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G.I. > Small bowel & Bowel Obstruction > Flashcards

Small bowel & Bowel Obstruction Flashcards

1
Q

Emergency conditions of small bowel?

A

Obstruction
Infarction
Haemorrhage

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2
Q

Obstruction

A

Due to fluid, gas, ischaemia, perforation

  • – Pain (colicky, central)
  • – absolute constipation
  • – vomiting
  • – burping
  • – abdo distension

Causes//

  • – within the lumen (gallstone, food, bezoar)
  • – within the wall (tumour, Crohn’s, radiation)
  • – outside the wall (adhesions, herniation)
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3
Q

Obstruction - presentation

A 
Distension
Vomiting 
Borborygmi (rumbling noise)
Pain
Faeculent vomiting

Look for cause of obstruction. Scar, hernias

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4
Q

Obstruction - Ix

A

> Urinalysis
Bloods
Gases

Confirming diagnosis//

  • AXR
  • Contrast CT
  • gastrograffi studies

identifying those who need surgery and those who will settle

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5
Q

“Drip and Suck”

A 
> ABC
> Analgesia
> Fluids with potassium
> Usually hypokalaemic and alkalotic 
> Catheterise
> NG tube 
> Antithromboembolism measures
  • up to 72 hours
  • intervene earlier if there is strangulation perforation, ischaemia
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6
Q

Surgical Management

A 
> Laparotomy 
> Operative principles
--- abx
--- antithromboembolic measures
--- usually a midline incision
--- can be laparoscopic
--- find obstruction by following collapsed or dilated bowel
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7
Q

Mesenteric ischaemia

A 
> Embolus, thrombosis
> Chronic
--- SMA
--- Cramps
--- angina of the guts
--- atherosclerosis

Acute
– small bowel usually becomes infarcted

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8
Q

Cause of mesenteric ischaemia

A

> Embolus from AF

  • – forms in left atrium
  • – sticks in narrow SMA

> In situ thrombosis from general gubbedness

  • –virchow’s triad
  • – dehydrated
  • – hypercoagulable
  • – compression
  • – vasocoonstricting drugs
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9
Q

Mesenteric ischaemia - diagnosis

A 
> Massive pain
> Acidosis 
> Lactate elevated
> WCC may be up
> CRP may be normal
> CT angiogram
> INTERVENE
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10
Q

Treatment - mesenteric ischaemia

A

QUICK TREATMENT.

Resect if non-viable.

Re-anastomose or staple

If viable perform an SMA embolectomy

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11
Q

Haemorrhage

A 
ABC
Exclude upper source
Vascular malformations
Ulceration
CT angiogram
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12
Q

Meckel’s diverticulum

A 
> 60 cm from IC valve
> Present before 2 years of age
> Remnant of omphalomesenteric duct
> Complications
--- bleed
--- ulcerate
--- obstruction
--- malignant change
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13
Q

Upper bowel obstruction - vomiting

A

> Large volumes of vomit

> Gastric, pancreatic and biliary secretions regurgitated into stomach

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14
Q

Distal small bowel/ large bowel obstruction

A

Colicky pain and distension

Vomiting - (faeculent)

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15
Q

Symptoms of intestinal obstruction

A 
> Vomiting
> Pain
> Constipation
> Distension
> Complete obstruction
> Incomplete obstruction
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16
Q

The more proximal the obstruction…

A

the earlier vomiting develops

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17
Q

Semi-digested food eaten a day or two previously suggests…

A

gastric outlet obstruction

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18
Q

copious bile-stained fluid suggests…

A

small bowel obstruction

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19
Q

Thicker, brown, foul-smelling vomit

A

Distal obstruction

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20
Q

Distension of bowel causes…

A

pain.

&

there are intermittent episodes of colicky pain.

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21
Q

Constipation

A

Propulsion of bowel contents is arrested.

Bowel gas is absorbed distal to the obstruction

Absolute constipation - neither faeces nor flatus

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22
Q

Large bowel obstruction

A

gradual onset of symptoms.

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23
Q

If oleo-caecal valve remains competent in large bowel obstruction…

A

Backward flow of contents is prevented.

Thin walled caecum progressively distends with swallowed air and eventually may rupture

  • – closed loop obstruction.
  • – at risk of perforation

COMPETENT valve is a big problem

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24
Q

If oleo-caecal valve becomes incompetent…

A

the small bowel distends, delaying onset of symptoms

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25
Q

Incomplete obstruction

  • symptoms
  • leads to
  • type of pain
A

Clinical features may be less defined.

Intermittent vomiting & erratic bowel habit

leads to gradual hypertrophy of muscle of the bowel wall proximally.

