Acute Surgery Flashcards
Appendicitis
Inflammation of veriform appendix, usually due to obstruction due to faecolith (hardened mass of faeces), foreign body or lymphoid hyperplasia
Sx: RIF pain (peri-umbilical at first then moves to RIF), anorexia, N+V
Signs: Pain at McBurney’s point (1/3 from ASIS to umbilicus), Rovsing’s sign (press on LIF fossa elicits pain on RIF), Psoas sign (pt lies flat, extends leg and pain elicited due to stretching iliopsoas muscle), fever
DDx: Acute cholecystitis, Merkel’s diverticulitis, Testicular torsion, ectoptic, ovarian pathology
Ix: FBC (mild leukocytosis), CT abdo pelvis, USS abdo (exclude ovarian pathology)
Tx: laparoscopic appendicectomy + prophylactic abx
Immediate appendiecectomy not indicated when:
- Advanced peritonitis - IV fluids, IV abx
- Appendix mass
- Resolved
Biliary Colic
Gallbladder contracts but outflow obstructed due to stone in neck of gallbladder (Hartman’s pouch) or cystic duct
Sx: Recurrent pain (esp. after eating fatty meal) radiates to r. scapula + epigastric pain
Not systemically unwell unlike acute cholecystitis
Tx: Elective laprascopy cholecystectomy
DDx (abdo colic): Ureteric colic (due to stone, tumour) Bladder colic Mechanical obstruction (partial or complete obstruction)
Acute Cholecystitis
Inflammation of gallbladder wall due to irritation of conc. bile contained within due to obstruction from gallstone
Sx: RUQ pain + fever
Signs: Fever, Positive Murphy’s sign (palpation of RUQ n+inspiration causes pain (as gallbladder moves down) and no pain on LUQ, palpable gallbladder
Ix: FBC (leukocytosis), LFTs (cholestatic: elevated Alk phos, bilirubin), Abdo USS (gallstones, thickened wall, pericholecystic fluid)
Tx: IV fluids, IV abx, NBM + Cholecystectomy
DDx: Acute pancreatitis, Perf DU
Complications:
Empyema, gangrene, perforation
Indications for cholecystectomy:
- Single complication
- Asymptomatic pts if at risk of complications e.g. diabetics
- Diabetics, history of pancreatitis
Complications of cholecystectomy:
Leakage of bile, jaundice
Obstructive jaundice
Stone in CBD
Sx: Pale stools, dark urine
Signs: Jaundice
DDx:
with jaundice: pancreatic carcinoma, cholangiocarcinoma, acute hepattis
without jaundice: intestinal obstruction
Ix: LFTs (Raised Alk phos), Abdo USS (gallstones, dilation of CBD >7mm), MRCP, ERCP
Tx: ERCP
Dx of stones in CBD:
With jaundice: - Pancreatic Ca. - Cholangiocarcinoma - Hepatitis Without jaundice: - Intestinal obstruction - Renal colic
Ascending Cholangitis
Stone obstructing CBD + infection proximal to blockage
Sx: RUQ + fever + jaundice
Reynauld pentad: RUQ pain + fever + jaundice + low BP + confusion
Tx: ABCDE, IVF, catheter, IV abx, HDU/ITU (if septic shock)
Urgent ERCP
Complications of ERCP
Pancreatitis, haemorrhage, perforation
Acute pancreatitis
Inflammation of pancreas due to autodigestion of pancreatic enzymes
Sx: Epigastric pain radiates to back, N+V
Signs: Tachy, fever, shock, Cullens sign (periumbilical bruising), Grey Turner’s sign (flank bruising)
Ix: FBC (anaemia, leukocytosis), Amylase (3x higher ULN), LFTs (raised bilirubin), ABG (hypoxia), USS (gallstones), CT abdo (necrosis, abscess, pseudocyst)
Tx: Supportive (analgesia, IV fluids, NBM (give pancreas rest), NG tube)
Glasgow Imrie score: 3 or more in 48hr = severe PaO2 Age >55 Neutrophils Calcium (low) Renal (urea) Elevated enzymes: AST, LDH Albumin Sugar (BM)
Complications:
abscess, necrosis, diabetes, renal failure (due to shock)
Gallstone ileus, Mirizzi syndrome
