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general surgery in gi tract Flashcards

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1
Q

what is the general approach to a presenting complaint

acute abdomen

A 
pain assessment - SOCRATES
associated symptoms
pmhx
dhx
shx
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2
Q

what are the general investigations for acute abdomen

A 
bloods: vbg,fbc,crp,u&e,lfts and amylase
urinalysis
imaging - erect and urine mc&s
cxr,axr,ctap,ct,angiogram,uss
endoscopy
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3
Q

how to manage acute abdomen

A

ABCDE approach
conservative management?
surgical management?

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4
Q

what is the general presentation for bowel ischaemia

A

sudden onset crampy abdo pain
severity of pain depends on length and thickness of colon affected
blood,loose stools
fever,signs of septic shock

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5
Q

what are the risk factors for bowel ischaemia

A 
age >65yr
cardiac arythmias, atherosclerosis
hypercoagulation, thrombophilia
vasculitis
scd
profound shock causing hypotension
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6
Q

how is acute mesenteric ischaemia different to ischaemic colitis

A

occurs in small bowel
usually occlusive due to thromboemboli
sudden onset - presentation and severity varies
abdo pain out of proportion of clinical signs

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7
Q

how is ischaemic colitis different to acute mesenteric ischaemia

A

occurs in large bowel
usually due to non occlusive low flow states/atherosclerosis
more mild and gradual
moderate pain and tenderness

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8
Q

what would you expect to see in the fbc of bowel ischaemia

A

neutrophilic leukocytosis

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9
Q

what would you expect to see in the vbg of bowel ischaemia

A

lactic acidosis

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10
Q

what might you see in a ctpap or ct angiogram of someone with bowel ischaemia

A

disrupted flow
vascular stenosis
‘pneumatosis intestinalis’ - transmural ischaemia/infarction
ischaemic colitis - thumbprint sign

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11
Q

when might you use endoscopy in someone with bowel ischaemia

A

for mild/moderate causes of ischaemic colitis

oedema, cyanosis, ulceration of mucosa

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12
Q

what is the conservative management for bowel ischaemia

A 
iv fluid resusitation
bowel rest
broad spectrum antibiotics( colonic ischaemia can result in bowel translocation + sepsis)
ng tube for decompression
treat/manage underlying cause
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13
Q

what are the indications for surgical management of bowel ischaemia

A 
small bowel ischaemia
signs of peritonitis/sepsis
haemodynamic instability
massive bleeding
fulminant colitis with toxic megacolon
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14
Q

what is the surgical management of bowel ischaemia

A

exploratory laparotomy - resection of necrotic bowel +- open surgical embolectomy or mesenteric arterial bypass
endovascular revascularisation - balloon angioplasty/thrombectomy
in patients without signs of ischaemia

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15
Q

typical presentation of appendicitis

A

initially periumbilical pain that migrates to RLQ (within 24hrs)
anorexia, nausea +- vomiting, low grade fever, change in bowel habit

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16
Q

what are the important signs of appenditicitis

A

mcburneys point - tenderness in rlq
blumbeg sign - tenderness expecially in rif
rovsing sign - rlq pain elicited on deep palpation of llq
psoas sign - rlq pain elicited on flexion of right hip against resistance
obturator sign - rlq pain on passive internal rotation of hip with hip and knee rotation

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17
Q

what would you expect to see on blood of one with appendicitis

A

fcb - neutrophilic leukocytosis
elevated crp
urinalysis - possible mild pyuria/haematuria
electrolyte imbalances in profound vomiting

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18
Q

what imaging techniques would be used for appendicitis

A

ct - gold standard in adults esp if age >50
uss - for children/pregnancy,breastfeeding
mri - in pregnancy if uss inconclusive

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19
Q

when might you use a diagnostic laparoscopy in appendicitis

A

if in persistent pain and inconclusive imaging

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20
Q

what scale is used for severity of appendicitis

A 
alvarado score:
rlq tenderness
fever
rebound tenderness
pain migration
anorexia
nausea and vomiting
wcc
neutrophilia
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21
Q

what is the conservative management for acute appendicitis

A

iv fluids
analgesia
iv/po antibiotics
in abscess,phlegmon or sealed perforation - resuscitation and iv antibiotics +- percutaneous drainage

