General Surgery in the GI tract Flashcards
Describe general approach to an acute abdomen
PC: Pain assessment (SOCRATES)*, associated symptoms
Investigations:
Bloods: VBG, FBC, CRP, U&Es (renal profile), LFTs +amylase
Urinalysis + Urine MC&S
Imaging: Erect CXR, AXR, CTAP, CT angiogram, USS
Endoscopy
Management options: ABCDE approach, Conservative management, Surgical management
What are differential diagnoses for pain in the right upper quadrant?
Bilary Colic Cholecystitis/Cholangitis Duodenal Ulcer Liver abscess Portal vein thrombosis Acute hepatitis Nephrolithiasis RLL pneumonia
What are differential diagnoses for pain in the epigastrium?
Acute gastritis/GORD Gastroparesis Peptic ulcer disease/perforation Acute pancreatitis Mesenteric ischaemia AAA (Abdominal Aortic Aneurysm) Aortic dissection Myocardial infarction
What are differential diagnoses for pain in the left upper quadrant?
Peptic ulcer Acute pancreatitis Splenic abscess Splenic infarction Nephrolithiasis LLL Pneumonia
What are differential diagnoses for pain in the right lower quadrant?
Acute Appendicitis Colitis IBD Infectious colitis Ureteric stone/Pyelonephritis PID/Ovarian torsion Ectopic pregnancy Malignancy
What are differential diagnoses for pain in the suprapubic/central region?
Early appendicitis Mesenteric ischaemia Bowel obstruction Bowel perforation Constipation Gastroenteritis UTI/Urinary retention PID
What are differential diagnoses for pain in the left lower quadrant?
Diverticulitis Colitis IBD (Inflammatory Bowel Disease) Infectious colitis Ureteric stone/Pyelonephritis PID/Ovarian torsion Ectopic pregnancy Malignancy
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 risk factors of bowel ischaemia?
Age >65 yr Cardiac arrythmias (mainly AF), atherosclerosis Hypercoagulation/thrombophilia Vasculitis Sickle cell disease Profound shock causing hypotension
What are the features of acute mesenteric ischaemia?
Affects small bowel, usually occlusive due to a thromboemboli, sudden onset (presentation + severity varies), abdominal pain out of proportion with clinical signs.
What are the features of ischaemic colitis?
Affects large bowel, usuallydue to non-occlusive low flow states, or atherosclerosis, mild and gradual, moderate pain and tenderness.
What investigations are carried out for bowel ischaemia?
Bloods:
FBC: neutrophilic leukocytosis
VBG: Lactic acidosis
Imaging: CTAP/CT Angiogram
Detects disrupted flow
Vascular stenosis
Pneumatosis intestinalis’ (transmural ischaemia /infarction)
Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)
Endoscopy:
For mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)
What are conservative management options for mild to moderate cases of ischaemic colitis?
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 indications for surgical management of ischemic colitis?
Small bowel ischaemia Signs of peritonitis orsepsis Haemodynamic instability Massive bleeding Fulminant colitis with toxic megacolon
What is exploratory laparotomy?
Resection of necrotic bowel +/-open surgicalembolectomy or mesenteric arterial bypass
What does endovascular revascularisation involve?
Balloon angioplasty/thrombectomy
In patients without signs of ischaemia
Describe presentation of acute appendicitis
Initially periumbilical pain that migrates to RLQ (within 24hours)
Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit
What are important clinical signs of acute appendicitis?
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 investigations are carried out for acute appendicitis?
Bloods:
FBC: neutrophilic leukocytosis
Increased CRP
Urinalysis: possible mild pyuria/haematuria
Electrolyte imbalances in profound vomiting
Imaging
CT: gold standard in adults esp. if age > 50
USS: children/pregnancy/breastfeeding
MRI: in pregnancy if USS inconclusive
Diagnostic Laparoscopy- In persistent pain & inconclusive imaging
What measures does the Alvarado score take into account?
RLQ tenderness, fever, rebound tenderness, pain migration, anorexia, nausea and vomiting, white cell count above 10,000, neutrophilia.
Calculates how possible appendicitis is.
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
What are 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
What else can be considered for conservative management of acute appendicitis?
Consider interval appendicectomy - rate of recurrence after conservative management of abscess/perforation is 12-24%
Compare laparoscopic vs open appendicetomy
Less pain Lower incidence of surgical site infection Decreased length of hospital stay Earlier return to work Overall costs Better quality of life scores
PILE CQ
What are the steps of laparoscopic appendicectomy?
- Trocar placement (usually 3)
- Exploration of RIF & identification of appendix
- Elevation of appendix + division of mesoappendix (containing artery)
- Based secured with endoloops and appendix is divided
- Retrieval of appendix with a plastic retrieval bag
- Careful inspection of the rest of the pelvic organs/intestines
- Pelvic irrigation (wash out) + Haemostasis
- Removal of trocars + wound closure
What is intestinal obstruction and what are the 2 main types?
Intestinal obstruction - restriction of normal passage of intestinal contents.
