Acute surgery/GI

Question 1

DDx abdominal pain

Answer 1

I would initially like to rule out the more life-threatening (SEVEN SINISTER) causes of acute abdominal pain. These would include (by quadrant clockw - UPD ORA)
o Ulcer, acute pancreatitis, DKA, bowel obstruction (volvulus, herniation, structural, +/- perf), ruptured ectopic pregnancy, ruptured spleen, and ruptured AAA. (UPD ORA)

Having ruled these out, I would then investigate for other acute causes of AA
o Biliary colic, cholecystitis or ascending cholangitis, acute hepatitis
o Chronic pancreatitis, gastritis
o Splenic sequestration, diverticulitis
o Pyelonephritis, testicular torsion, ectopic pregnancy, strangulated hernia, other gynae causes
o Generalised: gastroenteritis, DKA, IBS, IBD, SBP
o Atypicals: lower lobe pneumonia, MI

Question 2

Red flags for AAA

Answer 2

CVS risk factors, calcified aorta on XR, abdo/back pain, known aortic aneurysm, history of collapse and profound hypotension / low Hb on gas

Question 3

Management of AAA

Answer 3

ABCDE with immediate involvement of surgical/vascular and ITU teams when recognised

Volume replacement with fluids and blood products
Monitor lactate

Full history and examination and if possible angiogram pre-operatively; however surgery must not be delayed

Survival in AAA surgery 20%; open or endovascular. CSF drain might reduce risk of spinal ischaemia. Control CVS risk factors after

Question 4

Classes of hypovolaemic shock (ATLS)

Answer 4

Class 1 - <15% blood volume loss, HR BP PP RR UO GCS BE stable

Class 2 - 15-30% blood volume loss, HR up, PP down, BP RR UO GCS stable, BE reduced
*blood products might be required

Class 3 - 30-40% blood volume loss, HR up, BP down, PP down, RR up, UO down, GCS mild reduced, BE reduced
*blood products required

Class 4 - 40%+ blood loss, HR up, BP down, PP down, RR up, UO down, GCS reduced, BE reduced
*massive transfusion required

Question 5

Haematemesis DDx

Answer 5

Haematemesis DDX:
* URT or higher source of bleeding: mouth injury, throat injury
* LRT: Lung Ca (haemoptysis)
* Oesophageal: Mallory Weiss tear, Oesophageal varices, Booerhave’s (oesophageal rupture after vomiting), oesophageal cancer
* Gastric: Ulcer bleeding

Question 6

Upper GI bleeding types

Answer 6

• Variceal: haematemesis > peritonitis
• Ulcer bleed: melaena > peritonitis
• Ulcer perforation: peritonitis > melaena

Question 7

ABCDE in UGIB

Answer 7

A
* OK

B
* SpO2, RR (high) [consider HFO2]

C
* Exam: cool, delayed CRT, pale
* Obs: shock (see ATLS classes), HR/BP/PP influenced accordingly
* Ensure ECG to look for myocardial ischeamie
* Assess fluid status: UO, MM
* Bloods: VBG (Hb and lactate), FBC, U&E, LFT, Clotting, G&S/X-M

D/E
* AVPU, GCS
* CBG and pupils
* Assess for other varices, rashes, signs of cause / melaena

Question 8

Management of variceal bleed

Answer 8

ABCDE approach

Vasoactive drugs along with aggressive IV fluids  EARLY
 Terlipressin 2mg IV (C/I in IHD)
 Ocreotide 50mcg

Endoscopic treatment ASAP
 Endoscopic variceal ligation EVL (banding)
 Sclerotherapy

Consider Sengstacken-Blakemore tube or Minnessota tube if waiting for endoscopy (temporary, up to 24h)

If failed endoscopy:
 Emergency TIPS (Trans juguar intrahepatic portosystemic shunt) – preformed by IR, NB worsens encephalopathy

Question 9

Management of bleeding gastric ulcer

Answer 9

Resuscitation preformed (ABCDE), including bloods for GS/XM

IV PPI: Esomeprazole 80mg IV

IV fluids, analgesic, monitor vital signs, consider transfusion (Hb<70)

Endoscopic (or, if failed, surgical) treatment.
 Adrenaline or VP injection into ucer
 Consider straight to surgery if ulcer has perforated

Question 10

Acute liver failure classification

Answer 10

• Hyperacute: Jaundice, with encephalopathy occurring in <7d
• Acute: J, with E occurring within 1-4wk of onset
• Subacute: J, with E occurring within 4-12wk of onset
• Acute-on-chronic: sudden deterioration (decompensation) in patients with chronic liver disease.