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22
Q

what are the indications for conservative management of acute appendicitis

A

after negative imaging in selected patients with clinically umcomplicated appendicitis
in delayed presentation with abscess/phlegmon formation - ct guided drainage
*consider interval appendicetomy - rate of recurrence after conservative management of abscess/perforation is 12-24%

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23
Q

why is laparoscopic preferred over open appendicetomy

A 
less pain
lower incidence of surgical site infection
decreased length of hospital stay
earlier return to work
overall costs
better quality of life scores
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24
Q

what are the steps in laparoscopic appendicetomy

A
  1. trocar placement - usually 3
  2. exploration of rif and identification of appendix
  3. elevation of appendix and division of mesoappendix(containing artery)
  4. base secured with endoloops and appendix is divided
  5. retrieval of appendix with plastic retrieval bag
  6. careful inspection of rest of pelvic organs/intestines
  7. pelvic irrigation and haemostasis
  8. removal of trocars and wound closure
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25
what is intestinal obstruction
restriction of normal passage of intestinal contents 2 main groups: paralytic(adynamic) ileus mechanical
26
how is mechanical obstruction classified
speed of onset: acute,chronic, acute on chronic site; high/low nature: simple/stangulating aetiology
27
what are the different causes of bowel obstruction in lumen
faecal impaction | gallstone 'ileus'
28
what are the causes in wall in bowel obstruction
chrons disease, tumours, diverticulitis of colon
29
what are the causes of bowel obstruction outside the wall
``` strangulated hernia (external/internal) volvulus obstruction due to adhesions/ bands ```
30
what is meant by simple bowel obstruction
bowel is occluded without damage to blood supply
31
what is meant by strangulating bowel obstruction
blood supply of involved segment of intestine is cut off | e.g strangulated hernia, volvulus, intussusception
32
what are some causes of small bowel obstruction
adhesions (60%) - hx of previous abdominal surgery neoplasia(20%) - primary,metastatic, extraintestinal incarcerated hernia chrons disease other e.g intussesception, foreign body,bezoar
33
what are some causes of large bowel obstruction
colorectal carcinoma volvulus - sigmoid, caecal diverticulitis - inflammation, strictures faecal impaction hirschsprung disease - commonly found in infants
34
what is the presentation of small bowel obstruction
colicky and central abdominal pain early onset of vomiting, large amounts and bilious constipation is a late sign less significant abdominal distention other signs: dehyration, increased high pitched tinkling bowel sounds, absent bowel sounds(late) diffuse abdominal tenderness
35
what is the presentation of large bowel obstruction
colicky or constant abdo pain late onset vomiting, initially bilious and progresses to faecal vomiting constipation is early sign abdominal distention is an early sign and significant other signs: dehyrdration, increased high pitched tinkling bowel sounds / absent bowel sounds(late) diffuse abdominal tenderness
36
how to diagnose bowel obstruction
- diagnosed by presnece of symptoms examinatio should always include search for hernias and abdo scars, incl laparoscopic portholes is it simple/strangulating
37
what are some features suggesting strangulation
``` change in character of pain from colicky to continuous tachycardia pyrexia peritonism bowel sounds absent/reduced leucocytosis elevated crp ```
38
where are common hernial sites
``` epigatric umbilical incisional inguinal femoral ```
39
bloods for bowel obstruction
wcc/crp usually normal u&e - electrolyte imbalance vbg - if vomiting hypocl-/k+ , metabolic alkalosis vbg if strangulation
40
imaging for bowel obstruction
erect cxr/axr sbo - dilated small bowel loops >3cm proximal to obstruction lbo - dilated large bowel >6cm ct abdo/pelvis
41
what would you see in an abdo x ray in small bowel obstruction
ladder pattern of dilated loops and their central position | striations that pass completely across width of distended loop produced by circular mucosal folds
42
what would you see in abdo xray in large bowel obstruction
distended large bowel tends to lie peripherally | show haustrations of taenia coli - do not extend across whole width of bowel
43
why is a ct scan useful in bowel obstruction
Can localize site of obstruction Detect obstructing lesions & colonic tumours May diagnose unusual hernias (e.g. obturator hernias).
44
supportive management in bowel obstruction
