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Finals > Gen Surg > Flashcards

Gen Surg Flashcards

1
Q

DDx of generalised abdo pain

A
  • peritonitis
  • ruptured AAA
  • intestinal obstruction
  • ischaemic colitis
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2
Q

DDx RUQ pain

A
  • Biliary colic
  • Acute cholecystitis
  • Acute cholangitis
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3
Q

DDx epigastric pain

A
  • Acute gastritis
  • Peptic ulcer disease
  • Pancreatitis
  • Ruptured AAA
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4
Q

Ddx central abdominal pain

A
  • Ruptured AAA
  • Intestinal obstruction
  • Ischaemic colitis
  • Early stages of appendicitis
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5
Q

DDx LIF pain

A
  • ectopic pregnancy
  • diverticulitis
  • Ruptured ovarian cyst
  • Ovarian torsion
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6
Q

DDx RIF pain

A
  • Acute appendicitis
  • Ectopic pregnancy
  • Ruptured ovarian cyst
  • Ovarian torsion
  • Meckel’s diverticulitis
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7
Q

DDx suprapubic pain

A
  • urinary retention
  • lower UTI
  • Pelvic inflammatory disease
  • Prostatitis
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8
Q

DDx loin to groin pain

A
  • Renal colic (kidney stones)
  • Ruptured AAA
  • Pyelonephritis
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9
Q

DDx testicular pain

A
  • testicular torsion
  • epididymo-orchitis
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10
Q

what is peritonitis

A

inflammation of the peritoneum, the lining of the abdomen

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11
Q

signs of peritonitis

A
  • guarding
  • rigidity
  • rebound tenderness
  • coughing test
  • percussion tenderness
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12
Q

Spontaneous bacterial peritonitis

A
  • associated with spontaneous infection of ascites in patients with liver disease
  • Mx: broad-spectrum antibiotics
  • poor prognosis
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13
Q

signs and sx of appendicitis

A
  • 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
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14
Q

Ix for appendicitis

A
  • inflammatory markers
  • USS
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15
Q

what is Meckel’s diverticulum

A
  • 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
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16
Q

what is mesenteric adenitis

A
  • 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
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17
Q

presentation of mesenteric adenitis

A
  • Crampy abdominal pain
  • poor appetite
  • sore throat
  • fever
  • cervical lymphadenopathy
  • tenderness in the RIF
  • usually in younger children
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18
Q

is SBO or LBO more common

A

small bowel obstruction

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19
Q

causes of bowel obstruction

A

Big 3 (90%)
1. adhesions (SB)
2. hernias (SB)
3. malignancy (LB)

Others
- volvulus (LB)
- diverticular disease
- strictures
- intusussusception

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20
Q

main causes of intestinal adhesions

A
  • Abdominal or pelvic surgery (particularly open)
  • Peritonitis
  • Abdominal or pelvic infections (e.g., PID)
  • Endometriosis
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21
Q

what is closed loop bowel obstruction

A
  • two points of obstruction along the bowel
  • expands, ischaemia, perforation
  • emergency surgery
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22
Q

presentation of bowel obstruction

A
  • vomiting (green bilious)
  • abdominal distension
  • diffuse abdo pain
  • constipation and lack of flatulence
  • tinkling bowel sounds
  • AXR: 3:6:9 SB:colon:caecum
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23
Q

what are valvulae conniventes

A
  • in small bowel
  • mucosal folds that form lines extending the full width of the bowel
  • AXR: line across entire width
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24
Q

what are haustra

A
  • in large bowel
  • pouches formed by the muscles in the walls
  • lines do not extend full width
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25
Q

Mx of bowel obstruction

A
  • drip and suck. NBM, IV fluids and NG tube with drain
  • exploratory surgery
  • stents can be used
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26
Q

what is an ileus

A
  • in small bowel
  • normal peristalsis stops
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27
Q

causes of ileus

A
  • injury to bowel
  • handling during surgery
  • inflam/infection
  • electrolyte imbalance
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28
Q

sx of ileus

A

similar to bowel obstruction
- Vomiting (green bilious)
- Abdominal distention and pain
- constipation and no flatulence
- Absent bowel sounds (as opposed to “tinkling” in obstruction)

