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Year 3 Surgery > Lower GI Conditions > Flashcards

Lower GI Conditions Flashcards

1
Q

What is constipation?

A

Difficulty in passing stools or an inability to pass stools

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2
Q

How can constipation present?

A

Straining
Lumpy/Hard stools
Feeling of incomplete evacuation
Fewer than 3 bowel movements a week

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3
Q

What are some causes of constipation?

A

Normal transit constipation
Slow colonic transport
Defecation problems

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4
Q

What is the treatment for constipation?

A 
Psychological support
Increased fluid intake
Increased activity
Increased dietary fibre
Fibre medication
Laxitives
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5
Q

What is diarrhoea?

A

A symptom that occurs in many conditions. Presents as loose/watery stools passed more than 3 times a day

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6
Q

What causes diarrhoea?

A

An unwanted substance triggers gut motility and secretions to remove it, increasing water in the bowel

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7
Q

What are the 2 broad causes of diarrhoea?

A

Secretory causes

Osmotic causes

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8
Q

What are secretory causes of diarrhoea?

A

Excess ion secretion gives excess Cl- or HCO3- in the bowel

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9
Q

What are osmotic causes of diarrhoea?

A

Gut lumen contains too much osmotic material

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10
Q

What is the appendix?

A

Diverticula off the caecum

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11
Q

Which artery supplies the appendix?

A

Ileocolic branch of Superior Mesenteric

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12
Q

How can appendicitis present?

A

Acute

Gangrenous

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13
Q

How does acute appendicitis present?

A

Mucosal Oedema

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14
Q

How does gangrenous appendicitis present?

A

Transmural inflammation and necrosis

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15
Q

How can the causes of appendicitis be classified?

A

Classic

Alternative

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16
Q

What happens in classic appendicitis?

A

The lumen of the appendix becomes blocked, increasing intraluminal pressure.
Venous pressure rises giving oedema, reducing arterial supply to the appendix causing ischaemia

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17
Q

What happens in alternative appendicitis?

A

A viral/bacterial infection causes mucosal changes that allow for bacterial invasion of the appendiceal wall

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18
Q

How does appendicitis manifest?

A

Poorly-localised peri-umbilical pain that moves to the R iliac fossa after 12-24h
Anorexia
Nausea and Vomiting
Low Grade fever

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19
Q

Why can the pain for appendicitis be felt in areas other than the RIF?

A

The position of the appendix varies slightly

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20
Q

Which position can the appendix be found in?

A 
Retrocoecal
Subcoecal
Pelvic
Pre-ileal
Post-ileal
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21
Q

What are some signs of appendicitis?

A 
Patient appears ill
Fever/Tachycardia
Lie still due to inflamed peritoneum
Localised R quadrant tenderness
Reboud tenderness in RIF
Pain localised to McBurney's Point
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22
Q

Where is McBurney’s Point?

A

2/3 of the way from Umbilicus to ASIS

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23
Q

How is the diagnosis of appendicitis confirmed?

A

History/exam is often enough

Bloods - Raised CRP/WCC

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24
Q

What needs to be excluded with possible appendicitis cases?

A

Ectopic pregnancy

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25
Q

What is the treatment for appendicitis?

A

Open appendicectomy

Laprascopic Appendicectomy

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26
Q

What is Diverticulosis?

A

Outpouchings of the mucosa and submucosa that herniate through the muscularis layers

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27
Q

Where is Diverticulosis common?

A

Colon, commonly sigmoid

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28
Q

What is thought to cause Diverticulosis?

A

Low fibre diet giving hard/bulky stool that needs more effort to pass

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29
Q

What is Acute Diverticulitis?

A

Diverticulae become inflamed/perforate.

The entrance to the diverticula is occluded by faeces giving inflammation

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30
Q

How can acute diverticulitis present?

A

Uncomplicated

Complicated

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31
Q

What is uncomplicated diverticulitis?

A

Diverticulitis with inflammation and small abscesses

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32
Q

What is complicated diverticulitis?

A

Diverticulitis with larger abcess formation

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33
Q

What are some symptoms of diverticulitis?

