General surgery Flashcards
what 6 things need to be addressed pre-op?
- pre-op assessment
- consent
- bloods (inc G&S/crossmatch)
- fasting
- medication changes
- VTE assessment
what is included in a pre-op assessment
a full hx of:
- PMH
- previous surgery
- previous adverse response to anaesthesia
- medications
- allergies
- smoking
- alcohol use
consider pregnancy in women of childbearing age
FH of sickle cell disease
general examination for CVS and resp disease
if malnourished (BMI<18.5), what may be required before surgery
- dietician input
- additional nutritional support before surgery + during admission
What is the ASA grade
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
ASA I?
normal healthy patient
ASA II?
mild systemic disease
ASA III?
severe systemic disease
ASA IV
severe systemic disease that constantly threatens life
ASA V
‘moribund’ + expected to die without the operation
ASA VI
declared brain-dead and undergoing an organ donation operation
E?
this is used for emergency operations
why do pts fast before surgery?
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
fasting for an operation typically involves?
- 6 hours of no food or feeds before operation
- 2 hours no clear fluids (fully nil by mouth)
what medications need to be stopped before surgery
- anticoagulants
- oestrogen containing contraception
- HRT
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
trx dose LMWH or an unfractionated heparin infusion
How long before surgery are DOACs stopped?
24-72 hours depending on half-life, procedure and kidney function
why are oestrogen containing contraception
and HRT stopped before surgery?
to reduce the risk of VTE
how long before surgery are oestrogen containing contraception
+ HRT stopped/
4 weeks
why do pts on long term steroids need more steroid before surgery?
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
what is the mnx for pts on long term steroids before surgery?
- additional IV hydrocortisone at induction + immediate postoperative period
- double normal dose once they are eating + drinking for 24–72 hours depending on the operation
what do you do in pts on insulin going for surgery?
- 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)
what PO anti-diabetic meds need to be adjusted or omitted around surgery and why?
- Sulfonylureas (gliclazide) : hypoglycaemia
- Metformin: lactic acidosis
- SGLT2 inhibitors (dapagliflozin): diabetic ketoacidosis
VTE prophylaxis before surgery?
- LMWH (enoxaparin)
- DOACs as an alternative
- intermittent pneumatic compression (inflating cuffs around the legs)
- anti-embolic compression stockings
what is the 4 criteria that a patient needs to meet to demonstrate capacity to make a decision?
- understand the decision
- retain the info long enough to make the decision
- weigh up the pros and cons
- communicate their decision
lasting power of attorney?
when a person legally nominates a person of their choice to make decisions on their behalf if they lack mental capacity.
Deprivation of liberty safeguards (DoLS) ?
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.
Consent form 1?
Patient consenting to a procedure
Consent form 2?
Parental consent on behalf of a child
Consent form 3?
Where the patient won’t have their consciousness impaired (e.g., a breast biopsy)
Consent form 4?
Where the patient lacks capacity
Acute Abdomen
differential diagnoses for generalised abdo pain (4)
- peritonitis
- ruptured AAA
- intestinal obstruction
- ischaemic colitis
Acute Abdomen
differentials for RUQ pain (3)
- biliary colic
- acute cholecystitis
- acute cholangitis
Acute Abdomen
differentials for epigastric pain (4)
- acute gastritis
- peptic ulcer disease
- pancreatitis
- ruptured AAA
Acute Abdomen
differentials for central abdo pain (4)
- ruptured AAA
- intestinal obstruction
- ischaemic colitis
- early stages of appendicitis
Acute Abdomen
differentials for right iliac fossa pain (5)
- acute appendicitis
- ectopic pregnancy
- ruptured ovarian cyst
- ovarian torsion
- Meckel’s diverticulitis
Acute Abdomen
differentials for left iliac fossa pain (4)
- diverticulitis
- ectopic pregnancy
- ruptured ovarian cyst
- ovarian torsion
Acute Abdomen
differentials for suprapubic pain (4)
- lower UTI
- acute urinary retention
- pelvic inflammatory disease
- prostatitis
Acute Abdomen
differentials for loin to groin pain (3)
- renal colic (kidney stones)
- ruptured AAA
- pyelonephritis
Acute Abdomen
differentials for testicular pain (2)
- testicular torsion
2. epididymo-orchitis
Signs of peritonitis
- 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
what causes localised peritonitis?
underlying organ inflammation e.g. appendicitis or cholecystitis
what causes generalised peritonitis?
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
what is spontaneous bacterial peritonitis associated with>
spontaneous infection of ascites in patients with liver disease
treated with broad-spectrum abx + carries poor prognosis
Appendicitis
peak incidence
10-20 years
Appendicitis
pathophysiology
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
Appendicitis
where is McBurney’s point?
1/3 of the distance from the anterior superior iliac spine (ASIS) to the umbilicus
Appendicitis
signs
- tenderness at McBurney’s point
- Rovsing’s sign
- guarding
- rebound tenderness
- percussion tenderness
Appendicitis
what is Rovsing’s sign?
palpation of the left iliac fossa causes pain in the RIF
Appendicitis
symptoms
- loss of appetite
- N+V
- low-grade fever
Appendicitis
what would suggest a ruptured appendix?
rebound tenderness + percussion tenderness –> peritonitis
Appendicitis
diagnosis
clinical presentation + raised inflammatory markers
CT scan can be useful in confirming diagnosis
USS often used to exclude gynae pathology
Appendicitis
what to do if clinical presentation is suggestive of appendicitis, but investigations are negative
diagnostic laparoscopy then surgeon can proceed to appendicectomy during the same procedure
Appendicitis
key differentials
- ovarian cysts
- Meckel’s Diverticulum
- Mesenteric Adenitis
Appendicitis
when does an appendix mass occur?
when the omentum surrounds + sticks to the inflamed appendix forming a mass in the right iliac fossa
Appendicitis
definitive mnx
appendicectomy
Appendicitis
complications of an appendicectomy
- bleeding, infection, pain + scars
- damage to bowel, bladder + other organs
- removal of normal appendix
- anaesthetic risks
- VTE
Bowel Obstruction
what is bowel obstruction
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!
Bowel Obstruction
which is more common, small or large?
small
Bowel Obstruction
what is third spacing?
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.
