General surg Flashcards
merican Society of Anaesthesiologist (ASA) classification
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.
AAA
Screening and repeat screening principles
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.
Presentation of achalasia
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
achalasia investigations
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
Acute cholecystitis
Key features
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
Management of acute cholecystitis
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.
eatures of severe acute cholecystitis
Symptoms of end organ damage: Resistant hypotension Lowered GCS Oliguria Hepatic dysfunction Lowered oxygen saturations
Management of severe acute cholecystitis
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
The 6Ps of acute limb ischaemia
Pulseless Painful Pale Paralysis Paraesthesia Perishingly cold
Acute mesenteric ischaemia
The most common site of occlusion is the superior mesenteric artery.
Acute pancreatitis
Symptoms
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.
Severity of pancreatitis
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
Acute pancreatitis
management
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.
Anal fistula
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.
Angiodysplasia
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).
Anorectal abscess
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).
Causes of epigastric pain
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.
Causes of central abdominal pain
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.
Rule of 9’s for estimating burns
Head = 9% Torso (front) = 18% Torso (back) = 18% Whole arm = 9% Hand = 1% Whole leg = 18%
Presentation of arterial ulcers
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.)
Presentation of venous ulcers
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.)
Ascending cholangitis - bacterial infection of the biliary tree.
harcot’s triad of (1/3 of patients):
Right upper quadrant pain
Fever
Jaundice
Management
Ascending cholangitis
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.
Boerhaave syndromes is an uncommon but life-threatening condition causes by a full thickness rupture of the oesophagus.
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
Buerger’s disease (thromboangiitis obliterans)
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).
Presentation of Pharyngeal Pouch
Presentation:
Dysphagia Regurgitation of undigested food Aspiration Chronic cough Weight loss
Causes of massive splenomegaly
Malaria
LeishManiasis
Chronic Myeloid Leukaemia
Myelofibrosis
