Abdomen and Trunk Flashcards
1
Q
Difference between direct and indirect inguinal hernia?
A
- indirect: remnants of patent processus vaginalis, arise lateral to inferior epigastric vessels, through deep ring
- direct: result of weak posterior wall of inguinal canal, arise medial to vessels, not within spermatic cord
2
Q
Contents of spermatic cord
A
3 arteries: to vas deferens, testicular, cremasteric
3 nerves: ilioinguinal nerve (L1), to cremaster (genitofemoral), autonomic (T10)
3 others: vas deferens, pampiniform plexus, lymphatics to para-aortic nodes
3
Q
What would you tell patients about their recovery from inguinal hernia repair?
A
- mobilisation early
- keep wound clean, can bathe immediately
- 6 weeks off work if heavy lifting
- avoid prolonged coughing and constipation
4
Q
Differential of lump in the groin
A
L - lymph node/lipoma S - sapheno-varix/skin lesion H - hernia A - aneurysmal dilatation of femoral artery P - psoas abcess/bursa E - ectopic/undescended testis
5
Q
What level does serum bilirubin need to rise to before jaundice can be detected on clinical exam?
A
Normal is 50 mmol/L to discolour sclera.
6
Q
How should obstructive jaundice be investigated?
A
- urine for bilirubin
- blood: FBC (anaemia, infection) U+Es (hepatorenal syn) LFTs, clotting
- radiological: USS (common bile duct dilation >8mm, stones, pancreatic mass) CT, ERCP, MRCP
7
Q
Causes of post-op jaundice
A
- pre-hepatic: haemolysis post transfusion
- hepatic: anaesthetics, sepsis, intra- or post-op hypotension
- post-hepatic: biliary injury
8
Q
Indications for forming a stoma
A
- feeding
- lavage
- decompression
- diversion: protect distal anastomosis, urinary post-cystectomy
- exteriorisation
9
Q
How would you prepare a patient for a stoma pre-op?
A
- psychosocial and physical prep
- explain indications and complications
- CNS in stoma care
- mark site with patient standing: within rectus muscle, away from scars, creases, bony point, waistline, easily accessible
10
Q
Complications of stoma formation
A
Specific (FOUL SHIT) - fluid loss - odour - ulceration of skin - leakage - stenosis - herniation/prolapse/retraction - ischaemia - terminal ileum loss General - stoma diarrhoea + hypokalaemia - nutritional disorders - renal and gall-stones following ileostomy - pscyhosexual - residual disease e.g. crohns
11
Q
Difference between ileostomy and colostomy
A
Ileostomy: RIF, spouted, watery content
Colostomy: LIF, flush with skin, formed stool
12
Q
How would you rehabilitate a patient following stoma placement?
A
- normal diet
- change bag once or twice-a-day
- ileostomies need base plate changed every 5 days
- psychological and psychosexual support
13
Q
Hepatomegaly causes
A
- physiological: reidel’s lobe, hyperexpanded chest
- infections: viral (hepatitis, EBV, CMV), bacterial (TB, abcesss), protozoal (malaria, schistosomaisis)
- alcoholic liver disease: fatty, cirrhosis
- metabolic: Wilson’s, haemochromatosis, infiltration (amyloid)
- malignant: primary/secondary, lymphoma, leukaemia
- CCF: RHF, TR, Budd-Chiari
14
Q
Significance of arterial bruit or venous hum over liver?
A
Arterial bruit = alcoholic hepatitis or carcinoma
Venous hum = portal hypertension
15
Q
What is portal hypertension?
A
- portal vein pressure > 10 mmHg
- portal flow greatly reduced or reduced
- pre-hep, hep and post hep causes
16
Q
What is an incisional hernia?
A
Extrusion of peritoneum and abdo contents through a weak scar or accidental wound on abdo wall. Represents a partial wound dehiscence where the skin remains intact.
17
Q
Complications of incisional hernia
A
- intestinal obstruction
- incarceration (irreducible)
- strangulation (compromised blood supply)
- skin excoriation
- persistent pain
18
Q
Predisposing factors to incisional hernias
A
- pre-op: age, immunocompromised, obesity, malignancy, distension from obstruction or ascites
- operative: poor technical closure, drains placed through wound
- post-op: wound infection, haematoma, early mobilisation, atelectasis and chest infection
19
Q
Incisional hernia treatment options
A
- non-surgical: truss/corset, weight-loss, other risk factor management
- surgical: optimise risk factors first, dissect sac, close defect +/- mesh
20
Q
Pathogenesis of umbilical herniae?
A
Defect through linea alba often due to obesity stretching.
- true umbilical herniae occur through umbilical scar, usually congenital
- paraumbilical herniae occur around scar
- neck of sac often tight, higher risk of strangulation
21
Q
Umbilical herniae in children
A
Minor defects common in neonates, often repair spontaneously.
