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Gastro > The Acute Abdomen + Peritonitis > Flashcards

The Acute Abdomen + Peritonitis Flashcards

1
Q

What is peritonitis

A

Inflammation of the peritoneum

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2
Q

What is primary

A

No cause found at laparotomy

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3
Q

What is secondary peritonitis

A

Underlying disease

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4
Q

What is localised

A

Certain part of abdomen

e.g. abscess

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5
Q

What is generalised [3]

A

Affects whole abdomen
>2 quadrants
Tenderness diffuse and inflammation widespread

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6
Q

What causes peritonitis

A
  1. Inflammation / obstruction +- perforation of
    - GI / biliary / female tract
    - Ulcer / gall bladder / appendix / IBD / malignancy
  2. Perforation of abdominal wall
  3. Haematogenous spread of infection
  4. Post-op - anastomotic leak
  5. Ischaemia
  6. Kidney / liver failure
  7. PD
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7
Q

Peritonitis symptoms [5]

A

Sudden severe abdominal pain
Lying still
Loss of appetite, Vomiting
Fever

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8
Q

How does colic present to peritonitis [2]

A

muscular spasm of a hollow viscous (gut, ureter, salpinx, uterus, bile duct or gallbladder)
Restlessness
Waxing and waning (except gallbladder colic which is dull and constant)

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9
Q

What are signs of peritonitis [5]

A 
Guarding
Rebound tenderness
Percussion tenderness - use to localise
Rigid abdomen
No bowel sounds
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10
Q

What are bowel sounds like in obstruction

A

High pitched

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11
Q

How do you investigate peritonitis [7]

A 
Urine dip, beta-HCG
Bloods - FBC, U+E, LFT, CRP
ABG (lactate)
CXR - erect (free air), abdominal (Rigler's sign)
USS / CT (perforation)
Gastrograffin (anastomotic leak)
Laparoscopy
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12
Q

What is contraindicated in peritonitis investigation?

A

Endoscopy

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13
Q

Immediate management of peritonitis [9]

A 
ABCDE & treat underlying cause
IV access & bloods
IV fluid resuscitation 
Ensure tissue perfusion and oxygenation
SEPSIS 6 
Catheter 
NG tube 
Analgesia
Anti-emetic
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14
Q

What antibiotics do you use in peritonitis? [2]

Subsequent mx of peritonitis [3]

A

CEFUROXIME and METRONIDAZOLE or GENT + MET

Drain abscess
Surgery - repair peritoneum
Treat cause

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15
Q

What are complications of peritonitis [4]

A

Abscess formation
Localized ileus
Sepsis
Septic shock

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16
Q

When does peritonitis not localise [3]

A

Contamination too rapid
Abscess ruptures
Immunocompromised

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17
Q

What is the acute abdomen?

A

Severe abdo pain which results in patient being referred for urgent surgical opinion

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18
Q

What are emergencies/ difficult to Dx conditions

A

Mesenteric ischaemia
Acute pancreatitis
Leaking/ ruptured AAA
Peritonitis after ruptured appendix

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19
Q

Pancreatitis

A

Presents with peritonitis signs but does not require laparotomy to Dx

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20
Q

How does AAA present [3]

A

Retroperitoneal back pain
Shock
Sudden collapse

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21
Q

Why is appendix rupture difficult

A

Unusual distribution of pain

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22
Q

What is somatic pain

A

Arise from abdominal wall
Peritoneum irritated
Intercostal nerves supply
Localised pain which tracks where fluid goes

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23
Q

What is visceral pain

A

Arise for organ / gut
Insensitivite to mechanical or thermal
Sensitive to distension / ischaemia / spasm
Autonomic

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24
Q

What are signs of organ rupture [3]

A

Shock
Abdo swelling
Mild peritonitis signs

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25
Q

What suggests abscess or localized peritonitis [3]

A

Swinging fever
Swelling
Increased WCC

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26
Q

What will be seen on examination [2]

A

Guarding

Rebound tenderness

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27
Q

What should you do prior to surgical referral in an acute abdomen? [6]

A 
Urine dip + MSSU
Bloods & culture
ABG 
Pregnancy test
ECG 
Imaging
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28
Q

What bloods [8]

