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GI > Lecture 4 - Hernias > Flashcards

Lecture 4 - Hernias Flashcards

1
Q

Visceral pain

A

Pain that results from:

  • Visceral stretching
  • Visceral inflammation
  • Visceral ischaemia

No somatic innervation therefore pain is:

  • poorly localised
  • often in midline

Nausea
Vomiting
Sweating

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2
Q

Spinal level of sympathetic innervation to gut

A

T5- L2

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3
Q

How are the presynaptic splanchnic nerves formed?

A

The preganglionic sympathetic fibres pass through the sympathetic chain without synapsing.

They amalgamate to form the presynapytic splanchnic nerves

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4
Q

3 presynaptic splanchnic nerves

A

Greater splanchnic nerve (T5 - T9)
Lesser splanchnic nerve (T10-T11)
Least splanchnic nerve (T12)

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5
Q

4 prevertebral ganglia

A

Coeliac
Renal
Superior mesenteric
Inferior mesenteric

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6
Q

Foregut pain

A

T5-T9 - Greater splanchnic nerve
Midline epigastric pain
Poorly localised

From: 
Liver
Gallbladder,
Stomach  
Spleen
Kidney
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7
Q

Midgut pain

A
  1. E.g. Caecul volvulus stimulates general visceral afferents
  2. Afferents to superior mesenteric ganglion
  3. To lesser splanchnic nerve (T10-T11)
  4. Sympathetic chain
  5. Dorsal horn of spine
  6. Converge with somatic afferents at T10-T11
  7. Brain interprets T10 - T11 dermatome pain in the peri-umbilical area
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8
Q

Hernia

A

Protrusion of part of the abdominal contents beyond the confines of the normal abdominal wall

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9
Q

Types of hernias

A

Direct
Indirect

Incarcerated
Not incarcerated

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10
Q

Hernias that are not incarcerated

A

Fullness/ swelling
Gets larger when intraabdominal pressure increases
Aches

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11
Q

Incarcerated hernias

A

Cannot be pushed back
Painful
Nausea and vomiting + signs of bowel obtruction
Systemic problems- bowel becomes ischaemic due to compromised blood supply

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12
Q

Causes of hernias

A

Weakness in the containing cavity

  • congenital
  • post surgery (incisional hernia)
  • Normal points of weakness

Anything that increases intra- abdominal pressure:

  • Obesity
  • Weightlifting
  • Chronic constipation or coughing (smoker)
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13
Q

Components of a hernia

A

Sac- pouch of peritoneum

Contents - structure within the abdominal cavity e.g. bowel or omentum

Coveringss - layers of the abdominal wall through which the hernia has passed

  • External oblique
  • Internal oblique
  • Transversus abdominis
  • Transversalis fascia
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14
Q

Weaknesses of the abdominal wall

A

Femoral canal
Inguinal canal
Previous incisions
Umbilicus

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15
Q

Inguinal canal

A

Oblique passage through the lower abdominal wall.

In males - abdomen to the testes where the testes passed through the inguinal canal from the abdomen to the scrotum

In females - Round ligament goes from the uterus to the labrium majora

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16
Q

Processus vaginalis

A

Pouch of peritoneum in males that obliterates once the testes have moved down.

Becomes the tunica vaginalis

17
Q

Gubernaculum

A

Condensed band of mesenchyme that links the inferior portion of the testes to the labioscrotal swelling

Becomes the scrotal ligament

18
Q

What occurs if the processus vaginalis doesn’t close?

A

There is a connection between the peritoneal cavity and the scrotum which can be the site of fluid collection and infection

19
Q

Borders of the inguinal canal

A

Anterior wall - External oblique

Posterior wall - Transversalis fascia and conjoint tendon

Medially = internal oblique and transversus abdominis

Floor - Inguinal ligament and lacunar ligament medially

Roof - Conjoint tendon

20
Q

Indirect hernias

A

Travel through the deep ring
Traverse the inguinal canal and exit the superficial ring

If it exits the superficial ring, can cause a scrotal hernia if the processus vaginalis is patent

21
Q

Direct hernias

A

Bulges directly through the abdominal wall through Hasselbach’s triangle in the vicinity of the superficial inguinal ring

22
Q

Percentage of abdominal hernias that are inguinal

A

75%

23
Q

Percentage of hernias that are indirect and the proportion of males to females

A

50%

Males 7x more likely

24
Q

Percentage of abdominal hernias that direct

A

25%

25
Q

Which type of hernia protrudes laterally to the inferior epigastric vessels?

A

Indirect

26
Q

Which type of hernia protrudes medially to the inferior epigastric vessels?

A

Direct

27
Q

Borders of Hesselbachs triangle

A

Medial - Rectus abdominis
Roof - Inferior epigastric vessels
Floor - inguinal ligament

28
Q

Femoral hernias

A

More common in females
Easily incarcerated and irreducible

Contents protrudes through the femoral ring of the femoral canal out of the saphenous ring

29
Q

Borders of the femoral ring

A

Laterally - Femoral vein

Medially - Lacunar ligament

30
Q

Omphalocele (4)

A

Failure of the midgut to return to the abdomen during development

Viscera persists outside the abdominal cavity within the umbilical ring covered in peritoneum

Feeding can occur

The abdominal cavity may not grow to correct the size to accommodate the viscera

31
Q

How to treat an omphalocele

A

Can surgically operate and push viscera back in

Mortality rate is high as often associated with other genetic problems

32
Q

Gastroschisis (6)

A

Defect in the ventral abdominal wall

The abdominal viscera are not covered in peritoneum - exposed to amniotic fluid

Problems with gut development - atresia, inflamed or short

Feeding problems

Better survival rates that omphalocele as not associated with other genetic factors

Defect can close at birth - push back in stepwise

33
Q

Umbilical hernia

A

Commonly in infants
Hernia bulges at the umbilicus
Not painful
80-90% close by 3 yrs old

34
Q

Paraumbilical hernia

A

Acquired in adults

Through linear alba in the region of the umbilicus

More common in females

Caused by obesity as there is an increase in intra-abdominal pressure

35
Q

Presentation of para umbilical hernias

A

Based around what happens to the loops of bowel

  • if trapped:
    Pain
    Vomiting
    Sepsis
36
Q

Incarcerated

A

Stuck - irreducible

Pain
Sepsis
Tissue breakdown

37
Q

Strangulated

A

Blood supply is disrupted and can lead to tissue necrosis

GI (18 decks)

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