General Surgery In The Gi Tract Flashcards
- What do we look for in regards to the patient’s PC (presenting complaint)?
- Pain assessment (SOCRATES)
- Associated symptoms
- PMHx (past medical history)
- DHX (drug history)
- SHx (social history)
What range of investigations are there
- Bloods- such as? (5)
- VBG
- FBC
- CRP
- U&Es (renal profile)
- LFTs + amylase
- Urinalysis + urine MC&S → check for UTI
- Imaging- such as? (5)
- Erect CXR
- AXR
- CTAP (CT of abdomen and pelvis)
- CT angiogram- when you suspect bleeding or infarction or large intraabdominal blood vessel
- USS
- Endoscopy
What are the 3 approaches to management
- ABCDE approach
- Airways
- Breathing
- Circulation
- Disability
- Exposure
- Conservative management
- Surgical management
RUQ
- Bilary Colic
- Cholecystitis/Cholangitis
- Duodenal Ulcer
- Liver abscess
- Portal vein thrombosis
- Acute hepatitis
- Nephrolithiasis
- RLL pneumonia
epigastrium
- Acute gastritis/GORD
- Gastroparesis
- Peptic ulcer disease/perforation
- Acute pancreatitis
- Mesenteric ischaemia
- AAA (Abdominal Aortic Aneurysm) Aortic dissection
- Myocardial infarction
LUQ
- Peptic ulcer
- Acute pancreatitis
- Splenic abscess
- Splenic infarction
- Nephrolithiasis
- LLL Pneumonia
RLQ
- Acute Appendicitis
- IBD
- Colitis
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
Suprapubic/central
- Early appendicitis
- Mesenteric ischaemia
- Bowel obstruction
- Bowel perforation
- Constipation
- Gastroenteritis
- UTI/Urinary retention
- PID
LLQ
- Diverticulitis
- IBD (Inflammatory Bowel Disease)
- Colitis
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
- What is the definition of intestinal obstruction?
Restriction of normal passage of intestinal contents
What are the 2 main groups of intestinal obstruction?
- Paralytic (adynamic) ileus e.g. someone with abdomen full of pus, this irritates bowel and bowel stops peristalsis (this is an ileus) and doesn’t stop til irritation gone
- Mechanical e.g. mechanically a bit of the bowel closes off
What are the 4 different ways to classify a mechanical intestinal obstruction?
Speed of onset:acute,chronic,acute on chronic
Site:high/low, synonymous with small and large bowel
Nature:simple or strangulated.
- Simple- bowel is occluded without damage to blood supply
- Strangulating- blood supply of involved segment of intestine is cut off e.g. in
- strangulated hernia
-volvulus
-intussusception
Aetiology: - Causes in the lumen e.g. faecal impaction, gallstone ‘ileus’ where gallstone erodes through gallbladder into bowel then gets wedged in it
- Causes in the wall- Crohn’s disease (thickening of small bowel wall), tumours, colon diverticulitis
- Causes outside the wall- strangulated hernia (external or internal), volvulus, obstruction due to adhesions or bands (this one is the commonest)
volvulus- what is it?
Imagine a party balloon being twisted giving you a closed loop
- intussusception- what is it?
When a bit of a bowel slides into the next bit
What are the causes of small bowel obstruction? (5)
- Adhesions (60%)- Hx of previous abdominal surgery
- Neoplasia (20%)- primary (rare), metastatic, extraintestinal- can happen in ovarian peritoneal disease
- Incarcerated hernia (10%)- external (abdominal wall), internal (mesenteric defect)
- Crohn’s Disease (5%)- acute (oedema), chronic (strictures)
- Other (5%)- intussusception, intraluminal (foreign body, bezoar
What are the causes of large bowel obstruction? (5)
- Colorectal cancer- commonest cause- usually obstructs on left hand side because on right the bowel can expand and compensate
- Volvulus- sigmoid, caecal
- Diverticulitis- inflammation, strictures
- Faecal impaction
- Hirschsprung disease- commonly found in infants/children (lack of nerve ganglions means bowels can’t do peristalsis)
4 main signs and symptoms of bowel obstruction
Abdominal pain
Vomiting
Absolute constipation
Abdominal dissension
How do signs and symptoms differ for small and large bowel obstruction
Abdominal pain
- Small bowel obstruction- colicky, central
- Large bowel obstruction- colicky or constant
Vomiting
- Small bowel obstruction- early onset, large amount, bilious (with bile)
- Large bowel obstruction- late onset, initially bilious, progresses to faecal vomiting (vomit looks like faeces)
- Absolute constipation
- Small bowel obstruction- late sign
- Large bowel obstruction- early sign
- Abdominal distention
- Small bowel obstruction- less significant
- Large bowel obstruction- early sign and significant
Signs for both small and large bowel obstruction
- Dehydration
- Increased high pitched tinkling bowel sounds aka borborygmi (early sign)
- or absent bowel sounds (late sign and a bad sign because peristalsis has stopped and they may have ischaemic bowel)
- Diffuse abdominal tenderness- worrying sign and should intervene soon
What are the 3 important things to remember about diagnosing bowel obstruction?
