General surgery Flashcards by Belle Storey

Give 3 symptoms of acute appendicitis

Umbilical to RIF pain
Mild pyrexia (37.5-38)
Loss of appetite (v common)
Nausea

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Why is the pain of appendicitis first felt in the periumbilical region

General irritation of the visceral peritoneum = T10 dermatome (periumbilical)

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Why does the pain of appendictis migrate to the RIF

Parietal peritoneum (well localised somatic innervation)

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Describe the psoas sign

Pain on extending hip if retrocaecal appendix

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Diagnosis of appendicitis and definitive management

Compatible history + exam with raised CPR
Neutrophil-predominant leucocytosis
Female pts: urinalysis (leucocytosis without nitrites), pregnancy test, ultrasound

Laparoscopic appendicetomy with prophylactic IV antibiotics

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Give 2 possible complications of appendicitis

sepsis
perforation
appendix mass (adhesion)
parayltic ileus
obstruction

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What is a diverticulum

Herniation of colonic mucosa through the muscular wall of the colon

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Which section of the colon are diverticula commoner in

sigmoid colon (majority of water has been reabsorbed by this point = high intraluminal pressure)

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Define diverticulosis, diverticular disease and diverticulitis

Diverticulosis = presence
Diverticular disease = symptomatic
Diverticulitis = inflammation

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Give one mainstay of the conservative management of diverticulitis

Increase dietary fibre
Analgesia
Antibiotics
Adequate hydration

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What are two possible complications of diverticulitis

Perforation
Blood loss
Abscess

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What is the definition of a hernia

protruding of a structure through the wall of cavity in which it is usually contained

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With relation to the pubic tubercle, how do you differentiate between inguinal and femoral hernias?

the neck of an inguinal hernia appears superior and medial to the pubic tubercle

the neck of a femoral hernia appears inferior and lateral to it

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Give 2 risk factors for inguinal hernias

prematurity
male sex (95%)
chronic cough
constipation
obesity
heavy lifting

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Give 2 complications following inguinal mesh repair surgery (open or laparoscopic)

Bleeding
Injury to ilioinguinal nerves
Injury to vas deferens
Bowel or bladder damage
Wound infection
Urinary retention
Recurrence

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What line divides internal and external haemorrhoids?

Dentate line

External: originate below, painful
Internal: originate above, not painful

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Other than PR bleeding, give 2 symptoms of haemorrhoids

Painless rectal bleeding most common symptom
Pain not significant unless piles are thrombosed
Anal pruritus
Soiling may occur with 3rd or 4th degree piles

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Grading of internal haemorrhoids

Grade I: do not prolapse
Grade II: prolapse on defecation but reduce spontaneously
Grade III: manually reduced
Grade IV: cannot be reduced

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Name 2 conservative management options for haemorrhoids

Increase fluid intake
Increase fibre intake
Topical local anaesthetics and topical steroids

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give 2 procedures to manage haemorrhoids

Rubber band ligation
Injection sclerotherapy

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Name 1 complication of haemorrhoids

Ulceration
Acute thrombosed external (purplish, oedematous, tender perianal mass)
Infection

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Presentation of acute mesenteric ischaemia

Abdo pain typically severe, sudden onset and out of keeping with physical exam

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what acid-base disturbance is commonly a/w acute mesenteric ischaemia

metabolic acidosis with raised lactate

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other than metabolic acidosis, give 2 other abnormalities found on blood tests in mesenteric ischaemia

raised WCC
raised lactate
raised Hb
raised amylase

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what is the gold standard for imaging in suspected acute mesenteric ischaemic

High resolution CT angiography (without oral contrast)

Management of acute mesenteric ischaemia and what are the aims of surgery

Immediate laparotomy Resection of necrotic bowel Revascularisation

Other than the spleen, name 2 other organs in the LUQ

Left kidney Left adrenal gland Stomach Pancreas Left lobe of lung

What is the function of the red pulp of the spleen?

filter and destroys defunct RBC

What is the function of the white pulp of the spleen?

lymphoid tissue which acts as part of the immune system

Apart from trauma, give 2 indications for splenectomy

Trauma Spontaneous rupture (EBV) Hypersplenism Malignancy (lymphoma, leukaemia) Splenic cyst

what types of organisms are people susceptible to following splenectomy

Encapsulated bacteria: *NHS* neisseria meningitidis haemophilus influenzae streptococcus pneumoniae

due to susceptibility to infection, give 2 important aspects of long-term management following splenectomy

lifelong prophylactic antibiotics (penicillin V or erythromycin) vaccination (pneumococcal, meningococcal, influenza)

What are Howell-Jolly bodies?

