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MRCS - Part A > General Surgery > Flashcards

General Surgery Flashcards

1
Q

What are causes of hyperamylasaemia?

A

Acute Pancreatitis
Pancreatic Pseudocyst
Mesenteric Infarct
Bowel Perforation
Acute cholecystitis
Diabetic Ketoacidosis

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2
Q

What are the borders of the femoral canal?

A

Lateral - Femoral vein
Medial - Lacunar ligament
Anterior - Inguinal ligament
Posterior - Pectineal ligament

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3
Q

What is a Meckel’s diverticulum?

A

Congenital abnormality resulting from incomplete obliteration of the vitello-intestinal duct.

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4
Q

What is the arterial supply of meckel’s diverticulum?

A

omphalomesenteric (vitelline) artery

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5
Q

What is the rule of 2s associated with a meckel’s diverticulum?

A

2% of population
2 inches long
2 feet proximal to the ileocaecal valce
2 times more common in men
2 types of tissue involved (ileal mucosa and ectopic gastric mucosa)

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6
Q

What are the complications of diverticular disease?

A

Diverticulitis
Haemorrhage
Fistula
Abscess

Faecal peritonitis
Diverticular phlegmon

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7
Q

What is Goodsal’s rule?

A

Anterior fistulae (9 o’clock to 3 o’clock) will tend to have an internal opening opposite to the external opening
Posterior fistulae (3 o’clock to 9 o’clock) tend to have a curved track that passes towards the midline ie 6 o’clock

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8
Q

What is the purpose of the femoral canal?

A

to allow for the physiological expansion of the femoral vein which lies lateral to it

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9
Q

What is a Littres hernia?

A

Hernia containing meckel’s diverticulum

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10
Q

What structures lie in the transpyloric place?

A

L1 vertebra
Pylorus of stomach
D1 of duodenum
Duodeno-jejunal flexure
Fundus of gallbladder
Neck of pancreas
Root of transverse mesocolon
Hepatic flexure of colon
Splenic flexure of colon
Hilum of spleen
Hila of kidneys
9th costal cartilage
Root of superior mesenteric artery
Splenic vein meets superior mesenteric vein to form portal vein
Termination of spinal cord and start of cauda equina
Cisterna chyli

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11
Q

What are the 4 physiological constrictions to the oesophagus?

A

A - arch of the aorta
B - Bronchus (left main stem)
C - Cricoid cartilage
D - Diaphragmatic hiatus

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12
Q

What is the arterial supply to thoracic oesophagus?

A

Branches of the thoracic aorta and inferior thyroid artery (a branch of the thyrocervical trunk)

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13
Q

What is the venous drainage of thoracic oesophagus?

A

Azygous vein and inferior thyroid vein (systemic venous drainage only)

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14
Q

What is the arterial supply of the abdominal oesophagus?

A

Left gastric artery and left inferior phrenic artery

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15
Q

What are the 2 venous drainage routes of the abdominal oesophagus?

A

Portal circulation via left gastric vein
Systemic circulation via azygous vein

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16
Q

What structures lie anterior to the thoracic oesophagus?

A

Trachea
Left recurrent laryngeal nerve
Pericardium
Thymus

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17
Q

What structures lie posterior to the thoracic oesophagus?

A

Thoracic vertebral bodies
Thoracic duct
Azygous veins
Descending aorta

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18
Q

What abdominal structures are considered intraperitoneal (completed covered by visceral peritoneum)?

A

Stomach
D1 of duodenum
Jejunum
Ileum
Transverse colon
Sigmoid colon
Liver
Spleen

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19
Q

What structures are retroperitoneal?

A

S - Suprarenal glands
A - Aorta + IVC
D - Duodenum (except proximal 3cm)
P - Pancreas (except tail)
U - Ureters
C - Colon (ascending and descending)
K - Kidneys
E - (O)eseophagus
R - Rectum

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20
Q

What is the communication between the lesser and greater sac called?

A

Foramen of winslow or epiploic foramen

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21
Q

What level is the celiac trunk located?

A

T12

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22
Q

What is the arterial supply of the lesser curvature of the stomach?

A

Right gastric artery (coeliac trunk->common hepatic artery->hepatic proper artery->right gastric artery)
Left gastric artery (directly from coeliac trunk)

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23
Q

What is the arterial supply of the greater curvature of the stomach?

