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Surgical Management Of GI Tract Flashcards

1
Q

Outline the differential diagnosis for RUQ pain

A

Bilary Colic
Cholecystitis/Cholangitis
Duodenal Ulcer
Liver abscess
Portal vein thrombosis
Acute hepatitis
Nephrolithiasis
RLL pneumonia

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2
Q

Outline the differential diagnosis for RLQ pain

A

Acute Appendicitis
Colitis
IBD
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy

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3
Q

Outline the differential diagnosis for epigastrium pain

A

Acute gastritis/GORD
Gastroparesis
Peptic ulcer disease/perforation
Acute pancreatitis
Mesenteric ischaemia
AAA (Abdominal Aortic Aneurysm) Aortic dissection
Myocardial infarction

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4
Q

Outline the differential diagnosis for suprapubic/central pain

A

Early appendicitis
Mesenteric ischaemia
Bowel obstruction
Bowel perforation
Constipation
Gastroenteritis
UTI/Urinary retention
PID

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5
Q

Outline the differential diagnosis for LUQ pain

A

Peptic ulcer
Acute pancreatitis
Splenic abscess
Splenic infarction
Nephrolithiasis
LLL Pneumonia

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6
Q

Outline the differential diagnosis for LLQ pain

A

Diverticulitis
Colitis
IBD (Inflammatory Bowel Disease)
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy

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7
Q

Outline the typical presentation of bowel ischaemia

A

Sudden onset crampy abdominal pain
•Severity of pain depends on the length and thickness of colon affected
•Bloody, loose stool (currant jelly stools)
•Fever, signs of septic shock

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8
Q

What are the risk factors for bowel ischaemia

A

Age >65 yr
•Cardiac arrythmias (mainly AF), atherosclerosis
•Hypercoagulation/thrombophilia
•Vasculitis
•Sickle cell disease
•Profound shock causing hypotension

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9
Q

Where does acute mesenteric ischaemia occur?

A

Small bowel

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10
Q

Where does ischaemic colitis occur?

A

Large bowel

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11
Q

Why is acute mesenteric ischaemia usually occlusive?

A

Due to thromboemboli

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12
Q

What is usually the cause of ischaemic colitis?

A

Usually due to non-occlusive low flow states, or atherosclerosis

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13
Q

Which has a more sudden onset: acute mesenteric ischaemia or ischaemic colitis?

A

Acute mesenteric ischaemia - sudden onset but presentation and severity varies
Ischaemic colitis is more mild and gradual

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14
Q

When investigating for bowel ischaemia, what would you look at in bloods?

A

FBC: neutrophilic leukocytosis
VBG: lactic acidosis

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15
Q

When investigating for bowel ischaemia what imaging is done and what does this detect?

A

CTAP/CT Angiogram
Detects
•Disrupted flow
•Vascular stenosis
•‘Pneumatosis intestinalis’ (transmural ischaemia/infarction)
•Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)

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16
Q

For what type of bowel ischaemia is endoscopy used to investigate?

A

For mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)

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17
Q

What type of management is used for mild to moderate cases of ischaemic colitis and what does this entail?

A

Conservative management:

IV fluid resuscitation
•Bowel rest
•Broad-spectrum ABx - colonic ischaemia can result in bacterial translocation & sepsis
•NG tube for decompression - in concurrent ileus
•Anticoagulation
•Treat/manage underlying cause
•Serial abdominal examination and repeat imaging

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18
Q

Conservative management is not suitable for which type of bowel ischaemia?

A

SB ischaemia

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19
Q

What are the surgical indications of bowel ischaemia?

A

Small bowel ischaemia
•Signs of peritonitis or sepsis
•Haemodynamic instability
•Massive bleeding
•Fulminant colitis with toxic megacolon

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20
Q

In the surgical management of bowel ischaemia, what is exploratory laparotomy?