Stone causing SBO (usually in terminal ileum). Usually enters via cholecystoduodenal (between gallbladder and duodenum) fistula
Rigler’s triad: Pneumobilia (air in biliary tree), SBO, gallstones
Ix: Abdo XR: pneumobilia, dilated small bowel loops, gallstones
Tx: IV fluids, abx, NBM, NG tube
Enterotomy (excision of intestines) + stone removal
Mirizzi syndrome
Gallstone in neck of gallbladder leading to compression/obstruction of common bile duct or common hepatic duct
Tx: Lap choly
Causes of pancreatitis
Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion bite Hypercalcaemia ERCP Drugs (Azathioprine, NSAIDs, thiadize)
Peritonitis
Infection of peritoneum
Aetiology: E.coli, Strep faecalis, pseudomonas
Causes: Trauma, perforation (peptic ulcer, appendix), acute cholecystitis, septicaemia
Sx: Severe pain radiates to shoulder, vomiting
Signs: fever, rigid abdo, rebound tenderness, no bowel sounds
If advanced: Abdomen distended+tympanic (high pitched due to air), Hippocratic facies (sunken eyes, skin is cold)
Ix: FBC (leukocytosis), Amylase (exclude pancreatitis), Erect CXR (air under diaphragm or perforated abdominal viscus (if perforated peptic ulcer), CT abdo (free gas, locate cause)
DDx: MI, AAA, intestinal obstruction
Tx: O2 (if <95%), IV fluids, abx, NG tube, analgesia, surgery (if infection can be removed e.g. peptic ulcer repair/appendiectomy)
Diverticulitis
Diverticula of colon are outpouchings of mucosa through muscle wall (usually sigmoid)
True diverticulum: outpouching covered by all layers of bowel (Merkel’s diverticulum)
False (outpouching lacking normal muscle layer (colonic diverticula)
Causes: low fibre diet, obesity, smoking
Complications of diverticula:
- Diverticulitis (inflammation of diverticula) leading to perforation - peritonitis, fistula with small bowel/bladder
- Large bowel obstruction
- Haemorrhage
Sx: LIF pain, altered bowel habits, PR bleeding
Signs: fever, guarding, vague mass on LIF, PR bleeding
Sx chronic divertilcular disease:
Changes in bowel habit, LBO, PR bleed (mucus, bright red)
Ix:
FBC (leukocytosis)
CXR (free air under diaphragm if perforation)
CT (thickened bowel wall, mass, abscess, fistula (between colon and bladder)
flexible sigmoidoscopy (exclude colon Ca)
CT colonography
DDx: IBD, colon ca.
Tx:
Supportive, high fibre diet, laxative
Diverticulitis:
Sx: fever, raised WC, signs peritonitis
Tx:
Acute: Supportive - NBM, IV abx, analgesia
Surgery: if fails respond to medical management, complications - perforation, abscess, obstruction
Abscess: Sx: swinging fever, increased WCC, Ix: US, abx+percutaneous drainage
Peritonitis due to perforation: Laparotomy (Hartman’s: sigmoidectomy + end colostomy) + abx
Visceral perforation
Perforation along GI tract
Causes: Peptic ulcers, sigmoid diverticulum, toxic megacolon, mesenteric ischaemia (due to infarction of intestinal tissue), recent surgery
Sx: pain, acute onset, vomting
Signs: peritonitis (rigid abdomen), septic
DDx: Acute pancreatitis, MI, ruptured AAA
Ix: FBC (raised WBC) Urinalysis (exclude renal and ovarian pathology) Erect CXR: free air under diaphragm CT: (location of perforation)
Tx: IV abx, IV fluid, NBM, analgesia
Surgical: Repair peptic ulcer with omental patch, repair diverticulum (Hartmann’s)
Wash-out
Complications: Sepsis, haemorrhage
Upper and Lower GI bleeding
Management: Assessment+resus, diagnosis of source of bleeding, treat bleeding
Assessment:
Sx: haematemesis, malaena
Signs: pupura (bleeding disorder), features liver disease (oesophageal varices), history of peptic ulcers (NSAIDS, H Pylori)
O2, IV fluids, Group and Save