Bowel Obstruction
3 big causes
- Adhesions (small bowel)
- Hernias (small bowel)
- Malignancy (large bowel)
Bowel Obstruction
other causes
- volvulus (large bowel)
- diverticular disease
- strictures (secondary to Crohn’s disease)
- intussusception (6m-2yrs)
Bowel Obstruction
what are adhesions
pieces of scar tissue that bind the abdo contents together
Bowel Obstruction
how do adhesions cause bowel obstruction
they can cause kinking or squeezing of the bowel
Bowel Obstruction
main causes of adhesions (4)
- abdo or pelvic surgery (esp open surgery)
- peritonitis
- abdo or pelvic infections (PID)
- endometriosis
less common: congenital or secondary to radiotherapy trx
Bowel Obstruction
what is closed-loop obstruction
where there are 2 points of obstruction along the bowel, meaning that there is a middle section sandwiched between 2 points of obstruction
Bowel Obstruction
how would adhesions cause closed-loop obstruction
compresses 2 areas of bowel
Bowel Obstruction
how would hernias cause closed-loop obstruction
could isolate a section of bowel blocking either end
Bowel Obstruction
how would volvulus cause closed-loop obstruction
where the twist isolates a section of intestine
Bowel Obstruction
how would a competent ileocecal valve cause closed-loop obstruction
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
Bowel Obstruction
causes of closed-loop obstruction
- adhesions
- hernias
- volvulus
- competent ileocecal valve + obstructing lesion
Bowel Obstruction
what could a closed-loop obstruction lead to?
bowel can’t drain and decompress so closed loop section will continue to expand leading to ischaemia + perforation
emergency surgery
Bowel Obstruction
key features (5)
- vomiting (esp green bilious vomiting)
- abdo distention
- diffuse abdo pain
- absolute constipation + lack of flatulence
- ‘tinkling’ bowel sounds may be heard in early bowel obstruction
Bowel Obstruction
Inx and key finding
abdo X-ray
- DISTENDED LOOPS OF BOWEL
- Valvulae conniventes
- Haustra
Bowel Obstruction
upper limits of the normal diameter of bowel
3cm small bowel
6cm colon
9cm caecum
Bowel Obstruction
what are Valvulae conniventes
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
Bowel Obstruction
what are haustra?
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
Bowel Obstruction
when would patients require urgent intervention?
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
Bowel Obstruction
initial mnx
- 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
Bowel Obstruction
what would the blood results show?
- electrolyte imbalances
- metabolic alkalosis: vomiting
- raised lactate: bowel ischaemia
Bowel Obstruction
imaging
- abdo x-ray
- erect chest x-ray: air under diaphragm if intra-abdo perforation
- contract abdo CT scan: to confirm dx
Bowel Obstruction
when to use conservative mnx
in the first instance in stable patients with obstruction secondary to adhesions or volvulus
where this fails, surgery is required
Bowel Obstruction
definitive mnx
surgery to correct the underlying cause:
- exploratory surgery: unclear
- adhesiolysis: treat adhesions
- hernia repair
- emergency resection: obstructing tumour
- stents: obstructing tumour
Acute Cholecystitis
what is it
inflammation of the gallbladder caused by a blockage of the cystic duct preventing the gallbladder from draining
Acute Cholecystitis
cause
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
Acute Cholecystitis
main presenting symptom
pain in the RUQ
may radiate to right shoulder
Acute Cholecystitis
other features
- fever
- N+V
- tachycardia + tachypnoea
- RUQ tenderness
- Murphy’s sign
- raised inflammatory markers + WBCs
Acute Cholecystitis
what is Murphy’s sign
- 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
Acute Cholecystitis
initial inx and results
abdo USS
- thickened gallbladder wall
- stones or sludge in gallbladder
- fluid around the gallbladder
Acute Cholecystitis
other inx
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)
Acute Cholecystitis
conservative mnx
- emergency admission
- nil by mouth
- IV fluids
- abx as per local guidelines
- NG tube if required for vomiting
Acute Cholecystitis
surgical mnx
- Endoscopic retrograde cholangio-pancreatography: removes stones trapped in CBD
- Cholecystectomy: may be performed within 72hrs of symptoms
Acute Cholecystitis
complications (4)
- sepsis
- gallbladder empyema
- gangrenous gallbladder
- perforation
Acute Cholecystitis
what is gallbladder empyema
infected tissue and puss collecting in the gallbladder
Acute Cholecystitis
mnx of gallbladder empyema
IV abx + either:
- cholecystectomy
- cholecystostomy (insert drain into gallbladder to allow infected contents to drain)
Acute Cholangitis
what is it
infection and inflammation in the bile ducts
surgical emergency
high mortality
Acute Cholangitis
why does it have a high mortality
sepsis and septicaemia
Acute Cholangitis
2 main causes
- obstruction in the bile ducts stopping bile flow eg. gallstones in the CBD
- infection introduced during an ERCP procedure
Acute Cholangitis
most common organism causes (3)
- Escherichia coli
- Klebsiella species
- Enterococcus species
Acute Cholangitis
what is Charcot’s Triad
- RUQ pain
- fever
- jaundice (raised bilirubin)
Acute Cholangitis
acute mnx
emergency admission:
- nil by mouth
- IV fluids
- blood cultures
- IV abx
- involvement of seniors and potentially HDU or ICU
Acute Cholangitis
list some imaging to diagnose CBD stones and cholangitis (from least to most sensitive)
- abdo USS
- CT
- MRCP
- Endoscopic US
Acute Cholangitis
definitive mnx
endoscopic retrograde cholangio-pancreatography (ERCP)
removes stones blocking bile duct
Acute Cholangitis
what procedures can be performed during an ERCP
- Cholangio-pancreatography
- Sphincterotomy
- Stone removal
- Balloon dilatation
- Biliary stenting
- Biopsy
Acute Cholangitis
what is Cholangio-pancreatography
retrograde injection of contrast into the duct through the sphincter of Oddi + x-ray images to visualise the biliary system
Acute Cholangitis
what is a Sphincterotomy
making a cut in the sphincter to dilate it and allow stone removal
Acute Cholangitis
what can be used if pts are less suitable for ERCP or where ERCP has failed?
