Upper GI Tract Flashcards
What investigation would you carry out next?
Case 1
45 yr ♂︎ carpenter
Hx
- 1 yr history of intermittent upper abdominal pain
- “My stomach is always worse when I’m hung over”
- A&E with worsening abdo pain for 3 hours & one vomit of gastric contents
PMHx – lower back pain.
SHx - smoker
DHx – ibuprofen PRN for past 2 yrs
O/E Afebrile HR 75, BP 130/75
- Abdomen soft, tender in epigastrium
- No J/ Cl / An / Cy
- CVS, RS, CNS, PNS – NAD
- Urine - NAD
- WCC 13.4
- Hb 15.1
- Plts 250
- INR & APTR Normal
- LFTs Normal
- CRP 15
- Amylase 71
ECG - Sinus rythm
Chest X ray, Abdominal X ray.
With the chest X ray you are looking for whether or not their is air under the diaphragm. With the abdominal X ray you are looking for free air but also whats going on with the large and small bowel.
Patient goes home as symptoms ease with mild analgaesics. Pain regresses two days later and is worsening and constant. His abdomen is rigid and he has tenderness in all four quadrants. Blood tests are done with whitE cell count and CRP raised. ECG shows sinus tachychardia. Further CXR &AXR are done. What do you think the most likely diagnosis is ?
Perforated discus, as CXR shows free subdiaphhragmatic air. Furthermore, AXR shows Riglers sign (Free intraperitoneal air)
What is the most likely perforated organ ?
Duodenum, commonest thing that perforates, as well as his alcohol and smoking history.
How do you manage a perforated viscus ?
Preoperative;
- Naso gastric tube to empty gastric contents, and prevent them going into the abdomen. IV fluids, antibiotics, NBM.
- ABX
Operative;
- Identification of aetology of peritonitis
- Eradication of the peritoneal source of contamination
- Peritoneal lavage and drainage
Treatment can range from conservative (Taylors approach) to more radical surgery (vagotomy, gastrectomy)
What is the most likely site of perforation ?
Anterior/Superior surface of first part of duodenum or pylorus. Duodenal perforation is 10x more likely than gastric perforation. You can get acute ulcers in patients with no history of ulcers.
What surgery do you have to mend a duodenal perforation ?
Laparascopic Omental Patch, typical place at d1.You take some omentum and cover the whole and then stitch it up. Very important to have alot of peritoneal lavage.
What is the ost likely postoperative diagnosis ?
- Stable and normal observations for first 48 hrs
- Day 3 post-op
- Complaining of SOB
- O2 sats drop from 99% to 87% on 2L nasal specs
- Spike of temperature to 385
- Sinus tachycardia 100 (no ECG changes)
- Bibasal creps on auscultation R>L
- pO2 8.2 on FiO2 of 0.35
Pneumonia
What is the most appropriate diagnosis ?
Case 1
Represents 2 days later with abdominal pain & vomiting
- Febrile 38, HR 110, BP 100/60, Sats 98% RA
- Abdomen soft but tender & guarding in epigastrium
- Hb 14.1, WCC 18, CRP 209, LFTs & U&Es normal
- ECG sinus tachycardia
- CXR & AXR unremarkable
Intra abdominal collection, treat with drainage and IV antibiotics.
What is the most likely diagnosis ?
Case 2
- 45 yr ♀♀︎
- Upper abdo pain intermittently for 1yr especially after eating Mars bars
- Now 2/7 severe upper abdominal pain associated with vomiting
- Overweight but otherwise fit and well
- O/E Temp 378, HR 100, BP 110/65
- Tender & guarding in epigastrium
- No J/ Cl / An / Cy
- CVS, RS, CNS –NAD
- Urine - NAD
- WCC 20, neutrophilia
- Hb 14
- Plts 230
- MCV 80
- INR & APTR Normal
- LFTs bilirubin 35, Alk phos 366
- CRP 150
- Amylase 2150
Gallstone pancreatitis, due to raised liver function tests which iondicate something is going on in the bile ducts, most common cause is gall stone getting stuck in the bile duct. Amylase is > 2000.
What is the criteria for the assesment of the severity of pancreatitis ?
Modified Glasgow criteria
What does PANCREAS stand for in Modified Glasgow criteria?
P - PO2<8KPa
A - age>55yrs
N - WCC>15
C - calcium<2mmol/L
R - renal: urea>16mmol/L
E - enzymes: AST>200iu/L, LDH>600iu/L
A - albumin<23g/L
S - sugar >10mmol/L
What score suggests severe pancreatitis?
3 or more within 48 hours of onset
What is an independent predictor of severe pancreatitis?
CRP > 200
What is the management for Acute pancreatitis?
4 principles of management;
- Fluid resuscitation; IV fluids, urinary catheter, strict fluid balance monitoring
- Analgesia
- Pancreatic rest; +/- nutritional support if prolonged recovery
- Determining underlying cause
95% settle with conservative treatment, surgery is very rare.
Would you prescribe antibiotics for severe pancreatitis ?
Only if it was necrotic pancreatitis / infected necrosis.
What would be your next investigation after inspecting gallstone pancreatitis?
Ultrasound scan of the abdomen.
After 5 days of treatment LFTs still not normal, what is your next investigation ?
MRCP
MRCP shows stones in the bile duct, what is your next investigation ?
ERCP
Patient still unwell after 7 days, low urine output, tachycardic, what is the best thing to do next ?
CT scan , mainly looking for complications of pancreatitis e.g. perforations, collections that need draining, necrosis and ischaemic large bowel.
Patient is discharged home as CT scan doesnt show anything other than the known pancreatitis, but returns with severe RUQ pain, soft tender abdomen and guarding in RUQ. Positive for Murphys sign, what do you do next ?
Cholecystisis, almost definately due to Murphys sign.
What is Murphys sign ?
Putting 2 fingers below subcostal margin on the right and ask patient to take a deep breath in, pushing the liver + gall bladder down if it is inflamed and hits your finger they go Oww.
What does Murphy’s sign suggest ?
Cholecystitis
What is the treatment for cholecystitis ?
- No acute laparoscopic cholecystectomy because of duration of symptoms
- Treated conservatively with fluid resuscitation & IV ABx
- Pain improving
- Inflammatory markers coming down (CRP 10)
- No fevers or tachycardia for 24 hrs
- Discharge with laparoscopic cholecystectomy set for 6/52
What are the two structures that you MUST identify and divide in a laparoscopic cholecystectomy ?
Cystic duct and Cystic artery.
