General Surgery Flashcards
1
Q
Where are most anal fissures located?
A
Posterior midline >90% (if alternative location think of underlying diagnosis e.g. CD)
2
Q
What is the management for acute anal fissures (<1 week)? 5 aspects
A
- high fibre diet
- bulk forming laxatives
- lubricants eg petroleum jelly
- topical anaesthetics
- analgesia
3
Q
What are 3 options for the management of chronic anal fissures?
A
- Same as acute
- Topical GTN
- If GTN not effective for 8 weeks - spinchterotomy or BOTOX
4
Q
Where are the mucosal vascular cushions found anally?
A
3, 7 and 11 o’clock
5
Q
What are haemorrhoids?
A
- haemorrhoidal tissue is part of the normal anatomy, contributes to anal continuence
- mucosal vascular cushions found in L lateral, R posterior and R anterior portions of anal canal
- haemorrhoids exist when they are enlarged, congested and symptomatic
6
Q
What are external vs internal haemorrhoids?
A
- external - originate below the dentate line
- internal - originate above dentate line
7
Q
How are haemorrhoids graded?
A
Grade I - do not prolapse out of anal canal
Grade II - prolapse on defecation, reduce spontaneously
Grade III - can be manually reduced
Grade IV - cannot be reduced
8
Q
What is considered the first line management for haemorrhoids?
A
increase dietary fibre + fluid
9
Q
What are 5 aspects of the management of haemorrhoids?
A
- increase dietary fibre + fluids
- topical local anaesthetics + steroids
- OP: rubber band ligation (superior), injection sclerotherapy
- Surgery - large symptomatic haemorrhoids, not responding to OP treatments
- Newer: Doppler-guided haemorrhoidal artery ligation, stapled haemorrhoidopexy
10
Q
What is the presentation of acutely thrombosed external haemorrhoids?
A
significant pain; purplish, oedematous, tender subcutaneous perianal mass
11
Q
What is the management of acutely thrombosed external haemorrhoids?
A
if patient presents within 72h - consider referral for excision
outside of 72h - stool softeners, ice packs, analgesia
12
Q
What is a spinal epidural abscess?
A
Collection of pus overlying the dura mater of the spinal cord
13
Q
What is the investigation of choice to diagnose spinal epidural abscess?
A
Whole spine MRI
14
Q
What is the commonest organism causing spinal epidural abscess?
A
Staphylococcus aureus
15
Q
In addition to the 4 Fs what are 4 additional risk factors for biliary colic / gallstones?
A
- diabetes mellitus
- Crohn’s disease
- Drugs: fibrates, COCP
- Rapid weight loss e.g. weight reduction surgery
16
Q
What is the lifelong antiplatelet management of peripheral arterial disease?
A
Clopidogrel
17
Q
What type of bowel obstruction is most likely to be caused by an incarcerated hernia?
A
SMALL bowel obstruction
18
Q
What is the leading cause of small bowel obstruction in developed countries?
A
postoperative adhesions (60%)
19
Q
What are 4 causes of small bowel obstruction?
A
- postoperative adhesions (commonest)
- malignancy
- Crohn’s disease
- hernias
20
Q
What is meant by simple SBO?
A
non-strangulated - occurs when loop of distended bowel twists on its mesenteric pedicle, arterial occlusion leads to bowel ischaemia and necrosis
21
Q
What is the commonest cause of strangulated small bowel obstruction?
A
adhesions
22
Q
What will abdominal Xray show in small bowel obstruction?
A
central gas shadows, no gas in large bowel; small bowel identified by valvulae conniventes that completely cross the lumen
23
Q
What are the 3 types of bowel ischaemia?
A
- acute mesenteric ischaemia (small bowel)
- chronic mesenteric ischaemia)
- colonic ischaemia (large bowel) commonest
24
Q
What are the 2 watershed areas of the colon?
A
- splenic flexure
- rectosigmoid junction
prone to ischaemia as they receive overlapping blood supply from most distal branches of SMA + IMA arteries
25
What are 4 causes of acute bowel ischaemia?
