General Surgery Flashcards
What is the pathogenesis of acute appendicitis?
Lymphoid hyperplasia or a faecolith—> obstruction of the appendiceal lumen —> gut organisms invading the appendix wall —> oedema +/- perforation
What is the classical sign seen in acute appendicitis?
Rovsing’s sign - palpation in the LIF causes pain the the RIF
What is the diagnostic investigation for small bowel obstruction?
CT abdomen
What is the first line imaging for small bowel obstruction?
Abdominal X-Ray
What is the most common cause of small bowel obstruction?
Adhesions are the most common cause, therefore ask about previous abdominal surgeries
What is a fistula?
An abnormal connection between two epithelial surfaces
Main causes of SBO?
- Adhesions
- Hernias
- Malignancy (large bowel)
Upper limits of bowel diabetes on X-Ray?
- 3 cm small bowel
- 6 cm colon
- 9 cm caecum
What is the pathophysiology of Paralytic ileus?
Peristalsis temporarily stops during post operative period
What X-Ray sign would you expect to see with Volvulus?
Coffee-bean sign
What is the conservative management option for volvulus?
Endoscopic decompression
What surgery is required for a sigmoid volvulus?
Hartmann’s procedure
What surgery is required for a caecal volvulus?
- Ileocaecal resection or
- Right hemicolectomy
What are the boundaries of Hesselbach’s triangle?
- Rectus Abdominis (medial)
- Inferior epigastric vessels (superior/lateral)
- Poupart’s (inguinal) ligament (inferior)
Risk factors for Diverticulosis?
- Increased age
- Low fibre diet
- Use of NSAIDs
- Obesity
First line oral antibiotic for Diverticulitis?
Co-Amoxiclav
What are the presenting features of chronic mesenteric ischaemia?
“Classic triad” of presenting features
- Colicky abdominal pain after eating
- Weight loss
- Abdominal Bruit
What imaging would you do to detect Chronic mesenteric ischaemia?
CT Angiogram
What is the key risk factor for Acute mesenteric ischaemia?
Atrial Fibrillation
What ABG finding would you expect with acute mesenteric ischaemia?
- Metabolic acidosis
- Raised lactate
What is the foregut supplied by?
Coeliac artery
- Includes stomach, part of duodenum, biliary system, liver, pancreas and spleen
What is the midgut supplied by?
Superior mesenteric artery
- Includes distal duodenum to the first half of the transverse colon
What is the hindgut supplied by?
Inferior mesenteric artery
- Includes the second half of the transverse colon to the rectum
What is the screening for Bowel Cancer in england?
- Age 60-74 years
- Frequency - Every 2 years
- Test FIT test on stoolWh
What is the tumour marker for Bowel cancer?
Carcinoembryonic antigen (CEA)
What is Charcot’s triad?
- RUQ pain
- Fever
- Jaundice
What organisms would you expect in Acute Cholangitis?
- E.Coli
- Klebsiella Species
- Enterococcus species
What is Trousseau’s sign and what does it indicated?
Migratory thrombophlebitis
Indicates Pancreatic cancer
What scar would you expect if a patient had had an open appendicectomy?
Lanz
What is Achalasia?
It is a rare neuromuscular disorder of the oesophagus characterised by the inability of the Lower Oesophageal sphincter to relax, often resulting in difficulty swallowing
What are the signs and symptoms of Achalasia?
- Dysphagia - usually has a gradual onset, over a period of years to months
- Regurgitation of undigested food
- Aspiration pneumonia (secondary to regurgitation)
- Retrosternal chest pain or heartburn
- Weight loss
What investigations can be used to diagnose Achalasia?
- Endoscopy: may reveal a dilated oesophagus.
- Oesophageal Manometry: GOLD STANDARD for diagnosis, demonstrating high resting pressure and incomplete relaxation of the LES
- Barium swallow: In advanced cases, a ‘birds beak’ appearance may be observed.
What are the treatment options for Achalasia?
- Medical therapy with botox or CCB or nitrates
- Surgical intervention with Oesophageal dilatation or Heller’s Myotomy
What are the causes of Acute Mesenteric Ischaemia?
- Arterial Embolism: This is the most common cause, often resulting from AF or IE
- Arterial Thrombosis: Usually associated with Atherosclerosis, especially in patients with a history of IHD or PVD
- Venous Thrombosis: Occurs less commonly and is often linked to hypercoagulable states
- Non-Occlusive Mesenteric Ischaemia: Typically linked with low flow states such as HF, shock or during major surgery
What are the signs and symptoms of Acute Mesenteric Ischaemia?
- Sudden Severe Abdominal pain and guarding, often out of proportion to the physical examination
- Nausea and vomiting
- Signs of shock, such as hypotension, tachycardia, altered mental state
- Metabolic acidosis on ABG
- Rectal bleeding can occasionally be seen in advanced ischaemia
What is the investigation of choice for Acute Mesenteric Ischaemia?
- CT Angiography
What is the management of Acute Mesenteric Ischaemia?
