General Surgery in the GI Tract Flashcards
What is the general approach to a patient presenting with acute abdominal pain?
PC = use SOCRATES for pain assessment
[Site, Onset, Character, Radiation, Association, Time course, Exacerbating/Relieving factors, Severity / Scale)
PMHx, DHx, SHx
Investigations
Management
What are some investigations that could be performed for acute abdominal pain?
Investigations ordered depend on the presentation
Bloods: VBG, FBC, CRP, U&Es (urea and electrolytes - renal profile), LFTs + amylase
Urinalysis + Urine MC&S - always do these, many acute abdominal issues come from UTIs
Imaging:
Erect CXR, AXR, CTAP (CT abdo and pelvis), CT angiogram (suspected bleeding or infarction of intraabdominal blood vessel), USS
Endoscopy
What are the management approaches for acute abdominal pain?
ABCDE approach - airways, breathing, circulation, disability, exposure
Conservative management
Surgical management
What are the differentials for RUQ / right hypochondriac pain?
Bilary Colic Cholecystitis/Cholangitis Duodenal Ulcer Liver abscess Portal vein thrombosis Acute hepatitis Nephrolithiasis RLL pneumonia
List not exhaustive
What are the differentials for epigastric pain?
Acute gastritis/GORD Gastroparesis Peptic ulcer disease/perforation Acute pancreatitis Mesenteric ischaemia AAA (Abdominal Aortic Aneurysm) Aortic dissection Myocardial infarction
List not exhaustive
What are the differentials for LUQ / left hypochondriac pain?
Peptic ulcer Acute pancreatitis Splenic abscess Splenic infarction Nephrolithiasis Left Lower Lobe Pneumonia
List not exhaustive
What are the differentials for RLQ / right iliac pain?
Acute Appendicitis Colitis IBD Infectious colitis Ureteric stone/Pyelonephritis PID/Ovarian torsion Ectopic pregnancy Malignancy
List not exhaustive
What are the differentials for suprapubic / central pain?
Early appendicitis Mesenteric ischaemia Bowel obstruction Bowel perforation Constipation Gastroenteritis UTI/Urinary retention PID - pelvic inflammatory disease
List not exhaustive
What are the differentials for LLQ / left iliac pain?
Diverticulitis Colitis IBD (Inflammatory Bowel Disease) Infectious colitis Ureteric stone/Pyelonephritis PID/Ovarian torsion Ectopic pregnancy Malignancy
List not exhaustive
How do patients with bowel ischaemia present clinically?
Sudden onset crampy abdominal pain
Severity of pain depends on the length and thickness of colon affected (positive correlation)
Bloody, loose stool (currant jelly stools)
Associated fever, signs of septic shock
What are the risk factors for bowel ischaemia?
Age >65 yrs Cardiac arrythmias (mainly AF) and history of atherosclerosis Hypercoagulation/thrombophilia Vasculitis Sickle cell disease Profound shock causing hypotension
What are the 2 types of bowel ischaemia?
- Acute mesenteric ischaemia
2, Ischaemic collitis
What are the main features of acute mesenteric ischaemia?
Small Bowel
Usually occlusive and secondary due to thromboemboli (SMA) - AF (atrial fibrillation) makes this more likely as cardiac arrythmia can throw small clots to block the SMA
Sudden onest (but presentation and severity varies)
Abdominal pain can be out of proportion of clinical signs
e.g. extreme pain but nothing clinically wrong OR something major clinically but patient feels well
What happens if the clot completely occludes / obstructs the SMA?
Lose all the bowel from the DJ (duodenojejunal) flexure to the splenic flexure - all the small bowel + 3/4 of large bowel
What are the main features of ischaemic Collitis?
Large bowel
Usually due to non-occlusive low flow states or atherosclerosis
More mild and gradual (80-85% of cases)
Moderate pain and tenderness
What investigations should be performed for suspected bowel ischaemia?
Bloods =
FBC: neutrophilic leukocytosis (abnormally high number of neutrophils)
VBG (venous blood gases): Lactic acidosis (low pH from build up of lactic acid due to late stage mesenteric ischaemia = dead bowel)
Imagings =
CTAP/CT Angiogram:
Detects - disrupted flow, vascular stenosis, ‘Pneumatosis intestinalis’ (transmural ischaemia/infarction), and Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)
Endoscopy =
For mild or moderate cases of ischaemic colitis (detects oedema, cyanosis, ulceration of mucosa)
What is the conservative management approach to an ischaemic bowel and when is it used?
