General surgery Flashcards
Lower GI bleeds:
- Medical name for PR bleed
- Causes
- Symptoms
- Investigations
- Management
- indications for surgery
Lower GI bleeds:
- Haematochezia
- Causes: diverticulitis, haemorrhoids, cancer, colitis, angiodysplasia
- Symptoms: fresh pr, pain, tenesmus
- Investigations: obs, dre, stool culture, bloods (fbc, crp, clotting, g&s), flexible sigmoidoscopy, if unstable ct angiogram
- Management: analgesia, transfusion if <70hb, iv fluids, reverse anticoags, adrenaline, endoscopic ligation/angiography
- indications: >60, still bleeding despite endoscopic intervention, recurrent, known cvs disease
Upper GI bleeds:
- Causes
- Risk factors
- Symptoms
- Investigations
- Management
Upper GI bleeds:
- Causes: PUD, oesophageal varices from liver disease, Mallory weis tear, meckels diverticulum, gastric cancer, oesophagitis
- Risk factors: h pylori, nsaids, alcohol, cirrhosis, vomiting, anticoags, age
- Symptoms: melena, coffee ground vomit (haematemesis), abdominal pain
- Investigations:
Glasgow blatchford at first assessment (predicts risk hence admission need) (urea, hb, sys bp, pulse, melena, syncope, hepatic disease)
rockfall score (used after endoscopy, predicts mortality + rebleeding) (age, comorb, shock features, source bleeding, stigmata of blood)
obs, Dre, bloods (fbc, crp, g&s, clotting, U+es (urea!!)), vbg for hb, ogd, CT abdomen with contrast
- Management: iv fluids, analgesia, transfusion if needed, endoscopy within 24 hours
if varices terlipressin + abx quinolone + endoscopic band ligation + band ligation. tips (transjugular intrahepatic portosystemic shunt - hepatic vein with portal vein connected) if still not working. sengstaken tube if uncontrolled. Prophylaxis: propranolol, endoscopic band ligation, tipss
If others then ppi. if pud adrenaline injections + cauterisation
Acute pancreatitis:
- Definition + pathophysiology
- Causes
- Symptoms
- Signs
- Investigations
- Other causes of increased amylase
- Glasgow modified criteria
- Management
- Complications
- Chronic
- Indicators of severe pancreatitis
Acute pancreatitis:
- Definition + pathophysiology: inflammation of pancreas. Causes release and early activation of digestive enzymes causing auto digestion of pancreas. Enzymes also break down fat and release of FA. These react with Ca and deposit in tissues causing fat sponication and hypocalcaemia.
- Causes: gallstones, ethanol, trauma, steroids, mumps, autoimmune sjogrens, scorpion venom, hypercalcaemia, ecrp, drugs
Drugs: azathioprine, furosemide, thiazides, statins, hydrochloroquine, oestrogen’s, protease inhibitors
- Symptoms: epigastric pain radiating to back, better leaning forward, n+v, fever, steatorrhea
- Signs: tender, Cullens (bruising around umbilicus) + grey turners (flanks - retroperitoneal haemorrhage), tetany
- Investigations: obs, urine dip, bloods (fbc, crp, U+es, lfts, serum amylase X3 inc but doesn’t correlate with severity, serum lipase more sensitive + specific), uss, erect axr, contrast ct
- Amylase: pancreatic pseudocyst, acute cholecystitis, DKA
- criteria predicts severity: Po2<8, age >55, neutrophils >15, ca <1.2, renal urea >16, enzyme alt >200/ldh>600, Albumin < 32, Sugar >10 - >3 = itu
- Management: supportive - aggressive fluid resus, analgesia iv opioids, antiemetics, enteral feeding, oxygen, cholecystectomy if due to gallstones
- Complications: pancreas necrosis, pancreatic pseudocyst (supportive, should resolve by 12 weeks, fine needle aspiration), dic, ards, hypocalc, hyperglycaemia, portal vein thrombosis
- Chronic: due to alc, tumours, stones. They also get diabetes here. There is pancreatic calcification seen on xray + CT is diagnostic, measure faecal elastase to determine exocrine function. Need creon, analgesia
- Indicators: hypocalc, hyperglyc, >55yrs, neutrophilia, inc ldh/ast
Bowel obstruction:
- Definition + pathophysiology
- Causes
- Symptoms
- Signs
- Investigations
- Management
- Complications
Bowel obstruction:
- Definition + pathophysiology: mechanical obstruction. Increased peristalsis + dilatation causes secretion fluids + electrolytes into bowel causing dehydration, oedema, ischaemia and perforation
- Causes: in large tumour, volvulus, diverticular disease. small adhesions, hernias, strictures.
