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Surgical Vivas > Any + General Surgery > Flashcards

Any + General Surgery Flashcards

1
Q

1 What is an abscess?

A

A collection of pus, enclosed by a zone of active inflammation

Forms in response to:

  • Pyogenic organisms resistant to phagocytosis or lysosomal destruction (S. aureus, S. pyogenes, E. coli, other Gram -ves
  • Localised tissue necrosis
  • Some organic foreign bodies e.g. wood splinters

Clinical features:

  • Neutrophil leukocytosis
  • Swining pyrexia

Management:

  • Drainage
  • Antibiotics (may halt expansion but rarely curative once abscess has fully formed
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2
Q

2 What is cancer staging?

A

The universal system for describing the severity of a cancer. The criteria are specific to each type of cancer but are related to properties of disease progression

  • Tissue grade/histopathology (how closely it resembles normal tissue)
  • Tumour size
  • Numer of tumours (primaries and metastatic)
  • Lymph node involvement
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3
Q

3 What modalities are used to stage cancer?

A

Each type of cancer has a preferred staging system, but commonly used systems include the TNM and Roman Numeral classifications

Roman Numberal

0 = in situ - abnormal cells are present but have not spread to nearby tissue. This is not cancer, but may become cancer

I = localised (invasion through basement membrane)

II = nodal spread (within primary organ)

III = regional spread (lymph nodes)

IV = distant spread (distant lymph node or metastasis via blood vessels)

TMN

Tis = carcinoma in situa

T1-4 = size and extent of primary

N0 = no regional lymph node involvement

N1-3 = extent of lymph node involvement

M0/1 = no mets/mets

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4
Q

4 What is the purpose of staging a patient’s cancer?

A
  1. Prognosis
  2. Management plan (curative vs palliative)
  3. Eligibility for various trials
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5
Q

5 What is neoplasia? Give examples of benign and malignant neoplasms

A

Neoplasia = abnormal growth of cells

Benign = slow, well-demarcated/encapsulated, similar histology to tissue of origin

E.g. adenoma, lipoma, fibroma, chondroma, haemangioma, papilloma, leiomyoma

Malignant = progressive/rapid, poorly defined, anaplastic tissue, pleiomorphic (nuclei of varying size and shape), stroma hyperplasia leading to characteristic tumour features (hard, obstruction, skin retraction)

E.g. carcinoma (e.g. SCC), sarcoma (e.g. GIST), leukaemia

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6
Q

6 What is a fistula?

A

Abnormal connection between two epithelialised surfaces

Causes

  • Infection e.g. anal fistula following rectal abscess burst
  • Inflammation e.g. Crohn’s disease
  • Malignant growth or ulceration e.g. colon carcinoma
  • Surgery e.g. biliary fistula after gallbladder surgery

Congenital e.g. rectovaginal fistula

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7
Q

7 What is a stoma?

A

An artificial anastomosis between a segment of the gastrointestinal or urinary tract and the skin of the anterior abdominal wall

Permanent: no remaining distal bowel segment

Temporary: emergency (relieve complete distal LBO to prevent perforation), defunctioning (diversion of faecal stream to protect the distal bowel)

Types

Loop = both proximal and distal segments drain to the surface, mainly for temporary defunctioning stoma

Split/spectacle = segmments brought to different skin sites

End = resite of anus to abdominal wall, usually permanent

Hartmann’s = emergency resection of rectosigmoid lesions where primary anastomisis isn’t advisable. May be rejoined months later

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8
Q
  1. What are the potential complications of a surgical procedure?
A

1. Anaesthesia

2. Operative

3. Post-operative

4. Medical comorbidities

—-

1. Anaesthesia

Local: injection site, infection, ischaemic necrosis due to vasoconstriction

Spinal/epidural: failure, nerve damage, vasodilation

General: electrolyte imbalance, cardio/resp/renal complications, hypothermia, reaction

2. Operative

Haemorrhage, tissue damage, inadequate operation, infection

3. Post-operative

Respiratory, VTE, fluid/electrolyte imbalance, AKI, pressure sores, paralytic ileus

4. Medical comorbidities

Decompensated HF, MI, arrhythmias, acute on chronic renal failure

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9
Q

9 What are the risk factors for a superficial wound infection

A

A superficial wound infection occurs within 30 days post-op and involves only skin and subcutaneous tissue with at least one of

  • Purulent drainage
  • Organisms isolated from aseptically obtained culture
  • Infection (rubor, tumour, calor, dolor)

Patient factors

Older age, immunosuppression, obesity, DM, smoking, malnutrition, peripheral vascular disease, chronic skin disease

Treatment factors

Emergency procedure, hypothermia, oxygenation, prolonged operative time/hospitalisation, inadequate abx prophylaxis, not sterile technique

Environmental factors

Poor wound care, inadequate asepsis/sterilisation/ventilation

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10
Q

10 How do you treat a superficial wound infection?

A

Usually caused by commensal skin flora - primary staph and strep

Principles of management:

  • Open and clean the wound
  • Apply a protective, fluid-absorbing dressing
  • Reserve abx for systemic illness or spreading cellulitis
Flu/di-cloxacillin = anti-staph (some strep cover)
Cephazolin = 1st gen cephalosporin = gram +, some gram - cover
Vancomycin = MRSA
Tazocin = Piperacillin (ext spec) + tazobactam (B-lactamase inhibitor) = strep, staph, anaerobes, most gram -
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11
Q

11. What are the principles of antibiotic prophylaxis for surgical patients?

A

Goals

  1. Prevent surgical site infections
  2. Optimise the outcome of the patient’s surgical procedure
  3. Minimise adverse effects
  • *Principles**
    1. Right indication - not indicated for clean procedures if there is no proesthetic materal involved
    2. Right antimicrobial agent - needs to cover skin flora at the site. Usually cefazolin
    3. Right dosage - therapeutic and not toxic
    4. Right timing - < 60 minutes before incision, ideally 15-30
    5. Right route - IV
    6. Right duration - 1 dose is usually sufficient
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12
Q

12. Why do surgical wound fail?

A

Operative

Opposing wound edges, poor aseptic technique, no prophylactic Abx
Wound under high tension → ischemia → dehiscence

Post-operative

Contamination, poor wound care

Patient factors

Increasing age
Stress
Comorbidities - diabetes, obesity, cancer, AIDS, smoking
Medications - steroids, anticoagulant and antiplatelet agents, chemotherapy, immunosuppressants

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13
Q

121 This patient has become aware of a skin abnormality for years that has developed hair growth during adolescence.

  1. What is the abnormality.
  2. What is its significance
  3. What treatment is needed?
A

Q1. Accessory nipple (occasionally becomes apparent during puberty, failure of regression of thickened endoderm during embryogenesis along mammary lines)

Q2. Supernumerary nipples are usually asymptomatic, but they can be of cosmetic concern to patients

Q3. Surgical excision - cosmetically unbearable, prevent pain/swelling during pregnancy

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14
Q

122 This is the abdominal photograph of an 80 year old woman who presents with a painful lump in the right groin. She has had it for 24 hours. Q1. What could it be? She has had generalized colicky abdominal pain from about 12 hours and some vomiting. Q2. What is the most likely diagnosis here? Q3. What is the most appropriate treatment strategy?

A

Q1. Hernia - inguinal or femoral

Q2. Strangulation

Q3. Immediate surgical repair, resection of any necrotic bowel

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15
Q

123 This lady had a swelling on the back of her lower neck. It has been present for years. It had slowly enlared over that time and is producing no other symptoms. Q1. What is the most likely diagnosis? Q2. What tests other than physical examination are likely to be helpful. Q3. What are the common complications of operative removal of this?

A

Q1. Lipoma (mature fat cells encased by thin fibrous tissue)

Q2. Investigations
Ultrasound - differentiate a lipoma from an epidermal cyst or ganglion
Biopsy - if painful, causes restriction of movement, rapidly enlarging, firm

Q3. Complications of Tx
Scarring, seroma, haematoma
Poor cosmesis

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16
Q

124 A 65 year old woman presents to the ED with vomiting, abdominal distention and colicky pain. She has never had an operation. She has a CT scan. Q1. What does this show? Q2. What does the surgical reistrar do the minute he sees this scan? Q3. What does he find? What is the treatment?

A

Q1. Small bowel obstruction, like secondary to hernia (if never had an operation)

Q2. Attempt to reduce the hernia

Q3.

ABCDE and appropriate resuscitation
2x IV large bore cannula - take FBC, group and hold, give fluids
Oxygen
Call for surgical consult
?GI decompression
Pain relief
Pre-operative Abx prophylaxis

Definitive - surgical repair

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17
Q

125 What is the massive transfusion protocol? In what circumstances should it be used?

A

Massive Transfusion Protocol (MTP) is the multi-disciplinary team management process for the critically bleeding patient anticipated to require massive transfusion. It outlines actions to be taken by the senior clinician attending to the patient, the transfusion laboratory staff, and the on-call haematologist/transfusion specialist.

Definitions:

  • *• Critically bleeding** = major haemorrhage that is life-threatening and likely to require massive transfusion
  • *• Massive transfusion** = half of one blood volume in 4 hours or more than one blood volume in 24 hours (adults)

Criteria for activation of MTP
• Actual/anticipated 4 units RBC in <4hrs + haemodynamically unstable ± anticipated ongoing bleeding
• Severe thoracic, abdominal, pelvic, or multiple long bone trauma
• Major obstetric, gastrointestinal, or surgical bleeding

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18
Q

126 A 75 year old lady was admitted with abdominal pain and vomiting, this Xray was taken. Q1. What are the possible causes of her small bowel obstruction? Q2. What are the priorities in managing her in the emergency department?

