Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Ok. Hi guys, my name is Amelia. Um, so we're gonna go through gi surgery today basically. So these are the Tyler, you're looking at like abdo pain, intestinal disorders, gastroesophageal and hepatopancreatic as well. Um, and this is basically everything that we're gonna go through in the lecture. Um, so in terms of gi surgery, you're basically looking at present different types of presentations. So you're looking at, um, bowel obstruction, acute appendicitis, gi perforation, bowel ischemia, gallbladder disease and acute pancreatitis. Um, and there's different kind of types of different ones. So bowel obstructions have different types of bowel obstruction, gi perforation. So on, we're gonna go through like most of it today. Um, so the main general approach for abdominal cases is first of all looking at the presenting complaint. So you do your pain assessment by Socrates as well as any associated symptoms. And then you're kind of looking at past medical history, drug history, social history, and then you move on to investigations. So investigations depend on the presentation, but generally you can break it down into bloods. So that could be a BGF B CCR pe and S if you want the renal profile LFT S and amylase. Um and then urinalysis can be quite useful as well. Um Imaging, so erect chest x rays, abdominal x rays, ct angiograms, if you're looking at an ambulance or thrombus and ultrasounds as well, and the other type of investigation you can do is an endoscopy. Um and then you're looking at management. So ABCD E approach, if the patients in critical condition, that's really important once the patient is stabilized and you're looking at kind of conservative managements versus surgical management. But again, we're gonna go through all of this. So the first thing you want to ask mainly is where is the pain and also where does the pain move to? And this is really important. So this is basically a diagram of what to expect based on the presentation of the pain. So general diffused pain indicates peritonitis basically. So that can be anywhere, just the whole abdomen as a whole. Um right upper quadrant, you're looking at whether we call it cholecystitis, cholangitis, left lower quadrant, perforated diverticulum from diverticulitis. Um And then if you're looking at epigastric, it can be radiating to the back that would indicate acute pancreatitis. Um If it's just epigastric, you could be looking at a perforated peptic ulcer. Um And then there's things that are a little bit more iffy. It's not 100% but umbilical um or central kind of pain to upper kind of sometimes indicates small bowel obstruction, umbilical to lower, can indicate large bowel obstruction. Um And then yeah, there is other things but those are kind of the main ones that you need to do. So, if we go back to this question, I've got a case up here. So a patient has come in complaining of central abdominal pain around the umbilical area. It's colicky in nature and associated with nausea and bilious vomiting. They haven't been able to pass stool for the last 24 hours, but they have been passing some wind. The abdomen is diffusely tender but not noticeably distended. So, if you were to have a quick think about what this could be. Yeah. So this is actually a case of small bowel obstruction. And I'm gonna go through the differences between small and large bowel obstruction. Now, so this is if you think about the presentations of both, it does kind of make that makes sense. So the small bowel has more frequent and strong peristaltic contractions to overcome an obstruction. And that's what leads to, uh, crampy colicky pain in the central abdomen. Um, so that's our umbilical or central pain. Um, the colon has slower peristalsis. So the pain would be less frequent and then in the small bowel obstruction. And if ischemia or perforation occurs, obviously, that can lead to more constant and severe pain, but generally, it's central umbilical pain for small bowel and central slash lower for large bowel. Um, in terms of the vomiting, then, so for small bowel obstruction. You're thinking that the obstruction is proximal. So your food, your secretions, all of that will accumulate quite quickly, um, leading to early vomiting. So the vomiting will happen a lot earlier in small bowel obstruction. Um, if it's lower in the small bowel, um, the obstruction, then the vomiting can be bilious due to bile reflux. And that's why we, I've mentioned bilious there in terms of low, uh, large bowel obstruction, the colon actually absorbs more fluid. So your vomiting would be more delayed compared to small bowel obstruction. And it can be bilious initially. But as the like obstruction lasts longer, the bacteria will kind of ferment contents and that's what causes the vomiting. Um, and then in terms of constipation. So for small bowel obstruction, constipation is a late sign. So some distal bowel contents can initially pass because you think that your obstruction is higher up, right? So anything past the obstructions should still kind of make its way out. Um, so you've kind of delayed your complete constipation. And then as the obstruction persists and peristalsis fails, then eventually you'll get absolute constipation. Whereas for large bowel obstruction, constipation is a very early sign. So because the obstruction is distal, there isn't really much passage of stool or gas very, very early on and then also abdominal distension. So small bowel obstruction, abdominal distension is less significant, the small bowel has a smaller diameter. So it doesn't really distend as much as the colon, but the large bowel obstruction and um, the colon has a larger capacity, so it can dilate quite significantly and that can lead to marked distension. Um There's a few other signs as well of small and large bowel obstruction. So, dehydration, um, high pitched tingling bowel sounds. If they mentioned that in a clinical case, you should be thinking, um, bowel obstruction or absent bowel sounds. So high pitch tingling would be an early sign, absent bowel sounds would be a late sign and then also just diffuse abdominal tenderness. So what are some important questions to ask in terms of past medical history? So you should be thinking, um, have you noticed any hernias or lumps? Have you had any past surgeries? Any fevers, night sweats, unexpected weight loss, if you're ever thinking cancer or malignancy fevers, night sweats, weight loss are like the three questions you should be asking. Um And why are we asking about hernias, surgeries? Basically, it's just because these can cause small bowel obstruction, essentially. So, adhesions, malignancy incarcerated hernias, Crohn's and interception, uh interception. So interception occurs when a segment of the bowel actually kind of telescopes or invaginate into the neck segment of the bowel. And that's what leads to obstruction, it can eventually lead to ischemia. Um because the invaginated segment, this part here, um that's highlighted in the red kind of that prevents the passage of intestinal contents leading to your dilation of the small bowel. And then for large bowel obstruction, you're looking at malignancy, sigmoid, volvulus, diverticulitis, fecal impaction and Hirschprung's disease. So Hirschprung's disease is a congenital condition where the enteric nervous system, um, doesn't develop in parts of the colon. And so those segments of the colon where it hasn't developed won't relax and that's gonna lead to your functional obstruction. So if we look at sigmoid volvulus in a bit more detail because this is quite a high yield. Um things that come up in exams. This is basically when the sigmoid colon twists around the mucin tree and it causes a closed loop obstruction that can eventually lead to ischemia, necrosis or even perforation if it's not treated. So, the main thing that you should be looking at is coffee bean sign. And you can see that here on this Abdo X ray. Um it's called coffee beans because it looks like a coffee bean. Basically, if you have a look at the kind of white line right in the middle, um that's meant to be the coffee bean. Um And basically, um in terms of management, you should be looking at conservative or surgical. So conservative management indications for this would be if there's no peritonitis, um no perforation. And if the patient is hemodynamically stable, and in that case, you do you untwist the um bowel with an rigid sigmoidoscopy and you basically insert the tube through the rectum and decompress the bulbus basically. And the second way to