disease of the small bowel and appendix part II Flashcards
what are the complications of appendectomy ?
pelvic abscess, wound infection, intra - abdominal abscess, ileus, DVT/PE, feacal fistula, portal pyaemia, right sides inguinal hernia
appendix - carcinoid
- can occur in 1/300/400 appendixes
- it is tumour of the crypts of Lieberkuhn and stains heavily with chromagrannin
- if >1cm then appendectomy alone is not enough to treat it
what happens in small bowel obstruction ?
(pathophys. = fluid, gas, ischaemia and perforation)
> patients experience central colicky pain that comes and goes
absolute constipation
will start feeling sick, vomiting and burping
abdominal distension
what causes small bowel obstruction ?
- lumen = gallstone, lump of food, bezoar (hair)
- within the wall = Crohn’s, radiation strictures, tumours
- outside the wall = adhesions, herniation (small bowel herniate)
what would small bowel obstruction look like on an x-ray ?
like the patient has swallowed a massive furry caterpillar
small bowel obstruction - presentation
- distension
- vomiting
- borborygmi (loud bowel sounds)
- pain
- faeculent vomiting
- presence of a cause
small bowel obstruction - investigations
>assessing the state of the patient: urinalysis bloods gases >confirming diagnosis: AXR contrast CT scan of abdomen Gastrograffin studies >then identifying who needs surgery and whose will settle
small bowel obstruction - treatment
“drip and suck”
ie put them on a drip and suck out all the fluid/air via NG tube
- ABCs
- analgesia
- fluids with potassium (are usually hypokalaemic and alkalotic)
- catheterise them
- NG tube (Ryles - needs to be big)
- antithromboembolism measures (at high risk for DVT)
*obviously everything is given IV
conditions:
- cannot drip and suck for hernias - these need surgical intervention
- usually drip and suck for 72 hours but earlier intervention is required for = strangulation, perforation, ischaemia
small bowel obstruction - surgical management
laparotomy
*can be done laparoscopically
-done with antibiotics, antithromboembolic measures, usually a midline incision, and the obstruction is found by following the collapsed or dilated bowel
mesenteric ischaemia prognosis
not a good prognosis, patients often die with dead guts or do not live good lives
causes of mesenteric ischaemia
-embolus or thrombosis (arterial and venous)
> embolus is usually patients with AF - formed in the left atrium and lodges into narrow SMA
in site thrombosis from general gubbedness (virchow’s, dehydrated, hypercoaguable, compression, vasoconstricting drugs)
- can be a chronic problem:
(atherosclerosis) sort of angina for the guts: their SMA might be stenotic due to stomach etc and these patients will present with cramping that will usually come on after eating
-can be acute:
>if the SMA is compromised then the whole small bowel dies
>if it’s just the IMA then the colon can carry on due to the marginal artery
when should we suspect mesenteric ischaemia ?
when people are in extreme pain but everything seems to be pretty much normal
- acidosis on gases
- lactate is elevated
- CRP may be normal and WCC may only be raised slightly
- CT angiogram
how do we fix acute mesenteric ischaemia ?
quickly !
- prepare patient and family for the worst
- resect the ischaemic part if non-viable
- re anastomose or staple and planned return
- if viable, can perform an SMA embolectomy
complications of mesenteric ischaemia surgery
-haemorrhage > ABCs, exclude upper source, vascular malformations, ulceration, CT angiogram, can be managed by interventional radiology
what is Meckel’s diverticulum ?
- theses ‘pouches’ form 2 feet from the ileocaecal valve
- congenital and presents before 2 years of age
- it is the remnant of the vitelline duct/omphalomesenteric duct that should’ve been absorbed
- complications = bleed, ulceration (Meckel’s diverticulitis), obstruction
