General Surgery Flashcards
1
Q
What are the therapeutic indications for upper GI endoscopy?
A
Treat bleeding lesions
Variceal banding and sclerotherapy
Stricture dilatation
Stent insertion
2
Q
What are the diagnostic indications for colonoscopy?
A
Rectal bleeding Iron deficiency anaemia Persistent diarrhoea Biopsy lesion seen on barium enema Assess/suspicion of IBD Colon cancer surveillance
3
Q
What are the therapeutic indications for colonoscopy?
A
Haemostasis Bleeding angiodysplasia lesion Volvulus untwisting Pseudo-obstruction Polypectomy
4
Q
What sedatives can be used in endoscopy?
A
Medazolam to remain conscious
Propofol for GA
5
Q
What is duodenal biopsy used for?
A
Gold standard diagnosis of Coeliac disease
6
Q
How far can a sigmoidoscopy view?
A
Rectum and sigmoid colon up to splenic flexure
7
Q
What are the dietary requirements to prepare for colonoscopy?
A
Low residue diet 1-2 days preop
Clear fluids but no solid food after lunch day before
8
Q
What bowel prep is used for colonoscopy?
A
Sodium picosulfate morning and afternoon day before
9
Q
What are the potential complications of colonoscopy?
A
Abdominal discomfort
Incomplete examination
Haemorrhage after biopsy or Polypectomy
Perforation
10
Q
How does a carcinoma differ in appearance to a polyp?
A
Carcinoma is irregular in shape/colour and is larger and more aggressive
11
Q
What does active ulcerative colitis look like on colonoscopy?
A
Mucosa red and inflamed
Friable - bleeds on touch
Severe: mucopurulent exudate, mucosal ulceration and bleeding
12
Q
What are the conservative measures for peptic disorders?
A
No spicy or acidic food
Reduce alcohol intake
Smoking cessation
Avoid certain meds eg NSAIDs
13
Q
What medications are used to treat peptic disorders?
A
Antacids
Alginates
H2 receptor antagonist
PPI
14
Q
What is triple therapy for peptic ulcers?
A
PPI
2 antibiotics
15
Q
What does a partial Gastrectomy involve?
A
Remove affected part of stomach
Anastomose remnant of stomach with either the duodenum or an ileal loop
16
Q
What are the long-term side effects of a partial gastrectomy?
A
Can only eat small meals Dumping Bilious vomiting Obstruction of gastric outlet Weight loss Vit B12 deficiency Iron deficiency anaemia Malignant change in gastric remnant
17
Q
What is dumping syndrome?
A
Fainting and swearing after eating
Food with high osmotic potential dumped in jejunum, causing oligaemia from rapid fluid shift
Helped by eating less glucose
18
Q
Why may vitamin B12 deficiency happen after gastric surgery?
A
No intrinsic factor production
19
Q
What is a Billroth I procedure?
A
Partial Gastrectomy with simple gastroduodenal re-anastomosis
20
Q
What is a Billroth II procedure?
A
Partial gastrectomy with gastrojejunal anastomosis
21
Q
What is a Roux-en-Y procedure?
A
Anastomosis between stomach and part of small bowel distal to the cut end
22
Q
When is surgery indicated for peptic ulcers?
A
Haemorrhage
Perforation
Pyloric stenosis
23
Q
What is an HSV?
A
Highly selective vagotomy
Vagus supply denervated where it supplies the lower oesophagus and stomach
24
Q
What is laparoscopic fundoplication?
A
Defect in diaphragm repaired by tightening the crura
Prevent reflux by wrapping fundus of stomach around lower oesophageal sphincter
25
What are the indications for surgery for obesity?
```
BMI >40 or >35 with significant comorbidities that would improve with surgery
Failure to loose weight over 6 months
As integrated approach to weight loss
Patient well-informed and motivated
BMI>50 surgery is 1st line
```
26
What are the main mechanisms underlying surgery for obesity?
Restrict calorie intake by reducing stomach capacity
| Reduced length of functional small bowel to reduce absorption
27
How does gastric banding work?
Creates a pre-stomach pouch by placing a band around the top of the stomach
Can adjust the band to alter restriction
28
What are the potential complications of gastric band surgery?
Pouch enlargement
Band slip/erosion
Port infection or breakage
29
How does gastric bypass surgery work?
