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Finals > General surgery > Flashcards

General surgery Flashcards

1
Q

what 6 things need to be addressed pre-op?

A
  1. pre-op assessment
  2. consent
  3. bloods (inc G&S/crossmatch)
  4. fasting
  5. medication changes
  6. VTE assessment
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2
Q

what is included in a pre-op assessment

A

a full hx of:

  1. PMH
  2. previous surgery
  3. previous adverse response to anaesthesia
  4. medications
  5. allergies
  6. smoking
  7. alcohol use

consider pregnancy in women of childbearing age

FH of sickle cell disease

general examination for CVS and resp disease

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3
Q

if malnourished (BMI<18.5), what may be required before surgery

A
  • dietician input

- additional nutritional support before surgery + during admission

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4
Q

What is the ASA grade

A

The American Society of Anaesthesiologists grading system classifies the physical status of the pt for anaesthesia

patients given grade to describe their current fitness prior to undergoing anaesthesia/surgery

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5
Q

ASA I?

A

normal healthy patient

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6
Q

ASA II?

A

mild systemic disease

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7
Q

ASA III?

A

severe systemic disease

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8
Q

ASA IV

A

severe systemic disease that constantly threatens life

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9
Q

ASA V

A

‘moribund’ + expected to die without the operation

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10
Q

ASA VI

A

declared brain-dead and undergoing an organ donation operation

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11
Q

E?

A

this is used for emergency operations

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12
Q

why do pts fast before surgery?

A

ensures they have an empty stomach for the duration of their operation

aim: reduce the risk of reflux of food around the time of surgery (particularly during intubation + extubation)

which subsequently can result in the patient aspiration their stomach contents into their lungs

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13
Q

fasting for an operation typically involves?

A
  • 6 hours of no food or feeds before operation

- 2 hours no clear fluids (fully nil by mouth)

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14
Q

what medications need to be stopped before surgery

A
  • anticoagulants
  • oestrogen containing contraception
  • HRT
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15
Q

what can be used to bridge the gap between stopping warfarin and surgery in higher risk pts? e.g. mechanical heart valves or recent VTE

A

trx dose LMWH or an unfractionated heparin infusion

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16
Q

How long before surgery are DOACs stopped?

A

24-72 hours depending on half-life, procedure and kidney function

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17
Q

why are oestrogen containing contraception

and HRT stopped before surgery?

A

to reduce the risk of VTE

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18
Q

how long before surgery are oestrogen containing contraception
+ HRT stopped/

A

4 weeks

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19
Q

why do pts on long term steroids need more steroid before surgery?

A

surgery adds additional stress to body which normally increases steroid production

in pts on long term steroids, there is adrenal suppression that prevents them from creating extra steroids required to deal with this stress

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20
Q

what is the mnx for pts on long term steroids before surgery?

A
  • additional IV hydrocortisone at induction + immediate postoperative period
  • double normal dose once they are eating + drinking for 24–72 hours depending on the operation
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21
Q

what do you do in pts on insulin going for surgery?

A
  • continue a lower dose (80%) of long-acting insulin
  • stop short acting insulin whilst fasting
  • start variable rate insulin infusion alongside glucose, NaCl + K infusion (sliding scale)
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22
Q

what PO anti-diabetic meds need to be adjusted or omitted around surgery and why?

A
  1. Sulfonylureas (gliclazide) : hypoglycaemia
  2. Metformin: lactic acidosis
  3. SGLT2 inhibitors (dapagliflozin): diabetic ketoacidosis
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23
Q

VTE prophylaxis before surgery?

A
  • LMWH (enoxaparin)
  • DOACs as an alternative
  • intermittent pneumatic compression (inflating cuffs around the legs)
  • anti-embolic compression stockings
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24
Q

what is the 4 criteria that a patient needs to meet to demonstrate capacity to make a decision?

A
  1. understand the decision
  2. retain the info long enough to make the decision
  3. weigh up the pros and cons
  4. communicate their decision
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25
Q

lasting power of attorney?

A

when a person legally nominates a person of their choice to make decisions on their behalf if they lack mental capacity.

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26
Q

Deprivation of liberty safeguards (DoLS) ?

A

involves an application made by a hospital or care home for patients who lack capacity to allow them to provide care and treatment.

Whilst in hospital, or a care home, the patient is under control and is not able to leave.

This means they are “deprived of their liberty” and require a legal framework to protect them.

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27
Q

Consent form 1?

A

Patient consenting to a procedure

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28
Q

Consent form 2?

A

Parental consent on behalf of a child

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29
Q

Consent form 3?

A

Where the patient won’t have their consciousness impaired (e.g., a breast biopsy)

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30
Q

Consent form 4?

A

Where the patient lacks capacity

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31
Q

Acute Abdomen

differential diagnoses for generalised abdo pain (4)

A
  1. peritonitis
  2. ruptured AAA
  3. intestinal obstruction
  4. ischaemic colitis
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32
Q

Acute Abdomen

differentials for RUQ pain (3)

A
  1. biliary colic
  2. acute cholecystitis
  3. acute cholangitis
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33
Q

Acute Abdomen

differentials for epigastric pain (4)

A
  1. acute gastritis
  2. peptic ulcer disease
  3. pancreatitis
  4. ruptured AAA
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34
Q

Acute Abdomen

differentials for central abdo pain (4)

A
  1. ruptured AAA
  2. intestinal obstruction
  3. ischaemic colitis
  4. early stages of appendicitis
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35
Q

Acute Abdomen

differentials for right iliac fossa pain (5)

A
  1. acute appendicitis
  2. ectopic pregnancy
  3. ruptured ovarian cyst
  4. ovarian torsion
  5. Meckel’s diverticulitis
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36
Q

Acute Abdomen

differentials for left iliac fossa pain (4)

A
  1. diverticulitis
  2. ectopic pregnancy
  3. ruptured ovarian cyst
  4. ovarian torsion
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37
Q

Acute Abdomen

differentials for suprapubic pain (4)

A
  1. lower UTI
  2. acute urinary retention
  3. pelvic inflammatory disease
  4. prostatitis
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38
Q

Acute Abdomen

differentials for loin to groin pain (3)

A
  1. renal colic (kidney stones)
  2. ruptured AAA
  3. pyelonephritis
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39
Q

Acute Abdomen

differentials for testicular pain (2)

A
  1. testicular torsion

2. epididymo-orchitis

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40
Q

Signs of peritonitis

A
  • guarding
  • rigidity: involuntary persistent tightness of the abdo wall muscles
  • rebound tenderness: rapidly releasing pressure on abdo creates worse pain than the pressure itself
  • coughing test: does coughing result in pain in the abdo?
  • percussion tenderness
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41
Q

what causes localised peritonitis?

A

underlying organ inflammation e.g. appendicitis or cholecystitis

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42
Q

what causes generalised peritonitis?

A

perforation of an abdo organ eg perforated duodenal ulcer or ruptured appendix releasing the contents into the peritoneal cavity + causing generalised inflammation of the peritoneum

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43
Q

what is spontaneous bacterial peritonitis associated with>

A

spontaneous infection of ascites in patients with liver disease

treated with broad-spectrum abx + carries poor prognosis

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44
Q

Appendicitis

peak incidence

A

10-20 years

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45
Q

Appendicitis

pathophysiology

A

pathogens get trapped due to obstruction at the point where the appendix meets the bowel

leading to infection + inflammation

may proceed to gangrene + rupture

which could lead to peritonitis

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46
Q

Appendicitis

where is McBurney’s point?

A

1/3 of the distance from the anterior superior iliac spine (ASIS) to the umbilicus

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47
Q

Appendicitis

signs

A
  • tenderness at McBurney’s point
  • Rovsing’s sign
  • guarding
  • rebound tenderness
  • percussion tenderness
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48
Q

Appendicitis

what is Rovsing’s sign?

A

palpation of the left iliac fossa causes pain in the RIF

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49
Q

Appendicitis

symptoms

A
  • loss of appetite
  • N+V
  • low-grade fever
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50
Q

Appendicitis

what would suggest a ruptured appendix?

A

rebound tenderness + percussion tenderness –> peritonitis

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51
Q

Appendicitis

diagnosis

A

clinical presentation + raised inflammatory markers

CT scan can be useful in confirming diagnosis

USS often used to exclude gynae pathology

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52
Q

Appendicitis

what to do if clinical presentation is suggestive of appendicitis, but investigations are negative

A

diagnostic laparoscopy then surgeon can proceed to appendicectomy during the same procedure

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53
Q

Appendicitis

key differentials

A
  • ovarian cysts
  • Meckel’s Diverticulum
  • Mesenteric Adenitis
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54
Q

Appendicitis

when does an appendix mass occur?

A

when the omentum surrounds + sticks to the inflamed appendix forming a mass in the right iliac fossa

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55
Q

Appendicitis

definitive mnx

A

appendicectomy

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56
Q

Appendicitis

complications of an appendicectomy

A
  • bleeding, infection, pain + scars
  • damage to bowel, bladder + other organs
  • removal of normal appendix
  • anaesthetic risks
  • VTE
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57
Q

Bowel Obstruction

what is bowel obstruction

A

when the passage of food, fluids and gas, through the intestines becomes blocked

causing build up of gas + faecal matter proximal to the obstruction (before the obstruction)

this causes back-pressure –> vomiting + dilatation of the intestines proximal to the obstruction

surgical emergency!

