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Phase 4 > Acute Surgery > Flashcards

Acute Surgery Flashcards

1
Q

What symptoms: investigations should be conducted in suspected appendicitis?

A

Localising LQ pain
Fever
Anorexia - key sign
Rovsing’s sign

Investigations:
FBC
- WCC

CRP

Pregnancy test

Urine dipstick testing

+/-
Ultrasound
CT

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2
Q

Contrast between mesenteric adenitis and appendicitis:

A

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

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3
Q

What is the history of someone with Mittelschmerz syndrome?

what investigations are done?

A
  • 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
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4
Q

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?

A

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.

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5
Q

What transfusion reactions can take place?

A
  1. Acute Haemolytic reaction:
    - sudden onset hypotension
    - tachycardia
    - pyrexia
    - Back pain (due to kidney injury)
    - bilirubinemia
  • stop transfusion
  • Fluids
  • furosemide - to filter
  • dialysis
  1. Allergic reactions - 2-3 hours
    - erythematous papular rashes
    - angioedema
    - pyrexia
    - wheals
  • stop transfusion
  • chlorphenamine 10mg IV
  1. Anaphylactic reaction
    - allergic reaction symptoms
    - bronchospasm
    - angioedema
    - blood pressure drop

*Adrenaline 0.5mg + chlorphenamine 10mg + Iv steroid 100mg

  1. Non - haemolytic febrile reaction
    - Fever
    - Rigors
    - N&V

*paracetamol

  1. Acute lung injury
    - respiratory collapse
    - pulmonary oedema
    - inflammation
  2. Delayed Extravascular Haemolysis reaction
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6
Q

What is the definitive diagnostic investigation for small bowel obstruction? and what other investigations are wanted?

A

Bloods:

  • FBC
  • U&Es
  • ABG/ VBG - lactate (assess for ischemia)
  • G&S
  • Amylase

Imaging:

  • CT abdomen with contrast
  • Gastrograffian studies

Special tests:
- colonoscopy

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7
Q

What would the outcome of bowel perforation be?

A

Septic Shock
Multiorgan failure
Death

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8
Q

What are some causes to bowel perforation?

A

Peptic ulcer

Diverticulitis

Appendicitis

Severe ischemia
- mesenteric ischemia

Obstructing lesion

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9
Q

What non - bowel related causes may lead to peritonitis with air under the diaphragm?

A

Rupture ovarian cyst

Ectopic pregnancy

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10
Q

What investigations should be done into potential bowel perforation?

A

Bloods:

  • FBC - WCC high
  • U&Es
  • Group and Save
  • CRP
  • ABG

Urinalysis
- exclude urological causes

Erect chest x-ray
CT - this is gold standard

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11
Q

In a Bowel perforation, what signs may be seen on xray?

A

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

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12
Q

What is the management of Perforated bowel?

A 
Broad spectrum antibiotics 
Fluids 
Analgesia 
Oxygen 
NIL by mouth/ NG tube

Surgical consult

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13
Q

What is the surgical management of a perforated bowel?

A

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

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14
Q

In a bowel perforation, what is the most important aspect of laparoscopic surgery?

A

Peritoneal lavage to wash out any substances.

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15
Q

What are some differentials do bowel perforation?

A

M.I
Pancreatitis
AAA
Tubulo-ovarian pathology

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16
Q

What are the causes of bowel obstruction?

A

Small bowel:

  • adhesions
  • Hernia
  • ileus
  • gallstone ileus

Large bowel:

  • Malignancy
  • diverticulum
  • Volvulus
  • faceal impactaction
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17
Q

What are some differentials to bowel obstruction?

A

Toxic megacolon
ileus
Constipation

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18
Q

What are the cardinal features of bowel obstruction?

A

Colicky pain

Bowel distention

Vomiting
- Biliary > Feculent vomit

Absolute constipation

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19
Q

What are the radiological findings of small bowel obstruction?

A

Centrally located
>3cm
Plicae circulares are visible - seen as lines all the way across the bowel

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20
Q

How is large bowel obstruction seen on an xray?

A

> 6cm (>9cm at caecum)
Peripherally located
Haustra present - usually seen as small line half way

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21
Q

What are the complications of bowel obstruction?

A

Ischemia
Perforation with faecal peritonitis
Dehydration - AKI

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22
Q

How is bowel obstruction treated, broadly?

A

Conservative management

Surgical:

  • Closed loop obstruction
  • signs of sepsis or perforation
  • Malignancy
  • Failure of conservative management >48 hours
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23
Q

What is the conservative approach to bowel obstruction?

A

Drip and Suck

  • NIL by mouth
  • NG tube - remove content
  • Analgesia
  • IV fluid - need a lot of this
  • Electrolyte replacement
    +/-
    Gastrografian studies
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24
Q

What key investigations should be done into bowel obstruction?

