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Y4 final checklist_ SURGERY > Surgery conditions (3) > Flashcards

Surgery conditions (3) Flashcards

1
Q

Pseudo-obstruction

  • another name
  • what is this
  • commonly affected locations
A

Pseudo-obstruction aka Ogilvie syndrome

  • disorder characterised by dilatation of the colon due to an adynamic bowel, in the absence of mechanical obstruction

Commonly affected sites: the caecum and ascending colon (but can affect the whole bowel)

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2
Q

Presentation of Pseudo-obstruction

A
  • clinical signs of mechanical obstruction but NO obstructing lesion found
  • Abdominal pain
  • Abdominal distension
  • Constipation
  • paradoxical diarrhoea
  • Vomiting
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3
Q

Pathophysiology of Pseudo-Obstrution

A

The exact mechanism is unknown → thought to be due to an interruption of the autonomic nervous supply to the colon → absence of smooth muscle action in the bowel wall

Untreated cases can result in an increasing colonic diameter → an increased risk of toxic megacolon, bowel ischaemia and perforation.

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4
Q

Causes of Pseudo-obstruction (6)

A
  • Electrolyte imbalance or endocrine disorders
    • Including hypercalcaemia, hypothyroidism, or hypomagnesaemia
  • Medication
    • Including opioids, calcium channel blockers, or anti-depressants
  • Recent surgery, severe illness, or trauma
  • Recent cardiac event
  • Parkinson’s disease
  • Hirschsprung’s disease
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5
Q

What electrolyte and endocrine imbalances may lead to Pseudo-obstruction? (3)

A
  • hypercalcaemia
  • hypothyroidism
  • hypomagnesaemia
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6
Q

What medication classes may lead to Pseudo-Obstruction? (3)

A
  • opioids
  • calcium channel blocker
  • anti-depressants
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7
Q
A
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8
Q

Clinical examination features in Pseudo-Obstruction

A

colonic-specific pathology→ bowel sounds are present.

The abdomen will be tympanic due to distension and you should palpate for focal tenderness

* Focal tenderness indicates ischaemia and is a key warning sign

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9
Q

Ix in Pseudo-Obstruction

A
  • Blood tests: FBC, CRP, U&Es, LFTs, Ca2+, Mg2+, and TFTs (to see if its infective, endo, erectrolyte-related)
  • Plain abdominal films (AXR) → show bowel distension, however this will be much the same as mechanical obstruction
  • abdominal-pelvis CT scan with IV contrast → show dilatation of the colon, as well as definitively excluding a mechanical obstruction and assessing for any complications (e.g. perforation)
  • Motility studies → in the long-term
  • potential biopsy of the colon at colonoscopy.
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10
Q

Non-surgical management of pseudo-obstruction

A

Most cases can be managed conservatively and do not require surgical intervention → treatment of the underlying acute illness will be required

  • NBM andIV fluids
  • if the patient is vomiting → NG tube should be inserted to aid decompression
  • analgesics
  • prokinetic anti-emetics
  • if pseudo-obstruction that do not resolve within 24hours → endoscopic decompression (flatus tube)
  • IV neostigmine (an anticholinesterase) may also be trialled
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11
Q

Surgical management of Pseudo-obstruction

A

If suspected ischaemia or perforation, or those not responding to conservative management → surgery

  • segmental resection +/- anastomosis → in the absence of perforation
  • caecostomy of ileostomy → to decompress the bowel in the long-term
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12
Q

What’s Paralytic Ileus?

A

Paralytic ileus = no peristalsis resulting in pseudo-obstruction

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13
Q

Causes of Paralytic ileus

A
  • post-op
  • Peritonitis
  • Pancreatitis or any localised inflammation
  • Poisons / Drugs: anti-AChM (e.g. TCAs)
  • Pseudo-obstruction
  • Metabolic: ↓K, ↓Na, ↓Mg, uraemia
  • Mesenteric ischaemia
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14
Q

Presentation of Paralytic Ileus

A
  • adynamic bowel secondary to the absence of normal peristalsis
  • SBO
  • Reduced or absent bowel sounds
  • Mild abdominal pain: not colicky
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15
Q

Prevention of paralytic ileus

A
  • ↓ bowel handling
  • Laparoscopic approach
  • Peritoneal lavage after peritonitis
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16
Q

Management of Paralytic Ileus

A

• Correct any underlying causes

  • Drugs
  • Metabolic abnormalities
  • Consider need for parenteral nutrition
  • Exclude mechanical cause if protracted
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17
Q

Pathophysiology of sigmoid volvulus

A
  • Long mesentery with narrow base predisposes to torsion
  • Usually due to sigmoid elongation secondary to chronic constipation
  • ↑ risk in neuropsych pts.: MS, PD, psychiatric
  • Disease or Rx interferes with intestinal motility

• → closed loop obstruction

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18
Q

Presentation of sigmoid volvulus

A
  • Commoner in males
  • Often elderly, constipated, co-morbid patients
  • Massive distension with tympanic abdomen
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19
Q

What’s a tympanic abdomen?

