General surgery Flashcards
When are the 3 times the WHO surgical safety checklist is completed?
Before the induction of anaesthesia
Before the first skin incision
Before the patient leaves theatre
what are some features of the WHO surgical safety checklist?
Patient identity
Allergies
Operation
Risk of bleeding
Introductions of all team members
Anticipated critical events
Counting the number of sponges and needles to ensure nothing is left inside the patient
what are aspects of a history that are important in a pre-operative assessment?
Past medical problems
Previous surgery
Previous adverse responses to anaesthesia
Medications
Allergies
Smoking
Alcohol use
Pregnancy
what are the ASA grades?
ASA I – normal healthy patient
ASA II – mild systemic disease
ASA III – severe systemic disease
ASA IV – severe systemic disease that constantly threatens life
ASA V – “moribund” and expected to die without the operation
ASA VI – declared brain-dead and undergoing an organ donation operation
E – this is used for emergency operations
what is a group and save?
sending off a sample of the patient’s blood to establish their blood group. The sample is saved in case they require blood to be matched to them for a blood transfusion.
what is a crossmatch?
process of actually taking a unit or more of blood off the shelf and assigning it to the patient in case they need it quickly. This is done where there is a higher probability that they will require blood products
How long should patients bet fasted of food and drink for before surgery?
6 hours of no food or feeds before operation
2 hours no clear fluids
what should you do to patients on Warfarin before surgery?
Stop it
monitor INR
can use treatment dose LMWH or unfractionated heparin infusion to bridge gap between stopping warfarin and surgery in high risk patients
What should you do to patients on DOACs before surgery?
Stop it 24-72hrs before
when should COCP an oestrogen containing HRT be stopped before surgery and why?
4 weeks
reduce risk of VTE
what is the management of patients on long-term corticosteroids before/after surgery?
Additional IV hydrocortisone at induction and for the immediate postoperative period (e.g., first 24 hours)
Doubling of their normal dose once they are eating and drinking for 24 – 72 hours depending on the operation
what should be adjusted in patients on sulfonylureas before surgery?
can cause hypoglycaemia and are omitted until the patient is eating and drinking
what is the management of patients on insulin undergoing surgery?
Continue a lower dose (BNF recommends 80%) of their long-acting insulin
Stop short-acting insulin whilst fasting or not eating, until eating and drinking again
Have a variable rate insulin infusion alongside a glucose, sodium chloride and potassium infusion (“sliding-scale”) to carefully control their insulin, glucose and potassium balance
what are the 4 different consent forms?
Consent Form 1: Patient consenting to a procedure
Consent Form 2: Parental consent on behalf of a child
Consent Form 3: Where the patient won’t have their consciousness impaired (e.g., a breast biopsy)
Consent Form 4: Where the patient lacks capacity
Adequate analgesia in the post-operative period is important to encourage the patient to:
Mobilise
Ventilate their lungs fully (reducing the risk of chest infections and atelectasis)
Have an adequate oral intake
what are risk factors for post-operative nausea and vomiting?
Female
History of motion sickness or previous PONV
Non-smoker
Use of postoperative opiates
Younger age
Use of volatile anaesthetics
name 3 prophylactic antiemetics that may be prescribed for PONV and their contraindications
Ondansetron (5HT3 receptor antagonist) – avoided in patients at risk of prolonged QT interval
Dexamethasone (corticosteroid) – used with caution in diabetic or immunocompromised patients
Cyclizine (histamine (H1) receptor antagonist) – caution with heart failure and elderly patient
Name 5 post-operative complications
Anaemia
Atelectasis
Infections
Wound dehiscence
Ileus
Haemorrhage
Deep vein thrombosis and pulmonary embolism
Shock due to hypovolaemia (blood loss), sepsis or heart failure
Arrhythmias
Acute coronary syndrome and cerebrovascular accident
Acute kidney injury
Urinary retention
Delirium
what is the management of anaemia post-op?
Hb under 100 g/l – start oral iron (e.g., ferrous sulphate 200mg three times daily for three months)
Hb under 70-80 g/l – blood transfusion in addition to oral iron
what are possible third spaces?
Peritoneal cavity (forming ascites)
Pleural cavity (forming pleural effusions)
Pericardial cavity (forming a pericardial effusion)
Joints (forming joint effusions)
what are some sources of fluid output?
