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304: Surgery > Upper & Lower GI > Flashcards

Upper & Lower GI Flashcards

1
Q

What are important questions to ask patients presenting with abdominal pain?

A
  • SOCRATES
  • Bowel
    • function, regularity, consistency
    • flatus, blood/mucus
  • N+V
    • blood/bile
  • Systemic symptoms
    • Pyrexia weight loss
  • Previous operations
  • Last E+D
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2
Q

What are other non GI causes of abdominal pain?

A
  • Abdominal Aortic Aneurysm (AAA)
  • Myocardial Infarction
  • Lower Respiratory Tract infection
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3
Q

What do these blood results suggest in someone presenting with sudden onset epigastric pain that is sharp, constant and radiates to the back?

A

Suggests Pancreatitis - obstructive picture

  • Bilirubin, ALP and ALT are all elevated: suggesting a gallstone cholicystic picture
  • Amylase is significantly elevated
  • suggests that the common bile duct may be blocked as well
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4
Q

What are the most common causes of Pancreatitis?

A

I GET SMASHED

  • Idiopathic
  • Gallstones
  • Ethanol (alcohol)
  • Trauma
  • Steroids
  • Mumps (re-infection in adulthood)
  • Autoimmune
  • Scorpion Venom
  • Hyperlipidaemia/hypothermia/hypocalcaemia
  • ERCP (Endoscopic retrograde cholangiopancreatography)
  • Drugs
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5
Q

What measures are used in the Modified Glasgow Score for Pancreatitis? What does it show?

A

P- PO2 <8

A- Age >55

N- Neutrophilia WCC >15

C- Ca+ <2mmol/L

R- Renal Function- Urea >16mmol/L

E- Enzymes- AST LDH > 600, AST >200

A- Albumin <32g/L

S- Sugar- >10mmol

  • It is a marker of how severe the patients condition is
  • 1 = mild, 2 = moderate, >3 = severe
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6
Q

What imaging is carried out in suspected pancreatitis?

A
  • USS - detects gallstones and pancreatic oedema
  • CT - more sensitive - can rule in our out necrosis/ collections
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7
Q

What does a severe scoring on the modified Glasgow score for pancreatitis indicate?

A
  • Score 3 or more within 48hrs of onset = SEVERE
  • Rx in HDU/ITU
  • 10-50% Mortality for SEVERE PANCREATITIS
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8
Q

What is the general management for a 60 y/o man with a PO2 <8 , severe epigastric tenderness, dehydrated, non distended good BS, localised guarding and a raised amylase

A
  • ABCD approach
    • Analgesia, IV fluids, +/- O2, cathetere + fluid balance
    • NBM +- NGT, +/- detox regime +/- anti-emetic
  • Further interventions
    • MRCP/ERCP
    • HDU/ITU potentially
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9
Q

What causes 80% of pancreatitis?

A
  • Gallstones
  • Alcohol
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10
Q

What are complications of pancreatitis

A
  • Hypovolaemic shock
  • Haemorrhagic pancreatitis
    • Gret Turner’s/ Cullen’s signs
  • Pseudocyst formation
    • pressure effect
  • Infected necrosis
  • ARDS (acute respiratory distress syndrome)
  • SIRS (systemic inflammatory response syndrome)
  • T2DM
  • Chronic pancreatitis
  • Multiple organ failure
  • Death
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11
Q

What does this chest radiograph show? +/- indicate

A
  • this is free air underneath the diagram
    • suggestive of bowel perforation
  • this image is taken erect
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12
Q

What are the complications of a peptic ulcer

  • management
A
  • Perforation
  • Erosion through mucosa into
    peritoneal cavity
  • Surgical emergency
  • laparotomy
  • Severe haematemesis
  • Erosion into a vessel
  • Medical emergency
  • Endoscopy → laparotomy if fails
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13
Q

What does this radiograph show?

A
  • free gas (black) and fluid (darker grey) around the edge of the liver
    • may be due to a bowel perforation
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14
Q

What are risk factors for peptic ulcer disease?

A
  • H.Pylori
  • NSAIDS
  • Smoking
  • Spiced foods
  • Blood group O
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15
Q

What are the different presentations for Gastric vs Duodenal ulcers?

A

Gastric

  • M:F – 3:1
  • Peak 50 years
  • 45% assoc H Pylori
  • Exacerbated by food

Duodenal

  • M:F – 5:1
  • Peak 25-30 years
  • 85% assoc H Pylori
  • Relieved by food
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16
Q

What is Murphys sign?

what does it indicate?

A

Asking a patient to inhale deebly whilst pallpating on the right costal margin

  • a positive sign will illicit pain
  • and this is indicative of acute cholicystits (inflammation of the gallbladder)
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17
Q

What is Rovsing’s sign?

What could this indicate?

A

When you press down on left lower quadrant of the abdomen and it illicits pain on the right lower quadrant

  • could indicate appendicits
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18
Q

What is the gold standard for imaging the gallbladder?

A

USS

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19
Q

What are the Risk factors for gallstones?

A
  • Fat
  • Female
  • Fertile
  • Fourties
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20
Q

How would you manage someone presenting with gallstones (cholelithiasis)?

