General Surgery

Question 1

ASA Grade

Answer 1

The American Society of Anesthesiologists (ASA) grading system classifies the physical status of the patient for anaesthesia. Patients are given a grade to describe their current fitness prior to undergoing anaesthesia/surgery:

ASA I – normal healthy patient
ASA II – mild systemic disease
ASA III – severe systemic disease
ASA IV – severe systemic disease that constantly threatens life
ASA V – “moribund” and expected to die without the operation
ASA VI – declared brain-dead and undergoing an organ donation operation
E – this is used for emergency operations

Question 2

Fasting before surgery

Answer 2

Patients undergo ‘fasting’ before surgery to ensure they have an empty stomach for the duration of their operation. The aim is to reduce the risk of reflux of food around the time of surgery (particularly during intubation and extubation), which subsequently can result in the patient aspirating their stomach contents into their lungs.

Fasting for an operation typically involves:

6 hours of no food or feeds before operation
2 hours no clear fluids (fully “nil by mouth”)

TOM TIP: When you assess an acutely unwell surgical patient, always consider whether there is any possibility they require emergency surgery. Acutely unwell surgical patients that potentially require emergency surgery are made nil by mouth and given maintenance IV fluids. Allowing them to eat and drink could have significant consequences if they need emergency surgery, and the anaesthetist and senior surgeon won’t be happy. This decision will often be reversed on the post-take ward round if the consultant or senior surgeon decides they are unlikely to need to go to theatre.

Question 3

Medication changes and surgery

Answer 3

Follow local guidelines for medication alterations before and after an operation.

Anticoagulants need to be stopped before major surgery. The INR can be monitored in patients on warfarin to ensure it returns to normal before the operation. Warfarin can be rapidly reversed with vitamin K in acute scenarios. Treatment dose low molecular weight heparin or an unfractionated heparin infusion may be used to bridge the gap between stopping warfarin and surgery in higher-risk patients (e.g., mechanical heart valves or recent VTE), and stopped shortly before surgery depending on the risk of bleeding and thrombosis. DOACs (e.g., apixaban, rivaroxaban or dabigatran) are stopped 24-72 hours before surgery depending on the half-life, procedure and kidney function.

Oestrogen-containing contraception (e.g., the combined contraceptive pill) or hormone replacement therapy (e.g., in perimenopausal women) need to be stopped 4 weeks before surgery to reduce the risk of venous thromboembolism (NICE guidelines 2010).

Long-term corticosteroids, equivalent to more than 5mg of oral prednisolone, require additional management around the time of surgery. Surgery adds additional stress to the body, which normally increases steroid production. In patients on long-term steroids, there is adrenal suppression that prevents them from creating the extra steroids required to deal with this stress. Management involves:

Additional IV hydrocortisone at induction and for the immediate postoperative period (e.g., first 24 hours)
Doubling of their normal dose once they are eating and drinking for 24 – 72 hours depending on the operation

Question 4

Diabetes and surgery

Answer 4

The stress of surgery increases blood sugar levels. However, fasting may lead to hypoglycaemia. In general, the risk of hypoglycaemia is greater than hyperglycaemia.

Certain oral anti-diabetic medications may need to be adjusted or omitted around surgery:

Sulfonylureas (e.g., gliclazide) can cause hypoglycaemia and are omitted until the patient is eating and drinking
Metformin is associated with lactic acidosis, particularly in patients with renal impairment
SGLT2 inhibitors (e.g., dapagliflozin) can cause diabetic ketoacidosis in dehydrated or acutely unwell patients

In patients on insulin going for surgery (follow the local policy):

Continue a lower dose (BNF recommends 80%) of their long-acting insulin
Stop short-acting insulin whilst fasting or not eating, until eating and drinking again
Have a variable rate insulin infusion alongside a glucose, sodium chloride and potassium infusion (“sliding-scale”) to carefully control their insulin, glucose and potassium balance

Question 5

VTE prophylaxis and surgery

Answer 5

Every patient admitted to hospital should be assessed for their risk of venous thromboembolism (VTE). Surgery, particularly where the patient is likely to be immobilised (e.g., orthopaedic surgery), significantly increases the risk of venous thromboembolism. There are local and national policies on reducing the risk that involve:

Low molecular weight heparin (LMWH) such as enoxaparin
DOACs (e.g., apixaban or rivaroxaban) may be used as an alternative to LMWH
Intermittent pneumatic compression (inflating cuffs around the legs)
Anti-embolic compression stockings

Question 6

Differential Diagnoses of Acute Abdominal Pain

Answer 6

It may be helpful to think of the causes as being related to pathology in the organs located in the area of the pain. Bear in mind the pain may not always be localised in the typical area, so keep an open mind for other possible differentials. This list is not exhaustive, and always keep your mind open to other possible differentials.

Generalised abdominal pain:

Peritonitis
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis

Right upper quadrant pain:

Biliary colic
Acute cholecystitis
Acute cholangitis

Epigastric pain:

Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured abdominal aortic aneurysm

Central abdominal pain:

Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis
Early stages of appendicitis

Right iliac fossa pain:

Acute appendicitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
Meckel’s diverticulitis

Left iliac fossa pain:

Diverticulitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion

Suprapubic pain:

Lower urinary tract infection
Acute urinary retention
Pelvic inflammatory disease
Prostatitis

Loin to groin pain:

Renal colic (kidney stones)
Ruptured abdominal aortic aneurysm
Pyelonephritis

Testicular pain:

Testicular torsion
Epididymo-orchitis

Peritonitis

Peritonitis refers to inflammation of the peritoneum, the lining of the abdomen. The signs of peritonitis are:

Guarding – involuntary tensing of the abdominal wall muscles when palpated to protect the painful area below
Rigidity – involuntary persistent tightness / tensing of the abdominal wall muscles
Rebound tenderness – rapidly releasing pressure on the abdomen creates worse pain than the pressure itself
Coughing test – asking the patient to cough to see if it results in pain in the abdomen
Percussion tenderness – pain and tenderness when percussing the abdomen

Localised peritonitis is caused by underlying organ inflammation, for example, appendicitis or cholecystitis.

Generalised peritonitis may be caused by perforation of an abdominal organ (e.g., perforated duodenal ulcer or ruptured appendix) releasing the contents into the peritoneal cavity and causing generalised inflammation of the peritoneum.

Spontaneous bacterial peritonitis is associated with spontaneous infection of ascites in patients with liver disease. This is treated with broad-spectrum antibiotics and carries a poor prognosis.

Question 7

Initial assessment of acute abdominal pain

Answer 7

Initial assessment of an acutely unwell patient is with an ABCDE approach, assessing and treating:

A – Airway: Ensure the patient’s airway is patent and secure.
B – Breathing: Assess the breathing, respiratory rate and oxygen saturations. Listen to the lungs. Provide oxygen if required.
C – Circulation: Assess the blood pressure, heart rate, heart sounds and perfusion (e.g., capillary refill time). Gain IV access (wide-bore cannulae are better), take bloods and provide an IV bolus of fluid if required.
D – Disability: Assess the consciousness level using AVPU or GCS scoring systems. Check the blood glucose level.
E – Exposure: Finish the full assessment, including examination of the abdomen.

TOM TIP: When asked “how would you manage this acute presentation?” in an exam or teaching session, the obvious and easy answer to start with is “I would start with an ABCDE approach”. This is a good answer because it shows you are considering the immediate assessment and stabilisation of the unwell patient ahead of jumping to more definitive management that would come after the initial assessment (such as “I would perform an immediate right hemicolectomy”). It is not such a good answer for patients that are not acutely unwell, so don’t use it in these scenarios, for example, if a GP supervisor asked how you would manage a patient presenting with a patch of psoriasis.

Question 8

Investigating acute abdominal pain

Answer 8

The following investigations are useful for obtaining a diagnosis and preparing the patient for theatre.

Full blood count (FBC) gives an indication of bleeding (drop in Hb) and infection / inflammation (raised WBC).

Urea and electrolytes (U&Es) give an indication of electrolyte imbalance and kidney function (useful prior to CT scans, as they require a contrast injection that can damage kidneys).

Liver function tests (LFTs) give an indication of the state of the biliary and hepatic system.

C-reative protein (CRP) gives an indication of inflammation and infection.

Amylase gives an indication of inflammation of the pancreas in acute pancreatitis.

International normalised ratio (INR) gives an indication of the synthetic function of the liver and is essential in establishing their coagulation prior to procedures.

Serum calcium is required to score acute pancreatitis and for other reasons (e.g., clotting and cardiac function).

Serum human chorionic gonadotropin (hCG) or urine pregnancy test is essential in females of child bearing age.

Arterial blood gas (ABG) analysis will show the lactate (an indication of tissue ischaemia) and pO2 (used for scoring in acute pancreatitis).

Serum lactate gives an indication of tissue ischaemia. It is a product of anaerobic respiration and can also be raised in dehydration or hypoxia. Lactate is also available on an ABG result as mentioned above.

Group and save is essential prior to theatre in case the patient requires a blood transfusion.

Blood cultures if infection is suspected.

Abdominal x-ray can provide evidence of bowel obstruction by showing dilated bowel loops.

Erect chest x-ray can demonstrate air under the diaphragm when there is an intra-abdominal perforation. This is caused by air within the peritoneal cavity (pneumoperitoneum).

Abdominal ultrasound can be useful in checking for gallstones, biliary duct dilatation and gynaecological pathology.

CT scans are often required to identify the cause of an acute abdomen and determine correct management.

Question 9

Managing acute abdominal pain

Answer 9

Initial management involves:

ABCDE assessment
Alert seniors of unwell patients: escalating to the registrar, consultant and critical care as required
Nil by mouth if surgery may be required or they have features of bowel obstruction
NG tube in cases of bowel obstruction
IV fluids if required for resuscitation or maintenance
IV antibiotics if infection is suspected
Analgesia as required for pain management
Arranging investigations as required (e.g., bloods, group and save and scans)
Venous thromboembolism risk assessment and prescription if indicated
Prescribing regular medication on the drug chart if they are being admitted (some may need to be withheld)

Patients being admitted to an acute surgical unit will usually be seen by a junior doctor, then reviewed by the surgical registrar if required. A consultant will then review that patient on the post-take ward round, creating a management plan that is then carried out by the junior doctors. This may involve further investigations, preparations for surgery or discharge depending on the presentation.

Further management steps if the patient requires surgery:

Taking consent for surgery (by someone suitably qualified)
Review by an anaesthetist
Putting on the theatre list
Crossmatch units of blood if required

Question 10

Appendicitis

Answer 10

Appendicitis is inflammation of the appendix. The peak incidence of appendicitis is in patients aged 10 to 20 years. It can occur at any age but is less common in young children and adults over 50 years.

