General Surgery Flashcards
What clinical signs are consistent with Pancreatic Cancer?
Trousseau’s sign
Courvoisier’s sign
What is Courvoisier’s sign?
A painless palpable gallbladder
Jaundice
What is Trousseau’s sign?
Migrator thrombophlebitis
What is a Zenker’s diverticulum?
Pharyngeal pouch - small bump in the pharynx, most common in the elderly
It occurs through a weakness in the muscle layer called the Killian dehiscence
How does a pharyngeal pouch usually present?
Dysphagia Chronic cough Weight loss Regurgitation Aspiration
How is a pharyngeal pouch diagnosed?
Barium swallow
Following initial resuscitation what should be given to patients awaiting endoscopy after an oesophageal varicie bleed?
IV Abx
Terlipressin
How should a perinatal abscess be managed?
Incision and drainage
Features of Lynch syndrome?
Strong familial prevealence of colorectral, endometrial cancer and ovarian cancer
Best initital management for patients with output stomas?
Restrict oral hypotonic fluid intake
Advise dextrose-saline solution
Prescribe oral loperamide and omeprazole
What is offered at the age of 55 as part of the NHS screening programme for colorectal cancer?
One-off flexible sigmoidoscopy
Detect and remove polyps
What type of colorectal tumours are suitable for anterior resection?
Anterior resection for tumours >8 cm from the anal canal or involving the proximal 1/3 of the rectum.
What tumours are a left hemicolectomy suitable for?
A left hemicolectomy is suitable for tumours of the distal transverse colon and descending colon
What are the components of Dukes staging of colorectal canceR?
A: limited to the bowel wall (i.e. not beyond the muscularis).
B: extending through the bowel wall (i.e. beyond the muscularis).
C: regional lymph node involvement.
D: distant metastaseis.
What diagnostic investigation is most sensitive for a hiatal hernia?
Barium swallow
Will demonstrate if the stomach is partially or completely intrathroacic
What drugs commonly cause cholestasis?
Coamoxiclav Flucloxacillin Nitrofurintonin Steroids Sulphonylurea Prochlorperazine
How is bilirubin conjugated and excreted?
Bilirubin is conjugated with glucuronic acid by glucronyltransferase and is then excreted in the bile.
In the bowel, bilirubin is converted to stercobilin by gut flora, which is then excreted in the faeces as well as urobilinogen, which is reabsorbed and converted into bile, excreted in the faeces or excreted in the urine.
What cancer is most associated with Barrets oesophagus?
Oesophogeal adenocarcinoma
What type of calcium distrubance is most commonly associated with abdominal pain#?
Hypercalcemia
If calcium is low suspect acute pancreatitis
What drug is used for acute management of a variceal haemorrhage?
Terlipressin
How does a pharangeal pouch present?
Dysphagia
Aspirtation pneumonia
Halitosis
What is the most common kind of stomach ulcer?
Duodenal
Gastric are less common
What kind of stomach ulcers are more likely to have associated weight loss?
Gastric ulcers
What kind of stomach ulcers have epigastric pain worsened by eating?
Gastric ulcers
What type of ulcer may occur at a stoma sight?
Pyoderma gangrenosum, a deep, painful, ulcer
Initial management of acute limb ischemia?
Analgesia
IV heparin
Vascular review
Common conseuqence of terminal ileus resection
Bile acid malabsorption
What is Mirrizi’s syndrome?
Causes an obstructive jaundice due to compression of the common bile duct secondary to presence of gallstones in the cystic duct itself or in Harmanns pouch
Conjugated hyperbilirubinaemia
Diagnosis confirmed by MRCP
Management laproscopic cholecystectomy
Definitive diagnostic test for acute mesenteric ischemia?
CT angiography
What is meant by the acute abdomen?
Recent, rapid onset of urgent abdominal or pelvic pathology, usually presenting with abdominal pain
Causes of generalised abdominal pain?
Peritonitis
Ruptured AAA
Intestinal obstruction
Ischemic colitis
Causes of right upper quadrant pain?
Bilary colic
Acute cholecystitis
Acute cholangitis
Causes of epigastric pain?
Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured AAA
Causes of central abdominal pain?
Ruptured AAA
Intestinal obstruction
Ischemic colitis
Early stage of appendicitis
Causes of RIF pain?
Acute appendicitis Ectopic pregnancy Ruptured ovarian cyst Ovarian torsion Meckel's diverticulitis
Causes of LIF pain?
Diverticulitis
Ectopic pregnancy
Ruptured ovarian cysts
Ovarian torsion
What is suprapubic pain?
