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🕺🏽gen surg > Large Bowel🥳 > Flashcards

Large Bowel🥳 Flashcards

1
Q

APPENDICITIS pathophysiology?

A
  • normally direct luminal obstruction (by what?). also by lymphoid hyperplasia, impacted stool or rarely appendiceal/caecal tumour
  • now commensal bacteria multiply leading to acute inflammation
  • also reduced venous drainage
  • both lead to inc pressure in appendix -> ischaemia
  • untreated? necrosis … perforation
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2
Q

APPENDICITIS risk factors?

A
  • FHx : ?% risk?
  • ethnicity : more common in? greater risk of perf in?
  • environmental: during what season is common?
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3
Q

APPENDICITIS clinical features?

A
  • abdo pain. peri umbilical (dull & poorly localised - why?) —> RIF (sharp & well localised - why?)
  • vomiting (before or after pain?)
  • anorexia
  • nausea
  • diarrhoea/constipation
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4
Q

APPENDICITIS on examination?

A
  • rebound tenderness & percussion pain & guarding over McBurney’s point (where is this?)
  • severe? sepsis signs eg ?
  • *appendiceal abscess may also present w RIF mass
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5
Q

APPENDICITIS specific signs on examination?

A
  • rovsings sign - RIF pain on palpation of ?

- psoas sign - RIF pain with extension of right ? (suggests retrocaecal appendix)

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6
Q

APPENDICITIS differential diagnoses?

A
  • gynae: ovarian cyst rupture, ectopic, PID
  • renal: ureteric stones, UTI, pyelonephritis
  • GI: IBD, meckel’s diverticulum, diverticula disease
  • urological: testicular torsion, epididymo-orchitis
  • **specifically in children? gastroenteritis, constipation, intussusception or UTI
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7
Q

APPENDICITIS lab tests?

A
  • urinalysis- why? when can leukocytes be present in the urine still?
  • preg test
  • bloods - fbc, crp
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8
Q

APPENDICITIS imaging?

A

clinical diagnosis is normally sufficient.
if clinical features inconclusive:
- USS - first line (especially transvaginal if other gynae pathology differentials). why is it good in kids?
- CT

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9
Q

APPENDICITIS management?

A
  • definitive treatment : laparoscopic appendicectomy

- maybe conservative antibiotic therapy in uncomplicated appendicitis

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10
Q

APPENDICITIS complications?

A
  • perf -> peritonitis
  • surgical site infection
  • appendix mass - what is this?
  • pelvic abscess - presents as palpable RIF mass, confirmed w CT, management?
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11
Q

DIVERTICULAR DISEASE information

A 
- diverticulum = outpouching through bowel wall. common in sigmoid 
4 manifestations of this condition:
- diverticulosis - ?
- diverticular disease - ?
- diverticulitis- ?
- diverticular bleed - ?
- M>F, developed countries
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12
Q

DIVERTICULAR DISEASE pathophysiology

A

aging bowel has become weakened over time -> stool inc luminal pressure -> results in outpouching of the mucosa through the weaker areas of the bowel wall
…
bacteria can overgrown in the outpouchings leading to inflammation. they can perf leading to diffuse peritonitis sepsis
…
chronic? fistula can form. what ones are most common?x2
…
diverticulitis is either simple (?) or complicated (?)

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13
Q

DIVERTICULAR DISEASE risk factors?

A

inc age, low dietary fibre, obesity, smoking, fhx, nsaid use

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14
Q

DIVERTICULAR DISEASE diverticulosis clinical features?

A

asymptomatic and found incidentally on ct or routine colonoscopy

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15
Q

DIVERTICULAR DISEASE clinical features?

A

intermittent lower abdo pain - colicky in nature & relieved by defecation
other sx: altered bowel habit, associated nausea, flatulence. no systemic features

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16
Q

DIVERTICULAR DISEASE acute diverticulitis clinical features ?

A
  • acute abdo pain, sharp, localised in the left iliac fossa, worsened w movement
  • perf? signs of localised peritonism or generalised peritonitis. V UNWELL
    • what meds can mask sx of diverticulitis?
17
Q

DIVERTICULAR DISEASE differentials?

A

IBS, bowel CA, mesenteric ischaemia, gynae causes, renal stones

18
Q

DIVERTICULAR DISEASE investigations?

A
  • bloods: what ones?
  • urine dip - why?
  • CT AP - what findings?x5
  • uncomplicated diverticular disease ? flex sig
19
Q

DIVERTICULAR DISEASE management ?

A
  • uncomplicated dd? analgesia, oral fluid intake encouragement. out pt colonoscopy to exclude CA
  • diverticular bleeds? manage conservatively as mostly self limiting. significant bleeding? resus w appropriate blood products + stablisation
    fail to respond? embolisation or surgical resection
  • acute diverticulitis? conservative mgmt - abx, iv fluids, analgesia. sx tend to improve in 2-3 days. clinical deterioration ? repeat imaging
20
Q

DIVERTICULAR DISEASE surgical management?