- Diagnosed by the presence of symptoms
- Examination should always include a search for hernias and abdominal scars, including laparoscopic portholes
- Is it simple or strangulating?
Features suggesting strangulation
- Change in character of pain from colicky to continuous
- Peritonism (symptom complex of vomiting, pain/abdo tenderness and shock)
- Tachycardia
- Pyrexia
- Leukocytosis
- Increased CRP
- Bowel sounds absent or reduced
Why is checking for strangulation important?
Strangulating obstruction with peritonitis has mortality of up to 15%
common hernial sites
- Inguinal and femoral hernias in groin are due to defects in abdominal wall
- Can get incisional hernia where you’ve had operation where skin has healed but underneath muscle has defect so bowel can come through that
- Umbilical hernias happen around umbilicus
- Epigastric hernias happen around epigastrium
Why is the neck of the hernia sac important?
- If it’s a large one, the bowel can get in and out easily
- The smaller the hole, the greater the chance there is of the hernia obstructing and strangulating
- e.g. in strangulated hernia pic, first venous return goes then bowel becomes oedematous then blood stops coming out which compresses arterial blood coming in causing ischaemic bowel
- What is a Richter’s hernia?
-
- Not all hernias are associated with obstruction
- This is a knuckle of bowel getting caught in a hernia but there’s still continuity of the bowel so you still have dead bowel without proper bowel obstruction
Investigations for obstruction
- Bloods- which ones and why?
- WCC/CRP usually normal (if raised then suspicion of strangulation/perforation)
- U&E: electrolyte imbalance e.g. if vomiting
- VBG if vomiting: HypoCl-, HypoK+ metabolic alkalosis
- VBG if strangulation: metabolic acidosis (lactate)
- Imaging- which ones?
- Erect CXR/AXR- what is the difference between SBO and LBO signs?
- SBO
- Ladder pattern of dilated small bowel loops >3cm proximal to obstruction
- Striations that pass completely across the width of the distended loop produced by the circular mucosal folds
- LBO
- Distended (dilated) large bowel tends to lie peripherally >6 cm or 9cm if caecum
- Show haustrations of taenia coli that don’t extend across the whole width of the bowel
- SBO
- CT abdo/pelvis- why? (4)
- Can see transition point- helps with surgery
- can see dilatation of proximal loops- give IV or oral contrast if possible
- Can localise site of obstruction and detect obstructing lesions and colonic tumours
- May diagnose unusual hernia (e.g. obturator hernias)
- Erect CXR/AXR- what is the difference between SBO and LBO signs?
