General surgery (4) (Common conditions) Flashcards
abdominal infections
- Acute diverticulitis
- Cholecystitis (with secondary infection)
- Ascending cholangitis
- Appendicitis
- Spontaneous bacterial peritonitis
- Intra-abdominal abscess
common. causes of intra-abdominal infection
- Anaerobes (e.g. bacteroides and clostridium)
- E. coli
- Klebsiella
- Enterococcus
- Streptococcus
common antibiotic regimes for intra-abdominal infection
Some common regimes for intra abdominal infection are:
- Co-amoxiclav alone
- Amoxicillin plus gentamicin plus metronidazole
- Ciprofloxacin plus metronidazole (penicillin allergy)
- Vancomycin plus gentamicin plus metronidazole (penicillin allergy)
Oral e.g. if mild diverticulitis
IV if more serious infection
general principle of treating intra-abdominal infections
- Broad spec antibiotic cover (unless culture results)
- Cover gram positive, negative and anaerobic bacteria
co-amox coverage
This provides good gram positive, gram negative and anaerobic cover. It does not cover pseudomonas or atypical bacteria
quinolones coverage
- Ciprofloxacin and levofloxacin provide reasonable gram positive and gram negative cover and also cover atypical bacteria however they don’t cover anaerobes so are usually paired with metronidazole when treating intra-abdominal infections.
metronidazole coverage
- This provides exceptional anaerobic cover but does not provide any cover against aerobic bacteria.
gentamicin
- This provides very good gram negative cover with some gram positive cover particularly against staphylococcus. It is bactericidal so works to kill the bacteria rather than just slowing it down.
vacomycin
- This provides very good gram positive cover including MRSA. It is often combined with gentamicin (to cover gram negatives) and metronidazole (to cover anaerobes) in patients with penicillin allergy.
cephalosporins
- These provide good broad spectrum cover against gram positive and gram negative bacteria but are not very effective against anaerobes. They are often avoided due to the risk of developing C. difficile infection.
tazocin and meropenem
- Piperacillin/Tazobactam (Tazocin) and Meropenem are heavy hitting antibiotics that cover gram positive, gram negative and anaerobic bacteria. They don’t cover atypical bacteria or MRSA and tazocin doesn’t cover ESBLs but they cover almost everything else. They are usually reserved for very unwell patients or those not responding to other antibiotics.
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Spontaneous Bacterial Peritonitis
This is a serious infection that typically occurs in patients with liver failure.
- Piperacillin/Tazobactam (Tazocin) is often first line
- Cephalosporins such as cefotaxime are also often used
- Levofloxacin plus metronidazole is an common alternative in penicillin allergy
This is a serious infection that typically occurs in patients with liver failure.
- Piperacillin/Tazobactam (Tazocin) is often first line
- Cephalosporins such as cefotaxime are also often used
- Levofloxacin plus metronidazole is an common alternative in penicillin allergy
intra-abdominal abscess
An intra-abdominal abscess is a collection of pus or infected fluid that is surrounded by inflamed tissue inside the abdomen. It can involve any abdominal organ, or it can settle in the folds of the bowel.
causes of intra-abdiominal abscess
- E.coli usually
RF for intrabdominal abscess
- Appendicitis
- Diverticulitis
- After surgery
- Diabetics
- IBD
presentation of intrabdominal abscess
- Fever
- Abdominal pain
- Chest pain or shoulder pain
- Lack of appetite
- N and V
- Mass in belly
- Clinical features of sepsis
investigations for intradbominal abscess
- Blood tests
- FBC
- WBC
- CRP
- U and E
- LFT
- CT
- Physical exam
treatment for intrabdominal abscess
- Percutaneous drainage
- Surgical
- Repair condition which has causes abscess
- Antibiotics
peri-anal abscess
Collection of pus in anal or rectal region. 1/3 of pt will have perianal fistula at time of presentation.
causes of peri-anal abscess
- Plugging of anal ducts which drain anal glands in the anal wall (mucus secretions help passage of faecal matter)
- Blockage of anal duct results in fluid stasis à infection
- Organisms
- E.coli
- Bacteroides spp
- Enterococcus spp
anal glands
- Located in intersphincteric space (bw internal and external anal sphincters)
- Abscesses categorised by area
- Perianal
- Ischiorectal
- Intersphincteric
- Supralevator
RF for perianal abscess
- Male>female
- Diabetes
- Crohns disease
- Foreign objects
presentation of perianal abscess
- Severe pain in perianal region
- Worse on direct pressure
- Systemic features
- Fever
- Rigors
- General malaise
- Sepsis
investigations for perianal abscess
- Routine bloods (FBC, UandEs, clotting and group and save)
- Hba1c- check for underlying DM
- MRI/CT scan if atypical presentation
management of perianal abscess
Initial management
- Abx and analgesia
Surgical management
- Main management: EUA rectum and I&D
- Examination under anaesthetic (EUA)
- Incision and drainage of abscess- left to heal by secondary intention
- Intra-operative proctoscopy to look for fistula-in anus
appendicitis
Inflammation of the appendix
peak incidence of appendicitis
- 10 to 20 years
presentation of appendicitis
Rebound tenderness and percussion tenderness suggest peritonitis, potentially indicating a ruptured appendix.