In patients with no signs of ischaemia/no signs of clinical deterioration Supportive management  NBM, IV peripheral access with large bore cannula - IV Fluid resuscitation IV analgesia, IV antiemetics, correction of electrolyte imbalances NG tube for decompression, urinary catheter for monitoring output Introduce gradual food intake if abdominal pain and distention improve
45
conservative treatment of bowel obstruction
Faecal impaction: stool evacuation (manual, enemas, endoscopic) Sigmoid volvulus: rigid sigmoidoscopic decompression SBO: oral gastrograffin (highly osmolar iodinated contrast agent) can be used to resolve adhesional small bowel obstruction
46
indications for surgical management of bowel ostruction
Haemodynamic instability or signs of sepsis Complete bowel obstruction with signs of ischaemia Closed loop obstruction Persistent bowel obstruction >2 days despite conservative management 
47
what are the operations for bowel obstruction
Exploratory laparotomy/Laparoscopy  Restoration of intestinal transit (depending on intra-operational findings) Bowel resection with primary anastomosis or temporary/permanent stoma formation or endoscopic stenting if obstruction is distal
48
how do gi perforations present
sudden onset severe abdominal pain associated with distention diffuse abdominal guarding, rigidity and rebound tenderness pain aggravated by movement nausea, vomiting, absolute constipation fever, tachycardia, tachypnoea, hypotension decreased or absent bowel sounds
49
what is the presentation of perforated peptic ulcer
sudden epigastric/diffuse pain referred shoulder pain - history of NSAIDs,steroids, recurrent epigastric pain
50
what is the presentation of perforated diverticulum
llq pain | constipation
51
what is the presentation of perforated appendix
migratory pain anorexia gradual worsening rlq pain
52
what is the presentation of perforated malignancy
change in bowel habit weight loss anorexia pr bleeding
53
blood investigations for gi perforation
fbc: neutrophilic leukocytosis possible elevation of urea and creatine vbg - lactic acidosis
54
what imaging is used to investigate gi perforations
erect cxr - check for subdiaphragmatic free air (pneumoperitoneum) ct abdo/pelvis - pneumoperitoneum, free gi content, localised mesenteric fat stranding - can exclude common differential diagnoses e.g pancreatitis
55
what are some differential diagnosis for gi perforation
acute cholecystitis appendicitis mi acute pancreatitis
56
what is the supportive management for gi perforations on presentation
``` nbm and ng tube iv peripheral access with large bore canuula - iv fluid resuscitation broad spectrum antibiotics iv ppi paraenteral analgesia and amt emetics urinary catheter ```
57
what is the conservative management in localised peritonitis without signs of sepsis * very rare
ir - guided drainage of intraabdominal collection | serial abdominal examination and abdominal imaging for assessment
58
surgical management in generalised peritonitis +- signs of sepsis
exploratory laparotomy/ laparoscopy primary closure of perforation with/without omental patch resection of perforated segment of bowel with primary anastmosis/temporary stoma obtain intra abdominal fluid for mc and s, peritoneal lavage
59
what is the surgery for perforated appendix
laparoscopy or open appendicectomy
60
what is the surgical management for malignancy in gi perforation
intraoperative biopsies if possible
61
symptoms of biliary colic
postprandial ruq pain with radiation to shoulder | nausea
62
expect to see in investigations of biliary colic
normal blood results | uss: cholelithiasis
63
symptoms of acute cholecystitis
acute, severe ruq pain fever murphys sign
64
what would you expect to see in investigations of acute cholecystitis
elevated wcc/crp | uss - thickened gallbladder wall
65
how to manage acute cholecystitis
``` fluids antibiotics analgesia blood cultures early or elective cholecystectomy (4-6wks) ```
66
symptoms of acute cholangitis
charcots triad: jaundice, ruq pain and fever
67
what would you expect to see in investigations of acute cholangitis
elevated lfts,wcc,crp, blood mcs (positive) | uss: biliary dilation
68
management of acute cholangitis
fluids iv antibiotics analgesia ercp within 72hrs for clearance of bileduct/stenting
69
what are the symptoms of acute pancreatitis
severe epigastric pain radiating to back nausea +- vomiting history of gallstones and ethanol use
70
what do you expect to find in investigations for acute pancreatitis
raised amylase/lipase high wcc/ low calcium ct and us to assess for complications/cause
71
what is the management for acute pancreatitis
admission score - glasglow imrie aggressive fluid resusitation,o2 analgesia and antiemetics itu/hdu involvement

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