General surgery Flashcards
appendicitis -definition and pathophysiology?
- inflammation of appendix
- lymphoid hyperplasia / faecolith obstructs appendiceal lumen, gut orgs invade wall
appendicitis Px?
- generalised abdo pain, migrates to McBurney’s in RIF
- fever
- anorexia
- N+V
- Rovsing’s
- Guarding
- rebound tenderness
- percussion tenderness
- Psoas sign (retrocaecal)
appendicitis DDx?
GI - obstruction, constipation, intussusception, diverticulitis, perf, Meckel’s diverticulum, mesenteric adenitis
Uro - torsion, renal calculi, UTI, pyelo
Gynae - ectopic, torsion, cyst rupture, acute salpingitis
Others - DKA, pneumonia
appendicitis Ix?
- clinical dx
- Bloods - raised CRP / WCC
- urine pregnancy test
- urine dip
- CT abdo
- USS - female pts (exclude gynae), children
- diagnostic laparoscopy
appendicitis Mx?
- appendicectomy - laparoscopic / open
- IV abx
- IV fluids
appendicitis Cx?
- appendix rupture, peritonitis
- appendix mass
- appendix abscess
bowel obstruction?
- blockage of flow of intestinal contents
- SBO>LBO
bowel obstruction pathophysiology?
- gas+faeces build up proximally -> vomiting, bowel dilatation
- fluid not absorbed in colon - 3rd space loss - hypovolaemia
- ischaemia, necrosis, perf
- closed-loop obstruction - eg 2 points of adhesions, hernias, volvulus, LBO + competent ileocaecal valve
- strangulated - blood supply compromised - pt more ill
causes of SBO?
- adhesions
- hernias
- strictures, intussusception, paralytic ileus, pseudo-obstruction, Hirschsprung’s
causes of LBO?
- malignancy
- volvulus
- strictures
- diverticular disease
bowel obstruction Px? SBO vs LBO?
- vomiting - green, bilious
- abdo distension
- diffuse abdo pain
- constipation, no flatulence
- tinkling bowel sounds
- maybe colon cancer sx - PR bleed, weight loss, change in bowel habit
SBO vs LBO
SBO - vomiting early, distension less, pain higher
LBO - pain more constant, later vomiting (more faecal)
bowel obstruction Ix?
- PR - no stool
- examine hernial orifices
- Bloods - FBC, U/E, G/S, LFTs, amylase, VBG (raised lactate - ischaemia, metabolic alkalosis - vomiting)
- AXR - distended loops of bowel
- Erect CXR - perf
- Abdo CT + contrast
bowel obstruction Mx?
- NBM
- analgesia, antiemetic
- IV fluids
- NG tube (Ryles)
- surgery - laparoscopy / laparotomy
paralytic ileus? causes Px, Ix, and Mx?
- functional reduced motility of gut, common post-op
Causes
- bowel injury, surgery, peritonitis, electrolyte imbalance, meds
Px
- N+V, green bilious vomit
- abdo distension, pain
- constipation, no flatulence
- absent bowel sounds
- dehydration\
Ix
- bloods inc Mg, phos, FBC, U/E
- CT scan
Mx
- NBM / sips
- IV fluids
- NG tube if vomiting
- mobilise
- TPN if needed
- correct electrolytes / meds
pseudo obstruction?
- functional obstruction of LI
- XR - colon dilatation
volvulus?
- torsion of colon around its mesenteric axis -> compromised blood supply + closed loop obstruction
- sigmoid 80%, caecum 20%
volvulus Px?
- as bowel obstruction
- constipation, bloating, abdo pain, N+V etc
volvulus Ix?
AXR
- sigmoid - LBO + coffee bean sign
- caecal - SBO
CT with contrast
volvulus Mx?
- NBM, IV fluids, NG tube
Sigmoid
- endoscopic decompression - rigid sigmoidoscopy
- surgical - Hartmann’s
Caecal
- surgical - right hemicolectomy / ileocaecal resection
hernia - definition and RFx?
protrusion of organ through weak point in cavity wall
RFs
- male, chronic cough, constipation, heavy lifting, ascites, past abdo surgery
hernia Px?
