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2. Y5 Zero to Finals: Surgery > General Surgery > Flashcards

General Surgery Flashcards

1
Q

define a fistula

A

an abnormal connection between 2 epithelial surfaces

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2
Q

what does a “mercedes benz” scar on the abdomen indicate?

A

liver transplant

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3
Q

what does a hockey stick scar indicate?

A

renal transplant

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4
Q

at which 3 stages is the surgical safety checklist carried out?

A
  • before induction of anaesthesia
  • before the first skin incision
  • before the patient leaves surgery
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5
Q

what is the ASA grade?

A

a scoring system to classify the physical status of a patient for anaesthesia

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6
Q

indications for a pre-op ECG?

A
  • possible CVD

- aged >65

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7
Q

how long should the patient have been nil by mouth for pre-surgery

A

6 hours of no food and 2 hours of no fluids (true NBM)

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8
Q

pre-op management of pts on warfarin?

A
  • stop warfarin
  • check INR
  • can give LMWH if high risk pt
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9
Q

when should contraception with oestrogen in it be stopped pre-op?

A

4 weeks before surgery

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10
Q

peri-op management of pts on long term steroids?

A
  • additional IV hydrocortisone at induction

- double normal steroid dose post-op

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11
Q

drugs to be stopped pre-op?

A
  • warfarin, DOACs
  • COCP
  • gliclazide (SFU)
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12
Q

diabetes drugs and their complications peri-op?

A
  • gliclazide (hypoglycaemia)
  • metformin (lactic acidosis)
  • dapagliflozin (SGLT2 inhibit, DKA)
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13
Q

management of insulin peri-op?

A
  • long acting: reduce dose
  • short acting: stop
  • start “sliding scale”
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14
Q

what is a “sliding scale”?

A

variable rate insulin infusion along with glucose, NaCl and K+ infusions

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15
Q

what are the options for VTE prophylaxis?

A
  • LMWH (enoxaparin)
  • DOAC (apixaban)
  • intermittent pneumatic compression devices (IPCD)
  • anti-embolic compression stockings
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16
Q

what are the 4 components of having the capacity to make a decision?

A
  • understanding information
  • retaining information
  • weighing up pros and cons
  • communicating the decision
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17
Q

what is a lasting power of attorney (LPA)?

A

when a person legally nominates someone to make decisions on their behalf IF they lack mental capacity

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18
Q

in which settings is a deprivation of liberty safeguards (DoLS) valid? what does this mean?

A
  • hospital
  • care home
  • the pt is unable to leave
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19
Q

what are the 4 types of consent form?

A
  • 1: pt consenting
  • 2: parent consenting on behalf of child
  • 3: pt will not lose consciousness for the procedure
  • 4: pt lacks capacity
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20
Q

NSAIDs are contraindicated in….

A
  • asthma
  • renal impairment
  • heart disease
  • gastric ulcers
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21
Q

what is patient controlled analgesia (PCA)?

A
  • IV infusion of a strong opiate (e.g. morphine) attached to a pump with a button
  • only pt should press this button
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22
Q

examples of strong opiates?

A
  • morphine
  • oxycodone
  • fentanyl
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23
Q

risk factors for post-op nausea and vomiting (PONV)?

A
  • female
  • younger age
  • prev Hx
  • Hx motion sickness
  • non-smoker
  • use of post-op opiates
  • use of volatile anaesthetics
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24
Q

which anti-emetics can be used prophylactically post-op?

A
  • ondansetron
  • dexamethasone
  • cyclizine
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25
Q

MOA of ondansetron? it should be avoided in….

A
  • serotonin receptor antagonist

- pts at risk of long QT interval

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26
Q

dexamethasone drug class? it should be used with caution in…

A
  • corticosteroid

- diabetes, immunocompromised pts

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27
Q

MOA of cyclizine? it should be used with caution in….

A
  • histamine receptor antagonist

- HF, elderly

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28
Q

which antiemetics can be used for episodes of PONV?

A
  • ondansetron
  • prochlorperazine
  • cyclizine
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29
Q

MOA of prochloperazine? it must be avoided in…

A
  • dopamine receptor antagonist

- parkinson’s!!!!

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30
Q

non-drug management of PONV?

A

pressure on P6 acupuncture point of wrist

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31
Q

3 methods of enteral feeding?

A
  • mouth
  • NG tube
  • PEG tube
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32
Q

what is total parenteral nutrition (TPN)?

A
  • IV infusion of all nutrients

- done via central line

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33
Q

potential post-op complications?

