Abdo surgery Flashcards
Which hernias can only be found in laparotomy
Obturator; Gluteal; Sciatic; Pelvic; Pudendal Hernia
Only arteries supplying rectus abdominus if patient has had CABG
Inferior epigastric
If difficult access in AAA surgery what structure needs to be divided
Left renal vein
Types of arterial aneurysm
Fusiform Aneurysms
Appear as symmetrical bulges around the circumference of the aorta. They are the most common shape of aneurysm.
Saccular Aneurysms
Asymmetrical and appear on one side of the aorta. They are usually caused by trauma or a severe aortic ulcer.
Which direction do aortic aneurysms rupture
- 20% rupture anteriorly into the peritoneal cavity. Very poor prognosis.
- 80% rupture posteriorly into the retroperitoneal space
Spurarenal AAA mx
hese patients will require a supra renal clamp and this carries a far higher risk of complications and risk of renal failure.
Features favoring a suitable aneurysm for EVAR
- Long neck
- Straight iliac vessels
- Healthy groin vessels
Anatomical relations of coeliac axis
Anteriorly -Lesser omentum
Right -
Right coeliac ganglion and caudate process of liver , IVC
Left- Left coeliac ganglion and gastric cardia
Inferior -
Upper border of pancreas and renal vein
What does the gasproduodenal artery branch into
Right gastroepiploic artery and the superior pancreaticoduodenal artery
Supraduodenal branches off it earlier
Branches of IVC and vertebrae levels
T8 Hepatic vein, inferior phrenic vein, pierces diaphragm
L1 Suprarenal veins, renal vein
L2 Gonadal vein L1-5 Lumbar veins
L5 Common iliac vein, formation of IVC
Patient has SVC obstruction, which collateral can be an alternative pathway
Azygos venous system
Internal mammary venous pathway- connect to superficial epigastric
Lateral thoracic venous system with connections to the sueperficial circumflex iliac and vertebral veins (2 pathways)
Relations of SMA
Superio- neck of pancreas
Postero-inferior- third part of duodenum , ucinate process
Posterior-left renal vein
Right- superior mesenteric vein
Branches of SMA
M iddle colic
I liocolic (Appendicular artery is the branch of iliocolic artery) I nferior pancreaticoduodenal
R ight colic
J ejunal+ i leal (12-15 branches)
Which structure does the midgut bend around to form midgut loop
SMA
Arteries encountered in each colorectal surgery
Right hemi- RC, iliocolic (+middle if extended
splenic- right extended
Left- IMA
Hartmann- high ligation of IMA
AP- IMA
A- IMA
Pudendal nerve branches
Inferior rectal - around anus, anal canal below pectinate line
Perineal - post scrotum
Dorsal penis/clotoris- body and glans of penis
Structures at transpyloric plane
From posterior to anterior, the significant structures crossed by transpyloric plane in midline are:
The conus or termination of the spinal cord L1 vertebra
Aorta
Superior mesenteric artery
Neck of the pancreas Superior mesenteric vein The pylorus of the stomach
More laterally at this level:
Kidney hila
Renal vein
Hilum of the spleen
Second part of duodenum
Origin of the portal vein Duodenojejunal flexure
Fundus of the gall bladder
9th costal cartilage
Content of rectus sheath
2 muscles- RA and pyramidalis
4 vessels
* Superior Epigastric Artery and Vein
* Inferior Epigastric Artery and Vein
6 nerves
* Lower five intercostal nerve (T7-T11)
* Subcostal nerve (T12)
Arterial supply of anterior abdomen
Lateral side (Deep Branches)
* 10th and 11th Posterior Intercostal Arteries (← Descending Aorta)
* Subcostal Artery (← Descending Aorta)
* Lumbar Arteries(all 4) (← Descending Aorta)
Anteriorly From Above Downwards(Deep Branches)
* Musculophrenic Artery (← Internal Mammary Artery)
* Superior Epigastric Artery (← Internal Mammary Artery)
Anteriorly From Below Upwards (Deep Branches)
* Inferior Epigastric Artery (← External Iliac Artery)
* Deep Circumflex Iliac Artery (← External Iliac Artery)
Superficial Arteries
* Superficial Circumflex Iliac Artery (← Femoral Artery) * Superficial Epigastric Artery (← Femoral Artery)
Thoracoepigastric veins
These are Longitudinal venous connections between Lateral Thoracic Vein (→ from Cephalic Vein) and Superficial Epigastric Vein (→ GSV).
Provide a collateral route for venous return if a caval or portal obstruction occurs.
Border of ischiorectal fossa
Anterior- perineal membrane
Post- G max, sactotuberous lig
Lateral- ischial tuberosity, obturator internees, pudendal canal (Alcock canal)
Medual- levator ani, ext anal sphincter
Apex- meeting of ob fascia and inf fascia pelvic diaphragm
Most common sites for intra abdominal collection when supine
Hepatorenal Pouch of Rutherford-Morrison (Right Subhepatic Space)
Features which should be expected/ or occur without pathology on abdo radiology
- In Chiladitis syndrome, a loop of bowel may be interposed between the liver and diaphragm, giving the mistaken impression that free air is present.
- Following ERCP (and Sphincterotomy) air may be identified in the biliary tree.
- Free intra abdominal air following laparoscopy / laparotomy, although usually dissipates after 48– 72 hours.
Mushroom, caterpillar, claw, thumb printing and coffee bean sign on AXR
Caterpillar and mushroom- pyloric stenosis
Thumb printing- pseudomembranous colitis, UC, crohns, DD, IC
Claw- interssusception
Coffee- sigmoid
Derivatives of Dorsal Mesogastrium
G. omentum (gastrosplenic, gastrophrenic, gastrocolic) Splenorenal ligament (pancreas tail is here…)
Spleen pancreas develop within but not from
Derivatives of ventral Mesogastrium
Liver
Lesser omentum
Nerve supply of oesophagus
The parasympathetic component of the cervical part is supplied by the recurrent laryngeal nerve (a branch of the vagus nerve (CN X)) while the sympathetic fibers arise from the cervical sympathetic trunk.
