GI presentations

Question 1

What are the common causes of upper gastrointestinal (GI) bleeding?

Answer 1

Common causes of upper GI bleeding include peptic ulcer disease (PUD), gastritis, Mallory-Weiss tear, malignancy, and varices.

Question 2

How does upper GI bleeding typically present, and what are the distinguishing features of malaena?

Answer 2

Upper GI bleeding may present as hematemesis (classically coffee ground) or malaena (tarry, black stool with a distinctive odor).

Question 3

What is the landmark anatomical feature for upper vs lower GI bleed?

Answer 3

Ligament of treitz, at the duodenojejunal junction

Question 4

Identify cause of presentation scripts of upper GI bleed:
1) vomiting –> bleed
2) 2 weeks post-up using diclofenac
3) chronic liver disease

Answer 4

1) Mallory Weiss tear
2) NSAIDs/peptic ulcer disease
3) Variceal origin

Question 5

Why might the hemoglobin level not drop immediately in an acute upper GI bleed?

Answer 5

The hemoglobin level may not drop immediately in an acute upper GI bleed because it may occur after volume resuscitation.

Question 6

How can plasma urea levels be helpful in distinguishing between upper and lower GI bleeds?

Answer 6

Plasma urea levels may rise in an upper GI bleed due to absorption of digested blood,

Question 7

Outlines management principles of upper GI bleed

Answer 7

1) resus
2) UGI endoscopy
If non-varices: inject adrenaline or clip, give IV omeprazole
If varies: banding, control portal hypertension (octreotide, B-blocker)

If above fails, surgery

Question 8

Blood appearances + cause:
1) post-defecation
2) on paper with severe pain
3) blood coating stool
4) blood alone
5) blood with mucus
6) blood mixed with stool/occult blood/anaemia

Answer 8

1) haemorrhoids
2) anal fissure
3) rectal cancer
4) diverticular/angiodysplasia/massive bleed
5) colitis (IBD etc)
6) colonic cancer

Question 9

How does the management of acute lower gastrointestinal (GI) bleeding differ from upper GI bleeding in terms of the role of endoscopy?

Answer 9

In acute lower GI bleeding, endoscopy has a more minor role. Approximately 95% of cases will stop bleeding without intervention, and the focus is on ensuring haemodynamic stability.

Question 10

What is the next step if bleeding ceases in acute lower GI bleeding, and why is it important?

Answer 10

If bleeding stops, patients generally require a routine colonoscopy to determine the cause and exclude cancer.

Question 11

In cases of ongoing bleeding with haemodynamic instability in acute lower GI bleeding, what intervention may be employed?

Answer 11

In cases of ongoing bleeding with haemodynamic instability, angiographic embolisation may be employed.

Question 12

When is surgery considered in the management of acute lower GI bleeding, and what is important to note about this option?

Answer 12

Surgery for acute lower GI bleeding is a last resort and is associated with a high mortality and morbidity rate.

Question 13

What are the three categories of causes for jaundice, and which category is most frequently encountered in surgery?

Answer 13

Jaundice can have pre-hepatic, intra-hepatic, or post-hepatic causes. In surgery, the most common causes are post-hepatic or obstructive.

Question 14

What are some common causes of obstructive jaundice?

Answer 14

Common causes of obstructive jaundice include gallstones, neoplasia, and benign biliary strictures.

Question 15

How does obstructive jaundice typically present, and what additional symptom may accompany it?

Answer 15

Obstructive jaundice is often first noticeable in the sclera and later in the skin. It may be accompanied by itch.

Question 16

How does the presence of pain in a jaundiced patient provide a clue to the possible origin of the jaundice?

Answer 16

The presence of pain suggests gallstones as the origin of jaundice, whereas painless jaundice may indicate a more serious underlying cause, particularly malignancy.

Question 17

What is Courvoisier’s law, and what does it suggest when applied to a jaundiced patient?

