General Surgery in the GI Tract

Question 1

What is the general approach to an acute abdomen (6)?

Answer 1

PC
* Pain assessment (SOCRATES), associated symptoms

PMHx

DHx

SHx

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

Management:
* ABCDE approach
* Conservative management
* Surgical management

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

Question 2

Give 3 differential diagnoses of a RUQ acute abdomen.

Answer 2

• Bilary Colic
• Cholecystitis / Cholangitis
• Duodenal Ulcer
• Liver abscess
• Portal vein thrombosis
• Acute hepatitis
• Nephrolithiasis
• RLL pneumonia

Question 3

Give 3 differential diagnoses of an epigastrium acute abdomen.

Answer 3

• Acute gastritis / GORD
• Gastroparesis
• Peptic ulcer disease/perforation
• Acute pancreatitis
• Mesenteric ischaemia
• AAA (Abdominal Aortic Aneurysm) Aortic dissection
• Myocardial infarction

Question 4

Give 3 differential diagnoses of a LUQ acute abdomen.

Answer 4

• Peptic ulcer
• Acute pancreatitis
• Splenic abscess
• Splenic infarction
• Nephrolithiasis
• LLL Pneumonia

Question 5

Give 3 differential diagnoses of a RLQ acute abdomen.

Answer 5

• Acute Appendicitis
• Colitis
• IBD
• Infectious colitis
• Ureteric stone / Pyelonephritis
• PID / Ovarian torsion
• Ectopic pregnancy
• Malignancy

Question 6

Give 3 differential diagnoses of a suprapubic / central
acute abdomen.

Answer 6

• Early appendicitis
• Mesenteric ischaemia
• Bowel obstruction
• Bowel perforation
• Constipation
• Gastroenteritis
• UTI / Urinary retention
• PID

Question 7

Give 3 differential diagnoses of a LLQ acute abdomen.

Answer 7

• Diverticulitis
• Colitis
• IBD (Inflammatory Bowel Disease)
• Infectious colitis
• Ureteric stone / Pyelonephritis
• PID / Ovarian torsion
• Ectopic pregnancy
• Malignancy

Question 8

What are the 2 main forms of bowel ischaemia?

Answer 8

• Acute mesenteric ischaemia (AMI) (small bowel)
• Ischaemic Colitis (IC) (large bowel)

Question 9

What is the clinical presentation of acute mesenteric ischaemia (SOCRATES)?

Answer 9

• Site: Small bowel
• Onset: Sudden (but presentation and severityvaries)
• Character: Crampy
• Radiation: Varies
• Association: Bloody, loose stool & Fever
• Time course: Hours until treatment
• Exacerbating / Relieving factors: Exacerbated by eating
• Severity: Abdominal pain out of proportion of clinical signs

Usually occlusive due to thromboemboli

Question 10

What is the clinical presentation of ischaemic colitis (SOCRATES)?

Answer 10

• Site: Large bowel
• Onset: More mild and gradual (80-85% of the cases)
• Character: Crampy
• Radiation: Varies
• Association: Bloody, loose stoole & Fever
• Time course: Hours until treatment
• Exacerbating / Relieving factors: Exacerbated by eating
• Severity: Moderate pain and tenderness

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

Question 11

What are the risk factors of bowel ischaemia (6)?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

Answer 11

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

Question 12

What investigations are recommended for suspected bowel ischaemia (4)?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

Answer 12

• Bloods
  
  • FBC
  • VBG
• Imaging
  
  • CTAP / CTAngiogram
• Endoscopy

Question 13

What blood abnormalities would one expect in a suspected bowel ischaemia (2)?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

Answer 13

• FBC: neutrophilic leukocytosis
• VBG: lactic acidosis

Question 14

What CTAP/CT angiogram abnormalities would one expect in a suspected bowel ischaemia?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

Answer 14

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

Question 15

What endoscopic abnormalities would one expect in a suspected bowel ischaemia?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

Answer 15

For mild or moderate cases of ischaemic colitis:
* Oedema / cyanosis / ulceration of mucosa

Question 16

When is conservative management indicated for bowel ischaemia?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

Answer 16

• Mild to moderate cases of ischaemic colitis (not suitable for SB ischaemia)

Question 17

What is the conservative management for bowel ischaemia (7)?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

Answer 17

• 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 18

When is surgical management indicated for bowel ischaemia (5)?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

Answer 18

• Small bowel ischaemia
• Signs of peritonitis or sepsis
• Haemodynamic instability
• Massive bleeding
• Fulminant colitis with toxic megacolon

Question 19

What is the surgical management for bowel ischaemia (2)?

