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Gastrointestinal
Anatomy & physiology
Drugs
Acid related disease drugs
Acid reducers
PPI’s
H2 antagonists
Mucosal strengtheners
Misoprostol
Antacids
Antiemetics
Metoclopramide
Ondansetron
Symptoms
Vomiting
Heamatemesis and malaena
Dysphagia
Dyspepsia
Abdominal distension
Diarrhoea
Constipation
PR bleeding
Steatorrhoea
Pathology
Salivary gland tumours
Disorders of the oesophagus
Motility disorders
Achalasia
Chagas disease
Mechanical block
Plummer-vinson syndrome
Pharyngeal pouch
Infectious Esophagitis
Oesophageal spasm
Upper GI bleed
Mallory weiss tear
Oesophageal varices
Gastro oesophageal reflux disease
Hiatus hernia
Oesophageal carcinoma

Anatomy & physiology
Retroperitoneal organs
“SAD PUCKER”
ñ s – suprarenal
ñ a – aorta & ivc
ñ d – duodenum (2, 3, 4)
ñ p – pancreas (except tail)
ñ u – ureter
ñ c – colon (ascending and descending)
ñ k – kidneys
ñ e – esophagus
ñ r – rectum
Layers of the gut wall
1
...
Submucosa – includes Meissner’s plexus
3
...
Serosa/adventitia
Frequencies of basal electrical rhythm
o Stomach – 3 waves/min
o Duodenum – 12 waves/min
o Ileum – 8 waves/min
Digestive tract histology
▪ Esophagus: nonkeratinsed stratified squamous epithelium
▪ Stomach: columnar epithelium
▪ Duodenum: villi and microvilli (increase absorptive surface), Brunner’s glands,
crypts of Lieberkuhn
▪ Jejunum: has largest number of goblet cells in small intestine
▪ Ileum: Peyer’s patches and crypts of Lieberkuhn
▪ Colon: crypts
Oesophagus

▪ 25cm in length
▪ Outer longitudinal and inner circular muscle layers
▪ Upper 1/3 = striated (voluntary), lower 1/3 = smooth muscle (involuntary), middle
1/3 = mixed
▪ Myenteric plexus lies between the two layers
▪ Mucosa is lined with keratinised squamous epithelium
▪ Defences against acid damage:
1
...
Salivary bicarbonate
3
...
Gravity

Stomach
◦ There is a transition to columnar epithelium at the GOJ
◦ 3 types of secretory cells
▪ Chief cells: secrete pepsin
▪ Parietal cells: secrete HCL and intrinsic factor
▪ Surface cells: secrete mucous and bicarbonate
◦ Nervous supply
▪ Parasympathetic: vagus (x) nerve
▪ Sympathetic: meissner's & auerbach's plexi
◦ Blood supply
▪ Coeliac trunk
◦ Acid secretion
▪ Stimulation
ñ Vagus nerve
ñ Gastrin
ñ Histamine
▪ Inhibtion
ñ Higher centres
ñ Low ph
ñ Cholecystokinin
ñ GIP
ñ Secretin

Small intestine
◦ 2-3m in length
◦ Enlarged surface area via VILLI and enterocytes
◦ Main function: absorption, mostly in the duodenum and jejanum
◦ Peyer's patches are lymphoid aggregates that take up antigen which stimulate B
cells to differentiate into IgA secreting plasma cells to deal with intraluminal
antigen
◦ Brunner’s glands: secrete alkaline mucus to neutralise acid contents entering the
duodenum from the stomach
...
Hypertrophy of Brunner’s
glands is seen in PUD
◦ 2 litres of alkaline fluid secreted daily contain mucus and digestive enzymes
◦ blood supply is from the SMA (at ampulla of vater)
Colon
◦ approx 1 m in length
◦ main function: absorption of water, Na and Cl
◦ blood supply: SMA and IMA

Pectinate line

◦ Formed where hindgut meets ectoderm
◦ Above pectinate line
▪ Internal haemorrhoids
▪ Adenocarcinoma (endoderm derivative)
▪ Arterial supply from superior rectal artery (branch of IMA)
▪ Venous drainage to superior rectal vein> IMA> portal system
◦ Below pectinate line
▪ External haemorrhoids
▪ Squamous cell carcinoma (ectoderm derivation)
▪ Arterial supply: inferior rectal artery (branch of internal pudendal artery)
▪ Venous drainage: inferior rectal vein>internal pudendal vein>internal iliac
vein>IVC
◦ N
...
INTERNAL HAEMORRHOIDS receive VISCERAL INNERVATION are
therefore NOT painful, they can be a feature of portal hypertension
...

