General Surgery in GI tract Flashcards
When checking for acute abdomen, how do you take a pain assessment and what else do you checkl
SOCRATES:
Site
Onset
Character
Radiation
Association
Time course
Exacerbating/Relieving factors
Severity
PMH
DH
SH
What are investigations for acute abdomen
Bloods: VBG, FBC, CRP, U&Es (renal profile), LFTs +amylase
Urinalysis + Urine MC&S
Imaging: Erect CXR, AXR, CTAP, CT angiogram, USS
Endoscopy
What is the management for acute abdomen
ABCDE approach
Conservative management
Surgical management
What is the presentation of bowel ischaemia?
Sudden onset crampy abdominal pain
Severity of pain depends on the length and thickness of colon affected
Bloody, loose stool (currant jelly stools)
Fever, signs of septic shock
What are the risk factors for bowel ischaemia?
Age >65 yr
Cardiac arrythmias (mainly AF), atherosclerosis
Hypercoagulation/thrombophilia
Vasculitis
Sickle cell disease
Profound shock causing hypotension
What is the difference between acute mesenteric ischaemia and ischaemic colitis
Acute/colitis
Small bowel
Occlusive due to thromboemboli / non-occlusive local flow states, or atherosclerosis
Sudden onset
Abdominal pain out of proportion of clinical signs/ moderate and tenderness
What investigations can you do for bowel ischaemia
Bloods
Imaging - CTAP/ CT Angiogram
Endoscopy
What are you checking for in bloods for bowel ischaemia
FBC: neutrophilic leukocytosis
VBG: Lactic acidosis (late sign so bowel already dead)
What are you trying to detect in imaging for bowel ischaemia
Disrupted flow
Vascular stenosis
‘Pneumatosis intestinalis’ (transmural ischaemia/infarction)
Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)
What is the purpose of endoscopy in bowel ischaemia
For mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)
What does the conservative management of bowel ischaemia in mild to moderate cases of ischaemic colitis (not SB ischaemia)
IV fluid resuscitation
Bowel rest
Broad-spectrum ABx - colonic ischaemia can result in bacterial translocation & sepsis
NG tube for decompression - in concurrent ileus
Anticoagulation
Treat/manage underlying cause
Serial abdominal examination and repeat imaging
What are the indications of bowel ischaemia in surgical management
Small bowel ischaemia
Signs of peritonitis orsepsis
Haemodynamic instability
Massive bleeding
Fulminant colitis with toxic megacolon
What do you do in surgical management for bowel ischaemia
Exploratory laparotomy:
-Resection of necrotic bowel +/-open surgicalembolectomy
or mesenteric arterial bypass
Endovascular revascularisation:
-Balloon angioplasty/thrombectomy
-In patients without signs of ischaemia
How is acute appendicitis presented and what are the clinical signs
Initially periumbilical pain that migrates to RLQ (within 24hours)
Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit
Important clinical signs:
McBurney’s point: tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
Blumberg sign: rebound tenderness especially in the RIF
Rovsing sign: RLQ pain elicited on deep palpation of the LLQ
Psoas sign: RLQ pain elicited on flexion of right hip against resistance
Obturator sign: RLQ pain on passive internal rotation of the hip with hip & knee flexion
What are the investigations for acute appendicitis
Bloods
Imaging
Diagnostic laparoscopy
What do bloods show with acute appendicitis
FBC: neutrophilic leukocytosis
↑ed CRP
Urinalysis: possible mild pyuria/haematuria
Electrolyte imbalances in profound vomiting
Wha are type of imagining for investigating acute appendicitis
CT: gold standard in adults esp. if age > 50
USS: children/pregnancy/breastfeeding
MRI: in pregnancy if USS inconclusive
What is the purpose of diagnostic laparoscopy
If it is hard to tell and there is persistent pain and inconclusive imagining
What is the Alvarado score
RLQ tenderness
Fever
Rebound tenderness
Pain migration
Anorexia
Nausea +/ vomitting
WCC>10.000
Neutrophilia
5-6 possible
What does the conservative management of acute appendicitis consist of**
Consists of:
IV Fluids, Analgesia, IV or PO Antibiotics
In abscess, phlegmon or sealed perforation
–Resuscitation + IV ABx +/- percutaneous drainage
Indications:
After negative imaging in selected patients with clinically uncomplicated appendicitis
In delayed presentation with abscess/phlegmon formation
CT-guided drainage
Consider interval appendicectomy - rate of recurrence after conservative management of abscess/perforation is 12-24%
What is the surgical management of acute appendicitis
Laparoscopic vs Open appendicectomy
Less pain
Lower incidence of surgical site infection
↓ed length of hospital stay
Earlier return to work
Overall costs
Better quality of life scores
What is bowel obstruction and what are the types
Intestinal obstruction - restriction of normal passage of intestinal contents.
Two main groups:
Paralytic (Adynamic) ileus (functional)
Mechanical.
Explain how mechanical bowel obstruction is classified
Speed of onset: acute, chronic, acute-on-chronic
Site: high or low
—roughly synonymous with small or large bowel obstruction
Nature: simple vs strangulating
—Simple: bowel is occluded without damage to blood supply.
