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GI Emergencies Flashcards

1
Q

What is peritonitis?

A

Inflammation of the serosal membrane that lines the abdominal cavity

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2
Q

What are the 2 categories of peritonitis?

A

Primary peritonitis
Secondary peritonitis

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3
Q

What is the difference between primary and secondary peritonitis?

A

Primary = spontaneous and not caused by pathology of an other

Secondary = breakdown of the peritoneal membrane leading to foreign substances entering the cavity

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4
Q

What is the peritoneal cavity?

A

The space between the visceral and parietal layers of the peritoneum

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5
Q

What are the 2 sections of the peritoneal cavity and what joins them?

A

Greater sac
Lesser sac

Foreman of Winslow

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6
Q

Go to the last slide and label the diagram

A

1 = parietal peritoneum
2 = visceral peritoneum
3 = peritoneal cavity
4 = greater sac
5 = lesser sac

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7
Q

What usually the cause for primary peritonitis?

A

Spontaneous bacterial peritonitis (SBP)

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8
Q

What is the pathophysiology of spontaneous bacterial peritonitis? (SBP/primary peritonitis)

A

An infection of ascitic fluid that cant be attributed to any intr-abdominal, ongoing inflammatory or surgically correctable condition

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9
Q

What condition do patients who have primary/spontaneous bacterial peritonitis have?

A

End stage liver disease/cirrhosis

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10
Q

How do patients with primary/sponteous bacterial peritonitis present?

A

Abdominal pain
Fever
Vomiting

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11
Q

How do you diagnose primary/sponetous bacterial peritonitis?

A

Aspirate the ascitic fluid
If neutrophil count>250cells/mm^3 then it’s Spontaneous Bacterial Peritonitis

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12
Q

What is secondary peritonitis?

A

The result of an inflammatory process in the peritoneal cavity secondary to inflammation, perofration or gangrene of an Intraabdominal or Retroperitoneal strucutre

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13
Q

What are the 2 types of secondary peritonitis?

A

Bacterial
Non bacterial

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14
Q

What are some bacterial causes of secondary peritonitis?

A

Perforated peptic ulcer disease
Perforated appendicitis
Perforated diverticulitis
Post surgery

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15
Q

What are some non bacterial causes of secondary peritonitis?

A

Tubal pregnancy that bleeds
Ovarian cysts

Blood irritates the peritoneal cavity

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16
Q

How can secondary peritonitis present?

A

Abdominal pain
Can have gradual or acute onset
Diffuse abdominal pain in perforated viscera

Patients often lie very as movement makes pain worse

Guarding on exam and rebound tenderness

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17
Q

How do you treat secondary peritonitis?

A

Control infectious source (surgery)
Eliminate bacteria and toxin (abx)
Maintain organ system function

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18
Q

What is bowel obstruction?

A

A mechanical or functional problem that inhibits the normal movement of gut contents

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19
Q

What are the 2 main causes of bowel obstruction in kids?

A

Intussusception
Intestinal atresia (congenital defect)

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20
Q

What is intestinal atresia?

A

When the lumen of intestine fails to recanalise
(Normally the duodenum most commonly affected)

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21
Q

What are the most common causes of bowel obstruction sin adults?

A

Adhesions
Incarcerated hernias

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22
Q

What is intussusception?

A

When one part of the gut tube inverts/telescopes into an adjacent section of gut (small intestine inverts into the large intestine)

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23
Q

What is the cause of intussusception?

A

Motility issues
A mass like a Meckels diverticulum

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24
Q

What is the cause of intussusception?

A

Motility issues
A mass like a Meckels diverticulum

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25
Q

What is the concern with intussusception?

A

Can lead to infarction of gut

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26
Q

How can intussusception cause infarction?

A

The inversion of the part of the gut compresses another part of the gut
This impairs lymphatic and venous drainage leading to oedema
If the oedema is large enough arterial supply is impaired

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27
Q

How does intussusception present?

A

Abdominal pain
Vomiting
Haematochezia

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28
Q

What is Haematochezia?

A

Fresh red blood in stool

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29
Q

How is intussusception treated?

A

Air enema (reverses the inversion)

Surgery

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30
Q

What are some causes of small bowel obstruction?

A

Adhesions
Hernias (incarcerated groin hernias)
IBD (crohns repeat episodes of transmural inflammation and healing

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31
Q

How does small bowel obstruction resent?

