General Surgery in the Gastrointestinal Tract Flashcards
(141 cards)
1
Q
What is the general approach when a patient initially presents with acute abdominal pain?
A
- Pain assessment
- PMH
- DHx
- SHx
- investigations
- management
2
Q
What are the different possible investigations when someone presents with acute abdominal pain?
A
- bloods
- urinalysis
- imaging
- endoscopy
3
Q
What are the different possible bloods when someone presents with acute abdominal pain?
A
- VBG
- FBC
- CRP
- U+Es
- LFTs
- Amylase
4
Q
What is the different possible imaging when someone presents with acute abdominal pain?
A
- erect CXR
- AXR
- CTAP
- CT angiogram
- USS
5
Q
What are the different possible forms of management when someone presents with acute abdominal pain?
A
- ABCDE approach
- Conservative management
- Surgical management
6
Q
What are the possible differential diagnosis for Right Upper Quadrant pain?
A
- Bilary Colic
- Cholecystitis/Cholangitis
- Duodenal Ulcer
- Liver abscess
- Portal vein thrombosis
- Acute hepatitis
- Nephrolithiasis
- RLL pneumonia
7
Q
What are the possible differential diagnosis for Right Lower Quadrant pain?
A
- Acute Appendicitis
- Colitis
- IBD
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
8
Q
What are the possible differential diagnosis for Epigastric pain?
A
- Acute gastritis/GORD
- Gastroparesis
- Peptic ulcer disease/perforation
- Acute pancreatitis
- Mesenteric ischaemia
- AAA (Abdominal Aortic Aneurysm)
- Aortic dissection
- Myocardial infarction
9
Q
What are the possible differential diagnosis for Suprapubic/Central pain?
A
- Early appendicitis
- Mesenteric ischaemia
- Bowel obstruction
- Bowel perforation
- Constipation
- Gastroenteritis
- UTI/Urinary retention
- PID
10
Q
What are the possible differential diagnosis for Left Upper Quadrant pain?
A
- Peptic ulcer
- Acute pancreatitis
- Splenic abscess
- Splenic infarction
- Nephrolithiasis
- LLL Pneumonia
11
Q
What are the possible differential diagnosis for Left Lower Quadrant pain?
A
- Diverticulitis
- Colitis
- IBD
- Infectious colitis
- Ureteric stone/Pyelonephritis
- PID/Ovarian torsion
- Ectopic pregnancy
- Malignancy
12
Q
How does bowel ischaemia present?
A
- 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
13
Q
What are the risk factors of bowel ischaemia?
A
- Age >65 yr
- Cardiac arrythmias (mainly AF), atherosclerosis
- Hypercoagulation/thrombophilia
- Vasculitis
- Sickle cell disease
- Profound shock causing hypotension
14
Q
Which part of the bowel tends to be affected by acute mesenteric ischaemia?
A
small bowel
15
Q
Which part of the bowel tends to be affected by ischaemic colitis?
A
large bowel
16
Q
What is the onset of acute mesenteric ischaemia?
A
sudden (presentation and severity varies)
17
Q
What is the clinical presentation of acute mesenteric ischaemia?
A
abdominal pain out of proportion of clinical signs
18
Q
What tends to cause acute mesenteric ischaemia?
A
occlusive due to thromboemboli
19
Q
What is the onset of ischaemic colitis?
A
mild and gradual (80-85% of cases)
20
Q
What is the clinical presentation of ischaemic colitis?
A
moderate pain and tenderness
21
Q
What tends to cause ischaemic colitis?
A
due to non-occlusive low flow states or atheroscleroiss
22
Q
What will the bloods show in bowel ischaemia?
A
FBC - neutrophilic leukocytosis
VBG - lactic acidosis
23
Q
What imaging should be done if bowel ischaemia is suspected?
A
- CTAP
- CT angiogram
24
Q
What can be seen on a CTAP/CT angiogram?
A
- disrupted flow
- vascular stenosis
- transmural ischaemia/infarction
- thumbprint sign (colitis)
25
What can be seen on an endoscopy with bowel ischaemia?
- oedema
- cyanosis
- ulceration of mucosa
26
What is the conservative management for mild/moderate cases of ischaemic colitis?
