Gastrointestinal emergencies Flashcards
(94 cards)
1
Q
Cardiovascular causes of the acute abdomen?
A
- Acute coronary syndrome
- Acute mesenteric ischaemia
- Ruptured AAA
- Aortic dissection
2
Q
Gastrointestinal causes of the acute abdomen?
A
- GI tract perforation
- Mechanical bowel obstruction
- Acute appendicitis
- Peptic ulcer disease
- Diverticulitis
- Constipation
*
3
Q
Biliary and pancreatic causes of the acute abdomen?
A
- Acute pancreatitis
- Gallstones
- Acute cholecystitis
- Ascending cholangitis
4
Q
Genitourinary causes of the acute abdomen?
A
- Ruptured ectopic pregnancy
- Ovarian torsion
- Testicular torsion
- Acute pyelonephritis
- Kidney stones
5
Q
Presentation of ruptured AAA?
A
- Sudden, severe chest/abdominal pain, radiates to the back
- Hypotension/shock
- Pulsatile mass in abdomen
6
Q
Diagnosis of ruptured AAA?
A
- If the patient is unstable, diagnosis should not delay management.
- If the patient is hemodynamically stable, abdominal ultrasound can confirm diagnosis.
- CT/MR angiography can be used to localise rupture site and plan surgical management.
7
Q
Presentation of oesophageal rupture?
A
- Mackler’s triad:
- Vomiting and/or retching
- Severe retrosternal pain that radiates to the back
- Subcutaneous/mediastinal emphysema
- Crackling sound when auscultating mediastinal region (Hamann sign)
8
Q
What is Boerhaave syndrome?
A
- Transmural oesophageal rupture secondary to severe vomiting/coughing
- Risk factors include chronic cough, alcoholism, repeated episodes of vomiting
9
Q
Diagnosis of oesophageal rupture?
A
- Chest x-ray
- Widened mediastinum
- Pneumomediastinum
- Pleural effusion
- CT scan
- Same findings as CXR
10
Q
What is shown on this x-ray?
A
- Pneumomediastinum (shown in green)
- This patient has Boerhaave syndrome (oesophageal rupture)
11
Q
Management of oesophageal rupture?
A
- ABCDE approach
- Nil-by-mouth
- Broad-spectrum IV antibiotic prophylaxis
- Non-surgical (expectant) management:
- Small, contained perforation
- Surgical management:
- Haemodynamic instability or larger perforation
- Surgical closure of the rupture
12
Q
Complications of peptic ulcer disease?
A
- Gastrointestinal bleeding
- Gastric ulcers of the lesser curvature may cause bleeding from the left gastric artery
- Posterior duodenal arteries may cause bleeding from the gastroduodenal artery
- Perforation
13
Q
Presentation of a perforated peptic ulcer?
A
- Sudden, diffuse abdominal pain
- Peritonism (guarding and rebound/percussion tenderness)
- Fever, tachycardia, hypotension
- Shoulder-tip pain (irritation of the phrenic nerve)
14
Q
Diagnosis of a perforated peptic ulcer?
A
- Upright chest x-ray
- 75% will have free air under the diaphragm
- Diagnosis is usually clinical
15
Q
Management of a perforated peptic ulcer?
A
- ABCDE
- Fluid resuscitation
- Nil-by-mouth
- Surgical repair using a patch of omentum
16
Q
Presentation of GI perforation?
A
- Sudden-onset diffuse abdominal pain
- Constipation/obstipation
- Nausea/vomiting
- Peritonism
- Guarding, rebound tenderness
17
Q
Diagnosis of GI perforation?
A
- Chest x-ray:
- Free air under the diaphragm
- Patient must be sat upright
- Can be done quickly in A&E, with much lower radiation dose than an abdominal x-ray
- Abdominal x-ray:
- Pneumoperitoneum
- CT with contrast
- Most sensitive investigation
- Shows pneumoperitoneum
18
Q
What does this x-ray show?