A

Resection of necrotic bowel +/- open surgical embolectomy
or mesenteric arterial bypass

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21
Q

In the surgical management of bowel ischaemia, what is endovascular revascularisation?

A

Balloon angioplasty/thrombectomy
•In patients without signs of ischaemia

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22
Q

outline the typical presentation of acute appendicitis

A

Initially periumbilical pain that migrates to RLQ (within 24hours)
Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit

Important clinical signs
McBurney’s point: tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
Blumberg sign: rebound tenderness especially in the RIF
Rovsing sign: RLQ pain elicited on deep palpation of the LLQ
Psoas sign: RLQ pain elicited on flexion of right hip against resistance
Obturator sign: RLQ pain on passive internal rotation of the hip with hip & knee flexion

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23
Q

when investigating acute appendicitis, what do you look for in bloods?

A

FBC: neutrophilic leukocytosis
↑ed CRP
Urinalysis: possible mild pyuria/haematuria
Electrolyte imbalances in profound vomiting

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24
Q

when investigating acute appendicitis what imaging is used for?

A

CT: gold standard in adults esp. if age > 50
USS: children/pregnancy/breastfeeding
MRI: in pregnancy if USS inconclusive

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25
when investigating acute appendicitis, when is diagnostic laparoscopy used?
in persistent pain or inconclusive imaging
26
what is the alvarado scoring system?
clinical scoring system assessing for: RLQ tenderness fever rebound tenderness pain migration anorexia nausea+/- vomiting WCC> 10.000 neutrophilia (left shift 75%)
27
what does the acute management of acute appendicitis consist of?
IV Fluids, Analgesia, IV or PO Antibiotics In abscess, phlegmon or sealed perforation Resuscitation + IV ABx +/- percutaneous drainage
28
what are the indications for conservative management of acute appenidicitis?
After negative imaging in selected patients with clinically uncomplicated appendicitis  In delayed presentation with abscess/phlegmon formation CT-guided drainage 
29
what is the rate of recurrence after conservative management of abscess/perforation and what should you consider in the conservative management of acute appendicitis because of this?
12-24% consider interval appendicectomy
30
what are the benefits of a laprascopic vs open appendicectomy?
Less pain Lower incidence of surgical site infection ↓ed length of hospital stay Earlier return to work Overall costs  Better quality of life scores
31
outline the steps of a laparoscopic appendicectomy
Trocar placement (usually 3) Exploration of RIF & identification of appendix Elevation of appendix + division of mesoappendix (containing artery) Base secured with endoloops and appendix is divided Retrieval of appendix with a plastic retrieval bag Careful inspection of the rest of the pelvic organs/intestines Pelvic irrigation (wash out) + Haemostasis Removal of trocars + wound closure
32
what is the most common cause of small bowel obstruction?
adhesions
33
what is an intestinal obstruction?
restriction of normal passage of intestinal contents. Two main groups: Paralytic (Adynamic) ileus Mechanical.
34
what four things are mechanical intestinal obstruction classified by?
speed of onset site nature aetiology
35
what are the two classifications of mechanical intestinal obstruction based on their nature?
: simple vs strangulating Simple: bowel is occluded without damage to blood supply. Strangulating: blood supply of involved segment of intestine is cut off (e.g. in strangulated hernia, volvulus, intussusception)
36
what are the different classifications of mechanical intestinal obstruction as based on their aetiology?
Causes in the lumen - faecal impaction, gallstone ‘ileus’ Causes in the wall - Crohn’s disease, tumours, diverticulitis of colon Causes outside the wall – Strangulated hernia (external or internal) Volvulus Obstruction due to adhesions or bands.
37
what are the five main types of small bowel obstruction as classified by their aetiology? list in order of most to least common
