Surgery Flashcards
List some causes of generalised abdominal pain
Peritonitis
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis
List some causes of right upper quadrant pain
Biliary colic
Acute cholecystitis
Acute cholangitis
List some causes of epigastric pain
Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured abdominal aortic aneurysm
List some causes of right iliac fossa pain
Acute appendicitis
Ectopic pregnancy
Ovarian torsion
Meckel’s diverticulitis
List some causes of left iliac fossa pain
Diverticulitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
List some causes of suprapubic pain
Lower urinary tract infection
Acute urinary retention
Pelvic inflammatory disease
Prostatitis
List some causes of loin to gorin pain
Renal colic
Ruptured aortic aneurysm
Pyleonephritis
List some causes of testicular pain
Testicular torsion
Epididymo-orchitis
What is peritonitis
Inflammation of the peritoneum
List some signs of peritonitis
Guarding - involuntary tensing of the abdominal wall muscles when palpated to protect the painful area
Rigidity - involuntary perisitent tightness or tensing of the abdominal wall muscles
Rebound tenderness - rapidly releasing pressure on the abdomen creating a worse pain than the pressuure itselg
Coughing test - coughing results in pain
Percussion tenderness - pain and tenderness when percussing the abdomen
What is local peritonitis
Caused by underlying organ inflammation
What is generalised peritonitis
Caused by perforation of the abdominal contewnts into the peritoneal cavity
What is spontaneous bacterial peritonitis
Associated with spontaenous infection of ascites in liver disease patients
How is spontaneous bacterial peritonitis treated
Broad spectrum antibiotics and supportive care
Describe the initial assessment of an acute abdomen patient
A to E approach
Airway - ensure secure and patent
breathing - RR, O2 sats, listen to lungs and give O2 if required
Circulation - assess BP, HR, heart sounds and perfusion. Gain IV access, take blood and provide IV bolus fluid if required
Disability - assess consciousness level - GCS/AVPU, check blood glucose
Exposure - examination of abdomen
What investigations are useful in obtaining a diagnosis in acute abdomen?
FBC - drop in Hb and infection/inflammation high WCC
U&Es - electrolyte imbalance and kidney function - prior to CT scans which require contrast
LFTs - biliary and hepatic system
CRP - inflammation and infection
Amylase - pancreatitis
INR - synthetic state of the liver, establish the coagulation prior to procedures
Serum calcium - score acute pancreatitis
Serum hCG or urine pregnancy test in women of child bearing age
ABG - lactate (tissue ischaemia) and pO2 (used in scoring of acute pancreatitis)
Serum lactate - tissue ischaemia as product of anaerobic respiration and can be raised in dehydration or hypoxia
Group and save - essential prior to theatre in case patient needs a blood transfusion
Blood cultures - infection suspected
Abdominal X-ray - bowel obstruction - dilated bowel loops
Erect CXR - air under diaphragm when there is intra-abdominal perforation - caused by air in the peritoneum
Abdominal USS - gallstones, biliary duct dilation and gynaecological pathology
CT scans - identify the cause of acute abdomen - determine the correct management
Describe the initial management of acute abdomen
ABCDE
Alert seniors - escalate to reg, consultant and critical care as required
NBM - surgery may be required
NG tube - bowel obstruction
IV fluids - resuscitation or maintenance
IV antibiotics – if infection is suspected
Analgesia 0 pain management
Arrange investigations
Venous thromboembolism risk assessment and prescription if indicated
Prescribe regular medication and see which should be withheld
What does the suffix -ostomy mean?
Creating a new opening
What are adhesions
Scar like tissue inside the body that bidns surfaces together
What is a fistula
Abnormal connection between two epithelial surfaces
What is tenesmus
The sensation of needing to open the bowels without being able to produce stool. Often accompanied with pain
Define hemicolectomy
Removing a portion of the large intestine (colon)
Define hartmann’s procedure
Proctosigmoidectomy - removal of the rectosigmoid colon with closure of the anorectal stump and formation of colostomy
What is an anterior resection
Removal of the rectum
What is a Whipples procedure
Pancreaticoduodenectomy -
Removal of the head of the pancreas, duodenum, gallbladder and bile duct
What is a Kocher incision for
Open cholecystectomy
What is a Chevron/rooftop incision for
Liver transplant, whipple procedure, pancreatic surgery or upper GI surgery
What is a Mercedes Benz incision for
Liver transplant
What is a midline incision for
General lapartomy
What is a paramedian incision for
Laparotomy
What is a hockey stick incision for
Renal transplant
What is a battle incision for
Open appendicetomy
What is a McBurney incision for
Open appendicetomy
What is a Lanz incision for
Open appendicetomy
What is a rutherford morrison incision for
Open appedicetomy and colectomy
Describe a pfannelstiel incision
Curved incision two fingers above pubic symphysis
C-section
Describe a Joel-Cohen incision
Straight incision slightly higher - recommended
C-section
Describe the incisions in laparoscopic surgery
Several 5-10mm incisions to allow the cameras and instruments to be inserted into the abdomen via port sites - site just above or below umbilicus
Describe diathermy
High frequency electrical current to cut through tissues or to stop bleeding. It causes localised burning of tissues - targeted incision with minimal bleeding
Monopolar diathermy - grounding plate under leg of patient to form a circuit of electricity. Causes localised burning and tissue damage. The electrical signal passes round the body but becomes weaker so does not damage other tissues
Bipolar diathermy - involves an instrument with two electrodes and current passes between the electrodes affecting the tissues - does not pass to rest of the body