A 
Abdo pain at sight of inflammation, usually lower left quadrant
Fever
Bloating
Constipation
Haematochezia
Fresh PR bleed
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34
Q

What are some signs of diverticulitis?

A

Localised abdominal tenderness
Distension
Reduced bowel sounds
Signs of Peritonitis

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35
Q

What tests are appropriate in diverticulitis?

A

Bloods - WCC/CRP
USS
CT
Colonoscopy

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36
Q

What is the treatment of diverticulitis?

A

Antibiotics
Fluid resus
Analgesia
Surgical intervention if perforated

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37
Q

What is Acute Mesenteric Ischaemia?

A

The sudden decrease in blood supply to the bowel, leading to bowel ischaemia, gangrene and death

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38
Q

What are some causes of acute mesenteric ischaemia?

A

Thrombus in Situ
Embolism
Non-occlusive cause
Venous occlusion/congestion

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39
Q

What are some risk factors for acute mesenteric ischaemia?

A

Hypertension
Hyperlipidaemia
Smoking
Af

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40
Q

What are clinical features of acute mesenteric ischaemia?

A

Generalised abdominal pain
Diffuse, constant
Nausea and Vomiting

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41
Q

What will examination demonstrate in acute mesenteric ischaemia?

A

Often nothing

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42
Q

What are some differentials with acute mesenteric ischaemia?

A

Peptic Ulcer Disease
Bowel Obstruction
AAA

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43
Q

Which investigations are appropriate for acute mesenteric ischaemia?

A

ABG - ?Acidosis/Lactate

FBC, U+E,LFTs

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44
Q

Which investigation is definitive with acute mesenteric ischaemia?

A

CT Abdo/Pelvis with Contrast

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45
Q

What is the management for acute mesenteric ischaemia?

A

Surgical intervention
Excision of the Necrotic Bowel
Revascularisation of the bowel

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46
Q

What is Crohn’s Disease?

A

A form of inflammatory bowel disease

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47
Q

Which areas of bowel are affected by Crohn’s disease?

A

Any part of the GI tract, commonly the distal ileum or proximal colon

48
Q

How is Crohn’s disease characterised?

A

Transmural inflammation, procuding deep ulcers and fissures giving affected bowel a cobblestone appearance

49
Q

Is the inflammation in Crohn’s disease constant?

A

No, the inflammation is intermittent forming skip lesions

50
Q

How does Crohn’s disease appear microscopically?

A

Non-caseating granulomatous inflammation

51
Q

What are some risk factors of Crohn’s disease?

A

Family Hx
Smoking
White European descent
Previous Appendicectomy

52
Q

What are some clinical features of Crohn’s disease?

A 
Episodic abod pain and diarrhoea
Mucus/Blood in diarrhoea
Malaise
Anorexia
Low grade fever
Oral and Peri-anal ulcers
53
Q

What are some extra-intestinal features of Crohn’s?

A 
MSK - Nail clubbing, metabolic bone disease
Skin - Erythema Nodosum
Eyes - Episcleritis, Iritis
HPB - Primary Sclerosing Cholangitis
Renal - Stones
54
Q

What investigations are appropriate with Crohn’s disease?

A 
Bloods
Faecal Calprotectin
AXR
Colonoscopy
CT
55
Q

What is the management for Crohn’s?

A

Fluid Resuscitation
Corticosteroids + Immunosuppresion
Smoking cessation

56
Q

What surgical options are there for Crohn’s disease?

A

Ileocoecal Resection
Surgery for Peri-anal disease
Stricturoplasty
Small/Large Bowel resections

57
Q

What are some complications of Crohn’s Disease?

A 
Fistulae
Stricture formation
Recurrent Peri-anal abscesses/fistulae
GI malignancy
Malabsorption
Osteoporosis
Increased risk of gallstones/renal stones
58
Q

What is Ulcerative colitis?

A

Most common form of IBD

59
Q

How is UC characterised?

A

Diffuse continuous mucosal inflammation of the large bowel, beginning in the rectum and spreading proximally

60
Q

Histologically, how does UC present

A

Inflammation of the mucosa and submucosa, crypt abscesses and goblet cell hyperplasia

61
Q

What are some clinical features of UC?