The thoracic part of the esophagus is innervated by the esophageal plexus, an autonomic nervous network surrounding the esophagus. The parasympathetic component of the plexus originates from the vagus nerve, while the sympathetic fibers also stem from the sympathetic trunk running along the neck.
LN drainage of oesophagus
Upper- deep cervical
Mid - posterior mediastinal
Lower- left gastric
GORD gold standard
pH monitoring
Red flags for upper GI malignancy
Any patient with dysphagia
Any patient >55yrs with weight loss and upper abdominal pain, dyspepsia, or reflux
Patients with persistent symptoms, despite trialling conservative management
Surgical intervention for GORD
Floppy Nissen 3600 fundoplication(Post. Partial & Ant. Partial)
Which cells are present in barrets
- Presence of goblet cells important in identification
- Squamous epithelium replaced by columnar epithelium in the lower oesophagus
Corkscrew sing on barium swallow
Diffuse oesophageal spasm
Pseudoachalasia
Extrinsic tumour at GEJ
Cancer at risk in achalasia
SCC
Tx of DOS
Nifedipine
Ix of achalasia
Endoscopy to exclude malignancy
Mamometry gold standard
Mx of achalasia
Endoscopic Balloon Dilatation
then Heller Myotomy
Mx of oesophageal cancer
Surgical resection–
o Neoadjuvent chemotherapy is given in most cases prior to surgery
o In general resections are not offered to those patients with distant metastasis, not to those with N2
disease.
In situ disease – Endoscopic Mucosal Resection
Ivor Lewis
Or Mckneown
Ivor lewis procedure
– Initial laparotomy and construction of a gastric tube(A Rooftop Incision is made)
– Right thoracotomy to excise tumor and create an esophagogastric anastomosis. (Incision through
5th ICS performed 10cm above the tumour)
– Preferred for middle & lower third tumor
– Azygos Vein is divided to allow mobilization of oesophagus
Post Ivor lewis complications
*Atelectasis– due to the effects of thoracotomy and lung collapse
*Anastomotic leakage – High risk because of a relatively devascularised stomach as the only blood supply is from Gastroepiploic Artery and others have been divided.
Arteries effected by ulcers
Post gastric- splenic
Lesser curv- left gastric
Greater- gastroepiploic (GDA)
Post duodenal- gastro duodenal (CHA)
Regulation of gastric acid production
Factors increasing
Vagus
Gastrin
Histamine
Decreasing
SS
Secretin
CCK
Dilafeuoy Lesion
Vascular malformation in gastric fundus
Difficult to see on endoscopy
Big haematemesis
No prior episodes
Upper GI bleed management
Blatchford - Hb, serum urea, pulse rate and blood pressure
>0 endoscopy
Rockall- mortality
Varices should be banded or subjected to sclerotherapy. If this is not possible owing to active bleeding then a Sengstaken- Blakemore tube -should get terli and abx before
Patients with erosive oesophagitis / gastritis should receive a proton pump inhibitor.
Identifiable bleeding points should receive combination therapy of injection of adrenaline
What needs to be divided to gain access to coeliac axis
Lesser omentum
Post gastrectomy complications
Anaemia
Metabolic Bone syndrome
Cancer- adeno
Dumping/diarrhoea
Early satiety
Bile reflux
Gastroparesis
Recurrent ulceration
ABCDEFG
Gastrectomy surgeries
Billroth 1- Distal 3rd stomach removed & anastomosis - duodenum
Bilroth 2- Removal of distal 2/3rd stomach & gastro– jejunostomy
Total and subtotal gastrectomy with Roux en. Y- oesophagus or stomach to jejneum and duodenojejenostomy
So stomach to jejenum and duodenum cut from stomach and stuck to jejenum
What can you use to identify appendix in surgery
Caecal taenia coli converge at base of appendix and form a longitudinal muscle cover over
Nerve injured in appendectomy
Illiohypogastric
Which parts of colon are intraperitoneal
The sigmoid,transverse and appendix are wholly intraperitoneal.
Colon polyp appearance in HNPCC
Mucinous, poorly differentiated and “signet-ring” in appearance.
Referral for colonoscopy
≥40yrs with unexplained weight loss and abdominal pain
≥50yrs with unexplained rectal bleeding
≥60yrs with iron‑deficiency anaemia or change in bowel habit
Positive occult blood screening test
Ix for rectal cancer tissue invasion
MRI
Dukes staging
Dukes A- bowel wall
B1- Musculosa propia
B2- through MP and serosa no LN
C- LN, no mets
C2->4
D- distant mets
Differentiating between UC and Crohns
EIM more common in UC
UC spares rectum
Fistula, fissure, mass, strciture, fat wrapping- CD
Psuedopolyp, goblet depletion, crypt abscess, malignancy- UC
Non- caesating granuloma, cobblestone mucosa- CD
Bleeding more common in UC
GB and kidney stones- CD
EIM of IBD
Arthritis
Uvesitis
Pyoderma gangrenosum
Clubbing
PSC- UC
Surgery for UC
Emergency - toxic megacolon, colonic perforation, or uncontrolled bleeding- Subtotal colectomy + end ileostomy
Electively- pan protocolectomy +/- ileoanal pouch
Dysplasia with mass- proctocolectomy
Mx of high output fistula
Octreotide
Fascia of rectum
Anteriorly lies the fascia of Denonvilliers.
Posteriorly lies Waldeyers fascia.
Nerve supply above and below pectinate line
Above- inf hypogastric L1,2
Pelvic splanchnic
Below- inferior rectal
Tx of haemorrhoids
Symptomatic 1st or 2nd- band ligation
2nd-3rd- Haemorrhoidal artery ligation - main vessel supplying the haemorrhoid is identified through Doppler and then tied off, such that the haemorrhoid infarcts and falls off.
