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Yr2 Lily BRS Gastro > General surgery in the GI tract > Flashcards

General surgery in the GI tract Flashcards

1
Q

what is the general approach to acute abdomen?

A

PC – Pain assessment (SOCRATES)*, associated symptoms

PMHx, DHx, SHx

Range of investigations (depending on presentation):
Bloods: VBG, FBC, CRP, U&Es (renal profile), LFTs +amylase
Urinalysis + Urine MC&S
Imaging: Erect CXR, AXR, CTAP (ct abdomen adn pelvis), CT angiogram, USS
Endoscopy

Management:
ABCDE approach (airways breathing circulation disability (GCS, eyes etc)
Conservative management
Surgical management

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2
Q

what are the differential diagnoses for RUQ pain?

A 
Bilary Colic
Cholecystitis/Cholangitis
Duodenal Ulcer
Liver abscess
Portal vein thrombosis
Acute hepatitis
Nephrolithiasis
RLL pneumonia
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3
Q

what are the differential diagnoses for epigastrium 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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4
Q

what are the differential diagnoses for LUQ pain?

A 
Peptic ulcer
Acute pancreatitis
Splenic abscess
Splenic infarction
Nephrolithiasis
LLL Pneumonia
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5
Q

what are the differential diagnoses for RLQ pain?

A 
Acute Appendicitis
Colitis
IBD
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy
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6
Q

what are the differential diagnoses for suprapubic/central pain?

A 
Early appendicitis
Mesenteric ischaemia
Bowel obstruction
Bowel perforation
Constipation
Gastroenteritis
UTI/Urinary retention
PID
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7
Q

what are the differential diagnoses for LLQ pain?

A 
Diverticulitis
Colitis
IBD (Inflammatory Bowel Disease)
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy
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8
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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9
Q

what are risk factors for 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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10
Q

what are the differences between acute mesenteric ischaemia and ischemic colitis?

A

Acute Mesenteric Ischaemia:
Small bowel

Usually occlusive due tothromboemboli

Sudden onset (but presentation and severityvaries)

Abdominal pain out of proportion of clinical signs

Ischaemic Colitis:
Large bowel

Usuallydue to non-occlusive low flow states, or atherosclerosis

More mild and gradual (80-85% of the cases)

Moderate pain and tenderness

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11
Q

what investigations are done for bowel ischaemia?

A

Bloods:
FBC: neutrophilic leukocytosis
VBG: Lactic acidosis (means it late stage and the bowel is dead already)

Imaging -CTAP/CTAngiogram:
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)

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12
Q

what is conservative management of bowel ischaemia?

A

Mild to moderate cases of ischaemic colitis (not suitable for SB ischaemia):
IV fluid resuscitation
Bowel rest(nil my mouth)
Broad-spectrum ABx - colonic ischaemia can result in bacterial translocation & sepsis
NG tube for decompression - in concurrent ileus (no peristalsis)
Anticoagulation
Treat/manage underlying cause
Serial abdominal examination and repeat imaging

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13
Q

what is surgical management of Bowel ischaemia?

A 
Indications:
Small bowel ischaemia
Signs of peritonitis orsepsis
Haemodynamic instability
Massive bleeding
Fulminant colitis with toxic megacolon

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

Endovascular revascularisation:
Balloon angioplasty/thrombectomy
In patients without signs of ischaemia

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14
Q

how does acute appendicitis present?

A

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

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15
Q

what investigations are done for acute appendicitis?

A

Bloods:
FBC: neutrophilic leukocytosis
↑ed 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

alvarado score is used to assess likelihood of appendicitis

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16
Q

what is conservative management of acute appendicitis?

A

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(as it would be a big undertaking to operate)

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

17
Q

what is surgical management of acute appendicitis?

A 
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

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
18
Q

how are bowel obstructions classified?

A

Intestinal obstruction - restriction of normal passage of intestinal contents.
Two main groups:
Paralytic (Adynamic) ileus
Mechanical.

Mechanical intestinal obstruction classified by:
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.

19
Q

what is the aetiology of bowel obstructions?

A

small bowel:
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:
Colorectal carcinoma
Volvulus - Sigmoid, Caecal
Diverticulitis - Inflammation, strictures
Faecal impaction
Hirschsprung disease - commonly found in infants/children

20
Q

how do small bowel obstructions present?

A

pain:
colicky central

vomiting:
Early onset
Large amount
Bilious

absolute constipation:
late sign

abdominal distention:
less significant

other signs:
Dehydration
Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign)
Diffuse abdominal tenderness

21
Q

how do large bowel obstructions present?

A

pain:
colicky or constant

vomiting:
Late onset
Initially bilious
Progresses to faecal vomiting

absolute constipation:
early sign

abdominal distention:
early sign and significant

other signs:
Dehydration
Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign)
Diffuse abdominal tenderness

22
Q

how are bowel obstructions diagnosed?

A

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? (simple, bowel is still viable)

Features suggesting strangulation are:
Change in character of pain from colicky to continuous
Tachycardia
Pyrexia
Peritonism
Bowel sounds absent or reduced
Leucocytosis
↑ed C-reactive protein

Strangulating obstruction
with peritonitis
has a mortality of up to 15%

23
Q

what investigations are done for bowel obstruction?

A

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

24
Q

what are the x ray signs for 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.

25
Q

what are the x ray signs for large bowel obstruction?

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.

26
Q

how are CT scans used in bowel obstruction?

A

Can localize site of obstruction

Detect obstructing lesions & colonic tumours

May diagnose unusual hernias (e.g. obturator hernias).

27
Q

how are bowel obstructions conservatively managed?

A

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

Conservative treatment:
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

28
Q

how are bowel obstructions managed surgically?

A

Indications:
Haemodynamic instability or signs of sepsis
Complete bowel obstruction with signs of ischaemia
Closed loop obstruction
Persistent bowel obstruction >2 days despite conservative management

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

(endoscopic stenting - distal obstruction, usually in patients with tumours)

29
Q

how does a GI perforation present?

A

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

30
Q

what are different types of GI perforations?

A

perforated peptic ulcer:
Sudden epigastric or diffuse pain
Referred shoulder pain
Hx of NSAIDs, steroids, recurrent epigastric pain

perforated diverticulum:
LLQ pain
constipation

perforated appendix:
migratory pain
anorexia
gradual worsening RLQ pain

perforated malignancy:
change in bowel habit
weight loss
anorexia
PR bleeding
31
Q

what investigations are done for a GI perforation?

A

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

Differential Diagnosis:
Acute cholecystitis, Appendicitis.
Myocardial infarction, Acute pancreatitis

32
Q

how are GI perforations managed conservatively?

A 
Supportive management on presentation:
NBM & NG tube 
IV peripheral access with large bore cannula -IV Fluid resuscitation
Broad spectrum Abx
IV PPI
Parenteral analgesia & antiemetics
Urinary catheter

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

33
Q

how are GI perforations managed surgically?

A

Surgical management in generalised peritonitis +/- signs ofsepsis:
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

34
Q

look in notes for a good table summarising biliary colic, acute cholecystitis, acute cholangitis and acute pancreatitis

A

okay

Yr2 Lily BRS Gastro (7 decks)

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