RBC where nuclear remnant still seen

Causes of acute pancreatitis?

I GET SMASHED Idiopathic Gallstones Ethanol Trauma Scorpion Mumps Autoimmune Steroids Hyperlipidaemia, hypothermia, hypercalcaemia ERCP Drugs

What blood test would confirm pancreatitis with a clinical picture

serum lipase (sensitive and specific) clinical diagnosis +/- ultrasound

Name 4 complications of acute pancreatitis

ARDS Psuedocyst Necrosis Abscess Chronic pancreatitis

describe the basis of management of pancreatitis

IV aggressive fluid resuscittaion Analgesia (IV morphine) NG tube ICU *do not offer prophylactic antibiotics*

What are the 4 main features of bowel obstruction

Constipation (may be complete = not passing flatus or stool) Colicky abdominal pain Vomiting Distention

what clinical sign would distinguish between ileus and mechanical obstruction

absence of bowel sounds indicates an ileus, tinkling indicates mechanical

what investigation would help to distinguish between small and large bowel obstruction

abdo X-ray small: valvulae conniventes large: haustra

immediate management of bowel obstruction

drip and suck: IV fluids NBM NG tube with free drainage IV antibiotics if signs of perforation or ischaemia

what is contained within bile

bile salts, bile pigments, cholesterol, phospholipid, electrolytes

name 2 types of gallstones based on composition

pigment stones cholesterol stones mixed stones

what are risk factors for developing gallstones

fat, forty, fertile, female, fair

what is Murphys sign

cessation of inhalation when pressing the gallbladder, positive if repeated on LIF and no pain

What imaging would confirm the diagnosis of cholecystitis

biliary ultrasound

Management of cholecystitis

NBM IV fluids analgesia antibiotics Defintive: cholecystectomy within 48h

Name the 4 lobes of the liver

right left caudate quadrate

Which ligament divides the anterior of the liver into the two anterior lobes

falciform ligament

Name 3 common origins of secondary tumour to the liver

bowel, breast, lung, uterus

what tumour marker is commonly raised in hepatocellular carcinoma

alpha fetoprotein

small bowel obstruction vs large bowel obstruction

small bowel: pain is higher vomiting occurs earlier abdominal distention is less

give 4 common causes of bowel obstruction

constipation adhesions hernias tumour diverticulitis

name 3 causes of hepatocellular carcinoma

viral hepatitis cirrhosis (alcohol, PBS)

Post surgical respiratory depression and other signs you might find

Opioid overdose Pinpoint / constricted / small pupils Dizziness / disorientation Shallow / slow / stopped breathing Cold / clammy / blue / purple / gray / ashen skin or fingernails Snoring / gurgling / snoring sounds Decreased GCS / GCS <15 / less responsive / unresponsive / unable to wake

Initial imaging to investigate ascending cholangitis

Abdo ultrasound

Patient with cholangitis has low BP, tachycardia and fever: what multi step management should be carried out immediately?

BUFALO Blood cultures Urine output Fluid challenge Antibiotics Lactate Oxygen

What is the pathophysiology of Mirizzi syndrome

Gallstone becomes impacted in cystic duct which causes compression of common hepatic duct resulting in jaundice

Most common histological subtype of rectal carcinoma

Adenocarcinoma

Give 2 possible causes of rectal bleeding in 70 y/o man

Rectal cancer Anal fissure Haemorrhoids Diverticular disease

Urgent investigation to confirm diagnosis of rectal cancer

Sigmoidoscopy + biopsy

Blood marker used to monitor response to treatment in rectal cancer

Carcinoembryonic antigen

Surgery offered for rectal carcinoma

Anterior resection

2 ways to differentiate an ileostomy and colostomy

Ileostomy: spouted, colostomy: flushed to skin Ileostomy: liquid contents, colostomy: solid

Factors indicating severe pancreatitis

Hypoxia Age >55 Hypocalcaemia Hyperglycaemia