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y2 brs (haroop) > General Surgery in the GI Tract > Flashcards

General Surgery in the GI Tract Flashcards

1
Q

Which GI disorders are associated with pain within the RUQ?

A
  • Biliary colic
  • Cholecystitis/cholangitis
  • Duodenal ulcer
  • Liver abscess
  • Portal vein thrombosis
  • Acute hepatitis
  • Nephrolithiasis
  • RLL pneumonia
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2
Q

Which GI disorders are associated with pain within the epigastrium?

A
  • Acute gastritis/GORD
  • Gastroparesis
  • Peptic ulcer disease/perforation
  • Acute pancreatitis
  • Mesenteric ischaemia
  • Abdominal aortic aneurysm
  • Aortic dissection
  • Myocardial infarction
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3
Q

Which GI disorders are associated with pain within the LUQ?

A
  • Peptic ulcer
  • Acute pancreatitis
  • Splenic abscess
  • Splenic infarction
  • Nephrolithiasis
  • LLL Pneumonia
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4
Q

Which GI disorders are associated with pain within the RLQ?

A
  • Acute appendicitis
  • Colitis
  • IBD
  • Infectious colitis
  • Ureteric stone/pyelonephritis
  • PID/Ovarian Torsion
  • Ectopic pregnancy
  • Malignancy
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5
Q

Which GI disorders are associated with suprapubic/central pain?

A
  • Early appendicitis
  • Mesenteric ischaemia
  • Bowel obstruction
  • Bowel perforation
  • Constipation
  • Gastroenteritis
  • UTI/Urinary retention
  • PID
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6
Q

Which GI disorders are associated with LLQ pain?

A
  • Diverticulitis
  • Colitis
  • IBD
  • Infectious colitis
  • Ureteric stone/pyelonephritis
  • PID/Ovarian torsion
  • Ectopic pregnancy
  • Malignancy
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7
Q

Which two main arteries supply the small intestine?

A

Coeliac artery

Superior mesenteric artery

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8
Q

Which arteries supply the colon?

A

SMA

IMA

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9
Q

Which artery supplies the rectum?

A

Internal iliac artery

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10
Q

What happens in bowel ischaemia?

A

In bowel ischaemia there is reduced blood flow and hypoperfusion to the gastrointestinal tract, predominantly due to thromboembolic events.

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11
Q

What are the presentations associated with bowel ischaemia?

A
  • Sudden onset crampy abdominal pain
  • Severity of pain depends on the length and thickness of colon affected
  • Bloody, loose stool
  • Fever, signs of septic shock
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12
Q

Partially altered blood is usually associated with which region of the GI tract?

A

Colon

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13
Q

Melaena is associated with which region of the GI tract?

A

Proximal small bowel

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14
Q

What are the risk factors for bowel ischaemia?

A
  • Age >65 years
  • Cardiac arrythmias (atrial fibrillation can potentiate the formation of clots due to turbulent flow, embolus into the SMA), and atherosclerosis.
  • Hypercoagulation/thrombophilia
  • Vasculitis
  • Sickle cell disease
  • Profound shock – hypotension
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15
Q

Why are cardiac arrythmias linked with bowel ischaemia?

A

atrial fibrillation can potentiate the formation of clots due to turbulent flow, embolus into the SMA

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16
Q

What is the main cause of acute mesenteric ischaemia?

A

Occlusive due to thrombo-emboli

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17
Q

What are the differences in onset between acute mesenteric ischaemia and ischaemia colitis?

A

Sudden onset v more mild and gradual

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18
Q

Moderate pain and tenderness is associated with what type of ischaemia?

A

Ischaemia colitis

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19
Q

What is the primary cause of ischaemia colitis?

A

Due to non-occlusive low flow states, or atherosclerosis

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20
Q

What investigations are conducted in a patient with suspected bowel ischaemia?

A

FBC - neutrophillic leuocytosis
VBG - Lactic acidosis - accumulation of lactate within the blood associated with late-stage mesenteric ischaemia (necrotic bowel)

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21
Q

An FBC in bowel ischaemia reveals what?

