General Surgery Flashcards
Dysphagia + regurgitation of stale food + halitosis
Dx
Investigation
Zenker’s diverticulum - pharyngeal pouch
Barium swallow - endoscopy is contraindicated
Old age patient with worsening dysphagia - for solids and then for soft foods and liquids
Long-standing gastric reflux
Suspect?
Oesophageal carcinoma
- barium swallow = irregular narrowing + proximal shouldering
Most common type of oesophageal ca
Adenocarcinoma
How is dx of oesophageal ca made
Upper GI endoscopy + biopsy
RFs for oesophageal ca (2)
GERD
Barrett’s oesophagus
Features of gastric carcinoma
Virchows node
Wt loss old age tiredness vomiting dyspepsia anemia
May have associated hepatomegaly and ascites
Late stage metastasises to liver
RFs gastric carcinoma (6)
Old age Blood group A H pylori Smoking Spicy food Pernicious anemia
Haemoglobin levels before surgery
- elective
- emergency
Elective :
<10 - delay , investigate anemia
<8 -transfuse and defer surgery
Emergency
<10 - proceed with surgery
<8 - transfuse blood + proceed with surgery
Causes of hypercalcemia
Multiple myeloma
Sarcoidosis
SCC of lung
Breast and prostate ca
Diverticulosis mainly occurs on
Sigmoid colon - left lower abdomen
Analgesia after open surgery
Patient controlled analgesia with morphine
Operating on patients with history of MI
No elective surgery fro at least 6 months after MI
Features of obstructive jaundice
Jaundice, dark urine, pale stools
Raised ALP
Most appropriate investigation obstructive jaundice
US abdomen
Causes of obstructive jaundice
Choledolithiasis
Cancer head of pancreas - painless jaundice
Periampullary tumour
Feared complication of hemicolectomy
Anastomotic leak
- 5-10 days after surgery
RFs for anastomotic leak
DM Smoking Immunocompromised - RA, asthma, COPD, steroid use Rectal anastomoses Peritoneal contamination
Complications of an anastomotic leak
Intra-abdominal abscess
Peritonitis
- start BSA and do CT abdo pelvis with contrast
Investigation done for suspected colorectal ca
Colonoscopy
Presentations of colorectal ca
Left
Right
Left -
obstructive sx, changes in bowel habits, dark blood per rectum
+anemia + wt loss
Right - caecal
Microscopic bleeding, obstructive sx less common as diameter is wider
Abscess at site of skin suture
Treatment
Local exploration
ABx and drainage
Chariots triad seen in
FRJ
Fever + right upper abdominal pain + jaundice
Ascending cholangitis
Reynolds Pentad
Charcot’s + confusion + hypotension
Management of ascending cholangitis
Broad spectrum antibiotic - ampicillin-sulbactam
Biliary drainage
Complications of thyroidectomy (4)
Hypocalcemia - parathyroid damage/removal
Acute airway obstruction - hematoma
= evacuate hematoma
Nerve injury
- unilateral to RLN - hoarseness
- bilateral to RLN- aphonia, airway obstruction
- ext branch sup laryngeal - dysphonia = loss of high pitched sounds = monotone
Wound infection
Rare and serious complication of hypocalcemia
Impetigo herpetiform
ECG findings hypocalcemia
Prolonged QT
Treatment of hypocalcemia
10 ml 10% calcium gluconate
Thyroid storm
Cause
Features
Manipulation of thyroid during surgery in hyperthyroid pt
Tachycardia, palpitation, high body temperature, diarrhoea, vomiting, reduced consciousness, tremors
Treatment of thyroid storm
Beta blockers - propanolol
- control tachy and tremors
High dose steroids - inhibits T4 to T3 conversion
Features of acute mesenteric ischemia
Causes
Sudden onset severe abd pain + tenderness - exceed physical signs
Abd distension + absent bowel sounds
VBG lactate is HIGH
Gangrene irreversible
AF - emboli occlude blood supply of large segment of mesentery
MI pt develops hypotension>low blood reaching mesentery
Treatment of acute mesenteric ischemia
O2
IV fluids, analgesia, antibiotics and then urgent surgery
Ischemic colitis
Features
Cause
Transient interruption of blood supply to colon
Gradual onset - over hours
Pain and tenderness = mod -severe, usually starts at LIF
+- bloody diarrhoea