Intramural - foreign body, ileus gallstone, faecal impaction
Luminal - strictures, intussusception, meckels
Extraluminal: tumour, adhesions, volvulus
- Symptoms: DISTENSION, colicky cramp pain, bilious N+V, not passing faeces/wind
- Signs: dehydration, distended, guarding, tinkling bowel sounds
- Investigations: obs, urine dip, bloods (lactate, U+es (urea), fbc, crp, creatinine), ct abdo pelvis contrast, axr, amylase is inc in small bowel
- Management: nbm, ng tube, iv fluids, catheter, analgesia, antiemetics, iv abx, Surgery or adhesiolysis
- Complications: infarction, dehyd, perforation, renal impairment
Appendicitis:
- Definition + pathophysiology
- Symptoms
- Signs
- DD
- Investigations
- Management
- Complications
Appendicitis:
- Definition + pathophysiology: inflammation of appendix due to lymphoid hyperplasia, faecolith or foreign body blocking entrance causing venous engorgement + dec arterial supply + bacterial multiply
- Symptoms: periumbilical pain then to sharp RIF, n+v (only couple of times), anorexia, mild fever
- Signs: lying still, tenderness at mcburneys point, rovsings sign, psoas sign (retrocaecal)
- DD: ectopic, pyeloneph, torsion, ibd
- Investigations: urine dip (mild leucocytosis), preg test, fbc (neutrophils high)/crp/u+es, uss women, ct man (unless thin, and classic symptoms)
- Management: analgesia, abx, appendicectomy lapro (+ abdo lavage if perforated), abx only for appendicael mass and then remove when mass gone
- Complications: peritonitis, abscess, small bowel obstruction
GI perforation:
- Causes
- Symptoms
- Signs
- Investigations
- Management
GI perforation:
- Causes: bowel obstruction, diverticulitis, appendicitis, malig, pud, trauma
- Symptoms: pain, n+v, tender, systemically unwell
- Signs: rigidity, guarding, rebound tenderness, sepsis signs
- Investigations: obs, fbc/crp/clot/g&s, axr/cxr (pneumoperitoneum, riglers sign), ct
- Management: emergency surgery, abx, iv resus, analgesia
Oesophageal cancer:
- Types + Risk factors
- Symptoms (5)
- Investigations
- When to refer for urgent OGD
- Management
Oesophageal cancer:
- Types + Risk factors: squamous (smoking, alcohol,vit a deficiency,achalasia), adenocarc (barrets simple sq -> columnar, gord, obesity, high fat)
- Symptoms (5): progressive dysphagia, dyspepsia, cough, hoarse, voice change, horners
- Investigations: ogd 2 ww
- When to refer for urgent OGD: >55
- Management: if adenocarc can resect + chemo, if scc just chemo/radio. If palliative: stent, thickened fluids
Gastric cancer:
- Type
- Risk factors
- Symptoms
- Signs
- Investigations
- Management
- Complications
Gastric cancer:
- Type: adenocarc
- Risk factors: h pylori, smoking, pernicious anaemia, atrophic gastritis
- Symptoms: early satiety, dyspepsia, b symptoms, melena, n+v
- Signs: epigastric mass, trosiers sign - left supraclavic node, acanthosis nigricans
- Investigations: ogd 2ww
- Management: mucosal resection, gastroectomy, chemo, nutrition
- Complications: malnutrition, perforation, vit b12 deficiency, iron deficiency anaemia, dumping syndrome (high osmotic value + glucose enters SI causing fluid shift + insulin + hypoglycemia)
Gallstones:
- Pathophysiology
- Risk factors
- Symptoms
- Investigations
- Management
- Complications (4)
Ascending cholangitis:
- Definition
- Causes (6)
- Symptoms
- Investigations
- Management
Gallstones:
- Pathophysiology: supersaturation of bile (cholesterol) blocks biliary system
- Risk factors: fem, fat, forty, fertile, fx
