GI presentations Flashcards
What is an acute abdomen and how do you assess a patient with this?
Sudden onset of severe abdominal pain
Need to decide if patient is critically unwell and needs surgical intervention so check observations and observe patient from bed with ABCDE
What are some causes of acute abdomen that require immediate urgent intervention?
Intraabdominal bleeding
Perforated viscus
Ischaemic bowel
A perforated viscus is a pathology that presents as acute abdomen and requires urgent intervention as it causes peritonitis. What are some causes of this and how will a patient present with this?
Peptic ulceration
Small or large bowel obstruction
Diverticular disease
IBD
Patients will lay completely still with generalised peritonitis (unlike renal colic where they will be moving to get comfortable)
Ischameic bowel (Acute Mesenteric Ischaemia) is a cause of acute abdomen that requires urgent surgical intervention. How will this present in a patient and how is it diagnosed?
Ischameic bowel (Acute Mesenteric Ischaemia) is a cause of acute abdomen that requires urgent surgical intervention. How will this present in a patient and how is it diagnosed?
What labatory tests and imaging should you do for all cases of acute abdomen?
A
Lab Tests
- Urine dipstick ±MC&S: check for signs of infection, haematuria, pregnancy
- ABG: for bleeding or septic patients. Look at O2, rapid Hb, lactate to see perfusion of organs
- Routine bloods: FBC, U&Es, LFTs, CRP, amylase and a group and save if likely to need surgery soon
Imaging
- eCXR: for pneumoperitoneum or lower lobe lung pathology
- US: kidneys, biliary tree, transvaginal
- CT
- ECG: to rule out cardiac pathology causing referred pain
What may a raised serum amylase level mean in a patient with acute abdomen?
- 3x normal limit: pancreatitis
- Raised but not 3x: perforated bowel, ectopic pregnancy, or diabetic ketoacidosis (DKA)
How is acute abdomen managed generally before a diagnosis is made?
IV access +/- fluids
Nil by mouth
Analgesics
Antiemetics
Initial imaging, bloods and urine dip
VTE prophylaxis
Consider NG tube and catheter if unwell to monitor fluid balance
What laparoscopic port site is almost always the same in every surgery?
Umbilicus for camera port
Common instruments include camera, cutting and dissecting scissors, and grippers
What are some of the causes of haematemesis?
A
Emergency (due to haemorraghe)
- Oesophageal varices: often due to portal hypertension from alcohol abuse. Needs urgent OGD
- Gastric ulceration: erosion into blood vessels, usually lesser curve of stomach and posterior duodenum. May have history of epigastric pain, NSAIDs, H.Pylori
Non-emergency
- Mallory-Weiss Tear: just needs reassurance and monitoring. If severe or prolonged this warrants OGD
- Oesophagitis: due to GORD, infections such as candidiasis, radiotherapy, Crohn’s, ingestion of toxic substances
Gastritis, Gastric malignancy, Meckel’s diverticulum
What is the Glasgow-Blatchford Bleeding Score?
Decide whether Upper GI bleed can be managed as outpatient or inpatient with endoscopy
Rockall Score (severity score for GI bleeding post-endoscopy)
How is haematemesis due to peptic ulcer disease and oesophageal varices managed?
- Initial: 2 large bore IV cannulas, start fluid resuscitation if needed, and crossmatch blood
Endoscopy:
- Peptic ulcer disease: Injection of adrenaline and cauterisation or embolisation of gastroduodenal artery. High dose IV PPI +/- eradication therapy
- Oesophageal varices: prophylactic antibiotics and Terlipressin.
Endoscopic banding, Somatostatin analogues (e.g. octreotide) or vasopressors (e.g. terlipressin), Long-term repeated banding and long term beta blockers
Why is urgent fluid resuscitation required in a bowel obstruction?
Once the bowel segment has become occluded, dilatation of the proximal limb of bowel occurs, resulting in an increased peristalsis of the bowel.
This leads to secretion of large volumes of electrolyte-rich fluid into the bowel (often termed ‘third spacing’).
What is the aetiology of small and large bowel obstructions?
Small bowel – adhesions and hernia
Large bowel – malignancy, diverticular disease, and volvulus
SURGICAL SIEVE: outside, within the wall, within the lumen
What are some differential diagnoses for bowel obstruction?
Pseudo-obstruction
Paralytic ileus
Toxic megacolon
Constipation
What investigations are done if you suspect a bowel obstruction?
Urgent bloods and a G+S due to third spacing
- VBG to look for raised lactate (ischaemia) or metabolic derangement due to vomiting/dehydration
- CT with IV contrast is imaging of choice
- AXR
- Water soluble contrast study (gastrograffin) in small bowel obstruction from adhesions from surgery
Why is CT imaging better than AXR for bowel obstructions?
(1) more sensitive
(2) can differentiate between mechanical obstruction and pseudo-obstruction
(3) can find site and cause of obstruction so good for operative planning
(4) presence of metastases if caused by a malignancy
What is a red flag that ischaemia may be developing in a suspected bowel obstruction?
Colicky pain that becomes constant in nature or worse on movement
Guarding and rebound tenderness
What is the first diagnosis you should consider with an acute abdomen?
GI perforation as delay in resuscitation and surgery can lead to septic shock, multi-organ dysfunction and death
What would you see on an AXR and eCXR with a GI perforation?
AXR
Rigler sign
Psoas sign (loss of the sharp delineation of the psoas muscle border due to fluid in the retroperitoneum)
eCXR (only 70% sensitivity so use CT)
Cupola sign (look under right diaphragm)
Pneumomediastinum or widened mediastinum if thoracic perforation
What are some causes of melaena?
Peptic ulcer disease
- Oesophageal varices
- Upper GI malignancy
Gastritis or Oesophagitis
Mallory–Weiss tear
Meckel’s diverticulum
What are some causes of rectal bleeding?
If haemodynamically unstable then suspect upper GI bleed until proven otherwise
Diverticular disease
Ischaemic or infective colitis
Haemorrhoids
Malignancy (ALWAYS SUSPECT)
Angiodysplasia
Crohn’s disease or Ulcerative colitis
Radiation proctitis.
anal fissure
What is the Oakland score?
]Score to stratify patients presenting with a lower GI bleed to determine if outpatient management is feasible
How is jaundice managed?
- Treat underlying cause e.g ERCP if gallstone causing obstructive jaundice
To treat itching give antihistamines or cholestyramine if obstructive jaundice
Monitor for coagulopathy, treating promptly (either vitamin K or FFP) - Oral glucose for hypoglycaemia
If confused due to decompensating liver disease (hepatic encephalopathy) give laxatives (lactulose or senna) +/- neomycin or rifaximin to reduce the number of ammonia-producing bacteria
What is the difference between acute and chronic pancreatitis?
Acute pancreatitis is a life threatening inflammatory process. Usually due to gall stones or binge drinking
Chronic pancreatitis develops insidiously over a long period of time and is characterised by progressive fibrosis and destruction of endo and exocrine glands. Usually due to chronic alcohol ingestion
