General Surgery Flashcards
What is the definition of a hernia?
Protrusion of viscera through it’s covering to an abnormal location
What is the definition of an emboli?
Solid or gas which has been carried in the bloodstream to a location different to its origin
What is the function of the ilioinguinal nerve?
Sensory supply of upper anteromedial thigh
What is the function of the genitofemoral nerve?
Sensory innervation of the upper thigh (anterior scrotum, mons pubis and labia majora)
What are things to look for on inspection during a DRE examination?
Skin tags Pilonidal sinus Abscess Anal warts Fissures Fistulas Excoriation External haemorrhoids
What are four potential causes of a right iliac fossa mass?
Caecal carcinoma, appendix abscess, Crohn’s disease, ovarian tumour/cyst
What would be the first investigation if you are considering an oesophageal carcinoma?
Uppper gastro-intestinal endoscopy
Manometry can be used to diagnose what condition which causes dysphagia?
Achalasia
What would achalasia look like on a barium swallow?
‘Bird’s beak’ appearance with a smooth tapering distally and possible oesophageal dilation above the lesion
How would a peptic stricture appear on barium swallow?
As a short pinch point (small area of narrowing)
How would oesophageal spasm appear on barium swallow?
One or more smooth areas of contraction in the oesophagus
What three investigations are used in staging oesophageal carcinoma?
Endoscopic ultrasound, PET scan, CT chest, abdomen and pelvis
Where are metastatic lesions likely to spread in oesophageal malignancy?
Liver and lung
What can commonly cause free intra-peritoneal air?
Perforated duodenal ulcer, perforated diverticulum, laparotomy 24 hours ago
Perforation of what structures cause gas to accumulate in the retroperitoneum?
Ascending colon, descending colon, 3rd part of the duodenum
What initial management is used for a volvulus of the sigmois colon?
Sigmoidoscopy and passage of decompressing flatus tube
What surgery may be required for recurrent sigmoid volulus?
Sigmoid colectomy
What causes a sigmois volulus?
Twisting of the bowel on lax mesentery
Which patients are more commonly affected by sigmoid volvulus?
Elderly or psychiatric patients
What percentage of colonic obstructions are from sigmoid volvulus?
1-2%
What are the six criteria for acute severe colitis established by Truelove and Witts?
- Frequency of stool >6 daily
- Overtly bloody stool
- Fever (>37.5)
- Tachycardia (>90)
- Anaemia (Hb<105)
- Raised ESR (>30)
In acute severe disease of UC why would a sigmoidoscopy be used over colonoscopy?
Colonoscopy increases risk of perforation
Why would you give heparin to a patient with acute severe colitis, what would make you not give it?
Patients with acute severe colitis are at high risk of thromboembolic events
Would give unless there is a significant haemorrhage
What medication is used in treatment of acute severe colitis?
Intravenous hydrocortisone 100mg every 6 hours
Bone protection from high steroids
Heparin as prophylactic
Why do patinets with long-standing ulcerative colitis need surveillance colonoscopies?
They are at increased risk of colonic carcinoma and need to be screened regularly with colonoscopy
What is thumbprinting on abdominal X-ray?
Radiographic sign of large bowel wall thickening from oedema or inflammation, the normal haustra become tickened appearing like thumbprint projections into lumen
What conditions are associated with toxic megacolon?
UC, Crohn’s, infective colitis
What is included in the standard trauma X-ray series?
Chest X-ray, lateral cervical spine, X-ray pelvis
What imaging modality is best for detection of splenic injuries?
CT
What is the most commonly injured solid organ in the abdomen?
The spleen
What precautions would you advice a patient about following splenectomy?
Vaccination (pneumococcal, meningococcal, haemophilus influenzae), long term penicillin V prophylaxis, caution with travel to areas of endemic malaria
Is achlasia associted with oesophageal malignancy?
Yes
What is achalasia?
Disease due to failure of normal peristalsis and relaxation of the lower oesophgeal sphincter
What tropical disease may cause similar clinical and imaging appearances to achalasia?
