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Phase 2 - General Surgery Placement > GI Surgical Presentations > Flashcards

GI Surgical Presentations Flashcards

1
Q

what is considered an ‘acute abdomen’ presentation?

A

sudden onset of severe abdominal pain usually in the last 24hours

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2
Q

which presentations require urgent surgical treatment?

A
  • bleeding
  • bowel perforation
  • ischaemic bowel
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3
Q

what GI presentations are considered to be less acute?

A
  • colic

- peritonism

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4
Q

what are common differentials for a patient presenting with epigastric pain?

A
  • peptic ulcer disease
  • cholecystitis
  • pancreatitis
  • myocardial infarction
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5
Q

what are common differentials for a patient presenting with peri-umbilical pain?

A
  • small bowel obstruction
  • large bowel obstruction
  • appendicitis (early)
  • abdominal aortic aneurysm
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6
Q

what are common differentials for a patient presenting with right upper quadrant pain?

A
  • cholecystitis
  • pyelonephritis
  • ureteric colic
  • hepatitis
  • pneumonia
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7
Q

what are common differentials for a patient presenting with left upper quadrant pain?

A
  • gastric ulcer
  • pyelonephritis
  • ureteric colic
  • pneumonia
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8
Q

what are common differentials for a patient presenting with right lower quadrant pain?

A
  • appendicitis (late)
  • ureteric colic
  • inguinal hernia
  • IBD
  • UTI
  • gynaecological
  • testicular torsion
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9
Q

what are common differentials for a patient presenting with left lower quadrant pain?

A
  • diverticulitis
  • ureteric colic
  • inguinal hernia
  • IBD
  • UTI
  • gynaecological
  • testicular torsion
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10
Q

what is the most serious cause of intra-abdominal bleeding?

A

a ruptured abdominal aortic aneurysm

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11
Q

what are other causes of intra-abdominal bleeding?

A
  • ruptured ectopic pregnancy
  • bleeding gastric ulcer
  • trauma
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12
Q

why is intra-abdominal bleeding such a concern?

A

patients can enter hypovolaemic shock because of it

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13
Q

what are the signs of hypovolaemic shock?

A
  • tachycardia
  • hypotension
  • pale and clammy
  • cool to touch
  • thready pulse
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14
Q

true or false: bowel perforation can cause peritonitis

A

true.

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15
Q

what is peritonitis?

A

inflammation of the peritoneum

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16
Q

what are the common causes of bowel perforation?

A
  • peptic ulceration
  • small/large bowel obstruction
  • diverticular disease
  • inflammatory bowel disease
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17
Q

how do patients usually present with peritonitis?

A
  • patients lie still and try not to move their abdomen
  • tachycardia
  • rigid abdomen with guarding
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18
Q

true or false: any patient in severe pain out of proportion to clinical signs has ischaemic bowel until proven otherwise

A

true.

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19
Q

what is blood abnormalities are found in a patient with ischaemic bowel?

A

raised lactate

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20
Q

how do patients usually present with ischaemic bowel?

A
  • diffuse constant pain
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21
Q

how do you definitely diagnose ischaemic bowel?

A

CT with contrast

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22
Q

what is colic pain?

A

abdominal pain that crescendos to very severe and then goes away completely

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23
Q

when is colic type pain most commonly seen?

A
  • ureteric obstruction

- bowel obstruction

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24
Q

true or false: biliary colic is a true colic pain

A

false.

biliary colic is false colicky pain as it does not go away completely but instead ‘waxes and wanes’

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25
Q

what is the difference between peritonitis and peritonism?

A

peritonism is localised inflammation of the peritoneum that has irritated the parietal layer whereas peritonitis irritates the visceral peritoneum

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26
Q

what are the common investigations done in acute abdomen cases and why?

A
  • urine dip: signs of infection or haematuria (also check pregnancy)
  • ABG: for bleeding patients to get a rapid haemoglobin and signs of hypoperfusion (lactate levels)
  • bloods: FBC, U&Es, LFTs, CRP, amylase
  • blood cultures: if considering infection
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27
Q

what level does amylase need to be to diagnose pancreatitis?

A

3x greater than the upper limit

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28
Q

what are the common imagings done in acute abdomen cases and why?

