Gen Surg - Others

Question 1

what are haemorrhoids

Answer 1

normal vascular and CT columns that exist in the anal canal — there are 3 in total

split into internal and external haemorrhoids — internal = above dentate line; external = below dentate line
internal = can bleed or prolapse
external = can thrombose

Question 2

what causes haemorrhoids

Answer 2

poor dietary habits
constipation — prolonged straining
increased intra-abdominal P

Question 3

what are the 4 degree of internal haemorrhoids

Answer 3

1st degree: bleeds only
2nd degree: prolapses BUT reduces spontaneously
3rd degree: prolapses BUT has to be manually reduced
4th degree: permanently prolapsed — may strangulate

Question 4

how does thrombosed external haemorrhoids present + how to manage

Answer 4

presentation : acute excruciating pain

Tx: surgical evacuation of haemorrhoid + excision of skin overlying

Question 5

how would u manage internal haemorrhoids that is bleeding/prolapsed

Answer 5

conservative Tx
secondary prevention
only evacuate when the natural desire to do so arises
minimise straining or lingering
increased dietary fibre
increased physical activity
sitz baths — warm water + 3x a day
(to clean perineum)

medical Tx
laxatives — stool softeners or bulking agents
topical analgesia + steroids
injection sclerotherapy —- for 1st or 2nd degree
rubber band ligation —- for 2nd degree
trans-anal haemorrhoidal dearterialisation — for 2nd & 3rd degree

surgical Tx = haemorrhoidectomy

Question 6

what are anal fissures

Answer 6

longitudinal split of the anoderm in the distal anal canal — extending from the anal verge proximally — towards (but not extending beyond) the dentate line

Question 7

what causes anal fissures

Answer 7

primary causes = local trauma
passage of hard stool
prolonged diarrhoea
vaginal delivery
anal sex

secondary causes
IBD — eg. CD
granulomatous diseases — eg. extrapulmonary TB, sarcoidosis
malignancy — eg. squamous cell anal ca, leukaemia
communicable diseases — eg. HIV, syphillis, chlamydia

Question 8

what defines acute or chronic anal fissure

Answer 8

acute = <6 wks of onset
chronic = >6wks of onset OR certain features
eg. fibrosis, fibrotic edges, perianal skin tag

Question 9

how do anal fissures present

Answer 9

pain — exacerbated by defecation
+/- bleeding
+/- perianal skin tags
+/- puritus ani

Question 10

how to manage anal fissures

Answer 10

conservative Tx = prevention
healthy bowel habits
high fibre diet
adequate fluids

medical Tx
laxatives
warm sitz baths — ie local wound care
analgesia

Question 11

what is an anal fistula

Answer 11

fistula: chronic abnormal connection between 2 epithelial-lined surfaces
anal fistula is when a fistula forms between the anus and an adjacent structure

Question 12

what can cause anal fistulas

Answer 12

anorectal abscess —- ruptures or is drained
CD
lymphogranuloma venereum
radiation proctitis
rectal foreign bodies
primary perianal actinomycosis

Question 13

how would an anal fistula present

Answer 13

symptoms (Hx)
intermittent rectal pain
chronic purulent discharge
pustule-like lesion in the peri-anal or buttock area
intermittent + malodorous perianal drainage & pruritus

signs (exam)
perianal skin — excoriated + inflamed
induration just below skin
proctosigmoidoscopy

Question 14

what classification used for anal fistulas

Answer 14

park’s classification
intersphincteric
trans-sphincteric
extrasphincteric
suprasphincteric

Question 15

management of anal fistulas

Answer 15

EUA examination under anaesthesia

options
fistulotomy
fistulectomy
seton insertion
advancement flap
plus and glues

Question 16

causes of upper GIB

Answer 16

peptic ulcers 36%
oesophagitis 24%
gastritis 22%
varices 11%

Question 17

risk factors for upper GIB

Answer 17

chronic liver disease
alcohol
smoking
NSAIDs
vomiting
steroids
PUD

Question 18

Ix for upper GIB

Answer 18

bloods
FBC
U&E
GXM if severe
coag profile
ABG + lactate

OGD

CT angiogram

Question 19

scoring system for upper GIB

Answer 19

Glasgow Blatchford scoring system
predicts need for intervention in upper GIB

Question 20

management of upper GIB

Answer 20

IV PPI bolus/transfusion

if stable = GI endoscopy in 24 hrs

if unstable = urgent endoscopy
stop haemorrhage via haemostatic clips, adrenaline injections, haemostatic powder