adhesions neoplasia incarcerated hernia crohns disease other
38
other than adhesions, neoplasia, incarcerated hernia and crohns disease, what else can cause small bowel obstruction?
Intussusception, intraluminal (foreign body, bezoar)
39
what are the five main causes of large bowel obstruction?
colorectal carcinoma volvulus diverticulitis faecal impaction Hirschsprung disease (commonly found in infants/children)
40
what are the differences in abdominal pain seen between small bowel vs large bowel obstruction?
small: colicky, central large: colicky or central
41
what are the differences in vomiting seen between small bowel vs large bowel obstruction?
small: early onset, large amount, bilious large: late onset, initially bilious, progresses to faecel vomiting
42
when does absolute constipation occur in small bowel obstruction?
late sign
43
when does absolute constipation occur in large bowel obstruction?
early sign
44
is abdominal distension more significant in small or large bowel obstruction?
large - an early and significant sign
45
what are the three important points to remember about intestinal obstruction?
diagnosed by the presence of symptoms examination should always include a search for hernias and abdominal scars - including laparoscopic portholes is it simple of strangulating
46
strangulating bowel obstruction with peritonitis has a mortality rate of up to_______
15%
47
what are the features that would suggest a strangulating bowel obstruction?
Change in character of pain from colicky to continuous Tachycardia Pyrexia Peritonism Bowel sounds absent or reduced Leucocytosis ↑ed C-reactive protein
48
what are the five most common hernial sites?
epigastric, umbilical, incisional, inguinal, femoral
49
when investigating for bowel obstruction what do you look for in bloods?
WCC/CRP usually normal (if raised suspicion of strangulation/perforation) U&E: electrolyte imbalance VBG if vomiting: HypoCl-,HypoK+ metabolic alkalosis VBG if strangulation: Metabolic Acidosis (lactate)
50
what imaging is used for bowel obstruction?
Erect CXR/AXR  SBO: Dilated small bowel loops >3cm proximal to the obstruction (central) LBO: Dilated large bowel >6cm (if caecum >9cm) predominantly peripheral CT abdo/pelvis → Transition point, dilatation of proximal loops – IV +/- oral contrast if possible
51
what are the signs of a small bowel obstruction as seen on an x-ray?
Ladder pattern of dilated loops & their central position Striations that pass completely across the width of the distended loop produced by the circular mucosal folds
52
what are the signs of a large bowel obstruction as seen on a abdominal xray?
Distended large bowel tends to lie peripherally Show haustrations of taenia coli - do not extend across whole width of the bowel.
53
in investigating bowel obstruction, what is CT used for?
Can localize site of obstruction Detect obstructing lesions & colonic tumours May diagnose unusual hernias (e.g. obturator hernias).
54
what is the immediate management of bowel obstruction?
conservative if no signs of ischaemia or clinical deterioration
55
what does the supportive management of bowel obstruction entail?
NBM, IV peripheral access with large bore cannula - IV Fluid resuscitation IV analgesia, IV antiemetics, correction of electrolyte imbalances NG tube for decompression, urinary catheter for monitoring output Introduce gradual food intake if abdominal pain and distention improve
56
what does the conservative treatment of bowel obstruction entail?
Faecal impaction: stool evacuation (manual, enemas, endoscopic) Sigmoid volvulus: rigid sigmoidoscopic decompression SBO: oral gastrograffin (highly osmolar iodinated contrast agent) can be used to resolve adhesional small bowel obstruction
57
what are the indications for surgical management of a small bowel obstruction?
Haemodynamic instability or signs of sepsis Complete bowel obstruction with signs of ischaemia Closed loop obstruction Persistent bowel obstruction >2 days despite conservative management 
58
what are the surgical options for a bowel obstruction?
Exploratory Laparotomy/Laparoscopy  Restoration of intestinal transit (depending on intra-operational findings) Bowel resection with primary anastomosis or temporary/permanent stoma formation (Endoscopic stenting)