A
  • ECG to rule out myocardial infarction
  • USS: area checked depends on specifics of case
  • erect CXR: to check for bowel perforation
  • CT depending on suspected diagnosis
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29
Q

what is haematemesis and how is it caused?

A

vomiting blood caused by bleeding in the upper GI tract

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30
Q

when is haematemesis considered an emergency?

A

if it is caused by oesophageal varices or gastric ulceration

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31
Q

when do you get non-emergency haematemesis?

A
  • mallory weiss tear

- oesophagitis

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32
Q

what are oesophageal varices?

A

dilations of porto-systemic venous anastomoses in the oesophagous
they are thin walled and prone to rupture

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33
Q

what causes oesophageal varices?

A

portal hypertension most commonly due to alcoholic liver disease

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34
Q

what investigations are done in a patient with suspected oesophageal varices?

A

an OGD to confirm diagnosis

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35
Q

what is a gastric ulceration?

A

erosion into the blood vessels that supply the upper GI tract

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36
Q

what causes gastric ulceration?

A
  • ulcer disease
  • h. pylori positive
  • history of NSAID or steroid use
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37
Q

which vessel is most commonly damaged in a gastric ulceration?

A

gastro-duodenal artery

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38
Q

what are mallory-weiss tears?

A

episodes of recurrent vomiting resulting in damage to the oesophageal epithelium - this leads to slight haematemesis

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39
Q

what are key points to note when taking a history of haematemesis?

A
  • history of dyspepsia, dysphagia, odynophagia
  • smoking and alcohol use
  • medication history
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40
Q

why would you do an erect chest xray in a patient with haematemesis?

A

if there is a perforated peptic ulcer, it may present with air under the diaphragm (pneumoperitoneum)

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41
Q

what other imaging should be done in a patient with haematemesis?

A

OGD and a CT abdomen with contrast

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42
Q

how would you manage a patient with peptic ulcer disease?

A
  • cauterise the bleeding

- begin IV PPI therapy to reduce acid secretion

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43
Q

how would you manage a patient with oesophageal varices?

A
  • endoscopic banding

- prophylactic antibiotics should be given

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44
Q

what is dysphagia?

A

difficulty in swallowing

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45
Q

true or false: dysphagia is oesophageal cancer until proven otherwise

A

true.

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46
Q

what investigation is done to find the cause of dysphagia?

A

an upper GI endoscopy +/- biopsy

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47
Q

what are the mechanical causes of dysphagia?

A
  • oesophageal or gastric malignancy
  • benign oesophageal strictures
  • extrinsic compression
  • pharyngeal pouch
  • foreign body
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48
Q

what are the neuromuscular causes of dysphagia?

A
  • post-stroke
  • achalasia
  • diffuse oesophageal spasm
  • myasthenia gravis
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49
Q

what clinical features should be assessed in a patient with dysphagia?

A
  • differentiate between odynophagia (pain on swallowing)
  • presence of regurgitation
  • sticking of food
  • hoarse voice and other cancer markers
  • referred pain to neck or ear
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50
Q

if the endoscopy is normal how would you further the investigations?

A

barium swallow or assess for motility disorders (manometry)

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51
Q

what is the management for dysphagia?

A

treat the underlying cause

if no underlying cause found, refer to SALT and dietician

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52
Q

what is a bowel obstruction?

A

the mechanical blockage of the bowel

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53
Q

what are the most common causes of small bowel obstruction?

A
  • adhesions
  • hernias
  • cancer
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54
Q

what are the most common causes of large bowel obstruction?

A
  • malignancy
  • diverticular disease
  • volvulus
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55
Q

true or false: a large bowel obstruction should be considered GI cancer until proven otherwise

A

true.

56
Q

what are the intraluminal causes of bowel obstruction?

A
  • gallstone ileus
  • foreign body
  • faecal impaction
57
Q

what are the mural causes of bowel obstruction?

A
  • cancer
  • strictures
  • intussussception
  • diverticular strictures
  • Meckel’s diverticulum
58
Q

what are the extramural causes of bowel obstruction?

A
  • hernias
  • adhesions
  • peritoneal metasteses
  • volvulus
59
Q

what happens in a bowel obstruction and why is it essential to monitor fluids?

