General Surgery Flashcards
1
Q
When is Nasojejunal feeding done?
A
Gastric disease
Reduced gastric emptying
Recent gastric surgery
2
Q
When is Gastrostomy feeding done?
A
Blocked/ dysfunctional Oesophagus
3
Q
When is Jejunostomy feeding done?
A
Stomach not accessible
Outflow obstruction
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)
5
Q
List 2 Lower GI Perforations and 1 upper GI Perforation
A
Lower: Perforated diverticulum, Perforated tumour
Upper: Duodenal ulcer
6
Q
2 most common causes of Small Bowel Obstruction
A
Adhesions (50-75%, most caused by previous abdo surgery)
Hernias (7-25%)
7
Q
List 3 common causes of large bowel obstruction
A
Colorectal cancer (65%)
Diverticular disease (20%)
Sigmoid Volvulus (10%)
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)
9
Q
How is an Upper GI bleed diagnosed
A
Gastroscopy, often done by Gastroenterologist
(OGD: Oesophago-Gastro-Duodenoscopy)
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.
11
Q
Outline Rigler’s Triad
A
Seen in gallstone ileus on AXR
SI obstruction
Air in bile ducts
Gallstone out of gallbladder
12
Q
Outline Perianal abscess treatment
Who is it commonly seen in
A
Surgery- Drainage
Medical- Consider Ceftriaxone or Metronidazole
Diabetics, Elderly, Obese, Immunocompromised
13
Q
What can untreated Perianal abscess cause
A
Necrotising fasciitis
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
15
Q
What does a trace of free fluid in the pelvis indicate
A
Appendicitis (Inflammatory response-> Mucosal oedema)
16
Q
List post-op complications of an appendicectomy
A
Stump appendicitis/ Stumpitis
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)
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
19
Q
It’s RFs for Oesophageal SCC
(Middle and Upper 1/3)
A
Achalasia
Smoking, Alcohol, Low Vit A
Fe deficiency (rarely)
20
Q
It’s RFs for Oesophageal Adenocarcinoma
(Lower 1/3)
A
GORD, Obesity, High fat intake
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)
22
Q
How are Oesophageal SCC and Adenocarcinoma treated
A
SCC: Chemo-radiotherapy
Adenocarcinoma;
- Neoadjuvant Chemo or Chemo-radiotherapy
- Oesophageal resection
23
Q
How is the Upper GI restored after an Oesophagectomy?
A
Stomach made into tube and bought into chest to replace Oesophagus.
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
25
List complications of an Oesophagectomy
Anastomosis leak
Re-operation
Penumonia
26
What is Troiser’s sign?
Palpable Left Supraclavicular L Node (Virchow’s)
27
What info is usually used to make a clinical diagnosis of GORD?
What initial investigation can be done to investigate symptoms?
Good history + PPI trial
OGD/ Upper GI Endoscopy (Mainly to exclude Malignancy + Investigate Reflux Complications)
28
What’s the gold standard for GORD diagnosis
24hr pH testing + Oesophageal Manometry to exclude oesophageal dysmotility
29
What are 3 indications for surgical treatment of GORD, rather than medication (PPI etc)
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)
30
List 3 surgical techniques used to treat GORD
Fundoplication
Stretta
Linx
31
Outline Fundoplication in treating GORD
(Nissen’s approach: Posterior 360 approach)
Gastro-Oesophgeal junction + Hiatus are dissected and Fundus wrapped around GOJ.
32
What are the main side effects of Fundoplication in GORD treatment
Dysphagia
Bloating
Inability to vomit
These often settle after 6wks, as swelling and inflammation recedes
33
Outline Stretta and Linx in treating GORD
Stretta: Radiofrequency energy delivered endoscopically to thicken LOS
Linx: String of magnetic beads wrapped around LOS laparoscopically, which tightens LOS
34
What is a Hiatus Hernia?
What are the 2 types? (Mixed can also occur)
(Most hernias are asymptomatic)
Protrusion of an organ from abdominal cavity into thorax, through Oesophageal hiatus
Sliding hiatus hernia (80%)
Rolling/ Para-Oesophgeal Hernia (20%)
35
Describe a Sliding Hiatus Hernia
How does it present specifically?
GOJ, Abdominal Oesophagus (frequently + Cardia) all move up through diaphragmatic hiatus into thorax
Constant reflux
36
Describe a Rolling/ Para-Oesophageal Hiatus Hernia
How does it present specifically?
Gastric fundus moves upwards to lie alongside normally positioned GOJ, creating a stomach “bubble”.
Some Dysphagia
37
List Hiatus Hernia RFs
Age (mainly)
Pregnancy
Obesity
Ascites
38
Compare Acute and Chronic Pancreatitis
Acute: Potentially life threatening
Chronic: Progressive fibrosis and destruction of Endo + Exocrine gland functions
- Amylase and Lipase not usually raised
39
List 10 Acute Pancreatitis causes (GET SMASHED)
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune disease
Scorpion venom
Hypercalcaemia
ERCP
Drugs (Azathioprine, NSAIDs, Diuretics)
40
Name a scoring system used to assess Acute Pancreatitis severity
Modified Glasgow Criteria;
- If within 48hrs of admission
- If 3/+ +ve factors, severe
41
Name tools other than Modified Glasgow criteria, used to assess Acute Pancreatitis severity
APACHE II
Ranson criteria
Balthazar score (CT scoring)
42
Treating any GI Perforation involves what 3 things
Identifying underlying cause
Appropriate management (Different for PUD, SI, LI)
Thorough washout (most important part)
43
Outline the specific surgical management technique for a Peptic Ulcer Peforation
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)
44
Outline the specific surgical management technique for a Small Bowel Peforation
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
45
Outline the specific surgical management technique for a Large Bowel Perforation
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
46
30% of UC pts will need surgery at some point.
