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General Surgery > Abdominal Surgery > Flashcards

Abdominal Surgery Flashcards

1
Q

What are the most common histological types of oesophageal cancer?

A

Squamous cell carcinoma of the upper oesophagus

Adenocarcinoma of the distal oesophagus - junction of the oesophagus and stomach

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2
Q

What are the risk factors for SCC of the oesophageal?

A

Low socioeconomic groups

Smoking

Alcohol

Males

Age +60

HPV infection

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3
Q

What are the risk factors for adenocarcinoma of the oesophagus?

A

Barrett’s oesophagus

GERD

Obesity

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4
Q

What are the symptoms of oesophageal cancer?

A

Dysphagia

Pain

Hoarseness

Cough with swallowing - oesophageal-tracheal fistula

Weight loss

Neck mass

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5
Q

What are the signs of oesophageal cancer?

A

Cervical lymph nodes

Hypercalcaemia - parathyroid hormone production

Dehydration, weight loss and muscle wasting

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6
Q

How is oesophageal cancer diagnosed?

A

History - Risk factors, symptoms

Examination - signs

Barium swallow

Endoscopy - direct visualization

FNA our Biopsy - histology

CT scan

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7
Q

What is the management of oesophageal cancer?

A

Surgical resection - oesophagectomy

Neoadjuvant Radiotherapy

Neoadjuvant Chemotherapy

Intubation - expandable stents insertions

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8
Q

What are the contraindications for surgery in oesophageal cancer?

A

Metastasis

Invasion of adjacent structures

Severe associated co-morbid diseases

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9
Q

What is the epidemiology of peptic ulcer disease?

A

Helicobacter pylori infection

NSAIDs

Acid hypersecretion

Smoking and alcohol

Genetic predisposition

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10
Q

What are the symptoms of peptic ulcer disease?

A

Epigastric pain relieved by food or antacids and worse when hungry

Nocturnal pain causing waking

Persistent pain or pain radiating to the back - penetrating ulcer

GERD (Heartburn)

Anorexia, vomiting and weight loss/gain

Epigastric tenderness

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11
Q

How would you diagnose peptic ulcer disease?

A

Gastroscopy - allows for biopsy to confirm/rule-out H.pylori or malignancy

Barium meal - seldom used

Gastrin levels - zollinger ellison syndrome

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12
Q

Describe the classification of gastric ulcers according to the Gaintree-Johnson classification

A

Type 1: At the incisura on the lesser curvature - not associated with acid hypersecretion

Type 2: Gastric and Duodenal ulcer secondary to gastric stasis usually due to acid hypersecretion

Type 3: Prepyloric ulcer usually due to acid hypersecretion

Type 4: High on lesser curvature close to gastro-oesophageal junction not associated with acid hypersecretion

Type 5: Secondary to chronic NSAIDs use

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13
Q

What are the complications of peptic ulcer disease?

A

Bleeding

Perforation

Stomach outlet obstruction

Penetration

Malignancy

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14
Q

What are the indications for surgery for peptic ulcer disease?

A

Non-healing ulcer

Perforation

Bleeding ulcer

Stomach outlet obstruction

Penetration into adjacent organs

Malignant transformation

Bile duct stricture

Fistulation

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15
Q

How do you manage Duodenal ulcers?

A

Truncal vagotomy with antrectomy - most effect acid reducing procedure

Truncal vagotomy with drainage procedure - for ineffective stomach emptying

Highly selective vagotomy

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16
Q

How do you manage gastric ulcers?

A

Type 1: Partial gastrectomy

Type 2: Truncal vagotomy with antrectomy/drainage

Type 3: Truncal vagotomy with antrectomy/drainage

Type 4: Partial gastrectomy (Pauchet procedure)

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17
Q

What are the clinical finding of a perforated peptic ulcer?

A

Anterior ulcers tends to perforate

Sudden severe upper abdominal pain with/without shoulder pain

Fetal position, motionless, avoids breathing

Tachycardia

Guarded abdominal examination

Lessened liver dullness due to free air in peritoneal cavity

Reduced bowel sounds

Raised WCC

X-ray shows free air under diaphragm

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18
Q

What is the management of a perforated peptic ulcer?

