A Mixture of Gastro and General Surgery - PowerPoint Presentation

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2. A Mixture of Gastro and General Surgery

3. oesophagusstomachduodenumpancreasjejunumileumappendixascending colontransverse colondescending colonsigmoid colonrectumlivergallbladderbile ductsanal canalcaecum

4. oesophagusstomachduodenumpancreasjejunumileumappendixascending colontransverse colondescending colonsigmoid colonrectumlivergallbladderbile ductscaecumanal canal

5. oesophagusstomachduodenumpancreasjejunumileumappendixascending colontransverse colondescending colonsigmoid colonrectumlivergallbladderbile ductscaecumanal canal

6. oesophagusstomachduodenumpancreasjejunumileumappendixascending colontransverse colondescending colonsigmoid colonrectumlivergallbladderbile ductscaecumanal canal

7. oesophagusstomachduodenumpancreasjejunumileumappendixascending colontransverse colondescending colonsigmoid colonrectumlivergallbladderbile ductscaecumanal canal

8. oesophagusstomachduodenumpancreasjejunumileumappendixascending colontransverse colondescending colonsigmoid colonrectumlivergallbladderbile ductscaecumanal canal

9. oesophagusstomachduodenumpancreasjejunumileumappendixascending colontransverse colondescending colonsigmoid colonrectumlivergallbladderbile ductscaecumanal canal

10. oesophagusstomachduodenumpancreasjejunumileumappendixascending colontransverse colondescending colonsigmoid colonrectumlivergallbladderbile ductscaecumanal canal

11. oesophagusstomachduodenumpancreasjejunumileumappendixascending colontransverse colondescending colonsigmoid colonrectumlivergallbladderbile ductscaecumanal canal

12. Blood Supply

13. Blood Supply ForegutMidgutHindgut

14. Blood Supply ForegutMidgutHindgutOesophagus, stomach, proximal duodenum, liver, gallbladder, spleenDistal duodenum, jejunum, ileum, cecum, appendix, ascending colon and proximal two thirds of the transverse colonDistal third transverse colon, descending colon and sigmoid colon and rectum.

15. Blood Supply ForegutMidgutHindgutOesophagus, stomach, proximal duodenum, liver, gallbladder, spleenDistal duodenum, jejunum, ileum, cecum, appendix, ascending colon and proximal two thirds of the transverse colonDistal third transverse colon, descending colon and sigmoid colon and rectum.Coeliac TrunkSuperior MesentericInferior Mesenteric Left gastric artery, splenic artery, common hepatic Inferior pancreatico-duodenal, intestinal, ileocolic, appendicular, right colic and middle colic artery Left colic artery, sigmoid, superior rectal

16. SMAIMA

17. SMAIMAInferior pancreato-duodenal

18. SMAIMAIleocolicAppendicularRight ColicMiddle Colic Left ColicSigmoid Superior Rectal

19. SMAIMAIleocolicAppendicularRight ColicMiddle Colic Left ColicSigmoid Superior Rectal Marginal Artery

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21. LaurenLauren is a 36 year old woman admitted to the surgical assessment with abdominal pain.What do you want to know?

22. LaurenLauren is a 36 year old woman admitted to the surgical assessment with abdominal pain.What do you want to know?SOCRATESFever?Vomiting?Bowel habit?Urinary symptoms and habit?Observations

23. LaurenLauren is a 36 year old woman admitted to the surgical assessment with abdominal pain.She has a 4 week history of intermittent painacross top of abdomen, worse after eating. Started as a niggling pain, but over last 3 days has been fairly constant and worst in epigastric region. Made worse by eating. Has vomited 6+ times in last 2 days. Urine quite dark. Slightly loose stools.She is otherwise fit and well. Works as teacher. Take lucette. No previous operations. Non-smoker, drinks about 10 units/week at weekends.

24. LaurenLauren is a 36 year old woman admitted to the surgical assessment with abdominal pain.On examination:Flushed, hunched over slightly.Soft abdomen, tender in right upper quadrant,epigastric region and left upper quadrant. Guarding in RUQ.Bowel sounds present. No organomegaly.Murphy’s positive. News 4: HR 98, T38.1, BP 136/82, RR22, sats 97 on air.

