General Surgery Flashcards
GI Bleed
Patients may rebleed despite endoscopic intervention.
What can be done if this fails?
Sengstaken-blakemore tube:
Bridging therapy, at risk of oesophageal necrosis if left > 24 hours.
Transjugular intrahepatic portosystemic shunt (TIPS) procedure
What is Transjugular intrahepatic portosystemic shunt (TIPS)?
Interventional radiological procedure to create a shunt between portal and systemic venous circulation to reduce portal pressure.
A definitive treatment in appropriately selected patients.
When should you admit someone with a lower GI bleed?
1) Over 60
2) Unstable
3) On aspirin/NSAID
4) Co-morbidities
1ST line treatment for lower GI bleed if
Unstable
Stable
Unstable: Angiogram CT with endoscopy
Stable - elective colonoscopy 2nd - Laparotomy if unclear
How to work out shock index?
HR / systolic blood pressure. >1 = shock
Main causes of Upper GI bleeda?
Peptic Ulcers (50%)
Gastritis (15-20%)
Varices (10-20%)
Mallory-Weiss (5-10%)
Risk factors for UGIB?
- Anticoagulants
- NSAIDs
- Alcohol
- CKD
- CLD
- Previous Peptic ulcer disease
Presentation of UGIB?
- Haematemesis
- Coffee ground vomit
- Malaena
How should UGIB be assessed?
Glasgow Blatchford Score / Rockall Score
What should be given if ulcers diagnosed in UGIB?
IV PPI
UGIB
When should platelets be given
If <50
UGIB
What should be given if patient bleeding and on warfarin
Prothrombin complex concentrate
Management of UGIB?
ABCDE Bloods (crossmatch 2 units) Access (2 large bore cannulas) Transfuse Endoscopy (within 24hrs) Drugs (stop anticoags/ NSAIDs)
Indications for surgery in UGIB?
> 60
bleeding continues after endoscopy
recurrent bleeding
- CVS disease and has poor response to hypotension
PEPTIC ULCERS
Main cause?
What % of duodenal/gastric ulcers are due to this cause?
H.pylori
95% of duodenal and 75% of gastric are due to HP
PEPTIC ULCERS
Drug causes?
NSAIDs SSRIs Steroids Bisphosphonates Zollinger - Ellison syndrome
How do NSAIDs cause ulcers?
Inhibit of COX-1 reduces prostaglandins which are mucosal protective
PEPTIC ULCERS
Presentation>
Epigastric pain//tenderness
N+V
Dyspepsia
How to test for H.pylori?
C13 breath test
Stool antigen test
IgG antibodies in blood (serology)
How would eating affect duodenal and gastric ulcer pain?
Duodenal - eating improves pain
Gastric - eating worsens pain
Management of PEPTIC ULCERS?
Endoscopy with urease test + biospy/ culture
HIGH DOSE PPI
How to eradicate H.pylori? (no penicillin allergy)
Triple therapy
PPI
amoxicillin
metronidazole/ clarithromycin
How to eradicate H.pylori? (penicillin allergy)
Triple therapy
PPI
metronidazole
clarithromycin
Complications of PUD?
Bleeding
IDA/ Haemorrhage
Perforation - leads to peritonitis
Gastric outlet obstruction (ulceration leads to scarring which leads to stricturing)
What should be given if 1st line h.pylori eradication therapy is unsuccessful?
Add quinolone or tetracycline
What drug is not recommended in UC
Methotrexate
UC vs Crohns
Location Type of inflammation histology diarrhoea Associations cancer risk ulcer appearance signs on x-ray smoking
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
Signs in both IBD types?
Erythema nodosum
Arthritis
diarrhoea
first line treatment of IBD?
Crohns - steroids then azathioprine/mercaptopurine/ methotrexate
UC - aminosalicylates then steroids
Drugs for maintaining remission in IBD?
Azathioprine / Mercaptopurine
Methotrexate in Crohns
Genetic associations in Coeliacs?
HLADQ2 and HLADQ8
Coeliac autoantibodies and signs on endoscopy?