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58
Q

Bowel Obstruction

which is more common, small or large?

A

small

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59
Q

Bowel Obstruction

what is third spacing?

A

GI tract secretes fluid that is later absorbed in the colon

when there is obstruction, fluid cannot reach the colon and be reabsorbed

causing fluid loss from the intravascular space into the GI tract –> hypovolaemia + shock

this abnormal loss of fluid is third-spacing.

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60
Q

Bowel Obstruction

3 big causes

A
  1. Adhesions (small bowel)
  2. Hernias (small bowel)
  3. Malignancy (large bowel)
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61
Q

Bowel Obstruction

other causes

A
  • volvulus (large bowel)
  • diverticular disease
  • strictures (secondary to Crohn’s disease)
  • intussusception (6m-2yrs)
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62
Q

Bowel Obstruction

what are adhesions

A

pieces of scar tissue that bind the abdo contents together

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63
Q

Bowel Obstruction

how do adhesions cause bowel obstruction

A

they can cause kinking or squeezing of the bowel

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64
Q

Bowel Obstruction

main causes of adhesions (4)

A
  1. abdo or pelvic surgery (esp open surgery)
  2. peritonitis
  3. abdo or pelvic infections (PID)
  4. endometriosis

less common: congenital or secondary to radiotherapy trx

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65
Q

Bowel Obstruction

what is closed-loop obstruction

A

where there are 2 points of obstruction along the bowel, meaning that there is a middle section sandwiched between 2 points of obstruction

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66
Q

Bowel Obstruction

how would adhesions cause closed-loop obstruction

A

compresses 2 areas of bowel

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67
Q

Bowel Obstruction

how would hernias cause closed-loop obstruction

A

could isolate a section of bowel blocking either end

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68
Q

Bowel Obstruction

how would volvulus cause closed-loop obstruction

A

where the twist isolates a section of intestine

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69
Q

Bowel Obstruction

how would a competent ileocecal valve cause closed-loop obstruction

A

a competent ileocecal valve does not allow any movement back into the ileum from the caecum

a section of bowel becomes isolated and the contents cannot flow in either direction

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70
Q

Bowel Obstruction

causes of closed-loop obstruction

A
  1. adhesions
  2. hernias
  3. volvulus
  4. competent ileocecal valve + obstructing lesion
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71
Q

Bowel Obstruction

what could a closed-loop obstruction lead to?

A

bowel can’t drain and decompress so closed loop section will continue to expand leading to ischaemia + perforation

emergency surgery

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72
Q

Bowel Obstruction

key features (5)

A
  1. vomiting (esp green bilious vomiting)
  2. abdo distention
  3. diffuse abdo pain
  4. absolute constipation + lack of flatulence
  5. ‘tinkling’ bowel sounds may be heard in early bowel obstruction
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73
Q

Bowel Obstruction

Inx and key finding

A

abdo X-ray

  • DISTENDED LOOPS OF BOWEL
  • Valvulae conniventes
  • Haustra
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74
Q

Bowel Obstruction

upper limits of the normal diameter of bowel

A

3cm small bowel

6cm colon

9cm caecum

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75
Q

Bowel Obstruction

what are Valvulae conniventes

A

mucosal folds that form lines extending the full width of the small bowel

these are seen on an abdo x-ray as lines across the entire width of the bowel

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76
Q

Bowel Obstruction

what are haustra?

A

like pouches formed by the muscles in the walls of the large bowel

they form lines that DO NOT extend the full width of the bowel

seen on abdo x-ray as lines that extend only part of the way across the bowel

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77
Q

Bowel Obstruction

when would patients require urgent intervention?

A

if they’re haemodynamically unstable and if they have developed:

  • hypovolaemic shock due to fluid stuck in the bowel rather than the intravascular space (third-spacing)
  • bowel ischaemia
  • bowel perforation
  • sepsis
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78
Q

Bowel Obstruction

initial mnx

A
  • ABCDE
  • full set of bloods
  • nil by mouth
  • IV fluids
  • NG tube w/ free drainage to allow stomach contents to freely drain + reduce the risk of vomiting + aspiration
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79
Q

Bowel Obstruction

what would the blood results show?

A
  • electrolyte imbalances
  • metabolic alkalosis: vomiting
  • raised lactate: bowel ischaemia
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80
Q

Bowel Obstruction

imaging

A
  • abdo x-ray
  • erect chest x-ray: air under diaphragm if intra-abdo perforation
  • contract abdo CT scan: to confirm dx
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81
Q

Bowel Obstruction

when to use conservative mnx

A

in the first instance in stable patients with obstruction secondary to adhesions or volvulus

where this fails, surgery is required

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82
Q

Bowel Obstruction

definitive mnx

A

surgery to correct the underlying cause:

  • exploratory surgery: unclear
  • adhesiolysis: treat adhesions
  • hernia repair
  • emergency resection: obstructing tumour
  • stents: obstructing tumour
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83
Q

Acute Cholecystitis

what is it

A

inflammation of the gallbladder caused by a blockage of the cystic duct preventing the gallbladder from draining

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84
Q

Acute Cholecystitis

cause

A

calculous cholecystitis: gallstones trapped in the neck of the gallbladder or the cystic duct

acalculous cholecystitis: eg pts on total parenteral nutrition or having long periods of fasting, where the gallbladder is not being stimulated by food to regularly empty resulting in a build up pressure

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85
Q

Acute Cholecystitis

main presenting symptom

A

pain in the RUQ

may radiate to right shoulder

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86
Q

Acute Cholecystitis

other features

A
  • fever
  • N+V
  • tachycardia + tachypnoea
  • RUQ tenderness
  • Murphy’s sign
  • raised inflammatory markers + WBCs
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87
Q

Acute Cholecystitis

what is Murphy’s sign

A
  • place hand in RUQ and apply pressure
  • pt takes deep breath in
  • gallbladder will move down during inspiration and come in contact with your hand
  • resulting in acute pain and sudden stopping of inspiration
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88
Q

Acute Cholecystitis

initial inx and results

A

abdo USS

  • thickened gallbladder wall
  • stones or sludge in gallbladder
  • fluid around the gallbladder
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89
Q

Acute Cholecystitis

other inx

A

magnetic resonance cholangiopancreatography (MRCP)

to visualise biliary tree in more detail if a common bile duct stone is suspected but not see on USS (bile duct dilatation or raised bilirubin)

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90
Q

Acute Cholecystitis

conservative mnx

A
  • emergency admission
  • nil by mouth
  • IV fluids
  • abx as per local guidelines
  • NG tube if required for vomiting
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91
Q

Acute Cholecystitis

surgical mnx

A
  • Endoscopic retrograde cholangio-pancreatography: removes stones trapped in CBD
  • Cholecystectomy: may be performed within 72hrs of symptoms
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92
Q

Acute Cholecystitis

complications (4)

A
  • sepsis
  • gallbladder empyema
  • gangrenous gallbladder
  • perforation
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93
Q

Acute Cholecystitis

what is gallbladder empyema

A

infected tissue and puss collecting in the gallbladder

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94
Q

Acute Cholecystitis

mnx of gallbladder empyema

A

IV abx + either:

  • cholecystectomy
  • cholecystostomy (insert drain into gallbladder to allow infected contents to drain)
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95
Q

Acute Cholangitis

what is it

A

infection and inflammation in the bile ducts

surgical emergency

high mortality

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96
Q

Acute Cholangitis

why does it have a high mortality

A

sepsis and septicaemia

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97
Q

Acute Cholangitis

2 main causes

A
  1. obstruction in the bile ducts stopping bile flow eg. gallstones in the CBD
  2. infection introduced during an ERCP procedure
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98
Q

Acute Cholangitis

most common organism causes (3)

A
  1. Escherichia coli
  2. Klebsiella species
  3. Enterococcus species
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99
Q

Acute Cholangitis

what is Charcot’s Triad

A
  1. RUQ pain
  2. fever
  3. jaundice (raised bilirubin)
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100
Q

Acute Cholangitis

acute mnx

A

emergency admission:

  • nil by mouth
  • IV fluids
  • blood cultures
  • IV abx
  • involvement of seniors and potentially HDU or ICU
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101
Q

Acute Cholangitis

list some imaging to diagnose CBD stones and cholangitis (from least to most sensitive)

A
  • abdo USS
  • CT
  • MRCP
  • Endoscopic US
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102
Q

Acute Cholangitis

definitive mnx

A

endoscopic retrograde cholangio-pancreatography (ERCP)

removes stones blocking bile duct

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103
Q

Acute Cholangitis

what procedures can be performed during an ERCP

A
  • Cholangio-pancreatography
  • Sphincterotomy
  • Stone removal
  • Balloon dilatation
  • Biliary stenting
  • Biopsy
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104
Q

Acute Cholangitis

what is Cholangio-pancreatography

A

retrograde injection of contrast into the duct through the sphincter of Oddi + x-ray images to visualise the biliary system

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105
Q

Acute Cholangitis

what is a Sphincterotomy

A

making a cut in the sphincter to dilate it and allow stone removal

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106
Q

Acute Cholangitis

what can be used if pts are less suitable for ERCP or where ERCP has failed?

