General Flashcards
What are the components of the WHO Checklist?
Three phases.
Sign in - led by anaesthetist, check the patient in, machine checks, anaesthetic concerns
Time out - led by surgeon, patient check, antibiotics, equipment check and sterility, VTE plan
Sign out - led by scrub team, procedure check, counts, specimens, equipment problems, postoperative plan
What is the audit cycle?
Identify issue
Define standards
Collect data
Analyse/interpret data
Implement change
Reaudit
How should patients with a pacemaker or ICD be managed intraoperatively?
Establish make and model
Ensure has had review by cardiac physiologist within 3 months and discuss case with them
Avoid diathermy, particularly monopolar, keep to short bursts or use ultrasonic dissectors
Some pacemakers can be deactivated by magnets, but not all.
How do cutting and coagulation diathermy work?
Passing high frequency AC to produce heat - 300kHz –> 10MHz
-Cutting = continuous low frequency
-Coag = intermittent high frequency
-Blend = continuous low frequency + intermittent high frequency
What is the difference between monopolar and bipolar diathermy?
Monopolar –> instrument –> patient –> plate (70cm2) (high power 400W)
Bipolar –> forceps ends (low power 50W)
How may groin hernias be classified?
European hernia society guidelines
1) Primary/recurrent
2) Size of defect
- 1 <1.5cm
- 2 1.5-3cm
- 3 >3cm
3) Site of defect (Lateral, medial, femoral)
What is the Shouldice technique?
Tissue repair of inguinal hernia
4 layers
- Deep upper TF –> lower TF (M–>L)
- Sup Upper TF –> Inguinal ligament (L –> M)
- Internal oblique/TA –> deep Inguinal ligament (L –> M)
- Internal oblique/TA –> sup Inguinal ligament (M –> L)
What are the risk factors for urinary retention after hernia repair?
Age
Laparoscopic approach
GA
What is the incidence and risk factors for chronic pain after hernia repair?
10-12% - bothersome in 0.5-6%
RF
- preop = young, female, preop pain, recurrence
- periop = less experienced, open, heavyweight mesh
- postop = complications, high post op pain
What are the management options for chronic pain after hernia repair?
–EHS guidelines
MDT
Consider LA/Steroid blocks
Consider triple neurectomy and mesh explantation after at least 1 year
RFA may be helpful
What would be an appropriate local anaesthetic choice for groin hernia repair?
Combination of lidocaine with adrenaline (7mg/kg) and bupivicaine (2.5mg/kg)
20mls 1% L+A
20mls 0.5% Bupivicaine
70kg.
What factors are important in the pharmacokinetics of LAs?
Protein binding - ability of drug to bind membrane proteins –> longer duration, less risk of toxicity
Lipid solubility - greater solubility == greater penetration of nerve membranes and increased rate of onset
-pKa - pH at which there is balance of ionised and non-ionised LA.
—Lower pKa, higher proportion in non-ionised form, more readily absorbed and more rapid onset
—Higher pKa, slower onset, more prolonged
What are the components of an enhanced recovery pathway?
Pre-admission - patient optimisation, comorbidities/anaemia addressed, patient education
Admission - day of surgery, carbohydrate loading, avoidance of bowel prep
Intra-op - minimally invasive, goal directed fluid management, individualised pain management, avoid tubes where possible
Post-op - early mobilisation, enteral nutrition and removal of tubes. Daily achievement goals
What are the criteria for discharge on ERAS?
1) Good pain control with oral analgesia
2) Eating and drinking without IVFs
3) Independently mobile
What structures drain lymph into the superficial inguinal nodes?
Skin and subcutaneous tissue of abdominal wall below umbilicus, perineum, buttocks, external genitalia and lower limbs
What is gynaecomastia and its common causes?
