General surgery Flashcards
acute generalised abdo pain
peritonitis
ruptured abdo aortic aneurysm
intestinal obstruction
ischemic colitits
acute right upper quadrant abdo pain
biliary colic
acute cholecystitis
acute cholangitis
acute epigastric pain
acute gastritis
peptic ulcer disease
pancreatitis
ruptured abdo aortic anyeusm
acute periumbilical abdo pain
early stage appendicitis
ruptured abdo aortic anyeusm
ischemic colitis
intestinal obstruction
acute right iliac fossa pain
acute appendicitis
ectopic pregnancy
ovarian torsion
ruptured ovarian cyst
meckles diverticulitis
acute left iliac fossa pain
diverticulitis
ectopic pregnancy
ovarian torsion
ruptured ovarian cysts
acute supra pubic pain
lower uti
acute urinary retention
pelvic inflammaotry disease
prostitatis
acute loin to groin pain
renal colic- kideny stones
ruptured abdo aortic aneurysm
pyelonephritis
acute testicular pain
testicular torsion
epididymo-orchitis
inital managemnt of acute abdome
abcde approach
airway
breathing
circualtion
disability= consiousness, gluocse levels
exposure- final assemsne tand abdo examination
investigations for acute abdoem
fbc= low hb? show bleed, wbc= inflam/infection
lft- liver function
u and e= electrolyte balance and see renal fucntion if going to have conrast
inr= see liver fuction and clotting ability
crp
amylase= see if inflam of pancreas
serum ca= score for acute pancreatitis
hCG/ urine preg test= all women child bearing age
serum lactate
abg= lactate and po2
group and save
blood culture- infection
abdo xray= bowel obstruction suspected see dialted bowel loops
erect cxr= show air under diapghragm if perforated intra bdo
abdo us - gallstones, gyny, biliary duct dilation
ct scans
what management is tere after abcde done for acute abdomen
alert sneior
nil by mouth ncase need surgery
bg tube if bowel obstructio
iv fluids may be needed
analgesia
iv antibiotics if infection
vte assesment
prescribe regular emds
signs of periotonitis
guarding - involuntary tensig of abdo wall muscles when palpated to protect area below
rigidity= involuntary persitant tightness
rebound tenderness= rapidly releasing pressure in the abdo creates worse pain than the presure itseld
coughing test- may result in pain in abdo
percussion tenderness
casues of localised peritonitis
underlying organ inflammation- appendicitis/ cholecystitis
casues of genrealsied periotnitis
perforation of abdo organ - ruptured appendix, perforated duodenal ulcer = release contents into abdo cavity
have gernealsied and localised peritonitis and what other casue of peritonitis
spontaneous bacteral peritonitis
= spontaenous infection of ascites in liver disease
trea ith brad spectrum antibiotcs
appendix is connecte to what
caecum
how does appendititis ocur
obstruction trap pathogens in appendix= infllamtion = can lead to gangrene and rupture
if rupture faecal contents and infective material in peritonal cavity= peritonitits
central abdo pain that moved to right iliac fossa in 12 hrs
appendicitis
rovsings sign can mean what
appendicitis
= press on left iliac fossa and get pain in right iliac fossa
s and s of appendicits
age of presentation
10-20 yrs old most common
can be in any age
less common over 50
abdo pain thats central and moves to roght iliac foss within 24 hrs
palaptation have tenderness at mc burneys point= 1/3 from of the distance from anterior superior iliac spine to umbillicus = line can feel the anterior iliac spine- most anterior boy bit and then a thrid away from this in a line to the belly button- bascially right iliac fossa
anorexia
nasuea and vomiting
low grade fever
rovsings sign= pain on right iliac
fossa when press on left
guarding
can get loin pain or bladder irritation, iritate ureter and abdo pain. can have diarrhoea if irritation of ileum
rebound tenderness in RIF
percussion tenderness
bottom two suggestive of peritonitis= ruptured appendix
what sings that appendix has ruptured
rebound tenderness
percsussion tenderness= peritonitits
how to diagnsoe appendicitis
alvarado score- help with probabiliyu
daignosis done by clinical presentation and raised inflammatory mnarkers
