Surgical GI Flashcards
Appearance of bowel obstruction on imaging:
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
LBO
- Haustra
- Peripheral
Cancer, volvulus, diverticular
SBO
- Loops central
- No gas in colon
- Plicae
Adhesions, herniae, Crohn’s
Sigmoid volvulus
‘Coffee bean sign’
Volvulus is a closed loop obstruction
–> Ischaemia, perforation
INFANTS = midgut volvulus (malrotation)
ELDERLY = sigmoid volvulus (chronic neurol, schiz meds)
General management in bowel obstruction:
- 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.
Hernia locations:
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
Signs and management of hernia:
- Incarceration
- Strangulation
INCARCERATED:
- Irreduceable, painful, +/- BO.
- Attempt reduction in ED:
–> Analgesia
–> Tilt bed
–> Firm, constant pressure
–> Surg consult.
STRANGULATED:
- ..+ Tender, warm, discoloured.
- OT
Clinical features of appendicitis:
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
Alvarado score (MANTRELS criteria):
Other: RIPASA, PAS (paediatric appendicitis score)
Antibiotic choice in peritonitis:
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
Define ‘uncomplicated’ and ‘complicated’ diverticulitis and their Mx:
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
Retroperitoneal haemorrhage:
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.
Causes of non-traumatic splenic rupture:
Malaria
EBV
Lymphoma + other myeloproliferative
Splenic: haemangioma, cancer, amyloid etc.
Sickle cell sequestration crisis
….any cause of diseased or enlarged spleen.
Diagnostic criteria for pancreatitis:
At least 2 of:
- Lipase or amylase THREE TIMES normal
- Radiological evidence
- Symptoms consistent with
Causes of pancreatitis:
Idiopathic
Alcohol
Gallstones
Sphincter of Oddi dysfunction/ obstruction
Post- ERCP
Hypercalcaemia
Trauma
Drugs: (NSAIDS, Bactrim, valpro)
RARE: scorpion, infection, autoimmune
Complications of pancreatitis:
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)
Amylase/lipase:
Diagnostic criteria (+ clinical/radiological features) when EITHER is 3x normal.
Lipase more specific to pancreas
Lipase elevated from 4 hours to 2 weeks
What metabolic/ electrolyte disturbances occur in severe pancreatitis?
Hypocalcaemia- marker of poor prognosis
Hyperglycaemia
High triglycerides
Metabolic acidosis- shock, loss of HCO3-rich pancreatic juice
Haemoconcentration (3rd spacing)
AKI
MODS
Management of pancreatitis:
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
Severity scoring in pancreatitis:
Modified Glascow- “PANCREAS’“
In first 48 hours:
- >3 = severe
Ransons similar
APACHE-II (most accurate, complicated +++)
Risk factors for gallstone disease:
Fat (and rapid weight loss)
Female
Forty
Fair (rare in non-caucasians)
Fertile (during pregnancy, OCP)
FHx
Lipid derangement
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
Complications of gallstone disease:
Cholecystitis (primary –> infected)
Cholangitis
Gram negative sepsis
Gallbladder empyema
Perforation
Pancreatitis
Gallstone ileus
Obstructive jaundice
Are antibiotics indicated in acute cholecystitis?
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
USS findings in acute cholecystitis:
- Distended
- Thickened >3mm
- Sonographic Murphy’s
- Cholelithiasis (hyperechoic with acoustic shadowing) (unless acalculous)
- Pericholecystic fluid
- Pneumobilia = INFECTION
Acalculous cholecystitis:
Occurs in:
- Critical illness
- HIV
- Long term TPN
Worse prognosis, more complications (Empyema, perforation, gangrene) –> Mortality 50%!
What does this show?
Pericholecystic free fluid
(+ thickened wall >3mm)
What is Charcot’s Triad?
For cholangitis. Present in 50-70%
- Fever
- Jaundice
- RUQ PAIN
Not pathognomic
Management of cholangitis:
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
Operative Mx options of biliary conditions:
- 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
ERCP vs MRCP
MRCP purely diagnostic, imaging only
ERCP diagnostic + interventional (remove stone, place stent etc.)
Discuss the role of ultrasound in biliary colic:
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)
What CBD diameter would suggest presence of a stone?
‘Dilated’ CBD if >6mm + 1mm for each decade above 60
What is Mirrizi syndrome?
When a gallstone impacted in the cystic duct causes external compression of the common hepatic duct = obstructive jaundice.
