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Surgery > General surgery > Flashcards

General surgery Flashcards

1
Q

acute generalised abdo pain

A

peritonitis
ruptured abdo aortic aneurysm
intestinal obstruction
ischemic colitits

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2
Q

acute right upper quadrant abdo pain

A

biliary colic
acute cholecystitis
acute cholangitis

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3
Q

acute epigastric pain

A

acute gastritis
peptic ulcer disease
pancreatitis
ruptured abdo aortic anyeusm

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4
Q

acute periumbilical abdo pain

A

early stage appendicitis
ruptured abdo aortic anyeusm
ischemic colitis
intestinal obstruction

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5
Q

acute right iliac fossa pain

A

acute appendicitis
ectopic pregnancy
ovarian torsion
ruptured ovarian cyst
meckles diverticulitis

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6
Q

acute left iliac fossa pain

A

diverticulitis
ectopic pregnancy
ovarian torsion
ruptured ovarian cysts

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7
Q

acute supra pubic pain

A

lower uti
acute urinary retention
pelvic inflammaotry disease
prostitatis

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8
Q

acute loin to groin pain

A

renal colic- kideny stones
ruptured abdo aortic aneurysm
pyelonephritis

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9
Q

acute testicular pain

A

testicular torsion
epididymo-orchitis

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10
Q

inital managemnt of acute abdome

A

abcde approach
airway
breathing
circualtion
disability= consiousness, gluocse levels
exposure- final assemsne tand abdo examination

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11
Q

investigations for acute abdoem

A

fbc= low hb? show bleed, wbc= inflam/infection
lft- liver function
u and e= electrolyte balance and see renal fucntion if going to have conrast
inr= see liver fuction and clotting ability
crp
amylase= see if inflam of pancreas
serum ca= score for acute pancreatitis
hCG/ urine preg test= all women child bearing age
serum lactate
abg= lactate and po2
group and save
blood culture- infection

abdo xray= bowel obstruction suspected see dialted bowel loops

erect cxr= show air under diapghragm if perforated intra bdo
abdo us - gallstones, gyny, biliary duct dilation

ct scans

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12
Q

what management is tere after abcde done for acute abdomen

A

alert sneior
nil by mouth ncase need surgery
bg tube if bowel obstructio
iv fluids may be needed
analgesia
iv antibiotics if infection
vte assesment
prescribe regular emds

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13
Q

signs of periotonitis

A

guarding - involuntary tensig of abdo wall muscles when palpated to protect area below
rigidity= involuntary persitant tightness
rebound tenderness= rapidly releasing pressure in the abdo creates worse pain than the presure itseld
coughing test- may result in pain in abdo
percussion tenderness

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14
Q

casues of localised peritonitis

A

underlying organ inflammation- appendicitis/ cholecystitis

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15
Q

casues of genrealsied periotnitis

A

perforation of abdo organ - ruptured appendix, perforated duodenal ulcer = release contents into abdo cavity

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16
Q

have gernealsied and localised peritonitis and what other casue of peritonitis

A

spontaneous bacteral peritonitis
= spontaenous infection of ascites in liver disease

trea ith brad spectrum antibiotcs

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17
Q

appendix is connecte to what

A

caecum

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18
Q

how does appendititis ocur

A

obstruction trap pathogens in appendix= infllamtion = can lead to gangrene and rupture
if rupture faecal contents and infective material in peritonal cavity= peritonitits

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19
Q

central abdo pain that moved to right iliac fossa in 12 hrs

A

appendicitis

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20
Q

rovsings sign can mean what

A

appendicitis
= press on left iliac fossa and get pain in right iliac fossa

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21
Q

s and s of appendicits
age of presentation

A

10-20 yrs old most common
can be in any age
less common over 50

abdo pain thats central and moves to roght iliac foss within 24 hrs

palaptation have tenderness at mc burneys point= 1/3 from of the distance from anterior superior iliac spine to umbillicus = line can feel the anterior iliac spine- most anterior boy bit and then a thrid away from this in a line to the belly button- bascially right iliac fossa

anorexia
nasuea and vomiting
low grade fever
rovsings sign= pain on right iliac
fossa when press on left
guarding
can get loin pain or bladder irritation, iritate ureter and abdo pain. can have diarrhoea if irritation of ileum
rebound tenderness in RIF
percussion tenderness
bottom two suggestive of peritonitis= ruptured appendix

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22
Q

what sings that appendix has ruptured

A

rebound tenderness
percsussion tenderness= peritonitits

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23
Q

how to diagnsoe appendicitis

A

alvarado score- help with probabiliyu
daignosis done by clinical presentation and raised inflammatory mnarkers

can do ct if need confrimation of diagnsosis esp if other differentials posisble

us can be done in feemales to exclude gyny

us can be done in children instead of ct if ct radiatio inappropriate
can do diagnostic laparascopy if clincial presentation suggest appendicitis but infecstigations say other wise. if need can then do appendicectomy at same time if needed

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24
Q

whats an appendix mass

A

on examination feel mass in rif
usually longer duration of onset
due to omentum sticking to inflammed appendix

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25
Q

treat appendix mass

A

antibtiocs and supportive treatment then appendicectomy once acute condition resolved

