General Surgery in the GI Tract Flashcards
1
Q
acute abdomen - general approach
A
PC - SOCRATES, associated symptoms, PMHx, DHx, SHx, Ix, management
2
Q
Ix for acute abdomen
A
Bloods: VBG, FBC, CRP, U&Es (renal profile), LFTs +amylase
Urinalysis + Urine MC&S
Imaging: Erect CXR, AXR, CTAP, CT angiogram, USS
Endoscopy
3
Q
management of acute abdomen
A
ABCDE approach
conservative management
surgical management
4
Q
differentials for acute abdomen - RUQ
A
Bilary Colic Cholecystitis/Cholangitis Duodenal Ulcer Liver abscess Portal vein thrombosis Acute hepatitis Nephrolithiasis RLL pneumonia
5
Q
differentials for acute abdomen - RLQ
A
Acute Appendicitis Colitis IBD Infectious colitis Ureteric stone/Pyelonephritis PID/Ovarian torsion Ectopic pregnancy Malignancy
6
Q
differentials for acute abdomen - epigastrium
A
Acute gastritis/GORD Gastroparesis Peptic ulcer disease/perforation Acute pancreatitis Mesenteric ischaemia AAA (Abdominal Aortic Aneurysm) Aortic dissection Myocardial infarction
7
Q
differentials for acute abdomen - suprapubic/central
A
Early appendicitis Mesenteric ischaemia Bowel obstruction Bowel perforation Constipation Gastroenteritis UTI/Urinary retention PID
8
Q
differentials for acute abdomen - LUQ
A
Peptic ulcer Acute pancreatitis Splenic abscess Splenic infarction Nephrolithiasis LLL Pneumonia
9
Q
differentials for acute abdomen - LLQ
A
Diverticulitis Colitis IBD (Inflammatory Bowel Disease) Infectious colitis Ureteric stone/Pyelonephritis PID/Ovarian torsion Ectopic pregnancy Malignancy
10
Q
presentation of bowel ischaemia
A
Sudden onset crampy abdominal pain
Severity of pain depends on the length and thickness of colon affected
Bloody, loose stool (currant jelly stools)
Fever, signs of septic shock
11
Q
risk factors for bowel ischaemia
A
Age >65 yr Cardiac arrythmias (mainly AF), atherosclerosis Hypercoagulation/thrombophilia Vasculitis Sickle cell disease Profound shock causing hypotension
12
Q
acute mesenteric ischaemia affects large or small bowel?
A
small
13
Q
ischaemic cholitis affects large or small bowel?
A
large
14
Q
is acute mesenteric ischaemia usually occlusive?
A
Usually occlusive due tothromboemboli
15
Q
is ischaemic colitis usually occlusive?
A
Usuallydue to non-occlusive low flow states, or atherosclerosis
16
Q
onset of acute mesenteric ischaemia
A
Sudden onset (but presentation and severityvaries)
17
Q
onset of ischaemic colitis
A
more mild and gradual
18
Q
abdominal pain in acute mesenteric ischaemia
A
out of proportion of clinical signs
19
Q
abdominal pain in ischaemic colitis
A
moderate pain and tenderness
20
Q
investigations for bowel ischaemia - bloods
A
FBC: neutrophilic leukocytosis
VBG: Lactic acidosis
21
Q
investigations for bowel ischaemia - imaging
A
CTAP/CTAngiogram
Detects
Disrupted flow
Vascular stenosis
‘Pneumatosis intestinalis’ (transmural ischaemia/infarction)
Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)
22
Q
investigations for bowel ischaemia - endoscopy
A
For mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)
23
Q
conservative management for mild to moderate cases of ischaemic colitis
A
IV fluid resuscitation, bowel rest, broad spectrum antibiotics, NG tube for decompression, anticoagulation, treat underlying cause
24
Q
indications for surgical management of bowel ischaemia
A
Small bowel ischaemia Signs of peritonitis orsepsis Haemodynamic instability Massive bleeding Fulminant colitis with toxic megacolon
25
surgical management options for bowel ischaemia
exploratory laparotomy
| endovascular revascularisation
26
exploratory laparotomy
Resection of necrotic bowel +/- open surgical embolectomy
| or mesenteric arterial bypass
27
endovascular revascularisation
Balloon angioplasty/thrombectomy
| In patients without signs of ischaemia
28
presentation of acute appendicitis
Initially periumbilical pain that migrates to RLQ (within 24hours)
Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit
29
important clinical signs in acute appendicitis
