General Surgery Flashcards by cole roberts

How can you differentiate the following in terms of pain, fever and jaundice?
Biliary Colic
Acute cholecystitis
Ascending cholangitis

Colic: Intermittent pain
Acute cholecystitis: Constant pain + fever
Ascending cholangitis*: Constant pain + Fever+ jaundice/raised bilirubin
*Also have confusion and hypotension

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What is the first line imaging for biliary pathology

USS to exclude obstruction

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What is the treatment for the following?
Biliary Colic
Acute Cholecystitis
Ascending cholangitis

Colic: Cholecystectomy within 6 weeks
Cholecystitis: Cholecystectomy in 1 week
Cholangitis: Urgent ERCP (24-48hrs)

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How can the following be differentiated from colic/acute cholangitis/ascending cholangitis?
Primary sclerosing cholangitis
Primary biliary sclerosis
Cholangiocarcinoma

Have RUQ pain and jaundice
No fever
PSC/PBC cause itching
RUQ mass +/- shoulder/umbilical nodes in cholangiocarcinoma

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What is the first and definitive line investigation in PSC/PBC?

USS for obstruction
MRCP for biliary tree visualisation

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What is the first line and definitive imaging in cholangiocarcinoma?

USS
CT

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What condition gives a ‘beaded’ appearance on MRCP?

PSC

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What RUQ pain condition is most associated with ulcerative colitis?

PSC

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How does PSC and PBC differ in terms of immune markers?

PSC: p-ANCA
PBC: AMA-2, raised IgM

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What can be used to treat itch due to raised bilirubin?

Cholestyramine

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Outline the treatments for
PSC
PBC
Cholangiocarcinoma

PSC: Liver transplant
PBC: Ursodeoxycholic acid  transplant
Cholangiocarcinoma: Typically palliative measures (can potentially resect if really

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What are the causes of acute pancreatitis?

I GET SMASHED
Idiopathic
Gallstones
Ethanol (alcohol)
Trauma
Steroids
MUMPS/malignancy
Autoimmune
Scorpion sting
Hypercalcaemia
ERCP
Drugs

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What scoring system is used for severe pancreatitis?

Glasgow criteria: PANCREAS
PaO2 < 8
Age >55
Neutrophils >15
Calcium < 2
Renal (urea > 16)
Enzymes LDH +++

Albumin <32
Sugar >10

Severe pancreatitis >=3

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What are the investigations for acute pancreatitis?

1st: Amylase/lipase (>=3x is diagnostic)
GS: CT with contrast
USS to check for obstructive cause

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What is the management of acute pancreatitis?

Slow enteral (NG tube) feeding 
IV Fluids and analgesia

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Milder pancreatitis symptoms 3 weeks post acute pancreatitis indicates what?

Pseudocyst
Milder symptoms and amylase raise
Conservative management

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How do you investigate chronic pancreatitis?

CT with contrast for calcification
Faecal elastase for malabsorption if above unclear

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How often should chronic pancreatitis have Hb1AC monitored?

Annually

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Painless jaundice indicates what?

Pancreatic cancer until proven otherwise

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What is the first line and GS investigations for pancreatic cancer?

1st: USS for obstruction
GS: High-res CT

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What cancer marker is relevant to pancreatic cancer?

CA 19-9 (also cholangiocarcinoma)

How do you manage pancreatic cancer?

2 week referral
Whipple’s or stenting for palliative cases

Umbilical pain that shifts to RIF worse on movement and pressing LIF is likely

Appendicitis
Rovsing’s sign is the LIF pressing causing RIF pain

Appendicitis symptoms + high fever + peritonitism indicates

Perforation

How is appendicitis diagnosed?

Clinical history + raised WCC diagnostic + Urine analysis for pregnancy + renal colic + CT if another diagnosis more likely

What is the treatment for appendicitis?

Prophylactic Abx + laparoscopic appendectomy

What are the features of bowel obstruction?

Green, bilious vomiting Constipation +/- tinkling bowel sounds Abdominal distention + pain

How can you differentiate between small and large bowel obstruction

Small // Large Adhesions, post-op ileus, hernia, intussusception // Malignancy, stricture, volvulus

What are the investigations for suspected obstruction

1. AXR for gross cause 2. Contrast CT for more detail CXR to exclude obstruction

How does an ileus present differently to a volvulus

Ileus has absent rather than tinkling bowel sounds

How does a caecal and sigmoid volvulus present image differently?

Caecal foetal sign Sigmoid  coffee bean White line tends to be on side of volvulus

How does bowel lumen dilation help diagnose obstruction

How does bowel lumen dilation help diagnose obstruction 3/6/9 rule \>3cm: Small \>6cm: Caecal \>9cm: Sigmoid

Patient presents with severe, sudden onset general abdominal pain. They are systemically well but have a history of AF, what is the likely diagnosis?

Mesenteric ischaemia

How can the following causes of bowel ischaemia be differentiated? Acute mesenteric ischaemia Chronic mesenteric ischaemia Ischaemic colitis

AMI: Acute pain, disproportionate to Obs CMI: Colicky pain, rarer IC: Transient pain, bloody diarrhoea, ‘thumbprinting on X-ray’. Cocaine use in young people

How do you image for bowel ischaemia

USS for obstruction CT for diagnosis + lactic acidosis and raised WCC on blood

What is the management for acute mesenteric ischaemia and ischaemic colitis?

AMI: Emergency surgery IC: Supportive

What hernias are found in the following places? Superior and medial to pubic tubercle Below and lateral to pubic tubercle Symmetrical bulge under umbilicus Asymmetrical bulge under umbilicus

Superior + medial: Inguinal Below and lateral: Femoral Symmetrical bulge under umbilicus: Umbilical Asymmetrical bulge under umbilicus: Paraumbilical

How can you determine if an inguinal hernia is direct or indirect? Why is this significant?

Reduce and press 2/3 between ASIS and pubic symphysis then get patient to cough Indirect will be restrained Direct will not Indirect more likely to be bowel so run risk of bowel strangulation

What is the management of an umbilical hernia in a child?

Observe for resolution until 2 If unresolved then operate

Fresh painless PR bleeding and altered bowel habit in patient without lumps or itch on PR exam indicates what

Diverticular disease

LIF pain (sometimes RIF), fever and systemically unwell +/- PR bleeds points towards what colorectal issue?

Diverticulitis

How do you investigate diverticulitis?

CT with contrast

mixed PR bleeding and altered bowel habit in elderly patient with microcytic anaemia suggests what?

Colon cancer

Who must get referred for suspected colorectal cancer?

\>=40yrs: abdo pain + weight loss \>=50yrs: Unexpected bleeding \>=60yrs: Change in bowel habit/microcytic anaemia with low ferritin

What does this AXR show

Small bowel obstruction ## Footnote **Valvulae conniventes: White lines going FULL WIDTH across bowel**

What does the following x ray show?

pneumoperitoneum Can see wall above diaphram on both sides

What are the causes of post-op pyrexia?

**W**ind: Pneumonia, atelectasis (1-2 days) **W**ater: UTI (\>3 days) **W**ound: Infections (\>5 days) **W**alking: DVT (\>1 week) **W**onder drugs/**W**hat did we do + abscess

What blood changes are seen in TPN?

Low phosphate, magnesium, zinc High glucose

What points towards toxic megacolon over sigmoid volvulus?

History of UC/IC More systemically unwell

Diarrhoea, abdo pain, joint pain +/- neuro or cardiac deficits is caused by what?

Whipple's disease (Tropheryma whipplei) PAS positive macrophages Co-trimox