General Surgery in GI tract

Question 1

When checking for acute abdomen, how do you take a pain assessment and what else do you checkl

Answer 1

SOCRATES:
Site
Onset
Character
Radiation
Association
Time course
Exacerbating/Relieving factors
Severity

PMH

DH

SH

Question 2

What are investigations for acute abdomen

Answer 2

Bloods: VBG, FBC, CRP, U&Es (renal profile), LFTs +amylase
Urinalysis + Urine MC&S
Imaging: Erect CXR, AXR, CTAP, CT angiogram, USS
Endoscopy

Question 3

What is the management for acute abdomen

Answer 3

ABCDE approach
Conservative management
Surgical management

Question 4

What is the presentation of bowel ischaemia?

Answer 4

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

Question 5

What are the risk factors for bowel ischaemia?

Answer 5

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

Question 6

What is the difference between acute mesenteric ischaemia and ischaemic colitis

Answer 6

Acute/colitis

Small bowel
Occlusive due to thromboemboli / non-occlusive local flow states, or atherosclerosis
Sudden onset
Abdominal pain out of proportion of clinical signs/ moderate and tenderness

Question 7

What investigations can you do for bowel ischaemia

Answer 7

Bloods
Imaging - CTAP/ CT Angiogram
Endoscopy

Question 8

What are you checking for in bloods for bowel ischaemia

Answer 8

FBC: neutrophilic leukocytosis
VBG: Lactic acidosis (late sign so bowel already dead)

Question 9

What are you trying to detect in imaging for bowel ischaemia

Answer 9

Disrupted flow
Vascular stenosis
‘Pneumatosis intestinalis’ (transmural ischaemia/infarction)
Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)

Question 10

What is the purpose of endoscopy in bowel ischaemia

Answer 10

For mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)

Question 11

What does the conservative management of bowel ischaemia in mild to moderate cases of ischaemic colitis (not SB ischaemia)

Answer 11

IV fluid resuscitation
Bowel rest
Broad-spectrum ABx - colonic ischaemia can result in bacterial translocation & sepsis
NG tube for decompression - in concurrent ileus
Anticoagulation
Treat/manage underlying cause
Serial abdominal examination and repeat imaging

Question 12

What are the indications of bowel ischaemia in surgical management

Answer 12

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

Question 13

What do you do in surgical management for bowel ischaemia

Answer 13

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

Question 14

How is acute appendicitis presented and what are the clinical signs

Answer 14

Initially periumbilical pain that migrates to RLQ (within 24hours)
Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit

Important clinical signs:
McBurney’s point: tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
Blumberg sign: rebound tenderness especially in the RIF
Rovsing sign: RLQ pain elicited on deep palpation of the LLQ
Psoas sign: RLQ pain elicited on flexion of right hip against resistance
Obturator sign: RLQ pain on passive internal rotation of the hip with hip & knee flexion

Question 15

What are the investigations for acute appendicitis

Answer 15

Bloods
Imaging
Diagnostic laparoscopy

Question 16

What do bloods show with acute appendicitis

Answer 16

FBC: neutrophilic leukocytosis
↑ed CRP
Urinalysis: possible mild pyuria/haematuria
Electrolyte imbalances in profound vomiting

Question 17

Wha are type of imagining for investigating acute appendicitis

Answer 17

CT: gold standard in adults esp. if age > 50
USS: children/pregnancy/breastfeeding
MRI: in pregnancy if USS inconclusive

Question 18

What is the purpose of diagnostic laparoscopy

Answer 18

If it is hard to tell and there is persistent pain and inconclusive imagining

Question 19

What is the Alvarado score

Answer 19

RLQ tenderness
Fever
Rebound tenderness
Pain migration
Anorexia
Nausea +/ vomitting
WCC>10.000
Neutrophilia

5-6 possible

Question 20

What does the conservative management of acute appendicitis consist of**

Answer 20

Consists of:
IV Fluids, Analgesia, IV or PO Antibiotics
In abscess, phlegmon or sealed perforation
–Resuscitation + IV ABx +/- percutaneous drainage

Indications:
After negative imaging in selected patients with clinically uncomplicated appendicitis
In delayed presentation with abscess/phlegmon formation
CT-guided drainage

Consider interval appendicectomy - rate of recurrence after conservative management of abscess/perforation is 12-24%

Question 21

What is the surgical management of acute appendicitis

Answer 21

Laparoscopic vs Open 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

Question 22

What is bowel obstruction and what are the types

Answer 22

Intestinal obstruction - restriction of normal passage of intestinal contents.
Two main groups:
Paralytic (Adynamic) ileus (functional)
Mechanical.

