GI Surgical Presentations Flashcards
what is considered an ‘acute abdomen’ presentation?
sudden onset of severe abdominal pain usually in the last 24hours
which presentations require urgent surgical treatment?
- bleeding
- bowel perforation
- ischaemic bowel
what GI presentations are considered to be less acute?
- colic
- peritonism
what are common differentials for a patient presenting with epigastric pain?
- peptic ulcer disease
- cholecystitis
- pancreatitis
- myocardial infarction
what are common differentials for a patient presenting with peri-umbilical pain?
- small bowel obstruction
- large bowel obstruction
- appendicitis (early)
- abdominal aortic aneurysm
what are common differentials for a patient presenting with right upper quadrant pain?
- cholecystitis
- pyelonephritis
- ureteric colic
- hepatitis
- pneumonia
what are common differentials for a patient presenting with left upper quadrant pain?
- gastric ulcer
- pyelonephritis
- ureteric colic
- pneumonia
what are common differentials for a patient presenting with right lower quadrant pain?
- appendicitis (late)
- ureteric colic
- inguinal hernia
- IBD
- UTI
- gynaecological
- testicular torsion
what are common differentials for a patient presenting with left lower quadrant pain?
- diverticulitis
- ureteric colic
- inguinal hernia
- IBD
- UTI
- gynaecological
- testicular torsion
what is the most serious cause of intra-abdominal bleeding?
a ruptured abdominal aortic aneurysm
what are other causes of intra-abdominal bleeding?
- ruptured ectopic pregnancy
- bleeding gastric ulcer
- trauma
why is intra-abdominal bleeding such a concern?
patients can enter hypovolaemic shock because of it
what are the signs of hypovolaemic shock?
- tachycardia
- hypotension
- pale and clammy
- cool to touch
- thready pulse
true or false: bowel perforation can cause peritonitis
true.
what is peritonitis?
inflammation of the peritoneum
what are the common causes of bowel perforation?
- peptic ulceration
- small/large bowel obstruction
- diverticular disease
- inflammatory bowel disease
how do patients usually present with peritonitis?
- patients lie still and try not to move their abdomen
- tachycardia
- rigid abdomen with guarding
true or false: any patient in severe pain out of proportion to clinical signs has ischaemic bowel until proven otherwise
true.
what is blood abnormalities are found in a patient with ischaemic bowel?
raised lactate
how do patients usually present with ischaemic bowel?
- diffuse constant pain
how do you definitely diagnose ischaemic bowel?
CT with contrast
what is colic pain?
abdominal pain that crescendos to very severe and then goes away completely
when is colic type pain most commonly seen?
- ureteric obstruction
- bowel obstruction
true or false: biliary colic is a true colic pain
false.
biliary colic is false colicky pain as it does not go away completely but instead ‘waxes and wanes’
what is the difference between peritonitis and peritonism?
peritonism is localised inflammation of the peritoneum that has irritated the parietal layer whereas peritonitis irritates the visceral peritoneum
what are the common investigations done in acute abdomen cases and why?
- urine dip: signs of infection or haematuria (also check pregnancy)
- ABG: for bleeding patients to get a rapid haemoglobin and signs of hypoperfusion (lactate levels)
- bloods: FBC, U&Es, LFTs, CRP, amylase
- blood cultures: if considering infection
what level does amylase need to be to diagnose pancreatitis?
3x greater than the upper limit
what are the common imagings done in acute abdomen cases and why?
- ECG to rule out myocardial infarction
- USS: area checked depends on specifics of case
- erect CXR: to check for bowel perforation
- CT depending on suspected diagnosis
what is haematemesis and how is it caused?
vomiting blood caused by bleeding in the upper GI tract
when is haematemesis considered an emergency?
if it is caused by oesophageal varices or gastric ulceration
when do you get non-emergency haematemesis?
- mallory weiss tear
- oesophagitis
what are oesophageal varices?
dilations of porto-systemic venous anastomoses in the oesophagous
they are thin walled and prone to rupture
what causes oesophageal varices?
portal hypertension most commonly due to alcoholic liver disease
what investigations are done in a patient with suspected oesophageal varices?
an OGD to confirm diagnosis
what is a gastric ulceration?
erosion into the blood vessels that supply the upper GI tract
what causes gastric ulceration?
- ulcer disease
- h. pylori positive
- history of NSAID or steroid use
which vessel is most commonly damaged in a gastric ulceration?
gastro-duodenal artery
what are mallory-weiss tears?
episodes of recurrent vomiting resulting in damage to the oesophageal epithelium - this leads to slight haematemesis
what are key points to note when taking a history of haematemesis?
