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Dannys Medicine Finals > General Surgery > Flashcards

General Surgery Flashcards

1
Q

GI Bleed

Patients may rebleed despite endoscopic intervention.

What can be done if this fails?

A

Sengstaken-blakemore tube:
Bridging therapy, at risk of oesophageal necrosis if left > 24 hours.

Transjugular intrahepatic portosystemic shunt (TIPS) procedure

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2
Q

What is Transjugular intrahepatic portosystemic shunt (TIPS)?

A

Interventional radiological procedure to create a shunt between portal and systemic venous circulation to reduce portal pressure.
A definitive treatment in appropriately selected patients.

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3
Q

When should you admit someone with a lower GI bleed?

A

1) Over 60
2) Unstable
3) On aspirin/NSAID
4) Co-morbidities

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4
Q

1ST line treatment for lower GI bleed if

Unstable
Stable

A

Unstable: Angiogram CT with endoscopy

Stable - elective colonoscopy 2nd - Laparotomy if unclear

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5
Q

How to work out shock index?

A

HR / systolic blood pressure. >1 = shock

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6
Q

Main causes of Upper GI bleeda?

A

Peptic Ulcers (50%)
Gastritis (15-20%)
Varices (10-20%)
Mallory-Weiss (5-10%)

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7
Q

Risk factors for UGIB?

A
  • Anticoagulants
  • NSAIDs
  • Alcohol
  • CKD
  • CLD
  • Previous Peptic ulcer disease
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8
Q

Presentation of UGIB?

A
  • Haematemesis
  • Coffee ground vomit
  • Malaena
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9
Q

How should UGIB be assessed?

A

Glasgow Blatchford Score / Rockall Score

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10
Q

What should be given if ulcers diagnosed in UGIB?

A

IV PPI

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11
Q

UGIB

When should platelets be given

A

If <50

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12
Q

UGIB

What should be given if patient bleeding and on warfarin

A

Prothrombin complex concentrate

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13
Q

Management of UGIB?

A 
ABCDE
Bloods (crossmatch 2 units)
Access (2 large bore cannulas) 
Transfuse 
Endoscopy (within 24hrs) 
Drugs (stop anticoags/ NSAIDs)
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14
Q

Indications for surgery in UGIB?

A

> 60
bleeding continues after endoscopy
recurrent bleeding
- CVS disease and has poor response to hypotension

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15
Q

PEPTIC ULCERS

Main cause?

What % of duodenal/gastric ulcers are due to this cause?

A

H.pylori

95% of duodenal and 75% of gastric are due to HP

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16
Q

PEPTIC ULCERS

Drug causes?

A 
NSAIDs
SSRIs
Steroids
Bisphosphonates 
Zollinger - Ellison syndrome
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17
Q

How do NSAIDs cause ulcers?

A

Inhibit of COX-1 reduces prostaglandins which are mucosal protective

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18
Q

PEPTIC ULCERS

Presentation>

A

Epigastric pain//tenderness
N+V
Dyspepsia

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19
Q

How to test for H.pylori?

A

C13 breath test
Stool antigen test
IgG antibodies in blood (serology)

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20
Q

How would eating affect duodenal and gastric ulcer pain?

A

Duodenal - eating improves pain

Gastric - eating worsens pain

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21
Q

Management of PEPTIC ULCERS?

A

Endoscopy with urease test + biospy/ culture

HIGH DOSE PPI

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22
Q

How to eradicate H.pylori? (no penicillin allergy)

A

Triple therapy

PPI
amoxicillin
metronidazole/ clarithromycin

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23
Q

How to eradicate H.pylori? (penicillin allergy)

A

Triple therapy

PPI
metronidazole
clarithromycin

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24
Q

Complications of PUD?

A

Bleeding
IDA/ Haemorrhage
Perforation - leads to peritonitis
Gastric outlet obstruction (ulceration leads to scarring which leads to stricturing)

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25
Q

What should be given if 1st line h.pylori eradication therapy is unsuccessful?

