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General surgery in the GI tract Flashcards

1
Q

Acute abdomen meaning

A

Acute onset abdo pain that will most likely rq surgery

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2
Q

Causes of acute abdomen

A

Infection - appendicitis, cholecystitis
Inflammation - pancreatitis,
Obstruction - bowel/fallopian tubes
Vascular accidents - arterial blockage leading to ischaemia

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3
Q

What is the general approach to acute abdomen conditions?

A

Presenting Complaint (SOCRATES), PMHx, Investigations and Management

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4
Q

What types of imaging are done for acute abdomen?

A

Erect CXR, Shows air below diaphragm due to bubble from perforation
AXR,
CT Angiogram, shows thrombus/embolus
USS,
CTAP

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5
Q

What are the different approaches for management of acute abdo?

A

ABCDE Approach, Conservative, Surgical

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6
Q

What are the range of investigations that are carried out in BI?

A

Bloods, Urine Analysis, Imaging, Endoscopy

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7
Q

What are two types of bowel ischaemia?

A

Acute Mesenteric Ischaemia, Ischaemic Colitis

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8
Q

What is the presentation of bowel ischaemia?

A

Sudden onset of abdominal cramp,
Severe pain w/o peritonitis/distention o/e
Bloody & loose stools,
fever

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9
Q

What are the risk factors for bowel ischaemia?

A

> 65yrs,
A.Fib, disrupts laminar flow -> clots
atherosclerosis
Hypercoagulation,
Vasculitis,
sickle cell -> occlusion

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10
Q

AMI characteristics

A

Small bowel
Occlusive - thromboemboli derived
sudden onset
abdo pain w/o clinical signs

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11
Q

IC characteristics

A

Large bowel
Non-occlusive - atherosclerosis
gradual onset
moderate pain

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12
Q

What bloods do you take in bowel ischaemia and why?

A

FBC (neutrophilia)
VBG (lactic acidosis)
Lactate (raised in AMI) shows switch to anaerobic resp

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13
Q

What imaging technique do you use for bowel ischaemia?

A

CTAP or CT Angiogram

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14
Q

What do you detect in imaging bowel ischaemia?

A

Disrupted flow,
Vascular stenosis,
Thumbprint sign (for colitis) - thickened wall
Pneumatosis Intestinalis (air stuck in bowel wall)

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15
Q

What can you see in endoscopy of bowel ischaemia?

A

Oedema, Cyanosis, Mucosa Ulceration

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16
Q

Which type of ischaemia can you do conservative management for?

A

Ischaemic Colitis (Large bowel)

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17
Q

What is the conservative management of bowel ischaemia?

A

IV Fluid,
Broad spectrum antibiotics,
NG tube for ileus - non contractile bowel
Anticoagulants,
Repeat imaging

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18
Q

What are the indications for surgical management?

A

Small bowel,
sepsis, - hard abdomen
haemodynamic instability, - dead part of bowel
toxic megacolon

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19
Q

What are the two types of surgical management of bowel ischaemia?

A

Exploratory Laparotomy,
Endovascular Revascularisation

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20
Q

What is exploratory laparotomy?

A

Resection of necrotic bowel, mesenteric artery bypass

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21
Q

What type of pain is present in acute appendicitis?

A

Periumbilical pain migrates to RLQ

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21
Q

What is endovascular revascularisation?

A

Balloon angioplasty/thromboectomy
px w/o ischaemia/peritonitis

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22
Q

What are the other signs of acute appendicitis?

A

Anorexia, nausea, fever, bowel habits

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23
Q

What are the important clinical signs in acute appendicitis?

A

McBurney’s Point, Blumberg Sign, Rovsig Sign, Psoas Sign, Obturator Sign

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24
Q

What is McBurneys Point?

A

Tenderness in RLQ (1/3 from right ASIS to umbilicus)

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25
Q

What is Blumberg Sign?

A

Rebound tenderness in Right iliac fossa

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26
Q

What is Rovsing Sign?

A

RLQ pain from deep palpation of LLQ

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27
Q

What is Psoas Sign?

A

RLQ pain from right hip flexion

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28
Q

What is Obturator Sign?

A

RLQ pain from internal rotation of hip with knee flexion

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29
Q

What is the grading for appendicitis and what does it consider?

A

Alvarado Score - RLQ tenderness, fever, nausea, WCC, neutrophilia
Not completely diagnostic

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30
Q

What bloods do you do for acute appendicitis and why?

A

FBC (neutrophilia)
CRP
U+E to check for electrolyte imbalance from vomit

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31
Q

What imaging techniques do you do in acute appendicitis?

A

CT,
USS, children, preggers, new mums due to radiation
MRI, w/ inconclusive uss

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32
Q

What is the conservative management of acute appendicitis?

A

IV Fluids, Analgesia, Oral Antibiotics, Percutaneous drainage of abscess

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33
Q

What are the indications for conservative management of acute appendicitis?

A

Negative imaging with uncomplicated appendicitis

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34
Q

What are the surgical managements for acute appendicitis?

A

Laparoscopic or Open Appendicectomy

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35
Q

What are the advantages of laparoscopic appendicectomy?

A

Less pain, less infection risk, faster recovery, cheaper

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36
Q

What is bowel obstruction?

A

Restriction of normal passage of intestinal contents

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37
Q

What are the two main groups of bowel obstruction?

A

Paralytic (adynamic) ileus, Mechanical

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38
Q

What are the two natures of bowel obstruction

A

Simple - blocked bowel w/o blood supply damage
Strangulating - blood supply cut off for affected area e.g. strangulated hernia, volvulus

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39
Q

Aetiology of bowel obstruction

A

Lumen - faecal impaction, gallstone ileus
In the wall - Crohn’s, tumour, diverticulitis
Outside wall - hernia, volvulus, obstruction

40
Q

What are the common aetiologies of small bowel obstruction? (ANCHIS)

A

Adhesions, Neoplasia, Crohn’s, Hernia, Intussusception, Surgery

41
Q

Presentation of small bowel obstruction

A

Colicky, central abdo pain
Early onset bilious vomiting
Late stage constipation
less significant distention

42
Q

What are the common aetiologies of large bowel obstruction? (CVD FH)

A

Colorectal carcinoma, Volvulus (sigmoid/caecal twisting), Diverticulitis, Faecal Impaction, Hirschsprung disease

43
Q

Presentation of large bowel obstruction

A

colicky, constant abdo pain
late onset bilious -> faecal vomiting
late stage constipation
significant abdo distention

43
Q

What are some other symptoms of bowel obstruction?

A

Dehydration, Diffuse abdominal tenderness, Tinkling/absent bowel sounds

44
Q

3 pts about diagnosis of obstructions

A
  1. Check for presence of symptoms
  2. Search for hernias / abdo scars
  3. simple vs strangulating
44
Q

Cardinal signs of bowel obstruction

A

Pain
vomiting
constipation
distention

45
Q

What are the features that suggest strangulation?

A

Colicky to constant, Tachycardia, Pyrexia, Leukocytosis, ^ CRP

46
Q

What are the common locations for hernias?

A

Epigastric, Umbilical, Incisional, Inguinal, Femoral

47
Q

What are three types of hernia?

A

Neck of Sac,
Strangulation, can cut of venous/arterial supply
Richter’s Hernia, part of wall protrudes, lumen is still viable

48
Q

What is a hernia

A

Protrusion of organ outside its cavity

49
Q

What are the blood investigations for bowel obstruction, and what should they be?

A

WCC/CRP (normal), raised in strangulation/perfo
U&E (imbalance)
VBG (vomiting - met alkalosis, hypo CL-/K+
strangulation - met acidosis, lactate buildup)

50
Q

What imaging do you do for bowel obstruction?

A

Erect CXR/AXR,
CT Abdo/Pelvis

51
Q

What would you see in an AXR of bowel obstruction?

A

Small bowel - dilated loops more central, striations across loop
Large bowel - dilated more peripheral, haustrations of taenia coli

52
Q

What would you see in a CT of bowel obstruction?

A

Localises site of obstruction - identify transition pt
sees collapsed and dilated loops & proximal dilation

53
Q

What are the indications for conservative management of bowel obstruction?

A

No signs of ischaemia or clinical deterioration

54
Q

What is the supportive management for bowel obstruction?

A

Nil by Mouth, IV Fluid - for resus
analgesia, antiemetics - correction of electrolytes
urinary catheter - monitor output
nasogastric tube - decompression/prevent aspiration

55
Q

What is the conservative treatment for bowel obstruction?

A

Stool evacuation (for faecal impaction),
sigmoidoscopic decompression (for volvulus),
oral gastrograffin (for adhesional SBO) - osmolar contrast agent .: absorbs fluid

56
Q

What are the indications for surgical management for bowel obstruction?

A

Haemodynamic Instability,
Sepsis,
Complete obstruction w/ signs of ischaemia
closed loop obs, two pts affected
persistent obstruction

57
Q

What are the techniques of surgical management for bowel obstruction?

A

Exploratory Laparotomy, Bowel resection with primary anastomosis, Endoscopic stenting

58
Q

What is the presentation of GI perforation?

A

Sudden onset severe abdominal pain,
Diffuse abdominal guarding & tenderness, Nausea,
Vomiting,
Absolute Constipation,
Fever,
Tachycardia, Hypotension, tachypnoea

59
Q

Exacerbation of GI perforation pain

A

Worsens with movement

60
Q

What are some different locations for GI perforation?

