Abdo Flashcards
What are the indications for laparoscopy?
✅ Diagnostic Purposes – Undiagnosed Abdominal Pain, Trauma, Suspected Malignancy
✅ Therapeutic Procedures – Cholecystectomy, Appendicectomy, Hernia Repair
✅ Emergency Cases – Perforated Viscus, Ectopic Pregnancy, Trauma
✅ Staging of Cancers – Ovarian, Gastric, Pancreatic Cancers
What are the types of stoma?
✅ Ileostomy – Usually Right Iliac Fossa, Spouted, Liquid Output
✅ Colostomy – Usually Left Iliac Fossa, Flush, Formed Output
✅ Urostomy (Ileal Conduit) – Urinary Diversion Using Ileum
✅ Loop vs End Stoma – Loop for Temporary Diversion, End for Permanent
What are the complications of renal transplant?
✅ Early (<1 Month): Rejection, Vascular Thrombosis, Infection
✅ Intermediate (1-6 Months): Opportunistic Infections (CMV), Medication Side Effects
✅ Late (>6 Months): Chronic Rejection, Malignancy (PTLD, Skin Cancer)
✅ General: Hypertension, Diabetes (from Immunosuppressants)
What potential surgeries may have been done for a midline laparotomy scar?
✅ Emergency Laparotomy (Perforation, Peritonitis, Ischaemic Bowel)
✅ Elective Surgery (Pancreatic, Gastric, Small Bowel Resection)
✅ Open AAA Repair
✅ Anterior Resection, Hartmann’s Procedure
What are the differentials for a midline laparotomy scar?
✅ Elective Surgeries: Anterior Resection, APER, Open AAA Repair
✅ Emergency Surgeries: Bowel Perforation, Adhesiolysis, Trauma Laparotomy
✅ Other Considerations: Small Bowel Resection, Peritoneal Dialysis Catheter
What could a small curved scar near the umbilicus indicate?
✅ Laparoscopic Port Site (Appendicectomy, Cholecystectomy)
✅ Umbilical Hernia Repair
✅ Feeding Tube (PEG, Jejunostomy)
✅ Drain Site (Peritoneal Dialysis, Abscess Drainage)
What medications are used in renal transplant?
✅ Immunosuppressants:
Calcineurin Inhibitors (Tacrolimus, Cyclosporine)
Antimetabolites (Mycophenolate, Azathioprine)
Steroids (Prednisolone)
✅ Other Important Medications:
Antibiotic Prophylaxis (Co-trimoxazole)
Antiviral Prophylaxis (Valganciclovir for CMV Prevention)
Statins, Antihypertensives (To Reduce Cardiovascular Risk)
What two classes of medications are most important to monitor in renal transplant?
✅ Immunosuppressants (Tacrolimus, Mycophenolate, Prednisolone) – Monitor Drug Levels, Side Effects, Infection Risk
✅ Antihypertensives (ACE Inhibitors, Calcium Channel Blockers) – Prevent Graft Hypertension & Prolong Survival
What could a 15 cm subcostal scar be for if it is relatively fresh?
✅ Open Cholecystectomy (If Right-Sided, Below Ribcage)
✅ Liver Resection (If More Extensive, Hepatic Surgery)
✅ Splenectomy (If Left-Sided, Trauma, Haematological Condition)
What could the well-healed scar across the abdomen and the lack of umbilicus indicate?
✅ Paraumbilical/Umbilical Hernia Repair with Mesh (Explains No Umbilicus)
✅ Previous Laparotomy with Mesh Repair (If Extensive Scar Across Abdomen)
✅ Abdominal Wall Reconstruction (For Recurrent Hernias, Complex Repairs)
What could two small haematomas on the abdomen indicate?
✅ Subcutaneous Injection Sites (LMWH, Insulin, Heparin)
✅ Post-Surgical Bruising (Recent Laparoscopy, Stoma Surgery, Port Insertion)
✅ Coagulopathy (Liver Disease, Anticoagulants, Thrombocytopenia)
✅ Trauma (Minor Blunt Injury, Post-Procedure Bleeding)
What could an oblique scar in the RIF with a tiny mass indicate?
✅ McBurney’s Scar (Open Appendicectomy)
✅ Hernia Repair (Inguinal, Femoral, Incisional Hernia)
✅ Renal Transplant Scar (If Near Rutherford-Morrison Region)
✅ Benign Soft Tissue Mass (Lipoma, Fibroma, Sebaceous Cyst)
What could two masses in the abdomen, one in RIF and a suprapubic mass, indicate?
