General Surgery Flashcards
Peptic Ulcer Disease causes
imbalance of protective mucus secretion and acid production
- NSAIDs
- H pylori
- ZES
- gastric bypass surgery
- physiological stress
H pylori features and actions
Gram -ve
spiral shaped bacillus
found in mucous layer of duodenal / gastric ulcers
=> cytokine / interleukin driven inflammatory response
^ gastric acid secretion > => histamine > + parietal cells
> damage of surface glycoproteins
> - bicarbonate production
ZES triad
severe peptic ulcer disease
gastric acid hypersecretion
gastrinoma
PUD investigations
Bedside: H pylori urease breath test
Bloods: anaemia
Imaging: OGD (visualise and biopsy), CXR if sus of perforation
PUD Conservative Management
lifestyle advice inc
- diet
- exercise
- alcohol
- smoking
- weight loss
NSAID / corticosteroid use
PPI Px
PUD surgical management indications
severe / relapsing disease
PUD surgical management options
partial gastrectomy
selective vagotomy
PUD complications
perforation
haemorrhage
pyloric stenosis
NSAID mechanism of gastric ulceration
- prostaglandin secretion
ZES most commonly associated condition
Multiple endocrine neoplasia syndrome
ZES investigation / definitive diagnosis
fasting gastrin levels
H pylori investigations / definitive diagnosis
carbon-13 urease breath test
stool antigen test
CLO test
blood vessel most likely involve in cases of posterior duodenal ulcer > upper GI bleeding
gastroduodenal artery
common site of ulceration
lesser curvature of proximal stomach
first section of the duodenum
most common causes for GI perforation
PUD
sigmoid diverticulum
acute abdomen investigations
A-E assessment, urinalysis, (ECG)
Routine baseline bloods + G+S (^WCC, ^ CRP common in perforation)
CXR (pneumoperitoneum), AXR / CT abdo
perforation management
early resuscitation broad spectrum Abx NBM + NG tube IV fluids analgesia
peptic ulcer perforation surgical management
omental patch
+ thorough washout
perforated diverticula surgical management
resection - Hartmann’s procedure
+ thorough washout
perforation complications
haemorrhage
infection - peritonitis / sepsis
Crohn’s pathology features
non-caseating granulomatosis mouth to anus skip lesions cobblestone appearance transmural inflammation relapsing, remitting disease
Crohn’s clinical features
aphthous ulcers peri-anal fissures + fistulas colicky abdominal pain diarrhoea +/- mucous / blood malnutrition / anorexia malaise, low grade fever peaks: 15-30 and 60-75 years
Crohn’s risk factors
family
smoking
white ethnicity
appendectomy
Crohn’s MSK manifestations
metabolic bone disease
enteropathic disease
Crohn’s dermatological manifestations
erythema nodosum
pyoderma gangrenosum
Crohn’s HPB and renal manifestations
gall stones
renal stones
cholangiocarcinoma
Crohn’s investigations
Bloods: anaemia, hypoalbuminaemia, inflammation (^CRP ^WCC) faecal calprotein colonoscopy + biopsy CT abdo + pelvis MRI
Crohn’s management
smoking cessation
ACUTE = oral corticosteroids + azathioprine
REMISSION = azathioprine / rituximab
Surgical = ileocaecal resection, SB / LB resection, stricturoplasty, perianal disease repair (abcess drainage / fissure lay down, fistulae repair)
Crohn’s complications
fistulae strictures recurrent perianal disease GI malignancy osteoporosis malabsorption gall stones renal stones
alcoholic liver disease management
alcohol abstinence
disulfram
non-alcoholic fatty liver disease management
lifestyle modifications (v caloric intake, ^ exercise)
viral hepatitis management
acute = supportive / symptomatic
antiviral drugs = peginterferon alpha / entecavir
preventative = immunisation
haemochromatosis management
therapeutic phlebotomy
iron chelation
dietary changes
treatment for benign symptomatic peptic strictures
balloon dilation
PPI
common complications of balloon dilation for peptic strictures
oesophageal perforation
signs of oesophageal perforation
