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BRS Y2 > General Surgery in the GI Tract > Flashcards

General Surgery in the GI Tract Flashcards

1
Q

What are the main blood investigations available?

A

VBG, FBC, CRP, urea and electrolytes, LFTs, amylase

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2
Q

What are the main imaging investigations available?

A

Erect CXR, AXR, CT angiogram, USS

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3
Q

How does bowel ischaemia present?

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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4
Q

What are some risk factors for bowel ischaemia?

A 
Age >65 yr
Cardiac arrythmias  Atherosclerosis	Hypercoagulation/thrombophilia
Vasculitis
Sickle cell disease 
Profound shock causing hypotension
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5
Q

What are the 2 main types of bowel ischaemia?

A

Acute mesenteric ischaemia

Ischaemic colitis

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6
Q

Describe acute mesenteric ischaemia in terms of area affected, onset and pain severity

A

It affects the small bowel
Sudden onset
Abdominal pain is out of proportion of clinical signs

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7
Q

Describe ischaemic colitis in terms of area affected, onset and pain severity

A

It affects the large bowel
Onset is usually more mild and gradual
Moderate pain and tenderness

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8
Q

Is acute mesenteric ischaemia occlusive or not?

A

Yes, due to thromboemboli

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9
Q

Is ischaemic colitis obstructive or not?

A

No, usually its due to low flow states or atherosclerosis

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10
Q

When CTAP or CT angiogram is done in bowel ischaemia what does one look for?

A

Disrupted flow
Vascular stenosis
Transmural ischaemia or infarction
Thumbprint sign

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11
Q

How is bowel ischaemia most often treated?

A

Usually surgical management is required

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12
Q

What does conservative management of bowel ischaemia involve?

A 
IV fluids
Bowel rest
Brad spectrum ABx
NG tube
Anticoagulation
Treat the cause
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13
Q

What are signs for surgical management in bowel ischaemia?

A 
Small bowel ischaemia
Signs of peritonitis or sepsis
Haemodynamic instability
Massive bleeding
Fulminant colitis with toxic megacolon
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14
Q

What are the main surgical ways of managing bowel ischaemia?

A 
Exploratory laparotomy (resect necrotic bowel etc)
Endovascular revascularisation (in patients without signs of ischaemia)
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15
Q

How does acute appendicitis present?

A 
Initially periumbilical pain that migrates to RLQ (within 24hours)
Anorexia 
Nausea +/- vomiting
Low grade fever
Change in bowel habit
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16
Q

What is the main clinical sign for acute appendicitis?

A

McBurney’s point: tenderness in the RLQ

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17
Q

What will be seen when bloods are done on a patient with acute appendicits?

A

FBC shows high neutrophils
Raised CRP
Mild pyuria or haematuria
Electrolyte imbalance if vomiting a lot

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18
Q

How are patients with suspected acute appendicitis imaged?

A

CT: gold standard in adults esp. if age > 50
USS: children/pregnancy/breastfeeding
MRI: in pregnancy if USS inconclusive

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19
Q

What score chart is used when acute appendicitis is suspected?

A

Alvarado score

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20
Q

What are the indications for conservative management of acute appendicits?

A

If imaging is negative and appendicitis is clinically uncomplicated
In delayed presentation with abscess/phlegmon formation

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21
Q

How is acute appendicits managed surgically?

A

Laparoscopic appedicectomy is preferred over open

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22
Q

What are the advantages of a laparoscopic appendicectomy over an open one?

A 
Less pain
Lower incidence of surgical site infection
Reduced length of hospital stay
Earlier return to work
Overall costs 
Better quality of life scores
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23
Q

Define an intestinal obstruction

A

Restriction of normal passage of intestinal contents

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24
Q

What are the 2 types of bowel obstruction?

A

Paralytic (adynamic) ileus

Mechanical

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25
Q

How are mechanical bowel obstructions classfied?

A

Speed of onset: acute, chronic, acute-on-chronic
Site: high or low
Nature: simple vs strangulating
Aetiology

26
Q

What is meant by a simple mechanical bowel obstruction?

A

The bowel is occluded without damage to blood supply

27
Q

What is meant by a strangulating mechanical bowel obstruction?

A

The blood supply of involved segment of intestine is cut off

28
Q

What are some causes of mechanical bowel obstruction originating in the lumen?

A

Faecal impaction, gallstone ‘ileus’

29
Q

What are some causes of mechanical bowel obstruction originating in the wall?

