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Lower GI Flashcards

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1
Q

Describe the differentials for acute lower abdominal pain

A

GI:

  • Appendicitis
  • Intestinal ischaemia
  • Diverticulitis
  • Bowel obstruction, strangulated hernia
  • Mesenteric adenitis (kids)
  • Meckel’s diverticulitis

Urological:

  • Renal colic
  • Pyelonephritis

Gynae:

  • PID
  • Ectopic pregnancy
  • Cyst accident: rupture, torsion
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2
Q

Describe the epidemiology of appendicitis

A 
Very common (12%)
Any age
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3
Q

Describe the presentation of appendicitis

A
  • Acute abdo pain: constant, increasing, umbilical->RIF
  • N+V, anorexia
  • Fever
  • Retrocaecal appendix may cause back/flank pain
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4
Q

Describe the signs of appendicitis on examination

A

-General: tachycardia, fever, sweating
-Abdo: RIF tenderness (McBurney’s sign), Rovsing’s sign (press on LIF), Psoas sign (flexed right hip), Obturator sign
+/- peritonitis if perf, sepsis, mass if abscess

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5
Q

Describe the investigations for acute appendicitis

A
  • History and examination
  • Bloods: FBC, CRP, U+Es, amylase/lipase, VBG, culture if indicated
  • Usually no need for further Ix. Imaging if unclear/>40: USS, CT/MRI
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6
Q

Describe the management of acute appendicitis

A
  • Make NBM, give analgesia, IV fluids, and IV Abx
  • Contact senior + surgeons
  • Laparoscopic appendicectomy +/-postop Abx
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7
Q

Describe the complications of appendicitis

A
  • Gangrenous appendix +/- perforation
  • Abscess
  • Phlegmon
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8
Q

Describe the postop care for appendicectomy

A
  • Admission usually until 1 day postop (longer if complicated), until E+D and infection settled
  • Need about 1 week off work/school
  • Avoid heavy lifting/manual labour/contact sports 1 month
  • No OP followup needed
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9
Q

Describe the risks of appendicectomy

A
  • Removal of normal appendix (1/5 no appendicitis)
  • Surgical: pain, bruising, wound infection, damage to other organs, intra-abdominal abscess, DVT
  • Anaesthetic: N+V, headache, muscle soreness, allergy/anaphylaxis, cardiac arrest, etc
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10
Q

Describe the types of intestinal ischaemia

A

1) Acute mesenteric ischaemia: affects SMA branches (SB mostly). Not very common
2) Chronic mesenteric ischaemia (intestinal angina)
3) Ischaemic colitis: most common. Affects IMA branches (LB)

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11
Q

Describe the epidemiology of intestinal ischaemia

A
  • Vasculopaths eg. AF, hypercoagulable state, smoking, HTN, DM
  • Older adults
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12
Q

Describe the aetiology of intestinal ischaemia

A

AMI:

  • Arterial compromise: embolism (50%, assoc w AF), thrombosis (20%), vasculitis
  • Venous compromise: thrombosis (5%)- hypercoagulable states
  • Hypoperfusion (20%): shock, surgery/trauma

CMI: atherosclerosis mostly
Ischaemic colitis: usually hypoperfusion

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13
Q

Describe the blood supply to the GI tract

A

Foregut: coeliac artery- common hepatic, splenic, left gastric arteries
Midgut: SMA- middle colic, right colic, ileocolic arteries
Hindgut: IMA- left colic, sigmoid, superior rectal arteries

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14
Q

Describe the divisions of the GI tract

A

Foregut: mouth to the 2nd part of the duodenum
Midgut: 2nd part of the duodenum up to 2/3 of the transverse colon
Hindgut: the distal 1/3 of the transverse colon to the anus

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15
Q

Describe the presentation of intestinal ischaemia

A
  • Ischaemic colitis: mild/mod abdo pain felt laterally, faecal urgency, bloody diarrhoea
  • AMI: severe acute abdominal pain, peri-umbilical and worsening. *Out of proportion to examination/obs. N+V, anorexia. +/- bloody diarrhoea
  • CMI: insidious onset. 1) episodes of colicky central postprandial abdo pain 2) Weight loss 3) Abdo bruit
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16
Q

What is the classic description of acute mesenteric ischaemia?