A

Nausea and vomiting EARLY ON

Abdominal pain (colicky pain) and distension
Absolute constipation (late)

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32
Q

What is meant by colicky abdominal pain?

A

Comes in waves due to the peristalsis

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33
Q

What point of the small bowel being obstructed would lead to the vomiting being bilious in a small bowel obstruction?

A

Distal to D2 since this is where bile drains into small intestine/duodenum

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34
Q

How is small bowel obstruction diagnosed?

A

Hx
Physcial exam (abdominal distension, inc/absent bowel sounds, hernia)
Imaging

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35
Q

What can cause large bowel obstruction?

A

Colon cancer (most common)
Diverticular disease
Volvulus (sigmoid or caecal)

36
Q

What is the function of the iliocecal valve and why is it important?

A

It prevents the backflow of large intestine contents into the small intestine

37
Q

What is a closed loop obstruction?

A

Where there are 2 points of obstruction
For example distal to the ileocecal valve

Inc risk of ischaemia and perofration in closed loop obstruction

38
Q

How does large bowel obstruction present?

A

Symptoms are gradual if cancer but abrupt with Volvulus

Change in bowel habit
Abdominal distension
Crampy abdominal pain
Nausea and vomiting (late)

39
Q

How does the nausea and vomiting differ in large and small bowel obstruction?

A

Small bowel is nausea and vomiting early on
Large bowel is nausea and vomiting late

This is since it takes longer for the gut contents to build up to stimulate vomiting in large bowel obstruction

40
Q

How is large bowel obstruction diagnosed?

A

Hx
Physical exam
Imaging

41
Q

What is a Volvulus?

A

When the large colon twists around its mesentry

42
Q

What part of the large intestine is Volvulus most common in ?

A

Sigmoid colon since faeces are solid, heav and high pressure

43
Q

What can lead to sigmoi overload?

A

Constipation
High fibre diets

44
Q

Which bowel can have an obstruction with a caecal Volvulus?

A

Small and large since it can back up into the small bowel

45
Q

What age group do large bowel obstructions typically occur in?

A

Old

46
Q

Go to the last slide and fill out the table labelled 2 for small bowel:

A

1 = colicky/in waves (3-4mins)
2 = relatively early
3 = relatively late
4 = younger

47
Q

Go to the last slide and fill out the table labelled 2 for large bowel:

A

1 = colicky/in waves (10-15mins)
2 = relatively late
3 = relatively early
4 = older

48
Q

Label image 3 saying which bowel is obstructed in each xray:

A

1 = small
2 = large

49
Q

How can you tell the difference between a a small bowel and large bowel obstruction on an x-ray?

A

Small bowel is more central and can see white lines going the full thickness = Plica circularis

Large bowel is more peripheral and are white lines called Haustra which dont span the full thickness

50
Q

What is Acute Mesenteric Ischaemia?

A

An MI of the gut
Symptomatic reduction in blood supply to the GI tract

51
Q

What is a risk factor of acute mesenteric ischaemia?

A

Female
Hx of peripheral vascular disease

52
Q

What is more common in acute mesenteric Ischaemia, arterial compromise or venous compromise?

A

Arterial

53
Q

What are the main causes of arterial problems leading to acute mesenteric ischaemia?

A

Acute occlusion:
Arterial embolism in Superior Mesenteric Artery (SMA)

Non occlusive mesenteric ischamiae (hypoperfusion due to low cardiac output like Conjestive Heart Failure)

54
Q

What is a venous issue that can cause acute mesenteric ischameia?

A

Mesenteric venous thrombosis
(Systemic coagulopathy and malignancy)

55
Q

How does mesenteric venous thrombosis cause acute mesenteric ischamia?

A

Venous blood backs up leading to arterial pressure increasing which decreases perfusion

56
Q

How does Acute Mesenteric Ischameia present?

A

Most are elderly patients with CVS risk factors

Excruciating abdominal pain
Pain 30mins after eating since GI demand goes up

Nashua and vomiting

Often pain left sided

57
Q

Why is pain of Acute Mesenteric Ischamia often left sided?

A

Splenic flexure has a very poor blood supply (water shed area) only has marginal artery supplying

58
Q

What investigations are done for Acute Mesenteric Ischaemia?

