General Surgery in the GI Tract Flashcards
List 8 examples of causes of acute RUQ pain
Bilary Colic
Cholecystitis/Cholangitis
Duodenal Ulcer
Liver abscess
Portal vein thrombosis
Acute hepatitis
Nephrolithiasis (aka kidney stones)
RLL pneumonia [Right Lower Lobe]
List 8 examples of causes of acute epigastrum pain
Acute gastritis/GORD
Gastroparesis
Peptic ulcer disease/perforation
Acute pancreatitis
Mesenteric ischaemia
AAA (Abdominal Aortic Aneurysm) Aortic dissection
Myocardial infarction
List 6 examples of causes of acute LUQ pain
Peptic ulcer
Acute pancreatitis
Splenic abscess
Splenic infarction
Nephrolithiasis
LLL Pneumonia
List 8 examples of causes of acute RLQ pain
Acute Appendicitis
Colitis
IBD
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy
List 8 examples of causes of acute suprapubic/central pain
Early appendicitis
Mesenteric ischaemia
Bowel obstruction
Bowel perforation
Constipation
Gastroenteritis
UTI/Urinary retention
PID (Pelvic inflammatory pain)
List 8 examples of causes of acute LLQ pain
Diverticulitis
Colitis
IBD (Inflammatory Bowel Disease)
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy
List 4 typical presentations 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
List 6 risk factors for bowel ischaemia
Age >65 yr
Cardiac arrythmias (mainly AF), atherosclerosis
Hypercoagulation/thrombophilia
Vasculitis
Sickle cell disease (Common)
Profound shock causing hypotension
What are the two different types of bowel ischaemia?
Acute Mesenteric Ischaemia
Ischaemic Colitis
List 4 different ways acute mesenteric ischaemia and ischaemic colitis differ from eachother.
Acute mesenteric iscahemia effects small bowel whereas IC affects large bowel
AMI (not myo infarct) has occlusive causes such as thromboemboli. Ischaemic collitis due to non-occlusive low flow states or atherosclerosis.
Acute mesenteric ischaemia has a sudden onset with varying severity whereas IC has a mild and gradual onset.
Acute mesenteric ischamia present with abdominal pain out of proportion to clinical signs whereas IC has moderate pain and tenderness
List 3 main investigations that should be performed in patients suspected of bowel ischaemia
Bloods: E.g. FBC, VBG
Imaging: CT angiogram
Endoscopy
What findings from a FBC and VBG would increase the suspicions of a patient having bowel ischaemia?
FBC would show neutrophilic leukocytosis (high neutrophils)
VBG: Could show lactic acidosis (indication of late stage bowel ischaemia)
What findings from a CT angiogram would increase the suspicions of a patient having bowel ischaemia?
Disrupted blood flow and vascular stenosis
Pneumatosis intestinalis (Radiological finding of gas in the bowels) Indicates transmural ischaemia/infarction
Thumbprint sign (unspecific sign of colitis)
N.B. CT angiogram showing disrupted blood flow
For a patient assumed to have mild/moderate cases of ischaemic colitis, what investigation could be considered and what are 3 common findings?
Endoscopy
Oedema
Cyanosis
Ulceration of mucosa
What is the management plan for mild/moderate ischaemic colitis? (7)
IV fluid resuscitation
Bowel rest (NIL by mouth)
Broad spectrum AB (reduces risk of sepsis and bacteraemia as a result of colon ischaemia)
NG tube (Ileus
Anticoagulation
Treat underlying cause
Serial abdominal examination and repeat imaging
Conservative management of mild/modrate ischaemic colitis is not suitable for?
Small bowel ischaemia (e.g. acute mesenteric ischaemia)
List 5 indications that a person suspected of bowel ischaemia should recieve surgical management?
Small bowel ischaemia (e.g. acute mesenteric ischaemia)
Signs of peritonitis or sepsis
Haemodynamic instability
Massive bleeding
Fulminant colitis with toxic megacolon
What type of surgery should be provided for patients with bowel ischaemia and what does the surgery involve?
Explorative laparotomy
Involves looking at the bowel directly for signs of necrosis. Any findings of necrotic bowel results in its resection.
Alongisde necrotic bowel resection, may or may not perform open surgical embolectomy (removal of embolus occluding blood supply) or a mesenteric artery bybass [alternate route for blood form aorta to supply the gut].
