General surgery Flashcards
1
Q
Acute abdomen sieve
A
ABC->P
- Appendix
- Bleeding/bowel obstruction/BV obstruction
- GI bleed
- Obstruction - small/large, mechanical/non-mechanical, complete/incomplete
- Ischaemia/infarct
- Cholecystitis/angiitis
- Pancreatitis/Perforation (upper/lower GI)
2
Q
Hernia (surgery) - def? types? Mx?
A
Def: protrusion of a viscus through its wall
Types:
- Incisional hernia - iatrogenic following surgery
- Groin hernia - ASIS & pubic tubercle palpated:
- Femoral (W>M) - below and lateral to the pubic tubercle, requires more urgent repair than inguinal hernia - high risk of strangulation
-
Inguinal - above & medial to the pubic tubercle
- Direct = weakness in posterior wall of inguinal canal, abdo contents emerge medial to deep ring and through superficial ring
- Indirect (75%, most common hernias in M/W) = abdo contents passes through inguinal canal through deep ring and exits via superficial ring
- Reduce hernia & compression on deep inguinal ring ask the patient to cough if it is direct it will reappear
- Other groin lumps:
- Lymphadenopathy - along inguinal ligament
- Vascular - pulsatile varicose veins below inguinal ligament
Mx: surgical (mesh)
NOTE: hernias are safer the larger the defect as less likely to strangulate
3
Q
What are the borders of Hesselbach’s triangle?
A
4
Q
Abdominal scars
A
- Midline sternotomy - AAA, laparotomy
- Rooftop scar - liver transplant, Whipple’s procedure, gastric surgery, oesophagectomy
- Kocher – open gallbladder surgery
- Nephrectomy can also be subcostal (like Kocher) or Rutherford-Morrison (hockey stick)
- Lanz/McBurney’s = Appendicectomy
- Pfannenstiel = C-section/prostatectomy/cystectomy
5
Q
RUQ pain investigations & Mx? Think biliary
A
US abdo
- Stone in CBD (common bile duct) –> ERCP
- Deranged LFTs/dilated ducts –> MRCP
- None of above –> cholecystectomy
6
Q
Gallstone complications
A
- Biliary colic
- Cholecystitis
- Mirizzi syndrome
- Ascending Cholangitis
- Pancreatitis
10
Q
What is TNM classification?
A
- TNM (tumour, nodes, mets)
11
Q
Colorectal cancer - Presentation? Ix? Mx? Screen?
A
Presentation:
- Bowel habit change
- Palpable mass
- IDA, PR bleed (clots, fresh)
- Acute (obstruction, perforation)
Ix: colonoscopy
Mx: based on TNM staging post-CT
- Colon cancer
- T4 (local advancement) –> neoadjuvant Tx
- Otherwise –> colonic resection –> if T3+/nodal disease –> adjuvant chemo
- Rectal cancer
- T3-4 –> neoadjuvant Tx –> colonic resection –> if T3+/nodal disease –> adjuvant chemo
- T1-2NOMO –> transanal excision
Screen: 60-74yrs FIT testing (or FOB)
14
Q
Painless, palpable gallbladder + jaundice = Courvoisier’s law –> indicates what?
A
Not gallstone-related
Most likely head of pancreas tumour
15
Q
Small bowel obstruction after cholecystitis - Dx?
A
Gallstone ileus
16
Q
Small bowel obstruction - key Sx? Evidence of ischaemia? Mx Pathway?
A
Key Sx: distension, vomiting, colicky abdo pain, absolute constipation
SBO highly suspected on AXR:
- Acutely unstable patient + imminent risk of death –> emergency laparotomy
- Otherwise –> CT abdo & pelvis with contrast (if eGFR <30 = no contrast)
- Bowel ischaemia/obstructive lesion/closed loop obstruction –> emergency laparotomy
- Otherwise –> adhesional SBO –> conservative Mx (drip & suck = Ryles NG decompression & IV fluids)
17
Q
‘Beads on string’ on ERCP - Dx?
A
Primary sclerosing cholangitis (PSC)
21
Q
Thousands of colonic polyps & AD APC gene mutation
A
FAP
Mx: Panproctocolectomy
22
Q
3 cardinal signs of small bowel obstruction?
