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Phase 4 Question Knowledge > General Surgery > Flashcards

General Surgery Flashcards

1
Q

Appenditis

A
  • inflammation of appendix
  • lymphoid hyperplasia / faecolith obstructs appendiceal lumen, gut orgs invade wall
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2
Q

Appendicitis Px

A
  • generalised abdo pain, migrates to McBurney’s in RIF
  • fever
  • anorexia
  • N+V
  • Rovsing’s
  • Guarding
  • rebound tenderness
  • percussion tenderness
  • Psoas sign (retrocaecal)
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3
Q

Appendicitis DDx

A

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

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4
Q

Appendicitis Ix

A
  • clinical dx
  • Bloods - raised CRP / WCC
  • urine pregnancy test
  • urine dip
  • CT abdo
  • USS - female pts (exclude gynae), children
  • diagnostic laparoscopy
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5
Q

Appendicitis Mx

A
  • appendicectomy - laparoscopic / open
  • IV abx
  • IV fluids
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6
Q

Appendicitis Cx

A
  • appendix rupture, peritonitis
  • appendix mass
  • appendix abscess
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7
Q

Bowel obstruction

A
  • blockage of flow of intestinal contents
  • SBO>LBO
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8
Q

Bowel obstruction patho

A
  • 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
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9
Q

Bowel obstruction causes

A

SBO

  • adhesions
  • hernias
  • strictures, intussusception, paralytic ileus, pseudo-obstruction, Hirschsprung’s

LBO

  • malignancy
  • volvulus
  • strictures
  • diverticular disease
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10
Q

Bowel obstruction Px

A
  • 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)

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11
Q

Bowel obstruction Ix

A
  • 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
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12
Q

Bowel obstruction Mx

A
  • NBM
  • analgesia, antiemetic
  • IV fluids
  • NG tube (Ryles)
  • surgery - laparoscopy / laparotomy
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13
Q

Paralytic ileus

A
  • 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
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14
Q

Pseudo-obstruction

A
  • functional obstruction of LI
  • XR - colon dilatation
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15
Q

Volvulus

A
  • torsion of colon around its mesenteric axis -> compromised blood supply + closed loop obstruction
  • sigmoid 80%, caecum 20%
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16
Q

Volvulus Px

A
  • as bowel obstruction
  • constipation, bloating, abdo pain, N+V etc
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17
Q

Volvulus Ix

A

AXR
- sigmoid - LBO + coffee bean sign
- caecal - SBO

CT with contrast

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18
Q

Volvulus Mx

A
  • NBM, IV fluids, NG tube

Sigmoid

  • endoscopic decompression - rigid sigmoidoscopy
  • surgical - Hartmann’s

Caecal

  • surgical - right hemicolectomy / ileocaecal resection
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19
Q

Hernia

A

protrusion of organ through weak point in cavity wall

RFs

  • male, chronic cough, constipation, heavy lifting, ascites, past abdo surgery
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20
Q

Hernia Px

A
  • soft lump
  • Reducible
  • Cough impulse
  • Worsened on standing
  • Aching, pulling, dragging sensation
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21
Q

Hernia Ix

A
  • lump examination
  • USS
  • CT / MRI
  • Erect CXR if ?strangulation/perf
  • Bloods - VBG, FBC, U/E, G/S, LFTs, CRP etc
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22
Q

Hernia Mx

A

Conservative

  • Truss

Surgical

  • tension-free repair - mesh repair
  • tension repair - suture muscles / tissues (rarely done)
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23
Q

Hernia Cx

A
  • 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
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24
Q

Inguinal hernia

A

Protrusion of abdo contents through inguinal canal….

