General surgery

Question 1

Small bowel stoma (ileostomy) location

Answer 1

right side more likely

Question 2

Large bowel stoma (colostomy) location

Answer 2

left side more likely

Question 3

Small bowel stoma contents

Answer 3

more likely to be more liquid, green, due to things not being properly digested yet and mixtures of enzymes etc

Question 4

Large bowel stoma contents

Answer 4

more likely to look more like faeces, a lot more water has been absorbed

Question 5

Inspection of small bowel stoma

Answer 5

stoma is everted, spouted a bit, so that enzymes don’t touch skin, ( less time for digestion because is more proximal, would break skin down if it was too close to skin)

Question 6

Inspection of large bowel stoma

Answer 6

stoma can be flat on skin, no enzymes

Question 7

Rutherfor morrison incision

Answer 7

Extraperitoneal approach to left or right lower quadrants
renal transplant

Question 8

Pfannenstiel incision

Answer 8

Transverse supra pubic, primarily used to access pelvic organs
c section etc

Question 9

Lanz incision

Answer 9

Incision in right iliac fossa
appendicitis

Question 10

Kocher’s incision

Answer 10

Incision under right subcostal margin
open cholecystectomy

Question 11

Rooftop incision

Answer 11

more unusual , upper GI surgery eg whipple procedure

Question 12

volvulus

Answer 12

• twisting of a loop of intestine around its mesenteric attachment, resulting in a closed loop bowel obstruction.
• The affected bowel can become ischaemic due to a compromised blood supply, rapidly leading to bowel necrosis and perforation.
• Most volvuli occur at the sigmoid colon and are a common cause of large bowel obstruction

Question 13

Volvulus Ix

Answer 13

Bloods - inc electrolytes, Ca2+, and TFTs to exclude any potential pseudo-obstruction
CT imaging - Very dilated sigmoid colon with a ‘whirl sign’, from the twisting mesentery around its base.
AXR- “coffee-bean sign” arising from the left iliac fossa

Question 14

Volvolus Mx

Answer 14

treated conservatively initially with decompression by sigmoidoscope and insertion of a flatus tube.
Surgery indicated if ischaemia/perforation/failed decompression

Question 15

Caecal volvulus epidemiology

Answer 15

bimodal age of onset
10-29 year group - intestinal malformation or excessive exercise as the predisposing cause
60-79 year group- more associated with chronic constipation, distal obstruction, or dementia.

Question 16

Caecal volvulus Mx

Answer 16

always laparotomy and ileocaecal resection

Question 17

Strangulated bowel obstruction

Answer 17

obstruction with compromised intestinal blood flow, resulting in bowel ischemia

Question 18

Causes of SBO

Answer 18

Adhesion
Hernia
Intussusception in children

Question 19

Causes of LBO

Answer 19

Malignancy
Diverticular disease
Volvulus

Question 20

Bowel obstruction pathophysiology

Answer 20

1. bowel segment occluded,
2. gross dilatation of the proximal limb of bowel occurs, resulting in an increased peristalsis of the bowel.
3. This leads to secretion of large volumes of electrolyte-rich fluid into the bowel (often termed ‘third spacing’). Leads to dehydration and hypovolemia.
4. Compression of intestinal veins and lymphatics leads to bowel wall edema leading to compression of intestinal arterioles and capillaries leading to bowel ischemia.

Question 21

SBO symptoms

Answer 21

early vomiting, pain,l ack of flatulence or passing stool

Question 22

LBO symptoms

Answer 22

early distension, pain, constipation, feculent vomiting is a late symptom,lack of flatulence or passing stool

Question 23

Bowel obstruction signs

Answer 23

Evidence of the underlying cause eg surgical scars
Dehydration and possible hypovolemia
Percussion may reveal a tympanic sound
auscultation may reveal high pitched ‘tinkling’ bowel sounds when it is early , absent bowel sounds when late

Question 24

Small bowel on AXR

Answer 24

Valvulae conniventes are mucosal folds that form lines that extend the full width of the small bowel.

Question 25

Large bowel on AXR

Answer 25

Haustra are indents that go Halfway

Question 26

Bowel obstruction on AXR

Answer 26

Upper limits of normal are: 3 cm small bowel, 6 cm colon, 9 cm caecum. Distended loops of bowel proximal to obstruction Dilated bowel values are 5, 8, 10 In SBO, The dilated loops are predominantly central. In LBO (esp. distal LBO): The dilated loops are predominantly peripheral. CT gold standard though

Question 27

Blood Ix for obstruction

Answer 27

FBC (Looking for leukocytosis or anaemia) CRP U&Es (Organ dysfunction or signs of hypovolaemia) LFTs Amylase Group and Save (G&S) VBG to evaluate the signs of ischaemia (high lactate) or for the immediate assessment of any metabolic derangement (secondary to dehydration or excessive vomiting)

Question 28

Bowel obstruction Mx

Answer 28

“drip and suck” Nil by mouth, bowel rest, NG tube on free drainage IV fluids, correction of electrolyte imbalance Urinary catheter and fluid balance IV analgesics ( avoid opioids if possible) Antiemetics Broad spectrum antibiotics given preoperatively Patients with closed loop bowel obstruction or evidence of ischaemia need urgent surgery

Question 29

SBO due to adhesions Mx

Answer 29

1. treated conservatively i 2. water soluble contrast study should be performed in cases that do not resolve within 24 hours 3. surgery

Question 30

Anastomotic leak

Answer 30

contents of a hollow organ that were joined surgically, leaks through a fault in the join

Question 31

Anastimotic leak clinical presentation

Answer 31

typically occur 5-7 days post surgery failure to thrive, a persistent low grade fever, prolonged ileus, abdominal pain, delirium, tachycardic, and / or with signs of peritonism. check for any faeculent / purulent material or bile in any drains.

