Group Teaching - Surgical management of the gastrointestinal tract

Question 1

Case 1

An 84 yr ♂ retired labourer
Living in a retirement home
Presents to A&E

PC
* 3/7 history of severe generalised abdominal pain.
* Grossly swollen abdomen.
* Not had his bowels open since the start of this episode.
* Not been able to pass flatus.
* Felt nauseated & anorexic - not vomited.
* Previously normal daily bowel motions - no blood or slime.
* Weight steady.

PMHx
* Arthritis of both hips
* Mild prostatic symptoms

DHx
* No medications of note

SHx
* Ex-smoker

General Examination
* Temp 372°C, pulse 98, blood pressure 170/90.
* In obvious pain, dehydrated, with a dry tongue.

Abdominal examination
* Abdomen was grossly distended & uniformly tender.
* No scars of previous surgery & hernial orifices were clear.
* No masses could be felt in the abdomen.
* No clinical evidence of free fluid.

Rectal examination
* Empty rectum with smooth enlargement of prostate.

Which would be more likely in this case, obstruction of the small or large bowel?

Answer 1

Large bowel

Question 2

Case 1

An 84 yr ♂ retired labourer
Living in a retirement home
Presents to A&E

PC
* 3/7 history of severe generalised abdominal pain.
* Grossly swollen abdomen.
* Not had his bowels open since the start of this episode.
* Not been able to pass flatus.
* Felt nauseated & anorexic - not vomited.
* Previously normal daily bowel motions - no blood or slime.
* Weight steady.

PMHx
* Arthritis of both hips
* Mild prostatic symptoms

DHx
* No medications of note

SHx
* Ex-smoker

General Examination
* Temp 372°C, pulse 98, blood pressure 170/90.
* In obvious pain, dehydrated, with a dry tongue.

Abdominal examination
* Abdomen was grossly distended & uniformly tender.
* No scars of previous surgery & hernial orifices were clear.
* No masses could be felt in the abdomen.
* No clinical evidence of free fluid.

Rectal examination
* Empty rectum with smooth enlargement of prostate.

Initial management:
* Patient given morphine for his pain.
* Had a nasogastric tube (NGT) passed → aspirated 300 ml of green fluid.
* An intravenous (IV) line inserted & started on IV fluids

What does the ABX demonstrate & what is the likely diagnosis?

Answer 2

• Enormously distended oval gas shadow, looped on itself to give typical ‘bent inner-tube sign’ OR ‘coffee bean sign’
• Haustrae don’t extend across the width of the gas shadow, suggesting this is large intestine

Appearances are typical of volvulus of the sigmoid colon

Question 3

Case 1

An 84 yr ♂ retired labourer
Living in a retirement home
Presents to A&E

PC
* 3/7 history of severe generalised abdominal pain.
* Grossly swollen abdomen.
* Not had his bowels open since the start of this episode.
* Not been able to pass flatus.
* Felt nauseated & anorexic - not vomited.
* Previously normal daily bowel motions - no blood or slime.
* Weight steady.

PMHx
* Arthritis of both hips
* Mild prostatic symptoms

DHx
* No medications of note

SHx
* Ex-smoker

General Examination
* Temp 372°C, pulse 98, blood pressure 170/90.
* In obvious pain, dehydrated, with a dry tongue.

Abdominal examination
* Abdomen was grossly distended & uniformly tender.
* No scars of previous surgery & hernial orifices were clear.
* No masses could be felt in the abdomen.
* No clinical evidence of free fluid.

Rectal examination
* Empty rectum with smooth enlargement of prostate.

Initial management:
* Patient given morphine for his pain.
* Had a nasogastric tube (NGT) passed → aspirated 300 ml of green fluid.
* An intravenous (IV) line inserted & started on IV fluids

What conservative management is effective in treating the majority of patients with a sigmoid volvulus?

Answer 3

• A sigmoidoscope is passed with the patient lying in the left lateral position.
• A large well lubricated, soft rubber rectal tube is passed along the sigmoidoscope.
• This usually untwists the volvulus, with release of vast quantities of flatus & liquid faeces.

Question 4

Case 1

An 84 yr ♂ retired labourer
Living in a retirement home
Presents to A&E

PC
* 3/7 history of severe generalised abdominal pain.
* Grossly swollen abdomen.
* Not had his bowels open since the start of this episode.
* Not been able to pass flatus.
* Felt nauseated & anorexic - not vomited.
* Previously normal daily bowel motions - no blood or slime.
* Weight steady.

PMHx
* Arthritis of both hips
* Mild prostatic symptoms

DHx
* No medications of note

SHx
* Ex-smoker

General Examination
* Temp 372°C, pulse 98, blood pressure 170/90.
* In obvious pain, dehydrated, with a dry tongue.

Abdominal examination
* Abdomen was grossly distended & uniformly tender.
* No scars of previous surgery & hernial orifices were clear.
* No masses could be felt in the abdomen.
* No clinical evidence of free fluid.

