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Y3 Surgery > General Surgery > Flashcards

General Surgery Flashcards

1
Q

What is the definition of an acute abdomen ?

A

A sudden onset severe abdominal pain.

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2
Q

What are some presentations of acute abdomen that require urgent intervention ?

A

Acute bleeding
Perforated viscus
Ischaemic bowel

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3
Q

What are some causes of acute bleeding causing an acute abdomen ?

A

Ruptured AAA
Ruptured ectopic pregnancy
Traumatic injury

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4
Q

What are the clinical features of a localised perforated viscus ?

A

Localised pain
Peritonism
Tachycardia
Pyrexia

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5
Q

What are some clinical features of general peritonitis ?

A

Tachycardia
Possible hypotension
Pyrexia
Rigid abdomen
Will look unwell

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6
Q

If someone has severe abdominal pain out of proportion to clinical signs what should be assumed until proven otherwise ?

A

Visceral ischaemia especially ischaemic bowel

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7
Q

What are some medical causes of abdominal pain that should be taken into account for an acute abdomen ?

A

DKA
MI
Addisonian crisis
Porphyria

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8
Q

What are some initial tests for an acute abdomen ?

A

Urine dipstick - haematuria
Pregnancy test
ABG - lactate to assess tissue perfusion
FBC, U&E’s, LFT’s, CRP and group and save
ECG - referred myocardial pain

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9
Q

What imaging should be used to assess an acute abdomen ?

A

Erect chest plain radiograph - free abdominal air
USS - renal tract, biliary tree, liver and uterus
CT abdomen and pelvis

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10
Q

What is haematemesis ?

A

Vomiting fresh blood usually due to an upper GI tract bleed

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11
Q

What are some causes of haematemesis ?

A

Oesophageal varices
Peptic ulcer disease
Mallory-Weiss tear
Oesophagitis
Less common - Gastric cancer or oesophageal cancer

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12
Q

What is oesophageal varices ?

A

Dilation of the porto-systemic anastomoses in the oesophagus. They commonly occur due to portal hypertension secondary to liver cirrhosis.

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13
Q

Why do oesophageal varices cause bleeding ?

A

The dilated veins are swollen and thin walled hence prone to rupture and the potential to cause a catastrophic haemorrhage.

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14
Q

What is a Mallory-Weiss tear ?

A

Typified by episodes of severe or recurrent vomiting then followed by minor haematemesis. Such forceful vomiting causes a tear in the epithelial lining of the oesophagus resulting in a small bleed.

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15
Q

What can cause oesophagitis ?

A

Inflammation of the intraluminal epithelial layer of the oesophagus most often due to reflux disease or less commonly infection, medication, radiotherapy or Crohn’s.

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16
Q

What key features should be asked about in the history of someone presenting with haematemesis ?

A

Timing
Frequency
Volume
Associated symptoms - dyspepsia, dysphagia, melaena or weight loss
PMH - smoking or alcohol status
Drug history - use of steroids, NSAIDs, anticoagulants or bisphosphonates

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17
Q

What are some initial investigations for haematemesis ?

A

Routine bloods - FBC, U&E’s, LFT’s and clotting
Group and save

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18
Q

What are some further investigations for haematemesis ?

A

OGD
If OGD is normal a CT can be performed

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19
Q

What is the management of haematemesis ?

A

Critically unwell - A to E
Large bore IV access
Urgent blood transfusion
Gastroscopy to assess cause
Treat cause

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20
Q

What is the management for oesophageal varices ?

A

Active resus - blood products, prophylactic ABx, terlipressin
Endoscopic banding

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21
Q

What is dysphagia ?

A

Difficulty in swallowing. Occurs from abnormal delay in the transit of liquids or solids during oropharyngeal or oesophageal stage os swallowing.

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22
Q

What are the 2 ways in which dysphagia can occur ?

A

Mechanical or motility

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23
Q

What are some mechanical causes of dysphagia ?

A

Oesophageal cancer
Gastric cancer
Benign oesophageal strictures
Extrinsic compression such as thyroid goitre
Pharyngeal pouch
Foreign body - children

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24
Q

What are some causes of motility related causes of dysphagia ?

A

Cerebrovascular accident
Achalasia
Diffuse oesophageal spasm
Myasthenia gravis
Muscular dystrophy

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25
Q

What should be asked about in the history of someone presenting with dysphagia ?

A

Is there difficulty in initiating the swallowing act ?
Do you cough after swallowing ?
Do you have to swallow a few times to get the food down ?
Any reflex or dyspepsia ?
Hoarse voice
Referred pain
Significant weight loss
Any odynophagia - painful swallowing

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26
Q

What are some investigations for dysphagia ?

A

Routine bloods - FBC, LFT’s and TFT’s
OGD
Manometry testing is performed to assess the motor function of the upper oesophageal sphincter

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27
Q

What is the management of dysphagia ?

A

Assess nutritional status and involve a dietician
Speech and language therapist ( eg following a stroke )
Medical management or surgical for correction of cause

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28
Q

What is a bowel obstruction ?

A

A mechanical blockage of the bowel whereby a structural pathology blocks the passage of intestinal contents.
This can cause gross dilation of the proximal bowel.

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29
Q

What are some causes of intraluminal bowel obstruction ?

A

Gallstone ileus, ingested foreign body, faecal impaction

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30
Q

What are some causes of mural bowel obstruction ?

A

Cancer
Inflammatory strictures
Intussusception
Diverticular strictures
Meckel’s diverticulum
Lymphoma

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31
Q

What are some causes of extramural bowel obstruction ?

A

Hernia
Adhesions
Volvulus

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32
Q

What are the most common causes of small bowel obstruction ?

A

Adhesions or hernias

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33
Q

What are the most common causes of large bowel obstruction ?

A

Malignancy
Diverticular disease
Volvulus

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34
Q

What are some clinical features of bowel obstruction ?

A

Abdominal pain - colicky or cramping
Vomiting - early in proximal obstruction but late in distal
Abdominal distension
Absolute constipation

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35
Q

What are some differentials for patients presenting with suspected bowel obstruction ?

A

Pseudo-obstruction
Paralytic ileus
Toxic mega colon
Constipation

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36
Q

What are some lab tests for bowel obstruction ?

A

Urgent bloods
Group and save
VBG

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37
Q

What imaging is done when suspected bowel obstruction ?

A

CT abdomen pelvis with IV contrast
Plain radiograph of the abdomen

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38
Q

What is seen on AXR in small bowel obstruction ?

A

Dilated bowel over 3cm
Central abdominal location
Valvulae conniventes

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39
Q

What is seen on an AXR in large bowel obstruction ?

A

Dilated bowel over 6cm or over 9cm at the caecum
Peripheral location
Haustral lines

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40
Q

What is the management of bowel obstruction ?

A

Urgent fluid resus
Nil by mouth and insert an NG tube
Urinary catheter
analgesia
Anti-emetics

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41
Q

When is surgical intervention indicated in bowel obstruction ?

