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187 Cards in this Set
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Which is the only thyroid cancer that can lead to hot nodules?
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follicular thyroid cancer as it may produce thyroid hormones.
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Composition of gallstones?
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80% are cholesterol stones, most of these are mixed
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Estrogen decreases the enzymatic conversion of cholesterol to bile acids- the relative increase in cholesterol fosters precipitation out of solution
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Incidence of gallstones?
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Age 30: 5%F 2%m
Age 55: 20% F 10% M Age 70: 30% F , 20% M 80% are cholesterol stones, most of these are mixed |
Pigmented stones relate to the supersaturation of bile by calcium hydrogen bilirubinate
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What reduces the formation of cholesterol stones?
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NSAIDS, caffeine
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What is the usual time course from stone development to symptoms?
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8 years
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Why can clofibrate cause cholesterol stones?
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bile salt depletion
same mechanism as chrohns causing malabsorption in distal ileum |
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What are the mechanisms of bilirubin stone formation
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1. Increased bili load e.g. haemolysis
2. Glucuronidases ---> form insoluble bilirubin. Made by bacteria that grow if there is stasis/obstruction 3. Cirrhosis- depletion of glucuronidase inhibitors in the bile |
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When in the time course of untreated cholecystitis does empyema usually form?
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2-3 days later
(forms a phlegmon, leads to sepsis and gangrene) Rare progression to fistula, gallstone ileus (will see gas in the biliary tree, small bowel obstruction) |
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Where do gallstones impact to cause ileus?
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duodeno-jejunal flexure, sphincter of oddi
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What is the false negative rate of ultrasound for cholecystitis?
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5%
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What is usually seen on ultrasound in cholecystitis?
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thickening of gallbladder wall (>4mm) and decreased density adjacent to it (=halo, means that surrounding oedema)
Ultrasound can also suggest duct stones (dilated) and can suggest pancreatitis (altered echogenicity of pancreas) |
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Half life of amylase in the blood and urine
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24 hours in the blood, 5 days in the urine
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How can cholescintography be read?
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IV 99TC HIDA: if fails to outline the gallbladder suggestive of cystic duct obstruction
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Why does everyone with biliary colic get LFT's and amylase?
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because 10% will have concommittant common bile duct stones- having said that; imaging will only be positive if stone is currently osbstructing the bile duct
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When are prophylactic antibiotics given for cholecystectomy?
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Age >40, duct stone is suspected, immune depressed, morbidly obese
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Prophylactic antibiotics for cholecystectomy
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single dose of 2nd generation cephlasporin
extend dose 24-48 hours if sepsis do an intra-operative cholangiography to look for bile duct stones |
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Do you treat incidentally found gallstones?
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no as have 1% convert to symptomatic/year
exception is diabetes as they have more severe cholecystitis |
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What is usually seen on ultrasound in cholecystitis?
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thickening of gallbladder wall (>4mm) and decreased density adjacent to it (=halo, means that surrounding oedema)
Ultrasound can also suggest duct stones (dilated) and can suggest pancreatitis (altered echogenicity of pancreas) |
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Management of gallstones found incidentally at laparotomy
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reomove if technichally/anaesthetically suitable as have high chance of becoming symptomatic- 75% at 12 months
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What is usually seen on ultrasound in cholecystitis?
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thickening of gallbladder wall (>4mm) and decreased density adjacent to it (=halo, means that surrounding oedema)
Ultrasound can also suggest duct stones (dilated) and can suggest pancreatitis (altered echogenicity of pancreas) |
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Half life of amylase in the blood and urine
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24 hours in the blood, 5 days in the urine
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Is a drain usually used after a lap chole?
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no- there is little evidence that it improves the outcome after a bile leak but causes lots of post-op pain
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How can cholescintography be read?
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IV 99TC HIDA: if fails to outline the gallbladder suggestive of cystic duct obstruction
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Half life of amylase in the blood and urine
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24 hours in the blood, 5 days in the urine
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In general, what are the difference in complications of lap versus open chole?
