Acute care- Gastro

Question 1

Where is McBurney’s point? What is the significance of this?

Answer 1

2/3s of the way from umbilicus to ASIS
Site of max. pain in appendicitis

Question 2

3 peritoneal signs specific for acute appendicitis

Answer 2

Rovsing’s Sign: palpation of LIF causes more pain in RIF

Psoas Sign: pain on extending hip (caused by retrocaecal appendix)

Obturator Sign: pain on flexion + internal rotation of hip (occurs if appendix in close proximity to obturator internus)

Question 3

Which additional examinations should be considered in suspected appendicitis?

Answer 3

Scrotal + groin exam: ?hernia/ testicular torsion

Pelvic exam: ?ectopic

Question 4

What investigations may be performed in appendicitis?

Answer 4

FBC: leucocytosis
CRP: high
Urine dip: r/o UTI
Pregnancy test: r/o ectopic

Question 5

Which imaging modalities may be used in appendicitis?

Answer 5

Thin males: clinical dx
USS: r/o pelvic organ pathology in females
CT: if diagnostic uncertainty

Question 6

Describe management for appendicitis

Answer 6

NBM
Analgesia IV
Laparoscopic appendicectomy
Prophylactic Abx: IV Ceftriaxone + Metronidazole

Question 7

most common causes of SBO?

Answer 7

ADHESIONs
Incarcerated hernias

Question 8

most common causes of LBO?

Answer 8

TUMOURS
Diverticular disease
Volvulus

Question 9

5 symptoms of intestinal obstruction

Answer 9

Severe abdo pain
Abdo distension
N+V (may be bile-stained or faeculent)
Absolute constipation
Decreased/ tinkling bowel sounds

Question 10

4 signs of bowel obstruction

Answer 10

Dehydration +/- hypovolemia (hypotension, dry mucous membranes)
Diffuse abdominal tenderness
Tympanic percussion
Tinkling/ absent bowel sounds

Question 11

What is complicated bowel obstruction?

Answer 11

BO a/w strangulation, ischaemic necrosis or perforation

Question 12

Describe initial management in suspected BO

Answer 12

A-E approach
Obtain IV access
IV fluid resus +/- electrolytes
NBM
NG tube with free drainage
Analgesia
Antiemetics
Obtain imaging

Question 13

Describe choice of imaging modality in suspected BO

Answer 13

Stable: CT AP with IV contrast (definitive, GS)
Unstable: AXR

Question 14

Describe imaging in SBO

Answer 14

Dilated bowel >3cm, predominantly central
VALVULAE CONNIVENTES (completely cross the lumen)
No gas in large bowel
Air-fluid level

Question 15

Describe imaging in LBO

Answer 15

Dilated bowel >6cm or >9cm if at caecum
Dilated loops predominantly peripheral
HAUSTRA which don’t cross whole lumen width
Air-fluid level

Question 16

Describe what management of BO depends on

Answer 16

Urgency of Mx depends on whether perforation is suspected
If cause of obstruction itself does not require surgery, conservative Mx for 72h can be trialled

Question 17

What further management may be required in BO?

Answer 17

IV abx if perforation suspected/ surgery planned
Exploratory laparotomy: irrigation, resection + address underlying cause

Question 18

In which cases is surgical management considered for BO?

Answer 18

Complicated BO
Closed loop obstruction
Strangulation
Haemodynamic instability not responding to fluids
Underlying cause necessitates e.g. tumour
Refractory to conservative Mx

Question 19

Which obstructions can be managed conservatively (at least initially)?

Answer 19

Post-op ileus
Partial BO

Question 20

What bloods should be taken in suspected intestinal obstruction?

Answer 20

FBC: high WCC, anaemia in Ca
CRP: HIGH
U+E’s: deranged due to vomiting
Glucose (Exclude DKA)
G+S

Question 21

Mx of SBO

Answer 21

NBM
IV fluids
NG tube with free drainage
Some settle with conservative Mx, but otherwise will require surgery

Question 22

% of LBO requiring surgery

Answer 22

75%

Question 23

3 presenting features of upper GI bleed

Answer 23

Haematemesis
Melena
Raised urea (protein meal of blood)

Question 24

4 oesophageal causes of upper GI bleed

Answer 24

Oesophageal varicies
Oesophagitis
Cancer
Mallory weiss tear

Question 25

Describe upper GI bleeds due to oesophageal varicies

Answer 25

May have associated stigmata of chronic liver disease Usually large vol of fresh blood. Swallowed blood may cause melena. Often a/w haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed.

