The Digestive System - GI Surgical Emergencies Flashcards
Peritonitis
Infl of serial membrane lining abdo cavity and the organs
Types of peritonitis
Primary - spontaneous
Secondary - to pathology in a visceral organ
Tertiary - persist/ recurs adequate initial treatment
Primary peritonitis
Spontaneous bacterial peritonitis (SBP)
Infection of ascitic fluid which arises in the absence of any other source of sepsis within the peritoneum or the adjacent tissues
Risk factors for primary peritonitis
Co-existence of GIT bleeding
Previous SBP
Low ascitic protein
What is SBP commonly seen in
Alcoholism and cirrhosis
Malignant mets
Hepatitis
CHF
SLE
Usually develops on top of pre-existing ascites
Px of SBP
Pyrexia - seen in 80%
Abdo pain
Peritoneal irritation - pain, rebound tenderness
What is diagnostic for SBP
> 250 polymorphonuclear WBCs in peritoneal fluid
Common organisms in SBP
E. coli
Strep
Enterococci
Treatment of SBP
Broad spectrum abx before culture results
3rd gen cephalosporins
Best-lactam combi e.g. piperacillin
Secondary peritonitis
Spillage of GI or gU micro-organism –. loss of integrity of mucosal barrier
May be disease, perforation, trauma, gangrene, obstruction, malignancy
Diseases that may cause secondary peritonitis
Appendicitis
Diverticulitis
Pancreatitis
IBD
In females, from an infected Fallopian tube or ruptured ovarian cysts
Px of 2’ peritonitis
Local pain from ruptured organ
Pts lie motionless/ curled
Rebound tenderness
Febrile
Death in 2’ peritonitis
Typically Gram-ve rod sepsis and potent endotoxins
Pathogens causing 2’ peritonitis - contamination form upper GI
Gram+ve organisms usually predominate
Incl yeasts, lactobacilli
Gram-ve rods if gastr9c acid suppressed
Pathogens causing 2’ peritonitis - contamination from distal bowel
Polymicrobial incl yeasts
GNR and anaerobes
Pathogens causing 2’ peritonitis - bloodstream/ lymphatic spread
Strep pneumonia
When does 3’ peritonitis occur
Within 48hrs of surgery
What is 3’ peritonitis typically caused by
Multidrug resistance organisms (ESBL, VRE) - difficult to treat
Abscesses
Severe complications of sepsis following surgery
Common sources of pyrexia in a surgical pt
Chest (infection)
Cut (wound infection)
Catheter (UTI)
Collections (abdo, pelvis)
Calves (DVT)
Cannula (infection)
Central line (infection)
CAPD
Continous ambulatory peritoneal dialysis
What does CAPD peritonitis involve
Skin organisms’ vs endogenous flora
Similar to endovascular device infection
Px of CAPD peritonitis
Same as 2’ peritonitis
What would be seen in dialysate in CAPD peritonitis
Cloudy
>100 WBCs, 50%
What is a peritoneal abscess
Infected fluid collection
Encapsulates by fibrinoid exudate, momentum and/or adjacent visceral organs
Loculation
Compartmentalisation of fluid-filled cavities by septa
Where do peritoneal abscesses usually occur
Sub-hepatic
Pelvic region
Paracolic gutter
Half with loculation
What may cause intra-ab abscesses
Faecal spillage from colonic source
Diverticular abscess
Necrotising abscess
Necrotising pancreatitis
Which antimicrobials to use for Gram-ve organisms
Amoxi*
Gentamycin
Co-amoxiclav
Cefuroxime
Cipro
Piperacillin
Which antimicrobials to use Gram+ve organisms
Amoxi
Gentamycin*
Co-amoxiclav
Piperacillin/ tazobactam
Vancomycin
Which antimicrobials to use for anaerobes
Metronidazole
Co-amoxiclav
Piperacillin
Hernia
Abnormal protrusion of a cavities through its wall
Defect in wall creates neck of hernia
Types of abdominal hernias
Epigastric
Umbilical
Spighelian
Excisional
Inguinal
Femoral
