Gastrointestinal Flashcards
Causes of intestinal obstruction
Dynamic Intraluminal ●Faecal impaction ●Foreign bodies ●Bezoars ●Gallstones
Intramural ●Stricture ●Malignancy ●Intussusception ●Volvulus
Extramural
●Bands/adhesions
●Hernia
Adynamic
● Paralytic ileus
● Pseudo-obstruction
NOTE: adhesions are most common cause ~40%
Most common cause of intestinal obstruction
Adhesions
~40%
Causes of strangulation
Direct pressure on the bowel wall
● Hernial orifices
● Adhesions/bands
Interrupted mesenteric blood flow
● Volvulus
● Intussusception
Increased intraluminal pressure
● Closed-loop obstruction
Rigler’s triad
Comprising:
1) small bowel obstruction
2) pneumobilia and
3) atypical mineral shadow on radiographs of the abdomen.
=gallstone ileus
Definition of volvulus
A volvulus is a twisting or axial rotation of a portion of bowel about its mesentery
The rotation causes obstruction to the
lumen (>180° torsion) and if tight enough also causes vascular occlusion in the mesentery (>360° torsion).
Sigmoid volvulus
Rotation nearly always occurs in the anticlockwise direction
Fulminant: sudden onset, severe pain, early vomiting, rapidly deteriorating clinical course;
Indolent: insidious onset, slow progressive course, less
pain, late vomiting
Indications for early intervention in bowel obstruction
Obstructed external hernia
Clinical features suspicious of intestinal strangulation
Obstruction in a ‘virgin’ abdomen
High-risk anastomosis
Oesophageal
Low-rectal
Risk factors for anastomotic leak
Patient factors:
- Steroids
- Immunosuppression
- Diabetes
- Age
- Male gender
- Malnutrition
- Low-flow states
Operative factors:
- Operation time > 2 hours
- Level of anatsomosis
- Tension of anastomosis
- Blood supply
Disease factors:
- unprepared bowel e.g. acute obstruction
- localised sepsis or malignancy
Presentation of anastomotic leak
Peritonitis
- Hypotensive, tachycardia, pyrexia, tachyponoea, rigid guarded abdomen
- The abdomen does not move with respiration
Abscess
- Swinging pyrexia
- Localised tenderness
Enteric fistula
Cardiovascular complications
-if patient develops sepsis may present as AF, SVT or MI
Investigation for anastomotic leak
If peritonitis, no further imaging required
-re-look laparotomy
For abscess and fistula
-CT imaging
Management of anatsomotic leak
Peritonitis
- Laparotomy and division of anstomosis
- Proximal used as stoma and diversion
- Essentially a Hartmans
- Cefuroxime 750mg TDS and Metronidazole 500mg TDS
May be able to use proximal diversion alone
Abscess
- IR drainage
- Open drainage if IR unsuccessful
- Cefuroxime 750mg TDS and Metronidazole 500mg TDS
- Monitor for progression to peritonitis
Fistula
- Antibiotics and conservative management
- Cefuroxime 750mg TDS and Metronidazole 500mg TDS
- Monitor for progression to peritonitis
Peptic ulcers
● Most peptic ulcers are caused by H. pylori or NSAIDs and changes in epidemiology mirror changes in these principal aetiological factors
● Duodenal ulcers are more common than gastric ulcers, but the symptoms are indistinguishable
● Gastric ulcers may become malignant and an ulcerated gastric cancer may mimic a benign ulcer
● Gastric antisecretory agents and H. pylori eradication therapy are the mainstay of treatment, and elective surgery is very rarely performed
● The long-term complications of peptic ulcer surgery may be difficult to treat
● The common complications of peptic ulcers are perforation, bleeding and stenosis
● The treatment of the perforated peptic ulcer is primarily surgical, although some patients may be managed conservatively
Perforated peptic ulcer operations
Open direct repair of the defect using transverse incision and omental patch
Distal gastrectomy with Roux-en-Y reconstruction is the
procedure of choice
Vagal denervation
Most operations are rendered obsolete by PPIs and endoscopic monitoring
When vagal denervation is required, a highly selective vagotomy is sometime perfomred
-integrity of GI tract maintained
Billroth II is very rarely performed
