General Surgery in GI Tract Flashcards
1
Q
What investigations could be carried out?
A
(depending on presentation):
- Bloods: VBG, FBC, CRP, U&Es (renal profile), LFTs +amylase
- Urinalysis + Urine MC&S
- Imaging: Erect CXR, AXR, CTAP, CT angiogram, USS
- Endoscopy
2
Q
What could the management involve?
A
- ABCDE approach
- Conservative management
- Surgical management
3
Q
What are some differential diagnosis in the right upper quadrant?
A
- Bilary Colic
- Cholecystitis/Cholangitis
- Duodenal Ulcer
- Liver abscess
- Portal vein thrombosis
- Acute hepatitis
- Nephrolithiasis
- RLL pneumonia
4
Q
What are some differential diagnosis in the lower upper quadrant?
A
- Peptic ulcer
- Acute pancreatitis
- Splenic abscess
- Splenic infarction
- Nephrolithiasis
- LLL Pneumonia
5
Q
What are some differential diagnosis in the right lower quadrant?
A
- Acute Appendicitis
- Colitis
- IBD
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
6
Q
What are some differential diagnosis in the left lower quadrant?
A
- Diverticulitis
- Colitis
- IBD (Inflammatory Bowel Disease)
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
7
Q
What are some differential diagnosis in the epigastrum quadrant?
A
- Acute gastritis/GORD
- Gastroparesis
- Peptic ulcer disease/perforation
- Acute pancreatitis
- Mesenteric ischaemia
- AAA (Abdominal Aortic Aneurysm)
- Aortic dissection
- Myocardial infarction
8
Q
What are some differential diagnosis in the suprapubic/central quadrant?
A
- Early appendicitis
- Mesenteric ischaemia
- Bowel obstruction
- Bowel perforation
- Constipation
- Gastroenteritis
- UTI/Urinary retention
- PID
9
Q
What is the presentation of bowel iscahemia?
A
- 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
10
Q
What are the risk factors of bowel ischaemia?
A
- Age >65 yr
- Cardiac arrythmias (mainly AF), atherosclerosis
- Hypercoagulation/thrombophilia
- Vasculitis
- Sickle cell disease
- Profound shock causing hypotension
11
Q
What bloods do you investigate for bowel ischaemia?
A
- FBC: neutrophilic leukocytosis
* VBG: Lactic acidosis
12
Q
What would you look for on imaging (CTAP/CT angiogram) when investigating bowel ischaemia?
A
- Disrupted flow
- Vascular stenosis
- ‘Pneumatosis intestinalis’ (transmural ischaemia/infarction)
- Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)
13
Q
What would be investigated using endoscopy in bowel ischaemia?
A
•For mild or moderate cases of ischaemic colitis ( you would see oedema, cyanosis, ulceration of mucosa)
14
Q
What would be signs in acute mesenteric ischaemia?
A
- Small bowel
- usually occlusive due to thromboemobli
- Sudden onset (but presentation and severity varies)
- Abdominal pain out of proportion of clinical signs
15
Q
What would be the signs of ischaemia colitis?
A
- Large bowel
- usually due to non-occlusive low flow states, or atherosclerosis
- More mild and gradual (80-85% of cases)
- Moderate pain and tenderness
16
Q
What is the conservative management of bowel ischaemia for mild to moderate cases of ischaemic colitis (not suitable for SB ischaemia)?
A
- 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
17
Q
What are the indications of surgical management for bowel ischaemia?
A
- Small bowel ischaemia
- Signs of peritonitis orsepsis
- Haemodynamic instability
- Massive bleeding
- Fulminant colitis with toxic megacolon
18
Q
What would exploratory laparotomy for bowel ischameia involve?
A
• Resection of necrotic bowel +/-open surgicalembolectomy
or mesenteric arterial bypass
19
Q
What would endovascular revascularisation for bowel ischameia involve?
A
- Balloon angioplasty/thrombectomy
* In patients without signs of ischaemia
20
Q
What is the presentation for acute appendicitis?
A
- Initially periumbilical pain that migrates to RLQ (within 24hours)
- Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit
21
Q
What is McBurney’s point?
