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BRS GASTROENTEROLOGY > 1b// General Surgery in the GI tract > Flashcards

1b// General Surgery in the GI tract Flashcards

1
Q

What is SOCRATES?

A

site
onset
character
radiation
association
time course
exacerbating/ relieving symptoms
severity

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2
Q

What is an acute abdomen?

A

An acute abdomen is a condition that demands urgent attention and treatment. The acute abdomen may be caused by an infection, inflammation, vascular occlusion, or obstruction. The patient will usually present with sudden onset of abdominal pain with associated nausea or vomiting.

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3
Q

What is the general approach to an acute abdomen?

A

PC (primary care)=> pain assessment (SOCRATES), associated symptoms

PMHx, DHx, SHx=> past medical Hx, drug Hx, social Hx

Range of investigations

Management

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4
Q

What investigations would you do for an acute abdomen?

A

Bloods: VBG, FBC, CRP, U&Es (renal profile), LFTs + amylase

Urinalysis + Urine MC&S

Imaging: Erect CXR, AXR, CTAP, CT angiogram, USS

Endoscopy

*depending on presentation

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5
Q

What type of management would you provide for acute abdomen?

A

ABCDE approach
conservative management
surgical management

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6
Q

What are differential diagnoses for RUQ?

A

Biliary Colic
Cholecystitis/Cholangitis
Duodenal Ulcer
Liver abscess
Portal vein thrombosis
Acute hepatitis
Nephrolithiasis
RLL pneumonia

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7
Q

What are differential diagnoses for epigastrium?

A

Acute gastritis/GORD
Gastroparesis
Peptic ulcer disease/perforation
Acute pancreatitis
Mesenteric ischaemia
AAA (Abdominal Aortic Aneurysm) Aortic dissection
Myocardial infarction

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8
Q

What are the differential diagnoses for LUQ?

A

Peptic ulcer
Acute pancreatitis
Splenic abscess
Splenic infarction
Nephrolithiasis
LLL Pneumonia

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9
Q

What are the differential diagnoses for RLQ?

A

Acute Appendicitis
Colitis
IBD
Infectious colitis
Ureteric stone/Pyelonephritis PID/Ovarian torsion
Ectopic pregnancy
Malignancy

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10
Q

What are the differential diagnoses for suprapubic/ central?

A

Early appendicitis
Mesenteric ischaemia
Bowel obstruction
Bowel perforation
Constipation
Gastroenteritis
UTI/Urinary retention
PID

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11
Q

What are the differential diagnoses for LLQ?

A

Diverticulitis
Colitis
IBD (Inflammatory Bowel Disease) Infectious colitis
Ureteric stone/Pyelonephritis PID/Ovarian torsion
Ectopic pregnancy
Malignancy

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12
Q

What is the presentation of bowel ischaemia?

A

Sudden onset crampy abdominal pain

Severity of pain depends on the length and thickness of colon affected

Bloody, loose stool (currant jelly stools)

Fever, signs of septic shock

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13
Q

What are the risk factors for bowel ischaemia? (6)

A

Age >65 yr

Cardiac arrhythmias (mainly AF), atherosclerosis

Hypercoagulation/ thrombophilia

Vasculitis

Sickle cell disease

Profound shock causing hypotension

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14
Q

Describe acute mesenteric ischaemia?

A

Small bowel

Usually occlusive due to thromboemboli

Sudden onset (but presentation and severity varies)

Abdominal pain out of proportion of clinical signs

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15
Q

Describe ischaemia colitis?

A

Large bowel

Usually due to non-occlusive low flow states, or atherosclerosis

More mild and gradual (80-85% of the cases)

Moderate pain and tenderness

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16
Q

What investigations would you do for bowel ischaemia?

A

Bloods

Imaging- CTAP/ Angiogram

Endoscopy

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17
Q

What are you looking out for in bloods for bowel ischaemia?

A

FBC: neutrophil leukocytosis

VBG (venous blood gas): lactic acidosis

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18
Q

What would you detect in the imaging for bowel ischaemia?

A

disrupted flow
vascular stenosis
pneumatosis intestinalis
thumbprint sign

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19
Q

What would you notice in endoscopies for ischaemic colitis?

A

for mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)

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20
Q

What is the conservative management for bowel ischaemia?

A

Mild to moderate cases of ischaemic colitis (not suitable for small bowel ischaemia)

  • IV fluid resuscitation
  • Bowel rest
  • Broad-spectrum ABx - colonic ischaemia can result in bacterial translocation & sepsis
  • Nasogastric tube for decompression - in concurrent ileus
  • Anticoagulation
  • Treat/manage underlying cause

** Serial abdominal examination and repeat imaging

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21
Q

What are the indications of necessary surgery for bowel ischaemia?

A

Small bowel ischaemia

Signs of peritonitis or sepsis

Haemodynamic instability

Massive bleeding

Fulminant colitis with toxic megacolon

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22
Q

What are the surgeries you could do for bowel ischaemia?

A

exploratory laparotomy

endovascular revascularisation

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23
Q

What is exploratory laparotomy?