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26
Q

management of appendicitis

A

admission to hosp
10yrs over usually seen by adult general surgeon
appendicectomy - laparascopic decreased risks and faster recovery than laparotomy

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27
Q

complications of appendicectomy

A

bleeding, scar, pain , infection
scar
damage bowel, bladder and other organs
remove of normal appendix
anesthesia risks
VTE- pe and dvt

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28
Q

whats more common bowel obstruction - large or small

A

small bowel obstruction more common than large

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29
Q

whats the pathology of bowel obstruction

A

get obstruction causing back pressure and casues vomiting and dilatation of bowel proximal to obatruction

gi tract secreted fluid tjats then reabsorbed in colon but in obstruction cant get there so less fluid reasborbed so less fluid in intravascualr sapce causing hypovolaemia and shock = called third spacing

higher up the obstriction the greater the fluid loss as less bowel to reabsrob

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30
Q

casues of bowel obstruction

A

hernia - small bowel
adhesion - small bowel
tumours - large bowel

others:
volvulus
diverticular disease
strictures- secondary to crohns
intussuscpetion- 6months - 2year olds

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31
Q

when taking history and thinking bowel obstruction what need to ask about

A

casues of bowel obstruction - so hernia, recent operation, bowel habit, weight loss, bleeding

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32
Q

what casues adhesions in bowel

A

adhesions= scar tissue thaa binds the abdo contents together so kink and sqeeze bowel

endometriosis
peritonitits
abdo/pelvic surgery- esp open surgery
abdo/pelvic infections- pelvic inflammatroy disease

can be congentiatal or secndary to radiotherpay

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33
Q

whats a closed loop obstriction

A

two pints of obstructio so middle section of bowel sandwhiched= no way to drain out and no way to decompress so keeps expanding and will cause ischemia and perforation

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34
Q

causes of closed loop obsutrcion

A

adhesions - that compress two areas of the bowel
hernias= that isolate a section of bowel blocking wither end
volvulus= twists section o intestine
single point of obstruction in large bowel with a compenent ileocaecal valve= so contents cant flow backwards

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35
Q

presentation of bowel obstruction

A

vomiting- esp green billious fluid
absolute constipation and no flatulence
abdo distention
diffuse abdo pain
tinkling bowel sounds may be heard early on

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36
Q

what see in abdo xray in bowel obstruction
diameter of normal upper limit of small, colon and caecum

A

distention of bowel loops

normal upper limits of diameter of bowel:
3cm cmall bowel
6cm colon
9 cm caecum

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37
Q

how to know its large or small bowel on abdo xray

A

valvulae connvientes = small bowel. mucosal folds go all around width

haurasistra= large bowel- dont go all across

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38
Q

initial management of bowel obstruction

A

abcde
bloods- u and e to see elctroylte imbalance
vbg= raised lactate due to ischemia and metbaolic alklalosis due to vomiting stomach acid
nil by mouth
iv fluids - electroyle balance and hydration
ng tube with free drainage

abdo xray

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39
Q

what investigations do bowel ostruction

A

bloods
abdo xray - initial imaging
erect cxr to see if air uder diapraghm= perforation
contrast abdo ct= need check u and e frst and have cannula in to check renal fucntion cus using contrast

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40
Q

what investigation is inital and what is for confirming diagnosis of bowel obstruction

A

inital= abdo xray
confrim diagnosis= contrast ct - remeber to check u and e for renal fucntion

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41
Q

wehn will urgent intervention be needed in bowel obsturction

A

haemodynamically unstable =
sepsis
bowel perforation
bowel ischemia
hypovolaemic shcok- due to thrid spacing

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42
Q

when do surgery for bowel obstriction

A

can do watch and wait conservcative if stable to see if reoslvoes.

surgery for exploraition, hernia repair, adhesiolysis, stent via colonsocpy if tumour blockijng way

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43
Q

whats ileus

A

peristalsis of small bowel temporaily stops

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44
Q

whats pseudo obstruction

A

large bowel
no mechanical cuse of obstruction = functional obstruction of bowel

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45
Q

casues of ileus

A

surgery of abdomen- handling intestine
injury to bowel
infection/inflammation of bowel or nearby:
appendicitits, pancreatitis, peritonitits, pneumonia

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46
Q

distended abdomen
absolute constipation and no flatulence
diffuse abdo pain
no bowel sounds
vomiting green bilious stuff

A

ileus

same as bowel obstruction but no bowel sounds wereas mechanical obstruction may hear tinkling osunds on early obstruction esp

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47
Q

management ileus

A

normally resolves by treating uderlying cause

supportive treatment
iv fluid - electrolyte balance and hydration
ng tube if vomiting
nil by mouth
mobilisation- stimulate peristalsis
TPN= total parenteral nutrition may be required whilst waiting for bowel to regain function

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48
Q

whats the two types of volvulus

A

sigmoid
caecum

causes closed loop obstruction

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49
Q

whats more common volvulus

A

sigmoid

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50
Q

when does signoid and caecal volvulus occur

A

sigmoid- older pts
chronic constipation and lenghtehtning of the mesentery attactehced to sigmoid colon - sigmoid colon becomes over loaded with faces and sinks downwards and twists

caecal- younger pts

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51
Q

risk facotrs for volvulus

A

chronic constipation
high fibre diet
neuropsychiatric disorders - parkinsons
nursing hoe residents
pregnacy
adhesion
over use of laxatives- sigmoid