Abdominal aorta
◦ “Some Prostitutes Cause Sagging Swollen Red Testicles (in men) Living In Sin
P – PHRENIC
C – COELIAC (T12)
S – SMA (L1)
S – SUPRARENAL (L1)
R – RENAL (L1)
T – TESTICULAR/OVARIAN (L2)
L – LUMBAR
I – IMA (L3)
S – SACRAL
N
...
bifurcation of abdominal aorta occurs at L4
N
...
arch of aorta “ABC’s”
(first coronary arteries)
A – Arch of aorta
B – Brachiocephalic
C – Common carotid (left)
S – Subclavian (left)

GI blood supply and innervations

Carbohydrate digestion
◦ Salivary amylase – starts digestion
◦ Pancreatic amylase – highest concentration in duodenum, hydrolyses starch to
oligosaccharides and disaccharides
◦ Oligosaccharide hydrolases – at brush border of intestine, the rate limiting step in
carbohydrate digestion, produce monosaccharides

Carbohydrate absorption
◦ Only monosacharrides (glucose, galactose, fructose) are absorbed by
ENTEROCYTES
◦ Glucose and galactose are taken up by SGLT1
◦ Fructose is taken up by facilitated diffusion by GLUT-5
◦ All are transported to blood by GLUT-2

Vitamin/mineral absorption
◦ Iron: absorbed as Fe2+ in duodenum
◦ Folate: absorbed in jejunum
◦ B12: absorbed in terminal ileum along with bile acids, requires INTRINSIC FACTOR

Types of pain
◦ VISCERAL PAIN
▪ Stretching or inflammation of a hollow muscular orgain
▪ Described as a dull or gnawing pain, may be colicky

▪ Pain not well localised (autonomic nerves)
▪ Pain at embryological origin (foregut, midgut, hindgut)
▪ May radiate to specific sites
◦ Gall bladder - tip of right scapula
◦ Diaphragm - shoulder tip
◦ Ureter - inguinal/scrotal
▪ Associated with visceral Sx
◦ Nausea
◦ Anorexia
◦ Pallor
◦ Sweating
▪ Colic: Characteristic type of visceral pain caused by contraction of smooth
muscle against an obstruction, come's and go's in waves, associated with
writhing/rolling around and vomiting
ñ PARIETAL PAIN
◦ Parietal peritoneum is innervated by pain sensitive fibres (somatic nerves)
◦ Pain is therefore well localised to the area overlying the inflammation or irritation
◦ It is aggravated by movement and characterised by guarding and rebound
tenderness

Abdominal scars

ñ SUBCOSTAL/KOCHER'S: cholecystectomy
ñ RIGHT PARAMEDIAN: laparotomy

ñ MIDLINE: laparotomy
ñ NEPHRECTOMY/LOIN: renal surgery
ñ GRIDIRON: appendicectomy
ñ LAPAROSCOPIC: cholecystectomy, appendicectomy, colectomies
ñ LEFT PARAMEDIAN: anterior rectal resection
ñ PFANNENSTIEL/TRANSVERSE SUPRAPUBIC: hysterectomy/other pelvic surgery
ñ INGUINAL REPAIR

Drugs
Acid related disease drugs
Acid reducers
PPI’s
H2 antagonists
Mucosal strengtheners
Misoprostol
Antacids
Antiemetics
Metoclopramide
Ondansetron

