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Small bowel & Bowel Obstruction Flashcards

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1
Q

Emergency conditions of small bowel?

A

Obstruction
Infarction
Haemorrhage

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2
Q

Obstruction

A

Due to fluid, gas, ischaemia, perforation

  • – Pain (colicky, central)
  • – absolute constipation
  • – vomiting
  • – burping
  • – abdo distension

Causes//

  • – within the lumen (gallstone, food, bezoar)
  • – within the wall (tumour, Crohn’s, radiation)
  • – outside the wall (adhesions, herniation)
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3
Q

Obstruction - presentation

A 
Distension
Vomiting 
Borborygmi (rumbling noise)
Pain
Faeculent vomiting

Look for cause of obstruction. Scar, hernias

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4
Q

Obstruction - Ix

A

> Urinalysis
Bloods
Gases

Confirming diagnosis//

  • AXR
  • Contrast CT
  • gastrograffi studies

identifying those who need surgery and those who will settle

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5
Q

“Drip and Suck”

A 
> ABC
> Analgesia
> Fluids with potassium
> Usually hypokalaemic and alkalotic 
> Catheterise
> NG tube 
> Antithromboembolism measures
  • up to 72 hours
  • intervene earlier if there is strangulation perforation, ischaemia
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6
Q

Surgical Management

A 
> Laparotomy 
> Operative principles
--- abx
--- antithromboembolic measures
--- usually a midline incision
--- can be laparoscopic
--- find obstruction by following collapsed or dilated bowel
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7
Q

Mesenteric ischaemia

A 
> Embolus, thrombosis
> Chronic
--- SMA
--- Cramps
--- angina of the guts
--- atherosclerosis

Acute
– small bowel usually becomes infarcted

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8
Q

Cause of mesenteric ischaemia

A

> Embolus from AF

  • – forms in left atrium
  • – sticks in narrow SMA

> In situ thrombosis from general gubbedness

  • –virchow’s triad
  • – dehydrated
  • – hypercoagulable
  • – compression
  • – vasocoonstricting drugs
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9
Q

Mesenteric ischaemia - diagnosis

A 
> Massive pain
> Acidosis 
> Lactate elevated
> WCC may be up
> CRP may be normal
> CT angiogram
> INTERVENE
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10
Q

Treatment - mesenteric ischaemia

A

QUICK TREATMENT.

Resect if non-viable.

Re-anastomose or staple

If viable perform an SMA embolectomy

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11
Q

Haemorrhage

A 
ABC
Exclude upper source
Vascular malformations
Ulceration
CT angiogram
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12
Q

Meckel’s diverticulum

A 
> 60 cm from IC valve
> Present before 2 years of age
> Remnant of omphalomesenteric duct
> Complications
--- bleed
--- ulcerate
--- obstruction
--- malignant change
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13
Q

Upper bowel obstruction - vomiting

A

> Large volumes of vomit

> Gastric, pancreatic and biliary secretions regurgitated into stomach

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14
Q

Distal small bowel/ large bowel obstruction

A

Colicky pain and distension

Vomiting - (faeculent)

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15
Q

Symptoms of intestinal obstruction

A 
> Vomiting
> Pain
> Constipation
> Distension
> Complete obstruction
> Incomplete obstruction
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16
Q

The more proximal the obstruction…

A

the earlier vomiting develops

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17
Q

Semi-digested food eaten a day or two previously suggests…

A

gastric outlet obstruction

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18
Q

copious bile-stained fluid suggests…

A

small bowel obstruction

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19
Q

Thicker, brown, foul-smelling vomit

A

Distal obstruction

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20
Q

Distension of bowel causes…

A

pain.

&

there are intermittent episodes of colicky pain.

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21
Q

Constipation

A

Propulsion of bowel contents is arrested.

Bowel gas is absorbed distal to the obstruction

Absolute constipation - neither faeces nor flatus

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22
Q

Large bowel obstruction

A

gradual onset of symptoms.

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23
Q

If oleo-caecal valve remains competent in large bowel obstruction…

A

Backward flow of contents is prevented.