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52
Q

presentation of volvulus

A

like bowel obstruction- cus it is its a closed loop obstruction

abdo distention
diffuse abdo pain
absolute constipation and no flatulence
vomiting- esp green bilious vomiting

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53
Q

diagnose volvulus

A

contrast CT = investigation choice to confri daignsois/ idnetify other pathology

can do abdo xray

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54
Q

abdo xray shows coffee bean sign in bowel
what is this

A

sigmoid volvulus

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55
Q

mangemnt of volvulus

A

inital- same obstruction
iv fluids, ng tube, nil by mouth

conserevative=
endoscopic decompression in sigmoid volvuus if no peritonitits - uses felxi sigmoidoscopy

surgical:
lapartomy
hartmanns procedure = sigmoid = remove rectosigmoid and make colostomy

ileocaecal resection or a right hemicolectomy in caecal volvusus

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56
Q

risk factors for bowel cancer

A

fam hist
FAP
HNPCC
IBD
low fibre high red mean and processed diet
obestiy and sedentary lifestyle
smoking
alcohol

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57
Q

whats FAP

A

familial adenomatous polyposis
autosomal domintant
polyps form in large bowel that can be cancerous
malfunction in tummour supressor gene = adenomatous polyposis coli -APC

treat- remove all large bowel to be prophylactiss

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58
Q

whats HNPCC

A

herediatry non polyposis colorectal cancer - lynch syndrome

autsomal dominant
mutation in dna mismact hrepair gene
increase risk of lots cancers
doesnt casue mulitple adenomas

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59
Q

when refer for 2ww for bowel cacner

A

over 40 and got unexplained weight loss and abdo pain

over 50 and got unexplained rectal bleeding
over 60 and got change bowel habit/ iron deficicey anemia

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60
Q

whats iron deficency anemia results

A

microcytic anemia with low ferritin levels

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61
Q

presentation bowel acner red flags

A

weight loss
unexpaliend abdo pain
change bowel habits- normally diarrhoea and increase frequency
rectal bleeding
iron deficicney aneamia
abdo/rectal mass
acturely present with obstruction

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62
Q

what to do for screening bowel cacner

A

FIT test

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63
Q

what to do for daignosis of bowel cancer

A

goldstanderad is colonoscopy with biopsy

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64
Q

what investigations do for bowel cacner

A

fit test- human hb in stool
can be used screening 60-74 every 2 years
can be used for pts who dont fit 2ww eg. under 60 with change bowel habit

colonoscopy woth biopsy - gold standerd for diangosis

felxi sigmoidoscopy = if only got rectal bleeding
ct colography- bowel prep and contrast - do if pt not fit for colonscopy

staging ct scan- thorax, abdo ,pelvis

carcinoembryonic antigen - tumour marker for bowel cancer = used to predict relaspe in pts who have had previous bowel cancer

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65
Q

managemnt of bowel cancer

A

chemo
radiotherpay
palliative
surgery- can be cure or palliative

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66
Q

whats right hemicolectomy

A

removeal of caecum, ascending and proximal transverse colon

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67
Q

left hemicolectomy

A

remove distal transverse colon and descinging colon

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68
Q

high anterior resection

A

remove signoid colon

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69
Q

low anterior resection

A

remove signoid colon, upper rectum but spare lower rectum and anus = anastamose between colon and rectum

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70
Q

abdomino perineal resection

A

remove rectum and anus and maybe sigmoid colon

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71
Q

hartmanns procedure

A

in emergency done
remove recto sigmoid colon and create colostomy. suture recostump closed
can be rversed

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72
Q

pt had surgyer for bowel cancer but not got increased urgencyand frequency
diff to cotrol flatulence
faecal inconitnence

A

lower anterior resection syndroe

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73
Q

complication bowel surgery

A

bleeding, pain, infection
dmaage to n, bv, bladder, bowel, ureter
post op ileus
anesthetic risks
laparscopic but then had be open
leakage/failure of anastamoses
need stoma
copuldnt remove tumour
intrabdo adhesions
change bowel habit
VTE
incisional hernia

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74
Q

follow up bowel cancer surgery etc what test to do

A

CEA- carcinoembryonic antigen
ct thorax,abo and pelvis

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75
Q

fore gut/ blood supply to foregut

A

coeliac artery
stomach,part duodenum, pancreas, spleen, biliary system

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76
Q

midgut and blood supply to it

A

superior mesenteric artery
distal part duodenum–> first half transverse colon

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77
Q

hingut and its blood supply

A

inferior mesenteric artery
second half trasnverse colon–> rectim

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78
Q

whats chronic mesenteric ischemia

A

like angina
narrowing of mesenteric arteries due to atherlosclerosis

intermittent abdo pain when the blood supply cant keep up with demand

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79
Q

central colicky abdo pain after eating - start 30 mins after eating, least 1-2hrs
abdominal bruit on auscultation abdo aorta
weight loss- cu dont want eat cus hurt

what is this

A

chronic mesenteric ischemia

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80
Q

risk factors chronic mesenteric ischemia

A

same as cvd
hypertension
diabetes
raised cholesterol
smoking
fam hist
inreased age