A

once blocked there is dilation of the proximal bowel, this increases peristalsis causing more fluid secretions to enter the bowel - therefore fluid resuscitation is needed

60
Q

what is a closed loop obstruction?

A

if there is a 2nd obstruction proximally it is a surgical emergency as the bowel will distend, become ischaemic and perforate

61
Q

what causes a closed loop obstruction?

A
  • a twist in the bowel (volvulus)

- a competent ileocaecal valve

62
Q

what are the clinical features of bowel obstruction?

A
  • abdominal pain and distension
  • vomiting (initially gastric, then bilious, then faeculent)
  • inability to pass flatus and constipation
63
Q

true or false: large bowel obstructions present with vomiting first

A

false.
large bowel obstructions present initially with complete constipation as the obstruction is more distal and will take longer to affect the small bowel

64
Q

what is heard on auscultation in a patient with a bowel obstruction?

A

tinkling bowel sounds

65
Q

what are the differential diagnoses for a patient with suspected bowel obstruction?

A
  • paralytic ileus
  • toxic megacolon
  • constipation
66
Q

what laboratory tests should be done in a patient with suspected bowel obstruction?

A 
FBC
CRP
U&Es - patient may be hypokalaemic
G&S and X-match
VBG to assess signs of ischaemia (raised lactate) and metabolic status
67
Q

what imaging should be done in a patient with suspected bowel obstruction?

A

CT abdomen with contrast is first line as is more sensitive for obstruction and can help identify the kind of obstruction
Abdo xray

68
Q

what will an abdominal xray show in small bowel obstruction?

A
  • dilated bowel >3cm

- central abdominal location

69
Q

what will an abdominal xray show in large bowel obstruction?

A
  • dilated bowel >6cm
  • peripherally located
  • visible haustra lines
70
Q

how would you conservatively manage a patient with bowel obstruction?

A

all patients need fluid resuscitation and fluid monitoring (catheter insertion)
patient will be NBM with a NG tube inserted
give pain relief

71
Q

when would you use surgical management in a patient with bowel obstruction?

A

if the bowel has become ischaemic or strangulated
if it is a closed loop obstruction
if patient fails to improve with 48hours despite conservative treatment

72
Q

what surgical interventions tend to occur?

A

tends to be a laparotomy with a resection of the bowel or a stoma being necessary

73
Q

what are the complications the can occur due to a bowel obstruction?

A
  • bowel ischaemia
  • bowel perforation causing faecal peritonitis
  • dehydration and renal damage
74
Q

what is a gastric perforation?

A

a break in the GI tract anywhere from the oesophagus to the anorectal junction

75
Q

what does a GI perforation have to potential to cause?

A

peritonitis which can lead to spesis and death

76
Q

what are the chemical causes of GI perforation?

A
  • peptic ulcer disease

- foreign body

77
Q

what are the infectious causes of GI perforation?

A
  • appendicitis
  • diverticulitis
  • cholecystitis
  • meckel’s diverticulum
78
Q

what are the ischaemic causes of GI perforation?

A
  • mesenteric ischaemia

- obstructive lesions that can lead to bowel distension and ischaemia

79
Q

what are the colitis causes of GI perforation?

A
  • fistular formation (e.g. from Crohn’s)

- toxic megacolon (e.g. c. diff or UC)

80
Q

what are the traumatic causes of GI perforation?

A
  • recent surgery anastomotic leak
  • endoscopy or NG tube damage
  • excessive vomiting leading to oesophageal perforation
81
Q

what are the clinical features of an intra-peritoneal GI perforation?

A
  • abdominal pain worse on movement

- distended abdomen

82
Q

what are the clinical features of a retro-peritoneal GI perforation?

A
  • shoulder tip pain

- back pain

83
Q

what are the common differential diagnoses considered in a patient with suspected GI perforation?

A
  • pancreatitis
  • MI
  • ruptured AAA
84
Q

what laboratory tests would you do if you suspected a patient had a bowel perforation?

A
  • FBC
  • U&Es
  • LFTs
  • CRP
  • G&S + X-match
  • urinalysis: to rule out urogenital pathology
85
Q

what imaging would you do in a patient with suspected bowel perforation and why?