Percutaneous transhepatic cholangiogram (PTC)
Acute Cholangitis
what is Percutaneous transhepatic cholangiogram (PTC)
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
Mesenteric Ischaemia
cause
lack of blood flow through the mesenteric vessels supplying the intestines, resulting in intestinal ischaemia
Mesenteric Ischaemia
what are the 3 main branches of the abdominal aorta that supply the abdominal organs
- coeliac artery
- superior mesenteric artery
- inferior mesenteric artery
Mesenteric Ischaemia
what does the foregut include
- stomach
- part of duodenum
- biliary system
- liver
- pancreas
- spleen
Mesenteric Ischaemia
what supplies the foregut
the coeliac artery
Mesenteric Ischaemia
what is included in the midgut
from the distal part of the duodenum to the 1st half of the transverse colon
Mesenteric Ischaemia
what supplies the midgut
the superior mesenteric artery
Mesenteric Ischaemia
what is included in the hindgut
from the 2nd half of the transverse colon to the rectum
Mesenteric Ischaemia
what supplies the hindgut
the inferior mesenteric artery
Mesenteric Ischaemia
what is chronic mesenteric ischaemia
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
Mesenteric Ischaemia
typical classic triad of chronic mesenteric ischaemia
- central colicky abdo pain after eating (30min after eating and lasts 1-2hrs)
- weight loss: due to food avoidance
- abdominal bruit may be heard on auscultation
Mesenteric Ischaemia
RFs for chronic mesenteric ischaemia
same as any other CVS disease:
- increased age
- FH
- smoking
- diabetes
- HTN
- raised cholesterol
Mesenteric Ischaemia
chronic mesenteric ischaemia dx
by CT angiography
Mesenteric Ischaemia
mnx of chronic mesenteric ischaemia
- reduce modifiable RFs
- secondary prevention: statins, antiplatelet med
- revascularisation
Mesenteric Ischaemia
how may revascularisation be performed
- 1st line: endovascular procedures eg: percutaneous mesenteric artery stenting
- open surgery eg: endarterectomy, re-implantation or bypass grafting
Mesenteric Ischaemia
cause of acute mesenteric ischaemia
rapid blockage in blood flow through the superior mesenteric artery
usually caused by a thrombus or embolus
Mesenteric Ischaemia
acute mesenteric ischaemia key RF
AF, where thrombus forms in RA them mobilises down aorta to superior mesenteric artery
Mesenteric Ischaemia
acute mesenteric ischaemia presentation
- acute, non-specific abdo pain which is disproportionate to the examination findings
- can develop shock, peritonitis, sepsis
Mesenteric Ischaemia
acute mesenteric ischaemia if not treated
necrosis of bowel tissue and perforation
Mesenteric Ischaemia
acute mesenteric ischaemia diagnostic test of choice
contrast CT: to assess bowel and blood supply
Mesenteric Ischaemia
acute mesenteric ischaemia blood gas
metabolic acidosis
raised lactate
Mesenteric Ischaemia
acute mesenteric ischaemia: why do patients require surgery
- to remove necrotic bowel
2. to remove or bypass the thrombus in the blood vessel
Mesenteric Ischaemia
acute mesenteric ischaemia prognosis
very high mortality (>50%)
Hernias
when do they occur
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
Hernias
presentation
- soft lump protruding from the abdo wall
- may be reducible
- may protrude on coughing or standing
- aching, pulling or dragging sensation
Hernias
why do hernias protrude on coughing or standing
cough: raises intra-abdo pressure
stand: pulled out by gravity
Hernias
complications (3)
- incarceration
- obstruction
- strangulation
Hernias
what is incarceration
the hernia cannot be reduced back into the proper position (irreducible)
the bowel is trapped in the herniated position
Hernias
what can incarceration lead to
obstruction and strangulation
Hernias
what is obstruction
where a hernia causes a blockage in the passage of faeces through the bowel
Hernias
what does obstruction present with
- vomiting
- generalised abdo pain
- absolute constipation (not passing faeces or flatus)
Hernias
what is strangulation
hernia is non-reducible AND the base of hernia becomes so tight that it cuts off the blood supply causing ischaemia
surgical emergency
Hernias
presentation of strangulation
pain and tenderness at the hernia site
Hernias
when assessing a hernia, what do you need to comment on and why?
the size of the neck/defect (narrow or wide)
as the wider the neck the lower risk of complications
Hernias
what is a Richter’s Hernia
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
Hernias
why worry about Richter’s hernias
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
Hernias
what is Maydl’s Hernia
where 2 different loops of bowel are contained within the hernia
Hernias
general mnx options (3)
- conservative mnx
- tension-free repair (surgery)
- tension repair (surgery)
Hernias
what is conservative mnx
leaving the hernia alone
most appropriate with a wide neck hernia and pts with co-morbidities
Hernias
what is involved in a tension-free repair
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
Hernias
what is involved in a tension repair
suturing muscles and tissue on either side of the defect back together
Hernias
how do inguinal hernias present as?
a soft lump in the inguinal region (in the groin)
Hernias
what are the 2 types of inguinal hernias
- indirect inguinal hernia
- direct inguinal hernia
Hernias
Ddx for a lump in the inguinal region
- 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
Hernias
what is an indirect inguinal hernia
where the bowel herniates through the inguinal canal
Hernias
where does the inguinal canal run between
the deep inguinal ring (where it connects to the peritoneal cavity)
and the superficial inguinal ring (where it connects to the scrotum)
Hernias
what is contained in the inguinal canal in males?
- spermatic cord
- Ilioinguinal nerve
- Genital branch of the genitofemoral nerve
Hernias
what is contained in the inguinal canal in females?
- round ligament
- ilioinguinal nerve
- genital branch of the genitofemoral nerve
Hernias
pathophysiology of an indirect inguinal hernia
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
Hernias
what is the specific finding to help differentiate from an indirect and direct inguinal hernia
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
Hernias
where is the deep inguinal ring on examination
at the midway point from the ASIS to the pubic tubercle
Hernias
why do direct inguinal hernias occur
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)
Hernias
what are the boundaries of Hesselbach’s triangle
RIP
Rectus abdominis muscle - medial border
Inferior epigastric vessels - superior/lateral border
Poupart’s ligament (inguinal ligament) - inferior border
Hernias
what are femoral hernias
herniation of the abdo contents through the femoral canal . this occurs below the inguinal ligament at the top of the thigh
Hernias
what is the opening between the peritoneal cavity and the femoral canal
the femoral ring
Hernias
why do femoral hernias have a high risk of incarceration, obstruction and strangulation
because the femoral ring leaves only a narrow opening for femoral hernias
Hernias
what are the boundaries of the femoral canal
FLIP
Femoral vein - lateral
Lacunar ligament - medial
Inguinal ligament - anterior
Pectineal ligament - posteriorly
Hernias
what is the femoral triangle
a larger area at the top of the thigh that contains the femoral canal
Hernias
what are the boundaries of the femoral triangle
SAIL
Sartorius - lateral
Adductor longus - medial
Inguinal Ligament - superior
Hernias
what are the contents of the femoral triangle from lateral to medial
NAVY-C
femoral Nerve femoral Artery femoral Vein Y fronts femoral Canal (containing lymphatic vessels and nodes)
Hernias
where do incisional hernias occur and why
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
Hernias
mnx of incisional hernias
difficult to repair with high rate of recurrence
often left alone if large with a wide neck and low risk of complications
Hernias
where do umbilical hernias occur and why
around the umbilicus due to a defect in the muscle around the umbilicus
Hernias
who are umbilical hernias common in
neonates and can resolve spontaenously
also older adults
Hernias
what is an epigastric hernia
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.