- soft lump
- Reducible
- Cough impulse
- Worsened on standing
- Aching, pulling, dragging sensation
hernia Ix?
- lump examination
- USS
- CT / MRI
- Erect CXR if ?strangulation/perf
- Bloods - VBG, FBC, U/E, G/S, LFTs, CRP etc
hernia Mx?
Conservative
- Truss
Surgical
- tension-free repair - mesh repair
- tension repair - suture muscles / tissues (rarely done)
hernia Cx?
- large neck, lower risk of cx
- incarceration - irreducible
- obstruction - bowel obstruction
- strangulation - irreducible + blood supply cut off - ischaemia, perf
- Richter’s hernia - part of bowel wall herniates
- Maydl’s hernia - 2 different loops of bowel in hernia
inguinal hernia?
Protrusion of abdo contents through inguinal canal
indirect inguinal hernia?
- 80%
- bowel herniates through inguinal canal
- lateral to inferior epigastric artery
direct inguinal hernia?
- 20%
- weakness in abdo wall at Hesselbach’s triangle
- medial to inferior epigastric artery
inguinal hernia Px?
- groin lump
- medial + superior to pubic tubercle
- disappears on pressure / lying down
inguinal hernia Mx?
- direct/indirect has no bearing on mx
- tx medically fit patients, even if asym
femoral hernia - Px and Mx?
- herniation of abdo contents through femoral canal
Px
- lump in groin +/- pain
- inferior + lateral to pubic tubercle
- typically non-reducible
Mx
- surgical repair
incisional hernia?
- protrusion of bowel through incision site in abdo wall
umbilical hernia?
- protrusion of abdo contents through umbilicus
epigastric hernia?
hernia in epigastric region
[Spigelian hernia]
Hernia between lateral border of rectus abdominis and linea semilunaris - site of spigelian fascia (aponeurosis between muscles of abdo wall)
Diastasis recti
Widening of linea alba, between rectus abdominis muscle, leading to herniation of bowel
Obturator hernia
Abdo / pelvic contents herniate through obturator foramen - due to defect in pelvic floor
hiatus hernia - definition and RFs?
- herniation of abdo viscera through oesophageal aperture of diaphragm
RFs - older, obesity, pregnancy, female, ascites
4 types of hiatus hernia?
Type 1
- sliding, 80%, stomach slides up, LOS less competent
Type 2
- rolling, 20%, fundus rises into thorax, GOJ remains in abdo
Type 3
- combination rolling / sliding
Type 4
- large opening, additional abdo organs enter
hiatus hernia Px?
- dyspepsia
- food reflux
- burping, bloating
- halitosis
hiatus hernia Ix?
- CXR, CT
- endoscopy
- barium swallow
hiatus hernia Mx?
- lose weight
- PPIs
- surgical repair - laparoscopic fundoplication (mainly rolling)
haemorrhoids - definition and RFs?
- enlarged anal vascular cushions
RFs
- constipation, straining, pregnancy, obesity, older age, weightlifting, chronic cough
haemorrhoid pathophysiology?
- anal cushions - specialised submucosal tissue with artery/vein connections
- anus described as clockface
Internal haemorrhoids
- above dentate line - not painful
External haemorrhoids
- below dentate line, may see externally, painful
Thrombosed
- strangulation at base of haemorrhoid -> thrombosis
Classification
1st degree – no prolapse
2nd degree – prolapse when straining, return on relaxing
3rd degree – prolapse when straining, no return on relaxing, can be pushed back
4th degree – prolapsed permanently
haemorrhoid Px?
- asym
- painless, bright red bleeding - on toilet / tissue
- sore / itchy anus
- lump near anus
- painful if thrombosed
- anaemia sx
- incontinence - 3/4th degree
- thrombosed - purplish, painful, swollen lump
haemorrhoid Ix?
- examine, PR
- proctoscopy
- ?bloods
- ?colonoscopy
haemorrhoid Mx?