A

Q1. Causes of small bowel obstruction

  • Extra-luminal: adhesion, hernia, volvulus
  • Intra-mural: stricture, small bowel neoplasm (adenocarcinoma, GIST, etc.)
  • Intra-luminal: intussussception, gallstones, impacted faeces, bezoar

Q2. Resus, NG tube decompression, pain management, surgical consult, NBM, prophylactic abx if for laparotomy

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19
Q

127 Q1. What is this structure and what operation is being attempted?

Q2. What symptoms would this patient have presented with?

Q3. What is the modern management of this condition?

(cholecystectomy)

A

Q1. Apparently is cholecystectomy (according to 2016 students)

Q2. Colicky RUQ pain, fever, Murphy’s sign

Q3. Laparoscopic cholecystectomy - preferably index admission procedure

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20
Q

129 Where is the appendix found?

A

Surface: right iliac fossa, close to McBurney’s point

Internal: blind ending arising from caecum, distal to ileo-caecal junction, at meeting point of the 3 teniae coli

Movement: suspended by mesoappendix (appendicular artery in free edge), rotates in arc around base, 30% pelvic, true retroperitoneal appendix lies behind caecum (can irritate R ureter and psoas when inflamed)

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21
Q

128 How do you categorise causes of abdominal pain?

A
  • *Anatomical**
  • RH: biliary pathology, hepatitis, lower lobe pneumonia
  • EPI: peptic ulcer, gastritis, biliary, pancreatitis, AMI
  • LH: splenic pathology, pancreatitis, lower bowel obstruction, lower lobe pneumonia
  • RL: renal colic, appendicitis
  • UMB: appendicitis (early), intestinal obstruction, mesenteric ischaemia, gastro, IBD
  • LL: renal colic, lower bowel obstruction
  • RI: appendicitis, inguinal hernia, IBD, female pathology
  • HYPO/SUPRA: cystitis, urinary retention, dysmenorrhoea, endometriosis, PID
  • LI: diverticulitis, female pathology, inguinal hernia

Mechanism
Inflammatory, ischaemic, mechanical, congenital, traumatic

Characteristics
Colic, peritonitis, diffuse, localised

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22
Q

130 When should you commence antibiotics in a patient who has symptoms and signs of appendicitis?

A

Initial treatment with antibiotic therapy alone may avoid the need for surgery in 60-80% of patients with uncomplicated appendicitis, but carries a 15-30% risk of readmission within one year and 40% at five years

The cornerstone of therapy is therefore surgical drainage and appendectomy

Empirical triple therapy (gent + ampicillin/amoxicillin + metronidazole)

If not perforated or no appendiceal abscess, discontinue following surgery

If complicated (perforation or appendiceal abscess), continue for 5 days, modifying Abx based on culture and sensitivity

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23
Q

131 What are the important differential diagnoses to consider when managing a 17 year old woman who has the symptoms and signs of appendicitis?

A
  • *Gynaecological**
  • Ectopic pregnancy
  • Ovarian torsion/rupture
  • PID
  • Mittelschmerz
  • *Gastrointestinal**
  • Mesenteric adenitis
  • Crohn’s disease
  • PUD
  • Cholecystitis
  • Meckel diverticulitis
  • *Urological**
  • Pyelonephritis/UTI
  • Ureteric stone
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24
Q

132 You (the candidate) are an Emergency Department resident. How would you proceed to manage a 22 year old female patient who presents to you with a 24 hour history of right iliac fossa pain?

A

Hx

  • SOCRATES
  • Bowel habits
  • Recent flu/URTI
  • Sexual activity
  • Menstrual hx
  • PMH: ongoing GIT, active/past malignancy, prev radiation, prev appendicetomy

Ex

  • Vitals
  • General inspection (still or writhing)
  • Full abdo and pelvic exam

Inv

  • B-hCG
  • Urinalysis
  • Bloods: FBC, UEC, LFTs, group and hold
  • Abdominal and pelvic USS

Alvarado scoring:
M igration of pain
A norexia or ketones in urine
N ausea vomiting
T enderness RLQ
R ebound tenderness
E levated temp > 37.5
L eukocytosis > 10
S hift-left of leukocytes (neutrophilia > 75%)

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25
Q

133 What is the indication for imaging in suspected appendicitis?

A

Not essential to diagnosis, used to increase specificity and decrease negative appendectomy rate

Indications: suspected but dx unclear. The patient should not be so unwell that delaying surgery may lead to perforation

USS: specific but not sensitive, identifies ddx, lower diagnostic accuracy but quicker

CT: sensitive (rules out other ddx in older pts), higher diagnostic accuracy but slower

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26
Q

134 Why does the pain and discomfort of appendicitis classically ‘migrate’ from generalized abdominal pain to become localised in the RIF?

