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Gastrointestinal Surgery Amelia Shabir as2322@ic.ac.ukTILOS COVERED Abdominal pain: Relate the symptoms and signs of abdominal pain to the diagnosis and treatment of common intra-abdominal pathology Intestinal disorders: Summarise the pathology and pathophysiology of small and large intestine disorders Intestinal disorders: Describe the clinical features and treatment options of small and large intestine disorders Gastrooesophageal disorders: Describe the clinical features and treatment options of gastrooesophageal disorders Hepatobiliary and pancreatic disorders: Describe the clinical features and treatment options of hepatobiliary and pancreatic disordersLECTURE TIMELINE 1. Where is 2. Bowelobstruction + 3.Appendicitis 4.Bowel Perforation 5.BowelIchaemia 6.Gallbladderdisease the pain? herniasPRESENTATION DIAGNOSIS MANAGEMENT Bowel obstruction SmallbowelObstruction Acutemesentericischaemia Largebowelobstruction Bowel Ischaemia Ischaemiccolitis Sigmoidvolvulus Hernias Biliarycolic Gallbladder disease Acutecholecystitis Ascendingcholangitis Acute Appendicitis Perforatedoesophagus (coveredinupperGItract) Perforatedpepticulcer GI perforation Acute pancreatitis – medicallymanagedbuta possibledifferential PerforatedDiverticulum Perforatedappendix PerforatedmalignancyHow do I know which organ is affected? SITE - “Where is the pain?” RADIATION/MIGRATION - “Where does the pain move to?”ABDOMINAL PAIN LOCATIONS AND RADIATIONS/MIGRATION PERFORATEDPEPTIC BILIARY COLIC/ ULCER CHOLECYSTITIS/ CHOLANGITIS R Hypochondriac Epigastric L Hypochondriac RUQ LUQ ACUTE PANCREATITIS SMALL BOWEL OBSTRUCTION AMI R Lumbar Umbilical/ Central L Lumbar LARGE BOWEL OBSTRUCTION RLQ LLQ ISCHAEMIC COLITIS PERFORATED R Iliac Suprapubic L Iliac 00 DIVERTICULUMCHARACTER - “Can you describe the pain?” ASSOCIATED SYMPTOMS – “Are you experiencing any other symptoms?”SMALL BOWEL OR LARGE BOWEL OBSTRUCTION? A patient comes in complaining of central abdominal pain, around the umbilical area. It is colicky in nature, and associated with nausea and bilious vomiting. They haven’t been able to pass stool for the last 24 hours, but have been passing some wind. Their abdomen is diffusely tender but not noticeably distended.SMALL BOWEL OR LARGE BOWEL OBSTRUCTION? A patient comes in complaining of central abdominal pain, around the umbilical area. It is colicky in nature, and associated with nausea and bilious vomiting. They haven’t been able to pass stool for the last 24 hours, but have been passing some wind. Their abdomen is diffusely tender but not noticeably distended. = SMALL BOWEL OBSTRUCTION! SMALL BOWEL OR LARGE BOWEL OBSTRUCTION? PRESENTATION OBSTRUCTION Colicky pain, Diffuse abdominal tenderness, ‘Tinkling’ bowel sounds SMALL BOWEL OBSTRUCTION LARGE BOWEL OBSTRUCTION Umbilical/Central pain Central/ Lower abdomen pain Early onset nausea and vomiting Late onset faecal vomiting progression from bilious vomiting (bilious) ABSOLUTE constipation (no passing stool OR GAS) Constipation (no passing stool) Abdominal distensionPAST MEDICAL HISTORY – What’s some important things to ask?PAST MEDICAL HISTORY – What’s some important things to ask? Any hernias or lumps noticed Any past surgeries – possible adhesions Any fevers, night sweats, unexpected weight loss - malignancySMALL BOWEL OR LARGE BOWEL OBSTRUCTION? CAUSE SMALL BOWEL OBSTRUCTION LARGE BOWEL OBSTRUCTION ADHESIONS MALIGNANCY Malignancy Sigmoid volvulus Incarcerated hernia Diverticulitis Crohns Faecal impaction Intussusception Hirschsprung diseaseSMALL BOWEL OR LARGE BOWEL OBSTRUCTION? VOLVULUS Sigmoid volvulus – twisted bowel COFFEE-BEAN SIGN CONSERVATIVE: Untwist via rigid sigmoidoscopy SURGICAL: Exploratory laparotomy + Hartmann’s procedure(resect sigmoid colon + form colostomy) High yield (therefore 1 slide to itself)SMALL BOWEL OR LARGE BOWEL OBSTRUCTION? INVESTIGATIONS ERECT CXR/ABDO X-Ray is first-line imaging 3/6/9 rule SMALL BOWEL