- history of dyspepsia, dysphagia, odynophagia
- smoking and alcohol use
- medication history
why would you do an erect chest xray in a patient with haematemesis?
if there is a perforated peptic ulcer, it may present with air under the diaphragm (pneumoperitoneum)
what other imaging should be done in a patient with haematemesis?
OGD and a CT abdomen with contrast
how would you manage a patient with peptic ulcer disease?
- cauterise the bleeding
- begin IV PPI therapy to reduce acid secretion
how would you manage a patient with oesophageal varices?
- endoscopic banding
- prophylactic antibiotics should be given
what is dysphagia?
difficulty in swallowing
true or false: dysphagia is oesophageal cancer until proven otherwise
true.
what investigation is done to find the cause of dysphagia?
an upper GI endoscopy +/- biopsy
what are the mechanical causes of dysphagia?
- oesophageal or gastric malignancy
- benign oesophageal strictures
- extrinsic compression
- pharyngeal pouch
- foreign body
what are the neuromuscular causes of dysphagia?
- post-stroke
- achalasia
- diffuse oesophageal spasm
- myasthenia gravis
what clinical features should be assessed in a patient with dysphagia?
- differentiate between odynophagia (pain on swallowing)
- presence of regurgitation
- sticking of food
- hoarse voice and other cancer markers
- referred pain to neck or ear
if the endoscopy is normal how would you further the investigations?
barium swallow or assess for motility disorders (manometry)
what is the management for dysphagia?
treat the underlying cause
if no underlying cause found, refer to SALT and dietician
what is a bowel obstruction?
the mechanical blockage of the bowel
what are the most common causes of small bowel obstruction?
- adhesions
- hernias
- cancer
what are the most common causes of large bowel obstruction?
- malignancy
- diverticular disease
- volvulus
true or false: a large bowel obstruction should be considered GI cancer until proven otherwise
true.
what are the intraluminal causes of bowel obstruction?
- gallstone ileus
- foreign body
- faecal impaction
what are the mural causes of bowel obstruction?
- cancer
- strictures
- intussussception
- diverticular strictures
- Meckel’s diverticulum
what are the extramural causes of bowel obstruction?
- hernias
- adhesions
- peritoneal metasteses
- volvulus
what happens in a bowel obstruction and why is it essential to monitor fluids?
once blocked there is dilation of the proximal bowel, this increases peristalsis causing more fluid secretions to enter the bowel - therefore fluid resuscitation is needed
what is a closed loop obstruction?
if there is a 2nd obstruction proximally it is a surgical emergency as the bowel will distend, become ischaemic and perforate
what causes a closed loop obstruction?
- a twist in the bowel (volvulus)
- a competent ileocaecal valve
what are the clinical features of bowel obstruction?
- abdominal pain and distension
- vomiting (initially gastric, then bilious, then faeculent)
- inability to pass flatus and constipation
true or false: large bowel obstructions present with vomiting first
false.
large bowel obstructions present initially with complete constipation as the obstruction is more distal and will take longer to affect the small bowel
what is heard on auscultation in a patient with a bowel obstruction?
tinkling bowel sounds
what are the differential diagnoses for a patient with suspected bowel obstruction?
- paralytic ileus
- toxic megacolon
- constipation
what laboratory tests should be done in a patient with suspected bowel obstruction?
FBC CRP U&Es - patient may be hypokalaemic G&S and X-match VBG to assess signs of ischaemia (raised lactate) and metabolic status
what imaging should be done in a patient with suspected bowel obstruction?
CT abdomen with contrast is first line as is more sensitive for obstruction and can help identify the kind of obstruction
Abdo xray
what will an abdominal xray show in small bowel obstruction?
- dilated bowel >3cm
- central abdominal location
what will an abdominal xray show in large bowel obstruction?
- dilated bowel >6cm
- peripherally located
- visible haustra lines
how would you conservatively manage a patient with bowel obstruction?
all patients need fluid resuscitation and fluid monitoring (catheter insertion)
patient will be NBM with a NG tube inserted
give pain relief
when would you use surgical management in a patient with bowel obstruction?
if the bowel has become ischaemic or strangulated
if it is a closed loop obstruction
if patient fails to improve with 48hours despite conservative treatment
what surgical interventions tend to occur?
tends to be a laparotomy with a resection of the bowel or a stoma being necessary
what are the complications the can occur due to a bowel obstruction?
