sepsis, perf, haemorrhoid and obstruction Flashcards
what are the mechanisms of bowel perf?
- ischaemia
- infection
- erosions
- physical distruption
what are the S&S of bowel perf?
abdo pain, rigidity and rebound tenderness
- starts at site of perf and then becomes global
- severe and worse on movement
Fever, N&V
after time the bowel becomes silent
what InV are done for bowel perf?
CXR/AXR - pneumoperitoneum
CT abdo
Bloods - leucocytosis
Group and Save for surgical
what are treatment options for bowel perf?
Open laparatomy to locate site
- resection or repair
- drainage
- peritoneal wash
IV fluids, IV ABx (broad spec) and bowel rest
what is intrabdominal sepsis?
an intra-abdominal collection of pus or infected material and is usually due to localised infection inside the peritoneal cavity that is contained by tissues or anatomy
what are the common locations of intrabdominal abscess?
alongside the organ of origin (e.g paracolic in diverticulitis)
Pelvic
Subphrenic
what are the causes of intraabdominal sepsis?
sigmoid diverticulitis acute appendicits severe acute cholecystitis Upper GI perf post anastomotic leak infected acute pancreatitis
what are the clinical features of intraabdominal sepsis?
constant, localised abdo pain malaise and anorexia fever shock features N&V sepsis signs
what InV are done in intraabdominal sepsis?
FBC
- increased WCC with left shift
- occasionally leucopenia
CT abdo
- visualisation of IAA (i.e air/fluid collection)
Increased CRP and ESR
Drainage and culture
what is the treatment of intrabdominal sepsis?
CT-guided percutaneous drainage
IV Abx
- amox, gent and met
Open surgical drainage if percutaneous drainage fails
what are the causes of SBO?
surgical adhesions hernia Crohns intestinal malignancy appendicitis
what is the classification of SBO?
partial obstruction
complete obstruction
simple obstruction - absence of peritonitis
complicated obstruction - ischaemia, gangrene, perf
what are the S&S of SBO?
Constipation
Cramping, intermittent, colicky abdo pain and tenderness
vomiting and nausea
abdo distension
tinkling bowel sounds and tympanic percussion
peritonitis
what are InV of SBO?
CTAP
- site and cause
AXR
- Dilated bowel >3cm
- central abdominal location
- valvulae connivontes visible (lines completely crossing the bowel)
ABG
- increased Lactate
- Hypochloremic hypokalemic metabolic alkalosis if perfuse vomiting
FBC, U&E’s, CRP
- increased WCC
- hyponatraemia, hypokalaemia, metabolic acidosis
- increased CRP
what are the treatment options for SBO?
NG tube placement and decompression
Analgesia and anti-emetic (PR diclofenac)
Fluids (these patients nearly always fluid deplete)
laparotomy and bowel resection
what are the causes of LBO?
colorectal malignancy
diverticular strictures
volvulus (loop of intestine twists around itself)
what the S&S of LBO?
severe abdo pain and distension faecal impaction N&V (facecal vomit in late disease) constipation empty rectum tinkling bowel sounds and tympanic percussion
what InV are done in LBO?
CTAP
- site and cause
AXR
- dilated bowel (>6cm or >9cm at caecum)
- peripheral location
- haustra lines visible
FBC, U&E’s, CRP
- increased WCC and CRP
- hypokalaemia
ABG
- lactate
- acidosis/alkalosis
barium or water soluable contrast enema
- tapering of bowel lumen at the site of obstruction
- Complete bowel obstruction: contrast would not be visible beyond obstruction
- Partial bowel obstruction: a trickle of contrast would be visible beyond obstruction
- Bird beak sign seen in volvulus
- Apple core sign seen in colonic
malignancy
what are treatment options for LBO?
fluids, analgesia, anti-emetic
NG tube and decompression
Stenting
Hemicolectomy, Hartman’s procedure, subtotal tolectomy
what are differences in how LBO and SBO presents?
SBO tends to be more colicky in nature, LBO can be more constant
vomiting is early onset in SBO and later onset in LBO
faecal vomiting can occur in LBO
constipation is late onset in SBO and early onset in LBO
what are haemorrhoids?
excessive amounts of the normal endoanal cushions that comprise of anorectal mucosa, submucosal tissue and submucosal vessels
can be internal or external
where does haemorrhoids typically occur?
3, 7 and 11 o’clock as seen in supine position
what are the clinical features of haemorrhoids?
rectal bleeding - bright red post defecation
perianal pain and discomfort
anal pruritis
anal mass
how are haemorrhoid diagnosed and treated ?
rigid sigmoidoscopy/protoscopy
- banding
- dilute phenol injections
- arterial ligation
- haemorrhoidectomy
what is ano-rectal sepsis?
a collection of pus in the anal or rectal region. More common in men than women and has a high rate of recurrence
what are common organisms in ano-rectal sepsis?
E. Coli and enterococcus
how does ano-rectal sepsis arise?
plugging of the anal ducts leading to fluid stasis, collection and infection
the anal glands are located at the intersphincteric space therefore infection of these glands can spread to the adjacent areas
how are anorectal abscesses catergorised?
by area;
- perianal
- ischiorectal
- intersphincteric
- supralevator
what are the clincal features of ano-rectal sepsis?
pain in perianal region (exacerbated by sitting)
localised swelling, itching or discharge
may be features of sepsis
erythematous, fluctuant, tender, perianal mass O/E and tenderness on PR
what is the management of ano-rectal sepsis ?
Co-amoxiclav (oral or IV depending on severity)
Analgesia
Incision and drainage under GA
Anal fistulotomy (ano-rectal abscesses often associated with anal fistula)
what are the complications of ano-rectal sepsis?
Nec fasc
anal fistula