Acid related disease drugs (GORD & PUD)
◦ Acid reducers
ñ Proton pump inhibitors
◦ Examples: Omeprazole, Lansoprazole
◦ MOA: Irreversible inhibition of H+/K+ ATPase that is responsible for H+
secretion from parietal cells
◦ Indications: PUD, GORD, H
...
It
imitates the action of endogenous prostaglandins in maintaining the integrity
of the mucosal barrier and promotes healing
ñ Indications: ulcer healing and ulcer prophylaxis with NSAID use (corrects the
prostaglandin deficit caused by NSAIDS), maintenance of patent ductus
arteriosus, also used to induce labour
ñ CI: should not be given to pts with hypotension
ñ SE: diarrhoea, abdo pain
▪ Antacids
ñ Examples: aluminium hydroxide, magnesium carbonate
ñ MOA: antacids consist of Al3+ and Mg2+ salts that are used to raise the
luminal pH of the stomach
...
pylori eradication regimens: PMC or PAC
ñ Antiemetics
◦ Metoclopramide
▪ MOA:
ñ D2 receptor antagonist
▪ SE:
ñ ↑Parkinsonian effects
ñ Drug interaction with digoxin and diabetic drugs

▪ CI in small bowel obstruction
◦ Ondansetron
▪ MOA
ñ 5-HT3 antagonist
ñ Powerful central acting antiemetic
▪ Control vomiting post op and patients undergoing chemo
Symptoms and signs
Vomiting
Heamatemesis and malaena
Dysphagia
Dyspepsia
Abdominal distension
Diarrhoea
Constipation
PR bleeding
Steatorrhoea
Nausea & vomiting
◦ GI causes
▪ Gastroenteritis
▪ peptic ulceration
▪ pyloric stenosis
▪ intestinal obstruction
▪ acute cholecystitis
▪ acute pancreatitis
◦ Non GI causes (abcdefghi)
▪ a - acute renal failure/addisons disease
▪ b - brain (raised icp)
▪ c - cardiac (mi)
▪ d – dka
▪ e - ears (e
...
labyrinthitis, menieres disease)
▪ f - foreign substances (etoh, drugs e
...
opiates)
▪ g - gravidity (e
...
hyperemesis gravidarum)
▪ h - hypercalcaemia, hyponatraemia
▪ i - infection (e
...
UTI, meningitis)
ñ Rx
◦ Treat underlying cause
◦ C
▪ Rehydrate, monitor fluid balance

◦ M
▪
▪
▪
▪
▪

Metaclopramide (GI causes)
Prochlorperazine (for metabolic causes)
Cinnarizine or Prochlorperazine (for vestibular disorders)
Domperidone (preferable in elderly due to less extrapyrimidal SE)
N
...
avoid drugs in pregnancy

ñ Upper GI bleed
◦ Causes (VARICES)
▪ V - Varices 10%
▪ A - Alcohol (Mallory-Weiss tear) 7%
▪ R – Rupture (Boerhaave’s syndrome: transmural oesophageal rupture
due to violent retching)
▪ I - Inflammation (gastritis)
▪ C – Carcinoma
▪ E - Esophagitis 6%
▪ S - Stomach Ulcer (50-70%)
◦ Sx
▪
▪
▪
▪

Heamatamesis: coffee ground or fresh
Melaena: dark, offensive, like tar
Postural hypotension
N
...
if massive upper GI bleed can present with fresh PR bleeding

◦ Mx
▪ Stabilisation
ñ ABCD
ñ Bloods: FBC, U&E, LFT, clotting, cross match 4-6 units
ñ Correct clotting abnormalities (VIT K, FFP, PLTS)
▪ Further management
1
...
If suspect VARICEAL BLEED THEN IV octreotide or terlipressin
3
...
If bleeding uncontrolled then sengstaken-blakemore tube
§

Px: ROCKALL SCORE: one score from pre-op (resus) phase and one
obtained post endoscopy

ñ Dysphagia
◦ Dysphagia "a concious difficulty in swallowing"
◦ Aphagia "a complete inability to swallow"
◦ Odynophagia "painful swallowing"