Describe absorbable sutures
Slowly absorbed and disappear over time - vicryl and monocryl
Used in tissues that heal well and remain sealed after suture absorbed such as abdominal cavity and closing the tissues beneath the dermis
Describe non-absorbable sutures
Remain in place for a long time to provide support
Nylon, silk, polypropylene
Interrupted or mattress suture and removed later once the skin has healed, fixing drains in place and removed later with the drain, connective tissues that heal slowly such as repairing tendons
How is the surface of skin closed
Staples
Interrupted suture - series of individual knows
Mattress suture - series of individual sutures that each go from one side of the wound, under and out the other side then back under again to the original side
Continius sutures 0 in and out, spiral shape
Subcuticular sutures - single absorbale suture side to side just below the skin to pull the edges together
Describe drains
Tubes in body to allow air and fluid to drain away preventing build up of air, pus, blood or other fluid collecting
Chest drain
How do you know if a chest drain is in the right place
Swinging - water in the drain will rise and fall due to normal pressure changes in the chest
When is the WHO surgical safety checklist performed
3 stages
- Before induction of anaesthesia
- Before the first skin incision
- Before the patient leaves theatre
List the factors checked in the WHO surgical checklist
Patient identity Allergies Operation Risk of bleeding Introductions of all team members Anticipated critical events Counting equipment to ensure nothing is still in the patient
Describe what happens in pre-operative assessment
Past medical problems Previous surgery Previous adverse responses to anaesthesia Medications Allergies Smoking Alcohol use Malnourished - dietician and additional nutritional support
Describe the ASA grade
American society of anesthiologists grading system classifies the physical status of the patient for anaesthesia
ASA1 - normal healthy patient
ASA 2 - mild systemic disease
ASA 3 - severe systemic disease
ASA 4 - severe systemic disease that constantly threatens life
ASA V - moribund and expected to fie without the operation
ASA VI - declared brain dead and undergoing organ donation
E - emergency operations
List some pre-op investigations
ECG - if known or possible CVD
Echo - heart murmurs, cardiac failure or symptoms
Lung function tests - known or possible respiratory disease
HbA1C - within last 3 months in patients with known diabetes
U&Es - at risk of AKI or electrolyte abnormalities due to medication
FBC - anaemia, CVD or kidney disease
Clotting if known liver disease
Group and save - send off sample of patients blood to establish blood group. Sample is saved in case they require blood to be matched to them for blood transfusion and no blood is assigned to them at this stage
Cross matching - acutely take a unit or more of blood and assign it to the patient in case they need it quick
MRSA screening
How long must patients fast for before surgery
6 hrs of no food or feeds before operation
2 hours of clear fluids (fully NBM)
How long before an operation should the COCP and HRT be stopped?
4 Weeks
What can be given to rapidly reverse anticoaglation in patients taking warfarin
Vitamin K
How long before surgery are DOACs stopped
24-72hrs
Describe the medication change before surgery in patients who take long term corticosteroids
Additional IV hydrocortisone at induction and for immediate postop period
Doubling of normal dose for 24-72hrs after operation
Describe insulin use in surgery
Reduce their ling acting insulin
Omit their short acting insulin
Place on variable rate insulin infusion alongside glucose, sodium and potassium
Describe the VTE prophylaxis during surgery
LMWH - enoxaparin
DOACs - apixaban, rivaroxaban
Intermittent pneumatic compression
Anti-embolic compression stockings
What is the extracellular space
Intravascular space - inside blood vessels
Interstitial space - functional tissue space between and around cells
Third space - third extracellular space
What is the third space
Areas of the body which do not usually contain fluid
Peritoneal cavity - ascites
Pleural cavity - pleural effusion
Pericardial cavity - pericardial effusion
joint - joint effusions
What are the two categories of fluid spaces in the body
Intracellular space
Extracellular space
Describe the process of third spacing
Fluid shifting into the third space
Development of oedema as excessive fluid moves into the intersitital space
Development of ascites, effusions or other non-functional space - hypotension and reduced perfusion of tissue
List some sources of fluid intake
Oral fluids
NG or PEG feeds
IV fluids
Total parenteral nutrition
List some sources of fluid output
Urine output Bowel or stoma output Vomit or stomach aspiration Drain output Bleeding Sweating
What are insensible fluid losses
Fluid output that is difficult to measure - respiration, stools, burns and sweat - estimated
What are some signs of hypovolaemia
Hypotension Tachycardia CRT >2 seconds Cold peripheries Raises RR Dry mucous membranes Reduced skin turgor Reduced urine output Sunken eyes Reduced body weight from baseline Feeling thirsty
What are some signs of hypervolemia
Peripheral oedema
Pulmonary oedema - SOB, raised JVP, reduced O2 sats, bibasal crackles
Raised JVP
Increased body weight from baseline
Describe the clinical picture of someone with third spacing
Low level of fluid in the intravascular space but excessive lfuid in other areas (interstitial fluid or peritoneal cavity)
Hypovolaemia signs and signs of fluid overload
List the main indications for IV fluid
Resuscitation
Replacement
Maintenance
Name the two main types of fluid
Crystalloids
Colloids
Describe crystalloids
Water with added salt or glucose - 0.9% sodium chloride 5% dextrose 0.18% sodium chloride 4% glucose Hartmann's solution Plasma lyte 148
What does 1 L normal 0.9% saline contain
1L water
154mmol Na
154mmol Cl
