Gastro PACES

Question 1

Causes of massive splenomegaly?

Answer 1

CML, Myelofibrosis, Malaria, Lymphoma

Question 2

Causes of palmar erythrema?

Answer 2

Chronic stable liver disease, cirrhosis, hyperthyroidism, pregnancy, RhA, polycythaemia

Question 3

Signs of chronic stable liver disease?

Answer 3

Palmar erythrema
 Dupuytren’s
 Clubbing
Corneal arcus
Gynaecomastia (failure of liver to break oestradiol down), axillary hair loss, spider naevi)
 Spider naevi (>5 is abnormal, sup. vena cava distribution) – also in those who take COCP and pregnancy

Question 4

Decompensated liver disease:

Answer 4

o Portal hypertension [SAVE]:
 Splenomegaly
 Ascites
 Varices
 Encephalopathy

o Failed clearance of bilirubin (jaundice)
o Failed clearance of ammonia (leads to encephalopathy)  flapping tremor (asterixis)

Question 5

How are sutures chosen?

Answer 5

Sutures chosen based on diameter, tissue strength, duration of closer
Larger no. of zeros = smaller diameter

Question 6

Absorbable sutures

Answer 6

Vicryl
Monocryl
PDS
Catgut (natural)

Question 7

Non-absorbable sutures

Answer 7

Nylon (ethilon)
Prolene
Silk
steel

Question 8

Monofilament sutures pros & cons?

Answer 8

Less trauma and tissue reaction
Lower risk of infection

Question 9

Braided/polyfilament pros and cons?

Answer 9

Easier to handle + retain knots
Increased risk of infection

Question 10

When to use monofilament

Answer 10

used for superficial wound closure (less tissue reaction)

Question 11

When to use non-absorbable sutures?

Answer 11

permanent support + slower healing tissued e.g. vascular anastomoses, tendon, fascia

Question 12

When to use absorbable sutures?

Answer 12

for deep or rapid healing tissues e.g. bowel/biliary/urinary anastomoses

Question 13

Complications with Total hip replacements?

Answer 13

Dislocation
Osteolysis
Metal sensitivity
Nerve injury
Chronic pain

Question 14

CI/ Complications of TED stockings?

Answer 14

patients with arterial disease of the lower limb (need to do ABPI first), severe skin breakdown (ulceration/ infection)

Question 15

Complications of oropharyngeal airway?

Answer 15

trauma to soft palate
airway hyperreactivity
gagging → vomiting and aspiration

Question 16

Complications/CI of nasopharyngeal airway?

Answer 16

Complications:
Nasal ulceration, bleeding, laceration of friable lymphoid tissue, rupture of a pharyngeal abscess, laryngospasm
Contraindication:
Patients with basal skull fractures/ severe head/ maxfax = potential passage through the cribriform plate

Question 17

Complications of ET tube?

Answer 17

Complications: include (but not exhaustive) inappropriate placing (oesophageal), injury to larynx, C spine injury, pneumothorax, atelectasis, sore throat, difficult wean and infection.

Question 18

Tracheostomy?

Answer 18

This is a temporary tracheostomy; it is an example of a definitive airway as it protects the patients lungs from aspiration.
One of the most common occasions you will see a tracheostomy is on a patient being ventilated on the intensive care unit.
Allows more efficient ventilation of the patient with a decreased dead space and also allows more effective suctioning of the airways.
Patients with upper airway obstruction/ severe maxfax trauma or after laryngeal surgery.

Question 19

Complications of tracheostomy?

Answer 19

Immediate: Bleeding, trauma to oesophagus and RLN, pneumothorax, can’t ventilate
Early: Tracheal erosion, tube displacement/obstruction, surgical emphysema, aspiration pneumonia, pneumomediastinum
Late: Tracheomalacia, tracheoesophageal fistula, tracheal stenosis

Question 20

iGels and laryngeal mask airways (LMA) what are they?

