The Digestive System - GI Surgical Emergencies Flashcards
(190 cards)
1
Q
Peritonitis
A
Infl of serial membrane lining abdo cavity and the organs
2
Q
Types of peritonitis
A
Primary - spontaneous
Secondary - to pathology in a visceral organ
Tertiary - persist/ recurs adequate initial treatment
3
Q
Primary peritonitis
A
Spontaneous bacterial peritonitis (SBP)
Infection of ascitic fluid which arises in the absence of any other source of sepsis within the peritoneum or the adjacent tissues
4
Q
Risk factors for primary peritonitis
A
Co-existence of GIT bleeding
Previous SBP
Low ascitic protein
5
Q
What is SBP commonly seen in
A
Alcoholism and cirrhosis
Malignant mets
Hepatitis
CHF
SLE
Usually develops on top of pre-existing ascites
6
Q
Px of SBP
A
Pyrexia - seen in 80%
Abdo pain
Peritoneal irritation - pain, rebound tenderness
7
Q
What is diagnostic for SBP
A
> 250 polymorphonuclear WBCs in peritoneal fluid
8
Q
Common organisms in SBP
A
E. coli
Strep
Enterococci
9
Q
Treatment of SBP
A
Broad spectrum abx before culture results
3rd gen cephalosporins
Best-lactam combi e.g. piperacillin
10
Q
Secondary peritonitis
A
Spillage of GI or gU micro-organism –. loss of integrity of mucosal barrier
May be disease, perforation, trauma, gangrene, obstruction, malignancy
11
Q
Diseases that may cause secondary peritonitis
A
Appendicitis
Diverticulitis
Pancreatitis
IBD
In females, from an infected Fallopian tube or ruptured ovarian cysts
12
Q
Px of 2’ peritonitis
A
Local pain from ruptured organ
Pts lie motionless/ curled
Rebound tenderness
Febrile
13
Q
Death in 2’ peritonitis
A
Typically Gram-ve rod sepsis and potent endotoxins
14
Q
Pathogens causing 2’ peritonitis - contamination form upper GI
A
Gram+ve organisms usually predominate
Incl yeasts, lactobacilli
Gram-ve rods if gastr9c acid suppressed
15
Q
Pathogens causing 2’ peritonitis - contamination from distal bowel
A
Polymicrobial incl yeasts
GNR and anaerobes
16
Q
Pathogens causing 2’ peritonitis - bloodstream/ lymphatic spread
A
Strep pneumonia
17
Q
When does 3’ peritonitis occur
A
Within 48hrs of surgery
18
Q
What is 3’ peritonitis typically caused by
A
Multidrug resistance organisms (ESBL, VRE) - difficult to treat
Abscesses
Severe complications of sepsis following surgery
19
Q
Common sources of pyrexia in a surgical pt
A
Chest (infection)
Cut (wound infection)
Catheter (UTI)
Collections (abdo, pelvis)
Calves (DVT)
Cannula (infection)
Central line (infection)
20
Q
CAPD
A
Continous ambulatory peritoneal dialysis
21
Q
What does CAPD peritonitis involve
A
Skin organisms’ vs endogenous flora
Similar to endovascular device infection
22
Q
Px of CAPD peritonitis
A
Same as 2’ peritonitis
23
Q
What would be seen in dialysate in CAPD peritonitis
A
Cloudy
>100 WBCs, 50%
24
Q
What is a peritoneal abscess
A
Infected fluid collection
Encapsulates by fibrinoid exudate, momentum and/or adjacent visceral organs
25
Loculation
Compartmentalisation of fluid-filled cavities by septa
26
Where do peritoneal abscesses usually occur
Sub-hepatic
Pelvic region
Paracolic gutter
Half with loculation
27
What may cause intra-ab abscesses
Faecal spillage from colonic source
Diverticular abscess
Necrotising abscess
Necrotising pancreatitis
28
Which antimicrobials to use for Gram-ve organisms
Amoxi*
Gentamycin
Co-amoxiclav
Cefuroxime
Cipro
Piperacillin
29
Which antimicrobials to use Gram+ve organisms
Amoxi
Gentamycin*
Co-amoxiclav
Piperacillin/ tazobactam
Vancomycin
30
Which antimicrobials to use for anaerobes
Metronidazole
Co-amoxiclav
Piperacillin
31
Hernia
Abnormal protrusion of a cavities through its wall
Defect in wall creates neck of hernia
32
Types of abdominal hernias