3rd-4th- haemorrhoidectomy
Goodsall rule
Anterior- straight path
Posterior curved path
Types of anal fistula
Superficial - superficial to sphincters
Intersphincteric- fistula penetrates through the internal sphincter but spares the external sphincter.
Suprashincteric - penetrates through the internal sphincter and then extends superiorly in the plane between the sphincters to pass above the external sphincter before extending to the perineum
Transphinteric- The fistula passes through both the internal and external sphincters through both
Extrasphincteric - laterally to the internal and external sphincter.
Tx of anal fistula
Intersphincteric- fistulotomy-make continuous with anus
Denatate line and above- seton suture
Others- fistulectomy- cut out
Mx of anal fissure
1st line- GTN- 8wks
2nd- if headache- diltiazem
Chronic- botulism toxin
Lateral internal sphincterotomy
Advancement flaps
Abdo pain, fever, multiple fine lesions between liver and abdo wall
Fitz High Curtis syndrome
Abdominal compartment syndrome dx
Sustained intra abdominal pressure >20mmHg along with new organ dysfunction / failure.
Tx of abdominal compartment syndrome
Non operative
Gastric decompression
Muscle relaxants
Drain fluid and consider fluid restrict
Surgical
Laparotomy and laparotomy with Bogota or VAC
Different GI parasitic infections
Enterobiasis- pruitis ani
Mebendazole
Ancylostoma- hookworm- larvae in stool- IDA- medendazole
Ascariasis- duodenum, lungs- mebendazole
Strongyloidiasis- skin- lungs- motile larvae in stool-
Mebendazole
Giardiasis- pear shaped- watery diarrhoea
Metronidazole
LN drainage of vagina
Superior – drains to external iliac nodes
Middle – drains to internal iliac nodes
Inferior – drains to superficial inguinal lymph nodes.
Where is leptin produced and what is its function
Produced by adipose tissue and acts on satiety centres in the hypothalamus and decreases appetite.
More adipose tissue (e.g. in obesity) results in high leptin levels.
Leptin stimulates the release of melanocyte
Where gherlin is produced and function
It is produced mainly by the fundus of the stomach and the pancreas. Ghrelin levels increase before meals and decrease after meals
Guidelines for bariatric surgery
BMI >/= 40 kg/m2 or between 35– 40 kg/m2 and other significant disease (for example, type 2 diabetes, hypertension) that could be improved with weight loss.
- All non– surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months.
- They are generally fit for anaesthesia and surgery
- They commit to the need for long– term follow– up
- First– line option for adults with a BMI > 50 kg/m2 in whom surgical intervention is considered appropriate; consider Orlistat if there is a long waiting list.
Types of bariatric surgery
Banding- laparoscopic reversible, slower WL
Bypass- jejunum bypass stomach but duodenum attached - greater WL, irreversible, B12 def in 50%
Sleeve gastrectomy-
Resection of stomach using stapling devices
* Body and fundus resected to leave a small section of stomach
Quadrate lobe borders
Porta hepatis lies behind
On the right lies the gallbladder fossa
On the left lies the fossa for the umbilical vein- ligamentum teres
Caudate lobe borders
-Lies behind the plane of the porta hepatis
* Anterior and lateral to the inferior vena cava
* Bile from the caudate lobe drains into both right and left hepatic ducts
- ligamentum venosum to left
Falciform ligament attachments and origin
2 layer fold peritoneum from the umbilicus to anterior liver surface
* Contains ligamentum teres (remnant umbilical vein)
* On superior liver surface it splits into the coronary and left triangular ligaments(which attach to diaphragm)
Ligamentum venosum
Remnant of ductus venosum- which allowed bypassage of liver
Sits posteriorly to left of caudate
Types of benign liver lesions
Haemangioma- most common of mesenchyme origin
Separated from liver by fibrous tissue
Hyperechoic US
Adenoma- women, OCP, hypotenuse on CT
Abscess- RUQ pain, fever, jaundice
Amoebic- fever, RUZ- US fluid filled poorly defined boundaries
Aspiration- anchovy paste- metronidazole
Hydatid- daughter-fibrotic reaction surrounding, mebendazole + surgical resection
Polycystic- PKD
What should be avoided with HCC
Liver biopsy
Liver biopsy of alcholic hepatitis
Mallory bodies
If CBD distended before operation
ERCP before operation- try to clear the duct by ERCP,sphincterotomy
Then operation later date
PSC vs PBC vs AIH
PSC- ulcerative colitis
Onion skin fibrosis
Intra and extra hepatic ducts
pANCA
PBC- Anti Mitochondiral AB
intra
IgM
Granuloma
CREST syndrome
AIHA- ANA SMA (1); Anti-Liver Kidney Microsome type I antibody (2)
CBD relations at origin
Medially- hepatic artery
Posterior- portal vein
CBD relations distally
- Duodenum - anteriorly
- Pancreas - medially and laterally
- Right renal vein - posteriorly
Features making each gall stone more likely
Multiple- mixed, Ca
Cholesterol- solitary
Bile- haemolytic anaemia, black
Outpouching in chronic cholecystiticits
Aschoff-Rokitansky Sinuses
→ These are outpouchings of GB mucosa into the GB muscle layer and subserosal tissue
→ Result of hyperplasia and herniation of epithelial cells through the fibromuscular layer of the GB wall.
