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Phase 1b - Gastroenterology > General Surgery in the GI Tract > Flashcards

General Surgery in the GI Tract Flashcards

1
Q

What is the general approach to an acute abdomen (6)?

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

Site
Onset
Character
Radiation
Association
Time course
Exacerbating/Relieving factors
Severity

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2
Q

Give 3 differential diagnoses of a RUQ acute abdomen.

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

Give 3 differential diagnoses of an epigastrium acute abdomen.

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

Give 3 differential diagnoses of a LUQ acute abdomen.

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

Give 3 differential diagnoses of a RLQ acute abdomen.

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

Give 3 differential diagnoses of a suprapubic / central
acute abdomen.

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

Give 3 differential diagnoses of a LLQ acute abdomen.

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 are the 2 main forms of bowel ischaemia?

A
  • Acute mesenteric ischaemia (AMI) (small bowel)
  • Ischaemic Colitis (IC) (large bowel)
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9
Q

What is the clinical presentation of acute mesenteric ischaemia (SOCRATES)?

A
  • Site: Small bowel
  • Onset: Sudden (but presentation and severityvaries)
  • Character: Crampy
  • Radiation: Varies
  • Association: Bloody, loose stool & Fever
  • Time course: Hours until treatment
  • Exacerbating / Relieving factors: Exacerbated by eating
  • Severity: Abdominal pain out of proportion of clinical signs

Usually occlusive due to thromboemboli

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10
Q

What is the clinical presentation of ischaemic colitis (SOCRATES)?

A
  • Site: Large bowel
  • Onset: More mild and gradual (80-85% of the cases)
  • Character: Crampy
  • Radiation: Varies
  • Association: Bloody, loose stoole & Fever
  • Time course: Hours until treatment
  • Exacerbating / Relieving factors: Exacerbated by eating
  • Severity: Moderate pain and tenderness

Usually due to non-occlusive low flow states, or atherosclerosis

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11
Q

What are the risk factors of bowel ischaemia (6)?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

A
  • Age >65 yr
  • Cardiac arrythmias (mainly AF), atherosclerosis
  • Hypercoagulation / thrombophilia
  • Vasculitis
  • Sickle cell disease
  • Profound shock causing hypotension
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12
Q

What investigations are recommended for suspected bowel ischaemia (4)?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

A
  • Bloods
    • FBC
    • VBG
  • Imaging
    • CTAP / CTAngiogram
  • Endoscopy
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13
Q

What blood abnormalities would one expect in a suspected bowel ischaemia (2)?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

A
  • FBC: neutrophilic leukocytosis
  • VBG: lactic acidosis
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14
Q

What CTAP/CT angiogram abnormalities would one expect in a suspected bowel ischaemia?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

A
  • Disrupted flow
  • Vascular stenosis
  • ‘Pneumatosis intestinalis’ (transmural ischaemia / infarction)
  • Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)
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15
Q

What endoscopic abnormalities would one expect in a suspected bowel ischaemia?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

A

For mild or moderate cases of ischaemic colitis:
* Oedema / cyanosis / ulceration of mucosa

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16
Q

When is conservative management indicated for bowel ischaemia?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

A
  • Mild to moderate cases of ischaemic colitis (not suitable for SB ischaemia)
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17
Q

What is the conservative management for bowel ischaemia (7)?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

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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18
Q

When is surgical management indicated for bowel ischaemia (5)?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

A
  • Small bowel ischaemia
  • Signs of peritonitis or sepsis
  • Haemodynamic instability
  • Massive bleeding
  • Fulminant colitis with toxic megacolon
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19
Q

What is the surgical management for bowel ischaemia (2)?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

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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20
Q

What is the clinical presentation of acute appendicitis (SOCRATES)?

A
  • Site:
    • McBurney’s point: tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
  • Onset: Sudden
  • Character: Sharp, stabbing
  • Radiation: Initially periumbilical pain that migrates to RLQ
  • Association: Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit
  • Time course: 24h escalation
  • Exacerbating/Relieving factors:
    • 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
  • Severity: Varies & increases through time
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21
Q

What is McBurney’s point?

Present in Acute Appendicitis

A
  • Tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
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22
Q

What is Blumberg point?

Present in Acute Appendicitis

A
  • Rebound tenderness especially in the RIF
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23
Q

What is Rovsing point?

Present in Acute Appendicitis

A
  • RLQ pain elicited on deep palpation of the LLQ
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24
Q

What is Psoas point?