The primary objectives in managing AMI are rapid diagnosis, stabilization of the patient, and restoration of bowel perfusion. This can be achieved through:
- Resuscitation: Including fluid management and correction of metabolic abnormalities
- Anticoagulation: Typically with intravenous heparin to limit progression of thrombosis or embolism
- Surgical intervention: Including embolectomy, arterial bypass, or bowel resection if necrosis is present
- Non-surgical intervention: Such as intra-arterial vasodilators or thrombolytic therapy
- Supportive care: Including analgesia, antibiotics if needed, and nutritional support.
What would you see in CT scan in Acute Mesenteric Ischaemia?
- Bowel wall thickening
- Arterial Occlusion
What is the pathophysiology of Acute pancreatitis?
- Begins with inflammation of the pancreas
- Triggers activation of digestive enzymes within the pancreas itself
- These enzymes autodigest the pancreatic tissue
- This sets off a cycle of inflammation and damage.
- This can lead to a pro-inflammatory response akin to SIRS
What is the primary symptoms of Acute Pancreatitis?
- Stabbing like epigastric pain radiating to the back
- Pain typically relieved by sitting forward or adopting foetal position
What blood investigations would you do for acute pancreatitis and what results would you expect?
- Full Blood Count (FBC) and Urea and Electrolytes: Elevated white blood cell count (leukocytosis) can suggest necrotizing pancreatitis.
- Liver Function Tests (LFTs): Abnormalities may be seen in gallstone-related pancreatitis.
- Lipase and Amylase: Lipase is more sensitive and specific. A threefold elevation in amylase levels strongly suggests acute pancreatitis. The degree of elevation doesn’t necessarily correlate with disease severity.
What imaging studies can be useful in acute pancreatitis?
- Ultrasound abdomen: Useful for detecting gallstones.
- Magnetic Resonance Cholangiopancreatography (MRCP): Detects obstructive pancreatitis.
- Endoscopic Retrograde Cholangiopancreatography (ERCP): Not only diagnostic but also therapeutic.
- CT pancreas scan: Performed later to identify complications like pseudocysts or necrotizing pancreatitis and is the gold standard for identifying severity and complications.
What score can be used to predict the severity of acute pancreatitis?
The modified Glasgow criteria.
Usually done at admission and after 48 hours of admission. The true score is performed after 48 hours. A score of 3 or more positive factors indicates transfer to ITU/HDU. These indicators are based on the degree of potential complications arising from pancreatitis, such as necrosis of surrounding tissue and therefore saponification, reduced hormone output (insulin) and ARDS.
It can be remembered by the mnemonic PANCREAS:
PaO2 < 8kPa (60mmHg)
Age > 55 years
Neutrophils - WBC >15 x109/l
Calcium < 2mmol/l
Renal function - Urea > 16mmol/l
Enzymes - AST/ALT > 200 iu/L or LDH > 600 iu/L
Albumin < 32g/l
Sugar - Glucose >10mmol/L
What are some local complications of Acute Pancreatitis?
- Peripancreatic fluid collection
- Pseudocyst
- Pancreatic Abscess
- Pancreatic necrosis
- Haemorrhage
What are some systemic complications of acute pancreatitis?
- Acute Respiratory Distress Syndrome
- Hypovolaemia
- Diabetes Mellitus
Why do you get haemodynamic instability in Acute Pancreatitis?
Pancreatic inflammation leads to release of inflammatory and vasoactive mediators. These in turn cause a combination of vascular injury, microscopic intravascular coagulation and vasoconstriction leading to fluid extravasation into third spaces (e.g. pleural effusions, pseudocyst)
What is an Anal Fissure?
- Linear tears or cracks in the distal anal canal, often causing pain and bleeding during or after bowel movements
What are some causes of anal fissures?
- Constipation: Hard stools can cause tearing in the distal anal canal
- Pregnancy: Increased risk during the third trimester and post delivery
What is the management of anal fissures?
- Treatment of constipation
- Topical analgesics such as lidocaine cream or jelly
- Application of topical vasodilators like nifedipine or nitroglycerine
- 2nd like includes topical CCB or oral nifedipine
- If any signs/symptoms of Crohn’s disease, should be referred to GI services
What is a common position of an anal fissure?
Fissure visible in the posterior midline on retraction of the buttock
What is an Anal Fistula?
It is an abnormal connection between the epithelialised surface of the anal canal and the perianal skin.
Often arises due to an anorectal abscess or certain inflammatory bowel diseases, especially Crohn’s disease
What investigations can you do for Anal fistulae?
- Physical examination, which can reveal the external opening of the fistula.
- Digital rectal examination, useful for determining the internal fistula opening.
- MRI: This is the investigation of choice, particularly in Crohn’s disease-associated anal fistulas, as it can characterise the fistula’s course and delineate soft tissue structures effectively.
- Endoanal ultrasound: This can also be used in some cases to evaluate the fistula’s characteristics.
What is the management for Anal Fistulae?
- Conservative: Pain management and wound care are integral parts of managing patients with anal fistulas.
- Medical: In the context of Crohn’s disease, biologic therapies such as anti-TNF agents may be used. Antibiotics are used in cases of ongoing infection.
