General surgery Flashcards
What is the general pathophysiology of bowel obstruction (4)
mechanical obstruction leads to increased peristalsis leads to fluid shifts into the bowel which is electrolyte rich, this causes 3rd spacing of fluids and the patient requires fluid resuscitation.
What is the pathophysiology of closed loop bowel obstruction (4)
proximal and distal loop of bowel become obstructed , causes distension, causes ischaemia can cause perforation. surgical emergency
what are two causes for small bowel obstruction?
adhesions and hernia
what are three causes for large bowel obstruction ?
malignancy, diverticulosis and volvulus
What are some intraluminal causes of bowel obstruction?
gallstone, foriegn body, fecal impaction
what are some mural causes of bowel obstruction?
intussection particularly in crohns disease , cancer, meckels diverticulum, lymphoma, stricture.
what are some extramural causes of bowel obstruction
hernia, adhesions, peritoneal mets, volvulus.
on an AXR how would you identify a bowel obstruction by the small bowel appearance?
dilated to > 3 cm and you can tell its the small intestine because of the valvulae conniventies lines will cross the whole bowel
what are some signs of large bowel obstruction on the AXR?
dilated bowel >6cm and >9cm at the caecum , haustal lines will be visible and they will go half way around the bowel
What are some clinical examination findings that may indicate a bowel obstruction?
abdominal distension
dry on exam
hernia may be visible
old surgical scars
cachexia
percussion for pympanic sound
tinkling bowel noises
if guarding or rebound tenderness developing then ischaemia may be present.
what is the treatment for bowel obstruction?
fluid assessment and resusitation
IDC insertion and monitoring fluid status
NG tube
gastrograffin study
if not improved within 48 hours may need laparotomy
if closed loop, need emergent laparotomy and defunctioning stoma.
What are the two main categories for dysphagia
mobility and mechanical
list the mechanical causes for dysphasia
esophageal/ H+N carcinoma
esphageal strictures or web
extrinsic compression i.e thyroid carcinoma or pharyngeal pouch
what are some motility disorders of the esophagus ?
CVA
achalasia
diffuse esophageal spasm
eosinophilic esophagitis
neurological disorders like MS
muscular disorders like MD
rheumatological conditions like systemic sclerosis
What ate treatment options of achalasia ?
Conservative: eating and sleeping upright. botox.
surgical: myotomy, balloon dilatation and esophagectomy
What are the treatment options of diffuse esophageal spasm?
calcium channel blockers , pheumatic dilatation, myotomy
What are some causes for gastric outlet obstruction?
pyloric ulcer, duodenal mass including lymphoma, foreign body , gastric cancer, bouveret syndrome from gall stone fistulation, pancreatic psuedotumour.
What is the treatment for gastric outlet obstruction?
hydration, NG tube, PPI
What are risk factors for gastric cancer?
H.Pylori infection, male, smoking, old, male, alcohol.
by what pathophysiological mechanism does H.Pylori create castric cancer?
infection, acute inflammation, chronic inflammation, metaplasia, dysplasia, then carcinoma.
what are some clinical features of gastric cancer. ?
virchows node, early satiety, malena, nausea and hematemesis.
what must be supplemented post gastrectomy ?
B12
What is the difference in location of the GOJ in sliding and rolling hiatus hernias?
sliding the GOJ moves up , rolling the GOJ is below the diaphragm and the fundus is above.
What are risk factors for hiatus hernia formation?
obesity, pregnancy, elevated intrathoracic pressure and chronic cough.
What are conservative management options for hiatus hernia?
weight loss, stop smoking, PPI , low fat diet and no alcohol.
What are the surgical management options for hiatus hernia?
curoplasty and fundoplication usually lap but can be open
What are some potential complications of fundoplication?
ischaemia becuase the left gastric and short gastric arteries are affected, dysphagia, inability to belch, can recur.
What is the management of a perforation in the GIT?
