General Surgery in the GI Tract Flashcards
What is the approach for the management of abdominal pain?
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 angiogram, USS
Endoscopy
Management
ABCDE approach
Conservative management
Surgical management
What could RUQ pain be?
Bilary Colic Cholecystitis/Cholangitis Duodenal Ulcer Liver abscess Portal vein thrombosis Acute hepatitis Nephrolithiasis RLL pneumonia
What could Epigastric pain be?
Acute gastritis/GORD Gastroparesis Peptic ulcer disease/perforation Acute pancreatitis Mesenteric ischaemia AAA (Abdominal Aortic Aneurysm) Aortic dissection Myocardial infarction
What could LUQ pain be?
Peptic ulcer Acute pancreatitis Splenic abscess Splenic infarction Nephrolithiasis LLL Pneumonia
What could RLQ pain be?
Acute Appendicitis Colitis IBD Infectious colitis Ureteric stone/Pyelonephritis PID/Ovarian torsion Ectopic pregnancy Malignancy
What could Suprapubic/Central pain be?
Early appendicitis Mesenteric ischaemia Bowel obstruction Bowel perforation Constipation Gastroenteritis UTI/Urinary retention PID
What could LLQ pain be?
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 the risks for Bowel Ischaemia?
Age >65 yr Cardiac arrythmias (mainly AF), atherosclerosis Hypercoagulation/thrombophilia Vasculitis Sickle cell disease Profound shock causing hypotension
What happens in Acute Mesenteric Ischaemia?
Small Bowel
Usually occlusive due to thromboemboli
Sudden onset
Abdominal pain out of proportion of clinical signs
What happens in Ischaemic Colitis?
Large Bowel
Usually due to non-occlusive low flow states
More mild and gradual
Moderate pain and tenderness
What Investigations would you do for Bowel Ischaemia?
Bloods
FBC: neutrophilic leukocytosis
VBG: Lactic acidosis - late stage
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
What is the management for mild/moderate ischaemic colitis (not small bowel 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 the indications for surgery in Bowel Ischaemia?
Small bowel ischaemia Signs of peritonitis orsepsis Haemodynamic instability Massive bleeding Fulminant colitis with toxic megacolon
What are the surgical options for Bowel Ischaemia?
Exploratory laparotomy:
Resection of necrotic bowel +/-open surgicalembolectomy
or mesenteric arterial bypass
Endovascular revascularisation:
Balloon angioplasty/thrombectomy
In patients without signs of ischaemia
What is the 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 the 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 are the investigations if you suspect Acute Pendicitis?
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
What are the classifications of the Alvarado score in Acute Appendicitis?
<4 - unlikely
5-6 - possible
>7 likely
WHta 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 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
Consider interval appendicectomy - rate of recurrence after conservative management of abscess/perforation is 12-24%
Why is Laparoscopic appendicectomy better than an open one?
Less pain Lower incidence of surgical site infection ↓ed length of hospital stay Earlier return to work Overall costs Better quality of life scores
What are the steps of a 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 happens in Bowel obstruction?
Restriction of normal passage of intestinal contents