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29
Q

Ix for post operative ileus

A

Deranged electrolytes can contribute to the development: check potassium, magnesium and phosphate

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30
Q

Mx of ileus

A
  • treat cause
  • supportive
  • NBM, IV fluids
  • NG if vomiting, TPN
  • mobilise
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31
Q

what is a volvulus

A
  • bowel twists around itself and the mesentery that it is attached to
  • close loop BO –>necrosis and perforation
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32
Q

types of volvulus

A
  • caecal
  • sigmoid
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33
Q

sigmoid volvulus features

A
  • more common
  • affects sigmoid colon
  • chronic constipation
  • assoc with high fibre diet and laxatives
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34
Q

caecal volvulus features

A
  • less common
  • younger patients
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35
Q

RF for volvulus

A
  • Neuropsychiatric disorders (e.g., Parkinson’s)
  • Nursing home residents
  • Chronic constipation
  • High fibre diet
  • Pregnancy
  • Adhesions
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36
Q

Presentation of volvulus

A

similar to BO
- Vomiting (green bilious)
- Abdominal distention
- Diffuse abdominal pain
- Absolute constipation and lack of flatulence

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37
Q

Mx of volvulus

A
  • conservative: endoscopic decompression
  • flexible sigmoidoscope
  • laparotomy
  • Hartmann’s procedure
  • ileocaecal resection or right hemicolectomy for caecal
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38
Q

Complications of hernias

A
  • incarceration (cannot be reduced, leads to O&S)
  • obstruction (blockage of faeces)
  • strangulation (non-reducible and blood supply gone)
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39
Q

Richter’s hernia

A
  • 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
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40
Q

Maydl’s Hernia

A

two different loops of bowel are contained within the hernia.

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41
Q

Mx of hernias

A
  • conservative
  • tension free repair (mesh)
  • tension repair (suture)
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42
Q

Inguinal hernias

A
  • 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
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43
Q

Femoral hernias

A
  • 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
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44
Q

incisional hernias

A
  • at site of previous surgery
  • difficult to repair
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45
Q

umbilical hernias

A
  • defect in the muscle around the umbilicus
  • common in neonates
  • resolve spontaneously by 3y/o
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46
Q

epigastric hernias

A

hernia in the epigastric area (upper abdomen)

47
Q

spigelian hernias

A
  • etween the lateral border of the rectus abdominis muscle and the linea semilunaris
  • Dx via USS
48
Q

hiatus hernias

A
  • 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)
49
Q

Hiatus hernia RF

A
  • age
  • obesity
  • pregnancy
50
Q

Presentation of hiatus hernias

A
  • dyspepsia (indigestion)
  • Heartburn
  • Acid reflux + reflux of food
  • Burping + Bloating
  • Halitosis (bad breath)
51
Q

Mx of hiatus hernias

A

conservative
surgical: lap fundoplication

52
Q

haemorrhoids

A
  • enlarged anal vascular cushions (control anal continence)
  • assoc with constripation and straining
  • MC in pregnancy, obesity, increased age, increased abdo pressure
53
Q

where are anal cushions located

A

clock face 3, 7 and 11

54
Q

classification of haemorrhoids

A
  • 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
55
Q

Sx of haemorrhoids

A
  • 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
56
Q

Mx of haemorrhoids

A
  • topical: reduce swelling. Anusol
  • increase fibre, laxatives, fluids
  • rubber band ligation
  • injection sclerotherapy
  • haemorrhoidal artery ligation, haemorrhoidectomy
57
Q

diverticulum, diverticulosis, diverticulitis

A
  • 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
58
Q

diverticulosis

A
  • 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
59
Q

acute diverticulitis presentation

A
  • Pain + tenderness in the LIF
  • Fever
  • Diarrhoea, N&V
  • Rectal bleeding
  • Palpable abdominal mass (if an abscess has formed)
  • Raised inflammatory markers and WCC
60
Q