What supportive management is there for obstruction
- NBM, IV peripheral access with large bore cannula- IV fluid resuscitation
- IV analgesia, IV antiemetics, correction of electrolyte imbalances
- NG tube for decompression (also removes problem of aspirational pneumonia), urinary catheter for monitoring so we can base fluid input on pee output
- Introduce gradual food intake if abdominal pain and distention improve
Conservative treatment for obstruction
- Faecal impaction- stool evacuation (manual, enemas, endoscopic)
- Sigmoid volvulus- rigid sigmoidoscopic decompression
- SBO- oral gastrogaffin (highly osmolar iodinated contrast agent) can be used to resolve adhesional small bowel obstruction
- When you have small bowel adhesion the more fluid you pump in the more it twists so if you decompress and suck fluid out it has a chance to straighten itself out
When do we do surgery for obstruction
- Haemodynamic instability or signs of sepsis
- Closed loop obstruction (intervene quickly before it becomes ischaemic)
- Complete bowel obstruction with ischaemic signs
- Persistent bowel obstruction >2 days despite conservative management
What operations are there for obstruction
- Exploratory laparotomy/laparoscopy to find what’s going wrong so we can remove it
- restoration of intestinal transit (depending on intra-operational findings)
- Bowel resection with primary anastomosis or temporary/permanent stoma formation
What do we do w unwell pts esp those w tumors for obstruction
- Give them endoscopic stenting
- Especially if obstruction is distal
How do patients present with bowel ischemia
- Sudden onset crampy abdominal pain
- Severity of pain depends on length and thickness of colon affected
- Bloody, loose stool (currant jelly stools)
- Fever, signs of septic shock
Risk factors for bowel ischemias
- Age >65 years
- Cardiac arrythmias (mainly AF), atherosclerosis
- Hypercoagulation/thrombophilia
- Vasculitis
- Sickle cell disease
- Profound shock causing hypotension (happens to patients undergoing cardiac surgery)
What are the 2 types of ischaemic bowel?
Acute mesenteric ischaemia and ischaemic colitis
Which bowel does Acute mesenteric ischaemia and ischaemic colitis affect
- Acute mesenteric ischaemia → small bowel
- Ischaemic colitis → large bowel
How is acute mesenteric ischemic caused
- usually occlusive and secondary to thromboemboli- who can this happen in?if someone has AF, a small clot can come and get blocked in SMA- superior mesenteric arteryIf there’s complete obstruction of the SMA that’s really bad because you lose all of bowel from DJ flexure to splenic flexure- all of small bowel and 3/4 of large bowel
How is ischemic colitis caused
Ischaemic colitis → usually due to non-occlusive low flow states, or atherosclerosis
ie low perusion causes ischaemia
Onset for acute mesenteric ischaemia and ischemic colitis
- Acute mesenteric ischaemia → sudden onset (but presentation and severity varies)
- Ischaemic colitis → more mild and gradual (80-85% of cases
Pain for acute mesenteric ischemia and ischaemic colitis
- Acute mesenteric ischaemia → abdominal pain out of proportion of clinical signs (often see no clinical signs at all)
- Ischaemic colitis → moderate pain and tenderness
What investigations do we do for ischemic bowels
Bloods
- FBC- neutrophilic leukocytosis
- VBG- lactic acidosis- what is this?
- A form of metabolic acidosis
- Associated with late stage mesenteric ischaemia and extensive transmural intestinal infarction
- late stage meaning bowel is already dead
Imaging
CTAP/CT to detect - Disrupted flow
- Vascular stenosis
- Pneumatosis intestinalis (transmural ischaemia/infarction) (gas trapped)
- Ischaemic colitis- a thumbprint sign (unspecific sign of colitis
Endoscopy
For mild or moderate causes of ischemic colitis, look for oedema cyanosis and ulceration of mucosa
What type of bowel ischaemia can we do conservative management for?
Mild to moderate cases of ischaemic colitis
Not suitable for acute mesenteric ischaemia
What does conservative management consist of? (7) for ischemia
- IV fluid resuscitation
- Bowel rest (NBM)
- Broad spectrum ABx- why?Colonic ischaemia can result in bacterial translocation and sepsis
- NG tube for decompression- why?They can get concurrent ileus- bowel is just not peristalsing
- Anticoagulation
- Treat/manage underlying cause
- Serial abdominal exams and repeat imaging to check for changes and e.g. if you see peritonitis you don’t want to continue conservative management
- What are the indications for it? (5)
- Small bowel ischaemia
- Fulminant colitis with toxic megacolon
- Signs of peritonitis or sepsis
- Haemodynamic instability
- Massive bleeding
- What is an exploratory laparotomy?Opening abdomen up for exploration
- What do we do in exploratory laparotomies for ischaemic bowel?Resection of necrotic bowel with or without open surgical embolectomy (putting balloon catheter in SMA to pull out thrombus) or mesenteric arterial bypass (rare)Image shows purple dead small bowel, with pink healthy large bowel at bottom of pic and relatively healthy small bowel on right side of pic
- What is endovascular revascularisation?
