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ESA 3 - Gastrointestinal System > GI Emergencies > Flashcards

GI Emergencies Flashcards

1
Q

What is peritonitis?

A

Inflammation of the peritoneum, typically caused by bacterial infection either via the blood or after rupture of an abdominal organ.

It can occur spontaneously. (Primary)

Occurs via breakdown of the peritoneal membrane leading to foreign substances entering cavity (secondary)

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2
Q

What is the connection between greater and lesser sac?

A

The foramen of winslow /The epiploic foramen

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3
Q

What is primary peritonitis?

A

Most commonly seen in patients with end stage liver disease (patients with cirrhosis)

It is an infection of ascetic fluid that cannot be attributed to any ongoing intra-abdominal inflammatory or surgically correctable condition.

Symptoms: abdominal pain, fever, vomiting -usually mild.

Diagnosed by aspirating ascitic fluid (high neutrophil count).

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4
Q

What is ascites?

A

Fluid in peritoneal cavity

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5
Q

How is ascites caused by cirrhosis?

A

A combination of:

  • Portal hypertension (increased hydrostatic pressure in the veins draining the gut)
  • Decreased liver function resulting in less albumin production (decreased intravascular oncotic pressure)
  • The result is the next movement of fluid into the peritoneal cavity
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6
Q

What is secondary peritonitis?

A

Secondary (surgical) peritonitis is a result of an inflammatory process in the peritoneal cavity secondary to inflammation, perforation, or gangrene of an intra-abdominal or retroperitoneal structure.

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7
Q

What are some common causes of secondary peritonitis?

A 
Bacterial peritonitis:
Peptic ulcer disease (perforated) 
Appendicitis (Perforated)
Diverticulitis (perforated)
Post Surgery

Non bacterial:
Tubal (ectopic) pregnancy that bleeds (peritoneal cavity is not enclosed in females)
Ovarian cyst
Blood is highly irritant to the peritoneal cavity.

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8
Q

Describe the clinical presentation of peritonitis

A

Abdominal pain -

Patients lie very still movement make it worse. Often have knees flexed and are breathing shallowly.

May come on gradually or acutely.

Diffuse abdominal pain is common in perforated viscera.

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9
Q

How do you treat peritonitis?

A

Control of infectous source -surgery

Eliminate bacteria and toxins - antibacterial therapy

Maintain organ system function - ITU

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10
Q

What is intussuseption?

A

Intussuseption is when one part of the gut give telescopes into an adjacent section.

Cause not well know:

  • Motility issues
  • ‘lead point’ (mass that precipitates telescoping action) -Meckel’s diverticulum, enlarged lymph nodes

Can extend quite far or even prolapse out of rectum.

When lymphatic and venous drainage impaired -oedema. If enough, can impede arterial supply (infarction).

Symptoms: abdominal pain, vomiting, haematochezia.

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11
Q

How do you treat intussuseption?

A

Air enema - fancy bicycle pump -pumps air into bowel.

Surgery

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12
Q

What are common causes of small bowel obstruction?

A

Intra-abdominal adhesions

  • Arise after 50% of abode surgeries
  • Damage to mesothelium
  • Also cause abdominal pain and infertility

Hernia’s

IBD

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13
Q

What are some common symptoms of small bowel obstruction?

A

Nausea and vomiting (bilious) are most common early symptoms.

Cramping every 3-5 minutes

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14
Q

How do you diagnose small bowel obstruction?

A

History - crampy, intermittent abdominal pain

Physical exam -abdo distention, increased / absent bowel sounds, hernia’s

Imaging

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15
Q

What are some common causes of large bowel obstruction?

A

Colon cancer
Diverticular disease
Volvulus - sigmoid, caecal

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16
Q

What are the symptoms of large bowel obstruction?

A

Change in bowel habits

Abdominal distention

Cramping abdominal pain

Nausea and vomitting

17
Q

What is a volvulus?

A

From Latin ‘to twist’

When part of the colon twists around its mesentry

Most common in sigmoid colon (60%) and caecum but can occur anywhere.

It results in obstruction.

18
Q

Where is a volvulus most common?

A

Sigmoid colon (60%) and caecum

19
Q

What can cause a volvulus?

A

Overload of the sigmoid colon (constipation)

Extra mass predisposes elongates the sigmoid (relatively smaller mesenteric attachment)

High fibre diet can also lead to sigmoid overload and twisting.

20
Q

What age groups get small vs large bowel obstruction?

A

Small bowel - younger
Large bowel - older

explained by causes as large bowel obstructions tend to develop over time.