A

Keep NPO

NG tube - decreases air in peritoneal cavity

IV fluids

IV antibiotics

IV H2 antagonist or PPIs

Laparotomy with omentopexy OR laparotomy with simple closure

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19
Q

When can a definitive ulcer operation be performed?

A

The patient is haemodynamically stable

Perforation has to occurred <24hrs ago

No associated risk factors

Failed medical treatment

Very large ulcers associated with severe bleeding, obstruction or repeated perforation

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20
Q

What are the complications of a gastrectomy?

A

Bleeding

Anastomoses leakage

Obstruction

Ulcer recurrence

Gastro-jejuno-colic fistula

Alkaline reflux gastritis

Dumping syndrome

Chronic gastroparesis

Malabsorption - anaemia

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21
Q

What are the risk factors for gastric cancer?

A

Diet - low fat, low protein, high salt, alcohol

Environmental - poor food prep and drinking water, smoking

Poor socioeconomic status

Genetic predisposition

H. Pylori infection

Prior gastric surgery

Gastric ulcer

Atrophic gastritis

Polyps

Males

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22
Q

Describe Lauren’s classification for intestinal gastric adenocarcinoma

A

Ulcerative

Usually in the Antrum of the stomach

Pre-existing gastric atrophy and intestinal metaplasia

Any blood type

More common in males

Older age

Gland formation

Haematogenous spread

Better prognosis

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23
Q

Describe Lauren’s classification for diffuse gastric cancer

A

No gastric atrophy or intestinal metaplasia usually

Blood group A

More common in females

Younger

Poorly differentiated, signet ring cells

Transmural or lymphatic spread

Poor prognosis

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24
Q

How would a patient with a gastric adenocarcinoma present?

A

Epigastric discomfort / indigestion

Weight loss, vomiting, anorexia

Dysphasia

Gastric outlet obstruction

Early satiety

Anaemia

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25
Q

What are the signs of advanced gastric adenocarcinoma?

A

Palpable abdominal mass

Palpable supraclavicular lymph-node’s (virchows LN / troisiers sign)

Sister Mary Joseph nodule

Irregular hepatomegaly

Ascites

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26
Q

How is gastric adenocarcinoma diagnosed?

A

Gastroscopy with biopsy for histological classification

Barium meal

CXR

FBC, U&E, LFTs, serum albumin

Blood gas

CT scan

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27
Q

How do you stage a gastric adenocarcinoma?

A

TNM staging

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28
Q

What is the management of a gastric carcinoma?

A

Subtotal gastrectomy- distal third tumors

Total gastrectomy - middle and proximal third tumors

Lymph nodes in close proximity are always removed

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29
Q

Describe the pathophysiology of bowel obstruction

A

Complete obstruction

> Intestine proximal to obstruction contracts vigorously trying to overcome obstruction

> colicky pain + increased bowel sounds

> abdominal distension

> proliferation of gas producing bacteria

> Further abdominal distension

> vomiting

> dehydration

> constipation

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30
Q

Describe La Place’s Law in terms of bowel obstruction

A

If the radius of bowel increases with a constant pressure. Then the tension exerted on the wall will be greater.

Meaning, If the pressure in the bowel is equal the area of bowel with the largest radius will have the greatest force/tension on its wall. The ceacum is the largest area of the bowel and tends to perforate more often

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31
Q

What are the causes of large bowel obstruction?

A

Colorectal Cancer

Faecal Impaction

Sigmoid Volvulus

Diverticular stricture

Adhesions

Foreign body

Hernia

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32
Q

What are the most common causes of small bowel obstruction?

A

Adhesions

Hernias

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33
Q

Describe a closed loop bowel obstruction

A

It is a complicated intestinal obstruction.

The bowel is obstructed at two points by an adhesive band or volvulus

Decompression can not occur pressure causes the loop to rise

This results in severe constant pain, local tenderness/peritonism

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34
Q

Describe a strangulated bowel obstruction

A

Requires urgent surgery

The blood supply of the obstructed bowel is occluded

This can result in necrosis/perforation of the involved segment

It can be caused by hernia, adhesions, volvulus and intussusception

It causes severe pain/tenderness/peritonism over the area, fever, tachycardia, leucocytosis

35
Q

What are the four cardinal features of mechanical intestinal obstruction?