- Symptoms: colicky RUQ pain worse after fatty eating + radiates to shouder, N+V, if acute cholecystitis also fever + murphys sign (cystic duct) (ecoli, kleb, in immunocompromised cryptospor or cmv)
- Investigations: urine dip, fbc/crp/lfts/amylase (inc alp/bili), uss, mrcp
- Management: analgesia diclofenac, antiemetics, fluids, lapro cholecystectomy (within 1 week if acute cholecystitis + abx), cons (fat, weight)
If assymp no treatment unless in CBD
- Complications (4): mirizzi syndrome (compression of common hepatic duct resulting in obstructive jaundice, needs MRCP), chronic cholecystitis, cholecystoduodenal fistula (gallstone ileus at terminal ileum needs laprotomy, bowel obstruction), gb empyema
Ascending cholangitis:
- Definition: biliary tree sepsis - in common bile duct (ecoli)
- Causes (6): gallstones, ercp, pancreatitis, cholangiocarc
- Symptoms: charcots (fever, pain ruq, jaundice), reynolds (+ hypotension, confusion)
- Investigations: + blood cultures
- Management: ERCP 24-48 hours, abx, cholecystectomy if bc of gallstones
Colorectal cancer:
- Type
- Risk factors
- Symptoms
- Investigations
- Management
- Familial adenomatous polyposis
- Lynch
Colorectal cancer:
- Type: adenocarcinoma
- Risk factors: ibd, decreased fibre, obesity, smoking/alcohol, fap, lynch syndrome
- Symptoms: altered bowel habits, b symptoms, blood, tenesmus, pain, mass - left appears first as more stenosing
- Investigations: stool cultures, fit fecal immunochemical test (normally 60-75 every 2 years), fbc/crp/clotting, u+es/cea, colonoscopy + biopsy
- Management
1. ascending, transverse: right hemicolectomy
2. transverse, descending: left hemicolectomy
3. sigmoid: high ant resection
4. sigmoid + upper rectum: low ant resection
5. rectum + anus: abdomino-perineal resection
6. emergency rectosigmoid: hartmanns
- Familial adenomatous polyposis: APC adenomatous polyposis coli gene - needs panprotocolectomy, also inc risk duodenal tumours
- Lynch (HNPCC): more common, auto dom, MSH2/ MLH1 gene, also increased risk of endometrial, ovarian, pancreatic - colonscopy every 2 years, aspirin
Hepatocellular carcinoma:
- Risk factors
- Symptoms
- Signs
- Investigations
- Management
Hepatocellular carcinoma:
- Risk factors: alcohol, hepatitis c in europe (b worldwide), hered haemochromatosis, prim biliary cholangitis, alpha 1 anti trypsin deficiency
- Symptoms: pruritis, fatigue, b symp, n+v, ruq pain
- Signs: jaundice, enlarged liver, bruising, confusion
- Investigations: fbc/crp/lfts/afp/clotting, uss liver (hypodense liver), ct
- Management: ablation, surgical resection, transplant, if mets sorafenib (inhibits angiogenesis)
Hernias:
- Definition
- Risk factors
- DD (3)
- Symptoms
- Investigations
- Management
- Inguinal
- Femoral
- Hiatal
- Incisional
- Umbilical
Hernias:
- Definition: abdominal contents out of its containing cavity
- Risk factors: obese, weight lifting, chronic cough, age, surgical wounds, constip
- DD (3): saphena varix, femoral art aneurysm, psoas abscess
- Symptoms: soft lump, incarcerated, strangulated
- Investigations: uss
- Management: treat any hernia, if fit + unilateral then open, bilat / recurrent then lapro
- Inguinal: superiomedial to pubic tubercle, direct through hasselbachs (medial to infepigastric vessels), indirect through inguinal canal (lat to epigastric vessels)
- Femoral: inferolateral, needs surgery bc strong surgical risk
- Hiatal: sliding (oseoph + cardia + GOJ slides up through diaph hiatus), rolling (fundus moves up lieing next to goj) - ppi + lifestyle advice, if doesn’t work then fundoplication. Found most commonly on OGD