Answer 17

Courvoisier’s law states that painless jaundice with a palpable gallbladder is indicative of malignant obstruction.

Question 18

Which blood tests can help differentiate between obstructive jaundice and hepatocellular jaundice, and what changes are typically observed?

Answer 18

In obstructive jaundice, there is a rise in conjugated bilirubin and biliary enzymes (ALP, GGT) over hepatocellular enzymes (AST, ALT).

Question 19

What is the initial test often performed to assess the presence of biliary tree dilation caused by obstruction?

Answer 19

Ultrasonography (USS) is often the initial test used to determine the presence of biliary tree dilation resulting from obstruction.

Question 20

Jaundice and USS findings, then what?

1) No biliary dilation
2) Biliary dilatation

Answer 20

1) reconsider other cholestatic or hepatic causes
2) if gallstones –> MRCP and or ERCP, or cholecystectomy.
If not gallstones, do a CT Abdo, which could show a tumour or stricture. This will need surgery or stenting or palliative care.

Question 21

What is the most common cause of small bowel obstruction?

Answer 21

Adhesions from previous surgery

Other causes: hernias or masses, inflammatory e,.g. Crohns

Question 22

What are the key elements in the presentation of small bowel obstruction in terms of history and examination?

Answer 22

In terms of history, small bowel obstruction presents with colicky pain followed by vomiting (bile, faeculent), distention, and obstipation. The duration between pain and vomiting may indicate the level of obstruction.

Examination may reveal scars, distention, visible peristalsis, increased bowel sounds (BS), and later on, silence.

Question 23

What could constant pain and very tender mean in the context of small bowel obstruction?

Answer 23

Could mean strangulation - emergency

Question 24

How to differentiate small bowl from large on imaging?

Answer 24

central location, plicae circulares

Question 24

What is the 3/6/9 rule?

Answer 24

This is the normal diameter for the small bowel, colon and cecum.

> > means distension e.g. obstruction.

Question 25

Describe a SBO on radiology?

Answer 25

Dilated loops (>3cm), prominent plicae circulares (coiled spring appearance)

Question 26

In cases of small bowel obstruction due to adhesions, what is the crucial factor to assess in the initial evaluation, and what signs suggest the presence of it?

Answer 26

The crucial factor to assess in the initial evaluation of adhesional small bowel obstruction is the presence of strangulation. Signs of strangulation include constant, non-cramping pain, peritonitis, tachycardia, fever, and leukocytosis.

Question 27

If strangulation is absent in a case of small bowel obstruction due to adhesions, what is the recommended management approach?

Answer 27

In the absence of strangulation, simple non-operative management is indicated. This includes nil by mouth (NBM), intravenous fluids, electrolyte correction, and analgesia.

‘Drip and suck’

Question 28

What is the recommended course of action if strangulation is confirmed in a case of small bowel obstruction due to adhesions?

Answer 28

If strangulation is present, it mandates an emergency laparotomy followed by intravenous fluid and electrolyte resuscitation.

Question 29

What is the management of non-adhesion SBO?

Answer 29

Usually surgical correction (e.g. hernia, neoplasm if resectable)

Question 30

What are some key elements in the presentation of large bowel obstruction in terms of history?

Answer 30

In terms of history, large bowel obstruction presents with abdominal pain, distension, constipation, and vomiting (usually occurring late in the course). Patients may also report fatigue, weight loss, and a prodromal change in bowel habit.

Question 31

What is the significance of right lower quadrant (RLQ) tenderness in the examination of a patient with large bowel obstruction?

Answer 31

RLQ tenderness indicates impending caecal perforation, which is a serious complication.

Question 32

What are some of the radiological features associated with large bowel obstruction?

Answer 32

Radiological features of large bowel obstruction include dilated bowel (>6cm), a peripheral location, caecal distention >9, haustra (incomplete compared to PC in SB)

Question 33

What are some common causes of large bowel obstruction?