1. arterial embolus (e.g. AF, mural thrombus after MI)
2. arterial thrombosis e.g. etherosclerosis
3. venous thrombosis e.g. hypercoagulability
4. intestinal hypoperfusion e.g. shock, HF
26
What is the investigation of choice for suspected intestinal ischaemia?
CT
27
What is the management of acute bowel ischaemia?
* surgical - needs to be assessed for viability + if necrotic needs to be resected
* in some instances, endovascular thrombolysis/thrombectomy may be beneficial
28
What is the management of chronic bowel ischaemia?
* if asymptomatic: conservative - smoking cessation & antiplatelet therapy
* if symptomatic: oepn or endovascular revascularisation
* nutrition - often malnourished at time of onset
29
What is the most important factor for improving survival in acute mesenteric ischaemia?
diagnosis before the occurrence of intestinal infarction
30
Which type of bowel ischaemia has the most favourable prognosis?
colonic ischaemia
31
What is Buerger's disease?
thromboangiitis obliterans - non-atherosclerotic vasculitis affecting predominantly medium-sized arteries
32
What is the typical patient affected by Buerger's disease?
young males who smoke
33
What are common symptoms of Buerger's disease?
* paraesthesia / cold sensation in fingers or limbs
* rest pain
* pain in lower limbs improves when leg hangs over edge of bed
* ulceration / gangrene
* superficial thrombophlebitis
* Raynaud's phenomenon
34
What is the commonest cause of varicose veins?
Reflux in great saphenous vein and small saphenous vein
35
What are 4 risk factors for varicose veins?
1. Pregnancy
2. Obesity
3. Increasing age
4. Female gender
36
What symptoms may patients complain of with varicose veins?
Itching, aching, throbbing
37
What are 8 symptoms which may be seen with chronic venous insufficiency?
1. Varicose eczema
2. Haemosiderin deposition
3. Lipodermatosclerosis- hard/tight skin
4. Atrophie Blanche - hypopigmentation
5. Bleeding
6. Superficial thrombophlebitis
7. Venous ulceration
8. DVT
38
What is the investigation of choice for varicose veins / chronic venous insufficiency?
Venous duplex US - shows retrograde flow
39
What are 4 conservative measures for varicose veins?
1. Leg elevation
2. Weight loss
3. Regular exercise
4. Graduated compression stockings
40
What are 5 reasons to refer varicose veins to secondary care?
1. Significant / troublesome lower limb pain, discomfort or swelling
2. Previous bleeding from varicose veins
3. Skin changes secondary to chronic CVI (eczema, hyperpigmentation)
4. Superficial thrombophlebitis
5. Active or healed venous leg ulcer
41
What are 3 possible active treatment options for varicose veins?
1. **Endothermal ablation** (radiofrequency or endovenous laser treatment)
2. **Foam sclerotherapy** (irritant foam - inflammatory response - vein closure)
3. **Surgery** - ligation or stripping
42
What is the management of peripheral arterial disease?
* treat comorbidities: HTN, DM, obesity
* **atorvastatin 80mg**
* **clopidogrel**
* exercise training programme
* quit smoking
43
What are 2 surgical approaches for severe PAD or critical limb ischaemia?
1. endovascular revascularisation
2. surgical revascularisation
44
How can endovascular revascularisation be performed in severe/critical PAD?
percutaneous transluminal angioplasty +/- stent placement
45
When are endovascular rather than surgical revascularisation approaches preferred in PAD?
short segment stenosis e.g. <10cm, aortic iliac disease and high-risk patients
46
What are 2 types of surgical revasculisation in PAD?
1. surgical bypass with autologous vein or prosthetic material
2. endarterectomy
47
Which patients are open surgical techniques in PAD preferred for?
long segment lesions (>10cm), multifocal lesions, lesions of common femoral artery and purely infrapopliteal disease
48
When is amputation used in PAD?
patients with critical limb ischaemia who are not suitable for other interventiosn such as angioplasty or bypass surgery
49
What are 2 specific drugs licensed for use in PAD?