Question 26

Describe upper GI bleeds due to oesophagitis

Answer 26

Small vol fresh blood, often streaking vomit. Malena rare. Often ceases spontaneously. Usually hx of antecedent GORD type Sx

Question 27

Describe upper GI bleeds due to oesophageal cancer

Answer 27

Usually small vol blood, except as a pre-terminal event with erosion of major vessels. Often associated Sx of dysphagia + constitutional Sx e.g. WL May be recurrent until malignancy managed.

Question 28

Describe upper GI bleeds due to Mallory Weiss tears

Answer 28

Typically brisk small-mod vol of bright red blood following a bout of repeated vomiting. Malena rare. Usually ceases spontaneously.

Question 29

List 4 gastric causes of upper GI bleeds

Answer 29

Gastric ulcer Gastric cancer Dieulafoy lesion Diffuse erosive gastritis

Question 30

Describe upper GI bleeds due to gastric ulcers

Answer 30

Small low vol bleeds are more common so tend to present as IDA. Erosion into a significant vessel may produce considerable haemorrhage + haematemesis.

Question 31

Describe upper GI bleeds due to Gastric cancer

Answer 31

Frank haematemesis or altered blood mixed with vomit. Prodromal features of dyspepsia + may have constitutional Sx. Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage.

Question 32

Describe upper GI bleeds due to Dieulafoy lesion

Answer 32

Often no prodromal features prior to haematemesis + melena AV malformation May produce quite a considerable haemorrhage May be difficult to detect endoscopically

Question 33

Describe upper GI bleeds due to Diffuse erosive gastritis

Answer 33

Haematemesis + epigastric discomfort. Usually underlying cause e.g. recent NSAID usage. Large vol haemorrhage may occur with considerable haemodynamic compromise

Question 34

Name 2 duodenal causes of upper GI bleeds

Answer 34

Duodenal ulcer Aorto-enteric fistula

Question 35

Describe upper GI bleeds due to Duodenal ulcers

Answer 35

Usually posteriorly sited + may erode the gastroduodenal artery. Ulcers at any site in the duodenum may present with haematemesis, melena + epigastric discomfort.

Question 36

Describe upper GI bleeds due to Aorto-enteric fistulas

Answer 36

In those with previous AAA surgery Rare but important cause of major haemorrhage a/w high mortality.

Question 37

Describe risk assessment in upper GI bleeds

Answer 37

Glasgow-Blatchford score: 1st Helps decide whether patients can be managed OP Rockall score: AFTER endoscopy Provides % risk of rebleeding + mortality inc. age, features of shock, co-morbidities, aetiology of bleeding + endoscopic stigmata of recent haemorrhage

Question 38

Describe resuscitation in an upper GI bleed

Answer 38

A-E. Site 2x wide-bore IV cannula Platelet transfusion if actively bleeding platelet count of <50 x 10*9/litre FFP if fibrinogen level of <1 g/L, or PT (INR) or APTT >1.5x normal PCC to those on warfarin + actively bleeding

Question 39

Describe use of endoscopy in an upper GI bleed

Answer 39

Offer immediately after resus in those with a severe bleed All should have endoscopy within 24h

Question 40

Mx of non-variceal bleeding

Answer 40

PPIs given if stigmata of recent haemorrhage on endoscopy If further bleeding; repeat endoscopy or IR or surgery

Question 41

Mx of variceal bleeding

Answer 41

Terlipressin + PPX Abx at presentation (pre-endoscopy) Band ligation for oesophageal varices Injections of N-butyl-2-cyanoacrylate for gastric varices Sengstaken-Blakemore tube if uncontrolled haemorrhage Transjugular intrahepatic portosystemic shunts (TIPSS) offered if bleeding from varices is not controlled with the above

Question 42

What is TIPSS? Name a common complication

Answer 42

Connects hepatic vein to portal vein Cx: exacerbation of hepatic encephalopathy

Question 43

What can be used for prophylaxis of variceal haemorrhage?

Answer 43

Propranolol Endoscopic variceal band ligation (if cirrhosis + med-large varicies)