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Gastrointestinal > Surgical GI > Flashcards

Surgical GI Flashcards

1
Q

Appearance of bowel obstruction on imaging:

A

XRAY
- Dilated bowel loops
–> Adults: “3-6-9 rule”
–> Kids: wider than lumbar vertebrae
- Multiple air-fluid levels
- Empty rectum (gas = partial)

Large bowel: Loops peripheral, haustra,
Small bowel: Loops central, plicae (or nil)

CT
- Transition point with distal collapse
- Thick bowel wall
- Pneumatosis

Ultrasound
- “To and fro” whirling
- No peristalsis

Barium enema rarely done

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2
Q
A

LBO

  • Haustra
  • Peripheral

Cancer, volvulus, diverticular

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3
Q
A

SBO

  • Loops central
  • No gas in colon
  • Plicae

Adhesions, herniae, Crohn’s

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4
Q
A

Sigmoid volvulus
‘Coffee bean sign’

Volvulus is a closed loop obstruction
–> Ischaemia, perforation

INFANTS = midgut volvulus (malrotation)
ELDERLY = sigmoid volvulus (chronic neurol, schiz meds)

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5
Q

General management in bowel obstruction:

A
  • Analgesia
  • NGT- decompression + free drainage
  • Antiemetics (avoid metoclopramide)
  • Fluid and electrolytes
  • Consider antis (translocation)
  • Definitive:
    –> May resolve with NGT
    –> Sigmoidoscopy for volvulus
    –> Endoscopic stents in malignancy
    –> Laparotomy if strangulating/ closed loop
    –> Decompressive stoma
    –> Resection
    etc.
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6
Q

Hernia locations:

A

INGUINAL- Emerges ABOVE pubis
- DIRECT
–> Through abdo wall near inguinal canal
–> Benign
- INDIRECT
–> Most common
–> Travels down through inguinal canal, incl. scrotum.
–> Can incarc/ strangulate

FEMORAL- Emerges BELOW pubis
- Most common femoral hernia
- Complications +

UMBILICAL/ PERIUMBILICAL
- Common in kids, self-resolve often

EPIGASTRIC
INCISONAL
SPIGELIAN
OBTURATOR

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7
Q

Signs and management of hernia:
- Incarceration
- Strangulation

A

INCARCERATED:
- Irreduceable, painful, +/- BO.
- Attempt reduction in ED:
–> Analgesia
–> Tilt bed
–> Firm, constant pressure
–> Surg consult.

STRANGULATED:
- ..+ Tender, warm, discoloured.
- OT

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8
Q

Clinical features of appendicitis:

A

Periumbilical (midgut pain) –> RLQ pain (focal peritonism)
Pain on movement/ cough/ bumps
Nausea, anorexia

McBurney tenderness
–> 1/3 ASIS to umbi
Rebound
Rovsing +
Psoas sign
–> R hip extension

PELVIC appendix atypical:
- No, or left-sided tenderness
- Bowel/ bladder irritation
Obturator sign (pelvic appendix)
–> R hip flex + int rotate

UTILISE SERIAL EXAMINATION

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9
Q

Alvarado score (MANTRELS criteria):

A

Other: RIPASA, PAS (paediatric appendicitis score)

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10
Q

Antibiotic choice in peritonitis:

A

SBP
- Ceftriaxone 1-2g IV

PERFORATED VISCUS
- Amoxicillin 2g IV QID
- Gentamicin 5mg/kg IV daily
- Metronidazole 500mg IV BD

OR: Ceftriaxone + metro.
OR: Tazocin

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11
Q

Define ‘uncomplicated’ and ‘complicated’ diverticulitis and their Mx:

A

COMPLICATED = perforation/ phlegmon/ abscess/ obstruction.
–> Triple antis
–> Surg: Cx, percut drain, OT.

UNCOMPLICATED
- Antibiotics not mandatory
- Can give if RFs, follow up risk etc.
–> Augmentin DF 5 days (or cipro+metro)
- Liquid and low-fibre diet (bowel rest)
- Colonoscopy in 6 weeks

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12
Q

Retroperitoneal haemorrhage:

A

CAUSES:
- Trauma (eg renal, IVC, duodenum)
- AAA
- Pancreatitis
- Bleeding diathesis

CLINICAL:
- Cullen (flank)
- Grey Turner (periumb)
- Inner thigh
- Scrotal

MANAGEMENT
- Usually conservative (analg, PRBC, monitor)
- Active + compromised: OT
- Percut drain large, chronic to avoid infection.

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13
Q

Causes of non-traumatic splenic rupture:

A

Malaria
EBV
Lymphoma + other myeloproliferative
Splenic: haemangioma, cancer, amyloid etc.
Sickle cell sequestration crisis

….any cause of diseased or enlarged spleen.