Outline Elective surgical treatment
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
47
List 4 complications of UC
Toxic megacolon
Colorectal carcinoma
Osteoporosis
Pouchitis (if had an IPAA operation)
48
70-80% of Crohn’s pts will need surgery at some point.
List 4 surgical treatments
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)
49
List 4 GI complications of Crohn’s
Fistula
Stricture
Recurrent peri-anal fistula
GI Malignancy
50
List 4 Extra-intestinal complications of Crohn’s
Osteoporosis (Malabsorption, long-term steroid use)
Increased risk of gallstones (reduce bile salt reabsorption)
Increased risk of renal stones
Erythema Nodosum
51
What are Rigler’s and Telltale Traingle signs?
They signify what?
Rigler’s: Crisp, clearly defined bowel wal
Telltale Traingle: Triangles/ Slivers of gas
Pneumoperitoneum
52
What does ‘thumbprinting’ show
(Wavy, undulating)
(Common: IBD, Ischaemia, Diverticulitis, Infection)
Oedema of colonic wall, haustra thickened and swollen
Signifies some form of colitis
53
Outline Lead pipe colon sign
No fold pattern, suggests colitis for long time
54
List 3 phases of CT with IV contrast (Look at Allergies, eGFR, good Venous access)
Systemic arterial (AAA, Stenoses etc)
Portal venous (Abdo or general purpose)
Delayed (Urological)
55
When may a CT with oral contrast be used
To look for GI tract leaks or Fistula
56
List risks of ERCP
Haemorrhage
Perforation
Pancreatitis (mild and self-limiting)
Repeated Cholangitis
57
Compare Charcot’s Triad and Reynold’s Pentad
Charcot: RUQ Pain, Jaundice, Fever
Reynold’s: RUQ Pain, Jaundice, Fever, Hypotension, Confusion
58
Outline Courvoisier’s Law
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)
59
What is Boerhaave’s Syndrome
Spontaneous perforation of the esophagus due to sudden increase in intraesophageal pressure combined with negative intrathoracic pressure
(Mallory-Weiss syndrome is not full thickness)
60
What causes Oesophageal perforations commonly
Iatrogenic or severe, forceful vomiting
61
How does an oesophageal full-thickness tear present
(Rupture to any part of oesophgeal wall, full ruptures have a mortality of 50-80%)
Mackler’s Triad (Only seen in 15% of pts): Pain, Vomit, SC Emphysema
- Severe, sudden, Retrosternal chest pain
- Respiratory distress
- Subcutaneous emphysema (Often absent)
62
List the 2 main categories of Oesophgeal tears
Full thickness (Perforation)
Superficial Mucosal tears (Mallory-Weiss)
63
Why is an Oesophgeal rupture a surgical emergency
Stomach contents leak into Mediastinum and Pleural cavity, -> severe inflammation
This will result in physiological collapse, multi-organ failure and death
64
What’s the most common site for oesophageal perforation
Just above diaphragm in postero-lateral position
65
What investigations are done for Oesophageal Perforations
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
66
Oesophageal perforation pts are often septic and haemodynamically unstable.
Outline non-definitive, non-surgical treatment
- 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
67
Where are Mallory-Weiss tears usually located?
Gastro-oesophageal junction
68
Outline causes/ RFs and Clinical features of Mallory-Weiss tears
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
69
Most Mallory-Weiss cases can be managed conservatively.
Outline Investigations (Same as for any Upper GI bleed)
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
70
Most Mallory-Weiss cases can be managed conservatively.
Outline Management (Same as for any Upper GI bleed)
Fluids. Transfusion if needed
Reduce bleeding: Non-selective B-blocker/ Cauterisation/ Adrenaline injection
- Oesophageal varices: Abx, Terlipressin, Endoscopic banding
IV PPI for 72hrs
71
Colorectal cancers originate from epithelial cells of colon/rectum, most commonly Adenocarcinomas.
Outline the progression/ development of them
Normal Mucosa-> Colonic adenoma/ polyps-> Invasive adenocarcinoma
(Adenomas may be present for 10yrs before progressing, 10% of cases progress)
72
75% of colorectal cancers are Sporadic, developing in people with no risk factors
List potential RFs
Increasing age, Male, FHx, Smoking, Excess alcohol
IBD, Low fibre, High processed meat intake
73
List classical clinical features of Bowel cancer- Left and Right
RHS Colon;
- Abdo pain
- Fe deficiency anaemia
- RIF Mass
LHS Colon;
- PR bleed
- Change in bowel habit
- Tenesmus
- LIF mass
74
List imaging investigations for suspected Colorectal cancer
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)
75
The main curative management of Colorectal cancer is surgery, followed by Primary Anastomosis/ Stoma formation.
