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AKT > General Surgery > Flashcards

General Surgery Flashcards

1
Q

Isotonic solutions include

A

Isotonic solutions (e.g., 0.9% saline, Hartmann’s and Plasma-Lyte) match the concentration of solutes (osmolality) in the plasma.

Hypertonic solutions (e.g., 3% saline) have a higher concentration of solutes than the plasma.

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2
Q

Hypotonic solutions risk and examples

A

Hypotonic solutions (e.g., 5% dextrose and 0.18% sodium chloride) have a lower concentration of solutes than the plasma.

Fluid moves out of the blood into the interstitial space - not used for fluid resuscitation, can lead to hypernatremia

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3
Q

What type of fluid should be used for fluid resusitation?

A

Isotonic
0.9% saline
Hartmann’s solution
Plasma-Lyte 148

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4
Q

Generalised abdo pain differentials

A

Peritonitis
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis

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5
Q

RUQ pain differentials

A

Biliary colic
Acute cholecystitis
Acute cholangitis

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6
Q

Epigastric pain differentials

A

Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured abdominal aortic aneurysm

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7
Q

Central (umbillicus) abdo pain differentials

A

Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis
Early stages of appendicitis

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8
Q

RIF pain differentials

A

Acute appendicitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
Meckel’s diverticulitis

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9
Q

LIF pain differentials

A

Diverticular disease
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion

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10
Q

Suprapubic pain differentials

A

Lower urinary tract infection
Acute urinary retention
Pelvic inflammatory disease
Prostatitis

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11
Q

Loin to groin pain differentials

A

Renal colic (kidney stones)
Ruptured abdominal aortic aneurysm
Pyelonephritis

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12
Q

Testicular pain differentials

A

Testicular torsion
Epididymo-orchitis

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13
Q

Signs of peritonitis

A

Guarding – involuntary tensing of the abdominal wall muscles when palpated to protect the painful area below

Rigidity – involuntary persistent tightness / tensing of the abdominal wall muscles

Rebound tenderness – rapidly releasing pressure on the abdomen creates worse pain than the pressure itself

Coughing test – asking the patient to cough to see if it results in pain in the abdomen

Percussion tenderness – pain and tenderness when percussing the abdomen

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14
Q

Define guarding

A

Involuntary tensing of the abdominal wall muscles when palpated to protect the painful area below

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15
Q

Three types of peritonitis and causes

A

Localised peritonitis is caused by underlying organ inflammation, for example, appendicitis or cholecystitis.

Generalised peritonitis may be caused by perforation of an abdominal organ (e.g., perforated duodenal ulcer or ruptured appendix) releasing the contents into the peritoneal cavity and causing generalised inflammation of the peritoneum.

Spontaneous bacterial peritonitis is associated with spontaneous infection of ascites in patients with liver disease. This is treated with broad-spectrum antibiotics and carries a poor prognosis.

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16
Q

McBurney’s point

A

Site of pain for appendicitis

Specific area one third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus.

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17
Q

Examination sign of appendicitis

A

Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF)

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18
Q

Examination sign of ruptured appendix

A

Rebound tenderness in the RIF (increased pain when suddenly releasing the pressure of deep palpation)

Percussion tenderness (pain and tenderness when percussing the abdomen)

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19
Q

Diagnosis of appendicitis

A

Diagnosis is based on the clinical presentation and raised inflammatory markers.

Performing a CT scan can be useful in confirming the diagnosis, particularly where another diagnosis is more likely. An ultrasound scan is often used in female patients to exclude ovarian and gynaecological pathology.

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20
Q

Fluid balance risk in bowel obstruction

A

The gastrointestinal tract secretes fluid that is later absorbed in the colon.

When there is an obstruction, and fluid cannot reach the colon, it cannot be reabsorbed. As a result, there is fluid loss from the intravascular space into the gastrointestinal tract. This leads to hypovolaemia and shock - is known as third spacing.

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21
Q

Causes of BO: 3 main and others

A

The “big three” causes account for around 90% of cases:

Adhesions (small bowel)
Hernias (small bowel)
Malignancy (large bowel)

Other
Volvulus (large bowel)
Diverticular disease
Strictures (e.g., secondary to Crohn’s disease)
Intussusception (in young children aged 6 months to 2 years)

22
Q

What are adhesions?

A

Adhesions are pieces of scar tissue that bind the abdominal contents together. They can cause kinking or squeezing of the bowel, leading to obstruction.

23
Q

Main causes of intestinal adhesions

A

Abdominal or pelvic surgery (particularly open surgery)
Peritonitis
Abdominal or pelvic infections (e.g., pelvic inflammatory disease)
Endometriosis

24
Q

Upper limits of the normal diameter of bowel are

A

3 cm small bowel
6 cm colon
9 cm caecum

25
Q

Signs on bloods of BO

A

Electrolyte imbalances (U&Es)
Metabolic alkalosis due to vomiting stomach acid (venous blood gas)
Bowel ischaemia (raised lactate – either on a venous blood gas or laboratory sample)

26
Q

The initial management of bowel obstruction - “drip and suck”

A

Nil by mouth (don’t put food or fluids in if there is a blockage)
IV fluids to hydrate the patient and correct electrolyte imbalances
NG tube with free drainage to allow stomach contents to freely drain and reduce the risk of vomiting and aspiration

27
Q

What is Ileus

A

Ileus is a condition affecting the small bowel, where the normal peristalsis that pushes the contents along the length of the intestines, temporarily stops. It may be referred to as paralytic ileus or adynamic ileus.