NG tube
fluid resus
IV abx
OT for washout (conservative if well contained)
what are the surgical treatment options for gastric, small intestine and large intestine perforation?
gastric : omental patch
small intestinal: resection +/- primary anastomosis or stoma.
large intestine : stoma is preferred
what are 5 causes of haematemesis?
mallory weis tear or boerharve syndrome
gastric or esophageal carcinoma
gastritis
vascular malformations (angiodysplasia)
varices
What are key questions to ask when taking the medical history of someone with haematemsis?
lifestyle factors like smoking or drinking
symptoms associated
drugs like NSAIDS, bisphosphonates, steroids and anticoagulants.
What is a scale used to determine the severity of an upper GI bleed?
Glasgow, blatchford bleeding scale.
What is the definition of Barrets esophagus?
any part of the esophagus which has had squamous to metaplastic columnar epithelium
What is the immediate management of known variceal bleeding
resusitation, antibiotics, blood products and octreotide to reduce splanchnic blood flow. balloon tamponade and banding are difinitive.
what is the initial investigations and management of a boer harve tear?
Investigate with CT chest:
treat with: agressive resusitation, antibiotics and antifungal, blood products, NG tube , treat the cause if there is distal obstruction.
what are the surgical management options for boerharve tear?
primary retpair, resection, esophagectomy, washout of the pleural cavity, they need a CT scan with contrast before eating and a lot con condieration need to be taken for their nutrition as they may need a jujostomy feeding tube
What are some common causes of malena?
angiodysplasia, gastric or duodenal bleeding ulcer, variceal bleed, cancers, gastritis from NSAIDS or H.Pylori, meckels diverticulum.
What are key things to remember in the examination of the abdomen with a patient with malena?
peritonism, hepatomegaly and any stigmata of liver disease, DRE
What marker is specifically elevated in malena?
urea
What are some options for a patient with malena who is not fit for a scope?
CT-a, capsule endoscopy, RBC skintography.
what is the treatment for angiodysplasia?
endoscopic argon plasma coagulation
What other options apart from argon coagulation can be useful for angiodysplasia? and what risks do they carry?
super selective arterial embolisation, carry the risk of arterial dissection and ischaemia of the tissue and hematoma. Surgery is another option for refractory bleeding.
What are some common causes of lower GI bleeding?
diverticuliits, malignancy, haemorhhoids, angiodysplasia, IBD, infective colitis.
When taking a history of rectal bleeding what are some questions you should ask as to the nature of the bleeding?
when did it start? how long does it last? colour? is it related to defecation? incoprorated into stool?
What are some key questions you should ask when taking a history of associated symtpoms of rectal bleeding?
any mucus? pain? malena? haematemesis? previous episodes and weight loss?
in a patient with rectal bleeding what important information woudl you obtain in a history about family and personal history?
family history fo bowel cancer or IBD. personal history of anticoagulant use.
what are 3 main categories for presentation with an acute andomen?
bleeding: AAA, ectopic, bleeding abscess.
perforated viscus
ischaemia: closed loop bowel obstruction
What investigations would you obtain for an acute abdomen?
bloods: FBC, UEC, CRP, ABG, pregnancy test, UA, USS and CT abdomen.
What is the most common cause of mesenteric ischaemia?
embolism in the SMA,
What investigation would you choose for investigation for mesenteric ischaemia?
CT arterial phase or invasive angiogram
how do you treat occlusive ischaemaia of the bowel?
surgically may require stenting, but if ischemic and peritonitic will need more urgent surgery
What causes pseudomembranous colitis?
C.Difficile has exotoxins which cause inflmaation.
What are the consequences of pseudomembranous colitis?
severe bloody diarrhoea, toxic megacolon
What is the treatment for mild and severe C.Diff infection?
oral metronidazole and oral vancomycin for severe.
What is carcinoid syndrome?
the syndrom occurs when a metastasis from a carcinoid tumour where the cells oversecrete their bio active mediators. such as serotonin , prostaglandins, and gastrin into circulation.
how does someone with carcinoid syndrome present?
flushed with palpitation, intermittent abdominal pain, diahroes,
What investigations can be carried out for investigating carcinoid tumour?
