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general GI surgery Flashcards

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1
Q

what does tinkling or high pitched bowel sounds indicate

A

Small bowel obstruction

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2
Q

Management options for acute Abdo

A

ABCDE approach
supportive management
conservative management
surgical management

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3
Q

Potential problems causing RUQ pain:

A
  1. biliary colic
  2. Cholecystitis/cholangitis
  3. duodenal ulcers
  4. liver abscess
  5. portal vein thromobsis
  6. acute hepatitis
  7. nephrolithiasis
  8. RLL pneumonia
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4
Q

Potential problems causing RLQ pain:

A
  1. acute appendicitis
  2. colitis
  3. IBD
  4. infectious colitis
  5. ureteric stone/polynephritis
  6. PID/ovarian torsion
  7. ectopic pregnancy
  8. malignancy
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5
Q

Potential problems causing Epigastrium pain:

A
  1. acute gastritis/GORD
  2. gastroparesis
  3. peptic ulcer disease/perforation
  4. acute pancreatitis
  5. mesenteric ischaemia
  6. AAA
  7. Aortic dissection
  8. MI
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6
Q

Potential problems causing suprapubic/central pain:

A 
early appendicitis
mesenteric ischaemia
bowel obstruction
bowel perforation
constipation
gastroenteritis
UTI/urinary retention
PiD
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7
Q

Potential problems causing LUQ pain:

A 
peptic ulcer
acute pancreatitis
splenic abscess/ splenic infarction
nephrolithiasis
LLL pneumonia
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8
Q

Potential problems causing LLQ pain

A 
diverticulitis
colitis
IBD
infectious colitis
ureteric stone/polynephritis
PID/ovarian torsion
Ectopic pregnancy
Malignancy
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9
Q

presentation of bowel ischaemia - symptoms and signs

A
  1. sudden onset crampy abdo pain
  2. severity of pain depends on length and thickness of abdo affected
  3. Bloody, loose stool (currant jelly)
  4. Fever, signs of septic shock
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10
Q

risk factors for bowel ischaemia

A 
age>65
cardiac arrythmias
hypercoagulation/thrombophilia
vasculitis
sickle cell disease
profound shock causing hypotension
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11
Q

which bowel does acute mesenteric ischaemia affecT

A

small

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12
Q

which bowel does ischaemic colitis affect

A

large

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13
Q

is acute mesenteric ischaemia occlusive/nonocclusive

A

usually occlusive due to thromboembol

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14
Q

is ischaemic colitis occlusive/nonocclusive

A

usually due to non-occlusive low flow states, or atherosclerosis

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15
Q

time onset of acute mesenteric ischaemia

A

sudden (presentation and severity varies)

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16
Q

time onset of ischaemic colitis

A

more mild and gradual usually

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17
Q

physical examination pain for acute mesenteric ischaemia

A

abdo pain out of proportion of clinical signs

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18
Q

pain rating for ischaemic colitis

A

moderate pain and tenderness

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19
Q

conservative management for mild/moderate ischaemic colitis

A
  • IV fluid resuscitation
  • bowel rest
  • broad spec ABx - colonic ischaemia can result in bacterial translocation + sepsis
  • NG tube for decompression: in concurrent ileus
  • anticoag
  • treat/manage underlying cause
  • serial abdo exam + repeat imaging
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20
Q

indications of surgery for bowel ischaemia

A

any small bowel ischaemia - straight to surgery

signs of peritonitis/sepsis
haemodynamic instability
massive bleeding
fulminant colitis with toxic megacolon

