GI surgeries

Question 1

How do you take a surgical history?

Answer 1

Pain assessment with SOCRATES, past medical + surgical history.

Question 2

How does bowel ischaemia usually present?

Answer 2

Sudden onset crampy abdominal pain, severity depending on length/thickness affected. Bloody, loose stool, fever, signs of septic chock

Question 3

What is acute mesenteric ischaemia? When does it usually happen? How does it present?

Answer 3

• Small bowel obstruction usually occlusive due to thromboemboli (potentially AF), usually clot in SMA.
• Sudden onset presentation, severity varies

Question 4

What is ischaemic colitis? What is it due to? How does it present?

Answer 4

Large bowel, usually due to non-occlusive flow states/atherosclerosis (eg artery blocked/narrowed). Milder/gradual onset, moderate pain and tenderness

Question 5

What are risk factors for bowel ischaemia?

Answer 5

Age >65, cardiac arrhythmias (AF), atherosclerosis, hypercoagulation/thrombophilia, vasculitis, sickle cell, profound shock causing hypotension (eg cardiac surgery)

Question 6

What are investigations done for bowel ischaemia?

Answer 6

• Blood (FBC for neutrophilic leucocytosis)
• VBG for lactic acidosis (low pH, metabolic acidosis).
• Imaging CTAP/CT angiogram to detect stenosis/disrupted flow/pneumatosis intestinalis
• endoscopy for mild/moderate cases can see oedema, cyanosis, ulceration of mucosa

Question 7

What is lactic acidosis associated with?

Answer 7

Late stage mesenteric ischaemia & extensive transmural intestinal infraction

Question 8

What sign is an unspecific sign of colitis (ischaemic colitis)?

Answer 8

thumbprint sign

Question 9

What is conservative management for bowel ischaemia? When is it used?

Answer 9

• For mild/moderate cases of ischaemic colitis (never for SB ischaemia!!!)
• IV fluids, bowel rest (NBM), broad spectrum antibiotics, NG tube for decompression in concurrent ileus, anticoagulation, treat/manage causes.
• Do repeat regular abdo exams/imaging to see changes & signs of peritonitis (pushes away from conservative management)

Question 10

What is surgical management of bowel ischaemia? When is it used?

Answer 10

• For SB ischaemia, signs of peritonitis/sepsis, haemodynamic instability, massive bleeding, fulminant colitis with toxic megacolon.
• Explaratory laparotomy (resection of necrotic bowel +/- open surgical embolectomy or mesenteric arterial bypass). -Or can do endovascular revascularisation (bal;oon angioplasty/thrombectomy) in those without signs of ischaemia (more chronic)

Question 11

How does acute appendicitis usually present?

Answer 11

Periumbilical pain radiating to RLQ within 24 hours, associated with anorexia, nausea +/- vomiting, low grade fever, change in bowel habit

Question 12

What are important clinical signs in acute appendicitis?

Answer 12

1. mcBurney’s point (tenderness in RLQ - line between right ASIS and umbilicus)
2. blumberg’s sign (rebound tenderness in RIF - right iliac fossa)
3. roysing sign (RLQ pain on deep palpation of LLQ)
4. psoas sign (RLQ pain on flexion of right hip against resistance)
5. obturator sign (RLQ pain on passive internal rotation of hip with hip & knee flexion).
   !!Signs not used as much as have imaging!!

Question 13

What are investigations for acute appendicitis? What imaging is used and in what cases?

Answer 13

• Bloods (raised neutrophils, high CRP, urine possible mild pyruria/haematuria, electrolyte imbalance if vomiting).
• Imaging: gold standard is CT in adults. USS in children/pregnancy/breastfeeding. MRI in pregnancy if USS inconclusive. Diagnostic laparoscopy in persistent pain & inconclusive imaging

Question 14

What is conservative management of acute appendicitis?

Answer 14

IV fluids, analgesia, IV or PO (per oral) antibiotics.

Question 15

What do you do in case of abscess, phlegmon or sealed perforation? (in context of appendicitis)

Answer 15

Resuscitation + IV antibiotics +/- percutaneous drainage. Consider interval appendicectomy

Question 16

What is surgical management of acute appendicitis? which is preferred and why?

Answer 16

Laparoscopic or open appendicectomy.

-Less pain, infection, hospital stay, easier return to work, cost, QOL with laparoscopic

Question 17

what are types of intestinal obstruction? How are they classified?

Answer 17

• Intestinal obstruction is restriction of normal passage of contents.
  1. paralytic ileus (abdomen full of pus irritating bowel and stopping peristalsis)
  2. mechanical obstruction (classified by speed of onset - acute/chronic/acute on chronic, site - high or low (roughly synonymous with small/large bowel)
• -> nature (simple or strangulating) - simple no damage to blood supply, strangulating blood supply cut off

Question 18

What are causes of bowel obstruction in lumen, wall and outside wall respectively?

Answer 18

1. lumen: faecal impaction, gallstone ileus
2. walls: crohns, tumour, diverticulitis)
3. outside wall (strangulated hernia, volvulus, obstruction due to adhesions/bands)

Question 19

What are causes of small bowel obstruction?