A
tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
22
Q
What is Blumberg sign?
A
rebound tenderness especially in the RIF
23
Q
What is Rovsing sign?
A
RLQ pain elicited on deep palpation of the LLQ
24
Q
What is Psoas sign?
A
RLQ pain elicited on flexion of right hip against resistance
25
What is obtruator sign?
RLQ pain on passive internal rotation of the hip with hip & knee flexion
26
What bloods do you order for acute appendicitis investigations?
* FBC: neutrophilic leukocytosis
* ↑ed CRP
* Urinalysis: possible mild pyuria/haematuria
* Electrolyte imbalances in profound vomiting
27
What imaging do you order for acute appendicitis investigations?
1. CT: gold standard in adults esp. if age > 50
2. USS: children/pregnancy/breastfeeding
3. MRI: in pregnancy if USS inconclusive
28
When do you use diagnostic laparoscopy for acute appendictis?
In persistent pain & inconclusive imaging
29
What does conservative management of acute appendicitis consist of?
•IV Fluids, Analgesia, IV or PO Antibiotics
•In abscess, phlegmon or sealed perforation
-Resuscitation + IV ABx +/- percutaneous drainage
30
What are the indications for conservative management of acute appendicitis?
•After negative imaging in selected patients with clinically uncomplicated appendicitis
•In delayed presentation with abscess/phlegmon formation
-CT-guided drainage
-Want to decrease treat and then come later for elective appendix removed
31
When do you consider interval appendicectomy?
rate of recurrence after conservative management of abscess/perforation is 12-24%
32
Why is laparscopic surgical management of acute appendicitis better than open appendectomy?
1. Less pain
2. Lower incidence of surgical site infection
3. ↓ed length of hospital stay
4. Earlier return to work
5. Overall costs
6. Better quality of life scores
33
What are the steps of laparoscopic appendicectomy?
1. Trocar placement (usually 3)
2. Exploration of RIF & identification of appendix
3. Elevation of appendix + division of mesoappendix (containing artery)
4. Based secured with endoloops and appendix is divided
5. Retrieval of appendix with a plastic retrieval bag
6. Careful inspection of the rest of the pelvic organs/intestines
7. Pelvic irrigation (wash out) + Haemostasis
8. Removal of trocars + wound closure
34
What is an intestinal obstruction?
-restriction of normal passage of intestinal contents.
-Two main groups:
•Paralytic (Adynamic) ileus
•Mechanical.
35
What is the speed of onset for mechanical intestinal obstruction?
acute, chronic, acute-on-chronic
36
What is the site classification for mechanical intestinal obstruction?
-high or low
| •roughly synonymous with small or large bowel obstruction
37
What is the nature classification for mechanical intestinal obstruction?
•Nature: simple vs strangulating
1. Simple: bowel is occluded without damage to blood supply.
2. Strangulating: blood supply of involved segment of intestine is cut off (e.g. in strangulated hernia, volvulus, intussusception)
38
What is the causes in the lumen for mechanical intestinal obstruction?
1. faecal impaction
| 2. gallstone ‘ileus’
39
What is the causes in the wall for mechanical intestinal obstruction?
1. Crohn’s disease
2. tumours
3. diverticulitis of colon
40
What is the causes outside the wall for mechanical intestinal obstruction?
1. Strangulated hernia (external or internal)
2. Volvulus
3. Obstruction due to adhesions or bands
41
What are causes of small bowel obstruction?
1. Adhesions (60%): history of previous abdominal surgery
2. Neoplasia (20%): primary, metastatic, extra intestinal
3. Incarcerated hernia (10%): external (abdominal wall), internal (mesenteric defect)
4. Crohn's disease (5%): acute (oedma), chronic(strictures)
5. Other (5%), intussusception, intraluminal (foreign body, bezoar)
42
What are causes of large bowel obstruction?
1. Colorectal carcinoma
2. Volvulus: sigmoid, caecal
3. Diverticulitis: inflammation, strictures
4. Faecal impaction
5. Hirschsprung disease: commonly found in infants/children
43
How is abdominal pain shown in small bowel obstruction vs large bowel obstruction?
