General Surgery Flashcards
Causes of appendicitis
- Faecolith = stone made of faeces
- Lymphoid hyperplasia
- Filarial worms
Presentation of appendicitis
- Abdominal pain in umbilical region that migrates to right iliac fossa (McBurney’s point) after a few hours
- Loss of appetite
- Nausea and vomiting
- Constipation (occasionally diarrhoea)
- Tenderness in RIF (McBurney’s = 2/3rds of way from umbilicus to ASIS) Guarding to RIF
- Rebound tenderness and percussion tenderness = peritonitis
- Tachycardia, fever
- Rovsing’s sign = press on LIF, hurts on RIF
- Psoas sign = pain on extending hip if retrocaecal appendix
- Cope sign = pain on flexion and internal rotation of R hip if appendix in close relation to obturator internus
Gold standard investigation for appendicitis
CT = reduces risk of removing healthy appendix
Investigations to rule out other pathology similar to appendicitis
Pregnancy test
Urinalysis
Pelvic/abdo US
Management of appendicitis
- Appendicectomy laparoscopically
- IV antibiotic pre-op to reduce wound infections = IV metronidazole/ cefuroxime
- Analgesia
- Resuscitation with IV fluids
Complications of appendicitis
- Perforation
- Appendix mass = When inflamed appendix becomes covered in omentum
- Appendix abscess = if mass fails to resolve but instead enlarges and patient gets more unwell
- Early surgical complications = surgical site infection, wound haemotoma
- Late surgical complications = SBO due to adhesion, incisional hernia
- Anaesthetic risks
- Removal of normal appendix
- VTE
- Peritonitis from ruptured appendix
What is acute mesenteric ischaemia?
Sudden decrease in blood supply to the bowel usually caused by an embolism in the superior mesenteric artery
Risk factors for acute mesenteric ischaemia
- Atherosclerosis
- Smoking
- COPD
- Arrhythmia (AF)
- Clotting disorders
- Medications = OCP, migraine
- Cocaine
Presentation of acute mesenteric ischaemia
- Acute severe sudden onset abdominal pain
- Diarrhoea
- Weight loss
- Melaena
- Rapid hypovolaemia = shock
- Pale skin, weak rapid pulse, reduce urine output, confusion
- Out of keeping with physical exam findings
Investigations for acute mesenteric ischaemia
- Bloods
o High lactate
o Raised Hb and WCC
o Persistent metabolic acidosis - CT/MRI angiography = Provides non-invasive alternative to simple arteriography
- Colonoscopy
Management of acute mesenteric ischaemia
- Immediate laparotomy usually required esp if signs of advanced ischaemia
- Fluid resuscitation
- Antibiotics = IV gentamicin and IV metronidazole
- IV heparin to reduce clotting
Complications of acute mesenteric ischaemia
- Septic peritonitis = Due to perforation
- Systemic inflammatory response syndrome progressing into multi-organ dysfunction syndrome
- Gangrene
- Scarring and narrowing of intestines
Risk factors for ischaemic colitis
- Atherosclerosis
- Drugs = contraceptive pill, antihypertensive, vasopressin, nicorandil drug
- Surgery = Cardiac bypass, aortic dissection and repair, aortoiliac reconstruction
- Vasculitis = SLE, sickle cell disease, polyarthritis nodosa
- Coagulation disorders thrombophilia
Presentation of ischaemic colitis
- Sudden onset lower left side abdominal pain
- Passage of bright red blood with/out diarrhoea
- Shock = Pale skin, weak rapid pulse, reduce urine output, confusion
- Evidence of underlying cardiovascular disease
Investigations of ischaemic colitis
- Urgent CT scan to exclude perforation
- AXR = thumbprinting
- Flexible sigmoidoscopy = Biopsy shows epithelial cell apoptosis
- Colonoscopy and biopsy
o Only done after patient has fully recovered to exclude stricture formation at site of disease