Prevention
- increase fibre, fluids, laxatives if needed
Topical
- anusol
- anusol HC
- germoloids cream
- proctosedyl ointment
Non-surgical
- rubber band ligation
- injection sclerotherapy
- infra-red coagulation
- bipolar diathermy
Surgical
- haemorrhoidal artery ligation
- haemorrhoidectomy
- stapled haemorrhoidopexy
anal fistula - definition and causes?
- abnormal connection between the epithelial surfaces of the anal canal + skin
Causes
- perianal sepsis, abscess, Crohn’s, TB, diverticular disease, rectal carcinoma
anal fistula Px?
- pain
- discharge - bloody / mucus
- pruritis ani
- swelling, red, abscess
- bowel incontinence
anal fistula Ix?
- exam, PR
- proctoscopy
- scans - USS, CT/MRI
anal fistula Mx?
- surgical - fistulotomy
- drain abscess
anal fissure - definition + causes?
- Tear in squamous-lined skin in lower anal canal, distal to dentate line
- 90% posterior, (ant after childbirth)
Causes
- hard faeces, STIs, trauma, Crohn’s, anal cancer
anal tissue Px?
- extreme pain, esp on defecation - passing shards of glass
- bright red, rectal bleeding
anal fissure Ix?
- exam
- PR if possible (pain)
anal fissure Mx?
- increase fibre + fluids, laxatives
Medical
- lidocaine ointment
- GTN ointment
- topical diltiazem
- botox injection
Surgical
- sphincterotom
anorectal abscess?
- collection of pus in anal/rectal region
- perianal abscess most commonly
- E coli / S aureus
- eg anal sex, DM, immunocompromised, IBD, malignancy
anorectal abscess Px?
painful swellings, tender
- pus discharge
anorectal abscess Ix?
- PR, inspection
- colonoscopy, bloods
- US / CT / MRI
anorectal abscess Mx?
- surgical excision / drainage
- abx
Pruritis ani
- perianal itching
Mx - avoid scented products
- use wet wipes over tissue
- avoid scratching
- ensure no faecal incontinence
Pilonidal disease - pathophysiology, Px and Mx?
- sinuses / cysts form at upper part of natal cleft of buttocks
Patho
- from hair getting trapped in pores
- inflammation, abscess
Px
- pain, purulent discharge, fluctuant swelling
Mx
- asym - hygiene
- sym - incision, drainage, excise pits
define diverticulum, diverticulosis, diverticular disease and diverticulitis
Diverticulum – outpouching of gut wall
Diverticulosis – presence of diverticula
Diverticular disease – symptomatic
Diverticulitis – inflammation of diverticulum
Diverticular disease pathophysiology - including RFx
- most commonly sigmoid colon
- increased pressure in lumen, mucosa herniates through gaps in circular muscle, forms pouches
Diverticulitis
- faeces obstructs neck of diverticulum, stagnation, bacteria grow, inflammation - perf, abscess, fistula, haemorrhage
RFs
- older age, low fibre diet, obesity, NSAIDs, smoking
Diverticular disease Px and Diverticulitis
Diverticular disease
- left lower abdo pain
- constipation, diarrhoea
- rectal bleeding
Diverticulitis
- Left lower abdo pain
- Fever
- Diarrhoea
- N+V
- Rectal bleeding
- Abscess – abdo mass
Diverticular disease and diverticulitis Ix?
Diverticular disease
- colonoscopy
- CT colonography
- Barium enema
Diverticulitis
- Bloods
- CT abdo + contrast
- erect CXR
(colonoscopy increases perf risk)
Mx of diverticular disease
- high fibre diet, wt loss
- ispaghula husk (avoid stimulant laxatives)
- mebeverine
- surgical resection
Mx of diverticulitis
Community - uncomplicated
- oral co-amox >5d
- analgesia
- clear fluid only until sx improve
- 2d follow up
Severe - admission
- NBM
- IV fluids
- IV abx
- analgesia
- surgical resection
Diverticular disease Cx
- Perforation
- Peritonitis
- Abscess
- Haemorrhage
- Fistula
- Ileus / obstruction
bowel ischaemia?