ñ Causes
◦ Mechanical block
▪ In the lumen
ñ Food bolus
ñ Foreign body
ñ Plummer-vinson syndrome (post-cricoid web & chronic iron deficiency
anaemia)
▪ In the wall
ñ Malignant stricture: pharyngeal, oesophageal or gastric cancer
ñ Benign oesophageal stricture (caused by GORD, corrosives, RT)
...
g
...
Pylori, treat if +ve
ñ most accurate non-invasive test is the carbon 13 breath test
▪ H
...
Coli (traveller’s)
ñ Viral
◦ Rotavirs (children)
◦ Norovirus (hospital)
ñ Parasitic
◦ Giadia
◦ Infectious colitis/dysentery (colon)
ñ Bacterial
◦ Shigella (Bacillary dysentery) most common in UK
◦ Clostridium difficile (pseudomembranous colitis)
ñ Protazoal
◦ Entamoeba histolytica (amoebic dysentery)
▪ Chronic: onset >2 weeks of Sx
ñ 5 ‘C’s
◦ Celiac disease
◦ Crohns

◦ Colitis (ulcerative)
◦ CF
◦ Cow’s milk intolerance
▪ Key questions
ñ 1
...
Is there blood, mucus or pus?
◦ Bloody diarrhoea (mixed in): infection
◦ Fresh PR bleeding: haemorrhoids, diverticulitis, colorectal Ca, anal
fissure, angiodysplasia
◦ Mucus: IBS, colonic adenocarcinoma, polyps
◦ 4
...
Is small or large bowel to blame?
◦ Large: watery stool, pain relived by defecation
◦ Small: steatorrhea
N
...
Food poisoning incubation periods
ñ
ñ
ñ
ñ

1-6 hours: Bacillus cerus (contaminated rice)
12-48 hours: Salmonella
48-72 hours: Shigella
49-96 hours: C
...
g Fybogel, isphagula husk
◦ Increase faecal mass therefore stimulate peristalsis
ñ Stimulant laxatives
◦ E
...
senna, sodium decussate, picosulfate
◦ Increase intestinal motility (prolonged use may cause hypokalaemia)
ñ Osmotic laxatives
◦ E
...
lactulose, phosphate enemas
◦ Retain fluid in the bowel

ñ Lower GI bleed
◦ Causes
▪ V
ñ
ñ
ñ
ñ

Haemorrhoids
Anal fissures
Mesenteric ischaemia
Angiodysplasia

▪ I
ñ Diverticulitis
ñ Infectious colitis
ñ IBD
▪ N
ñ Malignancy
▪ T
ñ Steatorrhoea
◦ Def: “fatty pale stools that are difficult to flush”
◦ Causes
▪ 1
...
Coeliac disease
▪ 3
...
Iron deficiency anaemia
◦ 2
...
Post-cricoid web
ñ Pharyngeal pouch
◦ Epid
▪ Elderly
◦ Pathophysiology
▪ Forms at an anatomical weakness between inferior pharyngeal muscle
posteriorly (Killian’s dehiscence)

◦ Clinical features
▪ 1
...
Regurgitating food
▪ 3
...
B
...
g
...
g
...
g
...
g
...
B
...
Pylori
◦ Zollinger-ellison syndrome
◦ Neurosurgery (cushing's ulcer)
◦ Burns (curling ulcer)
ñ Types
◦ Gastric ulcers
▪ Epigastric pain related to meals
◦ Duodenal ulcers

▪ 4 times more common than gastric ulcers
▪ Epigastric pain between meals relieved by eating
▪ Hypertrophy of Brunner’s glands
ñ Sx
◦
◦
◦
◦
◦

Epigastric pain (sometimes radiating through to the back if posterior ulcer)
Vomiting
w/l
Iron-deficiency anaemia
Complications
▪ Upper GI bleed
▪ Perforation

ñ N
...
As the ulcer erodes through the mucosa, underlying blood vessels are
exposed and may bleed
ñ Ix: positive urease test
ñ Rx
◦ C
▪ Avoid foods that worsen Sx, stop smoking and NSAIDs
◦ M
▪ H
...
Pylori
ñ
ñ
ñ
ñ

G-ve spiral rod
>50% of >50 y/o's have infection
Primary cause of PUD
Causes chronic gastritis and associated with gastric carcinoma