A

Suspicion of intestinal ischaemia
Closed loop bowel obstruction
A cause that requires surgical correction
If patients don’t improve with conservative measures

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42
Q

What is often performed during surgery for bowel obstruction ?

A

A laparotomy and resection of bowel.
This may result in a defunctioning stoma

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43
Q

What are some complications for bowel obstruction ?

A

Bowel ischaemia
Bowel perforation
Intravascularly fluid deplete - AKI or other end organ damage

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44
Q

What will a delay in the resuscitation and definitive surgery for a perforation of the bowel lead to ?

A

Septic shock
Multi-organ failure
Death

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45
Q

What are some causes of upper GI tract perforations ?

A

Peptic ulcer disease
Gastric cancer or oesophageal cancer
Foreign body ingestion
Excessive vomiting

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46
Q

What are some causes of lower GI tract perforations ?

A

Diverticulitis
Colorectal cancer
Appendicitis
Meckel’s diverticulitis
Foreign body insertion
Severe colitis
Toxic mega colon

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47
Q

What are some causes that can cause any part of the GI tract to perforate ?

A

Iatrogenic - gastroscopy or colonoscopy
Trauma
Mesenteric ischaemia
Obstructing lesions

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48
Q

What are some clinical features of oesophageal ruptures ?

A

Abdominal pain - rapid and severe
Systemically unwell
Malaise
Vomiting
Lethargy
Rigid abdomen

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49
Q

What are some investigations for bowel perforation ?

A

Urgent bloods - FBC, U&E’s, LFT’s, CRP, clotting and group and save
CT scan abdomen pelvis with IV contrast ( in upper GI perforation oral contrast may be used )
Erect AXR and CXR

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50
Q

What is the management of a suspected GI perforation ?

A

Broad spectrum ABx
Nil by mouth and insert NG tube
IV fluid resus and analgesia
Surgery - identify problem, appropriate management and thorough wash out

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51
Q

What is the surgical management for a peptic ulcer perforation ?

A

Either open or laparoscopically and a patch of omentum is tacked loosely over the ulcer

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52
Q

What is the surgical management for a small bowel perforation ?

A

Bowel resection +/- primary anastomosis +/- stoma formation

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53
Q

What is the surgical management for a large bowel perforation ?

A

Bowel resection +/- stoma formation

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54
Q

What is melaena ?

A

Refers to black tarry stools which usually occurs as a result of upper GI bleeding.

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55
Q

What are some differentials for melaena ?

A

Peptic ulcer disease
Variceal bleeds
Upper GI malignancy
Gastritis or oesophagitis

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56
Q

What are some clinical features that should be asked about when someone presents with melaena ?

A

Colour and texture of the stool - jet black, tar-like and sticky
Associated symptoms - haematemesis, abdominal pain, weight loss, dysphagia
PMH - smoking and alcohol
Drug history - steroids, NSAIDs, anticoagulants or iron

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57
Q

What are some investigations that should be performed when suspecting melaena ?

A

Routine bloods - FBC, U&E’s, LFT’s and clotting
Urea : creatinine ratio
Group and save
OGD
CT angiogram

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58
Q

What is the management of melaena ?

A

A to E approach
Blood products if unstable or low Hb
Treat underlying cause

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59
Q

What is rectal bleeding ?

A

The passage of fresh blood per rectum. It is generally caused by bleeding for the lower GI tract.

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60
Q

What are some differentials for fresh rectal bleeding ?

A

Diverticulosis
Haemorrhoids
Malignancy
Angiodysplasia
UC
Crohn’s

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61
Q

What should be asked about when someone is presenting with PR bleeding ?

A

Duration, frequency, colour,
Pain ?
Haematemesis ?
Melaena
Any PR mucus
Weight loss
Family history - bowel cancer

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62
Q

What are some investigations for PR bleeding ?

A

FBC, U&E’s, LFT’s and clotting
Group and save
Stool cultures
Urgent CT angiogram
OGD

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63
Q

What is the management of PR bleeding ?

A

Settle spontaneously
Unstable - urgent resus, wide bore IV access and blood products given
Hb below 70 is given blood transfusion
Arterial embolisation or endoscopic haemostasis methods
Surgical intervention is rarely needed

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64
Q

During general inspection what should be assessed when standing at the end of the bed ?

A

Age
Confusion ?
Pain
Obvious scARS
Distension
Pallor
Jaundice
Oedema
Cachexia
Stoma bags, drains, feeding tubes

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65
Q

When inspecting the hands what is looked for in an abdominal exam ?

A

Palm - pallor, erythema, dupuytren’s contracture

Nail - koilonychia or leukonychia

Finger clubbing
Flapping tremor

Pulse

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66
Q

When inspecting the face what is looked for in an abdominal exam ?

A

Eyes - Conjunctival pallor, jaundice in the sclera, corneal arcus, xanthelasma

Mouth - angular stomatitis, glossitis, oral candidiasis, ulcers, dehydration

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67
Q

What lymph node when enlarged is an early sign or metastatic intrabdominal malignancy ?

A

Left supraclavicular lymph node - Virchow’s triad

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68
Q

When inspecting the abdomen what is looked for in an abdominal exam ?

A

Scars
Distension
Caput medusae
Striae
Hernias

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69
Q

What should be done before palpating the abdomen ?

A

Position the patient lying flat on the bed
Ask if any abdo pain
Eyeline at level of the patient

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70
Q

What are some causes of hepatomegaly ?

A

Hepatitis
Hepatocellular carcinoma
Wilson’s disease
Haemochromatosis
Leukaemia
Myeloma

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71
Q

What is murphy’s sign ?

A

Position your fingers at the right costal margin in the mid-clavicular line.
Ask patient to take a deep breath.
If pain occurs cholecystitis is suggested

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72
Q

What are some causes of splenomegaly ?

A

Portal hypertension secondary to liver cirrhosis
Haemolytic anaemia
Splenic metastases
Glandular fever

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73
Q

What are some causes of enlarged kidneys ?

A

Polycystic kidney disease
Amyloidosis
Renal tumour

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74
Q

How is shifting dullness assessed during an abdominal exam ?

A

Percuss from the umbilical region to the patient’s left flank. If dullness is node this may suggest the presence of ascitic fluid.
Ask the patient to then roll onto their side
Keep on side for 30s and then repeat percussion.
If ascites is present the previous area of dullness may now be resonant.

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75
Q

When auscultating the bowel what are some sounds that suggest pathology ?

A

Tinkling - bowel obstruction
Absent - suggest ileus

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76
Q

What arteries should be assessed for bruits in an abdominal exam ?

A

Aortic bruits - 1 to 2cm superior to the umbilicus
Renal bruits - may suggest renal artery stenosis

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77
Q

Why should the legs be assessed in an abdominal exam ?

A

Evidence of pitting oedema which may suggest hypoalbuminaemia

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78
Q

How would you complete the abdominal exam ?

A

Check hernial orifices
Perform a DRE
Perform an examination of the external genitalia

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79
Q

What is GORD ?