A

Right gastroepiploic artery (coeliac trunk->common hepatic artery->gastroduodenal artery->right gastroepiploic)
Left gastroepiploic artery (coeliac trunk->splenic artery-> left gastroepiploic artery)

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24
Q

What is a richter’s hernia?

A

When the anti-mesenteric wall of the intestine protrudes causing strangulation without obstruction

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25
Q

When might Rovsing’s sign be absent in appendicitis?

A

retrocaecal appendicitis

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26
Q

What part of the duodenum is most likely to get duodenal ulcers?

A

D1

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27
Q

Which part of the duodenum is intraperitoneal?

A

Proximal 3cm of D1

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28
Q

Macroscopic features of the jejunum that differ from ileum

A

Located in LUQ rather than RLQ
Thicker intestinal wall
Longer vasa rectae
Less arterial arcades
More red in colour rather than pink
More plicae circulares

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29
Q

What artery supplies arterial blood to the midgut?

A

Superior mesenteric artery

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30
Q

What artery supplies arterial blood to the hindgut?

A

Inferior mesenteric artery

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31
Q

At what level does the superior mesenteric artery arise?

A

L1

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32
Q

What muscle controls the upper oesophageal sphincter? And what is it’s innervation?

A

Cricopharyngeas muscle
Pharyngeal plexus from recurrent laryngeal nerve (+/- the external branch of the superior laryngeal nerve)

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33
Q

Why are the transverse colon and sigmoid colon more mobile?

A

Because they are intraperitoneal structures with their own mesentary (transverse mesocolon and sigmoid mesocolon)

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34
Q

What characteristics of the large bowel differentiate it from the small bowel?

A

Omental appendicies - pouches of peritoneum, filled with fat (more abundant in sigmoid colon)
Teniae coli - 3 longitudinal muscles that converge at root of the appendixe
Haustra - sacculations of colon, formed due to contraction of teniae coli
Larger diameter

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35
Q

Where is the junction between the embryological midgut and hindgut?

A

2/3 way along the transverse colon

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36
Q

What are the branches of the inferior mesenteric artery?

A

Left colic artery - divides into ascending and descending branches of left colic artery
Sigmoid branches
Superior rectal artery

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37
Q

What is the most common position of the appendix?

A

Retrocaecal

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38
Q

Describe the pattern of pain in appendicitis

A

Inflammation of the appendix causes swelling and stretching of the visceral peritoneum. The visceral peritoneum receives its afferent nerve fibres from T10 so there is referred pain to umbilical region.
As the inflammation advances, it spreads to parietal peritoneum which localises the pain at McBurney’s point

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39
Q

Where is McBurney’s point?

A

1/3 of the way from the right ASIS to umbilicus

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40
Q

How can you find the appendix during surgery?

A

Trace the teniae coli back to their root as the 3 longitudinal muscles converge at the appendix

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41
Q

Which part of the large intestine do not have omental appendices?

A

Caecum

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42
Q

What blood vessels does the transverse mesocolon contain?

A

Middle colic artery and vein

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43
Q

Which artery provides collateral blood supply to the colon?

A

Marginal artery of Drummond

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44
Q

What separates the rectum from the sacrum, coccyx, sacral nerves, middle sacral artery and sacral veins?

A

Waldeyer’s Fascia

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45
Q

What type of epithelium lines the rectum?

A

Columnar epithelium

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46
Q

What type of muscle makes up the internal anal sphincter?

A

Smooth muscle

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47
Q

What muscle does the external anal sphincter blend into?

A

Puborectalis

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48
Q

Where are the anal glands located?

A

Behind the anal valves which are folds at the lower end of the anal columns (columns of morgagni)

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49
Q

Which part of the anal canal is surrounded by the external sphincter?

A

Lower 2/3

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50
Q

What is the dentate line?

A

Also known as the pectinate, it lies along the anal valves.
Separates the endoderm which is superior to the line and the ectoderm which is inferior.
Superior to the line is columnar epithelium and inferior to the line is non-keratinised squamous epithelium.

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51
Q

What type of carcinoma occurs inferior to the dentate line of the anus?

A

Squamous cell carcinoma

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52
Q

What is the blood supply of the anus superior to the dentate line?

A

superior rectal artery, branch of the inferior mesenteric artery

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53
Q

What type of carcinoma occurs superior to the dentate line?