Hernias
where do Spigelian hernias occur
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
Hernias
what is the spigelian fascia
an aponeurosis between the muscles of the abdo wall
Hernias
presentation of Spigelian Hernias
non-specific abdo wall pain
there may not be a noticeable lump
narrower base
Hernias
what is Diastasis Recti (aka rectus diastasis and recti divarication)
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
Hernias
when does the gap in a Diastasis Recti become most prominent
when the pt lies on their back and lifts their head
there is a protruding bulge along the middle of the abdo
Hernias
how does a Diastasis Recti occur?
congenital or due to weakness in connective tissue eg following pregancy or in obese pts
Hernias
trx of diastasis recti
none in most cases but surgical repair is possible
Hernias
what is a hiatus hernia
the herniation of the stomach up through the diaphragm
Hernias
pathophysiology of a hiatus hernia
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
Hernias
what is a a Type 1 hiatus hernia
Sliding: stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up the thorax
Hernias
what is a Type 2 hiatus hernia
Rolling: seperate portion of the somach (eg fundus) folds around and enters through the diaphragm opening, alongside the oesophagus
Hernias
what is a type 3 hiatus hernia
combination of sliding and rolling
Hernias
what is a type 4 hiatus hernia
refers to a large hernia that allows other intra-abdo organs to pass through the diaphragm opening (eg bowel, pancreas or omentum)
Hernias
what are 3 key RFs in hiatus hernias
age
obesity
pregnancy
Hernias
hiatus hernia presentation
dyspepsia with:
- heartburn
- acid reflux
- reflux of food
- burping
- bloating
- halitosis (bad breath)
Hernias
imaging for hiatus hernias
intermittent so may not be seen
- CXR
- CT
- Endoscopy
- barium swallow
Hernias
trx of hiatus hernias
- conservative: medical trx of GOR)
- laparoscopic fundoplication
Hernias
what is involved in laparoscopic fundoplication
tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter
Hernias
what are obturator hernias
where the abdo or pelvic contents herniate through the obturator foramen at the bottom of the pelvis
Hernias
why do obturator hernias occur
due to a defect in the pelvic floor
Hernias
who are obturator hernias common in
women, esp older age
after multiple pregnancies and vaginal deliveries
Hernias
obturator hernia symptoms
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
Hernias
obturator hernia: what is Howship-Romberg sign
pain extending from the inner thigh to the knee when the hip is internally rotated
due to compression of the obturator nerve
Hernias
diagnostic inx for obturator hernias
CT or MRI or found incidentally during pelvic surgery
Haemorrhoids
what are they
enlarged anal vascular cushions often associated with constipation and straining
Haemorrhoids
whom are they more common in
- pregnancy women
- obesity
- increased age
- increased intra-abdo pressure (weightlifting, chronic cough)
Haemorrhoids
why do they often occur in pregnancy
due to constipation, pressure from the baby in the pelvis and the effects of hormones that relax the connective tissues
Haemorrhoids
what are anal cushions
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
Haemorrhoids
what is the blood supply for anal cushions
the rectal arteries
Haemorrhoids
where are the anal cushions usually located
at 3, 7 and 11 o’clock
Haemorrhoids
1st degree
no prolapse
Haemorrhoids
2nd degree
prolapse when straining and return on relaxing
Haemorrhoids
3rd degree
prolapse when straining,
do not return on relaxing
but can be pushed back
Haemorrhoids
4th degree
prolapsed permanently
Haemorrhoids
common presentation
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
Haemorrhoids
is the blood mixed with the stool
No
you should think of an alternative diagnosis
Haemorrhoids
examination findings for external (prolapsed) haemorrhoids
visible on inspection as swellings covered in mucosa
Haemorrhoids
examination findings for internal haemorrhoids
may be felt on PR exam (although difficult or not possible)
they may appear if the pt is asked to ‘bear down’ on inspection
Haemorrhoids
how are they visualised and inspected
proctoscopy
inserting a hollow tube (proctoscope) into the anal cavity to visualise the mucosa
Haemorrhoids
Ddx in pts presenting with sx such as rectal bleeding (4)
- anal fissures
- diverticulosis
- IBD
- colorectal cancer
Haemorrhoids
what can be given for symptomatic relief
Topical trx
- Anusol
- Anusol HC
- Germoloids cream
- Proctosedyl ointment
Haemorrhoids
what does Anusol contain
chemicals to shrink the haemorrhoids ‘astringents’
Haemorrhoids
what does Anusol HC contain
astringents and hydrocortisone
only used short term
Haemorrhoids
what do germoloids cream contain
lidocaine
Haemorrhoids
what does Proctosedyl ointment contain
cinchocaine and hydrocortisone
short term only
Haemorrhoids
prevention and trx of constipation
- increase fibre in diet
- good fluid intake
- laxatives where required
- consciously avoiding straining when opening their bowels
Haemorrhoids
non surgical trx
- rubber band ligation
- injection sclerotherapy
- infra-red coagulation
- bipolar diathermy
Haemorrhoids
what is rubber band ligation
fitting a tight rubber band around the base of the haemorrhoid to cut off the blood supply
Haemorrhoids
what is injection sclerotherapy
injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy
Haemorrhoids
what is infra-red coagulation
infra-red light is applied to damage the blood supply
Haemorrhoids
what is bipolar diathermy
electrical current applied directly to the haemorrhoid to destroy it
Haemorrhoids
surgical options (3)
- haemorrhoidal artery ligation
- haemorrhoidectomy
- stapled haemorrhoidectomy
Haemorrhoids
what is haemorrhoidal artery ligation
using a proctoscope to identify the blood vessel that supplies the haemorrhoids and suturing it to cut off the blood supply
Haemorrhoids
what is a Haemorrhoidectomy
excising the haemorrhoid.
Removing the anal cushions may result in faecal incontinence.