Question 11

Overview of causes of acute liver failure

Answer 11

Viral: Hepatitis ABDE – RARELY C, almost never

Drugs: paracetamol overdose (Hyperacute), idiosyncratic drug reactions (ie. Anti TB)

Less common causes: AI hepatitis, Budd-Chiari, pregnancy, Wilsons disease, haemochromatosis, malignancy, mushroom poisoning

Question 12

Presentation of acute liver failure

Answer 12

Jaundice, unwell, confusion. hepatic flap, acute ascites

Question 13

Management of acute liver failure

Answer 13

Resuscitation: ABCDE, move to ITU with specialist care.
Treat cause (ie. N-acetylcysteine for paracetamol)

Other treatment and prevention of complications:
* Monitor: vital signs, PT, pH, and urine
* Manage encephalopathy: lactulose and phosphate eenmas
* Infection prophylaxis: Abios and antifungal trophylaxis
* Glycaemic control
* Coagulopathy monitoring: IV vitK, FFP, platelet infusions
* Gastric protection: Omeprazole 40mg IV OD
* NO SEDATIVES or liver metabolized drugs to be given!
* Cerebral odema control - IV mannitol
* Renal: monitor fluid balance and U&E; consider haemofiltration and nutritional support.
* Transplantation workup if arterial pH<7.3, PT>100, Creat >300. Or :if patient very young or old, BR300, or caused by chronic liver disease

Question 14

Causes of pancreatitis

Answer 14

IGETSMASHED: Idiopathic, gallstones, ethanol (alcohol, 80%), trauma, steroids, maligngnt/mumps, AI, scorpion bites, Hyperlipid/HyperCa2+/HyperPTH, ERCP, drugs

Question 15

Eponymous signs in pancreatitis

Answer 15

 Grey-Turner’s – bruising on flanks (Turn around = Flanks+back)
 Cullen’s – bruising in umbilical (C=upside down U for umbilicus)
 Fox’s – Eccyhmosis over inguinal ligament area
 Chovstek’s – facial spasm when facial nerve tapped due to hyperCa

Question 16

Glasgow scoring system for severity of pancreatitis components

Answer 16

PANCREAS
PO2<8, Age>55, Neut WC>15, Ca<2, Renal Ur>16, Enzymes ALT/AST or LDH raised, Albumin <32, Sugar (glucose>10)

Question 17

Management of pancreatitis

Answer 17

ABCDE approach and stabilize the patient; consider admission to HDU and ICU

Assessment of severity: modified Glasgow / APACHE / Balthazar on CT

Nutritional support:
o NBM
o Insert Ryles tube for decompression
o TPN + Fluid resuscitation in first instance, slowly reestablish feeding

Analgesia
o Morphine sulphate 1-5mg IV every 4h

Anti-emetic
o Ondasentron 4mg IV every 6h

Replacement of:
o Calcium: Hypocalcaemia commong, Ca gluconate 15g/d IV
o Mg: MgSo4 1g IV TDS
o Insulin: 0.1u/kg if BM low

Empirical Abx therapy: Ceftriaxone 1g/d +/- Metronidazole 500mg TDS

Alcohol induced
o Chlordiazepoxide
o Pabrinex IV

Infected necrosis
o Percutaneous catheter drainage
o Larger drain or surgical necrosectomy

Question 18

Peritonitis causes

Answer 18

• SBP,
• Bowel perforation (II obstruction –pain, BS tinkling, Constip, distension)
• Peritoneal hamorrage
• Intraperitoneal inflammation

Question 19

Management of SBP

Answer 19

o Get ascitic sample and send ideally before antibiotics
o Empirical antibiotics IV - Ceftriaxone 1g IV BD + Vancomycin 1g BD [PO Cipro if not septic]
o Renal patient: IV albumin

Question 20

Obstruction/perforation management pre-op

Answer 20

o NG tube decompress (Ryles) + NBM
o IV fluids 0.9% saline
o Analgesia + antiemetic
o Catheter
o Surgical bloods
o Pre operative antibiotics: Ceftriaxone 1g + Metronidazole 500mg