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Liverpool Year 5 > Acute Surgery > Flashcards

Acute Surgery Flashcards

1
Q

Side effects of corticosteroids:

A

Corticosteroids (think CORTICOSTEROIDS):

Cushing’s syndrome

Osteoporosis

Retardation of growth

Thin skin, easy bruising

Immunosuppression

Cataracts and glaucoma

Oedema

Suppression of HPA axis

Teratogenic

Emotional disturbance (including psychosis)

Rise in BP

Obesity (truncal)

Increased hair growth (hirsutism)

Diabetes mellitus

Striae

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2
Q

What are the “3 I’s” of “Thumbprinting” ?

A

Infection (C.diff or salmonella colitis) / Inflammation (UC or Crohn’s) / Ischaemia (Ischaemic colitis)

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3
Q

Surgical Sieve “TIN CAN BEDs”

A 
Trauma
Infection
Neoplasm 
Congenital 
Acquired
Neuro
Blood
Endocrine
Drugs
Syphilis
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4
Q

List Dysphagia (difficulty swallowing) differentials

A

Oesophageal carcinoma (Squamous/ adenocarcinoma)
Achalasia (LES dysfunction)
Oesophageal / peptic stricture
Hyperthyroidism
Oesophageal candidiasis (immunosuppressed patients)
Bulbar Palsy (CN IX - XII)
Trypanosomiasis (Chagas’ disease) tropical disease
GORD
Extrinsic Malignancies (lung/lymph node) can externally compress oesophagus)

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5
Q

Name the 3 Bacteria that can cause life threatening infections in patients with splenectomy.

A 
Neisseria Meningitidis (aka Menigococcus)
Streptococcus Pneumonia (aka Streptococcus)
Haemophilus Influenza
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6
Q

Most common places for oesophageal metastases

A

The 2 L’s - Liver and Lungs

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7
Q

List differentials for a RIF mass

A

Appendix abscess / Mass (omentum envelopes inflammed appendix giving a mass like feeling on palpation)
Hepatomegaly
Crohn’s
Caecal carcinoma
Meckels diverticulum (paeds)
Ileo-ceacal stricture (Yersinia and TB - 2 rare but important differentials to be excluded with CXR)

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8
Q

List the causes of Pancreatitis

A

I GET SMASHED

Iatrogenic
Gall stones
Ethanol (alcohol)
Trauma 
Steroids
Mumps
Autoimmune 
Scorpion bite
Hyperlipidaemia 
ERCP
Drugs (Azothioprine/ Anticonvulsants (ex. sodium valproate) / Antimicrobials (metronidazole) / Diuretics (ex. Thiazides and Furosemide)
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9
Q

List post surgical complications of GI surgery

A 
Infection (Suture site/from laporotomy/UTI/ Hospital acquired pneumonia) 
DVT/PE
Haemorrhage 
Obstruction
Paralytic ileus (bowel goes to sleep)
Anastomotic leak
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10
Q

Name the 3 Features of Charcot’s Triad and which condition this indicates.

A

Fever (usually with rigors)
Jaundice
RUQ pain

Ascending Cholangitis (infection of the biliary tree)

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11
Q

5 risk factors for acute cholecystitis

A 
5F's
Female 
Forty 
Fat
Fertile 
Family History

Pregnancy / oral contraceptives (oestrogen causes more bile to be secreted into bile duct) / any condition that causes haemolysis (sickle cell disease etc) / Malabsorption (ileal resection / crohns)

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12
Q

What is the normal diameters of the Small bowel / Large bowel / Appendix / Caecum ?

A

3-6-9 rule

Small bowel <3cm
Large bowel <6cm
Appendix <6mm
Caecum <9cm

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13
Q

What is Murphy’s sign?

A

Apply pressure to RUQ and ask patient to inhale. Cessation of inspiratory effort due to pain in RUQ is indicative of Gall bladder Inflammation (i.e cholecystitis and not biliary colic).

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14
Q

Name 6 complications of gall stones

A

Acute Pancreatitis
Gall bladder mucocoele (mucous filled overdistended gall bladder - can become infected and lead to empyema)
Porcelain gall bladder (calcified gall bladder wall)
Small bowel obstruction (lodge at ileo-coecal valve)
Ascending cholangitis (infection of biliary tree)

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15
Q

List the Glasgow-Imrie score criteria that determines the severity of Pancreatitis?