A 
FBC
U+E
LFT
CRP
Amylase / lipase (pancreas)
Lactate (mesenteric ischaemia)
Glucose
Calcium
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29
Q

Why is it important to do ECG

A

Diseases above diaphragm

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30
Q

What imaging before surgery? [6]

A 
USS / CT
AXR 
CXR
CT if time
CT angio (if bruits detected)
CT-KUB (renal stone)
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31
Q

What do you do before surgery

A 
ABC
Resuscitate
NBM if scan / surgery
Fluid If needed
X-match and transfuse 
Analgesia
Anti-emetic
IV Ax
Thrombo-prophylaxis
NG aspiration
Nutrition
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32
Q

What is seen on a CT scan if perforation

A

Air between abdominal wall and skin

Same as hernia

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33
Q

What are common causes of acute abdomen

A 
Acute appnedicitis
Obstruction
Urinary tract
Biliary tract
Trauma
Malignancy
Perforated ulcer / gall stone
Pancreatitis
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34
Q

What causes epigastric pain [6]

A 
Gastritis
Peptic ulcer
Biliary colic
Pancreatitis
Perforation
Diseases above diaphragm
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35
Q

What diseases above diaphragm [5]

A 
Inferior MI
PE
DKA
Poison
Pneumonia
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36
Q

What should you do for diseases above [3]

A

CXR
ECG
Blood glucose

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37
Q

What causes umbilical pain [7]

A 
Crohns 
Small bowel obstruction
Appendicits
Adhesions
Malignancy
Mesenteric ischaemia
Ruptured AA
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38
Q

What causes hypogastric/suprapubic pain [5]

A 
Constipation
Diverticulitis
Colon cancer
Volvulus
Testicular/ovarian
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39
Q

What causes RLQ / LLQ pain

A 
Appendicits
Ruptured ectopic 
Renal stone
Pyelonephritis
Hernia
Mesenteric adenitis
Perforation
Diverticulitis
Testicular / ovarain torsion 
PID
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40
Q

What causes LUQ pain

A 
Pneumonia
Ruptured spleen
Ruptured AA
Pyelonephritis
Renal colic
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41
Q

What causes RUQ pain

A 
Appendicits
Pneumonia
Acute cholecystitis 
Cholangitis
Choledohcolithathis
Hepatitis
Biliary colic 
Ulcers
Pyelonephritis
Renal colic
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42
Q

Surgical causes abdominal distension

A 
Pregnancy
Obstruction 
Volvulus
Ascites 
Retention
Ovarian cancer
Constipaiton
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43
Q

What factors make obstruction more likely? [2]

A

Surgery Hx due to adhesions

Cancer

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44
Q

When is ascites likely [2]

A

Alcohol

CF

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45
Q

What are 5Fs

A 
Fat
Faeces
Flatus
Fetus
Fluid
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46
Q

Define appendix

A

a prominent lymphoid tissue which regresses with age

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47
Q

What causes appendicitis

What bacteria cause appendicitis

A

Obstruction - fecalith, bezoar, filarial worms, lymphoid hyperplasia
Infection

Enterus vemicularis

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48
Q

Pathogenesis of appendicitis [5]

A
  • Fills with mucous and swell
  • eventually causing thrombosis, occlusion of small vessels and stasis of lymphatic flow.
  • Appendix becomes ischaemic and necrotic
  • Bacteria leak out through walls and pus forms around the appendix.
  • Eventual rupture
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49
Q

Presentation Appendicitis

Symptoms [3]
Signs [5]

A

Symptoms

  • Periumbilical pain that moves to RIF
  • Anorexia - pain usually proceeds any vomiting
  • Usually constipated +/- diarrhea

Signs

  • Tachycardia, fever,
  • furred tongue, foetor
  • lying still, positive cough test
  • Guarding, rebound tenderness,
  • McBurney’s point, Rovsings sign
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50
Q

What is Murphys triad

Investigations: appendicitis [5]

A

Murphys triad
- Pain, vomiting, fever

  • FBC (neutrophilic leucocytosis)
  • CRP
  • Urine test - neutrophils + leucocyte (no nitrites), pregnancy test
  • USS >6cm diameter + rule out gynae
  • CT (not routine)
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51
Q

Appendicitis management
Simple appendicitis [2]
Perforated appendicitis [2]

A

Simple appendicitis: laparoscopic appendectomy, prophylactic IV abx (metronidazole and cefuroxime)

Perforated appendicitis: copious abdominal lavage and appendectomy

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52
Q

What are the differentials for appendicitis [8]

What should you beware in elderly?