Urine output
Bowel or stoma output (particularly diarrhoea)
Vomit or stomach aspiration
Drain output
Bleeding
Sweating
what are some signs of hypovolaemia?
Hypotension (systolic < 100 mmHg)
Tachycardia (heart rate > 90)
Capillary refill time > 2 seconds
Cold peripheries
Raised respiratory rate
Dry mucous membranes
Reduced skin turgor
Reduced urine output
Sunken eyes
Reduced body weight from baseline
Feeling thirsty
what are some signs of fluid overload?
Peripheral oedema
Pulmonary oedema
Raised JVP
Increased body weight from baseline
what are the 3 main indications for IV fluids?
Resuscitation (e.g., sepsis or hypotension)
Replacement (e.g., vomiting and diarrhoea)
Maintenance (e.g., nil by mouth due to bowel obstruction)
Name 3 crystalloid fluids?
0.9% sodium chloride
5% dextrose
0.18% sodium chloride in 4% glucose
Hartmann’s solution
how much sodium is in 1L of saline?
154 mmol
what volume over what time should resuscitation fluids be given?
500 ml fluid bolus over 15 minutes (“stat”)
Repeat boluses of 250 – 500 mls of fluid if required, each time followed by a reassessment
Seek expert help if the patient is not responding, particularly after 2 litres of fluid
what are the approximate requirements of maintenance IV fluids?
25 – 30 ml / kg / day of water
1 mmol / kg / day of sodium, potassium and chloride
50 – 100 g / day of glucose
Causes of acute generalised abdominal pain ?
Peritonitis
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis
causes of acute RUQ pain?
Biliary colic
Acute cholecystitis
Acute cholangitis
causes of acute epigastric pain?
Acute gastritis
Peptic ulcer disease
Pancreatitis
Ruptured abdominal aortic aneurysm
causes of acute central abdominal pain?
Ruptured abdominal aortic aneurysm
Intestinal obstruction
Ischaemic colitis
Early stages of appendicitis
causes of RIF pain?
Acute appendicitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
Meckel’s diverticulitis
causes of acute LIF pain?
Diverticulitis
Ectopic pregnancy
Ruptured ovarian cyst
Ovarian torsion
causes of acute suprapubic pain?
Lower urinary tract infection
Acute urinary retention
Pelvic inflammatory disease
Prostatitis
causes of acute loin to groin pain?
Renal colic (kidney stones)
Ruptured abdominal aortic aneurysm
Pyelonephritis
causes of acute testicular pain
Testicular torsion
Epididymo-orchitis
what are the signs of peritonitis?
Guarding
Rigidity
Rebound tenderness
Coughing test
Percussion tenderness
what is the initial management of an acute abdomen?
ABCDE assessment
Alert seniors of unwell patients
Nil by mouth if surgery may be required or they have features of bowel obstruction
NG tube in cases of bowel obstruction
IV fluids if required for resuscitation or maintenance
IV antibiotics if infection is suspected
Analgesia as required for pain management
Arranging investigations as required (e.g., bloods, group and save and scans)
Venous thromboembolism risk assessment and prescription if indicated
Prescribing regular medication
where is McBurney’s point?
one third of the distance from the anterior superior iliac spine (ASIS) to the umbilicus
what are the classical features of appendicitis?
Central abdo pain -> RIF (McBurney’s point)
Anorexia
N+V
Low grade fever
Rovsing’s sign
Guarding
Rebound tenderness
Percussion tenderness
what is Rovsing’s sign?
palpation of the left iliac fossa causes pain in the RIF
What is a diagnosis of appendicitis base on?
clinical presentation and raised inflammatory markers
what is the main imaging option to confirm a diagnosis of appendicitis?
CT
name 3 key differentials for appendicitis
Ectopic pregnancy
Ovarian cysts
Meckel’s diverticulum
Mesenteric adenitis
what is the first line management of appendicitis?
Laparoscopic appendicectomy
Name 3 complications of an Appendicectomy
Bleeding, infection, pain and scars
Damage to bowel, bladder or other organs
Removal of a normal appendix
Anaesthetic risks
Venous thromboembolism
what are the big 3 causes of bowel obstruction?
Adhesions (small bowel)
Hernias (small bowel)
Malignancy (large bowel)
what are the main causes of intestinal adhesions?
