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Gastroenterology > General surgery in the GI tract > Flashcards

General surgery in the GI tract Flashcards

1
Q

What is the general approach/ overview of care for acute abdomen issues?

A
  1. Presenting complaint: Pain assessment (SOCRATES), associated symptoms
  2. PMH, DH, SH
  3. Investigations:
    - Bloods: VBG, FBC, CRP, U&Es (renal profile), LFTs +amylase
    - Urinalysis + Urine MC&S
    - Imaging: Erect CXR, AXR, CTAP, CT angiogram, USS
    - Endoscopy
  4. Management:
    - ABCDE approach
    - Conservative management
    - Surgical management
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2
Q

What differential diagnoses is associated with pain in the the RUQ?

A

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

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3
Q

What differential diagnoses is associated with pain in the the Epigastrium?

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 differential diagnoses is associated with pain in the LUQ?

A

Peptic ulcer
Acute pancreatitis
Splenic abscess
Splenic infarction
Nephrolithiasis
LLL Pneumonia

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5
Q

What differential diagnoses is associated with pain in the RLQ?

A

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

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6
Q

What differential diagnoses is associated with pain in the Suprapubic?

A

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

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7
Q

What differential diagnoses is associated with pain in the LLQ?

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 clinical presentations 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
    (as soon as they present with symptoms TREAT- even if CT is normal)
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9
Q

Why are clinical presentations important to act on in suspected bowel ischaemia?

A

Important to intervene before the bowel dies:
- we only see signs of ischaemia in imaging when it’s too late

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10
Q

What are the risk factors for bowel ischaemia?

A

Age >65 yr
Cardiac arrythmias (mainly AF), atherosclerosis (narrow the lumen, decrease flow)
Hypercoagulation/thrombophilia
Vasculitis
Sickle cell disease
Profound shock causing hypotension

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11
Q

What is Acute mesenteric ischaemia?

A

reduced blood supply to the small bowel

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12
Q

What is Ischaemic colitis?

A

reduced blood supply to the large bowel

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13
Q

What is the difference between acute mesenteric ischaemia vs ischaemic colitis?

A

AMI:
- tends to be transmural- whole bowel dies
- affects the small bowel
- Usually occlusive due tothromboemboli
- Sudden onset (but presentation and severityvaries)
- Abdominal pain out of proportion of clinical signs

IC:
- less likely for the whole bowel to die- usually just part of it
- affects the large bowel
- Usuallydue to non-occlusive low flow states, or atherosclerosis
- More mild and gradual (80-85% of the cases)
- Moderate pain and tenderness

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14
Q

What investigations are used to monitor suspected bowel ischaemia?

A
  1. Bloods:
    FBC: neutrophilic leukocytosis
    VBG: Lactic acidosis (type of acidosis that occurs due to lactic acid- only occurs when bowel is dead)
  2. Imaging:
    CTAP/CTAngiogram detects: disrupted flow, vascular stenosis, ‘Pneumatosis intestinalis’ (transmural ischaemia/infarction again at this point bowel is dead), Ischaemic colitis: Thumbprint sign where mucosa pertrudes (unspecific sign of colitis)
  3. Endoscopy: For mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)
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15
Q

What is the conservative management for bowel ischaemia?

A

Mild to moderate cases of ischaemic colitis- reversible with treatment (not suitable for SB ischaemia):
- 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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16
Q

What are the surgical management 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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17
Q

What symptoms/ signs indicate patient requires surgical management for possible bowel ischaemia?

A

Small bowel ischaemia
Signs of peritonitis orsepsis
Haemodynamic instability
Massive bleeding
Fulminant colitis with toxic megacolon
(NOTE: you can only say there is no ischaemia after looking at the WHOLE bowel with a camera)

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18
Q

What are the presentations for 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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19
Q

What clinical signs are associated with acute appendicitis?