Bowel ischaemia:
* Acute mesenteric ischaemia (AMI) (small bowel)
* Ischaemic Colitis (IC) (large bowel)

Answer 19

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

Question 20

What is the clinical presentation of acute appendicitis (SOCRATES)?

Answer 20

• Site:
  
  • McBurney’s point: tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
• Onset: Sudden
• Character: Sharp, stabbing
• Radiation: Initially periumbilical pain that migrates to RLQ
• Association: Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit
• Time course: 24h escalation
• Exacerbating/Relieving factors:
  
  • 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
• Severity: Varies & increases through time

Question 21

What is McBurney’s point?

Present in Acute Appendicitis

Answer 21

• Tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)

Question 22

What is Blumberg point?

Present in Acute Appendicitis

Answer 22

• Rebound tenderness especially in the RIF

Question 23

What is Rovsing point?

Present in Acute Appendicitis

Answer 23

• RLQ pain elicited on deep palpation of the LLQ

Question 24

What is Psoas point?

Present in Acute Appendicitis

Answer 24

• RLQ pain elicited on flexion of right hip against resistance

Question 25

What is Obturator point? ## Footnote Present in Acute Appendicitis

Answer 25

* RLQ pain on passive internal rotation of the hip with hip & knee flexion

Question 26

What investigations are recommended in suspected acute appendicitis (7)?

Answer 26

* Bloods * **FBC** * **CRP** * **Urinalysis** * **Electrolytes** * Imaging * **CT** * **USS** * **MRI** * **Diagnostic Laparoscopy ** * In persistent pain & inconclusive imaging

Question 27

What blood abnormalities would one expect in a suspected acute appendicitis (4)?

Answer 27

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

Question 28

What are the indications for each imaging used in a suspected acute appendicitis? ## Footnote CT / USS / MRI

Answer 28

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

Question 29

What are the alvarado score requirements (8)?

Answer 29

* **RLQ tenderness** - 2 * **Fever ( > 37.3 °C)** - 1 * **Rebound tenderness** - 1 * **Pain migration** - 1 * **Anorexia** - 1 * **Nausea**+/- vomiting - 1 * **WCC  > 10.000** - 2 * **Neutrophilia** (Left shift 75%) - 1

Question 30

What does the alvarado score indicate?

Answer 30

* ≤ 4 Unlikely appendicitis * 5 - 6 Possible appendicitis * ≥ 7 Likely appendicitis

Question 31

What are the indications for conservative management for acute appendicitis?

Answer 31

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

Question 32

What is the conservative management for acute appendicitis (3)?

Answer 32

* **IV Fluids** * **Analgesia** * IV or PO **Antibiotics** ## Footnote In abscess, phlegmon or sealed perforation: * **Resuscitation + IV ABx +/- percutaneous drainage** Rate of recurrence after conservative management of abscess/perforation is 12-24%

Question 33

Why is laparoscopic appendicectomy preferred over open appendicectomy (6)?

Answer 33

* **Less pain** * **Lower incidence** of surgical site **infection** * **Decreased** length of **hospital stay** * **Earlier return to work** * **Overall costs** * **Better quality of life scores**

Question 34

What are the steps of laparoscopic appendicectomy (8)?

Answer 34

1. Trocar placement (usually 3) 1. Exploration of RIF & identification of appendix 1. Elevation of appendix + division of mesoappendix (containing artery) 1. Based secured with endoloops and appendix is divided 1. Retrieval of appendix with a plastic retrieval bag 1. Careful inspection of the rest of the pelvic organs/intestines 1. Pelvic irrigation (wash out) + Haemostasis 1. Removal of trocars + wound closure

Question 35

What is mechanical intestinal obstruction classified by (4)?

Answer 35

* **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 36

What is the clinical presentation of small bowel obstruction (SOCRATES)?

Answer 36

* Site: **Central abdomen** * Onset: **Vary** depending on cause (usually mild) * Character: **Colicky** * Radiation: **Vary** depending on cause (sometimes back or chest) * Association: Early onset **vomiting** / Late **constipation** / **Dehydration** / Increased high pitched **tinkling bowel sounds** (early sign), or **absent bowel sounds** (late sign) * Time course: **Vary** depending on cause (Few hours - Few days / May decrease by itself or require medical intervention) * Exacerbating / Relieving factors: Exacerbated by **eating**, **drinking** and **movement** * Severity: **Vary** depending on cause

Question 37

What is the aetiology of small bowel obstruction (5)?

Answer 37

* **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)

Question 38

What is the clinical presentation of large bowel obstruction (SOCRATES)?

