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Year 3 Surgery > General Surgery > Flashcards

General Surgery Flashcards

1
Q

When is Nasojejunal feeding done?

A

Gastric disease

Reduced gastric emptying

Recent gastric surgery

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2
Q

When is Gastrostomy feeding done?

A

Blocked/ dysfunctional Oesophagus

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3
Q

When is Jejunostomy feeding done?

A

Stomach not accessible

Outflow obstruction

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4
Q

Compare how Upper and Lower GI Perforations are treated

A

Upper: Closed

Lower: Resected (bowel section removed, remaining parts need to be joined)

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5
Q

List 2 Lower GI Perforations and 1 upper GI Perforation

A

Lower: Perforated diverticulum, Perforated tumour

Upper: Duodenal ulcer

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6
Q

2 most common causes of Small Bowel Obstruction

A

Adhesions (50-75%, most caused by previous abdo surgery)

Hernias (7-25%)

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7
Q

List 3 common causes of large bowel obstruction

A

Colorectal cancer (65%)

Diverticular disease (20%)

Sigmoid Volvulus (10%)

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8
Q

The management of SI Obstruction is usually surgery, except for 2 situations.

Describe these

A

Adhesional SI Obstruction (May be suitable for conservative management)

Sigmoid Volvulus (May be suitable for Endoscopic decompression to suck everything out)

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9
Q

How is an Upper GI bleed diagnosed

A

Gastroscopy, often done by Gastroenterologist

(OGD: Oesophago-Gastro-Duodenoscopy)

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10
Q

In Gallstone Ileus, how does a gallstone big enough to cause obstruction enter the SI

A

Gallbladder is close to Duodenum .can also be in terminal ileum

Frequent gallbladder inflammation can cause a fistula to form, which gallstone can pass through.

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11
Q

Outline Rigler’s Triad

A

Seen in gallstone ileus on AXR

SI obstruction
Air in bile ducts
Gallstone out of gallbladder

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12
Q

Outline Perianal abscess treatment

Who is it commonly seen in

A

Surgery- Drainage
Medical- Consider Ceftriaxone or Metronidazole

Diabetics, Elderly, Obese, Immunocompromised

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13
Q

What can untreated Perianal abscess cause

A

Necrotising fasciitis

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14
Q

Outline ABCDE in reading AXR

(Can use ABDO X)

A

A: Air in wrong place

B: Bowel (Dilation, Volvulus, Distension, Hernia, Wall thickening)

C: Calcification

D: Disability (Bones and organs)

E: Everything else

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15
Q

What does a trace of free fluid in the pelvis indicate

A

Appendicitis (Inflammatory response-> Mucosal oedema)

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16
Q

List post-op complications of an appendicectomy

A

Stump appendicitis/ Stumpitis

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17
Q

List 4 complications of appendicitis

A

Perforation
Surgical site infection

Appendix mass (Omentum + SI adhere to Appendix)

Pelvic abscess (Fever, Palpable RIF mass, ABx and drainage to treat)

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18
Q

When should an OGD be done as an Inpatient

A

Gastric outflow obstruction

If pt has Gastric Band/ Balloon

Dysphagia

Upper GI bleed

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19
Q

It’s RFs for Oesophageal SCC

(Middle and Upper 1/3)

A

Achalasia

Smoking, Alcohol, Low Vit A

Fe deficiency (rarely)

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20
Q

It’s RFs for Oesophageal Adenocarcinoma

(Lower 1/3)

A

GORD, Obesity, High fat intake

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21
Q

What investigations can be done to stage Oesophageal cancer, after an OGD done?

(If any palpable cervical lymph nodes, can do Fine Needle Aspiration)

A

CT- Chest-Abo-Pelvis + PET-CT (Distant metastases)

Endoscopic USS (Oesophageal wall penetration)

Staging Laparoscopy (Intra-peritoneal metastases) (Not done routinely)

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22
Q

How are Oesophageal SCC and Adenocarcinoma treated

A

SCC: Chemo-radiotherapy

Adenocarcinoma;
- Neoadjuvant Chemo or Chemo-radiotherapy
- Oesophageal resection

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23
Q

How is the Upper GI restored after an Oesophagectomy?

A

Stomach made into tube and bought into chest to replace Oesophagus.

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24
Q

List 4 approaches of Oesophagectomy + Oesophgeal Restoration

A

Ivor-Lewis procedure: Right Thoracotomy w/ laparotomy

McKeown Procedure: R Thoracotomy w/ Abdominal + Neck incision

Left Thoracotomy w/ or w/o neck incision

Left Thoraco-abdominal incision

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25
Q

List complications of an Oesophagectomy

A

Anastomosis leak
Re-operation
Penumonia

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26
Q

What is Troiser’s sign?

A

Palpable Left Supraclavicular L Node (Virchow’s)

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27
Q

What info is usually used to make a clinical diagnosis of GORD?

What initial investigation can be done to investigate symptoms?

A

Good history + PPI trial

OGD/ Upper GI Endoscopy (Mainly to exclude Malignancy + Investigate Reflux Complications)

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28
Q

What’s the gold standard for GORD diagnosis

A

24hr pH testing + Oesophageal Manometry to exclude oesophageal dysmotility

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29
Q

What are 3 indications for surgical treatment of GORD, rather than medication (PPI etc)

A

Failure to respond/ or only partial response to medications

Pt prefers to avoid life-long medication

Pts with GORD complications (Aspiration pneumonia, Barret’s, Oesophgeal Strictures and Cancer)

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30
Q

List 3 surgical techniques used to treat GORD

A

Fundoplication

Stretta

Linx

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31
Q

Outline Fundoplication in treating GORD

(Nissen’s approach: Posterior 360 approach)

A

Gastro-Oesophgeal junction + Hiatus are dissected and Fundus wrapped around GOJ.

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32
Q

What are the main side effects of Fundoplication in GORD treatment

A

Dysphagia
Bloating
Inability to vomit

These often settle after 6wks, as swelling and inflammation recedes

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33
Q

Outline Stretta and Linx in treating GORD

A

Stretta: Radiofrequency energy delivered endoscopically to thicken LOS

Linx: String of magnetic beads wrapped around LOS laparoscopically, which tightens LOS

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34
Q

What is a Hiatus Hernia?

What are the 2 types? (Mixed can also occur)

(Most hernias are asymptomatic)

A

Protrusion of an organ from abdominal cavity into thorax, through Oesophageal hiatus

Sliding hiatus hernia (80%)
Rolling/ Para-Oesophgeal Hernia (20%)

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35
Q

Describe a Sliding Hiatus Hernia

How does it present specifically?

A

GOJ, Abdominal Oesophagus (frequently + Cardia) all move up through diaphragmatic hiatus into thorax

Constant reflux

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36
Q

Describe a Rolling/ Para-Oesophageal Hiatus Hernia

How does it present specifically?

A

Gastric fundus moves upwards to lie alongside normally positioned GOJ, creating a stomach “bubble”.