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25
Q

Indirect inguinal hernia

A
  • 80%
  • bowel herniates through inguinal canal
  • lateral to inferior epigastric artery
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26
Q

Direct inguinal hernia

A
  • 20%
  • weakness in abdo wall at Hesselbach’s triangle
  • medial to inferior epigastric artery
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27
Q

Inguinal hernia Px

A
  • groin lump
  • medial + superior to pubic tubercle
  • disappears on pressure / lying down
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28
Q

Inguinal hernia Mx

A
  • direct/indirect has no bearing on mx
  • tx medically fit patients, even if asym
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29
Q

Femoral hernia

A
  • herniation of abdo contents through femoral canal

Px

  • lump in groin +/- pain
  • inferior + lateral to pubic tubercle
  • typically non-reducible

Mx

  • surgical repair
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30
Q

Incisional hernia

A
  • protrusion of bowel through incision site in abdo wall
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31
Q

Umbilical hernia

A
  • protrusion of abdo contents through umbilicus
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32
Q

Epigastric hernia

A

hernia in epigastric region

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33
Q

Spigelian hernia

A

Hernia between lateral border of rectus abdominis and linea semilunaris - site of spigelian fascia (aponeurosis between muscles of abdo wall)

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34
Q

Diastasis recti

A

Widening of linea alba, between rectus abdominis muscle, leading to herniation of bowel

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35
Q

Obturator hernia

A

Abdo / pelvic contents herniate through obturator foramen - due to defect in pelvic floor

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36
Q

Hiatus hernia

A
  • herniation of abdo viscera through oesophageal aperture of diaphragm

RFs

  • older, obesity, pregnancy, female, ascites
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37
Q

Hiatus hernia types

A

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
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38
Q

Hiatus hernia Px

A
  • dyspepsia
  • food reflux
  • burping, bloating
  • halitosis
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39
Q

Hiatus hernia Ix

A
  • CXR, CT
  • endoscopy
  • barium swallow
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40
Q

Hiatus hernia Mx

A
  • lose weight
  • PPIs
  • surgical repair - laparoscopic fundoplication (mainly rolling)
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41
Q

Haemorrhoids

A
  • enlarged anal vascular cushions

RFs

  • constipation, straining, pregnancy, obesity, older age, weightlifting, chronic cough
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42
Q

Haemorrhoids patho

A
  • 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

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43
Q

Haemorrhoids Px

A
  • 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
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44
Q

Haemorrhoids Ix

A
  • examine, PR
  • proctoscopy
  • ?bloods
  • ?colonoscopy
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45
Q

Haemorrhoids Mx

A

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
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46
Q

Anal fistula

A
  • abnormal connection between the epithelial surfaces of the anal canal + skin

Causes

  • perianal sepsis, abscess, Crohn’s, TB, diverticular disease, rectal carcinoma
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47
Q

Anal fistula Px

A
  • pain
  • discharge - bloody / mucus
  • pruritis ani
  • swelling, red, abscess
  • bowel incontinence
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48
Q

Anal fistula Ix

A
  • exam, PR
  • proctoscopy
  • scans - USS, CT/MRI
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49
Q

Anal fistula Mx

A
  • surgical - fistulotomy
  • drain abscess
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50
Q

Anal fissure

A
  • 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
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51
Q

Anal fissure Px

A
  • extreme pain, esp on defecation - passing shards of glass
  • bright red, rectal bleeding
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52
Q

Anal fissure Ix

A
  • exam
  • PR if possible (pain)
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53
Q

Anal fissure Mx

A
  • increase fibre + fluids, laxatives

Medical

  • lidocaine ointment
  • GTN ointment
  • topical diltiazem
  • botox injection

Surgical

  • sphincterotomy
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54
Q

Anorectal abscess

A
  • collection of pus in anal/rectal region
  • perianal abscess most commonly
  • E coli / S aureus
  • eg anal sex, DM, immunocompromised, IBD, malignancy
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55
Q

Anorectal abscess Px

A
  • painful swellings, tender
  • pus discharge
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56
Q

Anorectal abscess Ix

A
  • PR, inspection
  • colonoscopy, bloods
  • US / CT / MRI
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57
Q

