Chapter 12 General Surgery

Question 1

What is a furnicle

Dr guggenheimer asked me this

Answer 1

Infected hair follicle with pus

Question 2

What is a carbuncle

Dr guggenheimer asked me this

Answer 2

Collection of furnicles

Question 3

Tx for carbuncle

Dr guggenheimer asked me this

Answer 3

Excision

Pack with I think benadjne soaked gauze

Question 4

Appendicitis facts: 1epidemiology, pathogenesis, clinical features, Inx, Tx, prognosis

t notes

Answer 4

• 6% of population, M>F

* 80% between 5-35 yr of age

Question 5

Appendicitis facts: epidemiology, 2pathogenesis, clinical features, Inx, Tx, prognosis

t notes

Answer 5

luminal obstruction –> bacterial overgrowth–> inflammation/swelling–> increased pressure–> localized ischemia–> gangrene/perforation–>localized abscess (walled off by omentum) or peritonitis
• etiology
- children or young adult: hyperplasia of lymphoid follicles, initiated by infection
- adult: fibrosis/stricture, fecolith, obstructing neoplasm
- other causes: parasites, foreign body

Question 6

Appendicitis facts: epidemiology, pathogenesis, 3clinical features, Inx, Tx, prognosis

t notes

Answer 6

•most reliable feature is progression of signs and symptoms
• low grade fever (38ºC), rises if perforation
• abdominal pain then anorexia, N/V
•classic pattern: 
ƒ McBurney’s sign
ƒ Rovsing’s sign
ƒ psoas sign
ƒ obturator sign

Question 7

ƒ McBurney’s sign

t notes

Answer 7

McBurney’s Sign
Tenderness 1/3 the distance from the
ASIS to the umbilicus on the right side

Question 8

ƒ Rovsing’s sign

t notes

Answer 8

inferior appendix: McBurney’s sign (see sidebar), Rovsing’s sign (palpation pressure to
left abdomen causes McBurney’s point tenderness). McBurney’s sign is present whenever
the opening of the appendix at the cecum is directly under McBurney’s point; therefore
McBurney’s sign is present even when the appendix is in different locations

Question 9

ƒ psoas sign

t notes

Answer 9

retrocecal appendix: psoas sign (pain on flexion of hip against resistance or passive
hyperextension of hip)

Question 10

ƒ obturator sign

t notes

Answer 10

pelvic appendix: obturator sign (flexion then external or internal rotation about right hip
causes pain)

Question 11

complications of appendicitis

t notes

Answer 11

ƒ perforation (especially if >24 h duration)

ƒ abscess, phlegmon

Question 12

Appendicitis facts: epidemiology, pathogenesis, clinical features, 4Inx, Tx, prognosis

t ntoes

Answer 12

laboratory
- mild leukocytosis with left shift (may have normal WBC counts)
- higher leukocyte count with perforation
B-hCG to rule out ectopic pregnancy
- urinalysis

Imagine, US cannot rule out append, Xray not speicfic, CT 94-100% accurate

Question 13

Appendicitis facts: epidemiology, pathogenesis, clinical features, Inx, 5Tx, prognosis

t notes

Answer 13

Treatment
• hydrate, correct electrolyte abnormalities
• appendectomy

-read up on this

Question 14

Appendicitis facts: epidemiology, pathogenesis, clinical features, Inx, Tx, 6prognosis

tnotes

Answer 14

mortality rate: 0.08% (non-perforated), 0.5% (perforated appendicitis)

Question 15

Advice on abx for cellulitis for Joyce ma

Answer 15

Rare that it’s gram negative

Cephazooin is broad spectrum

If ever swabbed and positive for Mrsa or mmsa use fluclox

Question 16

MRCP

Answer 16

Magnetic resonance cholangiopancreatography

Question 17

ERCP

Answer 17

Endoscopic retrograde cholangiopancreatography

Question 18

Volvulus
1Definition, Risk Factors, Clinical Features, Investigations, Treatment

tnotes

Answer 18

• rotation of segment of bowel about its mesenteric axis
• sigmoid (65%), cecum (30%), transverse colon (3%), splenic flexure (2%)
• 5-10% of large bowel obstruction; 25% of intestinal obstruction during pregnancy

Question 19

Volvulus
Definition, 2Risk Factors, Clinical Features, Investigations, Treatment

tnotes

Answer 19

• age (50% of patients >70 yr: stretching/elongation of bowel with age is a predisposing factor)
• high fibre diet (can cause elongated/redundant colon), chronic constipation, laxative
abuse, pregnancy, bedridden, institutionalization (less frequent evacuation of bowels)
• congenital hypermobile cecum

Question 20

Volvulus
Definition, Risk Factors, 3Clinical Features, Investigations, Treatment

tnotes

Answer 20

symptoms due to bowel obstruction (see Large Bowel Obstruction, GS30) or intestinal ischemia
(see Intestinal Ischemia, GS24)
• colicky abdominal pain, persistence of pain between spasms, abdominal distention, vomiting

Question 21

Volvulus
Definition, Risk Factors, Clinical Features, 4Investigations, Treatment

tnotes

Answer 21

• AXR (classic findings): “omega”, “bent inner-tube”, “coffee-bean” signs
• barium/Gastrografin® enema: “ace of spades” (or “bird’s beak”) appearance due to funnel-like
luminal tapering of lower segment towards volvulus
• sigmoidoscopy or colonoscopy as appropriate
• CT

Question 22

Volvulus
Definition, Risk Factors, Clinical Features, Investigations, 5Treatment

tnotes

Answer 22

• initial supportive management (same as initial management for bowel obstruction (see Large
Bowel Obstruction, GS30)
• cecum
ƒ nonsurgical
Š may attempt colonoscopic detorsion and decompression
ƒ surgical
Š right colectomy + ileotransverse colonic anastomosis
sigmoid
ƒ nonsurgical
Š decompression by flexible sigmoidoscopy and insertion of rectal tube past obstruction
Š subsequent elective surgery recommended (50-70% recurrence)
ƒ surgical: Hartmann procedure (if urgent)
Š indications: strangulation, perforation, or unsuccessful endoscopic decompression

Question 23

Cecal Volvulus

t ntoes

Answer 23

Cecal Volvulus
AXR: Central cleft of “coffee bean” sign
points to RLQ

Question 24

Sigmoid Volvulus

Answer 24

Sigmoid Volvulus
AXR: Central cleft of “coffee bean” sign
points to LLQ
Barium enema: “ace of spades” or
“bird's beak” sign

Question 25

Vicryl

Answer 25

Used for internal and dissolved

• Joyce

Question 26

Prolene

Answer 26

Used for external and doesn’t dissolves

-Joyce