Week 8 Flashcards
What 5 things are important to consider in assessing the severity of liver cirrhosis?
Encephalopathy Ascites Bilirubin Albumin Prothrombin time
Loss of haustral markings in the distal part of the bowel suggests which disease?
Ulcerative Colitis
Which test is the single most important factor for considering suitability for a liver transplant?
Arterial pH
Behavioural changes, clumsiness and excess salivation could indicated which condition?
Wilson’s Disease
What is Wilson’s Disease treated with?
Penicillamine
How would achalasia present differently to oesophageal malignancy in terms of dysphagia?
Achalasia would present with dysphagia to both liquids and solids from the outset whereas oesophageal malignancy would involve progressive symptoms with dysphagia first to solids and then to liquids.
How are alcohol units calculated?
(Volume (ml) x ABV) Divided by 1000
What is the most likely cause of an elevated ALT and AST in the 10,000s?
Paracetamol overdose
Can pain be felt above or below the dentate line in the anal canal?
Anything below the dentate line will be very painful but anything above will not cause pain as there are no sensory fibres to this area
What are haemorrhoids?
Disrupted and enlarged vascular cushions in the lower rectum and the anal canal
What percentage of the population will have symptomatic haemorrhoids at some point in their life?
10%
What is the classical position of the haemorrhoids when the patient is in the lithotomy position and what does this correspond to?
The position corresponds to the branches of the superior haemorrhoids artery at 3, 7 and 11 o’clock
What can cause haemorrhoids?
***Constipation and prolonged straining
Congestion from a pelvic tumour
Pregnancy
Portal hypertension
How might haemorrhoids present?
Painless bleeding - bright red (on the paper/ in the pan)
Perianal itchiness
Anaemia
Describe the classification of haemorrhoids
1st degree - remain in the rectum
2nd degree - protrude through the rectum on defecation but then reduce
3rd degree - ^ &require reduction
4th degree - remain persistently prolapsed
What investigations might be done for haemorrhoids?
Abdominal exam (to rule out other causes) PR exam Proctoscopy (to visualise internal haemorrhoids) Flexible sigmoidoscopy
How would haemorrhoids be managed/ treated?
Topical analgesics Stool softeners Topical steroids Sclerotherapy Rubber band ligation Haemorrhoidectomy HALO/ THD procedure
- For acutely thrombosis/ painful haemorrhoids
- ice compressions and topical GTN or diltiazem to reduce sphincter spasm
What is a rectal prolapse? What is the difference between a type 1 and type 2 prolapse?
A rectal prolapse is a protruding mass from the anus, especially during defecation
Type 1 - partial - just mucosal layers
Type 2 - complete - transmural / all layers
How would a rectal prolapse present?
Protruding mass
Bleeding and mucus per rectum
Poor anal tone on examination
How would a rectal prolapse be managed? consider management of both a complete and incomplete prolapse
Incomplete - Dietary advice and treatment of constipation Complete - Bulking agent - Delform's procedure - Perineal rectopexy - Abdominal rectopexy - Anterior resection
What are some of the causes of rectal prolapse?
Lax sphincter
Prolonged straining
Chronic neurological and psychological disorders
What is an anal fissure? Where do these most commonly occur?
A tear in the anal margin due to the massage of a constipated stool
- Usually midline posteriorly but can be anterior
What is the typical presentation of an anal fissure? Which age group are they most common in?
- Sharp and severe pain on defecation after constipation
- pain may last for up to half an hour and becomes dull in character
- Bright red rectal bleeding
- Most common in young people - very rare in the elderly
How are anal fissure managed?
- Stool softeners and dietary advice
- Topical diltiazem or GTN ointment (pharmacological sphyncterotomy)
- Sphyncterotomy
- Botox injection
What is meant by ‘Fistula in Ano’ ?
An abnormal communication between two epithelial surfaces - the anal canal and the peri-anal skin
What is the most common cause of fistula-in-ano? State the other less common causes
Inadequate treatment of an anorectal abscess
Crohn’s
Carcinoma
TB
How might Fistula-In-Ano present?
Pain
Bright red PR bleeding
Incontinence of flatus/ stool
How would fistula-in-ano be investigated?
EUA of anorectum
Rigid sigmoidoscopy and proctoscopy
Flexible sigmoidoscopy
MRI
How is fistula-in- and managed?