What does 1L 5% dextrose contain
1 L water
No electrolytes
50g glucose
What can too much normal saline cause
Hypernatraemia
What can too much 5% dextrose cause
Oedema and hyponatraemia - hypotonic fluid
What does 1L Hartmanns solution contain
1L water 131mmol Na 111 mmol Cl 5 mmol K 2 mmol Ca 29mmol lactate - buffer the solution - reduce the risk of acidosis
Describe colloids
Larger molecules that stay in the intravascular space longer - help retain the fluid in intravascular space
eg. human albumin solution - used in patients with decompensated liver disease. Increases plasma oncotic pressure drawing in and retaining fluid
What does tonicity refer to
The osmotic pressure gradient between two fluids across a membrane - determines whether water molecules will move across the membrane by osmosis
Describe how you give a fluid bolus in resus situation
500ml bolus over 15mins (stat)
Reassess ABCDE
Repeat boluses 250-500ml if required followed by reassement each time
How much water does a person need a day in terms of maintenance
25-30ml/kg/day
How much sodium, potassium and chloride does a person need in a day for maintenance
1mmol/kg/day
How much glucose does a person need a day for maintenance
50-100g/day
What is appendicitis
Inflammation and infection of the appendix
Can rupture
Describe the pain in appendicitis
Starts as central abdominal pain that moves down to become localised at the right iliac fossa in the first 24hrs
List some features other than abdominal pain which present in appendicitis
Loss of appetite Nausea and vomiting Low grade fever Guarding Rebound tenderness on RIF Percussion tenderness
What is Rovsing’s sign?
Appendicitis - Palpation of the LIF causes pain in the RIF
Where is McBurney’s point
1/3 From the ASIS to the umbilicus
What is rebound tenderness a sign of
Peritonitis
How is appendicitis diagnosed
Clinical presenation
Raised inflammatory markers
CT scan if other diagnosis more likely
USS in children and females (exclude gynae problem)
Period of observation if unclear or when clear clinical presentation but negative investigations perform a diagnostic laparoscopy
List some differentials of appendicitis
Ectopic pregnancy
Meckel’s diverticulum
Ovarian cysts
Mesenteric adenitis
Describe an appendix mass
Where the omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa.
How is an appendix mass managed
Conservatively with supportive treatment and antibiotics followed by appendicectomy once the acute condition has resolved
What is the management of appendicitis
Appendicectomy - laparoscopic is preferred to open
Which bowel obstruction is most common
Small bowel
Describe third spacing in bowel obstruction
The bowel secretes fluid which in normal instances is reabsorbed in the colon. When there is an obstruction, the fluid cannot be reabsorbed so there is fluid loss from the intravascular space into the GI tract. This leads to hypovolaemia and shock. The higher up in the intestine, the greater the fluid loss
List some causes of bowel obstruction
Adhesions (small bowel)
Hernias (small bowel)
Malignancy (large bowel)
Others: Volvulus (large bowel), diverticular disease, strictures, intussusception in children
List the main causes of intestinal adhesions
Abdominal or pelvic surgery
Peritonitis
Abdominal or pelvic infection
Endometriosis
What is meant by closed loop obstruction
Two points of obstruction along the bowel - middle section sandwiched between two points of obstruction
The contents of closed loop section do not have an open end where they can drain and decompress, therefore the section will inevitably continue to expand, leading to ischaemia and perforation
List some causes of closed loop obstruction
Adhesions
Hernia
Volvulus - twist
Single point of obstruction and competent ileocaecal valve
What is meant by a competent ileocecal valve in terms of obstruction
Ileocaecal valve does not allow any movement back into the ileum from the caecum
When there is a large bowel obstruction and a competent ileocecal valve, a section of bowel becomes isolated and the contents cannot flow in either direction
List some key features in bowel obstruction
Vomiting - bilious green vomit
Abdominal distension
Diffuse abdominal pain
Absolute constipation and lack of flatulence
Tinkling bowel sounds heard early in obstruction
What might be seen on abdominal X-ray in bowel obstruction
Distended loops of bowel
3cm small bowel
6cm colon
9cm caecum
What are valvulae conniventes
Small bowel mucosal folds
Extend the full width of the small bowel
What are haustra
Pouches formed by the muscles in the large bowel walls. They form lines which do not extend the full width - only part of the way across the bowel
Describe the inital management of bowel obstruction
ABCDE
Fluids - hypovolaemic shock due to third spacing
U&Es - electrolyte imbalance
Lactate - vowel ischaemia
Metabolic alkalosis - VBG - vomiting stomach acid
Drip and suck - NBM, IV fluids, NG tube with free drainage (allow stomach contents to freely drain and reduce risk of aspiration and vomiting)
What investigations might be useful in bowel obstruction
Abdominal Xray
Contrast abdominal CT scan - confirm diagnosis, establish site and cause. Also used to diagnose intra-abdominal perforation
Erect CXR - air under diaphragm
Describe the management of bowel obstruction after initial management
Conservative if volvulus or adhesions and patient stable
Laparotomy or laparoscopy - exploratory surgery, adhesolysis, hernia repair, emergency resection of tumour
Colonoscopy - stents in bowel if obstruction due to tumour and not for resection
Describe ileus
Normal peristalsis of the small bowel temporality stops
Describe pseudo-obstruction
Functional obstruction of the large bowel - patients present with intestinal obstruction but no mechanical cause is found
Less common than ileus affecting the small bowel
List some causes of ileus
Injury to the bowel
Handling of the bowel during surgery - most common
Inflammation or infection in or nearby the bowel
