Surgical Presenting Complaints

Question 1

Upper GIT Bleed - Hx

Answer 1

• Haematemesis? -> is the blood fresh, coffee ground or altered?
• Amount of blood?
• Volume of vomit?
• How many episodes?
• Malaena?
• Previous episodes?

Question 2

Upper GIT Bleed - associated features

Answer 2

• Anorexia
• Dyspepsia
• Epigastric pain (SOCRATES)
• Features of chronic liver disease
• Weight loss

Question 3

Upper GIT Bleed - Differentials

Answer 3

Oesophageal - oesophagitis, carcinoma, varices, Mallory-Weiss tear, hiatal hernia
Gastric - peptic ulcer, benign and malignant tumours
Duodenal - duodenitis, peptic ulcer

• Most common = peptic ulcer disease

Question 4

Lower GIT Bleeding - Types of Bleeding

Answer 4

• Spotting and fresh blood - haemorrhoids or fissure
• Fresh and/or profuse bleeding - diverticular disease, IBD, carcinoma
• Dark/altered blood - lesions in proximal colon (diverticular disease or carcinoma)
• Red currant jelly stool - intussusception
• Mucoid, bloody diarrhoea - enteric infections
• Bloody diarrhoea - ischaemic colitis

Question 5

Lower GIT Bleeding - Associated Features

Answer 5

• Altered bowel habits
• Abdominal pain/discomfort
• Mucus in stool
• Tenesmus
• Weight loss

Question 6

Lower GIT Bleeding - Causes

Answer 6

D - diverticular disease - most common
H - Haemorrhoids
C - CRC
I - IBD, infection (gastroenteritis - campylobactor, shigellosis, amoebea
Anal fissure
Colonic polyps

Question 7

Diarrhoea - Hx

Answer 7

Age
< 40 - IBS, infective, IBD
> 40 - carcinoma

Diarrhoea - increased frequency, increased volume

• Frequency - how many times in 24hrs are the bowels opening? Do you have to get up at night to open bowels?
• Consistency
• Watery, clear frothy
• Fluid/brown
• Semi-formed or solid
• Blood
• Mucus
• Fat (steatorrhoea)

Associated Features:

• Systemic signs - anaemia, fever, arthritis
• Nausea and vomiting, dehydration
• Abdominal pain - SOCRATES
• Weight loss, loss of appetite
• Recent foreign travel
• Family hx of IBD, polyps or cancer

Question 8

Diarrhoea - Differentials

Answer 8

Colonic causes

• Inflammatory Bowel disease
• Infective colitis
• Bacterial: Campylobactor pylori, Shigella, E. coli, S typhi, Cholera, Clostridium difficile
• Viral: rotavirus, adenovirus, astrovirus
• Protozoal: Giardia, Entamoeba
• Left-sided colonic malignancy
• Ischaemic colitis
• Overflow diarrhoea secondary to constipation
• Coeliac disease
• Secretory - post small bowel resection
• Hyperthyroidism
• Alcohol
• Medications

Fatty - hepatobiliary disorders, pancreas exocrine insufficiency

Question 9

Jaundice - History

Answer 9

A - Alcohol consumption
B - Blood transfusion 
D - Drugs - recreational
F - Fever, family history, food poisoning
M - Medications
P - Previous history
S - Sexual contacts, stool colour - pale
T - Travel history
U - Urine colour - dark
W - Weight loss

Question 10

PR Bleeding - Differentials

Answer 10

Anatomical - diverticulosis
Infective - bacterial (Shigellosis, Campylobacter), protozoal (amobea)
Inflammatory - IBD
Neoplastic - CRC
Vascular - haemorrhoids, ischaemic colitis, angiogysplasia, radiation-induced

Question 11

PR Bleeding - History

Answer 11

• Prior episodes of bleeding
• Medications - NSAIDs, antiplatelets, anticoagulants
• Travel/food hx
• Weight loss
• Fever, sweats
• Abdominal pain (presence of abdominal pain suggests presence of inflammatory bleeding source - ischaemic or infectious colitis or a perforation)
• Prior endoscopy (gastroscopy/colonoscopy)
• Family hx
• Radiation exposure

Question 12

PR Bleeding - Approach to management

Answer 12

• IV access
• Resuscitation - fluids/blood
• Exclusion of upper GIT bleeding with upper endoscopy
• Evaluation of lower GI source

Question 13

PR Bleeding - Investigations

Answer 13

Blood

• FBC - WBC, Hb
• UEC
• LFT’s
• Coagulation profile
• Group and hold, cross match

Stool - MCS - if worried about infective cause

Question 14

PR Bleeding - exclusion of upper GIT bleeding

Answer 14

• 10-15% of patients with severe haematochezia will have an upper GI source
• Findings that are suggestive of upper GI source:
• Haemodynamic instability
• Orthostatic hypotension
• Elevated BUN
• Blood clots in the stool decrease the likelihood of an upper GI source
• Investigations:
• Upper endoscopy once patient is appropriately resuscitated

Question 15

PR Bleeding - evaluation of lower GIT source

Answer 15

• Initial examination of choice = colonoscopy
• CT angiography (requires active bleeding at time of imaging)
• Radionuclide imaging (red cell scan)
• Normal CT - takes images in portal venous phase
• CT angiography - images in arterial phase