A

A condition whereby gastric acid from the stomach leaks into the oesophagus.

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80
Q

What is the pathophysiology of GORD ?

A

Lower oesophageal sphincter controls the passage of contents from the oesophagus to the stomach.
As part of the normal function, episodic sphincter relaxation is expected however in GORD these episodes become more frequent and allow the reflux of gastric contents.

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81
Q

What are some risk factors for GORD ?

A

Age
Obesity
Male
Gender
Alcohol
Smoking
Intake of caffeinated or fatty / spicy foods

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82
Q

What are some clinical features of GORD ?

A

Chest pain - burning retrosternal sensation, worse after meals, lying down
Excessive belching, odynophagia
Cough
Dysphagia

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83
Q

What are some investigations for GORD ?

A

Clinical diagnosis
Upper GI endoscopy
24hr pH monitoring

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84
Q

What are some red flags that require an urgent endoscopy ?

A

Patients with dysphagia
Any patients over 55 with weight loss and upper abdominal pain, dyspepsia if reflux

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85
Q

What are some pre-surgical management options for GORD ?

A

Avoiding known precipitants ( alcohol, coffee, fatty foods)
Weight loss
Smoking cessation
PPI - usually lifetime

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86
Q

What are the 3 main indications for surgery for GORD ?

A

Failure to respond to medical therapy
Patient preference to avoid life-long medication
Patients with complications of GORD

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87
Q

What is the main surgical intervention for GORD ?

A

Fundoplication - the gastro-oesophageal junction and hiatus are dissected and the fundus is wrapped around the GOJ recreating the lower oesophageal sphincter

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88
Q

What are the main side - effects of anti-reflux surgery ?

A

Dysphagia
Bloating
Inability to vomit

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89
Q

What are some complications of GORD ?

A

Aspiration pneumonia
Barrett’s oesophagus
Oesophageal strictures
Oesophageal cancer

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90
Q

What are the 2 main types of oesophageal cancer ?

A

Squamous cell carcinoma
Adenocarcinoma

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91
Q

What is squamous cell carcinoma of the oesophagus commonly associated with ?

A

Smoking
Excessive alcohol consumption
Low vitamin A levels
Chronic Achalasia

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92
Q

What is adenocarcinoma of the oesophagus commonly associated with ?

A

Barrett’s oesophagus which can progress into dysplasia and then it can become malignant.
GORD
Obesity
High fat intake

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93
Q

What are some clinical features of oesophageal cancer ?

A

Dysphagia
Weight loss
Odynophagia
Hoarseness

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94
Q

What are some initial investigations for people with suspected GI malignancy ?

A

urgent GI endoscopy - biopsy then sent for histology

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95
Q

What are some further investigations to help assess oesophageal cancer ?

A

CT chest-abdomen-pelvis
PET-CT scan
Endoscopic USS
Staging laparoscopy

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96
Q

What is the prognosis of oesophageal cancer ?

A

Most present with advanced disease
70% are treated palliatively

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97
Q

What is the management each type of oesophageal cancer ?

A

Squamous cell - difficult to operate on so definitive chemo-radiotherapy

Adenocarcinoma - neoadjuvant chemotherapy or chemo-radiotherapy followed by oesophageal resection

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98
Q

What are some complications of surgery in oesophageal cancer ?

A

Anastomotic leak
Re-operation
Pneumonia
Death

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99
Q

What is the palliative management for oesophageal cancer ?

A

Oesophageal stent

Radiotherapy and/or chemotherapy to reduce tumour size and bleeding or improve symptoms

Nutritional support

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100
Q

What is a hernia ?

A

A protrusion of a whole part of an organ through the wall of the cavity that contains it into an abnormal position.

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101
Q

What is a hiatal hernia ?

A

The protusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus. Typically the stomach herniating.
Common

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102
Q

What are the 2 subtypes of hiatus hernia ?

A

Sliding hiatus hernia - the GOJ, the abdominal part of the oesophagus and the cardia moves upwards through the diaphragmatic hiatus into the thorax

Rolling or para-oesopgheal hernia - upward movement of the gastric fundus occurs to lie alongside a normally positioned GOJ which creates a bubble of stomach in the thorax.

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103
Q

What are the risk factors for a hiatal hernia ?

A

Age
Pregnancy
Obesity
Ascites

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104
Q

What are some clinical features of hiatal hernias ?

A

Asymptomatic
May have GORD symptoms
Vomiting and weight loss
Anaemia
Hiccups

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105
Q

What are some investigations for hiatal hernias ?

A

OGD is gold standard
Incidental finding either on CT or MRI

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106
Q

What is the conservative management for hiatal hernias ?

A

PPI’s
Weight loss
Alteration of diet
Smoking cessation
Reduction in alcohol intake

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107
Q

When is surgical management indicated for hiatal hernias ?

A

Remaining symptomatic despite maximal medical therapy

Increased risk of strangulation / volvulus

Nutritional failure

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108
Q

What are the 2 aspects of hiatus hernia surgery ?

A

Cruroplasty - hernia is reduced from the thorax into the abdomen.
Fundoplication - the gastric fundus is wrapped around the lower oesophagus and stitched in place

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109
Q

What are the complications of hiatus hernia surgery ?

A

Recurrence of the hernia
Abdominal bloating
Dysphagia
Fundal necrosis

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110
Q

What are some complications of hiatal hernias ?

A

Prone to incarceration and strangulation
Gastric volvulus

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111
Q

A gastric volvulus presents with Borchardt’s triad. What does this contain ?

A

Severe epigastric pain
Retching without vomiting
Inability to pass an NG tube

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112
Q

What is a peptic ulcer ?

A

A break in the lining of the GI tract extending through the muscular layer of the bowel wall.

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113
Q

Where are the most common sites for a peptic ulcer to form ?

A

Lesser curvature of the proximal stomach
First part of the duodenum

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114
Q

What is the aetiology of peptic ulcer disease ?

A

The normal GI mucosa is protected by numerous defensive mechanisms such as surface mucous secretion and HCO3- ion release.
Peptic ulcer disease occurs when there is an imbalance of these.
Most commonly from Helicobacter pylori or NSAIDs use

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115
Q

Why do NSAIDs cause peptic ulcers ?

A

Their action in inhibiting prostaglandin synthesis resulting in a reduced secretion of glycoprotein, mucous and phospholipids by the gastric epithelial cells which would otherwise normally protect the gastric mucosa.

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116
Q

How does Helicobacter Pylori cause peptic ulcers ?

A

It is a gram negative spiral-shaped bacillus found in the mucous layer of those with duodenal ulcers or gastric ulcers.
It survives in the stomach by producing an alkaline micro-environment and induces an inflammatory response in the mucosa leading to eventual ulceration.

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117
Q

What are some risk factors for peptic ulcers ?

A

H. Pylori infection
Prolonged NSAID use
Corticosteroid use
Previous gastric bypass surgery
Physiological stress

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118
Q

What are the clinical features of peptic ulcer disease ?

