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Medicine > General surgery > Flashcards

General surgery Flashcards

1
Q

Small bowel stoma (ileostomy) location

A

right side more likely

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2
Q

Large bowel stoma (colostomy) location

A

left side more likely

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3
Q

Small bowel stoma contents

A

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

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4
Q

Large bowel stoma contents

A

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

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5
Q

Inspection of small bowel stoma

A

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)

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6
Q

Inspection of large bowel stoma

A

stoma can be flat on skin, no enzymes

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7
Q

Rutherfor morrison incision

A

Extraperitoneal approach to left or right lower quadrants
renal transplant

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8
Q

Pfannenstiel incision

A

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

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9
Q

Lanz incision

A

Incision in right iliac fossa
appendicitis

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10
Q

Kocher’s incision

A

Incision under right subcostal margin
open cholecystectomy

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11
Q

Rooftop incision

A

more unusual , upper GI surgery eg whipple procedure

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12
Q

volvulus

A
  • 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
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13
Q

Volvulus Ix

A

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

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14
Q

Volvolus Mx

A

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

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15
Q

Caecal volvulus epidemiology

A

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.

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16
Q

Caecal volvulus Mx

A

always laparotomy and ileocaecal resection

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17
Q

Strangulated bowel obstruction

A

obstruction with compromised intestinal blood flow, resulting in bowel ischemia

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18
Q

Causes of SBO

A

Adhesion
Hernia
Intussusception in children

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19
Q

Causes of LBO

A

Malignancy
Diverticular disease
Volvulus

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20
Q

Bowel obstruction pathophysiology

A
  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.
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21
Q

SBO symptoms

A

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

22
Q

LBO symptoms

A

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

23
Q

Bowel obstruction signs

A

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

24
Q

Small bowel on AXR

A

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

25
Q

Large bowel on AXR

A

Haustra are indents that go Halfway

26
Q

Bowel obstruction on AXR

A

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

27
Q

Blood Ix for obstruction

A

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)

28
Q

Bowel obstruction Mx

A

“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

29
Q

SBO due to adhesions Mx

A
  1. treated conservatively i
  2. water soluble contrast study should be performed in cases that do not resolve within 24 hours
  3. surgery
30
Q

Anastomotic leak

A

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

31
Q

Anastimotic leak clinical presentation

A

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.

32
Q

Anastomotic leak Ix

A

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

33
Q

Anastomotic leak Mx

A

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

34
Q

Abdominal wound dehiscence Mx

A

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

35
Q

Clinical presentation of bowel ischemia

A

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

36
Q

Bowel ischaemia signs

A

Abdominal tenderness
Weight loss in chronic mesenteric ischemia
Abdominal bruit

37
Q

Bowel ischaemia risk factors

A

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

38
Q

Bowel ischaemia Ix

A

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

39
Q

Bowel ischaemia imaging

A

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

40
Q

Bowel ischaemia Mx

A

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

41
Q

Ischaemic colitis

A

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

42
Q

Superior mesenteric artery supplies

A

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

43
Q

Inferior mesenteric artery supplies

A

the left colon from the splenic flexure to the rectum

44
Q

Ischemic colitis likely location

A

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

45
Q

Aetiology of ischaemic colitis

A

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

46
Q

acute mesenteric ischaemia

A

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

47
Q

Acute mesenteric ischaemia dx

A

CT scan with IV contrast

48
Q

Acute mesenteric ischaemia Mx

A

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

49
Q

Chronic mesenteric ischemia

A

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).

50
Q

Chronic mesenteric ischemia clinical presentation

A

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

51
Q

Chronic mesenteric ischemia diagnostic test

A

CT angiography is the diagnostic test of choice

52
Q

Chronic mesenteric ischemia Mx

A

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

Medicine (72 decks)

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