General surgery Flashcards

1
Q

Acute abdomen sieve

A

ABC->P

  • Appendix
  • Bleeding/bowel obstruction/BV obstruction
    • GI bleed
    • Obstruction - small/large, mechanical/non-mechanical, complete/incomplete
    • Ischaemia/infarct
  • Cholecystitis/angiitis
  • Pancreatitis/Perforation (upper/lower GI)
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2
Q

Hernia (surgery) - def? types? Mx?

A

Def: protrusion of a viscus through its wall

Types:

  • Incisional hernia - iatrogenic following surgery
  • Groin hernia - ASIS & pubic tubercle palpated:
    • Femoral (W>M) - below and lateral to the pubic tubercle, requires more urgent repair than inguinal hernia - high risk of strangulation
    • Inguinal - above & medial to the pubic tubercle
      • Direct = weakness in posterior wall of inguinal canal, abdo contents emerge medial to deep ring and through superficial ring
      • Indirect (75%, most common hernias in M/W) = abdo contents passes through inguinal canal through deep ring and exits via superficial ring
      • Reduce hernia & compression on deep inguinal ring ask the patient to cough if it is direct it will reappear
    • Other groin lumps:
      • Lymphadenopathy - along inguinal ligament
      • Vascular - pulsatile varicose veins below inguinal ligament

Mx: surgical (mesh)

NOTE: hernias are safer the larger the defect as less likely to strangulate

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3
Q

What are the borders of Hesselbach’s triangle?

A
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4
Q

Abdominal scars

A
  • Midline sternotomy - AAA, laparotomy
  • Rooftop scar - liver transplant, Whipple’s procedure, gastric surgery, oesophagectomy
  • Kocher – open gallbladder surgery
  • Nephrectomy can also be subcostal (like Kocher) or Rutherford-Morrison (hockey stick)
  • Lanz/McBurney’s = Appendicectomy
  • Pfannenstiel = C-section/prostatectomy/cystectomy
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5
Q

RUQ pain investigations & Mx? Think biliary

A

US abdo

  • Stone in CBD (common bile duct) –> ERCP
  • Deranged LFTs/dilated ducts –> MRCP
  • None of above –> cholecystectomy
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6
Q

Gallstone complications

A
  • Biliary colic
  • Cholecystitis
  • Mirizzi syndrome
  • Ascending Cholangitis
  • Pancreatitis
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10
Q

What is TNM classification?

A
  • TNM (tumour, nodes, mets)
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11
Q

Colorectal cancer - Presentation? Ix? Mx? Screen?

A

Presentation:

  • Bowel habit change
  • Palpable mass
  • IDA, PR bleed (clots, fresh)
  • Acute (obstruction, perforation)

Ix: colonoscopy

Mx: based on TNM staging post-CT

  • Colon cancer
    • T4 (local advancement) –> neoadjuvant Tx
    • Otherwise –> colonic resection –> if T3+/nodal disease –> adjuvant chemo
  • Rectal cancer
    • T3-4 –> neoadjuvant Tx –> colonic resection –> if T3+/nodal disease –> adjuvant chemo
    • T1-2NOMO –> transanal excision

Screen: 60-74yrs FIT testing (or FOB)

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14
Q

Painless, palpable gallbladder + jaundice = Courvoisier’s law –> indicates what?

A

Not gallstone-related

Most likely head of pancreas tumour

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15
Q

Small bowel obstruction after cholecystitis - Dx?

A

Gallstone ileus

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16
Q

Small bowel obstruction - key Sx? Evidence of ischaemia? Mx Pathway?

A

Key Sx: distension, vomiting, colicky abdo pain, absolute constipation

SBO highly suspected on AXR:

  • Acutely unstable patient + imminent risk of death –> emergency laparotomy
  • Otherwise –> CT abdo & pelvis with contrast (if eGFR <30 = no contrast)
    • Bowel ischaemia/obstructive lesion/closed loop obstruction –> emergency laparotomy
    • Otherwise –> adhesional SBO –> conservative Mx (drip & suck = Ryles NG decompression & IV fluids)
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17
Q

‘Beads on string’ on ERCP - Dx?