These additional procedures tend to be performed in severe cases
What non surgical, invasive procedure can be considered in patients with chronic ischaemia/ in patients with no signs of ischeamia?
Endovascular revascularisation (e.g. Balloon angioplasty/thrombectomy)
List 5 important clinical signs of acute appendicitis
McBurney’s sign: Tenderness in the RLQ (lateral third between ASIS and umbillicus)
Blumberg sign: Rebound tenderness in right iliac fossa (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
Tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
McBurney’s point
Rebound tenderness especially in the RIF
Blumberg sign
RLQ pain elicited on deep palpation of the LLQ
Rovsing sign
RLQ pain elicited on flexion of right hip against resistance
Psoas sign
RLQ pain on passive internal rotation of the hip with hip & knee flexion
Obturator sign
List 4 examples of findings which may support suspicion of acute appendicitis.
Neutrophilic leukocytosis
Elevated CRP
Mild Pyuria ( WBC in urine)
Mild Haematuria
Electrolyte imbalances in profound vomitting
What is the gold standard imaging for diagnosis of acute appendicitis (esp in age > 50)?
CT scan
CT scan is gold standard for diagnosing acute appendicitis. What 2 other imaging techniques could be performed and when would they be more suitable over a CT scan?
USS: Children, Pregnant women, Breastfeeding
MRI: In pregnancy if USS is inconclusive
If a patient suspected of appendicitis has persistent pain and no inclocusive imaging, what is the next step of action to confirm suspicions?
Diagnostic laproscopy (Keyhole surgery)
Name the scoring system that can help in diagnosis of acute appendicitis
Alvarado score
State the alvarado scoring range which would suggest a person is unlikely, possible or likely to have acute appendicitis
< 4 = Unlikely
5-6 = possible
> = Likely
What is the conservative management plan for acute appendicitis?
IV fluid
IV or PO ABs
Analgesia
In abscess, phlegmon or sealed perforation (Resuscitation + IV ABx +/- percutaneous drainage)
What is the conservative management plan for acute appendicitis characterised by in abscess, phlegmon or sealed perforation?
Resuscitation + IV ABx +/- percutaneous drainage
What are the 2 main indications to provide a patient with acute appendicitis only conservative management?
After negative imaging in selected patients with clinically uncomplicated appendicitis
In delayed presentation with abscess/phlegmon formation [e.g. complain of weeks worth of pain and find abscess] (CT-guided drainage is advised and see how that goes)
Why should all patients recieving conservative management for appendicitis be considered for interval appendicetomy?
Should be considered as rate of reccurence after conservative treatment is 12-24%
What are two surgical options for an appendicetomy?
Laproscopy
Open apendicetomy
List 6 benefits of laproscopy over open apendicetomy
Less pain
Lower incidence of surgical site infection
↓ed length of hospital stay
Earlier return to work
Overall costs
Better quality of life scores
List 8 steps of laproscopic appendicetomy
- 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
Define bowel obstruction
Condition characterised by restriction of normal passage of intestinal contents.
What are the two main groups of bowel obstruction?
Paralytic ileus (basically more functional)
Mechanical (e.g. physical obstruction)
Mechanical intestinal obstruction can be classified by speed of onset, site, nature and aetiology. What are the 3 different types of onset?
Acute
Chronic
Acute-on-chronic
Mechanical intestinal obstruction can be classified by speed of onset, site, nature and aetiology. What are the 2 sites of obstruction?
High (usually small bowel)
Low (Usually large bowel)
Mechanical intestinal obstruction can be classified by speed of onset, site, nature and aetiology. What are the 2 potential natures of the mechanical obstruction?
Simple (Obstruction which does not compromise blood supply)
Strangulating: Blood supply of the component of bowel obstructed is comprimised (e.g. strangulated hernia, volvulus, intussusception)
Give 3 examples of causes of strangulated mechanical bowel obstrcution?
Strangulated hernia
Volvulus (loop of intestine twists around itself and the mesentery that supplies it)
Intussusception (parts of the intestine slip into the lumen of other portions of the intestine)
What 3 aetiological causes are considered in the classification of mechanical bowel obstruction?