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21
Q

who is endovascular revascularisation offered to

A

patient without signs of ischaemia

-> balloon angioplasty/thrombectomy

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22
Q

where is presenting pain in acute appendicitis

A

periumbilical pain that migrates -> RLQ

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23
Q

symptoms appendicitis associated with

A

anorexia!
nausea/vom
low grade fever
change in bowel habit

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24
Q

important signs in acute appendicitis

A
  • Mcburney’s point
  • Blumberg sign
  • Rovsing sign
  • Psoas sign
  • Obturator sign
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25
What is Mcburney's point?
tenderness in the RLQ | 1/3 from ASIS to umbilicus
26
blumberg sign
acute appendicitis | rebound tenderness in right iliac fossa
27
Rovsing sign
RLQ pain elicited by deep palpation of LLQ
28
psoas sign
RLQ pain elicited on flexion of right hip against resistance
29
obturator sign
RLQ pain on passive internal rotation of the hip with hip+knee flexion
30
imaging for acute appendicitis investigations
CT (gold standard in adults esp if age > 50) - USS kids/preg/breastfeeding - MRI in pregn if USS inconclusive
31
when would you do a diagnostic laparoscopy for acute appendicitis investigation?
persistent pain + inconclusive imaging
32
what score is used to determine likelihood of acute appedncitis
ALVARADO SCORE
33
conservative management of acute appendicitis
IV fluids, analgesia, IV antibiotics | in abscess/phlegmon/sealed perforation -> resuscitation + IV AB +/- percutaneous drainage
34
indications for conservative management of acute appendicitis
- ve imaging in selected patients with clinically uncomplicated appendicitis - in delayed presentation with abscess/phlegmon formation (trying to take out appendix would be v hard) - > CT guided drainage - > revisit later to do interval appendicectomy
35
laparoscopic vs open appendicectomy
``` less pain lower incidence of surgical site infection decreased length hospital stay earlier return to work less overall cost better QoL scores ```
36
features used to classify mechanical intestinal obstruction
speed of onset nature aetiology
37
the two natures of mechanical bowel obstruction are:
1. simple (occluded without damage to blood supply) 2. strangulating (blood supply involved segment of intestine is cut off e.g. strangulated hernia, volvulus, intussusception)
38
luminal causes of bowel obstruction
faecal impaction | gallstone 'ileus'
39
wall causes of bowel obstruction
crohn's tumours diverticulitis of the colon
40
outside of wall causes of bowel obstruction
- strangulated hernia (ext/int) - volvulus - obstruction due to adhesions/bands
41
what is described as the restriction of normal passage of intestinal contents?
intestinal obstruction
42
Two main groups of bowel obstruction
- paralytics (adynamic) ileus | - mechanical
43
causes of small bowel obstruction
``` 1 adhesions 2 neoplasia 3 incarcerated hernia 4 crohns disease other ```
44
5 cause of large bowel obstruction
``` colorectal carcinoma volvulus diverticulitis faecal impaction hirschprung disease ```
45
3 points to remember about bowel obstruction
diagnosed by presence of symptoms examination should always include a search for hernias/abdominal scars simple or strangulating?
46
features suggesting strangulating bowel obstruction
``` change in character of pain from colicky -> continuous bowel sounds absent/reduced tachycardia pyrexia peritonism leucocytosis increased c reactive protein ```
47
what would a VBG show in a strangulated obstruction
metabolic acidosis due to lactate
48
imaging for bowel obstruction
erect CXR | Ct abdo/pelvis
49
small bowel obstruction X ray findings
``` dilated small bowel loops shows striations (ladder pattern) ```
50
large bowel obstruction x ray findings
dilated large bowel usually not central show striations only at sides of bowel not middle (tenia coli)
51
when to decide conservative management of bowel obstruction
patients with no ischaemia or signs of clinical deterioration
52
supportive management of bowel obtruction
NBM IV access for fluids, analgesia, electrolyte balances NG tube for decompression urinary catheter for monitoring
53
conservative management of bowel obstruction caused by faecal impaction
stool evacuation - enema, endoscopic
54
conservative management for sigmoid volvulus causing bowel obstruction
rigid sigmoidoscopic decompression
55
conservative management of small bowel obstruction
oral gastrograffin for adhesions
56
indications for surgery for bowel obstruction
haemodynamically unstable complete obstruction with signs of ischaemia closed loop obstruction persistent - over 2 days despite con management
57
presentation of bowel perforation
sudden onset severe abdo pain associated with distension diffuse abdo guarding, rigidity, rebound tenderness pain aggravated by movement fever, tachycardia, tachypnoea, hypotension decreased/absent bowel sounds
58
commonest cause of GI perforation
perforated peptic ulcers
59
causes of GI perforation
peptic ulcer perf diverticulum perf appendix perf malignancy perf
60
signs of peptic ulcer perforation
sudden epigastric or diffuse pain referred shoulder pain (phrenic nerve) history of NSAIDs, steroids or recurrent epigastric pain
61
presentation of perforated diverticulum
more insidious onset LLQ pain constipation
62
presentation of perforated appendix
migratory pain anorexia gradually worsening RLQ pain
63
presentation of perforated malignancy
change in bowel habit, weight loss, anorexia in previous histories post rectal bleeding
64
blood results for GI perforation
neutrophilic leucocytosis elevated urea, creatinine VBG = lactic acidosis
65
imaging for GI perforations
Erect CXR | Ct abdo/epvis
66
signs on X ray of GI perforation
sub-diaphragmatic free air pneumoperitoneum localised mesenteric fat stranding
67
differential Dx for GI perforation
acute cholecystitis, appendicitis myocardial infarction acute pancreatitis
68
conservative management of GI perforations
``` NBM, NGT IV fluids, PPI broad spectrum antibiotics parenteral analgesia and antiemetics urinary cath ```
69
surgery for perforated peptic ulcer
primary closure +/- omental patch | resection of perforated segment, primary anastamosis or temporary stoma
70
surgery option for perforated GI
exploratory lap | obtain intrabdominal fluid for microbiology culture and screen
71
surgery for perforated appendix
lap or open appendicectomy
72
surgery for perforated malignancy
intraoperative biopsies with primary closure
73
murphys sign
acute cholecystitis | pain when palpating under costal margin right hand side and asking patient to breathe deeply
74
signs of acute cholecystitis
acute severe RUQ pain fever positive murphys sign
75
signs of biliary colic
postprandial RUQ pain with shoulder radiation | nausea
76
what is charcots triad (jaundice, RUQ pain, fever) associated with
acute cholangitis
77
signs of acute pancreatitis
severe epigastric pain radiating to back nausea/vom history of gallstones or alcohol
78
investigation findings for biliary colic
normal bloods | ultrasound shows cholelithiasis
79
investigation findings for acute cholecystitis
elevated WCC and CRP | ultrsound thickened gallbladder wall
80
investigation findings for acute cholangitis
elevated LFTs, WCC, CRP, blood cultures positive | ultrasound biliary dilatation
81
management of biliary colic
analgesia antiemetics spasmolyitics followup elective cholecystectomy
82
management for acute cholecystitis
``` fluids antibiotics analgesia blood cultures early or elective cholecystectomy ```
83
management of acute cholangitis
fluids IV antibiotics analgesia ECRP for bile duct clearance or stenting
84
management for acute pancreatitis
glasgow admission score aggressive fluid resus analgesia, antiemetics ICU involvement
85
approach to an acute abdomen
ABCDE | then SOCRATES history

BRS Year 2 (67 decks)

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