Lower GI Flashcards
Risk factors for anastomotic leak
Patient factors
- Chronic malnutrition
- Immunosuppresion
- Diabetes
- High-dose steroids
Disease factors
- Unprepared bowel e.g. obstruction
- Sepsis: localised or generalised
- Malignancy
Operative factors
- Blood supply to bowel ends
- Level of anastomosis
- Tension at anastomosis
Patient factors anastomotic leak
- Chronic malnutrition
- Immunosuppresion
- Diabetes
- High-dose steroids
Disease factors for anastomotic leak
- Unprepared bowel e.g. obstruction
- Sepsis: localised or generalised
- Malignancy
Operative factors for anastomotic leak
- Blood supply to bowel ends
- Level of anastomosis
- Tension at anastomosis
Presentation of anastomotic leak
Peritonitis
Abscess
Enteric fistula
Change in physiology: AF, SVT
Management of anastomotic leak + peritonism
If peritonism present = indication fur urgent re-look laparotomy
IV antibiotics, prepare for theatre
Usually febrile, tachypneoic, and tachycardic
Management of anastomotic leak, no peritonism but localised tenderness
Likely abscess formation
If no peritonism –> CT abdo pelvis
Percutaneous drainage and IV antibiotics
Management of anastomotic leak, fistulation
Often mistaken for wound infection as discharge from wound
Prolonged antiobtioics is all that is required if there is an unobstructed fistulation
Mat require surgical repair if persistent
Surgical management of peritonitic anastomotic leak
Urgent re-look laparotomy, no imaging
IV antibiotics
IV fluids
NBM
Surgical options 1. Divide anastomosis and bring out proximal stoma OR 2. Definition anastomosis with loop ileostomy OR 3. Re-form / repair anastomosis OR 4. Place drain near to anastomosis
Definition of incarcerated hernia
All or part of the hernia irreducible
Definition of obstructed hernia
Obstructed bowel loop due to kinking in the hernia
This will nearly always lead to strangulation if left
Defintion of strangulated hernia
Blood supply to the sac in hernia is cut-off resulting in ischaemia
- venous and lymphatic occlusion
- swelling
- compression and arterial/capillary occlusion
Presents as severe pain and obstruction
Differential diagnosis of acute groin swelling
Incarcerated groin hernia
-inguinal or femoral
Acute epididymo-orchitis
Torsion of the testes
Iliopsoas abscess
-tenderness below the inguinal ligament
Acute iliofemoral lymphadenopathy
Acute saphena varix
Femoral artery aneurysm
Cause of post-operative atelectasis
Increased risk
-pre-existing respiratory disease
Caused by:
- irritation of respiratory tract by intimation –> increased mucous secretion by goblet cells
- positive pressure ventilation causing barotrauma
- lying prone, under ventilation of bvases
- splinting in laparoscopic procedures
- post-operative pain –> inhibition of effective cough
Management of post-operative atelectasis
Investigate and rule out other causes of temperature
PCA analgesia
Rolled-up towel for coughing
Chest physiology
Incentive spirometry
Causes of post-operative pyrexia
Immediate
- anastomotic leak
- DVT / PE
- peritonitis
Early
- atelectasis
- HAP
- UTI
5 days
- wound infection
- HAP
- DVT / PE
Risk factors for wound dehiscence
Pre-operative factors
- Anaemia
- Jaundice
- Diabetes
- Protein deficiency
- Vitamin C deficiency
- Smoking
- Increasing age
- Male > female
Operarive factors -Poor surgical technique, i.e. not following Jenkin's rule -Bowel handling --> ileus -Leakage of bowel contents -Emergency surgery >6 hours
Post-operative factors
- Chronic cough
- Distension
- Increased BMI
- Constipation
- Prolonged ventilation
- Post-op transfusion
- Poor tissue perfusion, ionotropes
Jenkin’s rule
Mass closure
Suture length = at least 4 x length of incision
Bites 1cm from edge, 1 cm apart
Management of wound dehiscence
A to E
IV Antibiotics
Saline-soaked gauze to cover
Return to theatre , GA, supine
Non-viable tissue removed
Repair with interrupted sutures
Pre-operative risk factors for wound dehiscence
Pre-operative factors
- Anaemia
- Jaundice
- Diabetes
- Protein deficiency
- Vitamin C deficiency
- Smoking
- Increasing age
- Male > female
Operative risk factors for wound dehiscence
Operarive factors -Poor surgical technique, i.e. not following Jenkin's rule -Bowel handling --> ileus -Leakage of bowel contents -Emergency surgery >6 hours