Cause= multi factorial - HF, MI, shock etc
Treatment of ischemic colitis
Conservative or surgical management
Respiatory alkalosis while on oxygen face mask
Next step
= hyperoxemia
Reduce O2
Post op oliguria
Investigation
Management
Usually happens after epidural analgesia
Post void residual volume on bladder scan
If > 500 - re insert catheter
Post op - hypotensive and oliguric
Iv fluid challenge
Might be internal bleeding or acute renal injury
RFs for anorectal abscess (3)
DM
Immunocompromised
Chromes disease
Perianal fistula management
Superficial (simple/low fistula)
= lay open (fistulotomy)
Deep (complex/high)
- crosses internal and external sphincters
= seton suture, ligation on inter-sphincteric fistula tract
Diabetic pre-op management
(T2DM)
Major surgery
Minor surgery
Major
- stop oral hypoglycemic before surgery
Minor
- continue same routine
Diabetic pre-op management
(T1DM)
Major surgery
Minor surgery
Major
= sliding scale IV insulin before surgery , continue until diet per mouth restored
Or start IV insulin, dextrose and saline pre-op
Minor
= omit insulin on day of surgery
No gastric bubbles seen
Oesophageal atresia
Single bubble sign
Gastric/pyloric atresia
Double bubble sign
Duodenal atresia
Triple bubble sign
Jejunal atresia
Post natal Xray shows NGT coiled in oesophagus
Oesophageal atresia
RFs of rectal ca
FHx Smoking Polyposis syndromes Low fibre diet IBD
Common precipitating factors of diverticulosis
Low fibre diet
Age > 50 Y
Management of bleeding diverticulitis
Urgent surgical ward admission
FBC, CRP
Colonoscopy to correct/stop bleeding
Haemorrhoid grading (4)
1- bleeding no prolapse
2- prolapse with delectation ; spontaneous reduction
3- prolapse with delectation - needs manual reduction
4- prolapsed, incarcerated - can’t be manually reduced
Acute gastric distension/dilatation
Cause
Management
Blood supply of stomach affected in certain abdominal surgeries
Accumulation of air inside stomach
NGT insertion - deflate stomach
How can acute gastric distension cause hypotension
Dilated stomach can compress surrounding vessels incl aorta so blood pressure drops
Treatment of carpal tunnel
Cute transverse carpal ligament
Aka flexor retinaculum/anterior annular ligament
Management of acute anal fissure (<6 wks)
Huber high fluid diet Bulk forming laxative s- Lactulose Petroleum jelly before defecating Topical anaesthetics Analgesia
Chronic canal fissure management
Same as acute
GTN - 1st line for chronic anal fissure
If not effective after 8 weeks - 2ry referral for sphincterotomy or Botox
Inguinal vs femoral hernia
Inguinal - above + medial to pubic tubercle , cough impulse, reducible
More in males
Femoral - below and lateral, rarely has cough impulse, irreducible (femoral canal is narrow)
- more in female , strangulate easily, below inguinal ligament
RFs for inguinal hernias
Male Lifting heavy objects Old age Chronic cough Prev abd surgery
Types of inguinal hernia
Indirect - Passes through Deep and superficial inguinal ring , lies lateral to inf epigastric a.
Direct - passes through posterior wall of inguinal canal
Lies medial to inferior epigastric a.
Cause of paralytic ileus (7)
Post op complication Electrolyte imbalance - hypokalemia, hypERcalcemia Anticholinergics Post trauma Opiates Peritonitis Immobilisation
Features of paralytic ileus
Abd distension - bloated no passing of flatus
Absent bowel sound s
Nausea, vomiting
Treatment of paralytic ileus
NGT and IV fluids
When should WBCs and CRP be repeated post op
After 24 hrs
Prophylactic ABx given before surgery of colon/rectum
Cefuroxime + metronidazole
Given within 30 mins of first incision or at anaesthesia induction
Tumour marker for hepatocellular ca
AFP
- is also a tumour marker for teratoma
Perianal hematoma
Treatment
Analgesics
Self resolving
Post thyroidectomy +SOB + stridor
Treatment
Cut subcutaneous sutures to relieve pressure
Consider intubation
Dunphy sign
Increased pain with any coughing or movement.