Rectal examination
* Empty rectum with smooth enlargement of prostate.

Initial management:
* Patient given morphine for his pain.
* Had a nasogastric tube (NGT) passed → aspirated 300 ml of green fluid.
* An intravenous (IV) line inserted & started on IV fluids

Further management: A flatus tube was tried in this patient, but was unsuccessful

What is the risk of leaving this untreated?

Answer 4

• Left untreated, the loop of sigmoid, with its blood supply cut off by the torsion, would undergo necrosis

Question 5

Case 1

An 84 yr ♂ retired labourer
Living in a retirement home
Presents to A&E

PC
* 3/7 history of severe generalised abdominal pain.
* Grossly swollen abdomen.
* Not had his bowels open since the start of this episode.
* Not been able to pass flatus.
* Felt nauseated & anorexic - not vomited.
* Previously normal daily bowel motions - no blood or slime.
* Weight steady.

PMHx
* Arthritis of both hips
* Mild prostatic symptoms

DHx
* No medications of note

SHx
* Ex-smoker

General Examination
* Temp 372°C, pulse 98, blood pressure 170/90.
* In obvious pain, dehydrated, with a dry tongue.

Abdominal examination
* Abdomen was grossly distended & uniformly tender.
* No scars of previous surgery & hernial orifices were clear.
* No masses could be felt in the abdomen.
* No clinical evidence of free fluid.

Rectal examination
* Empty rectum with smooth enlargement of prostate.

Initial management:
* Patient given morphine for his pain.
* Had a nasogastric tube (NGT) passed → aspirated 300 ml of green fluid.
* An intravenous (IV) line inserted & started on IV fluids

Further management: A flatus tube was tried in this patient, but was unsuccessful

What is the next step in managing this patient?

Answer 5

• Exploratory Laparotomy & Sigmoid Colectomy with end colostomy (Hartmann’s Procedure)

Question 6

Case 2

An 84 yr ♂ presented to A&E complaining of 1/7 Hx of:
Abdominal pain
Nausea
Breathlessness

PMHx
* Chronic obstructive pulmonary disease.

SHx
* Ex-smoker, stopped 3 years ago.

O/E
* Looks pale and sweaty
* HR 90, BP 100/60, Temp 372°C, SpO2 95% (on air)
* Abdominal distension & periumbilical guarding
* Hernial orifices were clear
* No abdominal scars
* Bowel sounds were absent
* Rectum empty on digital examination

Clinical scenario is suspicious for acute mesenteric ischemia (AMI).
Why?

Answer 6

• Elderly patient who is an ex-smoker – increased risk of cardiovascular disease
• Short history
• Central pain with guarding
• No previous abdominal scar or hernia
• No bowel sounds
• Poor general condition
• Increased serum lactate

Question 7

Case 2

An 84 yr ♂ presented to A&E complaining of 1/7 Hx of:
Abdominal pain
Nausea
Breathlessness

PMHx
* Chronic obstructive pulmonary disease.

SHx
* Ex-smoker, stopped 3 years ago.

O/E
* Looks pale and sweaty
* HR 90, BP 100/60, Temp 372°C, SpO2 95% (on air)
* Abdominal distension & periumbilical guarding
* Hernial orifices were clear
* No abdominal scars
* Bowel sounds were absent
* Rectum empty on digital examination

What investigation would you order next & why?

Answer 7

What Ix?
* Computed Tomography (CT) - abdomen and pelvis with contrast

Why?
* May demonstrate thrombus in the mesenteric arteries & veins.
* Abnormal enhancement of bowel wall.
* Presence of embolus or infarction of other organs.

Question 8

Case 2

An 84 yr ♂ presented to A&E complaining of 1/7 Hx of:
Abdominal pain
Nausea
Breathlessness

PMHx
* Chronic obstructive pulmonary disease.

SHx
* Ex-smoker, stopped 3 years ago.

O/E
* Looks pale and sweaty
* HR 90, BP 100/60, Temp 372°C, SpO2 95% (on air)
* Abdominal distension & periumbilical guarding
* Hernial orifices were clear
* No abdominal scars
* Bowel sounds were absent
* Rectum empty on digital examination

How would you manage this patient?

Answer 8

Emergency exploratory laparotomy
Goals of surgery:
* Restoration of SMA blood flow
* Resection of nonviable bowel

Exploratory Laparotomy
* Midline incision.
* Evaluate the abdominal viscera
* If obvious intestinal necrosis – resection of the affected bowel loops.

Damage control laparotomy:
* Stapled off bowel ends may be left in discontinuity
* Re-inspect after a period of continued ICU resuscitation to restore physiological balance.

Restoration of blood flow in SMA by:
* Embolectomy of SMA – in embolic AMI
* Endovascular management of SMA thrombus – in thrombotic AMI
* Arterial bypass of SMA - in thrombotic AMI