Exam Qs Flashcards
Risk factors for Biliary colic
5Fs
Fair, fat, forty, fertile, family hx
Symptoms of biliary colic
- No inflammatory response
- Sudden pain, dull, colicky (waxes and wanes, not true colick)
- RUQ focus
- N&V
- Fatty foods make worse
- Settles with analgesia
Investigations for biliary colic
- FBC and CRP for inflammation
- U&Es - assess for dehydration
- LFTs - damage to liver can occur
Amylase - damage to pancreas can occur
Imaging for biliary colic
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
Management of biliary colic
- Analgesia eg morphine.
- Elective cholecystectomy can avoid future recurrence with worse consequences
Offer lifestyle advice
what is courvisiers law
Courvoisier’s Law - If gallbladder palpable and jaundice, it’s a cancer of biliary tree or pancreas.
Symptoms of pancreatic cancer
- Pain in abdomen radiating to back
- Obstructive Jaundice
- Steatorrhoea - pale and floating
- Weight loss, cachexia
Signs of pancreatic cancer
• Abdo mass palpable
Jaundiced.
Investigations of pnacreatic cancer
- FBC - anemia of chronic disease
- Pancreatic amylase
- LFTs - Raised ALP, gamma-GT, bilirubin (obstructive jaundice)
- CA19-9 tumour marker for pancreatic cancer
Imaging for pancreatic cancer and use
- Abdo USS - Pancreatic mass, dilated biliary tree
- CT scan - disease staging.
- Endoscopic USS used for fine needle aspiration biopsy
Management of pancreatic cancer
• Surgery - Whipples: ○ 40% mortality ○ Due to risk of forming pancreatic fistula • Chemotherapy: ○ After surgery use 5-FU • Palliative Care:
Biliary stenting
Rectal carcinoma symptoms
- Pain and fresh bleeding
- Mucus and discharge from anus
- Palpable mass
- Pruritis
- Tenesmus and fecal incontinence possible
Investigations for rectal carcinoma
- FBCs - anemia of chronic disease
- DRE
- Biopsy
Imaging for rectal carcinoma
- USS guided FNA of inguinal lymph nodes
- CT-thorax-abdo-pelvis for mets
- MRI pelvis - local invasion
Management of rectal carcinoma
• Chemo and radiotherapy:
○ 5-FU and external beam radiotherapy used
• Surgery:
○ After failure of chemoradiotherapy or early T1N0 carcinomas
○ Abdominoperineal resection
Symptoms of hemorrhoids
- Painless fresh bleeding
- Palpable mass
- Pruritic
- Soiling - mucus or impaired continence
RFs of hemorrhoids
- Chronic constipation
- Age
- Raised intra-abdo pressure eg pregnancy, chronic cough, ascites
Classification of hemorrhoids
- 1st degree - in rectum
- 2nd degree - prolapse through anus on defecation but spontaneously reduce
- 3rd - degree - prolapse on defecation but require digital reduction
4th degree - persistently prolapsed
Investigations for hemorrhoids
- Proctoscopy
- FBC - anemia due to bleeding
Colonoscopy to exclude malginancy
Management of hemorrhoids
• Conservative:
○ 1st and 2nd degree treated with rubber band ligation
• Surgical:
○ Hemorrhoidectomy if symptomatic
Endovascular repair vs open repair - differences
- 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
Acute limb ischemia etiology
3 main causes:
• Thrombosis in situ
• Embolism
• Trauma inc compartment syndrome
acute limb ischemia management - initially, conservatively, surgically, and long term
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.
Clinical features of acute limb ischemia
6 Ps: • Pain • Pulseless • Perishingly cold • Parasthesia • Paralysis • Pallor
Sudden onset
Investigations for acute limb ischemia
- Bloods - FBC, clotting, U&E (electrolyte imbalances), serum lactate (ischemia), thrombophilia screen
- ECG - AF
- Doppler USS both limbs
- Consider CT angiography
What is leriche syndrome?
- PAD affecting aortic bifurcation.
* Buttock or thigh pain with erectile dysfunction
RFs for chronic limb ischemia
- Smoking
- Diabetes
- Hypertension
- Hyperlipidemia
- Age
Family Hx
Staging and symptoms for chronic limb ischemia
Stage I Asymptomatic
Stage II Intermittent claudication
Stage III Ischaemic rest pain
Stage IV Ulceration or gangrene, or both
3 definitions of chronic limb ischemia
- Ischemic rest pain for 2wks+, needing opiate analgesia
- Presence of gangrene
- ABPI <0.5
2 Differentials for chronic limb ischemia
- Spinal stenosis - symptoms relieved by sitting rather than sitting
- Acute limb ischemia
Investigations for chronic limb ischemia
• 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
Management of chronic limb ischemia
Medically: • Lifestyle advice • Statins • Aspirin or clopidogrel • Optimise diabetes control
Surgically:
• Angioplasty
• Bypass grafting
• Amputation
D dimer reference ranges
<230 ng/ml - negative test
Admitting t1 diabetics for surgery
- Need to be first on morning list and admitted night before op
- Night before - reduce subcut insulin dose by 1/3rd.
- Omit morning insulin and use IV insulin infusion
- 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.
Admitting t2dm for surgery
• 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.
Whyd does post op hypotension occur
• Occurs due to drugs, epidurals, or hypovolemia
Why can hypovolemia occur during surgery
○ Blood loss
○ Sepsis
○ GI losses - diarrhoea, vomiting
○ Low albumin
Why can epidurals cause hyp0otension and treatment
○ Block sympathetic nerve fibres - decreasing systemic resistance
○ Pooling of blood in peripheries mimicks hypovolemia
○ Treatment - elevate legs only, small bolus fluid
Treatment for post op hypotension
○ Bloods if indicated
○ Fluid boluses 250-500 ml
How do you treat hyperkalaemia
• Stabilise myocardium ○ IV calcium gluconate • Reduce serum K ○ Salbutamol nebs and insulin with dextrose • Reduce total body K ○ Oral calcium resonium
How do you treat hypokalaemia
- Treat cause
* IV K replacement
State the ASA grading system and % mortality resulting
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
What is a hartmanns procedure. whats it used for
- 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
Symptoms of adhesions?
- Colicky pain
- Constipation
- Fecal vomiting
Abdo distension
Investigations and imaging for adhesions?
- Bloods - FBC, U&E, Clotting, group and save, Crossmatch
- ABG - serum lactate for ischemia signs
- Imaging - Abdo Xray, abdo CT
Managament of adhesions?
• 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
Where can epidural and spinal be done?
epidural - anywhere
spinal - below L2
Abx prophylaxis given for GI - open without sepsis, intra abdo with sepsis, laparoscopic
- 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
Abx prophylaxis for vascular
• Fluclox 1g IV
Prophylaxis for VTE
- LMWH - Dalteparin
* TED stockings - if ABPI is >0.9 and no history of arterial disease
What is an ivor lewis procedure?
esophagectomy
