General Flashcards
Which respiratory measurements are reduced in the obese?
Tidal volume
Vital capacity
TLC
FRC
minute ventilation increased
Where in relation to the uterine artery does the ureter pass?
Posterior - ‘water under the bridge’
30d mortality of Haemorrhagic peptic ulcer?
8.6%
What is the required skin margin for a BCC?
5mm (95% clearance - 85% at 3mm)
If recurrent - 5-10mm
What is the most common cause of upper GI bleeding (in patients who have an OGD)?
Peptic ulcer (26%)
Then oesophagitis (17%)/gastritis (16%)/duodenitis (9%)
Varices (9%)
Malignancy (3%)
MW-tear (3%)
12% no cause found
Which nerve is often sacrificed in malignant parotid surgery?
Facial nerve
Which trace element is most important for wound healing?
Zinc
-copper less so
Within which ligament do the ovarian vessels run?
Suspensory ligament of ovary
May anastomose with uterine arteries in broad ligament
How do you insert a Sengstaken Blakemore tube (7)?
1) Insert to 50cm
2) inflate gastric balloon with increments of 100ml ensuring in stomach not oesophagus (i.e. gradual pressure increase), with IR to confirm position
3) Apply traction to balloon to OG junction (0.5-1kg)
4) If persistent bleeding inflated oesophageal balloon to 35-45mmHg
5) consider further traction up to 1.1kg if necessary
6) once haemostasis achieved, reduce pressure by 5mmHg every 3 hours and maintain at 24mmHg for 24 hours
7) Deflate balloon every 6 hours
What type Choledochal cyst is found with Caroli’s disease?
Type 5
What is the reversal agent for Dabigatran?
Idarucizumab
What are the characteristics of the Truelove and Witts criteria?
For acute severe colitis Frequency of blood stools >6 Temperature >37.8 Heart rate >90 Haemoglobin <10.5 ESR >30 (can exchange for CRP>30)
If signs of systemic toxicity the rate of colectomy goes from 8.5% –> 30% –> 48%
What is the typical threshold for radiological drainage of diverticular abscess?
4cm
What is the most common pathological organism in SBP in adults?
E.Coli and Klebsiella.
Consider prophylaxis with fluoroquinolones in high risk.
What is the eponymous name for a femoral hernia occurring behind the vessels?
Narath hernia
What is the evidence for use of SEMS for obstructing cancer?
The CREST trial (2019) - better short term outcomes and lower permanent stoma rate
What Ig crosses the placenta in RHD?
IgG
What is the daily recommended protein?
0.75g/kg
What is the most common site of sarcoma?
Extremeties in 40%
What cancers are associated with HPV 16/18?
Cervical cancer Anal cancer Penile cancer Vulval cancer Oropharyngeal cancer
What is the most common cause of visceral ischaemia?
Embolism (50%)
What are the types of BCC?
Nodular (commonest 60%, frequently on face)
Superficial (can use 5-FU)
Morpheaform (more aggressive, needs Mohs)
Cystic
Basosquamous (also more aggressive)
Which ovarian tumour type is most frequently associated with torsion?
Teratoma
What is the most common USS finding in ectopic pregnancy?
Adnexal mass (50-60%) Extrauterine gestational sac (35-50%) 20% can have intrauterine fluid collection - pseudosac
What is the maximum dosing of Bupivicaine?
2mg/kg - but based on IBW, so 150mg
= 30ml 0.5%
= 60ml 0.25%
Not affected by adrenaline as related to protein binding
How are choledochal cysts managed?
Usually with complete duct excision/reconstruction
Risk of pancreatitis, cholangitis, stricture, malignancy (6-30%, usually type 1/4a)
Infants also need early excision due to risk of liver fibrosis (<1month)
Risk of biliary malignancy persists after excision
Type 4 may need hepatectomy or liver transplant, others can usually be managed with Roux-en-y
Which blood group plasma products can be infused into any recipient?
Group AB (reverse of PRC transfusion)
What is the eponymous name for a type 5 Choledochal cyst?
Caroli’s disease
From which muscle does the cremaster arise?
Internal oblique
What are the maximal doses of LAs?
Lidocaine 3mg/kg - max 200mg
Lidocaine + Adrenaline 7mg/kg - max 500mg
Bupivicaine 2mg/kg to max of 150mg
Calculated by IBW
What kind of diathermy is used for ERCP?
Monopolar cutting (risk of bleeding)
What proportion of inguinal hernias will present as an emergency?
about 5%
What are the general indications for intubation? (4)
Lungs - O2, CO2, Work of breathing
Brain - aspiration risk or ICP control
Heart - failure or advanced support
Control - facilitate transfer/intervention
Where does Adrenaline exert its main effects?
Beta1 receptors
What are the characteristics of the flow phase of response to trauma?
Catabolic phase for 1-2 weeks Anabolic recovery phase for months -Negative nitrogen balance -Increased BMR/REE -Increased gluconeogenesis -Increased glucagon, insulin, cortisol, insulin resistance
What are the management considerations of large perforated peptic ulcers (>4cm)?
1) raises suspicion of malignancy
2) 10-16% of gastric perforations (1% of cancers)
3) For giant ulcers, resection and reconstruction recommended (may need damage control)
What conditions are associated with CDH1 mutation?
Diffused gastric cancer and lobular breast carcinoma
Which portal vein does not follow normal pattern of biliary drainage?
Left portal vein (embryological conduit between umbilical vein and ductus venous)
What is the treatment of choice for TPN extravasation?
Hyaluronidase to periphery of extravasation site (within 60 minutes)
Promotes tissue permeability
What is the initial management of acute severe colitis?
100mg IV Hydrocortisone QDS
Stool culture x 3 for C.Diff
Consider Flexi and biopsy for CMV
Consider AXR (>5.5cm = megacolon)
If still severe on D3 consider rescue - Infliximab, Cyclosporin or surgery
What degree of bleeding can be detected by a CT Angiogram
0.3ml/min
How frequently does extravasation associated with chemotherapy occur?