A

Percutaneous transhepatic cholangiogram (PTC)

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107
Q

Acute Cholangitis

what is Percutaneous transhepatic cholangiogram (PTC)

A

radiologically guided insertion of a drain through the skin and liver, into the bile ducts

the drain relieves the immediate obstruction

a stent can be inserted to give longer lasting relief of obstruction

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108
Q

Mesenteric Ischaemia

cause

A

lack of blood flow through the mesenteric vessels supplying the intestines, resulting in intestinal ischaemia

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109
Q

Mesenteric Ischaemia

what are the 3 main branches of the abdominal aorta that supply the abdominal organs

A
  1. coeliac artery
  2. superior mesenteric artery
  3. inferior mesenteric artery
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110
Q

Mesenteric Ischaemia

what does the foregut include

A
  • stomach
  • part of duodenum
  • biliary system
  • liver
  • pancreas
  • spleen
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111
Q

Mesenteric Ischaemia

what supplies the foregut

A

the coeliac artery

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112
Q

Mesenteric Ischaemia

what is included in the midgut

A

from the distal part of the duodenum to the 1st half of the transverse colon

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113
Q

Mesenteric Ischaemia

what supplies the midgut

A

the superior mesenteric artery

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114
Q

Mesenteric Ischaemia

what is included in the hindgut

A

from the 2nd half of the transverse colon to the rectum

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115
Q

Mesenteric Ischaemia

what supplies the hindgut

A

the inferior mesenteric artery

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116
Q

Mesenteric Ischaemia

what is chronic mesenteric ischaemia

A

aka intestinal angina

the result of narrowing of the mesenteric blood vessels by atherosclerosis

results in intermittent abdo pain when the blood supply cannot keep up with the demand

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117
Q

Mesenteric Ischaemia

typical classic triad of chronic mesenteric ischaemia

A
  1. central colicky abdo pain after eating (30min after eating and lasts 1-2hrs)
  2. weight loss: due to food avoidance
  3. abdominal bruit may be heard on auscultation
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118
Q

Mesenteric Ischaemia

RFs for chronic mesenteric ischaemia

A

same as any other CVS disease:

  • increased age
  • FH
  • smoking
  • diabetes
  • HTN
  • raised cholesterol
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119
Q

Mesenteric Ischaemia

chronic mesenteric ischaemia dx

A

by CT angiography

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120
Q

Mesenteric Ischaemia

mnx of chronic mesenteric ischaemia

A
  • reduce modifiable RFs
  • secondary prevention: statins, antiplatelet med
  • revascularisation
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121
Q

Mesenteric Ischaemia

how may revascularisation be performed

A
  • 1st line: endovascular procedures eg: percutaneous mesenteric artery stenting
  • open surgery eg: endarterectomy, re-implantation or bypass grafting
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122
Q

Mesenteric Ischaemia

cause of acute mesenteric ischaemia

A

rapid blockage in blood flow through the superior mesenteric artery

usually caused by a thrombus or embolus

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123
Q

Mesenteric Ischaemia

acute mesenteric ischaemia key RF

A

AF, where thrombus forms in RA them mobilises down aorta to superior mesenteric artery

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124
Q

Mesenteric Ischaemia

acute mesenteric ischaemia presentation

A
  • acute, non-specific abdo pain which is disproportionate to the examination findings
  • can develop shock, peritonitis, sepsis
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125
Q

Mesenteric Ischaemia

acute mesenteric ischaemia if not treated

A

necrosis of bowel tissue and perforation

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126
Q

Mesenteric Ischaemia

acute mesenteric ischaemia diagnostic test of choice

A

contrast CT: to assess bowel and blood supply

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127
Q

Mesenteric Ischaemia

acute mesenteric ischaemia blood gas

A

metabolic acidosis

raised lactate

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128
Q

Mesenteric Ischaemia

acute mesenteric ischaemia: why do patients require surgery

A
  1. to remove necrotic bowel

2. to remove or bypass the thrombus in the blood vessel

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129
Q

Mesenteric Ischaemia

acute mesenteric ischaemia prognosis

A

very high mortality (>50%)

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130
Q

Hernias

when do they occur

A

when there is a weak point in the cavity wall, usually affecting the muscle to fascia

this weakness allows a body organ (eg bowel) that would normally be contained within that cavity to pass through the cavity wall

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131
Q

Hernias

presentation

A
  • soft lump protruding from the abdo wall
  • may be reducible
  • may protrude on coughing or standing
  • aching, pulling or dragging sensation
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132
Q

Hernias

why do hernias protrude on coughing or standing

A

cough: raises intra-abdo pressure
stand: pulled out by gravity

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133
Q

Hernias

complications (3)

A
  1. incarceration
  2. obstruction
  3. strangulation
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134
Q

Hernias

what is incarceration

A

the hernia cannot be reduced back into the proper position (irreducible)

the bowel is trapped in the herniated position

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135
Q

Hernias

what can incarceration lead to

A

obstruction and strangulation

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136
Q

Hernias

what is obstruction

A

where a hernia causes a blockage in the passage of faeces through the bowel

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137
Q

Hernias

what does obstruction present with

A
  • vomiting
  • generalised abdo pain
  • absolute constipation (not passing faeces or flatus)
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138
Q

Hernias

what is strangulation

A

hernia is non-reducible AND the base of hernia becomes so tight that it cuts off the blood supply causing ischaemia

surgical emergency

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139
Q

Hernias

presentation of strangulation

A

pain and tenderness at the hernia site

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140
Q

Hernias

when assessing a hernia, what do you need to comment on and why?

A

the size of the neck/defect (narrow or wide)

as the wider the neck the lower risk of complications

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141
Q

Hernias

what is a Richter’s Hernia

A

very specific situation that can occur in any abdo hernia

only part of the bowel wall + lumen herniate through the defect, with the other side of that section of the bowel remaining within the peritoneal cavity

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142
Q

Hernias

why worry about Richter’s hernias

A

can become strangulated where the bloody supply to that portion of the bowel wall is constricted and cut off

they’ll progress very rapidly to ischaemia and necrosis and should be operated on immediately

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143
Q

Hernias

what is Maydl’s Hernia

A

where 2 different loops of bowel are contained within the hernia

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144
Q

Hernias

general mnx options (3)

A
  1. conservative mnx
  2. tension-free repair (surgery)
  3. tension repair (surgery)
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145
Q

Hernias

what is conservative mnx

A

leaving the hernia alone

most appropriate with a wide neck hernia and pts with co-morbidities

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146
Q

Hernias

what is involved in a tension-free repair

A

placing a mesh over the defect in the abdo wall

mesh is sutured to the muscles and tissues on either side of the defect

over time, tissue grow into the mesh and provide extra support

lower recurrence rate than a tension repair but may have chronic pain

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147
Q

Hernias

what is involved in a tension repair

A

suturing muscles and tissue on either side of the defect back together

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148
Q

Hernias

how do inguinal hernias present as?

A

a soft lump in the inguinal region (in the groin)

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149
Q

Hernias

what are the 2 types of inguinal hernias

A
  • indirect inguinal hernia

- direct inguinal hernia

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150
Q

Hernias

Ddx for a lump in the inguinal region

A
  • femoral hernia
  • lymph node
  • Saphena varix (dilation of saphenous vein at junction with femoral vein in groin)
  • femoral aneurysm
  • abscess
  • undescended/ectopic testes
  • kidney transplant
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151
Q

Hernias

what is an indirect inguinal hernia

A

where the bowel herniates through the inguinal canal

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152
Q

Hernias

where does the inguinal canal run between

A

the deep inguinal ring (where it connects to the peritoneal cavity)

and the superficial inguinal ring (where it connects to the scrotum)

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153
Q

Hernias

what is contained in the inguinal canal in males?

A
  1. spermatic cord
  2. Ilioinguinal nerve
  3. Genital branch of the genitofemoral nerve
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154
Q

Hernias

what is contained in the inguinal canal in females?

A
  1. round ligament
  2. ilioinguinal nerve
  3. genital branch of the genitofemoral nerve
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155
Q

Hernias

pathophysiology of an indirect inguinal hernia

A

normally, after the testes descend through the inguinal canal, the deep inguinal ring closes and the processus vaginalis is obliterated

however, in some pts, the inguinal ring remains patent and the processus vaginalis remains intact

this leaves a tract from the abdo contents through the inguinal canal and into the scrotum

the bowel can herniate along this tract creating an indirect inguinal hernia

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156
Q

Hernias

what is the specific finding to help differentiate from an indirect and direct inguinal hernia

A

if indirect:
the hernia will remain reduced when pressure is applied with 2 fingertips to the deep inguinal ring

if direct: pressure over the deep inguinal ring will not stop the herniation

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157
Q

Hernias

where is the deep inguinal ring on examination

A

at the midway point from the ASIS to the pubic tubercle

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158
Q

Hernias

why do direct inguinal hernias occur

A

due to weakness in the abdo wall at Hesselbach’s triangle

the hernia protrudes directly through the abdo wall, through Hesselbach’s triangle (not along a canal like an indirect)

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159
Q

Hernias

what are the boundaries of Hesselbach’s triangle

A

RIP

Rectus abdominis muscle - medial border

Inferior epigastric vessels - superior/lateral border

Poupart’s ligament (inguinal ligament) - inferior border

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160
Q

Hernias

what are femoral hernias

A

herniation of the abdo contents through the femoral canal . this occurs below the inguinal ligament at the top of the thigh

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161
Q

Hernias

what is the opening between the peritoneal cavity and the femoral canal

A

the femoral ring

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162
Q

Hernias

why do femoral hernias have a high risk of incarceration, obstruction and strangulation