A 
Gastroenteritis
IBS, Crohns
Constipation
Peptic ulcer 
UTI 
Ectopic pregnancy
PID
Mesenteric adenitis

Beware of underlying malignancy in elderly

53
Q

Describe an atypical presentation of appendicitis [2]

A

Retrocaecal retroperitoneal appendix > flank or RUQ pain, PR painful
Can occur in pregnancy

54
Q

Complications of appendicitis

A
  • Perforation
  • Appendix mass - when inflamed appendix becomes covered in omentum, could also be in tumor
  • Appendix abscess
55
Q

What is ischaemic colitis [2]

Presentation [3]

A

Ischaemic colitis describes an acute but transient compromise in the blood flow to the large bowel. This may lead to inflammation, ulceration and haemorrhage.
Bloody diarrhea + abdo pain

56
Q

Where is common site

A

Splenic flexure

57
Q

How do you Dx [2] and treat [2]

A

CT = 1st line
AXR

Supportive
Surgery if peritonitis / perforation / haemorrhage

58
Q

What is mesenteric ischaemia?

Aetiology

A

Typically small bowel in contrast to ischaemic colitis

Due to embolism of SMA etc

59
Q

What are the symptoms [4]

Mesenteric ischemia

A

Sudden onset abdo pain out of proportion of physical exam findings
Rectal bleeding
Diarrhoea
Fever

60
Q

What are RF for bowel ischaemia / mesenteric [7]

A 
Age
Smoking, Cocaine
Hypertension, DM
Malignancy
Endocarditis, AF** (mesenteric)
Surgery 
Abdominal aneurysm
61
Q

How do you treat mesenteric ischaemia

A

Urgent surgery - laparotomy

High mortality

62
Q

What is a volvulus [2]

A

Torsion of bowel resulting in a closed loop obstruction that can cause strangulation or incarceration

63
Q

Where is volvulus common

A

Sigmoid

Can occur gastric / caecal

64
Q

What are symptoms of volvulus [3]

Describe presentation of small intestine, caecal, sigmoid

A
  1. Absolute constipation
  2. Abdo pain + bloating
  3. N+V

Small intestine: SBO symptoms
Caecal: LBO symptoms

Sigmoid: sudden left sided abdominal pain with abdominal distention

65
Q

What is bowel volvulus associated with [5]

A

Elderly, Constipation
Neuro: Duchennes / PD
Schizophrenia
Chagas disease

Caecal - preg / adhesions / fistula, Crohns

66
Q

How do you Dx and Rx [3]

A

AXR

Central distended bowel in cecum

67
Q

Tx of volvulus
Caecal [2]
Sigmoid [2]

A

Caecal

  • Laparotomy for resection of affected segment
  • +/- anastomosis

Sigmoid

  • Emergency sigmoidoscopy, rectal tube insertion and
  • Laparotomy for sigmoidectomy +/- anastomosis
68
Q

Gastric volvulus
Aetiology
Risk factors [2]

A

Aetiology: twisting of stomach more than 180 degrees
Risk factors:
- Congenital eg pyloric stenosis
- Acquired (surgery)

69
Q

Gastric volvulus
Symptoms [3]
Ix [2]
Mx [2]

A

Symptoms:

  • Vomiting, pain, failure to pass NGT
  • saliva regurgitation
  • dysphagia

Ix: erect CXR, AXR (gastric dilation, double fluid level)

Mx: resuscitation, laparotomy

70
Q

What is a diverticulum

A

Outpouching of gut wall
Usually at site of entry of arteries
Intraluminal pressure forces mucosa to herniate through gut at weak points

71
Q

Where is common site for diverticulum

A

Sigmoid colon as this is where the luminal pressures are highest

72
Q

What is diverticular disease

What is diverticulosis

A

Symptomatic diverticulum

The state of having diverticula which are asymptomatic

73
Q

What are the symptoms of diverticular disease [7]

A

Pain LLQ
Relieved by defecation
N+V, bloating, flatulence
Altered bowel habit
Dysuria - bladder irritation due to inflamed bowel
PR bleeding
Pneumaturia or faecaluria may suggest colovesical fistula while vaginal passage of faeces or flatus may suggest a colovaginal fistula.