- Incisional: inc risk of midline, steroids, smoking, diab
- Umbilical
- Paraumbilical: only just fat so dw about strangulation
- epigastric: common in obese/chronic coughers
Congenital: if inguinal repair ASAP. If umbilical manage conservatively
Volvulus:
- Definition + types
- Risk factors
- Symptoms
- Investigations
- Management
Volvulus:
- Definition + types: twisting of the bowel around its mesenteric attachment - sigmoid or caecal
- Risk factors: sigmoid (age, constip, parkinsons, excessive laxatives), caecal (preg, adhesions)
- Symptoms: sudden bowel obstruction signs
- Investigations: axr (coffee bean in sigmoid + large bowel obstruction, caecal embryo sign + small bowel obstruction )
- Management: for sigmoid sigmoidoscopy rigid with rectal tube insertion for endoscopic decompression, normally operative for caecal
Cholangiocarcinoma:
- Definition
- Risk factors
- Symptoms
- Signs
- Investigations
- Management
Cholangiocarcinoma:
- Definition: biliary system malig
- Risk factors: prim sclerosing cholangitis, liver flukes, uc, diabetes, gallstones
- Symptoms: persistent biliary colic, anorexia
- Signs: painless jaundice, cachexia, courvoisiers law, periumbilical lymphad (sister mary josephs nodes), virchows node
- Investigations: lfts cholestatic (inc alt, bili, ygt), uss, ca199, mrcp
- Management: resection, stenting, bypass, chemo/radio
Pancreatic cancer:
- Definition
- Risk factors
- Symptoms
- Signs
- Investigations
- Management
Pancreatic cancer:
- Definition: adenoc, 60% head
- Risk factors: chronic pancreatitis, age, alcohol, diabetes, HNPCC
- Symptoms: pruitis, weight loss, abdo pain, pancreatitis, diabtes
- Signs: painless jaundice, cachectic, abdo mass (hepatomeg if mets, enlarged gb, epigastric mass), migratory thrombophlebitis (trousseau sign), steatorrrhoea
- Investigations: LFTs (alt/ ygt inc as cholestatic lfts), ca199, uss abdo, HRCT gold standard (dilatation of common bile duct + pancreatic ducts - double duct sign)
- Management: chemo, pancreatoduodenectomy (PUD and dumping syndrome SE), palliative stent via ercp + creon
Diverticular disease:
- Definition + pathophysiology
- Risk factors
- Symptoms
- Signs
- Investigations
- Management
- Complications
Diverticular disease:
- Definition + pathophysiology: herniation of the colon mucosa wall and bacteria causes inflammation
- Risk factors: constipation, age, obesity, sedimentary lifestyle
- Symptoms: fresh blood, fever, pain relieved by defecation (sharp LIF if inflammed), N+V, altered bowel habits
- Signs: tender lif, pyrexia, anorexia
- Investigations: stool culture, faecal calp, fbc/crp/u+es, flexible sigmoidoscopy (abdo ct scan if v unwell), cxr/axr
- Management: abx, analgesia, fluids, embolise if bleed, hartmanns if perforated, admit if no improvement in 72 hours for iv ceft + metron
- Complications: recurrent, perforation, fistula, pericolic abscess
Haemorrhoids:
- Definition + grades
- Risk factors
- Symptoms
- Investigations
- Management
Haemorrhoids:
- Definition + grades: enlarged submucosal anal cushions
1. no prolapse
2. spont reduces
3. reduced manually
4. can’t be reduced
- Risk factors: constipation, weight lifting, obesity, pregnancy, ibd
- Symptoms: if internal painless, if external painful, bleeding, itchy (if thrombosed v painful, purple lump)
- Investigations: dre
- Management: increase fibre, topical steroid, jelly, bulk forming laxatives. if chronic try above and also (>6 weeks) topical glyceryl trinitrate (relaxes sphincter) and if no improvement after 8 weeks then refer. If thrombosed within 72 hours refer to excise