Haemorrhoids
what is Stapled haemorrhoidectomy
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.
Haemorrhoids
what are thrombosed haemorrhoids caused by
strangulation at the base of the haemorrhoid resulting in thrombosis (a clot) in the haemorrhoid
Haemorrhoids
presentation of a thrombosed haemorrhoid
- purplish, very tender, swollen lumps around the anus
PR exam can’t be done due to the pain
Haemorrhoids
mnx of a thrombosed haemorrhoid
consider admission if the pt presents within 72h with extreme pain.
May benefit from surgical mnx
resolve with time, may take several weeks
Cholangiocarcinoma
what is it
a type of cancer that originates in the bile ducts
the majority are adenocarcinomas
Cholangiocarcinoma
what is the most common site
perihilar region :
where the R + L hepatic duct have joined to become the common hepatic duct just after leaving the liver
Cholangiocarcinoma
key risk factors (2)
- primary sclerosing cholangitis
- liver flukes (parasitic infection found in Southeast Asia + Europe)
Cholangiocarcinoma
ulcerative colitis –>
are at risk of PSC whom are at risk of cholangiocarcinomas
Cholangiocarcinoma
key presenting feature
OBSTRUCTIVE JAUNDICE:
- pale stools
- dark urine
- generalised itching
Cholangiocarcinoma
non-specific signs and symptoms
- unexplained weight loss
- RUQ pain
- palpable gallbladder (swelling due to an obstruction in the duct distal to the gallbladder)
- hepatomegaly
Cholangiocarcinoma
what does Courvoisier’s law state
a palpable gallbladder + jaundice is unlikely to be gallstones
the cause is usually Cholangiocarcinoma or pancreatic cancer
painless jaundice Ddx
- cancer of the head of the pancreas
2. cholangiocarcinoma
Cholangiocarcinoma
dx
CT or MRI
+
histology from biopsy
Cholangiocarcinoma
what does a staging CT scan involve
a full CT thorax, abdomen and pelvis (CTTAP)
used to look for metastasis and other cancers
Cholangiocarcinoma
what tumour marker may be raised
CA 19-9
carbohydrate antigen
Cholangiocarcinoma
what may cause a raised CA 19-9
Cholangiocarcinoma
pancreatic cancer
number of other malignant and non-malignant conditions
Cholangiocarcinoma
what would MRCP be used for
to assess the biliary system in detail to assess the obstruction
Cholangiocarcinoma
what can ERCP used for
to put a stent and relive the obstruction
and obtain a biopsy from the tumour
Cholangiocarcinoma
mnx in early cases
Curative surgery may be possible in early cases.
may be combined with radiotherapy and chemotherapy.
Cholangiocarcinoma
mnx (palliative trx)
- stents: relieve biliary obstruction
- surgery: improve sx e.g. bypass the biliary obstruction
- palliative chemo
- palliative radio
- end of life care with sx control
Pancreatic cancer
why is it bad
often diagnosed late and has a very poor prognosis
Pancreatic cancer
what kind are they usually and where do they occur
adenocarcinomas
head of the pancreas
Pancreatic cancer
how does it cause obstructive jaundice
if a tumour in the head of the pancreas grows large enough it can compress the bile ducts
Pancreatic cancer
where do they tend to metastasise
liver, then peritoneum
lungs
bone
Pancreatic cancer
key presenting feature
painless obstructive jaundice:
- yellow skin + sclera
- pale stools
- dark urine
- generalised itching
Pancreatic cancer
presentation (other than painless obstructive jaundice)
- 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
Pancreatic cancer
when should pt be referred on a 2 week wait referral
> 40 with jaundice
Pancreatic cancer
when should a pt be referred for a direct access CT abdo
> 60 with weight loss + and additional symptom:
- diarrhoea
- back pain
- abdo pain
- Nausea
- Vomiting
- constipation
- new onset diabetes
what is the only scenario where GPs can refer directly for a CT scan
suspected pancreatic cancer
Pancreatic cancer
what is Trousseau’s sign of malignancy
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.
Pancreatic cancer
dx
CT + histology from biopsy
Pancreatic cancer
what does Staging CT scan involve
a full CT thorax, abdo, pelvis (CT TAP)
to look for metastasis and other cancers
Pancreatic cancer
what tumour marker may be raised
CA 19-9
Pancreatic cancer
what may MRCP be used for
assess the biliary system in detail to assess the obstruction.
Pancreatic cancer
what may ERCP be used for
to put a stent in and relieve the obstruction
and also obtain a biopsy from the tumour.
Pancreatic cancer
how may biopsy be taken
taken through the skin (percutaneous) under ultrasound or CT guidance
or during an endoscopy under ultrasound guidance.
Pancreatic cancer
where will mnx be decided
at a hepatobiliary (HPB) MDT meeting
Pancreatic cancer
what are the surgical options to remove tumour
- Total pancreatectomy
- Distal pancreatectomy
- Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure)
- Radical pancreaticoduodenectomy (Whipple procedure)
Pancreatic cancer
when curative trx is not possible, what may palliative trx involve
- 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
Pancreatic cancer
what is Whipple Procedure
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
Pancreatic cancer
what is a modified Whipple procedure
involves leaving the pylorus in place.
aka pylorus-preserving pancreaticoduodenectomy (PPPD).
Pancreatitis
3 main causes
- alcohol
- Gallstones
- post-ERCP
Pancreatitis
how do gallstones cause pancreatitis
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
Pancreatitis
I GET SMASHED causes
Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion sting Hyperlipidaemia ERCP Drugs: furosemide, thiazide diuretics + azithioprine
Pancreatitis
how does acute pancreatitis present
- severe epigastric pain
- radiating through the back
- associated vomiting
- abdo tenderness
- systemically unwell
Pancreatitis
what is used to assess the severity of pancreatitis
The Glasgow Score. It gives a numerical score based on how many of the key criteria are present
Pancreatitis
what is the criteria for the Glasgow score
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)
Pancreatitis
what does a Glasgow Score of 0 or 1 indicate
mild pancreatitis
Pancreatitis
what does a Glasgow score of 2 indicate
moderate pancreatitis
Pancreatitis
what does a Glasgow score of 3 or more indicate
severe pancreatitis
Pancreatitis
inx
- raised AMYLASE
- CRP
- US: gallstones
- CT: complications
glasgow score inx:
- FBC: WCC
- U&E: urea
- LFT: transaminases + albumin
- Ca
- ABG: PaO2 + blood glucose
Pancreatitis
where should you consider admission for moderate or severe cases
HDU or ICU
Pancreatitis
mnx
- 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)
Pancreatitis
how long will it take most pts to improve
3-7d
Pancreatitis
complications
- necrosis
- infection
- abscess
- acute peripancreatic fluid collections
- pseudocysts: collection of pancreatic juice) can develop 4w after acute pancreatitis
- chronic pancreatitis
what is chronic pancreatitis
chronic inflammation in the pancreas
results in fibrosis and reduced function of the pancreatic tissue
Chronic Pancreatitis
most common cause
alcohol
Chronic Pancreatitis
presentation
similar to acute but generally less intense and longer lasting
Chronic Pancreatitis
complications
- 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
Chronic Pancreatitis
mnx
- 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
Bowel Cancer
RFs
- 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
Bowel Cancer
RF: what is Familial adenomatous polyposis (FAP)
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)
Bowel Cancer
RF: Familial adenomatous polyposis (FAP) mnx
panproctocolectomy to prevent development of bowel cancer
Bowel Cancer
RF: what is Hereditary nonpolyposis colorectal cancer (HNPCC) aka Lynch syndrome
autosomal dominant condition
mutations in DNA mismatch repair (MMR) genes
higher risk of colorectal cancer
does not cause adenomas
tumours develop in isolation.