can do ct if need confrimation of diagnsosis esp if other differentials posisble
us can be done in feemales to exclude gyny
us can be done in children instead of ct if ct radiatio inappropriate
can do diagnostic laparascopy if clincial presentation suggest appendicitis but infecstigations say other wise. if need can then do appendicectomy at same time if needed
whats an appendix mass
on examination feel mass in rif
usually longer duration of onset
due to omentum sticking to inflammed appendix
treat appendix mass
antibtiocs and supportive treatment then appendicectomy once acute condition resolved
management of appendicitis
admission to hosp
10yrs over usually seen by adult general surgeon
appendicectomy - laparascopic decreased risks and faster recovery than laparotomy
complications of appendicectomy
bleeding, scar, pain , infection
scar
damage bowel, bladder and other organs
remove of normal appendix
anesthesia risks
VTE- pe and dvt
whats more common bowel obstruction - large or small
small bowel obstruction more common than large
whats the pathology of bowel obstruction
get obstruction causing back pressure and casues vomiting and dilatation of bowel proximal to obatruction
gi tract secreted fluid tjats then reabsorbed in colon but in obstruction cant get there so less fluid reasborbed so less fluid in intravascualr sapce causing hypovolaemia and shock = called third spacing
higher up the obstriction the greater the fluid loss as less bowel to reabsrob
casues of bowel obstruction
hernia - small bowel
adhesion - small bowel
tumours - large bowel
others:
volvulus
diverticular disease
strictures- secondary to crohns
intussuscpetion- 6months - 2year olds
when taking history and thinking bowel obstruction what need to ask about
casues of bowel obstruction - so hernia, recent operation, bowel habit, weight loss, bleeding
what casues adhesions in bowel
adhesions= scar tissue thaa binds the abdo contents together so kink and sqeeze bowel
endometriosis
peritonitits
abdo/pelvic surgery- esp open surgery
abdo/pelvic infections- pelvic inflammatroy disease
can be congentiatal or secndary to radiotherpay
whats a closed loop obstriction
two pints of obstructio so middle section of bowel sandwhiched= no way to drain out and no way to decompress so keeps expanding and will cause ischemia and perforation
causes of closed loop obsutrcion
adhesions - that compress two areas of the bowel
hernias= that isolate a section of bowel blocking wither end
volvulus= twists section o intestine
single point of obstruction in large bowel with a compenent ileocaecal valve= so contents cant flow backwards
presentation of bowel obstruction
vomiting- esp green billious fluid
absolute constipation and no flatulence
abdo distention
diffuse abdo pain
tinkling bowel sounds may be heard early on
what see in abdo xray in bowel obstruction
diameter of normal upper limit of small, colon and caecum
distention of bowel loops
normal upper limits of diameter of bowel:
3cm cmall bowel
6cm colon
9 cm caecum
how to know its large or small bowel on abdo xray
valvulae connvientes = small bowel. mucosal folds go all around width
haurasistra= large bowel- dont go all across
initial management of bowel obstruction
abcde
bloods- u and e to see elctroylte imbalance
vbg= raised lactate due to ischemia and metbaolic alklalosis due to vomiting stomach acid
nil by mouth
iv fluids - electroyle balance and hydration
ng tube with free drainage
abdo xray
what investigations do bowel ostruction
bloods
abdo xray - initial imaging
erect cxr to see if air uder diapraghm= perforation
contrast abdo ct= need check u and e frst and have cannula in to check renal fucntion cus using contrast
what investigation is inital and what is for confirming diagnosis of bowel obstruction
inital= abdo xray
confrim diagnosis= contrast ct - remeber to check u and e for renal fucntion
wehn will urgent intervention be needed in bowel obsturction
haemodynamically unstable =
sepsis
bowel perforation
bowel ischemia
hypovolaemic shcok- due to thrid spacing
when do surgery for bowel obstriction
can do watch and wait conservcative if stable to see if reoslvoes.