A

Remember Mnemonic PANCREAS (1 point for each)

PaO2 (<60 mmHg / < 8kPa )
Age (> **55** y/o)
Neutrophilia (>15)
Calcium (<2)
uRea (>16)
Enzymes (LDH > 600 AST/ALT > 200)
Albumin (<32)
Sugar (glucose >10)

If 3 or greater - Severe pancreatitis is likely

https://www.mdcalc.com/calc/3287/glasgow-imrie-criteria-severity-acute-pancreatitis

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16
Q

State Courvoisier’s Law:

A

Painless jaundice and palpable RUQ mass is indicative that pathology is not caused by gall stones and thus an obstructing pancreatic or biliary neoplasm until proven other wise. Could also be a gall bladder stricture.

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17
Q

What is a Krukenberg Tumour?

A

Rare tumours that arise in the ovaries of women as a result of metastases of a gastric malignancy.

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18
Q

At what level of serum bilirubin does jaundice become clinically evident?

A

2-3 mg/dL or 34-51 µM

Normal Bilirubin: 0-21 µM

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19
Q

Name the most common infective organisms in ascending cholangitis

A

E.Coli (27%) / Klebsiella (16%) / Enterococcus (15%)

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20
Q

List the Features of Reynad’s Pentad and the pathology this pentad is associated with.

A 
RUQ pain 
Fever
Jaundice 
Hypotension 
Confusion

Cholangitis (patients may also present with tachycardia)

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21
Q

List the causes of cholangitis.

A

Usually due to obstruction of the biliary tree

Gall stones
ERCP
Cholangiocarcinoma

More rarely
Primary sclerosing cholangitis
Ischaemic cholangiopathy (damage/stricturing of biliary tree due to lack of blood flow).
Parasitic infection

22
Q

What is the mortality rate of Cholangitis?

A

5-10% when treated with antibiotics

23
Q

What is the initial steps of management in cholangitis

A

IV Fluids
Broad spec Antibiotics (do not delay and wait for culture results as these patients can become septic very quickly)
Analgesia

Other investigaitons
LFTs
Bloods (FBC)
Culture

Imaging:
Ultrasound for stones and duct dilatation

MRCP if dilatation but no stone identified on ultrasound

ERCP for biliary decompression sphincterotomy/stenting if stone identified.

Patient may need laparoscopic cholecystectomy in the long term.

If patient too unwell for ERCP then a percutaneous transhepatic cholangiography (PTC) can be performed.

24
Q

List the common sites of metastases for Colon Cancer.