Bowel Cancer
presentation
- 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
Bowel Cancer
mnx for unexplained iron deficient anaemia
2 week wait referral
colonoscopy and gastroscopy (“top and tail”) for GI malignancy
Bowel Cancer
what is the FIT test
Faecal immunochemical tests
look very specifically for the amount of human haemoglobin in the stool
Bowel Cancer
when is a FIT test used
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
Bowel Cancer
at what age are people sent a FIT test for screening and how often
aged 60 – 74 years
every 2 years
Bowel Cancer
what happens if a FIT test is positive
sent for colonoscopy
Bowel Cancer
who is offered a colonscopy at regular intervals to screen for bowel cancer
People with risk factors such as FAP, HNPCC or IBD
Bowel Cancer
gold standard inx
colonoscopy
Any suspicious lesions can be biopsied to get a histological diagnosis, or tattoo in preparation for surgery.
Bowel Cancer
what is sigmoidoscopy and when used
endoscopy of the rectum and sigmoid colon only
in cases where the only feature is rectal bleeding
Bowel Cancer
when is a CT colonography considered
in patients less fit for a colonoscopy but it is less detailed and does not allow for a biopsy.
Bowel Cancer
what inx to look for metastasis and other cancers
Staging CT scan: full CT thorax, abdomen and pelvis (CT TAP).
Bowel Cancer
inx used for predicting relapse in patients previously treated for bowel cancer
Carcinoembryonic antigen (CEA)
Bowel Cancer
what is Carcinoembryonic antigen (CEA)
a tumour marker blood test for bowel cancer. This is not helpful in screening
Bowel Cancer
what is Duke’s classification
the system previously used for bowel cancer. Now TNM
Bowel Cancer
TNM: TX
unable to assess size
Bowel Cancer
TNM: T1
submucosa involvement
Bowel Cancer
TNM: T2
involvement of muscularis propria (muscle layer)
Bowel Cancer
TNM:T3
involvement of the subserosa and serosa (outer layer), but not through the serosa
Bowel Cancer
TNM: T4
spread through the serosa (4a) reaching other tissues or organs (4b)
Bowel Cancer
TNM: NX
unable to assess nodes
Bowel Cancer
TNM: N0
no nodal spread
Bowel Cancer
TNM: N1
spread to 1-3 nodes
Bowel Cancer
TNM: N2
spread to more than 3 nodes
Bowel Cancer
TNM: M0
no metastasis
Bowel Cancer
TNM: M1
metastasis
Bowel Cancer
mnx
- Surgical resection
- Chemotherapy
- Radiotherapy
- Palliative care
Bowel Cancer
what is Low Anterior Resection Syndrome
may occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectum
Bowel Cancer
sx of Low Anterior Resection Syndrome
- Urgency and frequency of bowel movements
- Faecal incontinence
- Difficulty controlling flatulence
Bowel Cancer
follow up
- Serum carcinoembryonic antigen (CEA)
- CT thorax, abdomen and pelvis
Ileus
aka?
paralytic ileus or adynamic ileus
Ileus
what is it
affects small bowel
the normal peristalsis that pushes the contents temporarily stops
what is pesudo-obstruction
a functional obstruction of the large bowel
pts present with intestinal obstruction but no mechanical cause is found
less common than ileus
Ileus
common causes
- injury to bowel
- handling of bowel during surgery
- inflammation or infection in, or nearby the bowel e.g. peritonitis, appendicitis, pancreatitis, pneumonia
- electrolyte imbalances
Ileus
when is the most common time you will see ileus
following abdo surgery
Ileus
signs and symptoms
akin to bowel obstruction:
- green bilious vomiting
- abdo distension
- diffuse abdo pain
- absolute constipation and lack of flatulence
- absent bowel sounds
Ileus
difference in examination of bowel sounds between ileus and mechanical obstruction
ileus: absent
mechanical obstruction: tinkling
Ileus
mnx
supportive:
- nill by mouth
- NG tube if vomiting
- IV fluids
- mobilisation
- total parenteral nutrition may be needed
in addition to colorectal cancer, patients with Lynch syndrome have an increased risk of malignancies of?
Endometrium
Ovaries
Sebaceous glands
Diverticular Disease
```
define diverticulum
pleural: diverticula
~~~
a pouch or pocket in the bowel wall, usually ranging in size from 0.5 – 1cm.
Diverticular Disease
define diverticulosis
the presence of diverticula, without inflammation or infection.
may be referred to as diverticular disease when patients experience sx
Diverticular Disease
define diverticulitis
inflammation and infection of diverticula
Diverticular Disease
what is the layer of muscle called in the large intestine
circular muscle
Diverticular Disease
where are the points of weakness in the circular muscle
where it’s penetrated by blood vessels
Diverticular Disease
what causes diverticula
- 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)
Diverticular Disease
does diverticula form in the rectum
no
Diverticular Disease
why does diverticula not form in the rectum
because it has an outer longitudinal muscle layer that completely surrounds the diameter of the rectum, adding extra support
Diverticular Disease
which parts of the colon are vulnerable to the development of diverticula
the areas that are not covered by teniae coli
3 longitudinal muscles that run along the colon, forming strips or ribbons called teniae coli
Diverticular Disease
Diverticulosis: what is the most commonly affected section of the bowel
sigmoid colon
Diverticular Disease
Diverticulosis: RFs
- increased age
- Low fibre diets
- obesity
- use of NSAIDs
Diverticular Disease
Diverticulosis: what increases the risk of diverticular haemorrhage
NSAIDs
Diverticular Disease
Diverticulosis: how is it diagnosed
incidentally on colonoscopy or CT scan
Diverticular Disease
Diverticulosis: trx in asymptomatic pts `
none but advice regarding a high fibre diet and weight loss is appropriate.
