GI surgery Flashcards
Which volvulus is more common
Sigmoid > Cecal
Risk factors for sigmoid volvulus
Old, constipation, chagas disease, Neurological disease and mental health condition
Risks for cecal volvulus
Adhesion and pregnancy
Sigmoid volvulus leads to
Large bowel obstruction; coffee bean sign aka bent inner tube sign on AXR
Caecal volvulus leads to
Small bowel obstruction
Management of sigmoid volvulus
Colonoscopy decompression aka Rigid sigmoidoscopy
laparoscopic or open sigmoid colectomy
Management of Cecal volvulus
laparoscopic or right hemicolectomy
no colonoscopy as can perforate cecum
Caecostomy
Hemorrhage in post-Op
Primary: during surgery
Reactive: At the end or early post op
Secondary: >24 hours due to infection
Post-op urinary retention
Drugs: opioids, epidural, antiACHM; pain- SNS
Pulmonary Atelectasis post op
General anaesthesia relayed, mucus plugging, absorption of distal air and collapse of lung;
Risks: smoking pre-op, Anaesthetic concentration, pain inhibits cough and respiratory excursion
Presents within first 48 hours, mild fever, dyspnea and dull bases with decreased air entry
Wound infections post-op
Typically occur 5 to 7 days post-op
S. Aureus and Coliforms
Wound dehiscence
10 days post op, preceded by serosanguinous discharge from the wound
Colonic surgery post op
Ileus, anastomosis leak, enterocutaneous fistula and abscess
Small bowel surgery Post op
Short gut syndrome
Post op pyrexia
early: Blood transfusion, physiological (SIRS), atelectasis (24-48h)
Delayed: pneumonia, VTE, wound infection, Anastomotic leak at 7 d
What is the most common cause of secondary peritonitis
Acute perforated appendicitis in under 45s
Elderly - Diverticultitis perforated
Investigation of choice in peritonitis
Abdominal CT scan
treatment of choice for peritonitis
IV metronidazole + Cefuxime
What is a fistula in Ano
Abnormal connection between ano-rectal canal and the skin
Presents with anal discharge and pain
May be purulent
Perianal fistula pathogenesis
occurs secondary to perianal sepsis and blocked intramuscular gland forming abscess, abscess forms a fistula
Associated to Crohns, Diverticular disease, rectal cancer
High and low Anal fistula
High: cross sphincter muscles above the dentate line
Low: below the dentate line
Goodsall’s Rule
Fistula anterior to anus track in a straight line
Fistula posterior to anus - has internal opening at 6 oclock position
Investigation in Anal fistula
MRI and endoanal USS
Treatment of anal fistula
examination under anaesthesia
Fistulotomy and excision - low fistula
High fistula: suture passed through fistula and gradually tightened over months
Treatment of perianal abscess
EUA and Incision and drainage
2 intention healing
complication is fistula
Which ulcer pain gets relieved by eating
Duodenal ulcer
Which ulcer pain gets worse on eating
Gastric; relieved by antacids
What are curling’s ulcers related to
Burns
Investigation of Peptic ulcers
Breath test, OGD - gold standard (stop PPI 2 weeks)
Gastrin levels for Zollinger-Ellison
Surgical management of peptic ulcers
Vagus nerve stimulates acid secretion and also by gastrin (from antral G cells)
- Vagotomy: truncal: prevents pyloric sphincter relaxation, combined with pyloroplasty or gastroenterostomy
Selective- nerves of laterhet left intact - Antrectomy with vagotomy: distal stomach removed
Subtotal gastrctomy with Roux-en-Y: Zollinger-Ellison
Dumpling syndrome
Abdo distention, flushing, n/v
hypoglycemia and hypovolemia
H pylori increases the risk of
Lymphoma and gastric primary adenocarcinoma
Triple and quadruple therapy - H pylori
Bismuth + metronidazole + Tetracycline + PPI
or
Clarithromycin + AMoxicillin + PPI
Gastrinoma located in pancreas, MEN1, hypersecretion of gastrin from tumor in pancreas or duodenum, diarrhea
Zollinger-Ellison syndrome
Cushing ulcer triad
