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General Surgery in the Gastrointestinal Tract Flashcards

1
Q

What is the general approach when a patient initially presents with acute abdominal pain?

A
  • Pain assessment
  • PMH
  • DHx
  • SHx
  • investigations
  • management
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2
Q

What are the different possible investigations when someone presents with acute abdominal pain?

A
  • bloods
  • urinalysis
  • imaging
  • endoscopy
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3
Q

What are the different possible bloods when someone presents with acute abdominal pain?

A
  • VBG
  • FBC
  • CRP
  • U+Es
  • LFTs
  • Amylase
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4
Q

What is the different possible imaging when someone presents with acute abdominal pain?

A
  • erect CXR
  • AXR
  • CTAP
  • CT angiogram
  • USS
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5
Q

What are the different possible forms of management when someone presents with acute abdominal pain?

A
  • ABCDE approach
  • Conservative management
  • Surgical management
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6
Q

What are the possible differential diagnosis for Right Upper Quadrant pain?

A
  • Bilary Colic
  • Cholecystitis/Cholangitis
  • Duodenal Ulcer
  • Liver abscess
  • Portal vein thrombosis
  • Acute hepatitis
  • Nephrolithiasis
  • RLL pneumonia
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7
Q

What are the possible differential diagnosis for Right Lower Quadrant pain?

A
  • Acute Appendicitis
  • Colitis
  • IBD
  • Infectious colitis
  • Ureteric stone/Pyelonephritis
  • PID/Ovarian torsion
  • Ectopic pregnancy
  • Malignancy
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8
Q

What are the possible differential diagnosis for Epigastric pain?

A
  • Acute gastritis/GORD
  • Gastroparesis
  • Peptic ulcer disease/perforation
  • Acute pancreatitis
  • Mesenteric ischaemia
  • AAA (Abdominal Aortic Aneurysm)
  • Aortic dissection
  • Myocardial infarction
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9
Q

What are the possible differential diagnosis for Suprapubic/Central pain?

A
  • Early appendicitis
  • Mesenteric ischaemia
  • Bowel obstruction
  • Bowel perforation
  • Constipation
  • Gastroenteritis
  • UTI/Urinary retention
  • PID
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10
Q

What are the possible differential diagnosis for Left Upper Quadrant pain?

A
  • Peptic ulcer
  • Acute pancreatitis
  • Splenic abscess
  • Splenic infarction
  • Nephrolithiasis
  • LLL Pneumonia
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11
Q

What are the possible differential diagnosis for Left Lower Quadrant pain?

A
  • Diverticulitis
  • Colitis
  • IBD
  • Infectious colitis
  • Ureteric stone/Pyelonephritis
  • PID/Ovarian torsion
  • Ectopic pregnancy
  • Malignancy
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12
Q

How does bowel ischaemia present?

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
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13
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
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14
Q

Which part of the bowel tends to be affected by acute mesenteric ischaemia?

A

small bowel

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15
Q

Which part of the bowel tends to be affected by ischaemic colitis?

A

large bowel

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16
Q

What is the onset of acute mesenteric ischaemia?

A

sudden (presentation and severity varies)

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17
Q

What is the clinical presentation of acute mesenteric ischaemia?

A

abdominal pain out of proportion of clinical signs

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18
Q

What tends to cause acute mesenteric ischaemia?

A

occlusive due to thromboemboli

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19
Q

What is the onset of ischaemic colitis?

A

mild and gradual (80-85% of cases)

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20
Q

What is the clinical presentation of ischaemic colitis?

A

moderate pain and tenderness

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21
Q

What tends to cause ischaemic colitis?

A

due to non-occlusive low flow states or atheroscleroiss

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22
Q

What will the bloods show in bowel ischaemia?

A

FBC - neutrophilic leukocytosis

VBG - lactic acidosis

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23
Q

What imaging should be done if bowel ischaemia is suspected?

A
  • CTAP

- CT angiogram

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24
Q

What can be seen on a CTAP/CT angiogram?

A
  • disrupted flow
  • vascular stenosis
  • transmural ischaemia/infarction
  • thumbprint sign (colitis)
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25
Q

What can be seen on an endoscopy with bowel ischaemia?

A
  • oedema
  • cyanosis
  • ulceration of mucosa
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26
Q

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

A
  • IV fluid resuscitation
  • Bowel rest
  • Broad-spectrum ABx
  • NG tube
  • Anti-coagulation
  • Treat/manage underlying cause
  • Serial abdominal examination and imaging
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27
Q

Why is ABx given in ischaemic colitis?