Is divarification of recti a hernia
No
There is no defect of wall
Recti shifted away from midline and sheath becomes lax
Who does divarification of recti affect
Seen in women after childbirth
Elderly men
Epidemiology of hernias
9x more common in men (except femoral)
Men have lifetime risk of 27%
Most commonly presents in ages 40-59
Px of hernias
Bulge or mass
Discomfort
Cough impulse
Px of obstructive hernias
N & V
Abdo pain
Distention
Absent bowel sounds
Px of strangulated hernias
Tenderness
Severe pain
Gangrenous mass
Classification of non-reducible hernias
Incarcerated
Obstructed
Strangulated
Spigelian hernias
Occurs between lateral border of rectus abdominis and linea semilunaris
Area of central weakness pushed dup - doesn’t go through anterior sheath
Incisional hernias
Occurs at sites where there gas been a previous surgical incision has been made
Range from small (few cm) to v large
Incarcerated hernias
Cannot be returned as they have formed adhesions outside but are still viable
Obstructed vs strangulated hernias
Bowel lumen becomes obstructed –> intestinal obstruction
Strangulated - blood flow to bowel stooped (ischaemic)
How are hernias repaired
Identify neck and sac of hernia, open up sac and reduce hernia content intra-ab
Neck is brought back together and covered w/ mesh
Different placement of mesh in hernia repairs
Onlay - over the top
Inlay - in between gap of muscle
Retro-muscular - beneath muscles
Preperitoneal and intraperitoneal - in peritoneal space
Best and worst place to put mesh in hernia repair
Inlay - worst, can be moved if intra-ab pressure increases
Pre/intraperitoneal - strongest, if intra-ab pressure increases, mesh is pushed up against muscle
Ddx for groin hernias
Malignant
Aneurysm caused by IVDUs
Venous swellings
How can we tell the difference between inguinal and femoral hernias
Relation to pubic symphysis
Femoral is below and lateral
Inguinal is above and medial
Features of direct inguinal hernias
Protrudes through Hesselbach trinagle - herniates through external and internal ring
Low rich of strangulation
Common in M
Seen in adults
Features of indirect inguinal hernia
Protrudes through inguinal ring (external only) - failure of processus vaginalis to close
Low risk of strangulation
Common in M
May occur in infants - congenital
Differentiating between direct and indirect inguinal hernia
Locate deep inguinal ring (midway of ASIS and pubic tubercle)
Manually reduce hernia towards deep ring and apply pressure
Ask pt to cough - if reappears, direct
Referral guidelines for hernia
Sx of strangulation/ obstruction
All females
Symptomatic males
Ix if diagnostic uncertainty for hernias
USS
if still unclear, MRI
Operative mx of hernias
Open vs laparoscopic (less painful, reduced recovery)
Incl herniotomy or hernioplasty
When is conservative mx used for hernias
Asymptomatic hernias (typically have wide neck)
Features of femoral hernias
Protrudes below inguinal ligament
High risk of strangulation
More common in F
Ddx for femoral hernias
Lymphadenopathy
Abscess
Femoral artery aneurysm
Lipoma
Inguinal hernia
Are trusses useful for femoral hernias
No - risk of strangulation
Complication of hernia repair
Bleeding
Infection
Recurrence - 10%
C/c pain
Cardinal sx of bowel obstruction
Absolute constipation - obstipation
Vomiting
Pian
Distended abdomen
Richter’s hernia
Only part of bowel walls and lumen herniate, other part remains in peritoneal cavity
Madyl’s hernia
Two diff loops of bowel contained within hernia
Hesselbach’s triangle boundaries