- Small bowel obstruction: colicky, central
| - Large bowel obstruction: colicky or constant
44
How is vomiting shown in small bowel obstruction vs large bowel obstruction?
- Small bowel obstruction: early onset, large amount, bilious
- Large bowel obstruction: late onset, initially bilious, progresses to faecal vomiting
45
How is absolute constipation shown in small bowel obstruction vs large bowel obstruction?
- Small bowel obstruction: late sign
| - Large bowel obstruction: early sign
46
How is abdominal distension shown in small bowel obstruction vs large bowel obstruction?
- Small bowel obstruction: less significant
| - Large bowel obstruction: early sign and significant
47
How are other signs shown in small bowel obstruction vs large bowel obstruction?
1. Dehydration
2. Increased high pitches tinkling bowel sounds (early sign), or absent bowel sounds (late sign)
3. Diffuse abdominal tenderness
48
What are the 3 important points to remember about intestinal obstruction?
1. Diagnosed by the presence of symptoms
2. Examination should always include a search for hernias & abdominal scars, including laparoscopic portholes
3. Is it simple or strangulating?
49
What are the features suggesting strangulation?
```
1. Change in character of pain from colicky to continuous
2, Tachycardia
3. Pyrexia
4. Peritonism
5. Bowel sounds absent or reduced
6. Leucocytosis
7. ↑ed C-reactive protein
```
50
What is the mortality of strangulating obstruction with peritonitis?
up to 15%
51
What are different types of hernias?
- neck of sac
- strangulated hernia
- richter's hernias
52
What are common hernial sites?
1. Epigastric
2. Umbilical
3. Incisional
4. Inguinal
5. Femoral
53
What bloods do you order for bowel obstruction?
* 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)
54
What imaging fo you order for bowel obstruction?
1. Erect CXR/AXR
•SBO: Dilated small bowel loops >3cm proximal to the obstruction (central)
•LBO: Dilated large bowel >6cm (if caecum >9cm) predominantly peripheral
2. CT abdo/pelvis → Transition point, dilatation of proximal loops – IV +/- oral contrast if possible
55
What would a small bowel obstruction show in abdominal x ray?
1. Ladder pattern of dilated loops & their central position
| 2. Striations that pass completely across the width of the distended loop produced by the circular mucosal folds
56
What would a large bowel obstruction show in abdominal x ray?
1. Distended large bowel tends to lie peripherally
| 2. Show haustrations of taenia coli - do not extend across whole width of the bowel
57
Why is a CT used in bowel obstruction?
* Can localize site of obstruction
* Detect obstructing lesions & colonic tumours
* May diagnose unusual hernias (e.g. obturator hernias).
58
What is the supportive management in patients with no signs of ischaemia/no signs of clinical deterioration with bowel obstruction?
1, NBM, IV peripheral access with large bore cannula - IV Fluid resuscitation
2. IV analgesia, IV antiemetics, correction of electrolyte imbalances
3. NG tube for decompression, urinary catheter for monitoring output
4. Introduce gradual food intake if abdominal pain and distention improve
59
What is the conservative management in patients with no signs of ischaemia/no signs of clinical deterioration with bowel obstruction?
1, Faecal impaction: stool evacuation (manual, enemas, endoscopic)
2. Sigmoid volvulus: rigid sigmoidoscopic decompression
3, SBO: oral gastrograffin (highly osmolar iodinated contrast agent) can be used to resolve adhesional small bowel obstruction
60
What are the indications for surgical management of bowel obstruction?
1. Haemodynamic instability or signs of sepsis
2. Complete bowel obstruction with signs of ischaemia
3. Closed loop obstruction
4. Persistent bowel obstruction >2 days despite conservative management
61
What operations would be used for surgical management of bowel obstruction?
1. Exploratory Laparotomy/Laparoscopy
2. Restoration of intestinal transit (depending on intra-operational findings)
3. Bowel resection with primary anastomosis or temporary/permanent stoma formation
62
What is the presentation fo GI perforation?
