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
What are the 2 main groups of Bowel obstruction?
Paralytic ileus
Mechanical
What classifies Mechanical Bowel obstruction?
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
What is the Aetiology of Small Bowel Obstruction?
Adhesions 60% - Hx of previous abdominal surgery
Neoplasia 20% - Primary, metastatic, extraintestinal
Incarcerated hernia 10% - External abdominal wall, internal (mesenteric effect)
Crohn’s disease 5% - Acute (oedema), Chronic (strictures).
Other 5% - Intussusception, Intraluminal
What is the Aetiology of Large Bowel Obstruction?
Colorectal Carcinoma
Volvulus - Sigmoid, Caecal
Diverticulitis - Inflammation, strictures
Faecal impaction
Hirschsprung’s disease - commonly found in infants/children
How do symptoms present in Small Bowel obstruction?
Abdominal Pain - Colicky, central
Vomiting - Early onset, large amount, bilious
Absolute Constipation - Late sign
Abdominal distension - Less Significant
Dehydration, increased high-pitched tinkling (early sign), absent bowel sounds (late sign), diffuse abdominal tenderness.
How do symptoms present in Large Bowel obstruction?
Abdominal Pain - Colicky, constant
Vomiting - Late onset, initially bilious, progresses to faecal vomiting.
Absolute constipation - Early sign
Abdominal distension - Early sign and significant
Dehydration, increased high-pitched tinkling (early sign), absent bowel sounds (late sign), diffuse abdominal tenderness.
What are the 3 main 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 features suggest Strangulation?
Change in character of pain from colicky to continuous Tachycardia Pyrexia Peritonism Bowel sounds absent or reduced Leucocytosis ↑ed C-reactive protein
Why is it important to diagnose strangulation?
Strangulating obstruction
with peritonitis
has a mortality of up to 15%
What are some common sites for hernias?
Epigastric Umbilical Incisional Inguinal Femoral SMALLER THE WHOLE, THE MORE DANGEROUS
What is Richter’s Hernia?
Knuckle of bowel gets caught, but there is still bowel continuity
What are the blood investigations 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 are the imaging investigations 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 is shown on a Small bowel obstruction X-ray?
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 is shown on a Large bowel obstruction X-ray
Distended large bowel tends to lie peripherally
Show haustrations of taenia coli - do not extend across whole width of the bowel
What does a CT scan show in bowel obstruction?
Can localize site of obstruction
Detect obstructing lesions & colonic tumours
May diagnose unusual hernias (e.g. obturator hernias).
What are the differences between the CT’s of SBO &LBO?
SBO - Collapsed & dilated loops of small bowel due to transition point in the pelvis
LBO -Sigmoid stricture with
proximal dilation
What is the conservative treatment of 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 is the supportive management 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 would be the indications for surgery in 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 surgeries are available 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 the presentation for GIPerforation?
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 is the presentation for (commonest) Perforated Peptic Ulcer?
Suddden Epigastric/Diffuse pain
Referred shoulder pain
History of NSAID’s, steroids, recurrent epigastric pain
What is the presentation of Perforated Diverticulum?
LLQ pain
Constipation
What is the presentation of Perforated appendix?
Migratory pain
Anorexia
Gradual worsening RLQ pain
What is the presentation for perforated malignancy?
Change in bowel habit
weight loss
Anorexia
PR Bleeding
What are the bloods for GI Perforation?
FBC: neutrophilic leukocytosis
Possible elevation of Urea, Creatinine
VBG: Lactic acidosis
What imaging is done for GI Perforation?
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 can give the same symptoms of GI Perforation?
Acute cholecystitis, Appendicitis.
Myocardial infarction, Acute pancreatitis
Chek amylase before theatre
What is the management on presentation of GI Perforation ( conservative)?
NBM & NG tube IV peripheral access with large bore cannula -IV Fluid resuscitation Broad spectrum Abx IV PPI Parenteral analgesia & antiemetics Urinary catheter
What would be the management in localised peritonitis without signs of sepsis?
IR - guided drainage of intra-abdominal collection
Serial abdominal examination & abdominal imaging for assessment
What is the surgical management of GI Perforation?
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 MicroscopyCulture&Sensitivity, peritoneal lavage ++++
If perforated appendix: Lap or open appendicectomy
If malignancy: intraoperative biopsies if possible
What conservative management is effective in treating the majority of patients with a sigmoid volvulus?
A sigmoidoscope is passed with the patient lying in the left lateral position.
A large well lubricated, soft rubber rectal tube is passed along the sigmoidoscope.
This usually untwists the volvulus, with release of vast quantities of flatus & liquid faeces.
How would you restore blood flow of the Superior Mesnteric artery?
Embolectomy of SMA – in embolic AMI
Endovascular management of SMA thrombus – in thrombotic AMI
Arterial bypass of SMA - in thrombotic AMI
What are the arterial issues leading to acute mesenteric ischaemia?
Embolism (50%)—Sources
From left auricle - atrial fibrillation.
A mural infarct.
Atheroma from aorta or aneurysm.
Endocarditis vegetations.
Left atrial myxoma.
Thrombosis (20–35 %)
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
Nonocclusive (<5%)
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
What are the venous causes of acute mesenteric ischaemia?
Venous (10 -15%) Superior mesenteric vein thrombosis Occurs in patients with: Portal hypertension Portal pyaemia Sickle cell disease
Related to the presence of an underlying hypercoagulable state
What is Portal Pyaemia?
Portal pyaemia (pylephlebitis)
Form of septic (often suppurative) thrombophlebitis of the portal venous system
Complication of intra-abdominal sepsis
Diverticulitis
AppendicitisAir in SMV & intrahepatic portal venous system
