Small Bowel Diseases

Question 1

In what 3 places can cause an obstruction in the small bowel occur

Answer 1

Within the lumen
Within the wall
Outside the wall

Question 2

Describe the 5 symptoms a patient would present with in a small bowel obstruction

Answer 2

Pain (colicky, central)
Absolute constipation
Vomiting
Burping
Abdominal Distension

Question 3

What could cause an obstruction within the lumen

Answer 3

Gallstones - fistulates the small bowel and then passes through before becoming stuck in the ileocaecal junction
Food
Bezoar (stony concretion formed in the stomach)

Question 4

What could cause an obstruction within the wall?

Answer 4

Tumour,
Crohn’s disease,
Radiation

Question 5

What could cause an obstruction outside the wall?

Answer 5

Adhesions,

Hernias (bits of bowel going places they shouldn’t)

Question 6

What is Borborygmi?

Answer 6

a rumbling or gurgling noise made by the movement of fluid and gas in the intestines.

Question 7

What investigations should we do for a suspected bowel obstruction?

Answer 7

Urinalysis
Full set of Bloods
Blood gases

Question 8

How do we confirm the diagnosis of a small bowel obstruction

Answer 8

AXR
Contrast CT of abdomen
Gastrograffin studies

Question 9

What is the treatment for a small bowel obstruction

Answer 9

ABC
Analgesia
Fluids with potassium
Catheterise
NG tube to drain the stomach 
Anti-thromboembolism measures

Question 10

Why do we give potassium to the patient?

Answer 10

K+ will have been lost in vomit

Question 11

What is drip and suck?

Answer 11

Conservative treatment

patient receives fluids and has a drainage NG

Question 12

How long do we drip and suck for?

Answer 12

72 hours is standard

Question 13

What 3 reasons would we intervene earlier than 72 hours?

Answer 13

Strangulation
Perforation
ischaemia

Question 14

What type of operation is performed to resolve an obstruction

Answer 14

Laparotomy - complete opening up of the stomach

Sometimes laparoscopic (keyhole)

Question 15

What can cause mesenteric ischaemia?

Answer 15

Embolus, thrombosis (arterial and venous)

Question 16

Describe chronic mesenteric ischaemia

Answer 16

Superior Mesenteric artery
cramps
angina of the gut
atherosclerosis

Question 17

Describe acute mesenteric ischaemia

Answer 17

Small bowel usually gets infarcted

Question 18

Why is the small bowel more likely to die than the large bowel?

Answer 18

Small only has one blood supply

the colon has the marginal artery of Drummond

Question 19

How do we diagnose mesenteric ischaemia?

Answer 19

Pain is out of proportion to clinical findings
Acidosis on gasses (low pH. high H+ concentration, high BE
Lactate elevated
CRP may be normal
WCC may be up a bit
CT angiogram

Question 20

How do we fix mesenteric ischaemia?

Answer 20

QUICKLY!
resect if non-viable
re-anastomse or staple and planned return

Question 21

How can we investigate a haemorrhage?

Answer 21

ABC 
Exclude upper source 
Vascular malformations
Ulceration
CT angiogram

Question 22

Describe Meckel’s Diverticulum

Answer 22

An embryological remnant of the vitello-intestinal duct and is present in 2% of the population.
Usually situated 50cm from the ileocaecal valve, may be of varying length and may be associated with other congenital abnormalities. Less than 5% produce symptoms due to complications

Question 23

What are 6 complications with Meckel’s Diverticulum

Answer 23

Bleed - prone to ulceration
Ulcerate 
Obstruction 
Malignant change
Diverticulitis 
Perforation

Question 24

How can we treat Meckel’s Diverticulum

Answer 24

Surgery to remove large diverticula

this is controversial

Question 25

What is the most common emergency operation

Answer 25

Appendectomy

Question 26

Describe the appendix

Answer 26

``` Vestigial organ Vermiform appendix retrocaecal the tip can vary in location The base is constant - at the convergence of the three taenia ```

Question 27

Is appendicitis more common in men or women

Answer 27

Men

Question 28

Who is usually affected by appendicitis

Answer 28

Children / early adulthood

Question 29

What is the class picture for appendicitis

Answer 29

``` Central pain that migrates to the right ileac fossa Anorexia Nausea no more than 1 or 2 vomits Mild ocnstipation ```

Question 30

What are the clinical signs of appendicitis

Answer 30

``` Mild pyrexia Mild tachycardia Localised painin the right ileac fossa Guarding of the abdomen Rebound tenderness ```

Question 31

Name 4 tests for appendicitis and describe each one

Answer 31

Rosving's- pressing on the left side of the body causes pain on the right Psoas - Good test in children. Patient keeps the right hip flexed to keep the appendix off the psoas Obturator - flexing the hip and internally rotating causes pain Pointing - where did the pain start and where is it now?

Question 32

What are the 4 special cases of appendicitis - what is special?

Answer 32

Obese - very difficult to examine and still claim hunger Elderly - gangrene and perforate more frequently. Usually have comorbid disease Children - dont sleep and wont eat Pregnancy - appendix is moved up and out - risk of miscarriage . Emergency MRI is required

Question 33

What is the Alvarado score?

Answer 33

The Alvarado Score for Acute Appendicitis determines likelihood of appendicitis based on symptoms, signs, and lab data.

Question 34

How do we manage appendicitis?

Answer 34

``` Analgesia Antipyretics Theatre Antibiotics Appendectomy ```

Question 35

What type of operation is best for an appendectomy

Answer 35

Laparasopic

Question 36

What are the 3 main emergency conditions affecting the small bowel?

Answer 36

Obstruction Infarction Haemorrhage