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81
Q

diangose chronic mesenteric ischemia

A

ct angiography

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82
Q

magement chronic mesenteric ischemia

A

secondary prevention= statin, antiplatlet meds
reduce modifiable rf
revascularisation - first line endovascular procedure = percutaneous mesenteric artery stening

or open surgery - endartectomy, reimplantation and bypass graft

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83
Q

pt has acute non specific abdo pain but the pain is v severe but not really any findings on examination

A

acute mesenteric ischemia

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84
Q

what is and the cause of acute mesenteric ischemia

A

typically a rapid blockage in blood flow of through the superior mesenteric artery usually due to thrombus
thrombus due to either forme din the bv or embolsism

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85
Q

risk factors of acute mesenteric ischemia

A

AF

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86
Q

investigfations for acute emsenteric ischemia

A

ct with xontrast- can swee bv and whats happening to bowel

metabolic acidosis and high lactate blood leveles = due to ischemia

87
Q

pt has non specfic abod pain
metabolic acidosis
high lactate levels

what is it

A

acute mesenteric ischemia

88
Q

mangament of acute mesenteirc ischemia

A

surgery:
need to remove the necrotic boweland remove or bypass the thrombus
v high mortalitly

89
Q

complications of acute mesenteric ischemia

A

can develop shock, sepsis, peritonitis

over time the ishcmia leads to necrosis of bowel and perforation

90
Q

diverticulosis
diverticular disease
diverticulitis

A

diverticulosis= got diverticula= out puches of bowel = normally large
diverticular disease= got symptoms due to the out puches

diverticulitis= the puches got infalmmed/ infected

91
Q

why does divertular disease occur

A

theres circular muscles in the large intestine but its weak where the bv penetrate = vulnerbale
the pressure in the lumen over time causes gap to form in areas of circular muscles = mucsoa herniate

theres longitudinal muscle in large bowel= teniae coli but doesnt go all way aorund diabteter.

doesnt happen in recutm cus got longitudianl m all around

92
Q

where most commonly diverticula form

A

sigmoid colon
can get in small bowel but less common than large

93
Q

risk factors diverticular disease

A

inreased age
low fibre diet
use NSAIDs –> increases risk of diverticular haemorrhage
obestity

94
Q

lower left abdo pain
constipation
rectal bleeding

A

diverticular disease

95
Q

investigfations and management diverticular idsease

A

ususlay incidental finidng on ct/ colonscopy dont need do anything if asymptomatic
give advice on high fibre diet and weight loss
use bulk forming laxatives if needed- ispaghula husk - dont use stimulant laxatives eg. senna
surgery to remove area

96
Q

what laxatives use in diverticualr disease

A

bulk forming laxatives = ispaghula husk

dont use stimulant laxatives eg. senna

97
Q

presentation of acute diverticulitits

A

pain and tenderness in left iliac fossa (remeber diverticula normally where the sigmoid colon is) / left lower abdomen
fever
diarrhoea
nausea nad vomititng
rectal bleeding palpable abdo mass if absess formed
rasied crp and rasied wbc

98
Q

management of uncolplicated acute diverticulitis

A

can be manged priary care
oral co amoxicalv at least 5 days
no solid foods- clear liquids only until symptoms go 2-3 days
follow up within 2 days
analgesia but avoid nsaids and opidios

99
Q

mangement of acute diverticulitis with severe abdo pain/ complications

A

admsision
deal how deal with sepsis./ any acute badomen ( like the patient who saw on home visit who called ambulace for)
iv fluids
iv antibiotics
nil by mouth
analgesia
urgent investigfations- ct
urgent surgery if comolciations

100
Q

complications of acute diverticulitis - think like lady who saw on home visit who called ambulance for

A

perforation
peritonitits
peridiverticular disease
large haemorrhage- need transfusion
fistula- connecting colon to bladder / vagina
ileus/ obstruction

101
Q

risk factors/associations aith haemorrhoids

A

constipation
straining
pregnancy
obesity
raised intra abdo p= weight lifting , chronic cough
increased age

102
Q

pathology if anal cushions

A

specialsied submucosal tissue that has vein and artery anastomoss in= v vascualr
help control anal continence

blood suplly from rectal arteries

usally 3,7,11 o clock

103
Q

wheres 12 o clock on anus

A

towards genitals

104
Q

classification of haemorhoids

A

1st degree= no prolapse
2nd degree= prolapse when straining but return to normal when relax
3rd degree= prolpase when straining, cant return back to normal when relaxed, can be pushed in
4th degree= prolapsed permeantly

105
Q

on exaination what will haemorrhoids look like

what investigation to see hameorrhoids properly

A

prolpased haemorhoids are visible on inspection
may feel internal haemorrhoids but may not feel
may appear prolapsed if ask pt to bear down on insepction
proctoscopy - to see them propely

106
Q

presntation of haemorrhoids

A

feel lump inside anus/ outside
can be asymptomatic
painless, birhgt red on paper- not mixed in with stool
sore itchy anus

