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Surgery finals > Lower GI > Flashcards

Lower GI Flashcards

1
Q

Describe the differentials for acute lower abdominal pain

A

GI:

  • Appendicitis
  • Intestinal ischaemia
  • Diverticulitis
  • Bowel obstruction, strangulated hernia
  • Mesenteric adenitis (kids)
  • Meckel’s diverticulitis

Urological:

  • Renal colic
  • Pyelonephritis

Gynae:

  • PID
  • Ectopic pregnancy
  • Cyst accident: rupture, torsion
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2
Q

Describe the epidemiology of appendicitis

A 
Very common (12%)
Any age
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3
Q

Describe the presentation of appendicitis

A
  • Acute abdo pain: constant, increasing, umbilical->RIF
  • N+V, anorexia
  • Fever
  • Retrocaecal appendix may cause back/flank pain
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4
Q

Describe the signs of appendicitis on examination

A

-General: tachycardia, fever, sweating
-Abdo: RIF tenderness (McBurney’s sign), Rovsing’s sign (press on LIF), Psoas sign (flexed right hip), Obturator sign
+/- peritonitis if perf, sepsis, mass if abscess

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5
Q

Describe the investigations for acute appendicitis

A
  • History and examination
  • Bloods: FBC, CRP, U+Es, amylase/lipase, VBG, culture if indicated
  • Usually no need for further Ix. Imaging if unclear/>40: USS, CT/MRI
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6
Q

Describe the management of acute appendicitis

A
  • Make NBM, give analgesia, IV fluids, and IV Abx
  • Contact senior + surgeons
  • Laparoscopic appendicectomy +/-postop Abx
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7
Q

Describe the complications of appendicitis

A
  • Gangrenous appendix +/- perforation
  • Abscess
  • Phlegmon
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8
Q

Describe the postop care for appendicectomy

A
  • Admission usually until 1 day postop (longer if complicated), until E+D and infection settled
  • Need about 1 week off work/school
  • Avoid heavy lifting/manual labour/contact sports 1 month
  • No OP followup needed
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9
Q

Describe the risks of appendicectomy

A
  • Removal of normal appendix (1/5 no appendicitis)
  • Surgical: pain, bruising, wound infection, damage to other organs, intra-abdominal abscess, DVT
  • Anaesthetic: N+V, headache, muscle soreness, allergy/anaphylaxis, cardiac arrest, etc
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10
Q

Describe the types of intestinal ischaemia

A

1) Acute mesenteric ischaemia: affects SMA branches (SB mostly). Not very common
2) Chronic mesenteric ischaemia (intestinal angina)
3) Ischaemic colitis: most common. Affects IMA branches (LB)

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11
Q

Describe the epidemiology of intestinal ischaemia

A
  • Vasculopaths eg. AF, hypercoagulable state, smoking, HTN, DM
  • Older adults
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12
Q

Describe the aetiology of intestinal ischaemia

A

AMI:

  • Arterial compromise: embolism (50%, assoc w AF), thrombosis (20%), vasculitis
  • Venous compromise: thrombosis (5%)- hypercoagulable states
  • Hypoperfusion (20%): shock, surgery/trauma

CMI: atherosclerosis mostly
Ischaemic colitis: usually hypoperfusion

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13
Q

Describe the blood supply to the GI tract

A

Foregut: coeliac artery- common hepatic, splenic, left gastric arteries
Midgut: SMA- middle colic, right colic, ileocolic arteries
Hindgut: IMA- left colic, sigmoid, superior rectal arteries

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14
Q

Describe the divisions of the GI tract

A

Foregut: mouth to the 2nd part of the duodenum
Midgut: 2nd part of the duodenum up to 2/3 of the transverse colon
Hindgut: the distal 1/3 of the transverse colon to the anus

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15
Q

Describe the presentation of intestinal ischaemia

A
  • Ischaemic colitis: mild/mod abdo pain felt laterally, faecal urgency, bloody diarrhoea
  • AMI: severe acute abdominal pain, peri-umbilical and worsening. *Out of proportion to examination/obs. N+V, anorexia. +/- bloody diarrhoea
  • CMI: insidious onset. 1) episodes of colicky central postprandial abdo pain 2) Weight loss 3) Abdo bruit
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16
Q

What is the classic description of acute mesenteric ischaemia?