A

Pain

Abdominal distension

Vomiting

Constipation/Obstipation

36
Q

How would you diagnose bowel obstruction?

A

History - Previous surgery, symptoms

Examination- especial abdominal and rectal examination

Bloods - FBC, U&E

AXR - supine or erect

Single contrast barium enema

37
Q

How do you distinguish between small bowel and large bowel on erect film?

A

Small bowel - fluid levels are more wide than high and descend stepwise from left to right

Large bowel - fluid levels are more high that wide

38
Q

What is the initial management of bowel obstruction?

A

Management is dependent on the cause

Admit to hospital 
IV fluids, NPO, NG tube
Analgesia
Correct dehydration/Imbalances
Monitor - BP, HR, urine output
39
Q

Describe the surgical management of bowel obstruction

A

Right sided obstruction - midline laparotomy with right hemi-colectomy and anastomoses

Left sided obstruction - resection of obstructing lesion and creation of a colostomy followed by eventual closure of the colostomy

40
Q

What is the difference between a true and false diverticulum?

A

True - contains all the layers of the intestinal wall which includes the mucosa, submucosa, serousa and muscle layer

False - contains no muscle layer of the instestinal wall

41
Q

Discuss Meckel’s Diverticulum

A

Common congenital abnormalities of the GIT

It is a TRUE diverticulum of the small bowel

It is known as the disease of 2’s
2 inches long
2 feet for the ileoceacal valve
2 types of mucosa
2 x more common in males
2% of the population

It is a remnant of the omphalmesenteric duct from the embryological period

It usually doesn’t cause any problems. But it maybe cause:
Mechanical intestinal obstruction
Bleeding per rectum
Diverticulitis
Neoplasia

It is managed by diverticulectomy or segmental resection

42
Q

Why don’t we find diverticula in the rectum?

A

The rectum has a completely circumferential longitudinal muscle layer which doesn’t allow for defects which lead to diverticulum

43
Q

Describe the pathogenesis of diverticulosis

A
  1. Increased intraluminal pressure in the colon cause diverticula through a defect in the muscle wall where small arteries pass
  2. Weakness/Degeneration of the musculature of the colon
44
Q

What are the consequences of diverticular disease of the colon?

A

Most are asymptomatic

Left iliac fossa pain

Perforation

Diverticulitis

Bleeding per rectum

45
Q

How is a sigmoid volvulus diagnosed?

A

Barium enema - birds beak appearance

AXR - dilated bowel loop “Bent inner tube” sign

46
Q

How would you manage an uncomplicated sigmoid volvulus?

A

Decompression via sigmoidoscope

Leave a flatus tube in place

Prepare bowel and patient for elective sigmoidectomy

47
Q

How would you manage a sigmoid volvulus complicated by necrosis?

A

Emergency laparotomy to resect the infected bowel without untwisting it

48
Q

Describe the pathogenesis of acute appendicitis

A 
Luminal obstruction
> increased mucus
> stasis
> bacterial overgrowth
> pus formation
> increased luminal pressure
> ischaemia/infarction
> perforation 
> generalized peritonitis
49
Q

What is the classic presentation of acute appendicitis?

A

Vague epigastric/umbilical pain which localizes to the right iliac fossa

Nausea and vomiting

Low grade fever

Anorexia

50
Q

What are the laboratory finding of acute appendicitis?

A

Raised WCC

Differential count shows raised neutrophils

Raised CRP

51
Q

Describe the radiological finding of acute appendicitis

A

AXR - faecolith may be visible, ill-defined right psoas margin

Abdo US - dilated non-compressable blind tubular structure

CT abdo - dilated appendix with thick wall, “fat stranding” or abscess

52
Q

Provide a DDx for right iliac fossa pain

A

PID in females

Ectopic pregnancy

Ovarian pathology

Endometriosis

Acute gastroenteritis

Crohn’s enteritis

TB

Meckel’s diverticulum

UTI

53
Q

What are the complications of acute appendicitis?

A

Perforation

Septic shock

Pylephlebitis

Liver abscess

Death

54
Q

How would you manage acute appendicitis?