Causes:
Oesophagus: Varices, Mallory Weiz tear, Borhaave’s syndrome
Stomach: Gastric ulcer, tumours,
Duodenum: Duodenal ulcer,
Small bowel: Meckel’s diverticulum, tumours
Large bowel: Diverticulitis, colitis (UC, ischaemic colitis), tumours
Ix: FBC
UEs (Urea high + low HB = upper GI bleed)
Coag screen
LFTs (liver disease)
Upper GI endposcopy (locate site of bleed, peptic ulcers can be treated with adrenaline)
Colonscopy: locate colonic sources
Tx:
Blood transfusion
Indications surgery: Bleeding despite endoscopic treatment
Ruptured AAA
Aneurysm: abnormal permanent dilation of aortic a
Sx: Severe back pain, radiation to groin
Signs: pulsatile mass
Ruptured:
Sx: Severe back pain, syncope, vomiting
Signs: Haemodynamically compromised: hypo, tachy
Triad of rupture AAA: Back pain, hypotensive, pulsatile mass
Ix: USS, CT with contrast
DDx: renal colic, MI
Tx: <5.5cm - Smoking cessation - BP control - Statin, aspirin
Indications for surgery:
>5.5cm
expanding >1cm/yr
symptomatic
- Endovascular aneurysm reapir (EVAR) - stent via femoral artery at aneurysm (decrease hospital stay after but higher rate of reintervention so not for younger pts)
- Open surgical repair (OSR) - (midline laparotomy - aneurysm replaced with graft)
Rupture:
Tx: O2, IV access (2 large bore cannulae), bloods (FBC, UEs, coag), crossmatch
Tx: prophylactic co-amox, straight to theatre
If unstable: open repair
If stable: CT to see if suitable for endovascular repair
Complications of AAA: rupture, retroperitoneal leak, embolisation, MI (coronary a. disease already common, surgery causes extra stress due to cross clamping aorta), aortoduodenal fisutla
Acute limb ischaemia
Sudden decrease in limb perfusion due to partial/complete arterial occlusion which threatens viability of limb
Causes: Embolus, thrombus in situ, trauma
Sx: Pain, pallor, parathesia, pulseless, perishingly cold, paralysis
DDx: chronic limb ischaemia, acute DVT, SC compression
Ix: FBC (anaemic), Group and Save,
ECG (AF), lactate (assess level of ischaemia), doppler US (biphasic in normal and monophasic in hardened arteries), CT arteriogram (site and extent of blockage)
Tx: O2, Heparin bolus and infusion Surgical 1st line: Baloon catheter embelectomy (Fogarthy catheter) 2nd line: open thromboembelectomy non-viable: amputation
Acute urinary retention
Acute retention: inability to pass urine, suprapubic pain, suprapubic mass
Chronic: Gradual enlargement of bladder, dribbling, incontinence, little/no pain
Management:
Diagnose cause
Assess renal damage
Asses general condition of pt
Signs: Suprapubic tenderness, enlarged bladder dull to percussion
Diagnose cause: Urinary stone, tumour , faecal impaction Acute causes: BPH Prostatic Ca Urethral stricture Drugs: Anitmuscarinics (decreased bladder sensation), Sympathomimetics (increases muscle tone for urethral sphincter), opioids (decreased bladder sensation) Neurological impairment (more chronic cause) - SC injury
Ix:
FBC (haematuria, infection)
PSA (do NOT check for Acute urinary retention) - raised in prostate ca, retention, infection, catheter)
UEs (renal impairment)
Urinalysis (infection)
PR (prostate enlargement, mass, anal tone)
US bladder (diagnostic) - post void residual vol >300ml: chronic
Tx:
Catheter
Treat underlying cause (BPH - Tamsolosin (a1 receptor antagonist - relaxation of smooth muscle bladder and prostate
Finasteride (5-alpha reductase inhibitor - stops conversion of testosterone into DHT, makes prostate smaller)
Complications:
Infection, AKI
Haematuria