6% of cases
Of which 30% result in ulceration
What is the benefit of splenectomy in Beta Thalassaemia?
Can decrease transfusion requirement by 50%
What is the definition of massive bleeding? (5)
- Blood loss of 1/2 circulating volume in 3 hours
- Blood loss of entire circulating volume in 24 hours
- Ongoing blood loss of >150ml/min
- Transfusion of 4 units PRC in 4 hours with ongoing bleeding
- Transfusion of 10 units PRC in 24 hours
From which skin level is Breslow thickness measured?
top of stratum granulosum
What is the half life of albumin?
20 days
How is Aortic stenosis graded?
Pressure gradient and aortic valve area
Mild <25mmHg and >1.5cm valve area
Moderate 25-40, 1.0-1.5
Severe >40 <1
What is the most common cause of peritoneal catheter associated infections?
Coagulase negative Staphylococcus (Staph. epidermidis)
What is the recommended first line treatment for C.Diff
Oral Vancomycin (NICE 2021)
Then PO Fidaxomicin
Then PO Vancomycin + IV Metro
What are the types of Choledochal cysts?
5 types
1) Dilatation of CBD (80-90%)
2) Cystic diverticulum of CBD
3) Arising from duodenal CBD at ampulla
4) Cystic dilatations of both intra- and extra-hepatic biliary tree
4a) L/R HD and CBD (15%) L»R
4b) CHD and CBD
5) Cystic dilatation of intrahepatic biliary tree only
In what proportion of cases does sigmoid volvulus recur?
50-90% (endoscopic resolution in 70-80% of patients)
Contrast enemas successful in 5%
Rarely resolves spontaneously
What is the mechanism of action of linezolid and macrolides?
Inhibition of protein synthesis (50s subunit)
What are the potential complications of diverticular disease?
Diverticulitis Bleeding Fistula Perforation Abscess Phlegmon
Which trial described management of necrotising pancreatitis?
The PANTER trial described the step-up approach to management
What is the characteristic side effect of Anthracyclines?
Cardiotoxicity
-Doxorubicin, epirubicin
What is the best approach for repair of a small perforated peptic ulcer (<2cm)
No evidence of benefit to omental patch over suture closure
What management should be instituted in acute variceal haemorrhage
1) Resuscitation
2) Vasconstrictors - Terlipressin or somatostatin >octreotide
3) Antibiotics
4) OGD with Variceal Band Ligation
5) for patients with Childs B or Childs C <14 early covered TIPPS (<72hr)
2015 BSG Guidelines
How do Meckels diverticula most frequently present?
Obstruction (40-50%) Peptic Ulceration (25%) Acute Inflammation (20%)
With normal renal function, how long before elective surgery should Rivaroxaban be stopped?
If low risk 24 hours
If high risk 48 hours
Restart 6-12 hours if low risk, if high risk then 48 hours
What is the treatment for chemotherapy extravasation?
Stop infusion, aspirate
Elevate limb
Warm compress with vinca alkaloids (vincristine)
Cold compresses with doxorubicin
Which nerve is at risk in an anterior approach to hip?
Femoral
How is T3 subdivided in rectal cancer?
T3a - <1mm from muscularis propria
T3b - 1-5mm from muscularis propria
T3c - >5mm from muscularis propria
What are the potential areas of portosystemic shunt in portal hypertension (4)
1) Rectum - Superior rectal (IMV) –> Middle/inferior rectal (Pudendal –> EIV)
2) Paraumbilical - recanalised vestigial umbilical vein –> Left portal vein
3) Oesophagus - left gastric vein –> azygous
4) Intrahepatic - portal vein and IVC
How long should antibiotics be given for in perforated peptic ulcer?
if not severely ill, consider 3-5 days - long course did not have any benefit in recent RCT
Antifungals should be given if immunocompromised, elderly, comorbid or prolonged ITU stay. First line would be fluconazole, upgraded to caspofungin if previously received fluconazole
Which artery typically causes bleeding from duodenal ulcers?
Gastroduodenal artery (must be triple looped)
What are the main stages of wound healing?
Haemostasis (platelets, fibrin rich clot)
Inflammation (neutrophils, Growth factors, fibroblasts, macrophages)
Regeneration (fibroblasts and epithelial cells, angiogenesis, looks like graduation tissue)
Remodelling (longest phase, fibroblasts –> myofibroblasts –> wound contraction)
How are Hepatitis C, D and E diagnosed?
Usually RNA PCR
In which Haematological condition are irradiated blood products required life long?
Hodgkins Lymphoma
An investigator wishes to determine whether individuals who have irritable bowel syndrome were likely to have been admitted to hospital as children with appendicitis. Which study type is appropriate?
Case controlled study. Used when the individual of interest already has the disease
What kind of diathermy is used for colonoscopy polypectomy?
Synergised diathermy using blend mode
What are the components of the Glasgow Score for Pancreatitis?
PaO2<7.9 Age>55 WCC>15 Ca<2 Urea>16 LDH>600 Albumin<32 Glucose>10
What intestinal parasitic infection can present with respiratory/wheezing symptoms?
Strongyloides stercoralis
What is the mechanism of action of gentamicin?
Inhibition of the 30s ribosome
What is the characteristic metabolic finding of pyloric stenosis?
Hypokalaemic, hypochloremic metabolic alkalosis
What evidence is there for laparoscopic washout in diverticulitis?
The LADIES, SCANDIV and DILALA trials looked at this.
There was a lower permanent stoma rate, but much higher reintervention rate than patients undergoing a Hartmanns
Risk of missed perforation 30% and missed cancer 10%
What AntiA/B Ig is present in type O patients?
IgG (IgM for ABs)
What is the contents of cryoprecipitate (4)?
Factor 8
Factor 13
Fibrinogen
vWF
What is the most common organism in Shilgella infection?
