General Surgery Flashcards
define a fistula
an abnormal connection between 2 epithelial surfaces
what does a “mercedes benz” scar on the abdomen indicate?
liver transplant
what does a hockey stick scar indicate?
renal transplant
at which 3 stages is the surgical safety checklist carried out?
- before induction of anaesthesia
- before the first skin incision
- before the patient leaves surgery
what is the ASA grade?
a scoring system to classify the physical status of a patient for anaesthesia
indications for a pre-op ECG?
- possible CVD
- aged >65
how long should the patient have been nil by mouth for pre-surgery
6 hours of no food and 2 hours of no fluids (true NBM)
pre-op management of pts on warfarin?
- stop warfarin
- check INR
- can give LMWH if high risk pt
when should contraception with oestrogen in it be stopped pre-op?
4 weeks before surgery
peri-op management of pts on long term steroids?
- additional IV hydrocortisone at induction
- double normal steroid dose post-op
drugs to be stopped pre-op?
- warfarin, DOACs
- COCP
- gliclazide (SFU)
diabetes drugs and their complications peri-op?
- gliclazide (hypoglycaemia)
- metformin (lactic acidosis)
- dapagliflozin (SGLT2 inhibit, DKA)
management of insulin peri-op?
- long acting: reduce dose
- short acting: stop
- start “sliding scale”
what is a “sliding scale”?
variable rate insulin infusion along with glucose, NaCl and K+ infusions
what are the options for VTE prophylaxis?
- LMWH (enoxaparin)
- DOAC (apixaban)
- intermittent pneumatic compression devices (IPCD)
- anti-embolic compression stockings
what are the 4 components of having the capacity to make a decision?
- understanding information
- retaining information
- weighing up pros and cons
- communicating the decision
what is a lasting power of attorney (LPA)?
when a person legally nominates someone to make decisions on their behalf IF they lack mental capacity
in which settings is a deprivation of liberty safeguards (DoLS) valid? what does this mean?
- hospital
- care home
- the pt is unable to leave
what are the 4 types of consent form?
- 1: pt consenting
- 2: parent consenting on behalf of child
- 3: pt will not lose consciousness for the procedure
- 4: pt lacks capacity
NSAIDs are contraindicated in….
- asthma
- renal impairment
- heart disease
- gastric ulcers
what is patient controlled analgesia (PCA)?
- IV infusion of a strong opiate (e.g. morphine) attached to a pump with a button
- only pt should press this button
examples of strong opiates?
- morphine
- oxycodone
- fentanyl
risk factors for post-op nausea and vomiting (PONV)?
- female
- younger age
- prev Hx
- Hx motion sickness
- non-smoker
- use of post-op opiates
- use of volatile anaesthetics
which anti-emetics can be used prophylactically post-op?
- ondansetron
- dexamethasone
- cyclizine
MOA of ondansetron? it should be avoided in….
- serotonin receptor antagonist
- pts at risk of long QT interval
dexamethasone drug class? it should be used with caution in…
- corticosteroid
- diabetes, immunocompromised pts
MOA of cyclizine? it should be used with caution in….
- histamine receptor antagonist
- HF, elderly
which antiemetics can be used for episodes of PONV?
- ondansetron
- prochlorperazine
- cyclizine
MOA of prochloperazine? it must be avoided in…
- dopamine receptor antagonist
- parkinson’s!!!!
non-drug management of PONV?
pressure on P6 acupuncture point of wrist
3 methods of enteral feeding?
- mouth
- NG tube
- PEG tube
what is total parenteral nutrition (TPN)?
- IV infusion of all nutrients
- done via central line
potential post-op complications?
- anaemia, shock
- sepsis
- atelectasis
- infections
- wound dehiscence
- ileus
- VTE
- urinary retention
- AF
what is a “third space”? give some examples
- space in body where there shouldn’t be any fluid
- peritoneal cavity (ascites)
- pleural cavity (pleural effusion)
- pericardial cavity (pericardial effusion)
- joints (effusion)
which pts require fluid restriction?
