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Gen Surg Flashcards

1
Q

What is the classic pain progression in appendicitis?

A
  • Starts as central abdominal pain.
  • Moves to the right iliac fossa (RIF) within 24 hours.
  • Localizes at McBurney’s point (1/3 distance from ASIS to umbilicus).
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2
Q

Name symptoms/signs of appendicitis.

A
  • Loss of appetite (anorexia).
  • Nausea and vomiting.
  • Low-grade fever.
  • Rovsing’s sign: RIF pain on palpation of left iliac fossa.
  • Guarding, rebound tenderness, and percussion tenderness in RIF
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3
Q

How is appendicitis diagnosed?

A
  • Clinical presentation and raised inflammatory markers.
  • CT scan: Confirms diagnosis, especially if unclear.
  • Ultrasound: Used in females and children to exclude other causes.
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4
Q

List some important differential diagnoses for appendicitis.

A
  • Ectopic pregnancy (test with hCG).
  • Ovarian cysts (rupture/torsion).
  • Meckel’s diverticulum (malformation of distal ileum).
  • Mesenteric adenitis (inflamed abdominal lymph nodes, often in children).

Always exclude pregnancy in females of childbearing age before further investigations.

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5
Q

Name some complications of appendicectomy.

A
  • Bleeding, infection, pain, and scars.
  • Damage to nearby organs (e.g., bowel, bladder).
  • Removal of a normal appendix.
  • Anaesthetic risks.
  • VTE
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6
Q

What is Rovsing’s sign?

A

Palpation of the left iliac fossa causes pain in the right iliac fossa.

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7
Q

What are the typical features of an abdominal hernia?

A
  • Soft lump protruding from the abdominal wall.
  • Lump may be reducible or worsen with coughing/standing.
  • Aching, pulling, or dragging sensation.
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8
Q

Name the three major complications of hernias.

A
  • Incarceration: Irreducible hernia with trapped bowel.
  • Obstruction: Blockage of bowel, causing vomiting, pain, and constipation.
  • Strangulation: Blood supply cut off, leading to ischaemia. Presents with severe tenderness and is a surgical emergency.
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9
Q

What factors reduce the risk of complications?

A

A wide neck of the hernia, allowing easy reduction.

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10
Q

What are the two types of inguinal hernias?

A

Indirect: Bowel herniates through the inguinal canal. Common in young males due to a patent processus vaginalis.

Direct: Herniates through a weak abdominal wall in Hesselbach’s triangle.

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11
Q

How do you differentiate indirect from direct inguinal hernias?

A

Indirect: Stays reduced with pressure over the deep inguinal ring.

Direct: Herniates regardless of pressure.

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12
Q

Mnemonic for Hesselbach’s triangle: RIP

A

R: Rectus abdominis (medial).
I: Inferior epigastric vessels (superior/lateral).
P: Poupart’s (inguinal) ligament (inferior).

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13
Q

Where do femoral hernias occur?

A

Through the femoral canal below the inguinal ligament.

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14
Q

Mnemonic for femoral canal boundaries: FLIP

A

F: Femoral vein (lateral).
L: Lacunar ligament (medial).
I: Inguinal ligament (anterior).
P: Pectineal ligament (posterior).

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15
Q

Why are femoral hernias high risk?

A

They have a narrow neck, increasing risk of incarceration, obstruction, and strangulation.

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16
Q

Who commonly gets umbilical hernias?

A

Neonates: Often resolves spontaneously.
Older adults: May require surgical repair.

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17
Q

What is a hiatus hernia?

A

Herniation of the stomach through the diaphragm into the thorax.

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18
Q

Types of hiatus hernias:

A

Sliding: Gastro-oesophageal junction slides into thorax.

Rolling: Fundus herniates separately alongside oesophagus.

Mixed: Combination of sliding and rolling.

Type 4: Large defect allowing other organs (e.g., bowel) into the thorax.

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19
Q

How are hiatus hernias treated?

A

Conservative: Manage GERD symptoms (heartburn, reflux).

Surgical: Laparoscopic fundoplication if severe.

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20
Q

What is a Richter’s hernia?

A

Only part of the bowel wall herniates, with a high risk of strangulation.

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21
Q

What is a Maydl’s hernia?

A

Hernia containing two loops of bowel, increasing complexity and risks.

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22
Q

What are the general options for managing hernias?

