Stomach, Small and Large Bowel

Question 1

4 cardinal symptoms of intestinal obstruction?

Answer 1

pain-colicky
absolute constipation- neither faeces nor flatus passed, obstipation= severe constipation due to obstruction
vomiting
abdominal distension

Question 2

describe characteristics of mesenteric ischaemia?

Answer 2

acute abdominal pain occurs with sudden mesenteric artery occlusion causing bowel infarction
ptnt usually middle-aged, male smoker, with other signs of arterial disease e.g. IC, angina or previous MI.
also occurs with volvulus, and presents similarly to venous occlusion seen in pro-thrombotic conditions.
abdom pain prod in SLE and sickle cell disease may be related to mesenteric ischaemia.

Question 3

what are the symptoms and signs of meckel’s diverticulitis indistiguishable from?

Answer 3

acute appendicitis

although pain and tenderness generally felt more towards centre of abdomen than RIF.

Question 4

what is gastroenteritis usually caused by?

Answer 4

campylobacter or viral infection

Question 5

how are diverticula thought to form?

Answer 5

disordered colonic peristalsis, which may be the result of constipation. Peristalsis in neighbouring colon segemnts causes high intraluminal pressure in between which may allow herniation of mucosa through bowel wall at points of wknesss e.g. where blood vessels enter.

Question 6

why do the appendix and rectum not have diverticula?

Answer 6

have continuous longitudinal muscle layer
rather than taenia- colonic diverticula occur between antimesenteric taenia and the omental and free taenia, at site of b.vessel entry.

Question 7

why might a diverticulum become inflamed?

Answer 7

thickened faecolith obstructs neck of diverticulum

Question 8

symptoms of acute diverticulitis?

Answer 8

lower abdominal colic
followed by constant LIF pain
rebound tenderness and guarding result

Question 9

complication of diverticula that carries a mortality of 50%?

Answer 9

perforation producing a faecal peritonitis

Question 10

how does haemorrhage occur with diverticula?

Answer 10

neck of diverticulum sandwiched between a faecolith and a colonic b.vessel

Question 11

CI to investigating diverticula with flexible sigmoidoscopy and colonoscopy?

Answer 11

acutely inflamed distal colon as bowel perforation may result
can also CT, and barium enema- good for diagnosis 6 wks following symptom resolution

Question 12

tment of acute diverticulitis or diverticular mass?

Answer 12

antibiotics- BS, cephalosporin combined with metronidazole.

high fibre diet once inflammation settled, fibre supplements

Question 13

usual operation for diverticulitis causing peritonitis?

Answer 13

Hartmann’s procedure: excise affected colon and create LIF end colostomy.
carried out as left colonic anastamoses have high leak rates if performed in obstructed bowel or if peritonitis.

Question 14

why might elective resection be carried out for diverticulosis?

Answer 14

for those with chronic symptoms e.g. pain or recurrent bleeding.
sigmoid colectomy with primary anastamosis usually sufficient.

Question 15

causes of stomach ischaemia?

Answer 15

RARE- as good anastamoses- collateral circulation?, e.g. lesser curvature supplied by both left gastric artery from celiac trunk at T12 and right gastric artery from common hepatic artery, and greater curvature- right gastroepiploic from gastroduodenal and left gastroepipoic from splenic.

causes= hiatal hernia or stomach folded in on itself

Question 16

contrast DRE for pseudobstruction and sigmoid volvulus?

Answer 16

air on DRE with pseudobstruction

Question 17

what sign may be visible on an abdominal X-ray if small bowel obstruction has been complicated by perforation?

Answer 17

Rigler’s sign= air on both sides of the bowel with intra-abdominal gas next to gas-filled loop of bowel, making bowel wall well defined.

Question 18

when is intestinal obstruction NOT operated on?

Answer 18

small bowel- adhesions, and no signs of peritonitis

large bowel- volvulus, and no signs of peritonitis

Question 19

investigation of intestinal obstruction?

Answer 19

AXR/CXR

with or without CT

Question 20

3 most common causes of small bowel obstruction?

Answer 20

adhesions
hernias
strictures- e.g. Crohn’s

Question 21

3 most common causes of large bowel obstruction?

Answer 21

cancer- 90% of LBOs
stricture- diverticular disease, Crohn’s-transmural inflammation
volvulus

Question 22

how can a benign stricture form obstructing outflow from stomach?

Answer 22

fibrotic healing post peptic ulcer

Question 23

location of deep inguinal ring?

Answer 23

mid point of inguinal ligament

indirect inguinal hernias go through DIR

Question 24

hernia characteristics of cause of SBO?

Answer 24

tender

if so, needs operation as increased risk of perforation and ischaemia

Question 25

importance of adequate exposure in AXR inferiorly (to both greater trochanters) in determining if small bowel obstruction present?

Answer 25

look for gas in rectum- if present, then NOT complete obstruction.

*perfect circle= bladder on CT

Question 26

peaks in incidence of gastric cancer?

Answer 26

55-65 yrs
2X common in males
assoc. with H.pylori and blood group A

Question 27

common 1st presentation of gastric cancer?

Answer 27

dyspepsia and indigestion pains

Question 28

post-gastrectomy complications?

Answer 28

diarrhoea
osmotic and hypoglycaemia dumping
anaemia
malnutrition

Question 29

what tment might early low-grade MALT lymphomas of the stomach respond to?

Answer 29

H.pylori eradication theapy= clarithromycin and amoxicillin/metronidazole + PPI

Question 30

immediate management of bowel obstruction?

Answer 30

drip and suck- IV fluids and NG tube, must rehydrate and correct electrolyte balance, and give bowel rest
also want FBC, Us and Es, amylase, AXR, erect CXR, catheterise to monitor fluid status

Question 31

what might CT show in bowel obstruction?

Answer 31

dilated, fluid-filled bowel and a transition zone at site ob obstruction= from dilated to non-dilated bowel

Question 32

symptoms of stomach volvulus?

Answer 32

vomiting, then retching
pain
failed attempts to pass NG tube
salive regurgitation

dysphagia and noisy gastric peristlasis (relieved by lying down) may occur in chronic volvulus

Question 33

RFs for stomach volvulus?

Answer 33

pyloric stenosis
congenital bands
bowel malformations
paraoesophageal hernia
gastric/oesophageal surgery

Question 34

tests for stomach volvulus?

Answer 34

look for gastric dilatation and a double fluid level on erect films