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GASTROENTEROLOGY 2 > GENERAL SURGERY IN GI TRACT > Flashcards

GENERAL SURGERY IN GI TRACT Flashcards

1
Q

What are the risk factors of bowel ischaemia?

A 
Age > 65 years
Cardiac arrythmias (AF)
Atherosclerosis
Hypercoagulation/thrombophilia
Vasculitis
Sickle cell disease
Profound shock causing hypotension
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2
Q

How does bowel ischaemia present?

A

Crampy abdominal pain depending on length and thickness of bowel affected
Bloody, loose stool (currant jelly stools)
Fever, signs a septic shock

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3
Q

How does acute mesenteric ischaemia usually occur?

A

Occlusion - usually SMA - due to thromboemboli

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4
Q

How does acute mesenteric ischaemia present specifically?

A

Sudden onset with abdominal pain out of proportion of clinical signs

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5
Q

How does acute ichaemic colitis usually occur?

A

Non-occlusive low flow states or atherosclerosis

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6
Q

How does ischaemic colitis present specifically?

A

Mild and gradual with moderate pain and tenderness

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7
Q

What investigations can you undertake for a patient with bowel ischaemia?

A

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

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8
Q

What is the conservative management for mild to moderate cases of ischaemic colitis?

A

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

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9
Q

What are the indications for surgery in bowel ischaemia?

A 
Small bowel ischaemia
Signs of peritonitis/sepsis
Haemodynamic instability
Massive bleeding
Fulminant colitis with toxic megacolon
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10
Q

What surgical procedures can be done for bowel ischaemia?

A

Exploratory laparotomy:
- resection of necrotic bowel +/- open surgical
embolectomy or mesenteric arterial bypass

Endovascular revascularisation:

  • Balloon angioplasty/thrombectomy
  • More for patients with chronic ischaemia
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11
Q

How does acute appendicitis present?

A 
Initially periumbilical pain that migrates to RLQ
Anorexia
Nausea +/- vomiting
Low grade fever
Change in bowel habit
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12
Q

Why can appendicitis cause a change in bowel habit?

A

Inflamed appendix is adjacent to rectum and can irritate it

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13
Q

List the important clinical signs of acute appendicitis and what they are

A

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

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14
Q

What investigations can be done for a patient suspected with acute appendicitis?

A

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

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15
Q

What can be used to guage how likely a patient has acute appendicitis?

A

Alvarado score

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16
Q

What is the conservative management for a patient with acute appendicitis?

A

IV fluid
Analgesia
IV/PO antibiotics

If abscess, phlegmon or seal perforation:
- resuscitation + IV antibiotics +/- percutaneous drainage

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17
Q

If a patient has delayed presentation of acute appendicitis with abscess/phlegmon formation what should be done?

A

Conservative management:

  • CT guided drainage
  • Antibiotics
  • Interval appendicectomy
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18
Q

Why is laparoscopic appendicectomy usually better than open appendicectomy in acute appendicitis?

A 
Less pain
Lower incidence of surgical infection
Decreased hospital stay
Earlier return to work
Overall costs
Better QOL score
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19
Q

List the steps for laparoscopic appendicectomy

A
  1. Trocars placement
  2. Explore RIF and identify appendix
  3. Elevate appendix and divide mesoappendix
  4. Secure base with endoloops and divide appendix
  5. Retrieve appendix with plastic retrieval bag
  6. Inspect rest of pelvic organs/intestines
  7. Pelvic irrigation + haemostasis
  8. Removal of trocars and wound closure
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20
Q

What are the two types of bowel obstruction?

A

Paralytic ileus - abdo full of pus causing irritation and prevents peristalsis until infection is gone

Mechanical

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21
Q

How is mechanical intestinal obstruction classified?

A

Speed of onset - acute, chronic, acute-on-chronic
Site - high or low (small or large bowel)
Nature - simple vs strangulating

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22
Q

What is the difference between simple and strangulating mechanical bowel obstruction?

A

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

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23
Q

What is the aetiology of mechanical bowel obstruction?

A

Lumen causes:

  • faecal impaction
  • gallstone ileus

Wall causes:

  • Crohn’s disease
  • Tumours
  • Diverticulitis

Causes outside of wall:

  • Strangulated hernia
  • Volvulus
  • Adhesions/bands
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24
Q

What is the aetiology of small bowel obstruction?

A 
Adhesions (60%)
Neoplasia (20%)
Incarcerated hernia (10%)
Crohn's disease (5%)
Other - intussusception, intraluminal (5%)
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25
Q

What is the aetiology of large bowel obstruction?

A

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

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26
Q

What are the symptoms of small bowel obstruction?

A

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

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27
Q

What are the symptoms of large bowel obstruction?

A

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

28
Q

How is bowel obstruction diagnosed?

A

Presence of symptoms

29
Q

What features suggest strangulation in intestinal obstruction?

A

Hernias
Abdominal scars

Change in pain from colicky to continuous
Tachycardia
Pyrexia
Peritonism
Bowel sounds absent/reduced
Leucocytosis
Increased C-reactive protein
30
Q

What does strangulated hernia cause and what increases the risk of strangulation?

A

Ischaemic bowel

The smaller the neck of the hernia sac the greater the risk of strangulation

31
Q

What is richter’s hernia?

A

Herniation of only a portion of the circumference of the bowel wall. Doesn’t cause obstruction of strangulation

32
Q

What some common sites of hernias?

A 
Epigastric
Umbilical
Incisional - skin healed but muscle still has defect
Inguinal
Femoral
33
Q

What are the investigations that you can do for a patient suspected with bowel obstruction?