Benign proliferation of glandular male breast tissue. Consider pseudogynaecomastia
- Physiological (30% neonatal, puberty, old age)
- Drug (20%, protate cancer drugs, cardiac, retroviral - Spironolactone, steroids, cannabis)
- Pathological causes (25%, hyperthyroidism, alcohol, cirrhosis, testicular malignancy)
- Idiopathic (25%)
What endocrine tests should be sent for assessment of gynaecomastia?
B-HCG, LH, testosterone, oestrogen, prolactin and AFP
Also renal, liver, thyroid function
What are the classical stages of Hidradenitis supparativa?
Three stages described by Hurley
1 - single/multiple abscesses
2 - recurrent abscesses with tract formation
3 - multiple tracts and abscesses involving a whole area
What is a hydrocele and how may they be classified?
An accumulation of fluid around the testis in the tunica vaginalis
Communicating (associated with hernia)
Non-communicating
How may hydroceles be repaired surgically?
Inguinal approach
- high ligation of PPV in infants
Scrotal approach
- Jaboulay procedure - resection of most of sac leaving a cuff of tissue which is everted and sutured along the cord
What are the surgical concerns for patients with Sickle-cell anaemia?
Vaso-occlusive crises precipitated by infections acidosis, dehydration, hypoxia, surgical trauma.
Ensure Hb >10.
Acute chest syndrome - 2/3 days post surgery, pulmonary infiltrates on chest x-ray
What is the embryological origin of a thyroglossal cyst?
The foramen caecum develops at the base of the tongue at about 4 weeks
Forms the thyroid which migrates to the 5th Cervical vertebrae between 1st and 2nd branchial arches
Along this tract cysts or ectopic thyroid tissue can be found, most commonly at the level of the thyroid
What USS findings would suggest pyloric stenosis in infants?
Thickness of >3mm or length >15mm
What are the typical findings of dehydration in infants?
Mild 1-5% - <24 hours
Moderate 6-10% - loss of skin turgor, weight loss, sunken eyes/fontanelle, lethargy, dry membranes
Severe 11-15% - skin mottling, CV instability, neurological involvement
What clinical features might make you consider NOM of SBO to be failing?
WSES Bologna guidelines
- No passage of contrast into colon after 24 hours after WSCI
- >72 hours symptoms
- >500ml NG on D3
- Peritonitis or ischaemia
Why is splenectomy effective for ITP?
-Site of anti platelet antibody production and subsequent destruction
- NB spleen is normal sized in these patients
What are the common indications for elective splenectomy?
Immunological (ITP, Spherocytosis (aim for >6 years), AIHA)
Haematological malignancies/staging
Splenic tumours (haemangioma, giant cysts, abscesses)
Gastric varices secondary to splenic vein thrombosis
What are the risk factors for OPSI?
Age (younger)
Indication (elective, haematological)
Timing - within 2 years
What are the risk factors for DVT?
Patient
- BMI
- FH and inherited thrombophilia
- Age
- Drugs (COCP)
- Malignancy
Condition
- Acute inflamatory
- Immobility
- Pregnancy
Procedural
- Prolonged surgery
- Pelvic surgery
What is the operation of choice for Malrotation of the Gut?
Ladd’s procedure.
-Division of Ladds bands
-Place colon on left side, remove appendix
What is the most common type of Diaphragmatic hernia?
Bochdalek hernia (usually left sided)
How does Hirshprungs disease typically present?
With failure to pass meconium in 48 hours
Diagnose with suction rectal biopsy
Treat with serial washouts and pull through at 6 months
High incidence of NEC
How does Pyloric stenosis tend to present?
Non bile stained vomiting at 4-6 weeks
Ramstedt pyloromyotomy
5-10% FH
Where is the most frequent location of a thyroglossal cyst?
Just inferior to hyoid (65%)
Treat with Sistrunk procedure - excision of hyoid bone
Thin walled and anechoic
Where are branchial cysts most frequently located?
Usually located anterior to SCM near angle of mandible
75% from second branchial cleft
Usually anechoic and water like unless infected
Where is a cystic hygroma most commonly found?