Post-operative risk factors for wound dehiscence
Post-operative factors
- Chronic cough
- Distension
- Increased BMI
- Constipation
- Prolonged ventilation
- Post-op transfusion
- Poor tissue perfusion, ionotropes
Classification of wound dehiscence
Superficial
- skin alone
- usually secondary to infection
Full-thickness
- disruption of the rectus sheath
- results in bowel protrusion
Signs of wound dehiscence
Usually 5-7 days post-op
Perioneal serous fluid leak
Pink colour –> imminent breakdown
Management of superficial wound dehiscence
If confirmed superficial
Wash area
Pack area
Antibiotics to treat wound infection
+/- VAC (must be confirmed superficial)
Indications for surgery in ulcerative colitis
Chronic symptoms despite maximal medical therapy
Not tolerating medical therapy e.g. osteoporosis or immunosuppression
Recurrent exacerbations affecting growth
High-grade dysplasia or DALM (dysplasia-associated lesion or mass)
Carcinoma
Surgical management of ulcerative colitis
Proctocolectomy
= rectum + colon
-ilioanal pouch
Panproctocolectomy
=anus + rectum + colon
-end-ileostomy
Colectomy
-performed as an emergency procedure only, not elective as not curative
Low anterior resection
=resection at peritoneal reflection
Left colon through to rectum
Ultra low anterior resection
= resection at junction to anal canal
No remaining anus
Complications of pelvic anastomosis
Leakage ~ 15%
Bleeding
Ischaemia –> perforation
Stenosis
Differential diagnosis for absolute constipation
- Large bowel obstruction
- Small bowel obstruction
- Ogilvies syndrome (pseudoobstruction)
- Ileus
Management of bowel obstruction
A to E VBG: lactate NG tube Analgesia IV fluids NBM G&S
AXR
CXR
If SBO, adhesions, conservative management 48 hours
If LBO, treat obstructing cause
- constipation –> evacuation
- volvulus -> sigmoidoscopy
- obstructing tumour –> Hartman’s procedure
Signs of sigmoid volvulus on AXR
Distended bowel with markings not spanning the width, suggesting haustra
Distended oval gas shadow looped on itself or the “coffee bean” sign
Management of sigmoid volvulus
A to E
IV access
Fluids
NBM
Left lateral rigid sigmoidoscope + flatus tube
Admit for 48 hours top observe for signs of bowel ischameia
If failed: sub-colectomy
Ogilvies syndrome
Occurs in:
- severely ill
- major surgery
- sepsis
- metabolic disturbances
- anti-cholinergics
Closed-loop obstruction
= indication for emergency surgery
Two points of obstruction
-competent ileocaecal valve = 1
Signs of small bowel on AXR
Valvulae conniventes
Centrally located
Indications for AXR
Bowel obstruction
Visceral perforation
Acute IBD
Abdominal trauma
Renal calculus
Management of small bowel obstruction
If virgin abdomen –> surgical management
If previous surgery, adhesions, conservative management for 48 hours
IBD small bowel obstructions are nearly always managed conservatively
Complications of small bowel obstruction
Aspiration
Perforation
Abscess
Sepsis
Resection –> short bowel syndrome
Wound dehiscence
Normal diameters of bowel on AXR
Small bowel <3cm
-perforates at 5cm,
Large bowel <6cm
Caecum <9cm
Causes of bowel obstruction
Intra-luminal
- faecal impaction
- gallstone ileus
- ingested foreign body
Mural
- carcinoma
- inflammatory stricture
- intussusception
- diverticular strictures
- meckel’s diverticulum
- lymphoma
Extra-mural
- hernias
- adhesions
- peritoneal mets
- volvulus
Intra-luminal causes of bowel obstruction
Intra-luminal
- faecal impaction
- gallstone ileus
- ingested foreign body
Mural causes of bowel obstruction
Mural
- carcinoma
- inflammatory stricture
- intussusception
- diverticular strictures
- meckel’s diverticulum
- lymphoma
Extra-luminal causes of bowel obstruction
Extra-mural
- hernias
- adhesions
- peritoneal mets
- volvulus
Clinical features of bowel obstruction
Abdominal pain
Absolute constipation
Vomiting
Distension
Rule of ischaemia
Any pain that was previously colicky, and is now constant, suggests ischaemia has developed
Indications for surgery in bowel obstruction
Closed-loop obstruction
Ischaemia
Perionitic
If gastrograffin doesn’t reach colon <6h = unlikely to resolve
Virgin abdomen and SBO
Failure of conservative management of SBO by 48 hours
Surgery required to treat primary pathology