Answer 38

* Site: **Central abdomen** * Onset: **Vary** depending on cause (usually mild) * Character: **Colicky or constant** * Radiation: **Vary** depending on cause (sometimes back or chest) * Association: Late onset **vomiting** / Early **constipation** / Early significant **abdominal distension** / **Dehydration** / Increased high pitched **tinkling bowel sounds** (early sign), or **absent bowel sounds** (late sign) * Time course: **Vary** depending on cause (Few hours - Few days / May decrease by itself or require medical intervention) * Exacerbating / Relieving factors: Exacerbated by **eating**, **drinking** and **movement** * Severity: **Vary** depending on cause

Question 39

What is the aetiology of large bowel obstruction (5)?

Answer 39

* **Colorectal carcinoma** * **Volvulus** * Sigmoid, Caecal * **Diverticulitis** * Inflammation, strictures * **Faecal impaction** * **Hirschsprung disease** * Commonly found in infants/children

Question 40

How is bowel obstruction diagnosed?

Answer 40

* Diagnosed by the **presence of symptoms**

Question 41

What are the 5 most common hernial sites?

Answer 41

Question 42

What are the 3 main types of hernias?

Answer 42

Question 43

What features are suggesting hernial strangulation (7)?

Answer 43

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

Question 44

What investigations are suggested in a suspected bowel obstruction (5)?

Answer 44

Bloods * **FBC** * **U&E** * **VBG** Imaging * **Erect CXR/AXR** * **CT abdo/pelvis**

Question 45

What blood abnormalities would one expect in a suspected bowel obstruction (4)?

Answer 45

* **WCC/CRP usually normal** (if raised suspicion of strangulation/perforation) * U&E: **electrolyte imbalance** * VBG: * VBG if **vomiting**: HypoCl^-, HypoK⁺ **metabolic alkalosis** * VBG if **strangulation**: **metabolic acidosis** (lactate)

Question 46

What erect CXR/AXR abnormalities would one expect in a suspected small bowel obstruction?

Answer 46

* Dilated small bowel loops **> 3cm** proximal to the obstruction (central)

Question 47

What erect CXR/AXR abnormalities would one expect in a suspected large bowel obstruction?

Answer 47

* Dilated large bowel **> 6cm** (if caecum **> 9cm**) predominantly peripheral

Question 48

Why would a CT scan be preferred over an erect CXR/AXR to diagnose bowel obstruction (3)?

Answer 48

* Can **localize** site of obstruction * **Detect obstructing lesions** & colonic **tumours** * **May diagnose unusual hernias** (e.g. obturator hernias)

Question 49

When is conservative management indicated for bowel obstruction?

Answer 49

* In patients with **no signs of ischaemia** / **no signs of clinical deterioration**

Question 50

What is the conservative management for bowel obstruction (cause dependent for faecal impaction / sigmoid volvulus / SBO)?

Answer 50

* **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 51

What is the supportive management for bowel obstruction (7)?

Answer 51

* **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 52

When is surgical management indicated for bowel obstruction (4)?

Answer 52

* **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 53

What is the surgical management for bowel obstruction (3)?

Answer 53

* **Exploratory Laparotomy / Laparoscopy** * **Restoration of intestinal transit** (depending on intra-operational findings) * **Bowel resection with primary anastomosis** or temporary / permanent stoma formation

Question 54

What is the clinical presentation of a perforated peptic ulcer (SOCRATES)?

Answer 54

* Site: **Epigastric** * Onset: **Sudden** * Character: **Constant** * Radiation: **Shoulder** pain * Association: **Nausea** / **Vomiting** / Absolute **Constipation** / **Fever** / **Tachycardia** / **Tachypnoea** / **Hypotension** / Decreased or **absent bowel sounds** * Time course: **Constant** until treatment * Exacerbating / Relieving factors: Pain aggravated by **movement** * Severity: **Severe**

Question 55

What is the clinical presentation of a perforated diverticulum (SOCRATES)?

Answer 55

* Site: **LLQ pain** * Onset: **Sudden** * Character: **Constant** * Radiation: - * Association: **Constipation** * Time course: **Constant** until treatment * Exacerbating / Relieving factors: Pain aggravated by **movement** * Severity: **Severe**

Question 56

What is the clinical presentation of a perforated appendix (SOCRATES)?