Present in Acute Appendicitis

A
  • RLQ pain elicited on flexion of right hip against resistance
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25
Q

What is Obturator point?

Present in Acute Appendicitis

A
  • RLQ pain on passive internal rotation of the hip with hip & knee flexion
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26
Q

What investigations are recommended in suspected acute appendicitis (7)?

A
  • Bloods
    • FBC
    • CRP
    • Urinalysis
    • Electrolytes
  • Imaging
    • CT
    • USS
    • MRI
  • Diagnostic Laparoscopy
    • In persistent pain & inconclusive imaging
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27
Q

What blood abnormalities would one expect in a suspected acute appendicitis (4)?

A
  • FBC: neutrophilic leukocytosis
  • Increased CRP
  • Urinalysis: possible mild pyuria / haematuria
  • Electrolyte imbalances in profound vomiting
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28
Q

What are the indications for each imaging used in a suspected acute appendicitis?

CT / USS / MRI

A
  • CT: gold standard in adults esp. if age > 50
  • USS: children / pregnancy / breastfeeding
  • MRI: in pregnancy if USS inconclusive
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29
Q

What are the alvarado score requirements (8)?

A
  • RLQ tenderness - 2
  • Fever ( > 37.3 °C) - 1
  • Rebound tenderness - 1
  • Pain migration - 1
  • Anorexia - 1
  • Nausea+/- vomiting - 1
  • WCC > 10.000 - 2
  • Neutrophilia (Left shift 75%) - 1
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30
Q

What does the alvarado score indicate?

A
  • ≤ 4 Unlikely appendicitis
  • 5 - 6 Possible appendicitis
  • ≥ 7 Likely appendicitis
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31
Q

What are the indications for conservative management for acute appendicitis?

A
  • After negative imaging in selected patients with clinically uncomplicated appendicitis
  • In delayed presentation with abscess / phlegmon formation
    • CT-guided drainage
32
Q

What is the conservative management for acute appendicitis (3)?

A
  • IV Fluids
  • Analgesia
  • IV or PO Antibiotics

In abscess, phlegmon or sealed perforation:
* Resuscitation + IV ABx +/- percutaneous drainage

Rate of recurrence after conservative management of abscess/perforation is 12-24%

33
Q

Why is laparoscopic appendicectomy preferred over open appendicectomy (6)?

A
  • Less pain
  • Lower incidence of surgical site infection
  • Decreased length of hospital stay
  • Earlier return to work
  • Overall costs
  • Better quality of life scores
34
Q

What are the steps of laparoscopic appendicectomy (8)?

A
  1. Trocar placement (usually 3)
  2. Exploration of RIF & identification of appendix
  3. Elevation of appendix + division of mesoappendix (containing artery)
  4. Based secured with endoloops and appendix is divided
  5. Retrieval of appendix with a plastic retrieval bag
  6. Careful inspection of the rest of the pelvic organs/intestines
  7. Pelvic irrigation (wash out) + Haemostasis
  8. Removal of trocars + wound closure
35
Q

What is mechanical intestinal obstruction classified by (4)?

A
  • 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.
36
Q

What is the clinical presentation of small bowel obstruction (SOCRATES)?

A
  • Site: Central abdomen
  • Onset: Vary depending on cause (usually mild)
  • Character: Colicky
  • Radiation: Vary depending on cause (sometimes back or chest)
  • Association: Early onset vomiting / Late constipation / Dehydration / Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign)
  • Time course: Vary depending on cause (Few hours - Few days / May decrease by itself or require medical intervention)
  • Exacerbating / Relieving factors: Exacerbated by eating, drinking and movement
  • Severity: Vary depending on cause
37
Q

What is the aetiology of small bowel obstruction (5)?

A
  • Adhesions (60%)
    • Hx of previous abdominal surgery
  • Neoplasia (20%)
    • Primary, Metastatic, 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)
38
Q

What is the clinical presentation of large bowel obstruction (SOCRATES)?

A
  • Site: Central abdomen
  • Onset: Vary depending on cause (usually mild)
  • Character: Colicky or constant
  • Radiation: Vary depending on cause (sometimes back or chest)
  • Association: Late onset vomiting / Early constipation / Early significant abdominal distension / Dehydration / Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign)
  • Time course: Vary depending on cause (Few hours - Few days / May decrease by itself or require medical intervention)
  • Exacerbating / Relieving factors: Exacerbated by eating, drinking and movement
  • Severity: Vary depending on cause
39
Q

What is the aetiology of large bowel obstruction (5)?