A

Conservative

  • IV fluids, analgesia then Anti-biotics, low fat diet send them home

Surgically

  • IV fluids, analgesia, chelcystectomy
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21
Q

What are complications of gallstones?

A
  • Empyema/mucocoele
  • Gallbladder perforation (rare)
  • Gallstone ileus
    • gall stone perforates small bowel
  • Pancreatitis
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22
Q

What is Ascending Cholangitis?

A

Infection of the bile duct, usually caused by ascending bacteria from the duodenum

most commonly Escherichia coli, Klebsiella, Enterobacter, Pseudomonas, and Citrobacter

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23
Q

How do people present with Ascending cholangitis?

A
  • Charcot’s triad
  • (RUQ pain, Jaundice, Pyrexia)
  • Reynold’s pentad
  • Charcot’s+ Shock + confusion
  • as well as RUQ pain, Jaundice, Pyrexia
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24
Q

What are causes of ascending cholangitis?

A
  • Gallstones
  • Strictures (benign/balignant)
  • Malignancy (CBD/ pancrease)
  • Iatrogenic - ERCP
  • Bacterial infection
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25
Q

What is Biliary Colic?

A

Acute gall bladder pain when gallstones transiently blocks the cystic duct and the gallbladder contracts

  • caused by fatty foods
  • patiently is systemically well
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26
Q

What is Dysphagia?

Causes

A

Difficulty swallowing

  • Malignancy
  • Neurological
    • Stroke, Parkisons, Myasthenia Gravis
  • Pharngeal pouch
  • Pharngitis
  • Radiotherapy
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27
Q

What is a pharngeal pouch (Zenker’s diverticulum)?

A

Occurs when part of the pharyngeal lining herniates through the muscles of the pharyngeal wall. This occurs mainly in older people.

causes dysphagia

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28
Q

Whats is the investigation pathway for someone presenting with dysphagia?

what would each pathway show?

A

Bloods: FBC, U&E, LFT

Distingiuish - Oesophageal or Oropharngeal

Oesophageal

  • Endoscopy and biopsy
    • Stricture,
    • Oesphagitis,
    • Dysmotility

Oropharngeal

  • Videofluoroscopic swallowing assessment
    • neurological disease: Pseudo/Bulbar palsy, Myasthenia gravis
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29
Q

What are Oesophageal cauees of dysphagia?

A
  • Stricture,
    • Benign: Peptic, Fibrous ring
    • Malignant: Carcinoma of stomach/ oesophagus, Extrinsic compression
  • Oesophagitis
    • Peptic
    • Candidiasis
    • Eosinophilic
  • Dysmotility
    • Achalasia
    • Non-speciifc motility disorder
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30
Q

A patient presents with weightloss and difficulty swallowing with a “sticking” feeling in their throat. They have on endoscopy and they get his image what is your top differential and management?

A

Oesophageal cancer

Management

  • Staging: CT, laparoscopy, EUS, PET
  • Surgical: Oesophagectomy
  • Medical: Chemotherapy radiotherapy
  • Palliative: Stenting
    • complications

8th most common cancer worldwide

2x more common in males

80% occur in >60 y/o

10-15% survival rate

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31
Q

What type of Oesophageal Cancers are there?

A
  • Squamous Cell Carcinoma (more common in far east 90%, 25-40% in the UK)
  • Tends to affect upper 2/3
  • Smoking
  • Alcohol
  • Adenocarcinoma (more common in west, 60-75% in the UK)
  • Tends to affect lower 1/3
  • GORD
  • Barrett’s oesophagus
  • Obesity
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32
Q

What are causes of Gord, and what are its complications?

A
  • 10-20% of population affected
  • Dyspepsia/heartburn/indigestion
  • decrease Lower oesophageal tone
  • Can be associated with Hiatus hernia
  • Can lead to Barrett’s oesophagus
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33
Q

What is Barret’s Oesophagus?

A

Barrett’s esophagus is a condition in which tissue that is similar to the lining of your intestine replaces the tissue lining your esophagus. People with Barrett’s oesophagus may develop a rare cancer called esophageal adenocarcinoma

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34
Q

What is the treatment for GORD?

A
  • PPI: (eg omeprazole)
    • wouldn’t use omeprazole in patients on hyponatremic medication
  • H2: antagonist (eg ranitidine)
  • Alginates: (eg Gaviscon)
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35
Q

What is seen in this image

Investigations, and treatment

A
  • Oesophageal dysmotility syndrome
  • decreased peristalsis
  • increased LES tone
  • Often painful
  • resulting in bird peaked stricture
  • Ix- Barium swallow, manometry, bx
  • Rx- Ca channel blockers, dilatation,
    Heller myotomy, POEM NOTES
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36
Q

What are potential differentials for the circular lesion on this image?

A

Keloid scar

Umbilical Hernia

Sister Mary Joseph umbilical nodule (metastatic cancer nodule)

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37
Q

What types of gastric cancer are there?

A

Gastric adenocarcinoma 74.6%

Gastric lymphoma 24%

  • Polypoid carcinoma; Large & bulky(25%)
  • Ulcerating deep,penetrating tumours that can extend through all walls(25%)
  • Superficial spreading - early gastric cancer(10%) (Japanese)
  • Linitis Plastica(10%) Leather bottle
  • Advanced(30%)
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38
Q

What are risk factors for gastric cancer?

