclerosis

More mild and gradual (80-85% of cases)

Moderate pain and tenderness

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16
Q

What investigations should you to for bowel ischaemia?

A

FBC: neutrophilic leukocytosis
VBG: Lactic acidosis
(Venous blood gasses)
- metabolic acidosis associated with late stage ischaemia

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17
Q

What imaging should you to for bowel ischaemia?

A

CTAP/CTAngiogram

Detects

Disrupted flow

Vascular stenosis

‘Pneumatosis intestinalis’ (transmural ischaemia/infarction)

Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)

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18
Q

When would you used endoscopy for bowel ischaemia?

A

For mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)

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19
Q

What is the conservative management approach to bowel ischaemia?

A

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

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20
Q

When would you take a more conservative approach to managing bowel ischaemia?

A

Mild to moderate cases of ischaemic colitis (not suitable for SB ischaemia)

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21
Q

When is surgical management indicated to bowel ischaemia?

A 
Small bowel ischaemia
Signs of peritonitis orsepsis
Haemodynamic instability
Massive bleeding
Fulminant colitis with toxic megacolon
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22
Q

What are the two types of surgical management?

A

Exploratory laparotomy

Endovascualr revascularisation

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23
Q

What is exploratory laparotomy?

A

Resection of necrotic bowel +/-open surgicalembolectomy

or mesenteric arterial bypass

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24
Q

What is endovascular revscualrisation?

A

Balloon angioplasty/thrombectomy

In patients without signs of ischaemia

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25
Q

How does acute appendicitis present?

A

Initially periumbilical pain that migrates to RLQ (within 24hours)
Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit

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26
Q

What are the important clinical signs in acute appendicitis?

A

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

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27
Q

What bloods are done for acute appendicitis?

A

FBC: neutrophilic leukocytosis
↑ed CRP
Urinalysis: possible mild pyuria/haematuria
Electrolyte imbalances in profound vomiting

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28
Q

What imaging is done for acute appendcitis?

A

CT: gold standard in adults esp. if age > 50
USS: children/pregnancy/breastfeeding
MRI: in pregnancy if USS inconclusive

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29
Q

When would you do a diagnostic laparoscopy for suspected acute appendicitis?

A

In persistent pain & inconclusive imaging

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30
Q

What is the diagnostic tool used for acute appendicits?

A

Alvardo score

6 clinical items

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31
Q

What are the clinical items used on the alvardo score?

A 
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
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32
Q

What is the conservative management of acute appendicitis?

A

IV Fluids, Analgesia, IV or PO Antibiotics
In abscess, phlegmon or sealed perforation
Resuscitation + IV ABx +/- percutaneous drainage

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33
Q

What are the indications for conservative management for acute appendicitis?

A

After negative imaging in selected patients with clinically uncomplicated appendicitis
In delayed presentation with abscess/phlegmon formation
CT-guided drainage

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34
Q

What must you always consider in acute appendicitis?

A

Consider interval appendicectomy - rate of recurrence after conservative management of abscess/perforation is 12-24%

35
Q

What are the benefits of laparoscopic appenicetomy?

A 
Less pain
Lower incidence of surgical site infection
↓ed length of hospital stay
Earlier return to work
Overall costs
Better quality of life scores
36
Q

What are the steps of laparoscopic appendicetomy?

A

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

37
Q

Define intestinal obstruction?

A

restriction of normal passage of intestinal contents

38
Q

What are the two main groups of bowel obstruction?

A

Paralytic (Adynamic) ileus

Mechanical.

39
Q

How do you classify mechanical intestinal obstruction?

A

Speed of onset
Site
Nature
Aetiology

40
Q

What are the different speeds of onset for bowel obstruction?

A

acute, chronic, acute-on-chronic

41
Q

What are the different sites of bowel obstruction?

A

high or low

roughly synonymous with small or large bowel obstruction

42
Q

What are the different natures of bowel obstruction?

A

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)

43
Q

What are the causes of bowel obstruction?

A

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.

44
Q

What are the main causes of small bowel obstruction?

A 
Adhesions (60%)
Neoplasia (20%)
Incarcerated hernia (10%)
Crohn's disease (5%)
Other (5%)
45
Q

What are the main causes of large bowel obstruction?

A 
Colorectal cancer
Volvulus
Diverticulitis 
Faecal impaction
Hirschsprung's disease
46
Q

How does small bowel obstruction present?

A

Colicky, central pain

Early onset vomiting - large amount and bilious

Constipation - late sign

Abdominal distention is less significant

47
Q

How does large bowel obstruction present?

A

Colicky or constant pain

Vomitting is late onset - initally billous progress to faecal vomiting

Constipation is early sign

Abdominal distention is early and significant

48
Q

What are other signs of bowel obstruction that are present in both?

A

Dehydration
Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign)
Diffuse abdominal tenderness

49
Q

What are the three important things about diagonisisng bowel obstruction?