A

Remember 3L’s : (oesophageal cancer is 2 L’s)
Liver
Lung
Lymph nodes

Also more rarely:
Bone
Peritoneum
Brain 
Skin
25
Colon carcinomas are most likely to be what kind of tumour?
Adenocarcinomas
26
Which kind of polyps are most likely to become malignant?
Sessile (adhered tightly to mucosal wall) and Villous (histological subdivision of polyps with large surface area)
27
What is the screening process for colorectal cancer in the UK?
Men and Women aged 60-75 are tested every 2 years using a FIT (Faecal Immunochemistry Test) whereby antibodies bind to haemoglobin to detect blood. If blood detected - specialist nurse carries out colonoscopy.
28
Give the ages and associated symptoms that need urgent investigation for bowel cancer.
<40 - Unexplained weight loss and abdominal pain <50 - Unexplained rectal bleeding (haematochezia) <60 - Iron deficient anaemia or change in bowel habit
29
Pseudo-Obstruction increases the risk of which three pathologies?
Toxic Megacolon Ischaemic Colitis Perforation
30
Causes of Pseudo-Obstruction
Surgery (orthopaedic) Severe illness (cardiac ischaemia) Trauma Electrolyte imbalance (Hypercalcaemia/Hypomagnesaemia/Hypothyroidism/Hypokalaemia) Neurological (Parkinsons/MS/Hirschsprung's disease) Medications (Opiates/Calcium channel blockers/Anti-depressants)
31
Identify the management steps of pseudo-obstruction.
Conservative (i.e Nil by mouth/ IV fluids/ NG tube if vomiting) If this fails to resolve within 48hrs Endoscopic decompression with flatus tube Failing this IV Neostigmine (anticholinesterase) - should be avoided if possible due to complications. Surgery required if all this fails or evidence of perforation
32
Which organs are retroperitoneal?
Remember mnemonic SAD PUCKER ``` Suprarenals (adrenal glands) Aorta/IVC Duodenum (except proximal cap 2cm) Pancreas Ureters Colon (Ascending and Descending) Kidneys Esophagus Rectum ```
33
List the main layers of the GI tract
Remember "Marks + Spencers X2" i.e MSMS Mucosa (3 layers - Epithelium / Lamina propria/ Muscularis interna) Submucosa Muscularis propria/externa (circular and longitudinal) Serosa or adventia (when it is fibrous connective tisseu) Remember muscularis propria is divided into 2 layers (circularis and longitudinal) by the myenteric/ auerbach plexus. Submucosal / Meissners plexus (Secretions and dilation of blood vessels) Myenteric / Auerbach's plexus (muscle relaxation)
34
Hirschsprung's disease is associated with an increased risk of developing which infection?
Clostridium difficile
35
List the complications of C.difficile Infection
``` Toxic Megacolon Perforation Peritonitis Sepsis Acute Renal Failure Hypokalaemia Hypoalbuminaemia ```
36
List two inflammatory areas associated with C.difficile infection
Iritis (inflammation of the Iris) | Arthritis
37
Name two classical features of a hernia on examination? And a situation where they cannot be exhibited.
``` Cough reflex (owing to an increase in intra-abdominal pressure) Can be reduced (i.e pushed back) ``` If bowel or mesentery gets caught in the hernial orifice (where they have herniated through the abdominal wall for example) then neither the cough reflex or reducibility are elicitable. This is called an incarcerated/obstructed hernia
38
Name the contents of the spermatic cord that pass through the processus vaginalis and inguinal canal?
Remember rule of 3's: 3 Arteries - Testicular / Cremasteric / Vas deferens 3 Nerves - Genitofemoral / Sympathetics / Ilioinguinal (not actually part of the cord but pass through the canal) 3 Other structures - Vas deferens / Veins (pampniform plexus) / Lymphatics
39
What are the components of Hesselbach's triangle?
Medial – lateral border of the rectus abdominis muscle. Lateral – inferior epigastric vessels. Inferior – inguinal ligament.
40
Features of Crohn's Disease
Remember Crow's Nests (dont set on fire - no smoking)
41
Features of Ulcerative Colitis
42
Pre-op assessment Includes _______
******PMH **(including anesthesia history - previus rxns or FH/ Sickle Cell disease) **ASA grade** **Consent ** **Fasting ** **Bloods** (FBC/U+Es/LFTs/HbA1C/ABG/Clotting/Group + save/Crossmatch) **Investigations** (ECG/Echo/Lung function tests (if resp disease) **MRSA Screening** **Medication changes - ** Stop: ***Anticoagulants** - Bleeding *** COCP or HRT** - VTE risk *** Corticosteroids** - adrenal suppression ***Diabetes**** **- Sulfonylureas (gliclazide - hypoglycaemia)/ Metformin (metabolic acidosis) /SGLT2 (DKA) ** VTE prophylaxis **
43
Post-operative anti-emetics and contra-indications
Prophylactic: Ondansetron (5HT3 antagonist) - avoid if prolonged QT risk **Dexamethasone **- avoid if diabetic or immunosuppressed Cyclizine (H1 receptor antagonist) - avoid in heart failure and elderly patients. Rescue: Ondansetron **Prochlorperazine** (dopamine antagonist) - avoid in parkinsons Cyclizine
44
Risk factors for Acute Mesenteric Ischaemia and Diagnositic Imaging of choice
Female Older Age Atrial Fibrillation High cholesterol High BP Contrast CT
45
Medications that need to be stopped prior to surgery
Anticoagulants COCP/HRT (4 weeks beforehand) Steroids (adrenal suppression) Diabetes (sulfonylureas/SGLT2 inhibitors/Metformin)
46
Which antiemetics should be avoided in a bowel obstruction secondary to a mechanical obstruction, as they stimulate peristalsis? What would the most appropriate choice of antiemetic be?
Prokinetic antiemetics such as **metoclopramide** should be avoided in a bowel obstruction secondary to a mechanical obstruction, as they stimulate peristalsis. **Cyclizine **would be an appropriate choice of antiemetic.
47
What bloods need to be monitored following prescribing of a LMWH post-operatively for VTE prophylaxis?
Potassium (hyperkalaemia risk) Platelets (LMWH induced thrombocytopenia) Renal function (U+E's - LMWH excreted renally)
48
Side effect to be aware of in bisphosphonates?
Ex. Alendronic acid Osteonecrosis of the Jaw Dysphagia/Oesophagitis/GORD
49
Risk factors for post-operative nausea and vomiting are:
Female History of motion sickness or previous PONV Non-smoker Use of postoperative opiates Younger age Use of volatile anaesthetics
50
Remember *Adhesional obstruction tends to be managed _____ (drip and suck) for a period of time (up to ____ hours). *Obstruction **without ** previous surgery usually requires operative intervention. A _____ study can be an aid to decision making after 48 hours of conservative management. Contrast reaching the colon predicts resolution without surgery. The hypertonic contrast medium itself can be therapeutic.
Conservatively 72 hrs gastrografin contrast ## Footnote file:///Users/cianohalloran/Downloads/Emergency%20General%20Surgery%20%20Commissioning%20Guide.pdf
51
What are the diameters of bowel obstruction?
3-6-6-9 rule !

Liverpool Year 5 (7 decks)

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