General Surgery Flashcards
What is the water distribution in the body?
2/3rds ICF
1/3rd ECF
What is the water distribution in the extracellular space?
Intravascular - 20%
Interstitial space - 80%
What is the third space
Areas that can collect fluid but shouldn’t. - e.g peritoneal cavity or joints
What is hypovolaemia?
Low amount of ECF
What are signs of hypovolaemia?
Hypotension
Tachycardia
CRT >2
Cold peripheries
Raised RR
Dry mucous membranes
Reduced skin turgor
Reduced urine output
Sunken eyes
Reduced body weight from baseline
Feeling thirsty
What are the indications for IV fluids?
Resuscitation
Replacement
Maintenance
What is the guidance for resuscitation fluids?
Initial 500ml fluid bolus over 15 mins (‘stat’)
Repeat boluses of 250ml-500ml if required each time followed by a reassessment
The rate of potassium infusion should not exceed what?
10mmol/hr
What are the recommendations for maintenance fluid amounts?
25-30ml/kg/day water
1mmol/kg/day of sodium, potassium and chloride
50-100g/day of glucose, to prevent ketosis
Weight is IBW
What is diverticulitis associated with?
Increased age
Low fibre diets
Obesity
NSAIDs
What type of laxatives should be avoided in diverticular disease?
Stimulant laxatives (e.g. Senna)
What is the management of acute uncomplicated diverticulitis?
Oral co-amoxiclav
Analgesia (avoiding NSAIDs and opiates)
Only taking clear liquids, avoiding solid food until symptoms improve
Follow up within 2 days
What are the complications of acute diverticulitis?
Perforation
Peritonitis
Peridiverticular abscess
Large haemorrhage
Fistula
Ileus/obstruction
What are the three main branches of the abdominal aorta that supply the abdominal organs?
Coeliac artery
Superior mesenteric artery
Inferior mesenteric artery
What is the foregut?
Stomach, part of the duodenum, biliary system, liver, pancreas and spleen. Supplied by the coeliac artery
What is the midgut?
Distal duodenum to the first half of the transverse colon. Supplied by the superior mesenteric artery
What is the hindgut?
Second half of the transverse colon to the rectum. Supplied by the inferior mesenteric artery
What is the classic triad of chronic mesenteric ischaemia?
Central colicky abdo pain after eating (starting around 30 mins after eating and lasting 1-2 hrs)
Weight loss
Abdo bruits
What is the cause of chronic mesenteric ischaemia?
Atherosclerosis
What is the management of chronic mesenteric ischaemia?
Reducing modifiable risk factors
Secondary prevention of CVS disease
Revascularisation to improve blood flow - percutaneous mesenteric artery stenting or open surgery.
What causes acute mesenteric ischaemia?
Thrombus - key risk factor is atrial fibrillation
How does acute mesenteric ischaemia present?
Acute, non-specific abdominal pain, disproportionate to examination findings
Shock, peritonitis, sepsis
Necrosis and perforation
How is acute mesenteric ischaemia diagnosed?
Contrast CT
Metabolic acidosis and raised lactate
What is the management for acute mesenteric ischaemia?
Surgery to:
Remove necrotic bowel
Remove or bypass the thrombus in the blood vessel
Very high mortality still
What type of cancer are most pancreatic cancers?
Adenocarcinoma, usually in the head
How do pancreatic cancers present?
Painless obstructive jaundice
Also:
Non-specific upper abdo or back pain
Unintentional weight loss
Palpable mass in the epigastric region
Change in bowel habit
Nausea or vomiting
New-onset diabetes or worsening of T2DM
What are the guidelines on suspected pancreatic cancer for GPs?
Direct access CT abdo if patient has weight loss and any of:
Diarrhoea
Back pain
Abdominal pain
Nausea
Vomiting
Constipation
New-onset diabetes
What is Courvoisier’s law?
Palpable gallbladder along with jaundice is unlikely to be gallstones - usually cholangiocarcinoma or pancreatic cancer
What is Trousseau’s sign of malignancy?
Migratory thrombophlebitis (blood vessels become inflames with an associated blood clot reoccurring in different locations over time)
Sign of pancreatic adenocarcinoma
What is a tumour marker for pancreatic cancer?
CA 19-9
CT TAP
MRCP
ERCP
What is the Whipple Procedure?
Remove a tumour in the head of pancreas that has not spread. Huge op.
Removes: head of pancreas, pylorus of stomach, duodenum, gallbladder, bile duct, relevant lymph nodes
What are the three main causes of pancreatitis?
Gallstones
Alcohol
Post-ERCP
What does IGETSMASHED stand for?
The long list of causes of pancreatitis:
Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion sting
Hyperlipidaemia
ERCP
Drugs (furosemide, thiazide diuretics and azathioprine)
How does acute pancreatitis typically present?
Acute onset of:
Severe epigastric pain
Radiating through to back
Vomiting
Associated tenderness
Systemically unwell
What are the investigations for acute pancreatitis?
FBC
U&E
LFT
Calcium
ABG
Amylase (raised x3)
Lipase (sensitive and specific)
CRP
USS
CT abdo
What does the Glasgow score assess?
The severity of pancreatitis
0 or 1 - mild
2 - moderate
3 or more - severe
What are the criteria for the Glasgow score?
PANCREAS
PaO2 <8KPa
Age >55
Neutrophils (WBC >15)
Calcium <2
uRea >16
Enzymes (LDH >600 or AST/ALT >200)
Albumin <32
Sugar (Glucose >10)
Management of acute pancreatitis?
ICU or HDU
Initial resuscitation
IV fluids
Nil by mouth
Analgesia
Careful monitoring
Treatment of gallstones
Antibiotics if infection
Treatment of complications
What are complications of acute pancreatitis?
Necrosis of the pancreas
Infection in a necrotic area
Abscess formation
Acute peripancreatic fluid collections
Pseudocysts (can develop 4 weeks after)
Chronic pancreatitis
What is the most common cause of chronic pancreatitis?
Alcohol
What are the complications of chronic pancreatitis?
Chronic epigastric pain
Loss of exocrine and endocrine function
Damage and strictures to the duct system, obstructing excretion of pancreatic juice and bile
Formation of pseudocysts or abscesses
What is the management of chronic pancreatitis?
No alcohol or smoking
Analgesia
Replacement pancreatic enzymes (Creon)
Subcutaneous insulin regimes
ERCP with stenting
Surgery