74
Q

What are RF for diverticular disease [5]

A 
Lack of fibre
Age
Obesity
Smoking
NSAID
75
Q

How do you Dx diverticular disease [6]

A

FBC: raised WCC
CRP: raised
Erect CXR: may show pneumoperitoneum in cases of perforation
AXR: may show dilated bowel loops, obstruction or abscesses
CT: this is the best modality in suspected abscesses
Colonoscopy: should be avoided initially due to increased risk of perforation in diverticulitis

76
Q

How do you treat diverticular disease in the community [4]

A

Antibiotics (oral)
Liquid diet
Analgesia

77
Q

What are complications of diverticular disease [5]

A 
Diverticulitis
Haemorrhage
Fistula (colovesical)
Perforation
Peritonitis, Abscess
78
Q

What is diverticulitis

A

Inflammation of a diverticulum

Beware in immunocompromised who present late

79
Q

What are signs of diverticulitis [5]

A
  • Low grade pyrexia
  • Tachycardia
  • Tender LIF: in 20% there will be a tender palpable mass due to inflammation or an abscess
  • Possibly reduced bowel sounds
  • Guarding, rigidity and rebound tenderness may suggest complicated diverticulitis with perforation
80
Q

How long should you wait before you admit patients with diverticulitis?

A 
If no improvement in 72h:
Admit
Analgesia
NBM
Iv fluid
Abx: IV ceftriaxone, metronidazole
Surgery for peritonitis / perforation
81
Q

2 investigations you should not do in acute diverticulitis as risk of perforation?

A

Colonoscopy

Barium enema

82
Q 
Management of
Abscess [2]
Perforation [2]
Hemorrhage [2]
Fistulae [1]
A

Abscesses: abx +/- US or CT guided drainage

Perforation: laparotomy and Hartmann’s procedure (temporary colostomy and partial colectomy)

Haemorrhage:

  • mx as per any rectal bleed; may require transfusion and elective embolization (diathermy and local adrenaline)
  • or colonic resection after colonoscopy or angiography

Fistulae: elective colonic resection

83
Q

Intestinal obstruction define

A

Failure of downward passage of intestinal contents

84
Q

Causes of intestinal obstruction

A

Mechanical vs pseudo obstruction

85
Q

Mechanical causes of intestinal obstruction. Give definitions of each [2]

A

Simple vs strangulated

o Simple obstruction: lumen obstructed without interference of blood supply
o Strangulation: obstruction with persistent interference of blood supply

86
Q

Simple causes of intestinal obstruction. Classify into 3 [4]

A
  • Lumen: gallstones, impacted feces
  • Mural: strictures
  • Extra-mural: adhesions
87
Q

Causes of strangulated intestinal obstruction [5]

A 
	Strangulated hernia 
	Intussusception 
	Late adhesive obstruction 
	Volvulus 
	Vascular adhesions
88
Q

Pseudo-obstruction [4]

A

Systemic/metabolic causes
Drugs
Spinal trauma, brain injury
Hirschsprung disease

89
Q

Describe some systemic/metabolic causes that can cause pseudo [2]

Describe some drugs that can cause pseudo [3]

A

Systemic/metabolic causes
 Dehydration, low K/Na/Ca
 Hypoxia, DKA, uremia

Drugs
 TCA, Lithium, GA

90
Q

Pathophysiology
Simple obstruction
1. Explain what happens to the intestine [4]

A

Intestinal:
Above obstruction
- initial increased peristalsis and distention with air and fluid later
- peristalsis ceases as bowel becomes flaccid and paralyzed
Below obstruction
- collapse, paralysis and pallor
At obstruction:
- perforation may eventually occur causing peritonitis

91
Q

Pathophysiology
Simple obstruction
2. Explain what happens to fluid and electrolyte balance
3. Explain what happens to gut flora