Anti-TTG
Anti- endomysial
Crypt hyperplasia
Villous atrophy
inflammatory infiltration
Coeliac Presentation
Weight loss
Fatigue
Mouth ulcers
Malabsorption - B12, folate iron deficiencies
Famous sign for Coeliacs
Dermatitis Herpetiformis Angular stomatitis (iron and b12 deficiencies)
Gold standard diagnosis of Coeliac disease?
Endoscopic intestinal biopsy
Complications for Coeliacs?
EATCL - enteropathy associateed T cell lymphoma (primary lymphoma of GI tract
small bowel adenocarcinoma
Associated diseases to Coeliacs?
Diabetes AI Hepatitis Osteoporosis PBC PSC Thyroid problems
Red flag features for referral? (GORD)
Dysphagia age over 55 weight loss Abdo pain / reflux Tx resistent dyspepsia Nausea + Vomiting Low Haemoglobin Increased platelets
what is barretts oesophagus
pre malignant condition where there is metaplasia from squamous to columnar epithelium with a risk of adenocarcinoma of the oesophagus
Treatment of barretts oesophagus?
PPIS + regular endoscopy
Laser ablation treatment for those with signs of Dysplasia
how to clinically diagnose IBS?
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
Tx of Diarrhoea (IBS)
Loperamide
Tx of Constipation (IBS)
Avoid lactulose as avoids bloating
Tx of cramps (IBS)
Hyoscine butylbromide
Differential Diagnosis of the Acute Abdomen
Pain in the: General / Central
- Peritonitis
- Ruptured AAA
- Obstruction
- Ischaemic Colitis
Differential Diagnosis of the Acute Abdomen
Pain in the: RUQ
Acute Cholecystitis
Acute Cholangitis
Biliary colic
Differential Diagnosis of the Acute Abdomen
Pain in the: Epigastric region
- Gastritis
- PUD
- Pancreatitis
- Ruptured AAA
- Inferior MIs (particularly in women)
Differential Diagnosis of the Acute Abdomen
Pain in the: RIF
- Meckel’s Diverticulum
- Appendicitis
- Ovarian cysts/ torsion
- Ectopic Pregnancy
Differential Diagnosis of the Acute Abdomen
Pain in the: LIF
- Diverticulitis
- Ovarian cysts/ torsion
- Ectopic Pregnancy
Differential Diagnosis of the Acute Abdomen
Pain in the: Suprapubic region
UTI
Urinary Retention
PID
Prostatitis
Differential Diagnosis of the Acute Abdomen
Pain in the: Loin to groin
Renal colic
pyelonephritis
Signs of Peritonitis?
- Guarding
- Rebound Tenderness
- Ridgity
- Pain on coughing
BOWEL OBSTRUCTION
3 main causes? (account for 90% of cases)
Adhesions
Hernias
Malignancy (accounts for 60% of large bowel obstruction)
BOWEL OBSTRUCTION
What are adhesions?
FIbrous scar tissue in small bowel that bind contents together
BOWEL OBSTRUCTION
Why may adhesions occur
Post operative
Peritonitis
PID
Endometriosis
BOWEL OBSTRUCTION
What is a closed loop obstruction?
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)
BOWEL OBSTRUCTION
Key features?
1) Abdo pain / distension
2) Vomiting (green bilious)
3) Obstipation / small volume diarrhoea
BOWEL OBSTRUCTION
Signs? + bloods
Tinkling/ absent bowel sounds
Tenderness / guarding
bloods - raised lactate = ischaemia
BOWEL OBSTRUCTION
Signs on x-ray?
Distended loops of bowel
What is the 3,6,9 rule
Small bowel >3cm abnormal
large bowel >6cm abnormal
Caecum >9cm abnormal
(obstruction sign)
BOWEL OBSTRUCTION
initial management?
“Drip and Suck”
1) Nil by mouth
2) IV Fluids
3) NG tube with free drainage
BOWEL OBSTRUCTION
Surgical options?