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lap has less minor complications, wound infections and respiratory morbidity, and quicker recovery but more major complications- the most important of which being bile duct injury
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Why does everyone with biliary colic get LFT's and amylase?
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because 10% will have concommittant common bile duct stones- having said that; imaging will only be positive if stone is currently osbstructing the bile duct
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How can cholescintography be read?
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IV 99TC HIDA: if fails to outline the gallbladder suggestive of cystic duct obstruction
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Why does everyone with biliary colic get LFT's and amylase?
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because 10% will have concommittant common bile duct stones- having said that; imaging will only be positive if stone is currently osbstructing the bile duct
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When are prophylactic antibiotics given for cholecystectomy?
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Age >40, duct stone is suspected, immune depressed, morbidly obese
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When are prophylactic antibiotics given for cholecystectomy?
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Age >40, duct stone is suspected, immune depressed, morbidly obese
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Prophylactic antibiotics for cholecystectomy
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single dose of 2nd generation cephlasporin
extend dose 24-48 hours if sepsis do an intra-operative cholangiography to look for bile duct stones |
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Do you treat incidentally found gallstones?
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no as have 1% convert to symptomatic/year
exception is diabetes as they have more severe cholecystitis |
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Prophylactic antibiotics for cholecystectomy
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single dose of 2nd generation cephlasporin
extend dose 24-48 hours if sepsis do an intra-operative cholangiography to look for bile duct stones |
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Do you treat incidentally found gallstones?
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no as have 1% convert to symptomatic/year
exception is diabetes as they have more severe cholecystitis |
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Management of gallstones found incidentally at laparotomy
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reomove if technichally/anaesthetically suitable as have high chance of becoming symptomatic- 75% at 12 months
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Management of gallstones found incidentally at laparotomy
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reomove if technichally/anaesthetically suitable as have high chance of becoming symptomatic- 75% at 12 months
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Is a drain usually used after a lap chole?
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no- there is little evidence that it improves the outcome after a bile leak but causes lots of post-op pain
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Is a drain usually used after a lap chole?
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no- there is little evidence that it improves the outcome after a bile leak but causes lots of post-op pain
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In general, what are the difference in complications of lap versus open chole?
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lap has less minor complications, wound infections and respiratory morbidity, and quicker recovery but more major complications- the most important of which being bile duct injury
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In general, what are the difference in complications of lap versus open chole?
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lap has less minor complications, wound infections and respiratory morbidity, and quicker recovery but more major complications- the most important of which being bile duct injury
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Current approach to cholecystectomy?
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usually start with lap: if biliary anatomy too complex due to severe infection- convert to open
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What % of people with gallstones present with complication of common bile duct stones?
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50% over the age of 60
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What does fluctuating jaundice suggest?
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intermittent obstruction from a stone or from a polypoid preampullary cancer
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When is percutaneous transhepatic cholangiography preferable to ERCP?
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Involves injection of contrast into the pancreatic duct- preferable to ERCP when the ampulla is inaccessible or when previous biliary surgery has transsected the bile duct
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How does CT cholangiography work?
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produces IV opacification of the bile duct- uses a contrast agent that is taken up by hepatocytes and enters the biliary tree- works if bilirubin <2x the normal level
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Indications for ERCP in choledocholithiasis?
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Diagnostic and therapeutic in the setting of cholangitis (reserve for those that need therapeutic intervention)- CT cholangiography has largely replaced ERCP when used for diagnostic reasons in a non-jaundiced patient.
Gallstones are poorly visualised on CT |
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Advantages of CT cholangiography over ultrasound?
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Other pathologies that are causes or complications of cholangitis (eg, ampullary tumors, pericholecystic fluid, liver abscesses) can be imaged.
Pathology that must be distinguished from cholangitis also can be observed (eg, right-sided diverticulitis, papillary necrosis, some evidence of pyelonephritis, mesenteric ischemia, ruptured appendix). Detection of biliary pathology with CT cholangiography approaches that of ERCP. |
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Advantages of MRCP in imaging cholangitis?