Lower urinary tract infection
Acute urinary retention
PID
Prostatitis
Causes of loin to groin pain?
Renal colic (kidney stones)
Ruptured AAA
Pyelonephritis
Causes of testicular pain?
Testicular torsion
Epididymo-orchitis
What is peritonitis?
Inflammation of the peritoneum (lining of the abdomen)
Signs of peritonitis?
Guarding (involuntary tensing of the abdominal wall muscles when palpated to protect the painful area below)
Rigidity (involuntary persistent tightness of abdominal wall muscles)
Rebound tenderness (releasing pressure causes more pain than the pressure itself)
Coughing test (coughing results in pain)
Percussion tenderness
Reduced/absent bowel sounfs (suggestive of paralytic illeus)
What causes localised peritonitis?
Underlying organ inflammation
Appendicitis, cholecystitits
What causes generalised peritonitis?
Perforation of an abdominal viscous(e.g. perforated duodenal ulcers, ruptured appendix) releasing contents into the peritoneal cavity and causing generalised inflammation of the peritoneum
What causes spontaneous bacterial peritonitis?
Spontaneous infection of ascities in patients with liver disease. Treated with broad spectrum antibiotics, carries a poor prognosis
How might you investigate the acute abdomen?
FBB: hb, WBC
U&E - electrolyte imbalance, kidney functions, prior to CT
LFTs give and indication of the bilary and hepatic systems
CRP - gives an indication of inflammation and infection
Amyalse gives an indication of inflammation of the of the pancreas
INR - synthetic liver fucntion, plus prep for procedure
Serum calcium - scoring acute pancreatitits
Beta-HCG in females of child bearing age
ABG - lactate (ischema) and pO2 (acute pancreatitis scoring)
Group and save - may req blood transfusion
Abdominal x ray: can show evidence of bowel obstruction (dilated loops)
Erect CXR: air under diaphragm when intra-abdominal perforation (pneumoperitoneum, air in abdominal cavity)
Abdominal USS: gallstones, billary duct dilation, gynae pathology
CT scans: identify the cause of an acute abdomen and determine management
Urine dip: UTI, haematuria
Initital management of a bowel obstruction?
NBM NG tube IV fluids Analgesia Anit-emetics
Causes of acutte abdomen that could lead to hypovolemic shock?
AAA
Ruptured ectopic pregnancy
Bleeding gastric ulcer
Trauma
Signs of hypovolemic shock?
Tachycardia Hypotension Pale Clammy Cool to touch
What, until proven otherwise, should be suspected in a patient with severe abdominal pain out of proprotion to their clinic signs? What other signs might be present?
Ischemic bowl
Acidaemic
Raised lactate
Diffuse, constant pain
What is colic?
Abdominal the crescendos to become very severe and then completely goes away
- billary
- ureteric
- bowel obstruction
What is peritonism?
Localised inflamation of the peritoneum, usually due to inflammation of a ciscus that then irritates the visceral (and subsequently, parietal peritoneum) before localising to another area or becoming generalised
What is looked for on USS KUB?
Hydronephrosis
Cortico-medullary differentiation
What is looked for in billary tree USS?
Presence of gallstones
Gallbladder thickening
Duct dilation
Why should patients with abdominal pain have an ECG?
Exclude cardiac pain (reffered)
Where do the vast majority of gastric cancers arise from?
Gastric mucosa (adenocarcinoma)
Adenocarcinoma makes up 90% of stomach cancers, what are the other types?
Conncective tissue, lymphoid or neuroendocrine mallignancy
Risk factors for gastric cancer?
H pylor infection Male gender INcreasing age Smoking Alcohol consumption High salt diet, positive family history, pernicious anaemia
What is H. Pylori?
H. Pylori is a gram negative helical bacterium that produces the urease enzyme
Breaks down urea into CO2 and ammonia
Ammonia neutralises stomach acid allowing the bacteria to to create an alkaline microenvironment
How does H pylori lead to gastric neoplasia?
Sets off a cycle of repeated damage to the epithelial cells, leading to inflammation, ulceration and ultimately gastric neoplasia.
What are the presenting symptoms of gastric cancer?
Dyspepsia (new onset, non-responsive to PPI) Dysphagia Early satiety Vomiting Melena Heametemisis Constitutional symptoms (late stage)
How can H pylori be diagnosed?
Blood antigen test
Stool antigen test
Urea breath test
How is H pylori erradicated?
PPI
Clarithromycin
Amoxocillin
What clinical signs may be present in late stage gastric cancer?
