General surgery (2) (Common conditions) Flashcards
intestinal obstruction summary
Passage of food, fluids and gas become blocked.
- Small bowel more common than large bowel
- Results in build up of gas and faecal matter proximal to obstruction
- Back pressure- vomiting and dilatation of proximal intestines
- Surgical emergency
how can intestinal obstruction cause dehydration
- Obstruction also reduces fluid reabsorption in the colon- fluid loss from intravascular space – hypovolaemia
- This is called third-spacing
- Higher up the obstruction the worse the fluid losses- less bowel where the fluid can be reabsorbed
3 main causes of intestinal obstruction
The big three (HAM)
• Hernias (small bowel)
• Adhesions (small bowel)
• Malignancy (large bowel)
causes of small bowel obstruction
- Hernias
- Adhesions
- Scar tissue that binds abdominal contents together
- Causing kinking or squeezing of the bowel
- Causes
- Surgery
- Peritonitis
- Infection
- Endometriosis
- Stricture
causes of large bowel obstruction
- Malignancy
- Volvulus- bowel twists on self
- Diverticular disease
causes of small and large bowel obsturction
- Stricture e.g. secondary to Crohns
- Intussusception (in young children 6m-2y)
RF for obstruction
- Abdominal surgery
- Cancer
- Hernias
- Crohns disease
presentation of obstruction
- Vomiting (particularly green bilious vomiting)
- Early- upper
- Later- lower
- Abdominal distention
- Diffuse abdominal pain
- Absolute constipation and lack of flatulence (early in lower,
Late in upper)
- “Tinkling” bowel sounds may be heard in early
bowel obstruction
investigations of obstruction
-
Abdominal X-ray – distended loops of bowel
- Upper limits of normal diameter of bowel
- 3cm small. Bowel
- 6cm colon
- 9cm caecum
- Upper limits of normal diameter of bowel
- May skip straight to contrast abdominal CT- confirm diagnosis and establish site and if perforation has occurred- modality of choice
- Blood tests: U and E (electrolytes), venous blood gas (metabolic alkalosis due to loss of HCL in vomit), vowel ischaemia- raised lactate)
small bowel AXR
- Dilated >3cm
- Central, valvulae conniventes
- String of pearls sign
- Paucity of gas in large bowel (i.e. not in the rectum)
large bowel obstruction AXR
- Colon >6cm, caecum >9cm
- Peripheral and haustra (don’t extend full width)
initial management of obstruction
- ABCDE
- Hypovolaemia shock due to third spacing
- Bowel ischaemia
- Bowel perforation
- Sepsis
- Nill by mouth
- Analgesia, catheterise
- IV fluids to hydrate and correct electrolyte imbalances
- NG tube with free drainage to allow stomach contents to freely drain and reduce risk of vomiting and aspiration
- Conservative treatment if adhesions or volvulus, where this fails- surgery
surgical intervention for obsturction
intervention (closed loop or ischaemia- pain)
- Definitive management – either laparoscopy or laparotomy
- Exploratory surgery in patients with an unclear underlying cause
- Adhesiolysis to treat adhesions
- Hernia repair
-
Emergency resection of the obstructing tumour- may need stoma
- Stents may be inserted- holds tumour out of the way
volvulus on x-ray
- Sigmoid volvulus- coffee bean appearance
- Caecal volvulus- fetal appearance
Closed loop obstruction
Where there are two points of obstruction along the bowel; meaning that there is a middle section sandwiched between two points of obstruction.
Result: contents of section of bowel does not have open end to drain- bowel continues to expand- ischaemia and perforation
This might happen with:
- Adhesions that compress two areas of bowel
- Hernias that isolate a section of bowel blocking either end
- Volvulus where the twist isolates a section of intestine
- A single point of obstruction in the large bowel, with an ileocaecal valve that is competent
what is the significance of a competent ileocaecal valve
- A competent ileocaecal valve does not allow any movement back into the ileum from the caecum. When there is a large bowel obstruction and a competent ileocaecal valve, a section of bowel becomes isolated and the contents cannot flow in either direction.