Epigastric
Umbilical
Spighelian
Excisional
Inguinal
Femoral
33
Is divarification of recti a hernia
No
There is no defect of wall
Recti shifted away from midline and sheath becomes lax
34
Who does divarification of recti affect
Seen in women after childbirth
Elderly men
35
Epidemiology of hernias
9x more common in men (except femoral)
Men have lifetime risk of 27%
Most commonly presents in ages 40-59
36
Px of hernias
Bulge or mass
Discomfort
Cough impulse
37
Px of obstructive hernias
N & V
Abdo pain
Distention
Absent bowel sounds
38
Px of strangulated hernias
Tenderness
Severe pain
Gangrenous mass
39
Classification of non-reducible hernias
Incarcerated
Obstructed
Strangulated
40
Spigelian hernias
Occurs between lateral border of rectus abdominis and linea semilunaris
Area of central weakness pushed dup - doesn't go through anterior sheath
41
Incisional hernias
Occurs at sites where there gas been a previous surgical incision has been made
Range from small (few cm) to v large
42
Incarcerated hernias
Cannot be returned as they have formed adhesions outside but are still viable
43
Obstructed vs strangulated hernias
Bowel lumen becomes obstructed --> intestinal obstruction
Strangulated - blood flow to bowel stooped (ischaemic)
44
How are hernias repaired
Identify neck and sac of hernia, open up sac and reduce hernia content intra-ab
Neck is brought back together and covered w/ mesh
45
Different placement of mesh in hernia repairs
Onlay - over the top
Inlay - in between gap of muscle
Retro-muscular - beneath muscles
Preperitoneal and intraperitoneal - in peritoneal space
46
Best and worst place to put mesh in hernia repair
Inlay - worst, can be moved if intra-ab pressure increases
Pre/intraperitoneal - strongest, if intra-ab pressure increases, mesh is pushed up against muscle
47
Ddx for groin hernias
Malignant
Aneurysm caused by IVDUs
Venous swellings
48
How can we tell the difference between inguinal and femoral hernias
Relation to pubic symphysis
Femoral is below and lateral
Inguinal is above and medial
49
Features of direct inguinal hernias
Protrudes through Hesselbach trinagle - herniates through external and internal ring
Low rich of strangulation
Common in M
Seen in adults
50
Features of indirect inguinal hernia
Protrudes through inguinal ring (external only) - failure of processus vaginalis to close
Low risk of strangulation
Common in M
May occur in infants - congenital
51
Differentiating between direct and indirect inguinal hernia
Locate deep inguinal ring (midway of ASIS and pubic tubercle)
Manually reduce hernia towards deep ring and apply pressure
Ask pt to cough - if reappears, direct
52
Referral guidelines for hernia
Sx of strangulation/ obstruction
All females
Symptomatic males
53
Ix if diagnostic uncertainty for hernias
USS
if still unclear, MRI
54
Operative mx of hernias
Open vs laparoscopic (less painful, reduced recovery)
Incl herniotomy or hernioplasty
55
When is conservative mx used for hernias
Asymptomatic hernias (typically have wide neck)
56
Features of femoral hernias
Protrudes below inguinal ligament
High risk of strangulation
More common in F
57
Ddx for femoral hernias
Lymphadenopathy
Abscess
Femoral artery aneurysm
Lipoma
Inguinal hernia
58
Are trusses useful for femoral hernias
No - risk of strangulation
59
Complication of hernia repair
Bleeding
Infection
Recurrence - 10%
C/c pain
60
Cardinal sx of bowel obstruction
Absolute constipation - obstipation
Vomiting
Pian
Distended abdomen
61
Richter's hernia
Only part of bowel walls and lumen herniate, other part remains in peritoneal cavity
62
Madyl's hernia
Two diff loops of bowel contained within hernia
63
