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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
What is McBurneys Point?
Tenderness in RLQ (1/3 from right ASIS to umbilicus)
25
What is Blumberg Sign?
Rebound tenderness in Right iliac fossa
26
What is Rovsing Sign?
RLQ pain from deep palpation of LLQ
27
What is Psoas Sign?
RLQ pain from right hip flexion
28
What is Obturator Sign?
RLQ pain from internal rotation of hip with knee flexion
29
What is the grading for appendicitis and what does it consider?
Alvarado Score - RLQ tenderness, fever, nausea, WCC, neutrophilia Not completely diagnostic
30
What bloods do you do for acute appendicitis and why?
FBC (neutrophilia) CRP U+E to check for electrolyte imbalance from vomit
31
What imaging techniques do you do in acute appendicitis?
CT, USS, children, preggers, new mums due to radiation MRI, w/ inconclusive uss
32
What is the conservative management of acute appendicitis?
IV Fluids, Analgesia, Oral Antibiotics, Percutaneous drainage of abscess
33
What are the indications for conservative management of acute appendicitis?
Negative imaging with uncomplicated appendicitis
34
What are the surgical managements for acute appendicitis?
Laparoscopic or Open Appendicectomy
35
What are the advantages of laparoscopic appendicectomy?
Less pain, less infection risk, faster recovery, cheaper
36
What is bowel obstruction?
Restriction of normal passage of intestinal contents
37
What are the two main groups of bowel obstruction?
Paralytic (adynamic) ileus, Mechanical
38
What are the two natures of bowel obstruction
Simple - blocked bowel w/o blood supply damage Strangulating - blood supply cut off for affected area e.g. strangulated hernia, volvulus
39
Aetiology of bowel obstruction
Lumen - faecal impaction, gallstone ileus In the wall - Crohn's, tumour, diverticulitis Outside wall - hernia, volvulus, obstruction
40
What are the common aetiologies of small bowel obstruction? (ANCHIS)
Adhesions, Neoplasia, Crohn's, Hernia, Intussusception, Surgery
41
Presentation of small bowel obstruction
Colicky, central abdo pain Early onset bilious vomiting Late stage constipation less significant distention
42
What are the common aetiologies of large bowel obstruction? (CVD FH)
Colorectal carcinoma, Volvulus (sigmoid/caecal twisting), Diverticulitis, Faecal Impaction, Hirschsprung disease
43
Presentation of large bowel obstruction
colicky, constant abdo pain late onset bilious -> faecal vomiting late stage constipation significant abdo distention
43
What are some other symptoms of bowel obstruction?
Dehydration, Diffuse abdominal tenderness, Tinkling/absent bowel sounds
44
3 pts about diagnosis of obstructions
1. Check for presence of symptoms 2. Search for hernias / abdo scars 3. simple vs strangulating
44
Cardinal signs of bowel obstruction
Pain vomiting constipation distention
45
What are the features that suggest strangulation?
Colicky to constant, Tachycardia, Pyrexia, Leukocytosis, ^ CRP
46
What are the common locations for hernias?
Epigastric, Umbilical, Incisional, Inguinal, Femoral
47
What are three types of hernia?
Neck of Sac, Strangulation, can cut of venous/arterial supply Richter's Hernia, part of wall protrudes, lumen is still viable
48
What is a hernia
Protrusion of organ outside its cavity
49
What are the blood investigations for bowel obstruction, and what should they be?
WCC/CRP (normal), raised in strangulation/perfo U&E (imbalance) VBG (vomiting - met alkalosis, hypo CL-/K+ strangulation - met acidosis, lactate buildup)
50
What imaging do you do for bowel obstruction?
Erect CXR/AXR, CT Abdo/Pelvis
51
What would you see in an AXR of bowel obstruction?
Small bowel - dilated loops more central, striations across loop Large bowel - dilated more peripheral, haustrations of taenia coli
52
What would you see in a CT of bowel obstruction?
Localises site of obstruction - identify transition pt sees collapsed and dilated loops & proximal dilation
53
What are the indications for conservative management of bowel obstruction?
No signs of ischaemia or clinical deterioration
54
What is the supportive management for bowel obstruction?
Nil by Mouth, IV Fluid - for resus analgesia, antiemetics - correction of electrolytes urinary catheter - monitor output nasogastric tube - decompression/prevent aspiration
55
What is the conservative treatment for bowel obstruction?
Stool evacuation (for faecal impaction), sigmoidoscopic decompression (for volvulus), oral gastrograffin (for adhesional SBO) - osmolar contrast agent .: absorbs fluid
56
What are the indications for surgical management for bowel obstruction?