A
  • Chronic gastritis
  • Hypochlorhydria
  • Infection with H.pylori
  • Previous partial gastrectomy – stump carcinoma
  • Diet
  • Nitrites
  • smoked & salted foods
  • pickled vegetables.
  • Smoking
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39
Q

What are the differentials with someone with this history and examination

  • PC: 4 weeks of constipation and then loose stool​
  • HPC: 1 stone weight loss 6 months ​
    • +abdominal distension. FIT test positive​
    • No pain, no vomiting, Previously BO regularly od.​
  • PMH: IHD, hypercholesterolaemia
  • Looks comfortable ​
  • Pale conjunctivae​
  • No abdominal tenderness​
  • Hugely distended abdomen, quiet BS​
  • PR- empty, No blood , No melaena​
  • OBS:​
  • HR110, BP 110/80, RR 28, Sats 96%, Afebrile
A
  • Colorectal malignancy​
  • Large bowel obstruction​
  • Small bowel obstruction​
  • Ischaemic bowel​
  • IBD​
  • IBS
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40
Q

What does this image show given this history

  • PC: 4 weeks of constipation and then loose stool​
  • HPC: 1 stone weight loss 6 months ​
    • +abdominal distension. FIT test positive​
    • No pain, no vomiting, Previously BO regularly od.​
  • PMH: IHD, hypercholesterolaemia
A

Left colon cancer with liver metastases

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41
Q

What is the management of Colorectal cancer?

A
  • Initial: ABCDE
  • NBM
  • IV fluids
  • Analgesia
  • ±O2
  • ±Anti-emetic
  • Fluid balance (consider catheter)
  • Correct electrolytes
  • Urgent CT – CAP
  • Stoma nurse (based on surgery needs)
  • Further: Endoscopy
  • Expediated v planned laparotomy eg impending perforation, peritonitis
  • Lap v open
  • Daylight hours v out of hours
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42
Q

What is the epidemiology of colorectal cancer?

A

50,000 cases a year in the UK

4th most common cancer in UK

after Breast, Lung, Prostate.

2nd most common cause of cancer death

15,000 deaths / year in UK (44/day)

Survival improving despite incidence rising

Overall survival 60% surgery all stages

Majority over 70 years old (60%)

SURVIVAL IS GOOD Women/Men

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43
Q

What are risk factors for Colorectal cancer?

A
  • Male
  • Increasing age
  • Smoking
  • Alcohol
  • Obesity
  • Family history
  • Inflammatory bowel disease
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44
Q

What are the criteria that make up the Two Week Rule (2WR) criteria in the UK

A
  • Over 40 with UNEXPLAINED weight loss
  • Over 50 with rectal bleeding
  • 60 or over with iron deficiency anaemia
  • 60 or over with a change in bowel habit
  • Palpable mass abdominally or rectally
  • Additionally population screening tests
  • Positive FOB / FIT Test
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45
Q

What is FOB/FIT test?

A
  • Population screening tests
  • (every 2 years in UK 50-74yrs)
  • FOB – faecal occult blood test
  • Gold standard
  • However picks up any blood in faeces- eg also from food
  • Needs 3 faeces samples from 3 separate bowel movements
  • FIT – faecal immunochemical test is an improved tool from FOB
  • More sensitive ( can system cope with increased demand v earlier detection is better for patient)
  • Can measure HOW much human blood
  • in stool rather than just Y/N
  • Increases uptake as 1 sample needed v 3
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46
Q

What tests are done to investigate for bowel cancer?

A
  • Luminal sample (Tissue)
  • Gold standard – colonoscopy – RISKS Flexible sigmoidoscopy LIMITED STUDY OGD – IDA or obstructive symptoms
  • Radiological
  • CT / MRI / USS / PET CT
  • ‘Virtual colonoscopy’ – CT Colonography
  • Other – Blood tests – CEA, LFT, FBC
  • FIT/FOB
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47
Q

What is the CEA Test

A

it’s a blood test that looks for the Carcinoembryonic Antigen which is a tumor marker produced in the colon and rectum

  • CEA is a glycoprotein produced in foetal GI tissues involved in cell adhesion. production stops at birth
    • normal levels in adults 2-4ng/ml
    • normal level in smoker <5ng/ml
  • A rising CEA can indicate progression or recurrence of tumour
  • Once tumour is removed CEA levels return to normal in 3/12 weeks
  • It’s not specific as it can be raised in
    • smokers
    • cancers of prostate, ovary, non cancerous breast diseases
    • lung, thyroid, emphysema
    • liver, cirrhosis
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48
Q

What are the risks of colonoscopy?

A

Bleeding Perforation

Missed pathology

Acute kidney injury

Risks of sedation (elderly, frail, aspiration)

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49
Q

What are the risks of Radiological investigaions

A

Perforation with CT colonography

Cancer - radiation dose

missed pathology - diverticular disease

50
Q

What Screening is available for bowel cancer?

