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 + endoscopic band ligation + band ligation. tips (transjugular intrahepatic portosystemic shunt) if still not working. sengstaken tube if uncontrolled
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: 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, antiemetics
- Complications: pancreas necrosis, pancreatic pseudocyst (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. 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, anorexia, fever
- Signs: lying still, tenderness at mcburneys point, rovsings sign, psoas sign (retrocaecal)
- DD: ectopic, pyeloneph, torsion, ibd
- Investigations: urine dip, preg test, fbc/crp/u+es, uss
- Management: analgesia, abx, appendicectomy lapro (+ abdo lavage if perforated)
- 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
- 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, 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, antiemetics, fluids, lapro cholecystectomy (within 1 week if acute cholecystitis + abx), cons (fat, weight)
- Complications (4): mirizzi syndrome, chronic cholecystitis, cholecystoduodenal fistula, 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
- 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 + fundoplication
- Incisional: inc risk of midline, steroids, smoking, diab
- Umbilical
Volvulus:
- Definition + types
- 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: pruritis, steatorrhoea, abdo pain
- Signs: painless jaundice, cachexia, courvoisiers law
- Investigations: lfts (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, abdo mass, cachectic, enlarged gb
- Investigations: fbc (bili, alt, ygt), ca199, uss abdo, CT
- Management: chemo, pancreatoduodenectomy, palliative stent via ercp + creon