Some Dysphagia

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37
Q

List Hiatus Hernia RFs

A

Age (mainly)

Pregnancy
Obesity
Ascites

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38
Q

Compare Acute and Chronic Pancreatitis

A

Acute: Potentially life threatening

Chronic: Progressive fibrosis and destruction of Endo + Exocrine gland functions
- Amylase and Lipase not usually raised

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39
Q

List 10 Acute Pancreatitis causes (GET SMASHED)

A

Gallstones
Ethanol
Trauma

Steroids
Mumps
Autoimmune disease
Scorpion venom
Hypercalcaemia
ERCP
Drugs (Azathioprine, NSAIDs, Diuretics)

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40
Q

Name a scoring system used to assess Acute Pancreatitis severity

A

Modified Glasgow Criteria;

  • If within 48hrs of admission
  • If 3/+ +ve factors, severe
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41
Q

Name tools other than Modified Glasgow criteria, used to assess Acute Pancreatitis severity

A

APACHE II

Ranson criteria

Balthazar score (CT scoring)

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42
Q

Treating any GI Perforation involves what 3 things

A

Identifying underlying cause

Appropriate management (Different for PUD, SI, LI)

Thorough washout (most important part)

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43
Q

Outline the specific surgical management technique for a Peptic Ulcer Peforation

A

Access via Upper Midline incision or Laparoscopically

Patch of Omentum (Graham patch) tacked loosely over ulcer

(Would be difficult to oversew due to tissue inflammation)

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44
Q

Outline the specific surgical management technique for a Small Bowel Peforation

A

Access via Midline Laparotomy

Small perforations can be oversewn if bowel is viable

Any doubt about bowel’s condition should lead to Bowel resection +/- Primary anastomosis +/- Stoma formation

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45
Q

Outline the specific surgical management technique for a Large Bowel Perforation

A

Access via Midline Laparotomy

Resection w/ Stoma formation is often preferred, as Anastomosis in presence of faecal contamination and an unstable pt is not recommended

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46
Q

30% of UC pts will need surgery at some point.

Outline Elective surgical treatment

A

Total Proctocolectomy is curative with the pt requiring an Ileostomy (Some pts may undergo Ileal pouch-anal anastomosis, IPAA)

Many pts will initially undergo a sub-total colectomy with rectum preservation

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47
Q

List 4 complications of UC

A

Toxic megacolon

Colorectal carcinoma

Osteoporosis

Pouchitis (if had an IPAA operation)

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48
Q

70-80% of Crohn’s pts will need surgery at some point.

List 4 surgical treatments

A

Ileocaecal resection (Removal of terminal ileum and caecum with anastomosis)

Small/ Large bowel resection

Surgery for Peri-anal disease

Stricturoplasty (Division of a stricture causing obstruction)

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49
Q

List 4 GI complications of Crohn’s

A

Fistula

Stricture

Recurrent peri-anal fistula

GI Malignancy

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50
Q

List 4 Extra-intestinal complications of Crohn’s

A

Osteoporosis (Malabsorption, long-term steroid use)

Increased risk of gallstones (reduce bile salt reabsorption)

Increased risk of renal stones

Erythema Nodosum

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51
Q

What are Rigler’s and Telltale Traingle signs?

They signify what?

A

Rigler’s: Crisp, clearly defined bowel wal

Telltale Traingle: Triangles/ Slivers of gas

Pneumoperitoneum

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52
Q

What does ‘thumbprinting’ show

(Wavy, undulating)

(Common: IBD, Ischaemia, Diverticulitis, Infection)

A

Oedema of colonic wall, haustra thickened and swollen

Signifies some form of colitis

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53
Q

Outline Lead pipe colon sign

A

No fold pattern, suggests colitis for long time

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54
Q

List 3 phases of CT with IV contrast (Look at Allergies, eGFR, good Venous access)

A

Systemic arterial (AAA, Stenoses etc)

Portal venous (Abdo or general purpose)

Delayed (Urological)

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55
Q

When may a CT with oral contrast be used

A

To look for GI tract leaks or Fistula

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56
Q

List risks of ERCP

A

Haemorrhage
Perforation
Pancreatitis (mild and self-limiting)
Repeated Cholangitis

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57
Q

Compare Charcot’s Triad and Reynold’s Pentad

A

Charcot: RUQ Pain, Jaundice, Fever

Reynold’s: RUQ Pain, Jaundice, Fever, Hypotension, Confusion

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58
Q

Outline Courvoisier’s Law

A

Jaundice with a painless palpable gallbladder is unlikely to be due to Gallstones, but due to Pancreas/ Gallbladder malignancy

(Caused by Chronic Inflammation so no damage or pain, whereas gallstones cause acute damage and inflammation- pain)

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59
Q

What is Boerhaave’s Syndrome

A

Spontaneous perforation of the esophagus due to sudden increase in intraesophageal pressure combined with negative intrathoracic pressure

(Mallory-Weiss syndrome is not full thickness)

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60
Q

What causes Oesophageal perforations commonly

A

Iatrogenic or severe, forceful vomiting

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61
Q

How does an oesophageal full-thickness tear present

(Rupture to any part of oesophgeal wall, full ruptures have a mortality of 50-80%)

A

Mackler’s Triad (Only seen in 15% of pts): Pain, Vomit, SC Emphysema

  • Severe, sudden, Retrosternal chest pain
  • Respiratory distress
  • Subcutaneous emphysema (Often absent)
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62
Q

List the 2 main categories of Oesophgeal tears

A

Full thickness (Perforation)

Superficial Mucosal tears (Mallory-Weiss)

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63
Q

Why is an Oesophgeal rupture a surgical emergency

A

Stomach contents leak into Mediastinum and Pleural cavity, -> severe inflammation

This will result in physiological collapse, multi-organ failure and death

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64
Q

What’s the most common site for oesophageal perforation

A

Just above diaphragm in postero-lateral position

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65
Q

What investigations are done for Oesophageal Perforations

A

Routine bloods, Group&Save

Initial imaging: CXR may show air in mediastinum or intra-thoracic air fluid levels

Definitive imaging;
- Urgent CT-Chest-Abdo-Pelvis w/ IV and Oral contrast
- May show Air/ Fluid in Mediastinum or Pleural Cavity

If high suspicion based on history and examination, urgent endoscopy

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66
Q

Oesophageal perforation pts are often septic and haemodynamically unstable.
Outline non-definitive, non-surgical treatment

A
  • Resuscitation, transfer to ICU/ HDU
  • Abx + AFx fcover
  • NBM for 1-2wks, w/ NG tube for drainage
  • Large-bore chest drain
  • Feeding Jejunostomy or Total Parenteral Nutrition, TPN
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67
Q

Where are Mallory-Weiss tears usually located?

A

Gastro-oesophageal junction

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68
Q

Outline causes/ RFs and Clinical features of Mallory-Weiss tears

A

After profuse vomiting, results in a short period of Hamatemesis

  • Generally small and self-limiting (in absence of clotting abnormalities or anti-coag drugs)
  • Rarely, present with haemorrhagic shock
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69
Q

Most Mallory-Weiss cases can be managed conservatively.

Outline Investigations (Same as for any Upper GI bleed)

A

Investigations;

  • VBG, Routine bloods (FBC, LFTs, Clotting, U&Es)
  • Group&Save for all pts. If significant, crossmatch 4 units
  • Definitive: OGD
  • Erect CXR, if Perforated Peptic Ulcer suspected
  • CT Abdo w/ IV Contrast
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70
Q

Most Mallory-Weiss cases can be managed conservatively.

Outline Management (Same as for any Upper GI bleed)

A

Fluids. Transfusion if needed

Reduce bleeding: Non-selective B-blocker/ Cauterisation/ Adrenaline injection
- Oesophageal varices: Abx, Terlipressin, Endoscopic banding

IV PPI for 72hrs

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71
Q

Colorectal cancers originate from epithelial cells of colon/rectum, most commonly Adenocarcinomas.

