Disease of small bowel and appendix

Question 1

what can cause obstruction inside the lumen?

Answer 1

gallstones
food
bezoar

Question 2

what can cause obstruction within the wall?

Answer 2

tumour
crohns
radiation

Question 3

what can cause obstruction outside the wall?

Answer 3

adhesions (most common, can be post surgery or congenital which presents late in life)
herniation

Question 4

what are the symptoms of small bowel obstruction?

Answer 4

pain (colicky, central)
absolute constipation
vomiting
burping
abdominal distension

Question 5

what is the typical presentation of small bowel obstruction?

Answer 5

distension
vomiting
borborygmi
pain
faeculent vomiting
presence of a cause (eg scar, hernias)

Question 6

how is the state of the patient assessed in small bowel obstruction?

Answer 6

urinalysis
bloods
gases

Question 7

how is small bowel obstruction diagnosed?

Answer 7

AXR
contrast CT
gastrograffin studies

Question 8

what does small/large bowel obstruction look like on XR?

Answer 8

small = multiple thickened loops
large = big distended large intestine

Question 9

what is drip and suck?

Answer 9

treatment for small bowel obstruction due to adhesions

1) ABC
2) analgesia
3) fluids with potassium
4) they are usually hypokalaemic and alkalotic
5) catheterise
6) NG tube (ryles tube not a feeding)
7) antithromboembolism measures (eg TED stockings)

Question 10

how long do you drip and suck for?

Answer 10

up to 72 hours usually
intervene earlier if
- strangulation
- perforation
- ishcaemia

Question 11

how can small bowel obstruction be surgically managed?

Answer 11

laparotomy

Question 12

what are the principles of a laparotomy?

Answer 12

antibiotics
antithrombotic measures
usually a midline incision
can be laparoscopic
find the obstruction by following collapsed or dilated bowel

Question 13

what is mesenteric ischaemia?

Answer 13

dead gut

Question 14

what is the difference between small/large bowel?

Answer 14

small bowel doesn’t have a marginal artery

Question 15

what can cause mesenteric ischaemia?

Answer 15

embolus (usually from AF, forms in left atrium, sticks in a narrow SMA)
thrombosis (virchows triad)
atherosclerosis

Question 16

what are the symptoms of mesenteric ischaemia?

Answer 16

Cramps, like angina of the gut

pain out of proportion with clinical findings

Question 17

why might the colon live when the small bowel is infarcted and dies?

Answer 17

colon has supply from marginal artery

Question 18

who is the typical patient for mesenteric ischaemia?

Answer 18

old lady on lots of morphine

Question 19

how is mesenteric ischaemia diagnosed?

Answer 19

acidosis on ABGs (low pH, high H+, high BE)
elevated lactate
CRP may be normal
WCC will be up (around 15)
CT angiogram
At laparotomy
Intervene before patient is moribund

Question 20

how is mesenteric ischaemia treated?

Answer 20

Must act quickly
Resect if non-viable
Re-anastamose or staple and planned return
If viable you can rarely perform an SMA embolectomy
Sometimes have to “open and close” = open up to find gangrene and tell them they are going to die slowly and painfully

Question 21

how much bowel do you need to survive?

Answer 21

30cm

so can only perform resection if 30cm or more is left

Question 22

how is small bowel haemorrhage diagnosed?

Answer 22

CT angiogram
ABC
exclude upper source
vascular malformations
ulcerations

Question 23

how is a small bowel haemorrhage usually managed?

Answer 23

interventional radiology

Question 24

what and where is a meckels diverticulum?

Answer 24

remnant of omphalomesenteric duct

60cm above IC valve

Question 25

how does meckels diverticulum present?

Answer 25

usually before age 2 | usually incidental

Question 26

what are the possible complications of meckels diverticulum?

Answer 26

Bleed (haematochezia) Ulcerate/meckels diverticulitis Obstruction Malignant change (0.5%)

Question 27

where is the appendix?