→ They are usually referred to as Adenomyomatosis
Absolute Contraindication of Lapchole
- VwB disease
– Abdominal sepsis
– Late pregnancy
Mirizzi syndrome
Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder
Most frequent organisms causing cholangitis
Escherichia coli Klebsiella species Enterococcus species Streptococcus species
Ix for cholecystitis
USS: 1st line
MRCP if any inconclusion
Cholangitis ix
USS
ERCP gold standard
Mx of biliary atresia
Roux-en-Y portojejunostomy (Kasai procedure)
When is pancreatitis severe on Glasgow scale
3 or more
Pancreatitis sequelae
Peripancreatic fluid collection- Located in or near the pancreas and lack a wall of granulation or fibrous tissue
Pseudocyst- collection is walled by fibrous or granulation tissue (lack an epithelial lining)and typically occurs 4 weeks or more after an attack of acute pancreatitis
Elevated amylase
Investigation is with CT, ERCP and MRI or Endoscopic USS
* Symptomatic cases may be observed for 12 weeks as up to 50% resolve
* Treatment is either with endoscopic or surgical cystogastrostomy or aspiration
Pancreatic necrosis- nvolve both the pancreatic parenchyma and surrounding fat- Radiological drainage or surgical necrosectomy.
Abscess
Haemorrhage
Ix and mx of pancreatic necrosis
CT - FNA If definitive needed
Pancreatic necrosectomy (open or endoscopic)
Systemic complications of pancreatitis
Disseminated Intravascular Coagulation (DIC)
Acute Respiratory Distress Syndrome (ARDS)
Hypocalcaemia
Fat necrosis from released lipases, results in the release of free fatty acids, which react with serum calcium to form chalky deposits in fatty tissue
Hyperglycaemia
Mx of acute pancreatitis
DCC
Fluid resus
NG tube
Catheterisation
Opioid analgesia
Broad spectrum ABx
Main cause of chronic pancreatitis
chronic alcohol abuse (60%) and idiopathic (30%).
Presentation of chronic pancreatitis
Chronic abdominal pain, however may also develop malabsorption, diabetes mellitus,
Ix of chronic pancreatitis
Serum amylase or lipase levels are often not raised
A faecal elastase level will be low
CT- pancreatic atrophy or calcification, as well as any pseudocysts present
Mx of chronic pancreatitis
enzyme replacement (including lipases), such as Creon®
fat-soluble vitamins (A, D, E and K), tand check bone density routinely.
Those with pancreatogenic diabetes may benefit insulin regimes, along with annual surveillance with HbA1c.
Where does pancreatic cancer occur and where does it often spread to
Head
Liver
Mx of pancreatic cancer in head and tail
Head- Whipples procedure
Dumping and ulcers
Tail- distal pancreatectomy and splenectomy with regional lymphadenectomy
All surgical patients should receive adjuvant chemotherapy
Sx of pancreatic cancer
WL
Painless jaundice
Trousseaus sign- Migratory superficial thrombophlebitis
Abdominal pain (non-specific) – due to invasion of the coeliac plexus or secondary to pancreatitis
Endocrine Tumours of the Pancreas
Gastrin-g- Zollinger Ellison
Glucagon-a- hyperglycaemia, necrolytic migratory erythema
Insulin-b- hypoglycaemia
SS-d- inhibits GH, TSH, prolactin- DM, steathorrea, gallstones (due to CCK inhibition)
VIP- non islet cells- normal secrete water and electrolytes into gut with relaxation-
Prolonged diarrhoea, severe hypokalaemia (verner Morrison syndrome)
Sx of insulinoma
Whippples triad
- Hypoglycaemia symptoms during fasting - ↓ FBS
- low glucose
- Symptoms relieved by i/v Dextrose
VIPoma sx
Wa : Watery
D Diarrhoea (Octreotide therapy gives prompt relief from diarrhea.)
H : Hypokalamia
A : Achlorhydria- no acid
Where are most of gastrinomas found
In gastrinoma triangle:
Superior- CBD
2/3rd part of duodenum (inferior)
Neck and body of pancreas (medial)
Mx of Zollinger Ellison syndrome
Octreotide- suppressing gastrin
Most gastrinomas in the pancreas can be removed by enucleation, and large tumors can be removed by
resective procedures.
What tissue is spleen derived from
Mesenchyme
What is in close relation to pancreatic tail
Splenic hilum
Ligaments of spleen and what is contained within them
Gastrosplenic- short gastric , Left Gastro-Epiploic Vessels
Splenorenal- tail of the pancreas. splenic artery. splenic vein.
Function of spleen
FISH
F iltration of encapsulated organisms and blood cells I mmunological function
S torage of platelets
H aematopoiesis in the foetus
Indication of splenectomy
- Trauma: 1/4 are iatrogenic
- Spontaneous rupture: EBV
- Hypersplenism: Hereditary Spherocytosis or Elliptocytosis - causing anaemia
- Malignancy: Lymphoma or Leukaemia
- Splenic Cysts, Hydatid Cysts, Splenic Absces
Cell changes after splenectomy
PLATELETS WILL RISE FIRST
- Immediately - Agranulocytosis (mainly Neutrophils), which is replaced by a Lymphocytosis & Monocytosis over the following weeks.
- In First Few Days - Target Cells, Siderocytes & Reticulocytes will appear.
