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General Surgery Flashcards

1
Q

Causes of jaundice

pre, intra and post hepatic

A

pre - gilbert’s disease, haemolytic anaemia, physiological in neonate

hepatic - alcohol, cirrhosis, NAFLD, hepatitis, PBC, PSC, carcinoma, heart failure, haemochromatosis

post - choledocholithiasis, head of pancreas cancer, biliary stricture

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2
Q

Labs for pre, intra and post hepatic jaundice

A

pre - unconjugated bilirubin, normal transaminases, intravascular haemolysis has Hb and hemosoderin in urine, IV and EV haemolysis has urobilinogen

hepatic - mixed bilirubin, tranaminitis, deranged synthetic function

post - conjugated, increased ALP/GGT, bilirubinuria (no urobilinogen; not making it to the SI)

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3
Q

types of biliary stones

A

mixed cholesterol (80%)
pure cholesterol
pigment stones - bilirubin
brown - infection

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4
Q

complications of gallstones

A 
biliary cholic
cholecystitis
choledocholithiasis
cholangitis
pancreatitis
gallstone ileum
gallbladder empyema
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5
Q

common bacteria in biliary tract

A 
klebsiella
enterococcus
e coli
enterobacter
proteus
pseuodmonas
serratia
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6
Q

pathogenesis of biliary colic vs acute cholecystitis

A

biliary colic - transient obstruction of GB neck or cystic duct, contraction against obstruction causes pain

acute cholecystitis - sustained obstruction of GB neck or cystic duct, obstruction leads to inflammation and bacterial inflammation, inflammation is detected by parietal peritoneum

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7
Q

management of acute cholecystitis

A

medical - gentamicin and amoxycillin

surgical - lap cholecystectomy with IOC or percutaneous cholecystostomy for those unfit for surgery

supportive - U/O, NBM, IV, analgesia, anti emetics, VTE prophylaxis

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8
Q

signs of CBD obstruction

A 
jaundice
raised bilirubin 
pale stool
dark urine
deranged LFTs
dilated bile ducts
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9
Q

complications of CBD obstruction

A 
cholangitis
pancreatitis
perforation 
biliary stricture
biliary cirrhosis
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10
Q

what is charcot triad and Reynolds pentad

A

for cholangitis

RUQ pain, fever, jaundice

pentad - add hypotension and altered LOC

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11
Q

Counselling for laparoscopic cholecystectomy

A

brief history

before - NBM, bloods, GA, prophylactic antibiotics

during - key hole, a few ports, IOC performed, GB removed

after - monitoring, ward, analgesia, chest physio, discharge next day
long term - recovery around 2 weeks, no heavy lifting, no driving until pain free

benefits - definitive, simple

risks - general, bleeding of cystic artery, perforation of biliary tree or gut, conversion to open, incisional hernias and adhesions

alternatives - open surgery, oral dissolution, watch and wait

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12
Q

what is courvoisier’s law

A

painless dilated palpable gallbladder with jaundice is unlikely gallstones

indicated head of pancreas or gallbladder malignancy

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13
Q

risk factors for hepatocellular carcinoma

A

chronic liver inflammation - viral hep, alcoholism, NAFLD, haemochromatosis, PBC

other - smoking, OCP, fam hx, aflatoxin

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14
Q

cancers that metastasise to the liver

A 
colorectal
stomach
pancreas
breast
lung
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15
Q

contraindications to liver transplant

A 
malignancy that is extra hepatic
severe cardioresp disease
ongoing alcohol or drug use
AIDS
sepsis
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16
Q

scoring of cirrhosis

A

child pugh

albumin
bilirubin 
coagulation - INR
distension - ascites
encephalopathy
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17
Q

clinical signs and management of splenic trauma

A

LUQ pain and tenderness

Kehr’s sign - radiating left shoulder pain

hypovolemic shock
peritonism

mx - bloods, fast USS, CT CAP with contrast, resuscitations, laparotomy

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18
Q

post splenectomy management

A

vaccinations

amoxycillin given to take at first sign of infection

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19
Q

general cause of the following patterns of onset for acute abdomen
- sudden, cramps and slow, severe and worsening, colicky

A

sudden - visceral perforation
crampy and slow - visceral obstruction
severe and steadily worsening - intestinal ischaemia
colicky - bowel obstruction or ureteric stones

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20
Q

red flag symptoms for upper GIT

A

ALARMS

anaemia
loss of weight
age >55
recent onset
malena or haematochezia
swallow difficulty
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21
Q

aetiology of PUD

A 
h.pylori
NSAIDs
physiological stress 
ischaemic 
zollinger-ellison
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22
Q

pathogenesis of PUD from h.pylori

A

stimulates acid hyper secretion from parietal cells
breaks down mucosal layer
inflammatory response
gastric metaplasia

protease - breaks down mucous
urease - converts urea to NH3 to neutralise acid
flagella - motile in mucus

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23
Q

diagnosis and eradication of h.pylori

A

dx - urea breath test, serology, stool Ag, biopsy

eradication - esomeprazole, clarithromycin, amoxicillin (PPI + gram -ve + gram +ve)

24
Q

duodenal vs gastric ulcers

A

duodenal - most common, epigastric pain relieved by eating, worse at night and before meals

gastric - lesser curvature, epigastric pain worse with meals, relieved with antacids