✅ Renal Transplant (RIF Mass, Paramedian Scar, Dull to Percussion)
✅ Simultaneous Pancreas-Kidney Transplant (Midline Scar, Second Mass in Suprapubic Area)
✅ Bladder Distension (If Suprapubic Mass is Soft, Dull, and Discomfort Present)
✅ Previous Pelvic Surgery (Hysterectomy, Ovarian Cystectomy, Urological Surgery)
🔹 Midline Scar Instead of Rutherford-Morrison → More Likely SPK Transplant
What does a paramedian scar overlying a mass in RIF suggest?
✅ Paramedian Scar in RIF + Mass in RIF → Common for Renal Transplant
✅ Dull to Percussion → Solid Organ, Likely Kidney
✅ Hickman Line Scar in Upper Chest → History of Dialysis Before Transplant
✅ No Cluster of Scars → Unlikely Laparoscopic or Stoma-Related Surgery
🔹 Hickman Line Often Used for Haemodialysis → Supports Renal Transplant History
What are other potential indications for a paramedian scar?
✅ Previous Renal Transplant (Common for Older Surgical Techniques)
✅ Ileal Conduit (Urostomy) Surgery
✅ Bowel Surgery (Ileocaecal Resection, Right Hemicolectomy for Crohn’s)
✅ Retroperitoneal Surgery (Aortoiliac Bypass, Lymph Node Dissection)
What do multiple abdominal scars suggest?
Previous Laparoscopic Surgery (Cholecystectomy, Hernia Repair, Appendicectomy)
Suprapubic Scar → Possible Previous C-Section, Urological or Gynaecological Surgery
Circular RIF Scar → Possibly a Stoma or PEG Site
✅ How Would You Like to Complete the Exam?
Check for Stoma, Hernias, and Surgical Changes (Palpation, Percussion, Auscultation)
Assess for Any Associated Organomegaly or Masses
Check for Peripheral Stigmata of Chronic Disease (Pallor, Jaundice, Clubbing)
How would you examine the hernial orifices?
✅ Patient Positioning:
Standing First (More Likely to Protrude), Then Lying Down
✅ Inspection:
Look for Visible Swelling at Groin, Umbilicus, Incisional Sites
Ask Patient to Cough or Perform Valsalva (See If Hernia Becomes More Prominent)
✅ Palpation:
Assess for Reducibility (Soft, Compressible vs. Irreducible Hernia)
Check Cough Impulse (Positive in Most Hernias, Absent in Strangulated Ones)
Differentiate Between Direct & Indirect Inguinal Hernia Using Finger in Inguinal Canal
✅ Percussion & Auscultation:
Percuss for Bowel Sounds (Suggests Hernia Contains Bowel, Likely Indirect Inguinal or Incisional Hernia)
🔹 Key Hernial Orifices to Examine:
Inguinal (Direct/Indirect), Femoral, Umbilical, Incisional, Spigelian
Why would someone have an ileostomy?
✅ Inflammatory Bowel Disease (IBD) – Crohn’s, Ulcerative Colitis (UC)
✅ Bowel Obstruction (Strictures, Volvulus)
✅ Colorectal Cancer (Resection Requiring Stoma Formation)
✅ Diverticular Disease (Complicated Perforation, Fistula Formation)
✅ Trauma (Bowel Injury, Resection Required)
What is the difference between temporary and permanent ileostomy?
✅ Temporary Ileostomy – Diverts Stool to Allow Bowel to Heal (E.g., Following Resection in IBD, Diverticular Disease, Perforation, Trauma)
✅ Permanent Ileostomy – Used If Entire Colon/Rectum Is Removed (E.g., Panproctocolectomy in UC, Familial Adenomatous Polyposis - FAP)
✅ Bowel Rest Needed To:
Prevent Further Inflammation/Injury (E.g., Acute Severe Crohn’s, Fistulating Disease)
Allow Resection Sites to Heal Without Faecal Contamination
Reduce Symptoms Like Severe Diarrhoea, Pain, Perforation Risk
What are the types of IBD?
✅ Ulcerative Colitis (UC) – Affects Colon Only, Continuous Mucosal Inflammation
✅ Crohn’s Disease – Anywhere in GI Tract (Mouth to Anus), Skip Lesions, Transmural Inflammation
✅ Indeterminate Colitis – Features of Both UC & Crohn’s, Often Diagnosed Post-Colectomy
🔹 UC = Mucosal Disease | Crohn’s = Transmural, Skip Lesions, Fistulae
Why else would someone with IBD have an ileostomy apart from bowel rest?