Question 11

Pathophysiology of appendicitis

Answer 11

The appendix is a small, thin tube arising from the caecum. It is located at the point where the three teniae coli meet (the teniae coli are longitudinal muscles that run the length of the large intestine). There is a single opening to the appendix that connects it to the bowel, and it leads to a dead end.

Pathogens can get trapped due to obstruction at the point where the appendix meets the bowel. Trapping of pathogens leads to infection and inflammation. The inflammation may proceed to gangrene and rupture. When the appendix ruptures, faecal contents and infective material are released into the peritoneal cavity. This leads to peritonitis, which is inflammation of the peritoneal lining.

Question 12

Signs and symptoms of appendicitis

Answer 12

The key presenting feature of appendicitis is abdominal pain. This typically starts as central abdominal pain that moves down to the right iliac fossa (RIF) within the first 24 hours, eventually becoming localised in the RIF. On palpation of the abdomen, there is tenderness at McBurney’s point. McBurney’s point refers to a specific area one third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus.

Other classic features are:

Loss of appetite (anorexia)
Nausea and vomiting
Low-grade fever
Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF)
Guarding on abdominal palpation
Rebound tenderness in the RIF (increased pain when suddenly releasing the pressure of deep palpation)
Percussion tenderness (pain and tenderness when percussing the abdomen)

Rebound tenderness and percussion tenderness suggest peritonitis, potentially indicating a ruptured appendix.

Question 13

Diagnosing appendicitis

Answer 13

Diagnosis is based on the clinical presentation and raised inflammatory markers. Performing a CT scan can be useful in confirming the diagnosis, particularly where another diagnosis is more likely. An ultrasound scan is often used in female patients to exclude ovarian and gynaecological pathology. Ultrasound can also be useful in children, where a CT scan is less appropriate due to the dose of radiation.

Appendicitis is mostly a clinical diagnosis (meaning it is based on signs and symptoms rather than diagnostic tests). Where the diagnosis is unclear, a period of observation may be used, with repeated examinations over time to see whether the symptoms resolve or worsen.

When a patient has a clinical presentation suggestive of appendicitis, but investigations are negative, the next step is to perform a diagnostic laparoscopy to visualise the appendix directly. The surgeon can proceed to an appendicectomy during the same procedure, if indicated.

Question 14

Differential diagnoses to appendicitis

Answer 14

Ectopic Pregnancy

Consider ectopic pregnancy in females of childbearing age. This is a gynaecological emergency with a relatively high mortality if mismanaged. A serum or urine human chorionic gonadotropin (hCG) to exclude pregnancy is essential.

Ovarian Cysts

Ovarian cysts can cause pelvic and iliac fossa pain, particularly with rupture or torsion.

Meckel’s Diverticulum

Meckel’s diverticulum is a malformation of the distal ileum that occurs in around 2% of the population. It is usually asymptomatic and does not require any treatment. However, it can bleed, become inflamed, rupture or cause a volvulus or intussusception.

Mesenteric Adenitis

Mesenteric adenitis describes inflamed abdominal lymph nodes. It presents with abdominal pain, usually in younger children, and is often associated with tonsillitis or an upper respiratory tract infection. No specific treatment is required.

TOM TIP: When seeing females of child-bearing age assume they are pregnant until proven otherwise with a pregnancy test. This is especially important in patients with abdominal pain (where ectopic pregnancy is a key differential), or where you are requesting x-rays or CT scans. Serum HCG is typically part of the normal abdominal pain blood panel in A&E.

Question 15

Appendix Mass

Answer 15

An appendix mass occurs when the omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa. This is typically managed conservatively with supportive treatment and antibiotics, followed by appendicectomy once the acute condition has resolved.

Question 16

Managing appendicitis

Answer 16

Patients with suspected appendicitis need emergency admission to hospital under the surgical team.

Removal of the inflamed appendix (appendicectomy) is the definitive management for acute appendicitis. Laparoscopic surgery is associated with fewer risks and faster recovery compared to open surgery.

Question 17

Complications of appendicectomy

Answer 17

Bleeding, infection, pain and scars
Damage to bowel, bladder or other organs
Removal of a normal appendix
Anaesthetic risks
Venous thromboembolism (deep vein thrombosis or pulmonary embolism)

TOM TIP: Older children, for example, those aged above 10 years, will often be managed by adult general surgical teams at local hospitals, provided there is a paediatric department in the hospital. This means you may end up visiting the paediatrics ward whilst on your adult surgery rotations. It is worth making friends with paediatric doctors and nurses, who can be very helpful if you are unsure about pain relief or IV fluids prescriptions in children, as this is quite different to adults.

Question 18

Bowel Obstruction

Answer 18

A bowel obstruction refers to when the passage of food, fluids and gas, through the intestines becomes blocked. Small bowel obstruction is more common than large bowel obstruction. Obstruction results in a build up of gas and faecal matter proximal to the obstruction (before the obstruction). This causes back-pressure, resulting in vomiting and dilatation of the intestines proximal to the obstruction. Bowel obstruction is a surgical emergency.

The gastrointestinal tract secretes fluid that is later absorbed in the colon. When there is an obstruction, and fluid cannot reach the colon, it cannot be reabsorbed. As a result, there is fluid loss from the intravascular space into the gastrointestinal tract. This leads to hypovolaemia and shock. This abnormal loss of fluid is referred to as third-spacing. The higher up the intestine the obstruction, the greater the fluid losses as there is less bowel over which the fluid can be reabsorbed.

Question 19

Causes of bowel obstruction

Answer 19

The “big three” causes account for around 90% of cases:

Adhesions (small bowel)
Hernias (small bowel)
Malignancy (large bowel)

Other causes include:

Volvulus (large bowel)
Diverticular disease
Strictures (e.g., secondary to Crohn’s disease)
Intussusception (in young children aged 6 months to 2 years)

TOM TIP: Learn to recite the “big three” causes of obstruction without any hesitation. These are the three causes of bowel obstruction you should produce if asked on a ward round or in an OSCE examination. When patients present with symptoms of bowel obstruction, don’t just think about obstruction, but also consider what the cause of the obstruction would be. Ask about hernias, change in bowel habit, weight loss and PR bleeding (bowel cancer) and about previous abdominal surgery that may have resulted in adhesions.

Question 20

Adhesions

Answer 20

Adhesions are pieces of scar tissue that bind the abdominal contents together. They can cause kinking or squeezing of the bowel, leading to obstruction. Adhesions typically cause obstruction in the small bowel, rather than the large bowel.

The main causes of intestinal adhesions are:

Abdominal or pelvic surgery (particularly open surgery)
Peritonitis
Abdominal or pelvic infections (e.g., pelvic inflammatory disease)
Endometriosis

Less commonly, they can be congenital or secondary to radiotherapy treatment.

Question 21

Closed-loop obstruction

Answer 21

Closed-loop obstruction describes a situation where there are two points of obstruction along the bowel; meaning that there is a middle section sandwiched between two points of obstruction. This might happen with:

Adhesions that compress two areas of bowel
Hernias that isolate a section of bowel blocking either end
Volvulus where the twist isolates a section of intestine
A single point of obstruction in the large bowel, with an ileocaecal valve that is competent
A competent ileocaecal valve does not allow any movement back into the ileum from the caecum. When there is a large bowel obstruction and a competent ileocaecal valve, a section of bowel becomes isolated and the contents cannot flow in either direction.

The contents of a “closed-loop” section of bowel do not have an open end where they can drain and decompress. Therefore, the closed-loop section will inevitably continue to expand, leading to ischaemia and perforation. Closed-loop obstruction requires emergency surgery.

Question 22

Presentation of bowel obstruction

Answer 22

The key features of bowel obstruction are:

Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
“Tinkling” bowel sounds may be heard in early bowel obstruction

Question 23

Abdominal X-ray of bowel obstruction

Answer 23

The key x-ray finding in bowel obstruction is distended loops of bowel.

The upper limits of the normal diameter of bowel are:

3 cm small bowel
6 cm colon
9 cm caecum

Valvulae conniventes are present in the small bowel and are mucosal folds that form lines extending the full width of the bowel. These are seen on an abdominal x-ray as lines across the entire width of the bowel.

Haustra are like pouches formed by the muscles in the walls of the large bowel. They form lines that do not extend the full width of the bowel. These are seen on an abdominal x-ray as lines that extend only part of the way across the bowel.

Question 24

Initial management of bowel obstruction

Answer 24

As with any unwell patient, start with an ABCDE approach. Patients with bowel obstruction may be haemodynamically unstable and require urgent intervention if they have developed:

Hypovolaemic shock due to fluid stuck in the bowel rather than the intravascular space (third-spacing)
Bowel ischaemia
Bowel perforation
Sepsis

A full set of bloods are required, as with any acute abdomen. Key things to look out for with bowel obstruction are:

Electrolyte imbalances (U&Es)
Metabolic alkalosis due to vomiting stomach acid (venous blood gas)
Bowel ischaemia (raised lactate – either on a venous blood gas or laboratory sample)

The initial management of bowel obstruction is casually described as “drip and suck”:

Nil by mouth (don’t put food or fluids in if there is a blockage)
IV fluids to hydrate the patient and correct electrolyte imbalances
NG tube with free drainage to allow stomach contents to freely drain and reduce the risk of vomiting and aspiration

Abdominal x-ray may be the initial imaging investigation. However, depending on the signs and symptoms, this may be skipped, and the patient sent straight for a CT scan.

Erect chest x-ray can demonstrate air under the diaphragm when there is an intra-abdominal perforation.

A contrast abdominal CT scan is usually required to confirm the diagnosis of bowel obstruction and establish the site and cause of the obstruction. It can also be used to diagnose an intra-abdominal perforation, if present.

Question 25

Surgical intervention in bowel obstruction

Answer 25

Conservative management may be used in the first instance in stable patients with obstruction secondary to adhesions or volvulus. Where this fails, surgery is required. The definitive management of bowel obstruction is with surgery (either laparoscopy or laparotomy) to correct the underlying cause: Exploratory surgery in patients with an unclear underlying cause Adhesiolysis to treat adhesions Hernia repair Emergency resection of the obstructing tumour Stents may be inserted into the bowel (during a colonoscopy) in patients with obstruction due to a tumour. Stents hold the tumour out of the way, creating space for the bowel contents to move through.

