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Periop > Exam Qs > Flashcards

Exam Qs Flashcards

1
Q

Risk factors for Biliary colic

A

5Fs

Fair, fat, forty, fertile, family hx

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2
Q

Symptoms of biliary colic

A
  • No inflammatory response
    • Sudden pain, dull, colicky (waxes and wanes, not true colick)
    • RUQ focus
    • N&V
    • Fatty foods make worse
    • Settles with analgesia
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3
Q

Investigations for biliary colic

A
  • FBC and CRP for inflammation
    • U&Es - assess for dehydration
    • LFTs - damage to liver can occur

Amylase - damage to pancreas can occur

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4
Q

Imaging for biliary colic

A

Use USS AP. Look for:
• Presence of gallstones
• Gallbladder wall thickness - thicker = inflamed
• Bile duct dilatation

Can also use a CT scan with higher sensitivity. MRCP is gold standard

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5
Q

Management of biliary colic

A
  • Analgesia eg morphine.
    • Elective cholecystectomy can avoid future recurrence with worse consequences

Offer lifestyle advice

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6
Q

what is courvisiers law

A

Courvoisier’s Law - If gallbladder palpable and jaundice, it’s a cancer of biliary tree or pancreas.

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7
Q

Symptoms of pancreatic cancer

A
  • Pain in abdomen radiating to back
    • Obstructive Jaundice
    • Steatorrhoea - pale and floating
    • Weight loss, cachexia
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8
Q

Signs of pancreatic cancer

A

• Abdo mass palpable

Jaundiced.

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9
Q

Investigations of pnacreatic cancer

A
  • FBC - anemia of chronic disease
    • Pancreatic amylase
    • LFTs - Raised ALP, gamma-GT, bilirubin (obstructive jaundice)
    • CA19-9 tumour marker for pancreatic cancer
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10
Q

Imaging for pancreatic cancer and use

A
  • Abdo USS - Pancreatic mass, dilated biliary tree
    • CT scan - disease staging.
    • Endoscopic USS used for fine needle aspiration biopsy
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11
Q

Management of pancreatic cancer

A 
• Surgery - Whipples:
		○ 40% mortality
		○ Due to risk of forming pancreatic fistula
	• Chemotherapy:
		○ After surgery use 5-FU
	• Palliative Care:

Biliary stenting

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12
Q

Rectal carcinoma symptoms

A
  • Pain and fresh bleeding
    • Mucus and discharge from anus
    • Palpable mass
    • Pruritis
    • Tenesmus and fecal incontinence possible
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13
Q

Investigations for rectal carcinoma

A
  • FBCs - anemia of chronic disease
    • DRE
    • Biopsy
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14
Q

Imaging for rectal carcinoma

A
  • USS guided FNA of inguinal lymph nodes
    • CT-thorax-abdo-pelvis for mets
    • MRI pelvis - local invasion
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15
Q

Management of rectal carcinoma

A

• Chemo and radiotherapy:
○ 5-FU and external beam radiotherapy used
• Surgery:
○ After failure of chemoradiotherapy or early T1N0 carcinomas
○ Abdominoperineal resection

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16
Q

Symptoms of hemorrhoids

A
  • Painless fresh bleeding
    • Palpable mass
    • Pruritic
    • Soiling - mucus or impaired continence
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17
Q

RFs of hemorrhoids

A
  • Chronic constipation
    • Age
    • Raised intra-abdo pressure eg pregnancy, chronic cough, ascites
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18
Q

Classification of hemorrhoids

A
  1. 1st degree - in rectum
    1. 2nd degree - prolapse through anus on defecation but spontaneously reduce
    2. 3rd - degree - prolapse on defecation but require digital reduction

4th degree - persistently prolapsed

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19
Q

Investigations for hemorrhoids

A
  • Proctoscopy
    • FBC - anemia due to bleeding

Colonoscopy to exclude malginancy

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20
Q

Management of hemorrhoids

A

• Conservative:
○ 1st and 2nd degree treated with rubber band ligation
• Surgical:
○ Hemorrhoidectomy if symptomatic

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21
Q

Endovascular repair vs open repair - differences

A
  • Long term is same
    • EV better short term - decreased hospital stay and 30 day mortality. But higher rate of reintervention and aneurysm rupture
    • Young fit pts open repair is better
22
Q

Acute limb ischemia etiology

A

3 main causes:
• Thrombosis in situ
• Embolism
• Trauma inc compartment syndrome

23
Q

acute limb ischemia management - initially, conservatively, surgically, and long term

A

Initial:
• Oxygen
• IV access
• Heparin

Conservative:
• LMWH

Surgical:
• Bypass surgery if completely occluded
• Angioplasty and stenting
• If limb non salvagable, amputate.

Long term:
• Lifestyle changes
• Low dose aspirin or clopidogrel
• Treat predisposing factors eg AF.

24
Q

Clinical features of acute limb ischemia

A 
6 Ps:
	• Pain
	• Pulseless
	• Perishingly cold
	• Parasthesia
	• Paralysis
	• Pallor

Sudden onset

25
Q

Investigations for acute limb ischemia

A
  • Bloods - FBC, clotting, U&E (electrolyte imbalances), serum lactate (ischemia), thrombophilia screen
    • ECG - AF
    • Doppler USS both limbs
    • Consider CT angiography
26
Q

What is leriche syndrome?

