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Year 3 Surgery > Lower GI Conditions > Flashcards

Lower GI Conditions Flashcards

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1
Q

What is constipation?

A

Difficulty in passing stools or an inability to pass stools

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2
Q

How can constipation present?

A

Straining
Lumpy/Hard stools
Feeling of incomplete evacuation
Fewer than 3 bowel movements a week

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3
Q

What are some causes of constipation?

A

Normal transit constipation
Slow colonic transport
Defecation problems

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4
Q

What is the treatment for constipation?

A 
Psychological support
Increased fluid intake
Increased activity
Increased dietary fibre
Fibre medication
Laxitives
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5
Q

What is diarrhoea?

A

A symptom that occurs in many conditions. Presents as loose/watery stools passed more than 3 times a day

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6
Q

What causes diarrhoea?

A

An unwanted substance triggers gut motility and secretions to remove it, increasing water in the bowel

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7
Q

What are the 2 broad causes of diarrhoea?

A

Secretory causes

Osmotic causes

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8
Q

What are secretory causes of diarrhoea?

A

Excess ion secretion gives excess Cl- or HCO3- in the bowel

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9
Q

What are osmotic causes of diarrhoea?

A

Gut lumen contains too much osmotic material

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10
Q

What is the appendix?

A

Diverticula off the caecum

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11
Q

Which artery supplies the appendix?

A

Ileocolic branch of Superior Mesenteric

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12
Q

How can appendicitis present?

A

Acute

Gangrenous

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13
Q

How does acute appendicitis present?

A

Mucosal Oedema

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14
Q

How does gangrenous appendicitis present?

A

Transmural inflammation and necrosis

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15
Q

How can the causes of appendicitis be classified?

A

Classic

Alternative

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16
Q

What happens in classic appendicitis?

A

The lumen of the appendix becomes blocked, increasing intraluminal pressure.
Venous pressure rises giving oedema, reducing arterial supply to the appendix causing ischaemia

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17
Q

What happens in alternative appendicitis?

A

A viral/bacterial infection causes mucosal changes that allow for bacterial invasion of the appendiceal wall

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18
Q

How does appendicitis manifest?

A

Poorly-localised peri-umbilical pain that moves to the R iliac fossa after 12-24h
Anorexia
Nausea and Vomiting
Low Grade fever

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19
Q

Why can the pain for appendicitis be felt in areas other than the RIF?

A

The position of the appendix varies slightly

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20
Q

Which position can the appendix be found in?

A 
Retrocoecal
Subcoecal
Pelvic
Pre-ileal
Post-ileal
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21
Q

What are some signs of appendicitis?

A 
Patient appears ill
Fever/Tachycardia
Lie still due to inflamed peritoneum
Localised R quadrant tenderness
Reboud tenderness in RIF
Pain localised to McBurney's Point
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22
Q

Where is McBurney’s Point?

A

2/3 of the way from Umbilicus to ASIS

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23
Q

How is the diagnosis of appendicitis confirmed?

A

History/exam is often enough

Bloods - Raised CRP/WCC

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24
Q

What needs to be excluded with possible appendicitis cases?