Question 26

Ileus

Answer 26

Ileus is a condition affecting the small bowel, where the normal peristalsis that pushes the contents along the length of the intestines, temporarily stops. It may be referred to as paralytic ileus or adynamic ileus. Pseudo-obstruction is a term used to describe a functional obstruction of the large bowel, where patients present with intestinal obstruction, but no mechanical cause is found. This is less common than ileus affecting the small bowel.

Question 27

Causes of ileus

Answer 27

There is a long list of things that can make the bowel unhappy, leading to ileus. Common causes are: Injury to the bowel Handling of the bowel during surgery Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia) Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia) The most common time you will see ileus is following abdominal surgery. This usually resolves with supportive care within a few days.

Question 28

Signs and symptoms of ileus

Answer 28

The signs and symptoms are akin to bowel obstruction, with: Vomiting (particularly green bilious vomiting) Abdominal distention Diffuse abdominal pain Absolute constipation and lack of flatulence Absent bowel sounds (as opposed to the “tinkling” bowel sounds of mechanical obstruction)

Question 29

Managing ileus

Answer 29

The ileus will usually resolve with treatment of the underlying cause. Management involves supportive care. Supportive care involves: Nil by mouth or limited sips of water NG tube if vomiting IV fluids to prevent dehydration and correct the electrolyte imbalances Mobilisation to helps stimulate peristalsis Total parenteral nutrition (TPN) may be required whilst waiting for the bowel to regain function

Question 30

Volvulus

Answer 30

Volvulus is a condition where the bowel twists around itself and the mesentery that it is attached to. The mesentery is the membranous peritoneal tissue that creates a connection between the bowel and the posterior abdominal wall. The bowel gets its blood supply from the mesentery (through the mesenteric arteries). Twisting in the bowel leads to a closed-loop bowel obstruction, where a section of bowel is isolated by obstruction on either side. The blood vessels that supply the bowel can be involved, cutting off the blood supply to the bowel, which leads to bowel ischaemia. Ischaemia leads to death of the bowel tissue (necrosis), and bowel perforation.

Question 31

Types of volvulus

Answer 31

There are two main types of volvulus depending on the area affected: Sigmoid volvulus Caecal volvulus Sigmoid volvulus is more common and tends to affect older patients. The twist affects the sigmoid colon. A key cause is chronic constipation and lengthening of the mesentery attached to the sigmoid colon. The sigmoid colon becomes overloaded with faeces, causing it to sink downwards causing a twist. It is also associated with a high fibre diet and the excessive use of laxatives. Caecal volvulus is less common and tends to affect younger patients. The twist occurs in the caecum.

Question 32

Risk factors for volvulus

Answer 32

Neuropsychiatric disorders (e.g., Parkinson’s) Nursing home residents Chronic constipation High fibre diet Pregnancy Adhesions

Question 33

Presentation of volvulus

Answer 33

The signs and symptoms are akin to bowel obstruction, with: Vomiting (particularly green bilious vomiting) Abdominal distention Diffuse abdominal pain Absolute constipation and lack of flatulence

Question 34

Diagnosing volvulus

Answer 34

Abdominal x-ray can show the “coffee bean” sign in sigmoid volvulus, where the dilated and twisted sigmoid colon looks like a giant coffee bean. A contrast CT scan is the investigation of choice to confirm the diagnosis and identify other pathology. TOM TIP: Remember the “coffee bean” sign for your MCQ exams. It is worth looking up photographs so that you can recognise it and immediately know the diagnosis (sigmoid volvulus) if it comes up.

Question 35

Managing volvulus

Answer 35

The initial management is the same as with bowel obstruction (nil by mouth, NG tube and IV fluids). Conservative management with endoscopic decompression can be attempted in patients with sigmoid volvulus (without peritonitis). A flexible sigmoidoscope is inserted carefully, with the patient in the left lateral position, resulting in a correction of the volvulus. A flatus tube / rectal tube is left in place temporarily to help decompress the bowel and is later removed. There is a risk of recurrence (around 60%). Surgical management involves: Laparotomy (open abdominal surgery) Hartmann’s procedure for sigmoid volvulus (removal of the rectosigmoid colon and formation of a colostomy) Ileocaecal resection or right hemicolectomy for caecal volvulus

Question 36

Hernias

Answer 36

Hernias occur when there is a weak point in a cavity wall, usually affecting the muscle or fascia. This weakness allows a body organ (e.g., bowel) that would normally be contained within that cavity to pass through the cavity wall.

Question 37

Presentation of hernias

Answer 37

There are many types of hernias that present differently depending on where they are and what organs are involved. The typical features of an abdominal wall hernia are: A soft lump protruding from the abdominal wall The lump may be reducible (it can be pushed back into the normal place) The lump may protrude on coughing (raising intra-abdominal pressure) or standing (pulled out by gravity) Aching, pulling or dragging sensation

Question 38

Complications of hernias

Answer 38

Incarceration is where the hernia cannot be reduced back into the proper position (it is irreducible). The bowel is trapped in the herniated position. Incarceration can lead to obstruction and strangulation of the hernia. Obstruction is where a hernia causes a blockage in the passage of faeces through the bowel. Obstruction presents with vomiting, generalised abdominal pain and absolute constipation (not passing faeces or flatus). Strangulation is where a hernia is non-reducible (it is trapped with the bowel protruding) and the base of the hernia becomes so tight that it cuts off the blood supply, causing ischaemia. This will present with significant pain and tenderness at the hernia site. Strangulation is a surgical emergency. The bowel will die quickly (within hours) if not corrected with surgery. There will also be a mechanical obstruction when this occurs. TOM TIP: Hernias that have a wide neck, meaning that the size of the opening that allows abdominal contents through is large, are at lower risk of complications. While the contents can easily pass out of this opening, they can also easily be put back, which puts them at a lower risk of incarceration, obstruction and strangulation. When assessing a hernia, always comment on the size of the neck/defect (narrow or wide), as this will help formulate a risk assessment and management plan for the hernia (such as how urgently they need to be operated on).

Question 39

Richter's Hernia

Answer 39

A Richter’s hernia is a very specific situation that can occur in any abdominal hernia. This is where only part of the bowel wall and lumen herniate through the defect, with the other side of that section of the bowel remaining within the peritoneal cavity. They can become strangulated, where the blood supply to that portion of the bowel wall is constricted and cut off. Strangulated Richter’s hernias will progress very rapidly to ischaemia and necrosis and should be operated on immediately.

Question 40

Maydl's Hernia

Answer 40

Maydl’s hernia refers to a specific situation where two different loops of bowel are contained within the hernia.

Question 41

General management options of abdominal wall hernias

Answer 41

There are general principles of management that apply to abdominal wall hernias. These are: Conservative management Tension-free repair (surgery) Tension repair (surgery) Conservative management involves leaving the hernia alone. This is most appropriate when the hernia has a wide neck (low risk of complications) and in patients that are not good candidates for surgery due to co-morbidities. Tension-free repair involves placing a mesh over the defect in the abdominal wall. The mesh is sutured to the muscles and tissues on either side of the defect, covering it and preventing herniation of the cavity contents. Over time, tissues grow into the mesh and provide extra support. This has a lower recurrence rate compared with tension repair, but there may be complications associated with the mesh (e.g., chronic pain). Tension repair involves a surgical operation to suture the muscles and tissue on either side of the defect back together. Tension repairs are rarely performed and have been largely replaced by tension-free repairs. The hernia is held closed (to heal there) by sutures applying tension. This can cause pain and there is a relatively high recurrence rate of the hernia.

Question 42

Inguinal hernias

Answer 42

Inguinal hernias present with a soft lump in the inguinal region (in the groin). There are two types: Indirect inguinal hernia Direct inguinal hernia There are a number of differential diagnoses for a lump in the inguinal region: Femoral hernia Lymph node Saphena varix (dilation of saphenous vein at junction with femoral vein in groin) Femoral aneurysm Abscess Undescended / ectopic testes Kidney transplant

Question 43

Indirect inguinal hernia

Answer 43

An indirect inguinal hernia is where the bowel herniates through the inguinal canal. The inguinal canal is a tube that runs between the deep inguinal ring (where it connects to the peritoneal cavity), and the superficial inguinal ring (where it connects to the scrotum). In males, the inguinal canal is what allows the spermatic cord and its contents to travel from inside the peritoneal cavity, through the abdominal wall and into the scrotum. In females, the round ligament is attached to the uterus and passes through the deep inguinal ring, inguinal canal and then attaches to the labia majora. During fetal development, the processus vaginalis is a pouch of peritoneum that extends from the abdominal cavity through the inguinal canal. This allows the testes to descend from the abdominal cavity, through the inguinal canal and into the scrotum. Normally, after the testes descend through the inguinal canal, the deep inguinal ring closes and the processus vaginalis is obliterated. However, in some patients, the inguinal ring remains patent, and the processus vaginalis remains intact. This leaves a tract or tunnel from the abdominal contents, through the inguinal canal and into the scrotum. The bowel can herniate along this tract, creating an indirect inguinal hernia. There is a specific finding of indirect inguinal hernias that help you differentiate them from a direct inguinal hernias. When an indirect hernia is reduced and pressure is applied (with two fingertips) to the deep inguinal ring (at the mid-way point from the ASIS to the pubic tubercle), the hernia will remain reduced.

Question 44

Direct inguinal hernias

Answer 44

Direct inguinal hernias occur due to weakness in the abdominal wall at Hesselbach’s triangle. The hernia protrudes directly through the abdominal wall, through Hesselbach’s triangle (not along a canal or tract like an indirect inguinal hernia). Pressure over the deep inguinal ring will not stop the herniation. Hesselbach’s triangle boundaries (RIP mnemonic): R – Rectus abdominis muscle – medial border I – Inferior epigastric vessels – superior / lateral border P – Poupart’s ligament (inguinal ligament) – inferior border

Question 45

Femoral hernias

Answer 45

Femoral hernias involve herniation of the abdominal contents through the femoral canal. This occurs below the inguinal ligament, at the top of the thigh. The opening between the peritoneal cavity and the femoral canal is the femoral ring. The femoral ring leaves only a narrow opening for femoral hernias, putting femoral hernias at high risk of: Incarceration Obstruction Strangulation Boundaries of the femoral canal (FLIP mnemonic): F – Femoral vein laterally L – Lacunar ligament medially I – Inguinal ligament anteriorly P – Pectineal ligament posteriorly Don’t get the femoral canal confused with the femoral triangle. The femoral triangle is a larger area at the top of the thigh that contains the femoral canal. You can remember the boundaries with the SAIL mnemonic: S – Sartorius – lateral border A – Adductor longus – medial border IL – Inguinal Ligament – superior border Use the NAVY-C mnemonic to remember the contents of the femoral triangle from lateral to medial across the top of the thigh: N – Femoral Nerve A – Femoral Artery V – Femoral Vein Y – Y-fronts C – Femoral Canal (containing lymphatic vessels and nodes)

Question 46

Incisional hernias

Answer 46

Incisional hernias occur at the site of an incision from previous surgery. They are due to weakness where the muscles and tissues were closed after a surgical incision. The bigger the incision, the higher the risk of a hernia forming. Medical co-morbidities put patients at higher risk due to poor healing. Incisional hernias can be difficult to repair, with a high rate of recurrence. They are often left alone if they are large, with a wide neck and low risk of complications, particularly in patients with multiple co-morbidities.