- Another technique to try prior to surgery
- Balloon angioplasty/thrombectomy
- In patients without signs of ischaemia
- What are the indications for it? (5)
Indications for surgical management for ischemic bowel
- Small bowel ischaemia
- Fulminant colitis with toxic megacolon
- Signs of peritonitis or sepsis
- Haemodynamic instability
- Massive bleeding
What do we do in exploratory laparotomies for ischaemic bowel?
Resection of necrotic bowel with or without open surgical embolectomy (putting balloon catheter in SMA to pull out thrombus) or mesenteric arterial bypass (rare)
What is endovascular revascularisation?
- Another technique to try prior to surgery
- Balloon angioplasty/thrombectomy
- In patients without signs of ischaemia
How does acute appendicitis present
- Initially periumbilical pain that migrates to RLQ (within 24 hours)
- Anorexia- What’s a good q to ask someone who has suspected appendicitis?Do they feel like eating a meal- they always will say absolutely not
- nausea +/- vomiting
- low grade fever
- change in bowel habit- why?Inflamed appendix in pelvis will be adjacent to rectum and could irritate rectum to alter bowel habit
What are important clinical signs to look out for in appendicitis
- McBurney’s point- what is it?Tenderness in RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
- Blumberg sign- what is it?Rebound tenderness (press down then release) especially in RIF
- Rovsing sign- what is it?RLQ pain elicited on deep palpation of the LLQ
- Psoas sign- what is it?RLQ pain elicited on flexion of right hip against resistance
- Obturator sign- what is it?RLQ pain on passive internal rotation of the hip with hip and knee flexion
Investigations for appendicitis
- Bloods- which ones? (4)
- FBC- neutrophilic leukocytosis
- Raised CRP
- Urinalysis- possible mild pyuria (WBCs in pee)/haematuria
- Electrolyte imbalances in profound vomiting
- Imaging- which ones?
- CT: gold standard in adults esp. if age >50 → main reason is to check if nothing else is going on
- USS: children/pregnancy/breastfeeding
- MRI: in pregnancy if USS inconclusive
- Diagnostic laparoscopy- when do we do this?In persistent pain and inconclusive imaging
- clinical scoring system for appendicitis
- RLQ tenderness- 2 points
- Rebound tenderness- 1 point
- Fever >37.3°C- 1 point
- Pain migration- 1 point
- Anorexia- 1 point
- Nausea +/- vomiting- 1 point
- WCC >10.000- 2 points
- Neutrophilia (left shift 75%)- 1 point
What is the Alvarado score?
clinical scoring system for appendicitis
- RLQ tenderness- 2 points
- Rebound tenderness- 1 point
- Fever >37.3°C- 1 point
- Pain migration- 1 point
- Anorexia- 1 point
- Nausea +/- vomiting- 1 point
- WCC >10.000- 2 points
- Neutrophilia (left shift 75%)- 1 point
≤4 unlikely
5-6 possible
≥7 likely
What does conservative management consist of? (4) for appendicitis
- IV fluids
- Analgesia
- IV or PO antibiotics
- In abscess, phlegmon or sealed perforation, we do resuscitation + IV ABx +/- percutaneous drainage (if there’s a collection)
What are the indications for conservative management for appendicitis
- After negative imaging in selected patients with clinically uncomplicated appendicits
- In delayed presentation with abscess/phlegmon formation and then you do CT guided drainage
Interval appendicectomy because rate of recurrence after conservative management of abscess/perforation is 12-24% (done after conservative management)
Why is laparoscopic better than open appendicectomy? (6)
- Less pain
- Lower incidence of surgical site infection
- Decreased length of hospital stay
- Earlier return to work
- Overall costs
- Better QoL scores
- What are the steps to a laparoscopic appendicectomy?
1) Trocar placement (usually 3 port sites)
2) Exploration of RIF and identification of appendix
3) Elevation of appendix and division of mesoappendix (containing artery)
4) Base secured with endoloops (like a lasso) and appendix 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
How do GI perforations present
- Sudden onset severe abdominal pain associated with distention
- Pain aggravated by movement
- Diffuse abdominal guarding, rigidity, rebound tenderness
- Nausea, vomiting, absolute constipation (due to ileus of chemical irritation rather than mechanical obstruction)
- Decreased or absent bowel sounds (because of ileus)
- Fever, tachycardia, tachypnoea, hypotension
Causes of GI perforation
- Perforated peptic ulcer- most common- how does it present?