Colicky pain due to peristalsis

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26
Q

Physical signs of intestinal obstruction

A

Dehydration

Abdo distension

Visible peristalsis

Relative lack of abdominal tenderness

Mass may be palpable

Centre of abdomen tends to be resonate due to gaseous distension

groins examined for hernia

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27
Q

Bowel sounds?

A

High pitched, tinkling.

Absent, echoing.

Water lapping against a boat

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28
Q

Bowel obstruction - investigations

A

Supine abdo xray**

Bowel proximal to obstruction is distended

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29
Q

Small bowel on Xray

A

“lines” go all the way across the bowel

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30
Q

Large bowel xray

A

Haustra

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31
Q

What is performed after supine AXR?

A

CT scan to confirm diagnosis

transition point between collapsed and distended bowel.

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32
Q

Initial management

A

Nil by mouth
Insert IV cannula and send bloods

Resus with IV fluids

Replace electrolyte loss

Pass a nasogastric tube to decompress the stomach
Drip and suck

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33
Q

Adhesions/bands

A

Mechanical cause of obstruction.

Congenital/iatrogenic

Small bowel loops should be free to move about

Can become stuck to each other and twist on each other

Collapse lumen

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34
Q

Incarcerated abdominal wall hernias

A

Mechanical cause of obstruction

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35
Q

Volvulus

A

A mobile loop of bowel rates causing obstruction at its neck.

sigmoid volvulus
closed loop structure
massively distended

caecal volvulus - hypermobile caecum.

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36
Q

Tumour

A

Most common - colonic cancer

Hypokalaemia/ hypocholaemic metabolic alkalosis

Losing chloride through vomiting

Losign H+ ions

Losing potassium as well

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37
Q

Inflammatory stricture

A
  1. Crohn’s disease - due to proximal hypertrophy
  2. Diverticular disease

incomplete usually

38
Q

Bolus obstruction

A
  1. Food bolus
  2. Impacted faeces
  3. impacted gallstone ileus
  4. Trichobezoar - hair ball
39
Q

What is a trichobezoar?

A

Hair ball

40
Q

Intussusception

A

a segment of bowel wall becomes telescoped into the segment distal to it

Usually initiated by a mass in the bowel wall - tumour

Overacvie lymphatic tissue

41
Q

Bowel Strangulation

A

> A segment of bowel becomes trapped
Venous return is obstructed
↑local intra vascular pressure, arterial inflow compromised

Infarction–> perforation

42
Q

Pain over a hernia

A

indicates bowel strangulation

surgical intervention.

can occur in external hernia or volvulus

43
Q

Paralytic ileus

A

Disruption of normal propulsive activity of GI tract

No peristalsis

Reent GI surgery
Inflammation w/ peritonitis
Diabetic keto acidosis

Symptoms and signs//

pain and high pitched sounds less common

Everything will be uniformly distended with no obvious point of obstruction

44
Q

Ogilvies Syndrome

A

Acute dilatation of colon in absence of colonic obstruction in ACUTELY UNWELL patients

hip replacement 
CABG
Spinal
Pneumonia
Frail/elderly

gaseous distension to distal rectum.

no “cut-off” point

Colonoscopic decompression if causing pain or resp compromise.

45
Q

Most common cause of bowel ischaemia?

A

Mesenteric artery occlusion

  • atherosclerosis
  • thromboembolism (AF)
46
Q

Other case of small bowel ischaemia?

A

Non-occlusive perfusion insufficiency

  • shock
  • strangulation obstructing venous return
  • drugs
  • hyper viscosity
47
Q

What is the most metabolically active part of the bowel wall?

A

Mucosa

48
Q

Longer time of ischaemia

A

greater the depth of damage

49
Q

In non occlusive ischaemia, what causes most tissue damage?

A

REPERFUSION INJURY

50
Q

Meckel’s diverticulum

A

Tubular structure - 2 inches long, 2 foot above IC valve in 2% of people.

May mimic appendicitis

True diverticulum (includes all layers)

51
Q

Commonest site of carcinoid tumours?

A

Appendix

52
Q

(Primary) Small bowel carcinoma associated with

A

Crohn’s disease and coeliac disease

late presentation

53
Q

What must acute inflammation invlove?

A

The muscle coat

54
Q

Appendicitis - complications

A 
Peritonitis
Rupture
Abscess
Fistula
Sepsis and liver abscess
55
Q

Classic coeliac disease rash?

A

Dermatitis herpetiformis

sub epithelial IgA deposition

56
Q

What is the component of gluten suspected to be the toxic agent in coeliac disease?