25. Abdominal ExamMurphy’s sign – tender on inspiration in RUQ, suggests inflamed gallbladderRosvig’s sign – tenderness in felt in RIF when LIF palpated, suggests appendicitisPsoas stretch – sharp RIF pain when right leg kept straight and lifted, suggests appendicitis (with a retrocaecal appendix)Rebound tenderness – pain felt when pressure/palpating hand is removed suddenly, inflammation of the abdominal wall +/- peritonitisTinkling bowel sounds – high pitched quick-sounding bowel sounds, bowel obstruction

26. LaurenLauren is a 36 year old woman admitted to the surgical assessment with abdominal pain.On examination:Flushed, hunched over slightly.Soft abdomen, tender in right upper quadrant,epigastric region and left upper quadrant. Guarding in RUQ.Bowel sounds present. No organomegaly.Murphy’s positive. News 4: HR 98, T38.1, BP 136/82, RR22, sats 97 on air.What next?

27. LaurenLauren is a 36 year old woman admitted to the surgical assessment with abdominal pain.Investigations:Basic bloods – FBC, U+E, LFT, clottingAdditional bloods – blood cultures, amylaseECGAbdominal ultrasound AXR/eCXREarly Management:Antibiotics (co-amoxiclav 1.2g TDS)IV fluidsNBMAnalgesia – paracetamol, morphine (5-10mg PO or SC)Anti-emetics (ondansetron, cyclizine, domperidone)?Omeprazole

28. LaurenLauren is a 36 year old woman admitted to the surgical assessment with abdominal pain.Bloods: Hb 134 Na 136 Bili 63 Clotting NADWCC 13.8 K 3.9 ALP 257Neut 9.3 Ur 5.3 ALT 56CRP 102 Crea 87 GGT 180Amy 56 Alb 40ECG: Sinus TachycardiaUltrasound: Thick walled gallbladder containing multiple calculiwith dilated CBD diameter of 9mm.

29. LaurenLauren is a 36 year old woman admitted to the surgical assessment with abdominal pain.Bloods: Hb 134 Na 136 Bili 63 Clotting NADWCC 13.8 K 3.9 ALP 257Neut 9.3 Ur 5.3 ALT 56CRP 102 Crea 87 GGT 180Amy 56 Alb 40ECG: Sinus TachycardiaUltrasound: Thick walled gallbladder containing multiple calculiwith dilated CBD diameter of 9mm. Fat, fair, female, fertile, family, forty Sudden weight loss, increasing age, diabetes

30. Cholecystitis – infection of gallbladder, usually precipitated by presence of gallstonesBiliary colic – pain from presence of gallstones in gallbladder +/- ductal system, without derangement of LFTs or presence of infectionCholangitis – infection of biliary, usually precipitated by presence of gallstones in the ductal system and associated with stasis or backflow of bile and LFT derrangement

31. LaurenLauren is a 36 year old woman admitted to the surgical assessment with abdominal painContinued management:MRCP - ?presence of intraductal stones that could be removed endoscopically ERCP – endoscopic examination and removal of stones from ductal systemUltimately, cholecystectomy.

32. LaurenLauren is a 36 year old woman admitted to the surgical assessment with abdominal painContinued management:MRCP - ?presence of intraductal stones that could be removed endoscopically ERCP – endoscopic examination and removal of stones from ductal systemUltimately, cholecystectomy.