Question 47

Umbilical hernias

Answer 47

Umbilical hernias occur around the umbilicus due to a defect in the muscle around the umbilicus. Umbilical hernias are common in neonates and can resolve spontaneously. They can also occur in older adults.

Question 48

Epigastric hernias

Answer 48

An epigastric hernia is simply a hernia in the epigastric area (upper abdomen).

Question 49

Spigelian hernias

Answer 49

A Spigelian hernia occurs between the lateral border of the rectus abdominis muscle and the linea semilunaris. This is the site of the spigelian fascia, which is an aponeurosis between the muscles of the abdominal wall. Usually, this occurs in the lower abdomen and may present with non-specific abdominal wall pain. There may not be a noticeable lump. An ultrasound scan can help establish the diagnosis. Spigelian hernias generally have a narrower base, increasing the risk of incarceration, obstruction and strangulation.

Question 50

Diastasis Recti

Answer 50

Diastasis recti may also be called rectus diastasis and recti divarication. It refers to a widening of the linea alba, the connective tissue that separates the rectus abdominis muscle, forming a larger gap between the rectus muscles. It is not technically a hernia. This gap becomes most prominent when the patient lies on their back and lifts their head. There is a protruding bulge along the middle of the abdomen. The linea alba is the aponeurosis of the two sides of the rectus abdominis muscle. The gap is created because the linea alba is stretched and broad. This can be congenital (in newborns) or due to weakness in the connective tissue, for example following pregnancy or in obese patients. No treatment is required in most cases, but surgical repair is possible.

Question 51

Obturator hernias

Answer 51

Obturator hernias are where the abdominal or pelvic contents herniate through the obturator foramen at the bottom of the pelvis. They occur due to a defect in the pelvic floor and are more common in women, particularly in older age, after multiple pregnancies and vaginal deliveries. They are often asymptomatic but may present with irritation to the obturator nerve, causing pain in the groin or medial thigh. Howship–Romberg sign refers to pain extending from the inner thigh to the knee when the hip is internally rotated and is due to compression of the obturator nerve. It can also present with complications of: Incarceration Obstruction Strangulation CT or MRI of the pelvis can establish the diagnosis. It may be found incidentally during pelvic surgery.

Question 52

Hiatus hernias

Answer 52

An hiatus hernia refers to the herniation of the stomach up through the diaphragm. The diaphragm opening should be at the level of the lower oesophageal sphincter and should be fixed in place. A narrow opening helps to maintain the sphincter and stop acid and stomach contents refluxing into the oesophagus. When the opening of the diaphragm is wider, the stomach can enter through the diaphragm and the contents of the stomach can reflux into the oesophagus. There are four types of hiatus hernia: Type 1: Sliding Type 2: Rolling Type 3: Combination of sliding and rolling Type 4: Large opening with additional abdominal organs entering the thorax Sliding hiatus hernia is where the stomach slides up through the diaphragm, with the gastro-oesophageal junction passing up into the thorax. Rolling hiatus hernia is where a separate portion of the stomach (i.e. the fundus), folds around and enters through the diaphragm opening, alongside the oesophagus Type 4 refers to a large hernia that allows other intra-abdominal organs to pass through the diaphragm opening (e.g., bowel, pancreas or omentum). Key risk factors are increasing age, obesity and pregnancy. Hiatus hernias present with dyspepsia (indigestion), with symptoms of: Heartburn Acid reflux Reflux of food Burping Bloating Halitosis (bad breath) Hiatus hernias can be intermittent, meaning they may not be seen on investigations. Hiatus hernias may be seen on: Chest x-rays CT scans Endoscopy Barium swallow testing Treatment is either: Conservative (with medical treatment of gastro-oesophageal reflux) Surgical repair if there is a high risk of complications or symptoms are resistant to medical treatment Surgery involves laparoscopic fundoplication. This involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.

Question 53

Haemorrhoids

Answer 53

Haemorrhoids are enlarged anal vascular cushions. It is not clear why they become enlarged and swollen, but they are often associated with constipation and straining. They are also more common with pregnancy, obesity, increased age and increased intra-abdominal pressure (e.g., weightlifting or chronic coughing). They often occur in pregnancy, most likely due to constipation, pressure from the baby in the pelvis and the effects of hormones that relax the connective tissues.

Question 54

Anal Cushions

Answer 54

The anal cushions are specialised submucosal tissue that contain connections between the arteries and veins, making them very vascular. They are supported by smooth muscle and connective tissue. They help to control anal continence, along with the internal and external sphincters. The blood supply is from the rectal arteries. The location of pathology at the anus is described as a clock face, as though the patient was in the lithotomy position (on their back with their legs raised). 12 o’clock is towards the genitals and 6 o’clock is towards the back. The anal cushions are usually located at 3, 7 and 11 o’clock.

Question 55

Classifying haemorrhoids

Answer 55

The classification of haemorrhoids depends on their size and whether they prolapse from the anus: 1st degree: no prolapse 2nd degree: prolapse when straining and return on relaxing 3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back 4th degree: prolapsed permanently

Question 56

Symptoms of haemorrhoids

Answer 56

Haemorrhoids may be asymptomatic. They are often associated with constipation and straining. A common presentation is with painless, bright red bleeding, typically on the toilet tissue or seen after opening the bowels. The blood is not mixed with the stool (this should make you think of an alternative diagnosis). Other symptoms include: Sore / itchy anus Feeling a lump around or inside the anus

Question 57

Examining haemorrhoids

Answer 57

External (prolapsed) haemorrhoids are visible on inspection as swellings covered in mucosa Internal haemorrhoids may be felt on a PR exam (although this is generally difficult or not possible) They may appear (prolapse) if the patient is asked to “bear down” during inspection Proctoscopy is required for proper visualisation and inspection. This involves inserting a hollow tube (proctoscope) into the anal cavity to visualise the mucosa.

Question 58

Managing haemorrhoids

Answer 58

Consider the differential diagnoses in patients presenting with symptoms such as rectal bleeding: Anal fissures Diverticulosis Inflammatory bowel disease Colorectal cancer Consider testing for anaemia if there is prolonged bleeding or clinical signs of anaemia. Topical treatments can be given for symptomatic relief and to help reduce swelling, for example: Anusol (contains chemicals to shrink the haemorrhoids – “astringents”) Anusol HC (also contains hydrocortisone – only used short term) Germoloids cream (contains lidocaine – a local anaesthetic) Proctosedyl ointment (contains cinchocaine and hydrocortisone – short term only) Prevention and treatment of constipation involves: Increasing the amount of fibre in the diet Maintaining a good fluid intake Using laxatives where required Consciously avoiding straining when opening their bowels There are a number of non-surgical treatments for haemorrhoids: Rubber band ligation (fitting a tight rubber band around the base of the haemorrhoid to cut off the blood supply) Injection sclerotherapy (injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy) Infra-red coagulation (infra-red light is applied to damage the blood supply) Bipolar diathermy (electrical current applied directly to the haemorrhoid to destroy it)

Question 59

Surgical options for haemorrhoids

Answer 59

Haemorrhoidal artery ligation involves using a proctoscope to identify the blood vessel that supplies the haemorrhoids and suturing it to cut off the blood supply. Haemorrhoidectomy involves excising the haemorrhoid. Removing the anal cushions may result in faecal incontinence. Stapled haemorrhoidectomy involves using a special device that excises a ring of haemorrhoid tissue at the same time as adding a circle of staples in the anal canal. The staples remain in place long-term.

Question 60

Thrombosed haemorrhoids

Answer 60

Thrombosed haemorrhoids are caused by strangulation at the base of the haemorrhoid, resulting in thrombosis (a clot) in the haemorrhoid. This can be very painful. Thrombosed haemorrhoids appear as purplish, very tender, swollen lumps around the anus. A PR examination is unlikely to be possible due to the pain. They will resolve with time, although this can take several weeks. The NICE Clinical Knowledge Summaries (2016) suggests considering admission if the patient present within 72 hours with extremely painful thrombosed haemorrhoids. They may benefit from surgical management.

Question 61

Diverticular disease

Answer 61

A diverticulum (plural diverticula) is a pouch or pocket in the bowel wall, usually ranging in size from 0.5 – 1cm. Diverticulosis refers to the presence of diverticula, without inflammation or infection. Diverticulosis may be referred to as diverticular disease when patients experience symptoms. Diverticulitis refers to inflammation and infection of diverticula.

Question 62

Pathophysiology of diverticular disease

Answer 62

The wall of the large intestine contains a layer of muscle called the circular muscle. The points where this muscle layer is penetrated by blood vessels are areas of weakness. Increased pressure inside the lumen over time, can cause a gap to form in these areas of the circular muscle. These gaps allow the mucosa to herniate through the muscle layer and pouches to form (diverticula). Diverticula do not form in the rectum, because it has an outer longitudinal muscle layer that completely surrounds the diameter of the rectum, adding extra support. In the rest of the colon, there are three longitudinal muscles that run along the colon, forming strips or ribbons called teniae coli. The teniae coli do not surround the entire diameter of the colon, and the areas that are not covered by teniae coli are vulnerable to the development of diverticula.

Question 63

Diverticulosis

Answer 63

Diverticulosis is sometimes described in layman’s terms as “wear and tear of the bowel”. The most commonly affected section of the bowel is the sigmoid colon. However, it can affect the entire large intestine in some patients. Small bowel diverticula are also possible but much less common. Diverticulosis is very common with increased age. Low fibre diets, obesity and the use of NSAIDs are risk factors. The use of NSAIDs increases the risk of diverticular haemorrhage. It is often diagnosed incidentally on colonoscopy or CT scans. Treatment is not necessary where the patient is asymptomatic. However, advice regarding a high fibre diet and weight loss is appropriate. Diverticulosis may cause lower left abdominal pain, constipation or rectal bleeding. Management is with increased fibre in the diet and bulk-forming laxatives (e.g., ispaghula husk). Stimulant laxatives (e.g., Senna) should be avoided. Surgery to remove the affected area may be required where there are significant symptoms.

