General Surgery Flashcards
Acute Abdo
- S+S
Acute Abdo S&S
- Pain
- Visceral/somatic
- Midline
- Referred
- Vomit
- Bowel alteration
Visceral abdo pain features
Visceral abdo pain
- Midline
- Autonomic
- Nausea
- ‘Organ pain’
Acute abdomen
- Causes
Causes of acute abdo
- Generalised peritonitis
- eg. Infective
- Localised peritonitis
- eg. Appendicitis
- Motility disorder
- eg. Obstructive cause
- Ischaemia
- eg. Infarct/torsion/necrosis
- Other
- eg. AAA
Complex surgical patients
- Four possibilities
Surgical complexity
- Diabetes
- Steroids
- Anti-coagulation
- NBM
Surgical emergent complications
Surgical complications
Early
- Bleed
- Cardiopulmonary emergency
Later
- DVT
- Ileus
- Sepsis
Acute abdomen
- Extrinsinc DDs
Acute abdomen extrinsic DDs
- Thoracic cause
- Neuropathology
- Metabolic
- Toxic
Abdo pain
- 8 common DDs
Common Abdo DDs
- Appendicitis
- Cholecystitis
- Pancreatitis
- Diverticulitis
- Obstruction
- KUB
- Gynaecological
- Non-specific
General Surgery
- History structure
General history
- HPC
- SQUITARS
- GI Sx
- GU/Gyn Sx
- PMH/DHx/Allergy
- FHx, SHx, SR
- Last Meal
Abdo Exam Structure
Abdo Exam Structure
- General exam
- Abdo
- Start Peripherally
- I,P,P,A
- Completion
- Groin/Hernial Orifices
- PR/PV/Scrotal
- Systemic
GI Perforation
- Causes
GI Perforations
- UGI
- Ulcer
- LGI
- Iatrogenic
- Diverticular
- Tumour
- Other
GI Perforation
- S&S
GI Perforation
- Pain
- Constant
- Sharp
- Nausea
- Suddenly more severe
- Peritonism
Acute Abdo Investigations
Acute Abdo
- Bedside
- ABG
- Bloods
- Most
- Imaging
- CT
Acute abdomen
- Surgical considerations
- Surgical approaches
Acute abdomen surgery
- Performance status
- Mortality
- Options
- UGI
- Closure - LGI
- Resection
- Colostomy
- UGI
Abdo Obstruction
- Symtoms
Abdo obstruction Sx
- Colicky pain
- Distension
- Vomiting
- Bowel stasis
Closed Loop Bowel
- Features
Closed Loop Obstruction
- Sigmoid obstruction
- Ileocecal competence
- Distension and perforation
Bowel obstruction
- Layers
Bowel obstruction categories
- Intraluminal
- Luminal
- Extraluminal
Bowel obstruction DDs
- Intra luminal
- FB
- Luminal
- Tumour
- Diverticulitis (20% LBO)
- Hirschprungs
- Achalasia
- Extra luminal
- Adhesions (50-75% SBO)
- Hernia (20% SBO)
- Malignancy (65% LBO)
- Volvulus
Bowel obstruction
- SBO common causes
- LBO common causes
- SBO
- Adhesions (50-75%)
- Herniation (20%)
- LBO
- Malignancy (65%)
- Diverticulitis (20%)
Bowel obstruction
- Signs
Bowel obstruction Signs
- Distension
- Hernia/scar visible
- BS tinkly/high pitched
- Sepsis/SIRS
Bowel obstruction
- Mx
Bowel Obstruction Mx
- Drip and suck
- Analgesia
- NBM
- Aspiration risk
- NG to release pressure
- Fluid balance
- IVI
- Catheter
- Imaging
- Definitive DDx
Lower GI Bleed Mx
Lower GI Bleed Mx
- Conservative first line
- STOP Anticoagulants
- Interventional radiology
- Colonoscopy
Clipping, diathermy, injection (epinephrine)
- Trans catheter arteriography - Surgical last line
- Urgent laparotomy
Hernia
- Definition
Hernias are:
- Protrusion
- Through containing cavity
- Organ displaced
Hernia
- Locations
Hernias
- Inguinal
- Femoral
- Umbilical
- Incisional
- Epigastric
- painful midline fat
Hernias
- Complication recognition
Recognising hernia complication
- Obstruction
- Strangulation
- Ischaemic pain
- Erythematous skin change (translocation)
- Non-reducible
- Systemic symptoms
HPB
- Escalating differentials;
Pain -> Fever
HBP
- Biliary colic
- Pain
- Cholecystitis
- Pain
- Inflammation of gall bladder
- Ascending cholangitis
- Pain
- Infection of biliary tree
- Gallstone ileus
- Fistula to duodenum
- (2cm sized stones would not pass through tree)
Peri-anal abscess
- Presentation
Peri-anal abscess
- Red
- Fluctuant
- Common presentation
Peri-anal abscess
- Management
Peri-anal abscess Mx
- Surgery
- Same day excision and drainage - SIRS -> ABx
- At Discharge
- Hygiene advice
Peri-anal abscess
- Complications and risk groups
Peri-anal abscess complications
- High-risk patients
- DM
- Obese
- Old
- Immunocompromised
- Necrotising fasciitis
Local anaesthesia
- Routes
LA Routes
- Central neuraxial
- Spinal
- Intrathecal/subarachnoid
- Epidural
- Between ligamentum flavum and dura mater
- Spinal
- Plexus blocks
- Nerve blocks
- Local anaesthesia
Neural plexuses of the gut?
