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Acute surgery Flashcards

1
Q

What is the peak age of incidence for appeenicitis

A

early teens to early twenties

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2
Q

What are the three types of appendicitis

A
  • mucosal
  • phlegmonous
  • necrotic
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3
Q

Describe the symptoms of appendicitisi

A
  • anorexia, fever, malaise
  • abdominal pain which starts centrally and localises to the RIF
  • diarrhoea is common
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4
Q

What are the clinical signs of appendicitis

A
  • fever, tachycardia
  • abdominal tenderness +/- peritonitis if perforated
  • tenderness over McBurney’s point
  • Rovsing’s sign
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5
Q

What is Rovsing’s sign

A

Palpation of LIF causes pain worsening over RIF

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6
Q

Give some differentials for appendicitis

A
  • Meckel’s diverticulum
  • tubo-ovarian pathology
  • ectopic pregnancy
  • crohn’s
  • gastroenteritis
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7
Q

How would you investigate ?appendicitis

A
  • diagnosis is usually clinical and investigations are usually unneccessary
  • CT is appropriate if needed
  • USS if ?tubo-ovarian pathology
  • Bloods (FBC, WCC, CRP, amylase, G+S, U&Es)
  • laparoscopy
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8
Q

What surgery is indicated in acute appendicitis

A

open or laparoscopic appendicectomy

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9
Q

What abx are given for appendix mass or abscess

A

metronidazole 500mg IV tds + cefuroxime 750mg IV tds

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10
Q

What is the sole blood supply of the appendix

A

appendicular artery - a terminal branch of the ileocolic)

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11
Q

Give some conditions which predispose to gall stone formation

A
  • hypercholesterolaemia
  • obesity
  • chronic haemolytic disorders
  • long-term parenteral nutrition
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12
Q

Describe biliary colic

A

intermittent severe epigastric and RUQ pain usually with n + v
tenderness may localise to gall bladder

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13
Q

What clinical sign is indicative of cholecystitis? Describe the sign

A

Murphy’s sign

- tenderness over gallbladder during inspiration

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14
Q

Descibe some complications of acute cholecystitis

A
  • formation of empyema or abscess of the gallbladder
  • perforation with biliary peritonitis
  • cholecystontri fistula formation (may la to gallston ileus)
  • jaundice due to compression of the adjacent common bile duct
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15
Q

What is Mirizzi syndrome

A

jaundice due to compression of the common bile duct

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16
Q

What investigations should be ordered for ?biliary colic

A
  • bloods (FBC, U&Es, amylase, LFTs, CRP, blood culture)

* ultrasound

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17
Q

What is the procedure of choice for diagnosis of biliary colic

A

ultrasound

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18
Q

How is cholecystectomy usually performed

A

laparoscopically

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19
Q

What management option may be used if the patient is too unwell for cholecystectomy

A

cholecystostomy

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20
Q

What are the commonest causes of pancreatitis

A
  • gallstones
  • alcohol
  • hyperlipidaemia
  • trauma
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21
Q

What does the acronym IGETSMASHED stand for in regards to causes of acute pancreatitis

A 
Idiopathic
Gallstones
Ethanol
Trauma (to pancreas)
Steroids
Mumps
Autoimmune
Scorpion sting!
Hyperlipidaemia + hypercalcaemia
ERCP
Drugs
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22
Q

What are the three types of acute pancreatitis

A
  • oedematous
  • severe/necrotising
  • haemorrhagic
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23
Q