A

Can be asymptomatic
Can have epigastric or retrosternal pain
Nausea
Bloating

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119
Q

What are some investigations for peptic ulcer disease ?

A

OGD
Testing for H. Pylori : carbon-13 urea breath test, serum antibiotics to H. Pylori or stool antigen test
OGD - biopsy and histology

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120
Q

What is the conservative management for peptic ulcer disease ?

A

Smoking cessation
Weight loss
Reduction in alcohol consumption
PPI

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121
Q

What are some complications for peptic ulcer disease ?

A

Perforation
Haemorrhage
Pyloric stenosis - rare

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122
Q

When is surgery required for peptic ulcer disease ?

A

In emergencies or in the management of Zollinger-Ellison syndrome

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123
Q

What is the most common type of gastric cancer ?

A

Adenocarcinoma

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124
Q

What are some risk factors for gastric cancer ?

A

Male
H . Pylori infection
Age
Smoking
Alcohol consumption
Salt in diet
Family history

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125
Q

What are some clinical features of gastric cancer ?

A

Often vague and non-specific
Dyspepsia
Dysphagia
Early satiety
Vomiting
Melaena
Weight loss
Epigastric mass
Ascites

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126
Q

What are some lab tests for gastric cancer ?

A

Urgent bloods

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127
Q

What imaging is performed when suspecting gastric cancer ?

A

OGD
Biopsy :
-histology
-CLO test
CT chest - abdomen - pelvis
Staging laparoscopy

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128
Q

What is the curative treatment for gastric cancer ?

A

Surgery
Peri-operative chemotherapy
Palliative - chemotherapy or stenting or surgery

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129
Q

What are some complications of gastric cancer ?

A

Gastric outlet obstruction
Iron deficiency anaemia
Perforation
Malnutrition

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130
Q

What are inguinal hernias ?

A

Inguinal hernia occurs when abdominal cavity contents enter into the inguinal canal.

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131
Q

What are the 2 main subtypes of inguinal hernias ?

A

Direct - bowel enters the inguinal canal directly through a weakness in the posterior wall of the canal termed Hesselbach’s triangle.

Indirect - bowel enters the inguinal canal via the deep inguinal ring

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132
Q

What are some risk factors for inguinal hernias ?

A

Male
Age
Raised intra-abdominal pressure - chronic cough, heavy lifting or chronic constipation
High BMI

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133
Q

What are some clinical features of inguinal hernias ?

A

Lump in the groin
Discomfort which can worsen with activity or standing
If it becomes incarcerated - painful and cant be reduced

134
Q

What are some investigations for inguinal hernias ?

A

Clinical diagnosis
USS if uncertain
Obstructed or strangulated - CT

135
Q

What is the management of inguinal hernias ?

A

Any symptomatic inguinal hernias should be offered surgical intervention.
Hernia repairs can be performed via open repair or laparoscopic.

136
Q

What are some complications of inguinal hernias ?

A

Incarceration
Strangulation
Obstruction

137
Q

What are some complications of elective inguinal hernia repairs ?

A

Haematomas or seroma formations
Recurrence
Chronic pain
Damage to vas deferens or testicular vessels

138
Q

What is femoral hernia at high risk of ?

A

Strangulation - they have a narrow neck

139
Q

What are some risk factors for femoral hernias ?

A

Female
Pregnancy
Raised intra-abdominal pressure
Age

140
Q

What are some clinical features of femoral hernias ?

A

Small lump in the groin - infero-lateral to pubic tubercle
Usually asymptomatic at presentation
Some may present as an emergency - obstruction or strangulation

141
Q

What are some investigations for femoral hernias ?

A

Pre-operative investigations - FBC, U&E’s, LFT’s, group and save, clotting, ABG

Diagnosis is usually clinical
USS - operator dependent
CT abdomen pelvis with contrast

142
Q

What is the management of femoral hernias ?

A

Surgically and within two weeks due to high risk of strangulation.
Low approach or high approach

143
Q

What are the serious complications of a hernia that require urgent intervention and describe them ?

A

Irreducible / incarcerated - the contents of the hernia are unable to return to their original cavity

Obstruction - the bowel lumen has become obstructed

Strangulation - compression of the hernia has compromised the blood supply leading to ischaemia

144
Q

What are some complications of femoral hernias ?

A

Strangulation
Obstruction

145
Q

What is gastroenteritis ?

A

Inflammation of the GI tract usually infective in origin.

146
Q

What is diarrhoea ?

A

3 or more loose stools or stools with increased liquid per day

147
Q

What is dysentery ?

A

Gastroenteritis characterised by loose stools with blood and mucus

148
Q

what is traveller’s diarrhoea ?

A

More than 3 loose stools commencing within 24 hours of foreign travel with or without cramps, nausea, fever or vomiting

149
Q

What are some risk factors for gastroenteritis ?

A

Poor food preparation
Immunocompromised
Poor personal hygiene

150
Q

What are some clinical features of gastroenteritis ?

A

Cramp - like abdominal pain
Diarrhoea ( with or without blood or mucus )
Vomiting
Weight loss
Pyrexia
Dehydration

151
Q

what specific features from the history should be noted for suspected cases of gastroenteritis ?

A

Bowel movements - blood stained, mucus, profusely watery

Affected family or friends

Recent travel abroad

Recent use of ABx

152
Q

What are some investigations for gastroenteritis ?

A

Not necessary for most cases as self-limiting
Stool culture

153
Q

What is the management of gastroenteritis ?

A

Rehydration
Education
Exclusion from work - 48 hours

Notifiable disease

154
Q

What are some infective causes of gastroenteritis ?

A

Norovirus

Rotavirus

Adenovirus

155
Q

what are some bacterial causes of gastroenteritis ?

A

Campylobacter
E. Coli
Salmonella
Shigella

156
Q

What parasites can cause gastroenteritis ?

A

Cryptosporidium
Entamoeba
Giardia
Schistosoma

157
Q

What is hospital acquired gastroenteritis ?

A

C. Difficile infection that usually develops following broad spectrum ABx disrupting the normal microbiota of the bowel.

158
Q

How does C. Difficile cause gastroenteritis ?

A

There is an overgrowth of C. Difficile bacteria leading to the organism being able to produce large amounts of exotoxins A & B. These cause a large immune response causing inflammatory exudate in the colonic mucosa. This causes severe bloody diarrhoea.

159
Q

What can a C. Difficile infection causing gastroenteritis lead to ?

A

Toxic mega colon

160
Q

What investigations should be performed for hospital acquired gastroenteritis ?

A

Stool culture
C. Difficile toxin testing

161
Q

What is the treatment for a C. difficile infection ?

A

IV fluid rehydration
Oral metronidazole
Vancomycin can be started in severe disease or if no improvemtn occurs after 72 hours

162
Q

What is appendicitis ?

A

Inflammation of the appendix - common surgical presentation

163
Q

How does acute appendicitis form ?

A

Typically caused by direct luminal obstruction usually secondary to faecolith, lymphoid hyperplasia or impacted stool.
When obstructed commensal bacteria in the appendix multiply causing inflammation.
This can result in increased pressure and ischaemia.