Anorectal abscess Mx

A
  • surgical excision / drainage
  • abx
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58
Q

Pruritis ani

A
  • perianal itching

Mx

  • avoid scented products
  • use wet wipes over tissue
  • avoid scratching
  • ensure no faecal incontinence
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59
Q

Pilonidal disease

A
  • 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
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60
Q

Diverticular disease

A

Diverticulum – outpouching of gut wall

Diverticulosis – presence of diverticula

Diverticular disease – symptomatic

Diverticulitis – inflammation of diverticulum

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61
Q

Diverticular disease patho

A
  • 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
62
Q

Diverticular disease Px

A

Diverticular disease

  • left lower abdo pain
  • constipation, diarrhoea
  • rectal bleeding

Diverticulitis

  • Left lower abdo pain
  • Fever
  • Diarrhoea
  • N+V
  • Rectal bleeding
  • Abscess – abdo mass
63
Q

Diverticular disease Ix

A

Diverticular disease

  • colonoscopy
  • CT colonography
  • Barium enema

Diverticulitis

  • Bloods
  • CT abdo + contrast
  • erect CXR

(colonoscopy increases perf risk)

64
Q

Diverticular disease Mx

A

Diverticular disease

  • high fibre diet, wt loss
  • ispaghula husk (avoid stimulant laxatives)
  • mebeverine
  • surgical resection

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
65
Q

Diverticular disease Cx

A
  • Perforation
  • Peritonitis
  • Abscess
  • Haemorrhage
  • Fistula
  • Ileus / obstruction
66
Q

Bowel ischaemia

A
  • intestinal ischaemia from lack of blood
  • foregut - coeliac artery
  • midgut - superior mesenteric artery
  • hindgut - inferior mesenteric artery
67
Q

Acute mesenteric ischaemia

A
  • rapid blockage of blood flow to gut
  • typically SMA, SI
  • thrombo/embolus, commonly AF
  • ischaemia -> necrosis, perf
68
Q

Acute mesenteric ischaemia Px

A
  • acute, non-specific abdo pain - disproportionate
  • shock, peritonitis, sepsis
  • fever
  • PR bleed
69
Q

Acute mesenteric ischaemia Ix

A
  • bloods - metabolic acidosis, raised lactate, WCC
  • contrast CT
70
Q

Acute mesenteric ischaemia Mx

A
  • surgery - laparotomy - bowel resection, thrombus removal (open/endo)
  • abx
71
Q

Chronic mesenteric ischaemia

A
  • intestinal angina
  • reduced blood supply to gut from atherosclerotic blood vessels

RFs

  • older age, FHx, smoking, DM, HTN, raised cholesterol, AF
72
Q

Chronic mesenteric ischaemia Px

A
  • central, colicky abdo pain after eating
  • wt loss - food avoidance
  • abdo bruit
  • PR bleed
73
Q

Chronic mesenteric ischaemia Ix

A
  • CT angio
74
Q

Chronic mesenteric ischaemia Mx

A
  • stop smoking
  • statins, antiplatelets
  • revascularisation - stent, endarterectomy, bypass
75
Q

Ischaemic colitis

A
  • 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
76
Q

Ischaemic colitis Px

A
  • shock
  • abdo pain
  • rectal bleed
77
Q

Ischaemic colitis Ix

A
  • AXR - thumbprinting
  • abdo CT
  • colonoscopy + biopsy / barium enema
78
Q

Ischaemic colitis Mx

A
  • supportive
  • fluids, abx
  • surgery - resection
79
Q

Colorectal cancer

A
  • 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
80
Q

Colorectal cancer RFs

A
  • Familial adenomatous polyposis (FAP)
  • Hereditary nonpolyposis colorectal cancer (HNPCC)
  • FHx
  • IBD
  • older
  • diet - red/processed meat, low fibre
  • obesity, sedentary
  • smoking, alcohol
  • colorectal polyps
81
Q