- HF
- CKD
- hyponatraemia (low Na+)
examples of insensible fluid loss?
- respiration
- in stool
- burns
- sweat
signs of hypovolaemia?
- systolic BP <100
- HR >90
- CRT >2 secs
- RR >20
- cold peripheries
- dry mucous mems, loss of skin turgor, sunken eyes
- reduced body weight
- reduced UO
signs of fluid overload?
- ankle oedema
- sacral oedema
- pulmonary oedema
- raised JVP
- increased body weight
signs O/E of pulmonary oedema?
- SOB
- reduced SpO2
- high RR
- bibasal crackles
what are the 3 main indications for IV fluids?
- resuscitation
- replacement
- maintenance
indications for fluid resuscitation?
- sepsis
- hypotension
examples of indications for fluid replacement?
- vomiting
- diarrhoea
example of indication for maintenance fluids?
NBM due to bowel obstruction
what are the 2 types of IV fluid?
- crystalloid
- colloid
examples of crystalloid fluids?
- 0.9% NaCl (normal saline)
- 5% dextrose
- hartmann’s solution
- plasma-lyte 148
which condition benefits from being given human albumin solution?
decompensated liver disease
what type of fluid is used in resuscitation? give some examples
isotonic ones:
- 0.9% saline
- hartmann’s solution
- plasma-lyte 148
how is fluid resuscitation carried out?
- A-E assessment to find out fluid status
- initial 500ml fluid bolus over 15 mins (stat)
- repeat A-E assessment
- repeat fluid bolus if necessary
- seek expert help if no response after 2L of fluid
which fluids can never be infused rapidly?
- any containing high K+ conc
- risk of arrhythmia or cardiac arrest
principles of using maintenance fluids?
- give for shortest time possible where patient is unable to take fluids PO
- stop as soon as PO fluids commence
examples of when maintenance fluids would be needed?
negative fluid balance unable to take PO fluids:
- NBM waiting for surgery
- bowel obstruction
what should be included in maintenance fluids?
- 25-30ml / kg / day water
- 1 mmol / kg / day Na+, K+ and Cl-
- 50-100g / day glucose
why is glucose included in maintenance fluids?
- to prevent ketosis
- NOT to meet nutritional needs
how is overprescribing of maintenance fluids in obese patients prevented?
use ideal body weight instead of BMI
monitoring requirements of maintenance fluids?
to be done at least daily:
- fluid status assessment
- look at fluid balance chart
- UEs
in which patient groups should maintenance fluids be prescribed with caution?
- elderly or frail
- significant oedema
- low or high Na+
- HF
- renal impairment
- liver impairment
differentials for generalised abdominal pain?
- peritonitis
- ruptured AAA
- bowel obstruction
- ischaemic colitis
differentials for RUQ pain?
- biliary colic
- acute cholecystitis
- acute cholangitis
differentials for epigastric pain?
- acute gastritis
- peptic ulcer disease
- pancreatitis
- ruptured AAA
differentials for central abdominal pain?
- ruptured AAA
- bowel obstruction
- ischaemic colitis
- appendicitis (early)
differentials for RIF pain?
- appendicitis (later)
- ectopic pregnancy
- ruptured ovarian cyst
- ovarian torsion
- meckel’s diverticulitis
differentials for LIF pain?
- diverticulitis
- ectopic pregnancy
- ruptured ovarian cyst
- ovarian torsion
differentials for suprapubic pain?
- LUTI
- urinary retention
- PID
- prostatitis
differentials for loin to groin pain?
- renal colic (stones)
- ruptured AAA
- pyelonephritis
differentials for testicular pain?
- testicular torsion
- epididymo-orchitis
signs of peritonitis?
- guarding
- rigidity
- rebound tenderness
- tender to percuss
- worse on coughing
how can peritonitis be classified?
- localised (organ inflamed)
- generalised (organ perforated)
- spontaneous bacterial (infection of ascitic fluid)
prognosis in SBP?
poor
management of the acute abdomen patient?