164
Q

What are the risk factors for appendicitis ?

A

Family history
Ethnicity
Seasonal presentation during the summer

165
Q

What are some clinical features of appendicitis ?

A

Abdominal pain ( initially peri-umbilical - dull, later migrates to the right iliac fossa - sharp )
Vomiting and nausea
Rebound tenderness
Fever
Guarding

166
Q

What are the specific signs to be aware of for appendicitis ?

A

Rovsing’s sign - RIF fossa pain on palpation of the LIF

Psoas sign - RIF pain with extension of the right hip

167
Q

What are some other differentials for someone presenting with appendicitis ?

A

Ovarian cyst rupture
ectopic pregnancy
UTI
IBD
Meckel’s diverticulum or diverticular disease
Testicular torsion

168
Q

What are some investigations for appendicitis ?

A

Urinalysis
Pregnancy test
Routine bloods - FBC, CRP, U&E’s, LFT’s
USS
CT abdomen - pelvis

169
Q

What is the definitive treatment for appendicitis ?

A

Laparoscopic appendicetomy

170
Q

What are some complications of appendicitis ?

A

Perforation
Surgical site infection
Appendix mass
Pelvic abscess

171
Q

What are some genetic mutations that predispose individuals to colorectal cancer ?

A

Adenomatous polyposis coli ( APC ) -mutation of the APC gene causing familial adenomatous polyposis

Hereditary nonpolyposis colorectal cancer - mutation to HNPCC leads to defects in the DNA repair

172
Q

What are some risk factors for colorectal cancer ?

A

Age
Male
Family history
IBD
Low fibre diet
High processed meat intake
Smoking
Excessive alcohol intake

173
Q

What are some clinical features of bowel cancer ?

A

Change in bowel habit
Rectal bleeding
Weight loss
Abdominal pain
Tenesmus

174
Q

What are some investigations for bowel cancer ?

A

FBC, LFT’s, clotting
Tumour marker - CEA
Colonoscopy with biopsy
CT chest-abdomen-pelvis with contrast
MRI rectum

175
Q

What is the staging system used for colorectal cancer ?

A

TNM
Dukes staging

176
Q

What is the management of colorectal cancer ?

A

Only definitive curative option is surgery although chemotherapy and radiotherapy have an important role as neoadjuvant and adjuvant treatments.

Most surgical plan is a regional colectomy followed by primary anastomosis or formation of a stoma.

177
Q

What is a Hartmann’s procedure ?

A

This procedure is used in emergency bowel surgery such as bowel obstruction or perforation. This involves a complete resection of the recto-sigmoid colon with the formation of an end colostomy and the closure of the rectal stump.

178
Q

What is a diverticulum ?

A

An outpouching of the bowel wall and is most commonly found in the sigmoid colon, but can be present throughout the large and small bowel.

179
Q

What is diverticulitis ?

A

Inflammation of the diverticula

180
Q

What is the pathophysiology of diverticular disease ?

A

The bowel naturally becomes weaker over time causing outpouching of the mucosa through the weaker areas.
Bacteria can overgrow within the outpouchings leading to inflammation of the diverticulum which can sometimes perforate.

181
Q

What are some risk factors for diverticular disease ?

A

Age
Low dietary fibre intake
Obesity
Smoking
Family history
NSAID use

182
Q

What are some clinical features of diverticulitis ?

A

Acute abdominal pain - sharp in nature, left iliac fossa, worsened by movement
Localised tenderness
Systemic upset

183
Q

What are some investigations for diverticulitis ?

A

Urine dipstick
FBC, CRP, U&E’s, faecal calprotectin
Group and save
VBG
CT abdomen pelvis with contrast
Flexible sigmoidoscopy

184
Q

What are some CT findings that suggest diverticulitis ?

A

Thickening of the colonic wall
Pericolonic fat stranding
Abscesses
Localised air bubbles
Free air

185
Q

How can uncomplicated diverticular disease be managed ?

A

Simple analgesia
Oral fluid intake

186
Q

How is acute diverticulitis managed ?

A

ABx
IV fluids
Analgesia
Surgical intervention - Hartmann’s procedure

187
Q

What are some complications of diverticulitis ?

A

Recurrence after treatment
Diverticular strictures - large bowel obstruction
Fistula formation

188
Q

What ages does Crohn’s usually occur ?

A

Bimodal peak
15 - 30 yrs and 60 - 80 yrs

189
Q

What is the pathophysiology of Crohn’s disease ?

A

It can affect any part of the GI tract ( mouth to anus ) although commonly targets the distal ileum or proximal colon.
Aetiology remains unknown

Microscopic appearance is non-caseating granulomatous inflammation.

190
Q

What can form in Crohn’s from transmural inflammation ?

A

Fistulas :
- Perianal
- entero-enteric
- recto-vaginal

191
Q

What is seen macroscopically in Crohn’s ?

A

Discontinuous inflammation - skip lesions
Fissures and deep ulcers - cobblestone appearance
Fistula formation

192
Q

What are the main risk factors for Crohn’s ?

A

Family history
Smoking

193
Q

What are some intestinal features of Crohn’s ?

A

Episodic abdominal pain - may be colicky
Diarrhoea - may contain blood or mucus
Oral aphthous ulcers
Perianal disease including with perianal abscess

194
Q

What are some extra-intestinal features of Crohn’s ?

A

Arthritis
Nail clubbing
Erythema nodosum
Anterior uveitis
Primary sclerosing cholangitis
Renal stones

195
Q

What are some pre-imaging investigations for Crohn’s ?

A

FBC, CRP
Faecal calprotectin
Stool sample

196
Q

What imaging is performed for Crohn’s ?

A

Colonoscopy is gold standard, biopsy is taken to confirm the diagnosis
CT abdomen - pelvis
MRI - disease severity

197
Q

What is the management for inducing remission in Crohn’s ?

A

Fluid resus
Nutritional support
Prophylactic heparin
Anti-embolic stockings

Corticosteroid therapy
Immunosuppressive agents - mesalazine or azathioprine

198
Q

What is the management for maintaining remission in Crohn’s ?

A

Azathioprine
Smoking cessation
Colonoscopic surveillance is offered

199
Q

When is surgical intervention indicted in Crohn’s disease ?

A

Failed medical management
Severe complications such as strictures or perforation

200
Q

What are some gastrointestinal complications of Crohn’s ?

A

Fistula
Stricture
Recurrent perianal fistulae
GI malignancy

201
Q

What are some extra-intestinal complications of Crohn’s ?

A

Malabsorption
Osteoporosis
Increased risk of gallstones
Increased risk of renal stones

202
Q

What is the peak incidence of UC ?

A

55 - 65 yrs

203
Q

What is the pathophysiology of UC ?

A

Diffuse continual mucosal inflammation of the large bowel, beginning in the rectum and spreading proximally.

204
Q

What are some histological changes in UC ?

