General Surgery in the GI Tract

Question 1

What are the main blood investigations available?

Answer 1

VBG, FBC, CRP, urea and electrolytes, LFTs, amylase

Question 2

What are the main imaging investigations available?

Answer 2

Erect CXR, AXR, CT angiogram, USS

Question 3

How does bowel ischaemia present?

Answer 3

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

Question 4

What are some risk factors for bowel ischaemia?

Answer 4

Age >65 yr
Cardiac arrythmias  Atherosclerosis	Hypercoagulation/thrombophilia
Vasculitis
Sickle cell disease 
Profound shock causing hypotension

Question 5

What are the 2 main types of bowel ischaemia?

Answer 5

Acute mesenteric ischaemia

Ischaemic colitis

Question 6

Describe acute mesenteric ischaemia in terms of area affected, onset and pain severity

Answer 6

It affects the small bowel
Sudden onset
Abdominal pain is out of proportion of clinical signs

Question 7

Describe ischaemic colitis in terms of area affected, onset and pain severity

Answer 7

It affects the large bowel
Onset is usually more mild and gradual
Moderate pain and tenderness

Question 8

Is acute mesenteric ischaemia occlusive or not?

Answer 8

Yes, due to thromboemboli

Question 9

Is ischaemic colitis obstructive or not?

Answer 9

No, usually its due to low flow states or atherosclerosis

Question 10

When CTAP or CT angiogram is done in bowel ischaemia what does one look for?

Answer 10

Disrupted flow
Vascular stenosis
Transmural ischaemia or infarction
Thumbprint sign

Question 11

How is bowel ischaemia most often treated?

Answer 11

Usually surgical management is required

Question 12

What does conservative management of bowel ischaemia involve?

Answer 12

IV fluids
Bowel rest
Brad spectrum ABx
NG tube
Anticoagulation
Treat the cause

Question 13

What are signs for surgical management in bowel ischaemia?

Answer 13

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

Question 14

What are the main surgical ways of managing bowel ischaemia?

Answer 14

Exploratory laparotomy (resect necrotic bowel etc)
Endovascular revascularisation (in patients without signs of ischaemia)

Question 15

How does acute appendicitis present?

Answer 15

Initially periumbilical pain that migrates to RLQ (within 24hours)
Anorexia 
Nausea +/- vomiting
Low grade fever
Change in bowel habit

Question 16

What is the main clinical sign for acute appendicitis?

Answer 16

McBurney’s point: tenderness in the RLQ

Question 17

What will be seen when bloods are done on a patient with acute appendicits?

Answer 17

FBC shows high neutrophils
Raised CRP
Mild pyuria or haematuria
Electrolyte imbalance if vomiting a lot

Question 18

How are patients with suspected acute appendicitis imaged?

Answer 18

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

Question 19

What score chart is used when acute appendicitis is suspected?

Answer 19

Alvarado score

Question 20

What are the indications for conservative management of acute appendicits?

Answer 20

If imaging is negative and appendicitis is clinically uncomplicated
In delayed presentation with abscess/phlegmon formation

Question 21

How is acute appendicits managed surgically?

Answer 21

Laparoscopic appedicectomy is preferred over open

Question 22

What are the advantages of a laparoscopic appendicectomy over an open one?

Answer 22

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

Question 23

Define an intestinal obstruction

Answer 23

Restriction of normal passage of intestinal contents

Question 24

What are the 2 types of bowel obstruction?

Answer 24

Paralytic (adynamic) ileus

Mechanical

Question 25

How are mechanical bowel obstructions classfied?

Answer 25

Speed of onset: acute, chronic, acute-on-chronic Site: high or low Nature: simple vs strangulating Aetiology

Question 26

What is meant by a simple mechanical bowel obstruction?

Answer 26

The bowel is occluded without damage to blood supply

Question 27

What is meant by a strangulating mechanical bowel obstruction?

Answer 27

The blood supply of involved segment of intestine is cut off

Question 28

What are some causes of mechanical bowel obstruction originating in the lumen?

Answer 28

Faecal impaction, gallstone ‘ileus’

Question 29

What are some causes of mechanical bowel obstruction originating in the wall?

Answer 29

Crohn’s disease, tumours, diverticulitis of colon

Question 30

What are some causes of mechanical bowel obstruction originating outside the wall?