Question 64

Presentation of acute diverticulitis

Answer 64

Diverticulitis refers to inflammation in the diverticula. Acute diverticulitis presents with: Pain and tenderness in the left iliac fossa / lower left abdomen Fever Diarrhoea Nausea and vomiting Rectal bleeding Palpable abdominal mass (if an abscess has formed) Raised inflammatory markers (e.g., CRP) and white blood cells

Question 65

Management of uncomplicated diverticulitis in primary care

Answer 65

Oral co-amoxiclav (at least 5 days) Analgesia (avoiding NSAIDs and opiates, if possible) Only taking clear liquids (avoiding solid food) until symptoms improve (usually 2-3 days) Follow-up within 2 days to review symptoms

Question 66

Managing complicated diverticulitis

Answer 66

Patients with severe pain or complications require admission to hospital. Hospital treatment involves management as with any patient with an acute abdomen or sepsis, including: Nil by mouth or clear fluids only IV antibiotics IV fluids Analgesia Urgent investigations (e.g., CT scan) Urgent surgery may be required for complications

Question 67

Complications of acute diverticulitis

Answer 67

Perforation Peritonitis Peridiverticular abscess Large haemorrhage requiring blood transfusions Fistula (e.g., between the colon and the bladder or vagina) Ileus / obstruction

Question 68

Mesenteric ischaemia

Answer 68

Mesenteric ischaemia is caused by a lack of blood flow through the mesenteric vessels supplying the intestines, resulting in intestinal ischaemia.

Question 69

Blood supply to the abdominal organs

Answer 69

There are three main branches of the abdominal aorta that supply the abdominal organs: Coeliac artery Superior mesenteric artery Inferior mesenteric artery The foregut includes the stomach and part of the duodenum, biliary system, liver, pancreas and spleen. This is supplied by the coeliac artery. The midgut is from the distal part of the duodenum to the first half of the transverse colon. This is supplied by the superior mesenteric artery. The hindgut is from the second half of the transverse colon to the rectum. This is supplied by the inferior mesenteric artery.

Question 70

Chronic mesenteric ischaemia

Answer 70

Chronic mesenteric ischaemia (also known as intestinal angina) is the result of narrowing of the mesenteric blood vessels by atherosclerosis. This results in intermittent abdominal pain, when the blood supply cannot keep up with the demand. It is similar to the pathophysiology of angina, where the blood supply is reduced by coronary artery disease, resulting in intermittent symptoms.

Question 72

Risk factors for chronic mesenteric ischaemia

Answer 72

Risk factors for chronic mesenteric ischaemia are the same as any other cardiovascular disease: Increased age Family history Smoking Diabetes Hypertension Raised cholesterol

Question 73

Diagnosing chronic mesenteric ischaemia

Answer 73

Diagnosis is by CT angiography.

Question 74

Managing chronic mesenteric ischaemia

Answer 74

Reducing modifiable risk factors (e.g., stop smoking) Secondary prevention (e.g., statins and antiplatelet medications) Revascularisation to improve the blood flow to the intestines Revascularisation may be performed by: Endovascular procedures first-line (i.e. percutaneous mesenteric artery stenting) Open surgery (i.e endarterectomy, re-implantation or bypass grafting)

Question 75

Acute mesenteric ischaemia

Answer 75

Acute mesenteric ischaemia is typically caused by a rapid blockage in blood flow through the superior mesenteric artery. This is usually caused by a thrombus (blood clot) stuck in the artery, blocking blood flow. The blood clot may be a thrombus that has developed inside the artery or an embolus from another site that has got stuck in the artery. A key risk factor is atrial fibrillation, where a thrombus forms in the left atrium, then mobilises (thromboembolism) down the aorta to the superior mesenteric artery, where it becomes stuck and cuts off the blood supply. Acute mesenteric ischaemia presents with acute, non-specific abdominal pain. The pain is disproportionate to the examination findings. Patients can go on to develop shock, peritonitis and sepsis. Over time, the ischaemia to the bowel will result in necrosis of the bowel tissue and perforation. Contrast CT is the diagnostic test of choice, allowing the radiologist to assess both the bowel and the blood supply. Patients will have metabolic acidosis and raised lactate level due to ischaemia. Patients require surgery to achieve two objectives: Remove necrotic bowel Remove or bypass the thrombus in the blood vessel (open surgery or endovascular procedures may be used) There is a very high mortality (over 50%) with acute mesenteric ischaemia.

Question 76

Bowel cancer

Answer 76

Bowel cancer is the fourth most prevalent cancer in the UK, behind breast, prostate and lung cancer. Bowel cancer usually refers to cancer of the colon or rectum. Small bowel and anal cancers are less common.

Question 78

Presentation of bowel cancers

Answer 78

The red flags that should make you consider bowel cancer are: Change in bowel habit (usually to more loose and frequent stools) Unexplained weight loss Rectal bleeding Unexplained abdominal pain Iron deficiency anaemia (microcytic anaemia with low ferritin) Abdominal or rectal mass on examination The NICE guidelines for suspected cancer recognition and referral (updated January 2021) give various criteria for a “two week wait” urgent cancer referral, depending on the patient’s age and combination of symptoms. For example: Over 40 years with abdominal pain and unexplained weight loss Over 50 years with unexplained rectal bleeding Over 60 years with a change in bowel habit or iron deficiency anaemia Patients may present acutely with obstruction if the tumour blocks the passage through the bowel. This presents a surgical emergency with vomiting, abdominal pain and absolute constipation. TOM TIP: Iron deficiency anaemia on its own without any other explanation (i.e. heavy menstruation) is an indication for a “two week wait” cancer referral for colonoscopy and gastroscopy (“top and tail”) for GI malignancy. This is because GI malignancies such as bowel cancer can cause microscopic bleeding (not visible in bowel movements) that eventually lead to iron deficiency anaemia.

Question 79

Faecal Immunochemical Test (FIT) and Bower Cancer Screening

Answer 79

Faecal immunochemical tests (FIT) look very specifically for the amount of human haemoglobin in the stool. FIT replaced the older stool test called the faecal occult blood (FOB) test, which detected blood in the stool but could give false positives by detecting blood in food (e.g., from red meats). FIT tests can be used as a test in general practice to help assess for bowel cancer in specific patients who do not meet the criteria for a two week wait referral, for example: Over 50 with unexplained weight loss and no other symptoms Under 60 with a change in bowel habit FIT tests are used for the bowel cancer screening program in England. In England, people aged 60 – 74 years are sent a home FIT test to do every 2 years. If the results come back positive they are sent for a colonoscopy. People with risk factors such as FAP, HNPCC or inflammatory bowel disease are offered a colonoscopy at regular intervals to screen for bowel cancer.

Question 80

Investigating bowel cancer

Answer 80

Colonoscopy is the gold standard investigation. It involves an endoscopy to visualise the entire large bowel. Any suspicious lesions can be biopsied to get a histological diagnosis, or tattoo in preparation for surgery. Sigmoidoscopy involves an endoscopy of the rectum and sigmoid colon only. This may be used in cases where the only feature is rectal bleeding. There is the obvious risk of missing cancers in other parts of the colon. CT colonography is a CT scan with bowel prep and contrast to visualise the colon in more detail. This may be considered in patients less fit for a colonoscopy but it is less detailed and does not allow for a biopsy. Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers. It may be used after a diagnosis of colorectal cancer, or as part of the initial workup in patients with vague symptoms (e.g., weight loss) in addition to colonoscopy as an initial investigation to exclude other cancers. Carcinoembryonic antigen (CEA) is a tumour marker blood test for bowel cancer. This is not helpful in screening, but it may be used for predicting relapse in patients previously treated for bowel cancer.

Question 81

Dukes' Classification

Answer 81

Dukes’ classification is the system previously used for bowel cancer. It has now been replaced in clinical practice by the TNM classification, but you may come across it in older textbooks or question banks. A brief summary is: Dukes A – confined to mucosa and part of the muscle of the bowel wall Dukes B – extending through the muscle of the bowel wall Dukes C – lymph node involvement Dukes D – metastatic disease

Question 82

TNM Classification

Answer 82

T for Tumour: TX – unable to assess size T1 – submucosa involvement T2 – involvement of muscularis propria (muscle layer) T3 – involvement of the subserosa and serosa (outer layer), but not through the serosa T4 – spread through the serosa (4a) reaching other tissues or organs (4b) N for Nodes: NX – unable to assess nodes N0 – no nodal spread N1 – spread to 1-3 nodes N2 – spread to more than 3 nodes M for Metastasis: M0 – no metastasis M1 – metastasis

Question 83

Managing bowel cancer

Answer 83

After a patient has a diagnosis, they are discussed at a multidisciplinary team (MDT) meeting. The colorectal MDT involves surgeons, oncologists, radiologists, histopathologists, specialist nurses and other health professionals to agree on the most appropriate management options. The choice of management depends on many factors: Clinical condition General health Stage Histology Patient wishes Options for managing bowel cancer (in any combination) are: Surgical resection Chemotherapy Radiotherapy Palliative care

Question 84

Surgical resection of bowel cancer

Answer 84

The ideal scenario with bowel cancer is to surgically remove the entire tumour. Removal of the section of bowel affected by the tumour can be potentially curative. Surgery can also be used palliatively, to reduce the size of the tumour and improve symptoms. Laparoscopic surgery (where possible) generally gives better recovery and fewer complications compared with open surgery. Robotic surgery is increasingly being used, which is essentially a more advanced laparoscopic procedure. Surgery involves: Identifying the tumour (it may have been tattooed during an endoscopy) Removing the section of bowel containing the tumour, Creating an end-to-end anastomosis (sewing the remaining ends back together) Alternatively creating a stoma (bringing the open section of bowel onto the skin) Operations Right hemicolectomy involves removal of the caecum, ascending and proximal transverse colon. Left hemicolectomy involves removal of the distal transverse and descending colon. High anterior resection involves removing the sigmoid colon (may be called a sigmoid colectomy). Low anterior resection involves removing the sigmoid colon and upper rectum but sparing the lower rectum and anus. Abdomino-perineal resection (APR) involves removing the rectum and anus (plus or minus the sigmoid colon) and suturing over the anus. It leaves the patient with a permanent colostomy. Hartmann’s procedure is usually an emergency procedure that involves the removal of the rectosigmoid colon and creation of an colostomy. The rectal stump is sutured closed. The colostomy may be permanent or reversed at a later date. Common indications are acute obstruction by a tumour, or significant diverticular disease.