Mx of diverticulitis

A

uncomplicated:
- oral co-amox, analgesia
complicated:
- NBM, IV abx, analgesia, surgery

61
Q

complications of diverticulitis

A
  • Perforation
  • Peritonitis
  • Peridiverticular abscess
  • Large haemorrhage requiring blood transfusions
  • Fistula (e.g., between the colon and the bladder or vagina)
  • Ileus / obstruction
62
Q

mesenteric ischaemia

A
  • 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
63
Q

presentation of chronic mesenteric ischaemia

A

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

64
Q

Ix and mx for chronic mesenteric ischaemia

A
  • Ix: CT angio
  • Mx: stop RFs, statins, antiplatelets, revascularisation by endovascular stent or open surgery
65
Q

acute mesenteric ischaemia

A
  • 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
66
Q

bowel cancer prevalence

A

4th most common after breast, prostate and lung

67
Q

Rf for bowel cancer

A
  • 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
68
Q

what is Familial adenomatous polyposis (FAP)

A

AD
malfunction in tumour suppressor genes
polyps in large intestine
remove whole of large intestine

69
Q

what is lynch syndrome

A

AD
higher risk of colorectal cancer

70
Q

presentation of bowel cancer

A
  • 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
71
Q

2WW criteria for bowel cancer

A
  • > 40 with abdo pain + unexplained weight loss
  • > 50 with unexplained rectal bleeding
  • > 60 with a change in bowel habit or iron deficiency anaemia
72
Q

Bowel cancer screening

A

Faecal Immunochemical Test (FIT)
54-74 y/o
if +ve need colonoscopy
FAP, HNPCC or IBD get regular colonoscopies

73
Q

Ix for bowel cancer

A
  • colonoscopy(gold standard)
  • sigmoidoscopy
  • CT colonography
  • Staging CT
  • CEA
74
Q

Classification of bowel cancer

A

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

75
Q

Mx of bowel cancer

A
  • surgical resection: right or left hemicol, high/low anterior resection,Hartmann
  • chemo
  • radiotherapy
  • palliative
76
Q

Colostomy vs ileostomy
Gastrostomy vs urostomy

A
  • 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
77
Q

Gallstones

A
  • made of cholesterol
  • complications of: acute cholecystitis, acute cholangitis, pancreatitis, obstructive jaundice
  • block drainage of pancreas
78
Q

cholecystitis v cholangitis v biliary colic

A

Cholecystitis: inflammation of the gallbladder
Cholangitis: inflammation of the bile ducts
Biliary colic: intermittent right upper quadrant pain caused by gallstones irritating bile ducts

79
Q

RF for gallstones

A

4F
- fat
- fair
- female
- forty

80
Q

presentation of gallstones

A
  • 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
81
Q

what is acute cholecystitis

A

inflammation of gallbladder
95% caused by gallstones

82
Q

presentation of acute cholecystitis

A
  • RUQ pain, can radiate to right shoulder
  • fever, N&V
  • tachycardia, CRP, WCC
  • Murphy’s sign
83
Q

Ix and Mx of acute cholecystitis

A
  • Ix: USS, MRCP
  • Mx: NBM, IV fluids, abx, ERCP, cholecystectomy
84
Q

what is acute cholangitis

A

inflammation in bile ducts
causes: obstruction in bile ducts and infection during ERCP

common organisms:
- ecoli
- klebsiella
- enterococcus

85
Q

charcot’s triad. in acute cholangitis

A
  • RUQ pain
  • fever
  • jaundice (raised bilirubin)
86
Q

Mx of acute cholangitis

A
  • emergency admission
  • IV fluids, blood cultures, IV abx

Imaging: (LS to MS)
- USS, CT, MRCP, ERCP

Mx- ERCP or percutaneous transhepatic cholangiogram

87
Q

what is cholangiocarcinoma

A
  • cancer originating in bile duct
  • majority adenocarcinoma
  • RF: PSC (+UC), liver flukes
88
Q