A
  • plain erect CXR would show pneumoperitoneum

- CT scan with a contrast swallow to show the location of the perforation

86
Q

how would you initially manage a patient with a suspected bowel perforation?

A
  • resuscitation as needed
  • broad spectrum IB antibiotics
  • NBM with nasogastric tube
  • IV fluid and analgesia
87
Q

what conservative management can be done in a patient with an oesophageal perforation?

A

treated with an endoscopically placed stent

88
Q

what conservative treatment can be done for a patient with a peptic ulcer perforation?

A

may heal on its own with bowel rest and PPI therapy

89
Q

what conservative management can be done in a patient with a diverticular abscess perforation?

A

if the perforation is <5cm they can be treated with a guided percutaneous drainage

90
Q

when is conservative management indicated in a patient with a bowel perforation?

A

if the patient is systemically ‘well’:

  • no signs of peritonitis or sepsis
  • CT scan shows the leak is contained
91
Q

when would a patient need surgical intervention in a bowel perforation?

A

if the patient is systemically unwell or have failed to be treated conservatively

92
Q

what kind of surgical management would occur in a patient with bowel perforation?

A
  • surgical washout
  • management of underlying cause (e.g. remove obstruction)
  • primary repair of perforation OR resection of diseased area with anastomoses or stoma formation
93
Q

when would a stoma be formed in a GI perforation surgery?

A

can be done in a small bowel perforation

usually done in a large bowel perforation

94
Q

what are the complications of a GI perforation?

A

peritonitis
sepsis
haemorrhage

95
Q

true or false: anastomoses are the most important part of surgical management of GI perforation

A

false.

the intraoperative washout is vital to reduce bacterial load - giving post-operative antibiotics is also key

96
Q

what is melena?

A

black tarry stools with a foul smell

97
Q

what is the most common cause of melena?

A

an upper GI bleed

98
Q

what pathologies can lead to an upper GI bleed?

A
  • peptic ulcer disease
  • liver disease (causing oesophageal varies)
  • gastric cancer
99
Q

when should you suspect peptic ulcer disease as the cause of melena?

A

if the patient has one of the following:

  • known peptic ulcer disease
  • history of NSAID/ steroid use
  • history that indicates epigastric ulceration
  • H. Pylori positive
100
Q

what is the important vessel to be aware of when you suspect a patient with melena has had a peptic ulceration?

A

gastroduodenal artery

101
Q

what is the most common cause for oesophageal varices?

A

alcoholic liver disease

102
Q

how do oesophageal varices form?

A

dilatations of the porto-systemic anastomoses in the oesophagus that can rupture due to portal hypertension secondary to liver cirrhosis

103
Q

what are common associated symptoms present with melena?

A

haematemesis, abdominal pain, history of dyspepsia, dysphasia, odynophagia

104
Q

what investigations would you do in a patient with melena?

A 
Bloods:
FBC - drop in Hb
LFTs - to show any liver damage
U&amp;Es - rise urea:creatinine + low Hb can indicate an upper GI bleed
G&amp;S and X-match

ABG: can show signs of hypoperfusion e.g. lactate

105
Q

why does a rise in urea:creatinine and a low Hb indicate an upper GI bleed?

A

digested haemoglobin produces urea as a by-product

this is absorbed by the intestine and will show in blood tests indicating blood in the digestive tract

106
Q

what imaging would you do for a patient with melena?

A
  • OGD is definitive and can form a part of the long-term management
  • CT abdomen to assess active bleeding
107
Q

how would you manage a patient with melena?

A
  • A-E approach to stabilise
  • OGD can be used to manage if:
    • peptic ulcer disease: cauterisation of the bleeding + PPI therapy
    • varices: endoscopic banding to stop the bleeding
    • malignancy: will need biopsies to further plan long term treatment
108
Q

what is the difference between melena and haematochezia?

A

melena is the passing of digested blood in the stool, haematochezia is the passing of fresh blood in the stool

109
Q

what causes fresh rectal bleeding?

A

bleeding from the lower GI tract:

  • diverticular disease
  • angiodysplasia
  • haemorrhoids
  • malignancy
110
Q

true or false: a patient with an large fresh rectal bleed who is haemodynamically unstable has an upper GI bleed until proven otherwise

A

true.

it can come from an actively bleeding stomach ulcer

111
Q

what is the most common cause of lower GI bleeding?