A

Add quinolone or tetracycline

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26
Q

What drug is not recommended in UC

A

Methotrexate

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27
Q

UC vs Crohns

Location 
Type of inflammation 
histology 
diarrhoea
Associations 
cancer risk
ulcer appearance
signs on x-ray
smoking
A

colon vs whole gut
continuous mucosal vs transmural with skip lesions
Crohns show granulomas and goblets cells
bloody vs non bloody
PSC uveitiis vs gallstones / renal stones, aphthous ulcers
more risk of CRC in UC
superficial psuedopolyps vs cobble stone deep ulcers
loss of haustrations vs kators sign (strictures) + rose thorn ulcers
should stop smoking in Crohns

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28
Q

Signs in both IBD types?

A

Erythema nodosum
Arthritis
diarrhoea

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29
Q

first line treatment of IBD?

A

Crohns - steroids then azathioprine/mercaptopurine/ methotrexate

UC - aminosalicylates then steroids

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30
Q

Drugs for maintaining remission in IBD?

A

Azathioprine / Mercaptopurine

Methotrexate in Crohns

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31
Q

Genetic associations in Coeliacs?

A

HLADQ2 and HLADQ8

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32
Q

Coeliac autoantibodies and signs on endoscopy?

A

Anti-TTG
Anti- endomysial

Crypt hyperplasia
Villous atrophy
inflammatory infiltration

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33
Q

Coeliac Presentation

A

Weight loss
Fatigue
Mouth ulcers
Malabsorption - B12, folate iron deficiencies

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34
Q

Famous sign for Coeliacs

A 
Dermatitis Herpetiformis 
Angular stomatitis (iron and b12 deficiencies)
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35
Q

Gold standard diagnosis of Coeliac disease?

A

Endoscopic intestinal biopsy

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36
Q

Complications for Coeliacs?

A

EATCL - enteropathy associateed T cell lymphoma (primary lymphoma of GI tract

small bowel adenocarcinoma

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37
Q

Associated diseases to Coeliacs?

A 
Diabetes
AI Hepatitis 
Osteoporosis 
PBC
PSC
Thyroid problems
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38
Q

Red flag features for referral? (GORD)

A 
Dysphagia 
age over 55
weight loss
Abdo pain / reflux
Tx resistent dyspepsia 
Nausea + Vomiting
Low Haemoglobin 
Increased platelets
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39
Q

what is barretts oesophagus

A

pre malignant condition where there is metaplasia from squamous to columnar epithelium with a risk of adenocarcinoma of the oesophagus

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40
Q

Treatment of barretts oesophagus?

A

PPIS + regular endoscopy

Laser ablation treatment for those with signs of Dysplasia

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41
Q

how to clinically diagnose IBS?

A

1) Abdominal pain relieved by defecation with associated change in bowel habit

PLUS 2 OF:

  • abnormal stool passage
  • bloating
  • worse symptoms after eating
  • PR mucous

PLUS

Normal inflammatory markers
negative faecal calprotectin
Negative coeliac serology
cancer not suspected / excluded

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42
Q

Tx of Diarrhoea (IBS)

A

Loperamide

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43
Q

Tx of Constipation (IBS)

A

Avoid lactulose as avoids bloating

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44
Q

Tx of cramps (IBS)

A

Hyoscine butylbromide

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45
Q

Differential Diagnosis of the Acute Abdomen

Pain in the: General / Central

A
  • Peritonitis
  • Ruptured AAA
  • Obstruction
  • Ischaemic Colitis
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46
Q

Differential Diagnosis of the Acute Abdomen

Pain in the: RUQ

A

Acute Cholecystitis
Acute Cholangitis
Biliary colic

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47
Q

Differential Diagnosis of the Acute Abdomen

Pain in the: Epigastric region

A
  • Gastritis
  • PUD
  • Pancreatitis
  • Ruptured AAA
  • Inferior MIs (particularly in women)
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48
Q

Differential Diagnosis of the Acute Abdomen

Pain in the: RIF

A
  • Meckel’s Diverticulum
  • Appendicitis
  • Ovarian cysts/ torsion
  • Ectopic Pregnancy
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49
Q