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14
Q

Diagnostic criteria for pancreatitis:

A

At least 2 of:
- Lipase or amylase THREE TIMES normal
- Radiological evidence
- Symptoms consistent with

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15
Q

Causes of pancreatitis:

A

Idiopathic
Alcohol
Gallstones
Sphincter of Oddi dysfunction/ obstruction
Post- ERCP
Hypercalcaemia
Trauma
Drugs: (NSAIDS, Bactrim, valpro)

RARE: scorpion, infection, autoimmune

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16
Q

Complications of pancreatitis:

A

Necrotising
–> SIRS/ shock/ MODS
–> DIC
Retroperitoneal haemorrhage
Pleural effusion
Ileus
Splenic vein thrombosis

Hypocalcaemia
Metabolic acidosis
Malabsorption
3rd spacing/ hypovolaemia
T2DM
Fat embolism

Pseudocyst (infection, mass effect, rupture, bleed)

17
Q

Amylase/lipase:

A

Diagnostic criteria (+ clinical/radiological features) when EITHER is 3x normal.

Lipase more specific to pancreas

Lipase elevated from 4 hours to 2 weeks

18
Q

What metabolic/ electrolyte disturbances occur in severe pancreatitis?

A

Hypocalcaemia- marker of poor prognosis
Hyperglycaemia
High triglycerides

Metabolic acidosis- shock, loss of HCO3-rich pancreatic juice

Haemoconcentration (3rd spacing)
AKI
MODS

19
Q

Management of pancreatitis:

A

Supportive.

Fluid replacement ++ and aggressive vasoactive support
–> Large 3rd space losses
–> SIRS ++ and hypotension
Electrolyte correction
–> Calcium
–> Glucose
NUTRITION
- Mild/mod: FAST 3-4 days
- Severe pancreatitis: EARLY ENTERAL feeds. Traditionally, ‘rest’ by direct jejunal feeds- no actual evidence

Consider antibiotics
–> Metronidazole or ‘penam
Treat cause
FASTHUGS
–> VTE prophylaxis
ICU if Glascow >3

20
Q

Severity scoring in pancreatitis:

A

Modified Glascow- “PANCREAS’“
In first 48 hours:
- >3 = severe

Ransons similar
APACHE-II (most accurate, complicated +++)

21
Q

Risk factors for gallstone disease:

A

Fat (and rapid weight loss)
Female
Forty
Fair (rare in non-caucasians)
Fertile (during pregnancy, OCP)
FHx
Lipid derangement

22
Q
A

Most gallstones only make it to cystic duct
–> colic (mobile)
–> cholecystitis (impacted)

If these cause Mirizzi (externally compress hepatic duct), OR they make it to common bile duct, this is when:
–> Cholangitis
–> Obstructive jaundice

23
Q

Complications of gallstone disease:

A

Cholecystitis (primary –> infected)
Cholangitis
Gram negative sepsis
Gallbladder empyema
Perforation
Pancreatitis
Gallstone ileus
Obstructive jaundice

24
Q

Are antibiotics indicated in acute cholecystitis?

A

Not always.

Usually simple INFLAMMATION initially (chemical, luminal distention + mucosal ischaemia)

50% get secondary INFECTION from GI flora.

Amoxicillin + Gent
Add the metro only if septic.
Gent only if pen allergic.
Augmentin if gent is CI

25
Q

USS findings in acute cholecystitis:

A
  • Distended
  • Thickened >3mm
  • Sonographic Murphy’s
  • Cholelithiasis (hyperechoic with acoustic shadowing) (unless acalculous)
  • Pericholecystic fluid
  • Pneumobilia = INFECTION
26
Q

Acalculous cholecystitis:

A

Occurs in:
- Critical illness
- HIV
- Long term TPN

Worse prognosis, more complications (Empyema, perforation, gangrene) –> Mortality 50%!

27
Q

What does this show?

A

Pericholecystic free fluid

(+ thickened wall >3mm)

28
Q

What is Charcot’s Triad?

A

For cholangitis. Present in 50-70%

  • Fever
  • Jaundice
  • RUQ PAIN

Not pathognomic

29
Q

Management of cholangitis:

A

Often full septic resus
Amoxycillin + Gentamicin
Gent only if pen allergic.
Augmentin if gent is CI

Urgent decompression:
–> ERCP
–> Percut ‘ostomy
–> Open drainage
GB doesn’t get taken out whilst actively infected

30
Q

Operative Mx options of biliary conditions:

A
  • Elective cholecystectomy (eg. resolved but recurrent colic)
  • Cholecystectomy within 7 days *(acute colic or cholecystitis)
  • Urgent decompression (cholangitis, severe cholecystitis)
    –> ERCP +/- stent
    –> Percut drain (‘stomy)
    –> Open
    GB doesn’t get taken out during acute, severe infection/inflamm
31
Q

ERCP vs MRCP

A

MRCP purely diagnostic, imaging only

ERCP diagnostic + interventional (remove stone, place stent etc.)

32
Q

Discuss the role of ultrasound in biliary colic:

A

Initial investigation of choice

84% sensitive –> Can miss stones that are bile-density, and only half CBD stones seen

If USS non-diagnostic, follow up with MRCP or ERCP.
(CT won’t see actual stones but will see secondary stuff)

33
Q

What CBD diameter would suggest presence of a stone?

A

‘Dilated’ CBD if >6mm + 1mm for each decade above 60

34
Q

What is Mirrizi syndrome?

A

When a gallstone impacted in the cystic duct causes external compression of the common hepatic duct = obstructive jaundice.

Gastrointestinal (7 decks)

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