Palpable epigastric mass Troisier signs (palpable left supraclavicular (Virchow) node) in metastatic abdominal malignancy
Mets: Hepatomegaly, ascites, jaundice, acanthosis nigricans
Differentials for gastric cancer?
Peptic ulcer disease
GORD
Gallstone disease
Pancreatic cancer
How is suspected gastric cancer investigated?
FBC
LFTs
Upper GI endoscopy (OGD) +/- biopsy
CT chest-abdo-pelvis and staging laparoscopy (peritoneal mets) to stage
Why are PET scans rarely used in staging gastric cancers?
Gastric cancers to not take up the radioactive tracer well
How are gastric cancers staged?
TNM
What should biopsies from gastric mallignancies be sent for?
Histology - grading of any neoplasia
CLO test - H pylroi
HER2/neu protein expression - allows target monotherapies if present
What is the mainstay of curative treatment in gastric cancer?
Surgery (+ adjuvant and neoadjuvant chemotherapy if tolerated)
Proximal gastric cancer - total gastrectomy
Distal gastric cancer (antrum or pylorus) - subtotal gastrectomy
What may patients with early T1a gastric tumours be offered as an alternative to total or sub-total gastrectomy?
Endoscopic Mucosal Resection (EMR) is suitable for tumours confined to the muscularis mucosa and has reduced morbidity and mortality
What is the most commonly used method in reconstruction the alimentary anatomy following gastrectomy?
Roux-en-Y reconstruction (best functional result, less bile reflux)
Distal oeosphagus is end to end anatsomosed with the small bowel
Proximal small bowel is end- to - side anastamosed to the small bowel
Complications of gasterectomy?
Anastomotic leak Re-operation Dumping syndrome Vitamin B-12 deficiency Death (3-5%)
What injection do patients require 3 monthly following gastrectomy?
Vitamin B12
What is the palliative management of gastric cancer?
Chemotherapy
Stention
Surgery (distal gastrectomy or bypass surgery, gastro-jejunostomy) if stenting fails or unavailable, or in palliation of bleeding gasrtic tumours
Best supportive care
Most common complications of gastric cancer?
Gastric outlet obstruction, iron-deficiency anaemia, perforation, malnutrition
What is gastric dumping syndrome?
Common following gastric bypass surgery
Early (10-30 mins post prandial) - Sudden and large passage of hypertonic gastric contents into the small intestine, resulting in an intraluminal fluid shift and subsequent intestinal distention
Late (1-3 hours post prandial) Surge in insulin production following the ‘dumping’ of food results in hypoglycemia
Presentation of gastric dumping syndrome~?
Early (10-30 mins post prandial): nausea, vommiting, diarrhoea, hypovolemia, leading to synpathetic response predominating with tachycardia and diaphoresis
Late (1-3 hours post prandial) - hypoglycemia
How can gastric dumping syndrome be managed?
Small volume and more frequent meals, avoidence of simple carbohydrates, separation of eating and drinking to reduce load on stomach.
Refer these patients to a dietician?
Treat hypoglycemia, intra-operative glucose management
Most common symptoms of dumping syndrome?
Sweating Tingling lips or extremities Tremor Dizziness Slurred speech
When should a patient be referred under the urgent pathway for OGD?
New onset dysphagia or aged >55 years presenting with weight loss and either upper abdominal pain, reflux, or dyspepsia
What are the main two types of oesophageal cancer?
Squamous cell carcinoma (developing world)
Adenocarcinoma (developed world)
Where does SCC typically occur in the oesophagus?
Middle and upper thirds
What is oesophageal SCC associated with?
Smoking Excessive alcohol consumption Chronic achalasia Low vitamin A levels Iron def
What is oesophageal adneocarcinoma associated with?
Metaplastic epithelium - Barrett’s oesophagus (progressing to dysplasia)
GORD
Obesity
High fat intake
Where in the oesophagus does adenocarcinoma typically occur?
Lower thirds
What vasculature runs near the oesophagus?
Inferior thyroid artery
Azygous vein
Thoracic aorta and oesophogeal branches
How does oesophageal cancer present?
Late stage usually
Dysphagia, progressive, starting with solids progressing to liquids
Odynophagia
Hoarseness
Cachexia, dehydration
Supracavicular lymphandenopathy
Signs of metastatic disease: jaundice, heaptomgealy, asicities)
How is dysphagia investigated?
Upper GI endoscopy (OGD) within two weeks +/- biopsy for histology
CT chest-abdomen-pelvis if OGD abnormal to search for mets
PET-CT for “
Staging laparoscopy for junctional tumours with an intra-abdominal component to look for intra-peritoneal metasteses
FNA of any palpable cervical lymph nodes
Bronchoscopy if hoarseness or haemoptysis
How is oesophageal SCC managed?