A
  • Conservative: Observation for wide-neck, low-risk hernias.
  • Tension-free repair: Use of a mesh for reinforcement.
  • Tension repair: Direct suturing of tissues (rarely done due to high recurrence).
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23
Q

How does a colostomy differ from an ileostomy in terms of stool output?

A

Colostomy: Drains more solid stool as water is reabsorbed in the remaining large intestine.

Ileostomy: Drains liquid stool as water is not absorbed in the small intestine.

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24
Q

Why does an ileostomy have a spout, and a colostomy does not?

A

An ileostomy has a spout to prevent the liquid and potentially irritating contents from coming into contact with the surrounding skin. Colostomy contents are solid and less irritating, so a spout is unnecessary.

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25
Q

What is the main use of a gastrostomy?

A

A gastrostomy provides a direct route for feeding into the stomach for patients who cannot meet their nutritional needs by mouth.

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26
Q

What does PEG stand for, and how is it related to gastrostomy?

A

PEG stands for percutaneous endoscopic gastrostomy. It refers to a method of creating a gastrostomy using an endoscopic procedure.

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27
Q

What are the two types of stomas used after bowel resection, and how do they differ?

A

End Stoma: Created by bringing one end of the bowel to the skin; may be permanent or reversible.

Loop Stoma: Temporary stoma with both proximal (productive) and distal openings to allow the distal bowel to heal.

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28
Q

What is an ileal conduit in urostomy formation?

A

An ileal conduit involves removing a segment of ileum, connecting the ureters to it, and bringing the end of the segment to the skin to drain urine.

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29
Q

What is a J-pouch, and when is it used?

A

A J-pouch is an internal reservoir created by folding the ileum into a pouch and connecting it to the anus. It is an alternative to a permanent ileostomy, used after panproctocolectomy to collect stools before defecation.

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30
Q

What are the common complications associated with stomas?

A

Psychosocial impact: Emotional and lifestyle changes.
Skin irritation: From leakage.
Parastomal hernia: Bowel herniating around the stoma.
High output: Dehydration and malnutrition (ileostomy).
Constipation: Seen with colostomies.
Stenosis: Narrowing of the stoma.
Retraction: Stoma sinking into the skin.
Prolapse: Telescoping of bowel through the stoma.
Granulomas: Raised red lumps around the stoma.
Bleeding: From the stoma or surrounding tissue.

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31
Q

What is the typical timeframe for reversing a loop colostomy or ileostomy?

A

6-8 weeks after the distal portion of the bowel has healed

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32
Q

How does a loop stoma structure differ from an end stoma?

A

A loop stoma has two openings:

Proximal (productive): Drains stool or urine and has a spout.

Distal: Non-functional, flat, and allows differentiation of bowel ends.

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33
Q

How can parastomal hernias be managed or prevented?

A
  • Proper stoma placement during surgery.
  • Wearing a supportive belt.
  • Avoiding heavy lifting or straining.
  • Surgical repair if necessary.
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34
Q

What is the American Society of Anesthesiologists (ASA) grading system used for?

A

To classify the physical fitness of a patient before surgery:

ASA I: Healthy patient
ASA II: Mild systemic disease
ASA III: Severe systemic disease
ASA IV: Life-threatening systemic disease
ASA V: Moribund, unlikely to survive without surgery
ASA VI: Brain-dead, undergoing organ donation
E: Emergency operation

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35
Q

Why is fasting required before surgery, and what are the typical rules?

A

Fasting reduces the risk of aspiration during surgery.

No food or feeds: 6 hours before surgery
No clear fluids: 2 hours before surgery

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36
Q

What precautions should be taken regarding anticoagulants before surgery?

A
  • Stop anticoagulants like warfarin and DOACs before major surgery.
  • Monitor INR for warfarin and reverse with vitamin K if necessary.
  • Use bridging therapy (e.g., low molecular weight heparin) in high-risk patients.
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37
Q

Why should oestrogen-containing contraception or HRT be stopped before surgery?

A

To reduce the risk of venous thromboembolism (VTE), they should be stopped 4 weeks before surgery.

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38
Q

How are long-term corticosteroids managed around the time of surgery?

A

Provide IV hydrocortisone during induction and immediate postoperative period.
Double the normal dose for 24–72 hours once the patient resumes eating and drinking.

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39
Q

Why might metformin be stopped before surgery?