A

Neutrophillic leucocytosis

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22
Q

A VBG in bowel ischaemia will reveal what?

A

Lactic acidosis, an accumulation of lactate within the blood

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23
Q

What imaging is used in detecting bowel ischaemia?

A

CT angiogram

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24
Q

What does CTAP detect in bowel ischaemia?

A

Detects any vascular stenosis and disrupted flow within the vasculature using an arterial contrast.
• ‘Pneumatosis intestinalis’ (Transmural ischaemia/infarction)
• Ischaemic: Thumbprint sign (unspecific sign of colitis).

Colonic thickening

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25
Q

What is pneumatosis intestinalis?

A

Transmural ischaemia/infarction

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26
Q

What does a ‘thumbprint sign’ suggest?

A

Ischaemia

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27
Q

What conservative management options for bowel ischaemia?

A
  • IV fluid resuscitation
  • Bowel rest (Nil by mouth)
  • Broad-spectrum antibiotics – Colonic ischaemia can result in bacterial translocation and sepsis.
  • NG tube for decompression – in concurrent ileus (Absent peristalsis)
  • Treat/manage underlying cause
  • Serial abdominal examination and repeat imaging
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28
Q

What is ileus?

A

Absent peristalsis

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29
Q

What is the surgical management for bowel ischaemia?

A

Exploratory laparotomy: Resection of necrotic bowel +/- surgical embolectomy or mesenteric arterial bypass.

Endovascular revascularisation: Balloon angioplasty/thrombectomy. In patients without signs of ischaemia.

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30
Q

What warrants a patient for surgical management of bowel ischaemia?

A
  • Small bowel ischaemia
  • Signs of peritonitis or sepsis
  • Haemodynamic instability
  • Massive bleeding
  • Fulminant colitis with toxic megacolon
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31
Q

What is explorative laparotomy?

A

Resection of necrotic bowel +/- surgical embolectomy or mesenteric arterial bypass.

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32
Q

What is endovascular revascularisation?

A

Balloon angioplasty/thrombectomy. In patients without signs of ischaemia.

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33
Q

What is acute appendicitis?

A

Acute inflammation of vermiform appendix , predominantly due to obstruction of the lumen of the appendix

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34
Q

What are the presentations of acute appendicits?

A
  • Initially periumbilical pain that migrates to the right lower quadrant.
  • Anorexia
  • Nausea +/- vomiting
  • Low grade fever
  • Change in bowel habit
35
Q

What is McBurney’s point?

A

Tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus.

36
Q

What is Blumberg sign?

A

Rebound tenderness in the right iliac fossa

37
Q

What is Rovsing sign?

A

RLQ pain elicited on deep palpation of the LLQ.

38
Q

What is Psoas sign?

A

RLQ pain elicited on flexion of right hip against resistance

39
Q

What is Obturator Sign?

A

RLQ pain on passive internal rotation of the hip & knee flexion.

40
Q

What are the blood signs with acute appendicits?

A
  • FBC: Neutrophilic leucocytosis
  • Increased CRP
  • Urinalysis: Possible mild pyuria/haematuria
  • Electrolyte imbalances in profound vomiting
41
Q

What imaging is associated with the diagnosis of acute appendicitis?

A
  • CT: Gold standard first line of investigation in adults >50.
  • USS: Children/pregnancy/breastfeeding
  • MRI: Pregnancy if USS inconclusive
42
Q

What is the conservative management for acute appendicitis?

A
  • IV Fluids, Analgesia IV or PO antibiotics
  • In abscess, phlegmon or sealed perforation
  • Resuscitation + IV antibiotics +/- percutaneous drainage.
43
Q

What scoring criteria is used for assessing acute appendicitis?

A

Alvarado score

44
Q

What Alvarado score categorises an increased likelihood of acute appendicitis?

A

> 7

45
Q

What is a phlegmon?

A

Phlegmon describes inflammation of soft tissue that transmits deep to the skin or inside the body.

46
Q

What is the surgical management for laparscopic appendicetomy?

