General Surgery Flashcards
Bowel ischaemia presentation
Sudden onset crampy abdominal pain
Bloody, loose stool
Fever, signs of septic shock
Bowel ischaemia risk factors
Older than 65 Cardiac arrhythmias, atherosclerosis Hypercoagulation Vasculitis Sickle cell disease
Small bowel ischaemia
Acute mesenteric ischaemia
Usually occlusive due to thromboemboli
Sudden onset
Pain out of proportion of clinical signs
Large bowel ischaemia
Ischaemia colitis
Usually due to non-occlusive low flow states or atherosclerosis
More mild and gradual
Moderate pain and tenderness
Bowel ischaemia investigation
Blood
- FBC - neutrophilic leukocytosis
- VBG - lactic acidosis
Imaging
- disrupted flow
- vascular stenosis
- ischaemic colitis - thumbprint sign (unspecific for colitis)
Endoscopy
-for mild or moderate cases of ischaemic colitis
Bowel ischaemia conservative management
For mild to moderate cases of ischaemic colitis (NOT for SBI)
IV fluid resus Bowel rest Broad spectrum antibiotics NG tube for decompression Anticoag
Bowel ischaemia surgical management
Indications
- small bowel ischaemia
- signs of peritonitis or sepsis
- haemodynamic instability
- massive bleeding
- toxic megacolon
Exploratory laparotomy- resection of necrotic bowel +/- open surgical embolectomy or mesenteric arterial bypass
Endovascular revascularisation - ballon angioplasty/thrombectomy in patients without signs of ischaemia
Acute appendicitis presentation
Periumbilical pain that migrates to RLQ
Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit
Clinical signs
McBurney’s point - tenderness in RLQ
Blumberg sugn - rebound tenderness especially in RIF
Rousing sign - RLQ pain on palpating of LL
Psoas sign - RLQ pain on flexion of right hip against resistance
Obturator sign - RLQ pain on passive internal rotation of hip with hip and knee flexion
Acute appendicitis investigation
Blood
- FBC neutrophilic leukocyotosis
- increased CRP
- electrolyte imbalance in profound vomiting
Imaging
- CT standard esp if older than 50
- USS children/pregnant/breastfeeding
- MRI in pregnancy if USS inconclusive
Diagnostic laparoscopy
-persistent pain and inconclusive imaging
Alvarado score
Acute appendicitis
RLQ 2 Fever 1 Rebound tenderness 1 Pain migration 1 Anorexia 1 Nausea +/- vomiting 1 WCC >10 1 Neutrophilic 1
=/<4 unlikely
5-6 possible
=/>7 likely
Acute appendicitis conservative management
IV fluids, analgesia, IV or PO antibiotics
In abscess, phlegmon or sealed perforation
-resus + IV AB +/- percutaneous drainage
Indications
- after negative imaging in selected patients with clinically uncomplicated appendicitis
- in delayed presentation with abscess/phlegmon formation - CT guided drainage
Consider interval appendicectomy
Acute appendicitis surgical management
Laparoscopic vs Open appendicectomy
- less pain
- lower incidence of surgical site infection
- shorter hospital stay
- better QOL
Bowel obstruction classification
Paralytic (adynamic) ileus OR mechanical
If mechanical:
Speed - acute, chronic, acute on chronic
Site - high or low (roughly same as small and large bowel obstruction)
Nature - simple or strangulating
Bowel obstruction causes
In lumen - faecal impaction, gallstone ‘ileus’
In wall - Crohn’s, tumour
Outside wall - strangulated hernia, volvulus, obstruction due to adhesion
Bowel obstruction aetiology
Small
- adhesions 60%
- neoplasia 20%
- incarcerated hernia (10%)
- Crohn’s disease (5%)
- other (5%)
Large
- colorectal carcinoma
- volvulus
- diverticulitis
- faecal impaction
- Hirschsprung disease
Bowel obstruction presentation
Abdo pain
S- colicky, central
L- colicky, constant
Vomit
S- early onset, large amount, bilious
L-late onset, initially bilious, progress faecal vomit
Absolute constipation
S- late sign
L- early sign
Abdo distention
S- less significant
L- early sign and significant
Other