Abdominal or pelvic surgery (particularly open surgery)
Peritonitis
Abdominal or pelvic infections (e.g., pelvic inflammatory disease)
Endometriosis
what are the presenting features of bowel obstruction?
Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
“Tinkling” bowel sounds may be heard in early bowel obstruction
what is the key abdominal x-ray finding in bowel obstruction?
distended loops of bowel
what are some complications of bowel obstruction?
Hypovolaemic shock
Bowel ischaemia
Bowel perforation
Sepsis
what is the initial management of bowel obstruction?
Nil by mouth
IV fluids
NG tube with free drainage
What is the 1st line and gold standard investigation for bowel obstruction?
1st: abdominal x-ray
Gold: contrast abdominal CT
what would an erect chest x-ray show in intra-abdominal perforation?
air under the diaphragm
what are common causes of ileus?
Injury to the bowel
Handling of the bowel during surgery
Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia)
Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia)
What are the signs and symptoms of ileus?
Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
Absent bowel sounds
what is the management of ileus?
Supportive care involves:
Nil by mouth or limited sips of water
NG tube if vomiting
IV fluids to prevent dehydration and correct the electrolyte imbalances
Mobilisation to helps stimulate peristalsis
Total parenteral nutrition (TPN) may be required whilst waiting for the bowel to regain function
What is volvulus?
bowel twists around itself and the mesentery
what are the 2 main types of volvulus?
Sigmoid volvulus
Caecal volvulus
Name 3 risk factors for volvulus
Neuropsychiatric disorders (e.g., Parkinson’s)
Nursing home residents
Chronic constipation
High fibre diet
Pregnancy
Adhesions
what is the sign on abdominal xray of sigmoid volvulus?
“coffee bean” sign
what is the investigation to confirm a diagnosis of volvulus?
contrast CT scan
what are the 3 key complications of hernias ?
Incarceration
Obstruction
Strangulation
what are the 4 types of hiatus hernias
Type 1: Sliding
Type 2: Rolling
Type 3: Combination of sliding and rolling
Type 4: Large opening with additional abdominal organs entering the thorax
what are the different degrees of haemorrhoids?
1st degree: no prolapse
2nd degree: prolapse when straining and return on relaxing
3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back
4th degree: prolapsed permanently
Name 3 risk factors for diverticulosis?
increased age
Low fibre diets
obesity
NSAIDs
what are the symptoms of acute diverticulitis?
Pain and tenderness in the left iliac fossa / lower left abdomen
Fever
Diarrhoea
Nausea and vomiting
Rectal bleeding
Palpable abdominal mass (if an abscess has formed)
Raised inflammatory markers (e.g., CRP) and white blood cells
what is the management of uncomplicated diverticulitis?
Oral co-amoxiclav (at least 5 days)
Analgesia (avoiding NSAIDs and opiates, if possible)
Only taking clear liquids (avoiding solid food) until symptoms improve (usually 2-3 days)
Follow-up within 2 days to review symptoms
what are complications of acute diverticulitis?
Perforation
Peritonitis
Peridiverticular abscess
Large haemorrhage requiring blood transfusions
Fistula (e.g., between the colon and the bladder or vagina)
Ileus / obstruction
What are the three main branches of the abdominal aorta that supply the abdominal organs?
Coeliac artery
Superior mesenteric artery
Inferior mesenteric artery
what does the foregut include and what blood vessel is it supplied by?
stomach and part of the duodenum, biliary system, liver, pancreas and spleen.
This is supplied by the coeliac artery.
what is the midgut and what is it supplied by?
distal part of the duodenum to the first half of the transverse colon.
This is supplied by the superior mesenteric artery.
what is the hindgut and what is it supplied by?
second half of the transverse colon to the rectum.
This is supplied by the inferior mesenteric artery.
what is the typical presentation of mesenteric ischaemia?
Central colicky abdominal pain after eating (starting around 30 minutes after eating and lasting 1-2 hours)
Weight loss (due to food avoidance, as this causes pain)
Abdominal bruit may be heard on auscultation
State 4 risk factors for mesenteric ischaemia
Increased age
Family history
Smoking
Diabetes
Hypertension
Raised cholesterol
How do you diagnose mesenteric ischaemia?
CT angiography
what is the management of mesenteric ischaemia?