Chaga’s disease (trypanosomiasis)
Can achalasia cause painful dysphagia?
Yes
Can achalasia cause aspiration pneumonia?
Yes
What are treatments frequently used for achalasia?
Balloon dilatation, botox injections, Heller’s myotomy
What are the different types of gallstones?
Cholesterol stones, pigment stones, mixed stones
Haemolytic anaemia is associated with which type of gallstone?
Pigment
Which two ducts come together to form the common bile duct?
The cystic duct and common hepatic duct
What are common risk factors for gallstone disease? (The 5 Fs)
Fat Female Fertile (being pregnant) Forty (peak age for women to present) Family history
What causes biliary colic?
Impaction of gallbladder neck by a gallstone, there is no inflammation but pain on contraction of gallbladder
Why do patients often experience biliary colic after a fatty meal?
Fatty acids stimulate the duodenum endocrine cells to produce CCK which stimulates the gallbladder to contract
How does pain usually differ between biliary colic and acute cholecystitis?
Biliary colic: sudden, dull, colicky
Acute cholecystitis: constant
What is a positive Murphy’s sign?
Whilst applying pressure to the RUQ, ask the patient to inspire. There will be a halt in inspiration due to pain with a positive test
What can a positive Murphy sign indicate?
An inflamed gallbladder
What are three things to look for on abdominal ultrasound when suspecting gallstone disease?
Gallbladder wall thickening, presence of gallstones/sludge, bile duct dilatation
What is charcot’s triad?
Jaundice, fever and RUQ pain
What is Reynold’s pentad?
Jaundice, fever, RUQ pain, hypotension, confusion
What is Alvarado scoring system used to help diagnose?
Appendicitis
What are some categories in alavadro scoring system?
Pain moving to RIF, anorexia, N+V, RIF tenderness, fever, raised WCC
Which out of biliary colic, acute cholecystitis and cholangitis will caise jaundice?
Cholangitis
What is often observed on ultrasound when cholangitis is present?
Common bile duct dilatation
What is the most common cause of cholangitis?
Gallstones- blocking biliary tract
Following an open appendectomy would you be concerned if there was free air beneath the diaphragm?
This is a normal finding after surgery
What are the 4HTs for reversible causes of cardiac arrest?
Hypovolaemia, hypo/hyperkalaemia, hypothermia, hypoxia
Toxins, cardiac Tamponade, Thrombus, Tension pneumothorax
What are indications for dialysis in patient with AKI using mneumonic AEIOU?
Acidosis Electrolytes Intoxications Overload Uraemia
What causes the majority of acute pancreatitis cases?
Gallstones and excess alchol consumption
What are causes of pancreatitis? (GET SMASHED)
G-gallstones E- ethanol T- trauma S- steroids M- mumps A- autoimmune S- scorpion sting H- hypercalcaemia E- ERCP D- drugs (e.g azathioprine, NSAIDs, diuretics)
What is pancreatitis?
Inflammation of the pancreas
What is the pathophysiology of acute pancreatitis?
Digestive enzymes are activated within the pancreas resulting in an inflammatory response
How does fat necrosis occur in acute pancreatitis?
Enzymes released from the pancreas into ystemic circulation causing autodigestion of fats which results in fat necrosis
Why can you get hameorrhage in retroperitoneal space with acute pancreatitis?
Enzymes released from pancreas into systemic circultion autodigest blood vessels
How do patients typically present with acute pancreatitis?
Severe epigastric pain which can radiate to the back, with nausea and vomiting
What do Cullen’s and Grey Turner’s signs suggest?
Retroperitoneal haemorrhage
Where does bruising occur with Cullen’s and Grey Turner’s signs?
Cullen’s: peri umbilical
Grey Turner’s: the flanks
What are some causes of abdominal pain which radiates to the back?
AAA, renal calculi, chronic pancreatitis, aortic dissection, peptic ulcer disease
Do serum amylase levels directly correlate with acute pancreatitis disease severity?