Rectus abdominis - medial
Inferior epigastric vessels - superior/ lateral
Inguinal ligament - inferior
Boundaries of femoral canal
Femoral vein - lateral
Lacunar ligament - medially
Inguinal ligament - anteriorly
Pectineal ligament - posteriorly
A/c abdo pain
Non-traumatic abdo pain lasting 5/7 or less
C/c abdo pain
Recurring or constant abdo pain of 2/12 or more
Sx of a/c or c/c abdo pain
Constant or episodic
Spp pain characteristics
Red flags
Dysphagia/ odynophagia
Palpitation
Chest sx
Signs of a/c or c/c abdo pain
Abdo distention
Tenderness
Grey Turner’s sign
+ve Carnett’s sigan
Rovsing sign
Guarding
Ddx of a/c abdo pain - diffuse
Pancreatitis
Bowel obstruction
Sickle cell crisis
Gastroenteritis
Mesenteric thrombosis
Extras - metabolic disorder , psychogenic illness
Ddx of a/c abdo pain - focal
A/c appendicitis
Biliary colic
A/c pancreatitis
A/c diverticulitis
Extras - ruputured adnexa cysts, ovarian torsion
Ddx of c/c abdo pain
Functional dyspepsia
IBS
IBD
PUD
Diverticular disease
Narcotic bowel syndrome (opined induced GI hyperplasia)
Ix for c/c abdo pain
Tends to be more focussed
Guided by red flag sx and signs
If c/c pancreatitis and 20-49yrs, excl CF, but if >40, excl cancer
Fecal fat/ elastase
Intestinal obstruction
Interruption in normal flow of intestinal content either due to mechanical occlusion of the intestinal lumen or black of peristalsis
Pathophysiology of intestinal obstruction
Mechanical obstruction
Fluid and electrolyte loss
Bacterial translocation and toxaemia
Ischaemia
Perforation and peritonitis
6 Fs of abdo distension
Fat
Foetus
Flatus
Fluid
Faeces
Fulminnat masses
Ddx of SBO - neonates
Duodenal/ jejunal atresia
Meconium ileus
Ddx of SBO - children
Pyloric stenosis
Intussusception
Parasites
Ddx of SBO - young adults
Adhesions
Hernias
Ileus
Gallstone ileus
Malignancy
Strictures
Ddx of SBO - older age
Paralytic ileus
Malignancy
Ddx of LBO
Hirchsprung’s disease
CRC
Diverticular
Volvulus
Ischaemic bowel
Faecal impaction
Main causes of bowel obstruction
Adhesions (SBO)
Hernias (SBO)
Malignancy (LBO)
Adhesions
Pieces of scar tissue binding abdo contents together
Main causes of intestinal adhesions
Abdo or pelvic surgery (esp open)
Peritonitis
Abdo or pevic infections
Endometriosis
Ix for bowel obstruction
Haemorrhage/ biochem - amylase may be raised in SBO
AXR (first line)
Gastrogratin (meal/ enema)
US - may show fluid or gas
CT - w/ IV +/- oral contrast (definitive dx)
AXR for bowel obstruction
Distended loops of bowel - 3-6-9 rule
Valvuale conniventes - mucosal folds across ENTIRE width of small bowel
Haustra - folds halfway across large bowel
Pneumonperitoneum suggest perforation
What type of shock are pts w/ bowel obstruction like to have
Hypovolameic - fluid stuck in bowel intreat of intra-vascular space (third-spacing)
Initial mx of bowel obstruction
‘Drip and suck’
NBM
IV fluids
NGT drainage
Analgesia
Hydostatic or pneumatic enema may be used for decompression
Definitive mx of bowel obstruction
Exploratory surgery to correct underlying cause
Adhesiolysis
Hernia repair
Emergency resection
Carnett’s sign
A/c abdo pain remains unchanged or increases earn abs muscles tensed
Differentiates intra-ab and abdo wall pathology
Differentials for pain in R hypochondrium
Gallstones
Hepatitis
Liver abscesses
Cholangitis
Cardiac/ lung causes
Differentials for pain in epigastrium
Oeosphagitis
PUD
Perforted ulcer
Pancreatitis
Differentials for pain in L hypochondrium
Spleen abscess
Spleen rupture
Splenomegaly
Differentials for pain in lumbar regions