A
  • anaemia, shock
  • sepsis
  • atelectasis
  • infections
  • wound dehiscence
  • ileus
  • VTE
  • urinary retention
  • AF
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34
Q

what is a “third space”? give some examples

A
  • space in body where there shouldn’t be any fluid
  • peritoneal cavity (ascites)
  • pleural cavity (pleural effusion)
  • pericardial cavity (pericardial effusion)
  • joints (effusion)
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35
Q

which pts require fluid restriction?

A
  • HF
  • CKD
  • hyponatraemia (low Na+)
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36
Q

examples of insensible fluid loss?

A
  • respiration
  • in stool
  • burns
  • sweat
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37
Q

signs of hypovolaemia?

A
  • 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
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38
Q

signs of fluid overload?

A
  • ankle oedema
  • sacral oedema
  • pulmonary oedema
  • raised JVP
  • increased body weight
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39
Q

signs O/E of pulmonary oedema?

A
  • SOB
  • reduced SpO2
  • high RR
  • bibasal crackles
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40
Q

what are the 3 main indications for IV fluids?

A
  • resuscitation
  • replacement
  • maintenance
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41
Q

indications for fluid resuscitation?

A
  • sepsis

- hypotension

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42
Q

examples of indications for fluid replacement?

A
  • vomiting

- diarrhoea

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43
Q

example of indication for maintenance fluids?

A

NBM due to bowel obstruction

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44
Q

what are the 2 types of IV fluid?

A
  • crystalloid

- colloid

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45
Q

examples of crystalloid fluids?

A
  • 0.9% NaCl (normal saline)
  • 5% dextrose
  • hartmann’s solution
  • plasma-lyte 148
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46
Q

which condition benefits from being given human albumin solution?

A

decompensated liver disease

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47
Q

what type of fluid is used in resuscitation? give some examples

A

isotonic ones:

  • 0.9% saline
  • hartmann’s solution
  • plasma-lyte 148
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48
Q

how is fluid resuscitation carried out?

A
  • 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
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49
Q

which fluids can never be infused rapidly?

A
  • any containing high K+ conc

- risk of arrhythmia or cardiac arrest

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50
Q

principles of using maintenance fluids?

A
  • give for shortest time possible where patient is unable to take fluids PO
  • stop as soon as PO fluids commence
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51
Q

examples of when maintenance fluids would be needed?

A

negative fluid balance unable to take PO fluids:

  • NBM waiting for surgery
  • bowel obstruction
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52
Q

what should be included in maintenance fluids?

A
  • 25-30ml / kg / day water
  • 1 mmol / kg / day Na+, K+ and Cl-
  • 50-100g / day glucose
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53
Q

why is glucose included in maintenance fluids?

A
  • to prevent ketosis

- NOT to meet nutritional needs

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54
Q

how is overprescribing of maintenance fluids in obese patients prevented?

A

use ideal body weight instead of BMI

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55
Q

monitoring requirements of maintenance fluids?

A

to be done at least daily:

  • fluid status assessment
  • look at fluid balance chart
  • UEs
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56
Q

in which patient groups should maintenance fluids be prescribed with caution?

A
  • elderly or frail
  • significant oedema
  • low or high Na+
  • HF
  • renal impairment
  • liver impairment
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57
Q

differentials for generalised abdominal pain?

A
  • peritonitis
  • ruptured AAA
  • bowel obstruction
  • ischaemic colitis
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58
Q

differentials for RUQ pain?

A
  • biliary colic
  • acute cholecystitis
  • acute cholangitis
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59
Q

differentials for epigastric pain?

A
  • acute gastritis
  • peptic ulcer disease
  • pancreatitis
  • ruptured AAA
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60
Q

differentials for central abdominal pain?

A
  • ruptured AAA
  • bowel obstruction
  • ischaemic colitis
  • appendicitis (early)
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61
Q

differentials for RIF pain?

A
  • appendicitis (later)
  • ectopic pregnancy
  • ruptured ovarian cyst
  • ovarian torsion
  • meckel’s diverticulitis
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62
Q

differentials for LIF pain?

A
  • diverticulitis
  • ectopic pregnancy
  • ruptured ovarian cyst
  • ovarian torsion
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63
Q

differentials for suprapubic pain?

A
  • LUTI
  • urinary retention
  • PID
  • prostatitis
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64
Q

differentials for loin to groin pain?

A
  • renal colic (stones)
  • ruptured AAA
  • pyelonephritis
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65
Q

differentials for testicular pain?

A
  • testicular torsion

- epididymo-orchitis

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66
Q

signs of peritonitis?