1. Sudden onset severe abdominal pain associated with distention
2. Diffuse abdominal guarding, rigidity, rebound tenderness
3. Pain aggravated by movement
4. Nausea, vomiting, absolute constipation
5. Fever, Tachycardia, Tachypnoea, Hypotension
6. Decreased or absent bowel sounds
63
How would a perforated peptic ulcer present?
1. Sudden epigastric or diffuse pain
2. Referred shoulder pain
3. History of NSAIDs, steroids, recurrent epigastric pain
64
How would a perforated diverticulum present?
1. LLQ pain
| 2. Constipation
65
How would a perforated appendix present?
1. Migratory pain
2. Anorexia
3. Gradual worsening RLQ pain
66
How would perforating malignancy present?
1. Change in bowel habit
2. Weight loss
3. Anorexia
4. PR bleeding
67
What bloods do you order for GI perforation?
* FBC: neutrophilic leukocytosis
* Possible elevation of Urea, Creatinine
* VBG: Lactic acidosis
68
What imaging do you order for GI perforation?
1, Erect CXR → subdiaphragmatic free air (pneumoperitoneum)
2. CT abdo/pelvis → Pneumoperitoneum, free GI content, localised mesenteric fat stranding
•can exclude common differential diagnoses such as pancreatitis
69
What could differential diagnosis be for GI perforation
* Acute cholecystitis, Appendicitis.
| * Myocardial infarction, Acute pancreatitis
70
What is the supportive management on presentation of GI perforation?
1. NBM & NG tube
2. IV peripheral access with large bore cannula - IV Fluid resuscitation
3, Broad spectrum Abx
4. IV PPI
5. Parenteral analgesia & antiemetics
6. Urinary catheter
71
What is the Conservative management in localised peritonitis without signs of sepsis - Very rare?
* IR - guided drainage of intra-abdominal collection
| * Serial abdominal examination & abdominal imaging for assessment
72
What is the surgical management in generalised peritonitis +/- signs of sepsis
1. Exploratory laparotomy/laparascopy
2. Primary closure of perforation with or without omental patch (most common in perforated peptic ulcer)
3. Resection of the perforated segment of the bowel with primary anastomosis or temporary stoma
4. Obtain intra-abdominal fluid for MC&S, peritoneal lavage ++++
5. If perforated appendix: Lap or open appendicectomy
6. If malignancy: intraoperative biopsies if possible
73
What are the symptoms of biliary colic?
1. Postprandial RUQ pain with radiation to the shoulder
| 2. Nausea
74
What are the investigations of biliary colic?
1. Normal blood results
| 2. USS: cholelithiasis
75
What is the management of biliary colic?
1. Analgesia, Antiemetics, Spasmolytics
| 2. Follow up for elective cholecystecotomy
76
What are the symptoms of acute cholecystitis?
1. Acute, severe RUQ pain
2. Fever
3. Murphy's sign
77
What are the investigations of acute cholecystitis?
1. Elevated WCC/CRP
| 2. USS: thickened gallbladder wall
78
What is the management of acute cholecystitis?
1. Fluids, ABx, analgesia, blood culture
| 2. Early (<72 hours) or elective cholecytsectomy (4-6 weeks)
79
What are the symptoms of acute cholangitis?
Charcot's triad: jaundice
| RUQ pain, fever
80
What are the investigation of acute cholangitis?
1. Elevated LFTs, WCC, CRP, Blood MCS (+ve)
| 2. USS: biliary dilation
81
What is the management of acute cholangitis?
1. Fluids, IV Abx, Analgesia
| 2. ERCP (within 72hrs) for clearance of bile duct or stenting
82
What are the symptoms of acute pancreatitis?
1. Severe epigastric pain radiating to the back
2. Nausea +/- vomiting
3. History of gallstones or EtOH use
83
What are the investigations of acute pancreatitis?
1. Raised amylase/lipase
2. High ECC/Low Ca2+
3. CT and US to assess for complications/cause
84
What is the management of acute pancreatitis?
1. Admission score (Glasgow-Imrie)
2. Aggressive fluid resuscitation, O2
3. Analgesia, Antiemetics
4. ITU/HDU involvement