A
Pneumoperitoneum (shown in green)
19
Q
Management of GI perforation?
A
- Supportive care
- Stable patient
- IV PPI
- Opioid analgesics (unless also bowel obstruction)
- Antiemetics
- Surgical management
- Most patients require an urgent exploratory laparotomy
20
Q
Commonest causes of small bowel obstruction?
A
- Bowel adhesions
- Commonest cause
- History of GI surgery
- Incarcerated hernias
- Second commonest cause
21
Q
Commonest causes of large bowel obstruction?
A
- Malignancy
- Commonest cause of LBO
- Diverticulitis
- Volvulus
22
Q
Presentation of mechanical bowel obstruction?
A
- Colicky abdominal pain
- Obstipation
- Abdominal distension
- Progressive nausea and (bilious) vomiting
- Tinkling bowel sounds
- History of abdominal surgery
23
Q
Diagnosis of mechanical bowel obstruction?
A
- Abdominal x-ray
- Distended loops of bowel proximal to the obstruction
- Air-fluid levels
- CT abdomen with contrast
- Similar findings
- Transition point at site of obstruction
24
Q
How to differentiate between SBO and LBO?
A
- The folds in the bowel on AXR
- Small bowel folds (valvulae conniventes) = visible across the whole width of the bowel
- Large bowel folds (haustra) = don’t completely transverse the bowel
- Rule of thumb - haustra can sometimes appear to cross the full width of the large bowel.
- The anatomical position of the distended bowel loops
- The history
- SBO = early vomiting, late obstipation
- LBO = early obstipation, late vomiting
25
What is the 3/6/9 rule?
* Upper limits of normal for the diameter of bowel segments are as follows:
* Small bowel = 3cm
* Large bowel = 6cm
* Caecum = 9cm
26
Management of mechanical bowel obstruction?
* Nil-by-mouth
* "Drip and suck"
* IV fluids
* Nasogastric tube decompression
* Most will require surgical management
27
Causes of paralytic ileus (functional bowel obstruction)
* Intraabdominal surgery
* Intraabdominal infection/inflammation
* Medications (e.g. anticholinergics, opioids)
* Hypokalaemia
* Sepsis
The 5 P's: **P**eritonitis, **P**ostoperative, low **P**otassium, **P**ainkillers (opioids), **P**elvic/spinal fractures are some of the common causes
28
Presentation of paralytic ileus?
* Constipation and reduced flatulence
* Continuous (non-colicky) abdominal pain
* Abdominal distention
* Nausea and vomiting
* Decreased or absent bowel sounds
29
Diagnosis of paralytic ileus?
* CT abdomen
* Gold standard
* Diffuse small and/or large bowel distention
* Abdominal x-ray
* Less sensitive than CT
* Same findings as CT
* Abdominal ultrasound
* Not routinely used in adults, but is the investigation of choice in children
30
Management of paralytic ileus?
* Nil-by-mouth
* "Drip and suck"
* IV fluids
* NG tube decompression
* Correct underlying cause if possible
* **Avoid opiate analgesia**
31
Presentation of acute appendicitis?
* Abdominal pain
* Initially central/diffuse
* Eventually localises to RIF
* Fever
* Tachycardia
* Nausea/anorexia
Examination
* Rosving's sign - palpation of LIF causes RIF pain
* Psoas sign - extension of right leg (in L lateral position) causes RIF pain
32
Diagnosis of acute appendicitis?
* FBC
* Neutrophilic leukocytosis
* Abdominal ultrasound
* Distended, aperistaltic appendix
* Abdominal CT scan
* Periappendiceal fat stranding
* Distended appendix
33
Management of acute appendicitis?
* Laparoscopic appendicectomy
* Prophylactic IV antibiotics
* If the appendix has perforated then patients will need a peritoneal lavage
34
Causes of intussusception?
* No identifiable cause in 75%
* Meckel's diverticulum (commonest cause found in children)
* Polyps/malignancy (commonest cause found in adults)
* Enlarged Peyer's patches
* Lymphoid patches on the wall of the ileum
* Can become hypertrophied after infection/vaccination
35
Presentation of intussusception?