Laying it open (fistulotomy) Insertion of Seton suture LIFT procedure Glue/ permacol Defunctioning colostomy
List 3 perioperative complications of GI surgery
Ileus
Anastamotic Dehiscence
Adhesions
What is ileus and how would this present post GI surgery?
Paralysis of intestinal motility
- Vomiting
- Abdominal distension
- Absent bowel sounds
- Dehydration
What is anastomotic dehiscence? State three types of this which could possibly occur post GI surgery
Breakdown of anastomosis
- intestinal
- vascular
- urological
How might anastomotic dehiscence present post surgery?
Peritonitis Abscess Fistula Bleeding /haematoma Leakage of urine / urinoma
Describe adhesions and how they occur
Handling of the bowels in surgery can cause inflammation which causes formation of fibrous tissue which tethers the bowel to itself or to adjacent structures
Can also occur;
- Due to inflammatory conditions e.g Crohn’s
- Secondary to infection
- Due to ischaemia
Post operative adhesions can cause small bowel obstruction. How does this present?
Vomiting
Chronic pain
Distension
Constipation
List some of the symptoms of intestinal obstruction
Constipation
Distension
Pain
Vomiting
Vomitus can give a clue as to the level of the obstruction within the bowels.
Describe the appearance of vomitus that might come from;
- Gastric outlet obstruction
- Upper small bowel obstruction
- Distal obstruction
- Gastric outlet obstruction
- Semi-digested food
- Upper small bowel obstruction
- Copius bile stained fluid
- Distal obstruction
- Thick, brown and foul smelling
Describe the two different types of pain bowel obstruction can cause and why they occur
Visceral pain - Due to stretch receptors when the bowel is distended
Colicky pain - Due to peristalsis trying to overcome the obstruction
What is meant by absolute constipation?
Neither faeces of flatus is passed rectally
Describe the difference in the situation if the large bowel is obstructed and the ileocaecal valve is competent or if the valve is incompetent
- Competent ileocaecal valve
- The thin walled caecum becomes distended - there can be no back flow into the small bowel so the caecum may rupture
- Incompetent ileocaecal valve
- Not ideal but it will actually save the patient’s life. There can be back flow into the small bowel which prevents mass build up in the caecum - the small bowel will become distended - lower risk of rupture
What can chronic incomplete obstruction do to the muscle of the proximal bowel wall?
Cause hypertrophy of the muscle of the proximal bowel wall
What are some of the physical signs of intestinal obstruction?
Dehydration
- Dry mouth and loss of elasticity of the skin
Abdominal Distension
Obstructing hernia
High pitched/ tinkling bowel sounds
Resonant abdomen due to gaseous distension
Palpable abdominal mass
Visible peristalsis
What investigations should be done for bowel obstruction?
Supine Abdominal X-ray
CT Scan
How can small bowel be distinguished form large bowel on an abdominal X-ray?
Small bowel is usually central and has valvular coniventes - lines that transverse the bowel
Large bowel is usually within its anatomical boundaries and has haustra - lines which only go partly across the bowel
How is obstruction managed?
Nil by mouth
IV cannula - fluids and electrolytes
Nasogastric tube to decompress the stomach
List some of the causes of mechanical bowel obstruction?
Volvulus Adhesions and bands Tumour Intussusception Bolus obstruction Inflammatory strictures Hernias
What are some of the causes of adhesions or bands which can cause bowel obstruction?
Congenital
Previous abdominal surgery
Peritonitis
Which two diseases can cause inflammatory strictures in the GI tract?
Crohn’s disease
Diverticular disease
List 4 different types of bolus obstructions which can cause obstruction of the bowel
Food bolus
Impacted faeces
Impacted gallstones
Trichobezoar
What is meant by Trichobezoar?
Hair balls
What is meant by intussusception?
When a segment of the bowel wall becomes telescoped into the segment distal to it
What can initiate intussusception?
Mass in the bowel wall
- enlarged lymph tissues
- tumours
Which age group is intussusception most common in?
Children
What is meant by bowel strangulation?
When a segment of the bowel becomes trapped, obstructing venous return
Adynamic bowel obstruction is when there is no actual physical obstruction, but the bowel behaves as if there is. State two forms of adynamic bowel obstruction
Pseudo-obstruction
Paralytic Ileus
What is meant by paralytic Ileus?
There is disruption of the normal propulsive activity in the GI tract due to failure of peristalsis
What are the risk factors for paralytic ileus?
Recent GI surgery
Inflammation with peritonitis
Diabetic keto-acidosis
What is meant by pseudo-obstruction?