A
  • UK NBCSP – National Bowel Cancer Screening Programme
  • Age 50 to 74 every two years (previously 60-74)
  • FOB – faecal occult blood test
  • Likely being replaced nationally with FIT
  • Faecal immunochemical test
  • ASYMPTOMATIC PATIENTS!!!
  • Variable uptake 50-60%
  • Lower in socially deprived areas
51
Q

What are the various types of polyps?

A
  • Hyperplastic – benign
  • Tubular adenoma <5% malignant. 70% of adenomas
  • Villous adenoma 30-40% malignant. 10% polyps
  • Tubulovillous adenoma 25% malignant. 20% of polyps
52
Q

What does a big colonic polyp indicate?

A
  • size does not always indicate malignancy
  • <1cm - 1% chance of malignancy
  • > 2cm - 40% chance of malignancy
53
Q

What is the treatment of a big colonic polyp?

A
  • TEMS – transanal endoscopic microsurgery
  • TAMIS – transanal minimally invasive surgery
  • Open surgery/ Laparoscopic/ Robotic
  • Colonoscopic endoscopic surgery (image)
    • EMR (Endoscopic Mucosal Resection) allows for removal of polyps confined to the mucosa often in a piecemeal fashion while
    • ESD (Endoscopic Submucosal Dissection)aims for enbloc resection for lesions extending into the submucosa. The most serious complications include bleeding, perforation and ?incomplete resection.
54
Q

What is an Abdominoperineal resection/ excision?

A

The sigmoid colon and entire rectum and anus is removed

The surgeon uses the descending colon to create a permanent stoma → colostomy allows faeces to exit the body

The anal area will be stitched up and permanently closed

55
Q

What are the basic principles of bowel surgery?

A
  • Take out the cancer
  • Leave a healthy margin of tissue
  • Make a join that has a good blood
    • supply that is tension free
    • or make a stoma
  • Take away the blood supply to the segment of colon that had the cancer
  • Following the blood supply are the lymphatics,
    • all removed as one envelope together
56
Q

What are the risk of surgery in colerectal cancer?

A
  • Infection
  • Bleeding
  • DVT/PE
  • Injury to Bowel/Bladder/
    • Ureteric/Vascular Injury/Pelvic Nerves
  • Anastomotic leak (5-20%)
  • MI/CVA/Resp failure/AKI
  • RECURRENCE
  • Further procedure / Treatment
  • Chronic pain
  • UK mortality for elective colorectal surgery 2.2% at 90 days
57
Q

What are non-surgical considerations for the patient post colerectal surgery?

A
  • Infection
  • Bleeding
  • DVT/PE
  • Injury to Bowel/Bladder/
    • Ureteric/Vascular Injury/Pelvic Nerves
  • Anastomotic leak (5-20%)
  • MI/CVA/Resp failure/AKI
  • RECURRENCE
  • Further procedure / Treatment
  • Chronic pain
  • UK mortality for elective colorectal surgery 2.2% at 90 days
58
Q

What staging is used in colorectal cancer?

A

TNM

Dukes - ABCD stage

59
Q

What Neoadjuvant therapy is available

A
  • Chemotherapy
  • Radiotherapy
  • Usually both (one sensitizes the other)
  • Goals
  • Downstage
  • Curative
  • Palliative
  • Reduce risk recurrence
  • FOLFOX – 5FU oxaliplatin (oral 5FU = capecitabine)
  • FOLFIRI – 5FU and Irinotecan
  • Short course 3 months. Long = 6 months
  • MDT….MDT…..MDT….
60
Q

What surveillance can be given following treatment?

A

5 years of follow-up

combination of colonoscopy, CT and CEA

clinical review

61
Q

What does this history suggest? - why?

PC: Generalised abdo pain and vomiting

HPC: Sudden onset 12 hours ago, Colicky, non-radiating, 4 x vomit green/yellow fluid. 7/10. BNO and no flatus

PMH: 3x C-section, HRT, open appendicectomy 20 years ago for perforated appendix

A

Small bowel obstruction

the vomiting is an early sign

62
Q

What would an abdominal radiograph show in Small bowel obstruction?

A

Valvuae conniventes

central loops/ air-fluid levels

63
Q

What are causes of small bowel obstruction?

A
  • Adhesions (60%)
  • Neoplasms (20%)
  • Hernias(10%)
  • Crohn’s (5%)
  • Volvulus (3%)
  • Pseudo-obstruction
  • Foreign bodies (eg GS ileus)
  • Ischaemic strictures
  • Intussusception (children)
  • Radiation enteritis
64
Q

What is the management of small bowel obstruction?

A
  • Initial
    • ABCDE
    • Anti-emetic
    • +- O2
    • FLuid balance +_ catheter
    • Analgesia
    • Urgent CT
  • Further
    • Surgical: Hernia repair, Adhesiolysis, Resection
65
Q

What differentials would you take from this history and examination?

