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Gastro 2 > General surgery in the GI tract > Flashcards

General surgery in the GI tract Flashcards

1
Q

What is acute abdomen?

A

-Umbrella term
-Acute onset of abdomen pain that requires surgery

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2
Q

How can acute abdomen be divided?

A

-Infection
-Inflammation
-Obstruction
-Vascular accident

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3
Q

What is assessed in acute abdomen?

A

Pain assessment

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4
Q

What investigations are used for acute abdomen?

A

-Bloods
-Urinalysis
-Imaging
-Endoscopy

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5
Q

What are imaging used for acute abdomen?

A

-Erect chest X-ray
-Abdominal X-ray
-CT arterial potopgraphy= portal venous system
-CT angiogram
-Ultrasound scan
-Endoscopy

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6
Q

Why is a erect chest X-ray useful?

A

Can see air below the diaphragm

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7
Q

What is the advantage of using CT over US?

A

-CT gives images that can be seen by doctors and other members of the team
-US gives no image so only person who has seen its is the person who carried out the US

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8
Q

What are the management for acute abdomen?

A

-ABCDE
-Conservative management
-Surgical management

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9
Q

What organs are in the RUQ?

A

-Liver
-Gallbladder, bile ducts
-Head of pancreas
-Antrum
-Right kidney and adrenal glands
-Hepatic flexure and right half of transverse colon

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10
Q

What organs are in the RLQ?

A

-Caecum
-Appendix
-Ascending colon
-Right ovary and fallopian tube
-Right ureter

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11
Q

What organs are in the epigastrium?

A

-Stomach
-Pancreas
-Duodenum

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12
Q

What organs are in the suprapubic region?

A

-Urinary bladder
-Sigmoid colon
-Uterus

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13
Q

What organs are in the LUQ?

A

-Largest part of stomach
-Spleen
-Left lobe of liver
-Body and tail of pancreas
-Left kidney and adrenal glands
-Splenic flexure of colon
-Transverse colon

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14
Q

What organs are in the LLQ?

A

-Descending colon
-Sigmoid colon
-Left ovary and fallopian tube
-Left ureter

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15
Q

What is the presentation of a patient with bowel ischaemia?

A

-Sudden onset crampy pain
-Bloody, loos stool (currant jelly stools)
-Fever, signs of septic shock

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16
Q

Why do you get currant jelly stools?

A

Ischaemia to mucosa and is shed with blood

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17
Q

What does the severity of pain of bowel ischaemia depend on?

A

-Length of bowel affected
-Thickness of bowel affected

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18
Q

What are the risk factors for bowel ischaemia?

A

-Over 65 years old
-Cardiac arrhythmias (mainly AF), atherosclerosis
-Hypercoagulation/thrombophilia
-Vasculitis
-Sickle cell disease
-Profound shock causing hypotension

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19
Q

What is small bowel ischaemia called?

A

Acute mesenteric ischaemia

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20
Q

What is large bowel ischaemia called?

A

Ischaemic colitis

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21
Q

What is the main cause of acute mesenteric ischaemia?

A

Occlusive due to thromboemboli

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22
Q

What is the main cause of ischaemic colitis?

A

-Non occlusive low flow rates
-Atherosclerosis

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23
Q

What is the difference in presentation in acute mesenteric ischaemia and ischaemic colitis?

A

-Sudden onset vs gradual
-Severe abdominal pain vs moderate pain

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24
Q

What bloods are used for bowel ischaemia?

A

-FBC= neutrophilic, leukocytes
-VBG= lactic acidosis

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25
Q

What imaging is used for bowel ischaemia?

A

-CTAP
-CT angiogram

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26
Q

What does CTAP/CT angiogram detect?

A

-Disrupted flow
-Vascular stenosis
-Pneumatosis intestinalis= transmural ischaemia/infarction
-Thumbprint sign for ischaemic colitis

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27
Q

What is the thumbprint sign?

A

Thickening of the bowel wall that looks like a thumbprint

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28
Q

When is endoscopy used for bowel ischaemia?

