Surgical abdomen Flashcards
Differential diagnoses for RUQ pain
Biliary Colic
Acute Cholecystitis
Acute Cholangitis
Differentials for RIF pain
Acute Appendicitis Ectopic Pregnancy Ovarian Cyst Meckel’s Diverticulitis Mesenteric adenitis
Differentials for epigastric pain
Pancreatitis
Peptic Ulcer Disease
Abdominal Aortic Aneurysm
Differentials for central/diffuse abdominal pain
Abdominal Aortic Aneurysm
Intestinal Obstruction
Ischaemic Colitis
Differentials for LIF pain
Diverticulitis
Ectopic Pregnancy
Ovarian Cyst
Differentials for suprapubic pain
Acute Urinary Retention
Pelvic Inflammatory Disease
Differentials for loin pain
Renal Colic (kidney stones) Abdominal Aortic Aneurysm Pyelonephritis
What is peritonitis
- Inflammation of the peritoneum (the lining of the abdomen)
- Localised peritonitis is caused by underlying organ inflammation
- Generalised peritonitis is caused by perforation of an abdominal orga
What must you always get before taking a patient to theatre
group and save
What is the management of an acute abdomen
ABCDE approach to prioritise resuscitation
Nil by mouth
IV access (the bigger the cannula the better)
IV fluids
IV antibiotics (if evidence of infective cause)
Analgesia and antiemetics
NG tube
Catheterise for fluid balance monitoring
Escalate
When do you place an NG tube
vomiting and suspected obstruction
What is appendicitis
The appendix is a small, thin tube of bowel sprouting from the caecum
Appendicitis is inflammation of the appendix
Results from obstruction of the appendix and subsequent infection and inflammation of the appendix
What are the symptoms of appendicitis
Abdominal pain, typically central then settling in the right iliac fossa (RIF)
Loss of appetite (anorexia), nausea and vomiting.
What are the signs of appendicitis
Tender to McBurney’s point
Guarding to RIF
Rebound tenderness and percussion tenderness indicate peritonitis
Rovsing’s sign
Where is McBurneys point
(1/3 the distance from the ASIS to umbilicus)
What is rebound tenderness
(increased pain when releasing deep palpation to the RIF)
What is Rovsings sign
(palpation of the left iliac fossa (LIF) causes pain in the RIF)
How do you diagnose appendicitis
- Often clinical
- CT: especially if other diagnosis more likely
- USS: exclude ovarian and gynae pathology
- If clinically appendicitis but tests are negative may proceed to diagnostic laparoscopy – appendicectomy
What is mesenteric adenitis
Abdominal pain caused by inflamed abdominal lymph nodes
Often associated with cough/cold
No treatment required
What is Meckels diverticulitis
Malformation of the distal ileum in 2% of the population
Can become inflamed and infected in the same way as the appendix
What may cause an appendendectal mass
When the omentum and / or bowel surround and stick to the inflamed appendix
Typically managed conservatively with supportive treatment and antibiotics, with appendicectomy once acute condition has resolved
What are the complications of appendectomy
Bleeding / infection / pain / scars Damage to bowel, bladder or other organs Removal of normal appendix Anaesthetic risk DVT / PE - Laparoscopic is associated with fewer risks and faster recovery versus open
What are the main causes of bowel obstructions
- Adhesions (scar tissue from previous surgery causing a kink in the bowel – think watering hose kinking)
- Hernias
- Malignancy
- Strictures
What are the signs and symptoms of obstruction
Increasing abdominal distention and diffuse pain
Absolute constipation and lack of flatulence
Vomiting
What is the initial management of Obstruction
‘Drip & suck’
- Nil by mouth
- IV fluids
- NG tube on free drainage (to allow stomach contents to freely drain and prevent the need for vomiting)
What may you see on abdominal x ray in an obstruction
Distended loops of bowel
Upper limits of normal are: 3 cm small bowel, 6 cm colon, 9 cm caecum
How can the small bowel be distinguished from large bowel
presence of valvulae conniventes and haustra.
What are Valvulae conniventes
present in small bowel, and are mucosal folds that form lines that extend the full width of the small bowe
What are haustra
pouches formed by the muscles in the walls of the large bowel, and form lines that do not extend the full width of the bowel.