Answer 19

Adhesions after surgery, neoplasia, incarcerated hernia, crohns

Question 20

What are causes of large bowel obstruction?

Answer 20

Colorectal cancer, volvulus (twisting of bowel itself), diverticulitis, faecal impaction, hirshprung’s disease (lack of ganglia - no peristalsis)

Question 21

What is the presentation of small bowel obstruction? What are signs? what sounds would we hear?

Answer 21

• Abdominal pain colicky and central, vomiting early onset, absolute constipation late sign, abdominal distension less significant.
• Signs: dehydration, increased high pitch bowel sounds. Absent bowel sounds later, diffuse abdominal tenderness

Question 22

What is presentation of large bowel obstruction? Signs?

Answer 22

• Pain colicky or constant, vomiting late, absolute constipation early, distention early and significant.
• Similar signs with SB obstruction

Question 23

How do you diagnose bowel obstruction?

Answer 23

Presence of symptoms. Should search for hernias and ab scars.

Question 24

What are features suggesting strangulation?

Answer 24

Change in character of pain from colicky to constant, tachycardia, pyrexia, peritoneum bowel sounds absent/reduced, leukocytosis, high CRP

Question 25

What types of hernias exist and when can strangulation happen?

Answer 25

Epigastric, umbilical, incisional, inguinal, femoral. If large defect bowel can go in and out without problem to blood supply, but if small defect higher chance of strangulation

Question 26

What is richer's hernia?

Answer 26

Knuckle of bowel caught but still continuity (without obstruction)

Question 27

What investigations for bowel obstruction? What can be seen if normal or strangulating?

Answer 27

Bloods - WCC/CRP normal unless strangulation/perforation. U&E for electrolytes. VBG: if vomiting & hypokalaemia maybe metabolic alkalosis. If strangulation metabolic acidosis (lactic acidosis). Imaging: erect CXR/AXR

Question 28

What is seen on imaging on small bowel obstruction?

Answer 28

Erect CXR/AXR: dilated small bowel loops >3cm proximal to obstruction (central)

Question 29

What is seen on imaging in large bowel obstruction?

Answer 29

Dilated large bowel >6cm (if caecum 9cm) predominantly peripheral.

Question 30

What does a CT abdo/pelvis show in bowel obstruction?

Answer 30

Shows transition point, dilation of proximal loops

Question 31

What does an AXR show in small bowel obstruction?

Answer 31

Ladder patterns of dilated loops and central position, striations that pass completely across width of distended bowel

Question 32

What does an AXR show in large bowel obstruction?

Answer 32

Distended large bowel peripherally, show haustriations of taenia coli (don’t extend whole width of bowel)

Question 33

What can a CT show in bowel obstruction?

Answer 33

Can localise site of obstruction (transition point), detect obstructing lesions/colonic tumours, unusual hernias

Question 34

What is conservative management of bowel obstruction and when is it done?

Answer 34

- In all except when sings of ischaemia/clinical deterioration. - Supportive: NBM, IV fluids, IV analgesia, anti-emetics, correct electrolyte imbalance, NG tube for decompression, urinary catheter to monitor output. Gradually introduce food when pain & distention improve

Question 35

What is done in case of faecal impaction?

Answer 35

Stool evacuation via manual, enema, endoscopic

Question 36

What is done in case of sigmoid volvulus?

Answer 36

Rigid sigmoidoscopic decompression to straighten large bowel

Question 37

What is done in case of small bowel obstruction? (adhesional)

Answer 37

Oral gastrograffin - highly osmolar iodinated contrast agent to resolve adhesional small bowel obstruction

Question 38

What are indications for surgery In small bowel obstruction?

Answer 38

Haemodynamic instability, sepsis signs, complete bowel obstruction with signs of ischaemia, closed loop obstruction, persistent bowel obstruction >2 days after conservative management

Question 39

What are operations done for bowel obstruction?

Answer 39

Exploratory laparotomy/laparoscopy, restoration of intestinal transit, bowel resection with primary anastamosis or temporary/permanent stoma formation

Question 40

How does a GI perforation present?

Answer 40

Sudden onset severe abdominal pain with distension, diffuse abdominal guarding, rigidity, rebound tenderness. Pain with movement, nausea, vomiting, absolute constipation, fever, tachycardia, tachypneoa, hypotension. Decreased/absent bowel sounds

Question 41

What are causes of GI perforation and how does each present?

Answer 41

1. perforated gastric ulcer (sudden epigastric or diffuse pain, referred shoulder pain because irritation of diaphragm, history NSAIDS, steroids, recurrent epigastric pain) 2. perforated diverticulum (LLQ pain, constipation) 3. perforated appendix (worsening RLQ pain, anorexia) 4. perforated malignancy (change in bowel habit, weight loss, anorexia, PR bleeding)

Question 42

What are investigations done in GI perforation? What would you see in imaging?

Answer 42

- Bloods (neutrophilic leucocytosis, maybe high urea/creatinine, lactic acidosis - imaging: erect CXR see subdiaphragmatic free air (pneumoperitoneum), - CT abdo/pelvis shows pneumoperitoneum and free GI content, localised mesenteric fat stranding

Question 43

What is conservative/supportive management on presentation of GI perforation?

