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BRS - Year 2 > 🍔Gastro🍔 - Surgery in the GI Tract > Flashcards

🍔Gastro🍔 - Surgery in the GI Tract Flashcards

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1
Q

What is the general approach to acute abdominal issues?

A

Presenting complaint - SOCRATES, associated symptoms
PMHx, DHx, SHx
Range of investigations - bloods, imaging, endoscopy etc…
Management - ABCDE, conservative, surgical etc…

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2
Q

When does intermittent pain occur in gastro?

A

Obstruction of hollow viscus - when no pushing pain may go completely

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3
Q

What is the difference between radiation and referred pain?

A
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4
Q

How is venous blood gas (VBG) helpful in acute abdominal presentations?

A

Lactate is a marker of anaerobic respiration - ischaemia

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5
Q

What is an erect chest x-ray useful for?

A

Helps identify air under the diaphragm - e.g. perforation of intraabdominal viscera

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6
Q

What is ultrasound useful for in abdominal presentations?

A

Looking for liver and gall bladder pathologies

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7
Q

What are the common differentials for RUQ pain?

A

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

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8
Q

What are the common differentials for epigastric pain?

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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9
Q

What are the common differentials for LUQ pain?

A

Peptic ulcer
Acute pancreatitis
Splenic abscess
Splenic infarction
Nephrolithiasis
LLL Pneumonia

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10
Q

What are the common differentials for RLQ pain?

A

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

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11
Q

What are the common differentials or Suprapubic/central pain?

A

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

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12
Q

What are the common differentials for LLQ pain?

A

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

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13
Q

What is the presentation of bowel ischaemia?

A

Sudden onset crampy abdominal pain - especially after eating
Severity of pain depends on the length and thickness of colon affected
Bloody, loose stool (currant jelly stools) - shedding of mucosa
Fever, signs of septic shock

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14
Q

What are the risk factors for bowel ischaemia?

A

Age >65 yr
Cardiac arrythmias (mainly AF), atherosclerosis
Hypercoagulation/thrombophilia
Vasculitis
Sickle cell disease
Profound shock causing hypotension

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15
Q

Compare acute mesenteric ischaemia to ischaemic colitis

A
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16
Q

What investigations should be done for suspected bowel ischaemia?

A

Bloods - high neutrophils, VBG - lactic acidosis
Imaging CTAP/CT angiogram - distrupted flow, vascular stenosis, Pneumatosis intestinalis, thumbprint sign
Endoscopy - mild/moderate ischaemic colitis (oedema, cyanosis, ulceration)

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17
Q

What is the thumb printing sign?

A

Disruption between layers
Parts of submucosa bulging out

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18
Q

What are the management options for mild/moderate ischaemic colitis?

A

Conservative management (not suitable for small bowel ischaemia)
IV fluids
Bowel rest
Broad-spectrum ABx
NG tube for decompression (concurrent ileus)
Anticoagulants
Serial abdominal examination and repeat imaging

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19
Q

Why do you give ABx in the context of ischaemic colitis?

A

Colonic ischaemia can result in bacterial translocation and sepsis

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20
Q

What are the indications for surgical management of bowel ischaemia?

A

Small bowel ischaemia
Signs of peritonitis orsepsis
Haemodynamic instability
Massive bleeding
Fulminant colitis with toxic megacolon

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21
Q

What are the surgical options for bowel ischaemia?

A

Exploratory laparotomy - Resection of necrotic bowel +/- open surgicalembolectomy or mesenteric arterial bypass
Endovascular revascularisation - balloon angioplasty/thrombectomy
In patients without signs of ischaemia

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22
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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23
Q

