Gen Surg Flashcards
DDx of generalised abdo pain
- peritonitis
- ruptured AAA
- intestinal obstruction
- ischaemic colitis
DDx RUQ pain
- Biliary colic
- Acute cholecystitis
- Acute cholangitis
DDx epigastric pain
- Acute gastritis
- Peptic ulcer disease
- Pancreatitis
- Ruptured AAA
Ddx central abdominal pain
- Ruptured AAA
- Intestinal obstruction
- Ischaemic colitis
- Early stages of appendicitis
DDx LIF pain
- ectopic pregnancy
- diverticulitis
- Ruptured ovarian cyst
- Ovarian torsion
DDx RIF pain
- Acute appendicitis
- Ectopic pregnancy
- Ruptured ovarian cyst
- Ovarian torsion
- Meckel’s diverticulitis
DDx suprapubic pain
- urinary retention
- lower UTI
- Pelvic inflammatory disease
- Prostatitis
DDx loin to groin pain
- Renal colic (kidney stones)
- Ruptured AAA
- Pyelonephritis
DDx testicular pain
- testicular torsion
- epididymo-orchitis
what is peritonitis
inflammation of the peritoneum, the lining of the abdomen
signs of peritonitis
- guarding
- rigidity
- rebound tenderness
- coughing test
- percussion tenderness
Spontaneous bacterial peritonitis
- associated with spontaneous infection of ascites in patients with liver disease
- Mx: broad-spectrum antibiotics
- poor prognosis
signs and sx of appendicitis
- central abdo and RIF pain
- tenderness at McBurney’s point (1/3 ASIS to umbilicus)
- loss of appetite
- N&V
- low grade fever
- Rovsing’s sign
- guarding, rebound and percussion tenderness
Ix for appendicitis
- inflammatory markers
- USS
what is Meckel’s diverticulum
- malformation of the distal ileum that occurs in around 2% of the population
- usually asymptomatic and does not require mx
- it can bleed, rupture or cause a volvulus or intussusception
what is mesenteric adenitis
- inflamed abdominal lymph nodes
- associated with tonsillitis or an upper RTI
- caused by viral or bacterial infections, such as streptococcal pharyngitis
- No specific mx is required
presentation of mesenteric adenitis
- Crampy abdominal pain
- poor appetite
- sore throat
- fever
- cervical lymphadenopathy
- tenderness in the RIF
- usually in younger children
is SBO or LBO more common
small bowel obstruction
causes of bowel obstruction
Big 3 (90%)
1. adhesions (SB)
2. hernias (SB)
3. malignancy (LB)
Others
- volvulus (LB)
- diverticular disease
- strictures
- intusussusception
main causes of intestinal adhesions
- Abdominal or pelvic surgery (particularly open)
- Peritonitis
- Abdominal or pelvic infections (e.g., PID)
- Endometriosis
what is closed loop bowel obstruction
- two points of obstruction along the bowel
- expands, ischaemia, perforation
- emergency surgery
presentation of bowel obstruction
- vomiting (green bilious)
- abdominal distension
- diffuse abdo pain
- constipation and lack of flatulence
- tinkling bowel sounds
- AXR: 3:6:9 SB:colon:caecum
what are valvulae conniventes
- in small bowel
- mucosal folds that form lines extending the full width of the bowel
- AXR: line across entire width
what are haustra
- in large bowel
- pouches formed by the muscles in the walls
- lines do not extend full width
Mx of bowel obstruction
- drip and suck. NBM, IV fluids and NG tube with drain
- exploratory surgery
- stents can be used
what is an ileus
- in small bowel
- normal peristalsis stops
causes of ileus
- injury to bowel
- handling during surgery
- inflam/infection
- electrolyte imbalance
sx of ileus
similar to bowel obstruction
- Vomiting (green bilious)
- Abdominal distention and pain
- constipation and no flatulence
- Absent bowel sounds (as opposed to “tinkling” in obstruction)
Ix for post operative ileus
Deranged electrolytes can contribute to the development: check potassium, magnesium and phosphate
Mx of ileus
- treat cause
- supportive
- NBM, IV fluids
- NG if vomiting, TPN
- mobilise
what is a volvulus
- bowel twists around itself and the mesentery that it is attached to
- close loop BO –>necrosis and perforation
types of volvulus
- caecal
- sigmoid
sigmoid volvulus features
- more common
- affects sigmoid colon
- chronic constipation
- assoc with high fibre diet and laxatives
caecal volvulus features
- less common
- younger patients
RF for volvulus
- Neuropsychiatric disorders (e.g., Parkinson’s)
- Nursing home residents
- Chronic constipation
- High fibre diet
- Pregnancy
- Adhesions
Presentation of volvulus
similar to BO
- Vomiting (green bilious)
- Abdominal distention
- Diffuse abdominal pain
- Absolute constipation and lack of flatulence
Mx of volvulus
- conservative: endoscopic decompression
- flexible sigmoidoscope
- laparotomy
- Hartmann’s procedure
- ileocaecal resection or right hemicolectomy for caecal
Complications of hernias
- incarceration (cannot be reduced, leads to O&S)
- obstruction (blockage of faeces)
- strangulation (non-reducible and blood supply gone)
Richter’s hernia
- only part of the bowel wall and lumen herniate through the defect, with the other side of that section of the bowel remaining within the peritoneal cavity
- strangulate and necrose quickly
Maydl’s Hernia
two different loops of bowel are contained within the hernia.