A

Third space loss

  • Failure of absorption of GI secretions in bowel
  • proximal to obstruction site
  • thus fluid sequesters into ECF
  • hypovolemia, dehydration

Bacterial proliferation:

  • bacterial accumulate proximal to obstruction
  • impairment of barrier fx of mucosa
  • bacterial translocation
92
Q

Pathophysiology: strangulation [4]

A

Vascular:
• Impaired venous return: bowel and mesentery are congested
• Impaired arterial supply: affected segment becomes black

Dehydration:

  • Serosanguinous fluid accumulates in peritoneal cavity
  • Blood also is lost to ‘third space’
93
Q

Whats the main difference in pathophysiology of simple vs strangulated obstruction

A

o Simple obstruction: death occurs due to peritonitis and fluid and electrolyte imbalance

o Strangulation: death occurs either due to peritonitis or hypovolemic shock and sepsis

94
Q

Dynamic vs adynamic intestinal obstruction

A

o Dynamic: increasing peristalsis working against obstructing agent
o Adynamic: peristalsis absent or ineffective with no effective propulsive waves

95
Q

State in each scenario which bowel will be dilated or collapse:
SBO
LBO with competent ileocecal valve
LBO with incompetent ileocecal valve

A

o SBO: obstruction confined to small bowel and large bowel NOT dilated or collapsed
o LBO:
 Competent ileocecal valve: small bowel is NOT dilated; large bowel becomes progressively dilated so perforation risk increases; perforation can occur at obstruction site or more commonly at cecum due to ischaemic change
 Incompetent ileocecal valve: small AND large bowel BOTH dilated

96
Q

Presentation of bowel obstruction [4]

A

Vomiting
Colicky pain
Bloating (abdominal distention)
Constipation (not always present)

97
Q

Describe pain and vomiting in SBO [5]

A

o Pain:
- generalised and colicky
- each attack lasts a few minutes
- then gradually disappears with periods of relief between attacks
o Vomiting:
- early vomitus is partly digested food
- then becomes bile stained and then feculent due to enteral bacterial growth

98
Q

What would indicate that its a jejunal obstruction [3]

A

generalised and colicky, [1] each attack lasts a few minutes and then gradually disappears [1] with periods of relief between attacks [1]

99
Q

What would indicate an ileal obstruction [2]

A
  • early vomitus is partly digested food, then becomes - bile stained and then feculent due to enteral bacterial growth
100
Q

Compare abdominal distention in jejunal vs ileal obstruction

Compare abdominal distention in LBO with competent and incompetent ileocecal valve

A

 Jejunal: minimal
 Ileal: central

 LBO with competent ileocecal valve: flank distension
 LBO with incompetent ileocecal valve: generalised distension

101
Q

Explain the difference between absolute and partial obstruction by constipation [2]

A

Absolute obstruction: no stool or flatus

Partial obstruction: continued passage of flatus and/or stool beyond 6-12h after symptom onset

102
Q

SBO subtypes: high [3], middle [3] low [3]

Describe differences in presentations

A
  • High: frequent vomiting, no distension, intermittent pain but not classical crescendo type
  • Middle: moderate vomiting and distension, intermittent crescendo colicky pain w/ free intervals
  • Low: late and feculent vomiting, marked distension, variable pain (may not be classical crescendo type)
103
Q

Bowel obstructions presenting without absolute constipation [4]

A
  • Richter’s hernia: antimesenteric wall of bowel herniates through a small defect and progresses more rapidly to gangrene than other hernias
  • Gallstone ileus
  • Acute mesenteric ischaemia
  • Intestinal obstruction associated with pelvic abscess
104
Q

Signs of intestinal obstruction

go through abdominal exam

A

• General: dehydration, tachycardia and shock
• Inspection: scars from previous surgery (adhesions), visible non-reducible hernia, visible peristalsis, stepladder appearance due to distended loops over each other
• Palpation: NO tenderness or rigidity in simple obstruction
• Auscultation:
o Early: loud, high pitched and frequent intestinal sounds
o Late: silent abdomen (ileus or peritonitis)
• Hernial orifices: features of strangulated external hernia
• PR: empty rectum, cause of obstruction (tumour, faecal impaction)

