GENERAL SURGERY Flashcards
What is the mnemonic for remembering causes of pancreatitis? What does it stand for?
I GET SMASHED
• Idiopathic • Gallstones • Ethanol • Trauma • Steroids • Mumps • Autoimmune • Scorpion sting • Hyperlipidaemia • ERCP Drugs
What are the three most common causes of pancreatitis?
Gallstones
Alcohol
ERCP
Name three drugs that commonly cause pancreatitis.
Furosemide
Thiazide diuretics
Azathioprine
How do gallstones cause pancreatitis?
Blockage of bile
Reflux causes inflammation
What are the risk factors for developing gallstones?
4Fs
Female
Fat
Forty
Fertile
Who most commonly develops alcohol pancreatitis?
Men, younger patients
How does acute pancreatitis present?
• Severe epigastric pain • Radiating through to the back • Associated vomiting • Abdominal tenderness Systemically unwell (e.g., low-grade fever and tachycardia)
What are the two main factors used to diagnose pancreatitis?
- Clinical symptoms
2. Raised amylase
Which scoring system is used in the management of pancreatitis?
Glasgow score
What is the mnemonic for remembering the Glasgow score?
P – Pa02 < 8 KPa A – Age > 55 N – Neutrophils (WBC > 15) C – Calcium < 2 R – uRea >16 E – Enzymes (LDH > 600 or AST/ALT >200) A – Albumin < 32 S – Sugar (Glucose >10)
What is the mnemonic for remembering the Glasgow score?
P – Pa02 < 8 KPa A – Age > 55 N – Neutrophils (WBC > 15) C – Calcium < 2 R – uRea >16 E – Enzymes (LDH > 600 or AST/ALT >200) A – Albumin < 32 S – Sugar (Glucose >10)
Which 5 blood tests are needed to calculate the Glasgow score?
- FBC - WCC
- U&E - urea
- LFTs - transaminases and albumin
- Calcium
- ABG - PO2 and glucose
How much does the amylase need to be raised in acute pancreatitis?
3x upper limit of normal
What is the first-line investigation for gallstone pancreatitis?
US - gallstones
What investigation is used to identify complications of pancreatitis?
CT abdomen - necrosis, fluid collection, abscess
When should you request a CT abdomen in suspected pancreatitis?
If the patient is becoming more unwell and you suspect complications.
What is the first-line treatment for pancreatitis?
FLUIDS!
1. A-->E resuscitation 2. IV fluids 3. Analgesia 4. NBM 5. Treat underlying cause/complications
When should you consider admission to critical care in acute pancreatitis?
Glasgow score >3 (severe pancreatitis)
What are the complications of fluid administration in pancreatitis?
Pulmonary oedema
How can you provide nutrition in a patient with pancreatitis who is NBM?
NJ tube (needs to be done in theatre)
What is the main cause of chronic pancreatitis?
Alcohol
Name some complications of chronic pancreatitis.
• Chronic epigastric pain
• Loss of exocrine function, resulting in a lack of pancreatic enzymes (particularly lipase) secreted into the GI tract
• Loss of endocrine function, resulting in a lack of insulin, leading to diabetes
• Damage and strictures to the duct system, resulting in obstruction in the excretion of pancreatic juice and bile
- Formation of pseudocysts or abscesses
What will the amylase show in chronic pancreatitis?
May not rise (pancreas has reduced function)
What medication is used to replace pancreatic enzymes?
Creon
How are the complications of chronic pancreatitis managed?
Diabetes = Insulin
Biliary obstruction = Stenting by ERCP
Abscess = Surgery
When do patients typically present with biliary injury following cholecystectomy?
2 weeks
What is mittleschmerz?
one-sided, lower abdominal pain associated with ovulation - often confused with appendicitis
Which organisms cause ascending cholangitis?
Escherichia coli
Klebsiella species
Enterococcus species
What are the features of ascending cholangitis?
Charcot’s triad:
fever
RUQ pain
jaundice
What are the causes of acute cholangitis?
Gallstones
ERCP
What can be tried in acute cholangitis if ERCP fails to remove the obstruction (most likely CBD stone)?
Percutaneous transhepatic cholangiogram (PTC)
What is the management of acute mesenteric Ischaemia?
Surgery:
- Remove necrotic bowel
- Bypass the thrombus
What is the imaging of choice in acute mesenteric Ischaemia?
CT abdomen
How does acute mesenteric Ischaemia present?
pain is disproportionate to the examination findings. Patients can go on to develop shock, peritonitis and sepsis.
What is another name for chronic mesenteric Ischaemia?
Intestinal angina
What is the management of chronic mesenteric Ischaemia?
Reducing modifiable risk factors (e.g., stop smoking) Secondary prevention (e.g., statins and antiplatelet medications) Revascularisation to improve the blood flow to the intestines
What are the three main branches of the abdominal aorta that supply the abdominal organs?
Coeliac artery
Superior mesenteric artery
Inferior mesenteric artery
Which artery supplies the foregut?
Coeliac artery
Which artery supplies the midgut (duodenum –> first half of transverse colon)?
Superior mesenteric artery
Which artery supplies the hindgut (second half of the transverse colon –> rectum)?
Inferior mesenteric artery
What is the difference between Ischaemia colitis and mesenteric Ischaemia?
