General Surgery In the GI Tract Flashcards
What range of investigations are there in a general abdominal assessment?
-Bloods
-Urinalysis
-Imaging
-Endoscopy
Give 5 diseases associated with the RUQ (right upper quadrant).
- Biliary Colic
- Duodenal Ulcer
- Liver abscess
- Portal vein thrombosis
- Acute hepatitis
- Nephrolithiasis
- RLL pneumonia
- Cholecystitis/Cholangitis
Give 5 diseases associated with the epigastrium.
- Acute gastritis/GORD
- Gastroparesis
- Peptic ulcer disease/perforation
- Acute pancreatitis
- Mesenteric ischaemia
- AAA (Abdominal Aortic Aneurysm) Aortic dissection
- Myocardial infarction
Give 5 diseases associated with the LUQ.
- Peptic ulcer
- Acute pancreatitis
- Splenic abscess
- Splenic infarction
- Nephrolithiasis
- LLL Pneumonia
Give 5 diseases associated with the right lumbar region.
- Acute Appendicitis
- IBD
- Colitis
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
Give 5 diseases associated with the suprapubic/central region.
- Early appendicitis
- Mesenteric ischaemia
- Bowel obstruction
- Bowel perforation
- Constipation
- Gastroenteritis
- UTI/Urinary retention
- PID
Give 5 diseases associated with the Lower left quadrant.
- Diverticulitis
- IBD (Inflammatory Bowel Disease)
- Colitis
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
What are the 2 main groups of intestinal obstruction?
- Paralytic (adynamic) ileus e.g. someone with abdomen full of pus, this irritates bowel and bowel stops peristalsis (this is an ileus) and doesn’t stop til irritation gone
- Mechanical e.g. mechanically a bit of the bowel closes off
What are the 4 different ways to classify a mechanical intestinal obstruction?
-Speed
-Site
-Nature
-Aetiology
What is meant by nature in the classification of mechanical intestinal obstructions.
Simple vs strangulating
- Simple- bowel is occluded without damage to blood supply
- Strangulating- blood supply of involved segment of intestine is cut off
What are the majority of small bowel obstructions caused by?
-Adhesions (from previous surgery)
-Neoplasia
(15% from hernias and Crohn’s disease)
What is volvulus?
Imagine a party balloon being twisted and giving a closed loop.
What are the commonest causes of large bowel obstruction
- Colorectal cancer- commonest cause- usually obstructs on left hand side because on right the bowel can expand and compensate
- Volvulus- sigmoid, caecal
- Diverticulitis- inflammation, strictures
- Faecal impaction
- Hirschsprung disease
What are the differences in the way abdominal pain presents in small and large bowel obstructions.
- Small bowel obstruction- colicky, central
- Large bowel obstruction- colicky or constant
What are the differences in the way vomiting presents in small and large bowel obstructions.
- Small bowel obstruction- early onset, large amount, bilious (with bile)
- Large bowel obstruction- late onset, initially bilious, progresses to faecal vomiting (vomit looks like faeces)
Whats the difference in the way absolute constipation presents in Small/Large bowel obstructions
- Small bowel obstruction- late sign
- Large bowel obstruction- early sign
What is the difference in the way absolute abdominal distention presents in Small/Large bowel obstructions
- Small bowel obstruction- less significant
- Large bowel obstruction- early sign and significant
What are features suggesting strangulation? (7)
- Change in character of pain from colicky to continuous
- Peritonism (symptom complex of vomiting, pain/abdo tenderness and shock)
- Tachycardia
- Pyrexia
- Leukocytosis
- Increased CRP
- Bowel sounds absent or reduced
What is a Richter’s hernia?
Hernia in the bowel not associated with obstruction.
What is CRP?
C reactive protein, marker for inflammation
What does VBG stand for
Venous blood gas. Tests for levels of oxygen and carbon dioxide in the blood.
What blood tests will you usually do with bowel obstruction?
- WCC/CRP usually normal (if raised then suspicion of strangulation/perforation)
- U&E: electrolyte imbalance e.g. if vomiting
- VBG if vomiting: HypoCl-, HypoK+ metabolic alkalosis
- VBG if strangulation: metabolic acidosis (lactate)
What supportive management is there for bowel obstruction
IV analgesia etc
What are the 2 types of ischaemic bowel?
-Acute mesenteric ischaemia (affects small bowel)
-Ischaemic colitis (affects large bowel)
What are the causes for acute mesenteric ischaemia and ischaemic colitis?
-Acute mesenteric ischaemia → usually occlusive and secondary to thromboembolus, if someone has AF, a small clot can come and get blocked in SMA- superior mesenteric artery
-Ischaemic colitis → usually due to non-occlusive low flow states, or atherosclerosis
What is an exploratory laparotomy?