Reducing modifiable risk factors (e.g., stop smoking)
Secondary prevention (e.g., statins and antiplatelet medications)
Revascularisation to improve the blood flow to the intestines
how does acute mesenteric ischaemia present?
acute, non-specific abdominal pain. The pain is disproportionate to the examination findings. Patients can go on to develop shock, peritonitis and sepsis.
what will a blood gas in a patient with acute mesenteric ischaemia show?
metabolic acidosis and raised lactate
name 4 risk factors or bowel cancer
Family history of bowel cancer
Familial adenomatous polyposis (FAP)
Hereditary nonpolyposis colorectal cancer (HNPCC)
Inflammatory bowel disease
Increased age
Diet (high in red and processed meat and low in fibre)
Obesity and sedentary lifestyle
Smoking
Alcohol
what are some red flags for bowel cancer?
Change in bowel habit
Unexplained weight loss
Rectal bleeding
Unexplained abdominal pain
Iron deficiency anaemia
Abdominal or rectal mass on examination
who and how often are FIT tests sent?
60 – 74 years are sent a home FIT test to do every 2 years
what is the gold standard investigation for bowel cancer?
Colonoscopy
what are most gallstones made of?
cholesterol
what are the 4 main risk factors for gallstones?
F – Fat
F – Fair
F – Female
F – Forty
what is the main symptom of gallstones?
biliary colic
what is the first line investigation for gallstones?
ultrasound scan
what are some signs/symptoms of acute cholecystitis?
RUQ pain that may radiate to the shoulder
Fever
Nausea
Vomiting
Tachycardia
Tachypnoea
Right upper quadrant tenderness
Murphy’s sign
Raised inflammatory markers and white blood cells
what is Murphy’s sign?
Place a hand in RUQ and apply pressure
Ask the patient to take a deep breath in
The gallbladder will move downwards during inspiration and come in contact with your hand
Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration
Name 3 complications of acute cholecystitis
Place a hand in RUQ and apply pressure
Ask the patient to take a deep breath in
The gallbladder will move downwards during inspiration and come in contact with your hand
Stimulation of the inflamed gallbladder results in acute pain and sudden stopping of inspiration
what can be used to remove trapped gallstone?
Endoscopic retrograde cholangio-pancreatography (ERCP)
what are the most common organisms in acute cholangitis?
Escherichia coli
Klebsiella species
Enterococcus species
what is Charcot’s triad in acute cholangitis?
Right upper quadrant pain
Fever
Jaundice (raised bilirubin)
what is the management of acute cholangitis?
Nil by mouth
IV fluids
Blood cultures
IV antibiotics
Involvement of seniors and potentially HDU or ICU
endoscopic retrograde cholangio-pancreatography (ERCP)
what is Courvoisier’s law
palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer
what is the key presenting feature of cholangiocarcinoma?
Obstructive jaundice
how is a diagnosis of cholangiocarcinoma?
imaging (CT or MRI) plus histology from a biopsy
what cancer marker is raised in cholangiocarcinoma?
CA 19-9
what type of cancer are the majority of pancreatic cancers?
adenocarcinomas
where do the majority of pancreatic cancers occur?
head of the pancreas
what is the key presenting feature of pancreatic cancer?
Painless obstructive jaundice
Name 3 key causes of pancreatitis
Gallstones
Alcohol
Post-ERCP
what are the presenting symptoms of pancreatitis?
Severe epigastric pain
Radiating through to the back
Associated vomiting
Abdominal tenderness
Systemically unwell
what is raised more than 3 times the upper limit of normal in pancreatitis?
Amylase
what score is used to assess the severity of pancreatitis?
Glasgow Score
0 or 1 – mild pancreatitis
2 – moderate pancreatitis
3 or more – severe pancreatitis
what are the criteria for the Glasgow score for pancreatitis?
P – Pa02 < 8 KPa
A – Age > 55
N – Neutrophils (WBC > 15)
C – Calcium < 2
R – uRea >16
E – Enzymes (LDH > 600 or AST/ALT >200)
A – Albumin < 32
S – Sugar (Glucose >10)
what is the most common cause of chronic pancreatitis?
Alcohol
what are some factors suggesting unsuitability for liver transplantation
Significant co-morbidities (e.g., severe kidney, lung or heart disease)
Current illicit drug use
Continuing alcohol misuse (generally 6 months of abstinence is required)
Untreated HIV
Current or previous cancer (except certain liver cancers)