A

Blood tests (metabolic acidosis or inc lactate levels indicate ischamia)

CXR for perforation

CT angiography

59
Q

How is acute mesenteric ischamia treated?

A

Surgery-resection of ischaemic bowel

Thrombolysis/angioplasty

60
Q

What are the 2 main causes of Upper GI bleeds?

A

Peptic ulceration

Oesophageal Varices

61
Q

What is a peptic ulcer?

A

When an ulcer forms in the oesophagus, stomach or small intestine

62
Q

What layers are affected in peptic ulceration?

A

Mucosa to submucosa through the Muscularis mucosa

63
Q

What are the 2 main types of peptic ulcers?

Which ones most commmon?

A

Gastric ulcer
Duodenal ulcer

Duodenal ulcer most common

64
Q

What artery is at risk if a duodenal ulcer ulcerated posteriorly?

A

Gastroduodenal artery (behind D1)

65
Q

What are the most common sites for gastric ulcers?

A

Lesser curve
Antrum

66
Q

What artery can a gastric body ulcer ulcerate into?

A

Splenic artery

67
Q

What are oesophageal Varices?

A

Portosystemic anastomoses that become distended due to portal hypertension

68
Q

What are some pre-hepatic, hepatic and post-hepatic causes of portal hypertension?

A

Pre-hepatic = portal venous thrombosis
Hepatic = cirrhosis
Post hepatic = hepatic vein thrombosis , right sided heart failure

69
Q

What veins are involved in the portosystemic anastomoses in oesophageal Varices?

A

Oesophageal branch of left gastric vein (from portal circ)
To the azygous drainage of the oesophagus (systemic circ)

70
Q

How is a major upper GI bleed , oesophageal Varices treated?

A

Endoscopy and band ligation

Blood transfusion (activate Major Haemorrhaging Protocol, blood bank keeps giving blood)

If bleeding not controll3d by banding do TIPS

71
Q

What is TIPS?

A

Trans jugular intrahepatic portosystemic shunt

72
Q

How does a Transjugukar intrahepatic portosystemic shunt (TIPS) help treat a haemorrhaging oesophageal Varices?

A

Where the portal vein is joined to another hepatic vein to help decrease portal vein pressure

73
Q

What is an abdominal aortic aneurysm?

A

The permanent pathological dilation of the aorta with a diameter more than 1.5 times the. Expected Anteroposterior diameter of that segment

74
Q

Where do the majority of abdominal aortic aneurysms occur?

A

Below the renal arteries

75
Q

What layer of the artery wall is normally affected in an abdominal aortic aneurysm?

A

Tunica media

76
Q

What is affected in the tunica media of the abdominal aorta in an aneurysm?

A

Elastin and collagen broken down (smooth muscle fine)

Lumen dilates

77
Q

What are the risks factors for an Abdominal Aortic Aneurysm?

A

Male
Family Hx
Old
Smoking

78
Q

How does an AAA present?

A

Asymptomatic until acute expansion or rupture

Can compress structures like stomach (vomit), bladder (urine freq) and vertebra (back pain)

79
Q

Once an AAA has ruptured how does it present?

A

Abdominal pain raidating to the back
Back
Pain
Pulsatilla abdominal mass
Hypotension leading to syncope

Most die before the hospital

80
Q

Why do some patients with ruptured AAA survive for longer than others?

A

Retroperitonuem is small so blood builds up and temporaliy compresses/tamponades the bleed

81
Q

What is done to investigate/diagnose an AAA?

A

Physical exam (pulsation abdominal mass)

Ultrasonography

CT

X-rays (if the aneurysm has calcified outside is visible)

82
Q

What are the non surgical treatments for an AAA?

A

Smoking cessation
Hypertension control
Surveillance with ultrasounds

83
Q

What point does an AAA need treatment?

A

When > 5.5cm (diameter)

84
Q

What are the 2 types of surgical repair for AAA?

A

Endovascular repair
Open surgical repair

85
Q

What is Endovascular repair for an AAA?

A

Aorta relined using an endograft which is inserted via femoral artery

86
Q

What is an open surgical repair for an AAA?

A

Clamp aorta
Open the aneurysm (remove thrombus and debris)
Then suture in a synthetic graft to replace the diseased segment

87
Q

What drug reduces portal venous pressure?

A

Terlipressin

GI (35 decks)

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