Small Bowel Obstruction Flashcards
Describe the incidence of appendicitis?
McBurney – 1/3rd along from the umbillicus Rare in infancy Usually childhood/young adulthood Another peak in the elderly M:F 3:2 before 25 years thereafter equal
What can cause appendicitis?
Obstruction of the lumen with faecolith – stones made of poo
Bacterial
Viral (clustering of cases) – especially in kids
Parasites
Describe the pathology of appendicitis?
Lumen may or may not be occluded Mucosal inflammation – increases blood supply into the appendix Lymphoid hyperplasia Obstruction Build up of mucus and exudate Venous obstruction Ischaemia..bacterial invasion through wall – black appendix Perforation
In what situation can peritonitis be fatal?
Age
Immunosuppression
Diabetes
Absence of omentum (previous surgery)
Ruptured - causes peritonitis
What are the clasical symptoms of appendicitis?
Central pain that migrates to RIF Anorexia Nausea One or two vomits May not have moved bowels Pelvic: vaguer pain localisation: rectal tenderness Elderly – atypical symptoms
What are the classical signs of appendicitis?
Mild pyrexia (never high temp initially) – 37.8-38.2
Mild tachycardia – around 100bpm
Localised pain in RIF
Guarding
Rebound – peritoneum moves fast when your hand it taken away
Name some specific named signs of appendicitis?
Rosving’s:
Pressing on the left causes pain on the right
Psoas:
Patient keeps the right hip flexed as this lifts an infmaled appendix off the psoas
Obturator:
If appendix is touching obturator internus, flexing the hip and internally rotting will cause pain
Pointing:
Where did it start, where it is now?
Name 3 rare forms of appendicitis?
Retrocaecal appendix: May be very few signs
Pelvic appendix: Diarrhoea, frequency of micturition
Postileal: Rare, diarrhoea, vomiting
How can appendicitis be diagnosed?
CLINICAL diagnosis – ultrasound scan useful in women and children but not men
USS useful in women and kids
AXR to exclude other causes – abdo x-ray – lots of radiation though so bad
Bloods (important CRP, WCC)
Urinalysis
MANTRELS mnemonic
What is the management of appendicitis?
Analgesia Antipyretics Theatre Antibiotics Appendicectomy - Laparascopic (best) - Convert to open sometimes (not first line) - Laparotomy sometimes
What is the management of an appendix mass?
Antibiotics first line
Can operate or not –don’t often go to theatre
Theatre if fails or complicated
- Tachycardia
- Worsening pain
- Increase in size
- Vomiting or copious NG aspirates (ileus)
What are the complications of appendicitis?
Pelvic abscess Wound infection Intra-abdominal abscess Ileus – bowels just stop working Respiratory DVT/PE Portal pyaemia Faecal fistula Adhesions Right sided inguinal hernia
Describe a carcinoid of the appendix?
Crypts of Lieberkuhn
Stains for chromagrannin
If less than 1cm appendicectomy alone
If greater than 2cm completion right hemi
What are the symptoms of small bowel obstruction?
Pain (colicky, central) Absolute constipation Vomiting Burping Abdominal distension
What causes small bowel obstruction?
Within the lumen (gallstone, food, bezoar)
Within the wall (tumour, Crohn’s, Radiation - causes stricture)
Outside the wall (Adhesions, Herniation) - most common
What are the clinical signs of SBO?
Distension Vomiting Borborygmi Pain Faeculent vomiting Presence of a cause
What investigations can be done for SBO?
Assessing the state of the patient - Urinalysis - Bloods - Gases Confirming the diagnosis - AXR - Contrast CT scan of abdomen (looks like the pateint has swallowed the very hungry caterpillar) - Gastrograffin studies – very rare
What is the management for small bowel obstruction?
"Drip and Suck" ABC Analgesia Fluids with Potassium They are usually hypokalaemic and alkalotic – need IV fluids Catheterise – urinary NG tube (Ryles tube not a feeding) Antithromboembolism measures – TED stockings
Up to 72 hours is standard Intervene earlier if: Strangulation Perforation Ischaemia
When would you not use the drip and suck technique?
when the pateint has a hernia
What is the surgical management of SBO?
Laparotomy
What is the cause of Mesenteric ischeamia?
Embolus, thrombosis (arterial and venous) from AF
- small intestine does not have a marginal artery so it is easier to be occluded
When would you suspect mesenteric ischeamia? (i.e. dead gut)
when the patient is requiring more pain relief than they should
How is mesenteric ischeamia diagnosed?
Pain out of proportion to the clinical findings
Acidosis on gases (low pH, high H+ concentration, high BE)
Lactate elevated
CRP may be normal
WCC may be up a bit
CT angiogram
At laparotomy
Intervene before your patient is moribund – at the point of death
How is mesenteric ischeamia managed?
Resect if non-viable
Re-anastomse or staple and planned return
If viable you can rarely perform an SMA embolectomy
What is Meckel’s diverticulum?
60cm from IC valve (2 feet) 2% of population Present before 2 years of age Usually incidental Remnant of the omphalomesenteric duct Complications - Bleed (haematochezia) - Ulcerate/meckels diverticulitis - Obstruction - Malignant change (0.5%)