Diverticular Disease
Diverticulosis: what sx may it cause
- lower left abdo pain
- constipation
- rectal bleeding
Diverticular Disease
Diverticulosis: mnx in pts with sx
- increase fibre
- bulk-forming laxatives (e.g.ispaghula husk)
Diverticular Disease
Diverticulosis: what laxatives should be avoided
Stimulant laxatives (e.g., Senna)
Diverticular Disease
Diverticulosis: mnx of significant sx
Surgery to remove the affected area
Diverticular Disease
acute diverticulitis: sx
- Pain and tenderness in the left iliac fossa
- Fever
- Diarrhoea
- N + V
- Rectal bleeding
Diverticular Disease
acute diverticulitis: signs
- Palpable abdominal mass (if an abscess has formed)
- Raised inflammatory markers (e.g., CRP) and WBCs
Diverticular Disease
acute diverticulitis: mnx of uncomplicated diverticulitis in primary care
- 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
Diverticular Disease
acute diverticulitis: when to admit
Patients with severe pain or complications
Diverticular Disease
acute diverticulitis: mnx in hospital
- Nil by mouth or clear fluids only
- IV antibiotics + fluids
- Analgesia
- Urgent inx (e.g. CT scan)
- Urgent surgery may be required for complications
Diverticular Disease
acute diverticulitis: complications
- Perforation
- Peritonitis
- Peridiverticular abscess
- Large haemorrhage requiring blood transfusions
- Fistula (e.g., between the colon and the bladder or vagina)
- Ileus / obstruction
Gallstones
The right hepatic duct and left hepatic duct leave the liver and join together to become the _____
common hepatic duct
Gallstones
what joins the common hepatic duct halfway along
The cystic duct from the gallbladder
Gallstones
what joins the common hepatic duct further along
The pancreatic duct from the pancreas
Gallstones
When the common bile duct and the pancreatic duct join they become the ___
ampulla of Vater
Gallstones
what does the ampulla of Vater open into
the duodenum
Gallstones
what is the ring of muscle surrounding the ampulla of Vater
sphincter of Oddi
Gallstones
what does the sphincter of Oddi do
controls the flow of bile and pancreatic secretions into the duodenum.
Gallstones
define cholestasis
blockage to the flow of bile
Gallstones
define cholelithiasis
gallstones are present
Gallstones
define choledocholithiasis
gall stones in the bile duct
Gallstones
define biliary colic
intermittent RUQ pain caused by gallstones irritating the bile ducts
Gallstones
define cholecystitis
inflammation of the gallbladder
Gallstones
define cholangitis
inflammation of the bile ducts
Gallstones
define gallbladder empyema
pus in the gallbladder
Gallstones
define cholecystectomy
surgical removal of the gallbladder
Gallstones
define cholecystostomy
inserting a drain into the gallbladder
Gallstones
the RFs for gallstones
fat
fair
female
forty
Gallstones
what is biliary colic caused by
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
Gallstones
presentation
- biliary colic
- Severe, colicky epigastric or RUQ pain
- Often triggered by meals (particularly high fat meals)
- Lasting 30 min - 8h
- N+V
Gallstones
complications
- Acute cholecystitis
- Acute cholangitis
- Obstructive jaundice (if the stone blocks the ducts)
- Pancreatitis
Gallstones
why are pts w/ gallstones + biliary colic advised to avoid fatty foods
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
Gallstones
what does raised biliruibin mean
an obstruction to flow of biliruibin within the biliary system
Gallstones
causes of raised ALP
- biliary obstruction
- pregnancy
- liver or bone malignancy
- primary biliary cirrhosis
- Paget’s disease of the bone
Gallstones
what are ALT and AST helpful markers of
hepatocellular injury
Gallstones
what LFTs would show an obstructive picture (e.g. gallstones)
higher rise in ALP
than in ALT + AST
Gallstones
what LFTs would show a hepatic picture (problem inside liver)
high ALT + AST compared with ALP
Gallstones
1st line inx
USS
Gallstones
when would MRCP (magnetic resonance cholangio-pancreatography) be used
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
Gallstones
what is the main indication for ERCP (endoscopic retrograde cholangio-pancreatography)
to clear stones in the bile ducts
Gallstones
what does ERCP involve
inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (the sphincter of Oddi)
Gallstones
what can the operator do in ERCP
- 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
Gallstones
key complications of ERCP
- Excessive bleeding
- Cholangitis (infection in the bile ducts)
- Pancreatitis
Gallstones
when are CT scans used
to look for differential diagnoses (e.g., pancreatic head tumour) and complications such as perforation and abscesses
Gallstones
when is cholecystectomy indicated (removal of gallbladder)
where patients are symptomatic of gallstones, or the gallstones are leading to complications (e.g., acute cholecystitis)
Gallstones
what is the incision called in laparoscopic cholecystectomy
“Kocher” incision
Gallstones
complications of cholecystectomy
- 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
Gallstones
what is Post-cholecystectomy syndrome
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.
Gallstones
sx of Post-cholecystectomy syndrome
- Diarrhoea
- Indigestion
- Epigastric or RUQ pain + discomfort
- Nausea
- Intolerance of fatty foods
- Flatulence
Stomas
what are they
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
Stomas
what is a stoma bag
fitted around the stoma to collect the waste products and is emptied as required
Stomas
what is a colostomy
where the large intestine (colon) is brought onto the skin
Stomas
where are colostomies located
left iliac fossa
Stomas
what kind of stools do colostomies drain, solid or more liquid
and why
solid as much of the water is reabsorbed in the remaining large intestine.
Stomas
what is an ileostomy
where the end portion of the small bowel (ileum) is brought onto the skin.