A
Vomiting
Colicky abdo pain
absolute constipation (including gas)
± distension
23
Q
AD mutation in mismatch repair gene (MMR) - Dx?
A
HNPCC (Lynch syndrome)
24
Q
Small bowel polyps, melanotic macules in lips/genitals, AD mutation in STK 11 gene - Dx?
A
Peutz-Jehger syndrome
26
Q
Closed-loop obstruction - significance?
A
High risk of bowel ischaemia (ischaemia is category 1 surgery - needs to be in surgery in 1hr)
27
Q
RIF tenderness after an appendicectomy - Dx?
A
Meckel’s diverticulum
28
Q
Unexplained acute large bowel dilatation - Dx?
A
Ogilvie syndrome
29
Q
Stoma differentiation & examination
A
Colostomy - RIF, flushed, normal faecal matter
Ileostomy - LIF, spouted (as contents irritant to skin), runny & green faecal matter
Urostomy (via ileal conduit) - if urinary flow not possible via bladder/urethra e.g. post-cystectomy with bladder cancer
- NOTE: nephrostomy is an opening created between the kidney & skin if urine flow from the kidney to the ureter is blocked e.g. in pyonephrosis (renal stones + inf)
Stoma examination:
- Hands around stoma and ask to cough –> check for hernia + check for skin changes
- Offer stoma rectal examination (finger into stoma)
30
Q
Splenectomy - indications? what is the problem? what is associated prophylaxis?
A
Indications:
- Traumatic rupture
- Idiopathic thrombocytopenia
- Spherocytosis
Problem: increased risk from encapsulated bacteria e.g. strep pneumo
Prophylaxis:
- Vaccines: Pneumococcus, Meningococcus, Haemophilus Influenzae Type B
- Penicillin V
31
Q
Abdo pain ddx?
A
Upper:
- RUQ pain: cholecystitis, ascending cholangitis, acute hepatitis
- Epigastric pain: PUD, GORD, pancreatitis
Middle:
- Flank pain: pyelonephritis (loin to groin pain)
- Umbilical pain - AAA (consider if >65yrs, HTN)
Lower:
- RIF pain: appendicitis, ureteric colic, hernia, testicular torsion
- Suprapubic pain: UTI
- LIF pain: diverticulitis, inflammatory colitis, ischaemic colitis, ureteric colic, hernia, testicular torsion
- In women - causes of lower Abdo pain: ectopic pregnancy, ovarian torsion, PID
- Ask about _P_ain, _P_regnancy, _P_V bleeding, _P_V discharge
NOTE: also consider psych cause of generalised abdo pain (esp in kids)
32
Q
Acute abdomen - def? immediate Tx & Ix?
A
Def: sudden, severe abdo pain that requires urgent medical/surgical attention
Immediate Tx & Ix:
- Immediate Tx - NBM, IV fluids, analgesia
- Bloods - VBG (lactate), amylase, G&S
- Imaging - AXR (bowel obstruction), CT-AP (perforation), USS (biliary)
33
Q
Biliary anatomy?
A
- Right and left hepatic ducts merge to form the common hepatic duct
- Gallbladder - stores & concentrates bile and releases it to emulsify fats
- Cystic duct connects gallbladder to the biliary tree
- Cystic duct and common hepatic duct come together to form the common bile duct
- Pancreatic duct feeds into the common bile duct - where it secretes exocrine hormones
- All of the above feed through the Ampulla of Vater into the duodenum –> allowing secretion of bile into the intestines
34
Biliary colic - Def? Presentation?
Cholecystitis - Def? Presentation? Ix?
Ascending cholangitis - Def? Presentation? Acute Mx?