A

Adenocarcinoma

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54
Q

What is the blood supply to the anus inferior to the dentate line?

A

Inferior rectal artery, branch of the internal pudendal artery

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55
Q

What spinal levels does the rectum lie between?

A

S3 - Coccyx

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56
Q

What are the 5 ligaments of the liver?

A

Right triangular ligament
Coronary ligament
Left triangular ligament
Falciform ligament
Ligamentum Teres (round ligament)

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57
Q

What is the ligamentum teres?

A

A cord like structure that runs between the falciform ligament and the umbilicus. It is a remnant of the fetal umbilical vein and attaches the anterior surface of the liver to the abdominal wall.

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58
Q

Where are the hepatic recesses?

A

Anatomical spaces where infection can collect and abscess can form.

Left and Right subphrenic space - split by the falciform ligament
Left subhepatic space - supracolic compartment, between inferior surface of liver and transverse mesocolon
Right subheptic space - Morison’s pouch

Morison’s pouch is deepest in supine position so common area for intestinal content to gravitate to in a perforation.

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59
Q

What lies in the porta hepatis?

A

Hepatic portal vein
Right and Left hepatic arteries
Right and Left hepatic ducts
+/- lymph nodes and nerves

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60
Q

What is the blood supply to the liver?

A

25% from the hepatic arteries (coeliac trunk -> common hepatic artery -> proper hepatic artery -> right and left hepatic arteries)
75% from hepatic portal vein

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61
Q

What are the borders of Calot’s triangle?

A

Medial – common hepatic duct.
Inferior – cystic duct.
Superior – cysticartery

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62
Q

What is the criteria for the critical view of safety in a cholecystecomy?

A
  1. The hepatocystic triangle is cleared of fat and fibrous tissue
  2. The lower one third (neck) of the gallbladder is separated from the liver to expose the cystic plate
  3. Two and only two structures should be seen entering the gallbladder
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63
Q

Where is the common bile duct formed?

A

Extrahepatic

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64
Q

What is the different between hepatocystic triangle and calot’s triangle?

A

The superior border in Calot’s triangle is the cystic artery where as the superior border in hepatocystic triangle is inferior surface of the liver

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65
Q

What are the content’s of hepatocystic triangle?

A

Right hepatic artery
Cystic artery
Lymph node of Lund
Lymphatics

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66
Q

What is the ROME IV criteria for IBS?

A

Recurrent abdominal pain or discomfort at 3 days per month for the past 3 months associated with two or more of the following:
- Improvement with defecation.
- Onset associated with a change in the frequency of stool.
- Onset associated with a change in the form of the stool.

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67
Q

What is Mirizzi syndrome?

A

Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder

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68
Q

What conditions are anal fissures associated with?

A

Sexually transmitted diseases (syphilis, HIV)
Inflammatory bowel disease (Crohn’s up to 50%)
Leukaemia (25% of patients)
Tuberculosis
Previous anal surgery

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69
Q

What are the borders of the femoral triangle?

A

Superior - Inguinal ligament
Lateral - Medial border of the sartorius muscle
Medial - Medial border of the adductor longus muscle. The rest of this muscle forms part of the floor of the triangle.

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70
Q

What are the extra-intestinal features of inflammatory bowel disease?

A

A - Aphthous Ulcers

P - Pyoderma Gangrenosum
I - Iritis
E - Erythema Nodosum

S - Sclerosing Cholangitis
A - Arthritis
C - Clubbing

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71
Q

What causes diarrhoea in Crohn’s disease?

A

Bile salt diarrhoea secondary to terminal ileal disease
Entero-colic fistula
Short bowel due to multiple resections
Bacterial overgrowth

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72
Q

What microscopic feature might be found in a gallbladder that has recurring episodes of cholecystitis and gallstones?

A

Aschoff-Rokitansky sinuses

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73
Q

Where in the gut is zinc absorbed?

A

Duodenum and jejunum

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74
Q

What are the features of an obturator hernia?

A

More common in females, multiparous or those who have recently lost weight
Abdominal contents through obturator foramen
Usually presents with bowel obstruction
Leg held in semi flexion
Pain radiates to ipsilateral knee

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75
Q

What is Howship-Romberg sign?

A

Inner thigh pain on internal rotation of the hip, seen in obturator hernia

76
Q

Histological features of UC?