Shigella soneii
Grame negative bacilli
Can give cipro if high risk
What is the cellular difference between acute and chronic inflammation
Acute - neutrophil dominant
Chronic - macrophage, plasma cells and lymphocytes
In whom do ovarian germ cell tumours tend to present?
Young patients <20 and AC/Asians
What general margin is required for sarcoma excision?
2cm
In patients with significant cardiac instability which anaesthetic agents may be favoured?
Etomidate (nb adrenal suppression, ponv)
Ketamine
Propofol and thiopentone can produce more cardiac depression
An abundance of free air is more likely seen with which visceral perforation?
Usually lower GI
What excision margins should be achieved with a BCC/SCC?
4mm sufficient (98% excision)
High risk SCC, size >2cm and poor differentiation –> 6mm
What is the enzymatic sequence for the creation of adrenaline?
Tyrosine –> Dopamine (by DOPA decarboxylase) –> NA –> A
What is the recommended treatment course for PID?
1 x 500mg IM Ceftriaxone + 14days of Doxy 100mgBD + Metro 400mg BD
What is the characteristic features of a contrast Xray for intestinal malrotation
Gasless abdomen, with corkscrew duodenum on contrast, with DJ flexure in RUQ
Usually isolated abnormality
Formation of LADDs band (caecum to RLQ retroperitoneum) and volving
1/500
What is the most frequent cause of acute Lower GI Bleeding?
Diverticular disease (50%) Angiodysplasia (40%)
Incidence of bleeding post polypectomy is 2%
85% resolve spontaneously
What are the types of opioid receptor?
δ (located in CNS)- Accounts for analgesic and antidepressant effects
k (mainly CNS)- analgesic and dissociative effects
Mu (central and peripheral) - causes analgesia, miosis, decreased gut motility
Nociceptin receptor (CNS)- Affect of appetite and tolerance to Mu agonists.
what type of bacteria is h.pylori?
Gram negative bacillus
How long before hernia repair should patients be advised to stop smoking?
4-6 weeks
Which botox is used clinically?
Botulinum toxin A
Inhibition of ACh release from NMJ
What are the three means of chronic inflammation?
Persistent infections (e.g. Mycobacterium TB) Prolonged exposure to no biodegradable substances (suture, silica) Autoimmune conditions
What proportion of liver volume is right side?
60%
What size mesh should be used for an umbilical hernia of size 1-4cm?
3cm overlap
What is the most common site of secondary TB?
The lungs
What does Prothrombin Complex Concentrate (octaplex/berriplex) contain
II, VII, IX and X along with protein C/S
Works more quickly than FFP - ?superceded by berriplex?
Which type of renal stone is most radio dense on plain X-ray?
Calcium phosphate
How do you confirm successful intubation?
End tidal CO2
What is the minimum acceptable mesh pore size?
> 1mm
What is the required excision margin for a skin SCC?
<2cm well differentiated - 4mm
>2cm, poor or face - 6-10mm
What are the indications for renal replacement therapy?
Diuretic resistant pulmonary oedema Refractory hyperkalaemia Metabolic acidosis Symptomatic uraemia Overdose of dialysable drugs
What is the rate of skip metastasis above the SLN in breast cancer?
3%
What is the most appropriate feeding strategy for patients with newly diagnosed Crohns disease?
Elemental - can induce remission in up to 80%
Where is most Na/water absorbed in the sb?
Ileum
What is the eponymous syndrome associated with adrenal haemorrhage?
Waterhouse-Friderichsen syndrome (fulminant meningoccemia)
What is the difference between lymphoedema praecox and lymphedema tarda?
Praecox presents in adolescence and tarda presents >35
What risk scores exist for Perforated peptic Ulcer?
Boey, PULP, ASA
NELA
Simple albumin is strongly prognostic
What are the indications for thoracotomy (5)?
- Haemothorax - >1500ml immediately or >200ml/hs for 2-4 hours
- Diaphragmatic/oesophageal laceration
- Widening of mediastinum >8cm
- Cardiac tamponade
- Large unevaluated clotted haemothorax
What are the different type of E.Coli infection?
Enteroinvasive - dysentery, large bowel necrosis/ulcers
Enterotoxigenic - SI, travellers diarrhoea
Enterohaermorrhagic - 0157, haemorrhage colitis, HUS and TTP
What degree of tumour shrinkage is implied by a partial response?
At least 50%
What fluid resuscitation should patients with burns receive?
Parkland formula - %burn x weight (kg) x 4
Give half in 8 hours then half in 16 hours
Rule of 9s for adults
Children similar but more for head and less for legs
What is the optimum treatment for gastric variceal bleeding?
Cyanoarcylate injection or thrombin
2015 BSG Guidelines
What is the optimum skin preparation agent?
2% alcoholic chlorhexidine
What is amifostine?
A chemotherapy adjunct which is used to:
- reduce nephrotoxicity of cisplatin
- reduce the proctitis with radiation
- reduce mucositis in head and neck cancers
What comprises a major haemorrhage protocol?
20ml/kg Blood
20ml/kg FFP
10ml/kg Platelets
5ml/kg Cryo
Aim for Hb>80, Platelets >75, Fibrinogen >1.5g/l (Cryo), INR<1.5 (FFP)
Nb TXA
What is the eponymous name of a hernia and hydrocele combined?
Gibbon hernia
From where are glomus tumours derived?
Tissue around AV shunts
What blood products should patients with variceal haemorrhage receive?
PRC target of 70-80g/l
Platelets if active bleeding and plt<50
FFP if fibrinogen <1g/L or PT/APTT>1.5
PCC for warfarinised patients
2015 BSG Guidelines
Why are neat alcohols not used for skin sterilisation?
Not sporicidal
What is the Hinchey classification of diverticulitis
1a) Pericolic inflammation
1b) Pericolic abscess
2a) Distant abscess amenable to drainage
2b) Complex abscess +/- fistula
3) Purulent peritonitis
4) Faecal peritonitis
What are the borders of a Petit hernia?
LD, Iliac crest and External oblique (inferior lumbar triangle)
From which AA are catecholamines primarily derived?
