Acute Surgery Flashcards
What symptoms: investigations should be conducted in suspected appendicitis?
Localising LQ pain
Fever
Anorexia - key sign
Rovsing’s sign
Investigations:
FBC
- WCC
CRP
Pregnancy test
Urine dipstick testing
+/-
Ultrasound
CT
Contrast between mesenteric adenitis and appendicitis:
Mesenteric Adenitis:
- background of URTI
- Pain doesn’t move - located to same place
- high fever
- Red/ flushed child
- High CRP
- child feels unwell then pain starts
Appendicitis:
- no background of infection
- pain is general then RLQ
- Lowish fever
- Anorexia
- child looks pale
- abdominal pain started first
**it is important to appreciate that mesenteric adenitis can become appendicitis due to swelling of the lymph nodes causing blockage
What is the history of someone with Mittelschmerz syndrome?
what investigations are done?
- Occurs 2 weeks following last period
- Supra pubic region pain
- 24-48 hour pain
Investigations:
- normal
- US may show small amount of fluid in abdomen
- due to a small amount of blood entering the peritoneum following ovulation
50 year old male present with sudden onset abdominal pain, which pain radiating to the back. What is the immediate worrying diagnosis? what investigation should be done?
Rupture AAA
CT Scan - if hemodynamically stable (they will have a haematoma)
*this should only be done if patient is stable. otherwise it is straight to theatre.
What transfusion reactions can take place?
- Acute Haemolytic reaction:
- sudden onset hypotension
- tachycardia
- pyrexia
- Back pain (due to kidney injury)
- bilirubinemia
- stop transfusion
- Fluids
- furosemide - to filter
- dialysis
- Allergic reactions - 2-3 hours
- erythematous papular rashes
- angioedema
- pyrexia
- wheals
- stop transfusion
- chlorphenamine 10mg IV
- Anaphylactic reaction
- allergic reaction symptoms
- bronchospasm
- angioedema
- blood pressure drop
*Adrenaline 0.5mg + chlorphenamine 10mg + Iv steroid 100mg
- Non - haemolytic febrile reaction
- Fever
- Rigors
- N&V
*paracetamol
- Acute lung injury
- respiratory collapse
- pulmonary oedema
- inflammation - Delayed Extravascular Haemolysis reaction
What is the definitive diagnostic investigation for small bowel obstruction? and what other investigations are wanted?
Bloods:
- FBC
- U&Es
- ABG/ VBG - lactate (assess for ischemia)
- G&S
- Amylase
Imaging:
- CT abdomen with contrast
- Gastrograffian studies
Special tests:
- colonoscopy
What would the outcome of bowel perforation be?
Septic Shock
Multiorgan failure
Death
What are some causes to bowel perforation?
Peptic ulcer
Diverticulitis
Appendicitis
Severe ischemia
- mesenteric ischemia
Obstructing lesion
What non - bowel related causes may lead to peritonitis with air under the diaphragm?
Rupture ovarian cyst
Ectopic pregnancy
What investigations should be done into potential bowel perforation?
Bloods:
- FBC - WCC high
- U&Es
- Group and Save
- CRP
- ABG
Urinalysis
- exclude urological causes
Erect chest x-ray
CT - this is gold standard
In a Bowel perforation, what signs may be seen on xray?
Free air under the diaphragm
- pneumoperitoneum
Rigler’s sign
- Both sides of the bowel can be seen - really highlighting th bowel
Psoas Sign
- Loss of the demarcation psoas sign seen
What is the management of Perforated bowel?
Broad spectrum antibiotics Fluids Analgesia Oxygen NIL by mouth/ NG tube
Surgical consult
What is the surgical management of a perforated bowel?
Source the cause
Repair the rupture - usually with an omental seal
or
Removal - Hartman’s procedure - diverticulitis
Peritoneal lavage - wash out to remove any contents
In a bowel perforation, what is the most important aspect of laparoscopic surgery?
Peritoneal lavage to wash out any substances.
What are some differentials do bowel perforation?
M.I
Pancreatitis
AAA
Tubulo-ovarian pathology
What are the causes of bowel obstruction?
Small bowel:
- adhesions
- Hernia
- ileus
- gallstone ileus
Large bowel:
- Malignancy
- diverticulum
- Volvulus
- faceal impactaction
What are some differentials to bowel obstruction?
Toxic megacolon
ileus
Constipation
What are the cardinal features of bowel obstruction?
Colicky pain
Bowel distention
Vomiting
- Biliary > Feculent vomit
Absolute constipation
What are the radiological findings of small bowel obstruction?