A

Crypt abscesses
Mucosal inflammation
Infiltration of lymphocytes into lamina propria

77
Q

What is the surgical management of UC when conservative management has failed?

A

Sub total colectomy and end ileostomy

78
Q

Features of mesenteric infarction

A

Pain out of proportion to physical signs
AF
Generalilsed abdominal pain
Bloody diarrhoea

79
Q

What is the first line treatment for anal cancer?

A

Radical chemoradiotherapy

80
Q

Features of post gastrectomy syndrome

A

Diarrhoea
Abdo pain
Hypoglycaemia
Vit B12 malabsorption
Iron malabsorption

81
Q

Genes involved in the adenoma-carcinoma sequence in colorectal cancer?

A

c-myc
APC
p53
K-ras
MCC
DCC
c-yes
bcl-2

82
Q

What is feltys syndrome

A

Rheumatoid disease
Splenomegaly
Neutropaenia

83
Q

Which type of polyp carries the greatest risk of malignant transformation

A

Villous polyp

84
Q

What drug may improve psuedo-obstruction?

A

Neostigmine

85
Q

Causes of perianal puritis

A

Systemic - DM, Hyperbilirubinaemia, aplastic anaemia eg leukaemia
Mechanical - diarrhoea, constipation, anal fissure
Infection - STDs eg syphilis
Dermatological
Drugs - Quinine, cholchicine
Topical agents

86
Q

What is the commonest site in the abdomen for fluid to collect following a perforated appendix?

A

pelvis

87
Q

What is the difference between mid-inguinal point and midpoint of inguinal ligament?

A

Mid inguinal point is half way between the pubic symphysis and ASIS where as the inguinal ligament runs between the pubic tubercle and ASIS

88
Q

What diameter of the caecum is pathological when seen on xray?

A

> 9cm

89
Q

What vein does the inferior mesenteric vein drain into?

A

Splenic vein

90
Q

PR bleeding, abdo pain, IDA and multiple duodenal ulcers on OGD indicate what?

A

Zollinger Ellison syndrome, gastrinomas

91
Q

What are the borders of the epiploic foramen?

A

Anterior - common bile duct, portal vein, hepatic artery
Posterior - IVC

92
Q

What is the blood supply to the adrenal gland?

A

Superior adrenal arteries- from inferior phrenic artery
Middle adrenal arteries - from aorta
Inferior adrenal arteries - from renal arteries

93
Q

What are the contents of the rectus sheath?

A

Inferior epigastric artery and vein
Superior epigastric artery and vein
Rectus abdominis
Pyramidalis

94
Q

What nerve roots supply the rectus abdominis?

A

T7-T12

Supplied by thoracoabdominal nerves

95
Q

What are the 3 points of the urogenital triangle?

What are the boundaries of the urogenital triangle?

A

Anteriorly - pubic symphysis
Laterally - Ischial tuberosities

Ischiopubic inferior rami
Transverse perineal muscles

96
Q

What hormone causes the gall bladder to contract?

A

Cholecystokinin

97
Q

What is heterotopia and what is an example of it?

A

Presence of a specified normal tissue type at a non-physiological site
Eg Meckels Diverticulum
On colonoscopy the mucusa is normal but there may be blood in the terminal ileum

98
Q

What is a Klatskin tumour?

A

cholangiocarcinoma (cancer of the biliary tree) occurring at the confluence of the right and left hepatic bile ducts.

99
Q

What is diaphragm disease?

A

The lumen of the small bowel is divided into short compartments by circular membranes of mucosa and sub-mucosa; these membranes have a pinhole lumen leading to frequent bouts of intestinal obstruction
Caused by longterm NSAID use

100
Q

What is the normal intragastric pH?

A

2

101
Q

Secretions from what structure contain the highest levels of potassium?

A

Rectum - 30mmol/L

102
Q

What are the features of Peutz-Jeghers syndrome?

A

Autosomal dominant
Responsible gene encodes serine threonine kinase LKB1 or STK11

Hamartomatous polyps in GI tract (mainly small bowel)
Pigmented lesions on lips, oral mucosa, face, palms and soles
Intestinal obstruction e.g. intussusception (which may lead to diagnosis)
Gastrointestinal bleeding

103
Q

Which cells produce insulin?

A

Beta cells

104
Q

What hormone causes satiety and what hormone causes hunger?

A

Satiety - leptin decreases appetite

Hunger - ghrelin increases appetite

105
Q

What are the layers of the adrenal gland and what is produced in them?