A

because the femoral ring leaves only a narrow opening for femoral hernias

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163
Q

Hernias

what are the boundaries of the femoral canal

A

FLIP

Femoral vein - lateral

Lacunar ligament - medial

Inguinal ligament - anterior

Pectineal ligament - posteriorly

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164
Q

Hernias

what is the femoral triangle

A

a larger area at the top of the thigh that contains the femoral canal

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165
Q

Hernias

what are the boundaries of the femoral triangle

A

SAIL

Sartorius - lateral

Adductor longus - medial

Inguinal Ligament - superior

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166
Q

Hernias

what are the contents of the femoral triangle from lateral to medial

A

NAVY-C

femoral Nerve 
femoral Artery 
femoral Vein 
Y fronts 
femoral Canal (containing lymphatic vessels and nodes)
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167
Q

Hernias

where do incisional hernias occur and why

A

at the site of an incision from previous surgery due to weakness where the muscles and tissues were closed after a surgical incision

the bigger the incision, the higher the risk of a hernia forming

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168
Q

Hernias

mnx of incisional hernias

A

difficult to repair with high rate of recurrence

often left alone if large with a wide neck and low risk of complications

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169
Q

Hernias

where do umbilical hernias occur and why

A

around the umbilicus due to a defect in the muscle around the umbilicus

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170
Q

Hernias

who are umbilical hernias common in

A

neonates and can resolve spontaenously

also older adults

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171
Q

Hernias

what is an epigastric hernia

A

a hernia in the epigastric area

caused by protrusion of extra-peritoneal fat or omentum through a defect in the linea alba between the xiphisternum and umbilicus.

managed by addressing RFs (obesity).

Symptomatic: surgery
asymptomatic: the hernia can be repaired for cosmetic benefit.

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172
Q

Hernias

where do Spigelian hernias occur

A

between the lateral border of the rectus abdominis muscle and the linea semilunaris

this is the site of the spigelian fascia,

usually occurs in the lower abdo

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173
Q

Hernias

what is the spigelian fascia

A

an aponeurosis between the muscles of the abdo wall

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174
Q

Hernias

presentation of Spigelian Hernias

A

non-specific abdo wall pain

there may not be a noticeable lump

narrower base

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175
Q

Hernias

what is Diastasis Recti (aka rectus diastasis and recti divarication)

A

widening of the linea alba (the connective tissue that separates the rectus abdominis)

forming a large gap between the rectus muscles

not technically a hernia

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176
Q

Hernias

when does the gap in a Diastasis Recti become most prominent

A

when the pt lies on their back and lifts their head

there is a protruding bulge along the middle of the abdo

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177
Q

Hernias

how does a Diastasis Recti occur?

A

congenital or due to weakness in connective tissue eg following pregancy or in obese pts

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178
Q

Hernias

trx of diastasis recti

A

none in most cases but surgical repair is possible

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179
Q

Hernias

what is a hiatus hernia

A

the herniation of the stomach up through the diaphragm

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180
Q

Hernias

pathophysiology of a hiatus hernia

A

diaphragm opening should be at level of lower oesophageal sphincter and fixed in place

a narrow opening help to maintain the sphincter and stop acid and stomach contents refluxing into the oesophagus

when the opening of the diaphragm is wider, the stomach can enter through the diaphragm and the contents of the stomach can reflux into the oesophagus

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181
Q

Hernias

what is a a Type 1 hiatus hernia

A

Sliding: stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up the thorax

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182
Q

Hernias

what is a Type 2 hiatus hernia

A

Rolling: seperate portion of the somach (eg fundus) folds around and enters through the diaphragm opening, alongside the oesophagus

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183
Q

Hernias

what is a type 3 hiatus hernia

A

combination of sliding and rolling

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184
Q

Hernias

what is a type 4 hiatus hernia

A

refers to a large hernia that allows other intra-abdo organs to pass through the diaphragm opening (eg bowel, pancreas or omentum)

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185
Q

Hernias

what are 3 key RFs in hiatus hernias

A

age
obesity
pregnancy

186
Q

Hernias

hiatus hernia presentation

A

dyspepsia with:

  • heartburn
  • acid reflux
  • reflux of food
  • burping
  • bloating
  • halitosis (bad breath)
187
Q

Hernias

imaging for hiatus hernias

A

intermittent so may not be seen

  • CXR
  • CT
  • Endoscopy
  • barium swallow
188
Q

Hernias

trx of hiatus hernias

A
  • conservative: medical trx of GOR)

- laparoscopic fundoplication

189
Q

Hernias

what is involved in laparoscopic fundoplication

A

tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter

190
Q

Hernias

what are obturator hernias

A

where the abdo or pelvic contents herniate through the obturator foramen at the bottom of the pelvis

191
Q

Hernias

why do obturator hernias occur

A

due to a defect in the pelvic floor

192
Q

Hernias

who are obturator hernias common in

A

women, esp older age

after multiple pregnancies and vaginal deliveries

193
Q

Hernias

obturator hernia symptoms

A

often asymptomatic

irritation to the obturator nerve causing pain in the groin or medial thigh

also can present with complications of incarceration, obstruction and strangulation

194
Q

Hernias

obturator hernia: what is Howship-Romberg sign

A

pain extending from the inner thigh to the knee when the hip is internally rotated

due to compression of the obturator nerve

195
Q

Hernias

diagnostic inx for obturator hernias

A

CT or MRI or found incidentally during pelvic surgery

196
Q

Haemorrhoids

what are they

A

enlarged anal vascular cushions often associated with constipation and straining

197
Q

Haemorrhoids

whom are they more common in

A
  • pregnancy women
  • obesity
  • increased age
  • increased intra-abdo pressure (weightlifting, chronic cough)
198
Q

Haemorrhoids

why do they often occur in pregnancy

A

due to constipation, pressure from the baby in the pelvis and the effects of hormones that relax the connective tissues

199
Q

Haemorrhoids

what are anal cushions

A

specialised submucosal tissue that contain connections between the arteries and veins, making them very vascular

they help control anal continence, along with the internal and external sphincters

200
Q

Haemorrhoids

what is the blood supply for anal cushions

A

the rectal arteries

201
Q

Haemorrhoids

where are the anal cushions usually located

A

at 3, 7 and 11 o’clock

202
Q

Haemorrhoids

1st degree

A

no prolapse

203
Q

Haemorrhoids

2nd degree

A

prolapse when straining and return on relaxing

204
Q

Haemorrhoids

3rd degree

A

prolapse when straining,

do not return on relaxing

but can be pushed back

205
Q

Haemorrhoids

4th degree

A

prolapsed permanently

206
Q

Haemorrhoids

common presentation

A

painless bright red bleeding typically on the toilet tissue or seen after opening the bowels

sore/itchy anus

feeling a lump around or inside the anus

207
Q

Haemorrhoids

is the blood mixed with the stool

A

No

you should think of an alternative diagnosis

208
Q

Haemorrhoids

examination findings for external (prolapsed) haemorrhoids

A

visible on inspection as swellings covered in mucosa

209
Q

Haemorrhoids

examination findings for internal haemorrhoids

A

may be felt on PR exam (although difficult or not possible)

they may appear if the pt is asked to ‘bear down’ on inspection

210
Q

Haemorrhoids

how are they visualised and inspected

A

proctoscopy

inserting a hollow tube (proctoscope) into the anal cavity to visualise the mucosa

211
Q

Haemorrhoids

Ddx in pts presenting with sx such as rectal bleeding (4)

A
  • anal fissures
  • diverticulosis
  • IBD
  • colorectal cancer
212
Q

Haemorrhoids

what can be given for symptomatic relief

A

Topical trx

  • Anusol
  • Anusol HC
  • Germoloids cream
  • Proctosedyl ointment
213
Q

Haemorrhoids

what does Anusol contain

A

chemicals to shrink the haemorrhoids ‘astringents’

214
Q

Haemorrhoids

what does Anusol HC contain

A

astringents and hydrocortisone

only used short term

215
Q

Haemorrhoids

what do germoloids cream contain

A

lidocaine

216
Q

Haemorrhoids

what does Proctosedyl ointment contain

A

cinchocaine and hydrocortisone

short term only

217
Q

Haemorrhoids

prevention and trx of constipation

A
  • increase fibre in diet
  • good fluid intake
  • laxatives where required
  • consciously avoiding straining when opening their bowels
218
Q

Haemorrhoids

non surgical trx

A
  • rubber band ligation
  • injection sclerotherapy
  • infra-red coagulation
  • bipolar diathermy
219
Q

Haemorrhoids

what is rubber band ligation

A

fitting a tight rubber band around the base of the haemorrhoid to cut off the blood supply

220
Q

Haemorrhoids

what is injection sclerotherapy

A

injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy

221
Q

Haemorrhoids

what is infra-red coagulation

A

infra-red light is applied to damage the blood supply

222
Q

Haemorrhoids

what is bipolar diathermy

A

electrical current applied directly to the haemorrhoid to destroy it

223
Q

Haemorrhoids

surgical options (3)

A
  • haemorrhoidal artery ligation
  • haemorrhoidectomy
  • stapled haemorrhoidectomy
224
Q

Haemorrhoids

what is haemorrhoidal artery ligation

A

using a proctoscope to identify the blood vessel that supplies the haemorrhoids and suturing it to cut off the blood supply

225
Q

Haemorrhoids

what is a Haemorrhoidectomy

A

excising the haemorrhoid.