Question 23

Explain how mechanical bowel obstruction is classified

Answer 23

Speed of onset: acute, chronic, acute-on-chronic

Site: high or low
—roughly synonymous with small or large bowel obstruction

Nature: simple vs strangulating
—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)

Aetiology:
Causes in the lumen - faecal impaction, gallstone ‘ileus’
Causes in the wall - Crohn’s disease, tumours, diverticulitis of colon
Causes outside the wall –
–Strangulated hernia (external or internal)
–Volvulus
—Obstruction due to adhesions or bands.

Question 24

Aetiology between small bowel obstruction and large bowel

Answer 24

Small Bowel Obstruction
Adhesions (60%)
Hx of previous abdominal surgery

Neoplasia (20%)
Primary, Metastatic, Extraintestinal

Incarcerated hernia (10%)
External (abdominal wall), Internal (mesenteric defect)

Crohn’s Disease (5%)
Acute (oedema), Chronic (strictures)

Other (5%)
Intussusception, intraluminal (foreign body, bezoar)

Large Bowel Obstruction
Colorectal carcinoma

Volvulus
Sigmoid, Caecal

Diverticulitis
Inflammation, strictures

Faecal impaction

Hirschsprung disease
commonly found in infants/children

Question 25

How is bowel obstruction presented between small and large**

Question 26

How to diagnose bowel obstruction

Answer 26

3x Important points to remember about intestinal 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?

Question 27

What are features suggesting strangulation ?

Answer 27

Change in character of pain from colicky to continuous Tachycardia Pyrexia Peritonism Bowel sounds absent or reduced Leucocytosis ↑ed C-reactive protein

Question 28

What is an example of a hernia without obstruction

Answer 28

Richters Hernia

Question 29

What are the investigations for bowel obstruction

Answer 29

Bloods: 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) Imaging: 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

Question 30

What is shown on an abdominal xray for small bowel obstruction

Answer 30

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

Question 31

What is shown on an abdominal xray for large bowel obstruction

Answer 31

Distended large bowel tends to lie peripherally Show haustrations of taenia coli - do not extend across whole width of the bowel.

Question 32

What is the purpose of a CT scan in bowel obstruction What can is show

Answer 32

Can localize site of obstruction Detect obstructing lesions & colonic tumours May diagnose unusual hernias (e.g. obturator hernias). Collapsed & dilated loops of small bowel due to transition point in the pelvis Sigmoid stricture with proximal dilation

Question 33

What is supportive management of bowel obstruction

Answer 33

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

Question 34

What is conservative treatment in patients with bowel obstruction

Answer 34

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

Question 35

What are indication for surgical management of bowel obstruction

Answer 35

Haemodynamic instability or signs of sepsis Complete bowel obstruction with signs of ischaemia Closed loop obstruction Persistent bowel obstruction >2 days despite conservative management 

Question 36

What are operations for bowel obstruction

Answer 36

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)

Question 37

What is the presentation of GI perforation

Answer 37

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

Question 38

What are different signs for different perforations**

Question 39

What are the investigations for GI perforation

Answer 39

Bloods FBC: neutrophilic leukocytosis Possible elevation of Urea, Creatinine VBG: Lactic acidosis Imaging 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

Question 40

What are differential diganosis for GI perforation

Answer 40

Acute cholecystitis, Appendicitis. Myocardial infarction, Acute pancreatitis

Question 41

What does supportive on management of GI perforation involve

Answer 41

NBM & NG tube IV peripheral access with large bore cannula - IV Fluid resuscitation Broad spectrum Abx IV PPI Parenteral analgesia & antiemetics Urinary catheter 

Question 42

What does conservative management in localised peritonitis without signs of sepsis involve

Answer 42

Very rare: IR - guided drainage of intra-abdominal collection Serial abdominal examination & abdominal imaging for assessment

Question 43

What does surgical management for GI perforation involve

Answer 43

Surgical management in generalised peritonitis +/- signs of sepsis: 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

Question 44

What conservative management is effective in treating the majority of patients with a sigmoid volvulus?

Answer 44

A sigmoidoscope is passed with the patient lying in the left lateral position. A large well lubricated, soft rubber rectal tube is passed along the sigmoidoscope. This usually untwists the volvulus, with release of vast quantities of flatus & liquid faeces.

Question 45

What is portal pyaemia

Answer 45

Portal pyaemia (pylephlebitis): Form of septic (often suppurative) thrombophlebitis of the portal venous system Complication of intra-abdominal sepsis --Diverticulitis ---Appendicitis Air in SMV & intrahepatic portal venous system

Question 46

What are the biliary and pancreatic causes of acute abdomen?**-