LGI Emergencies - Bowel Obstruction, Appendicitis, Peritonitis, Mesenteric ischemia, Necrotising enterocolitis, Bowel cancer Flashcards
Small bowel obstruction
- most common causes
- presentation
- investigations, diagnosis
MOST COMMON - adhesions from past surgery
Hernias
Thickened gut wall from Crohns
Diffuse abdo pain
EARLY N+V
Complete constipation - no farts, stools
Abdo distension
Tinkling bowel sounds
Symptoms associated with complications
Definitive - CT
1st line - Abdo Xray
-distended bowel loops (3+) with fluid level
-valvulae coniventes cross bowel completely
Small and large bowel obstruction
-management
Conservative - drip and suck
- IV fluid resus, analgesia, antiemetics
- NG tube suction to decompress bowel
- monitor fluid balance with catheter
If no past surgery, unlikely to resolve with conservative
Surgery - laparotomy if
-no resolution within 2 days
-complications
-cause that needs surgical intervention
Large bowel obstruction
- most common causes
- presentation
- diagnosis, investigations
MOST COMMON - cancer especially in distal colon due to narrower lumen
- volvulus
- diverticular disease
Diffuse abdo pain
LATE N+V
Complete constipation - no farts, stools
Abdo distension
Tinkling bowel sounds
Symptoms associated with complications
Definitive - CT
1st line - AXR
-dilated bowel loops (6+ distal, 9+ proximal)
-haustra (halfway)
Mesenteric ischemia
- pathophysiology
- presentation
Inadequate blood flow to mesenteric vessels supplying GI tract
-often due to embolus (AF, IE) or atherosclerosis
Abdo pain after eating, sudden onset and out of keeping with physical exam findings
-soft non tender abdo, no guarding
N+V
Hx of AF, peripheral vasculopathy
Mesenteric ischemia
-investigations
-management
CT Angio
Emergency laparotomy with ABx - remove necrotic bowel
Supportive - IV fluids, analgesia, broad spec, LMWH
Peritonitis - septic, guarding, MOF
Appendicitis
-presentation
EG dull => RIF localised pain
Fever
N+V, constipated
Perforation - guarding, rebound
Palpable abscess
Rovsings => LIF palpation leads to RIF pain
Psoas => pain extending right hip due to irritation to psoas
Appendicitis
-investigations
High CRP + compatible history and exam = clinical diagnosis
FBC - neutrophilia
U&E, LFT - routine
Amylase - rule out pancreatitis
Rule out other differentials
Abdo US - rule out pelvic causes
-urinedip - UTI
-pregnancy test - ectopics
Appendicitis management
- uncomplicated
- acutely unwell/septic/perforated
Uncomplicated
-preop ABx => appendectomy
Acutely unwell/septic/perforated
- IMMEDIATE - fluid resus, ABx
- DEFINITIVE - appendectomy + postop ABx
Consider Abx therapy if minimal signs and patient is well
Spontaneous bacterial peritonitis
-pathophysiology
-risk factors
-presentation
-diagnosis
-management
-prophylaxis
Infection of ascitic fluid which hasn’t come from any other intraabdominal/ongoing inflammatory/surgically correctable condition
End stage liver disease - hepatic enceph, decompensated cirrhosis, ascities,
Ascities
Abdo pain
N+V
Fever
Paracentesis
-neutrophils 250+
-culture - most common Ecoli
IV cefotaxime
Prophylaxis given if
-past SBP
PO ciprofloxacin with cirrhosis + ascities + ascitic protein of U15g/L until ascites as resolved
Necrotising enterocolitis
-pathophysiology
-presentation
-investigations
-management
Neonatal emergency, affecting premature and low birth weight neonates due to intestinal immaturity
Can deteriorate in hours
Vomiting, tired
Shiny distended abdo
Periumbilical redness
Abdo tenderness
Bilious gastric aspirate, bloody stool
Shocked
AXR
-pneumatosis intestinalis
-portal vein gas
-dilated bowel loops
-pneumoperitoneum
Bloods
-inflammatory markers
-blood gas
-routine biochem
-blood cultures
NG abdo decompression
Bowel rest - parenteral nutrition
Broad spec IV ABx - penicillin, gent, metronidazole
If perforated/deteriorating => peritoneal drain, laparotomy with resection of necrotised bowel and stoma formation
Bowel cancer
-referral guidelines
-screening test
Urgent referral if
-40+ and unexplained weight loss and abdo pain
-50+ rectal bleeding
-60+ Fe deficiency anemia, change in bowel habit
-positive FIT test
Can use FIT to determine need for 2ww referral if
-abdo mass
-change in bowel habit
-Fe deficiency anemia
60-74, every 2 years
-positive => colonoscopy
Can use FIT testing if 2ww criteria not met
Bowel cancer
-types and genetics
-presentation
-investigations
-management
95% - sporadic
5% - HNPCC (Lynch)
-association with endometrial cancer)
U1% - FAP
Amsterdam criteria to identify Lynch
-min 3 family members with colon cancer
-2 generations affected
-1 diagnosed U50
Change in bowel habit
Rectal bleeding => anemia
Abdo pain, bowel obstruction
Unexplained weight loss
CEA
Colonoscopy - biopsy
CTCAP - staging
Surgery - segmental resection
Chemo, RT, targeted therapy
Colorectal cancer, types of surgery depending on location of cancer
-caecal, ascending, proximal transverse
-distal transverse, descending
-sigmoid
-upper rectum
-lower rectum
-anal verge
Caecal, ascending, proximal transverse => right hemi
Distal transverse, descending => left hemi
Sigmoid => high anterior resection
Upper rectum => anterior resection (TME)
Lower rectum => anterior resection (low TME)
Anal verge => abdomino-perineal excision of rectum
HARTMANN’S ONLY USED IN BOWEL EMERGENCIES
-sigmoid colectomy + end stoma which can be revised later