Zollinger-ellison syndrome
ñ Def:
◦ “Gastrin secreting adenoma”
ñ Tumour is usually pancreatic in origin but may arise from the stomach
ñ May occur as part of MEN TYPE 1
ñ 50% are malignant
ñ Causes severe gastric and duodenal ulceration
ñ Clin feat
◦ Pain and dyspepsia
▪ From multiple ulcers
◦ Steatorrhea
▪ From acid-related inactivation of digestive enzymes and mucosal damage in
small bowel
◦ Diarrhoea
▪ Due to copious acid secretion
Gastritis
ñ Def: “Inflammation of the stomach”
ñ Types:
◦ Acute gastritis (erosive)
▪ Disruption of mucosal barrier → inflammation
▪ Causes
ñ NSAIDs (↓PGE2 → ↓ gastric mucosa protection)
ñ ETOH
ñ Burns (Curling’s ulcer - ↓plasma volume → sloughing of gastric mucosa)
ñ Cushing’s ulcer - ↑ vagal stimulation → ↑Ach → ↑H+ production
◦ Chronic gastritis (non-erosive)
▪ Type A (fundus/body)
ñ Autoimmune disorder characterised by Autoantibodies to parietal cells,
pernicious Anaemia, and Achlorydria
▪ Type B (antrum)
ñ Most common type, caused by H
...
Pylori uses flagella to move to the antrum which is the least acidic area
...

Gastric carcinoma

ñ Epid
◦ Incidence lower in western world especially common in Japan
◦ Mostly adenocarcinoma, most commonly in pyloric region
...
Polypoid/fungating
◦ 2
...
Ulcerating and raised
◦ 4
...
B
...
g
...
Pylori causes
recruitment of lymphocytes into the stomach wall
ñ In a minority of these patients continued stimulation of these B lymphocytes can
lead to marginal zone lymphoma
ñ Rx: Abx
Dumping syndrome
ñ Def:
◦ “A complication of gastric surgery characterised by an inappropriate metabolic
response to eating”
ñ Sx
◦
◦
◦
◦

Palpitations
Sweating
Hypotension
Light-headedness

ñ Early Dumping
◦ Vagally mediated response to gastric emptying
ñ Late Dumping
◦ Due to hypoglycaemia, rebound insulin mediated phenomenen following
transient hyperglycaemia due to heavy carbohydrate load in duodenum
Pyloric stenosis
ñ Epid:
◦ More common in males
◦ Ages 2-10 weeks
ñ Sx
◦ Projectile vomiting (unaltered food)
◦ Dehydration
◦ Constipation
ñ Signs
◦ Palpable mass in epigastrium (represents pyloric thickening)
ñ Ix
◦ Bloods
▪ Hypochloraemic acidosis

◦ Imaging
▪ U/S
ñ Rx
◦ Surgical
Gastric polyps
ñ Multiple haemartomartous polyps are occasionally found in Peutz-Jeghers and
Adenomata in Polyposis coli
ñ Adenomatous polyps should be removed in view of their malignant potential

Gastroparesis
ñ Def: “decreased gastric motility resulting in vomiting, bloating and W/L”
ñ Causes:
◦ Idiopathic
◦ DM
◦ Autonomic neuropathy
◦ Following vagotomy
ñ Ix
◦ Barium meal
ñ Rx
◦ Pro-motility agents such as metaclopramide, domperidone, erythromycin
Disorders of small bowel
Coeliac disease
Carcinoid tumours
Whipple’s disease
Angiodysplasia
Small bowel infarction
Lactose intolerance
Coeliac disease
ñ Def: “gluten sensitive enteropathy”
ñ Epid
◦ Common
◦ Can occur at any age but peaks in babies and third decade
ñ Pathophysiology