A

If strangulation:

  • WCC/CRP raised
  • Lactic acidosis (VBG)

If vomiting:

  • Electrolyte imbalance
  • HypoCl-, HypoK+, metabolic alkalosis

Erect CXR/AXR
CT abdo/pelvis

34
Q

What do you expect to see on an abdominal xray in a patient with small bowel obstruction?

A

Ladder pattern of dilated loops and central position

Striations that pass across width of distended loops > 3cm produced by circular mucosal folds

35
Q

What do you expect to see on an abdominal xray in a patient with large bowel obstruction?

A

Distended large bowel usually lies peripherally

Haustrations of taenia coli - don’t extend across whole width of bowel

36
Q

What is the purpose of CT scan in a patient with bowel obstruction?

A

Can localise site of obstruction
Detect obstructing lesions and colonic tumours
May diagnose unusual hernias

37
Q

What do you expect to see on a CT scan of a patient with bowel obstruction?

A

Collapse and proximal loop dilatation due to transition point in pelvis

38
Q

In which bowel obstruction patients is conservative management employed?

A

Patients with no signs of ischaemia/clinical deterioration

39
Q

What is the supportive management of bowel obstruction?

A 
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
40
Q

What is the conservative management of bowel obstruction?

A 
Stool evacuation (faecal impaction)
Rigid sigmoidoscopic decompression (sigmoid volvulus)
Oral gastrograffin (adhesional small bowel obstruction)
41
Q

What are the indications for surgery in a patient with bowel obstruction?

A

Haemodynamic instability
Signs of sepsis
Complete bowel obstruction with ischaemia
Closed loop obstruction
Persistant bowel obstruction > 2 days despite conservative management

42
Q

What procedures can be done for a patient with bowel obstruction?

A

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

43
Q

How do GI perforations present?

A 
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
44
Q

How does a perforated peptic ulcer specifically present and what increases the risk?

A

Sudden epigastric/diffuse pain
Referred shoulder pain (irritation of diaphragm)

History of NSAIDs, steroids, recurrent epigastric pain

45
Q

How does a perforated diverticulum of large bowel specifically present?

A

Insidious onset
LLQ pain
Constipation

46
Q

How does a perforated appendix specifically present?

A

Migratory pain
Anorexia
Gradual worsening RLQ pain

47
Q

How does a perforated malignancy specifically present?

A

Change in bowel habit
Weight loss
Anorexia
PR bleeding

48
Q

What investigations can be done for a patient suspected with GI perforation?

A

FBC: neutrophilic leukocytosis
Maybe elevation of urea/creatinine
VBG: lactic acidosis

Erect CXR: subdiaphragmatic free air (pneumoperitoneum)
CT abdo/pelvis: pneumoperitoneum, localised fat stranding

49
Q

What is the purpose of imaging in a patient with GI perforation?

A

Localises where perforation might be

Can exclude common differential diagnoses

50
Q

What are the differential diagnoses of GI perforation?

A

Acute cholecystitis
Appendicitis
Myocardial infarction
Acute pancreatitis

51
Q

Describe supportive therapy for patients with GI perforation

A

Done on presentation:

  • Nil by mouth + NG tube
  • IV fluid resuscitation
  • IV PPI
  • Broad spec antibiotics
  • Parenteral analgesia + antiemetics
  • Urinary catheter
52
Q

What does conservative management in a patient with GI perforation and LOCALISED peritonitis without signs of sepsis look like?

A

Interventional radiopathy - guided percutaneous drainage of intra-abdominal collection

Serial abdominal examination and abdo imaging for assessment

53
Q

What does surgery for a patient with GI perforation and GENERALISED peritonitis +/- signs of sepsis involve?

A

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

54
Q

What are the symptoms of biliary colic?

A

Post prandial RUQ pain with shoulder radiation

Nausea

55
Q

What are the symptoms of acute cholecystitis?

A

Acute, severe RUQ pain
Fever
Murphy’s sign

56
Q

What are the symptoms of biliary cholangitis?

A

Charcot’s triad:

  • jaundice
  • RUQ pain
  • fever
57
Q

What are the symptoms of acute pancreatitis?

A

Severe epigastric pain with back radiation
Nausea +/- vomiting
History of gallstones or ethanol use

58
Q

What investigations are done for a patient with biliary colic?

A

Normal blood

USS: cholelithiasis

59
Q

What investigations are done for a patient with acute cholecystitis?

A

Elevated WCC/CRP

USS: thickened gallbladder wall

60
Q

What investigations are done for a patient with acute cholangitis?

A

Elevated LFTs, WCC, CRP
+ve MCS
USS: biliary dilation

61
Q

What investigations are done for a patient with acute pancreatitis?

A

Raised amylase/lipase
High WCC/Low Ca2+
CT/USS for complications/cause

62
Q

What is the management for a patient with biliary colic?

A

Analgesia, antiemetics, spasmolytics

Follow up for elective cholecystectomy

63
Q

What is the management for a patient with acute cholecystitis?

A

Fluids, antibiotics, analgesia, blood cultures

Early or elective cholecystectomy

64
Q

What is the management for a patient with acute cholangitis?

A

Fluids, IV antibiotics, analgesia

ERCP for clearance of bile duct or stenting

65
Q

What is the management for a patient with acute pancreatitis?

A 
Admission score (glascow-imrie)
Aggressive fluid resuscitation 
O2
Analgesia, antiemetics
ITU/HDU involvement

GASTROENTEROLOGY 2 (7 decks)

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