Removing the anal cushions may result in faecal incontinence.

226
Q

Haemorrhoids

what is Stapled haemorrhoidectomy

A

using a special device that excises a ring of haemorrhoid tissue

at the same time as adding a circle of staples in the anal canal.

The staples remain in place long-term.

227
Q

Haemorrhoids

what are thrombosed haemorrhoids caused by

A

strangulation at the base of the haemorrhoid resulting in thrombosis (a clot) in the haemorrhoid

228
Q

Haemorrhoids

presentation of a thrombosed haemorrhoid

A
  • purplish, very tender, swollen lumps around the anus

PR exam can’t be done due to the pain

229
Q

Haemorrhoids

mnx of a thrombosed haemorrhoid

A

consider admission if the pt presents within 72h with extreme pain.

May benefit from surgical mnx

resolve with time, may take several weeks

230
Q

Cholangiocarcinoma

what is it

A

a type of cancer that originates in the bile ducts

the majority are adenocarcinomas

231
Q

Cholangiocarcinoma

what is the most common site

A

perihilar region :

where the R + L hepatic duct have joined to become the common hepatic duct just after leaving the liver

232
Q

Cholangiocarcinoma

key risk factors (2)

A
  • primary sclerosing cholangitis

- liver flukes (parasitic infection found in Southeast Asia + Europe)

233
Q

Cholangiocarcinoma

ulcerative colitis –>

A

are at risk of PSC whom are at risk of cholangiocarcinomas

234
Q

Cholangiocarcinoma

key presenting feature

A

OBSTRUCTIVE JAUNDICE:

  • pale stools
  • dark urine
  • generalised itching
235
Q

Cholangiocarcinoma

non-specific signs and symptoms

A
  • unexplained weight loss
  • RUQ pain
  • palpable gallbladder (swelling due to an obstruction in the duct distal to the gallbladder)
  • hepatomegaly
236
Q

Cholangiocarcinoma

what does Courvoisier’s law state

A

a palpable gallbladder + jaundice is unlikely to be gallstones

the cause is usually Cholangiocarcinoma or pancreatic cancer

237
Q

painless jaundice Ddx

A
  1. cancer of the head of the pancreas

2. cholangiocarcinoma

238
Q

Cholangiocarcinoma

dx

A

CT or MRI
+
histology from biopsy

239
Q

Cholangiocarcinoma

what does a staging CT scan involve

A

a full CT thorax, abdomen and pelvis (CTTAP)

used to look for metastasis and other cancers

240
Q

Cholangiocarcinoma

what tumour marker may be raised

A

CA 19-9

carbohydrate antigen

241
Q

Cholangiocarcinoma

what may cause a raised CA 19-9

A

Cholangiocarcinoma

pancreatic cancer

number of other malignant and non-malignant conditions

242
Q

Cholangiocarcinoma

what would MRCP be used for

A

to assess the biliary system in detail to assess the obstruction

243
Q

Cholangiocarcinoma

what can ERCP used for

A

to put a stent and relive the obstruction

and obtain a biopsy from the tumour

244
Q

Cholangiocarcinoma

mnx in early cases

A

Curative surgery may be possible in early cases.

may be combined with radiotherapy and chemotherapy.

245
Q

Cholangiocarcinoma

mnx (palliative trx)

A
  • stents: relieve biliary obstruction
  • surgery: improve sx e.g. bypass the biliary obstruction
  • palliative chemo
  • palliative radio
  • end of life care with sx control
246
Q

Pancreatic cancer

why is it bad

A

often diagnosed late and has a very poor prognosis

247
Q

Pancreatic cancer

what kind are they usually and where do they occur

A

adenocarcinomas

head of the pancreas

248
Q

Pancreatic cancer

how does it cause obstructive jaundice

A

if a tumour in the head of the pancreas grows large enough it can compress the bile ducts

249
Q

Pancreatic cancer

where do they tend to metastasise

A

liver, then peritoneum
lungs
bone

250
Q

Pancreatic cancer

key presenting feature

A

painless obstructive jaundice:

  • yellow skin + sclera
  • pale stools
  • dark urine
  • generalised itching
251
Q

Pancreatic cancer

presentation (other than painless obstructive jaundice)

A
  • new onset diabetes or worsening of T2 diabetes
  • non-specific upper abdo or back pain
  • unintentional weight loss
  • palpable mass in the epigastric region
  • change in bowel habit
  • N+V
252
Q

Pancreatic cancer

when should pt be referred on a 2 week wait referral

A

> 40 with jaundice

253
Q

Pancreatic cancer

when should a pt be referred for a direct access CT abdo

A

> 60 with weight loss + and additional symptom:

  • diarrhoea
  • back pain
  • abdo pain
  • Nausea
  • Vomiting
  • constipation
  • new onset diabetes
254
Q

what is the only scenario where GPs can refer directly for a CT scan

A

suspected pancreatic cancer

255
Q

Pancreatic cancer

what is Trousseau’s sign of malignancy

A

refers to migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma

Thrombophlebitis: blood vessels become inflamed with an associated blood clot (thrombus) in that area

Migratory: thrombophlebitis reoccurring in different locations over time.

256
Q

Pancreatic cancer

dx

A

CT + histology from biopsy

257
Q

Pancreatic cancer

what does Staging CT scan involve

A

a full CT thorax, abdo, pelvis (CT TAP)

to look for metastasis and other cancers

258
Q

Pancreatic cancer

what tumour marker may be raised

A

CA 19-9

259
Q

Pancreatic cancer

what may MRCP be used for

A

assess the biliary system in detail to assess the obstruction.

260
Q

Pancreatic cancer

what may ERCP be used for

A

to put a stent in and relieve the obstruction

and also obtain a biopsy from the tumour.

261
Q

Pancreatic cancer

how may biopsy be taken

A

taken through the skin (percutaneous) under ultrasound or CT guidance

or during an endoscopy under ultrasound guidance.

262
Q

Pancreatic cancer

where will mnx be decided

A

at a hepatobiliary (HPB) MDT meeting

263
Q

Pancreatic cancer

what are the surgical options to remove tumour

A
  • Total pancreatectomy
  • Distal pancreatectomy
  • Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure)
  • Radical pancreaticoduodenectomy (Whipple procedure)
264
Q

Pancreatic cancer

when curative trx is not possible, what may palliative trx involve

A
  • Stents inserted to relieve the biliary obstruction
  • Surgery to improve symptoms (e.g., bypassing the biliary obstruction)
  • Palliative chemotherapy (to improve symptoms and extend life)
  • Palliative radiotherapy (to improve symptoms and extend life)
  • End of life care with symptom control
265
Q

Pancreatic cancer

what is Whipple Procedure

A

pancreaticoduodenectomy

a surgical operation to remove a tumour of the head of the pancreas that has not spread.

It involves the removal of the:

  • Head of the pancreas
  • Pylorus of the stomach
  • Duodenum
  • Gallbladder
  • Bile duct
  • Relevant lymph nodes
266
Q

Pancreatic cancer

what is a modified Whipple procedure

A

involves leaving the pylorus in place.

aka pylorus-preserving pancreaticoduodenectomy (PPPD).

267
Q

Pancreatitis

3 main causes

A
  • alcohol
  • Gallstones
  • post-ERCP
268
Q

Pancreatitis

how do gallstones cause pancreatitis

A

gallstones get trapped at the end of the ampulla of Vater

blocking the flow of bile and pancreatic juice into the duodenum

the reflux of bile into the pancreatic duct and the prevention of pancreatic juice containing enzymes from being secreted, result in inflammation in the pancreas

269
Q

Pancreatitis

I GET SMASHED causes

A 
Idiopathic
Gallstones
Ethanol 
Trauma
Steroids 
Mumps 
Autoimmune 
Scorpion sting
Hyperlipidaemia 
ERCP 
Drugs: furosemide, thiazide diuretics + azithioprine
270
Q

Pancreatitis

how does acute pancreatitis present

A
  • severe epigastric pain
  • radiating through the back
  • associated vomiting
  • abdo tenderness
  • systemically unwell
271
Q

Pancreatitis

what is used to assess the severity of pancreatitis

A

The Glasgow Score. It gives a numerical score based on how many of the key criteria are present

272
Q

Pancreatitis

what is the criteria for the Glasgow score

A 
PANCREAS
P – Pa02 < 8 KPa
A – Age > 55
N – Neutrophils (WBC > 15)
C – Calcium < 2
R – uRea >16
E – Enzymes (LDH > 600 or AST/ALT >200)
A – Albumin < 32
S – Sugar (Glucose >10)
273
Q

Pancreatitis

what does a Glasgow Score of 0 or 1 indicate

A

mild pancreatitis

274
Q

Pancreatitis

what does a Glasgow score of 2 indicate

A

moderate pancreatitis

275
Q

Pancreatitis

what does a Glasgow score of 3 or more indicate

A

severe pancreatitis

276
Q

Pancreatitis

inx

A
  • raised AMYLASE
  • CRP
  • US: gallstones
  • CT: complications

glasgow score inx:

  • FBC: WCC
  • U&E: urea
  • LFT: transaminases + albumin
  • Ca
  • ABG: PaO2 + blood glucose
277
Q