Answer 27

most are retrocaecal base always at converegence of the 3 taenai coli tip can vary

Question 28

what artery supplies the appendix?

Answer 28

``` appendicular artery end artery (stops at appendix) ```

Question 29

describe the incidence of appendicitis?

Answer 29

``` declining incidence rare in infancy usually in childhood/young adults another peak in elderly more common in males before age 25, then the same ```

Question 30

what causes appendicitis?

Answer 30

no real underlying hypothesis faecolith obstruction viral (in clustering of cases) bacterial

Question 31

describe the pathology of appendicitis?

Answer 31

``` lumen may/may not be occluded mucosal inflammation lymphoid hyperplasia obstruction mucus/exudate build up venous obstruction ischaemia perforation presence of inflammtions in abdomen brings the greater omentum down, small bowel adheres, phlegmonous mass peritonitis can be fatal (if appendix bursts) ```

Question 32

who is a ruptured appendix more likely in?

Answer 32

elderly immunosuppressed diabetes absence of omentum (ie. surgery)

Question 33

what is the classic picture of appendicitis?

Answer 33

``` Central pain that migrates to RIF Anorexia Nausea One or two vomits May not have moved bowels Pelvic: vaguer pain localisation: rectal tenderness Elderly ```

Question 34

what are the classical signs of appendicitis?

Answer 34

``` mild pyrexia (not too high, <40) mild tachycardia localised pain in RIF guarding rebound ```

Question 35

what are some specific signs of appendicitis?

Answer 35

``` Rosving’s = Pressing on the left causes pain on the right Psoas = Patient keeps the right hip flexed as this lifts an infmaled appendix off the psoas Obturator = If appendix is touching obturator internus, flexing the hip and internally rotting will cause pain Pointing = Where did it start, where it is now? ```

Question 36

what are some special cases that might not present with classical signs?

Answer 36

retrocaecal appendix = few signs pelvic appendix = diarrhoea, frequent micturition Postileal = rare, diarrhoea, vomiting

Question 37

name 4 groups of people that can present with special cases/symptoms of appendicitis?

Answer 37

obese (still claim hunger) elderly (more gangrene/perforation) children (don't sleep/eat) pregnancy (appendix moves up and out, MRI useful, operate early - lap is safe and feasible)

Question 38

what might the differential diagnosis be in children?

Answer 38

``` Gastroenteritis Mesenteric adenitis Meckel’s diverticulum Intususseption Henoch-Schonlein Purpura Lobar pneumonia ```

Question 39

what might the differential diagnosis be in women?

Answer 39

Mittelschmerz Ovarian cyst Salpingitis Ectopic pregnancy

Question 40

how is appendicitis investigated?

Answer 40

``` clinical diagnosis Ultrasound useful in women/kids AXR to exclude other cause (not first line) Bloods (CRP< WCC) Urinalysis (check pregnancy etc) ```

Question 41

what is alvadro score?

Answer 41

uses mantrels scoring system to determine appendicitis - score to move/cough/laugh - flushed red face - foetor oris

Question 42

how is appendicitis treated?

Answer 42

``` analgesia antipyretics theatre antibiotics appendicectomy - laparascopic (best) - open (not first line) - laparotomy sometimes ```

Question 43

what is appendix mass?

Answer 43

late presentation of appendicitis | inflamed

Question 44

how is appendix mass treated?

Answer 44

antibiotics first line | don't often operate, only if treatment fails or complicated

Question 45

what is an appendix abscess?

Answer 45

delayed presentation liquidised treated with radiological drain

Question 46

what are some complications of appendix abscess?

Answer 46

``` Pelvic abscess Wound infection Intra-abdominal abscess Ileus Respiratory DVT/PE Portal pyaemia Faecal fistula Adhesions Right sided inguinal hernia ```

Question 47

what is carcinoid of the appendix?

Answer 47

cancer in crypts of lieberkuhn metastatic risk stains for chromagrannin

Question 48

how is carcinoid of the appendix treated?

Answer 48

appenicectomy if <1cm | completion right hemi if >2cm