- over Following Weeks - Cytoplasmic Inclusions seen e.g., Howell Jolly Bodies
. - Other changes include Target Cells and Pappenheimer bodies
Complications of splecentomy
- Haemorrhage (may be early and either from Short Gastric or Splenic hilar vessels)
- Pancreatic fistula (from iatrogenic damage to pancreatic tail)
- Thrombocytosis: Prophylactic aspirin
- Encapsulated bacterial infection
Gross pathology of ulcers
50% <2cm
Oval with straight walls
Smooth base
histology of ulcers
1- superficial necrotic fibrinoid
2- active cellular nets infiltrate
3- granulation
4- fibrocartilingeous scar, arteries thick and thromboses
When to use surgery for ulcer
If perf or massive haemorrhage
Non resolving or relapsing
> 3cm - medical not working for 6-8w
SE of vagotomy
Obstruction
Gallstones
Vomiting
Diarrhoea
Dumping syndrome
IDA
B12 def
Tx of perforated small stomach ulcer
Excisions and closure
Due likely being malignant
If larger- total or partial gastrectomy
H pylori appearance
Gram neg
Flagellated spiral bacillus
Urease enzyme
H pylori test and mx
Urea breath test or stool antigen
If test neg- PPI for 1/2 months until ulcer healed
Positive- PPI + amor 1g/met 400mg + clarith 500mg 7d
Factors assessed in blatchford score
Urea
Hb
SBP
Pulse
CO morbidities- melena, syncope, hepatic disease, HF
PHUCS
Factors Rockall score asseses
Age
Shock-BP/pulse
Source of bleeding
Comorbidities
Stigmata of recent bleeding- e.g clots
mx of UGI haemorrhage
Endoscopy- <24hrs presentation
Adrenaline injections- 4 quadrant
Clips, bipolar
Then pharm therapy- pH >6, eradication of H pylori
Indications of surgical tx bleeding ulcer
Continue bleeding
1 rebleed, 2 if <60
> 50 requiring 4U of blood
<50 6U in 24 hrs
Surgical mx of bleeding ulcer
Underunning vessel with suture
Peptic- excision if on greater curve
Gastrotomy if lesser
Duodenal - duodenotomy then vagotomy and pyloroplasty
Ulcer perforation tx
Laparotomy
Gastric- greater curve- ulcer excision and closure with omental patch
Lessier- distal- billroth
Proximal- subtotoal
Duodenal - simple closure with mental patch and peritoneal lavage
Presentation of gastric outlet obstruction
Projectile of undigested food
Epigastric pain
Electrolyte imbalance
Palpable stomach
Mx of gastric outlet obstruction
Correct fluid and electrolyte imbalance
Endoscopy- diagnostic and enable balloon dilation
Surgical- gastroenterostomy
What increases risk of gastric carcinoma
Chronic atropic gastritis
Men
Pernicious anaemia
H pylori
Microscopic feature of gastric carcinoma
All adenocarcinoma
Intestinal - malignant glands
Diffuse- small malignant cells- better prog
Signet- large vacuole of mucin - worse prog
Diagnosis of gastric carcinoma
Endo wits biopsy
Staging with CT
Mx of gastric carcinoma
Pre op PEG if malnourishment or obstruction
Only to those with widespread mets
Sub total- >5-10cm from OGJ
Total <5cm
Oesophagogastrectomy- type 2 extending to oesophagus
endoscopic resection- confined
Lymphadenectomy- D2
Chemo- most
Gastric lymphomas type and mx
B cell 98%- MALT
Peyers patches
Paraproteinaeomia
H pylori eradication
T cell
Full thickness high grade solitary lesion- surgery
Diffuse low grade- chemo
Common location of GI ulcers
80% duodenum- first part
Stomach- lesser curvature or border of antrum/body
Complications of ulcers
Strictures and obstruction
Haemorrhage
Perforation
Signs of appendicitis
Rovsing Sign
Rebound tenderness over McBurney point
Psoas sign- passive extension of right hip
Obturator - internal rotation of hip
Appendicits dx
Clinical - important in children
Elevation of neutrophils
USS
Presentation and dx of acute SI ischaemia
Severe out of proportion pain
Vomitting
Raised WCC
Acidosis
Angiogram and CT
Non occlusive mesenteric ischamia causes
Prolonged low flow state
CHF, arythmie, hypovolaemai
Mesenteric vein thrombosis signs and mx
Patchy necrosis
Hypercoagulable state- sepsis, OCP
Thick abdo bowel wall on AXR
Mx with anticoagulation
Small bowel bleeding dx and mx
Occult- non visible
Evert- visible
Angiogrpahy or enteroscopy
Excision
Mesenteric angiography with embolisation or injection of vasocontrictor
Merkels diverticulum presentation
Usually asymptomatic
Present before 2
Painless bleed
If pain- complications- obstruction, intusseption ect
Bleed- heterotopic mucosa
Tx of mickel Diverticulum
Lap resection
Resection of diverticulum and adjacent areas
Cell types of GI stromal tumour
Smooth muscle pacemaker cell of Cajal
Mutation of GI stromal tumour
KIT gene
pdf less common
Cells identifiable on pathology of stromal tumours
Spindle cells
Small bowel lymphoma RF and dx
Coeliac disease
Small bowel enema and CT
Resection
Duodenal adenocarcioma tx
Pancreaticoduodenectomy
Effects of jejunum resection
Reduced absorption of ADEK, Ca, Mg, Folate
Amino acids, mono, lipids
Results in diarrhoea
Most recover
Folic acid never recovers- give supplements
Effects of ileum resection
B12 def - if >1m - B12 injection to prevent meg anaemia
Reduced bile salt respiration - gallstones, ADEK
Diarrhoea- increased fats and Bile salts
Short bowel syndrome
Resection of >80%less than 200cm
Parenteral nutrition for 3m
Pathology of short bowel syndrome
Few days- dilates, lengthens and thickens
Interstitial villi hypertrophy
Hyperplasia
Reason for resecting >80% of small bowel
Mesenteric ischameia
Crohns
NEC
Mx of short bowel syndrome
Initial
Fluid and elec replacement
TPM
Long term
Glutamine and GH Supplementation
Low fat, high carb, high fibre diet
Cell types with crohns and UC
Th17- crohns
Th2- UC
Most specific finding in Crohns
Granulomas
(aggregation of macrophages)
Features that point more towards Crohns on examination
Erythema nodosum
Mass in RIF
Fistula
Fissure
Amyloidosis
Ix of IBD
Sigmoidosocpy
Barium enema- cobblestone
Blood tests- hosepipe
What to test for when giving azathioprine
TPMT level
If deficient- bone marrow suppression
Major Complications of IBD
Crohns- stricutres, obstruction
Fistula
Perianal sepsis
Perf
UC
Toxic megacolon
Perf
Haemorrhage
Malignancy
Coeliac variant allele
HLA DQ2
Extrainterstinal symptoms of coeliac
Anaemia
Osteopenia
Motor weakness
Amenorrheoa
Dermatitis herpetiformis
Dx of coeliac
IgA TTG
Biopsy of duodenum
Villous atrophy, crypt hyperplasia, increased intra-epithelial lymphocytes
○ Villous:crypt ratio should be 3-5:1 - this increases / reverses
○ >20 IEL / 100 enterocytes
Types of adenoma of bowel
Tubular- multiple, lower malignant potential
Villous - large, sensile, shaggy, resctum- malignant potential
Tubulovillous
Types of FAP
FAP- most severe
Attenuated FAP- APC gene , late onset
AR FAP- MUTYH
Ix of FAP
Colonoscopy- favour right side common polyps
Genetic testing
When to suspect pout jaggers
2 or motor harmatomotous polyps in GI tract
Mucocutaneous pigmentation
Hereditary haemorrhgaic telangiectasia
Small AV malformations
Nose bleeds
Bleeding in GI tract
Telengectasia
Olser Weber rendu
Findings on CT of diverticulitis
Pericolic fat stranding
Wall thickeneing
Diverticula
Mx of fistula
Sepsis
Nutrition- high output- swap oral fluids to IV, fluid balance
Anatomy
Plan- conservative or surgical
Most posterior structure of aorta hepatis
Portal vein
CBD right, CHA left ant
Level where oesophagus starts, pierces diaphragm and ends
Starts at C6
Pierces diaphragm at T10
Ends at T11
Normal cells of oesophagus
Non keratinised Strat Squamous
Greater omentum
In children
Contains?