* Acute colicky abdominal pain
* Infants often draw legs up during episodes
* **Sausage-shaped** RUQ mass
* Vomiting
* **"Redcurrant jelly**" stools (due to PR bleeding)
36
Diagnosis of intussusception?
* Abdominal ultrasound (best initial investigation)
* Target sign - telescoping section of bowel appears as rings on a target
* Contrast enema with ultrasound/fluoroscopy (best confirmatory test)
* Abdominal CT
* Used if the diagnosis is equivocal after ultrasound and AXR
37
Management of intussusception?
* NGT decompression and fluid resuscitation if needed
* Non-surgical
* Air enema is the treatment of choice
* Surgical management
* Indicated if the patient is unstable (e.g. perforation) or if a pathological lead point is suspected (e.g. malignancy)
38
Presentation of acute mesenteric ischaemia?
- Age \> 60, VTE risk factors (usually have AF).
- Severe pain out of proportion to examination findings (often normal BP, HR etc.)
- Diffuse abdo pain and distension
- Nausea and vomiting
39
Diagnosis of acute mesenteric ischaemia?
- Lactic acidosis
- Abdominal x-ray: normal early on, progressing to pneumatosis (gas in the walls of the intestines).
- CT angiography gold standard
40
Management of acute mesenteric ischaemia?
* ABCDE
* NGT decompression
* IV fluid resuscitation
* Prophylactic IV antibiotics
* Emergency laparotomy and resection of necrotic bowel preferred in most
* If the patient is stable revascularization may be attempted
* Optimise AF treatment if appropriate to reduce the risk of recurrence
41
Types of volvulus and malrotation?
* Sigmoid colon - commoner in the elderly
* Caecal volvulus - commoner in 40-60 year-olds
* Midgut volvulus and malrotation - commoner in children
42
Presentation of volvulus?
* Abdominal pain
* Episodic
* Relieved by the explosive passage of stool/gas
* Distension
* Vomiting & constipation
* Peritonitis if the bowel perforates
43
Diagnosis of volvulus?
* Abdominal x-ray
* Sigmoid volvulus: large bowel obstruction with 'coffee bean sign'
* Caecal volvulus: small bowel obstruction
44
What is shown on this x-ray?
Sigmoid volvulus with the coffee bean sign
45
Management of volvulus?
* Sigmoid volvulus
* Rigid/flexible endoscopic decompression, detorsion, and reduction
* Surgery if bowel perforates
* Caecal volvulus
* Typically requires surgical management
* Right hemicolectomy is often needed
46
What is acute megacolon?
* Imbalance in parasympathetic and sympathetic nervous system → progressive abdominal distention
* Often occurs in seriously ill patients who have undergone major surgery
47
Management of acute megacolon?
* Supportive measures
* NGT decompression
* Nil-by-mouth
* IV fluids
* Neostigmine
* Surgery
* Indicated if conservative measures fail
48
What is toxic megacolon?
* A form of megacolon occurring as a result of infective/inflammatory colitis
* Commonly secondary to C. difficile infection
* May also occur secondary to IBD
49
Presentation of toxic megacolon?
* Bloody diarrhoea
* Vomiting
* Abdominal distention and pain
* Signs of sepsis
50
Diagnosis of toxic megacolon?
* Abdominal x-ray
* Dilated colon
* Loss of haustration
* Multiple air-fluid levels
51
Management of toxic megacolon?
* Supportive care
* Will likely need escalating to HDU/ICU
* Nil-by-mouth
* NGT
* IV fluid
* Surgery
* If no improvement within 24-72 hours or the development of complications
52
Presentation of a strangulated abdominal hernia?
* Acute abdominal pain localising to the site of the hernia
* Features of bowel obstruction (if bowel is part of hernial contents)
* Tender, irreducible hernia
* Toxic appearance, fever, signs of sepsis
53
Management of a strangulated abdominal hernia?