Jejunum attached to small stomach pouch
Allows food to bypass distal stomach, duodenum and proximal jejunum
Restriction and malabsorption
30
What are the potential complications of gastric bypass surgery?
```
Micronutrient deficiency
Dumping syndrome
Wound infection
Hernias
Malabsorption
Diarrhoea
Mortality 0.5%
```
31
What is the incidence of pancreatic cancer?
8 per 100,000 females
10 per 100,000 males
32
What is the incidence of oesophageal cancer?
8 per 100,000 females
| 16 per 100,000 males
33
What are the risk factors for oesophageal cancer?
```
Obesity
Barrett's oesophagus
Reflux
Smoking
Alcohol
```
34
What is the type of cancer found more commonly in the distal oesophagus?
Adenocarcinoma
35
What is the type of cancer found more commonly in the proximal oesophagus?
Squamous cell carcinoma
36
How does oesophageal cancer present?
```
Dysphagia
Weight loss
Regurgitation
Retrosternal chest pain
Hoarseness of voice
Cough
```
37
What are the risk factors for stomach cancer?
H.pylori infection
| Smoking
38
What are the common presenting symptoms of gastric cancer?
Non-specific: dyspepsia, weight loss, vomiting, dysphagia, anaemia, epigastric pain
39
Where does gastric cancer commonly spread?
Ovaries
40
What signs suggest gastric cancer is incurable?
```
Epigastric mass
Hepatomegaly
Jaundice
Ascites
Large left supraclavicular mode
```
41
How do bile duct and gallbladder cancers present?
```
Obstructive jaundice
Pruritis
Abdominal pain
Weight loss
Anorexia
```
42
What is the most common cancer in the liver?
Mets from colorectal cancer
| Rarely kidney or endocrine mets
43
What proportion of liver resections are for primary liver cancer?
10%
44
What are the different types of pancreatectomy?
Whipple
Distal
Total
45
What are the diagnostic indications for upper GI endoscopy?
```
Haematemesis
New dyspepsia >55yo
Gastric biopsy ?cancer
Duodenal biopsy
Persistent vomiting
Iron deficiency
```
46
Why do high levels of unconjugated bilirubin make you ill?
It crosses the BBB
47
Where does unconjugated bilirubin come from?
Mainly moron RBC breakdown
| Some from myoglobin
48
Where are bile salts reabsorbed?
Terminal ileum
49
What are the functions of bile?
Helps absorb fats
Neutralises chyme
Excretes cholesterol
50
What are the causes of pre-hepatic jaundice?
Haemolysis eg spherocytosis
| Gilbert's syndrome - defect in liver uptake of unconjugated bilirubin
51
What are the blood test findings in Gilbert's syndrome?
Raised bilirubin
| Normal LFTs
52
What are the causes of hepatic jaundice?
Viral or alcoholic hepatitis
Drug induced eg amoxicillin and flucloxacillin
Cirrhosis
53
What is surgical jaundice?
Obstructive (post-hepatic) jaundice
54
What is the most common cause of obstructive jaundice?
Gallstones
55
What are the other causes of obstructive jaundice?
Malignant
Benign eg biliary stricture
Autoimmune eg sclerosing Cholangitis
Congenital
56
What does a rapid rise in bilirubin suggest?
Malignancy
57
What malignancies can cause obstructive jaundice?
```
Hilar cholangiocarcinoma
Gallbladder
Distal cholangiocarcinoma
Ampullary tumours
Pancreatic
```
58
What do you need to ask about in a history of obstructive jaundice?
```
Abdominal pain
Fever
Itching
Alcohol
Drugs
Weight loss
```
59
What are you looking for on physical examination of someone with jaundice?
```
Masses
Hepato/Splenomegaly
Stigmata of liver disease
Ascites
Caput medusa
```
60
What do raised ALP and bilirubin suggest?
Obstructive cause of jaundice
61
How do you manage stones in the common bile duct?
ERCP
62
What is Courvoisier's law?
In the presence of jaundice, a palpable gallbladder is unlikely to be gallstones
63
What are the risk factors for gallstones?
```
Fair
Fat
Female
Fertile
Forty
```
64
What are the most common type of gallstones?
Mixed (cholesterol and pigment)
65
What is biliary colic?
Pain in the absence of infection
Most common presentation of gallstones
Transient obstruction of cystic duct by gallstone
66
How does biliary colic present?