surgery for exploraition, hernia repair, adhesiolysis, stent via colonsocpy if tumour blockijng way
whats ileus
peristalsis of small bowel temporaily stops
whats pseudo obstruction
large bowel
no mechanical cuse of obstruction = functional obstruction of bowel
casues of ileus
surgery of abdomen- handling intestine
injury to bowel
infection/inflammation of bowel or nearby:
appendicitits, pancreatitis, peritonitits, pneumonia
distended abdomen
absolute constipation and no flatulence
diffuse abdo pain
no bowel sounds
vomiting green bilious stuff
ileus
same as bowel obstruction but no bowel sounds wereas mechanical obstruction may hear tinkling osunds on early obstruction esp
management ileus
normally resolves by treating uderlying cause
supportive treatment
iv fluid - electrolyte balance and hydration
ng tube if vomiting
nil by mouth
mobilisation- stimulate peristalsis
TPN= total parenteral nutrition may be required whilst waiting for bowel to regain function
whats the two types of volvulus
sigmoid
caecum
causes closed loop obstruction
whats more common volvulus
sigmoid
when does signoid and caecal volvulus occur
sigmoid- older pts
chronic constipation and lenghtehtning of the mesentery attactehced to sigmoid colon - sigmoid colon becomes over loaded with faces and sinks downwards and twists
caecal- younger pts
risk facotrs for volvulus
chronic constipation
high fibre diet
neuropsychiatric disorders - parkinsons
nursing hoe residents
pregnacy
adhesion
over use of laxatives- sigmoid
presentation of volvulus
like bowel obstruction- cus it is its a closed loop obstruction
abdo distention
diffuse abdo pain
absolute constipation and no flatulence
vomiting- esp green bilious vomiting
diagnose volvulus
contrast CT = investigation choice to confri daignsois/ idnetify other pathology
can do abdo xray
abdo xray shows coffee bean sign in bowel
what is this
sigmoid volvulus
mangemnt of volvulus
inital- same obstruction
iv fluids, ng tube, nil by mouth
conserevative=
endoscopic decompression in sigmoid volvuus if no peritonitits - uses felxi sigmoidoscopy
surgical:
lapartomy
hartmanns procedure = sigmoid = remove rectosigmoid and make colostomy
ileocaecal resection or a right hemicolectomy in caecal volvusus
risk factors for bowel cancer
fam hist
FAP
HNPCC
IBD
low fibre high red mean and processed diet
obestiy and sedentary lifestyle
smoking
alcohol
whats FAP
familial adenomatous polyposis
autosomal domintant
polyps form in large bowel that can be cancerous
malfunction in tummour supressor gene = adenomatous polyposis coli -APC
treat- remove all large bowel to be prophylactiss
whats HNPCC
herediatry non polyposis colorectal cancer - lynch syndrome
autsomal dominant
mutation in dna mismact hrepair gene
increase risk of lots cancers
doesnt casue mulitple adenomas
when refer for 2ww for bowel cacner
over 40 and got unexplained weight loss and abdo pain
over 50 and got unexplained rectal bleeding
over 60 and got change bowel habit/ iron deficicey anemia
whats iron deficency anemia results
microcytic anemia with low ferritin levels
presentation bowel acner red flags
weight loss
unexpaliend abdo pain
change bowel habits- normally diarrhoea and increase frequency
rectal bleeding
iron deficicney aneamia
abdo/rectal mass
acturely present with obstruction
what to do for screening bowel cacner
FIT test
what to do for daignosis of bowel cancer
goldstanderad is colonoscopy with biopsy
what investigations do for bowel cacner
fit test- human hb in stool
can be used screening 60-74 every 2 years
can be used for pts who dont fit 2ww eg. under 60 with change bowel habit
colonoscopy woth biopsy - gold standerd for diangosis
felxi sigmoidoscopy = if only got rectal bleeding
ct colography- bowel prep and contrast - do if pt not fit for colonscopy
staging ct scan- thorax, abdo ,pelvis
carcinoembryonic antigen - tumour marker for bowel cancer = used to predict relaspe in pts who have had previous bowel cancer
managemnt of bowel cancer
chemo
radiotherpay
palliative
surgery- can be cure or palliative
whats right hemicolectomy
removeal of caecum, ascending and proximal transverse colon
left hemicolectomy
remove distal transverse colon and descinging colon
high anterior resection
remove signoid colon
low anterior resection
remove signoid colon, upper rectum but spare lower rectum and anus = anastamose between colon and rectum
abdomino perineal resection
remove rectum and anus and maybe sigmoid colon
hartmanns procedure
in emergency done
remove recto sigmoid colon and create colostomy. suture recostump closed
can be rversed
pt had surgyer for bowel cancer but not got increased urgencyand frequency
diff to cotrol flatulence
faecal inconitnence
lower anterior resection syndroe
complication bowel surgery
bleeding, pain, infection
dmaage to n, bv, bladder, bowel, ureter
post op ileus
anesthetic risks
laparscopic but then had be open
leakage/failure of anastamoses
need stoma
copuldnt remove tumour
intrabdo adhesions
change bowel habit
VTE
incisional hernia
follow up bowel cancer surgery etc what test to do
CEA- carcinoembryonic antigen
ct thorax,abo and pelvis
fore gut/ blood supply to foregut
coeliac artery
stomach,part duodenum, pancreas, spleen, biliary system
midgut and blood supply to it
superior mesenteric artery
distal part duodenum–> first half transverse colon
hingut and its blood supply
inferior mesenteric artery
second half trasnverse colon–> rectim