A

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

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25
Q

What is the physical examination that can be done into cholecystitis?

A

Murphy’s sign

- halting of inspiration when compressing the edge of the rectus abdominis at the 11th intercostal margin

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26
Q

What are the differential diagnoses to cholecystitis?

A

GORD
Peptic ulcer
Acute pancreatitis
Inflammatory bowel disease

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27
Q

What investigations should be done into biliary colic/ Cholecystitis?

A

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

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28
Q

What may be seen on ultrasound of the gallbladder pathology?

A

Gall bladder sludge
- start of gallstones

Thickening of gallbladder wall
- inflammation

Dilated biliary ducts

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29
Q

How is Biliary Colic managed?

A

Lifestyle changes

Analgesia - Paracetamol/ NSAIDs +
Antiemetics

Elective cholecystectomy - within 6 weeks

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30
Q

How is cholecystitis managed?

A 
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

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31
Q

What are the complications of cholecystitis?

A

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

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32
Q

What are the causes of appendicitis?

A

Faecolith impaction
Lymphoid hyperplasia
Caecal tumour

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33
Q

Outwith McBurney’s point what other sign may be seen in acute appendicitis?

A

Rovsing’s sign

Psoas Sign
- extension of the hip compresses the appendix against the psoas muscle causing pain

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34
Q

What are some differentials to appendicitis pain?

A

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

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35
Q

What investigations should be done into appendicitis?

A

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-

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36
Q

How should a patient with appendicitis be managed?

A

IV fluids
IV analgesia
Catheterisation

Appendectomy - laparoscopically is preferred choice.
+/-
Prophylactic antibiotics

*there is debate that some can be treated with antibiotics alone.

37
Q

What are some of the complications of appendicitis?

A

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

38
Q

What are some causes of abdominal distention?

A 
F's: 
Fat 
Fluid 
Flatus 
Faeces 
Fotus 
Fulminant mass
39
Q

What signs may be seen when visually inspecting a patient that they have pancreatitis?

A

Cullen’s sign - bruising epiastrically

Grey Turner’s Sign - Flank bruising

40
Q

What investigations want to be done into acute pancreatitis?

A

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

41
Q

What is the criteria for the risk assessment of pancreatitis?

A 
PaO2 <8 
Age >55 
Neutrophils >15 
Calcium <2 
Renal Urea >15
Enzymes LDH >600
Albumin <32 
Sugar >10

> 3 or more admit to ICU

42
Q

Broadly speaking what is general management of pancreatitis?

A

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.

43
Q

What is the management of pancreatitis?

A

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
44
Q

What are the systemic complications of acute pancreatitis?

A

Within early days:

  • DIC
  • ARDS
  • Hypocalcemia
  • Pleural effusion
  • Hypoglycaemia
  • Hypovolemic shock
45
Q

What are the local complications of acute pancreatitis?

A

Pancreatic necrosis

Pancreatic pseudocyst

46
Q

How does a AAA rupture present?

A

Abdominal Pain
Back pain
Vomiting
Syncope

Classic triad is:

  • Abdominal pain
  • Back pain
  • Pulsatile abdominal mass
47
Q

What immediate investigation should be done for ruptured AAA?

A

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
48
Q

What is the management during a ruptured AAA?

A

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

49
Q

In the setting of an upper G.I bleed what question do you want to the patient?

A

Episodes like this before? Evidence of melena?
- if so how was it managed

Drugs - any anti-coagulation

Alcohol use?

Know liver disease?

Dyspepsia pains?

50
Q

What can be used to predict the risk of rebleeding?

A

Age
Shock
Comorbidities
Endoscopic findings - spurting blood?

51
Q

What other scoring system can be used for acute pancreatitis other than glasgow criteria?

A

APACHE II

52
Q

When is ERCP recommended following pancreatitis?

A

72 hours

53
Q

Name 4 causes of acute abdomen in RLQ in a young male:

A

acute appendicitis

meckel’s diverticulum

adenitis

testicular torsion

54
Q

What features of appendicitis can be found clinically?

A

Furred tongue
Fotor

Mcburney’s point
Rovsing’s sign
Psoas sign

55
Q

What signs would suggest perforated viscus?

A

Rigid abdomen
Absent bowel sounds
Percussion tenderness

Erect CXR needed

56
Q

What pain medication is contraindicated in acute pancreatitis and why?

A

Morphine

  • causes spasm of sphincter of oddi
57
Q

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?

A

PPI
- omeprazole

Hong Kong Criteria

58
Q

On a scope if there is found to be ulceration, what additional tests/ treatment should be conducted?

A

Urea breath test

Withhold of NSAIDs, Aspirin, Anti-coagulants (if safe)

PPI

59
Q

On discharge of an upper G.I bleed, what should be done?

