General Surgery Flashcards
Main causes of pancreatitis?
Gallstones
Alcohol
Post-ERCP
Pancreatitis causes pneumonic
- I – Idiopathic
- G – Gallstones
- E – Ethanol
- T – Trauma
- S – Steroids
- M – Mumps
- A – Autoimmune
- S – Scorpion sting
- H – Hyperlipidaemia
- E – ERCP
- D – Drugs (furosemide, thiazide diuretics, azathioprine)
Investigation for severity of pancreatitis?
Glasgow score
Glasgow score pneumonic?
(<3 = mild/moderate, >3 = severe):
* P – PaO2 <8kPa
* A – Age > 55
* N – Neutrophils (WBC >15)
* C – Calcium < 2
* R – Renal, Urea >16
* E – Enzymes, LDH >600 or AST/ALT >200
* A – Albumin <32
* S – Sugar (glucose >10)
What is Cullen’s sign?
Bluish discolouration around umbilicus
What is Grey-turner’s sign?
Bluish discolouration around flank
What is Fox’s Sign?
Bluish discolouration around inguinal ligament
What enzymes are replaced in pancreatic enzyme replacement?
CREON - Lipase + amylase + protease
What is acute cholangitis?
Bile duct inflammation
What is cholecystitis?
Gallbladder inflammation
What is cholestasis?
Biliary obstruction
Biliary colic px
- Intermittent RUQ/epigastric pain due to bile duct blockage
- Associated with eating fatty foods
- Pain may radiate to shoulder tip
- Pain lasts between 30 mins and 8 hours
- N&V
What triggers contraction of the gallbladder?
Fat -> CKK secretion into duodenum
Ix of biliary colic?
- LFT (↑bilirubin, ↑ALP, ↑ALT) + ultrasound
- MRCP if ultrasound negative but:
a. Dilated bile duct and/or
b. Abnormal LFT
Mx of gallbladder stones?
1 Asymptomatic -> no treatment
2 Symptomatic -> laparoscopic cholecystectomy (removal of gallbladder)
- Within 1 week if acute cholecystitis
3 Gallbladder empyema + surgery contra-indicated or conservative mx unsuccessful
-> Percutaneous cholecystostomy (drain pus from gallbladder)
Mx of common bile duct stones?
Asymptomatic or symptomatic:
-> Clear the bile duct + laparoscopic cholecystectomy
Clear bile duct with ERCP while awaiting laparoscopic cholecystectomy
If ERCP doesn’t work -> temporary stent for drainage
What is ascending cholangitis?
Ascending bacterial infection of biliary tree.
The blocking gallstones initiate an inflammatory response -> Toxin release [emergency]
Ix & Mx of ascending cholangitis
Ix – FBC (↑WCC, ↑ESR, ↑CRP), serum amylase
* USS
Mx – IV antibiotics, urgent biliary drainage
Appendicitis px:
- Abdo pain – Starts central and moves to RIF over 24h, worse on movement
- Low grade fever, N&V, loss of appetite
- Guarding
What is Rovsing’s sign?
Left iliac fossa palpation increase pain in RIF
What is McBurney’s point?
Maximal tenderness 2/3rds way along a line drawn from umbilicus to the anterior superior iliac spine
Dx of appendicitis?
Ultrasound, abdo CT, MRI
Who is at risk of diverticular disease?
Elderly, low fibre diet, obese, NSAID use
What is diverticulosis and px?
Colonic muscle over-activity -> Herniation of mucosa and submucosa through muscular layer
Asymptomatic
Large, painless rectal bleed
Mx of diverticular disease?
- Increase fibre, avoid NSAIDs
- Bulk forming laxatives
- Avoid stimulant laxatives (senna)
- Anti-spasmodic for abdo cramps
- Analgesia (paracetamol)
Mx of diverticulitis?
Severe -> hospital assessment
Systemically unwell:
- Oral Co-amoxiclav
Systemically well:
- No antibiotics, analgesia only
Px of diverticulitis?
Inflammation and infection of diverticula:
- Fever
- Sudden change in bowel habit & rectal bleeding
- LLQ tenderness
Diverticular disease complications?
Bleeding, infection, perforation, peritonitis, fistula and obstruction
Causes of bowel obstruction?
Adhesions
Hernias
Malignancy
Volvulus
Diverticular disease
Intussusception
Meckel’s divectulum
What is a volvulus?
Bowel twists around itself and the mesentery -> closed loop bowel obstruction
X-ray – “Coffee bean”
What is intussusception?
Bowel telescopes into itself
Intussusception px?
- Redcurrant jelly stool
- RLQ tenderness
- Sausage shape mass
Meckel’s diverticulum ix?
Best ix – technetium scan
Common ix – CTAP
Volvulus Ix & Mx?
Dx – contrast CT
Mx - Drip & suck, consider surgery
Meckel/s diverticulum mx?
Mx – excise diverticulum if symptomatic
Bowel obstruction mx?
Initial mx – Drip and suck
* Nasogastric decompression & IV fluids
Are there any complications?
* Hypovolaemic shock, bowel ischaemia, bowel perforation, sepsis
Final mx – Surgical intervention or conservative if stable patient?
Bowel obstruction Ix?
Bloods
* U&Es
* VBG – metabolic alkalosis or ^lactate
Imaging
* Abdo X-ray, are there distended loops of bowel?
* CTAP if severe
Bowel obstruction px?
- Diffuse abdominal pain & distention
- Vomiting (green bilious)
- Absolute constipation and lack of flatulence
- “Tinkling” bowel sounds
What is a closed-loop bowel obstruction?