107
Q

differentials for haemorrhoids

A

= differentials for rectal bleeding
IBD
colorectal cancer
anal fissures
diverticulosis

108
Q

managemnt of haemorrhoids

A

consider testing for anemia if got proglonged bleeding / signs of anemia

topical treatment:
for symptoamtic treatment and reduce the swelling
- anusol= chemical that shirnks them

  • anusol HC- got hydrocortisone in = short term use only
    germoloids cream = lidocaine= LA
    proctosedyl ointment = cinchocaine an dhydrocortisone = short term use only

prevention and treamtment for constipation:
- increase fibre
drink fluids
laxatives
encourage to not strain

non surgical=
rubber band ligation
injection slcerotherpay = slcerosisi and atrophy
infra red coagualtion= dmaage blood supply
bipolar diathermy = electric current

surgical:
haemorrhoid artery ligation haemorrhoidectomy = removing anal cusion and s can get faecal incontinece
stapled hamorrhoiectomy

109
Q

how to tell difference bwetween colostomy and ileostomy

A

colostomy = colon brought to skin- more solid stools- flatter to the skin as sold contents less irriatating to skin
typically left iliac fossa but can be anywhere

ileostomy = ileum brought to skin
liquid stools
have a spout
typically right iliac fossa but can be anywehre

110
Q

whats a gastrostomy

A

connection between stomach and abdo wall
can be used to provitde feeds into the stumach
percutaneous endoscopic gastrostomy = fitted by endoscopy

111
Q

whats urostomy

A

opening of urinary system to skin
have a spout normally right iliac fossa

112
Q

when is an end colostomy irreversible

A

when abdomino-perineal resecntion- rectum and anus removed

113
Q

when may panproctocolectomy be done

A

total coletomy with removal large bowel, rectum and anus - IBD and FAP
or can do a j pouch

114
Q

whats a j pouch

A

ileo-anal anastamosis

115
Q

gall stones are mostly made of what

A

cholesterol

116
Q

what complciations can gall stones cause

A

pancreatitis
acute cholangitits
acute cholecysitits

117
Q

what forms the common hepatic duct

A

right hepatic duct and left hepatic duct

118
Q

whats the duct from the gallbaldder called

A

cystic duct

119
Q

the common bile duct and pancreatic duct join and become what

A

ampulla of Vater which opens into dudoennum. sphincter of oddi is ring of muscle around ampulla of Vater

120
Q

whats s and s of biliary colic

A

intermitent right upper quadrant pain caused by glalstones obstructing drainaige of gall bladder

121
Q

risk factrs for gallstone

A

forty
fair
female
fat

122
Q

presentation of gallstones

A

biliary colic- intermittent right upper quadrant pain / epigastric
pain often triggered by eating esp high fat meals - last 30 mins -8hrs
may have N and V

may present with the complications of gallstones :
acute cholecystitis, acute cholagntitis, pacnreatitis, obstructive jaundice

123
Q

what triggers the bilairy colic in gallstones

A

when fat enters digestive system the duodenum secretes CCK which triggers cotraction of gallbladder - stone in their obstrcuting flow so get colic
pts should avoid fatty meals to prevent cck release and gallbladder contraction

124
Q

with gallstones what will the liver function tests show

A

raised billirubin = pale stools and dark urine = obstrucive picture

raised ALP

ALT AND AST can be raised but not as much proprtion of alp

125
Q

raised billirubin due to obstruction in bilairy system
what cause

A

gall stones in bile duct
external mass pressing on bile duct= cholangiocarcinoma, cancer of head of pacnreas

126
Q

for a biliary obstruction picture ALP will be rasied and what two other signs may have

A

jaundice
right upper quadrant pain

127
Q

alp can be rasied when

A

bilairy obstruction

liver/bone malignancy
primary biliary cirrhois

pagets diease
others

128
Q

what investigation do for gallstones

A

us
although limties to pt weight, gaseous bowel obstructing view, discomfort from the probe

129
Q

what oes acute cholescystitis look like on US

A

thickened gallbladder wall, stones/sludge in gallbladder nad. fluid around gallbaldder

130
Q

what other investigations for gall bladder apart from forst line US

A

MRCP- snesitive to view bilaiory tree in detail
used if us doesnt show scans but theres bile duct dilatation / raised billirubin suggesting obstruction

ERCP
- endocpe doen

indication to do ERCP is to celar stones from bile duct
can inject contrast and take x ray to visualise biliary system
can perfrom sphincterotomy on the sphincte rof Oddi if its dysfucntional
clear stones from duct
insert stents
take biopsy

CT scans - less sueful for looking at bilairy system for fall stones. nmay be done todiagnose other casues

131
Q

complaiction of ERCP

A

execessive bleeding
cholangitits - infection in bile duct
pancreatitis

132
Q

managment of gallstones

A

if asymptomatic treat conservatively and no management

symptoms / complications then cholecystectomy - can remove gall stone sby ERCP if needed first

laparoscopic prefered. if open then leaves kocher incision

133
Q

complications of cholecystectomy

A

bleeding, infection, pain, ascar
damage to bile duct = leakage and strictures
stones left in bile duct
damage to bowel , bv, other organs
anestheitc risk