Tyrosine
What are the antiseptic preps of choice?
0.5% chlorhex in 70%alcohol hydrex
2% chlorhex in 70%alcohol (chloraprep)
What is hiflow nasal oxygen and its characteristics?
Ultra high flow oxygen rates - 50-60l/min
- humidified
- well tolerated
- T1RF (although can washout CO2)
- applies some PEEP due to flow rate
What is Bouveret’s syndrome?
Gastric outlet obstruction caused by gallstones
Which type of breast cancer is characterised by a lymphocytic infiltrate?
Medullary
What is the most common cause of intussusception?
Lymphoid hyperplasia in Peyer’s patches of gut. Most prominent in ileocolic segment
Other causes include Meckel’s diverticula, Duplication cysts, B cell lymphoma
Tend to present 2months to 2 years
When is oesophageal perforation most likely after ingesting Alkaline agents?
3 days. Perform OGD within 12-24 hours
What variables comprise the SOFA score (8)?
MAP GCS Creatinine Urine output Platelet count Bilirubin Inotrope use PaO2/FiO2 ratio
A Patey mastectomy requires division of which muscle?
Pectoralis minor
What is the diagnostic test for thalasaemia?
High performance liquid chromatography
What is the incidence of chronic pain after inguinal hernia repair?
10-15%
Which patients with melanoma should receive staging imaging?
IIC without SLNB or suspected III/IV
Consider MRI for <24
how does lidocaine work?
Blockade of axonal sodium channels
Types of hernias
1) Bochdalek
2) Obturator
3) Lumbar hernia
4) Richters Hernia
5) Morgagni Hernia
6) Littres Hernia
1) Most common congenital, 85% Left M>F, associated with lung hypoplasia
2) Hernia through obturator canal, F>M, behind pectinous muscle
3) Lumbar triangle (crest of ilium inferiorly, EO laterally and LD medially)
4) Antimesenteric border of bowel
5) Rare, herniation through foramen of Morgagni, more on right
6) Inguinal hernia containing Meckel’s diverticulum
what is the mechanism of action of TXA?
Prevents conversion of plasminogen to plasmin (and hence fibrin degradation)
Which artery can be encountered and is at risk during Femoral hernia repair (medially)
Obturator artery
What factors shift the oxygen-hb dissociation curve to the right?
Left shift = increased oxygen binding (decreased delivery)
Right shift = decreased oxygen binding (increased delivery)
CADET face right CO2 Avid DPG Exercise Temperature
What is the pathological process in HIT?
Antibodies to Heparin-Platelet 4 complex (HP4)
Which nerve is at risk in a posterior approach to the hip?
Sciatic (and both inferior/superior gluteal nerves)
What is Beck’s triad?
Pericardial tamponade
- Raised JVP
- Muffled heart sounds
- Narrow pulse pressure
What size of non-enhancing area of pancreas defines necrosis?
> 3cm
What are some characteristics associated with Choledochal cysts?
F:M = 4:1
Increased risk with anomalous pancreaticobiliary duct union (APBDU) or long common channel >10mm due to risk of enzyme reflux
80% present in childhood
What is the minimal amount of blood required to produce melaena?
60ml
How is the anion gap calculated?
(Na + K) - (Cl+HCO3)
Normal 10-18mmol/l
What are the components of the Rockall score?
Age
Shock
Comorbidities (CLD/CRF/malig worse than IHD/others)
Diagnosis (MW
What drains should be left after peptic ulcer repair?
Probably none, but could leave a suture site (WSES guidelines 2020)
What is the inheritance of Peutz Jeghers syndrome?
Autosomal dominant
What is Mackler’s triad?
Boerhaave’s syndrome
- Vomiting
- Pain
- SC emphysema
How does botox exert its effects?
Inhibition of release of Acetyl Choline into neuronal synapse
What are the physiological effects seen with laparoscopy?
Increased - airway pressure, V/Q mismatch, SVR
Decreased - FRC, pulmonary compliance, venous return
What are Kidney stones most frequently comprised of
40% Calcium oxalate
20% Calcium oxalate/phosphate
15% Calcium phosphate
15% Ammonium magnesium phosphate (Struvite)
10% Uric acid
What is the mechanism of action of unfractionated heparin?
Activation of antithrombin 3
which characteristics can be calculated from an art line?
Left ventricular contractility
Stroke volume
Peripheral vascular resistance
Fluid responsiveness
What is the cause of pinworm?
Enterobiasis vermicularis
With what tumours are Bartonella infections associated?
Vascular tumours such as haemangiosarcomas
What is Bergmans triad?
Fat embolism
- Dyspnoea
- Petechiae of axilla or thorax
- Altered mental status
In which inherited bleeding tendency is bleeding time increased?
von Willebrand’s disease (nb other platelet problems as well)
What is the eponymous name for a femoral hernia occurring anterior to the vessels?
Velpeau hernia
What is the MUST tool?
Assessment of malnutrition
BMI (if <18.5 = 2)+ Unplanned weight loss(0-5,5-10,10) + acute illness/no intake >5 days
Score of 2/more or at high risk
How should patients with UGI bleed be risk stratified?
Using the Glasgow-Blatchford score
0-1 - outpatient OGD
2-6 - I/P OGD
7+ - urgent I/P OGD
What is the mechanism of action of gentamicin and tetracyclines?
Inhibit protein synthesis by 30s subunit
In which situation are IgM Anti Heb B seen?
Acute infection
Which mutation is associated with BCCs in Gorlin’s syndrome?
PTCH1
In ABO incompatibility transfusion reactions in patients with blood type O what Ig is implicated?
IgG
How does bupivacaine work?
Binds to intracellular portion of sodium channels
Very cardiotoxic - contraindicated in regional
Levobupivicaine (chirocaine) less cardio toxic and causes less vasodilation
What is an important differential for pyogenic granuloma?
Amelanocytic melanoma
How does chlorhexidine work?
lysis of cell wall
What is Dieulafoys triad?
