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CST Interview > Lower GI > Flashcards

Lower GI Flashcards

1
Q

Risk factors for anastomotic leak

A

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
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2
Q

Patient factors anastomotic leak

A
  • Chronic malnutrition
  • Immunosuppresion
  • Diabetes
  • High-dose steroids
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3
Q

Disease factors for anastomotic leak

A
  • Unprepared bowel e.g. obstruction
  • Sepsis: localised or generalised
  • Malignancy
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4
Q

Operative factors for anastomotic leak

A
  • Blood supply to bowel ends
  • Level of anastomosis
  • Tension at anastomosis
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5
Q

Presentation of anastomotic leak

A

Peritonitis

Abscess

Enteric fistula

Change in physiology: AF, SVT

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6
Q

Management of anastomotic leak + peritonism

A

If peritonism present = indication fur urgent re-look laparotomy

IV antibiotics, prepare for theatre

Usually febrile, tachypneoic, and tachycardic

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7
Q

Management of anastomotic leak, no peritonism but localised tenderness

A

Likely abscess formation

If no peritonism –> CT abdo pelvis

Percutaneous drainage and IV antibiotics

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8
Q

Management of anastomotic leak, fistulation

A

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

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9
Q

Surgical management of peritonitic anastomotic leak

A

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
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10
Q

Definition of incarcerated hernia

A

All or part of the hernia irreducible

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11
Q

Definition of obstructed hernia

A

Obstructed bowel loop due to kinking in the hernia

This will nearly always lead to strangulation if left

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12
Q

Defintion of strangulated hernia

A

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

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13
Q

Differential diagnosis of acute groin swelling

A

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

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14
Q

Cause of post-operative atelectasis

A

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
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15
Q

Management of post-operative atelectasis

A

Investigate and rule out other causes of temperature

PCA analgesia

Rolled-up towel for coughing

Chest physiology

Incentive spirometry

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16
Q

Causes of post-operative pyrexia

A

Immediate

  • anastomotic leak
  • DVT / PE
  • peritonitis

Early

  • atelectasis
  • HAP
  • UTI

5 days

  • wound infection
  • HAP
  • DVT / PE
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17
Q

Risk factors for wound dehiscence

A

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
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18
Q

Jenkin’s rule

A

Mass closure

Suture length = at least 4 x length of incision

Bites 1cm from edge, 1 cm apart

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19
Q

Management of wound dehiscence

A

A to E

IV Antibiotics

Saline-soaked gauze to cover

Return to theatre , GA, supine

Non-viable tissue removed

Repair with interrupted sutures

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20
Q

Pre-operative risk factors for wound dehiscence

A

Pre-operative factors

  • Anaemia
  • Jaundice
  • Diabetes
  • Protein deficiency
  • Vitamin C deficiency
  • Smoking
  • Increasing age
  • Male > female
21
Q

Operative risk factors for wound dehiscence

A 
Operarive factors 
-Poor surgical technique, i.e. not following Jenkin's rule
-Bowel handling --> ileus
-Leakage of bowel contents
-Emergency surgery
>6 hours
22
Q

Post-operative risk factors for wound dehiscence

A

Post-operative factors

  • Chronic cough
  • Distension
  • Increased BMI
  • Constipation
  • Prolonged ventilation
  • Post-op transfusion
  • Poor tissue perfusion, ionotropes
23
Q

Classification of wound dehiscence

A

Superficial

  • skin alone
  • usually secondary to infection

Full-thickness

  • disruption of the rectus sheath
  • results in bowel protrusion
24
Q

Signs of wound dehiscence

A

Usually 5-7 days post-op

Perioneal serous fluid leak
Pink colour –> imminent breakdown

25
Q

Management of superficial wound dehiscence

A

If confirmed superficial

Wash area
Pack area
Antibiotics to treat wound infection
+/- VAC (must be confirmed superficial)

26
Q

Indications for surgery in ulcerative colitis

A

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

27
Q

Surgical management of ulcerative colitis

A

Proctocolectomy
= rectum + colon
-ilioanal pouch

Panproctocolectomy
=anus + rectum + colon
-end-ileostomy

Colectomy
-performed as an emergency procedure only, not elective as not curative

28
Q

Low anterior resection

A

=resection at peritoneal reflection

Left colon through to rectum

29
Q

Ultra low anterior resection

A

= resection at junction to anal canal

No remaining anus

30
Q

Complications of pelvic anastomosis

A

Leakage ~ 15%

Bleeding

Ischaemia –> perforation

Stenosis

31
Q

Differential diagnosis for absolute constipation

A
  1. Large bowel obstruction
  2. Small bowel obstruction
  3. Ogilvies syndrome (pseudoobstruction)
  4. Ileus
32
Q

Management of bowel obstruction

A 
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
33
Q

Signs of sigmoid volvulus on AXR

A

Distended bowel with markings not spanning the width, suggesting haustra

Distended oval gas shadow looped on itself or the “coffee bean” sign

34
Q

Management of sigmoid volvulus

A

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

35
Q

Ogilvies syndrome

A

Occurs in:

  • severely ill
  • major surgery
  • sepsis
  • metabolic disturbances
  • anti-cholinergics
36
Q

Closed-loop obstruction

A

= indication for emergency surgery

Two points of obstruction
-competent ileocaecal valve = 1

37
Q

Signs of small bowel on AXR

A

Valvulae conniventes

Centrally located

38
Q

Indications for AXR

A

Bowel obstruction

Visceral perforation

Acute IBD

Abdominal trauma

Renal calculus

39
Q

Management of small bowel obstruction

A

If virgin abdomen –> surgical management

If previous surgery, adhesions, conservative management for 48 hours

IBD small bowel obstructions are nearly always managed conservatively

40
Q

Complications of small bowel obstruction

A

Aspiration

Perforation

Abscess

Sepsis

Resection –> short bowel syndrome

Wound dehiscence

41
Q

Normal diameters of bowel on AXR

A

Small bowel <3cm
-perforates at 5cm,

Large bowel <6cm

Caecum <9cm

42
Q

Causes of bowel obstruction

A

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
43
Q

Intra-luminal causes of bowel obstruction

A

Intra-luminal

  • faecal impaction
  • gallstone ileus
  • ingested foreign body
44
Q

Mural causes of bowel obstruction

A

Mural

  • carcinoma
  • inflammatory stricture
  • intussusception
  • diverticular strictures
  • meckel’s diverticulum
  • lymphoma
45
Q

Extra-luminal causes of bowel obstruction

A

Extra-mural

  • hernias
  • adhesions
  • peritoneal mets
  • volvulus
46
Q

Clinical features of bowel obstruction

A

Abdominal pain

Absolute constipation

Vomiting

Distension

47
Q

Rule of ischaemia

A

Any pain that was previously colicky, and is now constant, suggests ischaemia has developed

48
Q

Indications for surgery in bowel obstruction

A

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

CST Interview (11 decks)

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