- A-E assessment
- escalate to seniors
- make pt NBM (if they might need surgery)
- NG tube (in BO)
- IV fluids if required
- IV ABx (in suspected infection)
- analgesia
- arrange investigations
- VTE assessment / prescription
pre-surgical management of acute abdomen?
- make NBM
- get consent (someone qualified should do this)
- anaesthetist review
- put on theatre list
- crossmatch units of blood
peak incidence of appendicitis?
- ages 10-20
- less common in young children and >50s
where is the appendix found?
- arises from caecum
- where the 3 teniae coli meet (longitudinal colon muscles)
what happens when the appendix ruptures?
- faecal matter released into peritoneal cavity
- irritates lining
- peritonitis
presentation of appendicitis?
- abdo pain which starts off central, then moves to RIF within 24h
- tenderness at mcburney’s point
- anorexia, N+V
- low-grade fever
- rovsing’s sign
- guarding
- rebound tenderness
- tender to percuss
where is mcburney’s point
1/3 of the way from the ASIS to the umbilicus
describe rovsing’s sign. where is this seen?
- palpating the LIF causes pain in the RIF
- appendicitis
how is appendicitis diagnosed?
- clinically
- CT may be used to confirm this
- laparoscopy is DIAGNOSTIC if still in doubt
- USS useful in females (rule out gynaecological stuff)
key differentials for appendicitis?
- ectopic pregnancy (check bHCG)
- ovarian cysts
- meckel’s diverticulum
- mesenteric adenitis
describe meckel’s diverticulum. which complications could it cause?
- malformation of distal ileum, typically asymptomatic
- volvulus
- intussusception
what is mesenteric adenitis? which conditions is it associated with?
- inflamed abdo lymph nodes
- tonsillitis
- URTI
what causes an appendix mass?
- when the omentum sticks to the inflamed appendix
- forms mass in RIF
management of appendicitis?
- emergency admission
- appendicectomy
- done either laparoscopically or open surgery
advantages of laparoscopic surgery over open surgery for appendicitis?
- fewer risks
- faster recovery
complications of appendicectomy?
- bleeding
- infection
- scarring
- pain
- damage to surrounding organs
- anaesthetic risks
- VTE
which type of bowel obstruction is more common, small or large?
small
how does bowel obstruction result in fluid loss? what determines the severity of this?
- colon should be absorbing fluid but the fluid cannot reach it because of blockage
- results in “third spacing”
- higher up the obstruction, the worse the third spacing
3 main causes of bowel obstruction?
- adhesions (small bowel)
- hernias (small bowel)
- malignancy (large bowel)
less common causes of bowel obstruction?
- volvulus (large bowel)
- diverticular disease
- strictures secondary to Crohn’s
- intusussception
causes of adhesions?
- abdo / pelvic surgery
- peritonitis
- abdo / pelvic infections
- endometriosis
presentation of bowel obstruction?
- green, bilious vomiting
- abdo distension
- diffuse abdo pain
- obstipation
- “tinkling” bowel sounds in early stages
initial investigation of choice and findings in bowel obstruction?
- XR
- distended loops of bowel
- valvulae conniventes (small bowel)
- haustra (large bowel)
complications of bowel obstruction?
- hypovolaemic shock (from third spacing)
- bowel ischaemia
- bowel perforation
- sepsis
findings on bloods in bowel obstruction?
- electrolyte imbalance
- metabolic alkalosis (due to vomiting)
- raised lactate (ischaemia)
initial management of a bowel obstruction?
- make NBM
- IV fluids
- NG tube with free drainage
investigations for bowel obstruction?
- abdo XR
- erect CXR (shows air under diaphragm)
- abdo CT with contrast
- bloods
surgical management of bowel obstruction?
- exploratory surgery if cause unclear
otherwise depends on cause:
- adhesiolysis
- hernia repair
- emergency resection
- stent to move tumour out of way if Ca cause
pathophysiology of ileus?
temporary cessation of peristalsis in the small bowel
causes of ileus?
