CRISP

Question 1

Differentials for RIF pain?

Answer 1

Bowel

• Appendicitis
• Inflammatory bowel disease /Terminal ileitis, colitis, SBO
• Mesenteric adenitis/ meckels diverticulitis/ right sided diverticulitis

Gyencologic

• Ectopic pregnancy
• Ruptured or torted ovarian cyst
• Tubo-ovarian abscess
• PID

Urologic

• Renal stones, infected/obstructed calculi, UTI cystitis/pyelonephritis
• testicular torsion, epididymoorchitis

Abdominal wall
- Inguinal hernia, necrotic LN

Question 2

What are the causes of SBO?

Answer 2

Commonest adhesional, hernias,

Can also be divided into extraluminal, intramural and luminal
- including extrinsic compression, volvulus, stricturing disease, malignancies, intersusception, foreign bodies

Question 3

What are the causes of LBO?

Answer 3

Volvulus
Malignancy
Stricturing disease

Question 4

Differentials for RUQ pain

Answer 4

Biliary: biliary colic, cholecystitis, choledocolithiasis, cholangitis
Pancreatitis
Duodenitis/gastritis, ulcer disease
Liver pathology: abscess/mass/malignancy, hepatitis
Pyelonephritis, ureteric stone, urosepsis
RLL pneumonia

Question 5

What is ERAS?

Multidisciplinary, multimodal model to optimise recovery, reduce LOS and improve outcomes

Answer 5

Enhanced recover after surgery

Question 6

What are the criteria for diagnosis of cholecystitis?

What’s the grading?

Answer 6

Tokyo criteria:
Local clinical signs: Murphy’s sign, RUQ tenderness/pain or palpable mass
Systematic inflammation: WCC/CRP elevated or fever >38
Imaging evidence-US

Mild: no systemic compromise

Mod: WCC >18, palpable RUQ mass, symptoms >72 hours. Marked local inflammation, gangrenous or emphysematous cholecystitis, pericholecystic or hepatic abscess

Severe: Hypotension req vasopressors, reduced consciousness, respiratory compromise, oliguria/severe AKI, coagulopathy or thrombocytopenia

Question 7

What’s warfarin?
How do you reverse warfarin?
Where’s it metabolised?

Answer 7

Warfarin is a Vitamin K antagonist. With Vitamin K being a cofactors for production of factors 2,7,9,10.

It acts on the extrinsic pathway and prolongs prothrombin time, measured by INR

It’s reversed with Vit K 10mg IV- but takes ~6 hours, rapid reversal with prothombinex (factors 2,9,10) by weight or FFP (directly replaces clotting factors).

Metabolised in liver by P450 enzymes

Question 8

What is heparin? How is it reversed?

Answer 8

Heparin is an anticoagulant that inhibits thrombin activation by potentiating anti-thrombin 3

It’s reversed with protamine, 1mg per 100units heparin. Can also give cryoprecipitate or FFP.

Question 9

What’s aspirin?

Answer 9

Aspirin is acetylsalicylic acid, an anti platelet agent, acts as a COX inhibitor to inhibit platelet aggregation.

Withhold 5/7 pre-op
No reversal agent, if profuse bleeding give fresh platelets

Most surgeries can safely be performed on aspirin

Question 10

Whats clopidogrel?

Answer 10

Clopidogrel is an anti-platelet agent that irreversibly inhibits ADP to prevent platelet aggregation

It should ideally be withheld 5/7 pre-op
Give fresh platelets if profusely bleeding

Question 11

What’s Ticagrelor?

Answer 11

An anti-platelet agent, that’s inhibits aggregation by acting of on ADP P2Y12 receptor

Should be withheld 5 days pre-op
If profusely bleeding give platelets

Question 12

What’s Dabigatran?
How is it monitored
How is it reversed?

Answer 12

Dabigatran is a direct thrombin inhibitor & direct oral anticoagulant

Monitored with TT thrombin time and thrombin inhibitor assay. Prolongs clotting time.

Reserved with idareyoucizamab only if TT is prolonged
Treat with activated charcoal within 2 hours or dialysis

Has 12 hour half life, but is renally cleared, withhold 24 hours if normal renal function, 48 hours if creatinine clearance 30-50, 72 hours if <30

Aim: normal APTT/PT or lvl <50ng/ml

Question 13

What’s Apixaban/Rivaroxaban?

How is it monitored? Reversed?

Answer 13

Direct oral anticoagulants that inhibit Factor 10a

Monitor with PT, APTT, factor 10a level

Reversal agent- andexxa not readily available

Can partially reverse with prothrombinex (factor 2,9,10) + recombinant factor 7

Ideally withhold 48 hours pre-op (24 hour half life)

Aim normal APTT, normal or mild prolonged PT, level <50ng/ml

Question 14

Differentials for upper GI bleeding

Answer 14

Gastric or duodenal ulcer, oesophagitis/gastritis/duodenitis, malignancy, Oesophageal varices, Mallory wise tear, oesophageal perforation

Question 15

What’s the diagnostic criteria for pancreatitis?

Answer 15

Atlanta criteria. Requires 2/3:

• pain consistent with pancreatitis
• lipase >3x upper limit of normal
• imaging findings consistent with pancreatitis

Question 16

What’s the criteria for pancreatitis severity?

Answer 16

Modified Atlanta criteria.
Mild: No local/systemic complications
Mod: Local complications including peri pancreatic collection, pancreatic necrosis of peri pancreatic fat necrosis, organ failure <48 hours, exac comorbidities
Severe: Organ failure >48 hours, including, respiratory compromise and AKI or Hypotension despite fluid resus

Question 17

What’s the diagnostic criteria for acute cholangitis?

Answer 17

Tokyo guidelines, requires evidence of:
Systemic inflammation: fever >38, Raised WCC/CRP
Cholestasis: Jaundice/elevated bilirubin, abnormal LFTs
Imaging: Biliary dilatation or obstruction

Question 18

What’s the severity criteria for cholangitis?

Answer 18

Tokyo guidelines
Mild: no systemic compromise
Mod: WCC >12 or <4, high fever >39, age >75, hyperbilirubinemia >50, hypoalbuminaemia
Severe: Organ dysfunction; CV requiring vasopressin every support, respiratory compromise, severe AKI or oliguria, Coagulopathy INR > 1.5, thrombocytopenia plts <100

Question 19

What are causes of cholangitis?

& what organisms cause it?

Answer 19

Choledocolithiasis 
Benign stricture
Malignant obstruction 
Extrinsic compression
Biliary stent obstruction
Strictured bilioenteric anastomoses 

Organisms: E. coli, klebsiella, enterococcus, streptococcus, enterobacter, pseudomonas

Question 20

How should breast lumps be worked up?

Answer 20

Triple assessment:
History-
Examination-
Imaging-

Question 21

Differentials for Low GI bleed?

Answer 21

Haemorrhoidal
Diverticular
Colorectal polyp or malignancy
Angiodysplasia
Colitis- infectious, inflammatory or ischaemic
Anorectal trauma, anal fissure/anal cancer

Small bowel angiodysplasia, tumour,
diverticular disease, bleeding meckels diverticuliticulum

Fast transit upper GI bleed- actively bleeding ulcer or tumour

Question 22

Define sepsis.

Define septic shock.

Answer 22

Sepsis= Life threatening organ dysfunction due to dysregulated host repose to infection.
> qSOFA HAT need 2/3 of:
> hypotension sbp 100, alt GCS, tachypnoea RR 22

Septic shock- persistent hypotension post resus, req vasopressors for MAP 65 & lactate >2