general surgery in gi tract Flashcards
what is the general approach to a presenting complaint
acute abdomen
pain assessment - SOCRATES associated symptoms pmhx dhx shx
what are the general investigations for acute abdomen
bloods: vbg,fbc,crp,u&e,lfts and amylase urinalysis imaging - erect and urine mc&s cxr,axr,ctap,ct,angiogram,uss endoscopy
how to manage acute abdomen
ABCDE approach
conservative management?
surgical management?
what is the general presentation for bowel ischaemia
sudden onset crampy abdo pain
severity of pain depends on length and thickness of colon affected
blood,loose stools
fever,signs of septic shock
what are the risk factors for bowel ischaemia
age >65yr cardiac arythmias, atherosclerosis hypercoagulation, thrombophilia vasculitis scd profound shock causing hypotension
how is acute mesenteric ischaemia different to ischaemic colitis
occurs in small bowel
usually occlusive due to thromboemboli
sudden onset - presentation and severity varies
abdo pain out of proportion of clinical signs
how is ischaemic colitis different to acute mesenteric ischaemia
occurs in large bowel
usually due to non occlusive low flow states/atherosclerosis
more mild and gradual
moderate pain and tenderness
what would you expect to see in the fbc of bowel ischaemia
neutrophilic leukocytosis
what would you expect to see in the vbg of bowel ischaemia
lactic acidosis
what might you see in a ctpap or ct angiogram of someone with bowel ischaemia
disrupted flow
vascular stenosis
‘pneumatosis intestinalis’ - transmural ischaemia/infarction
ischaemic colitis - thumbprint sign
when might you use endoscopy in someone with bowel ischaemia
for mild/moderate causes of ischaemic colitis
oedema, cyanosis, ulceration of mucosa
what is the conservative management for bowel ischaemia
iv fluid resusitation bowel rest broad spectrum antibiotics( colonic ischaemia can result in bowel translocation + sepsis) ng tube for decompression treat/manage underlying cause
what are the indications for surgical management of bowel ischaemia
small bowel ischaemia signs of peritonitis/sepsis haemodynamic instability massive bleeding fulminant colitis with toxic megacolon
what is the surgical management of bowel ischaemia
exploratory laparotomy - resection of necrotic bowel +- open surgical embolectomy or mesenteric arterial bypass
endovascular revascularisation - balloon angioplasty/thrombectomy
in patients without signs of ischaemia
typical presentation of appendicitis
initially periumbilical pain that migrates to RLQ (within 24hrs)
anorexia, nausea +- vomiting, low grade fever, change in bowel habit
what are the important signs of appenditicitis
mcburneys point - tenderness in rlq
blumbeg sign - tenderness expecially in rif
rovsing sign - rlq pain elicited on deep palpation of llq
psoas sign - rlq pain elicited on flexion of right hip against resistance
obturator sign - rlq pain on passive internal rotation of hip with hip and knee rotation
what would you expect to see on blood of one with appendicitis
fcb - neutrophilic leukocytosis
elevated crp
urinalysis - possible mild pyuria/haematuria
electrolyte imbalances in profound vomiting
what imaging techniques would be used for appendicitis
ct - gold standard in adults esp if age >50
uss - for children/pregnancy,breastfeeding
mri - in pregnancy if uss inconclusive
when might you use a diagnostic laparoscopy in appendicitis
if in persistent pain and inconclusive imaging
what scale is used for severity of appendicitis
alvarado score: rlq tenderness fever rebound tenderness pain migration anorexia nausea and vomiting wcc neutrophilia
what is the conservative management for acute appendicitis
iv fluids
analgesia
iv/po antibiotics
in abscess,phlegmon or sealed perforation - resuscitation and iv antibiotics +- percutaneous drainage
what are the indications for conservative management of acute appendicitis
after negative imaging in selected patients with clinically umcomplicated appendicitis
in delayed presentation with abscess/phlegmon formation - ct guided drainage