- Abdominal pain
- Central abdominal pain that moves down to the right iliac fossa (RIF) within first 24 hours -> localised in the RIF
- McBurneys point
- the point on the lower right quadrant of the abdomen at which tenderness is maximal in cases of acute appendicitisLoss of appetite (anorexia)
- Nausea and vomiting
- Low-grade fever
- Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF)
- Guarding on abdominal palpation
- Rebound tenderness in the RIF (increased pain when suddenly releasing the pressure of deep palpation)
- Percussion tenderness (pain and tenderness when percussing the abdomen)
rovsings sign
palpation of the left iliac fossa causes pain in the RIF
McBurneys point
- the point on the lower right quadrant of the abdomen at which tenderness is maximal in cases of acute appendicitis
investigations for appendicitis
- Clinical presentation
- Raised inflammatory markers (CRP)
- CT scan
- US to exclude ovarian and gynaecological pathology
- If clinical presentation suggestive of appendicitis, but investigation negative- diagnostic laparoscopy to visualise appendix directly
pathophysiology of appendicitis
- The appendix is a small, thin tube arising from the caecum.
- It is located at the point where the three teniae coli meet (the teniae coli are longitudinal muscles that run the length of the large intestine). There is a single opening to the appendix that connects it to the bowel, and it leads to a dead end.
- Pathogens can get trapped due to obstruction at the point where the appendix meets the bowel. Trapping of pathogens leads to infection and inflammation.
- The inflammation may proceed to gangrene and rupture. When the appendix ruptures, faecal contents and infective material are released into the peritoneal cavity.
- This leads to peritonitis, which is inflammation of the peritoneal lining.
Differing position of appendix can present with diff symptoms
e.g. can get Upper right quadrant pain
management of appendicitis
-
Conservative
- antibiotics
-
Surgical
- appendicectomy
- laparoscopic surgery associated with fewer risk and faster recovery compared to open surgery
- appendicectomy
Complications of Appendicectomy
- Bleeding, infection, pain and scars
- Damage to bowel, bladder or other organs
- Removal of a normal appendix
- Anaesthetic risks
- Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
Diverticular disease
Diverticulum (plural diverticula) is a pouch or pocket in the bowel wall, usually ranging in size from 0.5 – 1cm.
- diverticulosis
- diverticulitis
diverticulosis
‘Wear and tear of bowel’. Most commonly affecting sigmoid colon.
- refers to the presence of diverticular disease, without inflammation or infection. Diverticulosis may be referred to as diverticular disease when patients experience symptoms.
- Most common cause of lower GI bleed
- very common in elderly
diverticulitis
refers to inflammation and infection of diverticular
pathophysiology of diverticular disease
- The point where blood vessels penetrate circular muscle is an area of weakness
- Gap forms in circular muscle due to increased pressure inside lumen
- Gaps allows mucosa to herniate through muscle layer and pouches form
- DOES NOT FORM IN rectum- longitudinal muscle
diverticulsosis
RF for diverticulosis
- Age
- Low fibre diet
- Obesity
- NSAIDs
presentation of diverticulosis
- Lower left abdominal pain
- Constipation
- Rectal bleeding
diagnosis of diverticulosis
often incidental on colonoscopy
management of diverticulosis
- Not necessary when pt asymptomatic
- Advice about high fibre diet and weight loss
- Avoid bulk forming (ispaghula husk) and stimulant laxative (Senna)
- Surgery to remove affected area if signif symptoms
presentation of acute diverticulitis
- Pain and tenderness in the left iliac fossa / lower left abdomen
- Fever
- Diarrhoea
- Nausea and vomiting
- Rectal bleeding
- Palpable abdominal mass (if an abscess has formed)
- Raised inflammatory markers (e.g., CRP) and white blood cells
management of acute diverticulitis
-
Uncomplicated
- Oral co-amoxiclav (at least 5 days)
- Analgesia (avoiding NSAIDs and opiates, if possible)
- Only taking clear liquids (avoiding solid food) until symptoms improve (usually 2-3 days)
- Follow-up within 2 days to review symptoms
-
Complicated or severe pain require admission (may need treatment for sepsis)
- Nil by mouth or clear fluids only
- IV antibiotics
- IV fluid
- Analgesia
- Urgent investigations (e.g., CT scan)
- Urgent surgery may be required for complications
complications of acute diverticulitis
- Perforation
- Peritonitis
- Peridiverticular abscess
- Large haemorrhage requiring blood transfusions
- Fistula (e.g., between the colon and the bladder or vagina)
- Ileus / obstruction
what is ileus
Ileus is a condition affecting the small bowel, where the normal peristalsis that pushes the contents along the length of the intestines, temporarily stops.
Usually resolves with supportive care within a few days
causes of ileus
- Injury to the bowel
- Handling of the bowel during surgery
- Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia)
- Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia)
presentation of ileus
- Vomiting (particularly green bilious vomiting)
- Abdominal distention
- Diffuse abdominal pain
- Absolute constipation and lack of flatulence
- Absent bowel sounds (as opposed to the “tinkling” bowel sounds of mechanical obstruction)
management of ileus
Supportive
- Nil by mouth or limited sips of water
- NG tube if vomiting to decompress stomach
- IV fluids to prevent dehydration and correct the electrolyte imbalances
- Mobilisation to helps stimulate peristalsis
- Total parenteral nutrition (TPN) may be required whilst waiting for the bowel to regain function