Two points of obstruction along bowel so there is a sandwiched middle section. Can occur with any bowel obstruction + competent ileocecal valve.
- The closed loop section cannot drain -> expansion -> ischaemia + perforation
Px of G.I perforation?
Rapid onset of abdo pain + systemically unwell (tachy, hypo)
- CXR will show air under diaphragm
Dx & Mx of G.I perforation?
Dx – CT with contrast
Mx – underlying + resus, fluids, analgesia, antibiotics
Types of peritonitis?
Spontaneous bacterial peritonitis – development of infection of ascitic fluid in peritoneum
o Liver failure, kidney failure
Secondary peritonitis (occurs 24-48 hours after rupture of abdo wall or organs)
o Ruptured organ – appendicitis, pancreatitis, diverticulitis, ruptured stomach ulcer, perforated colon
Peritonitis px?
Px:
- Dull, generalised abdo pain which becomes severe
- Guarding and rigidity
- Rebound tenderness
- Cough test (coughing elicits pain)
Types of intestinal ischaemia?
- Acute mesenteric ischaemia
- Chronic mesenteric ischaemia
- Colonic ischaemia
Px of acute mesenteric ischaemia
Non-specific abdo pain
-> Shock, peritonitis & sepsis
Px of chronic mesenteric ischaemia?
- Colicky abdo pain after eating
- Weight loss
- Abdo bruit
Px of colonic ischaemia?
- Lateral cramping pain
- Urgent need to defecate with pain
Dx & Mx of intestinal ischaemias
Acute mesenteric ischameia:
Dx - Contrast CT
Mx - Remove thrombus + necrotic bowel
Chronic mesenteric bowel & colonic ischaemia:
Dx - CT angiogram
Mx:
1.Lifestyle
2. Statins, antiplatelets
3. Revascularisation
Rx of colorectal cancer?
Family history
FAP
Lynch syndrome
IBD
Smoker
High red meat diet
Urgent referral criteria for bowel cancer?
Urgent referral (<2 weeks):
- >40y with abdo pain and unexplained weight loss
- >50y with unexplained rectal bleeding
- >60y with iron-deficiency anaemia or change in their bowel habit
- Occult blood in faeces
Screening Ix for bowel cancer?
QFIT
- People aged 50-74 are screened for bowel cancer every two years in Scotland
What is removed in a right hemicolectomy?
Caecum, ascending and proximal transverse
What is removed in a left hemicolectomy?
Distal transverse and descending
What is removed in a high anterior resection?
Sigmoid colon
What is removed in a low anterior resection?
Sigmoid + upper rectum
What is removed in a abdomino-perineal resection?
Rectum + anus +/- sigmoid
What is a Hartmann’s surgery?
Can be elective or emergency removal of rectosigmoid and creation of a colostomy
What is low anterior resection syndrome?
Anastomosis of colon and rectum
Pancreatic cancer common px
Mostly adenocarcinomas at head of pancreas -> compression of bile ducts -> painless obstructive jaundice
+ weight loss
What are the symptoms of painless obstructive jaundice?
Yellow skin and sclera
Pale stools
Dark urine
Itching
Referral criteria for pancreatic cancer?
- > 40 with jaundice – 2 week wait referral
- > 60 with weight loss + non-specific symptom (weight loss, abdo pain, epigastric mass, N&V, constipation / diarrhoea, new onset diabetes) -> direct access CT abdomen
Rx for cholangiocarcinoma
PSC - primary sclerosing cholangitis
Px of cholangiocarcinoma?
- Obstructive jaundice – pale stools, dark urine, generalised itch
- Weight loss
- RUQ pain
- Palpable gallbladder
Ix & Mx of cholangiocarcinoma?
Ix – Imaging + history
- CA 19-9 tumour marker
- MRCP to observe obstruction
Mx:
- Curative surgery not often possible
- Stent insertion by ERCP to relieve biliary obstruction
How many weeks for an anal fissure to be chronic?
6 weeks
Primary and secondary anal fissure differences on ex?
Primary – singular in posterior midline of anus
Secondary – multiple, irregular outline or occur laterally
Mx of anal fissure?
- Ensure soft stools fibre diet?
- Anal hygiene (cleaning and kept dry, not straining)
- Analgesia – paracetamol or ibuprofen
o Adult with extreme pain on defecation -> topical anaesthetic (lidocaine 5%)
One week without improvement in an adult with primary anal fissure -> rectal GTN 0.4% BID
Px of peri-anal abscess?
- Constant throbbing pain in perineum
- Intermittent discharge near anal region
- Skin lesion near anus
- Fever, chills, urinary retentions
- IBD (Crohn’s)
Mx of peri-anal abscess?
Incision + drainage, consider fistulotomy & antibiotics
Location of inguinal hernia?
Superomedial to pubic tubercle
Location of femoral hernia?
Inferolateral to pubic tubercle
What is an indirect inguinal hernia?
Hernia via incomplete closure of outpouching of peritoneum which allowed testes decent
Who gets what type of inguinal hernia?
Direct (20%):
- Older patients secondary to abdo wall laxity
Indirect (80%):
- Congenital
- Paediatric cases
What is an incarcerated hernia?
Hernia can’t be reduced
What is a strangulated hernia?
Non-reducible hernia + hernia has cut off blood supply -> ischaemic bowel (significant pain)
Hernia mx?
- Small & asymptomatic -> watchful waiting
o 1/3rd never have symptoms - Symptomatic hernia -> surgical repair + prophylactic antibiotics
Acute mesenteric ischaemia causes?
Rapid blockage of blood vessel
* Embolus (50%)
* Thrombus (20%)
* Hypo-perfusion
* Vasculitis