A

diverticular disease

112
Q

how do diverticular bleeds tend to present?

A

they tend to be painless

113
Q

what is angiodyplasia?

A

small arterio-venous malformations in the colonic wall

114
Q

what are haemorrhoids?

A

pathologically engorged vascular cushions in the anal canal

115
Q

how does haemorrhoid bleeding tend to present?

A

as a mass with pruritis, or fresh red rectal bleeding

blood tends to be on the tissue rather than mixed in with stool

116
Q

how does a haemorrhoid present if it is thrombosed?

A

it is highly painful for the patient

117
Q

what investigations would you do in a patient with a PR bleed?

A
  • routine bloods (FBC, U&Es, LFTs)
  • clotting screen
  • G&S
  • stool cultures
118
Q

what imaging investigation would you do in a patient with a PR bleed?

A
  • flexible sigmoidoscopy or a full colonoscopy if results are inconclusive
  • CT angiogram can be used to identify the bleeding vessel and for therapeutic embolisation if needed
119
Q

how would you initially manage a patient with a PR bleed?

A
  • ABCDE approach with two large bore cannula, IV fluid, and blood products if needed
  • patients with unstable or ongoing bleeding need resus, an urgent endoscopy +/- CT angiogram
120
Q

true or false: most patients need surgical intervention in a PR bleed

A

false.

95% of PR bleeds settle spontaneously and stable patients with a normal Hb are investigated as outpatients

121
Q

what is jaundice?

A

yellow discolouration of the sclera and the skin due to high bilirubin levels (>50)

122
Q

where does bilirubin come from?

A

it is a normal breakdown product from RBCs

123
Q

how is bilirubin normally excreted?

A

it is conjugated by the liver to become water soluble and then excreted via bile into the GI tract - most is excreted via faeces whereas some is reabsorbed into the bloodstream and excreted by the kidneys

124
Q

what are the three types of jaundice?

A

pre-hepatic
intra-hepatic
post-hepatic

125
Q

what is pre-hepatic jaundice?

A

excessive breakdown of RBCs leading to excess bilirubin that the liver cannot all conjugate, leaving unconjugated bilirubin in the bloodstream

126
Q

what is intra-hepatic jaundice?

A

liver dysfunction making it unable to conjugate bilirubin or cirrhosis leading to compression of the biliary tree causing obstruction

127
Q

true or false: in intra-hepatic jaundice, only conjugated bilirubin is present in the blood

A

false.

there is both conjugated and unconjugated bilirubin - giving a ‘mixed picture’

128
Q

what is post-hepatic jaundice?

A

an obstruction of the biliary drainage, leading to excess conjugated bilirubin in the blood

129
Q

what are the causes of pre-hepatic jaundice?

A

haemolytic anaemia

130
Q

what are the causes of intra-hepatic jaundice?

A 
alcoholic liver disease
viral hepatitis
hereditary haemochromatosis
medication
hepatocellular carcinoma
131
Q

what are the causes of post-hepatic jaundice?

A

gall stones
strictures
pancreatic cancers
abdominal masses

132
Q

true or false: conjugated bilirubin can be excreted by urine and gives it a darker colour

A

true

133
Q

what blood would you take in a patient with jaundice?

A

FBC (anaemia, raised MCV seen in liver disease)
U&Es (establish baseline)
LFTs (checking for signs of liver disease)
Coagulation screen (check liver function)

134
Q

what are the significance of LFT tests in a patient with jaundice?

A

bilirubin - the severity of jaundice
albumin - assess liver synthesis function
AST and ALT - markers of hepatocellular injury
ALP - raised in biliary obstruction
GGT - specific for biliary obstruction

135
Q

what imaging would you do in a patient with jaundice?

A

USS abdomen is first line to identify any obstructive or obvious liver pathology
MRCP can be done if USS was inconclusive and if jaundice was obstructive

136
Q

what are the complications of jaundice?

A

may be indicative of liver failure so monitor coagulation and check for low blood sugar

Phase 2 - General Surgery Placement (14 decks)

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