A

Bloody diarrhoea
Malaise
Anorexia
Low Grade Pyrexia

62
Q

What are some extra-intestinal manifestations of UC?

A

MSK - Nail clubbing
Skin - Erythema Nodosum
Eyes - Episcleritis/Iritis
HPB - Primary Sclerosing Cholangitis

63
Q

What is Peritonitis?

A

Inflammation of the serosal membrane that lines the abdominal cavity. Breakdown of the peritoneal membranes allows foreign substances into the cavity giving inflammation

64
Q

How can Peritonitis be classified?

A

Primary/Spontaneous Bacterial Peritonitis

Secondary/Surgical Peritonitis

65
Q

What is Primary peritonitis?

A

Infection of ascitic fluid within the abdomen, often secondary to chronic liver disease

66
Q

How is primary peritonitis diagnosed?

A

Aspiration of the ascitic fluid

67
Q

What is Secondary peritonitis?

A

Inflammation of the peritoneum secondary to inflammation/perforation of an intra-abdominal/retroperitoneal structure

68
Q

What are some causes of secondary peritonitis?

A 
Peptic ulcer disease
Appendicitis
Diverticulitis
Post-surgery
Tubal pregnancy
Ovarian cyst
69
Q

How does peritonitis present?

A

Acute

Diffuse abdominal pain

70
Q

What is the treatment for peritonitis?

A

Supportive
Antibiotics
Surgical washout if appropriate

71
Q

What is a Hernia?

A

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

72
Q

What does a hernia consist of?

A

Sac - Pouch of peritoneum
Contents - Bowel etc
Coverings - Layers of abdominal wall

73
Q

What are some pre-disposing factors for hernias?

A

Inguinal/Femoral canals
Umbilicus
Previous incisions

74
Q

How does an indirect inguinal hernia present?

A

Lateral to inferior epigastric vessels

75
Q

How does a direct inguinal hernia present?

A

Medial to inferior epigastric vessels, through hesselbachs triangle

76
Q

What are the borders of hesselbachs triangle?

A

Medial - Rectus Abdominus
Superior - Inferior Epigastric Vessels
Inferior - Inguinal ligament

77
Q

What is a stoma?

A

Opening of bowel/intestine onto the surface of the abdomen

78
Q

How does a stoma appear?

A

Fleshy and moist, patients have no sensation of sphincter

79
Q

Which types of stoma are there?

A

Ileostomy
Colostomy
Loop
End

80
Q

What is an Ileostomy?

A

Made from Ileum of small bowel in RIF
Sprouted to help drainage
Produces porridge-like stools
Drainable bag in place

81
Q

What is a Colostomy?

A

Large bowel stoma, usually L sided, often sigmoid
Flush to skin
Soft to formed stool output
Closed bag

82
Q

What is a Loop Ileostomy?

A

Often temporary
A loop of bowel is brought to the skin surface, opened, inverted and sutured
2 openings, 1 used
Usually to “Defunction” bowel to allow anastomosis healing

83
Q

What is an End Ileostomy?

A

The cut end of bowel is moved to the surface, inverted and sutured.
Permanent

84
Q

What is a Volvulus?

A

Twisting of a loop of intestine around its mesenteric attachment leading to a closed loop bowel obstruction

85
Q

What can Volvulus lead to?

A

Ischaemia of the affected bowel giving bowel necrosis and perforation

86
Q

Where do Volvuli commonly occur?

A

Sigmoid colon

87
Q

What are some risk factors for Sigmoid volvulus?

A 
Increasing age
Neuropsychiatric Disorders
Resident in a Nursing Home
Chronic constipation
Male gender
Previous abdominal operations
88
Q

What are some clinical features of a Sigmoid Volvulus?

A

Colicky Pain
Abdominal distension
Rapid onset

89
Q

What investigations are appropriate for a suspected Sigmoid Volvulus?

A

AXR - ?Coffee Bean sign

CT Abdo

90
Q

What are the management options for a sigmoid volvulus?