✅ Severe Fistulating Crohn’s Disease (To Divert Stool & Reduce Fistula Output)
✅ Refractory IBD Not Responding to Medical Treatment (Steroids, Biologics Failed)
✅ Colorectal Cancer in IBD (High-Risk Dysplasia, Resection Needed)
✅ Toxic Megacolon (Life-Threatening Complication of UC, Requires Surgery)
What type of IBD needs a panproctocolectomy?
✅ Ulcerative Colitis (UC) – If Severe, Unresponsive to Treatment, Risk of Malignancy
✅ Familial Adenomatous Polyposis (FAP) – Prevents Colorectal Cancer
🔹 Panproctocolectomy = Removal of Colon, Rectum, & Anus → Permanent Ileostomy
Who would you give an ileo-anal pouch?
✅ Patients Undergoing Panproctocolectomy for UC or FAP Who Want Continence
✅ Good Sphincter Function Needed (Otherwise, Risk of Incontinence)
✅ Younger Patients Preferable (Better Functional Outcomes)
🔹 J-Pouch Formed from Ileum, Connected to Anus → Allows Normal Defecation
What are other potential indications for the paramedian scar?
✅ Renal Transplant (Older Technique Before Rutherford-Morrison Incision Used)
✅ Urostomy (Ileal Conduit for Bladder Cancer, Urological Conditions)
✅ Right Hemicolectomy (For Caecal/Ascending Colon Cancer)
✅ Retroperitoneal Surgery (Lymph Node Dissection, Aortic Surgery)
How would you manage a patient recently post-op with multiple abdominal scars?
✅ Assess for Post-Op Complications
Infection (Fever, Erythema, Wound Discharge, Raised CRP/WCC)
Haemorrhage (Low BP, Tachycardia, Low Hb, Expanding Haematoma)
Anastomotic Leak (Pain, Peritonism, Rising Inflammatory Markers, Free Gas on CT Abdomen)
✅ Supportive Management
IV Fluids, Electrolyte Replacement (Especially If Ileostomy – High Output Risk)
Analgesia (Avoid NSAIDs in Renal Patients, Consider Opioids with Laxatives)
Stoma Care (Check Output, Ensure Functioning, Prevent Dehydration)
✅ Plan for Further Monitoring (Bloods, Imaging If Needed, Nutritional Support)
🔹 Key Investigations: Bloods, Wound Cultures, Stoma Output, CT If Concerned
What type of stoma could an atypical double Kocher’s scar indicate?
✅ Loop or End Ileostomy (If Spouted & RIF Location)
✅ Colostomy (If Flush, Usually LIF – But RIF Possible If Previous Surgery)
✅ Urostomy (Ileal Conduit – If Urinary Output in Stoma Bag)
🔹 Kocher’s Scar Suggests Hepatobiliary Surgery (E.g., Previous Liver or Biliary Surgery)
How do an ileostomy and colostomy differ?
Feature
Ileostomy
Colostomy
Location
Right Iliac Fossa (RIF)
Left Iliac Fossa (LIF)
Appearance
Spouted (To Protect Skin from Enzymatic Output)
Flush with Skin
Consistency of Output
Liquid, High Output (1-2L/Day)
More Formed, Normal Faeces
Common Indications
IBD, Familial Adenomatous Polyposis, Bowel Rest
Cancer, Diverticular Disease, Trauma
Complications
High Output → Dehydration, Skin Excoriation
Constipation, Parastomal Hernia
🔹 Spouted = Ileostomy | Flush = Colostomy | RIF = Ileostomy | LIF = Colostomy
What about the mucosa in ileostomy vs. colostomy?
✅ Ileostomy Mucosa: Shiny, Red, Moist, Richly Vascular (Small Intestine)
✅ Colostomy Mucosa: Darker, Thicker, More Rugose (Resembles Large Bowel)
What does Kocher’s Scar + RIF Stoma indicate?
Likely Ileostomy (Hepatobiliary Surgery Possible Before)
What is the difference between Ileostomy and Colostomy?
Ileostomy has spouted output and liquid output, while Colostomy has flush output and formed output.
What is the appearance of Ileostomy mucosa?
Shiny, Red, Moist, Richly Vascular (Small Intestine)
What is the appearance of Colostomy mucosa?
Darker, Thicker, More Rugose (Resembles Large Bowel)
What is the enzymatic activity and risk associated with Ileostomy?
Ileostomy is more enzymatically active, leading to a higher risk of skin excoriation.