Mx of hernias
- conservative
- tension free repair (mesh)
- tension repair (suture)
Inguinal hernias
- direct (weakness in the abdominal wall at Hesselbach’s triangle. Not reducible)
- indirect (bowel herniates through the inguinal canal. Reducible with pressure)
- superior and medial to pubic tubercle
< 6 weeks old = correct within 2 days
< 6 months = correct within 2 weeks
< 6 years = correct within 2 months
Femoral hernias
- herniation of the abdominal contents through the femoral canal
- below inguinal ligament
- femoral ring is narrow so high risk of strangulation
- inferior and lateral to the pubic tubercle
- surgery within 2 weeks
incisional hernias
- at site of previous surgery
- difficult to repair
umbilical hernias
- defect in the muscle around the umbilicus
- common in neonates
- resolve spontaneously by 3y/o
epigastric hernias
hernia in the epigastric area (upper abdomen)
spigelian hernias
- etween the lateral border of the rectus abdominis muscle and the linea semilunaris
- Dx via USS
hiatus hernias
- herniation of the stomach up through the diaphragm
- Type 1: Sliding (stomach slides up with the Go junction)
- Type 2: Rolling (separate part of stomach folds around)
- Type 3: Combination of sliding and rolling
- Type 4: Large opening with additional abdominal organs entering the thorax (bowel, pancreas, omentum)
Hiatus hernia RF
- age
- obesity
- pregnancy
Presentation of hiatus hernias
- dyspepsia (indigestion)
- Heartburn
- Acid reflux + reflux of food
- Burping + Bloating
- Halitosis (bad breath)
Mx of hiatus hernias
conservative
surgical: lap fundoplication
haemorrhoids
- enlarged anal vascular cushions (control anal continence)
- assoc with constripation and straining
- MC in pregnancy, obesity, increased age, increased abdo pressure
where are anal cushions located
clock face 3, 7 and 11
classification of haemorrhoids
- 1st degree: no prolapse
- 2nd degree: prolapse when straining and return on relaxing
- 3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back
- 4th degree: prolapsed permanently
Sx of haemorrhoids
- asymp or with constipation
- painless bright red bleeding
- not mixed in with stool
- sore/itchy anus
- lump around or inside anus
- PR exam
- proctoscopy for proper visualisation
Mx of haemorrhoids
- topical: reduce swelling. Anusol
- increase fibre, laxatives, fluids
- rubber band ligation
- injection sclerotherapy
- haemorrhoidal artery ligation, haemorrhoidectomy
diverticulum, diverticulosis, diverticulitis
- diverticulum: pouch or pocket in the bowel wall
- diverticulosis: presence of diverticula, without inflammation or infection. Diverticulosis may be referred to as diverticular disease when patients experience symptoms
- divertulitis: inflammation and infection of diverticula
diverticulosis
- mainly affects sigmoid
- common with increased age, obesity, low fibre, NSAID
- diagnose via CT or colonoscopy
- No mx if asymptomatic, can give bulk forming laxative
acute diverticulitis presentation
- Pain + tenderness in the LIF
- Fever
- Diarrhoea, N&V
- Rectal bleeding
- Palpable abdominal mass (if an abscess has formed)
- Raised inflammatory markers and WCC
Mx of diverticulitis
uncomplicated:
- oral co-amox, analgesia
complicated:
- NBM, IV abx, analgesia, surgery
complications of diverticulitis
- Perforation
- Peritonitis
- Peridiverticular abscess
- Large haemorrhage requiring blood transfusions
- Fistula (e.g., between the colon and the bladder or vagina)
- Ileus / obstruction
mesenteric ischaemia
- caused by a lack of blood flow through the mesenteric vessels supplying the intestines, resulting in intestinal ischaemia
- 3 main branches of AA that supply abdo: coeliac artery, SMA, IMA
presentation of chronic mesenteric ischaemia
due to atherosclerosis
triad:
1. Central colicky abdominal pain after eating (starting around 30 minutes after eating and lasting 1-2 hours)
