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