A

drum-like sounds heard over air-filled structures during the abdominal examination

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20
Q

Ix in sigmoid volvulus

A

AXR → •characteristic inverted U / coffee bean sign

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21
Q

Management of sigmoid volvulus

A
  • sigmoidoscopy and flatus tube insertion
  • Monitor for signs of bowel ischaemia following

decompression

• Sigmoid colectomy → occasionally required

  • Failed endoscopic decompression
  • Bowel necrosis

• Often recurs → elective sigmoidectomy may be

needed

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22
Q

What is caecal volvulus associated with?

A

congenital malformation where caecum is

not fixed in the RIF

23
Q

Sign of caecal volvulus on AXR

A

Embryo sign

24
Q

Management of caecal volvulus

A

Only ~10% of pts. can be detorsed with colonoscopy

  • typically requires surgery
  • Right hemi with ileocolic anastomosis
  • Caecostomy
25
Q

Associations with caecal volvulus

A
  • all ages
  • adhesions
  • pregnancy
26
Q

Triad of gastro-oesophageal obstruction

A
  • Vomiting → retching with regurgitation of saliva
  • Pain
  • Failed attempts to pass an NGT
27
Q

Risk factors for gastro-oesophageal obstruction

A

Congenital

  • Bands
  • Rolling / Paraoesophageal hernia
  • Pyloric stenosis

Acquired

  • Gastric / oesophageal surgery
  • Adhesions
28
Q

Ix in gastro-oesophageal obstruction

A
  • Gastric dilatation
  • Double fluid level on erect films
29
Q

Management of gastro-oesophageal obstruction

A
  • Endoscopic manipulation
  • Emergency laparotomy
30
Q

Features of small bowel obstruction

A
  • central abdominal pain
  • nausea and vomiting
  • ‘constipation’ with complete obstruction
  • abdominal distension may be apparent, particularly with lower levels of obstruction
31
Q

What’s closed-loop obstruction?

A
  • If there is a second obstruction proximally (such as in a volvulus or in large bowel obstruction with a competent ileocaecal valve) t
  • This is a surgical emergency as the bowel will continue to distend, stretching the bowel wall until it becomes ischaemic and / or perforates.
32
Q

The most common causes of obstruction:

A. Small Bowel

B. Large Bowel

A
  • Small bowel – adhesions and herniae
  • Large bowel – malignancy, diverticular disease, and volvulus
33
Q

Intramural, mural and extramural caues of bowel obstruction

A
34
Q

What cause of large bowel obstruction should be always considered?

A

large bowel obstruction should be considered to be caused by a GI cancer until proved otherwise

35
Q

How does vomiting look like in a bowel obstruction?

A

Vomiting – initially of gastric contents, before becoming bilious and then eventually faeculent (a dark-brown foul-smelling vomitus)

36
Q

What bloods to do in a bowel obstruction?

A
  • FBC
  • CRP
  • U&Es
  • LFTs
  • Group and Save (G&S)
  • monitor for electrolyte changes and third-space losses
  • VBG venous blood gas → to evaluate the signs of ischaemia (high lactate) or for the immediate assessment of any metabolic derangement (secondary to dehydration or excessive vomiting)
37
Q

What’s that?

A

CT representing features of a small bowel obstruction

38
Q

AXR features of:

A. Small Bowel Obstruction

B. Large Bowel Obstruction

A

​Small bowel obstruction:

  • Dilated bowel (>3cm)
  • Central abdominal location
  • Valvulae conniventes visible (lines completely crossing the bowel)

Large bowel obstruction:

  • Dilated bowel (>6cm, or >9cm if at the caecum)
  • Peripheral location
  • Haustral lines visible (lines not completely crossing the bowel, ‘indents that go Halfway are Haustra’)
39
Q

(3) Modes of imaging in bowel obstruction (Ix)

A
  • CT scan with IV contrast → gold standard
  • AXR →characteristic patterns to distinguish between small vs large bowel obstruction
  • Contrast fluoroscopy → useful in small bowel obstruction caused by adhesions from previous surgery
40
Q

General management of (all patients) bowel obstruction

A
  • definitive management → dependent on the aetiology and whether it has been complicated by bowel ischaemia, perforation, and/or peritonism
  • urgent fluid resuscitation + fluid balance
  • urinary catheter
  • NBM
  • NG tube to decompress bowel
  • analgesia
41
Q

When urgent surgery is required in the cases of bowel obstruction?