List 5 non-emergency types
- (Extended) Right Hemilectomy
- Left Hemilectomy
- Sigmoidcolectomy
- Anterior Resection
- Abdominoperinel (AP) Resection
76
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)
Hartmann’s Procedure
Complete resection of Recto-sigmoid Colon w/ End Colostomy and Rectal Stump closure
77
Describe (Extended) Right Hemilectomy
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
78
Describe Left Hemilectomy
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
79
Describe Sigmoidcolectomy
For Sigmoid Colon tumours
IMA fully dissected out w/ tumour
80
Describe Anterior Resection
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.
81
Describe AP Resection
For Low Rectal tumours, typically if <5cm from Anus
Excision of Distal Colon, Rectum + Anal sphincters
Resulting in Permanent Colostomy
82
How can colorectal cancer with bowel obstruction be relieved?
Decompressing colostomy/ Endoscopic stenting
83
When are Chemo and Radiotherapy used in Colorectal cancer
(Radio rarely used in rectal cancer, due to risk of SI damage)
Chemo: Advanced Colorectal cancer
Radio: Neo-adjuvant or alongside Chemo
84
Compare MRCP and ERCP
MRCP;
- Non-invasive
- Not good for pts who are claustrophobic
ERCP;
- Invasive
- Risk of Pancreatitis
85
List causes of Cholangitis
RFs: Lipids, COCP, Fibrates
Common organisms: E. coli, Klebsiella, Enterococcus
Common Causes: Gallstones, ERCP, Cholangiocarcinoma
Rarer Causes: Pancreatitis, Parasitic infections, PSC, Ischaemic Cholangiopathy
86
List clinical features of Cholangitis
RUQ Pain, Fever, Jaundice, HypoT, Confusion (Charcot’s, Reynold’s)
Itching, Rigors, RUQ Tenderness, Tachycardia
87
How do the presentations of Biliary Colic and Cholecystitis differ to Cholangitis
Biliary Colic: RUQ Pain, No fever/ Jaundice or Leucocytosis
Cholecystitis: RUQ Pain + Fever, No jaundice
88
List Investigations for Cholangitis
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
89
Outline Immediate management of Cholangitis
Fluids, Analgesia, Abx (Metronidazole)
Sepsis 6 if septic
90
Outline Definitive management of Cholangitis
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.
91
Gallstones form due to bile supersaturation.
List the 3 main types
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
92
What are Cholesterol and Pigment stones associated with?
Cholesterol: Linked to Poor diet and Obesity
Pigment: Haemolytic Anaemia
93
List the common RFs for Gallstone disease
“5 Fs” + others
FHx, Fat, Female, Fertile, ≥40
Pregnancy, Haemolytic Anaemia, Malabsorption, Oestrogen contraceptives
94
Biliary colic pain may radiate to Back/ Epigastrium.
Why may pain be precipitated by fatty foods
Fatty acids stimulate Duodenum to release CCK, stimulating GB contraction
95
How can Acute Cholecystitis present
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)
96
List investigations for Gallstones
FBC, LFTs, CRP, Amylase
Urinalysis, Pregnancy test
1: Abdominal USS
2: MRCP (Gold Standard)
97
What 3 things are looked for on a Trans-abdominal USS
Presence of Gallstones/ Sludge (Start of gallstone formation)
GB Wall thickness
Bile Duct Dilation
98
Outline Biliary Colic management
Lifestyle changes (Weight loss, Exercise)
Analgesia- IM Diclofenac
Elective Lap Cholecystectomy within 6wks (Best outcomes within 1wk)
(Removed w/ Cystic Duct + Artery)
99
Outline Acute Cholecystitis management
Analgesia, Anti-emetic, Fluids, IV Abx (Co-amoxiclav +/- Metronidazole)
Laparoscopic Cholecystectomy indicated within 1wk of presentation
100
Outline Acute Cholecystitis management for those not fit for surgery and not responding to Abx
Percutaneous Cholecystostomy to drain infection
(Risk of re-infection remains)
101
List complications of Gallstone disease
(Not Cholangitis, Biliary colic, Pancreatitis, Acute Cholecystitis)
- Mirizzi Syndrome
- GB Empyema
- Chronic Cholecystitis (-> GB Carcinoma, Biliary-enteric Fistula)
- Bouveret’s Syndrome and Gallstone Ileus
102
Describe Mirizzi Syndrome
Outline Presentation, Diagnosis, Management
Stone in Hartmann’s Pouch can cause compression of adjacent Common Hepatic Duct
Presentation: Obstruction jaundice
Diagnosis: MRCP
Management: Lap Cholecystectomy
103
Describe GB Empyema
Outline Presentation, Diagnosis, Management
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)
104
Describe Chronic Cholecystitis
Outline Presentation, Diagnosis, Management
Persistent GB wall inflammation
Presentation: Ongoing RUQ/ Epigastric pain w/ N+V
Diagnosis: CT
Management: Elective Cholecystectomy
105
Outline Bouveret’s Syndrome and Gallstone Ileus
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
What is Dumping Syndrome
Compare the 2 types
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
List causes of Dumping syndrome
Surgery to remove part/ all of stomach
Stomach bypass surgery for weight loss
Oesophagectomy
108
Dumping syndrome can present with early and late symptoms.
List early symptoms
Early;
- N+V, Diarrhoea
- Abdo cramping
- Bloating/ feeling full
- Flushing, Sweating, Dizziness
- Tachycardia
109
Dumping syndrome can present with early and late symptoms.