No
What intial labatory test would you consider for acute pancreatitis?
Serum amylase, LFTs, serum lipase (if available at the hospital)
What is the management of acute pancreatits?
IV fluid resuscitation, analgesia, NG tube if vomiting profusely, encourage oral intake as soon as tolerated
What level of serum amylase is diagnostic of acute pancreatitis?
3 times the normal upper limit
What is a pancreatic pseudocyst?
A collection of fluid containg pancreatic enzymes, blood and necrotic tissue, forming typically a few weeks post acute pancreatitis episode
What surgery may be required for pancreatic necrosis?
Necrosectomy
What is an adhesion?
Fibrous tissue that binds two surfaces of the body which are usually separate
What is a fistula?
An abnormal connection between two epithelial surfaces
What is tenesmus?
The sensation of needing to open bowels without being able to produce stools
What happens in a hemicolectomy?
Removal of a portion of the colon
What is a Hartmann’s procedure?
Proctosigmoidectomy- removal of the rectosigmoid colon with closure of the anorectal stump and formation of a colostomy
What is an anterior resection in general surgery?
Removal of the rectum
What is a Whipple procedure?
Pancreaticoduodenectomy- removal of the head of the pancreas, duodenum, gallbladder and bile duct
What type of diathermy would you use for surgery on a patient with a pacemaker?
Bipolar diathermy
What is the ASA grading system?
ASA grading system classifies physical status of the patient for anaesthesia from 1 (normal healthy) to 6 (brain-dead undergoing organ donation)
Where is the most common area of duodenal ulceration?
The cap (first section) which ascends superiorly from pylorus of stomach
How are the different sections of the duodenum categorised?
D1- superior
D2- descending
D3- inferior
D4 ascending
What are the two most common causes of duodenal ulcers?
H. Pylori infection and chronic NSAID therapy
What are some ways to reduce post op ileus?
Limit bowel handling and opiate use
Mobilise ASAP
Avoid fluid overload (bowel oedema)
Extensive small bowel resections for Crohn’s disease can lead to what syndrome?
Short bowel syndrome
What is a Hartmann’s procedure?
Complete resection of the rectum and sigmoid colon with the formation of an end colostomy and closure of rectal stump
How should abdominal wound dehiscence initially be managed?
Cover wound with saline-soaked gauze and give Iv broad-spectrum antibiotics
What is wound dehiscence?
When a surgical wound reopens
What is the management of anal fissure?
(1st line) GTN ointment or diltiazem cream applied topically
Botulinum toxin
Then internal sphincterotomy if fail to respond to others
What are some typical spinal features seen in ankylosing spondylitis?
Loss of lumbar lordosis and progressive kyphosis of cervical-thoracic spine
What are the 3 categories of spina bifida?
Myelomeningocoele, spina bifida occulta and meningocoele
What are features of anal fissures?
Painful, bright red rectal bleeding
Most commonly on posterior midline (if in other location consider underlying cause)
What are some general risk factors for VTE?
Cancer/chemo, over 60, high BMI, dehydration, clotting disorder, HRT or COCP, pregnant, varicose veins, significant medical comorbidity
What are two types of mechanical VTE prophylaxis?
Compression stockings
Intermittent pneumatic compression device
What are some pharmacological options for VTE prophylaxis?
Low molecular weight heparin (e.g enoxiparin)
Unfractionated heparin
Fondaparinux sodium
How long would you advice women to stop their COCP before surgery?
4 weeks before surgery
What test is helpful to assess the exocrine function in chronic pancreatitis?
Faecal elastase
Patients with a cholangiocarcinoma may have a raise in which tumour marker?
CA 19-9
Levels of what enzyme are best for investigating suspected acute pancreatitis of a late presentation >24 hours
Serum lipase (has a longer half life than amylase)
Where are diverticula most commonly found in the bowel?
Sigmoid colon
What are the four different disease manifestations of diverticulum?