A

Urgent surgery in:

  • closed-loop bowel obstruction

OR

  • evidence of ischaemia (pain worsened by movement, focal tenderness and pyrexia)
42
Q

Management of adhesional small bowel obstruction

A
  • treated conservatively in the first instance (unless there is evidence of strangulation / ischaemia)
  • A water soluble contrast study should be performed in cases that do not resolve within 24 hours conservative management ⇒ If contrast does not reach the colon by 6 hours then it is very unlikely that it will resolve ⇒patient should be taken to theatre
43
Q

Management of ‘virgin abdomen’ small bowel obstruction

A

Large bowel obstruction or small bowel obstruction in a patient who has not had previous surgery (termed a “virgin abdomen”) rarely settles without surgery.

44
Q

When is the surgical intervention indicated in bowel obstruction? (4)

A

Surgical intervention is indicated in patients with:

  • Suspicion of intestinal ischaemia or closed loop bowel obstruction
  • Small bowel obstruction in a patient with a virgin abdomen
  • A cause that requires surgical correction (such as a strangulated hernia or obstructing tumour)
  • If patients fail to improve with conservative measures (typically after ≥48 hours)
45
Q

What a surgery for bowel obstruction would involve?

A
  • depend on the underlying cause
  • generally → laparotomy
  • if resection of bowel is required → the re-joining of obstructed bowel is often not possible → stoma may be necessary
46
Q

(3) types of management of splenic trauma

A
47
Q

What’s Kehr’s sign?

A

Kehr’s Sign

  • Shoulder tip pain secondary to blood in the peritoneal cavity
  • Left Kehr sign → classic symptom of ruptured

spleen

48
Q

(4) classification of spleen rupture

A

1: capsular tear
2: Tear + parenchymal injury
3: Tear up to the hilum
4: Complete fracture

49
Q

Management of splenic trauma

A
  • Haemodynamically unstable: laparotomy
  • Stable 1-3: observation in HDU
  • stable 4: consider laparotomy
  • Suture lac or partial / complete splenectomy

Classification

1: capsular tear
2: Tear + parenchymal injury
3: Tear up to the hilum
4: Complete fracture

50
Q

Vaccinations following splenectomy

A

splenectomy → patients are particularly at risk from pneumococcus, Haemophilus, meningococcus and Capnocytophaga canimorsus infections

Vaccination

  • if elective, should be done 2 weeks prior to operation
  • Hib, meningitis A & C
  • annual influenza vaccination
  • pneumococcal vaccine every 5 years
51
Q

Antibiotic prophylaxis following splenectomy

A

Antibiotic prophylaxis

  • penicillin V: clear guidelines do not exist of how long antibiotic prophylaxis should be continue
  • It is generally accepted though that penicillin should be continued for at least 2 years and at least until the patient is 16 years of age, although the majority of patients are usually put on antibiotic prophylaxis for life
52
Q

Indications for splenectomy

A
  • Trauma: 1/4 are iatrogenic
  • Spontaneous rupture: EBV
  • Hypersplenism: hereditary spherocytosis or elliptocytosis etc
  • Malignancy: lymphoma or leukaemia
  • Splenic cysts, hydatid cysts, splenic abscesses
53
Q

Complications of splenectomy

A
  • Haemorrhage
  • Pancreatic fistula (from iatrogenic damage to pancreatic tail)
  • Thrombocytosis: prophylactic aspirin
  • Encapsulated bacteria infection e.g. Strep. pneumoniae, Haemophilus influenzae and Neisseria meningitidis
54
Q

Post-splenectomy changes

A
  • Platelets will rise first → ITP should be given after splenic artery clamped
  • Blood film will change over following weeks, Howell-Jolly bodies will appear
  • Other blood film changes include target cells and Pappenheimer bodies
  • Increased risk of post-splenectomy sepsis, therefore prophylactic antibiotics and pneumococcal vaccine should be given

Y4 final checklist_ SURGERY (25 decks)

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