59
outline the presentation for a GI perforation
Sudden onset severe abdominal pain associated with distention Diffuse abdominal guarding, rigidity, rebound tenderness Pain aggravated by movement Nausea, vomiting, absolute constipation Fever, Tachycardia, Tachypnoea, Hypotension Decreased or absent bowel sounds
60
outline the specific presentation for a perforated peptic ulcer?
Sudden epigastric or diffuse pain Referred shoulder pain Hx of NSAIDs, steroids, recurrent epigastric pain
61
outline the specific presentation for a perforated diverticulum
LLQ pain and constipation
62
outline the specific presentation for a perforated appendix?
migratory pain anorexia gradual worsening RLQ pain
63
outline the specific presentation for a perforated malignancy
Change in bowel habit Weight loss Anorexia PR Bleeding
64
when investigating for a GI investigation what do you look for in bloods?
FBC: neutrophilic leukocytosis Possible elevation of Urea, Creatinine VBG: Lactic acidosis
65
when investigating for a GI perforation what imaging is used?
erect CXR CT abdo/pelvis
66
what are you looking for in an erect CXR if investigating for GI perforation?
subdiaphragmatic free air (pneumoperitoneum)  
67
what are you looking for in a CT abdo/pelvis when investigating for a GI perforation?
Pneumoperitoneum, free GI content, localised mesenteric fat stranding can exclude common differential diagnoses such as pancreatitis
68
what are the differential diagnosis for a GI perforation
Acute cholecystitis, Appendicitis. Myocardial infarction, Acute pancreatitis
69
what is the supportive management plan on presentation for a GI perforation?
NBM & NG tube IV peripheral access with large bore cannula - IV Fluid resuscitation Broad spectrum Abx IV PPI Parenteral analgesia & antiemetics Urinary catheter 
70
outline the steps of conservative management in localised peritonitis without signs of sepsis?
IR - guided drainage of intra-abdominal collection Serial abdominal examination & abdominal imaging for assessment
71
what are the options for surgical management in generalised peritonitis +/- signs of sepsis?
Exploratory laparotomy/laparoscopy Primary closure of perforation with or without omental patch (most common in perforated peptic ulcer) Resection of the perforated segment of the bowel with primary anastomosis or temporary stoma  Obtain intra-abdominal fluid for MC&S, peritoneal lavage ++++ If perforated appendix: Lap or open appendicectomy If malignancy: intraoperative biopsies if possible
72
what are the symptoms associated with biliary colic?
postprandial RUQ pain with radiation to the shoulder and nausea
73
what are the symptoms associated with acute cholecystitis?
acute, severe RUQ pain fever murphys sign
74
what are the symptoms associated with acute cholangitis?
charcots triad: jaundice RUQ pain, fever
75
what are the symptoms associated with acute pancreatitis?
severe epigastric pain radiating to the back nausea w/without vomiting Hx of gallstones or EtOH use
76
What are the positive investigative results for suspected biliary colic?
normal blood results USS: cholelithiasis
77
What are the positive investigative results for suspected acute cholecystitis?
elevated WCC/CRP USS: thickened gallbladder wall
78
What are the positive investigative results for suspected acute cholangitis?
elevated LFTs, WCC, CRP, blood MCS (+ve) USS: biliary dilatation
79
What are the positive investigative results for suspected acute pancreatitis?
raised amylase/ lipase high WCC/ low Ca2+ CT and US to assess for complications/ cause
80
what are the initial management steps for biliary colic?
analgesia, antiemetics, spasmolytics
81
what are the initial management steps for acute cholecystitis?
fluids, ABx, analgesia, blood cultures. early or elective cholecystectomy
82
what are the initial management steps for acute cholangitis?
fluids, IV ABx, analgesia ERCP within 72hrs for clearance of bile duct or stenting
83
what are the initial management steps for acute pancreatitis?
Admission score (Glasgow-Imrie) Aggressive fluid resuscitation, O2 Analgesia, Antiemetics ITU/HDU involvement

Y2 GASTRO (10 decks)

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