A

Decompression with endoscopy + flatus tube insertion

Resection of necrotic bowel

91
Q

What is Pseudo-Obstruction

A

Dilation of the Colon due to an adynamic bowel in the absence of mechanical obstruction

92
Q

Which area of colon most commonly has Pseudo-Obstruction?

A

Caecum and Ascending Colon

93
Q

What is thought to be the pathophysiology of pseudo-obstruction?

A

Interruption of the autonomic nervous supply in the colon leading to an absence of smooth muscle action

94
Q

What are the possible complications of pseudo-obstruction?

A

Toxic Megacolon
Bowel Ischaemia
Perforation

95
Q

What are some causes of pseudo-obstruction?

A

Electrolyte imbalance
Medication
Recent surgery, illness or trauma
Neurological disease

96
Q

What are some clinical features of pseudo-obstruction?

A

Abdominal pain/distension
Constipation
Vomiting

97
Q

Which investigations are appropriate for suspected pseudo-obstruction?

A

AXR - ? Dilated bowel loops

CT

98
Q

What management for pseudo-obstruction is appropriate?

A 
NBM
NG to decompress stomach
Endoscopic decompression with flatus tube
Nutritional support
Surgical resection
99
Q

What is Bowel Obstruction?

A

A mechanical blockage of the bowel where a structural pathology physically blocks the passage of intestinal contents

100
Q

Once occluded, what happens to the affected section of Bowel?

A

Gross dilatation of the proximal limb of the bowel leading to increased peristalsis. This also leads to secretions of large volumes of electrolyte-rich fluid into the bowel

101
Q

What is a Closed-Loop obstruction?

A

Two occlusions affecting the same loop of bowel

102
Q

Why is a Closed-Loop obstruction a surgical emergency?

A

The bowel will continue to distend, leading to eventual ischaemia and/or perforation

103
Q

What are some common causes of Small Bowel Obstruction?

A

Adhesions

Herniae

104
Q

What are some common causes of Large Bowel Obstruction?

A

Malignancy
Diverticular Disease
Volvulus

105
Q

Where can the obstruction be located irrespective of the bowel segment?

A

Intraluminal
Mural
Extramural

106
Q

What are some Intraluminal causes of bowel obstruction?

A

Gallstone Ileus
Ingested foreign body
Faecal impaction

107
Q

What are some Mural causes of bowel obstruction?

A 
Carcinoma
Inflammatory strictures
Intussusception
Diverticular strictures
Meckel's Diverticulum
Lymphoma
108
Q

What are some Extramural causes of bowel obstruction?

A

Hernias
Adhesions
Peritoneal Metastases
Volvulus

109
Q

What are some common clinical features with Bowel obstruction?

A

Abdo pain - Colicky/Cramping in nature
Vomiting - Initially gastric, then billious and faeculent
Abdo distension
Absolute constipation

110
Q

What may become apparent in bowel obstruction on examination?

A 
Signs of underlying cause - Surgical scars, cachexia from malignancy
Abdo distension
Focal tenderness
Guarding
Rebound tenderness
Tympanic to percussion
Tinkling bowel sounds
111
Q

Which investigations are appropriate with suspected bowel obstruction?

A

FBC,U+E,CRP,LFTs,G+S
VBG - ?Ischaemia
CT Abdo + Contrast
CXR/AXR

112
Q

What conservative management is recommended with confirmed obstruction?

A

Drip and Suck

113
Q

What steps are involved with Drip and Suck?

A 
NBM
NG tube to decompress stomach
IV fluids
Urinary Catheter 
Anaelgesia
114
Q

When is a water-soluble contrast study recommended with confirmed obstruction?

A

If there is no improvement in symptoms 24 hours post commencement of management

115
Q

When is surgical intervention appropriate with confirmed bowel obstruction?

A

Suspicion of Intestinal Ischaemia or Closed-Loop obstruction
SBO in a virgin abdomen
Cause that needs surgical intervention
Failure to improve after 48h

116
Q

What procedure is appropriate to correct bowel obstruction?

A

Laparotomy or resection

117
Q

What are some potential complications of Bowel Obstruction?

A

Ischaemia
Bowel perforation giving peritonitis
Dehydration leading to renal impairment

Year 3 Surgery (10 decks)

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