Colorectal cancer Px

A
  • change in bowel habit - diarrhoea, constipation, freq
  • wt loss
  • PR bleed
  • mucus
  • tenesmus
  • abdo pain
  • IDA - fatigue, weakness, SOB
  • abdo/rectal mass
  • intestinal obstruction
82
Q

Colorectal cancer screening

A
  • 60-74yo - sent home FIT test to do every 2 yrs, colonoscopy if positive
  • Pts with FAP, HNPCC, IBD - colonoscopy at regular intervals
83
Q

Colorectal cancer 2ww referral criteria

A

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

84
Q

Colorectal cancer Ix

A
  • FIT test
  • colonoscopy +/- biopsy
  • CT colonography
  • CT TAP
  • serum CEA
  • Bloods - FBC etc
85
Q

Colorectal cancer staging

A

Dukes

A – mucosa + part of muscle of bowel wall

B – through muscle of wall

C – lymph node involvement

D – mets

TNM

Tumour, node, mets

86
Q

Colorectal cancer Mx

A
  • MDT
  • surgical resection - anastomosis/stoma
  • chemo
  • radio
  • palliative
  • Follow up - rpt CEA, CT TAP
87
Q

Colorectal cancer operations

A

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

88
Q

Lower anterior resection syndrome

A
  • after bowel resection, anastomosis between colon + rectum

Px

  • urgency, freq of bowel movts
  • faecal incontinence
  • difficulty controlling flatulence
89
Q

Colonic polyps

A
  • 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 colonoscopy
90
Q

Oesophageal cancer

A
  • 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, alcohol…
91
Q

Oesophageal cancer Px

A
  • dysphagia, solids then liquids
  • anorexia
  • wt loss
  • vomiting
  • odynophagia
  • hoarseness
  • melaena
  • cough
  • lymphadenopathy
  • retrosternal chest pain
92
Q

Oesophageal cancer Ix

A
  • OGD
  • Endoscopic US?
  • CT TAP
  • Barium swallow
93
Q

Oesophageal cancer Mx

A
  • surgical resection (Ivor-Lewis oesophagectomy)
  • chemo
94
Q

Benign oesophageal lesions

A
  • benign growths in oesophagus, 1% all tumours, leiomyoma

Px

  • asym
  • dysphagia
  • retrosternal pain
  • food regurg

Ix

  • OGD
  • barium swallow
  • biopsy

Mx

  • endoscopic / surgical resection
95
Q

Gastric cancer

A
  • stomach cancer - adenocarcinoma
  • intestinal (well formed) / diffuse (worse)

RFs

  • H pylori
  • atrophic gastritis
  • smoking
  • diet, blood group A
96
Q

Gastric cancer Px

A
  • abdo pain
  • dyspepsia
  • wt loss
  • anorexia
  • N+V
  • dysphagia
  • UGIB
  • anaemia
  • lymphadenopathy
  • mets - bone, brain, liver, lung
97
Q

Gastric cancer Ix

A
  • OGD + biopsy
  • ?endoscopic USS
  • CT / MRI / PET
98
Q

Gastric cancer mx

A
  • surgical - mucosal resection / partial/total gastrectomy
  • chemo
99
Q

Gastrectomy cx

A
  • dumping syndrome
  • wt loss, early satiety
  • IDA
  • osteoporosis, osteomalacia
  • B12 deficiency
100
Q

SI tumours

A
  • 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
101
Q

Pancreatic cancer

A
  • 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
102
Q

Pancreatic cancer Px

A
  • 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
103
Q

Pancreatic cancer referral

A

> 40yo + jaundice - 2ww

> 60yo + wt loss + additional sx (below) - direct access CT abdo
- Diarrhoea, back pain, abdo pain, N/V, constipation, new onset DM

104
Q

Pancreatic cancer Ix

A
  • BM
  • LFTs, CA 19-9
  • MRCP / ERCP
  • trans-abdo USS
  • CT TAP
  • Biopsy - percutaneous / endoscopic
105
Q