List late symptoms (due to low glucose)
dizziness, weakness, sweating, hunger, fast heart rate
fatigue, confusion, shaking
110
List Investigations for Crohn’s (Non-R and Radiological)
What can the Radiology ones show
Non-radiological: Bloods, Faecal Calprotectin, Colonoscopy
CT: Bowel Obstruction, Perforation or Intra-abdominal collections
MRI: SI Involvement, Enteric fistulae, Peri-anal disease
111
List investigations for Diverticular disease and Diverticulitis
- 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
Which classification system can be used to stage Acute Diverticulitis
Hinchey classification
(It is based on CT findings)
113
How is Diverticular Disease managed
(Non-surgical)
If Uncomplicated, Analgesia+Oral Fluids
If minor bleed, is self-limiting. If major, Embolisation or Surgical resection
114
How is Acute Diverticulitis managed
Most cases: Conservatively w/ Analgesia, Abx, IV Fluids
115
When is Diverticular disease managed surgically
How is it done
Perforation
Hartmann’s procedure (At later date, Anastomosis w/ Colostomy reversal may be possible- happens in 50% of cases)
116
CT Colonogram/ Colonography can be used to investigate PR bleeding.
List 2 disadvantages of this technique
Misses small polyps (<5mm)
Requires more preparation
117
Which lymph nodes drain the:
- Left Colon
- Rectum
Left Colon:
- Pericolic
- Inferior Mesenteric (-> Para-aortic)
Rectum:
- Upper 2/3 of Rectum: Inferior Mesenteric
- Lower 1/3 of Rectum: Inguinal
118
List 4 Pt and 4 Surgical RFs for Post-op Ileus
Pt: Elderly, Electrolyte imbalance, Neurological disorder, Anti-cholinergics/ Opiates
Surgical;
- Pelvic surgery, Intestinal handling, Intestinal resection
- Peritoneal contamination (Pus, Faeces)
119
An Anastomotic leak is considered a technical factor and the surgeon is at fault until proven otherwise.
List 3 pt and 6 surgical RFs
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
How are Anastomotic leaks managed operatively
- Conservatively: For collections <5cm, IV Abx used
- Laparotomy + Ileostomy + Abdo washout
- Radiologically guided drain insertion
121
Why may Lipase be measured rather than Amylase, to investigate Pancreatitis
(Amylase must be >300 to diagnose. Normal=100)
Amylase: May be normal 12-24hrs after attack onset
Lipase: 72hrs after onset
122
Pancreatitis increases the risk of Thrombosis.
Outline Aetiology and Mortality of Cullen’s and Grey-Turner’s signs
Haemorrhage in Retro-peritoneal space
80% mortality if visible
123
Should Pancreatitis pts be kept NBM or allowed to Eat+Drink
Allow to eat + drink
(Evidence shows: Pt does better if eating normally or NG Feeding)
124
Pseudocysts are a local complication of Pancreatitis.
How long must you wait before draining one
At least 6wks
125
List 4 Systemic Complications of Acute Pancreatitis
(Occur within days of initial onset)
DIC, ARDS, Hypocalcaemia, Hyperglycaemia
126
Other than Pseudocysts, describe a local complication of Acute Pancreatitis
How is it Investigated and Manged
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
Pancreatic Necrosis is prone to infection. Suspect this if there is clinical deterioration w/ raised infection markers
How is this diagnosed
Fine needle aspiration of the necrosis
128
Describe a Pancreatic Pseudocyst
(Formed weeks after initial episode, lack an epithelial lining but have a Vascular Fibrotic wall around collection)
Collection of fluid containing Enzymes, Blood, Necrotic tissue.
Usually seen in Lesser Sac
129
Pancreatic Pseudocysts are prone to Infection, Rupture and Haemorrhage.
How are they managed
50% resolve spontaneously, so usually conservatively
Unlikely to resolve spontaneously, if present >6wks;
- Surgical debridement
- Endoscopic drainage (often into stomach)
130
Oesophageal motility disorders typically present in what way?
List the 2 major causes of Oesophageal Dysmotility
Dysphagia of Solids+Liquids
Achalasia
Diffuse Oesophageal Spasm
131
Compare the composition of the 3 thirds of the Oesophagus
Upper 1/3: Skeletal
Middle 1/3: Transition zone (Both types)
Lower 1/3: Smooth
132
What triggers Primary and Secondary Peristaltic waves in Oesophagus
Primary: Initiated by swallowing centre
Secondary: In response to distension
133
Oesophageal motility disorders have a variable and atypical presentation, so other pathologies are investigated first.
List 3 differentials
GORD, Oesophageal malignancy, Angina Pectoris
134
What is Achalasia?
Failed LOS Relaxation + Progressive failure of smooth muscle contraction
(Progressive destruction of ganglion cells in Myenteric Plexus)
135
How does Achalasia present
Progressive Dysphagia of Solids+Liquids
Regurgitation, Aspiration, Vomit, W Loss
Heartburn/ Retrosternal Chest Pain refractory to PPIs
136
How is Achalasia investigated?
OGD to exclude cancer
Manometry: Peristalsis absence, Failed LOS Relaxation, High Resting LOS Tone
Barium swallow: “Birds Beak” in Advanced disease
137
How is Achalasia managed non-surgically
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
How is Achalasia managed Surgically
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
What is Diffuse Oesophageal Spasm, DOS?