33. Dear Doctor, Lauren was admitted to CRH with a 4 week history of upper abdominal pain. This pain worsened acutely over the preceding 3 days, and she developed vomiting and fevers.Her blood tests revealed raised inflammatory markers and obstructive pattern LFT derangement. USS – multiple calculi in thick walled gallbladderMRCP – 7mm stone in common bile duct.Lauren was treated with IV antibiotics and underwent ERCP to remove ductal stone. She then underwent laparoscopic cholecystectomy on 04/02/21. She recovered well post operatively.Diag: Cholecystitis She is now medically fit for discharge with PO antibiotics and analgesia. No follow up required.Many thanksPresenting ComplaintInvestigationsManagementDiagnosisFollow upDischarge instructions

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35. PyelonephritisRenal ColicCholecystitisGastritis Biliary colicPneumonia PyelonephritisRenal ColicPancreatitisGastritisUlcers Biliary colic PneumoniaGastritisRefluxBiliary colicUlcersMIRenal colicDiverticulitisDiverticulitisInguinal or femoral herniaOvarian abscess, cyst or torsionUTIPelvic painAppendicitis Diverticulitis (Asian population)Inguinal or femoral herniaOvarian pathologyAppendicitisBiliary pathologyUmbilical herniaEarly appendicitis Others: constipation, IBS

36. Principles of Abdominal Pain If they’re feverish or other signs of infection, start broad spectrum antibiotics early If they’re stable, start with plain films and USS If they’re unwell, CT (after d/w senior) Around 30% of non-specific abdominal pains will have no obvious causeImaging:Erect CX – to look for perforationAXR – faecal loading, dilated bowel loops, specific items such as volvulus or foreign bodyUSS – hydronephrosis, gallstones and cholecystitis, bile duct dilatation, ovarian cysts or abscessesCT-KUB (non-contrast) – hydronephrosis, stones, pyelonephritis CT-AP (contrast) – obstruction, ~appendicitis, colitis, diverticulitis, collections, abscesses or fistulas, hernias

37. Erect Chest X-Ray

38. Abdominal X-Ray

39. Abdominal X-Ray

40. Abdominal X-RayHow shall we approach laxatives in this patient?

41. Abdominal X-RayHow shall we approach laxatives in this patient?PR exam – stool in rectum?If yes >> phosphate enema (glycerin suppositories if you’re being nice, but probably not going to be effective)If no >> we’ve already excluded obstruction (phew)Osmotic laxatives – lactulose and laxido (macrogol)Faecal softeners – docusate Stimulant laxatives – sodium picosulfate, bisacodyl, docusate, sennaBulk-forming laxatives – ispughula husk

42. Abdominal X-Ray

43. Abdominal X-Ray

44. Abdominal X-Ray

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47. HerniasOn Examination:Redness (or purpleness)PainFirmIrreducible Other red flags: symptoms of bowel obstruction, peritonism Common sites: umbilicus, incisional, inguinal/femoral, parastomal,

48. NazirNazir is a 68 year old gentleman presenting to ED with sudden onset brown vomiting. What do you want to know?

49. NazirNazir is a 68 year old gentleman presenting to ED with sudden onset brown vomiting. What do you want to know?Onset CharacterStable?Infectious features – fevers, others at home unwell, recent travel, loose stools Bowel habit

50. NazirNazir is a 68 year old gentleman presenting to ED with sudden onset brown vomiting. Started vomiting this morning, initially brought his breakfast back up but then continued to vomit and it became brown and smelly. His abdomen has become painful throughout. Bowel habit has been variable – has been sluggish and slow last 3-4 weeks, then had an episode of loose yesterday lunch time, and hasn’t passed any stool today. O/E: Distended but soft abdomen, generally tender but no guarding.News 3, HR 92, BP 108/65, T37.7, RR18, Sats 95.PMH: Angina (GTN spray), HTN, T2DM (insulin dependent), gallbladder removed 4 years ago, BPH

51. NazirNazir is a 68 year old gentleman presenting to ED with sudden onset brown vomiting. Started vomiting this morning, initially brought his breakfast back up but then continued to vomit and it became brown and smelly. His abdomen has become painful throughout. Bowel habit has been variable – has been sluggish and slow last 3-4 weeks, then had an episode of loose yesterday lunch time, and hasn’t passed any stool today.Hb 92 U+Es NADWCC 12.1 LFTs NADMCV 78 Clotting NADCRP 87

52. NazirNazir is a 68 year old gentleman presenting to ED with sudden onset brown vomiting. Investigations:eCXRAXRECGGroup + Save(Early) Management:NBM and IV fluidsBroad spectrum IV antibiotics* What about anti-emetics? What about laxatives?What about analgesia?