Differential Diagnosis of the Acute Abdomen

Pain in the: LIF

A
  • Diverticulitis
  • Ovarian cysts/ torsion
  • Ectopic Pregnancy
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50
Q

Differential Diagnosis of the Acute Abdomen

Pain in the: Suprapubic region

A

UTI
Urinary Retention
PID
Prostatitis

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51
Q

Differential Diagnosis of the Acute Abdomen

Pain in the: Loin to groin

A

Renal colic

pyelonephritis

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52
Q

Signs of Peritonitis?

A
  • Guarding
  • Rebound Tenderness
  • Ridgity
  • Pain on coughing
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53
Q

BOWEL OBSTRUCTION

3 main causes? (account for 90% of cases)

A

Adhesions
Hernias
Malignancy (accounts for 60% of large bowel obstruction)

54
Q

BOWEL OBSTRUCTION

What are adhesions?

A

FIbrous scar tissue in small bowel that bind contents together

55
Q

BOWEL OBSTRUCTION

Why may adhesions occur

A

Post operative
Peritonitis
PID
Endometriosis

56
Q

BOWEL OBSTRUCTION

What is a closed loop obstruction?

A

two points of obstruction - nowhere to drain or decompress = EMERGENCY SURGERY

(could be 1 point of obstruction but competent ileocaecal valve does not allow movement BACK into the ileum)

57
Q

BOWEL OBSTRUCTION

Key features?

A

1) Abdo pain / distension
2) Vomiting (green bilious)
3) Obstipation / small volume diarrhoea

58
Q

BOWEL OBSTRUCTION

Signs? + bloods

A

Tinkling/ absent bowel sounds
Tenderness / guarding

bloods - raised lactate = ischaemia

59
Q

BOWEL OBSTRUCTION

Signs on x-ray?

A

Distended loops of bowel

60
Q

What is the 3,6,9 rule

A

Small bowel >3cm abnormal
large bowel >6cm abnormal
Caecum >9cm abnormal

(obstruction sign)

61
Q

BOWEL OBSTRUCTION

initial management?

A

“Drip and Suck”

1) Nil by mouth
2) IV Fluids
3) NG tube with free drainage

62
Q

BOWEL OBSTRUCTION

Surgical options?

A
  • Laparscopy / Laparotomy
  • Adhesiolysis
  • Resection of tumour
  • Hernia repair
63
Q

Treatment of ACPO?

A

Pseudo- obstruction

Neostigmine to encourage motility

64
Q

When is ACPO typically seen?

A

Post partum after C-section

65
Q

What is Volvulus?

A

Twisting of the bowel around itself and the mesentery

66
Q

Treatment of Volvulus

A

Drip and Suck

then Endoscopic Decompression

67
Q

Associations with volvulus?

A 
Old age
Neuro disorders (Parkinson's)
68
Q

Definition of:
Diverticulosis
Diverticular Disease
Diverticulitis

A

Diverticulosis - diverticula presence
Diverticular Disease - symptomatic diverticula
Diverticulitis - inflamed diverticula

69
Q

Diverticular Disease

What is it?

A

Herniation of the colonic mucosa through muscular wall of the colon

70
Q

Diverticular Disease

Where is it likely?

A

Usually between taenia coli where vessels pierce the muscle

71
Q

Diverticular Disease

Risk factors?

A 
Diet of red meat and low fibre 
Smoking
Obesity
NSAIDs
Increasing age
72
Q

Diverticular Disease

Diagnosis?

A

Colonoscopy / CT scan

73
Q

Diverticular Disease

Symptoms?

A
  • Lower left abdo pain
  • Constipation
  • Rectal bleeding
  • Altered bowel habit
74
Q

Management of Diverticular Disease?

A

High fibre

Bulk forming laxatives

75
Q

Name a bulk forming laxative

A

Fybogel (ispaghula husk)

76
Q

What should be avoided in Diverticular Disease

A

Stimulant laxatives e.g. senna

77
Q

Additional signs that suggest Diverticulitis?