A

colitis ischaemia can cause bacterial translocation and sepsis

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28
Q

What are the indications for surgical management of bowel ischaemia?

A
  • small bowel ischaemia
  • signs of peritonitis or sepsis
  • haemodynamic instability
  • massive bleeding
  • fulminant colitis with toxic megacolon
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29
Q

What are the 2 surgical options for bowel ischaemia?

A
  • exploratory laparotomy

- endovascular revascularisation

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30
Q

What is involved in a exploratory laparotomy?

A

Resection of necrotic bowel +/-open surgicalembolectomy or mesenteric arterial bypass

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31
Q

What is involved in a endovascular revascularisation?

A
  • Balloon angioplasty/thrombectomy

- In patients without signs of ischaemia

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32
Q

How does acute appendicitis present?

A
  • initially periumbilical pain that migrates to the RLQ (within 24 hours)
  • anorexia
  • nausea (+/- vomiting)
  • low grade fever
  • change in bowel habit
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33
Q

Where is McBurney’s point?

A

tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)

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34
Q

Where is Blumberg point?

A

rebound tenderness especially in the RIF

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35
Q

Where is Rovsing point?

A

RLQ pain elicited on deep palpation of the LLQ

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36
Q

Where is Psoas point?

A

RLQ pain elicited on flexion of right hip against resistance

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37
Q

Where is Obturator point?

A

RLQ pain on passive internal rotation of the hip with hip & knee flexion

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38
Q

What are the possible investigations for suspected appendicitis?

A
  • bloods
  • imaging
  • diagnostic laparoscopy
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39
Q

What would the bloods show in acute appendicitis?

A
  • FBC: neutrophilic leukocytosis
  • high CRP
  • urine: mild pyuria/haematuria
  • electrolyte imbalances due to vomiting
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40
Q

What imaging is done in suspected acute appendicitis?

A
  • CT
  • USS
  • MRI
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41
Q

When is a CT done in suspected acute appendicitis

A

gold standard in adults (>50)

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42
Q

When is a USS done in suspected acute appendicitis

A
  • children
  • pregnancy
  • breastfeeding
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43
Q

When is a MRI done in suspected acute appendicitis

A

in pregnancy if the USS is inconclusive

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44
Q

When would you do a diagnostic laparoscopy?

A
  • in persistent pain

- inconclusive imaging

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45
Q

What is the conservative management plan for acute appendicitis?

A
  • IV fluids
  • analgesia
  • IV or PO ABx
    In abscess: plegmon or sealed perforation
  • resuscitation
  • IV ABx
  • +/- percutaneous drainage
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46
Q

What are the indications for conservative management of appendicitis

A
  • After negative imaging in selected patients with clinically uncomplicated appendicitis
  • In delayed presentation with abscess/phlegmon formation
    (CT-guided drainage)
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47
Q

Why would you consider a interval appendicectomy?

A

rate of recurrence after conservative management of abscess/perforation is 12-24%

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48
Q

Why is a laparoscopic appendicectomy preferred over open?

A
  • less pain
  • low risk of site infection
  • reduced length of hospital stay
  • earlier return to work
  • overall costs
  • better QOL
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49
Q

What are the steps of a laparoscopic addendicectomy?

A

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

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50
Q

What is an intestinal obstruction?

A

restriction of the normal passage of intestinal contents

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51
Q

What are the 2 main types of intestinal obstructions?

A
  • paralytic (adynamic) ileus

- mechanical obstruction

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52
Q

What are the possible speeds of onset of a mechanical bowel obstruction?

A
  • acute
  • chronic
  • acute on chronic
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53
Q

What are the possible sites of a mechanical bowel obstruction?

A
  • high or low

- dependent on either large or small bowel obstruction

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54
Q

What are the 2 different types of mechanical bowel obstruction?

A
  • simple

- strangulating

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55
Q

What happens in a simple mechanical bowel obstruction?

A

bowel is occluded without damage to blood supply

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56
Q

What happens in a strangulating mechanical bowel obstruction?

A

blood supply of the involved segment of intestine is cut off

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57
Q

What are some examples of a strangulating mechanical bowel obstruction?

A
  • strangulated hernia
  • volvulus
  • intussusception
58
Q

What are the possible places of the causes of a bowel obstruction?

A
  • lumen
  • wall
  • outside the wall
59
Q

What causes in the lumen can cause a bowel obstruction?

A
  • faecal impaction

- gallstone ‘ileus’

60
Q

What causes in the wall can cause a bowel obstruction?