Outline the progression/ development of them

A

Normal Mucosa-> Colonic adenoma/ polyps-> Invasive adenocarcinoma

(Adenomas may be present for 10yrs before progressing, 10% of cases progress)

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72
Q

75% of colorectal cancers are Sporadic, developing in people with no risk factors

List potential RFs

A

Increasing age, Male, FHx, Smoking, Excess alcohol
IBD, Low fibre, High processed meat intake

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73
Q

List classical clinical features of Bowel cancer- Left and Right

A

RHS Colon;
- Abdo pain
- Fe deficiency anaemia
- RIF Mass

LHS Colon;
- PR bleed
- Change in bowel habit
- Tenesmus
- LIF mass

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74
Q

List imaging investigations for suspected Colorectal cancer

A

Gold standard: Colonoscopy w/ Biopsy (If not, CT Colonography)

Staging investigations;
- CT-Chest-Abdo-Pelvis
- MRI Rectum (for rectal cancer only)
- Endo-anal USS (Assess suitability for trans-anal resection)

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75
Q

The main curative management of Colorectal cancer is surgery, followed by Primary Anastomosis/ Stoma formation.

List 5 non-emergency types

A
  • (Extended) Right Hemilectomy
  • Left Hemilectomy
  • Sigmoidcolectomy
  • Anterior Resection
  • Abdominoperinel (AP) Resection
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76
Q

The main curative management of bowel cancer is surgery, generally being Regional Colectomy followed by Primary Anastomosis/ Stoma formation.

Describe 1 emergency type (Perforation, Obstruction)

A

Hartmann’s Procedure

Complete resection of Recto-sigmoid Colon w/ End Colostomy and Rectal Stump closure

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77
Q

Describe (Extended) Right Hemilectomy

A

For Caecal/ Ascending Colon tumours

Extended operation performed for Transverse Colon tumours

Ileocolic, Right Colic + Right branch of Middle Colic (SMA Branches) divided+removed w/ their mesenteries

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78
Q

Describe Left Hemilectomy

A

For Descending Colon Tumours

Left branch of Middle Colic vessels (SMA/SMV branches)
IMV + Left Colic vessels (IMA/ IMV branches)
All these are divided + removed w/ their mesenteries

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79
Q

Describe Sigmoidcolectomy

A

For Sigmoid Colon tumours

IMA fully dissected out w/ tumour

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80
Q

Describe Anterior Resection

A

For High Rectal tumours, typically if >5cm from anus.

Leaves Rectal Sphincter intact if anastomosis performed.

Often, defunctioning loop ileostomy done to protect anastomosis and reduce complications if it leaks.

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81
Q

Describe AP Resection

A

For Low Rectal tumours, typically if <5cm from Anus

Excision of Distal Colon, Rectum + Anal sphincters

Resulting in Permanent Colostomy

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82
Q

How can colorectal cancer with bowel obstruction be relieved?

A

Decompressing colostomy/ Endoscopic stenting

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83
Q

When are Chemo and Radiotherapy used in Colorectal cancer

(Radio rarely used in rectal cancer, due to risk of SI damage)

A

Chemo: Advanced Colorectal cancer

Radio: Neo-adjuvant or alongside Chemo

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84
Q

Compare MRCP and ERCP

A

MRCP;
- Non-invasive
- Not good for pts who are claustrophobic

ERCP;
- Invasive
- Risk of Pancreatitis

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85
Q

List causes of Cholangitis

RFs: Lipids, COCP, Fibrates
Common organisms: E. coli, Klebsiella, Enterococcus

A

Common Causes: Gallstones, ERCP, Cholangiocarcinoma
Rarer Causes: Pancreatitis, Parasitic infections, PSC, Ischaemic Cholangiopathy

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86
Q

List clinical features of Cholangitis

A

RUQ Pain, Fever, Jaundice, HypoT, Confusion (Charcot’s, Reynold’s)

Itching, Rigors, RUQ Tenderness, Tachycardia

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87
Q

How do the presentations of Biliary Colic and Cholecystitis differ to Cholangitis

A

Biliary Colic: RUQ Pain, No fever/ Jaundice or Leucocytosis

Cholecystitis: RUQ Pain + Fever, No jaundice

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88
Q

List Investigations for Cholangitis

A

Bloods- FBC, LFTs, Blood cultures (Only +ve in 20%)

Biliary tract USS: Shows dilation (Usually <6mm) or possible stones
Gold standard: ERCP, however MRCP recommended first

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89
Q

Outline Immediate management of Cholangitis

A

Fluids, Analgesia, Abx (Metronidazole)
Sepsis 6 if septic

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90
Q

Outline Definitive management of Cholangitis

A

Endoscopic Biliary Decompression, removing blockage in biliary tree.

  • ERCP w/ or w/o a Sphincterectomy and Stenting
  • If too sick: Percutaneous Transhepatic Cholangiography (PTC)

In long-term, pts may need Cholecystectomy if caused by Gallstones.

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91
Q

Gallstones form due to bile supersaturation.

List the 3 main types

A

Cholesterol – Composed purely of cholesterol, from excess cholesterol production

Pigment – Composed purely of bile pigments, from excess bile pigments production

Mixed stones – Comprised of both cholesterol and bile pigments

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92
Q

What are Cholesterol and Pigment stones associated with?

A

Cholesterol: Linked to Poor diet and Obesity

Pigment: Haemolytic Anaemia

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93
Q

List the common RFs for Gallstone disease

“5 Fs” + others

A

FHx, Fat, Female, Fertile, ≥40

Pregnancy, Haemolytic Anaemia, Malabsorption, Oestrogen contraceptives

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94
Q

Biliary colic pain may radiate to Back/ Epigastrium.

Why may pain be precipitated by fatty foods

A

Fatty acids stimulate Duodenum to release CCK, stimulating GB contraction

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95
Q

How can Acute Cholecystitis present

A

Constant RUQ/ Epigastrium pain, w/ signs of Inflammation (Fever, Lethargy)

RUQ Tenderness, May show +ve Murphy’s sign

May show Guarding (May suggest GB Perforation)

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96
Q

List investigations for Gallstones

A

FBC, LFTs, CRP, Amylase
Urinalysis, Pregnancy test

1: Abdominal USS
2: MRCP (Gold Standard)

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97
Q

What 3 things are looked for on a Trans-abdominal USS

A

Presence of Gallstones/ Sludge (Start of gallstone formation)

GB Wall thickness

Bile Duct Dilation

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98
Q

Outline Biliary Colic management

A

Lifestyle changes (Weight loss, Exercise)
Analgesia- IM Diclofenac
Elective Lap Cholecystectomy within 6wks (Best outcomes within 1wk)

(Removed w/ Cystic Duct + Artery)

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99
Q

Outline Acute Cholecystitis management

A

Analgesia, Anti-emetic, Fluids, IV Abx (Co-amoxiclav +/- Metronidazole)

Laparoscopic Cholecystectomy indicated within 1wk of presentation

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100
Q

Outline Acute Cholecystitis management for those not fit for surgery and not responding to Abx

A

Percutaneous Cholecystostomy to drain infection

(Risk of re-infection remains)

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101
Q

List complications of Gallstone disease

(Not Cholangitis, Biliary colic, Pancreatitis, Acute Cholecystitis)

A
  • Mirizzi Syndrome
  • GB Empyema
  • Chronic Cholecystitis (-> GB Carcinoma, Biliary-enteric Fistula)
  • Bouveret’s Syndrome and Gallstone Ileus
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102
Q