A

Admit - if uncertain then re-evaluate every 4 hours

IV fluids and analgesia

Antibiotics - gentamicin (E. Coli) or cephzol

55
Q

What are the histological classifications of large bowel polyps?

A

Neoplastic - malignant/benign

Hamartoma

Inflammatory

Other

56
Q

Discuss Familial Adenomatous Polyposis (FAP)

A

Autosomal dominant inherited condition

Very High Pre-malignant condition for colorectal ca

Polyps also occurs in duodenum and small bowel

Management is restorative proctolectomy (all large bowel mucosa is removed)

Need to have annual upper GIT endoscopy post proctolectomy coz patients have a high risk of duodenal carcinoma

57
Q

List the risk factors / pre-malignant factors for colorectal carcinoma

A

Western diet - high fat, low fiber

Genetic factors:
Family history
FAP
Lynch syndrome type I/II

Ulcerative colitis

Previous irradiation

Implantation of ureters in colon

Colorectal schistosomiasis

58
Q

How did you diagnose colorectal carcinoma?

A

History and examination - NB PR Exam

Sigmoidoscopy

Barium enema of colonoscopy

CT abdo

59
Q

Discuss a fungating colorectal adenocarcinoma

A

Usually in the right colon

Few symptoms
Early: peri umbilical/epigastric discomfort 30mins after a meal

60
Q

Discuss a annular stenosing colorectal adenocarcinoma

A

Typically left colon/sigmoid

GERD

Increasing Constipation or alternating episodes of constipation and diarrhea

61
Q

Discuss a malignant ulcer colorectal adenocarcinoma

A

Typically in the rectum

Blood/Mucus per rectum

Tenesmus

Spurious diarrhea

Do NOT diagnose this radiologically

62
Q

Discuss your approach to a patient with colorectal carcinoma

A

History - suggestive symptoms

Examination - all especially PR exam; looking for signs

Special investigations -
Colonoscopy/Sigmoidoscopy and biopsy
Barium enema
Tumour markers CEA
FBC for Fe anaemia
CT abdo
Staging
TNM
CXR
LFTs
Abdo US

Surgical resection - colectomy/hemicolectomy with removal of regional lymph nodes

Adjuvant Chemo/radiotherapy

6 monthly follow-ups - Exam, LFTs, CXR, US abdo, CEA levels

2 yearly colonoscopies

63
Q

List the 2 most common causes of obstructive jaundice

A

Gallstones

Head of pancreas carcinoma

64
Q

Provide a DDx for obstructive jaundice due to luminal obstruction

A

Gallstones

Parasites

  • Ascaris Lumbricoides
  • Daughter cyst of Enchinococcus cyst
65
Q

What are the signs of obstructive jaundice?

A

Yellow skin and sclera

Dark Urine

Pale stools

Itching

RUQ pain and tenderness

66
Q

How would you investigate Obstructive jaundice?

A

Urine dipstick

    • bilirubin
    • urobilinogen

FBC
* Increased WCC with cholangitis

LFTs

  • Low albumin
  • Increased Alkaline phosphate and GGT

Ultrasound

  • Visualization of obstruction - cystic/solid
  • Billiary Dilatation above the obstruction
  • Level of obstruction
  • Hyperechoic mass > gallstone
  • Distended gallbladder + thickened wall > acute cholecystitis

AXR
* Radio-opaque gallstones (10-20%) - Brown and black stones coz’ it contains calcium

ERCP
* Filling defect

67
Q

What are the consequences of gallstones in the gallbladder?

A

Mostly asymptomatic

Gallstone dyspepsia

  • Upper abdominal discomfort
  • Aversion of fatty foods
  • Flatulence

Biliary colic

  • Colic-like pain in RUQ - radiates to right scapula
  • Nausea and vomiting
  • Tenderness over gallbladder

Acute cholocystitis

Carcinoma of the gallbladder

68
Q

What are the symptoms and signs of acute cholecystitis?

A

BIliary colic > constant pain in RUQ

Pyrexia

Murphy’s sign (+)

Raised WCC

Paralytic ileus
*Constipation

69
Q

How would you manage acute cholecystitis due to gallstones?

