Surgery conditions (2) Flashcards
Shoulder tip pain following a peritoneal perforation suggests irritation of where?
Diaphragm
What’s intussusception?
Intussusception ⇒ the invagination of one portion of bowel into the lumen of the adjacent bowel, most commonly around the ileo-caecal region
Intussusception usually affects infants between 6-18 months old.
Boys are affected twice as often as girls
Presentation/features of Intussusception
- paroxysmal abdominal colic pain
- during paroxysm the infant will characteristically draw their knees up and turn pale
- vomiting
- bloodstained stool - ‘red-currant jelly’ - is a late sign
- sausage-shaped mass in the right upper quadrant
Ix for Intussusception (1)
ultrasound → may show a target-like mass
Management of intussusception
- reduction by air insufflation under radiological control→ first-line
- if this fails + signs of peritonitis → surgery
Possible cause of intussusception
- Hypertrophied Peyer’s patch
- Meckel’s
- HSP
- Peutz-Jeghers
- Lymphoma
Does intussusception occur in adults?
Intussusception rarely occurs in an adult
• If it does, consider neoplasm as lead-point
What is the blood supply to the ascending colon?
Superior Mesenteric Artery
Causes of GI (gastro-intestinal) perforation
The most common: peptic ulcers (gastric or duodenal) and sigmoid diverticulum
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Chemical
- Peptic ulcer disease
- Foreign body (e.g. battery or caustic soda)
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Infection
- Diverticulitis
- Cholecystitis
- Meckel’s Diverticulum
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Ischaemia
- Mesenteric ischaemia
- Obstructing lesions → resulting in bowel distension and subsequent ischaemia and necrosis
-
Colitis
- Toxic Megacolon (e.g. Clostridum Difficile or Ulcerative Colitis)
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Iatrogenic
- Recent surgery (including anastomotic leak)
- Endoscopy or overzealous NG tube insertion
-
Penetrating or blunt trauma
- Shear forces from acceleration-deceleration or high forces over small surface area (e.g. a handle bar)
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Direct rupture
- Excessive vomiting leading to oesophageal perforation (Boerhaave Syndrome)
Clinical features of GI perforation
- pain → typically this is rapid onset and sharp in nature.
- systemically unwell → may also have associated malaise, vomiting, and lethargy
- features of sepsis
- features of peritonism, which may be localised or generalized (a rigid abdomen)
Ix in GI perforation
- ### routine baseline blood tests + G&S
- WCC and CRP → commonly raised
- amylase → often mildly elevated in perforation
- urinalysis → to exclude both renal and tubo-ovarian pathology
- erect chest radiograph (eCXR) can show free air under the diaphragm. Pneumomediastinum or widened mediastinum
- CT scan → confirming any free air presence and suggesting a location of the perforation (as well as a possible underlying cause).
- abdominal radiograph (AXR) → show signs of perforation
Signs of GI perforation on abdominal X ray
- Rigler’s sign – both sides of the bowel wall can be seen, due to free intra-abdominal air acting as an additional contrast
- Psoas sign – loss of the sharp delineation of the psoas muscle border, secondary to fluid in the retroperitoneum
Management of GI perforation (general)
- Broad spectrum antibiotics should be started early, especially in patients
- NIL and NG tube
- IV fluid support
- analgesia
Following this standard initial approach, management becomes highly individualised, taking into account the site of perforation and patient factors. However, most patients with a perforated viscus will require theatre for repair and control of contamination.
Key aspects to consider in surgical intervention for perforated GI (3)
- Identification and (where possible) management of underlying cause
- Appropriate management of perforation, such as:
- Repairing perforated peptic ulcer with an omental patch
- Resecting a perforated diverticulae (e.g. via a Hartmann’s procedure)
- Thorough washout
In which groups of patients, should we consider conservative management of GI perforation?
Physiologically well patients may be managed conservatively, including patients with:
- Localised diverticular abscess / perforation with only localised peritonitis and tenderness, and no evidence of generalised contamination on CT imaging
- Patients with a sealed upper GI perforation on CT imaging without generalised peritonism
- Elderly frail patients with extensive co-morbidities who would be very unlikely to survive surgery
Complications of GI perforation
- infection (peritonitis and sepsis)
- haemorrhage,
Surgical approach in perforation of stomach and duodenum
- Any stomach or duodenum perforation can be accessed typically via an upper midline incision (also can be done laparoscopically), and a patch of omentum is tacked loosely over an ulcer which would otherwise be difficult to oversew due to tissue inflammation
- All gastric ulcers should be biopsied to exclude malignancy
The surgical approach in perforation of small bowel
- Small bowel perforations can be accessed via a midline laparotomy
- small perforations can be oversewn if the bowel is viable, yet any doubt about the condition of bowel should lead to resection and primary anastomosis +/- stoma formation
Surgical approach to large bowel perforation
- can be accessed via midline laparotomy
- anastomosis in the presence of faecal contamination and an unstable patient is not recommended, so a resection with stoma formation is the preferred option
What’s GIST?
Gastro-Intestinal stromal tumour
- Commonest mesenchymal tumour of the GIT
- >50% occur in the stomach
Epidemiology
- M=F
- ~60yrs
- ↑ with NF1
Pathophysiology of GIST
- what cells
- what is seen on OGD
GIST = gastro-intestinal stromal tumour
- Arise from intestinal cells of Cajal
- Located in muscularis propria
- Pacemaker cells
• OGD: well-demarcated spherical mass with central
punctum
Duke staging for Colorectal ca (components)
TMN staging for colorectal ca