A

Diagnosed by the presence of symptoms
Examination should always include a search for hernias & abdominal scars, including laparoscopic portholes
Is it simple or strangulating?

50
Q

What features suggest strangulation?

A 
Change in character of pain from colicky to continuous
Tachycardia
Pyrexia
Peritonism
Bowel sounds absent or reduced
Leucocytosis
↑ed C-reactive protein
51
Q

What are common hernial sites?

A 
Epigastric
Ubmilical
Incscional 
Inguinal
Feomral
52
Q

What are the different types of hernia?

A

Neck of sac
Strangulated
Richter’s

53
Q

What are the blood results for bowel obstruction?

A

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)

54
Q

What imaging is done for bowel obstruction?

A

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

55
Q

What is seen on AXR for small bowel obstruction?

A

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.

56
Q

What is seen on AXR for large bowel obstruction?

A

Distended large bowel tends to lie peripherally

Show haustrations of taenia coli - do not extend across whole width of the bowel.

57
Q

What can CT scans do re bowel obstruction?

A

Can localize site of obstruction
Detect obstructing lesions & colonic tumours
May diagnose unusual hernias (e.g. obturator hernias).

58
Q

What is the supportive mangement for bowel obstruction?

A

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

59
Q

What is the conservative treatment for bowel obstruction?

A

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

60
Q

What are the indications of surgical management for bowel obstruction?

A

Haemodynamic instability or signs of sepsis
Complete bowel obstruction with signs of ischaemia
Closed loop obstruction
Persistent bowel obstruction >2 days despite conservative management

61
Q

What is the surgical process for bowel obstruction?

A

Exploratory Laparotomy/Laparoscopy

Restoration of intestinal transit (depending on intra-operational findings)

Bowel resection with primary anastomosis or temporary/permanent stoma formation

62
Q

How does GI perforation present?

A

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

63
Q

What are the features of perforated peptic ulcer?

A

Sudden epigastric or diffuse pain
Referred shoulder pain - diaphragm irritation Phrenic nerve innervates shoulder
Hx of NSAIDs, steroids, recurrent epigastric pain

64
Q

What are the features of perforated diverticulum?

A

LLQ pain

Constipation

65
Q

What are the features of perforated appendix?

A

Migratory pain
Anorexia
Gradual worsening RLQ pain

66
Q

What are the features of perforated malignancy?

A

Change in bowel habit
Weight loss
Anorexia
PR Bleeding

67
Q

What bloods are done for GI perforations?

A

Change in bowel habit
Weight loss
Anorexia
PR Bleeding

68
Q

What imaging are done for GI perforations?

A

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

69
Q

What is the supportive management for GI perforation?

A 
NBM & NG tube 
IV peripheral access with large bore cannula -IV Fluid resuscitation
Broad spectrum Abx
IV PPI
Parenteral analgesia & antiemetics
Urinary catheter
70
Q

What is the conservative management for GI perforation?

A

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

71
Q

What are the stages of surgical management for GI Perforation?

A

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

72
Q

What are the stages of surgical management for GI Perforation?

A

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

73
Q

What are the symptoms of biliary collic?

A

PostprandialRUQ pain with radiation to the shoulder.

Nausea

74
Q

What are the investigations for biliary collic?

A

Normal blood results

USS: cholelithiasis

75
Q

How do you manage biliary collic?

A

Analgesia, Antiemetics, Spasmolytics

Follow up for elective cholecystectomy

76
Q

What are the symptoms of acute cholycystisis?

A

Acute, severe RUQ pain
Fever
Murphy’s sign

77
Q

What are the investigations for acute cholycystisis?

A

Elevated WCC/CRP

USS: thickened gallbladder wall

78
Q

What is the management for acute cholycystisis?

A

Fluids, ABx, Analgesia, Blood cultures

Early (<72 hours) or elective cholecystectomy (4-6 weeks)

79
Q

What are the symptoms of acute cholangitis?

A

Charcot’s triad: jaundice, RUQ pain, fever

80
Q

What are the investigations for acute cholangitis?

A

Elevated LFTs, WCC, CRP, Blood MCS (+ve)

USS: bilary dilatation

81
Q

What is the management for acute cholangitis?

A

Fluids, IV Abx, Analgesia

ERCP (within 72hrs) for clearance of bile duct or stenting

82
Q

What are the symptoms of acute pancreatitis?

A

Severe epigastric pain radiating to the back
Nausea +/- vomiting
Hx of gallstones or EtOH use

83
Q

What are the investigations for acute pancreatitis?

A

Raised amylase/lipase
High WCC/Low Ca2+
CT and US to assess for complications/cause

84
Q

What is the management for acute pancreatitis?

A

Admission score (Glasgow-Imrie)
Aggressive fluid resuscitation, O2
Analgesia, Antiemetics
ITU/HDU involvement

Year 2 Gastro (10 decks)

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