Answer 20

Supraglottic airway devices that are used as a step prior to intubation i.e. do not prevent aspiration therefore not a definitive airway

Question 21

When to use LMA?

Answer 21

Elective surgical procedures i.e. day cases/ <2hr ops, cardiac arrests and prehospital airway management (bridge to ET). They have benefits that include reduced trauma to the oropharynx (seen with intubation) and therefore can be used to reduce hospital stays in elective patients

Question 22

Contraindications/complications of LMA/iGels?

Answer 22

Contraindications: Trismus (lockjaw), limited mouth opening, pharyngo-perilaryngeal abscess, trauma or mass, reduced chest compliance
Complications: Inflation of the device can also cause pressure lesions and nerve palsies. Dislodgement, leak and aspiration as is not definitive airway

Question 23

Laryngoscope

Answer 23

Indications: A laryngoscope is used to aid ET intubation, visualisation of larynx to aid diagnosis of vocal problems and strictures.
Complications:
Inexperienced users of laryngoscopes can cause severe harm to the patient including mild soft tissue injury, laryngeal and pharyngeal scarring, ulceration and abscess formation. & C spine injury

Question 24

Nasal Cannulae

Answer 24

It is widely used to carry 1-3L of oxygen per minute (can be upto 4L/min). This delivers between 28-44% of oxygen.
These cannulae differ from high-flow therapy (NIV).
Complications: nasal sores/ ulcerations and epistaxis, therefore patients are encouraged to apply water-based creams to moisturise.

Question 24

Self-Inflatable Bag-Valve-Mask

Answer 24

Very useful in delivering high levels of oxygen even at low-flow rates.
Can deliver 100% oxygen with flows above 10L/min.
Indications: patients in resp failure, apnoea, patients unable to protect their own airway, patients undergoing anaesthesia in elective procedures
Complications:
Barotrauma from too much lung inflation
Gastric insufflation → vomiting and aspiration

Question 24

Indication for intubation

Answer 24

Decreased consciousness and loss of airway reflexes (gcs <8) - failure to protect against aspiration
Failure to oxygenate (T1RF) - resp pathology, ARDS, pul oedema
Failure to ventilate (T2RF) - tiring pt eg life threatening asthma
Failure to maintain airway patency - upper airway obstruction, angioedema, facial/ upper airway trauma.

Question 25

Central Line Insertion Pack

Answer 25

Seldinger central line kits include a 3-5 lumen cannula, guide wire, dilator, scalpel, and introducer needle.
Central venous catheters are placed often into the subclavian or internal jugular veins via ultrasound. They are useful in the delivery of medications/fluids that may be harmful orally or peripherally. Blood tests and central venous pressures can also be obtained.

Key indications include: parenteral nutrition, emergency venous access, fluid resuscitation, infusion of irritant drugs, vasopressors, inotropes.

Complications on insertion include: pneumothorax, sepsis, thrombosis and misplacement

Seldinger technique. Order CXR to confirm placement

Question 26

Hickman vs Tesio

Answer 26

Hickman = 2 ports and 1 tube
Tesio = 2 ports and 2 tubes
Tunnelled central line
Inserted into subclavian through subcut tunnel (decreases incidence of line infection)
Long term use (months to years)

Question 26

The definitive airway: what is it?

Answer 26

Infraglottic (crosses cords), secure (cuffed), prevents aspiration of gastric contents, condeliver max conc of o2

Question 27

Indications for tesio/hickman?

Answer 27

IV admin of meds
Abx, chemotherapy
Regular vascular access
RRT
Blood sampling

Question 28

TESIO indications?

Answer 28

Indication: haemodialysis. Inserted under x-ray guidance
Cuff promotes a tissue reaction with allows for a better seal.

Question 29

Hickman indications?

Answer 29

Long-term parenteral nutrition, long-term intravenous antibiotic therapy and chemotherapy.

Question 30

PICC line?