CP (mediastinitis)
SOB
surgical emphysema palpable in the neck
oesophageal perforation post procedure imaging
CT with oral contrast
immediate management of oesophageal varices
fluid resuscitation +/- blood transfusion
IV terlipressin (vasopressin analogue)
IV Abx
Refer to on-call endoscopy service
bleeding varies surgical mangement
band ligation / sclerotherapy
LT / non-acute varices management
non-selective beta blocker
pre-hepatic jaundice blood results
^ bilirubin (unconjugated)
normal ALP / ALT
anaemia
hepatic jaundice blood results
^ bilirubin (mixed)
^^ ALP
^ ALT
post-hepatic jaundice blood results
^ bilrubin (conjugated)
^ ALP
^^ ALT
assessments for a patient with jaundice
VTE assessment + INR
A to E assessment
investigations for a patient with jaundice
abdo examination + full set of obs urinalysis INR bloods - LFTs, coagulations, TGs liver screen - haemachromatosis, autoimmune liver disease, hepatitis liver USS Abdo CT (!!! renal impairment)
immediate prescriptions for a patient with jaundice
IV fluids if dehydrated
Vitamin K if abnormal INR
TEDS (thromboembolism-deterrent stockings) + LMWH (slows liver necrosis + v risk of VTE)
Courvoiser’s law
palpable gall bladder + painless jaundice is NOT (unlikely to be) gall stone pathology
causes of post-hepatic jaundice
pancreatic carcinoma
cholangiocarcinoma
primary sclerosing cholangitis
cancer of ampulla of Vater
H pylori management + MOA
amoxicillin beta lactam
clarithromycin X protein synthesis
lanzoprazole irreversibly block gastric proton pump of parietal cells
2WW indications for OGD
new onset dysphagia
age > 55 with weight loss and dyspepsia / abdo pain / dyspepsia
tumor marker for oesophageal ca
CEA
vitamin deficiency associated with ^ alcohol intake
vitamin B
drainage and feeding indications post gastric pull through
NBM for 5-7 days
jejenostomy feeding / parenteral feeding
thoracotomy tubes to X hyilarthorax / haemothorax
pathophysiology of third space fluid accumulation in acute pancreatitis
acute pancreatitis > => inflammatory + vasoactive mediators
> vasoconstriction, microscopic intravascular coagulation, vascular injury
=> fluid accumulation in the third spaces
acute pancreatitis complications
pancreatic pseudocyst
third space fluid accumulation > AKI / pleural effusion / ARDS
L / R colonic cancer presentation
L sided = earlier presentation, may present with bowel obstruction ie. fresh rectal bleeding, tenesmus, mass: DRE / left iliac fossa
R sided = later presentation, iron def anaemia + vague abdominal pain + occult bleeding + R sided abdo mass
Nb. stool in R = semi-liquid and will not present with obstructive picture
risk factors for gallstones
fat female 40s fertile + pregnancy haemolytic anaemias => black gall stones bowel resection (X terminal ileum) eg. Crohn's rapid weight loss
how are gall stones diagnosed
transabdominal USS
MRCP = gold standard
what are the complications of actue pancreatitis
Systemic: ARDS, DIC, hypocalcaemia, hyperglycaemia
Pancreatic: pseudocyst, necrosis, chronic pancreatitis
bruising in umbilicus sign
Cullen’s sign
indicates bleeding into intraperitoneal space, common in acute pancreatitis
what is the gold standard imaging modality for ? bowel obstruction
CT WITH IV CONTRAST
haematemesis, XS alcohol intake, stigmata of chronic liver disease
Pathophysiology:
CLD > portal hypertension > oesophageal varices > rupture => haematemesis
scoring in acute pancreatitis
Glascow
scoring in acute upper GI bleed
Rockall = morality (after endoscopy)
Glascow Blatchford = need for admission / blood transfusion / endoscopy
oesophageal varices management
major haemorrhage pathway + resuscitation
urgent gastro referral + endoscopy
IV terlipressin
IV omeprazole
IV Abx eg. co-amoxiclav
Surgical: adrenaline injection, cautery, endoscopic banding, balloon tamponade
consider TIPS (Transjugular intrahepatic portosystemic shunt)