53. Nazir

54. NazirBowel obstruction

55. NazirBowel obstruction- Adhesions (70%)Strangulated herniasMalignancyIleus Hirschprung’s Congenital malformations

56. NazirBowel obstruction- Adhesions (70%)Strangulated herniasMalignancyIleus Hirschprung’s Congenital malformations

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58. NazirDoctor come quick!Nazir is now scoring an 8!HR 115 (2)BP 98/62 (2)RR 24 (2)T 38.4 (1)Sats 95 oa (1)He looks clammy and uncomfortable, he’s hunched over with knees bent clutching his abdomen and unsettled.O/E: distended, firm abdomen. Diffusely tender throughout with guarding all over abdomen, particularly tender on the right side. Rebound tenderness

59. NazirPeritonitic abdomen- Tender (localised or diffuse)- Guarding (localised or diffuse)- Rebound tenderness- Signs of shock, haemodynamic instability – tachycardia, hypotension, elevated resp rate- Fever

60. NazirDoctor come quick!Nazir is now scoring an 8!HR 115 (2) 500ml STAT NaCl 0.9% or Hartmann’sBP 98/62 (2) Analgesia – morphine S/C 5-10mgRR 24 (2) Add in Gentamicin (local guidelines vary)T 38.4 (1) O2 2L nasal cannulaSats 95 oa (1)He looks clammy and uncomfortable, he’s hunched over with knees bent clutching his abdomen and unsettled.O/E: distended, firm abdomen. Diffusely tender throughout with guarding all over abdomen, particularly tender on the right side. Rebound tendernessCT-AP with contrast

61. NazirDoctor come quick!Nazir is now scoring an 8!HR 115 (2) 500ml STAT NaCl 0.9% or Hartmann’sBP 98/62 (2) Analgesia – morphine S/C 5-10mgRR 24 (2) Add in Gentamicin (local guidelines vary)T 38.4 (1) O2 2L nasal cannulaSats 95 oa (1)He looks clammy and uncomfortable, he’s hunched over with knees bent clutching his abdomen and unsettled.O/E: distended, firm abdomen. Diffusely tender throughout with guarding all over abdomen, particularly tender on the right side. Rebound tendernessCT-AP with contrast

62. Types of Bowel Resectionhttps://www.bcm.edu/sites/default/files/styles/full_width_component_image_standard/public/media/images/colectomy-types.jpg?h=7c71ab5e&itok=SmwpRlWP

63. Types of Bowel Resectionhttps://www.bcm.edu/sites/default/files/styles/full_width_component_image_standard/public/media/images/colectomy-types.jpg?h=7c71ab5e&itok=SmwpRlWP

64. Nazir Blood products TPN Staging CT-TAP Referral to MDT

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66. LynLyn is a 56 year old woman sent in by her GP due to deranged blood tests.Hb 118 Na 132 Bili 130 Pt 15.6WCC 7.7 K 3.3 ALP 387 APPT 28MCV 107 Ur 3.4 ALT 460Neut 5.5 Crea 56 GGT 1020Plt 130 AST 897What strikes you about these blood results?What questions are you going to ask in your history?What investigations are you going to organise next?

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68. Key Points:ALT + AST elevation indicates hepatocellular damageAn AST:ALT ratio greater than 2:1 indicates alcoholic aetiology of hepatocellular damage – typically ALT>AST in non-alcoholic liver disease ALP + GGT elevation indicates cholestasisALP elevation alone may not be liver disease – it can also be elevated due to osteoblast activity (i.e. children and adolescents growing rapidly, people with fractures, perimenopausal women, people with Paget’s disease of the bone), during the third trimester of pregnancy and temporarily following ingestion of fatty foods in people with blood type O GGT will often also rise acutely when there is significant consumption of alcohol Albumin, bilirubin and prothrombin time give an indication of synthetic function in the liver. If you know there is damage to the liver, they are helpful at evaluating the degree of damage >

69. LynLyn is a 56 year old woman sent in by her GP due to deranged blood tests.Hb 118 Na 132 Bili 130 Pt 15.6WCC 7.7 K 3.3 ALP 387 APPT 28MCV 107 Ur 3.4 ALT 460Neut 5.5 Crea 56 GGT 1020Plt 130 AST 897Lyn’s LFTs suggest hepatocellular damage. Additionally, AST:ALT >2:1.She also has a macrocytic anaemia – what causes of macrocytic anaemiacan you think of? How do we look into this?How will we correct her electrolyte dysfunction?