A

Non-granulomatous inflammation of the mucosa and submucosa
Crypt abscesses
Goblet cell hypoplasia

205
Q

What are some macroscopic changes in UC ?

A

Continuous inflammation ( proximal from rectum )
Pseudopolyps and ulcers may form

206
Q

What are some clinical features of UC ?

A

Insidious in onset
Bloody diarrhoea
Proctitis - inflammation is confined to the rectum only
PR bleeding
Frequency and urgency of defection
Malaise, anorexia, pyrexia

207
Q

What are some extra-intestinal manifestations of UC ?

A

Arthritis
Erythema nodosum
Anterior uveitis
Primary sclerosing cholangitis

208
Q

What are some investigations for UC ?

A

FBC, U&E’s, LFT’s, CRP, clotting
Faecal calprotectin
Stool sample
Colonoscopy with biopsy
Plain film abdominal radiograph or CT abdomen - pelvis

209
Q

what are some features that can be seen on an AXR in UC ?

A

Mural thickening and thumb printing
A lead pipe colon

210
Q

Why should anti-motility drugs be avoided in acute attacks of UC ?

A

They can precipitate toxic megacolon

211
Q

What is the management for inducing remission in UC ?

A

Fluid resus
Nutritional support
Prophylactic heparin
Corticosteroid therapy
Immunosuppressive agents - ciclosporin

212
Q

What is the management for maintaining remission in UC ?

A

Immunomodulators - mesalazine or sulfasalazine or azathioprine
Colonoscopic surveillance

213
Q

What are some indications for surgery in UC ?

A

Refractory to medical management
Toxic megacolon
Bowel perforation

214
Q

What are some complications for UC ?

A

Toxic megacolon
Colorectal carcinoma
Osteoporosis
Pouchitis

215
Q

What is a volvulus ?

A

The 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.

216
Q

Where is the most common location for a volvulus and why is it the most common ?

A

Sigmoid colon
It has a long mesentery which makes the segment of bowel more prone to twist.

217
Q

What are some risk factors for a volvulus ?

A

Age
Neuropsychiatric disorders
Resident in a nursing home
Chronic constipation
Male
Previous abdominal operations

218
Q

What are some clinical features of a volvulus ?

A

Clinical symptoms of bowel obstruction
Colicky pain
Abdominal distension
Absolute constipation

219
Q

What are some investigations for a volvulus ?

A

FBC, U&E’s, TFT’s and Ca2+
CT abdomen - pelvis with contrast
AXR - coffee bean sign

220
Q

What is the conservative management of a volvulus ?

A

Decompression by sigmoidoscope and insertion of a flatus tube.

221
Q

what are the indications for surgery for a volvulus ?

A

Colonic ischaemia or perforation
Repeated failed attempts at decompression
Necrotic bowel noted at endoscopy

222
Q

What are some complications for a volvulus ?

A

Bowel ischaemia and perforation
Risk of recurrence
Complications from a stoma

223
Q

What are haemorrhoids ?

A

An abnormal swelling or enlargement of the anal vascular cushions.

224
Q

What is the tole of anal vascular cushions ?

A

They act to assist the anal sphincter in maintaining continence.

225
Q

What are some risk factors for haemorrhoids ?

A

Excessive straining - chronic constipation
Age
Raised abdominal pressure - pregnancy, chronic cough or ascites

226
Q

What are some clinical features of haemorrhoids ?

A

Painless bright red rectal bleeding - commonly after defection. Blood is seen on the surface rather than mixed into the stool

Rectal fullness
Pruritus

227
Q

What are some investigations for haemorrhoids ?

A

Proctoscopy
FBC, clotting screen
Colonoscopy

228
Q

What is the management of haemorrhoids ?

A

Conservative - increase fibre and fluid intake
Prescribe laxatives
Topical analgesia if painful
Surgery if conservative treatment fails

229
Q

What is an anal fissure ?

A

A tear in the mucosal lining of the anal canal most commonly due to trauma from defection of hard stool.

230
Q

What are some risk factors for an anal fissure ?

A

Constipation
Dehydration
IBD
Chronic diarrhoea

231
Q

What are some clinical features of anal fissures ?

A

Intense pain post defecation
Bleeding
Itching

232
Q

What is the management for anal fissures ?

A

Conservative :
Analgesia
Fluid and fibre intake
Stool softening laxatives - Movicol or lactulose

Medical :
GTN cream

Surgery
(Chronic fissures )

233
Q

What is jaundice ?

A

The yellow discolouration of the sclera and skin that is due to hyperbilirubinaemia.

234
Q

What are the types of jaundice ?

A

Pre-hepatic
Hepatocellular
Post-hepatic

235
Q

What is the normal process in which bilirubin is excreted ?

A

Bilirubin undergoes conjugation within the liver, making it water-soluble. It is then excreted via the bile into the GI tract, the majority of which is egested in the faeces as urobilinogen and stercobilin.

236
Q

How does pre-hepatic jaundice occur ?

A

There is excessive red cell breakdown which overwhelms the liver’s ability to conjugate bilirubin. This causes an unconjugated hyperbilirubinaemia.

237
Q

How does hepatocellular jaundice occur ?

A

There is dysfunction of the hepatic cells. Part of the liver loses the ability to conjugate bilirubin which leads to both conjugates and unconjugated bilirubin in the blood.

238
Q

how does post-hepatic jaundice occur ?

A

There is obstruction of the biliary drainage. The bilirubin that is not excreted will have been conjugated by the liver causing a conjugated hyperbilirubinaemia.

239
Q

How are some causes of pre-hepatic jaundice ?

A

haemolytic anaemia
Gilbert’s syndrome

240
Q

what are some causes of hepatocellular jaundice ?

A

Alcoholic liver disease
Viral hepatitis
Medications
Hereditary haemochromatosis
Primary biliary cirrhosis

241
Q

What are some causes of post-hepatic jaundice ?

A

Gallstones
Cholangiocarcinoma
Pancreatic cancer
Drug induced cholestasis

242
Q

What are some laboratory tests that should be performed for someone presenting with jaundice ?

A

LFT’s
Coag screen
FBC
U&E’s

243
Q

What imaging can be performed for jaundice ?

A

USS abdomen
Magnetic resonance cholangiopancreatography

244
Q

What is the management for jaundice ?

A

Treat underlying cause.
Anti-histamines if pruritus
Monitor coagulopathy

245
Q

What are some types of gall stone ?

A

Cholesterol stones - excess cholesterol production - links to poor diet, obesity,

Pigment stones - excess bile pigment production - links to haemolytic anaemias

Mixed

246
Q

What are some risk factors for gallstones ?

A

(Five F’s)
Fat
Female
Fertile
Forty
family history
Pregnancy
Oral contraceptives
Haemolytic anaemias

247
Q

What is biliary colic ?

A

This occurs when the gallbladder neck becomes impacted by a gall stone. There is no inflammatory response yet the contraction of the gallbladder against the occluded neck will cause pain.

248
Q

What are some clinical features of biliary colic ?

