GI Emergencies

Question 1

What is Peritonitis?

Answer 1

Inflammation of the serosal membrane that lines the abdominal cavity. There are 2 types, primary (spontaneous) and secondary.

Question 2

What is Primary Peritonitis?

Answer 2

Usually a spontaneous bacterial peritonitis, most commonly seen in patients with end stage liver disease (cirrhosis).
It is an infection of ascitic fluid that cannot be explained to any intra-abdominal ongoing inflammatory, or surgically correctable condition.

Question 3

What is ascites?

Answer 3

Pathological collection of fluid within the peritoneal cavity.

Question 4

What causes ascites in cirrhosis?

Answer 4

1. Portal hypetension: causing increased hydrostatic pressure in the veins draining the gut.
2. Decreased liver function resulting in less albumin production: decreasing intravascular oncotic pressure.
3. The result is the net movement of fluid into the peritoneal cavity.

Question 5

What are the symptoms of Spontaneous Bacterial Peritonitis?

Answer 5

1. Abdominal pain.
2. Fever.
3. Vomiting.
   Symptoms are usually mild.

Question 6

How do you diagnose Spontaneous Bacterial Peritonitis?

Answer 6

Aspirating ascitic fluid, looking for a neutrophil count of more than 250cells/mm^3.

Question 7

What is Secondary Peritonitis?

Answer 7

Breakdown of the peritoneal membrane leading to foreign substances entering the cavity.
Secondary peritonitis is a result of an inflammatory process in the peritoneal cavity secondary to inflammatory, perforation or gangrene of an intra-abdominal or retroperitoneal structure.
If a viscera perforates then the content will enter the peritoneal cavity.

Question 8

What are the common bacterial causes of secondary peritonitis?

Answer 8

1. Peptic Culver disease (perforated).
2. Appendicitis (perforated).
3. Diverticulitis (perforated).
4. Post surgery.

Question 9

What are the common non-bacterial causes of secondary peritonitis?

Answer 9

1. Ectopic pregnancy that bleeds.
2. Ovarian cysts.
   Blood is irritant to the peritoneal. cavity.

Question 10

What is a Bowel Obstruction?

Answer 10

A mechanical/functional problem that inhibits the normal movement of the gut contents. Can affect the large and small intestine, at any age.

Question 11

What are the commonest causes of children bowel obstruction?

Answer 11

1. Intussusception.

2. Intestinal atresia.

Question 12

What are the commonest cause of adult bowel obstruction?

Answer 12

1. Adhesions.

2. Incarcerated hernias.

Question 13

What is Intussusception?

Answer 13

When one part of the gut tube telescope into an adjacent section. Can extend quite far.

Question 14

What is the cause of Intussusception?

Answer 14

Potentially due to motility issues with a lead point (mass that precipitates the telescoping action) like Meckel’s diverticulum or an enlarged lymph nodes. As soon as lymphatic and venous drainage is impaired you get oedema, enough oedema can impede the arterial supply.

Question 15

What are the symptoms of Intussusception?

Answer 15

1. Abdominal pain.
2. Vomiting.
3. Haematochezia.

Question 16

How do you treat Intussusception?

Answer 16

1. Air enema: mainly effective for treating children.

2. Surgery.

Question 17

What are the symptoms of Small Bowel Obstruction?

Answer 17

1. Nausea (early).
2. Vomiting (early).
3. Abdominal distension.
4. Absolute constipation (late).

Question 18

What is Small Bowel Obstruction caused by?

Answer 18

1. Intra-abdominal adhesions: abnormal fibrous bands between organs or tissues or both in the abdominal cavity. Usually the greater omentum or the bowel, damage to the mesothelium. This causes abdominal pain and potential secondary infertility.
2. Hernias: can narrow the lumen enough to cause obstruction: incarcerated groin hernias.
3. Inflammatory bowel disease: Crohn’s: repeated episodes of inflammation/healing causes narrowing.

Question 19

How do you diagnose Small Bowel Obstruction?

Answer 19

1. History: abdominal pain is crampy, intermittent.
2. Physical examination: abdominal distension, increasing/absent bowel sounds, presence of hernias.
3. Imaging.

Question 20

Who does the Large Bowel Obstruction commonly affect?

Answer 20

Affects the older generation.

Question 21

What are the common cause of Large Bowel Obstruction?

Answer 21

1. Colon cancer.
2. Diverticula disease.
3. Volvulus- Sigmoid, Caecal

Question 22

What are the symptoms of Large Bowel Obstruction?

Answer 22

1. Change in bowel habit (cancer).
2. Abdominal distension.
3. Crampy abdominal pian.
4. Nausea/vomiting (later).

Question 23

What is a Volvulus?

Answer 23

A part of the colon twists around its mesentery. Commonest in the sigmoid colon, causing obstruction.

Question 24

What causes Volvulus?

Answer 24

Can result from overloading sigmoid colon in constipation. The extra mass predisposes it to elongate the sigmoid as it has a small mesenteric attachment. Higher fibre diets can also lead to sigmoid overload and twisting.
Caecal volvulus results in small and large bowel obstruction.

Question 25

Compare a Small and Large Bowel Obstruction?