A
  • PAD affecting aortic bifurcation.

* Buttock or thigh pain with erectile dysfunction

27
Q

RFs for chronic limb ischemia

A
  • Smoking
    • Diabetes
    • Hypertension
    • Hyperlipidemia
    • Age

Family Hx

28
Q

Staging and symptoms for chronic limb ischemia

A

Stage I Asymptomatic
Stage II Intermittent claudication
Stage III Ischaemic rest pain
Stage IV Ulceration or gangrene, or both

29
Q

3 definitions of chronic limb ischemia

A
  • Ischemic rest pain for 2wks+, needing opiate analgesia
    • Presence of gangrene
    • ABPI <0.5
30
Q

2 Differentials for chronic limb ischemia

A
  • Spinal stenosis - symptoms relieved by sitting rather than sitting
    • Acute limb ischemia
31
Q

Investigations for chronic limb ischemia

A 
• ABPI - 
		○ <0.9 mild. <0.8 moderate. <0.5 severe.
		○ >1.2 - calcification and hardening of arteries can cause falsely high ABPI
	• Doppler USS
	• CVS risk assessment:
		○ Blood pressure
		○ Blood glucose
		○ Lipid profile
		○ ECG

Buerger’s test
• Raise pts legs while supine
• They go pale until theyre lowered again
• Angle of <20 degs indicates severe ischemia

32
Q

Management of chronic limb ischemia

A 
Medically:
	• Lifestyle advice
	• Statins
	• Aspirin or clopidogrel
	• Optimise diabetes control

Surgically:
• Angioplasty
• Bypass grafting
• Amputation

33
Q

D dimer reference ranges

A

<230 ng/ml - negative test

34
Q

Admitting t1 diabetics for surgery

A
  1. Need to be first on morning list and admitted night before op
    1. Night before - reduce subcut insulin dose by 1/3rd.
    2. Omit morning insulin and use IV insulin infusion
    3. Prescribe 5% dextrose at a rate of 125ml/hr and check BM every 2 hrs

Continue until they can eat and drink. Then give SC insulin 20 mins before meal and stop their IV infusion 45 minutes after they’ve eaten.

35
Q

Admitting t2dm for surgery

A

• Diet controlled, no changes needed.
• If on oral hypoglycemics:
a. Stop metformin on morning of surgery, others stopped night before
b. Put on IV insulin with 5% dextrose and commence as with type 1.

36
Q

Whyd does post op hypotension occur

A

• Occurs due to drugs, epidurals, or hypovolemia

37
Q

Why can hypovolemia occur during surgery

A

○ Blood loss
○ Sepsis
○ GI losses - diarrhoea, vomiting
○ Low albumin

38
Q

Why can epidurals cause hyp0otension and treatment

A

○ Block sympathetic nerve fibres - decreasing systemic resistance
○ Pooling of blood in peripheries mimicks hypovolemia
○ Treatment - elevate legs only, small bolus fluid

39
Q

Treatment for post op hypotension

A

○ Bloods if indicated

○ Fluid boluses 250-500 ml

40
Q

How do you treat hyperkalaemia

A 
• Stabilise myocardium
		○ IV calcium gluconate
	• Reduce serum K
		○ Salbutamol nebs and insulin with dextrose
	• Reduce total body K
		○ Oral calcium resonium
41
Q

How do you treat hypokalaemia

A
  • Treat cause

* IV K replacement

42
Q

State the ASA grading system and % mortality resulting

A

ASA Grade Criteria Absolute mortality (%)
I Normal, healthy 0.1
II Mild systemic disease 0.2
III Severe systemic illness, a functional limitation of their activity 1.8
IV Severe systemic illness, constant threat to life 7.8
V Moribund 9.4

43
Q

What is a hartmanns procedure. whats it used for

A
  • Rectosigmoid resection with formation of an end colostomy and closure of rectal stump
  • Anastomosis with reversal of colostomy may be possible later
  • Used to treat obstructive cancers in rectosigmoid
44
Q

Symptoms of adhesions?

A
  • Colicky pain
    • Constipation
    • Fecal vomiting

Abdo distension

45
Q

Investigations and imaging for adhesions?

A
  • Bloods - FBC, U&E, Clotting, group and save, Crossmatch
    • ABG - serum lactate for ischemia signs
    • Imaging - Abdo Xray, abdo CT
46
Q

Managament of adhesions?

A

• Conservative:
○ Tube decompression - tube passed into stomach and allows built up pressure to be released
○ Pt to be NBM and given IV fluids and analgesia
• Surgical:

Laparoscopic adhesiolysis

47
Q

Where can epidural and spinal be done?

A

epidural - anywhere

spinal - below L2

48
Q

Abx prophylaxis given for GI - open without sepsis, intra abdo with sepsis, laparoscopic

A
  • Open without sepsis - Gentamycin IV + metronidazole 500g
    • Intra-abdo with sepsis - piperacillin-tazobactam 4.5g TDS IV and gentamicin IV
    • Laparoscopic surgery - co-amox 1.2g IV
49
Q

Abx prophylaxis for vascular

A

• Fluclox 1g IV

50
Q

Prophylaxis for VTE

A
  • LMWH - Dalteparin

* TED stockings - if ABPI is >0.9 and no history of arterial disease

51
Q

What is an ivor lewis procedure?

A

esophagectomy

Periop (2 decks)

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