Hesselbach's triangle boundaries
Rectus abdominis - medial
Inferior epigastric vessels - superior/ lateral
Inguinal ligament - inferior
64
Boundaries of femoral canal
Femoral vein - lateral
Lacunar ligament - medially
Inguinal ligament - anteriorly
Pectineal ligament - posteriorly
65
A/c abdo pain
Non-traumatic abdo pain lasting 5/7 or less
66
C/c abdo pain
Recurring or constant abdo pain of 2/12 or more
67
Sx of a/c or c/c abdo pain
Constant or episodic
Spp pain characteristics
Red flags
Dysphagia/ odynophagia
Palpitation
Chest sx
68
Signs of a/c or c/c abdo pain
Abdo distention
Tenderness
Grey Turner's sign
+ve Carnett's sigan
Rovsing sign
Guarding
69
Ddx of a/c abdo pain - diffuse
Pancreatitis
Bowel obstruction
Sickle cell crisis
Gastroenteritis
Mesenteric thrombosis
Extras - metabolic disorder , psychogenic illness
70
Ddx of a/c abdo pain - focal
A/c appendicitis
Biliary colic
A/c pancreatitis
A/c diverticulitis
Extras - ruputured adnexa cysts, ovarian torsion
71
Ddx of c/c abdo pain
Functional dyspepsia
IBS
IBD
PUD
Diverticular disease
Narcotic bowel syndrome (opined induced GI hyperplasia)
72
Ix for c/c abdo pain
Tends to be more focussed
Guided by red flag sx and signs
If c/c pancreatitis and 20-49yrs, excl CF, but if >40, excl cancer
Fecal fat/ elastase
73
Intestinal obstruction
Interruption in normal flow of intestinal content either due to mechanical occlusion of the intestinal lumen or black of peristalsis
74
Pathophysiology of intestinal obstruction
Mechanical obstruction
Fluid and electrolyte loss
Bacterial translocation and toxaemia
Ischaemia
Perforation and peritonitis
75
6 Fs of abdo distension
Fat
Foetus
Flatus
Fluid
Faeces
Fulminnat masses
76
Ddx of SBO - neonates
Duodenal/ jejunal atresia
Meconium ileus
77
Ddx of SBO - children
Pyloric stenosis
Intussusception
Parasites
78
Ddx of SBO - young adults
Adhesions
Hernias
Ileus
Gallstone ileus
Malignancy
Strictures
79
Ddx of SBO - older age
Paralytic ileus
Malignancy
80
Ddx of LBO
Hirchsprung's disease
CRC
Diverticular
Volvulus
Ischaemic bowel
Faecal impaction
81
Main causes of bowel obstruction
Adhesions (SBO)
Hernias (SBO)
Malignancy (LBO)
82
Adhesions
Pieces of scar tissue binding abdo contents together
83
Main causes of intestinal adhesions
Abdo or pelvic surgery (esp open)
Peritonitis
Abdo or pevic infections
Endometriosis
84
Ix for bowel obstruction
Haemorrhage/ biochem - amylase may be raised in SBO
AXR (first line)
Gastrogratin (meal/ enema)
US - may show fluid or gas
CT - w/ IV +/- oral contrast (definitive dx)
85
AXR for bowel obstruction
Distended loops of bowel - 3-6-9 rule
Valvuale conniventes - mucosal folds across ENTIRE width of small bowel
Haustra - folds halfway across large bowel
Pneumonperitoneum suggest perforation
86
What type of shock are pts w/ bowel obstruction like to have
Hypovolameic - fluid stuck in bowel intreat of intra-vascular space (third-spacing)
87
Initial mx of bowel obstruction
'Drip and suck'
NBM
IV fluids
NGT drainage
Analgesia
Hydostatic or pneumatic enema may be used for decompression
88
Definitive mx of bowel obstruction
Exploratory surgery to correct underlying cause
Adhesiolysis
Hernia repair
Emergency resection
89
Carnett's sign
A/c abdo pain remains unchanged or increases earn abs muscles tensed
Differentiates intra-ab and abdo wall pathology
90
Differentials for pain in R hypochondrium
Gallstones
Hepatitis
Liver abscesses
Cholangitis
Cardiac/ lung causes
91
Differentials for pain in epigastrium
Oeosphagitis
PUD
Perforted ulcer
Pancreatitis
92
Differentials for pain in L hypochondrium
Spleen abscess
Spleen rupture
Splenomegaly
93
Differentials for pain in lumbar regions
