General surgery in GI tract Flashcards
how to interpret abdominal pain
SOCRATES pain assessment
PMHx/ DHx/ SHx
Investigations - bloods/ urinalysis/ imaging/ endoscopy
Management - ABCDE/ conservative/ surgical
RUQ pain
biliary colic
cholecystitis
acute hepatitis
Epigastrium pain
acute gastritis
peptic ulcer disease
acute pancreatitis
LUQ pain
Peptic ulcer
acute pancreatitis
RLQ pain
acute appendicitis
colitis
IBD
Suprapubic/ central pain
early appendicitis
bowel obstruction
LLQ pain
diverticulitis
colitis
IBD
what is bowel ischaemia presentation
sudden crampy pain
bloody, loose stool
fever - signs of septic shocl
risk factors for bowel ischaemia
age over 65 cardiac arrythmias sickle cell disease vasculitis shock - hypotension
what is acute mesenteric ischaemia
small bowel - usually occlusive due to thromboemboli
SUDDEN ONSET
what is ischaemic colitis
large bowel - usually due to non-occlusive low flow states
MILD/ GRADUAL ONSET
What are the investigations of bowel ischaemia
Bloods - lactic acidosis
Imaging - disrupted flow/ vascular stenosis/ detects
Endoscopy - ulceration of mucosa/ oedema
what is the conservative management of bowel ischaemia?
IV fluid resuscitation Bowel rest - nil by mouth broad spectrum AB - sepsis anticoagulation serial abdo examination + repeat imaging
what is the surgical management of bowel ischaemia?
exploratory laparotomy - resection of necrotic bowel
endovascular revasculisation - balloon angioplasty - in patients without signs of ischaemia
presentation of acute appendicitis?
periumbilical pain that migrates to RLQ
anorexia
nausea
Clinical signs of appendicitis
mcburney’s point - tenderness in RLQ
Blumberg sign - rebound tenderness in RIF
Rovsing sign - RLQ pain on palpitation of LLQ
Psoas sign - RLQ pain on flexion of right hip against resistance
Obturator sign - RLQ pain on passive internal rotation of hip
Investigations for acute appendicitis
Bloods - raised neutrophils/ CRP/ urinalysis + electrolyte imbalance
Imaging - CT/USS/MRI
Diagnostic laparoscopy - persistent pain + inconclusive imaging
what is the criteria for appendicitis
alvarado score
more than/ equal to 7 = likely
conservative management of appendicitis
IV fluids
analgesia
PO AB
Surgical management of appendicitis
Laparoscopic appendicectomy
Open appendicectomy
what is bowel obstruction
intestinal obstruction - restriction of the normal passage of intestinal contents
what are the main groups of bowel obstruction
paralytic - stops working (irritation of the ileus)
Mechanical
most common cause of small bowel obstruction
adhesions
neoplasia
most common cause of large bowel obstruction
colorectal carcinoma
volvulus - intestine twists around itself and the mesentery that supports it, creating an obstruction
presentation of bowel obstruction
abdo pain
vomiting
absolute constipation
abdominal distention
how is bowel obstruction diagnosed
presence of symptoms
examination should always include a search for hernia + abdo scars
simple or strangulating
pain changes from colicky to continuous
where are common areas for hernias
epigastric umbilical incisional inguinal femoral
how does a hernia occur
neck of sac turns to strangulated hernia - lack of venous return = dead bowel
investigations for bowel obstruction
Bloods:
- metabolic acidosis (lactate)
- electrolyte imbalance - vomiting
WCC/ CRP is usually normal
Imaging:
- CXR/ AXR - dilated bowel loops
CT abdo/ pelvis - dilatation of proximal loops
conservative management for bowel obstruction
nil by mouth
IV fluids - correction of electrolyte imbalance + analgesia
NG tube for decompression
catheter for monitoring output
introduce gradual food intake if abdo pain improves
what is gastrograffin
osmolar iodinated contrast agent - can resolve adhesional small bowel obstruction
what are the surgical interventions for bowel obstruction
exploratory laparoscopy/ laparotomy
restoration of intestinal transit
bowel resection with primary anastomosis
endoscopic stenting
when do you implement surgical interventions for bowel obstruction
signs of sepsis
closed loop obstruction !!
persistent bowel obstruction for more than 2 days despite conservative management
complete bowel obstruction with ischaemia
what is a GI perforation presentation
sudden onset with severe abdo pain
abdo rigid + guarding
nausea + vomiting
Pain aggravated by movement
investigations for a GI perforation
bloods - lactic acidosis + elevation of urea + creatinine
Imaging - free air on CXR/ CT abdo
conservative management for GI perforation
NG tube IV fluid resus Broad spectrum Abx IV PPI catheter analgesia
surgical management for GI perforation
exploratory laparoscopy/ laparotomy
primary closure of perforation
resection of perforated segment
LAVAGE
what is sigmoid volvulus
Large, elongated, relatively atonic colon, particularly in the sigmoid segment
large bowel obstruction
conservative management for sigmoid volvulus
sigmoidoscope passed with patient lying in left lateral position + soft rubber rectal tube passed along sigmoidoscope + untwists volvulus + flatus + liquid faeces released
what to do if conservative management doesn’t work for sigmoid volvulus
exploratory laparoscopy + sigmoid colectomy with end colostomy (hartmann’s procedure)
what is portal pyaemia
septic thrombophlebitis of portal venous system