A

Resection of necrotic bowel +/- open surgical embolectomy or mesenteric arterial bypass

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24
Q

What is an embolectomy?

A

also sometimes called thrombectomy — is the removal of a blood clot (thrombus) that’s keeping blood from flowing through a blood vessel normally

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25
Q

What is endovascular revascularisation and when would you do it?

A

balloon angioplasty/ thrombectomy

in patients without signs of ischaemia

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26
Q

How does acute appendicitis present?

A

Initially periumbilical pain that migrates to RLQ (within 24hours)

Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit

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27
Q

What are the important clinical signs of acute appendicitis? (5)

A

McBurney’s point
Blumberg sign
Rovsing sign
Psoas sign
Obturator sign

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28
Q

What is McBurney’s point?

A

tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)

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29
Q

What is Blumber sign?

A

rebound tenderness especially in the RIF

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30
Q

What is Rovsing sign?

A

RLQ pain elicited on deep palpation of the LLQ

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31
Q

What is Psoas sign?

A

RLQ pain elicited on flexion of right hip against resistance

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32
Q

What is obturator sign?

A

RLQ pain on passive internal rotation of the hip with hip & knee flexion

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33
Q

What are the investigations for acute appendicitis?

A

Bloods

Imaging

Diagnostic laparoscopy

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34
Q

What do you look out in bloods for acute appendicitis?

A

FBC: neutrophilic leukocytosis

increased CRP

Urinalysis: possible mild pyuria/ haematuria

electrolyte imbalances in profound vomiting

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35
Q

What is pyuria?

A

a condition in which you have high levels of white blood cells (leukocytes) or pus in your urine (pee)

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36
Q

What type of imaging do you use for different patients for acute appendicitis?

A

CT: adults esp over 50

USS: children/ pregnancy/ breastfeeding

MRI: in pregnancy if USS inconclusive

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37
Q

When do you use diagnostic laparoscopy for acute appendicitis?

A

in persistent pain and inconclusive imaging

38
Q

What score do you use to measure likeliness of acute appendicitis and what does it include?

A
39
Q

What does the conservative management of acute appendicitis consist of?

A

IV Fluids, Analgesia, IV or PO Antibiotics

In abscess, phlegmon or sealed perforation
- Resuscitation + IV ABx +/- percutaneous drainage

40
Q

What are the indications for conservative management for acute appendicitis? And what treatment should you consider?

A

After negative imaging in selected patients with clinically uncomplicated appendicitis

In delayed presentation with abscess/phlegmon formation
- CT-guided drainage

Consider interval appendicectomy - rate of recurrence after conservative management of abscess/perforation is 12-24%

41
Q

Laparoscopic vs Appendectomy. (6)

A

Less pain

Lower incidence of surgical site infection

Decreased length of hospital stay

Earlier return to work

Overall costs

Better quality of life scores

42
Q

What are the steps of laparoscopic appendicectomy?

A
43
Q

What is the classification of bowel/ intestinal obstruction?

A

2 main groups:

Paralytic (Adynamic) ileus

Mechanical

44
Q

What is intestinal obstruction?

A

restriction of normal passage of intestinal contents

45
Q

How is mechanical intestinal obstruction classified by?

A

Speed of onset
Site
Nature
Aetiology

46
Q

What is the small bowel obstruction aetiology?

A
47
Q

What is the large bowel obstruction aetiology?

A
48
Q

Small bowel vs Large bowel signs and symptoms:
Abdominal pain?

A

small=> colicky, central

large=> colicky or constant

49
Q

Small bowel vs Large bowel signs and symptoms:
Vomiting?

A

small=> early onset, large amount, bilious

large=> late onset, initially bilious, progresse to faecal vomiting

50
Q

Small bowel vs Large bowel signs and symptoms:
absolute constipation?

A

small=> late sign

large=> early sign

51
Q

Small bowel vs Large bowel signs and symptoms:
abdominal distention?

A

small=> less significant

large=> early sign and significant

52
Q

What are other signs of both small and large bowel obstruction?

A

Dehydration

Increased high pitched tinkling bowel sounds (early sign), or absent bowel sounds (late sign)

Diffuse abdominal tenderness

53
Q

What type of obstruction has a mortality of up to 15%?

A

strangulating obstruction with peritonitis

54
Q

How is bowel obstruction diagnosed?

A

diagnosed by the presence of symptoms

55
Q

What should the examination of bowel obstruction always include?

A

search for hernias and abdominal scars, including laparoscopic portholes

56
Q

If the bowel obstruction is not simple what is it?

A

strangulating

57
Q

What are the features that suggest strangulation obstruction?

A

Change in character of pain from colicky to continuous

Tachycardia

Pyrexia

Peritonism

Bowel sounds absent or reduced

Leucocytosis

↑ed C-reactive protein

58
Q

What is paralytic ileus?

A

Paralytic ileus is the condition where the motor activity of the bowel is impaired

59
Q

What are the common sites for hernias?

A

epigastric
umbilical
incisional
inguinal
femoral

60
Q

What are the types of hernias?

A

neck of sac
strangulated hernia
Richter’s hernia

61
Q

What investigations do you do for bowel obstruction?