Question 85

Complications of surgery for bowel cancer

Answer 85

Bleeding, infection and pain Damage to nerves, bladder, ureter or bowel Post-operative ileus Anaesthetic risks Laparoscopic surgery converted during the operation to open surgery (laparotomy) Leakage or failure of the anastomosis Requirement for a stoma Failure to remove the tumour Change in bowel habit Venous thromboembolism (DVT and PE) Incisional hernias Intra-abdominal adhesions

Question 86

Low Anterior Resection Syndrome

Answer 86

Low anterior resection syndrome may occur after resection of a portion of bowel from the rectum, with anastomosis between the colon and rectum. It can result in a number of symptoms, including: Urgency and frequency of bowel movements Faecal incontinence Difficulty controlling flatulence

Question 87

Follow-up after bowel cancer surgery

Answer 87

Patients will be followed up for a period of time (e.g., 3 years) following curative surgery. This includes: Serum carcinoembryonic antigen (CEA) CT thorax, abdomen and pelvis

Question 88

Stomas

Answer 88

Stomas are artificial openings of a hollow organ (for example the bowel). The bowel or urinary system is artificially opened onto the surface of the abdomen, allowing faeces or urine to drain, bypassing the distal portions of the bowel or urinary tract. A specially adapted bag (stoma bag) is fitted around the stoma to collect the waste products and is emptied as required. A colostomy is where the large intestine (colon) is brought onto the skin. Colostomies drain more solid stools, as much of the water is reabsorbed in the remaining large intestine. They can be flatter to the skin (compared with ileostomies which have a spout), as the solid contents are less irritating to the surrounding skin. They are typically located in the left iliac fossa (LIF). An ileostomy is where the end portion of the small bowel (ileum) is brought onto the skin. Ileostomies drain more liquid stools, as the fluid content is normally reabsorbed later, in the large intestine. They have a spout, which allows them to drain directly into a tightly fitting stoma bag without the contents coming into contact with the surrounding skin. They are typically located in the right iliac fossa (RIF). A gastrostomy involves creating an artificial connection between the stomach and the abdominal wall. This can be used for providing feeds directly into the stomach in patients that cannot meet their nutritional needs by mouth. Percutaneous endoscopic gastrostomy (PEG) refers to when the gastrostomy is fitted by an endoscopy procedure. A urostomy involves creating an opening from the urinary system onto the skin. They have a spout and are typically located in the right iliac fossa (RIF). All patients with stomas should have training on how to manage the stoma and have regular follow-up with a specialist stoma nurse.

Question 89

End Colostomy / End Ileostomy

Answer 89

An end colostomy is created after the removal of a section of the bowel, where the end part of the proximal portion of the bowel is brought onto the skin. Faeces are able to drain out of the end colostomy into a stoma bag. The other open end of the remaining bowel (the distal part) is sutured and left in the abdomen. It may be reversed at a later date, where the two ends are sutured together creating an anastomosis. End colostomies are permanent after resection of abdomino-perineal resection (APR) because the entire rectum and anus have been removed. These are usually located in the lower left abdomen. End ileostomies are permanent after a panproctocolectomy (total colectomy with removal of the large bowel, rectum and anus), for example in the treatment of inflammatory bowel disease or familial adenomatous polyposis (FAP). An alternative to this is to create an ileo-anal anastomosis (J-pouch). This is where the ileum is folded back on itself and fashioned into a larger pouch that functions a bit like a rectum. This “J-pouch” is then attached to the anus and collects stools prior to the person passing a motion.

Question 90

Loop Colostomy / Loop Ileostomy

Answer 90

A loop colostomy or loop ileostomy is a temporary stoma used to allow a distal portion of the bowel and anastomosis to heal after surgery. They may be called a “covering” or “defunctioning” loop colostomy or ileostomy, as they allow faeces to bypass the distal, healing portion of bowel until healed and ready to restart normal function. They are usually reversed around 6-8 weeks later. The bowel is partially opened and folded so that there are two openings on the skin side-by-side, attached in the middle. “Loop” refers to it being the two ends (proximal and distal) of a section of small bowel being brought out onto the skin. The proximal end (the productive side) is turned inside out to form a spout to protect the surrounding skin. This distal end is flatter. This allows you to distinguish between the proximal and distal portions of the bowel.

Question 91

Urostomy

Answer 91

A urostomy is used to drain urine from the kidney, bypassing the ureters, bladder and urethra. This may be used after a cystectomy (removal of the bladder). Forming a urostomy involves creating an ileal conduit. A section of the ileum (15 – 20cm) is removed and end-to-end anastomosis is created so that the bowel is continuous. The ends of the ureters are anastomosed to the separated section of the ileum. The end of the section is brought out onto the skin as a stoma and drains urine directly from the ureters into a urostomy bag. Urostomy bags need to fit tightly around the urostomy to avoid urine coming in contact with the skin. Urine in contact with the skin will cause irritation and skin damage.

Question 92

Complications of stomas

Answer 92

Stomas have a number of possible complications: Psycho-social impact Local skin irritation Parastomal hernia Loss of bowel length leading to high output, dehydration and malnutrition Constipation (colostomies) Stenosis Obstruction Retraction (sinking into the skin) Prolapse (telescoping of bowel through hernia site) Bleeding Granulomas causing raised red lumps around the stoma

Question 93

Gallstones

Answer 93

Gallstones are small stones that form within the gallbladder. The stones form from concentrated bile from the bile ducts. Most stones are made of cholesterol. These may be completely asymptomatic. They can also cause pain and lead to complications, such as acute cholecystitis, acute cholangitis and pancreatitis. Gallstones blocking the drainage of the pancreas (i.e. the pancreatic duct) result in pancreatitis.

Question 94

Anatomy of the biliary system

Answer 94

The right hepatic duct and left hepatic duct leave the liver and join together to become the common hepatic duct. The cystic duct from the gallbladder joins the common hepatic duct halfway along. The pancreatic duct from the pancreas joins with the common hepatic duct further along. When the common bile duct and the pancreatic duct join they become the ampulla of Vater, which then opens into the duodenum. The sphincter of Oddi is a ring of muscle surrounding the ampulla of Vater that controls the flow of bile and pancreatic secretions into the duodenum.

Question 95

Gallbladder and Gallstones definitions

Answer 95

Cholestasis: blockage to the flow of bile Cholelithiasis: gallstone(s) are present Choledocholithiasis: gallstone(s) in the bile duct Biliary colic: intermittent right upper quadrant pain caused by gallstones irritating bile ducts Cholecystitis: inflammation of the gallbladder Cholangitis: inflammation of the bile ducts Gallbladder empyema: pus in the gallbladder Cholecystectomy: surgical removal of the gallbladder Cholecystostomy: inserting a drain into the gallbladder

Question 96

Risk factors for gallstones

Answer 96

F – Fat F – Fair F – Female F – Forty

Question 97

Presentation of gallstones

Answer 97

Patients with gallstones may be completely asymptomatic. The typical symptom of gallstones is biliary colic. Biliary colic is caused by stones temporarily obstructing drainage of the gallbladder. It may get lodged at the neck of the gallbladder or in the cystic duct, then when it falls back into the gallbladder the symptoms resolve. It causes symptoms of: Severe, colicky epigastric or right upper quadrant pain Often triggered by meals (particularly high fat meals) Lasting between 30 minutes and 8 hours May be associated with nausea and vomiting Alternatively, patients may present with a complication of gallstones, such as: Acute cholecystitis Acute cholangitis Obstructive jaundice (if the stone blocks the ducts) Pancreatitis TOM TIP: Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum. CCK triggers contraction of the gallbladder, which leads to biliary colic. Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction. Exams may test this mechanism, so it is worth remembering.

Question 98

Liver Functions Tests

Answer 98

Bilirubin Bilirubin normally drains from the liver, through the bile ducts and into the intestines. Raised bilirubin (jaundice) with pale stools and dark urine represents an obstruction to flow within the biliary system. Obstruction may be caused by a gallstone in the bile duct or an external mass pressing on the bile ducts (e.g., cholangiocarcinoma or tumour of the head of the pancreas). Alkaline Phosphatase Alkaline phosphatase (ALP) is a non-specific marker. It is an enzyme originating in the liver, biliary system and bone, and abnormal results can indicate liver or bone problems. It is often raised in pregnancy due to production by the placenta. A raised ALP is consistent with biliary obstruction in presence of right upper quadrant pain and/or jaundice. Raised alkaline phosphatase can also be caused by liver or bone malignancy, primary biliary cirrhosis, Paget’s disease of the bone and many other things. Aminotransferases Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are enzymes produced in the liver. They are helpful as markers of hepatocellular injury (damage to the liver cells). In patients with cholestasis (e.g., due to gallstones), ALT and AST can increase slightly, with a higher rise in ALP (“an obstructive picture”). If ALT and AST are high compared with the ALP level, this is more indicative of a problem inside the liver with hepatocellular injury (“a hepatitic picture”).

Question 99

Ultrasound and gallstones

Answer 99

An ultrasound scan is a useful first-line investigation for symptoms of gallstone disease, for example, abdominal pain, right upper quadrant pain and jaundice. It is the most sensitive initial imaging test for gallstones (CT scans are not good at identifying gallstones or biliary disease). Ultrasound is limited by the patient’s weight, gaseous bowel obstructing the view and discomfort from the probe. Ultrasound Findings Ultrasound can be helpful in identifying: Gallstones in the gallbladder Gallstones in the ducts Bile duct dilatation (normally less than 6mm diameter) Acute cholecystitis (thickened gallbladder wall, stones or sludge in gallbladder and fluid around the gallbladder) The pancreas and pancreatic duct

Question 100

Magnetic Resonance Cholangio-Pancreatography

Answer 100

A magnetic resonance cholangio-pancreatography (MRCP) is an MRI scan with a specific protocol that produces a detailed image of the biliary system. It is very sensitive and specific for biliary tree disease, such as stones in the bile duct and malignancy. MRCP is used in a number of scenarios for gaining a detailed picture of the biliary system, such as identifying biliary strictures or congenital abnormalities. With gallstone disease, MRCP is typically used to investigate further if the ultrasound scan does not show stones in the duct, but there is bile duct dilatation or raised bilirubin suggestive of obstruction.

Question 101

Endoscopic Retrograde Cholangio-Pancreatography

Answer 101

An endoscopic retrograde cholangio-pancreatography (ERCP) involves inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (the sphincter of Oddi). This gives the operator access to the biliary system. The main indication for ERCP is to clear stones in the bile ducts. ERCP allows the operator to: Inject contrast and take x-rays to visualise the biliary system and diagnose pathology (e.g., stones or strictures) Perform a sphincterotomy on the sphincter of Oddi if it is dysfunctional (blocking flow) Clear stones from the ducts Insert stents to improve bile duct drainage (e.g., with strictures or tumours) Take biopsies of tumours Key complications of ERCP are: Excessive bleeding Cholangitis (infection in the bile ducts) Pancreatitis

Question 102

CT scans and gallstones

Answer 102

CT scans are less useful for looking at the biliary system and for gallstones. They may be used to look for differential diagnoses (e.g., pancreatic head tumour) and complications such as perforation and abscesses.