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very good for imaging the liver- especially vascular anatomy and bile ducts- even in jaundice
Good for assessing resectability of lesions |
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Most common cause of biliary strictures?
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malignancy in surrounding organ: pancreas, gallbladder, duodenum, porta hepatis
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What is isotope scanning useful for in the setting of cholangitis
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Not used very often
Useful for defining site of leak in biliary firsula |
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Causes of benign biliary strictures
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Often as a result of damage during cholecystectomy- can occur immeadiately or after a 10 year delay
other causes: biliary atresia |
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How does a cholangiocarcinoma invade
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usually locally into surrounding vessels and liver
Can cause vascular occlusion leading to segmental or hemilobular atrophy of the liver |
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Anything special about cholangiocarcinomas occuring at the distal end of the bile duct?
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usually polypoid, better prognosis than a klatskin tumout
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Prognosis of cholangiocarcinoma
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Generally dismal. If resectable there is a 30% survival at 3 years. If non-resectable manage with palliative bypass surgery/stenting or- plastic stents stay patent for three months, metal stents last longer but can't be removed intraluminal iridium brachytherapy/PDT/ chemoradiotherapy(gemcytabine, cisplatin)
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Procedural pain relief for cholangiocarcinoma
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celiac plexus block via regional injection of alcohol or other sclerosing agent- relieves pain in the mid back which is associated with retroperitoneal tumour growth
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When should biliary atresia be surgically corrected?
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presents in the first few weeks of life- surgically corrected before 8 weeks
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What is biliary atresia associated with
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intestinal malrotation and genitourinary abnormalities
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Management of biliary atresia
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hepatojejunostomy when a bit of the bile duct is present or portoenterostomy if it is severe (more common)
Often will need liver transplant |
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What is a choledochal cyst?
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cystic dilatation of the intra/extrahepatic ducts
Presents usually before age 16 but 20% will present in adulthood |
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Complications of choledochal cyst?
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cholangitis
pancreatitis stone formation jaundice 25% of untreated cysts develop cholangiocarcinoma |
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Management of choledochal cyst
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cyst excision if preferred
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Who gets symptoms in biliary spasm
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susceptible individuals, often young women
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Diagnosis of biliary spasm
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ERCP with manometry to demonstrate high pressure contractions with retrograde peristalsis
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Management of bilary spasm
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antispasmodics
endocopic sphincterotomy is an option but symptoms has vatiable sucess |
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Pre-operative management of a jaundiced patient
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correct coagulopathy
antiviotics central venous pressure mkonitoring and urinary catheterisation aggressive rehydration to reduce risk of renal failure |
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post operative management of a jaundiced patient
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expect termporary wortening of LFT's
enteric nutrition/TPN Remove drains after bile no longer leaking |
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What is the most common benign liver neoplasm
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Hemangioma- found in up to 7% of autopsy specimens
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Most common cause of HCC in western countries
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approx 90% due to alcoholic cirrhosis
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When are metastases of colorectal cancer in the liver potentially curanle?
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if there is no extrahepatic disease
if there are fewer than 4 mets lesions are anatomically resectable with 1cm resection margin * age alone is not a mortality risk factor, often do not need a blood transfusion |
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Management of sepsis post resection of a liver metastasis
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Usually in the form of a local abscess- manage via a radiologically placed drain
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What is the use of cryotherapy in the management of metastases to the liver
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for unresectable disease- does not destroy much normal liver
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How does regional/hepatic artery chemotherapy work?
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5FU or other chemotherapy into a hepatic artery- may ectend life in patients with unresectable liver metastases
No benefit in patients with extrahepatic disease Catheter insered into the gastroduodenal artery with its tip in the common hepatic artery Gallblasdder is removed- as can cause toxic cholecystitis Survival advantage (20 vs 8m in untreated) and less systemic toxicity. Can get arterial thombosis or aneurism as well as catheter related problems. |
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Role of hepatic artery embolisation?