Answer 33

Common causes of large bowel obstruction include fecal matter, carcinoma, diverticular disease, sigmoid volvulus, and inflammatory bowel disease (IBD).

Question 34

Why is fluid resus important in bowel obstruction?

Answer 34

Occlusion = dilatation before this, increased peristalsis and secretion of electrolyte-rich fluid into the bowel (third spacing)

Question 35

SHAVING mnemonic for Sbo?

Answer 35

Stricture, hernia, adhesions, volvulus, intussusscsption/IBD, neoplasms, gallstones

Question 36

What is an example of closed loop obstruction?

Answer 36

e.g. a large bowel obstruction with a competent ileocecal valve –> distension –> ischaemia –> perforation

Question 37

Compare palpation exam for bowel obstruction compared to ischaemia?

Answer 37

BO - abdominal tenderness
ischaemia - guarding, rebound tenderness

Question 38

Diff dx for bowel obstruction?

Answer 38

pseudo-obstruction, paralytic ileus, toxic megacolon, constipation

Question 39

Outline conservative management of an adhesional bowel obstruction (no signs of ischaemia/perforation)

Answer 39

NBM, insert nasogastric to decompress bowel.
IV fluids (drip)
Urinary catheter, fluid balance charts
Analgesia, anti-emetics

Question 40

What indicates the need for surgical management in BO?

Answer 40

• suspicion of ischaemia or closed loop (e.g. exquisite tenderness, guarding)
• cause requires surgery (e.g. hernia, tumour)
• failure to improve with conservative treatment >48 hours

Question 41

What is the management of pseudo-obstruction?

Answer 41

IV fluids/electrolytes,
prokinetics e.g. metoclopramide
Colonoscopy

Question 42

Why is it crucial to differentiate between mechanical large bowel obstruction and pseudo-obstruction?

Answer 42

It is important to differentiate between mechanical large bowel obstruction and pseudo-obstruction because pseudo-obstruction, characterized by paralysis of the hind gut and massive colonic distention, does not require the same immediate surgical intervention as a mechanical obstruction.

Question 43

In cases of large bowel obstruction, where is perforation most likely to occur, and what action is mandated if this occurs or is suspected?

Answer 43

Perforation of the obstructed large bowel is most likely to occur at the caecum. If this has occurred or impending caecal perforation is suspected, emergency surgical management is mandatory.

Question 44

What are the key elements in the presentation of perforation?

Answer 44

Perforation is characterized by severe abdominal pain, signs of peritonitis on abdominal examination, and may be accompanied by systemic sepsis.

Question 45

How can free gas be detected on an erect CXR in cases of suspected perforation, and what are the limitations of this method?

Answer 45

An erect CXR may demonstrate free gas under the right hemi diaphragm. However, it’s important to note that a stomach bubble will be present under the left hemi diaphragm. While an erect CXR is a valuable tool, it is not 100% sensitive for detecting perforation.

Question 46

In cases where doubt remains with a negative erect CXR, what imaging technique provides greater sensitivity for detecting free gas and may offer further insights into the source of perforation?

Answer 46

f doubt remains with a negative CXR, a CT abdomen is recommended. It demonstrates free gas with far greater sensitivity and may provide additional information about the source of the perforation.

Question 47

What is an alternative imaging option if a CT abdomen is not available for suspected cases of perforation?

Answer 47

If CT is not available, a left lateral decubitus film is another option for detecting free gas.

Question 48

What are some common causes of intra-abdominal viscus perforation?

Answer 48

Causes include diverticulitis, peptic ulcer disease, malignancy, and, rarely, appendicitis.

Question 49

What is the crucial initial management for patients with perforation of intra-abdominal viscera?

Answer 49

Start with IV fluid resuscitation and prompt IV antibiotic administration.

Question 50

In the case of perforated diverticulitis, what is the standard surgical approach?

Answer 50

Perform a laparotomy, cleanse the area, and execute a Hartmann’s resection of the sigmoid colon, followed by creating an end colostomy.