Electrolyte imbalance - hypokalaemia and hyponatraemia
List the signs and symptoms of bowel obstruction
Vomiting - green bilious vomit
Abdominal distension
Diffuse abdominal pain
Absolute constipation and lack of flatulence
Absent bowel sounds - as opposed to tinkling bowel sounds of mechanical obstruction
Describe the management of ileus
NBM NG tube if vomiting IV fluids - prevent dehydration and correct electrolyte imbalances Mobilisation Total parenteral nutrition
What is volvulus
Where the bowel twists round itself and the mesentery it is attached to
What is mesentery
Membranous peritoneal tissue that creates a connection between the bowel and the posterior abdominal wall
What does a volvulus cause
Closed loop obstruction
How does volvulus affect the blood vessels supplying the bowel
Mesenteric arteries supply the bowel and if involved they can cut off the supply to the bowl leading to ischaemia, necrosis and bowel perforation
Name the two types of volvulus
Sigmoid
Caecal
Describe sigmoid volvulus
Most common
Affects older people
Twist affects the sigmoid colon
Caused by chronic constipation where the mesentery lengthens and twists, high protein diet and excessive use of laxatives
Describe caecal volvulus
Less common
Affects younger patients
List some risk factors for volvulus
Neuropsychiatric disorders - PD Nursing home residents Chronic constipation High fibre diet Pregnancy Adhesions
Describe the presentation of volvulus
Green bilious vomiting
Abdominal distension
Diffuse abdominal pain
Absolute constipation and lack of flatulence
How is volvulus diagnosed
Abdominal Xray
Contrast CT scan
What is the pathognomonic sign of volvulus
Coffee bean sign
Describe the management of volvulus
NBM
NG tube
IV fluids
Conservative management - endoscopic decompression with sigmoid voluvlus. Flexible sigmoidoscope is inserted with patient in left lateral potion, correction of the volvulus. A flatus tube/rectal tube is left temporarily in place to decompress the bowl and is later removed
Surgical management
- Laparotomy
- Hartmann’s procedure - removal of rectosigmoid colon and formation of colostomy
- Ileocaecal resection or right hemicolectomy for caecal volvulus
What is Rigler’s sign
Double wall sign
Signifies free air in the abdomen
What is the Borchardt’s triad of gastric volvulus
Vomiting
Severe epigastric pain
Failed NG tube attempts
What are the features of gallstone ileus
Small bowel obstruction
Pneumobilia - air in the biliary tree
What is a hernia
The protrusion of a viscus/part of a viscus through a hole/defect in the wall of its containing cavity into an abnormal position
Describe the presenting features of a hernia
Soft lump protruding from abdominal wall
Lump may be reducible
Lump may protrude on coughing or standing
Aching, pulling or dragging sensation
List the three complications of hernias
Incarceration
Obstruction
Strangulation
Describe what is meant by incarceration of a hernia
Irreducibility of the hernia - can lead to obstruction and strangulation
Describe what is meant by obstruction of a hernia
Blockage in passage of faces through the bowel
Vomiting, generalised abdominal pain and absolute constipation
Describe what is meant by a strangulated hernia
Non-reducible hernia and the base becomes so tight it cuts off the blood supply causing ischemia
How does a strangulated hernia present
Significant pain and tenderness at the hernia site
Mechanical obstruction
Describe what affects the risk of obstruction and strangulation of a hernia
The size of the neck - hernias with a large neck at lower risk
If the hernia is reducible
Describe Richters hernia
Part of the bowel wall and lumen herniate through the defect with the other side of the section of bowel remaining in the peritoneal cavity
Becomes strangulated and rapidly necrotic
Describe a Maydl’s hernia
2 different loops of bowel are contained within the hernia
Describe the management of hernias
Conservative - do nothing Tension free repair (surgery) - mesh Tension repair (surgery) - sutures
What is found in the inguinal canal
Spermatic cord - males
Round ligament - females
What is the inguinal canal
Tube that runs between the deep inguinal ring and superficial inguinal ring
Describe an indirect hernia and how to examine one
Passage of bowel through the deep inguinal ring
When pressure applied to the deep ring (midway between ASIS and pubic tubercle) the hernia is reduced and remains reduced
Describe a direct inguinal hernia and how to examine one
Occur due to weakness in the abdominal wall at Hesselbach’s triangle
The hernia protrudes directly through the abdominal wall
Pressure over the deep ring will not stop herniation
List the boundaries of Hesselbach’s triangle
Rectus abdominis muscle - medial border
Inferior epigastric vessels - superior and lateral border
Pouparts ligament (inguinal ligament) - inferior border
Describe a femoral hernia
Herniation of the abdominal contents through the femoral canal
Below the inguinal ligament at the top of the thigh
List the boundaries of the femoral canal
Femoral vein laterally
Lacunar ligament medially
Inguinal ligament anteriorly
Pectineal ligament posteriorly
Describe the contents of the femoral triangle from lateral to medial
Femoral nerve
Femoral artery
Femoral vein
Femoral canal
Describe incisional hernias
Site of an incision from previous surgery
Weakness where the muscles and tissues were closed after a surgical incision
Bigger the incision and if co-morbidities which delay wound healing
Describe an umbilical hernia
Occur around the umbilicus due to a defect in the muscle around the umbilicus
More common in neonates and resolve spontaneously, also in older adults
Describe epigastric hernias
Hernia in epigastric area
Describe diastasis recti
Rectus diastasis and recti divarication
Refers to widening of the linea alba, the connective tissue that separates the rectus abdominis muscle, forming a larger gap between the rectus muscle