Posterior to SCM
Usually present <2
Typically hypo echoic on USS
How do infantile haemangiomas present?
Rapidly growing neck mass that often spontaneously regresses
Contains calcified phleboliths on XR
What is the most common cause of PR bleeding in young children?
Probably Meckel’s or a polyp
IBD in older children
What is the best imaging test for a Meckel’s diverticulum?
Technetium 99
How do Meckel’s most frequently present if symptomatic?
Obstruction
Only 5% symptomatic
2% of population, 2 inches long , 2feet from IC valve
What is the incidence of Cryptorchidism?
Defined by failure to reach bottom of scrotum by 3 months, then 1-2%.
5% at birth
What congenital defects are associated with cryptorchidism?
PPV
Abnormal epididymis
Cerebral palsy
Learning difficulties
Wilms Tumour
Abdominal wall defects
What is the increased risk of testicular cancer with undescended testis?
40 times normal risk (seminoma)
50% of intra-abdominal will become malignant
When should an orchidopexy be performed for cryptorchidism?
6-18months of age.
If impalpable in the groin then laparoscopic exploration and 1/2 stage procedure
Above 2 the Sertoli cells degrade, and if presenting in teenage years, probably should just have orchidectomy
When does intestinal rotation occur in embryological development?
About the 4th week 270deg anticlockwise twist
What is the characteristic X-ray finding of duodenal atresia?
Double bubble sign on plain X-ray
40% have Down’s
8% of Downs have duodenal atresia
Treated with duodenoduodenostomy through transverse incision. Has good outcomes
How frequent is umbilical hernia in infants?
Up to 20%. Majority close spontaneously
What is the most common infective organism causing Omphalitis?
Staph Aureus
How does a persistent urachus present?
Urinary discharge from umbilicus
How does a persistent Vitello-intestinal duct present?
Umbilical discharge of small bowel content - often a Meckel’s diverticulum
How are paediatric inguinal hernias repaired?
High risk of strangulation <1 and should be repaired urgently. If >1, ?electively
Herniotomy is the treatment of choice
Females should have bilateral exploration ?lap
What are indications for circumcision?
Lichen sclerosus> BXO
Paraphimosis
Recurrent balanitis
Persistent phimosis - but only if pathological. 10% of 11 year olds non-retractile (does not matter)
When should a paediatric hydrocele be considered for treatment in children?
> 12 months and not decreasing in size –> referral
Ligation of PPV usually >2 years
How should microscopic haematuria be investigated in children?
If asymptomatic, may be benign and resolve. Consider repeating in 6 months
Red flag features include abnormal renal function, proteinuria, signs of fluid overload, hypertension or frank haematuria
Consider diagnosis of Alport syndrome or structural abnormalities
NB wilms (mass)
What is the peak incidence of Intussusception?
5-7 months, 70%<1 year
What proportion of thyroid nodules are cancerous?
<1%
Prevalence of nodules on USS c .50%
c.2,200 annual diagnoses of thyroid cancer
What are the effects of a GA on the liver in patients with cirrhosis?
Susceptibility to hyperaemia and hypotension due to hyper dynamic circulation
Risk of hepatic ischaemia, risk of halothane toxicity
How can patients with liver cirrhosis be risk stratified for surgery?
Childs-Pugh A/B/C
Mortality = 10/30/80%
Composite of:
1) encephalopathy
2) Ascites
3) Bilirubin
4) Albumin
5) INR
MELD/UK-ELD
How is an undescended testicle defined?
Failure to descend to normal position by 3 months of age
90% unilateral, 70% right
What are the phases of healing of an anastomosis?
Lag phase (0-4) - acute inflammatory response to clear wound debris
Proliferative (3-14) fibroblast proliferation and immature collagen
Remodelling/maturation (10+) collagen remodelling
What are the risk factors for anastomotic leak?
