Surgical Management Of GI Tract Flashcards
Outline the differential diagnosis for RUQ pain
Bilary Colic
Cholecystitis/Cholangitis
Duodenal Ulcer
Liver abscess
Portal vein thrombosis
Acute hepatitis
Nephrolithiasis
RLL pneumonia
Outline the differential diagnosis for RLQ pain
Acute Appendicitis
Colitis
IBD
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy
Outline the differential diagnosis for epigastrium pain
Acute gastritis/GORD
Gastroparesis
Peptic ulcer disease/perforation
Acute pancreatitis
Mesenteric ischaemia
AAA (Abdominal Aortic Aneurysm) Aortic dissection
Myocardial infarction
Outline the differential diagnosis for suprapubic/central pain
Early appendicitis
Mesenteric ischaemia
Bowel obstruction
Bowel perforation
Constipation
Gastroenteritis
UTI/Urinary retention
PID
Outline the differential diagnosis for LUQ pain
Peptic ulcer
Acute pancreatitis
Splenic abscess
Splenic infarction
Nephrolithiasis
LLL Pneumonia
Outline the differential diagnosis for LLQ pain
Diverticulitis
Colitis
IBD (Inflammatory Bowel Disease)
Infectious colitis
Ureteric stone/Pyelonephritis
PID/Ovarian torsion
Ectopic pregnancy
Malignancy
Outline the typical presentation of bowel ischaemia
Sudden onset crampy abdominal pain
•Severity of pain depends on the length and thickness of colon affected
•Bloody, loose stool (currant jelly stools)
•Fever, signs of septic shock
What are the risk factors for bowel ischaemia
Age >65 yr
•Cardiac arrythmias (mainly AF), atherosclerosis
•Hypercoagulation/thrombophilia
•Vasculitis
•Sickle cell disease
•Profound shock causing hypotension
Where does acute mesenteric ischaemia occur?
Small bowel
Where does ischaemic colitis occur?
Large bowel
Why is acute mesenteric ischaemia usually occlusive?
Due to thromboemboli
What is usually the cause of ischaemic colitis?
Usually due to non-occlusive low flow states, or atherosclerosis
Which has a more sudden onset: acute mesenteric ischaemia or ischaemic colitis?
Acute mesenteric ischaemia - sudden onset but presentation and severity varies
Ischaemic colitis is more mild and gradual
When investigating for bowel ischaemia, what would you look at in bloods?
FBC: neutrophilic leukocytosis
VBG: lactic acidosis
When investigating for bowel ischaemia what imaging is done and what does this detect?
CTAP/CT Angiogram
Detects
•Disrupted flow
•Vascular stenosis
•‘Pneumatosis intestinalis’ (transmural ischaemia/infarction)
•Ischaemic colitis: Thumbprint sign (unspecific sign of colitis)
For what type of bowel ischaemia is endoscopy used to investigate?
For mild or moderate cases of ischaemic colitis (oedema, cyanosis, ulceration of mucosa)
What type of management is used for mild to moderate cases of ischaemic colitis and what does this entail?
Conservative management:
IV fluid resuscitation
•Bowel rest
•Broad-spectrum ABx - colonic ischaemia can result in bacterial translocation & sepsis
•NG tube for decompression - in concurrent ileus
•Anticoagulation
•Treat/manage underlying cause
•Serial abdominal examination and repeat imaging
Conservative management is not suitable for which type of bowel ischaemia?
SB ischaemia
What are the surgical indications of bowel ischaemia?
Small bowel ischaemia
•Signs of peritonitis or sepsis
•Haemodynamic instability
•Massive bleeding
•Fulminant colitis with toxic megacolon
In the surgical management of bowel ischaemia, what is exploratory laparotomy?
Resection of necrotic bowel +/- open surgical embolectomy
or mesenteric arterial bypass
In the surgical management of bowel ischaemia, what is endovascular revascularisation?
Balloon angioplasty/thrombectomy
•In patients without signs of ischaemia
outline the typical presentation of acute appendicitis
Initially periumbilical pain that migrates to RLQ (within 24hours)
Anorexia, nausea +/- vomiting, low grade fever, change in bowel habit
Important clinical signs
McBurney’s point: tenderness in the RLQ (lateral 1/3 of a hypothetical line drawn from the right ASIS to the umbilicus)
Blumberg sign: rebound tenderness especially in the RIF
Rovsing sign: RLQ pain elicited on deep palpation of the LLQ
Psoas sign: RLQ pain elicited on flexion of right hip against resistance
Obturator sign: RLQ pain on passive internal rotation of the hip with hip & knee flexion
when investigating acute appendicitis, what do you look for in bloods?
FBC: neutrophilic leukocytosis
↑ed CRP
Urinalysis: possible mild pyuria/haematuria
Electrolyte imbalances in profound vomiting
when investigating acute appendicitis what imaging is used for?
CT: gold standard in adults esp. if age > 50
USS: children/pregnancy/breastfeeding
MRI: in pregnancy if USS inconclusive
when investigating acute appendicitis, when is diagnostic laparoscopy used?
in persistent pain or inconclusive imaging
what is the alvarado scoring system?
clinical scoring system assessing for:
RLQ tenderness
fever
rebound tenderness
pain migration
anorexia
nausea+/- vomiting
WCC> 10.000
neutrophilia (left shift 75%)
what does the acute management of acute appendicitis consist of?
IV Fluids, Analgesia, IV or PO Antibiotics
In abscess, phlegmon or sealed perforation
Resuscitation + IV ABx +/- percutaneous drainage
what are the indications for conservative management of acute appenidicitis?
After negative imaging in selected patients with clinically uncomplicated appendicitis
In delayed presentation with abscess/phlegmon formation
CT-guided drainage
what is the rate of recurrence after conservative management of abscess/perforation and what should you consider in the conservative management of acute appendicitis because of this?
12-24%
consider interval appendicectomy
what are the benefits of a laprascopic vs open appendicectomy?
Less pain
Lower incidence of surgical site infection
↓ed length of hospital stay
Earlier return to work
Overall costs
Better quality of life scores
outline the steps of a laparoscopic appendicectomy
Trocar placement (usually 3)
Exploration of RIF & identification of appendix
Elevation of appendix + division of mesoappendix (containing artery)
Base secured with endoloops and appendix is divided
Retrieval of appendix with a plastic retrieval bag
Careful inspection of the rest of the pelvic organs/intestines
Pelvic irrigation (wash out) + Haemostasis
Removal of trocars + wound closure
what is the most common cause of small bowel obstruction?
adhesions
what is an intestinal obstruction?
restriction of normal passage of intestinal contents.
Two main groups:
Paralytic (Adynamic) ileus
Mechanical.