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