◦ Gliadin provokes an inflammatory response that results in villous atrophy in
proximal small bowel
◦ Caused by an immunological reaction to gliadin found in Wheat, Barley, and Eye
ñ Sx
◦ Asymptomatic
◦ W/L
◦ Abdo pain
◦ Steatorrhoea
◦ Malaise
◦ Failure to thrive
◦ Associations
▪ Other autoimmune diseases
▪ Dermatitis herpetiformis (Itchy rash, Rx with dapsone)
▪ Iron deficiency anaemia
▪ Osteomalacia
▪ Small bowel lymphoma
◦ Ix
▪ Antiendomyseal ABs
▪ Antigliadin ABs (may become negative after treatment)
▪ Upper GI endoscopy with duodenal Bx’s (increase in lymphocyte density,
villous atrophy, crypt hyperplasia)
◦ N
...
Idiopathic mucosal enteropathy is a disorder that presents in the same way
as ceoliac disease, a jejuna Bx shows villous atrophy but the disorder is
unresponsive to dietary gluten withdrawal
◦ Rx
▪ Gluten-free diet
ñ N
...
Gluten is not found in rice and maize
Carcinoid Tumours
ñ Epid
◦ Relatively common (50% of small bowel tumours) but carcinoid syndrome is rare
ñ Pathophysiology
◦ Originate from neuro-endocrine cells
◦ Most common sites: appendix, terminal ileum, rectum
◦ Carcinoid syndrome occurs when secondaries in the liver release serotonin into
the systemic circulation
ñ Clinical features (carcinoid syndrome)
◦ Lindsey Davies Fed Brown Rav
▪ Local e
...
obstruction
▪ Diarrhoea
▪ Flushing
▪ Bronchospasm

▪ RHF
ñ Ix
◦ The tumours secrete serotonin and therefore can be detected by assay of its
metabolite: 5-HIAA in urine
ñ Rx
◦ Octreotide
Angiodysplasia
ñ Def: “Tortuous dilation of vessels → bleeding”
ñ May be found throughout the GIT
ñ Occurs in elderly
ñ It is a rare but significant cause of GI haemorrhage
ñ Frequently presents as occult iron deficiency anaemia
ñ Ix
◦ Gastroscopy
◦ Colonoscopy
◦ Angiography
ñ Rx
◦ Heat
◦ Laser coagulation
◦ Hemicolectomy if severe
Small bowel infarction
ñ Pathophysiology
◦ Usually occurs in 3 setting
▪ 1
...
If SMA or one of its arteries are compromised by either in-situ thrombosis
or emboli e
...
AF
▪ 3
...
B
...
g
...
g
...
g
...
diff usually precipitated by broad
spectrum ABx”

ñ ABx – all the ‘C’s
◦ Clindamycin
◦ Ciprofloxacin
◦ Cephalosporins (third generation)
ñ Ix
◦ Toxin in stool
◦ PCR
◦ Endoscopy shows inflamed mucosa with ‘yellow pseudomembranes’
ñ Rx
◦ Oral vancomycin
◦ Metronidazole

Peutz-Jegher’s syndrome
ñ Autosomal dominant syndrome featuring multiple non-malignant hamartomas
throughout the GIT along with hyperpigmented mouth, lips, hands and genitalia
ñ Associated with ↑ risk of CRC

Haemorrhoids
ñ Def: “Congested vascular cushions”
ñ RF
◦ 1
...
Pregnancy
◦ 3
...
The contents (e
...
bowel, omentum)
◦ 2
...
g
...
Defect
ñ Nomenclature
◦ Reducible: sac can be returned to its original cavity
◦ Irreducible: sac unable to return to its original cavity
◦ Obstructed: contains obstructed bowel
◦ Strangulated: blood supply of contents compromised
ñ Anatomy
◦ Abdo wall muscles ‘TIRE’
▪ Transverse abdominus