1. **naftidrofuryl oxalate**: vasodilator, sometimes used for patients with poor QOL
2. **cilostazol**: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects
50
Which patients with breast cancer are offered surgery?
vast majority - with exception of frail, elderly lady with metastatic disease (may be better managed with hormonal therapy)
51
What determines breast cancer management prior to surgery?
presence/absence of **palpable axillary lymphadenopathy**
* absent: pre-op axillary US before primary surgery, if negative - sentinel node biopsy
* clinically palpable - axillary node clearance at primary surgery
52
What are 4 factors that determine whether mastectomy or wide local excision should be performed for breast cancer?
1. multifocal = mastectomy, solitary = WLE
2. central = mastectomy, peripheral = WLE
3. large lesion small breast = mastectomy, small lesion in large breast = WLE
4. DCIS >4cm = mastectomy, DCIS <4cm = WLE
53
What anti-cancer treatment is offered after wide local excision for breast cancer?
whole-breast radiotherapy
| may reduce risk of recurrence by 2/3
54
When is radiotherapy offered after mastectomy in breast cancer? 2 situations
1. T3-T4 tumours
2. 4 or more positive axillary nodes
55
Which hormonal therapy drugs are used in breast cancer and when?
* tamoxifen: pre- and peri-menopausal women
* anastrozole / aromatase inhibitors: post-menopausal
56
What accounts for the difference in hormone therapy for breast cancer in pre- vs post-menopausal women?
in post-menopausal women, aromatisation accounts for most oestrogen production
57
What are 3 important side effects of tamoxifen?
1. increased risk of endometrial cancer
2. venous thromboembolism
3. menopausal symptoms
58
What is the commonest type of biological therapy for breast cancer?
trastuzumab (Herceptin)
59
When is biological therapy e.g. trastuzumab used in breast cancer?
HER2 positive (20-25% of tumours)
60
In which patients is trastuzumab contraindicated?
heart disorders
61
What are 2 situations when chemotherapy is used in breast cancer?
1. neoadjuvant chemotherapy to downstage primary lesion
2. after surgery if there is axillary node disease - **FEC-D** used
62
What are 2 medical options for the management of obesity?
1. orlistat (Alli - OTC lower dose version)
2. liraglutide
63
What is the mechanism of action of orlistat?
pancreatic lipase inhibitor
64
What are the adverse effects of orlistat?
faecal urgency / incontinence and flatulence
65
What are the criteria for prescribing orlistat?
* BMI >28 with associated risk factors OR
* BMI >30
and:
* continued weight loss e.g. 5% at 3 months
66
What is the maximum duration orlistat should be prescribed for?
<1 year
67
How is liraglutide administered?
once daily subcutaneous injection
68
What are the NICE critiera for liraglutide use for weight loss?
BMI >35, prediabetic hyperglycaemia
69
What are the locations of haemorrhoids classically?
3, 7, 11 o'clock
70
What are the key features of an anal fissure?
* painful rectal bleeding
* midline location - 6 and 12
* can become chronic (>6 weeks): ulcer, sentinal pile, enlarged anal papillae
71
What are 2 causes of ano-rectal abscesses?
1. E. coli
2. Staph aureus
72
What is the commonest anal neoplasm?
squamous cell carcinoma
73
What is a solitary rectal ulcer?
associated with chronic straining and constipation - histology shows mucosal thickening, lamina propra replaced with collagen + smooth muscle (fibromuscular obliteration)
74
What should be done if someone is investigated for DVT, has a raised d-dimer and is commenced on DOAC, then ultrasound is negative?
stop DOAC and repeat Doppler US in 1 week
75
What should be done if someone has a high DVT Wells score, but then negative proximal leg vein US?
**d-dimer** - if negative consider alternative diagnosis
if positive stop DOAC and repeat US in 1 week
76
What is the maximum duration of time to wait for investigations of DVT (d-dimer / dopper US) to come back?