—-Strangulating: blood supply of involved segment of intestine is cut off (e.g. in strangulated hernia, volvulus, intussusception)
Aetiology:
Causes in the lumen - faecal impaction, gallstone ‘ileus’
Causes in the wall - Crohn’s disease, tumours, diverticulitis of colon
Causes outside the wall –
–Strangulated hernia (external or internal)
–Volvulus
—Obstruction due to adhesions or bands.
Aetiology between small bowel obstruction and large bowel
Small Bowel Obstruction
Adhesions (60%)
Hx of previous abdominal surgery
Neoplasia (20%)
Primary, Metastatic, Extraintestinal
Incarcerated hernia (10%)
External (abdominal wall), Internal (mesenteric defect)
Crohn’s Disease (5%)
Acute (oedema), Chronic (strictures)
Other (5%)
Intussusception, intraluminal (foreign body, bezoar)
Large Bowel Obstruction
Colorectal carcinoma
Volvulus
Sigmoid, Caecal
Diverticulitis
Inflammation, strictures
Faecal impaction
Hirschsprung disease
commonly found in infants/children
How is bowel obstruction presented between small and large**
How to diagnose bowel obstruction
3x Important points to remember about intestinal obstruction:
Diagnosed by the presence of symptoms
Examination should always include a search for hernias & abdominal scars, including laparoscopic portholes
Is it simple or strangulating?
What are features suggesting strangulation ?
Change in character of pain from colicky to continuous
Tachycardia
Pyrexia
Peritonism
Bowel sounds absent or reduced
Leucocytosis
↑ed C-reactive protein
What is an example of a hernia without obstruction
Richters Hernia
What are the investigations for bowel obstruction
Bloods:
WCC/CRP usually normal (if raised suspicion of strangulation/perforation)
U&E: electrolyte imbalance
VBG if vomiting: HypoCl-,HypoK+ metabolic alkalosis
VBG if strangulation: Metabolic Acidosis (lactate)
Imaging:
Erect CXR/AXR
—SBO: Dilated small bowel loops >3cm proximal to the obstruction (central)
—-LBO:Dilated large bowel >6cm (if caecum >9cm) predominantly peripheral
CT abdo/pelvis→ Transition point, dilatation of proximal loops – IV +/- oral contrast if possible
What is shown on an abdominal xray for small bowel obstruction
Ladder pattern of dilated loops & their central position
Striations that pass completely across the width of the distended loop produced by the circular mucosal folds
What is shown on an abdominal xray for large bowel obstruction
Distended large bowel tends to lie peripherally
Show haustrations of taenia coli - do not extend across whole width of the bowel.
What is the purpose of a CT scan in bowel obstruction
What can is show
Can localize site of obstruction
Detect obstructing lesions & colonic tumours
May diagnose unusual hernias (e.g. obturator hernias).
Collapsed & dilated loops of small bowel due to transition point in the pelvis
Sigmoid stricture with proximal dilation
What is supportive management of 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
What is conservative treatment in patients with 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
What are indication for surgical management of bowel obstruction
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 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)
What is the presentation of GI perforation
Sudden onset severe abdominal pain associated with distention
Diffuse abdominal guarding, rigidity, rebound tenderness
Pain aggravated by movement
Nausea, vomiting, absolute constipation
Fever, Tachycardia, Tachypnoea, Hypotension
Decreased or absent bowel sounds
What are different signs for different perforations**
What are the investigations for GI perforation
Bloods
FBC: neutrophilic leukocytosis
Possible elevation of Urea, Creatinine
VBG: Lactic acidosis
Imaging
Erect CXR→ subdiaphragmatic free air (pneumoperitoneum)
CT abdo/pelvis→Pneumoperitoneum, free GI content,localised mesenteric fat stranding
–can exclude common differential diagnoses such as pancreatitis
What are differential diganosis for GI perforation
Acute cholecystitis, Appendicitis.
Myocardial infarction, Acute pancreatitis
What does supportive on management of GI perforation involve
NBM & NG tube
IV peripheral access with large bore cannula -IV Fluid resuscitation
Broad spectrum Abx
IV PPI
Parenteral analgesia & antiemetics
Urinary catheter
What does conservative management in localised peritonitis without signs of sepsis involve
Very rare:
IR - guided drainage of intra-abdominal collection
Serial abdominal examination & abdominal imaging for assessment
What does surgical management for GI perforation involve
Surgical management in generalised peritonitis +/- signs ofsepsis:
Exploratory laparotomy/laparoscopy
Primary closure of perforation with or withoutomental patch (most common in perforated pepticulcer)
Resection of theperforated segment of the bowelwith primary anastomosis or temporary stoma
Obtainintra-abdominal fluid for MC&S, peritoneal lavage ++++
If perforated appendix: Lap or open appendicectomy
If malignancy: intraoperative biopsies if possible
What conservative management is effective in treating the majority of patients with a sigmoid volvulus?
A sigmoidoscope is passed with the patient lying in the left lateral position.
A large well lubricated, soft rubber rectal tube is passed along the sigmoidoscope.
This usually untwists the volvulus, with release of vast quantities of flatus & liquid faeces.
What is portal pyaemia
Portal pyaemia (pylephlebitis):
Form of septic (often suppurative) thrombophlebitis of the portal venous system
Complication of intra-abdominal sepsis
–Diverticulitis
—Appendicitis
Air in SMV & intrahepatic portal venous system
What are the biliary and pancreatic causes of acute abdomen?**-