Causes in the lumen (e.g. faecal impactation)
Causes in the wall (e.g. crohn’s disease, tumorsm, colon diverticula)
Causes outside the wall (e.g. volvolus, strangulated hernia, obstruction due to adhesions or bands)
Give 3 examples of causes of mechanical bowel obstruction due to problems in the lumen
Faecal impactation
Gallstone ileus
Give 3 examples of causes of mechanical bowel obstruction due to problems in the wall of the intestine
Crohn’s disease
Tumor
Colon diverticula
Give 3 examples of causes of mechanical bowel obstruction due to problems outside the wall of the bowel
Strangulated hernia
Volvulus
Adhesions or bands
What is the most common cause of small bowel obstruction?
Adhesions (60%) [Usually in patients with previous abdominal surgery]
List 5 potential causes of small bowel obstruction from most common to least
Adhesion (60%)
Neoplastic causes (20%) [e.g. primary, metastatic or 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)]
List 5 potential causes of large bowel obstruction
Colorectal carcinoma
Volvulus
Diverticulus
Faecal impactation
Hirschsprung disease (common in children/infants)
List 5 main signs/symptoms of bowel obstruction
Abdominal pain
Vomiting
Absolute constipation
Abdominal distention
Other signs: Dehydration, Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign), Diffuse abdominal tenderness
How does the symptoms of small bowel obstruction differ to large bowel obstruction?
Abdominal pain: Colicky and central (SB) vs Colicky and constant (LB)
Vomitting: Early onset, large amount and billous [green] (SB) vs late onset, intially billous but progresses to faecal vomitting (LB)
Absolute constipation: Late sign (SB) vs early sign (LB)
Abdominal distention: Less significant (SB) vs early sign and significant (LB)
Examination of a patient with suspicion of bowel obstruction should always involve?
Search for hernias & abdominal scars, including laparoscopic portholes
List 6 signs/symptoms of bowel obstruction which could indicate that cause is strangulating in nature.
Change in character of pain from colicky to continuous
Tachycardia
Pyrexia
Peritonism
Bowel sounds absent or reduced
Leucocytosis
↑ed C-reactive protein
Why should strangulating bowel obstruction require immediate medical attention?
Strangulating obstruction with peritonitis has a mortality of up to 15%
List 5 common hernia sites
Epigastrum
Umbilical
Incisional
Inguinal
Femoral
What is a Ritcher’s Hernia?
Potrusion or strangulation where only part of the cirumference of the intestine’s antimesenteric border is within the hernial sac.
(Can have ischaemia due to strangulation but no bowel obstruction as a result)
List 4 typical blood results in patients with bowel obstruction.
WBC: Normal unless strangulation or peforation of bowel
U&E: electrolyte imbalance (due to vomitting)
VBG if vomiting: HypoCl-,HypoK+ metabolic alkalosis
VBG if strangulation: Metabolic Acidosis (lactate)
What 2 types of imaging should be conducted in patient suspected with bowel obstruction
Erect CXR/AXR [standing]
CT abdo/pelvis
What CXR/AXR findings are indicative of small bowel obstrcution?
Dilated small bowel loops( >3cm) proximal to the obstruction (central)
What CXR/AXR findings are indicative of large bowel obstrcution?
Dilated large bowel >6cm (if caecum >9cm) predominantly peripheral
What are CT scans useful in identifying in patients suspected of bowel obstruction? (3)
What CT abdo/pelvic findings are indicative of bowel obstrcution?
Can localize site of obstruction
Detect obstructing lesions & colonic tumours
May diagnose unusual hernias (e.g. obturator hernias).
Dilation of proximal loops
Usually with bowel obstruction, conservative management is sufficient. However this should only be the management plan if?
The patient has no signs of ischaemia or no signs of clinical deterioration
List 7 supportive management and conservative treatment options for a patient with bowel obstruction with no signs of ischaemia or clinical deterioriation.
Supportive management:
NBM with IV fluid resusciation
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:
Stool evacuation (e.g. enemas, manual or endoscopic removal) if faecal impactation
Rigid sigmoidoscopic decompression if sigmoid volvulus
Oral gastrograffin (highly osmolar iodinated contrast agent) can be used to resolve adhesional small bowel obstruction
Patient with no signs of ischaemia/no signs of clinical deterioration has been shown to have faecal impactation. What conservative treatment should be considered in this patient?
Stool evacuation (manual, edema, endoscopic)
Patient with no signs of ischaemia/no signs of clinical deterioration has been shown to have igmoid volvulus. What conservative treatment should be considered in this patient?