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palliates a large painful liver in metastases to the liver (these have an arterial supply)
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Systemic chemotherapy used for liver metastases for colorectal cancer?
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5FU + pral capecitabine
ivermectin/oxaliplatin |
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Who does large bowel pbstruction occur in?
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elderly
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Causes of large bowel obstruction
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Cancer of the colon (50%)- 50% sigmoid as narrol lumen and firm poo, splenic flexuse is second most common site
sigmoid volvulus diverticular disease pseudoobstruction (AND imbalance, increases SNS) |
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Features of right large bowel obstruction?
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less common, less obvious. If at iliocecal junction looks just like SBO
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Features of large bowel obstruction from diverticular disease
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usually in sigmoid colon
diverticulosis+ scarring --> muscle wall hypertrophy and structuring, may look like large bowel cancer |
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Why can fecal impaction present like fecal incontinence?
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fecal bolus relaxes the rectosphincteric reflex
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What do you see on AXR in sigmoid volvulus?
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distended cecum in RUQ
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workup of a suspected large bowel obstruction?
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plain AXR- if see free gas/peritonitis then immeadiate surgical management is indicated.
If see a distended colon: proceed to a gastrigraffin enema (diagnostic and therapeutic in cases of fecal impaction) If see a stricture: surgical management If see a volvulus: endoscopic decompression and/or surgery If see pseudoobstruction: manage conservatively for 24 hours then mechanical evacuation, prokinetics, colonoscopic decompression, and surgery |
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What do you see on AXR in sigmoid volvulus?
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distended cecum in RUQ
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Management of malignant structures that have led to a bowel obstruction?
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surgery or a metallic stent if rectal/rectosigmoid- this stent can either be palliative or stay in place for a few weeks before a resection and an anastomosis be done- these stents are expensive and may perforate or bleed
Right colonic obstructions are threated with a right colectomy and a primary anastomosis between the ileum and the transverse colon. Patients with high risk fectures (advanced age, complete obstruction or severe comorbidities) may benefit from stent placement until they are optimised for the surgical procedure. |
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workup of a suspected large bowel obstruction?
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plain AXR- if see free gas/peritonitis then immeadiate surgical management is indicated.
If see a distended colon: proceed to a gastrigraffin enema (diagnostic and therapeutic in cases of fecal impaction) If see a stricture: surgical management If see a volvulus: endoscopic decompression and/or surgery If see pseudoobstruction: manage conservatively for 24 hours then mechanical evacuation, prokinetics, colonoscopic decompression, and surgery |
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Management of large bowel obstruction caused by diverticular disease
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Medical therapy for the infection
Surgical resection follows the same preinciples as the treatment of carcinomas- may need to remove the entire sigmoid If sepsis present do a Hartmann's procedure |
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Management of malignant structures that have led to a bowel obstruction?
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surgery or a metallic stent if rectal/rectosigmoid- this stent can either be palliative or stay in place for a few weeks before a resection and an anastomosis be done- these stents are expensive and may perforate or bleed
Right colonic obstructions are threated with a right colectomy and a primary anastomosis between the ileum and the transverse colon. Patients with high risk fectures (advanced age, complete obstruction or severe comorbidities) may benefit from stent placement until they are optimised for the surgical procedure. |
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Most common approach to a left malignant large bowel obstruction?
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3 stage procedure involving a proximal colostomy with resection weeks later and closure of the colostomy weeks/months later. Recently one stage resections with on table with total colonic lavages have been done to well patients.
If there has been perforation of the bowel or sepsis- do a Hartman's procedure |
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What is a hartman's procedure
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Sigmoid colostomy + oversewing of the rectal stump
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Management of cancer of the spenic flexure/proximal colon/cecum?