70. LynLyn is a 56 year old woman sent in by her GP due to deranged blood tests.Hb 118 Na 132 Bili 130 Pt 15.6WCC 7.7 K 3.3 ALP 387 APPT 28MCV 107 Ur 3.4 ALT 460Neut 5.5 Crea 56 GGT 1020Plt 130 AST 897Lyn is a nurse. She works in a nursing home which has seen more than a third of its patients die from coronavirus in the last year. She went to her GP because she’s been feeling very run down and tired. She’s also very achy and weak.She been drinking more and more over lockdown – 1-2 bottles of wine a night and a litre of vodka per week. She knows she shouldn’t be drinking this much but she can’t cope with work.She has paroxysmal AF for which she takes bisoprolol and PRN flecainide.

71. LynLyn is a 56 year old woman sent in by her GP due to deranged blood tests.Hb 118 Na 132 Bili 130 Pt 15.6WCC 7.7 K 3.3 ALP 387 APPT 28MCV 107 Ur 3.4 ALT 460Neut 5.5 Crea 56 GGT 1020Plt 130 AST 897Lyn is a nurse. She works in a nursing home which has seen more than a third of its patients die from coronavirus in the last year. She went to her GP because she’s been feeling very run down and tired. She’s also very achy and weak.She been drinking more and more over lockdown – 1-2 bottles of wine a night and a litre of vodka per week. She knows she shouldn’t be drinking this much but she can’t cope with work.She has paroxysmal AF for which she takes bisoprolol and PRN flecainide.

72. LynLyn is a 56 year old woman sent in by her GP due to deranged blood tests.Abdomen exam:Leukonychia, palmar erythema, clubbing, asterixis, bruising, excoriations, jaundice, caput medusae, striae, organomegaly, shifting dullnessFurther investigations: NILS (hepatitis B +C, haemochromatosis (ferritin and transferrin sats), autoimmune disease (AMA, a-SMA, ANA, serum immunoglobulins), TFTs, alpha-1 antitrypsin, coeliac screen) USS liver (why?) OGD (why?)

73. LynManagement:Detox regime of benzodiazepine: Usually chlordiazepoxideDay 1: 20 mg chlordiazepoxide four times daily.Day 2: 15 mg chlordiazepoxide four times daily.Day 3: 10 mg chlordiazepoxide four times daily.Day 4: 5 mg chlordiazepoxide four times daily.Day 5: 5 mg chlordiazepoxide twice daily. Chesterfield uses diazepam Lorazepam where there’s evidence of liver impairment

74. LynManagement:PabrinexProphylaxis: Two pairs of ampules STAT, then one pair of ampules twice a day for three days, then thiamine 100mg OD ongoing Treatment:2–3 pairs 3 times a day for 3–5 days, followed by 1 pair once daily for a further 3–5 days or for as long as improvement continues.

75. LynManagement:PabrinexProphylaxis: Two pairs of ampules STAT, then one pair of ampules twice a day for three days, then thiamine 100mg OD ongoing Treatment:2–3 pairs 3 times a day for 3–5 days, followed by 1 pair once daily for a further 3–5 days or for as long as improvement continues.Hb 118 Pt 15.6WCC 7.7 APPT 28MCV 107 Neut 5.5 Plt 130

76. LynUSS – enlarged liver with fatty infiltrate and areas of coarse echo texture. No focal lesions. Patent portal vein. Moderate amount ascites in lower abdomen.OGD – 3 oesophageal varices identified, no bleeding points