A

Metformin is associated with the risk of lactic acidosis, particularly in patients with renal impairment.

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40
Q

How is insulin managed in patients undergoing surgery?

A
  • Continue 80% of long-acting insulin.
  • Stop short-acting insulin while fasting.
  • Use a variable rate insulin infusion (“sliding scale”) with a glucose, sodium chloride, and potassium infusion.
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41
Q

What is the risk of SGLT2 inhibitors in surgical patients?

A

SGLT2 inhibitors (e.g., dapagliflozin) can increase the risk of diabetic ketoacidosis in dehydrated or acutely unwell patients.

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42
Q

What are common antiemetics used to prevent or treat PONV?

A

Ondansetron (5HT3 antagonist): Avoid in prolonged QT interval.

Dexamethasone (corticosteroid): Use with caution in diabetes or immunocompromised patients.

Cyclizine (H1 antagonist): Caution in heart failure or elderly patients.

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43
Q

What haemoglobin thresholds are used to guide post-operative anaemia management?

A

Hb < 100 g/L: Start oral iron (e.g., ferrous sulphate 200 mg TDS for 3 months).

Hb < 70-80 g/L: Blood transfusion plus oral iron.

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44
Q

What is the main risk of using 0.9% saline for resuscitation?

A

Hypernatraemia and hyperchloraemic metabolic acidosis.

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45
Q

Name two isotonic fluids commonly used for resuscitation.

A

Hartmann’s solution and Plasma-Lyte 148.

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46
Q

What is a potential risk of hypotonic fluids like 5% dextrose?

A

Hyponatraemia and fluid shift to the interstitial space.

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47
Q

What does a 1L bag of Hartmann’s solution contain?

A

Sodium (131 mmol), chloride (111 mmol), potassium (5 mmol), calcium (2 mmol), and lactate (29 mmol).

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48
Q

What is the maximum safe rate for potassium infusion in most cases?

A

10 mmol/hour.

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49
Q

Name four causes of generalised abdominal pain.

A

Peritonitis
Ruptured AAA
Intestinal obstruction
Ischaemic colitis.

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50
Q

What are common causes of right upper quadrant pain?

A

Biliary colic
Acute cholecystitis
Acute cholangitis

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51
Q

What conditions are associated with epigastric pain?

A

Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured AAA

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52
Q

Name causes of central abdominal pain.

A

Ruptured AAA
Intestinal obstruction
Ischaemic colitis
Early stage appendicitis

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53
Q

What are possible causes of right iliac fossa pain?

A

Acute appendicitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
Meckel’s diverticulitis

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54
Q

What conditions might cause left iliac fossa pain?

A

Diverticulitis
Ectopic
Ruptured ovarian cyst
Ovarian torsion

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55
Q

What are common causes of suprapubic pain?

A

Lower UTI
Acute urinary retention
PID
Prostatitis

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56
Q

What might cause loin-to-groin pain?

A

Renal colic
Ruptured AAA
Pyelonephritis

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57
Q

Name two causes of testicular pain.

A

Testicular torsion
Epididymo-orchitis

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58
Q

How does the location of the bowel obstruction affect fluid loss?

A

Higher obstructions cause greater fluid loss because less bowel is available to reabsorb fluid.

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59
Q

What are the two main types of volvulus?

A

Sigmoid volvulus and caecal volvulus.

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60
Q

What is a common cause of sigmoid volvulus?

A

Chronic constipation leading to elongation of the mesentery and faecal overload.

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61
Q

Name five risk factors for volvulus.

A

Neuropsychiatric disorders (e.g., Parkinson’s), nursing home residency, chronic constipation, high-fibre diet, and pregnancy.

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62
Q

What is the characteristic x-ray finding in sigmoid volvulus?

A

The “coffee bean” sign, representing a dilated and twisted sigmoid colon

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63
Q

What is the investigation of choice for diagnosing volvulus?

A

A contrast CT scan.

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64
Q

What is the initial management for volvulus?

A

The same as bowel obstruction: nil by mouth, NG tube, and IV fluids.

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65
Q

How is conservative management performed in sigmoid volvulus?

A

Endoscopic decompression using a flexible sigmoidoscope, with a flatus or rectal tube left temporarily in place

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66
Q

What is the recurrence rate of sigmoid volvulus after conservative management?

A

Around 60%.

