GI4 Flashcards
Acute abdo
What is appendicitis?
Inflammation of the appendix
What is the typical presentation of appendicitis?
Umbilical pain which moves to the RIF
Acute onset
4-40 yrs old
what is the aetiology of appendicitis?
Gut organisms invade the appendix after luminal obstruction
Leads to oedema, ischaemic necrosis, and perforation
What are the signs of appendicitis?
Epigastric pain (early) RIF pain (late) Peritonitis Rovsing's sign Cope's psoas sign Cope's obturator sign Rebound tenderness
What are the signs of peritonitis?
Keeps very still
Abdo pain upon movement
Rigid abdomen
What is Rovsing’s sign?
Pain in RIF upon palpation of LIF
What is Cope’s psoas sign?
Pain upon extending the hip
seen only in retroperitoneal appendices
What is Cope’s obturator sign?
Pain on passive flexion and internal rotation of the hip
What are the investigations for appendicitis?
Bloods- raised WCC, CRP
USS
CT
What is the scoring system for appendicitis?
Alvarado score
What is the management for appendicitis?
Appendectomy
Metronidazole and cefuroxime prophylactic ABx
What are the complications of appendicitis?
Perforation
Appendix mass
Appendix abscess
What is diverticular disease?
Diverticulosis associated with complications
What is diverticulosis?
Presence of diverticulae outpuchings of the colonic mucosa and submocusa
What is diverticulitis?
Acute inflammation and infection of a diverticulae
What is the classification of diverticular disease?
Hinchey classification Ia: phlegmon Ib/II: localised abscess III: perforation with purulent peritonitis IV: faecal peritonitis
What are the symptoms of diverticular disease?
Bloody stool
LIF pain
Fever
Urinary symptoms- if there is a bladder fistula
What are the signs of diverticular disease?
LIF pain
Risk of peritonism
What are the investigations for diverticular disease?
Bloods- FBc, clotting, G+S Barium enema (if chronic presentation) flexisig +/- colonoscopy CT (if acute) Erect CXR- assess for pneumoperitoneum
What is the treatment for an acute presentation of diverticular disease?
IV hydration Bowel rest Surgery (if recurent attack/complications) -Hartmann's -Primary anastamosis
What is the treatment for a chronic presentation of diverticular disease?
Soluble high-fibre diet Anti-inflammatories eg. mesalazine Surgery (if recurent attack/complications) -Hartmann's -Primary anastamosis
What is Hartmann’s procedure?
Resection of the diseased bowel and an end-colostomy formation, with an anorectal stump.
This is used when primary anastamoses are not possible (eg. inflammation)
What is a primary anastamosis?
Resection of the diseased bowel and joining up the two resected ends
What are the complications of diverticular disease?
Diverticulitis Faecal peritonitis Fistulas Peri-colic abscess Colonic obstruction Perforation
What is the definition of a hernia?
Displacement of part of an organ protruding through the wall of a cavity containing it
What are the symptoms of a hernia?
Groin lump
Groin pain
Vomiting
Scrotal swelling
What is a strangulated hernia?
An ischaemic hernia due to a constriction around the vasculature
Which patients tend to have femoral hernias?
Females
Older
Which patients tend to have inguinal hernias?
Males
Younger
Which hernia is more often strangulated, hence requiring surgery?
Femoral hernias
What are the signs of a hernia?
Appears on coughing
Reducible via supination/pressure
Tender, red, colicky, abdo pain, distension, vomiting if strangulated
What are the borders of Hesselbach’s triangle?
Inferior epigastric vessels
Inguinal ligament
Lateral border of rectus abdominis
What are the differences between direct and indirect inguinal hernias?
Direct:
-medial to the IE vessels
-enters through a weak point of Hesselbach’s triangle
Indirect:
-lateral to the IE vessels
-passes through the inguinal canal due to a failure of embryonic closure of the processus vaginalis
How can you clinical differentiate between a direct and indirect inguinal hernia?
Reduce the hernia
Place a finger over the deep inguinal ring
Ask the Pt to cough
The hernia won’t reappear if it’s indirect
What are the investigations for a hernia?
Mostly a clinical diagnosis
Can do USS
What is the management for a femoral hernia?
Surgical repair
What is the management for an inguinal hernia?
Reassurance
Elective surgery
What is pancreatitis?