- Laparscopy / Laparotomy
- Adhesiolysis
- Resection of tumour
- Hernia repair
Treatment of ACPO?
Pseudo- obstruction
Neostigmine to encourage motility
When is ACPO typically seen?
Post partum after C-section
What is Volvulus?
Twisting of the bowel around itself and the mesentery
Treatment of Volvulus
Drip and Suck
then Endoscopic Decompression
Associations with volvulus?
Old age Neuro disorders (Parkinson's)
Definition of:
Diverticulosis
Diverticular Disease
Diverticulitis
Diverticulosis - diverticula presence
Diverticular Disease - symptomatic diverticula
Diverticulitis - inflamed diverticula
Diverticular Disease
What is it?
Herniation of the colonic mucosa through muscular wall of the colon
Diverticular Disease
Where is it likely?
Usually between taenia coli where vessels pierce the muscle
Diverticular Disease
Risk factors?
Diet of red meat and low fibre Smoking Obesity NSAIDs Increasing age
Diverticular Disease
Diagnosis?
Colonoscopy / CT scan
Diverticular Disease
Symptoms?
- Lower left abdo pain
- Constipation
- Rectal bleeding
- Altered bowel habit
Management of Diverticular Disease?
High fibre
Bulk forming laxatives
Name a bulk forming laxative
Fybogel (ispaghula husk)
What should be avoided in Diverticular Disease
Stimulant laxatives e.g. senna
Additional signs that suggest Diverticulitis?
Pyrexia/ Tachycardia
Guarding Tenderness
Increased CRP/WBC
How is Diverticulitis diagnosed
CT abdo/ pelvis
Management of Uncomplicated Diverticulitis?
Co - amoxiclav 7-10 days (metronidazole if allergic) Analgesia clear liquids for 2/3 days Fluids Urgent CT
What analgesia should be avoided in Diverticulitis
NSAIDs and opiates
Diverticulitis
How can this be classified to determine if surgery is needed?
Modified Hinchey Classification
Describe the Modified Hinchey Classification
IA - Confined pericolic inflammation IB - Confined pericolic abscess II - Pelvic, retroperitoneal or distant intrabdominal abscess III - generalised purulent peritonitis IV - faecal peritonitis
Surgical procedure for Severe diverticulitis?
Hartmann’s Procedure
Less severe cases of Diverticulitis that still require surgery?
Laparoscopic washout + drain insertion
Complications of Diverticulitis
Fistula
Colonic Stricture
Bleeding
MESENTERIC ISCHAEMIA
Define the anatomical landmarks of the
Foregut
Midgut
Hindgut
and their vascular supply
Foregut - mouth to ampulla of vater - coeliac trunk
Midgut - ampulla to 2/3 of colon - SMA
Hindgut - distal 1/3 + rectum - IMA
MESENTERIC ISCHAEMIA
Classical cause?
Emboli of mesenteric artery
MESENTERIC ISCHAEMIA
High risk factor?
Atrial Fibrillation
Endocarditis
MESENTERIC ISCHAEMIA
Immediate treatment of acute?
Mortality percentage?
Immediate laparotomy / Embolectomy
50% mortality
MESENTERIC ISCHAEMIA
Treatment if due to Thrombosis?
Bypass graft
MESENTERIC ISCHAEMIA
Presentation of acute?
Diagnosis?
Non specific abdo pain
CT with contrast
MESENTERIC ISCHAEMIA
Triad of chronic symptoms?
1) Abdo pain after eating
2) Weight loss
3) Abdominal bruit
MESENTERIC ISCHAEMIA
diagnosis of chronic?
CT angiography
MESENTERIC ISCHAEMIA
Treatment of chronic?
Revascularisation (percutaneous mesenteric artery stenting
MESENTERIC ISCHAEMIA
Cause of chronic?
Atherosclerosis of SMA
Symptoms of Ischaemic Colitis and classical appearance on x-ray?
Abdo pain + bloody diarrhoea
Thumbprinting on abdominal x-ray due to mucosal oedema/ haemorrhage
What is a hernia?