A
  1. McBurney’s point: tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
  2. Blumberg sign: rebound tenderness especially in the RIF
  3. Rovsing sign: RLQ pain elicited on deep palpation of the LLQ
  4. Psoas sign: RLQ pain elicited on flexion of right hip against resistance
  5. Obturator sign: RLQ pain on passive internal rotation of the hip with hip & knee flexion
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20
Q

What investigations are used to detect suspected acute appendicitis?

A
  1. Bloods
    FBC: neutrophilic leukocytosis
    ↑ed CRP
    Urinalysis: possible mild pyuria/haematuria
    Electrolyte imbalances in profound vomiting
  2. Imaging
    CT: gold standard in adults esp. if age > 50
    USS: children/pregnancy/breastfeeding
    MRI: in pregnancy if USS inconclusive
  3. Diagnostic Laparoscopy
    In persistent pain & inconclusive imaging
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21
Q

What scoring system is used to help diagnose acute appendicitis?

A

The Alvarado score: this is a clinical scoring system used in the diagnosis of appendicitis.
scores:
- RLQ tenderness
- Fever
- Rebound tenderness
- Pain
- Anorexia
- Nausea/ vomiting
- WCC
- Neutrophilia
≤4 Unlikely
5-6 possble
≥7 Likely

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22
Q

What are the conservative management options for acute appendicitis?

A
  1. IV Fluids, Analgesia, IV or PO Antibiotics
    (usually surgery is just given but when there is an abscess, surgery can become difficult- deal with it 1st)
  2. In abscess, phlegmon or sealed perforation
    - Resuscitation + IV ABx +/- percutaneous drainage
  3. (After negative imaging in selected patients with clinically uncomplicated appendicitis& In delayed presentation with abscess/phlegmon formation)
    CT-guided drainage
  4. Consider interval appendicectomy - rate of recurrence after conservative management of abscess/perforation is 12-24%
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23
Q

What are the surgical management options for acute appendicitis?

A
  • Laparoscopic appendicectomy
  • Open appendicectomy
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24
Q

Compare Open appendicectomy with Laparascopic appendicectomy

A

LA is superior as it involves:
- 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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25
Q

What are the steps for Laparoscopic Appendicectomy?

A

(NO NEED TO MEMORISE IN DETAIL JUST BE AWARE):
1. Trocar placement (usually 3)
2. Exploration of RIF & identification of appendix
3. Elevation of appendix + division of mesoappendix (containing artery)
4. Base 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

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26
Q

What is meant by intestinal obstruction?

A

restriction of normal passage of intestinal contents.

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27
Q

What are the 2 types of intestinal obstruction you can have?

A
  1. Paralytic (Adynamic) ileus
  2. Mechanical.
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28
Q

How can you classify mechanical intestinal obstruction?

A
  1. Speed of onset: acute, chronic, acute-on-chronic
  2. Site: high (small bowel) or low (large bowel)
    - roughly synonymous with small or large bowel obstruction
  3. Nature: simple vs strangulating
    - Simple: bowel is occluded without damage to blood supply. (non tender)
    - Strangulating: blood supply of involved segment of intestine is cut off (e.g. in strangulated hernia, volvulus, intussusception)
  4. Aetiology:
    - Causes in the lumen - faecal impaction, gallstone ‘ileus’ (actually a mechanical obstruction)
    - Causes in the wall - Crohn’s disease, tumours, diverticulitis of colon
    - Causes outside the wall –
    * Strangulated hernia (external- breach in the abdo wall or internal- lesion made in body/open)
    * Volvulus
    * Obstruction due to adhesions or bands.
29
Q

What are the causes of small bowel obstruction?

A
  1. Adhesions (60%)
    Hx of previous abdominal surgery
  2. Neoplasia (20%)
    Primary, Metastatic, Extraintestinal
  3. Incarcerated hernia (10%)
    External (abdominal wall), Internal (mesenteric defect)- gastric bypasses make a whole through mesenteric to get to bowel- hole doesn’t close properly
  4. Crohn’s Disease (5%)
    Acute (oedema), Chronic (strictures)
  5. Other (5%)
    Intussusception, intraluminal (foreign body, bezoar)
30
Q

What are the causes of large bowel obstruction?