Answer 25

1. Small is more common is younger people and large in older people. 2. Depends on the competence of the ileo-caecal valve: if it is competent the colon cannot decompress. proximally. Closed loop obstruction causes ischaemia and perforation. 2. Abdominal pain is colicky 3-4 minutes in small bowel obstruction and 10-15 minutes in large bowel. 3. Vomiting is early in SI and late in LI. 4. Constipation is late in SI and early in LI.

Question 26

How can we identify a large or small intestine problem on CT?

Answer 26

The small intestine has central lines, a smaller lumen and is more in the middle. The large intestine is peripheral, has haustra and a larger lumen.

Question 27

What is Acute Mesenteric Ischaemia?

Answer 27

A symptomatic reduction in blood supply to the GI tract.

Question 28

Who are commonly affected by Acute Mesenteric Ischaemia?

Answer 28

Females with a history of peripheral vascular disease. | Elderly patients with cardiovascular risk factors.

Question 29

What are the causes of Acute Mesenteric Ischaemia?

Answer 29

1. Acute occlusion: due to arterial embolism in SMA. 2. Non-occlusive mesenteric ischaemia: low cardiac output. 3. Mesenteric venous thrombosis: systemic coagulopathy and malignancy.

Question 30

What are the symptoms of Acute Mesenteric Ischaemia?

Answer 30

Non-specific so hard to diagnose. 1. Abdominal pain is disproportionate to the clinical findings: classically pain comes on 30 minutes after eating and lasts 4hours. 2. Nausea and vomiting. 3. Pain is often left sided because the blood supply to the splenic flexure is most fragile.

Question 31

How do you investigate Acute Mesenteric Ischaemia?

Answer 31

1. Blood tests: metabolic acidosis/increased lactate levels. 2. Erect chest X-ray: check for perforation. 3. CT angiography: intravenous contrast.

Question 32

How do you treat Acute Mesenteric Ischaemia?

Answer 32

1. Surgery: resection of ischaemic bowel: bypass graft. | 2. Thrombolysis/angioplasty.

Question 33

What are the causes of major upper GU bleeding?

Answer 33

1. Peptic Ulcers. | 2. Oesophageal Varices.

Question 34

What is a Peptic Ulcer?

Answer 34

Disruption in the gastric/duodenal mucosa usually greater than. 5mm in diameter, going through to the submucosa through the muscuarlis mucosa. Commonly in the duodenum, can dig into the gastro-dudodenal artery lies behind the first part of the duodenum. Gastric ulcers commonly effect the lesser serve and antrum of the stomach.

Question 35

What are oesophageal varices?

Answer 35

A pathology due to portal hypertension in an area with porto-systemic anastamosise. The oesophagus drains into the left gastric vein and then into t he portal vein as well as draining into the azygous drain and to the superior vena cava.

Question 36

What are the causes of portal hypertension?

Answer 36

1. Pre-hepatic: portal-vein thrombosis. 2. Hepatic: Cirrhosis, schistosomaiasis. 3. Post-hepatic: hepatic vein thrombosis and RHF.

Question 37

How do you treat Oesophageal Varices?

Answer 37

1. Band Ligation. If bleeding not controlled: 2. Transjugular- Intrahepatic Portosystemic Shunt: an expandable metal placed in the liver to bridge the portal vein to the hepatic vein To decompress the pressure and reduce the variceal pressure and the ascites. 3. Drug: Terlipressin: reduces portal venous pressure.

Question 38

What is a Abdominal Aortic Aneurysm?

Answer 38

A permanent pathological dilation of the aorta with a diameter of more than 1.5 times the expected anteroposterior diameter of the segment for a given sex and body size. 3cm or more.

Question 39

What is the Pathophysiology of AAA?

Answer 39

Commonly affected the renal arteries-> infrarenal. Usually due to the degeneration of the media layer of the arterial wall due to elastin and collagen degeneration. The lumen gradually starts to dilate.

Question 40

What are the risk factors of AAA?

Answer 40

1. Male, 2. Inherited risk. 3. Increasing age, 4. Smoking.

Question 41

What is the presentation of someone with AAA?

Answer 41

1. Abdominal pain. 2. Back pain. 3. Pulsatile abdominal mass. 4. Transient hypotension causing syncope. The retroperitoneum can temporarily temponade and stabilise the bleed. 5. Sudden cardiovascular collapse. Can cause symptoms in other systems due to compression.

Question 42

How do you diagnose AAA?

Answer 42

1. Physical examination: presence of a pulsatile abdominal mass, sometimes. 2. Ultrasonography: non-invasive, can detect free peritoneal blood. 3. Computed Tonography: can detect a lot of anatomy and be used for planning for elective surgery. 4. Plain x-rays: if the aneurysm has calcified.

Question 43

How do we treat AAA?

Answer 43

1. Smoking cessation. 2. Hypertension control. 3. Surveillance: if greater than 5.5cm refer to surgeon. 4. Endovascular repair: endograft stent, inserted. through the femoral artery below the renal artery and above the common iliac. 5. Open s surgical repair: clamp the aorta and suture in a synthetic graft to replace the diseased segment.