Describe Mirizzi Syndrome

Outline Presentation, Diagnosis, Management

A

Stone in Hartmann’s Pouch can cause compression of adjacent Common Hepatic Duct

Presentation: Obstruction jaundice
Diagnosis: MRCP
Management: Lap Cholecystectomy

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103
Q

Describe GB Empyema

Outline Presentation, Diagnosis, Management

A

GB fills with Pus

Presentation: Similar to Acute Cholecystitis
Diagnosis: USS or CT scan

Management: Lap Cholecystectomy (may need intra-op drainage or Percutaneous Cholecystostomy)

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104
Q

Describe Chronic Cholecystitis

Outline Presentation, Diagnosis, Management

A

Persistent GB wall inflammation

Presentation: Ongoing RUQ/ Epigastric pain w/ N+V

Diagnosis: CT
Management: Elective Cholecystectomy

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105
Q

Outline Bouveret’s Syndrome and Gallstone Ileus

A

GB inflammation can cause a fistula between GB walls and SI (Cholecystoduodenal fistula)

Can cause bowel obstruction:
Bouveret’s Syndrome: Stone in Proximal Duodenum-> Gastric outlet obstruction
Gallstone Ileus: Stone in Terminal Ileum-> Obstruction

106
Q

What is Dumping Syndrome

Compare the 2 types

A

When food moves too quickly from Stomach to Duodenum after eating

(75%) Early: 10-30mins after eating
(25%) Late: 1-3 hrs after eating

107
Q

List causes of Dumping syndrome

A

Surgery to remove part/ all of stomach

Stomach bypass surgery for weight loss

Oesophagectomy

108
Q

Dumping syndrome can present with early and late symptoms.

List early symptoms

A

Early;
- N+V, Diarrhoea
- Abdo cramping
- Bloating/ feeling full
- Flushing, Sweating, Dizziness
- Tachycardia

109
Q

Dumping syndrome can present with early and late symptoms.

List late symptoms (due to low glucose)

A

dizziness, weakness, sweating, hunger, fast heart rate
fatigue, confusion, shaking

110
Q

List Investigations for Crohn’s (Non-R and Radiological)

What can the Radiology ones show

A

Non-radiological: Bloods, Faecal Calprotectin, Colonoscopy

CT: Bowel Obstruction, Perforation or Intra-abdominal collections
MRI: SI Involvement, Enteric fistulae, Peri-anal disease

111
Q

List investigations for Diverticular disease and Diverticulitis

A
  • Bloods, VBG, G+S
  • CT-Abdo-Pelvis (Thick Colon wall, Fat Stranding, Abscess, Free air)

If uncomplicated:
- Flexi-Sig
- CT Colonography if contra-I

112
Q

Which classification system can be used to stage Acute Diverticulitis

A

Hinchey classification

(It is based on CT findings)

113
Q

How is Diverticular Disease managed

(Non-surgical)

A

If Uncomplicated, Analgesia+Oral Fluids

If minor bleed, is self-limiting. If major, Embolisation or Surgical resection

114
Q

How is Acute Diverticulitis managed

A

Most cases: Conservatively w/ Analgesia, Abx, IV Fluids

115
Q

When is Diverticular disease managed surgically

How is it done

A

Perforation

Hartmann’s procedure (At later date, Anastomosis w/ Colostomy reversal may be possible- happens in 50% of cases)

116
Q

CT Colonogram/ Colonography can be used to investigate PR bleeding.

List 2 disadvantages of this technique

A

Misses small polyps (<5mm)

Requires more preparation

117
Q

Which lymph nodes drain the:
- Left Colon
- Rectum

A

Left Colon:
- Pericolic
- Inferior Mesenteric (-> Para-aortic)

Rectum:
- Upper 2/3 of Rectum: Inferior Mesenteric
- Lower 1/3 of Rectum: Inguinal

118
Q

List 4 Pt and 4 Surgical RFs for Post-op Ileus

A

Pt: Elderly, Electrolyte imbalance, Neurological disorder, Anti-cholinergics/ Opiates

Surgical;
- Pelvic surgery, Intestinal handling, Intestinal resection
- Peritoneal contamination (Pus, Faeces)

119
Q

An Anastomotic leak is considered a technical factor and the surgeon is at fault until proven otherwise.

List 3 pt and 6 surgical RFs

A

Pt;
- Meds (CSs, Immunosuppression)
- Smoking + Alcohol, Co-morbidities (DM, Obesity, Malnutrition)

Surgical;
- Emergency op, Long op, Peritoneal contamination
- Oesophageal-gastric or Rectal anastomosis
- Blood flow affected, Stapler failure

120
Q

How are Anastomotic leaks managed operatively

A
  • Conservatively: For collections <5cm, IV Abx used
  • Laparotomy + Ileostomy + Abdo washout
  • Radiologically guided drain insertion
121
Q

Why may Lipase be measured rather than Amylase, to investigate Pancreatitis

(Amylase must be >300 to diagnose. Normal=100)

A

Amylase: May be normal 12-24hrs after attack onset

Lipase: 72hrs after onset

122
Q

Pancreatitis increases the risk of Thrombosis.

Outline Aetiology and Mortality of Cullen’s and Grey-Turner’s signs

A

Haemorrhage in Retro-peritoneal space

80% mortality if visible

123
Q

Should Pancreatitis pts be kept NBM or allowed to Eat+Drink

A

Allow to eat + drink

(Evidence shows: Pt does better if eating normally or NG Feeding)

124
Q

Pseudocysts are a local complication of Pancreatitis.

How long must you wait before draining one

A

At least 6wks

125
Q

List 4 Systemic Complications of Acute Pancreatitis

(Occur within days of initial onset)

A

DIC, ARDS, Hypocalcaemia, Hyperglycaemia

126
Q

Other than Pseudocysts, describe a local complication of Acute Pancreatitis

How is it Investigated and Manged

A

Pancreatic Necrosis, due to ongoing inflammation leading to Ischaemia

Investigation: CT

Management: Pancreatic Necrosectomy
- Usually 3-5wks after symptom onset after walled-off necrosis has developed

127
Q

Pancreatic Necrosis is prone to infection. Suspect this if there is clinical deterioration w/ raised infection markers

How is this diagnosed

A

Fine needle aspiration of the necrosis

128
Q

Describe a Pancreatic Pseudocyst

(Formed weeks after initial episode, lack an epithelial lining but have a Vascular Fibrotic wall around collection)

A

Collection of fluid containing Enzymes, Blood, Necrotic tissue.

Usually seen in Lesser Sac

129
Q

Pancreatic Pseudocysts are prone to Infection, Rupture and Haemorrhage.

How are they managed

A

50% resolve spontaneously, so usually conservatively

Unlikely to resolve spontaneously, if present >6wks;
- Surgical debridement
- Endoscopic drainage (often into stomach)

130
Q

Oesophageal motility disorders typically present in what way?

List the 2 major causes of Oesophageal Dysmotility

A

Dysphagia of Solids+Liquids

Achalasia
Diffuse Oesophageal Spasm

131
Q

Compare the composition of the 3 thirds of the Oesophagus

A

Upper 1/3: Skeletal

Middle 1/3: Transition zone (Both types)

Lower 1/3: Smooth

132
Q

What triggers Primary and Secondary Peristaltic waves in Oesophagus

A

Primary: Initiated by swallowing centre

Secondary: In response to distension

133
Q

Oesophageal motility disorders have a variable and atypical presentation, so other pathologies are investigated first.

List 3 differentials

A

GORD, Oesophageal malignancy, Angina Pectoris

134
Q

What is Achalasia?