Chromogranin A or B, pancreatic polypeptide, needs endoscopy and biopsy, needs imaging with skintogrpahy or Ct
What is the treatment for neuroendocrine tumours?
if well differentiated and only in bowel and liver then resection, if poorly differentiated or spread further then palliative . can treat carcinoid syndrome with somatostatin analogues like octreatide.
What are some common risk factors for adenocarcinoma of the bowel?
chrones disease, lunch syndrome, puertz yajer syndrome, familial adenomatous polyposis, coeliac disease and old age. high meat in take. family history., smoking . alcohol.
What are 6 common presentations of appendicitis?
tender McBurneys point 1/3 of the way to the umbilicaus,
positive rosvigs sign
possibly psoas sign if retrocaecal appendix
presentations starts with dull periumbilical pain
which will radiate to the RIF
eventually associated with guarding and rigidity from peritonitis.
what investigations woudl youchoose to infestigate RIF pain?
bloods, inc cloags, adn pregnancy test, UA, USS abdomena dn then CT
what specific imagign modality would you choose for rectal carcinoma?
MRI rectum
When would an APR be used over an abdominal resection?
if the lesion is < 5 cm from the anus.
Where is the bowel is radiotherapy used?
rectal not bowel cancer.
What type of cancer is anal cancer ususally
SCC
What is the man cause of anal cancer?
HPV
What are some other causes of anal cancer
HIV, chrons, immuocompomise, skin cancers, age, smoking,
Where would spread from anal cancer go?
to the iliac nodes , meso rectal adn para-aortic.
how woudl you investigate for anal cancer?
proctoscopy, smear for cytology, vault exam in women, if positive lymphadenopathy then biopsy the node.
How do you treat anal cancer?
chemo rads, surgical resection APR or full posterior exenteration.
what are some complications of anal radiation?
dry vagina, proctitis, dermatitis, cystiits, diarrhoea, fecal incontience,
What are someinvestigations for anal abscess?
HBA1C for diabetes, and inflmamtory markers.
When might further imaging be helpful in anal abscess?
when the abscess is higher up like ischiorectal or pupralevator.
what is the man stay of treatment for anal abscess?
antibiotics and incision adn drainage.
While perfroming the incision and drainage what is important to examine for?
any fistua present. and remember to allow to heal my secondary intention.
What are the 4 grades of haemohhoids
- Stay inside
- 2 retract inside post defecation
- Need digitation to retract
- Cannot retract
chat are causes of haemorrhoids?
straining, pregnancy, raised intra abdominla pressure.
how do you investigate for haemohhoids?
need a colonoscopy to make sure nothing else is causing symtposm.
what are some medical manaemetn options for haemorrhoids?
Ice and lignocaine gel
what type fo haemohhoid can be treated with a rubber band ligation?
1st and 2nd degree haemohhoids.
3rd adn 4th degree haemohhoids are most suitable for what surgical treatmetn?
haemohhoidectomy
What are complications of haemohhoids surgery?
recurrence, stricturing or fecal incontinence
What is the most common cause fo peri-anal fistula?
absecss
What are other cuases of anal fistula?
chrones disease, diabetes, systemica illness, anal trauma, radiation.
What surgical treatment options are there for anal fistula ?
fistulotomy, glue, seton
What are conservative measures for treating rectal prolapse?
increased fiber, and fluids
What surgical treatment options are there for rectal proplaspse?
rectopexy , rectum is fixed to the sacral primenence with stitches or mesh . can be by the abdominal approach or perineal.
What are the two types of cadaveric organ donors?
Donation after brainstem death (DBD)
donation after circulatory death (DCD)
What are contraindications for a heart transplant?
active infection ie TB, BMI >35, pulmonary hypertension, malignancy.
What are contraindications to lung transplant?
active malignancy or infection and any chest wall deformity
What are some early complications from a lung transplant?
bronchial dehiscence and air in the mediastinum
re-perfusion injury (may require ECMO)
infections due to immunocompromised.
what are some complications of renal transplant?
delayed graft function: defined if needing dialysis within 1 week of surgery.
vascular complications: early renal artery adn vein thrombosis. late: renal artery stenosis.
Ureteral: urine leaks, stricture at the anastomosis.
very long term: high risk of dying from cardiovascular disease.
What ar common complciations post liver transplant?
bleeding and death within a year, primary grant non function , arterial and venous thrombosis is the most common, biliary complications like leaks and strickures, rejection,
What are some complications post pancreas transplant?
acute rejection
pancreatig leak
portal venous thrombosis.
pancreatitis
What are some special things to mention in the consent for a diagnositic lap?
all the normal things
Bleeding, pain, infection, anesthetic risks.
+ remember
early
stoma formation
late
hernia
adhesions
and need for further operations
What are some special things to mention in the consent for EUA?
all the normal things
Bleeding, damage to surrounding structures, pain, infection, anesthetic risks, VTE. Small risk of MI, CVA or death.
+
recurrence and may require another surgery
damage to the sphincter
What are some special things t mention in the consent for a hartmans?
all the normal things
Bleeding, damage to surrounding structures, pain, infection, anesthetic risks, VTE. Small risk of MI, CVA or death.
+
ileus
dehissence of the rectal stump anastomosis.
Stoma problems like retraction, hernia, prolapse.
inability to restore the bowel again in the future.
what are some special things to remember with consenting someone for a bowel resection?
all the normal things
Bleeding, damage to surrounding structures, pain, infection, anesthetic risks, VTE. Small risk of MI, CVA or death.
all the things to do with stoma
+
short gut syndrome
What are some key things to consent someone for in an appendicectomy ?
all the normal things
Bleeding, damage to surrounding structures, pain, infection, anesthetic risks, VTE. Small risk of MI, CVA or death.
+
need to add if attached to ovary may need to take that too.
+ conversion to open
What are the key things to consent for in abscess drainage
all the normal things
Bleeding, damage to surrounding structures, pain, infection, anesthetic risks, VTE. Small risk of MI, CVA or death.
But also scarring and risk of re-accumulation
what are some key things to consent someone for in an inguinal hernia repair?
all the normal stuff + possible conversion to open.
+
altered sensation to the ilioingional or genitofemoral nerves
seroma/ scrotal swelling
testicular atrophy
recurrence
for open and lap procedures what must be conveyed to the patient?
they likelyhave chronic pain in the eare pre op- this may continue post op
What are some key things to discuss when consenting for a hiatus hernia repair?
all the usual things
conversion to open
will possibly reguire a thoracic drain
pneumothorax or surgical emphysema
esopahgeal or gastric perforation
long term
difficulty belching
bloating
dysphagia if too tight
re-do operation if too loose.
apart from all the normal lap stuff what else do you specifically need to consent someone for in a sleeve gastrectomy?
anastomotic leak
metabolic and endocrine disturbances
failure to lose weight
What are some of the specific things to consent in a Roux-en -Y surgery?
all the laparoscopic stuff
and
anaesomotic leak
gastric ulcer
metabolic and endocrine disturbances
internal hernia
failure to lose wieght
What are some things to consent for an esophagectomy?
injury to extensive surrounding structures for lymphadenopathy.
high risk of anastomotic leak 8 %
chyle leak 3%
re-operation 10%
nutritional deciciencies
Some things to consent someone for in endoscopy?
bleeding, especially if varices
perforation
sedation
damage to teeth
aspiration
What are key things to consent in a lap chole?
all the normal Lap stuff
+
bile leak
conversion to open
leaving as a subtotal cholecystectomy with drain insertion
diarrhoea or reflux gastritis
bile duct structure
Apart from all the Lap and stoma stuff what else do you need to talk to the patient about for an APR?
sexual dysfunction
In an anterior resection what are some additional specific things which you need to talk to the paiten about?
sexual dysfunction as well as “low anterior resection syndrome” tennismus, fecal incontinence feelings.
when consenting for fistula surgery what are soem key things to remember ?
high recurrence
anal strciture
lay open and will take 12 weeks to improve