A

Pain - sudden, dull, colicky
RUQ and may radiate to the epigastrium
Precipitated by fatty foods
Nausea and vomiting

249
Q

What are some clinical features of cholecystitis ?

A

Constant pain in the RUQ or epigastrium
Signs of inflammation such as fever or lethargy

250
Q

What is murphy’s sign ?

A

While applying pressure to the RUQ ask the patient to inspire.
Murphy’s sign is positive when there is a halt in inspiration due to pain, indicated an inflamed gallbladder.

251
Q

What are some investigations if gall stone disease is suspected ?

A

Urinalysis and pregnancy test
FBC and CRP - raised WCC
LFT’s - raised ALP
Amylase - assess for pancreatitis
Trans-abdominal USS
Magnetic resonance cholangiopancreatography

252
Q

What can usually be visualised on an USS in there is gallstone disease ?

A

Presence of gallstones or sludge
Gallbladder wall thickness
Bile duct dilation

253
Q

What is the management of biliary colic ?

A

Analgesia - paracetamol +/- NSAIDs +/- opiates
Low fat diet
Weight loss
Increasing exercise
Elective laparoscopic cholecystectomy

254
Q

What is the treatment for acute cholecystitis ?

A

Appropriate IV ABx
Analgesia
Anti-emetics
Laparoscopic cholecystectomy

255
Q

What are some complications of gallstone disease ?

A

Mirizzi syndrome
Gallbladder empyema
Chronic cholecystitis
Gallstone ileus

256
Q

What is cholangitis ?

A

Infection of the biliary tree. It is caused by a combination of biliary outflow obstruction and biliary infection.

257
Q

What are some causes of cholangitis ?

A

Gallstones
ERCP
Cholangiocarcinoma

258
Q

What is the most common infective organism for cholangitis ?

A

E. Coli
Klebsiella species
Enterococcus

259
Q

What are some clinical features of cholangitis ?

A

RUQ pain
Fever
Jaundice
Pruritus
Pyrexia

260
Q

What are some PMH to indicate cholangitis ?

A

Gallstones
Recent biliary tract instrumentation
Previous Cholangitis

261
Q

What is in the charcot’s triad for cholangitis ?

A

Jaundcie
Fever
RUQ pain

262
Q

What are some investigations for cholangitis ?

A

FBC
LFT’s - raised ALP +/- GCT with raised bilirubin
Blood cultures
USS of the biliary tract
Gold standard - ERCP

263
Q

What is the immediate management for cholangitis ?

A

2 x wide bore cannula access
Fluid resus
Broad spectrum ABx - co-amoxiclav or metronidazole

264
Q

What is the definitive management of cholangitis ?

A

Endoscopic biliary decompression
ERCP - with or without sphincterotomy and stenting

265
Q

What are some complications of cholangitis ?

A

Repeated cholangitis
Bleeding
Perforation

266
Q

What are some factors that increase the risk of mortality in someone with cholangitis ?

A

Delayed diagnosis
Liver failure
Cirrhosis
CKD
Hypotension
Female
Over 55

267
Q

What is a cholangiocarcinoma ?

A

A malignancy of the biliary system. It can occur at any site alongside the biliary tree.

268
Q

What is the most common type of cholangiocarcinoma ?

A

Adenocarcinoma arising from cholangiocytes within the biliary tree with squamous cell carcinomas

269
Q

What are the main risk factors for cholangiocarcinoma ?

A

Primary sclerosing cholangitis
Intraductal gallstone formation
Infective
Toxins
Liver cirrhosis

270
Q

What are some clinical features of cholangiocarcinoma ?

A

Asymptomatic
Jaundice
Pruritus
Steatorrhoea
Non-specific abdominal pain
Dark urine
Weight loss
Lethargy

271
Q

What are some investigations for cholangiocarcinoma ?

A

Tumour markers - CEA and CA19-9
FBC, CRP, LFT’s
Magnetic resonance cholangiopancreatography
CT imaging
Staging - CT imaging and contract-enhanced MRI of the liver

272
Q

What is the management for cholangiocarcinoma ?

A

Complete surgical resection
Chemotherapy and radiotherapy - adjuvant therapy
Palliative - stenting, surgery, radiotherapy and chemotherapy

273
Q

What is a liver abscess ?

A

Typically results from a poly microbial bacterial infection spreading from the biliary or gastrointestinal tract.

274
Q

what are some common causes of liver abscesses ?

A

Cholecystitis
Cholangitis
Diverticulitis
Appendicitis
Sepsis

275
Q

What are some features of liver abscesses ?

A

Fever
Rigors
Abdominal pain
Weight loss
Jaundice
Fatigue
RUQ tenderness
Hepatomegaly

276
Q

What are some investigations for liver abscesses ?

A

FBC - leucocytosis
LFT’s - raised ALP, deranged ALT
USS
CT abdomen - pelvis with contrast

277
Q

What is the management of liver abscesses ?

A

Fluid resus
ABx
Image guided aspiration of the abscess

278
Q

What are some risk factors for liver cancer ?

A

Liver cirrhosis
Aflatoxin exposure
Hepatocellular adenoma
Smoking
Advanced age
Positive family history

279
Q

What are some clinical features of liver cancer ?

A

Fatigue
Weight loss
Irregular enlarged liver
Jaundice
Ascites

280
Q

What are some investigations for liver cancer ?

A

FBC, LFT’s and clotting
Alpha fetoprotein level
USS
MRI or CT - further assess lesions
Biopsy can be used

281
Q

What is the staging system for liver cancer ?

A

Barcelona clinic liver cancer staging system

282
Q

What is the management for liver cancer ?

A

Liver transplantation or liver resection
Ablative techniques
Metastatic disease - anti-angiogenic agents

283
Q

When is liver transplantation indicated ?

A

One lesion over 5cm or up to 3 lesions all over 3cm

There is no vascular infiltration

No extra-hepatic manifestations

284
Q

Why is metastasis to the liver common ?

A

Spread can occur via the portal circulation

285
Q

What is acute pancreatitis ?

A

Inflammation of the pancreas. It is distinguished from chronic by its limited damage to the secretory function of the gland with no gross structural damage developing.

286
Q

What are some causes of acute pancreatitis ?

A

Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune disease - SLE
Scorpion venom
Hypercalcaemia
Endoscopic retrograde cholangio-pancreatography
Drugs - azathioprine, NSAIDs, diuretics

287
Q

What are some clinical features of acute pancreatitis ?

A

Severe epigastric pain which can radiate through to the back
Nausea and vomiting

288
Q

What are some investigations for acute pancreatitis ?

A

FBC, U&E’s
LFT’s - ALT raised
Serum amylase
Serum lipase
Abdominal USS
CT abdomen - pelvis with constraint

289
Q

What is the management of acute pancreatitis ?

A

No curative management
IV fluids
Nasogastric tube if vomiting
Catheterisation - fluid balance chart
Opioid analgesia
ABx - prophylaxis can be considered

290
Q

What are some systemic complications for acute pancreatitis ?