Usually palliative
Curative: chemo-radiotherapy
How is oesophogeal adenocarcinoma managed?
Mostly palliatively, but if curative treatment:
Neo-adjuvant chemothreapy or chemo-radiotherapy followed by oesophageal resection (oesophagectomy or EMR if high grad Barret’s or early stage cancer)
Oesphagectomy involved removing the tumour, top of stomach and surrounding lymph nodes. The stomach is made into a conduit and borugh up the chest to replace the oesophagus. One lung needs to be deflated during surgery for aprox two hours, and patients will not recover fully for 6-9 months.
What surgical approaches may be taken?
Right thoracotomy with laparotomy - Ivor-Lewis procedure
Right thoracotomy with abdominal and neck incision - MecKeown procedure
Left thoracotomy with or without neck incision
Left thoraco-abdominal incision (starting above umbilicas extending round back to below left shoulder blade)
Palliative options for oesophogeal cancer?
Oesophageal stent
Radiotherapy and or chemotherapy can be used to reduce tumour size and bleeding
Nutritional support: thicken fluids, nutritional supplements, RIG if enteral feeds not tolerated
At what vertebral level does the oesophagus originate?
C6
Aetiology of acute pancreatitits?
Gallstones Ethanol Trauma Steroids Mumps Autoimmune (SLE, Sjorgen's) Scorpion venom Hypercalcemia ERCP Drugs
What drugs may cause acute pancreatitis?
Azathioprine
NSAIDs
Diuretics
How is acute pancreatitis distinguished from chronic pancreatitis?
Extent of damage to the secretory function of the gland - no gross structual damage in acute
Pathogenisis of acute pancreatitis?
Premature and exaggerated activation of digestive enzymes within the pancreas
Pancreatic inflammatory response causes and increase in vascular permeability
Subsequent fluid shifts (third spacing)
Enzymes released from pancreas into the systemic circultion
Autodigestion of fats and blood vessels (fat necrosis, bleeding into retroperitoneal space)
Release of free fatty acides reacts with serum calcium to cause chalky depsosits in the fatty tissue, resulting in hypocalcemia
What does severe end-stage pancreatitis result in?
Partial or complete necrosis of the pancreas
How does pancreaitits present?
Sudden onset of severe epigastric pain which can radiate through to the back
Nausea and vommiting
Epigastric tenderness +/- gaurding
Cullen’s sign, Grey turner’s sign
Tetany (from hypocalcemia)
Concurrent obstructive jaundice (if gallstone aeitiology)
WHat is Cullen’s sign?
Bruising around the umbilicus
What is Grey Turner’s sign?
Flank brusing
Why does Cullen’s and Grey Turner’s signs occur?
Retroperitoneal haemmorhage
Causes of abdominal pain radiating to the back?
Pancreatiitis (chronic or acute) AAA Renal calculi Aortic dissection Peptic ulcer disease
How should you investigate acute pancreatitis (excluding routine bloods as per abdominal pain)
Serum amylase
LFTs - concurrent cholestatic elemant to the clinical pictutre
Serum lipase
Abnominal USS - ?gallstone
Contract CT if USS inconclusive, and also 6-10 days after admission in patient with features of persistent inflammatory response or organ failure
Whilst not routinely performed for acute pancreatitis, an AXR can show what?
Sential loop sign - dilated proximal bowel loop adjacent to the pancreas, which occurs secondary to the localised inflammation
When should a CXR be performed in acute pancreatitits?
Look for pleural effusion or ARDS
What serum amylase is diagnostic of acute pancreatitits?
3x the upper limit of normal, although not related to disease severity
What ALT level strongly suggest gallstone ateiology in acute pancreatitits?
> 150
What is the most accurate blood test for acute pancreatitis and why is it not used?
Serum lipase
Remains elevated longer than amylase
Not available our routinely performed in many hospitals
What is used to asses the severity of acute pancreatitits within the first 48 hours of admission?
Modified glasgow criteria
What is the modified Glasgow criteria?
pO2 <8kPa Age > 55 Neutrophiles (WCC>15) Calcium <2 Renal (urea>16) Enzymes LDH>600 or AST>200 Albumin <32 Sugar > 10
What does it mean if a patient has 3 or more factors within the first 48 hours of admission of the modified Glasgow criteria?
Severe pancreatitis, high dependency care referral warrented
What will a contrast-enhanced CT scan show after 48hr of initial presentation of acute pancreaitits?