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67
Q

What are the surgical options for sigmoid volvulus?

A

Hartmann’s procedure (removal of the rectosigmoid colon with colostomy)

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68
Q

What are the surgical options for caecal volvulus?

A

Ileocaecal resection or right hemicolectomy.

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69
Q

Where are the anal cushions located anatomically?

A

At 3, 7, and 11 o’clock when the patient is in the lithotomy position.

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70
Q

What are the four degrees of haemorrhoids?

A

1st degree: No prolapse.
2nd degree: Prolapse with straining, return on relaxing.
3rd degree: Prolapse with straining, can be manually reduced.
4th degree: Permanently prolapsed.

71
Q

What differential diagnoses should be considered for rectal bleeding besides haemorrhoids?

A

Anal fissures
diverticulosis
IBD
colorectal cancer

72
Q

What are the main components of non-surgical haemorrhoid treatment?

A
  • Topical treatments (e.g., Anusol, Anusol HC, Germoloids cream).
  • Preventing constipation (dietary fibre, fluids, laxatives, avoiding straining).
73
Q

Name three non-surgical procedures for haemorrhoids.

A
  • Rubber band ligation.
  • Injection sclerotherapy.
  • Infra-red coagulation.
74
Q

What is haemorrhoidal artery ligation?

A

Suturing the blood vessel supplying the haemorrhoids using a proctoscope.

75
Q

What are the risks of haemorrhoidectomy?

A

Faecal incontinence due to removal of the anal cushions.

76
Q

What are thrombosed haemorrhoids?

A

Haemorrhoids with a clot due to strangulation at the base, causing severe pain and purplish, swollen lumps.

77
Q

What should be done for extremely painful thrombosed haemorrhoids presenting within 72 hours?

A

Consider surgical management and possible admission.

78
Q

Differentiate between diverticulosis, diverticular disease, and diverticulitis.

A

Diverticulosis: Presence of diverticula without inflammation or infection.

Diverticular disease: Symptomatic diverticulosis.

Diverticulitis: Inflammation and infection of diverticula

79
Q

How do diverticula form in the bowel wall?

A

Increased pressure causes herniation of mucosa through weak points in the circular muscle where blood vessels penetrate.

80
Q

Why don’t diverticula form in the rectum?

A

The rectum has a continuous outer longitudinal muscle layer that supports the bowel wall.

81
Q

What are teniae coli, and how do they contribute to diverticula formation?

A

Teniae coli are longitudinal muscle strips along the colon, leaving areas not covered by muscle vulnerable to diverticula.

82
Q

Which section of the bowel is most commonly affected by diverticulosis?

A

The sigmoid colon.

83
Q

Name three risk factors for diverticulosis.

A

Low fibre diets.
Obesity.
NSAID use.

84
Q

What symptoms may occur in diverticulosis, and how are they managed?

A

Symptoms: Lower left abdominal pain, constipation, or rectal bleeding.

Management: High-fibre diet and bulk-forming laxatives (e.g., ispaghula husk); avoid stimulant laxatives like Senna.

85
Q

What are the key symptoms of acute diverticulitis?

A
  • Left iliac fossa pain and tenderness.
  • Fever.
  • Diarrhoea.
  • Nausea and vomiting.
  • Rectal bleeding.
  • Palpable mass (abscess).
  • Raised inflammatory markers (e.g., CRP, WBC).
86
Q

How is uncomplicated diverticulitis managed in primary care?

A
  • Oral co-amoxiclav (5 days minimum).
  • Analgesia (avoiding NSAIDs/opioids).
  • Clear liquids only until symptoms improve.
  • Follow-up in 2 days.
87
Q

What is the hospital management for severe diverticulitis?

A
  • NBM or clear fluids.
  • IV antibiotics and fluids.
  • Analgesia.
  • Urgent investigations (e.g., CT scan).
  • Surgery if complications arise.
88
Q

Name five complications of acute diverticulitis.

A
  • Perforation.
  • Peritonitis.
  • Peridiverticular abscess.
  • Large haemorrhage requiring transfusion.
  • Fistula formation (e.g., colon to bladder or vagina).
89
Q

Name the three main branches of the abdominal aorta that supply the abdominal organs.

A
  • Coeliac artery.
  • Superior mesenteric artery.
  • Inferior mesenteric artery.
90
Q

Which areas are supplied by the coeliac artery?