Appendicitis
- hyperaesthesia
- tenderness
- guarding
over McBurney’s point
What is the daily protein requirement?
0.8-1.5g/kg/day
When should patients undergo radiologically guided drainage of pancreatic necrosis?
> 30% necrosis for culture
How is cardiac output calculated?
CO = HR X SV
CO = MAP X SVR
What is the Neve supply to biceps femoris?
Tibial nerve (L5,S1,S2)
What are the different type of E.Coli infection?
Enteroinvasive - dysentery, large bowel necrosis/ulcers
Enterotoxigenic - SI, travellers diarrhoea
Enterohaermorrhagic - 0157, haemorrhage colitis, HUS and TTP
What is the difference between Lynch 1 and Lynch 2 syndromes?
Lynch 1 CRC only
Lynch 2 - others (inc ovarian, endometrial)
What are the characteristic findings of colonic CMV on biopsy
Multiple intranuclear inclusion biopsies on H&E
What are some premalignant skin lesions?
Extra-mammary Paget’s disease
Bowen’s disease
Cutenaous horm
Giant congenital pigmented naevus
Adenoma sebaceum is not (benign flat lesions in tuberous sclerosis)
What is the mechanism of action of quinolones and metronidazole?
Inhibit DNA synthesis
What percentage of paediatric splenic injuries can be managed conservatively?
90%
What should be done for secondary prophylaxis of oesophageal varies?
Repeat VBL 2-4 weekly until eradicated
NSBB
TIPPS if rebelled (PTFE Covered stents)
2015 BSG Guidelines
Which infections can be associated with splenomegaly?
EBV
Malaria
Leishmainasis
Infective endocarditis
(Not listeria)
What are the immediate physiological effects of laparoscopy?
Stretching of peritoneum –> vagal stimulation
Sinus Brady/nodal rhythm
Hypercarbia/acidosis
Where do congenital diaphragmatic hernias most frequently occur?
Posterolateral Bochdalek hernia Defect in pleuroperitoneal fold 78% Left 20% right 2%bilateral
What are the important determinants of a severe attack of pancreatitis?
1) Obesity
2) APACHE Score >8 in first 24 hours
3) After 48 hours any of:
CRP>150, Glasgow >3, persistent Organ failure
How are type 4 hypersensitivity reactions primarily mediated?
T cells
When should burn fluid resus be instituted?
> 15% BSA involvement (2nd degree or more)
What are the excision margins for melanoma (pTis, pT1, pT2, pT3, pT4)
Stage 0 - 0.5cm
Stage 1 - 1cm
Stage 2 - 2cm
pTis - 2-5mm
pT1 (0-1mm) 1cm
pT2 (1-2mm) 1-2cm
pT3 (2-4mm)/pT4 - 2cm
How long should Apixaban be discontinued prior to surgery
48 hours (half life is 12 hours)
For rivaroxaban and dabigatran probably 48-72 hours - variable half life
What is the most common place for inguinal hernias to recur?
47% Pubic tubercle
40% deep ring
13% entire back wall
What are the adverse consequences of massive transfusion?
Hypothermia
Hyperkalaemia
Acidosis
Hypocalcaemia
What anticoagulant can be used for prevention of VTE in patients with HIT?
Fondaparinux (Synthetic Xa inhibitor)
What is the T staging of melanoma?
Tis T0 T1 ≤1mm Breslow Thickness (to deepest point) T2 1-2mm T3 2-4mm T4>4mm
Ta/b if ulcerated
Which organ is most often injured in blunt abdominal trauma?
The spleen
How is pancreatic necrosis defined on CT?
> 3cm area of no contrast uptake
What size overlap of mesh for laparoscopic ventral hernias?
5cm
What is the reversal success rate after vasectomy?
55% if <10 years
In unstable patients, what are the risks of laparoscopy?
Increases in:
1) SVR
2) MAP
3) afterload
4) HR
5) IVC pressure
6) RR
7) Peak airway pressure
8) PaCO2
Decreases in:
1) SV
2) venous return
3) Thoracic compliance
Risk factors for PUD?
1) NSAIDS (inhibit prostaglandin synthesis)
2) Smoking (inhibits HCO3- and nicotine increases H+)
3) H.pylori
4) Bariatric marginal ulcer
5) Fasting
6) Drugs
7) Zollinger-Ellison syndrome (consider if recurrent and multiple)
8) Alcohol
In which types of sarcoma is neoadjuvant treatment used?
Ewings and Rhabdomyosarcoma
Through which defect do Morgagni hernias occur?
Anterior space of Larrey
Where are ectopic pregnancies most likely to occur?
Ampulla of Fallopian tube
What grading system is used for SCC?
Broder's grade Grade 1 - well 2 - moderate 3 - poor 4 - anaplastic
What are some causes of a raised anion gap acidosis?
Lactate: shock
Ketone: diabetic ketoacidosis, alcohol
Urate: renal failure
Acid poisoning: salicylates, methanol
What is the Forrest classification of peptic ulcer bleeding?
Acute Haemorrage
1a) Active spurter
1b) Active oozing
Signs of recent haemorrhage
2a) Non-bleeding visible vessel
2b) Adherent clot
2c) Flat fomented haematin on ulcer base
Lesions without active bleeding
3) Clean -based ulcer
What is the reversal agent for Rivaroxaban?
Andexanet alfa
What are some risk factors for PONV?
Female Smoker Previous history Opiates Hypotension Ophthalmic/gynae surgery
What ECG features may be seen with hypokalaemia?
U waves Small/absent T waves Prolonged PR interval ST depression Long QT interval
What factors does heparin administration affect?
2, 9, 10 and 11
What is the reinfarct rate if a GA is performed within 1 month of a MI?
32%
What is Meig’s syndrome?
Triad of benign ovarian tumour, ascites and pleural effusion that resolves after resection of tumour
What is the most accurate means of establishing burns coverage?