VTE
post cholecystectomy syndrome

134
Q

whats post cholecystectomy syndrome

A

occur after cholecystectomy
may be due to changes in bile flow
symptoms s improve with time

diarrhoea
indigestion
epigastric/RUQ pain / discomfort
nasuea
intolerenac eof fatty foods
flatulence

135
Q

whats the casues of acute cholecystits

A

mainly are due to gallstone trapped in neck of gallbladder or in cystic duct = calculous cholecystitis

few cases the gallbladder cant empty for other reasons = acalculous cholecystitis

eg. if pt in icu and not eaten / period of starving then the gallbladder nmot beig stimulatedby food to regulary emoty results in build up of presure

136
Q

acute cholecsytitis present

A

right upper quadrant pain that may radiate to right shoulder !!

fever
nausea and vomiting
tachycardia, tachypnoea
RUQ tenderness
murphys sign
raised inlafmamtory markers and wbc

137
Q

whats murphys sign

A

place hand on RUQ
apply pressure
ask pt deep breath in
c
brings gallbladder down to hand and casues lots of pain and stop ispiration

138
Q

pt has murphys sign
what does this mean they could have

A

acute cholecysrtitis

139
Q

pt has right upper quadrant pain radiating rto right shoulder

A

acute cholecystitis

140
Q

imaging for acute choelcsytts

A

abdo US
MRCP can be done to virew in more detail if common bile duct stone susepcted but not see on US

141
Q

signs of acute cholecystitis on abdo US

A

thickened gallbladder wall
sludge/stones in gallbladder
fluid around gallbladder

142
Q

when may you susepct a common bile duct stone

A

bile duct dilatation
raised billirubin

143
Q

how to manage acute cholecystitis

A

conservative:
nil by mouth
iv fluids antibiotcs
NG tube if vomiting

ERCPto remove stones in common bile duct

cholecystectomy - done within 72 hrs of symtoms in acute admission - may delay 6-8 wwweeks from start stymotims to allow inflmation to settle

144
Q

complications of acute cholecystitis

A

sepsis
perforation
gallbladder empyema
gangrenous gallbladder

145
Q

whats gallblader empyema and mangament of it

A

infected tissue and pus in gallbladder
antibiotocs and either cholecystectomy or cholecystotomy (insert drain into gallbladder and drain it)

146
Q

whats acute cholangitits

A

infection and infalmmation of bile ducts

147
Q

why is acute cholangitis a srugical emergency

A

can lead to sepsis and septicaemia

148
Q

main two casues of acute cholangitits

A

obstruction in bile duct stopping bile flow eg. gall stone in common bile duct
infection introduced during ERCP

149
Q

whats the common organsism to casue acute cholangitits

A

e coli

klebsiella species

enterococcus species

150
Q

fever
RUQ pain
jaundice (rasied billirubin)
what is this

A

acute cholangitits
when have three togerher= charcots triad

151
Q

causes of pancreatitis

A

I GET SMASHED
idiopathic
gallstones
ethanol
trauma
steroids
mumps
autoimmune
scorpion sting
hyperlipidaemia
ERCP- psot
drugs- thiazide diuretics, azathioprine, furosemide

152
Q

gallstones causing pancreatitis are more common in who

A

women
older pt

153
Q

alcohol casue of pancreatitis are more common in who

A

men
younger pt

154
Q

whats the three big casues of pancreatitis

A

alcholol misuse - directly toxic to pancreatic cells
ERCP
gallstones

155
Q

differentials of acute pancreatitis

A

peptic ulcer perforation
abdominal aorta aneurysm rupture
rupture of ectopic pregnancy
bowel obstruction
ischemia bowel

MI
biliary colic/ acute cholangititis, acute cholcystitis gastroenteritis
viral hepaitits

156
Q

pt has acute onset of severe epigastric pain that came on after a bit meal. the pain raidates through to the back/ scapula

A

acute pancreatitis

157
Q

presentation of acute pancreatitis

A

sudden onset
severe epigastric pain that may radiate through to back
vomiting
abdo tenderenes
systemiccaly unwell- low grade fever, tachycardia
may come on after fatty meal/ may come on few hrs after lots drinking session
jaundice
diarrhoea

158
Q

investigations for pancreatitis

A

do so can do glasgow score

u and e = urea
fbc= wbc
calcium
lft= ast/alt/ldh
amylase
ABG - p02 and blood glucose
crp= can monitor inflammation

US to asses for gallstone casue first line for gallstones

ct abdomen if suspect complciations

159
Q

whats the glasgow score

A

asses severity of pancreaitits
P= P02 less than 8
Age- over 55
N- neutrophils- wbc over 15
Calcium less than 2
urea more than 16
enzymes= ast / alt more than 200, LDH more than 600
albumin less than 32
sugar- glucose more than 10 (he endocrine function not working)

0-1= mild
2= moderate
3 or more severe pancreatitis

160
Q

whats a key investigation for pancreatitis that help diagnosis with clinical picture

A

amylase blood levels- acute have 3 x normal upper limit
may not be raised in chronic pacnreatitis as have lost function of the pancreas