Renal colic - comes in waves
Pyelonephritis
94
Differentials for pain in RIF
Appendicitis
CD flare
Ovarian cyst
Hernias
Ectopic cyst
95
Differentials for pain in umbilical region
Early appendicitis
Meckel diverticulitis
Lymphoma
96
Differentials for pain in hypogastric region
Testicular torsion
Urinary retention
Cystitis
97
Differentials for pain in LIF
Diverticulitis
UC flare
Constipation
Hernias
98
Mechanisms leading to bowel perforation
Ischaemia: obstruction --> hypo perfusion --> necrosis
Infl/ infection: diverticulitis, IBD (esp CD), appendicitis
Erosion: ulceration, tumour
Physical disruption: trauma, iatrogenic
99
Sx of bowel perforation
Septic shock
Abdo pain
Distension
Fever/ chills
Guarding
100
Mx of bowel perforation
Surgical repair
Bowel rest
IV fluids
IV broad-spectrum abx
101
Tools used in pre op risk stratification
ASA
Performance status
POSSUM
APACHE
102
POSSSUM
Physiological and Operative Severity
Score for enumeration of mortality and morbidity
103
ASA tool
American Society of Anaesthesiologist
Ranges from 1 - 6
1 is healthy and 6 is brain dead, 4 is severe disease that is a constant threat to life
104
What do pre-op tests depend on
Minor, intermediate, major or complex surgery
Depends on ASA grade
105
Examples of minor surgery
Excising skin lesions
Draining breast abscess
106
Examples of intermediate surgery
Primary repair of inguinal hernia
Excising VVs in legs
Tonsillectomy
107
Examples of major or complex surgery
Joint replacement
Colonic resection
Hysterectomy
Lung operations
108
When would cardiopulmonary exercise testing be required
Thoracic and upper GI major surgeries
109
Pre op consent process
Procedure
Benefits
Risks/ complications
Alternatives
Info leaflets
110
Effects of resp disease in surgery
Air trapping & bronchospasm - seen in asthma, emphysema
Excess pulm secretions - bronchiectasis, c/c bronchitis
Reduced lung compliance - pulm fibrosis, pleural plaques
Reduced ventilatory capacity - OSA, neuromuscular disease
111
Optimisation of resp conditions pre op
Smoking cessation, nicotine testing (reduces risk of infection by 50% in just 8/52)
Pre-op PT
Optimising medical therapy
112
When are METs performed
Metabolic equivalent tests
Part of detailed hx and exam in pts w/ CDV disease
Pts who cannot meet 4x the metabolic demands of normal daily activities are at increased risk
113
Peri-op mx in cardiac disease
Don't start cardiac meds w/ possible exception of diuretics
Consider adding drugs e.g. BB - reduces cardiac complication in high-risk pts
Ideally should start several weeks before surgery
114
Pacemaker checks pre -op
What type - single/ dual chamber, biventricualr, ICD
When was it inserted, indication
Last check and next check
Check w/ anaesthetists
115
Pre-op mx - renal disease
Detailed hx and exam
Consultant w/ pts renal physician
Assessment of current renal function
116
Peri-op mx - renal disease
Careful attention to fluid and electrolyte balance
Careful attention to drugs, contrast dyes
117
What are we aiming for in peri-op mx in DM
Avoiding hypoglycaemia
Aim for mean blood glucose conc of 5-7
Monitor capillary glucose every 2-4hrs during surgery
118
What does peri-op mx in DM depend on
Usual diabetes mx e.g. diet only, insulin
Grade of surgery - minor (eating within few hrs) or major (NBM > 6 hrs)
119
Depending of clinical urgency, what can anaemia be treated w/ pre-op
Oral or parenteral iron
Blood transfusion
Epo pre-op or peri-op
120
Issues w/ treating anaemia in Jehovah's witness' peri-op
Discuss w/ pt and think of auto transfusion, cell saver, plasma
121
Peri-op mx for bleeding risk
Assess for bleeding risk - coagulopathy from platelet disorder, organ dysfunction, meds etc