Gap becomes more prominent when the patient lies on their back and lifts their head - protruding buldge along the middle of the abdomen
Who is more at risk of diastasis recti
Pregnancy
Obesity
Connective tissue disease
Can be congenital
Describe an obturator hernia and its sign
Where abdominal or pelvic contents herniate through the obturator foramen at the bottom of the pelvic. They occur due to a defect in the pelvic floor and are more common in women, old age, after multiple pregnancies and vaginal deliveries
Present with irritation of the obturator nerve
Howship-romberg sign - pain extending from the inner thigh to the knee when the hip is internally rotated
What is a hiatus hernia
Herniation of the stomach up through the diaphragm
4 types
Sliding - stomach slides up through the diaphragm with the gastro-oesophageal junction passing into the thorax
Rolling hiatus hernia - separate portion of the stomach folds around and enters the diaphragm opening alongside the oesophagus
Type 4 - large hernia that allows other intra-abdominal organs to pass through the diaphragm opening
List some risk factors for hiatus hernias
Increasing age
Pregnancy
Obesity
List the symptoms of hiatus hernias
Heartburn Acid reflux Reflux of food Burping Bloating Halitosis
List some investigations for hiatus hernias
CXR
CT scan
Endoscopy
Barium swallow test
How is hiatus hernia treated?
Conservative - medical management of GORD
Surgical repair - high risk of complications or symptoms resistant to medical Rx- fundoplication
Describe haemorrhoids
Enlarged anal vascular cushions
List some risk factors for haemorrhoids
Pregnancy
Obesity
Increased age
Increased abdominal pressure - weigh lifting and constipation
What are the anal cushions
Specialised submucosal tissue that contain connections between the arteries and veins, making them very vascular. They are supported by smooth muscle and connective tissue. They help to control anal continence along with internal and external sphincters - blood supply is from the rectal arteries
Describe the classification of haemorrhoids
1st degree - no prolapse
2nd degree - prolapse when straining and return on relaxing
3rd degree - prolapse when straining, does not return on relaxing but can be pushed back
4th degree - prolapse permanently
List some symptoms of haemorrhoids
Constipation Straining Bright red, painless bleeding - toilet tissue or seen after opening the bowels Blood is not mixed with stool Sore/itchy anus Feeling a lump inside or around anus
Describe the examination of haemorrhoids
External (prolapsed) haemorrhoids are visible on inspection as swellings covered in mucosa
Internal haemorrhoids may be felt on PR exam
They may appear (prolapse) if the patient is asked to bear down during inspection
Proctoscopy is required for proper visualisation and inspection - visualise the mucosa
Describe the management of haemorrhoids
Topical treatment - anusol, germaloid cream
Prevention and treatment of constipation - increase fibre intake, maintain good fluid intake, using laxatives, consciously avoiding straining when opening bowels
Non-surgical options - rubber band ligation, injection sclerotherapy, infra-red coagulation, bipolar diathermy
Surgical - haemorrhoidal artery ligation, haemorrhoidectomy, stapled haemorrhoidectomy
What are thrombosed haemorrhoids
Strangulation at base of haemorrhoid and blood clot inside
Painful
Purple, very tender, swollen lumps around anus
Resolve with time although very painful may require admission for surgery if patient presents <72hrs
What is diverticulosis
Presence of diverticula with or without inflammation or infection
What is diverticulitis
Inflammation and infection of diverticula
How does diverticulosis occur
Large instestine contains a layer of muscle called the circular muscle. Points penetrated by blood vessels are areas of weakness. Increased pressure inside the lumen over time causes a gap to form in these areas and allow mucosa to herniate through the muscle layer and pouches to form
List some risk factors for diverticulosis
Increased age
Low fibre diet
Obesity
Use of NSAIDs
What symptoms may diverticulosis present with
Lower left abdominal pain
Constipation
Rectal bleeding
Describe the management of diverticulosis
High fibre diet
Bulk forming laxatives
Stimulant laxatives
Describe how patients with acute diverticulitis present
Pain and tenderness in the LIF Fever Diarrhoea Nausea and vomiting Rectal bleeding Palpable abdominal mass Raised inflammatory markers and WBC
Describe the management of uncomplicated diverticulitis
Oral co-amoxiclav
Analgesia
Only taking clear liquids until symptoms improve
Follow up within 2 days to review symptoms
Describe the management of complicated diverticulitis
NBM IV antibiotics IV fluids Analgesia Urgent investigations Urgent surgery may be required for complications
List some complications of acute diverticulitis
Perforation Peritonitis Peri diverticular abscess Large haemorrhage requiring blood transfusions Fistula Ileus/obstruction
What is mesenteric ischaemia
Lack of blood flow through the mesenteric vessels supplying the intestines, resulting in ischaemia
Which artery supplies the foregut
Coeliac artery
Describe what is meant by the foregut
Stomach, part of duodenum, biliary system, liver, pancreas and spleen
Which artery supplies the midgut
Superior mesenteric artery
What comprises the midgut
Distal duodenum to the first half of the transverse colon
Which artery supplies the hindgut
Inferior mesenteric artery
What comprises the hindgut
Second half of the transverse colon to the rectum
Describe chronic mesenteric ischaemia
Intestinal angina
Atherosclerosis causing narrowing to the mesenteric blood vessels
Triad
- Central colicky abdominal pain after eating (starting 30 mins after and lasting 1-2hrs)
- Weight loss due to food avoidance
- Abdominal bruit may be heard on auscultation
List some risk factors for chronic mesenteric ischaemia
Increased age Family history Smoking Diabetes Hypertension Raised cholesterol
How is chronic mesenteric ischaemia diagnosed?