A

The foregut, including the stomach, duodenum (part), biliary system, liver, pancreas, and spleen.

91
Q

What does the superior mesenteric artery supply?

A

The midgut, from the distal duodenum to the first half of the transverse colon.

92
Q

What is supplied by the inferior mesenteric artery?

A

The hindgut, from the second half of the transverse colon to the rectum.

93
Q

What causes chronic mesenteric ischaemia?

A

Atherosclerosis leading to narrowing of the mesenteric blood vessels

94
Q

What is the “classic triad” of symptoms for chronic mesenteric ischaemia?

A
  • Central colicky abdominal pain after eating (30 minutes post-meal, lasting 1-2 hours).
  • Weight loss (due to food avoidance).
  • Abdominal bruit on auscultation.
95
Q

Name some risk factors for chronic mesenteric ischaemia.

A

Increased age.
Family history.
Smoking.
Diabetes.
Hypertension.
Raised cholesterol.

96
Q

How is chronic mesenteric ischaemia diagnosed and managed?

A

Diagnosis: CT angiography.

Management:
- Modify risk factors (e.g., stop smoking).
- Secondary prevention (e.g., statins, antiplatelets).
- Revascularisation via:
Endovascular procedures (first-line; percutaneous stenting).
Open surgery (e.g., endarterectomy, re-implantation, bypass grafting)

97
Q

What are the key clinical features of acute mesenteric ischaemia?

A

Acute, non-specific abdominal pain disproportionate to examination findings.
Progression to shock, peritonitis, and sepsis.

98
Q

What diagnostic test is preferred for acute mesenteric ischaemia, and what lab findings are expected?

A
  • Diagnostic Test: Contrast CT scan.
  • Lab Findings: Metabolic acidosis and raised lactate levels
99
Q

What are the two main objectives of surgery in acute mesenteric ischaemia?

A

Remove necrotic bowel.
Remove or bypass the thrombus in the blood vessel.

100
Q

What is the prognosis for acute mesenteric ischaemia?

A

Very high mortality rate (>50%).

101
Q

List key risk factors for colorectal cancer.

A
  • Family history.
  • Familial adenomatous polyposis (FAP).
  • Lynch syndrome (HNPCC).
  • IBD
  • Increased age.
  • Diet (high red/processed meat, low fibre).
  • Obesity, sedentary lifestyle.
  • Smoking, alcohol.
102
Q

What is Familial Adenomatous Polyposis (FAP)?

A

An autosomal dominant condition due to APC gene mutations causing numerous colonic polyps with high cancer risk. Treated by prophylactic panproctocolectomy.

103
Q

What is Lynch syndrome (HNPCC)?

A

An autosomal dominant condition from mutations in DNA mismatch repair genes, increasing colorectal cancer risk without forming polyps.

104
Q

What are the red-flag symptoms of bowel cancer?

A
  • Change in bowel habits.
  • Unexplained weight loss.
  • Rectal bleeding.
  • Unexplained abdominal pain.
  • Iron deficiency anaemia.
  • Abdominal/rectal mass
105
Q

What acute presentation may occur with bowel cancer?

A

Obstruction

106
Q

How is bowel cancer screening performed in England?

A

People aged 60–74 receive a FIT test every 2 years to check for human haemoglobin in stool. Positive tests prompt a colonoscopy.

107
Q

What is the Faecal Immunochemical Test (FIT)?

A

A stool test that detects human haemoglobin, used in screening and assessing bowel cancer risk in specific patients.

108
Q

What is the gold-standard investigation for bowel cancer?

A

Colonoscopy, allowing for biopsy or tumour tattooing.

109
Q

Summarize the Dukes’ classification for bowel cancer.

A

A: Confined to mucosa/muscle layer.
B: Through muscle wall.
C: Lymph node involvement.
D: Metastatic disease.

110
Q

Summarize the TNM classification for staging bowel cancer

A

T: Tumour extent (T1-T4).
N: Nodes (N0-N2).
M: Metastasis (M0-M1).

111
Q

List complications of bowel cancer surgery.

A
  • Bleeding, infection, and pain.
  • Nerve, bladder, or bowel damage.
  • Post-op ileus.
  • Anastomosis leakage.
  • Stoma requirement.
  • VTE
  • Intra-abdominal adhesions.
112
Q

What are symptoms of Low Anterior Resection Syndrome?