A

Primary sclerosing cholangitis (PSC)

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21
Q

Thousands of colonic polyps & AD APC gene mutation

A

FAP

Mx: Panproctocolectomy

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22
Q

3 cardinal signs of small bowel obstruction?

A

Vomiting

Colicky abdo pain

absolute constipation (including gas)

± distension

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23
Q

AD mutation in mismatch repair gene (MMR) - Dx?

A

HNPCC (Lynch syndrome)

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24
Q

Small bowel polyps, melanotic macules in lips/genitals, AD mutation in STK 11 gene - Dx?

A

Peutz-Jehger syndrome

26
Q

Closed-loop obstruction - significance?

A

High risk of bowel ischaemia (ischaemia is category 1 surgery - needs to be in surgery in 1hr)

27
Q

RIF tenderness after an appendicectomy - Dx?

A

Meckel’s diverticulum

28
Q

Unexplained acute large bowel dilatation - Dx?

A

Ogilvie syndrome

29
Q

Stoma differentiation & examination

A

Colostomy - RIF, flushed, normal faecal matter

Ileostomy - LIF, spouted (as contents irritant to skin), runny & green faecal matter

Urostomy (via ileal conduit) - if urinary flow not possible via bladder/urethra e.g. post-cystectomy with bladder cancer

  • NOTE: nephrostomy is an opening created between the kidney & skin if urine flow from the kidney to the ureter is blocked e.g. in pyonephrosis (renal stones + inf)

Stoma examination:

  • Hands around stoma and ask to cough –> check for hernia + check for skin changes
  • Offer stoma rectal examination (finger into stoma)
30
Q

Splenectomy - indications? what is the problem? what is associated prophylaxis?

A

Indications:

  • Traumatic rupture
  • Idiopathic thrombocytopenia
  • Spherocytosis

Problem: increased risk from encapsulated bacteria e.g. strep pneumo

Prophylaxis:

  • Vaccines: Pneumococcus, Meningococcus, Haemophilus Influenzae Type B
  • Penicillin V
31
Q

Abdo pain ddx?

A

Upper:

  • RUQ pain: cholecystitis, ascending cholangitis, acute hepatitis
  • Epigastric pain: PUD, GORD, pancreatitis

Middle:

  • Flank pain: pyelonephritis (loin to groin pain)
  • Umbilical pain - AAA (consider if >65yrs, HTN)

Lower:

  • RIF pain: appendicitis, ureteric colic, hernia, testicular torsion
  • Suprapubic pain: UTI
  • LIF pain: diverticulitis, inflammatory colitis, ischaemic colitis, ureteric colic, hernia, testicular torsion
  • In women - causes of lower Abdo pain: ectopic pregnancy, ovarian torsion, PID
    • Ask about _P_ain, _P_regnancy, _P_V bleeding, _P_V discharge

NOTE: also consider psych cause of generalised abdo pain (esp in kids)

32
Q

Acute abdomen - def? immediate Tx & Ix?

A

Def: sudden, severe abdo pain that requires urgent medical/surgical attention

Immediate Tx & Ix:

  • Immediate Tx - NBM, IV fluids, analgesia
  • Bloods - VBG (lactate), amylase, G&S
  • Imaging - AXR (bowel obstruction), CT-AP (perforation), USS (biliary)
33
Q

Biliary anatomy?

A
  • Right and left hepatic ducts merge to form the common hepatic duct
  • Gallbladder - stores & concentrates bile and releases it to emulsify fats
  • Cystic duct connects gallbladder to the biliary tree
  • Cystic duct and common hepatic duct come together to form the common bile duct
  • Pancreatic duct feeds into the common bile duct - where it secretes exocrine hormones
  • All of the above feed through the Ampulla of Vater into the duodenum –> allowing secretion of bile into the intestines
34
Q

Biliary colic - Def? Presentation?

Cholecystitis - Def? Presentation? Ix?

Ascending cholangitis - Def? Presentation? Acute Mx?

