S9: GI emergencies & infections Flashcards
What is peritonitis?
Inflammation of the serosal membrane that lines the abdominal cavity
Can be primary or secondary
Describe primary peritonitis
Spontaneous bacterial peritonitis – infection of ascitic fluid that cannot be attributed to any intra-abdominal, ongoing inflammatory or surgically correctable condition
Most common in patients with end stage liver disease (cirrhosis):
1) Portal hypertension – increased hydrostatic pressure in the veins
2) Decreased liver function resulting in less albumin production
3) Result = net movement of fluid into the peritoneal cavity
Symptoms: abdominal pain, fever & vomiting (normally mild symptoms, diagnosed by aspirating ascitic fluid)
Describe secondary peritonitis
A result of an inflammatory process in the peritoneal cavity secondary to inflammation, perforation, or gangrene of an intra-abdominal/retroperitoneal structure
Common causes: peptic ulcer disease (perforated), appendicitis (perforated), diverticulitis (perforated) & post surgery
Non bacterial causes: tubal pregnancy that bleeds & ovarian cyst
Describe the clinical presentation and treatment of peritonitis
Abdominal pain – may come on gradually/acutely
-diffuse abdominal pain is common in perforated viscera
Patients often lie very still – any movement makes the pain worse (often have knees flexed & shallow breathing)
Treatment: control the infectious source (surgery), eliminate bacteria and toxins (antibiotics) & maintain organ system function
Describe bowel obstruction
Mechanical or functional problem that inhibits the normal movement of gut contents
Can affect the large and small intestine
Common causes in children: intussusception & intestinal atresia
Common causes in adults: adhesions & incarcerated hernias
Describe intussusception
One part of the gut tube telescopes into an adjacent section
Cause is not well known
Can extend quite far (can prolapse out of rectum); as soon as the lymphatic and venous drainage is impaired you get oedema
Symptoms: abdominal pain, vomiting & haematochezia
Treatment: air enema & surgery
Describe small bowel obstruction
Nausea and vomiting (bilious) – most common symptoms, can have abdominal distension & abdominal constipation (late)
Caused by:
1) Intra-abdominal adhesions – arise after abdominal surgeries, damage to mesothelium
2) Hernias can narrow lumen enough to cause obstruction
3) Crohn’s – repeated episodes of inflammation/healing causes narrowing
Diagnosis: history – abdominal pain is crampy & intermittent, physical examination & imaging
Describe large bowel obstruction
Typically affects older age groups
Common causes: colon cancer, diverticular disease & volvulus
Symptoms often appear gradually if caused by cancer but are abrupt with volvulus: change in bowel habit, abdominal distension, crampy abdominal pain & nausea/vomiting (late)
What is a volvulus?
Part of the colon twists around its mesentery
Most common in sigmoid colon and caecum – results in obstruction
Can result from overloaded sigmoid colon – extra mass predisposes & elongates the sigmoid
Caecal volvulus results in small and large bowel obstruction
Compare small and large bowel obstruction
Small bowel: 1) Younger age group 2) Abdominal pain – colicky (3-4 mins) 3) Vomiting – relatively early 4) Constipation – relatively late 5) Imaging – bowel > 3cm, central position & plica circularis Large bowel: 1) Older age group 2) Abdominal pain – colicky (10-15 mins) 3) Vomiting – relatively late 4) Constipation – relatively early 5) Imaging – peripheral, bowel > 6cm, haustra don’t go all the way across
Describe acute mesenteric ischaemia
Symptomatic reduction in blood supply to the GI tract
Risk factors: females, history of peripheral vascular disease
Causes: acute occlusion, non-occlusive mesenteric ischaemia & mesenteric venous thrombosis
Symptoms: abdominal pain disproportionate to clinical findings (comes on 30 mins after eating), nausea, vomiting, left-sided pain
Describe investigations and treatment for acute mesenteric ischaemia
Investigations: blood tests, erect chest x-ray & CT angiography
Treatment: surgery – resection of ischaemic bowel, thrombolysis/angioplasty
Mortality is high – often older patients with comorbidities
Describe peptic ulceration
20-50% of acute upper GI bleeding
Disruption in the gastric/duodenal mucosa
Duodenal ulcers most common, then gastric ulcers
Describe oesophageal varices
Example of porto-systemic anastomosis
Portal drainage – oesophageal veins drain into left gastric vein, drains into portal vein
Systemic drainage – oesophageal veins drain into azygous vein, drains into superior vena cava
Endoscopy & band ligation
If bleeding not controlled by banding – transjugular intrahepatic portosystemic shunt (TIPS), drug treatment (terlipressin)
Describe an abdominal aortic aneurysm
Permanent pathological dilation of the aorta > 1.5 times the expected AP diameter of that segment
Usually due to the degeneration of the media layer of the artery
Risk factors: male, inherited risk, increasing age & smoking
Most AAAs are infrarenal
Describe the clinical presentation of an AAA
Normally asymptomatic until acute expansion or rupture
Usual presentation: abdominal pain, back pain, pulsatile abdominal mass, transient hypotension & sudden cardiovascular collapse