whats chronic mesenteric ischemia
like angina
narrowing of mesenteric arteries due to atherlosclerosis
intermittent abdo pain when the blood supply cant keep up with demand
central colicky abdo pain after eating - start 30 mins after eating, least 1-2hrs
abdominal bruit on auscultation abdo aorta
weight loss- cu dont want eat cus hurt
what is this
chronic mesenteric ischemia
risk factors chronic mesenteric ischemia
same as cvd
hypertension
diabetes
raised cholesterol
smoking
fam hist
inreased age
diangose chronic mesenteric ischemia
ct angiography
magement chronic mesenteric ischemia
secondary prevention= statin, antiplatlet meds
reduce modifiable rf
revascularisation - first line endovascular procedure = percutaneous mesenteric artery stening
or open surgery - endartectomy, reimplantation and bypass graft
pt has acute non specific abdo pain but the pain is v severe but not really any findings on examination
acute mesenteric ischemia
what is and the cause of acute mesenteric ischemia
typically a rapid blockage in blood flow of through the superior mesenteric artery usually due to thrombus
thrombus due to either forme din the bv or embolsism
risk factors of acute mesenteric ischemia
AF
investigfations for acute emsenteric ischemia
ct with xontrast- can swee bv and whats happening to bowel
metabolic acidosis and high lactate blood leveles = due to ischemia
pt has non specfic abod pain
metabolic acidosis
high lactate levels
what is it
acute mesenteric ischemia
mangament of acute mesenteirc ischemia
surgery:
need to remove the necrotic boweland remove or bypass the thrombus
v high mortalitly
complications of acute mesenteric ischemia
can develop shock, sepsis, peritonitis
over time the ishcmia leads to necrosis of bowel and perforation
diverticulosis
diverticular disease
diverticulitis
diverticulosis= got diverticula= out puches of bowel = normally large
diverticular disease= got symptoms due to the out puches
diverticulitis= the puches got infalmmed/ infected
why does divertular disease occur
theres circular muscles in the large intestine but its weak where the bv penetrate = vulnerbale
the pressure in the lumen over time causes gap to form in areas of circular muscles = mucsoa herniate
theres longitudinal muscle in large bowel= teniae coli but doesnt go all way aorund diabteter.
doesnt happen in recutm cus got longitudianl m all around
where most commonly diverticula form
sigmoid colon
can get in small bowel but less common than large
risk factors diverticular disease
inreased age
low fibre diet
use NSAIDs –> increases risk of diverticular haemorrhage
obestity
lower left abdo pain
constipation
rectal bleeding
diverticular disease
investigfations and management diverticular idsease
ususlay incidental finidng on ct/ colonscopy dont need do anything if asymptomatic
give advice on high fibre diet and weight loss
use bulk forming laxatives if needed- ispaghula husk - dont use stimulant laxatives eg. senna
surgery to remove area
what laxatives use in diverticualr disease
bulk forming laxatives = ispaghula husk
dont use stimulant laxatives eg. senna
presentation of acute diverticulitits
pain and tenderness in left iliac fossa (remeber diverticula normally where the sigmoid colon is) / left lower abdomen
fever
diarrhoea
nausea nad vomititng
rectal bleeding palpable abdo mass if absess formed
rasied crp and rasied wbc
management of uncolplicated acute diverticulitis
can be manged priary care
oral co amoxicalv at least 5 days
no solid foods- clear liquids only until symptoms go 2-3 days
follow up within 2 days
analgesia but avoid nsaids and opidios
mangement of acute diverticulitis with severe abdo pain/ complications
admsision
deal how deal with sepsis./ any acute badomen ( like the patient who saw on home visit who called ambulace for)
iv fluids
iv antibiotics
nil by mouth
analgesia
urgent investigfations- ct
urgent surgery if comolciations
complications of acute diverticulitis - think like lady who saw on home visit who called ambulance for
perforation
peritonitits
peridiverticular disease
large haemorrhage- need transfusion
fistula- connecting colon to bladder / vagina
ileus/ obstruction
risk factors/associations aith haemorrhoids
constipation
straining
pregnancy
obesity
raised intra abdo p= weight lifting , chronic cough
increased age
pathology if anal cushions
specialsied submucosal tissue that has vein and artery anastomoss in= v vascualr
help control anal continence
blood suplly from rectal arteries
usally 3,7,11 o clock
wheres 12 o clock on anus
towards genitals
classification of haemorhoids
1st degree= no prolapse
2nd degree= prolapse when straining but return to normal when relax
3rd degree= prolpase when straining, cant return back to normal when relaxed, can be pushed in
4th degree= prolapsed permeantly
on exaination what will haemorrhoids look like
what investigation to see hameorrhoids properly
prolpased haemorhoids are visible on inspection
may feel internal haemorrhoids but may not feel
may appear prolapsed if ask pt to bear down on insepction
proctoscopy - to see them propely
presntation of haemorrhoids
feel lump inside anus/ outside
can be asymptomatic
painless, birhgt red on paper- not mixed in with stool
sore itchy anus
differentials for haemorrhoids
= differentials for rectal bleeding
IBD
colorectal cancer
anal fissures
diverticulosis
managemnt of haemorrhoids
consider testing for anemia if got proglonged bleeding / signs of anemia