A

DIC
ARDS
Hypocalcaemia
Hyperglycaemia

291
Q

What are some local complications for acute pancreatitis ?

A

Pancreatic necrosis
Pancreatic pseudocyst

292
Q

What is chronic pancreatitis ?

A

A chronic fibro-inflammatory disease of the pancreas resulting in progressive and irreversible damage to the pancreatic parenchyma.

293
Q

What are some causes of chronic pancreatitis ?

A

Chronic alcohol abuse
Idiopathic
Metabolic - hyperlipidaemia, Hypercalcaemia
Infection

294
Q

What are some clinical features of chronic pancreatitis ?

A

Chronic pain - epigastrium
Endocrine insufficiency - DM
Exocrine insufficiency - malabsorption ( weight loss, diarrhoea and stearrhoea )
Cachexia

295
Q

What happens to amylase and lipase levels in chronic pancreatitis ?

A

Amylase and lipase are often not raised

296
Q

What does CT imaging show in chronic pancreatitis ?

A

Pancreatic atrophy or calcification as well as pseudocysts

297
Q

What is the management of chronic pancreatitis ?

A

Analgesia
Enzyme replacement - Creon
Vitamin replacements
Steroids
Non-surgical - ERCP
Surgery

298
Q

What is whipple’s procedure ?

A

It involves removal of the head of the pancreas, the antrum of the stomach, the 1st and 2nd parts of the duodenum, the common bile duct and the gall bladder.

299
Q

What is the most common type of pancreatic cancer ?

A

Ductal carcinoma arising from the exocrine portion of the organ and compromises up to 90%

300
Q

Where is the most common site of pancreatic cancer ?

A

Head of the pancreas

301
Q

What are some risk factors of pancreatic cancer ?

A

Smoking
Chronic pancreatitis
Dietary factors - high red meat intake, low fruit and vegetables
Family history

302
Q

What are some clinical features of pancreatic cancer ?

A

Most are unresectable at diagnosis
Obstructive jaundice
Weight loss
Abdominal pain

303
Q

What investigations should be performed for pancreatic cancer ?

A

Initial blood tests - FBC, LFT’s
CA19-9 is a tumour marker
Abdominal USS
CT chest-abdomen-pelvis with contrast

304
Q

What is the management of pancreatic cancer ?

A

Only curative management is radical resection ( only 20% have resectable tumours )
Head of the pancreas tumour - pancreaticduodenectomy
Body or tail - distal pancreatectomy

305
Q

What are some complications from surgery for pancreatic cancer ?

A

Pancreatic fistula
Delayed gastric emptying
Pancreatic insufficiency

306
Q

What is a splenic infarct ?

A

An occlusion of the splenic artery or one of its branches resulting in tissue necrosis.

307
Q

What are some causes of a splenic infarct ?

A

Haematological conditions - lymphoma, sickle cell disease, hypercoagulability
Embolic conditions - endocarditis, AF, post MI mural thrombus

308
Q

What are some clinical features of a splenic infarct ?

A

LUQ pain which may radiate to the left shoulder
Fever
Nausea or vomiting
Pleuritic chest pain
Some may be asymptomatic

309
Q

What are some investigations for a splenic infarct ?

A

CT abdomen with IV contrast
FBC, U&E’s, LFT’s and coag screen
D dimer

310
Q

What is the initial management of a splenic infarct ?

A

Analgesia
IV fluids

311
Q

What is the long term management for a splenic infarct ?

A

Splenectomy
Low dose antibiotic cover
Regular vaccinations

312
Q

What are some complications of a splenic infarct ?

A

Splenic abscess
Auto-splenectomy

313
Q

What are some causes of splenic ruptures ?

A

Blunt trauma
Seat-belt injuries in a road traffic accident
Falls onto the left hand side
Iatrogenic
Splenomegaly due to infection or haematological malignancies

314
Q

What are some clinical features of splenic ruptures ?

A

Abdominal pain
Clinical features of hypovolaemic shock
LUQ tenderness

315
Q

What are some investigations for splenic ruptures ?

A

Haemodynamically unstable - laparotomy

Haemodynamically stable - urgent CT chest abdomen pelvis with contrast

316
Q

What is the management of a splenic rupture ?

A

Iv fluid
Analgesia
Unstable - urgent laparotomy
Prophylactic antibiotics
Embolisation

317
Q

What are some complications for conservative treatment for splenic rupture ?

A

Ongoing bleeding
Splenic necrosis
Splenic abscess or cyst
Thrombocytosis

318
Q

What is embolisation in splenic injuries ?

A

Patients with vascular abnormalities or high grade splenic injuries may benefit from embolisation of splenic vessels
The aim is to decrease the rate of laparotomy and splenectomy.

319
Q

Why is it important to give prophylactic antibiotics after a splenectomy ?

A

The spleen is an immunologically active organ and destroys encapsulated organisms. Asplenic patients are therefore unable to mount a normal immunological response against these organisms which can lead to sepsis.

320
Q

What are some basic principles for the management of a wound ?

A

Haemostasis
Cleaning the wound
Analgesia
Skin closure
Dressing and follow up advice

321
Q

When there is a significant injury or laceration of a vessel what steps should be taken to make the bleeding ?

A

Pressure
Elevation
Tourniquet
Suturing

322
Q

How should a wound be cleaned ?

A

Disinfect the skin
Decontaminate the wound by removing foreign bodies
Debridement any devitalised tissue
Irrigate the wound with saline
Antibiotics for high risk wounds or signs of infection

323
Q

What analgesia is used in wound management ?

A

Infiltration with local anaesthetic is the most common form of analgesia with regular paracetamol
Maximum level of lidocaine is 3mg/kg

324
Q

What are some skin closure methods for wound management ?

A

Skin adhesive strips
Tissue adhesive glue
Sutures
Staples

325
Q

What is the layers of dressings used for wound management ?

A

First layer is non-adherent ( saline soaked gauze )
Second layer has absorbent material to attract any wound exudate
Last layer is a soft gauze tape to secure the dressing

326
Q

Following initial wound management what advise should be given to the patient ?

A

Seek medical attention for any signs of infection
Take simple analgesia
Keep the wound dry
Sutures and strips should be removed after 10-14 days

327
Q

What are the 3 types of stomas ?

A

Colostomy
Ileostomy
Urostomy

328
Q

What are colostomies ?

A

They are stomas made from the large bowel and are found on the left iliac fossa.
The contents should be solid or semi-solid as the faeces have had time to travel through the colon undergoing water absorption.

329
Q

What is an ileostomy ?

A

They are created using the small bowel and typically located in the right iliac fossa. Less water has been absorbed in the small bowel so the contents tend to be mushy or liquids.

330
Q

Why in an ileostomy is there a spout of bowel sticking out of the skin ?

A

The enzymes in the small bowel can irritate the skin. This allows the faeces to drain without touching the skin

331
Q

What is a urostomy ?

A

They are created after a cystectomy and are typically located in the right iliac fossa.
An ileal conduit is used to route the urine out of the abdomen into the bag.

Y3 Surgery (8 decks)

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