4 hours - if a proximal leg vein US / d-dimer cannot be carried out within 4 hours interim therapeutic anticoagulation should be administered
77
What is the only way to cure colorectal cancer?
resectional surgery
78
What are the resection and anastomosis performed for caecal, ascending or proximal transverse colon cancers?
* right hemicolectomy
* ileo-colic anastomosis
79
What are the resection and anastomosis performed for distal transverse or descending colon cancers?
* left hemicolectomy
* colo-colon
80
What are the resection and anastomosis performed for sigmoid colon cancers?
* high anterior resection
* colo-rectal
81
What are the resection and anastomosis performed for upper rectum cancers?
* anterior resection (TME)
* colo-rectal
82
What are the resection and anastomosis performed for low rectum cancers?
* anterior resection (low TME)
* colo-rectal +- defunctioning stoma
83
What are the resection and anastomosis performed for anal verge cancers?
* abdomino-perineal excision of rectum
* no anastomosis
84
Whhen is chemotherapy used in colorectal cancer?
* neoadjuvant for rectal cancers
* adjuvant
* metastatic disease
85
What are 2 common chemotherapy regimens for colorectal cancer?
1. FOLFOX
2. FOLFIRI
86
When is radiotherapy used in colorectal cancer?
rectal cancers - neoadjuvant or adjuvant
87
What are 2 types of targeted therapies used in colorectal cancer and when are they used?
* bevacizumab (anti-VEGF)
* cetuximab (anti-EGFR)
* used particularly for metastatic disease
88
How does the management of colorectal cancer change in the emergency setting e.g. bowel obstruction?
* risk of anastomosis much greater - particularly if colon-colon
* end colostomy safer, performed in acute setting and can be reversed later
89
What is Hartmann's procedure?
when emergency sigmoid colon resection performed and end-colostomy fashioned; reversed at later date
90
Are ileo-colic anastomoses safe in the emergency setting?
yes (unlike left-sided resections with anastomoses)
91
What is the management of asymptomatic gallstones in the **gallbladder**?
reassure - no management required if found incidentally and symptom-free for 12 months before diagnosis
92
What is the commonest aetiology of CBD gallstones in the west?
most result from migration from the gallbladder
93
What is the diagnostic workup for gallstones?
abdominal US, LFTs
94
If gallstones are suspected in the bile duct but do not show on abdominal US, what are 2 diagnostic options?
1. MRCP
2. intraoperative imaging
95
What is the management of acute cholecystitis?
cholecystectomy - ideally within 48h of presentation
96
What is the management of gallbladder abscess?
* Ideally surgery although subtotal cholecystectomy may be needed if Calot's triangle is hostile
* In unfit patients, percutaneous drainage may be considered
97
What is the management of cholangitis?
* Fluid resuscitation
* Broad-spectrum intravenous antibiotics
* Correct any coagulopathy
* Early ERCP
98
What is the presentation of gallstone ileus?
* Patients may have a history of previous cholecystitis and known gallstones
* Small bowel obstruction (may be intermittent)
99
What is the management of gallstone ileus?
* Laparotomy and removal of the gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction.
* The fistula between the gallbladder and duodenum should not be interfered with
100
What may cause acalculous cholecystitis?
patients with intercurrent illness e.g. diabetes, organ failure; systemically unwell
101
What is the management of acalculous cholecystitis?
If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy
102
What is the management of asymptomatic gallstones in the CBD?
surgical management should be considered
103
What is done during cholecystectomy surgery to confirm anatomy or exclude CBD stones? 2 options
* intraoperative cholangiography
* laparoscopic US
104
What are 2 options if CBD stones are found intra-operatively during cholecystectomy?
1. early ERCP in day or so afterwards
2. immediate surgical exploration of bile duct
105
What is the cut off size for bile ducts that should not be explored during surgery (cholecystectomy)?
<8mm
106
What size of gallstones may be safely left in the biliary tree and will usually pass spontaneously?
<5mm
107
What are 4 risks of ERCP?