CT angiography
Describe the management of intestinal angina
Reducing modifiable risk factors
Secondary prevention - statins and antiplatelet medication
Revascularisation to improve the blood flow to the intestines - endovascular procedures or open surgery
Describe acute mesenteric ischaemia
Rapid blockage in blood flow through the superior mesenteric artery - thrombus
What is a key risk factor for acute mesenteric ischaemia
AF - thrombus forms in the left atrium, then mobilises (thromboembolism) down the aorta to the superior mesenteric artery where it becomes stuck and cuts off the blood supply
How does acute mesenteric ischaemia present
Intense pain that is disproportionate to the examination findings
Patients can go on to develop shock, peritonitis and sepsis and necrosis of the bowel and perforation
How is acute mesenteric ischaemia diagnosed
Contrast CT
Metabolic acidosis
Raised lactate
Describe the treatment of mesenteric ischaemia
Remove the necrotic bowel
Bypass or remove the thrombus in the blood vessel
List some risk factors of bowel cancer
Family history Age Smoking Familial adenomatous polyposis Hereditary nonpolyposis colorectal cancer - lynch syndrome Obesity Alcohol
Describe familial adenomatous polyposis
Autosomal dominant condition involving malfunctioning of the tumour suppressor genes (adenomatous polyposis coli)
Many polyps forming along the large intestine before age 40
These have the potential to become cancerous
Patients have their entire large intestine removed prophylactically (pan proctocolectomy) `
Describe hereditary nonpolyposis colorectal cancer
Lynch syndrome
Autosomal dominant
Mutations of DNA mismatch repair genes
Patients are at a higher risk of a number of cancers but particularly colorectal cancer
List some red flags for bowel cancer
Change in bowel habit - usually more frequent and loose Unexplained weight loss Rectal bleeding Unexplained abdominal pain Iron deficency anatima Abdominal or rectal mass on examination
List the people referred under the 2 week wait pathway for bowel cancer
Over 40 with abdominal pain and unexplained weight loss
Over 50 with unexplained rectal bleeding
Over 60 with change in bowel habit or iron deficiciency anaemia
Describe the FIT test
Faecal immunochemical test - amount of human haemoglobin in the stool - replaced the faecal occult test - could detect blood in stool from meat
Used in patients who may have bowel cancer who do not meet requirements for 2 week wait referral
Describe bowel cancer screening
FIT testing for people aged 60-74 every 2 years
If positive - referred for colonoscopy
Patients with risk factors such as FAP, HNPCC or inflammatory bowel cancer offered regular colonoscopy
List the investigations for bowel cancer
Colonoscopy Sigmoidoscopy CT colonography Staging CT - CT TAP CEA blood test - carcinoembryonic antigen - tumour marker blood test in bowel cancer - not helpful in screening but may be used in predicting relapse in patients previously treated for bowel cancer
Describe the Dukes staging system for bowel cancer
Dukes classification
Dukes A - confined to mucosa and part of the muscle of the bowel wall
Dukes B - extending through the muscle of the bowel wall
Dukes C - lymph node involvement
Dukes D - metastatic disease
Describe the TNM classification for bowel cancer
Tumour
TX - unable to assess size
T1 - submucosa involvement
T2 - involvement of muscularis propria
T3 - Involvement of the subserosal and serosa but not through the serosa
T4 - spread through the serosa reaching other tissues (a) or organs (b)
Nodes NX - unable to assess nodes N0 - no nodal spread N1 - spread to 1 or 3 nodes N2 - spread to more than 3 nodes
Metastasises
M0 - no metastasise
M1 - metastasis
Describe the management of bowel cancer
Surgical resection - laparoscopic surgery
Chemotherapy
Radiotherapy
Palliative care
Describe bowel cancer surgery
Identifying the tumour
Remove the section of bowel containing the tumour
Create an end to end anastomosis
Alternatively create a stoma
Hemicolectomy
High anterior resection - sigmoid colon
Low anterior resection - removing the sigmoid colon and the upper rectum
Abdominal-perineal resection - removing the rectum and anus
Hartman’s procedure - emergency procedure involves removal of the rectosigmoid colon and creation of colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date
List the complications of surgery for bowel cancer
Bleeding, infection and pain Damage to nerves, bladder, ureter or bowel Post-op ileus Anaesthetic risks Laparoscopic surgery converted to open Requirement of stoma Failure to remove tumour Change in bowel habit VTE Incisional hernia Adhesions
What can a low anterior resection cause
Urgency
Frequency
Faecal incontinence
Difficulty controlling flatulence
Describe the follow up for bowel cancer
Serum carcinoembryonic antigen (CEA)
CT thorax, abdomen and pelvis
What are stomas
Artificial openings of hollow organ
What is a colostomy
Large intestine
Drain more solid stool as water reabsorbed by remaining large bowel - flush to the skin as solid stool less irritating to the skin
Located in LIF
What is an ileostomy
Located in RIF
Have a spout
Drain liquid contents
What is a gastrostomy
Creating an artificical connection between the stomach and abdominal wall