You are asked to see an 82 year old retired army officer, living in a retirement home who was sent to A&E by his GP. The patient reports a 3 day history of severe generalised abdominal pain, during which time his abdomen has become grossly distended

  • Admits to taking a ‘few tablets of codeine here and there for aches and pains’
  • Has not opened bowels since the start of this episode – no flatus
  • Nausea, no vomiting
  • Anorexia
  • PMH: RTHR, no previous abdo surgery or hernias
  • SH: Smokes a pipe

Examination

  • Grossly distended
  • Generally tender
  • No masses/scars/hernias
  • Tinkling bowel sounds
  • No systemic Sx
  • PR: empty rectum, no blood/stool
  • Obs:
  • HR 100, BP 100/70, RR 18, Sats 88%, Afebrile
A

Large bowel obstruction

Small bowel obstruction

Ischaemic bowel

Pseudo-obstruction Ogilvie’s syndrome

Ileus

66
Q

What is the modality of this image and what pathology does it show?

A

Sigmoid voluvulus

67
Q

What are the characteristics of a sigmoid volvulus

A
  • Distended oval gas shadow loop on itself to give a coffee bean sign
  • Haustra
  • In a sigmoid volvulus, the bowel rotates on its mesentery → strangulated obstructed bowel
68
Q

How would you manage a patient with sigmoid volvulus?

A
  • Initial:
    • ABCDE
    • NBM & NGT (bowel rest)
    • IV fluids
    • Analgesia
    • ±O2
    • ±Anti-emetic
    • Fluid balance (consider catheter)
    • Correct electrolytes
    • Urgent CT
  • Further
    • Careful decompression with a Flexi sigmoidoscope
    • laboratory if there’s evidence of ischaemia
69
Q

What are the causes of large bowel obstruction?

A
  • Neoplasms (60%)
  • Diverticulitis (20%)
  • Caecal/sigmoid volvulus (5%)
  • Hernias
  • IBD
  • Adhesions
  • Constipation/faecal impaction
  • Pseudo-obstruction
  • MND/MS/spinal cord lesions
  • Hirschprung’s disease-children
70
Q

What are the differentials for this presentation?

Ms F, 22Y

PC: RIF pain

HPC: Sudden onset RIF pain, Constant ache, Non-radiating, nausea- no vomiting and anorexia, Worse when moving/coughing, 8/10. Periods irregular

PMH: nil

O/E: Tender RIF +++, Localised guarding, rebound tenderness

A
  • Appendicitis
  • Gynae:
  • Ectopic
  • Ovarian torsion
  • Ruptured ovarian cyst
  • Mesenteric adenitis
  • Hernia
  • Meckel’s diverticulum
  • Caecal tumours/diverticulum
  • UTI
  • Renal colic
  • Testicular torsion
  • Gastroenteritis
  • Cholecystitis/Pancreatitis
71
Q

What are the common characteristics of Appendicitis?

A
  • occurs at any age
    • uncommon <4 or > 80
    • peak 13-35 y/o
  • can be associated with diarrhoea
  • classically central abdominal pain radiating to the right iliac fossa
  • Would be present with Rovsings sign
  • McBurney’s point would be the area of most tenderness
    • site of the base of the appendix
72
Q

What is the management for appendictis?

A
  • Initial:
    • ABCDE
    • NBM
    • IV fluids
    • Analgesia
    • Fluid balance (consider urinary catheter
    • ±O2
    • ±Anti-emetic
    • Antibiotics
  • Further
    • Lao/open appedndicetomy
73
Q

What are complications of an appendectomy?

A
  • Perforation
  • Abscess - RIF/pelvic
  • RIF -appendix’ mass (asherent caecum/omentum)
  • Sepsis
  • Death
74
Q

What are the differentials for this presentation?

Mrs L, 72Y

PC: LIF pain

HPC: 2/7 intermittent LIF pain, worsening, now constant, diarrhoea and nausea.

PMH: IBS, AF, HTN

O/E: Tender LIF, Localised guarding

A
  • Diverticulitis
  • IBD
  • Ischaemic colitis
  • Gastroenteritis
  • Colon Ca
  • Gynae
  • Renal Colic
  • Pseudomembranous colitis
75
Q

What is the management of diverticulisis?

A
  • Initial:
    • ABCDE
  • Abx
  • NBM
  • IV fluids
  • Analgesia
  • ±O2
  • Fluid balance (consider catheter
  • Anti-emetic
  • Consider further imaging
  • Further:
  • Colonoscopy
  • Rx complications
  • Hartmann’s Procedure if perforation
76
Q

Explain what Diverticular disease is and it’s charchteristics

A
  • Acquired outpouchings of colonic mucosa and overlying connective tissue through the colonic wall
  • Tend to occur along lines where colonic arteries penetrate
  • Peak age 50-70
    • common over the age of 30
  • Diverticulosis- Presence of diverticulae, usually asymptomatic but can cause IBS symptoms
  • Diverticulitis- Inflammation of a diverticulum à not necessarily due to bacteria.
77
Q

What are the complications of diverticular disease?

A
  • Abscess
  • Fistula
    • between the bowel and the bladder
  • Stricture
  • Perforation
  • Haemorrhage
  • Sepsis
78
Q

What are the differentials of for thsi presentation?