o Confirm mucosal healing - Barium enema = Thumb printing of submucosal swelling at splenic flexure
Management of ischaemic colitis
- Fluid replacement
- Antibiotics
Complications of ischaemic colitis
- Gangrenous ischaemic colitis
o Presenting with peritonitis and hypovolaemic shock
o Requires prompt resuscitation following by surgical resection of affected bowel and stoma formation - Inflammation
- Ulceration
- Haemorrhage
Epidemiology of oesophageal tumour
- SCC (upper 2/3) = common in China, Africa, Iran
- Adenocarcinoma (lower 1/3) = western countries
Risk factors for oesophageal tumour
- Diets low in fibre, carotenoids, folate and vit C
- Alcohol
- Smoking
- Obesity = increased reflux
- GORD/ Barrett’s oesophagus
- Achalasia
Presentation of oesophageal tumour
- Progressive dysphagia
o Initially difficulty swallowing solids but then liquids follows within weeks
o If dysphagia to solids and liquids from start = benign - Weight loss and Anorexia
- Hoarseness and cough = upper 1/3
- Pain
- Difficulty in swallowing saliva, coughing and aspiration into lungs = oesophageal obstruction
- Vomiting
- Sx of GI blood loss
- Lymphadenopathy
Investigations of oesophageal tumour
- Upper GI endoscopy (Oesophagoscopy) with biopsy
- Barium swallow = See strictures
- Endoscopic US
- CT scan/MRI/PET for tumour staging
Management of oesophageal tumour
- Surgical resection
o if tumour has not infiltrated outside oesophageal wall
o Combined with chemotherapy before surgery +/- radiotherapy - Treatment of dysphagia
o Endoscopic insertion of expanding metal stent across tumour to ensure oesophageal patency
o Laser and alcohol injections = tumour necrosis and increase lumen size
Epidemiology of gastric tumours
- Incidence increases with age = peak at 50-70 yrs
- Highest incidence in Eastern Asia, Eastern Europe and South America
Risk factors for gastric tumours
- First degree relative with gastric cancer = CDH1 gene
- Dietary factors High salt and nitrates, Pickled food
- Alcohol
- Smoking
- Helicobacter pylori infection
- Loss of p53 and APC genes
- Pernicious anaemia = accompany atrophic gastritis
Protective factors for gastric tumours
Non-starchy veg, fruit, garlic and low salt
Types of gastric tumours
- Intestinal/ type 1
o Well-formed and differentiated glandular structures
o More likely distal stomach and occur in patients with atophic gastritis - Diffuse/ type 2
o Poorly cohesive undifferentiated cells
o Tend to infiltrate the gastric wall
o Can involve any part of stomach, especially cardia
Presentation of gastric tumours
- Epigastric pain = constant and severe
- Nausea and vomiting
- Weight loss and anorexia
- Dysphagia
- Dyspepsia (indigestion)
- Liver metastasis jaundice
- Anaemia = occult blood loss
- Metastases occur in bone, brain and lung
- Palpable lymph node in supraclavicular fossa (Virchow’s node) usually on left side
Investigations for gastric tumours
- Gastroscopy and biopsy
- Endoscopic ultrasound to evaluate the depth of invasion
- CT/MRI for staging
- PET scan to identify metastases
Management of gastric tumours
- Nutritional support
- Surgery and combination chemotherapy = Epirubicin and Cisplatin + 5-fluorouracil
- Post-op radiotherapy
Colorectal carcinoma risk factors
- Diet Low fibre, high red meat and sat animal fat, high sugar
- Colorectal polyps
- Alcohol and smoking
- Obesity
- Adenomas
- Ulcerative colitis
- Familial adenomatous polyposis
- Lynch syndrome (HNPCC)
Protective factors for colorectal carcinoma
Vegetables, garlic, milk, exercise, low-dose aspirin
Metastases of colorectal carcinoma
Liver and lung
Presentation of colorectal carcinoma
- Closer cancer to outside more visible blood and mucus
- Right sided = asymptomatic, weight loss, abdo pain, Iron deficiency anaemia due to bleeding, Mass
- Left sided and sigmoid
o Change in bowel habit with blood and mucus in stools
o Alternation constipation and diarrhoea
o Colicky abdominal pain - Rectal carcinoma Rectal bleeding and mucus
o When cancer grows = thinner stools and cramping rectal pain
Emergency presentation of colorectal carcinoma
Absolute constipation, Colicky abdominal pain, Abdominal distension, Vomiting
Investigations for colorectal carcinoma
- Colonoscopy with biopsy = removal of polyps
- MRI/CT chest, abdo, pelvis = determine spread
Screening test for colorectal carcinoma
Faecal immunochemical testing = screening
Tumour marker for colorectal carcinoma
CEA
Classification of colorectal carcinoma
Dukes
- A = limited to inner lining of bowel
- B = extension through muscle layer of bowel
- C = involvement of regional lymph nodes
- D = distant metastases
Management of colorectal carcinoma
- Surgery Only indicated if no metastasis
- Endoscopic stenting For palliation in malignant obstruction (Decreases need for colostomy)
- Radiotherapy Palliation for colonic cancer or used pre-op in rectal cancer
- Chemotherapy If Dukes C then give chemo post-op = reduce risk of death
Causes of acute upper GI bleeding
- Oesophageal
o Oesophageal varices
o Oesophagitis
o Cancer
o Mallory Weiss tear - Gastric
o Gastric ulcer
o Gastric cancer
o Dieulafoy lesion
o Diffuse erosive gastritis - Duodenal
o Duodenal ulcer
o Aorto-enteric fistula
Presentation of acute upper GI bleeding
- Haematemesis bright red/coffee ground
- Melena black, tarry stool
- Raised urea
- Oesophageal varices stigmata of chronic liver disease
- Peptic ulcer disease abdominal pain
Risk assessment used before endoscopy
Blatchford score (used at first assessment)
o Urea
o Hb
o Systolic blood pressure
o Pulse
o Presentation with melaena
o Presentation with syncope
o Hepatic disease
o Cardiac failure
Risk assessment used after endoscopy
Rockall score (used after endoscopy)
o Risk of rebleeding and mortality
o Age, features of shock, co-morbidities, aetiology of bleeding, endoscpic stigmata of recent haemorrhage
Management of upper GI bleeding
- Resuscitation
o Platelet transfusion actively bleeding and platelet count of <50
o FFP fibrinogen <1g/L or prothrombin time >1.5x normal
o Prothrombin complex concentrate warfarin and actively bleeding - Urgent Endoscopy within 24 hrs
- Non-variceal bleeding PPI after endoscopy
- Variceal bleeding terlipression and prophylactic Abx before endoscopy
o Band ligation for oesophageal varices
Causes of small bowel obstructions
- Adhesions = Usually secondary to previous abdominal surgery
- Hernia
- Malignancy
- Crohn’s disease
- Abdominal surgery
Presentation of small bowel obstruction
- Colicky abdominal pain
- Vomiting (bilious containing bright green bile)
- Nausea and anorexia
- Constipation
- No passage of wind = occurs late in SBO
- Tenderness = Strangulation
- Abdominal distension
- Tinkling bowel sounds
Abdo XR findings in small bowel obstruction
o Central gas shadows completely cross lumen and no gas in large bowel
o Distended loops of bowel proximal to obstruction
o Fluid levels seen
Management of small bowel obstruction
- Nil by mouth + IV fluids
- NG tube on free drainage
- Bowel decompression
- Analgesia and antiemetic
- Surgery = Remove obstruction done by laparotomy
Complications of small bowel obstruction
- Ischaemia
- Necrosis
- Perforation
Causes of large bowel obstruction
- Colorectal malignancy (US/Europe)
- Volvulus (Africa)
- Diverticular disease
Presentation of large bowel obstruction
- Abdominal pain = more constant than SBO
- Late vomiting = more faecal like
- Constipation
- Fullness/bloating/nausea
- Abdominal distension
- Bowel sounds normal then increased then quiet later
- Palpable mass = hernia, distended bowel loop or caecum
Abdo XR findings in large bowel obstruction
o Coffee bean sign
o Peripheral gas shadows proximal to blockage
o Caecum and ascending colon distended
Other investigations for large bowel obstruction
- Digital rectal exam = empty rectum, hard stools, blood
- FBC = Low Hb sign of chronic occult blood loss
Management of large bowel obstruction
- Sigmoid volvulus rigid sigmoidoscopy with rectal tube insertion
- Caecal volvus right hemicolectomy
- Bowel decompression
- Surgery = Remove obstruction done by laparotomy
Risk factors for a Mallory-Weiss tear
- Alcoholism
- Forceful vomiting
- Eating disorders
- Male
- NSAID abuse
Presentation of Mallory-Weiss tear
- Postural hypotension
- Vomiting
- Haematemesis after vomiting
- Retching
- Dizziness
Management of Mallory-Weiss tear
- Most bleeds are minor and heal in 24 hrs
- Endoscopy
- Haemorrhage may be large but tend to stop spontaneously
- If surgery required then involves oversewing of tear but this is rarely needed
Risk factors for gallstones
- Female, Fat, Forty, Fair, Fertile (more kids increases risk of gallstones)
- Smoking
- Rapid weight loss (weight reduction surgery)
- Diet high in animal fat and low in fibre
- Diabetes mellitus
- COCP
- Liver cirrhosis
- Crohn’s disease
- Fibrates
Complications of gallstones
- Acute cholecystitis
- Empyema = gallbladder fills with pus
- Carcinoma
- Mirizzi’s syndrome = stone in gallbladder presses on bile duct jaundice
- Obstructive jaundice
- Cholangitis = inflammation of bile duct
- Pancreatitis
- Gallstone ileus
What is acute cholecystitis?
Gallbladder inflammation secondary to retained bile within gallbladder
Causes of acute cholecystitis
- Gallstone blocking cystic duct
- Injury during surgery
- Septicaemia
Presentation of acute cholecystitis
- Initially continuous epigastric pain
o Progression with severe localised right upper quadrant abdominal pain
o Pain may radiate to right shoulder
o Pain associated with RUQ tenderness and muscle guarding or rigidity - Vomiting
- Fever, sweating and signs of systemic upset
- Loss of appetite
- Local peritonitis
- Gallbladder mass
- Murphy’s sign positive inspiratory arrest upon palpation of RUQ
Investigations for acute cholecystitis
- Blood tests = Raised WCC, CRP, serum bilirubin, ALP, aminotransferase levels
o LFTs normal - Abdo US Thick walled, shrunken gallbladder, stones, pericholecystic fluid, CBD
- AXR = porcelain gallbladder
Management of acute cholecystitis
- IV fluids
- IV antibiotics = co-amoxiclav
- Laparoscopic cholecystectomy within 1 week of diagnosis
What is ascending cholangitis
Infection and obstruction of biliary tree caused by a gallstone
Risk factors for ascending cholangitis
- Gallstones
- Benign biliary strictures following biliary surgery
- Cancer of head of pancreas bile duct obstruction
- Parasites can cause blockage = Far East and Mediterranean
Presentation of ascending cholangitis
- Charchot’s triad
o RUQ pain
o Fever with rigors
o Jaundice (cholestatic) = Dark urine, pale stools, itchy skin, yellow
1st line investigation of ascending cholangitis
Transabdominal US = dilation of common bile duct
Gold standard investigation for ascending cholangitis
MRCP
Management of ascending cholangitis
- IV antibiotics = cefotaxime and metronidazole
- Urgent (24-48 hrs) biliary drainage using endoscopic retrograde cholangio-pancreatography (ERCP) with sphincterotomy
o Removal of stones using basket or balloon
o Crushing of stones
o Stent placement - Percutaneous Transhepatic Cholangiography (PTC)
What is primary biliary cholangitis?