105
Q

Red flags for strangulation [6]

A

• Pain: more severe and never completely absent between attacks
• Shock: present and progressive
• Tenderness and rigidity: localised and rebound tenderness
• NG suction fails after 1-2h: fails to relieve pain
• Raised WCC
• ABG: metabolic acidosis
- External hernia feels tense, tender, irreducible with no expansible impulse on cough

106
Q

Ix: bloods [4]

A

FBC (leucocytosis in peritonitis or strangulation),
U&E and creatinine (electrolyte disturbance in SBO),
LFT (liver mets in LBO),
Clotting (abnormal in sepsis due to strangulation or peritonitis)

107
Q

X-ray Imaging:
CXR [1]
AXR SBO [3]
AXR LBO [3]

A

o Erect CXR: pneumoperitoneum (free air under diaphragm) indicating perforation

	SBO: 
- dilated small bowel loops with fluid levels (minimal in proximal, large in distal)
- vavulae conniventes - lines extend all the way across
- maximum normal diameter is 35mm
	LBO: 
- large bowel loops
- haustra extend 1/3 of the way across
- maximum normal diameter is 55mm
108
Q

Investigations: contrast studies [2]

What can CT abdominal show? [3]

A

o Contrast studies:

1) Gastrograffin follow through: if small bowel loops on AXR; may have therapeutic effect in adhesions; if contrast seen in large bowel at 24h this indicates non-surgical resolution of obstruction
2) Gastrograffin enema: if large bowel loops seen on AXR

o CT abdo: confirms dx [1] if transition point seen and identifies obstruction level [1] and staging if secondary to malignancy[1]

109
Q

Immediate management [4]

What to avoid at this stage?

A

Drip and suck

  1. NG tube - symptomatic relief from vomiting and abdo pain and reduces aspiration risk
  2. Fluid resus - isotonic fluids; assess response by pulse and urine output; correct K+ abnormalities if found

Avoid prokinetic anti-emetics e.g. metoclopramide

110
Q

Early surgery indications [5]

A 
Obstructed hernia, 
suspected strangulation, 
SBO in virgin abdomen,
failure or conservative mx in adhesive SBO, 
obstructing tumour on CT
111
Q

Surgical: general obstruction [1]
For obstructed hernia
For obstructing tumor

A

 Laparotomy or laparoscopy: cause of obstruction identified and corrected

 Obstructed hernia: explored and viable bowel reduced into abdo cavity with non-viable bowel resected
 Obstructing tumour:
Hartmann’s procedure: resection of rectosigmoid colon with an END COLOSTOMY and rectal stump

112
Q

When is conservative management indicated?

A

Incomplete SBO

113
Q

Intussusception adult
Ax [2]
Pathogenesis

A

Ax:

  • large polyp, sub mucous lipoma
  • polypoid tumors, inverted Merckels diverticulum

Pathogenesis:

  • telescoping of one segment into another
  • polyp/tumour leading point
  • usually colocolic
114
Q

Intussusception adult
Sxs [2]
Ix
Mx

A

Abdominal lump/mass
Incomplete obstruction
Ix: CT (target sign)
Mx: laparotomy for resection of affected segment +/- anastomosis

115
Q

Gallstone ileus
Ax [3]
Ix [2]
Mx [2]

A
  • Gallstone fistulae allows gallstone to become impacted in terminal ileum
  • Dynamic obstruction
  • SBO, history of biliary colic
  • Ix:
    1. AXR (air in biliary tree)
    2. CT
  • Mx:
    Laparotomy
    Laparoscopy with enterotomy to remove stone
116
Q

Paralytic ileus

Aetiology [4]

A
  • Post-op (major abdo surgery)
  • Infective (generalized peritonitis)
  • Reflex (post spinal #)
  • Fluid & electrolyte abnormalities
117
Q

Paralytic ileus
Symptoms [3]
Signs [3]

A

Symptoms:

  • Vomiting, increased gastric NGT aspirate
  • Progressive abdominal distention
  • No pain

Signs:

  • False shifting dullness
  • No bowel sounds, occasional high pitched intestinal sounds
  • Due to fluid passage from one intestinal segment to another
118
Q