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Resection and end to end iliocolic anastomosis if well enough
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Most important vessel for acute mesenteric ischemia
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SMA
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Most important vessel for acute mesenteric ischemia
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SMA
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Types of mesenteric ischemia
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occlusive or low flow state (inadequate perfusion, hypotension, spasm, intestinal distension)- usually in ICU patients
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Types of mesenteric ischemia
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occlusive or low flow state (inadequate perfusion, hypotension, spasm, intestinal distension)- usually in ICU patients
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Types of mesenteric ischemia
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occlusive or low flow state (inadequate perfusion, hypotension, spasm, intestinal distension)- usually in ICU patients
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What are the main causes of SMA occlusion leading to acute mesenteric ischemis
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embolic : uncommon
thrombosis venous thrombosis |
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What are the main causes of SMA occlusion leading to acute mesenteric ischemis
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embolic : uncommon
thrombosis venous thrombosis |
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What are the main causes of SMA occlusion leading to acute mesenteric ischemis
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embolic : uncommon
thrombosis venous thrombosis |
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Progression of symptoms in acute mesenteric ischemia
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1. intense loss of circulating blood volume and acidosis
2. reperfusion injury (xanthine oxidase leads to superoxide production) 3. muscosal disruption and bacterial invasion- septicaemia and both hypovolaemia and septic shock |
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Progression of symptoms in acute mesenteric ischemia
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1. intense loss of circulating blood volume and acidosis
2. reperfusion injury (xanthine oxidase leads to superoxide production) 3. muscosal disruption and bacterial invasion- septicaemia and both hypovolaemia and septic shock |
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Progression of symptoms in acute mesenteric ischemia
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1. intense loss of circulating blood volume and acidosis
2. reperfusion injury (xanthine oxidase leads to superoxide production) 3. muscosal disruption and bacterial invasion- septicaemia and both hypovolaemia and septic shock |
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Tupical patient with acute mesenteric ischemia
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often elderly with cardiac disease and peripheral vascular disease
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Tupical patient with acute mesenteric ischemia
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often elderly with cardiac disease and peripheral vascular disease
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Most important vessel for acute mesenteric ischemia
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SMA
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Tupical patient with acute mesenteric ischemia
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often elderly with cardiac disease and peripheral vascular disease
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Types of mesenteric ischemia
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occlusive or low flow state (inadequate perfusion, hypotension, spasm, intestinal distension)- usually in ICU patients
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What are the main causes of SMA occlusion leading to acute mesenteric ischemis
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embolic : uncommon
thrombosis venous thrombosis |
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Progression of symptoms in acute mesenteric ischemia
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1. intense loss of circulating blood volume and acidosis
2. reperfusion injury (xanthine oxidase leads to superoxide production) 3. muscosal disruption and bacterial invasion- septicaemia and both hypovolaemia and septic shock |
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Tupical patient with acute mesenteric ischemia
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often elderly with cardiac disease and peripheral vascular disease
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When does bloody diarrhoes occur in acute mesenteric ischemia?
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a late sign when infarction occurs- versus ischemic colitis where profuse bloody diarrhoea is an early and frequent sign
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Bloods in acute mesenteric ischemia
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increased WCC, PO4, metabolic acidosis --> all imply bowel necrosis
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What does peritonism mean in mesenteric ischemia
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irreversible damage has been done
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Radiographic changes in acute mesenteric ischemia?
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initially all normal- later ileus as well as air in the liver and the portal vein
If stable do visceral angiography for diagnosis- but 1/3 non-occlusive so cannot rule out |
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Management of acute mesenteric ischemia
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rehydration and monitoring
blood cultures and antibiotics angiography when stable: if thrombotic give hepatin to prevent clot extension and countteract DIC thrombolytic is suspect irreversible ischemia vasodilatory aget for non-occlusive mesenteric ischemia, also epidural block may help relieve the reflex component of the vasospasm |
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What parts of the colon are most affected by thrombotic mesenteric ischemia?
(laparotomy findings) |
usually thrombosis occurs in the proximal SMA
damage to the whole midgut from the ligament of Trietz to the splenic flexure |
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What is the most common site for embolism in acure mesenteric ischemia?