Weakness of cavity wall meaning bowel protrudes through
HERNIA
Typical features?
Palpable lump that is reducible that may protrude when coughing
Percentage of hernias that are inguinal?
75% (95% of inguinal hernias are male)
What is a Richter Hernia?
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
What is in the inguinal canal in men and women?
Men - spermatic cord
Women - round ligament that attaches to uterus and labia majora
Types of inguinal hernia?
Direct - protrudes through abdominal wall
Indirect -bowel herniates through inguinal canal
Borders of Hesselbach’s triangle?
Rectus abdominus - medial border Inferior epigastric vessels - superior Pouparts ligamant (inguinal ligament) - inferior
How can you tell between indirect and direct on examination?
When an indirect is reduced to the deep inguinal ring it will remain reduced
Complications of Femoral hernia?
Incarceration (irreducible)
Obstruction (blockage of faeces passing)
Strangulation (cut off blood supply)
Borders of the femoral triangle?
SAIL
Sartorius (lateral) Adductor longus (medial) Inguinal Ligament (superior)
Contents of Femoral triangle?
NAVY- C (lateral to medial)
FEMORAL Nerve Artery Vein Y fronts Canal
What does the femoral canal contain?
Vessels and lymph nodes
What is a Sliding hiatus hernia?
Gastro-oesophageal junction emerges through diaphragm into the thorax (95% of hiatus hernias)
What is a rolling hiatus hernia?
Another part of the stomach e.g. fundus enters through diaphragm
Risks of hiatus hernias?\
Symptoms?
Increasing age
Pregnancy
Obesity
Symptoms of Dyspepsia
What surgery is required for Hiatus Hernias?
Laparoscopic Fundoplication - tying fundus of stomach around lower oesophagus to narrow the LOS
BOWEL CANCER
What parts of the colon are most likely to be cancerous?
Rectum 40% SIgmoid 30% Descending colon 5% Transverse 10% Ascending/ Caecum 15%
BOWEL CANCER
What is HNPCC and its associated genes?
Autosomal dominant - high risk of CRC and Endometrial cancer + pancreatic cancer
Associated genes? MSH2 and MLH1
BOWEL CANCER
What is FAP?
Autosomal dominant - Hundreds of polyps by time patient is 40 due to malfunctioning tumour suppressor genes called APC
BOWEL CANCER
Red flags?
- Change in bowel habit
- Unexplained weight loss
- Rectal bleeding
- Unexplained abdo pain
- Iron Deficiency Anaemia
- Abdo/ Rectal mass on examination
BOWEL CANCER
Referral guidance? (2 weeks)
Over 40 with abdo pain AND unexplained weight loss
Over 50 with unexplained rectal bleeding
Over 60 with change in bowel habit OR IDA
BOWEL CANCER
Urgent referral?
Mass found on examination or <50 with any two symptoms suggesting referral
BOWEL CANCER
Are people screened?
Yes
FIT test for 60-74v year olds every 2 years which detect and quantify amount of blood in stool
Abnormality detected = colonoscopy
BOWEL CANCER
Gold standard diagnosis?
Colonoscopy
BOWEL CANCER
how is it staged?
TNM by CT
What is Hartmanns Procedure?
Emergency Rectosigmoid removal + colostomy
What is removed in Right hemicolectomy?
Ascending colon
Proximal transverse colon
Caecum
What is removed in left hemicolectomy?
DIstal transverse colon
Descending colon
What is removed in High anterior resection?
sigmoid colon
What is removed in low anterior resection?
upper rectum and sigmoid
What is removed in Abdomino - perineal resection?
rectum + anus
What is a Direct inguinal hernia?
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
Vertebral level of GI arteries?
coeliac trunk, SMA, IMA
Coeliac trunk (T12),
SMA (L1),
IMA (L3)
By which mechanism does loperamide act through to slow down bowel movements?
Loperamide is a μ-opioid receptor agonist which does not have systemic effects as it is not absorbed through the gut