Question 103

Managing gallstones

Answer 103

Asymptomatic patients with gallstones may be treated conservatively, with no intervention required. Patients with symptoms or complications of gallstones are treated with cholecystectomy, which is surgical removal of the gallbladder (provided they are fit for surgery).

Question 104

Cholecystectomy

Answer 104

Cholecystectomy involves surgical removal of the gallbladder. It is indicated where patients are symptomatic of gallstones, or the gallstones are leading to complications (e.g., acute cholecystitis). Stones in the bile ducts can be removed before (by ERCP) or during surgery. Laparoscopic cholecystectomy (keyhole surgery) is preferred to open cholecystectomy (with a right subcostal “Kocher” incision), as it has less complications and a faster recovery.

Question 105

Complications of cholecystectomy

Answer 105

Complications of cholecystectomy include: Bleeding, infection, pain and scars Damage to the bile duct including leakage and strictures Stones left in the bile duct Damage to the bowel, blood vessels or other organs Anaesthetic risks Venous thromboembolism (deep vein thrombosis or pulmonary embolism) Post-cholecystectomy syndrome Post-cholecystectomy syndrome involves a group of non-specific symptoms that can occur after a cholecystectomy. They may be attributed to changes in the bile flow after removal of the gallbladder. Symptoms often improve with time. Symptoms include: Diarrhoea Indigestion Epigastric or right upper quadrant pain and discomfort Nausea Intolerance of fatty foods Flatulence

Question 106

Acute Cholecystitis

Answer 106

Acute cholecystitis refers to inflammation of the gallbladder, which is caused by a blockage of the cystic duct preventing the gallbladder from draining. It is a key complication of gallstones, and the majority of cases (around 95%) are caused by gallstones (calculous cholecystitis). Gallstones may be trapped in the neck of the gallbladder or in the cystic duct. In a small number of cases, the dysfunction in gallbladder emptying is caused by something other than gallstones (acalculous cholecystitis). One scenario where this may occur is in patients on total parental nutrition or having long periods of fasting (for example in ICU for other serious conditions), where the gallbladder is not being stimulated by food to regularly empty, resulting in a build-up of pressure.

Question 107

Presentation of acute cholecystitis

Answer 107

The main presenting symptom of cholecystitis is pain in the right upper quadrant (RUQ). This may radiate to the right shoulder. Other features include: Fever Nausea Vomiting Tachycardia (fast heart rate) and tachypnoea (raised respiratory rate) Right upper quadrant tenderness Murphy’s sign Raised inflammatory markers and white blood cells Murphy’s sign is suggestive of acute cholecystitis: Place a hand in RUQ and apply pressure Ask the patient to take a deep breath in The gallbladder will move downwards during inspiration and come in contact with your hand Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration

Question 108

Imaging acute cholecystitis

Answer 108

The first step is an abdominal ultrasound scan. Signs of acute cholecystitis on ultrasound are: Thickened gallbladder wall Stones or sludge in gallbladder Fluid around the gallbladder Magnetic resonance cholangiopancreatography (MRCP) may be used to visualise the biliary tree in more detail if a common bile duct stone is suspected but not seen on an ultrasound scan (e.g., bile duct dilatation or raised bilirubin).

Question 109

Managing acute cholecystitis

Answer 109

Patients with suspected acute cholecystitis need emergency admission for investigations and management. Conservative management involves: Nil by mouth IV fluids Antibiotics (as per local guidelines) NG tube if required for vomiting Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to remove stones trapped in the common bile duct. Cholecystectomy (removal of the gallbladder) is usually be performed during the acute admission, within 72 hours of symptoms. In some cases, it may be delayed for 6-8 weeks after the acute episode to allow the inflammation to settle.

Question 110

Complications of acute cholecystitis

Answer 110

Sepsis Gallbladder empyema Gangrenous gallbladder Perforation

Question 111

Gallbladder empyema

Answer 111

Gallbladder empyema refers to infected tissue and pus collecting in the gallbladder. Management involves IV antibiotics and one of two main options: Cholecystectomy (to remove the gallbladder) Cholecystostomy (inserting a drain into the gallbladder to allow the infected contents to drain)

Question 112

Acute Cholangitis

Answer 112

Acute cholangitis is infection and inflammation in the bile ducts. It is a surgical emergency and has a high mortality due to sepsis and septicaemia. There are two main causes of acute cholangitis: Obstruction in the bile ducts stopping bile flow (i.e. gallstones in the common bile duct) Infection introduced during an ERCP procedure The most common organisms are: Escherichia coli Klebsiella species Enterococcus species

Question 113

Charcot's triad

Answer 113

Acute cholangitis presents with Charcot’s triad: Right upper quadrant pain Fever Jaundice (raised bilirubin) TOM TIP: It is worth remembering Charcot’s triad. If you see a patient in your exams with fever, raised bilirubin and right upper quadrant pain, you know the diagnosis is acute cholangitis.

Question 114

Managing Acute Cholangitis

Answer 114

Patients with suspected acute cholangitis need emergency admission for investigations and management. Patients need acute management of sepsis and acute abdomen, including: Nil by mouth IV fluids Blood cultures IV antibiotics (as per local guidelines) Involvement of seniors and potentially HDU or ICU Imaging to diagnose common bile duct (CBD) stones and cholangitis (from least to most sensitive) are: Abdominal ultrasound scan CT scan Magnetic resonance cholangio-pancreatography (MRCP) Endoscopic ultrasound An endoscopic retrograde cholangio-pancreatography (ERCP) is required to remove stones blocking the bile duct. It involves inserting an endoscope down the oesophagus, past the stomach, to the duodenum and the opening of the common bile duct (the sphincter of Oddi). This gives the operator access to the biliary system. A number of procedures can be performed during an ERCP: Cholangio-pancreatography: retrograde injection of contrast into the duct through the sphincter of Oddi and x-ray images to visualise biliary system Sphincterotomy: making a cut in the sphincter to dilate it and allow stone removal Stone removal: a basket can be inserted and pulled through the common bile duct to remove stones Balloon dilatation: a balloon can be inserted and inflated to treat strictures Biliary stenting: a stent can be inserted to maintain a patent bile duct (for strictures or tumours) Biopsy: a small biopsy can be taken to diagnose obstructing lesions Percutaneous transhepatic cholangiogram (PTC) involves radiologically guided insertion of a drain through the skin and liver, into the bile ducts. The drain relieves the immediate obstruction. A stent can be inserted to give longer-lasting relief of obstruction. This is an option for patients that are less suitable for ERCP, or where ERCP has failed.

Question 115

Cholangiocarcinoma

Answer 115

Cholangiocarcinoma is a type of cancer that originates in the bile ducts. The majority are adenocarcinomas. It may affect the bile ducts inside the liver (intrahepatic ducts) or outside the liver (extrahepatic ducts). The most common site is in the perihilar region, where the right and left hepatic duct have joined to become the common hepatic duct, just after leaving the liver. Key risk factors include: Primary sclerosing cholangitis Liver flukes (a parasitic infection) TOM TIP: Patients with ulcerative colitis are at risk of developing primary sclerosing cholangitis. Patients that have primary sclerosing cholangitis are at risk of developing cholangiocarcinoma (10-20%). Primary sclerosing cholangitis is the key risk factor worth remembering for your exams. The other notable cause is parasitic infection with liver flukes, which are found in various parts of Southeast Asia and Europe.

Question 116

Presentation of cholangiocarcinoma

Answer 116

Obstructive jaundice is the key presenting feature to remember. Obstructive jaundice is also associated with: Pale stools Dark urine Generalised itching Other non-specific signs and symptoms include: Unexplained weight loss Right upper quadrant pain Palpable gallbladder (swelling due to an obstruction in the duct distal to the gallbladder) Hepatomegaly Courvoisier’s law states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer. TOM TIP: Painless jaundice should make you think of cholangiocarcinoma or cancer of the head of the pancreas. Pancreatic cancer is more common, so this is likely the answer in your exams.

Question 117

Investigating cholangiocarcinoma

Answer 117

Diagnosis is based on imaging (CT or MRI) plus histology from a biopsy. Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers. CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in cholangiocarcinoma. It is also raised in pancreatic cancer and a number of other malignant and non-malignant conditions. Magnetic resonance cholangio-pancreatography (MRCP) may be used to assess the biliary system in detail to assess the obstruction. Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour.

Question 118

Managing cholangiocarcinoma

Answer 118

Management will be decided at a multidisciplinary team (MDT) meeting. Curative surgery may be possible in early cases. It may be combined with radiotherapy and chemotherapy. In most cases, curative surgery is not possible. Palliative treatment may involve: Stents inserted to relieve the biliary obstruction Surgery to improve symptoms (e.g., bypassing the biliary obstruction) Palliative chemotherapy Palliative radiotherapy End of life care with symptom control

Question 119

Pancreatic cancer

Answer 119

Pancreatic cancer is often diagnosed late and has a very poor prognosis. The vast majority are adenocarcinomas, and most occur in the head of the pancreas (as opposed to the body and tail). Once a tumour in the head of the pancreas grows large enough it can compress the bile ducts, resulting in obstructive jaundice. Pancreatic cancers tend to spread and metastasise early, particularly to the liver, then to the peritoneum, lungs and bones. The average survival, when diagnosed with advanced disease, is around 6 months. When caught early, the cancer is isolated to the pancreas and surgery is possible, the 5-year survival is still around 25% or less.

Question 120

Presentation of pancreatic cancer

Answer 120

Painless obstructive jaundice is a key presenting feature that should make you immediately consider pancreatic cancer (the key differential is cholangiocarcinoma). This occurs when a tumour at the head of the pancreas compresses the bile ducts, blocking the flow of bile out of the liver. It presents with: Yellow skin and sclera Pale stools Dark urine Generalised itching The other presenting features for pancreatic cancer can be vague: Non-specific upper abdominal or back pain Unintentional weight loss Palpable mass in the epigastric region Change in bowel habit Nausea or vomiting New-onset diabetes or worsening of type 2 diabetes TOM TIP: It is worth noting that a new onset of diabetes, or a rapid worsening of glycaemic control type 2 diabetes, can be a sign of pancreatic cancer. Keep pancreatic cancer in mind if a patient in your exams or practice has worsening glycaemic control despite good lifestyle measures and medication.