Pancreatic odema and swelling
Non-enhancing areas suggestive of pancreatic necrosis
How is acute pancreatitits managed?
IV fluid resucitation - balanced crystalloid
O2 as required
NG tube if vomiting profusely
Catheterisation to monitor urine out put (aim >0.5ml/kg/hr)
Opiod analgesia
If gallstones ERCP and spinchterotomy
When should a borad-spectrum antibiotic such as imipenem be considered for prophalaxis against infection in acute pancreatitits?
confirmed pancreatic necrosis
What should be advised once a patient with pancreatitis secondary to gallstones has been stablised?
Early laparoscopic cholecystectomy
What complications of pancreatitis tend to occur within days of initial onset?
Systemic complications such as: Disseminated Intravascular Coagulation DIC Acute Respiratory Distress Syndrome Hypocalcemia Hyperglycemia
Why might hyperglycemia occur secondary to pancreatitits?
Destruction of islets of Langerhans and subesquent disturbances to insulin metabolism
What should be suspected in patients with evidence of persistent systemic inflammation for more than 7-10 days after the onset of pancreatitis?
Ischemic infarction of the pancreatic tissue, confirmed by CT imaging
How is pancreatic necrosis managed?
Pancreatic necrosectomy (open or endoscopic) Broad spectrum abx
Definitive diagnosis of infected pancreatic necrosis can be confirmed by what?
FNA
What is a pancreatic pseudocyst?
Collection of fluid containing pancreatic enzymes, blood and necrotic tissue, can occur anywhere within or adjacent to the pancreas
Lack an epithelial lining, instead have a vascular and fiboritic wall surrounding the collection
Where to pancreatic pseudocysts typically occur?
Lesser sac obstructing the gastro-epiploic foramen by inflammatory adhesions
How long after the initial acute pancreatitis episode do pancreatic pseudocyts tend to occur?
Weeks
How are pancreatic pseudocyts managed?
About 50% will spontaneously resolve, hence conservative management is usually the initial treatment of choice. Cysts which have been present for longer than 6 weeks are unlikely to resolve spontaneously. Treatment options include surgical debridement or endoscopic drainage
N.B. prone to haemorrhage or rupture, can become infected
What is a stoma?
Surgically created opening into a hollow organ
What does a colonostomy open into?
Large bowel
What does an ileostomy open into?
The ileum
What does a urostomy open into?
The urinary system
What are colostomy stomas situated?
Left illiac fossa
Where are ileostomys siutated?
Right iliac fossa
What stomas will be spouted?
Ileostomy
Urostomy
What stoma is flush to the skin?
Colonoscopy
What with the conistency of an ileostomy be?
Watery, greener
What is to consistency of a colonostomy contents?
Thick and sludgey
What will urostomy output look like?
Urine
How many lumens does a loop stoma have?
Two
How many lumens does an end stoma have?
One
Potential complications of a stoma?
Parastomal hernia (colostomy) Prolapse Retraction Infarction (turns jet black) Ulceration Fistulation Local skin irritation Loss of bowel length leading to high output dehydration and malnurtition Granulomas causing raised red lumps around the stoma Stenosis Constipation (colostomies)
Where are urostomies usually located?
RIF
What is an end colostomy?
Removal of a section of bowel, where the end part of the proximal bowel is brough onto the skin. The other open end of remaining bowel (distal part) is sutured and left in the abdomen. It may be reversed at a later date, were the two ends are sutured together, creatining an anastomisis
When are end colostomies permanent?
End colostomies are permanent after resection of abdomino-perineal resection (APR) because the entire rectum and anus have been removed. These are usually located in the lower left abdomen.
What procedure forms an end illeostomy?
Panproctocolectomy
End ileostomies are permanent after a panproctocolectomy (total colectomy with removal of the large bowel, rectum and anus)
What is a panproctocolectomy?
Total collectomy with removal of the large bowel, rectum and anus
What is a panproctocolectomy used to treat?
IBD
Familial adenmoatous polyposis (FAP)
Alternative to panproctocolectomy?
Ileo-anal anastomosis (J-pouch)
What does a loop colostomy/ileostomy allow?
Distal portion of the bowel and anastomosis to heal after the surgery, allow faeces to bypass the distal, healing portion of the bowel until healed and ready to restart normal function, they are usually reveresed 6-8 hours.
The bowel is partially opened and folder so that there are two opening on the skin side-by-side, attached in the middle.
Proximal end is turned outside to form a spout, distal and is flatter.
How is a urostomy formed?