A
  1. Trocar placement
  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
47
Q

What are the advantages of laparscopic appendicetomy over open?

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
48
Q

What is bowel obstruction?

A

In small bowel obstruction there is a mechanical disruption in the patency of the gastrointestinal tract – emesis (vomiting), absolute constipation and abdominal pain.

In large bowel obstruction: A mechanical interruption to the flow of intestinal contents.

49
Q

What are the five main causes of small bowel obstruction?

A 
Adhesions
Neoplasia
Incarcerated hernia
Crohn's disease
Other
50
Q

What are the main causes of large bowel obstruction?

A 
Colorectal carcinoma 
Volvulus
Diverticulitis
Faecal impaction 
Hirschsprung disease
51
Q

What type of pain is associated with small bowel obstruction?

A

Colicky, and central

52
Q

How would you describe vomiting in small obstruction?

A

Early onset, large amount, bilious

53
Q

How would you describe vomiting in large bowel obstruction?

A

Late onset
Initially bilious
Progresses to faecal vomiting

54
Q

What features suggest strangulation?

A
  • Change in character of pain from colicky to continuous
  • Tachycardia
  • Pyrexia
  • Peritonism
  • Bowel sounds absent or reduced
  • Leucocytosis
  • Increased C-reactive protein
55
Q

What is a hernia?

A

A hernia refers to which an organ is displaced and protrudes through the wall of the cavity containing it.

56
Q

What are the three types of GI hernias?

A

Neck of Sac
Strangulated hernia
Richter’s hernia

57
Q

What is a neck of sac hernia?

A

As a consequence of the tight neck, the vasculature becomes compromised.
• Proximal bowel becomes distended due to obstructed flow
• Neck of a large hernia sac is transected at the midpoint of the inguinal canal.

58
Q

What is a strangulated hernia?

A

A section of bowel protrudes through a weakened area of abdominal muscle, the surrounding muscle compresses around the tissue, compromising the blood supply.
• Venous return is impaired.
• Oedematous  Increase’s blood pressure to prevent arterial flow into the affected area.
• Manifests as hypoperfusion and bowel ischaemia.

59
Q

What is a Richter’s hernia?

A

Richter hernia is a herniation of only a portion of the circumference of the bowel wall through the fascial defect.
• There is continuous colonic flow of chyme throughout the bowel without strangulation.

60
Q

What blood tests are performed in a patient with bowel obstruction?

A
  • WCC/CRP: Normal (Raised - suspect of strangulation/perforation).
  • U&E: Electrolyte imbalance
  • VBG: Vomiting – Low chloride and potassium + metabolic alkalosis
  • VGG if strangulation: Metabolic acidosis (Lactate elevated)
61
Q

What imaging is performed in a patient with suspected bowel obstruction?

A

Erect CXR/AXR
• Small bowel: Dilated small bowel loops >3cm proximal to the obstruction (central).
• Large bowel: Dilated large bowel >6cm (caecum >9cm) predominantly peripheral.
• CT abdo/pelvis  Transition point, dilation of proximal loops -IV+/-oral contrast if possible.

62
Q

What are the characteristic imaging patterns for a small bowel obstruction?

A
  • Ladder pattern of dilated loops and their central position

* Striations that pass completely across the width of the distended loop produced by the circular mucosal folds.

63
Q

What are the characteristic features of a large bowel obstruction on an X-ray?

A

Large Bowel Obstruction
• Distended large bowel tends to lie peripherally
• Show haustrations of taenia coli – do not extend across whole width of bowel

64
Q

Why is a CT scan conducted in a patient with a bowel obstruction?

A

A CT scan is conducted in order to localise the exact site of obstruction.
• Detect obstructing lesions and colonic tumours
• May diagnose unusual hernias (obturator hernias)

65
Q

What is the Supportive management for bowel obstruction?

A

In patients with no signs of ischaemia/no signs of clinical deterioration.
Supportive management
• NBM, IV peripheral access with large bore cannula- IV fluid resuscitation.
• IV analgesia, IV anti-emetics, correction of electrolyte imbalances
• Nasogastric tube for decompression (removes chance of aspiration pneumonia), urinary catheter for monitoring output
• Introduce gradual food intake if abdominal pain and distention improve.