Question 32

Anastomotic leak Ix

Answer 32

ix for sepsis, lactate for tissue ischaemia A CT abdomen and pelvis with rectal contrast fluoroscopic water-soluble enema.

Question 33

Anastomotic leak Mx

Answer 33

small leak can be managed conservatively with bowel rest, IV fluids and antibiotics larger leaks require emergency laparascopic exploration with potential further surgery.

Question 34

Abdominal wound dehiscence Mx

Answer 34

Coverage of the wound with saline impregnated gauze (on the ward) IV broad-spectrum antibiotics eg IV ceftriaxone and metronidazole Analgesia IV fluids Arrangements made for a return to theatre

Question 35

Clinical presentation of bowel ischemia

Answer 35

sudden onset, severe pain Hematochezia/melaena Nausea, Diarrhoea fever

Question 36

Bowel ischaemia signs

Answer 36

Abdominal tenderness Weight loss in chronic mesenteric ischemia Abdominal bruit

Question 37

Bowel ischaemia risk factors

Answer 37

Cardiovascular disease risk factors Hypercoagulable states Atrial fibrillation Myocardial infarction Structural heart defects Vasculitis Constipation Shock + congestive HF ( exacerbates low flow state) Long term laxative use Colonic carcinoma Use of vasopressors, digitalis, cocaine

Question 38

Bowel ischaemia Ix

Answer 38

FBC- leukocytosis, anaemia UE - renal dysfunction and dehydration Amylase - rises late LFTs ABG /lactate low bicarbonate points to a metabolic acidosis coag ECG - arrhythmias or acute infarction that may be the aetiology

Question 39

Bowel ischaemia imaging

Answer 39

CXR - perforation AXR- air-fluid levels or bowel dilation,thumb-printing sign CT gold standard first line for acute ischaemia Sigmoidoscopy or colonoscopy - diagnosis of colonic ischaemia

Question 40

Bowel ischaemia Mx

Answer 40

Resuscitation and supportive measures ( O2, fluids, NBM,NG, correct electrolytes etc) Abx presence of infarction, perforation, or peritonitis warrants urgent exploratory laparotomy or laparoscopy

Question 41

Ischaemic colitis

Answer 41

describes an acute but transient compromise in the blood flow to the large bowel. This may lead to inflammation, ulceration and haemorrhage

Question 42

Superior mesenteric artery supplies

Answer 42

distal duodenum, jejunum,ileum and the right colon from the cecum to the splenic flexure

Question 43

Inferior mesenteric artery supplies

Answer 43

the left colon from the splenic flexure to the rectum

Question 44

Ischemic colitis likely location

Answer 44

more likely to occur in 'watershed' areas such as the splenic flexure

Question 45

Aetiology of ischaemic colitis

Answer 45

Usually caused by transient hypoperfusion Thromboembolism Hypotension, hypovolaemia ( eg sepsis, dehydration, hemorrhage) Cardiovascular surgery ( especially aortic repairs or cardiac bypass) Vasoconstrictive drugs Thrombophilias ( eg antiphospholipid syndrome) Colonic obstruction from eg tumours, adhesions

Question 46

acute mesenteric ischaemia

Answer 46

cute inadequate blood flow to the small intestine (arterial or venous) that can result in bowel infarction

Question 47

Acute mesenteric ischaemia dx

Answer 47

CT scan with IV contrast

Question 48

Acute mesenteric ischaemia Mx

Answer 48

surgical emergency IV fluids, a catheter inserted, and a fluid balance chart started broad-spectrum antibiotics Excision of necrotic or non-viable bowel/Revascularization of the bowel, involving removal of any thrombus or embolism via radiological intervention

Question 49

Chronic mesenteric ischemia

Answer 49

caused by a reduced blood supply to the bowel which gradually deteriorates over time as a result of atherosclerosis in the coeliac trunk, superior mesenteric artery (SMA), and/or inferior mesenteric artery (IMA).

Question 50

Chronic mesenteric ischemia clinical presentation

Answer 50

Postprandial pain - 10mins-4hrs after eating , Dull, epigastric Weight loss – a combination of decreased calorie intake and malabsorption Concurrent vascular co-morbidities Change in bowel habit

Question 51

Chronic mesenteric ischemia diagnostic test

Answer 51

CT angiography is the diagnostic test of choice

Question 52

Chronic mesenteric ischemia Mx

Answer 52

conservative - modify risk factors, especially smoking cessation, and commencing antiplatelet and statin therapy to minimise disease progression. Surgery- both endovascular and open procedures are options