A

Generalised abdo = initial appendiceal obstruction, slow visceral (group B) afferent innervation, visceral nociceptors sensitive to stretch and chemical irritation

  • poorly localised, deep, cramping
  • embryologically mid-gut structure therefore felt generally mid-gut/central

Localised RIF = inflammation spread to parietal peritoneum, somatic (class A-delta or C) afferent innervation, sensitive to pressure pain laceration temp

  • localised, sharp/dull, burning, local peritonitis (tenderness, guarding, rebound tenderness)
  • somatic nerve overlap with overlying abdominal wall
27
Q

135 What are the indications for a laparoscopic approach to appendicectomy?

A

Depends on experience of the surgeon

Indications

  • Uncomplicated or complicated
  • Uncertain diagnosis
  • Non-pregnant women
  • Children
  • Obese (reduced incision size)

Benefits = quicker recovery, fewer wound infections, easier in the obese, ability to assess pelvis in women

Negatives = higher rate of intra-abdo abscess, longer operation, higher costs, technically more demanding

28
Q

136 What are the classical symptoms and signs of acute appendicitis?

A

Symptoms - central colicky periumbilical pain migrating to RIF, anorexia, N/V

Signs - fever, McBurney’s point tenderness, peritoneal signs, Rovsing’s/psoas/obturator sign (highly specific in 3-12 year olds)

29
Q

137 What is a sentinel node biopsy in the management of breast cancer?

A

Sentinel node = the first lymph node to receive lymphatic drainage from the primary tumour in question

Sentinel node biopsy is performed after diagnosis of breast cancer and is one of the most important prognostic factors for a patient. It is performed on the principle that migratory tumour cells from a primary tumour will metastasise to only one or a few (sentinel) lymph nodes before involving others.

Procedure:

1) Blue dye or radiolabelled colloid is injected into the dermal or parenchymal area of the tumour
2) This tracer then flows passively through lymphatic channels
3) Sentinel nodes are identified using a gamma probe
4) These are then biopsied for histopathology, allowing for staging and optimised management

Node positive = indication for complete axillary lymph node dissection
Node negative = less likely to have spread to axillary lymph nodes, ALND not required

Common sites of lymphatic spread for breast carcinoma include axillary, suprclavicular, and internal mammary nodes

30
Q

138 What is a hernia?

A

Protrusion, bulge, or projection of an organ through the body wall that normally contains it

31
Q

139 What is the anatomical difference between an inguinal hernia and a femoral hernia?

A

Inguinal = above the inguinal ligament, in the inguinal canal

Femoral = below the inguinal ligament, in the femoral canal

32
Q

140 On examination, what is the difference between an inguinal hernia and a femoral hernia?

A

Inguinal

  • Above the inguinal ligament
  • Medial to the pubic tubercle

Femoral

  • Below the inguinal ligament
  • Lateral to the pubic tubercle
33
Q

141 What is the importance of deciding whether a hernia is inguinal or femoral?

A

Indications for surgical treatment

  • Symptomatic hernia (esp with symptoms of bowel obstruction)
  • Femoral hernia (small indistensible opening so more readily strangulates)
  • Strangulated/incarcerated hernia

Contraindications

  • Pregnancy
  • Active infection

Watch and wait

  • Appropriate for some asymptomatic inguinal hernias
  • Not recommended for femoral hernias
34
Q

142 What is the difference between an incarcerated or irreducible hernia, and a strangulated hernia?

A

Incarceration = trapping within the hernia sac such that it cannot be reduced/pushed back into the abdominal wall

Strangulated = incarcerated hernia with compromised blood supply causing ischemia

1) Constriction of neck / twisting
2) Reduced venous and lymphatic outflow
3) Oedema of incarcerated tissue
4) Arterial obstruction
5) Ischaemia and necrosis

35
Q

143 A 75 yoa woman presents to the emergency department with a 24 hour history of vomiting and cramping abdominal pain. She has not passed flatus or stool for 24 hours. She has no relevant previous medical history. On examination, she has a distended abdomen, and a tender, red coloured lump in the right groin.

What is the most likely diagnosis and what should be done to help this patient?

A

Likely diagnosis = strangulated hernia (inguinal or femoral)

Ddx: incarcerated hernia, iliopsoas abscess, acute ileofemoral lymphadenopathy, acute saphena varix

Management:

  • Establish IV access and place on fluid balance
  • Catheterise
  • Symptomatic relief: anti-emetics, analgesia
  • Bloods: FBC, UEC, group and save
  • Pre-operative antibiotics
  • Surgical repair
36
Q

144 What are the common causes of a lower GI bleed?

A
37
Q

145 What are the signs and symptoms of a lower GI bleed?

A

Signs:

  • Anaemia secondary to occult bleed (dyspnoea, palpitations, fatigue)
  • Abdominal tenderness, mass, distension

Symptoms:

  • Haemodynamic instability (unlikely, most lower GI bleeds are small vessel)
  • Haematochezia
  • Malaena
  • Fever
  • Associated symptoms (abdominal/perianal pain, changed bowel habits, weight loss, diarrhoea)
38
Q