A

Outer - Glomerulosa - Aldosterone
Middle - Fasciculata - Glucocorticoids
Inner - Reticularis - Androgens

106
Q

3 factors that increase gastric acid production and 3 factors that decreased gastric acid production

A

Increase:
Gastrin, Histamine, vagal nerve stimulation

Decrease:
Somatostatin, CCK and Secretin

107
Q

Gastro-intestinal stromal tumours are derived from what cells?

A

Interstitial cells of Cajal

108
Q

Features of Yersinia enterocolitica

A

Gram negative, coccobacilli
Can be mistaken for appendicitis
Typically produces a protracted terminal ileitis
Usually sensitive to quinolone or tetracyclines

109
Q

Features of Campylobacter jejuni

A

Spiral, gram negative rods
Usually infects caecum and terminal ileum with local lymphadenopathy
Viral like symptoms (feverm malaise, nausea)
Has marked right iliac fossa pain
Reactive arthritis is seen in 1-2% of cases

110
Q

What is Boerhaave syndrome?

A

The Mackler triad of boerhaave syndrome:
1. vomiting
2. Thoracic pain
3. Subcutaneous emphysema.
Represents oesophageal rupture.
Associated with alcohol abuse.

111
Q

Examples of encapsulated organisms that cause an increased risk of infection following splenectomy?

A

Escherichia coli
Streptococcus pneumoniae
Salmonella
Klebsiella pneumoniae
Haemophilus influenzae
Pseudomonas aeruginosa
Neisseria meningitidis
Bacteroides fragilis
Cryptococcus neoformans (yeast)

112
Q

What is Ladd’s procedure?

A

Laparotomy and division of congenital adhesions
For midgut volvulus in infants

113
Q

How does intestinal malrotation present?

A

Bilious vomiting
Duodenal-jejunal flexure is on the right rather than left

114
Q

What is Kasai’s procedure for?

A

Biliary atresia

115
Q

What is Ramstedts’s pyloromyotomy for?

A

Pyloric stenosis

116
Q

What is the most common abdominal emergency in children under 1 year of age?

A

Inguinal hernia
Followed by intussuseption

117
Q

What is the APC gene responsible for?

A

APC is a tumour suppressor gene involved in the downregularion of beta catenin through the Wnt signalling pathway
Chromosome 5

118
Q

What other features are associated with colonic polyps in Familial adenomatous popyposis?

A

Stomach, small bowel, pancreas and biliary tree polyps
Desmoid tumours
Papillary thyroid cancer
Gardner Syndrome
Medulloblastomas (Turcot syndrome)

119
Q

What other cancers are associated with lynch syndrome?

A

Colonic
Female: Genitalia: Endometrial, ovarian
Other GI: Gastric, Small bowel, Pancreatic, Biliary tree
Urological: Prostate, Urinary tract, Kidney
Brain: Glioblastomas

120
Q

What mutation causes Peutz-Jeghers syndrome?

A

STK11 (LKB1) on chromosome 19

121
Q

Which polyposis syndrome causes intestinal hamartomas, intestinal obstruction and intussusception?

A

Peutz-Jeghers syndrome

122
Q

What cancers are associated with Peutz-Jeghers syndrome?

A

GI: Intestinal, Gastric, Pancreatic
Female: Breast, Ovarian, Cervical
Male: Testicular

123
Q

What polyposis syndrome is associated with clusters of black-brown freckles about the lips, the buccal mucosa, and the perianal and genital area?

A

Peutz-Jeghers syndrome

124
Q

What polyposis syndrome is associated with trichelommomas, lipomas and acral keratosis?

A

Cowden disease

125
Q

What is the genetic mutation in cowden disease?

A

PTEN gene on chromosome 10q22

126
Q

What are considered high risk findings at baseline colonoscopy?

A

More than 2 premalignant polyps including 1 or more advanced colorectal polyps
OR
More than 5 pre malignant polyps

127
Q

Which of the polyposis syndromes are autosomal recesive?

A

MYH associated polyposis

128
Q

What is the difference between R0, R1 and R2 resection?

A

R0 - Cure or complete remission
R1 - Microscopic residual tumour
R2 - Macroscopic residual tumour

129
Q

What blood vessel needs to be ligated in an extended right hemicolectomy that is not ligated in a standard right hemicolectomy?

