Before exam Flashcards
What is critical limb ischaemia
- can be seen as the extreme of intermittent claudciation
- rest pain (constant pain and opiate analgesia) and tissue loss
- less than 50mmHg at ankle
- blood flow is so little that they get pain without doing anything
- often get pain at night
In critical limb ischaemia what is the blood pressure at the ankle
- less than 50mmHg at ankle
What are the treatment options for peripheral vascular disease
• Conservative
– Lifestyle modification (exercise)
- diets - reduce refined sugar and fats
– Stop smoking
• Medical
– Risk factor optimisation
• Surgical
– Endovascular - Angioplasty
– Open - Surgical bypass
– Adjuncts
list what makes up the Glasgow coma score
- best motor response
- best verbal response
- eye opening
Best motor response 6 - obeying commands 5 - localising to pain 4 - Withdrawing to pain 3 - Flexor response to pain 2- extensor response to pain 1 - No response to pain
Best verbal response 5 - oriented (time, place, person) 4 - confused conservation 3 - inappropriate speech 2 - incomprehensible sounds 1 - None
Eye Opening 4 - spontaneous 3 - In response to speech 2 - in response to pain 1 - None
what is a decorticate posture and what does it mean
(arms bent inwards on chest, thumbs tucked in a clenched fist, legs extended) = implies damage above the level of the red nucleus in the midbrain
What is a deceberate poster and what does it mean
decerebrate posture (adduction and internal rotation of shoulder, pronation of forearm) = implies midbrain damage below the level of the red nucleus
Describe the ASA grades
- grade 1 = normal health patient - wihtout any clinically important comorbidity and without clinically significant past/present medicial history
- grade 2 = a patient with mild systemic disease (any alcohol consumption puts you here)
- grade 3 = a patient with severe systemic disease
- grade 4 = a patient with severe systemic disease that is a constant threat to life
- suffix E = Emergency
- ASA 5 = moribund patient not expected to survive the next 24 hours
- ASA 6 = brain dead
give examples of surgery grades
Grade 1 = minor
- excision of lesion of skin;drainage of breast abscess
Grade 2 = intermediate
- primary repair of inguinal hernia, excision of varicose veins of leg, tonsillectomy, adenotonsillectomy, knee arthroscopy
Grade 3 = major
- total abdominal hysterectomy; endoscopic resection of prostate, lumbar disectomy, thyroidectomy
Grade 4 = major +
- total joint replacement, lung operations, colonic resection, radical neck dissection
Do you stop taking warfarin before surgery
Minor surgery – can be undertaken without stopping (if INR<3.5 it may be safe to proceed)
Major surgery – stop for 3-5d pre-op; vitK ± FFP or Beriplex® may be needed for emergency reversal of INR; one elective option is conversion to heparin (when re-warfarinizing give LMWH until INR is therapeutic as warfarin is initially prothrombotic)
What happens to the contraceptive pill before surgery
- Stop 4 weeks before major/leg surgery
- ensure alternative contraception is used
- restart 2 weeks after surgery
Name the components of the stress response to surgery
- Sympathetic autonomic nervous system which results in an increased secretion of adrenaline
- Anterior pituitary - increased risk of ACTH - leading to increased cortisol risk
- increased ADH
- growth hormone is increase
- increased breakdown of carbohydrates
- protein metabolism is increased
- fat metabolism is increased
describe the blood supply of the dudenum
- strong blood supply and branches are closely realted
- gastroduodenal artery from the right hepatic artery passes behind the 1st section
- this gives rise to the superior pancreaticduodenal artery
- there are recurrent branches from the inferior pancreaticduodenal artery from the superior mesenterci artery
How do you distinguish direct from indirect hernias
- reduce the hernia and occlude the deep inguinal ring with two fingers
Ask the patient to cough or stand
- if the hernia is restrained it is indirect
- if the hernia is not it is direct
- Gold standard for determining type of inguinal hernia is at surgery; direct hernias arise medial to the inferior epigastric vessels, indirect hernia are lateral
how much fluid is in each of the fluid compartments in the body
- for a 70kg man, total body fluid = 42L (60% of body weight)