A

Severe abdominal pain out of proportion to clinical findings (eg. no tenderness, no systemic changes)

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17
Q

Describe the investigations for intestinal ischaemia

A
  • History and examination
  • Urine dip
  • Bloods: FBC, CRP, U+Es, VBG, clotting, LFTs
  • Urgent contrast CT -> CTA

After Dx:

  • ECG (check AF)
  • Bloods: lipids, HbA1c (look for modifiable RFs)
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18
Q

Describe the signs of intestinal ischaemia on CT

A
  • Bowel wall thickening
  • Luminal dilatation
  • Gas in the bowel wall
  • Thumbprinting (oedema)
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19
Q

Describe the management of acute mesenteric ischaemia

A
  • Make NBM, analgesia (opioid), IV fluids and IV Abx
  • Consider blood transfusion
  • Senior + surgeons
  • Consider endovascular treatment (stenting, thrombectomy) or surgical Mx (laparotomy + resection of infarcted/necrotic bowel)
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20
Q

Describe the management of chronic mesenteric ischaemia

A

Conservative:
-Lifestyle modifications: weight loss, diet, smoking, exercise

Medical:
-RF modification eg. HTN, glycaemic control, statin

Surgical/interventional: revascularisation

  • Mesenteric bypass
  • Angioplasty
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21
Q

Describe the management of ischaemic colitis

A

Can usually be managed conservatively unless complications/severe ischaemia

Conservative:
-Supportive: analgesia, bowel rest, IV fluids

Medical:
-IV Abx, IV fluids and prophylactic LMWH

Surgical/interventional:
-Resection and stoma formation if complicated

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22
Q

Describe the complications of intestinal ischaemia

A

Strictures
Fear of food
Surgical complications: short bowel syndrome, high output stoma, etc

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23
Q

Describe the signs of peritonitis

Study These Flashcards
A
  • Generalised abdominal tenderness
  • Guarding, rigidity
  • Rebound + percussion tenderness
  • Absent bowel sounds
24
Q

What causes peritonitis?