*consider interval appendicetomy - rate of recurrence after conservative management of abscess/perforation is 12-24%
why is laparoscopic preferred over open appendicetomy
less pain lower incidence of surgical site infection decreased length of hospital stay earlier return to work overall costs better quality of life scores
what are the steps in laparoscopic appendicetomy
- trocar placement - usually 3
- exploration of rif and identification of appendix
- elevation of appendix and division of mesoappendix(containing artery)
- base secured with endoloops and appendix is divided
- retrieval of appendix with plastic retrieval bag
- careful inspection of rest of pelvic organs/intestines
- pelvic irrigation and haemostasis
- removal of trocars and wound closure
what is intestinal obstruction
restriction of normal passage of intestinal contents
2 main groups:
paralytic(adynamic) ileus
mechanical
how is mechanical obstruction classified
speed of onset: acute,chronic, acute on chronic
site; high/low
nature: simple/stangulating
aetiology
what are the different causes of bowel obstruction in lumen
faecal impaction
gallstone ‘ileus’
what are the causes in wall in bowel obstruction
chrons disease, tumours, diverticulitis of colon
what are the causes of bowel obstruction outside the wall
strangulated hernia (external/internal) volvulus obstruction due to adhesions/ bands
what is meant by simple bowel obstruction
bowel is occluded without damage to blood supply
what is meant by strangulating bowel obstruction
blood supply of involved segment of intestine is cut off
e.g strangulated hernia, volvulus, intussusception
what are some causes of small bowel obstruction
adhesions (60%) - hx of previous abdominal surgery
neoplasia(20%) - primary,metastatic, extraintestinal
incarcerated hernia
chrons disease
other e.g intussesception, foreign body,bezoar
what are some causes of large bowel obstruction
colorectal carcinoma
volvulus - sigmoid, caecal
diverticulitis - inflammation, strictures
faecal impaction
hirschsprung disease - commonly found in infants
what is the presentation of small bowel obstruction
colicky and central abdominal pain
early onset of vomiting, large amounts and bilious
constipation is a late sign
less significant abdominal distention
other signs: dehyration, increased high pitched tinkling bowel sounds, absent bowel sounds(late)
diffuse abdominal tenderness
what is the presentation of large bowel obstruction
colicky or constant abdo pain
late onset vomiting, initially bilious and progresses to faecal vomiting
constipation is early sign
abdominal distention is an early sign and significant
other signs: dehyrdration, increased high pitched tinkling bowel sounds / absent bowel sounds(late)
diffuse abdominal tenderness
how to diagnose bowel obstruction
- diagnosed by presnece of symptoms
examinatio should always include search for hernias and abdo scars, incl laparoscopic portholes
is it simple/strangulating
what are some features suggesting strangulation
change in character of pain from colicky to continuous tachycardia pyrexia peritonism bowel sounds absent/reduced leucocytosis elevated crp
where are common hernial sites
epigatric umbilical incisional inguinal femoral
bloods for bowel obstruction
wcc/crp usually normal
u&e - electrolyte imbalance
vbg - if vomiting hypocl-/k+ , metabolic alkalosis
vbg if strangulation
imaging for bowel obstruction
erect cxr/axr
sbo - dilated small bowel loops >3cm proximal to obstruction
lbo - dilated large bowel >6cm
ct abdo/pelvis
what would you see in an abdo x ray in small bowel obstruction
ladder pattern of dilated loops and their central position
striations that pass completely across width of distended loop produced by circular mucosal folds
what would you see in abdo xray in large bowel obstruction
distended large bowel tends to lie peripherally
show haustrations of taenia coli - do not extend across whole width of bowel
why is a ct scan useful in bowel obstruction
Can localize site of obstruction
Detect obstructing lesions & colonic tumours
May diagnose unusual hernias (e.g. obturator hernias).