Answer 30

Inserted into basilic or cephalic veins with tip sitting in SVC, CXR used to check placement
Medium term use (weeks to months), tends to have a longer catheter vs central lines

Indications: IV admin of medication - abx, chemo, Poor peripheral access

Question 31

Complications of PICC lines?

Answer 31

Immediate: haemorrhage, pneumothorax, arterial puncture, arrhythmias, cardiac tamponade, air embolism
Delayed: venous stenosis, thrombosis, erosion of vessel, line fracture, catheter colonisation, line related sepsis

Question 32

Port-a-Cath?

Answer 32

Long term chemo or Abx.
Centrally placed catheter, SC port made of silicone.
Accessed with Huber point needle. Low infection risk as skin breech very small

Question 33

Epidural insertion pack

Answer 33

Touhy/Epidural needle – Touhy type needle is provided with clear depth marking for accurate insertion depth reading.
Epidural catheter- It is specially designed for short term and long term anaesthesia and pain relief into extradural space
Epidural catheter adapter – This catheter adapter is for safe and secure attachment to the catheter for convenience of the procedure

Question 34

Swan ganz catheter

Answer 34

Used to measure the pressures in the heart, the pulmonary artery wedge pressure and can also be used to measure the cardiac output.

These are used in the intensive care setting and are typically inserted into a central vein

Used in ICU/ in cardiogenic or septic shock
Inserted into a central vein
HOWEVER use has not actually shown to improve outcome…
Indications:
Flow directed pulmonary artery catheter
Measure pulmonary capillary wedge pressure
Measure CO

Question 35

Dever’s retractor

Answer 35

This is a type of retractor which is used in open abdominal surgery to allow the surgeon to operate.
There are different sizes and types of retractors available. You may frequently be asked to use one during you clinical training when you are assisting in theatre.
Can be bent into a suitable shape
Complication: damage to skin and internal structures

Question 36

Self-retaining retractor

Answer 36

This is a type of retractor used to hold wounds open, e.g. during a hernia repair or an appendicectomy.
Complications: damage to nerves and vessels

Question 37

Laproscopy port?

Answer 37

Complications
Initial entry carries highest risk of visceral perforation
Extra care taken at extremes of BMI and previous laparotomy

Question 38

Trucut Needle

Answer 38

This is a trucut biopsy needle which is used to take histological specimens from lesions, e.g. breast lumps or liver.
The procedure can be performed under local anaesthetic.

Complications: bleeding, pain, Ca seeding

Question 39

Image quality for CXRs?

Answer 39

RIPE
Rotation: clavicle position
Inspiration: 7 anterior/9 posterior
Penetration: visible spine processes behind mediastinum
Exposure: apices to below the diaphragm

Question 40

CXR - what to look for?

Answer 40

A = airway
Trachea patent and central
B = breathing and bones
Lung fields esp apex
Lung markings
Fractures
C = circulation
Cardiomegaly
Cardio/costophrenic angles
D = diaphragm
Air under the diaphragm
E = everything else
Foreign bodies/artefacts
Subcutaneous emphysema

Question 41

Heart failure signs on CXR:

Answer 41

Alveolar batwing shadowing
Kerley B lines
Cardiomegaly
Upper lobe Diversion
Pleural Effusion

Question 42

Ix for pleural effusion

Answer 42

A-E
Pleural aspiration for testing, chest drain for treatment
Bedside – sputum culture
Bloods – FBC CRP UE LFT autoimmune screen
Imaging – fibroscan, ECHO,
Send fluid off for: cytology, culture, biochemistry, culture

Question 43

Describing pulmonary effusion CXR

Answer 43

Rotation Ok, inspiration good, slight underpenetration
A ok
B – interstitial shadowing pulmonary infiltrates upper lobe diversion
Cardiomegaly
Some blunting and effusions
E no rib fractures, Pacemaker seen
What is the most likely diagnosis?
Pulmonary oedema / acute heart failure

Question 44

Presenting AXRs?