- IV fluid resuscitation
- Bowel rest
- Broad-spectrum ABx
- NG tube
- Anti-coagulation
- Treat/manage underlying cause
- Serial abdominal examination and imaging
27
Why is ABx given in ischaemic colitis?
colitis ischaemia can cause bacterial translocation and sepsis
28
What are the indications for surgical management of bowel ischaemia?
- small bowel ischaemia
- signs of peritonitis or sepsis
- haemodynamic instability
- massive bleeding
- fulminant colitis with toxic megacolon
29
What are the 2 surgical options for bowel ischaemia?
- exploratory laparotomy
| - endovascular revascularisation
30
What is involved in a exploratory laparotomy?
Resection of necrotic bowel +/- open surgical embolectomy or mesenteric arterial bypass
31
What is involved in a endovascular revascularisation?
- Balloon angioplasty/thrombectomy
| - In patients without signs of ischaemia
32
How does acute appendicitis present?
- initially periumbilical pain that migrates to the RLQ (within 24 hours)
- anorexia
- nausea (+/- vomiting)
- low grade fever
- change in bowel habit
33
Where is McBurney's point?
tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
34
Where is Blumberg point?
rebound tenderness especially in the RIF
35
Where is Rovsing point?
RLQ pain elicited on deep palpation of the LLQ
36
Where is Psoas point?
RLQ pain elicited on flexion of right hip against resistance
37
Where is Obturator point?
RLQ pain on passive internal rotation of the hip with hip & knee flexion
38
What are the possible investigations for suspected appendicitis?
- bloods
- imaging
- diagnostic laparoscopy
39
What would the bloods show in acute appendicitis?
- FBC: neutrophilic leukocytosis
- high CRP
- urine: mild pyuria/haematuria
- electrolyte imbalances due to vomiting
40
What imaging is done in suspected acute appendicitis?
- CT
- USS
- MRI
41
When is a CT done in suspected acute appendicitis
gold standard in adults (>50)
42
When is a USS done in suspected acute appendicitis
- children
- pregnancy
- breastfeeding
43
When is a MRI done in suspected acute appendicitis
in pregnancy if the USS is inconclusive
44
When would you do a diagnostic laparoscopy?
- in persistent pain
| - inconclusive imaging
45
What is the conservative management plan for acute appendicitis?
- IV fluids
- analgesia
- IV or PO ABx
In abscess: plegmon or sealed perforation
- resuscitation
- IV ABx
- +/- percutaneous drainage
46
What are the indications for conservative management of appendicitis
- After negative imaging in selected patients with clinically uncomplicated appendicitis
- In delayed presentation with abscess/phlegmon formation
(CT-guided drainage)
47
Why would you consider a interval appendicectomy?
rate of recurrence after conservative management of abscess/perforation is 12-24%
48
Why is a laparoscopic appendicectomy preferred over open?
- less pain
- low risk of site infection
- reduced length of hospital stay
- earlier return to work
- overall costs
- better QOL
49
What are the steps of a laparoscopic addendicectomy?
1 - Trocar placement (usually 3)
2 - Exploration of RIF & identification of appendix
3 - Elevation of appendix + division of mesoappendix (containing artery)
4 - Based secured with endoloops and appendix is divided
5 - Retrieval of appendix with a plastic retrieval bag
6 - Careful inspection of the rest of the pelvic organs/intestines
7 - Pelvic irrigation (wash out) + Haemostasis
8 - Removal of trocars + wound closure
50
What is an intestinal obstruction?
restriction of the normal passage of intestinal contents
51
What are the 2 main types of intestinal obstructions?
- paralytic (adynamic) ileus
| - mechanical obstruction
52
What are the possible speeds of onset of a mechanical bowel obstruction?
- acute
- chronic
- acute on chronic
53
What are the possible sites of a mechanical bowel obstruction?
- high or low
| - dependent on either large or small bowel obstruction
54
What are the 2 different types of mechanical bowel obstruction?
- simple
| - strangulating
55
What happens in a simple mechanical bowel obstruction?
bowel is occluded without damage to blood supply
56
What happens in a strangulating mechanical bowel obstruction?
blood supply of the involved segment of intestine is cut off
57
What are some examples of a strangulating mechanical bowel obstruction?