Question 121

Referral and pancreatic cancer

Answer 121

The NICE guidelines on suspected cancer (last updated January 2021) give the criteria for when to refer for suspected pancreatic cancer: Over 40 with jaundice – referred on a 2 week wait referral Over 60 with weight loss plus an additional symptom (see below) – referred for a direct access CT abdomen The NICE guidelines suggest a GP referral for a direct access CT abdomen (or ultrasound if not available) to assess for pancreatic cancer if a patient has weight loss plus any of: Diarrhoea Back pain Abdominal pain Nausea Vomiting Constipation New-onset diabetes

Question 122

Courvoisier’s law

Answer 122

Courvoisier’s law states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.

Question 123

Trousseau's sign of malignancy

Answer 123

Trousseau’s sign of malignancy refers to migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma. Thrombophlebitis is where blood vessels become inflamed with an associated blood clot (thrombus) in that area. Migratory refers to the thrombophlebitis reoccurring in different locations over time.

Question 124

Investigating pancreatic cancer

Answer 124

Diagnosis is based on imaging (usually CT scan) plus histology from a biopsy. Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers. CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in pancreatic cancer. It is also raised in cholangiocarcinoma and a number of other malignant and non-malignant conditions. Magnetic resonance cholangio-pancreatography (MRCP) may be used to assess the biliary system in detail to assess the obstruction. Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour. Biopsy may be taken through the skin (percutaneous) under ultrasound or CT guidance, or during an endoscopy under ultrasound guidance.

Question 125

Managing pancreatic cancer

Answer 125

Management will be decided at a hepatobiliary (HPB) MDT meeting. Surgery to remove the tumour is more likely to be considered with small tumours isolated in the head of the pancreas (about 10% of cases). There are a number of surgical options depending on the location of the tumour: Total pancreatectomy Distal pancreatectomy Pylorus-preserving pancreaticoduodenectomy (PPPD) (modified Whipple procedure) Radical pancreaticoduodenectomy (Whipple procedure) In most cases, curative surgery is not possible. Palliative treatment may involve: Stents inserted to relieve the biliary obstruction Surgery to improve symptoms (e.g., bypassing the biliary obstruction) Palliative chemotherapy (to improve symptoms and extend life) Palliative radiotherapy (to improve symptoms and extend life) End of life care with symptom control Whipple Procedure A Whipple procedure (pancreaticoduodenectomy) is a surgical operation to remove a tumour of the head of the pancreas that has not spread. A Whipple procedure is a massive operation so patients need to be in good baseline health. It involves the removal of the: Head of the pancreas Pylorus of the stomach Duodenum Gallbladder Bile duct Relevant lymph nodes A modified Whipple procedure involves leaving the pylorus in place. It is also known as a pylorus-preserving pancreaticoduodenectomy (PPPD).

Question 126

Pancreatitis

Answer 126

Pancreatitis refers to inflammation of the pancreas. It can be categorised as acute pancreatitis or chronic pancreatitis. This section relates mainly to acute pancreatitis. Acute pancreatitis presents with a rapid onset of inflammation and symptoms. After an episode of acute pancreatitis, normal function usually returns. Chronic pancreatitis involves longer-term inflammation and symptoms with a progressive and permanent deterioration in pancreatic function.

Question 127

Causes of pancreatitis

Answer 127

The three key causes of pancreatitis to remember are: Gallstones Alcohol Post-ERCP Gallstone pancreatitis is caused by gallstones getting trapped at the end of the biliary system (ampulla of Vater), blocking the flow of bile and pancreatic juice into the duodenum. The reflux of bile into the pancreatic duct, and the prevention of pancreatic juice containing enzymes from being secreted, results in inflammation in the pancreas. Gallstone pancreatitis is more common in women and older patients. Alcohol is directly toxic to pancreatic cells, resulting in inflammation. Alcohol-induced pancreatitis is more common in men and younger patients. I GET SMASHED is a popular mnemonic for remembering a long list of causes of pancreatitis: I – Idiopathic G – Gallstones E – Ethanol (alcohol consumption) T – Trauma S – Steroids M – Mumps A – Autoimmune S – Scorpion sting (the one everyone remembers) H – Hyperlipidaemia E – ERCP D – Drugs (furosemide, thiazide diuretics and azathioprine)

Question 128

Presentation of pancreatitis

Answer 128

Acute pancreatitis typically presents with an acute onset of: Severe epigastric pain Radiating through to the back Associated vomiting Abdominal tenderness Systemically unwell (e.g., low-grade fever and tachycardia) Acute pancreatitis is a clinical diagnosis, based mainly on the presenting features and the amylase level.

Question 129

Investigating pancreatitis

Answer 129

Initial investigations are required as with any presentation of an acute abdomen. Importantly these need to include those required for calculating the Glasgow score: FBC (for white cell count) U&E (for urea) LFT (for transaminases and albumin) Calcium ABG (for PaO2 and blood glucose) Amylase is raised more than 3 times the upper limit of normal in acute pancreatitis. In chronic pancreatitis it may not rise because the pancreas has reduced function. Lipase is also raised in acute pancreatitis. It is considered more sensitive and specific than amylase. C-reactive protein (CRP) can be used to monitor the level of inflammation. Ultrasound is the initial investigation of choice in assessing for gallstones. CT abdomen can assess for complications of pancreatitis (such as necrosis, abscesses and fluid collections). It is not usually required unless complications are suspected (e.g., the patient is becoming more unwell).

Question 130

Glasgow score

Answer 130

The Glasgow score is used to assess the severity of pancreatitis. It gives a numerical score based on how many of the key criteria are present: 0 or 1 – mild pancreatitis 2 – moderate pancreatitis 3 or more – severe pancreatitis The criteria for the Glasgow score can be remembered using the PANCREAS mnemonic (1 point for each answer): P – Pa02 < 8 KPa A – Age > 55 N – Neutrophils (WBC > 15) C – Calcium < 2 R – uRea >16 E – Enzymes (LDH > 600 or AST/ALT >200) A – Albumin < 32 S – Sugar (Glucose >10)

Question 131

Management of acute pancreatitis

Answer 131

Patients with acute pancreatitis can become very unwell rapidly. They require admission to supportive management. Moderate or severe cases should be considered for management on the high dependency unit (HDU) or intensive care unit (ICU). Management involves: Initial resuscitation (ABCDE approach) IV fluids Nil by mouth Analgesia Careful monitoring Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy) Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area) Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections) Most patients will improve within 3-7 days.

Question 132

Complications of acute pancreatitis

Answer 132

Necrosis of the pancreas Infection in a necrotic area Abscess formation Acute peripancreatic fluid collections Pseudocysts (collections of pancreatic juice) can develop 4 weeks after acute pancreatitis Chronic pancreatitis

Question 133

Chronic Pancreatitis

Answer 133

Chronic pancreatitis refers to chronic inflammation in the pancreas. It results in fibrosis and reduced function of the pancreatic tissue. Alcohol is the most common cause. It presents with similar symptoms to acute pancreatitis, but generally less intense and longer-lasting. Key complications are: Chronic epigastric pain Loss of exocrine function, resulting in a lack of pancreatic enzymes (particularly lipase) secreted into the GI tract Loss of endocrine function, resulting in a lack of insulin, leading to diabetes Damage and strictures to the duct system, resulting in obstruction in the excretion of pancreatic juice and bile Formation of pseudocysts or abscesses

Question 134

Managing chronic pancreatitis

Answer 134

Abstinence from alcohol and smoking is important in managing symptoms and complications. Analgesia can be used to manage the pain, although it can be severe and difficult to manage. Replacement pancreatic enzymes (Creon) may be required if there is a loss of pancreatic enzymes (i.e. lipase). Otherwise, a lack of enzymes leads to malabsorption of fat, greasy stools (steatorrhoea), and deficiency in fat-soluble vitamins. Subcutaneous insulin regimes may be required to treat diabetes. ERCP with stenting can be used to treat strictures and obstruction to the biliary system and pancreatic duct. Surgery may be required by specialist centres to treat: Severe chronic pain (draining the ducts and removing inflamed pancreatic tissue) Obstruction of the biliary system and pancreatic duct Pseudocysts Abscesses

Question 135

Liver transplant

Answer 135

The most obvious source for a liver is from a healthy person that has just died. When an entire liver is transplanted from a deceased donor to a recipient it is known as an orthotopic transplant. This translates as straight (ortho-) in place (-topic). The liver can regenerate as an organ. Therefore, it is possible to take a portion of the organ from a living donor, transplant it into a patient and have both regenerate to become two fully functioning organs. This is known as a living donor transplant. It is also possible to split the organ of a deceased person into two and transplant it into two patients and have them regenerate to their normal size in each recipient. This is known as split donation.

Question 136

Indications of liver transplant

Answer 136

Indications for liver transplant can be split into two categories: acute liver failure or chronic liver failure. They may also be used in specific cases of hepatocellular carcinoma. Acute liver failure usually requires an immediate liver transplant, and these patients are placed on the top of the transplant list. The most common causes are acute viral hepatitis and paracetamol overdose. Chronic liver failure patients can wait longer for their liver transplant and are put on a standard transplant list. It is normal for it to take around 5 months for a liver to become available.

Question 137

Factors Suggesting Unsuitability for Liver Transplantation

Answer 137

The British Society of Gastroenterologists provides guidelines on liver transplantation (2019), including when to refer and the contraindications. Contraindications include: Significant co-morbidities (e.g., severe kidney, lung or heart disease) Current illicit drug use Continuing alcohol misuse (generally 6 months of abstinence is required) Untreated HIV Current or previous cancer (except certain liver cancers)

Question 138

Liver transplant surgery

Answer 138

The liver transplant surgery is carried out in a specialist transplant centre. It involves a “rooftop” or “Mercedes Benz” incision along the lower costal margin for open surgery. The liver is mobilised away from the other tissues and excised. The new liver, biliary system and blood supply is then implanted and connected.

Question 139

Post-transplantation care in liver transplant

Answer 139

Patients will require lifelong immunosuppression (e.g., steroids, azathioprine and tacrolimus) and careful monitoring of these drugs. They are required to follow lifestyle advice and require monitoring and treatment for complications: Avoid alcohol and smoking Treating opportunistic infections Monitoring for disease recurrence (i.e. of hepatitis or primary biliary cirrhosis) Monitoring for cancer as there is a significantly higher risk in immunosuppressed patients Monitoring for evidence of transplant rejection: Abnormal LFTs Fatigue Fever Jaundice