```
McBurney's point
Blumberg sign
Rovsing sign
Psoas sign
Obturator sign
```
30
McBurney's point
tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
31
Blumberg sign
rebound tenderness especially in the RIF
32
Rovsing sign
RLQ pain elicited on deep palpation of the LLQ
33
Psoas sign
RLQ pain elicited on flexion of right hip against resistance
34
Obturator sign
RLQ pain on passive internal rotation of the hip with hip & knee flexion
35
investigations for acute appendicitis - bloods
FBC: neutrophilic leukocytosis
^ CRP
Urinalysis: possible mild pyuria/haematuria
Electrolyte imbalances in profound vomiting
36
investigations for acute appendicitis - imaging
CT: gold standard in adults esp. if age > 50
USS: children/pregnancy/breastfeeding
MRI: in pregnancy if USS inconclusive
37
investigations for acute appendicitis - diagnostic laparoscopy
In persistent pain & inconclusive imaging
38
Alvarado score includes what criteria?
```
RLQ tenderness
fever
rebound tenderness
pain migration
anorexia
nausea +/- vomiting
WCC >10000
neutrophilia
```
39
what is Alvarado score?
clinical scoring system used in the diagnosis of appendicitis
40
conservative management of acute appendicitis
IV Fluids, Analgesia, IV or PO Antibiotics
In abscess, phlegmon or sealed perforation
Resuscitation + IV ABx +/- percutaneous drainage
41
indications in acute appendicitis
After negative imaging in selected patients with clinically uncomplicated appendicitis
In delayed presentation with abscess/phlegmon formation
CT-guided drainage
42
surgical management of acute appendicitis
laparoscopic appendectomy
| open appendectomy
43
steps of laparoscopic appendectomy
Trocar placement (usually 3) > Exploration of RIF & identification of appendix > Elevation of appendix + division of mesoappendix (containing artery) > Based secured with endoloops and appendix is divided > Retrieval of appendix with a plastic retrieval bag > Careful inspection of the rest of the pelvic organs/intestines > Pelvic irrigation (wash out) + Haemostasis > Removal of trocars + wound closure
44
intestinal obstruction
restriction of normal passage of intestinal contents
45
two main groups of bowel obstruction?
Paralytic (Adynamic) ileus
| Mechanical.
46
mechanical intestinal obstruction is classified by?
speed of onset
site
nature
aetiology
47
speed of onset of mechanical intestinal obstruction
acute, chronic, acute-on-chronic
48
site of mechanical intestinal obstruction
high or low
| roughly synonymous with small or large bowel obstruction
49
nature of mechanical intestinal obstruction
Simple: bowel is occluded w/o damage to blood supply
Strangulating: blood supply of involved segment of intestine cut off (e.g. in strangulated hernia, volvulus, intussusception)
50
aetiology of mechanical intestinal obstruction
lumen - faecal impaction, gallstone ‘ileus'
in the wall - Crohn’s disease, tumours, diverticulitis of colon
outside the wall
- Strangulated hernia (external or internal), Volvulus, Obstruction due to adhesions or bands.
51
abdominal pain in small bowel obstruction
colicky, central
52
abdominal pain in large bowel obstruction
colicky or constant
53
vomiting in small bowel obstruction
early onset
large amount
bilious
54
vomiting in large bowel obstruction
Late onset
Initially bilious
Progresses to faecal vomiting
55
absolute constipation in small bowel obstruction
late sign
56
absolute constipation in large bowel obstruction
early sign
57
abdominal distention in small bowel obstruction
less significant
58
abdominal distention in large bowel obstruction
early sign and significant
59
other signs on presentation of bowel obstruction
Dehydration
Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign)
Diffuse abdominal tenderness
60
3x Important points to remember about intestinal obstruction
Diagnosed by the presence of symptoms
Examination should always include a search for hernias & abdominal scars, including laparoscopic portholes
Is it simple or strangulating?