* ABCDE and resuscitation
* Surgical hernia repair
* Do not attempt manual reduction as this can cause generalised peritonitis
54
Presentation of acute cholecystitis?
* Right upper quadrant pain
* Typically more severe and prolonged (\> 6hrs) than biliary colic
* Positive Murphy's sign
* Sudden pausing during inspiration on deep palpation of the RUQ due to pain.
* Fever, anorexia
* Guarding
55
Diagnosis of acute cholecystitis?
* Blood tests to support clinical diagnosis
* Raised WCC and CRP
* LFTs - transaminitis
* RUQ ultrasound scan if the diagnosis is uncertain
* Shows gallbladder wall thickening
56
Management of acute cholecystitis?
* Elective laparoscopic cholecystectomy (within 1 week)
* Prophylactic IV antibiotics
57
Pathophysiology of acute cholecystitis?
* Biliary tract obstruction → bile stasis → ascending bacterial infection
* May be iatrogenic through the introduction of GI contents into bile ducts e.g. ERCP, biliary stenting, or liver transplantation
58
Presentation of ascending cholangitis?
* Charcot's triad (present in up to 70%)
* RUQ pain
* Jaundice
* Fever
* Reynold's pentad
* Charcot's triad
* Mental status changes
* Hypotension
59
Diagnosis of ascending cholangitis?
* Laboratory tests to confirm clinical diagnosis
* FBC → raised WCC
* CRP → raised
* LFT → cholestasis (raised ALP, bilirubin, GGT, ALT)
* RUQ ultrasound scan if diagnosis is uncertain
* Shows dilated common bile duct
60
Management of ascending cholangitis?
* IV antibiotics
* ERCP after 24-48 hrs to relieve any obstruction
61
Risk factors for spontaneous bacterial peritonitis?
* Liver disease and ascites
* Upper GI bleeding
* Previous SBP
62
Presentation of spontaneous bacterial peritonitis?
* Diffuse abdominal pain and tenderness
* Fever and rigors
* Worsening ascites
* New-onset or worsening encephalopathy
63
Diagnosis of spontaneous bacterial peritonitis?
* Paracentesis and M, C & S of ascitic fluid
* Commonest organism found is E. coli
64
Management of spontaneous bacterial peritonitis?
* IV antibiotics (usually cefotaxime)
* Antibiotic prophylaxis is given if a patient with ascites:
* Has had a previous episode of SBP
* Has fluid protein \< 15g/L
65
Causes of acute pancreatitis?
**I GET SMASHED**
* I - iatrogenic
* G - gallstones
* E - ethanol (alcohol intoxication)
* T - trauma
* S - steroids
* M - mumps
* A - autoimmune
* S - scorpion venom
* H - hyperlipidaemia, hypercalcaemia
* E - ERCP
* D - drugs (e.g. azathioprine, loop diuretics, anticonvulsants)
66
Clinical features of acute pancreatitis?
* Constant, severe epigastric pain
* Classically radiates to the back
* Nausea, vomiting
* Fever
* Signs of shock: hypotension, tachycardia, oliguria/anuria
* Cullen's sign - periumbilical bruising
* Gray-Turner's sign - flank bruising
67
Diagnosis of acute pancreatitis?
* Early ultrasound scan important to assess whether gallstones are involved as this affects management
* Serum markers to aid clinical diagnosis
* Serum amylase raised in 75% of patients
* Serum lipase - longer half-life so may be useful for later presentation
68
What scoring system is used to assess severity?
Glasgow score
69
Management of acute pancreatitis?
* Aggressive fluid resuscitation
* Analgesia - IV opioids
* Don't need to be nil-by-mouth unless they are vomiting
* Patients with acute pancreatitis due to gallstones should undergo early cholecystectomy
* Patients with biliary obstruction should undergo early ERCP
70
What scoring system is used to assess acute upper GI bleeding?