66
Q

What is the conservative management for bowel obstruction?

A
  • Faecal impaction: Stool evacuation (manual, enemas, endoscopic)
  • Sigmoid volvulus (obstruction caused by twisting of intestines): Rigid sigmoidoscopic decompression – removal of fluid results in bowel collapse to straighten and improve distention.
  • SBO: Oral gastrograffin (Highly osmolar iodinated contrast agent) – can be used to resolve adhesional small bowel obstruction.
67
Q

What is a sigmoid volvulus?

A

obstruction caused by twisting of intestines

68
Q

How can a sigmoid volvulus be resolved?

A

Rigid sigmoidoscopic decompression – removal of fluid results in bowel collapse to straighten and improve distention.

69
Q

What is oral gastrograffin?

A

Highly osmolar iodinated contrast agent

70
Q

What are the indications for the surgical management of bowel obstruction?

A
  • Haemodynamic instability or signs of sepsis
  • Complete bowel obstruction with signs of ischaemia (VBG detects elevated lactate).
  • Closed loop obstruction
  • Persistent bowel obstruction > 2 days despite conservative management
71
Q

What operations are performed for bowel obstruction?

A
  • Exploratory laparotomy/laparoscopy
  • Restoration of intestinal transit (depending on intra-operation findings)
  • Bowel resection with primary anastomosis or temporary/permanent stroma formation
72
Q

What is a GI perforation?

A

Gastrointestinal perforation occurs when a hole forms through the stomach, large bowel or small intestine.

73
Q

What are the symptoms associated with a GI perforation?

A
  • Sudden onset severe abdominal pain associated with distension
  • Diffuse abdominal guarding, rigidity, rebound tenderness.
  • Pain aggravated by movement
  • Nausea, vomiting, absolute constipation
  • Fever, tachycardia, tachypnoea, hypotension
  • Decreased, or absent bowel sounds
74
Q

What is rebound tenderness?

A

A clinical sign in which there is pain upon removal of pressure rather than application of pressure to the abdomen.

75
Q

What symptoms are associated with a perforated peptic ulcer?

A

Sudden epigastric or diffuse pain
Referred shoulder pain
Hx of NSAIDs, steroids, recurrent epigastric pain

76
Q

What symptoms are associated with a perforated diverticulum?

A

Lower left quadrant pain
Constipation
Insidious, perforations seal off, perorated

77
Q

What symptoms are associated with a perforated appendix?

A

Migratory pain
Anorexia
Gradual worsening RLQ pain

78
Q

What symptoms are associated with a perforated malignancy?

A

Change in bowel habit
Weight loss
Anorexia
PR bleeding

79
Q

What blood investigations are conducted in patients with GI perforations?

A
  • FBC: Neutrophilic leucocytosis
  • Possible elevation of urea, creatinine
  • VBG: Lactic acidosis
80
Q

What causes an inflated-lift diaphgram?

A

GI perforation, gas accumulation

81
Q

What imaging is performed for a GI perforation?

A
  • 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
82
Q

What are the supportive management plans for GI perforations?

A
  • NBM & nasogastric tube
  • IV peripheral access with large bore canula – IV fluid restriction
  • Broad spectrum antibiotics
  • IV proton-pump inhibitors
  • Parenteral analgesia & anti-emetics
  • Urinary catheter
83
Q

What are the conservative management plans for GI perforations?

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.

84
Q

What are the surgical interventions for a GI perforation?

A
  • Exploratory laparotomy/laparoscopy
  • Primary closure of perforation with or without omental patch (most common in perforated peptic ulcer)
  • Resection of the perforated segment of the bowel with primary anastomosis or temporary stoma.
  • Obtain intra-abdominal fluid for MC&S, peritoneal lavage
  • If perforated appendix  Lap or open appendicectomy
  • If malignancy  Intraoperative biopsies.

y2 brs (haroop) (62 decks)

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