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middle colic artery
midgut but sparing of the proximal jejunum and the right transverse colon Can treat with embolectomy/patch graft (antimesenteric) etc, |
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Options on laparotomy for mesenteric ischemia
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purpose is to define viable versus non-viable bowel and spare as much viable bowel as possible
1. may close without further activity if mostly dead and will need TPN 2. Resect dead bowel and externalise both ends- restore continuity in 4-6m 3. primary anasomosis if viability assured 4, 2nd look laparotomy in 24-48 hours and TPN supplementation - if extensive bowel involvement |
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Prognosis of acute mesenteric ischemia
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infarct- 90% mortality
emboli- slightly better non-occlusive worse |
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Epidemiology and causes of mesenteric venous thrombosis?
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<10% of infarcts
20% idiopathic causes: portal hypertension, haem diseases/malignancy, IBD, sepsis, OCP reaction, trauma |
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Symptomatology of mesenteric venous thrombosis?
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insidious onset with vagua abdominal discomfort and nausea
late: acute abdomen and leukocytosis |
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How is mesenteric venous thrombosis diagnosed?
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radiography: non-specific ileus with dilated small bowel loops
DPL; serosanguinous fluid diagnosis made at surgery: congested, cyanotic, oedematous bowel with pulsatile medenteric artery |
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Management of mesenteric venous thrombosis?
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resus and surgery
usually damage is limited so a segmental resection with primary end-end anastomosis is possible Anticoagulate after surgery as 20% recurr- at least 6months of warfarin is inficated |
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Normal length of small bowel
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350cm
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When does short bowel syndrome occur?
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if lose > 50-70% of remaining length or have <100cm of small bowel
If <100 cm of distal ileum: bile salt malabsorption, ADEK loss and steatorrhea |
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Malabsorption of different nutrients in short bowel
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protein/fat worse than carbohydrate
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How long does small adaptation continue after a resection?
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most in the 1st 6m but continues for 3 years
Younger adapt better better function when the iliocecal valve is patent: this decreases the bacterial colonisation of the ileum and slows intestinal transit |
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Initial enteral feeds after a small bowel resection
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initially 5% dextrose + 1/2 normal saline, as adapts add simple sugars, peptides, electrolytes and small amounts of fats, vitamins and trace elements.
Initially dilute and later hyperosmolar glutamine infusions to protect musosal growth |
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Normal length of small bowel
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350cm
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When does short bowel syndrome occur?
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if lose > 50-70% of remaining length or have <100cm of small bowel
If <100 cm of distal ileum: bile salt malabsorption, ADEK loss and steatorrhea |
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Malabsorption of different nutrients in short bowel
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protein/fat worse than carbohydrate
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How long does small adaptation continue after a resection?
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most in the 1st 6m but continues for 3 years
Younger adapt better better function when the iliocecal valve is patent: this decreases the bacterial colonisation of the ileum and slows intestinal transit |
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Initial enteral feeds after a small bowel resection
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initially 5% dextrose + 1/2 normal saline, as adapts add simple sugars, peptides, electrolytes and small amounts of fats, vitamins and trace elements.
Initially dilute and later hyperosmolar glutamine infusions to protect musosal growth |
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Additives to early enteral feeding after a bowel resection?
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antidiarrhoeals
bulking agent cholestyramine if bile salt malabsorption is a problem H2RA/PPI is too much gastric secretion somatostatin analogues (decrease fistula output, slow intestinal transit, increase absorption) |
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Is there a good correlation between angiographic findings and clinical disease in chronic mesenteric ischemia?
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no
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Manasgement of chronic medenteric ischemia?
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surgery if there is clinical evidence of ischemia and critical stenosis in 2/3 vesseks
bypass graft with prosthetic material and autogenous venous graft |
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Which parts of the col9on are most susceptible to ischemia in ischemic collitis?
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Griffith's point- at splenic fexure (SMA/IMA watershed)
Sudek's critical point (IMA/hypogastric watershed) |
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Phases of ischemic colitis
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1. reversible/ submucosal (thumbprinting on AXR(
2. Ischemic stricute - partial thickness, late and unpredictable event 3. Gangrene: full thickness necrosis, perforation, sepsis and death. Avoid contrast studies |
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Symptoms of ischemic colitis?