A
  1. Colorectal carcinoma
  2. Volvulus
    Sigmoid, Caecal
  3. Diverticulitis
    Inflammation, strictures
  4. Faecal impaction
  5. Hirschsprung disease
    commonly found in infants/children
31
Q

What are the symptoms/ clinical presentations of small bowel obstruction?

A
  • Colicky, central abdominal pain
  • Vomiting= early onset (S.B. found higher up) large amount and bililous
  • Constipation= late sign
  • Abdominal distention= less significant
  • Dehydration
  • Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign)
  • Diffuse abdominal tenderness
32
Q

What are the symptoms/ clinical presentations of large bowel obstruction?

A
  • Colicky or constant abdominal pain
  • Vomiting= late onset (LB found lower down- may contain fecal material) initially bililous, progresses to faecal vomiting
  • Constipation= early sign (less to come out)
  • Abdominal distention= early sign and significant
  • Dehydration
  • Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign)
  • Diffuse abdominal tenderness
33
Q

How is intestinal obstruction diagnosed?

A

Diagnosed by the presence of symptoms
Examination should always include a search for hernias & abdominal scars, including laparoscopic portholes
Is it simple or strangulating? (strangulating- immediate action required v. painful)
Strangulating obstruction with peritonitis has a mortality of up to 15%

34
Q

How can you tell if there is strangulation associated with the intestinal obstruction?

A

Features suggesting strangulation are:
- Change in character of pain from colicky to continuous
- Tachycardia
- Pyrexia
- Peritonism
- Bowel sounds absent or reduced
- Leucocytosis
- ↑ed C-reactive protein

35
Q

What are the most common hernial sites?

A
  • Epigastric
  • Umbilical
  • Incisional
  • Inguinal
  • Femoral
36
Q

What types of hernias can you have with the bowel?

A

“Neck of sac”: caused by defect in the wall- peritoneum outpouching
“Strangulated hernia”: causes bowel obstruction
“Richter’s hernia”: does not cause bowel obstruction

37
Q

What investigations are used to monitor suspected bowel obstruction?

A
  1. Bloods
    - 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)
  2. Imaging
    - 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
Q

What are the X-Ray features seen with small bowel obstructions?

A
  • 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
Q

What are the X-Ray features seen with large bowel obstructions?

A
  • Distended large bowel tends to lie peripherally
  • Show haustrations of taenia coli - do not extend across whole width of the bowel
40
Q

Why are CT scans used to detect bowel obstruction?

A

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

41
Q

What are the features seen on CT scan for bowel obstruction?

A
  • Collapsed & dilated loops of small bowel due to transition point in the pelvis
  • Sigmoid stricture with proximal dilation
42
Q

What is the conservative management for bowel obstruction?

A

In patients with no signs of ischaemia/no signs of clinical deterioration

  1. Faecal impaction: stool evacuation (manual, enemas, endoscopic)
  2. Sigmoid volvulus: rigid sigmoidoscopic decompression
  3. SBO: oral gastrograffin (highly osmolar iodinated contrast agent)can be used to resolve adhesionalsmall bowel obstruction (IF UNRESOLVED- OPERATE)
43
Q

What supportive management is used to manage bowel obstruction?

A

In patients with no signs of ischaemia/no signs of clinical deterioration

  1. NBM, IV peripheral access with large bore cannula -IV Fluid resuscitation
  2. IV analgesia, IV antiemetics, correction of electrolyte imbalances
  3. NG tube for decompression, urinary catheter for monitoring output
  4. Introduce gradual food intake if abdominal pain and distention improve
44
Q

When is surgical management required for bowel obstruction?

A

Indications:
- 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
Q

What are the surgical management options for bowel obstruction?

A

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

(Endoscopic stenting)

46
Q

What are the symptoms/ clinical presentations of GI perforation?

A
  • 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
Q

What presentations are seen with perforated peptic ulcers?