RUQ pain, colicky in nature
Abrupt onset, ?exacerbated by fatty foods
Associated with nausea and vomiting
No raised WCC or pyrexia
67
How is biliary colic managed?
Try not to admit
| Bring back as day case for lap chole
68
What is acute chole cystitis?
Obstruction of cystic duct by gallstone
| Leading to inflammation and involvement of parietal peritoneum
69
What is Murphy's sign?
Deep breath in - liver moves down - you can feel gallbladder
| If this causes pain, indicates gallbladder is inflamed (acute cholecystitis)
70
What are the notable biochemical abnormalities in acute cholecystitis?
WCC raised
| Mildly raised ALP
71
What is the investigation of choice for gallstones?
Ultrasound: 90% sensitive and specific
72
Why should you check amylase when gallstones are suspected?
Not uncommon to have cholecystitis and pancreatitis at the me time
73
What constitutes evidence of stones in the common bile duct?
Visible jaundice
Intrahepatic dilatation
Cystic duct dilated
74
What is ERCP?
Endoscopic retrograde cholangiopancreatography
75
What drug therapy may be used to treat small gallstones?
Chenodeoxycholic acid
76
What is the likely diagnosis with RUQ pain, fever and jaundice?
Cholangitis
77
What is the likely diagnosis with RUQ pain and a fever?
Acute cholecystitis
78
What are the indications for lap chole?
Symptomatic gallstone disease
| Asymptomatic gallstones with a reasonable likelihood of future complications
79
What are the local complications of gallstones?
```
Mucocoele
Empyema
Gangrene or perforation
Fistula
Mirizzi syndrome
```
80
How does a gallstone lead to development of a mucocoele?
Stone blocked in duct causes stasis of fluid in gallbladder
Leads to infection
Can lead to gallbladder necrosis
81
What is gallstone ileus?
Fistula allows gallstone to pass from gallbladder into colon
82
What is Charcot's triad?
Fever
RUQ pain
Jaundice
83
What is choledocholithiasis?
Stones within common bile duct
84
What are the indications for ERCP?
Evidence of stones in common bile duct (after MRCP has confirmed)
Severe acute gallstone pancreatitis
Diagnostic for acute pancreatitis
Assess and treat strictures, ampullary adenomas
85
What can ERCP show?
Stricture
Tumour
Gallstones
86
What is the purpose of stenting in ERCP?
To widen common bile duct if it is narrowed or blocked
| Allows bile into duodenum
87
What are the complications of ERCP?
Pancreatitis
Gut perforation, bleeding, infection
Chest infection
88
What forms the common bile duct?
Common hepatic duct + cystic duct + pancreatic duct
89
Where does the common bile duct enter the duodenum?
Ampulla of Vater
90
Where is the ampulla of Vater?
Posterior-medial wall of duodenum
91
What are the functions of the pancreas?
Secretes proemzymes and bicarbonate
| Endocrine function - insulin and glucagon
92
How does acute pancreatitis present?
Epigastric pain - constant, max intensity several hours after onset
Radiates to back
Aggravated by movement and relieved by sitting up
Associated nausea and vomiting
93
What are the causes of acute pancreatitis?
GET SMASHED
| Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion bite, Hyperlipidaemia, ERCP, Drugs
94
What are the signs of acute pancreatitis?
```
Epigastric tenderness
Abdominal distension
Fever and tachycardia
Grey-Turners sign
Jaundice
```
95
What is Grey-Turner's sign?
Bruising in flank
96
What are the differential diagnoses of acute pancreatitis?
```
Perforated duodenal ulcer
Mesenteric infarction
MI
AAA
Cholecystitis/Cholangitis
```
97
Name a grading scale used for acute pancreatitis
Glasgow
| Ranson
98
How do you manage mild acute pancreatitis?
```
IV fluids
Catheterise
Correct electrolytes
Hourly obs
Identify and treat precipitating cause once settled
```
99
How do you treat severe pancreatitis?
Antibiotics
Consider escalation
Feed them if tolerated - catabolic state!
100
What are the systemic complications of acute pancreatitis?
Shock (GI fluid loss)
Pulmonary insufficiency
Metabolic: low calcium, magnesium and albumin
DIC
Systemic cytokine activation: multiple organ dysfunction syndrome
101
Why is there a 2nd peak in mortality after 2-4 weeks in acute pancreatitis?
Local complications mainly due to pancreatic necrosis
102
How is pancreatic necrosis manages?