Autoimmune chronic liver disorder where interlobular bile ducts become damaged by chronic inflammatory process causing progressive cholestasis
Associations of PBC
- Sjogren’s syndrome
- Rheumatoid arthritis
- Systemic sclerosis
- Thyroid disease
Presentation of primary biliary cholangitis
- Early: asymptomatic or fatigue, pruritus
- Cholestatic jaundice
- Hyperpigmentation (especially over pressure points)
- RUQ pain (10%)
- Xanthelasmas, xanthomata
- Clubbing
- Hepatosplenomegaly
- Late: liver failure
Investigations for PBC
- Anti-mitochondrial antibodies (M2 subtype)
- Smooth Muscle antibodies
- Raised serum IgM
- US or MRCP required before diagnosis to exclude extrahepatic biliary obstruction
Management of PBC
- Ursodeoxycholic acid
- Pruritus cholestyramine
- Fat-soluble vitamin supplementation
- Liver transplantation if bilirubin >100
Complications of PBC
- Cirrhosis portal hypertension ascites, variceal haemorrhage
- Osteomalacia and osteoporosis
- Hepatocellular carcinoma
What is primary sclerosing cholangitis?
Biliary disease of unknown cause characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts
Associations of PSC
- Ulcerative colitis
- Crohn’s
- HIV
Presentation of PSC
- Cholestasis jaundice, pruritus
- RUQ pain
- Fatigue
Investigations for PSC
- Raised bilirubin and ALP
- ERCP or MRCP multiple biliary strictures giving ‘beaded’ appearance
- P-ANCA positive
- Liver biopsy fibrous, obliterative cholangitis, ‘onion skin’
Risk factors for cholangiocarcinoma
- Primary sclerosing cholangitis
- Associated with infestation with parasitic worms
- Typhoid
- Liver fluke
- Biliary cysts
- Inflammatory bowel disease
Presentation of cholangiocarcinoma
- Painless jaundice
- Weight loss and anorexia
- Malaise
- Nausea and vomiting
- Fever
- Abdominal pain +/- ascites
Investigations of cholangiocarcinoma
- CA19-9, CEA, CA 125 raised
- Raised bilirubin and ALP
- CT/MRI
- MRCP to take biopsy
Management of cholangiocarcinoma
- Early diagnosis can be cured with surgical resection
- ERCP can place stent in bile duct to allow drainage of bile and improve Sx
- Resistant to chemo and radiotherapy
Risk factors for Pancreatic adenocarcinoma
- Smoking
- Excessive intake of alcohol or coffee
- Excessive use of aspirin
- Diabetes
- Chronic pancreatitis
- Genetic mutation predisposing to pancreatic cancer
- Family history
Presentation of pancreatic adenocarcinoma
- Non-specific upper abdominal/back pain
- Painless obstructive jaundice = pale stools and dark urine
- Unintentional weight loss and anorexia
- Steatorrhoea
- Palpable mass in epigastric region
- Non-tender palpable gallbladder
- Acute pancreatitis
- Diabetes
Tumour marker for pancreatic cancer
CA19-9
Investigation for pancreatic cancer
- CT scan for staging
- Endoscopic ultrasound with biopsy
Management for pancreatic cancer
- Whipple’s procedure
o Tumour of head of pancreas with no spread
o Remove head of pancreas, gallbladder, duodenum and pylorus - Distal pancreatectomy of tumour body/tail
- Adjuvant chemotherapy
- Palliative care
Causes of ascites
- Local inflammation
o Peritonitis or intra-abdominal surgery
o Abdominal cancers
o Infection - Low protein
o hypoalbuminaemia
o nephrotic syndrome
o malnutrition
o Peritoneal carcinomatosis
o Tuberculous peritonitis
o Pancreatitis
o Bowel obstruction
o Biliary ascites
o Postoperative lymphatic leak
o Serositis in connective tissue diseases - Low flow
o Cirrhosis/ alcoholic liver disease