Provide feeds directly into the stomach in patients who can not meet their nutritional needs by mouth
What is a PEG
When gastrostomy inserted by endoscopy procedure
What is a urostomy
Creating an opening from the urinary system onto the skin - spout and located in RIF
Describe an ileoanal anastomosis
J pouch
Ileum folded back on itself and fashioned into a larger pouch that functions like a rectum
What are loop -ostomys
Temporary stoma used to allow a distal portion of the bowel and anastomosis to heal after surgery
List some complications of stomas
Psycho-social Local skin irritation Parastomal hernia Loss of bowel length - high output, dehydration and malnutrition Constipation in colostomies Stenosis Obstruction Retraction Prolapse - telescoping of bowel Bleeding Granulomas
What are gallstones
Stones made from cholesterol
What are some risk factors for gallstones
Fat
Fair
Female
Forty
Describe biliary colic
Stones temporarily obstruct drainage of bile and when the stones fall back into the gallbladder the symptoms resolve
Describe the symptoms of biliary colic
Severe, colicky, epigastric or right upper quadrant pain
Often triggered by meals
Lasting 30mins to 8 hrs
May be associated with nausea and vomiting
What is triggered by fat entering the digestive system
Cholecystokinin (CKK)
Triggers contraction of the gallbladder, leading to biliary colic
Describe the liver function tests in gallstone disease
Bilirubin - high, obstructive jaundice
ALP - high
AST/ALT < ALP - high
What symptoms may a patient experience with obstructive jaundice
Jaundice
Pale stool
Dark urine
Give some causes of raised ALP
Liver or bone malignancy Primary biliary cirrhosis Pagets disease of the bone Pregnancy Any fracture
What is the first line investigation for gallstone diseasee
USS
What may be seen on USS in gallbladder disease
Bile duct dilation (<6mm is normal)
Stones in gallbladder or ducts
Acute cholecystitis - thickened gallbladder wall, stones or sludge in gallbladder and fluid around the gallbladder
Pancreas and pancreatic duct
What might ultrasound in gallbladder disease be limited by?
Patients weight
Gaseous bowel obstructing view
Discomfort from probe
What imaging procedure is used to clear stones in the bile ducts and to investigate the biliary disease further
ERCP (endoscopic retrograde cholangio-pancreatography)
List some complicatons of ERCP
Excessive bleeding
Cholangitis - infection in bile ducts
Pancreatitis
Name a 2nd line imaging technique in gallstone disease
MRCP
Magnetic resonance cholangio-pancreatography
Describe the management of gallstone disease
Conservative management if asymptomatic
Cholecystectomy if symptomatic - surgical removal of gallbladder - laparoscopic sugery is preferable to open
List some complications of cholecystectomy
Bleeding, infection, pain and scars
Damage to the bile duct - leakage and strictures
Stones left in the bile duct
Damage to the bowel, blood vessels and other organs
Anaesthetic risks
Venous thromboembolism
Post-cholecystectomy syndrome
What is post-cholecystectomy syndrome
Non specific symptoms that can occur after a cholecystectomy - often improves over time
Diarrhoea Indigestion Epigastric or RUQ pain Nausea Intolerance of fatty food Flatulence
What is acute cholecystitis
Inflammation of the gallbladder
Caused by gallstones trapped in neck of gallbladder/cystic duct
Can also be caused if patient not eaten for a while and gallbladder not stimulated by food to empty so build up of pressure
Describe the presentation of acute cholecystitis
RUQ pain - may radiate to right shoulder Fever Nausea and vomiting Tachycardia and tachypnoea Murphy's sign RUQ tenderness Raised inflammatory markers and WBC
Describe Murphy’s sign
Place hand in RUQ and apply pressure
Ask pt to take deep breath in
Gallbladder moves downwards during inspiration and comes into contact with your hand
Stimulation of the inflamed gallbladder results in acute pain and cessation of inspiration
What are the ultrasound findings of acute cholecystisi
Thickened gallbladder wall
Stones/sludge in gallbladder
Fluid around gallbladder
Describe the management of acute cholecystitis
NBM IV fluid Antibiotics - local guidelines NGT if vomiting ERCP - remove stones Cholecystectomy - <72hrs of symptoms, may be delayed for 6-8weeks to allow the inflammation o settle
List some complications of acute cholecystitis
Sepsis
Gallbladder empyema
Gangrenous gallbladder
Peroration
Describe gallbladder empyema
Infected tissue and pus collecting in the gallbladder
Describe the management of gallbladder empyema
Cholecystectomy - removal of gallbladder
Cholecystostomy - drain for contents to drain out
What is acute cholangitis
Inflammation and infection in the bile ducts
What are the two main causes of acute cholecystitis
Obstruction in bile duct due to stones
Infection introduced by ERCP procedure
List the most common organisms of acute cholangitis
E.coli
Klebsiella
Enterococcus
Describe the presentation of acute cholangitis
Charcot’s triad
RUQ
Fever
Jaundice
Describe the management of acute cholangitis
NB, IV fluid Blood cultures IV antibiotics Involve seniors - HDU/ICU
Imaging - Abdominal USS, CT, MRCP, ERCP, PTC (percutaneous transhepatic cholangiogram when ERCP failed or unsuitable - drain through the skin)
What type of cancer is cholangiocarcinoma
Adenocarcinoma
What is cholangiocarcinoma a cancer of?