Hypertension + widening pulse pressure and bradycardia due to ICP
Type A gastritis vs Type B gastritis
Type a: autoimmune gastritis, Pernicious anemia, anti-pariteal antibodies
Type b: pylorus and antrum, H, pylori, increased risk of gastric and duodenal adenocarcinoma
painless Jaundice, Dark urine and light stools, Nausea, pain after eating, unintended weight loss, upper abdominal pain, back pain, cachexia, virchow’s nodes, Courvoisers sign and trousseau’s syndrome - Migratory thrombophlebitis
Pancreatic cancer
Risks for pancreatic cancer
Smoking, inflammation (chronic), high fat diet, Etoh and DM
Signs of pancreatic cancer
palpable GB + jaundice + Trousseau + splenomegaly + Ascites
Investigation of pancreatic cancer
Cholestatic LFTs + Ca19-9
USS: pancreatic mass, dilated ducts and hepatic metastasis
Endoscopic USS > CT/MRI for staging
CXR: metastasis
ERCP: shows anatomy, allows stent and biopsy
Surgical treatment of pancreatic cancer
Whipple’s Pancreaticoduodenectomy
Palliation - P/C or endoscopic stenting
pain relied coeliac plexus block
Lower 3rd oesophagus, GORD related and barretts - cancer
Adenocarcinoma
upper and middle third, Associated with alcohol and smoking
SCC
Progressive dysphagia from solids to liquids, weight loss, retrosternal chest pain, lymphadenopathy and upper third hoarseness - recurrent laryngeal nerve and cough and aspiration pneumonia
Oesophageal cancer
Diagnosis of oesophageal cancer
Upper GI endoscopy- biopsy
BA swallow: apple core stricture
Staging: CT/ EUS
Surgical treatment of oesophageal cancer
Oesophagectomy
Ivor-lewis, McKeown and trans-hiatal
Palliative: laser coagulation, stenting, radiotherapy
Following a viral infection, enlargement of LNs causing pain, tenderness and fever
Causes: high temp, tenderness is generalised, lymphocytosis, Post URTI and photophobia
Mesenteric adenitis
Ileal remnant of vitellointestinal duct that joins the yolk sac to the mid gut
Meckel’s diverticulum
PC of meckel’s
Rectal bleeding, diverticulitis, intussuception, volvulis, malignant change into adenocarcinoma, raspberry tumor
Investigation: Pertechenecate scan
Surgical resection is required
Triad of mesenteric ischemia
Acute abdominal pain + PR bleeding + shock + No abdominal signs
AF can be seen
Imaging in mesenteric ischemia
AXR: gas less bowel
Arteriography, CT angi, MRI angio
management in ischemic bowel
Resection of the necrotic bowel
Imaging in bowel onstruction
AXR- fluid levels and CT
gastrograffin - mechanical obstruction
AXR findings in Obstruction
> 3 cm, central, many loops and many short fluid level- SBO
>6cm or >9 cecum, peripheral, haustra, gas present, few loops - LBO
Management of Bowel Obstruction
NBM, IV fluids, NGT and cathetrise
Surgery: closed loop, neoplasm, strangulation or perforation with peritonitis, failed conservative
LBO: hartmann’s, colectomy, bypass, loop ileostomy or colostomy, caecostomy
Strictures, transmural, cobblestone mucosa, granuloma, fistula, aphthous ulcers
Crohn’s
Mucosal, pseudopolyps, bloody stools, tenesmus, urgency , CRC
UC
Associations of IBD with systemic diseases
Erythema nodusum, pyoderma gang, iritis, arthritis, PSC + cholangiocarcinoma
induce Remission in mild to moderate UC
5ASA and prednisolone
Maintaining remission in UC
5ASA Po, azathioprine or Mercaptopurine
Infliximab 3rd line
Surgical treatment in UC
Emergency: Total or subtotal colectomy with end ileostomy + mucus fistula
panprotocolectomy + end ileostomy
Elective: pan proctocolectomy with end ileostomy
Types of hiatus hernia
Sliding common - GOJ slides up into chest, associated with GORD
Rolling: Stomach into the chest with oesophagus; stangulation risk
Investigation and treatment of hiatus hernia
CXR- gas bubble and fluid level
Ba swallow: diagnostic choixe
OGD: oesophagitis
Repair of rolling hernia
Surgical repair of inguinal hernia