A
  • guarding
  • rigidity
  • rebound tenderness
  • tender to percuss
  • worse on coughing
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67
Q

how can peritonitis be classified?

A
  • localised (organ inflamed)
  • generalised (organ perforated)
  • spontaneous bacterial (infection of ascitic fluid)
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68
Q

prognosis in SBP?

A

poor

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69
Q

management of the acute abdomen patient?

A
  • 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
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70
Q

pre-surgical management of acute abdomen?

A
  • make NBM
  • get consent (someone qualified should do this)
  • anaesthetist review
  • put on theatre list
  • crossmatch units of blood
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71
Q

peak incidence of appendicitis?

A
  • ages 10-20

- less common in young children and >50s

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72
Q

where is the appendix found?

A
  • arises from caecum

- where the 3 teniae coli meet (longitudinal colon muscles)

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73
Q

what happens when the appendix ruptures?

A
  • faecal matter released into peritoneal cavity
  • irritates lining
  • peritonitis
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74
Q

presentation of appendicitis?

A
  • 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
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75
Q

where is mcburney’s point

A

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

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76
Q

describe rovsing’s sign. where is this seen?

A
  • palpating the LIF causes pain in the RIF

- appendicitis

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77
Q

how is appendicitis diagnosed?

A
  • clinically
  • CT may be used to confirm this
  • laparoscopy is DIAGNOSTIC if still in doubt
  • USS useful in females (rule out gynaecological stuff)
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78
Q

key differentials for appendicitis?

A
  • ectopic pregnancy (check bHCG)
  • ovarian cysts
  • meckel’s diverticulum
  • mesenteric adenitis
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79
Q

describe meckel’s diverticulum. which complications could it cause?

A
  • malformation of distal ileum, typically asymptomatic
  • volvulus
  • intussusception
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80
Q

what is mesenteric adenitis? which conditions is it associated with?

A
  • inflamed abdo lymph nodes
  • tonsillitis
  • URTI
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81
Q

what causes an appendix mass?

A
  • when the omentum sticks to the inflamed appendix

- forms mass in RIF

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82
Q

management of appendicitis?

A
  • emergency admission
  • appendicectomy
  • done either laparoscopically or open surgery
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83
Q

advantages of laparoscopic surgery over open surgery for appendicitis?

A
  • fewer risks

- faster recovery

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84
Q

complications of appendicectomy?

A
  • bleeding
  • infection
  • scarring
  • pain
  • damage to surrounding organs
  • anaesthetic risks
  • VTE
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85
Q

which type of bowel obstruction is more common, small or large?

A

small

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86
Q

how does bowel obstruction result in fluid loss? what determines the severity of this?

A
  • 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
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87
Q

3 main causes of bowel obstruction?

A
  • adhesions (small bowel)
  • hernias (small bowel)
  • malignancy (large bowel)
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88
Q

less common causes of bowel obstruction?

A
  • volvulus (large bowel)
  • diverticular disease
  • strictures secondary to Crohn’s
  • intusussception
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89
Q

causes of adhesions?

A
  • abdo / pelvic surgery
  • peritonitis
  • abdo / pelvic infections
  • endometriosis
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90
Q

presentation of bowel obstruction?

A
  • green, bilious vomiting
  • abdo distension
  • diffuse abdo pain
  • obstipation
  • “tinkling” bowel sounds in early stages
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91
Q

initial investigation of choice and findings in bowel obstruction?

A
  • XR
  • distended loops of bowel
  • valvulae conniventes (small bowel)
  • haustra (large bowel)
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92
Q

complications of bowel obstruction?

A
  • hypovolaemic shock (from third spacing)
  • bowel ischaemia
  • bowel perforation
  • sepsis
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93
Q

findings on bloods in bowel obstruction?

A
  • electrolyte imbalance
  • metabolic alkalosis (due to vomiting)
  • raised lactate (ischaemia)
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94
Q

initial management of a bowel obstruction?

A
  • make NBM
  • IV fluids
  • NG tube with free drainage
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95
Q

investigations for bowel obstruction?

A
  • abdo XR
  • erect CXR (shows air under diaphragm)
  • abdo CT with contrast
  • bloods
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96
Q

surgical management of bowel obstruction?

A
  • exploratory surgery if cause unclear

otherwise depends on cause:

  • adhesiolysis
  • hernia repair
  • emergency resection
  • stent to move tumour out of way if Ca cause
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97
Q

pathophysiology of ileus?

A

temporary cessation of peristalsis in the small bowel

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98
Q

causes of ileus?