146 What is the management of a large LGI bleed?

A

1) Triage to appropriate management setting
• High-risk features (haemodynamic instability, persistent bleeding, and/or significant comorbid illness ⇒ ICU
• Most other patients ⇒ regular medical ward
• Low-risk patients (young, otherwise healthy, minor self-limited rectal bleeding suspected from anal source) ⇒ outpatient may be appropriate
• Call surgical/interventional radiology registrar for consult, escalate if patient deteriorates

2) General supportive measures
• Supplemental O2 by nasal prongs
• NBM (should urgent upper endoscopy be required)
• 2 x large-bore IVC or central venous line with CVP measurement
• Bloods - FBC, UEC, LFTs, coags, group and hold

3) Appropriate fluid/blood resuscitation
• Patients with active bleeding - IV fluids (e.g. 500mL normal saline over 30 minutes) while being typed and cross-matched
• Failure of BP to respond to initial fluid resuscitation may require increased rate of administration or urgent intervention (e.g. angiography)
• Decision to initiate blood transfusion must be individualised
- Young without co-morbidity ⇒ Hb < 70 g/L
- Older with severe comorbid illness ⇒ Hb < 90 g/L

4) Management of coagulopathies, anti-coagulation, and anti-platelet
• Decisions regarding management of anti-coagulation/platelet should be individualised
• Active bleeding + coagulopathy (PTT prolonged and INR >1.5) OR thrombocytopenia (< 50,000/μL) ⇒ transfusion with FFP/platelets
• In all cases, risk of reversing/holding anticoagulation should be weighed against risk of continued bleeding

5) Definitive management
• Colonoscopy
• Angiogram + embolization
• Emergency surgery

39
Q

147 What is a Meckels Diverticulum?

A

A congenital outpouching of the bowel arising from incomplete obliteration of the vitelline duct (i.e. omphalimesenteric duct, joining the yolk sac to the mid-gut lumen) during the 5th week of foetal development

Rule of 2s: 2% population, 2% become symptomatic, 2 inches long, 2 feet proximal to ileocaecal valve, 2/3 have ectopic mucosa, 2 types of ectopic tissue (90% gastric, 5% pancreatic)

BUT, most of these 2s are false! It’s much less common, and is more variable in size and location

40
Q

148 What symptoms can be caused by a Meckels diverticulum and why?

A

Often asymptomatic

Painless PR bleeding (frank blood or occult)

  • Acid-secreting gastric mucosa causes inflammation and ulceration of adjacent small bowel wall
  • Progression to perforation causes bleeding from wall
  • ?Painless as intra-luminal mid-gut pain response only to chemical irritation or distension

Inflammation (i.e. diverticulitis)

  • Good mimic of appendicitis
  • Theory: inflammation triggered by micro-perforation
  • Can progress to perforation just like appendicitis

Bowel obstruction (abdo distension, N/V, cramping paroxysmal pain in periumbilical region)

1) Band adhesion from residual vitelline duct acts as focus for volvulus
2) Can also cause stricturing in chronic inflammation
3) Meckels acts as a lead point for telescoping (intussusception) of bowel

41
Q

149 What are the causes of an obstruction of a luminal structure (e.g the bowel, the ureter, biliary tree, or blood vessel)?

A

Intraluminal:

  • Impacted faeces
  • Stones (gall, kidney)
  • Thrombus/embolus
  • Bezoar

Intramural:

  • Tumour (benign or malignant)
  • Lymphoma
  • Stricture (inflammatory, NSAID-induced)
  • Intussusception
  • Atherosclerosis

Extramural:

  • Adhesions
  • Congenital bands
  • Tumours
  • Hernias
  • Prostatic hypertrophy
  • Mirizzi syndrome

Functional/pseudo-obstructions: post-op ileus, electrolyte abnormality, medication-induced

42
Q

150 What are the signs and symptoms of an upper GI bleed?

A

Upper GI bleed = source above the duodenaljejunal flexure (where the ligament of Treitz attaches)

Symptoms: syncope (decreased BV), haematemesis, malaena/haematochezia (irritative effect of blood causes rapid evacuation), abdo/epigastric pain, dyspepsia

Signs: haemodynamic instability (tachy, hypotension, slow cap refill, diaphoresis), conjunctival pallor (anaemia), elevated urea:creatinine (overload of nitrogen being digested in GI tract)

43
Q

151 What is the treatment of an upper GI bleed?

A

Initial measures

1) Determine if patient is shocked - BP, HR, VBG lactate/Hb/HCT
2) Supportive measures - high flow O2, venous access, bloods, pain relief, transfusion if shocked
3) IDC to monitor urine output
4) IV PPI infusion
5) Correct clotting abnormalities
5) Call for surgical/gastro consult
6) Consider NG tube
7) Additional - NBM, PICC for CVP monitoring

Definitive

  • Urgent gastroscopy for diagnosis and treatment
  • Have patient prepared for emergency surgery (if endoscopy fails to achieve haemostasis)