161
Q

difference between chronic and acute pancreatitis

A

acute= rapid onset inflam, after epidosed normal fucntion of pacnreas return

chronic = gradual more progressive onset with permentant deterioration of pancreatic function

162
Q

complications acute pancretitis

A

necrosis of pancreas
infection of necrotic area
absecc foramtion
acure peripancreatic fluid collection
chronic pancreatitis
pseudocysts can occur 4 weeks after

163
Q

manage acute pancreatitis

A

abcde
iv fluids
stuff for glasgow score
antibiotics if infection eg. abseccs, necrotic tissue
nil by mouth - if mode- sevre so they are vomiting too. Enteral nutrtion- by tube. If mild so not vomiting etc and just the pain then can eat orally
analgesia
monitor
if gallstone pancreatitis treat gallstones- ERCP/ cholecystectomy
treat complciations - endocsopic/ perecutaneous drainiage

imrpove 3-7 days

164
Q

pt has recurrent upper abdo pain

drink lots alcohol

A

chronic pancreatitis

suspect chronic pacnreatitis in pt with recurrent/ persistant upper abdo/ generalised abdo pain esp if history of excess alcohol use

165
Q

most common casue chronic pancreatitis

A

alcholol

166
Q

s and s chronic pancreatitis

A

like acute but less intestes and longer lasting - epigastric/upper abdo pain that may radiate to bakc
nasuea vomiting
diarrhoea
may have steatohrea
amy present with complciations - eg. diabtetes

167
Q

complications chronic pancreatitis

A

chronic epigastric pain
loss exocrine fucntion= less enzymes esp lipase ==? steathorrea
loss endocrine function- less insulin- diabetes
damage and stricutres to duct= obstruction of secretion of pacnreatic juice and bile

pseudocysts/ absess

168
Q

mangament chronic pancreatitis

A

analgesia for pain
stop smoking, stop alcohol!!
replace enzymes if needed- creon = if not may be deficinet in fat soluble vitamins and have steathorrea
subcut insulin if diabtetic
ERCP- stenting for stricutres/ obstruction
surgery can treat chronic pain - remove the inflammed tissues/ drain ducts
surgery for obstruction pseudocysts, absecess

169
Q

what drugs can casue pacnreatitis

A

alcohol
steroids
furosemide
thiazide diuretics
azathioprine

170
Q

wat imaging to diagnose common bile duct stones and cholangitits

A

abdo us
ct
MRCP
ERCP- most sensitive

171
Q

managment of acute cholangitis

A

manage sepsis and acute abdoemn=
iv fluids
nil by mouth
iv antibiotics
blood cultures

ERCP - removal of stones

172
Q

what can you do in ERCp

A

removal of stones
cholangio pancreatography - injection contrast and x rays
spincterotomy- cut sphincter to increase diamater - helps removal of stones
balloon dilatation - treat strictures
biliary stenting - maintain a patent bile duct - tumour / stricture
biopsy - daignose obstructing lesion

173
Q

painless obstructive jaundice most likely casue

A

pancreatic cancer
other differential when see this is cholangiocarcinoma but pancreatic cacner is more likely than gallbladder cancer

174
Q

pancreatic cancer mainly what type and where metastitise to and where in pancreas most common

A

most are adenocarcinomas
most in head of pacnreas
liver first then bone, lungs and peritoneum

175
Q

palpable liver and jaundice

A

cholangiocarcinoma or pancreatic cacner - less likely to be gallstines by courvisers law

176
Q

presentation of pacnreatic cancer

A

painless obstructive jaundice
pale stool
dark urine

yellow skin and sclera
genrerlaised itching

others:
non specific upper abdo pain/ back pain
unitentional weight loss
palpable mass in epigastric region
chage in bowel habit
n/vnew onset diabetes / worsening t2dm

177
Q

diabetic pt :
pt has poor glycemic control but they actually have a good lifestyle and taking medication

A

suspect pancreatic cancer

178
Q

when to refer pt on 2 ww for pancreatic cancer suspcion

A

over 40 with jaundice

179
Q

pt over 40 and got jaundice. what do

A

2 ww

180
Q

over 60 with weight loss and got one of :
diarrhoea
back pain
ado pain
nasuea
vomiting
constipation
new onset diabetes

what do

A

direct acess CT abdo - only time gp can do this

181
Q

pt 66
weight loss and back pain

what do

A

direct acess ct abdo suspect pancreatic cancer

182
Q

investigations for pancreatic cacer

A

diagnostic= CT and histology from biopsy

staging ct- thoax, abdo, pevis

CA19-9= carbodhydrate antigen = tumour marker- may be raised in pancreatic cancer/ cholangiocarcinoma and others

MRCP- se bilairy detail

ERCP- stent to relive obstruction and biopsy

biopsy via percutaneous under us/ct GUIDANCE

183
Q

managment pancreatic cancer

A

surgery of small in head of pancreas - total pancreatectomy
distal pancreacectomy
whipple = remove pylorus, head pancreas, duodenum, gallbladder bile duct , relevanet lymph nodes
modified whipple= pylorus preserving

palliative :
stent to relive obstruction
surgery to improive symptoms
chemo, radiotherpy

e of l care

184
Q

cholangiocarcinoma is what

A

cancer in bile ducts

185
Q

type of cancers common for cholangiocarcnoma and where

A

majority adenocarcinoma
affect intrahepatic ducts or extrahepatic ducts

most common site is perihilar region- l and r hepatic duct join to form common hepatic duct