A

Admit

IV fluids

NPO

Analgesia - Pethidine

Broad spectrum antibiotics - Cephzol / Amoxicillin + Gentamicin

Cholecystectomy within 3-4 days

70
Q

How is Acute cholecystitis diagnosed?

A

Ultrasound

  • Distended gallbladder
  • Thickened gallbladder wall
  • Sonographic Murphy’s sign - Localised tenderness

Tc-99m HIDA scintigram

  • Done under sonar
  • Isotope reaches bowel but no activity seen in gallbladder
71
Q

What is the management of symptomatic gallstones?

A

Laproscopic cholecystectomy

Open cholecystectomy if…

  • Evidence of severe/perforated acute cholecystitis
  • Exploration of bile duct required
72
Q

What are the clinical features of an adenocarcinoma of the pancreas?

A

Painless obstructive jaundice
* Preceded by vague, deep-seated abdominal pain + bachache (poor prognostic indicator)

Anorexia, weight loss

Palpable gallbladder

Liver palpable - congestion

73
Q

How would you diagnose a tumour of the pancreas?

A

LFTs
* Total bilirubin >10x normal favours malignant obstructive jaundice

Tumour Markers
* Elevated CA19-9

Ultrasound

  • Biliary/pancreatic duct dilatation
  • Cystic neoplasn

Abdominal CT scan

  • Visualize tumour
  • Biliary/pancreatic duct dilatation
  • Local infiltration
  • LN/Liver metastases

ERCP

  • Site and form of biliary obstruction
  • Displacement/obstruction of pancreas
74
Q

What is the treatment for pancreatic tumours?

A

Surgical resection (whenever possible)

Islet cell tumours / cystadenoma
* Simple enucleation

Head of pancreas / peri-ampullary tumors
* Whipple operation (Pancreaticduodectomy)

Body/tail pancreatic tumour
* Distal pancreaticduodectomy + excision of spleen and splenic vessels

Unresectable tumour
* Palliative - Gallbladder/bileduct anastomosis to small bowel

75
Q

What is the prognosis of adenocarcinoma of the pancreas?

A

Poor :(

Without resection 1 year survival <10%

With resection 1 year survival ± 12%

76
Q

When would you perform surgery for portal hypertension?

A

(When there’s complications)

Bleeding Oesophageal Varices

  • Who failed other treatment modalities
  • Good operative risk

Ascites

Hypersplenism

77
Q

What are the endoscopic treatment interventions for oesophageal varices?

A

Sclerotherapy

Rubber band ligation

78
Q

What are the invasive radiological treatment procedures for oesophageal varices?

A

Embolisation

Transjugular intrahepatic portosystemic shunt (TIPSS)

79
Q

What are the surgical treatment procedures for oesophageal varices?

A

Porto-caval / Meso-caval shunt

  • Creation of a communication between the hypertensive portal venous system and low pressure systemic system
  • Normalises pressure in portal venous system
  • Manages ascites and hypersplenism as well
80
Q

What are the complications of the surgical treatment for oesophageal varices?

A

Hepatic encephalopathy

81
Q

What are the risk factors for hepatocellular carcinoma?

A

Hep B/C infection

Cirrhosis

Aflatoxin contaminated foods

Alcoholic

82
Q

How would you diagnose a hepatocellular carcinoma?

A

History - suggestive symptoms and risk factors

  • RUQ pain
  • Abdominal mass
  • Loss of appetite and weight loss
  • Jaundice

Examination: Palpable mass / jaundice

Macroscopic features

  • Large - single well-circumscribed
  • Nodular - multiple nodules
  • Diffuse - ill-defined, wide infiltration, most common in SA

Alpha - Fetoprotein will be raised

U/S - visualise mass

CT scan - Staging

83
Q

What is the management of an organ-confined hepatocellular carcinoma?

A

Tumour resection (where possible)

  • Most effective
  • Not done if there’s cirrhosis coz’ of bleeding risk and decreased liver function

Liver transplant
* Cirrhotic patients

84
Q

What is the management of a non-resectable (not organ-confined) hepatocellular carcinoma?

A

Intralesional injections with 95% ethanol

Chemotherapy via the hepatic artery

Radiofrequency ablation

General Surgery (7 decks)

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