A

Biliary colic:

  • Def: pain due to blockage of bile flow due to a gallstone
  • Presentation: RUQ pain, worse after fatty meals (stimulates gallbladder contraction –> bile release for fat emulsification)

Cholecystitis:

  • Def: inflammation of the gallbladder (typically in context of gallstones)
  • Presentation: RUQ pain (+ tenderness - Murphy’s sign), FEVER
    • ​Murphy’s only +ve if not present on the left as well
  • Ix:
    • Urine dip – infection, bHCG
    • Bloods – FBC, U&E, LFTs, CRP, amylase, clotting screen
    • Imaging – USS (want to be fasted – so gallbladder larger), erect CXR (pneumoperitoneum – perforation of duodenum)

Ascending cholangitis:

  • Def: inf ascending the biliary tree, usually in the context of gallstone
  • Presentation (due to obstruction of Common Bile Duct - bile stagnates and becomes infected):
    • Charcot’s triad - RUQ pain, fever, JAUNDICE
    • Reynold’s pentad (severe) - above + shock + confusion
  • ​Surgical EMERGENCY - Mx via sepsis 6 protocol (abx = Tazocin) + drain obstruction:
    • Endoscopic retrograde cholangiopancreatography (ERCP) - Dx & Tx (dye can be used to enhance the obstruction) - endoscope passed up to Ampulla of Vater with wire passed into the biliary system
      • Complications: pancreatitis, bleeding (from dilation of AoV), perforation
    • Percutaneous transhepatic cholangiogram (PTC) - interventional radiology - passing a wire through the liver into a hepatic duct and then into the top end of the biliary tree –> dislodge stone/alternative route for bile to flow - leave in cholecystostomy
    • Cholecystostomy - interventional radiology - insert wire directly into the gallbladder and allow it to be drained - leave in cholecystostomy
    • Patients will likely require a later cholecystectomy (after dealing with the acute infection)
35
Q

Appendicitis - presentation? DDx? Scoring? Mx?

A

Presentation:

  • Acute umbilical to RIF pain (McBurney’s point)
  • Tenderness + guarding (if rigid abdo - perforated apendix)
  • N&V –> anorexia (not wanting to eat anything from nausea), change in bowel habit
  • Rovsig’s sign - pain in RIF on LIF palpation
  • Psoas sign & Obturator sign

DDx: ectopic, ovarian torsion, IBS/D, bowel obstruction

Ix:

  • Urinalysis, bloods - FBC, U&E, CRP
  • USS abdo/pelvis –> consider contrast-enhanced CT-AP

Alvarado score - >4 = likely appendicitis

Mx:

  • A-E (incl. fluids)
  • Sepsis bundle - abx when Dx confirmed
  • Laparoscopic appendicectomy
  • Conservative only if uncomplicated appendicitis
36
Q

Oesophageal cancer - Presentation? Types? Mx?

A

Presentation: progressive dysphagia (solids –> then liquids) + FLAWS

Types:

  • Squamous cell carcinoma (SCC) - less common in UK, middle oesophagus, RFs: alcohol, smoking
  • Adenocarcinoma - most common in UK, lower oesophagus, assoc w/ GORD (long-term –> metaplasia - Barrett’s oesophagus –> eventually become dysplastic/ malignant)

Mx: SURGICAL

  • Ivor Lewis oesophagectomy - involves midline laparotomy + right thoracotomy (stomach is mobilised and pushed through oesophageal hiatus)
  • McKeown oesophagectomy - as above + left neck incision (oesophagus can be pulled up through neck incision)
37
Q

Bowel obstruction - immediate Mx, small vs large bowel obstruction - causes, features, Mx?

A

Immediate Mx:

  • NBM, Ryles tube (aspirate stomach contents)
  • IV fluids
  • AXR -> CT (identify transition point of obstruction)

Small bowel obstruction:

  • Causes: Adhesions (prev surgery?), Hernia, Malignancy (incl. non-GI e.g. ovarian)
  • Features: central dilated loops of bowel, >3cm, valvulae coniventes
  • Mx: surgery (but can be counterintuitive if surgery was cause), gastrografin (oral contrast medium, acts as an osmotic laxative)

Large bowel obstruction:

  • Causes: tumour, volvulus
  • Features: peripheral dilated loops of bowel, >6cm, haustra
  • Mx: surgery, flatus tube (in sigmoid volvulus)

NOTE: 3/6/9 rule

38
Q

Right & left hemicolectomy - indications, process & what are you left with?

Panproctocolectomy - indications, process & what are you left with?

