Surgical Conditions Flashcards
What are some of the causes of RUQ pain?
- Gallbladder: Acute Cholecystitis, cholangitis, biliary colic
- Liver: hepatitis, hepatomegaly
- Kidney: pyelonephritis
- Lung: RLL pneumonia
- Appendicitis
What are some of the causes of epigastric pain?
- Acute pancreatitis
- Peptic ulcer
- Acute cholecystitis
- MI
- Perforated oesophagus
What are some of the causes of LUQ?
- Spleen: ruptured spleen
- Stomach: gastric ulcer
- Aorta: AAA
- Kidney: pyelonephritis
- Lungs: LLL Pneumonia
What are some of the causes of periumbilical pain?
- Intestine: intestinal obstruction, diverticulitis
- Acute pancretitis
- Early appendicitis
- mesenteric thrombosis
- AAA
What are some of the causes of RLQ pain?
- Intestine: Appendicitis, crohn’s disease, Meckel’s diverticulitis, Incarcerated hernia, perforated caecum
- Renal: kidney stones
- Gynae: tubo-ovarian abscess, ruptured ectopic pregancny
What are some of the causes of LLQ pain?
- GI: sigmoid diverticulitis, Crohn’s, UC, perforated colon, incarcerated hernia
- Renal: kidney stones
- Gynae: tubo-ovarian abscess, ruptured ectopic pregnancy
What are some endocrine causes of an acute abdomen/abdominal pain?
DKA, thyrotoxicosis, addison’s disease
What are some important questions to ask in hx for someone presenting with acute abdomen?
- SOCRATES for pain
- Assoc symptoms:
- Vomiting?
- malaena/haematemesis
- Change in bowels? change in stool?
- Fevers/rigors/weight loss?
- Rash? - indicative of jaundice
- Urinary symptoms/change in urine color/blood in urine?
- Gynae/obstetric hx - last period? pregnant? hx of STI, ectopic?
- Past surgeries?
What investigations for patient presenting with acute abdomen?
- Bedside tests: BP, oxy sat, temperature, urine dip + pregnancy test!, ECG
- Bloods:
- FBC - for anaemia, infection, active bleeding
- Inflammatory markers
- LFTs - for hepatobiliary pathology
- Serum amylase/lipase - if suspect pancreatitis
- Glucose - DKA?
- ABGs - sepsis? intestinal ischaemia?
- Imaging:
- AXR/erect CXR
- ultrasound - for gallstones/kidney stones
- Endoscopic investigations - gastroscopy? colonoscopy?
What is the initial management of patients with acute abdomen?
- A to E assessment
- Keep patients NBM
- Oxygen as appropriate
- IV fluids
- Analgesia
- NG tube if vomiting severely/obstruction suspected
- Antiemetic
- Prophylactic Antibiotics - IV ceph + metronidazole
- Surgical/gynae review
Causes of intestinal obstruction?
Divided into:
- Extramural:
- adhesions - from previous surgery/peritoneal infection
- Hernias
- Tumours - from other organs
- Volvulus
- Intramural
- Strictures - due to crohn’s, diverticulitis
- Tumours - colon cancer
- Intussusecption/hirschsprung’s
- Luminal
- Faecal impaction
- Gallstones
What are some presentations of obstruction?
Symptoms
- Nausea and vomiting - early in SBO, late (and faeculant) in LBO
- Constipation - late in SBO, early in LBO
- colicky abdominal pain - more frequent in SBO
- Dysphagia
- Abdominal distension
Signs
- Dehydration - due to water remaining unabsorbed and vomiting
- Abdominal distension, peristalsis
- Percussion - hyperresonant
- Auscultation - tinkling in obstruction, silent in paralysis
- PR exam - empty rectal ampulla
- Check hernial orifices
AXR signs for SBO and LBO?
- SBO: valvulae conniventes, more centrally located, >3cm dilated
- LBO: haustra present, peripherally located, >6cm
Management of bowel obstruction?
- Resus: IV fluids, analgesia, restore metabolic abnormalities
- Uncomplicated obstruction:
- Intestinal decompression - endoscopic bowel decompression, dilatation of strictures, stents
- bowel rest
- Complicated obstruction
- Surgical intervention indications:
- Ischaemia, perforation, peritonitis, irreducible hernia.
- Bowel resection of any non-viable bowel + anastomosis/stoma
- Surgical intervention indications:
Causes of Upper GI Bleed?
- Peptic ulceration
- Gastroduodenal ulcerations
- Oesophagitis
- Oesophageal varies
- Mallory Weiss tear
- Oesophageal/stomah cancer
- Drugs - steroids, NSAIDs, Anticoagulants
- Vascular malformations
How do you assess the risk of patients with UGIB
Using Glasgow-blatchford Score and Rockall Score:
- GBS: to assess need for intervention
- Rockall: to assess mortality
Describe the assessment of patients with UGIB
- A to E assessment
- Resuscitation:
- Two large bore IV access
- Fluid resuscitation
- Blood transfusion according to local guidelines
- Bloods for FBC, U&Es, LFTs, Coag Screen, Group and X-match (2-6 units).
- Risk assessment using GBS and Rockall score
- Endoscopy (within 24hrs):
- Non-variceal bleed:
- Clips/thermal coagulation/fibrin + adrenaline
- Variceal bleed
- Terlipressin - offered to patients with suspected variceal bleed at presentation.
- Prophylactic antibiotics (co-amox) - offered at presentation.
- Oesophageal varices: band ligation, TIPS if not controlled
- Gastric varices: injection of N-butyl-2-cyanoacrylate, TIPS if not controlled.
- Non-variceal bleed:
Causes of Lower GI Tract Haemorrhage?
- Anatomical: diverticular disease, Meckel’s diverticulum
- Vascular: colonic angiodysplasia, ischaemic colitis, vascular malformation
- Inflammatory: IBD
- Infectious: haemorrhagic gastroenteritis
- Neoplastic: Colorectal cancer, polyps
- Anorectal: internal haemorrhoids, rectal varices
VAAIINN
Investigations to carry out for lower GI bleed?
- Bedside: BP, temp, stool sample
- Bloods: FBC, U&Es, LFTs, coagulation screen, inflammatory markers, Group and save
- Imaging: AXR, sigmoidoscopy, colonoscopy, CT angio if suspect ischaemic colitis
Red Flags for Lower GI tract bleed?
- Weight loss
- Age <50
- Change in bowel habits
- Blood in stool
- Iron-deficiency anaemia
- Strong Family Hx of colorectal cancer
What are the watershed areas in the intestine and where are they located?
Collateralisation of blood flow is more limited and more prone to ischaemia. Located at splenic flexure and recto-sigmoid junction
What is the management of Ischaemic colitis?
- Resus - IV fluids, oxygen, correct co-morbidities
- Empirical antibiotics
- Medical:
- Heparin, vasodilator (papaverine), thrombolysis (if aetiology is embolus)
- Surgical
- Embolectomy
- angioplasty
- Surgical resection - for non-viable areas
Causes of Dysphagia?
- Inflammatory: oesophagitis, candidiasis, tonsilitis
- Neuromotility disorders: stroke, parkinson’s, MS, Achalasia, Oesophageal spasm, Myasthenia Gravis
- Mechanical obstruction:
- Luminal - foreign bodies
- Mural - strictures, tumours, diverticulum
- Extramural - retrosternal goitre, lung/bronchial Ca, rolling hiatus hernia, thoracic aortic aneurysm.
How do you investigate dysphagia?
- Barium swallow
- Endoscopy
- Manometry