  • 38yr old financial analyst
  • Recently quit smoking
  • Presents with bloody diarrhoea for 4 weeks
  • BO x8 /day
  • Nocturnal episodes
  • Feels unwell
  • Temp 38, HR 92, BP 120/70, Mild abdominal tenderness
A
  • Ulcerative Cholitis
  • Chrons disease
  • Infection
  • Diverticulitis
  • Colerectal cancer
  • IBS
  • Coeliac disease
  • any other cause of diarrhoea + haemorrhoids
79
Q

What investigations would you do for this presentation?

  • 38yr old financial analyst
  • Recently quit smoking
  • Presents with bloody diarrhoea for 4 weeks
  • BO x8 /day
  • Nocturnal episodes
  • Feels unwell
  • Temp 38, HR 92, BP 120/70, Mild abdominal tenderness
A
  • Bloods
    • CRP/ESR
    • U&E
    • FBC
    • Coeliac serology
  • Stool
    • Culture
    • Calprotectin
      • marker of bowel inflammation with high sensitivity
      • used in young people IBD vs. IBS
      • not a good detecting cancer
      • predictor of relapse in IBD
  • Colonscopy + biopsies
80
Q

What are the two types of IBD’s?

give features of the diseases

A

Ulcerative Cholitis

  • relapsing and remitting inflammotry disease of the colonic mucosa
  • effects the colon only
  • always starts distally in the rectum and is continous
  • typically presents 20-40y/o
  • smoking is protective of UC

Crohn’s disease

  • chronic inflammatory disease that is characterized by transmural granulomatos inflammation affecting any part of the GI tract
  • most commonly effects the terminal ileu, (70%)
  • “skip lesions” unaffect section of bowel inbetween
  • effects the dull thickness of the bowel wall
    • perforating
    • fistulating
    • stricuting
81
Q

What are the signs and symptoms of UC & Crohn’s

82
Q

What are the histopathological difference between UC and Crohns disease?

A

Ulcerative Colitis

  • Chronic inflammatory cells
  • Mucosal only
  • Crypt abscesses
  • Crypt distortion
  • Goblet depletion

Crohn’s disease

  • Chronic inflammatory cell
  • Full wall thickness invasion
  • lymphoid hyperplasia
  • Granulomata
83
Q

What is the aetiology of IBD?

A
  • Familial/Complex genetic
  • Luminal antigens
  • Diet
  • Bacteria [MICROBIOME]
  • Mucosal Barrier Dysfunction
  • Smoking
  • Makes Crohn’s worse
  • Quitting may make UC worse
84
Q

What is the management of IBD?

A
  • Admit for clinical assessment A to E
  • AXR ?
    • at each stage of assessment rule out Toxic mega-colon
  • CT abdo/pelvis
  • Medical management including Thrombo-prophylaxis
  • IV steroids +/- rectal steroid enemas & Adcal D3
  • Anti-inflammatory
  • Immunosuppression
  • Biologics
  • Inform surgical team / stoma nurses
  • Inform patient re possibility of needing surgery
85
Q

What is used to assess the severity of Ulcerative colitis?

A

Truelove and Witts Criteria

86
Q

What is the timeline of treatment for the management of IBD?

A
  • At day 3 there must be significant improvement or treatment must be escalated.
    • repeat AXR
    • repeat Flexi sigmoidscopy
    • Immunospression: Ciclosporin or Biologic Infliximab
    • Surgical review/ Stoma therapist review
  • At day 7 must also have a response or escalate to surgery

Response at day 3 or 7

  • Reduce oral steroids - prednisolone
    • continue Adcal D3 whilst on prednisolone or budesonide
  • establish Maintenance therapy
    • 5-Amino Salicylic acid (5-ASA) - anti-inflammatory
    • Cyclosporing and Azathioprine/ Mercaptopurine (immunosuppressive medication)
    • Biologics used to treat IBD: inflicimab, Asalimumab, Vedolizumab, Golimumab
      • Chimeric monoclonal antibodies used to treat auto-immune diseases
      • given as slow injection every 6/8 weeks
      • Anti-TNF, Anti-IL, Anti-Integrin
87
Q

What surgery is given to IBD patients with no response to medical management after 7 days?

A
  • Subtotal colectomy + ileostomy (stoma)
    • colectomy saple sent to confirm UC or Crohns
  • rectum left in-situ
88
Q

What are the indications for surgery in Ulcerative colitis?

A
  • Fulminant colitis wth toxic dilation/ perforation
  • Colitis unresposneive to medical therapy
  • Steroid dependence
  • Dysplasia/malignancy
89
Q

What curative surgery is done in UC?

A
  • Ileostomy or Ileo-anal pouch operation
  • Neorectum reservoir made from doubled back ileum to stimulate rectum
90
Q

What are some problems of a Ileo-anal pouch?

A
  • Pouchitis
  • Ciffitis
  • Poor pouch function
  • Dysplasia
  • Fertility
  • What if it’s Crohn’s
    • ileum is most commonly effect (70%)
91
Q

What is the long term outlook for IBD patients?

A
  • Relapsing remitting
  • Frequent steroid-requiring flares → azathioprine
  • Steroid dependent or unresponsive to medication (chronic active)→ biologics or surgery
  • After 8-10 years regular screening colonoscopy to rule out cancer
  • 0.3%/year 20% at 30yrs
92
Q

What are addtional problems for chidren with IBD?