- injury to bowel
- handling of bowel in surgery
- local inflamm / infection (e.g. peritonitis, appendicitis, pancreatitis)
- electrolyte imbalance
which electrolyte imbalances could cause ileus?
- hypokalaemia
- hyponatraemia
commonest time to have ileus? prognosis?
- straight after abdo surgery
- self-resolves within a few days
presentation of ileus?
literally identical to that of BO:
- green, bilious vomiting
- abdo distension
- diffuse abdo pain
- obstipation
- ABSENT bowel sounds instead of tinkling
management of ileus?
- make NBM
- NG tube if vomiting
- IV fluids
- mobilisation (stimulates peristalsis)
- TPN whilst waiting for peristalsis to kick in
pathophysiology of volvulus?
- bowel twists around on itself and surrounding mesentery
- causes closed-loop obstruction
what is a closed loop bowel obstruction?
when an area of bowl is isolated by obstruction on either side of it
types of volvulus? hint: where they happen
- sigmoid volvulus
- caecal volvulus
most common type of volvulus? typical demographic affected?
- sigmoid volvulus
- elderly
risk factors for volvulus?
- parkinson’s
- being a nursing home resident
- chronic constipation
- high fibre diet
- pregnancy
- presence of adhesions
presentation of volvulus? hint: same as BO
- green, bilious vomiting
- abdo distension
- diffuse abdo pain
- obstipation
how is volvulus diagnosed?
- abdo XR shows “coffee bean” sign in sigmoid volvulus
- confirmed with contrast CT
initial management of volvulus?
same initial management as BO:
- make NBM
- NG tube
- IV fluids
conservative management of volvulus?
endoscopic decompression
surgical management of volvulus?
- laparotomy
- hartmann’s procedure
- ileocaecal resection / right hemicolectomy if caecal
presentation of abdominal wall hernia?
- soft lump
- may be reducible
- may protrude on coughing or standing
- aching, pulling or dragging sensation
complications of hernias?
- incarceration
- bowel obstruction
- strangulation and ischaemia
how does a strangulated hernia present? what’s the significance of this?
- pain and tenderness over lump
- needs emergency surgery, bowel will be dead in hours
describe a maydl’s hernia
a hernia with 2 different loops of bowel in it
describe a richter’s hernia
- hernia where only part of the bowel lumen and wall are in it
- prone to strangulation
management options for a hernia?
- conservative
- tension-free surgical repair
- tension surgical repair
which hernias can be managed conservatively?
- hernias with a wide neck (low risk of complications)
- where pts have too many comorbidities for surgery
how can inguinal hernias be classified?
- direct
- indirect
differentials for lump in inguinal region?
- inguinal hernia
- femoral hernia
- swollen lymph node
- saphena varix
- femoral aneurysm
- abscess
- undescended / ectopic testis
- kidney transplant
what is an indirect inguinal hernia?
bowel herniating through the inguinal canal
what is the inguinal canal? where does it run between?
- tube connecting peritoneal cavity to scrotum
- deep inguinal ring
- superficial inguinal ring
describe the course of the round ligament in females?
- uterus
- deep inguinal ring
- inguinal canal
- labia majora
where is the deep inguinal ring found?
halfway between ASIS and pubic tubercle
how can an indirect inguinal hernia be differentiated from a direct one?
- reduce the hernia
- apply pressure at the location of the deep inguinal ring
- hernia should REMAIN reduced in doing this
what causes direct inguinal hernias to form?
weakness of the abdo wall at hesselbach’s triangle
RIP: borders of hesselbach’s triangle?
- rectus abdominis
- inferior epigastric vessels
- poupart’s (inguinal) ligament
describe a femoral hernia
abdo contents herniating through the femoral canal
FLIP: boundaries of the femoral canal?
- femoral vein
- lacunar ligament
- inguinal ligament
- pectineal ligament
what is the femoral triangle?
large area at top of thigh which contains the femoral canal
where do incisional hernias occur?
at the site of incision of past surgery
typical demographic affected by umbilical hernias? prognosis?
- neonates
- good, self-resolving
describe a hiatus hernia
stomach herniating through hole in diaphragm
4 types of hiatus hernia?