A

Crohn’s disease, tumours, diverticulitis of colon

30
Q

What are some causes of mechanical bowel obstruction originating outside the wall?

A 
Strangulated hernia (external or internal)
Volvulus
Obstruction due to adhesions or bands
31
Q

How do small and large bowel obstruction differ in terms of abdominal pain?

A

Small bowel= colicky and central

Large bowel= colicky or constant

32
Q

How do small and large bowel obstruction differ in terms of vomitting?

A

Small bowel= early onset, large amounts and bilious

Large bowel= late onset, initially bilious and progresses to faecal vomitting

33
Q

How do small and large bowel obstruction differ in terms of absolute constipation?

A

Small bowel= its a late sign

Large bowel= its an early sign

34
Q

How do small and large bowel obstruction differ in terms of abdominal distention?

A

Small bowel= less significant

Large bowel= significant and an early sign

35
Q

What happens to hydration levels in bowel obstruction?

A

Dehydration occours

36
Q

What sounds will be heard in early or late bowel obstruction?

A 
Early= increased high pitched tinkling sounds
Late= bowel sounds absent
37
Q

What are the 3 things to remember in intestinal obstruction?

A

It can be diagnosed by the presence of symptoms
Examination should include looking for hernias and abdominal scars
Always try to decide if its simple or strangulating

38
Q

What features of bowel obstruction indicate that its strangulating?

A 
Change in character of pain from colicky to continuous
Tachycardia
Pyrexia
Peritonism (swelling of peritoneum)
Bowel sounds absent or reduced
Leucocytosis
High C-reactive protein
39
Q

What are common sites of hernias?

A 
Epigastric
Umbilical
Incisional
Inguinal
Femoral
40
Q

What are the 3 types of hernia?

A

Neck of sac
Strangulated
Richter’s

41
Q

What is special about Richter’s hernia?

A

It isn’t associated with obstruction but neck of sac and strangulated are

42
Q

In bowel obstruction what happens to WCC and CRP?

A

They are usually normal but may be raised if there is strangulation or perforation

43
Q

In bowel obstruction what happens to urea and electrolytes?

A

There is an imbalance

44
Q

In bowel obstruction what will VBG show if they are vomiting?

A

Low chloride
Low potassium
Metabolic alkalosis

45
Q

In bowel obstruction what will VBG show if there is strangulation?

A

Metabolic acidosis

46
Q

What will abdominal x ray show in small bowel obstruction?

A

Ladder pattern of dilated loops in a central position

47
Q

What will abdominal x ray show in large bowel obstruction?

A

Distended bowel that lies peripherally

48
Q

What are the indications for surgical management of bowel obstruction?

A

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

49
Q

What surgery is performed for bowel obstruction?

A

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

50
Q

How does GI perforation present?

A 
Sudden onset severe abdominal pain associated with distention
Diffuse abdominal guarding, rigidity, rebound tenderness
Pain aggravated by movement
Nausea
Vomiting
Absolute constipation
Fever
Tachycardia
Tachypnoea
Hypotension
Decreased or absent bowel sounds
51
Q

What will bloods show in GI perforation?

A

High neutrophils
Urea and creatinine may be elevated
VBG shows lactic acidosis

52
Q

What are important differential diagnoses to consider when GI perforation is suspected?

A

Acute cholecystitis
Appendicitis
Myocardial infarction
Acute pancreatitis

53
Q

What are indications for surgical management of GI perforation

A

In generalised peritonitis +/- signs of sepsis

54
Q

What are the symptoms of biliary colic?

A

Postprandial RUQ pain that radiates to the shoulder

Nausea

55
Q

What are the symptoms of acute cholecystitis?

A

Acute severe RUQ pain
Fever
Murphy’s sign

56
Q

What is a positive murphy’s sign and when is it used?

A

A positive Murphy’s sign is seen in acute cholecystitis.
It is elicited by firmly placing a hand at the costal margin in the right upper abdominal quadrant and asking the patient to breathe deeply, if they have pain on inhalation and the gallbladder comes into contact with the hand its positive

57
Q

What are the symptoms of acute cholangitis?

A

Charcot’s triad= jaundice, RUQ pain, fever

58
Q

What are the symptoms of acute pancreatitis?

A

Severe epigastric pain that radiates to the back
Nausea with possible vomiting
Past history of gallstones

59
Q

What is volvulus

A

When a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction

60
Q

What shows up on x ray when someone has volvulus of the large bowel?

A

Coffee bean sign- its the loop of the large bowel thats been twisted on itself

BRS Y2 (85 decks)

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