Surgery conditions (1) Flashcards
The most common age group for developing appendicitis
most common in young people aged 10-20 years
The nature of abdominal pain in the appendicitis
- peri-umbilical abdominal pain → visceral stretching of appendix
- radiating to the right iliac fossa (RIF) →localised parietal peritoneal inflammation
(migration of the pain from the centre to the RIF)
- the pain being worse on coughing or going over speed bumps
- Children typically can’t hop on the right leg due to the pain
Other (than abdominal pain) features of appendicitis
- vomit once or twice (marked and persistent vomiting is unusual)
- diarrhoea → rare (but pelvic appendicitis may cause localised rectal irritation of some loose stools; pelvic abscess may also cause diarrhoea)
- mild pyrexia - temperature is usually 37.5-38oC. Higher temperatures are more typical of conditions like mesenteric adenitis
- anorexia
- around 50% of patients have the typical symptoms of anorexia, peri-umbilical pain and nausea followed by more localised right lower quadrant pain
What are the features of examination in a patient with appendicitis? (3)
- generalised or local peritonism if perforation has occurred
- digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even right-sided tenderness with a pelvic appendix
- Rovsing’s sign (palpation in the LIF causes pain in the RIF)
Diagnosis (and Ix) of appendicitis
- typically raised inflammatory markers coupled with compatible history and examination findings should be enough to justify appendicectomy
- neutrophil-predominant leucocytosis is seen in 80-90%
- urine analysis: useful to exclude pregnancy in women, renal colic and urinary tract infection. In patients with appendicitis, urinalysis may show mild leucocytosis but no nitrites
- ultrasound → useful in females where pelvic organ pathology is suspected. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion
Do we do CT scans for appendicitis?
CT scans are widely used in patients with suspected appendicitis in the US but this practice has not currently reached the UK → due to the concerns regarding excessive ionising radiation and resource limitations
Management of appendicitis
- appendicectomy → an open or laparoscopic approach
- prophylactic intravenous antibiotics
- patients with perforated appendicitis (typical around 15-20%) require copious abdominal lavage
Tenderness over what spot is indicative of appendicitis?
Psoas muscle location (spinal level) and insertion
- the psoas muscle T12 - L5
- inserting on the lesser trochanter of the femur
Complications of untreated psoas muscle abscess
Left untreated it can lead to septicaemia and multi-organ failure
Cause of psoas abscess
- It can be of the primary origin or a result of spread from local sources such as pyelonephritis or inflammatory bowel disease
- the most common causative organism is staphylococcus or streptococcus
Risk factors for development of psoas abscess
- immunosuppression (e.g. HIV, cancer and diabetes)
- intravenous drug use
- previous surgery
- tuberculosis
Presentation of psoas abscess
- pain → usually non-specific initially but increases over several days
- fever → may be present but not always
- position of comfort → patient lying on their back with slightly flexed knees (evidence psoas irritation)
- inability to weight bear or pain when moving the hip is usually evident
What’s a comfortable position of a patient with a psoas abscess?
patient lying on their back with slightly flexed knees (evidences psoas irritation)
Investigations in psoas abscess (3)
- bloods → evidence of an infection
- septic screen → systemic inflammatory response syndrome criteria are met
- MRI → gold standard
- Plain radiographs → not useful for identifying an abscess although are useful for ruling out differentials
- CT abdomen →may identify the abscess
Management of psoas abscess
- antibiotic therapy +/- drainage
- managing any predisposing risk factors if appropriate
Psoas sign of appendicitis
Pain on extending the hip: retrocaecal appendix
What is Meckel’s diverticulum?
- a congenital diverticulum of the small intestine
It is a remnant of the omphalomesenteric duct (also called the vitellointestinal duct) and contains ectopic ileal, gastric or pancreatic mucosa
Role of ‘2’ in Meckel’s Diverticulum
Rule of 2’s
- occurs in 2% of the population
- is 2 feet from the ileocaecal valve
- is 2 inches long
Presentation of Meckel’s Diverticulum
- usually asymptomatic
- abdominal pain mimicking appendicitis
- rectal bleeding
- intestinal obstruction: secondary to an omphalomesenteric band (most commonly), volvulus and intussusception
Management of Meckel’s diverticulum
Removal →if narrow neck or symptomatic
Options are:
- wedge excision
OR
- formal small bowel resection and anastomosis
What can be seen on histology of gastric cancer?
