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BRS Phase 1b > General Surgery in the GI Tract > Flashcards

General Surgery in the GI Tract Flashcards

1
Q

What is the approach for the management of abdominal pain?

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 angiogram, USS
Endoscopy

Management
ABCDE approach
Conservative management
Surgical management

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2
Q

What could RUQ pain be?

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

What could Epigastric pain be?

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 could LUQ pain be?

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

What could RLQ pain be?

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

What could Suprapubic/Central pain be?

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

What could LLQ pain be?

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

What is the presentation of Bowel Ischaemia?

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 the risks 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 happens in Acute Mesenteric Ischaemia?

A

Small Bowel
Usually occlusive due to thromboemboli
Sudden onset
Abdominal pain out of proportion of clinical signs

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11
Q

What happens in Ischaemic Colitis?

A

Large Bowel
Usually due to non-occlusive low flow states
More mild and gradual
Moderate pain and tenderness

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12
Q

What Investigations would you do for Bowel Ischaemia?

A

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

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13
Q

What is the management for mild/moderate ischaemic colitis (not small bowel ischaemic colitis)?

A

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

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14
Q

What are the indications for surgery in Bowel Ischaemia?

A 
Small bowel ischaemia
Signs of peritonitis orsepsis
Haemodynamic instability
Massive bleeding
Fulminant colitis with toxic megacolon
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15
Q

What are the surgical options for Bowel Ischaemia?

A

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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16
Q

What is the presentation of Acute Appendicitis?

A

Initially periumbilical pain that migrates to RLQ (within 24hours)
Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit

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17
Q

What are the clinical signs of Acute Appendicitis?

A

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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18
Q

What are the investigations if you suspect Acute Pendicitis?

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

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19
Q

What are the classifications of the Alvarado score in Acute Appendicitis?

A

<4 - unlikely
5-6 - possible
>7 likely

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20
Q

WHta does conservative management of acute appendicitis consist of

A

IV Fluids, Analgesia, IV or PO Antibiotics
In abscess, phlegmon or sealed perforation
Resuscitation + IV ABx +/- percutaneous drainage

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21
Q

What are the indications for conservative management of acute appendicitis?

A

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%

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22
Q

Why is Laparoscopic appendicectomy better than an open one?

A 
Less pain
Lower incidence of surgical site infection
↓ed length of hospital stay
Earlier return to work
Overall costs
Better quality of life scores
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23
Q

What are the steps of a Laparoscopic Appendicectomy?

A

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

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24
Q

What happens in Bowel obstruction?

A

Restriction of normal passage of intestinal contents

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25
What are the 2 main groups of Bowel obstruction?
Paralytic ileus | Mechanical
26
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
27
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
28
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
29
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.
30
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.
31
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?
32
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 ```
33
Why is it important to diagnose strangulation?
Strangulating obstruction with peritonitis has a mortality of up to 15%
34
What are some common sites for hernias?
``` Epigastric Umbilical Incisional Inguinal Femoral SMALLER THE WHOLE, THE MORE DANGEROUS ```
35
What is Richter's Hernia?
Knuckle of bowel gets caught, but there is still bowel continuity
36
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)
37
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
38
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.
39
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
40
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).
41
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
42
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 adhesional small bowel obstruction
43
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
44
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 
45
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
46
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
47
What is the presentation for (commonest) Perforated Peptic Ulcer?
Suddden Epigastric/Diffuse pain Referred shoulder pain History of NSAID's, steroids, recurrent epigastric pain
48
What is the presentation of Perforated Diverticulum?
LLQ pain | Constipation
49
What is the presentation of Perforated appendix?
Migratory pain Anorexia Gradual worsening RLQ pain
50
What is the presentation for perforated malignancy?
Change in bowel habit weight loss Anorexia PR Bleeding
51
What are the bloods for GI Perforation?
FBC: neutrophilic leukocytosis Possible elevation of Urea, Creatinine VBG: Lactic acidosis
52
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
53
What can give the same symptoms of GI Perforation?
Acute cholecystitis, Appendicitis. Myocardial infarction, Acute pancreatitis Chek amylase before theatre
54
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  ```
55
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
56
What is the surgical management of GI Perforation?
Surgical management in generalised peritonitis +/- signs of sepsis Exploratory laparotomy/laparascopy Primary closure of perforation with or without omental patch (most common in perforated peptic ulcer) Resection of the perforated segment of the bowel with primary anastomosis or temporary stoma  Obtain intra-abdominal fluid for MicroscopyCulture&Sensitivity, peritoneal lavage ++++ If perforated appendix: Lap or open appendicectomy If malignancy: intraoperative biopsies if possible
57
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.
58
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
59
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
60
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
61
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

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