Lund Browder chart > Wallace rule of nines
Which mutations are associated with Polymerase ‘proof reading’ polyposis syndrome (PPAP)
POLD1/POLE genes
Which antiretroviral is most classically associated with pancreatitis?
Didanosine
What is the most common genetic influence on DVT?
FVL (7% prevalence)
Activated protein C deficiency
What are the characteristics of antithrombin deficiency?
AD
Rare
Heparin ineffective
10 x risk
What type of thrombosis is APL associated with?
Both arterial and venous
How does dopamine work at intermediate doses?
Dopamine has varying effects due to alpha-1, beta-1 and dopaminergic acitivity
2-10ug/kg/min
Mostly Cardiac
B-1 –> increased contractility and HR
Increased CO and D effects –> increased mesenteric blood flow
Mild vasoconstriction
How does CPAP differ from BIPAP?
CPAP continuous pressure of 10 (PEEP) up to 40-50% FiO2 (nb risk of aspiration)
Helps for T1RF
BIPAP dual level - PEEP + and inspiratory
the added hilevel helps for CO2 blow off in T2RF
What is the total body water composition in males?
60% of weight therefore 42kg of 70kg
2/3 intracellular
1/3 extracellular - 75% interstitial 25% intravascular
What is the risk of recurrent MI if surgery is conducted within 30 days of MI?
30%, 14% death
Decreases to:
- 7% at 2 months
- 4% at 3 months
- 9% at 6 months
What is the most common type of hepatitis in children?
Hepatitis A
RNA Picornovirus
Usually resolves spontaneously
Hepatitis A IgM
What is the minimum obligatory length of jejunum proximal to a jejunostomy required to avoid supplementary fluid/nutrition
100cm.
An investigator wishes to determine the prevalence of acute colitis within a defined population. Which study type is appropriate?
Cross-sectional
What are hedgehog inhibitors used for?
Metastatic unresectable BCCs
In which setting should DOACs be avoided?
APL
Which fingers tend to be affected most in Dupuytrens contracture?
Ring and little.
Middle may be affected in advanced cases. rarely index and thumb
Which type of renal tract stones are more likely to occur with short gut syndrome?
Calcium oxalate stones - increased colonic absorption of calcium oxalate
Which clotting factors are consumed most rapidly in DIC?
V and VIII
What are the typical constituents of TPN?
Glucose, lipids, electrolytes. (No albumin)
What cancers are associated with EBV?
Burkitt's lymphoma Hodgkin's lymphoma Post transfusion lymphoma Nasopharyngeal carcinoma Gastric
How can Hydatid cyst be classified?
Gharbi classification Type 1 - Purely cystic Type 2 - membrane partly detached Type 3 - Multicystic lesion with septae Type 4 - Degenerated with pseudo-solid appearances Type 5 Calcified cyst
What is the most common cause of vascular prosthetic infections?
Stap epidermis
What is the cause of hydatid cyst?
Echinococcus granulosus
Cestode with characterstic 3 segments
Rupture of mature cyst can cause reinfection or anaphylaxis
Two cyst walls - peri cyst (host) endocyst (organism)
Usually treat with mebendazole. Can use PAIR technique for multiple or deep seated if Type1/2
What is Riglers triad?
Gallstone ileus AXR
- SBO
- Gallstone
- Air in biliary tree
What is the key plasma mediator of DIC?
Tissue factor - rich in lungs, brain and placenta, not normally exposed to blood
TF triggers extrinsic and then intrinsic clotting pathways
How is SIRS defined?
Any two of:
T<36 or >38
HR>90
WCC>12 or <4 with >10% immature bands
RR>20 or PaCO2<4.26
What are 5 inotropic agents used in critical care?
Noradrenaline α agonist Vasopressor action, minimal effect on cardiac output
Adrenaline α and β receptor agonist Increases cardiac output and peripheral vascular resistance
Dopamine β1 agonist Increases contractility and rate
Dobutamine β1 and β2 agonist Increases cardiac output and decreases SVR
Milrinone Phosphodiesterase inhibitor Elevation of cAMP levels improves muscular contractility, short half life and acts as vasodilator
What ECG features may be seen with hyperkalaemia?
Peaked T waves
P wave flattening
Prolonged PR Interval
Widened QRS
What is Whipple’s triad?
Insulinoma
- Hypoglycaemia during attacks
- Resolution of symptoms with correction of blood glucose
- Symptomatic at low blood sugars
What proportion of patients with asymptomatic hernias will present with increasing or pain or complications within 5 years?
25%
What is the mechanism of action of Dabigatran?
Direct thrombin inhibition
Is family history associated with inguinal hernia development?
Yes
What are the components of the Glasgow Blatchford Score? (4+4)
Urea
Hb
SBP
HR
Maelena
CLD
CHF
Syndope
What is the most common cause of GORD?
Increased transit lower oesophageal sphincter relaxations
What type of ovarian cancer is strongly associated with BRCA?
Serous ovarian cancer - 10-20% risk of BRCA
Prior to low bleeding risk procedures what is an acceptable platelet level?
> 50
How can poorly differentiated skin SCCs be distinguished from melanoma?
Using S100 immunochemistry
In patients with an UGI bleed, how should anticoagulants be managed?
Continue aspirin
Stop P2Y12 inhibitors until haemostasis UNLESS stents (40% risk of death/mi if stopped <1year), aiming to restart within 5-7 days
Stop warfarin and DOACs (nb idarucizumab and andexanet)
BSG guidelines 2020
In ABO incompatibility transfusion reactions in patients with blood type A/B what Ig is implicated?
IgM
How is Giardiasis treated?
Metronidazole
What is the generic name for vicryl?
Polyglactin 910
How can superficial partial thickness and deep partial thickness burns be differentiated?
no blanching with deep partial thickness
Which familial condition is associated with papillary thyroid cancer?
FAP
What is Borchardt’s triad?
Gastric volvulus
- sudden epigastric pain
- inability to vomit
- inability to pass NG tube
What is the difference between hypertrophic and keloid scars?