A

Failed LOS Relaxation + Progressive failure of smooth muscle contraction

(Progressive destruction of ganglion cells in Myenteric Plexus)

135
Q

How does Achalasia present

A

Progressive Dysphagia of Solids+Liquids
Regurgitation, Aspiration, Vomit, W Loss
Heartburn/ Retrosternal Chest Pain refractory to PPIs

136
Q

How is Achalasia investigated?

A

OGD to exclude cancer

Manometry: Peristalsis absence, Failed LOS Relaxation, High Resting LOS Tone
Barium swallow: “Birds Beak” in Advanced disease

137
Q

How is Achalasia managed non-surgically

A

Many pillows, Eat slowly, Chew thoroughly, Plenty of fluids w/ meals
Ca blockers/ Nitrates for short-term relief.
Endoscopic Botox injections into LOS effective for few months only.

138
Q

How is Achalasia managed Surgically

A

Endoscopic Balloon Dilation: Dilation of a balloon inserted into LOS

Laparoscopic Heller myotomy: Division of LOS fibres which fail to relax
- Less side effects than Endoscopic method

Per Oral Endoscopic Myotomy (POEM): Newer, More effective, Higher incidence of reflux

139
Q

What is Diffuse Oesophageal Spasm, DOS?
What can it progress to?

(Thought to be due to dysfunction of oesophageal inhibitory nerves)

A

Multi-focal High Amplitude Contractions

Can progress to Achalasia

140
Q

How does Diffuse Oesophageal Spasm, DOS present

A

Severe Dysphagia to Solids + Liquids

Central Chest pain- Usually exacerbated by food

141
Q

Why can Angina Pectoris be difficult to distinguish from Diffuse Oesophageal Spasm, DOS

A

Both respond to Nitrates

142
Q

List Investigations for Diffuse Oesophageal Spasm, DOS

A

Endoscopy: Rule out Cancer
Manometry: Repetitive, Simultaneous, Ineffective Contractions
May be LOS dysfunction

Barium Swallow: “Corkscrew”

143
Q

How is Diffuse Oesophageal Spasm, DOS managed

A

Smooth Muscle relaxing agents: Nitrates/ CCBs for symptomatic relief
Pneumatic Dilation: Consider if DOS + LOS Hypertone
Myotomy: For severe cases

144
Q

Most Gastric Cancers are Adenocarcinomas

List 7 RFs

A

Fhx, Male, Elderly
H. pylori, Smoking + Alcohol, Salt in diet
Pernicious anaemia

145
Q

How does Gastric Cancer present?
Include metastatic signs

(Pts often present at an advanced stage)

A

Dyspepsia, Dysphagia, Early Satiety, Vomiting, Malaena.
Epigastric mass

Metastatic signs: Hepatomegaly, Ascites, Jaundice, Troisier sign, Acanthosis nigricans

146
Q

List Imaging tests done to investigate Gastric Cancer

A

Urgent OGD + Biopsies;
- Histology
- CLO test (H. pylori)
- HER2/ Neu protein expression

CT-Chest-Abdo-Pelvis + Staging laparoscopy (for Metastases)
- CT can show Gastric Wall Thickening

147
Q

Other than Curative treatment how are Gastric Cancers managed

A

Nutritional status assessment

Definitive nutritional support (NG or RIG tube) pre- or post- treatment

148
Q

Outline Gastric Cancer Curative treatment

A

Peri-op Chemo, if fit

Surgery, including lymph nodes;
- Total Gastrectomy (Proximal G Cancer)
- Subtotal Gastrectomy (Distal G Cancer/ Antrum/ Pylorus)

EMR, if presenting with early T1a tumours (Confined to Muscularis Mucosa)

149
Q

The most commonly used method in post-Gastrectomy reconstruction is Roux-en-Y.

(Gives the best functional result, w/ less bile reflux)

Describe it

A

Distal Oesophagus directly anastomosed to SI

Distal duodenum end-to-side anastomosed to SI

150
Q

QoL remains poor for upto 6mths Post-Gastrectomy.

List Specific Complications

A

Death
Anastomotic leak
Re-op

Dumping Syndrome
B12 deficiency (May need Tri-monthly injections)

151
Q

Most Gastric Cancer pts present at a late stage, so are Managed Palliatively.

Outline this

A

Chemo + Stenting for pts w/ Gastric Outflow Obstruction

Palliative surgery;
- Distal gastrectomy or Bypass (Gastro-Jejunostomy)
- Can be used when Stenting fails/ unavailable

152
Q

List complications of Gastric Cancer

(10-yr survival rate: 15%, although most present at advanced stage with metastases, which have 5-yr survival: <5%)

A

Gastric Outflow Obstruction
Fe-deficiency anaemia
Perforation
Malnutrition

153
Q

What causes Angiodysplasia

A

Formation of Arteriovenous malformations between previously healthy vessels.

(Most commonly in Caecum and Ascending Colon)

154
Q

How does Angiodysplasia present?

A

PR Bleed + Anaemia, in 1 of 3 ways;
- Asymptomatic
- Painless occult PR Bleed
- Acute haemorrhage

155
Q

List investigations for Angiodysplasia

A
  • FBC, U&E, LFT, Clotting, G+S, Crossmatch
  • OGD +/- Colonoscopy (Exclude cancer)
  • Capsule Endoscopy (SI Bleeds)
  • Mesenteric Angiography (Radionuclide/ CT/ MRI)
156
Q

How is Angiodysplasia managed conservatively

A

Rest, IV Fluids

Potentially Tranexamic acid

157
Q

How is Persistent/Severe Angiodysplasia managed non-surgically?

A

1: Endoscopy;
- Argon Plasma Coagulation
- Others: Electrocautery, Laser Photoblation, Sclerotherapy, Band ligation

Mesenteric Angiography: Catheterisation + embolisation of bleeding vessel

158
Q

How is Angiodysplasia managed surgically?

A

Resection + Anastomosis of affected bowel segment (Only consider if necessary, as high mortality)

159
Q

List 3 indications for Angiodysplasia being treated surgically

A

Severe bleeding continues despite non-surgical management

Acute Severe life-threatening GI Bleed

Multiple Angiodysplastic Lesions

160
Q

List Angiodysplasia + treatment complications

A

Re-bleeding post-op is common

Endoscopy: Bowel perforation (V small risk)
Mesenteric Angiography: Haematoma, Arterial dissection, Thrombosis, Bowel Ischaemia

161
Q

List RFs for SI cancer

A

Increasing age
Crohn’s/ Coeliac
Genetic conditions (FAP, Lynch syndrome)

Smoking + Alcohol
Obesity
Low fibre intake, High red meat intake

162
Q

How does SI cancer present, include metastatic symptoms

A

Obstructional symptoms, Palpable Abdo mass
Less commonly, PR bleed

Metastatic: Cachexia, Jaundice, Hepatomegaly, Ascites

163
Q

Outline Imaging Investigations for SI tumours

A
  • OGD+Biopsy: For Proximal Duodenal tumours
  • MRI Enterography, EUS, Capsule Endoscopy if OGD can’t reach tumour
  • CT can be done, + PET-CT for staging
164
Q

Outline SI Cancer Management

(Benign + Adenocarcinoma)

A

Benign: Resection +/- Chemo or Chemoradio

Adenocarcinoma: Surgical resection
- Duodenal: Segmental duodenal or Whipple’s (Pancreaticoduodenectomy)
- Adjuvant Chemo for L Nodes

165
Q

What % of SI cancer pts have Metastases at time of presentation

(Stage IV- Distant mets)

A

A third

166
Q

What are GEP-NETs, Gastroenteropancreatic Neuroendocrine Tumours

Where are they found

A

NETs from cells in GI Tract or Pancreas (All have malignant potential)

Mainly SI. Rectum+Stomach as well

167
Q

20% of Functional GEP-NET pts have Carcinoid syndrome

What is this

A

Metastasised cells of a Carcinoid Tumour oversecrete bioactive mediators into blood.

