Surgical Management Of GI Tract Flashcards
Outline the differential diagnosis for RUQ pain
Bilary Colic
Cholecystitis/Cholangitis
Duodenal Ulcer
Liver abscess
Portal vein thrombosis
Acute hepatitis
Nephrolithiasis
RLL pneumonia
Outline the differential diagnosis for RLQ pain
Acute Appendicitis
Colitis
IBD
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy
Outline the differential diagnosis for epigastrium pain
Acute gastritis/GORD
Gastroparesis
Peptic ulcer disease/perforation
Acute pancreatitis
Mesenteric ischaemia
AAA (Abdominal Aortic Aneurysm) Aortic dissection
Myocardial infarction
Outline the differential diagnosis for suprapubic/central pain
Early appendicitis
Mesenteric ischaemia
Bowel obstruction
Bowel perforation
Constipation
Gastroenteritis
UTI/Urinary retention
PID
Outline the differential diagnosis for LUQ pain
Peptic ulcer
Acute pancreatitis
Splenic abscess
Splenic infarction
Nephrolithiasis
LLL Pneumonia
Outline the differential diagnosis for LLQ pain
Diverticulitis
Colitis
IBD (Inflammatory Bowel Disease)
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy
Outline the typical presentation of bowel ischaemia
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
What are the risk factors for bowel ischaemia
Age >65 yr
•Cardiac arrythmias (mainly AF), atherosclerosis
•Hypercoagulation/thrombophilia
•Vasculitis
•Sickle cell disease
•Profound shock causing hypotension
Where does acute mesenteric ischaemia occur?
Small bowel
Where does ischaemic colitis occur?
Large bowel
Why is acute mesenteric ischaemia usually occlusive?
Due to thromboemboli
What is usually the cause of ischaemic colitis?
Usually due to non-occlusive low flow states, or atherosclerosis
Which has a more sudden onset: acute mesenteric ischaemia or ischaemic colitis?
Acute mesenteric ischaemia - sudden onset but presentation and severity varies
Ischaemic colitis is more mild and gradual
When investigating for bowel ischaemia, what would you look at in bloods?
FBC: neutrophilic leukocytosis
VBG: lactic acidosis
When investigating for bowel ischaemia what imaging is done and what does this detect?
CTAP/CT Angiogram
Detects
•Disrupted flow
•Vascular stenosis
•‘Pneumatosis intestinalis’ (transmural ischaemia/infarction)
•Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)
For what type of bowel ischaemia is endoscopy used to investigate?
For mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)
What type of management is used for mild to moderate cases of ischaemic colitis and what does this entail?
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
Conservative management is not suitable for which type of bowel ischaemia?
SB ischaemia
What are the surgical indications of bowel ischaemia?
Small bowel ischaemia
•Signs of peritonitis or sepsis
•Haemodynamic instability
•Massive bleeding
•Fulminant colitis with toxic megacolon
In the surgical management of bowel ischaemia, what is exploratory laparotomy?
Resection of necrotic bowel +/- open surgical embolectomy
or mesenteric arterial bypass
In the surgical management of bowel ischaemia, what is endovascular revascularisation?
Balloon angioplasty/thrombectomy
•In patients without signs of ischaemia
outline the typical presentation of acute appendicitis
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
when investigating acute appendicitis, what do you look for in bloods?
FBC: neutrophilic leukocytosis
↑ed CRP
Urinalysis: possible mild pyuria/haematuria
Electrolyte imbalances in profound vomiting
when investigating acute appendicitis what imaging is used for?
CT: gold standard in adults esp. if age > 50
USS: children/pregnancy/breastfeeding
MRI: in pregnancy if USS inconclusive
when investigating acute appendicitis, when is diagnostic laparoscopy used?
in persistent pain or inconclusive imaging
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%)
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
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
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
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
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
what is the most common cause of small bowel obstruction?
adhesions
what is an intestinal obstruction?
restriction of normal passage of intestinal contents.