OBSTRUCTION LARGE BOWEL OBSTRUCTION 1. Central loops 1. Peripheral loops 2. Valvulae 2. Haustrations of conniventes taenia coli (The bowel lines are (the bowel lines go across the width of only really seen at the loop) the edges)SMALL BOWEL OR LARGE BOWEL OBSTRUCTION? INVESTIGATIONS CT-scan with IV contrast is gold-standard for diagnosis – locate and identify obstruction Fluid filled, dilated bowel loopsWhy should we check for a hernia if the patient has a bowel obstruction? “Irreducible lump” -> incarceration “loss of blood supply” -> STRANGULATED HERNIA COLICKY PAIN -> CONTINUOUS!! - Pyrexia, tachycardia - Peritonism - ABSENT bowel sounds - metabolic acidosis/ high lactate - raised CRP MEDICAL EMERGENCY: Can lead to ischaemia – necrosis - death “Lump in the inguinal region” <- Richter’s hernia “when only part of the bowel lumen is herniated” Rare but high risk of strangulationMANAGEMENT SUPPORTIVE = “Drip and Suck” CONSERVATIVE = Reversible causes SURGICAL DRIP: Faecal impaction -> stool evacuation If: 1. signs of bowel ischaemia - IV fluid resuscitation large bore cannula (lactate high, no bowel sounds) - IV anti-emetics Sigmoid volvulus -> rigid sigmoidoscopy 2. conservative management not - IV analgesia decompression working after 2 days SUCK 3. Sepsis/ blood pressure drop Adhesions -> oral gastrogaffin - patient NBM 4. Closed loop obstruction - NG tube decompression - Monitor urine output EXPLORATORY LAPAROTOMY/ Resection of any LAPARASCOPY dead bowel, resulting in primary anastomosis or Endoscopic stenting stomaCHARACTER - “Can you describe the pain?” ASSOCIATED SYMPTOMS – “Are you experiencing any other symptoms?”SBAQ : A patient comes in with right iliac fossa pain, and you suspect appendicitis. Which of the following clinical signs are NOT indicative of appendicitis? A. Psoas sign B. Mc Burney’s point tenderness C. Murphy’s sign D. Rovsing sign E. Blumberg signAPPENDICITIS – CLASSICAL SIGNS Movement of pain from umbilical region to right iliac fossa over 24hrs Anorexia with nausea and possible vomiting or change in bowel habit Fever umbilicus McBurney’s point tenderness ASIS Rovsing’s sign – RLQ pain on deep palpation of LLQ Psoas sign – RLQ pain on extension of right hip Blumberg sign: rebound tenderness in RIFAPPENDICITIS - INVESTIGATIONS Adults esp >50yrs Children/ pregnant/ breastfeeding CT USS (ultrasound scan) You won’t need to read one! INCONCLUSIVE BUT IN A LOT OF PAIN? Diagnostic laparoscopyMANAGEMENT CONSERVATIVE/SUPPORTIVE SURGICAL If: THE DEFAULT OPTION!! 1. Clinically uncomplicated appendicitis in high surgical risk patient Either laparoscopic or open appendicectomy, 2. You have an abscess or phlegmon (localized acute inflammation) – though we may take it out Laparoscopic preferred later to avoid recurrence (interval (less risk of infection, less pain, faster recovery) appendicectomy) The conservative 3 ;) - IV Fluids - IV analgesia - IV or PO antibioticsVSAQ: Identify the abnormality in this X-rayVSAQ: Identify the abnormality in this X-ray Sub-diaphragmatic free-air Aka pneumoperitoneumVSAQ: What can this abnormality be a sign of?GI perforation: Identification Pain is SUDDEN ONSET, constant + Sub-diaphragmatic free air/ severe, worse on movement pneumoperitoneum PERITONITIC: Guarding, rigidity, “localized fat stranding” on CT rebound tenderness everywhere Free content in abdomen Nausea, vomiting High lactate Septic shock? Fever, tachycardia, tachypnoea, hypotension Perforatedoes(coveredinupperGItract) May depend on location, so for eachtedpepticulcer possible source of perforatiPerforatedDiverticulum Absent bowel sounds about how you would identify the organ responsible Perforatedappendix PerforatedmalignancyGI perforation: IdentificationMANAGEMENT SUPPORTIVE CONSERVATIVE SURGICAL If: KEEP THEM STABLE If: - peritonitis is generalized - IV fluid resuscitation large bore cannula - peritonitis is localized - no signs of sepsis - and/or signs of sepsis - Urinary catheter OPEN UP + CLEAN SYMPTOM RELIEF - Drain intra-abdominal Exploratory laparotomy/laparoscopy collection minimally invasively MC&S of fluid, peritoneal lavage - Parenteral anti-emetics + analgesia - NBM + NG tube feeding - do a series of examinations and imaging to check sucess FIX THE CAUSE: COVER YOUR BASES Perforatedpepticulcer - broad spectrum antibiotics Omental patch closure PerforatedDiverticulum Resection + Primary anastomosis/stoma - IV PPI (if you suspect peptic ulcer Perforatedappendix Appendicectomy perforation) Perforatedmalignancy Intraoperative biopsyVSAQ: Identify the abnormality in this X-rayVSAQ: Identify the abnormality in this X-ray Toxic megacolon (due to fulminant ie. Severe colitis to the point where the colon myenteric plexus get damaged, so it stops working and dilates) BOWEL ISCHAEMIA: Identification ACUTE MESENTERIC ISCHAEMIA ISCHAEMIC COLITIS Pain is more gradual/ milder Pain is SUDDEN ONSET, COLICKY, SEVERE Think VASCULAR thromboembolism = fast onset THUMBPRINTING on CT/X-ray They’ll have: - risk factors for a clot e.g. older, Signs of oedema, cyanosis, ulceration on atherosclerosis, AF, thrombophilia endoscopy - occlusion risk e.g. sickle cell – VENOUS cause Pneumatosis intestinalis (air in walls of bowel) on CT - are hypoperfused e.g. in profound shock Lactate high, possible acidosis Currant jelly stools (bloody and loose) Vascular occlusions (looking darker) on CT with contrastManagement ACUTE MESENTERIC ISCHAEMIA ISCHAEMIC COLITIS SURGICAL! Straight away if AMI CONSERVATIVE/SUPPORTIVE CLEAR DEAD BOWEL: - IV fluids Exploratory laparotomy + resection of necrotic bowel - NBM or just liquids - Broad spectrum Abx FIX THE BLOOD SUPPLY OF SMA: - NG tube decompression (if ileus in toxic megacolon) Possible embolectomy or mesenteric arterial bypass - Anticoagulation (new!) - Repeat imaging and examination revascularization, balloon angioplasty or thrombectomy) SURGICAL If septic/peritonitic, BP low, massive bleeding, toxic megacolon Same ideaCHOLANGITIS, CHOLECYSTITIS, OR JUST BILIARY COLIC? 1. Patient presents with severe, sudden-onset constant pains in RUQ of abdomen. Reports a temperature of 38.0C, and when you press on their RUQ on inspiration, their breathing is halted. No jaundice, though WCC+CRP is elevated 2. Patient presents with severe constant pains in RUQ of abdomen. They look jaundiced, and they report a temperature of 38.2C. Their LFTs are elevated, alongside their CRP+WCC. 3. Patient gets dull, colicky pain in RUQ of abdomen especially after meals where they eat fatty food. It goes away relatively quickly. They feel a bit nauseous at times. No fever , no jaundice, mild pain on palpation.CHOLANGITIS, CHOLECYSTITIS, OR JUST BILIARY COLIC? 1. Patient presents with severe, sudden-onset constant pains in RUQ of abdomen. Reports a temperature of 38.0C, and when you press on their RUQ on inspiration, their breathing is halted. No jaundice, though WCC+CRP is elevated = CHOLECYSTITIS 2. Patient presents with severe constant pains in RUQ of abdomen. They look jaundiced, and they report a temperature of 38.2C. Their LFTs are elevated, alongside their CRP+WCC.= CHOLANGITIS 3. Patient gets dull, colicky pain in RUQ of abdomen especially after meals where they eat fatty food. It goes away relatively quickly. They feel a bit nauseous at times. No fever, no jaundice, mild pain on palpation. = BILIARY COLIC Should becovered in moredetail in yourothertopics SURGICAL MANAGEMENT – TAKE IT OUT BILIARY COLIC = elective cholecystectomy (4-6 weeks) to prevent stones from getting fully stuck in future CHOLECYSTITIS = EARL Y (<72hrs) or elective cholecystectomy as stones must be stuck CHOLANGITIS = ERCP (<72hrs) to clear bile duct or put in a stent Endoscopic Retrograde CholangiopancreatographyQUESTIONS + FEEDBACK https://teachmesurgery.com/general/presentations/acute-abdomen/ Fantastic resource for learning about surgery – TEACH ME SURGERY.Com -> Thank you for listening – any questions? ☺ as2322@ic.ac.uk