topical treatment:
for symptoamtic treatment and reduce the swelling
- anusol= chemical that shirnks them
- anusol HC- got hydrocortisone in = short term use only
germoloids cream = lidocaine= LA
proctosedyl ointment = cinchocaine an dhydrocortisone = short term use only
prevention and treamtment for constipation:
- increase fibre
drink fluids
laxatives
encourage to not strain
non surgical=
rubber band ligation
injection slcerotherpay = slcerosisi and atrophy
infra red coagualtion= dmaage blood supply
bipolar diathermy = electric current
surgical:
haemorrhoid artery ligation haemorrhoidectomy = removing anal cusion and s can get faecal incontinece
stapled hamorrhoiectomy
how to tell difference bwetween colostomy and ileostomy
colostomy = colon brought to skin- more solid stools- flatter to the skin as sold contents less irriatating to skin
typically left iliac fossa but can be anywhere
ileostomy = ileum brought to skin
liquid stools
have a spout
typically right iliac fossa but can be anywehre
whats a gastrostomy
connection between stomach and abdo wall
can be used to provitde feeds into the stumach
percutaneous endoscopic gastrostomy = fitted by endoscopy
whats urostomy
opening of urinary system to skin
have a spout normally right iliac fossa
when is an end colostomy irreversible
when abdomino-perineal resecntion- rectum and anus removed
when may panproctocolectomy be done
total coletomy with removal large bowel, rectum and anus - IBD and FAP
or can do a j pouch
whats a j pouch
ileo-anal anastamosis
gall stones are mostly made of what
cholesterol
what complciations can gall stones cause
pancreatitis
acute cholangitits
acute cholecysitits
what forms the common hepatic duct
right hepatic duct and left hepatic duct
whats the duct from the gallbaldder called
cystic duct
the common bile duct and pancreatic duct join and become what
ampulla of Vater which opens into dudoennum. sphincter of oddi is ring of muscle around ampulla of Vater
whats s and s of biliary colic
intermitent right upper quadrant pain caused by glalstones obstructing drainaige of gall bladder
risk factrs for gallstone
forty
fair
female
fat
presentation of gallstones
biliary colic- intermittent right upper quadrant pain / epigastric
pain often triggered by eating esp high fat meals - last 30 mins -8hrs
may have N and V
may present with the complications of gallstones :
acute cholecystitis, acute cholagntitis, pacnreatitis, obstructive jaundice
what triggers the bilairy colic in gallstones
when fat enters digestive system the duodenum secretes CCK which triggers cotraction of gallbladder - stone in their obstrcuting flow so get colic
pts should avoid fatty meals to prevent cck release and gallbladder contraction
with gallstones what will the liver function tests show
raised billirubin = pale stools and dark urine = obstrucive picture
raised ALP
ALT AND AST can be raised but not as much proprtion of alp
raised billirubin due to obstruction in bilairy system
what cause
gall stones in bile duct
external mass pressing on bile duct= cholangiocarcinoma, cancer of head of pacnreas
for a biliary obstruction picture ALP will be rasied and what two other signs may have
jaundice
right upper quadrant pain
alp can be rasied when
bilairy obstruction
liver/bone malignancy
primary biliary cirrhois
pagets diease
others
what investigation do for gallstones
us
although limties to pt weight, gaseous bowel obstructing view, discomfort from the probe
what oes acute cholescystitis look like on US
thickened gallbladder wall, stones/sludge in gallbladder nad. fluid around gallbaldder
what other investigations for gall bladder apart from forst line US
MRCP- snesitive to view bilaiory tree in detail
used if us doesnt show scans but theres bile duct dilatation / raised billirubin suggesting obstruction
ERCP
- endocpe doen
indication to do ERCP is to celar stones from bile duct
can inject contrast and take x ray to visualise biliary system
can perfrom sphincterotomy on the sphincte rof Oddi if its dysfucntional
clear stones from duct
insert stents
take biopsy
CT scans - less sueful for looking at bilairy system for fall stones. nmay be done todiagnose other casues
complaiction of ERCP
execessive bleeding
cholangitits - infection in bile duct
pancreatitis
managment of gallstones
if asymptomatic treat conservatively and no management
symptoms / complications then cholecystectomy - can remove gall stone sby ERCP if needed first
laparoscopic prefered. if open then leaves kocher incision
complications of cholecystectomy
bleeding, infection, pain, ascar
damage to bile duct = leakage and strictures
stones left in bile duct
damage to bowel , bv, other organs
anestheitc risk
VTE
post cholecystectomy syndrome
whats post cholecystectomy syndrome
occur after cholecystectomy
may be due to changes in bile flow
symptoms s improve with time
diarrhoea
indigestion
epigastric/RUQ pain / discomfort
nasuea
intolerenac eof fatty foods
flatulence
whats the casues of acute cholecystits
mainly are due to gallstone trapped in neck of gallbladder or in cystic duct = calculous cholecystitis
few cases the gallbladder cant empty for other reasons = acalculous cholecystitis
eg. if pt in icu and not eaten / period of starving then the gallbladder nmot beig stimulatedby food to regulary emoty results in build up of presure
acute cholecsytitis present
right upper quadrant pain that may radiate to right shoulder !!