Creation of an ileal conduit.
Section of illeum removed and end-to-end anastomisis is screated so bowel in coninous. Ends of ureters are anatsomosed and separated to section the ileum. The end of the section is brough out onto the skin as a stoma and drains directly from the ureters into a urostomy bag.
What do gallstones form from?
Concentrated bile in the bile duct, most are made from cholesterol
Complications of gallstones?
Acute cholecystitits
Acute cholangitis
Pancreatitis (if blocking the pancreatic duct)
Obstructive jaundice
Basic anatomy of the bile duct system
Right and left hepatic ducts leave the liver and join together to become the common hepatic duct.
Cystic duct from gallbladder joins the common hepatic duct halfway along.
Pancreatic duct from the pancreas joints with the common hepatic duct further along.
Common bile duct and pancreatic duct join to become the ampulla of Vater, which opens into the duodenum.
What is the sphincter of Oddi?
Ring of muscle surrounding the ampulla of Vater that controls the flow of bile and pancreatic secretions in the duodenum.
What is cholestasis?
Blockage to flow of bile
What is cholelithiasis?
Presence of gallstones
What is choledocholithiasis?
Gallstones in the bile duct
What is billary colic
intermittent right upper quadrant pain caused by gallstones irritating bile ducts
What is cholecystitits?
Inflammation of the gallbladder
What is cholangitis?
Inflammation of the bile ducts
What is gallbladder empyema?
Pus in the gallbladder
What is a cholecystostomy?
Insertion of a drain into the gallbladder
What are the risk factors for gallstones?
Fat
Fair
Female
Forty
Typical presentation of gallstones (if symptomatic)
Billary colic
Severe, colicky epigastric or right upper quadrant pain
Often triggered by meals (particularly high fat meals)
Lasting between 30 minutes and 8 hours
May be associated with nausea and vomiting
What does raised jaundice, raised serum bilirubin, pale stools and dark urine represent?
Obstruction caused by a gallstone in the bile duct or an external mass pressing on the bile ducts (e.g. cholangiocarcinoma or tumour of head of pancreas)
What can a raised ALP indicated?
Liver pathology Bone pathology (Paget's, bone malignancy) Pregnancy (production by the placenta) Billary obstruction Billary chirrosis
What are ALT and AST helpful markers of?
Hepatocellular injury
What does a higher ALP compared to AST and ALT?
Obstructive picture
What do a higher ALT and AST compared to ALP indicate?
Hepatic picture
First line investigation for suspected gallstone disease?
USS
What is USS of the bilary tract limited by?
Patient weight
Gaseous bowel obstructing the view
Discomfort from the probe
What might be found on USS of the billary tract?
Gallstones in the gallbladder
Gallstones in the ducts
Bile duct dilatation (normally less than 6mm diameter)
Acute cholecystitis (thickened gallbladder wall, stones or sludge in gallbladder and fluid around the gallbladder)
The pancreas and pancreatic duct
What is a magnetic resonance cholangio-pancreatography?
MRI scan with a specific protocol that produces a detailed image of the biliary system. It is very sensitive and specific for biliary tree disease, such as stones in the bile duct and malignancy.
When does gallstone disease warrent MRCP?
If USS does not show stones in the duct but there is bile duct dilation or raised bilirubin suggestive of obstruction
Key complications of ERCP
Excessive bleeding
Cholangitis (infection in the bile ducts)
Pancreatitis
The main indication for ERCP
Clear stones in the bile duct
What can be done during an ERCP?
Inject contrast and take x-rays to visualise the biliary system and diagnose pathology (e.g., stones or strictures)
Perform a sphincterotomy on the sphincter of Oddi if it is dysfunctional (blocking flow)
Clear stones from the ducts
Insert stents to improve bile duct drainage (e.g., with strictures or tumours)
Take biopsies of tumours
Complications of cholecystectomy?
Bleeding, infection, pain and scars
Damage to the bile duct including leakage and strictures
Stones left in the bile duct
Damage to the bowel, blood vessels or other organs
Anaesthetic risks
Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
Post-cholecystectomy syndrome
What are the to approaches to cholecystectomy?
Laparoscopic
Open - Kocher incision
What is post-choecystectomy syndrome?
Diarrhoea Indigestion Epigastric or right upper quadrant pain and discomfort Nausea Intolerance of fatty foods Flatulence
Why does post-cholecystectomy syndrome?
Attributed to changes in the bile flow after removal of the gallbladder
What is cutaneous wound healing?
Process by which the skin repairs itself after damage?
Types of wound healing?
Primary intention
Secondary intention
What are the four stages that occur in wound healing?