▪ Internal obliques
▪ Rectus abdominus
▪ External oblique

◦ Inguinal Canal

◦ Surface anatomy

ñ Inguinal Hernia
◦ Epid
▪ Common
▪ More common on R side (appendicectomies)
▪ M:F 9:1
◦ Cause
▪ Congenital
ñ Patent processus vaginalis
▪ Acquired
ñ Increased IAP e
...
obesity, chronic cough, straining
ñ Weakness in wall e
...
due to previous surgery
◦ Sx
▪ Hx of lump +/- dragging pain
▪ Emergency: features of obstruction or strangulation
◦ Types
▪ Direct:
ñ Protrudes through the inguinal (Hesselbach’s) triangle
ñ Reduces directly backwards, appears medial to the deep ring therefore
cannot be controlled by pressure over it, does not extend into the scrotum
▪ Indirect:
ñ Goes through the INternal (deep) ring, external (superficial) inguinal ring
and INto the scrotum
ñ Occurs in INfants due to failure of processus vaginalis to close
ñ Reduces up laterally, controlled by pressure over the deep ring
ñ most common type of hernia overall

▪ “MD's don't LIe”
ñ Medial Direct, Lateral Indirect
ñ Direct hernias pass medial to the inferior epigastric artery, indirect pass
lateral to it
ñ N
...
This is how at one can tell whether it is direct or indirect during
surgery

▪ DDx
ñ Hernia: inguinal/femoral
ñ Lymphadenopathy
ñ Vascular: Saphena varix, femoral aneurysm
ñ Lipoma
▪ Ix
ñ Usually diagnosed clinically but can do US
▪ Rx

ñ C
◦ Decrease IAP (i
...
treat cough/constipation), some pts may not be
surgical candidates, they may wear a hernial truss
ñ S
◦ Nearly all patients, open/laporoscopic, if sutures are used then =
herniorrhaphy, if a mesh is used then = hernioplasty
...
B
...
B
...
g obesity, chronic cough, straining
▪ Weakness in wall e
...
due to previous surgery
ñ Sx
◦ Non-emergency
▪ Lump in groin
◦ Emergency
▪ Features of obstruction/strangulation (red and hot)
ñ Rx
◦ C
▪ Not recommended since these hernias are at high risk of obstruction
◦ S
▪ Preferable
Surgery
Small bowel obstruction

Appendicitis
Ischaemic colitis
Perforation
Diverticula disease
Meckel’s diverticulum
Hirshsprung’s disease
Duodenal atresia
Meconium ileus
Necrotising enterocolitis

Small bowel obstruction
ñ Def: “blockage of small bowel”
ñ Pathophysiology
◦ Fluid and gas can build up proximal to the obstruction → fluid and electrolyte
imbalances and abdo pain
ñ Causes

N
...
Adhesions occur from previous surgery
ñ Sx
◦ 4 cardinal features
▪ 1
...
Abdo distension
▪ 3
...
Vomiting (if occurs late then distal), (if non-faeculent then proximal, if
faeculent then distal)
▪ N
...
Classically high pitched tinkling bowel sounds
▪ N
...
In partial obstruction there is continued passage of flatus but no stool
◦ Features of strangulation
▪ Fever
▪ Tachycardia
▪ Change from colicky to constant pain
▪ Peritonitis
▪ Leucocytosis
▪ Absent bowel sounds

◦ Ix
▪ Bloods: ↑WCC, metabolic alkalosis (due to vomiting)
▪ AXR
ñ SBO: central dilated loops with striations (Taenii coniventes) that cross
the whole bowel
ñ LBO: peripherally placed, haustra
▪ Presence of radiopaque material at cecum suggests gallstones ileus
◦ Rx
▪ C
ñ If uncomplicated then “drip and suck” - NGT and IV fluids
▪ S
ñ If evidence of strangulation
Intussusception
ñ Def: “Telescoping of bowel into distal segment”
ñ Majority of cases occur in children (usually idiopathic, may be viral)
ñ Unusual in adults
ñ Results in bowel obstruction
Volvulus
ñ Def: “twisting of bowel around its mesentery”
ñ Usually in elderly
ñ Results in obstruction

Appendicitis

ñ Appendix: “10cm extension of the caecum near the ileocaecal valve”
ñ Epid
◦ More prevalent with western diet
◦ Do not tend to get appendicitis at extremes of life, because in young the neck of
the appendix is wide, and in the elderly it is virtually obliterated
ñ Pathophysiology
◦ Occurs when appendix is obstructed by a faecolith, foreign body, stricture from
prev inflammation etc
...
LIF pain
2
...
PR bleed
4
...
B
...
B

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