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
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)
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
Diverticular disease
Diverticulum (plural diverticula) is a pouch or pocket in the bowel wall, usually ranging in size from 0.5 – 1cm.
- diverticulosis
- diverticulitis