- Submucosal
- MeisSNer’s
- Mucosa layer
- MYentric
- AUerbach’s
- Muscularis externa
Male Groin Lump
- Eight DDx
Male Groin Lump
Vascular
- Femoral pseudoaneurysm
- Saphena varix
- Inguinal lymphadenopathy
GI
4. Inguinal hernia (Direct/indirect)
GU
- Ectopic/undescended testis
- Hydrocele
MSK
- Psoas abscess
- Lipoma
Hiatus hernia
- Presentation
Hiatus Hernia S&S
- Heartburn/GORD
- Dysphagia
- Odynophagia
- Hoarseness
- Chest pain
- SoB
Hernia repair
- Three Surgical Approaches
Hernia repair
- Open non-mesh (primary tissue)
- Open-mesh
- Laparoendoscopic-mesh
Abdo Exam
- Peritonitis Suspicion
- Checks
- Techniques
Abdo peritonitis suspicion
Checks
- Stuck tummy in and out
- Cough
Techniques
- Palpate opposite to pain
- Percussion tenderness instead of rebound tenderness
PID
- Three complications
PID Complications
- Tubo-ovarian abscess
- Infertility
- Ectopic pregnancy
Uncomplicated adult Appendicitis
- Management
- NBM
- Fluids and analgesia
- Involve obstetrics
- Prophylactic antibiotics
- Laparoscopy appendicectomy
Complicated adult appendicitis
- management
- Supportive treatment
- Emergency appendicectomy
- Laparoscopic
Gallstone pancreatitis
- management
- Fluid resus
- Analgesia and oxygen
- Antiemetic
- Empiric ABx
- ERCP
Alcohol pancreatitis
- Management
Alcohol pancreatitis
- Fluids and oxygen
- Analgesia and antiemetic
- Empiric ABx
- Vitamin replacement
- Pabrinex - Anti withdrawal
- Chlordiazepoxide - Calcium and magnesium
Active peptic ulcer
- Management
Peptic ulcer management
- Evaluation and transfusion
- Blatchford - Endoscopy
- PPI
- Repeat endoscopy
- Interventional radiology
- Surgery
Peptic ulcer (no bleeding) - Management
Peptic ulcer not bleeding
- H Pylori eradication therapy
- PPI
- Clarithromycin/Metronidazole - Healing therapy
- PPI 8 weeks
- Amoxicillin
Inguinal hernia (stable)
- Management
Inguinal hernia management
1. Watchful waiting
- Elective repair
- open mesh
(Low risk low recurrence)
Eg. Lichtenstein
- Laparoscopic
(Large mesh)
- Prophylactic ABx
- Cefazolin
- Vancomycin
- Clindamycin
Femoral hernia
Management
Femoral hernia
- Surgery
- Open
- Lap
Crohn’s disease
- Maintenance therapy
Crohn’s maintenance
- Azathioprine (or mercaptopurine)
- Parenteral methotrexate
(If CST dependent) - TNF if needed to induced remission
- Vedolizumab
- Ustekinumab - Infliximab and adalimumab
- growing evidence
Acute Crohn’s
- Mild - Moderate Mx
Acute Crohn’s
- Mild
- Budesonide - Moderate
- Budesonide
- ABx
- Azathioprine/Mercaptopurine
- Biologics
(Infliximab, adalimumab, Vedolizumab)
Acute Crohn’s
- Severe Mx
Severe Crohns Mx
1 Hospitalisation
2 IV steroids
- Prednisolone/Hydrocortisone
Methylprednisolone
3 ABx in sepsis
4 Biologics
3 Surgery
Ulcerative colitis
- Moderate-severe flareup
UC Mx
Moderate
1 Oral CST
Budesonide/Prednisone
2 Biologic
- Infliximab/adalimumab
- Golimumab/vedolizumab
- Ustekinumab
3 Immunomodulator
- Aza/merca/metho
4 JAK-1i
Tofactinib
5 Colectomy
Severe
1 Hospital admission
2 Hydrocortisone/Methylprednisolone
3 Ciclosporin/infliximab
4 Surgery
Ulcerative colitis mx
- Mild acute
Mild UC Mx
1 Aminosalicylate
- Mesalazine
2 Topical steroid