- sliding
- rolling
- mixed sliding and rolling
- large opening (more organs than just stomach entering thorax)
risk factors for hiatus hernia?
- ageing
- obesity
- pregnancy
presentation of hiatus hernia?
- heartburn
- acid / food reflux
- burping
- bloating
- bad breath
investigations for hiatus hernia?
- not always present so not always visible
- CXR
- CT
- endoscopy
- barium swallow testing
management of hiatus hernia?
- conservative
- surgical laparoscopic fundoplication
what is a haemorrhoid?
an enlarged anal vascular cushion
risk factors for haemorrhoids?
- constipation, straining
- pregnancy
- obesity
- ageing
- increased intra-abdominal pressure
give examples of how intra-abdominal pressure could be raised
- weightlifting
- chronic coughing
how can haemorrhoids be classified?
- 1st deg: no prolapse
- 2nd deg: prolapse when straining, disappears on relaxing
- 3rd deg: prolapse when straining and does NOT disappear on relaxing, but can be pushed back
- 4th deg: prolapsed permanently
presentation of haemorrhoids?
- can be asymptomatic
- painless, bright red bleeding
- blood NOT mixed in with stool
- sore / itchy anus
- palpable lump around / inside anus
signs O/E of haemorrhoids?
- external ones are visible on inspection
- internal ones may be felt on PR exam
differentials for rectal bleeding?
- haemorrhoids
- anal fissures
- diverticulosis
- IBD
- colorectal Ca
non-surgical management of haemorrhoids?
- topical astringent (e.g. anusol)
- germoloid cream
- prevent / treat constipation
- avoid straining
- rubber band ligation
- injection sclerotherapy
- infra-red coagulation
- bipolar diathermy
surgical management of haemorrhoids?
- haemorrhoidal artery ligation
- haemorrhoidectomy
- stapled haemorrhoidectomy
what causes a haemorrhoid to become thrombosed?
when there is strangulation at the base of the haemorrhoid
presentation of thrombosed haemorrhoid?
- purplish, very tender lumps around anus
- PR impossible due to pain
what is a diverticulum?
a pouch in the bowel wall
what is the difference between diverticulosis / diverticular disease and diverticulitis?
- first one is presence of diverticula without any inflamm / infection
- second one is where there IS inflamm / infection present
which parts of the bowel wall are most susceptible to diverticula forming?
areas where there are no teniae coli
most commonly affected portion of the bowel in diverticulosis?
sigmoid colon
risk factors for diverticulosis?
- ageing
- low fibre diet
- obesity
- NSAID use
how is diverticulosis diagnosed?
usually asymptomatic, incidental finding on colonoscopy / CT scans
how could diverticulosis present?
- usually asymptomatic
- LIF pain
- constipation
- rectal bleeding
management of diverticulosis?
- increase dietary fibre
- bulk-forming laxatives (ispaghula husk)
- avoid stimulant laxatives (senna)
- surgery if symptoms are significant
how does acute diverticulitis present?
- pain and tenderness in LIF
- fever
- diarrhoea
- N+V
- rectal bleeding
- palpable abdo mass
- raised inflamm markers and WCC on bloods
management of uncomplicated diverticulitis?
- no need for admission
- PO co-amox for 5 days
- analgesia, but avoid NSAIDs and opiates
- clear liquid diet until symptoms improve
- follow up in 2 days to review symptoms
management of severe diverticulitis?
- hosp admission
- make NBM
- IV ABx
- IV fluids
- analgesia
- urgent CT
- urgent surgery if there is any complication
complications of acute diverticulitis?
- perforation
- peritonitis
- abscess
- large haemorrhage (give transfusion)
- fistula
- ileus / obstruction
3 main arteries supplying abdominal arteries?