Stomas
what kind of stools do ileostomies drain, solid or more liquid
and why
liquid stools, as the fluid content is normally reabsorbed later, in the large intestine
Stomas
do ileostomies have a spout
yes, which allows them to drain directly into a tightly fitting stoma bag without the contents coming into contact with the surrounding skin
Stomas
where are ileostomies found
right iliac fossa
Stomas
what is a gastrostomy
creating an artificial connection between the stomach and the abdominal wall
Stomas
what are gastrostomies for
providing feeds directly into the stomach in patients that cannot meet their nutritional needs by mouth
Stomas
what is a Percutaneous endoscopic gastrostomy (PEG)
when the gastrostomy is fitted by an endoscopy procedure
Stomas
what is a urostomy
creating an opening from the urinary system onto the skin
drains urine from the kidney, bypassing the ureters, bladder and urethra.
Stomas
do urostomies have a spout
yes
Stomas
where are urostomies found
in the right iliac fossa
Stomas
what is an end colostomy
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.
Stomas
when are end colostomies permanent
after resection of abdomino-perineal resection (APR) because the entire rectum and anus have been removed
Stomas
when are end ileostomies permanent
after a panproctocolectomy (total colectomy with removal of the large bowel, rectum and anus)
eg after trx of IBD or FAP
Stomas
what is a ileo-anal anastomosis (J-pouch)
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
Stomas
what is a loop colostomy or loop ileostomy
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
Stomas
what does ‘loop’ refer to
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.
Stomas
when may urostomies be used
after a cystectomy
Stomas
what do you need to create in a urostomy
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.
Stomas
what can urine coming into contact with the skin cause
irritation and skin damage
Stomas
complications
- 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
which condition is a risk factor for gallbladder carcinoma
ulcerative colitis due to its association with primary sclerosing cholangitis
which surgical interventions are suitable for a mass in the lower third of the rectum
- Abdominoperineal resection (APE)
- Low anterior resection
when would you choose a Abdominoperineal resection (APE) over a low anterior resection
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.
what is wet gangrene
infectious gangrene, and includes necrotising fasciitis. gas gangrene, gangrenous cellulitis
presentation of wet gangrene
necrotic area is poorly demarcated from the surrounding tissue and patients are pyrexial/septic
what is dry gangrene
ischaemic gangrene and occurs secondary to chronically reduced blood flow
presentation of dry gangrene
the necrotic area is well demarcated from the surrounding tissue and patients are do not show signs of infection
what is the name of a left sided supraclavicular lymph node
Virchow’s node (supplied by the intra-abdominal lymph system)
what does an enlarged Virchow’s node suggest
Troisier’s sign, which suggests the presence of a gastric malignancy
severe pain, PR exam not possible
what is it
anal fissure
abdominal pain, non-bloody diarrhoea and weight loss). Physical findings (aphthous ulcers, RIF mass and erythema nodosum)
what is it
crohn’s
classification of surgical wounds
clean wound
- no break in the surgical asepsis
- resp. GI _ urogenital system not entered
classification of surgical wounds
clean contaminated wound
- minor break in the surgical asepsis
- elective opening of resp, GI + urogenital system w/ minimal leak
classification of surgical wounds
contaminated wound
- major break in the surgical asepsis
- spillage from GI tract, urogenital system in presence of infection
classification of surgical wounds
dirty wound
- purulent inflammation resp, GI + urogenital tract perforation
- presence of gross foreign material + necrotic tissue
what is the most accurate test to investigate Meckel’s Diverticulum
99 Technetium scan`
what is the most suitable trx for a pregnant lady presenting with a >10mm renal stone
ureteroscopic stone removal
what are the 3 types of gallstones
- Pigment (<10%)
- Cholesterol (90%)
- Mixed
what are pigment gallstones associated with
haemolysis, stasis and infection.
what does free air under the diaphragm suggest
perforation
mass that extrudes during defecation and is associated with rectal mucus discharge, perianal pain and bleeding, faecal incontinence
what is it
rectal prolapse
Causes of post-op pyrexia
Wind: Pneumonia and atelectasis (1-2 days post-op) Water: UTI (>3 days) Wound: Infections (> 5 days) Wonder drugs: Anaesthesia Walking: DVT (>1 week)
bilateral dullness and mild pyrexia
CXR: bilateral non-lobar shadowing at the bases of the lung fields
what is it
basal atelectasis
first line management of atelectasis
Chest physiotherapy
what is mesenteric adenitis
inflammation and swelling in the lymph nodes inside the abdomen.
which age group does mesenteric adenitis typically affect
children + adolescents
how does mesenteric adenitis present
like appendicitis, following a bacterial or viral illness (e.g. Yersina, Campylobacter or Salmonella)
does crohn’s increase the risk of developing gall stones
yes
does Chronic proteus infection predispose to staghorn renal calculi
yes
what is the name of the incision for the horizontal incision in the right iliac fossa used for appendicectomy.
Lanz incision
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
saphena varix: a dilation of the great saphenous vein near the saphenofemoral junction caused by incompetence at the saphenofemoral valve
what cancers are people FAP at increased risk of
- colorectal cancer
- duodenal cancer
where are femoral hernias located in relation to the pubic tubicle and inguinal ligament
below the inguinal ligament
below and lateral to the pubic tubercle
mnx of femoral hernias
Urgent surgical referral because high risk of strangulation
what is malignant hyperthermia
a life-threatening syndrome triggered by inhalation anaesthetics or suxamethonium
cause of malignant hyperthermia
- autosomal dominant mutation in the ryanodine receptor 1, increasing calcium levels in the sarcoplasmic reticulum and increasing metabolic rate
presentation of malignant hyperthermia
presents at the induction of general anaesthesia:
- increased body temperature
- muscle rigidity
- metabolic acidosis
- tachycardia
- increased exhaled CO2
mnx of malignant hyperthermia
- stop the triggering agent
- administer IV dantrolene (a ryanodine receptor antagonist)
- restore normothermia
reduced air entry bilaterally with dull lung bases and reduced fremitus, 1 day post op
what could it be
pulmonary atelectasis
signet ring cells on biopsy, what is it
gastric adenocarcinoma
previous open appendicectomy scar name
Lanz
what is Boerhaave syndrome
life-threatening condition caused by a full thickness rupture of the oesophagus.
presentation of Boerhaave syndrome
- Severe tearing chest pain worse on swallowing
- Hamman sign represents air within the subcutaneous space: crackling between S1 and S2
what is gallstone ileus
- 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
why is an ileal resection a RF for gallstones
Bile salts are reabsorbed in the terminal ileum; thus its resection increases the risk of stone formation.
hoarse voice, difficulty swallowing, loss of weight. which part of the oesophagus is it and why
upper 1/3 because her hoarse voice may suggest involvement of the recurrent laryngeal nerve
