General surgery in GI tract

Question 1

how to interpret abdominal pain

Answer 1

SOCRATES pain assessment
PMHx/ DHx/ SHx
Investigations - bloods/ urinalysis/ imaging/ endoscopy
Management - ABCDE/ conservative/ surgical

Question 2

RUQ pain

Answer 2

biliary colic
cholecystitis
acute hepatitis

Question 3

Epigastrium pain

Answer 3

acute gastritis
peptic ulcer disease
acute pancreatitis

Question 4

LUQ pain

Answer 4

Peptic ulcer

acute pancreatitis

Question 5

RLQ pain

Answer 5

acute appendicitis
colitis
IBD

Question 6

Suprapubic/ central pain

Answer 6

early appendicitis

bowel obstruction

Question 7

LLQ pain

Answer 7

diverticulitis
colitis
IBD

Question 8

what is bowel ischaemia presentation

Answer 8

sudden crampy pain
bloody, loose stool
fever - signs of septic shocl

Question 9

risk factors for bowel ischaemia

Answer 9

age over 65
cardiac arrythmias
sickle cell disease
vasculitis
shock - hypotension

Question 10

what is acute mesenteric ischaemia

Answer 10

small bowel - usually occlusive due to thromboemboli

SUDDEN ONSET

Question 11

what is ischaemic colitis

Answer 11

large bowel - usually due to non-occlusive low flow states

MILD/ GRADUAL ONSET

Question 12

What are the investigations of bowel ischaemia

Answer 12

Bloods - lactic acidosis
Imaging - disrupted flow/ vascular stenosis/ detects
Endoscopy - ulceration of mucosa/ oedema

Question 13

what is the conservative management of bowel ischaemia?

Answer 13

IV fluid resuscitation
Bowel rest - nil by mouth
broad spectrum AB - sepsis
anticoagulation
serial abdo examination + repeat imaging

Question 14

what is the surgical management of bowel ischaemia?

Answer 14

exploratory laparotomy - resection of necrotic bowel

endovascular revasculisation - balloon angioplasty - in patients without signs of ischaemia

Question 15

presentation of acute appendicitis?

Answer 15

periumbilical pain that migrates to RLQ
anorexia
nausea

Question 16

Clinical signs of appendicitis

Answer 16

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

Question 17

Investigations for acute appendicitis

Answer 17

Bloods - raised neutrophils/ CRP/ urinalysis + electrolyte imbalance
Imaging - CT/USS/MRI
Diagnostic laparoscopy - persistent pain + inconclusive imaging

Question 18

what is the criteria for appendicitis

Answer 18

alvarado score

more than/ equal to 7 = likely

Question 19

conservative management of appendicitis

Answer 19

IV fluids
analgesia
PO AB

Question 20

Surgical management of appendicitis

Answer 20

Laparoscopic appendicectomy

Open appendicectomy

Question 21

what is bowel obstruction

Answer 21

intestinal obstruction - restriction of the normal passage of intestinal contents

Question 22

what are the main groups of bowel obstruction

Answer 22

paralytic - stops working (irritation of the ileus)

Mechanical

Question 23

most common cause of small bowel obstruction

Answer 23

adhesions

neoplasia

Question 24

most common cause of large bowel obstruction

Answer 24

colorectal carcinoma

volvulus - intestine twists around itself and the mesentery that supports it, creating an obstruction

Question 25

presentation of bowel obstruction

Answer 25

abdo pain vomiting absolute constipation abdominal distention

Question 26

how is bowel obstruction diagnosed

Answer 26

presence of symptoms examination should always include a search for hernia + abdo scars simple or strangulating pain changes from colicky to continuous

Question 27

where are common areas for hernias

Answer 27

``` epigastric umbilical incisional inguinal femoral ```

Question 28

how does a hernia occur

Answer 28

neck of sac turns to strangulated hernia - lack of venous return = dead bowel

Question 29

investigations for bowel obstruction

Answer 29

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

Question 30

conservative management for bowel obstruction

Answer 30

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

Question 31

what is gastrograffin

Answer 31

osmolar iodinated contrast agent - can resolve adhesional small bowel obstruction

Question 32

what are the surgical interventions for bowel obstruction

Answer 32

exploratory laparoscopy/ laparotomy restoration of intestinal transit bowel resection with primary anastomosis endoscopic stenting

Question 33

when do you implement surgical interventions for bowel obstruction

Answer 33

signs of sepsis closed loop obstruction !! persistent bowel obstruction for more than 2 days despite conservative management complete bowel obstruction with ischaemia

Question 34

what is a GI perforation presentation

Answer 34

sudden onset with severe abdo pain abdo rigid + guarding nausea + vomiting Pain aggravated by movement

Question 35

investigations for a GI perforation

Answer 35

bloods - lactic acidosis + elevation of urea + creatinine | Imaging - free air on CXR/ CT abdo

Question 36

conservative management for GI perforation

Answer 36

``` NG tube IV fluid resus Broad spectrum Abx IV PPI catheter analgesia ```

Question 37

surgical management for GI perforation

Answer 37

exploratory laparoscopy/ laparotomy primary closure of perforation resection of perforated segment LAVAGE

Question 38

what is sigmoid volvulus

Answer 38

Large, elongated, relatively atonic colon, particularly in the sigmoid segment large bowel obstruction

Question 39

conservative management for sigmoid volvulus

Answer 39

sigmoidoscope passed with patient lying in left lateral position + soft rubber rectal tube passed along sigmoidoscope + untwists volvulus + flatus + liquid faeces released

Question 40

what to do if conservative management doesn't work for sigmoid volvulus

Answer 40

exploratory laparoscopy + sigmoid colectomy with end colostomy (hartmann's procedure)

Question 41

what is portal pyaemia

Answer 41

septic thrombophlebitis of portal venous system