The Glasgow-Blatchford scale. Variables included are:
* Urea
* Haemoglobin
* Systolic BP
* The presence of:
* Syncope
* Malaena
* Tachycardia
* Hepatic failure
* Cardiac failure
A score of 0 indicates a patient can be considered for early discharge
71
Resuscitation of a patient with an acute upper GI bleed?
* ABCDE
* Wide-bore IV access (e.g. 2 x grey cannulas)
* Platelet transfusion
* Actively bleeding and platelets \< 50 x 109
* Fresh frozen plasma
* Fibrinogen \< 1g/L
* APTT or PT \> 1.5 x normal
* Prothrombin complex concentrate
* Taking warfarin and bleeding
72
Investigation of patients with acute upper GI bleeding?
* Upper GI endoscopy
* Should be offered immediately after resuscitation if severe bleeding
* All patients should have endoscopy within 24 hours
73
Management of variceal bleeding?
* Terlipressin and prophylactic antibiotics should be given at presentation
* Before endoscopy if known history of varices
* Elastic band ligation of oesophageal varices is first line
* If vessels can't be visualised (too much blood) or elastic band ligation fails to control bleeding, a Sengstaken-Blakemore tube can be inserted
* Expands against the walls of the oesophagus and physically tamponades the vessels
* Mustn't be left in longer than 2 days as can cause oesophageal necrosis
* Definitive management of varices is a transjugular intrahepatic portosystemic shunt (TIPS) procedure that relieves backpressure in the portal vein.
74
Management of non-variceal bleeding?
* Endoscopy to look for cause
* IV PPIs
* Only given after endoscopy if confirmed non-variceal bleed
75
Priorities in assessment and management of a lower GI bleed?
1. **Consider** (and exclude by urgent endoscopy) an **upper GI source** of bleeding
2. **Urgent involvement of surgical teams** if there is major blood loss and/or haemodynamic instability
3. Consider and correct **clotting abnormalities**
* Consider reversing anticoagulation
4. **Blood transfusion**
* Transfuse when Hb \< 80g/L if bleeding has stopped
* Threshold is Hb \< 100g/L if ongoing bleeding
5. **Admit or discharge?**
* Minor lower GI bleeding that stops spontaneously → early outpatient sigmoidoscopy
* Admit if moderate/severe bleeding or significant comorbidities
76
Investigation of a suspected acute flare-up of IBD?
* Abdominal x-ray to rule-out toxic dilatation (megacolon) or proximal constipation
* Blood tests:
* FBC
* CRP (raised in 90%)
* In patients with normal CRP platelets can be a marker of disease severity
* U&Es
* Dehydration indicates late presentation and a severe flare
* Stool sample
* Infection can trigger flares
* Rule-out C. difficile → pseudomembranous colitis
77
Management of an acute flare-up of ulcerative colitis?
* Drug therapy
* Oral prednisolone (poorly absorbed in severe flare → IV hydrocortisone)
* Ciclosporin/infliximab if poor response to steroids
* Surgery
* If medical management fails
* Crohn's disease must be definitively ruled-out
* Colectomy/hemicolectomy depending on how diffuse the illness is
78
Management of an acute flare-up of Crohn's disease?
* Drug management
* Glucocorticoids (PO or IV) are first-line to induce remission
* Azathioprine or mercaptopurine may be used second-line
* TPMT levels must be measured before starting these
* Methotrexate is an alternative second-line drug
* Infliximab can be used in refractory cases
* Surgical management
* Reserved for when medical management fails
* Recurrence within one year in 80% of cases
* Aims to remove as little of the gut as possible
* May end up with a short gut/ileostomy
79
Causes of acute liver failure?
* Hepatotoxic substances
* Drugs: paracetamol
* Alcohol
* Cocaine (causes vasoconstriction → hepatic hypoperfusion)
* Infections
* Hepatitis A, B, E (or superinfection with B & D)
* Vascular
* Budd-Chiari syndrome (hepatic vein thrombosis)
* Pregnancy-related
* HELLP syndrome, acute fatty liver of pregnancy
* Autoimmune hepatitis
80
Clinical features of acute liver failure?