1. bleeding
2. duodenal perforation
3. cholangitis
4. pancreatitis
108
What is abdominal wound dehiscence?
all layers of abdominal mass closure fail and viscera protrude externally (30% mortality)
109
How can abdominal wound dehiscence be classified?
* **superficial** (skin wound alone fails)
* **complete** (failure of all layers)
110
What are 7 factors that increase the risk of abdominal wound dihiscence?
1. malnutrition
2. vitamin deficiencies
3. jaundice
4. steroid use
5. major wound contamination e.g. faecal peritonitis
6. poor surgical technique (mass closure technique preferred)
111
What are 5 aspects of the management of sudden full abdominal wound dehiscence?
1. cover wound with saline impregnated gauze (on ward)
2. IV AB - broad spec
3. IVF
4. analgesia
5. arrange return to theatre
112
What are the key features of a breast fibroadenoma?
* common < 30 years
* breast mice - discrete, non tender, mobile
113
What are the key features of fibroadenosis?
* lumpy painful breasts
* middle aged women
* symptoms may worsen prior to menstruation
114
What are the key features of breast cancer?
* hard irregular lump
* may be nipple inversion / skin tethering
115
What are the key features of Paget's disease of the breast?
* intraductal carcinoma
* reddening and thickening (may resemble eczema) of nipple / areola
116
What are the key features of mammary duct ectasia?
* dilatation of large breast ducts
* common around menopause
* tender lump around areola +- green nipple discharge
* if ruptures - local inflammation
* sometimes referred to as plasma cell mastitis
117
What are the the key features of duct papilloma?
* local areas of epithelial proliferation in large mammary ducts
* hyperplastic lesions rather than malignant or premalignant
* blood stained discharge
118
What are the key features of breast abscess?
common in lactating women
red, hot tender swelling
119
What is the screening programme for colorectal cancer?
* FIT sent every 2 years
* aged 60-74 years in England
* aged 50 - 74 years in Scotland
120
What proportion of patients with positive FIT have cancer at colonoscopy?
approx 1 in 10 (4/10 have polyps)
121
What is the precursor to most colorectal cancers?
adenomatous polyps
122
What organism is the commonest cause of breast abscess in lactational women?
Staphylococcus aureus
123
What is the management of breast abscess?
incision + drainage or needle aspiration (using US) + abx
124
When is breast cancer screening offered?
every 3 years (mammogram) between age 50- 70 years
125
What are 9 indications for referral to the breast clinic for screening in patients with a first or second degree relative with breast cancer?
1. age of diagnosis < 40 y
2. bilateral breast cancer
3. male breast cancer
4. ovarian cancer
5. Jewish ancestry
6. sarcoma in a relative younger than age 45 years
7. glioma or childhood adrenal cortical carcinomas
8. complicated patterns of multiple cancers at a young age
9. paternal history of breast cancer (two or more relatives on the father's side of the family)
126
What are 6 indications for referring a woman to breast clinic for further assessment to be screened from a younger age?
1. first-degree female relative diagnosed with breast cancer at **younger than age 40 years**
2. first-degree **male** relative diagnosed with breast cancer at any age
3. first-degree relative with **bilateral breast cancer** where the first primary was diagnosed at younger than age **50 years**
4. **two first-degree relatives**, or **one first-degree and one second-degree relative**, diagnosed with breast cancer at any agee
5. first-degree or second-degree relative diagnosed with **breast cancer** at any age and one first-degree or second-degree relative diagnosed with **ovarian cancer** at any age (one of these should be a first-degree relative), or
6. **three** first-degree or second-degree relatives diagnosed with breast cancer at any age
127
What is the management of breast cysts?
* **aspiration** of cyst (risk of breast cancer)
* blood stained / persistently refill: **biopsy or excise**
128
What is the management of a fibroadenoma?
* > 3cm: surgical excision
* Phyllodes tumours - widely excise, (mastectomy if large)
129
What is breast sclerosing adenosis?
radial scars and complex sclerosing lesions
130
What are 4 features of the presentation of breast sclerosing adenosis?
