General surg

Question 1

merican Society of Anaesthesiologist (ASA) classification

Answer 1

ASA grade I is defined as normal healthy patients, who are non-smokers and with no/minimal alcohol intake.
ASA grade II is defined as patients with mild systemic disease e.g. well controlled diabetes or hypertension, current smoker, obesity (BMI 30-40), and mild lung disease.
ASA grade III is defined as patients with severe systemic disease e.g. poorly controlled diabetes or hypertension, COPD, morbid obesity (BMI >40), history of ACS/stroke/TIA >3 months ago.
ASA grade IV is defined as patients with severe systemic disease that is a constant threat to life e.g. MI/stroke/TIA within 3 months, severe valve dysfunction, severe reduction in ejection fraction, sepsis.
ASA grade V is defined as moribund patients not expected to survive the operation e.g. ruptured abdominal aortic aneurysm, massive bleed, intracranial haemorrhage with mass effect.
ASA grade VI is defined as a patient declared brain-dead whose organs are being removed for donation.

Question 2

AAA

Screening and repeat screening principles

Answer 2

If small AAA (3-4.4cm) – offered yearly repeat ultrasound
If medium AAA (4.5-5.4cm) – offered repeat ultrasound every 3 months
If large AAA (>5.5cm) – surgery generally recommended.

Question 3

Presentation of achalasia

Answer 3

Dysphagia – gradual onset (months to years)
Regurgitation of undigested food
Aspiration
Retrosternal chest pain / heartburn – often does not respond to PPI
Weight loss – often mild

Question 4

achalasia investigations

Answer 4

nvestigations

Endoscopy – may show dilated oesophagus, containing residual material. It also rules out other more sinister pathologies.
Oesophageal manometry – shows high pressure and incomplete lower oesophageal sphincter relaxation
Barium swallow – shows classic ‘bird’s beak appearance’ in advanced disease

Question 5

Acute cholecystitis

Key features

Answer 5

Key features of acute cholecystitis

Right upper quadrant/epigastric pain (radiating to right shoulder tip if the diaphragm is irritated)
Fever
Nausea and vomiting
Right upper quadrant tenderness
Murphy's sign positive

Question 6

Management of acute cholecystitis

Answer 6

Management of acute cholecystitis is usually supportive unless there is immediate threat to life. The definitive treatment is a cholecystectomy as inflammation in the gallbladder is likely to recur.

Supportive care includes keeping nil-by-mouth, IV fluids, antibiotics and analgesia. Signs of septic shock should be closely monitored.

Question 7

eatures of severe acute cholecystitis

Answer 7

Symptoms of end organ damage:
Resistant hypotension
Lowered GCS
Oliguria
Hepatic dysfunction
Lowered oxygen saturations

Question 8

Management of severe acute cholecystitis

Answer 8

The same treatment as moderate disease but will require ITU admission
Urgent cholecystostomy to drain the gallbladder and may have a cholecystectomy after 6 weeks.
Laparoscopic surgery is preferred as shows better post-operative outcomes. An open procedure may be required if:

Patient acutely unwell
Gallbladder mass present
Significant inflammation or bleeding
Previous abdominal surgery (due to presence of adhesions)
Pregnancy

Question 9

The 6Ps of acute limb ischaemia

Answer 9

Pulseless
Painful
Pale
Paralysis
Paraesthesia
Perishingly cold

Question 10

Acute mesenteric ischaemia

Answer 10

The most common site of occlusion is the superior mesenteric artery.

Question 11

Acute pancreatitis

Symptoms

Answer 11

Symptoms

Acute pancreatitis is associated with a stabbing-like, epigastric pain which radiates to the back that is relieved by sitting forward or lying in the fetal position.
Vomiting is highly associated with this.
Importantly, past medical history and social history is vital. A recent alcoholic binge or a history of gallstones are highly suggestive.