A

Bloods

Imaging

62
Q

What do you look out for in bloods for bowel obstruction?

A

WCC/CRP usually normal (if raised suspicion of strangulation/perforation)

U&E: electrolyte imbalance

VBG if vomiting: HypoCl-,HypoK+ metabolic alkalosis

VBG if strangulation: Metabolic Acidosis (lactate)

63
Q

What imaging do you do for bowel obstruction?

A

Erect CXR/AXR
- SBO: Dilated small bowel loops >3cm proximal to the obstruction (central)
- LBO: Dilated large bowel >6cm (if caecum >9cm) predominantly peripheral
- 3cm for small, 6cm for large, 9cm for caecum (3,6,9 rule)

CT abdo/pelvis → Transition point, dilatation of proximal loops – IV +/- oral contrast if possible

64
Q

What does an abdominal x-ray look like for small bowel obstruction?

A

Ladder pattern of dilated loops & their central position

Striations that pass completely across the width of the distended loop produced by the circular mucosal folds.

65
Q

What does an abdominal x-ray look like for large bowel obstruction?

A

Distended large bowel tends to lie peripherally

Show haustrations of taenia coli - do not extend across whole width of the bowel

66
Q

What does CT scans do for bowel obstructions?

A

Can localize site of obstruction

Detect obstructing lesions & colonic
tumours

May diagnose unusual hernias (e.g.
obturator hernias).

67
Q

What do CT scans look like for bowel obstructions?

A
68
Q

When do you give supportive/ conservative management for bowel obstruction?

A

In patients with no signs of ischaemia/no signs of clinical deterioration

69
Q

What is the supportive treatment for bowel obstruction? (4)

A
70
Q

What is the conservative treatment for bowel obstruction?

A

Faecal impaction: stool evacuation (manual, enemas, endoscopic)

Sigmoid volvulus: rigid sigmoidoscopic decompression

SBO: oral gastrografin (highly osmolar iodinated contrast agent) can be used to resolve adhesional small bowel obstruction

71
Q

What are the indications to give surgical management for bowel obstruction?

A

Haemodynamic instability or signs of sepsis

Complete bowel obstruction with signs of ischaemia

Closed loop obstruction

Persistent bowel obstruction >2 days despite conservative management

72
Q

What are the possible operations for bowel obstruction?

A

Exploratory Laparotomy/Laparoscopy

Restoration of intestinal transit (depending on intra-operational findings)

Bowel resection with primary anastomosis or temporary/permanent stoma formation

(Endoscopic stenting)

73
Q

What is endoscopic stenting?

A

Endoscopic stenting is a medical procedure by which a stent, a hollow device designed to prevent constriction or collapse of a tubular organ, is inserted by endoscopy

74
Q

What is the presentation of GI perforation?

A

Sudden onset severe abdominal pain associated with distention

Diffuse abdominal guarding, rigidity, rebound tenderness

Pain aggravated by movement

Nausea, vomiting, absolute constipation

Fever, Tachycardia, Tachypnoea, Hypotension

Decreased or absent bowel sounds

75
Q

What is the presentation of perforated peptic ulcer?

A
76
Q

What is the presentation of perforated diverticulum?

A
77
Q

What is the presentation of perforated appendix?

A
78
Q

What is the presentation of perforated malignancy in GI?

A
79
Q

What investigations do you do for GI perforation?

A

Bloods

Imaging

80
Q

What are the differential diagnoses for GI perforations?

A

Acute cholecystitis, Appendicitis.

Myocardial infarction, Acute pancreatitis

81
Q

What do you look out for in bloods of GI perforation?

A

FBC:> neutrophilic leukocytosis

Possible elevation of Urea, creatinine

VBG: lactic acidosis

82
Q

What will you see in imaging for GI perforation?

A

Erect CXR → subdiaphragmatic free air (pneumoperitoneum)

CT abdo/pelvis → Pneumoperitoneum, free GI content, localised mesenteric fat stranding
- can exclude common differential diagnoses such as pancreatitis

83
Q

What is the supportive management on presentation of GI perforation?

A

NBM & NG tube

IV peripheral access with large bore cannula - IV Fluid resuscitation

Broad spectrum Abx

IV PPI

Parenteral analgesia & antiemetics

Urinary catheter

84
Q

What is PPI?

A

proton pump inhibitor

85
Q

When do use conservative management for GI perforation and what is included?

A

Conservative management in localised peritonitis without signs of sepsis

Very rare

IR - guided drainage of intra-abdominal collection

Serial abdominal examination & abdominal imaging for assessment

86
Q

When do you use surgical management for GI perforation and what is included?

A
87
Q

What are the symptoms, investigations and management of biliary colic?

A
88
Q

What are the symptoms, investigations and management of acute cholecystitis?

A
89
Q

What are the symptoms, investigations and management of acute cholangitis?

A
90
Q

What are the symptoms, investigations and management of acute pancreatitis?

A
91
Q

Do you understand all of these concepts?

A

Y/ N

BRS GASTROENTEROLOGY (25 decks)

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