A
  • Sudden epigastric or diffuse pain
  • Referred shoulder pain
  • Hx of NSAIDs, steroids, recurrent epigastric pain`
48
Q

What presentations are seen with perforated diverticulum?

A
  • LLQ pain
  • Constipation
49
Q

What presentations are seen with perforated appendix?

A
  • Migratory pain
  • Anorexia
  • Gradual worsening RLQ pain
50
Q

What presentations are seen with perforated malignancy?

A
  • Change in bowel habit
  • Weight loss
  • Anorexia
  • PR Bleeding
51
Q

What investigations are used to monitor suspected GI perforation?

A
  1. Bloods
    - FBC: neutrophilic leukocytosis
    Possible elevation of Urea, Creatinine
    - VBG: Lactic acidosis
  2. Imaging
    - 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
52
Q

What differential diagnoses can be associated with GI perforation?

A
  • Acute cholecystitis, Appendicitis.
  • Myocardial infarction, Acute pancreatitis
53
Q

What is the supportive management options for treatment of GI perforation?

A

Supportive management on presentation:
- NBM & NG tube
- IV peripheral access with large bore cannula -IV Fluid resuscitation
- Broad spectrum Abx
- IV PPI
- Parenteral analgesia & antiemetics
- Urinary catheter

54
Q

When is conservative management given in GI perforation?

A

Conservative management in localised peritonitis without signs of sepsis
Very rare

55
Q

What are the conservative management options for GI perforation?

A

Conservative management in localised peritonitis without signs of sepsis
Very rare:
- IR - guided drainage of intra-abdominal collection
- Serial abdominal examination & abdominal imaging for assessment

56
Q

What are the surgical management options for GI perforation?

A

Surgical management in generalised peritonitis +/- signs ofsepsis:
1. Exploratory laparotomy/laparoscopy
2. Primary closure of perforation with or withoutomental patch (most common in perforated pepticulcer)
3. Resection of theperforated segment of the bowelwith primary anastomosis or temporary stoma
4. Obtainintra-abdominal fluid for MC&S, peritoneal lavage ++++
5. If perforated appendix: Lap or open appendicectomy
6. If malignancy: intraoperative biopsies if possible

57
Q

What are the symptoms of Biliary colic?

A
  • PostprandialRUQ pain with radiation to the shoulder.
  • Nausea
58
Q

What investigations are used for biliary colic?

A
  • Normal blood results
  • USS: cholelithiasis
59
Q

What is the management for biliary colic?

A
  • Analgesia, Antiemetics, Spasmolytics
  • Follow up for elective cholecystectomy
60
Q

What are the symptoms of acute cholecystitis?

A
  • Acute, severe RUQ pain
  • Fever
  • Murphy’s sign
61
Q

What are the investigations for acute cholescystitis?

A
  • Elevated WCC/CRP
  • USS: thickened gallbladder wall
62
Q

What is the management for acute cholecystitis?

A
  • Fluids, ABx, Analgesia, Blood cultures
  • Early (<72 hours) or elective cholecystectomy (4-6 weeks)
63
Q

What are the symptoms of acute cholangitis?

A
  • Charcot’s triad: jaundice, RUQ pain, fever
64
Q

What investigations are used for acute cholangitis?

A
  • Elevated LFTs, WCC, CRP, Blood MCS (+ve)
  • USS: bilary dilatation
65
Q

What is the management of acute cholangitis?

A
  • Fluids, IV Abx, Analgesia
  • ERCP (within 72hrs) for clearance of bile duct or stenting
66
Q

What are the symptoms of acute pancreatitis?

A
  • Severe epigastric pain radiating to the back
  • Nausea +/- vomiting
  • Hx of gallstones or EtOH use
67
Q

What investigations are used for acute pancreatitis?

A
  • Raised amylase/lipase
  • High WCC/Low Ca2+
  • CT and US to assess for complications/cause
68
Q

what is the management for acute pancreatitis?

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

Gastroenterology (9 decks)

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