A

Arrange urea breath test

Continue PPIs for 6 weeks, then consider switching to H2 antagonist

Repeat scope 8 weeks

60
Q

What is the general management for an acute abdomen:

A 
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
61
Q

What are some indications that that a bowel is no longer viable following an obstruction?

A

Lack of peristalsis
Loss of sheen
Lack of pulsation
Black colour

62
Q

What signs may be seen on x-ray of a perforation?

A

Pneumoperitoneum

Rigler’s sign
- both on both sides of the diaphragm

63
Q

What is the definitive management for a perforated gastric ulcer?

A

Laparotomy
- Repair ulcer
+/-
Partial gastrectomy

Send specimens for sampling of cancer

64
Q

A patient with bowel obstruction what things may you look for on the abdomen to give clues to the aetiology?

A

Surgical Scars

Hernias

65
Q

What radiological study can be done into bowel obstruction, which may also have a therapeutic effect?

A

Gastrograffin

66
Q

What are the surgical procedures that are done for bowel obstruction?

A

Small bowel:
- Adhesiolysis

Large Bowel:

  • Hartman’s
  • Colectomy
  • Palliative bypass
67
Q

What are the cardinal signs of gastric obstruction and how is it managed?

A

Retching - salvia brought up not vomit
Abdominal pain
Unable to pass NG tube down

  • Endoscopic manipulation
  • Emergency laparoscopy
68
Q

What are some of the causes of an ileus?

A 
Post surgery - bowel being handled 
Ischemia 
Electrolyte abnormalities - Hypo K+, Hyper Ca
Peritonitis 
Pancreatitis
69
Q

What imaging do you want in diverticulitis?

A

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
70
Q

What is the management of severe diverticulitis?

A

Bed rest

NBM

IV fluids

IV antibiotics

+/-
Surgical - Hartmann’s procedure

71
Q

Which way does cecal and sigmoid volvulus twist?

A

Caecal - clockwise

Sigmoidal: Anti-clockwise

72
Q

How is an appendicitis abscess managed and how does it present clinically?

A

Low quadrant mass that doesn’t get better with patient deterioration

NIL by mouth
IV antibiotics
IV fluids
+/- CT drainage

73
Q

Following bloods - what is the most appropriate investigation in diverticulitis?

A

CT Abdo/ Pelvis

74
Q

What are the risk factors for gastric carcinoma?

A

Gastritis

  • H.Pylori
  • Autoimmune

Blood group Type A

Smoking

Nitrates

Partial Gastrectomy

75
Q

Biggest symptom of gastric cancer?

A

Dyspepsia

76
Q

Name the tumours found in the small bowel:

A

Adenocarcinoma
MALT Lymphoma
Carcinoid
Gastrointestinal stromal tumours

77
Q

How does Gastro-intestinal tumour present and how is it treated?

A

Arises from Cajal cells

Presents:

  • abdominal fullness
  • Bleeding

Treatment:

  • Imatinib
  • Resection
78
Q

When an abdominal mass is felt, what do you want to know about it?

A 
Site 
Consistency 
Mobile 
Painful 
Superficial/ Deep 
Associated with Lymph nodes
79
Q

What are some causes of abdominal masses?

A

Upper:

  • Stomach carcinoma
  • Hepatomegaly
  • AAA
  • Cholecystitis

Lower:

  • AAA
  • Appendicitis
  • Colorectal cancer
  • Ovarian mass
  • Pregnancy/ fibroid
80
Q

List some causes of obstructive jaundice other than stone and pancreatic cancer:

A

External compression of lymph nodes
Cholangiocarcinoma
Stricture formation - congenital
PSC

81
Q

In the setting of a lower G.I bleed, what investigations do you want? and what would be the definitive surgery?

A

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

82
Q

How is gastric outlet obstruction treated?

A

Endoscopic dilation
PPIs
Gastric by pass

Malignant:

  • pyloric stenting
  • Gastric bypass
83
Q

How is acute cholecystitis treated?

A

IV Antibiotics
NIL by mouth
Antiemetics

Elective cholecystectomy
Drainage of empyema if develops

84
Q

What investigations should be done into large PR bleeding and what is the treatment?

A

Colonoscopy/ Sigmoidoscopy

Mesenteric Angiography

Radiolabeled Red Blood Cell Scan

Treatment:

  • Colonoscopic control of bleeding
  • Surgical removal of bowel if source can’t be found
85
Q

If suspected pancreatitis has been going on for >24 hours what is the most sensitive test?

A

Serum Lipase

86
Q

What is the surgery that is conducted for failed endoscopic management of varices?

A

Trans- Intrahepatic Portal Systemic Shunt

  • TIPSS
87
Q

What is the preferred scoping method for severe active ulcerative colitis?

A

Flexible sigmoidoscopy

- because there is increased risk of perforation with colonoscopy

88
Q

What is the management of severe UC?

A

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

Phase 4 (49 decks)

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