Pts on anti-coag usually require pre-op stoppage/ reversal
122
How long should warfarin be withheld for pre op
5/7 to allow INR to fall to <1.5
123
Common indications for bridging therapy peri-op
Metal valves
Cardiac stents
Stroke
Uncontrollable AF
124
How long should clopi + asp be withheld for pre op
7 to 10 days
125
Post-op problems near
Confusion
126
Post-op problems - GI
Ileus
Nausea
Vomiting
127
Post-op problems - kidneys
Low urine output
128
Metabolic effect of unrelieved pain post-op
Catabolism due to increased cortisol, glucagon, catecholamines
129
CDV effect of unrelieved pain post-op
Increased myocardial oxygen demand
Increased coagulation
130
Resp effect of unrelieved pain post-op
Decreased functional residual capacity
Retention of sputum
131
GI effect of unrelieved pain post-op
Vomiting ileus
132
Renal effect of unrelieved pain post-op
Water and Na retention
133
Psychological effect of unrelieved pain post-op
Anxiety, depression
Increased subjective pain experience
134
WHO analgesic ladder
Step 1 - paracetamol, NSAIDs
Step 2 - tramadol, codeine plus Step 1
Step 3 - Morphine, methadone, oxycodone plus Step 1
135
Resp complications post-op
Atelactasis, chest infection
PE
Pulm oedema
136
Post-op mx to prevent resp complications
Effective analgesia - allows deep breathing, mobilisation
Chest physio
Nutrition
Fluid balance
137
Cardiovasc complications post-op
MI
Arrhythmias
Sinus tachycardia
Sinus Brady
138
Mx of arrhythmias post-op
Treat electrolytes, hypotension, hypoxia, amiodaron cardioversion
139
What might cause sinus tachy post op
Pain
Anxiety
Hypovolaemia
Sepsis
Hypoxia
140
Preventing cardiac complications post-op
Adequate analgesia
Supplemental oxygen therapy
Maintaining an even fluid balance
141
Pre-renal causes of a/c renal failure post-op
Hypotension
Hypovolaemia
142
Renal causes of a/c renal failure post-op
Nephrotoxic drugs
Myoglobinuria (muscle damage)
Sepsis
143
Post renal causes of a/c renal failure post-op
Ureteric injury
Blocked catheter
144
How may post-op confusion px as
Restlessness
Anxiety
Incoherent speech
Pulling of cannula
145
Causes of post-op pyrexia
Wound
Intra-ab collection
Chest infection
Leaks (seen in GI surgery)
VTE
Urine catheter infection
Line infection
146
Where are pressure sores typically seen in
Sacrum
Greater trochanter
Heels
147
Who are most at risk of pressure sores
Those w/ nutritional stratus
Dehydration
Lack of mobility - early mobilisation is key
148
What are haemorrhoids
Enlarged anal vascular cushions - VV of anal can
149
Sx of haemorrhoids
Bleeding - typically painless
Prolapse
Irritation
150
Internal vs external haemorrhoids
External - below dentate line, more painful and prone to thrombosis
Internal - above
151
Risk factors for haemorrhoids
Grade 1 - mno prolapse
Grade 2 - prolapse but reduces spontaneously (after defecation)
Grade 3 - prolapse, stay reduced if pushed back manually
Grade 4 - irreducible
152
Risk factors/ causes of haemorrhoids
Constipation +/- straining
Heavy lifting
C/c cough (increased intra-ab pressure) - COPD
Pregnancy/ childbirth
153
Ddx of haemorrhoids
Anal tissue
Ano-rectal polyps
Mucosal prolapse
Ano-rectal carcinomas
154
Mx of haemorrhoids - Grade 1
Conservative - reassurance, diet
Topical steroids to alleviate itch
155
Mx of haemorrhoids - Grade 1
Conservative - reassurance, diet, anaesthetic ointments
Topical steroids to alleviate itch
156
Mx of haemorrhoids - Grade 2
Rubber band ligation
Sclerotherapy
Infrared photocoagulation
157
Mx of haemorrhoids - Grade 3
Ruber band ligation
158
Mx of haemorrhoids - Grade 4
Surgical haemorrhoidectomy
159
Risks of haemorrhoidectomy