**Biliary colic:**
* **Def:** pain due to blockage of bile flow due to a gallstone
* **Presentation:** RUQ pain, worse after fatty meals (stimulates gallbladder contraction --\> bile release for fat emulsification)
**Cholecystitis:**
* **Def:** inflammation of the gallbladder (typically in context of gallstones)
* **Presentation:** RUQ pain (+ tenderness - Murphy's sign), _FEVER_
* Murphy's only +ve if not present on the left as well
* Ix:
* Urine dip – infection, bHCG
* Bloods – FBC, U&E, LFTs, CRP, amylase, clotting screen
* Imaging – USS (want to be fasted – so gallbladder larger), erect CXR (pneumoperitoneum – perforation of duodenum)
**Ascending cholangitis:**
* **Def:** inf ascending the biliary tree, usually in the context of gallstone
* **Presentation** (due to obstruction of Common Bile Duct - bile stagnates and becomes infected):
* Charcot's triad - RUQ pain, fever, _JAUNDICE_
* Reynold's pentad (severe) - above + **shock** + **confusion**
* **Surgical EMERGENCY** - Mx via _sepsis 6_ protocol (abx = Tazocin) + drain obstruction:
* **Endoscopic retrograde cholangiopancreatography (ERCP)** - Dx & Tx (dye can be used to enhance the obstruction) - endoscope passed up to Ampulla of Vater with wire passed into the biliary system
* Complications: **_pancreatitis_**, bleeding (from dilation of AoV), perforation
* **Percutaneous transhepatic cholangiogram (PTC)** - interventional radiology - passing a wire through the liver into a hepatic duct and then into the top end of the biliary tree --\> dislodge stone/alternative route for bile to flow - leave in cholecystostomy
* **Cholecystostomy** - interventional radiology - insert wire directly into the gallbladder and allow it to be drained - leave in cholecystostomy
* Patients will likely require a later _cholecystectomy_ (after dealing with the acute infection)
35
Appendicitis - presentation? DDx? Scoring? Mx?
Presentation:
* Acute umbilical to _RIF pain_ (McBurney's point)
* Tenderness + guarding (if rigid abdo - perforated apendix)
* N&V --\> anorexia (not wanting to eat anything from nausea), change in bowel habit
* Rovsig's sign - pain in RIF on LIF palpation
* Psoas sign & Obturator sign
DDx: ectopic, ovarian torsion, IBS/D, bowel obstruction
Ix:
* Urinalysis, bloods - FBC, U&E, CRP
* USS abdo/pelvis --\> consider contrast-enhanced CT-AP
**Alvarado score** - \>4 = likely appendicitis
Mx:
* A-E (incl. fluids)
* Sepsis bundle - abx when Dx confirmed
* **Laparoscopic appendicectomy**
* Conservative only if uncomplicated appendicitis
36
Oesophageal cancer - Presentation? Types? Mx?
**Presentation:** progressive dysphagia (solids --\> then liquids) + FLAWS
**Types:**
* Squamous cell carcinoma (SCC) - less common in UK, **_middle oesophagus_**, RFs: alcohol, smoking
* Adenocarcinoma - most common in UK, **_lower oesophagus_**, assoc w/ _GORD_ (long-term --\> metaplasia - Barrett's oesophagus --\> eventually become dysplastic/ malignant)
**Mx:** SURGICAL
* **Ivor Lewis oesophagectomy** - involves _midline laparotomy_ + _right thoracotomy_ (stomach is mobilised and pushed through oesophageal hiatus)
* **McKeown oesophagectomy** - as above + _left neck incision_ (oesophagus can be pulled up through neck incision)
37
Bowel obstruction - immediate Mx, small vs large bowel obstruction - causes, features, Mx?
**Immediate Mx:**
* NBM, Ryles tube (aspirate stomach contents)
* IV fluids
* AXR -\> CT (identify transition point of obstruction)
**Small bowel obstruction:**
* _Causes_: _Adhesions_ (prev surgery?), Hernia, Malignancy (incl. non-GI e.g. ovarian)
* _Features_: central dilated loops of bowel, \>3cm, valvulae coniventes
* _Mx_: surgery (but can be counterintuitive if surgery was cause), gastrografin (oral contrast medium, acts as an osmotic laxative)
**Large bowel obstruction:**
* _Causes_: tumour, volvulus
* _Features_: peripheral dilated loops of bowel, \>6cm, haustra
* _Mx_: surgery, flatus tube (in sigmoid volvulus)
NOTE: 3/6/9 rule
38
Right & left hemicolectomy - indications, process & what are you left with?
Panproctocolectomy - indications, process & what are you left with?