A

Pyrexia/ Tachycardia
Guarding Tenderness
Increased CRP/WBC

78
Q

How is Diverticulitis diagnosed

A

CT abdo/ pelvis

79
Q

Management of Uncomplicated Diverticulitis?

A 
Co - amoxiclav 7-10 days (metronidazole if allergic) 
Analgesia
clear liquids for 2/3 days
Fluids 
Urgent CT
80
Q

What analgesia should be avoided in Diverticulitis

A

NSAIDs and opiates

81
Q

Diverticulitis

How can this be classified to determine if surgery is needed?

A

Modified Hinchey Classification

82
Q

Describe the Modified Hinchey Classification

A 
IA - Confined pericolic inflammation 
IB - Confined pericolic abscess 
II - Pelvic, retroperitoneal or distant intrabdominal abscess
III - generalised purulent peritonitis 
IV - faecal peritonitis
83
Q

Surgical procedure for Severe diverticulitis?

A

Hartmann’s Procedure

84
Q

Less severe cases of Diverticulitis that still require surgery?

A

Laparoscopic washout + drain insertion

85
Q

Complications of Diverticulitis

A

Fistula
Colonic Stricture
Bleeding

86
Q

MESENTERIC ISCHAEMIA

Define the anatomical landmarks of the

Foregut
Midgut
Hindgut

and their vascular supply

A

Foregut - mouth to ampulla of vater - coeliac trunk
Midgut - ampulla to 2/3 of colon - SMA
Hindgut - distal 1/3 + rectum - IMA

87
Q

MESENTERIC ISCHAEMIA

Classical cause?

A

Emboli of mesenteric artery

88
Q

MESENTERIC ISCHAEMIA

High risk factor?

A

Atrial Fibrillation

Endocarditis

89
Q

MESENTERIC ISCHAEMIA

Immediate treatment of acute?

Mortality percentage?

A

Immediate laparotomy / Embolectomy

50% mortality

90
Q

MESENTERIC ISCHAEMIA

Treatment if due to Thrombosis?

A

Bypass graft

91
Q

MESENTERIC ISCHAEMIA

Presentation of acute?

Diagnosis?

A

Non specific abdo pain

CT with contrast

92
Q

MESENTERIC ISCHAEMIA

Triad of chronic symptoms?

A

1) Abdo pain after eating
2) Weight loss
3) Abdominal bruit

93
Q

MESENTERIC ISCHAEMIA

diagnosis of chronic?

A

CT angiography

94
Q

MESENTERIC ISCHAEMIA

Treatment of chronic?

A

Revascularisation (percutaneous mesenteric artery stenting

95
Q

MESENTERIC ISCHAEMIA

Cause of chronic?

A

Atherosclerosis of SMA

96
Q

Symptoms of Ischaemic Colitis and classical appearance on x-ray?

A

Abdo pain + bloody diarrhoea

Thumbprinting on abdominal x-ray due to mucosal oedema/ haemorrhage

97
Q

What is a hernia?

A

Weakness of cavity wall meaning bowel protrudes through

98
Q

HERNIA

Typical features?

A

Palpable lump that is reducible that may protrude when coughing

99
Q

Percentage of hernias that are inguinal?

A

75% (95% of inguinal hernias are male)

100
Q

What is a Richter Hernia?

A

protrusion and/or strangulation of only part of the circumference of the intestine’s antimesenteric border through a rigid small defect of the abdominal wall

101
Q

What is in the inguinal canal in men and women?

A

Men - spermatic cord

Women - round ligament that attaches to uterus and labia majora

102
Q

Types of inguinal hernia?

A

Direct - protrudes through abdominal wall

Indirect -bowel herniates through inguinal canal

103
Q

Borders of Hesselbach’s triangle?

A 
Rectus abdominus - medial border 
Inferior epigastric vessels - superior
Pouparts ligamant (inguinal ligament) - inferior
104
Q

How can you tell between indirect and direct on examination?

