General Surgery Flashcards
Inguinal Hernia (medial or lateral to the Epigastric artery ) medial
*indirect hernia (congenital not closing of deep ring ). > pass deep ring lat. to inf. epigastric
then protude from sup. ing. ring ,
above&medial to pubic tubercle
- femoral» below&lat. to pubic tubercle
- direct(weakness of the ant abd wall esp Conjoint tendon = internal oblique + transverse abdomenalis )»medial to inf. epigastric vs
Anal fissures or Hemorrhoid
Hemorrhoid (internal and external via DENTATE line )
Splashing of blood / prolapse when straining / bright red blood / Covering the stool
Painless
a streak of blood on TOILET PAPER
Internal haemorrhoids can be missed with a DRE,
we need a proctoscope or a rigid sigmoidoscope to diagnose them.
Tx
1) Conservative - digital replacement /
Anal fissures (3,7,11)
Painful
Streaks of Blood on the STOOL
Anorectal Abscess consist of Perianal, 60% Ischiorectal, 20% Intersphinteric, 5% Supralevator, 4% Postanal abscesses are types of Anorectal abscess.
Perianal abscess will be in the submucosal or subcutaneous area of the anus.
Ddx
Inflammatory Bowel Disease
Anal Cancer
Colon Cancer
Abscess Management = Incision and Drainage (Antibiotics if certain condition)
Give ANTIBIOTICS only in case of DIABETES/ Immunosuppression / Valvular Ht disease/ Sepsis
Anal Fissure:
Acute (<6wks) & Chronic (>6wks)
C/F: Severe pain during defecation +
blood streaked stools +
long H/O constipation & straining +
pt refuses rectal examination due to fear of pain
- Rx :
Medical Mx (1st line)
Keep stools soft (adequate fluids + vegetables + laxatives for constipation :
Isapgul for adults, lactulose for children) +
Topical GTN cream (0.4%) (reduces anal tone)
If severe pain during defecation -> 1-2ml of lidocaine before toilet for max 2wks
Refer to 2ndary care if not resolves within 2wks for children & 6-8wks for adults, or asymptomatic adults with anal fissure over 12-16wks
2ndary Care : Topical CCB (2% Diltiazem or Nifedipine) cream PR or Botulinum toxin (expensive)
if fails –> go for surgery : LATERAL INTERNAL SPHINCTEROTOMY (best) or Fissurectomy
Mesenteric ischaemia(Infarct / irreversible gangrene / AF and embolus ) vs Ischaemic colitis (angina comes and go)
Mesenteric ischaemia
Sudden onset
pain is unproportionate to clinical findings / Absent Bowel sounds
elderly patient with AF and embolus
Urgent surgery to restore blood flow and remove necrotic ts
Ischaemic colitis
Multifunctional - transient interruption of blood supply
Moderate Colicky abdominal Pain start at Left iliac fossa
Bloody Diarrhoea
Conservative or Surgery
Bleeding per rectum Investigation
AGE > 55 (can be CA) - colonoscopy
Age < 55 (if you think Hemorrhoids )- proctoscopy or rigid sigmoidoscopy
painless bleeding per rectum +
no finding on examination
if more than 55 years = colonoscopy (likely cancer )
if less than 55 years = proctoscopy (likely haemorrhoids)
Paralytic ileus (absent BS) (X ray abdomen ) (IV and NG suction ) Anastomosis Ileus (CT abdomen )Vs IO ( increased BS)
Paralytic ileus.
common after major surgeries and extensive bowel handeling.
excessive opiate analgesia.
Tx - NG tube suction and give IV fluids. reduce opiates.
maintain electrolytes and encourage mobilisation.
> 60 IDA with no occult blood in the stool
IF Cancer where? Right Sided or Left Sided
IDA without obvious rectal bleeding= Cecum tumor (Right Sided ) (Polypoidal or cauliflower cancer )
With obvious occult blood in stool (Old age ) = Most common Sigmoid Colon(Left sided ) Ulcerative
Recto Vaginal fistula
1st - Tissue damage / Injury
2nd - Crohn’s Disease
Crohn’s Disease
most common site of inflammation is the ileum
Least common site is the rectum
Enterovaginal fistula is highly unlikely due to two reasons.
- Illeum rarely forms a fistula with vagina.
- In the stem it is clearly said fouls smelly feculant dischage.
Right sided stomas are less feculent than Left sided ones. due to anatomical proximity
Recto vaginal fistulas are common
35 yr Post OP CS cant pass urine
Most commonly dt effect of Epidural
Single Most Appropriate Investigation»_space;»> Bladder scan (a type of USG to Measure urine volume before and after voiding and also residual vol )
not IVU or USG
New inserted catheter removed within 48 hr
In CS removed same day or the next day
If Post Void Residual Volume 300-500mm and unable to void or uncomfortable and
If PVRV>500 mm »_space;» reinsert catheter
P or R or S hemorrhage
Primary Hemorrhage: immediately after Sx
Reactionary Hemorrhage: within first 24 hours of Sx
Secondary Hemorrhage: occurs 24 hours or more post Sx.