Answer 30

``` Strangulated hernia (external or internal) Volvulus Obstruction due to adhesions or bands ```

Question 31

How do small and large bowel obstruction differ in terms of abdominal pain?

Answer 31

Small bowel= colicky and central | Large bowel= colicky or constant

Question 32

How do small and large bowel obstruction differ in terms of vomitting?

Answer 32

Small bowel= early onset, large amounts and bilious | Large bowel= late onset, initially bilious and progresses to faecal vomitting

Question 33

How do small and large bowel obstruction differ in terms of absolute constipation?

Answer 33

Small bowel= its a late sign | Large bowel= its an early sign

Question 34

How do small and large bowel obstruction differ in terms of abdominal distention?

Answer 34

Small bowel= less significant | Large bowel= significant and an early sign

Question 35

What happens to hydration levels in bowel obstruction?

Answer 35

Dehydration occours

Question 36

What sounds will be heard in early or late bowel obstruction?

Answer 36

``` Early= increased high pitched tinkling sounds Late= bowel sounds absent ```

Question 37

What are the 3 things to remember in intestinal obstruction?

Answer 37

It can be diagnosed by the presence of symptoms Examination should include looking for hernias and abdominal scars Always try to decide if its simple or strangulating

Question 38

What features of bowel obstruction indicate that its strangulating?

Answer 38

``` Change in character of pain from colicky to continuous Tachycardia Pyrexia Peritonism (swelling of peritoneum) Bowel sounds absent or reduced Leucocytosis High C-reactive protein ```

Question 39

What are common sites of hernias?

Answer 39

``` Epigastric Umbilical Incisional Inguinal Femoral ```

Question 40

What are the 3 types of hernia?

Answer 40

Neck of sac Strangulated Richter's

Question 41

What is special about Richter's hernia?

Answer 41

It isn't associated with obstruction but neck of sac and strangulated are

Question 42

In bowel obstruction what happens to WCC and CRP?

Answer 42

They are usually normal but may be raised if there is strangulation or perforation

Question 43

In bowel obstruction what happens to urea and electrolytes?

Answer 43

There is an imbalance

Question 44

In bowel obstruction what will VBG show if they are vomiting?

Answer 44

Low chloride Low potassium Metabolic alkalosis

Question 45

In bowel obstruction what will VBG show if there is strangulation?

Answer 45

Metabolic acidosis

Question 46

What will abdominal x ray show in small bowel obstruction?

Answer 46

Ladder pattern of dilated loops in a central position

Question 47

What will abdominal x ray show in large bowel obstruction?

Answer 47

Distended bowel that lies peripherally

Question 48

What are the indications for surgical management of bowel obstruction?

Answer 48

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 49

What surgery is performed for bowel obstruction?

Answer 49

Exploratory laparotomy/laparoscopy Restoration of intestinal transit Bowel resection with primary anastomosis or temporary/permanent stoma formation

Question 50

How does GI perforation present?

Answer 50

``` 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 51

What will bloods show in GI perforation?

Answer 51

High neutrophils Urea and creatinine may be elevated VBG shows lactic acidosis

Question 52

What are important differential diagnoses to consider when GI perforation is suspected?

Answer 52

Acute cholecystitis Appendicitis Myocardial infarction Acute pancreatitis

Question 53

What are indications for surgical management of GI perforation

Answer 53

In generalised peritonitis +/- signs of sepsis

Question 54

What are the symptoms of biliary colic?

Answer 54

Postprandial RUQ pain that radiates to the shoulder | Nausea

Question 55

What are the symptoms of acute cholecystitis?

Answer 55

Acute severe RUQ pain Fever Murphy's sign

Question 56

What is a positive murphy's sign and when is it used?

Answer 56

A positive Murphy's sign is seen in acute cholecystitis. It is elicited by firmly placing a hand at the costal margin in the right upper abdominal quadrant and asking the patient to breathe deeply, if they have pain on inhalation and the gallbladder comes into contact with the hand its positive

Question 57

What are the symptoms of acute cholangitis?

Answer 57

Charcot's triad= jaundice, RUQ pain, fever

Question 58

What are the symptoms of acute pancreatitis?

Answer 58

Severe epigastric pain that radiates to the back Nausea with possible vomiting Past history of gallstones

Question 59

What is volvulus

Answer 59

When a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction

Question 60

What shows up on x ray when someone has volvulus of the large bowel?

Answer 60

Coffee bean sign- its the loop of the large bowel thats been twisted on itself