Signet ring cells
- they contain a large vacuole of mucin which displaces the nucleus to one side
- higher numbers of signet ring cells are associated with a worse prognosis
Associations with gastric cancer (7)
- H. pylori infection
- blood group A: gAstric cAncer
- gastric adenomatous polyps
- pernicious anaemia
- smoking
- diet: salty, spicy, nitrates
- may be negatively associated with duodenal ulcer
Features of gastric cancer
- dyspepsia
- nausea and vomiting
- anorexia and weight loss
- dysphagia
Investigations for gastric cancer
- diagnosis: endoscopy with biopsy
- staging: CT or endoscopic ultrasound
Cellular progression leading to gastric cancer
stepwise progression of the disease through:
intestinal metaplasia → atrophic gastritis and (subsequent dysplasia) → cancer
Classification of tumours of gastro-oesophageal junction (3 types)
Ix used to stage gastric cancer
- CT scanning of the chest abdomen and pelvis is → first -line staging investigation
- Laparoscopy → to identify occult peritoneal disease
- PET CT (particularly for junctional tumours)
Management of gastric cancer
- Proximally sited disease greater than 5-10cm from the OG junction may be treated by sub total gastrectomy
- Total gastrectomy if tumour is <5cm from OG junction
- For type 2 junctional tumours (extending into oesophagus) oesophagogastrectomy
- Endoscopic sub mucosal resection → in early gastric cancer confined to the mucosa
- Lymphadenectomy
- chemotherapy either pre or post operatively
Compare:
Mesenteric Ischaemia vs. Ischaemic Colitis
Factors predisposing to bowel ischaemia
- increasing age
- AF - particularly for mesenteric ischaemia
- other causes of emboli: endocarditis, malignancy
- cardiovascular disease risk factors: smoking, hypertension, diabetes
- cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use
Presentation of bowel ischaemia
- abdominal pain - in acute mesenteric ischaemia this is often of sudden onset, severe and out-of-keeping with physical exam findings
- rectal bleeding
- diarrhoea
- fever
- bloods typically show an elevated white blood cell count associated with a lactic acidosis
Characteristics of abdominal pain in mesenteric ischaemia (2)
- sudden onset, severe
- out-of-keeping with physical exam findings
Diagnostic investigation of choice for bowel ischaemia
CT
Causes of Acute Mesenteric Ischaemia
Causes
- Arterial: thrombotic (35%), embolic (35%)
- Non-occlusive (20%)
- Splanchnic vasoconstriction: e.g. secondary to shock
- Venous thrombosis (5%)
- Other: trauma, vasculitis, strangulation
Presentation of Acute Mesenteric Ischaemia
Nearly always small bowel
• Triad
- Acute severe abdominal pain ± PR bleed
- Rapid hypovolaemia → shock
- No abdominal signs Degree of illness >> clinical signs
• May be in AF
How do bloods look like in Acute Mesenteric Ischaemia?
Bloods
- ↑Hb: plasma loss
- ↑WCC
- ↑ amylase
- Persistent metabolic acidosis: ↑lactate
Imaging in Acute Mesenteric Ischaemia
- AXR: gasless abdomen
- Arteriography / CT/MRI angio
Complications of Acute Mesenteric Ischaemia
- Septic peritonitis
- SIRS → MODS
Management of Acute Mesenteric Ischaemia
- Fluids
- Abx: gent + met
- LMWH
- Laparotomy: resect necrotic bowel
*urgent surgery is usually required
*poor prognosis, especially if surgery delayed
Another / informal name for Chronic Mesenteric Ischaemia
‘intestinal angina’ → colickly, intermittent abdominal pain occurs
Cause of chronic small bowel ischaemia
atheroma + low flow state (e.g. LVF)
Presentation of Chronic Small Bowel Ischaemia
- Severe, colicky post-prandial abdo pain
- “gut claudication”
- PR bleeding
- Malabsorption
- Wt. loss
Management of Chronic Small Bowel Ischaemia
Angioplasty
Cause of Chronic Large Bowel Ischaemia
low flow in IMA territory
Presentation of Chronic Large Bowel Ischaemia
- Lower, left-sided abdominal pain
- Bloody diarrhoea
- Pyrexia
- Tachycardia
Ix of Chronic Large Bowel Ischaemia (3)
- ↑WCC
- Ba enema: thumb-printing
- MR angiography
Management of Chronic large Bowel Ischaemia
- Usually conservative: fluids and Abx
- Angioplasty and endovascular stenting
Pathophysiology of Ischaemic Colitis
- an acute but transient compromise in the blood flow to the large bowel → inflammation, ulceration and haemorrhage
- more likely to occur in ‘watershed’ areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries
Ix for Ischaemic Colitis
- ‘thumbprinting’ may be seen on abdominal x-ray due to mucosal oedema/haemorrhage
Management of ischaemic colitis
- usually supportive
- surgery may be required in a minority of cases if conservative measures fail
Indications would include generalised peritonitis, perforation or ongoing haemorrhage