Technical:
- Blood supply
- Tension
- Contamination
Patient:
- Malnutrition
- Steroids
- DM
- Malignancy, radiation, chemotherapy
- Hypotension/shock
- Emergency
How do chemotherapy agents work?
- Anti-metabolites e.g. Methotrexate - inhibit DNA synthesis (folate), 5-FU (pyrimidines)
- Inhibition of microtubule assembly (Vinka Alkaloids)
- DNA Cross linking (prevents DNA repair, platinums)
- Inhibitor of topoisomerase (prevent DNA-coiling e.g. anthracyclines)
What are the side effects of chemotherapy?
General - N/V, BM toxicity, GI toxicity, alopecia, infertility
Specific
- Cardiomyopathy - doxorubicin
- Cyclophosphamide - haemorrhage cystitis
- Hepatic damage - methotrexate
- Skin pigmentation - 5-FU
- Peripheral neuropathy - Oxaliplatin
What is clinical governance?
A framework by which NHS organisations are accountable for improving their services and safeguarding standards of care. Ultimately the Chief executive is responsible
What are the 7 pillars of clinical governance?
SPARE-IT
Staffing and staff management
Patient involvement
Audit
Risk management
Effectiveness
Information use
Training and education
S
What is an audit?
A process used by clinicians to improve patient care by assessing practice, comparing it to accepted standards and making changes if necessary
How should patients with suspected C. Diff be managed?
- Isolated within 2 hours
- Gloves + Aprons and hand washing
- Stool sample –> micro
Who should receive a 2 week wait referral for bowel cancer?
FIT +ve
40 + with weight loss + abdominal pain
50 + with unexplained rectal bleeding
60 + with IDA or CIBH
Rectal/abdominal mass
What common gene mutations are seen in colorectal cancer?
APC
K-ras
p53
What are the risk factors for CRC?
Genetic - APC, HNPCC with various mutations
Lifestyle - obesity, low fibre, high processed meat, obesity, smoking, alcohol
PMH - IBD
What is the TNM staging of CRC?
T1 Invading mucosa/submucosa
T2 Invading muscularis propria
T3 Invading subserosa
T4 Invading visceral peritoneum/other organs
N1 1-3
N2 4+
How could you negotiate a tight stricture in colonoscopy?
Scope guide
Patient positioning
Buscopan
Paediatric endoscopy
Experience colleague
CT Colon….
What are the causes of Cushings syndrome?
ACTH dependent
- Cushings disease
- Ectopic secretion (SCLC, bronchial carcinoid)
ACTH independent
- Adrenal Adenoma/Adenocarcinoma
- Bilateral adrenal hyperplasia
- Iatrogenic (Steroids)
How can the difference causes of Cushings syndrome be differentiated?
1) Confirm syndrome - Low dose dexamethasone suppression test (should have suppressed cortisol in the morning)
2) Confirm source
–If ACTH high
—- High dose dexamethasone suppression test
—– Pituitary relatively suppressed, ectopic not suppressed
3) Image
-If High ACTH - CX and MRI pituitary
-If low ACTH - CT and MRI abdomen
How can patients with ectopic secretion of ACTH from cancers be managed?
Interruption of steroidogenesis using
- Ketoconazole
- Mitotane
- Metyrapone
What are possible complications of diathermy?
Inadvertent application
Heat transference
Plate burns
Spirit based burns
Explosion large bowel
What is the critical view of safety?
1)Hepatocystic triangle cleared for fat and fibrous tissue (c duct, CHD, inferior edge of liver)
2) Lower 1/3 of GB separated from cystic plate
3) two structures entering gallbladder
What is the cause of an in-growing toenail?
Lateral projection of nail growing into peri-ungal soft tissue, mostly great toe.
Nail fold penetrated, and colonised with bacteria/fungi
Oedema, erythema, pain abscess, granulation tissue
What is the anatomy of the nail?
Nail plate - body and root lie on nail bed
Germinal matrix runs form lunula to eponychium
Cuticle most distal portion of eponychium
How would you treat ingrowing nails?