A
  • Colorectal carcinoma
  • Volvulus
    • Sigmoid, Caecal
  • Diverticulitis
    • Inflammation, strictures
  • Faecal impaction
  • Hirschsprung disease
    • Commonly found in infants/children
40
Q

How is bowel obstruction diagnosed?

A
  • Diagnosed by the presence of symptoms
41
Q

What are the 5 most common hernial sites?

42
Q

What are the 3 main types of hernias?

43
Q

What features are suggesting hernial strangulation (7)?

A
  • Change in character of pain from colicky to continuous
  • Tachycardia
  • Pyrexia
  • Peritonism
  • Bowel sounds absent or reduced
  • Leucocytosis
  • Increased C-reactive protein
44
Q

What investigations are suggested in a suspected bowel obstruction (5)?

A

Bloods
* FBC
* U&E
* VBG

Imaging
* Erect CXR/AXR
* CT abdo/pelvis

45
Q

What blood abnormalities would one expect in a suspected bowel obstruction (4)?

A
  • WCC/CRP usually normal (if raised suspicion of strangulation/perforation)
  • U&E: electrolyte imbalance
  • VBG:
    • VBG if vomiting: HypoCl-, HypoK+ metabolic alkalosis
    • VBG if strangulation: metabolic acidosis (lactate)
46
Q

What erect CXR/AXR abnormalities would one expect in a suspected small bowel obstruction?

A
  • Dilated small bowel loops > 3cm proximal to the obstruction (central)
Small bowel obstruction 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.
47
Q

What erect CXR/AXR abnormalities would one expect in a suspected large bowel obstruction?

A
  • Dilated large bowel > 6cm (if caecum > 9cm) predominantly peripheral
Large bowel obstruction Distended large bowel tends to lie peripherally Show haustrations of taenia coli - do not extend across whole width of the bowel
48
Q

Why would a CT scan be preferred over an erect CXR/AXR to diagnose bowel obstruction (3)?

A
  • Can localize site of obstruction
  • Detect obstructing lesions & colonic tumours
  • May diagnose unusual hernias (e.g. obturator hernias)
49
Q

When is conservative management indicated for bowel obstruction?

A
  • In patients with no signs of ischaemia / no signs of clinical deterioration
50
Q

What is the conservative management for bowel obstruction (cause dependent for faecal impaction / sigmoid volvulus / SBO)?

A
  • 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
51
Q

What is the supportive management for bowel obstruction (7)?

A
  • 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
52
Q

When is surgical management indicated for bowel obstruction (4)?

A
  • Haemodynamic instability or signs of sepsis
  • Complete bowel obstruction with signs of ischaemia
  • Closed loop obstruction
  • Persistent bowel obstruction > 2 days despite conservative management
53
Q

What is the surgical management for bowel obstruction (3)?

A
  • Exploratory Laparotomy / Laparoscopy
  • Restoration of intestinal transit (depending on intra-operational findings)
  • Bowel resection with primary anastomosis or temporary / permanent stoma formation
54
Q

What is the clinical presentation of a perforated peptic ulcer (SOCRATES)?

A
  • Site: Epigastric
  • Onset: Sudden
  • Character: Constant
  • Radiation: Shoulder pain
  • Association: Nausea / Vomiting / Absolute Constipation / Fever / Tachycardia / Tachypnoea / Hypotension / Decreased or absent bowel sounds
  • Time course: Constant until treatment
  • Exacerbating / Relieving factors: Pain aggravated by movement
  • Severity: Severe
55
Q

What is the clinical presentation of a perforated diverticulum (SOCRATES)?

A
  • Site: LLQ pain
  • Onset: Sudden
  • Character: Constant
  • Radiation: -
  • Association: Constipation
  • Time course: Constant until treatment
  • Exacerbating / Relieving factors: Pain aggravated by movement
  • Severity: Severe
56
Q

What is the clinical presentation of a perforated appendix (SOCRATES)?

A
  • Site: RLQ pain
  • Onset: Sudden
  • Character: Gradual worsening pain
  • Radiation: Migratory pain
  • Association: Nausea / Vomiting / Absolute Constipation / Fever / Tachycardia / Tachypnoea / Hypotension / Decreased or absent bowel sounds
  • Time course: Constant until treatment
  • Exacerbating / Relieving factors: Pain aggravated by movement
  • Severity: Severe
57
Q

What is the clinical presentation of a perforated malignancy (SOCRATES)?