Inflammation of the pancreas, can be both acute or chronic
What are the symptoms of acute pancreatitis?
Epigastric pain
Radiating to the back
Relieved on sitting forwards
Pain worst on movement
What are the causes of acute pancreatitis?
GET SMASHED
Gallstones Ethanol Trauma Steroids Mumps/Malignancy Autoimmune Scorpion venom Hyperlipidaemia/calcaemia/parathyroidism ERCP Drugs eg. thiazides
What are the signs of acute pancreatitis?
Epigastric tenderness Fever Shock Tachycardia/pnoea Reduced bowel sounds Cullen's sign Grey-Turner's sign Fox's sign
What is Cullen’s sign?
Umbilical bruising
What is Grey-Turner’s sign?
Flank bruising
What is Fox’s sign?
Bruising over the inguinal ligament
What are the investigations for acute pancreatitis?
Bloods- amylase, FBC, X-match
USS- ?gallstones
Erect CXR/AXR- ?pleural effusion
CT- exclude other causes
What is the scoring system for pancreatitis?
PANCREAS Modified Glasgow Score
What does PANCREAS stand for in the Modified Glasgow Score and what is the minimum score for a severe rating?
PaO2: <7.9kPa Age: >55 Neutrophils: >15x10^9/L Calcium: <2mmol/L Renal function: >16mmol/L Enzymes: LDH >600U/L; AST >200U/L Albumin: <32g/L Sugar: >10mmol
Severe: >3
What is the treatment for acute pancreatitis?
Fluid balance Catheter and NG tube Analgesia, glucose control ERCP for gallstones Catheter drain/necrosectomy
What are the symptoms of chronic pancreatitis?
Recurrent epigastric pain
Relieved on sitting forwards
Pain worst on movement
WL, bloating, steatorrhoea
What are the signs of chronic pancreatitis?
Epigastric tenderness Cullen's sign Grey-Turner's sign Fox's sign Signs of complications
What are the investigations for chronic pancreatitis?
Bloods- amylase (normal), FBC, X-match
Faeces- faecal elastase (raised)
AXR- pancreatic calcification
MCRP/ECRP- duct dilation/strictures
What is the treatment for chronic pancreatitis?
Fluid balance Catheter and NG tube Analgesia, glucose control ERCP for gallstones Catheter drain/necrosectomy
What are the complications for chronic pancreatitis?
Pseudocysts
Duodenal obstruction
Pancreatic ascites
What are the symptoms of intestinal obstruction?
Diffuse pain
Constipation
Vomiting
Abdominal distension
What are the risks for intestinal obstruction?
Hernia Hx
Malignancy Hx
Surgery Hx- adhesions
What are the signs for intestinal obstruction?
Abdominal distension
Pyrexia/sweating (potential perforation/infarction)
High pitched, tinkling bowel sounds
OR absent bowel sounds
What are the investigations for an intestinal obstruction?
Bloods- FBc, U+E, X-match
Plain AXR and CT- ?volvulus, ?malignancy
what is the rule for normal bowel sizes?
3, 6, 9
3cm- small bowel
6cm- large bowel
9cm- caecum
What is the management for an intestinal obstruction?
Drip and suck (IV drip and NG tube)
Conservative if volvulus decompresses
Laparotomy, esp if peritonitic
What is intestinal ischaemia?
Impaired bloodflow to the intestine, resulting in ischaemia of the bowel wall
What are the symptoms of acute intestinal ischaemia?
Sudden onset diffuse pain
What are the risk factors of acute intestinal ischaemia?
Old age Cardiovascular disease AF Hypotensive state -eg. car accidents
What are the signs of acute intestinal ischaemia?
Can be normal
Diffuse abdo pain
Shock signs
What are the investigations for acute intestinal ischaemia?
AXR- perforation, megacolon, Rigler sign
Angiography- show blockages
ECG- look for MI/AF
What are the symptoms of chronic intestinal ischaemia?
Intermittent gut claudication
Post-prandial pain
PR bleed
WL
What are the risk factors of chronic intestinal ischaemia?
Old age
Cardiovascular disease
Heart failure Hx
What are the signs of acute intestinal ischaemia?
Can be normal
PR bleed on DRE
What are the investigations for chronic intestinal ischaemia?