Thin walled caecum progressively distends with swallowed air and eventually may rupture

  • – closed loop obstruction.
  • – at risk of perforation

COMPETENT valve is a big problem

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24
Q

If oleo-caecal valve becomes incompetent…

A

the small bowel distends, delaying onset of symptoms

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25
Incomplete obstruction - symptoms - leads to - type of pain
Clinical features may be less defined. Intermittent vomiting & erratic bowel habit leads to gradual hypertrophy of muscle of the bowel wall proximally. Colicky pain due to peristalsis
26
Physical signs of intestinal obstruction
Dehydration Abdo distension Visible peristalsis Relative lack of abdominal tenderness Mass may be palpable Centre of abdomen tends to be resonate due to gaseous distension groins examined for hernia
27
Bowel sounds?
High pitched, tinkling. Absent, echoing. Water lapping against a boat
28
Bowel obstruction - investigations
Supine abdo xray**** Bowel proximal to obstruction is distended
29
Small bowel on Xray
"lines" go all the way across the bowel
30
Large bowel xray
Haustra
31
What is performed after supine AXR?
CT scan to confirm diagnosis transition point between collapsed and distended bowel.
32
Initial management
Nil by mouth Insert IV cannula and send bloods Resus with IV fluids Replace electrolyte loss Pass a nasogastric tube to decompress the stomach Drip and suck
33
Adhesions/bands
Mechanical cause of obstruction. Congenital/iatrogenic Small bowel loops should be free to move about Can become stuck to each other and twist on each other Collapse lumen
34
Incarcerated abdominal wall hernias
Mechanical cause of obstruction
35
Volvulus
A mobile loop of bowel rates causing obstruction at its neck. sigmoid volvulus closed loop structure massively distended caecal volvulus - hypermobile caecum.
36
Tumour
Most common - colonic cancer Hypokalaemia/ hypocholaemic metabolic alkalosis Losing chloride through vomiting Losign H+ ions Losing potassium as well
37
Inflammatory stricture
1. Crohn's disease - due to proximal hypertrophy 2. Diverticular disease incomplete usually
38
Bolus obstruction
1. Food bolus 2. Impacted faeces 3. impacted gallstone ileus 4. Trichobezoar - hair ball
39
What is a trichobezoar?
Hair ball
40
Intussusception
a segment of bowel wall becomes telescoped into the segment distal to it Usually initiated by a mass in the bowel wall - tumour Overacvie lymphatic tissue
41
Bowel Strangulation
> A segment of bowel becomes trapped > Venous return is obstructed > ↑local intra vascular pressure, arterial inflow compromised Infarction--> perforation
42
Pain over a hernia
indicates bowel strangulation surgical intervention. can occur in external hernia or volvulus
43
Paralytic ileus
Disruption of normal propulsive activity of GI tract No peristalsis Reent GI surgery Inflammation w/ peritonitis Diabetic keto acidosis Symptoms and signs// pain and high pitched sounds less common Everything will be uniformly distended with no obvious point of obstruction
44
Ogilvies Syndrome
Acute dilatation of colon in absence of colonic obstruction in ACUTELY UNWELL patients ``` hip replacement CABG Spinal Pneumonia Frail/elderly ``` gaseous distension to distal rectum. no "cut-off" point Colonoscopic decompression if causing pain or resp compromise.
45
Most common cause of bowel ischaemia?
Mesenteric artery occlusion - atherosclerosis - thromboembolism (AF)
46
Other case of small bowel ischaemia?
Non-occlusive perfusion insufficiency - shock - strangulation obstructing venous return - drugs - hyper viscosity
47
What is the most metabolically active part of the bowel wall?
Mucosa
48
Longer time of ischaemia
greater the depth of damage
49
In non occlusive ischaemia, what causes most tissue damage?
REPERFUSION INJURY
50
Meckel's diverticulum
Tubular structure - 2 inches long, 2 foot above IC valve in 2% of people. May mimic appendicitis True diverticulum (includes all layers)
51
Commonest site of carcinoid tumours?
Appendix
52
(Primary) Small bowel carcinoma associated with
Crohn's disease and coeliac disease late presentation
53