3 Oral Budesonide
4 Oral prednisolone
Uncomplicated Diverticulitis
- Mx
Uncomplicated Diverticulitis Mx
- Analgesia
- Paracetamol
(Perf with NSAIDs and Opioids) - Antispasmodic
- Dicycloverine (musc.) - Oral antibiotic
- Co-amox - Low-residue diet
(low fibre eg. refined bread, white rice)
Diverticulitis w/ rectal bleeding
- Mx
Bleeding diverticulitis
- Unstable
- Resuscitate
- CT
- Endoscopy - Stable
- Colonoscopy
- Injection, thermal
- Band ligation - Fluids and Analgesia
(Ideally paracetamol) - IV ABx
- Co-amox
- Cefuroxime + met
- Gent+met+amox
Diverticulitis management
1 W/ Abscess
2 W/ Perforation
Complicated diverticulitis
3cm+ abscess
- Radiological drainage
- CT or USS - Surgery if necessary
Perforation
- Laparoscopic lavage
- Resection
- If faecal peritonitis - Emergency surgery
- Colectomy
- Hartmann’s
Cholelithiasis
- Management
Cholelithiasis Mx
- Analgesia
- Anti-spasmodic
- Hyoscine (buscopan) - Elective lap. chole.
- No ABx
Choledocholithiasis
- Management
Choledocholithiasis
- ERCP
- Lap chole
- Analgesia
- Anti-spasmodic
- Hyoscine (buscopan)
Cholecystitis
- Management
Cholecystitis Mx
- Analgesia
- Fluids
- Antibiotics
- If evidence of infection - Lap chole
Severe Cholecystitis
- Mx
Severe Cholecystitis Mx
- ICU admission and fluids
- Analgesia
- ABx
- Percutaneous Cholecystectomy
- Empyema
- Unfit for GA - Delayed Cholecystectomy
- Fit for GA
Acute Cholangitis
- Management
Acute Cholangitis Mx
- IV Broad spec
- Tazocin (Pip/tazo)
- Primaxin (Imi/cilastatin)
- Cefur+met - Biliary decompression
- ERCP (+-sphincerotomy)
- PTC (percutoenous trans-hepatic cholangiography) - Lithotripsy
- Opioid + paracetamol
- Surgical decompression
- Lap choledochotomy or chole
Small bowel obstruction
- Alternative DDx
SBO DDx
- Constipation (pseudo-obs)
- Amytriptyline/imipramine - Ileus
- LBO
- Gastroenteritis
- Apendicitis
- Pancreatitis
Small Bowel Obstruction
- Mx (no complications)
SBO Mx (no complications)
- Drip and suck
- Fluids and analgesia
- NG Decompression
- Exploratory lap
- Refractory
Small Bowel Obstruction (complex)
- Mx
Small bowel obstruction
- Mx
- Fluids, analgesia
- NG decompression
- CT Underlying cause
- Consider endoscopic ballon
- Eg. Appendix, tumour, hernia - Surgery within 6 hours
- Ischaemia
- Strangulation
- Peritonitis
Hartmann’s Procedure
- Indications
Hartmann’s Procedure Indications
- Emergency bowel obstruction
- Sigmoid perforation
- Diverticulitis - Sigmoid obstruction
- Malignancy
Hartmann’s Procedure
- Result
Hartmann’s Procedure
- Result
- Sigmoid colectomy
- End colostomy
Hartmann’s Procedure
- Risks (general and specific)
Hartmann’s Risks
General
- Bleeding and infection
- Ileus and DVT
Specific
- Local damage
- SB, KUB - Incisional hernia
- Stump blow-out
- Stoma
- prolapse/hernia
- retraction/stenosis - Irreversibility
Ivor Lewis Procedure
- Approach
Ivor Lewis Approach
- Right thoracotomy
2 .Laparotomy
Oesophagectomy
- Result
Oesophagectomy result
- Removal of tumour
- Removal of top of stomach
- Removal of lymph nodes
- Production of ‘conduit’
Ivor Lewis
- Risks
Ivor Lewis Risks
Common
- Bleeding and infection
- DVT
Specific