- 2/3 is intracellular 28L
- 1/3 is extracellular 14L
- different types of IV fluids will equilibrate with the different fluid compartments depending n the osmotic content of the given fluid
What are the two types of IV fluid
- Crystalloids
- Colloids
Name the types of crystalloids
- 5% glucose (dextrose)
- 0.9% sodium chloride (normal saline)
- hypertonic glucose (10% or 50%)
- glucose with sodium chloride (1/5 of normal saline)
- Hartmann’s solution
What are colloids
- have a high osmotic content similar to that of plasma and therefore remain in the intravascular space for longer than other fluids
- therefore appropriate for fluid resuscitation but not for general hydration
- expensive and may cause anaphylactic reactions
What should you use in poor urine output
- aim for >1mg/kg/h, minium is >0.5ml/kg/h
- give fluid challenge , e.g. 500ml 0.9% saline over 1 hour
- recheck urine output
- if not catheterised, exclude retention
- if catheterised ensure catheter is not blocked
What should you do with shock for fluid balance
– resuscitate with colloid or 0.9% saline via large-bore cannulae; identify type of shock
How does pancreatic cancer present if it is in the body and tail of pancreas tumours
- painless obstructive jaundice
- epigastric pain (radiating to back and relieved by sitting forwards) in 75%
What does blood show in pancreatic cancer
- cholestatic jaundice
- increase in CA-19-9 - non specific but helps assess prognosis
What chemotherapy agents are used in colonic cancer
FOLFOX regiment
- fluorouracil
- Folinic acid
- Oxaliplatin
What are the signs of gastric cancer
Suggests incurable disease
- epigastric mass
- hepatomegaly
- jaundice
- ascites
- Virchow’s node
- acanthosis nigricans
What is a Billroth I
- partial gastrectomy with simple gasproduodenal re-anastomosis
What is a billroth II gastrectomy
partial gastrectomy with gastrojejunal anastomosis; duodenal stump is oversewn (leaving blind afferent loop) and anastomosis is achieved by a longitudinal incision into the proximal jejunum
What happens if amylase increases with abdominal pain after a gastrectomy
if with abdominal pain, this may indicate afferent loop obstruction after Billroth II surgery and requires emergency surgery
How do you treat diverticular disease
- Antispasmodics
- Surgical resection
At what stage do you need surgery for diverticulitis
- Stage 1 = pericolic or mesenteric abscess = surgery rarely needed
- Stage 2 = walled off pelvic abscess = may resolve without surgery
- Stage 3 = generalised purulent peritonitis = surgery required
- Stage 4 = generalised faecal peritonitis = surgery required
What are the complications of diverticulitis
- perforation
- haemorrhage
- fistulae
- abscesses
- post-infective strictures
What is the treatment of a perforation of diverticulitis
- Hartmann’s procedure may be performed; primary anastomosis possible in some patients
- emergency laparoscopic management emerging alternative
What are the associated signs with acute appendicitis
- tachycardia
- fever
- peritonism with guarding or rebound tenderness or percussion tenderness in RIF
- anorexia
- vomiting - rare
- Constipation usual - though diarrhoea may occur
What antibiotics are you on appendicitis
- Piperacillin/Tazobactam 4.5g/8h, 1-3 doses IV starting 1h pre-op – reduces wound infections
- Give longer course if perforated
Define jaundice
- yellowing of the skin, sclera and mucosa from an increase in plasma bilirubin
- visible at > 60umol/L
What are the two cases of jaundice
- Unconjugated hyperbilirubinaemia - water insoluble so does not enter urine
- Conjugated hyperbilirubinaemia - water soluble so enters the urine and makes the urine dark, less conjugated bilirubin enters the gut (due to cholestasis) and the faeces become pale
Describe the pathophysiology of pre hepatic jaundice
- excess red blood cell breakdown overwhelms the livers ability to conjugate bilirubin this leads to unconjugated hyperbilirubinaemia
- this is not water soluble so cannot be excreted into the urine
- intestinal bacteria convert some of the extra bilirubin into urobilinogen which is reabsorbed and is excreted by the kidney therefore urinary urobilinogen is increased
Name the pre-hepatic cause of jaundice
Congenital RBC issues Cell shape - sickle cell disease - hereditary spherocytosis - hereditary elliptocytosis Enzyme - GP6D deficiency - pyruvate kinase deficiency Haemoglobin - thalassaemia