Pancreatic cancer Mx

A

Surgical

  • total / distal pancreatectomy
  • pylorus-preserving pancreaticoduodenectomy (PPPD)
  • Whipple’s - pancreaticoduodenectomy
  • chemo
  • ERCP + stent
106
Q

Anal cancer

A
  • 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
107
Q

Anal cancer Px

A
  • perianal pain, bleeding
  • palpable lesion
  • faecal incontinence
108
Q

Anal cancer Ix

A
  • T stage assessment - examine, DRE, anoscopic exam + biopsy, palpate nodes
  • CT / MRI / endo-anal USS / PET
  • test for eg HIV
109
Q

Anal cancer Mx

A
  • chemo / radio
  • surgical excision
110
Q

Stoma

A
  • artificial opening of hollow organ
  • eg bypass distal structures
  • stoma bag to collect waste
  • stoma nurse follow up
111
Q

Colostomy

A
  • LI brought onto skin
  • solid stools
  • no spout, flatter to skin
  • LIF
112
Q

Ileostomy

A
  • SI brought to skin
  • drains liquids, irritating to skin
  • spout -> tight-fitting bag
  • RIF
113
Q

Gastrostomy

A
  • artificial connection between stomach + abdo wall
  • provide feeds
  • PEG - percutaneous endoscopic gastrostomy
114
Q

Urostomy

A
  • opening from urinary system onto skin
  • drain from kidney, bypass ureters, bladder, urethra
  • eg post-cystectomy
  • create ileal conduit
  • spout
  • RIF
115
Q

End colostomy / ileostomy

A
  • section of bowel removed, end part of proximal bowel brought to skin, end of distal bowel sutured up
  • can be reversed
116
Q

Loop colostomy / ileostomy

A
  • temporary stoma to allow distal bowel to heal
  • bowel partially opened - 2 openings at skin side-by-side
117
Q

Stoma cx

A
  • psychosocial
  • skin irritation
  • Parastomal hernia
  • Loss of bowel length - high output, dehydration, malnutrition
  • Constipation
  • Stenosis
  • Obstruction
  • Retraction - sinking into skin
  • Prolapse
  • Bleeding
  • Granulomas
118
Q

Biliary colic

A
  • Intermittent RUQ pain caused by gallstones passing through biliary tree
119
Q

Gallstones causes

A
  • cholesterol
  • bile pigment - calcium - eg haemolysis
  • biliary stasis
120
Q

Gallstones RFs

A
  • fair, fat, female, fertile (pregnant), forty
  • DM, Crohn’s, rapid wt loss, cOCP
121
Q

Biliary colic Px

A
  • colicky RUQ pain, worse after eating fatty foods, radiation to R shoulder
  • N+V
  • no fever
122
Q

Biliary colic Ix

A
  • LFTs - raised ALP, if bilirubin raised, obstruction in CBD - AST/ALT normal
  • USS
  • MRCP
  • CT - maybe for pancreas
123
Q

Biliary colic Mx

A
  • elective laparoscopic cholecystectomy
  • ERCP
  • analgesia
124
Q

Acute cholecystitis

A
  • inflammation of gallbladder
  • secretion obstructed, increased secretion, distension, compromise vascular supply
  • 90% gallstones, 10% other (TPN, ill, hypoperfusion…)
125
Q

Acute cholecystitis Px

A
  • RUQ pain, shoulder
  • fever
  • Murphy’s sign positive
126
Q

Acute cholecystitis Ix

A
  • 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
127
Q

Acute cholecystitis Mx

A
  • NBM
  • IV fluids
  • IV abx
  • ERCP
  • laparoscopic cholecystectomy - hot <72hrs / cold in 6-8wks
128
Q

Acute cholecystitis cx

A
  • sepsis
  • gallbladder empyema
  • gangrene / perf
129
Q

Ascending cholangitis

A
  • infection of biliary tree
  • E coli, klebsiella, enterococcus

Causes

  • gallstones, ERCP
  • infection ascends up CBD from duodenum
130
Q

Ascending cholangitis Px

A

Charcot’s triad

  • RUQ pain
  • fever
  • jaundice

Reynold’s pentad

  • hypotension
  • confusion
131
Q

Ascending cholangitis Ix

A
  • bloods - deranged LFTs (ALP higher), raised bilirubin/CRP/WCC
  • USS
  • MRCP
132
Q

Ascending cholangitis Mx

A
  • NBM
  • IV fluids
  • IV abx
  • ERCP
  • percutaneous transhepatic cholangiogram (PTC)
133
Q

Cholangiocarcinoma

A
  • 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
134
Q

Cholangiocarcinoma Px

A
  • 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
135
Q

Cholangiocarcinoma Ix

A
  • CA19-9
  • raised ALP, bilirubin
  • CT / MRI
  • biopsy
  • MRCP
136
Q

Cholangiocarcinoma Mx

A
  • surgical resection
  • ERCP
  • chemo / radio
137
Q

Acute pancreatitis

A
  • inflammation of pancreas
  • autodigestion of pancreatic tissue by enzymes -> necrosis
138
Q

Acute pancreatitis causes

A

I GET SMASHED

idiopathic
gallstones
ethanol
trauma
steroids
mumps, coxsackie B
autoimmune
scorpion sting
hyperlipidaemia, also Ca, hypothermia
ERCP
drugs - furosemide, thiazides, azathioprine….

139
Q

Acute pancreatitis Px

A
  • severe epigastric pain, radiates to back
  • N+V
  • abdo tenderness
  • fever, tachycardia
  • Cullen’s, Grey-Turner’s sign
  • ischaemic retinopathy
140
Q

Acute pancreatitis Ix

A
  • bloods - FBC, U/E, LFT, Ca, ABG, amylase, CRP, ?lipase
  • USS
  • CT abdo
  • severity score - Glasgow, APACHE II, Ranson
141
Q

Acute pancreatitis Mx

A
  • A-E
  • IV fluids
  • analgesia
  • NBM if vomiting
  • Tx cause - ERCP, cholecystectomy…
  • Abx if infection
  • may need debridement
142
Q

Acute pancreatitis Cx

A
  • necrosis of pancreas
  • infection of necrosis
  • pancreatic abscess
  • peripancreatic fluid collections
  • pseudocysts
  • chronic pancreatitis
  • haemorrhage
143
Q

Chronic pancreatitis

A
  • chronic inflammation of pancreas
  • fibrosis, reduced function
  • alcohol most commonly, also CF, HHC, as acute
144
Q

Chronic pancreatitis Px

A
  • sx as acute, less intense, longer lasting
  • pain worse 15-30mins after meal
  • steatorrhoea
  • DM
145
Q

Chronic pancreatitis Ix

A
  • AXR - pancreatic calcification
  • CT
  • faecal elastase - assess exocrine function
  • secretin stimulation test
  • MRI / endoscopic USS
146
Q

Chronic pancreatitis Mx

A
  • stop smoking, alcohol
  • analgesia
  • creon
  • S/C insulin
  • ERCP + stent - strictures
  • surgery
147
Q

Chronic pancreatitis Cx

A
  • chronic pain
  • loss of pancreatic enzymes
  • lack of insulin
  • strictures
  • pseudocysts, abscesses
148
Q

Anastomotic leak

A
  • 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
149
Q

Boerhaave’s syndrome

A
  • 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
150
Q

Bariatric surgery

A

Primarily restrictive

  • laparoscopic gastric banding
  • sleeve gastrectomy
  • intrinsic gastric balloon

Primarily malabsorptive

  • Biliopancreatic diversion with duodenal switch

Mixed

  • Roux-en-Y gastric bypass surgery
151
Q

Lower GI bleed

A
  • 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

Phase 4 Question Knowledge (30 decks)

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