Answer 43

NBM & NG tube decompression, IV fluids, broad spectrum Abx, IV PPI, parenteral analgesia & antiemetics, urinary catheter

Question 44

What can you do if localised peritonitis without sepsis signs (rare)?

Answer 44

IV guided drainage of intra abdominal collection, series of exams for change/assessment

Question 45

What surgical management done for generalized peritonitis with out without signs of sepsis in GI obstruction?

Answer 45

Exploratory laparotomy/laparoscopy, primary closure of perforation.

Question 46

What do you do if duodenal perforation?

Answer 46

Omental patch to close it

Question 47

Management if diverticulum perforation?

Answer 47

Resection of perforated segment of bowel with primary anastamosis or temporary stoma

Question 48

Why should you take culture from perforation?

Answer 48

Perforations can be malignancy

Question 49

What to do if appendix perforation?

Answer 49

Laparoscopic or open appendicectomy

Question 50

How does biliary colic present? What is seen in blood? What is seen in USS? How do you manage it?

Answer 50

Post-prandial RUQ pain with radiation to shoulder + nausea. Blood normal. USS shows cholelithiasis. Manage with analgesia, antiemetics, spasmolytics + elective cholecystectomy

Question 51

How does acute cholecystitis present? What is seen on bloods? What is seen on USS? Management?

Answer 51

Acute, severe RUQ pain, fever, murphy's sign. Elevated WWC/CRP. USS shows thickened gallbladder. Manage with fluids, antibiotics, analgesia, blood culture + early or elective cholecystectomy

Question 52

How does acute cholangitis present? What is seen on blood and USS? Management?

Answer 52

Charcot's triad: jaundice, RUQ pain, fever. Elevated LFTs, WCC, CRP. USS shows biliary dilatation. Manage with antibiotics, fluids, analgesia, ERCP to clear bile duct or stenting

Question 53

How does acute pancreatitis present? Bloods? CT/US? Management?

Answer 53

- Severe epigastric pain radiating to back, nausea +/- vomiting, history gallstones, alcohol use. - Bloods show high amylase/lipase, high WCC/low calcium. CT & US assess complications/causes. - Admission score (glasgow imrie score), aggressive fluid, O2, analgesia, anti-emetics, ITU/HDU involvement

Question 54

How does sigmoid volvulus present? What is seen on imaging?

Answer 54

Large bowel obstruction, pain, grossly distended abdomen. ABX shows distended oval gas shadow looped on itself (coffee bean sign) & haustra don’t extend across width of gas shadow.

Question 55

What conservative management is effective in treating majority of patients with sigmoid volvulus

Answer 55

sigmoidoscope passed with patient lying In left lateral position. Large well lubricated soft rubber rectal tube passed along sigmoidoscopy to untwist volvulus releasing flatus & liquid faeces

Question 56

Risk of untreated sigmoid volvulus?

Answer 56

Loop of sigmoid with its blood supply cut off by torsion would undergo necrosis

Question 57

If sigmoidoscopy does not work (serious sigmoid volvulus) what do you do?

Answer 57

Exploratory laparotomy & sigmoid colectomy with end colostomy (hartmann's procedure) - take twisted part of bowel & resect, making colostomy.

Question 58

What to do if serious sigmoid volvulus but bowel looks viable or patient not fit enough for bowel resection?

Answer 58

sigmoidopexy (not ideal)

Question 59

If suspecting acute mesenteric ischaemia what do you do?

Answer 59

1. Exploratory laparotomy (midline incision, evaluate viscera, if intestinal necrosis resect affected bowel loops). 2. Damage control laparotomy - stapled off bowel ends may be left in discontinuity, re0inspect after period of ICU resuscitation to restore physiological balance

Question 60

How do you restore blood flow in SMA?

Answer 60

1. Embolectomy of SMA (in embolic AMI). 2. Endovascular management of SMA thrombus (in thrombosis AMI). 3. Arterial bypass of SMA (in thrombotic AMI)

Question 61

What are arterial causes of acute mesenteric ischaemia?

Answer 61

1. embolism (50%): from left auricle (AF), mural infarct, atheroma from aorta or aneurism, endocarditis vegetations, left atrial myxoma 2. thrombosis (20-35%): blocks origin of SMA causing ischaemia to full length of small bowel. Due to atherosclerosis (often all main abdominal vessels) 3. non-occlusive (rare): hypotension/hypoperfusion, vasospasm in shock (NOMI), critically ill with vasopressor requirement, undergoing dialysis with large volume fluid removal

Question 62

Venous causes of AMI?

Answer 62

SMV thrombosis (in those with portal hypertension, portal pyaemia, sickle cell disease --> underlying hyper-coagulable state)

Question 63

What is portal pyaemia (pyelophebitis)?

Answer 63

Form of septic (often suppurative) thrombophlebitis of portal venous system. Complications of intra-abdominal sepsis (diverticulitis, appendicitis). See air in SMV & intra-hepatic portal venous system