A
  • injury to bowel
  • handling of bowel in surgery
  • local inflamm / infection (e.g. peritonitis, appendicitis, pancreatitis)
  • electrolyte imbalance
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99
Q

which electrolyte imbalances could cause ileus?

A
  • hypokalaemia

- hyponatraemia

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100
Q

commonest time to have ileus? prognosis?

A
  • straight after abdo surgery

- self-resolves within a few days

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101
Q

presentation of ileus?

A

literally identical to that of BO:

  • green, bilious vomiting
  • abdo distension
  • diffuse abdo pain
  • obstipation
  • ABSENT bowel sounds instead of tinkling
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102
Q

management of ileus?

A
  • make NBM
  • NG tube if vomiting
  • IV fluids
  • mobilisation (stimulates peristalsis)
  • TPN whilst waiting for peristalsis to kick in
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103
Q

pathophysiology of volvulus?

A
  • bowel twists around on itself and surrounding mesentery

- causes closed-loop obstruction

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104
Q

what is a closed loop bowel obstruction?

A

when an area of bowl is isolated by obstruction on either side of it

105
Q

types of volvulus? hint: where they happen

A
  • sigmoid volvulus

- caecal volvulus

106
Q

most common type of volvulus? typical demographic affected?

A
  • sigmoid volvulus

- elderly

107
Q

risk factors for volvulus?

A
  • parkinson’s
  • being a nursing home resident
  • chronic constipation
  • high fibre diet
  • pregnancy
  • presence of adhesions
108
Q

presentation of volvulus? hint: same as BO

A
  • green, bilious vomiting
  • abdo distension
  • diffuse abdo pain
  • obstipation
109
Q

how is volvulus diagnosed?

A
  • abdo XR shows “coffee bean” sign in sigmoid volvulus

- confirmed with contrast CT

110
Q

initial management of volvulus?

A

same initial management as BO:

  • make NBM
  • NG tube
  • IV fluids
111
Q

conservative management of volvulus?

A

endoscopic decompression

112
Q

surgical management of volvulus?

A
  • laparotomy
  • hartmann’s procedure
  • ileocaecal resection / right hemicolectomy if caecal
113
Q

presentation of abdominal wall hernia?

A
  • soft lump
  • may be reducible
  • may protrude on coughing or standing
  • aching, pulling or dragging sensation
114
Q

complications of hernias?

A
  • incarceration
  • bowel obstruction
  • strangulation and ischaemia
115
Q

how does a strangulated hernia present? what’s the significance of this?

A
  • pain and tenderness over lump

- needs emergency surgery, bowel will be dead in hours

116
Q

describe a maydl’s hernia

A

a hernia with 2 different loops of bowel in it

117
Q

describe a richter’s hernia

A
  • hernia where only part of the bowel lumen and wall are in it
  • prone to strangulation
118
Q

management options for a hernia?

A
  • conservative
  • tension-free surgical repair
  • tension surgical repair
119
Q

which hernias can be managed conservatively?

A
  • hernias with a wide neck (low risk of complications)

- where pts have too many comorbidities for surgery

120
Q

how can inguinal hernias be classified?

A
  • direct

- indirect

121
Q

differentials for lump in inguinal region?

A
  • inguinal hernia
  • femoral hernia
  • swollen lymph node
  • saphena varix
  • femoral aneurysm
  • abscess
  • undescended / ectopic testis
  • kidney transplant
122
Q

what is an indirect inguinal hernia?

A

bowel herniating through the inguinal canal

123
Q

what is the inguinal canal? where does it run between?

A
  • tube connecting peritoneal cavity to scrotum
  • deep inguinal ring
  • superficial inguinal ring
124
Q

describe the course of the round ligament in females?

A
  • uterus
  • deep inguinal ring
  • inguinal canal
  • labia majora
125
Q

where is the deep inguinal ring found?

A

halfway between ASIS and pubic tubercle

126
Q

how can an indirect inguinal hernia be differentiated from a direct one?

A
  • reduce the hernia
  • apply pressure at the location of the deep inguinal ring
  • hernia should REMAIN reduced in doing this
127
Q

what causes direct inguinal hernias to form?

A

weakness of the abdo wall at hesselbach’s triangle

128
Q

RIP: borders of hesselbach’s triangle?

A
  • rectus abdominis
  • inferior epigastric vessels
  • poupart’s (inguinal) ligament
129
Q

describe a femoral hernia

A

abdo contents herniating through the femoral canal

130
Q

FLIP: boundaries of the femoral canal?

A
  • femoral vein
  • lacunar ligament
  • inguinal ligament
  • pectineal ligament
131
Q

what is the femoral triangle?