Rigid sigmoidoscopic decompression
Patient with no signs of ischaemia/no signs of clinical deterioration has been shown to have SBO secondary to adhesions. What conservative treatment should be considered in this patient?
Oral gastrogaffin (adhesions can twist so has chance to straighten out)
Patient with bowel obstruction has been shown to display worsening clinical sypmtoms and signs of ischaemia (e.g. neutrophilic leukocytosis). What is the management plan for this patient?
Surgical management
List 4 indications for surgical management of 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
List 4 surgical procedures that are involved in management of bowel obstruction
Explorative laproscopy/laparotomy
Restoration of intestinal transit (depending on intra-operational findings)
Bowel resection with primary anastomosis or temporary/permanent stoma formation
List 6 general presentations of GI perforation
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
List 4 examples of types of GI perfoartions
Perforated Peptic Ulcer
Perforated Diverticulum
Perforated Appendix
Perforated Malignancy
Alongside general presentations of a GI perforation, what are 3 additional signs/symptoms which can indicate a person has a perforated peptic ulcer?
Sudden epigastric pain or diffuse pain
Referred shoulder pain
Hx of NSAIDs, steroids, recurrent epigastric pain
Alongside general presentations of a GI perforation, what are 3 additional signs/symptoms which can indicate a person has a perforated diverticulum
LLQ pain
Constipation
Alongside general presentations of a GI perforation, what are 3 additional signs/symptoms which can indicate a person has a perforated appendix?
Migratory pain
Anorexia
Gradual worsening RLQ pain
Alongside general presentations of a GI perforation, what are 3 additional signs/symptoms which can indicate a person has a perforated appendix?
Change in bowel habit
Weight loss
Anorexia
PR Bleeding
What are 3 typical blood results found in patients with GI perforation?
FBC: Neutrophilic leukocytosis
Possible elevation of urea, creatinine
VGB: Lactic acidosis
What erect CXR finding is indicative of GI perforation?
Subdiaphragmatic free air (pneumoperitoneum)
What erect CT abdo/pelvis findings are indicative of GI perforation? (3)
Pneumoperitoneum
Free GI content
Localised mesenteric fat stranding
Why is CT abdo/pelvis specifically useful when a patient is suspected of having a GI perforation?
Can rule out common differential diagnoses such as acute pancreatitis
List 4 differential diagnoses that should be considered alongside a GI perforation.
Acute cholecystitis
Appendicitis.
Myocardial infarction
Acute pancreatitis
What is the conservative management plan for a patient with a GI perforation?
NIL by mouth and NG tube
IV fluids
Broad spectrum antibiotics
IV PPI
Parenteral analgesia & antiemetics
Urinary catheter
Alongside suportive management of a GI perforation. What 2 additional conservative management plans are implemented in patients with a GI perforation with localised peritonitis and no signs of sepsis? (2)
IR - guided drainage of intra-abdominal collection
Serial abdominal examination & abdominal imaging for assessment
N.B. This is very rare to have this type of presentation and often patients would need surgery
What is the management plan for patients with GI perforation with localised peritonitis and signs of sepsis?
Surgical management (e.g. exploratory laproscopy/laparotomy
List the 6 general steps performed in surgical management of a patient with a GI perforation
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 microscopy, culture and sensitivity, peritoneal lavage ++++
If perforated appendix: Lap or open appendicectomy
If malignancy: intraoperative biopsies if possible
What are 2 symptoms indicative of biliary colic?
Post-prandial (mealtime) RUQ pain with radiation to the shoulder
Nausea
What 2 findings from investigation can support diagnosis of biliary colic?
USS: Showing cholelithiasis (gallstone)
Normal blood test results
What is the management plan for a patient diagnosed with biliary colic?
Analgesia
Antiemetics
Spasmolytics
Follow up for elective cholecystectomy
What are 3 signs/symptoms indicative of acute cholecystitis?
Acute, severe RUQ pain
Fever
Murphy’s sign (Pain upon inspiriation and palpation of right subcostal margin)
What 2 findings from investigation can support diagnosis of acute cholecystitis
Elevated WCC/CRP
USS: thickened gallbladder wall
What is the management plan for a patient diagnosed with acute cholecystitis?
Fluids, ABx, Analgesia, Blood cultures
Early (<72 hours) or elective cholecystectomy (4-6 weeks)
What symptoms are indicative of acute cholangitis?
Charcot’s triad: jaundice, RUQ pain, fever