What can it progress to?
(Thought to be due to dysfunction of oesophageal inhibitory nerves)
Multi-focal High Amplitude Contractions
Can progress to Achalasia
140
How does Diffuse Oesophageal Spasm, DOS present
Severe Dysphagia to Solids + Liquids
Central Chest pain- Usually exacerbated by food
141
Why can Angina Pectoris be difficult to distinguish from Diffuse Oesophageal Spasm, DOS
Both respond to Nitrates
142
List Investigations for Diffuse Oesophageal Spasm, DOS
Endoscopy: Rule out Cancer
Manometry: Repetitive, Simultaneous, Ineffective Contractions
May be LOS dysfunction
Barium Swallow: “Corkscrew”
143
How is Diffuse Oesophageal Spasm, DOS managed
Smooth Muscle relaxing agents: Nitrates/ CCBs for symptomatic relief
Pneumatic Dilation: Consider if DOS + LOS Hypertone
Myotomy: For severe cases
144
Most Gastric Cancers are Adenocarcinomas
List 7 RFs
Fhx, Male, Elderly
H. pylori, Smoking + Alcohol, Salt in diet
Pernicious anaemia
145
How does Gastric Cancer present?
Include metastatic signs
(Pts often present at an advanced stage)
Dyspepsia, Dysphagia, Early Satiety, Vomiting, Malaena.
Epigastric mass
Metastatic signs: Hepatomegaly, Ascites, Jaundice, Troisier sign, Acanthosis nigricans
146
List Imaging tests done to investigate Gastric Cancer
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
Other than Curative treatment how are Gastric Cancers managed
Nutritional status assessment
Definitive nutritional support (NG or RIG tube) pre- or post- treatment
148
Outline Gastric Cancer Curative treatment
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
The most commonly used method in post-Gastrectomy reconstruction is Roux-en-Y.
(Gives the best functional result, w/ less bile reflux)
Describe it
Distal Oesophagus directly anastomosed to SI
Distal duodenum end-to-side anastomosed to SI
150
QoL remains poor for upto 6mths Post-Gastrectomy.
List Specific Complications
Death
Anastomotic leak
Re-op
Dumping Syndrome
B12 deficiency (May need Tri-monthly injections)
151
Most Gastric Cancer pts present at a late stage, so are Managed Palliatively.
Outline this
Chemo + Stenting for pts w/ Gastric Outflow Obstruction
Palliative surgery;
- Distal gastrectomy or Bypass (Gastro-Jejunostomy)
- Can be used when Stenting fails/ unavailable
152
List complications of Gastric Cancer
(10-yr survival rate: 15%, although most present at advanced stage with metastases, which have 5-yr survival: <5%)
Gastric Outflow Obstruction
Fe-deficiency anaemia
Perforation
Malnutrition
153
What causes Angiodysplasia
Formation of Arteriovenous malformations between previously healthy vessels.
(Most commonly in Caecum and Ascending Colon)
154
How does Angiodysplasia present?
PR Bleed + Anaemia, in 1 of 3 ways;
- Asymptomatic
- Painless occult PR Bleed
- Acute haemorrhage
155
List investigations for Angiodysplasia
- FBC, U&E, LFT, Clotting, G+S, Crossmatch
- OGD +/- Colonoscopy (Exclude cancer)
- Capsule Endoscopy (SI Bleeds)
- Mesenteric Angiography (Radionuclide/ CT/ MRI)
156
How is Angiodysplasia managed conservatively
Rest, IV Fluids
Potentially Tranexamic acid
157
How is Persistent/Severe Angiodysplasia managed non-surgically?
1: Endoscopy;
- Argon Plasma Coagulation
- Others: Electrocautery, Laser Photoblation, Sclerotherapy, Band ligation
Mesenteric Angiography: Catheterisation + embolisation of bleeding vessel
158
How is Angiodysplasia managed surgically?
Resection + Anastomosis of affected bowel segment (Only consider if necessary, as high mortality)
159
List 3 indications for Angiodysplasia being treated surgically
Severe bleeding continues despite non-surgical management
Acute Severe life-threatening GI Bleed
Multiple Angiodysplastic Lesions
160
List Angiodysplasia + treatment complications
Re-bleeding post-op is common
Endoscopy: Bowel perforation (V small risk)
Mesenteric Angiography: Haematoma, Arterial dissection, Thrombosis, Bowel Ischaemia
161
List RFs for SI cancer
Increasing age
Crohn’s/ Coeliac
Genetic conditions (FAP, Lynch syndrome)
Smoking + Alcohol
Obesity
Low fibre intake, High red meat intake
162
How does SI cancer present, include metastatic symptoms
Obstructional symptoms, Palpable Abdo mass
Less commonly, PR bleed
Metastatic: Cachexia, Jaundice, Hepatomegaly, Ascites
163
Outline Imaging Investigations for SI tumours
- 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
Outline SI Cancer Management
(Benign + Adenocarcinoma)
Benign: Resection +/- Chemo or Chemoradio
Adenocarcinoma: Surgical resection
- Duodenal: Segmental duodenal or Whipple’s (Pancreaticoduodenectomy)
- Adjuvant Chemo for L Nodes
165
What % of SI cancer pts have Metastases at time of presentation
(Stage IV- Distant mets)
A third
166
What are GEP-NETs, Gastroenteropancreatic Neuroendocrine Tumours
Where are they found
NETs from cells in GI Tract or Pancreas (All have malignant potential)
Mainly SI. Rectum+Stomach as well
167
20% of Functional GEP-NET pts have Carcinoid syndrome
What is this
Metastasised cells of a Carcinoid Tumour oversecrete bioactive mediators into blood.