- strangulated hernia
- volvulus
- intussusception
58
What are the possible places of the causes of a bowel obstruction?
- lumen
- wall
- outside the wall
59
What causes in the lumen can cause a bowel obstruction?
- faecal impaction
| - gallstone 'ileus'
60
What causes in the wall can cause a bowel obstruction?
- Crohn's disease
- tumours
- diverticulitis of the colon
61
What causes in the lumen can cause a bowel obstruction?
- Strangulated hernia (internal or external)
- Volvulus
- Obstruction due to adhesions or bands
62
What are the main causes of a small bowel obstruction?
- Adhesions (60%)
- Neoplasia (20%)
- Incarcerated hernia (10%)
- Crohn's disease (5%)
- Other (5%)
63
What are the main causes of a large bowel obstruction?
- colorectal carcinoma
- volvulus
- diverticulitis
- faecal impaction
- Hirschsprung disease (kids)
64
What sort of pain is associated with a small bowel obstruction?
- colicky
| - central
65
What sort of pain is associated with a large bowel obstruction?
- colicky
| - constant
66
What type of vomiting is associated with a large bowel obstruction?
- late onset
- initially bilious
- progression to faecal vomiting
67
What type of vomiting is associated with a small bowel obstruction?
- early onset
- large amount
- bilious
68
What type of sign is constipation in a small bowel obstruction?
late sign
69
What type of sign is constipation in a large bowel obstruction?
early sign
70
How significant is abdominal distention in a small bowel obstruction?
less significant
71
How significant is abdominal distention in a large bowel obstruction?
early sign and significant
72
What are the other signs of a bowel obstruction?
- dehydration
- diffuse abdominal tenderness
- early sign: high pitched bowel sounds
- late sign: absent bowel sounds
73
How are bowel obstructions diagnosed?
by the presence of symptoms
74
What should always be done in an abdominal exam?
search for:
- hernias
- abdominal scars (like surgical)
75
What clinical features are suggestive of strangulation?
- pain change from colicky to continuous
- tachycardia
- pyrexia
- peritonism
- absent or reduced bowel sounds
- leucocytosis
- increased CRP
76
What are the common hernia sites?
- epigastric
- umbilical
- incisional
- inguinal
- femoral
77
What are the different types of hernias?
- neck of sac
- strangulated hernia
- richter's hernia
78
What is Richter's hernia?
only part of the circumference of the intestine's antimesenteric border through a defect of the abdominal wall
79
What bloods are done in a suspected bowel obstruction?
- WCC/CRP
- U+E
- VBG (if vomiting or strangulation)
80
What would bloods show in a bowel obstruction?
WCC/CRP - normal, raised in perforation or strangulation
U+E - electrolyte imbalance
VBG (vomiting) - hypoCl-, hypoK+ and metabolic alkalosis
VBG (strangulation) - metabolic acidosis (lactate)
81
What imaging is done in a suspected bowel obstruction?
- erect CXR, AXR
| - CTAP (IV/oral contrast if possible)
82
What would you see on an erect CXR/AXR in a small bowel obstruction?
- 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
83
What would you see on an erect CXR/AXR in a large bowel obstruction?
- Distended large bowel tends to lie peripherally
| - Show haustrations of taenia coli - do not extend across whole width of the bowel
84
What would you see on an CTAP in a bowel obstruction?
- Collapsed & dilated loops of small bowel due to transition point in the pelvis
- Sigmoid stricture with proximal dilation
85
What can a CTAP do?
- Can localize site of obstruction
- Detect obstructing lesions & colonic tumours
- May diagnose unusual hernias (e.g. obturator hernias).
- May demonstrate thrombus in the mesenteric arteries & veins.
- Abnormal enhancement of bowel wall.
- Presence of embolus or infarction of other organs.
86
When would you use conservative management of a bowel obstruction?
in patients with no sign of ischaemia/no signs of clinical deterioration
87
What is the supportive management plan of a bowel obstruction?