61
features suggesting strangulation
```
Change in character of pain from colicky to continuous
Tachycardia
Pyrexia
Peritonism
Bowel sounds absent or reduced
Leucocytosis
↑ed C-reactive protein
```
62
common hernial sites
```
epigastric
umbilical
incisional
inguinal
femoral
```
63
intestinal hernias
neck of sac
strangulated hernias
Richter's hernia
64
investigations of bowel obstruction - bloods
WCC/CRP usually normal (if raised suspicion of strangulation/perforation)
U&E: electrolyte imbalance
VBG if vomiting: HypoCl-,HypoK+ metabolic alkalosis
VBG if strangulation: Metabolic Acidosis (lactate)
65
investigations of bowel obstruction - imaging
Erect CXR/AXR
SBO: Dilated small bowel loops >3cm proximal to the obstruction (central)
LBO: Dilated large bowel >6cm (if caecum >9cm) predominantly peripheral
CT abdo/pelvis → Transition point, dilatation of proximal loops – IV +/- oral contrast if possible
66
small bowel obstruction - abdominal x ray
Ladder pattern of dilated loops & their central position
| Striations that pass completely across the width of the distended loop produced by the circular mucosal folds
67
large bowel obstruction - abdominal x ray
Distended large bowel tends to lie peripherally
| Show haustrations of taenia coli - do not extend across whole width of the bowel
68
use of CT in bowel obstruction
Can localize site of obstruction
Detect obstructing lesions & colonic tumours
May diagnose unusual hernias (e.g. obturator hernias).
69
supportive management in patients with no signs of ischaemia/no signs of clinical deterioration
NBM, IV peripheral access with large bore cannula - IV Fluid resuscitation
IV analgesia, IV antiemetics, correction of electrolyte imbalances
NG tube for decompression, urinary catheter for monitoring output
Introduce gradual food intake if abdominal pain and distention improve
70
conservative management in patients with no signs of ischaemia/no signs of clinical deterioration
Faecal impaction: stool evacuation (manual, enemas, endoscopic)
Sigmoid volvulus: rigid sigmoidoscopic decompression
SBO: oral gastrograffin (highly osmolar iodinated contrast agent) can be used to resolve adhesional small bowel obstruction
71
indications for surgical management of bowel obstruction
Haemodynamic instability or signs of sepsis
Complete bowel obstruction with signs of ischaemia
Closed loop obstruction
Persistent bowel obstruction >2 days despite conservative management
72
operations for bowel obstruction
Exploratory Laparotomy/Laparoscopy
Restoration of intestinal transit (depending on intra-operational findings)
Bowel resection with primary anastomosis or temporary/permanent stoma formation
73
presentation of GI perforation
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
74
presentation of perforated peptic ulcer
Sudden epigastric or diffuse pain
Referred shoulder pain
Hx of NSAIDs, steroids, recurrent epigastric pain
75
presentation of perforated diverticulum
LLQ pain
| Constipation
76
presentation of perforated appendix
Migratory pain
Anorexia
Gradual worsening RLQ pain
77
presentation of perforated malignancy
Change in bowel habit
Weight loss
Anorexia
PR Bleeding
78
list biliary and pancreatic causes of acute abdomen
biliary colic
acute cholecysitis
acute cholangitis
acute pancreatitis
79
symptoms of biliary colic
Postprandial RUQ pain with radiation to the shoulder.
| Nausea
80
symptoms of acute cholecysitis
Acute, severe RUQ pain
Fever
Murphy's sign
81
symptoms of acute cholangitis
Charcot's triad: jaundice, RUQ pain, fever
82
symptoms of acute pancreatitis
Severe epigastric pain radiating to the back
Nausea +/- vomiting
Hx of gallstones or EtOH use