Symptoms: Flushing, Palpitations, Diarrhoea, Intermittent Abdo Pain

168
Q

What are Carcinoid tumours

A

Neuroendocrine cell neoplasia in GI tract, Lung or Pancreas

169
Q

List Lab Tests used to investigate GEP-NETs

A

CgA, Chromogranin A- Found in high concentrations (Test CgB, if low)

PP, Pancreatic Polypeptide;
- If CgA+B normal
- High in many GEP-NETs

5-HIAA may be checked

170
Q

Outline imaging tests for GEP-NETs

A

CT: Limited Sensitivity, unless Lymphadenopathy or Liver Mets present

CT Enteroclysis: More sensitive than routine CT

Gold standards- w/ Biopsy;
- Endoscopy for Gastric, Duodenal, Colorectal NETs
- EUS for Pancreatitis NETs

Whole Body Somatostatin Receptor Scintigraphy (SSRS): Metastatic pt w/o known primary tumour

171
Q

Surgery is the only curative GEP-NET management.

Outline symptomatic control in those with Carcinoid Syndrome

A

Somatostatin analogues- Mainly Octreotide or Lanreotide

172
Q

How are Gastric NETs managed surgically?

A

Usually, with Endoscopic Resection + Annual Surveillance

More aggressive lesions: Gastrectomy w/ Regional Lymph Node clearance

173
Q

Volvulus can cause obstructed bowel to become ischaemic-> Necrosis + Perforation

Where do most Volvulus occur?
What are they the 3rd most common cause of?

A

Sigmoid Colon

LI Obstruction (After Cancer and Diverticular disease)

174
Q

Why are Volvuli more common in the Sigmoid Colon

A

Long Mesentery (Increases with age), so bowel more prone to twisting on its Mesenteric Base

175
Q

List RFs for Volvulus (Mainly, Sigmoid)

A

Male, Elderly, Neuropsychiatric disorder
Nursing home resident
Chronic constipation/ Laxative use
Previous Abdo operation

176
Q

How does Volvulus present

A

Colic pain, Abdo distension, Absolute Constipation (Vomit is a late sign)
O/E: Tympanic (Drum-like) to Percussion

177
Q

How is Volvulus investigated?
(Sam as for any bowel obstruction)

A

Bloods- U&E, Ca, TFTs (Exclude Pseudo-obstruction)
AXR
CT-Abdo-Pelvis w/ Contrast (“Whirl sign”)

178
Q

Outline Volvulus Management Conservatively

A

Decompression by Sigmoidoscope + Insertion of Flatus Tube

(Tube left in-situ for upto 24hrs)

179
Q

Outline Sigmoid Volvulus Management Surgically

What are 3 indications

A

Usually Hartmann’s

  • Colonic ischaemia/ perforation
  • Repeated decompression failure
  • Bowel necrosis found at Endoscopy
180
Q

Outline Surgical management of Recurrent Volvulus

A

Elective op to prevent further recurrence

Most commonly, Sigmodectomy w/ Primary Anastomosis

181
Q

What’s the 2nd most common site for a Volvulus

Compare the causes in the 2 age ranges of onset

A

Caecum

10-29: Intestinal malformation, Excessive exercise
60-79: Chronic constipation, Distal obstruction, Dementia

182
Q

Outline Investigation + Results that can be used to diagnosis Caecal Volvulus

A

CT Imaging shows;
- Distended Caecum
- Mesenteric “Swirl”
- SI Obstruction

AXR:
- “Embryo sign”

183
Q

How is Caecal Volvulus managed

(Always surgically)

A

Laparotomy + Ileocaecal resection

184
Q

What is Pseudo-obstruction? (Ogilvie syndrome in Acute Setting)
(Caecum + Ascending Colon mostly affected, but can affect whole bowel)

List 4 causes

A
  • Colonic dilation due to Adynamic Bowel, in absence of Mechanical Obstruction
  • Medication, Neurological disease
  • Recent surgery/ trauma/ severe illness
  • Electrolyte imbalance/ Endocrine disorders
185
Q

List 3 Complications of Pseudo-obstruction

A

Perforation, Ischaemia, Toxic Megacolon

186
Q

How should Pseudo-obstruction be investigated

A

Bloods- U&E, Ca, Mg, TFTs

AXR will look similar to Mechanical Obstruction, so not useful for definitive diagnosis

CT-Abdo-Pelvis w/ IV Contrast: Will show Colon dilation, Exclude Mechanical cause, Assess for complications

187
Q

Outline Pseudo-obstruction management

A

Conservative: NBM, Fluids, NG Tube if vomit

If no resolution within 24-48hrs:
- Endoscopic Decompression, involving Flatus Tube insertion
- IV Neostigmine (Anticholinesterase) may be trialled

188
Q

List surgical management options for Pseudo-obstruction

(Done in absence of Perforation/ Ischaemia, if non-responding)

A

Segmental resection +/- Anastomosis

Alternative procedures to decompress bowel in long-term;
- Caecostomy/ Ileostomy

189
Q

Most Anal cancers are SCCs, arising from below the Dentate Line.

What types are the remainder?

A

Adenocarcinomas, arising from Upper Anal Canal epithelium + Crypt glands

190
Q

What condition may precede Invasive SCC?
What is this strongly linked to?

A

AIN, Anal Intraepithelial Neoplasia
Infection with HPV (Mainly strains 16+18)

191
Q

List Anal Cancer RFs

A

HPV, HIV, Crohn’s
Increasing age, Smoking, Immunosuppression

192
Q

Outline Anal Cancer presentation

(O/E: Look for Ulcers, Wart-like lesions, look at Inguinal Lymph nodes)

A

Rectal Bleeding/ Pain (50% of pts)
Anal discharge, Itching, Palpable mass

Perianal infection + Peri-anal Fistula (Local invasion)
Incontinence + Tenesmus (Anal sphincter involvement)

193
Q

Outline Investigations for Anal Cancer

A

Proctoscopy. EUA, w/ Biopsy
Smear test to exclude CIN. Consider HIV test

Staging;
- USS Guided FNA of palpable Inguinal Nodes
- CT-Thorax-Abdo-Pelvis
- MRI Pelvis

194
Q

How is Anal Cancer managed

A

Chemo-radio, often 1st line

External Beam radiotherapy to Anal Canal + Inguinal nodes, in addition to dual chemo agents (Mitomycin + 5-FU)

195
Q

How is Anal Cancer managed surgically?

(Usually for Advanced disease after Chemo failure, or early T1N0 carcinomas)

A

AP Resection

Reviewed every 3-6mths for 2yrs, then less frequent reviews.

(Most recurrences occur in 1st 3yrs post-op)

196
Q

List complications of Anal Cancer

A

Subfertility, Incontinence, Vaginal dryness, ED, Rectovaginal Fistula

Chemoradio-related Pelvic Toxicity: Dermatitis, Diarrhoea, Proctitis, Cystitis

197
Q

Describe the 4 Classes of Haemorrhoids

A

1st Degree: Remain in rectum

2nd Degree: Prolapse when bearing down, spontaneously reduce

3rd Degree: Prolpase when bearing down, need manual reduction

4th Degree: Persistently prolapsed

198
Q

List RFs for Haemorrhoids

A

Increasing age
Excessive strain (Chronic constipation)
Raised Intra-Abdo pressure

Pelvic/ Abdo masses, Fhx, Cardiac failure, Portal Hypertension

199
Q

How do non-thrombosed Haemorrhoids present?