Two main groups:
Paralytic (Adynamic) ileus
Mechanical.
what four things are mechanical intestinal obstruction classified by?
speed of onset
site
nature
aetiology
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)
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.
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
other than adhesions, neoplasia, incarcerated hernia and crohns disease, what else can cause small bowel obstruction?
Intussusception, intraluminal (foreign body, bezoar)
what are the five main causes of large bowel obstruction?
colorectal carcinoma
volvulus
diverticulitis
faecal impaction
Hirschsprung disease (commonly found in infants/children)
what are the differences in abdominal pain seen between small bowel vs large bowel obstruction?
small: colicky, central
large: colicky or central
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
when does absolute constipation occur in small bowel obstruction?
late sign
when does absolute constipation occur in large bowel obstruction?
early sign
is abdominal distension more significant in small or large bowel obstruction?
large - an early and significant sign
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
strangulating bowel obstruction with peritonitis has a mortality rate of up to_______
15%
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
what are the five most common hernial sites?
epigastric, umbilical, incisional, inguinal, femoral
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)
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
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
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.
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).
what is the immediate management of bowel obstruction?
conservative if no signs of ischaemia or clinical deterioration
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
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 adhesionalsmall bowel obstruction
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
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)
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
outline the specific presentation for a perforated peptic ulcer?
Sudden epigastric or diffuse pain
Referred shoulder pain
Hx of NSAIDs, steroids, recurrent epigastric pain
outline the specific presentation for a perforated diverticulum
LLQ pain and constipation
outline the specific presentation for a perforated appendix?
migratory pain
anorexia
gradual worsening RLQ pain
outline the specific presentation for a perforated malignancy
Change in bowel habit
Weight loss
Anorexia
PR Bleeding
when investigating for a GI investigation what do you look for in bloods?
FBC: neutrophilic leukocytosis
Possible elevation of Urea, Creatinine
VBG: Lactic acidosis
when investigating for a GI perforation what imaging is used?
erect CXR
CT abdo/pelvis
what are you looking for in an erect CXR if investigating for GI perforation?
subdiaphragmatic free air (pneumoperitoneum)
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
what are the differential diagnosis for a GI perforation
Acute cholecystitis, Appendicitis.
Myocardial infarction, Acute pancreatitis
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
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
what are the options for surgical management in generalised peritonitis +/- signs of sepsis?
Exploratory laparotomy/laparoscopy
Primary closure of perforation with or withoutomental patch (most common in perforated pepticulcer)
Resection of theperforated segment of the bowelwith primary anastomosis or temporary stoma
Obtainintra-abdominal fluid for MC&S, peritoneal lavage ++++
If perforated appendix: Lap or open appendicectomy
If malignancy: intraoperative biopsies if possible
what are the symptoms associated with biliary colic?
postprandial RUQ pain with radiation to the shoulder and nausea
what are the symptoms associated with acute cholecystitis?
acute, severe RUQ pain
fever
murphys sign
what are the symptoms associated with acute cholangitis?
charcots triad: jaundice
RUQ pain, fever
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
What are the positive investigative results for suspected biliary colic?
normal blood results
USS: cholelithiasis
What are the positive investigative results for suspected acute cholecystitis?
elevated WCC/CRP
USS: thickened gallbladder wall
What are the positive investigative results for suspected acute cholangitis?
elevated LFTs, WCC, CRP, blood MCS (+ve)
USS: biliary dilatation
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
what are the initial management steps for biliary colic?
analgesia, antiemetics, spasmolytics
what are the initial management steps for acute cholecystitis?
fluids, ABx, analgesia, blood cultures. early or elective cholecystectomy
what are the initial management steps for acute cholangitis?
fluids, IV ABx, analgesia
ERCP within 72hrs for clearance of bile duct or stenting
what are the initial management steps for acute pancreatitis?
Admission score (Glasgow-Imrie)
Aggressive fluid resuscitation, O2
Analgesia, Antiemetics
ITU/HDU involvement