28
Q

What is volvulus

A

Volvulus is a condition where the bowel twists around itself and the mesentery that it is attached to. As the bowel gets its blood supply from the mesentery (through the mesenteric arteries) - blood supply to the bowel can be cut off leading to bowel ischaemia. Ischaemia leads to death of the bowel tissue (necrosis), and bowel perforation.

29
Q

Volvulus RF

A

Neuropsychiatric disorders (e.g., Parkinson’s)
Nursing home residents
Chronic constipation
High fibre diet
Pregnancy
Adhesions

30
Q

The typical features of an abdominal wall hernia are

A

A soft lump protruding from the abdominal wall
The lump may be reducible (it can be pushed back into the normal place)
The lump may protrude on coughing (raising intra-abdominal pressure) or standing (pulled out by gravity)
Aching, pulling or dragging sensation

31
Q

3 Complications of hernias

A

Incarceration is where the hernia cannot be reduced back into the proper position (it is irreducible).

Obstruction is where a hernia causes a blockage in the passage of faeces through the bowel. Obstruction presents with vomiting, generalised abdominal pain and absolute constipation (not passing faeces or flatus).

Strangulation is where a hernia is non-reducible (it is trapped with the bowel protruding) and the base of the hernia becomes so tight that it cuts off the blood supply, causing ischaemia.

32
Q

Richter’s Hernia

A

Only part of the bowel wall and lumen herniate through the defect, with the other side of that section of the bowel remaining within the peritoneal cavity. They can become strangulated, easily

33
Q

Indirect inguinal hernia

A

The inguinal ring remains patent, and the processus vaginalis remains intact. This leaves a tract or tunnel from the abdominal contents, through the inguinal canal and into the scrotum. The bowel can herniate along this tract, creating an indirect inguinal hernia.

34
Q

Examination of indirect vs direct inguinal hernia

A

When an indirect hernia is reduced and pressure is applied (with two fingertips) to the deep inguinal ring (at the mid-way point from the ASIS to the pubic tubercle), the hernia will remain reduced.

35
Q

Direct inguinal hernias

A

Direct inguinal hernias occur due to weakness in the abdominal wall at Hesselbach’s triangle. Pressure over the deep inguinal ring will not stop the herniation.

36
Q

Boundaries of Hesselbach’s triangle

A

R – Rectus abdominis muscle – medial border
I – Inferior epigastric vessels – superior / lateral border
P – Poupart’s ligament (inguinal ligament) – inferior border

37
Q

Boundaries of the femoral canal

A

F – Femoral vein laterally
L – Lacunar ligament medially
I – Inguinal ligament anteriorly
P – Pectineal ligament posteriorly

38
Q

Boundaries of femoral triangle

A

S – Sartorius – lateral border
A – Adductor longus – medial border
IL – Inguinal Ligament – superior border

39
Q

Contents of femoral triangle from lateral to medial

A

N – Femoral Nerve
A – Femoral Artery
V – Femoral Vein
Y – Y-fronts
C – Femoral Canal (containing lymphatic vessels and nodes)

40
Q

Classical presentation of chronic bowel ischemia

A

Central colicky abdominal pain after eating (starting around 30 minutes after eating and lasting 1-2 hours)

Weight loss (due to food avoidance, as this causes pain)

Abdominal bruit may be heard on auscultation

41
Q

Diagnosis of chronic bowel ischemia

A

Diagnosis is by CT angiograph

42
Q

Key RF for Acute Mesenteric Ischaemia

A

Atrial fibrillation

43
Q

Diagnosis of acute mesenteric ischaemia

A

Contrast CT is the diagnostic test of choice, allowing the radiologist to assess both the bowel and the blood supply. Patients will have metabolic acidosis and raised lactate level due to ischaemia.

44
Q

Courvoisier’s law

A

Palpable gallbladder along with painless jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.

45
Q

CA 19-9 (carbohydrate antigen) raised in

A

Cholangiocarcinoma
Pancreas cancer

46
Q

Whipple’s procedure

A

A Whipple procedure (pancreaticoduodenectomy) is a surgical operation to remove a tumour of the head of the pancreas that has not spread.

Removal of

Head of the pancreas
Pylorus of the stomach
Duodenum
Gallbladder
Bile duct
Relevant lymph nodes

47
Q

Acute appendicitis signs and symptoms

A

Severe epigastric pain
Radiating through to the back
Associated vomiting
Abdominal tenderness
Systemically unwell (e.g., low-grade fever and tachycardia)

48
Q

Post splenectomy blood film features

A

Howell- Jolly bodies
Pappenheimer bodies
Target cells
Irregular contracted erythrocytes

49
Q

What is Rigler’s sign and what does it suggest?

A

Free air in the abdomen
Double wall sign (looks like the intestine has two walls)

50
Q

What analgesics should be avoided in patients with renal transplant

A

Non steroidal anti inflammatory drugs (diclofenac) may be nephrotoxic and therefore are usually avoided in patients who have undergone renal transplants.

51
Q

When can serum amylase levels rise?

A

Serum amylase levels can rise in small bowel obstruction not just pancreatitis

52
Q

How is peptic ulcer perforation confirmed

A

The perforation is confirmed by free air under the diaphragm.

AKT (16 decks)

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