Pancreatitis

where should you consider admission for moderate or severe cases

A

HDU or ICU

278
Q

Pancreatitis

mnx

A
  • Initial resus (ABCDE)
  • IV fluids
  • Nil by mouth
  • Analgesia
  • Careful monitoring
  • Trx of gallstones in gallstone (ERCP / cholecystectomy)
  • Abx if evidence of specific infection (e.g., abscess or infected necrotic area)
  • Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)
279
Q

Pancreatitis

how long will it take most pts to improve

A

3-7d

280
Q

Pancreatitis

complications

A
  • necrosis
  • infection
  • abscess
  • acute peripancreatic fluid collections
  • pseudocysts: collection of pancreatic juice) can develop 4w after acute pancreatitis
  • chronic pancreatitis
281
Q

what is chronic pancreatitis

A

chronic inflammation in the pancreas

results in fibrosis and reduced function of the pancreatic tissue

282
Q

Chronic Pancreatitis

most common cause

A

alcohol

283
Q

Chronic Pancreatitis

presentation

A

similar to acute but generally less intense and longer lasting

284
Q

Chronic Pancreatitis

complications

A
  • chronic epigastric pain
  • loss of exocrine function: resulting in lack of pancreatic enzymes (lipase esp) secreted into the GI tract
  • loss of endocrine function: resulting in lack of insulin –> diabetes
  • damage + strictures to the duct system: obstruction in the excretion of pancreatic juice + bile
  • formation of pseudocysts or abscesses
285
Q

Chronic Pancreatitis

mnx

A
  • abstinence from alcohol + smoking
  • analgesia
  • Creon (replacement lipase)
  • subcut insulin regimes if diabetic
  • ERCP w/ stenting if stricture + obstruction
  • surgery: drain duct + remove inflamed pancreatic tissue
286
Q

Bowel Cancer

RFs

A
  • Familial adenomatous polyposis (FAP)
  • Hereditary nonpolyposis colorectal cancer (HNPCC), aka Lynch syndrome
  • FH of bowel cancer
  • IBD
  • increased age
  • diet: red, processed meat, low in fibre)
  • obesity + sedentary lifestyle
  • smoking
  • alcohol
287
Q

Bowel Cancer

RF: what is Familial adenomatous polyposis (FAP)

A

autosomal dominant condition

malfunctioning of the tumour suppressor genes called adenomatous polyposis coli (APC)

results in many polyps (adenomas) developing along the large intestine

potential to become cancerous (usually before the age of 40)

288
Q

Bowel Cancer

RF: Familial adenomatous polyposis (FAP) mnx

A

panproctocolectomy to prevent development of bowel cancer

289
Q

Bowel Cancer

RF: what is Hereditary nonpolyposis colorectal cancer (HNPCC) aka Lynch syndrome

A

autosomal dominant condition

mutations in DNA mismatch repair (MMR) genes

higher risk of colorectal cancer

does not cause adenomas

tumours develop in isolation.

290
Q

Bowel Cancer

presentation

A
  • Change in bowel habit (loose and frequent)
  • Unexplained weight loss
  • Rectal bleeding
  • Unexplained abdo pain
  • Iron deficiency anaemia
  • Abdominal or rectal mass on examination
  • obstruction: vomiting, abdo pain, constipation
291
Q

Bowel Cancer

mnx for unexplained iron deficient anaemia

A

2 week wait referral

colonoscopy and gastroscopy (“top and tail”) for GI malignancy

292
Q

Bowel Cancer

what is the FIT test

A

Faecal immunochemical tests

look very specifically for the amount of human haemoglobin in the stool

293
Q

Bowel Cancer

when is a FIT test used

A

GP to help assess for bowel cancer in specific patients who do not meet the criteria for a two week wait referral

and bowel cancer screening programme

294
Q

Bowel Cancer

at what age are people sent a FIT test for screening and how often

A

aged 60 – 74 years

every 2 years

295
Q

Bowel Cancer

what happens if a FIT test is positive

A

sent for colonoscopy

296
Q

Bowel Cancer

who is offered a colonscopy at regular intervals to screen for bowel cancer

A

People with risk factors such as FAP, HNPCC or IBD

297
Q

Bowel Cancer

gold standard inx

A

colonoscopy

Any suspicious lesions can be biopsied to get a histological diagnosis, or tattoo in preparation for surgery.

298
Q

Bowel Cancer

what is sigmoidoscopy and when used

A

endoscopy of the rectum and sigmoid colon only

in cases where the only feature is rectal bleeding

299
Q

Bowel Cancer

when is a CT colonography considered

A

in patients less fit for a colonoscopy but it is less detailed and does not allow for a biopsy.

300
Q

Bowel Cancer

what inx to look for metastasis and other cancers

A

Staging CT scan: full CT thorax, abdomen and pelvis (CT TAP).

301
Q

Bowel Cancer

inx used for predicting relapse in patients previously treated for bowel cancer

A

Carcinoembryonic antigen (CEA)

302
Q

Bowel Cancer

what is Carcinoembryonic antigen (CEA)

A

a tumour marker blood test for bowel cancer. This is not helpful in screening

303
Q

Bowel Cancer

what is Duke’s classification

A

the system previously used for bowel cancer. Now TNM

304
Q

Bowel Cancer

TNM: TX

A

unable to assess size

305
Q

Bowel Cancer

TNM: T1

A

submucosa involvement

306
Q

Bowel Cancer

TNM: T2

A

involvement of muscularis propria (muscle layer)

307
Q

Bowel Cancer

TNM:T3

A

involvement of the subserosa and serosa (outer layer), but not through the serosa

308
Q

Bowel Cancer

TNM: T4

A

spread through the serosa (4a) reaching other tissues or organs (4b)

309
Q

Bowel Cancer

TNM: NX

A

unable to assess nodes

310
Q

Bowel Cancer

TNM: N0

A

no nodal spread

311
Q

Bowel Cancer

TNM: N1

A

spread to 1-3 nodes

312
Q

Bowel Cancer

TNM: N2

A

spread to more than 3 nodes

313
Q

Bowel Cancer

TNM: M0

A

no metastasis

314
Q

Bowel Cancer

TNM: M1

A

metastasis

315
Q

Bowel Cancer

mnx

A
  • Surgical resection
  • Chemotherapy
  • Radiotherapy
  • Palliative care
316
Q

Bowel Cancer

what is Low Anterior Resection Syndrome

A

may occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectum

317
Q

Bowel Cancer

sx of Low Anterior Resection Syndrome

A
  • Urgency and frequency of bowel movements
  • Faecal incontinence
  • Difficulty controlling flatulence
318
Q

Bowel Cancer

follow up

A
  • Serum carcinoembryonic antigen (CEA)

- CT thorax, abdomen and pelvis

319
Q

Ileus

aka?

A

paralytic ileus or adynamic ileus

320
Q

Ileus

what is it

A

affects small bowel

the normal peristalsis that pushes the contents temporarily stops

321
Q

what is pesudo-obstruction

A

a functional obstruction of the large bowel

pts present with intestinal obstruction but no mechanical cause is found

less common than ileus

322
Q

Ileus

common causes

A
  • injury to bowel
  • handling of bowel during surgery
  • inflammation or infection in, or nearby the bowel e.g. peritonitis, appendicitis, pancreatitis, pneumonia
  • electrolyte imbalances
323
Q

Ileus

when is the most common time you will see ileus

A

following abdo surgery

324
Q

Ileus

signs and symptoms

A

akin to bowel obstruction:

  • green bilious vomiting
  • abdo distension
  • diffuse abdo pain
  • absolute constipation and lack of flatulence
  • absent bowel sounds
325
Q

Ileus

difference in examination of bowel sounds between ileus and mechanical obstruction

A

ileus: absent

mechanical obstruction: tinkling

326
Q

Ileus

mnx

A

supportive:

  • nill by mouth
  • NG tube if vomiting
  • IV fluids
  • mobilisation
  • total parenteral nutrition may be needed
327
Q

in addition to colorectal cancer, patients with Lynch syndrome have an increased risk of malignancies of?

A

Endometrium
Ovaries
Sebaceous glands

328
Q

Diverticular Disease

```
define diverticulum
pleural: diverticula
~~~

A

a pouch or pocket in the bowel wall, usually ranging in size from 0.5 – 1cm.

329
Q

Diverticular Disease

define diverticulosis

A

the presence of diverticula, without inflammation or infection.

may be referred to as diverticular disease when patients experience sx

330
Q

Diverticular Disease

define diverticulitis

A

inflammation and infection of diverticula

331
Q

Diverticular Disease

what is the layer of muscle called in the large intestine

A

circular muscle

332
Q

Diverticular Disease

where are the points of weakness in the circular muscle

A

where it’s penetrated by blood vessels

333
Q

Diverticular Disease

what causes diverticula

A
  • Increased pressure inside the lumen over time, can cause a gap to form in these areas of weakness in the circular muscle.
  • These gaps allow the mucosa to herniate through the muscle layer and pouches to form (diverticula)
334
Q

Diverticular Disease

does diverticula form in the rectum

A

no

335
Q

Diverticular Disease

why does diverticula not form in the rectum

A

because it has an outer longitudinal muscle layer that completely surrounds the diameter of the rectum, adding extra support

336
Q

Diverticular Disease

which parts of the colon are vulnerable to the development of diverticula

A

the areas that are not covered by teniae coli

3 longitudinal muscles that run along the colon, forming strips or ribbons called teniae coli

337
Q

Diverticular Disease

Diverticulosis: what is the most commonly affected section of the bowel

A

sigmoid colon

338
Q

Diverticular Disease

Diverticulosis: RFs

A
  • increased age
  • Low fibre diets
  • obesity
  • use of NSAIDs
339
Q

Diverticular Disease

Diverticulosis: what increases the risk of diverticular haemorrhage

A

NSAIDs

340
Q

Diverticular Disease

Diverticulosis: how is it diagnosed

A

incidentally on colonoscopy or CT scan

341
Q

Diverticular Disease

Diverticulosis: trx in asymptomatic pts `

A

none but advice regarding a high fibre diet and weight loss is appropriate.