Centrally located
>3cm
Plicae circulares are visible - seen as lines all the way across the bowel
How is large bowel obstruction seen on an xray?
> 6cm (>9cm at caecum)
Peripherally located
Haustra present - usually seen as small line half way
What are the complications of bowel obstruction?
Ischemia
Perforation with faecal peritonitis
Dehydration - AKI
How is bowel obstruction treated, broadly?
Conservative management
Surgical:
- Closed loop obstruction
- signs of sepsis or perforation
- Malignancy
- Failure of conservative management >48 hours
What is the conservative approach to bowel obstruction?
Drip and Suck
- NIL by mouth
- NG tube - remove content
- Analgesia
- IV fluid - need a lot of this
- Electrolyte replacement
+/-
Gastrografian studies
What key investigations should be done into bowel obstruction?
Bloods
- FBC
- CRP
- Group and save
- U&Es - AKI
- ABG
X-rays
- CT contrast - gold standard
- ABX
- CXR - erect
Water soluble contrast study
- done in conservative management after 24 hours
What is the physical examination that can be done into cholecystitis?
Murphy’s sign
- halting of inspiration when compressing the edge of the rectus abdominis at the 11th intercostal margin
What are the differential diagnoses to cholecystitis?
GORD
Peptic ulcer
Acute pancreatitis
Inflammatory bowel disease
What investigations should be done into biliary colic/ Cholecystitis?
Bloods:
- FBC
- U&Es
- LFTs
- CRP
- Amylase *always do an amylase
Orifices:
- Pregnancy test - this should always be done to rule out any cause
Imaging:
- Ultrasound
- MRCP
+/- ERCP
What may be seen on ultrasound of the gallbladder pathology?
Gall bladder sludge
- start of gallstones
Thickening of gallbladder wall
- inflammation
Dilated biliary ducts
How is Biliary Colic managed?
Lifestyle changes
Analgesia - Paracetamol/ NSAIDs +
Antiemetics
Elective cholecystectomy - within 6 weeks
How is cholecystitis managed?
NIL by mouth IV antibiotics - Co-amoxiclav + metronidazole IV fluids Analgesia *sepsis 6 if patient is septic
Laparoscopic cholecystectomy should be ideally performed within 72 hours or within 1 week
**if a patient is not fit enough for surgery then percutaneous drainage can be done
What are the complications of cholecystitis?
Gallbladder empyema
- abscess formation
- septic
- CT diagnosis
Chronic cholecystitis
Bouveret’s syndrome
- fistula forms to duodenum allowing stone blockage there
Gallstone ileus
- fistula formation allows gallstone through and block the ileum
What are the causes of appendicitis?
Faecolith impaction
Lymphoid hyperplasia
Caecal tumour
Outwith McBurney’s point what other sign may be seen in acute appendicitis?
Rovsing’s sign
Psoas Sign
- extension of the hip compresses the appendix against the psoas muscle causing pain
What are some differentials to appendicitis pain?
Gynecological causes
- ectopic pregnancy
- Rupture cyst
Urological causes
- renal colic
- pyelonephritis
G.I
- Crohn’s disease
- Mesenteric adenitis
- Merkel’s diverticulum
- Diverticulitis
Male:
- Testicular torsion
What investigations should be done into appendicitis?
Bloods:
- FBC - WCC
- CRP
- U&Es
- Amylase
- B- hCG
Orifices:
- urine dipstick - rule out urological causes
- B- hCG
X-rays:
- Transabdominal US - if uncertain diagnosis
- CT abdominal - in older patients to rule out malignancy
S-
How should a patient with appendicitis be managed?
IV fluids
IV analgesia
Catheterisation
Appendectomy - laparoscopically is preferred choice.
+/-
Prophylactic antibiotics
*there is debate that some can be treated with antibiotics alone.
What are some of the complications of appendicitis?
Perforation
- Bowel perforation management
Appendix mass - becomes adherent to omentum
- antibiotics
Pelvis Abscess
- presents with continual pain and fever
conservative management with antibiotics is advised
- follow up with CT scan
*large amount can be due to malignancy
What are some causes of abdominal distention?
F's: Fat Fluid Flatus Faeces Fotus Fulminant mass
What signs may be seen when visually inspecting a patient that they have pancreatitis?
Cullen’s sign - bruising epiastrically
Grey Turner’s Sign - Flank bruising
What investigations want to be done into acute pancreatitis?