fever
nausea and vomiting
tachycardia, tachypnoea
RUQ tenderness
murphys sign
raised inlafmamtory markers and wbc
whats murphys sign
place hand on RUQ
apply pressure
ask pt deep breath in
c
brings gallbladder down to hand and casues lots of pain and stop ispiration
pt has murphys sign
what does this mean they could have
acute cholecysrtitis
pt has right upper quadrant pain radiating rto right shoulder
acute cholecystitis
imaging for acute choelcsytts
abdo US
MRCP can be done to virew in more detail if common bile duct stone susepcted but not see on US
signs of acute cholecystitis on abdo US
thickened gallbladder wall
sludge/stones in gallbladder
fluid around gallbladder
when may you susepct a common bile duct stone
bile duct dilatation
raised billirubin
how to manage acute cholecystitis
conservative:
nil by mouth
iv fluids antibiotcs
NG tube if vomiting
ERCPto remove stones in common bile duct
cholecystectomy - done within 72 hrs of symtoms in acute admission - may delay 6-8 wwweeks from start stymotims to allow inflmation to settle
complications of acute cholecystitis
sepsis
perforation
gallbladder empyema
gangrenous gallbladder
whats gallblader empyema and mangament of it
infected tissue and pus in gallbladder
antibiotocs and either cholecystectomy or cholecystotomy (insert drain into gallbladder and drain it)
whats acute cholangitits
infection and infalmmation of bile ducts
why is acute cholangitis a srugical emergency
can lead to sepsis and septicaemia
main two casues of acute cholangitits
obstruction in bile duct stopping bile flow eg. gall stone in common bile duct
infection introduced during ERCP
whats the common organsism to casue acute cholangitits
e coli
klebsiella species
enterococcus species
fever
RUQ pain
jaundice (rasied billirubin)
what is this
acute cholangitits
when have three togerher= charcots triad
causes of pancreatitis
I GET SMASHED
idiopathic
gallstones
ethanol
trauma
steroids
mumps
autoimmune
scorpion sting
hyperlipidaemia
ERCP- psot
drugs- thiazide diuretics, azathioprine, furosemide
gallstones causing pancreatitis are more common in who
women
older pt
alcohol casue of pancreatitis are more common in who
men
younger pt
whats the three big casues of pancreatitis
alcholol misuse - directly toxic to pancreatic cells
ERCP
gallstones
differentials of acute pancreatitis
peptic ulcer perforation
abdominal aorta aneurysm rupture
rupture of ectopic pregnancy
bowel obstruction
ischemia bowel
MI
biliary colic/ acute cholangititis, acute cholcystitis gastroenteritis
viral hepaitits
pt has acute onset of severe epigastric pain that came on after a bit meal. the pain raidates through to the back/ scapula
acute pancreatitis
presentation of acute pancreatitis
sudden onset
severe epigastric pain that may radiate through to back
vomiting
abdo tenderenes
systemiccaly unwell- low grade fever, tachycardia
may come on after fatty meal/ may come on few hrs after lots drinking session
jaundice
diarrhoea
investigations for pancreatitis
do so can do glasgow score
u and e = urea
fbc= wbc
calcium
lft= ast/alt/ldh
amylase
ABG - p02 and blood glucose
crp= can monitor inflammation
US to asses for gallstone casue first line for gallstones
ct abdomen if suspect complciations
whats the glasgow score
asses severity of pancreaitits
P= P02 less than 8
Age- over 55
N- neutrophils- wbc over 15
Calcium less than 2
urea more than 16
enzymes= ast / alt more than 200, LDH more than 600
albumin less than 32
sugar- glucose more than 10 (he endocrine function not working)
0-1= mild
2= moderate
3 or more severe pancreatitis
whats a key investigation for pancreatitis that help diagnosis with clinical picture
amylase blood levels- acute have 3 x normal upper limit
may not be raised in chronic pacnreatitis as have lost function of the pancreas
difference between chronic and acute pancreatitis
acute= rapid onset inflam, after epidosed normal fucntion of pacnreas return
chronic = gradual more progressive onset with permentant deterioration of pancreatic function
complications acute pancretitis
necrosis of pancreas
infection of necrotic area
absecc foramtion
acure peripancreatic fluid collection
chronic pancreatitis
pseudocysts can occur 4 weeks after
manage acute pancreatitis
abcde
iv fluids
stuff for glasgow score
antibiotics if infection eg. abseccs, necrotic tissue
nil by mouth - if mode- sevre so they are vomiting too. Enteral nutrtion- by tube. If mild so not vomiting etc and just the pain then can eat orally