342
Q

Diverticular Disease

Diverticulosis: what sx may it cause

A
  • lower left abdo pain
  • constipation
  • rectal bleeding
343
Q

Diverticular Disease

Diverticulosis: mnx in pts with sx

A
  • increase fibre

- bulk-forming laxatives (e.g.ispaghula husk)

344
Q

Diverticular Disease

Diverticulosis: what laxatives should be avoided

A

Stimulant laxatives (e.g., Senna)

345
Q

Diverticular Disease

Diverticulosis: mnx of significant sx

A

Surgery to remove the affected area

346
Q

Diverticular Disease

acute diverticulitis: sx

A
  • Pain and tenderness in the left iliac fossa
  • Fever
  • Diarrhoea
  • N + V
  • Rectal bleeding
347
Q

Diverticular Disease

acute diverticulitis: signs

A
  • Palpable abdominal mass (if an abscess has formed)

- Raised inflammatory markers (e.g., CRP) and WBCs

348
Q

Diverticular Disease

acute diverticulitis: mnx of uncomplicated diverticulitis in primary care

A
  • PO co-amoxiclav (at least 5d)
  • Analgesia (avoid NSAIDs + opiates)
  • Only take clear liquids (avoid solid food) until sx improve (usually 2-3d)
  • Follow-up within 2d
349
Q

Diverticular Disease

acute diverticulitis: when to admit

A

Patients with severe pain or complications

350
Q

Diverticular Disease

acute diverticulitis: mnx in hospital

A
  • Nil by mouth or clear fluids only
  • IV antibiotics + fluids
  • Analgesia
  • Urgent inx (e.g. CT scan)
  • Urgent surgery may be required for complications
351
Q

Diverticular Disease

acute diverticulitis: complications

A
  • Perforation
  • Peritonitis
  • Peridiverticular abscess
  • Large haemorrhage requiring blood transfusions
  • Fistula (e.g., between the colon and the bladder or vagina)
  • Ileus / obstruction
352
Q

Gallstones

The right hepatic duct and left hepatic duct leave the liver and join together to become the _____

A

common hepatic duct

353
Q

Gallstones

what joins the common hepatic duct halfway along

A

The cystic duct from the gallbladder

354
Q

Gallstones

what joins the common hepatic duct further along

A

The pancreatic duct from the pancreas

355
Q

Gallstones

When the common bile duct and the pancreatic duct join they become the ___

A

ampulla of Vater

356
Q

Gallstones

what does the ampulla of Vater open into

A

the duodenum

357
Q

Gallstones

what is the ring of muscle surrounding the ampulla of Vater

A

sphincter of Oddi

358
Q

Gallstones

what does the sphincter of Oddi do

A

controls the flow of bile and pancreatic secretions into the duodenum.

359
Q

Gallstones

define cholestasis

A

blockage to the flow of bile

360
Q

Gallstones

define cholelithiasis

A

gallstones are present

361
Q

Gallstones

define choledocholithiasis

A

gall stones in the bile duct

362
Q

Gallstones

define biliary colic

A

intermittent RUQ pain caused by gallstones irritating the bile ducts

363
Q

Gallstones

define cholecystitis

A

inflammation of the gallbladder

364
Q

Gallstones

define cholangitis

A

inflammation of the bile ducts

365
Q

Gallstones

define gallbladder empyema

A

pus in the gallbladder

366
Q

Gallstones

define cholecystectomy

A

surgical removal of the gallbladder

367
Q

Gallstones

define cholecystostomy

A

inserting a drain into the gallbladder

368
Q

Gallstones

the RFs for gallstones

A

fat
fair
female
forty

369
Q

Gallstones

what is biliary colic caused by

A

stones temporarily obstructing drainage of the gallbladder.

It may get lodged at the neck of the gallbladder or in the cystic duct, then when it falls back into the gallbladder the symptoms resolve

370
Q

Gallstones

presentation

A
  • biliary colic
  • Severe, colicky epigastric or RUQ pain
  • Often triggered by meals (particularly high fat meals)
  • Lasting 30 min - 8h
  • N+V
371
Q

Gallstones

complications

A
  • Acute cholecystitis
  • Acute cholangitis
  • Obstructive jaundice (if the stone blocks the ducts)
  • Pancreatitis
372
Q

Gallstones

why are pts w/ gallstones + biliary colic advised to avoid fatty foods

A

fat that enters the digestive system causes cholecystokinin (CCK) secretion from the duodenum

CCK triggers contraction of the gallbladder, which leads to biliary colic

avoiding fatty foods prevents CCK release and gallbladder contraction

373
Q

Gallstones

what does raised biliruibin mean

A

an obstruction to flow of biliruibin within the biliary system

374
Q

Gallstones

causes of raised ALP

A
  • biliary obstruction
  • pregnancy
  • liver or bone malignancy
  • primary biliary cirrhosis
  • Paget’s disease of the bone
375
Q

Gallstones

what are ALT and AST helpful markers of

A

hepatocellular injury

376
Q

Gallstones

what LFTs would show an obstructive picture (e.g. gallstones)

A

higher rise in ALP

than in ALT + AST

377
Q

Gallstones

what LFTs would show a hepatic picture (problem inside liver)

A

high ALT + AST compared with ALP

378
Q

Gallstones

1st line inx

A

USS

379
Q

Gallstones

when would MRCP (magnetic resonance cholangio-pancreatography) be used

A

to investigate further if the USS does not show stones in the duct, but there is bile duct dilatation or raised bilirubin suggestive of obstruction

380
Q

Gallstones

what is the main indication for ERCP (endoscopic retrograde cholangio-pancreatography)

A

to clear stones in the bile ducts

381
Q

Gallstones

what does ERCP involve

A

inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (the sphincter of Oddi)

382
Q

Gallstones

what can the operator do in ERCP

A
  • Inject contrast and take x-rays to visualise the biliary system and diagnose pathology (e.g., stones or strictures)
  • Perform a sphincterotomy on the sphincter of Oddi if it is dysfunctional (blocking flow)
  • Clear stones from the ducts
  • Insert stents to improve bile duct drainage (e.g., with strictures or tumours)
  • Take biopsies of tumours
383
Q

Gallstones

key complications of ERCP

A
  • Excessive bleeding
  • Cholangitis (infection in the bile ducts)
  • Pancreatitis
384
Q

Gallstones

when are CT scans used

A

to look for differential diagnoses (e.g., pancreatic head tumour) and complications such as perforation and abscesses

385
Q

Gallstones

when is cholecystectomy indicated (removal of gallbladder)

A

where patients are symptomatic of gallstones, or the gallstones are leading to complications (e.g., acute cholecystitis)

386
Q

Gallstones

what is the incision called in laparoscopic cholecystectomy

A

“Kocher” incision

387
Q

Gallstones

complications of cholecystectomy

A
  • Bleeding, infection, pain and scars
  • Damage to the bile duct inc leakage and strictures
  • Stones left in the bile duct
  • Damage to bowel, blood vessels or other organs
  • Anaesthetic risks
  • VTEs
  • Post-cholecystectomy syndrome
388
Q

Gallstones

what is Post-cholecystectomy syndrome

A

a group of non-specific symptoms that can occur after a cholecystectomy. They may be attributed to changes in the bile flow after removal of the gallbladder.

389
Q

Gallstones

sx of Post-cholecystectomy syndrome

A
  • Diarrhoea
  • Indigestion
  • Epigastric or RUQ pain + discomfort
  • Nausea
  • Intolerance of fatty foods
  • Flatulence
390
Q

Stomas

what are they

A

artificial openings of a hollow organ

The bowel or urinary system is artificially opened onto the surface of the abdomen, allowing faeces or urine to drain, bypassing the distal portions of the bowel or urinary tract

391
Q

Stomas

what is a stoma bag

A

fitted around the stoma to collect the waste products and is emptied as required

392
Q

Stomas

what is a colostomy

A

where the large intestine (colon) is brought onto the skin

393
Q

Stomas

where are colostomies located

A

left iliac fossa

394
Q

Stomas

what kind of stools do colostomies drain, solid or more liquid

and why

A

solid as much of the water is reabsorbed in the remaining large intestine.

395
Q

Stomas

what is an ileostomy

A

where the end portion of the small bowel (ileum) is brought onto the skin.

396
Q

Stomas

what kind of stools do ileostomies drain, solid or more liquid

and why

A

liquid stools, as the fluid content is normally reabsorbed later, in the large intestine

397
Q

Stomas

do ileostomies have a spout

A

yes, which allows them to drain directly into a tightly fitting stoma bag without the contents coming into contact with the surrounding skin

398
Q

Stomas

where are ileostomies found

A

right iliac fossa

399
Q

Stomas

what is a gastrostomy

A

creating an artificial connection between the stomach and the abdominal wall

400
Q

Stomas

what are gastrostomies for

A

providing feeds directly into the stomach in patients that cannot meet their nutritional needs by mouth

401
Q

Stomas

what is a Percutaneous endoscopic gastrostomy (PEG)

A

when the gastrostomy is fitted by an endoscopy procedure

402
Q

Stomas

what is a urostomy

A

creating an opening from the urinary system onto the skin

drains urine from the kidney, bypassing the ureters, bladder and urethra.