- coeliac artery (foregut)
- superior mesenteric artery (midgut)
- inferior mesenteric artery (hindgut)
presentation of chronic mesenteric ischaemia? hint: triad
- abdo pain
- weight loss
- abdominal bruit on auscultation
describe the abdo pain felt in chronic mesenteric ischaemia
- central
- colicky
- comes on 30 mins after eating
- lasts 1-2 hours
how does chronic mesenteric ischaemia result in weight loss?
food avoidance due to pain after eating
risk factors for chronic mesenteric ischaemia?
same as any other cardiovascular disease:
- ageing
- FHx
- smoking
- DM
- HTN
- raised cholesterol
how is chronic mesenteric ischaemia diagnosed?
on CT angiography
management of chronic mesenteric ischaemia?
- address modifiable risk factors
- statins and antiplatelets (secondary prevention)
- revascularisation (improve blood flow to intestines)
how is revascularisation performed for chronic mesenteric ischaemia?
either:
- endovascular (percutaneous mesenteric artery stenting), 1st line
- open surgery (endarterectomy or bypass)
key risk factor for acute mesenteric ischaemia?
AF (basically an embolic stroke but in the gut)
early presentation of acute mesenteric ischaemia?
- abdo pain disproportionately worse than findings O/E
later presentation of acute mesenteric ischaemia?
- shock
- peritonitis
- sepsis
- bowel perforation
first line investigation in acute mesenteric ischaemia?
contrast CT
findings on bloods in acute mesenteric ischaemia?
- metabolic acidosis
- raised lactate
management of acute mesenteric ischaemia?
surgery to remove bowel and remove / bypass thrombus in artery
prognosis in acute mesenteric ischaemia?
- poor
- >50% mortality rate !
risk factors for bowel Ca?
- FHx
- familial adenomatous polyposis (FAP)
- HNPCC
- IBD
- ageing
- diet
- obesity
- sedentary lifestyle
- smoking
- alcohol
which aspects of diet can increase risk of bowel Ca?
- high red meat
- high processed meat
- low fibre
what does FAP result in? pattern of inheritance?
- adenomas (polyps) develop in the large intestine
- polyps can become malignant, usually before age of 40
- autosomal dominant
how can bowel Ca be prevented in someone with FAP?
entire large intestine removed
which familial conditions increase the risk of bowel Ca?
- FAP
- HNPCC (esp colorectal Ca)
presentation of bowel Ca?
- change in bowel habit (typically more loose and frequent motions)
- unexplained weight loss
- rectal bleeding
- unexplained abdo pain
- Fe def anaemia (microcytic, low ferritin)
- abdo / rectal mass O/E
2WW criteria for bowel Ca?
- > 40 with abdo pain and unexplained weight loss
- > 50 with unexplained PR bleeding
- > 60 with change in bowel habit or Fe def anaemia
what does FIT testing look for? what is it used for?
- amount of human Hb in stool
- to screen for bowel Ca
why is the FOB test for bowel Ca not very accurate?
- just detects any form of blood
- false positives from red meat blood
who gets screened for bowel Ca? how often is this done?
- those aged 60-74
- they get sent a FIT test every 2 years
how is the FIT test result interpreted?
if positive, invite them to colonoscopy
investigations for bowel Ca?
- colonoscopy (gold standard)
- sigmoidoscopy
- CT colonography
- CT TAP (thorax, abdo, pelvis - done for staging)
- CEA tumour marker on bloods
how is bowel Ca classified?
TNM system or using dukes’ classification:
- A: confined to mucosa of bowel wall
- B: extends through muscle of wall
- C: lymph nodes
- D: metastatic disease
management of bowel Ca?
- surgical resection
- chemo / radiotherapy
- palliative care
what is low anterior resection syndrome? how does it present?
- complication of having bowel surgically resected
- urgency, frequency and incontinence of BMs
- difficulty in controlling flatulence
investigations following curative surgery for bowel Ca?
- serum CEA levels
- CT TAP
what are most gallstones made of?
cholesterol
complications of gallstones?
- acute cholecystitis
- acute cholangitis
- obstructive jaundice
- pancreatitis
4Fs: risk factors for gallstones?
- fat
- fair
- female
- forty
presentation of gallstones?