Two main groups: Paralytic (Adynamic) ileus, Mechanical.
How is mechanical intestinal obstruction 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
What are the aetiologies of bowel obstruction?
- 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.
What are the aetiologies of small bowel obstruction?
- Adhesions (60%) - history of past abdominal surgery
- Neoplastic (20%) - primary, metastatic, extraintestinal
- Incarcerated hernia (10%) - external in abdominal wall or internal mesenteric defect
- Crohn’s Disease (5%) - acute (oedema), chronic (strictures)
- Other - intussusception, intraluminal (foreign body, bezoar)
What are the aetiologies of large bowel obstruction?
- Colorectal carcinoma
- Volvulus - sigmoid, caecal
- Diverticulitis - inflammation, strictures
- Faecal impaction
- Hirschsprung disease - common in children
Describe the signs of small bowel obstruction
- Colicky, central abdominal pain
- Early onset, large amount and bilious vomiting
- Late sign is absolute constipation
- Abdominal distension is a less significant sign
Describe the signs of large bowel obstruction
- Colicky or constant abdominal pain
- Late onset vomiting which is initially bilious but turns to faecal vomiting
- Absolute constipation is an early sign
- Abdominal distention is an early, significant sign
What are common signs of large and small bowel obstruction?
- Dehydration
- Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign)
- Diffuse abdominal tenderness
What are 3 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 a strangulating obstruction?
Change in character of pain from colicky to continuous Tachycardia Pyrexia Peritonism Bowel sounds absent or reduced Leucocytosis ↑ed C-reactive protein
What is a possible clinical outcome of strangulation?
Strangulating obstruction with peritonitis has a mortality of up to 15%.
What are common hernal sites and 3 types of hernia?
Common sites: Epigastric, umbilical, incisional, inguinal and femoral
3 types: Neck of sac, strangulated hernia, Richter’s hernia
What blood investigations need to be carried out 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)`
What imaging should be carried out for bowel obstruction?
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 will an abdominal X-ray show in the case of a 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 will an abdominal X-ray show in the case of a large bowel obstruction?
Distended large bowel tends to lie peripherally.
Show haustrations of taenia coli - do not extend across whole width of the bowel.
Why is CT useful for bowel obstruction?
- Can localize site of obstruction
- Detect obstructing lesions & colonic tumours
- May diagnose unusual hernias (e.g. obturator hernias).
What are supportive management options for bowel obstruction?
- 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 are conservative treatment options for 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 indications 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 carried out 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
What is 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 signs of a perforated peptic ulcer?
Sudden epigastric or diffuse pain
Referred shoulder pain
Hx of NSAIDs, steroids, recurrent epigastric pain
What are signs of a perforated diverticulum?
LLQ pain
Constipation
What are signs of a perforated appendix?
Migratory pain
Anorexia
Gradual worsening RLQ pain
What are the signs of a perforated malignancy?
Change in bowel habit
Weight loss
Anorexia
PR Bleeding
What investigations are carried out in the case of a GI perforation and what would they show?
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 supportive management options for a GI perforation?
NBM & NG tube IV peripheral access with large bore cannula -IV Fluid resuscitation Broad spectrum Abx IV PPI Parenteral analgesia & antiemetics Urinary catheter
What are conservative management options in localised peritonitis without signs of sepsis?
Is very rare. IR - guided drainage of intra-abdominal collection. Serial abdominal examination & abdominal imaging for assessment.
What are surgical management options in the case of peritonitis with or without sepsis?
¬1. Exploratory laparotomy/laparascopy
- 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 are symptoms, investigations and management options for biliary colic?
Symptoms: PostprandialRUQ pain with radiation to the shoulder. Nausea.
Investigations: Normal blood results. USS: cholelithiasis.
Management: Analgesia, Antiemetics, Spasmolytics. Follow up for elective cholecystectomy.
What are symptoms, investigations and management options for acute cholecystitis?
Symptoms: Acute, severe RUQ pain. Fever. Murphy’s sign.
Investigations: Elevated WCC/CRP. USS: thickened gallbladder wall
Management: Fluids, ABx, Analgesia, Blood cultures. Early (<72 hours) or elective cholecystectomy (4-6 weeks).
What are symptoms, investigations and management options for acute cholangitis?
Symptoms: Charcot’s triad: jaundice, RUQ pain, fever
Investigations: Elevated LFTs, WCC, CRP, Blood MCS (+ve). USS: bilary dilatation.
Management: Fluids, IV Abx, Analgesia
ERCP (within 72hrs) for clearance of bile duct or stenting
What are symptoms, investigations and management options for acute pancreatitis?
Symptoms: Severe epigastric pain radiating to the back. Nausea +/- vomiting. Hx of gallstones or EtOH use.
Investigations: Raised amylase/lipase. High WCC/Low Ca2+. CT and US to assess for complications/cause.
Management: Admission score (Glasgow-Imrie). Aggressive fluid resuscitation, O2. Analgesia, Antiemetics. ITU/HDU involvement.