Total vs subtotal colectomy - process & what are you left with?
Hartmann procedure - indications, process & what are you left with?
Anterior vs AP resection - indications, process & what are you left with?
Urostomy (ileal conduit) - indications & process?
**Right hemicolectomy** - right colon
* Indication: problems affecting the right side of the colon e.g. malignancy
* Process: removing from ileocaecal valve to 1/3 the way along the transverse colon
* What are you left with:
* Primary anastomoses (ileum attached to the remaining colon)
* Sometimes left with a stoma
**Left hemicolectomy** - left colon
* Indication: problems affecting the descending colon e.g. tumour
* Process: removing from 2/3 the way along the transverse colon to the sigmoid area
* What are you left with: primary anastomoses from the transverse colon to the sigmoid colon
**Panproctocolectomy** - total colon & rectum e.g. UC
* Indication: a diffuse disease affecting the full colon e.g. FAP (familial adenomatous polyposis) or UC
* Process: remove full colon & rectum (from ileocaecal valve to the anus)
* What are you left with: **_end ileostomy_** (loose end of ileum brought to the skin)
**Total colectomy vs subtotal colectomy**
* Total colectomy:
* Process: remove full colon but not the rectum
* What are you left with: **_ileal-pouch anal anastomosis_** (loose end of ileum used to reform a rectum, don't need a stoma)
* Subtotal colectomy:
* Process: remove colon except for the rectum and part of the sigmoid colon
* What are you left with: **_end-ileostomy & rectal/sigmoid stump_**
**Hartmann procedure** - emergency sigmoid colon
* Indication: emergency circumstances for diseases affecting sigmoid colon e.g. malignant obstruction, sigmoid volvulus, diverticular complication (e.g. perforation - healing suboptimal so don't want to create anastomoses as unlikely to succeed)
* Process: sigmoidectomy
* What are you left with: **_end-colostomy and rectal stump_** --\> at a future date can be reversed but many just stay with end-colostomy
**Anterior vs AP resection** - for rectal tumours (A higher; P lower)
* Anterior:
* Indication: _higher_ rectal tumours
* Process: removing sigmoid colon + top part of the rectum
* What are you left with: end-colostomy/primary anastomoses ± **_defunctioning loop ileostomy_**
* DLI - loop of ileum brought to surface, split so 2 lumens on surface --\> divert faecal stream (into stoma bag) from distal anastomosis = gives best chance of healing
* NOTE: sometimes low anterior resection is performed where the distal margin of resection is brought down (very little rectum remains)
* AP (abdominoperineal):
* Indication: _low_-lying rectal tumours
* What are you left with: end-colostomy
* Process: remove everything up to the top of the sigmoid colon
**Colostomy (ileal conduit)**
* Indications:
* Bladder cancer (had cystectomy)
* Neurogenic bladder
Radiation injury to the bladder
* Chronic pelvic pain
* Process: removing some ileum, forming pouch & bringing to surface so forms stoma - ureters are connected to this pouch
39
Acute pancreatitis - causes? Patterns of injury? Pathophysiology? Ix? Mx? Complications? Severity score?
* Causes: alcohol, gallstones (GET SMASHED)
* Duct obstruction: _gallstones (50%),_ trauma, tumours
* Metabolic/toxic: _alcohol (33%),_ drugs, hypercalcaemia/hyperlipidaemia
* Ischaemia: shock
* Infection/inflammation: viruses (mumps), AI
* Patterns of injury:
* **Periductal** – cause: duct obstruction
* Necrosis of acinar cells near ducts
* **Perilobular** – cause: ischaemia (shock)
* Necrosis @edges of lobule – blood supply comes w/ ducts = periphery most affected
* **Panlobular** – develops as ½ progress
* **Pathophysiology:** vicious cycle **-** activated enzymes --\> acinar necrosis --\> enzyme release
* Lipase release --\> fat necrosis (Ca ions bind to free fatty acids forming soaps = yellow/white deposits)
* Ix:
* Bloods – FBC, U&E, LFTs, CRP, Amylase
* Imaging – USS (looking for biliary problem, sentinel loop – early sign of ileus), CXR
* NOTE: Epigastric pain --\> remember to do rectal exam (looking for melaena)
* Mx - supportive (IV fluids + analgesia first)
* Resus patient (IV fluids, analgesia, antiemetic, abx) --\> ITU if glasgow score \>3
* VTE prophylaxis
* Complications:
* Pancreatic pseudocyst – cystic space wo/ epithelial lining, lined with necrotic & granulation tissue --\> can be infected --\> abscess
* Systemic: shock, hypoglycaemia, hypocalcaemia
Severity criteria = **GLASGOW score (PANCREAS):**
* **P**aO2
* **A**ge
* **N**eutrophils (WBC)
* **C**a
* **R**enal funct (urea)
* **E**nzymes (LDH)
* **A**lbumin
* **S**ugar (glucose)
40
Autograft vs allograft vs isograft vs xenograft/heterograft?