403
Q

Stomas

do urostomies have a spout

A

yes

404
Q

Stomas

where are urostomies found

A

in the right iliac fossa

405
Q

Stomas

what is an end colostomy

A

created after the removal of a section of the bowel, where the end part of the proximal portion of the bowel is brought onto the skin

Faeces are able to drain out of the end colostomy into a stoma bag

The other open end of the remaining bowel (the distal part) is sutured and left in the abdomen

It may be reversed at a later date, where the two ends are sutured together creating an anastomosis.

406
Q

Stomas

when are end colostomies permanent

A

after resection of abdomino-perineal resection (APR) because the entire rectum and anus have been removed

407
Q

Stomas

when are end ileostomies permanent

A

after a panproctocolectomy (total colectomy with removal of the large bowel, rectum and anus)

eg after trx of IBD or FAP

408
Q

Stomas

what is a ileo-anal anastomosis (J-pouch)

A

the ileum is folded back on itself and fashioned into a larger pouch that functions a bit like a rectum.

This “J-pouch” is then attached to the anus and collects stools prior to the person passing a motion

409
Q

Stomas

what is a loop colostomy or loop ileostomy

A

a temporary stoma used to allow a distal portion of the bowel and anastomosis to heal after surgery

they allow faeces to bypass the distal, healing portion of bowel until healed and ready to restart normal function

410
Q

Stomas

what does ‘loop’ refer to

A

2 ends (proximal and distal) of a section of small bowel being brought out onto the skin.

the proximal end (productive side) is turned inside out to form a spout to protect the surrounding skin. This distal end is flatter.

411
Q

Stomas

when may urostomies be used

A

after a cystectomy

412
Q

Stomas

what do you need to create in a urostomy

A

ileal conduit:

  • 15-20cm of the ileum is removed
  • end-to-end anastomosis is created so that the bowel is continuous.
  • The ends of the ureters are anastomosed to the separated section of the ileum.
  • The end of the section is brought out onto the skin as a stoma and drains urine directly from the ureters into a urostomy bag.
413
Q

Stomas

what can urine coming into contact with the skin cause

A

irritation and skin damage

414
Q

Stomas

complications

A
  • Psycho-social impact
  • Local skin irritation
  • Parastomal hernia
  • Loss of bowel length leading to high output, dehydration and malnutrition
  • Constipation (colostomies)
  • Stenosis
  • Obstruction
  • Retraction (sinking into the skin)
  • Prolapse (telescoping of bowel through hernia site)
  • Bleeding
  • Granulomas causing raised red lumps around the stoma
415
Q

which condition is a risk factor for gallbladder carcinoma

A

ulcerative colitis due to its association with primary sclerosing cholangitis

416
Q

which surgical interventions are suitable for a mass in the lower third of the rectum

A
  • Abdominoperineal resection (APE)

- Low anterior resection

417
Q

when would you choose a Abdominoperineal resection (APE) over a low anterior resection

A

if the tumour is too close to the anal verge (<8cm)

there will not be enough room to form an anastomosis and therefore an AP resection is required.

418
Q

what is wet gangrene

A

infectious gangrene, and includes necrotising fasciitis. gas gangrene, gangrenous cellulitis

419
Q

presentation of wet gangrene

A

necrotic area is poorly demarcated from the surrounding tissue and patients are pyrexial/septic

420
Q

what is dry gangrene

A

ischaemic gangrene and occurs secondary to chronically reduced blood flow

421
Q

presentation of dry gangrene

A

the necrotic area is well demarcated from the surrounding tissue and patients are do not show signs of infection

422
Q

what is the name of a left sided supraclavicular lymph node

A

Virchow’s node (supplied by the intra-abdominal lymph system)

423
Q

what does an enlarged Virchow’s node suggest

A

Troisier’s sign, which suggests the presence of a gastric malignancy

424
Q

severe pain, PR exam not possible

what is it

A

anal fissure

425
Q

abdominal pain, non-bloody diarrhoea and weight loss). Physical findings (aphthous ulcers, RIF mass and erythema nodosum)

what is it

A

crohn’s

426
Q

classification of surgical wounds

clean wound

A
  • no break in the surgical asepsis

- resp. GI _ urogenital system not entered

427
Q

classification of surgical wounds

clean contaminated wound

A
  • minor break in the surgical asepsis

- elective opening of resp, GI + urogenital system w/ minimal leak

428
Q

classification of surgical wounds

contaminated wound

A
  • major break in the surgical asepsis

- spillage from GI tract, urogenital system in presence of infection

429
Q

classification of surgical wounds

dirty wound

A
  • purulent inflammation resp, GI + urogenital tract perforation
  • presence of gross foreign material + necrotic tissue
430
Q

what is the most accurate test to investigate Meckel’s Diverticulum

A

99 Technetium scan`

431
Q

what is the most suitable trx for a pregnant lady presenting with a >10mm renal stone

A

ureteroscopic stone removal

432
Q

what are the 3 types of gallstones

A
  1. Pigment (<10%)
  2. Cholesterol (90%)
  3. Mixed
433
Q

what are pigment gallstones associated with

A

haemolysis, stasis and infection.

434
Q

what does free air under the diaphragm suggest

A

perforation

435
Q

mass that extrudes during defecation and is associated with rectal mucus discharge, perianal pain and bleeding, faecal incontinence

what is it

A

rectal prolapse

436
Q

Causes of post-op pyrexia

A 
Wind: Pneumonia and atelectasis (1-2 days post-op)
Water: UTI (>3 days)
Wound: Infections (> 5 days)
Wonder drugs: Anaesthesia
Walking: DVT (>1 week)
437
Q

bilateral dullness and mild pyrexia

CXR: bilateral non-lobar shadowing at the bases of the lung fields

what is it

A

basal atelectasis

438
Q

first line management of atelectasis

A

Chest physiotherapy

439
Q

what is mesenteric adenitis

A

inflammation and swelling in the lymph nodes inside the abdomen.

440
Q

which age group does mesenteric adenitis typically affect

A

children + adolescents

441
Q

how does mesenteric adenitis present

A

like appendicitis, following a bacterial or viral illness (e.g. Yersina, Campylobacter or Salmonella)

442
Q

does crohn’s increase the risk of developing gall stones

A

yes

443
Q

does Chronic proteus infection predispose to staghorn renal calculi

A

yes

444
Q

what is the name of the incision for the horizontal incision in the right iliac fossa used for appendicectomy.

A

Lanz incision

445
Q

dragging sensation
soft, compressible, non-tender lump in the right groin. The lump is more prominent on standing. The lump has a purple/blue discolouration.

what could it be

A

saphena varix: a dilation of the great saphenous vein near the saphenofemoral junction caused by incompetence at the saphenofemoral valve

446
Q

what cancers are people FAP at increased risk of

A
  • colorectal cancer

- duodenal cancer

447
Q

where are femoral hernias located in relation to the pubic tubicle and inguinal ligament

A

below the inguinal ligament

below and lateral to the pubic tubercle

448
Q

mnx of femoral hernias

A

Urgent surgical referral because high risk of strangulation

449
Q

what is malignant hyperthermia

A

a life-threatening syndrome triggered by inhalation anaesthetics or suxamethonium

450
Q

cause of malignant hyperthermia

A
  • autosomal dominant mutation in the ryanodine receptor 1, increasing calcium levels in the sarcoplasmic reticulum and increasing metabolic rate
451
Q

presentation of malignant hyperthermia

A

presents at the induction of general anaesthesia:

  • increased body temperature
  • muscle rigidity
  • metabolic acidosis
  • tachycardia
  • increased exhaled CO2
452
Q

mnx of malignant hyperthermia

A
  • stop the triggering agent
  • administer IV dantrolene (a ryanodine receptor antagonist)
  • restore normothermia
453
Q

reduced air entry bilaterally with dull lung bases and reduced fremitus, 1 day post op

what could it be

A

pulmonary atelectasis

454
Q

signet ring cells on biopsy, what is it

A

gastric adenocarcinoma

455
Q

previous open appendicectomy scar name

A

Lanz

456
Q

what is Boerhaave syndrome

A

life-threatening condition caused by a full thickness rupture of the oesophagus.

457
Q

presentation of Boerhaave syndrome

A
  • Severe tearing chest pain worse on swallowing

- Hamman sign represents air within the subcutaneous space: crackling between S1 and S2

458
Q

what is gallstone ileus

A
  • when a gallstone is able to erode through the gallbladder wall
  • a fistula can form between the gallbladder and small bowel
  • If a large gallstone travels through this fistula it can get trapped in narrow areas of the bowel leading to small bowel obstruction
459
Q

why is an ileal resection a RF for gallstones

A

Bile salts are reabsorbed in the terminal ileum; thus its resection increases the risk of stone formation.

460
Q

hoarse voice, difficulty swallowing, loss of weight. which part of the oesophagus is it and why

A

upper 1/3 because her hoarse voice may suggest involvement of the recurrent laryngeal nerve

Finals (47 decks)

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