A

Painless bright PR Bleed (commonly after defecation, often seen on paper)

Itching, Tenesmus, Lump, Soiling

200
Q

Large Haemorrhoids can Thrombose. How do these pts present?

Outline Examination findings of a Thrombosed, Prolapsed Haemorrhoid

A

Very painful, often present in A&E

Peri-anal mass;
- Purple/ Blue
- Oedematous
- Tense
- Tender

201
Q

How are Haemorrhoids investigated

A

Proctoscopy: Typically done to confirm diagnosis

FBC + Coag: If Major Bleed/ Anaemia signs

Flexi-Sig or Colonoscopy may be considered

202
Q

Most Haemorrhoids can be managed conservatively, especially if asymptomatic.

Outline this

(Avoid Oral opioids as it can worsen Constipation)

A

Lifestyle advice (Raise Fluid+Fibre intake)

Laxatives
Topical Analgesia

203
Q

Outline Non-surgical Haemorrhoid management

When is it used

A

Rubber-Band Ligation
(Complications: Recurrence, Pain, Bleed)

If Symptomatic 1st+2nd degree Haemorrhoids

204
Q

Outline Surgical Haemorrhoid managements

When are they used

A
  • Haemorrhoidal Artery Ligation, HAL
  • For 2nd or 3rd degree haemorrhoids
  • Haemorrhoidectomy (5% of pts need)
  • Symptomatic, despite Conservative treatment, Unfit for Banding/ Injection (mainly 3rd/ 4thº)
205
Q

List Haemorrhoidectomy complications

A

Bleed, Infection, Constipation

Stricture, Anal fissures, Incontinence

206
Q

List Complications of Haemorrhoids

A

Thrombosis
Ulceration/ Gangrene (Due to thrombosis)
Skin tags
Peri-anal Sepsis

207
Q

Outline Anal fissure non-surgical management

A

Analgesia
Trial stool softening laxatives
Raised Fluid and Fibre intake

Topical anaesthetics + Hot baths (Sitz baths) can help relax sphincter and healing.

If still symptomatic, GTN/ Diltiazem cream. (Promote blood supply for healing)

208
Q

Outline Anal Fissure Surgical management

A

Botox injections into Internal Sphincter to relax and promote healing

Lateral Sphincterectomy of Internal Sphincter

(LS of External S can cause Incontinence)

209
Q

When is an Anal Fissure managed surgically?

What’s the main complication?

A

Chronic fissure (After 6-8wks) where medical management has failed to resolve symptoms

Incontinence

210
Q

What is Pilonidal sinus disease?

(A disease of the inter-gluteal region, mostly affects men 30-60, but doesn’t usually occur after 45)

A

Formation of a sinus in the cleft of the buttocks

211
Q

Outline the most widely accepted theory for Pilonidal sinus disease

A

Infection/ inflammation of hair follicle in IG Cleft, obstructs opening.

Cavity is formed containing a cyst, connecting to skin via Sinus Tract

212
Q

List RFs for Pilonidal sinus disease

A

Caucasian, Male
Coarse dark body hair
Sitting for Prolonged periods, Friction, Local trauma, Obesity
Sweating, Poor hygiene

213
Q

How does Pilonidal sinus disease present

A

Discharge + Intermittent Sacrococcygeal pain

214
Q

When can a Pilonoidal Abscess form?

How does this present

A

When a Pilonidal sinus gets infected

Swollen, red region
O/E: Fluctuant, tender mass

215
Q

What Investigations can be done to ensure a Pilonoidal Sinus is not a Peri-Anal fistula

A

Rigid Sigmoidoscopy
MRI

To look for internal opening

216
Q

Pilonidal sinus disease eases with age.

How is it managed Conservatively

A

Shaving of affected region + Plucking any hair embedded in sinus

If accessible, sinuses can be washed out to prevent infection

217
Q

Abx can be used in septic Pilonoidal sinus disease

How are Pilonoidal Abscesses treated

A

Surgical drainage

218
Q

How is Chronic Pilonidal sinus disease managed Surgically

A

Removal of Sinus Tract

Tract excision + laying open the wound for 2ndary Wound Closure

Tract excision, then Primary wound closure

219
Q

When treating Pilonidal sinus disease, compare use of Primary and Secondary wound closure, after Tract Excision

A

Secondary;
- Low recurrence rates
- Can take longer to heal
- Increased infection risk

Primary;
- High recurrence rates
- Pts may need reconstructive surgery due to tissue loss

220
Q

List symptoms of Pharyngeal pouch (Zenkers Diverticulum)

(May be Asymptomatic)

A

Dysphagia, Aspiration, Halitosis, Regurgitation, Weight loss

221
Q

How can a Pharyngeal pouch be diagnosed

A

Barium swallow
OGD

222
Q

Outline presentation of Intussusception

(Peaks between 3mths-2yrs)

A
  • Severe, colic pain-> Screaming
  • Vomit: May be bile stained
  • Redcurrant jelly stool
  • Sausage shaped mass in abdomen
223
Q

How is Intussusception managed

A

Child well: Rectal air insufflation/ Contrast enema

Child unwell/ Perforation: Laparotomy

224
Q

Cholangiocarcinomas are cancers of the biliary system.

Describe them

(95% are Adenocarcinomas. Remaining majority are SCCs)

A

Typically slow-growing tumours that invade locally

Spread to Peritoneal cavity, Lung, Liver

225
Q

Identify the most common site for bile duct cancers (Klatskin tumours)

A

Bifurcation of R and L Hepatic Ducts

226
Q

Why is there a higher incidence of Cholangiocarcinomas in SE Asia

A

Association with Chronic Endemic Parasitic infections from liver flukes

227
Q

List RFs for Cholangiocarcinomas

A

Primary Sclerosing Cholangitis
UC
Infection (Liver flukes, HIV, Hep virus)
Toxins (Chemicals- Rubber, Aircraft industry)
Congenital
Alcohol excess
DM

228
Q

How do Cholangiocarcinomas present

(Don’t include usual cancer symptoms)

A

Usually asymptomatic until late stage

Jaundice, Pale stool, Dark urine
Itching

Less common;
- RUQ pain, Early satiety

229
Q

List Lab test results suggesting Cholangiocarcinoma

A

Tumour markers, CEA, CA19-9, may be elevated

Elevated Bilirubin, ALP, Gamma-GT (Sign of Obstructive Jaundice)

230
Q

List Imaging investigations for Cholangiocarcinoma

A

USS may be used to confirm obstruction
MRCP: Optimal method

ERCP: May be used to demonstrate obstruction site + to obtain samples (cytology, histology)

CT: For staging
Angiography: Pre-op planning

231
Q

Outline non-palliative Cholangiocarcinoma Management

A

Complete resection is curative (but 10-15% of pts operable at presentation)

Intrahepatic or Klatskin tumours: Partial Hepatectomy + Biliary tree reconstruction
Distal Common Duct tumours: Whipple’s (Pancreaticoduodenoctomy)

Consider Radiotherapy. Limited evidence for post-op Chemo

232
Q

Most Cholangiocarcinomas are treated Palliatively only

Outline thes treatment options

A

Stenting: ERCP may be used to relieve obstruction

Surgery: Bypass procedures, if obstruction not relieved by stenting

Medical:
- Radiotherapy
- Combo of chemo agents can be used, but no major benefit w/o Radiotherapy

233
Q

List Cholangiocarcinoma complications

A

Increased risk of Biliary Tract Sepsis (due to obstruction)

Secondary Biliary Cirrhosis (10-20% of pts)

234
Q

50% of Cholangiocarcinoma pts undergoing curative resection have a recurrence within 5yrs

Long term survival is poor. What is the average survival time after diagnosis?