Sterile necrosis managed conservatively
| Infected necrosis needs debridement
103
What are the local complications of pancreatitis?
Necrosis
Abscess
Pancreatic pseudo cyst
Ascites, fistulae, duct stricture, haemorrhage
104
Define chronic pancreatitis
Recurrent or persistent abdominal pain with evidence of exo/endocrine pancreatic insufficiency
105
What are the causes of chronic pancreatitis?
```
Alcohol, tobacco
Idiopathic
Genetic
Autoimmune
Recurrent and severe acute pancreatitis
Obstructive
```
106
How does chronic pancreatitis present?
Recurrent epigastric pain radiating to back
Anorexia and weight loss
Steatorrhea and malabsorption
Diabetes
107
How is chronic pancreatitis diagnosed?
Clinical history and findings
Radiological evidence of calcification, fibrosis of gland
Analysis of endocrine and exocrine function
108
How do you treat chronic pancreatitis?
Creon with each meal
Opiate analgesia
Give up alcohol
Diabetic control
109
What surgery may be used for chronic pancreatitis?
Resection - remove abnormal part of pancreas
| Drainage - small bowel anastomosed to pancreatic duct, or core out pancreatic head
110
What proportion of cases of acute pancreatitis are cause by gallstones or alcohol?
80%
111
How is serum amylase relevant to acute pancreatitis?
X3 upper limit is diagnostic
| NOT prognostic - use scoring systems instead
112
What is an acute abdomen?
Recent or sudden onset unexpected signs/symptoms including abdominal pain
113
What are the causes of visceral pain?
Stimulation of receptors in smooth muscle, eg
Ischaemia
Distension/stretching
Tension
114
Why is visceral pain poorly localised?
Conducted by autonomic nerves
| Poorly localised in midline, following embryological origin
115
What are the associated features of visceral pain?
Malaise
Nausea
Vomiting
Sweating
116
What is somatic pain?
Stimulation of pain receptors in parietal peritoneum
117
Why is somatic pain well-localised?
Conducted by segmental somatic nerves
118
What is referred pain?
Due to common central neural pathways in the spinal cord, where somatic nerves and visceral organs share pathways
119
What causes the majority of 'acute abdomens'?
Nonspecific ie tummy ache!
| 34% of presentations
120
What is the second most common cause of an acute abdomen?
Acute appendicitis
121
What does sudden onset abdominal pain suggest?
Perforation
| Rupture
122
Name 3 colic syndromes
Biliary colic
Ureteric colic
Small bowel obstruction
123
What does gradual onset abdominal pain suggest?
Inflammatory conditions
Obstructive processes
Other mechanical processes
124
What features may be associated with an acute abdomen?
```
Appetite
Nausea and vomiting
Distension
Altered bowel habit
Weight loss
```
125
What other systems do you need to ask about with an acute abdominal presentation?
Gynae: LMP, PV discharge
Urinary: frequency, urgency, pain, haematuria
126
What other medical conditions may present as an acute abdomen?
MI
Pneumonia or pleurisy
Herpes zoster
Diabetic ketoacidosis
127
What features of an acute abdomen suggest malignancy?
```
Intermittent pain of over 48h duration
Altered bowel habit
Distension
Mass
Weight loss
```
128
What features suggest intestinal obstruction?
```
Colicky severe pain
No aggravating factors
Vomiting/constipation (depending on level of obstruction)
Previous surgery
Distension
High pitched bowel sounds
```
129
What features suggest a perforated viscus?
```
Sudden onset pain
Constant severe pain
Aggravated by movement or coughing
Diffuse tenderness
Silent rigid abdomen
```
130
What features suggest an AAA?
Sudden onset central abdominal pain
Collapsed
Hypotensive
131
Where should you start on palpation of the abdomen?
Away from the site of pain!
132
What does guarding suggest?
Peritonitis
133
What bedside investigations would you perform for an acute abdomen?
```
BMs
Urinalysis
Pregnancy test
ECG
Obs
```
134
What laboratory investigations would you order for an acute abdomen?
FBC, UEs, serum amylase
| LFTs, ABG, clotting, group&save
135
How do you manage an acute abdomen?
```
NBM
IV fluids
Obs
Thromboprophylaxis
Analgesia/antiemetic
```
136
What is the lifetime prevalence of acute appendicitis?
8. 6% men
| 6. 7% women
137
What are the causes of acute appendicitis?