A

-Mild/moderate cases of ischaemic colitis

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29
Q

What are signs of mild/moderate iscahemic colitis?

A

-Oedema
-Cyanosis
-Ulceration of mucosa

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30
Q

What is the management for mild/moderate ischaemic colitis?

A

-IV fluid resuscitation
-Bowel rest
-Broad spectrum antibiotics
-NG tube for decompression
-Anticoagulation
-Treat/manage underlying cause
-Serial abdominal examinations and repeat imaging

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31
Q

Why is broad spectrum antibiotics given to patients with bowel ischaemia?

A

-Bowel ischaemia can result in bacterial translocation and sepsis

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32
Q

What does decompression mean in bowel ischaemia?

A

Relieving pressure in the colon

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33
Q

When is surgery considered in bowel ischaemia?

A

-Small bowel ischaemia
-Signs of peritonitis/sepsis
-Haemodynamic instability
-Massive bleeding
-Fluminant colitiis with toxic megacolon

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34
Q

What is fulminant colitis?

A

Severe form of ulcerative colitis

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35
Q

What is the main surgery done for bowel ischaemia?

A

-Resection of necrotic bowel

36
Q

When is endovascular revascularisation considered?

A

-In patients with no signs of ischaemia

37
Q

How does pain present in acute appendicitis?

A

-Periumbilical pain migrates to RLQ (within 24 hours)

38
Q

What are symptoms of acute appendicitis?

A

-Anorexia
-Nausea
-Vomiting
-Low grade fever
-Change in bowel habit

39
Q

What are clinical signs in acute appendicitis?

A

-McBurney’s sign
-Blumberg sign
-Rovsing sign
-Psoas sign
-Obturator sign

40
Q

What is McBurney’s sign?

A

Tenderness in the RLQ

41
Q

What is Blumberg sign?

A

Rebound tenderness especially in the RIF

42
Q

What is rovsing sign?

A

RLQ pain elicited on deep palpation of the LLQ

43
Q

What is psoas sign?

A

RLQ pain elicited on flexion of right hip against resistance

44
Q

What is obturator sign?

A

RLQ pain on passive internal rotation of hip with hip and knee flexion

45
Q

What is rebound tenderness?

A

Push down on abdomen and release and there is more pain upon releasing

46
Q

What signs in bloods would we see in acute appendicitis?

A

-FBC: Neutrophilic leukocytosis= abnormally high neutrophil count
-Increased CRP
-Urinalysis: possible mild pyuria/haematuria
-Electrolyte imbalances in profound vomiting

47
Q

What is the most suitable imaging for acute appendicitis in adults?

A

CT
(Esp >50)

48
Q

What is the most suitable imaging for acute appendicitis in children/pregnancy/breastfeeding?

A

Ultrasound

49
Q

What is the most suitable imaging for acute appendicitis for pregnancy when USS is inconclusive?

A

MRI

50
Q

What scale is used to check for acute appendicitis?

A

Alvarado score

51
Q

When is diagnostic laparoscopy used in acute appendicitis?

A

-Persistent pain and inconclusive imaging

52
Q

What is general management for acute appendicitis?

A

-IV fluids
-Analgesia
-IV/PO antibiotics

53
Q

What is management for acute appendicitis in abscess, phlegmon or sealed perforation?

A

Resuscitation + IV ABx +/- percutaneous drainage

54
Q

What is phlegmon?

A

Inflamed soft tissue that spread under the skin or inside the body

55
Q

What are the pros of laparoscopic appendicectomy vs open appendicectomy?

A

-Less pain
-Lower incidence of surgical site infection
-Decreased length of hospital stay
-Earlier return to work
-Cheaper
-Better quality of life scores

56
Q

What are the 2 main groups of bowel obstruction?

A

-Paralytic= bowel does not work
-Mechanical= something obstructs

57
Q

How is mechanical intestinal obstruction classified by?

A

-Speed of onset
-Site
-Nature
-Aetiology

58
Q

How is speed of onset classified in mechanical intestinal obstruction?

A

-Acute
-Chronic
-Acute on chronic

59
Q

How is site classified in mechanical intestinal obstruction?