Ischaemic colitis:
- less severe
- multifactorial
- Transient
- “thumb printing”
- conservative management
What are the four manifestations of diverticulum?
Diverticulosis - outpouching (happens normally with ageing)
Diverticular disease - symptoms arising from the diverticula
Diverticulitis - inflammation of the diverticula
Diverticular bleed - where the diverticula erodes into a vessel and causes large volume painless bleed
What are the risk factors for diverticula disease?
Low fibre diet Age Obesity Smoking Family hx NSAIDs
What are the primary investigations for patients presenting with lower abdominal pain and bowel symptoms?
Routine bloods - FBC, U&Es, CRP
VBG - check lactate (sign of severity)
(+group & save if suspected bleed)
(+faecal calprotectin if the diagnosis is less clear)
Urine dip
CTAP
What findings will be made on a CTAP?
Thickening of the colonic wall
Pericolonic fat stranding
Localised free air bubbles or free air
How does diverticulitis present?
LLQ pain - typically colicky, may be relieved by defecation Altered bowel habit Nausea Flatulence NO systemic features
How does acute diverticulitis present?
Acute onset abdominal pain - LIF, worsened by movement
Systemically unwell - nausea, vomiting, fever
Which drugs can mask the symptoms of diverticulitis?
Steroids
Immunosuppressants
What is meant by simple and complex diverticulitis?
Simple = just inflammation Complex = abscess or fistula
How should diverticula abscesses be managed?
<5cm = conservatively, IV abx, sometimes drainage >5cm = surgical management
How is diverticulitis classified?
Hinchey staging
What is the underlying pathophysiology? What is the most common histological type of colorectal cancer?
Originate from the epithelial cells lining the colon or rectum
Adenocarcinoma
Name three rarer histological types of colorectal cancer
lymphoma (~1%)
carcinoid (<1%)
sarcoma (<1%).
What are the risk factors for colorectal cancer?
- Age
- Male
- Family history
- IBD
- Low fibre diet
- High processed meat intake
- Smoking
Alcohol
Name two genetic conditions that predispose colorectal cancer.
Adenomatous polyposis coli (APC) = A tumour suppressor gene, mutation of the APC gene results in growth of adenomatous tissue, such as Familial Adenomatous Polyposis (FAP)
Hereditary nonpolyposis colorectal cancer (HNPCC) = Lynch Syndrome
A DNA mismatch repair gene, mutation to HNPCC leads to defects in DNA repair, such as Lynch syndrome
Who is called for bowel cancer screening?
Every 2 years to men and women aged 60-75 years
What screening test is used for bowel cancer?
Faecal immunochemistry test (FIT)
How does colorectal cancer present?
Change in bowel habit Rectal bleeding Weight loss* Abdominal pain Symptoms of (iron-deficiency) anaemia
*late sign, often metastatic disease
When should patients be referred for urgent investigation for bowel cancer?
≥40yrs with unexplained weight loss and abdominal pain
≥50yrs with unexplained rectal bleeding
≥60yrs with iron‑deficiency anaemia or change in bowel habit
Positive occult blood screening test
What is the gold standard for diagnosing bowel cancer?
Colonoscopy with biopsy
What staging criteria is used to assess the spread of bowel cancer?
Duke’s staging
What type of resection can be done to treat bowel cancer?
Right hemicolectomy involves removal of the caecum, ascending and proximal transverse colon.
Left hemicolectomy involves removal of the distal transverse and descending colon.
High anterior resection involves removing the sigmoid colon (may be called a sigmoid colectomy).
Low anterior resection involves removing the sigmoid colon and upper rectum but sparing the lower rectum and anus.
Abdomino-perineal resection (APR) involves removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy.
What is Courvoisier’s law?
states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.
What are the risk factors for cholangiocarcinoma?
Primary sclerosing cholangitis Liver flukes (a parasitic infection)
How does cholangiocarcinoma present?
Obstructive jaundice is the key presenting feature to remember. Obstructive jaundice is also associated with:
Pale stools
Dark urine
Generalised itching
How can you differentiate between small and large bowel on AXR?
Small bowel = valvulae coniventes (all the way across, close together)
Large bowel = haustra (halfway across, further apart)
Name 4 types of extra-luminal gas
Intraperitoneal gas
Retroperitoneal (extraperitoneal) gas
Gas in the bowel wall (pneumatosis intestinalis)
Gas in the biliary system (pneumobilia)
Name 4 causes of small bowel obstruction
adhesions, hernias, gallstone ileus, malignancy
Name 3 causes of large bowel obstruction
carcinoma, diverticular disease, volvulus
What is ileus?
Ileus is a condition affecting the small bowel, where the normal peristalsis that pushes the contents along the length of the intestines, temporarily stops. It may be referred to as paralytic ileus or adynamic ileus.
Give some causes of ileus
Injury to the bowel
Handling of the bowel during surgery
Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia)
Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia)
What is the management of ileus?
Nil by mouth or limited sips of water
NG tube if vomiting
IV fluids to prevent dehydration and correct the electrolyte imbalances
Mobilisation to helps stimulate peristalsis
Total parenteral nutrition (TPN) may be required whilst waiting for the bowel to regain function