A

large area at top of thigh which contains the femoral canal

132
Q

where do incisional hernias occur?

A

at the site of incision of past surgery

133
Q

typical demographic affected by umbilical hernias? prognosis?

A
  • neonates

- good, self-resolving

134
Q

describe a hiatus hernia

A

stomach herniating through hole in diaphragm

135
Q

4 types of hiatus hernia?

A
  • sliding
  • rolling
  • mixed sliding and rolling
  • large opening (more organs than just stomach entering thorax)
136
Q

risk factors for hiatus hernia?

A
  • ageing
  • obesity
  • pregnancy
137
Q

presentation of hiatus hernia?

A
  • heartburn
  • acid / food reflux
  • burping
  • bloating
  • bad breath
138
Q

investigations for hiatus hernia?

A
  • not always present so not always visible
  • CXR
  • CT
  • endoscopy
  • barium swallow testing
139
Q

management of hiatus hernia?

A
  • conservative

- surgical laparoscopic fundoplication

140
Q

what is a haemorrhoid?

A

an enlarged anal vascular cushion

141
Q

risk factors for haemorrhoids?

A
  • constipation, straining
  • pregnancy
  • obesity
  • ageing
  • increased intra-abdominal pressure
142
Q

give examples of how intra-abdominal pressure could be raised

A
  • weightlifting

- chronic coughing

143
Q

how can haemorrhoids be classified?

A
  • 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
144
Q

presentation of haemorrhoids?

A
  • can be asymptomatic
  • painless, bright red bleeding
  • blood NOT mixed in with stool
  • sore / itchy anus
  • palpable lump around / inside anus
145
Q

signs O/E of haemorrhoids?

A
  • external ones are visible on inspection

- internal ones may be felt on PR exam

146
Q

differentials for rectal bleeding?

A
  • haemorrhoids
  • anal fissures
  • diverticulosis
  • IBD
  • colorectal Ca
147
Q

non-surgical management of haemorrhoids?

A
  • topical astringent (e.g. anusol)
  • germoloid cream
  • prevent / treat constipation
  • avoid straining
  • rubber band ligation
  • injection sclerotherapy
  • infra-red coagulation
  • bipolar diathermy
148
Q

surgical management of haemorrhoids?

A
  • haemorrhoidal artery ligation
  • haemorrhoidectomy
  • stapled haemorrhoidectomy
149
Q

what causes a haemorrhoid to become thrombosed?

A

when there is strangulation at the base of the haemorrhoid

150
Q

presentation of thrombosed haemorrhoid?

A
  • purplish, very tender lumps around anus

- PR impossible due to pain

151
Q

what is a diverticulum?

A

a pouch in the bowel wall

152
Q

what is the difference between diverticulosis / diverticular disease and diverticulitis?

A
  • first one is presence of diverticula without any inflamm / infection
  • second one is where there IS inflamm / infection present
153
Q

which parts of the bowel wall are most susceptible to diverticula forming?

A

areas where there are no teniae coli

154
Q

most commonly affected portion of the bowel in diverticulosis?

A

sigmoid colon

155
Q

risk factors for diverticulosis?

A
  • ageing
  • low fibre diet
  • obesity
  • NSAID use
156
Q

how is diverticulosis diagnosed?

A

usually asymptomatic, incidental finding on colonoscopy / CT scans

157
Q

how could diverticulosis present?

A
  • usually asymptomatic
  • LIF pain
  • constipation
  • rectal bleeding
158
Q

management of diverticulosis?

A
  • increase dietary fibre
  • bulk-forming laxatives (ispaghula husk)
  • avoid stimulant laxatives (senna)
  • surgery if symptoms are significant
159
Q

how does acute diverticulitis present?

A
  • pain and tenderness in LIF
  • fever
  • diarrhoea
  • N+V
  • rectal bleeding
  • palpable abdo mass
  • raised inflamm markers and WCC on bloods
160
Q

management of uncomplicated diverticulitis?

A
  • 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
161
Q

management of severe diverticulitis?

A
  • hosp admission
  • make NBM
  • IV ABx
  • IV fluids
  • analgesia
  • urgent CT
  • urgent surgery if there is any complication
162
Q

complications of acute diverticulitis?

A
  • perforation
  • peritonitis
  • abscess
  • large haemorrhage (give transfusion)
  • fistula
  • ileus / obstruction
163
Q

3 main arteries supplying abdominal arteries?