Only repair if symptomatic
22
Q
Causes of acquired umbilical herniae in adults
A
- pregnancy
- ascites
- ovarian cysts
- fibroids
- bowel distension
23
Q
How would an umbilical hernia be repaired?
A
- optimise concurrent medical problems
- Mayo’s ‘vest-over-pants’ op
- dissect sac, reduce contents, excise sac, sublay extraperitoneal mesh below rectus, suture upper edge of rectus over lower edge with interrupted mattress non-absorbable sutures
24
Q
Splenomegaly causes
A
- Infective: EBV, CMV, HIV, I.E. malaria
- Haematological: haemolytic anaemia, myeloproliferative disorders, sickle-cell, leukaemia (CML), lymphoma
- Portal hypertension: cirrhosis, vein thrombosis
- Systemic diseases: amyloidosism, sarcoidosis, RA (Felty’s)
25
Causes of massive splenomegaly
- myelofibrosis
- CML
- malaria
26
Indications for splenectomy
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Trauma
Hypersplenism:
- autoimmune thrombocytopaenia/haemolytic anaemia
- hereditary spherocytosis
- thrombotic thromovytopaenia
- sickle-cell/thalassaemia
- myelofibrosis, CML, Hodgkin's
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27
Functions of the spleen
- produces IgM
- filters micro-organisms esp encapsulated
- sequesters and removes old RBCs and platelets
- recycles iron
- pools platelets (30%)
28
Immunisations before splenectomy
- pneumococcal
- HIB
- meningococcal
- annual flu
- consider lifelong penicillin
- warn about risk of malaria
29
Blood film appearences post splenectomy
- increased platelet count and size
- increased neutrophils
- nucleated red cells with Howell-Jolly bodies and target cells
- increased leukocytosis to infection
30
Assessing severity of UC
- Motions per day
- rectal bleeding
- temperature
- pulse rate
- haemoglobin
- ESR
31
Indications for surgery in IBD
- Acute severe UC: toxic megacolon (>6cm), perforation, severe GI bleeding
- Chronic UC: medical Mx failure, malignant transformation, maturation failure in children
- Crohn's: abscess, fistulae, stenosis causing obstruction, control acute/chronic bleeding
32
Hepatobiliary complications of IBD
- Liver: fatty change, hepatitis, cirrhosis, amyloidosis
| - Biliary system: gallstones, PSC, cholangiocarcinoma
33
Surgical options for UC
- subtotal colectomy with ileostomy +/- mucous fistula formation: op of choice for acute severe colitis, leaves distal sigmoid and rectum.
- panproctocolectomy: all colon + rectum + anus. Permanent thus only as patient choice or if no other option.
- restorative proctocolectomy: avoids permanent stoma: formation of ileal pouch anastomosed to anus, often covered by diverting loop ileostomy
34
Surgical options for Crohn's
- preserve as much small bowel as possible
- limited ileocaecectomy for distal ileal disease
- colonic defuctioning loop ileostomy may be needed for failure medical therapy
- occasionally subtotal colectomy with permanent end ileostomy
- pouch surgery generally contraindicated in Crohn's
35
What is a hydrocoele?
Excess accumulation of fluid in the processus vaginalis
36
Anatomical classification of hydrocoeles
- Vaginal: fluid in tunica vaginalis which surround testes but does not extend up cord
- Cord: fluid around spermatic cord, difficult to distinguish from inguinal hernia
- Congenital: sac communicates directly with peritoneum thus filled with peritoneum fluid
- Infantile: only obliterated at deep ring thus fluid around cord and testes but does not communicate
37
Hydrocoele treatment
- exclude malignancy
- watch and wait
- aspiration relieves symptoms but often reaccumulates
- Lord's plication
- Jaboulay's operation
38
What is a secondary hydrocoele?
Vaginal hydrocoele can be due to local pathology:
- testicular tumours
- torsion
- orchitis
- trauma
- following inguinal hernia repair
39
Epididymal cyst treatment
- leave alone if not troublesome, esp in young men
- very large or painful cysts can be removed
- occasionally total epididymal excision indicated to prevent frequent recurrence of painful cysts
40
Aetiology of varicoceles
- dilated tortuous 'varicose' veins in pampiniform plexus
- occur in 15% young men around puberty
- if suddenly appear in older men, exclude underlying retroperitoneal disease including left renal carcinoma
41
Why are 98% of varicoceles left-sided?