- bowel ischaemia
- bowel perforation causing faecal peritonitis
- dehydration and renal damage
what is a gastric perforation?
a break in the GI tract anywhere from the oesophagus to the anorectal junction
what does a GI perforation have to potential to cause?
peritonitis which can lead to spesis and death
what are the chemical causes of GI perforation?
- peptic ulcer disease
- foreign body
what are the infectious causes of GI perforation?
- appendicitis
- diverticulitis
- cholecystitis
- meckel’s diverticulum
what are the ischaemic causes of GI perforation?
- mesenteric ischaemia
- obstructive lesions that can lead to bowel distension and ischaemia
what are the colitis causes of GI perforation?
- fistular formation (e.g. from Crohn’s)
- toxic megacolon (e.g. c. diff or UC)
what are the traumatic causes of GI perforation?
- recent surgery anastomotic leak
- endoscopy or NG tube damage
- excessive vomiting leading to oesophageal perforation
what are the clinical features of an intra-peritoneal GI perforation?
- abdominal pain worse on movement
- distended abdomen
what are the clinical features of a retro-peritoneal GI perforation?
- shoulder tip pain
- back pain
what are the common differential diagnoses considered in a patient with suspected GI perforation?
- pancreatitis
- MI
- ruptured AAA
what laboratory tests would you do if you suspected a patient had a bowel perforation?
- FBC
- U&Es
- LFTs
- CRP
- G&S + X-match
- urinalysis: to rule out urogenital pathology
what imaging would you do in a patient with suspected bowel perforation and why?
- plain erect CXR would show pneumoperitoneum
- CT scan with a contrast swallow to show the location of the perforation
how would you initially manage a patient with a suspected bowel perforation?
- resuscitation as needed
- broad spectrum IB antibiotics
- NBM with nasogastric tube
- IV fluid and analgesia
what conservative management can be done in a patient with an oesophageal perforation?
treated with an endoscopically placed stent
what conservative treatment can be done for a patient with a peptic ulcer perforation?
may heal on its own with bowel rest and PPI therapy
what conservative management can be done in a patient with a diverticular abscess perforation?
if the perforation is <5cm they can be treated with a guided percutaneous drainage
when is conservative management indicated in a patient with a bowel perforation?
if the patient is systemically ‘well’:
- no signs of peritonitis or sepsis
- CT scan shows the leak is contained
when would a patient need surgical intervention in a bowel perforation?
if the patient is systemically unwell or have failed to be treated conservatively
what kind of surgical management would occur in a patient with bowel perforation?
- surgical washout
- management of underlying cause (e.g. remove obstruction)
- primary repair of perforation OR resection of diseased area with anastomoses or stoma formation
when would a stoma be formed in a GI perforation surgery?
can be done in a small bowel perforation
usually done in a large bowel perforation
what are the complications of a GI perforation?
peritonitis
sepsis
haemorrhage
true or false: anastomoses are the most important part of surgical management of GI perforation
false.
the intraoperative washout is vital to reduce bacterial load - giving post-operative antibiotics is also key
what is melena?
black tarry stools with a foul smell
what is the most common cause of melena?
an upper GI bleed
what pathologies can lead to an upper GI bleed?
- peptic ulcer disease
- liver disease (causing oesophageal varies)
- gastric cancer
when should you suspect peptic ulcer disease as the cause of melena?
if the patient has one of the following:
- known peptic ulcer disease
- history of NSAID/ steroid use
- history that indicates epigastric ulceration
- H. Pylori positive
what is the important vessel to be aware of when you suspect a patient with melena has had a peptic ulceration?
gastroduodenal artery
what is the most common cause for oesophageal varices?
alcoholic liver disease
how do oesophageal varices form?
dilatations of the porto-systemic anastomoses in the oesophagus that can rupture due to portal hypertension secondary to liver cirrhosis
what are common associated symptoms present with melena?
haematemesis, abdominal pain, history of dyspepsia, dysphasia, odynophagia
what investigations would you do in a patient with melena?
Bloods: FBC - drop in Hb LFTs - to show any liver damage U&Es - rise urea:creatinine + low Hb can indicate an upper GI bleed G&S and X-match
ABG: can show signs of hypoperfusion e.g. lactate
why does a rise in urea:creatinine and a low Hb indicate an upper GI bleed?
digested haemoglobin produces urea as a by-product
this is absorbed by the intestine and will show in blood tests indicating blood in the digestive tract
what imaging would you do for a patient with melena?