Answer 56

* Site: **RLQ pain** * Onset: **Sudden** * Character: **Gradual worsening pain** * Radiation: **Migratory** pain * Association: **Nausea** / **Vomiting** / Absolute **Constipation** / **Fever** / **Tachycardia** / **Tachypnoea** / **Hypotension** / Decreased or **absent bowel sounds** * Time course: **Constant** until treatment * Exacerbating / Relieving factors: Pain aggravated by **movement** * Severity: **Severe**

Question 57

What is the clinical presentation of a perforated malignancy (SOCRATES)?

Answer 57

* Site: **RLQ pain** * Onset: **Sudden** * Character: **Gradual worsening pain** * Radiation: **Migratory** pain * Association: **Nausea** / **Vomiting** / Absolute **Constipation** / **Fever** / **Tachycardia** / **Tachypnoea** / **Hypotension** / Decreased or **absent bowel sounds** / **Weight loss** / **Anorexia** / **PR Bleeding** * Time course: **Constant** until treatment * Exacerbating / Relieving factors: Pain aggravated by **movement** * Severity: **Severe**

Question 58

What investigations are recommended in a suspected GI perforation (5)?

Answer 58

Bloods * **FBC** * **U&E** * **VBG** Imaging * **Erect CXR** * **CT abdo / pelvis**

Question 59

What blood abnormalities would one expect in a suspected GI perforation (3)?

Answer 59

* FBC: **neutrophilic leukocytosis** * Possible **elevation of Urea & Creatinine** * VBG: **Lactic acidosis**

Question 60

What Erect CXR abnormalities would one expect in a suspected GI perforation?

Answer 60

* Subdiaphragmatic free air (pneumoperitoneum)  

Question 61

What CT abdo / pelvis abnormalities would one expect in a suspected GI perforation?

Answer 61

* Pneumoperitoneum, free GI content, localised mesenteric fat stranding * Can exclude common differential diagnoses such as pancreatitis

Question 62

What is the supportive management on presentation of GI perforation (6)?

Answer 62

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

Question 63

When is conservative management indicated in GI perforation?

Answer 63

* **Localised peritonitis without signs of sepsis** ## Footnote Very rare

Question 64

What is the conservative management of GI perforation?

Answer 64

* IR - guided **drainage of intra-abdominal collection** * Serial **abdominal examination & abdominal imaging** for assessment

Question 65

What is the surgical management in GI perforation?

Answer 65

* **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 66

What are the symptoms of biliary colic (2)?

Answer 66

* Postprandial **RUQ pain** with **radiation** to the **shoulder** * **Nausea**

Question 67

What are the abnormal investigations would one expect in a suspected biliary colic (2)?

Answer 67

* **Normal blood** results * **USS**: **cholelithiasis**

Question 68

How is biliary colic managed (4)?

Answer 68

* **Analgesia** * **Antiemetics** * **Spasmolytics** * Follow up for **elective cholecystectomy**

Question 69

What are the symptoms of acute cholecystitis (3)?

Answer 69

* **Acute**, severe **RUQ pain** * **Fever** * **Murphy's sign**

Question 70

What are the abnormal investigations would one expect in a suspected acute cholecystitis (3)?

Answer 70

* Elevated **WCC** * Elevated **CRP** * **USS**: **thickened gallbladder wall**

Question 71

How is acute cholecystitis managed (5)?

Answer 71

* **Fluids** * **ABx** * **Analgesia** * **Blood cultures** * Early (< 72 hours) or elective **cholecystectomy** (4-6 weeks)

Question 72

What are the symptoms of acute cholangitis (3)?

Answer 72

Charcot's triad: * **Jaundice** * **RUQ pain** * **Fever**

Question 73

What are the abnormal investigations would one expect in a suspected acute cholangitis (5)?

Answer 73

* Elevated **LFTs** * Elevated **WCC** * Elevated **CRP** * **Blood MCS (+ve)** * **USS**: **bilary dilatation**

Question 74

How is acute cholangitis managed (5)?

Answer 74

* **Fluids** * IV **ABx** * **Analgesia** * **ERCP** (within 72hrs) for clearance of bile duct or stenting

Question 75

What are the symptoms of acute pancreatitis (3)?

Answer 75

* Severe **epigastric pain** radiating to the **back** * **Nausea +/- vomiting** * **Hx** of **gallstones** or **EtOH use**

Question 76

What are the abnormal investigations would one expect in a suspected acute pancreatitis (4)?

Answer 76

* Elevated **amylase** * Elevated **lipase** * Elevated **WCC** * Low **Ca²⁺** * CT and US to assess for complications / cause

Question 77

How is acute pancreatitis managed (5)?

Answer 77

* Admission score (Glasgow-Imrie) * **Aggressive fluid resuscitation** * **O2** * **Analgesia** * **Antiemetics** * **ITU/HDU involvement**