Question 12

Severity of pancreatitis

Answer 12

t can be remembered by the mnemonic PANCREAS:

PaO2 < 8kPa (60mmHg)
Age > 55 years
Neutrophils - WBC >15 x109/l
Calcium < 2mmol/l
Renal function - Urea > 16mmol/l
Enzymes - AST/ALT > 200 iu/L or LDH > 600 iu/L
Albumin < 32g/l
Sugar - Glucose >10mmol/L

Question 13

Acute pancreatitis

management

Answer 13

anagement

The management of pancreatitis is to help maintain electrolyte imbalances and compensate for the third space losses seen in this disease. Supportive care is the main way of facilitating this –

Aggressive fluid resuscitation with crystalloids

Aim to keep urine output > 30 mL/hour
Start with a 1 litre bolus and try to maintain adequate urine output. This usually amount to a fluid requirement of 3 – 5 ml/kg/hr
Catheterisation

Analgesia

Strong analgesia in the form of opioids are needed
Anti-emetics

IV antibiotics are shown to have no real effect in outcome unless necrotising pancreatitis is present. Necrotising pancreatitis is a complication of severe pancreatitis representing inadequate fluid resuscitation during initial management. It is usually diagnosed by CT scan. Routinely giving antibiotics in pancreatitis is not current clinic practice.

Calcium may be given if hypocalcaemia is present, but is not prescribed prophylactically.

Insulin may also be given in the presence of hyperglycaemia due to the damaged pancreas reducing release of the hormone.

Question 14

Anal fistula

Answer 14

Patients typically present with anal discharge and discomfort.
On physical examination the external fistula opening may be visible.
It is important to perform a digital rectal examination to check for the location of the internal fistula opening.

MRI is the best investigation to characterise the course of the fistula as it shows soft tissue structures well.

Question 15

Angiodysplasia

Answer 15

painless, chronic, intermittent lower GI bleed (fresh PR bleed if the lesions are in the colon, and melaena if the lesions are in the upper GI tract).

Question 16

Anorectal abscess

Answer 16

Patients typically present with perianal pain and swelling.
physical inspection, there is a fluctuant tender peri-anal swelling

Management

Anorectal abscesses require early drainage, to prevent spread of the infection which can cause sepsis. Perianal abscesses can be drained in A&E under local anaesthetics (deeper perirectal abscesses with sphincter extension may require drainage in the operating theatre).

Question 17

Causes of epigastric pain

Answer 17

Duodenal/gastric ulcers: suspect if the pain is relieved by antacids, and made worse by certain foods. Risk factors include H. pylori infection, NSAID use, and smoking. In a perforated ulcer the patient will be acutely unwell and haemodynamically unstable.

Oesophagitis: suspect if there is heartburn or acid regurgitation. Risk factors include obesity and the presence of a hiatus hernia.

Acute pancreatitis: suspect if there is concomitant nausea, vomiting, and anorexia. Risk factors include gallstones and alcohol abuse.

Ruptured abdominal aortic aneurysm: patients present with the triad of epigastric/back pain plus pulsatile abdominal mass plus hypotension.

Question 18

Causes of central abdominal pain

Answer 18

Bowel obstruction, early appendicitis, acute gastritis, acute pancreatitis, and ruptured abdominal aortic aneurysm.

Less common but extremely important causes include ischaemic bowel disease.

It is important to consider non-gastrointestinal causes such as pneumonia, acute coronary syndrome, and diabetic ketoacidosis.

Question 19

Rule of 9’s for estimating burns

Answer 19

Head = 9%
Torso (front) = 18%
Torso (back) = 18%
Whole arm = 9%
Hand = 1%
Whole leg = 18%

Question 20

Presentation of arterial ulcers

Answer 20

Arterial ulcers typically present in elderly men, venous ulcers typically present in middle-aged women.

The ulcer: arterial ulcers occur distally (e.g. at the heel or the toe tips), are small and deep, have a ‘punched out’ margin, and do not bleed/ooze.

Arterial ulcers will typically occur with other features of peripheral arterial disease (weak distal pulses, skin/hair atrophy etc.)

Question 21

Presentation of venous ulcers

Answer 21

Venous ulcers occur in the gaiter area, are large and shallow, have sloping edges, and bleed/ooze.

Venous ulcers will typically occur with other features of chronic venous insufficiency (haemosiderin deposition, lipodermatosclerosis, atrophie blanche etc.)

Question 22

Ascending cholangitis - bacterial infection of the biliary tree.

