Abdominal Surgery Flashcards
What are the most common histological types of oesophageal cancer?
Squamous cell carcinoma of the upper oesophagus
Adenocarcinoma of the distal oesophagus - junction of the oesophagus and stomach
What are the risk factors for SCC of the oesophageal?
Low socioeconomic groups
Smoking
Alcohol
Males
Age +60
HPV infection
What are the risk factors for adenocarcinoma of the oesophagus?
Barrett’s oesophagus
GERD
Obesity
What are the symptoms of oesophageal cancer?
Dysphagia
Pain
Hoarseness
Cough with swallowing - oesophageal-tracheal fistula
Weight loss
Neck mass
What are the signs of oesophageal cancer?
Cervical lymph nodes
Hypercalcaemia - parathyroid hormone production
Dehydration, weight loss and muscle wasting
How is oesophageal cancer diagnosed?
History - Risk factors, symptoms
Examination - signs
Barium swallow
Endoscopy - direct visualization
FNA our Biopsy - histology
CT scan
What is the management of oesophageal cancer?
Surgical resection - oesophagectomy
Neoadjuvant Radiotherapy
Neoadjuvant Chemotherapy
Intubation - expandable stents insertions
What are the contraindications for surgery in oesophageal cancer?
Metastasis
Invasion of adjacent structures
Severe associated co-morbid diseases
What is the epidemiology of peptic ulcer disease?
Helicobacter pylori infection
NSAIDs
Acid hypersecretion
Smoking and alcohol
Genetic predisposition
What are the symptoms of peptic ulcer disease?
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
How would you diagnose peptic ulcer disease?
Gastroscopy - allows for biopsy to confirm/rule-out H.pylori or malignancy
Barium meal - seldom used
Gastrin levels - zollinger ellison syndrome
Describe the classification of gastric ulcers according to the Gaintree-Johnson classification
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
What are the complications of peptic ulcer disease?
Bleeding
Perforation
Stomach outlet obstruction
Penetration
Malignancy
What are the indications for surgery for peptic ulcer disease?
Non-healing ulcer
Perforation
Bleeding ulcer
Stomach outlet obstruction
Penetration into adjacent organs
Malignant transformation
Bile duct stricture
Fistulation
How do you manage Duodenal ulcers?
Truncal vagotomy with antrectomy - most effect acid reducing procedure
Truncal vagotomy with drainage procedure - for ineffective stomach emptying
Highly selective vagotomy
How do you manage gastric ulcers?
Type 1: Partial gastrectomy
Type 2: Truncal vagotomy with antrectomy/drainage
Type 3: Truncal vagotomy with antrectomy/drainage
Type 4: Partial gastrectomy (Pauchet procedure)
What are the clinical finding of a perforated peptic ulcer?
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
What is the management of a perforated peptic ulcer?
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
When can a definitive ulcer operation be performed?
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
What are the complications of a gastrectomy?
Bleeding
Anastomoses leakage
Obstruction
Ulcer recurrence
Gastro-jejuno-colic fistula
Alkaline reflux gastritis
Dumping syndrome
Chronic gastroparesis
Malabsorption - anaemia
What are the risk factors for gastric cancer?
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
Describe Lauren’s classification for intestinal gastric adenocarcinoma
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
Describe Lauren’s classification for diffuse gastric cancer
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
How would a patient with a gastric adenocarcinoma present?
Epigastric discomfort / indigestion
Weight loss, vomiting, anorexia
Dysphasia
Gastric outlet obstruction
Early satiety
Anaemia
What are the signs of advanced gastric adenocarcinoma?
Palpable abdominal mass
Palpable supraclavicular lymph-node’s (virchows LN / troisiers sign)
Sister Mary Joseph nodule
Irregular hepatomegaly
Ascites
How is gastric adenocarcinoma diagnosed?
Gastroscopy with biopsy for histological classification
Barium meal
CXR
FBC, U&E, LFTs, serum albumin
Blood gas
CT scan
How do you stage a gastric adenocarcinoma?
TNM staging
What is the management of a gastric carcinoma?
Subtotal gastrectomy- distal third tumors
Total gastrectomy - middle and proximal third tumors
Lymph nodes in close proximity are always removed
Describe the pathophysiology of bowel obstruction
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
Describe La Place’s Law in terms of bowel obstruction
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
What are the causes of large bowel obstruction?
Colorectal Cancer
Faecal Impaction
Sigmoid Volvulus
Diverticular stricture
Adhesions
Foreign body
Hernia
What are the most common causes of small bowel obstruction?
Adhesions
Hernias
Describe a closed loop bowel obstruction
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
Describe a strangulated bowel obstruction
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
What are the four cardinal features of mechanical intestinal obstruction?
Pain
Abdominal distension
Vomiting
Constipation/Obstipation
How would you diagnose bowel obstruction?
History - Previous surgery, symptoms
Examination- especial abdominal and rectal examination
Bloods - FBC, U&E
AXR - supine or erect
Single contrast barium enema
How do you distinguish between small bowel and large bowel on erect film?
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
What is the initial management of bowel obstruction?
Management is dependent on the cause
Admit to hospital IV fluids, NPO, NG tube Analgesia Correct dehydration/Imbalances Monitor - BP, HR, urine output
Describe the surgical management of bowel obstruction
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
What is the difference between a true and false diverticulum?
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
Discuss Meckel’s Diverticulum
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
Why don’t we find diverticula in the rectum?
The rectum has a completely circumferential longitudinal muscle layer which doesn’t allow for defects which lead to diverticulum
Describe the pathogenesis of diverticulosis
- Increased intraluminal pressure in the colon cause diverticula through a defect in the muscle wall where small arteries pass
- Weakness/Degeneration of the musculature of the colon
What are the consequences of diverticular disease of the colon?