```
Faecolith
Foreign body
Tumour
Worms
Trauma
Lymphadenitis
```
138
What is the pathological process in acute appendicitis?
Blockage of outflow (eg by swollen lymph glands caused by inflammation)
Stasis
Infection
139
How long after onset of symptoms does perforation occur in acute appendicitis?
24 to 36 hours
140
Why is a perforated appendix bad?
Leads to peritonitis
141
What is the classic presentation of acute appendicitis?
Vague peri umbilical pain
Localising to right iliac fossa
Nausea, vomiting, anorexia
Guarding in peritonitis
142
What other conditions can mimic appendicitis?
```
Ectopic pregnancy
Pancreatitis
Gastroenteritis
Ulcerative colitis
UTI
```
143
What is rebound tenderness?
Pain on removal of pressure
| Indicates peritonitis
144
Where is McBurney's point?
1/3 between ASIS and umbilicus
145
What is the psoas sign?
Pain on hip flexion
| Inflamed caecum/appendix irritates psoas muscle
146
Why is ultrasound done in suspected acute appendicitis?
Doesn't pick up appendicitis, but would show other pathologies eg ovarian cyst or gastroenteritis
147
What imaging does show acute appendicitis?
CT abdomen
148
How is WCC affected by appendicitis?
May be raised, but can still be normal
149
What are the complications of acute appendicitis?
Infections of wound or pelvic abscess
Bleeding
Fistulation
150
How do you manage a well patient with acute appendicitis?
```
Observe
Analgesia
NBM
?antibiotics
Re-assessment
```
151
When is surgery indicated for acute appendicitis?
Peritonitis
| Unwell
152
What are the causes of upper GI bleeding?
Oesophagus: tumour, MWT, varices
Stomach: tumour, ulcer, erosions
Duodenum: ulcers, haemobilia
153
What small bowel pathology can cause bleeding?
Tumours
Ulceration
IBD
Meckel's diverticulum
154
What large bowel pathologies can cause bleeding?
```
Tumours
Diverticular disease
Radiation damage
AV malformation
IBD
```
155
What anal pathologies can cause bleeding?
Piles
| Varices
156
How do you manage an upper GI bleed?
```
Resuscitation/stabilisation of patient
OGD +/- ulcer intervention
PPI + H.pylori eradication
Treatment for varices
Surgery only if above measures fail
```
157
What are the causes of small amounts of rectal bleeding?
Haemorrhoids
Colorectal cancer
Colitis
Vascular is
158
What are the causes of massive rectal bleeding?
Colonic diverticular disease
| Angiodysplasia
159
How do you manage a PR bleed?
Resuscitation: 2 large bore cannulae, IV fluids
Catheterise
Oxygen
Adrenaline - vasoconstriction to stop bleeding
Operative management difficult due to lack of precise site
160
Define shock
Inadequate tissue perfusion to meet the metabolic needs of the tissue
161
What are the classes of hypovolaemic shock?
1 - less than 15% total blood volume lost
2 - 15-30%
3 - 30-40%
4 - >40%
162
What are the causes of an upper GI perforation?
Ulcers
| Cancer
163
What are the causes of small bowel perforation?
Cancers
Foreign bodies
Obstruction
Trauma
164
What are the causes of large bowel perforation?
```
Diverticular disease
Cancer
Obstruction
IBD
Iatrogenic
```
165
How does a perforated bowel present?
Abdominal pain
Generalised peritonitis
Hyper-dynamic circulation - tachycardia, pyrexia, flushed
Shocked
166
When is conservative management of bowel perforation used?
No generalised sepsis or peritonitis
167
How is bowel perforation managed initially?
```
Resuscitation - IV fluids
Oxygen
Catheter
IV antibiotics
Analgesia
```
168
How would bowel perforation be managed conservatively?
Antibiotics
Bed rest
PPI for UGI
Radiological drainage where required
169
What is the mortality from faecal peritonitis?
50%
170
What is an ileostomy?
Surgical opening constructed by bringing the end/loop of small intestine out onto the surface of the skin
171
What is a colostomy?
Healthy end of large intestine drawn through incision in anterior abdominal wall
172
How do you tell the difference between an ileostomy and a colostomy?
Ileostomy has a spout
| Colostomy flush with skin
173
What are the causes of rectal bleeding?
```
Diverticulitis
Colorectal cancer
Haemorrhoids
Crohn's or UC
Perinatal disease
Angiodysplasia
```
174
What bloods would you order for a PR bleed?