- intestinal ischaemia from lack of blood
- foregut - coeliac artery
- midgut - superior mesenteric artery
- hindgut - inferior mesenteric artery
Acute mesenteric ischaemia
- rapid blockage of blood flow to gut
- typically SMA, SI
- thrombo/embolus, commonly AF
- ischaemia -> necrosis, perf
Acute mesenteric ischaemia Px
- acute, non-specific abdo pain - disproportionate
- shock, peritonitis, sepsis
- fever
- PR bleed
Acute mesenteric ischaemia Ix
- bloods - metabolic acidosis, raised lactate, WCC
- contrast CT
Acute mesenteric ischaemia Mx
- surgery - laparotomy - bowel resection, thrombus removal (open/endo)
- abx
Chronic mesenteric ischaemia - definition + RFx
- intestinal angina
- reduced blood supply to gut from atherosclerotic blood vessels
RFs - older age, FHx, smoking, DM, HTN, raised cholesterol, AF
Chronic mesenteric ischaemia Px
- central, colicky abdo pain after eating
- wt loss - food avoidance
- abdo bruit
- PR bleed
Chronic mesenteric ischaemia Ix
- CT angio
Chronic mesenteric ischaemia Mx
- stop smoking
- statins, antiplatelets
- revascularisation - stent, endarterectomy, bypass
Ischaemic colitis - definition + causes
- acute transient drop in blood supply to large bowel
- eg watershed areas - splenic flexure
- leads to inflammation, ulceration, haemorrhage
Causes
- thromboembolism, reduced CO, drugs, vasculitis
Ischaemic colitis Px
- shock
- abdo pain
- rectal bleed
Ischaemic colitis Ix
- AXR - thumbprinting
- abdo CT
- colonoscopy + biopsy / barium enema
Ischaemic colitis Mx
- supportive
- fluids, abx
- surgery - resection
colorectal cancer
- cancer of colon/rectum
- usually adenocarcinoma
- majority distal colon
- normal epithelium -> adenoma -> colorectal AC
- spread through bowel wall, lymphatics, vessels, mets to liver, lung, brain
Colorectal cancer RFs
- Familial adenomatous polyposis (FAP)
- Hereditary nonpolyposis colorectal cancer (HNPCC)
- FHx
- IBD
- older
- diet - red/processed meat, low fibre
- obesity, sedentary
- smoking, alcohol
- colorectal polyps
Colorectal cancer Px
- change in bowel habit - diarrhoea, constipation, freq
- wt loss
- PR bleed
- mucus
- tenesmus
- abdo pain
- IDA - fatigue, weakness, SOB
- abdo/rectal mass
- intestinal obstruction
colorectal cancer screening
- 60-74yo - sent home FIT test to do every 2 yrs, colonoscopy if positive
- Pts with FAP, HNPCC, IBD - colonoscopy at regular intervals
Colorectal cancer 2ww referral criteria
Do FIT test, then refer if positive with:
- Abdo mass
- Change in bowel habit
- Iron deficiency anaemia
- >40yo, abdo pain + unexplained wt loss
- <50, rectal bleeding + abdo pain / wt loss
- >50yo, unexplained rectal bleeding / abdo pain / wt loss
- >60yo, change in bowel habit / anaemia
Colorectal cancer Ix
- FIT test
- colonoscopy +/- biopsy
- CT colonography
- CT TAP
- serum CEA
- Bloods - FBC etc
Colorectal cancer staging
Dukes
A – mucosa + part of muscle of bowel wall
B – through muscle of wall
C – lymph node involvement
D – mets
TNM
Tumour, node, mets
Colorectal cancer Mx
- MDT
- surgical resection - anastomosis/stoma
- chemo
- radio
- palliative
- Follow up - rpt CEA, CT TAP
Colorectal cancer operations
Caecal, ascending, proximal transverse colon - right hemicolectomy
Distal transverse, descending colon - left heimcolecomy
Sigmoid colon - high anterior resection
Upper rectum - anterior resection (TME - total mesorectal excision)
Low rectum - anterior resection (low TME)
Anal verge - abdomino-perineal excision of rectum
Lower anterior resection syndrome
- after bowel resection, anastomosis between colon + rectum
Px
- urgency, freq of bowel movts
- faecal incontinence
- difficulty controlling flatulence
colonic polyps - RFs, Px, Ix, Mx
- abnormal tissue growth on colonic mucosa
- adenoma
- FAP / HNPCC
RFs
- FHx, >50yo, IBD, overweight, smoking
Px
- asym
- rectal polyps / mass
- PR bleed
- diarrhoea, abdo pain, mucous, ?obstruction
Ix
- colonoscopy + biopsy
- genetic testing
- CT colonography
Mx
- remove during colonoscop
oesophageal cancer? types and RFs?