A
  • Crohn’s disease
  • tumours
  • diverticulitis of the colon
61
Q

What causes in the lumen can cause a bowel obstruction?

A
  • Strangulated hernia (internal or external)
  • Volvulus
  • Obstruction due to adhesions or bands
62
Q

What are the main causes of a small bowel obstruction?

A
  • Adhesions (60%)
  • Neoplasia (20%)
  • Incarcerated hernia (10%)
  • Crohn’s disease (5%)
  • Other (5%)
63
Q

What are the main causes of a large bowel obstruction?

A
  • colorectal carcinoma
  • volvulus
  • diverticulitis
  • faecal impaction
  • Hirschsprung disease (kids)
64
Q

What sort of pain is associated with a small bowel obstruction?

A
  • colicky

- central

65
Q

What sort of pain is associated with a large bowel obstruction?

A
  • colicky

- constant

66
Q

What type of vomiting is associated with a large bowel obstruction?

A
  • late onset
  • initially bilious
  • progression to faecal vomiting
67
Q

What type of vomiting is associated with a small bowel obstruction?

A
  • early onset
  • large amount
  • bilious
68
Q

What type of sign is constipation in a small bowel obstruction?

69
Q

What type of sign is constipation in a large bowel obstruction?

A

early sign

70
Q

How significant is abdominal distention in a small bowel obstruction?

A

less significant

71
Q

How significant is abdominal distention in a large bowel obstruction?

A

early sign and significant

72
Q

What are the other signs of a bowel obstruction?

A
  • dehydration
  • diffuse abdominal tenderness
  • early sign: high pitched bowel sounds
  • late sign: absent bowel sounds
73
Q

How are bowel obstructions diagnosed?

A

by the presence of symptoms

74
Q

What should always be done in an abdominal exam?

A

search for:

  • hernias
  • abdominal scars (like surgical)
75
Q

What clinical features are suggestive of strangulation?

A
  • pain change from colicky to continuous
  • tachycardia
  • pyrexia
  • peritonism
  • absent or reduced bowel sounds
  • leucocytosis
  • increased CRP
76
Q

What are the common hernia sites?

A
  • epigastric
  • umbilical
  • incisional
  • inguinal
  • femoral
77
Q

What are the different types of hernias?

A
  • neck of sac
  • strangulated hernia
  • richter’s hernia
78
Q

What is Richter’s hernia?

A

only part of the circumference of the intestine’s antimesenteric border through a defect of the abdominal wall

79
Q

What bloods are done in a suspected bowel obstruction?

A
  • WCC/CRP
  • U+E
  • VBG (if vomiting or strangulation)
80
Q

What would bloods show in a bowel obstruction?

A

WCC/CRP - normal, raised in perforation or strangulation
U+E - electrolyte imbalance
VBG (vomiting) - hypoCl-, hypoK+ and metabolic alkalosis
VBG (strangulation) - metabolic acidosis (lactate)

81
Q

What imaging is done in a suspected bowel obstruction?

A
  • erect CXR, AXR

- CTAP (IV/oral contrast if possible)

82
Q

What would you see on an erect CXR/AXR in a small bowel obstruction?

A
  • 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

83
Q

What would you see on an erect CXR/AXR in a large bowel obstruction?

A
  • Distended large bowel tends to lie peripherally

- Show haustrations of taenia coli - do not extend across whole width of the bowel

84
Q

What would you see on an CTAP in a bowel obstruction?

A
  • Collapsed & dilated loops of small bowel due to transition point in the pelvis
  • Sigmoid stricture with proximal dilation
85
Q

What can a CTAP do?

A
  • Can localize site of obstruction
  • Detect obstructing lesions & colonic tumours
  • May diagnose unusual hernias (e.g. obturator hernias).
  • May demonstrate thrombus in the mesenteric arteries & veins.
  • Abnormal enhancement of bowel wall.
  • Presence of embolus or infarction of other organs.
86
Q

When would you use conservative management of a bowel obstruction?

A

in patients with no sign of ischaemia/no signs of clinical deterioration

87
Q

What is the supportive management plan of a bowel obstruction?

A
  • 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
88
Q

What is the conservative management plan of faecal impaction?

A

stool evacuation (manual, enemas, endoscopic)

89
Q

What is the conservative management plan ofsigmoid volvulus?

A

rigid sigmoidoscopic decompression

90
Q

What is the conservative management plan of a small bowel obstruction?

A

oral gastrograffin (highly osmolar iodinated contrast agent)can be used to resolve adhesionalsmall bowel obstruction

91
Q

What are the indications for the surgical management of a bowel obstruction?