Corhn ‘s Disease
Crohn’s Disease: -
site: mouth to anus - skip lesions - cobblestone appearance -
affects ALL layers of intestine -
****increased goblet cells -
transmural granulomas + - skin tags, perianal fistula + -
Kantour’s string sign, Rose thorn ulcer +
Ulcerative Colitis: - COLON -
affects INNERmost lining of colon -
loss of haustrations - crypt abscesses + -
****decreased goblet cellls -
toxic megacolon -
bloody diarrhea
Ddx of colo-rectal Carcinoma SITE and Presentation
Rectal - Change in Bowel habit / Red bleeding / incomplete and painful deification
Sigmoid colon - Change in Bowel habit / Dark red bleeding
Right sided location - IDA / Mass / wt loss
40% emergency - Large bowel O / Peritonitis / Perforation
Colicky pain / Bloating
Carpel tunnel syndrome
Tingling and numbness on not relieved with steroids
Flexor Retinaculum= Transverse Carpal Ligament = Anterior Annular Ligament
Tests: TINLE’S test, Nerve conduction study, Electromyogram
Mx: braces/splint, NSAID, Steroid injection»_space; Temporary
CHOLECYSITITS = inflammation = Fever + Pain + J
Cholelithiasis = Galls stones in the GB (pain only when GB contracts after meals ) NOFEVER (5-F Syndrome—fair, fat, female, fertile and over forty).
Acute Pancreatitis = Alcohol + Fatty stool
RECURRENT attacks of RUQ following FATTY meals are characteristic for GALLSTONES
during the attack»_space; N ,V,Abd.pain& fatty diarrhea while in
CHOLECYSTITIS (INFLMATION) the Fever+ Acute severe RUQ pain with +ve murphy sign
Post Splenectomy / Remembrance Day (Nov 11) Vaccination
Another clue here, is that the pt. came on the Remembrance Day which is (November 11th).
So it would be better to give the Influenza vaccine prior to the “Peak flu season”
Other post-splenectomy vaccines:
- Pneumococcal vaccine —> Given 2-3 weeks after surgery and every 5 years.
- Influenza —> Annually
- Meningococcal —> Every 5 years
Hi B Inflenzae vaccination is no longer recommended due to excellent current control of Hib
Upper Right Quardrant Pain Radiating to the left Shoulder
Stable/ Dx Gall stones / Mgx
Gall Stones without symptoms - Reassure
Gall Stones with Symptoms (Stable ) - Elective surgery
Emergency lapratomy
Gangrenous gall bladder
Perforated gall bladder and
Detoriating patient with sepsis
Pharyngeal Pouch (Zenker's Diverticulum ) Stale food / Bad Breath Old age / Men 5 times > female Endoscopy Contraindicated (perforation ) Barium meal dx
Indications to Post phone the surgery
MI have to wait 6 months
Indications to postpone an elective surgery
1.Cardiac disease less than 6 months ago (M.I etc)
2.Uncontrolled D.M
3.Chest infection
4.Uncontrolled HTN
5. For Hb == If hb<10 postpone and investigate first
If hb<8 with symptoms then postpone and do blood transfusion
Generalized Guarding and Rigidity and increased PR after Sudden onset of abdominal pain / NV / Fever 38.7
Think of Acute Abdomen (Perforation of Diverticulum or appendix )
Thyroglossal Cyst (not thyroid nodule )
most common neck mass in children (10 year kid)
Cystic, painless and non tender,
MOVES WITH TONGUE PROTRUSION AND SWALLOWING
When infected: tender red hot, fever +/- dysphagia and dysphonia.
*****USG is the standard/best confirmatory inv ++++++++++++++++++
Thyroid scan when ectopic thyroid tissue diagnosis is needed. (most common site)
Rx: Sistrunk
D/D - Brachial cyst Cystic hygroma
CS 3130
35 year old 10 day post of Laparoscopic Cholecystectomy (BMI <21 )
With RUQ pain and Fever / increased HR BP RR
Most appropriate investigation
If Patient is OBEASE and COMPLICATED L. Cholecystectomy
then SUSPECT BILE LEAK
Healthy and BMI 21 within normal (Uncomplicated )- -SUSPECT ABSCESS
ERCP»_space;> High suspicion of Bile leak
MRCP»_space;> Moderate suspicion of Bile leak
CT abdomen»_space;» High suspicion of ABSCESS
Haemorrhoid Grade with no symptoms»_space;» what to do
Gall stone+ no symptop= Reassurance
Gallstone in CBD+ no symptom= Laparoscopic cholecystectomy or ERCP
Haemorrhoid+No symptom=no action required (How terrible the Haemorrhoid looks)
Inguinal Hernia in an elderly person+ No symptom=No action required
Old and WT LOSS over MONTHS
/ incomplete defication / Change in Bowel habits /
BUT PR examination - Found no mass
Colo-Rectal Carcinoma
Tenesmus
Secretion of Mucus and blood in the stool
Ddx Diverticulitis Pain left iliac fossa after some DAYS FEVER / TACHYCARDIA Left iliac fossa tenderness
Hyper Oxyaemia / Hyperoxia
PaO2 >16 mmHg
Lead to oxygen Toxicity / Breathing oxygen at High Partial Pressure
Become breathless and dyspneic
Appendicitis and Tx and Investigation
Uncomplicated
Complicated (perforation )
most important risk factor for CA colon / ovary / bladder
colon CA: AGE / Family
ovarian cancer: FAMILY HISTORY
urinary bladder CA: SMOKING
Gastric : Age / H pylori / Blood Gp A (Virchow LN enlargement )
When to give Antibiotics before Elective anterior restoration
For an elective lower bowel surgery,
it would be expected that bowel preparation was done.