Total vs subtotal colectomy - process & what are you left with?

Hartmann procedure - indications, process & what are you left with?

Anterior vs AP resection - indications, process & what are you left with?

Urostomy (ileal conduit) - indications & process?

A

Right hemicolectomy - right colon

  • Indication: problems affecting the right side of the colon e.g. malignancy
  • Process: removing from ileocaecal valve to 1/3 the way along the transverse colon
  • What are you left with:
    • Primary anastomoses (ileum attached to the remaining colon)
    • Sometimes left with a stoma

Left hemicolectomy - left colon

  • Indication: problems affecting the descending colon e.g. tumour
  • Process: removing from 2/3 the way along the transverse colon to the sigmoid area
  • What are you left with: primary anastomoses from the transverse colon to the sigmoid colon

Panproctocolectomy - total colon & rectum e.g. UC

  • Indication: a diffuse disease affecting the full colon e.g. FAP (familial adenomatous polyposis) or UC
  • Process: remove full colon & rectum (from ileocaecal valve to the anus)
  • What are you left with: end ileostomy (loose end of ileum brought to the skin)

Total colectomy vs subtotal colectomy

  • Total colectomy:
    • Process: remove full colon but not the rectum
    • What are you left with: ileal-pouch anal anastomosis (loose end of ileum used to reform a rectum, don’t need a stoma)
  • Subtotal colectomy:
    • Process: remove colon except for the rectum and part of the sigmoid colon
    • What are you left with: end-ileostomy & rectal/sigmoid stump

Hartmann procedure - emergency sigmoid colon

  • Indication: emergency circumstances for diseases affecting sigmoid colon e.g. malignant obstruction, sigmoid volvulus, diverticular complication (e.g. perforation - healing suboptimal so don’t want to create anastomoses as unlikely to succeed)
  • Process: sigmoidectomy
  • What are you left with: end-colostomy and rectal stump –> at a future date can be reversed but many just stay with end-colostomy

Anterior vs AP resection - for rectal tumours (A higher; P lower)

  • Anterior:
    • Indication: higher rectal tumours
    • Process: removing sigmoid colon + top part of the rectum
    • What are you left with: end-colostomy/primary anastomoses ± defunctioning loop ileostomy
      • DLI - loop of ileum brought to surface, split so 2 lumens on surface –> divert faecal stream (into stoma bag) from distal anastomosis = gives best chance of healing
    • NOTE: sometimes low anterior resection is performed where the distal margin of resection is brought down (very little rectum remains)
  • AP (abdominoperineal):
    • Indication: low-lying rectal tumours
    • What are you left with: end-colostomy
    • Process: remove everything up to the top of the sigmoid colon

Colostomy (ileal conduit)

  • Indications:
    • Bladder cancer (had cystectomy)
    • Neurogenic bladder
      Radiation injury to the bladder
    • Chronic pelvic pain
  • Process: removing some ileum, forming pouch & bringing to surface so forms stoma - ureters are connected to this pouch
39
Q

Acute pancreatitis - causes? Patterns of injury? Pathophysiology? Ix? Mx? Complications? Severity score?

A
  • Causes: alcohol, gallstones (GET SMASHED)
    • Duct obstruction: gallstones (50%), trauma, tumours
    • Metabolic/toxic: alcohol (33%), drugs, hypercalcaemia/hyperlipidaemia
    • Ischaemia: shock
    • Infection/inflammation: viruses (mumps), AI
  • Patterns of injury:
    • Periductal – cause: duct obstruction
      • Necrosis of acinar cells near ducts
    • Perilobular – cause: ischaemia (shock)
      • Necrosis @edges of lobule – blood supply comes w/ ducts = periphery most affected
    • Panlobular – develops as ½ progress
  • Pathophysiology: vicious cycle - activated enzymes –> acinar necrosis –> enzyme release
    • Lipase release –> fat necrosis (Ca ions bind to free fatty acids forming soaps = yellow/white deposits)
  • Ix:
    • Bloods – FBC, U&E, LFTs, CRP, Amylase
    • Imaging – USS (looking for biliary problem, sentinel loop – early sign of ileus), CXR
    • NOTE: Epigastric pain –> remember to do rectal exam (looking for melaena)
  • Mx - supportive (IV fluids + analgesia first)
    • Resus patient (IV fluids, analgesia, antiemetic, abx) –> ITU if glasgow score >3
    • VTE prophylaxis
  • Complications:
    • Pancreatic pseudocyst – cystic space wo/ epithelial lining, lined with necrotic & granulation tissue –> can be infected –> abscess
    • Systemic: shock, hypoglycaemia, hypocalcaemia