Left testicular vein:
- is more vertical where it connects to the renal vein
- is longer than the right
- frequently lacks terminal valve
Also, the left renal vein can be compressed by colon
42
Varicocele treatment
Transfemoral radiological embolisation of testicular vein
Surgical ligation of veins
- Palomo op: high retroperitoneal approach
- Inguinal approach
- Laproscopic
43
Causes of a right iliac fossa mass
- from skin and soft tissues: sebaceous cyst, lipoma, sarcoma
- from bowel: caecal Ca, Crohn's mass, TB mass, appendicular mass/abscess
- from gyane organs: ovarian tumour, fibroid uterus
- from male repro organs: undescended testis, ectopic testis
from urological system: transplanted kidney, ectopic kidney, bladder diverticulum
- from blood vessels: external/common iliac artery aneurysm, lymphadenopathy
44
Investigations for a RIF mass
- USS
- CT
- IV contrast CT
45
Causes of a left iliac fossa mass
- from skin and soft tissues: sebaceous cyst, lipoma, sarcoma
- from bowel: diverticular mass, colon Ca, faecal mass
- from gyane organs: ovarian tumour, fibroid uterus
- from male repro organs: undescended testis, ectopic testis
from urological system: transplanted kidney, ectopic kidney, bladder diverticulum
- from blood vessels: external/common iliac artery aneurysm, lymphadenopathy
46
Major indications/causes for kidney transplant
End stage renal failure due to:
- DM
- Hypertensive renal disease
- Glomerulonephritis
- PCKD
47
How is 'matching' of transplanted kidneys performed?
- ABO
| - HLA: DR > B > A
48
Stages of transplant rejection
- Hyperacute: within hrs from preformed antibodies
- Accelerated acute: 1-4 days from secondary immune response (T mem cell activation)
- Acute: 5 days-2 weeks from cell-mediated immunity
- Chronic: humoral mechanisms most important
49
Signs of renal transplant rejection?
- graft tenderness
- reduced urine output
- rising creatinine
50
Causes of ascites?
- CLD
- RHF
- Intra-abdominal malignancy
- Hypoalbuminaemia
- Nephrotic syndrome
- TB
- Chylous ascites
51
Differential of epigastric mass
- from skin and soft tissues: sebaceous cyst, sarcoma, lipoma, hernia
- from GI tract: stomach Ca, hepatomegaly, pancreatic Ca, pancreatic pseudocyst
- from vascular system: AAA, retroperitoneal lymphadenopathy
52
Causes of dysphagia
Mechanical
- Lumen: FB, oesophageal web
- Wall: Ca, oesophagitis, Barrett's, stricture
- Outside wall: retrosternal goitre, lung Ca, pharyngeal pouch
Coordination abnormalities
- Motility disorder: spasm, achalasia
- Neuromuscular disease: MG, bulbar palsy (MND), CVA
53
Enlarged kidney differential
```
Congenital
- cystic disease
- horseshoe kidney
- hypertrophic single kidney
Acquired
- Renal: cysts, tumours, hydronephrosis, pyonephrosis, perinephric abcess, renal vein thrombosis
- Systemic: DM, amyloidosis, SLE
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54
Beck's triad
For renal cell Ca
- haematuria
- loin mass
- loin pain
55
Classification of breast disease
Malignant
- Ductal Ca (70%)
- Lobular Ca (20%)
- Other: mucinous, tubular, medullary (10%)
Benign
- Congenital: extra nipples, hypoplasia
- Aberrations of normal dev and involution (ANDI): fibroadenomas, cysts, sclerotic/fibrotic lesions
- Non-ANDI: infective, lipomas, fat necrosis
56
Indications for mastectomy
- patient preference
- clinical evidence of multifocal/multicentric disease
- large lump in small breast tissue
- nipple involvement
57
Preparing a patient for breast surgery
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Physical
- mark site
- explain procedure + post op drain
- expect numb skin in axilla and upper arm (T1) as intercostal nerve is divided
- anaesthetic work-up including CX (pul mets)
Psychological
- breast care nurse
- fully explanation of reasons for op
- reconstruction options discussion
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58
When should post-mastectomy drain be removed?
Often two placed (axilla and at breast)
| - 3-5 days, until drainage
59
Types of breast reconstruction
Timing
- immediate
- delayed
Technique
- Tissue expansion (implants): subcutaneous or submuscular
- Autologous tissue: transverse rectus abdominis myocutaneous (TRAM) flap, deep inferior epigastric perforator (DIEP) flap, superficial IEP, latissimus dorsi flap.
60
Define Hernia
A protrusion of a hollow viscus or part of a viscus through a defect of the walls of its containing cavity into an abnormal position
61
Define Ileus
A condition where there is absence of peristalsis in the intestine.
Usually occurs a few days after a laparotomy
62
Causes of increased amylase
Acute pancreatitis, cholecystitis, mesenteric infarction, GI perforation, renal failure (failure to excrete amylase)
63
Define Leriche Syndrome
Leriche syndrome, is atherosclerotic occlusive disease involving the abdominal aorta and/or both of the iliac arteries
64
Symptoms of Leriche syndrome
1. Claudication of the buttocks and thighs
2. Atrophy of the musculature of the legs
3. Impotence (due to paralysis of the L1 nerve)
65
Complications of UC
```
Perforation
Bleeding
Malnutrition
Toxic megacolon
PSC
Colon cancer
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