What must acute inflammation invlove?
The muscle coat
54
Appendicitis - complications
``` Peritonitis Rupture Abscess Fistula Sepsis and liver abscess ```
55
Classic coeliac disease rash?
Dermatitis herpetiformis sub epithelial IgA deposition
56
What is the component of gluten suspected to be the toxic agent in coeliac disease?
Gliadin - leading to t cell mediated reaction
57
Coeliac disease - what happens to enterocytes
LOSS of enterocytes due to IEL mediated damage Loss of villous structure, loss of SA reduction in absorption FLAT mucosal biopsy
58
Coeliac disease lesions are worse in?
Duodenal biopsy
59
What antibodies are present in coeliac disease?
anti-TTG anti-endomesial anti-gliadin
60
Coeliac leads to malabsorption of... leading to...
malabsorption of fat --> STEATORRHOEA
61
Coeliac has reduced hormone production. Leading to...
Recuded pancreatic secretion and bile flow. --> gallstones
62
Coeliac disease
``` Loss of weight Anaemia Abdominal bloating Failure to thrive Vitamin deficiencies T cell lymphomas Carcinoma Gall stones Ulcerative jejenoilleitis ```
63
Causes of malabsorption
Common// ``` Coeliac Crohn's Post infectious Biliary obstruction Cirrhosis ``` Uncommon// ``` Pancreatic cancer parasites bacterial overgrowth drugs short bowel ```
64
Fat malabsorption
Digestive Absorptive Post absorptive a physiological defect in any of these can lead to malabsorption
65
Carb malabsorption
Quite uncommon Severe oancreatic insufficiency (alpha-amylase)
66
What can lead to vitamin b12 deficiency?
Deficiency of gastric intrinsic factor (pernicious anaemia)
67
Menkes disease
"Kinky hair disease" caused by disorder of cellular copper transport
68
What is lactase deficiency confirmed by?
Hydrogen breath test
69
Tropical sprue
Leads to malabsorption Colonisatio of the intestine by infectious or alterations in intestinal bacterial flora diarrhoea, steatorrhoea, weight loss, nausea, anorexia, anaemia
70
Crohns disease
Abdo pain and tenderness - RLQ Diarrhoea, fever and weight loss
71
What are punched out lesions a sign of?
Crohn's disease
72
Giardia Lamblia
parasitic infection Water supplies that may be contaminated diarrhoea, flatulence, abdo cramps, epigastric pain and nausea. Malabsorption w steatorrhoea an weight loss Stool sample x 3 METRONIDAZOLE
73
PMHx that may indicate malabsorption
Gastric/small bowel resection Gastrointestinal division Radiation expsosure Travel
74
Gingival hyperplasai
Scurvy Vitamin C deficiency weak collagen formation
75
Acrodermatitis Enteropathica
Imparied zinc uptake | perioral rash
76
Lack of iron
Glossitis Angular stomatitis spooning of nails
77
Large MCV (mean corpuscular volume) =
Macrocytic anaemia
78
Investigations for malabsorption
``` FBC Coagulation LFTs MCV Albumin Ca/Mg Stool ``` Endoscopy
79
Bacterial overgrowth causing malabsorption
diarrhoea, steatorrhoea, macrolytic anaemia E. coli or bactericides Evidence of - fistulas, diverticula, strictures, Crohn's disease High folate levels Surgical correction Tetracyclines
80
What are the intestinal glands/crypts called?
Crypts of Lieberkühn
81
S.I. regions
Duodenum - contains brunner's glands Jejunum - tallest villi. located on permanent circular folds of the mucosa and submucosa----- plicae circularis Ileum - Peyer's patches
82
What do Brunner's glands produce?
Thin, alkaline mucous to neutralise the chyme
83
Jejunum has...
Plicae circularis | Closely packed folding do not disappear when intestine is distended
84
Ileum has large aggregations of..
lymphoid tissue Peyer's patches
85
Cells of large intestine
Absorptive cells - removal of salts and water Goblet cells - secret of mucous to lubricate colon arranged in crypts
86
Gastro-duodenal junction
Stratified squamous to columnar epithelium
87
Longitudinal muscle of large intestine
3 muscular strips Teniae coli
88
The appendix has a lot of ...tissue
Lymphoid
89
Rectoanal junction
Rectum - columnar epithelium Anus - stratified squamous
90
Where is the myenteric plexus?
Between the 2 muscle layers
91
Where is the submucosal plexus?
In the submucosa controls muscular is mucosae and regulates secretion in the epithelium

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