General surgery Flashcards
Acute abdomen sieve
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)
Hernia (surgery) - def? types? Mx?
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
What are the borders of Hesselbach’s triangle?
Abdominal scars
- 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
RUQ pain investigations & Mx? Think biliary
US abdo
- Stone in CBD (common bile duct) –> ERCP
- Deranged LFTs/dilated ducts –> MRCP
- None of above –> cholecystectomy
Gallstone complications
- Biliary colic
- Cholecystitis
- Mirizzi syndrome
- Ascending Cholangitis
- Pancreatitis
What is TNM classification?
- TNM (tumour, nodes, mets)
Colorectal cancer - Presentation? Ix? Mx? Screen?
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)
Painless, palpable gallbladder + jaundice = Courvoisier’s law –> indicates what?
Not gallstone-related
Most likely head of pancreas tumour
Small bowel obstruction after cholecystitis - Dx?
Gallstone ileus
Small bowel obstruction - key Sx? Evidence of ischaemia? Mx Pathway?
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)
‘Beads on string’ on ERCP - Dx?
Primary sclerosing cholangitis (PSC)
Thousands of colonic polyps & AD APC gene mutation
FAP
Mx: Panproctocolectomy
3 cardinal signs of small bowel obstruction?
Vomiting
Colicky abdo pain
absolute constipation (including gas)
± distension
AD mutation in mismatch repair gene (MMR) - Dx?
HNPCC (Lynch syndrome)
Small bowel polyps, melanotic macules in lips/genitals, AD mutation in STK 11 gene - Dx?
Peutz-Jehger syndrome
Closed-loop obstruction - significance?
High risk of bowel ischaemia (ischaemia is category 1 surgery - needs to be in surgery in 1hr)
RIF tenderness after an appendicectomy - Dx?
Meckel’s diverticulum
Unexplained acute large bowel dilatation - Dx?
Ogilvie syndrome
Stoma differentiation & examination
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)
Splenectomy - indications? what is the problem? what is associated prophylaxis?
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
Abdo pain ddx?
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)
Acute abdomen - def? immediate Tx & Ix?
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)
Biliary anatomy?
- 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
Biliary colic - Def? Presentation?
Cholecystitis - Def? Presentation? Ix?
Ascending cholangitis - Def? Presentation? Acute Mx?
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)
-
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
Appendicitis - presentation? DDx? Scoring? Mx?
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
Oesophageal cancer - Presentation? Types? Mx?
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)
Bowel obstruction - immediate Mx, small vs large bowel obstruction - causes, features, Mx?
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
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?
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
Acute pancreatitis - causes? Patterns of injury? Pathophysiology? Ix? Mx? Complications? Severity score?
- 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
-
Periductal – cause: duct obstruction
-
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)
Autograft vs allograft vs isograft vs xenograft/heterograft?
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
Tumour markers for different cancers?
Ca 19-9, CEA, AFP, CA125, LDH
- 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
How long after surgery would you worry about leaking anastomoses? Presentation? Appropriate Ix?
3 days
Abdo tenderness & guarding
Erect CXR, CT abdo
Subcutaneous emphysema, vomiting, chest pain - Dx?
Boerhaave syndrome (oesophageal rupture)
High ALP + GGT with a background of ulcerative colitis - likely Dx? Ix of choice?
Dx: PSC
Ix: MRCP (beads on a string appearance)
How long to fast before surgery?
2h for clear liquids, 6h for solids
Ix for acute abdomen?
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
Diverticulosis vs Diverticular disease vs Diverticulitis? Acute diverticulitis classification?
Presentation? Ix? Mx?
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:
- a) Pericolic phlegmon & inflammation, no fluid collection b) pericolic abscess <4cm
- Pelvic/interloop abscess/abscess >4cm
- Purulent peritonitis
- 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
- Uncomplicated:
