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Y3 surgery old > General Surgery > Flashcards

General Surgery Flashcards

1
Q

What isa perianal fistula?

A

Abnormal connection between the anal canal and perianal skin

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2
Q

What is the relationship between anorectal abscess and perianal fistula

A

Around 25-40% of abcesses lead to fistular formation

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3
Q

What is an anorectal abscess?

A

Collection of pus in the anal or rectal region

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4
Q

Who is most affected by anorectal abscesses

A

20-60 y/o
Men

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5
Q

What are the causes of anorectal abscess?

A

Infection in cyrptoglandular epilithelium
Crohns

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6
Q

How would a patient with anorectal abscess present

A

Severe throbbing or stabbing pain, localised swelling, itching or discharge
fever, malaise, constipation , bleeding

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7
Q

What are the sites for anorectal abcesses

A

Supralevator
Ischiorectal
Ischiosphincteric
Perianal

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8
Q

What is the most common site of an anorectal abcess

A

Perianal

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9
Q

What would you find on examination of a perianal abscess

A

Erythematous, fluctuant, tender perianal mass.

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10
Q

How do you a treat a perianal abscess?

A

Incision and draining, either using a cruciate or elliptical incision. Then proctoscopy should be performed to check for fistula

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11
Q

When would you prescribe IV antibiotics for an anorectal abscess

A

I.v antibiotics indicated in the following situations:
Immunosuppressants
Valvular heart disease
Prosthetic devices
Sepsis or extensive cellulitis
Crohns disease

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12
Q

What are the risk factors for perianal fistula ?

A

IBD
Systemic diseases
History of trauma
Previous radiation therapy

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13
Q

What is a complex perianal fistula?

A

above or passing through the external sphincter, involving > 30%

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14
Q

How does a perianal fistula present?

A

Hx of recurrent abscess
leaking faeces
Pain

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15
Q

What would you see on examination of an anorectal fistula

A

External opening visible
Erythema
Proctoscopy–> internal opening

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16
Q

What is the Goodsall rule?

A

If the external opening is posterior to the transverse anal line, the fistula tract will follow a curved course to the posterior midline

If the external opening is anterior to the transverse anal like, the fistula tract will be in a straight line to the denate line

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17
Q

Where are the sites of anorectal fistula?

A

Extrasphincteric
Suprasphincteric
Transsphincteric
Intersphincteric
Submucosal

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18
Q

What sites of anorectal fistula are simple and which are complex

A

Simple- intersphincteric and low-lying transsphincteric, submucosal

Complex- Suprasphincteric
Extrasphincteric or high fistulas
Fistulas with multiple tracts
Recurrent fistulas
Fistulas related to IBD, infection or radiation

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19
Q

What is a simple anorectal fistula

A

minimal or no involvement of external sphincter or puborectalis

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20
Q

How do you treat a simple anorectal fistula?

A

Fistulotomy (laying it open)

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21
Q

How do you treat a complex anorectal fistula?

A

Placement of a seton through the fistula attempts to bring together and close the tract

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22
Q

Define abdominal aortic aneurysm

A

Dilatation of the abdominal aorta greater than 3cm

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23
Q

Where are most AAAs situated?

A

Below the renal arteries - infrarenal.

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24
Q

Thinking of the tunica layers in arteries, what is AAA usually due to?

A

Degeneration of the tunica media - specifically the elastin and collagen.

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25
Q

How do AAA present?

A

Asymptomatic. PMH of atherosclerosis, trauma, infection, connective tissue disease, inflammatory disease. Pulsatile mass felt in the abdomen above the umbilicus.

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26
Q

How do ruptured AAA present?

A

Persistent abdo AND back pain. Dizzy, syncopal, LOC, SOB, shock. Sudden CVS collapse

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27
Q

How are AAAs investigated?

A

Screening programme in 65th year for men. US confirms Dx, CT with contrast is then done to check surrounding anatomy and to plan for elective surgery.

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28
Q

What advice can you give someone who has AAA?

A

Improve BP control, smoking cessation, exercise, weight loss, statins and aspirin therapy

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29
Q

Who would be suitable to have AAA surgery?

A

If AAA is 5.5cm1cm/year or if symptomatic

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30
Q

What surgical treatments are available for AAA?

A

Open repair or endovascular repair (keyhole).

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31
Q

What can serum calcium be helpful for looking at/diagnosing?

A

Acute pancreatitis, Clotting, cardiac function

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32
Q

What is peritonitis?

A

Inflammation of the lining of the abdomen

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33
Q

How do femoral hernias present?

A

Groin lump, inferior to inguinal ligament and inferior and lateral to the pubic tubercle.

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34
Q

How do strangulated femoral hernias present?

A

Similar to bowel obstruction. Nausea and vomitting, colicky abdo pain, slightly distended abdo

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35
Q

What are the RF for gallbladder carcinoma??

A

Hx of gallstones or chronic cholecystitis

Porcelain gallbladder
Smoking
Obesity
Primary sclerosing cholangitis
UC/crohns colitis
Oestrogens
Occupational exposure

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36
Q

How does gallbladder carcinoma present?

A

Usually presents late with vague symptoms of abdo pain

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37
Q

What are ddx for a patient with dyspepsia?

A

GORD, peptic ulcer, gallstones, gastritis, gastric cancer, NSAID associated erosions

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38
Q

What is painless jaundice a sign of?

A

Pancreatic cancer

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39
Q

A man is 60 years old and has a recent diagnosis of DM. He has lost a stone and has a yellow tinge to his skin. What may he have a diagnosis of?

A

Pancreatic cancer - recent onset of DM over age of 60. Painless jaundice is a clue too.

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40
Q

What is the most common type of gastric cancer?

A

Adenocarcinoma

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41
Q

What are 4 risk factors for developing gastric cancer?

A

Any 4 of male, H. pylori infection, increasing age, smoking, positive fhx, alcohol consumption, increased dietary salt, pernicious anaemia

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42
Q

How would a patient with gastric cancer present?

A

Specific: Dyspepsia, early satiety, vomiting and dysphagia.

General cancer sx: anorexia, weight loss, anaemia

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43
Q

What is trosiers sign?

A

Presence of palpable left supraclavicular node- sign of metastatic abdominal cancer (usually gastric)

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44
Q

A 43 year old patient presents with early satiety, what are your differentials?

A

Ovarian cancer, GORD, gastritis, peptic/duodenal ulcer, gastric cancer

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45
Q

Why is gastric cancer so hard to diagnose?

A

Vague and non-specific symptoms

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46
Q

What are differentials to consider when meeting a patient with dyspepsia, early satiety, anorexia and vomiting?

A

Gastric cancer, peptic ulcer disease, gallstone disease, pancreatic cancer

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47
Q

As well as trosier’s sign, what are other signs of metastatic gastric cancer?

A

Hepatomegaly, ascites, jaundice, acanthosis nigricans

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48
Q

What imaging would you do in a patient with a suspected gastric cancer?

A

Upper GI endoscopy (OGD) with anyone who has new onset dysphagia or >55yrs with weight loss and either: upper abdo pain, reflux or dyspepsia

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49
Q

Why do you perform an OGD in a patient with suspected gastric cancer?