A
  • Haemodynamic instability or signs of sepsis
  • Complete bowel obstruction with signs of ischaemia
  • Closed loop obstruction
  • Persistent bowel obstruction >2 days despite conservative management
92
Q

What are the different surgical options for a bowel obstruction?

A
  • Exploratory Laparotomy/Laparoscopy
  • Restoration of intestinal transit (depending on intra-operational findings)
  • Bowel resection with primary anastomosis or temporary/permanent stoma formation
93
Q

How does a gastric perforation present?

A
  • Sudden onset severe abdominal pain 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
94
Q

What are the clinical signs of a perforated peptic ulcer?

A
  • sudden epigastric or diffuse pain
  • referred shoulder pain
  • Hx of NSAIDs, steroids and recurrent epigastric pain
95
Q

What are the clinical signs of a perforated diverticulum?

A
  • LLQ pain

- Constipation

96
Q

What are the clinical signs of a perforated appendix?

A
  • Migratory pain
  • Anorexia
  • Gradual worsening RLQ pain
97
Q

What are the clinical signs of a perforated malignancy?

A
  • Change in bowel habit
  • Weight loss
  • Anorexia
  • PR Bleeding
98
Q

What bloods are done for a suspected GI perforation?

A
  • FBC
  • U+E
  • VBG
99
Q

What would the bloods be in a GI perforation?

A

FBC: neutrophilic leukocytosis
U+E: high urea and creatinine
VBG: lactic acidosis

100
Q

What imaging is done for a suspected GI perforation?

A
  • erect CXR

- CTAP

101
Q

What would an erect CXR show in a GI perforation?

A

subdiaphragmatic free air (pneumoperitoneum)

102
Q

What would an erect CTAP show in a GI perforation?

A
  • Pneumoperitoneum
  • free GI content
  • localised mesenteric fat stranding
    (can exclude common differential diagnoses)
103
Q

What are the possible differentials for a GI perforation?

A
  • acute cholecystitis
  • appendicitis
  • myocardial infarction
  • acute pancreatitis
104
Q

What is the supportive management plan for a GI perforation?

A
  • NBM & NG tube
  • IV peripheral access with large bore cannula -IV Fluid resuscitation
  • Broad spectrum Abx
  • IV PPI
  • Parenteral analgesia & antiemetics
  • Urinary catheter
105
Q

when is conservative management of a GI perforation used?

A
  • localised peritonitis

- no signs of sepsis

106
Q

What is the conservative management plan for a GI perforation?

A
  • IR - guided drainage of intra-abdominal collection

- Serial abdominal examination & abdominal imaging for assessment

107
Q

What are the indications for the surgical management of a GI perforation?

A
  • generalised peritonitis

- signs of sepsis

108
Q

What are the different options of surgical management of a GI perforation?

A
  • Exploratory laparotomy/laparascopy
  • Primary closure of perforation with or withoutomental patch
  • Resection of theperforated segment of the bowelwith primary anastomosis or temporary stoma
  • Obtainintra-abdominal fluid for MC&S, peritoneal lavage ++++
  • Lap or open appendicectomy
  • intraoperative biopsies if possible
109
Q

What is the most common surgical management of a perforated peptic ulcer?

A

Primary closure of perforation with or withoutomental patch

110
Q

What would be done with a perforated appendix?

A

Lap or open appendicectomy

111
Q

What would be done with a perforated malignancy?

A

intraoperative biopsies if possible

112
Q

What are the symptoms of biliary colic?

A
  • PostprandialRUQ pain with radiation to the shoulder.

- Nausea

113
Q

What are the symptoms of acute cholecystitis?

A
  • Acute, severe RUQ pain
  • Fever
  • Murphy’s sign
114
Q

What are the symptoms of acute cholangitis?

A

Charcot’s triad:

  • jaundice
  • RUQ pain
  • fever
115
Q

What are the symptoms of acute pancreatitis?

A
  • Severe epigastric pain radiating to the back
  • Nausea +/- vomiting
  • Hx of gallstones or EtOH use
116
Q

What investigations are done in suspected biliary colic?

A
  • Normal blood results

- USS: cholelithiasis

117
Q

What investigations are done in suspected acute cholecystitis?

A
  • Elevated WCC/CRP

- USS: thickened gallbladder wall

118
Q

What investigations are done in suspected acute cholangitis?

A
  • Elevated LFTs, WCC, CRP, - Blood MCS (+ve)

- USS: bilary dilatation

119
Q

What investigations are done in suspected acute pancreatitis?