21
Q

What is the difference in symptoms between small and large bowel obstruction?

A

Small bowel - colicky abdominal pain every 3-4 mins, vomiting relatively early and constipation late.

Large bowel - colicky abdominal pain every 10-15 mins, vomiting relatively late and constipation early.

22
Q

What is acute mesenteric ischaemia?

A

Sypmtomatic reduction in blood supply to the GI tract.

Most common in females (75%) and if you have a history of peripheral vascular disease.

Symptoms: Nausea, vomiting, abdominal pain - left sided as blood supply to splenic flexure is most fragile.

23
Q

What are the different types of acute mesenteric ischaemia?

A

Acute occlusion - 70% of cases, causes by an arterial embolism in SMA (50%)

Non-occlusive mesenteric ischaemia - (20%) - low cardiac output

Mesenteric venous thrombosis (5-10%) - systemic coagulopathy, malignancy

24
Q

Who is acute mesenteric ischaemia common in?

A

Older people with CVS risk factors.

More common in females.

If pain comes on about 30mins after eating, lasts 4 hours and is disproportionate to finding - consider this.

25
Q

What investigations do you go for acute mesenteric ischemia?

A

Blood tests - metabolic acidosis, increased lactate levels

Erect chest X-Ray (check perforation)

CT angiography (sensitivity >90%) -IV contrast

26
Q

How do you treat acute mesenteric ischaemia?

A

Surgery - resection og ischaemic bowel

Thrombolysis / angioplasty

27
Q

What is the major cause of upper GI bleeding?

A

Peptic ulcers

28
Q

What is a peptic ulcer?

A

Disruption in the gastric / duodenal mucosa -greater than 5mm in diameter.

Duodenal ulcer is most common - first part of duodenum as gastro-duodenal artery lies behind here

Also occur in the stomach - commonly in the lesser curve and the antrum

29
Q

What are some causes of portal hypertension?

A

Anything that slows blood flow into the portal vein

Pre-hepatic (portal venous thrombosis)

Hepatic (cirrhosis / schistosomiasis)

Post hepatic (hepatic venous thrombosis, RHF)

30
Q

Why varies common in distal oesophagus?

A

Lots of blood vessels here from both the portal and systemic circulation.

Portal drainage - oesophageal veins drain into left gastric vein which drains into portal vein.

Systemic drainage - oesophageal vein drain to azygous vein which drains into SVC.

31
Q

How do you treat oesophageal varices?

A

Band ligation

Transjugular portosystemic shunt:

  • Expandable metal plate placed within the liver
  • Bridges the portal vein to the hepatic vein
  • Decompresses the portal vein pressure
  • Reduction in variceal pressure
  • Reduction in ascites

Drug treatment - Terlipressin to reduce portal venous pressure.

32
Q

What is an abdominal aortic aneurysms?

A

Pathological dilation of the aorta with a diameter 1.5 times the expected anteroposterior diameter of that segment, given the persons sex and body size (usually >3cm).

Most are infrarenal

33
Q

What are the risk factors for AAAs?

A

Males
Inherited risk
Increased age
Smoking

34
Q

How will an AAA present before rupture?

A

usually asymptomatic but can cause symptoms by compressing other nearly structures (stomach -nausea, bladder - urinary frequency, vertebra - back pain)/

35
Q

How does an AAA present when ruptured?

A

Abdominal pain

Back pain

Pulsatile abdominal mass

Transient hypotension -syncope. Retroperitoneum can temporarily tamponade the bleed.

Sudden CV collapse - 65% of AAAs die before hospital.

36
Q

How do you diagnose AAAs?

A

Physical exam -pulsatile abdominal mass (<50% cases)

Ultrasonography - non-invasive and very specific and sensitive. Also detect peritoneal blood.

CT - detect relevant surrounding anatomy, planning for elective surgery

Plain X-Ray -calcified = seen on plain X-Ray

37
Q

How do you treat AAAs?

A

Smoking cessation and hypertension control

Surveillance of AAA - less than 5.5cm okay but if over, vascular surgeons

Surgery - endovascular repair -relining the aorta using an endograft (exoskeleton of metallic stents over a fabric lining). iIt is inserted through the femoral artery and seals below the renal arteries and above the common iliacs.

38
Q

How do you repair AAA?

A

Open surgical repair

  • Clamp aorta
  • Open the aneurysm (remove thrombus and debris)
  • Suture in a synthetic graft to replace diseased segment.

ESA 3 - Gastrointestinal System (18 decks)

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