Renal colic - comes in waves
Pyelonephritis
Differentials for pain in RIF
Appendicitis
CD flare
Ovarian cyst
Hernias
Ectopic cyst
Differentials for pain in umbilical region
Early appendicitis
Meckel diverticulitis
Lymphoma
Differentials for pain in hypogastric region
Testicular torsion
Urinary retention
Cystitis
Differentials for pain in LIF
Diverticulitis
UC flare
Constipation
Hernias
Mechanisms leading to bowel perforation
Ischaemia: obstruction –> hypo perfusion –> necrosis
Infl/ infection: diverticulitis, IBD (esp CD), appendicitis
Erosion: ulceration, tumour
Physical disruption: trauma, iatrogenic
Sx of bowel perforation
Septic shock
Abdo pain
Distension
Fever/ chills
Guarding
Mx of bowel perforation
Surgical repair
Bowel rest
IV fluids
IV broad-spectrum abx
Tools used in pre op risk stratification
ASA
Performance status
POSSUM
APACHE
POSSSUM
Physiological and Operative Severity
Score for enumeration of mortality and morbidity
ASA tool
American Society of Anaesthesiologist
Ranges from 1 - 6
1 is healthy and 6 is brain dead, 4 is severe disease that is a constant threat to life
What do pre-op tests depend on
Minor, intermediate, major or complex surgery
Depends on ASA grade
Examples of minor surgery
Excising skin lesions
Draining breast abscess
Examples of intermediate surgery
Primary repair of inguinal hernia
Excising VVs in legs
Tonsillectomy
Examples of major or complex surgery
Joint replacement
Colonic resection
Hysterectomy
Lung operations
When would cardiopulmonary exercise testing be required
Thoracic and upper GI major surgeries
Pre op consent process
Procedure
Benefits
Risks/ complications
Alternatives
Info leaflets
Effects of resp disease in surgery
Air trapping & bronchospasm - seen in asthma, emphysema
Excess pulm secretions - bronchiectasis, c/c bronchitis
Reduced lung compliance - pulm fibrosis, pleural plaques
Reduced ventilatory capacity - OSA, neuromuscular disease
Optimisation of resp conditions pre op
Smoking cessation, nicotine testing (reduces risk of infection by 50% in just 8/52)
Pre-op PT
Optimising medical therapy
When are METs performed
Metabolic equivalent tests
Part of detailed hx and exam in pts w/ CDV disease
Pts who cannot meet 4x the metabolic demands of normal daily activities are at increased risk
Peri-op mx in cardiac disease
Don’t start cardiac meds w/ possible exception of diuretics
Consider adding drugs e.g. BB - reduces cardiac complication in high-risk pts
Ideally should start several weeks before surgery
Pacemaker checks pre -op
What type - single/ dual chamber, biventricualr, ICD
When was it inserted, indication
Last check and next check
Check w/ anaesthetists
Pre-op mx - renal disease
Detailed hx and exam
Consultant w/ pts renal physician
Assessment of current renal function
Peri-op mx - renal disease
Careful attention to fluid and electrolyte balance
Careful attention to drugs, contrast dyes
What are we aiming for in peri-op mx in DM
Avoiding hypoglycaemia
Aim for mean blood glucose conc of 5-7
Monitor capillary glucose every 2-4hrs during surgery
What does peri-op mx in DM depend on
Usual diabetes mx e.g. diet only, insulin
Grade of surgery - minor (eating within few hrs) or major (NBM > 6 hrs)
Depending of clinical urgency, what can anaemia be treated w/ pre-op
Oral or parenteral iron
Blood transfusion
Epo pre-op or peri-op
Issues w/ treating anaemia in Jehovah’s witness’ peri-op
Discuss w/ pt and think of auto transfusion, cell saver, plasma
Peri-op mx for bleeding risk