* Hepatic encephalopathy
* Altered consciousness
* Asterixis
* Jaundice
* Pruritis
* Abdominal pain
* Nausea and vomiting
* Anorexia
81
Definition of acute liver failure?
ALF is defined as:
* Severe acute liver injury
* Encephalopathy
* Impaired liver synthetic function (prothrombin time/international normalized ratio 1.5)
* In the absence of pre-existing liver disease
82
Investigation of suspected acute liver failure?
1. Detailed drug history (including any herbal and over-the-counter medications) from the patient or family members
* If ALF is suspected to be due to paracetamol poisoning start NAC without delay
2. Arrange urgent investigations:
* PT, APTT, INR
* FBC
* Blood glucose
* U&Es - ?hepatorenal syndrome
* LFT
* ABG if reduced consciousness
* Culture and microscopy of ascitic fluid
* Liver ultrasound
83
Management of acute liver failure
* Seek hepatology advice
* Escalate to HDU (or ITU if encephalopathy is severe)
* Manage complications (e.g. AKI, sepsis, SBP)
* Liver transplantation
* Indications vary depending on pathology
* Generally require deranged INR (\> 6.5)
84
What is decompensated liver disease?
* Background of chronic liver disease
* Acute hepatic decompensation → liver failure
* Jaundice
* Prolongation of the prothrombin time/international normalized ratio
* Extrahepatic organ failure
85
Management of decompensated chronic liver disease?
1. Fluid and electrolyte balance
2. Thromboprophylaxis - LMWH
* Increased risk of thromboembolism despite prolonged PT/APTT
3. Drugs
* IV vitamin K & oral folic acid once daily
* Avoid opioids and sedatives
4. Nutritional support
86
What is hepatorenal syndrome?
* AKI in the context of acute, severe liver failure when other causes of AKI have been excluded
* Low albumin → low oncotic pressure → ascites → hypovolemia → renal hypoperfusion → activation of RAA system → renal artery constriction → further renal hypoperfusion and AKI
87
LFT results in alcoholic hepatitis?
* Gamma-**GT** characteristically raised (**G**in and **T**onic → g**GT** raised in ALD)
* Transaminitis
* AST:ALT normally \> 2, ratio \> 3 → suggests severe alcoholic hepatitis
88
Management of alcoholic hepatitis?
* Supportive care (e.g. nutritional support, fluid balance etc.)
* Glucocorticoids is sometimes beneficial
* "Discriminant function" is a score used to determine this
* Calculation involves PT and bilirubin levels
* Improves symptoms but increases the risk of infection and doesn't improve prognosis
* Pentoxyphylline sometime used
89
Clinical features of hepatic encephalopathy?
* Confusion, altered GCS
* Asterixis - "liver flap"
* Apraxia (e.g. can't draw a 5-pointed star)
* Likely jaundiced
90
Investigation and diagnosis of hepatic encephalopathy?
* Investigations
* Check for infection (e.g. FBC)
* Abdominal x-ray (?constipation)
* PR examination & stool sample (?GI bleed)
* EEG
* Diagnosis
* Usually clinical diagnosis, investigations help identify precipitating factor
91
Grading of hepatic encephalopathy?
1. Irritability
2. Confusion, inappropriate behaviour
3. Incoherent, restless
4. Coma
92
Management of hepatic encephalopathy?
* Lactulose 1st line - increases GI clearance of ammonia, decreasing absorption
* Rifaximin - antibiotic that alters gut fauna, decreasing ammonia production
* Liver transplantation if the above fail
93
What is Budd-Chiari syndrome?
* Hepatic vein thrombosis
* Causes triad of symptoms:
* Abdominal pain: sudden onset, severe
* Ascites → abdominal distension
* Tender hepatomegaly
94
Diagnosis of Budd-Chiari syndrome?
Ultrasound with doppler flow studies