Answer 22

harcot’s triad of (1/3 of patients):
Right upper quadrant pain
Fever
Jaundice

Question 23

Management

Ascending cholangitis

Answer 23

Management

Resuscitation including intravenous fluids and antibiotics (according to local guidelines). Critical care may be required depending on the presence or severity of shock and organ failure
Biliary drainage may be required
Endoscopic drainage – ERCP (Endoscopic retrograde cholangiopancreatography). This may involve stent placement for strictures.
Percutaneous drainage – PTC (Percutaneous transhepatic cholangiography)
Surgical drainage
Assessment and management of predisposing cause – for example, if gallstones – consider cholecystectomy. If malignant stricture, this would need further investigation and management as appropriate.

Question 24

Boerhaave syndromes is an uncommon but life-threatening condition causes by a full thickness rupture of the oesophagus.

Answer 24

Presentation

It classically occurs in middle aged alcoholic men after repeating vomiting. It presents as:

Severe tearing chest pain worse on swallowing
Little/no haematemsis
Signs of shock
Subcutaneous emphysema
Pneumomediastinum, pleural effusions, pneumothorax on x-ray

Question 25

Buerger's disease (thromboangiitis obliterans)

Answer 25

non-atherosclerotic vasculitis caused by occlusion in small and medium-sized arteries. acutely ischaemic limb, without a background of peripheral claudication. anagement is with smoking cessation ± vasoactive medication (such as nifedipine).

Question 26

Presentation of Pharyngeal Pouch

Answer 26

Presentation: ``` Dysphagia Regurgitation of undigested food Aspiration Chronic cough Weight loss ```

Question 27

Causes of massive splenomegaly

Answer 27

Malaria LeishManiasis Chronic Myeloid Leukaemia Myelofibrosis

Question 28

Chronic mesenteric ischaemia

Answer 28

Patients typically present with diffuse, colicky abdominal pain which is worse after eating. Weight loss is a common feature, as patients avoid eating due to the pain. There may be associated diarrhoea and melaena or haematochezia (secondary to mucosal sloughing). On physical examination there is commonly abdominal tenderness. An epigastric bruits may be present (secondary to turbulent flow in the narrowed vessels).

Question 29

Causes of chronic urinary retention

Answer 29

BPH (most common) Prostate cancer Drugs such as antihistamines, anticholinergics or antispasmodics Congenital conditions such as posterior urethral valves

Question 30

Colonic polyps | Neoplastic polyp types

Answer 30

``` Neoplastic polyps are typically adenomas. Adenomatous polyps are further classified according to morphology into: Tubular polyps Tubulovillous polyps Villous polps Microtubular polyps Serrated polyps ``` Villous polyps are more likely to cause hypokalaemia and are more likely to progress to colorectal cancer.

Question 31

Colonic polyps | Non-neoplastic polyps types

Answer 31

on-neoplastic polyps are entirely benign. They are further classified into: Hyperplastic polyps Inflammatory polyps Hamartomas. Inflammatory polyps typically occur in IBD. Hamartomas are found in Peutz-Jeghers syndrome.

Question 32

Duke's classification of colon cancer

Answer 32

Duke's classification can be used to stage colorectal cancer: A: limited to the bowel wall (i.e. not beyond the muscularis). B: extending through the bowel wall (i.e. beyond the muscularis). C: regional lymph node involvement. D: distant metastases. It is important to learn the Duke's staging for examinations.

Question 33

TNM staging of colorectal cancer

Answer 33

T: Tis (carcinoma in situ/intramucosal cancer), T1 (extends through the mucosa into the submucosa), T2 (extends through the submucosal into the muscularis), T3 (extends through the muscularis into the subserosa), T4 (extends into neighbouring organs or tissues). N: N0 (no regional lymph node involvement), N1 (metastasis to 1-3 regional lymph nodes), N2 (metastasis to 4 or more regional lymph nodes). M: M0 (no distant metastasis), N1 (distant metastasis). Staging informs both the prognosis and the treatment plan

Question 34

Principles of screening for colorectal cancer

Answer 34

Faecal occult blood test (FOBT) every 2 years for men and women age 60-74. If positive patients are referred for colonoscopy. One-off flexible sigmoidoscopy for men and women at the age of 55. This is typically done to detect and remove polyps.

Question 35

rgent 2 week wait referral for possible colorectal cancer

Answer 35

Aged > 40 with unexplained weight loss AND abdominal pain Aged > 50 with unexplained rectal bleeding Aged > 60 and over with any of: Iron–deficiency anaemia Changes in their bowel habit (old guidelines say this had to last more than 6 weeks, but this no longer applies) Proven faecal occult blood on testing (appointment within 2 weeks) Rectal or abdominal mass Aged under 50 with rectal bleeding AND any of the following unexplained symptoms: Abdominal pain Change in bowel habit Weight loss Iron-deficiency anaemia

Question 36

Surgery of Rectal Cancer

Answer 36

For patients with rectal cancer suitable for surgery: Anterior resection for tumours >8 cm from the anal canal or involving the proximal 1/3 of the rectum. Abdomino-perineal (AP) resection for tumours <8 cm from the anal canal or involving the distal 2/3 of the rectum. Patients with stage III disease benefit from post-operative chemotherapy. Patients with stage IV disease benefit from post-operative chemoradiotherapy.

Question 37

Complications of central line insertion

Answer 37