Acute dilation of the colon in the absence of physical obstruction
What are the risk factors for pseudo-obstruction?
Hip replacement surgery
Coronary artery bypass grafts
Pneumonia
Frail and elderly patients
What is the definition of a hernia?
A protrusion of a viscus or part of a viscus through the wall that is designed to contain it
What are the 3 layers which a hernia is composed of?
- A sac (peritoneum)
- Coverings of the sac
- The contents of the hernia (e.g small bowel/ momentum e.t.c)
List some of the types of hernias
Inguinal Femoral Epigastric Paraumbilical Incisional Parastomal
Which two types of hernia are classified as groin hernias?
Inguinal
Femoral
Inguinal hernias are much more common in men - what is the reason for this?
The testicles pass through the inguinal canal during development meaning the canal is much wider in males - making them more susceptible
Who get femoral hernias?
Elderly women/ women who have had several children
The inguinal ring has the following; - Posterior wall - Anterior wall - Floor - Roof What structures make up these areas?
Posterior wall = transversals fascia
Anterior wall = aponeurosis of external oblique, internal oblique
Floor =
Inguinal ligament and the lacunar ligament
Roof =
Transversalis fascia
Internal oblique
Transversus abdominus
What is meant by an irreducible hernia?
The hernial sac can’t be pushed back to its right place in the abdominal cavity
What is meant by incarceration of a hernia?
The contents of the hernial sac are stuck inside by adhesions
What is meant by a strangulated hernia?
Ischaemia has occurred
Where anatomically are femoral hernias found?
Below and lateral to the pubic tubercle
How are femoral hernias managed?
They often present acutely and require an op more urgently than inguinal hernias do
The procedures;
‘Lockwood’s’ (low approach)
‘McEvedy’s (high approach)
What are some of the risk factors for inguinal hernias?
Male Increasing age Obesity Chronic cough Previous hernia
Where anatomically are inguinal hernias found?
Above and medial to the pubic tubercle
What is the difference between a direct and an indirect inguinal hernia?
A direct inguinal hernia is medial to the inferior epigastric vessels - it herniates through a weakness in the posterior wall of the inguinal canal
An indirect hernia is lateral to the inferior epigastric vessels - the abdominal contents protrude trough the deep inguinal ring
Are inguinal hernias more common on the left or the right side?
More common on the right than on the left
How are inguinal hernias managed?
If asymptomatic - don’t need management
Open hernia surgery
Laparoscopic surgery
Laparoscopic surgery is now the preferred treatment than open surgery for inguinal hernias. What are its pros and cons?
PROS - Doesn't leave patients with chronic pain - Lower rates of infection post op - Faster recovery CONS - Harder surgery - Isn't done for emergencies
What are some of the possible complications of surgery for inguinal hernias?
Recurrence Urinary retention Haematoma Chronic pain / numbness Wound infection Testicular atrophy
Why do epigastric hernias occur? Are they more common in males or females?
Occur due to a defect in the linea alba between the xiphoid process and the umbilicus
More common in males
What are some of the risk factors for paraumbilical hernias?
Obesity
Pregnancy
Ascites
Where do incisional hernias occur?
At the site of a previous abdominal incision
What are the common paediatric hernias?
Umbilical and inguinal hernias
What investigations can be done for pancreatitis?
FBC
Elevated amylase
Ultrasound
ERECT CXR ( looks for perforation)
CT
Describe the typical presentation of appendicitis
Central abdominal pain which later localises to the RIF
- fever and elevated inflammatory markers are possible
What investigations should be done for appendicitis?
Ultrasound
Describe the possible presentation of diverticulitis and how it might be investigated
Lower abdominal pain classically in the LIF which can present with diarrhoea and PR bleeding +elevated inflammatory markers
- CT to investigate
How does cholecystitis present and how would it be investigated?
RUQ pain - biliary colic - exaggerated by eating +deranged LFTs
- Investigated with ultrasound and MRCP/ERCP
How is haematemesis investigated?
Endoscopy - intervention or biopsy can be done with this
CT with IV contrast - angiography or intervention can be done
What investigations should be done for dysphagia?
Endoscopy
Barium contrast
What investigations might be done for a patient with a change in bowel habit?
PR exam
Flexible sigmoidoscopy
CT virtual colonography
What investigations should be done for jaundice?
Ultrasound
MRCP/ERCP
CT
What investigation should be done for small bowel ischaemia?
CT angiogram - looks at the patency of the vessels
