HPIP Flashcards
Markers of BO
D lactate
CK
BB isoenzymes (ALP raised in damaged mucosa - COELIAC, IBD, infarction)
Intestinal FA binding protein (in cystolic cells of GI mucosa)
AXR finding SBO (supine)
Staircased air and fluid filled bowel + No air in colon
CT sensitivity and specificity SBO + closed loop
95 sen , 96 spec SBO
60 CLO
what study SBO in preg
USS
Study for ischemia
Findings ischemia
Findings necrosis
CT oral and IV contrast
Altered bowel enhancement
Mesenteric venous gas, pneumoperiotneum, pneumatosis
Ileus treatment
1) ng , ivf, rx underlying
2) peripherally active μ opioid receptor antagonists (alvimopan, methyl naltrexone)
Ogilvies disease Rx
Neostigmine - req cardiac monitoring w atropine available
Defecation and flatus within 10 mins
Sympathetic blockade in 10 min via epidural anaesthesia can help as well
Causes of appendicitis
Faecoliths (hardened stools)
Incompletely digested foods
Lymphoid hyperplasia (post viral/bacteria)
Intraluminal scarring
Bacteria
Viruses
Tumours
Why is perforation at base of appendix different
Because appendical obstruction will lead to bacterial overgrowth and luminal obstruction and increase Intraluminal pressure then inhibit flow of lymph and blood and then vascular thrombosis and ischemic necrosis with perforation of distal appendix
If base of appendix perforation think another disease process e.g IBD
Perforation of appendicitis sfx (3)
Severe peritonitis
Abscess (leak contained by momentum)
Infective suppurative thrombosis of the portal vein
1. Local infection → 2. Bacterial spread to mesenteric veins → 3. Thrombus formation in portal vein → 4. Thrombus becomes infected → 5. Risk of septic emboli to the liver (→ hepatic abscesses)
Dif between N&V in appendicitis and gastroenteritis
N&V precedes pain GE
N&V post pain Appendicitis
Most common symptoms appendicitis
abdo pain (95%)
Anorexa (70%)
Nausea (>65%)
Vomiting (50-60%)
Migration pain to RIF (50-60%)
Constipation (4-16%)
Diarrhea (4-16%)
Fever (10-20%)
Regional anatomic variations
Retrocaecal (64%)
Pelvic (32%)
Sub caecal (2%) (b/w pelvic and retrocaecal)
Pre Ileal (1%) - behind ileum
Post-ileal (0.5%) - in front ileum
Why is pain non specific initially appendicitis / central than localized
Visceral perioteneum has non specific sensory receptor feedback , as transmural inflammation/appendicitis progresses and starts irritatating the parietal peritoneum which has specific sensory innervation it will go to RIF
Parietal peritoneal irritation associated with muscle rigidity and stiffness
Inflamed appendix below pelvic brim or behind caecum
Less tenderness of anterior wall
Pelvic appendicitis patients are..
More likely to have suprapubic pain, dysuria, urinary freq, diarrhea, tenesmus
Why do children’s appendicitis worsen more rapidly?
Smaller/thinner omentum- less risk of intrabadominal spread, less likely to wall off spread
In elderly patients symptoms of appendicitis
Less pronounced
Nausea anorexia emesis
Bowel obstruction can happen secondary to appendicitis? Why
Can be due to appendiceal inflammation and phlegmon or abscess formation
Labs in appendicitis
Mild leukocytosis
Amylase, lipase
Left shift of Polymorphonuclear cells
If appendix touches bladder or ureter - sterile pyuria, haematuria on dipstick
Female pregnancy test
Patients at risk of nutrient deficiencies
Chronically ill
Alcoholic / drug abuse
Poverty
Post variation surgeries
Refugees and camp populations
Hidden hunger
Subclinical vitamin deficiencies in normal population (esp geriatric and poor due to lack of nutrient dense foods)
Iron absorption affected by
Calcium , lead (large amounts)
Ascorbic acid, amino acids (large amounts)
Radiology principles appendicitis
AXR caveat
USS sens, spec
Findings
C
Faecolith on AXR not diagnostic but can be associated with it
USS - 0.86 sensitivity, 0.81 specificity
Findings: wall thickening, increased appendiceal diameter, presence of free fluid
CT- 0.94 sens, 0.96 spec
Dilatation > 6 mm with wall thickening, a lumen that does not fill with enteric contrast, fatty tissue stranding or air surrounding which inflammation
Pregnancy appendicitis
Uterus may push appendix up to RUQ
USE USS
IC patients
mild tenderness
Enterocolitis due to abdo pain, fever and neutropenic chemo is a concern
Obturator sign + (int rotation hip)
Iliopsoas sign + (extending R Hip)
Pelvic appendicitis
retrocaecal appendicitis