Diverticulosis, diverticular disease, diverticulitis, diverticular bleed
What is diverticulitis?
Inflammation of a diverticula from bacterial overgrowth within the outpouching
What is a diverticular bleed?
When a diverticula erodes into a vessel and causes a large volume painless bleed
What are some risk factors for the formation of diverticula?
Low fibre diet, smoking, obesity, family history, NSAID use
What are some clinical features of diverticular disease?
Intermittent lower abdo pain (typically colicky and relieved by defecation)
May also have associated change in bowel habit, nausea and flatulence
What drugs that a patient may be taking can mask symptoms of diverticulitis?
Corticosteroids or immunosuppressants
What is obturator sign when looking for appendicitis?
Pain with right knee flexed and right hip rotated internally
Positive sign indicates potential appendicitis
What is psoas sign when looking for appendicitis?
Pain on extension of the hip (if retrocaecal appendix)
What investigation would you request to rule out a post-operative intra-abdominal collection?
CT
What size would a diverticular/pericolic abscess need to be for you to consider radiological drainage over IV antibiotics?
5cm
What are some findings on CT that may been seen with diverticulitis?
Thickening of colonic wall, pericolonic fat stranding, abscesses, free air
Would you do a colonoscopy for a presenting case of suspected diverticulitis?
No because of the risk of perforation
How would you manage a patient with uncomplicated diverticular disease?
Simple analgesia, encourage oral fluid intake
If a diverticular bleed fails to respond to conservative management, what are the surgical options?
Embolisation, surgical resection
How would you manage acute diverticulitis conservatively?
Fluids, antibiotics, analgesia- should improve in a few days
What surgical procedure may be required in diverticulitis patients with perforation with faecal peritonitis or overwhelming sepsis?
Hartmann’s procedure: sigmoid colectomy with formation of end colostomy
How may a colovesical fistula present?
Recurrent UTIs, pneumoturia, or faecal matter in urine
What are the most common complications of diverticular disease?
Strictures and fistula formation
What is a peptic ulcer?
a break in the lining of the GI tract extending to the muscularis mucosae
Where are peptic ulcers most likely to occur?
The lesser curvature of the stomach and 1st part of duodenum
How does H-pylori infection lead to peptic ulcer disease?
Induces release of histamine which cause parietal cells to produce more acid
Down-regulates bicarbonate production
What symptoms may a patient have with peptic ulcer disease?
Epigastric/retrosternal pain, nausea, bloating, post-prandial discomfort, early satiety
With regards to eating when is the pain worse for gastric ulcers and duodenal ulcers?
Pain from gastric ulcers exacerbate by eating
Pain from duodenal ulcers are worse 2-4 hours after eating or are alleviated by eating
When would you consider an urgent referral for upper oesophageal-gastro-duodenoscopy?
New-onset dysphagia
>55 with weight loss and abdo pain/reflux/dyspepsia
New onset dyspepsia not responding to PPI
What is Zollinger-Ellison syndrome?
A triad of severe peptic ulcer disease, gastric acid hypersecretion, gastrinoma
What is the characteristic finding in Zollinger-Ellison syndrome?
Fasting gastrin of >1000 pg/ml
What should patients do about their current medication before a H.Pylori test?
Stop any current medical therapy for their symptoms 2 weeks prior to investigation
What lifestyle advice would you give a patient with peptic ulcer disease?
Smoking cessation, reduce alcohol intake, weight loss, avoid NSAIDs
What medication would we give a patient with peptic ulcer disease (not caused by H.Pylori)?
PPI e.g omeprazole
What is the triple therapy we use for H.pylori infection?
PPI with oral amoxicillin and clarithromycin/metronidazole for 7 days
What is the most common organism to cause cholangitis?
E Coli
Where is McBurney’s point?
Two thirds of the way from the umbilicus to the ASIS
What is the howship-Romberg sign and what pathology is this specific to?
Pain extending from the inner thigh to the knee when the hip is internally rotated.
This is due to compression of the obturator nerve e.g obturator hernia