Haemodynamic Instability, Sepsis, Complete obstruction w/ signs of ischaemia closed loop obs, two pts affected persistent obstruction
57
What are the techniques of surgical management for bowel obstruction?
Exploratory Laparotomy, Bowel resection with primary anastomosis, Endoscopic stenting
58
What is the presentation of GI perforation?
Sudden onset severe abdominal pain, Diffuse abdominal guarding & tenderness, Nausea, Vomiting, Absolute Constipation, Fever, Tachycardia, Hypotension, tachypnoea
59
Exacerbation of GI perforation pain
Worsens with movement
60
What are some different locations for GI perforation?
Peptic Ulcer, Diverticulum, Appendix, Malignancy
61
Symptoms of perforated peptic ulcer
Sudden epigastric/diffuse pain referred shoulder pain Hx of NSAIDs, steroids
62
Symptoms of perforated diverticulum
LLQ Constipation
63
Symptoms of perforated appendix
Anorexia Migratory pain, umbilicus to RLQ
64
Symptoms of perforated malignancy
Weight loss change in bowel habit anorexia PR bleeding
65
What imaging do you do for GI perforation?
CXR, CT abdo pelvis
66
What do you see in an erect CXR for GI perforation?
Subdiaphragmatic free air, due to release of air from site of perforation
67
What do you see in a CT of abdo/pelvis?
Localised fat stranding, pneumoperitoneum
68
What are the differentials for GI perforation?
Acute cholecystitis, Appendicitis, MI, Acute pancreatitis
69
What is the supportive management for GI perforation?
Nil by mouth, Nasogastric tube, IV fluids, Broad spectrum antibiotics, Analgesia, Antiemetics, Urinary catheter
70
What are the indications for conservative management in GI perf and how common is this?
Localised peritonitis, without signs of sepsis (very rare)
71
What are the indications of surgical management of GI perforation?
Generalised peritonitis with or without signs of sepsis
72
What are the surgical procedures used for GI perforation?
Exploratory Laparotomy, Closure of perforation, Resection with anastomosis, biopsy for malignancy
73
What are the symptoms of biliary colic?
Postprandial RUQ (shoulder radiation), Nausea
74
What does ultrasound show in biliary colic?
Cholelithiasis
75
What is the management of biliary colic?
Analgesia, Antiemetics, Spasmolytics
76
What are the symptoms of acute cholecystitis?
Acute severe RUQ, Murphy's sign (pain when palpation during inhaling), fever
77
What does ultrasound show in acute cholecystitis?
Thickened gall bladder wall
78
What is the management of acute cholecystitis?
Fluids, Antibiotics, Analgesia, Blood Culture -> cholecystectomy
79
What are the symptoms of acute cholangitis?
Charcot's Triad: jaundice, RUQ pain, fever
80
What do blood tests show in acute cholangitis?
Elevated LFTs, WCC, CRP
81
What does ultrasound show in acute cholangitis?
Biliary Dilatation
82
Cholangitis vs Cholecystitis
Cholangitis - inflamm of biliary tree, usually due to bacterial infection Cholecystitis - inflamm of gallbladder usually due to gallstones
83
What is the management of acute cholangitis?
Fluids, IV Antibiotics, Analgesia, ERCP for clearing bile duct
84
What are the symptoms of acute pancreatitis?
Severe epigastric pain radiating to back, nausea, Hx of gallstones, ethanol
85
What can blood tests show for acute pancreatitis?
Raised amylase, Low calcium
86
What do you use imaging for in acute pancreatitis?
CT and USS for assessing complications
87
Commonest causes of small bowel obstruction
Hx of abdo operation Strangulated external hernia
88
What is the coffee bean sign an indication of
AXR sigmoid volvulus, usually v large due to distension
89
Treatment for sigmoid volvulus
rigid sigmoidoscopy (flexible but firm) untwists volvulus releases flatus/lq faeces
90
Risk of leaving sigmoid volvulus untreated
Loop of sigmoid will have blood supply cut off -> necrosis pressure build up -> perforation
91
Steps of exploratory laparotomy
Midline incision Evaluate abdo viscera Resect necrosed bowel loops
92
What is damage control laparotomy
Staple bowel ends, move to ICU to restore physiological balance resume surgery after period of time
93
How to restore blood flow in SMA (Superior mesenteric artery)
Embolectomy - in embolic AMI Endovascular management of thrombus / Arterial bypass of SMA - in thrombotic AMI
94
Aterial causes of AMI
Embolism - A.fib, atheroma, endocarditis Thrombosis - atherosclerosis Nonocclusive - hypotension/hypoperfusion, vasospasm in shock
95
Venous causes of AMI
SMV thrombosis occurs w/ portal hypertension, sickle cell
96
Portal Pyaemia
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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