- “biliary colic”:
- severe RUQ colicky pain
- triggered by meals (esp fatty ones)
- lasts 30 mins - 8 hours
- associated N+V
findings on LFTs in gallstones?
- raised bilirubin if gallstone is in bile duct (obstructing it)
- significantly raised ALP
- slightly raised ALT / AST
first line investigation in gallstones?
USS
findings on USS in gallstones?
- stones in GB / ducts
- bile duct dilatation (should be <6mm diameter)
- acute cholecystitis
findings on USS indicative of acute cholecystitis?
- thickened GB wall
- stones / sludge in GB
- fluid surrounding GB
management of gallstones in bile duct?
ERCP
complications of ERCP procedure?
- excessive bleeding
- cholangitis (infection of bile ducts)
- pancreatitis
management of gallstones?
- if asymptomatic, then nothing
- cholecystectomy (GB removal)
- ERCP if in bile ducts
what is post-cholecystectomy syndrome? features?
- complication of GB removal
- diarrhoea
- nausea, indigestion
- epigastric / RUQ pain
- flatulence
what is acute cholecystitis?
inflammation of gallbladder
causes of acute cholecystitis?
anything compressing cystic duct:
- gallstones
- tumour
- infection
- fasting (GB not stimulated to move)
presentation of acute cholecystitis?
- RUQ pain+/- radiates to R shoulder
- fever
- N+V
findings O/E of acute cholecystitis?
- high HR
- high RR
- RUQ tenderness
- murphy’s sign
findings on bloods in acute cholecystitis?
- raised inflamm markers
- raised WCC
describe murphy’s sign
- put pressure on RUQ and ask pt to breathe in
- in acute cholecystitis, this is painful
- pt will suddenly stop breathing in
first line investigation in acute cholecystitis?
abdo USS
findings on USS in acute cholecystitis?
- thickened GB wall
- stones / sludge in GB
- fluid around GB
management of acute cholecystitis?
- needs emergency admission
- make NBM
- IV fluids
- ABx
- NG tube insertion if vomiting
- ERCP to remove stones stuck in CBD
- cholecystectomy if <72h of symptom onset
complications of acute cholecystitis?
- sepsis
- GB empyema
- gangrenous GB
- GB perforation
what is GB empyema? how is it managed?
- pus in GB due to infection
- cholecystectomy (GB removal)
- cholecystostomy (draining infected contents)
what is acute cholangitis?
- infection and inflammation of bile ducts
- surgical emergency
2 main causes of acute cholangitis?
- obstruction (e.g. stones) in bile ducts stopping slow
- infection from ERCP procedure
commonest causative organisms in acute cholangitis?
- E. coli
- klebsiella
- enterococcus
presentation of acute cholangitis? hint: triad
charcot’s triad:
- RUQ pain
- fever
- jaundice
management of acute cholangitis?
- needs emergency admission
- make NBM
- IV fluids
- blood cultures
- IV ABx
- involve senior ICU staff
- ERCP
- PTC (drain insertion) if ERCP fails
key complications of acute cholangitis?
- sepsis
- septicaemia
- cause a high mortality rate
which procedures can be carried out in ERCP for acute cholangitis?
- cholangio-pancreatography
- sphincterotomy
- stone removal
- balloon dilatation
- stenting
- biopsy
what is a cholangiocarcinoma? what is the most common type?
- Ca of bile ducts
- adenocarcinoma
risk factors for cholangiocarcinoma?
- PSC
- liver flukes (parasitic infection)
presentation of cholangiocarcinoma?
- painless, obstructive jaundice
- unexplained weight loss
- RUQ pain
- palpable GB
- hepatomegaly
signs of obstructive jaundice?
- yellow skin and sclera
- pale stools
- dark urine
- generalised itching
what is courvoisier’s law? what is the significance of this?
- a palpable GB with jaundice is unlikely to be gallstones
- makes cholangiocarcinoma / pancreatic Ca more likely
investigations for cholangiocarcinoma?
- CT TAP for staging
- CA 19-9 (tumour marker, raised)
- MRCP
- ERCP to put stent in and relieve obstruction
management of cholangiocarcinoma?