A

Peptic Ulcer, Diverticulum, Appendix, Malignancy

61
Q

Symptoms of perforated peptic ulcer

A

Sudden epigastric/diffuse pain
referred shoulder pain
Hx of NSAIDs, steroids

62
Q

Symptoms of perforated diverticulum

A

LLQ
Constipation

63
Q

Symptoms of perforated appendix

A

Anorexia
Migratory pain, umbilicus to RLQ

64
Q

Symptoms of perforated malignancy

A

Weight loss
change in bowel habit
anorexia
PR bleeding

65
Q

What imaging do you do for GI perforation?

A

CXR, CT abdo pelvis

66
Q

What do you see in an erect CXR for GI perforation?

A

Subdiaphragmatic free air, due to release of air from site of perforation

67
Q

What do you see in a CT of abdo/pelvis?

A

Localised fat stranding, pneumoperitoneum

68
Q

What are the differentials for GI perforation?

A

Acute cholecystitis, Appendicitis, MI, Acute pancreatitis

69
Q

What is the supportive management for GI perforation?

A

Nil by mouth, Nasogastric tube, IV fluids, Broad spectrum antibiotics, Analgesia, Antiemetics, Urinary catheter

70
Q

What are the indications for conservative management in GI perf and how common is this?

A

Localised peritonitis, without signs of sepsis (very rare)

71
Q

What are the indications of surgical management of GI perforation?

A

Generalised peritonitis with or without signs of sepsis

72
Q

What are the surgical procedures used for GI perforation?

A

Exploratory Laparotomy,
Closure of perforation,
Resection with anastomosis,
biopsy for malignancy

73
Q

What are the symptoms of biliary colic?

A

Postprandial RUQ (shoulder radiation), Nausea

74
Q

What does ultrasound show in biliary colic?

A

Cholelithiasis

75
Q

What is the management of biliary colic?

A

Analgesia, Antiemetics, Spasmolytics

76
Q

What are the symptoms of acute cholecystitis?

A

Acute severe RUQ,
Murphy’s sign (pain when palpation during inhaling),
fever

77
Q

What does ultrasound show in acute cholecystitis?

A

Thickened gall bladder wall

78
Q

What is the management of acute cholecystitis?

A

Fluids, Antibiotics, Analgesia, Blood Culture -> cholecystectomy

79
Q

What are the symptoms of acute cholangitis?

A

Charcot’s Triad: jaundice, RUQ pain, fever

80
Q

What do blood tests show in acute cholangitis?

A

Elevated LFTs, WCC, CRP

81
Q

What does ultrasound show in acute cholangitis?

A

Biliary Dilatation

82
Q

Cholangitis vs Cholecystitis

A

Cholangitis - inflamm of biliary tree, usually due to bacterial infection
Cholecystitis - inflamm of gallbladder usually due to gallstones

83
Q

What is the management of acute cholangitis?

A

Fluids, IV Antibiotics, Analgesia, ERCP for clearing bile duct

84
Q

What are the symptoms of acute pancreatitis?

A

Severe epigastric pain radiating to back,
nausea,
Hx of gallstones, ethanol

85
Q

What can blood tests show for acute pancreatitis?

A

Raised amylase, Low calcium

86
Q

What do you use imaging for in acute pancreatitis?

A

CT and USS for assessing complications

87
Q

Commonest causes of small bowel obstruction

A

Hx of abdo operation
Strangulated external hernia

88
Q

What is the coffee bean sign an indication of

A

AXR
sigmoid volvulus, usually v large due to distension

89
Q

Treatment for sigmoid volvulus

A

rigid sigmoidoscopy (flexible but firm)
untwists volvulus releases flatus/lq faeces

90
Q

Risk of leaving sigmoid volvulus untreated

A

Loop of sigmoid will have blood supply cut off -> necrosis
pressure build up -> perforation

91
Q

Steps of exploratory laparotomy

A

Midline incision
Evaluate abdo viscera
Resect necrosed bowel loops

92
Q

What is damage control laparotomy

A

Staple bowel ends, move to ICU to restore physiological balance
resume surgery after period of time

93
Q

How to restore blood flow in SMA (Superior mesenteric artery)

A

Embolectomy - in embolic AMI
Endovascular management of thrombus / Arterial bypass of SMA - in thrombotic AMI

94
Q

Aterial causes of AMI

A

Embolism - A.fib, atheroma, endocarditis
Thrombosis - atherosclerosis
Nonocclusive - hypotension/hypoperfusion, vasospasm in shock

95
Q

Venous causes of AMI

A

SMV thrombosis
occurs w/ portal hypertension, sickle cell

96
Q

Portal Pyaemia

A

aka pylephlebitis (inflamm of vein due to infection)
can be complication of sepsis
causes air in the liver due to bacterial translocation

Gastro (10 decks)

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