General surgery in GI Flashcards
Bowel ischaemia- small vs large bowl- name of condition
Mesenteric ischaemia: small bowel
Ischaemic colitis: Large bowel
Acute Mesenteric Ischaemia-
where
cause
onset
pain?
Small bowel
Usually occlusive due to thromboemboli
Sudden onset (but presentation and severity varies)
Abdominal pain out of proportion of clinical signs
Ischaemic Colitis
where
cause
onset
pain?
Large bowel
Usually due to non-occlusive low flow states, or atherosclerosis
More mild and gradual (80-85% of the cases)
Moderate pain and tenderness
Bowel ischaemia- presentation
Acute/chronic pain
All over abdomen
Rectal bleeding colonic ischaemia
Bowel ischaemia- risk factors
Age >65yrs, arrhythmias, atherosclerosis, hypercoagulation/thrombophilia, vasculitis, SCD, hypotension (due to shock)
bowel ischaemia -Investigations
Bloods: FBC, VBG
Imaging (CT angiogram): detects disrupted flow
Endoscopy: for mild or moderate cases of ischaemic colitis
Bowel ischaemia - conservative Management
For mild to moderate cases
-IV fluid resuscitation
-Bowel rest
-Broad-spectrum antibiotics
-NG tube for decompression
-Anticoagulation
-Treat/manage underlying cause
-Repeated imaging and examinations
Bowel ischaemia -Surgical management
Indications: small bowel ischaemia, signs of sepsis, instability bp, massive haemorrhage, severe colitis with toxic megacolon
Laparotomy: resection of necrotic bowel ± open surgical embolectomy or mesenteric arterial bypass
Endovascular revascularisaiton: balloon angioplasty/ thrombectomy; in patients without signs of ischaemia
Acute appendicitis-Examination and what is McBurney’s point:
General inspection: pain (worsen on movement), lying still (peritonitis).
McBurney’s point: tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
Appendicitis- 4 signs
-Rovsing’s Sign
-obturator sign
-psoas sign
-rebound tenderness
what is rovsing’s sign
Pain is greater in RIF than LIF when LIF is pressed
what is Obturator sign
Pain on passive flexion and internal rotation of the hip
what is psoas sign
Pain on extending hip (only with retrocaecal appendix)
what is Rebound tenderness
If infection involves peritoneum
Appendicitis investigations
1st line: CT abdomen
USS: used in children/pregnancy/breastfeeding
Bloods: neutrophilic leukocytosis, elevated CRP
appendicitis investigation- alvorado score
-right lower quadrant tenderness (2)
-temp 37.c + (1)
-rebound tenderness (1)
-anorexia (1)
-Nausea/vomiting (1)
-migration of pain to right lower quadrant (1)
-leukocytosis 10,000+ (2)
-left shift- (1)
1-4: Discharge ,
5-6: Observe,
7-10: Surgery,
Appendicitis - Management- conservative
IV fluids, analgesia, IV/PO antibiotics
recurrence after conservative management-consider interventional appendicetomy
Appendicitis - Management- surg
Laparoscopic vs Open appendicectomy
-Less pain
-Lower incidence of surgical site infection
-↓ed length of hospital stay
-Earlier return to work
-Better quality of life scores
Bowel obstruction- presentation, cause- SBO vs LBO
SBO =central pain. abdominal distension less sig. early onset- vomiting
LBO=constant pain. abdominal distension sig. early sign=absolute constipation
dehydration/absent bowel sound (late sign)
Cause:
SBO =adhesions; neoplasia.
LBO= colorectal tumours, volvulus + diverticulitis
Bowel obstruction -INVESTIGATION
AXR: Rigler’s sign, volvulus (caecal or sigmoid)
CT abdomen
Bloods: FBC, X-match, U&Es etc.
Bowel obstruction- What is seen on x-ray and CT purpose
SBO =central loops, striations completely visible
LBO = peripheral large bowels
CT scans can localise site of obstruction
Bowel obstruction - management- conservative
-Faecal impaction-stool evacuation
-Sigmoid volvulus – rigid sigmoidoscope decompression
Bowel obstruction - management- Supportive
Fluids
Analgesia
NBM
NG tube for decompression
Gradual food intake
Bowel obstruction - management -surg
Laparotomy
Bowel resection + anastomosis
GI perforation presentation overview
Sudden abdominal pain
N&V
Constipated
Shock -> tachycardia, hypotension, tachypnoea
GI perforation- 4 types of cause and presentation
perforated peptic ulcer
-sudden epigastric pain
-referred to shoulder
-hX of NSAIDs, steroids
perforated diverticulum
-LLQ pain
-constipation
perforated appendix
-migratory pain
-anorexia
-gradual worsening RLQ pain
perforated malignancy
-change in bowel habit
-weight loss
-anorxia
-PR bleeding
GI perforation- blood and imaging results
Bloods
-FBC – neutrophilic luekocytosis, lactic acidosis
-Inflammatory markers raised
Imaging
-Pneumperitoneum- presence of gas in abdominal cavity
GI perforation supportive management and surg
Supportive management
Fluids, analgesia, NBM
Surgical
-Laparotomy
-Resection of perforated segment + anastomosis
Sigmoid volvulus- sign on X-ray
X-ray – coffee bean sign
Sigmoid volvulus- treatment
- rigid sigmoidoscope: untwists the volvulus and leads to release of lots of flatus + liquid faeces
- Surgical if this doesn’t work: hartmanns procedure
what happens if you leave sigmoid volvulus untreated
tissue undergoes necrosis and bowel death
Biliary Colic- management
Analgesia, Antiemetics,
Follow up for elective cholecystectomy
Acute Cholecystitis- symptom and treatment
Fever/ Murphy’s sign
Fluids, ABx, Analgesia, Blood cultures
elective cholecystectomy
Acute Cholangitis symptom and treatment
Charcot’s triad: jaundice, RUQ pain, fever
Fluids, IV Abx, Analgesia
ERCP (Endoscopic retrograde cholangiopancreatography) (within 72hrs) for clearance of bile duct or stenting