Dehydration, increased high pitched tinkling bowel sounds (early) or absent bowel sounds (late), diffuse abdo tenderness
Bowel obstruction diagnosis
Diagnosed by symptoms
Search for hernias and abdo scars
Simple or strangulating
Features suggesting strangulating bowel obstruction
Colicky to continuous Tachy Pyrexia Peritonism Bowel sounds absent or reduced Increased CRP
Types of hernia
Neck of sac
Strangulated
Richter’s
Bowel obstruction investigations
Blood
- electrolyte imbalance
- vomiting - hypocalcemia, hypokalemia, metabolic alkalosis
- strangulation - metabolic acidosis
Imaging
-erect CXR/AXR
—s - ladder pattern of dilated loops
—l - distended large bowel lie peripherally
-CT abdo/pelvis - dilation of proximal loops
Bowel obstruction conservative management
SUPPORTIVE NBM, IV fluid resus IV analgesia NG tube Urinary catheter to monitor
CONSERVATIVE
Faecal impaction - stool avacuation
Sigmoid volvulus
Oral gastrograffin for adhesions small bowel obstruction
Gradual food intake if abdo pain and distention improve
Bowel obstruction surgical management
Indication
- haemodynamic instability or sign of sepsis
- Complete bowel obstruction with signs of ischaemia
- Closed loop obstruction
- Persistent bowel obstruction more than 2 days despite conservative management
Operation
- exploratory laparotomy/laparoscopy
- restoration of intestinal transit
- bowel resection with primary anastomosis
GI perforation presentation
Sudden onset severe abdo pain, distention
Diffuse abdo guarding, rigidity, rebound tenderness
Pain aggravated by movement
Nausea, vomiting, constipation
Fever, tachy, tachypnoea, hypotension
Decreased or absent bowel sounds
Perforated peptic ulcer presentation
Sudden epigastric or diffuse pain
Referred shoulder pain
History of NSAIDs, steroids, recurrent epigastric pain
Perforated diverticulum
LLQ pain
Constipation
Perforated appendix presentation
Migratory pain
Anorexia
Gradual worsening RLQ pain
Perforated malignancy presentation
Change in bowel habit
Weight loss
Anorexia
PR bleeding
GI perforation investigation
Blood
- neutrophilic leukocytosis
- possible elevation of urea, creatinine
- lactic acidosis
Imaging
- erect CXR subdiaphragmatic free air
- CT abdo/pelvis pneumoperitoneum, free GI content localised fat stranding
Differential
- acute cholecystitis, appendicitis
- myocardial infarction, acute pancreatitis
GI perforation surgical management
Laparotomy/laparoscopy
Primary closure with or without Omental patch
Resection of perforation with primary anastomosis or temporary stoma
Peritoneal lavage
If perforated appendix - lap or open appendicectomy
If perforate malignancy - intraoperative biopsy
Biliary and pancreatic causes
Biliary colic
Acute cholecystitis
Acute cholangitis
Acute pancreatitis
Biliary colic symptoms
Postprandial RUQ pain with radiation to shoulder
Nausea
Biliary colic investigation
Normal blood results
USS cholelithiasis
Biliary colic management
Analgesia, antiemetics
Follow up for elective cholecystectomy
Acute cholecystitis symptoms
Acute severe RUQ pain
Fever
Murphy’s sign
Acute cholecystitis investigation
Elevated WCC/CRP
USS thickened gall bladder wall
Acute cholecystitis management
Fluids, antibiotics, analgesia, blood culture
Early or elective cholecystectomy
Acute cholangitis symptoms
Charcot’s triad - jaundice, RUQ pain, fever
Acute cholangitis investigation
Elevated LFT, WCC, CRP, blood MCS
USS biliary dilatation
Acute cholangitis management
Fluids, IV antibiotics analgesia
ERCP for clearance of bile duct or stenting
Acute pancreatitis symptoms
Severe epigastric pain radiating to back
Nausea/vomiting
History of gallstones or EtOH use
Acute pancreatitis investigations
Raise amylase/lipase
High WCC, low calcium
CT and US to asses for complications or cause
Acute pancreatitis management
Admission score (Glasgow-Imrie)
Aggressive fluid resus, oxygen
Analgesia, antiemetics
ITU/HDU involvement