2. Weight loss (due to food avoidance, as this causes pain)
3. Abdominal bruit on auscultation
Ix and mx for chronic mesenteric ischaemia
- Ix: CT angio
- Mx: stop RFs, statins, antiplatelets, revascularisation by endovascular stent or open surgery
acute mesenteric ischaemia
- rapid blockage of SMA
- acute non specific abdo pain
- pain disproportionate to examination
- develop shock, peritonitis, sepsis, necrosis of bowel
- Mx: remove necrotic bowel + remove or bypass thrombus
bowel cancer prevalence
4th most common after breast, prostate and lung
Rf for bowel cancer
- FH
- Familial adenomatous polyposis (FAP)
- Hereditary nonpolyposis colorectal cancer (HNPCC)-Lynch syndrome
- IBD
- Increased age
- Diet (high in red processed meat and low fibre)
- Obesity and sedentary
- Smoking
- alcohol
what is Familial adenomatous polyposis (FAP)
AD
malfunction in tumour suppressor genes
polyps in large intestine
remove whole of large intestine
what is lynch syndrome
AD
higher risk of colorectal cancer
presentation of bowel cancer
- Change in bowel habit (usually to more loose and frequent stools)
- Unexplained weight loss
- Rectal bleeding
- Unexplained abdo pain
- Iron deficiency anaemia
- Abdo or rectal mass
2WW criteria for bowel cancer
- > 40 with abdo pain + unexplained weight loss
- > 50 with unexplained rectal bleeding
- > 60 with a change in bowel habit or iron deficiency anaemia
Bowel cancer screening
Faecal Immunochemical Test (FIT)
54-74 y/o
if +ve need colonoscopy
FAP, HNPCC or IBD get regular colonoscopies
Ix for bowel cancer
- colonoscopy(gold standard)
- sigmoidoscopy
- CT colonography
- Staging CT
- CEA
Classification of bowel cancer
TNM
TX – unable to assess size
T1 – submucosa involvement
T2 – involvement of muscularis propria (muscle layer)
T3 – involvement of the subserosa and serosa (outer layer), but not through the serosa
T4 – spread through the serosa (4a) reaching other tissues or organs (4b)
NX – unable to assess nodes
N0 – no nodal spread
N1 – spread to 1-3 nodes
N2 – spread to more than 3 nodes
Mx of bowel cancer
- surgical resection: right or left hemicol, high/low anterior resection,Hartmann
- chemo
- radiotherapy
- palliative
Colostomy vs ileostomy
Gastrostomy vs urostomy
- Colostomy: large intestine brought onto skin, drain solid stool, flatter to skin, in LIF
- Ileostomy: end of SB is brought to skin, drain liquid stool, have a spout, in RIF
- gastrostomy: feed directly into stomach, PEG
- urostomy: spout, RIF
Gallstones
- made of cholesterol
- complications of: acute cholecystitis, acute cholangitis, pancreatitis, obstructive jaundice
- block drainage of pancreas
cholecystitis v cholangitis v biliary colic
Cholecystitis: inflammation of the gallbladder
Cholangitis: inflammation of the bile ducts
Biliary colic: intermittent right upper quadrant pain caused by gallstones irritating bile ducts
RF for gallstones
4F
- fat
- fair
- female
- forty
presentation of gallstones
- Biliary colic
- Severe, colicky epigastric or RUQ pain
- triggered by meals (high fat meals)
- Lasting between 30 minutes and 8 hours
- associated with n&v
- ALP and bilirubin rise
- Ix: USS, MRCP
- Mx: ERCP, cholecystectomy
what is acute cholecystitis
inflammation of gallbladder
95% caused by gallstones
presentation of acute cholecystitis
- RUQ pain, can radiate to right shoulder
- fever, N&V
- tachycardia, CRP, WCC
- Murphy’s sign
Ix and Mx of acute cholecystitis
- Ix: USS, MRCP
- Mx: NBM, IV fluids, abx, ERCP, cholecystectomy
what is acute cholangitis
inflammation in bile ducts
causes: obstruction in bile ducts and infection during ERCP
common organisms:
- ecoli
- klebsiella
- enterococcus
charcot’s triad. in acute cholangitis
- RUQ pain
- fever
- jaundice (raised bilirubin)
Mx of acute cholangitis
- emergency admission
- IV fluids, blood cultures, IV abx
Imaging: (LS to MS)
- USS, CT, MRCP, ERCP
Mx- ERCP or percutaneous transhepatic cholangiogram