A

For visualisation and biopsy

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50
Q

On histology what would the appearance of cells be for a patient with gastric cancer?

A

Signet ring cells

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51
Q

What is the purpose of CT abdo-pelvis and laparoscopy in a patient with confirmed gastric cancer?

A

CT is used to make the treatment plan and the laparoscopy is used for staging

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52
Q

How do you treat early gastric tumour?

A

T1a- endoscopic mucosal resection is used

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53
Q

What is the curative management of gastric cancer?

A

Surgery- offered to fit enough patient, with peri-operative chemo.

Proximal gastric cancer- total gastrectomy
Distal gastric cancer- subtotal gastrectomy

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54
Q

What are the palliative treatment options for gastric cancer?

A

May incl chemo, best supportive care and stenting
Palliative surgery can be used when stenting fails

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55
Q

What are the two types of oesophageal cancer?

A

Squamous cell carcinoma and adenocarcinoma

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56
Q

What are the demographics and affected areas for the different types of oesophageal cancer?

A

Squamous call carcinoma-more common in the DEVELOPING world, middle and upper thirds of the oesophagus, associated with smoking and drinking

Adenocarcinoma- more common in the DEVELOPED world, lower 3rd of the oesophagus, associated with Barretts oesophagus

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57
Q

What are the RF for oesophageal squamous cell carcinoma?

A

Chronic achalasia, low vit A

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58
Q

What are the RF for oesophageal adenocarcinoma?

A

GORD, obesity and high fat intake

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59
Q

How do patients with oesophageal cancer present?

A

Progressive dysphagia, weight loss due to dysphagia or cancer, odynophagia, hoarseness

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60
Q

How would a patient with oesophageal cancer look on examination?

A

Evidence of recent weight loss, cachexia, signs of dehydration, supraclavicular lymphadenopathy, signs of mets (ascites, jaundice, hepatomegaly)

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61
Q

What are the red flag symptoms that would make you request a 2WW endoscopy?

A

Any patient with new onset dysphagia OR >55 years with weight loss AND one of: dyspepsia OR upper abdo pain OR reflux

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62
Q

How do you investigate a ?oesophageal cancer

A

OGD- to visualise the malignancy
CT CAP and PET-CT for distant mets
Endoscopic US- to measure T-stage (penetration into oesophageal wall)
Staging laparoscopy- look for intraperitoneal mets
If there are any palpable cervical lymph nodes, may be investigated via FNA
Hoarseness and haemoptysis- investigate via bronchoscopy

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63
Q

How do you treat a squamous cell oesophageal cancer ?

A

Hard to operate, definitive chemo and radiotherapy

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64
Q

How do you treat Adenocarcinoma off the oesophagus?

A

Neoadjuvant chemo or chemo-radiotherapy followed by oesophageal resection

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65
Q

What are the risks associated with surgical treatment of oesophageal cancer?

A

Anastomotic leak, reoperation, pneumonia and death

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66
Q

What does palliative treatment for oesophageal cancer consist of?

A

Symptom control:
Patient has difficulty swallowing–> oesophageal stent
Radiotherapy and/or chemo to help reduce tumour size to reduce sx
Nutritional support–> disease progression can lead to significant dysphagia and cachexia–> thickened fluid and nutritional supplements should be offered

RIG inserted if cannot tolerate enteral feeds

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67
Q

Define a hernia

A

Protrusion of a whole or part of an organ through the wall of a cavity that contains it into an abnormal position

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68
Q

What is a hiatus hernia?

A

Protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus.

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69
Q

Which organ usually protrudes in a hiatus hernia?

A

Stomach. (Small bowel, colon or mesentery rarely herniate).

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70
Q

What are the two sub classifications of hiatal hernias?

A

Sliding or rolling.

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71
Q

Define a sliding hiatus hernia

A

Sliding = cardia of stomach moves upwards or slides upwards through the diaphragmatic hiatus into the thorax.

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72
Q

Define a rolling hiatus hernia

A

Upward movement of the fundus of the stomach, so it lies alongside the gastro-oesophageal junction. This creates a ‘bubble’ of stomach in the thorax. Has a peritoneal sac = so a true hernia!

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73
Q

Name a risk factors of hiatus hernia

A

Age - age related loss of diaphragmatic tone, increased abdominal pressure, increased size of hiatus, pregnancy, obesity, ascites.

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74
Q

How does a hiatus hernia present?

A

Mainly asymptomatic!!!
Symptoms include GORD, vom, weight loss, bleeding, anaemia, hiccups, palpitations, swallowing difficulties.

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75
Q

What are differentials of hiatus hernia?

A

Cardiac chest pain, gastric or pancreatic cancer (if early satiety or weight loss), GORD.

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76
Q

What investigations might you do for suspected hiatus hernia?

A

Oesophagogastroduodenoscopy = gold standard. This would show upward displacement of GO junction.
Can be diagnosed incidentally - CT or MRI scan. Contrast swallow can also diagnose.

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77
Q

How is hiatus hernia managed conservatively?

A

Conservatively - PPI - reduces gastric acid secretion. Lifestyle modification - weight loss, low fat diet, earlier meals, smaller portions, sleep with head raised. Smoking cessation, reduce alcohol intake.

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78
Q

How is hiatus hernia managed surgically?

A

If symptomatic, if increased risk of strangulation, nutritional failure. Can do Cruroplasty and Fundoplication.

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79
Q

What are complications of hiatus hernia surgery?

A

Recurrance, abdominal bloating, dysphagia, fundal necrosis (blood supply via left gastric artery and short gastric vessels are disrupted).

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80
Q

What are complications of hiatus hernias?

A

Incarceration, strangulation, gastric volvulus.

Presents as Borchardt’s triad

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81
Q

What is Borchardt’s triad

A

Severe epigastic pain, retching without vomiting, unable to pass NG tube.

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82
Q

What is a direct inguinal hernia?

A

Bowel enters the inguinal canal through a weakness in Hesselback’s triangle (posterior wall).

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83
Q

What is an indirect inguinal hernia?

A

Bowel enters the inguinal canal via the deep inguinal ring.

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84
Q

Why may a direct inguinal hernia come about?

A

Secondary to an increased abdominal pressure or abdominal wall laxity.

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85
Q

Why may an indirect inguinal hernia come about?

A

From incomplete closure of processus vaginalis.

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86
Q

Name a RF for an inguinal hernia?

A

Male, raised intra abdominal pressure, obesity, increased age

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87
Q

How does an inguinal hernia present?

A

Lump in groin. Bowel obstruction. Mild-moderate discomfort which worsens with activity or standing.

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88
Q

What investigations would you carry out for suspected inguinal hernia?

A

Usually diagnosed by clinical features. USS recommended as first line imagining. CT imaging required if there are features of obstruction or strangulation.

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89
Q

How are inguinal hernias managed?

A

Surgical intervention - open or laparoscopic repair. Open repairs are preferred for primary inguinal hernias. Lapro is preferred in bilateral or recurrent hernias.

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90
Q

What are complications of inguinal hernia?

A

Incarceration, strangulation, obstruction

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91
Q

What are post op complications of inguinal hernia repair?

A

Pain, bruising, haematoma, recurrence, chronic pain, damage to vas deferent or testicular vessels.

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92
Q

What is the pathophysiology of femoral hernias?

A

Abdominal viscera or the abdominal omentum pass through the femoral ring, and into the potential space - the femoral canal

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93
Q

What are risk factors of having a femoral hernia?

A

Female, pregnancy, raised intra abdominal pressure from heavy lifting etc, increasing age.

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94
Q

How do femoral hernias present?

A

Small lump in groin but otherwise asymptomatic usually. Can present as an emergency. Found medial to the femoral pulse and inferno-lateral to the pubic tubercle.

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95
Q

What investigations would you do for a suspected femoral hernia?

A

USS. CT abdo-pelvis. Lump to be explored surgically.

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96
Q

How is a femoral hernia managed surgically?

A

Managed within 2 weeks of presentation, due to high risk of strangulation. Managed by surgical reduction and narrowing the femoral ring.

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97
Q

What are complications of femoral hernia?

A

Risk of strangulation.
Risk of obstruction.
Increased morbidity and 20 times higher mortality.
Risk of bowel resection, wound infection and cardioresp complications - if acute femoral hernia.

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98
Q

What is the pathophysiology of an incisional hernia?

A

Surgical incision of anterior abdominal wall means they become weakened and disrupted. Contents of abdominal herniate through this weakness.

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99
Q

What are RF for incisional hernia?

A

Emergency surgery, BMI>25, midline incision, post op wound infection, DM, steroid use, connective tissue disorders, increasing age, smoker.

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100
Q

How does an incisional hernia present?

A

Reducible, soft, non-tender swelling near site of previous surgical wound. Can be tender, painful and erythematous if incarcerated. Mass is palpable, may be reducible into abdominal cavity.

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101
Q

What investigations would you carry out for suspected incisional hernia?

A

Diagnosis made on clinical picture. CT imaging done to confirm.

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102
Q

How is incisional hernia managed?

A

Case-by-case different. Surgery is only usually for symptomatic hernias. Can do suture repair, open or laparoscopic repair, abdominal wall reconstruction.

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103
Q

What is an umbilical hernia?

A

Part of abdomen protrudes through opening in abdominal muscles near to the navel, causing belly button to swell.
In babies if opening that umbilical cord passes through does not close properly.

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104
Q

How does an umbilical hernia present?

A

Infants. Protrusion of soft swelling at the navel. Protrudes further on infant crying, straining or coughing. Painless.

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105
Q

What are RF for umbilical hernias?

A

Premature babies, low birth weight. Increased abdominal pressure (in adults).

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106
Q

Why is umbilical hernia at risk of incarceration?

A

Narrow neck of umbilicus = higher risk.

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107
Q

What is achalasia?

A

Failure of the LOS to relax

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108
Q

How does achalasia present?

A

Gradual onset of dysphagia of food and liquids
Regurg of food
Aspiration
Heartburn that often does not respond to PPI

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109
Q

What can achalasia lead to?

A

It is a risk factor for oesophageal squamous cell carcinoma

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110
Q

How does large bowel obstruction present?

A

Abdominal pain
Bloating
Absolute constipation
Nausea and vomiting

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111
Q

What are the causes of large bowel obstruction?

A

Colonic tumour
Volvulus (sigmoid or caecal)
Hernias
Adhesions

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112
Q

What investigations would you do for a large bowel obstruction?

A

Abdominal xray
CT abdo to establish a cause

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113
Q

What are red flag symptoms for Colorectal cancer?

A

Change in bowel habit, rectal bleeding, weight loss, iron deficiency anaemia, tenesmus

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114
Q

What are the risk factors for anal fissures?

A

Constipation and pregnancy (particularly in 3rd trimester and delivery)

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115
Q

How do you manage anal fissures?

A

Treatment of constipation- laxatives/fibre in diet
Topical analgesics- lidocaine cream/jelly
Topical vasodilators- nifedipine or nitroglycerine

Second line treatment incl topical CCB (diltiazem)

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116
Q

What are tympanic sounds in the abdomen?

A

Occurs over the air filled structures- should sound this way in the midline of the abdomen. It sounds long, high pitched and loud

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117
Q

What are the features of chronic pancreatitis?

A

Epigastric pain that radiates through to the back (exacerbated by fatty food/alcohol and relieved by sitting back), steatorrhoea, weight loss and diabetes mellitus.

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118
Q

A patient comes in with jaundice, upon investigation, the cause is post- hepatic. What are your ddx?

A

acute cholangitis, cholecystitis, bile duct strictures, obstructive choledocholithiasis, external compression from extra- billiard tumour, pancreatic tumour, primary biliary cirrhosis and primary sclerosing cholangitis

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119
Q

You meet a 68 year old M, who has chronic alcoholism . He has come in with lethargy and jaundice, what are you ddx?

A

Alcoholic liver disease, viral hep, hepatocellular carcinoma,hepatocellular adenoma,

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120
Q

What is the most sensitive blood test for diagnosis of acute pancreatitis?

A

Lipase! NOT amylase - as can rise and fall quickly, so can lead to false -ve.

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121
Q

A patient comes in and has unexplained microcytic anaemia and weight loss. What is your next investigation?

A

Colonoscopy/lower GI tract investigation as could have colorectal cancer.

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122
Q

How would you manage post-op ileus?

A

Conservatively - insert NG tube for stomach decompression for symptom control. Place pt on NBM regime to allow bowel to rest. Reduce opiate analgesia as reducing bowel motion. Do daily bloods as could have electrolyte abnormalities and AKI can develop. Encourage mobilisation.

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123
Q

What is post operative ileus?

A

A deceleration or arrest in intestinal motility following surgery. Classified as a functional bowel obstruction and is v common after abdominal or pelvic oath surgery.

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124
Q

How does post operative ileus present?

A

Failure to pass faeces or wind. Sensation of bloating and distension. Nausea and vomiting. On examination, there is abdominal distension and absent bowel sounds.

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125
Q

What is Buerger’s disease?

A

Non atherosclerotic vasulitis in small and medium sized arteries. Usually young male, smoker, Mediterranean origin

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126
Q

How does Buerger’s disease present

A

Acutely ischaemic limb without peripheral claudication

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127
Q

What is the management of gallstones?

A

Asymptomatic patients will be treated without investigation
Patients with symptoms or complications can be treated with cholecystectomy

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128
Q

What conditions increase risk of anal carcinoma?

A

HPV, Chrons, HIV

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129
Q

Patient presents with lower Gi bleed. What are the your differentials?

A

Chrons, UC, haemorrhoids, anal fissure, colorectal cancer, anal cancer, diverticula disease, colonic polyps.

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130
Q

What is a serious complication of total parental nutrition?

A

Refeeding syndrome

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131
Q

What does ischaemic colitis usually present with?

A

Acute rectal bleeding due to tissue necrosis.

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132
Q

How does mesenteric ischaemia present?

A

Sudden serve abdo pain out of proportion with clinical exam. N&V, signs of shock, metabolic acidosis on ABG, PR bleed seen in advanced ischaemia

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133
Q

How can diverticulitis present?

A

Left lower quadrant pain, fever, N and Vom. PR bleeding and pain

134
Q

What are the symptoms of gallstone disease?

A

Can be asymptomatic
RUQ pain
Biliary colic
Nausea
Vomitting
Pale urine
Dark stools
Fever
Jaundice

135
Q

What are the risk factors of gallstone disease?

A

Fair, fat, forty, family history, fertile
Poor diet
Oral contraceptives
Pregnancy
Malabsorption
Ethnicity- Native American and hispanic

136
Q

What is biliary colic?

A

Stone is temporarily obstructing the neck of the gall bladder, impeding drainage

137
Q

What are the symptoms of biliary colic?

A

Severe colicky RUQ pain
Often triggered by fatty meals
Nausea and vomitting

138
Q

What is the most likely picture of LFTs when a patients presents with biliary colic?

A

Raised ALP, raised bilirubin

139
Q

What is the first line investigation for patients who have suspected gallstone disease?

A

Ultrasound (trans abdominal)- helpful in identifying any gallstones in the gallbladder, gallstones in the ducts, bile duct dilatation, acute cholecystitis (thicken GB wall, or sludge in the gallbladder with fluid around the gallbladder)

140
Q

What is the indication of MRCP in suspected gallstone disease?

A

Investigate further if ultrasound doesn’t show the presence of stones, but there is dilatation of the bile duct or raised bilirubin which suggests obstruction

141
Q

What is acute cholecystitis?

A

Gallstone blocking the cystic duct or neck of the gallbladder causing the gallbladder to become inflamed.

142
Q

What are the signs and symptoms of acute cholecystitis?

A

Pain in the RUQ
Fever
Nausea
Vomiting
Tachycardia and tachypnoea
Murphy’s sign positive

143
Q

What is Murphy’s sign?

A

Hand on the RUQ and apply pressure, ask patient to take a deep breath in, the gallbladder will move downwards and come in contact with your hand and cause pain for the patient.

144
Q

What is the first line investigation for acute cholecystitis?

A

Abdo ultrasound showing thickened gallbladder wall, stones or sludge in gallbladder, fluid around the gallbladder

145
Q

What is the management of acute cholecystitis?

A

Conservative includes, Nil by mouth, Co-amoxiclav +/- metronidazole, antiemetics

Laproscopic cholecsytectomy is performed usually during the acute admission (within 72 hours) and sometimes delayed by 6-8 weeks to allow for the inflammation to subside

146
Q

What is acute cholangitis?

A

Biliary outflow obstruction and infection
Due to gallstone which fully stops bile flow, causing stasis and then infection
ERCP, infection introduced

147
Q

What is Charcot’s triad?

A

Presentation of acute cholangitis
RUQ pain
Fever
Jaundice

148
Q

What are the most common organisms causing acute cholangitis?

A

Escherichia coli
Klebsiella species
Enterococcus species

149
Q

How would a patient with acute cholangitis behave on examination?

A

Confused
RUQ tenderness
Jaundice
Hypotension
Tachycardic

150
Q

Why is acute cholangitis a surgical emergency?

A

Due to the risk of sepsis and septicaemia

151
Q

What would investigations find in acute cholangitis?

A

FBC- leukocytosis
LFTs-elevated ALP +/- GGT & bilirubin
blood cultures - not always positive

ultrasound buliary tract - duct dilation

152
Q

How is acute cholangitis managed?

A

risk of sepsis- fluid resuscitation, routine bloods,
blood cultures, broad spectrum Abx
(co-amoxiclav + metronidazole)

definitive managment:
endoscopic biliary decompression using ERCP
cholecystectomy maybe required if
gallstones the underlying cause

153
Q

What is thumbprinting indicative of?

A

large bowel thickening usually caused by oedema

154
Q

Why is opiate analgesia a RF for anal fissures?

A

Opiates cause constipation —> stool is hard and patient will strain —> increases the risk of tearing skin of anal canal

155
Q

What is the triad of Acute mesenteric ischaemia?

A

severe abdominal pain, unremarkable abdo exam and shock

156
Q

What is oedematous bowel indicative of?

A

It is a non-specific sign but indicates an inflammatory process, e.g. necrotic bowel

157
Q

What are differentials of right iliac fossa pain?

A

acute appendicitis, mesenteric adenitis, crohns, diverticulitis (but usually on the left), inflamed Meckel’s diverticulum, ovarian torsion, ectopic pregnancy, ovarian cyst, testicular torsion, pyelonephritis, ureteric colic

158
Q

What are the causes of small bowel obstruction?

A

Adhesions, incarcerated hernias, crohns disease, appendicitis, malignancy, gallstone ileus, foreign body ingestion

159
Q

How does peripheral arterial disease present?

A

Walking impairment,
pain in buttocks and thighs that are relieved by rest, pale cold leg,
hair loss,
weak pulses,
ulcers
poorly healing wounds

160
Q

How does chronic limb ischaemic present?

A

Cramping pain in the calf after walking, which is relieved by rest.

161
Q

What is the significance of polyps in the colon?

A

10% progressive from benign adenomas to invasive adenocarcinoma

162
Q

What is the APC gene?

A

It is present in FAP (familial Adenomatous polyposis) and is a tumour suppressor gene, results in the growth of polyps

163
Q

What is the HNPCC gene and what condition does it give you?

A

It is a mismatch repair gene, giving you Lynch syndrome and increases your chance of colorectal cancer

164
Q

What are the risk factors for colorectal cancer?

A

Male, increasing age, family hx, low fibre diet, increased processed meat intake, smoking, alcohol excess

165
Q

How does colorectal cancer present?

A

Weight loss, change in bowel habit, PR bleeding, abdominal pain, iron deficiency anaemia.

166
Q

How does presentation of colorectal cancer differ on location?

A

Right sided (ascending colon)- FUNGATING, change in bowel habit happens later on, abdo pain, iron deficiency anaemia, palpable mass in the R iliac fossa- presents later at diagnosis

Left sided (descending colon)- STENOSING, change in bowel habit early on, rectal bleeding, palpable mass in the LIF, tenesmus, presents earlier

167
Q

When would you refer via 2 WW with suspected colorectal cancer?

A

40 years or more with unexplained weight loss and abdo pain
50 years or more with unexplained rectal bleeding
60 years or more with iron deficiency anaemia or change in bowel habit

168
Q

What lab investigations would you do for a suspected colorectal cancer?

A

FBC, LFTs and Clotting
May show a microcytic (iron deficiency anaemia)

169
Q

What is your first line investigation for a suspected colorectal cancer?

A

Colonoscopy with biopsy
If unable to do a colonoscopy, CT colonography

170
Q

What is the role of alternative imaging (CT, MRI etc.) in colorectal cancer?

A

CT TAP, once diagnosed for staging and distant mets
MRI rectum for rectal tumours- to see tumour depth
Endo-anal ultrasound for T1/2 rectal tumours to determine suitability for trans-anal resection

171
Q

How do you approach management of colorectal cancer

A

Discussion with the MDT

Very small tumours may be suitable for endoscopic resection

Surgery is the main curative treatment

R.Sided tumour- right hemicolectomy
L.Sided tumour- left hemicolectomy
Sigmoid colon tumour- Sigmoidectomy
High Rectal tumour- Anterior resection with loop ileostomy
Low Rectal tumour- Abdominoperineal resection

CHEMO- used Neo-adjuvant or adjuvant, usually in patients with advanced disease
RADIOTHERAPY-used more in rectal cancer

172
Q

What is the aim of palliation in colorectal cancer?

A

Reduce cancer growth and focus on symptom control

173
Q

What is a cholangiocarcinoma?

A

Cancer of the biliary system

174
Q

What is a Klaskin tumour?

A

A tumour at the bifurcation of the L and R hepatic duct. It is a slow growing tumour which invades local lymph nodes

175
Q

What are the risk factors for cholangiocarcinoma?

A

Primary scerlosing cholangitis
UC
Infective causes (liver flukes, HIV, hep)
Airplane and rubber fumes
Congential
Alcohol excess
DM

176
Q

What are the clinical features of cholangiocarcinoma?

A

usually asymptomatic until later stages
post hepatic jaundice
pruritus
pale stools and dark urine

Less commonly- RUQ pain, early satiety, weight loss, anorexia and malaise

177
Q

How does cholangiocarcinoma present on examination?

A

Jaundice and cachexia and courvoisiers rule applies

178
Q

What is courvoisiers law?

A

Palpable gallbladder with painless jaundice–> pancreatic or biliary pathology should be suspected

179
Q

What do you expect to be present on LFTs in a cholangiocarcinoma?

A

Obstructive jaundice, elevated bilirubin, ALP, y gamma transferase

180
Q

What is the gold standard imaging for cholangiocarcinoma?

A

MRCP
ERCP can be used to obtain samples

181
Q

What is the most common aim of treatment with cholangiocarcinoma?

A

Palliative

182
Q

What is the definitive cure of cholangiocarcinoma?

A

Surgery

183
Q

How do you treat a Klaskin tumour?

A

Partial hepatectomy and reconstruction of biliary tree

184
Q

What are the palliative treatment options for cholangiocarcinoma?

A

Stenting- to relieve the obstruction
Bypass surgery- to bypass the obstruction, stenting doesn’t work
Palliative radiotherapy- to prolong survival some chemo agents may be used with radiotherapy

185
Q

What are some conditions that can predispose you to hepatocellular carcinoma?

A

Viral hep B and c
Hereditary haemochromatosis
Primary biliary cirrhosis

186
Q

What are some risk factors for hepatocellular carcinoma?

A

Male
Over 70
Fhx liver disease
High alcohol intake
aflatoxin poisoining
smoking
viral hep b and c

187
Q

How do patients with hepatocellular carcinoma present?

A

Similar to liver cirrhosis
Vague and non-specific symptoms: leathery, weight loss, fatigue, fever
Dull ache in RUQ is uncommon but if present can be suspicious of malignancy

188
Q

What are the examination findings of a patient with hepatocellular carcinoma?

A

Large, craggy, tender and irregular liver–>v suggestive of malignancy

189
Q

What are the blood abnormalities in a patient with hepatocellular carcinoma?

A

LFTs deranged
Low platelets and clotting due to liver failure
Alpha fetoprotein should be measure as is raised in 70% of cases, and is good indication of treatment progress

190
Q

What investigative imaging do you use in hepatocellular carcinoma?

A

US. Mass >2cm, with raised alpha fetoprotein (AFP) is virtually diagnostic of hepatocellular carcinoma

Rising AFP with nodular liver–> MRI

191
Q

What is the name of the staging criteria for hepatocellular carcinoma?

A

Barcelona Clinic (no need to know the different stages_)

192
Q

When can transplantation be considered in hepatocellular carcinoma?

A

Milan Criteria is used and needs to be fulfilled:
One lesion less than 5cm or 3 lesions are smaller than 3 cm
No extra hepatic manifestations
No vascular infiltration

193
Q

When would surgery be indicated in a patient with hepatocellular carcinoma?

A

Good baseline function and no cirrhosis

194
Q

What are the non-surgical treatment options fo hepatocellular carcinoma?

A

Image guided ablation- low grade tumours
Alcohol ablation

Transarteril chemoembolisation

195
Q

Which organs metastasise to the liver most frequently?

A

bowel, breast, stomach, pancreas and lung

196
Q

Whats the most common type of tumour is in pancreatic cancer?

A

ductal carcinoma, which is from the exocrine part of the pancreas

197
Q

Where do pancreatic tumours arise from?

A

Head- 60-70%
Body and tail - 20-25%
Diffuse- 10-20%

Body and tail tumours more likely to be diagnosed at advance stages compared to head

198
Q

What are the risk factors for pancreatic tumours?

A

Smoking
Chronic pancreatitis
Poor diet- high red meat and low fruit and veg
late onset DM
Fhx

199
Q

What is the presentation of pancreatic cancer?

A

Usually non-specific
Can get:
obstructive jaundice
weight loss
non-specific abdo pain

200
Q

How does a patient with pancreatic cancer appear on examination?

A

Cachexia
jaundiced
malnourished
courvoisiers law applies

201
Q

What is a RF for appendicitis?

A

In 20s-30s. FHx. Caucasian. Seasonal RF - summer.

202
Q

How does appendicitis present?

A

Generalised peri-umbilical pain which later localises in the RIF. Vomiting, nausea, diarrhoea/constipation,

203
Q

What is found on examination of a pt with appendicitis?

A

Guarding, rebound tenderness, percussion over McBurney’s point. Rovsing’s sign - pain in RIF when palpate LIF. Psoas sign - RIF pain with extension of the right hip.

204
Q

Name four investigations you might do for suspected appendicitis

A

Urinalysis - check pregnancy and urological causes. Bloods - FBC, U+Es, CRP, serum beta-hCG.
US and CT, laparoscopic investigation.

205
Q

How is appendicitis managed?

A

Laparascopic appendectomy, open appendectomy with a Lanz incision. Appendix to be sent to histopathology to look for malignancy. May need abs and percutaneous drainage. Analgesia.

206
Q

Name a complication of appendicitis

A

Perforation. Surgical site infection. Abscess formation.

207
Q

What are RF for Chrons? And what are RF for UC?

A

Chrons - smoking, Fox, environment. UC - caucasian, genetics, environment

208
Q

How does Chrons present?

A

Episodic abdo pain. D-, stools may have mucus and blood. Malabsorption. Oral aphthous ulcers, perianal disease, arthritis, erythema nodosum, uveitis, renal stones, hepatobillary problems.

209
Q

How does UC present?

A

Bloody diarrhoea, gradual onset, PR bleeding, mucus discharge, frequency and urgency of defecation, malaise, anorexia, low grade pyrexia, arthritis, erythema nodosum, uveitis, primary sclerosing cholangitis

210
Q

What investigations would you do for suspected IBD (Chrons, UC)?

A

FBC, CRP, faecal calprotein, LFTs, stool sample, colonoscopy, CT abdo and pelvis. For Chron’s - MRI, proctosigmoidoscopy. For UC - AXR or CT for toxic megacolon or bowel perforation and to see mural thickening, thumb printing or lead pipe colon.

211
Q

How is remission induced in Chrons?

A

Fluid resus, nutritional support, prophylactic heparin (as flare ups are a prothrombotic state), corticosteroid treatment, immunosuppressive treatments - mesalazine.

212
Q

How is remission maintained in Chrons?

A

Azathioproine - 1st line monotherapy. Smoking cessation. Colonoscopic surveillance if had disease for over 10yrs with more than 1 segment affected. Refer to specialist nurse and nutritional support.

213
Q

How is UC managed presenting to hospital ?

A

Fluid resus, nutritonal support, prophylactic heparin. Induce remission with steroids and immunosuppressive agent.
Need to maintain remission too with immunomodulatord.
Colonoscopic surveillance.
Refer to specialist nurse.

214
Q

How is Chron’s surgically managed?

A

ileocaecal resection - where you remove the terminal ileum and caecum with primary anastomosis. Small or large bowel resection. Surgery for peri-anal disease.

215
Q

How is UC surgically managed?

A

Total proctocolectomy is curative. Initially, pt may have subtotal colectomy.

216
Q

Name 2 complications of Chron’s

A

Fistula,
strictures,
recurrent perianal fistulas,
GI malignancy,
malabsorption - leading to growth delay.
Osteoporosis,
increased risk of gall stones and renal stones

217
Q

What is a complication of UC?

A

Toxic megacolon, colorectal carcinoma, osteoporosis, pouchitis (inflame of ilea pouch).

218
Q

What are diverticula?

A

Outpouchings of mucosa through weaker areas of the bowel wall.

219
Q

Distinguish between diverticulosis, diverticular disease and diverticulitis

A

Diverticulosis = presence of diverticula. Diverticular disease = symptomatic diverticula. Diverticulitis = inflammation of the diverticula

220
Q

What are RF for diverticula?

A

Age, low fibre diet, obesity, Fox, NSAID use.

221
Q

How does diverticular disease present?

A

Intermittent lower abdo pain. Colicky. Pain relived by defecation, nausea, flatulence

222
Q

How does acute diverticulitis present?

A

Acute abdo pain, sharp and localised to LIF. Worsened by movement. Localised tenderness, reduced appetite, pyrexia, nausea.

223
Q

What is the pathophysiology of acute diverticulitis?

A

Bacteria grow in the outpouchings - causes inflammation. Can be simple, where its just inflam or complicated, where there is an abscess or perforation.

224
Q

How may diverticular bleed present?

A

Painless PR bleed in diverticulosis. Painful PR bleed in diverticulitis.

225
Q

How is diverticular disease managed?

A

Simple analgesia, increased fluid intake, colonoscopy to exclude malignancy.

226
Q

What are complications of diverticular disease?

A

Acute diverticulitis, diverticular bleed.

227
Q

What is conservative management of acute diverticulitis?

A

Abx, IV fluids, analgesia. Sx should improve in 2-3 days.

228
Q

What surgical interventions are available for acute diverticulitis?

A

Hartmann’s procedure - sigmoid colostomy with formation of end colostomy.

229
Q

What is a complication of acute diverticulitis?

A

Recurrance, strictures, fistula formation, diverticular bleed.

230
Q

How is diverticular bleed managed?

A

Self limiting. Can do flexible sigmoidoscopy to check for malignancy.

231
Q

Name a cause of intraluminal intestinal obstruction?

A

Gallstone ileus, foreign body, faecal impaction.

232
Q

Name a cause of mural intestinal obstruction

A

Malignancy, strictures, intussusception, mocker’s diverticulum, lymphoma.

233
Q

Name a cause of extraluminal intestinal obstruction

A

Hernia, adhesions, peritoneal mets, volvulus

234
Q

What is the most common cause of small bowel obstruction?

A

Adhesions, hernias

235
Q

How does small bowel obstruction present?

A

Abdo pain, vomiting, abdo distension, absolute constipation

236
Q

What would be seen on examination for small bowel obstruction?

A

tinkling bowel sounds, focal tenderness.

237
Q

What imaging would you do for small bowel obstruction? And what would you see?

A

AXR - see centrally dilated bowel >3cm. Valvulae conniventes are visible. Can do CT scan with IV contrast. Can do CXR - see pneumoperitoneum if perforated.

238
Q

What initial management options would you discuss for small bowel obstruction?

A

Urgent fluid resus, catheter to monitor fluid output, pt NBM, insert NG tube to decompress bowel

239
Q

When is surgery indicated for small bowel obstruction?

A

Intestinal ishaemia, closed loop bowel obstruction. If hernia is present and strangulated - need surgical correction.

240
Q

What are complications of small bowel obstruction?

A

Bowel ischaemia, bowel perforation, dehydration and renal impairment

241
Q

What are most common causes of large bowel obstruction?

A

Malignancy, diverticular disease, volvulus

242
Q

What is seen on AXR of large bowel obstruction?

A

Peripherally dilated bowel. Haustral lines visible.

243
Q

How do oesophageal varices present?

A

Haemetemesis, Malena, light headedness, LOC. Can also have associated signs: jaundice, ascites, raised JVP, bruising (sign of impaired coag due to liver disease), caput medusa

244
Q

A pt has presented with hematemesis. You suspect oesophageal varices; what questions may you ask in the Hx?

A

Alcohol intake? Hep B/C?

245
Q

What investigations would you do for definitive diagnosis of oesophageal varices?

A

OGD. or CT w/ contrast if patient is unstable for OGD or the OGD is unremarkable

246
Q

During OGD, how can oesophageal varices be managed?

A

Endoscopic banding. Prophylactic AB and somatostatin analogues. Sengstaken- Blackmore tube/balloon tamponade. TIPS considered if band ligation does not work.

247
Q

How are bleeding oesophageal varices initially managed?

A

A-E. Wide bore cannulas. Major haemorrhage protocol - bloods, platelets, clotting factors. May need platelet transfusion. Blood transfusion if low Hb or unstable. Coag reversal if on blood thinners.

248
Q

What red flag in Hx would warrant an urgent OGD?

A

Adult with alcohol Hx presenting with haematemesis. Or adult who has haematemesis that is v unstable.

249
Q

How does peptic ulcer disease present?

A

General symptoms - epigastric or retroperitoneal pain, nausea, bloating, and affected by eating —>Gastric ulcer - worse on eating. Duodenal ulcer - intermittint abdominal pain, relieved by eating.
Can present with complications of ulcers - bleeding, perforation, gastric obstruction.

250
Q

What might you ask about when a pt presents with a peptic ulcer?

A

NSAID use, steroid use, if they have had a H pylori test. Have they had previous epigastric pain? Previous bypass surgery?Physiological stress?

251
Q

Name a differential of peptic ulcer disease

A

ACS, GORD, Gallstone disease, gastric malignancy, pancreatitis.

252
Q

What causes Mallory-Weiss tear?

A

Severe or recurrent vomiting, followed by minor haematemesis. Tear in epithelial lining of oesophagus - so get small bleed.

253
Q

How does Mallory-Weiss tear present?

A

Haematemesis after retching, Malena, light headedness, dizzy, abdo pain.

254
Q

What investigation would you do for suspected Mallory Weiss tear?

A

OGD if worsening or prolonged haematemesis .

255
Q

How is Mallory-weiss tear managed?

A

Endoscopy. Clip with or without adrenaline. Or thermal coagulation with adrenaline. Or thrombin or fibrin with adrenaline.

256
Q

Define oesophagitis

A

Inflammation of the intraluminal epithelial layer of the oesophagus. this can be due to - GORD, infections like thrush, meds like bisphosphonates, radiotherapy, ingesting toxic substances and Chrons.

257
Q

How does oesophagitis present?

A

Pain in the abdomen and chest (can be severe), nausea, heartburn, acidic taste in mouth, bloating/belching, symptoms worse after a meal, cough, sore throat, hoarseness of voice.

258
Q

How may Meckel’s diverticulum present?

A

Bright red blood in stools. Child with rectal bleeding ++.. Malena. Obstruction.

259
Q

How is Meckel’s managed?

A

Resection of diverticulum.

260
Q

What are the three classes of lower GI bleeding

A

Occult, Moderate and Massive

261
Q

What do we mean by occult lower GI bleed?

A

Presents with anaemia

262
Q

What do we mean by moderate lower GI bleed?

A

Rectal bleeding - fresh, dark or Malena BUT pt is haemodynamically stable.

263
Q

What is a massive lower GI bleed?

A

Large amounts of fresh blood loss. Shock - systolic BP below 90mmHg. Bleeding for over 3 days, or rebleed in a week. Need a transfusion of 2+ units of blood. Hb is less than 6g/dl, initial drop in haematocrit.

264
Q

What are two common causes of a lower GI bleed?

A

Diverticular disease, diverticulitis, UC, Chrons, Infective colitis, Haemmorhoids, Colorectal malignancy, Angiodysplasia, Ischaemic colitis.

265
Q

How can haemorrhoids be classified?

A

1st degree - remain in rectum. 2nd degree - prolapse through rectum on defecation and spontaneously reduce. 3rd degree - prolapse on defectation and are manually reduced. 4th degree - persistently prolapsed

266
Q

How are 1st and 2nd degree haemorrhoids managed?

A

Rubber band ligation

267
Q

How can 2nd and 3rd degree haemorrhoids be managed?

A

Haemorrodial artery ligation (id the main vessel of the haemorrhoid through Doppler and tie it off —> haemorrhoid infarcts and falls off).

268
Q

In which classifications of haemorrhoids would haemorrhoidectomy be considered?

A

3rd and 4th degree

269
Q

Name two differentials for haemorrhoids

A

IBD, malignancy, diverticular disease, anal fissure (in ano), perianal abscess, external piles

270
Q

How can R sided colorectal malignancy present?

A

Abdo pain, iron deficiency anaemia, palpable mass in the RIF, present later than L sided

271
Q

How can L sided colorectal malignancy present?

A

Rectal bleeding, change in bowel habits, tenesmus, palpable mass in the LIF or on PR exam.

272
Q

Describe/write out the modified Glasgow criteria to assess the severity of pancreatitis

A

score >3= severe pancreatitis neeeds high
dependency care

P pO2 <8kPa
Age>55
Neutrophils >15x109/L
Calcium <2mmol/L
Renal function (urea) >16 mmol/L
Enzymes LDH>600U/L OR AST >200u/l
Albumin <32g/L
Sugar (blood glucose) >10mmol/L

273
Q

How is acute pancreatitis managed?

A

Treat underlying cause if appropriate - urgent ERCP and cholecystectomy.
Supportive measures - IV fluid resus, NG tube if vomiting, catheterise, opined analgesia

274
Q

How do anal fissures present?

A

Pain on defecation - passing shards of glass. Bleed bright red on loo roll.

275
Q

How des anal cancer present?

A

Pain, bleeding, anal discharge, pruritus, palpable mass, increasing pt age, incontience or tenesmus

276
Q

What may you ask a pt about if you suspect anal cancer? (RF)

A

HPV infection in past - 16 and 19. Smoking. Immunosuppresision. Immunosuppressive drugs, hx of cancer, older age, many sexual partners, Chrons

277
Q

How does ischaemic colitis present?

A

Generalised abdo pain +++, not explained by findings; diffuse and constant in nature. Nausea and vomiting.

278
Q

What is found on examination of pt with ischaemic colitis?

A

Non-specific tenderness. If perforated - signs of peritoneum - tachycardia, low bp, guarding, laying v still.

279
Q

How is ischaemic colitis managed (definitive)?

A

Excision of necrotic bowel if unable to revascularise. Revascularisation of the bowel.

280
Q

What are differentials of ischaemic colitis?

A

Peptic ulcer disease, bowel perforation, Symptomatic AAA.

281
Q

What is involved in a colonostomy?

A

Colon is brought to the surface of the skin. Located in the LIF. contents are more solid as water is reabsorbed in LI. Flat to the skin.

282
Q

What is involved in a Ileostomy?

A

Ileum brought to the skin, located at RIF. Spout created as contents are liquid.

283
Q

Describe a loop stoma

A

Loop of bowel is taken through the abdo wall - proximal and distal ends are left open. . Temporary colostomy to allow distal portion of the bowel and anastomosis to heal after surgery. Usually reversed 6-8weeks later.

284
Q

Name four complications of a stoma

A

Local skin irritation,
Parastomal hernia
Psycho-social impact
High output = dehydration and malnutrition
Stenosis
Obstruction
Retraction
Prolapse

285
Q

Describe the Hartmann’s procedure

A

A sigmoid colectomy, proximal colon used to form a temporary end colostomy. The distal bowel is sewn over as a rectal stump. This is used in an emergency (i.e. bowel obstruction, ischaemia, toxic megacolon, or perforation

286
Q

What is a rare but serious complication of gallstone disease?

A

Gallstone ileus

287
Q

What is gallstone ileus?

A

Gallstone passing into the intestinal system via a biliary-enteric fistula causing distal obstruction

288
Q

What is Zenker’s Diverticulum?

A

Pharyngeal pouch- it is a diverticulum of the mucosa of a the pharynx

289
Q

How does Zenker’s diverticulum present?

A

dysphagia, regurgitation of food, sensation of food being stuck in the throat, halitosis. Key finding is gurgling sounds found in the neck

290
Q

What investigations are done for Zenker’s diverticulum?

A

Video fluoroscopy

291
Q

What are some complications of Zenker’s diverticulum?

A

Aspiration pneumonia, fistulas into trachea–> obstruction or into major blood vessels–> bleeding

292
Q

How does a large bowel obstruction look on X-ray?

A

Peripherally dilated loops of bowel

293
Q

What is a krukenberg tumour?

A

Development of mets to the ovaries

294
Q

what is the embryo sign on AXR?

A

Caecal volvulus

295
Q

What are some complications of ERCP?

A

Haemorrhage
Perforation
Acute Pancreatitis
Aspiration pneumonia
Ascending cholangitis

296
Q

What is Courvoisier’s law?

What can you infer about the diagnosis from this?