What investigations should you order for ? obstruction
Abdominal x ray
CT scan
FBC, U&Es, LFTs, CRP
Gas: lactate if ? perf
What is a sigmoid volvulus
Counterclockwise twisting
The sigmoid colon becomes overloaded with faeces, causing it to sink downwards causing a twist or torsion
What is a caecal volvulus
Clockwise twisting (Caecal – Clockwise)
What are the risk factors of a volvulus
Psychiatric disorders Neurological disorders Nursing home residents Chronic constipation Pelvic masses (including pregnancy) Adhesions
what are the complications of a volvulus
Obstruction
Ischaemia
Perforation
How do you diganose a volvulus
Presents as intestinal obstruction
Abdominal xray
CT scan to confirm diagnosis and identify other pathology
What do you see on an abdominal x ray with a volvulus
coffee bean sign (dilated, twisted sigmoid colon that looks like a giant coffee bean)
What is the treatment of volvulus
Endoscopic decompression (for sigmoid volvulus with no peritonitis only)
Laparotomy
Hartmann’s procedure (sigmoid)
right hemicolectomy (caecal)
What are the symptoms of bowel cancer
Change in bowel habit (usually to more loose and frequent stools) Weight loss PR bleeding Tenesmus Iron Deficiency Anaemia Obstruction
What is tenesmus
(feeling of full rectum even after opening bowels)
What type of iron deficiency do you see in bowel ca
(microcytic anaemia with low ferritin)
What are the risk factors for bowel ca
In the UK it is the third most prevalent cancer
- FH
- other cancers
- age
- IBD
- diet (red meat, low fibre)
What investigations should be conducted if suspecting a bowel cancer
- Endoscopy to visualize full colon
- CT colonography
- CT with bowel prep and contrast to visualize the colon (not fit for colonoscopy_
- Staging CT scan: CT TAP
- Carcinomembryonic Antigen (CEA)?
What is Carcinomembryonic Antigen CEA
Tumour marker blood test for bowel cancer
Not useful in screening
Useful in predicting relapse of previously treated bowel cancer
How do we treat bowel cancers
Decision taken by MDT
Based on clinical condition, general health, staging radiography, histology and patient wishes
Options are surgical resection, chemotherapy, radiotherapy and palliation in any combination
What are the complications of surgery for bowel resections
Bleeding / infection / pain Damage to nerves, bladder, ureter or bowel Post op ileus Anaesthetic risks Conversion to open Anastomotic leak / failure Requirement for a stoma Failure to remove the tumour DVT/PE Hernias Adhesions
What is a covering loop ileostomy
A temporary ileostomy created to protect a distal anastomosis
Typically left for 6-8 weeks to allow healing of the anastomosis, after which is it reversed
“Loop” refers to it being the two ends (proximal and distal) of a section of small bowel being brought out onto skin
Proximal end (the productive side) has turned inside out to form a spout to protect the surrounding skin
Usually located lower right side of abdomen
what is a right hemicolectomy
remove tumours of the caecum, ascending and proximal transverse colon:
What is a left hemicolectomy
remove tumours of the distal transverse and descending colon
what is a sigmoid colectomy
remove tumours of the sigmoid colon:
What is an anterior resection
remove tumours of the low sigmoid colon or higher rectum
What is a Abdominoperineal Resection (APR)
remove tumours of the lower rectum.
- removes the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus.
It leaves the patient with a permanent colostomy:
what is followed up following a curative resection
CT T.A.P. at 1 and 2 or 3 years
Colonoscopy at 1 and 5 years
CEA 6 monthly for 3 years
Thereafter based on local policy
What is acute mesenteric ischaemia
Caused by bloods clots blocking blood supply in mesenteric vessels (embolus or thrombus)
What are the symptoms of acute mesenteric ischaemia
- non-specific abdominal pain (disproportionate to exam findings)
- shock
- peritonitis
- systemic inflammatory response
Risk factors of acute mesenteric adenitis
Older age
Atrial fibrillation
Atherosclerosis
Coagulation disorders
What is the management of acute mesenteric adenitis
Fluid resuscitation
Thrombolysis
Surgical intervention
Very poor prognosis
What is considered the foregut (blood supply)
Stomach and part of duodenum, biliary system, liver, pancreas
Celiac artery
What is considered the mid-gut (blood supply)
Duodenum to 1st half of transverse colon
Superior mesenteric artery
What is considered the hindgut (blood supply)
2nd half of transverse colon to rectum
Interior mesenteric
What is a Permanent (end) Ileostomy
After total colectomy for Inflammatory Bowel Disease (UC/Crohns) or Familial Adenomatous Polyposis (FAP)
Most often in lower right abdomen
What is a colostomy
After abdomino-perineal resections (APR) for low rectal cancers
Permanent
Most often in lower left abdomen
Produces stools just like an anus
What is a urostomy
- To allow draining of urine from kidney, bypassing the ureter, bladder and urethra (e.g cystectomy)
- Ileal conduit urinary diversion
What is Ileal conduit urinary diversion
Section of ileum (15-20cm) is removed and end to end anastomosis is created
Ends of the ureters are anastomosed to this section of ileum
The end of the section is brought out onto the skin as a stoma
This stoma then works to drain urine directly from the ureters into a bag
What are the complications of stomas
Psycho-social impact Local skin irritation around stoma Parastomal hernia Loss of bowel length leading to high output, dehydration and malnutrition Constipation (colostomies) Obstruction Retraction Bleeding Granulomas Prolapse (telescoping of bowel through hernia site) Stenosis