A
  • coeliac artery (foregut)
  • superior mesenteric artery (midgut)
  • inferior mesenteric artery (hindgut)
164
Q

presentation of chronic mesenteric ischaemia? hint: triad

A
  • abdo pain
  • weight loss
  • abdominal bruit on auscultation
165
Q

describe the abdo pain felt in chronic mesenteric ischaemia

A
  • central
  • colicky
  • comes on 30 mins after eating
  • lasts 1-2 hours
166
Q

how does chronic mesenteric ischaemia result in weight loss?

A

food avoidance due to pain after eating

167
Q

risk factors for chronic mesenteric ischaemia?

A

same as any other cardiovascular disease:

  • ageing
  • FHx
  • smoking
  • DM
  • HTN
  • raised cholesterol
168
Q

how is chronic mesenteric ischaemia diagnosed?

A

on CT angiography

169
Q

management of chronic mesenteric ischaemia?

A
  • address modifiable risk factors
  • statins and antiplatelets (secondary prevention)
  • revascularisation (improve blood flow to intestines)
170
Q

how is revascularisation performed for chronic mesenteric ischaemia?

A

either:

  • endovascular (percutaneous mesenteric artery stenting), 1st line
  • open surgery (endarterectomy or bypass)
171
Q

key risk factor for acute mesenteric ischaemia?

A

AF (basically an embolic stroke but in the gut)

172
Q

early presentation of acute mesenteric ischaemia?

A
  • abdo pain disproportionately worse than findings O/E
173
Q

later presentation of acute mesenteric ischaemia?

A
  • shock
  • peritonitis
  • sepsis
  • bowel perforation
174
Q

first line investigation in acute mesenteric ischaemia?

A

contrast CT

175
Q

findings on bloods in acute mesenteric ischaemia?

A
  • metabolic acidosis

- raised lactate

176
Q

management of acute mesenteric ischaemia?

A

surgery to remove bowel and remove / bypass thrombus in artery

177
Q

prognosis in acute mesenteric ischaemia?

A
  • poor

- >50% mortality rate !

178
Q

risk factors for bowel Ca?

A
  • FHx
  • familial adenomatous polyposis (FAP)
  • HNPCC
  • IBD
  • ageing
  • diet
  • obesity
  • sedentary lifestyle
  • smoking
  • alcohol
179
Q

which aspects of diet can increase risk of bowel Ca?

A
  • high red meat
  • high processed meat
  • low fibre
180
Q

what does FAP result in? pattern of inheritance?

A
  • adenomas (polyps) develop in the large intestine
  • polyps can become malignant, usually before age of 40
  • autosomal dominant
181
Q

how can bowel Ca be prevented in someone with FAP?

A

entire large intestine removed

182
Q

which familial conditions increase the risk of bowel Ca?

A
  • FAP

- HNPCC (esp colorectal Ca)

183
Q

presentation of bowel Ca?

A
  • 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
184
Q

2WW criteria for bowel Ca?

A
  • > 40 with abdo pain and unexplained weight loss
  • > 50 with unexplained PR bleeding
  • > 60 with change in bowel habit or Fe def anaemia
185
Q

what does FIT testing look for? what is it used for?

A
  • amount of human Hb in stool

- to screen for bowel Ca

186
Q

why is the FOB test for bowel Ca not very accurate?

A
  • just detects any form of blood

- false positives from red meat blood

187
Q

who gets screened for bowel Ca? how often is this done?

A
  • those aged 60-74

- they get sent a FIT test every 2 years

188
Q

how is the FIT test result interpreted?

A

if positive, invite them to colonoscopy

189
Q

investigations for bowel Ca?

A
  • colonoscopy (gold standard)
  • sigmoidoscopy
  • CT colonography
  • CT TAP (thorax, abdo, pelvis - done for staging)
  • CEA tumour marker on bloods
190
Q

how is bowel Ca classified?

A

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
191
Q

management of bowel Ca?

A
  • surgical resection
  • chemo / radiotherapy
  • palliative care
192
Q

what is low anterior resection syndrome? how does it present?

A
  • complication of having bowel surgically resected
  • urgency, frequency and incontinence of BMs
  • difficulty in controlling flatulence
193
Q

investigations following curative surgery for bowel Ca?

A
  • serum CEA levels

- CT TAP

194
Q

what are most gallstones made of?

A

cholesterol

195
Q

complications of gallstones?

A
  • acute cholecystitis
  • acute cholangitis
  • obstructive jaundice
  • pancreatitis
196
Q

4Fs: risk factors for gallstones?

A
  • fat
  • fair
  • female
  • forty
197
Q

presentation of gallstones?