A
  • in pts w perf w faecal peritonitis or overwhelming sepsis
  • hartmanns procedure (what is this?)
    • an anastomoses w reversal or colostomy may be possible at a later date
21
Q

DIVERTICULAR DISEASE complications?

A
  • recurrence
  • diverticular stricture - following repeated episodes of inflammation. bowel becomes scarred and fibrotic resulting in a benign stricture. can cause large bowel obstruction so sigmoid colectomy needed
  • fistula - due to repeated inflammation. most common types?? how do they present??
22
Q

CROHNS clinical features?

A

episodic abdo pain (colicky), diarrhoea (may contain blood or mucus). systemic sx: malaise, anorexia, low grade fever, malabsorption & malnourishment. oral aphthous ulcer & perianal disease
extra intestinal features: msk (?), skin (?), eyes (?), HPB (?), renal (?)

23
Q

CROHNS investigations?

A
  • bloods -?
  • faecal calprotectin
  • gold standard - colonoscopy
24
Q

CROHNS management ?

A
  • medical : gastroenterologist. induce remission:1st corticosteroid then azatioprine etc. maintain remission:azathiprine, smoking cessation. colonoscopies offered if has disease for >10 yrs and >1 segment of bowel affected due to inc CA risk. IBD nurse specialist
  • surgical: if failed medical mgmt or severe comps (eg strictures or perks). ops inc: ileocaecal resection, small bowel/large bowel resection, peri anal disease surgery, stricturoplasty. ** pre op optimisation important !!
25
Q

CROHNS comps?

A
  • gi: fistula, stricture, recurrent perianal fistula, gi CA
  • extra intestinal : malabsorption,osteoporosis, inc risk gallstones, inc risk renal stones

explain all above!!!

26
Q

UC clincial features?

A

insidious in onset - bloody diarrhoea, proctitis, pr bleed, mucus discharge, inc fre & urgency defecation, tenesmus
more widespread colonic involvement? bloody diarrhoea + clinical features of dehydration & electrolyte imbalance
systemic sx? malaise, anorexia, low grade pyrexia
- OE? normal…severe abdo pain???? suspect toxic megacolon etc!! will show sings of peritonism
- extra intestinal features : msk (?), skin (?), eyes (?), HPB (?)

27
Q

UC differentials?

A 
crohns
chronic infections (eg?x3)
mesenteric ischaemia 
radiation colitis 
CA
IBS
coeliac
28
Q

UC investigations ?

A
  • bloods - ?
  • faecal calprotectin
  • stool sample sent for MC&S
  • colonoscopy w biopsy
  • acute exacerbation? AXR or CT to assess for toxic megacolon or perf
    typical AXR features?x3
29
Q

UC management ?

A
  • medical: gastroenterologist. inducing remission : corticosteroid + immunosuppressive therapy. maintain remission: immunosuppressive eg mesalazine, >10 yr of disease + >1 segment affected? colonoscopy due to inc CA risk, IBD nurse specialist
  • surgical : indications for acute surgical treatment: refractory to med management, toxic megacolon, bowel perf. typically require segmental bowel resection & defunctioning stoma (why/). elective? total proctocolectomy (w end ileostomy) is curative but disease control: IRA or panprctocolectomy w IPAA
30
Q

VOLVULUS what is it?

A

twisting of a loop of intestine around its mesenteric attachment resulting in a closed loop bowel obstruction. affected bowel can become ischaemic due to compromised blood supply leading to necrosis & perf

31
Q

VOLVULUS most common site?

A

sigmoid - long mesentery (inc w age) means this portion is more prone to twisting on its mesenteric base.
other common places?

32
Q

VOLVULUS risk factors?

A

inc age, neuropsychiatric disorders, nursing home resident, chronic constipation or laxative use, male, prev abdo ops

33
Q

VOLVULUS clinical features?

A

pt presents w bowel obstruction

  • colicky pain, abdo distension, absolute constipation, vomiting (later on, why?)
  • rapid onset (?), high degree of abdo distension
34
Q

VOLVULUS OE?

A
  • abdo is tympanic to percussion

- examine for signs of perf or peritonism!!

35
Q

VOLVULUS differentials?

A
  • alternative causes for bowel obstruction
  • severe constipation
  • severe sigmoid diverticular disease
36
Q

VOLVULUS investigations ?

A
  • bloods - ?
  • CT AP w contrast - what does it identify ? it’ll show very dilated sigmoid w a ? sign from the twisted mesentery
  • AXR shows ? sign in the LIF. if ileocaecal valve incompetent?
37
Q

VOLVULUS management?

A
  • conservative: decompression by sigmoidscope (describe this process) & insertion of a flatus tube (what is this?)
  • surgery (hartmanns) is indicated if: there’s colonic ischaemia or perf, there were repeated failed attempts @ decompression or there was necrotic bowel noted @ endoscopy.
38
Q

VOLVULUS comps?

A
  • immediate: bowel ischaemia, perf

- long term: risk of recurrence, stoma comps

39
Q

VOLVULUS caecal vs sigmoidal

A

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🕺🏽gen surg (8 decks)

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