- curative surgery in early cases
- rest is palliative
commonest site for a pancreatic Ca?
head of pancreas
prognosis of pancreatic Ca?
- very poor
- avg survival = 6m
- 5YS = <25%
presentation of pancreatic Ca?
- painless obstructive jaundice
- non-specific upper abdo / back pain
- unintentional weight loss
- palpable mass in epigastric region
- change in bowel habit
- N+/-V
- new onset / worsening T2DM
describe trosseau’s sign of malignancy. where is it seen?
- migratory thrombophlebitis in someone with Ca
- seen in pancreatic Ca
investigations in pancreatic Ca?
- diagnosed on CT with histology from biopsy
- CT TAP for staging
- CA 19-9
- MRCP
- ERCP to put stent in
- biopsy
management of pancreatic Ca?
- 90% of cases are palliative
- 10% can have a form of surgery
- total / distal pancreatectomy
- whipple procedure
palliative care options in cholangiocarcinoma and pancreatic Ca?
- stents
- surgery for symptom relief
- palliative chemo
- palliative radio
- EOL care with symptom control
which structures are removed in whipple procedure?
- head of pancreas
- pylorus of stomach
- duodenum
- GB
- bile duct
- relevant lymph nodes
3 key causes of acute pancreatitis?
- gallstones
- alcohol
- post-ERCP
which demographics are more likely to get gallstone pancreatitis?
- women
- older pts
which demographics are more likely to get alcohol-induced pancreatitis?
- men
- younger pts
presentation of acute pancreatitis?
- severe epigastric pain
- radiates to back
- associated vomiting
- abdo tenderness
- systemic signs (low-grade fever, tachycardia)
how is acute pancreatitis diagnosed?
- clinically
- plus raised amylase level on bloods
investigations for acute pancreatitis?
- FBC
- UEs
- LFT
- Ca
- ABG (check PaO2 and glucose)
which score can be used to assess severity of acute pancreatitis?
- Glasgow score
- 2 = moderate, 3 = severe
management of acute pancreatitis?
- A-E assessment
- IV fluids
- make NBM
- analgesia
- ERCP if caused by gallstones
- ABx if evidence of specific infection
- treat complications
complications of acute pancreatitis?
- necrosis of pancreas
- infection
- abscess
- pseudocysts (up to 4w after pancreatitis)
- chronic pancreatitis
commonest cause of chronic pancreatitis?
alcohol
complications of chronic pancreatitis?
- chronic pain
- diabetes
- pseudocysts
- abscesses
how does chronic pancreatitis result in diabetes?
- pancreas loses its endocrine function
- stops secreting insulin
- T1DM occurs
management of chronic pancreatitis?
- abstinence from both alcohol and smoking
- analgesia
- creon (replacement enzymes)
- SC insulin regime
- ERCP with stenting if strictures / obstruction present
- surgery
how does chronic pancreatitis result in steatorrhoea?
- pancreas loses its exocrine function
- stops releasing lipase
- steatorrhoea and vit deficiencies occur
indications for liver transplant?
- chronic liver failure
- paracetamol OD
- acute viral hepatitis
- HCC
who gets priority in liver transplants?
- acute ones
- chronic ones get put on a list, wait approx 5m
which patient factors suggest they may not be suitable for a liver transplant?
- severe comorbidities (e.g. bad CKD, HF)
- excessive weight loss / malnutrition
- active hep B / C
- end-stage HIV
- active alcohol use
how long should a patient have been abstinent for before a liver transplant?
at least 6m
after care / advice following a liver transplant?
- lifelong immunosuppression
- treat any opportunistic infections
- stop alcohol + smoking
- monitor for disease recurrence (e.g. hep, PBC)
- monitor for Ca (increased risk due to immunosuppression)
- monitor for evidence of transplant rejection
drugs used for immunosuppression post-liver transplant?
- steroids
- azathioprine
- tacrolimus
signs of liver transplant rejection?
- abnormal LFTs
- fatigue
- fever
- jaundice