o Acute liver failure
o Liver mets
o Budd-chiari syndrome,
o Right heart failure,
o constrictive pericarditis
o Portal vein thrombosis
o Myoxoedema
Presentation of ascites
- Mild abdominal pain and discomfort
o If severe pain = bacterial peritonitis - Distended abdomen
- Respiratory distress and difficulty eating
- Fullness in flanks and shifting dullness
- Scratch marks on abdomen causing by itching due to jaundice
- Peripheral oedema
Investigations for ascites
- Aspiration of 10-20ml of fluid using ascitic tap
o Raised WCC = bacterial peritonitis
o Gram stain and culture
o Cytology to find malignancy
o Amylase to exclude pancreatic ascites - Protein measurement of ascitic fluid from ascitic tap
o Transudate = low protein (<30g/L) – less bad
o Exudate = high protein (>30g/L) – very bad
o Serum-ascites albumin gradient >11g/L indicates portal hypertension
Management of ascites
- Treat underlying cause
- Reduce dietary sodium to reduce fluid retention
- Fluid restriction if Na <125
- Aldosterone antagonist (oral spironolactone)
- Drain fluid Relieve symptomatic tense ascites
- Prophylactic oral ciprofloxacin for pts with cirrhosis and ascites with ascitic protein 15g/l or less
- Transjugular Intrahepatic Portosystemic Shunt
Causes of peritonitis
- Bacterial (more common) E.coli, staph. aureus
- Chemical bile, old clotted blood, ectopic pregnancy
Presentation of peritonitis
- Sudden onset with acute severe abdominal pain followed by general collapse and shock
o When peritonitis secondary to inflammatory disease, onset less rapid with initial features being those of underlying disease
o Pain relieved by resting hands on abdomen = stopping movement of peritoneum and pain
o Poorly localised then moving to one point on abdomen and becoming localised - Rigidity, Tender hard abdomen ascites
- Fever
- Tachycardia
- Shock = hypotension, hypoxia
- Silent abdomen
- Guarding Speedbumps are painful
- Nausea and vomiting
Investigations for peritonitis
- Blood test
o Raised WCC and CRP
o Blood cultures - Paracentesis neutrophil count >250
- Erect CXR Free air under diaphragm indicates performed colon
- Abdominal XR Exclude bowel obstruction and foreign body
- CT abdomen/pelvis Exclude ischaemia as cause of pain
Management of peritonitis
- IV broad spectrum antibiotics = cephalosporin/ cefotaxime
- Surgery
o Peritoneal lavage of abdominal cavity
o Specific treatment of underlying condition
Complications of peritonitis
Sepsis
Local abscess formation
Kidney failure
Paralytic ileus
Risk factors for inguinal hernia
- Male
- Chronic cough (cystic fibrosis)
- Constipation
- Urinary obstruction
- Heavy lifting
- Ascites
- Past abdominal surgery
- Smoking
- Low BMI
Presentation of inguinal hernia
- Patient can usually reduce hernia themselves
- Commonly painless swelling in groin that develops over time (May come and go)
o But if painful then indicates strangulation - Bulging associated with coughing or straining = bowel movement, heavy lifting
- Scrotal swelling in males
- Constipation/ change in bowel habit
- Burning sensation in groin
- Strangulation pain, fever, increase in size of hernia, erythema, peritonic features, bowel obstruction, bowel ischaemia
Management of inguinal hernia
- Use of truss to contain and prevent further progression of hernia
- Surgery
o Only if very symptomatic or strangulated
o Prosthetic mesh, open repair, laparoscopy
o Pre-op = diet and stop smoking