What is the most common type of acute pancreatitis

A

Oedematous

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24
Q

What are some symptoms of acute pancreatitis

A
  • severe epigastric pain radiating to the back
  • severe nausea and vomiting
  • fever, dehydration, hypotension, tachycardia
  • epigastric tenderness associated with guarding +/- rigidity in severe cases
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25
What are the two clinical signs associated with haemorrhagic pancreatitis
* cullen's sign - periumbilical ecchymosis | * grey-turner's sign - left flank ecchymosis
26
What bloods should be saved in ?acute pancreatitis
* FBC, CRP, WCC * amylase * U&Es * LFTs * coag * group and save
27
What score is used to assess severity of an acute pancreatitis attack
Glasgow Imrie criteria
28
What level of serum amylase is diagnostic of acute pancreatitis
>1000U (but may be normal even in severe cases)
29
What other causes may there be for elevated serum amylase
* intestinal ischaemia * leaking aneurysm * perforated ulcer * cholecystitis * ovarian tumours can also elevate amylase
30
What imaging must be ordered - in which order of importance - for ?acute pancreatitis
* USS * AXR * CT
31
How is acute pancreatitis treated?
* maybe antibiotics * CT scan to identify development of phlegmon, necrosis, or haemorrhage * fluid and nutritional support * surgical debridement may be required in infected necrotic pancreatitis but is associated with a very poor prognosis
32
What predicts mortality in acute pancreatitis
* pancreatic necrosis | * presence of sepsis, including MODS`
33
What is the only absolute indicate for surgery for acute pancreatitis
infected pancreatic necrosis
34
What is acute peritonitis defined as
acute inflammation in th peritoneal cavity
35
What is primary peritonitis
typically a streptococcal infection
36
What are common causes of secondary peritonitis
* perforated appendicitis * perforated peptic ulcer * perforated diverticular disease * pancreatitis * perforated ischaemic bowel or tumour * post-surgical intervention
37
What are symptoms of acute peritonitis
* anorexia and fever * severe generalised abdominal pain radiating to shoulders and back * abdo pain worse when moving, coughiing, sneezing
38
What signs might you find on examination of a patient with acute peritonitis
* guarding, abdominal tenderness, tenderness on percussion, board-like rigidity * fever, tachycardia
39
What bloods should you order for acute peritonitis
``` FBC (WCC, Hb) CRP U&Es (Na, K) LFTs group + save Coag Amylase ```
40
Most causes of acute peritonitis require surgery - in which case is surgery usually contraindicated?
acute pancreatitis
41
What is the imaging investigation of choice for diagnosing most peritonitis
CT abdo
42
What IV antibiotics should be started especially if surgery is likely in peritonitis
metronidazole 500mg IV tds + cefuroxime 750mg IV tds
43
What is diverticular disease
development of outpouchings of colonic mucosa which can become inflamed
44
What age group of diverticulosis common in
50-70 - although it is inreasing in frequency in younger patients
45
How does acute diverticuliris present
* sudden onset left iliac fossa pain with fever, nausea and frquntly with loos stools * tachycardia common
46
What are the main concerning complications of diverticular disease
* paracolic/pericolic mass/abscess * fistula * peritonitis (2* to perforation) * striture formation
47
Where does diverticular disease commonly form a fistula?
typically the vagina in females or bladder in both sexes | colovaginal/colovesical
48
How is diverticular disease usually diagnosed?
double contrast barium enema
49
How are acute complications of diverticular disease diagnosed
usually with CT scan
50
What IV abx should you give for acute diverticulitis
metronidazole 500mg IV tds + cefuroxime 750mg IV tds
51
What preventitive abx can you give for recurrent episodes of acute diverticulitis
ciprofloxacin 500mg PO od (6 week course)
52
What does melaeena imply
bleeding proximal to the splenic flexure of the colon
53
Give some common causes of upper GI bleeding
* peptic ulcer * gastritis/oesophagitis * Mallor-Weiss tear * NSAIDs, steroids, thrombolytics, anti-coagulants
54
What might a history of heavy alcohol use or stigmata of liver disease indicate in UGIB
Bleeding oesophgeal varices or gastritis
55
How is UGIB managed
* cross-match blood * 2 wide bore IVs if haemodynamically unstable * endoscopy often indicated
56
Which scoring system can be used to determine risk and indication for endscopy in UGIB
Glasgow-Blatchford score
57
Give some common causes of lower GI bleeding
* diverticulitis * bleeding vascular ectasias * colorectal cancer * haemorrhois * IBD * Meckel's diverticulum
58
Which bloods should be ordered for a LGIB
``` FBC LFTs U&Es CRP Glucose Amylase Coagulation Group and save ```
59
What imaging might you order for LGIB
* erect CXR? | * upper endoscopy may be indicated if there is haemodynamic instability
60
What fluid managment should be set up for LGIB
* 2 wide bore IV * fluid challenge crystalloid * urinary cath and monitor output
61
What IV abx might you commence in LGIB with ?sepsis or perforation?
metronidazole 500mg IV tds + cefuroxime 750mg IV tds
62
If a patient with an LGIB feels the need to get out of bed to pass stool, why should you not allow them to get out of bed?
It may be another large bleed which could result in collapse if they try to walk
63
What does SIRS stand for
systemic inflammatory response syndrome
64
What is SIRS
a pro-inflammatory state that does not include a documented source of infection
65
What is MODS?
multiple organ dysfunction syndrome
66
What signs in a normal set of obs may indicate sepsis?
* tachycardia >90bpm * tachypnoea * pyrexia
67
What is the 'take 3 give 3' rule for sepsis?
Take cultures, measure urine output, and lactate | Give oxygen, fluid challnge, an IV abx
68
At what diameter is surgery indicated for AAA
>5.5cm
69
What are the three broad groups in ruptured AAAs
* those who are unsuitable for surgery * contained leak * free rupture
70
What symptoms are suggestive of ruptured AAA
* sudden severe epigastric pain radiating to back or loin | * collapse due to hypotension
71
Why should you not immediately give fluids/blood in ruptured AAA?
permissable hypotension
72
What is the 'drapd aorta' sign indicative of on CT
impending AAA ruptur or contained leakage
73
What is the basic principles of AAA rupture repair surgery
* clamp superior abdominal aorta * introduce graft * close sac over graft * revascularise
74
What are possible complications of AAA rupture surgery
* lower limb embolism * gut ischaemia/infarct * renal failure * death
75
Is a AAA usually above or below the level of the renal arteries
below
76
What are the 6 Ps of acute limb ischaemia
``` Pulseless Pallor Perishingly cold Paraesthesia Paralysis Pain ```
77
What are the two main causes of acute limb ischaemia
* emboli | * acute thrombosis in a vessel with pre-existing atherosclerosis
78
What are rare causes of acute limb ischaemia
* aortic dissection * intra-arterial drug use * trauma * peripheral aneurysm (particularly popliteal) Iatrogenic injury
79
What are the two main complications of acute limb ischaemia
death | limb loss
80
In what time period does acute limb ischaemia cause irreversible damage
6 hours
81
What bloods should be taken in acute limb ischaemia
``` FBC Troponin Glucose Clotting Group and Save ```
82
What dose and analgesia is recommended for acut limb ischaemia
5-10mg morphine IM
83
What clinical signs indicate that the limb ischaemia is irreversible? What does this mean?
* fixed mottling * woody muscles painful to touch * petechial haemorrhages in skin - the limb cannot be saved, so amputation is the only option
84
What are the three categories of limb viability
* irreversible * complete * incomplete
85
What systemic complications will arise from failing to amputate an irreversibly ischaemic limb
* hyperkalaemia * acidosis * acute renal failure * cardiac arrest

Year 4 (13 decks)

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