Study These Flashcards
A 
SBP 
2˚ causes:
-Perforation eg. BO, appendix, ulcer, diverticulum
-Peritoneal dialysis
-Pancreatitis
-Trauma eg. surgical wound
-PID
25
Describe the epidemiology of bowel obstruction
Common cause of emergency surgery SBO: more common in previous surgeries + Crohn’s LBO: less common than SBO.
26
Describe the aetiology of bowel obstruction
Can be: outside bowel wall (adhesions, hernias), within the wall (malignancy), within the lumen SBO: adhesions (50-80%), strangulated hernia (20%), Crohn’s, malignancy LBO: malignancy! Diverticular strictures, volvulus
27
Describe the pathophysiology of bowel obstruction
Mechanical obstruction -> reduced blood flow ->ischaemia -> necrosis -> perforation + transudate into luman -> dehydration + electrolyte imbalance
28
Describe the presentation of bowel obstruction
- Absolute constipation - Acute abdominal pain: diffuse, colicky, worsening * *Constant pain may indicate ischaemia - Vomiting (occurs earlier in SBO, bad sign in LBO) - Abdominal distension * *LBO: possible Hx suggestive of malignancy
29
Describe the investigations for bowel obstruction
- History and examination (including DRE) - Urine: dip, UPT, MCS - Blood: FBC, CRP, U+Es, VBG (for acidosis and lactate), culture (if febrile), lipase/amylase, glucose, clotting - Imaging: urgent CT (best), AXR (not as good)
30
Describe the initial management of bowel obstruction (acute)
``` A to E as needed Call senior Make NBM IV access and bloods, fluid resus Analgesia NG tube decompression if SB distension/vomiting Call surgeons ```
31
Describe the management of bowel obstruction (eg treatment)
Conservative (simple adhesional SBO): -Drip and suck for max 72 hours Surgical (non-adhesional SBO, complicated SBO, any LBO): -Exploratory laparoscopy w/ resection + stoma formation
32
What are the differences between ischaemic colitis and acute mesenteric ischaemia?
IC: affects large bowel (IMA), usually more mild/mod pain, bloody diarrhoea AMI: affects small bowel (SMA), severe pain with no clinical signs initially
33
Where is the most common site of rupture in LBO?
Caecum
34
Where is the most common site of volvulus?
Sigmoid (75%) | Caecum
35
Describe the signs of bowel obstruction on examination
General: tachypnoea, tachycardia, pyrexia, hypotension Abdo distension Diffuse tenderness +/- caecal tenderness (imminent perf) Hyperactive bowel sounds -Peritonitis: rigidity and guarding, rebound tenderness, absent bowel sounds -Hernia
36
Define volvulus
Twisting of a loop of bowel on its mesentery
37
Define bowel obstruction
Mechanical blockage of the bowel, preventing flow of contents
38
Describe the presentation of volvulus on imaging
Classically on AXR: - Coffee bean sign: sigmoid volvulus - Embryo sign: caecal volvulus CT: whirl sign
39
Describe the pathophysiology of volvulus
Sigmoid: Chronic constipation -> chronic faecal loading -> extension of sigmoid colon -> ^ risk of torsion Torsion -> impaired blood flow -> ischaemic/necrosis -> bowel obstruction
40
Describe the management of volvulus
Initial: -Fluid resus, analgesia, IV Abx and NGT if indicated Medical: -Endoscopic decompression, detorsion -> place soft rectal tube -> 72 hours do surgery Surgical: if perf/ischaemia - HD unstable: Hartmann's - HD stable: sigmoid colectomy + 1˚ anastomosis
41
Describe the imaging findings of bowel obstruction and how to distinguish SBO and LBO
Dilated bowel loops (3, 6, 9 cm- SB, LBO, caecum) Rigler's sign (can see both sides of bowel wall) in pneumoperitoneum, string of pearls sign, air fluid level SBO: presence of valvulae conniventes (fully cross bowel) LBO: presence of haustra (not fully cross)
42
Describe the aetiology of GI perforation
``` Infection: appendicitis, diverticulitis Obstruction Ischaemia: AMI, ischaemic colitis Ulceration Trauma ```
43
Describe the presentation of GI perforation
BG of cause eg. obstruction, appendicitis - > acutely worsening pain, becomes constant + severe - > sepsis/HD unstable
44
Describe management of GI perforation
``` Initial: A to E Make NBM IV access and bloods, IV fluid resus, IV BS ABx, analgesia Call surgeons ``` Emergency surgery- laparoscopy/laparotomy
45
Describe the epidemiology/RF of rectal prolapse
Occurs in children + elderly | Assoc w multiple pregnancies, obesity, chronic straining/cough
46
Describe the presentation of rectal prolapse
Painless rectal mass Incontinence or constipation Tenesmus, pruritus
47
Describe the signs of rectal prolapse on examination
Bright pink lump at the anus +/- bleeding May be reducible May have concentric rings (full thickness prolapse) In F: may also have vaginal/uterine prolapse
48
Describe the management of rectal prolapse
Conservative: if v frail, mild prolapse -Lifestyle: reduction, weight loss, increase fibre + hydration Medical: -Sclerotherapy Surgical: definitive - Laparoscopic rectopexy - Perineal procedures eg. Delorme/Altemeier procedure
49
Describe the causes of PR bleeding
- Infection/inflammation: acute diverticulitis, IBD, dysentery - Malignancy: colorectal cancer - Vascular: intestinal ischaemia, haemorrhoids - Trauma eg. fissure, foreign body, colonoscopy
50
Describe the presentation of colorectal cancer
- PR bleeding - Change in bowel habits - Tenesmus - Pain (abdo, on defaecation) - Systemic symptoms: weight loss, fever, sweats
51
Describe the assessment of PR bleeding
-History and examination (abdo and PR) -Bloods: FBC, CRP, U+Es, LFTs, clotting, CEA -Imaging: flexi sig -> colonoscopy + additional if Dx of cancer eg. CT AP, CXR, USS liver
52
Describe the 2WW referral criteria for suspected colorectal malignancy
Always refer: >40 : unexplained weight loss + abdo pain > 50: unexplained rectal bleeding > 60: unexplained Fe deficiency anaemia OR change in bowels Anyone with positive FIIT test -Consider for anyone <50 with rectal bleeding + other factors eg. weight loss, pain, change in bowels, anaemia
53
Describe the epidemiology and risk factors for colorectal cancer
Epidemiology: Western countries, M > F, very common RFs: -Non-modifiable: M, older age, genetics, IBD -Modifiable: diet, obesity, smoking
54
Describe the staging of colorectal cancer
Duke's + TNM | Duke's: A (confined to wall), B (spread through bowel wall), C (spread to LNs), D (mets)
55
Describe the management of colorectal cancer
Medical + surgical Medical: adjuvant/neoadjuvant chemo/radio Surgical: for all early stage -Resection. Type depends on lymphatic drainage (follows arterial supply)
56
Describe the screening for colorectal cancer
Every adult 60-75 in the UK is sent FIT test in the mail every 2 years (also done at 56 years) + FIT -> colonoscopy Increased screening for higher risk groups with colonoscopy, frequency depends on risk group * Most IBD: after 8-10 from Dx and possibly 3-5 yearly * UC + PSC: yearly
57
Describe some familial syndromes associated with colorectal cancer
FAP: APC gene mutation. Many many polyps, will eventually go on to have cancer -> prophylactic colectomy before 20 years Lynch syndrome/ HNPCC: ^ risk of breast/uterine etc Peutz-Jegher syndrome: buccal freckles, GI hamartomas

Surgery finals (16 decks)

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