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Gastroenterology > General Surgery in the GI Tract > Flashcards

General Surgery in the GI Tract Flashcards

1
Q

acute abdomen - general approach

A

PC - SOCRATES, associated symptoms, PMHx, DHx, SHx, Ix, management

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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

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3
Q

management of acute abdomen

A

ABCDE approach
conservative management
surgical management

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4
Q

differentials for acute abdomen - RUQ

A 
Bilary Colic
Cholecystitis/Cholangitis
Duodenal Ulcer
Liver abscess
Portal vein thrombosis
Acute hepatitis
Nephrolithiasis
RLL pneumonia
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5
Q

differentials for acute abdomen - RLQ

A 
Acute Appendicitis
Colitis
IBD
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy
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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
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7
Q

differentials for acute abdomen - suprapubic/central

A 
Early appendicitis
Mesenteric ischaemia
Bowel obstruction
Bowel perforation
Constipation
Gastroenteritis
UTI/Urinary retention
PID
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8
Q

differentials for acute abdomen - LUQ

A 
Peptic ulcer
Acute pancreatitis
Splenic abscess
Splenic infarction
Nephrolithiasis
LLL Pneumonia
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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
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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

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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
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12
Q

acute mesenteric ischaemia affects large or small bowel?

A

small

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13
Q

ischaemic cholitis affects large or small bowel?

A

large

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14
Q

is acute mesenteric ischaemia usually occlusive?

A

Usually occlusive due tothromboemboli

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15
Q

is ischaemic colitis usually occlusive?

A

Usuallydue to non-occlusive low flow states, or atherosclerosis

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16
Q

onset of acute mesenteric ischaemia

A

Sudden onset (but presentation and severityvaries)

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17
Q

onset of ischaemic colitis

A

more mild and gradual

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18
Q

abdominal pain in acute mesenteric ischaemia

A

out of proportion of clinical signs

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19
Q

abdominal pain in ischaemic colitis

A

moderate pain and tenderness

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20
Q

investigations for bowel ischaemia - bloods

A

FBC: neutrophilic leukocytosis
VBG: Lactic acidosis

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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)

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22
Q

investigations for bowel ischaemia - endoscopy

A

For mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)

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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

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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
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25
Q

surgical management options for bowel ischaemia

A

exploratory laparotomy

endovascular revascularisation

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26
Q

exploratory laparotomy

A

Resection of necrotic bowel +/-open surgicalembolectomy

or mesenteric arterial bypass

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27
Q

endovascular revascularisation

A

Balloon angioplasty/thrombectomy

In patients without signs of ischaemia

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28
Q

presentation of acute appendicitis

A

Initially periumbilical pain that migrates to RLQ (within 24hours)
Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit

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29
Q

important clinical signs in acute appendicitis

A 
McBurney's point
Blumberg sign
Rovsing sign
Psoas sign
Obturator sign
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30
Q

McBurney’s point

A

tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)

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31
Q

Blumberg sign

A

rebound tenderness especially in the RIF

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32
Q

Rovsing sign

A

RLQ pain elicited on deep palpation of the LLQ

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33
Q

Psoas sign

A

RLQ pain elicited on flexion of right hip against resistance

34
Q

Obturator sign

A

RLQ pain on passive internal rotation of the hip with hip & knee flexion

35
Q

investigations for acute appendicitis - bloods

A

FBC: neutrophilic leukocytosis
^ CRP
Urinalysis: possible mild pyuria/haematuria
Electrolyte imbalances in profound vomiting

36
Q

investigations for acute appendicitis - imaging

A

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

37
Q

investigations for acute appendicitis - diagnostic laparoscopy

A

In persistent pain & inconclusive imaging

38
Q

Alvarado score includes what criteria?

A 
RLQ tenderness
fever
rebound tenderness
pain migration
anorexia
nausea +/- vomiting
WCC >10000
neutrophilia
39
Q

what is Alvarado score?

A

clinical scoring system used in the diagnosis of appendicitis

40
Q

conservative management of acute appendicitis

A

IV Fluids, Analgesia, IV or PO Antibiotics
In abscess, phlegmon or sealed perforation
Resuscitation + IV ABx +/- percutaneous drainage

41
Q

indications in acute appendicitis

A

After negative imaging in selected patients with clinically uncomplicated appendicitis
In delayed presentation with abscess/phlegmon formation
CT-guided drainage

42
Q

surgical management of acute appendicitis

A

laparoscopic appendectomy

open appendectomy

43
Q

steps of laparoscopic appendectomy

A

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
Q

intestinal obstruction

A

restriction of normal passage of intestinal contents

45
Q

two main groups of bowel obstruction?