- 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
88
What is the conservative management plan of faecal impaction?
stool evacuation (manual, enemas, endoscopic)
89
What is the conservative management plan ofsigmoid volvulus?
rigid sigmoidoscopic decompression
90
What is the conservative management plan of a small bowel obstruction?
oral gastrograffin (highly osmolar iodinated contrast agent) can be used to resolve adhesional small bowel obstruction
91
What are the indications for the surgical management of a bowel obstruction?
- Haemodynamic instability or signs of sepsis
- Complete bowel obstruction with signs of ischaemia
- Closed loop obstruction
- Persistent bowel obstruction >2 days despite conservative management
92
What are the different surgical options for a bowel obstruction?
- Exploratory Laparotomy/Laparoscopy
- Restoration of intestinal transit (depending on intra-operational findings)
- Bowel resection with primary anastomosis or temporary/permanent stoma formation
93
How does a gastric perforation present?
- Sudden onset severe abdominal pain 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
94
What are the clinical signs of a perforated peptic ulcer?
- sudden epigastric or diffuse pain
- referred shoulder pain
- Hx of NSAIDs, steroids and recurrent epigastric pain
95
What are the clinical signs of a perforated diverticulum?
- LLQ pain
| - Constipation
96
What are the clinical signs of a perforated appendix?
- Migratory pain
- Anorexia
- Gradual worsening RLQ pain
97
What are the clinical signs of a perforated malignancy?
- Change in bowel habit
- Weight loss
- Anorexia
- PR Bleeding
98
What bloods are done for a suspected GI perforation?
- FBC
- U+E
- VBG
99
What would the bloods be in a GI perforation?
FBC: neutrophilic leukocytosis
U+E: high urea and creatinine
VBG: lactic acidosis
100
What imaging is done for a suspected GI perforation?
- erect CXR
| - CTAP
101
What would an erect CXR show in a GI perforation?
subdiaphragmatic free air (pneumoperitoneum)
102
What would an erect CTAP show in a GI perforation?
- Pneumoperitoneum
- free GI content
- localised mesenteric fat stranding
(can exclude common differential diagnoses)
103
What are the possible differentials for a GI perforation?
- acute cholecystitis
- appendicitis
- myocardial infarction
- acute pancreatitis
104
What is the supportive management plan for a GI perforation?
- NBM & NG tube
- IV peripheral access with large bore cannula - IV Fluid resuscitation
- Broad spectrum Abx
- IV PPI
- Parenteral analgesia & antiemetics
- Urinary catheter
105
when is conservative management of a GI perforation used?
- localised peritonitis
| - no signs of sepsis
106
What is the conservative management plan for a GI perforation?
- IR - guided drainage of intra-abdominal collection
| - Serial abdominal examination & abdominal imaging for assessment
107
What are the indications for the surgical management of a GI perforation?
- generalised peritonitis
| - signs of sepsis
108
What are the different options of surgical management of a GI perforation?
- Exploratory laparotomy/laparascopy
- Primary closure of perforation with or without omental patch
- Resection of the perforated segment of the bowel with primary anastomosis or temporary stoma
- Obtain intra-abdominal fluid for MC&S, peritoneal lavage ++++
- Lap or open appendicectomy
- intraoperative biopsies if possible
109
What is the most common surgical management of a perforated peptic ulcer?
Primary closure of perforation with or without omental patch
110
What would be done with a perforated appendix?
Lap or open appendicectomy
111
What would be done with a perforated malignancy?
intraoperative biopsies if possible
112
What are the symptoms of biliary colic?
- Postprandial RUQ pain with radiation to the shoulder.
| - Nausea
113
What are the symptoms of acute cholecystitis?
- Acute, severe RUQ pain
- Fever
- Murphy's sign
114
What are the symptoms of acute cholangitis?
Charcot's triad:
- jaundice
- RUQ pain
- fever
115
What are the symptoms of acute pancreatitis?
- Severe epigastric pain radiating to the back
- Nausea +/- vomiting
- Hx of gallstones or EtOH use
116
What investigations are done in suspected biliary colic?
- Normal blood results
| - USS: cholelithiasis
117
What investigations are done in suspected acute cholecystitis?
- Elevated WCC/CRP
| - USS: thickened gallbladder wall
118
What investigations are done in suspected acute cholangitis?