- Sudden epigastric or diffuse pain
- Referred shoulder pain- due to irritation of diaphragm (innervated by phrenic nerve which also innervated right shoulder)
- Hx of NSAIDs, steroids, recurrent epigastric pain
- Perforated diverticulum- how does it present? (2)
- LLQ pain- insidious onset
- Constipation
- Perforated appendix- how does it present? (3)
- Migratory pain
- Anorexia
- Gradual worsening RLQ pain
- Perforated malignancy- how does it present? (4)
- Change in bowel habit
- PR bleeding
- Weight loss
- Anorexia
Investigations for perforation
- Bloods- which ones? (3)
- FBC- neutrophilic leukocytosis
- VBG- lactic acidosis
- Possible elevation of urea, creatinine
- Imaging- which ones?Helps us localise perforation
- Erect CXR- subdiaphragmatic free air (pneumoperitoneum)
- CT abdo/pelvis → pneumoperitoneum, free GI content, localised mesenteric fat stranding- can exclude common differentials like pancreatitis
What differentials are there with the same symptoms? (4) for perforation
- Acute cholecystitis
- Acute pancreatitis
- Appendicitis
- MI
so always check amylase before sending someone off for surgery
What supportive management is there? (6) for perforation
- IV peripheral access with large bore cannula- IV fluid resuscitation
- NBM and NG tube (to decompress)
- Broad spectrum Abx
- Parenteral analgesia and antiemetics
- IV proton pump inhibitors
- Urinary catheter
Which patients do we do conservative management in for perforation
In patients with localised peritonitis without signs of sepsis (not generalised peritonitis)
This is very rare though, most patients will need surgery
We do IR guided drainage of intra abdominal collection and serial abdominal examination for asessement
What conservative management is there for perforation
- Interventional radiography (IR)- guided drainage of intra-abdominal collection
- Serial abdominal exams and abdominal imaging for assessment to look for changes
Which patients do we do surgical management in
Patients with generalised peritonitis +/- signs of sepsis
What surgical management options are there for perforation
- Exploratory laparotomy/laparoscopy- find hole and deal with it
- Primary closure of perforation +/- omental patch e.g. A in pic (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 (microscopy culture and sensitivity), peritoneal lavage
What do we do if there’s a perforated appendix?
Lap or open appendicectomy
What do we do if there’s a malignancy?
Intraoperative biopsies if possible
Biliary colic
- Symptoms? (2)
- Post prandial RUQ pain with radiation to shoulder
- Nausea
- Investigations? (2)
- Normal bloods
- Cholelithiasis (gallstone) on USS
- Management? (2)
- Conservative- analgesia, antiemetics, spasmolytics
- Follow up for elective cholecystectomy
Acute cholecystitis
- Symptoms? (3)This is infection of gallbladder
- Acute, severe RUQ pain
- Fever
- Murphy’s sign- how is it different from pleuritic chest pain?
- Murphy’s sign is placing hand in RUQ and it may feel non tender, then ask patient to take deep breath in and liver pushes gallbladder down which touches hand and patient yelps
- Pleuritic chest pain is when you take deep breath in and you feel sharp pain in chest wall, not abdomen
- Investigations? (2)
- Elevated WCC/CRP
- USS- thickened gallbladder wall
- Treatment? (2)
- Fluids, ABx, analgesia, blood cultures
- Early (<72 hours) or elective cholecystectomy (4-6 weeks)
Acute cholangitis
- Symptoms and cause?
- Charcot’s triad- jaundice, RUQ pain, fever
- Usually is obstruction of biliary tree
- Investigations? (2)
- Elevated LFTs, WCC, CRP, blood MCS (+ve)
- USS- biliary dilatation
- Treatment? (2
- Fluids, IV Abx, analgesia
- ERCP (within 72 hours) for clearance of bile duct or stenting
Acute pancreatitis
- Symptoms? (3)
- Severe epigastric pain radiating to back
- Nausea +/- vomiting
- Hx of gallstones or EtOH use
- Investigations? (3)
- Raised amylase/lipase
- High WCC/low Ca2+
- CT and US to assess for complications/cause
- Treatment? (4)
- Glasgow-Imrie admission score
- Analgesia, antiemetics
- Aggressive fluid resuscitation, O2
- ITU/HDU involvement