Symptoms: Flushing, Palpitations, Diarrhoea, Intermittent Abdo Pain
168
What are Carcinoid tumours
Neuroendocrine cell neoplasia in GI tract, Lung or Pancreas
169
List Lab Tests used to investigate GEP-NETs
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
Outline imaging tests for GEP-NETs
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
Surgery is the only curative GEP-NET management.
Outline symptomatic control in those with Carcinoid Syndrome
Somatostatin analogues- Mainly Octreotide or Lanreotide
172
How are Gastric NETs managed surgically?
Usually, with Endoscopic Resection + Annual Surveillance
More aggressive lesions: Gastrectomy w/ Regional Lymph Node clearance
173
Volvulus can cause obstructed bowel to become ischaemic-> Necrosis + Perforation
Where do most Volvulus occur?
What are they the 3rd most common cause of?
Sigmoid Colon
LI Obstruction (After Cancer and Diverticular disease)
174
Why are Volvuli more common in the Sigmoid Colon
Long Mesentery (Increases with age), so bowel more prone to twisting on its Mesenteric Base
175
List RFs for Volvulus (Mainly, Sigmoid)
Male, Elderly, Neuropsychiatric disorder
Nursing home resident
Chronic constipation/ Laxative use
Previous Abdo operation
176
How does Volvulus present
Colic pain, Abdo distension, Absolute Constipation (Vomit is a late sign)
O/E: Tympanic (Drum-like) to Percussion
177
How is Volvulus investigated?
(Sam as for any bowel obstruction)
Bloods- U&E, Ca, TFTs (Exclude Pseudo-obstruction)
AXR
CT-Abdo-Pelvis w/ Contrast (“Whirl sign”)
178
Outline Volvulus Management Conservatively
Decompression by Sigmoidoscope + Insertion of Flatus Tube
(Tube left in-situ for upto 24hrs)
179
Outline Sigmoid Volvulus Management Surgically
What are 3 indications
Usually Hartmann’s
- Colonic ischaemia/ perforation
- Repeated decompression failure
- Bowel necrosis found at Endoscopy
180
Outline Surgical management of Recurrent Volvulus
Elective op to prevent further recurrence
Most commonly, Sigmodectomy w/ Primary Anastomosis
181
What’s the 2nd most common site for a Volvulus
Compare the causes in the 2 age ranges of onset
Caecum
10-29: Intestinal malformation, Excessive exercise
60-79: Chronic constipation, Distal obstruction, Dementia
182
Outline Investigation + Results that can be used to diagnosis Caecal Volvulus
CT Imaging shows;
- Distended Caecum
- Mesenteric “Swirl”
- SI Obstruction
AXR:
- “Embryo sign”
183
How is Caecal Volvulus managed
(Always surgically)
Laparotomy + Ileocaecal resection
184
What is Pseudo-obstruction? (Ogilvie syndrome in Acute Setting)
(Caecum + Ascending Colon mostly affected, but can affect whole bowel)
List 4 causes
- Colonic dilation due to Adynamic Bowel, in absence of Mechanical Obstruction
- Medication, Neurological disease
- Recent surgery/ trauma/ severe illness
- Electrolyte imbalance/ Endocrine disorders
185
List 3 Complications of Pseudo-obstruction
Perforation, Ischaemia, Toxic Megacolon
186
How should Pseudo-obstruction be investigated
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
Outline Pseudo-obstruction management
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
List surgical management options for Pseudo-obstruction
(Done in absence of Perforation/ Ischaemia, if non-responding)
Segmental resection +/- Anastomosis
Alternative procedures to decompress bowel in long-term;
- Caecostomy/ Ileostomy
189
Most Anal cancers are SCCs, arising from below the Dentate Line.
What types are the remainder?
Adenocarcinomas, arising from Upper Anal Canal epithelium + Crypt glands
190
What condition may precede Invasive SCC?
What is this strongly linked to?
AIN, Anal Intraepithelial Neoplasia
Infection with HPV (Mainly strains 16+18)
191
List Anal Cancer RFs
HPV, HIV, Crohn’s
Increasing age, Smoking, Immunosuppression
192
Outline Anal Cancer presentation
(O/E: Look for Ulcers, Wart-like lesions, look at Inguinal Lymph nodes)
Rectal Bleeding/ Pain (50% of pts)
Anal discharge, Itching, Palpable mass
Perianal infection + Peri-anal Fistula (Local invasion)
Incontinence + Tenesmus (Anal sphincter involvement)
193
Outline Investigations for Anal Cancer
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
How is Anal Cancer managed
Chemo-radio, often 1st line
External Beam radiotherapy to Anal Canal + Inguinal nodes, in addition to dual chemo agents (Mitomycin + 5-FU)
195
How is Anal Cancer managed surgically?
(Usually for Advanced disease after Chemo failure, or early T1N0 carcinomas)
AP Resection
Reviewed every 3-6mths for 2yrs, then less frequent reviews.