Bloods:
- FBC - WCC
- U&Es
- LFTs
- CRP
- Blood glucose
- Ca2+
- ABG ** - PaO2, LDH
- Amylase **
- **serum lipase following >24 hours
Orifices:
- Urine analysis - B- hCG
X-ray:
- Ultrasound - of biliary tract to look for stones
- Abdominal CT scan if the diagnosis is uncertain
- ERCP - done 24 hours after to assess for blockage
ECG
Special test
- Lipase - most sensitive but rarely done
What is the criteria for the risk assessment of pancreatitis?
PaO2 <8 Age >55 Neutrophils >15 Calcium <2 Renal Urea >15 Enzymes LDH >600 Albumin <32 Sugar >10
> 3 or more admit to ICU
Broadly speaking what is general management of pancreatitis?
There is no cure to pancreatitis, so the management is supportive, and organ support.
if there is evidence of gallstones or bile duct blockage then an ERCP should be done when reasonable to do so.
What is the management of pancreatitis?
Severe >3 should be managed in ICU
NIL BY MOUTH
NG tube
IV fluids
- Hartmanns
Analgesia
- opioids
Organ support in HUD
- renal dialysis
Further treatment:
- ERCP
- Alcohol abstinence - 3 months
- Cholecystectomy
What are the systemic complications of acute pancreatitis?
Within early days:
- DIC
- ARDS
- Hypocalcemia
- Pleural effusion
- Hypoglycaemia
- Hypovolemic shock
What are the local complications of acute pancreatitis?
Pancreatic necrosis
Pancreatic pseudocyst
How does a AAA rupture present?
Abdominal Pain
Back pain
Vomiting
Syncope
Classic triad is:
- Abdominal pain
- Back pain
- Pulsatile abdominal mass
What immediate investigation should be done for ruptured AAA?
Bloods:
- FBC
- U&;Es
- Cross Match
If patient is stable:
- CT *this is to assess if the patient is suitable for EVAR
If patient is unstable:
- Surgery
Contact:
- local vascular unit
- anaesthetist
- Vascular surgeon
What is the management during a ruptured AAA?
ABCDE
- High flow oxygen
- IV access
- Bloods taken off
- Modest amount of morphine
- IV Fluids - do not raise pressure quickly or chase normal blood pressure as not to dislodge clot.
Transfer to Vascular surgical theatre immediately
In the setting of an upper G.I bleed what question do you want to the patient?
Episodes like this before? Evidence of melena?
- if so how was it managed
Drugs - any anti-coagulation
Alcohol use?
Know liver disease?
Dyspepsia pains?
What can be used to predict the risk of rebleeding?
Age
Shock
Comorbidities
Endoscopic findings - spurting blood?
What other scoring system can be used for acute pancreatitis other than glasgow criteria?
APACHE II
When is ERCP recommended following pancreatitis?
72 hours
Name 4 causes of acute abdomen in RLQ in a young male:
acute appendicitis
meckel’s diverticulum
adenitis
testicular torsion
What features of appendicitis can be found clinically?
Furred tongue
Fotor
Mcburney’s point
Rovsing’s sign
Psoas sign
What signs would suggest perforated viscus?
Rigid abdomen
Absent bowel sounds
Percussion tenderness
Erect CXR needed
What pain medication is contraindicated in acute pancreatitis and why?
Morphine
- causes spasm of sphincter of oddi
Following an upper G.I bleed, the patient should be started on what medication after the scope and what protocol is used to manage this?
PPI
- omeprazole
Hong Kong Criteria
On a scope if there is found to be ulceration, what additional tests/ treatment should be conducted?
Urea breath test
Withhold of NSAIDs, Aspirin, Anti-coagulants (if safe)
PPI
On discharge of an upper G.I bleed, what should be done?
Arrange urea breath test
Continue PPIs for 6 weeks, then consider switching to H2 antagonist
Repeat scope 8 weeks
What is the general management for an acute abdomen:
ABCDE NIL by mouth Oxygen \+/- NG tube IV access IV fluids IV antibiotics - this is true for any suspicion of infection - For organ perforation IV Antiemetics Catheterise - monitor fluid output Obtain results from investigations Escalate as needed - surgery/ consultant
What are some indications that that a bowel is no longer viable following an obstruction?
Lack of peristalsis
Loss of sheen
Lack of pulsation
Black colour
What signs may be seen on x-ray of a perforation?
Pneumoperitoneum
Rigler’s sign
- both on both sides of the diaphragm
What is the definitive management for a perforated gastric ulcer?