Risk stratification:

  • High risk (>60yo, shock/hypotension, Hb <100, severe comorbidities) = IV fluid resus, admit HDU, continuous observation, endoscopy w/n 12hrs
  • Low risk (<60yo, euvolemic, Hb >100, previously fit) = admit to ward, observe, d/c w/n 5 days if no further bleeding, elective endoscopy
44
Q

152 What do you do as the intern if you think someone is having an acute UGI bleed?

A
  1. Triage (assess for shock, haemodynamic stability
  2. Supportive measures (high flow O2, sedative?, 2 x large-bore IVC, draw bloods, NG tube, catheterise to monitor urine output)
  3. Fluid resuscitation (1L crystalloid over 20-30mins)
  4. Blood transfusion (if still shocked after 2 fluid boluses)
  5. Medication (PPI, pain relief)
  6. Call for surgical/gastro consult
45
Q

153 What are the risk factors contributing to the aetiology of a peptic ulcer?

A
  1. H. Pylori infection - produces urease allowing formation of ammonia cloud that protects it from acid
  2. NSAIDs - COX pathway inhibition results in decreased protective prostaglandin
  3. Smoking
  4. Increasing age
  5. High risk ICU patients - NBM/no enteral feeding can lead to stress ulcers
46
Q

154 What are the initial investigations in the ED for a perforated ulcer?

A

Rapid diagnosis is essential - excellent prognosis w/n first 6 hours but deteriorates with more than 12 hour delay

  1. Bloods
    - FBC - assess blood loss
    - UEC - assess renal perf/function
    - LFTs - assess liver perf/function
    - Coags - assess clotting
    - Group and save - if infusion req
    - Lipase - rule out pancreatitis
  2. ABG (lactate as indicator of organ perfusion)
  3. CXR (erect), AXR - free air under diaphragm (sufficient to proceed if present)
  4. USS/CT (if necessary) - aids ddx rule out, may show free air/fluid
47
Q

155 What are the physical signs suggestive of a perforated ulcer?

A
  1. Initial phase (0-2 hours)
    - Tachycardia, a weak pulse, cool extremities, and a low temperature​
    - Abdominal rigidity (may not be present immediately)
  2. Second phase (2-12hrs)
    - Peritonitic signs - marked rigidity, guarding, rebound tenderness
    - Obliteration of liver dullness to percussion due to peritoneal air
    - Tender pelvic peritoneum (palpated at rectal examination)
    - RLQ tenderness (fluid moving down the pericolic gutter)
  3. Third phase (>12hrs)
    - Increasing abdominal distension, reduced pain/tenderness/rigidity
    - Increasing temperature and hypovolemia due to “third spacing”
    - Persisting/advancing peritonitis
48
Q

156 What are the symptoms suggestive of a perforated peptic ulcer?

A
  1. Initial phase (w/n 2hrs)
    - Sudden abdo pain (epigastric -> generalised)
    - Tachy, weak pulse, cool extremities
    - Abdominal rigidity (as it progresses)
    - Nausea, haematemesis
  2. Second phase (2-12hrs)
    - Lessening pain
    - Peritonitic signs - guarding, rebound tenderness
  3. Third phase (>12hrs)
    - Increasing abdo distension, reduced pain/tenderness/rigidity
    - Increasing temp and hypovolemia due to “third spacing”
    - Persisting/advancing peritonitis
49
Q

157 What is the treatment for a perforated duodenal ulcer?

A

Initial

1) ABC
2) Supportive measures - high flow O2, venous access, IV fluid bolus, bloods, transfusion if required
3) IDC to monitor urine output
4) IV PPI
5) NG tube
6) Empirical antibiotics
7) Surgical consult + NBM

Definitive

Laparotomy
A peritoneal toilet is performed to remove fluid and food contaminating the peritoneal cavity
Suture a vascularised flap of omentum over the defect

Follow with H. pylori eradication therapy

50
Q

158 How do you (as a surgical or ED intern) get a patient with a perforated ulcer ready for theatre?

A

1) Conduct initial management - resus, IDC, medical therapy (IV PPI, fluids, analgesia, anti-emetics), correct electrolytes, correct coagulation abnormalities
2) NBM
3) Call blood bank if anticipating needing blood
4) Call surgeon
5) Call anaesthetist
6) Give booking slip to theatre NUM
7) Consent patient - explain exploratory laparotomy, outline risks (haemorrhage, blood transfusion, stoma, re-operation, infection)

51
Q

159 You are the general surgery resident on call, you are asked to review a 70 year old man who is 72 hours post knee replacement on the orthopaedic ward. He has abdominal pain and distension, he has not passed stool or wind since the first day post surgery, he started vomiting this evening. He is usually well, with no chronic health problems found in his pre-surgery investigations.

What are you going to do?

What is the likely diagnosis?

What is the management?