AXR
Angiography
ECG
A nervous 16-year-old college student attends the local A&E department with her boyfriend, complaining of an episode of sudden onset right-sided pain in her abdomen. Physical examination of the patient is unremarkable except from a small scar located near the inguinal ligament. What is the most appropriate first line investigation in this case?
A. USS of the abdomen B. 𝞫-hCG test C. Full blood count D. CT scan of the abdomen E. No investigations, immediate surgery
B. 𝞫-hCG test
Scar indicates likely appendectomy Hx
Risk of pregnancy
A 26-year-old professional rugby player presents to the A&E department with abdominal pain in the umbilical area. On initial inspection, the gentleman is feverish with a temperature of 38C and a BP of 115/90. The admitting doctor suspects a diagnosis of appendicitis from the history and performs an abdominal physical examination and passively extends the gentleman’s right hip which elicits pain. Which eponymous sign of appendicitis is being demonstrated here and what does it represent?
A. Cope’s sign, and a retrocaecal appendix
B. Psoas sign, and a retrocaecal appendix
C. Psoas sign, and an appendix located next to obturator externus
D. Rovsing’s sign, and a retrocaecal appendix
E. Rovsing’s sign, and an appendix located next to obturator externus
B. Psoas sign, and a retrocaecal appendix
A feverish 56-year-old woman attends her GP complaining of a sudden appearance of bloody stools. She adds that she has experienced a few episodes of bloody stools before but did not seek medical attention and apart from a fever, she has had no other constitutional symptoms. The GP notes that the patient’s diet is particularly low in fibre and on physical examination, tenderness is found on pressure to the LIF. A DRE shows fresh blood upon removal of a gloved finger. What is the most likely diagnosis?
A. Angiodysplasia B. Diverticulosis C. Diverticulitis D. Mallory-Weiss tear E. Gastroenteritis
C. Diverticulitis
A feverish 65-year-old is brought to the local A&E department by her daughter. She complains about nausea, LIF pain and vomiting. The attending doctor takes a full history and performs an abdominal examination and subsequently makes a diagnosis of acute diverticulitis with some associated signs of peritonism. A erect AXR is taken which shows some air under the diaphragm. What is the most appropriate surgical procedure?
A. Hartmann’s procedure B. Primary anastomosis C. Colectomy and end-ileostomy formation D. Delorme’s procedure E. Whipple’s procedure
A. Hartmann’s procedure
A 26-year-old bodybuilder attends the local day-surgical clinic upon referral from his GP due to a groin lump. The general surgical registrar suspects a hernia and so performs a simple test to ascertain the type of hernia to determine the most appropriate management. The doctor reduces the hernia and then places their finger over the deep inguinal ring. The patient is asked to cough and the hernia does not reappear. What is the most likely type of hernia?
A. Femoral hernia B. Direct inguinal hernia C. Indirect inguinal hernia D. Spigelian hernia E. Hiatus hernia
C. Indirect inguinal hernia
Which of the following may be raised in chronic pancreatitis?
A. Amylase B. Calcium C. Faecal elastase D. Albumin E. Haematocrit
C. Faecal elastase
Which of the following is not a cause of acute pancreatitis?
A. Mumps B. Hypocalcaemia C. Thiazide drugs D. Trinidad scorpion bite E. Steroids
B. Hypocalcaemia
An overweight 65-year-old woman visits her general practitioner with discomfort in her right groin. On examination, the suggestion of a reducible groin lump is noted. She is routinely referred to the surgical outpatient clinic with a possible diagnosis of inguinal hernia. However, two weeks later and before her surgical appointment, she again visits her general practitioner, this time with vomiting, diarrhoea, and colicky abdominal pain. What is the next most appropriate management step?
A. Administer antibiotics B. Give IV fluids C. Insert an NG tube D. Give IV fluids and insert an NG tube E. Administer an enema
D. Give IV fluids and insert an NG tube
A 70-year-old gentleman presents to the A&E department with sudden-onset severe diffuse abdominal pain. Observations are taken in the ambulance which show an irregularly irregular pulse rate of 130 and a blood pressure of 76/60mmHg. An abdominal X-ray is performed as soon as possible which shows the Rigler sign and the physician diagnoses an acute form of mesenteric ischaemia with perforation. What is the most likely cause for the acute onset of the mesenteric ischaemia?
A. Atherosclerotic disease B. Embolism C. Thrombosis D. Polycythaemia vera E. Idiopathic
B. Embolism