A
  • Raised amylase/lipase
  • High WCC/Low Ca2+
  • CT and US to assess for complications/cause
120
Q

What is the management plan for biliary colic?

A
  • Analgesia
  • Antiemetics
  • Spasmolytics
  • Follow up for elective cholecystectomy
121
Q

What is the management plan for acute cholecystitis?

A
  • Fluids
  • ABx
  • Analgesia
  • Blood cultures
  • Early (<72 hours) or elective cholecystectomy (4-6 weeks)
122
Q

What is the management plan for acute cholangitis?

A
  • Fluids
  • IV Abx
  • Analgesia
  • ERCP (within 72hrs) for clearance of bile duct or stenting
123
Q

What is the management plan for acute pancreatitis?

A
  • Admission score (Glasgow-Imrie)
  • Aggressive fluid resuscitation,
  • O2
  • Analgesia
  • Antiemetics
  • ITU/HDU involvement
124
Q

What are the 2 most common causes of a small bowel obstruction?

A
  • previous abdominal operation

- strangulated external hernia

125
Q

What would suggest volvulus of the sigmoid colon?

A
  • Enormously distended oval gas shadow, looped on itself (coffee bean sign)
126
Q

What conservative management is effective in treating the majority of patients with a sigmoid volvulus?

A
  • A sigmoidoscope with a soft rubber rectal tube is passed with the patient lying in the left lateral position.
  • This usually untwists the volvulus, with release of vast quantities of flatus & liquid faeces
127
Q

What happens if sigmoid volvulus goes untreated?

A

the loop of sigmoid would undergo necrosis

128
Q

What happens next if sigmoid volvulus is not resolved by the sigmoidoscope untwisting?

A

Hartmann’s Procedure:

Exploratory Laparotomy & Sigmoid Colectomy with end colostomy

129
Q

What presentation suggests an acute mesenteric ischaemia?

A
  • increased risk of CVD
  • central pain with guarding
  • no bowel sounds
  • increased lactate
130
Q

How do you treat a blockage of the SMA causing mesenteric ischaemia?

A
  • Emergency exploratory laparotomy
  • restore SMA blood flow
  • resection of non-viable bowel
131
Q

How do you surgically restore blood flow in the SMA?

A
  • Embolectomy of SMA – in embolic AMI
  • Endovascular management of SMA thrombus – in thrombotic AMI
  • Arterial bypass of SMA - in thrombotic AMI
132
Q

What happens in an exploratory laparotomy?

A
  • Midline incision.
  • Evaluate the abdominal viscera
  • If obvious intestinal necrosis – resection of the affected bowel loops.
133
Q

What happens in a damage-control laparotomy?

A
  • Stapled off bowel ends may be left in discontinuity

- Re-inspect after a period of continued ICU resuscitation to restore physiological balance

134
Q

What is portal pyaemia?

A

form of septic (often suppurative) thrombophlebitis of the portal venous system

135
Q

What tends to cause portal pyaemia?

A

Complication of intra-abdominal sepsis
Diverticulitis
Appendicitis

136
Q

How can portal pyaemia be seen on a CTAP?

A

Air in SMV & intrahepatic portal venous system

137
Q

What are the 3 different arterial causes of acute mesenteric ischaemia?

A
  • embolisms (50%)
  • thrombosis (20-35%)
  • non-occlusive (<5%)
138
Q

What can cause an arterial embolism causing acute mesenteric ischaemia?

A
  • From left auricle - atrial fibrillation.
  • A mural infarct.
  • Atheroma from aorta or aneurysm.
  • Endocarditis vegetations.
  • Left atrial myxoma.
139
Q

What can cause arterial thrombosis causing acute mesenteric ischaemia?

A
  • Blocks origin of superior mesenteric artery & can cause ischaemia of full length of small bowel.
  • Due to atherosclerosis
  • Often all main splanchnic vessels—coeliac, superior & inferior mesenteric arteries
140
Q

What is an arterial non-occlusive cause of acute mesenteric ischaemia?

A
  • Due to hypotension/hypoperfusion.
  • Due to vasospasm in shock—nonocclusive mesenteric ischaemia (NOMI).
  • Critically ill patients with vasopressor requirements
  • Those undergoing dialysis with large volume fluid removal
141
Q

What can cause SMvenous thrombosis causing acute mesenteric ischaemia?

A 
Occurs in patients with:
- Portal hypertension
- Portal pyaemia
- Sickle cell disease
(Related to the presence of an underlying hypercoagulable state)

BRS YR2 (70 decks)

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