General surgery in the GI tract Flashcards

1
Q

What are the presentations for bowel ischaemia?

How does this differ between the SB and LB?

A

Current jelly stool on PR
Fever
Septic shock
Crampy pain

SB - sudden onset, LB - milder & more gradual pain

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2
Q

What are the risk factors for bowel ischaemia? (5)

A

Age >65
Cardiac arrhythmias (esp AF), atherosclerosis
Hypercoagulation/thrombophilia
Vasculitis
Sickle cell disease

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3
Q

What investigations would you do for bowel ischaemia?

A

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

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4
Q

What are the conservative management options for bowel ischaemia?

What type of bowel ischaemia is this applicable to?

A

IV fluid resuscitation
Antibiotics
Anticoagulation
NG tube for decompression
Bowel rest
Continuous monitoring

Mild-moderate ischaemic colitis, not SB

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5
Q

What surgical management options are there for bowel ischaemia?

A

Exploratory laparotomy
Endovascular revascularisation

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6
Q

What is the typical presentation for acute appendicitis? (5)

A

Initial periumbilical pain, migrates to RLQ within 24 hours
Anorexia
Nausea & vomiting
Fever
Changes in bowel habit

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7
Q

Where is McBurney’s point?

A

1/3 along the way from R ASIS to umbilicus

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8
Q

What is Blumberg’s sign? What does it show?

A

Rebound tenderness
Perotonitis

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9
Q

What is Rovsing’s sign?

A

RLQ pain during deep palpation of LLQ

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10
Q

What is the psoas sign?

A

RLQ pain when flexing right hip against resistance

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11
Q

What is the obturator sign?

A

RLQ on passive internal rotation of hip while hip & knee are flexed

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12
Q

What would bloods show in acute appendicitis?

A

FBC: neutrophilic leukocytosis
CRP: raised
Electrolyte imbalances if vomiting

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13
Q

What imaging should be done in acute appendicitis?

What investigation should be done if all imaging is inconclusive?

A

CT - gold standard if under 50
Ultrasound - children, breastfeeding, pregnancy
MRI - pregnancy if US inconclusive

Diagnostic laparoscopy

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14
Q

What is included in the Alvarado score for acute appendicitis? (MANTRELS)

What are the scoring criteria?

A
  1. Migration of pain to RLQ (1)
  2. Anorexia (1)
  3. Nausea & vomiting (1)
  4. Tenderness in RLQ (2)
  5. Rebound tenderness (1)
  6. Elevated temperature >37.3C (1)
  7. Leukocytosis >10 (2)
  8. Shifted neutrophils to left 75% (1)

<4 unlikely, 5-6 possible, >7 likely (out of 10)

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15
Q

What conservative management options are there for acute appendicitis?

A

IV fluids
Analgesia
Antibiotics
Percutaneous drainage if abscess seen

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16
Q

What are the surgical management options for acute appendicitis?

A

Laparoscopic appendectomy
Open appendectomy

Interval appendectomy - delayed removal of appendix after initial presentation to reduce rate of recurrence

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17
Q

What are the two main groups of bowel obstruction?

A
  1. functional - paralytic ileus (lack of muscle contraction)
  2. mechanical
18
Q

How is mechanical bowel obstruction classified? (4)

A
  1. Speed of onset - acute vs chronic, acute-on-chronic
  2. Site - high or low
  3. Nature (blood supply) - simple vs strangulated
  4. Aetiology - lumen, wall, outside bowel
19
Q

What are some common causes of small bowel obstruction? (4)

A

Adhesions
Neoplasia
Incarcerated hernia
Crohn’s

20
Q

What are some common causes of large bowel obstruction? (5)

A

Colorectal carcinoma
Volvulus
Diverticulitis
Faecal impaction
Hirschspring disease - lack of peristalsis in a section of the colon

21
Q

Describe vomiting symptoms in SB and LB obstruction?

A

SB - early onset, bilious
LB - late onset, can progress to faecal vomiting

22
Q

Describe absolute constipation and abdominal distension in SB and LB obstruction?

A

SB - late sign, less significant
LB - early sign, significant

23
Q

What are some signs of bowel obstruction? (6)

A

Abdominal pain
Vomiting
Constipation
Abdominal distention
Dehydration
Tinkling bowel signs (early), absent bowel sounds (late)

24
Q

What signs are seen in strangulated obstructions?

A

Pain changes from colicky to continuous
Tachycardia
Fever
Peritonism
Absent bowel sounds
Leucocytosis
Raised CRP

25
What are some common sites of hernias? (6)
Epigastric Umbilical Periumbilical Incisional Inguinal Femoral
26
What is a Richter's hernia?
Strangulated but no obstruction
27
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
28
What are the normal widths of the bowel on an X-ray?
SB - 3cm LB - 6cm Caecum - 9cm
29
What conservative management is used to treat sigmoid volvulus?
Sigmoidoscopy Pass soft rubber tube along (flatus tube) Usually untwists and releases contents
30
What are the conservative management options for bowel obstruction?
IV fluids, NBM IV analgesia, antiemetics, electrolyte correction NG decompression Stool evacuation
31
What contrast agent can be used to visualise small bowel obstructions?
Gastrografin on CT scans
32
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
33
What surgical management options are there for bowel obs?
Exploratory laparotomy/laparoscopy Bowel resection with primary anastomosis Stoma
34
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
35
What investigations can be done for GI perforation?
Bloods - FBC, U&E, VBG X-ray & CT - air under diaphragm
36
What are the conservative management options for GI perforation? (6)
NBM & NG tube IV fluids Antibiotics IV proton pump inhibitors Analgesia & antiemetics Urinary catheter
37
What are the symptoms of biliary colic (gallstones)?
Postprandial RUQ pain Radiation to back and right shoulder Nausea
38
What symptoms are seen in acute cholecystitis?
Murphy's sign Acute, severe RUQ pain Fever
39
Symptoms in acute cholangitis
Jaundice RUQ pain Fever | (Charcot's triad)
40
What is a coffee bean sign on an X-ray indicative of?
Sigmoid volvulus
41
What is portal pyaemia? | What is the most common aetiology?
Infection and thrombosis in portal vein | Intra-abdominal infection