MLA Conditions - G.I

• • Appendicitis refers to the inflammation of the appendix, a narrow, finger-like pouch extending from the caecum, the initial part of the large intestine.
  • Most common acute emergency
• What does appendicitis refer to?

  Inflammation of the appendix
• What is the appendix?

  A narrow, finger-like pouch extending from the caecum
• What is the most common acute emergency related to the appendix?

  Appendicitis
• What typically causes acute appendicitis?

  An obstruction within the appendix
• What can cause the blockage leading to acute appendicitis?

  Fibrous tissue, a foreign body, or a hardened mass of stool (faecolith)
• What happens after the blockage in acute appendicitis?

  Bacterial multiplication and infiltration of the appendix's wall lead to tissue damage
• What can result from tissue damage in acute appendicitis?

  Pressure-induced necrosis and the potential for perforation
• What can develop due to thrombosis in the appendix's arterial supply?

  Gangrene
• What is the initial symptom of acute appendicitis?

  Progressively worsening periumbilical pain
• Where does the pain typically migrate in acute appendicitis?

  To the right iliac fossa
• What gastrointestinal symptoms are associated with acute appendicitis?

  Nausea, vomiting, anorexia, and changes in bowel habits
• What systemic features may indicate infection in appendicitis patients?

  Fever and tachycardia
• What might clinical examination reveal in a patient with appendicitis?

  Localized tenderness and guarding in the right iliac fossa
• Where is McBurney's point located?

  One-third of the way from the anterior superior iliac spine to the umbilicus
• What is Rovsing's sign?

  Pain in the right iliac fossa with palpation of the left iliac fossa
• What may occur in cases of perforation of the appendix?

  The abdomen may become rigid, and signs of peritonitis may develop
• What is the Psoas sign?

  Pain with passive extension of the right thigh
• What is the Obturator sign?

  Pain with passive internal rotation of the right hip
• What is a retrocecal appendix?

  An appendix that may not exhibit classical signs of appendicitis
• What are the differential diagnoses for acute appendicitis?

  1. Bowel obstruction

  • Symptoms: Persistent vomiting, severe abdominal pain, bloating, inability to pass gas or stool, constipation

  1. Gastroenteritis

  • Symptoms: Nausea, vomiting, diarrhea, abdominal cramping, fever

  1. Ectopic pregnancy

  • Symptoms: Lower abdominal pain (often unilateral), vaginal bleeding, symptoms of pregnancy
• What investigations are performed for suspected appendicitis?

  • Bedside:
  • VBG to check lactate levels
  • Pregnancy test (urine hCG) for females of reproductive age
  • Urine dip for leukocytes
  • Laboratory:
  • FBC for white cell count
  • CRP for inflammation
  • U&Es for renal function
  • LFTs and amylase to rule out biliary differentials
  • Clotting, G&S for theatre
  • Blood cultures if sepsis is suspected
  • Imaging:
  • Erect chest x-ray to rule out perforation
  • CT or ultrasound of the right iliac fossa for evaluation
• How is acute appendicitis primarily diagnosed?

  As a clinical diagnosis
• What is the first line management for acute appendicitis after administration of medication?

  Laparoscopic appendicectomy
• What should be done if there is evidence of perforation in appendicitis?

  Open appendicectomy is preferred, with copious lavage in theatre
• What does NICE guidelines suggest for negative imaging in uncomplicated acute appendicitis?