A

Likely diagnosis: acute colonic pseudo-obstruction (Ogilvie syndrome) - acute dilation of the colon in the absence of mechanical obstruction
• Hospitalised patients with severe illness or post-surgery (particularly joint replacement, CABG)
• Elderly sedentary patients immobilised after surgery
• Symptoms present on average 5 days after surgery
- Immediately after abdominal surgery = paralytic ileus
• Main clinical features = abdominal distension, N/V, constipation, obstipation

Evaluation:

1) Primary survey
2) History
- Check operative report
- SOCRATES of pain
- Post-op dietary intake
- Medication review
3) Examination
- Abdominal exam with PR
- Examine surgical wound
4) Labs
- FBC, UEC, lactate, LFTs (rule out other causes)
5) Imaging
- Erect CXR (gas under diaphragm) + AXR (dilated bowel)
- CT abdomen (to establish diagnosis and rule out other causes)

Management

1) Serial physical examinations, XR, labs every 12-24hrs to evaluate colonic diameter
- Risk of colonic ischaemia and perforation
2) Conservative
- NBM
- IV fluids and electrolyte balance
- Discontinue medications ↓ gut motility (e.g. opiates, calcium channel blockers, medications with anti-cholinergic s/e)
- Treatment of underlying disease
- Decompression by NG tube
- Encourage ambulation
3) Neostigmine (ACh inhibitor)
4) Colonoscopic decompression
5) Percutaneous/surgical cecostomy

52
Q

160 What are the common skin cancers?

A

Melanoma

SCC

BCC

53
Q

161 What features of a mole on the skin would make you concerned that it had become malignant?

A

Red flags

A symmetry
B orders irregular, bleeding
C olour (blue-black, red halo), crusting/ulceration
D iameter >6mm
E volution or recent change (satellite or in-transit lesions, pain/itching)

54
Q

162 What are the principles of initial treatment of a mole on the skin that you are concerned may have undergone malignant change?

A

1) Excisional biopsy of suspicious moles
- Histopathology review of tissue
- 1-3mm margins + subcutaneous fat

2) Assessment of staging
- Sentinel node biopsy/lymphoscintogram (indicated for depth >1mm)
- CT/PET (for detection of mets)

3) Definitive management plan
- Surgery: wide local excision, lymph node clearance
- Adjuvant therapy: RT/chemotherapy relatively ineffective, new immunotherapies may improve outcomes
- Palliation

55
Q

163 What is a volulus of the colon?

A

Def: condition in which the bowel becomes twisted on its mesentery, causing partial or complete obstruction and vascular compromise

Sigmoid colon is most commonly affected due to its long mesentery

2nd most common is the caecum (25-40%)

  • Twin incidence peaks at 10-29 (malformation, excessive exercise) and 60-79 (chronic constipation, distal obstruction, dementia)
  • Higher chance of ischaemia so surgical management is normally the primary option

Pathogenesis (sigmoid):

  • Long-standing history of chronic constipation → elongation and atonic colon (“acquired megacolon”)
  • Patients most at risk of faecal loading = elderly, mental health patients, severe learning difficulties
  • Sigmoid loop becomes heavy with faeces and gas and becomes twisted on mesenteric pedicle
  • This creates a closed-loop obstruction → venous infarction → perforation → faeculent peritonitis

Clinical features:

  • Abdominal distension
  • Tympanic bowel sounds
  • Variable abdominal pain (but rarely tender)
  • Absolute constipation
  • On PR, rectum is empty but capacious (roomy)
56
Q

164 How is a sigmoid volvulus treated (after initial history, examination and investigation)?

A

Key investigative finding = bean-shaped bowel loop in LUQ on AXR

Management:

1) Decompression using flatus tube, or sigmoidoscope (preferred, can assess necrosis off tissue)
- Success = gush of liquid faeces and flatus so STAND CLEAR!
- Very high recurrence rate

2) Confirm success with AXR

3) Surgical (primary anastomosis or Hartmann’s) - indications:
- Failed attempt at decompression
- Necrotic bowel noted at decompression
- Suspected or proven perforation or peritonitis

57
Q

165 This 18 year old man has this lump in his groin. What is the most likely diagnosis? What are the differential diagnoses?

A

1) Herniation
- Direct inguinal = Hesselbach’s triangle
- Indirect inguinal = through inguinal canal (more common in men)
- Femoral = through femoral canal (cough impulse rare, rarely reducible, more common in women)

Ddx

2) Inguinal lymph adenopathy = no cough impulse, can feel above the mass
3) Saphena varix (dilation of long saphenous vein before it enters femoral vein) = cough impulse, fluid thrill, empties on pressure, disappears when supine, varicose veins present
4) Femoral artery aneurysm = male, >65yo, expansile pulsation
5) Iliopsoas abscess = TB abscess of lumbar vertebrae, pyogenic abscess originating from within the abdomen

58
Q

166 This 18 year old man has this lump in his groin. It is a hernia. What is most likely to be in the hernia?

A

Inguinal

Extra-peritoneal fat (if small)
Peritoneum (if small)
Omentum (common)
Small bowel (common)
Large bowel (less common)
Appendix (less common)