A

Ectopic pregnancy

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25
What is the treatment for appendicitis?
Open appendicectomy | Laprascopic Appendicectomy
26
What is Diverticulosis?
Outpouchings of the mucosa and submucosa that herniate through the muscularis layers
27
Where is Diverticulosis common?
Colon, commonly sigmoid
28
What is thought to cause Diverticulosis?
Low fibre diet giving hard/bulky stool that needs more effort to pass
29
What is Acute Diverticulitis?
Diverticulae become inflamed/perforate. | The entrance to the diverticula is occluded by faeces giving inflammation
30
How can acute diverticulitis present?
Uncomplicated | Complicated
31
What is uncomplicated diverticulitis?
Diverticulitis with inflammation and small abscesses
32
What is complicated diverticulitis?
Diverticulitis with larger abcess formation
33
What are some symptoms of diverticulitis?
``` Abdo pain at sight of inflammation, usually lower left quadrant Fever Bloating Constipation Haematochezia Fresh PR bleed ```
34
What are some signs of diverticulitis?
Localised abdominal tenderness Distension Reduced bowel sounds Signs of Peritonitis
35
What tests are appropriate in diverticulitis?
Bloods - WCC/CRP USS CT Colonoscopy
36
What is the treatment of diverticulitis?
Antibiotics Fluid resus Analgesia Surgical intervention if perforated
37
What is Acute Mesenteric Ischaemia?
The sudden decrease in blood supply to the bowel, leading to bowel ischaemia, gangrene and death
38
What are some causes of acute mesenteric ischaemia?
Thrombus in Situ Embolism Non-occlusive cause Venous occlusion/congestion
39
What are some risk factors for acute mesenteric ischaemia?
Hypertension Hyperlipidaemia Smoking Af
40
What are clinical features of acute mesenteric ischaemia?
Generalised abdominal pain Diffuse, constant Nausea and Vomiting
41
What will examination demonstrate in acute mesenteric ischaemia?
Often nothing
42
What are some differentials with acute mesenteric ischaemia?
Peptic Ulcer Disease Bowel Obstruction AAA
43
Which investigations are appropriate for acute mesenteric ischaemia?
ABG - ?Acidosis/Lactate | FBC, U+E,LFTs
44
Which investigation is definitive with acute mesenteric ischaemia?
CT Abdo/Pelvis with Contrast
45
What is the management for acute mesenteric ischaemia?
Surgical intervention Excision of the Necrotic Bowel Revascularisation of the bowel
46
What is Crohn's Disease?
A form of inflammatory bowel disease
47
Which areas of bowel are affected by Crohn's disease?
Any part of the GI tract, commonly the distal ileum or proximal colon
48
How is Crohn's disease characterised?
Transmural inflammation, procuding deep ulcers and fissures giving affected bowel a cobblestone appearance
49
Is the inflammation in Crohn's disease constant?
No, the inflammation is intermittent forming skip lesions
50
How does Crohn's disease appear microscopically?
Non-caseating granulomatous inflammation
51
What are some risk factors of Crohn's disease?
Family Hx Smoking White European descent Previous Appendicectomy
52
What are some clinical features of Crohn's disease?
``` Episodic abod pain and diarrhoea Mucus/Blood in diarrhoea Malaise Anorexia Low grade fever Oral and Peri-anal ulcers ```
53
What are some extra-intestinal features of Crohn's?
``` MSK - Nail clubbing, metabolic bone disease Skin - Erythema Nodosum Eyes - Episcleritis, Iritis HPB - Primary Sclerosing Cholangitis Renal - Stones ```
54
What investigations are appropriate with Crohn's disease?
``` Bloods Faecal Calprotectin AXR Colonoscopy CT ```
55
What is the management for Crohn's?
Fluid Resuscitation Corticosteroids + Immunosuppresion Smoking cessation
56
What surgical options are there for Crohn's disease?
Ileocoecal Resection Surgery for Peri-anal disease Stricturoplasty Small/Large Bowel resections
57
What are some complications of Crohn's Disease?
``` Fistulae Stricture formation Recurrent Peri-anal abscesses/fistulae GI malignancy Malabsorption Osteoporosis Increased risk of gallstones/renal stones ```
58
What is Ulcerative colitis?
Most common form of IBD
59
How is UC characterised?
Diffuse continuous mucosal inflammation of the large bowel, beginning in the rectum and spreading proximally
60
Histologically, how does UC present
Inflammation of the mucosa and submucosa, crypt abscesses and goblet cell hyperplasia
61
What are some clinical features of UC?
Bloody diarrhoea Malaise Anorexia Low Grade Pyrexia
62
What are some extra-intestinal manifestations of UC?
MSK - Nail clubbing Skin - Erythema Nodosum Eyes - Episcleritis/Iritis HPB - Primary Sclerosing Cholangitis
63
What is Peritonitis?
Inflammation of the serosal membrane that lines the abdominal cavity. Breakdown of the peritoneal membranes allows foreign substances into the cavity giving inflammation
64
How can Peritonitis be classified?
Primary/Spontaneous Bacterial Peritonitis | Secondary/Surgical Peritonitis
65
What is Primary peritonitis?
Infection of ascitic fluid within the abdomen, often secondary to chronic liver disease
66
How is primary peritonitis diagnosed?
Aspiration of the ascitic fluid
67
What is Secondary peritonitis?
Inflammation of the peritoneum secondary to inflammation/perforation of an intra-abdominal/retroperitoneal structure
68
What are some causes of secondary peritonitis?
``` Peptic ulcer disease Appendicitis Diverticulitis Post-surgery Tubal pregnancy Ovarian cyst ```
69
How does peritonitis present?
Acute | Diffuse abdominal pain
70
What is the treatment for peritonitis?
Supportive Antibiotics Surgical washout if appropriate
71
What is a Hernia?
Protrusion of part of the abdominal contents beyond the normal confines of the abdominal wall
72
What does a hernia consist of?
Sac - Pouch of peritoneum Contents - Bowel etc Coverings - Layers of abdominal wall
73
What are some pre-disposing factors for hernias?