Attaches?
Less developed in children under 5
Contains gastroepiploic arteries
Attaches to stomach and transverse colomn
Difficult splenectomy
Drain has clear fluid with what biochem
Elevated amylase
Renal hilum structure order
Vein anterior - remember has to be divided in some aortic surgery
Artery post
Ureter- inferior
Which vein is the varicose in oesophageal varies
Hemiazygous
Embryological origin of ureter
Mesonephric duct
Route of ureter
Posterior to gonadal
Anterior to iliac vessels
Posterior to vas deferens
Small yellow nodule found in inguinal canal of term baby
Adrenal Rest
Benign tumour that regress
What is the round ligament of liver and what is a remnant of
Ligamentum teres
Forms part of free edge of falciform ligament
Remnant of left umbilical vein
What are the medial and median arcuate ligaments
Median- remnant of urachus where urine would leave fetus
Medial- remnants of umbilical arteries
From internal iliac
Hernia management
First time- open with mesh in adults, herniotomy in children
Recurrent or bilateral- laparoscopic TEP
Stoma after sub total colectomy
End ileostomy and rectal stump
Which ligaments contain splenic and short gastric arteries
Splenic- splenorenal
Shorts gastric-gastrosplenic
Staging of colon cancer vs rectal
Colon- CT chest abdo pelvis
Rectum- MRI rectum with CT chest abdo pelvis
Patient has a >2cm adrenal mass, tests and CT otherwise normal, mx?
Adrenalectomy
Which structures can be damaged posteriorly with caecal mobilisation
Ureters and Gonadal vessels
Which vessels cause significant bleeding in aortic repair
Lumbar arteries
As EVAR does not include them
Which artery requires high ligation in right hemicolectomy for removal of caecum
Ileo colic
Middle usually preserved
Mobilisation of the left lobe of the liver will facilitate surgical access to which of the following?
Oesophagus
Unpaired abdo aortic branches
Coeliac
SMA
IMA
Median sacral
What is the quadrate lobe functionally
Left
Where is the bare area of liver, which lobe is more affected
Posterior
Right more affected
Drainage of right adrenal
IVC
Blood supply of bile duct
Hepatic artery
Oesophagectomy and an oesophagogastric anastomosis is constructed. The arterial supply to the gastric component is mainly provided by which of these vessels?
Right gastro epiploic
How far is the gap between coeliac and SMA
1cm
What has to be divided in splenectomy
Short gastric artery as in gastrosplenic ligament
where do pancreaticoduodenal veins drain
SMV
Location of kidney hilum, lower border and upper border
Left L1, right L-2
Lower L3
Upper 11th rib
Ectopic kidney, where is adrenal found
Usual position
Ant to posterior gastrosplenic, lienorenal , splenic artery vein
Gastrosplenic
Splenic artery
Vein
Lienorenal
What is a strong indicator of IBD
Incontinence and nocturnal diarrhoea
What appendicitis can be Rovsig Sign negative
Retrocaecal
Mx of gallstone ileus causing SBO
Remove gallstone via proximal enterotomy
Decompress bowel
Leave gallbladder in situ
Management of splenic vein thrombosis
Splenectomy
Pregnant with ?perf, what investigations
CT abdo
Hepatocellular adenoma in male
Should be resected as greater risk of malignant transformation
Carcinoma resected, 8 months later has jaundice with intra hepatic duct dilation, dx?
Peri hilar lymphadenopathy
Mx of pseudocyst from pancreatitis
Elective cystogastrostomy
Where stomach and cyst connected- so cyst drains
Mx of acute cholagntitis, with empyema and mirizzi syndrome
Cholecystostomy and T tube
On lap for choles, calot triangle hard to determine, dx
Mirizzi
Loop colostomy, become swollen, tender
Obstructed incisional hernia
Loop colostomy reversals are at high risk of this complication as the operative site is at increased risk of the development of post operative wound infections.
What is useful to mobilsie when trying to do open adrenal surgery
Mobilisation of the hepatic flexure and right colon
Annular pancreas where will it obstruct
2nd part of duodeunum
left side of colon is pulled and there is bleeding in parabolic gutters what is damaged
Spleen
The spleen is commonly torn by traction injuries in colonic surgery. The other structures are associated with bleeding during colonic surgery but would not manifest themselves as blood in the paracolic gutter prior to incision of the paracolonic peritoneal edge.