Blumberg sign

A

Rebound tenderness especially in the right iliac fossa

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24
Q

Rovsing sign

A

RLQ pain elicited on deep palpation of the LLQ

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25
Psoas sign
RLQ pain elicited on flexion of right hip against resistance
26
Obturator sign
RLQ pain on passive internal rotation of the hip with hip & knee flexion
27
What would you see in bloods for acute appndicitis?
FBC - neutrophilic leukocytosis Eleveated CRP Urinalysis - possible mild pyuria/haematuria Electrolyte imbalances (if profound vomiting)
28
What imaging would be done for acute appendicitis?
CT - gold standard in adults (esp age >50) Ultrasound - children, pregnancy, breastfeeding MRI - pregnancy if USS inconclusive
29
When would you do a diagnostic laparoscopy in acute appendicitis?
Persistent pain and inconclusive imaging
30
What is the Alvarado score?
31
What is the conservative management for acute appendicitis?
IV fluids, analgesia, IV/PO antibiotics
32
What are the indications for conservative management in acute appendicitis?
After negative imaging in selected patients with clinically uncomplicated appendicitisIn IN delayed presentation with abscess or phlegmon formation - CT guided drainage
33
What should be considered in the case of an appendix abscess/perforation?
Consider interval appendicectomy - rate of recurrence after conservative management of abscess/perforation is 12-24%
34
What are the advantages of laparoscopic appendicectomy?
Less pain Lower incidence of surgical site infection ↓ed length of hospital stay Earlier return to work Overall costs  Better quality of life scores
35
Outline the steps of laparoscopic appendicectomy
36
What are the classifications of bowel obstruction?
Paralytic (adynamic) ileus Mechanical
37
How can mechanical intestinal obstruction be classified?
Speed of onset - acute, chronic, acute-on-chronic Site - high(vomiting, severe pain) or low(constipation) Nature - simple vs strangulating Aetiology
38
What is simple vs strangulating bowel obstruction?
Simple: bowel is occluded without damage to blood supply Strangulating: blood supply of involved segment of intestine is cut off (e.g. in strangulated hernia, volvulus, intussusception)
39
What are the aetiologies of bowel obstruction?
40
Compare the aetiologies of small vs large bowel obstructions
41
Compare the presentation of small and large bowel obstructions
42
What should be considered when diagnosis bowel obstruction?
Diagnosed by the presence of symptoms Examination should always include a search for hernias & abdominal scars, including laparoscopic portholes Is it simple or strangulating?
43
What features suggest strangulating bowel obstruction
Change in character of pain from colicky to continuous Tachycardia Pyrexia Peritonism Bowel sounds absent or reduced Leucocytosis ↑ed C-reactive protein
44
Why is it so important that strangulating obstructions are caught quickly?
Strangulating obstruction with peritonitis has a mortality of up to 15%
45
What are the common hernial sites?
46
What are the common types of hernias?
47
What are the blood tests for bowel obstruction?
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)
48
What are the imaging options for bowel obstruction?
Erect CXR/AXR SBO: Dilated small bowel loops >3cm proximal to the obstruction (central) LBO: Dilated large bowel >6cm (if caecum >9cm) predominantly peripheral CT abdo/pelvis → Transition point, dilatation of proximal loops – IV +/- oral contrast if possible
49
What will be seen on an abdominal x-ray in small bowel obstruction?
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
50
What will be seen on an abdominal x-ray in large bowel obstruction?
Distended large bowel tends to lie peripherally Show haustrations of taenia coli - do not extend across whole width of the bowel
51
What is a CT scan helpful for in bowel obstruction?
Can localize site of obstruction Detect obstructing lesions & colonic tumours May diagnose unusual hernias (e.g. obturator hernias)
52
When can conservative management be employed in patients with bowel obstruction?
No signs of ischaemia/no signs of clinical deterioration
53
What are the conservative and supportive management options for bowel obstruction?
54
What are the indications for surgical management of bowel obstruction?
Haemodynamic instability or signs of sepsis Complete bowel obstruction with signs of ischaemia Closed loop obstruction Persistent bowel obstruction >2 days despite conservative management 
55
What are the operative options for surgical management of bowel obstructions?
Exploratory Laparotomy/Laparoscopy  Restoration of intestinal transit (depending on intra-operational findings) Bowel resection with primary anastomosis or temporary/permanent stoma formation (Endoscopic stenting)
56
What is the presentation of GI perforation?
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
57
What are the different common aetiologies of GI perforation?
Perforated peptic ulcer Perforated diverticulum Perforated appendix Perforated malignancy
58
What are the features of a perforated peptic ulcer?
Sudden epigastric or diffuse pain Referred shoulder pain Hx of NSAIDs, steroids, recurrent epigastric pain
59
What are the features of a perforated diverticulum?
LLQ pain Constipation
60
What are the features of a perforated appendix?
Migratory pain Anorexia Gradual worsening RLQ pain
61
What are the features of a perforated malignancy?
Change in bowel habit Weight loss Anorexia PR Bleeding
62
What would the bloods look like in a patient with GI perforation?
FBC: neutrophilic leukocytosis Possible elevation of Urea, Creatinine VBG: Lactic acidosis
63
What imaging would be used in a patient with suspected GI perforation?
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
64
What are the differential diagnoses in a patient with possible GI perforation?
Acute cholecystitis, Appendicitis Myocardial infarction, Acute pancreatitis
65
What is the first treatment given to a patient presenting with GI perforation?
NBM & NG tube IV peripheral access with large bore cannula - IV Fluid resuscitation Broad spectrum Abx IV PPI Parenteral analgesia & antiemetics Urinary catheter 
66
When is conservative management taken for GI perforation?
in localised peritonitis without signs of sepsis - **Very rare** IR - guided drainage of intra-abdominal collection Serial abdominal examination & abdominal imaging for assessment
67
What are the surgical options for a GI perforation?
Exploratory laparotomy/laparoscopy Primary closure of perforation with or without omental patch (most common in perforated peptic ulcer) Resection of the perforated segment of the bowel with primary anastomosis or temporary stoma  Obtain intra-abdominal fluid for MC&S, peritoneal lavage ++++ If perforated appendix: Lap or open appendicectomy If malignancy: intraoperative biopsies if possible
68
What are the biliary and pancreatic causes of acute abdominal presentations?
Biliary colic Acute cholecystitis Acute cholangitis Acute pancreatitis
69
Outline biliary colic
70
Outline acute cholecystitis
71
Outline acute cholangitis
72
Outline acute pancreatitis
73
What does this x-ray show?
Enormously distended oval gas shadow, looped on itself to give typical "bent, inner-tube sign" or "coffee bean sign" **Volvulus**
74
What is a volvulus?
Loop of intestine twists around itself and the mesentery that supplies it, causing a bowel obstruction
75
What is the conservative treatment for a volvulus?
Sigmoidoscope passed with the patient lying in the left lateral position Large, well lubricated, soft rubber rectal tube passed along sigmoidoscope Untwists the volvulus, release of vast quantities of flatus and liquid faeces
76
If a flatus tube is unsuccessful in treating volvulus, what is the risk in leaving it untreated
Left untreated, the loop of intestine would undergo necrosis This is because its blood supply is cut off by the torsion
77
What is the next step (after a failed flatus tube) in managing a case of sigmoidal volvulus?
Exploratory laparotomy and sigmoid colectomy with end colostomy Hartmann's procedure

BRS - Year 2 (75 decks)

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