Appendicitis
Greatest risk factors for colorectal ca
Old age
Family history
Greatest risk of urinary bladder ca
Smoking
Sigmoid ca vs caecal ca
Sigmoid - left lower abdominal pain/mass + bleeding PR
Caecal - rt lower abdominal pain/mass
No bleeding PR
Both have old age, weight loss and anemia in common
Commonest site of ischemic colitis
Splenic flexure and rectosigmoid
- this area has fewer collaterals (weak spots / watersheds)
Fluid filled mass in midline of the neck , moves upwards on tongue protrusion on swallowing
Likely dx?
Most appropriate investigation
Thyroglossal cyst
US
Features of oropharyngeal ca
Lump/ulcer in mouth or throat
Referred otalgia
Persistent sore throat and painful swallowing
Typically old and a smoker
Features of nasopharyngeal ca
Swollen cervical LNs
Eustachian tube obstruction - Otitis media, epistaxis, nasal obstruction
CHL, tinnitus
RFs nasopharyngeal ca
EBV
Smoking
Alcohol
Features of tonsil ca
Persistent sore throat
Progressive hoarseness
Dysphagia + painful swallowing
Palpable lump on ant lateral neck
Tonsil ca spreads to
Mandible
Trismus + throat pain
Features of Quinsy
Trismus Saliva dribbling Otalgia Hot potato voice Uvular deviation Red and inflamed bulge above and lateral to tonsil
Plummer Vinson is common in
Postmenopausal women
It’s a RF for oropharyngeal ca
Pt not breathing after being exposed to burn
Intubation has failed
What is the next step
Cricothyroidotomy
- cricothyroid membrane pierced
Noisy hyperactive bowel sounds + constipation
Abd pain and distension
Likely dx
Next best step
Intestinal obstruction
IV fluids, analgesics order XR - multiple air fluid levels
Urgent referral to surgical ward
Head of pancreas ca
Features
Back pain Wt loss, hx of smoking, alcohol Obstructive jaundice = raised total and conjugated bilirubin Pale stool, dark urine, pruritus , raised ALP Abnormal LFTs High blood glucose
Head of pancreas ca vs cholangiocarcinoma
CC - pain in RUQ
P - pain in back
Blood glucose elevation only seen in pancreatic ca
CC = jaundice weight loss and RUQ pain
Head of pancreas ca
Initial investigation
Investigation of choice
US
HRCT-IOC
What used to assess prognosis of head of pancreas ca
CA 19-9
Management of head of pancreas ca
W/o. Mets - whipples resection
= panceaticoduodenectomy
W/ mets - palliative ERCP with stent
Colorectal screening
Fecal immunochemicaltest
60-74 = every 2 years = England
50-75 - in Scotland
Cervical ca screening
Pap smear - cytology HPV
25-49 YO - every 3 years
50-64 Y - every 5 years
Which hernia can descend into scrotum
Indirect inguinal hernia
Common causative organism of breast abscess
S.aureus
Courvoisiers sign
Non tender palpable distended gallbladder
Seen in pancreatic ca
Testis ca
Request ____
Lactate dehydrogenase
What increases risk of testicular ca* by x10
Hx of undescended testis
*seminoma esp , request LDH
Treatment of bowel obst caused by advance malignancy or chemo
Palliative colostomy
Most common site of fistula in Crohn’s disease
Rectovaginal - female
Male - bladder + rectum
Surgical management of inguinal hernia
1st time - open repair with prosthetic mesh , placed posterior to the cord structures
Recurrent - laparoscopic approach , mesh
Femoral hernia vs inguinal hernia management
Inguinal -
Surgery not required unless symptomatic or irreducible
Femoral - surgical repair even if asymptomatic
Splenectomy vaccines
Pneumococcal + meningococcal. Vaccine
= pre splenectomy
*also given every 5 years after splenectomy
Influenza vaccine
= post splenectomy
* all hyposplenic or asplenic plts should receive this vaccine annually , best time is autumn Oct-Nov
IDA is common presentation of what ca
Colon ca - right sided
Left sided too + blood in stool
Newly formed ulcer on top of SCC
Think
SCC
Suspected appendicitis
- hemodynamically stable male/female
- unstable
Unstable- theatre, exploaratory laparotomy y
Stable
- young fit male - threatre - laparoscopic
- young fit female - US, then take to theatre
= r/o gyne cause
Anyone >50 Y - CT to r/o cancer
Most common type of colorectal ca
Adenocarcinoma
