General Surgery

Question 1

what are stomas?

Answer 1

they are artificial openings of hollow organs - opened onto the surface of abdomen and contents are collected into bag

Question 2

what is the difference between colostomy and ileostomy?

Answer 2

ileostomy has more irritant contents so has a spout, is more likely to be in RIF and has liquid contents, colostomy is in LIF, solid and flat to skin

Question 3

when is an end stoma permanent?

Answer 3

after APR or panproctocolectomy

Question 4

what are complications of stomas?

Answer 4

hernia, psychosocial, local skin irritation, loss of bowel length, dehydration, malnutrition, constipation, stenosis, obstruction, retraction, prolapse, bleeding, granulomas

Question 5

list differentials for acute abdominal pain?

Answer 5

generalised: ischaemic colitis, ruptured AAA, peritonitis, intestinal obstruction
RUQ: biliary colic, cholecystitis, cholangitis
epigastric: gastritis, peptic ulcers, pancreatitis, ruptured AAA
loin to groin: ruptured AAA, renal colic, UUTI
testicular: torsion, epididymo-orchitis
central: ruptured AAA, ischaemic colitis, early appendicitis, intestinal obstruction
RIF: appendicitis, ectopic pregnancy, ruptured ovarian cyst, ovarian torsion, Meckel’s diverticulum
LIF: diverticulitis, ectopic, ruptured cysts, torsion
suprapubic: LUTI, retention, PID, prostatitis

Question 6

what are the signs of peritonitis?

Answer 6

guarding, rigidity, rebound tenderness, coughing test, percussion test

Question 7

how is the acute abdomen investigated?

Answer 7

A-E
FBC, U&Es, LFTs, CRP, amylase, INR, Ca, hcg, ABG, lactate, G&S, cultures
AXR, CXR, A USS, CT abdo

Question 8

how is the acute abdomen managed?

Answer 8

A-E, escalate, NBM, NGT, IVf, IV ABx, analgesia, VTE risk assess, prescribe regular meds, XM

Question 9

what are the risk factors for bowel cancer?

Answer 9

FHx, FAP, increasing age, HNPCC, IBD, diet, obesity, sedentary lifestyle, smoking, alcohol

Question 10

how does bowel cancer present?

Answer 10

mass (abdo/rectal), weight loss, unexplained abdominal pain, rectal bleeding, iron deficiency anaemia, change in bowel habit

Question 11

what is the 2 ww criteria for bowel cancer?

Answer 11

> 40y with unexplained abdominal pain and weight loss
50 with unexplained PR bleeding
60 with change in bowel habit or anaemia

Question 12

how is bowel cancer investigated?

Answer 12

screening: FIT >60-60 as per 2ww or 60-74 every 2 years
colonoscopy and biopsy, sigmoidoscopy, CT colonography, regular screening if RFs, staging CTTAP, CEA for relapse

Question 13

what classification is used for bowel cancer?

Answer 13

Duke’s and TNM

Question 14

how is bowel cancer managed?

Answer 14

surgical resection - lap, open, robotic
hemi colectomy, APR, anterior resections, Hartmann’s
chemotherapy, radiotherapy, palliation

Question 15

how is bowel cancer followed up?

Answer 15

CEA, CTTAP

Question 16

what are some complications of surgery for bowel cancer?

Answer 16

pain, bleeding, infection, damage to structures, ileus, anaesthetic risks, risk of changing to open, leak or fail of anastamoses, VTE, change in bowel habit, failure to remove, adhesions, stoma, hernia, lower anterior resection syndrome

Question 17

what is volvulus?

Answer 17

it is when the bowel twists around itself and mesentery - closed loop bowel obstruction - ischaemia, necrosis and perforation
investigated with AXR and CT

Question 18

summarise sigmoid volvulus?

Answer 18

it is more common and in older patients
it is caused by chronic constipation and lengthening of mesentery attached to sigmoid - faecal overload - sinks down
associated with high fibre and laxatives
shows coffee bean sign on AXR

Question 19

summarise caecal volvulus?

Answer 19

less common, more in younger patients
foetal sign on AXR

Question 20

what are the risk factors for volvulus?

Answer 20

neuropsychiatric disorders, nursing home, chronic constipation, high fibre, pregnancy, adhesions

Question 21

how does volvulus present?

Answer 21

vomiting (green bilious), distension, diffuse pain, absolute, constipation, no flatulence

Question 22

how is volvulus managed?

Answer 22

NBM, NGT, conservative - endoscopic decompression for sigmoid
surgical - laparotomy, Hartmann’s (sigmoid), ileocaecal resection, right hemicolectomy (caecal)

Question 23

what is cholangitis?

Answer 23

it is infection and inflammation of bile ducts - emergency - sepsis

Question 24

what causes cholangitis and how does it present?

Answer 24

it is caused by obstruction, infection, ERCP
E coli, enterococci, Klebsiella
it presents with RUQ pain, fever and jaundice

Question 25

how is cholangitis investigated and managed?

Answer 25

Ix: abdo USS, CT, MRCP, endoscopic USS
Mx - acute: NBM, IVf, culture, IV ABx, HDU/ICU
definitive: ERCP for stones (and cholangiopancreatography, sphincterectomy, removal, dilatation and stenting, biopsy), percutaneous transhepatic cholangiogram for drainage to relieve obstruction if ERCP not suitable or failed

Question 26

what is cholangiocarcinoma?

Answer 26

it is bile duct cancer - adenocarcinomas - can be intra or extra hepatic

Question 27

what are the risk factors for cholangiocarcinoma?

Answer 27

liver flukes, PSC

Question 28

how does cholangiocarcinoma present?

Answer 28

pale stools, dark urine, itching, weight loss, RUQ pain, palpable gallbladder, hepatomegaly

Question 29

how is cholangiocarcinoma investigated?

Answer 29

CT/MRI, biopsy, CTTAP, Ca 19-9, MRCP, ERCP

Question 30

how is cholangiocarcinoma managed?

Answer 30

radio and chemo (only curative if early presentation)
stents, palliative surgery, chemo, radio, EoL control