A
  • Site: RLQ pain
  • Onset: Sudden
  • Character: Gradual worsening pain
  • Radiation: Migratory pain
  • Association: Nausea / Vomiting / Absolute Constipation / Fever / Tachycardia / Tachypnoea / Hypotension / Decreased or absent bowel sounds / Weight loss / Anorexia / PR Bleeding
  • Time course: Constant until treatment
  • Exacerbating / Relieving factors: Pain aggravated by movement
  • Severity: Severe
58
Q

What investigations are recommended in a suspected GI perforation (5)?

A

Bloods
* FBC
* U&E
* VBG

Imaging
* Erect CXR
* CT abdo / pelvis

59
Q

What blood abnormalities would one expect in a suspected GI perforation (3)?

A
  • FBC: neutrophilic leukocytosis
  • Possible elevation of Urea & Creatinine
  • VBG: Lactic acidosis
60
Q

What Erect CXR abnormalities would one expect in a suspected GI perforation?

A
  • Subdiaphragmatic free air (pneumoperitoneum)
61
Q

What CT abdo / pelvis abnormalities would one expect in a suspected GI perforation?

A
  • Pneumoperitoneum, free GI content,localised mesenteric fat stranding
    • Can exclude common differential diagnoses such as pancreatitis
62
Q

What is the supportive management on presentation of GI perforation (6)?

A
  • NBM & NG tube
  • IV peripheral access with large bore cannula - IV Fluid resuscitation
  • Broad spectrum Abx
  • IV PPI
  • Parenteral analgesia & antiemetics
  • Urinary catheter
63
Q

When is conservative management indicated in GI perforation?

A
  • Localised peritonitis without signs of sepsis

Very rare

64
Q

What is the conservative management of GI perforation?

A
  • IR - guided drainage of intra-abdominal collection
  • Serial abdominal examination & abdominal imaging for assessment
65
Q

What is the surgical management in GI perforation?

A
  • Exploratory laparotomy/laparoscopy
  • Primary closure of perforation with or without omental patch (most common in perforated pepticulcer)
  • Resection of the perforated segment of the bowel with primary anastomosis or temporary stoma
    • Obtainintra-abdominal fluid for MC&S, peritoneal lavage ++++
    • If perforated appendix: Lap or open appendicectomy
    • If malignancy: intraoperative biopsies if possible
66
Q

What are the symptoms of biliary colic (2)?

A
  • Postprandial RUQ pain with radiation to the shoulder
  • Nausea
67
Q

What are the abnormal investigations would one expect in a suspected biliary colic (2)?

A
  • Normal blood results
  • USS: cholelithiasis
68
Q

How is biliary colic managed (4)?

A
  • Analgesia
  • Antiemetics
  • Spasmolytics
  • Follow up for elective cholecystectomy
69
Q

What are the symptoms of acute cholecystitis (3)?

A
  • Acute, severe RUQ pain
  • Fever
  • Murphy’s sign
70
Q

What are the abnormal investigations would one expect in a suspected acute cholecystitis (3)?

A
  • Elevated WCC
  • Elevated CRP
  • USS: thickened gallbladder wall
71
Q

How is acute cholecystitis managed (5)?

A
  • Fluids
  • ABx
  • Analgesia
  • Blood cultures
  • Early (< 72 hours) or elective cholecystectomy (4-6 weeks)
72
Q

What are the symptoms of acute cholangitis (3)?

A

Charcot’s triad:
* Jaundice
* RUQ pain
* Fever

73
Q

What are the abnormal investigations would one expect in a suspected acute cholangitis (5)?

A
  • Elevated LFTs
  • Elevated WCC
  • Elevated CRP
  • Blood MCS (+ve)
  • USS: bilary dilatation
74
Q

How is acute cholangitis managed (5)?

A
  • Fluids
  • IV ABx
  • Analgesia
  • ERCP (within 72hrs) for clearance of bile duct or stenting
75
Q

What are the symptoms of acute pancreatitis (3)?

A
  • Severe epigastric pain radiating to the back
  • Nausea +/- vomiting
  • Hx of gallstones or EtOH use
76
Q

What are the abnormal investigations would one expect in a suspected acute pancreatitis (4)?

A
  • Elevated amylase
  • Elevated lipase
  • Elevated WCC
  • Low Ca2+
  • CT and US to assess for complications / cause
77
Q

How is acute pancreatitis managed (5)?

A
  • Admission score (Glasgow-Imrie)
  • Aggressive fluid resuscitation
  • O2
  • Analgesia
  • Antiemetics
  • ITU/HDU involvement

Phase 1b - Gastroenterology (13 decks)

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