A

Severe abdominal pain out of proportion to clinical findings (eg. no tenderness, no systemic changes)

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17
Q

Describe the investigations for intestinal ischaemia

A
  • History and examination
  • Urine dip
  • Bloods: FBC, CRP, U+Es, VBG, clotting, LFTs
  • Urgent contrast CT -> CTA

After Dx:

  • ECG (check AF)
  • Bloods: lipids, HbA1c (look for modifiable RFs)
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18
Q

Describe the signs of intestinal ischaemia on CT

A
  • Bowel wall thickening
  • Luminal dilatation
  • Gas in the bowel wall
  • Thumbprinting (oedema)
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19
Q

Describe the management of acute mesenteric ischaemia

A
  • Make NBM, analgesia (opioid), IV fluids and IV Abx
  • Consider blood transfusion
  • Senior + surgeons
  • Consider endovascular treatment (stenting, thrombectomy) or surgical Mx (laparotomy + resection of infarcted/necrotic bowel)
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20
Q

Describe the management of chronic mesenteric ischaemia

A

Conservative:
-Lifestyle modifications: weight loss, diet, smoking, exercise

Medical:
-RF modification eg. HTN, glycaemic control, statin

Surgical/interventional: revascularisation

  • Mesenteric bypass
  • Angioplasty
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21
Q

Describe the management of ischaemic colitis

A

Can usually be managed conservatively unless complications/severe ischaemia

Conservative:
-Supportive: analgesia, bowel rest, IV fluids

Medical:
-IV Abx, IV fluids and prophylactic LMWH

Surgical/interventional:
-Resection and stoma formation if complicated

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22
Q

Describe the complications of intestinal ischaemia

A

Strictures
Fear of food
Surgical complications: short bowel syndrome, high output stoma, etc

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23
Q

Describe the signs of peritonitis

A
  • Generalised abdominal tenderness
  • Guarding, rigidity
  • Rebound + percussion tenderness
  • Absent bowel sounds
24
Q

What causes peritonitis?

A 
SBP 
2˚ causes:
-Perforation eg. BO, appendix, ulcer, diverticulum
-Peritoneal dialysis
-Pancreatitis
-Trauma eg. surgical wound
-PID
25
Q

Describe the epidemiology of bowel obstruction

A

Common cause of emergency surgery
SBO: more common in previous surgeries + Crohn’s
LBO: less common than SBO.

26
Q

Describe the aetiology of bowel obstruction

A

Can be: outside bowel wall (adhesions, hernias), within the wall (malignancy), within the lumen
SBO: adhesions (50-80%), strangulated hernia (20%), Crohn’s, malignancy
LBO: malignancy! Diverticular strictures, volvulus

27
Q

Describe the pathophysiology of bowel obstruction

A

Mechanical obstruction -> reduced blood flow
->ischaemia -> necrosis -> perforation
+ transudate into luman -> dehydration + electrolyte imbalance

28
Q

Describe the presentation of bowel obstruction

A
  • Absolute constipation
  • Acute abdominal pain: diffuse, colicky, worsening
  • *Constant pain may indicate ischaemia
  • Vomiting (occurs earlier in SBO, bad sign in LBO)
  • Abdominal distension
  • *LBO: possible Hx suggestive of malignancy
29
Q

Describe the investigations for bowel obstruction

A
  • History and examination (including DRE)
  • Urine: dip, UPT, MCS
  • Blood: FBC, CRP, U+Es, VBG (for acidosis and lactate), culture (if febrile), lipase/amylase, glucose, clotting
  • Imaging: urgent CT (best), AXR (not as good)
30
Q

Describe the initial management of bowel obstruction (acute)

A 
A to E as needed
Call senior
Make NBM 
IV access and bloods, fluid resus
Analgesia
NG tube decompression if SB distension/vomiting
Call surgeons
31
Q

Describe the management of bowel obstruction (eg treatment)

A

Conservative (simple adhesional SBO):
-Drip and suck for max 72 hours

Surgical (non-adhesional SBO, complicated SBO, any LBO):
-Exploratory laparoscopy w/ resection + stoma formation

32
Q

What are the differences between ischaemic colitis and acute mesenteric ischaemia?

A

IC: affects large bowel (IMA), usually more mild/mod pain, bloody diarrhoea
AMI: affects small bowel (SMA), severe pain with no clinical signs initially

33
Q

Where is the most common site of rupture in LBO?

A

Caecum

34
Q

Where is the most common site of volvulus?

A

Sigmoid (75%)

Caecum

35
Q

Describe the signs of bowel obstruction on examination

A

General: tachypnoea, tachycardia, pyrexia, hypotension
Abdo distension
Diffuse tenderness +/- caecal tenderness (imminent perf)
Hyperactive bowel sounds
-Peritonitis: rigidity and guarding, rebound tenderness, absent bowel sounds
-Hernia

36
Q

Define volvulus

A

Twisting of a loop of bowel on its mesentery

37
Q

Define bowel obstruction

A

Mechanical blockage of the bowel, preventing flow of contents

38
Q

Describe the presentation of volvulus on imaging

A

Classically on AXR:

  • Coffee bean sign: sigmoid volvulus
  • Embryo sign: caecal volvulus

CT: whirl sign

39
Q

Describe the pathophysiology of volvulus

A

Sigmoid:
Chronic constipation -> chronic faecal loading
-> extension of sigmoid colon -> ^ risk of torsion