Excessive collagen not bound to original injury in keloid
When should patients with perforated gastric ulcers have a repeat endoscopy?
6 weeks
What is Quicke’s triad?
Haemobilia
- Pain
- UGI Bleed
- Jaundice
What are some causes of normal anion gap metabolic acidosis?
GI HCO3 loss
Renal tubular acidosis
Drugs e.g. acetazolamide
Addisons disease
What are the characteristics of the ebb phase response to trauma?
- Increased sympathetic activity
- decreased BMR/energy expenditure
- increased gluconeogenesis/glycogenolysis
How long after placing a bare metal stent (cardiac) should surgery be delayed?
At least 1 month - 6 months for DES
Risk of sudden occlusion with BMS is less
Which type of renal stone is most radio dense?
Calcium phosphate
What is the inpatient mortality from variceal haemorrhage?
15%
What is the cure rate of splenectomy for ITP?
90%
What is Virchows triad
Risk of VTE
- Flow
- Vessel
- Coagulability
What is the most common cause of retroperitoneal abscess?
Renal infections (50%)
What innervation does the genital branch of the genitofemoral nerve provide?
Cremaster muscle and side of scrotum/labia
What is the incidence of a Meckels diverticulum?
2% (rule of 2s - 2inch/5cm long, 2feet (60cm) from IC valve - in ADULTS!, 2% incidence
What evidence is there fore laparoscopic approach to perforated peptic ulcer disease?
Meta-analysis of 8 RCTs by Cirocchi
Concluded less pain/wound infections, but similar major outcomes
What is Cushings triad?
Raised ICP
- bradycardia
- hypertension/raised PP
- Irregular respirations
What study reporting guidelines exist (6)?
CONSORT - RCT IDEAL - Surgical Innovation MOOSE - Meta-analysis of observational studies PRISMA - systematic Reviews STROBE - Observational studies TRIPOD - Predictive models
How is minor surgery managed in Haemophillia A?
Desmopressin immediately prior
Severe may require repeated infusions of product
How often is pneumococcal vaccine given post splenectomy?
5 yearly
What is the difference between a Sengstaken-Blakemore and Minnesota tube?
SSB has 3 ports (two balloons, one gastric aspiration channel)
Minnesota has 4 - extra oesophageal aspiration channel
Which clotting factors does Heparin prevent activation of?
2, 9, 10 and 11
How does the momentum induce haemostasis?
Abundance of tissue factor activating extrinsic coagulation pathway
Which nerve is at risk in a posterior approach to elbow?
Ulnar
In which patients should VHL be screened for?
CNS haemangioblastomas
How is an LA overdose treated?
Stop injecting High flow O2 CVS monitoring Lipid emulsion (intralipid 20%) at 1.5ml/kg over 1 minute Consider infusion at 0.25ml/kg/in
What is Sipple’s syndrome?
MEN2a
What is Bowens disease?
SCC insitu of skin
Full thickness atypic of dermal keratinocytes over a broad zone
Where is most of dietary iron absorbed?
Duodenum
What effect does chronic anaemia have on the O2Hb dissociation curve?
Shift to right as 2,3 DPG increased
What is the initial inflation pressure of a Sengstaken Blakemore tube?
35-40mmHg, then deflated to 25mmHg when bleeding stops
What is the mechanism of penicillins/cephalosporins?
Inhibition of cell wall formation
When should a sentinel lymph node biopsy be offered for malignant melanoma?
Breslow thickness >1mm
What proportion of circulating cortisol is protein bound
90%
What is the most common cause of biliary disease in HIV?
(Secondary) Sclerosing cholangitis
from infections e.g. CMV, Crypto, Microsporidia
What are the indications for transfer to burns centre?
> 15% BSA
Face/hands/genitals affected
Deep PT or FT burns
Significant electrical or chemical burns
What is the best treatment for primary prophylaxis of variceal haemorrhage in Cirrhotic liver disease?
For Grade 2 or 3 varices - Non cardio selective beta blockers - propranolol>nadolol>carvedilol
For grade 1 varices without red signs, repeat OGD 1 year
2015 BSG Guidelines
What is Becks triad?
For Cardiac tamponade - muffled heart sounds, raised JVP and low BP
What antibiotic prophylaxis is required for endoscopy?
Routine - none
CVS disease - none
Therapeutic procedures - ERCP, PEG, PEC, EUSFNA –> 1 x dose
What is MESNA?
A drug given to treat haemorrhagic cystic from cyclophosphamide
How does water appear in a T2 weighted MRI
T2 = Water White
If a non-operative approach is taken to perforated peptic ulcer, what treatments are required?
PPI
ABx
Anti-secretory (octreotide)
What proportion of pancreatitis is caused by alcohol?
25%
50% GS
25% others
What is the optimum treatment for diffuse gastric bleeding?
Argon plasma coagulation + PPI +/- proceed to surgery
What are the metabolic effects of adrenergic receptor agonism?
Alpha
- inhibits insulin release
- stimulates glycogenolysis
- stimulates glycolysis
Beta
- Stimulates glucagon
- Stimulates ACTH
- stimulates lipolysis
What are the greatest risk factors for rebreeding with UGI bleeds?
Active bleeding 100% Visible vessel 50% Non bleeding ulcer with clot 30-35% Oozing ulcer 10-27% Clean based ulcer <3%
What are the borders of a Grynfeltt hernia?
Quadratus lumborum, internal oblique muscle and 12th rib (Superior lumbar triangle)
In premenopausal women which tumour markers are helpful for complex ovarian masses?
AFP, Beta-HCG, LDH
What treatments are appropriate for UGI ulcer bleeds at endoscopy?
Combination therapy including Adrenaline injection +
1) Thermal method (APC or heater)
2) Clip
3) Fibrin or thrombin injection
PPI infusion
Biopsy to exclude cancer
Even in cancer, attempt endoscopic approaches first
How does dopamine work at high doses?