186
Q

risk factors for cholangiocarcinom

A

primary sclerosing cholangitits- rf of getting PSC is ulcerative colitits

liver flukes= parasitic infection - from south east asia and europw

187
Q

palpable gallbladder and jaundice is likely to be what

A

cholangiocarcinoma or pancreatic cancer - less likely be gallstones according to courvoisers law

188
Q

painless jaundice think what

A

pancreatic cancer - tumour in head or cholangiocarcinoma

189
Q

presentation of cholangiocarcinoma

A

painless jaundice
obstructive jaunce: pale stools, dark urine, generalised itching

others:
unexplained weight loss
RUQ pain
palpable gallbladder - swelling due to obstruction dustal to gall bladder
hepatomegaly

190
Q

investigations of cholangiocarcinmoma

A

CT/MRI and histology from biospy= diangogis

ct staging - Thorax, abco, pelviis
CA19-9 = carbodhydrate antigen= tumour marker can be raused
MRCP = see bilairy system more

ERCP= stent / biopsy

191
Q

CA19-9 is rasied in what

A

cholangiocarcinoma
pancreatic cancer
others

192
Q

cholangiocarcinoma and pancreatic cacner have what incommon

A

painless jaundice
CT/mri to diagnose with histology
rasied CA-19-9
palpable gallbladder
obstrucitve jaundice = pale stools, dark urine, genrealsied ithcing

193
Q

management cholagiocarcinoma

A

curative srugery if esrly
most palliative :
stents to relvie
surgery to inmprove symtpoms - bypass bilory obstruction
palliative chemo/radiothepry
e of life symptom control

194
Q

mercedes scar

A

liver trasnplant

195
Q

rooftop scar

A

liver transplant

196
Q

hockey stick scar

A

kidney trasnplant

197
Q

Left lower quadrant pain, low-grade fever in elderly patient

A

diverticulitits
- may have diarrhoea. then constipation
nasuea and amalasie

198
Q

what hernia is painful: incarcerated or strangulated

A

strangulated

199
Q

medial and superior to pubic tubercle lump

A

inguinal hernia

200
Q

lateral and inferior to pubic tubercle lump

A

femoral hernia

201
Q

whats the most common casue of small bowel obsstruction

A

adhesions
if pt had abdo surgery eg. appenciectomy always then think could be casuing small bowel obstrution - esp if got constipation, distention and early vomit

202
Q

treatment samll bowel obstruction

A

drip and suck
iv fluids with added potassium=> the proximal part of the bowel to the occluded bit will undergo more peristaliss (trying to move stuff) and so bowel will secrete more electroyltes including potassium which dont want to go hypo cus heart
ng tube

203
Q

most specific gold standard test for acute pancreatitis

A

lipase

amylase works and if 3x normal but lipase most specific

204
Q

treatment of c diff infection

A

vancomycin
if not respond then oral fidaxomicin

205
Q

Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAg

A

implies chronic HBV infection

206
Q

ppi can casue what change i electroyltes

A

hyponatreamia

207
Q

A 46-year-old man presents to the emergency department complaining of 3 days of watery diarrhoea which is occasionally bloody. On further questioning, he reveals cramping abdominal pain over the same period. He has dry mucous membranes and a prolonged capillary refill. Five days ago, he was started on a new medication by his GP.

What medication is most likely to cause this presentation?

A

climdamycin - can casue c diff

208
Q

fever, jaundice and right upper quadrant pain

A

ascending cholangiis

209
Q

richters hernia

A

Richter’s hernia is characterised by the absence of symptoms of obstruction even in the presence of strangulation, as the bowel lumen is patent while bowel wall is compromised. The VBG shows a low pH (acidotic) with a low pCO2 (due to partial respiratory compensation) and low bicarbonate (suggesting the cause of acidosis is metabolic) - metabolic acidosis which can occur due to the build-up of lactate.

210
Q

biliary colic

A

gallstones in way
when eat heavy meal esp if fatty the gallbladder contracts to put bile into intestne and this then means bile trying to get past the stone and so pushing it so comes in waves the pain and last 1-2 hrs not long
ruq pain

211
Q

A 37-year-old attends surgery due to a one day history of severe central abdominal pain radiating through to the back. He has vomited several times and is guarding on examination. Parotitis and spider naevi are also noted.

A

acute pancreatitis
spider naevi and parotitis suggest high alchol intake

212
Q

drugs causing pancreatitis

A

azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate

213
Q

treatment of un ruptured sigmoid volvulus

A

Sigmoid volvulus is a common pathology in the elderly which can initially be managed non-operatively with flatus tube decompression, avoiding the need for surgery which is higher risk in this age group. Decompression this way usually results in resolution of the volvulus without recurrence. Second line treatment is insertion of a percutaneous colostomy tube to decompress the volvulus when flatus tube decompression has proven unsuccessful or recurrence has occurred despite multiple attempts.

Surgery (7 decks)

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