Conservative management
Wedge excision
- Digital block with plain 1% bupivicaine
- Rubber tourniquet
- Lift lateral quarter of nail with haemostat
- Divide nail to underlying matrix and remove
- Debride bed
-Apply 80% phenol with cotton bud for 30-60s and irrigate
- Dress toe
What are the borders of the inguinal canal?
Superior - Muscles (IO, TA)
Anterior - Aponeurosis (EOA/IOA)
Inferior - Ligament (inguinal/lacunar)
Posterior - Tendon (Transversalis facia/conjoint)
MALT
What re the risk factors for Melanoma?
Fitzpatrick skin type 1
Sun exposure and sunburn in childhood
Other skin lesions esp melanomas, giant congenital pigmented hairy naevus
Immunosuppression
Xeroderma pigmentosa
What clinical features are suggestive of melanoma?
Asymmetry
Border irregularity
Colour variability
Diameter >6mm
Evolving/extra features (bleeding, itching, elevation)
Why is CO2 used for pneumoperitoneum?
Normal end product of metabolism and readily cleared by body
highly soluble in tissue
non-combustible
high diffusion coefficient
lowest risk of gas embolism
How is Botox administered for incisional hernia repair?
-3 sites on each side of lateral abdomen in EO,IO and TA
- total of 300 units
- increases stretch by about 30-50%
What is CEA?
Protein produced by some types of cancer including colon, breast, lung, liver, stomach
Can be raised incidentally from
Smoking, IBD and chronic liver disease
Normally less than 2.5ug/l
What are the complications of radiation induced bowel injury?
Obstruction
Malabsorption
Short gut syndrome
Fistula
Chronic inflammation
Sepsis
What factors increase the risk of radiation induced bowel injury?
CVS risk factors
Low BMI, old/young
Genetic predisposition - Ataxia telangiectasia
How does radiotherapy work?
Electron stream –> free radical mediated DNA damage
Normal cells more likely to be able to repair DNA damage
Oxygen dependent (nb necrotic cores)
When is a death reported to the coroner?
No doctor attended deceased during illness
Not seen within 14 days of death or after death
Cause of death unknown
Death occurred during an operation/before recovery from anaesthetic
Death due to industrial disease
Death sudden/unexpected/unnatural
What bias exists in a screening program?
Lead-time bias
Selection bias
Length bias
What are the cervical, AAA, breast and bowel screening programs?
Cervical - 25-64 every 3-5 years
AAA - USS at 65 in males
Breast - 50 every 3 years, 1:25 recall of whom 1:4 have cancer
Colorectal - 60-74 biennial FIT test
What are concerning causes of a new varicocele?
Left –> renal tumour
Right –> retroperitoneal tumour
What is the difference between split thickness and full thickness skin grafts?
SSG - epidermis and thin layer of papillary dermis, extracted with dermatome, often meshed (allows fluid escape, larger wound)
FTSG - epidermis and all of dermis - smaller defects. Harvested from neck, ear, groin, less contraction and better cosmesis
What antibiotics should be used for Gram +ve aerobes
Staphylococcus Aureus, Strep Pneumo, Enterococcus
Coamox, Gent, Teic, Vanc
What antibiotics should be used for Gram +ve anaerobes
C. Diff
Vanc, Met
What antibiotics should be used for Gram -ve aerobes
Bacteroides
Co-amoxiclav, Metronidazole
What antibiotics should be used for Gram -ve anaerobes?
E.Coli, Kelbisella, Pseudomonas
Co-amoxiclav, Gent
Where is an impalpable testis in an infant most likely found?
10% inguinal
40% intra-abdominal
50% absent
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 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
Where do congenital diaphragmatic hernias most frequently occur?
Posterolateral Bochdalek hernia
Defect in pleuroperitoneal fold
78% Left
20% right
2%bilateral
Through which defect do Morgagni hernias occur?