Dermatome area for blockade for inguinal hernia repair
T12
Campers and scarpers fasciae
Campers superficial fatty
Scarpers deep membranous
Which plane inferior epigastric vessel lie
Between TA and peritoneum
Medial to deep ring
Pseudo obstruction vs constipation
Constipation- LIF pain, no distended loops, faecal loading
PO- illness, post surgery
Dilated bowel, electrolytes disturbance
Patient with ileostomy and hypocalcaemia cause
Hypomagnesium due to high output stoma
What communicates freely with hepatorenal space
Right paracolic gutter
Ligament cut to give greater mobility for poster access to kidney
Costoverterbal
L1-2 body to 12th rib
Which part of the duodenum does the IVC pass posterior to
First and Third
Right renal artery relation to IVC
Posterior
Attachment and relation of pyrimidalis
Anterior to RA
Originates pubis and symph to linea alba
Linea semilunari and what crosses it
Lateral margin of rectus
Inferior epigastric and medial umbilical cross posteriorly below arcuate
Borders of lesser sac
Anterior- visceral peritoneum of posterior stomach
Lesser omentum
Gastrocolic omentum
Posterior- transverse mesocolon, peritoneum covering pancreas, left kidney, duodenum and diaphragm
Superiorly by the peritoneum covering the caudate lobe of the liver and laterally on the left side by the gastrosplenic and splenorenal ligaments
Location of bare area of liver
Between coronary ligament
Triangle
Portal vein relation to hepatic artery and bile duct
Posterior
Artery left of bile duct
Jejunum vs ileum
Jejunum longer
Thicker walls
Less prominent arcades
Longer VR
Less fat
Less payers patches
More prominent plicae circulars
Jejunum more prominent valvular conniventes
Bigger lumen
Ligament of Trietz connects
Originates from the duodenojejunal flexure/4th part of duodenum to right crus
Which artery is clamped in lesser omentum
Hepatic proper
Cause of annular pancreas, week occurring and syndrome associated
Failure of ventral bud to rotate around the duodenum
Happens in 7th week
Downs
Gerotas fasciae in nephrectomy
Incised in simple nephrectomy
Excised in radical
Where does the transverse mesocolon attach to in pancreas and which artery it contains
Head, neck and body
Middle colic arteries
SMV, IMV relations to duodenum and pancreas
SMV runs anterior to third part of duodenum
Then Uncinate process lies posterior to SMV
SMV then passes behind neck of pancreas to from portal vein
IMV lies behind body of pancreas where it joins splenic vein
Portal vein formed behind neck of pancreas and anterior to IVC
Passes posterior to 1st duodenum to liver
What does a femoral hernia compress
Goes through femoral canal
Can compress femoral vein which lies laterally
Root of mesentery attachments
Left of L2 vertebrae at duodenojejunal junction to right of SI joint
What structures cross root of mesentary
Aorta
IV
Third duodenum
Psoas
Right ureter
Right gonadal
What cell lines ureters
Transitional
What organ borders kidney without any fascia or peritoneum separating
Tail of pancreas
Where is the duct of santorini
Accessory duct of pancreas
SMA in relation to duodenum, IMA, SMV, splenic and left renal vein
Anterior to third duodenum- if compress Wilkie syndrome
Right of IMA
Left of SMV
Posteiro inferior to splenic
Anterior to left renal - nutcracker
What lies anterior to right adrenal gland
IVC and right lobe of liver- bare area
Ribs spleen is located at
Between 9 and 11
Cystic duct in relation to right renal vein and hepatic artery
Right of hepatic artery
Anterior to renal vein
Ureter and uterine artery relationship
Uterine artery initially lateral
Then cross over superiorly and anterior to it
Local anaesthetic for appendectomy
On ilihypogastric T12-L1
2cm medial to ASIS
and ilioinguinal L1-2
1-2cm lateral to pubic tubercle
Where is the mesh attached to in Lichtenstein repair
Reflected inguinal ligament
Segments of liver supplied by which portal vein
2,3,4 (quadrate)- left portal vein
5,8- right anterior
6,7- right posterior
1 caudate- can be both
What makes obturator hernias worse
Pain is worse with hip extension medial rotation and abduction
Traction of what could cause splenic damage
Splenorenal and splenocoloic ligaments together
Bleeding gin oesophageal varicose caused by which vessels
Superficial oesophageal - as drain in to left gastric
Pancreatic lymphatic spread
Coeliac, paraduodenal, lesser greater curvature of stomach, hilum of spleen
DIrect spread of pancreatic cancer
Stomach, duodenum, reotrperitoneum
What splits the foregut and midgut
Major duodenal papilla
What can be used to identify superficial ring
Intercrural fibres
Run across external oblique
Surgery with major kidney bleed
Simple nephrectomy
Through midline incision
Where does lesser omentum attach to liver
Ligamentum venosum
Which arteries does lesser omentum contain
Right gastric
Levels of kidney coverings
Kidney
Capsule
Perinephric Fat
Gerotas fascia
Pararenal fat
Layer UC effects up to
Mucosa/submucosa
Patient presents with distention, crohns and CT shows strictures what mx
IV HC and parenteral nutrition
If fails stricutroplasty
Indications for proctocolectomy in UC
Elective- chronic steroid dependent or systemic SE from treatment, dysplasia
PSC- increased risk of cancer- more likely to require
Pouchitis following protoceletomy repair
Cipro/met
Absolute CI to restorative proctocolectomy pouch
Small bowel involvement and anal disease - Crohns or cancer
Most common liver tumour
Haemangioma