What is the effluent of an Ileostomy like?
High Output (Liquid, Green-Brown, >1L/day Initially)
Gradually thickens over time but never fully formed.
What are the risks associated with Ileostomy effluent?
Risk of dehydration and electrolyte imbalance (particularly Na+, K+, Mg2+).
What are the early complications of stomas?
Ischaemia/Necrosis, Retraction, High Output leading to Dehydration and Electrolyte Imbalance.
What are the late complications of stomas?
Parastomal Hernia, Skin Excoriation, Prolapse, Stenosis.
What could happen to a hernia over time?
Enlargement, Incarceration, Strangulation leading to compromised blood supply and ischaemia.
How would a strangulated hernia present?
Severe localized pain, irreducible and tender swelling, skin changes, signs of bowel obstruction, signs of sepsis.
What are the extrinsic causes of small bowel obstruction?
Adhesions, Hernias, Volvulus, Tumours.
What are the intrinsic causes of small bowel obstruction?
IBD, Radiation Enteritis, Ischaemic Strictures.
What are the intraluminal causes of small bowel obstruction?
Gallstone Ileus, Bezoars, Foreign Bodies.
What is Gallstone Ileus?
Obstruction of small bowel by a large gallstone that has entered via a fistula between gallbladder and small bowel.
Where in the ileum does the gallstone become impacted?
Terminal Ileum (Most Narrowed Part of Small Bowel Before Entering Caecum).
How is Gallstone Ileus different from Paralytic Ileus?
Gallstone Ileus is a mechanical obstruction, while Paralytic Ileus is a functional failure of peristalsis.
What are the bowel sounds in Gallstone Ileus?
High-Pitched, Tinkling Bowel Sounds due to mechanical obstruction.
How would you manage someone with small bowel obstruction?
Immediate assessment, IV fluids, NG tube for decompression, urinary catheter for fluid balance monitoring.
What is likely a central venous line used for?
Long-Term Chemotherapy, IV Antibiotics, Total Parenteral Nutrition (TPN).
What are the complications of TPN?
Local complications include line infection and venous thrombosis; systemic complications include metabolic disturbances and liver disease.
How to manage post-transplant patients?
Monitor for graft rejection, immunosuppressants, infection prophylaxis, BP & CV risk control, regular bloods.
What is another name for an Ileal Conduit?
Urostomy (Ileal Conduit) created using a segment of ileum to divert urine.
How to examine for a parastomal hernia?
Look for bulging around stoma site, palpable defect, and check for complications.
How to manage a parastomal hernia?
Conservative management if asymptomatic; surgical management if symptomatic or complicated.
What could two midline laparotomy scars and an inguinal scar indicate?
Multiple abdominal surgeries, possibly emergency followed by elective surgery.
What are the indications for midline laparotomy?
Emergency surgeries like bowel perforation, peritonitis, bowel obstruction, and elective surgeries like major cancer surgery.
Why would a patient have two midline laparotomies?
Separate surgeries for different indications, recurrence of disease, complications from the first surgery.
Why might a patient have a revision operation?
Surgical complications, disease recurrence or progression, transplant rejection or failure.
What are the differences between Crohn’s Disease and Ulcerative Colitis?
CD has skip lesions and transmural involvement; UC has continuous involvement and mucosal/submucosal only.
What could the inguinal scar be for?
Hernia repair, varicocele surgery, orchidopexy, or vascular access surgery.
What are the differentials for the two midline laparotomy scars and inguinal scar?
Elective surgeries like AAA repair, IBD surgery, cancer surgery; emergency surgeries like bowel obstruction repairs.
What is Open AAA Repair?
A surgical procedure involving midline laparotomy to repair an abdominal aortic aneurysm.
What types of surgeries are included in IBD Surgery?
Multiple resections, panproctocolectomy for ulcerative colitis, and strictureplasty for Crohn’s disease.
What are examples of Cancer Surgery?
Gastrectomy, colectomy, and pancreatic surgery.
What are Emergency Surgeries for bowel obstruction?
Adhesiolysis, bowel resections, and hernia repair.
What surgeries are performed for Peritonitis/Perforation?
Repairs for peptic ulcer, ruptured appendix, and diverticulitis perforation.
What are Multiple Trauma Laparotomies?
Damage control surgery followed by delayed repair.
What does an inguinal scar likely indicate?
Likely hernia repair, but could also be varicocele surgery, orchidopexy, or vascular access.
What do midline laparotomy scars suggest?
They suggest repeated major abdominal surgery.