A
  • “biliary colic”:
  • severe RUQ colicky pain
  • triggered by meals (esp fatty ones)
  • lasts 30 mins - 8 hours
  • associated N+V
198
Q

findings on LFTs in gallstones?

A
  • raised bilirubin if gallstone is in bile duct (obstructing it)
  • significantly raised ALP
  • slightly raised ALT / AST
199
Q

first line investigation in gallstones?

A

USS

200
Q

findings on USS in gallstones?

A
  • stones in GB / ducts
  • bile duct dilatation (should be <6mm diameter)
  • acute cholecystitis
201
Q

findings on USS indicative of acute cholecystitis?

A
  • thickened GB wall
  • stones / sludge in GB
  • fluid surrounding GB
202
Q

management of gallstones in bile duct?

A

ERCP

203
Q

complications of ERCP procedure?

A
  • excessive bleeding
  • cholangitis (infection of bile ducts)
  • pancreatitis
204
Q

management of gallstones?

A
  • if asymptomatic, then nothing
  • cholecystectomy (GB removal)
  • ERCP if in bile ducts
205
Q

what is post-cholecystectomy syndrome? features?

A
  • complication of GB removal
  • diarrhoea
  • nausea, indigestion
  • epigastric / RUQ pain
  • flatulence
206
Q

what is acute cholecystitis?

A

inflammation of gallbladder

207
Q

causes of acute cholecystitis?

A

anything compressing cystic duct:

  • gallstones
  • tumour
  • infection
  • fasting (GB not stimulated to move)
208
Q

presentation of acute cholecystitis?

A
  • RUQ pain+/- radiates to R shoulder
  • fever
  • N+V
209
Q

findings O/E of acute cholecystitis?

A
  • high HR
  • high RR
  • RUQ tenderness
  • murphy’s sign
210
Q

findings on bloods in acute cholecystitis?

A
  • raised inflamm markers

- raised WCC

211
Q

describe murphy’s sign

A
  • put pressure on RUQ and ask pt to breathe in
  • in acute cholecystitis, this is painful
  • pt will suddenly stop breathing in
212
Q

first line investigation in acute cholecystitis?

A

abdo USS

213
Q

findings on USS in acute cholecystitis?

A
  • thickened GB wall
  • stones / sludge in GB
  • fluid around GB
214
Q

management of acute cholecystitis?

A
  • 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
215
Q

complications of acute cholecystitis?

A
  • sepsis
  • GB empyema
  • gangrenous GB
  • GB perforation
216
Q

what is GB empyema? how is it managed?

A
  • pus in GB due to infection
  • cholecystectomy (GB removal)
  • cholecystostomy (draining infected contents)
217
Q

what is acute cholangitis?

A
  • infection and inflammation of bile ducts

- surgical emergency

218
Q

2 main causes of acute cholangitis?

A
  • obstruction (e.g. stones) in bile ducts stopping slow

- infection from ERCP procedure

219
Q

commonest causative organisms in acute cholangitis?

A
  • E. coli
  • klebsiella
  • enterococcus
220
Q

presentation of acute cholangitis? hint: triad

A

charcot’s triad:

  • RUQ pain
  • fever
  • jaundice
221
Q

management of acute cholangitis?

A
  • needs emergency admission
  • make NBM
  • IV fluids
  • blood cultures
  • IV ABx
  • involve senior ICU staff
  • ERCP
  • PTC (drain insertion) if ERCP fails
222
Q

key complications of acute cholangitis?

A
  • sepsis
  • septicaemia
  • cause a high mortality rate
223
Q

which procedures can be carried out in ERCP for acute cholangitis?

A
  • cholangio-pancreatography
  • sphincterotomy
  • stone removal
  • balloon dilatation
  • stenting
  • biopsy
224
Q

what is a cholangiocarcinoma? what is the most common type?

A
  • Ca of bile ducts

- adenocarcinoma

225
Q

risk factors for cholangiocarcinoma?

A
  • PSC

- liver flukes (parasitic infection)

226
Q

presentation of cholangiocarcinoma?

A
  • painless, obstructive jaundice
  • unexplained weight loss
  • RUQ pain
  • palpable GB
  • hepatomegaly
227
Q

signs of obstructive jaundice?

A
  • yellow skin and sclera
  • pale stools
  • dark urine
  • generalised itching
228
Q

what is courvoisier’s law? what is the significance of this?

A
  • a palpable GB with jaundice is unlikely to be gallstones

- makes cholangiocarcinoma / pancreatic Ca more likely

229
Q

investigations for cholangiocarcinoma?

