GENERAL SURGERY IN GI TRACT Flashcards
What are the risk factors of bowel ischaemia?
Age > 65 years Cardiac arrythmias (AF) Atherosclerosis Hypercoagulation/thrombophilia Vasculitis Sickle cell disease Profound shock causing hypotension
How does bowel ischaemia present?
Crampy abdominal pain depending on length and thickness of bowel affected
Bloody, loose stool (currant jelly stools)
Fever, signs a septic shock
How does acute mesenteric ischaemia usually occur?
Occlusion - usually SMA - due to thromboemboli
How does acute mesenteric ischaemia present specifically?
Sudden onset with abdominal pain out of proportion of clinical signs
How does acute ichaemic colitis usually occur?
Non-occlusive low flow states or atherosclerosis
How does ischaemic colitis present specifically?
Mild and gradual with moderate pain and tenderness
What investigations can you undertake for a patient with bowel ischaemia?
FBC: neutrophilic leukocytosis
VBG: lactic acidosis (late stage mesenteric ischaemia)
CTAP/CT angiogram: disrupted flow, vascular stenosis, transmural ischaemia/infarction, thumbprint sign in IC
Endoscopy for mild/moderate cases of IC
What is the conservative management for mild to moderate cases of ischaemic colitis?
IV fluid resuscitation
Bowel rest - nil by mouth
Broad spec antibodies (IC can cause sepsis)
NG tube for decompression for concurrent ileus
Anticoagulation
Treat/manage underlying cause
Serial abdo examination and repeat imaging
What are the indications for surgery in bowel ischaemia?
Small bowel ischaemia Signs of peritonitis/sepsis Haemodynamic instability Massive bleeding Fulminant colitis with toxic megacolon
What surgical procedures can be done for bowel ischaemia?
Exploratory laparotomy:
- resection of necrotic bowel +/- open surgical
embolectomy or mesenteric arterial bypass
Endovascular revascularisation:
- Balloon angioplasty/thrombectomy
- More for patients with chronic ischaemia
How does acute appendicitis present?
Initially periumbilical pain that migrates to RLQ Anorexia Nausea +/- vomiting Low grade fever Change in bowel habit
Why can appendicitis cause a change in bowel habit?
Inflamed appendix is adjacent to rectum and can irritate it
List the important clinical signs of acute appendicitis and what they are
McBurney’s point: RLQ tenderness
Blumberg sign: rebound tenderness esp RIF
Rovsing sign: RLQ pain on deep palpation of LLQ
Psoas sign: RLQ pain on flexion of right hip against res
Obturator sign: RLQ pain on passive internal rotation of hip with hip and knee flexion
What investigations can be done for a patient suspected with acute appendicitis?
FBC: neutrophilic leukocytosis
Raised CRP
Urinalysis: possible mild pyuria/haematuria
Electrolyte imbalance in profound vomiting
CT - gold standard in adults
USS - children, pregnancy, breast feeding
MRI - in pregnancy is USS inconclusive
Diagnostic Laparoscopy - persistent pain and inconclusive imaging
What can be used to guage how likely a patient has acute appendicitis?
Alvarado score
What is the conservative management for a patient with acute appendicitis?
IV fluid
Analgesia
IV/PO antibiotics
If abscess, phlegmon or seal perforation:
- resuscitation + IV antibiotics +/- percutaneous drainage
If a patient has delayed presentation of acute appendicitis with abscess/phlegmon formation what should be done?
Conservative management:
- CT guided drainage
- Antibiotics
- Interval appendicectomy
Why is laparoscopic appendicectomy usually better than open appendicectomy in acute appendicitis?
Less pain Lower incidence of surgical infection Decreased hospital stay Earlier return to work Overall costs Better QOL score
List the steps for laparoscopic appendicectomy
- Trocars placement
- Explore RIF and identify appendix
- Elevate appendix and divide mesoappendix
- Secure base with endoloops and divide appendix
- Retrieve appendix with plastic retrieval bag
- Inspect rest of pelvic organs/intestines
- Pelvic irrigation + haemostasis
- Removal of trocars and wound closure
What are the two types of bowel obstruction?
Paralytic ileus - abdo full of pus causing irritation and prevents peristalsis until infection is gone
Mechanical
How is mechanical intestinal obstruction classified?