A
  • Urgency and frequency of bowel movements.
  • Faecal incontinence.
  • Difficulty controlling flatulence.
113
Q

What does follow-up after curative surgery involve?

A
  • Serum CEA monitoring.
  • CT TAP
114
Q

What is the primary composition of gallstones?

A

Gallstones are primarily made of cholesterol, formed from concentrated bile.

115
Q

Describe the anatomy of the bile drainage system.

A

The right and left hepatic ducts => the common hepatic duct.
The cystic duct from the gallbladder + common hepatic duct => common bile duct.
Common bile duct + the pancreatic duct at the ampulla of Vater, which opens into the duodenum, controlled by the sphincter of Oddi.

116
Q

What is choledocholithiasis?

A

Choledocholithiasis is the presence of gallstones in the bile duct.

117
Q

What are the typical symptoms of biliary colic?

A

Severe colicky epigastric or right upper quadrant pain, often triggered by fatty meals, lasting 30 minutes to 8 hours, with possible nausea and vomiting.

118
Q

How can gallstones lead to pancreatitis?

A

Gallstones blocking the pancreatic duct can obstruct pancreatic drainage, causing inflammation

119
Q

Which imaging modality is first-line for suspected gallstone disease?

A

USS

120
Q

What are the ultrasound findings associated with gallstones?

A

Gallstones in the gallbladder, bile duct stones, bile duct dilatation, and features of acute cholecystitis such as a thickened gallbladder wall or pericholecystic fluid.

121
Q

What is the role of MRCP in gallstone diagnosis?

A

MRCP provides detailed imaging of the biliary tree and is used when ultrasound findings are inconclusive.

122
Q

What is ERCP, and when is it used?

A

ERCP (Endoscopic Retrograde Cholangio-Pancreatography) is used to diagnose and treat bile duct stones by clearing stones, performing sphincterotomy, or inserting stents.

123
Q

How do liver function tests aid in diagnosing gallstones?

A

Raised bilirubin, ALP, and mildly elevated ALT/AST suggest biliary obstruction due to gallstones.

124
Q

What is post-cholecystectomy syndrome?

A

A condition involving non-specific symptoms like diarrhea, indigestion, epigastric pain, or intolerance to fatty foods after gallbladder removal.

125
Q

What are the complications of gallstones?

A

acute cholecystitis
acute cholangitis
obstructive jaundice
pancreatitis.

126
Q

Name some complications associated with cholecystectomy.

A

bleeding
infection
bile duct damage
stones left in the bile duct
post-cholecystectomy syndrome.

127
Q

What are the potential complications of an ERCP?

A

Complications include excessive bleeding, cholangitis, and pancreatitis.

128
Q

What is biliary colic triggered by?

A

Biliary colic is triggered by fatty meals due to cholecystokinin (CCK)-induced gallbladder contraction.

129
Q

What is acalculous cholecystitis, and when does it occur?

A

Acalculous cholecystitis is gallbladder inflammation without gallstones, often occurring in patients on total parenteral nutrition or experiencing prolonged fasting.

130
Q

What is Murphy’s sign, and how is it performed?

A

Murphy’s sign is a clinical test suggestive of acute cholecystitis:
- Place a hand on the RUQ and apply pressure.
- Ask the patient to take a deep breath.
- Acute pain and cessation of inspiration when the inflamed gallbladder contacts the examiner’s hand indicate a positive Murphy’s sign.

131
Q

What are the ultrasound findings in acute cholecystitis?

A
  • Thickened gallbladder wall
  • Stones or sludge in the gallbladder
  • Fluid around the gallbladder
132
Q

When is cholecystectomy typically performed for acute cholecystitis?

A

During acute admission, within 72 hours of symptom onset.
In some cases, it may be delayed for 6–8 weeks to allow inflammation to settle.

133
Q

List the potential complications of acute cholecystitis.

A
  • Sepsis
  • Gallbladder empyema
  • Gangrenous gallbladder
  • Perforation
134
Q

What are the two main causes of acute cholangitis?

A
  • Obstruction in the bile ducts stopping bile flow (e.g., gallstones in the common bile duct).
  • Infection introduced during an ERCP procedure.
135
Q

Name the most common organisms involved in acute cholangitis.

A
  • Escherichia coli
  • Klebsiella species
  • Enterococcus species
136
Q

What is Charcot’s triad, and what condition does it indicate?