(Most recurrences occur in 1st 3yrs post-op)
196
List complications of Anal Cancer
Subfertility, Incontinence, Vaginal dryness, ED, Rectovaginal Fistula
Chemoradio-related Pelvic Toxicity: Dermatitis, Diarrhoea, Proctitis, Cystitis
197
Describe the 4 Classes of Haemorrhoids
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
List RFs for Haemorrhoids
Increasing age
Excessive strain (Chronic constipation)
Raised Intra-Abdo pressure
Pelvic/ Abdo masses, Fhx, Cardiac failure, Portal Hypertension
199
How do non-thrombosed Haemorrhoids present?
Painless bright PR Bleed (commonly after defecation, often seen on paper)
Itching, Tenesmus, Lump, Soiling
200
Large Haemorrhoids can Thrombose. How do these pts present?
Outline Examination findings of a Thrombosed, Prolapsed Haemorrhoid
Very painful, often present in A&E
Peri-anal mass;
- Purple/ Blue
- Oedematous
- Tense
- Tender
201
How are Haemorrhoids investigated
Proctoscopy: Typically done to confirm diagnosis
FBC + Coag: If Major Bleed/ Anaemia signs
Flexi-Sig or Colonoscopy may be considered
202
Most Haemorrhoids can be managed conservatively, especially if asymptomatic.
Outline this
(Avoid Oral opioids as it can worsen Constipation)
Lifestyle advice (Raise Fluid+Fibre intake)
Laxatives
Topical Analgesia
203
Outline Non-surgical Haemorrhoid management
When is it used
Rubber-Band Ligation
(Complications: Recurrence, Pain, Bleed)
If Symptomatic 1st+2nd degree Haemorrhoids
204
Outline Surgical Haemorrhoid managements
When are they used
- 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
List Haemorrhoidectomy complications
Bleed, Infection, Constipation
Stricture, Anal fissures, Incontinence
206
List Complications of Haemorrhoids
Thrombosis
Ulceration/ Gangrene (Due to thrombosis)
Skin tags
Peri-anal Sepsis
207
Outline Anal fissure non-surgical management
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
Outline Anal Fissure Surgical management
Botox injections into Internal Sphincter to relax and promote healing
Lateral Sphincterectomy of Internal Sphincter
(LS of External S can cause Incontinence)
209
When is an Anal Fissure managed surgically?
What’s the main complication?
Chronic fissure (After 6-8wks) where medical management has failed to resolve symptoms
Incontinence
210
What is Pilonidal sinus disease?
(A disease of the inter-gluteal region, mostly affects men 30-60, but doesn’t usually occur after 45)
Formation of a sinus in the cleft of the buttocks
211
Outline the most widely accepted theory for Pilonidal sinus disease
Infection/ inflammation of hair follicle in IG Cleft, obstructs opening.
Cavity is formed containing a cyst, connecting to skin via Sinus Tract
212
List RFs for Pilonidal sinus disease
Caucasian, Male
Coarse dark body hair
Sitting for Prolonged periods, Friction, Local trauma, Obesity
Sweating, Poor hygiene
213
How does Pilonidal sinus disease present
Discharge + Intermittent Sacrococcygeal pain
214
When can a Pilonoidal Abscess form?
How does this present
When a Pilonidal sinus gets infected
Swollen, red region
O/E: Fluctuant, tender mass
215
What Investigations can be done to ensure a Pilonoidal Sinus is not a Peri-Anal fistula
Rigid Sigmoidoscopy
MRI
To look for internal opening
216
Pilonidal sinus disease eases with age.
How is it managed Conservatively
Shaving of affected region + Plucking any hair embedded in sinus
If accessible, sinuses can be washed out to prevent infection
217
Abx can be used in septic Pilonoidal sinus disease
How are Pilonoidal Abscesses treated
Surgical drainage
218
How is Chronic Pilonidal sinus disease managed Surgically
Removal of Sinus Tract
Tract excision + laying open the wound for 2ndary Wound Closure
Tract excision, then Primary wound closure
219
When treating Pilonidal sinus disease, compare use of Primary and Secondary wound closure, after Tract Excision
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
List symptoms of Pharyngeal pouch (Zenkers Diverticulum)
(May be Asymptomatic)
Dysphagia, Aspiration, Halitosis, Regurgitation, Weight loss
221
How can a Pharyngeal pouch be diagnosed
Barium swallow
OGD
222
Outline presentation of Intussusception
(Peaks between 3mths-2yrs)
- Severe, colic pain-> Screaming
- Vomit: May be bile stained
- Redcurrant jelly stool
- Sausage shaped mass in abdomen
223
How is Intussusception managed
Child well: Rectal air insufflation/ Contrast enema
Child unwell/ Perforation: Laparotomy
224
Cholangiocarcinomas are cancers of the biliary system.