Assess for bleeding risk - coagulopathy from platelet disorder, organ dysfunction, meds etc
Pts on anti-coag usually require pre-op stoppage/ reversal
How long should warfarin be withheld for pre op
5/7 to allow INR to fall to <1.5
Common indications for bridging therapy peri-op
Metal valves
Cardiac stents
Stroke
Uncontrollable AF
How long should clopi + asp be withheld for pre op
7 to 10 days
Post-op problems near
Confusion
Post-op problems - GI
Ileus
Nausea
Vomiting
Post-op problems - kidneys
Low urine output
Metabolic effect of unrelieved pain post-op
Catabolism due to increased cortisol, glucagon, catecholamines
CDV effect of unrelieved pain post-op
Increased myocardial oxygen demand
Increased coagulation
Resp effect of unrelieved pain post-op
Decreased functional residual capacity
Retention of sputum
GI effect of unrelieved pain post-op
Vomiting ileus
Renal effect of unrelieved pain post-op
Water and Na retention
Psychological effect of unrelieved pain post-op
Anxiety, depression
Increased subjective pain experience
WHO analgesic ladder
Step 1 - paracetamol, NSAIDs
Step 2 - tramadol, codeine plus Step 1
Step 3 - Morphine, methadone, oxycodone plus Step 1
Resp complications post-op
Atelactasis, chest infection
PE
Pulm oedema
Post-op mx to prevent resp complications
Effective analgesia - allows deep breathing, mobilisation
Chest physio
Nutrition
Fluid balance
Cardiovasc complications post-op
MI
Arrhythmias
Sinus tachycardia
Sinus Brady
Mx of arrhythmias post-op
Treat electrolytes, hypotension, hypoxia, amiodaron cardioversion
What might cause sinus tachy post op
Pain
Anxiety
Hypovolaemia
Sepsis
Hypoxia
Preventing cardiac complications post-op
Adequate analgesia
Supplemental oxygen therapy
Maintaining an even fluid balance
Pre-renal causes of a/c renal failure post-op
Hypotension
Hypovolaemia
Renal causes of a/c renal failure post-op
Nephrotoxic drugs
Myoglobinuria (muscle damage)
Sepsis
Post renal causes of a/c renal failure post-op
Ureteric injury
Blocked catheter
How may post-op confusion px as
Restlessness
Anxiety
Incoherent speech
Pulling of cannula
Causes of post-op pyrexia
Wound
Intra-ab collection
Chest infection
Leaks (seen in GI surgery)
VTE
Urine catheter infection
Line infection
Where are pressure sores typically seen in
Sacrum
Greater trochanter
Heels
Who are most at risk of pressure sores
Those w/ nutritional stratus
Dehydration
Lack of mobility - early mobilisation is key
What are haemorrhoids
Enlarged anal vascular cushions - VV of anal can
Sx of haemorrhoids
Bleeding - typically painless
Prolapse
Irritation
Internal vs external haemorrhoids
External - below dentate line, more painful and prone to thrombosis
Internal - above
Risk factors for haemorrhoids
Grade 1 - mno prolapse
Grade 2 - prolapse but reduces spontaneously (after defecation)
Grade 3 - prolapse, stay reduced if pushed back manually
Grade 4 - irreducible
Risk factors/ causes of haemorrhoids
Constipation +/- straining
Heavy lifting
C/c cough (increased intra-ab pressure) - COPD
Pregnancy/ childbirth
Ddx of haemorrhoids
Anal tissue
Ano-rectal polyps
Mucosal prolapse
Ano-rectal carcinomas
Mx of haemorrhoids - Grade 1
Conservative - reassurance, diet
Topical steroids to alleviate itch
Mx of haemorrhoids - Grade 1
Conservative - reassurance, diet, anaesthetic ointments
Topical steroids to alleviate itch
Mx of haemorrhoids - Grade 2
Rubber band ligation
Sclerotherapy
Infrared photocoagulation
Mx of haemorrhoids - Grade 3
Ruber band ligation
Mx of haemorrhoids - Grade 4
Surgical haemorrhoidectomy
Risks of haemorrhoidectomy