A
  • Growth
  • Development
  • Bone health
  • Nutrition
  • Body Image / relationships
  • Education / Career choices
  • Disease progression
  • Early control imperative
93
Q

What imaging is done for Crohns?

A

MRI

Small bowel follow through

Capsule endoscopy (if there are no stricture)

94
Q

What are the clinical presentations of complications of Crohn’s disease?

A
  • Obstruction
  • Fistula formation
  • To skin (especially wounds)
  • Peri-anal
  • To another hollow organ e.g. another bowel loop, bladder, vagina
  • Malabsorption / weight loss
  • Anaemia
95
Q

What are the complications of treatment for IBD with steroids?

A
  • Weight gain and abnormal fat distribution (buffalo hump, moon face)
  • Thin skin, easy bruising, striae, acne, red face
  • Hirsutism or hair loss
  • Osteoporosis
  • Proximal myopathy
  • Menstrual irregularities
  • Hypertension
  • Hypokalaemia (and therefore alkalosis)
  • Impaired glucose tolerance
  • Depression / Mental disturbance / psychosis
  • (In children – growth and developmental delay)
96
Q

What are the complications of treatment for IBD with Immunosupression drugs: Azathioprine/Mercaptopurine

A
  • Myelotoxicity
  • Hepatotoxicity
  • Pancreatitis
  • Gastrointestinal intolerance
  • Flu-like symptoms
  • Susceptibility to infection – esp. viral
  • Lymphoma
  • Skin cancer
97
Q

What are the complications of treatment for IBD with Biologics:

Infliximab/ Adalimumab

A
  • Allergic reactions / anaphylaxis
  • Local reaction to injection
  • Reactivation of latent infection esp. TB
  • Susceptibility to infection esp. opportunistic
  • Lymphoma
  • Other cancers: lung, skin
98
Q

What are the complications of treatment for IBD with Anti-inflammatory 5-ASAs

A
  • Safe
  • Occasionally worsen diarhoea
  • Very rare;y assocaited with renal impairment
99
Q

What are some surgical complications to consider in treating IBD

A
  • Resect minimal amount possible
  • Extensive resection does not reduce relapse
  • At risk of repeat resections and short bowel
  • Possible to do strictureplasty rather than resect?
  • Anastomosis (especially in the acute situation) at high risk of break-down / fistula formation → protect with defunctioning stoma
  • Patients on steroids and with nutritional compromise are at particularly high risk
100
Q

What are the general complications of IBD

A
  • Nutritional
  • Short bowel
  • Anaemia
  • Osteoporosis
  • Cancer risk
  • Thromboembolism
  • Social
  • Sexual
  • Family planning
  • Psychological impact
101
Q

What are extr-intestinal manifestations of IBD?

A
  • Arthritis
  • Mouth ulcers
  • Erythema nodosum
  • Pyoderma gangrenosum
  • Scleritis
  • Anterior Uveitis
102
Q

What is Primary Sclerosing Cholangitis?

Symptoms signs, treatment, associated complications

A
  • Progressive scarring/stricturing of bile ducts. Hepatitis, Liver fibrosis, Cirrhosis and Liver necrosis
  • Associated with UC
  • Symptoms and signs – RUQ pain, Rigors, Night sweats, Wt loss, Jaundice, Hepatosplenomegaly
  • Treatment = Liver transplant
  • Associated with higher risk of bowel cancer in UC and a high risk of cholangiocarcinoma
103
Q

What is important to consider in the nutrition of IBD patients?

A
  • maintian a diet that is suffiecnt to maintian
    • growth, pregnancy, bone health, healing
  • to induce remission in Crohn’s disease
    • normal diet replaced by forumal feed
      • this is as effective as steroids in paediatric studies
      • minimal side effects
      • improves nutrion & supports growth
  • to maintain remision in Crohn’s disease
    • supplemental forumal feed/part replacement
104
Q

What can be done to prevent stoma bag leakages?

A
  • Woder esdhesive section
  • Warm bags stick better than cold bags
  • bags can be filled with gas very quickly- adhesive can be peeled back to release pressure without complete removal
105
Q

What types of stomas are there?

A
  • Permanent or temporary
  • Ileostomey
  • Colostomy
  • Double barreled, Loop, End

depends on the indication

106
Q

What are the indications for an ileostomy, how would you recognise one?

A

Indications

  • divert from a large bowel obstruction
  • to allow bowel rest: fistula, perforation, anastomosis
  • uncontrolled IBD, UC/ CD

Recognition

  • usually in the right inguinal region
  • more spouted, to protect skin
  • contents of the bag: liquid stool
  • surrounding skin may be irritated
107
Q

What types of Ileostomies are there?

A
  • End ileostomy. This is a permanent ileostomy with one opening from the ileum to the skin
    • e.g. ulcerative colitis leading to pancolectomy
  • Loop ileostomy. This can be a temporary ileostomy with a proximal opening of small bowel and a distal opening of small bowel. Sharing a posterior wall.
    • Usually to protect a distal anastomosis
  • Double Barreled stoma. This can be a temporary ileostomy with a proximal and distal opening. Separate tubes.
108
Q

Why woould you need to rest an anastomosis?