  A non-operative management strategy with IV fluids and antibiotics can be safe and effective
• Gangrene is a serious condition that occurs when body tissue dies due to a lack of blood supply or a severe bacterial infection. It most commonly affects the extremities, such as fingers, toes, and limbs, but can also occur in internal organs.
• • Cholecystitis refers to the acute or chronic inflammation of the gallbladder, which is commonly precipitated by cholelithiasis (gallstones)
  • 15% of adults who present with right upper quadrant pain = cholecystitis
  • Cholecystitis can be categorised into acute or chronic forms based on the duration and progression of inflammation, and into calculous or acalculous types based on the presence or absence of gallstones.
• • PATHOPHYSIOLOGY
  • Cholecystitis predominantly results from the obstruction of the cystic duct by gallstones. This obstruction can lead to an infection in the gallbladder caused by organisms including:
  • E.coli (most common) Klebsiella Enterococcus
• • SYMPTOMS (Acute Cholecystitis)
  • Right upper quadrant/epigastric pain, which can radiate to the right shoulder tip if the diaphragm is irritated
  • Fever
  • Nausea and vomiting
  • Right upper quadrant tenderness
  • Positive Murphy's sign
  • In cases with associated biliary obstruction, patients may exhibit jaundice, dark urine, and pale stools. However, these are not key features of cholecystitis.
• The differential diagnoses for cholecystitis primarily include other conditions that cause right upper quadrant pain.

  • Acute pancreatitis: Epigastric pain radiating to the back, nausea and vomiting, tenderness of the abdomen.
  • Peptic ulcer disease: Epigastric pain that may be relieved by eating, dark stool (melena), nausea and vomiting.
  • Hepatitis: Jaundice, fatigue, pale stools, dark urine, and flu-like symptoms.
  • Right lower lobe pneumonia: Cough, fever, shortness of breath, and right-sided abdominal pain.
• • The first line investigation for suspected cholecystitis is an ultrasound examination of the abdomen, which can identify gallstones, gallbladder wall thickening, and pericholecystic fluid.
  • Alongside this, blood tests including FBC, U+Es, CRP and LFTs will help reveal if there is an underlying infection/evidence of sepsis, as well as any cholestasis
  • CT abdomen-pelvis (rarely MRI) is helpful to look for complications e.g. perforation, collections
• Diagnosis is primarily made with an abdominal ultrasound.
• • the management of cholecystitis includes conservative measures, antibiotics, and surgical intervention, depending on the subtype and clinical circumstances.
  • Elective laparoscopic cholecystectomy is recommended for both acute calculous cholecystitis (after symptom resolution) and chronic cholecystitis. The timing of surgery may vary, with "hot" cholecystectomy addressing acute inflammation and "cold" cholecystectomy focusing on non-urgent cases.
• • Acute Calculous Cholecystitis:
  • Conservative Management: In mild cases, patients may be managed conservatively with bowel rest, fasting, and intravenous fluids to relieve symptoms.
  • Antibiotics: Antibiotics, often covering common pathogens like Escherichia coli and Klebsiella pneumoniae, are typically prescribed. - What antibiotics could this be?
  • Cholecystectomy: The definitive treatment for acute calculous cholecystitis is laparoscopic cholecystectomy, which is recommended during the same hospital admission or within a week.
• • Acalculous Cholecystitis:
  • Prompt Surgery: Acalculous cholecystitis is considered a surgical emergency, and prompt cholecystectomy is typically recommended.
• • Chronic Cholecystitis:
  • Elective Cholecystectomy: For patients with chronic cholecystitis, an elective laparoscopic cholecystectomy may be performed to prevent recurrent episodes and complications.
  • Symptomatic Management: In some cases, patients may initially receive symptomatic management and dietary modifications, but surgery is eventually recommended.
• Hot Elective Cholecystectomy:

  • In cases of acute cholecystitis where the patient's condition has improved with conservative management, but the inflammation is still present, an elective ("hot") laparoscopic cholecystectomy should be performed within 6 weeks of the acute episode.
  • This approach balances the need to address the underlying cause with allowing the patient's condition to stabilise.
• • Cold Elective Cholecystectomy:
  • In cases of chronic cholecystitis or asymptomatic gallstones, where there is no acute inflammation or infection, an elective ("cold") laparoscopic cholecystectomy can be scheduled based on the patient's convenience and availability.
  • This approach avoids the urgency associated with acute inflammation.
• Acute Cholecystitis: This is characterised by the sudden onset of inflammation in the gallbladder. It is often associated with the presence of gallstones, particularly when one of these stones obstructs the cystic duct, leading to a buildup of bile and subsequent inflammation.