- Elevated LFTs, WCC, CRP, - Blood MCS (+ve)
| - USS: bilary dilatation
119
What investigations are done in suspected acute pancreatitis?
- Raised amylase/lipase
- High WCC/Low Ca2+
- CT and US to assess for complications/cause
120
What is the management plan for biliary colic?
- Analgesia
- Antiemetics
- Spasmolytics
- Follow up for elective cholecystectomy
121
What is the management plan for acute cholecystitis?
- Fluids
- ABx
- Analgesia
- Blood cultures
- Early (<72 hours) or elective cholecystectomy (4-6 weeks)
122
What is the management plan for acute cholangitis?
- Fluids
- IV Abx
- Analgesia
- ERCP (within 72hrs) for clearance of bile duct or stenting
123
What is the management plan for acute pancreatitis?
- Admission score (Glasgow-Imrie)
- Aggressive fluid resuscitation,
- O2
- Analgesia
- Antiemetics
- ITU/HDU involvement
124
What are the 2 most common causes of a small bowel obstruction?
- previous abdominal operation
| - strangulated external hernia
125
What would suggest volvulus of the sigmoid colon?
- Enormously distended oval gas shadow, looped on itself (coffee bean sign)
126
What conservative management is effective in treating the majority of patients with a sigmoid volvulus?
- A sigmoidoscope with a soft rubber rectal tube is passed with the patient lying in the left lateral position.
- This usually untwists the volvulus, with release of vast quantities of flatus & liquid faeces
127
What happens if sigmoid volvulus goes untreated?
the loop of sigmoid would undergo necrosis
128
What happens next if sigmoid volvulus is not resolved by the sigmoidoscope untwisting?
Hartmann’s Procedure:
| Exploratory Laparotomy & Sigmoid Colectomy with end colostomy
129
What presentation suggests an acute mesenteric ischaemia?
- increased risk of CVD
- central pain with guarding
- no bowel sounds
- increased lactate
130
How do you treat a blockage of the SMA causing mesenteric ischaemia?
- Emergency exploratory laparotomy
- restore SMA blood flow
- resection of non-viable bowel
131
How do you surgically restore blood flow in the SMA?
- Embolectomy of SMA – in embolic AMI
- Endovascular management of SMA thrombus – in thrombotic AMI
- Arterial bypass of SMA - in thrombotic AMI
132
What happens in an exploratory laparotomy?
- Midline incision.
- Evaluate the abdominal viscera
- If obvious intestinal necrosis – resection of the affected bowel loops.
133
What happens in a damage-control laparotomy?
- Stapled off bowel ends may be left in discontinuity
| - Re-inspect after a period of continued ICU resuscitation to restore physiological balance
134
What is portal pyaemia?
form of septic (often suppurative) thrombophlebitis of the portal venous system
135
What tends to cause portal pyaemia?
Complication of intra-abdominal sepsis
Diverticulitis
Appendicitis
136
How can portal pyaemia be seen on a CTAP?
Air in SMV & intrahepatic portal venous system
137
What are the 3 different arterial causes of acute mesenteric ischaemia?
- embolisms (50%)
- thrombosis (20-35%)
- non-occlusive (<5%)
138
What can cause an arterial embolism causing acute mesenteric ischaemia?
- From left auricle - atrial fibrillation.
- A mural infarct.
- Atheroma from aorta or aneurysm.
- Endocarditis vegetations.
- Left atrial myxoma.
139
What can cause arterial thrombosis causing acute mesenteric ischaemia?
- Blocks origin of superior mesenteric artery & can cause ischaemia of full length of small bowel.
- Due to atherosclerosis
- Often all main splanchnic vessels—coeliac, superior & inferior mesenteric arteries
140
What is an arterial non-occlusive cause of acute mesenteric ischaemia?
- Due to hypotension/hypoperfusion.
- Due to vasospasm in shock—nonocclusive mesenteric ischaemia (NOMI).
- Critically ill patients with vasopressor requirements
- Those undergoing dialysis with large volume fluid removal
141
What can cause SMvenous thrombosis causing acute mesenteric ischaemia?
```
Occurs in patients with:
- Portal hypertension
- Portal pyaemia
- Sickle cell disease
(Related to the presence of an underlying hypercoagulable state)
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