A

Middle colic artery

130
Q

A tumour is which part of the bowel requires an extended hemicolectomy?

A

Transverse colon

131
Q

Which polposis syndrome is characterised by right sided colonic malignancy and endometrial cancer?

A

Lynch syndrome
Mutation in the mismatch repair gene

132
Q

How does gastric cancer cause obstructive jaundice when associated with Lynch syndrome?

A

Nodal spread along the hepatoduodenal ligament nodes to occlude the porta hepatis resulting in jaundice.

133
Q

Where in the gut is calcium absorbed?

A

Small bowel

134
Q

What does TME stand for in cancer surgery?

A

Total mesorectal excision

135
Q

What is hartmann’s procedure?

A

Complete excision of the sigmoid colon and rectum, formation of end colostomy and closure of the rectal stump

136
Q

What are desmoid tumours?

A

Fibrous neoplasms of the musculoaponeurotic structures
Typically contain myofibroblasts

137
Q

What liver lesions are linked to the COCP?

A

Liver cell adenomas
They appear as non encapsulated, mixed echoity and heterogenous texture

138
Q

What organism is most commonly responsible for cholangitis?

A

E.coli

139
Q

What liver disease is associated with watercress?

A

Fasicola hepatica
Also known as the common liver fluke (parasitic trematode)
2 phases of illness
Diagnosis is either by stool sample or serology
Treated with triclabendazole

140
Q

What is jenkins rule in regards to wound closure?

A

the length of suture material required is 4x the length of the wound

141
Q

Which gastrointestinal parasitic disorder shows cysts on stool microscopy?

A

Cryptosporidium

142
Q

What are the fat soluble vitamins?

A

A, D, E, K

143
Q

What is the kasai procedure?

A

Roux en Y portojejunostomy for biliary atresia

144
Q

Which organisms are resistant to chlorine?

A

Giardia
Crytosporidium
Hepatitis A

144
Q

Where does the adrenal vein drain into?

A

R= IVC
L = Inferior phrenic vein then left renal vein

145
Q

What infective organism is carried by birds?

A

campylobacter jejuni

146
Q

What skin lesion is associated with a glucagonoma?

A

necrolytic migratory erythema.

147
Q

Which tumour marker should be measured to monitor for a carcinoid tumour?

A

5 HIAA in a 24 hour urine collection

(5 hydroxyindoleacetic acid)

148
Q

What pain relief is used following a haemorrhoidectomy?

A

Caudal block

149
Q

What is the lymphatic drainage of the rectum?

A

Superior to dentate line - mesorectal lymph nodes
Inferior to dentate line - inguinal lymph nodes

150
Q

Profuse watery infections are characteristic of which GI infection?

A

Vibrio cholera

151
Q

What is dysphagia lusoria?

A

Compression of the esophagus from any of several congenital vascular abnormalities.
Diagnosed on CT Angiogram

152
Q

What are melanosis coli a feature of?

A

Laxative abuse

153
Q

What is the most common viral infection in solid organ transplant patients?

A

Cytomegalovirus

154
Q

How to tell the difference between cryptosporidium and giardia?

A

Cryptosporidium is associated with immunocompromised patients, diarrhoea is the main symptoms

Giardia occurs in immunocompetent patients and has abdominal pain and bloating as well as loose stool. Causes malabsorption so stools are fatty and float.

Both protazoal, cyst forming infections.

155
Q

Which parasitic infection causes worms and eggs to be seen on stool microscopy?

A

Ascariasis - Ascaris lumbricoides

156
Q

What drug is used to treat most worm parasites?

A

Mebendazole

157
Q

What are the attachments, blood and nerve supply of the external oblique?

A

Ribs 5-12 to iliac crest and pubic tubercle

Lower posterior intercostal arteries, subcostal arteries and deep circumflex iliac arteries.

Thoracoabdominal nerves (T7-T12) and subcostal nerves (T12)

158
Q

What are the attachments, blood and nerve supply of the internal oblique

A

Inguinal ligament, iliac crest and lumbodorsal fascia to ribs 10-12

Lower posterior intercostal arteries, subcostal arteries, superior and inferior epigastric arteries, superficial and deep circumflex iliac arteries, posterior lumbar arteries

Thoracoabdominal nerves (T7-T12), subcostal nerves (T12) and branches of lumbar plexus)

159
Q

What is the nerve supply to the pyramidalis?

