Bowel

Question 1

Define ileus. Give some examples.

Answer 1

Decreased motor activity of GI tract

No bowel sounds

e.g. post-op (due to nervous irritation or electrolyte imbalances), long-term constipation (learning difficulties –> pseudo-obstruction/paralytic ileus)

Question 2

Describe the features of small bowel obstruction. Give some examples of causes.

Answer 2

> 3cm
Early vomiting, late absolute constipation
Mild distension
Colicky pain

Causes: adhesions, hernias, tumours, inflammation

Question 3

Describe the features of large bowel obstruction. Give some examples of causes.

Answer 3

> 6cm, >9cm (caecum)
Early absolute constipation, late faeculant vomiting
Significant distension

Causes: colorectal cancer, diverticular strictures, hernias, volvulus, pseudo-obstruction

Question 4

What are the signs on examination of bowel obstruction?

Answer 4

Dilated loops of bowel

Absence of gas distal to obstruction (most commonly absence of gas in rectum)

Tinkling bowel sounds

Question 5

Contrast large bowel obstruction with a competent and incompetent ileocaecal valve.

Answer 5

Competent = distension of large bowel and caecum with relatively normal small bowel –> high risk of colonic perforation (no mechanism to lower luminal pressure)

Incompetent = dilatation of both small and large bowel, colon distal to obstruction collapsed and free of gas –> lower risk of colonic perforation

Question 6

Define volvulus.

Answer 6

Twisting of organ around mesentery, causing obstruction.

Enclosed bowel loop dilates and perforates or causes ischaemia of proximal bowel (due to venous dilatation and oedema)

Restricted to either sigmoid or caecum.

Most common is sigmoid (coffee bean sign towards RUQ due to dilatation of proximal bowel).

Caecal volvulus less common (mobile caecum on right side with distal colon “collapse”)

Question 7

What is toxic megacolon?

Answer 7

Acute deterioration in ulcerative colitis

Colonic dilatation, oedema, pseudopolyps

AXR not gold standard for detecting infection/inflammation (but may see some acute/chronic signs)

Question 8

Give some causes of perforation.

Answer 8

Peptic ulcers 
Diverticula 
Tumour 
Obstruction 
Trauma 
Iatrogenic (laparoscopic procedures have gas remain for a few days post-op)

Question 9

What is the management of small bowel obstruction?

Answer 9

NG tube (decompress bowel, reduce risk of perforation)

Fluids

CT scan

Surgery/wait and see/drip and suck

Question 10

What is the management of large bowel obstruction?

Answer 10

NG tube if vomiting

Fluids

CT scan (NG tube important to prevent aspiration whilst lying supine for the scan)

Surgery/wait and see

Question 11

What is the management of volvulus?

Answer 11

Sigmoid volvulus:
Call surgical registrar —> ?CT scan, flatus tube to decompress, ?surgery

Caecal volvulus:
CT scan, surgery

Question 12

What is the management of suspected perforation?

Answer 12

CT scan

Question 13

Give some differentials for haematemesis and melaena?

Answer 13

• peptic ulcer disease
• erosive gastritis
• Mallory-Weiss tear
• oesophagitis
• ruptured oesophageal varices
• vascular abnormalities
• oesophageal/gastric neoplasm
• perforation

Question 14

What is the relevant history in haematemesis and melaena?

Answer 14

Differentiate haematemesis from haemoptysis

• hypovolaemia symptoms
• Rx = NSAIDs, excessive alcohol, iron
• FHx = bleeding disorders, gastric cancer
• PMHx = previous upper GI bleeds

Question 15

What are the general and specific examinations in haematemesis and melaena?

Answer 15

GENERAL

• anaemia
• jaundice
• clubbing
• lymphadenopathy
• skin: bruises, pupura
• cachexia

SPECIFIC

• rigid abdomen
• epigastric tenderness
• epigastric mass
• liver disease sequelae
• Gray-Turner’s
• Boerhaave’s syndrome

Question 16

Contrast oesophageal rupture and Boerhaave’s syndrome.

Answer 16

Oesophageal rupture:

• caustic ingestion pill oesophagitis
• Barrett’s oesophagus
• infectious ulcers (AIDS)
• dilatation of oesophageal strictures

Spontaneous perforation most commonly due to full thickness tear due to sudden increase in intraoesophageal pressure and relatively negative intrathoracic pressure

Boerhaave’s syndrome = reserved when oesophagus ruptures due to vomiting

Question 17

What are the investigations indicated in haematemesis and melaena?

Answer 17

• endoscopy within 24hrs
• bloods: FBC, Hb, G&S, PTT/APTT/INR, LFTs, U&Es, calcium, gastrin
• imaging: CXR, AXR, CT/US

Question 18

What is the management of haematemesis and melaena?

Answer 18

• fluids
• local haemorrhage protocol
• ?transfusion
• Blatchford score –> endoscopy –> Rockall score
• endoscopy: peptic ulcers, variceal bleeding