Paralytic ileus
Investigation
Management

A

AXR (dilated large and small bowel loops)

Mx:

  • NGT, IV fluids, correction of electrolyte imbalance
  • TPN if indicated
  • Manage underlying cause
119
Q

Ogilvie’s syndrome
Epidemiology
Ax
Associated features [6]

A 
AKA large bowel pseudo-obstruction
Epidemiology: elderly
Ax: idiopathic
Associated features:
- Recent surgery
- Severe pulmonary or CV disease
- Electrolyte imbalance
- Medications
- Malignancy
- Systemic infection
120
Q 
Ogilvie's syndrome
What type of bowel obstuction
Presentation
Ix [3]
Mx
A

Adynamic obstruction
Presents with symptoms of LBO
Ix
• Bloods: U&E and creatinine (hyponatraemia, hypokalaemia, hypomagnesaemia), calcium (hypo or hypercalcaemia)
• AXR: generalised dilatation large bowel loops with visible air in the rectum
• CT abdo: generalised dilatation of large bowel loops with NO transition point or identifiable obstruction

Mx: supportive w/ mx of underlying cause

121
Q

Acute mesenteric ischaemia- causes: [5]

A

Arterial - thrombosis or embolism
Non-occlusive
Venous
Other

122
Q 
Acute mesenteric ischaemia- causes 2 :
Thrombotic [3]
Embolic [4]
Non-occlusive [3]
Venous [2]
Other [4]
A

• Arterial (thrombotic or embolic): superior mesenteric artery (SMA)
o Thrombosis: atherosclerosis, polycythaemia, OCP
o Embolism: arrhythmia, post-MI mural thrombus, AAA, thoracic aortic aneurysm
• Non-occlusive: low cardiac output, recent cardiac surgery, renal failure
• Venous: mesenteric vein thrombosis (younger pts, hypercoagulable state, smaller segments) due to portal HTN
• Other: trauma, vasculitis, RT, strangulation (e.g. volvulus or hernia)

123
Q

Acute mesenteric ischaemia:
Collateral arteries [3]
Ischaemia [4]

A

Usually small bowel
Collateral arteries:
- Small intestine supplied by coeliac artery and SMA
- Collateral arteries exist between SMA and IMA but this is limited at watershed areas
Ischemia:
- Hypoperfusion leads to ischemia
- Bowel necrosis > septic peritonitis
- SIRs, multi-organ dysfunction (bacterial translocation through gut wall)
- Reperfusion injury can also occur

124
Q

Where are the watershed areas?

A

Splenic flexure

Rectosigmoid junction

125
Q

Acute mesenteric ischaemia:
Sxs [3]
Ix [6]
Mx

A

Sxs:

  • classic triad:
  • acute severe abdo pain
  • no abdo signs signs (but marked tenderness and rigidity later on)
  • rapid hypovolaemia and shock

Ix:

  • Bloods
  • ABG
  • CXR
  • AXR
  • CT abdo pelvis triple phase with IV contrast
  • Invasive arteriography or CT/MR angiography
126
Q

Acute mesenteric ischaemia:

  • Bloods [3]
  • ABG
  • CXR
  • AXR [3]
  • CT [3]
A
  • Bloods: FBC (elevated Hb due to plasma loss, leucocytosis), amylase (moderately raised), lactate (elevated)
  • ABG: metabolic acidosis with raised anion gap (lactic acidosis)
  • CXR: pneumoperitoneum if perforation
  • AXR: gasless abdo in early stages, then air fluid level and bowel dilatation due to ischaemia
  • CT: oedematous bowel progressing to loss of bowel wall enhancement and pneumatosis intestinalis (can see on AXR too)
127
Q

Acute mesenteric ischaemia:
Initial management
Surgical options

A

Initial:

  • NGT
  • IV fluid resus
  • IV ceftriaxone, metronidazole
  • Heparin
  • Catheter

Exploratory laparotomy or invasive angioplasty

128
Q

Exploratory laparotomy for acute mesenteric ischemia [3]

A
  • SMA embolectomy may salvage bowel in early stages
  • but most often resection with stoma formation
  • ITU with sedation post-op with planned re-look laparotomy at 24-48h to check viability of remaining bowel

Gastro (17 decks)

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