Haemostasis
Inflammation
Proliferation
Remoddeling
What happens in the hameostasis phase of primary intention
Action of platelets and cytokines forms a haematoma and
Causes vasconstriction, limiting blood loss at the affected area
The close proximity of the wound edges allows for ease of clot formation and prevents infection by forming a scab
What happens in the proliferation phase of primary intention healing?
Cytokines released by inflammatory cells drive the proliferation of fibroblasts
And formation of granulation tissue
Angiogenesis is promoted by the presence of growth mediators (e.g. VEGF)
Allows for further maturation of the granulation tissue
Production of collagen by fibroblasts
Allows for closure of wound within about a week
What happens in the inflammation phase of primary intention?
A cellular inflammation response acts to remove any cell debris and pathogens present
What is the remodelling phase of healing by primary intention?
Collagen fibres are deposited within the wound to provide strength in the region, with fibroblasts subsequently undergoing apoptosis
What is typically the end result of healing by primary intention?
Completed return to function with mininmal scaring and loss of skin appendages
Why is correct suture tension important?
Too loose and the wound edges will not be properly opposed, limiting the primary intention healing and reducing the wound strength
Too tight and the blood supply to the region may become compromised and lead to tissue necrosis and wound breakdown
What happens during haemostasis in secondary intention healing?
A large fibrin mesh forms which fills the wound
What happens in the inflammation phase of secondary intention?
An inflammatory response acts to remove and cell debris and pathogen present
Larger amount of cell debris present, and the inflammatory reaction tends to be more intense than in primary intention
What happens in the proliferation phase of secondary intention and why is it an important step?
Granulation tissue forms at the bottom of the wound
Important as the epithelia can only proliferate and regenerate once granulation tissue fills the wound to the level of the original epithelium, once the granulation tissue reaches this level the epithelia can completely cover the wound
What happens in the remoddeling stage of secondar intention healing?
Inflammatory response resolves, wound contraction occurs
When does healing by primary intention occur?
Wounds with dermal edges that are close together
When does healing occur by secondary intention?
When the sides of the wound are not opposed, therefore healing must occur from the bottom of the wound upwards?
What cells are vital in secondary intention?
Myofibroblasts - modified smooth muscle cells, that contain actin and myosin, and act to contract the wound; decreasing the space between the dermal edges. They also can deposit collage for scar healing.
What are keloid scars?
An uncommon complication from wound healing (particularly in people with darker skin) whereby there is excessive collage production, leading to extensive scarring. This can occur in both primary and secondary intention healing.
Local factors that affect wound healing?
Type, size, location of wound Local blood supply Infection Foreign material or contamination Radiation damage
What systemic factors affect wound healing?
Increasing age
Co-morbidities, especially CV disease or DM
Nutritional deficiencies (especially vitamin C)
Obestity
Four classes of surgical contamination?
Clean
Clean-contaminated
Contaminated
Dirty
What is clean contamination?
Elective, non-emergency, non-traumatic, and primary closed, with GI, biliary and GU tracts remaining intact
What is clean contamination?
Urgent or emergency case that is otherwise clean
Elective opening of respiratory tract, GI, bililary or GU tract with minimal spillage and not encountering infected urine or bile
What does contaminated mean?
Gross spillage from GI tract or entry into biliary or GU tract (in presence of infected bile or urine)
Penetrating trauma < 4 hours old or a chronic open wound to be grafted or covered
What is a dirty wound?
Purulent inflammation
Preoperative perforation of respiratory, GI, biliary, or GU tract, or a penetration trauma >4 hours old
Basic principals of management of a wound or laceration?
Haemostasis Cleaning the wound Analgesia Skin closure Dressing and follow-up advise
Methods to aid haemostasis?
Pressure
Elevation
Torniquet
Suturing
The five aspects of wound cleaning?
Disinfect - antiseptic
Decontaminate - removal forigen bodies
Debride devitalised tissue
Irrigate with saline (low perrsure as long as no obvious contamination)
Antibiotics for high risk wounds or signs of infection
Whats the maximum level of lidocan alone?
3mg/kg
Whats tha maximum level of lidocane with the addition of adrenaline?
7mg/kg
What’s the maximum level of lidocaine with the addition of adrenaline?
7mg/kg
When should adrenaline not be used with local anaesthetic?
If administering in or near appendages (e.g. a finger)
Methods of skin closure (manually opposed)?
Skin adhesive strips (if no risk factors for infection present)
Tissue adhesive glue (small laccerations with easily opposable edges)
Sutures (laceration greater than 5cm, deep dermal wounds, locations prone to flexion tension or wetting)
Staples (scalp wounds)
What should patients be advised following initial wound management?