25
complications of PUD
``` IDA haemorrhage perforation gastric outlet obstruction gastric cancer ```
26
Ddx hematemesis
``` varices oesophagitis mallory weiss tear PUD gastritis gastric or oesophageal cancer ```
27
classification of hiatus hernias
sliding (90%) - GOJ +/- cardia hernias through oesophageal hiatus rolling - fundus herniates alongside normal GEJ creating a bubble of stomach
28
management of hiatus hernias
conservative - weight loss, smaller meals, smoking cessation, PPI surgery - if severe symptoms, fundoplication
29
pathophysiology of indirect inguinal hernia
incomplete obliteration of processus vaginalis leaves open communication with internal peritoneum
30
course of the inguinal canal
inferiorly and medially, deep to superficial, through abdominal wall superior and parallel to inguinal ligament lateral to inferior epigastric artery
31
location of deep and superficial inguinal ring
deep - mid inguinal point between ASIS and pubic symphysis superficial - opening of external oblique superior to pubic tubercle
32
walls of the inguinal canal
posterior - transversalis fascia anterior - external oblique roof - transversalis fascia, transversus abdomens and internal oblique floor - inguinal ligament
33
contents of inguinal canal in males and females
male - spermatic cord, ilioinguinal nerve female - round ligament, ilioinguinal nerve
34
contents of spermatic cord
3 arteries - cremasteric, ductus deferens, testicular 3 nerves - genital branch of genitofemoral, sympathetic fibres, cremasteric 3 other - ductus deferens, lymphatics, pampiniform plexus
35
what is hesselbach's triangle and what the the borders
direct hernias go through here superolateral - inferior epigastric vessels medial - rectus abdominus lateral border inferior - inguinal ligament
36
risk factors for hernias
``` male weak abdominal wall - scar, congenital chronic cough constipation straining to urinate vomiting pregnancy and childbirth heavy lifting obesity ```
37
management options for hernias
conservative - if hernia is reducible and asx - abdominal binder - correct cause of raised IAP surgery - incarceration, obstruction, strangulation
38
indirect vs direct vs femoral hernia
indirect - most common, superior to inguinal ligament, medial to pubic tubercle, cough impulse positive over deep ring direct - less common, through hasselbachs triangle, less complications, bulge will be medial in cough impulse femoral - more in females, inferior to inguinal ligament, lateral to pubic tubercle, no cough impulse, often irreducible, medial to femoral artery and vein
39
specific complications of hernia repair
``` scrotal haematoma urinary retention scar - hernia, adhesion infection of mesh chronic inguinal pain nerve injury - ilioinguinal and femoral testicular atrophy damage to vas deferens ```
40
causes of SBO
extramural - adhesion, hernia, mass intramural - intussusception, stricture, ischaemia, neoplasm intraluminal - gallstone ileum, FB
41
4 hallmarks of SBO
abdominal pain - colicky and cramping, central vomiting - bilious then feculent absolute constipation abdominal distension
42
red flags for SBO
constant pain increased severity generalised peritonsim feculent emesis
43
Ix for SBO
bedside - dipstick, VBG, bHCG bloods - FBC, UEC, CMP, LFT, lipase, G&H imaging - erect CXR, AXR, CT abdo
44
CT findings for SBO
dilated small bowel loops >3cm, mucosal folds go across entire lumen, distal bowel decompression
45
management of SBO
conservative - drip and suck - NGT with suction and NBM - IVF surgical - obstruction >48hrs conservative - strangulation, perforation - triple Abx therapy
46
causes of LBO
most common - CRC, diverticular disease, volvulus extramural - volvulus, adhesion intramural - CRC, diverticulitis, stricture intraluminal - faecal impaction, FB pseudo-obstruction
47
management of LBO
IVF drip and suck surgery supportive
48
gastric cancer diffuse (hereditary) vs adenocarcinoma (sporadic)
diffuse - rare, genetic mutation, diffuse thickening of stomach wall, infiltrates entire stomach, poor prognosis adenocarcinoma - more common, lifestyle risk factors, projectile tumour, better prognosis
49
symptoms and signs of appendicitis
sx - migratory abdo pain, n&v, anorexia signs - still, febrile, involuntary guarding, peritonism, mcburney's point, rousing's, psoas and obturator sign
50
management of appendicitis
active - lap appendicectomy with cephazolin and metro supportive
51
specific risks of appendicectomy
``` abdominal abscess adhesions incisional hernia damage to bowel (resect bowel) conversion to open if appendix is adhered to colon, need to remove part of that too ```
52
types of neoplastic and non neoplastic polyps
neoplastic - adenomas (tubular, tubulovillous, villous), hamartomas non neoplastic - hyperplastic, inflammatory pseudopolyps
53
hyperplastic polyp vs adenoma
hyperplastic polyp - common, <5mm, no malignancy potential adenoma - 3-10mm, can become malignant, dysplastic
54
Types of benign breast conditions
Inflammatory - mastitis, abscess, ductal ectasia, fat necrosis Benign neoplasms - fibrocystic change, fibroadenoma, lipoma
55
Treatment of mastitis and breast abscess
Flucloxacillin and continued breast feeding for both Abscess - I&D Paracetamol, hot and cold packs, correct breastfeeding positioning and attachment
56
2 types of invasive breast cancers
ductal - dense fibrous stroma with radiating bands lobular - pleomorphic small cells form linear single-line clusters, stromal pattern of spread

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