presentation of cholangiocarcinoma

A
  • obstructive jaundice
  • pale stools, dark urine
  • pruritus
  • weight loss, RUQ pain, palpable gallbadder
  • hepatomegaly
89
Q

what is Courvoisier’s law

A

palpable gallbladder + jaundice = cholangiocarcinoma or pancreatic cancer

90
Q

Ix for cholangiocarcinoma

A

HRCT thorax, abdo, pelvis
CA19-9
MRCP, ERCP

91
Q

Mx of cholangiocarcinoma

A

early stage curative surgery
palliative: stent, surgery, chemo/radio, EOL care

92
Q

pancreatic cancer features

A
  • poor prognosis
  • mostly adenocarcinoma in the head
  • obstructive jaundice
  • metastasise early
93
Q

presentation of pancreatic cancer

A
  • painless obstructive jaundice KEY
  • pruritis
  • upper abdo/back pain
  • mass in epigastric region
  • change in bowel habit
  • new onset diabetes/worsening T2DM
94
Q

2WW for pancreatic cancer

A
  • > 40 + jaundice
  • > 60 + weight loss +:

Diarrhoea
Back pain
Abdominal pain
Nausea
Vomiting
Constipation
New-onset diabetes

95
Q

Ix for pancreatic cancer

A
  • CT thorax, abdo pelvis
  • CA19-9
  • MRCP
  • ERCP
  • biopsy
96
Q

what is a whipple procedure

A
  • 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

97
Q

What is pancreatitis

A

acute: rapid, normal function returns
chronic: progressive and permanent deterioration

98
Q

causes of pancreatitis

A

I GET SMASHED
- Idiopathic
- Gallstones KEY
- Ethanol KEY
- Trauma
- Steroids
- Mumps
- Autoimmune
- Scorpion bites
- Hyperlipidaemia
- ERCP KEY
- Drugs (furosemide, thiazide diuretics, azathioprine)

99
Q

Presentation of pancreatitis

A
  • severe epigastric pain
  • Radiating through to the back
  • vomiting
  • Abdominal tenderness
  • Systemically unwell
  • Amylase 3x normal
  • lipase (more sensitive/specific)
  • USS
100
Q

score for severity of pancreatitis

A

GLASGOW

101
Q

Mx of acute pancreatitis

A
  • IV fluids, analgesia
  • abx if infection
102
Q

complications of pancreatitis

A
  • Necrosis of the pancreas
  • Infection in a necrotic area
  • Abscess
  • Acute peripancreatic fluid collections
  • Pseudocysts 4 weeks after acute pancreatitis
  • Chronic pancreatitis
103
Q

Cause of chronic pancreatitis

A
  • MC is alcohol
  • similar sx to acute but less intense and longer lasting
  • Ix: CT
104
Q

Mx of chronic pancreatitis

A
  • abstain from alcohol/smoking
  • analgesia
  • Creon
  • subcut insulin
  • surgery
105
Q

Femoral nerve injury

A

weak hip flexion, weak knee extension, and impaired quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh

106
Q

what does lateral cutaneous nerve supply

A
  • 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.
107
Q

duodenal atresia

A
  • neonate
  • double bubble sign AXR
  • Few hours after birth
  • Mx: Duodenoduodenostomy
108
Q

Fitz Hugh Curtis syndrome

A

pelvic inflammatory disease (usually Chlamydia) causes the formation of fine peri hepatic adhesions

109
Q

Imaging for biliary colic

A

USS abdo

110
Q

what is angiodysplasia

A
  • where abnormal blood vessels in the gastrointestinal tract can cause bleeding
  • presents with painless bleeding and is not associated with abdominal pain or tenderness.
111
Q

psoas abscess presentation

A

external rotation of the hip causes pain
rare
more likely with underlying pathology e.g. TB

112
Q

anal fissure presentation

A
  • <6 weeks = acute, chronic > 6 weeks
  • painful, bright red, rectal bleeding
  • at 12 and 6 position, if not think other cause
113
Q

Mx of anal fissure

A

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

114
Q

in colorectal surgery when do you give prophylactic abx

A
  • at time of incision

Finals (26 decks)

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