Acute Surgery Flashcards
Side effects of corticosteroids:
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
What are the “3 I’s” of “Thumbprinting” ?
Infection (C.diff or salmonella colitis) / Inflammation (UC or Crohn’s) / Ischaemia (Ischaemic colitis)
Surgical Sieve “TIN CAN BEDs”
Trauma Infection Neoplasm Congenital Acquired Neuro Blood Endocrine Drugs Syphilis
List Dysphagia (difficulty swallowing) differentials
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)
Name the 3 Bacteria that can cause life threatening infections in patients with splenectomy.
Neisseria Meningitidis (aka Menigococcus) Streptococcus Pneumonia (aka Streptococcus) Haemophilus Influenza
Most common places for oesophageal metastases
The 2 L’s - Liver and Lungs
List differentials for a RIF mass
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)
List the causes of Pancreatitis
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)
List post surgical complications of GI surgery
Infection (Suture site/from laporotomy/UTI/ Hospital acquired pneumonia) DVT/PE Haemorrhage Obstruction Paralytic ileus (bowel goes to sleep) Anastomotic leak
Name the 3 Features of Charcot’s Triad and which condition this indicates.
Fever (usually with rigors)
Jaundice
RUQ pain
Ascending Cholangitis (infection of the biliary tree)
5 risk factors for acute cholecystitis
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)
What is the normal diameters of the Small bowel / Large bowel / Appendix / Caecum ?
3-6-9 rule
Small bowel <3cm
Large bowel <6cm
Appendix <6mm
Caecum <9cm
What is Murphy’s sign?
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).
Name 6 complications of gall stones
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)
List the Glasgow-Imrie score criteria that determines the severity of Pancreatitis?
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
State Courvoisier’s Law:
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.
What is a Krukenberg Tumour?
Rare tumours that arise in the ovaries of women as a result of metastases of a gastric malignancy.
At what level of serum bilirubin does jaundice become clinically evident?
2-3 mg/dL or 34-51 µM
Normal Bilirubin: 0-21 µM
Name the most common infective organisms in ascending cholangitis
E.Coli (27%) / Klebsiella (16%) / Enterococcus (15%)
List the Features of Reynad’s Pentad and the pathology this pentad is associated with.
RUQ pain Fever Jaundice Hypotension Confusion
Cholangitis (patients may also present with tachycardia)
List the causes of cholangitis.
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
What is the mortality rate of Cholangitis?
5-10% when treated with antibiotics
What is the initial steps of management in cholangitis
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.
List the common sites of metastases for Colon Cancer.
Remember 3L’s : (oesophageal cancer is 2 L’s)
Liver
Lung
Lymph nodes
Also more rarely: Bone Peritoneum Brain Skin
Colon carcinomas are most likely to be what kind of tumour?
Adenocarcinomas
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)
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.
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
Pseudo-Obstruction increases the risk of which three pathologies?
Toxic Megacolon
Ischaemic Colitis
Perforation
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)
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
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
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)
Hirschsprung’s disease is associated with an increased risk of developing which infection?
Clostridium difficile
List the complications of C.difficile Infection
Toxic Megacolon Perforation Peritonitis Sepsis Acute Renal Failure Hypokalaemia Hypoalbuminaemia
List two inflammatory areas associated with C.difficile infection
Iritis (inflammation of the Iris)
Arthritis
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
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
What are the components of Hesselbach’s triangle?
Medial – lateral border of the rectus abdominis muscle.
Lateral – inferior epigastric vessels.
Inferior – inguinal ligament.
Features of Crohn’s Disease
Remember Crow’s Nests (dont set on fire - no smoking)
Features of Ulcerative Colitis
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 **
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
Risk factors for Acute Mesenteric Ischaemia and Diagnositic Imaging of choice
Female
Older Age
Atrial Fibrillation
High cholesterol
High BP
Contrast CT
Medications that need to be stopped prior to surgery
Anticoagulants
COCP/HRT (4 weeks beforehand)
Steroids (adrenal suppression)
Diabetes (sulfonylureas/SGLT2 inhibitors/Metformin)
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.
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)
Side effect to be aware of in bisphosphonates?
Ex. Alendronic acid
Osteonecrosis of the Jaw
Dysphagia/Oesophagitis/GORD
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
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
file:///Users/cianohalloran/Downloads/Emergency%20General%20Surgery%20%20Commissioning%20Guide.pdf
What are the diameters of bowel obstruction?
3-6-6-9 rule !