Mesenteric ischaemia:
- Definition
- Risk factors
- Signs
- Investigations
- Mx
Mesenteric ischaemia:
- Definition: decreased blood flow to the mesenteric vessels causing intestine ischaemia (mostly SMA + splenic flexure)
- Risk factors: diab, htn, hyperchol, smok, fx, AF
- Signs: central v painful colicky pain after eating, weight loss, abdo bruit
- Investigations: ct angiogram, HIGH LACTATE / WCC
- Mx: URGENT LAPROTOMY percut mesent art stenting endovasc, statins
Stomas:
- Types (3)
- Reasons for non anastomosing
- Complications of stomas (7) - early and late
Stomas:
- Types (3) - colonostomy (LIF, flushed), ileostomy (RIF, spout), urostomy (RIF)
- Anastomosing: infection, bowel length bad, poor blood supply
- Complications of stomas (7) - early and late
Early: necrosis, faecal impaction, leaking
Late: retraction, stenosis, pyschosexual, parastomal hernia, bowel prolapse
Once you’ve done a loop check in 6 weeks via a dye to check if anastomosis distal is ok
Inflammatory bowel disease:
- Clinical features (6)
- Risk factors (4)
- Microscopic UC + Crohns
- Macroscopic UC + crohns
- Extra intestinal features (6)
- Complications (6)
- Investigations
- Management
Inflammatory bowel disease:
- Clinical features (6): blood, mucus, change bowel habits, tenesmus, abdo pain
- Risk factors (4): smoking (UC), fx, abx
- Microscopic UC + Crohns: in UC crypt cell abscesses/ goblet cell hypoplasia/ non granulomatous inflamm in mucosa/submucosa. In Crohns non caseating granulomas + transmural + goblet cells
- Macroscopic UC + crohns: in UC contin, granular/pseudopolyps appearance + loss haustra. In crohns cobblestone, skip lesions and anywhere in GI, perianal disease (fistula - metronidazole, abscess, stricture, skin tags, ulcers)
- Extra intestinal features (6): arthritis, episcleritis, erythema nodosum, osteoporosis - these related to disease activity. Ant uveitis, pyoderma gangrenoosum, clubbing, prim sclerosing cholangitis - not related to activity
- Complications (6): toxic megacolon, colorectal cancer, osteoporosis, fistulas/strictures
- Investigations: culture stool, faec calp, fbc/crp, colonoscopy/endo
- Management
Severity of UC:
- mild: <4 stools day
- mod: 4-6
- sev: >6 bloody + systemic upset
Anal fissure:
- Definition
- Risk factors
- Symptoms
- Mx
Anal fissure:
- Definition: tear in squamous lining of distal anal canal. Post and Ant. if lateral think ibd
- Risk factors: constip, crohns, stis
- Symptoms: v painful poo, bleed
- Mx: inc fluids, bulk forming laxatives, topical anaesthetics, lubricants, analgesia, topic gtn if chronic (>6 weeks), sphincterotomy or botulin injection if doesn’t work
Perianal abscess:
- Definition
- Causes
- Symptoms
- Ix
- Mx
Perianal abscess:
- Definition: pus collection in subcut tissue of anus - ecoli, staph aures
- Causes: crohns, diab
- Symptoms: pain worse when sitting, discharge, fever SPIKING
- Ix: if unsure cultures, crp/fbc, transperineal uss GOLD STANDARD
- Mx: incision + drainage under GA only bc la doesnt work for abscesses
symptoms of cholangiocarc vs pancreatic
chol is biliary colic symptoms, anorexia, jaundice and weight loss, periumbilical lymph ad (suster mary joseph nodes), left suprclavic adenoathy (virchow) and palp mass ruq (courvoisier sign)
pancreatic is painless jaundice, pain, anorexia, weight loss
Anal cancer:
- Risk factors
- Ix
- Risk factors: hpv16/18, msm, cervical cancer, smoking, immunosuppression
- ix: ct, mri