1. breast lump or pain
2. mammographic changes which may mimic carcinoma
3. distortion of distal lobular unit without hyperplasia
4. disorder of involution
131
Is breast sclerosing adenosis pre-malignant?
no
132
What is the management of breast sclerosing adenosis?
lesions should be biopsied, excision not mandatory
133
How does epithelial hyperplasia of the breast present?
generalised lumpiness thorugh to discrete lump
134
What is epithelial hyperplasia of the breast?
increased cellularity of terminal lobular unit, atypical features may be present
135
What features in breast epithelial hyperplasia confer a greater risk of malignancy?
* atypical features
* FH of breast cancer
136
What is the management of a duct papilloma?
microdochectomy
137
What is a normal ABPI?
0.9-1.2 (<0.9 - arterial disease, > 1.3 can also indicate arterial disease due to arterial calcification)
138
What is the first line management of venous ulceration?
compression banaging (4 layer)
139
What are 3 aspects of the maangement of venous ulceration?
1. compression bandaging
2. oral pentoxifylline (peripheral vasodilator)
3. flavinoids
140
What type of volvulus acconuts for the majority of cases? What is the remainder?
* sigmoid volvulus - 80% of cases
* caecal volvulus - 20% ocases
141
How can you distinguish between sigmoid and caecal volvulus?
sigmoid causes large bowel obstruction, caecal volvulus causes small bowel obstruction
142
What are 5 associations of sigmoid volvulus?
1. older age
2. chronic constipation
3. Chagas disease
4. neurological conditions - Parkinson's, Duchenne MD
5. Psychiatric conditions e.g. schizophrenia
143
What are 3 associations of caecal volvulus?
1. affects all ages
2. adhesions
3. pregnancy
144
What is the sign on AXR of sigmoid volvulus?
coffee bean sign
145
What is the management of sigmoid volvulus?
rigid sigmoidoscopy with rectal tube insertion
146
What is the management of caecal volvulus?
operative - often R hemicolectomy
147
What are the initial steps for investigation for suspected acute limb-threatening ischaemia?
* handheld arterial Doppler exam
* if Doppler signals present - ABPI
148
In acute limb-threatening ischaemia what are 4 features suggestive of thrombus?
1. pre-existing claudication + sudden deterioration
2. no obvious embolic source
3. reduced/absent pulses in contralateral limb
4. widespread vascular disease e.g. MI, stroke, TIA, previuos vascular surgery
149
In acute limb-threatening ischaemia what are 5 features suggestive of embolus?
1. sudden onset of painful leg (<24h)
2. no h/o claudication
3. obvious source of embolus e.g. AF, recent MI
4. no evidence of peripheral vascular disease (normal pulses contralateral limb)
5. evidence proximal aneurysm (abdo aorta, popliteal)
150
What is the initial management of acute limb-threatening ischaemia?
* analgesia - IV opioids
* IV UFH
* vascular review
151
What are 5 options for definitive management in acute limb threatening ischaemia?
1. intra-arterial thrombolysis
2. surgical embolectomy
3. angioplasty
4. bypass surgery
5. amputation - if irreversible ischaemia
152
Is there an increased risk of malignancy with fibroadenoma?
no
153
What is the commonest type of breast cancer?
invasive ductal carcinoma (no special type)
154
What are 4 commonest types of breast cancer?
1. invasive ductal carcinoma (commonest)
2. invasive lobular carcinoma
3. ductal carcinoma in situ (DCIS)
4. lobular carcinoma in situ (LCIS)
155
What is an indication to refer someone with a forearm laceration to plastics?
involvement of tendon sheath
156
What are 4 aspects of staging in patients diagnosed with colorectal cancer?
1. CEA
2. CT TAP
3. colnoscopy OR CT colonography
4. if tumour below peritoneal reflection - mesorectal evluation with MRI
157
When is hormonal therapy offered for breast cancer?
if tumours positive for hormone receptors