Inguinal/Femoral canals Umbilicus Previous incisions
74
How does an indirect inguinal hernia present?
Lateral to inferior epigastric vessels
75
How does a direct inguinal hernia present?
Medial to inferior epigastric vessels, through hesselbachs triangle
76
What are the borders of hesselbachs triangle?
Medial - Rectus Abdominus Superior - Inferior Epigastric Vessels Inferior - Inguinal ligament
77
What is a stoma?
Opening of bowel/intestine onto the surface of the abdomen
78
How does a stoma appear?
Fleshy and moist, patients have no sensation of sphincter
79
Which types of stoma are there?
Ileostomy Colostomy Loop End
80
What is an Ileostomy?
Made from Ileum of small bowel in RIF Sprouted to help drainage Produces porridge-like stools Drainable bag in place
81
What is a Colostomy?
Large bowel stoma, usually L sided, often sigmoid Flush to skin Soft to formed stool output Closed bag
82
What is a Loop Ileostomy?
Often temporary A loop of bowel is brought to the skin surface, opened, inverted and sutured 2 openings, 1 used Usually to "Defunction" bowel to allow anastomosis healing
83
What is an End Ileostomy?
The cut end of bowel is moved to the surface, inverted and sutured. Permanent
84
What is a Volvulus?
Twisting of a loop of intestine around its mesenteric attachment leading to a closed loop bowel obstruction
85
What can Volvulus lead to?
Ischaemia of the affected bowel giving bowel necrosis and perforation
86
Where do Volvuli commonly occur?
Sigmoid colon
87
What are some risk factors for Sigmoid volvulus?
``` Increasing age Neuropsychiatric Disorders Resident in a Nursing Home Chronic constipation Male gender Previous abdominal operations ```
88
What are some clinical features of a Sigmoid Volvulus?
Colicky Pain Abdominal distension Rapid onset
89
What investigations are appropriate for a suspected Sigmoid Volvulus?
AXR - ?Coffee Bean sign | CT Abdo
90
What are the management options for a sigmoid volvulus?
Decompression with endoscopy + flatus tube insertion | Resection of necrotic bowel
91
What is Pseudo-Obstruction
Dilation of the Colon due to an adynamic bowel in the absence of mechanical obstruction
92
Which area of colon most commonly has Pseudo-Obstruction?
Caecum and Ascending Colon
93
What is thought to be the pathophysiology of pseudo-obstruction?
Interruption of the autonomic nervous supply in the colon leading to an absence of smooth muscle action
94
What are the possible complications of pseudo-obstruction?
Toxic Megacolon Bowel Ischaemia Perforation
95
What are some causes of pseudo-obstruction?
Electrolyte imbalance Medication Recent surgery, illness or trauma Neurological disease
96
What are some clinical features of pseudo-obstruction?
Abdominal pain/distension Constipation Vomiting
97
Which investigations are appropriate for suspected pseudo-obstruction?
AXR - ? Dilated bowel loops | CT
98
What management for pseudo-obstruction is appropriate?
``` NBM NG to decompress stomach Endoscopic decompression with flatus tube Nutritional support Surgical resection ```
99
What is Bowel Obstruction?
A mechanical blockage of the bowel where a structural pathology physically blocks the passage of intestinal contents
100
Once occluded, what happens to the affected section of Bowel?
Gross dilatation of the proximal limb of the bowel leading to increased peristalsis. This also leads to secretions of large volumes of electrolyte-rich fluid into the bowel
101
What is a Closed-Loop obstruction?
Two occlusions affecting the same loop of bowel
102
Why is a Closed-Loop obstruction a surgical emergency?
The bowel will continue to distend, leading to eventual ischaemia and/or perforation
103
What are some common causes of Small Bowel Obstruction?
Adhesions | Herniae
104
What are some common causes of Large Bowel Obstruction?
Malignancy Diverticular Disease Volvulus
105
Where can the obstruction be located irrespective of the bowel segment?
Intraluminal Mural Extramural
106
What are some Intraluminal causes of bowel obstruction?
Gallstone Ileus Ingested foreign body Faecal impaction
107
What are some Mural causes of bowel obstruction?
``` Carcinoma Inflammatory strictures Intussusception Diverticular strictures Meckel's Diverticulum Lymphoma ```
108
What are some Extramural causes of bowel obstruction?
Hernias Adhesions Peritoneal Metastases Volvulus
109
What are some common clinical features with Bowel obstruction?
Abdo pain - Colicky/Cramping in nature Vomiting - Initially gastric, then billious and faeculent Abdo distension Absolute constipation
110
What may become apparent in bowel obstruction on examination?
``` Signs of underlying cause - Surgical scars, cachexia from malignancy Abdo distension Focal tenderness Guarding Rebound tenderness Tympanic to percussion Tinkling bowel sounds ```
111
Which investigations are appropriate with suspected bowel obstruction?
FBC,U+E,CRP,LFTs,G+S VBG - ?Ischaemia CT Abdo + Contrast CXR/AXR
112
What conservative management is recommended with confirmed obstruction?
Drip and Suck
113
What steps are involved with Drip and Suck?
``` NBM NG tube to decompress stomach IV fluids Urinary Catheter Anaelgesia ```
114
When is a water-soluble contrast study recommended with confirmed obstruction?
If there is no improvement in symptoms 24 hours post commencement of management
115
When is surgical intervention appropriate with confirmed bowel obstruction?
Suspicion of Intestinal Ischaemia or Closed-Loop obstruction SBO in a virgin abdomen Cause that needs surgical intervention Failure to improve after 48h
116
What procedure is appropriate to correct bowel obstruction?
Laparotomy or resection
117
What are some potential complications of Bowel Obstruction?
Ischaemia Bowel perforation giving peritonitis Dehydration leading to renal impairment

Year 3 Surgery (10 decks)

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