Autograft: tissue from the same patient
Allograft: tissue from same species not genetically identical
Isograft: tissue from identical twin
Xenograft/heterograft: tissue from different species
41
Tumour markers for different cancers?
Ca 19-9, CEA, AFP, CA125, LDH
* CA 19-9 – associated with pancreatic cancer and cholangiocarcinoma
* CEA – colorectal cancer
* AFP – hepatocellular or testicular cancer
* CA-125 – ovarian cancer
* LDH – cell death somewhere
42
How long after surgery would you worry about leaking anastomoses? Presentation? Appropriate Ix?
3 days
Abdo tenderness & guarding
Erect CXR, CT abdo
43
Subcutaneous emphysema, vomiting, chest pain - Dx?
Boerhaave syndrome (oesophageal rupture)
44
High ALP + GGT with a background of ulcerative colitis - likely Dx? Ix of choice?
Dx: PSC
Ix: MRCP (beads on a string appearance)
45
How long to fast before surgery?
2h for clear liquids, 6h for solids
46
Ix for acute abdomen?
Bedside: urine dip
Bloods: VBG, FBC, U&E, CRP, LFTs + Bone profile, Amylase, Clotting, G&S ± BC (if temp)
Imaging: erect CXR, AXR
* CTKUB if thinking renal stones
* CTAP if collecting/perforation/obstruction
* CT angiogram if ischaemia/bleeding/AAA
* USS/MRCP if cholecystitis/gall stones
47
Diverticulosis vs Diverticular disease vs Diverticulitis? Acute diverticulitis classification?
Presentation? Ix? Mx?
**Diverticulosis:** colonic outpouching in mucosa & submucosa of colon - happen @weak points in colonic wall subject to increased pressure (common in elderly, low fibre diet)
**Diverticular disease:** above + Sx
**Diverticulitis:** infection & inflammation of diverticulum
* **Hinchey classification** for acute diverticulitis:
1. a) Pericolic phlegmon & inflammation, no fluid collection b) pericolic abscess \<4cm
2. Pelvic/interloop abscess/abscess \>4cm
3. Purulent peritonitis
4. Faeculent peritonitis
Presentation:
* RFs: \>50yrs, low dietary fibre
* LIF pain, raised WCC, fever, painless rectal bleed
Ix:
* FBC, U&E, CRP, (BC, ABG & lactate if septic)
* **_Contrast CT abdo_** (if suspected acute diverticulitis)
* Other imaging:
* CXR (rule out pneumoperitoneum)
* Colonoscopy/sigmoidoscopy (if Dx unclear, could be cancer/ischaemia)
* CT angiogram (if excess bleeding)
Mx:
* Asymptomatic diverticulosis:
* Increased fibre & fluids
* Excercise, weight loss, stop smoking
* Fybogel - if constipated
* Symptomatic diverticular disease:
* Above + paracetamol
* _PO Dicycloverine_ = anti-spasmodic (for abdo cramping)
* Acute diverticulitis:
* Uncomplicated:
* Low-residue diet + Paracetamol + PO Dicycloverine
* Oral abx (amoxicillin)
* Complicated:
* Excess bleeding - resus + endoscopic Tx (e.g. band ligation, 2nd = surgery)
* Abscess/perf/fistulae/obstruct - radiological drainage/surgery + IV abx
* Reccurent = open/laparoscopic resection