A

Paralytic (Adynamic) ileus

Mechanical.

46
Q

mechanical intestinal obstruction is classified by?

A

speed of onset
site
nature
aetiology

47
Q

speed of onset of mechanical intestinal obstruction

A

acute, chronic, acute-on-chronic

48
Q

site of mechanical intestinal obstruction

A

high or low

roughly synonymous with small or large bowel obstruction

49
Q

nature of mechanical intestinal obstruction

A

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
Q

aetiology of mechanical intestinal obstruction

A

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
Q

abdominal pain in small bowel obstruction

A

colicky, central

52
Q

abdominal pain in large bowel obstruction

A

colicky or constant

53
Q

vomiting in small bowel obstruction

A

early onset
large amount
bilious

54
Q

vomiting in large bowel obstruction

A

Late onset
Initially bilious
Progresses to faecal vomiting

55
Q

absolute constipation in small bowel obstruction

A

late sign

56
Q

absolute constipation in large bowel obstruction

A

early sign

57
Q

abdominal distention in small bowel obstruction

A

less significant

58
Q

abdominal distention in large bowel obstruction

A

early sign and significant

59
Q

other signs on presentation of bowel obstruction

A

Dehydration
Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign)
Diffuse abdominal tenderness

60
Q

3x Important points to remember about intestinal obstruction

A

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
Q

features suggesting strangulation

A 
Change in character of pain from colicky to continuous
Tachycardia
Pyrexia
Peritonism
Bowel sounds absent or reduced
Leucocytosis
↑ed C-reactive protein
62
Q

common hernial sites

A 
epigastric
umbilical
incisional
inguinal
femoral
63
Q

intestinal hernias

A

neck of sac
strangulated hernias
Richter’s hernia

64
Q

investigations of bowel obstruction - bloods

A

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
Q

investigations of bowel obstruction - imaging

A

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
Q

small bowel obstruction - abdominal x ray

A

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
Q

large bowel obstruction - abdominal x ray

A

Distended large bowel tends to lie peripherally

Show haustrations of taenia coli - do not extend across whole width of the bowel

68
Q

use of CT in bowel obstruction

A

Can localize site of obstruction
Detect obstructing lesions & colonic tumours
May diagnose unusual hernias (e.g. obturator hernias).

69
Q

supportive management in patients with no signs of ischaemia/no signs of clinical deterioration

A

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
Q

conservative management in patients with no signs of ischaemia/no signs of clinical deterioration

A

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 adhesionalsmall bowel obstruction

71
Q

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

72
Q

operations for bowel obstruction

A

Exploratory Laparotomy/Laparoscopy
Restoration of intestinal transit (depending on intra-operational findings)
Bowel resection with primary anastomosis or temporary/permanent stoma formation

73
Q

presentation of GI perforation

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

74
Q

presentation of perforated peptic ulcer

A

Sudden epigastric or diffuse pain
Referred shoulder pain
Hx of NSAIDs, steroids, recurrent epigastric pain

75
Q

presentation of perforated diverticulum

A

LLQ pain

Constipation

76
Q

presentation of perforated appendix

A

Migratory pain
Anorexia
Gradual worsening RLQ pain

77
Q

presentation of perforated malignancy

A

Change in bowel habit
Weight loss
Anorexia
PR Bleeding

78
Q

list biliary and pancreatic causes of acute abdomen

A

biliary colic
acute cholecysitis
acute cholangitis
acute pancreatitis

79
Q

symptoms of biliary colic

A

PostprandialRUQ pain with radiation to the shoulder.

Nausea

80
Q

symptoms of acute cholecysitis

A

Acute, severe RUQ pain
Fever
Murphy’s sign

81
Q

symptoms of acute cholangitis

A

Charcot’s triad: jaundice, RUQ pain, fever

82
Q

symptoms of acute pancreatitis

A

Severe epigastric pain radiating to the back
Nausea +/- vomiting
Hx of gallstones or EtOH use

Gastroenterology (9 decks)

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