Torsion -> impaired blood flow -> ischaemic/necrosis
-> bowel obstruction

40
Q

Describe the management of volvulus

A

Initial:
-Fluid resus, analgesia, IV Abx and NGT if indicated

Medical:
-Endoscopic decompression, detorsion -> place soft rectal tube -> 72 hours do surgery

Surgical: if perf/ischaemia

  • HD unstable: Hartmann’s
  • HD stable: sigmoid colectomy + 1˚ anastomosis
41
Q

Describe the imaging findings of bowel obstruction and how to distinguish SBO and LBO

A

Dilated bowel loops (3, 6, 9 cm- SB, LBO, caecum)
Rigler’s sign (can see both sides of bowel wall) in pneumoperitoneum, string of pearls sign, air fluid level

SBO: presence of valvulae conniventes (fully cross bowel)
LBO: presence of haustra (not fully cross)

42
Q

Describe the aetiology of GI perforation

A 
Infection: appendicitis, diverticulitis
Obstruction
Ischaemia: AMI, ischaemic colitis
Ulceration 
Trauma
43
Q

Describe the presentation of GI perforation

A

BG of cause eg. obstruction, appendicitis

  • > acutely worsening pain, becomes constant + severe
  • > sepsis/HD unstable
44
Q

Describe management of GI perforation

A 
Initial:
A to E
Make NBM 
IV access and bloods, IV fluid resus, IV BS ABx, analgesia
Call surgeons

Emergency surgery- laparoscopy/laparotomy

45
Q

Describe the epidemiology/RF of rectal prolapse

A

Occurs in children + elderly

Assoc w multiple pregnancies, obesity, chronic straining/cough

46
Q

Describe the presentation of rectal prolapse

A

Painless rectal mass
Incontinence or constipation
Tenesmus, pruritus

47
Q

Describe the signs of rectal prolapse on examination

A

Bright pink lump at the anus
+/- bleeding
May be reducible
May have concentric rings (full thickness prolapse)
In F: may also have vaginal/uterine prolapse

48
Q

Describe the management of rectal prolapse

A

Conservative: if v frail, mild prolapse
-Lifestyle: reduction, weight loss, increase fibre + hydration

Medical:
-Sclerotherapy

Surgical: definitive

  • Laparoscopic rectopexy
  • Perineal procedures eg. Delorme/Altemeier procedure
49
Q

Describe the causes of PR bleeding

A
  • Infection/inflammation: acute diverticulitis, IBD, dysentery
  • Malignancy: colorectal cancer
  • Vascular: intestinal ischaemia, haemorrhoids
  • Trauma eg. fissure, foreign body, colonoscopy
50
Q

Describe the presentation of colorectal cancer

A
  • PR bleeding
  • Change in bowel habits
  • Tenesmus
  • Pain (abdo, on defaecation)
  • Systemic symptoms: weight loss, fever, sweats
51
Q

Describe the assessment of PR bleeding

A

-History and examination (abdo and PR)
-Bloods: FBC, CRP, U+Es, LFTs, clotting, CEA
-Imaging: flexi sig -> colonoscopy
+ additional if Dx of cancer eg. CT AP, CXR, USS liver

52
Q

Describe the 2WW referral criteria for suspected colorectal malignancy

A

Always refer:
>40 : unexplained weight loss + abdo pain
> 50: unexplained rectal bleeding
> 60: unexplained Fe deficiency anaemia OR change in bowels
Anyone with positive FIIT test

-Consider for anyone <50 with rectal bleeding + other factors eg. weight loss, pain, change in bowels, anaemia

53
Q

Describe the epidemiology and risk factors for colorectal cancer

A

Epidemiology: Western countries, M > F, very common
RFs:
-Non-modifiable: M, older age, genetics, IBD
-Modifiable: diet, obesity, smoking

54
Q

Describe the staging of colorectal cancer

A

Duke’s + TNM

Duke’s: A (confined to wall), B (spread through bowel wall), C (spread to LNs), D (mets)

55
Q

Describe the management of colorectal cancer

A

Medical + surgical

Medical: adjuvant/neoadjuvant chemo/radio

Surgical: for all early stage
-Resection. Type depends on lymphatic drainage (follows arterial supply)

56
Q

Describe the screening for colorectal cancer

A

Every adult 60-75 in the UK is sent FIT test in the mail every 2 years (also done at 56 years)
+ FIT -> colonoscopy

Increased screening for higher risk groups with colonoscopy, frequency depends on risk group

  • Most IBD: after 8-10 from Dx and possibly 3-5 yearly
  • UC + PSC: yearly
57
Q

Describe some familial syndromes associated with colorectal cancer

A

FAP: APC gene mutation. Many many polyps, will eventually go on to have cancer -> prophylactic colectomy before 20 years
Lynch syndrome/ HNPCC: ^ risk of breast/uterine etc
Peutz-Jegher syndrome: buccal freckles, GI hamartomas

Surgery finals (16 decks)

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