what is cholangiocarcinoma
- cancer originating in bile duct
- majority adenocarcinoma
- RF: PSC (+UC), liver flukes
presentation of cholangiocarcinoma
- obstructive jaundice
- pale stools, dark urine
- pruritus
- weight loss, RUQ pain, palpable gallbadder
- hepatomegaly
what is Courvoisier’s law
palpable gallbladder + jaundice = cholangiocarcinoma or pancreatic cancer
Ix for cholangiocarcinoma
HRCT thorax, abdo, pelvis
CA19-9
MRCP, ERCP
Mx of cholangiocarcinoma
early stage curative surgery
palliative: stent, surgery, chemo/radio, EOL care
pancreatic cancer features
- poor prognosis
- mostly adenocarcinoma in the head
- obstructive jaundice
- metastasise early
presentation of pancreatic cancer
- painless obstructive jaundice KEY
- pruritis
- upper abdo/back pain
- mass in epigastric region
- change in bowel habit
- new onset diabetes/worsening T2DM
2WW for pancreatic cancer
- > 40 + jaundice
- > 60 + weight loss +:
Diarrhoea
Back pain
Abdominal pain
Nausea
Vomiting
Constipation
New-onset diabetes
Ix for pancreatic cancer
- CT thorax, abdo pelvis
- CA19-9
- MRCP
- ERCP
- biopsy
what is a whipple procedure
- remove a tumour of the head of the pancreas that has not spread. Big procedure
Removes:
Head of the pancreas
Pylorus of the stomach
Duodenum
Gallbladder
Bile duct
Relevant lymph nodes
What is pancreatitis
acute: rapid, normal function returns
chronic: progressive and permanent deterioration
causes of pancreatitis
I GET SMASHED
- Idiopathic
- Gallstones KEY
- Ethanol KEY
- Trauma
- Steroids
- Mumps
- Autoimmune
- Scorpion bites
- Hyperlipidaemia
- ERCP KEY
- Drugs (furosemide, thiazide diuretics, azathioprine)
Presentation of pancreatitis
- severe epigastric pain
- Radiating through to the back
- vomiting
- Abdominal tenderness
- Systemically unwell
- Amylase 3x normal
- lipase (more sensitive/specific)
- USS
score for severity of pancreatitis
GLASGOW
Mx of acute pancreatitis
- IV fluids, analgesia
- abx if infection
complications of pancreatitis
- Necrosis of the pancreas
- Infection in a necrotic area
- Abscess
- Acute peripancreatic fluid collections
- Pseudocysts 4 weeks after acute pancreatitis
- Chronic pancreatitis
Cause of chronic pancreatitis
- MC is alcohol
- similar sx to acute but less intense and longer lasting
- Ix: CT
Mx of chronic pancreatitis
- abstain from alcohol/smoking
- analgesia
- Creon
- subcut insulin
- surgery
Femoral nerve injury
weak hip flexion, weak knee extension, and impaired quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh
what does lateral cutaneous nerve supply
- sensation to the anterior and lateral aspect of the thigh. Entrapment is commonly due to intra and extra pelvic causes.
- Mx: involves local anaesthetic injections.
duodenal atresia
- neonate
- double bubble sign AXR
- Few hours after birth
- Mx: Duodenoduodenostomy
Fitz Hugh Curtis syndrome
pelvic inflammatory disease (usually Chlamydia) causes the formation of fine peri hepatic adhesions
Imaging for biliary colic
USS abdo
what is angiodysplasia
- where abnormal blood vessels in the gastrointestinal tract can cause bleeding
- presents with painless bleeding and is not associated with abdominal pain or tenderness.
psoas abscess presentation
external rotation of the hip causes pain
rare
more likely with underlying pathology e.g. TB
anal fissure presentation
- <6 weeks = acute, chronic > 6 weeks
- painful, bright red, rectal bleeding
- at 12 and 6 position, if not think other cause
Mx of anal fissure
acute
- soften stool
- high-fibre diet with high fluid intake
- bulk-forming laxatives are first-line - if not tolerated then lactulose
- lubricants such as petroleum jelly
- topical anaesthetics
- analgesia
chronic anal fissure
- the above should be continued
- topical glyceryl trinitrate (GTN) 1st line
- if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
in colorectal surgery when do you give prophylactic abx
- at time of incision