A

Subcostal nerve (T12)

160
Q

What structures lie anterior and posterior to the SMA?

A

Anterior - pyloric part of stomach, splenic vein and neck of pancreas

Posterior - uncinate part of pancreas, inferior part of duodenum, left renal vein

161
Q

What are the causes of pancreatitis?

A

G - gall stones
E - ethanol
T - trauma

S - steroids
M - mumps
A - autoimmune disease eg SLE/sjogren’s
S - scorpion venom
H - hypercalcaemia
E - ERCP
D - drugs eg azathioprine, NSAIDs, diuretics

162
Q

Which type of scorpion causes pancreatitis?

A

Tityus toxin from the tityus serrulatus scorpion family

163
Q

Why does pancreatitis cause retroperitoneal bleeding?

A

Excessive release of digestive enzymes into systemic circulation causes necrosis of fat and blood vessels. Peripancreatic vessels are eroded and can cause bleeding into retroperitoneal space.

164
Q

How does pancreatitis cause hypocalcaemia?

A

Systemic circulation of digestive enzymes causes necrosis of fats. This leads to increased circulation of free fatty acids which react with serum calcium to cause chalky deposits in fat and hypocalcaemia.

165
Q

What condition might cause amylase to be normal in pancreastitis?

A

hypertriglyceridaemia

166
Q

When does amylase and lipase start rising, peak and return to normal in pancretitis?

A

Amylase - starts rising at 3-6 hours, peaks at 12 hours and returns to normal in 3-5 days

Lipase - starts rising at 4-8 hours, peaks at 24 hours and returns to normal in 8-14 days

167
Q

Why do we test for LDH in pancreatitis?

A

LDH is a marker of cell necrosis and is therefore indicative of pancreatic necrosis and worse prognosis.
It peaks at 48-72 hours.
It is used for scoring

168
Q

What does a sentinal loop sign on AXR indicate?

A

Pancreatitis
It is due to a proximal dilated loop of small bowel due to localised inflammation.

169
Q

What nerve injury is most common during anterior resection of rectum?

A

Hypogastric autonomic nerve injury -> impotence

170
Q

What is a Dieulafoy lesion?

A

Tortuous arteriole in the submucosa of the lesser curvature of the stomach (vascular malformation). Rare cause of brisk haematemesis.

171
Q

What is boas sign?

A

Hyperaesthesia of the tip of the right scapula and is seen classically in association with acute cholecystitis

172
Q

What is diaphragm disease?

A

Associated with NSAIDs and more common in the elderly.
The lumen of the small bowel is divided into short compartments by circular membranes of mucosa and sub-mucosa; these membranes have a pinhole lumen leading to frequent bouts of intestinal obstruction.

173
Q

What cell type in gastric cancer indicates worse prognosis?

A

Signet ring cell

174
Q

Infection by which organism may result in a clinical picture resembling achalasia of the oesphagus?

A

Trypanosoma Cruzi

175
Q

What are the 3 types of colonic peristalsis?

A

Segmentation contractions
Antiperistaltic waves towards ileum
Mass movements

176
Q

What incision is usually used for a femoral hernia with bowel obstruction?

A

McEvedy

177
Q

What biologic agent is used in gastrointestinal stromal tumours?

A

Imatinib

178
Q

What are the borders of the inguinal canal?

A

Anterior - aponeurosis of the external oblique (+ internal oblique aponeurosis medially)
Posterior - Transversalis fascia
Floor - Inguinal ligament
Roof - Transversalis fascia, tranversus abdominis, internal oblique

179
Q

What structure does the inguinal ligament arise from?

A

External oblique aponeurosis

180
Q

What is courvoisier’s sign?

A

Painless jaundice and an enlarged gallbladder is an obstructing pancreatic cancer until proven otherwise

181
Q

What 5 groups of lymph nodes does pancreatic cancer spread to?

A

Coeliac axis
Paraduodenal peritoneum
Lesser curvature of the stomach
Greater curvature of the stomach
Hilum of the of the spleen

182
Q

What vessel is likely to cause bleeding from an ulcer in the deep ulcer on the posterior wall of the stomach?

A

Splenic

183
Q

How does carbohydrate loading drinks help improve outcomes in ERAS?

A

Improve nitrogen balance and reduce insulin resistance

184
Q
A

MRCS - Part A (16 decks)

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