Severity criteria = GLASGOW score (PANCREAS):

  • PaO2
  • Age
  • Neutrophils (WBC)
  • Ca
  • Renal funct (urea)
  • Enzymes (LDH)
  • Albumin
  • Sugar (glucose)
40
Q

Autograft vs allograft vs isograft vs xenograft/heterograft?

A

Autograft: tissue from the same patient

Allograft: tissue from same species not genetically identical

Isograft: tissue from identical twin

Xenograft/heterograft: tissue from different species

41
Q

Tumour markers for different cancers?

Ca 19-9, CEA, AFP, CA125, LDH

A
  • CA 19-9 – associated with pancreatic cancer and cholangiocarcinoma
  • CEA – colorectal cancer
  • AFP – hepatocellular or testicular cancer
  • CA-125 – ovarian cancer
  • LDH – cell death somewhere
42
Q

How long after surgery would you worry about leaking anastomoses? Presentation? Appropriate Ix?

A

3 days

Abdo tenderness & guarding

Erect CXR, CT abdo

43
Q

Subcutaneous emphysema, vomiting, chest pain - Dx?

A

Boerhaave syndrome (oesophageal rupture)

44
Q

High ALP + GGT with a background of ulcerative colitis - likely Dx? Ix of choice?

A

Dx: PSC

Ix: MRCP (beads on a string appearance)

45
Q

How long to fast before surgery?

A

2h for clear liquids, 6h for solids

46
Q

Ix for acute abdomen?

A

Bedside: urine dip

Bloods: VBG, FBC, U&E, CRP, LFTs + Bone profile, Amylase, Clotting, G&S ± BC (if temp)

Imaging: erect CXR, AXR

  • CTKUB if thinking renal stones
  • CTAP if collecting/perforation/obstruction
  • CT angiogram if ischaemia/bleeding/AAA
  • USS/MRCP if cholecystitis/gall stones
47
Q

Diverticulosis vs Diverticular disease vs Diverticulitis? Acute diverticulitis classification?

Presentation? Ix? Mx?

A

Diverticulosis: colonic outpouching in mucosa & submucosa of colon - happen @weak points in colonic wall subject to increased pressure (common in elderly, low fibre diet)

Diverticular disease: above + Sx

Diverticulitis: infection & inflammation of diverticulum

  • Hinchey classification for acute diverticulitis:
    1. a) Pericolic phlegmon & inflammation, no fluid collection b) pericolic abscess <4cm
    2. Pelvic/interloop abscess/abscess >4cm
    3. Purulent peritonitis
    4. Faeculent peritonitis

Presentation:

  • RFs: >50yrs, low dietary fibre
  • LIF pain, raised WCC, fever, painless rectal bleed

Ix:

  • FBC, U&E, CRP, (BC, ABG & lactate if septic)
  • Contrast CT abdo (if suspected acute diverticulitis)
  • Other imaging:
    • CXR (rule out pneumoperitoneum)
    • Colonoscopy/sigmoidoscopy (if Dx unclear, could be cancer/ischaemia)
    • CT angiogram (if excess bleeding)

Mx:

  • Asymptomatic diverticulosis:
    • Increased fibre & fluids
    • Excercise, weight loss, stop smoking
    • Fybogel - if constipated
  • Symptomatic diverticular disease:
    • Above + paracetamol
    • PO Dicycloverine = anti-spasmodic (for abdo cramping)
  • Acute diverticulitis:
    • Uncomplicated:
      • Low-residue diet + Paracetamol + PO Dicycloverine
      • Oral abx (amoxicillin)
    • Complicated:
      • Excess bleeding - resus + endoscopic Tx (e.g. band ligation, 2nd = surgery)
      • Abscess/perf/fistulae/obstruct - radiological drainage/surgery + IV abx
    • Reccurent = open/laparoscopic resection