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Gastroenterology > General Surgery > Flashcards

General Surgery Flashcards

1
Q

Bowel ischaemia presentation

A

Sudden onset crampy abdominal pain
Bloody, loose stool
Fever, signs of septic shock

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2
Q

Bowel ischaemia risk factors

A 
Older than 65
Cardiac arrhythmias, atherosclerosis 
Hypercoagulation
Vasculitis
Sickle cell disease
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3
Q

Small bowel ischaemia

A

Acute mesenteric ischaemia
Usually occlusive due to thromboemboli
Sudden onset
Pain out of proportion of clinical signs

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4
Q

Large bowel ischaemia

A

Ischaemia colitis
Usually due to non-occlusive low flow states or atherosclerosis
More mild and gradual
Moderate pain and tenderness

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5
Q

Bowel ischaemia investigation

A

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

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6
Q

Bowel ischaemia conservative management

A

For mild to moderate cases of ischaemic colitis (NOT for SBI)

IV fluid resus 
Bowel rest
Broad spectrum antibiotics 
NG tube for decompression 
Anticoag
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7
Q

Bowel ischaemia surgical management

A

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

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8
Q

Acute appendicitis presentation

A

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

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9
Q

Acute appendicitis investigation

A

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

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10
Q

Alvarado score

A

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

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11
Q

Acute appendicitis conservative management

A

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

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12
Q

Acute appendicitis surgical management

A

Laparoscopic vs Open appendicectomy

  • less pain
  • lower incidence of surgical site infection
  • shorter hospital stay
  • better QOL
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13
Q

Bowel obstruction classification

A

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

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14
Q

Bowel obstruction causes

A

In lumen - faecal impaction, gallstone ‘ileus’
In wall - Crohn’s, tumour
Outside wall - strangulated hernia, volvulus, obstruction due to adhesion

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15
Q

Bowel obstruction aetiology

A

Small

  • adhesions 60%
  • neoplasia 20%
  • incarcerated hernia (10%)
  • Crohn’s disease (5%)
  • other (5%)

Large

  • colorectal carcinoma
  • volvulus
  • diverticulitis
  • faecal impaction
  • Hirschsprung disease
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16
Q

Bowel obstruction presentation

A

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

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17
Q

Bowel obstruction diagnosis

A

Diagnosed by symptoms
Search for hernias and abdo scars
Simple or strangulating

18
Q

Features suggesting strangulating bowel obstruction

A 
Colicky to continuous
Tachy
Pyrexia
Peritonism 
Bowel sounds absent or reduced 
Increased CRP
19
Q

Types of hernia

A

Neck of sac
Strangulated
Richter’s

20
Q

Bowel obstruction investigations

A

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

21
Q

Bowel obstruction conservative management

A 
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

22
Q

Bowel obstruction surgical management

A

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
23
Q

GI perforation presentation

A

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

24
Q

Perforated peptic ulcer presentation

A

Sudden epigastric or diffuse pain
Referred shoulder pain
History of NSAIDs, steroids, recurrent epigastric pain

25
Q

Perforated diverticulum

A

LLQ pain

Constipation

26
Q

Perforated appendix presentation

A

Migratory pain
Anorexia
Gradual worsening RLQ pain

27
Q

Perforated malignancy presentation

A

Change in bowel habit
Weight loss
Anorexia
PR bleeding

28
Q

GI perforation investigation

A

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
29
Q

GI perforation surgical management

A

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

30
Q

Biliary and pancreatic causes

A

Biliary colic
Acute cholecystitis
Acute cholangitis
Acute pancreatitis

31
Q

Biliary colic symptoms

A

Postprandial RUQ pain with radiation to shoulder

Nausea

32
Q

Biliary colic investigation

A

Normal blood results

USS cholelithiasis

33
Q

Biliary colic management

A

Analgesia, antiemetics

Follow up for elective cholecystectomy

34
Q

Acute cholecystitis symptoms

A

Acute severe RUQ pain
Fever
Murphy’s sign

35
Q

Acute cholecystitis investigation

A

Elevated WCC/CRP

USS thickened gall bladder wall

36
Q

Acute cholecystitis management

A

Fluids, antibiotics, analgesia, blood culture

Early or elective cholecystectomy

37
Q

Acute cholangitis symptoms

A

Charcot’s triad - jaundice, RUQ pain, fever

38
Q

Acute cholangitis investigation

A

Elevated LFT, WCC, CRP, blood MCS

USS biliary dilatation

39
Q

Acute cholangitis management

A

Fluids, IV antibiotics analgesia

ERCP for clearance of bile duct or stenting

40
Q

Acute pancreatitis symptoms

A

Severe epigastric pain radiating to back
Nausea/vomiting
History of gallstones or EtOH use

41
Q

Acute pancreatitis investigations

A

Raise amylase/lipase
High WCC, low calcium
CT and US to asses for complications or cause

42
Q

Acute pancreatitis management

A

Admission score (Glasgow-Imrie)
Aggressive fluid resus, oxygen
Analgesia, antiemetics
ITU/HDU involvement

Gastroenterology (11 decks)

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