A
  • Right upper quadrant pain
  • Fever
  • Jaundice (raised bilirubin)

It indicates acute cholangitis.

137
Q

What are the initial steps in managing acute cholangitis?

A
  • Nil by mouth
  • IV fluids
  • Blood cultures
  • IV antibiotics (guided by local protocols)
  • Senior clinician involvement and potential transfer to HDU or ICU
138
Q

What is a percutaneous transhepatic cholangiogram (PTC), and when is it used?

A

PTC is a radiologically guided procedure where a drain is inserted through the skin and liver into the bile ducts to relieve obstruction. It is used when ERCP is unsuitable or has failed. A stent can be put in.

139
Q

Where is the most common site of cholangiocarcinoma?

A

The perihilar region, where the right and left hepatic ducts join to form the common hepatic duct.

140
Q

What are the key risk factors for cholangiocarcinoma?

A
  • Primary sclerosing cholangitis
  • Liver flukes (parasitic infections)
141
Q

What is the key presenting feature of cholangiocarcinoma?

A

Obstructive jaundice.

142
Q

What does Courvoisier’s law state about jaundice and a palpable gallbladder?

A

A palpable gallbladder with jaundice is unlikely to be caused by gallstones and is more likely due to cholangiocarcinoma or pancreatic cancer.

143
Q

What is the significance of painless jaundice in clinical exams?

A

It suggests cholangiocarcinoma or cancer of the head of the pancreas.

144
Q

What are the primary imaging and diagnostic tools for cholangiocarcinoma?

A
  • CT scan (thorax, abdomen, pelvis for staging).
  • MRI with MRCP to assess the biliary system.
  • Biopsy for histological confirmation.
145
Q

What tumour marker is often raised in cholangiocarcinoma?

A

CA 19-9 (carbohydrate antigen 19-9).

146
Q

What is the most common type of pancreatic cancer?
Where do most pancreatic cancers occur?

A

The vast majority of pancreatic cancers are adenocarcinomas.
Most occur in the head of the pancreas.

147
Q

What is the average survival rate for patients diagnosed with advanced pancreatic cancer?

A

6 months

148
Q

What is the 5-year survival rate for patients with early pancreatic cancer?

A

25% or less

149
Q

What is the key presenting feature of pancreatic cancer?

A

Painless obstructive jaundice, which occurs when a tumor in the head of the pancreas compresses the bile ducts.

150
Q

What are the NICE guidelines for referring a patient over 40 with jaundice for suspected pancreatic cancer?

A

2ww

151
Q

When should a patient over 60 with weight loss and an additional symptom be referred for a direct access CT abdomen?

A

If they present with weight loss plus any of the following symptoms:
- Diarrhea
- Back pain
- Abdominal pain
- Nausea
- Vomiting
- Constipation
- New-onset diabetes

152
Q

What is Trousseau’s sign of malignancy, and how is it related to pancreatic cancer?

A

Trousseau’s sign refers to migratory thrombophlebitis (inflammation of blood vessels with clots). It is associated with pancreatic adenocarcinoma.

153
Q

What are the potential surgical options for pancreatic cancer?

A
  • Total pancreatectomy
  • Distal pancreatectomy
  • Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure)
  • Radical pancreaticoduodenectomy (Whipple procedure)
154
Q

When is surgery considered for pancreatic cancer?

A

Surgery is more likely to be considered if the tumor is small and isolated to the head of the pancreas (about 10% of cases).

155
Q

What is the Whipple procedure?
What is the difference between a Whipple procedure and a modified Whipple procedure?

A

A Whipple procedure (pancreaticoduodenectomy) involves removing the head of the pancreas, pylorus of the stomach, duodenum, gallbladder, bile duct, and relevant lymph nodes.
The modified Whipple procedure (PPPD) involves leaving the pylorus in place.

156
Q

What are the three main causes of acute pancreatitis?

A

Gallstones
Alcohol
Post-ERCP

157
Q

What is the mnemonic to remember the causes of pancreatitis?

A

“I GET SMASHED”

I – Idiopathic
G – Gallstones
E – Ethanol (alcohol)
T – Trauma
S – Steroids
M – Mumps
A – Autoimmune
S – Scorpion sting
H – Hyperlipidaemia
E – ERCP
D – Drugs (e.g., furosemide, thiazide diuretics, azathioprine)

158
Q

What are the key symptoms of acute pancreatitis?