A
  • CT TAP for staging
  • CA 19-9 (tumour marker, raised)
  • MRCP
  • ERCP to put stent in and relieve obstruction
230
Q

management of cholangiocarcinoma?

A
  • curative surgery in early cases

- rest is palliative

231
Q

commonest site for a pancreatic Ca?

A

head of pancreas

232
Q

prognosis of pancreatic Ca?

A
  • very poor
  • avg survival = 6m
  • 5YS = <25%
233
Q

presentation of pancreatic Ca?

A
  • 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
234
Q

describe trosseau’s sign of malignancy. where is it seen?

A
  • migratory thrombophlebitis in someone with Ca

- seen in pancreatic Ca

235
Q

investigations in pancreatic Ca?

A
  • diagnosed on CT with histology from biopsy
  • CT TAP for staging
  • CA 19-9
  • MRCP
  • ERCP to put stent in
  • biopsy
236
Q

management of pancreatic Ca?

A
  • 90% of cases are palliative
  • 10% can have a form of surgery
  • total / distal pancreatectomy
  • whipple procedure
237
Q

palliative care options in cholangiocarcinoma and pancreatic Ca?

A
  • stents
  • surgery for symptom relief
  • palliative chemo
  • palliative radio
  • EOL care with symptom control
238
Q

which structures are removed in whipple procedure?

A
  • head of pancreas
  • pylorus of stomach
  • duodenum
  • GB
  • bile duct
  • relevant lymph nodes
239
Q

3 key causes of acute pancreatitis?

A
  • gallstones
  • alcohol
  • post-ERCP
240
Q

which demographics are more likely to get gallstone pancreatitis?

A
  • women

- older pts

241
Q

which demographics are more likely to get alcohol-induced pancreatitis?

A
  • men

- younger pts

242
Q

presentation of acute pancreatitis?

A
  • severe epigastric pain
  • radiates to back
  • associated vomiting
  • abdo tenderness
  • systemic signs (low-grade fever, tachycardia)
243
Q

how is acute pancreatitis diagnosed?

A
  • clinically

- plus raised amylase level on bloods

244
Q

investigations for acute pancreatitis?

A
  • FBC
  • UEs
  • LFT
  • Ca
  • ABG (check PaO2 and glucose)
245
Q

which score can be used to assess severity of acute pancreatitis?

A
  • Glasgow score

- 2 = moderate, 3 = severe

246
Q

management of acute pancreatitis?

A
  • A-E assessment
  • IV fluids
  • make NBM
  • analgesia
  • ERCP if caused by gallstones
  • ABx if evidence of specific infection
  • treat complications
247
Q

complications of acute pancreatitis?

A
  • necrosis of pancreas
  • infection
  • abscess
  • pseudocysts (up to 4w after pancreatitis)
  • chronic pancreatitis
248
Q

commonest cause of chronic pancreatitis?

A

alcohol

249
Q

complications of chronic pancreatitis?

A
  • chronic pain
  • diabetes
  • pseudocysts
  • abscesses
250
Q

how does chronic pancreatitis result in diabetes?

A
  • pancreas loses its endocrine function
  • stops secreting insulin
  • T1DM occurs
251
Q

management of chronic pancreatitis?

A
  • abstinence from both alcohol and smoking
  • analgesia
  • creon (replacement enzymes)
  • SC insulin regime
  • ERCP with stenting if strictures / obstruction present
  • surgery
252
Q

how does chronic pancreatitis result in steatorrhoea?

A
  • pancreas loses its exocrine function
  • stops releasing lipase
  • steatorrhoea and vit deficiencies occur
253
Q

indications for liver transplant?

A
  • chronic liver failure
  • paracetamol OD
  • acute viral hepatitis
  • HCC
254
Q

who gets priority in liver transplants?

A
  • acute ones

- chronic ones get put on a list, wait approx 5m

255
Q

which patient factors suggest they may not be suitable for a liver transplant?

A
  • severe comorbidities (e.g. bad CKD, HF)
  • excessive weight loss / malnutrition
  • active hep B / C
  • end-stage HIV
  • active alcohol use
256
Q

how long should a patient have been abstinent for before a liver transplant?

A

at least 6m

257
Q

after care / advice following a liver transplant?

A
  • 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
258
Q

drugs used for immunosuppression post-liver transplant?

A
  • steroids
  • azathioprine
  • tacrolimus
259
Q

signs of liver transplant rejection?

A
  • abnormal LFTs
  • fatigue
  • fever
  • jaundice

2. Y5 Zero to Finals: Surgery (8 decks)

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