A
  • patients who are at high risk for anastomotic leak
    • eg, malnourished, high-dose steroids, DM
  • who have an intestinal anastomosis <5 to 7 cm from the anal verge (low anastomosis below the peritoneal reflection)
  • hemodynamically unstable (eg, trauma, sepsis, perforation)
109
Q

What are the indications for a Colostomy? How would you recognise one?

A

Indications

  • divert froma large bowel obstruction
  • allow bowel to rest due to fistula, perforation, complicated diverticulitis
  • trauma

Recognition

  • in the left illiac fossa region
  • more flush to the skin
  • more solid formed stool matter
110
Q

What types of colostomies are there?

when would they be done?

A

Permanent end colostomy- In the case of a large resection (e.g. tumour, diverticulitis) and unable to join remaining bowel or the patient is not fit for a second operation.

Temporary end colostomy- In the case that pathology needs to settle or patient needs to be ‘fitter’ before the second operation.

Loop colostomy- share a posterior wall- to protect a distal anastomosis usually.

111
Q

What is a Urostomy/ when are they indicated?

how would you recognise one?

A

Indications

  • created following a cystectomy (urinary bladder removal)
    • drains urine from the ureters to skin and into the stoma bag
    • connection between the ureters and skin → ‘ileal conduit’ as it is made from a piece of the ileum

Recognition

  • located in the right illiac fossa
  • bag will contain urine
112
Q

What is considered when positioning a stoma?

A
  • it is away from the site of the incision
  • away from bony prominences
  • positioned where it can be strenghted by the rectus sheath
  • away from the belt lin
  • accessible to the patient

marked pre=operatively with the help of the stoma nurse

113
Q

What are stoma complications? Immediate, Early, Late

A

Immediate (days)

  • GA complications
  • Necrosis
  • Bleeding
  • Retraction
  • Infection
  • Psychological

Early (weeks)

  • Stenosis/ obstruction
  • High output – dehydration/electrolyte imbalance
  • Retraction
  • Skin irritation
  • Infection
  • Psychological

Late (months)

  • Stenosis/ obstruction
  • Parastomal hernia
  • Retraction
  • Prolapse
  • Fistula formation
  • Skin irritation
  • Infection
  • Psychological
114
Q

Explain a Hartmann’s operation

A

where a necrotic or non-viable section of the bowel is removed with the distal section being closed and left in the abdomen (rectal stump) and the more proximal section is made into and end colostomy

There is usually the intention to reverse the proccedure

115
Q

What is the initial approach to a patient with the following stoma site?

What does it show?

A
  • ABCDE approach
  • Take a full history
  • Perform a thorough, abdominal examination → then focus on the stoma always take of the stoma bag
  • Perform digital exammination of the stoma

Shows a nectotic stoma

116
Q

What are the causes of a necrotic stoma?

A

Insufficient blood supply for various reasons…. global or local hence A → E

  • Poorly vascularised piece of bowel (mesentery has been stripped /twisted or the trephine (skin hole) is too small)
  • Poorly perfused systemically. Need to assess the extent of the necrosis.
  • If extensive devascularisation of the small bowel then stoma needs revising
  • If limited to the stoma mucosa (blood blister) (usually the case) then simple observation.

however the insufficient perfusion may lead to future stricture/ stenosis

117
Q

What could be the cause of a non-functioning ileostomy in a patient with a history of Crohns, abdominal pain and vommiting

A
  • Stenosis
    • can occur in ealry postop period but is more likely to develop months later
  • Stoma fistula
  • Entercutaneous fistula?
  • Constipation
  • Adhesions
  • Parastomal hernia
  • New onset of malignancy
118
Q

What is an important link between Crohn’s disease and stomas?

A

Crohn’s causes trasnmural inflammation and can lead to stenosis and/or fistual formation

119
Q

What constitutes a High output stoma?

what are possible complications and the accompanying management?

A
  • A stoma with an output of more than 500ml in 24 hours
  • There is a risk of dehydration and electrolyte disturbance
  • IV fluids, correct electrolytes
120
Q

What pathology is seen in this image?

A

Parastomal Hernia

weakness in the abdominal wall → protrusion of the bowel

121
Q

What is this pathology and how is it managed?

A
  • Small prolapse can be initially managed conservatively :
    • Cool compresses and application of an osmotic agent (sugar) to reduce oedema, followed by manual reduction of the prolapse and application of a binder.
      • BUT will recur…
  • Large prolapse, recurrent small prolapse or prolapse producing ischemic changes, or mucosal irritation and bleeding.
    • Requires surgical intervention- resection and refashioning of stoma.
122
Q

What are risk factors , complications and managment for a Parastomal hernia?

A

Risk factors

  • Obesity
  • Cough
  • Not fashioning stoma in rectus

Complications

  • incarcerated
    • stuck and unable to be pushed back in
  • obstructed
  • strangulated → needs repair

Management

  • reduce the hernia (difficult and not very successful)
  • put mesh over the hernia
  • hernia belt
    • as long as it’s not incarcerated
  • recreate a new stoma

304: Surgery (7 decks)

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