Opening abdomen up for exploration
How does acute appendicitis present?
- Initially periumbilical pain that migrates to
RLQ (within 24 hours) - nausea +/- vomiting
- low grade fever
What are important clinical signs to look out for? (Signs & points)
Hint: acronym PROBM
-Psoas sign
-Rovsing sign
-Obturator sign
-Blumberg sign
-McBurney’s point
RLQ pain elicited on flexion of right hip against resistance is what?
Psoas sign
RLQ pain elicited on deep palpation of the LLQ is what?
Rovsing sign.
RLQ pain on passive internal rotation of the hip with hip and knee flexion is what?
Obturator sign
Rebound tenderness (press down then release) especially in RIF, is what?
Blumberg sign (Blumberg-> bouncy->rebound tender)
Tenderness in RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus) is what?
McBurney’s point
What is the clinical scoring system for appendicitis?
The Alvarado score
After conservative management of acute appendicitis, what do we consider?
Interval Appendicectomy
What is better laparoscopic or open appendicectomy?
Laparoscopic surgery (less invasive better patient QOL)
How do GI perforations present? (6)
- Sudden onset severe abdominal pain associated with distention
- Pain aggravated by movement
- Diffuse abdominal guarding, rigidity, rebound tenderness
- Nausea, vomiting, absolute constipation (due to ileus of chemical irritation rather than mechanical obstruction)
- Decreased or absent bowel sounds (because of ileus)
- Fever, tachycardia, tachypnoea, hypotension
What is the most common cause of GI perforations?
Perforated peptic ulcer
Where can you also get pain with a perforated peptic ulcer and why?
Referred shoulder pain- due to irritation of diaphragm (innervated by phrenic nerve which also innervated right shoulder)
What are the 4 causes of GI perforation (The 4 main examples)
-Perforated peptic ulcer
-Perforated diverticulum
-Perforated appendix
-Perforated malignancy
How does a perforated diverticulum present?
- LLQ pain- insidious onset
- Constipation
How does a perforated appendix present?
- Change in bowel habit
- PR bleeding
- Weight loss
- Anorexia
What are the 2 types of investigations we do for gastric perforations?
- FBC- neutrophilic leukocytosis
- VBG- lactic acidosis
- Possible elevation of urea, creatinine
What imaging can we do to help us localize the perforation?
-Erect chest x-ray
-CT abdo/pelvis
What would an erect chest x-ray help us detect?
subdiaphragmatic free air.
What surgical management options are there for patients with generalized pancreatitis +/- signs of sepsis?
Exploratory laparotomy
What Biliary colic symptoms (Gallbladder/gallstones)
Sudden, intense pain in the right upper Quad that may radiate up to the shoulder seen typically after eating a large, fatty meal.
What investigations would you do for biliary colic symptoms?
Ultrasound to find gallstones.
How do you manage biliary colic/ gallstones
- Conservative- analgesia, antiemetics, spasmolytics
- Follow up for elective cholecystectomy
What is cholecystitis?
Infection of the gallbladder.
Symptoms of cholecystitis?
- Acute, severe RUQ pain
- Fever
-MURPHY’S SIGN
What is pleuritic chest pain?
Chest pain when you take deep breath in and you feel sharp pain in chest wall, not abdomen
What is this:
Placing hand in RUQ, it may feel non tender, then ask patient to take deep breath in and liver pushes gallbladder down which touches hand and patient yelps
Murphy’s sign
What Investigations would you do to diagnose Acute cholecystitis and what would you find?
Blood tests: Elevated WCC/CRP
Ultra sound scan: thickened gallbladder wall
What is acute cholangitis?
Acute cholangitis is a medical condition characterized by inflammation of the bile ducts within the liver.
What usually causes acute cholangitis?
Blockage of billiary tree, usually due to gallstones.
What are the symptoms of acute cholangitis?
Charcot’s triad- jaundice, RUQ pain, fever
What would you see on an ultrasound of someone with acute cholangitis?
Biliary tree dilation
What investigations would you do for acute cholangitis and what would you find?
LFT (liver function test)- Elevated
WCC- Elevated
CRP-Elevated
Blood cultures (+ve)
What should you do within 72 hours for clearance of the bile duct?
ERCP
Acute pancreatitis symptoms
- Severe epigastric pain radiating to back
- Nausea +/- vomiting
What is the most common cause of acute pancreatitis?
Gallstones
What would you find in investigations for acute pancreatitis?
- Raised amylase/lipase
- High WCC/low Ca2+
What is used to predict the severity and likelihood of mortality in individuals with acute pancreatitis.
Glasgow-imrie admission score
What are antiemetics?
Drugs used to treat nausea and vomiting.