Speed of onset - acute, chronic, acute-on-chronic
Site - high or low (small or large bowel)
Nature - simple vs strangulating
What is the difference between simple and strangulating mechanical bowel obstruction?
Simple - bowel occluded without damage to blood supply
Strangulating - blood supply of involved segment of intestine is cut off e.g. volvulus, intussusception, strangulating hernia
What is the aetiology of mechanical bowel obstruction?
Lumen causes:
- faecal impaction
- gallstone ileus
Wall causes:
- Crohn’s disease
- Tumours
- Diverticulitis
Causes outside of wall:
- Strangulated hernia
- Volvulus
- Adhesions/bands
What is the aetiology of small bowel obstruction?
Adhesions (60%) Neoplasia (20%) Incarcerated hernia (10%) Crohn's disease (5%) Other - intussusception, intraluminal (5%)
What is the aetiology of large bowel obstruction?
Colorectal cancer - usually left side (RHS can expand)
Volvulus
Diverticulitis
Faecal impaction
Hirschsprung disease - no nerve cell ganglion in segment of bowel so no peristalsis
What are the symptoms of small bowel obstruction?
Colicky, central abdo pain
Early onset, bilious vomiting
Constipation (late sign)
Less significant abdo distention
Dehydration
High pitched tinkling bowel sounds (early) or absent bowel sounds (late)
Diffuse abdo tenderness
What are the symptoms of large bowel obstruction?
Colicky or constant pain
Late onset, initially bilious then faecal vomiting
Constipation (early sign)
Abdominal distention (early sign, significant)
Dehydration
High pitched tinkling bowel sounds (early) or absent bowel sounds (late)
Diffuse abdo tenderness
How is bowel obstruction diagnosed?
Presence of symptoms
What features suggest strangulation in intestinal obstruction?
Hernias
Abdominal scars
Change in pain from colicky to continuous Tachycardia Pyrexia Peritonism Bowel sounds absent/reduced Leucocytosis Increased C-reactive protein
What does strangulated hernia cause and what increases the risk of strangulation?
Ischaemic bowel
The smaller the neck of the hernia sac the greater the risk of strangulation
What is richter’s hernia?
Herniation of only a portion of the circumference of the bowel wall. Doesn’t cause obstruction of strangulation
What some common sites of hernias?
Epigastric Umbilical Incisional - skin healed but muscle still has defect Inguinal Femoral
What are the investigations that you can do for a patient suspected with bowel obstruction?
If strangulation:
- WCC/CRP raised
- Lactic acidosis (VBG)
If vomiting:
- Electrolyte imbalance
- HypoCl-, HypoK+, metabolic alkalosis
Erect CXR/AXR
CT abdo/pelvis
What do you expect to see on an abdominal xray in a patient with small bowel obstruction?
Ladder pattern of dilated loops and central position
Striations that pass across width of distended loops > 3cm produced by circular mucosal folds
What do you expect to see on an abdominal xray in a patient with large bowel obstruction?
Distended large bowel usually lies peripherally
Haustrations of taenia coli - don’t extend across whole width of bowel
What is the purpose of CT scan in a patient with bowel obstruction?
Can localise site of obstruction
Detect obstructing lesions and colonic tumours
May diagnose unusual hernias
What do you expect to see on a CT scan of a patient with bowel obstruction?
Collapse and proximal loop dilatation due to transition point in pelvis
In which bowel obstruction patients is conservative management employed?
Patients with no signs of ischaemia/clinical deterioration
What is the supportive management of bowel obstruction?
Nil by mouth IV fluid resuscitation with electrolytes IV analgesia, antiemetics NG tube - decompression Urinary catheter to monitor output Introduce gradual food if abdominal pain and distention improve
What is the conservative management of bowel obstruction?
Stool evacuation (faecal impaction) Rigid sigmoidoscopic decompression (sigmoid volvulus) Oral gastrograffin (adhesional small bowel obstruction)
What are the indications for surgery in a patient with bowel obstruction?
Haemodynamic instability
Signs of sepsis
Complete bowel obstruction with ischaemia
Closed loop obstruction
Persistant bowel obstruction > 2 days despite conservative management
What procedures can be done for a patient with bowel obstruction?