Removal of anal cushions may result in faecal incontinence
Recurence
Pain
Impacted faeces
160
Cause of thrombosed haemorrhoids
Strangulation at base of haemorrhoids --> thrombosis
161
Px of thrombosed haemorrhoids
Significant pain
Purplish, oedematous, tender perianal mass
162
Mx of thromboses haemorrhois
If pts presents within 72hrs, refer for excision
Pts can be managed with stool softeners, ice packs and analgesia
163
Effects of sclerotherapy injection in haemorrhoids
Fixation - prevents prolapse
Fibrosis protects veins
Prevents distension
164
Anal fissure
Tear causing a painful, linear ulcer at margin of anus (squamous lining)
<6 wks is a/c and more is c/c
165
Risk factors/ causes of anal fissures
Constipation
IBD (CD)
STI e.g. HIV, Herpes, syphilis
Pregnancy
166
Sx of anal fissures
Severe pain during and after boowel motion
Bright red rectal bleeidng
Itch
90% of anal tissues on posterior midline, if alternative locations, consider causes like CD, lymphoma, anal cancer etc
167
Dx of anal fissures
Physical exam is diagnostic - difficult due to pain
Triad of sentinel skin tag (externally), fissure and a hypertrophied papilla (internally)
168
Sentinel pile
Oedematous skin tag at the lower end of c/c anal fissure
169
Mx of a/c anal fissure
Soften stool - diet, bulk-forming laxatives
Lubricants before defecation e..g vaseline
Topical anesthetics
170
Mx of c/c fissure
Topical GTN or CCB - 1st line
Botox injection
Surgery - sphincterotomy
171
Presentation of superficial abscesses
Pain
Swelling
Discomfort on walking and sitting
Tenderness
Fever
172
Px of deep abscesses
Lack typical features
Diffuse pelvic pain and raised body temp
173
Cause of perianal abscess
Cryptoglandular theory
Anal glands may become infected when a crypt is occluded by impaction of fecal matter, oedema, IBD, trauma 2' to hard stool or foreign body
174
Anal fistula
Abnormal communication between the interior of the anal canal or rectum and skin surface
175
Px of fistula
Depends on the severity of inflammation.
Excretion of pus, serous fluid or faeces may lead to pruritus ani, itching and skin maceration.
176
Ix for perianal abscess and fistula
Physical exam is diagnostic
Rectoscopy/ proctoscoy (if tolerated)
MRI for deeper abscesses
177
Mx of anal abscess
Surgical drainage - cruciate incision
Sometimes a drain may be left
178
Mx of anal fistula
Seton - helps drain and prevent abscess
Fistulotomy
Fibrin glue
179
Pruritus ani
Condn characterised by intense perianal icthing and burning
180
Pruritus ani
Condn characterised by intense perianal icthing and burningSx
181
Sx of pruritus ani
Itching
Burning
Irritation
Worse at night
182
Examination findings for pruritus ani
Reddened oedematous ulcerations
Excoriations
Skin atrophic or hypertrophic w/ associated nodularity and scarring
183
Ix for pruritus ani
Proctoscopy and sigmoidoscopy
Stool assessment
184
Ddx fro pruritus ani
Haemorrhoids
Anal fistula
Contact dermatitis
DM
Pin worm
185
Mx of pruritus ani
Keep area dry
Diet modification
Soothing creams
Topical steroids
Gloves to avoid nocturnal scratching
186
Types of stoma
Colostomy - large bowel (L)
Ileostomy - small bowel (R)
187
Indications for ileostomy
Defunctioning bowel to protect distal anastomosis e.g. rectal cancer surgery
CD
Faecal incontinence
Bowel ischaemia
188
Indications for colostomy
Bowel cancer
CD
Diverticulitis
Anal/ vaginal/ cervical cancer
Bowel incontinence
189
Psychosocial implications of stoma
Anxiety/ depression
Poor body image
Social isolation
Adjustment problems
Embarrassment
Sexual function
190
Common complications of stomas
Parastomal hernias
Proplase
Retraction
Ischaemia
Pyoderma gangrenosum