Femoral
Small bowel
Omentum

59
Q

167 What are the common methods of repairing an inguinal hernia in a fit 18 year old?

A

1) Watchful waiting with eventual elective repair
2) Surgical repair - open vs. laparoscopic, local vs. general anaesthesia

Open mesh repair = tension-free mesh, usually placed anterior to the hernia defect
Open non-mesh repair = Shouldice (division of inguinal canal layers, reconstruction by overlap), Desarda (flap of external oblique aponeurosis used as patch), Bassini (primary tissue approximation)

Laparoscopic with mesh only = posterior approach to hernia, mesh covered with peritoneum to keep it away from bowel and prevent adhesion

Indications for surgery = symptomatic, femoral, or strangulated/incarcerated hernia
Contraindications for surgery = pregnancy, active infection

Contraindications for mesh = active groin infection, systemic sepsis, active smoker

Indications for open approach = prior pelvic surgery, infection, strangulation, large scrotal hernia
Indications for laparoscopic approach = bilateral hernias, recurrence, femoral, physically active job/lifestyle (reduced pain, faster recovery)
Contraindications for laparoscopic = can’t tolerate GA, ascites, active infection, as for open indications

60
Q

168 What are the common complications of an inguinal hernia repair, and what are the serious complications of this operation?

A
  • *Common**
  • Wound infection
  • Scrotal haematoms
  • *Serious**
  • Recurrence (2-25%)
  • Chronic groin pain due to trapping of the ilioinguinal nerve
  • Testicular atrophy due to damage to the testicular artery
  • Anaesthetic complications - anaphylaxis, cardiovascular arrest
61
Q

169 What is the most significant abnormality in this photo (the photo is a lump in the neck of a 70 yoa man). Where, anatomically, is it, what is the differnetial diagnosis?

A

Describing lumps: Surgeons Cut The Fat PERfectly

Site, size, surface
Colour, contour (well-defined or irregular?), consistency (soft/firm/hard)
Tenderness, temperature, transluminable
Fluctuance, fixity (to underlying tissue or overlying skin), fields (draining lymph nodes in the area)
Pulsatile, Expansile, Reducible

Differentials:
• Inflammatory
- Infectious lymphadenopathy
- Non-infectious lymphadenopathy (e.g. sarcoidosis, Kawasaki’s)
• Neoplastic
- Metastatic disease from head/neck carcinoma
- Thyroid mass
- Salivary gland neoplasm
- Paragangliomas
- Schwannoma
- Lymphoma
• Congenital
- Brachial cleft cyst
- Thyroglossal duct cyst
- Vascular abnormalities
- Ranula
- Dermoid cyst

62
Q

170 What specific history and examination will you perform for a 70 yoa man who presents with a lump in the neck that is clearly not in the thyroid or other midline structures?

A

A neck mass in a patient >40yo should be considered neoplastic and potentially malignant until proven otherwise

HPC:

  • How long has the lump been present?
  • Has it changed recently?
  • Does it fluctuate over time? If so, what precipitates enlargement?
  • Is it painful?
  • (Suggestive of cervical node mets): voice change, hoarseness, dysphagia, otalgia
  • Constitutional symptoms: fever, night sweats, weight loss, bone pain

PMH - any chronic medical conditions (thyroid, cancer, autoimmune, HIV)

PSH - any recent or past neck or head surgery or intubation? Any other surgeries?

Fx - malignancy or cancer

Social - smoking, alcohol, drug use

Examination:

  • General physical inspection (for signs of infection or inflammatory conditions)
  • Palpation of neck mass (describe characteristics - Surgeons Cut The Fat PERfectly)
  • Examine oral cavity and oropharynx (inspection, palpation of floor of mouth/tongue/neck)
63
Q

171 This man has complained about a swelling at his umbilicus.

Q1. What can you see and what is the diagnosis?

Q2. What is the likely contents?

Q3. What is the risk of serious complications with this hernia as it stands.

Q4. What would be the correct approach if this were to become acutely painful and incarcerated?

A

1) Umbilical/paraumbilical hernia
- Description: position (umbi/paraumbi), size, “intrabdominal protrusion/mass”

2) Likely contents are omentum or peritoneal fat, knuckle of bowel (Richter’s hernia) also possible
3) Incarceration/obstruction is more likely in adults and is more often the presentation in men
4) Open repair or laparoscopic repair (for large hernias)

64
Q

This is the laparoscopic view of the lower abdomen.

Q1. What is visible here?

Q2. How can the bowel be injured at Laparoscopy and what are the consequences?

A

Q1. Pelvic structures, kidneys, ureter, vessels, bowel

Q2.

  • Injury during abdominal access, due to insufflation pressure, due to instrumentation
  • Incidental trauma, bleeding, perforation, abdominal hypertension, abdominal compartment syndrome

Surgical Vivas (14 decks)

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