A

Gliadin - leading to t cell mediated reaction

57
Q

Coeliac disease - what happens to enterocytes

A

LOSS of enterocytes due to IEL mediated damage

Loss of villous structure, loss of SA

reduction in absorption

FLAT mucosal biopsy

58
Q

Coeliac disease lesions are worse in?

A

Duodenal biopsy

59
Q

What antibodies are present in coeliac disease?

A

anti-TTG
anti-endomesial
anti-gliadin

60
Q

Coeliac leads to malabsorption of… leading to…

A

malabsorption of fat

–> STEATORRHOEA

61
Q

Coeliac has reduced hormone production. Leading to…

A

Recuded pancreatic secretion and bile flow.

–> gallstones

62
Q

Coeliac disease

A 
Loss of weight 
Anaemia
Abdominal bloating 
Failure to thrive 
Vitamin deficiencies 
T cell lymphomas
Carcinoma
Gall stones
Ulcerative jejenoilleitis
63
Q

Causes of malabsorption

A

Common//

Coeliac
Crohn's
Post infectious
Biliary obstruction
Cirrhosis

Uncommon//

Pancreatic cancer
parasites
bacterial overgrowth
drugs
short bowel
64
Q

Fat malabsorption

A

Digestive
Absorptive
Post absorptive

a physiological defect in any of these can lead to malabsorption

65
Q

Carb malabsorption

A

Quite uncommon

Severe oancreatic insufficiency (alpha-amylase)

66
Q

What can lead to vitamin b12 deficiency?

A

Deficiency of gastric intrinsic factor (pernicious anaemia)

67
Q

Menkes disease

A

“Kinky hair disease”

caused by disorder of cellular copper transport

68
Q

What is lactase deficiency confirmed by?

A

Hydrogen breath test

69
Q

Tropical sprue

A

Leads to malabsorption

Colonisatio of the intestine by infectious or alterations in intestinal bacterial flora

diarrhoea, steatorrhoea, weight loss, nausea, anorexia, anaemia

70
Q

Crohns disease

A

Abdo pain and tenderness - RLQ

Diarrhoea, fever and weight loss

71
Q

What are punched out lesions a sign of?

A

Crohn’s disease

72
Q

Giardia Lamblia

A

parasitic infection

Water supplies that may be contaminated

diarrhoea, flatulence, abdo cramps, epigastric pain and nausea. Malabsorption w steatorrhoea an weight loss

Stool sample x 3

METRONIDAZOLE

73
Q

PMHx that may indicate malabsorption

A

Gastric/small bowel resection

Gastrointestinal division

Radiation expsosure

Travel

74
Q

Gingival hyperplasai

A

Scurvy

Vitamin C deficiency

weak collagen formation

75
Q

Acrodermatitis Enteropathica

A

Imparied zinc uptake

perioral rash

76
Q

Lack of iron

A

Glossitis
Angular stomatitis
spooning of nails

77
Q

Large MCV (mean corpuscular volume) =

A

Macrocytic anaemia

78
Q

Investigations for malabsorption

A 
FBC
Coagulation
LFTs
MCV
Albumin
Ca/Mg
Stool

Endoscopy

79
Q

Bacterial overgrowth causing malabsorption

A

diarrhoea, steatorrhoea, macrolytic anaemia

E. coli or bactericides

Evidence of - fistulas, diverticula, strictures, Crohn’s disease

High folate levels

Surgical correction
Tetracyclines

80
Q

What are the intestinal glands/crypts called?

A

Crypts of Lieberkühn

81
Q

S.I. regions

A

Duodenum - contains brunner’s glands

Jejunum - tallest villi. located on permanent circular folds of the mucosa and submucosa—– plicae circularis

Ileum - Peyer’s patches

82
Q

What do Brunner’s glands produce?

A

Thin, alkaline mucous to neutralise the chyme

83
Q

Jejunum has…

A

Plicae circularis

Closely packed folding
do not disappear when intestine is distended

84
Q

Ileum has large aggregations of..

A

lymphoid tissue

Peyer’s patches

85
Q

Cells of large intestine

A

Absorptive cells - removal of salts and water

Goblet cells - secret of mucous to lubricate colon

arranged in crypts

86
Q

Gastro-duodenal junction

A

Stratified squamous to columnar epithelium

87
Q

Longitudinal muscle of large intestine

A

3 muscular strips

Teniae coli

88
Q

The appendix has a lot of …tissue

A

Lymphoid

89
Q

Rectoanal junction

A

Rectum - columnar epithelium

Anus - stratified squamous

90
Q

Where is the myenteric plexus?

A

Between the 2 muscle layers

91
Q

Where is the submucosal plexus?

A

In the submucosa

controls muscular is mucosae and regulates secretion in the epithelium

G.I. (20 decks)

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