Exploratory laparotomy/laparoscopy
Restoration of intestinal transit depending on intra-op findings
Necrotic bowel resection with primary anastamosis or temporary/permanent stoma formation
Endoscopic stenting - instead of surgery if obstruction is distal and usually reserved for patients with tumours
How do GI perforations present?
Sudden onset severe abdominal pain with distention Diffuse abdo guarding, rigidity, rebound tenderness Pain worsened by movement Nausea Vomiting Absolute constipation due to ileus Fever Tachycardia Tachypnoea Hypotension Decreased/absent bowel sounds
How does a perforated peptic ulcer specifically present and what increases the risk?
Sudden epigastric/diffuse pain
Referred shoulder pain (irritation of diaphragm)
History of NSAIDs, steroids, recurrent epigastric pain
How does a perforated diverticulum of large bowel specifically present?
Insidious onset
LLQ pain
Constipation
How does a perforated appendix specifically present?
Migratory pain
Anorexia
Gradual worsening RLQ pain
How does a perforated malignancy specifically present?
Change in bowel habit
Weight loss
Anorexia
PR bleeding
What investigations can be done for a patient suspected with GI perforation?
FBC: neutrophilic leukocytosis
Maybe elevation of urea/creatinine
VBG: lactic acidosis
Erect CXR: subdiaphragmatic free air (pneumoperitoneum)
CT abdo/pelvis: pneumoperitoneum, localised fat stranding
What is the purpose of imaging in a patient with GI perforation?
Localises where perforation might be
Can exclude common differential diagnoses
What are the differential diagnoses of GI perforation?
Acute cholecystitis
Appendicitis
Myocardial infarction
Acute pancreatitis
Describe supportive therapy for patients with GI perforation
Done on presentation:
- Nil by mouth + NG tube
- IV fluid resuscitation
- IV PPI
- Broad spec antibiotics
- Parenteral analgesia + antiemetics
- Urinary catheter
What does conservative management in a patient with GI perforation and LOCALISED peritonitis without signs of sepsis look like?
Interventional radiopathy - guided percutaneous drainage of intra-abdominal collection
Serial abdominal examination and abdo imaging for assessment
What does surgery for a patient with GI perforation and GENERALISED peritonitis +/- signs of sepsis involve?
Exploratory laparotomy/laparascopy
Intra-abdo fluid for culture and peritoneal lavage
Primary closure of perforation with/out omental patch (commonly in perforated peptic ulcer)
Resection of perforated segment with primary anastamoses/temporary stoma (usually perforated diverticulum)
Laparoscopic/open appendicectomy is perforated appendix
Intraoperative biopsy if malignancy
What are the symptoms of biliary colic?
Post prandial RUQ pain with shoulder radiation
Nausea
What are the symptoms of acute cholecystitis?
Acute, severe RUQ pain
Fever
Murphy’s sign
What are the symptoms of biliary cholangitis?
Charcot’s triad:
- jaundice
- RUQ pain
- fever
What are the symptoms of acute pancreatitis?
Severe epigastric pain with back radiation
Nausea +/- vomiting
History of gallstones or ethanol use
What investigations are done for a patient with biliary colic?
Normal blood
USS: cholelithiasis
What investigations are done for a patient with acute cholecystitis?
Elevated WCC/CRP
USS: thickened gallbladder wall
What investigations are done for a patient with acute cholangitis?
Elevated LFTs, WCC, CRP
+ve MCS
USS: biliary dilation
What investigations are done for a patient with acute pancreatitis?
Raised amylase/lipase
High WCC/Low Ca2+
CT/USS for complications/cause
What is the management for a patient with biliary colic?
Analgesia, antiemetics, spasmolytics
Follow up for elective cholecystectomy
What is the management for a patient with acute cholecystitis?
Fluids, antibiotics, analgesia, blood cultures
Early or elective cholecystectomy
What is the management for a patient with acute cholangitis?
Fluids, IV antibiotics, analgesia
ERCP for clearance of bile duct or stenting
What is the management for a patient with acute pancreatitis?
Admission score (glascow-imrie) Aggressive fluid resuscitation O2 Analgesia, antiemetics ITU/HDU involvement