Autoimmune haemolytic anaemia
Drugs
- penicillin
- sulphasalazine
- antimalarials
Infections
- malaria
Mechanical
- metallic valve prostheses
- DIC
transfusion reaction s
paroxysmal nocturnal haemoglobinuria
describe the pathophysiology of hepatocellular causes of bilirubi
- disorders of uptake, conjugation or secretion of bilirubin leading to mixed conjugated and unconjugated hyperbilirubinaemia
- cirrhosis
- malignancy - primary or metastases
- viral hepatitis
- Drugs
- Enzymes
What is Dubin-Johnson syndrome
- Autosomal recessive (cMOAT gene) with excretion of conjugated bilirubin – leads to pigmented liver
- Increase in conjugated bilirubin with no other enzyme changes
- High coproporphyrin
Name the causes of post hepatic jaundice
- Billary tree obstruction
- primary biliary cirrhosis (ANA and anti-microbial Abs)
- primary sclerosis cholangitis (ANCA, anti-smooth muscle Abs, 80% have UC, association with cholangiocarcinoma)
- Drugs
What are the causes of jaundice in a previously stable patient with cirrhosis
- Sepsis (UTI, pneumonia, peritonitis)
- malignancy (hepatocellular carcinoma)
- alcohol
- Drugs
- GI bleeding
How do you define constipation
- defined as the passage of less than or equal to 2 bowel motions a week often passed with difficulty, straining or pain and a sense of incomplete evacuation
What does it mean if you have constipation and
- rectal bleeding
- distension and active bowel sounds
- menorrhagia
- rectal bleeding = cancer
- distension and active bowel sounds = stricture and GI obstruction
- menorrhagia = hypothyroidism
What are the general causes of constipation
- poor diet +- lack of exercise
- poor fluid intake/dehydration
- IBS
- old age
- post-operative pain
- hospital environment (lack of privacy, having to use a bed pan)
What are the endocrine causes of constipation
- hypercalcaemia
- hypothyroidism
- hypokalaemia
- porphyria
- lead poisoning
How does bulking agents work
- this is when you increase in faecal mass so stimulating peristalsis
- this must be taken with plenty of fluids and may take days to act
What are the contraindications of bulking agents
- difficulty in swallowing
- GI obstruction
- colonic atony
- faecal impaction
Name some examples of stimulant laxatives
- Bisacodyl tablets (5-10mg at night) or suppositories (10mg in morning)
- Senna (2-4 tablets at night)
- Docusate sodium and Dantron – have stimulant and softening action
- Glycerol suppositories – act as rectal stimulant
- Sodium picosulfate (5-10mg at night) – potent stimulant
How do stimulant laxatives work
increased intestinal mobility so do not use in intestinal obstruction or acute colitis
Name some stool softeners
- Arachis oil enemas – lubricate and soften impacted faeces
- Liquid paraffin – should not be used for prolonged period
What are the side effects of stool softeners
- anal seepage
- lipid pneumonia
- malabsorption of fat soluble vitamins
How does lactulose work
Synthetic disaccharide, produces osmotic diarrhoea of low faecal pH that discourages growth of ammonia-producing organisms
What do osmotic laxatives do
retain fluid in the bowel
name the types of osmotic laxatives
- Lactulose 30-50mL/12h (initial dose)
- Macrogel e.g. Movicol
- magnesium salts e.g. magnesium hydroxide, magnesium sulfate
- sodium salts e.g. microlette and microlax enemas
- phosphate eneams
What is the thumbprinting sign
if someone was to put there thumbs on either side of the bowel this is thumb printing of the bowel this represents diffuse oedema of the bowel
PRESNET IN ISCHAEMIC COLITIS
What are the causes of thumbprinting sign
- ischaemic/inflammatory bowel diease
- pseudomembranous colitis
- diverticulitis
- lymphoma
- amyloid
- typhoid
What is pneumobilia
gas within the biliary tree
What can cause gas within the biliary tree
- incompetent sphincter of oddi; sphinterectomy (50% at 1 year)
- pancreatitis
- gallstone disease
- Biliary - enteric anastomosis
- biliary entery fistula
- infection: cholangitis
What is sacral ilietus
- when you cannot see the sacral ileus joint and it increases in whitness
- associated with ankolysing spondylitis and IBD
- fusing of the sacral ileus joint
What structures lie in the retroperitoneum
- D2
- D3
- Ascending colon
- descending colon
- rectum
- adrenal glands
- aorta
- IVC
- pancreas except tail, ureters and kidneys