``` Air embolism Bleeding Pneumothorax Infection Phrenic nerve palsy ```

Question 38

Complications of laparoscopic cholecystectomy

Answer 38

Haemorrhage – Post-cholecystectomy syndrome – Vague set of symptoms seen in 10 – 15% of patients after cholecystectomy, and is thought to be due to the loss of reservoir of bile through removal of the gall bladder. Symptoms can include colicky abdominal pain, diarrhea, vague abdominal pain and jaundice Bile duct injury: A form of post-hepatic jaundice and will present with dark coloured urine and stools. However, if the presentation is delayed it can lead to chemical peritonitis of the abdominal cavity. Pneumoperitoneum due to laparoscopic technique can develop into several complications if air becomes trapped in the subcutaneous space leading to subcutaneous emphysema, pneumothorax or air embolism

Question 39

Complications of Parental Feeding

Answer 39

``` Thrombosis (which may lead to pulmonary embolism) Sepsis (typically Staph epidermidis, Staph aureus, Candida, Pseudomonas) Hypophosphataemia Hypomagnesaemia Zinc deficiency Hyperglycaemia Metabolic acidosis (normal anion gap) Villous atrophy ```

Question 40

Complications of thyroid surgery

Answer 40

Hypocalcaemia (secondary to hypoparathyroidism) Hypothyroidism Recurrent or superior laryngeal nerve damage Neck haematoma Thyrotoxic storm

Question 41

Important drugs to stop before surgery

Answer 41

Cardiovascular drugs: Clopidogrel should be stopped 7 days before surgery, warfarin should be (generally) stopped 5 days before surgery and instead patients should be on low molecular weight heparin until the night before ACE inhibitors should be stopped the day before surgery. Diabetes drugs: Insulin should be held on the day of surgery (only the short-acting preparations), sulfonylureas should be held on the day of surgery (due to the risk of hypoglycaemia). Note that metformin can be given as normal for short procedures. For longer procedures when the patient is not eating and drinking for several days metformin should be held and variable-rate insulin prescribed. The pill should be stopped 4-6 weeks before surgery, and re-started at least 2 weeks after surgery (when the patient is mobile). This reduces the risk of DVT.

Question 42

Rovsing's sign

Answer 42

This is when palpation of the left lower quadrant of a patient's abdomen increases the pain felt in the right lower quadrant. It is a sign of appendicitis.

Question 43

Boas' sign

Answer 43

This is hyperaesthesia (increased sensitivity) below the right scapula. It may be a sign of acute cholecystitis,

Question 44

Cullen's sign

Answer 44

This is irregular purple-ish discolouration of the umbilical area due to intraperitoneal haemorrhage.

Question 45

Management of anal fissures

Answer 45

Treatment of constipation – laxatives/fibre in diet Topical analgesics – lidocaine cream / jelly Topical vasodilators e.g. nifedipine or nitroglycerine

Question 46

Risk factors of gallbladder carcinoma

Answer 46

Risk factors of gallbladder carcinoma The most common risk factor is a history of gallstones or chronic cholecystitis, but others include: ``` Porcelain gallbladder Smoking Obesity Primary sclerosing cholangitis Ulcerative colitis/Crohn's colitis Oestrogens Occupational exposure (pesticides, radiation, heavy metals, vinyl chloride) ```

Question 47

Management | gallbladder carcinoma

Answer 47

Management The most effective treatment is a cholecystectomy (surgical removal of the gallbladder) with partial liver and lymph node dissection. However, with gallbladder cancer's extremely poor prognosis, most patients will die within a year of surgery. If surgery is not possible, endoscopic stenting of the biliary tree can reduce jaundice and a stent in stomach may relieve vomiting. Chemotherapy and radiation may also be used with surgery.

Question 48

Complications of gallstones can be considered by location:

Answer 48