A

When an indirect is reduced to the deep inguinal ring it will remain reduced

105
Q

Complications of Femoral hernia?

A

Incarceration (irreducible)
Obstruction (blockage of faeces passing)
Strangulation (cut off blood supply)

106
Q

Borders of the femoral triangle?

A

SAIL

Sartorius (lateral)
Adductor longus (medial)
Inguinal Ligament (superior)
107
Q

Contents of Femoral triangle?

A

NAVY- C (lateral to medial)

FEMORAL 
Nerve 
Artery
Vein
Y fronts
Canal
108
Q

What does the femoral canal contain?

A

Vessels and lymph nodes

109
Q

What is a Sliding hiatus hernia?

A

Gastro-oesophageal junction emerges through diaphragm into the thorax (95% of hiatus hernias)

110
Q

What is a rolling hiatus hernia?

A

Another part of the stomach e.g. fundus enters through diaphragm

111
Q

Risks of hiatus hernias?\

Symptoms?

A

Increasing age
Pregnancy
Obesity

Symptoms of Dyspepsia

112
Q

What surgery is required for Hiatus Hernias?

A

Laparoscopic Fundoplication - tying fundus of stomach around lower oesophagus to narrow the LOS

113
Q

BOWEL CANCER

What parts of the colon are most likely to be cancerous?

A 
Rectum 40% 
SIgmoid 30%
Descending colon 5%
Transverse 10%
Ascending/ Caecum 15%
114
Q

BOWEL CANCER

What is HNPCC and its associated genes?

A

Autosomal dominant - high risk of CRC and Endometrial cancer + pancreatic cancer

Associated genes? MSH2 and MLH1

115
Q

BOWEL CANCER

What is FAP?

A

Autosomal dominant - Hundreds of polyps by time patient is 40 due to malfunctioning tumour suppressor genes called APC

116
Q

BOWEL CANCER

Red flags?

A
  • Change in bowel habit
  • Unexplained weight loss
  • Rectal bleeding
  • Unexplained abdo pain
  • Iron Deficiency Anaemia
  • Abdo/ Rectal mass on examination
117
Q

BOWEL CANCER

Referral guidance? (2 weeks)

A

Over 40 with abdo pain AND unexplained weight loss

Over 50 with unexplained rectal bleeding

Over 60 with change in bowel habit OR IDA

118
Q

BOWEL CANCER

Urgent referral?

A

Mass found on examination or <50 with any two symptoms suggesting referral

119
Q

BOWEL CANCER

Are people screened?

A

Yes

FIT test for 60-74v year olds every 2 years which detect and quantify amount of blood in stool

Abnormality detected = colonoscopy

120
Q

BOWEL CANCER

Gold standard diagnosis?

A

Colonoscopy

121
Q

BOWEL CANCER

how is it staged?

A

TNM by CT

122
Q

What is Hartmanns Procedure?

A

Emergency Rectosigmoid removal + colostomy

123
Q

What is removed in Right hemicolectomy?

A

Ascending colon
Proximal transverse colon
Caecum

124
Q

What is removed in left hemicolectomy?

A

DIstal transverse colon

Descending colon

125
Q

What is removed in High anterior resection?

A

sigmoid colon

126
Q

What is removed in low anterior resection?

A

upper rectum and sigmoid

127
Q

What is removed in Abdomino - perineal resection?

A

rectum + anus

128
Q

What is a Direct inguinal hernia?

A

When abdominal contents pushes into the inguinal canal through a weak spot (Hasselbach Triangle) and passes through the superficial inguinal ring MEDIAL to inferior epigastric artery

129
Q

Vertebral level of GI arteries?

coeliac trunk, SMA, IMA

A

Coeliac trunk (T12),
SMA (L1),
IMA (L3)

130
Q

By which mechanism does loperamide act through to slow down bowel movements?

A

Loperamide is a μ-opioid receptor agonist which does not have systemic effects as it is not absorbed through the gut

Dannys Medicine Finals (9 decks)

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