A

-High or low
-Refers to small bowel or large bowel obstruction

60
Q

How is nature classified in mechanical intestinal obstruction?

A

-Simple= bowel obstructed with no damage to blood supply
-Strangulating= blood supply of involved segment is cut off

61
Q

What are causes of mechanical intestinal obstruction in the lumen?

A

-Faecal impaction
-Gallstone ‘ileus’

62
Q

What are the causes of mechanical intestinal obstruction in the wall?

A

-Crohn’s disease
-Tumours
-Diverticulitis of colon

63
Q

What are the causes of mechanical intestinal obstruction outside the wall?

A

-Strangulated hernia (external or internal)
-Volvulus
-Obstruction due to adhesions or bands

64
Q

What is volvulus?

A

-Part of intestine twists around itself and the mesentery causing bowel obstruction

65
Q

What are the symptoms of bowel obstruction?

A

-Pain
-Vomiting
-Constipation
-Abdominal distention

66
Q

What features suggest strangulations in bowel obstruction?

A

-Change in character of pain from colicky to continuous
-tachycardia
-Pyrexia
-Peritonism= inflammation of peritoneum
-Bowel sounds absent or reduced
-Leucocytosis
-Increased CRP

67
Q

What does peritonism do to the abdomen?

A

Causes hard abdomen

68
Q

What is Richter’s hernia?

A

Part of intestinal wall protrudes and can become ischaemic but rest of intestine is healthy

69
Q

What bloods are normally done for bowel obstruction?

A

-WCC and CRP= normal
-U and E= electrolyte imbalance

70
Q

When is VBG performed?

A

-If vomiting= ⬇Cl-, ⬇K+, metabolic alkalosis
-If strangulation= metabolic acidosis due to ⬆lactate

71
Q

What are the imaging test used for bowel obstruction?

A

-Erect chest X-ray/ abdominal X-ray
-CT abdomen/pelvis

72
Q

What is observed in bowel obstruction in erect CXR/AXR?

A

-SBO= dilated small bowel loops
-LBO= dilated large bowel

73
Q

Why do you use CT for bowel obstruction?

A

To see transition point where normal bowel becomes ischaemic and becomes normal again

74
Q

How can you identify small bowel on X-ray?

A

-Striations that pass completely across
-Central

75
Q

How can you identify large bowel on X-ray?

A

-Haustrations of taenia coli do not extend across whole width of bowel
-Distended large bowel lies peripherally

76
Q

When is surgical management in bowel obstruction indicated?

A

-Haemodynamic instability and signs of sepsis
-Complete bowel obstruction with signs of ischaemia
-Closed loop obstruction
-Persistent bowel obstruction >2 days despite conservative management

77
Q

What are possible operations that can be done for bowel obstruction?

A

-Exploratory laparotomy/laparoscopy
-Restoration of intestinal transit
-Bowel resection with primary anastomosis or temporary/permanent stoma formation

78
Q

What are indications of perforated peptic ulcer?

A

-Sudden epigastric/diffuse pain
-Referred shoulder pain
-History of NSAIDs, steroids, recurrent epigastric pain

79
Q

What are indications of perforated diverticulum?

A

-LLQ pain
-Constipation

80
Q

What are indications of perforated appendix?

A

-Migratory pain
-Anorexia
-Gradual worsening RLQ pain

81
Q

What are indications of perforated malignancy?

A

-Change in bowel habit
-Weight loss
-Anorexia
-PR bleeding

82
Q

What are seen in bloods for GI perforation?

A

-FBC: neutrophilic, leukocytosis
-Possible elevation of urea, creatinine
-VBG: lactic acidosis

83
Q

What are imaging used for GI perforations?

A

-Erect CXR
-CT abdo/pelvis

84
Q

What is seen in erect CXR in GI perforations?

A

-Subdiaphragmatic free air (pneumoperitoneum)

85
Q

What is seen in CT abdomen/pelvis in GI perforation?

A

-Pneumoperitoneum
-Free GI content
-Localised mesenteric fat stranding
-What caused it?
-What level is it?

Gastro 2 (11 decks)

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