The bile ducts - intra/extrahepatic ducts
Where is the most common site for cholangiocarcinoma
Perihilar region - where right and left hepatic duct have joined to become the common hepatic duct just after leaving the liver
List two risk factors for cholangiocarcinoma
Primary sclerosing cholangitis
Liver flukes - parasitic infection
Describe the presentation of cholangiocarcinoma
Obstructive jaundice - pale stool, itching, dark urine Unexplained weight loss RUQ pain Palpable gallbladder Hepatomegaly
Describe Courvoisier’s law
Palpable gallbladder along with jaundice is unlikely to be gallstones - cause is usually a cancer
Describe the investigations for cholangiocarcinoma
CT/MRI plus histology for diagnosis
CT thorax, abdo and pelvis for staging
CA19-9 - tumour marker for cholangiocarcinoma and pancreatic cancer
MRCP - detail obstruction
ERCP - stent and relive obstruction and obtain biopdy
Describe the management of cholangiocarcinoma
MDT
Curative surgery - if early
Radiotherapy and Chemotherapy
Most cases not curable so palliative therapy and stents to relive obstruction, surgery to improve symptoms
What type of cancer is pancreatic cancer
Adenocarcinoma
Which part of the pancreas is most often affected by cancer
The head
Where do pancreatic cancers metastasise to
Liver
Peritoneum
Lungs
Bone
Describe the presentation of pancreatic cancer
Painless obstructive jaundice - tumour compresses bile ducts - yellow skin and sclera, pale stool, dark urine, generalised itching
Non-specific upper abdominal or back pain
Unintentional weight loss
Palpable mass in the epigastric region
Change in bowel habit
Nausea and vomiting
New onset diabetes or worsening of type 2 diabetes
Who should you refer when suspecting pancreatic cancer
> 40 with jaundice - 2 week wait
>60 with weight loss and additional symptom - GP referral for direct access CT abdomen
Describe trousseau’s sign of malignancy
Migratory thrombophlebitis - blood vessels inflamed with associated blood clot in that area - reoccurring in different locations over time
List some investigations for pancreatic cancer
CT plus histology Staging CT - TAP - mets CA19-9 - pancreatic, cholangiocarcinoma marker MRCP - biliary system for obstruction ERCP - stenting Biopsy - may be taken percutaenously
Describe the management of pancreatic cancer
Hepatobiliary MDT
Surgery - when small and isolated - total pancreatectomy, distal pancreatectomy, pylorus preserving pancreaticoduodenectomy (modified Whipples), radical pancreaticoduodenectomy (Whipple procedure)
Most cases surgery is not possible and palliative treatment involving stents, surgery to improve symptoms, palliative chemo and radiotherapy
What does a Whipple procedure involve the removal of
Head of pancreas Pylorus of the stomach Duodenum Gallbladder Bile duct Relevant lymph nodes
List the causes of pancreatitis
Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion sting Hyperlipidaemia ERCP Drugs - furosemide, thiazide diuretics and azathioprine
List the investigations for pancreatitis
FBC - WCC U&Es - Ur LFT - AST/ALT and albumin Calcium ABG - PaO2 and blood glucose Amylase - raised more than 3 times the upper limit of normal in acute pancreatitis CRP US - gallstones CT abdomen - complications of pancreatitis
Which scoring system is used for severity of pancreatitis
Glasgow score
List the criteria of the Glasgow score
PaO2 <8 Age >55 Neutrophils (WBC>15) Calcium <2 uRea >16 Enzymes (LDH >600 or AST/ALT >200) Albumin <32 Sugar >10
Describe the Glasgow score results
0 or 1 - mild pancreatitis
2 - moderate pancreatitis
>3 - severe pancreatitis
Describe the management of acute pancreatitis
Initial resusitiation IV fluids NBM Analgesia Careful monitoring Treatment of gallstone pancreatitis Antibiotics if evidence of infection Treatment of complications
What is the prognosis for acute pancreatitis
most improve within 3-7 days
List some complications of acute pancreatitis
Necrosis of the pancreas Infection in necrotic area Abscess formation Acute peripancreatic fluid collection Pseudocyst - collection of pancreatic juice can develop 4 weeks after Chronic pancreatitis
Describe chronic pancreatitis
Chronic pancreatic inflammation resulting in fibrosis and reduced function of pancreatic tissue
What is the most common cause of chronic pancreatitis
Alcohol
List some symptoms of chronic pancreatitis
Chronic epigastric pain
Loss of exocrine function - lack of pancreatic enzymes - fatty, greasy stools and malabsorption
Loss of endocrine function - lack of insulin - diabetes
Damage and strictures to the duct system - obstruction in the excretion of pancreatic juice and bile
Formation of pseudocysts and abscesses
Describe the management of chronic pancreatitis
Abstinence from alcohol and smoking
Analgesia
Replacement of pancreatic enzymes - Creon
Subcutaneous insulin regimes
ERCP with stenting
Surgery - severe chronic pain, obstruction to biliary tree, pseudocyst drainage and abscess drainage
What test is a marker of pancreatic insufficiency
Faecal elastase