Removal of anal cushions may result in faecal incontinence
Recurence
Pain
Impacted faeces
Cause of thrombosed haemorrhoids
Strangulation at base of haemorrhoids –> thrombosis
Px of thrombosed haemorrhoids
Significant pain
Purplish, oedematous, tender perianal mass
Mx of thromboses haemorrhois
If pts presents within 72hrs, refer for excision
Pts can be managed with stool softeners, ice packs and analgesia
Effects of sclerotherapy injection in haemorrhoids
Fixation - prevents prolapse
Fibrosis protects veins
Prevents distension
Anal fissure
Tear causing a painful, linear ulcer at margin of anus (squamous lining)
<6 wks is a/c and more is c/c
Risk factors/ causes of anal fissures
Constipation
IBD (CD)
STI e.g. HIV, Herpes, syphilis
Pregnancy
Sx of anal fissures
Severe pain during and after boowel motion
Bright red rectal bleeidng
Itch
90% of anal tissues on posterior midline, if alternative locations, consider causes like CD, lymphoma, anal cancer etc
Dx of anal fissures
Physical exam is diagnostic - difficult due to pain
Triad of sentinel skin tag (externally), fissure and a hypertrophied papilla (internally)
Sentinel pile
Oedematous skin tag at the lower end of c/c anal fissure
Mx of a/c anal fissure
Soften stool - diet, bulk-forming laxatives
Lubricants before defecation e..g vaseline
Topical anesthetics
Mx of c/c fissure
Topical GTN or CCB - 1st line
Botox injection
Surgery - sphincterotomy
Presentation of superficial abscesses
Pain
Swelling
Discomfort on walking and sitting
Tenderness
Fever
Px of deep abscesses
Lack typical features
Diffuse pelvic pain and raised body temp
Cause of perianal abscess
Cryptoglandular theory
Anal glands may become infected when a crypt is occluded by impaction of fecal matter, oedema, IBD, trauma 2’ to hard stool or foreign body
Anal fistula
Abnormal communication between the interior of the anal canal or rectum and skin surface
Px of fistula
Depends on the severity of inflammation.
Excretion of pus, serous fluid or faeces may lead topruritus ani, itching and skin maceration.
Ix for perianal abscess and fistula
Physical exam is diagnostic
Rectoscopy/ proctoscoy (if tolerated)
MRI for deeper abscesses
Mx of anal abscess
Surgical drainage - cruciate incision
Sometimes a drain may be left
Mx of anal fistula
Seton - helps drain and prevent abscess
Fistulotomy
Fibrin glue
Pruritus ani
Condn characterised by intense perianal icthing and burning
Pruritus ani
Condn characterised by intense perianal icthing and burningSx
Sx of pruritus ani
Itching
Burning
Irritation
Worse at night
Examination findings for pruritus ani
Reddened oedematous ulcerations
Excoriations
Skin atrophic or hypertrophic w/ associated nodularity and scarring
Ix for pruritus ani
Proctoscopy and sigmoidoscopy
Stool assessment
Ddx fro pruritus ani
Haemorrhoids
Anal fistula
Contact dermatitis
DM
Pin worm
Mx of pruritus ani
Keep area dry
Diet modification
Soothing creams
Topical steroids
Gloves to avoid nocturnal scratching
Types of stoma
Colostomy - large bowel (L)
Ileostomy - small bowel (R)
Indications for ileostomy
Defunctioning bowel to protect distal anastomosis e.g. rectal cancer surgery
CD
Faecal incontinence
Bowel ischaemia
Indications for colostomy
Bowel cancer
CD
Diverticulitis
Anal/ vaginal/ cervical cancer
Bowel incontinence
Psychosocial implications of stoma
Anxiety/ depression
Poor body image
Social isolation
Adjustment problems
Embarrassment
Sexual function
Common complications of stomas
Parastomal hernias
Proplase
Retraction
Ischaemia
Pyoderma gangrenosum