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LIF pain
bloody diarrhoea fever abdominal distension |
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Diagnosis of ischemic colitis?
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imaging e.g. thumbprinting of bowel is a hint
colonoscopy on unprepared bowel and biopsy for definitive diagnosis |
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Managaement of ischemic colitis
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early: bowel rest, fluids, antibiotics (most recover)
surgery: peritonitis, perforation and sepsis. Stoma and oversewing/stapling/externalisation of distal part. |
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Prognosis is ischemic colitis?
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Approx 20% mortality (if folliwing aortic surgery esp. AAA repair)
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Where is the initial pain of accute appendicitis?
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midgut pain, peruiumbilical
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prodrome of acute appendicitis?
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12-24 hours
anorexia, nausea, vom |
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Who gets RUQ pain in acute appendicitis?
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long appendix
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Pain of retrocecal appendicitis?
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loin pain
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Frequency of mesenteric adenitis in ppl getting appendicectomy?
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5%
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Clinical course of mesenteric adenitis
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(enlarged lymph nodes in mesentry of terminal ileum, mimic of appendicitis)
more common in kids often a history of fever/sore throat no rigidity spontaneous improvement in 24-36 hours remove appendix anyway |
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Management of appendiceal abscess
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drain under CT guidance
if phlegmon present- bowel rest/IV antibiotics (85% sucessful, 25% repeat sepsis) Appendicectomy 6-8 weeks later if >35 do a barium enema/colonoscopy first (to rule our perforated cecal cancer with pericolic abscess) |
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Properties of Meckels
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antimesenteric
true diverticulum has its own blood supply 20% have heterotopic epithelium |
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How can Meckels cause an SBO?
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intussuception
band between diverticulum and umbilicus: kinking/volvulus Diverticulitis |
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Management of Meckels?
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If symptomatic: resect diverticulum and involved small bowel
If found incidentally: leave unless band, <2y/o, palpable heterotopia, adhesions (evidence of past diverticulitis) |
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Indications for open surgical drainage in an intra-abdominal abscess?
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if multiloculated, deep, fails to resolve with percutaneous drainage
extraperitoneal approach is preferred- to avoid further contamination of the peritoneum. Transvaginal/transrectal approach for bulging pelvic abscesses. |
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What comes first: abscess drainage or antibiotics?
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antibiotics
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Where is the pacemaker that controles colonic motility?
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in the transverse colon- also the major region of storage
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Assessment of constipation
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roadio-opaque markers + standard timed plain film xrays
disorders of defacation: defacating proctography |
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Most common position for a gastric ulcer?
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pre-pyloric
May erode major vessels |
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Inidications for surgery for a peptic ulcer vleed
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massive haemorrhahe + loss >6U and endoscopic therapy failed
elderly esp. if large ulcer is present as tolerate blood loss poorly |
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Mortality from ulcer bleed
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5-20%- mainly because elderly
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What are some emergency surgeries for variceal bleeds?
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sutre varices- ligation
disconnection procedure- completely devascularise stomach |
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Flora of the lower urinary tract
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Staph epidermitis
streptococci diptherioids Gram negative rods |
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What part of the bowel is most commonly affected by diverticular disease?
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sigmoid colon
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What % of diverticulosis is asymptomatic?
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80%
Some patients complain of symptoms such as cramping, bloating, flatulence and irregular defacation- but unclear whether these are attributable to the diverticulosis or coexistant IBS |
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What is diverticulitis?
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micro or macroperforation of a diverticulim
Primary process is thought ti be erosion of the diverticular wall by increased intraluminal pressure or stool within a diverticulum |
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Most common complaine in diverticulitis?
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Left lower quadrant pain
often present for several days before admission Up to 1/2 had similar episodes |
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What is the mechanism of diverticular bleeding
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as diverticulum herniates- stretches vessel leading to exxentric intimal thickening and thinning of the media
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Ct features of acute diverticulitis?