Suitable only for mild to moderate cases of ischaemic collitis (not suitable for small bowel ischaemia)
IV fluid resuscitation
Bowel rest - nil by mouth
Broad-spectrum antibiotics - as colonic ischaemia can result in bacterial translocation and subsequent sepsis
NG tube for decompression - in concurrent ileus
Anticoagulation
Treat/manage underlying cause
Serial abdominal examination and repeat imaging - check for changes(e.g. perotonitis inside the abdomen) / progress of treatment
When is surgical management used for ischaemic bowel?
Almost a necessity in most patients
Required in: Small bowel ischaemia Signs of peritonitis or sepsis Haemodynamic instability Massive bleeding Fulminant colitis with toxic megacolon
What are the two types of surgical management?
Exploratory laparotomy =
Explore everything from the DJ flexure to the rectum
Resect necrotic bowel with or without open surgical embolectomy (baloon catheter in SMA) or mesenteric arterial bypass
Endovascular revascularisation =
Balloon angioplasty/thrombectomy
In patients without signs of ischaemia
How does acute appendicitis present clinically?
Initially periumbilical pain that migrates to RLQ (within 24hours)
Usually associated with anorexia, nausea +/- vomiting, low grade fever, change in bowel habit (due to inflamed appendix located next to the rectum, irrtating it, hence altering the bowel habit)
Good way to test for anorexia - ask to get them a meal, if they refuse, likely to be appendicitis
What are the important clinical signs in acute appendicitis?
McBurney’s point = usually where the appendix lies (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus), tenderness in the RLQ
Blumberg sign = rebound tenderness especially in the RIF (right iliac fossa) - press down and suddenly release = patient suddenly jump
Rovsing sign = RLQ pain elicited on deep palpation of the LLQ - press down on the left iliac fossa but they report pain in the right iliac fossa due to moving of the perotineum causing irritation on the other side
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 should be carried out for suspected 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 laparotomy = only used in persistent pain and inconclusive imaging
What is the diagnostic tool used for acute appendicits?
Alvardo score = consists of 6 clinical items:
(brackets represent points awarded for each sign)
RLQ Tendereness (2) Fever (1) Rebound tenderness (1) Pain migration (1) Anorexia (1) Nausea +/- vomiting (1) WCC > 10,000 (2) Neutrophilia (left shift) (1)
≤4 Unlikely
5-6 Possible
≥7 Likely
What is the conservative management for acute appendicitis?
When do you use conservative management?
Conservative Management =
IV Fluids, Analgesia, IV or PO Antibiotics
In abscess, phlegmon or sealed perforation - resuscitation + IV antibiotics +/- percutaneous drainage
Only used when =
After negative imaging in selected patients with clinically uncomplicated appendicitis
Usually when patient presents late with mass/abscess/phlegmon formation in their RIF (right iliac fossa) = CT-guided drainage and IV antibiotics as surgery to now take appendix out is a major undertaking so it is far better to treat conservatively
What is an interval appendicectomy and why is it used after conservative management of acute appendicitis?
Take out appendix electively on a scheduled date
Although late presentations are treated conservatively initially due to risk of surgery complications
After consevative management, most patients are later revisted with an interval appendicectomy as rate of recurrence after conservative management of abscess/perforation is 12-24%, so appendix is taken out later electively before it causes further issues
What are the benefits of laparoscopic over open appendicectomy ?
Less pain Lower incidence of surgical site infection Decreased length of hospital stay Earlier return to work Overall costs Better quality of life scores
Most patients are home the next day = quick recovery time
What are the steps of laparoscopic appendicectomy?
Trocar placement (usually at 3 port sites)
Exploration of RIF & identification of appendix
Elevation of appendix + division of mesoappendix (containing artery)
Based secured with endoloops and appendix is divided - so first you mobilise the appendix, then you lasso around the base and tighten
Retrieval of appendix with a plastic retrieval bag - to avoid infection spreading in the abdo cavity and port site
Careful inspection of the rest of the pelvic organs/intestines
Pelvic irrigation (lavage / wash out) + Haemostasis
Removal of trocars + wound closure
What is bowel / intestinal obstruction?
Restriction of normal passage of intestinal contents