Anterior space of Larrey
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 a Meckel’s diverticulum embryological origin?
Remnant of Vitelli intestinal duct (can be attached to umbilicus - rarely discharging)
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 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
How do Meckels diverticula most frequently present?
Obstruction (40-50%)
Peptic Ulceration (25%)
Acute Inflammation (20%)
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
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
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 degree of bleeding can be detected by a CT Angiogram
0.3ml/min
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 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
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 is Becks triad?
For Cardiac tamponade - muffled heart sounds, raised JVP and low BP
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
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 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 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 does Prothrombin Complex Concentrate (octaplex/berriplex) contain
II, VII, IX and X along with protein C/S
What is the required excision margin for a skin SCC?
<2cm well differentiated - 4mm
>2cm, poor or face - 6-10mm
What is the required skin margin for a BCC?
5mm (95% clearance - 85% at 3mm)
If recurrent - 5-10mm
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
When should a sentinel lymph node biopsy be offered for malignant melanoma?
Breslow thickness >1mm
Which patients with melanoma should receive staging imaging?
IIC without SLNB or suspected III/IV
Consider MRI for <24
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
What is the typical threshold for radiological drainage of diverticular abscess?
4cm
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 potential complications of diverticular disease?
Diverticulitis
Bleeding
Fistula
Perforation
Abscess
Phlegmon
When is oesophageal perforation most likely after ingesting Alkaline agents?
3 days. Perform OGD within 12-24 hours
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
When should patients undergo radiologically guided drainage of pancreatic necrosis?
> 30% necrosis for culture
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
NICE Guidelines
What size of non-enhancing area of pancreas defines necrosis?
> 3cm
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 action of TXA?
Prevents conversion of plasminogen to plasmin (and hence fibrin degradation)
What is the minimal amount of blood required to produce melaena?
60ml
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
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 the optimum treatment for gastric variceal bleeding?
Cyanoarcylate injection or thrombin
2015 BSG Guidelines
What is the inpatient mortality from variceal haemorrhage?
15%
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
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
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
What is the optimum treatment for diffuse gastric bleeding?
Argon plasma coagulation + PPI +/- proceed to surgery
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
How do you insert a Sengstaken Blakemore tube?
- Insert into stomach and inflate gastric balloon under IR and pull back to GOJ with traction
- Inflate balloon to compress oesophagus 35-45mmHg
- reduce pressure by 5mmHg every 3 hours and maintain for 24 hours, deflating every 6 hours
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
30d mortality of Haemorrhagic peptic ulcer?
8.6%
What risk scores exist for Perforated peptic Ulcer?
Boey, PULP, ASA
NELA
Simple albumin is strongly prognostic
If a non-operative approach is taken to perforated peptic ulcer, what treatments are required?
PPI
ABx
Anti-secretory (octreotide)
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
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 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)
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
What drains should be left after peptic ulcer repair?
Probably none, but could leave a suture site (WSES guidelines 2020)
When should patients with perforated gastric ulcers have a repeat endoscopy?
6 weeks
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
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
Which artery typically causes bleeding from duodenal ulcers?
Gastroduodenal artery (must be triple looped)
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
What are the structures related to the pharyngeal pouches and arches?
Thyroid not related to any
Inferior parathyroid = 3
Superior parathyroid = 4
What is the differential diagnosis of constipation in children?
In infants need to exclude neurologic/structural problems including anal/intestinal atresia and Hirschprungs, but often decreased fibre in diet.
Can present late occasionally, but usually fibre related when older. Can get into fissure cycle.
How is dehydration assessed in children?
What are Never events?
Surgical - wrong site surgery, wrong implant, retained FB
Medical - misuse of strong K+, wrong med route, overdose of insulin, overdose of non-cancer methotrexate, miss election of high strength midzaolam
Mental health - collapsible shower and curtain rails
General - falls, entrapment in bed rails, ABO incompatible transfusion, misplaced NG tube, scalding, connection of air instead of oxygen