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Increased soft tissue density within pericolic fat
colonic diverticula bowel wall thickening phlegmons (soft tissue masses), abscesses (pericolic fluid collection) |
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Management of mild diverticulitis
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low residue diet
7-10d of augmentin or cephalexin + metrinidazole if no improvement 48 hrs- consider ct abdo Confirm dx by colonoscopy 6 weeks later: 33% of diagnoses will be incorrect |
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Management of severe/complicated diverticulitis
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systemic feat/peritonism/fail to respond to outpt rx
bowel rest and IV amp + gent + metro Switcyh to oral and start low res diet once afebrole for 24 hours |
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Indications for surg mx of diverticulitis?
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peritonitis associated with perforation
abscess that is not amenable to percutaneous drainage bowel obstruction. |
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Are diverticula always apparent on external examination of the colon?
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no, project ebtween the appendices epiploicae
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What preceeds the appearance of actual diverticula in diverticulosis?
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Shortening and thickening of the sigmoid: thickening of both the longditudional and circular muscle of the colon
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What are the two layes of diverticula?
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inner mucosal and outer serosal
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Examination in diverticulosis
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sigmoid colon is often palpable- may also be palpated in the pelvis on rectal examination
makes rigid sigmoidoscopy difficult to advance beyond the rectosigmoid junction |
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What is Saint's triad?
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diverticular disease
cholelithiasos hiatus hernia |
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Indications for elective management of diverticular disease (surgical)
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chronic sx despite use of a high fibre diet and buld forming agents
recurrent acute diverticulitis persistent tender mass inability to distinguish colonic lesion from carcinoma Elective operations more common in younger (<55) and immunosuppressed |
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Timing of resection for diverticular disease
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8 weeks after most recent episode of diverticulitis
Only segment of colon with inflammatory reaction removed- in general this includes entire sigmoid colon and rectosigmoid junction down to the upper rectum primary colorectal anastomosis laproscopic approach |
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What do you use for pain relief in acute diverticulitis
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pethidine
avoid morphine as it increases intraluminal pressure |
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Operative options for diverticular disease
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percutaneous abscess drainage- leave catheter in and regularly irrigate with normal saline until drainage ceases and cavity completely collapsed
Hartman's procedure: if purulent or faecal peritonitis is present Proximal diverting colostomy with closure 2-3m later (reversal easier than hartmans but initial dissection more extensive and can spread the sepsis) On table large vowel irrigation and primary closure (only if sepsis v. confined) |
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Gender of patients with colovesical fistula?
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male, throught that urerus is a protective shield between the bladder and colon in females
presents with recuttent UTI's CT most useful for dx |
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Prevalence of mesenteric adenitis in patients getting an appendicectomy?
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5%
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Antibiotic prophylaxis for lap chole
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metranidazole + cephazolin/gent
metro may be omitted if <60, elective surgery, non likely to be exploring the bile duct i.e. not in the emergency setting |
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Management of cholangitis
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Antibiotics, fluids, correction of coagulopathy
80% respond to conservative management- then biliary drainage can be performed on an elective basis |
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Indications for urgent biliary decompresson in cholangitis?
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persistent abdominal pain
hypotension despite adequate resus fever >39 Mental confusion Drain with ERCP. 50% mortality if have Raynaud's pentad. |
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Antibiotics for ascending cholangitis?
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ampicillin + gentamycin
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Organisms found in a psoad abscess
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Depends on source
S. aureus (haematogenous, osteomyelitis) Mixed enteric flora: intra-abdominal or pelvic |
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Sx of psoas abscess
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fever
low abdo or back pain pain referred to hip or knee + ve psoas sign In TB can present as swelling or 'cold abscess' below the inguinal ligameny |
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Diagnosis of psoas abscess
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CT
MRI may give better visualisation of adjacent soft tissue structures i.e. vertebral bodies |
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Where is the mass of a psoas abscess?
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inguinal
occasionally extends downwards and presents as a painful/painless mass below the inguinal ligameny |
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