A

12-18mths after diagnosis

(Most pts have unresectable disease at presentation)

235
Q

List 3 local complications of Acute Pancreatitis

A

Pancreatic Pseudocyst
Splenic Artery Pseudo-aneurysm
Pancreatic Necrosis

236
Q

Outline the 4 scenarios of blood with stool

A

Blood mixed with stool;
- Lesion proximal to Sigmoid Colon (Soft stool in Proximal Colon mixes well)

Blood streaked on stool;
- Sigmoid/ Anorectal bleed

Blood separate from stool;
- If blood after stool: Anal condition
- If blood on own: Diverticular disease, Angiodysplasia, IBD, Cancer

Blood only on toilet paper;
- Minor bleed from anal canal
- Mostly Anal Fissure/ Haemorrhoids

237
Q

Compare Ileostomy and Colostomy

A

Ileostomy;
- Spout to prevent skin irritation
- Watery/ Mushy contents

Colostomy;
- Flushed mucosa
- Semi-formed stool

238
Q

A third of pts with Peri-anal Fistula have Anorectal Abscesses

List RFs for Peri-anal Fistula

A

Perianal abscess
IBD
Systemic disease (TB, HIV, DM)
Trauma to anal region
Previous radiotherapy to anal region

239
Q

How do Peri-anal fistulae present

A
  • Recurrent Perianal abscesses
  • Discharge onto perineum (Mucus, Blood, Pus, Faeces)

O/E;
- External opening on perineum
- These can be fully open or covered in granulation tissue
- Fibrous tract may b felt under skin on DRE

240
Q

Outline the Goodsall Rule

A

External opening Post. to transverse anal line;
- Fistula tract will follow Curved course to post. midline

Eternal opening Ant. to transverse anal line;
- Fistula tract will follow straight course to Dentate line

241
Q

Outline Investigations for a Peri-anal Fistula

A

Proctoscopy to visualise opening of tract in anal canal
MRI to visualise tract anatomy

242
Q

List the 4 classes of Anal Fistulae, according to Park’s Classification System

A

Inter-sphincteric

Trans-sphincteric

Supra-sphincteric

Extra-sphincteric

243
Q

If Asymptomatic, Anal fistulae may be managed Conservatively

Outline Surgical Treatment

A

Fistulotomy (Superficial disease)
- Laying tract open (cut through Skin + SC tissue)
- Healing by 2ndary tract excision

Seton placement through Fistula (High tract disease);
- Brings together + Closes tract

(Common to need repeat procedures over next mths)

244
Q

Describe Incontinence as a complication of Anal fistulae

A

If Low tract course (Tract through less SC tissue + Muscle);
- Faecal incontinence rare post-op

If High tract course (Tract through more SC tissue + Muscle);
- Faecal incontinence post-op more likely

245
Q

Outline features of FAP

(Gardener’s Syndrome is a variant- Supernumerary teeth, Epidermal cysts, Osteomas, Thyroid tumours)

A
  • APC gene mutation, Aut Dominant
  • 100s-1000s of Polyps
  • High risk of Duodenal cancer
246
Q

Outline features of HNPCC/ Lynch Syndrome

A
  • MLH1/MSH2 gene mutation, Aut Dom
  • Less Polyps than in FAP
  • Increased risk of Gastric, Endometrial, Breast, Prostate cancer
247
Q

Outline features of Peutz-Jegher’s Syndrome

A
  • SI Obstruction due to Hamartomas throughout GI tract
  • Pigmented lesions in Oral Mucosa, Palms, Plantar surfaces
248
Q

Trousseau’s Syndrome is particularly related to Pancreatic and Lung Cancer

Describe it

A

Migratory Thrombophlebitis affecting body extremities

249
Q

How should Femoral hernias be managed?

A

All need surgery due to high strangulation risk

(Urgent/ <2wks, if Bowel obstruction OR Irreducible OR Strangulated)

250
Q

List Early/ Post-op Stoma complications

A

Bleeding, Oedema, Separation, Fistulae
Necrosis (Due to surgical complications)

High Output (>1500ml/24hrs, Increased bag emptying frequency, Watery consistency)

251
Q

List Late Stoma complications

A

Retraction: Lies below skin level, due to intestine section used being too short

Prolpase: Inner part of bowel pushed out, can be manually reduced

Stenosis: Faeces as thin strip (Stoma= Oedematous, Glistening, Mushroom shaped)

Granulomas, Skin problems, Parastomal hernia (Bulge around stoma)

252
Q

Which drugs cause Pancreatitis

FATSHEEP

A

Furosemide
Azathioprine
Thiazides/ Tetracyclines
Statins/ Sulfonamides/ Sodium Valproate/ Steroids
Hydrochlorothiazide
Estrogens
Ethanol
Protease inhibitors and NRTIs

253
Q

How is Chronic pancreatitis treated

A

Ethanol abstinence, good diet

Analgesia
Insulin and pancreatic enzyme replacement

Coeliac plexus block
Pancreatectomy

254
Q

Outline the modified Glasgow-Imrie score for Pancreatitis

A

PaO2 <8Kpa
Age >55
Neutrophils: Lymphocytes >15x10^9
Calcium <2mmol/L
Renal function: Urea> 16mmol/l
Enzymes: LDH >600, ALT/AST >200
Albumin <32g/l
Sugar: Glucose >10mmol/L

255
Q

How is acute pancreatitis treated?

A

Ideally in HDU/ ITU

  • Fluids, Opiate analgesia
  • NG Tube if vomiting. Encourage oral intake
  • Catheterise + Fluid balance chart to monitor urine output
256
Q

List complications of a Lap-Cholecystectomy

(BradyC + Pneumoperitoneum can occur during op leading to PThorax, PE, SC Emphysema)

A
  • Infection, Haemorrhage, Urinary retention
  • Bile Leak, Bile Duct injury
  • Post-cholecystectomy syndrome (Vague symptoms- Colic, Diarrhoea, Jaundice, Abdo Pain)
257
Q

List Bedside + Labaratory investigations for Appendicitis

A

Bedside: Urine dip, Pregnancy Test, VBG (Lactate)

Lab: FBC, CRP, U&Es, LFTs, Amylase, Clotting, G+S, Blood Culture

258
Q

List Imaging investigations for Appendicitis if in doubt

(Clinical diagnosis)

A

Erect CXR
CT AP, USS of RIF

259
Q

Describe Bowel Cancer Screening in the UK

A

2 methods

  • Faecal immunochemistry test: For people aged 60-74 (Every 2 years, Men+Women)
  • Bowel scope screening: For people ≥56 (Only in some parts of England)
260
Q

Outline Mx of High and Low grade Dysplasia in Barret’s Oesophagus

A

Low: High dose PPI + 6-monthly endoscopies

High:
- Endoscopic resection (Radiofrequency/ Photodynamic/ Laser Ablation)
- May have Oesophagectomy if fit

Year 3 Surgery (7 decks)

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