supportive management in bowel obstruction
In patients with no signs of ischaemia/no signs of clinical deterioration
Supportive management
NBM, IV peripheral access with large bore cannula -IV Fluid resuscitation
IV analgesia, IV antiemetics, correction of electrolyte imbalances
NG tube for decompression, urinary catheter for monitoring output
Introduce gradual food intake if abdominal pain and distention improve
conservative treatment of bowel obstruction
Faecal impaction: stool evacuation (manual, enemas, endoscopic)
Sigmoid volvulus: rigid sigmoidoscopic decompression
SBO: oral gastrograffin (highly osmolar iodinated contrast agent)can be used to resolve adhesionalsmall bowel obstruction
indications for surgical management of bowel ostruction
Haemodynamic instability or signs of sepsis
Complete bowel obstruction with signs of ischaemia
Closed loop obstruction
Persistent bowel obstruction >2 days despite conservative management
what are the operations for bowel obstruction
Exploratory laparotomy/Laparoscopy
Restoration of intestinal transit (depending on intra-operational findings)
Bowel resection with primary anastomosis or temporary/permanent stoma formation
or endoscopic stenting if obstruction is distal
how do gi perforations present
sudden onset severe abdominal pain associated with distention
diffuse abdominal guarding, rigidity and rebound tenderness
pain aggravated by movement
nausea, vomiting, absolute constipation
fever, tachycardia, tachypnoea, hypotension
decreased or absent bowel sounds
what is the presentation of perforated peptic ulcer
sudden epigastric/diffuse pain
referred shoulder pain
- history of NSAIDs,steroids, recurrent epigastric pain
what is the presentation of perforated diverticulum
llq pain
constipation
what is the presentation of perforated appendix
migratory pain
anorexia
gradual worsening rlq pain
what is the presentation of perforated malignancy
change in bowel habit
weight loss
anorexia
pr bleeding
blood investigations for gi perforation
fbc: neutrophilic leukocytosis
possible elevation of urea and creatine
vbg - lactic acidosis
what imaging is used to investigate gi perforations
erect cxr - check for subdiaphragmatic free air (pneumoperitoneum)
ct abdo/pelvis - pneumoperitoneum, free gi content, localised mesenteric fat stranding
- can exclude common differential diagnoses e.g pancreatitis
what are some differential diagnosis for gi perforation
acute cholecystitis
appendicitis
mi
acute pancreatitis
what is the supportive management for gi perforations on presentation
nbm and ng tube iv peripheral access with large bore canuula - iv fluid resuscitation broad spectrum antibiotics iv ppi paraenteral analgesia and amt emetics urinary catheter
what is the conservative management in localised peritonitis without signs of sepsis
* very rare
ir - guided drainage of intraabdominal collection
serial abdominal examination and abdominal imaging for assessment
surgical management in generalised peritonitis +- signs of sepsis
exploratory laparotomy/ laparoscopy
primary closure of perforation with/without omental patch
resection of perforated segment of bowel with primary anastmosis/temporary stoma
obtain intra abdominal fluid for mc and s, peritoneal lavage
what is the surgery for perforated appendix
laparoscopy or open appendicectomy
what is the surgical management for malignancy in gi perforation
intraoperative biopsies if possible
symptoms of biliary colic
postprandial ruq pain with radiation to shoulder
nausea
expect to see in investigations of biliary colic
normal blood results
uss: cholelithiasis
symptoms of acute cholecystitis
acute, severe ruq pain
fever
murphys sign
what would you expect to see in investigations of acute cholecystitis
elevated wcc/crp
uss - thickened gallbladder wall
how to manage acute cholecystitis
fluids antibiotics analgesia blood cultures early or elective cholecystectomy (4-6wks)
symptoms of acute cholangitis
charcots triad: jaundice, ruq pain and fever
what would you expect to see in investigations of acute cholangitis
elevated lfts,wcc,crp, blood mcs (positive)
uss: biliary dilation
management of acute cholangitis
fluids
iv antibiotics
analgesia
ercp within 72hrs for clearance of bileduct/stenting
what are the symptoms of acute pancreatitis
severe epigastric pain radiating to back
nausea +- vomiting
history of gallstones and ethanol use
what do you expect to find in investigations for acute pancreatitis
raised amylase/lipase
high wcc/ low calcium
ct and us to assess for complications/cause
what is the management for acute pancreatitis
admission score - glasglow imrie
aggressive fluid resusitation,o2
analgesia and antiemetics
itu/hdu involvement