A

Courvoisier’s law = Painless jaundice with a palpable gallbladder means the diagnosis is unlikely to be stones

Conclusion: Will need to be obscuring the common bile duct (e.g. stricture / pancreatic mass) to cause jaundice. Can often cause fever and pain too

297
Q

Give an example of when you might use an MRCP and another example of when an ERCP would be more appropriate

A

MRCP - diagnostic tool e.g. suspect gall stone blocking CBD

ERCP - investigation + intervention. e.g. carcinoma of head of pancreas - place stent to open up duct

298
Q

Treatment of chronic anal fissure?

A

Topical glyceryl trinitrate

299
Q

Complications of gastrectomy? (stomach removal for stomach cancer)

A

B12 deficiency (need 3 month B12 injections)
dumping syndrome
re-operation
Death
Anastamotic leak

300
Q

Differentials for generalised acute abdominal pain?

A

Peritonitis
Ruptured AAA
Intestinal obstruction
Ischaemic colitis

301
Q

Differentials for RUQ pain?

A

Biliary colic
Acute cholangitis
Acute cholecystitis

302
Q

Differentials for Epigastric pain

A

Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured AAA

303
Q

Differentials for periumbilical pain?

A

Ruptured AAA
Intestinal obstruction
Ischaemic colitis
Early sign of appendicitis

304
Q

RIF pain - differentials?

A

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

305
Q

Differentials for LIF pain?

A

Diverticulitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion

306
Q

Suprapubic pain - differentials?

A

Lower UTI
Acute urinary retention
PID
Prostatitis

307
Q

Loin to groin pain - differentials?

A

Renal colic - kidney stones
Ruptured AAA
Pyelonephritis

308
Q

Testiular pain - differentials?

A

Testicular torsion
Epididymo-orchitis

309
Q

Sigmoid volvulus RF?

A

Older patients
Chronic constipation
Chagas disease
Neuro conditions- parkisons, Duchenne muscular dystrophy
psych conditions e.g. schizophrenia

310
Q

Clinical features of sigmoid volvulus?

A

Constipation
abdo bleeding
abdo pain
nausea and vomitting

311
Q

Axr of sigmoid volvulus?

A

Large bowel obstruction and coffee bean sign

312
Q

Management of sigmoid volvulus?

A

Rigid sigmoidoscopy with rectal tube insertion

313
Q

Management of caecal volvulus?

A

usually operative, right hemicolectomy is often needed

314
Q

abdominal pain, vomitting and bloating post bowel surgery?

A

post-operative ileus

315
Q

causes pancreatitis?

A

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion stings
Hypertriglyceridaemia
ERCP
Drugs

316
Q

Presentation of pancreatitis?

A

Severe epigastric pain radiating to back, relieved when leaning forward
Vomiting
Abdo tenderness
Systemically unwell

317
Q

Investigations in pancreatitis?

A

FBC- to see WCC
U&Es- urea
LFTs- albumin and transaminases
CRP
Calcium
VBG for PaO2 and blood glucose
Amylase- 3x upper limit of normal

318
Q

Complications of pancreatitis?

A

Pseudocyst
Pancreatic necrosis
Abscess formation
chronic pancreatitis

319
Q

What is the most likely operation in a patient with a loop ileostomy and an anus?

A

In a loop ileostomy 2 bowel ends are visible. The patient is likely to have had an anterior resection (for high rectal cancer >5cm from anus) with formation of a temporary loop ileostomy (to allow for healing of the distal anastomosis).

320
Q

What are the early complications of a stoma?

A

mechanical and functional

Early mechanical - bowel ischaemia/necrosis, bowel retraction, and para-stomal abscess formation.

Early functional -poor stoma function and high output stoma.

321
Q

What are the late complications of stoma?

A

mechanical, functional and psychosocial.

Late mechanical - para-stomal hernia formation, bowel stenosis and prolapse, adhesion formation leading to bowel obstruction, and para-stomal dermatitis.

Late functional -bowel dysmotility (leading to constipation/diarrhoea) and malabsorption (e.g. if the terminal ileum is removed this can cause B12 deficiency).

Psychosocia -difficulties with body image and sexual activity.

322
Q

What is the best initial management for patients with high output stomas (4 points)?

A

Restrict oral hypotonic fluid intake, advise dextrose-saline solution, prescribe oral loperamide and omeprazole

323
Q

What criteria are involved in the Glasgow-Blatchford score?

A

Anaemia, urea, BP, HR, melaena, syncope, hepatic disease, cardiac failure

324
Q

What are the causes of an upper gastrointestinal bleed?

A

Variceal haemorrhage
Inflammation - oesophagitis, gastritis
Peptic ulcer disease
Malignancy
Mallory-Weiss tear
Dieulafoy’s lesion
Aorto-enteric fistula

325
Q

causes of lower GI bleeding?

A

Vascular causes include angiodysplasia and ischaemic colitis.

Inflammatory causes include inflammatory bowel disease (Crohn’s disease and ulcerative colitis).

Infective causes include infectious colitis.

Neoplastic causes include colorectal cancer and anal cancer.

Anatomical anorectal causes include haemorrhoids and anal fissure.

Anatomical small bowel/colon causes include diverticular disease, Meckel’s diverticulum and colonic polyps.

Note that upper GI bleeding may cause a lower GI bleed (due to rapid transit).

Non-GI causes include endometriosis.

326
Q

What is the difference between the use of the Glasgow-Blatchford score and the Rockall score?

A

The Glasgow-Blatchford score is used pre-endoscopy and the Rockall score can be used in patients post-endoscopy.

327
Q

What does the Rockall score involve?

A

age, systolic blood pressure, pulse rate, comorbidities (before endoscopy) and diagnosis and signs of recent haemorrhage (after endoscopy)

328
Q

Pt has occult GI bleeding and bloods show iron deficiency anaemia. What are next steps in managing this?

A

Pt needs colonoscopy and endoscopy

329
Q

Pancreatic cancer lab investigations?

A

FBC- anaemia or thrombocytopenia and LFTs- raised bilirubin, raised ALP, gamma GT
CA19-9 to assess response to treatment

330
Q

Imaging used for pancreatic cancer?

A

Abdo USS- may show pancreatic mass or dilated biliary tress

CT- gold standard preliminary diagnosis

CT TAP- good for staging

Biopsy

331
Q

contraindications to laprascopic surgery

A

Absolute contraindications:
- haemodynamic instability/shock
- raised intracranial pressure
- acute intestinal obstruction (i.e. dilated bowel loops (e.g. > 4 cm)
- uncorrected coagulopathy

Relative contraindications:
- cardiac or respiratory failure
- recent laparotomy (within 4-6 weeks)
- abdominal aortic aneurysm (increased risk of vascular rupture)
- pregnancy (risk of injury to uterus)
- extensive adhesions from previous bowel surgery

332
Q

complications of laprascopic surgery

A

include:

  • general risks of anaesthetic
  • vasovagal reaction (e.g. bradycardia) in response to abdominal distension
  • extra-peritoneal gas insufflation: surgical emphysema
  • injury to gastro-intestinal tract
  • injury to blood vessels e.g. common iliacs, deep inferior epigastric artery

Y3 surgery old (6 decks)

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