% of people with anomalies in biliary trees and what are the common ones
50%
Anomalies in duct- 12%
25% right hepatic crosses infant of common hepatic instead of behind it
Chronic alcohol intake effect on haem
Macro anaemai
BM suppression
Thrombocytopaenia
Coagulopathies
Stomach thickened, reduced distensibility, cells signet ring with mucin
Linitis plastica
Normal size of small, large bowel and caecum
Upper limit of normal
3
6
9
Hallmarks of toxic megacolon
Large than 6cm
Non obstructive
Signs of systemic toxicity
Mx of toxic megacolon
Medical- fluid, abx, NG, bowel rest
If no- surgical
Mx of colonicvesicle fistula
Surgical removal
Glasgow scoring and mortality
PaO2<8
Age >55
Neuts >15
Ca <2
Renal >16
Enz LDH >600, AST >200
Albumin <32
Sugar >10
Mortality
3-4 20%
5-6 40%
>6- 100%
Alvadro scoring
Migratory RIF
Anorexia
N+V
RIF tenderness-2
Rebound
Fever
Leucocytosis -2
Left shift
<5 unlikely
5-6 may require scan
>7 strong
Meckels diverticulum presentation age, location
Ileum anti mesenteric border
60cm from valve
Usually present before 2
% of gallstones that show on X ray
15%
Most common gallstones
Cholestrol
RF for HCC
Poorly controlled T2DM
Men
Hep B C
HIV
FAP associated features
Hypertrophy of retinal pigment
Desmoid tumours
Osteoma jaw
Adenoma duodenum
Gardners with EIM
Commonest complication of rectal prolapse
Incontinence
Also can cause incarceration, strangulation, ulceration
Sign of amoebic liver abscess on CXR
Blunting of costophrenic angle
Asymptomatic gallstone tx
None
Biliary atresia sx
Hepatosplenomegaly
Pale stool
Dark urine
All this not usually present at birth
No tree dilation
Mx of dumping syndrome
Several small meals
avoid simple sugars
High fibre
Ocreotide/PPI if conservative efails
Dysphagia, raynauds, furrowing of lips and tapered fingers
CREST
Screening of FAP
Chromosome 5
Opthalmoscopy
Abx after spelenectomy
Usually just 2 years
Lifelong- invasive pneumococcal, splenic malignant, irradiation or gVHD
Infection most likely <16, >50 and first 2 years
Vaccines in splenectomy
AT least 2 weeks before for elective
If emergency - 2 weeks after
One dose of Him/MenC MenB
1 month after MenB 1
SAAG levels for exudative and causes
<1.1
Infection, malignancy
Hereditary angioeoedma
Nephrotic - low albumin
Imaging for complex fistulas
MRI
Haemorrhoid needing manual reduction, thromboses with sig bleeding tx
Stapled haemorrhoidopexy
Cause of hypoclacaemia in pancreatitis
Fat saponification
Location of pancreatic pseudocyst
Lesser sac
pH monitoring of GORD
Probs placed in oesophagus and continuously reads oesophageal acidity
Muscle of oesophagus
Inner circular and outer longitudinal muscular coat
Striated in upper
Smooth in lower
Overlap in middle
Thick darkened axilla, warty lesions casques
GI cancers
DM
Dermatitis herpatifemormis
Itchy blisters knee, elbows, scalp
Highest sensitivity and spec for H pylori
Urea breath test
How to assess exocrine function of pancreas
Lundh meal
Dex and milk pwder
Measure lipase
Faecal elestace better used
Where does salmonella typhi collect
Peyer patches
Highest conc in ileum
Intusspection gender and time of year
Male winter
PBC bloods
High ALP, normal ish AST
High protein- Anti mito
High bilirubin
Ramstedt pyloromyotomy division layers
Parietal and visceral peritoneum
Serosa
Longitudinal muscle
Circular muscle
Mucosa left in tact
Peutz mutation and features
STK11 AD
Mainly polyp of SI
Intusspection
Demoid cyst
Parastomal hernia rate, sx and mx
10% of colostomies
More common if not through RA
Asymptomatic
Rarely need mx
Pigment laden Macrophages with peroidic acid shiff staining
Melonosis coli
What do NSAIDs inhibits that causes ulceration
COX2
Covnerts arachnoid acid to PG H2 which protects
Commonest cause of biliary strictures
Iatrogenic after surgery
Most common cause of anal fistula
Anorectal abscess
FAP surveillance
Relatives with 50% of inheritance
1-3 years 12-14 until 30
3-5 until 60
Upper GI at 25
Child Purgh scoring
Albumin
Ascites
Bilirubin
Coagulopathy - PT
Encephalopathy
Score >10 decompensation
42% of 5YS
RF gastric carcinoma
H pylori
Pernicious anaemia
Prev gastric surgery
Blood group A
Signet ring , mucinouos tumour, appearance colon and associations
HNPCC
Endometrium and stomach
Other blood test for coeliac disease
Endomysial AB
Repair for umbilical hernia in child
Mayo repair
Hoarse voice with oesophageal cancer
RLN involvement
Alcoholic found to have TG of 26, what is the casue
Increased synthesis of TG for incorporation into VLDL in the liver
As alcohol favour fat synthesis
Most common benign tumour in oesophagus
Leimyoma
Benign 1% of all tumours in oesophagus
Extensive iliocolic resection effect on PTH
Secondary hyperparathyroid
Persistent pain, fever, fullness in abdo after acute panc , ix
CT
Pseudo cyst
BALTHAZAR scoring for pancreatitis
Uses CT to score severity
Direction sigmoid volvulus occurs in and sign on AXR
Anticlockwise
Coffee bean
Diverticulitis in elderly, perforated but absence peritonitis
IV ABx and monitor
mx of sigmoid volvulus
Flatus tube flex sig
If any necrosis- laparotomy
Glasgow score of 5 mortality
40%
Hydatid vs amoebic infection
Amoebic causes dysentry
Mesenteric adentiis features
After URTI
Mild peritonitis reaction - shifting tenderenss
Large PR bleed post AAA repair
Aort enteric fistula
Ix for pancreatitis
CT
Triad of gastric volvulus
Epigastric pain
Retching without vomiting
Unable to pass NG tube
Most common secondary generalised peritontiis
Small intestine perf