Most are asymptomatic
Left iliac fossa pain
Perforation
Diverticulitis
Bleeding per rectum
How is a sigmoid volvulus diagnosed?
Barium enema - birds beak appearance
AXR - dilated bowel loop “Bent inner tube” sign
How would you manage an uncomplicated sigmoid volvulus?
Decompression via sigmoidoscope
Leave a flatus tube in place
Prepare bowel and patient for elective sigmoidectomy
How would you manage a sigmoid volvulus complicated by necrosis?
Emergency laparotomy to resect the infected bowel without untwisting it
Describe the pathogenesis of acute appendicitis
Luminal obstruction > increased mucus > stasis > bacterial overgrowth > pus formation > increased luminal pressure > ischaemia/infarction > perforation > generalized peritonitis
What is the classic presentation of acute appendicitis?
Vague epigastric/umbilical pain which localizes to the right iliac fossa
Nausea and vomiting
Low grade fever
Anorexia
What are the laboratory finding of acute appendicitis?
Raised WCC
Differential count shows raised neutrophils
Raised CRP
Describe the radiological finding of acute appendicitis
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
Provide a DDx for right iliac fossa pain
PID in females
Ectopic pregnancy
Ovarian pathology
Endometriosis
Acute gastroenteritis
Crohn’s enteritis
TB
Meckel’s diverticulum
UTI
What are the complications of acute appendicitis?
Perforation
Septic shock
Pylephlebitis
Liver abscess
Death
How would you manage acute appendicitis?
Admit - if uncertain then re-evaluate every 4 hours
IV fluids and analgesia
Antibiotics - gentamicin (E. Coli) or cephzol
What are the histological classifications of large bowel polyps?
Neoplastic - malignant/benign
Hamartoma
Inflammatory
Other
Discuss Familial Adenomatous Polyposis (FAP)
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
List the risk factors / pre-malignant factors for colorectal carcinoma
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
How did you diagnose colorectal carcinoma?
History and examination - NB PR Exam
Sigmoidoscopy
Barium enema of colonoscopy
CT abdo
Discuss a fungating colorectal adenocarcinoma
Usually in the right colon
Few symptoms
Early: peri umbilical/epigastric discomfort 30mins after a meal
Discuss a annular stenosing colorectal adenocarcinoma
Typically left colon/sigmoid
GERD
Increasing Constipation or alternating episodes of constipation and diarrhea
Discuss a malignant ulcer colorectal adenocarcinoma
Typically in the rectum
Blood/Mucus per rectum
Tenesmus
Spurious diarrhea
Do NOT diagnose this radiologically
Discuss your approach to a patient with colorectal carcinoma
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
List the 2 most common causes of obstructive jaundice
Gallstones
Head of pancreas carcinoma
Provide a DDx for obstructive jaundice due to luminal obstruction
Gallstones
Parasites
- Ascaris Lumbricoides
- Daughter cyst of Enchinococcus cyst
What are the signs of obstructive jaundice?
Yellow skin and sclera
Dark Urine
Pale stools
Itching
RUQ pain and tenderness
How would you investigate Obstructive jaundice?
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
What are the consequences of gallstones in the gallbladder?
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
What are the symptoms and signs of acute cholecystitis?
BIliary colic > constant pain in RUQ
Pyrexia
Murphy’s sign (+)
Raised WCC
Paralytic ileus
*Constipation
How would you manage acute cholecystitis due to gallstones?
Admit
IV fluids
NPO
Analgesia - Pethidine
Broad spectrum antibiotics - Cephzol / Amoxicillin + Gentamicin
Cholecystectomy within 3-4 days
How is Acute cholecystitis diagnosed?
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
What is the management of symptomatic gallstones?
Laproscopic cholecystectomy
Open cholecystectomy if…
- Evidence of severe/perforated acute cholecystitis
- Exploration of bile duct required
What are the clinical features of an adenocarcinoma of the pancreas?
Painless obstructive jaundice
* Preceded by vague, deep-seated abdominal pain + bachache (poor prognostic indicator)
Anorexia, weight loss
Palpable gallbladder
Liver palpable - congestion
How would you diagnose a tumour of the pancreas?
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
What is the treatment for pancreatic tumours?
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
What is the prognosis of adenocarcinoma of the pancreas?
Poor :(
Without resection 1 year survival <10%
With resection 1 year survival ± 12%
When would you perform surgery for portal hypertension?
(When there’s complications)
Bleeding Oesophageal Varices
- Who failed other treatment modalities
- Good operative risk
Ascites
Hypersplenism
What are the endoscopic treatment interventions for oesophageal varices?
Sclerotherapy
Rubber band ligation
What are the invasive radiological treatment procedures for oesophageal varices?
Embolisation
Transjugular intrahepatic portosystemic shunt (TIPSS)
What are the surgical treatment procedures for oesophageal varices?
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
What are the complications of the surgical treatment for oesophageal varices?
Hepatic encephalopathy
What are the risk factors for hepatocellular carcinoma?
Hep B/C infection
Cirrhosis
Aflatoxin contaminated foods
Alcoholic
How would you diagnose a hepatocellular carcinoma?
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
What is the management of an organ-confined hepatocellular carcinoma?
Tumour resection (where possible)
- Most effective
- Not done if there’s cirrhosis coz’ of bleeding risk and decreased liver function
Liver transplant
* Cirrhotic patients
What is the management of a non-resectable (not organ-confined) hepatocellular carcinoma?
Intralesional injections with 95% ethanol
Chemotherapy via the hepatic artery
Radiofrequency ablation