Dopamine has varying effects due to alpha-1, beta-1 and dopaminergic acitivity
10-20ug/kg/min
Vasoconstrictive (a1) and cardiac
May reduce renal and mesenteric blood flow
What is a Meckel’s diverticulum embryological origin?
Remnant of Vitelli intestinal duct (can be attached to umbilicus - rarely discharging)
At what threshold chance of identifying a mutation should BRCA screening be offered?
10% chance
An investigator wishes to determine whether individuals who work in one occupation are more likely to develop leukaemia than those in a different occupation. Which study type is most appropriate?
Cohort study - useful where groups are identified in advance of the condition
What conditions are associated with Dupuytren’s contracture?
Idopathic
Liver cirrhosis
Alcoholism
TB (historically)
What is the abnormality in patients with hereditary spherocytosis?
Spectrin deficiency –> RBC deformation
Risk of gallstones. Splenectomy when haemolytic crises increase
What is the most common cause of acute bacterial diarrhoea?
Campylobacter jejuni
Spiral/comma shaped Gram-ve rods
Usually affects TI >colon
Can mimic appendicitis
What is the failure rate for vasectomy?
1/2000
how do sarcomas primary spread?
Haematogenous (often lung)
How does dopamine work at low doses?
Dopamine has varying effects due to alpha-1, beta-1 and dopaminergic acitivity
Low does - <2ug/kg/min
- Mostly renal
- Increased blood flow (renal, cerebral, coronary and mesnteric due to vasodilatation (D receptors)
Which ovarian tumour subtype has the worst prognosis?
Clear cell carcinoma
What class of agent is 5-FU?
Antimetabolite (also Methotrexate, 6-mercaptopurine)
- S-phase drug mimic of uracil incorporated into RNA
- Skin changes, neurotoxicity, neuropathy, marrow suppression
What class of agent is Doxorubicin?
Anthracycline (Adriamycin)
- inhibits DNA/RNA synthesis
- Risks - cardiac toxicity dose related, AML
What type of agent is Etoposide?
Topoisomerase 2 inhibitor
What type of agent is Cisplatin?
Alkylating agent (also cyclophosphamide) Crosslinks DNA in G1 phase
Risks - myelosuppression, ototoxicity, nephrotoxicity
What type of agent is Vincristine?
Vinca alkaloid
M phase specific inhibition of microtubule formation
Main risk neurotoxicity
How does paclitaxel work?
Prevents microtubule breakdown in m phase
Main risk is neuropathy
What threshold HbA1c should be used to suggest referral for optimisation before elective surgery?
Above 8.5% or 69mmol/mol
CPOC guidelines 2021
How should metformin be managed in the preoperative period?
If taken 1-2 times per day – continue
If taken 3 times per day - omit lunchtime dose
If contrast used and eGFR<60, omit on day and for 48 hours
(CPOC guidelines 2021)
How should sulphonylureas be managed in the preoperative period?
Omit on morning of surgery
If AM operation and twice daily, can take PM
(CPOC guidelines 2021)
How should glitazones, DPP4 inhibitors (Gliptins) and GLP-1 receptor agonists (e.g. exenatide) be managed preoperatively?
Take as normal
Omit SGLT-2 inhibitors (e.g. dapagliflozin) on day of surgery
(CPOC guidelines 2021)
What glucose level defines hypoglycaemia?
<4mmol/l - ‘looming’ at 4-6
What is the cause of toxic shock syndrome?
Exotoxin mediated illness most commonly by group A Strep (usually bad skin infection empyema, septic arthritis, new fasc) or Staph Aureus (more likely with tampons etc - menstrual vs non-menstrual)
What are risk factors for toxic shock syndrome?
DM
Alcoholism
Injuries or surgical procedures
What blood tests might be suggestive of necrotising fasciitis?
CRP>150 WCC>25 Creatinine >141 Glucose >10 Hb<110 Sodium <135
Laboratory risk indicator for necrotising fasciitis (LRINEC)
What treatment is required after drainage of uncomplicated paronychia?
No antibiotics
What are risk factors for paronychia?
Trauma Artificial nails manicures Occupational Oncychocryptosis Onychophagia
What is the lymphatic drainage of the uterus?
Fundus runs with ovarian vessels mostly - so to para-aortic, however some may pass through round ligament to inguinal nodes
Lower body - broad ligament –> iliac nodes
What is the lymphatic drainage of the cervix?
3
- laterally through broad ligament –> EI nodes
- uterosacral fold –> presacral nodes
- posterolaterally –> iliac nodes
What is the diagnostic test for acute amoebic dysentery
Entamoeba histolytica stool ELISA
Which chemotherapeutic agent causes dose related lung damage?
Bleomycin
Which chemotherapeutic agent causes loss of deep tendon reflexes?
Vincristine
Also paralytic ileum, sensory motor neuropathy
Which chemotherapeutic agent causes conjunctivitis and cerebellar toxicity?
Cytosine arabinoside
Which chemotherapeutic agent causes dose related pancreatitis?
Asparginase
What are the myotomes associated with reflexes - Biceps, Triceps, Supinator, Knee and Ankle?
Biceps - C5/6 Triceps - C7/8 Supinator - C5/6 Knee - L3/4 Ankle - S1/2
Through which receptor does erythromycin exert its pro kinetic effects?
Motilin receptor
What are the types of Necrotising Fasciitis?
Type 1 - polymicrobial (dm, immuno)
Type 2 - usually strep
Type 3 marine
Type 4 fungal
How is sepsis defined in the SEPSIS 3 consensus?
Life-threatening organ dysfunction caused by a dysregulated host response to infection
What is the expected HbA1c threshold for elective surgery?
69mmol/l (8.5%)
What is an appropriate tidal volume for ventilated patients with ARDS?
low volume 6ml/kg (as opposed >10ml/kg)
In septic shock, when is Sodium bicarb indicated?
pH≤7.2 and AKI 2-3
In sepsis when should enteral feeding be instituted?
within 72 hours
Which muscle abducts the vocal cords?
Posterior cricoarytenoid (innervated by RLN)