``` Gallbladder Biliary colic cute or chronic cholecystitis Empyema/mucocoele Mirizzi's syndrome Cholangiocarcinoma ``` Bile ducts Obstructive jaundice Pancreatitis Cholangitis Duodenum Gallstone ileus Bouveret's syndrome (gastric outlet obstruction secondary to impaction of a gallstone in the pylorus or proximal duodenum)

Question 49

eatures of Biliary Colic

Answer 49

Features of biliary colic: Colicky right upper quadrant pain Worse after eating No fever Murphy's sign negative

Question 50

Features of Acute Cholecystitis

Answer 50

Right upper quadrant/epigastric pain (radiating to right shoulder tip if the diaphragm is irritated) Fever Nausea and vomiting Right upper quadrant tenderness

Question 51

Gastric carcinoma can be split up into two types of cancer:

Answer 51

Intestinal Associated with H. pylori, tobacco smoking, achlorhydria and chronic gastritis Commonly on lesser curvature of the stomach Diffuse Not associated with H. pylori Associated with signet cells

Question 52

ndications for Urgent Referral for OGD

Answer 52

Current guidelines include urgent referral (within 2 weeks) for patients with: Dysphagia (at any age) Aged 55 and over with weight loss AND – Upper abdominal pain OR reflux OR dyspepsia Upper abdominal mass consistent with stomach cancer

Question 53

Management of haemorrhoids

Answer 53

Grade 1 haemorrhoids (i.e. no prolapse) can be managed conservatively, ± topical corticosteroids to alleviate pruritus. Grade 2 haemorrhoids (i.e. prolapse on straining which spontaneously reduces) can be managed with rubber band ligation (preferred), sclerotherapy, or infrared photocoagulation. Grade 3 haemorrhoids (i.e. prolapse on straining and require manual reduction) are managed with rubber band ligation. Grade 4 haemorrhoids (i.e. prolapse on straining and can't be manually reduced), external haemorrhoids, or lower grade haemorrhoids failing to respond to less invasive measures are managed with surgical haemorrhoidectomy. All patients should be advised to consume a diet rich in fibre and fluids, to reduce the risk of constipation.

Question 54

NICE criteria for a 1 hour CT Head

Answer 54

GCS <13 on initial assessment GCS <15 2 hours after the trauma Suspected open or depressed skull fracture Evidence of basal skull fracture (e.g. panda eyes, mastoid bruising, rhinorrhoea) Post-event seizure New focal neurology More than 1 episode of vomiting

Question 55

NICE Criteria for an 8 hour CT Head

Answer 55

If a patient has experienced loss of consciousness or amnesia since the trauma they should receive a CT head within 8 hours if they also have one of the following: Age >65. Bleeding//clotting disorders. Dangerous mechanism of injury (e.g. hit by car, fall from >1m). More than 30min retrograde amnesia from the event.

Question 56

Large Bowel Obstruction

Answer 56

Presentation Abdominal pain – often cramping Bloating Absolute constipation – not passing wind and faeces Nausea and vomiting – may occur, but occurs more commonly in small bowel obstruction. Vomiting is a later sign in large bowel obstruction

Question 57

Management of Type A dissections

Answer 57

tanford type A aortic dissection (involving the ascending aortic arch) requires immediate open surgical repair.

Question 58

Management of Type B dissections

Answer 58

Management of Type B dissections For uncomplicated Stanford type B aortic dissection (involving only the descending aorta) there is no evidence that medical therapy is inferior to a surgical approach. Medical therapy: Intravenous beta blockade (e.g. with labetalol). Intravenous morphine. T If beta blockade is insufficient, alternative antihypertensive vasodilator therapy should be administered (e.g. nitroprusside or diltiazem). For type B dissection with complication (such as ischaemia, expansion, persistent pain, or aortic rupture), endovascular stent-graft repair is indicated.