analgesia
monitor
if gallstone pancreatitis treat gallstones- ERCP/ cholecystectomy
treat complciations - endocsopic/ perecutaneous drainiage
imrpove 3-7 days
pt has recurrent upper abdo pain
drink lots alcohol
chronic pancreatitis
suspect chronic pacnreatitis in pt with recurrent/ persistant upper abdo/ generalised abdo pain esp if history of excess alcohol use
most common casue chronic pancreatitis
alcholol
s and s chronic pancreatitis
like acute but less intestes and longer lasting - epigastric/upper abdo pain that may radiate to bakc
nasuea vomiting
diarrhoea
may have steatohrea
amy present with complciations - eg. diabtetes
complications chronic pancreatitis
chronic epigastric pain
loss exocrine fucntion= less enzymes esp lipase ==? steathorrea
loss endocrine function- less insulin- diabetes
damage and stricutres to duct= obstruction of secretion of pacnreatic juice and bile
pseudocysts/ absess
mangament chronic pancreatitis
analgesia for pain
stop smoking, stop alcohol!!
replace enzymes if needed- creon = if not may be deficinet in fat soluble vitamins and have steathorrea
subcut insulin if diabtetic
ERCP- stenting for stricutres/ obstruction
surgery can treat chronic pain - remove the inflammed tissues/ drain ducts
surgery for obstruction pseudocysts, absecess
what drugs can casue pacnreatitis
alcohol
steroids
furosemide
thiazide diuretics
azathioprine
wat imaging to diagnose common bile duct stones and cholangitits
abdo us
ct
MRCP
ERCP- most sensitive
managment of acute cholangitis
manage sepsis and acute abdoemn=
iv fluids
nil by mouth
iv antibiotics
blood cultures
ERCP - removal of stones
what can you do in ERCp
removal of stones
cholangio pancreatography - injection contrast and x rays
spincterotomy- cut sphincter to increase diamater - helps removal of stones
balloon dilatation - treat strictures
biliary stenting - maintain a patent bile duct - tumour / stricture
biopsy - daignose obstructing lesion
painless obstructive jaundice most likely casue
pancreatic cancer
other differential when see this is cholangiocarcinoma but pancreatic cacner is more likely than gallbladder cancer
pancreatic cancer mainly what type and where metastitise to and where in pancreas most common
most are adenocarcinomas
most in head of pacnreas
liver first then bone, lungs and peritoneum
palpable liver and jaundice
cholangiocarcinoma or pancreatic cacner - less likely to be gallstines by courvisers law
presentation of pacnreatic cancer
painless obstructive jaundice
pale stool
dark urine
yellow skin and sclera
genrerlaised itching
others:
non specific upper abdo pain/ back pain
unitentional weight loss
palpable mass in epigastric region
chage in bowel habit
n/vnew onset diabetes / worsening t2dm
diabetic pt :
pt has poor glycemic control but they actually have a good lifestyle and taking medication
suspect pancreatic cancer
when to refer pt on 2 ww for pancreatic cancer suspcion
over 40 with jaundice
pt over 40 and got jaundice. what do
2 ww
over 60 with weight loss and got one of :
diarrhoea
back pain
ado pain
nasuea
vomiting
constipation
new onset diabetes
what do
direct acess CT abdo - only time gp can do this
pt 66
weight loss and back pain
what do
direct acess ct abdo suspect pancreatic cancer
investigations for pancreatic cacer
diagnostic= CT and histology from biopsy
staging ct- thoax, abdo, pevis
CA19-9= carbodhydrate antigen = tumour marker- may be raised in pancreatic cancer/ cholangiocarcinoma and others
MRCP- se bilairy detail
ERCP- stent to relive obstruction and biopsy
biopsy via percutaneous under us/ct GUIDANCE
managment pancreatic cancer
surgery of small in head of pancreas - total pancreatectomy
distal pancreacectomy
whipple = remove pylorus, head pancreas, duodenum, gallbladder bile duct , relevanet lymph nodes
modified whipple= pylorus preserving
palliative :
stent to relive obstruction
surgery to improive symptoms
chemo, radiotherpy
e of l care
cholangiocarcinoma is what
cancer in bile ducts
type of cancers common for cholangiocarcnoma and where
majority adenocarcinoma
affect intrahepatic ducts or extrahepatic ducts
most common site is perihilar region- l and r hepatic duct join to form common hepatic duct
risk factors for cholangiocarcinom
primary sclerosing cholangitits- rf of getting PSC is ulcerative colitits
liver flukes= parasitic infection - from south east asia and europw
palpable gallbladder and jaundice is likely to be what