- Surgical: This usually involves fistulotomy, which is the surgical opening of the fistula tract. In complex or high fistulas, seton placement or advancement flap procedures may be employed.
What is Angiodysplasia?
It is a vascular malformation of the GI tract characterised by the formation of fragile. leaky vascular malformations.
How does Angiodysplasia present?
- Typically presents with chronic, intermittent, painless lower GI bleeding
What imaging can you do to diagnose angiodysplasia?
- Colonosopy: to visualise lesions
- Capsule endoscopy: if suspected in the small bowel
- CT or MRI: used to rule out other pathology
- Angiography: Can be diagnostic and therapeutic
What is an anorectal abscess?
- Localised collection of pus in the perianal or rectal spaces, commonly arising from an infection in the anal glands
How does an anorectal abscess present?
- Perianal pain: often severe and aggravated by sitting or bowel movements
- Perianal swelling: This may be fluctuant and tender upon examination
- Systemic: Fever, tachycardia
What is the gold standard investigation for Anorectal abscess?
MRI Pelvis
What are some complications of appendicitis?
- Perforation
- Local abscess formation
- Gangrene
- Postoperative wound infection
- Peritonitis
How long should antibiotics be given for uncomplicated appendicectomy?
IV Antibiotics given as 1 dose before surgery followed by 2 doses every 8 hours after surgery
What are the causes of Ascending Cholangitis?
- Biliary calculi (accounts for 50%)
- Benign biliary stricture (20%)
- Malignancy
What is the first line imagine for ascending cholangitis?
- US Abdomen
What gives the best accuracy in diagnosing ascending cholangitis?
Magnetic resonance cholangiopancreatography
What is Ascending Cholangitis caused by?
Ascending cholangitis is caused by a blockage of the biliary duct which is superimposed with an infection. The most common cause of blockage is gallstones.
What is Boerhaave syndrome?
An uncommon, life-threatening condition caused by a full-thickness rupture of the oesophagus.
What is the presentation of Boerhaave syndrome?
- Severe tearing chest pain that worsens on swallowing
- Minimal or no haematemesis
- Signs of shock
- Subcutaneous emphysema
What is the first-line investigation in Boerhaave syndrome and what would you expect to see?
A CXR
Subcutaneous emphysema, pneumoperitoneum and pneumomediastinum
What is the management of Boerhaave syndrome?
- IV fluid resus
- IV antibiotics to cover for mediastinitis
- Surgical correction of the rupture
What is the name for when two different loops of bowel are contained within a hernia?
Maydl’s hernia
What blood results may be deranged in acute diverticulitis?
- Raised inflammatory markers
- White blood cell count
What dietary changes do the NICE clinical knowledge summaries suggest in the management of uncomplicated acute diverticulitis?
- Only consume clear liquids until symptoms resolve
Where is the deep inguinal ring located?
The mid-way point from the ASIS to the pubic tubercle
What condition refers to pus in the gallbladder?
Gallbladder empyema
What term 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?
Closed-loop obstruction
What pattern of enzymes will be seen on liver function tests in patients with cholestasis?
ALT and AST can increase slightly
With a higher rise in ALP
What investigation and finding can be used to assess for intra-abdominal perforation?
Erect CXR
Air under the diaphragm
What scoring system can be used to calculate the probability of appendicitis?
Alvarado score
What scoring system is used to assess the severity of pancreatitis?
Glasgow score
What is the definition of a hernia?
Protrusion of part or whole of an organ or tissue through the wall of the cavity that
normally contains it
How do direct hernias enter the inguinal canal?
In direct inguinal hernias, the bowel enters the inguinal canal ‘directly’ through a weakness in the posterior wall of the canal
How do indirect hernias enter the inguinal canal?
In indirect inguinal hernias, the bowel enters the inguinal canal via the deep inguinal ring
Which type is more commonly seen in infants and what is the
pathophysiological basis behind this?
Indirect inguinal hernias
(Occur because of a) patent processus vaginalis
Which nerve is likely to have been damaged intra-operatively during a elective repair of an inguinal hernia?
Ilioinguinal nerve
What is the gold-standard investigation for suspected splenic infarction?
CT Abdominal scan with IV contrast
What is the most common type of hernia?
Inguinal hernias
Why do femoral hernias occur?
When abdominal viscera or omentum passes through the femoral ring and into the potential space of the femoral canal
How do you manage femoral hernias?
All femoral hernias should be managed surgically. For those presenting electively, these should be fixed ideally within 2 weeks of presentation, due to their high risk of strangulation.
What surgical procedure would you do for rectal cancer on the anal verge?
Abdomino-perineal excision of rectum
What are the absolute contraindications to laparoscopic surgery?
Absolute contraindications
- Haemodynamic instability/shock
- Raised intracranial pressure
- Acute intestinal obstruction with dilated bowel loops (e.g. > 4 cm)
- Uncorrected coagulopathy
What is the treatment for Fissure in Ano?
Stool softeners, topical diltiazem or GTN, Botulinum toxin, sphincterotomy
What is the treatment for fistula in ano?
Lay open if low, no sphincter involvement or IBD, if complex, high or IBD insert seton and consider other options