- cancer of oesophagus
AC
- most common in UK
- in lower 1/3
- RFs - GORD, Barrett’s (squamous epithelium -> simple columnar), smoking, obesity
SCC
- most common type in developing world
- upper 2/3
- RFs - smoking, alcoho
Oesophageal cancer Px
- dysphagia, solids then liquids
- anorexia
- wt loss
- vomiting
- odynophagia
- hoarseness
- melaena
- cough
- lymphadenopathy
- retrosternal chest pain
Oesophageal cancer Ix
- OGD
- Endoscopic US?
- CT TAP
- Barium swallow
Oesophageal cancer Mx
- surgical resection (Ivor-Lewis oesophagectomy)
- chemo
Benign oesophageal lesions (Px, Ix and Mx)
- benign growths in oesophagus, 1% all tumours, leiomyoma
Px - asym
- dysphagia
- retrosternal pain
- food regurg
Ix - OGD
- barium swallow
- biopsy
Mx - endoscopic / surgical resectio
gastric cancer - definition and RFs
- stomach cancer - adenocarcinoma
- intestinal (well formed) / diffuse (worse)
RFs
- H pylori
- atrophic gastritis
- smoking
- diet, blood group A
gastric cancer Px ?
- abdo pain
- dyspepsia
- wt loss
- anorexia
- N+V
- dysphagia
- UGIB
- anaemia
- lymphadenopathy
- mets - bone, brain, liver, lung
gastric Ca Ix?
- OGD + biopsy
- ?endoscopic USS
- CT / MRI / PET
gastric Ca Mx?
- surgical - mucosal resection / partial/total gastrectomy
- chemo
gastrectomy complications?
- dumping syndrome
- wt loss, early satiety
- IDA
- osteoporosis, osteomalacia
- B12 deficiency
SI tumours - RFs, Px, Ix and Mx
- rare, tend to be AC / non-Hodgkin’s in ileum
RFs
- coeliac’s, Crohn’s
Px
- anaemia, mass, pain, diarrhoea, anorexia, wt loss
Ix
- endoscopy + biopsy
- ?US
- CT
Mx
- surgical resection
- chemo / radio
pancreatic cancer? associated with?
- cancer of pancreas
- mostly AC
- 99% exocrine component
- 60% at head, 25% body, 15% tail
- early mets, poor prognosis
Associations
- older, smoking, DM, chronic pancreatitis, HNPCC, MEN, BRCA2, KRAS
Pancreatic cancer Px
- painless obstructive jaundice - pale stools, dark urine, pruritis
- abdo mass - epigastric / hepatomegaly / gallbladder
- anorexia, wt loss
- epigastric pain
- steatorrhoea, DM
- back pain
- migratory thrombophlebitis
- lymphadenopathy
Pancreatic cancer referral
> 40yo + jaundice - 2ww
> 60yo + wt loss + additional sx (below) - direct access CT abdo
- Diarrhoea, back pain, abdo pain, N/V, constipation, new onset DM
Pancreatic cancer Ix
- BM
- LFTs, CA 19-9
- MRCP / ERCP
- trans-abdo USS
- CT TAP
- Biopsy - percutaneous / endoscopi
Pancreatic cancer Mx
Surgical
- total / distal pancreatectomy
- pylorus-preserving pancreaticoduodenectomy (PPPD)
- Whipple’s - pancreaticoduodenectomy
- chemo
- ERCP + stent
anal cancer - definition and RFx?