- Anastomotic leak
- Re-operation
- Pneumonia
- Death (4%)
Open inguinal repair
- Types
Open inguinal repair
- Herniotomy
- Infants
- Ligation and excision - Herniorrhaphy
- Suture repair of posterior wall - Hernioplasty
- Reinforcement with mesh
Inguinal hernia repair
- Common method
Inguinal hernia repair
- Lichtenstein tension-free mesh repair
Inguinal hernia repair
- Risks
Inguinal hernia repair risks
Common
- Bleeding and infection
- DVT/Stroke/MI/Death
- Anaesthetic
- Teeth, throat
- Reactions
- Cardio-resp.
Specific
- Pain
- 1/50: long -term
- 3/50: worsened - Resection
- Local damage
- Bowel, bladder
- Spermatic cord (vas def) - Seroma
Femoral hernia
- Presentation
Femoral hernia presentation
- Small groin lump
- infero-lateral - 30% emergency
- Multiparous, female
- Increasing age
- Intra-abdominal pressure
- Chronic constipation
Femoral hernia
- Emergency management
Femoral hernia emergency
- Exploration in theatre
- Rarely image
- Risk of infarction
Small umbilical hernia
- Management
Small umbilical hernia
- Watchful waiting
- Elective repair
- 4-5 yo
- risk of incarceration
Large umbilical hernia
- Management
Large umbilical hernia
- Elective repair 2-3 yo
- 1.5-2cm+ unlikely to close - Earlier repair if Sx
- Pain
- Incarceration
Incarcerated umbilical hernia
- Management
Incarcerated umbilical hernia
- Immediate attempt at reduction
- Milk air or fluid out
- Observe for peritonitis - Emergency repair
- If strangulated
- If peritonitic
- Assess bowel integrity
Lower GI Bleeds
8 Common Causes
Lower GI Bleeds
Common
- Diverticulitis
- Colonic angiodysplasia
- Ischaemic colitis
- IBD
- Infectious colitis
- Haemorrhoids/fissure
- Colorectal cancer
Lower GI Bleeds
5 Uncommon Causes
Uncommon
- Meckel’s
- Children or young - Telangiectasia
- Radiation induced - Dieulafoy’s lesion
- Tortuous arteriole - Aorto-enteric fistula
- Severe bleed - Vasculitis
- SLE, PAN
Angiodysplasia of colon
- Presentation
Angiodysplasia presentation
- Bleeding
- Painless
- Intermittent
- Fresh or malaena
- Self-limiting (can be massive) - 60+yo
- Anaemic
- SoB, Fatigue, Weakness
Colon angiodysplasia
- Emergency Management
Colon angiodysplasia emergency
- Upper endoscopy
- Exclude upper bleed - Embolisation
- CT Angio
- IV Access and support - Colonoscopy
- Absence of angiography
- Cautery
- Clips
- Epinephrine - Surgery
- Life-threatening haemorrhage
- Enteroscopy
- Sub-total colectomy
Colonic angiodysplasia
- Stable Management
Stable angiodysplasia mx
- Interventional endoscopy
- Cautery, clips, epinephrine - Embolisation
if negative endoscopy
- CT Angiography - Wireless capsule
- Enteroscopy
- Alternative to angiogram - Surgery
- If angiography not available - Medical mx
- Octreotide
(somatostatin analogue)
- Oestrogens
- Thalidomide
(Immunomodulatory)
Ischaemic bowel peritonitic
- Embolic management
Embolic bowel ischaemia
- Resus and support
- IV ABx
- Cef/levoflox and met - Surgery
- Exploratory laparotomy
- Embolectomy/reconstruction
- Bypass +/- Resection - Post-op heparin
- (after 48 hours)
Non-occlusive Mesenteric Ischaemia
- Management (Peritonitic)
NOMI Mx
- Resus and support
- IV ABx