Answer 44

Assess image type and quality - projection of image (AP) - either supine or erect, exposure of image - ?whole abdomen from diaphragm to pelvis visible
Interpretation - BBC
B = bowels and other organs
Small bowel - more central, valvulae conniventes across whole width, normally <3cm, caecum < 9cm
Large bowel - peripheries, haustra and plicae semilunaris, <6cm
Faeces often mottled appearance and seen in colon
B = bones
C = calcification and artefact

Question 45

Toxic megacolon?

Answer 45

Toxic megacolon - colonic dilatation without obstruction associated with colitis
IBD mostly, also infective colitis

Also lead pipe - loss of normal haustral markings secondary to chronic colitis (IBD)

Thumb printing in toxic megacolon may also be present +/- pseudopolyps

Question 45

Faecal loaded bowel/ faecal impaction AXR?

Answer 45

mottled appearance due to gas in to the faecal matter

Question 45

Treating large bowel obstruction?

Answer 45

A-E
Drip and suck – NBM, IV fluids, analgaesia
Refer to surgeons
What is the single most important investigation to order next?
CT abdomen to find cause, is it volvulus etc

Question 46

Gout on imaging?

Answer 46

Soft tissue swelling in early disease
Periarticular erosions ‘punched out lesions’ in late disease
Normal joint space

Question 46

RA hands X-rays

Answer 46

RhA hands - LESS
In MCPs

REMEMBER - to present as a symmetrical polyarthropathy, with your top ddx as rheumatoid arthritis

Loss of joint space
Erosions
Soft tissue swelling
See through bones (osteopenia)

Plus other cardinal signs of RhA e.g. Z thumb, Boutonniere’s deformity, swan-neck deformity etc

Question 46

RFs for subarachnoid haemorrhage?

Answer 46

PKD, HTN, idiopathic usually, AVM

Question 46

Psoriatic arthropathies

Answer 46

Psoriatic arthropathy
Pencil in cup

X-ray showing some of changes in seen in psoriatic arthropathy. Note that the DIPs are predominately affected, rather than the MCPs and PIPs as would be seen with rheumatoid. Extensive juxta-articular periostitis is seen in the DIPs but the changes have not yet progressed to the classic ‘pencil-in-cup’ changes that are often seen.

Question 47

Complications of subarachnoid haemorrhage?

Answer 47

Vasospasm – presents like a stroke
Hyponatraemia – can be SIADH
Rebleed - coil ASAP if possible
Death

Question 48

Describe CT subarachnoid haemorrhage

Answer 48

hyperdensity in the subarachnoid space, sulcul effacement (so ↑ ICP, bone OK, Vs Ok (no midline shift)

Question 49

Extradural haematoma findings on CT?

Answer 49

lentiform or convex hyperdense lesion in right hemisphere, causing sulcal effacement and small degree midline shit, no bone fracture, right ventricles effacement, sulci effacement. Extracranial haematoma

Question 50

Treatment for extradural haemorrhage

Answer 50

How would you manage this patient?
A-E approach
Refer to neurosurgery - burr holes
How would know if this patient was deteriorating?
Monitor GCS, GCS will drop as disease progresses (typically lucid interval then unconscious). If lose consciousness again → emergency as could be herniating

Question 51

Acute subdural haematoma on CT?

Answer 51

crescent shaped area of hyperdensity, following subdural space in right hemisphere, extending from frontal lone posteriorly, with midline shift, ventricular and sulcal effacement, no bone fractures

Question 52

RFs for subdural haematoma?

Answer 52

Elderly
Anticoagulant therapy
Alcohol excess
High falls risk

Question 53

Chronic subdural haematoma: CT findings?

Answer 53

Chronic subdural - cresent shaped hypodense collection that spreads across the hemisphere and is not limited by the suture lines. There is also effacement of the ipsilateral ventricle.