```
FBC
UE
LFT
Clotting
Amylase
CRP
Group&save
```
175
How does angiodysplasia present?
Fresh PR bleed in the elderly
176
What are the causes of colitis?
Inflammatory
Infective
Ischaemic
Radiation
177
How does smoking influence inflammatory bowel disease?
Protective for UC
| Increases risk of Crohn's
178
Name 3 extra-GI manifestations of inflammatory bowel disease
Erythema nodosum
Arthropathy
Uveitis/iritis
179
What area of the GI tract is most commonly affected in Crohn's?
Terminal ileum
180
What is the incidence of ulcerative colitis?
10-20 per 100,000 per year
181
What is the peak age of onset for ulcerative colitis?
10-40 years
182
What are the symptoms of ulcerative colitis?
```
Bloody diarrhoea
Abdominal pain
Urgency
Systemic: fever, malaise, weight loss
Extracolonic: joint pain, sore eyes, cutaneous
```
183
What is the medical treatment for ulcerative colitis?
Steroids: topical, oral or IV
5-ASA preparations eg sulfasalazine
Cyclosporine
184
What are the indications for surgery in ulcerative colitis?
```
Failed medical treatment
Haemorrhage
Perforation
Cancer
Extra-intestinal manifestations
```
185
How does surgery affect prognosis for ulcerative colitis?
It is curative
186
What is the incidence of Crohn's disease?
5-10 per 100,000 per year
187
What is the peak age of onset of Crohn's disease?
2 peaks
15-30
60-80
188
What are the symptoms of Crohn's disease?
```
General malaise, anorexia, weight loss
Intermittent diarrhoea
Abdominal pain
Mouth ulcers
Recurrent perianal abscesses
Fistula symptoms
Eye and joint problems
```
189
What is the medical treatment for Crohn's disease?
```
Steroids
ASA preparations
Azathioprine
Methotrexate
Metronidazole
```
190
What are the indications for surgery in Crohn's disease?
```
Failed medical therapy
Fistula +/- abscess
Obstruction secondary to strictures
Cancer
Haemorrhage
Perforation
Growth retardation in children
```
191
What is the difference between an ileoanal pouch and an ileostomy?
Pouch forms a reservoir for storing liquid motion to maintain continence
Small bowel can be connected to the anus
192
What categories of causes are there for intestinal obstruction?
Extramural
Intramural
Intraluminal
193
What are the 3 commonest causes of small bowel obstruction?
Adhesions
Hernia
Tumour
194
What are adhesions?
Bowel obstruction caused by fibrous tissue usually resulting from previous surgery
195
What are the intramural causes of intestinal obstruction?
Inflammation
Tumours
Strictures
196
What should you be thinking of in small bowel obstruction with no previous surgery?
Tumour
197
What are the symptoms of small bowel obstruction?
Abdominal pain - colicky at first, more regular and shorter duration than large bowel. Periumbilical pain
Vomiting
Distension
Failure to pass flatus
198
What are the signs of small bowel obstruction?
```
Tachycardia
Hypotension
Fever
Distension
Look for hernias
Visible peristalsis
Tenderness - indicates imminent perforation
High-pitched, tinkling bowel sounds
```
199
How do you distinguish between small and large bowel on X-Ray?
Small bowel has complete lines across and is more central
SB diameter 2.5cm
LB diameter 5.5-6cm
200
When is surgery indicated for small bowel obstruction?
```
Non-adhesion all obstruction
Perforation evidence on imaging
Fever
Marked tenderness indicating peritonitis
Failure of resolution of adhesion all obstruction
```
201
What are the three most common causes of large bowel obstruction?
Colorectal carcinoma
Diverticular disease
Volvulus
202
How does large bowel obstruction present differently to small bowel obstruction?
No vomiting if ileocaecal valve competent
Interval between bouts of pain longer
Rectal exam may reveal a mass
203
What radiological investigations are used for bowel obstruction?
AXR
CXR (erect)
CT scan
204
Definitive management for bowel obstruction is surgery, with which 2 exceptions?
Adhesions with no signs of peritonitis
| Volvulus with no signs of peritonitis
205
Where do the majority of colorectal cancers occur?
Rectum (27%)
206
How does colon cancer present?
```
Vague ill health
Acute or chronic obstruction
Perforation
Bleeding
Anaemia
Tenesmus
```
207
Where does colon cancer commonly spread to?