- OGD is definitive and can form a part of the long-term management
- CT abdomen to assess active bleeding
how would you manage a patient with melena?
- A-E approach to stabilise
- OGD can be used to manage if:
- peptic ulcer disease: cauterisation of the bleeding + PPI therapy
- varices: endoscopic banding to stop the bleeding
- malignancy: will need biopsies to further plan long term treatment
what is the difference between melena and haematochezia?
melena is the passing of digested blood in the stool, haematochezia is the passing of fresh blood in the stool
what causes fresh rectal bleeding?
bleeding from the lower GI tract:
- diverticular disease
- angiodysplasia
- haemorrhoids
- malignancy
true or false: a patient with an large fresh rectal bleed who is haemodynamically unstable has an upper GI bleed until proven otherwise
true.
it can come from an actively bleeding stomach ulcer
what is the most common cause of lower GI bleeding?
diverticular disease
how do diverticular bleeds tend to present?
they tend to be painless
what is angiodyplasia?
small arterio-venous malformations in the colonic wall
what are haemorrhoids?
pathologically engorged vascular cushions in the anal canal
how does haemorrhoid bleeding tend to present?
as a mass with pruritis, or fresh red rectal bleeding
blood tends to be on the tissue rather than mixed in with stool
how does a haemorrhoid present if it is thrombosed?
it is highly painful for the patient
what investigations would you do in a patient with a PR bleed?
- routine bloods (FBC, U&Es, LFTs)
- clotting screen
- G&S
- stool cultures
what imaging investigation would you do in a patient with a PR bleed?
- flexible sigmoidoscopy or a full colonoscopy if results are inconclusive
- CT angiogram can be used to identify the bleeding vessel and for therapeutic embolisation if needed
how would you initially manage a patient with a PR bleed?
- ABCDE approach with two large bore cannula, IV fluid, and blood products if needed
- patients with unstable or ongoing bleeding need resus, an urgent endoscopy +/- CT angiogram
true or false: most patients need surgical intervention in a PR bleed
false.
95% of PR bleeds settle spontaneously and stable patients with a normal Hb are investigated as outpatients
what is jaundice?
yellow discolouration of the sclera and the skin due to high bilirubin levels (>50)
where does bilirubin come from?
it is a normal breakdown product from RBCs
how is bilirubin normally excreted?
it is conjugated by the liver to become water soluble and then excreted via bile into the GI tract - most is excreted via faeces whereas some is reabsorbed into the bloodstream and excreted by the kidneys
what are the three types of jaundice?
pre-hepatic
intra-hepatic
post-hepatic
what is pre-hepatic jaundice?
excessive breakdown of RBCs leading to excess bilirubin that the liver cannot all conjugate, leaving unconjugated bilirubin in the bloodstream
what is intra-hepatic jaundice?
liver dysfunction making it unable to conjugate bilirubin or cirrhosis leading to compression of the biliary tree causing obstruction
true or false: in intra-hepatic jaundice, only conjugated bilirubin is present in the blood
false.
there is both conjugated and unconjugated bilirubin - giving a ‘mixed picture’
what is post-hepatic jaundice?
an obstruction of the biliary drainage, leading to excess conjugated bilirubin in the blood
what are the causes of pre-hepatic jaundice?
haemolytic anaemia
what are the causes of intra-hepatic jaundice?
alcoholic liver disease viral hepatitis hereditary haemochromatosis medication hepatocellular carcinoma
what are the causes of post-hepatic jaundice?
gall stones
strictures
pancreatic cancers
abdominal masses
true or false: conjugated bilirubin can be excreted by urine and gives it a darker colour
true
what blood would you take in a patient with jaundice?
FBC (anaemia, raised MCV seen in liver disease)
U&Es (establish baseline)
LFTs (checking for signs of liver disease)
Coagulation screen (check liver function)
what are the significance of LFT tests in a patient with jaundice?
bilirubin - the severity of jaundice
albumin - assess liver synthesis function
AST and ALT - markers of hepatocellular injury
ALP - raised in biliary obstruction
GGT - specific for biliary obstruction
what imaging would you do in a patient with jaundice?
USS abdomen is first line to identify any obstructive or obvious liver pathology
MRCP can be done if USS was inconclusive and if jaundice was obstructive
what are the complications of jaundice?
may be indicative of liver failure so monitor coagulation and check for low blood sugar