The complications of bowel obstruction include:
*
- Bowel ischaemia
- Bowel perforation leading to faecal peritonitis (high mortality)
- Dehydration and renal impairment
hernias (summary)
Occur when there is a weak point in a cavity wall, affecting muscle or fascial- this weakness allows body organ e.g. bowel that would. Normally be contained within that cavity to be passed through the cavity wall
types of hernia
- Inguinal
- Femoral
- Umbilical
- Incisional
- Hiatus hernia
Specific abdominal hernias
-
Richter’s hernia
- Specific situation
- Only part of bowel wall and lumen herniate through defect, other side of that section of bowel remains within peritoneal cavity
- Risk of strangulation
- Surgical emergency
-
Maydls hernia
- Two diff loops of bowel are contained within hernia
assessing a hernia
- does it go back in by itself or is it reducible
- get patient to cough and feel over
- get patient to lie down
- pain?
When assessing a hernia, always comment on the size of the neck/defect (narrow or wide), as this will help formulate a risk assessment (risk of strangulation reduced if wider neck) and management plan for the hernia (such as how urgently they need to be operated on).
causes of hernias
anything which increases pressure in abdomen
- Lifting heavy objects
- Diarrhoea or constipation
- Persistent coughing
risk factors of henrias
- Pregnancy
- Weight-lifting
- Constipation
- Obesity
presentation of hernia
- A soft lump protruding from the abdominal wall
- The lump may be reducible (it can be pushed back into the normal place)
- The lump may protrude on coughing (raising intra-abdominal pressure) or standing (pulled out by gravity)
- Aching, pulling or dragging sensation
complications of hernias
incarceration
obstruction
strangulation
incarceration vs strangulation
-
Incarceration
- Where hernia cannot be reduced back into proper position (irreducible)
- Can lead to obstruction and strangulation of hernia- bowel ischemia
-
Strangulation
- Non reducible and base of hernia becomes so tight it cuts of blood supply- ischaemia
- Significant pain and tenderness
- Surgical emergency
obstruction caused by hernia
- Blockage in passage of faeces through bowel
- Vomiting, pain and absolute constipation
investigation fo hernia
- Clinical examination
- Ultrasound or CT
- If negative but high clinical suspicion- MRI
conservative management of hernia
- Leaving hernia
- Appropriate when hernia is wide neck and if pt not a good candidate for surgery
hernia surgical repair : tension free repair
- Placing mesh over the defect in the abdominal wall
- Mesh is sutured to the muscles and tissues on either side of the defect, covering and preventing herniation of the cavity contents
- Over time tissue grows into mesh- more support
- Complications- chronic pain due to mesh
- Lower recurrent rate than tension repair
hernia surgical repair : tension repair
- Suture the muscles and tissues on either side of the defect back together
- Rarely performed
- Complications – pain
- High recurrence rate of hernia
gallstones
Stones form in the gallbladder and are made from concentrate bile from the bile duct (mostly cholesterol). Leads to complications such as:
- Biliary colic
- Acute cholecystitis
- Acute cholangitis
- Acute pancreatitis (when stones block the pancreatic duct)
risk factors for gallstones
- Fs
* Fat, Fair, Female,Forty
presentation of gallstones general
- Asymptomatic (sometimes)
-
Biliary colic
- After meal
- RUQ pain/ N+V
- 30-8 hours
-
Acute cholecystitis
- Positive murphy’s sign
-
Ascending cholangitis
- Charcots triad-jaundice
basic anatomy of bile duct
- The right hepatic duct and left hepatic duct leave the liver and join together to become the common hepatic duct.
- The cystic duct from the gallbladder joins the common hepatic duct halfway along.
- The pancreatic duct from the pancreas joins with the common bile duct further along.
- When the common bile duct and the pancreatic duct join they become the ampulla of Vater, which then opens into the duodenum.
- The sphincter of Oddi is a ring of muscle surrounding the ampulla of Vater that controls the flow of bile and pancreatic secretions into the duodenum.