Direct - up to 2 cm within bowel wall
Lymphatic
Blood - liver via portal vein
208
How does rectal cancer present?
```
Bleeding
Change in bowel habit (constipation or diarrhoea)
Urgency
Incomplete evacuation
Wet wind
Tenesmus
Colic
```
209
What is a more worrying change in bowel habit and why?
Diarrhoea - growth in lower GI tract makes them want to go more, mucus may be produced, or it may be a sign of incomplete emptying
210
What is Duke's A?
Tumour confined to muscle
94% 5-year survival
211
What is duke's B?
Tumour spread through muscle
| 76% 5-year survival
212
What is duke's C?
Spread into lymph nodes
| 32% 5-year survival
213
What is duke's D?
Distant metastasis
214
What are the surgical options for rectal cancer?
Anterior resection if >5 cm from anus
| Abdomino-perineal resection with end colostomy if within 5cm of anus
215
What are the rules of tumour resection?
Resect distally 2cm and proximally 5cm
Take out blood supply to area
Can't leave behind any bowel whose blood supply you have removed
216
What is the 5-year survival rate of colorectal cancer that has metastasised?
35-40%
217
How is radiotherapy used in rectal cancer?
Pre-operative
| Reduces local recurrence rate
218
What vessel is most commonly affected in mesenteric ischaemia?
Superior mesenteric artery
219
What is the most common cause of mesenteric ischaemia?
Thrombosis
220
What is the classic triad of features of acute mesenteric ischaemia?
Acute severe abdominal pain: constant, central/RIF
No abdominal signs
Rapid hypovolaemia leading to shock
221
What are the life-threatening complications of acute mesenteric ischaemia?
Septic peritonitis
| Progression of SIRS into MODS
222
How do you manage acute mesenteric ischaemia?
IV fluid resus
ABx (gentamicin and metronidazole)
Heparin
Surgery to remove necrosis bowel
223
What is chronic mesenteric ischaemia also known as?
Intestinal angina
224
What are the features of chronic mesenteric ischaemia?
```
Severe colicky post-prandial abdominal pain (gut claudication)
Weight loss
Upper abdominal bruit
PR bleed
Malabsorption
Nausea and vomiting
History of vascular disease
```
225
What is chronic colonic ischaemia?
Ischaemic colitis
| Low flow in Inferior Mesenteric Artery territory
226
What are the features of ischaemic colitis?
Lower left-sided abdo pain plus bloody diarrhoea
227
What is a strawberry naevus?
Cavernous haemangioma
228
How do you treat strawberry naevus?
Involutes within first 2 years of life
| May cause amblyopia if it keeps the eye closed - propranolol to reduce BP if affecting eyes or airway
229
What is a capillary haemangioma otherwise known as?
Port-wine stain
230
What causes spider naevi?
High levels of oestrogen
231
Why may spider naevi occur in cirrhosis of the liver?
Oestrogen normally broken down in liver
Cirrhosis in men causes gynaecomastia and testicular atrophy too
232
Why may obese men appear feminine?
Oestrogen precursors are produced in the adrenal cortex then converted in peripheral fat
233
What is a papilloma?
Abnormal growth within the skin
234
What are the different types of papilloma?
Smooth, pedunculated
Sessile
Pigmented
235
In what condition do you get sessile papillomas?
HPV
236
What are the 6Ss of examining a lump?
```
Site
Size
Shape
Smoothness
Surface
Surroundings
```
237
What lumps are intradermal?
Sebaceous cyst
Abscess
Dermoid cyst
Granulomas
238
What are the differential diagnoses for a subcutaneous lump?
Lipoma
Ganglion
Neuroma
Lymph node
239
What is transillumination?
Shine a light through a lump
| If it glows red this is transilluminable eg hydrocoele
240
What is a neurofibroma?
Benign nerve sheath tumour in peripheral nervous system
241
What is tennell's sign?
Tap on lump/area and it causes tingling
242
What is a lipoma?
Benign lump beneath the skin, in subcutaneous fat
243
What is fluctuancy?
Only seen in cysts
| Moveable and compressible
244
What is the pathology leading to formation of a ganglion?
Myxomatous degeneration of joint capsules, forming a jelly-like substance
245
What do sebaceous cysts contain?
Keratin
246
Where can sebaceous cysts occur?