Laparotomy
- Repair ulcer
+/-
Partial gastrectomy
Send specimens for sampling of cancer
A patient with bowel obstruction what things may you look for on the abdomen to give clues to the aetiology?
Surgical Scars
Hernias
What radiological study can be done into bowel obstruction, which may also have a therapeutic effect?
Gastrograffin
What are the surgical procedures that are done for bowel obstruction?
Small bowel:
- Adhesiolysis
Large Bowel:
- Hartman’s
- Colectomy
- Palliative bypass
What are the cardinal signs of gastric obstruction and how is it managed?
Retching - salvia brought up not vomit
Abdominal pain
Unable to pass NG tube down
- Endoscopic manipulation
- Emergency laparoscopy
What are some of the causes of an ileus?
Post surgery - bowel being handled Ischemia Electrolyte abnormalities - Hypo K+, Hyper Ca Peritonitis Pancreatitis
What imaging do you want in diverticulitis?
Acute:
- Erect chest x-ray
- look for perforation
- CT abdomen and pelvis
Chronic:
- Gastrograffin enema
- Flexible sigmoidoscope
- Colonoscopy
- sigmoidoscopy and colonoscopy are contraindicated in acute flares
What is the management of severe diverticulitis?
Bed rest
NBM
IV fluids
IV antibiotics
+/-
Surgical - Hartmann’s procedure
Which way does cecal and sigmoid volvulus twist?
Caecal - clockwise
Sigmoidal: Anti-clockwise
How is an appendicitis abscess managed and how does it present clinically?
Low quadrant mass that doesn’t get better with patient deterioration
NIL by mouth
IV antibiotics
IV fluids
+/- CT drainage
Following bloods - what is the most appropriate investigation in diverticulitis?
CT Abdo/ Pelvis
What are the risk factors for gastric carcinoma?
Gastritis
- H.Pylori
- Autoimmune
Blood group Type A
Smoking
Nitrates
Partial Gastrectomy
Biggest symptom of gastric cancer?
Dyspepsia
Name the tumours found in the small bowel:
Adenocarcinoma
MALT Lymphoma
Carcinoid
Gastrointestinal stromal tumours
How does Gastro-intestinal tumour present and how is it treated?
Arises from Cajal cells
Presents:
- abdominal fullness
- Bleeding
Treatment:
- Imatinib
- Resection
When an abdominal mass is felt, what do you want to know about it?
Site Consistency Mobile Painful Superficial/ Deep Associated with Lymph nodes
What are some causes of abdominal masses?
Upper:
- Stomach carcinoma
- Hepatomegaly
- AAA
- Cholecystitis
Lower:
- AAA
- Appendicitis
- Colorectal cancer
- Ovarian mass
- Pregnancy/ fibroid
List some causes of obstructive jaundice other than stone and pancreatic cancer:
External compression of lymph nodes
Cholangiocarcinoma
Stricture formation - congenital
PSC
In the setting of a lower G.I bleed, what investigations do you want? and what would be the definitive surgery?
FBC
Mesenteric angiography
Colonoscopy/ sigmoidoscopy
Radiolabeled Red cell Scan
Surgical resection of the bleeding area or if that can’t be identified then colectomy
or
Embolisation at angiography
How is gastric outlet obstruction treated?
Endoscopic dilation
PPIs
Gastric by pass
Malignant:
- pyloric stenting
- Gastric bypass
How is acute cholecystitis treated?
IV Antibiotics
NIL by mouth
Antiemetics
Elective cholecystectomy
Drainage of empyema if develops
What investigations should be done into large PR bleeding and what is the treatment?
Colonoscopy/ Sigmoidoscopy
Mesenteric Angiography
Radiolabeled Red Blood Cell Scan
Treatment:
- Colonoscopic control of bleeding
- Surgical removal of bowel if source can’t be found
If suspected pancreatitis has been going on for >24 hours what is the most sensitive test?
Serum Lipase
What is the surgery that is conducted for failed endoscopic management of varices?
Trans- Intrahepatic Portal Systemic Shunt
- TIPSS
What is the preferred scoping method for severe active ulcerative colitis?
Flexible sigmoidoscopy
- because there is increased risk of perforation with colonoscopy
What is the management of severe UC?
IV steroids
IV fluids
LMWH
Calcium and Vitamin D supplementation (due to risk from steroids)
3-5day:
- rescue therapy
- infliximab or ciclosporin
10days:
- sub- total colectomy
or
- total Proctocolectomy