Following initial wound management, advise patients to:
Seek medical attention for any signs of infection
Take simple analgesia (e.g. paracetamol)
Keep the wound dry as much as possible, even if wearing a waterproof dressing
How do you dress a wound to a non-infected laceration?
When applying a wound dressing to a non-infected laceration, the first layer should be non-adherent (such as a saline-soaked gauze), followed by an absorbent material to attract any wound exudate, and finally soft gauze tape to secure the dressing in place.
When should sutures or adhesive strips?
10-14 days after initial wound closure (or 3-5 days if on the head)
After how long will tissue adhesive flue naturally slough off?
1-2 weeks
Why do malnourished patients make poor surgical candiates?
Surgery causes physiological stress with a resultant hyper-metabolic state and catabolic response.
Malnourished patients have reduced nutritional reserves
How is BMI calculated?
Weight / Height2
What should be done with a patient with a MUST score of 1 (medium risk)
Document dietary intake for 3 days
If adequete repeat screening (hospital weekly, care home monthly, community 2-3monthly)
If inadequete clinical concern follow local policy
What should be done about a MUST score of 2 or more?
Dietician ref
Sets goals to improve and increase overall nutritional intake
Monitor and review care plan (weekly if in hospital otherwise monthly)
What BMI scores on a MUST calculation?
18.5-20 = 1
Under 18.5 = 2
What unplanned weight loss across 3-6 months scores on MUST?
5-10% = 1
Over 10 % = 2
What will be added to a patients MUST score if they are acutely ill and there has been or is likely to be no nutritional intake for >5 days?
2 points
Hiearchy of Feeding?
Oral nutritional supplements NGT PEG/RIG Jeujunostomy Paraentral nutrition
When should oral nutritional supplements be introduced?
If unable to eat sufficient calories
What should NGT feeding be used?
If unable to intake sufficient calories orally or dysfunctional swallow
When should gastostomy feeding (PEG/RIG) be used?
If oesophagus blocked/dysfunctional
When should jejunal feeding be used?
If stomach inaccessible or outflow obstruction
When should parentral nutrition be used?
If jejunum inaccessible or intestinal failure
What is the snap pneumonic for management of intestinal failure undergoing surgery?
Sepsis – Any overwhelming infection present must be corrected otherwise feeding will be largely useless
Nutrition – Once the infection is corrected, suitable nutritional support should be provided
Anatomy – Define the anatomy of the GI tract so that surgery can be planned
Procedure – Definitive surgery once any infection eradicated, the patient nourished, and the anatomy defined
What does a low serum albumin reflect?
A low serum albumin reflects either chronic inflammation, protein losing enteropathy, proteinuria, or hepatic dysfunction, but does not reflect malnutrition (as witnessed by the fact that patients with severe anorexia nervosa have a normal serum albumin).
Up to what point pre surgery can patients have clear fluids?
2 hours
From what period before surgery must a patient be NBM (excluding clear fluids)?
6 hours
Why should paients with entero-cutaneous fistulae avoid PN straight away ?
The proportion of ECF that will heal with PN is small.
How should patients with an entero-cutaneous fistula have their nutrition managed?
High fistula (jejunal): enteral or parentral nutrition Low fistula (ileum/colon): treated with low fibre diet
How is a high output stoma managed?
Reduction in hypotonic fluids to 500ml/day
Reduction in gut motility with high dose loperamide and codeine phosphate
Reduction in secretions with high dose PPI BD
Use of WHO solution to reduce sodium losses
Low fibre diet to reduce intraluminal retention of water
Complications of TPN
Catheter placement and maintenance: Pneumothorax Thromboembolisim Infections IV nutrition Fluid balance Hyperglycemia/Hypoglycemia Electrolyte imbalance (K, Phosp, Mg) Hepatic toxicity Bleeding
What is a fistula?
An abnormal connection between two epithelial surfaces
What does Hartmann’s procedure involve?
Removal of the rectosigmoid colon with closure of the anorectal stump and formation of a colostomy
What does Whipple’s procedure involve?
Removal of: Head of pancreas, duodenum, gallbladder, bile duct
What incision is used for renal transplant?
Hockey-stick incision
What might cause haematemisis?
Bleeding from part of the upper GI tract: Oesophageal Varicies Gastric ulceration Mallor-Weiss Tear Oesophagitis Gastritis Gastric mallginancy Meckel's diverticulum Dieulafoy lesions (vascular lesion)