if massive haemorrhage = ABCDs
2 large bore 14-16G IV cannulas
transfuse IV crystalloids, if severe = unmatched O -ve blood initially —- matched blood once available
activate massive transfusion protocol
balanced transfusion — 1:1:1 RCC, FFP, platelets
reverse any anticoags + correct any underlying coag deficits

if suspected variceal bleeding = IV terlipression + octreotide
+/- Sengstaken-Blakemore tube (in ED setting)
OGD for variceal banding
+/- TIPS Transjugular intrahepatic portosystemic shunt

Question 21

what is dysphagia and odynophagia and what are their DDx

Answer 21

dysphagia: difficulty swallowing
odynophagia: painful swallowing

DDx

intraluminal
foreign body
food bolus
oesophageal webs

intramural
lump — benign vs malignant
GERD
oesophagitis
dysmotility disorders
scleroderma
stricture
eosinophilic oesophagitis
neuro
hiatal hernia
volvulus

extraluminal
lymphadenopathy
goitre
pharyngeal pouch
haematoma

others
oesophageal rupture
Mallory-Weiss tear
oesophageal ulcers

Question 22

what is GERD

Answer 22

it is a condition that develops when reflux of stomach contents causes troublesome symptoms and/or complications

Question 23

risk factors of GERD

Answer 23

causes of increased intra-abdominal P
obesity
pregnancy

causes of loss of anti-reflux mechanisms
alcohol
smoking
fam Hx
DM
hiatal hernia
oesophageal dysmotility
gastric dysfunction
meds

Question 24

Ix for GERD

Answer 24

urease breath test — for H.pylori

Upper GI Endoscopy

contrast swallow

ambulatory pH and impedence monitoring

oesophageal manometry

Question 25

management of GERD

Answer 25

conservative Tx
lifestyle — reduce alcohol, smoking cessation, weight loss
review meds causing dyspepsia – eg. NSAIDs

medical Tx
PPIs —- if ineffective = add H2 antagonist
metoclopramide/domperidone —prokinetic agent
Tx of H.pylori if present

surgical Tx = laparoscopic Nissen (360 degrees) fundoplication

Question 26

what is Barrett’s oesophagus

Answer 26

when the normal squamous epithelial lining of the distal oesophagus changes to metaplastic columnar epithelium

Question 27

risk factors of barrett’s oesophagus

Answer 27

smoking
alcohol
obesity
white
male
>50 y/o

Question 28

management of barrett’s oesophagus

Answer 28

high dose PPI — symptom control
aspirin – reduces progression to high grade dysplasia

monitoring: surveillance endoscopy

Question 29

what is a hiatal hernia

Answer 29

the displacement of part or all of the stomach through the oesophageal hiatus

Question 30

what types of upper GI hernias are there

Answer 30

type 1: sliding hiatal hernia
2-3: para-oesophageal hernia — incl rolling hernia
4: intrathoracic herniation of abdominal viscera

Question 31

presentation of hiatal hernia

Answer 31

asymptomatic 50%

symptomatic (Hx)
epigastric or chest pain
heartburn, regurgitation
post-prandial fullness
dysphagia

iron deficiency anaemia

Question 32

Ix for suspected hiatal hernia

Answer 32

CXR
contrast swallow
CT TAP
oesophageal manometry — to guide choice of fundoplication

note: NO OGD!!!

Question 33

management of hiatal hernias

Answer 33

conservative Tx = weight loss, smoking cessation, alcohol reduction

medical Tx
PPIs
domperidone — prokinetic agent

surgical Tx
indication: symptomatic
most common = laparoscopic transabdominal repair

if emergency presentation of gastric volvulus =NG tube decompression
failure = urgent surgical repair

Question 34

complications of hiatal hernia

Answer 34

GERD
anaemia
gastric outlet obstruction
gastric volvulus
gastric ischaemia