General surgery in the GI tract Flashcards
What are the presentations for bowel ischaemia?
How does this differ between the SB and LB?
Current jelly stool on PR
Fever
Septic shock
Crampy pain
SB - sudden onset, LB - milder & more gradual pain
What are the risk factors for bowel ischaemia? (5)
Age >65
Cardiac arrhythmias (esp AF), atherosclerosis
Hypercoagulation/thrombophilia
Vasculitis
Sickle cell disease
What investigations would you do for bowel ischaemia?
Bloods: FBC (neutrophilic leukocytosis), VBG (lactic acidosis) - both are late signs
CT: disrupted flow, vascular stenosis, thumbprint sign for ischaemic colitis
Late sign: Pneumatosis intestinalis - air inside bowel wall
Endoscopy
What are the conservative management options for bowel ischaemia?
What type of bowel ischaemia is this applicable to?
IV fluid resuscitation
Antibiotics
Anticoagulation
NG tube for decompression
Bowel rest
Continuous monitoring
Mild-moderate ischaemic colitis, not SB
What surgical management options are there for bowel ischaemia?
Exploratory laparotomy
Endovascular revascularisation
What is the typical presentation for acute appendicitis? (5)
Initial periumbilical pain, migrates to RLQ within 24 hours
Anorexia
Nausea & vomiting
Fever
Changes in bowel habit
Where is McBurney’s point?
1/3 along the way from R ASIS to umbilicus
What is Blumberg’s sign? What does it show?
Rebound tenderness
Perotonitis
What is Rovsing’s sign?
RLQ pain during deep palpation of LLQ
What is the psoas sign?
RLQ pain when flexing right hip against resistance
What is the obturator sign?
RLQ on passive internal rotation of hip while hip & knee are flexed
What would bloods show in acute appendicitis?
FBC: neutrophilic leukocytosis
CRP: raised
Electrolyte imbalances if vomiting
What imaging should be done in acute appendicitis?
What investigation should be done if all imaging is inconclusive?
CT - gold standard if under 50
Ultrasound - children, breastfeeding, pregnancy
MRI - pregnancy if US inconclusive
Diagnostic laparoscopy
What is included in the Alvarado score for acute appendicitis? (MANTRELS)
What are the scoring criteria?
- Migration of pain to RLQ (1)
- Anorexia (1)
- Nausea & vomiting (1)
- Tenderness in RLQ (2)
- Rebound tenderness (1)
- Elevated temperature >37.3C (1)
- Leukocytosis >10 (2)
- Shifted neutrophils to left 75% (1)
<4 unlikely, 5-6 possible, >7 likely (out of 10)
What conservative management options are there for acute appendicitis?
IV fluids
Analgesia
Antibiotics
Percutaneous drainage if abscess seen
What are the surgical management options for acute appendicitis?
Laparoscopic appendectomy
Open appendectomy
Interval appendectomy - delayed removal of appendix after initial presentation to reduce rate of recurrence
What are the two main groups of bowel obstruction?
- functional - paralytic ileus (lack of muscle contraction)
- mechanical
How is mechanical bowel obstruction classified? (4)
- Speed of onset - acute vs chronic, acute-on-chronic
- Site - high or low
- Nature (blood supply) - simple vs strangulated
- Aetiology - lumen, wall, outside bowel
What are some common causes of small bowel obstruction? (4)
Adhesions
Neoplasia
Incarcerated hernia
Crohn’s
What are some common causes of large bowel obstruction? (5)
Colorectal carcinoma
Volvulus
Diverticulitis
Faecal impaction
Hirschspring disease - lack of peristalsis in a section of the colon
Describe vomiting symptoms in SB and LB obstruction?
SB - early onset, bilious
LB - late onset, can progress to faecal vomiting
Describe absolute constipation and abdominal distension in SB and LB obstruction?
SB - late sign, less significant
LB - early sign, significant
What are some signs of bowel obstruction? (6)
Abdominal pain
Vomiting
Constipation
Abdominal distention
Dehydration
Tinkling bowel signs (early), absent bowel sounds (late)
What signs are seen in strangulated obstructions?
Pain changes from colicky to continuous
Tachycardia
Fever
Peritonism
Absent bowel sounds
Leucocytosis
Raised CRP
What are some common sites of hernias? (6)
Epigastric
Umbilical
Periumbilical
Incisional
Inguinal
Femoral
What is a Richter’s hernia?
Strangulated but no obstruction
What bloods can be done to investigate bowel obstruction?
U&E - electrolyte imbalances
WCC/CRP - raised in strangulations/perforations
VBG - if vomiting low K+ and Cl-, metabolic alkalosis
VBG - if strangulated, metabolic acidosis
What are the normal widths of the bowel on an X-ray?
SB - 3cm
LB - 6cm
Caecum - 9cm
What conservative management is used to treat sigmoid volvulus?
Sigmoidoscopy
Pass soft rubber tube along (flatus tube)
Usually untwists and releases contents
What are the conservative management options for bowel obstruction?
IV fluids, NBM
IV analgesia, antiemetics, electrolyte correction
NG decompression
Stool evacuation
What contrast agent can be used to visualise small bowel obstructions?
Gastrografin on CT scans
What are the indications for surgical management of bowel obstructions?
Haemodynamically unstable
Complete bowel obs with ischaemia
Closed loop obstruction
Persistent obs after 2 days of conservative management
What surgical management options are there for bowel obs?
Exploratory laparotomy/laparoscopy
Bowel resection with primary anastomosis
Stoma
What are the presentations for GI perforation?
Sudden onset severe abdo pain
Distention
Diffuse guarding, rigidity, rebound tenderness
Pain worse on movement
Nausea & vomiting
Constipation
Fever, tachycardia, hypotension, tachypneoa
Decreased bowel sounds
What investigations can be done for GI perforation?
Bloods - FBC, U&E, VBG
X-ray & CT - air under diaphragm
What are the conservative management options for GI perforation? (6)
NBM & NG tube
IV fluids
Antibiotics
IV proton pump inhibitors
Analgesia & antiemetics
Urinary catheter
What are the symptoms of biliary colic (gallstones)?
Postprandial RUQ pain
Radiation to back and right shoulder
Nausea
What symptoms are seen in acute cholecystitis?
Murphy’s sign
Acute, severe RUQ pain
Fever
Symptoms in acute cholangitis
Jaundice
RUQ pain
Fever
(Charcot’s triad)
What is a coffee bean sign on an X-ray indicative of?
Sigmoid volvulus
What is portal pyaemia?
What is the most common aetiology?
Infection and thrombosis in portal vein
Intra-abdominal infection