- malignancy in anal canal
- 80% SCC
- anal margin tumour - spread to inguinal lymph nodes
- proximal tumours - spread to pelvic
RFs
- HPV 16/18, anal intercourse, MSM, HIV, cervical cancer/CIN, smoking
Anal cancer Px
- perianal pain, bleeding
- palpable lesion
- faecal incontinence
Anal cancer Ix
- T stage assessment - examine, DRE, anoscopic exam + biopsy, palpate nodes
- CT / MRI / endo-anal USS / PET
- test for eg HIV
Anal cancer Mx
- chemo / radio
- surgical excision
stoma
- artificial opening of hollow organ
- eg bypass distal structures
- stoma bag to collect waste
- stoma nurse follow up
Colostomy
- LI brought onto skin
- solid stools
- no spout, flatter to skin
- LIF
ileostomy
- SI brought to skin
- drains liquids, irritating to skin
- spout -> tight-fitting bag
- RIF
Gastrostomy
- artificial connection between stomach + abdo wall
- provide feeds
- PEG - percutaneous endoscopic gastrostomy
urostomy
- opening from urinary system onto skin
- drain from kidney, bypass ureters, bladder, urethra
- eg post-cystectomy
- create ileal conduit
- spout
- RIF
End colostomy / ileostomy
- section of bowel removed, end part of proximal bowel brought to skin, end of distal bowel sutured up
- can be reversed
Loop colostomy / ileostomy
- temporary stoma to allow distal bowel to heal
- bowel partially opened - 2 openings at skin side-by-side
Stoma cx
- psychosocial
- skin irritation
- Parastomal hernia
- Loss of bowel length - high output, dehydration, malnutrition
- Constipation
- Stenosis
- Obstruction
- Retraction - sinking into skin
- Prolapse
- Bleeding
- Granulomas
Biliary colic
- Intermittent RUQ pain caused by gallstones passing through biliary tree
Gallstones causes
- cholesterol
- bile pigment - calcium - eg haemolysis
- biliary stasis
gallstone RFx?
- fair, fat, female, fertile (pregnant), forty
- DM, Crohn’s, rapid wt loss, cOCP
Biliary colic Px
- colicky RUQ pain, worse after eating fatty foods, radiation to R shoulder
- N+V
- no fever
Biliary colic Ix
- LFTs - raised ALP, if bilirubin raised, obstruction in CBD - AST/ALT normal
- USS
- MRCP
- CT - maybe for pancreas
Biliary colic Mx
- elective laparoscopic cholecystectomy
- ERCP
- analgesia
Acute cholecystitis
- inflammation of gallbladder
- secretion obstructed, increased secretion, distension, compromise vascular supply
- 90% gallstones, 10% other (TPN, ill, hypoperfusion…)
Acute cholecystitis Px
- RUQ pain, shoulder
- fever
- Murphy’s sign positive
Acute cholecystitis Ix
- LFTs - typically normal, may be deranged in Mirizzi syndrome (gallstone in distal cystic duct compressing on CBD)
- raised CRP/WCC
- USS
- MRCP
- consider HIDA scan
Acute cholecystitis Mx
- NBM
- IV fluids
- IV abx
- ERCP
- laparoscopic cholecystectomy - hot <72hrs / cold in 6-8wks
Acute cholecystitis cx
- sepsis
- gallbladder empyema
- gangrene / perf
Ascending cholangitis
- infection of biliary tree
- E coli, klebsiella, enterococcus
Causes - gallstones, ERCP
- infection ascends up CBD from duodenum
Ascending cholangitis Px
Charcot’s triad
- RUQ pain
- fever
- jaundice
Reynold’s pentad - above plus ..