Anywhere you have hair!
247
Where do dermoid cysts occur and why?
Midline of face
Lateral canthus
Behind ear
Arise from cystic changes in epithelial remnants at lines of embryological fusion
248
What is the differential diagnosis for a dermoid cyst?
Thyroglossal cyst - this would move up when the tongue is poked out
249
What are implantation dermoid cysts?
Skin beneath skin produced hair and leads to a cyst
| Commonest in fingers eg manual workers
250
What is a fistula?
Abnormal connection between 2 epithelial surfaces
251
What is a pilonidal sinus?
Nest of hairs beneath the skin
Hairy bottom - keep sitting on it and pushing hair beneath the skin
Can cause continual infections
252
Where do keratocanthomas commonly occur?
Face/neck
253
What is a keloid scar?
Benign tumour
Commonest in Afro-Caribbean people over the sternum
If they're a keloid maker, they will get keloid scares - minimise chances with steroid injections
254
What is erythema ab igne?
Holding hot water bottle against abdomen
| Common in alcoholics
255
What is the gate theory of pain?
There is a certain area of space in the dorsal column for nerves to get through (of all modalities)
More traffic of other sensory modalities means there is less space for pain fibres to get through and stimulate pain sensation
256
What are the 5 different types of ulcers?
```
Sloping
Punched-out
Undermined
Rolled
Everted
```
257
Give an example of a cause of a punched-out ulcer
Trophic eg diabetes due to lack of nerve supply
258
Give an example of a sloping ulcer
Healing venous ulcer
259
What are boils?
Furuncles
| Abscesses involving a hair follicle and associated gland
260
What is hidradenitis suppurativa?
Continuous infection in armpit
261
Define hernia
The protrusion of an organ through its containing wall
262
What are the basic features of all hernias?
Occur at a weak spot
May reduce on lying down, or with direct pressure
May have an expansile cough impulse
263
Name 5 common hernias
```
Inguinal
Femoral
Incisional
Epigastric
Umbilical
```
264
What is the clinical significance of the lymphatic drainage of the testicles?
Drain to paraaortic nodes so show no lymphadenopathy in malignancy
265
Where does a direct inguinal hernia protrude?
Medial to inferior epigastric artery
| Outside spermatic cord
266
Where is the femoral canal?
Below and lateral to the pubic tubercle
267
Where is the mid-inguinal point?
Midway between ASIS and pubic symphysis
268
What is the function of the femoral canal?
Allow expansion of femoral vein
| Eg on standing
269
Why is a femoral hernia potentially more dangerous than other hernias?
```
Lacunar ligament (medial to canal) is very tough
Femoral hernia much more likely to strangulate and kill
```
270
What are the 4 benign perianal conditions?
Piles
Perianal sepsis (fistula/abscess)
Fissure
Pilonidal sinus
271
How are piles graded?
1-4 depending on degree of prolapse
272
What are the symptoms of piles?
Bright red bleeding
| Prolapse
273
What are grade 1 piles?
Only bleeding, no prolapse
274
What are grade 2 piles?
Prolapse only on defecation
275
What are grade 3 piles?
Prolapse, but can push it back up
276
What are grade 4 piles?
Permanent prolapse
277
How do you confirm the presence of piles?
Proctoscopy
278
What are the conservative measures for piles?
High fibre diet
Plenty of fluids
Avoid straining
279
What are the medical interventions for piles?
Creams
| Stool softeners eg fybogel
280
What are the surgical options for piles?
Banding
Injection
HALO
Haemorrhoidectomy and put stitches in piles
281
What are the symptoms of anal fissures?
Anal pain
Bit of bleeding
Pain after defecation lasting up to several hours
282
What is the classic presentation of an anal fissure?
Constipation for a while
Then passing a hard stool
Tears the ectoderm and creates a fissure
283
What are the conservative measures for an anal fissure?
Prevent constipation
| Creams: GTN or diltiazem
284
Which patients are at increased risk of perianal sepsis?
Diabetes
Immunocompromised
Older people
Obese people
285
What can chronic perianal sepsis lead to?
Fistula formation
286
What is the cryptoglandular theory of anal abscess formation?
12-20 glands in intersphincteric space
They secrete mucus to lubricate the anal canal
Glands become blocked and form abscesses
Pus can track down to lie under the anal skin and form an abscess there
287
What is a pilonidal sinus?
Nest of hairs
| Pits in midline