This will reduce the bacterial load,
so IV antibiotics at induction of anesthesia would be adequate.
Thyroidectomy complication
2 nerves 3 complications
Thyroidectomy Complications—-
RECURRENT LARYNGEAL NERVE:
U/L— Hoarseness
B/L— Aphonia and Airway obstruction (with stridor seen)
SUPERIOR LARYNGEAL NERVE -
External Branch: – Dysphonia (inability to create High-pitch sound) – Singers harmed! (Monotone voice)
Thyroidectomy complication
2 nerves 3 complications
Thyroidectomy Complications—-
RECURRENT LARYNGEAL NERVE:
U/L— Hoarseness
B/L— Aphonia and Airway obstruction (with stridor seen)
SUPERIOR LARYNGEAL NERVE -
External Branch: – Dysphonia (inability to create High-pitch sound) – Singers harmed! (Monotone voice)
Insulin Regime
Perianal Fistula Management
Superficial / Simple / Low fistula (sphincters and muscles not Involved ) Lay open (fistulotomy - open wound healing )
Deep / Complex / High fistula
Ligation of the intersphincteric fistula tract
Diverticulitis (Pouching of Large colon dt unknown causes )
Age>40
Constipation and low fibre diet
acute onset of LEFT sided abdominal pain +
massive per rectal bleeding = Haematochezia
nausea & vomitting +
fever & tachycardia +
constipation & bloating + LEFT ILIAC FOSSA tenderness +
low fibre diet/eats lots of canned meat**
Ix - CT Scan of abdomen
Rx :if haemodynamically unstable due to massive bleeding = urgent admission & resuscitate + IV antibiotics (cefuroxime + metro)
Child with Oral burn not breathing well
Intubation has failed
what to do next
In case of emergency,
if intubation fails :
2nd line –> Cricothyrodotomy (easier) - short term solution Provide Oxygenation and not Ventilation
2cm transverse inscision through the skin and cricothyroid membrane .
Tracheostomy takes more skill & has more risk of injury but overall better in long term care
Car accident / Hemi arthroplasty(head of femur replacement )
Most common post-operation complication
Post op infection
Not avascular necrosis
Not fat embolus
Radical inguinal orchiectomy(with external oblique fascia closure after surgery if not hernia )
Inguinal or Incisional hernia
after Post op Testicular tumor removal via Inguinal approach
Timing is key.
Incisional hernia occurs after 3-6months post op
Inguinal hernia if < 3 months
USG or CT best initial investigation ????? in Different Jaundice pt
Red flag signs for Pancreatic Cancer - CT»_space;>USG»_space;» Ca 19-9 (80% sensitive)
(Wt loss / Painless Jaundice / Back pain and Epigastric pain / alcohol drinking / new T1 DM )
J with Epigastric or RUQ pain (Gall stones )- USG
Free Screening test IN UK - BBC
Breast
Bowel Colon
Cervical
SU 0369
Stoma closed
then stoma
Murphy’s Triad ( Appendicitis vs Ectopic preg Vs Splangitis VS ovarian torsion )
Murphy’s triad is seen in appendicitis.
It consists of,
1) right iliac fossa pain
2) nausea and vomiting
3) fever
Shifting pain from the abdomen to the Right iliac fossa /Rebound tenderness
To Do Ct abdomen GI 1471
Suspected Abscess,
Suspected Pancreatic Cancer,
Anastomotic Leakage,
pt >50y with suspected cancer —-> CT Abdomen
Corhns Disease
pt with CD + recent oncet increase in diarrhea +
Fever+ high TLC + very high CRP»_space;» ilial Abscess
CT ABDOMEN to decide whether to perform :
1) percutaneous drainage OR 2) surgical drainage
Crohn’s Disease
Entero - Vaginal fistula choose in the following order
1) Reto Vg fistula
2) ileum Vg fistula (If rectal is not in the options )
3) Sigmoido Vg fistula (least least common sit )