77. LynUSS – enlarged liver with fatty infiltrate and areas of coarse echo texture. No focal lesions. Patent portal vein. Moderate amount ascites in lower abdomen.OGD – 3 oesophageal varices identified, no bleeding points >> Carvedilol reduces risk of bleeding Input from alcohol liaison team.Disulfiram vs Acamprosate

78. LynUSS – enlarged liver with fatty infiltrate and areas of coarse echo texture. No focal lesions. Patent portal vein. Moderate amount ascites in lower abdomen.OGD – 3 oesophageal varices identified, no bleeding points >> Carvedilol reduces risk of bleeding Input from alcohol liaison team.Disulfiram vs Acamprosate

79. LynOh no, Lyn is back. 18 months later (you’ve moved onto gastro now from EMU), Lyn is readmitted. She is similarly jaundiced, and now her abdomen is distended and tense. Her respiratory rate is elevated (28) and she’s requiring 3L of oxygen to saturate at 95%. Her bloods show a similar picture to last time. Her CXR is clear.What has happened to Lyn?

80. LynOh no, Lyn is back. 18 months later (you’ve moved onto gastro now from EMU), Lyn is readmitted. She is similarly jaundiced, and now her abdomen is distended and tense. Her respiratory rate is elevated (28) and she’s requiring 3L of oxygen to saturate at 95%. Her bloods show a similar picture to last time. Her CXR is clear.What has happened to Lyn?Decompensated alcoholic liver disease: Acute deterioration characterised by ascites, jaundice, variceal haemorrhage, hepatorenal syndrome or hepatic encephalitis.

81. LynOh no, Lyn is back. Detoxification Treatment dose pabrinex Lactulose Ascitic drainage Can drain many, many litres Give 20% HAS concurrently, 100ml for every 2 litres drained Platelets should be >40 (risk of haemorrhage) Monitor BP closely – if systolic >100mmHg free drainage over the first 4 hours then 1L per hour If systolic <100mmHg, slower drainage, approx. 0.5L per half an hour May require concurrent IV fluid replacement if symptomatic of dehydration/hypotension Diuretics?

82. LynLyn continues to deteriorate. You’re asked to see her on nights because her urine output has dropped to between 5-13mls per hour for the last 6 hours. When you get there, she’s NEWSing 12.HR 81BP 88/52 (2) RR 28 (3)T 36.1 Sats 93% on 5L (4)Confused (3)What has she developed?

83. LynLyn continues to deteriorate. You’re asked to see her on nights because her urine output has dropped to between 5-13mls per hour for the last 6 hours. When you get there, she’s NEWSing 12.HR 81BP 88/52 (2) RR 28 (3)T 36.1 Sats 93% on 5L (4)Confused (3)Hepatic encephalitis.VBGAmmonia (needs to be taken to lab immediately, on ice) Fluid challenge (how much?) Discussion with ITU

84. LynLyn continues to deteriorate. You’re asked to see her on nights because her urine output has dropped to between 5-13mls per hour for the last 6 hours. When you get there, she’s NEWSing 12.HR 81BP 88/52 (2) RR 28 (3)T 36.1 Sats 93% on 5L (4)Confused (3)Hepatic encephalitis.VBGAmmonia (needs to be taken to lab immediately, on ice) Fluid challenge (how much?) Discussion with ITU

85. Gastro and gen surg conditions1. GORD 2. Oesophageal motility disorder: achalasia, scleroderma 3. Oesophago-gastric varices 4. Oesophageal cancer 5. Mallory-weiss tear 6. Gastritis 7. Peptic ulcers 8. Hernia9. Ascites 10. Alcoholic liver disease 11. Viral Hepatitis12. Cirrhosis 13. Liver abscess 14. Liver failure 15. Metabolic causes of liver disease 16. Portal HT 17. Biliary tract disease18. Primary biliary cirrhosis19. Diverticulitis 20. Pancreatitis 21. Peritonitis 22. IBS 23. Intestinal obstruction 24. Volvulus 25. Perianal disorders 26. Intestinal malignancies