Lichtenstein repair open approach laproscopic: bilateral repair and recurrent hernia primary unilateral - Open Children- sac excision - hernitomy
symptoms of Haemorrhoids
Fresh PR bleeding, pruritus ani, lump in perianal area and thrombosis
Investigation of hemorrhoids
proctoscopy and DRE
management of hemorrhoids
rubber bind ligation, injection sclerotherapy, excision for acutely thrombosed within 72 hours
Metaplasia of squamous epithelium
Barretts
Metaplasia to dysplasia to adenocarcinoma
Cancer
Surgical management of GORD
nissen fundoplication: severe sxs, refarctory to medical therapy and confirmed reflux on pH monitoring
GORD investigation
High risk OGD
24 hour manometry and pH
Risk factors for gastric cancer
Atrophic gastritis, pernicious anemia, nitrates, smoking, BG-A, partial gastrectomy
Pathology of gastric cancer
adenocarcinoma + H pylori- MALToma
SXS: late pC, weight lost, anorexia, dyspepsia, dysphagia and n/v, acanthosis nigricans
Surgical management of gastric cancer
Pyloric stenting and bypass procedures
resection endoscopically
total gastrectomy
Choice of investigation for biliary colic
USS
uncertain- HIDA
dilated ducts seen MRCP
Murphy sign
pain and breath catch on GB and absent on left
Boas’s sign
hyperaesthesia below right scapula
empyema
High fever, RUQ mass and P/C drainage
Riger’s triad for gallstone ileus
pneumobilia + sbo + RLQ Gallstone
Ascending cholangitis
1st line USS
1st ERCP
PTC
Reynolds pentad
fever + RUQ + Jaundice + confusion + hypotension
Hypovolemia + retroperitoneal hemorrhage + pancreatic necrosis
Acute pancreatitis
Causes of acute pancreatitis
mostly gallstones
alcohol
others- ethanol, idiopathic, trauma, steroids, mumps, ERCP
Modified glasgow scale
paO2, age, neutrophils, Calcium low, renal function, LDH, albumin and sugar
Imaging in acute pancreatitis
US, Contrast CT**
treatment in pancreatitis
ERCP if gallstones
ERCP + sphincterotomy
Surgical treatment in acute pancreatitis
Pancreatic necrosis, abscess
laparotomy + necrosectomy
peritoneal lavage
Complications of acute pancreatitis
ARDS, pleural effusion, shock, DIC
late: necrosis, infection, abscess, pseudocyst, bleeding, thrombosis, fistula
pseudocyst of pancreas
lesser sac, 4-6 weeks after acute attack, pain and early satiety, infection can occur
persistent raised amylase
PC drainage under US/Ct
Chronic pancreatitis causes
alcohol is most common
Pain into back, steatorrhea, weight loss, polyuria and polydipsia, pseudocyst, elastase and exocrine function
CT calcification
Surgical treatment of chronic pancreatitis
Distal pancreatectomy
whipples
drainage and stenting
Hellers cardiomyotomy
Achalasia
ANal fissure treatment
EUA
medical: laxative, lignocaine, GTN, diazepam, and botulinum injection
Surgical treatment of anal fissures
lateral partial sphincterotomy
Hinchey grading
diverticultis small confined pericolic abscesses large abscess Generalized peritonitis faecal peritonitis
Surgical therapy in diverticulitis
Hartmann’s
Colon cancer treatment
Caecal, ascending, or proximal transverse colon: right hemicolectomy
Distal transverse descending colon: left hemicolectomy
Sigmoid colon: High anterior resection
Upper rectum: anterior resection with TME
low rectum: anterior resection with low TME
anal verge APER
Familal adenomatous polyposis
Autosomal dominant, APC gene, 100-1000s adenomas by 16 years of age
Variants
Attenuated- <100 >50 CRC
Gardners: TODE- thyroid, osteoma, dental problem, epidermal cysts
treat using prophylactic colectomy before 20
Hereditary non-polyposis colorectal cancer
Autosomal dominant, commonest CRC
Lynch 1: right sided CRC
lynch 2: CRC + gastric, prostate and breast
Peutz-Jeghers
Autosomal dominant
increased cancer risk, hyperpigmentations
appendicitis pain veretbrae
t10-11
McBurney’s point
Guarding and tenderness
psoas sign
retrocecal appendix