<3 RBCs/HPF (high power field) either visible (gross/frank) or non-visible (microscopic or dipstick)
Risk fx: Male, smoking, chemical exposure (aromatic amines), recurrent UTIs
Causes:
Glomerular: IgA nephropathy, Alport’s syndrome (hereditary nephritis)
Non-glomerular:
Upper tract - Pyelonephritis, renal stone, renal cell cancer
Lower tract - UTI, BPH, transitional cell carcinoma
Psuedo-haematuria: menstruation, beets, drugs (rifampicin)
Ix: UEs (renal function) Urinalysis (UTI) Urine culture PSA (prostate ca) Cystoscopy US KUB (Upper urinary tract) (renal stones)
Testicular pain
Surgical emergency - torsion of spermatic cord leading to strangulation of gonadal blood supply which can cause testicular necrosis
Sx: Sudden onset pain in groin/lower abdo + vomiting
Signs: swollen scrotum, cremasteric reflex absent (testicle pulled up when inner thigh stroked)
Risk fx: trauma, straining, lifting
DDx: Strangulated inguinal hernia, epididymitis (UTI, STI, urethral stricture), appendicitis
Ix: Scrotal US (see if there is testicular perfusion)
Tx: Surgical exploration and detorsion - untwist spermatic cord and sutured to tunica vaginalis. Fixation of other testis
Head trauma
A-E
Assess cervical spine: hard collar
Ay: GCS <8 requires anaesethetics
B: ABG
C: Raised ICP (brady, hypertension), hypotension rarely due to head trauma but other cause e.g. ruptured spleen
D: GCS, pupils, BM
E: fractures, laceration, basal skull fractures (racoon eyes, bruising behind ear, blood from ear)
Red flags: dilated pupils (cerebral compression), signs basal skull fracture, focal neuro deficit
Ix: CT head, CT C spine
Neuro referral:
GCS <8
Unexplained confusion >4hrs
Focal neuro signs
Sepsis (cellulitis, abscess)
Cellulitis (inflammation of connective tissue)
Cause: B-haemolytic Group A Streptococcus
Signs: skin is red, hot, blanches on pressure, cutaneous gangrene
Tx: Immbolisation, Abx, Observe (nec fasc)
Abscess: localised collection of pus
Cause: Staph. aureus
Sx: swinging fever, malaise
Signs: hard, red, painful
Tx: drainage
Blood transfusion: acute transfusion reactions
Complications:
Acute transfusion reactions
Pulmonary complications
Transfusion transmitted infections
Sx of acute transfusion reactions: Fever, Tachy, hyper/hypotension, flushing
Tx: Stop transfusion, A-E
Mild transfusion reactions
Causes: febrile non-haemolytic transfusion reactions, mild allergic reaction
Tx: paracetamol, restart at slower infusion
Moderate transfusion reactions
Tx: IV chlorampenamine (anti-histamine), steroids, salbutamol nebs, IM adrenaline (treat like prophylaxis)
Severe transfusion reactions:
- Acute haemolytic transfusion reaction - ABO incompatibility
Sx: feeling of apprehension, flushed, SOB
Signs: dark urine (haemolysis), fever, hypotension
- Bacterial contamination
Sx: cloudy urine (platelets in urine)
Pulmonary complications of blood transfusion
TACO (transfusion associated circulatory overload)
- Circulatory overload
Acute onset of respiratory distress within 24 hrs of transfusion
Risk fx: Age, pre-existing HF or renal impairment
TACO checklist required before blood transfusion
How to prevent TACO:
Take pts weight into account, fluid balace, slower transfusion
TRALI (transfusion associated acute lung injury)
- Immune mediated
Acute dyspnoea with hypoxia and bilateral pulm infiltrates in 6hrs of transfusion
- HLA/HNA antibodies from donor
Blood transfusion: Transfusion transmitted infections
Causes: Bacterial contamination - Can occur with platelets Viral Parasitic Prion
Occurs in less than 8 in 100,000 people