investigations for gallstones
- LFTS
- US
- MRCP
- ERCP
- CT scan
liver function tests and gallstones
- Bilirubin
- Raised bilirubin (jaundice) due to blockage in the in common bile ducts
- Pale stool and dark urine
- Causes: gallstones, chlangiocarcinoma or tumour of pancreas
- Alkaline phosphatase
- Biliary obstruction
- Also- liver or bone problems and pregnancy
- Gamma-glutamyl transferase GTT to check biliary problem
- Alanine aminotransferase (ALT) and Aspartate aminotransferase (AST)
- Hepatocellular injury
- ALT better
US and and gallstones
- Can locate gallstone
- Limited by: pt weight, gaseosus bowel obstructing view and discomfort
MRCP
Magnetic resonance cholangio-pancreatography (MRCP)
- MRI scan- detailed image of biliary system
ERCP
-
Endoscopic retrograde cholangio- pancreatography
- Involves inserting endoscope down oesophagus, past stomach and into the sphincter of oddi up into common bile duct
- Main indication: clear stones in bile duct
- Allows operator to:
- Inject contrast and take x-rays
- Clear stones
- Insert stents
- Biopsy of tumour
- Complications
- Excessive bleeding
- Cholangitis (infection)
- Pancreatitis
CT scans and gallstones
- Less useful
- Good for differentiations and complications
key definitions for gallstones
- Cholestasis: blockage to the flow of bile
- Cholelithiasis: gallstone(s) are present
- Choledocholithiasis: gallstone(s) in the bile duct
- Biliary colic: intermittent right upper quadrant pain caused by gallstones irritating bile ducts
- Cholecystitis: inflammation of the gallbladder
- Cholangitis: inflammation of the bile ducts
- Gallbladder empyema: pus in the gallbladder
- Cholecystectomy: surgical removal of the gallbladder
- Cholecystostomy: inserting a drain into the gallbladder
three different and worsening presentations of gallstones
biliary colic → acute cholecystitis → ascending cholangitis
biliary colic pathophysiology
- Due to cholecystokinin (CCK) release after meal, which causes the gall bladder contract and push a gallstone up against the neck of the gall bladder- temporary obstruction of biliary duct
- Gall stones happily sitting within gall bladder, but can cause sudden onset of RUQ pain typically a few hours after eating a fatty meal
presentation of biliary colic
- Severe, colicky epigastric or right upper quadrant pain
- Radiates to back
- Often triggered by meals (particularly high fat meals)
- Lasting between 30 minutes and 8 hours
- May be associated with nausea and vomiting
treatment of biliary colic
pain relief and elective cholecystectomy removal
acute cholecysittis pathophysiology
Inflammation of gallbladder caused by full impaction of stone in cystic duct- preventing gallbladder draining→ can cause dilatation of the gall bladder
presentation of acute cholecysitits
- RUQ pain
- Fever, N and V
- Tachycardia
- Raised CRP
- Positive Murphy signà place a hand on right side of the patients stomach and ask them to take a deep breathe in- will push gall bladder down and cause them to take a sharp breathe in pain (wont happen on left hand side)
- Pain which radiates to shoulder (shared phrenic nerve innervation)
- Imaging
- MRCP or US
treatment for acute cholecysitits
- pain relief and Ab
- Cholecystectomy
gallbladder empyema
infected tissue and puss in gallbladder- IV antibiotics and surgery
ascending cholangitis
Infection and inflammation in bile duct- high mortality rate
causes of ascending cholangitis
- Gallstone in CBD or infection due to ERCP
- E.coli, klebsiella
presentation of ascending cholangitis
charcots triad
charcots triad
- Inflammation (pyrexia and rigors)
- RUQ pain,
- jaundice (when stone reaches common bile duct)
management of ascending cholangitis
- acute management of sepsis and acute abdomen (BUFALO)
- imaging to diagnose CBD stone and cholangitis
- most sensitive MRCP or endoscopic ultrasound
- ERCP required for stone removal
- Percutaneous transhepatic cholangiogram
if no symptoms of gall stones
no intervention required
cholecystectomy
- Surgical removal of the gall bladder
- When pts symptomatic or stone leading to acute cholecystitis
- Stones removed by ERCP or during surgery
- Laparoscopic cholecystectomy (keyhole) preferred) to open (kocher incision)
- Faster recovery less complications
- Bleeding, infection, pain scars
- Damage to bile duct- stricture
- Stones left In bile duct
- Anaesthetic risk
- VTE
- Post cholecystectomy syndrome
- Faster recovery less complications
post-cholecystectomy syndrome
involves a group of non-specific symptoms that can occur after a cholecystectomy. They may be attributed to changes in the bile flow after removal of the gallbladder. Symptoms often improve with time. Symptoms include:
- Diarrhoea
- Indigestion
- Epigastric or right upper quadrant pain and discomfort
- Nausea
- Intolerance of fatty foods
- Flatulence