Cef/levoflox + met - Aetiology +-resection
- CHF/Arrhythmia
- Shock/HD - Post-op heparin
VT Ischaemic bowel
- Management (peritonitic)
Venous bowel ischaemia mx
- Resus
- IV ABx
- Cef/levoflox + met - Anti-coagulate
- Heparin
- Warfarin (3-6/12)
4. Surgery Infarction/peritonitis - Open - +/- Thrombectomy - +/- Resection
Ischaemic bowel management
- Fulminant colitis
Fulminant ischaemic colitis
- Resus
- IV ABx
Cef/levoflox + met - Colectomy
- Subtotal or total
- Unresponsive to therapy
- Hartmann’s or Ileostomy
Ischaemic bowel (stable) - Embolic management
Embolic bowel ischaemia
- Resus and support
- Surgery
- Consider thrombolytic therapy
- Exploratory laparotomy
- Embolectomy/reconstruction
- Bypass +/- Resection - Post-op heparin
- (after 48 hours)
Ischaemic bowel (stable) - Thrombotic management
Thrombotic bowel ischaemia
- Resus and support
- Angiography
- Endovascular for chronic
- Stenting
- Aspiration thrombectomy
- Local drug instillation - Surgery
- Exploratory laparotomy
- Embolectomy/reconstruction
- Bypass +/- Resection - Post-op heparin
- (after 48 hours)
Colorectal cancer
- Presentation
Colorectal cancer presentation
- 55+
Obesity - Rectal bleeding
- Change in BMs
- Anaemia
- Genetics
- IBD
- FAP/APC (Adenomatous polyposis coli)
- Lynch (HNPCC) - Rectal mass
- MRI/USS
Rectal cancer mx
- Suitable for surgery
Rectal cancer mx
Stage I:
- Local or radical excision
- Transanal
- TEM (Endoscopic microsurgery) - Radio +- chemo
Stage II-III:
- TNT (total neoadj)
- Radical resection
+ Pre chemo-radio
+ Post chemo
Stage IV:
- Surgical resection
- lung/liver - Local ablation
- Needle inserted with radio waves - Chemo-radio
Rectal cancer mx
- Not suitable for surgery
Colorectal cancer mx
Stage I-IV
- Chemo + Stenting
- oxaliplatin+flurouracil +folate
- oxaliplatin + capecitabine - VEGFi or EGFRi
- bevacizumab/cetuximab - Alternative chemo +stent
- Nivolumab/ipilmumab
- Entrectinib
Colon cancer mx
- Suitable for surgery
Colon cancer mx
Stage I-III
- Resection
- Adjuvant Chemo
Stage IV
- Neoadj and resection
+ Local ablation
- VEGF/EGFRi
-Surgical resection
(incl. lung or liver)
+ Local ablation
+ Post op chemo
Colon cancer mx
- Non-surgical
Colon cancer mx
- Non-surgical
Stage I-IV
- Chemo +stenting
- Oxaliplatin +fluorouricil +folate
- Capecitabine + oxaliplatin - VEGF/EGFR
- Alternative chemo + stenting
Non-occlusive mesenteric ischaemia
- Aetiologies
- Presentation
NOMI
Aetiologies 1. Cardiac disease Eg. MI 2. Systemic hypotension - Septic/haemorrhagic/cardiac 3. Blunt trauma 4. Iatrogenic - Dialysis - Thoracic surgery - Medication Vasospasm eg. Digoxin
Presentation
- Critically ill patients
- AF
Fulminant colitis
- Aetiologies
- Pathophysiology
Fulminant colitis
Aetiologies
1. UC
- Crohn’s
- Infective
- Neutropenic
- Ischaemic
Pathophysiology
- Gross inflammation
- interleukins
- NO - Loss of neurogenic tone
- Severe dilation
- Risk of perforation
LAR vs APR
- Indications
- Results
Lower anterior resection
- Rectal sphincter spared
- Rectal cancer
- Diverticulitis
- Proximal two-thirds of rectum
Abdominoperineal resection
- Permanent colostomy
- Rectal cancer lower 1/3
- Anal cancer