- hypotension
- confusion
Ascending cholangitis Ix
- bloods - deranged LFTs (ALP higher), raised bilirubin/CRP/WCC
- USS
- MRCP
Ascending cholangitis Mx
NBM
- IV fluids
- IV abx
- ERCP
- percutaneous transhepatic cholangiogram (PTC)
Cholangiocarcinoma
- cancer of bile ducts
- majority AC
- can be intra/extrahepatic, most commonly perihilar region (R+L hepatic ducts join to form CBD)
RFs - PSC
- liver flukes
Cholangiocarcinoma Px
- obstructive jaundice, pale stools, dark urine, itchy
- biliary colic sx
- wt loss, anorexia
- palpable mass in RUQ with jaundice
- periumbilical lymphadenopathy
- left supraclavicular adenopathy
- hepatomegaly
Cholangiocarcinoma Ix
- CA19-9
- raised ALP, bilirubin
- CT / MRI
- biopsy
- MRCP
Cholangiocarcinoma Mx
- surgical resection
- ERCP
- chemo / radio
acute pancreatitis
- inflammation of pancreas
- autodigestion of pancreatic tissue by enzymes -> necrosis
Acute pancreatitis causes
I GET SMASHED
idiopathic
gallstones
ethanol
trauma
steroids
mumps, coxsackie B
autoimmune
scorpion sting
hyperlipidaemia, also Ca, hypothermia
ERCP
drugs - furosemide, thiazides, azathioprine
Acute pancreatitis Px
- severe epigastric pain, radiates to back
- N+V
- abdo tenderness
- fever, tachycardia
- Cullen’s, Grey-Turner’s sign
- ischaemic retinopathy
Acute pancreatitis Ix
- bloods - FBC, U/E, LFT, Ca, ABG, amylase, CRP, ?lipase
- USS
- CT abdo
- severity score - Glasgow, APACHE II, Ranson
Acute pancreatitis Mx
- A-E
- IV fluids
- analgesia
- NBM if vomiting
- Tx cause - ERCP, cholecystectomy…
- Abx if infection
- may need debridement
Acute pancreatitis Cx
- necrosis of pancreas
- infection of necrosis
- pancreatic abscess
- peripancreatic fluid collections
- pseudocysts
- chronic pancreatitis
- haemorrhage
chronic pancreatitis?
- chronic inflammation of pancreas
- fibrosis, reduced function
- alcohol most commonly, also CF, HHC, as acute
Chronic pancreatitis Px
- sx as acute, less intense, longer lasting
- pain worse 15-30mins after meal
- steatorrhoea
- DM
Chronic pancreatitis Ix
- AXR - pancreatic calcification
- CT
- faecal elastase - assess exocrine function
- secretin stimulation test
- MRI / endoscopic USS
Chronic pancreatitis Mx
- stop smoking, alcohol
- analgesia
- creon
- S/C insulin
- ERCP + stent - strictures
- surgery
Chronic pancreatitis Cx
- chronic pain
- loss of pancreatic enzymes
- lack of insulin
- strictures
- pseudocysts, abscesses
anastomotic leak? Px, Ix, Mx
- leak of luminal contents from surgical join
Px
- pt deteriorating / not progressing after surgery
- 3-5d post-op
- abdo pain
- sepsis
- prolonged ileus
- peritonism
Ix
- Bloods - FBC, CRP, coag, ABG
- CT with contrast
Mx
- NBM
- broad spec IV abx
- IV fluids
- catheter
- surgical intervention
Boerhaave’s syndrome
- spontaneous rupture of oesophagus after repeated vomiting
- rupture usually distal, on left side
Px - sudden onset severe chest pain
- subcut emphysema
Ix - CT contrast swallow
Mx - thoracotomy + lavage
Cx - sepsis, mediastinitis
bariatric surgery options?
Primarily restrictive
- laparoscopic gastric banding
- sleeve gastrectomy
- intrinsic gastric balloon
Primarily malabsorptive
- Biliopancreatic diversion with duodenal switch
Mixed
- Roux-en-Y gastric bypass surgery
Lowe GI bleed - causes, Px, Ix, Mx
- PR bleed from lower GI tract - eg colonic
Causes
- colitis, diverticular disease, cancer, haemorrhoids, angiodysplasia
Px
- bright/dark red bleed on PR
Ix
- examination, PR proctoscopy
- CT angio
Mx
- A-E
- blood resus
- endoscopy
- surgical - resection
- Oakland score - for safe discharge post lower GI bleed