cholangiocarcinoma or pancreatic cancer - less likely be gallstones according to courvoisers law
painless jaundice think what
pancreatic cancer - tumour in head or cholangiocarcinoma
presentation of cholangiocarcinoma
painless jaundice
obstructive jaunce: pale stools, dark urine, generalised itching
others:
unexplained weight loss
RUQ pain
palpable gallbladder - swelling due to obstruction dustal to gall bladder
hepatomegaly
investigations of cholangiocarcinmoma
CT/MRI and histology from biospy= diangogis
ct staging - Thorax, abco, pelviis
CA19-9 = carbodhydrate antigen= tumour marker can be raused
MRCP = see bilairy system more
ERCP= stent / biopsy
CA19-9 is rasied in what
cholangiocarcinoma
pancreatic cancer
others
cholangiocarcinoma and pancreatic cacner have what incommon
painless jaundice
CT/mri to diagnose with histology
rasied CA-19-9
palpable gallbladder
obstrucitve jaundice = pale stools, dark urine, genrealsied ithcing
management cholagiocarcinoma
curative srugery if esrly
most palliative :
stents to relvie
surgery to inmprove symtpoms - bypass bilory obstruction
palliative chemo/radiothepry
e of life symptom control
mercedes scar
liver trasnplant
rooftop scar
liver transplant
hockey stick scar
kidney trasnplant
Left lower quadrant pain, low-grade fever in elderly patient
diverticulitits
- may have diarrhoea. then constipation
nasuea and amalasie
what hernia is painful: incarcerated or strangulated
strangulated
medial and superior to pubic tubercle lump
inguinal hernia
lateral and inferior to pubic tubercle lump
femoral hernia
whats the most common casue of small bowel obsstruction
adhesions
if pt had abdo surgery eg. appenciectomy always then think could be casuing small bowel obstrution - esp if got constipation, distention and early vomit
treatment samll bowel obstruction
drip and suck
iv fluids with added potassium=> the proximal part of the bowel to the occluded bit will undergo more peristaliss (trying to move stuff) and so bowel will secrete more electroyltes including potassium which dont want to go hypo cus heart
ng tube
most specific gold standard test for acute pancreatitis
lipase
amylase works and if 3x normal but lipase most specific
treatment of c diff infection
vancomycin
if not respond then oral fidaxomicin
Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAg
implies chronic HBV infection
ppi can casue what change i electroyltes
hyponatreamia
A 46-year-old man presents to the emergency department complaining of 3 days of watery diarrhoea which is occasionally bloody. On further questioning, he reveals cramping abdominal pain over the same period. He has dry mucous membranes and a prolonged capillary refill. Five days ago, he was started on a new medication by his GP.
What medication is most likely to cause this presentation?
climdamycin - can casue c diff
fever, jaundice and right upper quadrant pain
ascending cholangiis
richters hernia
Richter’s hernia is characterised by the absence of symptoms of obstruction even in the presence of strangulation, as the bowel lumen is patent while bowel wall is compromised. The VBG shows a low pH (acidotic) with a low pCO2 (due to partial respiratory compensation) and low bicarbonate (suggesting the cause of acidosis is metabolic) - metabolic acidosis which can occur due to the build-up of lactate.
biliary colic
gallstones in way
when eat heavy meal esp if fatty the gallbladder contracts to put bile into intestne and this then means bile trying to get past the stone and so pushing it so comes in waves the pain and last 1-2 hrs not long
ruq pain
A 37-year-old attends surgery due to a one day history of severe central abdominal pain radiating through to the back. He has vomited several times and is guarding on examination. Parotitis and spider naevi are also noted.
acute pancreatitis
spider naevi and parotitis suggest high alchol intake
drugs causing pancreatitis
azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate
treatment of un ruptured sigmoid volvulus
Sigmoid volvulus is a common pathology in the elderly which can initially be managed non-operatively with flatus tube decompression, avoiding the need for surgery which is higher risk in this age group. Decompression this way usually results in resolution of the volvulus without recurrence. Second line treatment is insertion of a percutaneous colostomy tube to decompress the volvulus when flatus tube decompression has proven unsuccessful or recurrence has occurred despite multiple attempts.