Question 59

Management of carotid artery stenosis

Answer 59

Surgical management of carotid artery stenosis Patients should undergo carotid endarterectomy if there is carotid artery stenosis of 70-99%, with symptoms of an ischaemic event such as a Stroke or TIA in the corresponding vascular territory. Non-surgical management of carotid artery stenosis If the patient does not meet the criteria for surgery, patients should receive best medical treatment with: Anti-platelet agents (first line is clopidogrel 75mg), Cholesterol lowering therapy, Blood pressure control, Lifestyle advice.

Question 60

Medical causes of the acute abdomen

Answer 60

Vascular causes: myocardial infarction, pericarditis, and pulmonary embolism (these may cause upper abdominal pain). Infective causes: gastroenteritis, pneumonia, and mesenteric adenitis. Inflammatory causes: vasculitis (such as Henoch-Schonlein purpura). Metabolic causes: DKA, Addison's, hypercalcaemia, and acute intermittent porphyria. Neurological causes: abdominal migraine, and irritable bowel syndrome. Toxin causes: poisoning e.g. lead or corrosive substance, withdrawal syndromes. Haematological causes: sickle cell crisis.

Question 61

Adenocarcinoma oesophagus r =isk

Answer 61

lower third of the oesophagus and is associated with obesity and gastro-oesophageal reflux disease. Recurrent reflux leads to metaplastic formations of mucin-producing glandular tissue known as Barrett's oesophagus.

Question 62

Interpretation of ABPI

Answer 62

``` More than 1.2: abnormal thickening of vascular walls (think diabetes) 0.9 - 1.2: Normal 0.8 - 0.9: Mild disease 0.5 - 0.8: Moderate disease Less than 0.5: Severe disease ```

Question 63

Causes of post-op pyrexia can be remembered using the 5 Ws mnemonic:

Answer 63

``` Wind: Pneumonia and atelectasis (1-2 days post-op) Water: UTI (>3 days) Wound: Infections (> 5 days) Wonder drugs: Anaesthesia Walking: DVT (>1 week) ```

Question 64

Renal stones presentation

Answer 64

Presentation Severe, intermittent loin pain, which can radiate to the groin. The patient often is restless. Haematuria – either macroscopic (visible) or microscopic (on dipstick only) - although a negative dipstick would not exclude a renal stone. Nausea and vomiting is common. Secondary infection of a stone may cause fever or signs of sepsis – this is a surgical emergency requiring urgent decompression.

Question 65

Renal stones management

Answer 65

Watchful waiting – this may be the best option in patients who have stones <5mm with no signs of obstruction, or if they are not keen to have any further interventions Percutaneous nephrolithotomy Used for patients with large (>2cm) stones or complex calculi such as staghorn calculi, cysteine stones Retrograde ureteral catheter inserted using a cystoscope, then an 18-gauge needle is used to access the renal collecting system under fluoroscopic guidance. Calculi are extracted using forceps. They may be fragmented using ultrasonic or pneumatic probes. Ureteroscopy Treatment of choice for management of distal or middle ureteric stones Treatment of choice for pregnant women These can be flexible or rigid. Sometimes stents can be placed during ureteroscopy to prevent ureteric obstruction Shock wave lithotropsy This involved high energy shock waves which are radiologically focused on the stone with the aid of fluoroscopy. The energy fragments the stone. Open stone surgery There is now a limited role for this given the above options. <1% of patients undergo this procedure, and it is mainly reserved for patients who have failed the above options, patients with complex / staghorn calculi, morbid obesity, or complex renal / ureteral anatomy. Prevention of stone formation Thiazides for hypercalciuria Allopurinol or potassium citrate for uric acid stones

Question 66

Abdomino-perineal (AP) resection indications and surgical technique

Answer 66

Used for tumours <8 cm from the anal margin. AP resection involves removal of the proximal sigmoid colon, rectum, and anus using both abdominal and perineal incisions. The bowel end is exteriorized to form a permanent end colostomy.

Question 67

Anterior resection indications and surgical technique

Answer 67

Used for tumours >8 cm from the anal margin. Anterior resection involves resection of the tumour and formation of a primary anastomosis between the 2 ends of bowel.

Question 68

Zenker's diverticulum

Answer 68

Zenker diverticulum is a 'false' diverticulum (does not involve 3 layers of the oesophageal wall). It is a herniation of pharyngeoesophageal mucosal tissue at the Killian triangle. It is highly associated with elderly populations. dysphagia, regurgitation of food (which can be several hours after eating) with a sensation of food being stuck in the throat.