Describe them
(95% are Adenocarcinomas. Remaining majority are SCCs)
Typically slow-growing tumours that invade locally
Spread to Peritoneal cavity, Lung, Liver
225
Identify the most common site for bile duct cancers (Klatskin tumours)
Bifurcation of R and L Hepatic Ducts
226
Why is there a higher incidence of Cholangiocarcinomas in SE Asia
Association with Chronic Endemic Parasitic infections from liver flukes
227
List RFs for Cholangiocarcinomas
Primary Sclerosing Cholangitis
UC
Infection (Liver flukes, HIV, Hep virus)
Toxins (Chemicals- Rubber, Aircraft industry)
Congenital
Alcohol excess
DM
228
How do Cholangiocarcinomas present
(Don’t include usual cancer symptoms)
Usually asymptomatic until late stage
Jaundice, Pale stool, Dark urine
Itching
Less common;
- RUQ pain, Early satiety
229
List Lab test results suggesting Cholangiocarcinoma
Tumour markers, CEA, CA19-9, may be elevated
Elevated Bilirubin, ALP, Gamma-GT (Sign of Obstructive Jaundice)
230
List Imaging investigations for Cholangiocarcinoma
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
Outline non-palliative Cholangiocarcinoma Management
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
Most Cholangiocarcinomas are treated Palliatively only
Outline thes treatment options
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
List Cholangiocarcinoma complications
Increased risk of Biliary Tract Sepsis (due to obstruction)
Secondary Biliary Cirrhosis (10-20% of pts)
234
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?
12-18mths after diagnosis
(Most pts have unresectable disease at presentation)
235
List 3 local complications of Acute Pancreatitis
Pancreatic Pseudocyst
Splenic Artery Pseudo-aneurysm
Pancreatic Necrosis
236
Outline the 4 scenarios of blood with stool
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
Compare Ileostomy and Colostomy
Ileostomy;
- Spout to prevent skin irritation
- Watery/ Mushy contents
Colostomy;
- Flushed mucosa
- Semi-formed stool
238
A third of pts with Peri-anal Fistula have Anorectal Abscesses
List RFs for Peri-anal Fistula
Perianal abscess
IBD
Systemic disease (TB, HIV, DM)
Trauma to anal region
Previous radiotherapy to anal region
239
How do Peri-anal fistulae present
- 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
Outline the Goodsall Rule
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
Outline Investigations for a Peri-anal Fistula
Proctoscopy to visualise opening of tract in anal canal
MRI to visualise tract anatomy
242
List the 4 classes of Anal Fistulae, according to Park’s Classification System
Inter-sphincteric
Trans-sphincteric
Supra-sphincteric
Extra-sphincteric
243
If Asymptomatic, Anal fistulae may be managed Conservatively
Outline Surgical Treatment
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
Describe Incontinence as a complication of Anal fistulae
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
Outline features of FAP
(Gardener’s Syndrome is a variant- Supernumerary teeth, Epidermal cysts, Osteomas, Thyroid tumours)
- APC gene mutation, Aut Dominant
- 100s-1000s of Polyps
- High risk of Duodenal cancer
246
Outline features of HNPCC/ Lynch Syndrome
- MLH1/MSH2 gene mutation, Aut Dom
- Less Polyps than in FAP
- Increased risk of Gastric, Endometrial, Breast, Prostate cancer
247
Outline features of Peutz-Jegher’s Syndrome
- SI Obstruction due to Hamartomas throughout GI tract
- Pigmented lesions in Oral Mucosa, Palms, Plantar surfaces
248
Trousseau’s Syndrome is particularly related to Pancreatic and Lung Cancer
Describe it
Migratory Thrombophlebitis affecting body extremities
249
How should Femoral hernias be managed?
All need surgery due to high strangulation risk
(Urgent/ <2wks, if Bowel obstruction OR Irreducible OR Strangulated)
250
List Early/ Post-op Stoma complications
Bleeding, Oedema, Separation, Fistulae
Necrosis (Due to surgical complications)
High Output (>1500ml/24hrs, Increased bag emptying frequency, Watery consistency)
251
List Late Stoma complications
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
Which drugs cause Pancreatitis
FATSHEEP
Furosemide
Azathioprine
Thiazides/ Tetracyclines
Statins/ Sulfonamides/ Sodium Valproate/ Steroids
Hydrochlorothiazide
Estrogens
Ethanol
Protease inhibitors and NRTIs
253
How is Chronic pancreatitis treated
Ethanol abstinence, good diet
Analgesia
Insulin and pancreatic enzyme replacement
Coeliac plexus block
Pancreatectomy
254
Outline the modified Glasgow-Imrie score for Pancreatitis
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
How is acute pancreatitis treated?
Ideally in HDU/ ITU
- Fluids, Opiate analgesia
- NG Tube if vomiting. Encourage oral intake
- Catheterise + Fluid balance chart to monitor urine output
256
List complications of a Lap-Cholecystectomy
(BradyC + Pneumoperitoneum can occur during op leading to PThorax, PE, SC Emphysema)
- Infection, Haemorrhage, Urinary retention
- Bile Leak, Bile Duct injury
- Post-cholecystectomy syndrome (Vague symptoms- Colic, Diarrhoea, Jaundice, Abdo Pain)
257
List Bedside + Labaratory investigations for Appendicitis
Bedside: Urine dip, Pregnancy Test, VBG (Lactate)
Lab: FBC, CRP, U&Es, LFTs, Amylase, Clotting, G+S, Blood Culture
258
List Imaging investigations for Appendicitis if in doubt
(Clinical diagnosis)
Erect CXR
CT AP, USS of RIF
259
Describe Bowel Cancer Screening in the UK
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
Outline Mx of High and Low grade Dysplasia in Barret’s Oesophagus
Low: High dose PPI + 6-monthly endoscopies
High:
- Endoscopic resection (Radiofrequency/ Photodynamic/ Laser Ablation)
- May have Oesophagectomy if fit