A
  • Severe epigastric pain, often radiating to the back
  • Vomiting
  • Abdominal tenderness
  • Systemic signs such as fever and tachycardia
159
Q

What lab test is crucial for diagnosing acute pancreatitis?
What additional lab test is helpful for diagnosing acute pancreatitis?

A

Amylase is typically raised more than three times the normal upper limit in acute pancreatitis.
Lipase, which is more sensitive and specific than amylase in diagnosing acute pancreatitis.

160
Q

What is the Glasgow score used for in acute pancreatitis?

What criteria are used to calculate the Glasgow score?

What Glasgow score indicates severe pancreatitis?

A

used to assess the severity of acute pancreatitis

The PANCREAS mnemonic helps remember the criteria:

P – PaO2 < 8 KPa
A – Age > 55
N – Neutrophils (WBC > 15)
C – Calcium < 2
R – Urea > 16
E – Enzymes (LDH > 600 or AST/ALT > 200)
A – Albumin < 32
S – Sugar (Glucose > 10)

A score of 3 or more indicates severe pancreatitis.

161
Q

What are common complications of acute pancreatitis?

A

Pancreatic necrosis
Infection of necrotic tissue
Abscess formation
Acute peripancreatic fluid collections
Pseudocysts (develop 4 weeks after acute pancreatitis)
Chronic pancreatitis

162
Q

What is the most common cause of chronic pancreatitis?

A

Alcohol

163
Q

What are the key complications of chronic pancreatitis?

A
  • Chronic epigastric pain
  • Loss of exocrine function (lack of pancreatic enzymes, particularly lipase)
  • Loss of endocrine function (leading to diabetes)
  • Damage to the pancreatic duct system
  • Pseudocyst and abscess formation
164
Q

What treatment is used if there is a loss of pancreatic enzymes in chronic pancreatitis?

A

Pancreatic enzyme replacement therapy (e.g., Creon) is used to manage malabsorption and steatorrhoea.

165
Q

What are the main indications for liver transplantation?

A
  • Acute liver failure: Requires urgent transplantation. Common causes include acute viral hepatitis and paracetamol overdose.
  • Chronic liver failure: Patients may wait longer for a transplant. They are placed on a standard transplant list.
  • Hepatocellular carcinoma: In certain cases of liver cancer, transplantation may be necessary.
166
Q

How urgent is transplantation for acute liver failure?

A

Patients with acute liver failure are placed at the top of the transplant list and typically require immediate transplantation.

167
Q

What are some contraindications for liver transplantation?

A
  • Significant co-morbidities (e.g., severe kidney, lung, or heart disease)
  • Current illicit drug use
  • Ongoing alcohol misuse (generally, 6 months of abstinence required)
  • Untreated HIV
  • Current or previous cancer (except in certain liver cancers)
168
Q

What is the lifelong care required after a liver transplant?

A

Immunosuppression: Patients require lifelong medications such as steroids, azathioprine, and tacrolimus to prevent rejection of the transplanted liver.

Lifestyle changes: Patients must avoid alcohol and smoking.

Monitoring: Regular monitoring for opportunistic infections, disease recurrence (e.g., hepatitis), and increased cancer risk due to immunosuppressive therapy.

169
Q

What are some complications to monitor for after a liver transplant?

A
  • Transplant rejection: Signs include abnormal liver function tests (LFTs), fatigue, fever, and jaundice.
  • Infections
  • Cancer risk due to immunosuppression
  • Disease recurrence (e.g., hepatitis or primary biliary cirrhosis)
170
Q

What are the rules for once-daily insulin dosage before surgery?

A

Reduce by 20% the day before, the day of, and the day after surgery.

171
Q

What are the rules for twice daily insulin dosage (long acting) before surgery?

A

the day before: no change

the day of: half morning dose, normal evening dose

the day after: half morning dose, normal evening dose

172
Q

What is the immediate management of wound dehiscence?

A
  • Coverage of the wound with saline impregnated gauze (on the ward)
  • IV broad-spectrum antibiotics
  • Analgesia
  • IV fluids
  • Arrangements made for a return to theatre
173
Q

What drugs can cause pancreatitis?

A

azathioprine
mesalazine
didanosine
bendroflumethiazide
furosemide
pentamidine
steroids
sodium valproate

MSRA (21 decks)

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